Every finding on record at Mill Town Health and Rehabilitation

Based on records reviewed and interviews, for one of four sampled residents (Resident #3), who required a mechanical lift for all transfers, the Facility failed to ensure he/she was provided with equipment that was specifically designed for and appropriate for safe use during a mechanical lift transfer. On 04/18/26 nursing staff attempted to transfer Resident #3 via mechanical lift using a repositioning device, not a designated lift sling, Resident #3 slid out of the mechanical lift, fell to the floor, hit his/her head and received skin tears as a result of the fall. Resident #3 was transferred to the Hospital Emergency Department and was diagnosed with an Intraparenchymal hemorrhage (brain bleed) as a result of the fall.Findings include:The Facility Policy, titled Safe Transfer with the Mechanical Lift, dated 06/2022, indicated manufacturer recommendations would be followed when using the mechanical lift to transfer residents to ensure the safety of the resident.Review of the User Instruction Manual for the Hoyer HPL700 (Mechanical Lift) indicated do not use a sling unless it was recommended for use with the lift.Resident #3 was admitted to the Facility in March 2024, diagnoses included spinal stenosis, lumbar disk degeneration, dementia, and atrial fibrillation.Review of Resident #3's Activities of Daily Living Care Plan, dated initiated 04/20/24 and reviewed with his/her annual Minimum Data Set (MDS) assessment dated [DATE], indicated he/she required two staff members assistance using the mechanical lift device for all transfers.Review of the Facility's Investigation Summary, undated, indicated that on 04/18/26, Resident #3 was being transferred by two Certified Nurse Aides (CNAs) using the mechanical lift, and during the transfer he/she fell from the mechanical lift to the floor, struck his/her head, and was transferred to the Hospital Emergency Department.Review of Resident #3's Hospital Computed Tomography (CT) Scan, dated 04/19/26, indicated he/she had an 8-millimeter (mm) Intraparenchymal Hemorrhage (IPH) within the left occipital (back) lobe of the brain.During a telephone interview on 05/26/26 at 09:00 A.M., CNA #11 said that on 04/18/26 she was Resident #3's assigned CNA on the 07:00 A.M. to 3:00 P.M., shift, and said she could not find a lift sling large enough to transfer him/her in the mechanical lift. CNA #11 said she found what she later was told was a repositioning device in a box in the laundry room, which was a large flat pad that had loops around the outside, but did not have the longer straps that would crisscross between the residents' legs, like the straps on a normal mechanical lift sling. CNA #11 said the fact that the leg straps were missing should have been an indicator that this device was not a mechanical lift transfer sling, and she should not have used it. CNA #11 said CNA #12 helped her transfer Resident #3 from his/her bed to his/her wheelchair at 09:00 A.M., using the repositioning device without incident.During a telephone interview on 05/26/26 at 10:50 A.M., CNA #12 said that on 04/18/26 at 09:00 A.M., he assisted CNA #11 to transfer Resident #3 from his/her bed to his/her wheelchair. CNA #12 said CNA #11 had already placed a sling pad device under Resident #3, so he did not see what was used. CNA #12 said he knew that repositioning devices are not supposed to be used with the mechanical lift.CNA #11 and CNA #12 said they left the sling/pad they used to transfer Resident #3 into the wheelchair underneath him/her.During a telephone interview on 05/19/26 at 1:17 P.M., CNA #1 said that on 04/18/26 at 6:30 P.M., she and CNA #2 attempted to transfer Resident #3 from his/her wheelchair back to bed using the mechanical lift. CNA #1 said there was already a sling pad under Resident #3, that he/she was a large person, and therefore she could not really see what type of pad was under him/her in the wheelchair when she hooked the mechanical lift up to the loops that were attached to the pad.CNA #1 said when she raised Resident #3 up from the wheelchair she noticed that he/she was positioned leaning forward, saw that the pad was not a mechanical lift sling, said she told CNA #2 that it was not a mechanical lift sling, and that they had to lower Resident #3 back onto the wheelchair. CNA #1 said by the time she noticed, it was too late because Resident #3 slid out from the pad and fell onto the floor.CNA #1 said when she attached the pad to the mechanical lift she had recognized that there were no leg straps that would have crisscross between Resident #3's legs, but said she had seen flat mechanical lift slings before, so that's what she thought it was, until Resident #3 was suspended in the lift and started to slip forward out of the pad.During a telephone interview on 05/21/26 at 10:45 A.M., CNA #2 said that on 04/18/26 at 6:30 P.M., she assisted CNA #1 with transferring Resident #3 from his/her wheelchair using the mechanical lift. CNA #2 said she hooked up one side of the lift sling/pad and said she noticed that the pad under Resident #3 seemed different than the usual mechanical lift slings they used. CNA #2 said the pad that was underneath Resident #3 did not have the long straps that crisscrossed between the residents' legs, so she assumed it was just a different type of mechanical lift sling/pad.During an interview on 05/20/26 at 11:28 A.M., Nurse #4 said that on 04/18/26 at 6:30 P.M., CNA #2 told her that Resident #3 had fallen out of the mechanical lift. Nurse #4 said Resident #3 had skin tears on his/her arms, and when she assessed him/her for injuries, Resident #3 said he/she had hit his/her head. Nurse #4 said Resident #3 was then transferred to the Hospital Emergency Department via 911 for evaluation.During an interview on 05/19/26 at 12:30 P.M., the Assistant Director of Nurses (ADON) said that during the facility's investigation of the incident, it was discovered that the pad used to transfer Resident #3 from his/her bed to his/her wheelchair on 04/18/26 was not a mechanical lift sling. The ADON said the pad was a repositioning pad, which is a large flat pad with handles around the edges used to reposition and slide a resident while they are in bed or from surface to surface, like when transferring from an ambulance gurney to a bed. The ADON said the Facility does not use these types of repositioning pads, and said they sometimes end up left behind by transport personnel when a resident is brought in from the Hospital. The ADON said repositioning pads are not intended or designed to be used as transfers slings with the mechanical lift.On 05/20/26, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of 04/21/26, which addressed the area(s) of concern as evidenced by:A. 04/19/26, Resident #3 was readmitted to the Facility with new diagnosis of Intraparenchymal Hemorrhage (IPH). Nursing staff continued to monitor his/her neurological signs and treatments were applied to his/her skin tears.B. 04/19/26, The ADON re-educated nursing staff on the Facility's policy for mechanical lift transfers and observations for competencies were conducted.C. 04/19/26, The DON and ADON located and removed all repositioning pads from the Facility.D. 04/20/26, an Ad Hoc QAPI Meeting was conducted, Facility leadership met to develop a plan to ensure mechanical lift transfers would be completed safely with the appropriate designated equipment.E. 04/20/26, the Facility Leadership conducted a Root Cause Analysis which indicated it was determined that the primary cause of Resident #3's fall from the mechanical lift was due to staff's utilization of an improper device (repositioning pad) in the place of a transfer sling specifically designed to be used with the mechanical lift.F. 04/20/26, Residents whose care plans indicated they required use of the mechanical lift were assessed by Nursing Management to ensure they were assigned the correct size and appropriate type of mechanical lift sling.G. The DON or designee will continue to conduct random observations of mechanical lift transfers 10 times a month for three months.H. The Unit Managers will conduct Audits of mechanical lift sling once a month for three monthsI. The ADON or designee will ensure all newly hired nursing staff complete mechanical lift transfer competencies upon hire.J. Audit findings and compliance trends will be reviewed at monthly QAPI meetings to evaluate effectiveness of interventions and determine if there is a need for additional corrective actions.K. The DON and/or designee are responsible for ongoing and overall compliance.

Based on records reviewed and interviews, for one of four sampled residents (Resident #1), the Facility failed to ensure nursing staff promptly notified his/her medical provider and health care proxy of a significant medication error.Findings include:The Facility Policy, titled, MD Notification, dated 02/2022, indicated nursing staff would notify the resident's physician of any change in the resident's condition, treatment, and/or medication issues.The Facility policy, titled Medication Error, dated as revised 07/2021, indicated:-Examples of medication errors included but were not limited to wrong medication, wrong dose, and wrong resident.-When a medication error was identified it would be reported to the resident's physician and representative.Resident #1 was admitted to the Facility in January 2025 with diagnoses that included Parkinson's Disease, diabetes, epilepsy, dementia, and atrial fibrillation.Review of Resident #1's Invocation of Health Care Proxy/Durable Power of Attorney for Health Care Form, dated 10/12/23, indicated Resident #1's Health Care Proxy was invoked.Review of Resident #1's Medication Administration Record (MAR) for 03/2026 indicated that on 03/29/26 he/she received the following morning medications:-Aspirin (blood thinner) 81 milligrams (mg) capsule by mouth, daily.-Clopidogrel (antiplatelet) 75mg tablet by mouth, daily.-Famotidine (prevents heartburn) 10mg tablet by mouth, daily.-Furosemide (diuretic) 20mg tablet QD-Isosorbide Mononitrate (improves blood flow to the heart) ER 30mg 3 tablets by mouth, daily.-Magnesium Oxide (supplement) 400mg tablet by mouth, daily.-Nuplazid (antipsychotic) 34mg capsule by mouth, daily.-Trazodone HCL (antidepressant) 50mg by mouth in the morning.-Carvidopa-Levodopa (antiparkinsonian) 25-100mg tablet by mouth, twice daily.-Carvedilol (anthypertensive) 3.125mg tablet by mouth, twice daily.-Divaloprex (anti seizure) delayed release sprinkle 125mg capsule by mouth, twice daily.-Klonopin (benzodiazepine anxiolytic) 0.5mg tablet by mouth, twice daily.-Metformin HCL (antidiabetic) 500mg, 2 tabs by mouth, twice daily.-Suralfate (for duodenal ulcers) 1 GM tablet by mouth, twice daily.-Buspirone HCL (anxiolytic) 5mg tablet by mouth, three times daily.-Gabapentin (anti seizure)100mg capsule 2 caps by mouth, three times daily.Review of the Medication Error Report, dated 03/30/26, indicated that on 03/29/26, the Director of Nurses was notified that Nurse #1 had administered Resident #2's morning medications to Resident #1, in error. The Report further indicated that Nurse #1 failed to notify Resident #1's physician and activated Health Care Proxy of the medication error.Review of Resident #2's MAR, dated 03/29/26, indicated that his/her morning medications [that were administered to Resident #1 in error] included the following:-Amlodipine Besylate (lowers blood pressure) 5mg tablet by mouth, daily.-Magnesium (supplement) 400 mg tablet by mouth, daily.-Pantoprazole Sodium (for acid reflux) 20 mg by mouth, daily.-Propanolol HCL (lowers blood pressure) 120 mg by mouth, daily.-Proscar (treats enlarged prostate) 5 mg tablet by mouth, daily.-Ativan (benzodiazepine anxiolytic) 1 mg by mouth, twice daily.-Clozaril (antipsychotic) 200 mg tablet by mouth, daily.-Depakote (antiseizure) 500 mg delayed release tablet by mouth, twice daily.-Risperidone (antipsychotic) 3 mg by mouth, twice daily.During a telephone interview on 05/19/26 at 08:35 A.M., Nurse #1 said that on 03/29/26 at 08:00 A.M., he prepared Resident #2's morning medications and asked a staff member (unable to recall exact name) who Resident #2 was. Nurse #1 said the staff member pointed in the direction of a table where three of the same gender residents were seated but did not specify who Resident #2 was. Nurse #1 said he did not ask the staff member to further clarify Resident #2's identity, but entered the Unit Dining Room, and asked for Resident #2 by name. Nurse #1 said Resident #1 responded that he was Resident #2, and so he administered Resident #2's medication to Resident #1 in error.Nurse #1 said he became aware of the medication error about an hour after he administered Resident #2's medication to Resident #1. Nurse #1 said he knew he was supposed to but said he did not notify Resident #1's physician or Health Care Proxy (HCP) because he felt panicked.During an interview on 05/18/25 at 2:35 P.M., Nurse #2 said that on 03/29/26 he was Resident #1's assigned nurse and had administered his/her scheduled medications to him/her that morning. Nurse #2 said that at 09:00 A.M., Resident #2 told him that Nurse #1 had given Resident #1 his/her medications. Nurse #2 said when he questioned Nurse #1, he said he had administered Resident #2's medications to Resident #1 in error.Nurse #2 said he called the Director of Nurses (DON) to alert her of the medication error, and said the DON told him to have Nurse #1 notify Resident #1's physician of the medication error. Nurse #2 said he knew Nurse #1 had not notified Resident #1's physician and said he also did not notify Resident #1's physician of the medication error.During an interview on 05/20/26 at 10:36 A.M., the Director of Nurses (DON) said that on 03/29/26 at 10:00 A.M., Nurse #2 notified her that Nurse #1 had administered Resident #2's medications to Resident #1 in error. The DON said she told Nurse #2 that Resident #1's physician needed to be notified of the error. The DON said she was not in the Facility on 03/29/26 and said she did not follow up with either nurse to ensure the physician and HCP had been notified of the medication error and said she did not know the physician had not been notified until the following morning.The DON said that either Nurse #1 or Nurse #2 should have notified Resident #1's physician of the medication error right away but had not.On 05/20/26, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of 04/08/26, which addressed the area(s) of concern as evidenced by:A. 03/30/26, The Facility notified Resident #1's physician and HCP of the medication error.B. 03/30/26, The Facility Leadership conducted a Root Cause Analysis of the medication error and subsequent failure by nursing staff to notify the physician and HCP of the error.C. 03/30/26, an Ad Hoc QAPI Meeting was conducted, indicated to review the incident and develop a corrective action plan to prevent future failure to notify the physician and resident representative of medication errors.D. 03/30/26, the ADON re-educated licensed staff that the physician and HCP/resident representative must be notified of any resident change in condition.E. 03/30/26, the ADON re-educated licensed staff to the five rights of medication passes.F. 04/07/26, The DON/designee conducted medication administration observations with licensed staff.G. 04/01/26, The Facility Leadership updated the Facility Policy for Medication Errors to include that the reporting of medication errors would be non-punitive.H. The DON/designee will conduct medication pass observations weekly.I. The Unit Managers/designee will conduct medication administration audits weekly.J. The DON/designee will conduct medication error tracking reviews monthly.K. Audit findings will be reviewed during the monthly QAPI meetings to evaluate effectiveness of interventions and determine the need for continued monitoring or additional corrective action.L. The DON/designee are responsible for ongoing compliance.

Based on records reviewed and interviews, for one of four sampled residents (Resident #1), the Facility failed to ensure he/she was free from a significant medication error, when on 03/29/26, Resident #1 was administered his/her scheduled morning medications, and he/she was also administered Resident #2's medications in error.Findings include:The Facility Policy, titled Medication Error, dated as revised 07/2021, indicated:-It was the Facility policy to support the correct administration of medication to residents at all times.-Examples of medication errors included but were not limited to wrong medication, wrong dose, and wrong resident.Resident #1 was admitted to the Facility in January 2025 with diagnoses that included Parkinson's Disease, diabetes, epilepsy, dementia, and atrial fibrillation.Review of Resident #1's Medication Administration Record (MAR) for 03/2026 indicated that on the morning of 03/29/26 he/she was administered the following scheduled medications:-Aspirin (blood thinner) 81 milligrams (mg) capsule by mouth, daily.-Clopidogrel (antiplatelet) 75mg tablet by mouth, daily.-Famotidine (prevents heartburn) 10mg tablet by mouth, daily.-Furosemide (diuretic) 20mg tablet QD-Isosorbide Mononitrate (improves blood flow to the heart) ER 30mg 3 tablets by mouth, daily.-Magnesium Oxide (supplement) 400mg tablet by mouth, daily.-Nuplazid (antipsychotic) 34mg capsule by mouth, daily.-Trazodone HCL (antidepressant) 50mg by mouth in the morning.-Carvidopa-Levodopa (antiparkinsonian) 25-100mg tablet by mouth, twice daily.-Carvedilol (anthypertensive) 3.125mg tablet by mouth, twice daily.-Divaloprex (anti seizure) delayed release sprinkle 125mg capsule by mouth, twice daily.-Klonopin (benzodiazepine anxiolytic) 0.5mg tablet by mouth, twice daily.-Metformin HCL (antidiabetic) 500mg, 2 tabs by mouth, twice daily.-Suralfate (for duodenal ulcers) 1 GM tablet by mouth, twice daily.-Buspirone HCL (anxiolytic) 5mg tablet by mouth, three times daily.-Gabapentin (anti seizure)100mg capsule 2 caps by mouth, three times daily.Review of the Medication Error Report, dated 03/30/26, indicated that on 03/29/26, the Director of Nurses was notified that Nurse #1 had administered Resident #2's morning medications to Resident #1, in error. Review of Resident #2's MAR for 03/2026 indicated that on the morning of 03/29/26, he/she was scheduled to have the following medications administered:-Amlodipine Besylate (lowers blood pressure) 5mg tablet by mouth, daily.-Magnesium (supplement) 400 mg tablet by mouth, daily.-Pantoprazole Sodium (for acid reflux) 20 mg by mouth, daily.-Propanolol HCL (lowers blood pressure) 120 mg by mouth, daily.-Proscar (treats enlarged prostate) 5 mg tablet by mouth, daily.-Ativan (benzodiazepine anxiolytic) 1 mg by mouth, twice daily.-Clozaril (antipsychotic) 200 mg tablet by mouth, daily.-Depakote (antiseizure) 500 mg delayed release tablet by mouth, twice daily.-Risperidone (antipsychotic) 3 mg by mouth, twice daily.Review of the Medication Error Report, dated 03/30/26, indicated that on 03/29/26 [around 8:00 A.M.], Nurse #1 administered Resident #2's morning medications to Resident #1, in error.During a telephone interview on 05/19/26 at 08:35 A.M., Nurse #1 said that on 03/29/26 at 08:00 A.M., he prepared Resident #2's morning medications, and asked a staff member (unable to recall exact name) who Resident #2 was. Nurse #1 said the staff member pointed in the direction of a table where three of the same gender residents were seated but did not specify who Resident #2 was. Nurse #1 said he did not ask the staff member to further clarify Resident #2's identity, but entered the Unit Dining Room, and asked for Resident #2 by name.Nurse #1 said Resident #1 responded that he was Resident #2, and so he administered Resident #2's medication to Resident #1 in error. Nurse #1 said he became aware of the medication error about an hour after he administered Resident #2's medication to Resident #1.During an interview on 05/18/25 at 2:35 P.M., Nurse #2 said that on 03/29/26 he was Resident #1's assigned nurse and had administered his/her scheduled medications to him/her that morning. Nurse #2 said that at around 09:00 A.M., Resident #2 told him that Nurse #1 had given his/her medications to Resident #1. Nurse #2 said when he questioned Nurse #1 about the medications, that Nurse #1 told him he had administered Resident #2's medication to Resident #1, in error.During an interview on 05/20/26 at 10:36 A.M., the Director of Nurses (DON) said that on 03/29/26 at 10:00 A.M., Nurse #2 notified her that Nurse #1 had administered Resident #2's medications to Resident #1 in error. The DON said Nurse #1 should have identified Resident #2 using another resident identifier before administering the medication but did not.On 05/20/26, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of 04/08/26, which addressed the area(s) of concern as evidenced by:A. Resident #1 was monitored by nursing for signs and symptoms of adverse reaction to the medications, he/she remained at baseline that day. Resident #1 was transferred to the hospital the next day related to complications from a Urinary Tract Infection and returned the same day.B. Facility Medical Director reviewed the medications error, and nursing actions implemented related to monitoring.C. 03/30/26, The Facility notified Resident #1's physician of the medication error.D. 03/30/26, The Facility Leadership conducted a Root Cause Analysis of the medication error incident.E. 03/30/26, an Ad Hoc QAPI Meeting Minutes was conducted to review the incident and develop a corrective plan to prevent future medication errors.F. 03/30/26, the ADON re-educated licensed staff that the physician must be notified of any resident change in condition.G. 03/30/26, the ADON re-educated licensed staff to the five rights of medication passes.H. 04/07/26, The DON/designee conducted medication administration observations with licensed staff.I. 04/2026, The Facility Leadership updated the Facility Policy for Medication Errors to include that the reporting of medication errors would be non-punitive.J. The DON/designee will conduct random medication pass observations weekly.K. The Unit Managers/designee will conduct medication administration audits weekly.L. The DON/designee will conduct medication error tracking reviews monthly.M. Medication Audit findings will be reviewed during monthly QAPI meetings to evaluate effectiveness of interventions and determine the need for continued monitoring or additional corrective action.N. The DON/designee are responsible for ongoing compliance.

Based on records reviewed and interviews, for two of three sampled residents (Resident #2 and Resident #3), who were both severely cognitively impaired, unable to formulate consent and found engaged in touching in a sexual manner, the Facility failed to ensure staff consistently implemented and followed their abuse policy related to reporting abuse allegations, when on 03/04/26 although Certified Nurse Aide #2 immediately reported to Nurse #1 that Resident #2 and Resident #3 were witnessed engaging in sexual behavior, Administration however, was not made aware until on 03/05/26 (the following morning), and failed to ensure their abuse policy aligned with the requirement for allegations of abuse to be reported to their State Agency within two hours.Findings include:Review of the Facility Policy titled Investigation of Resident Abuse, Neglect, Mistreatment, Misappropriation of Resident Property Complaints/Allegations, dated June 2022, indicated any complaint, observation, or suspicion of resident abuse, neglect, mistreatment or misappropriation of resident property is reported to the Massachusetts Department of Public Health, Division of Health Care Quality and other appropriate agency as deemed appropriate in accordance with state and federal law. The Policy indicated the Unit Manager/Supervisor will notify the Director of Nurses and the Administrator within two hours (or sooner), after the allegation if there is abuse or bodily harm. The Policy's reporting requirements indicated that the Administrator and Director of Nursing will be notified immediately, (based on the time frames set forth by Centers for Medicare and Medicaid Services and State Regulatory Agency), upon receipt of an allegation of resident abuse, neglect, mistreatment or misappropriation of resident property. The Policy indicated that additionally, if abuse is suspected or confirmed, a report will be made within 24 hours to the Department of Public Health.Review of the report submitted by the Facility via the Health Care Facility Reporting System, dated as created on 03/05/26 at 1:29 P.M., indicated [on 3/04/26 during the evening shift] that evidently Resident #2 wandered into Resident #3's room, sat on his/her bed, and both cognitively impaired Residents were found touching each other in a sexual manner. Review of Resident #2's clinical record indicated that his/her diagnoses included dementia, aphasia, conversion disorder and post-traumatic stress disorder.Review of Resident #2's annual Minimum Data Set (MDS) assessment, dated 02/25/26, indicated he/she rarely/never made himself/herself understood or understood others, and had severely impaired cognitive skills for daily decision making. Review of Resident #2's Care Plan Report, dated 03/03/26, indicated he/she wandered aimlessly, and may significantly intrude on the privacy of others or activities. Care Plan Interventions include to distract with pleasant diversions and structured activities.Review of Resident #3's clinical record indicated that his/her diagnoses included vascular dementia.Review of Resident #3's quarterly MDS assessment, dated 02/17/26, indicated he/she usually made himself/herself understood and usually understood others, and during a brief interview for mental status had severely impaired cognitive patterns.Review of Resident #3's Care Plan Report, reviewed and renewed with his/her most recent MDS, indicated he/she had impaired cognitive function or impaired thought processes due to dementia. Interventions include to cue, reorient and supervised as needed.During a telephone interview on 03/26/26 at 2:35 P.M., Certified Nurse Aide (CNA) #2 said Resident #2 was known to wander throughout the secure unit. CNA #2 said on 3/04/26, she recalled seeing Resident #2 in the dining room at 6:00 P.M. as she left to provide another resident care. CNA #2 said at 6:15 P.M., as she walked out of that resident's room, she noticed Resident #3's door was ajar and Resident #2 seated on Resident #3's bed. CNA #2 said Resident #2 did not reside in Resident #3's room. CNA #2 said she immediately entered, saw Resident #3 lying in bed with no clothing covering his/her genital area. CNA #2 said Resident #2, while sitting next to Resident #3 on his/her bed, was touching Resident #3's genital area with one hand. CNA #2 said one of Resident #3's hands covered Resident #2's hand while the other hand touched Resident #2's chest under his/her shirt. CNA #2 said she removed Resident #2 from Resident #3's room and immediately reported the incident to Nurse #1.During an interview on 03/24/26 at 2:30 P.M., Nurse #1 said on 03/04/26 at about 6:15 P.M., CNA #2 reported Resident #2 was found to have wandered into Resident #3's bedroom and they were engaged in sexual activity. Nurse #1 said she reported the incident to Assistant Director of Nursing (ADON) either by telephone or email to receive guidance. Nurse #1 said she reported the incident to the Director of Nursing (DON) by text that night (on 03/04/26) sometime after 11:00 P.M. (around four hours after the alleged incident occurred). Nurse #1 said she should have immediately called to ensure the DON was notified after CNA #2 reported the incident to her. Nurse #1 said she was distracted by tasks such as, ensuring Resident #2 and Resident #3 remained separated, conducting their skin checks, investigating the incident, and ensuring the oncoming 11:00 P.M. to 7:00 A.M. shift received information on the incident.During an interview on 03/24/26 at 3:05 P.M., the ADON said she did not recall being contacted or informed of the incident involving sexual activity between Resident #2 and Resident #3 on 03/04/26, by staff.During an interview on 03/24/26 at 12:18 P.M., the Director of Nursing (DON) said she was unaware of the incident which occurred at 6:15 P.M. on 03/04/26 between Resident #2 and Resident #3 until she saw Nurse #1's text at about 5:00 A.M. on 03/05/26 (almost 11 hours after the alleged incident occurred). The DON said she then notified the Administrator by text that morning. The DON said an allegation of resident-to-resident sexual abuse should have been immediately reported to Administration, per Facility policy.During an interview on 03/24/26 at 3:15 P.M., the Administrator said he was not aware of the incident involving Resident #2 and #3, until the DON notified him of the allegation by text on 03/05/26, which was received as he was arriving to the Facility at 8:00 A.M. (almost 14 hours after the incident occurred).During a telephone interview on 04/03/26 at 2:20 P.M., the Administrator said it was determined based on review of the Facility's Policy titled Investigation of Resident Abuse, Neglect, Mistreatment, Misappropriation of Resident Property Complaints/Allegations, dated June 2022, that it had not been fully updated to accurately reflect current reporting requirements. The Administrator said allegations of abuse were expected to be reported immediately, not within two hours, to himself and the Director of Nurses, and that the report submitted by the Facility via the Health Care Facility Reporting System to the State Agency, regarding abuse allegations, must be submitted within two hours.

Based on records reviewed and interviews, for two of three sampled residents (Resident #2 and Resident #3), who were severely cognitively impaired and had been found by staff touching each other is a sexual manner, the Facility failed to ensure staff immediately reported an allegation of resident to resident sexual abuse to Administrative staff as required, so the Facility could report the incident to the State Survey Agency, within the two hour required time frame. On 03/04/26 although a staff member witnessed Resident #2 and Resident #3 engaging in sexual behavior with each other, it was not successfully reported to Administration until the following morning on 03/05/26, (almost 11 hours after the alleged incident occurred) and not reported to their State Agency until 1:29 P.M. that afternoon (more than 18 hours later).Findings include:Review of the Facility Policy titled Investigation of Resident Abuse, Neglect, Mistreatment, Misappropriation of Resident Property Complaints/Allegations, dated June 2022, indicated any complaint, observation, or suspicion of resident abuse, neglect, mistreatment or misappropriation of resident property is reported to the Massachusetts Department of Public Health, Division of Health Care Quality and other appropriate agency as deemed appropriate in accordance with state and federal law. Review of Resident #2's clinical record indicated that his/her diagnoses included dementia, aphasia, conversion disorder and post-traumatic stress disorder.Review of Resident #2's annual Minimum Data Set (MDS) assessment, dated 02/25/26, indicated he/she rarely/never made himself/herself understood or understood others, and had severely impaired cognitive skills for daily decision making. Review of Resident #3's clinical record indicated that his/her diagnoses included vascular dementia.Review of Resident #3's quarterly MDS assessment, dated 02/17/26, indicated he/she usually made himself/herself understood and usually understood others, and during a brief interview for mental status had severely impaired cognitive patterns.During a telephone interview on 03/26/26 at 2:35 P.M., Certified Nurse Aide (CNA) #2 said on 03/04/26 around 6:15 P.M., as she walked out of a resident's room she noticed Resident #3's door was ajar and Resident #2 seated on Resident #3's bed. CNA #2 said Resident #2 did not reside in Resident #3's room. CNA #2 said she immediately entered, saw Resident #3 lying in bed with no clothing covering his/her genital area. CNA #2 said Resident #2, while sitting next to Resident #3 on his/her bed, was touching Resident #3's genital area with one hand. CNA #2 said one of Resident #3's hands covered Resident #2's hand while the other hand touched Resident #2's chest under his/her shirt. CNA #2 said she removed Resident #2 from Resident #3's room and immediately reported the incident to Nurse #1.During an interview on 03/24/26 at 2:30 P.M., Nurse #1 said on 03/04/26 at about 6:15 P.M., CNA #2 reported to her that Resident #2 was found to have wandered into Resident #3's bedroom and they were engaged in sexual activity. Nurse #1 said she reported the incident to Assistant Director of Nursing (ADON) either by telephone or email to receive guidance. Nurse #1 said she reported the incident to the Director of Nursing (DON) by text that night (on 03/04/26) sometime after 11:00 P.M. (around four hours after the alleged incident occurred). Nurse #1 said she should have immediately called to ensure the DON was notified after CNA #2 reported the incident to her.During an interview on 03/24/26 at 3:05 P.M., the ADON said she did not recall being contacted and/or informed of the incident involving sexual activity between Resident #2 and Resident #3 on 03/04/26.During an interview on 03/24/26 at 12:18 P.M., the Director of Nursing (DON) said she was unaware of the incident that occurred at 6:15 P.M. on 03/04/26 between Resident #2 and Resident #3 until she saw Nurse #1's text at about 5:00 A.M. on 03/05/26 (11 hours later). The DON said she then notified the Administrator by text that morning. The DON said the allegation of resident to resident sexual abuse should have been immediately reported to Administration per Facility policy.During an interview on 03/24/26 at 3:15 P.M., the Administrator said he was not aware of the incident until the DON notified him of the allegation by text on 03/05/26, which was received as he was arriving to the Facility at 8:00 A.M. The Administrator said the incident was not reported to the State Agency within two hours as required, and that their report of the incident was not created or submitted via the Health Care Facility Reporting System until the afternoon on 03/05/26. Review of the report submitted by the Facility via the Health Care Facility Reporting System, in which they reported the incident of 03/04/26 with Resident #2 and Resident #3 (both cognitively impaired residents) were found touching each other in a sexual manner, indicated the Report was dated as created/submitted on 03/05/26 at 1:29 P.M. (more than 18 hours after the alleged incident occurred),

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a diagnoses of diabetes with physician's orders related to monitoring his/her blood glucose levels and had been found on the floor after an unwitnessed fall, the Facility failed to ensure he/she was provided with care and services that met professional standards of nursing practice, when nurses 1) failed to recognize signs and symptoms of hypoglycemia (low blood sugar) and assess and treat him/her per physician's orders, and 2) failed to adequately assess and provide first aid for a potential burn, after being observed to have a reddened area after having been found down and lying up against a baseboard heater.Findings include:1) The Facility Policy, titled Hypoglycemia, dated as revised 06/19/24, indicated nursing staff would appropriately respond to and treat residents who experienced a hypoglycemia episode, and would refer to the hypoglycemia protocol.The normal range for fingerstick blood sugar (BS) is 90-150 mg/dL (5.0-8.3 mmol/L) for fasting measurements and 90-180 mg/dL (5.0-10.0 mmol/L) for non-fasting measurementsThe Facility's Hypoglycemia Protocol, dated as revised 06/19/24, indicated:-Prompt interventions would be provided for residents who experienced hypoglycemia.-Signs and symptoms of hypoglycemia included changes in behavior, numbness of the tongue and lips, trembling, weakness, dizziness, faintness, slurred speech, stupor, and unconsciousness.-Staff would perform a fingerstick to measure blood glucose.-If the resident's fingerstick blood glucose level was less than 70 milligrams per deciliter (mg/dL) nursing staff would immediately administer a rapidly absorbed simple carbohydrate such as juice or sugar packets, or if the resident was unconscious, administer intermuscular glucagon.-Nursing staff would notify the physician and obtain further instruction.According to Centers for Disease Control and Prevention (CDC).gov, signs and symptoms of a stroke can include:-Sudden numbness or weakness in the face, arm, or leg, especially on one side of the body.-Sudden confusion, trouble speaking, or difficulty understanding speech.-Sudden trouble seeing in one or both eyes.-Sudden trouble walking, dizziness, loss of balance, or lack of coordination.Resident #1 was admitted to the Facility in July 2017, diagnoses included dementia, chronic embolism and thrombosis of the lower extremities, diabetes, and chronic ulcer of the right calf.Review of Resident #1's Order Summary Report for January 2026, indicated he/she had the following Physician's Orders that were initiated 06/16/23:-If Resident #1's Fingerstick Blood Glucose is less than or equal to 70 milligrams per deciliter (mg/dL), and he/she is willing and able to swallow, administer 15 to 20 Grams (G) of carbohydrates and reassess every 15 minutes.-Check Fingerstick Blood Glucose every 15 minutes until EMS arrives as needed for unresponsiveness with blood glucose less than 70 mg/dL.-Glucagen (glucose) Hypokit solution, inject 1 mg intramuscularly as needed to fingerstick blood glucose under 70 mg/dL if resident #1 is unable or unwilling to swallow.Review of the Nurse Progress Note, dated 01/23/26, indicated that at 3:30 P.M., Resident #1 was found on the floor in his/her room, and was lying against the heater (baseboard). The Note indicated Resident #1 was slow to respond, the right side of his/her mouth had a slight droop, his/her hand grasps were equal however he/she was unable to hold his/her right arm up. The Note indicated Resident #1 was transferred to the Hospital Emergency Department via 911.Review of the Fire Department Patient Care Report, dated 01/23/26, indicated Emergency Medical Services (EMS) assessed Resident #1 at the Facility at 3:50 P.M., [around 20 minutes after being found on the floor by nursing] and his/her fingerstick blood glucose measured 24 mg/dL. The Patient Care Report indicated EMS staff administered oral glucose and 1 mg intramuscular (IM) glucose. The Patient Care Report indicated that after treatment for hypoglycemia was administered, Resident #1 became more alert, was answering questions appropriately, and denied any numbness, tingling, dizziness, or weakness. The Patient Care Report indicated Facility nursing staff said they had not checked Resident #1's fingerstick blood glucose.Review of Resident #1's Medication Administration Record (MAR), dated 01/23/26, indicated that although Resident #1 was found on the floor and was noted to have a change in mental status, there was no documentation to support that nursing staff assessed Resident #1's fingerstick blood glucose to check for the potential of a hypoglycemia episode or provided treatment, per physician's orders.Review of Resident #1's Hospital Emergency Department (ED) Provider Note, dated 01/23/26, indicated he/she was transferred to the ED after an unwitnessed fall at the Facility, was diagnosed with hypoglycemia and EMS had treated Resident #1 for hypoglycemia prior to arrival at the ED and his/her mentation was appropriate upon arrival to the ED.During an interview on 02/03/26 at 10:33 A.M., Unit Manager #1 said that on 01/23/26 at 3:30 P.M., Resident #1 was found on the floor in his/her room by a physician. Unit Manager #1 said she immediately went to Resident #1's room and found him/her lying on the floor on his/her right side, leaning up against the baseboard heater. Unit Manager #1 said Resident #1 was slow to respond as though he/she was in a daze when she asked him/her questions. Unit Manager #1 said the right side of Resident #1's face was drooping, and he/she could not hold his/her right arm up. Unit Manager #1 said she thought Resident #1 was having a stroke, and said she called the Nurse Educator to help. Unit Manager #1 said she knew Resident #1 was diabetic but did not think to check his/her fingerstick blood glucose. Unit Manager #1 said when EMS arrived, they checked his/her fingerstick blood glucose and it was 24 mg/dL (low).During an interview on 02/03/26 at 12:00 P.M., the Nurse Educator said that at 3:30 P.M. on 01/23/26, Unit Manager #1 notified her that Resident #1 was having stroke-like symptoms. The Nurse Educator said Resident #1's symptoms included weakness, slurred speech, delayed response, and facial droop. The Nurse Educator said she asked what Resident #1's vital signs were and someone [exact name unknown] said they were stable. The Nurse Educator said she did not think to ask what Resident #1's fingerstick blood glucose was, but in hindsight she said she would have obtained his/her fingerstick glucose level. The Nurse Educator said symptoms of hypoglycemia can mimic symptoms of a stroke, and said nursing should have obtained Resident #1's fingerstick blood glucose and followed the Facility's hypoglycemia protocol.2) The Facility Policy, titled Burns: First Aid, dated 12/02/13, indicated nursing staff would assess and provide first aid for burn injuries to relieve pain and prevent infection.Review of Resident #1's Nurse Progress Note, dated 01/23/26, indicated that his/her right arm had a reddened area from having been up against the baseboard heater.Review of Resident #1's Hospital ED Provider Note, dated 01/23/26, indicated he/she was also diagnosed with a large burn injury with skin sloughing (shedding or rolling away) on his/her back and right arm.Review of Resident #1's Hospital Discharge Note, dated 01/24/26, indicated he/she was discharged to another hospital for specialized burn treatment to the burns on his/her back and arm.Review of Resident #1's Hospital admission History and Physical, dated 01/24/26, indicated he/she was admitted to the Hospital and diagnosed with deep partial thickness second and third degree burns to his/her back and upper right arm as a result of contact with a radiator baseboard.During an interview on 02/03/26 at 10:33 A.M., Unit Manager #1 said when she went to Resident #1's room after being told he/she was on the floor, saw him/her lying up against the baseboard heater, knew the baseboard was hot so she placed her hand between Resident #1 and the baseboard heater. Unit Manager #1 said she could not keep her hand there for more than a few seconds because the baseboard was so hot.Unit Manager #1 said she knew she had to get Resident #1 away from the baseboard because he/she was directly on it and was at risk for a burn. Unit Manager #1 said she and two Certified Nurse Aides got him/her off the floor and back into bed. Unit Manager #1 said Resident #1 had a reddened area on the outside of his/her upper right arm that she thought was a burn from having been up against the baseboard but said she did not administer first aid to the burn and did not assess Resident #1's back for the potential of any other injuries.During an interview on 02/03/26 at 12:00 P.M., the Nurse Educator said that on 01/23/26 while responding to Resident #1's fall and change in condition, she was not aware that Resident #1 had been lying against the baseboard heater, was unaware of the potential burn area on his/her upper right arm area, and said first aid should have been administered to the burn.During an interview on 02/03/26 at 3:10 P.M., the Director of Nurses (DON) said symptoms of stroke and symptoms of hypoglycemia are often similar, and nursing staff should have obtained Resident #1's fingerstick blood glucose and followed the Facility's hypoglycemia protocol but had not.The DON said nursing staff should have provided first aid to Resident #1's burns but had not.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure they maintained a complete and accurate medical record when nursing staff failed to document neurological signs following an unwitnessed fall.Findings include:The Facility Policy, titled Charting and Documentation, dated 06/2022, indicated that all services provided to the resident, observations, and any changes in the resident's medical or mental condition would be documented in the resident's medical record.The Facility Policy titled Falls, dated 06/2022, indicated that if a resident had an unwitnessed fall, the Neurological Assessment would be initiated, and neurological signs would be taken and documented for a minimum of 72 hours.The Facility Policy, titled Neurological Assessment, dated 09/01/04, indicated a neurological assessment was a simple, quick assessment tool used to establish a baseline and recognize neurological trends and changes in a resident's condition. The assessment included cognitive status, pupillary response, blood pressure, heart rate, temperature, respirations, and grip strength. Frequency of neurological checks would be as follows:-Every 15 minutes for one hour-Every hour for four hours-Every four hours for 24 hours-Every eight hours until a total of 72 hours had elapsed (longer if the resident remained unstable).Resident #1 was admitted to the Facility in July 2017, diagnoses included dementia, chronic embolism and thrombosis of the lower extremities, diabetes, and chronic ulcer of the right calf.Review of the Facility's Falls and Incident Assessment Tool, dated 01/22/26, indicated that at 4:15 P.M., Resident #1 was found sitting on his/her bathroom floor following an unwitnessed fall. The Assessment Tool indicated Resident #1's neurological signs were within normal limits upon initial assessment following the unwitnessed fall.Review of Resident #1's Neurological Assessment flow sheet, dated 01/22/26, indicated nursing documented three neurological assessments on 01/22/26. However, the space where the time of the assessments was supposed to be recorded, was instead filled in with his/her blood pressure, and there was no time documented for when the assessments were obtained. The only other neurological assessment documented was timed 03:00 A.M., on 01/23/26, with no other post fall neurological assessments documented by nursing on the flow sheet or in Resident #1's medical record.During an interview on 02/03/26 at 3:10 P.M., the Director of Nurses (DON) said nursing should have documented Resident #1's neurological signs, after his/her unwitnessed fall, according to facility policy but had not.

Based on record review and interview the facility failed to ensure behavioral health services, related to Substance Use Disorder (SUD), were provided to one Resident (#70) out of a total sample of 22 residents. Specifically, the facility failed to follow up with Resident #70 as indicated by providing psychiatric talk therapy; and, during the time behavioral health services failed to follow up with Resident #70, after he/she used an illicit substance (cocaine) which required hospitalization. Findings Include: Review of the facility policy titled, Treatment Options for Residents with Substance Use Disorder, dated 11/4/24, indicated The facility will offer appropriate and individualized treatment for all residents living with the disease of addiction or with a history of substance use disorder. Any resident admitted to the facility who is diagnosed with a substance use disorder, or is diagnosed with such while a resident, will be offered and supported with enrolling and attending appropriate, evidence based, and effective treatment from local Opioid Treatment Programs (OTP), Office Based Addiction Treatment (OBAT, or Office Based Opioid Treatment ([NAME]) programs. The facility is responsible for contacting and establishing a relationship with local treatment programs to off OTP/OBAT/[NAME] services to any resident Newly admitted residents with substance use disorders will be assessed by licensed substance use clinician, or designee, and offered appropriate referral to local OTP/[NAME]/OBAT if indicated, feasible, and warranted and agreed upon by resident. Substance use clinician, or designee, will provide resources to residents who request and/or accept referral to substance use treatment and will be supported/assisted with initiating treatment. Residents with substance use disorders and actively being treated as well as residents with a history of substance use disorder, will be offered behavioral health services and continued counseling. Residents with substance use disorders and actively being treated as well as residents with a history of substance use disorder, will have substance use disorder evaluations completed on admission and an individualized care plan completed by the IDT. Review of the facility policy titled, Acute Intoxication Due to Use of Opioids, dated 11/4/24, indicated Documentation and Post Intoxication Management: The Resident's care plan must be updated with information regarding substance used, and intervention to address the substance use. The resident's care team must be informed of the incident. Education about the dangers of intoxication and the dangers surrounding the use of psychoactive substances, e.g. effect of tolerance on use, must be given to the resident in a supportive manner. Resident #70 was admitted to the facility in April 2025 with diagnoses that included opioid abuse, psychoactive substance abuse, post-traumatic stress disorder (PTSD), and major depressive disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/9/25, indicated he/she scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. Further review indicated his/her PHQ 2-9 (resident mood interview) score was 18 indicating moderately severe depression. Review of Resident #70's admission substance abuse evaluation, dated 4/7/25, indicated he/she actively used substances within the last three months. Review of Resident #70's substance use disorder care plan, dated 4/10/25, indicated the following interventions: - Assist me with my treatment program for substance use disorder which may include a Medication Assisted Treatment program. - I will be open to therapeutic discussions surrounding my substance use. - I will work towards developing coping strategies designed with me to support me in recovery. Review of Resident #70's physician order, dated 4/3/25, indicated May have Psych consult as needed. Review of Resident #70's psychiatric services and counseling consent indicated the Resident signed and consented to both medication management and talk therapy services on 4/3/25. Review of Resident #70's medical record failed to indicate he/she was ever seen by behavioral services for any service other than medication management. Review of Resident #70's social services admission note, dated 4/11/25, indicated Substance use being managed by methadone which is provided by [outside services]. He/she will be followed by substance use counselor & psych. He/she appears to be adjusting to the environment & attends smoking group. Care ongoing. Review of Resident #70's SUD counselor initial note, dated 4/25/25, indicated He/she is living with early onset substance use disorders (SUD) and has a severe trauma history. The Resident may benefit from tenets of trauma informed care including creating safe emotional space, actively listening, and providing empathy while validating and offering choices. The Resident has agreed to individual substance use therapy with this writer. Per medical record, assessment, and interview the Resident is living with active opiate and stimulant use disorders along with PTSD, anxiety and depression. Review of Resident #70's Medical Doctor (MD) progress note, dated 4/7/25, indicated During hospitalization he/she was evaluated by addiction team. Further review of the note failed to indicate any interventions or review of his/her SUD diagnosis outside of medication management. Review of Resident #70's Nurse Practitioner (NP) note, dated 5/1/25, indicated Patient has also significant history of polysubstance use disorder. There was no further mention of any intervention for the use disorder. Review of Resident #70's at risk progress note, dated 5/1/25, indicated Substance use being managed by methadone which is provided by [outside services]. He/she will be followed by substance use counselor. Review of Resident #70's SUD counselor progress note, dated 5/10/25, indicated This writer attempted to meet with the Resident on this day to no avail for he/she reports not feeling up to it. It was agreed this writer would re-approach later in the week. Review of Resident #70's progress notes from 5/11/25 to 5/27/25 failed to indicate that the SUD counselor attempted to follow up with the Resident. Review of Resident #70's nursing progress note, dated 5/23/25, indicated resident was observed sitting in the lobby area next to the elevator, he/she appears disheveled, pupils dilated, face is flush, he/she is diaphoretic, speech is slurred and is unable to put a proper sentence together. He/she is nodding her head as he/she tries to answer questions. when asked if he/she was feeling ill, he/she replied no, when asked if he/she had taken something not prescribed, he/she again stated no. NP notified, order to send to ED (emergency department) for evaluation d/t (due to) change in mental status. Review of Resident #70's nursing progress note written by the staff development coordinator, dated 5/23/25, indicated this writer s/w (spoke with) AJH ED. resident will be admitted with dx: pneumonia. tox screen positive for cocaine. Review of Resident #70's progress notes from his/her return from the hospital on 5/24/25 to 5/27/25 failed to indicate that the SUD counselor, social worker, MD or NP reassessed or met with the Resident about his/her use of an illicit substance. Review of Resident #70's substance use disorder care plan failed to indicate the care plan was reviewed or revised with interventions addressing his/her substance use since his/her return from the hospital on 5/24/25 after using an illicit substance. Review of Resident #70's medical record failed to indicate that the resident was provided talk therapy by psychiatric services since his/her admission to the facility. Review of the Facility assessment dated [DATE], indicated the facility accepts residents with behavioral health diagnoses including SUD and provides annual training's to their staff. During an interview on 5/28/25 at 9:42 A.M., the Social Worker said when a resident is admitted with a SUD diagnosis, she will complete a SUD assessment and a comprehensive care plan. The Social Worker said the building has recently been admitting residents with the SUD diagnosis and they have hired another social worker to help out. The Social Worker said she is not aware of anyone actively using in the building. The Social Worker then said she was aware of Resident #70 actively using on 5/23/25 and did not call the SUD counselor but the Director of Nurses should have when the resident returned from the hospital on 5/24/25. The Social Worker said she should have done a new SUD assessment and updated the Residents care plan but did not because she has not had time. The Social Worker said the facility also offers behavioral health services such as medication management with a psychiatric nurse practitioner and psychiatric counseling with a therapist; however, she did not ensure Resident #70 was set up with psychiatric counseling talk therapy as he/she was only seen by the med management psychiatric Nurse Practitioner. The Social Worker said she did not contact psychiatric services since the Resident has returned to the building after being confirmed to use cocaine. The Social Worker said the Resident should have been offered Narcotics Anonymous (NA) and/or Alcoholics Anonymous (AA) but was not offered those services on admission. The Social Worker said she mainly works on discharge planning and getting residents resources once they leave the facility. During an interview on 5/28/25 at 9:55 A.M., the Director of Nursing (DON) said the SUD program is new at the facility and they have a substance abuse disorder counselor who comes in weekly and as needed, the DON said the SUD counselor was just in over the weekend. The DON said Resident #70 used an illegal substance that was confirmed by the hospital on 5/23/25, but he did not call the SUD counselor when he/she returned on 5/24/25. The DON said he told staff to do more frequent checks on the Resident when he/she returned to the facility. The DON said he expected social services to reassess the Resident and update his/her care plan to add more specific resident centered interventions to protect the Resident. During a follow up interview on 5/29/25 at 9:39 A.M., the DON said the social workers role in the SUD program is completing the SUD assessment, d/c planning, and referring to services when the resident leaves the facility out in the community. The DON said social services should be setting up virtual meetings while here at the facility but he is unaware of any residents actually accessing these meetings. The DON said the social worker should be meeting with SUD residents frequently and should be receiving psych services including talk therapy. The DON said it is prudent to have more things for the Resident to prevent relapse and we as a facility are stumbling and trying to do our best with a new program. During an interview on 5/28/25 at 10:41 A.M., the Nurse Practitioner (NP) said the expectation of the facility is when a resident is admitted with SUD diagnosis they should be supported by the facility with services. The NP said the Resident re-admitted with and had recent and chronic use of drugs. The NP said the facility should have updated the plan of care and completed a new assessment. The NP said the Resident needs extra support with his/her history. The NP said if the facility is going to have SUD residents then they need to provide the correct support. During an interview on 5/29/25 at 8:44 A.M., the SUD counselor said he has been working for the facility for about four weeks. The SUD counselor said he comes in weekly and as needed by the facility. The SUD counselor said he was unaware Resident #70 used drugs on 5/23/25 and was not told until 5/28/25 when the building contacted him to come and assess the Resident. The SUD counselor said he was in over the weekend and no one told him the Resident had used drugs. The SUD counselor said he would like to start individual and bigger groups. The SUD counselor said he is not sure who completed referrals to NA/AA and is not sure who sets it up at the facility, but he has not offered those to Resident #70. The SUD counselor said for the SUD program to work the entire disciplinary team need to be involved. During an interview on 5/28/25 at 11:12 A.M., Resident #70 was tearful and upset and said he/she has been struggling lately and would love to have someone to talk to because he/she wants to do better. The Resident said the facility said today they will be getting him/her more services. During a follow up interview on 5/29/25 at 9:09 A.M., the Social Worker said the facility has been taking SUD admissions for a few months and the SUD program expectations when a resident has SUD is to treat for medical and address the SUD through care planning, meetings, and other resources if the resident is open to it. The Social Worker said social services supports residents with their recovery and what they need at discharge. The Social Worker said while they are at the facility they can talk to the social worker, behavioral health team that offers both talk therapy and med management. The social worker said she did not follow-up with the Resident to ensure she was receiving all possible services from the behavioral health team. The Social Worker said she tries to do check-ins and should be writing notes after. The Social Worker said we are building on the SUD program because it is new here at the building. The Social Worker said the building may need a counselor that comes in frequently as she is not a SUD counselor and she more focuses on day to day things and discharge planning. During an interview on 5/29/25 at 9:25 A.M., the Medical Director (MD) who is also Resident #70's primary doctor at the facility said SUD programming at the facility focuses on the medical issues as the main issue and to provide services for SUD like behavioral health services. The MD said psych services are very important both medication management and talk therapy. The MD said it is very important because SUD is a mental issue. The MD said she does not recall knowing the Resident was struggling. The MD said when the Resident returned to the facility the social worker should have reassessed him/her and psych services, including the SUD counselor, should have been notified immediately. The MD said SUD is a hard diagnosis and those residents need the correct support in place including non-medical interventions. During an interview on 5/29/25 at 10:37 A.M., the Administrator said the SUD program was initiated at the facility about 4 weeks ago. He said they hired another social worker to help out the one social worker for the SUDs program. The Administrator said the residents the facility is accepting are here for medical reasons and the idea is the medical concerns get taken care of then they get discharged back to the community. The Administrator said they know residents need support for their addiction problems while the medical problems are being taken care of. The Administrator said the SUD counselor is here twice a week and as needed at night and the social worker is here for support for all the residents. The Administrator said the social worker should be checking in frequently and should step in if SUDS counselor is not here. The Administrator said the social worker should be setting up services while they are here and getting the residents what they need such as behavioral health services, addiction meetings and community resources. The Administrator said he is looking to set up NA/AA going forward. The Administrator said we are new at this and the SUD programming needs strengthening.

Based on record review, and interview, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for six Residents (#14, #36, #65, #5, #29 and #62), out of 22 sampled residents. Specifically: 1. For Resident #14 the facility failed to ensure the MDS assessment was accurately coded for skin conditions (section M). 2. For Resident #36 the facility failed to ensure the MDS assessment was accurately coded for the use of restraints. 3. For Residents #65, #5 and #29, the facility failed to ensure the MDS assessment was accurately coded related to pneumococcal vaccination status. 4. For Resident #62, the facility failed to ensure the MDS assessment was accurately coded for a resident who had been discharged . Findings include: 1. Resident #14 was admitted to the facility in December 2024 with diagnoses of necrotizing fasciitis, septicemia and diabetes mellitus. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/7/25, indicated that Resident #14 scored a 15 out of 15 on the Brief Interview for Mental Status exam, indicating the Resident was cognitively intact. Review of section M of the discharge return anticipated assessment, dated 12/23/25, indicated Resident #14 had four stage four pressure ulcers. Review of section M of the OBRA (Omnibus Budget Reconciliation Act) admission assessment, dated 1/14/25, indicated Resident #14 had a stage four pressure ulcer. Review of section M of the discharge return anticipated assessment, dated 1/23/25, indicated Resident #14 had a stage four pressure ulcer. Review of section M of the OBRA (Omnibus Budget Reconciliation Act) admission assessment, dated 2/7/25, indicated Resident #14 had a stage four pressure ulcer. Review of Resident #14's medical record failed to indicate the Resident ever had pressure ulcers during his/her admission. During an interview on 5/29/25 at 11:15 A.M. the MDS nurse said she was not aware of Resident #14 having pressure ulcers and that she would consider any MDS submissions indicating the Resident had stage four pressure injuries inaccurate. During an interview on 5/29/25 at 10:44 A.M. the Director of Nursing (DON) said Resident #14 did not have pressure ulcers during his/her admission and that any MDS assessments indicating the Resident did have pressure ulcers were inaccurate. 2. Resident #36 was admitted to the facility in December 2019 with diagnoses that included Alzheimer's disease, failure to thrive and pain. Review of the most recent MDS, dated [DATE] indicated that the Resident was unable to participate in the Brief Interview for Mental Status and was assessed by staff as having severe cognitive impairment. Further review of the MDS indicated bedrails are used daily as physical restraints. On 5/27/25 at 7:51 A.M., the surveyor observed Resident #26 sleeping in bed. Resident #36's bed did not have any bedrails on it. On 5/28/25 at 7:36 A.M., the surveyor observed Resident #26 sleeping in bed. Resident #36's bed did not have any bedrails on it. Review of Resident #36's active care plan failed to indicate the use of restraints or bedrails. Review of the most recent Siderail/Position Device/Restraint Screen, dated 12/12/24, indicated No side rails used and failed to indicate the use of any restraints. During an interview on 5/29/25 at 7:53 A.M., Unit Manager #1 said that the use of bedrails is determined by the bedrail assessment. She said Resident #36 does not use bedrails. Unit Manager #36 said that bedrails are not used as a restraint in the facility, they are used only for mobility. She said the MDS assessment is inaccurate, to code the use of bedrails daily used as a restraint for Resident #36. During an interview on 5/29/25 at 8:18 A.M., the Minimum Data Set (MDS) Nurse said that bedrails are not used as a restraint in the facility. She also said that part of completing the MDS Assessment would be assessing the resident and observing their environment. She said if the resident does not use bedrails, then it should not be coded on the MDS, she said the MDS was inaccurate, to code the use of bedrails as a restraint for Resident #36. During an interview on 5/29/25 at 10:03 A.M., the Director of Nurses said that bedrails are not used as a restraint on any residents in the facility, only as a mobility enabler to support independence. He said that bedrails coded as a restraint on the MDS would be inaccurate for Resident #36. 3a. Resident #65 was admitted to the facility in June 2024 with diagnoses that included post-traumatic stress disorder and depression. Review of Resident #65's most recent Minimum Data Set (MDS) Assessment, dated 3/21/25, indicated a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15 indicating that the Resident has severe cognitive impairment. The MDS assessment further indicated that the Resident was not up to date with the pneumonia vaccine, and that the vaccine had not been offered to the Resident. Review of Resident #65's medical record indicated a consent to receive the pneumococcal vaccine signed and dated 10/7/24, indicating that the vaccine was offered to the Resident. During an interview on 5/29/25 at 9:36 A.M., the Infection Preventionist said that Resident #65 was offered the pneumonia vaccine but had not received it. During an interview on 5/29/25 at 10:01 A.M., the Director of Nurses said that the MDS documented as not offered would be inaccurate and that if the Resident signed consent to receive the vaccine, then they should have received it. 3b. Resident #5 was admitted to the facility in April 2023 with diagnoses that included anemia and dementia. Review of Resident #5's most recent MDS, dated [DATE], indicated a BIMS score of 5 out of a possible 15, indicating severe cognitive impairment. The MDS further indicated that the Resident's pneumonia vaccine is up to date. Review of Resident #5's medical record indicated a consent to receive the pneumococcal vaccine signed and dated 9/20/24. Further review of the medical record failed to indicate that the Resident received the pneumococcal vaccine. During an interview on 5/29/25 at 9:36 A.M., the Infection Preventionist said that she is aware that Resident #5 has a signed consent to receive the pneumococcal vaccine, but that he/she has not received it yet. The Infection Preventionist said that the facility has been unable to obtain the vaccines from the pharmacy. During an interview on 5/29/25 at 10:01 A.M., the Director of Nurses said that he was not aware that the facility was unable to obtain the pneumococcal vaccine from the pharmacy. He said that if the Resident has consented to the vaccine, then it should be administered. The Director of Nurses further said that the MDS coding of up to date would not be accurate since the Resident had not received the vaccine. 3c. Resident #29 was admitted to the facility in in November 2023 with diagnoses that included parkinsonism and dementia. Review of Resident #29's most recent MDS Assessment, dated 4/30/25, indicated a BIMS score of 6 out of a possible 15, indicating that the Resident had severe cognitive impairment. Further review of the MDS indicated that the Resident's pneumococcal vaccine is up to date. Review of Resident #29's medical record indicated a consent to receive the pneumococcal vaccine signed and dated 9/21/24. Further review of the medical record failed to indicate that the Resident received the pneumococcal vaccine. During an interview on 5/29/25 at 9:36 A.M., the Infection Preventionist said that she is aware that Resident #29 has a signed consent to receive the pneumococcal vaccine, but that he/she has not received it yet. The Infection Preventionist said that the facility has been unable to obtain the vaccines from the pharmacy. During an interview on 5/29/25 at 10:01 A.M., the Director of Nurses said that he was not aware that the facility was unable to obtain the pneumococcal vaccine from the pharmacy. He said that if the Resident has consented to the vaccine, then it should be administered. The Director of Nurses further said that coding the vaccine as up to date would be inaccurate since the Resident had not received the vaccine. 4. Resident #62 was admitted to the facility in October 2023 with diagnoses that included dementia, depression and adult failure to thrive. Review of the most recent Minimum Data Set (MDS) Assessment, dated 12/1/24, indicated that the Resident could not participate in the Brief Interview for Mental Status (BIMS) assessment and was assessed by staff to have modified independence for cognitive skills of daily decision making. This assessment indicated that the Resident was able to recall the current season, and the location of their own room. Review of the medical record indicated that Resident #62 was transferred out of the facility to the hospital on [DATE], and Discharge, return anticipated MDS Assessment was completed. Further review of the medical record failed to indicate that the Resident returned to the facility after the hospital transfer on 11/20/24. During an interview on 5/29/25 at 8:18 A.M., the MDS nurse said that the 12/1/24 MDS Assessment for Resident #62 would be inaccurate because he/she did not return to the facility, therefore staff could not perform a staff assessment of cognition. During an interview on 5/29/25 at 10:03 A.M., the Director of Nurses said that Resident #62 did not return to the facility following hospitalization and went to a different facility. He said that a staff assessment of cognition could not be completed if the Resident was not in the facility and the MDS would be inaccurate.

2b. Resident #2 was admitted to the facility in April 2021 with diagnoses including stroke resulting in hemiplegia, diabetes and unspecified protein-calorie malnutrition. Review of Resident #2's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) and the staff assessed him/her to have severe cognitive impairment. The MDS also indicated Resident #2 is dependent for all functional tasks. Review of Resident #2's physician orders indicated the following order initiated on 8/12/24: -Weekly skin check every day shift, every Mon (Monday). Review of Resident #2's potential for skin alteration care plan last revised 3/19/25, indicated the following intervention: - weekly comprehensive skin assessment, observe skin daily during care and report any concerns to MD (physician). Review of the latest Norton Scale Assessment (a tool used to assess the risk of pressure ulcers in patients), dated 3/4/25, indicated Resident #2 had a risk score of 6 which indicated a high risk for pressure ulcer development. The Norton Scale also indicates that for a score of 10 or less weekly skin checks are recommended. Review of Resident #2's weekly skin checks indicated nursing had not completed a skin check for the past four weeks, since 5/1/25. During an interview on 5/29/25 at 8:23 A.M., Unit Manager #1 said all residents are expected to have weekly skin checks and there would not be a reason for anyone to not having a skin check. Unit Manager #1 said there was recently an upgrade to the electronic medical record system and the scheduling for assessments was somehow erased and that may be the reason for skin assessments not being completed as ordered. During an interview on 5/29/25 at 10:09 A.M., the Director of Nurses said that skin checks should be completed weekly, as indicated in the physician's orders. The Director of Nurses further said that the Electronic Medical Record just had an update, and some assessments were not retriggered, but that the physician's orders should have reminded the nurses to complete them. 2c. Resident #21 was admitted to the facility in July 2017 with diagnoses including Alzheimer's Disease, diabetes, heart failure and muscle weakness. Review of Resident #21's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 which indicated the Resident is cognitively intact. Review of Resident #21's physician orders indicated the following order initiated on 8/11/24: -Weekly Skin Check, every day shift every Sat (Saturday). Review of Resident #21's potential for skin alteration care plan last revised 5/27/25, indicated the following intervention: -Complete Skin Condition check weekly. Review of the latest Norton Scale Assessment (a tool used to assess the risk of pressure ulcers in patients), dated 5/22/25, indicated the Resident had a risk score of 10 which indicated a high risk for pressure ulcer development. The Norton Scale also indicates that for a score of 10 or less weekly skin checks are recommended. Review of Resident #21's weekly skin checks for the past two months indicated the nursing staff had failed to complete the skin check on 4/28/25, 5/10/25 and 5/17/25. During an interview on 5/29/25 at 8:23 A.M., Unit Manager #1 said all residents are expected to have weekly skin checks and there would not be a reason for anyone to not having a skin check. Unit Manager #1 said there was recently an upgrade to the electronic medical record system and the scheduling for assessments was somehow erased and that may be the reason for skin assessments not being completed as ordered. During an interview on 5/29/25 at 10:09 A.M., the Director of Nurses said that skin checks should be completed weekly, as indicated in the physician's orders. The Director of Nurses further said that the Electronic Medical Record just had an update, and some assessments were not retriggered, but that the physician's orders should have reminded the nurses to complete them. 2d. Resident #28 was admitted to the facility in April 2025 with diagnoses including dementia and delusion orders. Review of Resident #28's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident scored a 3 out of a possible 15 on the Brief Interview for Mental Status which indicated he/she has severe cognitive impairment. The MDS also indicated Resident #28 requires maximal assistance from staff for all functional tasks. Review of Resident #28's physician orders failed to indicate and order for weekly skin checks. Review of the latest Norton Scale Assessment (a tool used to assess the risk of pressure ulcers in patients), dated 4/28/25, indicated the Resident had a risk score of 11 which indicated a moderate risk for pressure ulcer development. The Norton Scale also indicates that for a score of 11-15 weekly skin checks are recommended. Review of Resident #28's weekly skin checks for the past two months indicated the nursing staff had failed to complete the skin check on 5/8/25 and 5/22/25. During an interview on 5/29/25 at 8:23 A.M., Unit Manager #1 said all residents should have orders for weekly skin checks and are expected to have weekly skin checks and there would not be a reason for anyone not having a skin check. Unit Manager #1 said there was recently an upgrade to the electronic medical record system and that could be the reason why Resident #28's skin check order was deleted. During an interview on 5/29/25 at 10:09 A.M., the Director of Nursing said every resident should have weekly skin checks. 3. Resident #28 was admitted to the facility in April 2025 with diagnoses including dementia and delusion orders. Review of Resident #28's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident scored a 3 out of a possible 15 on the Brief Interview for Mental Status which indicated he/she has severe cognitive impairment. The MDS also indicated Resident #28 requires maximal assistance from staff for all functional tasks. Review of Resident #28's physician orders indicated the following order: -Seroquel Oral Tablet (an antipsychotic medication) 25 MG (milligrams). Give 1 tablet by mouth two times a day for Dementia with delusions, agitation, initiated on 4/22/25. Review of the pharmacy recommendation dated 5/8/25 indicated: -Please consider performing the AIMS testing now and every six months to monitor for tardive dyskinesia. Review of Resident #28's medical record failed to indicate an AIMS assessment was completed prior to the initiation of Seroquel, after the pharmacy recommendation or subsequently after. During an interview on 5/28/25 at 2:37 P.M., Unit Manager #1 said the AIMS assessment is typically done by the psychiatric nurse practitioner. Review of Resident #28's behavioral health notes from the psychiatric nurse practitioner failed to indicate an AIMS assessment had been completed. During a follow up interview on 5/29/25 at 8:23 A.M., Unit Manager #1 said she clarified the timing of the AIMS assessment with the Director of Nursing, and he said the AIMS assessment should be completed upon admission if a resident is admitted on an antipsychotic or upon starting the antipsychotic. Unit Manager #1 said the nursing staff missed this assessment for Resident #28. During an interview on 5/28/25 at 10:06 A.M., the Director of Nursing said nursing should complete an AIMS assessment upon admission or upon the initiation of an antipsychotic medication to get a baseline status of the resident. Based on observations, interviews, and record review, the facility to ensure that services provided met professional standards for five Residents (#11, #36, #2, #21, #28), out of 22 total sampled residents. Specifically, 1. For Resident #11, the facility failed ensure that the air mattress was functioning. 2. For Residents #36, #2, #21, #28 the facility failed to ensure weekly skin checks were completed as indicated in the physician's orders. 3. For Resident #28, the facility failed to complete a baseline AIMS (Abnormal Involuntary Movement Scale) assessment upon admission and at the initiation of an antipsychotic medication. Findings include: 1. Resident #11 was admitted to the facility in September 2019 with diagnoses that include anoxic brain damage, aphasia following cerebral infarction and dysphagia (difficulty swallowing). Review of the most recent Minimum Data Set (MDS) Assessment, dated 3/19/25, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, indicating that the resident is cognitively intact. Further review of the MDS indicated that the Resident requires supervision or touching assistance with meals and is dependent on staff for Activities of Daily Living. The MDS also indicated that the Resident is at risk for developing pressure ulcers, but did not currently have any pressure ulcers. On 5/27/25 at 7:52 A.M., the surveyor observed Resident #11 sleeping in bed. Resident #11 had an air mattress on his/her bed. The air mattress was deflated and was not functioning. On 5/27/25 at 8:06 A.M., the surveyor observed Resident #11 eating breakfast in his/her bed. The air mattress on the bed was deflated and was not functioning. On 5/27/25 at 8:20 A.M., staff removed Resident #11's breakfast tray and left the room. The air mattress on the bed was deflated and was not functioning. Resident #11 said that he/she was not comfortable in the bed and had pain. On 5/27/25 at 9:02 A.M., two staff members were providing care to Resident #11. The air mattress on the bed remained deflated and not functioning during this time. On 5/28/25 at 7:37 A.M., Resident #11 was awake in bed. The air mattress was set to max inflation (>400 pounds). There was a handwritten note on the air mattress pump that said 5/28 7 am air mattress deflated, on max to refill. Resident #11 said, please help me, I am so uncomfortable. Review of most recent Norton Assessment (An assessment to determine a resident's risk for skin breakdown), dated 3/27/25, indicated a score of 8, which indicates high risk for skin breakdown. Review of Resident #11's active physician orders failed to indicate an order for an air mattress. Review of Resident #11's active care plan failed to indicate the use of an air mattress or air mattress settings. During an interview on 5/28/25 at 12:16 P.M., Nurse #6 said that she worked with Resident #11 on 5/27/25. She said that after the Certified Nurse's Aides provided care to Resident #11, they informed her that the air mattress was not functioning. Nurse #6 said this has been happening as the plug easily gets pulled out of the wall. Nurse #6 said that she would have expected the staff who provided and cleared Resident #11's breakfast the previous day to notice the air mattress was deflated and not functioning. Nurse #6 reviewed Resident #11's medical record and said that Resident #11 did not have a physician's order for the air mattress, but he/she should have. Nurse #6 said that an order would instruct nursing to check the settings and function of the mattress every shift. Nurse #6 said that Resident #11 did not have any open skin areas, but did have a fragile area to his/her buttock which is why he/she utilizes an air mattress. During an interview on 5/28/25 at 12:20 P.M., Unit Manger #1 said that she found Resident #11's air mattress unplugged and not functioning this morning, and she had placed the note on the pump. She said that staff should have noticed the mattress was not functioning. Unit Manager #1 said any resident who utilizes an air mattress should have a physician's order indicating the appropriate setting, and to check the function of the mattress. She said if Resident #11 had an order, it would have triggered staff to check the function. She said a non-functioning air mattress places the resident at risk for skin breakdown. During an interview on 5/29/25 at 10:14 A.M., The Director of Nurses said that all residents on an air mattress should have a physician's order, otherwise the nurses would not know the settings to maintain. He said the order would also call for checking the function every shift. The Director of Nurses said that he would expect any staff who enter the room to notice if the air mattress is not functioning. The Director of Nurses further said that a non-functioning air mattress places the resident at risk for skin breakdown. 2a. Review of the facility policy, titled Skin Care Program and Protocols, revised in June 2022, indicated, but was not limited to, the following: - Designated nurses are to provide direct surveillance of the skin problems weekly and they must monitor the ordered treatments and preventative measures are being carried out appropriately. Resident #36 was admitted to the facility in December 2019 with diagnoses that included Alzheimer's disease, failure to thrive and pain. Review of Resident #36's most recent Minimum Data Set (MDS) Assessment, dated 3/13/25, indicated that the Resident was not able to participate in the Brief Interview for Mental Status Exam, and was assessed by staff as having severe cognitive impairment. Review of Resident #36's active skin care plan, dated as revised 7/4/23, indicated, The Resident is at risk for skin breakdown due to decreased mobility, refusal of care, B&B (bowel and bladder) incontinence and protein calorie malnutrition Norton Score less than 15, with interventions that included comprehensive skin assessment weekly. Review of physician's orders indicated the following: - Weekly Skin Check every day shift every Wed, dated 8/16/24. Review of the assessments tab in the Electronic Medical Record indicated that the most recently completed skin check was completed on 5/1/25, and skin checks were missed, as ordered on 5/7/25, 5/14/25, 5/21/25 and 5/28/25. Further review of the assessment tab indicated a skin assessment that had been opened on 5/14/25 but left blank and was not signed as completed. Review of the most recent Norton Assessment (an assessment to determine a resident's risk for skin breakdown), dated 12/12/24 indicated a score of 7, indicating high risk for skin breakdown Review of May 2025 Treatment Administration Record (TAR) indicated that the weekly skin check was completed as ordered on 5/7, 5/14 and 5/21 and 5/28. Review of Progress notes from 5/1- 5/28 failed to indicate refusal of skin checks or that any skin checks were completed. During an interview on 5/29/25 at 7:56 A.M., Unit Manager #1 said that there should be a physician's order for weekly skin checks. She said that if a nurse is signing them off as completed on the TAR, then they should be completing the assessment. The surveyor and Unit Manager #1 reviewed Resident # 36's medical record and she said that skin checks were not completed on 5/7, 5/14, 5/21 or 5/28 as indicated in physician's orders. During an interview on 5/29/25 at 10:09 A.M., the Director of Nurses said that skin checks should be completed weekly, as indicated in the physician's orders. The Director of Nurses further said that the Electronic Medical Record just had an update, and some assessments were not retriggered, but that the physician's orders should have reminded the nurses to complete them.

Based on observation, record review and interviews, the facility failed to review and implement wound physician treatment recommendations for one Resident (#14) out of a total sample of 22 residents. Findings include: Review of the facility policy, titled Skin Care Program and Protocols, revised in June 2022, indicated, but was not limited to, the following: - Designated nurses are to provide direct surveillance of the skin problems weekly and they must monitor the ordered treatments, and preventative measures are being carried out appropriately. - All treatments require an MD (medical doctor) order, as well as appropriate documentation. - Treatment orders must include the type of dressing to be used, frequency of the dressing change (the dressing should be changed with the least frequency as possible). Resident #14 was admitted to the facility in December 2024 with diagnoses of necrotizing fasciitis, septicemia and diabetes mellitus. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/7/25, indicated that Resident #14 scored a 15 out of 15 on the Brief Interview for Mental Status exam, indicating the Resident was cognitively intact. Review of Resident #14's care plans indicated the resident had potential/actual impairment to skin with the following interventions: - Follow the facility protocols for treatment of injury, initiated on 12/19/24. - Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations, initiated on 12/19/24. Review of Resident #14's most recent wound evaluation and management summary, signed by the wound physician on 5/13/25, indicated the Resident had a post-surgical wound of the right buttock with the following treatment recommendation: -Gauze island with border apply twice daily for 23 days; hypochlorous acid solution (vashe) apply twice daily for 23 days. Further review of the wound evaluation and management summary indicated Resident #14 had an abdominal skin tear with the following treatment recommendation: -Gauze sponge non-sterile apply once daily for 23 days; change every four hours and as needed if saturated. Review of Resident #14's wound evaluation and management summaries, dated 12/10/24, 12/17/24, 12/23/24, 1/14/25, 1/21/25, 2/4/25, 2/11/25, 2/18/25, 3/4/25, 3/13/25, 3/20/25, 3/25/25, and 4/1/25, indicated the Resident had a post-surgical wound of the right buttock with the following treatment recommendation: -Foam with border (silicone-sacrum) apply twice daily; hypochlorous acid solution (vashe) apply twice daily. Review of Resident #14's wound evaluation and management summaries, dated 4/8/25, 4/15/25, 4/22/25, 4/30/25, and 5/6/25 indicated the Resident had a post-surgical wound of the right buttock with the following treatment recommendation: -Hypochlorous acid solution (vashe) apply twice daily; Gauze Island with border apply twice daily. Review of Resident #14's wound evaluation and management summaries, dated 4/8/25, 4/15/25, 4/22/25, and 4/30/25 indicated the Resident had an abdominal skin tear with the following treatment recommendation: -Gauze sponge non-sterile apply once daily; Bacitracin (a topical antibiotic ointment) apply once daily. Review of Resident #14's wound evaluation and management summary, dated 5/6/25 indicated the Resident had an abdominal skin tear with the following treatment recommendation: -Gauze sponge non-sterile apply once daily. Review of Resident #14's outpatient wound appointment summary, dated 4/28/25, indicated the following recommendation: -Lightly pack lower quadrant abdominal wound with dry gauze and cleanse twice daily. Review of Resident #14's physician orders indicated the following order: - Right buttock wound wet to dry dressing twice a day, and also if soaked. Place saline-soaked gauze over the wound followed by dry abdominal pad or dry gauze over the wet dressing. Then secure with large adhesive boarder gauze to keep intact, initiated on 12/17/24. - Wound care, apply dry gauze to right open area abdominal fold. Change twice daily, initiated on 5/28/25. Further review of the Residents physician orders failed to indicate that the facility ever implemented the buttocks wound treatment recommendations the wound physician made on 12/10/14, 12/17/24, 12/23/24, 1/14/25, 1/21/25, 2/4/25, 2/11/25, 2/18/25, 3/4/25, 3/13/25, 3/20/25, 3/25/25, 4/1/25, 4/8/25, 4/15/25, 4/22/25, 4/30/25, 5/6/25 and 5/13/25 or that the facility ever initiated bacitracin for the abdominal wound as recommended on 4/8/25, 4/15/25, 4/22/25 and 4/30/25. Review of the physician's orders indicated that the wound physician's recommendation to apply gauze to the abdominal wound was initiated 50 days after it was initially recommended by the wound physician and after the surveyor brought the concern to the attention of the facility. Review of Resident #14's physician orders, medication administrations records and treatment administration records failed to indicate that there was physician-ordered treatment in place for the Resident's abdominal wound, which was originally identified on 4/8/25, prior to 5/28/25. During an interview on 5/28/25 at 8:31 A.M., Nurse #3 said the wound physician rounds on residents once a week and that one of the facility nurses accompanied him. Nurse #3 said the wound physician would verbally communicate recommendations and document them in his notes which the unit manager would then review. Nurse #3 said he would expect wound physician recommendations to be implemented right away and would expect a physician order for a wound treatment to be in place for any wounds. Nurse #3 said Resident #14 had a wound on his/her buttocks and that the treatment for the buttocks wound should include vashe. During an interview and observation on 5/28/25 at 8:42 A.M., Unit Manager #1 said the wound physician came to the facility once a week and that she would typically accompany him during his rounds but that the wound physician did not round last week. Unit Manager #1 said that when the wound physician made a recommendation for an order for a treatment, it would be implemented on the same day the recommendation was made. The Unit Manager then checked Resident #14's abdominal fold and said there was an open area that should be packed with gauze and that she thought there was already an order for gauze; there was no gauze or wound treatment present on or around the wound at the time of the observation. During a follow-up interview on 5/29/25 at 11:51 A.M. Unit Manager #1 said pretty much everyone knew that the treatment for Resident #14's buttocks wound was vashe but that the current order needed to be updated to reflect the wound physician's recommendations as the Resident should be receiving vashe. Unit Manager #1 said some nurses could have been using normal saline for the treatment of the Resident's buttocks wound as that's what the order currently indicated to use. During an interview on 5/28/25 at 10:43 A.M. Nurse Practitioner (NP) #1 said the wound physician came to the facility every Tuesday morning and that Unit Manager #1 accompanied him. NP #1 said she would document if she disagreed with the wound physician recommendations but that she had not disagreed with any wound physician recommendations for Resident #14. NP #1 said she was not aware of the wound physician's recent recommendations for Resident #14's wounds. During interviews on 5/28/25 at 2:14 P.M. and 5/29/25 at 9:24 A.M., the Medical Director said she would expect the wound physician's recommendations to be implemented right away and that she had not disagreed with any wound physician recommendations for Resident #14. The Medical Director said she was under the impression that the Resident was receiving vashe and that the nurses had told her the bacitracin was in place for the Resident's abdominal wound. The Medical Director said she would expect the treatments to be in place for Resident #14's wounds. The Medical Director said that she would have expected the wound treatment order for Resident #14's buttocks wound to be changed from normal saline to vashe as recommended by the wound physician. During an interview on 5/28/25 at 10:02 A.M. the Wound Physician said he came to the facility once a week and that Unit Manager #1 would usually accompany him during his rounds. The Wound Physician said he would verbally relay recommendations and document the recommendations in his notes which were made available to the facility on the same day. He said he would expect an order for a wound treatment but that he didn't know if there was an order for Resident #14's wound treatments. The Wound Physician said he would assume there was an order for vashe and that he would have expected the recommendations for bacitracin and gauze for the abdominal wound to have been implemented. The Wound Physician said he was not aware that his recommendations were not implemented. During an interview on 5/28/25 at 2:54 P.M. the Director of Nursing said he would expect the wound physician's recommendations to be implemented as soon as possible and that he would expect a physician's order to be in place for any wound treatments.

Based on observations and interviews the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically, 1. The facility failed to ensure that medications were dated once opened, according to manufacturer's guidelines. Further, the facility failed to ensure that medications with shortened expiration dates were removed from the medication cart when expired and were not available for administration in one of two medication carts observed. 2. The facility failed to ensure treatment carts were locked while a nurse was not present on both the second and third floor units. 3. The facility failed to ensure nursing staff kept the medication cart clean and organized in one of one medication cart observed on the second-floor unit. 4. The facility failed to ensure nursing staff stayed with the surveyors while doing the medication storage task on both the second and third floor units. Findings include: Review of the facility policy titled, Medication Storage in the Facility, dated 6/22, indicated the following: -It is the policy of the facility that medications, treatments, and biological are stored safely, securely, and properly following manufacturer's recommendations or facility policy. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms, carts, and medication supplies are locked or attended by personas with authorized access. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, unlabeled, or with out secure closures are immediately removed from stock, disposed of according to procedures for medication destruction , an reordered from the pharmacy if a current order exists. 1. On [DATE] at 11:36 A.M., the surveyor observed the following with Nurse #2 in the 3rd floor low side medication cart: - two Albuterol inhalers, opened, in-use and undated. The inhaler indicates to discard after 12 months. - two Dulera inhalers, opened, in-use and undated. The inhaler indicates to discard after 12 months. - one Incruse Ellipta inhaler, opened, in-use and undated. The inhaler indicates to discard after 6 weeks. - one Spiriva inhaler, opened, in-use and undated. The packaging indicates to discard three months after the insertion of the cartridge (which was inserted). - one Breo Ellipta inhaler, opened, in-use and undated. The inhaler indicates to discard after 6 weeks. During an interview on [DATE] at 11:37 A.M., Nurse #2 said the inhalers are all open and have been used many times by the residents, but they are not dated when they were opened. Nurse #2 said the inhalers should be dated when opened because they expire in so many days after opening. On [DATE] at 11:39 A.M., the surveyor made the following observations of the second-floor west medication cart: - one Incruse Ellipta inhaler, opened in-use and undated. The inhaler indicates to discard after 6 weeks. - one Spiriva respimat inhaler, opened, in-use and undated. The packaging indicates to discard three months after the insertion of the cartridge (which was inserted). - An opened and undated bottle of prostat liquid protein. Instructions on the bottle indicate to discard three months after opening. During an interview on [DATE] at 11:50 A.M., Nurse #3 said that inhalers and other medications like prostat with shortened expiration dates should be dated when opened. During an interview on [DATE] at 7:51 A.M., Unit Manager #1 said that inhalers and other medications with shortened expiration dates should be labeled with an open date. During an interview on [DATE] at 9:54 A.M., the Director of Nursing (DON) said all inhalers and other medications with a shortened life should be dated once opened by the nurse who opens the inhaler, if not it puts the resident at risk because the inhalers expire usually after 28 days. 2. On [DATE] from 7:17 A.M. to 7:50 A.M., the surveyor observed both treatment carts on the third-floor unit unlocked and unsupervised. The surveyor was able to access the treatment cart which contained medicated ointments and creams in it. Multiple staff members and residents were observed to go by the carts. On [DATE] at 7:55 A.M. the surveyor and Nurse #4 observed the high side treatment cart on the third-floor unit unlocked. Nurse #4 said the treatment cart should be locked at all times unless a nurse is present at it. On [DATE] at 8:25 A.M., the surveyor observed the low side treatment cart on the third-floor unit unlocked and unsupervised. The surveyor was able to access the treatment cart which contained medicated ointments and creams in it. On [DATE] at 6:42 A.M. the surveyor observed an unlocked treatment cart on the third- floor unit. The surveyor was able to access the treatment cart which contained medicated ointments and creams in it. On [DATE] at 6:46 A.M. the surveyor observed two unlocked treatment carts on the second-floor unit. The surveyor was able to access the treatment cart which contained medicated ointments and creams in it. On [DATE] at 7:42 A.M., the surveyor observed one unlocked treatment cart on the second- floor unit. Multiple residents were also observed ambulating in the hallway past the unlocked treatment cart. During an interview and observation on [DATE] at 7:51 A.M., Unit Manager #1 observed the unlocked treatment cart and said that all treatment and medication carts should be locked and secured when unattended. During an interview on [DATE] at 9:54 A.M., the Director of Nursing (DON) said treatment carts are expected to be locked at all times unless a nurse is working in that cart. The DON said it can put residents at risk if they are able to access the treatment supplies. 3. On [DATE] at 11:39 A.M., the surveyor made the following observations of the second-floor west medication cart: - A bottle of liquid Trizomal Glutathione (a supplement that supports overall health) with no cover on it. - Nine loose pills in one of the medication cart draws. - A sticky red substance that was spilled in the medication cart. During an interview on [DATE] at 11:50 A.M., Nurse #3 said that medication carts should be kept clean and free of spills and other loose pills. He further said that storing liquid medication without a cover should not happen. During an interview on [DATE] at 7:51 A.M., Unit Manager #1 said that her expectation is that medication carts are kept clean and tidy. During an interview on [DATE] at 9:54 A.M., the Director of Nursing (DON) said he expects nursing to keep their medication carts clean of loose pills and spills. 4. During the observation of the medication cart on [DATE], the nurse unlocked the medication cart for the surveyor at 11:39 A.M., and did not return to the medication cart until 11:50 A.M., 11 minutes after unlocking the medication cart for the surveyor. During an observation of the medication room on [DATE] at 11:38 A.M., on the third-floor unit, medication room Nurse #4 left the surveyor alone in the medication room and did not return. During an interview on [DATE] at 11:50 A.M., Nurse #3 said that he should not have walked away and left the medication cart unattended with the surveyor. During an interview on [DATE] at 7:51 A.M., Unit Manager #1 also said that the nurse should not have left the surveyor unsupervised at the medication cart or in the medication room. During an interview on [DATE] at 9:54 A.M., the Director of Nursing (DON) said nursing staff are expected to stay with the surveyors while the surveyor is in the medication cart and the medication room.

Based on record review and interview, the facility failed to administer Pneumococcal vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations for three Residents (#65, #29 and #5), out of a total sample of five residents reviewed for immunizations. Findings include: Review of facility policy titled, Immunizations and Vaccines- Residents, dated as revised 02/2022, indicated the following: -It is the policy of the facility that all residents receive immunizations and vaccinations that assist in preventing infectious diseases, unless medically contraindicated, or otherwise ordered by the resident's attending physician, or refused by the resident or resident's activated HCP (health care proxy). -Procedure: 1. Vaccine information statements and consent for pneumococcal, influenza and covid-19 will be a part of the residents' admission packed. Consent for these vaccinations will be obtained from the resident or resident representative at the time of admission. -2. Orders for administration of pneumococcal vaccine, covid-19 and annual influenza vaccine will be obtained/ or written by the resident's MD/NP (Medical Doctor/ Nurse Practitioner) on admission. Review of the CDC guidance Pneumococcal Vaccine Timing for Adults, dated 10/2024, indicated but was not limited to the following: For Adults [AGE] years old or older, vaccine recommendations are as follows: -Unvaccinated adults should receive: a) PCV20 (Prevnar 20, a pneumococcal conjugate vaccine) or PCV21 vaccine (Capvaxive, a pneumococcal conjugate vaccine) or b) PCV15 followed by PPSV23 at least one year later -Adults who have received PPSV23 vaccine only (at any age): a) PCV20 or PCV21 vaccine administered at least one year after PPSV23 was received -Adults who have received PCV13 vaccine at any age: a) PCV20 or PCV21 vaccine administered at least one year after PCV13 was received -Adults who have received PCV13 at any age and PPSV23 when younger than age [AGE]: a) PCV20 or PCV21 at least 5 years after PCV13 or PPSV20 vaccine was received. 1a. Resident #65 was admitted to the facility in June 2024 with diagnoses that included post-traumatic stress disorder and depression. Review of Resident #65's most recent Minimum Data Set (MDS) Assessment, dated 3/21/25, indicated a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15 indicating that the Resident has severe cognitive impairment. The MDS further indicated that Resident #65's pneumococcal vaccination was not up to date, and the vaccine was not offered to the resident. Review of Resident #65's medical record indicated a consent to receive the pneumococcal vaccine signed and dated 10/7/24. Further review of the medical record failed to indicate that the Resident received the pneumococcal vaccine. During an interview on 5/29/25 at 9:36 A.M., the Infection Preventionist said that she is aware that Resident #65 has a signed consent to receive the pneumococcal vaccine, but that he/she has not received it yet. The Infection Preventionist said that the facility has been unable to obtain the vaccines from the pharmacy. During an interview on 5/29/25 at 10:01 A.M., the Director of Nurses said that he was not aware that the facility was unable to obtain the pneumococcal vaccine from the pharmacy. He said that if the Resident has consented to the vaccine, then it should be administered. 1b. Resident #29 was admitted to the facility in November 2023 with diagnoses that included parkinsonism and dementia. Review of Resident #29's most recent MDS Assessment, dated 4/30/25, indicated a BIMS score of 6 out of a possible 15, indicating that the Resident had severe cognitive impairment. Further review of the MDS indicated that the Resident's pneumococcal vaccine is up to date. Review of Resident #29's medical record indicated a consent to receive the pneumococcal vaccine signed and dated 9/21/24. Further review of the medical record failed to indicate that the Resident received the pneumococcal vaccine. During an interview on 5/29/25 at 9:36 A.M., the Infection Preventionist said that she is aware that Resident #29 has a signed consent to receive the pneumococcal vaccine, but that he/she has not received it yet. The Infection Preventionist said that the facility has been unable to obtain the vaccines from the pharmacy. During an interview on 5/29/25 at 10:01 A.M., the Director of Nurses said that he was not aware that the facility was unable to obtain the pneumococcal vaccine from the pharmacy. He said that if the Resident has consented to the vaccine, then it should be administered. 1c. Resident #5 was admitted to the facility in April 2023 with diagnoses that included anemia and dementia. Review of Resident #5's most recent MDS, dated [DATE], indicated a BIMS score of 5 out of a possible 15, indicating severe cognitive impairment. The MDS further indicated that the Resident's pneumonia vaccine is up to date. Review of Resident #5's medical record indicated a consent to receive the pneumococcal vaccine signed and dated 9/20/24. Further review of the medical record failed to indicate that the Resident received the pneumococcal vaccine. During an interview on 5/29/25 at 9:36 A.M., the Infection Preventionist said that she is aware that Resident #5 has a signed consent to receive the pneumococcal vaccine, but that he/she has not received it yet. The Infection Preventionist said that the facility has been unable to obtain the vaccines from the pharmacy. During an interview on 5/29/25 at 10:01 A.M., the Director of Nurses said that he was not aware that the facility was unable to obtain the pneumococcal vaccine from the pharmacy. He said that if the Resident has consented to the vaccine, then it should be administered.

Based on record review and interviews, the facility failed to report a potential allegation of abuse for one Resident (#7) out of a total sample of 22 residents. Findings include: Review of the facility policy titled, Investigation of Resident Abuse, Neglect, Mistreatment, Misappropriation of Resident Property Complaints/Allegations, dated as last revised 6/2022, indicated the following: -Any complaint, observation, or suspicion of resident abuse, neglect, mistreatment, exploitation, or misappropriation of resident property is thoroughly investigated and reported to the Massachusetts Department of Public Health, Division of Health Care Quality and any other appropriate agency has deemed appropriate in accordance with state and federal law. -One abuse, neglect, mistreatment, exploitation, or misappropriation of resident property is observed, suspected, or reported to any facility employee, the employee will immediately notify the unit manager/supervisor, and they will immediately report the issue to the Administrator or DON in his/her absence. -The Administrator and Director of Nursing will be notified immediately, upon receipt of an allegation of resident abuse, neglect, mistreatment, or misappropriation of resident property. Review of the facility policy titled, Resident Protection During Abuse Investigation Policy and Procedure, dated revised 6/22, indicated the following: -Any employee who is accused of resident abuse, neglect, mistreatment, exploitation, or misappropriation of resident property will be suspended without pay pending further investigation. The status of his/her employment will be determined by the outcome of the internal investigation by the facility and the external final investigation by the Department of Public Health. -An incident of abuse, neglect, mistreatment, or misappropriation of resident property must be reported to the unit manager/supervisor who will examine the resident and document findings in the medical record and internal abuse reporting form. -The results of the investigation are reported to the administrator within three days and officials in accordance with state law within 5 days of the incident if the alleged violation is verified. -The Administrator or designee will inform the resident and or the resident's representative of the results of the investigation and corrective actions. Resident #7 was admitted to the facility in June 2021 with diagnoses including acute pain due to trauma, osteoporosis with pathological fracture of vertebra(e) (back bone) and muscle weakness. Review of Resident #7's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status score of 15 out of a possible 15 which indicated the Resident is cognitively intact. The MDS also indicated Resident #7 requires supervision for functional tasks. Review of Resident #7's MDS, dated [DATE], indicated the Resident is on scheduled pain medication. Review of a grievance form, dated 10/24/24, indicated the following grievance written by a staff member: Concern: -(The Resident) asked the 11-7 nurse (name) at 12 am if (he/she) could have Tylenol for pain in (his/her) shoulders, hips and back. (The nurse) told (him/her) no because she didn't think (the Resident) was in pain. (The nurse) did not offer anything else to (the Resident) instead of the Tylenol. (The Resident) waited for the 7-3 shift to come in so (he/she) could ask again for something and at this point was in tears due to (his/her) pain. Action taken: -DON (Director of Nursing) spoke to nurse in question who reports that she gave Tylenol to (the Resident). Follow-up: -F/u (follow-up) when resident return from MLOA on 11/12/24. Resident didn't remember receiving dose/situation but reports enough time has passed that (he/she) is indifferent with resolution. Lyrica (pain medication) started upon readmission. At the time of this incident, Resident #7 had the following physician orders: -Pain evaluation: Document verbal/nonverbal signs of pain every shift, initiated on 3/29/23. -Meloxicam oral tablet (a nonsteroidal anti-inflammatory drug (NSAID) used to relieve pain, inflammation, and stiffness) 15 MG (milligrams). Give one tablet at bedtime for supplement, initiated on 5/20/24. -Tylenol tablet 325 MG give two tablets by mouth every 6 hours as needed for fever or pain, initiated 6/16/21. -May apply generic muscle rub to lower back and bilateral shoulders as needed for pain, initiated on 10/18/24. Review of the Medication Administration Report (MAR) for October 2024 indicated the following: -Resident #7 was assessed for pain on the shift the incident occurred by the nurse mentioned in the grievance, however there was no number scale used/reported for the pain and no nursing note. -Resident #7 did not receive any pain medication from the nurse listed in the grievance throughout the shift. -Resident #7 received Tylenol at 7:45 A.M., when the next nurse started the new shift and at this time the Resident's pain was assessed to be an 8 out of 10 on the pain assessment scale. The Nurse mentioned in the grievance form is no longer an employee of the facility and was unavailable for interview. During an interview 5/19/25 at approximately 8:30 A.M., Resident #7 said he/she did not remember this incident from October. Resident #7 said he/she does have pain at times and when he/she receives pain medication it helps. During an interview on 5/28/25 at 12:33 P.M., the Director of Nursing said if a resident is voicing pain, he would expect the nursing staff to assess the resident's pain level and if the resident has an order in place for an as needed pain medication he would expect the nursing staff to provide that medication. The Director of Nursing said if the pain medication is provided, this would be documented on the MAR and if not on the MAR he could not assume the medication was provided. The Director of Nursing said he does not fully remember the incident in October and reviewed the grievance form and the MAR with the surveyor. After review, the Director of Nursing said he could not recall ever seeing that the medication was never given and did not feel that the nurse adequately managed Resident #7's pain. The Director of Nursing said that if a nurse does not address the pain of a resident and another staff member brings it to the attention of management that is a concern for him. The Director of Nursing said not addressing a resident's pain is considered to be neglect and this would need to be investigated and reported, not just written up as a grievance. The Director of Nursing said this incident was not reported to the state agency secondary to a full investigation not having been completed.

Based on record review and interviews, the facility failed to fully investigate a potential allegation of neglect for one Resident (#7) out of a total sample of 22 residents. Findings include: Review of the facility policy titled, Investigation of Resident Abuse, Neglect, Mistreatment, Misappropriation of Resident Property Complaints/Allegations, dated as last revised 6/2022, indicated the following: -any complaint, observation, or suspicion of resident abuse, neglect, mistreatment, exploitation, or misappropriation of resident property is thoroughly investigated and reported to the Massachusetts Department of Public Health, Division of Health Care Quality and any other appropriate agency has deemed appropriate in accordance with state and federal law. -One abuse, neglect, mistreatment, exploitation, or misappropriation of resident property is observed, suspected, or reported to any facility employee, the employee will immediately notify the unit manager/supervisor, and they will immediately report the issue to the Administrator or DON in his/her absence. -Investigation of the allegation will begin immediately. The Unit Manager supervisor will notify the Director of Nursing and the Administrator immediately upon the allegation if there is abuse or bodily harm and within 24 hours if the allegation does not include abuse and does not result in bodily injury. -The resident is interviewed. The interview is documented, dated, signs nurse, nurse manager, or designee. -The staff member/resident implicated is interviewed. The staff member must document their knowledge version of the incident in written narrative, including the date, their signature, and the telephone number where they can be reached. -If a staff member has been implicated in an incident involving resident abuse, neglect, mistreatment, exploitation, or misappropriation of resident property the associate is suspended immediately pending investigation. Suspension may continue pending further investigation and a determination by the Department of Public health, division of healthcare quality. Interview all witnesses to the incident. Witnesses must document their knowledge, independently or with assistance, in written narrative, including the date, their signature, and a telephone number where they may be contacted. -The Administrator and Director of Nursing will be notified immediately, upon receipt of an allegation of resident abuse, neglect, mistreatment, or misappropriation of resident property. Review of the facility policy titled, Resident Protection During Abuse Investigation Policy and Procedure, dated revised 6/22, indicated the following: -any employee who is accused of resident abuse, neglect, mistreatment, exploitation, or misappropriation of resident property will be suspended without pay pending further investigation. The status of his/her employment will be determined by the outcome of the internal investigation by the facility and the external final investigation by the Department of Public Health. -All alleged or suspected abuse, neglect, mistreatment, or misappropriation of resident property will be caused for a thorough investigation conducted immediately by the management of (the facility). -staff must report such allegations without fear of retaliation from the facility or staff. -An incident of abuse, neglect, mistreatment, or misappropriation of resident property must be reported to the unit manager/supervisor who will examine the resident and document findings in the medical record and internal abuse reporting form. -The unit manager/supervisor, and/or the director of nursing will complete the investigation form with a written, dated, signed statement from all persons involved. -The investigation form and written statements from all persons involved will be forwarded to the Administrator immediately. Both the Director of Nursing and the Administrator will conduct an immediate investigation. -If abuse, neglect, mistreatment, or misappropriation is suspected or substantiated, the employee will immediately be sent home in full disciplinary action will be enforced including suspension and or termination of employment pending outcome of the investigation. -The accused employee will not be permitted to enter the facility unless otherwise directed by the administrator, until the investigation has been completed, and final resolution has been given. -The Administrator or designee will inform the resident and or the resident's representative of the results of the investigation and corrective actions. Resident #7 was admitted to the facility in June 2021 with diagnoses including acute pain due to trauma, osteoporosis with pathological fracture of vertebra(e) (back bone) and muscle weakness. Review of Resident #7's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status score of 15 out of a possible 15 which indicated the Resident is cognitively intact. The MDS also indicated Resident #7 requires supervision for functional tasks. Review of Resident #7's MDS dated [DATE] indicated the Resident is on scheduled pain medication. Review of a grievance form dated 10/24/24, indicated the following grievance written by a staff member: Concern: -(The Resident) asked the 11-7 nurse (name) at 12 am if (he/she) could have Tylenol for pain in (his/her) shoulders, hips and back. (The nurse) told (him/her) no because she didn't think (the Resident) was in pain. (The nurse) did not offer anything else to (the Resident) instead of the Tylenol. (The Resident) waited for the 7-3 shift to come in so (he/she) could ask again for something and at this point was in tears due to (his/her) pain. Action taken: -DON (Director of Nursing) spoke to nurse in question who reports that she gave Tylenol to (the Resident). Follow-up: -F/u (follow-up) when resident return from MLOA on 11/12/24. Resident didn't remember receiving dose/situation but reports enough time has passed that (he/she) is indifferent with resolution. Lyrica (pain medication) started upon readmission. -The attached statement from the nurse in question was dated 11/7/24, 2 weeks after the incident. -The grievance also failed to indicate the staff member who made the grievance was interviewed. Review of Resident #7's medical record indicated the Resident was sent out to the hospital on [DATE], a week after this incident. At the time of this incident, Resident #7 had the following physician orders: -Pain evaluation: Document verbal/nonverbal signs of pain every shift, initiated on 3/29/23. -Meloxicam oral tablet (a nonsteroidal anti-inflammatory drug (NSAID) used to relieve pain, inflammation, and stiffness) 15 MG (milligrams). Give one tablet at bedtime for supplement, initiated on 5/20/24. -Tylenol tablet 325 MG give two tablets by mouth every 6 hours as needed for fever or pain, initiated 6/16/21. -May apply generic muscle rub to lower back and bilateral shoulders as needed for pain, initiated on 10/18/24. Review of the Medication Administration Report (MAR) for October 2024 indicated the following: -Resident #7 was assessed for pain on the shift the incident occurred by the nurse mentioned in the grievance, however there was no number scale used/reported for the pain and no nursing note. -Resident #7 did not receive any pain medication from the nurse listed in the grievance throughout the shift. -Resident #7 received Tylenol at 7:45 A.M., when the next nurse started the new shift and at this time the Resident's pain was assessed to be an 8 out of 10 on the pain assessment scale. The Nurse mentioned in the grievance form is no longer an employee of the facility and was unavailable for interview. During an interview 5/19/25 at approximately 8:30 A.M., Resident #7 said he/she did not remember this incident from October. Resident #7 said he/she does have pain at times and when he/she receives pain medication it helps. During an interview on 5/28/25 at 12:33 P.M., the Director of Nursing said if a resident is voicing pain, he would expect the nursing staff to assess the resident's pain level and if the resident has an order in place for an as needed pain medication he would expect the nursing staff to provide that medication. The Director of Nursing said if the pain medication is provided, this would be documented on the MAR and if not on the MAR he could not assume the medication was provided. The Director of Nursing said he does not fully remember the incident in October and reviewed the grievance form and the MAR with the surveyor. After review, the Director of Nursing said he could not recall ever seeing that the medication was never given and did not feel that the nurse adequately managed Resident #7's pain. The Director of Nursing said that if a nurse does not address the pain of a resident and another staff member brings it to the attention of management that is a concern for him. The Director of Nursing said not addressing a resident's pain is considered to be neglect and this would need to be investigated, not just written up as a grievance. The Director of Nursing said the nurse's interview was not done timely and a full investigation into this neglect was not completed by the facility.

Based on observation, record review and interview the facility failed to ensure assistance with Activities of Daily Living was provided for two Residents (#27 and #11) out of a total sample of 22 residents. Specifically: 1. For Resident #27 the facility failed to ensure supervision and cueing with meals was provided. 2. For Resident #11 the facility failed to ensure supervision with meals was provided. Findings include: The facility policy titled Activities of Daily Living (ADL) Support, dated 6/2022, indicated the following: 1. Residents will perform self-care with ADLs at the level on the CNA care plan of care card or assigned tasks. If the resident shows a change in the ADL function the nurse will be notified. 5. Assure adequate intake at each meal by encouraging, cueing, prompting and or feeding as needed. Notify nurses of changes in resident's normal intake. 1. Resident #27 was admitted to the facility in September 2018 and has diagnoses that include dementia without behavioral disturbance. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/26/25, indicated that Resident #27 was unable to participate in the Brief Interview for Mental Status exam and was assessed by staff to have severely impaired cognition. The MDS further indicated that Resident #27 required supervision or touching assistance for eating. Review of Resident #27's current Activities of Daily Living care plan, last updated 10/23/23, included the following intervention: -Eating: Continual Supervision ratio 1 no > [greater than] than 8 for verbal cues and encouragement to eat and drink. Review of Resident #27's current Nutrition care plan, last updated 3/24/25, indicated the Resident has chronic Mod (moderate) protein-cal (calorie) malnutrition (dx <diagnosis> in place) due to BMI (body mass index) < [less than]18, Inadequate oral intake at times, loss of muscle mass. Chewing/swallowing difficulty r/t (related to) dementia/dysphagia AEB (as evidenced by) diagnosis, diet order, SLP (speech and language pathologist). Review of Resident #27's current Kardex (care card with resident specific instructions to guide the nurses and Certified Nursing Assistants (CNAs) with care, indicated: -Eating: Continual Supervision ratio 1 no > than 8 for verbal cues and encouragement to eat and drink. Review of the most recent Nutrition Assessment, dated 3/24/25, indicated that Resident #27 is frail and underweight with little body mass. According to the assessment Resident #27's appetite: fair, best when presented one item at a time. On 5/27/25 at 8:04 A.M., Resident #27 was observed in bed, alone in his/her room with breakfast on the tray table directly in front of him/her. Resident #27 was attempting to self-feed, but the food was dropping on his/her chest. Resident #27 was laughing to him/herself and said, I keep dropping it and can't find it. The surveyor continued to make the following observation: -At 8:14 A.M., Resident #27 remained alone trying to clean the food off his/her chest. There were no staff present to supervise or to provide assistance or cues. On 5/28/25 at 7:56 A.M., Resident #27 was observed in bed, alone in his/her room with the curtain pulled around the bed, with breakfast on the tray table directly in front of him/her. The surveyor continued to make the following observations: -At 8:04 A.M., Resident #27 was observed scooping oatmeal out of the bowl, and placing it on his/her tray, saying aloud here you go, eat this, here you go repeatedly. -At 8:07 A.M., Resident #27 was observed as he/she attempted to take a sip of juice. Resident #27 accidentally spilled the juice on his/her chest., appeared to be distressed by the spill and said oh no as he/she grimaced and pulled the gown off his/her chest. -At 8:09 A.M., Resident #27 resumed scooping the oatmeal onto the tray and repeatedly said yes, that's good, eat that, mmm, good. -At 8:14 A.M., Resident #27 said aloud yes I am all wet now as he/she used his/her hands to pick up the food and feed him/herself the food that had fallen into his/her lap. -By 8:21 A.M., 25 minutes since the initial observation, Resident #27 remained alone, and no staff had supervised, cued or encouraged the Resident with the meal and most of the oatmeal was in two piles on the tray and minced eggs and meat in his/her lap. During an interview on 5/28/25 at 10:16 A.M., Certified Nursing Assistant (CNA) #1 said Resident #27 requires total assistance with ADL care and cannot do anything for him/herself because his/her dementia has worsened. CNA #1 said that Resident #27 will feed him/herself but needs a lot of cues and encouragement because the Resident thinks that he/she needs to feed his/her babies. CNA #1 said that Resident #27 is supposed to eat in the dining room so that staff can provide the supervision and cueing and that CNAs have access to the care card daily. During an interview on 5/28/25 at 10:23 A.M., Nurse #3 said Resident #27 requires supervision and cueing with his/her meals and should not be left alone in his/her room during meals. During an interview on 5/28/25 at 12:33 P.M., the Director of Nursing said that if a resident's care plan indicates that they require continual supervision and cues with eating then he would expect that staff be in the room to supervise the resident and provide cues as needed or that the resident eat in the main dining room where staff are able to provide the supervision and cueing as needed. 2. Resident #11 was admitted to the facility in September 2019 with diagnoses that include anoxic brain damage, aphasia following cerebral infarction and dysphagia (difficulty swallowing). Review of the most recent Minimum Data Set (MDS) Assessment, dated 3/19/25, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, indicating that the resident is cognitively intact. Further review of the MDS indicated that the Resident requires supervision or touching assistance with meals and is dependent on staff for Activities of Daily Living. On 5/27/25 at 8:06 A.M., the surveyor observed Resident #11 in bed eating breakfast. There were no staff in the Resident's room providing supervision. On 5/27/25 at 8:30 A.M., the surveyor observed Resident #11 in bed eating breakfast. Resident #11 had food on his/her face and large amounts of food spilled on his/her chest and abdomen. Resident #11 said that he/she was not in a comfortable position to eat. Resident #11 was observed coughing on fluids. On 5/28/25 at 7:53 A.M., the surveyor observed a staff member set up Resident #11's breakfast tray and leave the room. Resident #11 was in bed at an approximate 45- degree angle. Resident #11 was observed to be coughing when drinking liquids. The surveyor then observed Resident #11 spill oatmeal and hot chocolate on him/herself. The surveyor then alerted the Unit Manager of the food spill. Review of Resident #11's physician's orders indicated the following -Regular diet, Puree (level 4) texture, Nectar (Mildly Thick 2) consistency. May have soft finger foods and pasta cut up. Cold cereal with breakfast. Crustless Grilled cheese sandwich on the side with lunch and dinner. for nutrition, dated 2/19/25. (sic) Review of Resident #11's active activities of daily living care plan, dated as revised on 7/27/23, indicated the following intervention: -Eating- continual supervision of 1/ assist as needed. Assist with hot liquids. (sic) Review of Resident #11's active nutrition care plan, dated as revised on 3/17/25 indicated the following interventions: -Monitor s/sx (signs and symptoms) dysphagia (coughing, choking, runny nose). (sic) -Monitor/document/report prn (as needed) any s/sx of dysphagia. (sic) Review of Resident #11's Kardex (a document that tells staff how much assistance a resident requires) indicated: -Eating - continual supervision of 1/ assist as needed. (sic) Review of Resident #11's most recent Nutrition Assessment, dated 3/17/25, indicated the following: -Nutritional Diagnosis or Risk: Chewing difficulty r/t (related to) dysphagia AEB (as exhibited by) diet order, dx (diagnosis) of dysphagia. -Self feeding difficulty at times r/t dementia AEB staff report. During an interview and observation on 5/28/25 at 8:01 A.M., Unit Manager #1 observed Resident #11 alone in his/her room with food and liquids spilled on him/herself. The surveyor and Unit Manager #1 reviewed the Resident's care plan and Unit Manager #1 said that Resident #11 needs supervision with his/her meals, and they were not getting it. Unit Manager #1 also said that the Resident was not in a high enough position to eat safely. During a follow up interview on 5/28/25 at 8:28 A.M., Unit Manager #1 said that the Certified Nurses Aide (CNA) who dropped off Resident #11's meal was not aware of the assistance needed. Unit Manager #1 said that the CNAs can access the resident Kardex through their charting system and it triggers from the care plan. During an interview on 5/29/25 at 10:11 A.M., The Director of Nurses said that he would expect that if Resident #11 was eating in his/her room, someone should be in the room supervising the resident.

Based on observations, interviews, and record review, the facility failed to implement safe smoking for one Resident (#70), out of two sampled residents who smoked cigarettes. Specifically for Resident #70, the facility failed to ensure a smoking assessment was completed and a plan of care was developed prior to the Resident smoking at the facility. Findings include: Review of the facility policy titled Smoking, dated 11/22, indicated: -Smoking assessments are performed with residents who state their desire to smoke in order to monitor their ability to perform safe smoking function. This assessment is a rudimentary review of the resident's abilities both cognitive and physical functioning. These assessments are conducted on admission/readmission, with a change in the resident's status, and at least quarterly thereafter. The interdisciplinary team will review all completed smoking assessments to determine the safest smoking plan with the resident. Selected safety precautions will be reviewed with the resident and/or the resident's agent. Resident #70 was admitted to the facility in April 2025 with diagnoses that included opioid abuse, psychoactive substance abuse, post-traumatic stress disorder, and major depressive disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/9/25, indicated Resident #70 scored a 15 out of 15 on the Brief Interview for Mental Status exam, indicating intact cognition. Review of Resident #70's medical record indicated on 4/3/25 Resident #70 signed the facility's smoking policy, however the record failed to indicate that a smoking assessment was completed or that a smoking care plan was developed. Review of Resident #70's at risk progress note, dated 5/1/25, indicated attends smoking groups. Review of Resident #70's respiratory therapist note, dated 5/25/25, indicated smoking cessation counseling done with patient. On 5/28/25 at 10:15 A.M., the surveyor observed Resident #70 outside the facility smoking a cigarette while staff were present. During an interview on 5/29/25 at 9:51 A.M., the Director of Nursing (DON) said he would expect a smoking assessment and care plan to be completed upon admission for a smoking resident. The DON said it is important to complete the assessment and the care plan to keep the resident safe.

2. Resident #2 was admitted to the facility in April 2021 with diagnoses including stroke resulting in hemiplegia, diabetes and unspecified protein-calorie malnutrition. Review of Resident #2's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) and the staff assessed him/her to have severe cognitive impairment. The MDS also indicated Resident #2 is dependent on enteral feeding for nutrition. Review of Resident #2's physician orders indicated the following orders: -Glucerna with carbsteady (enteral feeding formula) 1.2 cal at 45ml/hr (milliliter per hour) via PEG tube (feeding tube) around the clock, every shift related to dysphagia. -Flush PEG tube with 200ml H20 (water) every 6 hours ATC (around the clock) for hydration. Programmed on pump for automatic flush, every shift related to dysphagia. On 5/27/25 at 7:52 A.M., Resident #2 was observed lying in bed. Next to the Resident was a pole consisting of a tube feeding pump, tube feeding formula in a gravity bag and a water bag. Both the formula and water bag were labeled 5/24/45, three days prior. On the Resident's bedside table was a half full bottle of formula not dated and warm to the touch. During an interview on 5/27/25 at 8:25 A.M., Nurse #3 observed Resident #2's feeding tube formula and water flush bags and the half full formula bottle. Nurse #3 said the open bottle of formula should have been dated and refrigerated after opening. Nurse #3 said the formula should not have been left on the Resident's side table due to the risk of it being used without knowing when it was open and not having been refrigerated. Nurse #3 also said all enteral feeding bags and water flush bags should be changed every 24 hours and these bags had not been changed for three days. On 5/28/25 at 12:17 P.M., Resident #2 was observed lying in bed and receiving enteral feeding. The formula bag and water flush bags were dated 5/27/25 at the time of 10:00 A.M. During an interview on 5/28/25 at 12:18 P.M., Unit Manager #1 and the surveyor observed Resident #2's enteral feeding formula together. The Unit Manager observed the bag dated for over 24 hours ago and said it should have been changed out. Unit Manager #1 said the formula bag and flush bag should be changed every 24 hours. Unit Manager #1 also said all open formula bottles need to be dated and refrigerated after opening. During an interview on 5/28/25 at 12:34 P.M., the Director of Nursing said the formula bag and flush bag should be changed every 24 hours. The Director of Nursing also said all open formula bottles need to be dated and refrigerated after opening. Based on observations, record review and interviews, the facility failed to ensure that services were provided in accordance with professional standards for two Residents (#17 and #2) with a gastrostomy tube (g-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition) out of two applicable residents, out of a total sample of 22 residents. Specifically, 1) For Resident #17 the facility failed to ensure tube feeding water flushes (intermittent boluses of water, stored in a separate bag, automatically dispensed during regular intervals in conjunction with enteral nutrition formula for purpose of hydration and maintenance of tube patency) was running at the correct setting as indicated in the physician's orders. 2) For Resident #2 the facility failed to properly label, date and store enteral feeding formula as well as change the enteral feeding formula and water flush bags every 24 hours. Findings Include: Review of the facility policy titled Enteral Nutrition Guidelines, dated and revised February 2007, indicated the following: 7. The nurse obtains a physician's order for placement of an enteral feeding tube. Feeding tube orders include the following information: -volume of water given as water flush. 13. The nurse irrigates the feeding tube with the prescribed amount of water every 4-8 hours to maintain or restore patency of the feeding tube and to provide free water to maintain adequate hydration of the resident. Resident #17 was admitted to the facility in September 2023, with diagnoses that included gastroparesis, severe protein-calorie malnutrition and unspecified psychosis. Review of Resident #17's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated the Resident scored a 15 out of possible 15 on the Brief Interview for Mental Status, indicating he/she was cognitively intact. Further review of the MDS indicated that Resident #17 required a feeding tube. On 05/27/25 at 09:25 A.M., the surveyor observed Resident #17 awake and lying in bed. Next to the Resident was a pole consisting of a tube feeding pump, tube feeding formula in a gravity bag and a water bag. The tube feeding pump was on and the tube feeding formula and water flush bag were connected to the Resident's abdomen. The tube feeding water flushes were set and running at 50 milliliters (ml) every four hours. On 05/27/25 at 11:50 A.M., the surveyor observed Resident #17 awake and lying in bed. Next to the Resident was a pole consisting of a tube feeding pump, tube feeding formula in a gravity bag and a water bag. The tube feeding pump was on and the tube feeding formula and water flush bag were connected to the Resident's abdomen. The tube feeding water flushes were set and running at 50 ml every four hours. On 05/28/25 08:12 A.M., the surveyor observed Resident #17 awake and lying in bed. Next to the Resident was a pole consisting of a tube feeding pump, tube feeding formula in a gravity bag and a water bag. The tube feeding pump was on and the tube feeding formula and water flush bag were connected to the Resident's abdomen. The tube feeding water flushes were set and running at 50 mml every four hours. Review of Resident #17's physician orders, dated 5/24/25, indicated the following: - H2O (water) flush both J (jejunostomy) and G (gastrostomy) tube ports with 60 mls of water each, every four hours for water. Review of Resident #17's tube feeding care plan indicated the following intervention revised and dated 5/12/25: -Nursing will provide care with tube feeding and water flushes. See MD (physician) orders for current feeding orders. Review of Resident #17's most recent Nutritional Assessment, dated 5/26/25 indicated the following: -Water Flush: 60ml via G and J tubes x 6/day =720ml. During an interview on 05/28/25 at 09:03 A.M., Nurse #5 said Resident #17's water flush setting was not correct and that the setting should be at 60 ml every 4 hours. During an interview on 5/28/25 at 10:27 A.M., the Dietitian said Resident #17 should receive 60 ml of water flushes every four hours. During an interview on 5/28/25 at 11:19 A.M., the Nurse Practitioner said nurses were expected to follow tube feeding and water flush orders as prescribed to prevent dehydration and lack of nutrition. During an interview on 5/28/25 at 12:57 P.M., the Director of Nursing said nurses were expected to follow physician orders as prescribed. Nurses should have checked the orders and called the dietitian to make sure Resident #17 was receiving the appropriate amount of water flushes.

Based on observation, interview, and record review, the facility failed to provide care and maintenance of a Peripherally Inserted Central Catheter (PICC: a flexible tube inserted through a vein in one's arm and passed through to the larger veins near the heart, used to deliver medications intravenously [IV] ), consistent with professional standards of practice for one Residents (#71), out of one Resident with a PICC Line. Specifically, for Resident #71, the facility failed to ensure that when the PICC line dressing was lifting (compromised), it was changed, and that the insertion site was able to be visualized. Findings include: Review of the Lippincott Manual of Nursing Practice, 11th Edition, dated 2021, included the following for documentation relative to PICC line assessment: Assess the catheter insertion site daily by inspection and palpation through the transparent semipermeable dressing to discern tenderness. Look at the catheter and cannula pathway, and check for bleeding, redness, drainage, and swelling. Review of the facility titled Peripheral and Midline IV Maintenance, dated 2/24, indicated This purpose of this procedure is to prevent complications associated with intravenous therapy. including catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings. 1. Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g., damp, loosened). 3. Change the dressing if it becomes damp, loosened or visibly soiled and: b. immediately if the dressing or site appears compromised. Resident #71 was admitted to the facility in April 2025 with diagnoses that included osteomyelitis of vertebra, intraspinal abscess, and low back pain. Review of Resident #71's Minimum Data Set (MDS) assessment, dated 4/9/25, indicated he/she scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident was cognitively intact. The MDS further indicated the Resident was receiving IV medications. On 5/27/25 at 8:05 A.M., the surveyor observed Resident #71 in bed with a PICC line in his/her left arm. The PICC line dressing was peeling off the skin and the insertion site was covered with gauze. The Resident said he/she has been applying tape to the dressing because it has been peeling off for days. On 5/27/25 at 11:59 A.M., the surveyor observed Resident #71 in bed with a PICC line in his/her left arm with IV antibiotics infusing. The PICC line dressing was peeling off the skin and the insertion site was covered with gauze. Review of Resident #71's PICC line care plan, dated 4/3/25, indicated Change the dressing at insertion site weekly and as needed. Observe the site of my PICC line each shift for infiltration and S/S (signs and symptoms) of infection. Review of Resident #71's physician order, dated 4/10/25, indicated PICC Dressing - Change every 7 days and PRN (as needed). Review of Resident #71's nursing progress note, dated 5/28/25, indicated PICC dressing left arm needed to be changed due to dressing edges loosening. On 5/28/25 at 11:15 A.M., Nurse #1 and the surveyor observed Resident #71's PICC Line dressing lifting around the edges and the insertion site was covered by gauze. Nurse #1 said the PICC line dressing needs to be changed immediately because the edges are lifting, and you are unable to see the insertion site so the nurses would not know if it is infected. During an interview on 5/29/25 at 9:55 A.M., The Director of Nursing (DON) said his expectation of the nurses are that they observe the PICC line every time they go into the Resident's room. The DON said he would expect the dressing to be changed immediately if it starts to lift off the skin as it puts the Resident at risk for infection and the insertion site should always be able to be visualized so nursing knows if the site is becoming infected.

Based on record review and interviews, the facility failed to assess and provide treatment for pain for one Resident (#7) with a diagnosis of acute pain due to trauma out of a total sample of 22 residents. Findings include: Review of the facility policy titled, Pain Assessment and Management, last revised 3/26/2009, indicated the following: -each resident has the right to expect a prompt, effective response to reports of pain. Therefore, it is the policy of this facility to: -To identify, assess and manage pain effectively and collaboratively with the interdisciplinary team. -To design a plan of care to achieve an optimal balance between pain relief and preservation of function, in accordance with the resident directed goals. Resident #7 was admitted to the facility in June 2021 with diagnoses including acute pain due to trauma, osteoporosis with pathological fracture of vertebra(e) (back bone) and muscle weakness. Review of Resident #7's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status score of 15 out of a possible 15 which indicated the Resident is cognitively intact. The MDS also indicated Resident #7 requires supervision for functional tasks. Review of Resident #7's MDS dated [DATE] indicated the Resident is on scheduled pain medication. Review of a grievance form dated 10/24/24, indicated the following grievance written by a staff member: Concern: -(The Resident) asked the 11-7 nurse (name) at 12am if (he/she) could have Tylenol for pain in (his/her) shoulders, hips and back. (The nurse) told (him/her) no because she didn't think (the Resident) was in pain. (The nurse) did not offer anything else to (the Resident) instead of the Tylenol. (The Resident) waited for the 7-3 shift to come in so (he/she) could ask again for something and at this point was in tears due to (his/her) pain. Action taken: -DON (Director of Nursing) spoke to nurse in question who reports that she gave Tylenol to (the Resident). Follow-up: -F/u (follow-up) when resident return(sic) from MLOA on 11/12/24. Resident didn't remember receiving dose/situation but reports enough time has passed that (he/she) is indifferent with resolution. Lyrica (pain medication) started upon readmission. At the time of this incident, Resident #7 had the following physician orders: -Pain evaluation: Document verbal/nonverbal signs of pain every shift, initiated on 3/29/23. -Meloxicam oral tablet (a nonsteroidal anti-inflammatory drug (NSAID) used to relieve pain, inflammation, and stiffness) 15 MG (milligrams). Give one tablet at bedtime for supplement, initiated on 5/20/24. -Tylenol tablet 325 MG give two tablets by mouth every 6 hours as needed for fever or pain, initiated 6/16/21. -May apply generic muscle rub to lower back and bilateral shoulders as needed for pain, initiated on 10/18/24. Review of the Medication Administration Report (MAR) for October 2024 indicated the following: -Resident #7 was assessed for pain on the shift the incident occurred by the nurse mentioned in the grievance, however there was no number scale used/reported for the pain and no nursing note. -Resident #7 did not receive any pain medication from the nurse listed in the grievance throughout the shift. -Resident #7 received Tylenol at 7:45 A.M., when the next nurse started the new shift and at this time the Resident's pain was assessed to be an 8 out of 10 on the pain assessment scale. Review of Resident #7's care plans failed to indicate a care plan for pain at the time of survey. The Nurse mentioned in the grievance form is no longer an employee of the facility and was unavailable for interview. During an interview 5/19/25 at approximately 8:30 A.M., Resident #7 said he/she did not remember this incident from October. Resident #7 said he/she does have pain at times and when he/she receives pain medication it helps. During an interview on 5/28/25 at 12:33 P.M., the Director of Nursing said if a resident is voicing pain, he would expect the nursing staff to assess the resident's pain level and if the resident has an order in place for an as needed pain medication he would expect the nursing staff to provide that medication. The Director of Nursing said if the pain medication is provided, this would be documented on the MAR and if not on the MAR he could not assume the medication was provided. The Director of Nursing said he does not fully remember the incident in October and reviewed the grievance form and the MAR with the surveyor. After review, the Director of Nursing said he could not recall ever seeing that the medication was never given and did not feel that the nurse adequately managed Resident #7's pain. During an interview on 5/28/25 at 11:19 A.M., Nurse Practitioner #1 said she is the provider for Resident #7 now, however, was not here in October. Nurse Practitioner #1 said she would expect people who are in pain to be medicated per physician orders.

Based on record review, policy review and interview the facility failed to notify the physician of a significant change in status for five Residents (#48, #79, #58, #9 and #60) out of a total sample of 26 residents. Specifically: -The facility failed to notify the physician or nurse practitioner when residents' blood glucose levels fell below parameters, or when insulin was held due to hypoglycemia. Findings include: Review of the facility policy Nursing Care of the Resident with Diabetes Mellitus (undated) indicated: -In type I (insulin-dependent diabetes mellitus) the body does not produce any significant amounts of insulin. -Normal blood glucose parameter is defined as 80-130 mg/dl (milligrams per deciliter) before meals and under 180 mg/dl after meals. -Conditions associated with diabetes include, but are not limited to, hypoglycemia, in which blood sugar levels are below the reference parameter, and hyperglycemia, in which blood sugar levels are above the reference parameter. Reference ranges for hypoglycemia are: -55-70 mg/dl, mild -40-55 mg/dl, moderate -Under 40 mg/dl, severe Symptoms associated with onset of hypoglycemia may include, but are not limited to: -Weakness -Increased heart rate -Blurred vision -Stupor (severe) -Unconsciousness (severe) -Convulsions (severe) -Coma (severe) Complications because of prolonged and poorly controlled diabetes include: -Heart disease -Kidney disease -Nerve, foot, and skin damage. For asymptomatic and responsive residents with hypoglycemia (under 70 mg/dl, or less than the physician-ordered parameter) the protocol requires, but is not limited to: -Nursing staff should document findings, notification to MD and any new orders given in progress note. Review of the facility's quality control log for blood glucometer readings dated March, April, May, and June 2024 indicated there were no significant variances and that the facility's glucometers were accurate and functioned normally. Findings include: 1. Resident #9 was admitted to the facility in October 2022, and had diagnoses which included type II diabetes mellitus, hypertension, and dementia. Review of Resident #9's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated a Brief Interview for Mental Status examination score of 3 out of a possible 15, indicating severe cognitive impairment. Resident #9 was dependent on staff for most activities of daily living. Resident #9's current care plan indicated he/she was diagnosed with diabetes mellitus and was at-risk for: difficulty controlling blood glucose levels, skin breakdown, nutritional problems, generalized pain, neuropathy, and retinopathy (nerve damage). Interventions included, but were not limited to: -Follow the hypoglycemic protocol as indicated. See Medication Administration Record (MAR). Review of Resident #9's MARs dated May and June 2024, indicated a physician's order dated 5/13/24, Basaglar KwikPen subcutaneous solution pen-injector 100 units per milliliter insulin glargine (a long acting insulin) inject 20 units subcutaneously at bedtime for type II diabetes. Hold if BS [blood sugar] less than 150. The MAR indicated on the following dates nursing staff failed to notify the physician or nurse practitioners (NP) that the Resident's blood glucose level was below 150, per facility policy. -5/14/24 at 8:11 P.M., glucose level 137. Review of the MAR and nursing progress notes indicated there was no physician or NP notification regarding the glucose level below 150. -5/15/24 at 8:53 P.M., blood glucose 144. Review of the MAR and nursing progress notes indicated there was no physician or NP notification regarding the glucose level below 150. -5/17/24 at 7:17 P.M., blood glucose 117. Review of the MAR and nursing progress notes indicated there was no physician or NP notification regarding the glucose level below 150. -5/25/24 at 8:16 P.M., blood glucose 138. Review of the MAR and nursing progress notes indicated there was no physician or NP notification regarding the glucose level below 150. -5/27/25 at 7:59 P.M., blood glucose 110. Review of the MAR and nursing progress notes indicated there was no physician or NP notification regarding the glucose level below 150. -6/2/24 at 8:26 P.M., blood glucose 71. Review of the MAR and nursing progress notes indicated there was no physician or NP notification regarding the glucose level below 150. -6/4/24 at 7:53 P.M., blood glucose 31 (severe). Review of the MAR and nursing progress notes indicated there was no physician or NP notification regarding the glucose level below 150. -6/10/24 at 9:29 P.M., blood glucose 147. Review of the MAR and nursing progress notes indicated there was no physician or NP notification regarding the glucose level below 150. -6/16/24 at 7:38 P.M., blood glucose 94. Review of the MAR and nursing progress notes indicated there was no physician or NP notification regarding the glucose level below 150. Resident #9's MARs dated May and June 2024 indicated a physician's order dated 6/16/23 to notify provider if blood glucose is below 70. The Resident's MAR and progress notes make no reference to nursing staff notifying the provider on the following dates: -5/13/24 at 7:30 A.M. blood glucose 65 -5/13/24 at 11:30 A.M., blood glucose 56 -5/30/24 at 4:30 P.M., blood glucose 69 -6/4/24 at 7:53 P.M., blood glucose 31 (severe). Review of Resident #9's Nurse Practitioner (NP) and physician progress notes dated May and June 2024 did not reference his/her low blood glucose levels, and levels outside the ordered parameters. On 6/17/24 at approximately 9:00 A.M., the surveyor attempted to contact Nurse #5 regarding her failure to notify the physician or NP about Resident #9's low blood glucose levels on 5/14/24, 5/17/24, 5/27/24 and 6/4/24. Nurse #5 did not respond to voice mail messages or texts. During an interview with Nurse #8 on 6/17/24 at approximately 2:10 P.M., regarding Resident #9's low glucose levels on 5/15/24, 5/17/24, 6/10/24 and 6/16/24, she said she did not notify the physician or NP. On 6/17/24 at approximately 10:40 A.M., the surveyor attempted to contact Nurse #9 regarding Resident #9's low glucose level on 5/25/24. Nurse #9 did not respond to voice mail messages or texts. During an interview with Nurse #6 on 6/17/24 at approximately 3:05 P.M., regarding Resident #9's low blood glucose level on 6/2/24. Nurse #6 said she did not notify the physician or NP. During an interview with Unit Manager #1 on 6/14/24 at approximately 11:00 A.M., regarding Resident #9's low blood glucose levels on 5/13/24 at 7:30 A.M. and 11:30 A.M., or on 5/30/24. Unit Manager #1 said she did not notify the physician or NP. During an interview with the Director of Nursing (DON) on 6/13/24 at 10:20 A.M., he said nursing staff should have followed Resident #9's physician's orders and the facility's hypoglycemic protocol. The DON reviewed the Resident's MAR for May and June 2024 and said nursing staff should have notified the physician or NP on those dates when the Resident's blood glucose was low. The DON said the Resident's blood glucose level of 31 on 6/4/24 was critically low. During an interview with the Medical Director on 6/14/24 at 11:37 A.M., she said nursing staff should follow the physician's orders and the hypoglycemic protocol for insulin-dependent diabetics. The Medical Director said that when a resident's blood glucose is under 70 nursing staff should give carbohydrates, notify the physician, monitor, and document responses to interventions. The Medical Director said that blood glucose levels below 50 are critical and the resident would likely need to be hospitalized for treatment and testing to determine if an underlying infection has caused hypoglycemia. The Medical Director said short term effects of critically low blood glucose levels can include hypoglycemic coma and death. The Medical Director said long term effects of untreated hypoglycemia include heart disease, kidney disease, neuropathy, nerve damage to the eyes and generalized weakness. 2. Resident #79 was admitted to the facility in August 2023, and had diagnoses which included type II diabetes mellitus, renal failure, hypertension, and dementia. Review of Resident #79's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated a Brief Interview for Mental Status examination score of 9 out of a possible 15, indicating moderate cognitive impairment. Resident #79 was dependent on staff for most activities of daily living. Review of Resident #79's current care plan indicated he/she had a diagnosis of diabetes and had difficulty controlling his/her blood glucose level. Interventions included: -Give me diabetic medication per my doctor's orders. -Follow the hypoglycemic protocol as indicated. See MAR. Review of Resident #79's physician order dated 11/30/23, indicated Humalog injection solution (insulin Lispro). Inject as per sliding scale. Review of Resident #79's MAR dated March 2024 indicated that on 3/21/24 at 10:35 P.M., his/her blood glucose was 15 (severe). There is no indication on either the MAR or progress notes that nursing staff notified the physician or NP about the Resident's severely low blood glucose level. Review of Resident #79's Nurse Practitioner (NP) and physician progress notes dated March, April and June 2024 did not reference the blood glucose level of 15. During an interview on 6/17/24 at approximately 2:10 P.M. with Nurse #10, she said the entry on Resident #79's MAR dated 3/21/24 of 15 must have been a typo. Nurse #10 said she did not notify the physician or NP. 3. Resident #48 was admitted to the facility in March 2024 and had diagnoses which included diabetes, hypertension, and cerebral vascular accident. Review of Resident #48's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated a Brief Interview for Mental Status examination score of 8 out of a possible 15, indicating moderate cognitive impairment. Resident #48 was dependent on staff for most activities of daily living. Review of Resident #48's current care plan indicated he/she had a diagnosis of diabetes and difficulty controlling his/her blood glucose level. Interventions included: -Give me diabetic medication per my doctor's orders. -Follow the hypoglycemic protocol as indicated. See me MAR. Review of Resident #48's physician's order dated 4/12/24 indicated Insulin lispro injection solution 100 units/milliliter. Inject as per sliding scale. Review of Resident #48's MAR dated May 2024 indicated that on 5/6/24 at approximately 4:00 P.M., his/her blood glucose level was 19 (severe). The MAR and progress notes indicated Nurse #12 did not notify the physician or NP about the Resident's severely low blood glucose level. Review of Resident #48's Nurse Practitioner (NP) and physician progress notes dated May and June 2024 did not reference the blood glucose level of 19. During an interview on 6/17/24 at approximately 1:10 P.M. with Nurse #12, she said she did not notify the physician or NP about the Resident's severely low blood glucose level. 4. Resident #58 was admitted to the facility in December 2023, and had diagnoses which included diabetes and hypertension. Review of Resident #58's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated a Brief Interview for Mental Status examination score of 15 out of a possible 15, indicating intact cognition. Resident #58 requires some assistance for most activities of daily living. Review of Resident #58's current care plan indicated he/she had a diagnosis of diabetes and difficulty controlling his/her blood glucose level. Interventions included: -Give me diabetic medication per my doctor's orders. -Follow the hypoglycemic protocol as indicated. See MAR. Review of Resident #58's physician's order dated 11/9/23, indicated Insulin lispro injection solution 100 units/milliliter. Inject as per sliding scale. Review of Resident #58's MAR dated April 2024 indicated that on 4/8/24 at approximately 11:00 A.M., his/her blood glucose level was 67, and on 4/9/24 at approximately 11:00 A.M. the blood glucose level was 66. The MAR and progress notes indicated nursing staff did not notify the physician regarding the Resident's low blood glucose level. Review of Resident #58's physician and NP progress notes dated April and May 2024 indicated they did not reference the Resident's low blood glucose levels on 4/8/24 and 4/9/24. On 6/17/24 at approximately 2:00 P.M., the surveyor attempted to contact Nurse #11 regarding Resident #58's blood glucose levels on 4/8/24 of 67, and of 66 on 4/9/24. Nurse #11 did not respond to voicemail messages or texts. 49880 5. Resident #60 was admitted to the facility in October 2023 with diagnoses that include type II diabetes, dementia, and obesity. Review of Resident #60's Minimum Data Set (MDS) assessment, dated 4/24/24, indicated a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating that the Resident has moderate cognitive impairment. The MDS further indicated that the Resident received insulin injections and hypoglycemic medication. According to the Centers for Disease Control (CDC), dated 5/14/24, a normal hemoglobin A1C level is below 5.7. Review of Resident #60's medical record indicated a hemoglobin A1C (a blood test that shows the average blood sugar level over the past two to three months) result of 8.0 on 3/25/24, indicating an elevated level. Review of Resident #60's physician's orders indicated the following: -Lantus Solution (a long-acting insulin) 25 units subcutaneously at bedtime, dated 10/31/23. -Humalog injection, give 3 units subcutaneously before meals, dated 12/5/23. -Humalog injection (a fast-acting insulin) inject as per sliding scale before meals and at bedtime -Blood sugar is 151-200 give 2 units of insulin -Blood sugar is 201-250 give 4 units of insulin -Blood sugar is 251-300 give 6 units of insulin -Blood sugar is 301-350 give 8 units of insulin -Blood sugar is 351-400 give 10 units of insulin -Call MD/NP (Physician/ Nurse Practitioner) if blood sugar over 400, dated 12/5/23. Review of Resident #60's active diabetes care plan, dated 11/15/23, indicated because I have diabetes, I am at risk for having difficulty controlling my blood sugars with interventions that include the following: -Follow the hypoglycemic protocol as indicated. See my MAR (medication administration record). -Watch me for signs of hypo/hyperglycemia (low and high blood sugars). Review of Resident #60's MAR failed to indicate orders for the facility's hypoglycemic protocol. Review of Resident #60's eMAR (electronic medication administration record) progress notes indicated the following: -A progress note dated 4/24/24 at 8:12 A.M., indicated that Resident #60 had a blood sugar of 77 and scheduled Humalog insulin was held. The progress note failed to indicate that a Physician or Nurse Practitioner (NP) was notified that the medication was not administered. -A progress note dated 5/2/24 at 4:03 P.M., triggered from the MAR indicated that Humalog insulin was not administered before dinner. The documented blood sugar at that time was 103, and the MAR documentation indicated the medication was not administered. Progress notes failed to indicate that a Physician or NP were notified that the medication was not administered. -A progress note dated 5/6/24 at 10:05 A.M., triggered from the MAR indicated that Humalog insulin was not administered. The documented blood sugar at the time was 92, and the MAR documentation indicated the medication was not administered. Progress notes failed to indicate that a Physician or NP were notified that the medication was not administered. -A progress note dated 5/12/24 at 11:57 A.M., indicated that Resident #60 had a blood sugar of 87 and that the scheduled dose of Humalog insulin at that time was held. The MAR indicated that the medication was not given. The progress notes failed to indicate that a Physician or NP were notified that the medication was not administered. -A progress note dated 5/22/24 at 7:48 A.M., indicated that Resident #60 had a blood sugar of 74 and that the scheduled dose of Humalog insulin was held at this time. The MAR indicated that the medication was not given. The progress notes failed to indicate that a Physician or NP were notified that the medication was not administered. -A progress note dated 5/23/24 at 7:56 A.M., indicated that Resident #60 had a blood sugar of 109 and that Humalog insulin was not administered. Progress notes failed to indicate that the Physician or NP were notified that the medication was not administered. -A progress note dated 5/24/24 at 4:25 P.M., indicated that Resident #60 had a blood sugar of 100 and per the MAR, the scheduled Humalog insulin was held. Progress notes failed to indicate that a Physician or NP were notified that the medication was not administered. -A progress note dated 5/24/24 at 8:12 P.M., indicated that Resident #60 had a blood sugar of 111. Review of the MAR at this time indicated that scheduled Lantus insulin was not administered. Progress notes failed to indicate that a Physician or NP were notified that the medication was not administered. -A progress note dated 5/29/24 at 7:47 A.M., indicated that Resident #60 had a blood sugar of 77 and that the scheduled dose of Humalog insulin was not administered. Review of progress notes failed to indicate that a Physician or NP were notified that the medication was not administered. -A progress note dated 6/4/24 at 7:55 A.M., indicated that Resident #60 had a blood sugar of 81 and that the scheduled dose of Humalog insulin was not administered. Progress notes failed to indicate that a Physician or NP were notified that the medication was not administered. -A progress note dated 6/17/14 at 7:51 A.M., indicated that Resident #60 had a blood sugar of 111 and that the scheduled dose of Humalog insulin was not administered. Progress notes failed to indicate that a Physician or NP were notified that the medication was not administered. Review of Resident #60's blood sugar readings indicated the following: -On 4/26/24 at 5:36 P.M., a blood glucose reading of 48 and at 5:55 P.M., a blood glucose reading of 57. On 4/26/24 at 7:32 P.M., and at 11:35 P.M., blood sugars levels of 74 were documented. Review of nursing progress notes on 4/26/24 indicated that orange juice was provided to the resident, but failed to indicate that a Physician or NP was notified of the hypoglycemic episode. Review of NP progress and visit notes dated from 4/26/24 to 5/29/24 failed to indicate that she was aware that insulin was being held at times for Resident #60. During an interview on 6/17/24 at 12:41 P.M., Nurse #1 said that he is assigned to care for Resident #60. He said that before breakfast Resident #60 had a blood sugar of 111, so he held his/her 3 units of Humalog insulin. Nurse #1 said that he did not have orders to hold it and that the Resident was not symptomatic of low blood sugars. Nurse #1 further said that he did not notify the Physician or NP that the medication was held. Nurse #1 said that a Physician or NP should be notified if a medication is held either due to parameters or nursing judgement and that it should be documented in a progress note. During an interview on 6/17/24 at 1:53 P.M., Unit Manager #1 said that if a nurse feels that a Resident's blood sugar is too low for insulin they will hold it, but that a Physician or NP should be notified. During an interview on 6/17/24 at 12:24 P.M., NP #1 said that she is rarely notified by the facility of low blood sugars for residents. NP #1 also said that if nursing staff provided an intervention for low blood sugars or if scheduled insulin was being held by the nurse she would expect to be notified. NP #1 said that the current order for Humalog insulin for Resident #60 does not have hold parameters, so if a nurse was holding it, she should be notified. She said she was not aware that the insulin was held before breakfast on 6/17/24 for Resident #60 and would not have recommended that it be held. NP #1 said that she assumes that all medications are administered as ordered unless she is told otherwise. NP #1 said that not being notified that medications are held could lead to her over or under dosing a resident with insulin or other medications. During an interview on 6/18/24 at 9:35 A.M., the Director of Nurses said that nurses can hold medications per parameters of the order or for nursing judgment, but if the medication is held the Physician or NP should be made aware and it should be documented in a progress note. During an interview with the Medical Director on 6/14/24 at 11:37 A.M., she said nursing staff should follow the physician's orders and the hypoglycemic protocol for insulin-dependent diabetics. The Medical Director said that when a resident's blood glucose is under 70 nursing staff should notify the physician or NP. The Medical Director said that blood glucose levels below 50 are critical and the resident would likely need to be hospitalized for treatment and testing to determine if an underlying infection caused the hypoglycemia. The Medical Director said short term effects of critically low blood glucose levels can include hypoglycemic coma and death. The Medical Director said long term effects of untreated hypoglycemia include heart disease, kidney disease, neuropathy, nerve damage to the eyes and generalized weakness. Refer to F684 and F726

Based on record review, policy review and interview for 5 residents (#48, #79, #58, #9 and #60) out of a total sample of 26 residents, the facility failed to ensure it administered insulin to residents diagnosed with diabetes, according to physician orders and facility policy. Specifically: 1. The facility failed to follow physician orders for when to give or hold insulin based on blood glucose levels. 2. The facility failed to follow its policy and procedures for hypoglycemia and hyperglycemia. Findings include: According to the Merk Manual Professional Version (revised October 2023) a plasma glucose level of less than 70 mg/dL (milligrams per deciliter), in patients treated with glucose-lowering medications such as insulin, is considered hypoglycemia and should be treated to avoid a further decrease in blood glucose and consequences of hypoglycemia. Review of the facility policy Nursing Care of the Resident with Diabetes Mellitus (undated) indicated: -In type I (insulin-dependent diabetes mellitus) the body does not produce any significant amounts of insulin. -Normal blood glucose parameter is defined as 80-130 mg/dl before meals and under 180 mg/dl after meals. -Conditions associated with diabetes include, but are not limited to, hypoglycemia, in which blood sugar levels are below the reference parameter, and hyperglycemia, in which blood sugar levels are above the reference parameter. -The nurse will closely monitor the diabetes management of cognitively impaired residents. Reference ranges for hypoglycemia are: -55-70 mg/dl, mild -40-55 mg/dl, moderate -Under 40 mg/dl, severe Symptoms associated with onset of hypoglycemia may include, but are not limited to: -Weakness -Increased heart rate -Blurred vision -Stupor (severe) -Unconsciousness (severe) -Convulsions (severe) -Coma (severe) Complications because of prolonged and poorly controlled diabetes include: -Heart disease -Kidney disease -Nerve, foot, and skin damage. For asymptomatic and responsive residents with hypoglycemia (under 70 mg/dl, or less than the physician-ordered parameter) the protocol requires nursing staff to: -Give the resident an oral form of rapidly absorbed glucose (juice or soda). -Recheck blood glucose in 15 minutes. -If blood glucose is over 130 mg/dl administer diabetic medications. -If blood glucose if under 70 mg/dl repeat oral glucose and recheck blood glucose in 15 minutes; or, -If no improvement, notify physician for further orders. -Document findings, notification to MD and any new orders given in progress note. The healthcare provider may designate an individualized parameter for hypoglycemia based on the resident's history of glycemic control. If so, use this number (along with clinical symptoms) to determine whether intervention with oral glucose is necessary. The facility's hypoglycemia protocol indicated documentation should reflect the carefully assessed diabetic resident and include, but is not limited to the following: -Level of consciousness -Assessment of the skin -Emotional reactions, moods -Assessment of pain -Motor weakness -Urinary symptoms -Bowel dysfunction -Blood pressure -Blood glucose results Review of the facility's quality control log for blood glucometer readings dated March, April, May, and June 2024 indicated there were no significant variances and that the facility's glucometers were accurate and functioned normally. Findings include: 1. Resident #9 was admitted to the facility in October 2022, and had diagnoses which included type II diabetes mellitus, hypertension, and dementia. Review of Resident #9's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated a Brief Interview for Mental Status examination score of 3 out of a possible 15, indicating severe cognitive impairment. Resident #9 was dependent on staff for most activities of daily living. Resident #9's current care plan indicated he/she was diagnosed with diabetes mellitus and was at-risk for: difficulty controlling blood glucose levels, skin breakdown, nutritional problems, generalized pain, neuropathy, and retinopathy (nerve damage). Interventions included, but were not limited to: -Give me diabetic medication per my doctor's orders. -Follow the hypoglycemic protocol as indicated. See Medication Administration Record (MAR). -Watch me for signs of hypoglycemia and hyperglycemia. Review of Resident #9's MARs dated May and June 2024, indicated a physician's order dated 5/13/24, Basaglar KwikPen subcutaneous solution pen-injector 100 units per milliliter insulin glargine (a long acting insulin) inject 20 units subcutaneously at bedtime for type II diabetes. Hold if BS [blood sugar] less than 150. The MAR indicated on the following dates nursing staff failed to follow the physician's orders and incorrectly administered insulin glargine when blood glucose levels were less than 150 mg/dl. -5/14/24 at 8:11 P.M., glucose level 137. The MAR indicated Nurse #5 attempted to administer 20 units of insulin glargine, but Resident #9 refused. The MAR also indicated that at this same time Nurse #5 administered 20 units of insulin glargine into the abdomen, contrary to the orders. -5/15/24 at 8:53 P.M., blood glucose 144. The MAR indicated Nurse #8 administered 20 units of insulin glargine, contrary to the orders. -5/17/24 at 7:17 P.M., blood glucose 117. The MAR indicated Nurse #5 administered 20 units of insulin glargine, contrary to the orders. -5/25/24 at 8:16 P.M., blood glucose 138. The MAR indicated Nurse #9 administered 20 units of insulin glargine, contrary to the orders. -5/27/25 at 7:59 P.M., blood glucose 110. The MAR indicated Nurse #5 administered 20 units of insulin glargine, contrary to the orders. -6/2/24 at 8:26 P.M., blood glucose 71. The MAR indicated Nurse #6 administered 20 units of insulin glargine, contrary to the orders. -6/4/24 at 7:53 P.M., blood glucose 31 (severe). The MAR indicated Resident #9 refused the dose of insulin glargine. The MAR also indicated that at this same time Nurse #5 administered 20 units of insulin glargine into Resident #9's abdomen, contrary to orders. -6/10/24 at 9:29 P.M., blood glucose 147. The MAR indicated Nurse #8 administered 20 units of insulin glargine, contrary to the orders. -6/16/24 at 7:38 P.M., blood glucose 94. The MAR indicated Nurse #8 administered 20 units of insulin glargine, contrary to the orders. Resident #9's MARs dated May and June 2024 indicated a physician's order dated 6/16/23, If FSBG [finger stick blood glucose] is less than or equal to 70 and Resident is responsive and able and willing to swallow, treat with 15-20 grams of carbohydrates and assess response. Recheck FSBG in 15 minutes (4-6 ounces of orange juice) every 15 minutes as needed related to type II diabetes mellitus with hyperglycemia. If FSBG is still less than or equal to 70, retreat by mouth (4-6 ounces of orange juice). If FSBG is greater than 70, monitor resident and offer a snack within 30 minutes. Notify provider. The MAR indicated on the following dates nursing staff failed to follow the physician's orders and the hypoglycemic protocol for treatment of blood glucose levels less than 70. The Resident's MAR and progress notes make no reference to nursing staff giving carbohydrates, rechecking blood glucose levels, or notifying the provider on the following dates: -5/13/24 at 7:30 A.M. blood glucose 65, obtained by Unit Manager #1 -5/13/24 at 11:30 A.M., blood glucose 56, obtained by Unit Manager #1 -5/30/24 at 4:30 P.M., blood glucose 69, obtained by Unit Manager #1 -6/4/24 at 7:53 P.M., blood glucose 31 (severe), obtained by Nurse #5. Resident #9's MAR dated May 2024 and June 2024, indicated a physician's order dated 6/16/23, Assess and monitor Resident response to hypoglycemic treatment as needed as related to type II diabetes mellitus with hyperglycemia. Nursing progress notes and the MARs indicated nursing staff failed to document that any interventions or monitoring occurred when the Resident's blood glucose was below 70 on 5/13/24, 5/30/24 and 6/4/24. Review of Resident #9's Nurse Practitioner (NP) and physician progress notes dated June 2024 did not reference the blood glucose level of 31 obtained on 6/4/24. On 6/17/24 at approximately 9:00 A.M., the surveyor attempted to contact Nurse #5 regarding her administration of insulin and failure to follow the hypoglycemic protocol for Resident #9 on 5/14/24, 5/17/24, 5/27/24 and 6/4/24. Nurse #5 did not respond to voicemail messages or texts. During an interview on 6/17/24 at approximately 2:10 P.M., Nurse #8 said that on 5/15/24, 5/17/24, 6/10/24 and 6/16/24, she made an error by administering insulin to the Resident when his/her blood glucose was below the parameter set by the physician. On 6/17/24 at approximately 10:40 A.M., the surveyor attempted to contact Nurse #9 regarding her administration of insulin to Resident #9 on 5/25/24. Nurse #5 did not respond to voicemail messages or texts. During an interview on 6/17/24 at approximately 3:05 P.M., Nurse #6 said she must have made an error when administering insulin to Resident #9 on 6/2/24 because the blood glucose level was below the parameter set by the physician. During an interview on 6/14/24 at approximately 11:00 A.M., Unit Manager #1 said she did not recall Resident #9's hypoglycemic episodes on 5/13/24 and 5/30/24. Unit Manager #1 said she did not recall that Resident #9 had low blood glucose levels on these dates, but that if Resident #9 was hypoglycemic she would have offered orange juice. Unit Manager #1 said she did not recall the facility's hypoglycemic protocol, which included retaking blood glucose levels after giving carbohydrates, and documenting the encounter on the MAR and progress notes. During an interview on 6/13/24 at 10:20 A.M., the Director of Nursing (DON) said nursing staff should have followed Resident #9's physician's orders and the facility's hypoglycemic protocol. The DON reviewed the Resident's MAR for May and June 2024 and said nursing staff should have held the insulin glargine on the dates when the Resident's blood glucose was below 150. The DON said that nursing staff should have followed physician orders, and notified the physician on those dates when the Resident's blood glucose was below 70. The DON said the Resident's blood glucose level of 31 on 6/4/24 was critically low. During an interview on 6/14/24 at 11:37 A.M., the Medical Director said nursing staff should follow the physician's orders and the hypoglycemic protocol for insulin-dependent diabetics. The Medical Director said that when a resident's blood glucose is under 70 nursing staff should give carbohydrates, notify the physician, monitor and document responses to interventions. The Medical Director said that blood glucose levels below 50 are critical and the resident would likely need to be hospitalized for treatment and testing to determine if an underlying infection has caused hypoglycemia. The Medical Director said short term effects of critically low blood glucose levels can include hypoglycemic coma and death. The Medical Director said long term effects of untreated hypoglycemia include heart disease, kidney disease, neuropathy, nerve damage to the eyes and generalized weakness. 2. Resident #79 was admitted to the facility in August 2023, and had diagnoses which included type II diabetes mellitus, renal failure, hypertension, and dementia. Review of Resident #79's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated a Brief Interview for Mental Status examination score of 9 out of a possible 15, indicating moderate cognitive impairment. Resident #79 was dependent on staff for most activities of daily living. Review of Resident #79's current care plan indicated he/she had a diagnosis of diabetes and had difficulty controlling his/her blood glucose level. Interventions included: -Give me diabetic medication per my doctor's orders. -Follow the hypoglycemic protocol as indicated. See MAR. Review of Resident #79's physician order dated 11/30/23, indicated Humalog injection solution (insulin Lispro). Inject as per sliding scale. Review of Resident #79's MAR dated March 2024 indicated that on 3/21/24 at 10:35 P.M., his/her blood glucose was 15 (severe). There was no indication on either the MAR or progress notes that nursing staff initiated the hypoglycemic protocol or notified the physician regarding the Resident's severely low blood glucose level. Review of Resident #9's Nurse Practitioner (NP) and physician progress notes dated March, April and June 2024 did not reference the blood glucose level of 15 obtained on 3/21/24. During an interview on 6/17/24 at approximately 2:10 P.M., Nurse #10, said the entry on Resident #79's MAR dated 3/21/24 of 15 must have been a typo. Nurse #10 said that if Resident #79's blood sugar was 15 she would have initiated the hypoglycemic protocol and notified the physician. 3. Resident #48 was admitted to the facility in March 2024 and had diagnoses which included diabetes, hypertension, and cerebral vascular accident. Review of Resident #48's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated a Brief Interview for Mental Status examination score of 8 out of a possible 15, indicating moderate cognitive impairment. Resident #48 was dependent on staff for most activities of daily living. Review of Resident #48's current care plan indicated he/she had a diagnosis of diabetes and difficulty controlling his/her blood glucose level. Interventions included: -Give me diabetic medication per my doctor's orders. -Follow the hypoglycemic protocol as indicated. See me MAR. Review of Resident #48's physician's order dated 4/12/24 indicated Insulin lispro injection solution 100 units/milliliter. Inject as per sliding scale. Review of Resident #48's MAR dated May 2024 indicated that on 5/6/24 at approximately 4:00 P.M., his/her blood glucose level was 19 (severe). The MAR and progress notes indicated Nurse #12 did not initiate the hypoglycemic protocol or notify the physician regarding the Resident's severely low blood glucose level. The code on the MAR (#9) indicated see progress notes. Review of the 5/6/24 nursing progress notes did not reference the blood glucose level of 18, or initiating the hypoglycemic protocol, or notifying the physician. Review of Resident #48's Nurse Practitioner (NP) and physician progress notes dated May and June 2024 did not reference the blood glucose level of 19 obtained on 5/6/24. During an interview on 6/17/24 at approximately 1:10 P.M., Nurse #12 said the entry on Resident #48's MAR dated 5/6/24 of 19 must have been a typo. Nurse #12 said that if Resident #48's blood sugar was 19 she would have initiated the hypoglycemic protocol and notified the physician. 4. Resident #58 was admitted to the facility in December 2023, and had diagnoses which included diabetes and hypertension. Review of Resident #58's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated a Brief Interview for Mental Status examination score of 15 out of a possible 15, indicating intact cognition. Resident #58 requires some assistance for most activities of daily living. Review of Resident #58's current care plan indicated he/she had a diagnosis of diabetes and difficulty controlling his/her blood glucose level. Interventions included: -Give me diabetic medication per my doctor's orders. -Follow the hypoglycemic protocol as indicated. See MAR. Review of Resident #58's physician's order dated 11/9/23, indicated Insulin lispro injection solution 100 units/milliliter. Inject as per sliding scale. Review of Resident #58's MAR dated April 2024 indicated that on 4/8/24 at approximately 11:00 A.M., his/her blood glucose level was 67, and on 4/9/24 at approximately 11:00 A.M. the blood glucose level was 66. The MAR and progress notes indicated nursing staff did not initiate the hypoglycemic protocol or notify the physician regarding the Resident's low blood glucose level. Review of Resident #58's physician progress note dated 4/15/24 does not reference his/her hypoglycemic events on 4/8/24 and 4/9/24. On 6/17/24 at approximately 2:00 P.M., the surveyor attempted to contact Nurse #11 regarding Resident #58's blood glucose level on 4/8/24 of 67, and his/her blood glucose level of 66 on 4/9/24. Nurse #11 did not respond to voicemail messages or texts. 49880 5. Resident #60 was admitted to the facility in October 2023 with diagnoses that include type 2 diabetes, dementia, and obesity. Review of Resident #60's Minimum Data Set (MDS) Assessment, dated 4/24/24, indicated a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating that the Resident had moderate cognitive impairment. The MDS further indicated that the Resident received insulin injections and hypoglycemic medication. According to the Centers for Disease Control (CDC), dated 5/14/24, a normal hemoglobin A1C level is below 5.7 Review of Resident #60's medical record indicated a hemoglobin A1C (a blood test that shows the average blood sugar level over the past two to three months) result of 8.0 on 3/25/24, indicating an elevated level. Review of Resident #60's physician's orders indicated the following: -Lantus Solution (a long-acting insulin) 25 units subcutaneously at bedtime, dated 10/31/23. -Humalog injection, give 3 units subcutaneously before meals, dated 12/5/23. -Humalog injection (a fast-acting insulin) inject as per sliding scale before meals and at bedtime: -Blood sugar is 151-200 give 2 units of insulin, -Blood sugar is 201-250 give 4 units of insulin -Blood sugar is 251-300 give 6 units of insulin -Blood sugar is 301-350 give 8 units of insulin -Blood sugar is 351-400 give 10 units of insulin -Call MD/NP (Physician/ Nurse Practitioner) if blood sugar over 400, dated 12/5/23. Review of Resident #60's active diabetes care plan, dated 11/15/23, indicated because I have diabetes, I am at risk for having difficulty controlling my blood sugars with interventions that include the following: -Follow the hypoglycemic protocol as indicated. See my MAR (medication administration record). -Watch me for signs of hypo/hyperglycemia (low and high blood sugars). Review of Resident #60's MARs dated April, May and June 23, 2024 failed to indicate orders for the facility's hypoglycemic protocol. Review of Resident #60's eMAR (electronic medication administration record) progress notes indicated the following: -A progress note dated 4/24/24 at 8:12 A.M., indicated that Resident #60 had a blood sugar of 77 and scheduled Humalog insulin was held. The progress note failed to indicate that a Physician or Nurse Practitioner (NP) were notified that the medication was not administered. -A progress note dated 5/2/24 at 4:03 P.M., triggered from the MAR indicated that Humalog insulin was not administered before dinner. The documented blood sugar at that time was 103, and the MAR documentation indicated the medication was not administered. Progress notes failed to indicate that a Physician or NP were notified that the medication was not administered. -A progress note dated 5/6/24 at 10:05 A.M., triggered from the MAR indicated that Humalog insulin was not administered. The documented blood sugar at the time was 92, and the MAR documentation indicated the medication was not administered. Progress notes failed to indicate that a Physician or NP were notified that the medication was not administered. -A progress note dated 5/12/24 at 11:57 A.M., indicated that Resident #60 had a blood sugar of 87 and that the scheduled dose of Humalog insulin at that time was held. The MAR indicated that the medication was not given. The progress notes failed to indicate that a Physician or NP were notified that the medication was not administered. -A progress note dated 5/22/24 at 7:48 A.M., indicated that Resident #60 had a blood sugar of 74 and that the scheduled dose of Humalog insulin was held at this time. The MAR indicated that the medication was not given. The progress notes failed to indicate that a Physician or NP were notified that the medication was not administered. -A progress note dated 5/23/24 at 7:56 A.M., indicated that Resident #60 had a blood sugar of 109 and that Humalog insulin was not administered. Progress notes failed to indicate that the Physician or NP were notified that the medication was not administered. -A progress note dated 5/24/24 at 4:25 P.M., indicated that Resident #60 had a blood sugar of 100 and per the MAR, the scheduled Humalog insulin was held. Progress notes failed to indicate that a Physician or NP were notified that the medication was not administered. -A progress note dated 5/24/24 at 8:12 P.M., indicated that Resident #60 had a blood sugar of 111. Review of the MAR at this time indicated that scheduled Lantus insulin was not administered. Progress notes failed to indicate that a Physician or NP were notified that the medication was not administered. -A progress note dated 5/29/24 at 7:47 A.M., indicated that Resident #60 had a blood sugar of 77 and that the scheduled dose of Humalog insulin was not administered. Review of progress notes failed to indicate that a Physician or NP were notified that the medication was not administered. -A pro progress note dated 6/4/24 at 7:55 A.M., indicated that Resident #60 had a blood sugar of 81 and that the scheduled dose of Humalog insulin was not administered. Progress notes failed to indicate that a Physician or NP were notified that the medication was not administered. -A progress note dated 6/17/14 at 7:51 A.M., indicated that Resident #60 had a blood sugar of 111 and that the scheduled dose of Humalog insulin was not administered. Progress notes failed to indicate that a Physician or NP were notified that the medication was not administered. Review of Resident #60's blood sugar readings indicated the following: On 4/26/24 at 5:36 P.M., a blood glucose reading of 48 and at 5:55 P.M., a blood glucose reading of 57. On 4/26/24 at 7:32 P.M., and at 11:35 P.M., blood sugars levels of 74 were documented. Review of nursing progress notes on 4/26/24 indicated that orange juice was provided to the resident, but failed to indicate that a Physician or Nurse Practitioner was notified of the hypoglycemic episode . Review of the Nurse Practitioner progress and visit notes dated from 4/26/24 to 5/29/24 failed to indicate that she was aware that insulin was being held at times for Resident #60. During an interview on 6/17/24 at 12:41 P.M., Nurse #1 said that he was assigned to care for Resident #60. He said that before breakfast Resident #60 had a blood sugar of 111, so he held his/her 3 units of Humalog insulin. Nurse #1 said that he did not have orders to hold it and that the Resident was not symptomatic of low blood sugars. Nurse #1 further said that he did not notify the Physician or NP that the medication was held. Nurse #1 said that a Physician or NP should be notified if a medication is held either due to parameters or nursing judgement and that it should be documented in a progress note. During an interview on 6/17/24 at 1:53 P.M., Unit Manager #1 said that if a nurse feels that a Resident's blood sugar is too low for insulin they will hold it, but that a Physician or NP should be notified. During an interview on 6/17/24 at 12:24 P.M., Nurse Practitioner (NP) #1 said that she is rarely notified by the facility of low blood sugars for residents. NP #1 also said that if nursing staff provided an intervention for low blood sugars or if scheduled insulin was being held by the nurse she would expect to be notified. NP #1 said that the current order for Humalog insulin for Resident #60 does not have hold parameters, so if a nurse was holding it, she should be notified. She said she was not aware that the insulin was held before breakfast on 6/17/24 for Resident #60 and would not have recommended that it be held. NP #1 said that she assumes that all medications are administered as ordered unless she is told otherwise. NP #1 said that not being notified that medications are held could lead to her over or under dosing a resident with insulin or other medications. During an interview on 6/18/24 at 9:35 A.M., the Director of Nurses said that nurses can hold medications per parameters of the order or for nursing judgment, but if the medication is held the Physician or NP should be made aware and it should be documented in a progress note. Refer to F726

Based on record review, policy review, staff education record review, Facility Assessment review, and interviews, the facility failed to ensure that the three out of thirteen nurses (Nurse #5, #6, and #10) completed annual training and competencies related to the provision of care and services for five insulin dependent Residents (#48, #79, #58, #9, and #60) out of a total sample of 26 Residents. Specifically, the facility failed to: 1.Notify the physician or nurse practitioner when residents' blood glucose levels fell below parameters, or when insulin was held due to hypoglycemia. 2.Follow physician orders for when to give or hold insulin based on blood glucose levels. Findings Include: According to the Board of Registration in Nursing, 244 CMR 9.00 &10.00: Standards of Conduct, Definitions and Severability; a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies and training in areas as indicated in the facility assessment: Medication: Awareness of any limitations of administering medications, administration of medications that residents need, by route; oral, nasal, buccal, sublingual, topical, subcutaneous, rectal, intravenous (peripheral or central lines), intramuscular, inhaled (nebulizer), vaginal, ophthalmic, etc. Assessment/management of polypharmacy. Management of Medical Conditions: Assessment, early in identification of problem/deterioration, management of medical and psychiatric symptoms and conditions such as heart failure, diabetes, chronic obstructive pulmonary disease (COPD), gastroenteritis, infections such as UTI and gastroenteritis, pneumonia, hypothyroidism. According to Management of Diabetes and Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association (February 2016), several organizations have developed diabetes guidelines for patients living in long term care settings. Almost all of these guidelines emphasize the need to individualize care goals and treatments related to diabetes, the need to avoid sliding scale insulin (SSI) as a primary means of regulating blood glucose, and the importance of providing adequate training and protocols to long term care staff who may be operating without the presence of a practitioner for prolonged periods. Review of the facility policy titled, Employee Compliance Training and Education, last revised 2022, indicated but was not limited to the following: -Milltown Health and Rehabilitation as part of its continued commitment to compliance with legal requirements, shall conduct initial employment training and mandatory annual compliance program and policy education and training for all employees. The facility also conducts mandatory periodic specific education and training. The facility employee attendance and participation in training programs is a condition of continued employment and failure to comply with training requirements will result in disciplinary action up to and including termination of employment. -Attendance at educational and training sessions is the responsibility of each employee and will be documented by the Compliance Officer. Review of the Milltown Health and Rehab Facility Assessment Tool, undated, indicated the following: Staff training/education and competencies: 2.Services and Care We Offer Based on our Residents ' Needs: Management of Medical Conditions: -Assessment. -Early identification of problems disorientation. -Management of medical and psychiatric symptoms. -Conditions such as heart failure. -Diabetes. -Chronic Obstructive Pulmonary Disease (COPD) -Gastroenteritis, infections such as UTI. -Pneumonia. -Hypothyroidism. Medications: -Awareness of any limitations of administering. -Medications. -Administration of Medication that residents need. -By route: oral, nasal, buccal, sublingual, topical, subcutaneous, rectal, intravenous (peripheral or central lines), intramuscular, inhaled (nebulizer), vaginal, ophthalmic, etc. 3.4 Describe the staff training/education and competencies that are necessary to provide the level and types of support and care needed for your resident population. Include staff certification requirements as applicable. Potential data sources include hiring, education training competency instructions and testing policies. Some examples of annual clinical competencies include but are not limited to the following: -Person centered care. -Infection Control. -Medication administration. -Resident assessments. -Measurements (e.g., BP (blood pressure), wt (weight), etc. -Specialized services (e.g., colostomy care, etc.). Resident #9 was admitted to the facility in October 2022, with diagnoses that included type II diabetes mellitus, hypertension, and dementia. Review of the medical record indicated on 5/14/24, 5/17/24, 5/27/24, and 6/2/24 Nurse #5 and Nurse #6 failed to follow the physician ' s order and incorrectly administered insulin glargine when blood glucose levels were less than 150mg/dl. Additionally, on 5/13/24, 5/30/24 and 6/4/24 Nurse #5 failed to follow the physician ' s order, the hypoglycemic protocol and notify the physician for treatment of blood glucose levels less than 70 mg/dl. Resident #79 was admitted to the facility in August 2023, with diagnoses that included type II diabetes mellitus, renal failure, hypertension, and dementia. Review of Resident #79 ' s Medication Administration Record (MAR) dated March 2024 indicated that on 3/21/24 his/her blood glucose was 15 (severely low). There was no indication on the MAR or progress notes that nursing staff followed the physician ' s orders, initiated the hypoglycemic protocol, or notified the physician regarding Resident #79 ' s severely low blood glucose level. During an interview on 6/17/24 at approximately 2:10 P.M., Nurse #10, said the entry on Resident #79's MAR dated 3/21/24 of 15 must have been a typo. Nurse #10 said that if Resident #79's blood sugar was 15 she would have initiated the hypoglycemic protocol and notified the physician. Resident #48 was admitted to the facility in March 2024, with diagnoses that included diabetes, hypertension, and cerebral vascular accident. Review of Resident #48's MAR dated May 2024 indicated that on 5/6/24 at approximately 4:00 P.M., his/her blood glucose level was 19 (severely low). The MAR and progress notes failed to indicate Nurse #12 initiated the hypoglycemic protocol or notify the physician regarding the Resident's severely low blood glucose level. The code on the MAR (#9) indicated see progress notes. Review of the 5/6/24 nursing progress notes did not reference the blood glucose level of 18, or initiating the hypoglycemic protocol, or notifying the physician. During an interview on 6/17/24 at approximately 1:10 P.M., Nurse #12 said the entry on Resident #48's MAR dated 5/6/24 of 19 must have been a typo. Nurse #12 said that if Resident #48's blood sugar was 19 she would have initiated the hypoglycemic protocol and notified the physician. Resident #58 was admitted to the facility in December 2023, with diagnoses that included diabetes and hypertension. Review of Resident #58's MAR dated April 2024 indicated that on 4/8/24 at approximately 11:00 A.M., his/her blood glucose level was 67, and on 4/9/24 at approximately 11:00 A.M. the blood glucose level was 66. The MAR and progress notes failed to indicate nursing staff initiated the hypoglycemic protocol or notify the physician regarding the Resident's low blood glucose level. On 6/17/24 at approximately 2:00 P.M., the surveyor attempted to contact Nurse #11 regarding Resident #58's blood glucose level on 4/8/24 of 67, and his/her blood glucose level of 66 on 4/9/24. Nurse #11 did not respond to voicemail messages or texts. Resident #60 was admitted to the facility in October 2023 with diagnoses that include type II diabetes, dementia, and obesity. Review of the medical record indicated on 4/2/4/24, 5/2/24, 5/6/24, 5/12/24, 5/22/24, 5/23/24, 5/24/24, 5/29/24, 6/4/24, and 6/17/24 Resident #60 ' s scheduled Humalog insulin was held. The progress notes failed to indicate that a Physician or Nurse Practitioner was notified that the medication was not administered. During an interview on 6/17/24 at 12:41 P.M., Nurse #1 said that he was assigned to care for Resident #60. He said that before breakfast Resident #60 had a blood sugar of 111, so he held his/her 3 units of Humalog insulin. Nurse #1 further said that he did not notify the Physician or NP that the medication was held. Nurse #1 said that a Physician or NP should be notified if a medication is held either due to parameters or nursing judgement and that it should be documented in a progress note. The Director of Nursing provided the surveyor with the education files for thirteen nurses. Review of the education records for three of thirteen licensed nurses failed to indicate that annual competencies for medication administration, specifically for insulin dependent residents, were completed in 2023 or thus far in 2024 for Nurse #5, #6, and #10. During an interview on 6/18/24 at 11:32 A.M., the Director of Nursing said the facility holds two annual competency fairs and it would be the expectation that all nursing competencies would be completed yearly to ensure all staff are competent in the care they provide. The Director of Nursing was unable to provide annual competency documentation for Nurse #5, #6 and #10 by the conclusion of survey.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was severely cognitively impaired and dependent on staff to meet his/her care needs, the Facility failed to ensure he/she was free from physical abuse when two staff members witnessed Certified Nurse Aide (CNA) #1 slap Resident #1 on his/her left thigh, in response to him/her being combative during care. A reasonable person with intact cognitive functioning would have experienced mental anguish as a result of being hit by a caregiver. Findings include: Review of the Facility Policy and Procedure titled, Investigation of Resident Abuse, Neglect, Mistreatment, Misappropriation of Resident Property Complaints/Allegations, dated as revised June 2022, indicated when abuse is is observed, suspected, or reported to any facility employee, the employee will immediately notify the Unit Manager/Supervisor and they will immediately report the issue to the Administrator or Director of Nurses (DON) in his/her absence. Review of the Facility Policy and Procedure titled, Resident Protection During Abuse Investigation, dated as revised June 2022, indicated any employee who is accused of resident abuse will be suspended pending further investigation. The Policy and Procedure indicated if abuse is suspected or substantiated, the employee will be immediately sent home. Resident #1's medical history included diagnoses of Dementia with behavioral disturbances and Encounter for Palliative Care. Review of Resident #1's Significant Change in Status Minimum Data Set (MDS) Assessment, dated 01/13/23, indicated he/she had severe cognitive impairment, required a two person extensive assist with transfers, extensive assist with activities of daily living, and displayed physical and verbal behavioral symptoms directed toward others. Review of Resident #1's Care Plan related to Behaviors, dated 01/13/23, indicated his/her behavioral problem included yelling out, screaming at others, resisting care, physical aggression, and grabbing at others. The Care Plan interventions included for caregivers to provide opportunity for positive interaction, to approach and speak in a calm manner, to divert attention, remove from situation, and take to alternate location as needed. During an interview on 03/01/23 at 11:05 A.M., Certified Nurse Aide (CNA) #2 said on 01/21/23 at approximately 7:30 P.M. she entered Resident #1's bedroom after hearing a commotion, and saw CNA #1 and CNA #3 transferring Resident #1 into a reclining chair. CNA #2 said she went in the room, stood in back of the reclining chair, and said CNA #3 was standing to the side of the chair, and CNA #1 was bent down in front of Resident #1, facing him/her. CNA #2 said Resident #1 tried to swat off CNA #1's glasses. CNA #2 said CNA #1 reacted instantly, and with an open hand, slapped Resident #1's left thigh. CNA #2 said she saw and heard the sound of the slap. CNA #2 said CNA #1 then looked at her and said words to the effect of you didn't see that! CNA #2 said CNA #1 appeared angry and frustrated at the time of the incident. CNA #2 said she immediately removed Resident #1 from the room into the hallway and reported the incident to Nurse #1. Review of CNA #3's written statement, dated 01/21/23, indicated as she and CNA #1 were putting Resident #1 back onto the reclining chair, CNA #2 walked into the room. The Statement indicated had Resident #1 pulled, scratched and pinched them. The Statement indicated after CNA #1 slapped Resident #1's leg, CNA #1 said to her (CNA #3) and CNA #2, that didn't happen! The Surveyor was unable to interview CNA #3, as she did not respond to the Department of Public Health's telephone or letter requests for an interview. Review of CNA #1's written statement, (undated), indicated on the evening of 01/21/23, she and a coworker (later identified as CNA #3) stopped transferring Resident #1 for a few minutes when Resident #1 was physically and verbally abusive. The Statement indicated Resident #1 calmed down, they explained what they were doing and told Resident #1 to stop. The Statement indicated they (CNA #1 and CNA #3) attempted again to transfer Resident #1 and when Resident #1 sat down, he/she pulled her coworker's (CNA #3's) hair and aggressively hit CNA #1 on the head knocking her glasses to the floor. The Statement indicated she (CNA #1) reacted quickly by slapping Resident #1's leg. The Surveyor was unable to interview CNA #1, as she did not respond to the Department of Public Health's telephone or letter requests for an interview. During an interview on 03/02/23 at 10:20 A.M., Nurse #1 said on 01/21/23, CNA #2 approached her sometime between 7:00 P.M. and 7:30 P.M. to report that she saw CNA #1 slap Resident #1's (left) leg. Nurse #1 said she spoke to CNA #1, and CNA #1 admitted to her that she slapped Resident #1. Nurse #1 said she assessed Resident #1, and there was no signs of physical injury and Resident #1 had no recollection of the incident due to cognitive impairment. During an interview on 03/01/23 at 12:30 P.M., the Director of Nurses (DON) said she was notified in the morning on 01/22/23 that CNA #1 allegedly abused Resident #1. The DON said during an interview with CNA #1, CNA #1 told her that while bent down, Resident #1 smacked her glasses off, and that was when she (CNA #1) hit Resident #1's shin. The DON said CNA #1 admitted to saying words to the effect of you didn't see that to CNA #1 and CNA #3. A reasonable person with intact cognitive functioning would have experienced mental anguish as a result of being hit by a caregiver.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had a diagnosis of right sided [CONDITION(S)] (muscle weakness or [CONDITION(S)] on one side of the body) and required physical assistance from staff with transfers, the Facility failed to ensure staff provided an appropriate level of assistance in an effort to maintain his/her safety to prevent incidents/accidents resulting in an injury. -On 05/14/22, Certified Nurse Aide (CNA) #1 assisted Resident #1 into his/her wheelchair and wheeled him/her into the bathroom, but remained behind the wheelchair during the transfer. CNA #1 was not in a position to reach or provide physical assistance to Resident #1 when he/she attempted to transfer from the wheelchair to the toilet. Resident #1 stood up from his/her wheelchair, as he/she attempted to transfer onto the toilet one of his/her legs got caught on one the legs of the over the toilet commode, and he/she fell . Resident #1 was transferred to the Hospital Emergency Department where he/she was diagnosed with fractures of his/her right and left nasal bones. Findings Include: Review of the Facility Policy titled Falls and Risk, dated 2017, indicated that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling. Review of the Facility Policy titled Falls-Clinical Protocol, dated 2017, indicated that risk factors for subsequent falling included gait and balance disorders, cognitive impairment, weakness, environmental hazards, and illnesses affecting the central nervous system. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 01/13/22, indicated he/she was admitted to the Facility in April 2021, diagnoses included; [CONDITION(S)] (also known as a stroke or [CONDITION(S)]), spastic [CONDITION(S)] ([CONDITION(S)] affecting one side of the body) and [CONDITION(S)] (weakness or inability to move one side of the body) following a [CONDITION(S)] affecting right dominant side, [CONDITION(S)] (loss of ability to understand or express speech, caused by brain damage) following a [CONDITION(S)], anxiety, and depression. The MDS indicated that Resident #1 required extensive physical assistance of one staff member for transfers. Review of Resident #1's At Risk for Falls Care Plan, dated as revised 02/14/2022, indicated Resident #1 was at risk for falls related to deconditioning, gait and balance problems, incontinence, and psychoactive medications. Review of Resident #1's Incident Report, dated 05/14/22, indicated that Nurse #1 heard a call for help, ran to Resident #1's room where she observed him/her on the floor with the top half of his/her body in the doorway to an adjoining room and his/her legs in the bathroom (bathroom was shared with two rooms with doors from each room leading to shared bathroom). The Report indicated that Resident #1's nose, bridge of nose, and left eye were bleeding, 911 was called, and he/she was transferred to the Hospital Emergency Department. Review of Resident #1's Nurse Progress Note, dated 05/14/22, indicated that Resident #1 was transferred out of the Facility via 911 at 6:55 A.M. due to a fall with a head strike. The Note indicated that Resident #1's foot got caught on the leg of the commode (which was positioned over the toilet to create a raised seat) during a transfer, he/she fell to the floor, and the CNA was unable to stop the fall. The Note indicated that Resident #1 fell on to his/her face, he/she had a cut on the [NAME] of his/her nose, and his/her left eye and nose were bleeding. Review of Certified Nurse Aide (CNA) #1's Written Witness Statement, dated 05/14/22, indicated that at 6:45 A.M., while she was transferring Resident #1 to the toilet, his/her foot got caught on the leg of the over the toilet commode, and he/she fell on his/her face. The Statement indicated that CNA #1 tried not to let it happen, was holding Resident #1 but could not stop the fall. During an interview on 06/22/22 at 10:51 A.M., CNA #1 said that at approximately 6:30 A.M. on 05/14/22, she helped transfer Resident #1 out of bed into his/her wheelchair by placing a gait belt on him/her and said although Resident #1 was able to stand and pivot, he/she was very unsteady. CNA #1 said Resident #1 required physical assistance of one staff member for transfers. CNA #1 said after Resident #1 was in his/her her wheelchair, she wheeled him/her to the bathroom and she remained standing behind the wheelchair while Resident #1 pulled himself/herself to a standing position using the grab bar on the wall across from the toilet. CNA #1 said as Resident #1 attempted to transfer himself/herself to the toilet, his/her left foot got caught on the leg of the over toilet commode. CNA #1 said although she had a gait belt on Resident #1, said she was only able to hold on it as Resident #1 stood up because she was behind the wheelchair. CNA #1 said when Resident #1's foot got caught, he/she fell forward and she was unable to stop him/her from falling because she was behind the wheelchair. CNA #1 said she should have been in front of Resident #1 to assist him/her during the transfer. During an interview on 05/14/22 at 12:13 P.M., Nurse #1 said that, at approximately 6:30-6:40 A.M. on 05/14/22, she heard CNA #1 yelling for help and when she arrived in Resident #1's room, she observed Resident #1 face down on the floor with his/her legs in the bathroom and much of his/her body (through the doorway) and on the floor in an adjoining room that shared the bathroom. Nurse #1 said Resident #1's past medical history included a stroke which left him/her completely weak on one side. Review of Resident #1's Hospital Diagnostic Imaging Report, dated 05/14/22, indicated that a CT scan of his/her head, cervical spine, and facial bones revealed fractures of his/her right and left nasal bones. During an interview on 06/27/22 at 11:03 A.M., the Occupational Therapist (OT) said prior to Resident #1's fall, on 05/14/22, Resident #1 required the use of a gait belt and physical assistance of one staff member for transfers. The OT said Resident #1's fall was the result of the CNA not being in the proper position when Resident #1 attempted to transfer onto the toilet. The OT said Resident #1 had an over the toilet commode over in his/her bathroom and said because the commode had four legs a resident could trip on them. The OT said due to Resident #1's dementia, symptoms from his/her [CONDITION(S)], fluctuating lower body strength and coordination issues, the CNA should have gotten in front of his/her wheelchair to guide and bring the wheelchair into the bathroom, so that she was positioned appropriately and in front of Resident #1 to assist with the transfer. The OT said that if the CNA was in the right position when Resident #1 attempted to transfer onto the toilet, she could have guided him/her when his/her foot got stuck, and would have been there to help. The OT said the CNA would have also been able to better see if Resident #1's feet were in the proper position and therefore provide the proper compensation. The OT said that the CNA should have held Resident #1's gait belt during his/her entire transfer and said if he/she attempted to use the gait belt from behind his/her wheelchair, it would not have been effective. The OT said gait belts were used for safety during transfers to provide assistance for residents with balance deficits during transfer, for safe body maneuvering, and in order to safely lower a resident to the floor or wheelchair to help prevent injury if a resident should start to fall. During an interview on 05/14/22 at 1:22 P.M., the Director of Nursing (DON) said Resident #1 had right sided weakness and for transfers. The DON said CNA #1 should have used the gait belt appropriately when she assisted Resident #1 to the bathroom and was going to need her assistance with transfer from the wheelchair to the toilet. The DON said after she investigated Resident #1's fall, she determined that CNA #1 should have been in front of Resident #1 rather than behind him/her when she assisted him/her with transferring from the wheelchair to the toilet.

Based on interview and record review, the facility failed to ensure that 1.) 4 sampled residents (#27, #29, #31 and #80) out of a total sample of 37 residents and 4 additional residents (#18, #33, #54 and #71) received education and were offered the Covid-19 vaccine and 2.) Two additional residents (#35 and #68) received their second Covid-19 vaccine. Findings include: During an interview with Administrator #1 and Interim Director of Nursing on 9/15/21 at 6:55 A.M., the Interim Director of Nursing said that the facility was currently experiencing an outbreak of Covid-19. She said that a staff member (CNA #1) had been tested on [DATE] as part of surveillance testing and the facility was notified of the positive COVID-19 result on 9/11/21. During an interview on 9/8/21 at 12:30 P.M., the Interim Director of Nursing said that there are 11 residents that have not been vaccinated for COVID-19. She said she is not aware why they have not been vaccinated, but that she would look into it. The Interim Director of Nursing said that she also had 2 residents that had only received one of the two required Covid-19 vaccinations. The Interim Director of Nursing said she did not know why but was in the process of communicating with the Medical Director as to what should be done for those two residents. During an interview on 9/15/21 at 4:00 P.M., Corporate Nurse #1 said that 3 of the 11 residents that the Interim Director of Nursing said were not vaccinated, were in fact vaccinated leaving 8 residents (#27, #29, #31 #80, #18, #33, #54 and #71) without any vaccine and 2 residents ( #35 and #68) that had received one dose. During an interview on 9/15/21 at 4:05 P.M., the Interim Director of Nursing said that the 8 remaining residents that have not been vaccinated have not received any education or signed an informed consent form. The Interim Director of Nursing said she gave that to the Infection Control Nurse to complete but does not know where the Infection Control Nurse is at with this process. The Interim Director of Nursing further said she was notified that day that the Infection Control Nurse will be out of work until December 2021. The Interim Director of Nursing said she would need to find someone to fill that slot. Review of facility documents indicated the facility had 8 residents who were unvaccinated for COVID-19 and 2 residents who had received one dose of the COVID-19 vaccine. Review of resident medical records indicated the following residents had received one dose of the COVID-19 vaccine: - Residents #35 and #68 Review of medical records failed to indicate the following residents were provided education or informed consent and had not received the COVID-19 vaccine: -Residents #27, #29, #31, #80, #18, #33, #54, #71.

Based on observation, record review and interview, the facility failed to protect residents from neglect by 1) failing to ensure there was clinical staff present to provide nursing services and assure residents safety on 1 of 3 occupied resident units, 2) failing to ensure there was adequate staff to provide 1:1 supervision as ordered by the physician to maintain safety, resulting in a fall with injury for 1 Resident (#44) and 3) failing to provide, for 1 Resident (#74) out of a total sample of 37 residents, Activities of Daily Living (ADL) including incontinence care and assistance with feeding from 7:00 A.M. until approximately 1:45 P.M., due to limited staff assigned to the unit, Findings include: 1) The facility failed to protect residents from neglect by failing to ensure there was clinical staff present to provide nursing services and assure resident safety on 1 of 3 occupied resident care units. Findings include: Review of facility policy titled 'Staffing', revised April 2007, indicated the following: *Policy Statement: -Our facility provides adequate staffing to meet needed care and services for our resident population. *Policy Interpretation and Implementation: - Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services. - Certified Nursing Assistants (CNAs) are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan On 9/7/21 at 6:55 A.M., the surveyor arrived onto the 1st floor unit. The surveyor was unable to locate a staff person. Observation of the 1st floor unit revealed two residents residing in two different rooms. The surveyor observed the staffing coordinator (who does not have a clinical background) sitting in the back of the nurses station, using a desktop computer. During an interview on 9/7/21 at 6:55 A.M., the staffing coordinator said that the 11:00 P.M.-7:00 A.M. shift nurse (#6) was also covering the 2nd floor unit. The staffing coordinator said she comes in at 6:00 A.M., but did not see the nurse on the 1st floor unit. She said there was a CNA (#3) covering the 1st floor unit but she left at 6:50 A.M. because of childcare. The staffing coordinator said there is a nurse scheduled to cover the 1st floor unit for the 7:00 A.M.- 3:00 P.M. shift but she hadn't arrived yet. The surveyor asked what would happen if the residents on the 1st floor unit needed assistance. The staffing coordinator said she would probably call someone on the second floor. The staffing coordinator said she was not a clinical staff and was just on the unit to use the computer. The staffing coordinator could not say how residents would have been able to get assistance if she had not come to the desk to use the computer. On 9/7/21 at 7:05 A.M., the surveyor observed CNA #11 standing at the 1st floor nurses station. During an interview on 9/7/21 at 7:05 A.M., CNA #11 said she is working on the second floor and they sent her down to the first floor until the nurse arrives. During an interview on 9/7/21 at 7:07 A.M., the staffing coordinator said she called for assistance after she spoke with the surveyor. On 9/7/21 at 7:20 A.M., the surveyor observed as Nurse #15 (scheduled to work on the unit for the 7-3 shift) arrived onto the 1st floor unit. On 9/7/21 at 7:10 A.M., the surveyor reviewed the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The review indicated that Resident #27 should have received the following medications at 6:00 A.M.: [MEDICATION(S)] (vitamin D3) 800 units, [MEDICATION(S)] 100 milligrams (mg) one by mouth and [MEDICATION(S)] ([CONDITION(S)] medication) 50 micrograms(mcg) by mouth every day. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/7/21 at 11:10 AM, Nurse #6 (who had been assigned to the 2nd floor unit on the 11-7 shift) said that she did not give Resident #27 his/her 6:00 A.M. medications. Nurse #6 said that she usually will give them on her way out of the building, after she finished her work on the 2nd floor unit, but she ran out of time and needed to leave the facility. Nurse #6 said she covers the 2nd floor unit and 1st floor unit about once a week and will come down if a resident requests an 'as needed' medication, if not, she said she stays on the 2nd floor because she has 40 residents upstairs and can't be down on the first floor. Nurse #6 said it isn't safe to leave the 2nd floor. Nurse #6 said she instructs the CNA assigned to check the residents every two hours and to call her if there is a problem, other than that she would not go downstairs. The surveyor asked if she performed needed assessments or observed Resident #27 or Resident #139, whom resided on the first floor unit, at all during the 11-7 shift. Nurse #6 said she did not see either of them at all the entire shift. Nurse #6 said she did not go to the 1st floor unit at all during the 11:00 P.M.- 7:00 A.M. shift on 9/6/21-9/7/21. 2) The facility failed to protect Resident #44 from neglect, by failing to ensure there was adequate staff to provide 1:1 supervision as ordered by the physician to maintain safety, resulting in a fall with injury. Resident #44 was admitted to the facility in March 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #44's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident had moderate cognitive impairment and scored a 10 out of 15 on the Brief Interview Status (BIMS). Further review of Resident #44's MDS indicated the Resident required assistance with all care activities and that the Resident had falls with injury since the previous assessment. Review of Resident #44's medical record indicated a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #44's care plans indicated he/she was a high risk for falls related to incontinence, poor safety awareness, restlessness and agitation, use of [CONDITION(S)] medication, anxiety, akathisia (a movement disorder characterized by inner restlessness), attempts to self transfer, recent fall history and indicated an intervention, dated 9/3/21, for Resident #44 to be 1:1 in arms reach to prevent falls. On 9/3/21 at 8:08 A.M., Resident #44 was observed in a wheelchair in front of the nurses station. Resident #44 appeared visibly restless and agitated and had a healing laceration over his/her left eyebrow, bruising to his/her left peri orbital area (area around the eye) and old bruises to the right and left sides of his/her forehead. Nurse #3 said that Resident #44 fell twice last night after returning from the hospital for a previous fall and said the Resident fell again this morning and pulled a chair on top of himself/herself. Nurse #3 said the Nurse Practitioner (NP) had ordered a 1:1 for the Resident. On 9/3/21 at 8:18 A.M., Nurse #3 said the medical records clerk was going to stay with the Resident for a brief period of time until a 1:1 could be arranged. Nurse #3 said a 1:1 will be used for a resident with multiple falls but there is not enough staff to have one and further said staffing is challenging. On 9/03/21 at 8:23 A.M., Nurse #3 said the floor staff, assigned to give care to all of the other residents on the unit, would alternate shifts in 30 minute increments to provide 1:1 supervision for the Resident. Review of Resident #44's Adult Protective Services Intake Report dated 9/5/21 indicated the following: -EMS (Emergency Medical Services) responded to the facility for a reported fall with arm injury and when they arrived to the unit that Resident #44 resided on, there was no staff at the nurse's station. EMS located a staff member at the end of one hall. EMS reported the staff member said she was a nurse on one side of the unit but was unaware that EMS had been called and was unsure where the nurse for the other side of the unit was. The report further indicated that EMS began a room to room search and located Resident #44 in his/her room laying on his/her back on the floor of his/her room with no one around the Resident. The report indicated that EMS assessed Resident #44 to have diminished mental status and that another staff member walked by the Resident's room and said that this was his/her normal mental status and that they were unsure of why EMS had been called or when Resident #44 had fallen. Further, the staff member reported that Resident #44 had initially been found on the floor of the hallway and then was moved back into his/her room. The report indicated that Resident #44 was noted to have multiple bruises across his/her head and arms in all different stages of healing and multiple skin tears in all different stages of healing. The report further indicated that Resident #44's room was noted to have multiple soiled adult diapers on the floor and the Resident smelled of urine and his/her pants were noted to be wet. During a record review of Resident #44's medical record on 9/7/21 at 8:00 A.M., the following was indicated: - Skin Only Evaluation dated 9/5/21 at 5:43 P.M.: Patient 1:1 supervision with 2 aides on entire floor. Patient fell in hallway when an aide was looking for assistance. Order to send to ER. Unwitnessed. Small skin tear noted. Will go to hospital. -Nurses Note dated 9/5/21 at 6:43 P.M. : Patient 1:1 supervision with 2 aides on entire floor. Unwitnessed fall. Patient combative and aggressive. Assist up to wheelchair. Small skin tear noted. Order to send to hospital to evaluate and treat. Review of Resident #44's Emergency Department document dated 9/5/21 indicated the following: - Patient presents to the emergency room for evaluation after an unwitnessed fall at nursing home. Apparently, the patient crawled out into the the hallway of the nursing home when staff found him/her. Patient states he/she fell out of bed. According to EMS (Emergency Medical Services) they could not find any staff that was aware of the patient, there was no staff on his/her floor at all, and they filed elder neglect paperwork. During an interview on 9/7/21 at 9:40 A.M., the Interim Director of Nursing said she was familiar with Resident #44 and that the Resident had multiple falls and was impulsive. The Interim Director of Nursing said that the expectation regarding the order and care plan intervention for 1:1 supervision for this Resident is that it should have been followed. During telephone interviews throughout the day on 9/7/21 and 9/16/21, Nurse #4 said she was working on 9/5/21 when Resident #44 fell . Nurse #4 said she was only notified that the Resident fell on ce during her shift and that the multiple notes written about his/her fall were related to the same fall. Nurse #4 said staff did their best to watch him/her during the shift but due to low staffing it was difficult. Nurse #4 said that there were only 2 Certified Nursing Assistants (CNAs) working on the unit (unit census was 41 residents) when Resident #44's fall happened and it was difficult to maintain the 1:1 for the Resident as ordered. Nurse #4 said that a CNA left the Resident alone in the hallway to ask for help and that's when the Resident fell . Nurse #4 said staff assisted him/her to a wheelchair and she observed a skin tear to the Resident but was unsure of the location. Nurse #4 said another nurse dressed the skin tear and then brought the Resident back to his/her room. Nurse #4 was unable to say if the Resident remained supervised as ordered after the fall and could not say why the Resident was found alone on the floor of his/her room by EMS. Nurse #4 said she had called Administrator #1 on 9/5/21 to say that there was not enough staff to provide a 1:1 for Resident #44 and ensure his/her safety and asked if Administrator #1 would come in to act as the 1:1. Nurse #4 said Administrator #1 told her she lived too far away and would not come in. Nurse #4 said that Resident #44 fell after she had contacted Administrator #1 asking her to come in to be the Resident's 1:1. Nurse #4 said she didn't think the staffing level was safe on the unit. Nurse #4 said she thought the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #4 said nursing staff had notified administration multiple times that they felt Resident #44 was unsafe in the facility and that they couldn't safely care for him/her. During an interview on 9/8/21 at 9:09 A.M., Administrator #1 said she was familiar with Resident #44. Administrator #1 said he/she has fallen more than any resident she has ever worked with. Administrator #1 said on 9/3/21 they talked about having staff with Resident #44 at all times as a 1:1. Administrator #1 said a nurse called her on 9/5/21 in the afternoon and asked her to come in to be the 1:1. Administrator #1 said she told the nurse no and that she would not come in because she lived too far away. Administrator #1 said the nurse then told her that the staff couldn't provide the 1:1 for Resident #44. Administrator #1 said she did not ask how many staff were on the unit and that she was unsure how many staff was present. Administrator #1 said she called the scheduler about an hour after receiving the call from nursing staff that they couldn't provide the 1:1 for Resident #44. Administrator #1 said she did not follow up with the nursing staff or the scheduler regarding the request from the nurse for a 1:1 for Resident #44. Administrator #1 was unsure as to when she was notified about Resident #44's fall and being sent to the hospital. During an interview on 9/8/21 at 11:06 A.M., The Staffing Coordinator said that there was a staffing issue on 9/5/21 during the 3-11 shift on the 3rd floor. The Staffing Coordinator said Administrator #1 asked her if she could come in to be Resident #44's 1:1 and she was unable to do it. The Staffing Coordinator said she reached out to staff to try to find someone but no one responded. The Staffing Coordinator was unable to say if she notified Administrator #1 or nursing staff that she was unable to find someone to act as a 1:1. See tag F689 and F835 3) The facility failed to protect Resident #74 from neglect by failing to provide Activities of Daily Living (ADL) care, including turning and repositioning in bed, incontinence care and assistance with feeding from 7:00 A.M., until approximately 1:45 P.M., due to limited staff assigned to the unit. Resident #74 was admitted to the facility in August 2019, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #74 was assessed by staff to have had severely impaired cognition. The MDS further indicated Resident #74 required total assist of two staff for all aspects of his/her Activities of Daily Living (ADL's). During a record review on 8/31/21 at 11:15 A.M., the record for Resident #74 indicated the following: * A current ADL care plan which indicated Resident #74 was dependent on staff for care. During an observation on 9/03/21 at 1:03 P.M., Resident #74 was observed alone in his/her room in bed sleeping, with a pudding container in his/her hand and an untouched lunch tray on the tray table directly in front of him/her. During an interview with the facility's Consulting Nurse (CN) #1 on 9/03/21 at 1:14 P.M., she said she was unable to locate a CNA or a nurse on Resident #74's end of the unit. CN#1 said she would leave the unit and see if she could find the staff elsewhere in the building. During an interview with Certified Nursing Assistant (CNA) #6 on 9/03/21 at 1:26 P.M., she said that she was the CNA responsible for Resident #74 but that on that date she hadn't seen or cared for Resident #74 since providing incontinence care at 7:00 A.M. CNA#6 said that Resident #74 was totally dependent on her for all ADL care including incontinence care and feeding, and that she had not had a chance that day to assist her with eating breakfast or lunch or to clean her because there were not enough staff on the unit and she was still providing morning care to other residents. CNA #6 said that it was impossible to provide the residents on the unit with the amount of care they needed due to the limited numbers of CNA's assigned. During an interview with Administrator #1 and CN#1 on 9/03/21 at 1:49 P.M., CN #1 said that she overheard CNA #6 had not cared for Resident #74 since the start of her shift nearly 7 hours prior and that they had initiated an investigation to determine if any other staff had provided the needed care. Administrator #1 and CN#1 said it was the expectation, because Resident #74 was totally dependent on staff for care, that he/she be turned and repositioned in bed every two hours, be checked for incontinence care needs every two hours and be fed his/her meals. Review of the state's Health Care Facility Reporting System (HCFRS) data base indicated that on 9/3/21 the facility had reported the incident regarding Resident #74's lack of care as neglect. During a follow-up interview with Administrator #1 on 9/07/21 at 9:09 A.M., she said that she had interviewed all facility staff and the hospice aide and hospice nurse assigned to Resident #74 and concluded that Resident #74 had not received any care from 7:00 A.M., until approximately 1:45 P.M., when the surveyor brought it to staff's attention. She indicated that the expectation was that staff provide dependent residents with care every two hours and that in this case that did not happen. Administrator #1 provided the surveyor with her investigative file which included a statement from CNA #6 that she had not provided Resident #74 with the required care due to low staffing. See F725 and F835

Based on observation, interview and schedule review, the facility failed to 1) ensure there was clinical staff present to provide nursing services and assure resident safety on 1 of 3 resident care units and 2) ensure there was sufficient staff available to provide safe and adequate care required to meet residents' needs. Findings include: Review of facility policy titled 'Staffing', revised April 2007, indicated the following: *Policy Statement: -Our facility provides adequate staffing to meet needed care and services for our resident population. *Policy Interpretation and Implementation: - Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services. - Certified Nursing Assistants (CNAs) are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan 1a. On 9/7/21 at 6:55 A.M., the surveyor arrived onto the 1st floor unit. The surveyor was unable to locate a staff person. Observation of the 1st floor unit revealed two residents residing in two different rooms. The surveyor observed the staffing coordinator (who does not have a clinical background) sitting in the back of the nurses station, using a desktop computer. During an interview on 9/7/21 at 6:55 A.M., the staffing coordinator said that the 11:00 P.M.-7:00 A.M. shift nurse (#6) was also covering the 2nd floor unit. The staffing coordinator said she comes in at 6:00 A.M., but did not see the nurse on the 1st floor unit. She said there was a CNA (#3) covering the 1st floor unit but she left at 6:50 A.M. because of childcare. The staffing coordinator said there is a nurse scheduled to cover the 1st floor unit for the 7:00 A.M.- 3:00 P.M. shift but she hadn't arrived yet. The surveyor asked what would happen if the residents on the 1st floor unit needed assistance. The staffing coordinator said she would probably call someone on the second floor. The staffing coordinator said she was not a clinical staff and was just on the unit to use the computer. The staffing coordinator could not say how residents would have been able to get assistance if she had not come to the desk to use the computer. On 9/7/21 at 7:05 A.M., the surveyor observed CNA #11 standing at the 1st floor nurses station. During an interview on 9/7/21 at 7:05 A.M., CNA #11 said she is working on the second floor and they sent her down to the first floor until the nurse arrives. During an interview on 9/7/21 at 7:07 A.M., the staffing coordinator said she called for assistance after she spoke with the surveyor. On 9/7/21 at 7:20 A.M., the surveyor observed as Nurse #15 arrived onto the 1st floor unit. During an interview on 9/7/21 at 7:21 A.M., Nurse #15 said that Nurse #6 was covering the 1st floor unit but was still working upstairs on the 2nd floor unit. Nurse #15 said she got the medication keys from Nurse #6 and came downstairs. On 9/8/21 at 8:05 A.M., the surveyor observed Nurse #6 as she exited the elevator and walked to the 1st floor unit nurses station. Nurse #6 spoke to Nurse #15 for approximately 1 minute and then began to walk off the unit to leave the building. During an interview on 9/8/21 at 8:07 A.M., the surveyor asked Nurse #6 if she conducted change of shift narcotic count with Nurse #15, Nurse #6 said she told Nurse #15 when she came up to the 2nd floor unit how many narcotics were left in the locked drawer, but no they did not conduct narcotic count as they were expected to. Nurse #6 said she was too busy on the second floor and there were only two controlled medication cards in the locked drawer. During interview on 9/8/21 at 8:08 A.M., Nurse #15 said that Nurse #6 should have come to the 1st floor unit to do narcotic count and Nurse #15 said she should not have just taken the medication/narcotic drawer keys from Nurse #6 but she needed to get started as she was late already and Nurse #6 could not come to the 1st floor because she was too busy on the 2nd floor unit. On 9/7/21 at 7:10 A.M., the surveyor reviewed the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The review indicated that Resident #27 should have received the following medications at 6:00 A.M.: [MEDICATION(S)] (vitamin D3) 800 units, [MEDICATION(S)] 100 milligrams (mg) one by mouth and [MEDICATION(S)] ([CONDITION(S)] medication) 50 micrograms(mcg) by mouth every day. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/7/21 at 11:10 AM, Nurse #6 said that she did not give Resident #27 his/her 6:00 A.M. medications. Nurse #6 said that she usually will give them on her way out of the building, after she finished her work on the 2nd floor unit, but she ran out of time and needed to leave the facility. Nurse #6 said she covers the 2nd floor unit and 1st floor unit about once a week and will come down if a resident requests an 'as needed' medication, if not, she said she stays on the 2nd floor because she has 40 residents upstairs and can't be down on the first floor. Nurse #6 said it isn't safe to leave the 2nd floor. Nurse #6 said she instructs the CNA assigned to check the residents every two hours and to call her if there is a problem, other than that she would not go downstairs. The surveyor asked if she performed needed assessments or observed Resident #27 or Resident #139, whom resided on the first floor unit, at all during the 11-7 shift. Nurse #6 said she did not see either of them at all the entire shift. Nurse #6 said she did not go to the 1st floor unit at all during the 11:00 P.M.- 7:00 A.M. shift on 9/6/21-9/7/21. 1b. During a record review, the staffing for the 1st floor unit from 8/7/21 through 9/7/21 was reviewed. For those 31 days, the floor was occupied by residents and the following was indicated: * For 3 of 31 days there was no nurse or Certified Nursing Assistant assigned to the unit on the 7-3 shift: 8/9, 8/20, 8/26 (CNA was listed as being at an appointment from 10:00 am on) * For 1 of 31 days there was no nurse or Certified Nursing Assistant (CNA) assigned to the unit on the 3-11 shift: 8/15 * For 1 of 31 days there was no nurse or Certified Nursing Assistant (CNA) assigned to the unit on the 11-7 shift: 8/15 * For 14 of 31 days no nurse was assigned to the unit on the 7-3 shift: 8/7, 8/11, 8/12, 8/14, 8/15, 8/16, 8/19, 8/20, 8/24, 8/26, 8/28, 8/29, 8/30, 8/31 * For 8 of 31 days no nurse was assigned to the unit on the 3-11 shift: 8/12, 8/14, 8/15, 8/22, 8/27, 8/28, 8/29, 8/30 * For 13 of 31 days no nurse was assigned to the unit on the 11-7 shift: 8/12, 8/14, 8/15, 8/16, 8/17, 8/22, 8/24, 8/27, 8/28, 8/29, 9/1, 9/5, 9/6 * For 15 of 31 days no Certified Nursing Assistant (CNA) was assigned to the unit on the 7-3 shift: 8/8, 8/9, 8/10, 8/13, 8/17, 8/20, 8/22, 8/26 (CNA was listed as being at an appointment from 10:00 A.M. on), 8/27, 9/1, 9/2, 9/3, 9/4, 9/5, 9/7 * For 23 of 31 days no Certified Nursing Assistant (CNA) was assigned to the unit on the 3-11 shift: 8/7, 8/8, 8/9, 8/10, 8/13, 8/15, 8/16, 8/17, 8/18, 8/19, 8/20, 8/22, 8/23, 8/24, 8/25, 8/31, 9/1, 9/2, 9/3, 9/4, 9/5, 9/6, 9/7 * For 15 of 31 days no Certified Nursing Assistant (CNA) was assigned to the unit on the 11-7 shift: 8/7, 8/9, 8/10, 8/11, 8/13, 8/15, 8/18, 8/19, 8/23, 8/25, 8/26, 8/30, 8/31, 9/2, 9/7 1c. Additionally, the records of the residents that occupied the 1st floor unit between 8/7/21- 9/7/21 were reviewed and the following was indicated: Resident #27 was admitted to the facility in 6/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #27 resided on the first floor resident unit 31 out of 31 days reviewed. Review of Resident #27's medical record indicated the following physician orders: -[MEDICATION(S)] Sodium Capsule 25 mcg (micrograms) daily at 6 A.M. not given 8/13, 8/15, 8/16. There was no nurse scheduled at the time the dose should have been administered. -[MEDICATION(S)] Sodium Capsule 50 mcg daily at 6 A.M. not given 8/17, 8/29, 8/30 . There was no nurse scheduled at the time the dose should have been administered. -Vital signs daily at 9 A.M. not done 8/7, 8/9, 8/14, 8/16, 8/19 . There was no nurse scheduled for the 7-3 shift on these dates. Resident #139 was admitted to the facility in 8/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #139's medical record indicated the following physician orders: -COVID 19 evaluation every shift not done 9/1 night shift and 9/5 night shift. There was no 11-7 nurse scheduled for these shifts. Resident #290 was admitted to the facility in 8/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #290 resided on the 1st floor unit 23 out of 31 days reviewed. Review of Resident #290's medical record indicated the following physician orders: - [MEDICATION(S)] (an anti depressant) give 7.5 milligrams (mg) at bedtime: not given 8/15 and 8/29. There was no 3-11 nurse scheduled on these dates. -[MEDICATION(S)] (an antidepressant) 50mg at 8A.M. daily: not given 8/11, 8/14, 8/16, 8/26, 8/28, 8/30, 8/31. There was no 7-3 nurse scheduled on these dates. -An order dated 8/13/21 for [CONDITION(S)] precautions four times a day not done on 8/14. There was no nurse scheduled for all 3 shifts on this day. -An order dated 8/16/21 for [CONDITION(S)] precautions every shift not done on the following shifts: 8/16 night shift (there was no 11-7 nurse), 8/19 day shift (there was no 7-3 nurse), 8/22 night shift (there was no 11-7 nurse), 8/28 evening and night shifts (there was no nurse for either shift), 8/29 night shift (there was no 11-7 nurse), 8/30 day and evening shifts (there was no nurse for either shift). During an interview on 9/8/22 at 9:22 A.M., Administrator #1 said that there should always be a clinical staff member on each unit if there are residents on that unit. Administrator #1 further said the expectation would be that nursing staff would administer medications and treatments and monitoring such as [CONDITION(S)] precautions and Covid monitoring according to orders. 2. On 9/2/21 at 8:36 A.M. through 9:15 A.M., observation of the 2nd floor dining room revealed a total 12 residents eating breakfast. There was one staff member (Nurse #11) present to provide supervision, cueing and feeding. One of the Residents ( #83) required 1:1 supervision due to a history of [CONDITION(S)] impaction. Nurse #11 spent the entire time feeding another resident and cueing a second resident, with her back to Resident #83. During an interview on 9/2/21 at 9:30 A.M., Nurse #11 said she knows that Resident #83 needs constant supervision but she was the only one in the dining room and another resident needed to be fed. Nurse #11 said they don't have enough staff to be able to staff the dining room and get the residents that eat in their rooms fed. During a record review on 9/07/21 at 1:00 P.M., the care needs of all residents at the facility (Certified Nursing Assistant -CNA care cards) were reviewed and the following was indicated: 1st floor unit=census is 2; 1 of 2 residents required physical assist with eating; 2nd floor unit= census is 42; 16 of 42 required physical assistance with eating, 23 of 42 require 2 person assist with bed mobility/transfers, 18 of 42 required 2 person assist for toileting; 3rd floor unit = census is 41; 18 of 41 required physical assistance with eating, 25 of 41 required 2 person assist with bed mobility/transfers, 12 of 41 required 2 person assist for toileting. During an interview with 3rd floor unit Nurse #14 on 9/8/21 at 5:04 A.M., she said that she was the only nurse on the floor with two Certified Nursing Assistants (CNA #12 and #15) and that the unit census was 40. During an observation on the facility's 3rd floor unit on 9/8/21 at 5:18 A.M., CNA #12 was observed alone in a room with a resident. CNA#12 was attempting to pull a brief off of the resident and at the same time roll the resident on to his/her side. During an interview with CNA #12 on 9/8/21 at 5:24 A.M., she said that the resident that she had been caring for required 2 staff to provide total care but because there were only 2 CNA's on the unit and most of the residents required two person care, they had no choice but to provide the care alone in order to get the care done for the residents. During an interview with CNA #15 on 9/8/21 at 5:42 A.M., she said that they used to have 3 CNA'S to ensure they could safely provide care to all the residents but that that had changed months ago and they had no other option than to provide care alone to residents that need two caregivers. During an observation on the 3rd floor unit on 9/15/21 at 8:05 A.M., the surveyor observed the breakfast truck delivered to the unit. The following observations were made: -At 8:14 A.M., a tray was delivered to Resident #74. It was placed on a tray table directly in front of Resident #74 and the staff person exited the room. At 8:17 A.M., the surveyor observed Resident #74 asleep, holding a fork. Review of the care card for Resident #74 indicated he/she required supervision and 1 person physical assistance with eating. -At 8:18 A.M., Resident #35 was observed alone in his/her room sleeping. An untouched breakfast tray was on the tray table directly in front of him/her. Review of the care card for Resident #35 indicated he/she required supervision and assist with eating. - At 8:22 A.M., Resident #33 was observed in the unit's main dining room, fiddling with the food on his/her tray. No staff were present in the dining room. Review of the care card for Resident #33 indicated he/she required supervision with eating. - At 8:25 A.M., Resident #67 was observed alone in his/her room with a breakfast tray directly in front of him/her. Review of the care card for Resident #67 indicated he/she required one person physical assist with eating. - At 8:27 A.M., Resident #69 was observed alone in his/her room. A nurse placed a breakfast tray directly in front of him/her and exited the room. Review of the care card for Resident #69 indicated he/she required extensive one person assist with eating. - At 8:34 A.M., Resident #62 was observed alone in his/her room with breakfast directly in front of him/her. Review of the care card for Resident #62 indicated he/she required one person physical assist with eating. - At 8:36 A.M., Resident #37 was observed in the unit's main dining room with breakfast placed on the table directly in front of him/her. No staff were present in the dining room. Review of the care card for Resident #37 indicated he/she required one person physical assist with eating. See tag F835

Based on observations, staff interviews and records reviewed, the facility 1) failed to ensure agency nurses received orientation to the facility, including knowing which nurse is in charge of the facility on off shifts, management of a crisis, emergency or disaster and how to reach the Administrator and Director of Nursing, 2) failed to ensure that 2 of 2 licensed nurses observed were trained and competent to properly open a cylinder of oxygen which is located on the code cart and used for medical emergencies, and 3) failed to ensure agency nurses were able to access the electronic medication dispensing system (Cubex), which contains medications used in emergency situations. Therefore, a resident experiencing an acute change in condition with the need for supplemental oxygen, a medical crisis with the need to initiate a Code Blue, the need to access and dispense medication related to an acute change, or in the event of a facility disaster such as a fire, the potential for severe adverse outcomes for multiple residents exists. Findings include: 1) On 9/15/21 at 5:02 A.M., on the 3rd floor unit, Nurse #19 was behind the nurse's station sitting with his head down and wearing headphones (ear buds). During an interview at that time, Nurse #19 said he was an agency nurse and that he had not gotten any orientation to the facility and said he was unsure of who was in charge of the building. Nurse #19 said he thought it was the nurse on duty on the 2nd floor unit (the only other nurse in the facility at that time). During an interview with Nurse #18 on the 2nd floor unit on 9/15/21 at 5:12 A.M., Nurse #18 said she was an agency nurse and had not received any orientation to the facility. She said that she was unsure who was in charge of the building at that time. During an interview on 9/15/21 at 11:55 A.M., the Interim Director of Nursing said that there is a packet for agency nurses that should be reviewed with them at the start of the shift. The Interim Director of Nursing said that the Staff Development Coordinator was supposed to be doing this but since she was absent, the Scheduling Coordinator was filling in. The Interim Director of Nursing said that the expectation would be that any agency nurse would receive orientation at the start of their shift, while also acknowledging the Scheduling Coordinator was not in the facility when the 11-7 shift worked. During interviews throughout the day on 9/15/21, the Scheduling Coordinator said the facility Staff Development Coordinator was out of work and that now she was responsible for ensuring agency nurses were given an orientation to the facility at the start of their shift. The Scheduling Coordinator said that the orientation involved going through a packet with the agency nurse and giving them a tour. The Scheduling Coordinator said she kept a binder with all of the completed forms related to orientation. The Scheduling Coordinator said she was not a clinical staff member, so if there were any clinical questions she would refer them to nursing. The Scheduling Coordinator said she had not provided orientation to Nurse #18 or #19 prior to their 11-7 shift and said she had not provided orientation to Nurse #14 prior to her shift on 9/12/21. Review of facility document titled 'Vero Agency Staff Facility Orientation', revised 2/26/21 indicated that agency staff should have been oriented and had an opportunity to ask questions on items which include: -Abuse prevention and who to report to -Fire Safety, Fire Drill procedure and use/ location of fire extinguisher reviewed (RACE/PASS) -How to reach the Administrator and Director of Nursing Services 2) On 9/7/21 at 9:55 A.M., during review of the code cart contents on the 2nd floor, the surveyor asked Nurse #8 if she would open the emergency oxygen cylinder. The surveyor observed as Nurse #8 made several attempts to open the cylinder of oxygen. Nurse #8 was unable to open the emergency oxygen cylinder. After 5 minutes Nurse #8 called Nurse #7 over and asked Nurse #7 to open the emergency oxygen cylinder. After several attempts, Nurse #7 was unable to open the emergency oxygen cylinder. During an interview on 9/7/21 at 10:10 A.M., the surveyor asked what Nurse #8 would do in an emergency situation if the resident needed oxygen. Nurse #8 said she did not know what she would do in that case. Nurse #8 said she worked for an agency and had not received any orientation in regard to the emergency equipment. Review of the resident care cards, provided by the facility, indicated that 53 of 85 residents residing in the facility on 9/7/21 were listed as being Full Code and therefore may require oxygen to be administered in a medical emergency. Facility staff competencies were requested for Nurse #7, hired in June 2021, and Nurse #8, temporary agency staff. The facility was unable to provide competencies for Nurse #7 or Nurse #8. During interviews throughout the day on 9/8/21, Administrator #1 said that she could not find any competencies for Nurse #7 and did not have anything for Nurse #8, who worked for the temporary staffing agency. Administrator #1 said there were no competencies on file for any of the nursing staff for 2020 or 2021. 3) The facility failed to ensure agency nurses were provided with access to the medication dispensing system (Cubex) which has an interim supply of medications for use in emergency and non-emergency dosing for nursing facility residents until the provider pharmacy can provide a regular supply of medication to the resident, resulting in 1 Resident (#3) receiving an unnecessary pain medication. Resident #3 was admitted to the facility in September of 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During record review 9/1/2021 at 8:44 A.M., the nursing progress notes indicated that Resident #3 had experienced a fall resulting in a wrist fracture. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Discontinue the [MEDICATION(S)] (narcotic medication to treat moderate to severe pain) when the [MEDICATION(S)] is available. Review of Resident #3's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's medical record indicated that [MEDICATION(S)] tablets were received from the pharmacy on 8/21/2021. Resident #3 received the 1st dose of [MEDICATION(S)] on 8/21/2021. The facility has a Cubex electronic medication dispensing system (Cubex) to provide an interim supply of medications for use in emergency and non-emergency administration for nursing facility residents until the provider pharmacy can provide a regular supply of medication to the resident. Review of the facility Cubex inventory on 9/1/2021 at 10:02 A.M., revealed that 6 [MEDICATION(S)] 50 mg tablets were available for administration on 8/14, 8/15, 8/16 and 8/19. During an interview 9/2/ at 4:25 P.M., Nurse #9 and Nurse #11 said that accessing the Cubex is a problem on the off shifts because most nurses are agency staff and agency nurses do not have access to the Cubex. Nurse #9 and Nurse #11 said they do their best to get any needed medications before the day shift nurses leave for the day. Both Nurse #9 and Nurse #11 are agency nurses and do not have access to the Cubex. During an interview 9/7/2021 at 2:48 P.M., the Interim Director of Nursing said the facility does have a Cubex medication system to assist with emergency and non-emergency interim medication use. She also said that agency nurses do not have access to the Cubex system and on occasion the system cannot be accessed due to no facility staff working at the time of need.

Based on document review and interview, the facility failed to maintain a complete and accurate Facility Assessment to reflect resident needs and staffing patterns and required competencies. Findings include: Review of facility document titled 'Facility Assessment Portfolio' dated August 2021 indicated the following: * Staffing plan- See attached Further review of the Facility Assessment failed to include any attachments or a staffing plan. * Staff Competency- Part 3 of the Facility Assessment indicated Facility resources needed to provide competent support and care for the resident population everyday and during emergencies and included facility staff members health care professionals and medical practitioners. The competency section did not include temporary nursing agency staff and did not provide what areas of nursing care they were required to be competent in. During an interview on 9/7/21 at 1:50 P.M., Administrator #1 said that there is no staffing assessment or plan for the facility. Administrator #1 was unable to provide the surveyor with a staffing assessment or plan or a contingency staffing plan. Administrator #1 was unable to say how they determine adequate staffing for the facility based on residents needs. During an interview on 9/15/21 at 7:36 A.M., Administrator #1 said that there had been no updates to the facility assessment or staffing plan that she was aware of. Administrator #1 said that she was working off a hand written formula to determine staffing. Administrator #1 was unable to answer how the facility determines average staffing ratios based on population and census and said that she had not gotten any assistance in determining this.

Based on observation, interview and document review, the facility failed to 1) ensure staff wore appropriate Personal Protective Equipment (PPE), during a COVID-19 outbreak, while providing care to decrease the risk of spread of infection related to the Covid-19 virus, 2) implement Transmission Based Precautions (TBP) for 1 of 1 applicable unvaccinated new admission (#139) from a hospital setting, 3) ensure staff performed Binax (rapid testing for Covid-19 virus) in a private setting to reduce the potential spread of infection, 4) ensure laundry staff properly donned appropriate PPE when handling soiled linen and properly performed hand hygiene after handling soiled linens to decrease the risk of spread of infection, 5) ensure there was an active Infection Control Committee (ICC) in place and failed to ensure infection control policies were signed and dated on an annual basis, and 6) ensure that 2 of 6 nurses (Nurse #7 and Nurse #16) performed hand hygiene properly during medication administration. Findings include: 1) The facility failed to ensure staff wore appropriate PPE, during a COVID-19 outbreak, while providing care. Review of facility document titled 'COVID-19 Outbreak Checklist', undated, indicated that if the facility identifies one new resident or staff case then the facility should take the following steps to mitigate any further transmission: * Personal Protective Equipment (PPE) and Hand Hygiene: - Use gowns and gloves for high contact care activities in addition to facemasks and eye protection for COVID-19 negative residents - Post precaution signs immediately outside of resident rooms indicating appropriate infection control and prevention precautions. Review of the facility PPE Guide Card, dated 10/27/20, indicated that if there are COVID-19 cases in the facility in the last 14 days, gowns and gloves are also recommended for any high contact care. During an interview with Administrator #1 and the Interim Director of Nursing on 9/15/21 at 6:55 A.M., the Interim Director of Nursing said that the facility was currently experiencing an outbreak of COVID-19. She said that a staff member Certified Nursing Assistant (CNA) #1 who worked on the 2nd floor unit had been tested on [DATE] as part of surveillance testing and the facility was notified of the positive COVID-19 result on 9/11/21. During an observation on the 2nd floor unit (the unit on which the positive staff member had worked) on 9/15/21 at 5:15 A.M., CNA #19 was observed bringing a bag full of soiled sheets out of a resident room. CNA #19 was only wearing a mask. During an interview on 9/15/21 at 5:17 A.M., CNA #19 said he just changed a resident. He said the resident had been incontinent. CNA #19 said he thought that because he was vaccinated, he only had to wear a mask. On 9/15/21 at 5:16 A.M., CNA #18 was observed in a resident's room, gathering soiled linens. CNA #18 was wearing a mask, goggles and gloves. CNA #18 was not wearing a precaution gown. During an observation on the 3rd floor unit on 9/15/21 at 5:02 A.M. the following observations were made: -Nurse #19 and 2 Certified Nursing Assistants (CNAs) (#12 and #15) were on the unit. None of the staff members were wearing eye protection of any type. -There was no signage on the unit to indicate that there had been a positive COVID-19 case in the facility in the past 14 days. -CNA#15 was wearing a mask under her nose and no eye protection while going in and out of occupied resident rooms. -At 5:20 A.M., CNA #12 and CNA#15 were observed providing direct care to residents in separate resident rooms not wearing eye protection or gowns. During an interview on 9/15/21 at 5:10 A.M., Nurse #19 said he was not aware of any COVID-19 positive cases in the facility. During an observation on 9/15/21 at 6:50 A.M., Nurse #19 was observed providing G-Tube care to a resident and Nurse #19 was not wearing a gown. On 9/15/21 at 8:26 A.M., an observation on the 2nd floor unit, revealed that staff had not posted the proper transmission-based precautions that indicates the proper PPE requirements during a COVID-19 outbreak on any of the resident rooms. There were not precaution carts set up on the unit to ensure staff would be able to access the proper PPE. During an interview on 9/15/21 at 8:40 A.M., Certified Nursing Assistant (CNA) #11 said they don't have any precaution gowns on the floor. CNA #11 said they used to keep at least one big precaution cart at the elevator, but that's been gone for a while now. During an interview on 9/15/21 at 9:00 A.M., Nurse #11 said that there is a new staff case of COVID-19 within the last few days. Nurse #11 thought she only had to wear just the mask and goggles for all care. She said she didn't know the requirements changed. During an interview on 9/15/21 at 9:15 A.M. Consultant Nurse #3 said they posted signage over the weekend and staff should be wearing a gown with high contact care. During an observation on 9/15/21 at 9:30 A.M., on the 2nd floor unit, with Consultant Nurse #3, revealed that there were no posted signs to indicate that the facility was in a COVID-19 outbreak on any resident room and there were no precaution carts set up to ensure staff had the appropriate PPE they needed to provide care. During an interview with Administrator #1, the Interim Director of Nursing and Corporate Nurse #1 on 9/15/21 at 11:31 A.M., the Interim Director of Nursing said that staff should be wearing full PPE during any direct care they are providing. The Interim Director of Nursing said full PPE would include a mask, eye protection, a gown and gloves. The Interim Director of Nursing said there should be signs on the unit indicating the facility was experiencing an outbreak of COVID-19. The Interim Director of Nursing further said the facility had enough PPE and had a large supply of disposable gowns. See tag F886 2) The facility failed to implement Transmission Based Precautions (TBP) for 1 of 1 applicable unvaccinated new admissions (Resident #139). Review of the [NAME] Summary of Centers for Disease Control (CDC) Personal Protective (PPE) Guidance, dated 10/27/20, indicated that new admissions should be quarantined, and staff should don full PPE (face mask, gowns, face shield, eye protection and gloves) when caring for these residents. On 8/31/21 at 10:15 A.M., during observation on the 2nd floor unit revealed Resident #139, a new admission from a hospital, who also had not received a vaccine for Covid -19, lying in his/her bed. There was no signage on his/her bedroom door to indicate he/she should be on TBPs or any cart setup with PPE supplies. On 8/31/21 at 10:20 A.M., Nurse #15 said that Resident #139 was a new admission and should be on precautions. She said she wasn't sure why he/she was not because she doesn't always work on this unit. On 8/31/21 at 4:15 P.M., during observation on the 2nd floor unit, revealed that there was no precaution cart set up or TBP signage outside of Resident #139's room. On 9/1/21 at 8:15 A.M., during observation on the 2nd floor unit, revealed that there was no precaution cart set up or TBP signage outside of Resident #139's room. During an interview on 9/1/21 at 3:05 P.M., Certified Nursing Assistant (CNA) #2 said she worked on the East side of the 2nd floor unit and there are no residents on precautions on this side of the unit as far as she knew. During an interview on 9/1/21 at 3:15 P.M., Nurse #11 said there isn't anyone on precautions. When the surveyor asked about Resident #139, Nurse #11 said that he/she is in with another resident so he/she can't be on precautions. Nurse #11 said anyone on precautions is in a private room. During an interview on 9/1/21 at 3:35 P.M., the Staff Development Nurse/Infection Preventionist (SDC/IP) said that any new admission should be in a room alone and quarantined. She said that staff should don full PPE when entering the residents room. The surveyor asked why Resident #139 was admitted to a room with a roommate. The SDC/IP said she did not know why. During an interview on 9/1/21 at 3:40 P.M., the Corporate Nurse said that a new admission, unvaccinated from the hospital, should have been monitored and in a room alone. 3) The facility failed to ensure staff performed Binax testing (rapid testing for Covid-19 virus) in a private setting to reduce the potential spread of infection. Findings include: On 9/7/21 at 8:42 A.M., during observation of the lobby area of the facility, revealed Housekeeper #1 performing Binax testing in the lobby corridor in the presence of another staff member. The surveyor observed as she pulled her mask down, inserted the Binax swab into her nostril and performed the test. Once she finished swabbing her nostrils, she held the swab in the air before placing it into the Binax card. Simultaneously, Housekeeper #2, who was approximately 2 feet from Housekeeper #1, pulled down her mask, inserted the Binax swab into her nose and once she finished swabbing her nostrils, with the swab exposed to the air, she placed it into the Binax card. During an interview on 9/7/21 at 8:45 A.M., Housekeeper #1 said that this is how they always do it. She said there are no private places to go. Housekeeper #1 said she couldn't go into the offices across from the lobby because they were not allowed. During an interview on 9/7/21 at 8:50 A.M., Receptionist #1 said that staff can go into the offices. Receptionist #1 said staff know they are supposed to conduct the testing in private. On 9/15/21 at 4:10 P.M., the surveyor observed an unidentified staff member in the lobby, self-performing Covid-19 Binax testing. Several staff members passed through as this staff member pulled down her mask, performed nasal swabbing and held the Binax swab in her hand, open to air, then she placed the swab in the Binax card to await results. During an interview on 9/15/21 at 4:15 P.M., the surveyor asked the Interim Director of Nursing (IDON), if she saw the unidentified staff member perform Binax testing in the lobby. The IDON said that she did, and staff need to be in a private space. The IDON said she thought she had curtailed that practice, but obviously did not. 4) The facility failed to ensure laundry staff properly donned appropriate PPE when handling soiled linen and properly performed hand hygiene after handling soiled linens to decrease the risk of spread of infection. On 9/8/21 at 11:13 A.M., during observation of the laundry area, revealed Laundry Worker (LW) #1 wearing a sleeveless T-shirt, shorts, gloves, mask and goggles. LW #1 lifted dirty blankets and sheets out of a soiled bin and carried them to the washing machine. The soiled linen touched his T-shirt - therefore contaminating his T-shirt. LW #1 then removed his gloves, and without performing hand hygiene, began folding clean johnnies. The [NAME] was pressed up against his contaminated T-shirt. When the surveyor asked him about the process of hand hygiene, he went into the soiled linen room and began washing his hands in a sink that was filled with soiled laundry, touching his hands with the contaminated linens. During an interview on 9/8/21 at 11:35 A.M., LW #1 said that he should have put on a gown before picking up the soiled linen. He said its very busy and sometimes he forgets. LW #1 said he tries to keep the soiled linens separate and because the area is small, he keeps the soiled johnnies in the handwashing sink. 5) The facility failed to ensure there was an active Infection Control Committee (ICC) in place and failed to ensure infection control policies were signed and dated on an annual basis. On 9/8/21 at 12:07 P.M., during review of the Infection Control book (given to the surveyor by the Interim Director of Nursing), lacked identification of the Infection Control Committee members, ICC meeting minutes or comprehensive policies related to infection prevention. The last date noted on the policies that were in the book was 2017. There was no indicator that an ICC signed and approved any infection control policies within the last 12 months. During an interview on 9/8/21 at 12:07 P.M., the Interim Director of Nursing said that the facility does not have a designated Infection Control Committee. She said that there has been changeover in the nurse management staff over the last several months. She said that approximately 3 weeks ago the SDC/IP from a sister facility came to this facility but has done little thus far in the way of infection control. 6) The facility failed to ensure that 2 of 6 nurses (Nurse #7 and Nurse #16) performed hand hygiene properly during medication administration. Review of the facility policy, entitled Injectable Medication Administration, not dated, indicated that staff must wash hands prior to preparation of medication. A. On 9/1/21 at 8:05 A.M., during observation of the medication pass on the 3rd floor unit, revealed Nurse #7 as she was preparing medications for administration to a resident. Nurse #7 finished preparing medications for a resident that contained an inhaler, insulin for injection and several by mouth medications. Nurse #7 had all the medications in her hand and realized she needed to change the insulin for injection. Nurse #7 discarded the original syringe of insulin and began searching through the medication cart for another vial of insulin. Once she found the correct insulin vial, she placed it on the med cart and without performing hand hygiene, she prepared a new syringe of insulin to inject the resident. Nurse #7 was called away to assist another resident. Nurse #7 placed all the medications in the medication cart and went to the resident. Nurse #7 returned to the medication cart, and without performing hand hygiene, she took the by mouth medications, the inhaler and the insulin filled syringe and proceeded to another resident's room to administer the medications. During an interview on 8:40 A.M., Nurse #7 said it was just so busy, she forgot to use the hand sanitizer after handling medications and then preparing new medications. B. On 9/1/21 at 9:18 A.M., during observation of the medication pass on the 3rd floor, revealed Nurse #16 as she was preparing medications for administration to a resident. Nurse #16 took the prepared medications (all by mouth medications) and entered the resident's room. Nurse #16 adjusted the resident's bed linen and questioned the resident in regard to another medication. Nurse #16 left the resident's room with medications in hand, placed them on the medication cart and without performing hand hygiene, opened the medication cart and prepared another medication for the resident. During an interview on 9/1/21 at 9:22 A.M., Nurse #16 said that she should have washed her hands before preparing the next medication.

Based on interview and document review, the facility failed to ensure staff were tested for Covid-19 as indicated, in response to a Covid-19 outbreak in the facility. Findings include: 1) Review of facility policy titled 'Long Term Care Surveillance Testing', dated 9/15/21, indicated the following: * Surveillance Testing Program: If the staff testing results indicate a positive COVID-19 staff member, then the provider must conduct outbreak testing of all residents and staff, including those who are fully vaccinated and those who are not, to ensure there are no resident cases and to assist in proper cohorting of residents. Testing must take place as soon as possible and within 48 hours. Review of facility document titled 'COVID-19 Outbreak Checklist', undated, indicated that if the facility identifies one new resident or staff case then the facility should take the following steps to mitigate any further transmission: *Testing: Once a new case is identified, the facility should initiate outbreak testing. Outbreak testing should include: -Testing all staff and residents as soon as possible and no later than 48 hours after identification of the positive. This testing should include a molecular test (i.e., PCR) for affected units. During an interview with Administrator #1 and Interim Director of Nursing on 9/15/21 at 6:55 A.M., the Interim Director of Nursing said that the facility was currently experiencing an outbreak of Covid-19. She said that Certified Nursing Assistant #1 had been tested on [DATE] as part of surveillance testing and that the facility was notified of the positive Covid-19 result on 9/11/21, 4 days after the test was conducted. During an interview on 9/15/21 at 11:31 A.M., Administrator #1 said the following: -She was notified of a positive case of Covid-19 in CNA#1 on Sat. [DATE]th in the evening. Administrator #1 said CNA#1 had been tested on [DATE], as a part of routine surveillance testing, and the facility received the positive Covid-19 results on 9/11/21. -Administrator #1 said that the facility initiated outbreak testing for residents on 9/11/21 and for employees on 9/12/21. Administrator #1 said that as of the 11:31 A.M. interview, some employee PCR tests had been obtained and others were still being collected. None of the collected employee tests had been sent out to the lab for processing. -Administrator #1 was unable to say how many staff still needed to be tested . -Administrator #1 said she doesn't have a way to send out mass notifications to staff to inform them of a positive Covid-19 test in the facility and to notify them to come to the facility for testing. She said she tries to capture staff when they arrive for work. Administrator #1 further said that since receiving the positive result on 9/11/21, not all staff had been tested . -Administrator #1 acknowledged that it was Day 4 of the Covid-19 outbreak and that the facility had not yet tested all staff or sent any employee tests out to the lab for processing. During interviews throughout the day on 9/15/21, the Interim Director of Nursing acknowledged the facility had the ability to do Binax testing (a rapid Covid-19 test that shows results within 15 minutes) but that they had chosen to do PCR testing for outbreak testing. The Interim Director of Nursing further said the following: -The facility had chosen to do Covid-19 testing, and not contact tracing, in response to the outbreak and that she was unable to say how many staff members had been tested and how many still needed to be tested . -The facility's Infection Control Nurse was out of work currently and that she would be covering until they could get a replacement. -That she had spoken with the Department of Public Health (DPH) Epidemiologist on Tuesday (9/14/21) in the late afternoon but could not recall what the conversation was. She couldn't recall if she told the Epidemiologist that the employee test specimens were still in the facility and that not all staff had been tested . The Interim Director of Nursing couldn't recall if the Epidemiologist asked her if staff had been tested . The Interim Director of Nursing said she still needed to review the Epidemiologist's email from the previous day that outlined what they had discussed regarding Covid-19 outbreak management.

Based on observation, interview and record review, the facility failed to ensure that 1) interventions were implemented to prevent falls, resulting in a fall with injury and 2) interventions to prevent elopement were implemented for 1 Resident (#44), 3) an entrapment and a fall were investigated for 1 Resident (#50) and 4) fall interventions were added to the plan of care after a fall for 1 Resident (#51) out of a total sample of 37 residents. Findings include: 1) The facility failed to ensure interventions were implemented to prevent falls, resulting in a fall with injury. Resident #44 was admitted to the facility in March 2021 with diagnoses including traumatic brain injury, dementia, multiple falls, anxiety and [CONDITION(S)]. Review of Resident #44's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident had moderate cognitive impairment and scored a 10 out of 15 on the Brief Interview Status (BIMS). Further review of Resident #44's MDS indicated the Resident required assistance with all care activities and that the Resident had falls with injury since the previous assessment. Review of Resident #44's care plans indicated he/she was a high risk for falls related to incontinence, poor safety awareness, restlessness and agitation, use of [CONDITION(S)] medication, anxiety, akathisia (a movement disorder characterized by inner restlessness), attempts to self transfer, recent fall history and indicated an intervention, dated 9/3/21, for Resident #44 to be 1:1 in arms reach to prevent falls. Review of Resident #44's medical record indicated the Resident had 42 falls reports between 3/26/21 and 9/3/21 Review of Resident #44's medical record indicated a physician's order, dated 9/3/21, for 1:1 sitter for safety, every shift. On 9/3/21 at 8:08 A.M., Resident #44 was observed in a wheelchair in front of the nurses station. Resident #44 appeared visibly restless and agitated and had a healing laceration over his/her left eyebrow, bruising to his/her left peri orbital area (area around the eye) and old bruises to the right and left sides of his/her forehead. Nurse #3 said that Resident #44 fell twice last night after returning from the hospital for a previous fall and said the Resident fell again this morning and pulled a chair on top of himself/herself. Nurse #3 said the Nurse Practitioner (NP) had ordered a 1:1 for the Resident. On 9/3/21 at 8:18 A.M., Nurse #3 said the medical records clerk was going to stay with the Resident for a brief period of time until a 1:1 could be arranged. Nurse #3 said a 1:1 will be used for a resident with multiple falls but there is not enough staff to have one and further said staffing is challenging. On 9/03/21 at 8:23 A.M., Nurse #3 said the floor staff, assigned to give care to all of the other residents on the unit, would alternate shifts in 30 minute increments to provide 1:1 supervision for the Resident. On 9/04/21, Resident #44 was observed alone in his/her room from 11:27 A.M. to 11:34 A.M. Review of Resident #44's Adult Protective Services Intake Report dated 9/5/21 indicated the following: -EMS (Emergency Medical Services) responded to the facility for a reported fall with arm injury and when they arrived to the unit that Resident #44 resided on, there was no staff at the nurse's station. EMS located a staff member at the end of one hall. EMS reported the staff member said she was a nurse on one side of the unit but was unaware that EMS had been called and was unsure where the nurse for the other side of the unit was. The report further indicated that EMS began a room to room search and located Resident #44 in his/her room laying on his/her back on the floor of his/her room with no one around the Resident. The report indicated that EMS assessed Resident #44 to have diminished mental status and that another staff member walked by the Resident's room and said that this was his/her normal mental status and that they were unsure of why EMS had been called or when Resident #44 had fallen. Further, the staff member reported that Resident #44 had initially been found on the floor of the hallway and then was moved back into his/her room. The report indicated that Resident #44 was noted to have multiple bruises across his/her head and arms in all different stages of healing and multiple skin tears in all different stages of healing. The report further indicated that Resident #44's room was noted to have multiple soiled adult diapers on the floor and the Resident smelled of urine and his/her pants were noted to be wet. During a record review of Resident #44's medical record on 9/7/21 at 8:00 A.M., the following was indicated: - Skin Only Evaluation dated 9/5/21 at 5:43 P.M.: Patient 1:1 supervision with 2 aides on entire floor. Patient fell in hallway when an aide was looking for assistance. Order to send to ER. Unwitnessed. Small skin tear noted. Will go to hospital. -Nurses Note dated 9/5/21 at 6:43 P.M. : Patient 1:1 supervision with 2 aides on entire floor. Unwitnessed fall. Patient combative and aggressive. Assist up to wheelchair. Small skin tear noted. Order to send to hospital to evaluate and treat. Review of Resident #44's Emergency Department document dated 9/5/21 indicated the following: - Patient presents to the emergency room for evaluation after an unwitnessed fall at nursing home. Apparently, the patient crawled out into the the hallway of the nursing home when staff found him/her. Patient states he/she fell out of bed. According to EMS (Emergency Medical Services) they could not find any staff that was aware of the patient, there was no staff on his/her floor at all, and they filed elder neglect paperwork. During an interview on 9/7/21 at 9:40 A.M., the Interim Director of Nursing said she was familiar with Resident #44 and that the Resident had multiple falls and was impulsive. The Interim Director of Nursing said that the expectation regarding the order and care plan intervention for 1:1 supervision for this Resident is that it should have been followed. During telephone interviews throughout the day on 9/7/21 and 9/16/21, Nurse #4 said she was working on 9/5/21 when Resident #44 fell . Nurse #4 said she was only notified that the Resident fell on ce during her shift and that the multiple notes written about his/her fall were related to the same fall. Nurse #4 said staff did their best to watch him/her during the shift but due to low staffing it was difficult. Nurse #4 said that there were only 2 Certified Nursing Assistants (CNAs) working on the unit (unit census was 41 residents) when Resident #44's fall happened and it was difficult to maintain the 1:1 for the Resident as ordered. Nurse #4 said that a CNA left the Resident alone in the hallway to ask for help and that's when the Resident fell . Nurse #4 said staff assisted him/her to a wheelchair and she observed a skin tear to the Resident but was unsure of the location. Nurse #4 said another nurse dressed the skin tear and then brought the Resident back to his/her room. Nurse #4 was unable to say if the Resident remained supervised as ordered after the fall and could not say why the Resident was found alone on the floor of his/her room by EMS. Nurse #4 said she had called the Administrator #1 on 9/5/21 to say that there was not enough staff to provide a 1:1 for Resident #44 and ensure his/her safety and asked if the Administrator #1 would come in to act as the 1:1. Nurse #4 said the Administrator #1 told her she lived too far away and would not come in. Nurse #4 said that Resident #44 fell after she had contacted the Administrator #1 asking her to come in to be the Resident's 1:1. Nurse #4 said she didn't think the staffing level was safe on the unit. Nurse #4 said she thought the Resident sustained a skin tear but she was unsure of the location. Nurse #4 said nursing staff had notified administration multiple times that they felt Resident #44 was unsafe in the facility and that they couldn't safely care for him/her. During an interview on 9/8/21 at 9:09 A.M., Administrator #1 said she was familiar with Resident #44. Administrator #1 said he/she has fallen more than any resident she has ever worked with. Administrator #1 said on 9/3/21 they talked about having staff with Resident #44 at all times as a 1:1. Administrator #1 said a nurse called her on 9/5/21 in the afternoon and asked her to come in to be the 1:1. Administrator #1 said she told the nurse no and that she would not come in because she lived too far away. Administrator #1 said the nurse then told her that the staff couldn't provide the 1:1 for Resident #44. Administrator #1 said she did not ask how many staff were on the unit and that she was unsure how many staff was present. Administrator #1 said she called the scheduler about an hour after receiving the call from nursing staff that they couldn't provide the 1:1 for Resident #44. Administrator #1 said she did not follow up with the nursing staff or the scheduler regarding the request from the nurse for a 1:1 for Resident #44. Administrator #1 was unsure as to when she was notified about Resident #44's fall and being sent to the hospital. During an interview on 9/8/21 at 11:06 A.M., The Staffing Coordinator said that there was a staffing issue on 9/5/21 during the 3-11 shift on the 3rd floor. The Staffing Coordinator said Administrator #1 asked her if she could come in to be Resident #44's 1:1 and she was unable to do it. The Staffing Coordinator said she reached out to staff to try to find someone but no one responded. The Staffing Coordinator was unable to say if she notified Administrator #1 or nursing staff that she was unable to find someone to act as a 1:1. 2) The facility failed to ensure elopement interventions were implemented. Resident #44 was admitted to the facility in March 2021 with diagnoses including traumatic brain injury, dementia, multiple falls, anxiety and [CONDITION(S)]. Review of Resident #44's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident had moderate cognitive impairment and scored a 10 out of 15 on the Brief Interview Status (BIMS). Further review of Resident #44's MDS indicated the Resident required assistance with all care activities and that the Resident had falls with injury since the previous assessment. Review of Resident #44's medical record indicated the following: - The Resident's Health Care Proxy was invoked effective 3/23/21 - A care plan initiated 7/16/21: *Focus- It is unsafe for the Resident to leave this facility, however he/she may attempt to do so related to decreased cognition, poor safety awareness, history of elopement, poor adjustment, dementia, history of wandering * Interventions- Please monitor the Resident's whereabouts frequently and re-direct him/her away from doors; initiated 7/16/21 - A physician's order dated 7/16/21 for a wander guard (a device used to prevent elopement) in place to the Resident's left ankle - A nurses note dated 7/16/21: Healthcare Proxy approved to place wander guard on the Resident -A nurses note dated 8/23/21 at 8:00 A.M.: Resident #44 was confused, restless, agitated at times, non compliant within baseline most of the 11-7 shift. Around 6 A.M., another Certified Nursing Assistant (CNA) from a lower floor reported that she needed help to stop the Resident from exiting this facility. Immediately, the Resident was persuaded to return to his/her room. The nurses note failed to indicate if the Resident's wander guard was in place at the time of the elopement. Review of the facility incident report indicated the following: - An incident report form dated 8/30/21: The Resident was found at approximately 6:30 A.M. in his/her wheelchair on the front patio by a staff member (contradicting the nurse's note). - An undated statement signed by the Scheduling Coordinator: On Monday 8/23 around 6:30 A.M., the Scheduling Coordinator was coming in to the building when she saw Resident #44 on the front patio. He/she was out of his/her wheelchair and was starting to walk. The Scheduling Coordinator ran to get on to the patio but was too late, the Resident had already fallen onto the ground. - A statement dated 8/23/21 and signed by the Interim Director of Nursing that she had interviewed Nurse #5 concerning Resident #44 being found on the patio by the Staffing Coordinator. The statement indicated that Nurse #5 told the Interim Director of Nursing that he saw the Resident with a CNA but he was never told that the CNA went downstairs to bring the Resident back to the unit. During an interview on 9/07/21 at 1:02 P.M., the Scheduling Coordinator said she saw the Resident on the front patio while she was walking into the building on her way in to work. The Scheduling Coordinator said Resident #44's wheelchair was by the door to the facility and that the Resident was on the ground. The Scheduling Coordinator said the Resident was alone. The Scheduling Coordinator said she entered the building from the same door the Resident had exited the facility from and told the CNA on the first floor to call for a nurse. The Scheduling Coordinator said a CNA from the 3rd floor came down to bring the Resident back up. During an interview on 9/07/21 at 1:59 P.M., the Interim Director of Nursing said that if a resident is found outside of the building, and has an activated Health Care Proxy, then it would be considered an elopement. The Interim Director of Nursing said she learned that the Resident had cut his/her wander guard off using a butter knife. The Interim Director of Nursing said staff was aware that the Resident was able to remove the wander guard but still continued to keep it as an elopement intervention. The Interim Director of Nursing said the wander guard was kept in the medication cart on the unit, and not on the Resident, so it wouldn't get lost. The Interim Director of Nursing was unable to say how long the wander guard was off of Resident #44 prior to his/her elopement. The Interim Director of Nursing said she interviewed Nurse #5 but did not have him complete a statement. The Interim Director of Nursing said the investigation was still ongoing and acknowledged this incident occurred on 8/23/21 (15 days prior to the interview). Attempts to interview Nurse #5 by telephone were unsuccessful. 3) For Resident #50, the facility failed to investigate an entrapment and a fall. Review of the facility policy Accidents and Incidents-Investigating and Reporting dated 2017 on 9/7/2021 at 1:51 P.M. indicated all accidents or incidents involving residents, employees, vendors etc., occurring on our premises shall be investigated and reported to the Administrator. Review of the nursing progress notes for Resident #50 indicated the Resident was yelling out for help on 5/4/2020 at 1:46 A.M. The Resident was found caught between the bed mattress and the bed side rails. The facility staff assisted the Resident back to the middle of the bed and observed scrapes under the breast and groin. These injuries were treated with cleansing and [MEDICATION(S)]. Resident #50 was admitted to the facility in March 2015 with diagnoses including [CONDITION(S)], [CONDITION(S)] and multiple [CONDITION(S)]. Resident #50 was cognitively intact, did not ambulate and required the assistance of 2 staff for most care needs. Review of the accident/incident file indicated no report or investigation into the entrapment. During an interview 9/7/2021, the Interim Director of Nursing said she could not find a file of the incident that occurred 5/4/2020 at 1:46 A.M. The Interim Director of Nursing also said that she did not work at the facility at that time. Further review of the nursing progress notes for Resident #50 indicated the Resident took a fall while sleeping, yelled out for help and was found on the floor 6/14/2020 at 9:18 A.M. The Resident complained of discomfort to the right side of his/her head after the fall. The incident file contained a completed incident report. No resident or staff interviews were included in the file. No investigation had been completed per facility policy. During an interview 9/7/2021, the Interim Director of Nursing said only the report was in the file, no interviews or investigation were included. The Interim Director of Nursing also said that she did not work at the facility at that time. 4) For Resident #51, the facility failed evaluate and implement interventions to prevent falls. Review of facility policy titled, Assessing Falls and Their Causes dated, 2017 indicated: When a resident falls, the following information should be recorded in the resident's medical record: 1. The condition in which the resident was found 2. Assessment data, including vital signs and any obvious injuries 3. Notification of the physician and family, as indicated. 4. Completion of a falls risk assessment 5. Appropriate interventions taken to prevent future falls Resident #51 was admitted to the facility in August 2020 with diagnoses including, acute kidney failure, [CONDITION(S)], scoliosis, and adult failure to thrive Review of Resident #51's most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated that he/she is cognitively intact with a score of 13 out of possible 15 on the Brief Interview for Mental Status (BIMS). Further review of the MDS indicated extensive assistance for bed mobility, transfers, and toileting. Review of Resident #51's medical record indicated the resident had a fall in July 2021. Nursing progress notes dated 7/15/21 and 7/16/21 indicated Resident #51 was status post a fall. A hospice note dated 7/20/21 indicated Resident #51 had a fall on 7/15/21 and was found on the floor in his/her room in between the two beds. Further review of Resident 51's medical record indicated no further nursing notes regarding incidents of falls or interventions put into place. Further review of Resident #51's medical record indicated a Physicians order dated 8/28/21 to send resident to the hospital for an evaluation due to a fall with a head strike. Review of incident reports for Resident #51 dated 7/12/21 and 7/14/21 indicated Resident #51 had fallen on both days. During an interview on 09/07/21 at 9:37 A.M. the Interim Director of Nursing said expectations for Nursing Staff following a fall include putting an immediate intervention in place which will be assessed the following morning in morning meeting. See F835

Based on observation, record review and interview, the facility failed to (1) promote the prevention of skin injury, (2) promote the healing of skin injury and (3) prevent further development of new skin injury for 1 Resident (#80) from a total sample of 37 residents. Findings include: Resident #80 was admitted to the facility in May 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 8/31/21 at 7:45 A.M., Resident #80 was lying in bed on a low air loss mattress in a fetal position. He/she appeared emaciated with visible muscle wasting. The Resident had no clothes on other than an adult brief, was unshaven and had long fingernails with brown caked material under each nail. A gauze wrapped dressing was seen on the left foot with bloody drainage and a dressing was in place to the left shin. The Resident's right hip had an exposed open wound approximately 3 x 1.5 inches with a dark brown center and very pink edges. Review of the Resident's Minimum Data Set (MDS) dated [DATE] indicated the Resident was cognitively intact with a BIMS score of 12 out of 15. The MDS further indicated that Resident #80 required assistance to reposition in bed and to get out of bed. He/she ambulated with a cane under supervision due to an unsteady gait. Resident #80's skin was intact and had no wounds. Review of the attending physician's admission history and physical dated 5/11/21, indicated that Resident #80 was alert, forgetful and cooperative during the exam with an irritable affect. The physician note further indicated the Resident was well developed, well nourished and in no acute distress. He/she had decreased strength in the left arm and leg. The Resident was having difficulty with ambulation up and down the hall due to the left sided weakness. Review of the clinical record indicated Resident #80 suffered a significant weight loss identified 6/7/21 and this weight change was considered severe by facility policy. Further record review 9/1/2021 indicated no evidence of the Resident's physician or dietitian notification of the significant weight change identified 6/7/21 with a 24 hour response required by facility policy. A nutritional intervention did not occur until 6/25/2021 (18 days after Resident #80's significant weight loss was documented). Resident #80 developed denuded (damaged skin from prolonged moisture and friction) skin to the coccyx area on 6/25/21. The following interventions were ordered on 6/25/21: - air mattress - multivitamins with minerals 1 tablet by mouth once daily - vitamin C 500 milligrams 1 capsule by mouth once daily - ensure plus liquid (nutritional supplement) 1 unit by mouth once daily - nutritional consult The denuded skin on the coccyx area deteriorated to an open pressure wound on 7/5/21. The Resident continued to lose weight and the nutritional consult ordered by the physician did not occur until 8/13/21. The dietician assessed the resident to have protein and calorie malnutrition related to poor appetite and nourishment. Review of the MDS dated [DATE] indicated Resident #80 had a Stage 1 wound. The skin was intact with redness present. During an interview 9/1/21 at 8:20 A.M., Nurse #10 said the Resident must be fed and usually eats 25% or less of his/her meal. She also said that the Resident will take liquids when offered. Review of the Resident #80's care plan, dated 8/17/21, identified the potential for pressure ulcer development related to decreased mobility, incontinence, hypertension, diabetes and pain. The goal of the care plan was the Resident would have intact skin, free of redness, blisters or discoloration through the next review date. Interventions to achieve the goal were to follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident needs moisturizer barrier applied every shift and as needed to skin. The Resident needs assistance to turn/reposition at least every 2 hours, more often as needed. Review of Resident #80's medical record indicated no evidence of sufficient monitoring or interventions regarding the Resident's nutritional status. There was no evidence of the Resident's intake and output documentation. The Wound Physician evaluated the Resident 8/9/21 at the request of the attending physician. The evaluation was as follows: - Site 1, Stage 2 pressure wound of the left, distal, medial foot. The wound is over 10 days duration, presents as a fluid filled blister that measured 2.5 x 4 centimeters (cm). Treatment plan was to off-load the wound. - Site 2, Stage 2 pressure wound of the left, medial, first toe. The wound is over 10 days duration, presents as a fluid filled blister measured 2.4 x 1.5 cm. Treatment plan was to off-load the wound. - Site 3, moisture associated skin damage of the left buttock. The wound is over 14 days duration, measured 2 x 1 cm. Treatment plan was [MEDICATION(S)] powder twice daily, off-load the wound and reposition per facility protocol. - Site 4, moisture associated skin damage of the right buttock. The wound is over 14 days duration, measured 2 x 1 cm. Treatment plan was [MEDICATION(S)] powder twice daily, off-load the wound and reposition per facility protocol. - Site 5, wound of the right flank. The wound is over 14 days duration, measured 2 x 3 cm. Treatment plan was xeroform sterile gauze with a gauze island dressing with a border and off-load the wound. The Wound Physician re-evaluated the Resident 8/30/21 at the request of the attending physician. The evaluation was as follows: - Site 1, Unstageable (due to necrosis) wound of the left, distal, medial foot with full thickness, measured 5x4 cm. No wound progress. Surgical debridement (cleaned the wound and removed any infected and dead tissue) was performed. Treatment plan was apply santyl (debridement ointment) once daily, alginate calcium (absorbs drainage) once daily and cover with gauze roll and secure with paper tape. Off-load the wound. - Site 2, Unstageable (due to necrosis) of the left, medial, first toe with full thickness, measured 4x2 cm. No wound progress. Surgical debridement was performed. Treatment plan was apply santyl once daily, alginate calcium once daily, cover with gauze roll and secure with paper tape. Off-load the wound. - Site 3, moisture associated skin damage of the left buttock with partial thickness, measured 2x1 cm. No wound progress. Treatment plan was [MEDICATION(S)] powder twice daily, off-load the wound and reposition per facility protocol. - Site 4, moisture associated skin damage of the right buttock with partial thickness, measured 2x1 cm. No wound progress. Treatment plan was [MEDICATION(S)] powder twice daily, off-load the wound and reposition per facility protocol. - Site 5, Unstageable deep tissue injury of the right, lateral hip with full thickness, measured 2x3 cm. No wound progress. Surgical debridement was performed. Treatment plan was santyl once daily with alginate calcium, gauze island dressing with a border and off-load the wound. - Site 6, Stage 2 wound of the left, medial shin with partial thickness. The wound is over 14 days duration, measured 3 x 1 x 0.1 cm. Wound has improved. Treatment plan was gauze island dressing with a border once daily and off-load the wound. - Site 7, Stage 2 pressure wound of the right, medial, thigh with partial thickness. The wound is over 10 days duration, measured 2 x 1.5 x 0.1 cm. No wound progress. Treatment plan was gauze island dressing with a border once daily and off-load the wound. - Site 8, Unstageable deep tissue injury of the right, distal, lateral foot with partial thickness. The wound is over 14 days duration, measured 2 x 2 cm. The treatment plan was skin prep once daily and off-load the wound. - Site 9, Stage 2 pressure wound of the left elbow with partial thickness. The wound is over 5 days duration. Presents as a fluid filled blister that measured 3 x 2 cm. Treatment plan is off-load the wound. The Wound Physician evaluated the Resident 9/27/21 at the request of the attending physician. The evaluation was as follows: - Site 1, Stage 4 pressure wound of the left, distal, medial foot with full thickness. The wound is over 55 days duration, measured 3 x 2 cm. No wound progress. Surgical debridement was performed. Treatment plan was santyl and alginate calcium once daily with gauze roll secured by paper tape. Off-load the wound. - Site 2, Unstageable (due to necrosis) of the left, medial, first toe with full thickness. The wound is over 55 days duration, measured 4 x 2.5 cm. No wound progress. Surgical debridement was performed. Treatment plan was santyl and alginate calcium once daily with gauze roll secured with paper tape. Off-load the wound. - Site 5, Unstageable deep tissue injury of the right, lateral hip with full thickness. The wound is over 59 days duration, measured 1 x 2 cm. Wound has improved. Treatment plan was alginate calcium covered with a gauze island dressing with a border once daily. Off-load the wound. - Site 6, Stage 2 pressure wound of the left, medial shin with partial thickness. The wound is over 40 days duration, measured 2 x 1 x 0.1. Wound has improved. Treatment plan was a gauze island dressing with a border once a day. Off-load the wound. - Site 7, Stage 2 pressure wound of the right, medial thigh was resolved. - Site 8, Unstageable deep tissue injury of the right, distal, lateral foot with partial thickness. The wound is over 31 days duration, measured 2 x 2 cm. No wound progress. Treatment plan was skin prep once daily and off-load the wound. - Site 10, moisture associated skin damage of the upper buttock with partial thickness. The wound is over 13 days duration, measured 1x1.5x0.2 cm. No wound progress. Treatment plan was xeroform sterile gauze, an ABD pad once daily and [MEDICATION(S)] powder to the peri-wound once daily. Resident #80 continued to lose weight, became contracted and had multiple deteriorated wounds. See F692 and F725

Based on observation, record review and interview, the facility 1) failed to follow their Weight Assessment and Intervention policy to identify a significant weight loss for 1 Resident (#80) and 2) failed to ensure weights were obtained in accordance with physician's orders and facility policy for 1 Resident (#49) from a total sample of 37 residents. Findings include: Review of the facility Weight Assessment and Intervention policy dated 2017 with a revision date of 2019, indicated the following: Nursing staff will measure resident weights on admission, the next day and weekly for 2 weeks or as recommended or ordered thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. Weights will be recorded in each unit's Weight Record chart or notebook and in the individual's medical record. The threshold for significant unplanned and undesired weight loss will be based on the following criteria (where percentage of body weight loss = (usual weight-actual weight) / (usual weight x 100): a. 1 month-5% weight loss is significant; greater than 5% is severe. b. 3 months-7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months-10% weight loss is significant; greater than 10% is severe. 1) Resident #80 was admitted to the facility in May of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation 8/31/21 at 7:45 A.M., Resident #80 was lying in bed in a fetal position. He/she appeared emaciated with visible muscle wasting. Review of the clinical record indicated Resident #80 weighed 178.4 pounds on admission in May 2021. He/she weighed 159.0 pounds in June 2021, which indicated a significant loss of 10.87% in 1 month and weighed 149.0 pounds in August 2021 which indicated a significant loss of 16.48 pounds in 3 months. These weight changes were considered severe by facility policy. Resident #80's recorded weights were: 5/8/21-178.4 standing. 5/8/21-178.4 standing. 5/9/21-no weight completed as required per policy. 5/17/21-no weight completed as required per policy. 5/24/21-no weight completed as required per policy. 6/7/21-159.0 by lift-10.87% significant weight loss in 1 month. 8/5/21-148.8 by lift-16.59% significant weight loss in 3 months. 8/9/21-149.0 by chair-16.48% significant weight loss in 3 months. Review of the Weight Assessment and Intervention policy indicated once a 3 pounds weight change has been confirmed, nursing will immediately notify the physician and the dietician. The physician and the dietician are expected to respond within 24 hours of the Resident's weight change. Further record review 9/1/2021 indicated no evidence the Resident's physician or dietician were notified of a significant weight change identified 6/7/21 with a 24 hour response. A nutritional intervention did not occur until 6/25/2021 (18 days after Resident #80's significant weight loss was documented). During an interview 9/1/21 at 8:20 A.M., Nurse #10 said the Resident must be fed and usually eats 25% or less of his/her meal. She also said that the Resident will take liquids when offered. During an interview 9/1/21 at 12:53 P.M., CNA #4 was attempting to feed Resident #80 and requested assistance from Nurse #10. The Resident consumed 25% of the meal and 3-6 ounce glasses of juice. CNA #4 said the Resident's appetite is not very good. Review of Resident #80's medical record indicated Ensure Plus (nutritional supplement) 1 unit daily by mouth and a nutritional consult were ordered on 6/25/2021. Record review indicated no evidence of the nutritional consult until 8/13/2021. During an interview on 9/2/2021 at 11:28 A.M., Dietician #1 said that she is in the facility 2 days weekly and further said to her knowledge the dietician position had been vacant for months. Dietician #1 said she did visit Resident #80 on the unit but did not document in the record other than the Minimum Data Set Assessment (MDS). Dietician #1 also said the Resident's quarterly nutritional assessment was completed 8/13/2021 which revealed severe chronic protein and calorie malnutrition related to poor oral intake secondary to the Resident's refusal of meals and that the Resident had a significant weight loss since admission. The Dietician said the Resident's wounds present were related to pressure injuries and inactivity. Dietician #1 said the nursing staff would offer an alternate meal when meals are refused and offer snacks throughout the day. Dietician #1 said she does not attend resident risk meetings but will bring any concerns to nursing staff and further said when resident weights are missing she does bring it to the nurses attention at morning meetings. 2) For Resident #49, the facility failed to ensure weights were obtained according to physician orders and failed to ensure a reweigh was performed in accordance with facility policy. a. Resident #49 was admitted to the facility in November 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) completed on 7/13/21 indicated Resident # 49 was cognitively intact and scored 13 out of 15 on the Brief Interview for Mental Status (BIMS), which indicates Resident #49 is cognitively intact. Review of Resident #49's medical record indicated that Resident #49 was not weighed for a period of 8 months between 12/14/20-8/4/21. Review of Physician's orders dated 4/12/2021 indicated that the Resident needed to be weighed weekly for four weeks then monthly thereafter. Review of Dietician #1 record review on 7/18/21 indicated she identified no recorded weights for Resident #49 from 12/14/20 to 8/4/21. During an interview on 9/2/2021 at 11:24 A.M., Dietician #1 said the Resident was not weighed for a period of 8 months. Dietician #1 said weights should be completed at admission, weekly, then monthly after. The Dietician #1 said staff should document if the resident refuses to be weighed. Review of the progress notes indicated that Resident #49 refused to be weighed only on 3/19/21 and 5/12/21. There was no indication that Resident #49 refused to be weighed at any other time. b.) Review of the facility policy titled Weight Assessment and Intervention, revised in 2019, indicated: *The facility may elect to treat any unplanned, undesired weight change of three (3) pounds or more from the previously recorded weight as a potential undesired weight change. Any (3) pound weight change will result in a reweigh within 24 hours. Once these three (3) pounds weight change have been confirmed, nursing will immediately notify the Physician and Dietitian of the weight change. Documentation of this notification shall be entered in the resident's medical records. Resident #49 was admitted to the facility in November 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) completed on 7/13/21 indicated Resident # 49 scored 13 out of 15 on the Brief Interview for Mental Status (BIMS), which indicates Resident #49 is cognitively intact. Review of Resident #49's medical record indicated the following: *On 5/25/20, Resident #49 weighed 195.6 lbs. (on a chair scale). *On 6/4/20, Resident #49 weighed 163.3 lbs (a 32.3 lb weight difference in 11 days that was not identified and addressed). During an interview on 9/3/2021 at 1:14 P.M., Certified Nursing Assistant (CNA) # 10 said if weights are suspected to be incorrect, reweighs are prompted by the nurse on the unit. During an interviews throughout the day on 9/7/21, Dietitian #1 said reweighs in the facility should be done for any weight change of 3 pounds, and a reweigh should be done within 24 hours. Dietician #1 said she had worked at the facility for 2 months and she was told when she was hired that it was the expectation that the dietitian, unit managers and Director of Nursing would have risk meetings (meetings to discuss weight loss) but that no risk meetings had been done as of yet because there were no unit managers in the facility. During an interview on 9/8/21 at 11:59 A.M., the Interim Director of Nursing said the expectation would be that for any weight loss of 2 pounds or more, residents would be reweighed within 24 hours by a nurse and an aide to validate the accuracy of the weight loss and that the residents would be tracked in risk meetings.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who upon readmission to the Facility in January 2021, was documented by nursing to have intact skin, and was assessed as being at increased risk for skin breakdown, the Facility failed to ensure Resident #1 received adequate treatment and services to prevent the development of a pressure injury and promote wound healing, when nursing failed to notify the physician on 5/05/21 of a new pressure injury to Resident's #1's right thumb until 5/10/21, which resulted in a delay in treatment and worsening of the pressure injury. Findings include: The Facility's Policy titled, Skin Assessment, dated 2018, indicated that if a resident experience a change in condition; altering his/her risk for skin breakdown, the facility shall re-assess the resident for a change in one's skin integrity. Resident #1 was admitted to the Facility in May 2019, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nursing Admission/Readmission, dated 1/29/21, indicated Resident #1 had no pressure injuries on re-admission, and no skin issues were documented. The Norton Score (Skin Risk Assessment), dated 3/31/21, indicated Resident #1 triggered as being at high risk for development of a pressure injury. Review of the Admission Minimum Data Set (MDS), dated [DATE], indicated Resident #1, was severely cognitively impaired, required an extensive assist of two staff persons for all care needs, had no unhealed pressure injuries, no other wounds or skin problems and was at an increased risk for development of pressure injuries. Review of the MDS, Care Areas Assessment, dated 3/23/21, indicated pressure injury triggered as an area of concern for Resident #1 and to address the pressure injury risk with a care plan. Review of Resident #1's medical record, indicated there was no documentation to support that Resident #1's right thumb pressure injury was assessed by nursing or that the physician was notified immediately on 5/05/21 of a new pressure injury to Resident's #1's right thumb, until 5/10/21. Review of Facility's Investigation, dated 05/12/21, indicated on 05/12/21 it was reported at the Risk Management weekly meeting, that Resident #1 had a pressure injury reported to nursing on 05/05/12 and that there was no documentation in Resident #1's nursing notes, treatment record or care plan indicating his/her development of a new pressure injury to the right thumb. Review of the Facility Weekly Skin Check, dated 5/27/21, indicated Resident #1 had developed a Stage II pressure injury to his/her right thumb. Review of the nursing documentation indicated length and width was unknown and depth of the right thumb pressure injury, was also not indicated. During an interview on 6/10/21 at 9:32 A.M., the Occupational Therapist (OT) said on 5/05/21 she found an open area on Resident #1's right thumb and reported it to Nurse #1 (who worked the day shift). The OT said Nurse #1 assessed Resident #1's right thumb. The OT said Resident #1 was at a high risk for skin breakdown, said she was concerned about maintaining Resident #1's skin integrity and that she wanted to keep Resident #1's right index finger off of his/her right thumb. The OT said on 5/05/21, later in the day Resident #1 was seen for another therapy session and saw that Resident #1's right thumb did not have a dressing covering his/her right thumb open area. The OT said she then spoke with Nurse #2 ( who worked the evening shift) about Resident #1's pressure injury since, Nurse #1 left for the day, and said Nurse #2 covered Resident #1's open area with a Band-Aid. Review of the Nurse Progress Note, dated 5/12/21 as a late entry for 5/10/21, indicated Resident #1 had an open area on his/her right thumb (finger contracted), the Nurse Practitioner was notified and nursing received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Treatment Administration Record (TAR), dated 5/05/21 through 5/31/21, indicated Resident #1's right thumb treatment order was not transcribed until 05/10/21, despite documentation that indicates Resident #1's change of condition was reported to Nursing on 5/05/21. During an interview on 6/17/21 at 11:00 A.M., Nurse #1 said she does not recall the OT notifying her on 5/05/21 about Resident #1's pressure injury to his/her right thumb. Nurse #1 said on 5/06/21 Resident #1's right thumb had a Band-Aid, and said she assessed his/her open area and cleaned the wound. Nurse #1 said she left a note for the Nurse Practitioner to obtain a treatment order for Resident #1's pressure injury. Nurse #1 said when she returned to work on 5/10/21, Resident #1 still did not have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #1 said she spoke with the Nurse Practitioner on 5/10/21 to obtain Resident #1's treatment order. Review of Nurse #2's written statement, dated on 5/12/21, indicated that on 5/05/21, the OT told her that Resident #1 had a small open area on his/her right thumb, and that Nurse #1 (from the day shift) was going to call the physician and obtain a dressing order. Nurse #2's written statement indicated Resident #1's wound measured 1.75 centimeters (cm) x 1.5 cm and that she placed a Band-Aid on his/her right thumb open area. During an interview on 6/10/21 at 3:43 P.M., Nurse #2 said on 5/05/21 Resident #1 did not have a dressing on his/her right thumb, and said the OT told her that said Nurse #1( who worked the day shift) was made aware of Resident #1's pressure injury. Nurse #2 said there were no physician treatment orders for Resident #1's right thumb pressure injury in his/her TAR. Nurse #2 said she did not follow up on Resident #1's pressure injury treatment, did not call the physician, but said she placed a Band-Aid on Resident #1's right thumb. Review of the Nurse Progress Note, dated 5/27/21, indicated Resident #1's wound dressing was changed, Resident #1's right thumb was erythematic (redness), surrounding skin was moist, and slightly cyanotic (bluish or grayish color). The Note indicated the OT reported noticing a foul smell coming from Resident #1's right thumb, and Resident #1 was observed in pain when moving his/her extremities. Review of Resident #1's Nurse Practitioner (NP) Note, dated 5/28/21, indicated Resident #1's was yelling out upon assessment of his/her right thumb, that Resident #1's hand was contracted around right thumb, an odor was present, with warmth and tenderness. The NP's Note indicated likely Resident #1 had developed wound [CONDITION(S)]. Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 6/16/21 at 11:54 A.M., The Regional Director of Clinical Operations said when a resident develops a new skin integrity concern; nurses need to notify the physician and transcribe any physician or treatment orders immediately, provide treatment care as ordered and notify the residents' responsible party of the new changes on the same day of occurrence. The Regional Director of Clinical Operations said it is the responsibility of the staff providing the wound care to the resident to document the care and to accurately complete the weekly skin checks.

Based on records reviewed and interviews, for one of two sampled units (Unit #2) that had a total daily census of 46 residents who required staff assistance or were totally dependent on staff to meet care needs, the Facility failed to ensure residents were free from abuse, including neglect with emotional harm, when as a result of insufficient staff levels, residents reported they were angry and upset with lack of staff assistance with care, that they were left in soiled incontinent briefs for hours despite asking for help, one resident reported feeling scared because of the lack of staff on the unit, and another stated that living in the Facility was a nightmare. Findings include: During the survey conducted over a three day period, resident and staff interviews were consistent with reports of insufficient staffing levels which directly resulted in the Facility's inability to adequately and safely meet resident care needs, but also contributed to residents' feeling of emotional distress and mental anguish. Resident and staff interviews were consistent and indicated that staffing has been short many times, especially on the evening shift. During an interview on 6/09/21 at 12:56 P.M., a resident said that he/she was sitting in his/her wheelchair for several hours, had been incontinent, was calling for assistance, and that a Certified Nurse Aide (CNA) told him/her there was not enough staff on that day to help transfer him/her into bed and assist with personal hygiene care. The resident said he/she had to call emergency medical services (911) to ask for help. The resident said he/she gets very uncomfortable and is physical pain, when not repositioned. The resident said, sitting and waiting for help that does not come, is upsetting and said morally it is not right to have to experience this. During an interview on 6/09/21 at 1:15 P.M., another resident said that he/she felt shaky inside and nervous, if he/she does not receive his/her medications on time. The resident said it is not fair that he/she has to wait and that is makes his/her anxiety worse. The resident said there is not enough staff to help the residents on the unit (Unit #2) with even their basic needs and said he/she feels scared at times. During an interview on 6/09/21 at 3:02 P.M., another resident said he/she had a scheduled visit with a family member, had requested assistance with personal hygiene prior to the visit and said he/she was told that there was not a staff member available to help him/her. The resident said he/she had asked for staff assistance before 10:00 A.M. and was left to sit in his/her wheelchair not dressed and was incontinent. The resident said he/she was upset, felt uncomfortable and was not assisted with personal care until 4:00 P.M.( approximate 6 hours later). The resident said he/she needs to ask for his/her scheduled medications to make sure he/she gets them on time, and said if they are late it affects how he/she physically feels the next day, in a negative way. During an interview on 6/11/21 at 7:58 A.M., another resident said the management team is always changing and that results in lack of communication and information shared with the residents. The resident said management is not at the facility long enough to see what the needs of the residents are or to address resident safety concerns. The resident said he/she is upset, angry and said that living in the facility is a nightmare. During an interview on 6/10/21 at 7:30 A.M., Nurse #5 said residents have been telling her they are waiting long periods of time to be assisted with care and said CNA's are unable to provide all the care required. Nurse #5 said she will provide care alone to residents (even if they require an assist of two) since there are no CNA's to help her. During an interview on 6/10/21 at 11:24 A.M., CNA #1 said residents tell staff they are frustrated and that they feel like they are not being cared for. CNA #1 said that the administrative team are aware of the staffing concerns and said she was told by administration that the facility does not have staff and to be patient. CNA #1 said that meeting resident care needs has been difficult. CNA #1 said one resident, who required a two person physical assist from staff, called the police recently on the evening shift because he/she had been waiting for hours to be assisted to back bed. During an interview on 6/10/21 at 10:48 A.M., Nurse #4 said, on one occasion most recently, she called the Administrator on the phone from her unit (#2) to ask for help since they were short staffed, and said that she reported staffing levels felt unsafe and that the residents needed more help than what assigned staff could provide. Nurse #4 said she was told by the Administrator that there was no one to help. Nurse #4 said shortly after the telephone call she went to speak directly with Administrator about Unit 2's safety concerns and said the Administrator had already left the Facility for the day. During an interview on 6/11/21 at 12:35 P.M., Nurse #7 said staffing has been an issue at the Facility. Nurse #7 when she was delivering a meal tray to a resident, she asked the resident if he/she needed help with the tray. Nurse #7 said the resident responded How do you suppose I would even want to eat when I have been laying in my own urine since midnight and I was told by staff there was no-one to help me., or words to that affect. Nurse #7 said the residents bed sheets were saturated in urine, that the urine had made an outline pattern on the sheets, and said it looked like the urine had been on bed sheets for a long period of time. During an interview on 6/11/21 at 2:45 P.M., Nurse #6 said staffing concerns have been affecting the residents and said What residents have endured is neglect and said she does not take the word neglect lightly, or words to that affect. Nurse #6 said the staffing schedules, for at the last several weeks, includes staff that are no longer working at the facility. Nurse #6 said resident care is not being provided at all times such as; basic hygiene needs, showers, oral care, nail care, and shaving are not being done. Nurse #6 said residents are not being turned and repositioned every two hours and call lights are not being answered in a timely manner. Nurse #6 said most of the time on the evening shift there are only two CNA's scheduled (for a total of 46 residents). Nurse #6 said at the start of her evening shift, many times residents are still in bed from the day shift. During an interview on 6/10/21 at 4:15 P.M., the Administrator and the Director of Nursing (DON) said the staffing schedules provided to the surveyors, were not correct, because they had not confirmed staffing for accuracy of the schedules. The DON said the facility does have staffing concerns, but said she had not confirmed staffing for 6/10/21 and said she was unaware that there was only one CNA on Unit 2, taking care of 46 residents. The Administrator and the DON said residents needs are being taken care of. Review of the Midnight Census for Unit #2, dated 06/10/21, indicated there was a total of 46 residents residing on the Unit. Review of the Minimum Data Sheet-Summary of Residents Care Needs, dated 6/10/21, indicated for the 46 residents identified as residing on Unit 2, they required the following; - 6 residents required one staff person assist with eating -3 residents required one staff person for supervision with eating -3 residents required mechanical lift transfers, with a minimum of two persons to assist -13 residents required two staff person assist with bathing -22 residents required one staff person assist with bathing -10 residents required two staff person assist with dressing -27 residents required one staff person assist with dressing -13 residents required two staff person assist with toilet use -22 residents required one staff person assist with toilet use -1 resident required one to two staff person assist with toilet use -3 residents required staff supervision with toilet use -11 residents required two staff person assist with mobility -22 residents required one staff person assist with mobility -1 resident required one to two staff persons assist with mobility -2 residents required staff supervision with mobility Review of the Staffing Schedule, dated 6/10/21, for Unit 2, indicated staffing levels were the following; 7:00 A.M. to 3:00 P.M., (Day Shift) - 2 Nurses and 3 CNA's 3:00 P.M. to 11:00 P.M., (Evening Shift) - 2 Nurses and 1 CNA 11:00 P.M. to 7:00 A.M., (Night Shift ) - 1 Nurse and 2 CNA's During an interview on 6/10/21 at 7:30 A.M., Nurse #5 said the staffing schedule for today, 06/10/21, on the Day Shift was not accurate. Nurse #5 said one of the staff nurses who was on the schedule to work the Day Shift does not even work at the facility any more, so she was the only nurse working the day shift on the unit. Nurse #5 said the staffing schedules look good because, nurses and CNA's who no longer are employed at the facility, are still put on the daily scheduled as working. During an interview on 6/10/21 at 3:27 P.M., Nurse #2 said today's staffing schedule (6/10/21) on the Evening Shift, that showed 2 CNA's were on the schedule to work, but said neither CNA were employed at the facility. Nurse #2 said most of the time on the Evening Shift only 2 CNA's are scheduled. Nurse #2 said the schedules have not been accurate for quite some time, and that administration is aware of the continued staffing concerns. During an interview on 6/10/21 at 4:05 P.M., the Unit 2 Manager said the staffing for 6/10/21 on the evening shift for 46 residents was only 2 CNA's, one of which was scheduled to stay after completion of the 06/10/21 day shift. However, review of the staffing schedule for 6/10/21, indicated the CNA from the Day Shift had left for the day, leaving just one CNA to care for 46 residents on the evening shift. During an interview on 6/10/21 at 4:07 P.M., CNA #2 said he was the only CNA working on Unit 2 as a CNA.

Based on records reviewed and interviews, for one of two nursing units, Unit 2, the Facility failed to ensure that there were sufficient staffing levels to provide the level of assistance needed for resident's with physical limitations, failed to ensure residents received assistance with activities of daily living, including but not limited to toileting and personal hygiene care needs, with some residents being left in bed all day, failed to ensure call lights were responded to timely with resident requests being addressed accordingly, which resulted in residents becoming angry, upset, uncomfortable and in pain, with one resident reporting he/she called emergency medical response (911) after being left in a soiled brief for hours and had unable to obtain assistance from staff for extended periods of time. - On 6/10/21, during the survey, review of the staffing schedule for the 3:00 P.M. to 11:00 P.M. shift for Unit #2 for 6/10/21, indicated there were two nurses and only one Certified Nurse Aide (CNA) assigned to the unit to meet all of the care needs of the residents. Unit #2 census on 6/10/21 was a of a total of 46 residents. Finding include: The Facility's Policy titled, Staffing, dated 2007, indicated that the Facility maintains adequate staffing on each shift to ensure that resident's needs and services are met. The Policy indicated the following; licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services, certified nursing assistants are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan and inquires or concerns relative to the Facility's staffing should be directed to the Administrator or his/her designee. Review of the Midnight Census for Unit #2, dated 06/210/21, indicated there was a total of 46 residents residing on the Unit. Review of the Minimum Data Sheet-Summary of Residents Care Needs, dated 6/10/21, indicated for the 46 residents identified as residing on Unit 2, they required the following; - 6 residents required one staff person assist with eating -3 residents required one staff person for supervision with eating -3 residents required mechanical lift transfers, with a minimum of two persons to assist -13 residents required two staff person assist with bathing -22 residents required one staff person assist with bathing -10 residents required two staff person assist with dressing -27 residents required one staff person assist with dressing -13 residents required two staff person assist with toilet use -22 residents required one staff person assist with toilet use -1 resident required one to two staff person assist with toilet use -3 residents required staff supervision with toilet use -11 residents required two staff person assist with mobility -22 residents required one staff person assist with mobility -1 resident required one to two staff persons assist with mobility -2 residents required staff supervision with mobility Review of the Staffing Schedule, dated 6/10/21, for Unit 2, indicated staffing levels were the following; 7:00 A.M. to 3:00 P.M., (Day Shift) - 2 Nurses and 3 CNA's 3:00 P.M. to 11:00 P.M., (Evening Shift) - 2 Nurses and 1 CNA 11:00 P.M. to 7:00 A.M., (Night Shift ) - 1 Nurse and 2 CNA's During an interview on 6/10/21 at 7:30 A.M., Nurse #5 said the staffing schedule for today, 06/10/21, on the Day Shift was not accurate. Nurse #5 said one of the staff nurses who was on the schedule to work the Day Shift does not even work at the facility any more, so she was the only nurse working the day shift on the unit. Nurse #5 said the staffing schedules look good because, nurses and CNA's who no longer are employed at the facility, are still put on the daily scheduled as working. Nurse #5 said staffing has consistently been short on Unit #2, for at least a couple of weeks. During an interview on 6/10/21 at 3:27 P.M., Nurse #2 said today's staffing schedule (6/10/21) on the Evening Shift, that showed 2 CNA's were on the schedule to work, but said neither CNA were employed at the facility. Nurse #2 said most of the time on the Evening Shift only 2 CNA's are scheduled. Nurse #2 said the daily staffing schedules have not been accurate and said that administration is aware of the continued staffing concerns. During an interview on 6/10/21 at 4:05 P.M., the Unit 2 Manager said the staffing for 6/10/21 on the evening shift for 46 residents was only 2 CNA's, one of which was scheduled to stay after completion of the day shift. However, review of the staffing schedule for 6/10/21, indicated the CNA from the Day Shift had left for the day, leaving just one CNA to care for 46 residents on the evening shift. During an interview on 6/10/21 at 4:07 P.M., CNA #2 said he was the only CNA working on Unit 2 as a CNA. During an interview on 6/09/21 at 2:15 P.M., the Director of Nursing (DON) said staffing has been an issue, that staffing has fluctuated and a new staff scheduler started 2 days ago. The DON said based on resident care needs, the following staffing levels were needed on Unit 2, in order to adequately provide care and services, to all residents. 7:00 A.M. to 3:00 P.M. (Day Shift) - 2 Nurses and 4 to 5 CNA's 3:00 P.M. to 11:00 P.M. (Evening Shift) - 2 Nurses and 4 CNA's 11:00 P.M. to 7:00 A.M. (Night Shift) - 1 Nurse and 2 CNA's During an interview on 6/09/21 at 10:20 A.M., the Ombudsman said he heard complaints from multiple residents that the facility had staffing issues. The Ombudsman said residents complained they are waiting for long periods of time to receive assistance, and that residents had left him voice messages sharing they were waiting for staff to assist them. The Ombudsman said a resident called emergency medical services (911) to ask for help since staff was not assisting with his/her needs. The Ombudsman said residents have also relayed concerns about medications not being administered timely and treatments are not being completed, as ordered by the physician. During an interview on 6/09/21 at 12:56 P.M., one resident said that he/she was sitting in his/her wheelchair for several hours, had been incontinent, was calling for assistance, and that a CNA told him/her there was not enough staff on that day to help transfer him/her into bed and assist with personal hygiene care. The resident said he/she had to call emergency medical services (911) to ask for help. The resident said that he/she needs staff assistance to turn and reposition every two hours while in bed, that there is not enough staff to help with this, and that moving in bed can be a challenge at times. The resident said he/she would get very uncomfortable when not assisted with repositioning. The resident said staffing is consistently short on his/her unit (Unit #2), and said many times there has only been one or two CNA's working on the evening shift. During an interview on 6/09/21 at 1:15 P.M., another resident said that he/she felt shaky inside and nervous, if he/she does not receive his/her medications on time. The resident said it is not fair that he/she has to wait. The resident said residents have to wait long periods of time for even basic things like a pillow or bed side table. The resident said there is just not enough staff to help the residents on his/her unit (Unit #2) with even basic needs. The resident said the lack of staff on the unit, makes him/she feel scared at times. During an interview on 6/09/21 at 3:02 P.M., another resident said he/she had a scheduled visit with a family member, had requested assistance with personal hygiene prior to the visit and said he/she was told that there was not a staff member available to help him/her. The resident said he/she had asked for staff assistance before 10:00 A.M. but was left to sit in his/her wheelchair not dressed, had been incontinent, but was not assisted by staff with personal care until 4:00 P.M.( approximately 6 hours later). The resident said he/she was upset and uncomfortable. The resident said the there has been many times, over the last several weeks, when there was one or two 2 CNA's working on the Day and Evening Shifts. The resident said currently there is just not enough staff to assist all of the residents. During an interview on 6/11/21 at 7:58 A.M., another resident said he/she continually needs to ask for his/her medications and for his/her wound dressing to be changed. The resident said many times, for the last few weeks, there has only been one or two CNA's working on the Day and Evening Shifts, and said there is not enough staff to assist with residents on the unit. The resident said management is always changing and said that results in lack of communication and information shared with the residents. The resident said management is not at the facility long enough to see what the needs of the residents are or to address resident safety concerns. The resident said he/she is upset, angry and said that living in the facility is a nightmare. Nurse #5 said scheduling only two 2 CNA's on the evening shift, to provide care to 46 residents, is not manageable. Nurse #5 said residents are telling her they are waiting long periods of time to be assisted with care and said CNA's are unable to provide all the care for residents that is required. Nurse #5 said she will provide care alone to residents, even if they are an assist of two, since there are no CNA's to help her. During an interview on 6/10/21 at 10:48 A.M., Nurse #4 said she has never seen staffing levels a bad as this. Nurse #4 said they have been very short staffed with CNA's and said resident care is not being done, per residents' plan of care. Nurse #4 said residents' are not getting scheduled showers, residents are not being assisted out of bed and into a chair/wheelchair, because there is not enough staff to manage care, including safe transfers. Nurse #4 said she called the Administrator to ask for help since they were short staffed, said that she told him that staffing levels felt unsafe and that the residents needed more help than what assigned staff could provide. Nurse #4 said she was told by the Administrator that there was no one to help. Nurse #4 said shortly after the telephone call she went to directly speak with the Administrator about Unit 2's safety concerns and said Administrator had already left the facility for the day. During an interview on 6/10/21 at 11:24 A.M., CNA #1 said the facility has had short staffing levels for quite sometime, and said that meeting resident care needs has been difficult. CNA #1 said showers are not being provided because they do not have enough staff to assist residents safely. CNA #1 said residents tell them they are frustrated and that they feel like they are not being cared for. CNA #1 said one resident, who required a two person physical assist from staff, called the police recently on the Evening Shift since he/she was waiting for hours to be assisted back to bed. CNA #1 said that administrative team is aware of the staffing concerns and said she was told the facility does not have staff and to be patient. During an interview on 6/10/21 at 11:58 P.M., CNA #3 said the facility has had staffing concerns for a while, and said they (CNA's) are unable to meet the needs of all the residents. CNA #3 said only 2 CNA's have been scheduled for the day and evening shifts (on Unit #2), to take care of 46 residents. CNA #3 said having only 2 CNA's affect the residents and the staffs ability of being able to provide them with safe care. CNA #3 said there are several residents on the Unit 2 that require a hoyer lift (mechanical lift), and a minimum of 2 staff must assist for a transfer. CNA #3 said another resident needed to get back into bed, was also a hoyer lift transfer, and there was no one to help with the transfer. CNA #3 said because there is not enough staff to assist her with the transfer, said the residents family member assisted her, so the resident did not have to wait for a long period of time. During an interview on 6/11/21 at 12:35 P.M., Nurse #7 said staffing has been an issue at the Facility for quite some time. Nurse #7 said to expect one or two CNA's to provide care to 46 residents on the evening shift was not reasonable or safe. Nurse #7 said she delivered a meal tray to a resident and asked the resident if he/she needed assistance. Nurse #7 said the resident responded How do you suppose I would even want to eat when I have been laying in my own urine since midnight and I was told by staff there was no-one to help me., or words to that affect. Nurse #7 said his/her bed sheets were saturated in urine, that the urine had made an outline pattern on the sheets, and said it looked like the urine had been on bed sheets for a long period of time. During an interview on 6/11/21 at 2:45 P.M., Nurse #6 said staffing concerns have been affecting the residents and said What residents have endured is neglect and said She does not take the word neglect lightly, or words to that affect. Nurse #6 said over the last month the facility has had a staffing crisis. Nurse #6 said the daily staffing schedules will include staff that are no longer work at the facility. Nurse #6 said resident care is not being provided consistently at all times such as; basic hygiene needs, showers, oral care, nail care and shaving, are not being done. Nurse #6 said residents are not being turned and repositioned every two hours and said call lights are not being answered in a timely manner. Nurse #6 said there is not enough staff to provide snacks, extra fluids throughout the day, or assist residents out and into bed. Nurse #6 said most of the time on the evening shift only 2 CNA's are scheduled. Nurse #6 said at the start of her evening shift, many times residents are still in bed from the day shift. During an interview on 6/10/21 at 4:15 P.M., the Administrator and the Director of Nursing (DON) said the staffing schedules provided to the surveyors, were not correct, because they had not confirmed staffing for accuracy on the schedules. The DON said the previous scheduler completed the schedules and currently he is not working at the facility. The DON said the facility has staffing concerns, but said she had not confirmed staffing for 6/10/21 and said she was unaware that there was only one CNA on Unit 2 taking care of 46 residents. The Administrator and the DON said the residents needs are being taken care of.

Based on records reviewed, and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure he/she was provided adequate supervision to prevent him/her from leaving the Facility undetected by staff. Resident #1 had gone missing for greater than three hours before staff realized he/she had eloped. The Facility was notified by the Police that Resident #1 was located at a Local Hospital Emergency Department and was being evaluated for his/her injuries. Resident #1 had a hematoma (bruise) to his/her forehead, a chipped tooth, abrasions, a fractured nasal bone, and lacerations to his/her face, he/she was readmitted to the Facility. Findings include: The Facility's Investigation Report, undated, indicated that on 1/28/20 at approximately 10:50 P.M., Resident #1 was unable to be located by staff, and Local Police were notified. The Report indicated staff said Resident #1 was last seen in the Facility around 7:00 P.M. The Report indicated that at 11:30 P.M., Resident #1 was located at a local Hospital Emergency Department, where he/she had been transported to after sustaining injuries from a fall during his/her elopement. The Hospital Discharge Summary, dated //28/20. indicated Resident #1 stated he/she went for a walk, fell on the sidewalk, tried to break the fall with his/her hands but said he/she struck the sidewalk very hard The Summary indicated Resident #1 had obvious signs of trauma and his/her injuries included the following: - head injury, hematoma (bruise) on his/her left anterior (front of) forehead, - laceration on bridge of nose that required three sutures to close, - laceration to upper lip that required three sutures to close, as well as a chipped tooth, - laceration on both hands, and abrasions to the right knee. The Summary indicated Resident #1 was not clear to month or day. Resident #1 was admitted to the Facility in August 2018, with [DIAGNOSES REDACTED]. The Elopement Care Plan, dated as initiated on 8/21/18, indicated Resident #1 was assessed as being at risk for elopement, did not understand the importance of the wander-guard device (a small transmitter which caused an alarm to sound when a person approached a doorway equipped with an alarm) and would go through great lengths with determination to remove the device. The Elopement Care Plan indicated that staff were to conduct frequent checks on Resident #1 for safety. The Care Plan indicated this intervention was discontinued on 1/15/20, because Resident #1 had made no attempts to elope in over six months. However, this conflicted with a Nurse Progress Note, dated 8/25/19, (approximately four months prior to the change in Resident #1's Care Plan), that indicated Resident #1 wandered off his/her second floor unit and was found on the first floor and had to be returned to his/her unit. It also conflicted with staff interviews that indicated Resident #1 continued to exhibit behaviors of exit seeking after dinner. During interviews on 2/4/20 with staff on the 3:00 P.M. to 11:00 P.M. shift, CNA #1, CNA #2, and CNA #3 said Resident #1 had frequent behaviors of verbalizing the desire to leave and with trying to leave the Facility, which typically happened in the evening after the dinner time meal. CNA #1, CNA #2, and CNA #3 said that Resident #1 would put on his/her coat as part of this behavior, and said staff would know to keep an eye on him/her and provide redirection. CNA #1, CNA #2 and CNA #3 said they were not asked by anyone from nursing about Resident #1's wandering or exit seeking behaviors. During interview on 2/4/20 at 4:10 P.M., CNA #1 said that on 1/28/20 on the 3:00 P.M. to 11:00 P.M. shift, she was the CNA assigned to provide care for Resident #1. CNA #1 said that on 1/28/20 she last saw Resident #1 at approximately 7:00 P.M., and realized Resident #1 was not on the unit at around 10:30 P.M. CNA #1 said she alerted Nurse #1 at that time. On 2/4/20 at 1:40 P.M., The Surveyor and the Administrator reviewed the Facility's security camera video footage from 1/28/20. The Administrator said the clocks on the individual cameras were not precisely synchronized, so times were approximate. The video footage indicated that at approximately 7:04 P.M., Resident #1 exited his/her room wearing a coat, and walked down the hall toward the elevator. At approximately 7:05:05 P.M., Resident #1 entered the elevator on the second floor. Per the video, staff were seen in the area near the elevator, however staff did not intervene. The video footage from inside the resident Coffee Shop located on the first floor was time-stamped 7:06:05 P.M., and showed Resident #1 exit through a door in the coffee chop. The video footage from the camera located in the front parking lot, time-stamped 7:05:45 P.M., showed Resident #1 exiting from the door in the Coffee Shop, walking down the driveway and away from the building. The Facility's policy, titled Elopement, dated 6/16/15, indicated the following: -Elopement was defined as a situation in which a resident who was cognitively, physically, mentally, emotionally, and/or chemically impaired wandered away, walked away, ran away, or otherwise left the Facility grounds unsupervised, unnoticed, and prior to their scheduled discharge, placing the resident at risk for harm. -Each Certified Nurse Aide (CNA) was responsible to observe their residents for safety and well being on a regular basis.

Based on interview, record review and observation, the facility failed to provide adequate pain management for 1 sampled Resident (#70) out of a total sample of 22 residents. Resident #70 had significant pain requiring increased use of PRN (as needed) for approximately four months which was not communicated to Resident #70's Physician or the Nurse Practitioner. Findings include: During an interview with Resident #70 on 1/22/20 at 8:23 A.M., the resident said that he/she has a toothache that has been ongoing for a while. Resident #70 said that he/she had tried to see a dentist outside the facility but was not accepted because of an insurance issue. The surveyor observed Resident #70 rubbing his/her right jaw. Resident #70 said that he/she is currently taking [MEDICATION NAME] and Tylenol for pain, as needed, and other pain medication (the resident could not recall the name) but that these medications only gives him/her temporary relief. Resident #70 was admitted to the facility in September 2019 with [DIAGNOSES REDACTED]. Review of Resident #70's Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #70 has frequent pain with severe intensity. Review of the facility Pain Clinical Control policy (undated) indicated the following: -The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. -The staff will evaluate and report how much and how often the individual ask for PRN (as needed) pain medication. -The staff will discuss significant changes in level of comfort with the attending Physician who will consider adjusting interventions accordingly. Review of Resident #70's pain assessment dated [DATE], indicated a 10 out of 10 pain scale in the mouth area. Review of Resident #70's physician's orders [REDACTED]. -Pain evaluation: document verbal/nonverbal sign of pain each shift -[MEDICATION NAME] 325 milligrams (mg), give 2 tablets (650 mg) by mouth every 6 hours as needed (PRN) for pain. -[MEDICATION NAME] 800 mg by mouth every 6 hours as needed for pain (dental). Review of Resident #70's medical record indicated that on 11/2/19, the Nurse Practitioner (NP) examined Resident #70 due to dental pain. The NP ordered [MEDICATION NAME] (a medication used to treat moderate to severe pain) 25 mg every 8 hours as needed for 10 days. Then on 12/2/19 the NP ordered [MEDICATION NAME] 25 mg every 6 hours as needed for mouth pain. Review of Resident #70's electronic medical administration record (EMAR) indicated the following: -October 2019, Resident #70 requested and received Tylenol 650 mg 6 times, and PRN [MEDICATION NAME] 800 mg 12 times for dental pain and had a pain scale level of 8 to 10, 7 times. -November 2019, Resident #70 requested and received PRN Tylenol 650 mg 13 times, PRN [MEDICATION NAME] 800 mg 27 times and PRN [MEDICATION NAME] 25 mg 4 times for dental pain and had a pain scale level 7 to 10, 28 times. - December 2019, Resident #70 requested and received PRN Tylenol 650 mg 20 times, PRN [MEDICATION NAME] 800 mg 31 times, and PRN [MEDICATION NAME] 25 mg 23 times for dental pain and had a pain scale level of 7 to 10, 17 times. - January 1 to 22, Resident #70 requested and received PRN Tylenol 650 mg 21 times, PRN [MEDICATION NAME] 800 mg 30 times, and PRN [MEDICATION NAME] 25 mg 22 times for dental pain and had a pain scale level of 7 to 10, 51 times. During an interview with Unit Manager (UM) #2 on 1/23/20 at 8:38 A.M., she said that Resident #70 was referred to a dentist, but was not seen because of an insurance problem. UM #2 said she was not aware that Resident #70 was utilizing PRN pain medications on a daily basis. During an interview with the Nurse Practitioner on 1/23/20 at 2:14 P.M., she said that she was not aware that Resident #70 had an increased or worsening pain level and increased utilization of PRN pain medications. The Nurse Practitioner said that nursing staff did not notify her that Resident #70 frequently utilized PRN medication to treat daily pain.

Based on observation, record review, and interview the facility failed to provide routine and emergency dental services, and assist residents to explore options for dental care for 2 Residents (#70 and #24) out of a total sample of 22 residents. Specifically, for Resident #70 failed to provide dental services when Resident #70 was in moderate to severe pain due to a toothache for a four month period of time. For Resident #24 the facility failed to provide dental services for routine care and cleanings. Findings include: Review of the facility policy titled Routine Dental Care, with a revision date of April 2007, indicated the following: *Policy statement-Each resident will receive routine dental care. *Our facility's routine dental care includes, but is not limited to: -An initial evaluation of the resident's dental needs. -Consultation with the resident, staff, and the dental consultant. -Daily dental and oral hygiene plan of care. -In service education; and -Preventative care and treatment. Review of the facility policy titled Dental Consultant with a revision date of April 2007, indicated the following: *Policy statement-Dental care shall be provided through the services of a consultant dentist. *Our facility does not maintain a resident Dentist on staff and therefore does not provide on-premises dental services. *A consultant Dentist is retained by our facility and is responsible for: -Providing consultation to physicians and providing other services relative to dental matters. -Providing a dental assessment of each resident within 90 days of admission. -Performing or supervising an annual dental re-evaluation for each resident. 1. For Resident #70 the facility failed to assist the resident in obtaining routine and emergency dental care and assisting Resident #70 in exploring alternative options or funding sources to meet his/her dental needs, over a period of 4 months, resulting in significant mouth pain. During an interview on 1/22/20 at 8:23 A.M., Resident #70 said he/she has a toothache that has been ongoing for a while and that he/she had tried to see a dentist outside the facility but was not accepted because of an insurance issue. The surveyor observed Resident #70 rubbing his/her right jaw. Resident #70 said that he/she is currently taking [MEDICATION NAME] and Tylenol for pain, as needed, and other pain medication (the resident could not recall the name) but that these medications only give him/her temporary relief. During an interview with Unit Manager (UM) #2 on 1/23/20 at 8:38 A.M., she said that Resident #70 was referred to a dentist, but was not seen because of an insurance problem. UM #2 said she was not aware that Resident #70 was utilizing PRN pain medications daily to treat dental pain. Resident #70 was admitted to the facility in September 2019 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #70 is alert and oriented with a Brief Interview for Mental Status Exam (BIMS) score of 14 out of 15. Further review indicated that Resident #70 has frequent pain with severe intensity. Review of Resident #70 nursing progress notes indicated the following: -9/12/2019 resident complaint of tooth tightness, and pain level of 10 out of 10. -9/16/2019 resident was not seen by the dentist as ordered by Nurse Practitioner due to an insurance issue. -9/20/2019 resident went out to Dr. Dental but not seen due to an insurance issue. Review of Resident #70's pain assessment dated [DATE] indicated a 10 out of 10 pain scale in the mouth area. Review of Resident #70's Physician's orders dated 9/11/19, indicated the following: -Pain evaluation: document verbal/nonverbal sign of pain each shift -[MEDICATION NAME] 325 milligrams (mg), give 2 tablets (650 mg) by mouth every 6 hours as needed (PRN) for pain. -[MEDICATION NAME] 800 mg by mouth every 6 hours PRN for pain (dental) Review of Resident #70's medical record indicated that on 11/2/19, the Nurse Practitioner (NP) examined him/her due to dental pain. The NP ordered [MEDICATION NAME] (a medication used to treat moderate to severe pain) 25 mg every 8 hours as needed for 10 days. Then on 12/2/19 the NP ordered [MEDICATION NAME] 25 mg every 6 hours as needed for mouth pain. Review of Resident #70's electronic Medication Administration Record [REDACTED] -October 2019, Resident #70 requested and received Tylenol 650 mg 6 times, and PRN [MEDICATION NAME] 800 mg 12 times for dental pain and had a pain scale level of 8 to 10, 7 times. -November 2019, Resident #70 requested and received PRN Tylenol 650 mg 13 times, PRN [MEDICATION NAME] 800 mg 27 times and PRN [MEDICATION NAME] 25 mg 4 times for dental pain and had a pain scale level 7 to 10, 28 times. - December 2019, Resident #70 requested and received PRN Tylenol 650 mg 20 times, PRN [MEDICATION NAME] 800 mg 31 times, and PRN [MEDICATION NAME] 25 mg 23 times for dental pain and had a pain scale level of 7 to 10, 17 times. - January 1-22,2020, Resident #70 requested and received PRN Tylenol 650 mg 21 times, PRN [MEDICATION NAME] 800 mg 30 times, and PRN [MEDICATION NAME] 25 mg 22 times for dental pain and had a pain scale level of 7 to 10, 51 times. During a follow up interview with Resident #70 on 1/23/20 at 10:23 A.M., the resident said that he/she did not have money to pay for a dental visit if the insurance does not cover it. The surveyor asked Resident #70 if the facility staff helped him/her explore other options/alternatives and arrangement to meet his/her dental needs and Resident #70 said no. Review of the Social Services notes since admission failed to indicate any discussions with Resident #70 regarding the lack of funding for dental care or exploration of alternative options to meet Resident #70's dental needs. During an interview on 1/23/20 at 11:20 A.M., the Social Worker said that she was not aware that Resident #70 was in constant pain and utilizing his/her PRN pain medication daily for dental pain. The Social Worker said that she could have arranged for emergency dental services for Resident #70 if she was notified that he/she was in constant pain. The Social Worker was unable to provide any evidence the facility had assisted the resident in obtaining routine and/or emergency dental care or insurance coverage for dental services. On 1/23/20 at 12:26 P.M., Social Worker said that she was able to make an appointment for Resident #70 to see a dentist tomorrow. Review of Resident #70's Dental consult dated 1/24/20, indicated a referral to an Oral Surgeon on 2/6/20 to evaluate his/her eight upper teeth. 2. For Resident #24, the facility failed to provide routine dental services. On 1/22/20, at 11:06 A.M., the surveyor observed that Resident #24's teeth were in poor condition and that Resident #24 had black areas on his/her left upper molars. Review of Resident #24's clinical record indicated an order dated 3/11/18, for Podiatry, Dental, Optometry or Audiology as needed. the order was carried over each month on the physician orders sheet and was currently included in the orders. Review of Resident #24's clinical record from 3/11/18 to present, failed to indicate any dental consults had been conducted. During an interview on 1/23/20, at 9:15 A.M., Resident #24 said that he/she would like to see a dentist for an annual check up and have regular cleanings. During an interview on 1/23/20, at 9:21 A.M., Unit Manager #1 said that residents are only seen by the dentist if there is a dental issue or if the the doctor writes an order. Unit Manager #1 also said that the facility doesn't have a dental provider in house and the residents would have to go see a provider in the community. Unit Manager #1 further said that Resident #24 has never been seen by a dentist since he/she has been at the facility, nor was Resident #24 offered routine dental services. During an interview on 1/24/20, at 11:02 A.M., the Director of Nurse's confirmed that Resident #24 had never been seen by a dentist nor was there any documenation in the clinical record that Resident #24 was offered routine dental services since his/her admission.

Based on records reviewed and interviews for 1 of 3 sampled Residents (Resident #1), who was a full code (Facility to interceded if a patient's heart stops beating or if the patient stops breathing), the Facility failed to meet the following; -Failed to ensure a thorough Clinical assessment was performed when Resident #1 was found unresponsive at 9:00 A.M. on [DATE]. -Failed to announce Code Blue (emergency response) over intercom system or gather emergency equipment in accordance with Facility's Code Blue Policy. -Failed to activate 911 for approximately 11 minutes after Resident #1 was found unresponsive. -Left Resident #1 alone for an unknown period of time and when Emergency Medical Services (EMS) arrived at 9:17 A.M. Resident #1 had no pulse, was not breathing and staff had not initiated Cardiopulmonary resuscitation (CPR) per EMS. Attempts at resuscitation by EMS was unresponsive and Resident #1 was pronounced dead in the emergency room at 9:57 A.M. on [DATE]. Findings Include: 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. The Massachusetts Board of Registration in Nursing (BORN) issues this Advisory Ruling on nursing practice pursuant to Massachusetts General Laws (M.G.L.), chapter 30A, section 8, and chapter 112, section 80B, dated [DATE], the nurse licensed by the Massachusetts Board of Registration in Nursing (BORN) is expected to engage in the practice of nursing in accordance with accepted standards of practice. It is the Board's current position that these standards, in the context of practice in a Massachusetts long-term care facility with 24-hour skilled nursing staff on duty, require the initiation of CPR when a patient or resident has experienced a [MEDICAL CONDITION] except when the patient or resident has a current, valid Do Not Resuscitate (DNR) order OR Signs of irreversible death. In the absence of a DNR order and in the absence of signs of irreversible death, the nurse is required to initiate CPR when a patient or resident has a [MEDICAL CONDITION]. According to the American Heart Association Chain of Survival, dated 2015, survival chances decline with every minute that passes by ,[DATE]%, within ,[DATE] minutes brain damage and permanent death start to occur, and after 10 minutes few attempts at resuscitation succeed. The Facility Policy titled, Code Blue Policy, dated ,[DATE], indicated patients found unresponsive, staff will call a Code Blue. Code Blue will be paged overhead three times including the location for Nurses and patient. A Nurse or CNA on the Unit of the Code Blue, will immediately go to the cart location and bring the Emergency Cart as well as the Automated External Defibrillator (AED) to the area of the Code Blue. The Code Team Leader will direct a staff member to initiate the emergency medical system by instructing another employee to call 911. If patient noted to have neither pulse nor respiration, the staff will initiate the CPR protocol per the basic life support guidelines and the AED will be used as per policy. CPR and the use of AED will continue until the paramedics/EMT's take over the code. A thorough report will be given to paramedics/EMT's upon arrival to the scene as to the timeline of the incident. If victim found to be stable, a minimum of 2 staff members will remain with the Resident at all times. Code Blue will remain in effect until the victim has been transferred to the care of EMS providers. The Massachusetts Medical Orders for Life Sustaining Treatment (MOLST), dated [DATE], indicated Resident #1 was a Full Code (Facility to interceded if a patient's heart stops beating or if the patient stops breathing) Resident #1's Care Plan, dated [DATE], indicated Advance Directive (A legal documentation in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness) as a Full Code. A Physician's Note, dated [DATE], indicated Resident #1's history included Coronary [MEDICAL CONDITION] (plaque buildup in arteries) status [REDACTED]. The Emergency Medical Service (EMS) Patient Care Report, dated [DATE] indicated the following; -At 9:11 A.M. a call was reviewed from Facility indicating Resident #1 experiencing a decline at 9:00 A.M. (11 minutes earlier). -For a period of 2 minutes the operator spoke with the Facility Staff who reported possible [MEDICAL CONDITION]. -At 9:13 A.M. EMS was dispatched, arrived at the Facility a 9:16 A.M. -At 9:17 A.M. EMS was at Resident #1's bedside indicating he/she had no pulse and was not breathing. A Nurse Progress Note (Late Entry) at 1:33 P.M., dated [DATE] indicated at 9:00 A.M. on [DATE] Nurse #1 entered Resident #1's room to give his/her 9:00 A.M. medications, at which time Nurse #1 saw Resident #1 lying on his right side in the bed. The note indicated Resident #1 appeared to breathing loudly but he/she did not respond when Nurse #1 called his/her name. Nurse #1 then shook him/her by the arm, his/her eyes opened but his/her eyes did not focus and pupils pinpointed. The Nurse Note (Late Entry) at 1:33 P.M., dated [DATE] indicated Nurse #1 called out for assistance to CNA #1 told her to stay with Resident #1 while she called 911. Nurse #1 ran to front of desk, grabbed her cell phone, ran back and EMS stayed on the phone with her and tried guiding her asking was it [MEDICAL CONDITION], MI etc . Resident #1's color was ashen (pale) and he/she had pulled off his/her hospital gown and it was on the floor. Resident #1's vital signs at 9:02 A.M. (Clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) were taken Heart Rate ,[DATE] with irregular breathing heavy respiratory rate 22 ( normal range of Heart rate ,[DATE] beats per minute and ,[DATE] breaths per minute). At 9:07 A.M. EMS arrived in Resident #1's room. Nurse #1 and CNA #1 were told to clear the room by EMS so they could work on him/her. EMS asked Nurse #1 to make copies of Resident #1's records and medications for transport to acute Hospital. Nurse #1 received a call from the hospital's emergency room at 9:50 A.M. on [DATE] stating that Resident #1 could not be revived and has died . The Surveyor interviewed Nurse #1 at 8:15 AM on [DATE]. Nurse #1 said Resident #1 did not respond to her when she entered his/her room on [DATE] at 9:00 AM, was unresponsive with eyes open and yelled for CNA #1 to come over and she was unable to wake Resident #1. Nurse #1 said she placed her pulse oximetry (a machine measures oxygen and heart rate) on his/her finger and Resident #'s heart rate was high and low. Nurse #1 said she did not perform any other assessments and did not need to check a carotid pulse by touch or stethoscope since the heart rate was on the pulse oximetry. Nurse #1 said she called 911 using her cell phone, described the symptoms of Resident #1 to 911 and by her description given to 911, 911 thought he/she was having a [MEDICAL CONDITION]. Nurse #1 said Resident #1 does not have a history of [MEDICAL CONDITION] or the Facility was not treating him/her with [MEDICAL CONDITION] medications. Nurse #1 said she walked continuously back and forth in the hallway, called upstairs to Nurse Supervisor stating she needed help and did not call a Code Blue. Nurse #1 said she did not know how to use the phone intercom to call a Code. Nurse #1 said EMS arrived quickly and when she was giving them report in Resident #1's room, Resident #1 stopped breathing and EMS started CPR. CNA #1's written statement (part of the Facility's investigation file), dated [DATE] indicated around 9:00 A.M. Nurse #1 called her into the room to overlook her concerns that Resident #1 might not be breathing. CNA #1 indicated I went in right away and yelled to him/her and lifted his/her head, his/her eyes rolled back so I told Nurse #1 to call 911. CNA #1 said there was no response or breathing from Resident #1. The Surveyor interviewed CNA #1 at 3:35 PM on [DATE]. CNA #1 said Nurse #1 came to get her across the hall from Resident #1's room at 9:00 A.M. on [DATE]. CNA #1 said to Nurse #1 she thought Resident #1 was not breathing. CNA # 1 said she entered Resident #1's room, yelled his/her name, tried to wake him/her up using her hands manually, Resident #1 had foaming at the mouth and both eyes were rolling back. CNA #1 said she told Nurse #1 to call 911. CNA #1 said Nurse #1 did not assess Resident #1's carotid pulse (located on either side of the neck which supplies blood to the brain), no Code Blue was called and no other staff was present. CNA #1 said to Nurse #1 Resident #1's chest was not rising, took his last breath and his/her skin color was gray/blue prior to EMT's arriving. CNA #1 said at some point she left Resident #1 alone to call the Nurse Supervisor on the second floor to let her know she needed help. CNA #1 said it was 20 minutes between the time Nurse #1 was concerned about Resident #1 and the time EMS arrived to the Facility. The Surveyor interviewed Nurse Supervisor at 2:50 P.M. on [DATE] and at 11:00 A.M. on [DATE]. The Nurse Supervisor said CNA #1 called asking for help on [DATE] and no mention of Resident #1 having a [MEDICAL CONDITION]. The Nurse Supervisor said no Code Blue was called that she was aware of and when she arrived to the first floor EMS was with Resident #1 and she did not assess him/her. The Nurse Supervisor said she assisted with transfer paperwork and the EMS was performing CPR on Resident #1 upon exiting Facility. The EMS Patient Care Report, dated [DATE] indicated, Crew Member #1 was dispatched to Facility for a report of Resident #1 possibly having a [MEDICAL CONDITION]. Nurse #1 was at the Nurse's Station upon EMS arrival and Nurse #1 was unable to give EMS a report of Resident #1's health status. Nurse #1 said to EMS she did not know and thought maybe he/she had a [MEDICAL CONDITION]. EMS entered into Resident #1's room and Resident #1 was not breathing and no pulse present. Documentation indicated Nurse #1 stated she went to Resident #1's room at 9:00 A.M. and found Resident #1 was unresponsive and called 911. Nurse #1 was unable to report to EMS Resident #1's vital signs. The Surveyor interviewed Crew Member #1 and Crew Member #2 at 9:40 A.M. on [DATE]. Crew Member #1 said he walked into the Facility, Nurse #1 was at the Nurse's desk and unable to report Resident #1's medical status to him. Nurse #1 reported to Crew Member #1 she did not know and thinks maybe he/she had a [MEDICAL CONDITION]. Nurse #1 walked with Crew Member #1 to Resident #1's room. Crew Member #1 entered Resident #1's room and Resident #1 was cyanotic (bluish or purplish discoloration of skin), was not breathing and without a pulse. Crew #1 said no staff was at the bedside of Resident #1 and no life saving measures or assessment was being preformed by a Facility's staff member. Crew Member #1 said no Facility's Code Cart was in Resident #1's room upon arrival and Crew Member #1 began CPR immediately. Crew Member #1 said prior to Resident #1 being transferred to the hospital he requested a copy of the vital signs, the events leading up to EMS arrival and Crew Member #1 did not receive the paperwork or a through report.

Based on interview and record review, for one of four sampled residents (Resident #1), the Facility failed to ensure Resident #1's CNA Kardex (plan of care) was implemented. Resident #1's CNA Kardex indicated he/she required extensive assistance of two or more people with the use of a gait belt for transfers. At approximately 7:15 A.M. on 4/3/15, Certified Nurse Aide (CNA) #1 transferred Resident #1 by herself, from the bed to a reclining chair. CNA #1 said she discovered the laceration on Resident #1's right leg immediately after the transfer. Resident #1 sustained a 5.2 cm laceration to the right leg, was transferred to the hospital and obtained eight sutures to close. Findings include: Resident #1's significant change in status Minimum Data Set assessment, dated 1/21/15, indicated he/she had moderate cognitive impairment and required extensive physical assistance with two or more people for transfers. Resident #1's CNA Kardex, not dated, indicated Resident #1 required extensive assistance of two or more staff for transfers with the use of a gait belt. The Surveyor interviewed Family Member #1 at 2:00 P.M. on 5/27/15. Family Member #1 said prior to Resident #1 sustaining the laceration to his/her leg, she had seen other CNAs occasionally transfer Resident #1 by themselves. The CNA Orientation Clinical Orientation Program and Checklist, dated 12/4/15, indicated CNA #1 demonstrated understanding of the use of the CNA Kardex for the Preceptor. The Surveyor interviewed CNA #1 at approximately 8:30 A.M. on 5/27/15. CNA #1 said the CNA Kardex provided information to ensure Residents received care as required. CNA #1 said she provided care for Resident #1 once or twice a week over the five months preceding April 2015. CNA #1 said she had seen other CNAs transfer Resident #1 without assistance. CNA #1 said she always transferred Resident #1 alone. CNA #1 said on 4/3/15 she did not read Resident #1's CNA Kardex and did not request assistance to transfer Resident #1. CNA #1 said she did not have a gait belt, but occasionally borrowed one from other CNAs. CNA #1 said she placed her arms under Resident #1's arms, held the back of Resident #1's pants and transferred Resident #1 without assistance from the edge of the bed onto the reclining chair alongside the bed. CNA #1 said she transferred Resident #1 in a quick motion without Resident #1 bearing weight to stand and pivot. CNA #1 said immediately after Resident #1 was seated, she noticed his/her legs were toward the left front corner of the reclining chair's leg rest. CNA #1 said she noticed the blood on Resident #1's right leg when she touched Resident #1's legs to straighten them. CNA #1 said she notified nursing staff. The Surveyor interviewed Nurse #1 at 12:55 P.M. on 5/26/15. Nurse #1 said Resident #1 was seated on the reclining chair, a puddle of blood was on the floor and was assessed as having sustained a 5.2 cm laceration above the right ankle. Nurse #1 said CNA #1 told her the injury was obtained when she transferred Resident #1 alone. Nurse #1 said CNA #1 told her she did not request assistance with the transfer. Nurse #1 said Resident #1 required a two person transfer, and the CNA Kardex was required to be followed. The Emergency Department Note, dated 4/3/15, indicated Client #1 was diagnosed with [REDACTED]. The Surveyor interviewed the Director of Nurses (DON) at approximately 10:05 A.M. on 5/26/15. The DON said Resident #1 required a two person assist for transfers. The DON said CNAs are required to check the CNA Kardex for residents prior to providing care.

Based on interview and record review, for one of four sampled residents (Resident #1), the Facility failed to ensure Resident #1 was transferred in accordance with the Certified Nurse Aide (CNA) Kardex (plan of care) to prevent injury. Resident #1's CNA Kardex indicated he/she required extensive assistance of two or more people with the use of a gait belt for transfers. At approximately 7:15 A.M. on 4/3/15, CNA #1 transferred Resident #1 by herself, from the bed to a reclining chair. CNA #1 said she discovered the laceration immediately after the transfer. Resident #1 sustained a 5.2 cm laceration to the right leg, was transferred to the hospital and obtained eight sutures to close. Findings include: Resident #1's significant change in status Minimum Data Set assessment, dated 1/21/15, indicated he/she had moderate cognitive impairment and required extensive physical assistance with two or more people for transfers. Resident #1's CNA Kardex, not dated, indicated Resident #1 required extensive assistance of two or more staff for transfers using a gait belt. The Surveyor interviewed Family Member #1 at 2:00 P.M. on 5/27/15. Family Member #1 said prior to Resident #1 sustaining the laceration to his/her leg, she had seen other CNAs occasionally transfer Resident #1 by themselves. The Surveyor interviewed CNA #1 at approximately 8:30 A.M. on 5/27/15. CNA #1 said the CNA Kardex provided information to ensure residents received care as required, on a daily basis. CNA #1 said she provided care for Resident #1 once or twice a week over the past five months. CNA #1 said she had seen other CNAs transfer Resident #1 without assistance. CNA #1 said she always transferred Resident #1 alone. CNA #1 said on 4/3/15 she did not read Resident #1's CNA Kardex and did not request assistance to transfer Resident #1. CNA #1 said she did not have a gait belt, but occasionally borrowed one from other CNAs. CNA #1 said she placed her arms under Resident #1's arms, held the back of Resident #1's pants and transferred Resident #1 without assistance from the edge of the bed onto the reclining chair alongside the bed. CNA #1 said she transferred Resident #1 in a quick motion without Resident #1 bearing weight to stand and pivot. CNA #1 said immediately after Resident #1 was seated, she noticed his/her legs were toward the left front corner of the reclining chair's leg rest. CNA #1 said she noticed the blood on Resident #1's right leg when she touched Resident #1's legs to straighten them. CNA #1 said although the reclining chair's vinyl leg rest padding was in place, she noticed a cap was missing from the top of a metal bar on the left front corner of the leg rest. The Surveyor interviewed Nurse #1 at 12:55 P.M. on 5/26/15. Nurse #1 said Resident #1 was seated on the reclining chair, a puddle of blood was on the floor, and Resident #1 was assessed as having sustained a 5.2 cm laceration above the right ankle. Nurse #1 said CNA #1 told her the injury was obtained when she transferred Resident #1 alone. Nurse #1 said CNA #1 told her she did not request assistance with the transfer. Nurse #1 said Resident #1 required a two person transfer, and the CNA Kardex was required to be followed. The Emergency Department Note, dated 4/3/15, indicated Client #1 was diagnosed with [REDACTED]. The Surveyor interviewed the Director of Nurses (DON) at approximately 10:05 A.M. on 5/26/15. The DON said Resident #1 required a two person assist for transfers. The DON said CNAs are required to check the CNA Kardex for residents prior to providing care. The Surveyor interviewed the Maintenance Director at 11:40 A.M. and at 3:25 P.M. on 5/26/15. The Maintenance Director said he did not recall if he inspected Resident #1's reclining chair after Resident #1 returned to the Facility from the hospital on [DATE], or the following day. The Maintenance Director said there was no indication that the reclining chair required any repairs, there were no sharp edges found, and he did not recall seeing any missing caps.

2. For Resident #9, the facility failed to provide adequate supervision for a Resident who was identified as having a history of falls and having a restraint applied to his/her wheelchair. The resident sustained [REDACTED]. Resident #9 was admitted to the facility on [DATE]. The Resident's [DIAGNOSES REDACTED]. In addition, the resident had a history of [REDACTED]. Review of a Restraint Evaluation dated 8/8/11 identified the Resident as having no insight or safety awareness, and having continued periods of restlessness and anxiety. It further indicated that the Resident was at risk for falls secondary to his/her attempts to stand without assist. A lap tray with a clip belt with velcro straps around the arms of the wheelchair was identified as a restraint to be used for the Resident when out of bed. Review of the Resident's care plan initiated on 8/24/11 identified the problem of falls and included the following interventions: out of room when out of bed do not leave unattended when lap tray is off Pommel cushion to wheelchair for positioning The 11/17/11 Significant Change Minimum Data Set (MDS) identified the Resident as having short and long-term memory loss and being severely cognitively impaired. It further identified the Resident as requiring extensive assistance of 2 in transfers, being non-ambulatory, having no falls and having a restraint applied: a chair that prevents rising. Review of an Event Report dated 1/4/12 identified the Resident as sustaining a fall out of his/her wheelchair with a tray table in place on 12/30/11 at 5:00 P.M. in the day room. According to the Report, the Resident's alarm sounded and staff found the Resident on the floor. The Resident slid under the clip tray (a restraint) attached to the Resident's wheelchair and onto the floor. The Resident did not sustain any injuries. An intervention implemented to prevent recurrence and/or injury was for staff to place the Resident in a supervised seating area. In addition, staff education was given on the application of the tray table to ensure maximum security when the Resident was out of bed to the wheelchair. On 1/5/12, the Resident fell again: Review of an Event Report dated 1/5/12 identified the Resident as sustaining a fall out of his/her wheelchair in his/her room on 1/5/12 at 6:30 P.M. The Report identified staff negligence as the reason for the Resident's fall. Specifically it identified that CNA #4 had unclipped the Resident's tray table, left the room to retrieve something and returned to find the Resident on the floor. Further information indicated that the Resident pushed the tray table out of his/her wheelchair and got out of the wheelchair. The CNA transferred the resident alone back to bed before informing the nurse. The Resident did not sustain any injuries. A Quarterly Restraint re-evaluation dated 1/24/12 indicated that the Resident has no insight regarding safety awareness and has continued periods of restlessness and anxiety. It further indicated the Resident remained at risk for falls secondary to his/her attempts to stand without assist. A physical restraint assessment dated [DATE] indicated an alarmed clip belt would be initiated. The 2/9/12 Quarterly MDS identified the Resident as having short and long-term memory loss and being severely cognitively impaired. It further identified the Resident as requiring extensive assistance in transfers, being non-ambulatory, having experienced a fall with no injury and having a restraint applied: a chair that prevents rising. Review of an Event Report dated 4/5/12 identified that the resident sustained [REDACTED].M. The Report indicated that the Resident may have removed the tray table and unclipped the seatbelt, noting that the alarm did not sound. Interventions implemented after the fall included a change to a clip restraint tray with a breakaway alarm clipped to the Resident's shirt and for the Resident to be seated in a supervised seating area. The care plan was updated on 4/5/12. It included the interventions of a clip belt as a restraint with a breakaway alarm in the wheelchair, anti-tippers and Pommel cushion. Review of an Event Report dated 4/15/12 at 10:35 P.M. identified that the resident sustained [REDACTED]. The Report indicated that the Resident had exhibited restlessness while in bed that evening and was toileted by staff. He/she was then brought out to the day room and given a snack. While seated in the day room, the Resident slid underneath his/her lap tray and fell to the floor. A clip tray table (restraint), a wedge cushion and a breakaway alarm were in place at the time of the fall. The Resident did not sustain any injuries. On 4/16/12, the care plan was updated to include the intervention: Dycem underneath Pommel cushion to prevent sliding. The care plan was updated again on 4/17/12 to include the intervention: Dycem underneath Pommel cushion to prevent sliding. The 5/11/12 Significant Change MDS did not identify any noted changes from those areas identified above in the 2/9/12 Quarterly MDS. Review of a Nursing note, dated 6/11/12 3:00-11:00 P.M. shift, identified that the Resident slipped underneath his/her tray table and onto the floor. The Resident did not sustain any injuries. The Resident was screened by Physical Therapy and issued a new Pommel cushion. Another measure noted was for the Resident to be kept in a supervised area when out of bed. The care plan was updated to include the interventions: 6/11/12.....Rehab screen submitted 6/11/12 6/12/12.....15 minute checks with advancement of time as indicated. Neuro checks every 72 hours per protocol 6/13/12.......Resident issued high back wheelchair with new Pommel cushion The 8/13/12 Quarterly MDS identified the Resident as having short and long-term memory loss and being severely cognitively impaired. It further identified the Resident as requiring extensive assistance in transfers, being non-ambulatory, having experienced a fall with no injury and having a restraint applied: a chair that prevents rising. The Resident was observed on the following days of survey: 8/29/12 at 4:15 P.M....The Resident was seated in the day room in a wheelchair with anti-tippers, a chair alarm and a tray table in place. 8/30/12 at 10:30 A.M...The Resident was seated in the day room in a wheelchair with anti-tippers, a chair alarm and a tray table in place, participating in an exercise activity. 9/4/12 at 9:40 A.M.....The Resident was seated in the hallway in a wheelchair with anti-tippers, a chair alarm and a tray table in place. During interview on 9/6/12 at 11:00 A.M., Unit Manager #2 said that this Resident had fallen from his/her wheelchair with a restraint in place on several occasions. The facility failed to provide proper supervision to this Resident who fell out of a restraint 4 times and failed to develop proper interventions to keep the Resident safe from further falls. Based on record review, observation and staff interviews, the facility failed to ensure that 2 Residents (#5 and #9 ) in a total sample of 19 residents, were provided adequate supervision to prevent accidents. Findings include: 1) For Resident #5, the facility failed to provide appropriate supervision, which resulted in the Resident having a fall from his/her tilt wheelchair and sustaining a left hip fracture. Resident #5 was admitted to the facility December 2005, with [DIAGNOSES REDACTED]. An incident report, dated 9/17/11, indicated that at 1:30 P.M. the Resident was found lying on the floor, on his/her left side, in front of his/her wheelchair, in the Unit 300 dayroom. The staff reported the alarmed seatbelt was not confirmed to be on the Resident; and that the Resident subsequently was found on the floor. A nursing note, dated 9/17/11, indicated that the Resident was found lying on his/her left side on the floor, in front of his/her wheelchair in the dayroom at 1:30 P.M. There were no bruises or injuries noted; however, the Resident was sent out to the hospital due to complaints of left hip pain. A Physical Therapy screening form, dated 9/20/11, indicated that the Resident was screened after a fall from his/her wheelchair. The findings included that the Resident needed to be reclined in the wheelchair except when eating and safety belt fastened. Record review indicated an annual Minimum Data Set ((MDS) dated [DATE], which identified the Resident's cognition as severely impaired, and that the Resident required total care with 2 staff persons and a mechanical lift for all transfers. An incident report, dated 4/20/12, indicated that at 5:15 P.M. in the Unit 300 dayroom, the Resident was found lying on the floor, and it was unwitnessed. The report further indicated that per the Director of Nursing, the Resident was found on the left side of the wheelchair, on the floor. The velcro belt was undone on the tilt wheelchair. Prior to the fall, the Resident was seated upright in the wheelchair at the table in the dayroom ready for supper. The facility called 911, and the Resident was sent out to the hospital for evaluation and treatment. Staff interviews after the fall were as follows: Certified Nursing Assistant (CNA) #1 said -- " I was on the hallway passing the trays when I heard someone yelling for help in the dining (TV room). I rushed in and the Resident was on the floor. After a few minutes the alarm was beeping, and the nurse rushed in too. The Resident has a history of unbuckling the safety belt". CNA #2 said - "on this day the Resident undid his/her belt 2-3 times. I put it back." A hospital discharge note, dated 4/20/12, indicated that even though there was no obvious fracture, the view of both the left hip and pelvis was limited. On 4/20/12 at 9:45 P.M., a physician/nurse practitioner communication and progress note, indicated that the Resident had an unwitnessed fall at 5:15 P.M. in the day room. Staff were questioning if the Resident had a fracture. The communication report indicated that prior to the Resident's fall, due to the Resident unbuckling the seat belt, the staff had to refasten the seat belt several times. Record review indicated a nursing note, dated 4/25/12, which indicated that the Resident was seen by Physical Therapy (PT) secondary to having a fall from the wheelchair. The Physical Therapist documented that the Resident presented at baseline for both transfers and positioning. Physical Therapist recommended continuing the care plan, which was to keep the wheelchair in a tilted position except when eating and staff are present. A nursing note, dated 5/21/12, indicated that the Nurse Practitioner, if the Resident's Guardian agreed, would make a referral for an orthopedic consult, due to the Resident's continued complaints of his/her left hip and knee pain. An orthopedic consult, dated 6/11/12 at 10:45 A.M., indicated that the Resident was being examined due to left hip pain, with the onset of 7 weeks ago. The orthopedic findings were that the Resident appeared to have sustained a fracture involving the left hip, due to a fall from a wheelchair 7 weeks prior. The recommendation was to send the Resident to the hospital for admission, and the orthopedic physician would see the Resident in consultation at the hospital. A hospital discharge summary, dated 6/12/12, indicated that upon examination and after a Computerized Tomography (CAT) scan was completed, the Resident did have an intertrochanteric left hip fracture, with an old appearing lateral left subcapital hip fracture as well.