Every finding on record at Norwood Healthcare

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who in the morning on 3/31/26 exhibited signs of acute pain in his/her right shoulder and arm, and had a new Physician's order for a STAT (without delay, immediately) x-ray, the Facility failed to ensure that he/she was provided with radiology services consistent with his/her Physician's Orders, when nursing did not follow up on the order and a STAT x-ray was not obtained, as a result he/she had to be transferred to the Hospital Emergency Department the following day to obtain an x-ray.Findings Include:Resident #1 was admitted to the Facility in March 2025, diagnoses included Alzheimer's, dementia, lack of coordination, difficulty walking, and history of falling.Review of Resident #1's Incident Report, dated 03/29/26, indicated that he/she had an unwitnessed fall, he/she was assessed and no injuries were noted.Review of Resident #1's Nurse Progress Note, dated 03/31/26 (written by Nurse #2), indicated Resident #1 was assessed that morning, he/she exhibited signs of acute pain in his/her right shoulder and arm and there was visible quarter size dark purple bruising to his/her right upper and lower arm. The Note indicated that Resident #1 showed facial grimacing, he/she said, ouch when his/her arm (right) was touched. The Note further indicated that Resident #1's Physician ordered a STAT x-ray of his/her right shoulder and upper and lower arm for acute pain due to trauma related to status post fall on 03/29/26.Review of Resident #1's Physician's Orders, dated 03/31/26, indicated an x-ray of his/her right shoulder and arm to rule out fracture was ordered. Review of Resident #1's Radiology Provider Confirmation Order, dated 03/31/26, indicated an x-ray was ordered at 11:52 A.M, priority STAT. During an in-person interview on 05/05/26 at 1:46 P.M. and a telephone interview on 05/07/26 at 10:55 A.M. Nurse #2 said she worked from 7:00 A.M. to 11:00 P.M. (double shift) on 03/31/26 and was assigned to care for Resident #1 (both shifts). Nurse #2 said during the morning she noticed that Resident #1 appeared to be in pain. Nurse #2 said she assessed Resident #1 and there were quarter size bruises on his/her right upper and lower arm and said when she touched his/her shoulder and arm, he/she said, Ow. Nurse #2 said she notified Resident #1's Physician and obtained an order for a STAT x-ray of his/her right shoulder and arm.Nurse #2 said she called the x-ray provider to inform them that Resident #1 had an order for a STAT x-ray of his/her right shoulder and arm (order confirmed by x-ray provider at 11:52 A.M., priority STAT). Nurse #2 said when there is an order for a STAT x-ray their x-ray provider usually comes to the facility within one to four hours.Nurse #2 said the x-ray provider had not come to the facility by the end of her second shift (11:00 P.M., more than 11 hours after she had placed the order for the STAT x-ray) and that she had not called the x-ray provider back at any time during her double shift that day to see when and what time they would be coming to do Resident #1's STAT x-ray. Nurse #2 said she informed the 11:00 P.M. to 7:00 A.M. shift nurse (identified as Nurse #5) that the x-ray provider had not come to do Resident #1's x-ray and to follow up with them.During an interview on 05/07/26 at 1:17 P.M., Nurse #5 said she worked the 11:00 P.M. to 7:00 A.M. (night shift) on 03/31/26 into 04/01/26 on Resident #1's unit. Nurse #5 said during change of shift report the 3:00 P.M. to 11:00 P.M. nurse (Nurse #2) informed her Resident #1 was supposed to have a STAT x-ray of his/her arm and that the x-ray provider had not come to do the x-ray. Nurse #5 said she did not call the x-ray provider to see when they would be coming to the facility.During an interview on 05/05/26 at 2:16 P.M., Nurse #3 said on the morning of 04/01/26 she informed the ADON that the x-ray provider had not come to do Resident #1's STAT x-ray. Nurse #3 said she called Resident #1's Physician and obtained an order to send him/her to the Hospital Emergency Department (ED) to have an x-ray done.Review of Resident #1's medical record indicated that there was no documentation to support that Nurse #2 followed up on the STAT x-ray before the end of her double shift on 3/31/26 at 11:00 P.M. (more than 11 hours after she obtained and placed the order) or that Nurse #5 followed up on the x-ray after being made aware during change of shift report that a STAT x-ray was still pending.During an in-person interview on 05/05/26 at 12:37 P.M. and a telephone interview on 05/07/26 at 1:53 P.M., the Assistant Director of Nursing (ADON) said on the morning of 04/01/26 she reviewed the 24-hour report and saw that Resident #1 was supposed to have a STAT x-ray of his/her right arm on 03/31/26. The ADON said she asked Nurse #3 if the x-ray provider had come to do Resident #1's x-ray and said Nurse #3 told her, they had not. The ADON said Nurse #3 notified Resident #1's Physician and an order was obtained to send him/her to the Hospital ED for an x-ray.The ADON said that the turnaround time for a STAT x-ray order to be done by the x-ray provider was four hours. The ADON said there was no documentation in Resident #1's medical record to support that nursing followed up with the x-ray provider as to why they had not come to do his/her x-ray.Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated that his/her x-ray results revealed a closed fracture of his/her right distal radius (broken wrist).During an in-person interview on 05/05/26 at 4:06 P.M and a telephone interview on 05/07/26 at 11:32 A.M., the Director of Nursing (DON) said on 03/31/26 Resident #1 was noted to be guarding his/her right arm, the Physician was notified and a STAT x-ray was ordered. The DON said the x-ray provider had not come to the facility to do Resident #1's x-ray on 03/31/26.The DON said that when there is an order for a STAT x-ray it is done within one to four hours by the x-ray provider. The DON said Nurse #2 did not follow up with the x-ray provider after four hours to see when they would be coming and that Nurse #2 should have notified Resident #1's Physician for further orders.The DON said that it was his expectation that nurses would follow up with the x-ray provider and that STAT orders are obtained.

Based on record review and interviews, the facility failed to develop, maintain, and implement an active, interdisciplinary, person centered care plan to address a known elopement risk for one Resident (#83), in a sample of 25, despite documented severe cognitive impairment (BIMS=3 on 11/24/25), exit seeking behavior, and a high risk elopement score of 14 (11/18/25). The facility resolved the elopement/wandering care plan on 11/28/25 without IDT review or subsequent risk reassessment, and did not implement effective interventions (e.g., wander alert specifications, door/elevator supervision) consistent with assessed needs. On 1/17/26, Resident #83 eloped from the facility, was not identified as missing until approximately 5:00 PM, and was located by police at Boston's South Station, approximately 21 miles away from the facility, and transported to the hospital, placing the Resident at a likelihood of serious harm and death. Findings include:Review of the facility's policy titled Policy: Care Plans, comprehensive person-centered, revised 1/2024, indicated but was not limited to:-a comprehensive, person-centered care plan will be developed for each resident. The care plan will include objectives that meet the resident's physical, psychosocial, and functional needs is developed for each resident [sic];-the interdisciplinary team (IDT) in conjunction with the resident and his/her family or legal representative, may assist with the development of a comprehensive care plan for each resident;-the care plan interventions are derived from information gathered as part of the comprehensive assessment;-the IDT may include: the provider, the nurse responsible for the resident, the aide responsible for the resident, nutrition staff, the resident or the resident's legal representative, other appropriate staff as determined by the resident's needs or as requested by the resident;-evaluation of residents is ongoing and care plans are revised as information about the resident and the resident's conditions change;-the IDT team reviews and updates the care plan when there has been a significant change in the resident's conditions, when there is a change and at least quarterly, in conjunction with the required quarterly MDS assessment. Resident #83 was admitted to the facility in November 2025 with diagnoses including dementia, insulin dependent type two diabetes, restlessness, and agitation. Review of the Resident's Minimum Data Set (MDS) assessment, dated 11/24/25, indicated Resident #83 scored 3 out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment, displayed disorganized thinking, and required supervision while walking. Review of the Resident's hospital records, dated 11/13/25, indicated but were not limited to:-Son reported Resident wandering and entering closets during the night;-Son reported the Resident had increasing aggressive and wandering behaviors and only brief and intermittent moments of clarity;-Patient not safe to discharge home as family is unable to provide necessary support;-Patient cannot be left alone without supervision due to current cognitive function and imbalance;-Hospital case worker indicated the Resident would need a secure unit and he/she was independent with a cane and potential to wander. 11/18/25 admission Note:Resident admitted from hospital with diagnosis of agitation related to cognitive decline. Past medical history of dementia, wandering behaviors. Brought to hospital by son on 11/13 for worsening agitation and confusion and wandering, noticing progressive decline since June 2025. 11/18/25 Nursing Evaluation:Resident was oriented to person, exit seeking, oblivious to needs or safety, watching others go out of doors, early dementia, elopement attempt in last 30 days. 11/18/25 Elopement Risk Assessment:Resident was oriented to person, was exit seeking, wanted to go home/leave, independently mobile with early dementia, and elopement attempt in the last 30 days; Resident is at risk for elopement. SCORE: 14 (High Risk). 11/20/25 Physician Evaluation:Resident claims he/she feels well, does not understand why he/she is here and wants to know when he/she can go home to live with his/her son. 11/24/25 Physician Evaluation:Resident wants to go home. 11/25/25 Psychiatric Evaluation:Resident said he/she liked the facility and enjoyed his/her roommate's company; however, he/she still wanted to go home. Attention: alert and oriented with confusion, impaired thought process, impaired judgement and memory. Review of Resident #83's active care plan did not indicate a care plan for wandering or elopement risk. Review of the resolved care plans indicated a care plan for wandering/elopement risk had been in place from 11/18/25 and resolved (discontinued) on 11/28/25. Review of the Resident's elopement risk and wandering care plan (active from 11/18/25 to 11/28/25) indicated, but was not limited to, the following:Focus:-Resident is an elopement risk/wanderer; Goal:-will not leave the facility unattended through review date;-safety will be maintained through the review date; Interventions:-distract wandering by offering pleasant diversions, structured activities, food, conversation, TV, book;-identify pattern of wandering and intervene as appropriate;-monitor triggers for wandering/eloping;-provide structured activities as needed;-Wander alert: (SPECIFY) Device # Model [sic] On 1/20/26 at 7:26 A.M., the Assistant Director of Nursing (ADON) said Resident #83 eloped over the weekend and could not be found until police located the Resident and took him/her to the hospital. Review of the elopement investigation documentation included, but was not limited to, the following:On 1/17/26, Resident #83:-asked for change for a $20 bill to give his/her son money for food and the bus that day;-was observed walking up and down the hallway as he/she usually does;-was observed wandering to and from the unit elevator for 20-30 minutes prior to eloping;-was heard asking another resident if their visitor had left yet;-was observed on surveillance cameras entering the elevator with an unknown person and exiting the front door;-around 5:00 P.M., staff could not locate Resident #83;-the facility notified police and the Resident's son (activated healthcare proxy);-the facility learned Resident #83 had a cell phone that was provided by his/her son;-police located Resident #83's cell phone signal and at 6:15 P.M. identified Resident #83 was on a train;-Officers were able to ping the Resident's phone approximately 10 miles southwest of the facility. Shortly after a ping was located east of the facility. The Resident was believed to be on the train with the next stop being in South Boston;-Officers made contact with Resident #83 at South Station and took him/her to the hospital for evaluation. During an interview on 1/20/26 at 11:18 A.M., MDS Nurse #1 said she completed Resident #83's admission MDS assessment, dated 11/24/25, which involved reviewing the Resident's entire medical record including progress notes, medication administration records, recorded behaviors, evaluations, social service documentation, and activities documentation; she said she looks everywhere. MDS Nurse #1 could not recall if she met with Resident #83 for this assessment. MDS Nurse #1 said she specifically reviewed information dated from 11/18/25 through 11/24/25 as this was the lookback period for Resident #83's admission MDS assessment. She said she did not see documentation that the Resident displayed wandering behavior, so she resolved the elopement risk/wanderer care plan. MDS Nurse #1 said she was aware that Resident #83 recently eloped on 1/17/26. She said she still agrees with her decision to resolve the Resident's elopement risk/wanderer care plan based on information gathered for the 11/24/25 MDS assessment. During an interview on 1/20/26 at 12:14 P.M., Nurse #2 said he completed Resident #83's elopement risk evaluation on 11/18/25 and determined him/her to be at high risk for elopement. Nurse #2 said because Resident #83 was assessed to be high risk for elopement on 11/18/25, the Resident should have an active elopement risk care plan in place. During an interview on 1/20/26 at 12:44 P.M., Consulting Staff #2 said the initial elopement evaluation indicated Resident #83 was at high risk for elopement and the Resident had a previous care plan for his/her wandering and elopement risk. She said modifying the plan of care for elopement is an interdisciplinary decision and would not hinge on information gathered for an MDS assessment. Consulting Staff #2 said the elopement risk/wanderer care plan should have remained in place until a subsequent elopement risk assessment was performed and the Interdisciplinary Team (IDT) deemed Resident #83 was no longer an elopement risk. Consultant #2 said the facility had no policy regarding elopement risk or elopement prevention. During an interview on 2/2/26 at 2:36 P.M., the Director of Nursing (DON) said care plans were created during admission and updated on an ongoing basis. He said an elopement risk care plan should not be resolved by the MDS nurse based on MDS assessments. The IDT would discuss the need to keep a resident on elopement risk, and if needed, re-evaluate the resident's risk for elopement. Refer to F689

Based on observation, record review, and interview, the facility failed to ensure adequate supervision and interventions were implemented to prevent accidents for one Resident (#83), out of a total sample of 25 residents. Specifically, the facility failed to ensure an elopement/wandering care plan and interventions for a resident assessed at high risk for elopement (score 14, 11/18/25) was maintained and implemented, failed to include the Resident in the elopement photo/binder alert system, and failed to prevent unsupervised exit through the main door, resulting in an elopement on 1/17/26. Resident #83 was not discovered missing from the facility until 5:00 P.M. and was located by the police at a South Boston train station, approximately 21 miles away, and hospitalized , placing the Resident at immediate risk of serious harm and death. Findings include:Review of the facility's policy titled Policy: Care Plans, comprehensive person-centered, revised 1/2024, indicated but was not limited to:-a comprehensive, person-centered care plan will be developed for each resident. The care plan will include objectives that meet the resident's physical, psychosocial, and functional needs is developed for each resident [sic];-the interdisciplinary team (IDT) in conjunction with the resident and his/her family or legal representative, may assist with the development of a comprehensive care plan for each resident;-the care plan interventions are derived from information gathered as part of the comprehensive assessment;-the IDT may include: the provider, the nurse responsible for the resident, the aide responsible for the resident, nutrition staff, the resident or the resident's legal representative, other appropriate staff as determined by the resident's needs or as requested by the resident;-the IDT team reviews and updates the care plan when there has been a significant change in the resident's conditions, when there is a change and at least quarterly, in conjunction with the required quarterly MDS assessment. Resident #83 was admitted to the facility in November 2025 with diagnoses including dementia, insulin dependent type two diabetes, restlessness, and agitation. Review of Resident #83's Minimum Data Set (MDS) assessment, dated 11/24/25, indicated the Resident:-scored 3 out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment;-displayed disorganized thinking;-required supervision while walking. Review of the Resident's hospital records, dated 11/13/25, indicated but were not limited to:-Son reported Resident wandering and entering closets during the night;-Son reported the Resident had increasing aggressive and wandering behaviors and only brief and intermittent moments of clarity;-Patient not safe to discharge home as family is unable to provide necessary support;-Patient cannot be left alone without supervision due to current cognitive function and imbalance;-Hospital case worker indicated the Resident would need a secure unit and he/she was independent with a cane and potential to wander. Further review of Resident #83's medical record included, but was not limited to, the following: -11/18/25 admission Note:Resident admitted from hospital with diagnoses of agitation related to cognitive decline. Past medical history of dementia, wandering behaviors. Brought to hospital by son on 11/13 for worsening agitation and confusion and wandering, noticing progressive decline since June 2025. -11/18/25 Nursing Evaluation:Resident was oriented to person, exit seeking, oblivious to needs or safety, watching others go out of doors, early dementia, elopement attempt in last 30 days. -11/18/25 Elopement Risk Assessment:Resident was oriented to person, was exit seeking, wanted to go home/leave, independently mobile with early dementia, and elopement attempt in the last 30 days; Resident is at risk for elopement. SCORE: 14 (High Risk). -11/19/25 Social Services Assessment:Resident had dementia with a BIMS score of 3; Resident wanders. -11/20/25 Physician Evaluation:Resident claims he/she feels well, does not understand why he/she is here and wants to know when he/she can go home to live with his/her son. -11/24/25 Physician Evaluation:Resident wants to go home. -11/25/25 Psychiatric Evaluation:Resident said he/she liked the facility and enjoyed his/her roommate's company; however, he/she still wanted to go home. Attention: alert and oriented with confusion, impaired thought process, impaired judgement and memory. -12/9/25 and 1/9/26 Nursing Summary Notes indicated the Resident wandered. Review of Resident #83's active care plan did not indicate a current care plan for wandering or elopement risk. Review of the Resident's previous care plans indicated an elopement risk/wanderer plan active from 11/18/25 to 11/28/25 which indicated, but was not limited to, the following:Focus:-Resident is an elopement risk/wanderer; Goal:-will not leave the facility unattended through review date;-safety will be maintained through the review date; Intervention:-distract wandering by offering pleasant diversions, structured activities, food, conversation, TV, book;-identify pattern of wandering and intervene as appropriate;-monitor triggers for wandering/eloping;-provide structured activities as needed;-Wander alert: (SPECIFY) Device # Model [sic]. On 1/13/26 at 12:43 P.M. and on 1/14/26 at 2:00 P.M., the surveyor observed Resident #83 ambulating up and down the unit hallway with his/her cane. On 1/20/26 at 7:26 A.M., the Assistant Director of Nursing (ADON) said Resident #83 eloped over the weekend and could not be found until police located the Resident and took him/her to the hospital. During an interview on 1/20/26 at 8:11 A.M., the Director of Nursing (DON) said Resident #83 eloped over the weekend and was a known elopement risk. He said the elopement investigation was still open. Review of Resident #83's medical record indicated, but was not limited to, the following:-11/21/25, Humalog insulin, inject as per sliding scale at 0800, 1200, 1700;-11/18/25, Humalog insulin, inject as per sliding scale at 2100;-Insulin Glargine at bedtime. During an interview on 1/20/26 at 10:12 A.M., Nurse #3 said the Resident often walked the unit, but she never noticed him/her linger around exits. She said she worked the day and evening shifts on the day Resident #83 eloped. Nurse #3 said she had given the Resident his/her morning and afternoon medications and treatments and when she went back around 5:00 P.M. to get the Resident's blood sugar reading, she could not find the Resident. She said the facility was searched and the elopement protocol was initiated. On 1/20/26 at 10:39 A.M., Consulting Staff #2 and the Administrator provided the surveyor documentation of the ongoing elopement investigation. During an interview on 1/20/26 at 10:39 A.M., the Administrator said he was the manager on duty and worked the front desk the day of the elopement. The Administrator said he left the front desk for a brief period and arrived back around 2:40 P.M. at which point he observed a person (Resident #83) at the door trying to exit the building. The Resident stated to the Administrator he/she was a visitor and wanted to exit the building. The Administrator asked the person if they signed out and he/she said yes. The Administrator said Resident #83 was not in the elopement binder, and he did not recognize the person as Resident #83, therefore, he unlocked the door and Resident #83 exited the building. Consulting Staff #2 and the Administrator said Resident #83 had been identified as an elopement risk and resided on a unit with an elevator that required a numerical code to call the elevator and a second code to move the elevator, plus a third code was needed to exit the main door. Consultant Staff #2 said since Resident #83 resided on what she believed to be a secure unit, he/she was not required to wear a wander bracelet (an electronic bracelet alarm system used to prevent residents with a tendency to wander from leaving monitored areas) and Resident #83 had no plan in place for elopement risk because his/her elopement risk care plan was resolved (discontinued) on 11/28/25. She said there was no evidence in the medical record indicating why the elopement care plan was resolved and Resident #83 should have been included in the elopement binder. During an interview on 1/20/26 at 11:18 A.M., the MDS Nurse said she completed Resident #83's admission MDS assessment in November. She said she did not see documentation that the Resident displayed wandering behavior, so she resolved the elopement risk/wanderer care plan. The MDS Nurse said she was aware that Resident #83 recently eloped. The MDS Nurse said she still agrees with her decision to resolve the Resident's elopement risk/wanderer care plan based on the MDS assessment. During an interview on 1/20/26 at 12:14 P.M., Nurse #2 said he completed Resident #83's elopement evaluation and determined him/her to be at high risk for elopement. Nurse #2 said based on the evaluation he would have expected the Resident's photo to be in the elopement binder and an elopement and wandering care plan to be in place. Review of the elopement investigation documentation included, but was not limited to, the following:On 1/17/26, Resident #83:-asked for change for a $20 bill to give his/her son money for food and the bus that day;-was observed walking up and down the hallway as he/she usually does;-was observed wandering to and from the unit elevator for 20-30 minutes prior to eloping;-was heard asking another resident if their visitor had left yet;-was observed on surveillance cameras entering the elevator with an unknown person and exiting the front door. Further review of the elopement investigation documentation indicated:-around 5:00 P.M., staff could not locate Resident #83;-the facility notified police and the Resident's son (activated healthcare proxy);-the facility learned Resident #83 had a cell phone that was provided by his/her son;-Consulting Staff #2 and the Administrator said they were unaware the Resident had a cell phone;-police located Resident #83's cell phone signal and at 6:15 P.M. identified Resident #83 was on a train. Review of the [NAME] Police Department Patrolman Narrative (Reference: 2 6NWD-52-OF), dated 1/17/26, indicated but was not limited to:-The reporting party was Resident #83's son;-Resident #83's son drove to the facility to try to help find the Resident at which point he then called the police;-Resident #83's son stated:Resident suffers from dementia and is a severe diabetic;Resident's blood sugars can be very volatile, and he/she needs to be monitored;Resident recently moved to the State, so he/she does not know the area much and due to dementia thinks at times he/she is in their home state.-There was a delay in reviewing video footage as the Administrator was waiting for the password to get into the system from someone that was not on site, then once in the system the Administrator did not know how to operate the system and requested the Officer do so. The Officer was only able to get glimpses of Resident #83 walking in the hallway around 8:00 A.M. that morning;-Officers were able to ping the Resident's phone approximately 10 miles southwest of the facility. Shortly after a ping was located east of the facility. The Resident was believed to be on the train with the next stop being in South Boston;-Officers made contact with Resident #83 at South Station and took him/her to the hospital for evaluation. Review of the Massachusetts Bay Transportation Authority commuter rail schedule as of 2/3/26 indicated a direct evening route from a [Town Name] train station to South Station (in South Boston) to be approximately 30 to 40 minutes in duration. South Station was indicated as being the last stop for that commuter line. Review of weather data obtained from the United States Department of Commerce indicated the temperatures on 1/17/26 in [town name], Massachusetts was a maximum of 40 degrees Fahrenheit and a minimum of 25 degrees Fahrenheit. Review of hospital records, dated 1/20/26, stated Resident #83 was alert and oriented x3; forgetful; intermittent confusion; reported the facility was giving him/her too many pills and he/she did not want to stay there. The Emergency Department (ED) team felt that patient did not have insight into his/her illness and need for medications; overall felt to lack capacity. In discussion with the patient's son, patient to return back to facility. However, patient then refused to leave ED despite use of olanzapine (an antipsychotic drug used to treat mental health conditions by stabilizing mood and reducing behavioral disturbances) 5 milligrams x1. Reattempted to discharge patient later in the evening but again patient refused. Given 250 milligrams of Depakote (an anti-epileptic drug commonly used as a mood stabilizer to manager specific, often severe, behavioral issues) to calm patient prior to discharge. During an interview on 1/20/26 at 12:44 P.M., Consulting Staff #2 said the initial elopement evaluation indicated Resident #83 was at high risk for elopement and the Resident had a care plan for his/her wandering and elopement risk. She said modifying the plan of care for elopement is an interdisciplinary decision and would not be based solely on information gathered for an MDS assessment. She said the elopement risk/wanderer care plan should have remained in place until a subsequent elopement risk assessment was performed and the IDT deemed Resident #83 was no longer an elopement risk. Consultant #2 said the facility had no policy regarding elopement risk or elopement prevention. On 2/2/26 at 3:16 P.M., the surveyor placed a call to Resident #83's son and left a message. The son called the surveyor back on 2/3/26. During a telephone interview on 2/3/26 at 12:09 P.M., Resident #83's son said the Resident moved to Massachusetts to live so he could take care of him/her. The son said the Resident is smart enough to [NAME] his/her way out of things which is why he opted for a secure facility. He said Resident #83 told him soon after admitting into the facility that if he did not get him/her out of the facility, he/she would jump out the window and that he/she was going to escape. The son said he notified a staff member about these statements. He said he was shocked when the Resident eloped as he was told the facility was a secure place. The son also said Resident #83 had his/her cell phone during the time of admission to the facility and the facility should have known about it as the Resident always carries his/her two wallets and cell phone on his/her person. The son went on to say that the facility called him twice on 1/17/26. During the first call, the facility asked him if he'd taken the Resident out of the building to which he replied he was the only authorized person to sign the Resident out of the building and he had not done so. He said the facility did not indicate they were searching for the Resident. The son said the facility called him a second time, about 30-60 minutes later, and asked again if he had taken Resident #83 out of the building. He replied he had not. The facility then notified him the Resident could not be found. He then drove approximately 30-35 minutes to the facility. The son said he called the police and was surprised the facility had not already done so given Resident #83 had dementia.

Based on interview and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) program with documentation of the development, implementation, and evaluation of corrective actions or performance improvement activities and failed to maintain a QAPI program which addressed the full range of care and services including clinical care. Findings include: Review of the facility's policy titled Quality Assurance Performance Improvement (QAPI), dated as last revised 6/2024, indicated but was not limited to the following:-The purpose of the committee is to review and analyze facility related data and direct appropriate actions for the facility response.-Our QAPI plan addresses: Clinical indicators, Environmental indicators, and Resident indicators.-We will identify areas of improvement and rank them by factors such as prevalence, risk, relevance, responsiveness, feasibility, and continuity. From this we will determine our Performance Improvement Projects (PIP).-The Administrator is responsible and accountable for developing, leading, and monitoring a QAPI program.-The committee maintains QAPI minutes, project, PIPs, Plan-Do-Study-Act (PDSA) reviews, data, data analysis and sample performance improvement support tools.-The QAPI Committee will complete an annual self-assessment / review of the QAPI program.-PIPs are reported by the project lead to the QAPI Committee verbally and documented in the meeting minutes.-The PDSA process and Root Cause Analysis (RCA) are used to identify improvement opportunities and understand how to improve them.-The QAPI Committee monitors the process according to pre-determined time frames, observing if the changes in the process resulted in the desired outcome. If the changes to the process have not resulted in the goal of the PIP, further changes are made and monitoring of the process takes place again.-The QAPI program will be evaluated annually. The key elements of the program will be reviewed to assure that they are occurring and that the program is efficient.-The plan will be revised annually. Review of the 2025 QAPI binder with the Administrator indicated the following:-No documented projects/PIPs that had been worked on throughout the year.-Sign-in sheets for the quarterly meetings and the lab/pharmacy reports for each quarter, but no meeting minutes.-Kitchen audits from July through October but failed to indicate a project and goal they were related to. During an interview on 1/20/26 at 3:00 P.M., the Administrator said they had one clinical project for pressure ulcers that just got started and he did not have any details on the project. He said the Director of Nurses (DON) did not have any other QAPI information in his office either. The Administrator said he did not have any other information regarding any plans they may or may not have been working on in 2025. He said there should have been documented projects to review but he does not have anything. He said he must re-do everything. During an interview on 1/20/26 at 4:34 P.M., the Assistant Director of Nurses (ADON) said the only PIP she has is related to pressure ulcers and it's new. She said they don't have any other formal QAPIs or PIPs that she is aware of. She said they work on things but not in a QAPI format. During an interview on 1/20/26 at 4:45 P.M., the DON said they have been working on psych consents for a few months but there was not a PIP for it, they were just making sure the consents were complete and accurate. He said it had been about three months, and they were almost done with the audit. He said they did not have any projects in QAPI format they were working on or that he could review from last year.

Based on interview and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) program with documentation of the development, implementation, and evaluation of corrective actions or performance improvement activities. Findings include: Review of the facility policy titled Quality Assurance Performance Improvement (QAPI) dated as last revised 6/2024 indicated but was not limited to the following:-The purpose of the committee is to review and analyze related data and direct appropriate actions for the facility.-It is the responsibility of the QAPI Committee to consider all data presented by the QAPI team and to direct the QAPI team to continue or conclude the assignment.-Our QAPI plan addresses Clinical Indicators, Environmental Indicators, and Resident Indicators.-We will identify areas of improvement and rank them by factors and determine our Performance Improvement Projects (PIP).-The Administrator is responsible and accountable for developing, leading, and monitoring the QAPI program.-The Committee maintains QAPI minutes, project, PIP, Plan-Study-Do-Act (PDSA) reviews, data analysis, and sample performance improvement support tools.-The QAPI Committee will complete an annual self-assessment / review of the QAPI program.-The QAPI team analyses data regularly as part of their project assignment.-The QAPI Committee monitors progress to ensure that interventions or actions are implemented and effective in making and sustaining improvements.-PIPs are reported to the project lead and documented in the meeting minutes. Review of the 2025 QAPI binder with the Administrator indicated the following:-No documented projects/PIPs that had been worked on throughout the year.-No evidence of data collection and analysis. During an interview on 1/20/26 at 3:00 P.M., the Administrator said he did not have any data on any projects to provide. He said there should be plans for each department to be working on something, but he did not have anything and therefore could not speak to what they had been doing or not doing last year or if the projects had to be revised or were effective. Additionally, he said the plan of correction from last year should be part of QAPI and he did not have anything related to that to be able to speak to it. He said Corporate has templates they have to fill in but they are not related to specific facility QAPI plans. He said the way they do QAPI has to change.

Based on interview and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) Committee which included the required members at their meetings. Specifically, the facility's Director of Nurses (DON) and Infection Preventionist (IP) failed to attend and participate in three of the last three quarterly QAPI meetings. Findings include: Review of the facility's policy titled Quality Assurance Performance Improvement, dated as last revised 6/2024, indicated but was not limited to the following:-The facility will form a QAPI that meets quarterly. The Committee must include the Medical Director, Administrator, Director of Nurses, Infection Preventionist, and two other staff members.-The purpose of the committee is to review and analyze related data and direct appropriate actions for the facility. Review of the quarterly sign-in-sheets for 2025 indicated the following:-April 2025: The DON was present. He also served as the IP at that time.-July 24, 2025: The DON and Assistant Director of Nurses (ADON)/IP were present.-October 2025: The DON and Assistant Director of Nurses (ADON)/IP were present. During an interview on 1/20/26 at 2:02 P.M., the ADON/IP said she has not attended a QAPI meeting since she was hired about six months ago. She said she thinks it is important for the IP to be part of the QAPI process, but she has not been. During an interview on 1/20/26 at 3:00 P.M., the Administrator said he could not speak to the meetings and/or attendance because he had no meeting minutes and could only refer to the sign-in sheets in the binder. He said he was not hired until November 2025. During an interview on 1/20/26 at 4:34 P.M., the ADON said she was not employed at the facility for the April meeting, and that was her signature on the July and October attendance sheets, but she said the previous Administrator would write up QAPI and just have her sign the attendance sheet. The ADON said they never had any meetings to discuss any QAPI plans/projects. During an interview on 1/20/26 at 4:45 P.M., the DON said he had attended and participated in QAPI meetings in the past as an ADON but in 2025 since taking over as DON he had never attended a QAPI meeting. He said the previous Administrator just had us sign the paper and we never had any meetings or discussions regarding projects to work on.

Based on document review and interview, the facility failed to provide training and education to all their staff to outline current elements, projects, goals, and revisions of the facility's Quality Assurance Performance Improvement (QAPI) program. Findings include: Review of the facility's policy titled Quality Assurance Performance Improvement (QAPI), dated as last revised 6/2024, indicated but was not limited to the following:-Communication about QAPI activities is shared via staff meetings and/or trainings.Review of the facility's education records on QAPI training indicated staff were trained on the general concept of QAPI but failed to indicate staff were educated on the facility's QAPI projects, plans, or goals as required.During an interview on 2/2/26 at 1:30 P.M., Consulting Staff #3 said she does not have any records related to any QAPI project and education/training from 2025. She said the online training record she provided was education on the general Policy and Procedure and was not specific to any projects the facility was working on.

Based on review of Resident Council Minutes, interviews, and record reviews, the facility failed to ensure concerns brought forward from the Resident Council were addressed and promptly resolved to ensure the residents felt their concerns were acted upon timely and included the facility response to the group. Findings include:Review of the facility's policy titled Resident Council, last revised on 2/24, indicated but was not limited to the following:-The facility will provide a designated staff person who is approved by the resident group and facility who is responsible for providing assistance and responding to written requests from group meetings.-Department heads must respond to grievances addressed in the minutes in writing before the next meeting.Review of Resident Council Minutes, dated 7/5/25, indicated the residents would like to get a video game, more hamburgers for evening meals, and evening activities once a month. The minutes also indicated that the residents would like to go outside more. The form indicated follow up was required but no follow-up was indicated as completed.Review of Resident Council Meeting Minutes, dated 8/7/25, indicated residents would like a Bingo evening activity with prizes; Kitchen director updated on residents getting more hamburgers. No follow up was reviewed, documented, or included from the meeting.Review of the Resident Council Meeting Minutes, dated 9/9/25, indicated No follow up was reviewed, documented, or included from the meeting.Review of the Resident Council Meeting Minutes, dated 10/9/25, indicated follow-up was needed, the residents said they would like to have a specific exercise activity called [NAME]-Boom more than one time a month, residents would like to get a video game. No follow up was reviewed, documented, or included. For the question asked if the facility addresses grievances, the answer was left blank, indicating it was not reviewed. Review of the Resident Council Meeting Minutes, dated 11/13/25, indicated no issues were discussed, no resident concerns were documented or reviewed, and no follow-up created. Review of the Resident Council Meeting Minutes, dated 12/9/25, indicated the residents would like more soup with meals, tomato and grilled cheese options, and would like to have a social event once a month with food. No follow up was reviewed, documented, or included.On 1/15/26 at 11:00 A.M., the surveyor held a Resident group meeting with 13 residents in attendance. The residents had the following concerns:7 out of 13 residents said they only discuss the activities department at Resident Council. 4 out of 13 residents said no one reviews the outcome of previously discussed concerns.5 out of 13 residents said they are unsure of the grievance process or the process for follow-up from requests made from Resident Council. During an interview on 1/14/26 at 4:10 P.M., the Activity Director said she verbally discusses any issue that arises at Resident Council with the appropriate department head. She said she doesn't have a way to track the follow-up from the department heads and bring it to the Resident Council Group meeting. She said she has never initiated a grievance form from a complaint at Resident Council. She said she does get complaints and issues, but she resolves the issues. She said for example there was a resident who was missing a shirt and she gave her one of hers. She said there is no way to track the completion and resolution of grievances or concerns. She said she verbally follows up with the residents if she receives an answer from the previous concerns at the following Resident Council Meeting. She said she was aware of the same topics being brought up multiple times with no follow-up indicated.During an interview on 1/15/26 at 2:15 P.M., the Director of Clinical Operations said she expects the staff responsible for facilitating Resident Council to address concerns across all departments and follow a process to initiate responses to provide the Resident Council Group. She said she would expect the Activity Director would be initiating grievances when residents voice a complaint or a group concern, she would expect there to be written follow-up from the department head. She said the Activity Director is responsible for this process and reporting back the responses.

Based on interview and document review, the facility failed to ensure residents had the right to voice and formulate grievances, have those grievances responded to promptly, and be provided a resolution to their grievance. Specifically, the facility failed to:1. Ensure residents had access to grievance forms and were aware they could formulate grievances anonymously, should they choose not to alert a staff member of their concern(s); and2. Maintain evidence demonstrating the results of all grievances for a period of no less than three years from the issuance of the grievance decision.Findings include: Review of the facility's policy titled Grievances, last revised 2/24, indicated but was not limited to the following:Guidelines:-The administrator is identified as the grievance official responsible for oversight of the grievance process in the facility. This includes responsibility for reviewing and tracking grievances, necessary investigating, ensuring that grievances are addressed and a response provided.-Any resident, and/or health care representative, family member, employee, or appointed advocate may file a grievance without fear of discrimination or reprisal in any form.Procedure:-If a resident, and or health care representative, or another interested family member of a resident has a complaint, a staff member will inform the person of the grievance process and assist the resident, or person acting on the resident's behalf, to file a written grievance with the facility using the grievance form as needed.-If the person filing the grievance is anonymous or wishes to remain anonymous confidentiality will be maintained, to the extent possible.-Upon receipt of a written grievance the Administrator will refer it to the appropriate department head for investigation. The department head will submit a response of the findings to the Administrator.-The Administrator will review the findings with the person investigating the grievance to determine what corrective actions need to be made.-Evidence of results of grievances will be maintained for three years.On 1/14/26 at 11:00 A.M., the surveyor held a Resident group meeting with 13 residents in attendance. The residents reported the following concerns:-11 out of 13 residents were not sure of the process for completing a grievance form, where they were located, or who the grievance officer was.-9 out of 13 residents were not sure what would be considered a grievance or how to formulate a grievance anonymously.On 1/15/26 at 12:30 P.M., the surveyor toured the building and failed to find information on the grievance process posted in the building.The surveyor observed an empty green folder in the lobby labeled grievances at the following times:-1/14/26 at 7:37 A.M.,-1/15/26 at 8:08 A.M-1/15/26 at 1:08 P.M.On 1/14/26 at 2:00 P.M., the surveyor toured the building and failed to find information on how to file a grievance, a way for residents to file a grievance anonymously, and the person responsible for the grievance process. During an interview on 1/14/26 at 4:51 P.M., Nurse #4 said the grievance forms are kept behind the enclosed nurses' station and she would give a resident a form if they asked for a grievance form. She said they are not accessible for the residents or visitors to obtain on their own. During an interview on 1/14/26 at 4:48 P.M., Nurse #1 said the grievance forms were behind the nurses' station on South 2 and were not accessible to residents without asking staff for assistance. She said residents have the ability to voice grievances verbally to staff and then the staff would interpret if they thought it is a complaint or a grievance and fill out a grievance form if warranted. She wasn't sure what the difference would be between a complaint or grievance, but she said not every complaint is a grievance but could not offer an example of what she meant. She said she was not sure who the grievance officer was in the building or the process. She said she would investigate to see if a grievance was valid and bring it to the social worker's attention or bring it up during the morning clinical meeting. She was unable to define or elaborate on what valid meant. During an interview on 1/14/26 at 4:10 P.M., the Activities Director said she was unsure of where to find a grievance form, and she believed they were obtained through the social worker. She said she was not sure of the grievance process. She said she was not sure how a resident would file a grievance anonymously if they have to ask for a grievance form from staff. She said she was not sure who is responsible for ensuring grievance forms are available for residents and visitors. During an interview on 1/15/26 at 1:20 P.M., the Administrator said he is the grievance officer and expects staff are assisting residents with grievances. He said he expects there are grievance forms available for residents and visitors to easily access and they should be able to file a grievance anonymously. He said he wasn't aware there wasn't a process in place for grievances to be filed anonymously. During an interview on 1/15/26 at 2:00 P.M., the Director of Clinical Operations said grievance forms should be readily available for residents and visitors, and they should be able to file grievances anonymously if they want. She said there should be information on the grievance process available for visitors and residents. 2. Review of facility grievances failed to indicate there were three years of resolved grievances. The facility was unable to provide grievances before the date of 1/2025.Facility staff provided the surveyor with a grievance book dated 2025 which indicated grievances starting in May 2025 through December 2025. During an interview on 1/14/26 at 3:00 P.M., the Administrator said he would look for three years of resolved grievances. During an interview on 1/15/26 at 1:20 P.M., the Administrator said he was able to find a few more grievances, but they were from the previous year. He said he was unable to find any additional grievances. He said he expects all grievance records to be retained.During an interview on 1/15/26 at 2:15 P.M., the Director of Clinical Operations said she expects that grievances are retained for three years after the resolution date.

Based on observations, interviews, and record review, the facility failed to ensure one Resident (#8), out of a total sample of 23 residents, received care and treatment in accordance with professional standards. Specifically, the facility failed to ensure a physician's order to increase Trazodone (antidepressant/used for behavior management) was transcribed into the electronic medical record and implemented. Findings include: Review of the Lippincott Manual of Nursing Practice, 11th Edition (2019) indicated: Scope of Practice, Licensure, and Certification: The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. The National Council of State Boards of Nursing and the National League of Nursing have developed standards that guide each State Board in the development of their licensure requirements and scope of practice rules. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice dated as revised April 11, 2018, indicated but was not limited to the following:Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Resident #8 was admitted to the facility in June 2025 with diagnoses which included depression, vascular dementia with or without behavioral disturbances, and Alzheimer's dementia. Review of the Minimum Data Set (MDS) Assessment, dated 12/19/25, indicated Resident #8 scored 3 out of 15 on the Brief Interview for Mental Status (BIMS) Assessment indicating he/she had severe cognitive impairment, was feeling down and depressed, and was administered antidepressant and antipsychotic medications. Review of the Active Physician's Orders in the electronic medical record indicated but were not limited to the following:-Trazodone 50 milligrams (mg) give 0.5 tablet by mouth two times daily (10/31/25) Review of the handwritten Physician's Orders in the paper medical record indicated but were not limited to the following:-11/18/25: Discontinue Trazodone 25mg twice daily (BID) and start Trazodone 50mg BID.-The order was written and signed by the Nurse Practitioner (NP). Review of the Medication Administration Records (MAR) from 11/18/25 through review on this day (1/16/26) indicated Resident #8 received Trazodone 25mg BID daily and not Trazodone 50mg BID as ordered on 11/18/25. Review of the psychiatric progress note, dated 11/25/25, indicated the reason for the visit was for a follow up after a Trazodone dose increase. The assessment indicated Resident #8 recently had a recommendation for an increase in Trazodone, which was not initiated because they were waiting for approval from the spouse. Additionally, he/she had been compliant with medication but sometimes was resistant to care. Review of the medical record indicated his/her Health Care Proxy (HCP) had been activated on admission and his/her spouse was not the activated Health Care Proxy (HCP) on file. Review of the progress notes failed to indicate why the order was not transcribed and implemented as ordered. During an interview on 1/15/26 at 10:15 A.M., Nurse #2 said handwritten orders are usually flagged if they need to be entered into the computer and he was not sure why this was never done. During an interview on 1/16/26 at 12:55 P.M., the Director of Nurses (DON) and Consulting Staff #2 said all orders written in the paper chart should be taken off and transcribed into the electronic medical record. They said they did not know why this order had not been taken off for almost three months. The DON said he thought the night shift was checking for missed orders, but there was not an actual process in place, and they don't document chart checks anymore. He said there is not a good system in place to make sure orders are not missed, because some orders go directly into the computer and others get written down and flagged for the nurses to take off and enter into the computer. During an interview on 1/16/26 at 2:35 P.M., Nurse #1 said the physician's orders in the paper chart are usually flagged and then the nurse on duty that shift takes the order off and enters it into the computer. She said she was not sure why this was never done.

Based on record review and interview, the facility failed to ensure that the necessary vision services were provided for one Resident (#1), out of a total sample of 23 residents. Findings include: The facility indicated they did not have a policy for Consultant Providers. Resident #1 was admitted to the facility in August 2025 with diagnoses which included diabetes mellitus with neuropathy, ketoacidosis, foot ulcer, and hyperglycemia. Review of the Minimum Data Set (MDS) Assessment, dated 11/21/25, indicated Resident #1 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) Assessment indicating he/she was cognitively intact. During an interview on 1/13/26 at 10:15 A.M., the surveyor observed Resident #1 wearing glasses. Resident #1 said he/she signed the consent for vision services and was told the eye doctor would see him/her at the facility. The Resident said his/her vision is so bad and it keeps getting worse. The Resident said he/she keeps asking about the eye doctor but has gotten nothing but the run around for months, no one will tell him/her when the eye doctor is coming. The Resident said their vision is so blurry, the left eye is worse than the right, and he/she has the highest cheaters he/she can get at the local pharmacy. The Resident said he/she often takes pictures of things with their phone to enlarge it so they can try and read it with their glasses on otherwise they cannot read anything. Review of the medical record indicated Resident #1 signed a consent / Request for Eye Health Services dated 8/15/25. Review of the Physician's Orders indicated but were not limited to the following:-Consults: Audiology, Dental, Optometry or Ophthalmology, Podiatry, Psych services as needed. (8/15/25) Review of the Social Service progress note, dated 9/10/25, indicated Resident #1 requested to be seen by the eye doctor through the vision services provider and nursing was made aware of the request. Further review of the progress notes failed to indicate why Resident #1 had not been seen since August 2025 (five months), when they were going to be seen, or anything else related to a pending eye appointment. During an interview on 1/15/26 at 10:15 A.M., Nurse #2 said the Director of Nurses (DON) organizes communication with the vision services provider. He said he thought the eye doctor came every couple of months and was not sure when he was coming again. He said if a resident wants to be seen they just tell the DON and he ensures they are on the list. During an interview on 1/15/26 at 12:44 P.M., the DON said he coordinates eye doctor visits with the vision services provider. He said he gets an email about a week before they come with a list of who will be seen. He said he was not sure when the last visit was or when the next visit was. He was unable to retrieve any emails from his computer regarding the eye doctor. He said if a consent is signed it is faxed over to the vision services provider and they add them to the list. He said he just started to keep copies of the consents but did not have Resident #1's in his office. He called the vision services provider and requested the visit summary log from August 2025 through January 2026. Review of the Visit Summary Log from the vision services provider for the Optometrist failed to indicate Resident #1 had been seen between August 2025 and January 2026. Additionally, the visit log indicated the eye doctor had been to the facility nine times in the last five months. During an interview on 1/15/26 at 2:40 P.M., Consulting Staff #2 said she was not sure of the process at this facility as far as who oversaw coordinating services. She said he/she has signed consent, should have been seen, and was not seen. During an interview on 1/15/26 at 2:42 P.M., the DON said Resident #1 had not been seen by the vision services provider and he did not know why. He called the vision services provider and confirmed he/she had never been seen and said they were going to email him a form to fill out so they could be seen. During an interview on 1/15/26 at 2:50 P.M., Nurse #1 said she had an email with a list of residents who had not been seen by an optometrist and why. She said Resident #1 was not seen because of insurance. She provided the surveyor with a list of patients with a Do Not Treat (DNT) Status. The full report was 10 pages long. Resident #1 was on page 8, and it indicated he/she had a DNT status date of 9/12/25 for insurance reasons. She said she had not done anything to get him/her seen and had not followed up with the vision services provider. Review of the DNT list provided indicated if the resident should be seen, please submit a new Request for Services form or [Vision Services Provider Name] Attending Physician Request for Services and a face sheet. For questions to call and/or email the scheduling team. During an interview with Consulting Staff #2 and the DON on 1/15/26 at 2:50 P.M., Consulting Staff #2 said Resident #1 should have been seen but wasn't. She said regardless of insurance we as the facility need to provide the services required and that did not happen. She said the facility must authorize the visit. She said she was not sure who had been getting the communication from the vision services provider or the DNT list, but they need a better process as no one had attempted to resolve this for months.

Based on record review and interview, the facility failed to implement an antibiotic stewardship program which included antibiotic use protocols and monitoring of antibiotic use in accordance with the facility's antibiotic stewardship program. Findings include: Review of the Centers for Disease Control and Prevention (CDC) guidance titled The Core Elements of Antibiotic Stewardship for Nursing Homes, undated, indicated but was not limited to the following: - The purpose of an antibiotic stewardship program is to improve the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance.- Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.- The CDC recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use.- Any action taken to improve antibiotic use is expected to reduce adverse events, prevent emergence of resistance, and lead to better outcomes for residents in this setting. Review of the facility's policy titled Antibiotic Stewardship Program, dated as revised 1/2024, indicated but was not limited to the following:-The antibiotic Stewardship Program establishes antibiotic treatment recommendations to optimize antibiotic prescribing, monitoring, and communication of resident changes in condition(s) to improve resident outcomes related to antibiotic usage.-The antibiotic stewardship program purpose is to monitor the use of antibiotics in residents.-When a culture and sensitivity (C&S) is ordered lab results and the current clinical situation will be communicated to the provider as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued.-The Infection Preventionist (IP), or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics.-The IP will monitor overtime and report to the Director of Nursing (DON) as warranted: Measures antibiotic use and tracks antibiotic starts through use of the line listing and pharmacy reports; antibiotic susceptibility patterns (annual antibiogram data); negative outcomes or events related to antibiotic use During an interview on 1/14/26 at 7:59 A.M., the Infection Preventionist (IP) said the facility utilizes McGeer Criteria for infection (standardized, evidence-based definitions) to determine if an illness meets the criteria for antibiotic use. Review of the facility's Surveillance Sheets for December 2025 indicated but were not limited to the following: Resident #58 had a concern for a urinary tract infection (UTI) with an onset date of 12/16/25 and was placed on Vantin (antibiotic).Resident #58 had a concern for a UTI with an onset date of 12/31/25 and was placed on a Macrobid (antibiotic).Review of Resident #58's McGeer Criteria for Infection, dated 12/17/25, indicated the Resident had Suprapubic pain (discomfort in lower abdomen), new or marked increase in urgency and frequency. The McGeer Criteria did not include the microbiologic criteria (urine culture results) to determine if the concern met criteria for infection.Further review of the medical record failed to include any further McGeer Criteria for Infection.Review of Resident #58's progress notes indicated an antibiotic was initiated on 12/16/25 after a recent hospitalization with no urine culture documented. A nursing note for 12/18/25 was written after the concern for antibiotic usage was brought to the facility's attention by the hospital and indicated the antibiotic should be changed to Macrobid 100 milligrams (mg) by mouth twice a day for seven days.Further review of the December 2025 Surveillance Sheets failed to indicate Resident #58 was placed on an antibiotic on 12/18/25.Review of the nursing and physician progress notes from 12/19/25 through 12/27/25 failed to indicate a reasoning for continued antibiotic usage.Review of the nursing progress note, dated 12/29/25, indicated Resident #58 returned to the facility after a recent hospitalization and was placed on Macrobid 100 mg by mouth two times a day for a UTI for 7 days.Further review of the physician and nurse practitioner progress notes failed to indicate any reasoning for continued antibiotic usage.During an interview on 1/20/26 at 12:38 P.M., the IP said when a resident is prescribed an antibiotic, the McGeer Criteria for Infection is completed in the medical record. She said any nurse can complete the form. The IP said the McGeer criteria should have been completed for each antibiotic Resident #58 was started on and it was not done. The IP said she does not maintain the Antibiotic Stewardship Program. The IP said she does not follow up with the providers or physicians when antibiotics are prescribed. The IP said she assumes she should be maintaining the program, however, was not instructed to do so. The IP said she only documents antibiotic information on her surveillance sheets.During an interview on 1/20/26 at 3:12 P.M., the Director of Nursing (DON) said the Antibiotic Stewardship Program is maintained by the IP. He said his expectations are for her to inform the prescribers and document in the medical record when a resident does not meet antibiotic usage criteria. The DON said he was not aware the Antibiotic Stewardship Program was not being implemented.

Based on record review and interview, the facility failed to ensure one Resident (#24), out of a total sample of 23 residents, was invited to his/her care planning meetings to participate in their plan of care.Findings include:Review of facility's policy titled Care Plans, Comprehensive Person-Centered, last revised on 1/24, indicated but was not limited to the following:-The resident will be informed of his or her right to participate in his or her treatment.-The interdisciplinary team (IDT) may include: the provider, the nurse responsible for the resident, the aide responsible for the resident, nutrition staff, the resident and the resident's legal representative, and other appropriate staff as determined by the resident's needs or as requested by the resident. Resident #24 was admitted to the facility in November 2025 with diagnoses including chronic obstructive pulmonary disease and emphysema.Review of the Minimum Data Set (MDS) assessment, dated 10/24/25, indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating that the Resident is cognitively intact.During an interview on 1/13/26 at 11:21 A.M., Resident #24 said he/she has not been invited to their care conference or any meetings with the interdisciplinary team to discuss their plan of care. Review of Resident #24's Care Plan Meeting Notes, dated 11/12/25 and 8/19/25, included no information relative to:-Whether the Resident and/or his/her Representative were invited to attend the meetings.-Whether the Resident and/or his/her Representative attended or did not attend the meetings.-Which members of the facility staff attended the meetings.During an interview on 1/14/26 at 4:10 P.M., the Activities Director said she used to attend care plan meetings prior to the previous social worker leaving in November. She said she isn't sure who coordinates the meetings now. She said she has not attended a care plan meeting since the new social workers started. During an interview on 1/15/26 at 12:11 P.M., Social Worker #2 said she expects residents and their representatives to participate in their care plan meetings. She said she thinks they are invited but is not sure of the process. She said Social Worker #1 is responsible for the care plan process.During an interview on 1/15/26 at 12:26 P.M., Social Worker #1 said she mails out invitations to the resident's responsible parties. She said she assumes the receptionist delivers the invitations to residents who are their own responsible person. She expects that Resident #24 would have received an invitation.During an interview on 1/15/26 at 10:27 A.M., the MDS Coordinator said she is not sure the process for inviting residents to their care plan meetings. She said she provides a list to each department for when the meeting should be scheduled but is unsure of the process for inviting residents who are their own responsible person.During an interview on 1/15/26 at 10:27 A.M., the Receptionist said the social workers are responsible for inviting residents who are their own responsible person. She said she isn't sure of which residents should receive an invitation. She said she hands the envelopes to mail to the postal worker to invite the resident representatives. During an interview on 1/15/26 at 2:15 P.M., the Director of Clinical Operations said she expects residents to be invited to participate in their care plan meetings and there needs to be a process in place for ensuring residents and their representatives are invited. She said she would expect Resident #24 to have been able to participate in their care plan meetings.

Based on record reviews and interviews, the facility failed to ensure one Resident (#8), out of a total sample of 23 residents, was free from unnecessary psychotropic medications by ensuring an as needed (PRN) dose of Zyprexa (antipsychotic) was limited to 14 days. Findings include: Review of the facility's policy titled Psychotropic Medication, dated as last revised July 2023, indicated but was not limited to the following:-Psychotropic medications will be prescribed at the lowest possible dosage and are subject to gradual dose reductions and re-review as needed.-The need to continue PRN orders for psychotropic medications beyond 14 days require that the practitioner document the rationale for the extended orders, the duration of the PRN order will be indicated in the order.-PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the health care practitioner has evaluated the resident for appropriateness of that medication. Resident #8 was admitted to the facility in June 2025 with diagnoses which included depression, vascular dementia with or without behavioral disturbances, and Alzheimer's dementia. Review of the Minimum Data Set (MDS) Assessment, dated 12/19/25, indicated he/she scored 3 out of 15 on the Brief Interview for Mental Status (BIMS) Assessment, indicating he/she had severe cognitive impairment, was feeling down and depressed, and was administered antidepressant and antipsychotic medications. Review of the Physician's Orders indicated but were not limited to the following:-Olanzapine (Zyprexa) Oral Tablet Disintegrating 5 milligrams (mg) give one tablet by mouth every 12 hours as needed for agitation or hallucinations (start date 6/18/25 and discontinue date 8/13/25). Review of the Medication Administration Records (MAR) from June through August 2025 indicated the following:-The order for Olanzapine did not have a 14-day stop date as required.-The order for Olanzapine was active for 57 days.-Resident #8 received the medication 4 times after the initial 14 days. Review of the medical record, including progress notes, failed to indicate the provider evaluated and extended the PRN order for an additional 14 days at each 14-day interval. The order remained active with an indefinite end date for 57 days. During an interview on 1/15/26 at 10:15 A.M., Nurse #2 said PRN psychotropic orders should be limited to 14 days and then reviewed by the physician, and he was unsure why this order was active for so long. During an interview on 1/16/26 at 12:55 P.M., the Director of Nurses (DON) and Consulting Staff #2 said all PRN orders for antipsychotics should be limited to 14 days and this one was not. Additionally, Consulting Staff #2 said the dashboard should be reviewed daily to ensure accuracy of orders and there needs to be a better system in place. During an interview on 1/16/26 at 2:35 P.M., Nurse #1 said PRN psychotropic orders should be limited to 14 days. She said she did not know why this order was active for so long.

Based on document review and interview, the facility failed to ensure that monthly Medication Regimen Reviews (MRR) were addressed and implemented in a timely manner for one Resident (#6), out of a total sample of 23 residents. Specifically, the facility failed to ensure a recommendation by the pharmacy consultant to obtain a Vitamin D level to consider tapering down the Vitamin D dose and signed by the physician was reviewed by nursing, transcribed, and implemented per the provider's order. Findings include: Review of the facility's policy titled Medication Regimen Review, dated 8/2020, indicated but was not limited to the following:-The consultant pharmacist identifies irregularities.-Resident specific irregularities and/or clinically significant risks resulting from or associated with medications are documented in the resident's active record and reported to the Director of Nurses (DON), Medical Director, and/or prescriber as appropriate.-Recommendations are acted upon and documented by the facility staff and/or the prescriber.-The DON or designated licensed nurse address and document recommendations. Resident #6 was admitted to the facility in October 2021 with diagnoses which include osteoporosis, nutritional deficiency, and disorder of bone density. Review of the Consultant Pharmacist Recommendation to Prescriber, dated 7/17/25, indicated the following:-The Resident has been receiving Vitamin D 50,000 units once weekly since 2023. This is typically a loading dose that can be tapered down. Please consider evaluating a Vitamin D level to see if the frequency can be reduced to once or twice monthly.-The physician signed and dated the report on 7/25/25 and indicated they agreed with the recommendation and ordered a Vitamin D level. Review of the medical record, including notes, orders, and labs, failed to indicate nursing had transcribed the order and scheduled the lab draw. Review of the Consultant Pharmacist Recommendation to Prescriber, dated 8/19/25, indicated the following:-The Resident has been receiving Vitamin D 50,000 units once weekly since 2023. This is typically a loading dose that can be tapered down. Please consider evaluating a Vitamin D level to see if the frequency can be reduced to once or twice monthly.-Reissued-Unable to locate response.- Done in July was handwritten above the provider response section of the form.-The form was unsigned by the physician. Review of the medical record, including notes, orders, and labs, failed to indicate nursing had transcribed the order and scheduled the lab draw prior to the recommendation being reissued. Review of the Lab order, dated 8/28/25, indicated check a Vitamin D level. Review of the Lab result, dated 8/29/25, indicated the lab was drawn at 11:42 A.M. and resulted at 3:25 P.M. Review of the Physician's Orders indicated on 9/1/25 the physician changed the Vitamin D order. During an interview on 1/16/26 at 1:28 P.M., the DON said he prints the recommendations and the nursing supervisor completes them. He said after the physician reviews and signs them nursing writes the orders. He said he does not oversee the process to ensure they are completed and was not sure why the order for the lab was not transcribed in July as it should have been and the lab not booked until after it was repeated. Additionally, he said the August recommendation was blank when he pulled it out and he just wrote Done in July on the blank recommendation when he provided the copy to the surveyor yesterday afternoon. He said he did not check to ensure it was done in July, he just assumed it was because the July recommendation was signed. He said he does not have a process to ensure the recommendations are followed up on, he just assumes they are taken care of. During an interview on 1/16/26 at 1:28 P.M., Consulting Staff #2 said the order for the 8/29/25 Lab was written on 8/28/25 after the recommendation was repeated. She said she was not sure why it was not done when the provider signed the first recommendation on 7/25/25 as it should have been. Additionally, she said there is not a process in place to ensure completion and there should be. During an interview on 1/16/26 at 2:35 P.M., Nurse #1 said she prints the recommendations, sorts them by doctor, gives them to the doctors, and then writes the orders, but does not have a system to make sure every single one is addressed. She said she was not here in July and was not sure why this order was never written.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure four of four kitchenettes were maintained in a clean, sanitary condition. Findings include: Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: 3-305.11 (A) Except as specified in paragraphs (B) and (C) of this section, food shall be protected from contamination by storing the food (1) in a clean, dry location. 4-602.13 Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 6-101.11 Surface Characteristics. (A) Except as specified in (B) of this section, materials for indoor floor, wall, and ceiling surfaces under conditions of normal use shall be: (1) SMOOTH, durable, and EASILY CLEANABLE for areas where FOOD ESTABLISHMENT operations are conducted. On 1/14/26, the surveyor made the following observations in the unit kitchenettes: 7:30 A.M. North 2 Unit-corner floor area with TV mount, box, and bag of clothes with a sizeable amount of mouse droppings underneath-one package peanut butter crackers, condiment packets between refrigerator and wall 7:40 A.M. South 2 Unit-missing floor tile in one corner at the floor/wall junction containing buildup of crumbs and debris 11:17 A.M. North 1 Unit-grout at floor/wall junction receded and collecting debris, crumbs, and buildup-missing floor tile-water bottle, condiment packets on floor between refrigerator and wall-paper towels and cups behind refrigerator 11:26 A.M. South 1 Unit-one package peanut butter crackers, condiment packets, broken tile pieces, and debris behind the refrigerator-broken tile in areas around perimeter of floor/wall junction-receding grout at floor/wall junction with debris buildup including mouse droppings During an interview on 1/14/26 at 2:00 P.M., the Corporate Food Service Director (FSD) said the expectation was for kitchenette floors to be kept clean and sanitary. During an interview on 1/20/26 at 2:00 P.M., the surveyor reviewed with the Director of Clinical Operations (DCO) photos of unit kitchenettes which included missing floor tile, receding grout, mouse droppings, buildup and debris (including cups, napkins, condiment packets, packages of peanut butter crackers). The DCO said she expected kitchenettes floors to be maintained in a clean and sanitary condition with no missing tiles or receding grout that harbors debris. During an interview on 01/20/26 at 2:49 P.M., the Housekeeping Manager (HM) said housekeeping staff checked kitchenettes on a daily basis, two to three times per day, and performed tasks such as taking out the trash, cleaning surfaces, and sweeping and mopping the floor. The HM said kitchenette floors should be kept clean and sanitary and should not have a buildup of debris or mouse droppings.

Based on record review and interview, the facility failed to provide written documentation related to transfer discharge notices and bed hold policy to the responsible person/invoked Health Care Proxy (HCP) upon five hospitalizations for one Resident (#8), out of a total of 23 sampled residents. Findings include: Review of the facility's policy titled Transfer and Discharge Documentation, dated as last revised 7/2024, indicated if a resident was being transferred or discharged because his/her needs cannot be met at the facility, documentation will include: The specific resident needs that cannot be met and that appropriate notice was provided to the resident and/or legal guardian. Resident #8 was admitted to the facility in June 2025 with diagnoses which include depression, vascular dementia with or without behavioral disturbances, and Alzheimer's dementia. Review of the Minimum Data Set (MDS) Assessment, dated 12/19/25, indicated Resident #8 scored 3 out of 15 on the Brief Interview for Mental Status (BIMS) Assessment, indicating he/she had severe cognitive impairment. Review of the Physician's Orders indicated Resident #8's HCP had been invoked on 6/17/25. Review of medical record census report indicated Resident #8 was transferred to the hospital five times between June and October 2025 (once each in June, July, and October, and twice in August). Review of the Discharge/Transfer Evaluations indicated but were not limited to the following:-June 2025: failed to indicate the HCP was provided a copy of the Bed Hold Policy and Notice of Transfer/Discharge.-July 2025: failed to indicate the HCP was provided a copy of the Bed Hold Policy and Notice of Transfer/Discharge.-August 2025 Transfer 1: failed to indicate the HCP was provided a copy of the Bed Hold Policy and Notice of Transfer/Discharge.-August 2025 Transfer 2: failed to indicate the facility completed the Discharge/Transfer Evaluations for this transfer.-October 2025: failed to indicate the HCP was provided a copy of the Notice of Transfer/Discharge. During an interview on 1/15/26 at 10:15 A.M., Nurse #2 said when a resident goes to the hospital the transfer/discharge notice and bed hold notice are part of the referral under evals and the nurse that is sending them out completes it with the HCP. During an interview on 1/16/26 at 12:46 P.M., the Director of Nurses (DON) and Consulting Staff #2 said the Transfer/Discharge and Bed Hold Notices should have been given to the HCP each time Resident #8 went to the hospital. Additionally, they said the boxes in the eval should have been checked and the name of who the notice was given to should be documented on each referral and they were incomplete. They said if the HCP is not in the building, then the nurse should call the HCP and email or mail the notices. The DON said the Social Worker (SW) should be following up to ensure they were sent to the correct person. During an interview on 1/16/26 at 2:35 P.M., Nurse #1 said the bed hold and transfer/discharge notices go to the HCP and that should be documented on the referral/evaluation. She said she thinks the SW usually follows up the next day to ensure they went out but she was not sure. During an interview on 1/15/26 at 12:11 P.M., Social Worker (SW) #2 said she mostly focuses on the MDS Assessments and the Evaluations because she was only in the building a couple days a week while SW #1 took on the Director role about a month ago. SW #2 said she and SW #1 are still figuring out everything that needs to be done and who is doing what with regard to paperwork versus the day to day follow up with resident issues. She said it is a work in progress right now.

Based on observation, interview, record review, and facility document review, the facility failed to ensure one Resident (#82), out of a total sample of 23 residents received food prepared in a form to meet the resident's individual dietary needs. Specifically, the facility failed to upgrade his/her diet per the Speech Language Pathologist (SLP) order for 14 days. Findings include: Review of the facility's policy titled Therapeutic Diets and Meal Plans, dated as last revised 6/2018, indicated but was not limited to the following:-The attending physician, license non-physician provider, or registered or licensed dietician with physician approval and as allowable by State Law, prescribe therapeutic diets.-Mechanically Altered Diet means one in which the texture of a diet is altered. When the texture is modified, the type of texture modification must be specific and part of the physician's or delegated registered or licensed dietician order.-The Speech Language Pathologist (SLP) may be consulted for evaluation of mechanically altered diets.-A physician's order is obtained for the appropriate therapeutic meal plan and/or mechanically altered diet.-A resident's therapeutic meal plan and/or mechanically altered diet is documented on the tray card, tray ticket, or individualized menu as a means of communication to the staff the prescribed diet.-Diet orders are written to conform to the terminology in the approved diet manual and therapeutic menu.-Diet orders that don't match the facility's standard terminology will be evaluated by the Registered Dietician (RD) to have then revised to the standard terminology. Review of the Menu Guide: [Corporate Name], dated Fall/Winter 2024/2025 indicated but was not limited to the following:-International Dysphagia Diet Standardization Initiative (IDDSI) Food Level 5/Minced and Moist Diet/(MM5) includes foods that are easy to swallow with no separate thin liquids because they are minced, soft, and moist and can be scooped and shaped. Review of the facility's Diet Texture Comparison Chart, dated September 2023, indicated but was not limited to the following:-IDDSI Diet: MM5 (minced and moist) / [Corporate Name] Diet: Dysphagia Mechanical.-All Diet orders must be written as [Corporate Name] diet orders.-Any resident admitted on an IDDSI diet must be evaluated by SLP to confirm appropriate [Corporate Name] diet order.-This chart is only to be used to convert an IDDSI Diet order to the safest texture until the resident is evaluated by SLP. Resident #82 was admitted to the facility in October 2025 with diagnoses which include obesity, dysphagia, and pneumonitis due to inhalation of food and vomit. Review of the Minimum Data Set (MDS) Assessment, dated 11/27/25, indicated Resident #82 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact and was on a mechanically altered diet. On 1/13/26 at 12:15 P.M., the surveyor observed Resident #82 sitting in bed with a pureed lunch meal in front of him/her. During an interview on 1/13/26 at 2:40 P.M., Resident #82 said he/she was still on a puree diet, did not know why, they wanted it changed, and said the pureed food is not good. The Resident said he/she only gets real food with the speech therapist like once a week. On 1/14/26 at 8:26 A.M., the surveyor observed Resident #82 sitting in bed with his/her breakfast tray in front of them. The plate had pureed pancakes and eggs on it. The meal ticket indicated his/her diet order was puree, No Added Salt (NAS), thin liquids. Resident #82 said their diet was supposed to be upgraded, but he/she gets the same stuff every day. Review of the SLP progress notes indicated but were not limited to the following:-1/2/26: Will upgrade to minced and moist consistency diet.-1/6/26: He/she is safest of Minced and Moist at this time. Review of the Active Physician's Orders indicated the following:-NAS Diet, Puree texture, thin liquids consistency. (11/25/25)-Discontinue (D/C) Pureed Diet. Upgrade diet to Minced and Moist Consistency. (1/2/26) Further review of the Diet Order to Upgrade diet to Minced and Moist indicated the following:-The order was written by the SLP.-The order category was entered as Other.-The order was signed by nursing and the physician. During an interview on 1/15/26 at 10:15 A.M., Nurse #1 said diet orders should be entered into the computer as a Diet order, not in the Other category. He said then the previous order should be discontinued and a diet slip filled out and sent to the kitchen to notify them of the change. He said in this case the new order was entered into the wrong category, the previous order was never discontinued, and the diet slip was never sent to the kitchen. He said Resident #83 has two conflicting active orders and he would have to clarify and fix them. Review of the nursing progress note, dated 1/15/26 at 1:44 P.M., indicated Nurse #1 was advised by the Dietician that the facility did not have a Minced and Moist consistency diet and he/she was to remain on pureed diet until re-evaluated by SLP. During an interview on 1/16/26 at 12:28 P.M., the Director of Nurses (DON) and Consulting Staff #2 said when SLP enters a new diet order the nurse is supposed to confirm it, complete and sign the new order, discontinue the previous order, and send the diet slip to the kitchen. They said these things did not happen. During an interview on 1/16/26 at 4:00 P.M., SLP/Rehab Staff #1 said the Minced and Moist diet converts to the facility Dysphagia Mechanical and that is what he recommended and thought Resident had been on for the last two weeks. He said no one from the facility had reached out to clarify the diet and he did not know why they did not implement the order properly. He said he normally writes the order; the nurse adjusts and clarifies it if needed, discontinues the previous order, and notifies the kitchen. He said he sees Resident #82 regularly, but he gets a regular solid consistency tray for food trials in place of what the kitchen had on the tray ticket, so he does not see what the tray ticket has printed on it. During an interview on 1/20/26 at 1:20 P.M., Corporate Food Service Manager (FSM)/Consulting Staff #4 said the IDDSI Minced and Moist Diet would convert to the [Corporate Name] Dysphagia Mechanical diet and the facility does offer that diet. During an interview on 1/20/26 at 1:20 P.M., Consulting Staff #2 said they do offer the Dysphagia Mechanical diet which is what the Minced and Moist would convert to.

Based on record reviews and interviews for one of three sampled residents (Resident #1), who had a Physician's Order for weekly weights times four (4) weeks, the Facility failed to ensure nursing provided care and services that met professional standards of quality, when his/her weights were not obtained per his/her Physician Order.Findings include:Review of the Facility Policy titled Weight Measurement, dated as last revised 04/2019, indicated each resident's weight will be obtained on admission and then weekly times four (4) weeks, subsequent weights will be monthly, unless physician's orders warrant more frequent.The Policy also indicated that the Registered Dietician will be the responsible for determining the desirable body weight range and will be documented on the initial medical nutrition therapy (MNT) assessment and reassessment.Review of the Facility Policy titled Medication and Treatment Orders, dated as last revised, 09/2024, indicated all orders for medication and treatments will be consistent with regulatory standards.The Policy further indicated medications and treatments shall be administered upon the written order of a person licensed and authorized.Resident #1 was admitted to the Facility in June 2025 diagnoses include an acute Cerebral Vascular Accident (CVA), Aphasia (language disorder that affects the ability to communicate), Heart Failure, Subarachnoid Hemorrhage (brain bleed), and Myocardial Infarction (MI).Review of Resident #1's Nutrition admission Assessment (written by the Registered Dietician (RD), dated 07/01/25, indicated that his/her sodium (Na) was 146 which was high (normal range 133-145), and staff were to encourage fluids especially since Resident #1 was taking diuretics (medication that increases urine output by the excretion of fluids and electrolytes from the body).The Assessment also indicated that the RD recommended that nursing was to obtain Resident #1's weight weekly times four (4) weeks.Review of Resident #1's Physician's Order, dated 07/01/25, indicated that nursing was to obtain his/her weight weekly times 4 weeks. Review of Resident #1's Treatment Administration Record (TAR), dated 07/01/25 through 07/18/25, indicated on 07/02/25 nursing staff obtained and documented that Resident #1 weighed 176 pounds.Review of Resident #1's Medical Record, including but not limited to nutrition notes, TAR, progress notes, care plans and physician notes, indicated that there was no documentation to support nursing obtained Resident #1's weights (due 07/09/25 and 07/16/25) as ordered by his/her physician.During a telephone interview on 10/01/25 at 1:37 P.M., the Registered Dietician (RD) said that she recommended that nursing monitor Resident #1's weight's weekly times 4 weeks due to Resident #1's high sodium level, poor oral intake, and because he/she was being administered 2 diuretics daily. The RD said she was not aware that nursing had not obtained weekly weights after obtaining the physician's order.During an interview on 09/30/25 at 3:33 P.M., the Evening Supervisor said that he could not locate Resident #1's weekly weights (due 07/09/25 and 07/16/25) and was unaware that nursing staff had not obtained Resident #1's weight as ordered. During an interview on 09/30/25 at 4:13 P.M., the Director of Nurses (DON) said that he was unaware that Resident #1 had a physician's order to obtain weekly weights times 4 weeks and said he could not locate any weights other than the weight obtained on 07/02/25.The DON said that it is the Facility's expectation that all nurses follow through with all physician's orders and if unable to do so, the nurse is to inform the DON and the Provider for additional guidance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had an activated Health Care Agent (HCA), the Facility failed to ensure that his/her HCA received written notice, including the reason for the change, when on 12/13/24 Resident #1's was moved to a new room without obtaining consent from and notifying his/her HCA of the room change. Findings include: Resident #1 was admitted to the Facility in December 2024 diagnoses include bilateral pulmonary embolisms (blood clots), left lower extremity deep vein thrombosis (blood clot), low back pain, and dementia. Review of Resident #1's Physician's Orders, dated 12/02/24, indicated that his/her Health Care Agent (HCA) had been responsible for his/her health care decisions. Review of Resident #1's Admission Minimum Data Set (MS) Assessment, dated 12/08/24, indicated he/she had moderate cognitive impairment. Review of Resident #1's Nurse Progress Note (written by the Nursing Supervisor), dated 12/13/24, indicated that he/she had been moved to a new room, appears comfortable and he/she was adjusting well. During a telephone interview on 02/05/25 at 11:11 A.M., Resident #1's HCA said that the facility was aware that his/her Health Care Proxy had been invoked and said as Resident #1's HCA, the Facility did not notify him of the room change on 12/13/24, the reason for the change, or the chance to appeal the Facility's decision. Review of Resident #1's Medical Record indicated that on or before 12/13/24, there was no documentation to support that Resident #1 and his/her HCA had been notified of and had agreed to a room change, met with a new roommate prior to the move, or were aware of the reason for the room change. During an interview on 02/11/25 at 1:32 P.M., the Social Worker (SW) said that she was aware that Resident #1's HCA was his/her responsible party. The SW said she was not aware that Resident #1 had his/her room changed on 12/13/24. The SW said that she could not locate the appropriate paperwork required to properly move a resident's room in his/her medical record. During an interview on 02/11/25 at 12:51 P.M., the Nursing Supervisor said that he thought the SW had notified Resident #1's HCA of the room change and said he did not contact the HCA about his/her room change that happened on 12/13/24. During an interview on 02/11/25 at 4:26 P.M., the Assistant Director of Nurses (ADON, currently acting as the Director of Nurses (DON), said that he was not aware that on 12/13/24, Resident #1 had a room change. The ADON said the Social Service Department was responsible for completing the appropriate paperwork and also provide the resident/responsible party with the opportunity to appeal the decision related to the room change. The ADON said it is the Facility's expectation that before moving a resident's room, the resident and/or Responsible Party must be notified, written request/permission must be obtained, roommate(s) needs to be notified, and the reason for the room change must be provided.

Based on observations, interviews and records reviewed, for one of three sampled Residents (Resident #1), whose history included a traumatic subarachnoid hemorrhage without loss of consciousness and unspecified intracranial injury without loss of consciousness (traumatic brain injury/TBI), after being hit by a car as a pedestrian, who had limited attention/concentration and impaired judgement/insight, had a court appointed legal guardian, resided on a secured unit, and who was assessed and care planned for the need for staff supervision while smoking and using smoking materials, the Facility failed to ensure they provided an adequate level of staff to supervise the outside smoking area, as well as monitor and supervise the facility lobby during smoking break times to prevent an incident/accident, including an elopement. On 5/02/24, Resident #1, who was attending the 4:00 P.M., scheduled supervised smoke break group, was given a cigarette by the Nurse Supervisor, however he/she did not stay and wait with the other residents as they were getting their smoking materials, and when the Nurse Supervisor let Resident #3 (who was independent and could go out unsupervised to smoke) out the locked front door by releasing the electronic lock on the front door from the reception desk, unbeknownst to the Nurse Supervisor, Resident #1 and Resident #2 (who required supervision with smoking), also exited the Facility. After about one minute of being outside, unsupervised as there was no staff member outside in the smoking area, Resident #1 walked off Facility grounds and eloped from the facility. Resident #1 was not determined to be missing by staff until almost fifteen minutes later, when the smoke break ended. Resident #1's whereabouts were unknown for approximately nine days, and on 5/10/24, the Massachusetts Department of Mental Health informed the Facility that he/she checked him/herself into a Hospital Emergency Department about 13 miles away from the Facility. Findings include: Review of the Facility Policy titled Elopements, dated as established 1/2017, indicated that staff should promptly report any resident who tries to leave the premise and attempt to prevent the departure in a courteous manner. Review of the Facility Policy titled Smoking Policy-Residents, dated as last revised 3/2024, indicated that residents were evaluated on admission to determine the resident's ability to smoke safely with or without supervision. The Policy indicated residents who are supervised for smoking will be monitored by a staff member or designee during the smoking time. Review of the Report submitted by the Facility to the Department of Public Health (DPH) via the Health Care Facility Reporting System (HCFRS), dated 5/02/24, indicated that on 5/02/24 at 4:18 P.M., residents exited the Facility front door for the supervised smoking time and staff realized [after checking with staff on Resident #1's unit after the smoke break was over] that Resident #1 was not in the group. The Report indicated the inside of the Facility and the grounds were searched with the help of the police and Resident #1 was not found. Review of Resident #1's medical record indicated he/she had been admitted to the Facility during August 2023 with diagnoses which included history of a traumatic subarachnoid hemorrhage without loss of consciousness and unspecified intracranial injury without loss of consciousness (traumatic brain injury/TBI), and bilateral tibia (large lower leg bone) open fractures after being hit by a car in June 2023, as a pedestrian. The Record also indicated Resident #1 medical history included paranoid schizophrenia, delirium, alcohol use disorder and Substance Use Disorder related history of cocaine abuse, uncomplicated and homelessness. The Record also indicated that Resident #1 had a court ordered legal guardian in place as of August 2023. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 3/01/24, indicated Resident #1's cognitive patterns were severely impaired. Review of the Behavioral Health Group Medication Management Note, dated 4/03/24, indicated Resident #1 was seen at the Facility for psychiatric evaluation and medication management. The Note indicated Resident #1's diagnoses included paranoid schizophrenia, alcohol abuse and cocaine use. The Note indicated Resident #1's psychiatric history, including history of inpatient or outpatient behavioral health services, was unknown. The Note indicated that Resident #1 exhibited anxiety, psychosis, circumstantial and disorganized thoughts and impaired long-term memory. The Note indicated that Resident #1 had limited attention/concentration and impaired judgement/insight. Review of Resident #1's Smoking Assessments, dated 9/30/23 and 11/30/23. indicated he/she was safe to light smoking materials with staff supervision. Review of Resident #1's Care Plan related to Smoking, dated as initiated 10/20/23, indicated that Resident #1 was to be supervised by staff in designated areas when smoking. The Care Plan goal indicated that Resident #1 would follow smoking policies and procedures and interventions, and his/her safety during smoking would be monitored. Review of the May 02, 2024 facility video surveillance camera footage, showed the following: - at 16:21:30 (4:21:30 P.M.), Residents #1, Resident #2 (who required supervision with smoking) and Resident #3 exit through the Facility front door, - at 16:21:44 (4:21:44 P.M.) Residents #1 and Resident #2 exchange a lighter while standing on the front stairs and light their cigarettes, - at 16:22:00 (4:22:00 P.M.) Residents #1 and Resident #2 descend the stairs and Resident #1 walks away from the smoking area, turing left down the Facility driveway and out of the view of the video surveillance camera, and, - at 16:22:30 (4:22:30 P.M., one full minute after Resident #1 and Resident #2 exited the facility) the Nurse Supervisor exits the front door with additional residents and they proceed to the smoking area. Review of the May 02, 2024 video surveillance camera footage from a second facility video camera showed the following: - at 16:22:30 (4:22:30 P.M.) Resident #1 approaches the end of the Facility driveway and the main road, and, - at 16:22:40 (4:22:40 P.M.) Resident #1 turned left at the end of the driveway and out of view of the video surveillance camera. Review of the May 02, 2024, footage showed the Resident #1 walked the distance from the bottom of the Facility front stairs to the end of the driveway (and off of the Facility property) in 40 seconds. During an interview on 5/08/24 at 3:35 P.M., the Nurse Supervisor said that on 5/02/24 around 4:00 P.M., he was seated at the reception desk monitoring the lobby and the locked front door. The Nurse Supervisor said that as residents arrived for the 4:00 P.M. smoking break time, that he dispensed cigarettes to them from the reception desk. The Nurse Supervisor said that, at one point, he saw Resident #3 waiting at the front door. The Nurse Supervisor said Resident #3 was able to leave the Facility independently. The Nurse Supervisor said that he released the electronic lock on the front door, using the release button located at the reception desk, to allow Resident #3 to exit. The Nurse Supervisor said that his view of the front door was partially obstructed when he was seated at the reception desk, that he did not see Resident #1 or Resident #2 standing with Resident #3, when he let Resident #3 out. The Nurse Supervisor said a short time later, after he finished dispensing cigarettes, [per the May 02, 2024, video footage was at 16:22:30 (4:22:30 P.M.,)] he exited the lobby with the remaining residents to go out to the smoking area. The Nurse Supervisor said that once out in the smoking area, he then noticed that Resident #1 wasn't present. The Nurse Supervisor said that he asked the other residents where Resident #1 was and said they told him that Resident #1 had not come outside to smoke. The Nurse Supervisor said that although he remembered giving Resident #1 a cigarette for the 4:00 P.M. smoking break, had documented that he gave him/her a cigarette, said he second guessed himself and trusted that the residents were correct that Resident #1 had not come outside to smoke. Although the Nurse Supervisor had a cell phone on him, he did not call Resident #1's unit to check on him/her but instead, after the smoking break, he checked with the staff on the North 2 Unit (where Resident #1 resided) and they told him that Resident #1 had gone down to smoke. Further review of the May 02, 2024, facility video surveillance camera footage revealed that the Nurse Supervisor and all of the residents who had smoked, returned inside the Facility via the front door by 16:34:51 (4:34:51 P.M.) about 12 minutes after Resident #1 had left the premises, and by the time the Nurse Supervisor checked with staff on Resident #1's unit to see if he/she was there, more than 15 minutes had passed since he/she first exited the facility. The Nurse Supervisor said that he notified the Director of Nurses and the Administrator that Resident #1 was missing and a search of the Facility and grounds was initiated. Review of the Facility Elopement Risk Evaluation Form used by the Facility indicated that residents who have a history of Substance Abuse or Psychosis should be considered at risk for elopement and a care plan should be initiated. Elopement Risk Evaluations conducted by nursing during Resident #1's stay at the Facility indicated the following: - Resident #1's Elopement Risk Assessment, dated 8/03/23, indicated he/she had a Substance Abuse History and Diagnosis/History of Psychosis, that the review of all triggers determination for this assessment by indicated he/she was not at risk for elopement and an elopement care plan was not developed. - However, Resident #1's Elopement Risk Assessment, dated 10/07/23, again indicated he/she had a Substance Abuse History and the review of all triggers determination for this assessment indicated he/she was at risk for elopement and that a care plan should be developed per Facility Policy, but was not. - Resident #1's Elopement Risk Assessment, dated on 11/30/23, again indicated he/she had a Substance Abuse History and Diagnosis/History of Psychosis, the review of all triggers determination for this assessment indicated he/she was not at risk for elopement and an elopement care plan was not developed. - Resident #1's Elopement Risk Assessment, dated 2/26/24, again indicated he/she had a Substance Abuse History and Diagnosis/History of Psychosis, the review of all triggers determination for the assessment indicated he/she was not at risk for elopement and an elopement care plan was not developed. Review of Resident #1's Care Plans indicated there was no documentation to support nursing having developed a care plan to address Resident #1's elopement risk, per their Elopement Risk criteria. During an interview on 5/08/24 at 3:09 P.M., the MDS Nurse said that she reviewed Resident #1's care plans, including all care plans concerns which had been developed and resolved previously during his/her stay at the Facility, and said the Facility had not developed a care plan to address his/her risk of elopement at any time during his/her stay. During an interview on 5/08/24 at 9:20 A.M. the Director of Nursing said that around 4:40 P.M. on 5/02/24, the Nurse Supervisor reported that Resident #1 was missing. The Director of Nurse said she supervised the search of the Facility and grounds while the Administrator and the Nurse Supervisor reviewed video surveillance camera footage of the 4:00 P.M. smoking break to identify whether Resident #1 left the Facility grounds during the smoking time. The Director of Nursing said that when the Administrator and Nurse Supervisor told her that they identified footage of Resident #1 leaving the Facility grounds at the beginning of the 4:00 P.M., smoking break, she notified the local police that the Facility had a missing resident. Review of the Police Report, dated 5/02/24, indicated the Facility notified local police at 17:25 (5:25 P.M.) that Resident #1 was missing, (which was about an hour after he/she left Facility grounds while attending the supervised 4:00 P.M., smoking break, during which he/she required supervision to be provided by staff to monitor him/her for safety). The Director of Nursing said that, as of 5/09/24, Resident #1 remained missing, that local hospitals and shelters had been contacted, without locating him/her. On 5/10/24 the Facility was notified by the Department of Public Health via an email that Resident #1 went to a local Hospital Emergency Department and checked him/herself in because he/she was not feeling well, and he/she returned to the facility that same day. On 5/09/24, the Facility was found to be in Past Noncompliance and presented the Surveyor with a plan of correction (with an effective date of 5/06/24) that addressed the area(s) of concern as evidenced by: A) On 5/03/24, the Facility developed a new Smoking Supervision Plan which included two staff members would be assigned, ensuring the safety of smokers during every smoking break time, one staff member would be physically, continuously present outside in the smoking area supervising smokers/dispersing cigarettes and a second staff member would continuously be present in the Facility lobby supervising the reception area and residents, staff and visitors as they egress through the locked front door. B) On 5/03/24, the Facility developed and implemented a Supervised Smoking Form for the smoking supervisor to document which residents attended the smoking break time, the return of smoking materials to the staff member supervising smoking break and the return of all residents inside of the Facility after the smoking break time was over. C) On 5/03/24 through 5/06/24, Administrative and Clinicial Management reviewed the facility Elopement Policy and Risk Evalaution Form for purpose of revision. The Assistant Director of Nursing (ADON) provided education to licensed nursing staff regarding completion of the Elopement Risk Assessments, accuracy and evaluation of the assessment, identifying triggers for risk of elopement, and residents with SUD and/or Psychosis must be considered at risk for and care planned for elopement. D) On 5/03/24, the Director of Nursing initiated a change to the daily Staffing Schedule to assign particular nursing staff members for transport of residents who smoke from North 2 (the secure unit) to the smoking area at the start of each smoking break time. E) On 5/03/24, the Director of Nursing and Administrator initiated a plan for a leadership staff member (Administrator, Manager of the Day, nursing supervisor) to assign specific staff members to supervise the reception area and for staff, resident, visitor egress through the locked front door during each Facility smoking break time. F) On 5/03/24 and on-going, the Administrator, Director of Nursing and Assistant Director of Nurses trained all staff involved in the supervision of smokers (nursing, reception, activities) on the new Smoking Supervision Plan and the Supervised Smoking Form. G) On 5/03/24, the Administrator and/or Director of Nursing and/or their designee initiated interviews of staff members to be conducted five times weekly for two weeks to determine their understanding and compliance of the new Smoking Supervision Plan. H) On 5/03/24, the Administrator and/or Director of Nursing and/or their designee initiated that five observations to be conducted by administrative staff weekly for two weeks during the resident smoking break time, for compliance. I) On 5/03/24, the Director of Nursing and/or Administrator and/or their designee initiated administrative staff review of the Supervised Smoking Forms, at least five times a week for two weeks. J) The Administrator and/or Designee reviewed the corrective actions plans in an ad hoc QAPI meeting, and will continue to review for compliance, at QAPI to ensure compliance. K) The Administrator and/or Designee are responsible for overall compliance.

Based on observation, interviews and records reviewed, for one of three sampled Residents (Resident #1), who had a history of being homeless, with alcohol and substance abuse disorders, was assessed to be at risk for elopement and his/her care plan indicated he/she was to remain in the Facility unless supervised due to a history of elopement, the Facility failed to ensure staff consistently implemented and followed interventions from his/her Plans of Care related to Elopement and Smoking, for safety. On 10/01/23, Resident #1 left his/her secure second-floor unit (North 2), unsupervised and unbeknownst to staff, took the elevator down to the first floor lobby and exited the Facility through a locked front door. Once outside of the front door, Resident #1 walked around the area where residents were smoking for approximately three minutes unnoticed by staff, before leaving the Facility grounds. Resident #1's whereabouts were unknown for approximately thirty-two hours, during which time a serious adverse outcome was likely to occur. On 10/02/23, Resident #1 called 911 from a train station (which was located 10 miles away from the facility) responding Emergency Medical Services found him/her to be intoxicated and he/she was transported a local Hospital Emergency Department for evaluation and treatment, as needed. Findings included: The Facility Policy titled Comprehensive Assessments and the Care Delivery Process, dated as last revised 8/2019, indicated that comprehensive assessments will be conducted to assist in developing person-centered care plans. The Policy indicated that care plan interventions would be selected and implemented. Review of Resident #1's admission Minimum Data Set Assessment, dated 7/16/23, indicated his/her cognitive patterns were severely impaired. Review of the medical record indicated that Resident #1's Health Care Proxy had been activated during June 2023 due to permanent incapacity related to dementia. The medical record indicated Resident #1's diagnoses included insulin dependent diabetes, severe alcohol use disorder, opioid use disorder, cirrhosis, hepatic encephalopathy and age related cognitive decline. Review of the report submitted by the Facility via the Health Care Facility Reporting System (HCFRS) on 10/01/23 indicated that on 10/01/23, Resident #1, a resident who resided on a secure unit, eloped from the Facility through the main entrance. During an interview on 10/03/23 at 1:10 P.M., Resident #1 said that he/she left the Facility and said he/she was not sure where he/she went or how he/she got there. Review of Resident #1's Care Plan related to Elopement Risk, dated as initiated 8/29/23, indicated that Resident #1 was at risk for elopement due to decreased safety awareness, decreased cognition, and indicated that the goal was for Resident #1 to remain within the Facility unless supervised. Additional interventions, dated as initiated 8/29/23, indicated staff were to engage Resident #1 in a structured activity program, to photograph Resident #1 for the wander notebook and to redirect him/her as needed. Review of Resident #1's Care Plan related to Smoking, dated as initiated 7/18/23, indicated Resident #1 had been assessed to be a supervised smoker. Additional interventions, dated as initiated 7/18/23, indicated staff were to monitor Resident #1's safety during smoking. During interviews on: - 10/03/23 at 9:30 A.M. with the Administrator, - 10/03/23 at 4:35 P.M. with Nurse #1, and, - 10/05/23 at 3:28 P.M. with the Social Worker, they said the following: Resident #1 required staff supervision when he/she left the North 2 Unit and said staff would escort him/her to the smoking area at designated smoking times where he/she was supervised while smoking. The Administrator said that Resident #1 was admitted in July 2023 to North 2 (a secure unit on the second floor). Review of the Schedule for 10/01/23 indicated Nurse #1, Certified Nurse Aide (CNA) #1 and CNA #2 worked on Resident #1's Unit (North 2) during the 7:00 A.M. to 3:00 P.M. shift. During interview on: - 10/03/23 at 4:35 P.M. with Nurse #1, - 10/04/23 at 1:00 P.M. with CNA #1, and, - 10/11/23 at 11:00 A.M. with CNA #2, they said the following: On 10/01/23, they saw Resident #1 between 12:45 P.M. and 1:00 P.M. in his/her room, they said he/she required supervision when leaving the North 2 Unit and when smoking, however, at approximately 2:15 P.M., they became aware that he/she could not be located on the North 2 Unit. Nurse #1, CNA #1 and CNA #2 said although Resident #1's care plan interventions included supervision when leaving the North 2 Unit, he/she had left the North 2 Unit unsupervised, unbeknownst to them at some time between 1:00 P.M. and 2:00 P.M. on 10/01/23. The Administrator said that he was the Manager on Duty (MOD) on 10/01/23. The Administrator said that his responsibilities as MOD included sitting at the Reception Desk answering the telephone and letting visitors, residents and staff in and out of the locked front door. The Administrator said that at 9:00 A.M., 1:00 P.M., 4:00 P.M. and 7:00 P.M., the Facility had supervised smoking times which were typically supervised by the CNAs from the units. The Administrator said because the Facility staffing was low on 10/01/23, he supervised the smokers from inside, in the lobby vestibule for the 1:00 P.M. smoking time. The Administrator said that during the 1:00 P.M. smoking time he also answered the telephone at the reception desk and obtained smoking materials for residents which were kept at the North 1/South 1 nurses station. In order for the Administrator or anyone else to obtain the resident's smoking materials they would need to leave the lobby area to access the North 1/South 1 Unit, and would therefore be unable to visualize and supervise any residents outside in the smoking area. During an interview on 10/05/23 at 2:28 P.M., the Director of Maintenance said that North 1 /South 1 nurses station was approximately 55 feet away and around a corner from the lobby vestibule and the front door area. During tours on 10/03/23 at 3:30 P.M. and 6:30 P.M., the Surveyor observed that the supervised smoking area was not visible from the North 1/South 1 nurses station. Review of the Facility's video surveillance camera footage, from 10/01/23, shows that Resident #1 exited the Facility front door holding a laundry bag full of clothes at 1:22 P.M. The video footage shows that Resident #1 walked around the smoking area, where other residents were smoking until 1:25 P.M., and then he/she walked up the Facility driveway and off the Facility grounds. The Administrator said that Resident #1's care plan interventions included supervision by staff at all times when he/she left the North 2 Unit, including when going out to smoke and while in smoking area. The Facility Internal Investigation Update, dated 10/05/23, indicated that on 10/02/23 the Facility was notified by a local hospital that Resident #1 had called 911 from a train station and had been brought to a local hospital for evaluation. Review of the Hospital After Visit Summary, dated 10/02/23, indicated Resident #1 was seen for severe Alcoholic Intoxication without complications. The Administrator said although he was letting visitors, residents and staff in and out of the locked front door and supervising the residents who were smoking during the 1:00 P.M. smoking time, he did not see Resident #1 exit the Facility through the front door at 1:22 P.M., did not see him/her walk around in the smoking area, walk up the driveway and off the Facility grounds. The Administrator said that his back may have been turned while he was on the telephone or he may have been at the North 1/South 1 nurses station getting cigarettes for other residents.

Based on observation, interview and records reviewed, for one of three sampled Residents (Resident #1), who had a history of being homeless, with alcohol and substance abuse disorders, resided on a secured unit in the facility, who was to remain in the Facility unless supervised due to a history of elopement and had an activated Health Care Proxy, the Facility failed to ensure he/she was provided with an adequate level of staff supervision to maintain his/her safety in an effort to prevent an elopement. On 10/01/23, Resident #1 left his/her secure second-floor unit (North 2), unsupervised and unbeknownst to staff, took the elevator down to the first floor lobby and exited the Facility through a locked front door. At the time of the elopement, a facility Administrative staff member was stationed in the lobby monitoring the locked front door, letting visitors, staff and residents in and out of the facility and was also responsible for supervising any residents who were out in the smoking area (located outside of the front door). Resident #1 walked out the front door and walked around the smoking area for approximately three minutes unnoticed by staff, before leaving the Facility grounds. Resident #1's whereabouts were unknown for approximately thirty-two hours, during which time a serious adverse outcome was likely to occur. On 10/02/23, Resident #1 called 911 from a train station (which was located 10 miles away from the facility) responding Emergency Medical Services found him/her to be be intoxicated and he/she was transported a local Hospital Emergency Department for evaluation and treatment, as needed. Findings included: The Facility Policy titled Elopements, dated as established 1/2017, indicated that the staff should promptly report any resident who tries to leave the premise and attempt to prevent the departure in a courteous manner. The Facility Policy titled Smoking Policy-Residents, dated as established 11/2017, indicated that residents were evaluated on admission to determine the residents ability to smoke safety with or without supervision. Review of the report submitted by the Facility via the Health Care Facility Reporting System (HCFRS) on 10/01/23 indicated that on 10/01/23, Resident #1, a resident who resided on a secure unit, eloped from the Facility through the main entrance. During an interview on 10/03/23 at 1:10 P.M., Resident #1 said that he/she left the Facility and he/she was not sure where he/she went or how he/she got there. During an interview on 10/05/23 at 10:36 A.M., Family Member #1 said that at 2:42 P.M. on 10/01/23, Nurse #1 notified her that Resident #1 had eloped from the Facility and was missing. Family Member #1 said that on 10/02/23 at 9:40 P.M., a hospital notified her that Resident #1 was at the hospital and was intoxicated. Family Member #1 said that Resident #1 had been found in a town about 10 miles away from the Facility and she did not know how he/she had gotten to the hospital. The Facility Internal Investigation Update, dated 10/05/23, indicated that on 10/02/23 the Facility was notified by a local hospital that Resident #1 had called 911 from a train station and had been brought to a local hospital for evaluation. Review of the Hospital After Visit Summary, dated 10/02/23, indicated Resident #1 was seen for severe Alcoholic Intoxication without complications. Review of the Police Report, dated 10/03/23, indicated Resident #1 was located by the police in a neighboring city at a hospital. The Police Report indicated the police officer interviewed Resident #1 at the Facility on 10/03/23, that he/she was confused and unaware of what was going on. The Report indicated Resident #1 said he/she was gone from the Facility for a very long time. Review of Resident #1's admission Minimum Data Set Assessment, dated 7/16/23, indicated his/her cognitive patterns were severely impaired. Review of the medical record indicated that Resident #1's Health Care Proxy had been activated during June 2023 due to permanent incapacity related to dementia. The medical record indicated Resident #1's diagnoses included insulin dependent diabetes, severe alcohol use disorder, opioid use disorder, cirrhosis, hepatic encephalopathy and age related cognitive decline. Review of Hospital History and Physical, dated 7/07/23 and provided to the Facility as part of Resident #1's referral to the Facility for admission, indicated he/she had eloped from the hospital and was brought back. The History and Physical indicated that Resident #1's discharge barriers included the need for a one to one sitter for elopement. Review of Resident #1's Facility Elopement Risk Evaluation, dated 9/28/23 indicated he/she was at low risk for elopement. However, although the Evaluation indicated Resident #1 was at low risk for elopement, and that he/she was not exit seeking in the facility, conflicted with information in his/her progress notes. Review of Resident #1's Progress Notes dated 9/05/23, 9/06/23, 9/08/23 9/09/23, 9/10/23, 9/12/23, 9/14/23, 9/18/23, 9/20/23 9/21/23 and 9/23/23 indicated Resident #1 exhibited exit seeking behaviors. During an interview on 10/05/23 at 3:28 P.M., the Social Worker said that although Resident #1's Elopement Risk Evaluation in September 2023 indicated low risk for elopement, his/her care plan for elopement risk remained in place and she continued to document his/her risk for elopement in the Facility's Elopement Book because he/she had recently been talking more often about wanting to leave the facility. Review of Resident #1's Care Plan related to Smoking, dated as initiated 7/18/23, indicated Resident #1 had been assessed to be a supervised smoker. Additional interventions, dated as initiated 7/18/23, indicated staff were to monitor Resident #1's safety during smoking. Review of Resident #1's Care Plan related to Elopement Risk, dated as initiated 8/29/23, indicated that Resident #1 was at risk for elopement due to decreased safety awareness, decreased cognition, and indicated that the goal was for Resident #1 to remain within the Facility unless supervised. Additional interventions, dated as initiated 8/29/23, indicated staff were to engage Resident #1 in a structured activity program, to photograph Resident #1 for the wander notebook and to redirect him/her as needed. During interviews on: - 10/03/23 at 9:30 A.M. with the Administrator, - 10/03/23 at 4:35 P.M. with Nurse #1, and, - 10/05/23 at 3:28 P.M. with the Social Worker, they said the following: Resident #1 required staff supervision when he/she left the North 2 Unit and said staff escorted him/her to the smoking area at designated smoking times where he/she was supervised while smoking. The Administrator said that Resident #1 was admitted in July 2023 to North 2 (a secure unit on the second floor). During tours of the facility on 10/03/23 at 11:00 A.M. and 1:00 P.M., the Surveyor observed that the two floors of the Facility were accessible by two elevators. The elevators could be called to and boarded from the first floor (North/South 1 Unit) or from the basement without any security intervention. In order to call the elevator to the North 2 Unit (where Resident #1 resided), code entry into a key pad adjacent to the elevator doors was required. Once the elevator was called to the North 2 Unit, it could be boarded and taken to the North/South 1 Unit or the basement without any additional security intervention. The Surveyor observed that the first floor (North/South 1 Unit) had direct and unrestricted access to the Facility lobby. The Surveyor observed that the Facility front door was directly accessible from the lobby. The Administrator confirmed that the two floors of the Facility were accessible by two elevators and the elevators could be called to and boarded from the first floor (North/South 1 Unit) or from the basement without any security intervention. The Administrator confirmed that in order to call the elevator to the North 2 Unit (where Resident #1 resided), code entry into a key pad adjacent to the elevator doors was required. The Administrator confirmed that once the elevator was called to the North 2 Unit, it could be boarded and taken to the North/South 1 Unit or the basement without any additional security intervention. The Administrator said that the front door of the Facility, located in the lobby on the first floor, was locked at all times. The Administrator said that the lock on the front door could be released in one of three ways, by entering a code into keypad beside the front door, by depressing a button behind the reception desk in the lobby or by depressing a button at the North 1/South 1 nursing station. During an interview and tour with the Administrator and the Director of Maintenance on 10/03/23 at 3:00 P.M., the Administrator and Director of Maintenance said (and the Surveyor observed) that after the front door lock was released, it remained unlocked for approximately 30 seconds after which it automatically re-locked. Review of the Schedule for 10/01/23 indicated Nurse #1, Certified Nurse Aide (CNA) #1 and CNA #2 worked on Resident #1's Unit (North 2) during the 7:00 A.M. to 3:00 P.M. shift. During an interview on 10/03/23 at 4:35 P.M. Nurse #1 said that she was the nurse on Resident #1's Unit (North 2) during the 7:00 A.M. to 3:00 P.M. shift 10/01/23. Nurse #1 said that Resident #1 had a difficult day and said that he/she told her he/she was going to leave and asked to speak to Family Member #1. Nurse #1 said that she tried to call Family Member #1 for Resident #1 and said she was not able to reach Family Member #1. Nurse #1 said that Resident #1 approached her approximately every five minutes during the shift asking about leaving and about calling Family Member #1 and Family Member #2. Nurse #1 said that around 1:00 P.M., she went to Resident #1's room to administer his/her insulin. Nurse #1 said that although his/her meal tray had been delivered, Resident #1 was in bed so she assisted him/her to sit up in front of his/her meal tray before administering the insulin. Nurse #1 said that about an hour later, when the Physical Therapist came to the North 2 Unit, the Physical Therapist said that she could not find Resident #1. Nurse #1 said that she searched the North 2 Unit and could not locate Resident #1, so she went to the smoking area to see if he/she was out smoking. Nurse #1 said that she did not locate Resident #1 in the smoking area and said that she reported to the Administrator that Resident #1 was missing. During an interview on 10/04/23 at 1:00 P.M., CNA #1 said that although she worked on 10/01/23 during the 7:00 A.M. to 3:00 P.M., she was not assigned as Resident #1's CNA. CNA #1 said that she escorted Resident #1 to smoke during the supervised smoking time at 9:30 A.M. and said she loaned him/her a quarter to buy a soda. CNA #1 said that after smoking at 9:30 A.M., Resident #1 returned to the North 2 Unit and she did not see him/her again until approximately 12:30 P.M. when she brought the lunch tray to him/her in his/her room. During an interview on 10/11/23 at 11:00 A.M., CNA #2 said she worked on the North 2 Unit on 10/01/23 during the 7:00 A.M. to 3:00 P.M. shift and said she was assigned to be Resident #1's CNA. CNA #2 said that Resident #1 went out to smoke at approximately 9:00 A.M. with CNA #1 and said he/she spent the remainder of the morning in his/her room which was his/her typical routine. CNA #2 said that although she was assigned to take Resident #1 and the other residents who smoked outside to smoke at 1:00 P.M., she did not because she was running late with her other assignments. CNA #2 said that the last time that she saw Resident #1 on 10/01/23, he/she was in his/her room. CNA #2 said that although she heard that Residents #1 and two other residents from the North 2 Unit had gone outside to smoke around 1:00 P.M. on 10/01/23, said she did not take them and she did not now how they got off of the North 2 Unit. The Administrator said that he was the Manager on Duty (MOD) on 10/01/23. The Administrator said that his responsibilities as MOD included sitting at the Reception Desk answering the telephone and letting visitors, residents and staff in and out of the locked front door. The Administrator said that at 9:00 A.M., 1:00 P.M., 4:00 P.M. and 7:00 P.M., the Facility had supervised smoking times. The Administrator said that the resident's smoked in an area outside of the front door. The Administrator said that CNAs assisted residents from the various units to the lobby and out to the smoking area. The Administrator said that although the CNAs typically supervised the residents while they were in the smoking area outside of the front door, said because the Facility staffing was low on 10/01/23, he supervised the smokers from inside, in the lobby vestibule for the 1:00 P.M. smoking time. The Administrator said that during the 1:00 P.M. smoking time he also answered the telephone at the reception desk and obtained smoking materials for residents which were kept at the North 1/South 1 nurses station. In order for the Administrator or anyone else to obtain the resident's smoking materials they would need to leave the lobby area to access the North 1/South 1 Unit, and would therefore be unable to visualize and supervise any resident outside in the smoking area. During an interview on 10/05/23 at 2:28 P.M., the Director of Maintenance said that North 1 /South 1 nurses station was approximately 55 feet and around a corner from the lobby vestibule and front door. During tours of the facility on 10/03/23 at 3:30 P.M. and 6:30 P.M., the Surveyor observed that the supervised smoking area was not visible from the North 1/South 1 nurses station. Review of facility's video surveillance camera footage from 10/01/23 showed four residents (Resident #3 and non-sampled Residents A, B and C) exited the Facility through the lobby door and walk to the smoking area at 1:12 P.M. and at 1:13 P.M., and that at 1:17 P.M., non-sampled Resident A re-enters the Facility through the lobby door. Review of video footage showed Resident #1 exited the Facility front door holding a laundry bag full of clothes at 1:22 P.M. on 10/01/23. The video footage showed Resident #1 walk around the smoking area until 1:25 P.M., when he/she then walked up the Facility driveway and off Facility grounds. During an interview on 10/05/23 at 4:07 P.M., the Physician said Resident #1 required supervision. The Physician said that Resident #1 was an insulin dependent diabetic and although his/her blood sugars were relatively stable, his/her blood sugar was tested four times daily and he/she received insulin according to his/her test results. The Physician said Resident #1 was not able to manage his/her insulin or blood sugar testing and required supervision. The Physician said that Resident #1 received two medications for cirrhosis: Lactulose (a laxative used to treat complications of liver disease) four times daily and Rifaximin (an antibiotic used to prevent recurrent hepatic encephalopathy) twice daily. The Physician said Resident #1 required supervision to take the Lactulose and Rifaximin as prescribed in order to treat mental status changes and confusion related to cirrhosis and hepatic encephalopathy. The Administrator said that although he recalled releasing the lock on the front door from the button at the reception desk for Resident #3 and non-sampled Resident A, B and C, he did not recall releasing the lock on the front door for Resident #1 and said he did not see Resident #1 exit the Facility. The Administrator was unable to explain how Resident #1 exited the Facility through the locked door. The Administrator said that although he was supervising the residents who were smoking, he did not see Resident #1 in the smoking area during the three minutes that he/she walked around the smoking area and walked up the driveway and off the Facility grounds. The Administrator said that his back may have been turned while he was on the telephone or he may have been at the North 1/South 1 nurses station getting cigarettes for other residents.

Based on observations, record review and interviews, the facility failed to prevent the development of a contracture for 1 Resident (#8) and failed to implement a left-hand roll splint for 1 Resident (#1), out of a total sample of 33 residents. Findings include: 1. Resident #8 admitted to the facility in January 2016 with diagnoses including dementia. Review of Resident #8's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15, indicating he/she has severe cognitive impairment. The MDS also indicated Resident #8 is dependent on staff for all mobility, bathing and dressing needs. On 7/18/23 at 8:35 A.M., Resident #8 was observed lying in bed. His/her left hand was in a closed, fisted position. The Resident was unable to open his/her hand. Resident #8 was unable to say how long he/she has been unable to vountarily open his/her hand. Review of Resident #8's medical record indicated the Resident does not have a neurological condition that would increase the presence of, or cause, contractures. Review of the documents titled, Licensed Nursing Summary for January 2023 through June 2023 failed to indicate Resident #8 had a contracture. Review of the last 6 months of nursing notes failed to indicate the facility identified the change of range of motion to Resident #8's left hand. Review of the last 6 months of physician notes failed to indicate Resident #8 had any impairments with range of motion. During an interview on 7/20/23 at 8:51 A.M., CNA (certified nursing assistant) #1 said Resident #8's hand has been closed in a fisted position for a while now. CNA #1 attempted to open Resident #8's hand and was unable to. CNA #1 said the nurse would have more information because the CNAs don't take care of range of motion concerns. During an interview on 7/20/23 at 9:07 A.M., Nurse #2 attempted to open the Resident's left hand and was unable to and said the Resident's hand was contracted. Nurse #2 said he was unsure of how long the Resident's hand had been like that but would not make a referral to the therapy department to treat it because it may be a long-standing issue. During an interview on 7/20/23 at 9:29 A.M., the Director of Rehabilitation (DOR) said the therapy department depends on referrals from the nursing staff to identify changes in residents' status and to know who needs a therapy evaluation. The DOR said these referrals come from the floor staff, the MDS nurse during Medicare meeting, and from risk meeting notes. The DOR said the therapy department should also be screening residents quarterly. The DOR provided the surveyor with the 2022 and 2023 therapy screening log and Resident #8 was not in the book. The DOR said that means the Resident has not been screened by therapy in the past two years. The DOR said Resident #8 has never been referred to therapy for a new contracture and has never received therapy for contracture management. The DOR said she would expect a referral to therapy for anyone who has a decrease in range of motion/new contracture. During an interview on 7/20/23 at 10:49 A.M., the Director of Nursing (DON) said she expects nursing to identify any changes in range of motion and notify the physician, health care proxy if applicable, and make a referral to the therapy department for an evaluation immediately. 36431 2. For Resident #1, the facility failed to ensure a hand roll was placed in Resident #1's left contracted hand in accordance with the medical plan of care. Resident #1 was admitted to the facility in June 2008 and has diagnoses that include but not limited to hemiplegia unspecified affecting left nondominant side, traumatic brain injury, convulsions, contracture left hand, dysphagia, and dementia. Review of the Minimum Data Set Assessment (MDS) with an assessment reference date of 5/11/23 indicated Resident #1 scored a 3 out of 15 on the Brief Interview for Mental Status Exam (BIMS) indicating a severe cognitive impairment and is dependent on staff for daily care including bed mobility, transfers, bathing, dressing and hygiene. Further, the MDS did not indicate Resident #1 rejected care. On 7/18/23 at 8:45 A.M., Resident #1 was observed resting in bed. The fingers on his/her left hand were curled in and contracted. Review of Resident #1's medical record on 7/18/23 indicated the following: -A physician's order dated 11/24/23, Left hand roll splint on following care and off in the afternoon. Skin check for irritation and/or redness and notify MD (medical doctor) if it occurs. The order did not indicate a specific time for left hand splint removal. -A Kardex, (a document that provides a plan of care for the Certified Nursing Assistants) did not indicate the use of a left-hand roll splint. -A care plan for risk of pain with a revision date of 8/29/19, with the intervention, left hand splint during the day shift to help maintain alignment, dated 1/16/18. During the survey the following observations were made: -On 7/19/23 at 12:26 P.M., Resident #1 was outside attending a cookout. Resident #1 did not have a left-hand roll splint applied. -On 7/19/23 at 2:35 P.M., Resident #1 was up in his/her wheelchair in the sitting room during the resident group meeting and was not wearing a left-hand roll splint. -On 7/19/23 at 4:13 P.M., Resident #1 was in a common space eating cheese curls. Resident #1 did not have a left-hand roll splint applied to his/her left-hand. Resident #1 said he/she had a hand roll once but did not know how long it has been since it has been used. -On 7/20/23 at 11:10 A.M., Resident #1 was in bed and his/her left hand was without a left-hand roll splint. During an interview on 7/20/23 at 12:07 P.M., CNA #6 said she has been caring for Resident #1 for a few months and Resident #1 requires complete care. CNA #6 said Resident #1 does not use a hand roll or device in his/her left hand and that she has never seen one. The surveyor and CNA #6 went to see Resident #1 and observed him/her to not have a left-hand roll splint applied. Resident #1 said he/she used to have one, but it has been lost. During an interview on 7/20/23 at 12:29 P.M., Nurse #8 said she did not know Resident #1 that well, but that if the left-hand roll was on the physician's orders and on the treatment administration record, it should be administered to Resident #1.

Based on observation, record review and interview the facility 1) failed to ensure interventions to prevent a fall for one Resident (#80) were implemented, 2. failed to ensure supervision was provided to prevent one Resident (#78) from leaving the building unattended putting him/her at risk in the community, 3) failed to follow the emergency safety procedures during a fire alarm, and 4) failed to ensure supervision was provided and smoking articles were maintained safely for 2 Resident (#26, and #43 ) out of eleven applicable residents. Findings include: 1. Review of the facility policy titled, Falls and Fall Risk, Managing, dated 12/2022, indicated the following: *Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. *The staff will implement a resident-centered fall care plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. *The staff will monitor resident's response to interventions intended to reduce falling or the risks of falling. Resident #80 was admitted to the facility in December 2020 with diagnoses including Alzheimer's Disease. Review of Resident #80's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15, indicating he/she has severe cognitive impairment. The MDS also indicated Resident #80 requires extensive assistance for all functional tasks. Review of an incident report dated 2/13/23 indicated Resident #80 slipped and fell into a wall and staff were required to lower him/her to the ground. Review of Resident #80's fall care plan indicated the following interventions were added on 2/14/23 after this incident: *PT (physical therapy) consult to evaluate fall. Continue to monitor for s/sx (signs and symptoms) of falls. *Resident will be screened by PT Review of Resident #80's medical record failed to indicate the Resident was ever seen by physical therapy. Review of the nursing evaluation dated 2/28/23 indicated Resident #80 requires continual supervision/assist of 1 for all mobility. Review of the incident report dated 3/17/23 indicated the following: *Resident #80 sustained an unwitnessed fall in his/her room. The Resident was previously attending an activity in the dining room and interviews with the activity staff indicated the Resident walked to and from the activity independently without assistance from staff. The fall resulted in Resident #80 sustaining a lower leg fracture. Review of Resident #80's activity of daily living care plan at the time of the fall indicated Resident #80 required continual supervision with ambulation. During an interview on 7/20/23 at 9:29 A.M., the Director of Rehabilitation (DOR) said the therapy department screens all falls as long as they are told of them. The DOR provided the surveyor with the therapy screening logs for 2023 and Resident #80 was not in the book as having been screened. The DOR said she was unaware of Resident #80's fall in February with a new intervention to be seen by physical therapy and this never occurred. During an interview on 7/21/23 at 9:50 A.M., the Activities Director said she and her staff are aware of the level of assistance residents require for ambulation due to her completing quarterly assessments. During an interview on 7/20/23 at 10:49 A.M., the Director of Nursing (DON) said if a resident sustains a fall, the staff should immediately assess the resident, notify the physician and health care proxy if indicated, and an investigation into the cause of fall should be completed. The DON said if a resident is continual supervision, staff should be supervising him/her at all times when out of bed. 36431 4. For Resident #26 and Resident #43 the facility failed to ensure supervision was provided during smoking and failed to ensure cigarettes and lighters were stored safely. Review of the document dated 6/28/23-7/4/23 titled Smoker, at risk provided by the facility in the surveyor binder, indicated the facility has 11 residents evaluated to smoke and all are recommended by the IDT (interdisciplinary team) as requiring supervision for smoking. Review of the facility's policy dated 11/2017 indicated the following: This facility shall establish and maintain safe resident smoking practices. Further review of the policy indicated, Guidelines, 1 Prior to and upon admission residents shall be informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. 6. The residents will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include the ability to smoke safely with or without supervision (per a completed Safe smoking evaluation). 12. Residents who have independent smoking privileges are not permitted to keep cigarettes pipes, tobacco and other smoking articles in their procession. All other forms of lighters, including matches, are prohibited. 13. Residents are not permitted to give smoking articles to other residents. 14. Residents without independent smoking privileges may not keep any smoking articles, including cigarettes, tobacco etc., except when they are under direct supervision. A) Resident #26 was admitted to the facility in 4/2019 and has diagnoses that include and are not limited to schizoaffective disorder, unsteadiness on his/her feet, and asthma. Review of Resident #26's record indicated Resident #26 had a smoking evaluation with an effective date of 5/8/23 with the IDT (interdisciplinary team) determination; Resident (#26) is safe to smoke with supervision without protective equipment. Resident (#26) is safe to light own cigarette with staff assistance. B) Resident #43 was admitted the facility in March 2017 and has diagnoses that include but not limited to chronic obstructive pulmonary disease, bipolar disorder and nicotine dependence. Review of Resident #43's medical record indicated Resident #43 had a smoking evaluation with an effective date of 6/26/23 with the IDT (interdisciplinary team) determination; Resident (#43) is safe to smoke with supervision without protective equipment. Resident (#43) is independent with lighting cigarette. On 7/18/23 at 4:00 P.M., the surveyor made the following observations: Nurse #5 pushed Resident #26 via wheelchair out to the area designated by a sign that as the designated smoking area and returned to the vestibule of the building many feet away and observed from there. Resident #43 was already outside, with no staff present, sitting at a table with a pack of [NAME] cigarettes and a lighter on top of his/her bag on the table in front of him/her. Resident #43 used the lighter and lit his/her cigarette and passed the lighter to Resident #26, who lit his/her cigarette, and both began to smoke. Resident #26 did not have an ashtray nearby and after a few puffs on the cigarette dropped the cigarette on the ground. During an interview at this time, Resident #43 said he/she had privileges to keep his/her own cigarettes and lighter. Resident #26 said he/she can keep her own cigarettes but bum's the lighter from his/her friend. Nurse #5 returned and asked Resident #26 why he/she put his/her cigarette on the ground? And then encouraged both residents to come back inside. During an interview on 7/19/23 at 6:04 P.M., Nurse #5 said he was taking Resident #26 out the day before (7/18/23) for fresh air and not to smoke. Nurse #5 said after he looked from the vestibule he realized both Residents were smoking. Nurse #5 said Resident #43 has been known to have his/her own cigarettes and lighter and they have discussed this with him/her and with his/her family. Nurse #5 said all residents who smoke including Resident #26 and Resident #43 require supervision from staff for safety. During an interview on 7/19/23 at 4:17 P.M., the Receptionist said all the cigarettes are kept for each resident who chooses to smoke in a locked box and are signed out and recorded. The Receptionist said no residents can smoke by themselves and a Certified Nursing Assistant (CNA) always goes out with the residents to supervise. At this time the Receptionist and Surveyor went out to observe the smoking area. Approximately four residents were in the designated smoking area and the CNA who was providing supervision was pointed out by the Receptionist as being at her car, which was a distance away and not observed to be providing direct supervision to the residents. During an interview on 7/19/23 at 5:35 P.M., the Regional Administrator said he would need to check the smoking policy for the facility but would expect supervision during smoking to be in the direct vicinity or have visual supervision.

Based on observations, interview and record reviews, the facility failed to have systems in place to ensure that 4 residents (#36, #74, #30 and #99), in a total sample of 29 residents, had interventions in place that were monitored, evaluated and consistently implemented, to prevent pressure sores from developing and to ensure residents with pressure ulcers received the necessary treatment and services to promote healing. Findings include: A review of the policy for pressure ulcer/injuries indicated the following: Avoidable means that the resident developed a pressure ulcer/injury and that one or more of the following was not completed: evaluation of the resident's clinical conditions, implementation of interventions that are consistent with residents needs, goals and professional standards of practice, monitor or evaluate the impact of the interventions and revision of the interventions as appropriate. A review of the policy for pressure ulcer/injury risk assessment indicated the following: If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin. Develop the resident-centered care plan and interventions based on the risk factors, the condition of the skin, the clinical condition and resident wishes and goals: interventions must be based on current, recognized standards of care, the effects of interventions must be evaluated, the care plan must be modified as the condition changes or if the current interventions are deemed inadequate. 1. For Resident #36, the facility failed to monitor air mattress settings to provide the resident with proper pressure reduction while sitting up in bed, failed to perform accurate weekly skin checks and failed to have a care plan in place for air mattress settings to prevent the development of 2 new shear pressure injuries and prevent optimal healing of an existing stage 4 pressure injury. Stage 4 Pressure Ulcer: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable pressure area/PI. Shearing occurs when layers of skin rub against each other or when the skin remains stationary and the underlying tissue moves and stretches and angulates or tears the underlying capillaries and blood vessels causing tissue damage. Resident #36 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score was 14 out of 15, indicated Resident #36 was cognitively intact. The MDS indicated the resident required two person assist with bed mobility, was at risk for pressure ulcers, had one unhealed stage 4 pressure ulcer and used a pressure reducing device for the bed. On [DATE] at 2:30 P.M., Resident #36 was interviewed and said he/she had a sore bottom. Resident #36 said this mattress was not very good, because when he/she frequently sat up in bed, he/she could feel the bed frame underneath. This surveyor observed the air mattress weight setting to be on #3 (140 pounds to 175 pounds) on alternating mode. Resident #36 said he/she weighed approximately 204 pounds. This surveyor observed Resident #36 sit up in the bed and the resident said he/she could feel the bed frame. A review of the current physician orders for Resident #36, indicated an order for [REDACTED]. Resident # 36's current care plan indicated Resident #36 had potential and actual alteration in skin integrity due to decreased/impaired mobility and resident's preference was to stay in bed. The intervention listed was for a specialty air mattress when in bed, check for functioning every shift but did not include the type of air mattress or settings. A review of the medical record indicated Resident #36 weighed 207 pounds on [DATE]. Review of a wound evaluation by the consultant wound physician, dated [DATE], indicated the following wounds: 1. Stage 4 pressure wound right ischium (site 5), measuring 1.0 x 0.8 x 0.5 centimeters (cm) with surface area of 0.8 cm squared with moderate serous drainage. The wound had deteriorated. 2. Shear wound of left buttocks (site 6), measuring 0.8 x 0.1 x 0.2 cm, with surface area of 0.08 cm squared with moderate serous drainage. The wound had deteriorated. Review of wound evaluation by the consultant wound physician, dated [DATE], indicated the following wounds: 1. Stage 4 pressure wound right ischium (site 5), measuring 0.4 x 0.2 x 0.1 centimeters (cm) with surface area of 0.8 cm squared with light serous drainage. The wound had improved. 2. Shear wound of left buttocks (site 6), had resolved. 3. Initial evaluation of new shear wound of right medial buttocks (site 8), measuring 2.8 x 1 x 0.1 cm with surface areas of 2.8 cm squared, with light serous drainage. 4. Initial evaluation of new shear wound of right lateral buttocks (site 9), measuring 1 x 0.6 x not measurable with surface area of 0.6 cm squared, with light serous drainage. A review of Weekly nursing skin evaluations: 1. [DATE] Resident #36 had right ischium healing wound, no signs of infection. 2. [DATE] Resident #36 had right ischium healing stage 4 wound with red wound bed, granulation noted, no signs of infection noted. 3. [DATE] Resident #36 had a right ischium wound, red with granulation, no drainage noted. Review of nursing note, dated [DATE], indicated Resident #36 was seen by the wound physician. The right ischium had deteriorated, physician and resident were aware. The shear wound on the left buttock had deteriorated and had moderate serous drainage. On [DATE] at 11:42 [NAME]M., Nurse #2 was interviewed and said she inspects the air mattresses every shift. Nurse #2 and the surveyor reviewed the medical record and Nurse #2 said she was unable to locate the settings for air mattresses in the medical record, the treatment administration record (TAR) or the care plans. During a subsequent observation on [DATE] at 12:35 P.M., the surveyor observed the air mattress of Resident #36 to remain set at #3 (140 pounds to 175 pounds) on alternating mode which was not adequate to provide pressure reduction for an individual who weighed 207 pounds. On [DATE] at 1:33 P.M., Day Supervisor (Wound Nurse) was interviewed and said, Resident #36 did have two new shear wounds identified by the wound doctor on [DATE]. She said the air mattress settings were kept locked in the medication room on the unit. The Day Supervisor provided this surveyor with a copy of air mattress settings from inside a locked medication room. The air mattress settings sheet included the residents name, room number, weight and numerical setting. There was no information for the manufacturers name or model number and no information for static or alternating airflow. The Day Supervisor said nursing staff should know the air mattress sheet is kept in the medication room. This surveyor informed the Day Supervisor that Resident #36's air mattress was observed to be on setting #3 ( 140 lbs. to 175 lbs.) with alternating air flow. The Day Supervisor said the air mattress should have been set on #4 (175 lbs. -210 lbs.) with static air flow. She said all air mattresses should be set on static air flow. 2. For Resident #74, the facility failed to identify a new pressure injury on the left ankle, maintain the air mattress in safe operating condition, maintain the correct settings on air mattress and follow the Physician's orders for Resident #74 to wear a pressure relieving boot on left foot. Resident #74 was admitted to the facility in ,[DATE], with a history of a stroke with right sided weakness. A review of the Quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated Resident #74 had moderately impaired cognition. The MDS indicated the resident required a two person assist with bed mobility and was at risk for pressure ulcers. A review of the current Physician's orders indicated to apply a Raffle boot/heel elevator (pressure relieving boot) to the left foot, until an Easy boot was available, every shift and for the left medial ankle wound, wash area with normal saline, pat dry, apply foam bandage dressing every two days. The Physician's orders did not include orders for an air mattress or settings for an air mattress. A review of current care plans indicated Resident #74 was at risk for pressure ulcers due to history of a stroke, right sided weakness and the resident refusing to get out of bed. Interventions included to perform weekly skin checks and provide pressure reduction/relieving mattress. The care plan interventions did not include a pressure relieving boot as indicated on the physician orders. On [DATE] at 9:40 [NAME]M., Resident #74 was observed by two surveyors to be lying on a deflated air mattress and the air mattress pump alarm was sounding. Nurse #2 was outside the room at her medication cart and was asked about the sounding alarm. She checked Resident #74's bed and said the air mattress was set on #5, but had low pressure. She turned the setting to #9 and squeezed the mattress at the head of the bed and stated the mattress had no air. At this time, the surveyors observed that Resident #74 to had a scabbed area on the inside of the left ankle, no dressing or protective boot were observed. On [DATE] at 10:40 [NAME]M., Maintenance Staff #1 was interviewed and said he inspected the air mattress and found the CPR (cardiopulmonary resuscitation) emergency tubes were disconnected and that was why the bed was deflated. The surveyor observed the setting on the air mattress was left on #9. On [DATE] at 09:07 [NAME]M., the surveyor observed Resident #74 lying in bed with no pressure relieving boot or dressing on the left ankle. On [DATE] at 11:15 [NAME]M., the surveyor observed Resident # 74 to be lying in bed. The air mattress pump was observed to be off and the mattress was partially deflated. This surveyor notified Nurse #5, who came to the room and observed the air mattress unplugged from the wall. Nurse #5 plugged in the air mattress and left the room. On [DATE] at 11:20 [NAME]M., CNA #1 was interviewed and said she noticed the air mattress pump was off at 10:15 [NAME]M. and she notified Nurse #5. On [DATE] at 3:03 P.M., Nurse #5 was interviewed and said she did not know why the mattress was unplugged or why the unplugged mattress had not been addressed when identified by CNA #1. Nurse #5 said she was not aware of any skin issues with Resident #74's left ankle and was not aware of an order for [REDACTED].>On [DATE] at 2:30 P.M., Nurse #1 and Nurse #2 with a surveyor present, performed a skin check on Resident #74. The surveyor observed with the nurses, a scabbed area, approximately 3 cm in diameter with surrounding red skin to the left medial ankle. Nurse #2 said the observed scabbed area was a pressure site because the resident leans on the area. Both nurses were unsure of when the area was first identified and if Resident #74 was receiving any treatment to the area. On [DATE] at 03:28 P.M., Nurse #5 approached the surveyor and said Resident #74 had pressure relieving boots to wear as needed, but refused them all the time. This surveyor and Nurse #5 went to Resident #74's room and were unable to locate any pressure relieving boots. Nurse # 5 said sometimes the boots were sent to laundry. Nurse #5 went to the laundry room and came back with a blue Prevolone soft bootie (pressure relieving). Nurse #5 said she had not seen the ankle boot on Resident #74 for a while. On [DATE] at 9:32 [NAME]M., this surveyor observed Resident #74 lying in bed with no dressing or pressure relieving boot on the left foot. This surveyor observed the blue Prevolone soft boot on the empty bed next to Resident #74. On [DATE] at 1:29 P.M., this surveyor observed Resident #74 lying in bed with the left side of the air mattress border wall deflated. The surveyor and Nurse #12 returned to inspect the mattress. Nurse #12 confirmed the left side wall was deflated and said she would notify maintenance. On [DATE] at 1:49 P.M., Maintenance staff #1 was interviewed and said he looked at Resident #74's air mattress and one of the tubes was disconnected. On [DATE] at 1:40 P.M., The Day Supervisor was interviewed and said Resident #74 was not being seen by the wound physician and she was not aware of any wound on the left ankle. She said the process was that if a nurse identified a wound, they would notify her and the resident would be seen by the wound physician. She was not aware Resident #74 had physician order for [REDACTED]. This surveyor and the Day Supervisor observed Resident #74 lying in bed. The air mattress was observed to be set on #4, alternate air flow pressure. The Day Supervisor reviewed the air mattress setting sheet and said Resident #74 was supposed to be on setting #5, static air pressure. The air mattress setting sheet did not indicate static pressure. She said all air mattresses should be set on static. On [DATE] at 4:27 P.M., The Day Supervisor was informed by this surveyor that a skin assessment was performed by Nurse #1 and Nurse #2 on [DATE] which identified a pressure site. A review of the weekly skin assessment, dated [DATE], did not indicate Resident #74 had a wound on the left ankle. The Day Supervisor said she was not made aware of the wound and it should have been identified on the weekly skin assessment. On [DATE] at 4:46 P.M., during an interview with Nurse #12, she said she was familiar with the wound care for Resident #74, as she had previously rounded with the wound physician. Nurse #12 said Resident #74 originally developed a shear wound to left ankle and was seen in a wound clinic for approximately several months at the beginning of the year. She said the ankle wound had previously resolved and the dressing had been discontinued. The ,[DATE] treatment administration record (TAR) for Resident #74 indicated the nurses were signing off as administering treatment for [REDACTED]. Nurse #12 said sometimes a physician would order a dressing to fragile skin to protect it. Nurse #12 said she observed the wound today and described it as a pressure wound and believed Resident #74 should be seen by the consultant wound physician. 3. For Resident #30, the facility failed to initiate a treatment change order for 5 days to a stage IV wound that had deteriorated, resulting in a delay in treatment and failed to ensure that care plan interventions for an air mattress were monitored and consistently implemented to promote wound healing. Resident #30 was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #30 was severely cognitively impaired, was unable to ambulate and totally dependent with two staff members for bed mobility and transferring between surfaces. The MDS indicated Resident #30 utilized a pressure reducing device for the bed. Review of the care plans for Resident #30 indicated resident had an air mattress in bed and to check functioning every shift. Review of the Physician's Orders, last dated and signed on [DATE] indicated: - air mattress when in bed as ordered, check for functioning every shift. The surveyor observed on [DATE] at 12:00 P.M., [DATE] at 2:42 P.M., and [DATE] at 8:21 [NAME]M., Resident #30 lying in bed, on a partially deflated air mattress, with the pump in the off position. On [DATE] at 9:58 [NAME]M., Certified Nursing Assistant (CNA) #4 was interviewed at the bedside of Resident #30. The CNA observed the air mattress and said the air mattress should be on all times. CNA #4 said she would check with the nurse about the air mattress and left the room. On [DATE] at 10:11 [NAME]M., during an interview at Resident #30's bedside with Nurse #10, she observed the air mattress and said the air mattress was not turned on. Nurse #10 said Resident #30 had a stage 4 pressure ulcer on the buttock area and the air mattress should always be on when the resident was lying in bed. Nurse #10 said she was unsure why the mattress was not turned on. Nurse #3 was made aware by the surveyor of the observations of Resident #30's air mattress in the off position. Review of the Wound Evaluation from the wound physician, dated [DATE], indicated: -stage 4 pressure wound to sacrum, wound size: 4 x 4 x 1.8 centimeters (cm) -wound progress: deteriorated -dressing treatment plan: [REDACTED] -Prolonged care was indicated for this patient due to: wound not showing improvement, indicating the need for a change in treatment plan. Review of the Progress Notes, dated [DATE] and titled Skin/Wound Note, indicated Resident #30 was seen by the wound doctor during weekly wound rounds. The note indicated a sacrum Stage 4 pressure ulcer had deteriorated, was larger in size, with moderate serous drainage and to continue with treatment, repositioning and air mattress. The Physician's orders were reviewed on [DATE] and indicated the following treatment order with an order date of [DATE]: - Stage 4 pressure wound sacrum: normal saline wash, pat dry, then apply [MEDICATION NAME] with silver and cover with gauze island (with border) every two days and as needed (PRN) or resolved, every day shift every two days for wound care A review of the ,[DATE] Treatment Administration Record (TAR) indicated a dressing change was performed on [DATE] as previously ordered on [DATE] ([MEDICATION NAME] with silver with gauze island, every two days). Based on the change in treatment by the wound physician on [DATE], a daily dressing was to be applied. Further review of the TAR failed to include a dressing change was completed on [DATE]. On [DATE] at 12:15 P.M., during an interview with the Day Supervisor, she said her role included the position of facility wound nurse, and completed weekly wound rounds with the wound physician. The Day Supervisor said it was her responsibility to print the wound physician consults, check for new orders, contact the primary physician and/or Nurse Practitioner and resident representative, enter the wound measurements on the Pressure Ulcer Evaluation, update care plans and assure all new orders are entered into the clinical record. The Day Supervisor said she completed wound rounds with the wound physician on [DATE] and Resident #30 was assessed at that time. The Day Supervisor said Resident #30's wound had deteriorated and the physician did not change the current treatment plan. On [DATE] at 12:30 P.M., the surveyor and the Day Supervisor reviewed the Wound Evaluation from the contracted wound physician, dated [DATE]. The wound evaluation indicated a change in treatment plan per the physician's wound care assessment and evaluation. The Day Supervisor said she must have missed the new orders for change in treatment, and would call the primary physician regarding the wound physician's recommendations, which resulted in a delay treatment change of five days for a deteriorating wound. 4. For Resident #99, the facility failed to ensure interventions of an air mattress and fusion cushion were monitored and evaluated to prevent a new pressure injury from developing. Resident #99 was admitted to the facility in ,[DATE] with a [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #99 required physical assist of two staff members with bed mobility and transferring between surfaces. The MDS also indicated that the resident utilized a wheelchair with a pressure reducing device and had a pressure reducing device for the bed. A review of the care plans for Resident #99 indicated that the resident had an air mattress that would be checked for placement and function every shift and the resident preferred the setting at 5. Resident #99 was interviewed on [DATE] at 11:00 [NAME]M. The resident said he/she had an open area on the buttocks and the staff had said this morning how bad it had gotten. The resident said this was the first he/she had heard the staff saying anything about his/her skin in a couple of weeks. The resident said he/she thought that the staff put medicine on it this morning. The resident was observed to be on an air mattress that was set on 5 at this time. A review of the medical record indicated an order for [REDACTED]. The medical record did not include any information on the type of cushion was provided on the resident's wheelchair. Nurse #6 was interviewed on [DATE] at 11:30 [NAME]M. The nurse said that on [DATE] he was in the room when the Certified Nursing Assistants (CNAs) were providing care and he noticed an open skin area on the buttock of Resident #99. Nurse #6 said he notified the Day Supervisor because the wound physician was going to be in the facility that day and he thought the wound physician could evaluate Resident #99 during rounds. Nurse #6 said the area was a stage 2 on the right coccyx with a couple of pin points of broken skin. The nurse said he applied the house barrier cream and confirmed that the physician had not been notified at this time. The Day Supervisor was interviewed on [DATE] at 11:30 [NAME]M. The Day Supervisor said the wound physician did not see the Resident on [DATE] because the resident was up in his/her wheelchair at the time. The Day Supervisor, whose role included being the facility wound nurse, said at this time the wound was not measured, she had not seen it and no evaluations of the wound had been conducted, per the facility policy. She did confirm that she had become aware of the wound the previous morning. A review of the medical record on [DATE] indicated that the resident had two open areas. A review of the facilities non-pressure ulcer evaluation dated [DATE] indicated that Resident #99 had developed shear injuries. The areas included the right lateral buttocks 3.5 cm (centimeters) by 1.2 cm by 0.1 cm and the right medial buttocks 4.0 cm by 0.5 cm by 0.2 cm. On [DATE] at 11:00 [NAME]M. Resident #99 was interviewed. The resident said that he/she was not aware that the wound physician was at the facility on [DATE] and would have preferred to see the physician. The resident's mattress was observed to be set at 5 at this time. The cushion on the Resident's wheelchair was observed to have a nozzle coming out of the right side of the cushion to indicate it required air. The Resident said he/she had never observed a staff member putting air in the wheelchair cushion. Nurse #12 was interviewed on [DATE] at 11:45 [NAME]M. The Nurse checked the physician orders for Resident #99 and said that air mattresses were set by weight and that since this resident weighed 138 pounds than the air mattress should be set between 1 and 2. The Nurse was observed to go in to the residents room and said that she changed the settings. The Nurse said that the rehabilitation department was responsible for checking on the air in the wheelchair cushion. The Staff Development Coordinator provided the surveyor with a manual for the air mattress for Resident #99. She said that the air mattress for Resident #99 was the only mattress in the facility that was set for comfort and the resident preferred the air mattress to be set at 5. The Day Supervisor/ wound nurse was interviewed on [DATE] at 1:30 P.M. She said the nurses were responsible for checking the air mattress function every shift and the air mattress settings were set by weight. She said a list of the air mattress settings were kept in the locked medication room. A review of the list indicated that the air mattress for Resident # 99 was to be set at 5. At 2:10 P.M. the surveyor and the Day Supervisor observed the air mattress of Resident #99 to be set at 1. She said she did not know this type of air mattress or why the setting on the list would be at 5 or why it was set to alternating air and added that all residents should be on a static air mattress. The Day Supervisor was interviewed on [DATE] at 4:30 P.M. She said she was unaware of the air mattress settings for Resident #99 and was unaware that the setting was based on comfort preference. She said that the air mattress was always set at 1 when she was in the room. She said that with the development of the new area on [DATE], she had not evaluated the interventions that were already in place to prevent the development of new pressure injury areas, per the facility policy. The Director of Rehabilitation was interviewed on [DATE] at 12:30 P.M. He said the rehabilitation department was not responsible for the monitoring of a wheel chair cushion and that it would be up to the nurses to monitor. The Director of Rehabilitation approached the surveyor at 12:45 P.M. and told the surveyor that Resident #99 had a foam cushion. The surveyor inquired why there was an air pump nozzle coming out the side of the wheelchair cushion. At 12:55 P.M. the Director of Rehabilitation returned to inform the surveyor that the Resident had a fusion cushion, which was a solid base of memory foam with a gluteal area of air cells. He said he would have to look in to the maintenance of the equipment as he was not sure. On [DATE] at 2:45 P.M. The Director of Rehabilitation said that he had reviewed the cushion for Resident #99. He said that the fusion cushion should be monitored daily. On [DATE] at 4:30 P.M. the Day Supervisor said she did not know the type of cushion on the wheelchair for the resident. She said that she would not have evaluated the cushion and that the rehabilitation department would have evaluated it. She said she had not had time to refer the resident to the rehabilitation department at this time (5 days after the area was discovered). On [DATE] at 2:55 P.M. the Physical Therapist (PT) was interviewed. The PT said that she had evaluated the positioning of Resident #99 and found that the fusion cushion needed more air. She said she had added air to the cushion and implemented an out of bed schedule for the resident. A review of the PT evaluation indicated that Resident #99 had developed two stage 2 wounds from lack of position changes.

Based on interviews and records reviewed, for one of eight sampled residents (Resident #3), the Facility refused to allow Resident #3 to return to the facility after requiring hospitalized from [DATE] through 12/5/18, because his/her new orders from the Hospital included a physician order [REDACTED]. Findings include: Resident #3's most recent Minimum Data Set Assessment, completed 12/11/18, indicated that his/her cognitive patterns were intact. The Surveyor interviewed Resident #3 at 11:45 A.M. on 2/6/19. Resident #3 said while he/she was in the Hospital, he/she was administered [MEDICATION NAME] for withdrawal after long term use of narcotic medication to manage pain. Resident #3 said that the Administrator refused to allow him/her to return to the facility on [MEDICATION NAME] and said he/she asked the Hospital to discontinue the [MEDICATION NAME] in order that the Facility would allow him/her to return. Review of the Hospital Case Management Progress Notes during Resident #3's hospitalized from [DATE] through 12/5/18 indicated the following: - Facility repeatedly refused Resident #3's request to return after the Hospital initiated Resident #3's treatment with [MEDICATION NAME]. - the Facility Administrator told the Hospital Case Managers that the Facility was not licensed to dispense [MEDICATION NAME] and would not allow Resident #3's return as long as he/she received [MEDICATION NAME]. - that Resident #3 had accepted a bed at another long term care facility, but returned to the Hospital within a few hours requesting that the [MEDICATION NAME] be discontinued so the Facility would allow his/her return. - Hospital discontinued Resident #3's [MEDICATION NAME] on 12/1/18 and Resident #3 returned to the facility on [DATE]. The Surveyor interviewed the Hospital Addiction Service Consultant at 12:40 P.M. on 2/5/19. The Addiction Service Consultant said that the Facility's Administrator refused to allow Resident #3 to return to the Facility from the hospital while he/she received [MEDICATION NAME]. The Hospital Addiction Service Consultant said several case management staff spoke to the Administrator and he continued to refuse to allow Resident #3 to return. The Surveyor interviewed the Administrator at 8:45 A.M. on 2/6/19. The Administrator said that it was a Massachusetts regulation that the Facility Medical Director be certified in the administration of [MEDICATION NAME] in order for the Facility to admit a resident on [MEDICATION NAME]. The Administrator said that because the Facility Medical Director was not appropriately certified, he could not allow Resident #3 to return while he/she took [MEDICATION NAME]. The Administrator said he did not refuse Resident #3's return from the hospital, but instead just did not allow him/her to return to the facility on [MEDICATION NAME]. The Hospital Addiction Service Consultant said and review of the Hospital Case Management Note, dated 11/27/18, indicated that case management staff provided the Administrator with education regarding Resident #3's right to access medications for substance use disorder, including [MEDICATION NAME], while in the Facility and the Administrator continued to refuse Resident #3's return.