Every finding on record at Nevins Nursing & Rehabilitation Center

Based on observation and interview, the facility failed to store and prepare food in accordance with professional food safety standards. Specifically, the facility failed to1. Ensure food items were stored appropriately in the main kitchen reach in and walk in refrigerator and2. Failed to ensure staff maintained proper hand hygiene while serving food on two of four units.Findings include:Review of the facility's policy titled Food Labeling Policy and Procedures for [The Facility], undated, indicated: Policy: All food items must be labeled accurately and clearly to ensure proper identification, traceability, and safe consumptions. Procedures: 1. Labeling Requirements: All food items must be labeled with the following information: Name of the item, date item was brought into facility, use-by or expiration date. Labels must be legible and securely attached to the container or packaging. 1. On 1/6/26 at 7:11 A.M., the surveyor observed the following in the reach-in refrigerator and walk-in refrigerators: -A shopping bag with containers of food. A staff person said that the bag contained a staff persons' lunch and should not be stored in the refrigerator. -A sandwich dated labeled use for 1/2/26 -A plastic cup filled with pasta salad, undated and unlabeled. -A bowl of breakfast sausages, undated and unlabeled. -Ten bowls of fruit, undated and unlabeled. -A container of a brown gravy- like substance, undated and unlabeled. During an interview on 1/7/26 at 10:58 A.M., the Food Service Director said all items in the refrigerator should be dated and labeled and the sandwich should have been disposed of. 2a. During an observation on 1/6/26 at 8:20 A.M., the surveyor observed a food service employee on the A unit pull a steam cart down the hallway with gloved hands. The employee proceeded to plug in the steam table with her same gloved hands. Without changing her gloves, pressed buttons on the upper part of the steam table, turning lights on. She then proceeded to grab a plate and serve residents meals without changing her gloves. During an interview on 1/7/26 at 1:09 P.M., the Food Service Director said that the staff should not be wearing gloves when serving the food, and that the employee should not have been touching the table and plug and then serving food without changing or removing her gloves and performing hand hygiene. 2b. During an observation on the Transitional Care Unit (TCU) on 1/7/26 at 12:30 P.M, the surveyor observed Diet Staff #1, without gloves on and without previously sanitizing her hands, obtain serving utensils from a metal bin by taking the utensils out of the bin by the bowl end (potentially contaminating the utensils) and then placing the bowl end of the utensil directly into the food. During an interview on 1/7/26 at 12:55 P.M., Diet Staff #1 said that she should not have touched the bowl end of the serving utensils. During an interview on 1/7/26 at 1:09 P.M., The Food Service Director said that the staff member should not have grabbed the utensils by the serving end with her bare hand and then use it to serve food.

Based on observation and interview, the facility failed to ensure resident meals were at an appropriate temperature and were palatable on 4 of 4 resident units. Findings include: During the initial screening process, multiple residents reported that meals are served cold and not palatable. During the Resident Group Interview held on 1/7/26 at 10:30 A.M., multiple participants reported that meals served to residents on the unit were cold, uncooked and not palatable. During an interview on 1/7/26 at 12:26 P.M., the Food Service Director (FSD) said that the food is brought up to the units on carts with closed cabinet doors and then plated on the units. On 1/7/26 at 12:47 P.M., the surveyor conducted a test tray on the B unit:Mashed Potato: 130 degrees Fahrenheit (F)Steamed Cauliflower: 119 degrees FPuree Meatloaf: 95 degrees F. The food items tasted cold and were not palatable. On 1/7/26 at 12:50 P.M., the surveyor conducted a test tray on the C unit:Meatloaf: 90 degrees F. Mashed Potato: 100 degrees F. Steamed Cauliflower: 90 degrees F. The food items tasted cold and were not palatable. On 1/7/26 at 12:55 P.M., the surveyor conducted a test tray on the A Unit:Clam Chowder: 120.6 degrees Fahrenheit (F)Mashed Potato: 146.8 degrees FMeatloaf: 136.6 degrees FSteamed Cauliflower: 112.2 degrees FThe food items tasted cold and were not palatable. On 1/7/26 at 12:55 P.M., the surveyor conducted a test tray on the TCU, (Transitional Care Unit):Mashed Potato: 122.9 degrees F.Steamed Cauliflower: 107 degrees F.Meatloaf: 147 degrees F.The mashed potato and cauliflower tasted cool and were not palatable. During an interview on 1/7/26 at 1:11 P.M., the FSD said that the expectation is for hot food items to be about 135 degrees when served to the resident.

Based on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments for three Residents (#16, #66, and #54) out of 34 total sampled residents. Specifically, the facility failed to:1.Ensure Resident #16's scheduled Tylenol was not left at the bedside while unsupervised by staff. 2. Ensure Resident #66's Augmentin Oral Tablet (antibiotic medication) was not left at the bedside while unsupervised by staff.3. Ensure Resident #54's Nasal Saline Solution was not left at the bedside while unsupervised by staff.Findings include: Review of the facility policy titled Storage of Medications, dated as revised in 2024, indicated but was not limited to the following:Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aids) are permitted to access medications, medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. 1.Resident #16 was admitted to the facility in March 2024 with diagnoses including spinal stenosis and bipolar disorder. Review of Resident #16's most recent Minimum Data Set (MDS) Assessment, dated 10/17/25, indicated Resident #16 was cognitively intact as evidence by a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15. On 1/6/26 at 8:00 A.M., the surveyor observed a medication cup on Resident #16's walker tray table with two white pills inside. Resident #16 stated that the medications inside the cup were Tylenol and he/she was waiting for breakfast to take them. Review of Resident #16's medical record failed to indicate that the Resident had met criteria to self-administer medications at his/her bedside. Review of Resident #16's physician order dated 9/29/24 indicated the following: -Acetaminophen Oral Tablet (Tylenol) Give 1000 mg (milligrams) by mouth three times a day for pain, scheduled at 8:00 A.M., 1:00 P.M., and 6:00 P.M. Review of the January 2026 Medication Administration Record indicated that Resident #16's scheduled 8:00 A.M. Tylenol was signed off as having received the medication on 1/6/26 at 7:39 A.M. During an interview on 1/7/26 at 11:13 A.M., Unit Manager #2 said medications are not supposed to be left at the bedside without a medication administration assessment completed and a physician's order. During an interview on 1/7/26 at 12:52 P.M., the Director of Nursing said medications should not be left at the bedside and signed off as administered when it was not. 2. Resident #66 was admitted to the facility in May 2025 with diagnoses including dysphagia, hypotension, and major depressive disorder. Review of Resident #66's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #66 had moderate cognitive impairment as evidence by a Brief Interview for Mental Status (BIMS) score of 12 out of a possible score of 15. On 1/6/26 at 8:21 A.M., the surveyor observed a medication cup on Resident #66's overbed table with one white oval pill inside. Resident #66 stated he/she did not know what the medication was or how it got there. Review of Resident #66's physician orders and care plans failed to indicate that the Resident had met criteria to self-administer medications at his/her bedside. Review of Resident #66's physician order dated 1/5/26 indicated the following: -Augmentin Oral Tablet 500-125 MG (milligrams) (Amoxicillin & Pot Clavulanate) Give 1 tablet by mouth two times a day for pneumonia for 7 Days. Scheduled for 6:00 A.M., and 6:00 P.M. Review of Resident #66's January Medication Administration Record indicated that Resident #66's scheduled 6:00 A.M., Augmentin was as having received the medication on 1/6/26. During an interview on 1/6/26 at 12:46 P.M., Nurse #4 said a Certified Nursing Assistant notified her about the pill that was found on the bedside table and removed it because she did not know what it was and said medication should not be left at the bedside. Nurse #4 said when she investigated the medication it was noted this was Resident #66's scheduled 6:00 A.M. antibiotic that was left by the overnight nurse. Nurse #4 said Resident #66 cannot self-administer medication and should not have medications left at the bedside because he/she has a cognitive impairment During an interview on 1/7/26 at 12:52 P.M., the Director of Nursing (DON) said Resident #66's medications should not be left at the bedside and signed off as administered when it was not. The DON said Resident #66 did not have a self-administration assessment completed and said the Resident was not deemed to be appropriate to self-administer medications. 3. Resident #54 was admitted to the facility in January 2024 with diagnoses including type one diabetes mellitus, anemia in chronic kidney disease (low red blood cells) and epistaxis (nose bleeds). Review of Resident #54's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #54 had intact cognition as evidence by a Brief Interview for Mental Status (BIMS) score of 14 out of a possible score of 15. On 1/6/26 at 8:21 A.M., the surveyor observed one open and undated bottle of Saline Nasal Spray Nasal Solution on Resident #54's overbed table. The Resident said staff leave it in his/her room and administer it when it is due. On 1/6/26 at 12:34 P.M., the surveyor observed one bottle of Saline Nasal Spray Nasal Solution on Resident #54's overbed table. On 1/7/26 at 7:47 A.M., 9:16 A.M., and 12:34 P.M., the surveyor observed one bottle of Saline Nasal Spray Nasal Solution on Resident #54's overbed table. Review of Resident #54s physician orders and care plans failed to indicate that the Resident had met criteria to self-administer medications at his/her bedside. Review of Resident #54's physician order dated 3/20/25 indicated the following: -Saline Nasal Spray Nasal Solution (Saline) 1 spray in both nostrils two times a day for dry nostrils. Scheduled for 9:00 A.M., and 6:00 P.M. Review of Resident #54's January Medication Administration Record indicated that Resident #54's scheduled 6:00 A.M. and 6:00 P.M., Saline Nasal Spray Nasal Solution was signed off as Resident receiving medication on 1/6/26 and 1/7/26. During an interview on 1/7/26 at 12:46 P.M., Nurse #3 said Resident #54 should not have the nasal spray stored in his/her room and said the bottle must be dated when opened and stored in the medication cart until it is due to be administered. Nurse #3 said Resident #54 has not been cleared to self-administer medications. During an interview on 1/7/26 at 9:49 A.M., Unit Manager #1 said medication must be dated when opened and stored in the locked medication cart and not kept in the residents' room. Unit Manager #1 said Resident #54 has not been assessed for self-administration of medications and should not have the medication in his/her room. During an interview on 1/7/26 at 12:52 P.M., the Director of Nursing said Resident #54 should not have the bottle of Nasal Saline Solution accessible in his/her room and said the bottle must be dated when opened and stored in the nursing cart.

Based on observations, interviews and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for three Residents, (#2, #136 and #66) out of a sample of 34 Residents. Specifically,1.For Resident #2, the facility failed to provide oxygen to the Resident as indicated in the physician's orders.2.For Resident #136, the facility failed to ensure oxygen equipment and tubing was labeled, when changed/dated and that respiratory assessments were documented as indicated in the physician's orders. 3. For Resident #66, the facility failed to ensure nebulizer equipment and tubing was labeled, when changed/dated. Findings include: Review of the facility policy titled 'Policy and Procedure: Oxygen (O2) Management' with no revision date, indicated the following: -To ensure the safe and effective administration of oxygen therapy to residents, in compliance with Massachusetts Department of Public Health and CMS guidelines. -It is the policy of the facility to provide oxygen therapy to residents as prescribed by their physician or nurse practitioner (NP), ensuring proper administration, monitoring, and documentation to maintain resident safety and well-being. Resident #2 was admitted to the facility in September 2025 with diagnoses including heart failure. Review of the Minimum Data Set (MDS) Assessment, dated 12/26/25, indicated a Brief Interview for Mental Status score (BIMS) of 9 out of a possible 15, indicating moderate cognitive impairment. Review of Resident #2's January 2026 physician's orders indicated the following: -Oxygen at 2 Liters via nasal cannula care and comfort every shift. Start date 1/5/26. On 1/6/26 at 8:15 A.M., the surveyor observed Resident #2 sleeping with the nasal cannula on. Oxygen was set at 3 Liters. On 1/7/26 at 7:48 A.M., and 10:44 A.M., the surveyor observed Resident #2 sleeping with the nasal cannula on. Oxygen was set at 3 Liters. During an interview and observation on 1/7/26 at 10:45 A.M., the surveyor and Nurse #1 observed Resident #2 sleeping with the nasal cannula on. The oxygen was set at 3 Liters. Nurse #1 said the Resident is on oxygen for comfort and the physician's orders states the oxygen should be set at 2 Liters. During an interview and medical record review on 1/7/26 at 11:04 A.M., Unit Manager #1 and the surveyor reviewed the Resident's medical record. The Unit Manager said that the Resident is currently on hospice and is on oxygen for comfort. The Unit Manager said the Resident's oxygen should be set at 2 Liters per the physician's orders. During an interview and medical record review on 1/7/26 at 11:38 A.M., the Director of Nurses reviewed the medical record and said the Resident is currently on hospice and on oxygen for comfort. The DON said the physician's orders should be followed and the oxygen should be set at 2 liters. 2. Resident #136 was admitted to the facility in March 2022 with diagnoses including, chronic diastolic congestive heart failure, moderate persistent asthma, essential primary hypertension, and morbid (severe) obesity. Review of the most recent Minimum Data Set assessment (MDS) assessment, dated 11/21/25, indicated the Resident scored a 14 out of a possible 15 on the Brief Interview for Mental Status exam, indicating intact cognition. On 1/6/26 at 8:35 A.M., the surveyor observed Resident #136 sitting up in bed with nasal canula tubing from an oxygen concentrator resting on his/her pillow. Resident #136 said he/she has been having shortness of breath at night and using oxygen. On 1/7/26 at 9:13 A.M., the surveyor observed Resident #136 receiving oxygen from a nasal canula from an oxygen concentrator. The oxygen tubing and one 540mL (milliliter) bottle of sterile water (used for humidification) was undated. The oxygen was set at 1.5 liters. Resident #136 said he/she was having shortness of breath overnight and said the overnight nurse placed him/her on oxygen. Resident #136 said he/she did not know his/her oxygenation saturation level because the nurse did not put that thing they use on my finger, referring to a pulse oximeter used to measure the level of oxygen in the blood. On 1/7/26 at 12:15 P.M., the surveyor observed Resident #136 receiving oxygen from a nasal canula from an oxygen concentrator. The oxygen tubing and one 540mL (milliliter) bottle of sterile water (used for humidification) was undated. The oxygen was set at 2 liters. Review of Resident #136's active physician orders indicated the following:-Oxygen at 2L (liters) via N.C (nasal cannula) to maintain oxygen saturation greater than 90% every 24 hours as needed for monitoring. Start Date 6/3/25.-Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 3 ml inhale orally as needed for congestion BID. Start Date 3/4/24. Review of Resident #136's asthma care plan dated 9/21/24, indicated the Resident has asthma and is at risk for SOB (shortness of breath)/Respiratory distress, allergies, CHF (congestive heart failure) and is at risk for Respiratory distress. The following care plan interventions included: - Give medications as ordered. Monitor/document side effects and effectiveness. Initiated 10/1/24.-Monitor for s/sx (signs/symptoms) of impending asthma attack: coughing spells, decreased energy, rapid breathing, complaint of chest tightness or hurting, wheezing, shortness of breath, tightness of neck or chest muscles, malaise or fatigue. Initiated 10/1/24.- Monitor VITAL SIGNS as needed, skin color, pulse oximetry, airway functioning and degree of restlessness which may indicate hypoxia. Initiated 10/1/24.- Resident Avoids Lying Flat due to shortness of breath, see ETAR (electronic treatment administration record) if noted. Initiated 10/1/24.- Monitor for any SOB (shortness of breath) and other related symptoms for any SOB while lying flat/upon exertion/at rest or if pt avoids lying flat d/t (due to) SOB. If any SOB is noted, elevate the head of bed or get pt (patient) OOB (out of bed), upright in chair, if able, to facilitate easier breathing. Take rest breaks if SOB is noted. Initiated 12/13/24. Review of Resident #136's medical record including Treatment Administration Record (TAR) and Medication Administration Record (MAR) for the month of January 2026 was left blank and contained no documentation of administration of Oxygen at 2L via N.C to maintain oxygen saturation greater than 90% every 24 hours as needed for monitoring per the physician order. Review of Resident #136's medical record failed to reflect an ongoing assessment of the Resident's respiratory status and response to oxygen therapy. The last documented oxygen saturation level was 90% on 12/26/25. Further review of the medical record failed to indicate physician orders were in place to change/date the oxygen tubing. During an interview on 1/7/26 at 9:23 A.M., Nurse #3 said Resident #136 uses oxygen as needed for shortness of breath and said respiratory assessments should be documented in the medical record. Nurse #3 said she was not aware that Resident #136 had shortness of breath overnight and said there is no respiratory assessment or documented oxygenation status. Nurse #3 reviewed the medical record and said Resident is currently receiving oxygen and it needs to be documented on the MAR, and a respiratory assessment must be completed. Nurse #3 said oxygen tubing and equipment must be dated weekly and stored appropriately when not in use. During an interview on 1/7/26 at 12:56 P.M., the Director of Nursing said physician's orders should be followed as ordered and said respiratory assessments must be documented. She further said that she would expect nurses to document the use of oxygen therapy in the medical record if administered. The DON said all oxygen equipment and nebulizer tubing should be changed weekly and should be dated, labelled and bagged. 3. Resident #66 was admitted to the facility in May 2025 with diagnoses including dysphagia, hypotension, and major depressive disorder. Review of Resident #66's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #66 had moderate cognitive impairment as evidence by a Brief Interview for Mental Status (BIMS) score of 12 out of a possible15. On 1/6/26 at 8:21 A.M., an uncovered nebulizer machine and mask were resting on top of a wheelchair, the tubing was undated. The Resident said he/she uses the nebulizer every day. On 1/6/26 at 11:30 A.M., an uncovered nebulizer machine and mask were resting on top of a wheelchair, the tubing was undated. On 1/7/26 at 8:06 A.M., an uncovered nebulizer machine and mask were resting on top of a wheelchair, the tubing was undated. Review of Resident #66's medical record indicated the following physician order:-Ipratropium- Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium- Albuterol) 1 application via mask three times a day for congestion for 5 Days. Start Date 1/2/26. Review of Resident #66's Medication Administration Record (MAR) indicated the Resident was receiving the oral inhalation medication via nebulizer three times daily. Review of Resident #66's medical record failed to indicate a physician's order or care plan for the care of the nebulizer machine, including tubing or mask, was developed or implemented. During an interview on 1/7/26 at 9:25 A.M., Nurse #3 said respiratory tubing and equipment must be changed and dated weekly and stored appropriately when not in use. During an interview on 1/7/26 at 12:58 P.M., the Director of Nursing said nebulizer equipment and tubing should be bagged, dated and changed weekly and documented in the medical record.

Based on observation, interview, and record review, the facility failed to consistently provide range of motion (ROM) care and treatment in accordance with professional standards of practice for one Resident (#36) out of a total sample of 34 residents. Specifically, the facility failed to ensure staff implemented physician's orders for his/her left-hand splint (a device to properly position and protect hand joints) use based on the Occupational Therapist's recommendation and failed to develop a comprehensive resident-centered care plan with individualized interventions for Resident #36 assessed left-hand contracture.Findings include:Resident #36 was admitted to the facility in March 2025 with diagnoses including dysarthria following cerebral infarction, hemiplegia, and hemiparesis affecting left non-dominant side, hypertension and vascular dementia.Review of Resident #36's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score 14 out of a possible 15, indicating intact cognition. The MDS also indicated Resident #36 requires substantial/maximal assistance and is dependent on staff for functional daily tasks. The surveyor made the following observations:-On 1/6/26 at 7:14 A.M., Resident #36 was observed lying in his/her bed. Resident #36 was not wearing a left-hand splint and there was no hand splint observed in the vicinity of the Resident's bed or in the room. The Resident had not received morning activities of daily living (ADL) care yet.-On 1/6/26 at 10:24 A.M., Resident #36 was observed sitting up in a wheelchair. Resident #36 was not wearing a left-hand splint and there was no hand splint observed in the vicinity of the Resident's bed or in the room.-On 1/7/26 at 7:15 A.M., Resident #36 was observed lying in his/her bed. Resident #36 was not wearing a left-hand splint and there was no hand splint observed in the vicinity of the Resident's bed or in the room. The Resident had not received morning ADL care yet.-On 1/7/26 at 10:49 A.M., Resident #36 was observed sitting up in a wheelchair. Resident #36 was not wearing a left-hand splint and there was no hand splint observed in the vicinity of the Resident's bed or room.Next to Resident #36's bed, hanging on the wall, were two photos of Resident #36 wearing a left-hand splint with the following directions:-Caregivers: Splint on left hand at night.-Night only thank you.Review of Resident #36's Occupational Therapy (OT) Discharge summary, dated [DATE], indicated: Patient tolerating splint for 2 hours during day to assess for redness/irritation. Caregivers trained and pictured proper orthotic donning provided in patients room to promote carryover amongst shifts. -Discharge Recommendations: Recommend resting hand spline (splint) applied to L (left) wrist/hand after dinner, overnight and removed in AM. -Functional Maintenance: Splint and Brace Program Established/Trained. Resting hand splint applied to LUE (left upper extremity) overnight only. Review of Resident #36's physician's orders on 1/6/26 indicated the following:-OT (occupational therapy): Other Rehabilitation Orders: (x) Splint to L HAND/WRIST per splint wearing schedule: OVERNIGHT ONLY- OFF DURING DAY. Verbal Active 3/28/25. The physician's order failed to include documentation to support a splint wearing schedule as the physician order was not completed. Review of Resident #36's Medication Administration Records and Treatment Administration Records failed to indicate the use of a left-hand splint due to the physician's order having incomplete directions for use.Review of Resident #36's plan of care on 1/6/26, failed to indicate Resident #36 had a left-hand contracture and failed include documentation to support a splint wearing schedule.During an interview on 1/7/26 at 10:40 A.M., Nurse #3 said Resident #36 has never worn a left-hand splint and said she has never seen one in his/her room and said the Resident does not have orders to apply a left-hand splint. During an interview on 1/7/26 at 10:59 A.M., Certified Nursing Assistant (CNA) #3 said Resident #36 does not wear a left-hand splint and she does not remember ever putting one on or taking one off him/her.During an interview on 1/7/26 at 11:08 A.M., Occupational Therapist (OT) #1 said Resident #36 should be wearing the left-hand splint and said staff education was provided and signs are posted in his/her room to remind staff to apply the hand splint. OT #1 said Resident #36 was evaluated in March 2025 and has a left-hand contracture and needs to wear the left-hand splint. During an observation and interview on 1/7/26 at 11:45 A.M., OT #2 said Resident #36 has a left-hand contracture and was evaluated in March 2025 and said orders were in place for the use of a left-hand splint at bedtime and said staff had completed education on applying and removing the splint and said she was not aware that the Resident was not wearing it. OT #1 asked Resident #36 if staff have been putting the splint on and Resident #36 said no that he/she has not seen the left-hand splint in a long time. Upon inspection in the Resident's room, OT #2 found a left-handed splint on top of a bureau located under wheelchair footrests and padding equipment. During an interview on 1/17/26 at 12:40 P.M., the Director of Nursing (DON) said recommendations and physician orders for Resident #36 should be followed. The DON said the physician order for applying the left-hand splint should be located on the MAR and TAR and said staff should be signing off on the physician order. The DON said the care plan should indicate that Resident #36 has a left-hand contracture and should be updated with interventions to include the use of the left-hand splint.

Based on observations, interviews and records reviewed, the facility failed to ensure standards of quality of care for one Resident (#36) out of a total sample of 34 residents. Specifically, the facility failed to follow up on a biopsy to Resident #36's nose, failed to identify a change in a skin condition on his/her nose, and failed to document the skin area on a skin assessment. Findings include:Review of the facility policy titled Skin Management Program Assessment and Prevention of Skin Breakdown, undated, indicated but was not limited to the following:The following measures will be employed as warranted for all residents noted to be at a moderate to high risk for the development of a skin breakdown via the Norton Plus Scale.7.Check the residents skin condition daily and whenever giving care for any signs or symptoms of skin irritation or breakdown.9. Perform and document weekly in the electronic health record the weekly skin check. 10. If a wound is identified the area will be assessed, measured, and documented weekly in the electronic health record.Review of the facility policy titled Change in a Residents Condition or Status, dated as revised February 2021, indicated but was not limited to the following:The nurse will notify the resident's attending physician or physician on call when there has been a (an); b. discovery of injuries of an unknown source; d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly.5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.Resident #36 was admitted to the facility in March 2025 with diagnoses including dysarthria following cerebral infarction, hemiplegia, and hemiparesis affecting left non-dominant side, hypertension and vascular dementia.Review of Resident #36's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score 14 out of a possible 15, indicating intact cognition. The MDS also indicated Resident #36 requires substantial/maximal assistance and is dependent on staff for functional daily tasks. On 1/6/26 at 7:14 A.M., Resident #36 was observed lying in bed. The Resident had a dark pink and red scabbed area in the crease of his/her left nostril. The Resident said he/she has an abscess on his/her nose that was biopsied last spring but needs to be rechecked. On 1/6/26 at 10:24 A.M., Resident #36 was observed sitting up in a wheelchair. The Resident had a dark pink and red scabbed area in the crease of his/her left nostril.On 1/7/26 at 7:24 A.M., Resident #36 was observed lying in bed. The Resident had a dark pink and red scabbed area in the crease of his/her left nostril.On 1/7/26 at 10:49 A.M., and at 11:08 A.M., Resident #36 observed sitting up in a wheelchair The Resident had a dark pink and red scabbed area in the crease of his/her left nostril.Review of Resident #36's physician orders indicated the following: Weekly skin check by licensed staff. Document findings in Skin Assessment one time a day every Thursday for Skin Check 7:00 A.M.-3:00 P.M. Start Date 5/29/25.Review of the skin check completed on 12/25/25 and 1/3/26 indicated the nurse documented the following: skin intact. Review of Resident #36's skin integrity care plan, date Initiated 2/12/25, indicated the following interventions:-Follow facility protocols for treatment of injury. -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.Review of the Nursing Progress notes for the month of December 2025 and January 2026 failed to mention the area observed on Resident #36's nose. During an interview on 1/7/26 at 9:21 A.M., Nurse #3 said the Resident has had an open area on his/her nose for a while now and said she noticed the area to Resident #36's nose had gotten worse and looked different with open areas that had dried blood and said the area should be documented on a skin check or in the medical record. The surveyor along with Nurse #3 reviewed the medical record and Nurse #3 said the area should have been documented on a skin check when it was noticed last week but was not documented. Nurse #3 said the area looks worse than when she saw it last week.Review of Resident #36's medical record indicated the following nursing progress note dated 4/30/25:Resident LOA (leave of absence) with staff from Element Care to go to his/her Dermatologist Appointment at 9:00AM. Returned back to (facility) 1:00PM Biopsy done to nose/right hand. will call back with the results, in 1-2 weeks. No new orders were given.Review of Resident #36's medical record indicated the following Physician consultation report dated 4/30/25: Biopsy done to nose/right hand. Will call for results in 1-2 weeks. see attached. No supporting documentation was attached to the report or located in the medical record.Review of Resident #36's medical record indicated a Skin Observation Tool dated 5/29/25, indicated scabbed area noted to left nostril.Further review of the medical record indicated the following Physician Progress note dated 5/13/25: Resident reports he/she went to the dermatologist last week and they did something to his/her area around the nose, but he/she is sure they did not take a biopsy. Physical Exam: Crusted plaque on the left nose with band-aid in place, looking covered with drainage.Assessment and Plan: 1 skin lesion-left nose was seen by the dermatologist and biopsy done results pending. Clean area and leave it open to air. Review of the medical record failed to indicate any follow up recommendations or results of the biopsy taken in April 2025. During an interview on 1/7/26 at 10:56 A.M., Unit Manager #1 said he was aware of the area on Resident #36's nose and said he would expect it to be documented on skin check and said he knew the Resident had a biopsy but was unable to obtain results. Unit Manager #1 said he would expect the nurses to document the area on a skin check and report to the physician if the open area is getting worse and bleeding. During an interview on 1/7/26 at 12:55 P.M., the Director of Nursing (DON) said all skin impairments, including skin tears, open areas, should be documented on skin checks, in progress notes and reported. The DON said she would expect the provider to be notified, to obtain new treatment orders, and interventions needed to update the plan of care for the area identified.

Based on record review and interview, the facility failed to ensure Advance Directives (written documents that instructs health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) were consistently documented in the medical record for one Resident (#66), out of a total sample of 34 residents.Findings include: Review of the facility policy titled Advanced Directives, dated as revised September 2022, indicated but was not limited to the following:The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy.-Information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section that is retrievable by any staff.-If the Resident or the resident's representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the residents' medical record and are readily retrievable by any facility staff member. -The Director of Nursing Services (DNS) or designee notified the attending physician of advance directives (or changes in advance directives) so that appropriate orders can be documented in the residents' medical record and plan of care.-The residents' wishes are communicated to the residents' direct care staff and physician by placing the advance directive documents in a prominent, accessible location in the medical record and discussing the residents wishes in care planning meetings. -The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive.-Changes or revocations of a directive must be submitted in writing to the administrator. The administrator may require new documents if changes are extensive. The interdisciplinary team will be informed of changes and/or revocations so that appropriate changes can be made in the resident medical record and care plan.Resident #66 was admitted to the facility in May 2025 with diagnoses including dysphagia, hypotension, and major depressive disorder. Review of Resident #66's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #66 had moderate cognitive impairment as evidence by a Brief Interview for Mental Status (BIMS) score of 12 out of a possible score of 15.Review of Resident #66's plan of care related to advanced directives, dated 5/16/25, indicated:- Provide education to resident/family regarding care options.- Review existing advance directives and whether the resident wishes to change or continue these instructions as part of the comprehensive care planning process and PRN (as needed).On 1/6/26, the surveyor observed in the electronic health record, in the clinical dashboard, that Resident #66's Code Status Advance Directive section was left blank.Review of Resident #66's active physician's orders, failed to indicate an order for advance directives was in place. Review of Resident #66's Medical Orders for Life Sustaining Treatment (MOLST) form dated 7/21/25, indicated:-Do Not Resuscitate.-Transfer to Hospital.Review of Resident #66's medical record included a MOLST indicating the following: Page 1 Section D of the MOLST indicated: -Do Not Resuscitate-Transfer to HospitalPage 2 Section G of the MOLST, was signed but did not indicate who was signing the form. The form did not include a legible printed name of the signer and was left blank, the form was not dated and was left blank, and the telephone number of the signer section was left blank. The MOLST was dated and signed 7/21/25 by the Nurse Practitioner.During an interview on 1/7/26 at 9:21 A.M., Nurse #3 reviewed Resident #66's clinical dashboard and she said that she was not sure what Resident #66's code status was due to the missing information and said there is no active physician order in place. Nurse #3 said she would need to review the medical record because she does not know the residents' code status.During an interview on 1/7/26 at 9:23A.M., the surveyor along with Unit Manager #1 and Nurse #3 reviewed Resident #66's clinical dashboard including physician orders and Unit Manager #1 said Advance Directive status should be documented in the electronic medical record with a physician order in place and said the care plan should indicate the code status but does not. Unit Manager #1 said he would need to check as he does not know the Resident's code status. During an interview on 1/7/26 at 10:50 A.M., Unit Manager #1 said he found the MOLST form and gave the surveyor a printed copy of a MOLST form dated 9/4/24. The MOLST form did not match the MOLST form that was located in Resident #66's physical medical chart. The MOLST form dated 9/4/24 indicated: -Do Not Resuscitate -Do Not Transfer to Hospital. The surveyor and Unit Manager #1 obtained the MOLST form dated 7/21/25 located in front of Resident #66's physical medial chart. During an interview on 1/7/26 at 10:55 A.M., Unit Manager #1 said the Resident #66's medical record has missing and conflicting code status information and said the MOLST form dated 7/21/25 should have been filled out completely because the Residents wishes had changed to be transported to the hospital. Unit Manager #1 said MOLST needs to be signed, dated and updated in the medical record. Review of Resident #66's medical record on 1/7/26 at 12:00 P.M., indicated the clinical dashboard Advance Directive code status section now indicated: Do Not Resuscitate, Do not intubate/ventilate/Do not use Non-invasive ventilation/ Do not transfer to Hospital.During an interview 1/7/26 at 12:49 P.M., the Director of Nursing (DON) said Resident #66's code status should consistently be documented in the medical record and include a physician order and said the plan of care should include the Advance Directive status. The DON said any updates to the Residents MOLST form should be complete and accessible in the medical record.

Based on record review and interview the facility failed to implement the plan of care for one Resident (#4) out of a total sample of 34 residents. Specifically, for Resident #4 the facility failed to obtain and document vital signs as indicated in the plan of care. Findings include:Review of the facility policy titled Care Plans, Comprehensive Person-Centered, dated as revised March 2022, indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Resident #4 was admitted to the facility in February 2025 with diagnoses including presence of a pacemaker, congestive heart failure and atrial fibrillation.Review of the Minimum Data Set (MDS) assessment, dated 11/14/25, indicated that Resident #4 had moderate cognitive impairment as evidenced by a score of 9 out of 15 on the Brief Interview for Mental Status exam. Further review indicated Resident #4 was dependent on staff for activities of daily living.Review of the care plan dated 3/3/25 indicated a focus of the resident has a pacemaker r/t (related to) atrial fibrillation with interventions including monitor vital signs (blood pressure, heart rate and respiratory rate) daily. Notify MD (medical doctor) of significant abnormalities. Review of the progress notes failed to indicate nursing obtained vital signs daily.Review of the treatment administration record, dated January 2026, failed to indicate vital signs were obtained daily.Review of the medication administration record, dated January 2026, failed to indicate vital signs were obtained daily.During an interview on 1/7/26 at 10:20 A.M., Unit Manager #1 said that nurses should follow the care plan. He then said that vital signs should be taken and documented on the treatment record per the care plan.During an interview on 1/7/26 at 11:25 A.M., the Director of Nursing said that care plans are to be followed by facility staff.

Based on observations, record review and interview the facility failed to ensure assistance with Activities of Daily Living were provided for two Residents (#62 and #129) out of a total sample of 34 Residents. Specifically,For Resident #62 the facility failed to provide supervision or touching assistance with meals as indicated in the Resident's plan of care.For Resident #129 the facility failed to provide continuous supervision with meals as indicated in the Resident's plan of care.Findings include:Review of the untitled policy provided to the surveyor when the Activities of Daily Living (ADL) policy was requested, undated, indicated the following: -Based on the comprehensive assessment of a patient and consistent with the patient's needs and choices, the Center must provide the necessary care and services to ensure that a patient's abilities in activities of daily living do not diminish unless circumstances of the individuals clinical condition demonstrate that such diminution was unavoidable. -The center must ensure that: a patient who is unable to carry out ADLs receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 1. Resident #62 was admitted to the facility in November 2025 with diagnoses that included protein-calorie malnutrition and adult failure to thrive. Review of Resident #62's most recent Minimum Data Set (MDS) assessment, dated 11/12/25, indicated a Brief Interview for Mental Status score of 14 out of 15, indicating intact cognition. The MDS further indicated that the Resident required supervision/ touching assistance for eating. During an observation on 1/6/26 at 8:26 A.M., the surveyor observed a Certified Nurse Aide (CNA) deliver the breakfast meal to the Resident in his/her room and then exit the room. The Resident was observed eating alone in his/her room in bed with the head of the bed elevated. During a continuous observation on 1/7/26 from 8:29 A.M. to 8:41 A.M., the surveyor observed a CNA deliver the breakfast meal to the Resident in his/her room. The CNA set up the meal and exited the room. The Resident was observed eating alone in his/her room in bed with the head of the bed elevated. Review of a Speech Therapy (ST) encounter note, dated 1/6/26, indicated the following: -Precautions: aspiration risk. -Skilled interventions addressing swallow dysfunction included liquid swallows to increase safe oral intake. Review of the Activities of Daily Living (ADL) care plan, dated as revised 11/11/25, indicated the following intervention: Eating: The resident requires one assist/supervision with meals, no straws at the bedside. Review of Resident #62's Kardex (a form that instructs staff on the level of assistance required to care for the resident) indicated the following: Eating: The resident requires one assist/supervision with meals, no straws at the bedside. Review of the Initial or Annual Nutrition Assessment, dated 11/6/25 indicated the following: -Pt (patient) reports occasional cough since admission on puree/NTL (nectar thickened liquids). Per nurse fully dependent. -Summary: intake variable- requires assist. Review of CNA documentation from 12/25/25 through 1/6/26 indicated that set up or clean up assistance was provided for meals and failed to indicate that supervision or touching assistance was provided as indicated in the Resident's plan of care. During an interview on 1/7/26 at 10:43 A.M., CNA #1 said that they use the Kardex on the computer that comes from the care plan for instructions on patient care. She said that if a Resident's Kardex says supervision or touching assistance, then the staff should remain with the resident while they are eating. During an interview on 1/7/26 at 11:13 A.M., the Director of Nurses said that if the resident's care plan indicates supervision or touching assistance is required, then someone should remain with the resident for the duration of the meal, or the resident should eat the meal in the dining room. She said the plan of care should be followed. 2. Resident #129 was admitted to the facility in October 2017 with diagnoses including dementia and chronic obstructive pulmonary disease (COPD). Review of Resident #129's most recent Minimum Data Set (MDS) assessment, dated 11/14/25, indicated Resident #129 had severe cognitive impairment as evidence by a Brief Interview for Mental Status (BIMS) score of 3 out of a possible score of 15. During an observation on 1/6/26 at 8:30 A.M., the surveyor observed Resident #129 sitting up alone in bed with the head of the bed elevated. Resident #129 had a plate of eggs and oatmeal on his/her bedside table that was directly in front of him/her. The eggs and oatmeal appeared untouched, and Resident #129 was observed pushing the plate away. During an observation on 1/6/26 at 8:36 A.M., the surveyor observed Certified Nurse Aide (CNA) #5 come into Resident #129's room. CNA #5 stated would you like a muffin because I know you don't like eggs. CNA #5 then exited the room. During an observation on 1/6/26 at 8:38 A.M., the surveyor observed CNA #/5 come back into Resident #129's room. CNA #5 removed the plate with eggs and oatmeal from in front of the Resident and placed down a plate with a cut-up muffin on it. CNA #5 then exited the room. During a continuous observation on 1/7/26 from 8:30 A.M. to 9:05 A.M., the surveyor observed CNA #5 deliver the breakfast meal to the Resident in his/her room. The CNA set up the meal and exited the room. The Resident was observed sitting up in his/her room in bed with the head of the bed elevated with a breakfast meal in front of him/her. The surveyor observed Resident #129 push his/her breakfast meal away multiple times and when asked by the surveyor if he/she was going to finish eating his/her breakfast, the Resident would reply where is my breakfast. The surveyor observed CNA #5 come into Resident #129's room multiple times to remind the Resident to eat and she would push the breakfast tray back in front of the Resident and exit the room. Resident #129 was observed leaving the breakfast meal untouched unless the Resident was reminded that the food was directly in front of him/her. Review of Resident #129's Activities of Daily Living care plan, revised on 9/30/25, indicated the following intervention: Require setup/clean up and continuous supervision with eating D/T (due to) decreased attention span, and nutrition concerns. Review of CNA documentation from 12/1/25 through 1/6/26 indicated that set up or clean up assistance was provided for meals and failed to indicate that continuous supervision was provided as indicated in the Resident's care plan. During an interview on 1/7/26 at 12:55 P.M., CNA #5 said a resident's level of assistance is reported during shift report and the residents electronic medical record would indicate if the resident needs assistance such as extensive or total assistance. CNA #5 said if a resident required continuous supervision, you would not leave the resident until the meal is over. CNA #5 said Resident #129 is continuous supervision because he/she needs help bringing food to his/her mouth. CNA #5 said she should not have left Resident #129 until the meal was completed. During an interview on 1/7/26 at 1:00 P.M., Unit Manager #2 said continuous supervision is a one-to-one sit down with the resident, and she would expect the CNAs to sit down with the residents until the entire meal is completed. During an interview on 1/7/26 at 11:13 A.M., the Director of Nurses said that if the resident's care plan indicates supervision or touching assistance is required, then someone should remain with the resident for the duration of the meal, or the resident should eat the meal in the dining room. She said the plan of care should be followed.

Based on observation, interview and record review the facility failed to provide a dignified dining experience for one Resident (#140) out of a total sample of 29 residents and on 2 of 4 nursing units. Specifically: 1. For Resident #140 the facility failed to ensure a dignified dining experience in both his/her room and in the unit dining room; and 2. on Units A and C the facility failed to ensure a dignified dining experience when Certified Nursing Assistants (CNAs) used their phones while feeding residents. Findings include: The facility policy titled Dignity, undated, indicated the following: -Treating residents with dignity and respect maintains and enhances each resident's self worth and improves his or her psychosocial well-being and quality of life. -Through example, education, and monitoring, the social service staff will promote the following types of staff interactions with residents, which maintain their dignity: -Promoting independence and dignity in dining. 1. Resident #140 was admitted to the facility in August 2024 and has diagnoses that include dementia and muscle weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/22/24, indicated that on the Brief Interview for Mental Status exam Resident #140 scored a 2 out of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #140 requires substantial/maximal assistance with eating Review of the most recent Licensed Nursing Summary, dated 11/29/24, indicates that Resident #140 requires 2 person assist for positioning and is dependent for eating. On 12/10/24 at 8:51 A.M., Resident #140 was observed awake, alert and confused in bed with the head of the bed at approximately a 30 degree angle. There was a tray table across the bed with breakfast placed on the table. Resident #140 was unsuccessfully trying to pull him/herself up by holding onto the tray table and reaching toward the plate of food. Resident #140 was unsuccessful at getting him/herself to a seated position or to reaching the food and rather lay in bed and looked at it. On 12/11/24 at 12:20 P.M., Resident #140 was observed seated and asleep in the unit dining room for lunch as the staff began passing lunch out. The surveyor continued to make the following observations: -At 12:34 P.M., a Certified Nursing Assistant (CNA) served Resident #140's tablemate. Resident #140 continued to sleep. At that time Resident #140 was the only one of 14 residents in the dining room not served. Staff were continuing to pass meals to the residents that were eating in their rooms. -At 12:43 P.M., the tablemate of Resident #140 completed his/her lunch and was served dessert. -By 12:45 P.M., Resident #140 had not been offered food and sat sleeping while his/her peers ate lunch and then dessert. On 12/12/24 at 8:27 A.M., a CNA knocked on resident #140's door, while carrying breakfast. The CNA called the resident by name, placed the breakfast on a tray table beside the bed and walked out. The resident was left in the bed laying flat, unable to reach the food and without feeding assistance. By 8:42 A.M., no staff had entered the room to assist Resident #140 to a seated position and feed him/her the breakfast. The surveyor entered the room which had an aroma of sausage and eggs filling the room. During an interview on 12/12/24 at 9:27 A.M., with Resident #140's Nurse Unit Manager #1 he said that Resident #140 is totally dependent with care and that staff should be providing that care. Nurse Unit Manager #1 said that staff should not deliver food to the Resident until they are ready to assist him/her with the meal. As well, Nurse Unit Manager #1 said that Resident #140 should not have to sit in the dining room, waiting to be fed while his/her tablemate ate lunch and dessert. During an interview on 12/12/24 at 9:58 A.M., the Director of Nursing (DON) said that staff should not leave food with a resident who is dependent until the resident is positioned properly and the staff are ready to sit down and feed them. DON said that it is the expectation that staff seat dependent residents at the same table so that they can be served and fed food at the same time. 45763 2. On 12/10/24 at 12:46 P.M., the surveyor observed a Certified Nursing Assistant (CNA) on the A Unit providing feeding assistance to a Resident. The CNA was scrolling through her phone which was laying flat on the Resident's bedside table adjacent to the Resident's meal tray. On 12/10/24 at 12:50 P.M., the surveyor observed a CNA entering multiple resident rooms during lunch time. The CNA had a wireless headphone in one ear; the wireless headphone was emitting sound audible to the surveyor. During an interview on 12/12/24 at 10:16 A.M., the Director of Nursing (DON) said staff should not be on their phones while providing feeding assistance and should not have wireless headphones on while in resident areas. 36797 3. On 12/10/24 at 1:05 P.M., the surveyor observed a Certified Nurses Aide (CNA) #4 on the C unit enter a resident's room, sit on the resident's bed and start to feed him/her. CNA #4 was scrolling on a cell phone while feeding the resident. During an interview on 12/12/24 at 8:09 A.M., Nurse Unit Manager #3 said that cell phones are not allowed in resident care areas. Nurse Unit Manager #3 added that it is not appropriate to be sitting on a resident's bed while assisting the resident with a meal.

Based on observations and interviews the facility failed to ensure drugs and biologicals were stored in accordance with accepted professional standards of practice. Specifically, nursing staff failed to secure their medication and treatment carts on three of four units. Findings include: Review of the facility policy titled Storage of Medications, dated November 2020, indicated the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Compartments (including, not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. On 12/10/24 at 8:03 A.M., the surveyor observed a treatment cart was unlocked and unsupervised on the B Unit. The surveyor was able to access the treatment cart. On 12/10/24 at 8:05 A.M., Nurse #3 came out of a patient room and observed the unlocked cart. Nurse #3 said the cart is supposed to be locked, my unit manager was just in it and must have left it unlocked. On 12/10/24 at 12:35 P.M. to 1:01 P.M., the surveyor observed the treatment cart was unlocked and unsupervised on the TCU (transitional care unit). On 12/11/24 at 7:02 A.M., the surveyor observed the treatment cart was unlocked and unsupervised on the TCU. On 12/11/24 at 10:43 A.M., the surveyor observed a medication cart unlocked and unsupervised on the A Unit. On 12/11/24 at 11:58 A.M. to 12:12 P.M., the surveyor observed the treatment cart was unlocked and unsupervised on the TCU. During an interview and observation on 12/11/24 at 12:12 P.M., Nurse #2 observed the treatment cart unlocked and said it should never be left unlocked unless the nurse is present at the cart. Nurse #2 said the medication carts should also be locked if a nurse is not present at the cart. 41105

Based on observation, policy review, and interview, the facility failed to store food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure that staff labeled food and that staff did not store drinks with resident food and ingredients. Findings include: Review of the facility's undated policy titled Food Storage Policy and Procedures for [NAME] Nursing & Rehabilitation Center, indicated, but was not limited to, the following: -All food items must be stored in a manner that prevents contamination, maintains nutritional value, and complies with all relevant health and safety regulations. -Label all items with the delivery date. -Personal food items brought in by residents or their families must be labeled with the resident's name and the date it was brought in. -Ensure staff are aware of and comply with all relevant health and safety regulations. -Conduct regular audits to ensure compliance with this policy. Review of the facility's undated policy titled Food Labeling Policy and Procedures for [NAME] Nursing & Rehabilitation Center revised, indicated, but was not limited to, the following: -All food items must be labeled accurately and clearly to ensure proper identification, traceability and safe consumption. -All food items must be labeled with the following information: o Name of the item o Date item was brought into facility, use-by or expiration date. o Any special storage instructions (e.g. Keep Refrigerated). -Labels must be legible and securely attached to the container or package. -Label all prepared food with the use-by/expiration date. -Personal food items brought in by residents or their families must be labeled with the resident's name and the date it was brought in. All food is safe for 72 hours if properly labeled/dated and stored. -Regularly check labels for accuracy and legibility. -Remove and discard any items that are past their use-by or expiration date. -Ensure staff understand the importance of accurate labeling for food safety and quality. On [DATE] at 7:12 A.M. the surveyor made the following observations during the initial kitchen walkthrough: -A water bottle with an employees initials written on the cap in the walk-in refrigerator stored directly next to and above resident food and ingredients. -An undated Ziploc bag containing cooked chicken in the walk-in refrigerator. -An undated pan containing yellow liquid, consistent in appearance with liquid eggs, in the walk-in refrigerator. -An undated piping bag containing whipped cream, stored in an undated Ziploc bag in the walk-in refrigerator. -An undated Ziploc bag containing cheddar cheese in the walk-in refrigerator. -An undated opened package of mozzarella cheese in the reach-in refrigerator. On [DATE] at 7:35 A.M. the surveyor made the following observations in the second floor shared kitchenette refrigerator: -An undated container of coleslaw with a resident's name written on it. -An undated plastic bag containing undated food containers with a resident's name written on them. -A large brown undated bag containing three undated plastic containers of take-out food with a resident's name written on them. -A container with turkey, cranberry sauce, mashed potatoes, and gravy dated [DATE]. Review of the sign, dated [NAME] Food Storage Policy taped to the front of the second floor shared kitchenette refrigerator indicated the following: -Resident food should be labeled with name date and room #. -Food will be discarded after three days. -Food not labeled will be discarded. On [DATE] at 7:47 A.M. the surveyor made the following observations in the first floor shared kitchenette refrigerator: -An undated pitcher containing cranberry juice. -A cake dated [DATE]. -An undated container of food. -Two undated Styrofoam containers with soup. -Four undated plastic containers of pre-portioned pudding with whipped cream. During an interview on [DATE] at 1:15 P.M., the Food Service Director (FSD) said the water bottle in the walk-in refrigerator belonged to staff and should not be stored with resident food or ingredients. The FSD said that all food should be labeled and dated when opened or prepared and then discarded after three days. The FSD said the kitchen staff should be checking the kitchenette every morning to discard anything undated/unlabeled and/or expired. The FSD said all food brought in from outside of the facility should be labeled/dated and discarded after three days. The FSD said she did not know if the undated liquid eggs were from that morning.

Based on record review and interview the facility failed to ensure the physician/nurse practitioner were notified of lab results for one Resident (#103) out of a total of 29 residents. Specifically the facility failed to : 1. notify the physician/nurse Practitioner of the recommendations, made by the covering nurse practitioner, to review labs on Monday; and 2. notify the physician/nurse practitioner of lab results reported to the facility on [DATE]. Findings include: Review of the facility policy titled Test Results, dated as revised April 2007, indicated that should test results be provided to the facility, the attending physician shall be promptly notified of the results. Resident #103 was admitted to the facility in November 2023 with diagnoses including stage four kidney disease, heart failure and diabetes. 1. Review of Resident #103's physician's order, dated 11/8/24, indicated the following orders: -A TSH (thyroid stimulating hormone) lab to be drawn in four weeks. Review of the hard copy of the 12/6/24 TSH level lab report indicated that Nurse #8 notified a covering Nurse Practitioner (NP) of the abnormal lab result. Nurse #8 wrote on the hard copy of the lab report that the covering NP directed Nurse #8 to keep the same dose of thyroid medication and to follow up with the regular NP on Monday (12/9/24). Review of the progress note, dated 12/6/24, indicated the TSH results were received and reported to a covering NP with NNO (no new orders), f/u (follow-up) with regular NP on Monday. During an interview on 12/11/24 at 1:49 P.M., NP #1 said that she was the regular NP for Resident #103 and had not been made aware of the abnormal TSH lab drawn from 12/6/24. NP #1 said that she initials the bottom corner of the hard copy of the lab reports to indicate that she has reviewed them. NP #1 then said that the abnormal TSH level needed to be addressed immediately. Review of the hard copy of the 12/6/24 TSH level lab report failed to indicate NP #1 initialed the document. During an interview on 12/12/24, at approximately 10:00 A.M. the Director of Nursing (DON)said that she would expect nursing to have followed up with Resident #103's MD/NP on 12/9/24 as instructed by the covering NP. 2. Review of Resident #103's physician's order, dated 11/8/24, indicated the following orders: -A repeat BMP (basic metabolic panel) lab to be drawn on 11/11/24; Review of the November 2024 and December 2024 progress notes failed to indicate that Resident #103's regular NP or the primary doctor were notified of the abnormal lab values drawn on 11/11/24. During an interview on 12/11/24 at 1:49 P.M., NP #1 said that she was the regular NP for Resident #103 and had not been made aware of the abnormal BMP lab results from 11/11/24 . During an interview on 12/12/24, at approximately 10:00 A.M. the Director of Nursing (DON)said that all abnormal labs should be reported to the primary physician/nurse practitioner.

Based on observation, record review and interview the facility failed to ensure comprehensive plans of care were developed for three Residents (#98, #52 and #22) out of a total sample of 29 residents. Specifically: 1. for Resident #98 the facility failed to develop a care plan regarding the Resident's history of Suicidal Ideation (SI); 2. for Resident #52 the facility failed to implement the physician's order for an air mattress; and 3. for Resident #22 the facility failed to develop a plan of care regarding the level of assistance the Resident requires with feeding. Findings include: Review of the facility policy, titled Care plans, Comprehensive Person-Centered, revised March 2022, indicated, but was not limited to, the following: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. - The comprehensive, person-centered care plan: Reflects currently recognized standards of practice for problem areas and conditions. - Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 1. For Resident #98 the facility failed to develop a care plan regarding the Resident's history of SI. Resident #98 was admitted to the facility in May 2021 with diagnoses that include anxiety and depression. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/1/24, indicated that on the Brief Interview for Mental Status exam Resident #98 scored a 15 out of a possible 15, indicating Resident #98 is cognitively intact. Review of Resident #98's Nurse Practitioner notes, dated 7/29/24, 10/4/24, and 12/3/24 indicated the Resident had a history of SI. Review of Resident #98's most recent behavioral health group note, dated 11/15/24, indicated Resident #9 had a history of SI/SA (suicide attempt)/SIB (self-injurious behaviors). Review of Resident #98's care plans failed to indicate that a care plan addressing the Resident's history of SI was ever developed. During an interview on 12/10/24 at 3:49 P.M., Certified Nursing Aide (CNA) #6 said she was not aware of Resident #98's history of SI. During an interview on 12/10/24 at 3:50 P.M., Nurse Unit Manager #3 said she was not aware Resident #98 had a history of SI, and that she would expect to have a care plan specifically addressing history of SI for residents with a history of SI. During an interview on 12/10/24 at 4:00 P.M., the Social Worker said she was not aware of the Resident's history of SI, and that there should be a care plan specifically addressing history of SI for residents with a history of SI. 2. For Resident #52 the facility failed to implement the physician's order for an air mattress. Resident #52 was admitted to the facility in February 2024 with a diagnosis of Alzheimer's Disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/30/24, indicated that on the Brief Interview for Mental Status exam Resident #52 scored a 0 out of a possible 15, indicating the Resident had severe cognitive impairment. Review of Resident #52's most recent Norton risk Assessment, dated 11/2/24, indicated Resident #52 was at high risk for skin breakdown. Review of Resident #52's most recent wound physician note, dated 12/9/24, indicated Resident #52 had an open wound on the left heel. Review of Resident #52's care plans indicated that Resident #52 had potential for pressure ulcer development related to immobility with the following intervention: -The Resident requires pressure relieving/reducing devices on chair, air mattress on bed settings of 150 (check every shift for settings and functionality), revised on 5/14/24. Review of Resident #52's physician orders indicated the following active order: -Air mattress setting: May be set at 150. Check Qshift (every shift) for functionality, initiated 3/2/24. On 12/11/24 at 2:52 P.M., the surveyor observed Resident #52 in his/her room in bed. The bed mattress was not an air mattress. On 12/12/24 at 7:18 A.M., the surveyor observed Resident #52 in his/her room in bed. The bed mattress was not an air mattress. During an interview and observation on 12/12/24 at 8:14 A.M., Nurse #6 said Resident #52 had a wound on his/her heel and that the Resident had an air mattress. The surveyor and Nurse #6 then observed Resident #52's room, Nurse #6 said that the mattress on the Resident's bed was not an air mattress but should have been as the Resident had an order and care plan indicating that the Resident needed an air mattress. During an interview on 12/12/24 at 8:51 A.M., the Director of Nursing (DON) said that she would expect a Resident to have an air mattress if the Resident had a care plan and physician order for one. 36797 3. For Resident #22 the facility failed to develop a plan of care regarding the level of assistance the Resident requires with feeding. Resident #22 was admitted to the facility in May 2024 with diagnoses including stroke, abnormal weight loss and dysphagia. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/4/24, indicated that on the Brief Interview for Mental Status exam Resident #22 scored a 7 out of 15, indicating severe cognitive impairment. The MDS further indicated Resident #22 requires supervision to touching assistance for eating. Review of the record failed to indicate a care plan had been developed regarding the level of assistance Resident #22 required with feeding. On 12/10/24 at 8:20 A.M., the surveyor observed Resident #22 in bed with a breakfast tray in front of him/her on the over the bed table, untouched. There were no staff present to provide supervision or touching assistance and Resident #22 was making no attempt to self feed. On 12/10/24 at 1:00 P.M., the surveyor observed Resident #22 in bed with a lunch tray, untouched, in front of him/her. There were no staff present to provide supervision or touching assistance and Resident #22 was making no attempt to self feed. Review of the Facility document titled Documentation Survey Report v2 (where CNA's document the level of care provided each shift) dated December 2024, indicated that Resident #22 required assistance with eating 14 out of 32 meals served. During an interview on 12/10/24 at 1:07 P.M. CNA #4 said that Resident #22 sometimes gets tired and needs help eating. CNA #4 said that a CNA should stay with the Resident while eating to ensure he/she is able to complete the meal. During an interview on 12/12/24 at 8:39 A.M., MDS Nurse #1 said that if the MDS indicates that a resident requires assistance with eating then a care plan should be developed to address the need. During an interview on 12/12/24 at approximately 10:00 A.M. the Director of Nursing said that all residents requiring assistance with eating should have a care plan in place to address the specific care need.

Based on interview and record review the facility failed to ensure for one Resident (#140) out of a total sample of 29 residents, that the interdisciplinary team reviewed and revised the plan of care after the quarterly review assessment. Specifically, for Resident #140, the facility failed to review and update a plan of care when the level of assistance with feeding increased. Findings include: Resident #140 was admitted to the facility in August 2024 and has diagnoses that include dementia and muscle weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/22/24, indicated that on the Brief Interview for Mental Status exam Resident #140 scored a 2 out of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #140 requires substantial/maximal assistance with eating Review of the most recent Licensed Nursing Summary, dated 11/29/24, indicates that Resident #140 requires: -Is dependent for eating. Review of the Nutrition note, dated 11/22/24, indicated: generally eats > 75% at meals w/ staff assistance. Review of the current ADL care plan included the following interventions: -EATING: The resident is able to with Setup/Cleanup , 1 assist may be needed at times when fatigue to ensure adequate intake (created 8/23/24, revised 9/3/24) On 12/10/24 at 8:51 A.M., Resident #140 was observed awake, alert and confused in bed with the head of the bed at approximately a 30 degree angle. There was a tray table across the bed with breakfast placed on the table. Resident #140 was unsuccessfully trying to pull him/herself up by holding onto the tray table and reaching toward the plate of food. Resident #140 was unsuccessful at getting him/herself to a seated position or to reaching the food and rather lay in bed and looked at it. On 12/11/24 at 8:25 A.M., a Certified Nursing Assistant (CNA) carried a plate of breakfast to Resident #140's room, placed it on a tray table out of Resident #140's reach and exited the room to continue passing breakfast to other residents. The surveyor continued to make the following observations: -By 8:35 A.M., no assist had been offered and Resident #140 remained unable to reach the breakfast. During an interview on 12/12/24 at 9:20 A.M., Resident #140's CNA (#3) said that Resident #140 is totally dependent for all his/her care including bed mobility and feeding. CNA #3 said that Resident #140 could sometimes hold a sandwich placed in his/her hand by staff. During an interview on 12/12/24 at 9:27 A.M., Nurse Unit Manager #1 said that Resident #140 is totally dependent with care. He said that he was not sure who was responsible to update the care plan and Kardex when a resident's status declines but that Resident #140's needed to be updated to reflect his/her current needs for feeding. During an interview on 12/12/24 at 10:00 A.M., with the Director of Nursing (DON) she said that it is the responsibility of the Nurse Unit Manager to update the care plan and Kardex. The DON said that both should reflect the resident's current status and care needs.

Based on observation, record review and interview, the facility failed to meet professional standards of practice for two Residents (#32 and #74) out of a total of 29 sampled residents. Specifically, 1. For Resident #32, the facility failed to implement a physician's order to apply air boots when in bed. 2. For Resident #74, the facility failed to obtain a physician's order for a wound treatment. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2018, indicated the following: - The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: - Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. 1. Resident #32 was admitted to the facility November 2024 with diagnoses that included dementia, obstructive sleep apnea, congestive heart failure, chronic obstructive pulmonary disease, and type 2 diabetes. Review of Resident #32's most recent Minimum Data Set (MDS) assessment, dated 12/3/24, indicated he/she scored an 11 out of a possible 15 on the Brief Interview for Mental Status exam indicating moderate cognitive impairments. The MDS further indicated Resident #32 has an unhealed unstageable wound and is at risk for developing pressure ulcers. Review of Resident #32's physician order, dated 12/5/24, indicated air booties on while in bed every shift. On 12/10/24 at 7:45 A.M. and 12:36 P.M., the surveyor observed Resident #32 in bed without air booties on and his/her heels flat on the mattress. On 12/11/24 at 7:03 A.M. and 10:04 A.M., the surveyor observed Resident #32 in bed with an air boot only on the left foot. On 12/12/24 at 6:56 A.M., the surveyor observed Resident #32 in bed without air booties on and his/her heels flat on the mattress. Review of Resident #32's wound care plan, dated 11/15/24, indicated administer treatments as ordered and monitor for effectiveness. Review of Resident #32's CNA (Certified Nurse Aide) Kardex (form that indicates the level assistance that each resident needs), dated 12/11/24, indicated resident to wear air booties while in bed. During an interview on 12/12/24 at 8:56 A.M., Nurse #4 said Resident #32 has a pressure ulcer on his/her right heel and should have air boots on when he/she is in bed as ordered. 36876 2. Resident #74 was admitted to the facility in July 2024 with diagnoses including Alzheimer's disease and dysphagia. Review of the most recent Minimum Data Set Assessment (MDS) assessment, dated 10/11/24, indicated Resident #74 was severely cognitively impaired evidenced by a score of seven out of a possible 15 on the Brief Interview for Mental Status exam. The MDS further indicated Resident #74 requires assistance with bathing and dressing. Review of the Skin Injury Checklist, undated, indicated that nursing and the Unit Manager are responsible for completing the form to include the following information: Root cause of the skin injury, updates to resident care plans, review of treatments an referrals as necessary. On 12/10/24 at 8:07 A.M., the surveyor observed Resident #74 resting in bed. Resident #74 had difficulty engaging in the interview process due to his/her cognition. Review of the clinical record indicated Resident #74 developed blood blisters on his/her right lower leg: -11/27/24: Nurse Progress note: Resident right lower extremity noted to be red warm and painful to touch. NP (Nurse Practitioner) notified and ordered Keflex (an antibiotic) 500 mg QID x5 days. -11/27/24: Nurse Practitioner note: Seen today at staff request. Right leg skin tear. Steri strips applied. Large blister on right lower leg. Appears to have purulent drainage. Surrounding erythema. -11/28/24: Nurse Progress note: Resident continues on ABT (antibiotic) for RLL (right lower leg) infection no adverse effects noted. Dressing applied as ordered. Pt remained in bed for this shift appetite noted to be poor. Family in to visit safety maintained. -11/30/24: Nurse Progress note: RLE (right lower extremity) inner aspect with fluid filled blister oozing large amount of thick yellow fluid, leg cleansed and ABD pads applied, wrapped with Kling. Continues on Amoxicillin and doxy for RLE infection, leg red and warm to touch. Temp 97.9, no s/e to [NAME] noted. -12/1/24: Nurse Progress note: alert /awake bed rest this shift. Appetite is fair, fluids encouraged and accepting well. Continues on po [NAME] due to RLE infection, no s/e noted, Temp 97.9, RLE with copious amount of thick yellow drainage from previous blister, ABD applied and wrapped with kling. Review of Resident #74's November and December 2024 physicians orders failed to indicate a treatment order addressing Resident #74 draining wound until 12/3/24. During an interview on 12/11/24 at 10:55 A.M., Nurse Practitioner (NP) #1 said that Resident #74 had a blood blister that was draining and she had ordered antibiotics to treat the infection and requested the Wound Physician come in and address the wounds. NP #1 said that she would expect a treatment to be implemented for wounds that are draining. NP #1 thought a wound treatment was in place. During an interview on 12/12/24 at 9:25 A.M., The Director of Nursing (DON) said she would expect wounds with drainage to have a treatment order.

Based on observation, interview and record review the facility failed to ensure assistance was provided with Activities of Daily Living (ADLs) for one Resident (#140) out of a total sample of 29 residents. Specifically, for Resident #140, the facility failed to provide assistance with bed mobility and feeding. Findings include: The facility policy titled Activity of Daily Living (ADLs), undated, indicated the following: - Based on the comprehensive assessment of a patient and consistent with the patient's needs and choices, the center must provide the necessary care and services to ensure that a patient's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. Activities of daily living (ADLs) include: - Dining-eating, including meals. (sic) Resident #140 was admitted to the facility in August 2024 and has diagnoses that include dementia and muscle weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/22/24, indicated that on the Brief Interview for Mental Status exam Resident #140 scored a 2 out of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #140 requires substantial/maximal assistance with eating. Review of the most recent Licensed Nursing Summary, dated 11/29/24, indicated that Resident #140 requires: - Two person assist for positioning - Is dependent for eating Review of the Nutrition note, dated 11/22/24, indicated: generally eats > 75% at meals w/ staff assistance. Review of the current ADL care plan included the following interventions: -1 to 2 assist for bed mobility and positioning Review of the nursing documentation for all days of survey indicated staff documented that Resident #140 had no behavior of rejecting care and required substantial/maximal assistance with meals. On 12/10/24 at 8:51 A.M., the surveyor observed Resident #140 awake, alert and confused in bed with the head of the bed at approximately a 30 degree angle. There was a tray table across the bed with breakfast placed on the table. Resident #140 was unsuccessfully trying to pull him/herself up by holding onto the tray table and reaching toward the plate of food. Resident #140 was unsuccessful at getting him/herself to a seated position or reaching the food. No staff were in the room. On 12/11/24 at 8:25 A.M., a Certified Nurse Aide (CNA) carried a plate of food to Resident #140's room, placed it on a tray table out of Resident #140's reach and exited the room to continue passing breakfast to other residents. The surveyor continued to make the following observations: - By 8:35 A.M., no assistance had been offered and Resident #140 remained without breakfast or feeding assistance. On 12/12/24 at 8:27 A.M., a CNA knocked on Resident #140's door, while carrying breakfast. The CNA called the Resident by name, placed the breakfast on a tray table beside the bed, and walked out. The Resident was left in the bed lying flat, unable to reach the food and without feeding assistance. By 8:42 A.M., no staff had entered the room to assist Resident #140 to a seated position and feed him/her the breakfast. During an interview on 12/12/24 at 9:20 A.M., Resident #140's CNA (#3) said that Resident #140 is totally dependent for all his/her care, including bed mobility and feeding. CNA #3 said that Resident #140 could sometimes hold a sandwich placed in his/her hand by staff. During an interview on 12/12/24 at 9:27 A.M., Unit Manager #1 said that Resident #140 is totally dependent with care, and it is the expectation that staff provide that care. During an interview on 12/12/24 at 10:00 A.M., with the Director of Nursing (DON) she said that it is the expectation that residents that who require care from staff receive that care.

Based on record review, interview and observation, the facility failed to ensure physicians orders for the prevention and care of pressure ulcers were followed for two Residents (#94 and 26) out of a total sample of 29 residents. Specifically: 1. for Resident #94, the facility failed to elevate his/her heels while lying in bed; and 2. for Resident #26, the facility failed to review or implement wound physician recommendations for a wound treatment. Findings include: 1. Resident #94 was admitted to the facility in March 2019 and has diagnoses which include cerebral vascular accident and hemiplegia. Review of Resident #94's most recent Minimum Data Set (MDS) assessment, dated 10/4/24, indicated that on the Brief Interview for Mental Status exam Resident #94 scored a 9 out of a possible 15, indicating moderately impaired cognition. The MDS further indicated that Resident #94 was dependent on staff for all activities of daily living and bed mobility, and was at risk for the development of pressure ulcers. Review of Resident #94's skin assessment, dated 10/1/24, indicated he/she was at a high risk for skin breakdown. Review of Resident #94's care plan dated 10/8/24, indicated he/she was at risk for skin impairment related to being dependent with activities of daily living and bed mobility. The care plan did not reference elevating heels while in bed. Review of Resident #94's current physician order, with a start date of 10/30/24, indicated: -Elevate heels while in bed, every shift. On 12/10/24 at 9:45 A.M., and 12:55 P.M., the surveyor observed Resident #94 lying in bed and his/her heels were not elevated. There was no flotation device in the bed. On 12/11/24 at 8:35 A.M., 9:47 A.M., and 12:15 P.M., the surveyor observed Resident #94 lying in bed and his/her heels were not elevated. There was no flotation device in the bed. On 12/12/24 at 7:39 A.M., the surveyor observed Resident #94 lying in bed and his/her heels were not elevated. There was no flotation device in the bed. During an observation and interview with Nurse Unit Manager #2 on 12/12/24 at 8:00 A.M., she said that it is the expectation that staff follow the physician's orders and that Resident #94's heels are supposed to be elevated when in bed. Nurse Unit Manager #2 and the surveyor entered Resident #94's bedroom and observed that Resident #94's heels were not elevated. 45763 2. Resident #26 was admitted to the facility in September 2024 with diagnoses including dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/30/24, indicated that on the Brief Interview for Mental Status exam Resident #26 scored a 0 out of 15, indicating severe cognitive impairment. Review of Resident #26's most recent Norton risk Assessment, dated 10/17/24, indicated the Resident was at high risk for skin breakdown. Review of Resident #26's current care plan indicated that the Resident had potential for further impairments to his/her skin related to dual incontinence, functional decline, and decreased safety awareness. Review of Resident #26's weekly wound observation tool, dated 10/17/24, indicated the Resident had acquired a stage II pressure ulcer on his/her coccyx on 10/17/24. Review of Resident #26's active physician orders indicated the following order: -Sacrum: wash NS (normal saline), pat dry, apply calcium alginate and cover with DPD (dry protective dressing). Skin prep peri wound daily. Every day shift for wound care, initiated 11/26/24. Review of the wound physician's note, dated 11/25/24, indicated Resident #26 had a sacral wound measuring 0.4 cm (centimeters) in length by 0.3 cm in width by 0.1 cm in depth. Further review of the wound physician's note indicated the following recommendation: -Wound Dressing: Calcium alginate and foam to the sacral wound changed twice daily and PRN (as needed). Skin prep to the periwound daily. Review of Resident #26's medical record failed to indicate that the wound physician's 11/25/24 recommendation for dressing changes twice a day was reviewed or implemented. Review of the wound physician's note, dated 12/2/24, indicated Resident #26 has a sacral wound measuring 0.4 cm (centimeters) in length by 0.3 cm in width by 0.1 cm in depth and has not improved. Further review of the wound physician's note indicated the following recommendation: -Wound Dressing: Vashe (or similar antibacterial wound cleanser, alginate and foam to the sacral wound changed twice daily and PRN (as needed). Skin prep to the periwound daily. Review of Resident #26's medical record failed to indicate that the wound physician's 12/2/24 recommendation for the addition of Vashe was reviewed or implemented. Review of the wound physician's note, dated 12/9/24, indicated Resident #26 had a sacral wound measuring 0.4 cm (centimeters) in length by 0.3 cm in width by 0.1 cm in depth and has not improved. Further review of the wound physician's note indicated the following recommendation: -Wound Dressing: Vashe (or similar antibacterial wound cleanser, alginate and foam to the sacral wound changed daily and PRN (as needed). Skin prep to the periwound daily. Review of Resident #26's medical record failed to indicate that the wound physician's 12/9/24 recommendation for the addition of Vashe was reviewed or implemented. During an interview on 12/11/24 at 4:14 P.M., Nurse #7 said the wound physician comes weekly to assess residents with wounds and provides written recommendations. The Nurse Practitioner (NP) would then review the wound physician's recommendations; Nurse #7 said she would expect the wound physician's recommendations to be implemented immediately. Nurse #7 said the risk of not implementing wound physician recommendations would be that the wound does not improve or worsens. Nurse #7 said that if the wound physician recommended Vashe that she would expect an order for vashe to be implemented and not normal saline. Nurse #7 said there is Vashe available in the facility and she was not aware of any recent shortages in Vashe. Nurse #7 said she would have also expected the recommendation for the dressing to be changed twice a day to have been implemented. During an interview on 12/11/24 at 4:31 P.M., Unit Manager #3 said the wound physician comes weekly to assess residents with wounds and provides written and verbal recommendations. Unit Manager #3 said the Unit Manager will then communicate the recommendations to the NP who agreed with the recommendations 99.9% of the time. Unit Manager #3 said she would expect the recommendations to be implemented either the same day or the next day after the recommendations were made. Unit Manager #3 said Resident #26 had a sacral wound, and that the facility carries Vashe. During an interview on 12/12/24 at 8:51 A.M., the Director of Nursing (DON) said the wound physician comes weekly to assess residents with wounds and provides written recommendations which then get distributed to each unit. The DON said it is the the Unit Managers responsibility to communicate the recommendations to the NP. The DON said she would expect nurses to write a note if the NP disagreed with a wound physician recommendation. The DON said the facility carries Vashe and that she would have expected the recommendation for Vashe to have been implemented for Resident #26. During an interview on 12/12/24 at 9:04 A.M., NP #1 said she would defer to the wound physician for wound treatment. NP #1 said she would expect Vashe to have been implemented for Resident #26 instead of normal saline if the wound physician recommended it because Vashe may better prepare the wound bed for treatment and thus promote wound healing.

Based on observation, record review and interview, the facility failed to provide adequate supervision per the plan of care to prevent falls for one Resident (#92) out of a total of 29 sampled residents. Specifically, the facility failed to monitor and assist Resident #92 when he/she was displaying symptoms of agitation and walking independently resulting in Resident #92 falling. Findings include: Review of Falls Prevention and Management Program, dated September 2018, indicated: -Management plans interventions based on each resident risk factors can assist in eliminating or reducing the incidence of falls as well as avoiding serious injury to the resident. -Residents having a history of falls or residents who are assessed to be a high fall risk will have an active problem included in their interdisciplinary plan of care. Care Plan measures/interventions will be listed for risk factors identified. -Staff should assess the environment for factors that could have contributed to the fall and address concerns accordingly. Resident #92 was admitted to the facility in December 2023 with diagnoses including dementia and cognitive communication deficient. Review of the most recent Minimum Data Set Assessment (MDS) assessment, dated 11/4/24, indicated Resident #92 was moderately cognitively impaired as evidenced by a score of eight out of a possible 15 on the Brief Interview for Mental Status exam. The MDS further indicated that Resident #92 required assistance with all activities of daily living. On 12/10/24 8:00 A.M., the surveyor observed Resident #92 resting in bed. The bed was in a low position and an alarm was in place. Resident #92 was unable to respond to the surveyor. Review of Resident #92's current care plans indicated: 1. Focus: The resident is/has potential to be verbally aggressive, becomes anxious/restless, displays impulsive/panic behavior. Poor impulse control, agitation/restlessness, Rummaging/refusing care Wandering/pacing/insomnia/not sleeping r/t (related to) Dementia dx (diagnosis) 1/4/24. Interventions: Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Provide 1-1, redirect, provide comfort, re-approach at a later time, remove pt (patient) current situation to ensure safety. 2. Focus: The Resident has an ADL (activities of daily living) self-care performance and mobility deficit r/t dementia. 11/14/23. Interventions: Resident ambulates with supervision and rolator walker. Transfers with one assist and will often attempt to transfer independently. Provide 1 assist for transfers and ambulation, short distances only. 1 assist for bed mobility and positioning. 12/18/23. 3. Focus: The resident is at risk for falls r/t recent functional decline and dementia with decreased safety awareness, 12/18/23. Interventions: Maintain a clutter-free environment in patient room and consistent furniture arrangement, 5/15/24. Anticipate and meet the resident's needs, 11/13/23. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, 11/13/23. Resident is not to be left alone on toilet, 7/29/24. Resident uses bed and chair electronic alarm. Ensure the device is in place and functioning each shift, 1/25/24. Review of the clinical record indicated that on 10/19/24 at 12:45 P.M., Resident #92 was ambulating independently on the unit, had an unwitnessed fall and was sent to the hospital for evaluation. Review of the hospital paper work indicated: CT scan which shows no obvious displaced fracture. Official report with possible left pelvic rami fracture which could be new. Additional review of the clinical record indicated that Resident #92 had previous falls on 9/18/24 and 10/6/24. Review of the fall investigation, dated 10/19/24, included multiple witnessed statements indicating Resident #92 had been agitated due to the fire alarm going off and was difficult to redirect. All six witness statements indicated that Resident #92 was walking independently and had an unwitnessed fall. Four of the witness statements indicated there was no chair alarm in place and it was not sounding at the time. Two of the witness statements failed to indicate any information related to a chair alarm. During an interview on 12/11/24 at 10:49 A.M., Nurse #1 said that Resident #92 had a lot of falls. Nurse #1 said on 10/19/24, Resident #92 was agitated as the fire alarm had gone off and he/she kept ambulating despite staff attempting to direct him/her into the dining area. Nurse #1 said Resident #92 was found on the floor in the hallway close to the fire doors and was sent to the hospital. Nurse #1 said that the fire alarms were no longer sounding when Resident #92 fell . Nurse #1 said that Resident #92 had a chair alarm at that time because he/she would get up to walk and he/she needed monitoring and supervision. Nurse #1 said that if staff were observing Resident #92 walking, it would be expected that staff would follow him/her and try to get him/her to sit down. Nurse #1 did not say why staff were not with Resident #92 while he/she was agitated and ambulating per his/her plan of care. During an interview on 12/11/24 at 11:54 A.M., Nurse Unit Manager #1 said that he was not working on the day Resident #92 fell but he thought the alarms were still sounding when he/she fell . Nurse Unit Manager #1 said that at that time, Resident #92 utilized a chair alarm because he/she would would frequently get up unassisted and that staff were expected to respond to the alarm and join Resident #92 while walking and then attempt to have him/her sit down. During an interview on 12/11/24 at 12:41 P.M., Certified Nursing Aide (CNA) #1 said that Resident #92 has had a lot of falls. CNA #1 said that Resident #92 was easily agitated and on 10/19/24, he/she had been walking without assistance. CNA #1 said that the fire alarms were no longer sounding at the time of the fall. CNA #1 said that Resident #92 had a chair alarm at the time and staff were expected to respond to the alarm and supervise him/her for safety if he/she was walking. CNA #1 did not say why staff were not with Resident #92 while he/she was agitated and ambulating per his/her plan of care. During an interview on 12/12/24 9:22 A.M., The Director of Nursing (DON) said that Resident #92 had history of falls. The DON said that resident care plans should be followed.

Based on observation, record review and interview, the facility failed to provide fortified foods for one Resident (#23) out of a total of 29 sampled residents. Findings include: Review of the facility's Internal Weighing Process, dated July 2022, indicated: -If the resident's weight is +/- 3 pounds (lbs) from one weight to the next the resident is to be re-weighed the following day. -If the resident's weight is confirmed by re-weigh the Staff Nurse is to record the weight in the Electronic Health Record and inform the Unit Manager and Dietitian. If weight loss is significant and a nutrition concern inform Medical Provider, resident and/or responsible party. -Consult the Dietitian to establish or consider appropriate interventions. Dietitian will write recommendations if needed in the Medical Record. Resident #23 was admitted to the facility in September 2024 with diagnoses including dementia and chronic pain. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/23/24, indicated Resident #23 was severely cognitively impaired as evidenced by a score of 5 out of a possible 15 on the Brief Interview Exam. The MDS further indicated that Resident #23 required assistance with bathing, dressing and toileting. On 12/10/24 at 8:58 A.M., the surveyor observed Resident #23 asleep in bed. His/her breakfast meal was untouched on a tray table. Resident #23 appeared thin and frail. Review of Resident #23's weights indicated: 11/4/2024: 111.4 Lbs 11/12/2024: 112.0 Lbs 11/19/2024: 110.2 Lbs 11/26/2024: 104.6 Lbs; A loss of 6.10% his/her body weight since 11/4/24. 12/2/2024: 105.0 Lbs Review of Resident #23's current care plans indicated: -Focus: The patient has suboptimal p.o. (by mouth) intake at meals and is at risk for malnutrition, 9/22/24. -Interventions Provide and serve supplements as ordered: house shakes a/o (as ordered) Provide, serve diet as ordered. Offer encouragement and cues. Monitor intake and record q meal (every). RD to evaluate and make diet change recommendations PRN (as needed). Weight at same time of day and record: weekly. Review of the progress note dated, 11/22/24 indicated: Received new orders from the Dietitian to add fortified food and calorie condiments at meals. Review of the current physician diet orders indicated: Regular diet, regular texture, add fortified foods and increase calorie condiments at meals, 11/22/24. Review of Resident #23's meal ticket indicated Resident #23 should receive fortified foods with all meals. On 12/10/24 at 12:47 P.M., the surveyor observed Resident #23 eating his/her lunch meal in the dining room. Resident #23 was pleasantly confused and said his/her meal was good. The surveyor observed 75% of the rice, chicken and vegetables present on his/her plate and no fortified foods. Certified Nursing Aide (CNA) #2 was present and said that Resident #23 is not a good eater. On 12/10/24 at approximately 12:50 P.M., the surveyor observed the steam table and inquired which food items were considered fortified and the Diet Aide said mashed potatoes. Resident #23 had not been served mashed potatoes. On 12/11/24 at 8:40 A.M., the surveyor observed Resident #23 eating breakfast in bed. The surveyor observed Resident #23's hot cereal's consistency was lumpy. On 12/11/24 at approximately 8:42 A.M., the surveyor observed the steam table and inquired which hot cereal was fortified. The Diet Aide showed the surveyor a container of creamy hot cereal and said that it was fortified, and the lumpy hot cereal was not. On 12/12/24 at 8:48 A.M.,the surveyor observed Resident #23 eating breakfast in bed. There was no hot cereal on his/her tray table. During an interview on 12/12/24 at 8:49 A.M., CNA #5 said she delivered Resident #23 his/her breakfast plate in his/her room. CNA #5 said that Resident #23 said he/she wasn't very hungry but the CNA left the food in there and did not remove any food items from the room. During an interview on 12/12/24 at 8:51 A.M., the Food Service Director (FSD) said that fortified foods for breakfast is a creamy hot cereal and mashed potatoes are fortified for the lunch and dinner meals. Nurse Unit Manager #2 joined the interview and said that Resident #23 is very picky and does not like the fortified food options. When asked if she had informed the Dietitian that Resident #23 did not like the fortified foods, she said she would have to discuss it with her. The FSD said that resident's with orders to receive fortified foods, and who have fortified foods indicated on their meal ticket, should be served fortified foods Review of Resident #23's clinical record and the facility's weekly risk notes failed to indicate that Resident #23 does not like or refuses fortified food at meals. During an interview on 12/12/24 at 10:49 A.M., the Dietitian said that Resident #23 has had a significant weight loss and interventions implemented were supplements and fortified foods. The Dietitian said she has not been told by nursing that Resident #23 does not like the fortified foods. The Dietitian said staff should serve fortified foods and the Resident does not have to eat the items if he/she does not want to. The Dietitian said that there had been issues at the facility with residents not receiving fortified foods at meals, as ordered.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at high risk for falls, was known to be impulsive and whose fall risk interventions included the use of monitoring devices (bed and chair alarms) to alert staff when he/she rose from a sitting or lying position, the Facility failed to ensure he/she was provided with the necessary level of staff supervision to maintain his/her safety, when on 05/22/24, after disabling his/her alarm, Nurse #1 left Resident #1 unattended on the commode, Resident #1 fell to the floor, complained of pain, and was transferred to the Hospital Emergency Department where he/she was diagnosed with a fractured right hip, which required surgical intervention to repair Findings include: The Facility's Policy, titled Falls Prevention and Management Program, dated 09/2018, indicated residents would be assessed for risk for falls and interventions would be implemented as appropriate. The Facility's Policy, titled Guidelines for the Use of Position Change Alarms, dated 2021, indicated position change alarms were defined as alerting devices that emitted an audible signal when a resident moved in a certain way and was intended to monitor a resident's movement when a resident who required contact guard or physical assistance was attempting to stand or transfer independently. Resident #1 was admitted to the Facility in December 2022, diagnoses included unsteadiness on feet, and cognitive decline. Review of Resident #1's Morse Fall Scales Assessments, dated 02/23/24 and 05/13/24, indicated he/she was assessed by nursing as being at high risk for falls. Review of Resident #1's Minimum Data Set (MDS) assessment, dated 05/17/24, indicated he/she was severely cognitively impaired. Review of Resident #1's Falls Care Plan, reviewed and renewed with his/her May MDS, with a target date of 09/17/24, indicated he/she had an intervention (dated as initiated on 12/27/22) for bed and chair alarms, and staff were to ensure the device was in place and functioning properly. Review of Resident #1's Care Kardex Report (utilized by Certified Nurse Aides and provides direct care staff with a brief overview of each resident's needs), indicated he/she required the use of bed and chair alarms. Review of Resident #1's Nurse Progress Note, dated 05/22/24, indicated his/her bed alarm was functioning and sounded when he/she transferred him/herself from bed to the bedside commode. The Note indicated that Nurse #1 responded and left Resident #1 alone in his/her room on the commode, then a few minutes later Nurse #1 heard a bang and found Resident #1 on the floor. The Note indicated Resident #1 later complained of pain, was screaming, and was transferred to the Hospital Emergency Department via 911. Review of Resident #1's Hospital X-ray Report of his/her right hip, dated 05/23/24, indicated he/she had an impacted right femoral neck fracture. Review of Resident #1's Hospital Discharge Summary, dated 05/30/24, indicated he/she was admitted to the Hospital 05/23/24, diagnosed with a right hip fracture and required an Open Reduction Internal Fixation (ORIF) surgical intervention. During a telephone interview on 06/20/24 at 9:32 A.M., Nurse #1 said she knew Resident #1, that he/she was known to be impulsive and to self-transfer. Nurse #1 said that on 05/22/24 at 8:15 P.M., she heard Resident #1's bed alarm sounding and when she got to his/her room, he/she had already self-transferred to his/her bedside commode. Nurse #1 said she turned off the bed alarm, gave Resident #1 his/her call bell, pulled the privacy curtain closed, and left Resident #1's room. Nurse #1 said she should not have left Resident #1 alone without an alarm in place. Nurse #1 said she was outside Resident #1's bedroom door at her medication cart for about five minutes, heard a loud bang, and said she found Resident #1 lying on the floor on his/her right side. Nurse #1 said at that time Resident #1 did not complain of any pain, and she and another staff member lifted him/her back into bed, then an hour later, Resident #1 started yelling in pain holding his/her right hip, and he/she was transferred to the Hospital Emergency Department via 911. During an interview on 06/18/24 at 11:23 A.M., Unit Manager #1 said Resident #1 was known to be impulsive and had a history of falls. Unit Manager #1 said Resident #1 should not have been left on the commode unsupervised, and without an alarm in place. During an interview on 06/18/24 at 01:18 P.M., The Director of Nurses (DON) said residents whose plan of care indicated they require a bed and chair alarm should not be left unattended while seated on a toilet or commode. The DON said Resident #1 should have been supervised for safety while seated on the commode but was not.

Based on observations, records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at high risk for falls, and whose comprehensive plan of care indicated he/she required the use of monitoring devices (bed and chair alarms) to alert staff when he/she attempted to stand or transfer alone, the Facility failed to ensure staff consistently implemented and followed interventions identified in his/her plan of care, when on 05/22/24, Nurse #1 left Resident #1 alone, without an alarm in place, seated on the commode in his/her room, Resident #1 fell , later complained of pain, was transferred to the Hospital Emergency Department and was diagnosed with a fractured right hip which required surgical intervention to repair. Findings include: The Facility's Policy, titled Comprehensive Person-Centered Care Plans, dated as revised 03/2022, indicated that a comprehensive, person-centered care plan to meet the resident's needs would be developed and implemented. The Facility's Policy, titled Guidelines for the Use of Position Change Alarms, dated 2021, indicated position change alarms were defined as alerting devices that emitted an audible signal when a resident moved in a certain way and was intended to monitor a resident's movement when a resident who required contact guard or physical assistance was attempting to stand or transfer independently. The Facility's Policy, titled Falls Prevention and Management Program, dated 09/2018, indicated residents would be assessed for risk for falls and interventions would be implemented as appropriate. Resident #1 was admitted to the Facility in December 2022, diagnoses included unsteadiness on feet, and cognitive decline. Review of Resident #1's Morse Fall Scales Assessment, dated 02/23/24 and 05/13/24, indicated he/she was assessed by nursing as being at high risk for falls Review of Resident #1's Minimum Data Set (MDS) assessment, dated 05/17/24, indicated he/she was severely cognitively impaired. Review of Resident #1's Falls Care Plan, reviewed and renewed with his/her May MDS (with a target date of 09/17/24), indicated he/she had an intervention, dated as initiated 12/27/22, for bed and chair alarms, and staff were to ensure the device was in place and functioning properly. Review of Resident #1's Care Kardex Report (utilized by Certified Nurse Aides and provides direct care staff with a brief overview of each resident's needs), dated 05/22/24, indicated he/she required the use of bed and chair alarms. Review of Resident #1's Nurse Progress Note, dated 05/22/24, indicated his/her bed alarm was functioning and sounded when he/she transferred him/herself from bed to the bedside commode. The Note indicated that Nurse #1 responded and left Resident #1 alone in his/her room on the commode, then a few minutes later Nurse #1 heard a bang and found Resident #1 on the floor. The Note indicated Resident #1 later complained of pain, was screaming, and was transferred to the Hospital Emergency Department via 911. Review of Resident #1's Hospital X-ray Report of his/her right hip, dated 05/23/24, indicated he/she had an impacted right femoral neck fracture. Review of Resident #1's Hospital Discharge Summary, dated 05/30/24, indicated he/she was admitted to the Hospital 05/23/24, diagnosed with a right hip fracture and required an Open Reduction Internal Fixation (ORIF) surgical intervention. During a telephone interview on 06/20/24 at 9:32 A.M., Nurse #1 said she knew Resident #1, that he/she was known to be impulsive and to self-transfer. Nurse #1 said that on 05/22/24 at 8:15 P.M., she heard Resident #1's bed alarm sounding and when she got to his/her room, he/she had already self-transferred to his/her bedside commode. Nurse #1 said she turned off the bed alarm, gave Resident #1 his/her call bell, pulled the privacy curtain closed, and left Resident #1's room. Nurse #1 said she was outside Resident #1's bedroom door at her medication cart for about five minutes and heard a loud bang, and said she found Resident #1 lying on the floor on his/her right side. Nurse #1 said at that time Resident #1 did not complain of any pain, and she and another staff member lifted him/her back into bed, then an hour later, Resident #1 started yelling in pain holding his/her right hip, and he/she was transferred to the Hospital Emergency Department via 911. During an interview on 06/18/24 at 11:23 A.M., Unit Manager #1 said Resident #1 was known to be impulsive and had a history of falls. Unit Manager #1 said Resident #1 should not have been left on the commode unsupervised, and without an alarm in place. During an observation on 06/18/24 at 11:38, on Resident #1's unit, accompanied by Unit Manager #1, upon entering the hallway, the Surveyor observed Certified Nurse Aide (CNA) #1 walk out of Resident #1's room and go to a linen cart located at the other end of the hall several yards away from Resident #1's room, observed CNA #1 walk back and enter Resident #1's room. Unit Manager #1 then entered Resident #1's room and said that he/she was in the bathroom, and seated on the toilet. Unit Manager #1 said there were no other staff members besides CNA #1 with Resident #1. Unit Manager #1 said Resident #1 was seated on the toilet, without an alarm, and there were no other staff present in the bathroom with Resident #1. Unit Manager #1 said CNA #1 should not have left Resident #1 alone without an alarm in place. During an interview on 06/18/24 at 12:11 P.M., Certified Nurse Aide (CNA) #1 said he was familiar with Resident #1 and said he/she is often on his assignment. CNA #1 said Resident #1 was known to be confused, impulsive, had a history of falls, and had bed and chair alarms in place. CNA #1 said when he transferred Resident #1 to the toilet, he had to disarm the chair alarm, and said there was not an alarm in place when he/she was seated on the toilet. CNA #1 said he left Resident #1 alone, without an alarm, on the toilet to get linen, and said he should not have. During an interview on 06/18/24 at 01:18 P.M., The Director of Nurses (DON) said residents whose plan of care indicated they required a bed and chair alarm should not be left unattended while seated on a toilet or commode. The DON said Resident #1 should have been supervised for safety while seated on the commode and on the toilet but was not.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed by nursing as being at high risk for falls, and who required physical assistance with the use of a gait belt by staff during transfers and ambulation, the facility failed to ensure Resident #1 was provided with an adequate level of staff assistance which included the use of an assistive device (gait belt) in an effort to maintain his/her safety during a transfer, to prevent an incident or accident resulting in an injury. On 03/20/23, Certified Nurse Aide (CNA) #1 provided Resident #1 with assistance with toliting. CNA #1 transferred Resident #1 from his/her wheelchair onto the toilet, however CNA #1 did not apply a gait belt to Resident #1 to assist him/her with the transfer, but instead CNA #1 held onto the back top section of Resident #1's brief while assisting him/her. Resident #1 fell , hit his/her head, was transferred to the Hospital Emergency Department for evaluation, was diagnosed with a right sided acute Subdural Hematoma (SDH, a clot of blood that develops between the surface of the brain and dura mater, the brain's tough outer covering) he/she was admitted , and required surgery to repair the SDH. Findings Include: Review of the Facility's Policy titled CNA Gait Belt Education and Receipt of Gait Belt Form, dated revised June 2013, indicated gait belts are to be used during transfers and ambulation on all residents who require more than contact guard assist and the gait belt is a mandatory part of the CNA uniform and must be worn while on duty. Review of the Facility's Policy titled Falls Prevention and Management Program, dated September 2018, indicated residents will be free from accidental injury as much as possible, by identifying and eliminating fall risk throughout the Facility. The Policy indicated it is committed to ensuring that each resident will be protected from falls, as possible, and all residents will have fall precautions implemented as appropriate. Resident #1 was admitted to the facility in May 2019, diagnoses included Cerebral Vascular Accident (CVA, stroke, damage to the brain from interruption of its blood supply), dysphagia (difficulty swallowing), lung cancer, hypertension, respiratory failure, muscle weakness, unsteadiness on feet, difficulty walking and a history of falls. Review of Resident #1's Morse Fall Risk Scale, dated 08/04/22, indicated he/she had a score of 55, was at high risk for falls, and that he/she overestimated or forgot his/her limits. Review of Resident #1's Occupational Therapy (OT) Discharge Summary, dated 11/22/22, indicated that he/she required partial to moderate physical assistance with toilet transfers. Review of Resident #1's Minimum Data Set (MDS) Assessment, dated 01/20/23, indicated he/she had a Brief Interview for Mental Status (BIMS) score of 10 and was moderately cognitively impaired (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). The MDS indicated that Resident #1 required the physical assistance from staff for transfers and ambulation. Review of Resident #1's Risk for Falls Care Plan, reviewed and renewed with his/her January 2023 MDS, indicated that Resident #1 was at high risk for falls related to incontinence, paralysis (loss of the ability to move in part or most of the body) and being unaware of his/her safety needs. Review of Resident #1's Activities of Daily Living Care Plan, reviewed and renewed with his/her January 2023 MDS, indicated Resident #1 required one person physical assistance with toileting and that his/her weight shifts when out of bed due to right hemiplegia (paralysis on one side of the body). Review of Resident #1's Nursing Summary, dated 02/26/23, indicated that he/she required physical assistance of staff member with care needs. The Summary indicated Resident #1 had right hemiparesis (weakness or the inability to move on one side of the body) and demonstrated the following; generalized weakness, decreased endurance, strength and range of motion, and contractures (right hand splint). Review of Resident #1's Nursing Progress Note, dated 03/20/23, indicated at approximately 7:30 A.M., a Certified Nurse Aide (CNA) asked for help with Resident #1 who had fallen. The Note indicated upon arrival to Resident #1's room, Resident #1 was alert, communicating with staff, at his/her baseline cognitively, and was lying on his/her right side (on the floor). The Note indicated Resident #1 had been bleeding from the right side of his/her head, a staff nurse applied pressure and an ice pack to Resident #1's head The Note indicated staff called the Emergency Medical Services (EMS) and Resident #1 was transferred to the Hospital Emergency Department (ED). Review of Resident #1's Hospital Emergency Department (ED) Note, dated 03/20/23, indicated Resident #1 was diagnosed with a right subdural hematoma (SDH, a clot of blood that develops between the surface of the brain and dura mater, the brain's tough outer covering), right intrarenchymal hemorrhage (IPH, refers to nontraumatic bleeding into the brain parenchyma) and left basal ganglia hemorrhage (stroke) after a witnessed fall. The ED Note indicated Resident #1 required an emergent right craniotomy (operation in which a small hole is made in the skull or a piece of bone from the skull is removed to show part of the brain) for evacuation of his/her right SDH. During an interview on 04/18/23 at 2:20 P.M., the Physical Therapist said gait belts are used for all residents during functional transfers and or mobility for safety unless the resident is independent. The Physical Therapist said Resident #1 was not independent with transfers and needed physical assistance of one staff member, with the use of the gait belt to provide safety. During an interview on 04/18/23, at 2:20 P.M., Certified Nurse Aide (CNA) #1 said on 03/20/23 she was transferring Resident #1 to his/her commode (a type of portable toilet chair) when Resident #1 fell on to the floor. CNA #1 said Resident #1 was in a standing position holding the safety bar on the wall and she was positioned behind Resident #1. CNA #1 said her right hand was located on Resident #1's lower back holding onto Resident #1's brief . CNA #1 said she held onto Resident #1's brief to help assist Resident #1 to stand. CNA #1 said she used her left hand to push the wheelchair out from behind Resident #1, and then crossed her left hand under her right arm to reach the commode to move it in place behind Resident #1. CNA #1 said as she was moving the commode towards Resident #1, Resident #1's right leg started to move and Resident #1 fell on to the floor landing on his/her right side. CNA #1 said Resident #1 needed assistance of one staff member with transfers and mobility. CNA #1 said any resident who required an assist of one, that staff needed to have a gait belt on the resident to provide safety. CNA #1 said on 03/20/23, when she transferred Resident #1, she did not have her gait belt on as part of her uniform, did not use a gait belt on Resident #1 during the transfer and said if she had asked the facility for a gait belt, a gait belt would of been provided. During an interview on 04/18/23 at 3:08 P.M., the Director of Nursing said on 03/20/23, CNA #1 said she did not use a gait belt with Resident #1 when she transferred him/her. The Director of Nursing said the Facility does have a Gait Belt Policy and the gait belt is considered a part of nursing staff members work uniform. The Director of Nursing said it is her expectation any resident that requires the assistance of one staff member or more for transfers or mobility, that staff were to use a gait belt to ensure safety. On 04/18/23, the Facility presented the Surveyor with a plan of correction that addressed the of concern identified in this survey; the Plan of Correction provided is as follows: A) Resident #1 on 03/20/23 was transferred to the Hospital Emergency Department and did not return to the Facility. B) All Residents that were identified as requiring more than contact guard assistance were reviewed to ensure that the appropriate level of staff assistance required devices were being provided. C) On 03/20/23, the Staff Development Coordinator conducted Educational In-services for nursing staff on the Facility's Gait Belt and Procedure Policy. The staff education included the following; proper use of a gait belt, gait belts are a mandatory part of the Certified Nursing Aide staff uniform and must be worn at all times during the shift, and gait belts are to be used during transfers and ambulation on all residents who require more than contact guard assist. D) On 3/21/23, the Staff Development Coordinator reviewed with the Nursing Management Team during their morning meeting the Facility Gait Belt and Procedure Policy and Weekly Random Spot Checks to be performed on staff. E) On 3/21/23 Weekly Random Spot Checks were conducted to ensure staff were wearing gait belt as part of their uniform and the gait belts are being used during transfers and or mobility with residents. F) Weekly Random Spot Checks will be conducted by Nursing Management Team and ongoing. G) Results of these audits will be brought to Quality Assurance & Performance Improvement (QAPI) committee meeting by the Nursing Management Team on 04/26/23. H) The Administrator/and or designee are responsible for overall compliance.

Based on observation, record review and interview the facility failed to identify and obtain treatment orders for 2 unstageable pressure areas on 1 Resident's (#4) foot out of a total sample of 26 residents. Findings include: Review of the facility policy titled Sin Management Program Assessment and Prevention of Skin Breakdown and not dated, indicated to check the resident's skin condition daily and whenever giving care for any signs or symptoms of skin irritation or breakdown. Further review indicated that if a wound is identified the area will be assessed, measured and documented weekly in the electronic health record. Further review indicated to perform and document weekly in the electronic medical health record the weekly skin check. Resident #4 was admitted to the facility in May 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set assessment dated [DATE], indicated that Resident #4 scored a 15 out of 15 on the Brief interview for Mental Status which indicated that she/he is cognitively intact. Further review failed to indicate that Resident #4 had any skin issues and her/his skin was intact. During an interview on 10/12/22, at 8:40 A.M., Resident #4 said that she/he has pressure areas on her/his left foot bunion and toe from new shoes. On 10/13/22, at 9:48 A.M., the surveyor and Unit Manager (UM) #2 observed Resident #4's feet. The surveyor and UM #2 observed an approximately 0.5 x 0.5 centimeter (cm) size blackened smooth area on the tip of the right great toe and a 1 cm x 1 cm blackened, thick scab like and firmly attached, area on the left foot bunion area. Review of the medical record indicated that a skin assessment had not been completed since 9/29/22. Further review indicated a facility document titled Skin Observation Tool dated 9/29/22, which indicated that Resident #4 had no open areas. Review of the nurse's notes failed to indicate Resident #4 had any pressure related skin areas. Review of the nurse practitioner's notes and the doctor's notes failed to indicate that Resident #4 had any pressure related areas. During an interview on 10/13/22, at 9:48 A.M., Resident #4 said that she had informed multiple staff members of the discomfort that her/his new shoes were causing her/his feet. Resident #4 then told UM #2 the names of the nurses she/he had informed of the pressure areas. During an interview on 10/13/22, at 9:56 A.M., UM #2 said that she was not aware of the pressure areas on Resident #4's feet. She then said that the staff members that Resident #4 said were told of the pressure areas were nurses who work on the unit. UM #2 then said that a nurse signed off on the Treatment Record that the weekly skin check was completed but that it is not in the medical record. During an interview on 10/13/22, at 11:18 A.M., Nurse #4 said that Resident #4 told her awhile ago, maybe a couple of weeks ago, that there was an area on her/his right great toe and bunion. Nurse #4 said that she applied skin prep to the areas to toughen the skin to prevent it from opening. Nurse #4 then said that she did not document the area, notify the doctor or write a nurse's note.

Based on records review and interviews for 1 of 3 sampled residents, Resident #3, the Facility failed to ensure that a treatment was Physician ordered and administered to Resident #3 by a licensed professional when, on 11/18/16, a Certified Nursing Assistant administered a hot water bottle to Resident #3's right ischial area (area on lower and back part of hip bone) and Resident #3 sustained a 19 centimeter by 12 centimeter burn. Findings include: The Facility Protocol, from Lippincott Nursing Manual 7th Edition, page 348 titled Heat Application, indicated that hot water bottle temperatures are to be adjusted as per Physician order [REDACTED]. Resident #3's Admission Minimum Data Set (MDS), dated [DATE], indicated Resident #3's medical [DIAGNOSES REDACTED]. Physical Therapy Certification Notes, electronically signed on 11/7/16 at 8:36 A.M., indicated Resident #3 had no sensation below the level of his/her spinal injury and he/she had poor trunk control. A Care Plan, titled Self-Care Performance Deficit and dated 11/17/16, indicated Resident #3 was unable to reposition himself/herself in bed and was dependent upon staff to assist when he/she needed to be repositioned. A Nurse's Progress Note, dated 11/18/16 and timed at 10:27 P.M., indicated that while Certified Nurse's Aides (CNA) were caring for Resident #3 they discovered a large burn to the right lateral section of his/her upper thigh which was the result of a hot water bottle that had been earlier placed under Resident #3, and the skin at the center of the burn was starting to peel. The Physician was notified and treatment orders were obtained. The Surveyor interviewed CNA #1 on 1/10/16 at 2:01 P.M. CNA #1 said, at approximately 8:00 P.M. on 11/18/16, after repositioning Resident #3 in his/her bed, Resident #3 asked her to fill a hot water bottle for his/her back. CNA #1 said she filled the hot water bottle from a faucet in the kitchen area, wrapped the hot water bottle in a pillow case, returned to Resident #3's room, and placed the hot water bottle underneath Resident #3's right thigh. CNA #1 said she was not aware of what temperature the hot water bottle was when she placed it underneath Resident #3. CNA #1 said she left the facility at approximately 9:00 P.M. and left the hot water bottle underneath Resident #3's right thigh. The Surveyor interviewed CNA #2 on 1/10/16 at 2:32 P.M. CNA #2 said on 11/18/16 at approximately 8:15 P.M. she assisted CNA #1 with repositioning Resident #3 and heard Resident #3 ask CNA #1 to fill the hot water bottle for him/her and to make it very hot. CNA #2 said she left Resident #1's room and did not observe CNA #1 fill or place the hot water bottle underneath Resident #3. CNA #2 said, at approximately 10:00 P.M., she went into Resident #3's room to assist with repositioning him/her and discovered the hot water bottle was still underneath Resident #3 and she observed resident #3's skin to be peeling, red and hot to the touch with the imprint of the whole water bottle visible on Resident #3's skin. A Nurse's Progress Note, dated 11/21/16 and timed at 11:05 A.M., indicated Resident #3's burn was assessed to be 19 centimeters by 12 centimeters, irregularly shaped, varied colors of skin including a red and purple center, pink edges, and peeling skin. The Surveyor interviewed the Director of Nursing (DON) on 1/3/17 at 11:20 A.M. The DON said Resident #3 did not have a Physician's treatment order for a hot water bottle and it was not within CNA #1's scope of practice to administer the hot water bottle to Resident #3, Resident #3 continues to receive daily treatments for the burn, and a Wound Specialist is scheduled to come to the Facility to assess and assist with treating Resident #1's burn.

Based on staff and resident interviews and clinical record review for 1 (Resident #1) of 22 sampled residents, the Facility failed to ensure a safe environment resulting in Resident #1 sustaining a chemical burn. On 9/2/14 Housekeeper #1 left a bottle of adhesive remover in Resident #1's room, which was within his/her reach. Resident #1 attempted to move the bottle from one side of the bed to other, and in the process of doing so, spilled the contents onto his/her person which resulted in Resident #1 sustaining a chemical burn. Findings include: Resident #1's demographic sheet indicated Resident #1 was admitted to the Facility in 11/2004 with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment for Resident #1 dated 7/25/14 indicated the Brief Interview for Mental Status (BIMS) score of 12/15, extensive assist for bed mobility, locomotion and dressing, total dependence for transfers. The Nursing note dated 9/2/14 indicated CNA #2 reported to Nurse #1 that Resident #1 spilled adhesive remover on his/her person and complained of left hip pain. The Nursing note indicated Nurse #1 assessed Resident #1 and found no signs of redness or tenderness at that time. Surveyor #1 and Surveyor #2 interviewed Housekeeper #1 at 11:42 A.M. on 9/25/14 with Environmental Services Director present. Housekeeper #1 said at approximately 10:30 A.M. on 9/2/14 she cleaned Resident #1's room. Housekeeper #1 said she believed she was interrupted and forgot the bottle of adhesive remover when she left Resident #1's room. Surveyor #1 and Surveyor #2 interviewed Certified Nurse Aide (CNA) #1 at 12:52 P.M. on 9/25/14. CNA #1 said she worked the day shift on 9/2/14 and her assignment included Resident #1. CNA #1 said she was last in the room of Resident #1's room at approximately 11:30 A.M. and did not see any chemical products in the room. Surveyor #1 and Surveyor #2 interviewed CNA #2 at 2:05 P.M. CNA #2 said she was assigned to work with Resident #1 on 9/2/14 for the evening shift. CNA #2 said she put Resident #1 into bed at approximately 3:30 P.M. and saw a bottle with an orange stripe on the table on the right side of Resident #1. CNA #2 said the bottle was turned with label facing the wall. CNA #2 said she thought it was soap because it was similar in appearance to the bottles of soap used to bathe the residents. CNA #2 said she left the room to care for another resident. Surveyor #2 interviewed Resident #1 at 11:54 A.M. on 9/2/14. Resident #1 said he/she was in bed and saw a bottle on his/her table on his/her right side of the bed. Resident #1 said he/she did not know what the bottle was and thought the lid was closed tightly. Resident #1 said he/she reached to her right side to move the bottle to the other side of her bed and place it with his/her personal care items. Resident #1 said the cover was not on tightly and as he/she moved it, the product spilled onto his/her person. Resident #1 said the product burned his/her skin describing it as terrible pain. Resident #1 said he/she does not know who left the bottle in his/her room. Surveyor #1 interviewed Nurse #1 at 2:55 P.M. on 9/24/14. Nurse #1 said when she entered Resident #1's room to give Resident #1 his/her 4:00 P.M. medications, the room contained a citrus scent. Nurse #1 said she asked Resident #1 if anyone sprayed the room which Resident #1 denied. Nurse #1 said Resident#1 reported having pain and when Nurse #1 looked at his/her abdomen it was slightly pink. Nurse #1 said she asked CNA #2 if she had smelled the citrus scent to which CNA #2 replied no. Nurse #1 said CNA #2 went back into Resident #1's room. CNA #2 said when she returned to Resident #1's room she said she smelled a strong citrus odor. CNA #2 said Resident #1's bed linen and johnnie (hospital gown) were wet with an orange colored liquid. CNA #2 said she saw a bottle on top of Resident #1 and the bottle label indicated it was adhesive remover. CNA #2 said she took the bottle and reported the incident to Nurse #1 and Charge Nurse #2. Nurse #1 said when CNA #2 brought the bottle of adhesive remover to her attention, she and CNA #2 brought the bottle of adhesive remover to Charge Nurse #2's attention and CNA #2 washed Resident #1 with soap and water. The Nurse Practitioner's Progress Note dated 9/4/14 indicated Resident #1 sustained a second degree chemical burn.