Every finding on record at Oakhill Healthcare

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who required the use of a mechanical lift with the assistance of two staff members for transfers, the Facility failed to ensure he/she was provided with the appropriate assistive device (correct size mechanical lift sling/pad) in order to maintain his/her safety during a transfer, when Certified Nurse Aide (CNA) #1 and CNA #2 used a sling pad that was too big for him/her, Resident #1 slid out of the sling pad during the transfer, fell to the floor, and was transferred to the Hospital Emergency Department (ED) for an evaluation. Findings Include: Review of the Facility's Policy titled, Safe Lifting and Movement of Residents, dated as revised May 2018, indicated the following: -in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents.-staff responsible for direct resident care will be trained in the use of manual and mechanical lifting devices.-mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary.-staff will be trained on the safe use and care of the machines and equipment used in this facility allowed to lift or move residents.-staff will obtain competency in using mechanical lifts and will receive periodic training for adherence to policies and procedures regarding use of equipment and safe lifting techniques.-enough slings, in the sizes required by residents in need, will be available at all times. Review of the Report submitted by the Facility via Health Care Reporting System (HCFRS), dated 04/30/26, indicated that on 04/27/26 at 5:00 A.M. Resident #1 was being transferred out of bed to wheelchair by two Certified Nurse Aides (CNAs) via the Hoyer lift. The Report indicated that CNA #1 was guiding the Hoyer (mechanical) lift and CNA #2 was assisting with the guidance of Resident #1. The Report indicated that as CNA #1 began to move the Hoyer lift towards the wheelchair, the Hoyer lift banged into the back wheel of the wheelchair causing Resident #1 to swing back and forth. The Report indicated that Resident #1 slid out through the opening at the bottom of the Hoyer pad (sling) onto the floor on his/her right side, and he/she complained of generalized pain. The Report further indicated that Resident #1 was assessed by the Nurse (later identified as Nurse #1) with no visible injuries noted, and he/she had complained of generalized pain. The Report indicated that Resident #1's provider was notified and he/she was transferred to the Hospital ED for evaluation. Resident #1 was admitted to the Facility in October 2023 diagnoses included dementia, low back pain, spondylosis with radiculopathy lumbar region (nerve compression caused by age-related degeneration of the spine), atrial fibrillation (irregular heartbeat), hypothyroidism, hypertension, and insomnia. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of 06 out of 15 (0-7 indicates severe cognitive impairment, 8-12 indicates moderate cognitive impairment, 13-15 indicates cognitively intact) and he/she was dependent on chair/bed-to-chair transfers with the assistance of two or more helpers. Review of Resident #1's Care Plan related to Activities of Daily Living (ADL), reviewed and renewed with his/her March 2026 MDS, indicated that he/she was dependent on transfers with the use of a Hoyer (mechanical) lift. Review of Resident #1's Fall Incident Report, dated 04/27/26, (completed by Nurse #1) indicated Nurse #1 was called by the CNA (later identified as CNA #1) that Resident #1 fell out of the Hoyer lift with a head strike. The Report indicated that Nurse #1 found Resident #1 on the floor on his/her right side. The Report indicated that per CNA (CNA #1) report, Resident #1 was in the Hoyer lift [sling/pad] to be transferred to his/her wheelchair; while turning the Hoyer lift the base of the lift hit the wheelchair, he/she slid off the Hoyer pad (sling) and fell on the ground [floor]. The Report further indicated that Resident #1 was assessed, he/she denied loss of consciousness (LOC), skin with no visible injury and his/her pain level was rated 10/10 (0-10 numeric pain scale is a standard tool used to measure pain intensity; 0 represents no pain, 1 to 3 mild pain, 4 to 6 moderate pain, 7 to 10 severe pain). The Report indicated that the Nurse Practitioner (NP) was notified and Resident #1 was sent to the Hospital ED for evaluation. During an in-person interview on 06/02/26 at 4:07 P.M. and a telephone interview on 06/04/26 at 8:51 A.M., (which included review of her written employee statement), Nurse #1 said that on 04/27/26 around 5:00 A.M., CNA #1 called her to Resident #1's room because he/she had fallen. Nurse #1 said that she went to Resident #1's room, observed him/her on the floor lying on his/her right side, the right side of his/her head was resting on one of the legs of the Hoyer lift and that the sling pad was hanging from the Hoyer lift bar. Nurse #1 said she immediately assessed Resident #1 and he/she had no visible injuries. Nurse #1 said she asked Resident #1 if he/she had pain, he/she stated yes, a lot and said she rated his/her pain level 10 out of 10. Nurse #1 said she notified the on-call NP, and an order was given to send Resident #1 to the Hospital ED for evaluation. Nurse #1 said she asked the CNAs what had happened and said CNA #1 told her that they (CNA #1 and CNA #2) were transferring Resident #1 with the Hoyer lift and that CNA #1 said when she turned the Hoyer lift, the base of the Hoyer lift hit the wheelchair and Resident #1 slid out of the sling pad onto the floor. Nurse #1 said she observed the sling pad (which was orange colored) hanging from the Hoyer lift bar after Resident #1's fall but she did not know what size that sling pad was and said she had not checked to see if the lower straps had been crisscrossed by the CNAs. Nurse #1 said the size of the mechanical lift sling pad to be used for transferring a resident is based on their weight and that the color of the sling pad indicates the size. Nurse #1 said she did not know if the CNAs had used the appropriate size sling pad to transfer Resident #1 because she did not know what the size of the orange sling pad (used by the CNAs) was. During an interview on 06/02/26 at 1:07 P.M., (which included review of her written employee statement), CNA #3 said she worked the 7:00 A.M. to 3:00 P.M. shift on 04/27/26 on Resident #1's unit. CNA #3 said at the start of her shift CNA #1 told her that Resident #1 had been sent to the Hospital because he/she fell out of the Hoyer lift and needed x-rays. CNA #3 said she asked CNA #1 how Resident #1 fell out of the Hoyer lift and said CNA #1 told her that she and CNA #2 did not have the right size sling pad and that CNA #1 told her that they had used an orange sling pad. CNA #3 said the size of the orange sling pad was extra-large and said that staff uses a blue mesh sling pad which is a size small to transfer Resident #1 with the Hoyer lift. Review of the Mechanical Lift Application and Use Competencies for CNA #1, dated 04/02/25, and CNA #2, dated 07/16/25, indicated they were both observed and determined to be competent performing transfers using a Mechanical lift, which included: -choose the proper lift sling according to the person's weight and the purpose of the lift; follow the manufacturer's guidelines for sling size; rationale ensures safety and proper use of equipment. -position the chair, wheelchair near the bed but with enough space for the lift to move and pivot; rationale minimizes risk of injury. During an in-person interview on 06/02/26 at 3:19 P.M. and a telephone interview on 06/04/26 at 9:22 A.M., (which included review of her written employee statement), Certified Nurse Aide (CNA) #2 said that on 04/27/26 she and CNA #1 used the Hoyer lift to transfer Resident #1 from his/her bed to the wheelchair. CNA #2 said they placed an orange sling pad under Resident #1; they hooked up the same color upper loops, the middle loops, and then crisscrossed the lower straps before hooking them onto the Hoyer lift. CNA #2 said CNA #1 operated the Hoyer lift, that CNA #1 raised the lift with Resident #1 seated in the sling/pad, pulled the Hoyer lift away from the bed, then CNA #1 turned the Hoyer lift to the right and said that she (CNA #2) heard a banging sound. CNA #2 said the bottom legs of the Hoyer lift hit the wheelchair, Resident #1 started to swing, and he/she slid out the bottom of the sling pad onto the floor landing on his/her right side. CNA #2 said when CNA #1 first raised Resident #1 up with the Hoyer lift for the transfer he/she was not in a full upright sitting position and said that his/her body was in more of a lying position. CNA #2 said for residents that are transferred with the Hoyer lift, the sling pads are usually left in their rooms. CNA #2 said they (CNAs) have always used a blue mesh sling pad to transfer Resident #1, but the blue mesh sling pad was not in his/her room that morning. CNA #2 said that CNA #1 had brought an orange sling pad into Resident #1's room, and they used it to use to transfer him/her. CNA #2 said that she did not know the size of an orange sling pad but said that the orange sling pad was too big for Resident #1. During an interview on 06/03/26 at 10:43 A.M., (which included review of her written employee statement), CNA #1 said on 04/27/26 she and CNA #2 used the Hoyer lift to transfer Resident #1. CNA #1 said she and CNA #2 positioned the sling pad under Resident #1, hooked the same color upper loops, crisscrossed the lower straps up under Resident #1's legs and hooked the loops of the legs to the lift and then hooked the middle loops to the lift last. CNA #1 said she operated and guided the Hoyer lift while CNA #2 stood on the side of Resident #1's wheelchair. CNA #1 said when she raised Resident #1 up off the bed he/she was in an upright sitting position, then she backed the Hoyer lift out from under the bed and said that as she turned the Hoyer lift to the right the legs of the lift hit the back of the wheelchair. CNA #1 said Resident #1 swung forward then swung backwards and said that he/she slid out the bottom of the sling pad and fell onto the floor landing on his/her right side. CNA #1 said when Resident #1 fell onto the floor he/she yelled Ow, she asked him/her if he/she was okay and Resident #1 said no. CNA #1 said the sling pads that are used to transfer residents with the Hoyer lift are left in their rooms. CNA #1 said the blue mesh sling pad in Resident #1's room was soiled and said that she went to the laundry room and the only clean sling pad available was an orange one. CNA #1 said she thought the size of an orange sling was small to medium, that she had used an orange sling pad to transfer Resident #1 before, but they (CNAs) usually use the blue mesh sling pad. CNA #1 said the size of the sling pad to be used is based on a resident's weight and said that the nurses inform the CNAs what size sling pad should be used for a resident. During an in-person interview on 06/02/26 at 4:42 P.M. and a telephone interview on 06/15/26 at 3:51 P.M., the Director of Nursing (DON) said she was notified on 04/27/26 by Nurse #1 that Resident #1 fell out of the mechanical lift, and he/she was transferred to the Hospital ED for evaluation. The DON said after Resident #1's fall she inspected the orange sling pad that was used to transfer Resident #1 it had no rips, tears or holes. The DON said CNA #1 and CNA #2 demonstrated to her how they transferred Resident #1. The DON said she could not understand how Resident #1 slid out from the bottom of the sling pad because CNA #1 and CNA #2 insisted that they had crisscrossed the lower straps between Resident #1's legs. The DON said that the CNAs had used an orange sling pad which was a larger sized sling pad and said that she thought an orange sling pad was too big for Resident #1.The DON said it was her expectation that the CNAs use the appropriate size sling pads for residents when transferring them with the Hoyer lift and that they follow the proper guidelines and safety when using the Hoyer lift. The DON said if the CNAs do not know or have any doubt of what size sling pad to use for a resident, they need to stop what they are doing and ask the Nurse.On 06/02/26, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction with an effective date of 05/02/26, which addressed the area(s) of concern as evidenced by: A. On 04/27/26, Resident #1 was assessed by the Nurse, and he/she was transferred to the Hospital ED for evaluation. Resident #1 did not return to the Facility. B. On 04/27/26, the Maintenance Director conducted an audit on all mechanical lifts in the Facility to ensure they were in proper working condition. C. On 04/27/26, the Director of Nursing inspected the Hoyer lift sling pad used to transfer Resident #1, and it was found to be in good condition with no rips or tears. D. On 04/27/26, the Director of Nursing inspected all Hoyer lift sling pads in the Facility to ensure they were in good condition with no rips or tears. E. On 05/01/26, the Rehab Department conducted Rehabilitation Screens/assessments on all residents who required transfer with a Hoyer lift to determine the appropriate pad/sling size to be used by staff for resident transfers. F. Nursing Management updated all residents' Care Plans and Kardex's for those residents who required transfer with a Hoyer lift to include the appropriate sling/pad size to be used for transfers. G. On 05/01/26 the Regional Clinical Educator and Unit Manager initiated education to all Licensed Nursing staff and Certified Nurse Aides on Hoyer lift transfers and return demonstration competencies were performed. H. The Director of Nursing and/or designee will continue to conduct Random Observation audits on residents' transfers via the Hoyer lift to ensure the proper lift pad is used and that staff are following proper procedure, starting with three times weekly for four weeks, then weekly for four weeks, then monthly for three months or until substantial compliance is achieved. I. The results of the Random Observation audits will be presented and reviewed at the monthly QAPI meeting for three months or until substantial compliance is achieved. J. The Director of Nursing and/or designee are responsible for overall compliance.

Based on record review and interview, the facility failed to ensure that specialized rehabilitation services were provided to assist in maintaining the highest practicable level functioning for one Resident (#33), out of a total sample of 19 residents. Findings include: Review of the Rehabilitation Consultant Company policy titled Policy: 8.1 - Evaluations, revised 7/21/25, indicated but was not limited to the following:POLICY:-all patients identified as needing an assessment of functional status or assessment of indicators impacting quality of life and having potential to benefit from rehabilitation, habilitative, and/or skilled functional maintenance therapy be evaluated to determine an appropriate plan of care;-an evaluation is an assessment of the patient's physical and functional status used to determine if Physical Therapy (PT), Occupational Therapy (OT), or Speech Therapy (ST) services are medically necessary, gather baseline data including objective findings, and establish a treatment plan with reasonable and attainable goals to be targeted within a defined time frame;-evaluations are administered with appropriate and relevant assessments, preferably standardized, using objective measures and/or tools;-an evaluation is required prior to implementing any skilled treatment plan. PROCEDURE:-scope of evaluations include case history, prior level of function, determination of medical necessity, onset of functional decline, as well as contraindications and precautions.-clinicians will determine and implement a plan of treatment consistent with current best practices in the field of rehabilitation, in collaboration with the patient and family;-evaluation results are the foundation for clinically based decisions regarding rehabilitation potential or the need for skilled functional maintenance therapy and/or habilitative interventions;-the evaluation will be provided to the ordering physician, and a physician signature and date of signature will be obtained for approval of the plan of treatment, within state, federal, and payor-specific guidelines. Review of Standards of Practice for Physical Therapy, dated 8/12/20, indicated but was not limited to:-Physical therapy personnel collaborate with all health services providers and with patients, clients, caregivers, and others as appropriate; and use a team and person-centered approach in coordinating and providing physical therapist services. Resident #33 was admitted to the facility in October 2025 with diagnoses which included adult failure to thrive, muscle atrophy, neuralgia (a nerve condition that can cause muscle weakness and coordination difficulties), neuropathy (a nerve condition with a potential side effect of weakness), and Parkinson's disease with dyskinesia (uncontrollable and involuntary bodily movements). Review of Resident #33's Minimum Data Set (MDS) Assessment, dated 10/16/25, indicated Resident #33 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the Resident was cognitively intact. The Resident was dependent on or required maximum assistance with Activities of Daily Living (ADLs). Review of the Resident's PT notes indicated Resident #33 was evaluated by PT on 10/13/25 and received skilled services on 10/13/25 and 10/14/25. The PT documentation indicated but was not limited to the following: 10/13/25 PT EVALUATION & PLAN OF TREATMENTPayer: Managed Care Part-BStart of Care: 10/13/25 Diagnoses: Parkinson's disease with dyskinesia with fluctuations, muscle wasting, and atrophy multiple sites Frequency: 4 times per weekDuration: 30 daysCertification Period: 10/13/25-11/11/25 Prior to Onset: Patient was able to independently transfer sit to stand and to independently ambulate with rolling walker in June 2025 prior to hospitalization Patient and Caregiver Goals: wants to improve functional mobility with reduced dependence on caregivers Potential for Achieving Rehab Goals: Patient demonstrates good rehab potential as evidenced by attentive to tasks, active participation in skilled treatment, motivated to participate and supportive caregivers/staff. Focus of Plan of Treatment: Compensation Participation = Patient/Caregiver participated Clinical Impressions: Patient will benefit on PT to increase muscle strength, standing balance/tolerance, range of motion, coordination and endurance to improve functional mobility with reduced physical assistance. The PT evaluation was electronically signed and dated by the Resident's physician, indicating the physician certified the need for these medically necessary services furnished under this plan of treatment while under the physician's care from 10/13/25 through 11/11/25. 10/14/25 PT DISCHARGE SUMMARYPayer: Managed Care Part-BPatient Progress and Response to Treatment: Patient has potential to progress and willing to participate.Discharge Reason: Other Review of the Resident's PT Treatment Encounter Notes indicated but were not limited to the following:10/14/25, discharged from PT today due to insurance status. During an interview on 12/30/25 at 12:25 P.M., Resident #33 said he/she used to be able to walk at home and the facility was not providing him/her any therapy services which he/she wanted in order to improve strength and be more independent. During an interview on 12/30/25 at 12:45 P.M., the Director of Rehab (DOR) said rehab services were not provided for Resident #33 due to insurance issues. The DOR said the rehab department/facility has been working since the Resident's admission to see if therapy services will be covered by the Resident's insurance. During an interview on 12/31/25 at 12:59 P.M., Certified Nurse Assistant (CNA) #3 said Resident #33 had asked many times for PT/OT and she notified nursing. She was unsure of the outcome. During an interview on 12/31/25 at 1:17 P.M., Nurse #3 said Resident #33 did not want to get out of bed when he/she was admitted to the facility, but he/she had slowly improved. Nurse #3 said the Resident told her he/she used to walk before he/she was admitted to the facility, so Nurse #3 requested therapy to assess the Resident, but therapy said they could not provide services due to an insurance issue. Review of Nursing Request for Rehab Screen forms indicated nursing requested a PT screen on 10/10/25. The DOR responded on the form that the Resident would be evaluated by PT on 10/13/25. Nursing submitted a PT/OT screen on 10/23/25 for independent feeding and adaptive utensils. The DOR responded on the form the Resident was not appropriate for therapy services at this time, will re-assess. During an interview on 12/31/25 at 1:45 P.M., the Administrator said the Therapy Consultant Company is responsible for insurance billing. He said the DOR should discuss with the Administrator any residents with insurance issues or non-coverage who would benefit from therapy services as the facility would pay for therapy services. The Administrator said he had approved payment for therapy services in the past for other residents. The Administrator said he was unaware of Resident #33's therapy recommendations, but if Resident #33 was evaluated as benefiting from therapy services, then he/she should have received the appropriate services. During an interview on 1/5/26 at 2:13 P.M., the Director of Nursing (DON) reviewed Resident #33's medical record and said the Resident was at higher risk for pain or wounds without therapy services. The DON said Resident #33 should have been followed by and provided therapy services even if the facility had to pay for it.

Based on interview and record review, the facility failed to follow professional standards of practice for one Resident (#27), out of a total sample of 19 residents, when they did not implement a physician's order for referral to psychiatric services following a monthly medication regimen review. Findings include: Review of the facility's policy titled Medication Regimen Review, dated 8/2020, indicated but was not limited to the following:- resident specific irregularities and/or clinically significant risks resulting from or associated with medications are documented in the resident's active medical 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 Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following:-The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated:-Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error.-In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber. Resident #27 was admitted to the facility in October 2025 and had diagnoses including: Extrapyramidal and movement disorder, Unspecified dementia without behavioral disturbance, nightmare disorder, and delusional disorder. Review of the Minimum Data Set assessment signed as completed in November 2025 indicated Resident #27 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15. Review of the monthly Medication Regimen Review (MRR) for Resident #27 from October 2025 indicated a consultant pharmacist recommendation to prescriber was left for the Physician and indicated the following:-10/6/25: Resident is receiving the following antipsychotic for insomnia - Seroquel. Although effective, antipsychotic medications are not normally indicated for sleep, due to increased potential for significant adverse reactions, especially in the elderly.-If medication is being used for an indication other than sleep, please clarify.Physician/Prescriber response:-10/10/25 Agree: Dx: Progressive supranuclear palsy; nightmare disorder. Refer to psych (psychiatric services). Review of the medical record indicated but was not limited to the following:-consent and information checklist offering services dated 10/3/25; the form failed to indicate the option for behavioral health services was discussed and the document was unsigned by Resident #27.-the medical record failed to indicate Resident #27 was offered the Physician ordered psych services or that services had been rendered During an interview on 1/2/26 at 11:25 A.M., the Director of Nurses (DON) said the October MRR clearly indicated an order to refer Resident #27 to psychiatric behavioral health services. She reviewed the medical record and said there is no indication in the medical record that the referral ever took place, and she did not know why the services were not offered to the Resident with a signed consent. During an interview on 1/2/26 at 12:06 P.M., the Licensed Mental Health Counselor (LMHC) from the facility's contracted psych services said Resident #27 was not on services and on review of the psych services computer system had never been referred or offered services. During an interview on 1/2/26 at 12:23 P.M., the Unit Manager said the process for MRR is that once they are sent to the DON by the pharmacist she reviews them with the Physician or Nurse Practitioner (NP), has them document any changes or new orders on the form, and then follows up by completing the changes and implementing the orders as indicated by her initials on the document. The Unit Manager reviewed the October 2025 MRR for Resident #27 and said she had initialed the NP orders to refer to psych services and add a diagnosis. She said on review of the medical record she did not carry out the order to refer Resident #27 to psych services and should have implemented the order as written and documented whether or not the Resident was agreeable.

Based on record review and interviews, the facility failed to ensure staff maintained accurate medical records for three Residents (#2, #87, #91), out of a total sample of 19 residents. Specifically, the facility failed:1. For Resident #2, to ensure the Resident's active Physician's Orders accurately reflected the Resident's advance directives as indicated on the Resident's Massachusetts Orders for Life Sustaining Treatment (MOLST);2. For Resident #87, to ensure information regarding a potential resident-to-resident altercation and follow up assessment and intervention were documented; and3. For Resident #91, to document information of an assessment on a potential cause for hospitalization or change in condition for Resident #91 prior to their transportation to the emergency room (ER). Findings include:1. Resident #2 was admitted to the facility in September 2025 with diagnoses including atrial fibrillation. Review of Resident #2's MOLST indicated the following: Do not resuscitate, use non-invasive ventilation, transfer to hospital, no dialysis, use artificial nutrition short term only signed by Resident #2's invoked Activated Health Care Proxy. Review of Resident #2's orders indicated the following: -Do not resuscitate, Honor the MOLST, use non-invasive ventilation, transfer to hospital, no dialysis, use artificial nutrition short term only, use artificial hydration short term only, dated 9/8/25 -Full Code, dated 9/5/25 During an interview on 12/31/25 at 10:45 A.M., Nurse #2 said Resident #2's code status was not accurately listed in the electronic health record. She said it is important for the advance directives to be accurate in the event of an emergency. She said the Resident's code status was unclear. During an interview on 12/31/25 at 10:58 A.M., the Director of Nurses (DON) said the medical record should reflect the accurate code status for the Resident. She said the orders should have been updated according to what the Resident's advanced directives were. She said she expects the order reflecting the Resident's full code to be discontinued when a MOLST was executed. 2. Resident #87 was admitted to the facility in July 2025 with diagnoses including: Metabolic encephalopathy, Cryptococcosis, Immune reconstitution syndrome, and altered mental status. Review of the medical record indicated the brief interview for mental status on the most reason minimum data set in October 2025 was not completed related to the Resident being rarely or never understood. Further review of the record indicated Resident #87 had a court ordered guardian. During an interview on 12/30/25 at 9:11 A.M., the guardian for Resident #87 said he was notified by the facility on Christmas night (12/25/25) of Resident #87 being molested by another resident who lives in the facility. He said he came to the facility and spoke with the police who came to the facility when the crime had been reported to them on that night by a nurse at the facility. He said he spoke with the police and decided not to press charges against the other resident to preserve Resident #87 from having to be involved in a legal situation related to their inability to communicate well. Review of the progress notes, evaluations and care plans for Resident #87 from 12/23/25 through 12/30/25 failed to indicate there were any potential incidents that may have occurred or any assessments or follow up conversations to ensure the Resident received any necessary emotional support following his alleged involvement in a resident-to-resident altercation with potential sexual contact. During an interview on 12/30/25 at 4:27 P.M., the Director of Nurses (DON) said she was aware that there was an alleged incident that had occurred on 12/25/25 and the staff had reported it to her. She said she would expect that there was some type of documentation of the event in the medical record to show that the incident had occurred, the police were called, and the family was notified, but on review of the medical record said there was no documentation of the alleged incident. During an interview on 12/30/25 at 4:55 P.M., the Administrator said he was informed on 12/25/25 at approximately 7:45 P.M., that Resident #87 may have been involved in an alleged incident with another resident. He said he didn't know the specifics but would suspect the information on the potential resident-to-resident contact and anything nursing did to intervene and assess the situation would be documented in the medical record. On review of the medical record, he said he was surprised there was no information in the record and there should be. During an interview on 12/31/25 at 3:15 P.M., the DON and Regional Nurse reviewed the medical record and said there is no documentation regarding the incident, follow up assessment, or any information at all that Resident #87 was involved in a potential resident-to-resident incident. The Regional nurse said there should have been a basic note indicating the Resident may have been involved in an incident and what steps the facility took to assess and then protect the Resident, but that information is not in the medical record. They said the medical record for Resident #87 is inaccurate and incomplete since it does not indicate that the Resident was involved in a potential incident on 12/25/25. 3. Resident #91 was admitted to the facility in October of 2025 with diagnoses including: Hepatic encephalopathy, disorder of the Urea cycle, Diabetes mellitus type 2 and mood disorder. Review of the medical record indicated Resident #91 suffered from severe cognitive impairment with a brief interview for mental status score of 2 out of 15 on the most recent Minimum Data Set, dated in October 2025. Review of the medical record indicated, but was not limited to the following: -10/20/25 labs were monitored -10/24/25 reddened sclera of the left eye was identified -10/27/25 a discharge/transfer evaluation was completed by the social worker on duty indicating the Resident was transferred to the hospital for a change in mental status The record failed to indicate through progress notes or assessments a reason for the Resident's transfer or attempted interventions by the clinical team. During an interview on 1/2/26 at 10:23 A.M., the Unit manager reviewed the medical record and said although she found the discharge/transfer evaluation completed by the social worker, she could not locate any documentation by nursing that would indicate why Resident #91 was transferred to the hospital or any possible change in condition. She said it is possible the Resident's wife/HCP had requested a transfer to the hospital, but that was not documented anywhere. She said regardless of the reason for Resident #91's transfer to the hospital there should be some documentation in the medical record to explain what had occurred and there was not. During an interview on 1/2/26 at 10:27 A.M., the DON said there is no documentation in Resident #91's medical record from 10/24/25 to the date of transfer to the hospital on [DATE] and the missing information made the record incomplete and inaccurate.

Based on observations and interviews, the facility failed to ensure residents had a homelike environment. Specifically, the facility failed to: 1. Ensure Resident #1's fall mats and walls were in good repair and clean; and 2. Ensure residents on the B-Unit and C-Unit had an environment that was in good repair and homelike.Findings include: 1. Resident #1 was admitted to the facility in August of 2018 with diagnoses including cerebrovascular accident (stroke).Review of the Minimum Data Set assessment, dated 10/16/25, indicated on the staff assessment for mental status the Resident has a short-term and long-term memory impairment.On 12/30/25 at 7:59 A.M., the surveyor observed the following in Resident #1's room:- Resident #1 in bed with a ripped fall mat with approximately a 6-inch by 14-inch area of stained foam exposed on the left side of the Resident's bed.-Two missing floor tiles on the right side of the bed-An area of the wall with brown stains approximately two and a half feet in width.The surveyor made the same subsequent observations on:12/30/25 at 10:56 A.M.,12/30/25 at 11:17 A.M.,12/30/25 at 12:34 P.M.,12/30/25 at 1:52 P.M., and12/30/25 at 3:30 P.M.During an interview on 12/30/25 at 10:50 A.M., Nurse #2 said if there was something emergent that needed to be fixed or cleaned, she would call Maintenance or Housekeeping. She said if it wasn't urgent but needed to be addressed, she would input the request into an electronic tracking log. She said there are no outstanding maintenance requests she is aware of on the unit.Review of the Maintenance Log, dated December 1-30, indicated no requests for Resident #1 were made prior to the surveyor inquiring about the Resident's environment with facility staff.During an interview on 12/30/25 at 3:14 P.M., Housekeeping Staff #1 said she has finished cleaning Resident #1's room for the day.During an interview on 12/30/25 at 3:42 P.M., Nurse #7 said he didn't know the process for maintenance requests because he doesn't work at the facility regularly. He said he wasn't sure how long the stains had been on the wall, and he said it looks to be the same color as Resident #1's liquid tube feed. He said the room needs attention from Housekeeping and Maintenance.During an observation with an interview on 12/31/25 at 7:19 A.M., the surveyor observed the same light brown stain on the wall and ripped floor mat. During this time the surveyor observed the Maintenance Director enter the room. He said he was made aware of the broken floor tiles and dirty wall. He said it should not look like this. The surveyor observed the ripped floor mats after Maintenance had attended to the room on:-12/31/25 at 8:45 A.M.,-1/5/26 at 7:42 A.M., and-1/6/26 at 10:40 A.M.During an interview at 1/6/26 at 10:44 A.M., the Administrator said the Resident's equipment and room should be in good repair and homelike. 2. On 1/6/26 at 7:48 A.M., the surveyor observed the following on the B-Unit:-room [ROOM NUMBER]'s screen door was ripped off of the hinge and duct tape was along the edge of door on the inside. -room [ROOM NUMBER]'s curtain to outside sliders was off track.-room [ROOM NUMBER]'s bottom drawer was missing a handle, and the closet door was without a handle.-room [ROOM NUMBER]'s wall was stained with drip stains behind the bed.-room [ROOM NUMBER]'s two bottom drawers were without hand pulls.-room [ROOM NUMBER]'s two bottom drawers were without hand pulls. On 1/6/26 at 8:04 A.M., the surveyor observed the following on the C-Unit:-room [ROOM NUMBER]'s closet door was in disrepair and falling off the track.-room [ROOM NUMBER] had a missing closet door.-room [ROOM NUMBER] had a missing closet door.-room [ROOM NUMBER] had a missing closet door.During an interview on 1/6/26 at 10:40 A.M., the Maintenance Director said he is new at the building and did not realize that a homelike environment meant furnishings being in good repair. He said he believed that Housekeeping was responsible for maintaining the floor mats. During an interview on 1/6/26 at 10:44 A.M., the Administrator said all areas of the building should be in good repair, clean, and homelike. He said the electronic system used for maintenance requests should be utilized for concerns like these and he expects them to be identified and addressed.

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:1. The main kitchen floor and walk-in refrigerator shelving were maintained in a sanitary and safe condition; and2. Labeling and dating of refrigerated items in two of four kitchenettes. Findings include: 1. Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: 3-305.11 (A) Except as specified in paragraphs (B) and (C) of this section, food shall be protected from contamination by storing the food (1) in a clean, dry location. 4-602.11 (D) Equipment is used for storage of packaged or unpackaged food such as a reach-in refrigerator and the equipment is cleaned at a frequency necessary to preclude accumulation of soil residues. 4-602.13 Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 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 Review of the facility's policy titled Cleaning and Sanitizing Stationary Foodservice Equipment and Work Surface, revised June 2018, indicated but was not limited to the following:POLICY: Stationary foodservice equipment and surfaces are cleaned, and food contact surfaces of stationary foodservice equipment and work surfaces are cleaned and sanitized to minimize the risk of pathogen and chemical food contamination. GUIDELINES:-The frequency of cleaning foodservice equipment and surfaces that are nonfood-contact surfaces is dependent on the type of equipment and is outlined on the cleaning schedule.-Cleaning and sanitizing other foodservice surfaces (such as shelving):>Scrape or remove food bits from the surface. Use a nylon brush or pad, or a cloth towel if needed;>Wash the surface with the cleaning solution using the correct cleaning tool, such as a cloth towel;>Rinse the surface;>Allow surface to air dry. On 12/30/25 at 7:30 A.M., the surveyor observed the following:-several missing floor tiles in the walk-in refrigerator with debris accumulation-receding and crumbling grout in areas of the dishwashing room containing accumulated water-black splotches throughout shelving used to store food in the walk-in refrigerator During an interview on 12/30/25 at 7:30 A.M., Dietary Aide #1 said floor cleaning consisted of sweeping and mopping the floor with no special method to clean the recessed grouting in the dish room. Dietary Aide #1 said it can be a challenge to get all the debris out of the grout. During an interview on 1/5/26 at 11:15 A.M., the Corporate Food Service Director (FSD) said the kitchen floors should be easily cleanable. She said the floor grout in the dish room was receding and should be replaced and the missing floor tiles in the walk-in refrigerator should also be replaced. During an observation and interview on 1/5/26 at 11:50 A.M., the Corporate FSD and surveyor observed the walk-in refrigerator shelving (in use with stored food) to have black splotches throughout. The Corporate FSD said the shelves should be cleaned regularly to prevent accumulation of debris. 2. Review of the facility's policy titled Food and Supply Storage, revised 06/2018, indicated but was not limited to the following:-Food, non-food items, and supplies used in food preparation and service shall be stored in such a manner as to maintain safety and sanitation of the food or supply for human consumption as outlined in the Federal Drug Administration Food Code, state regulations, and city/county health codes.-Food products that are opened and not completely used; transferred from its original package to another storage container; or prepared at the facility and stored should be labeled as to its contents and used by dates. Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following:Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.(B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. On 12/30/25 at 4:16 P.M., the surveyor observed in the A-Wing kitchenette:-One container of thickened liquid, opened, with no date indicating when it was opened or when to use it by.-One homemade smoothie-type drink with no label or date. During an interview on 12/30/25 at 4:16 P.M., Nurse #8 said all items in kitchenette refrigerators should be labeled and dated and opened items should be labeled with the date they were opened. On 1/5/26 at 10:32 A.M., the surveyor observed in the B-Wing kitchenette:-Two thickened liquids, opened, with no date indicating when they were opened or when to use them by.-One single serve nutritional supplement container, opened, with no label or use by date. On 1/5/26 at 2:15 P.M., the surveyor observed in the B-Wing kitchenette:-Two thickened liquids, opened, with no date indicating when they were opened or when to use them by.-One single serve nutritional supplement container, opened, with no label or date indicating when it was opened or when to use it by. During an interview on 1/5/26 at 3:01 P.M., the FSD said items in the kitchenette refrigerators should be labeled and dated and any opened items should be labeled with the date it was opened. The FSD said the thickened liquids and opened nutritional supplement should have been labeled and dated.

Based on observation, interview, and document review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to ensure proper hand hygiene after handling contaminated equipment and follow infection control standards while administering medications for two Residents (#15 and #44), out of five residents observed during medication administration.Findings include:Review of the facility's policy titled Administering Oral Medications, dated as revised 11/2025, indicated but was not limited to the following:-Perform hand hygiene-Select the drug from the medication cart-Perform hand hygieneReview of the facility's policy titled Handwashing/Hand Hygiene, dated as last revised 7/2024, indicated but was not limited to the following:-This facility considers hand hygiene the primary means to prevent the spread of infections.-All staff shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.-Use an alcohol-based hand rub containing at least 62% alcohol or alternatively, soap and water for the following:-Before and after direct contact with residents-Before preparing or handling medications-After handling contaminated equipment-To protect residents from health care associated infectionsOn 12/31/25 at 8:53 A.M., the surveyor observed Nurse #4 standing next to her medication cart that was in the hallway. Resident #15 was seated in a wheelchair positioned on the side of the medication cart. Nurse #4 lifted the Resident's left shirt sleeve and placed a blood pressure cuff on his/her left arm. Nurse #4 did not clean the cuff prior to applying it to the Resident's arm and did not perform hand hygiene. Nurse #4 then recorded the blood pressure, removed the cuff and placed it back into the medication cart. Nurse #4 did not clean the blood pressure cuff or perform hand hygiene. Nurse #4 then reached back into her medication cart and started preparing medications and administered the medications to the Resident.On 12/31/25 at 9:10 A.M., the surveyor observed Nurse #4 prepare Resident #44's morning medications which included the following:-Advair 21 micrograms (mcg) inhaler (treats asthma) two puffs by mouth twice a day.-Nurse #4 entered Resident #44's room with the Advair in her hand and handed it to the Resident; the Resident self-administered two puffs by mouth.-Nurse #4 took the used inhaler from the Resident with her bare hands and exited the room.-Nurse #4 placed the used inhaler directly on top of her medication cart, without a clean barrier.-Nurse #4 then opened her medication cart drawer without performing hand hygiene.-Nurse #4 then picked up the used inhaler, put it in a bag and stored it in the medication cart and performed hand hygiene.-Nurse #4 did not clean the top of the medication cart and started preparing other medications.During an interview on 12/31/25 at 11:05 A.M., Nurse #4 said she should have cleaned her hands before and after taking the Resident's blood pressure. She said her normal practice is to clean her blood pressure cuff before and after each use; she just forgot. Nurse #4 said she should have completed hand hygiene after administering medications and cleaned the top of the medication cart because the used inhaler was placed on top of the cart.During an interview on 1/5/26 at 2:52 P.M., the Director of Nursing (DON) said her expectations were for any shared equipment to be cleaned before and after use. She said hand hygiene must be performed prior to and after medication administration. The DON said if any dirty items are placed on the medication cart during a medication pass, it must be cleaned prior to preparing any more medications due to the risk of cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect).

Based on record review and interview, the facility failed for one Resident (#7), out of a total sample of 19 residents, to notify the physician of a significant weight loss of 11 percent over 90 days, that was unplanned and unexpected. Findings include:Review of the facility's policy titled Nutrition, dated as revised 6/2018, indicated but was not limited to the following: - the Physician is notified and consulted when there is a significant change in the resident's nutritional status Review of the facility's policy titled Change in a Resident's condition or status, dated as revised 7/2024, indicated but was not limited to the following: - the facility professional staff will communicate with physician's regarding changes in condition as warranted- the Nurse will notify the resident's provider or on call provider when there has been a change in resident condition (not limited to)-significant change in the resident's physical condition Resident #7 was admitted to the facility in August 2025 and had diagnoses including: Enterocolitis due to clostridium difficile (C. diff), obesity class 3, noninfective gastroenteritis, and gastro-esophageal reflux disease without esophagitis. Review of the Minimum Data Set (MDS) completed in November 2025 indicated the Resident had a significant weight loss but was not on a prescribed weight loss regimen. Review of the Nutritional Assessment, dated 11/19/25, indicated but was not limited to the following: - Diet: Consistent carbohydrate (CCHO); consistency is regular with thin liquids; with standard portion sizes- Weight: 225.7 pounds (lbs.) on 11/18/25; weight 90 days ago 254.4 lbs.; percent of weight change in 90 days is minus (-) 11% Review of progress notes, Physician notes, and Nurse Practitioner (NP) notes failed to indicate the Physician or NP was notified of the significant weight loss. During an interview on 12/31/25 at 10:28 A.M., Nurse #1 said she was aware of the Resident's weight loss, and she is Resident #7's primary nurse. She said she did not notify the physician or NP of the Resident's significant weight loss and that is why there are no documents in the medical record that indicate the physician or NP are aware of the change in the Resident's condition. During an interview on 12/31/25 at 10:36 A.M., the Physician said he was not made aware that Resident #7 had a significant weight loss and that is why he had not addressed the weight loss in the medical record. During an interview on 12/31/25 at 2:49 P.M. with the Director of Nurses (DON) and Regional Nurse, the DON said she would expect that the Physician or NP would be notified of a significant weight loss so they could evaluate the Resident or implement some type of intervention. The DON and Regional Nurse reviewed Resident #7's medical record and said there was no documentation that the Physician or NP was notified of Resident #7's significant weight loss. The DON said the facility should have notified either the Physician or NP and did not.

Based on record review and interviews, the facility failed to ensure for one Resident (#2), out of a total sample of 19 residents, that the Resident was free from chemical restraints. Specifically, the facility failed to address a recommended gradual dose reduction (GDR) of his/her physician's ordered Risperidone (antipsychotic medication). Findings include:Review of the facility's policy titled Psychotropic Medication, last revised 7/23, indicated but was not limited to the following:-psychoactive medications will be prescribed at the lowest possible dosage and are subject to gradual dose reduction and re-review as needed.-A physician's order and an appropriate diagnosis is required for psychotropic medicationResident #2 was admitted to the facility in September 2025 with diagnoses including dementia. Review of the current Physician's Orders indicated Resident #2 had an order for Risperidone oral tablet 1 milligram (MG) with instructions to give 1 MG by mouth twice daily.Review of the Minimum Data Set assessment, dated 9/5/25, indicated Resident #2 was taking an antipsychotic medication and no GDR had been attempted. Review of the psychiatric Nurse Practitioners (NP) note, dated 9/26/25, indicated the Resident was seen for an initial assessment for medication management. Review of the note indicated previous med trials or GDRs: unknown why on risperidone.Review of the psychiatric NP note, dated 10/20/25, indicated the following: psychiatric medications reviewed with unclear reason for antipsychotic use. Given significant risks in the elderly and mood and behavior stability since admission we will recommend slight GDR of Risperidone. Plans/Recommendations: recommend Risperdal GDR decrease to 0.5 MG in AM 1 MG at night. Review of the psychiatric NP's note, dated 11/25/25, indicated the practitioner would still recommend a trial of Risperidone GDR. During an interview on 12/31/25 at 10:42 A.M., Nurse #2 said there is a log where staff will write down names of residents who need to be seen by psychiatric services. She said after the visits the Director of Nurses (DON) receives the recommendations electronically to review with the physician. She said she was unaware of any recommended GDR for this Resident; she said the Resident has not had any delusions or hallucinations that she is aware of. She said she was not sure what diagnosis the antipsychotic was treating. Review of the NP visit summary, dated 10/30/25, failed to indicate acknowledgement of the recommendations and that they were addressed. Review of NP visit summary, dated 11/25/25, failed to indicate acknowledgement of the recommendations and that they were addressed. During an interview on 12/31/25 at 2:28 P.M., the Psychiatric NP said there are communication books on the unit with whom the facility puts names of residents in for her to visit and see. She said she initials them when they have been seen. She said her recommendations have gone to previous DONs and she just recently was asked by the facility to add the current DON. She said she was not sure if the recommendations she made were discussed with the physician after the second visit so that is why she recommended the GDR again. At this time the Resident has not had a decrease in his Risperidone as previously recommended. She said Resident #2 does not have a diagnosis that Risperidone would be appropriate for, and her notes reflect the Resident has been stable, and no hallucinations or delusions are noted. During an interview on 12/31/25 at 2:45 P.M, the Physician said he was not made aware of these recommendations from behavior health services and said he typically follows the psychiatric nurse practitioner's recommendations and would have approved a GDR. He said he wanted to review his notes to see if there was any additional documentation he could provide.During an interview on 1/5/26 at 7:55 A.M., the Unit Manager said there was no additional documentation from the physician indicating the physician was made aware of the recommendations. During an interview on 1/5/26 at 3:31 P.M., the DON said she can't speak to what was being done prior to her employment, but she said she has just received the recommendations and sees that there were two recommendations for Resident #2 that were not followed up on. She said she expects a process where the recommendations are made by the psychiatric NP and then the physician is made aware of them. She said the goal of GDRs is to be on the least amount of medication as possible while still treating any symptoms.

Based on interview, record review, and policy review, the facility failed for one Resident (#87), out of a total sample of 19 residents, to implement their abuse policy and procedure when there was a report of potential sexual abuse on 12/25/25. Findings include: Review of the facility's policy titled Abuse Investigation and Reporting, dated as revised 2/2024, indicated but was not limited to the following:-each resident has the right to be free from verbal, sexual, physical, and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of their property-the facility administrator will be the abuse prevention coordinatorDefinitions:Sexual abuse: any nonconsensual sexual contact. Includes but is not limited to sexual harassment, sexual coercion, or sexual assault of a resident.Identification and reporting:-to proactively identify any event that may be potential abuse, neglect, involuntary seclusion, or misappropriation of resident property and properly report that event to the appropriate agencies-each facility shall report to the Department suspected resident abuse, neglect, mistreatment or misappropriation-alleged violations are reported to the administrator and to other officials in accordance with state law. Alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in process. The result of the investigations must be reported in accordance with state/federal law within 5 business days of the incident and if the alleged violation is verified appropriate corrective action must be taken.Elder Justice Act:-report to DPH and local law enforcement any reasonable suspicion of a crime committed against an individual who is a resident of, or receiving care from, the facility. If the events that cause reasonable suspicion result in serious bodily injury, the report must be made immediately (but no later than two hours) after forming the suspicion. Otherwise, the report must not be made later than 24 hours after forming the suspicion. Crime is defined by local law jurisdiction.Abuse investigation Procedure:Upon receiving a report of an allegation of abuse the following actions will be taken:-staff witnessing a potentially inappropriate treatment, or receiving an allegation verbally will immediately report the event to the nursing supervisor/management-the nursing supervisor, or if directed to do so, nurse assigned to the resident will physically examine the resident for injuries-the nursing supervisor or designee will take appropriate steps to protect the resident, if applicable, from further mistreatment, and ensure appropriate care is provided- separate accused/suspected employee or resident from alleged victim and other residents-provide emotional support to the alleged victim-in the case of abuse (suspected, witnessed or alleged) the nursing supervisor/nurse will notify the provider, health care proxy (HCP), responsible party, Administrator and Director of nurses (DON)-interviews of appropriate individuals; any individuals who may have knowledge of the event should be interviewed. This may include the alleged victim, employees, visitors and other residents; the social worker may interview other potential victims. During an interview on 12/30/25 at 9:11 A.M., the guardian/responsible party for Resident #87 said he was notified by the facility on Christmas night (12/25/25) of Resident #87 being molested by another resident who lives in the facility. He said he came to the facility and spoke with the police who came to the facility when the crime had been reported to them on that night by a nurse at the facility. He said he spoke with the police and decided not to press charges against the other resident to preserve Resident #87 from having to be involved in a legal situation related to their inability to communicate well. Review of the medical record for Resident #87 failed to indicate the Resident was involved in an alleged resident-to-resident sexual abuse situation or that any events had occurred on 12/25/25 that resulted in the police coming to the facility to see the Resident or his/her guardian. A telephone call was placed to the Certified Nursing Assistant (CNA) who witnessed the alleged inappropriate sexual contact, but a return call had not been received. During an interview on 12/30/25 at 4:27 P.M., the DON said it was reported to her that this Resident was found by a CNA with another resident leaving his/her room and their genitals were exposed by being pulled out the side of their undergarment. She said the CNA reported it to the nurse and the nurse reported it to her. She said she directed the staff to contact the police, write statements and place the accused on checks for safety. She said she does not have the statements written by the staff because after she had contacted the Administrator about the incident he told her nothing needed to be done because the residents involved were friends. During an interview on 12/30/25 at 4:55 P.M., the Administrator said he was informed on 12/25/25 at approximately 7:45 P.M., that Resident #87 may have been touched in a sexual manner by another resident. He said that since the residents were friends, he didn't think it was necessary to do anything about the alleged contact. He said Resident #87 is not capable of making their own decisions and had a court appointed guardian, who was also a family member and therefore would not be capable to consenting to any potential sexual relationship and that the alleged aggressor was cognitively intact. He said in retrospect the facility should have implemented their abuse policy and reported and investigated the alleged incident of sexual abuse and did not. During an interview on 12/31/25 at 3:19 P.M., the Regional Nurse said that upon reviewing the available information, the facility should have identified that Resident #87 was involved in a potentially sexually inappropriate resident-to-resident altercation and implemented their full abuse policy but did not. He and the DON said the abuse policy was not followed in the manner it should have been and it was the management team that dropped the ball.

Based on interview and review of the Healthcare Facility Reporting System (HCFRS), the facility failed for one Resident (#87), out of a total sample of 19 residents, to report an alleged violation of potential sexual abuse within 24 hours as required under the Elder Justice Act. Findings include: Review of the facility's policy titled Abuse Investigation and Reporting, dated as revised 2/2024, indicated but was not limited to the following:-each resident has the right to be free from verbal, sexual, physical, and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of their property-the facility administrator will be the abuse prevention coordinatorDefinitions:Sexual abuse: any nonconsensual sexual contact. Includes but is not limited to sexual harassment, sexual coercion, or sexual assault of a resident.Identification and reporting:-to proactively identify any event that may be potential abuse, neglect, involuntary seclusion, or misappropriation of resident property and properly report that event to the appropriate agencies-each facility shall report to the Department suspected resident abuse, neglect, mistreatment or misappropriation-alleged violations are reported to the administrator and to other officials in accordance with state law. Alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in process. The result of the investigations must be reported in accordance with state/federal law within 5 business days of the incident and if the alleged violation is verified appropriate corrective action must be taken.Elder Justice Act:-report to DPH and local law enforcement any reasonable suspicion of a crime committed against an individual who is a resident of, or receiving care from, the facility. If the events that cause reasonable suspicion result in serious bodily injury, the report must be made immediately (but no later than two hours) after forming the suspicion. Otherwise, the report must not be made later than 24 hours after forming the suspicion. Crime is defined by local law jurisdiction. During an interview on 12/30/25 at 9:11 A.M., the guardian/responsible party for Resident #87 said he was notified by the facility on Christmas night (12/25/25) of Resident #87 being molested by another resident who lives in the facility. He said he came to the facility and spoke with the police who came to the facility when the crime had been reported to them on that night by a nurse at the facility. He said he spoke with the police and decided not to press charges against the other resident to preserve Resident #87 from having to be involved in a legal situation related to their inability to communicate well. Review of the HCFRS for the facility on 12/30/25 at 9:36 A.M., failed to indicate the facility had reported any alleged incidents of potential abuse or any incidents at all regarding Resident #87 in the month of December 2025. During an interview on 12/30/25 at 4:27 P.M., the Director of Nurses (DON) said it was reported to her that this Resident was found by a certified nurse assistant (CNA) with another resident leaving his/her room and their genitals were exposed by being pulled out the side of their undergarment. She said the CNA reported it to the nurse and the nurse reported it to her. She said she directed the staff to contact the police, write statements and place the accused on checks for safety. She said she did not report the incident because when she spoke with the Administrator he had told her that there is no issue since the residents involved were known to be friends. She said she had a feeling and should have reported it but did not. During an interview on 12/30/25 at 4:55 P.M., the Administrator said he was informed on 12/25/25 at approximately 7:45 P.M., that Resident #87 may have been touched in a sexual manner by another resident. He said that since the residents were friends, he didn't think it was necessary to do anything about the alleged contact and did not report the incident in accordance with the abuse policy. He asked the surveyor if the facility should bother to report the incident at this time since it should have been reported in the two-hour timeframe on the day of the occurrence and was informed that the facility should follow their company approved abuse policy. He said looking back at the situation the incident should have been reported within the two-hour time frame by the facility and wasn't. During an interview on 12/31/25 at 3:19 P.M., the Regional Nurse said that upon reviewing the available information, the facility should have identified that Resident #87 was involved in a potentially sexually inappropriate resident-to-resident altercation, and the event should have been reported in accordance with the abuse policy and Elder Justice Act and was not.

Based on interview and document review, the facility failed to thoroughly investigate allegations of sexual abuse for one Resident (#87), out of a total sample of 19 residents. Findings include: Review of the facility's policy titled Abuse Investigation and Reporting, dated as revised 2/2024, indicated but was not limited to the following:-each resident has the right to be free from verbal, sexual, physical, and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of their property-the facility administrator will be the abuse prevention coordinatorDefinitions:Sexual abuse: any nonconsensual sexual contact. Includes but is not limited to sexual harassment, sexual coercion, or sexual assault of a resident.Identification and reporting:-to proactively identify any event that may be potential abuse, neglect, involuntary seclusion, or misappropriation of resident property . Alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in process. The result of the investigations must be reported in accordance with state/federal law within 5 business days of the incident and if the alleged violation is verified appropriate corrective action must be taken.Abuse investigation Procedure:Upon receiving a report of an allegation of abuse the following actions will be taken:-staff witnessing a potentially inappropriate treatment, or receiving an allegation verbally will immediately report the event to the nursing supervisor/management-the nursing supervisor, or if directed to do so, nurse assigned to the resident will physically examine the resident for injuries-the nursing supervisor or designee will take appropriate steps to protect the resident, if applicable, from further mistreatment, and ensure appropriate care is provided- separate accused/suspected employee or resident from alleged victim and other residents-provide emotional support to the alleged victim-in the case of abuse (suspected, witnessed or alleged) the nursing supervisor/nurse will notify the provider, health care proxy (HCP), responsible party, Administrator and Director of nurses (DON)-interviews of appropriate individuals; any individuals who may have knowledge of the event should be interviewed. This may include the alleged victim, employees, visitors and other residents; the social worker may interview other potential victims. During an interview on 12/30/25 at 9:11 A.M., the guardian/responsible party for Resident #87 said he was notified by the facility on Christmas night (12/25/25) of Resident #87 being molested by another resident who lives in the facility. He said he came to the facility and spoke with the police who came to the facility when the crime had been reported to them on that night by a nurse at the facility. He said he spoke with the police and decided not to press charges against the other resident to preserve Resident #87 from having to be involved in a legal situation related to their inability to communicate well. A telephone call was placed to the Certified Nursing Assistant (CNA) who witnessed the alleged inappropriate sexual contact, but a return call had not been received. Review of the Healthcare Facility Reporting System (HCFRS) for the facility on 12/30/25 at 9:36 A.M., failed to indicate the facility had completed an investigation into the alleged incident on 12/25/25 for Resident #87. During an interview on 12/30/25 at 4:27 P.M., the Director of Nurses (DON) said it was reported to her that this Resident was found by a CNA with another resident leaving his/her room and their genitals were exposed by being pulled out the side of their undergarment. She said the CNA reported it to the nurse and the nurse reported it to her. She said she directed the staff to contact the police, write statements and place the accused on checks for safety. She said she does not have the statements written by the staff and had not read or reviewed the record, followed up on the situation, or completed an investigation regarding the allegation. She said after her conversation in which she reported the incident to the Administrator she didn't think it was necessary. During an interview on 12/30/25 at 4:55 P.M., the Administrator said he was informed on 12/25/25 at approximately 7:45 P.M., that Resident #87 may have been touched in a sexual manner by another resident. He said that since the residents were friends, he didn't think it was necessary to do anything about the alleged contact. He said Resident #87 is not capable of making their own decisions and had a court appointed guardian, who was also a family member and therefore would not be capable to consenting to any potential sexual relationship and that the alleged aggressor was cognitively intact. He said in hindsight he can see how the facility should have investigated the situation prior to making a judgement or assumption of assumed consent and the incident should have been investigated since it does fall under the abuse statue for possible sexual abuse. He said the police were called and did come to the facility, but he is unaware of the outcome of that occurrence and did not request a copy of the police report. He said the incident hasn't been investigated by the facility so it's hard to say whether any wrongdoing potentially occurred. He said the incident should have been investigated in line with the facility policy. During an interview on 12/31/25 at 9:45 A.M., the DON said she found the original statements she asked the staff to write and was obtaining more investigation information at this time. She said once the investigation was completed it would be put in HCFRS. Review of the progress notes, evaluations and care plans for Resident #87 from 12/23/25 through 12/30/25 failed to indicate there were any potential incidents that may have occurred or any assessments or follow up conversations to ensure the Resident received any necessary emotional support. Review of the facility incident report for resident-to-resident altercation regarding Resident #87 on 12/25/25 indicated but was not limited to the following: -the incident report was started and completed on 12/25/25-the police, responsible party for Resident #87, physicians, and DON were all notified of the incident on 12/25/25-the alleged aggressor was placed on 15-minute checks During an interview on 12/31/25 at 3:19 P.M., the Regional Nurse said the process for incident reports is that they are reviewed by the team at morning meeting the day after they are completed. The Regional Nurse said that upon reviewing the available information, the facility should have identified that Resident #87 was involved in a potentially sexually inappropriate resident-to-resident altercation and fully investigated the incident. He said regardless of any friendship the residents may have had, the facility had an obligation to ensure no abuse occurred. He said the investigation was ongoing at this time.

Based on record review and interview, the facility failed to provide indwelling catheter (a flexible tube inserted into the bladder to drain urine outside of the body) care and management consistent with professional standards for one Resident (#65), out of a total sample of 19 residents. Specifically, the facility failed to ensure the Foley catheter was positioned below the bladder draining with the flow of gravity.Findings include:Resident #65 was admitted to the facility in October 2024 with diagnoses including benign prostatic hyperplasia and malignant neoplasm of right kidney.Review of Resident #65's most recent Minimum Data Set (MDS) assessment indicated the Resident had an indwelling catheter.Review of Resident #65's current Physician's Orders indicated but was not limited to the following:Foley Cath care every shift, dated 10/25/24, indefinite. Review of Resident #65's care plan indicated the following:-The Resident has an indwelling catheter, dated 11/7/24.-The Resident will not develop any complications associated with catheter usage through the next review, revision dated 11/13/25.-Keep drainage bag below level of bladder, date initiated on 10/25/24.The surveyor observed Resident #65's catheter drainage bag positioned on the side of his/her elevated head of bed as follows:-12/30/25 at 8:04 A.M.-12/30/25 11:47 A.M.-12/30/25 12:35 P.M.-12/30/25 3:51 P.M.-12/31/25 7:13 A.M., and-12/31/25 8:21 A.M. On 12/31/25 at 7:34 A.M., the surveyor observed two staff members in Resident #65's room delivering the breakfast tray and offering to reposition the Resident for their meal; the catheter drainage bag was positioned at the level of the Resident's head. There was a staff member on each side of the bed near the Resident's head of bed. Neither staff member moved the catheter drainage bag to standard positioning, below the bladder level. During an interview on 12/31/25 at 8:21 A.M., Nurse #2 said the drainage bag should be positioned below the bladder. She said the drainage bag is too high. She said she didn't see it positioned incorrectly when she was in the room. She said the tubing should be flowing down with gravity to avoid any urine flowing back into the bladder.During an interview on 12/31/25 at 12:49 P.M., the Director of Nurses (DON) said the bag was positioned incorrectly and should have been placed in the correct position by nursing staff. She said the flow appears sedentary because it has to drain upwards and said the standard of care is for the drainage bag to flow with gravity and be below the bladder.

Based on observation and interview, the facility failed to ensure medications with a shortened expiration date were properly labeled once opened, in one medication cart out of three medication carts observed.Findings include: Review of the facility's policy titled Storage Medications, dated as revised 8/2024, indicated but was not limited to the following:-Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations.-Certain medications or package types, ophthalmic (eye drops) require an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency.-When the manufacturer has specified a usable duration after opening (i.e. beyond use date), the nurse shall place a date opened sticker on the medication and record the date opened and the new date of expiration.On 12/31/25 at 3:33 P.M., the surveyor observed the medication cart with Nurse #4 on Unit C Side 1 and made the following observations:Three bottles of Cosopt (used to treat increased pressure inside the eye) eye drops, for two different residents, opened and in use with no opened date.One bottle of Latanoprost (used to treat increased pressure inside the eye) drops, opened and in use with no open date.During an interview on 12/31/25 at 3:38 P.M., Nurse #4 said eye drops are only good for 28 days after opening and require the open date to be written on the bottle. Nurse #4 said if they are not dated upon opening, she has no way of knowing when they expire. During an interview on 1/5/26 at 2:57 P.M., the Director of Nursing (DON) said medications such as eye drops have a shortened expiration date and should be labeled with the open and discard date upon opening to ensure they are not used after the shortened expiration date.

Based on observation, document review, and interview, the facility failed to maintain accurate medical records in accordance with professional standards and practices for five Residents (#9, #15, #17, #55, and #10), out of 18 sampled residents. Specifically, the facility failed: 1. For Resident #9, to obtain a matching Physician's order for advanced directives in the Resident's Electronic Medical Record (EMR) which accurately reflected his/her wishes as indicated on the Resident's Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form; 2. For Resident #15, to obtain a matching Physician's order for advanced directives in the EMR which accurately reflected his/her wishes as indicated on the Resident's MOLST form; 3. For Resident #17, to ensure his/her medical records contained an active and current [NAME] Treatment Plan (court approved treatment plan for the administration of antipsychotic medications); 4. For Resident #55, to ensure that documentation of physician visits was part of the medical record in a timely manner; and 5. For Resident #10, to ensure his/her medical record contained the Level 2 Pre-admission Screening and Resident Review (PASARR) that had been completed on [DATE]. Findings Include: 1. Resident #9 was admitted to the facility in [DATE] with diagnoses including dementia and weakness. Review of Resident #9's MOLST, dated [DATE], in the paper medical record indicated but was not limited to: -Do Not Resuscitate -Do Not Intubate and Ventilate -Transfer to Hospital Review of Resident #9's current Physician's Orders in the EMR indicated but was not limited to: -Do Not Resuscitate, DNI (Do not intubate), Do Not Transfer to Hospital (unless needed for comfort), dated [DATE] During an interview on [DATE] at 1:28 P.M., Nurse #11 said when the Physician or their designee signed a new MOLST form the nurse would put the order for advanced directives into the Resident's EMR. Nurse #11 said in case of an emergency the nurses would follow the MOLST. Nurse #11 said a resident's MOLST and his/her Physician orders should match. During an interview on [DATE] at 1:41 P.M., the Director of Nursing (DON) reviewed Resident #9's MOLST and physician's orders. The DON said the expectation was for the MOLST and physician's orders to match, but Resident #9's did not match as they should have. 2. Resident #15 was admitted to the facility in [DATE] with diagnoses including dementia. Review of Resident #15's MOLST, dated [DATE], in the paper medical record indicated but was not limited to: -Do Not Resuscitate -Do Not Intubate and Ventilate -Do Not Transfer to Hospital (unless needed for comfort) Review of Resident #15's current Physician's Orders in the EMR indicated but was not limited to: -Do Not Resuscitate, DNI (Do not intubate), Transfer to Hospital, dated [DATE] During an interview on [DATE] at 1:28 P.M., Nurse #11 said when the Physician or their designee signed a new MOLST form the nurse would put the order for advanced directives into the Resident's EMR. Nurse #11 said in case of emergency the nurses would follow the MOLST. Nurse #11 said a resident's MOLST and his/her Physician orders should match. During an interview on [DATE] at 1:41 P.M., the DON reviewed Resident #15's MOLST and physician's orders. The DON said the expectation was for the MOLST and physician's orders to match, but Resident #15's did not match as they should have. 3. Resident #17 was admitted to the facility in [DATE] with diagnoses including traumatic brain injury and cognitive impairment. Review of the Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident #17 had a Guardian and received antipsychotic medications on a routine basis. Review of Resident #17's medical record indicated the court issued an expansion of the Guardianship on [DATE] and authorized administration of antipsychotic medication via a [NAME] Treatment Plan which expired on [DATE] at 4:00 P.M. Further review of Resident #17's medical record failed to indicate a current [NAME] Treatment Plan was obtained. During an interview with record review on [DATE] at 2:30 P.M., the Social Worker (SW) reviewed Resident #17's medical record and said she did not see a current copy of Resident #17's [NAME] Treatment Plan. During an interview on [DATE] at 3:30 P.M., the SW provided the surveyor with a current [NAME] Treatment Plan for Resident #17 dated [DATE] that the facility's lawyer had faxed over. During an interview on [DATE] at 3:38 P.M., the DON said Resident #17's medical record should have contained a current [NAME] Treatment Plan. The DON said the expectation is for all residents to have a complete and accurate medical record. 4. Review of the facility's policy titled Physician Services, last revised February 2020, indicated but was not limited to: Policy Interpretation and Implementation: - Physician orders and progress notes shall be maintained in accordance with current regulations and facility policy. Resident #55 was admitted to the facility in [DATE] with diagnoses including cerebral infarct (stroke), diabetes mellitus, and hypertension. Review of Resident #55's medical record indicated he/she was seen by the Physician on [DATE], as evidenced by a Physician's Progress Note. Further review of Resident #55's medical record indicated there was a 210-day span from the last physician visit to the next one as evidenced by a Physician's Progress Note dated [DATE]. During an interview on [DATE] at 12:35 P.M., Physician #1 reviewed Resident #55's medical record and then reviewed his resident visit history in his records. Physician #1 said he had seen Resident #55 on [DATE]. Physician #1 said his note from [DATE] should have been in Resident #55's medical record. During an Interview on [DATE] at 3:38 P.M., the DON said the physician should have had all his notes in Resident #55's medical record. The DON said the expectation is for all residents to have a complete and accurate medical record. 43935 5. Resident #10 was admitted to the facility in [DATE] with diagnoses including anxiety, depression, and insomnia. Review of the Pre-admission Screening and Resident Review (PASARR) for mental illness, mental retardation, or developmental disability indicated but was not limited to the following: - Level one PASARR was completed prior to admission by the discharging facility in [DATE] and indicated Resident #10 had a positive screen for serious mental illness (SMI) - PASARR Level 2 was not indicated due to exempt hospital discharge (allowing the Resident to remain in the skilled nursing facility for up to a maximum of 30 days without further evaluation) - Review of the PASARR Level 1 under the 30 day exemption indicated: If the nursing facility determines that the resident's stay will exceed the 30-day exemption period, the nursing facility must complete Section G (requesting a level 2 PASARR) in this form and submit the Level 1 form to Department of mental health (DMH)/designee by no later than the 25th calendar day after admission. During an interview on [DATE] at 4:01 P.M., Regional Nurse #2 said the facility does not have a policy for medical records but the expectation is they are complete and accurate. Review of the medical record on [DATE] failed to indicate a Level 2 PASARR was completed as required. During an interview on [DATE] at 10:58 A.M., the Social Worker said she was unsure where the Level 2 PASARR for Resident #10 was and would look into the situation and get back to the survey team. During an interview on [DATE] at 1:15 P.M., the Social Worker said the Level 2 PASARR was complete and in the PASARR portal and not available for review in the medical record as it should have been. She said the PASARR should be in the medical record to ensure the record was complete and it was not.

Based on interview and document review, the facility failed to explain binding arbitration agreements and provide the Residents or their responsible party with the right to fully review the agreement for two of two Residents (#60 and #92) that had signed Arbitration agreements in the facility. Findings include: During an interview on 11/3/24 at 9:34 A.M., the Administrator said the facility offered arbitration agreements, he was responsible for overseeing the arbitration agreement process and there were no residents currently residing in the facility that had ever signed an arbitration agreement. Review of the medical records for Resident #60 and Resident #92 on 11/4/24 indicated both Residents had a signed arbitration agreement in their records. During a follow up interview on 11/5/24 at 9:38 A.M., the Administrator said he is responsible for having the residents or their responsible party review and potentially sign the arbitration agreements in the facility at this time. He said there are not currently any resident in the facility who have a signed arbitration. He was made aware the the surveyor found signed arbitration forms in the medical records and said he would have to look into things to see what was happening because he was not aware of that. On 11/5/24 at 10:30 A.M., the Administrator provided a list to the survey team that indicated two Residents had signed into arbitration that currently reside in the facility. Resident #60 was admitted to the facility in October 2024 with diagnoses including: unspecified dementia, diabetes mellitus and hypertension. Review of the Brief Interview for Mental Status (BIMS), dated 10/23/24, indicated the Resident suffered from severe cognitive impairment with a score of 3 out of 15. Further review of the medical record indicated the Resident's healthcare proxy (HCP) was activated to make all medical decisions on behalf of the Resident. Review of the Arbitration agreement, dated as completed 10/8/24, indicated the HCP for Resident #60 signed the agreement. During an interview on 11/5/24 at 10:05 A.M., Resident #60's HCP said she does not know what an arbitration agreement is. When the form was reviewed with her, she said she certainly would never have signed that form had anyone read it or explained it to her. She said the form was presented to her in a pile of multiple forms for consent and she signed all of them as directed by the nurse who presented them to her and she did not have any parts of this document explained to her nor did she review the form or have a copy for review. She said she would need to contact the facility to determine next steps in rescinding the form since it was signed under false pretenses. During an interview on 11/5/24 at 10:22 A.M., Nurse #1 said there are many documents the nurses are required to review with the residents or their HCP during the admission process including forms about their rights and consents. She said they have the forms signed and place them in the records and offer the copy of resident's rights to the resident or their HCP. She said the arbitration form is not read to the resident or HCP or explained in great detail, but they are offered to read it if they want to. She said she does not review with them that they are signing away their right to seek legal justice and use a neutral arbitrator should an issue arise or that they can rescind the document if they sign it within thirty days. She said it is just one of the numerous forms that was signed during the admission process and she was not aware of the specifics. During an interview on 11/5/24 at 10:27 A.M., Nurse #4 said she was unsure what an arbitration agreement was, but then said it was familiar to her when the surveyor explained and presented the form. She said the nurses are going through large amounts of information with the residents and/or their families at the time of admission and this form is part of that process. She said she explains the form, that it is a right that they can exercise, and then tells them they can read it if they want and asks them to sign it and offers them copies of all documents they sign. She said she does not explain the document in any way or explain that it contains information on a neutral arbitrator to settle disputes, a neutral venue, a right to decline to sign, or that the document outlives the resident and can only be rescinded in writing in the first 30 days. She said she has never read the document and was unaware it said all that and has never explained any of that to a resident or responsible party. She said she just has them sign what is in the packet and places it in their medical record. She said she herself did not fully understand the agreement so she wouldn't be qualified to explain the legal information in the document to others. Resident #92 was admitted to the facility in October 2024 with diagnoses including: dementia and hypertension. Review of the BIMS, dated 10/24/24, indicated the Resident had moderately impaired cognition with a score of 12 out of 15. Further review of the medical record indicated the HCP for Resident #92 was activated for a short-term duration of 30 days on 10/30/24. Review of the Arbitration agreement, dated as completed 10/18/24, indicated Resident #92 had signed his/her own agreement. During an interview on 11/5/24 at 10:57 A.M., Resident #92 said the word arbitration is not familiar to him/her and upon being read the document said the information is unfamiliar to them. He/She said it appears they signed the document and would sign anything the nurses asked them too because he/she trusts they needed all the paperwork to provide him/her care. During a follow up interview on 11/5/24 at 11:07 A.M., Nurse #4 said she completed the arbitration form with Resident #92 whose cognition fluctuates between fully understanding and not understanding. She said the Resident was his/her own person at the time of the signature, but again she cannot say that she fully explained the form to the Resident prior to it being signed. During an interview on 11/5/24 at 3:47 P.M., the Administrator said at this time the process for Arbitration agreements is that they are having the nurses complete the arbitration agreements with the residents or their responsible party. He said Arbitration agreements should be fully explained to the person agreeing to sign into arbitration with the key points of longevity of the document, it consisting of using a neutral arbitrator in a neutral venue for dispute resolution, foregoing the judicial system, and being binding unless rescinded in 30 days in writing. He agreed that there was no way the nurses would know what the document was they were asked to have the Resident's sign or explain and said he should be the one to review the legal document in full with an explanation to anyone who is interested in signing. He said he was unaware that the nurses had anyone sign the document and that is why a list could not be produced for the survey team upon entrance or until he was made aware that arbitration agreements were in the medical records. He said the process of having Arbitration agreements explained and signed needed improvement. On 11/5/24 at 4:44 P.M., the Administrator said the facility does not have a policy or document indicating what the procedure is for the completion of an arbitration form.

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. Have voiced grievances investigated and addressed, for two Residents (#86 and #68), out of a sample of 18 residents; and 2. Ensure residents had access to grievance/concern forms so they could formulate grievances anonymously, should they choose not to alert a staff member to their concern. Findings include: Review of the facility's policy titled Grievances, dated as revised 12/2018, indicated but was not limited to the following: - it is the policy of this facility to make information on how to file a grievance available to residents and/or resident representatives - the facility will support the right of each resident to voice grievances and to ensure that after a grievance has been received, the grievance official (administrator or designee) will work collaboratively with team members to resolve the issue and provide written decision to the resident and/or family - grievances and complaints may be submitted orally or in writing - if a grievance is submitted orally, the facility employee taking the grievance must write it up on the grievance form - if a person filling out the grievance is anonymous or wishes to remain anonymous, confidentiality will be maintained to the extent possible 1A. Resident #86 was admitted to the facility in June 2024 with diagnoses including: Chronic respiratory failure with hypercapnia (buildup of carbon dioxide in the bloodstream) and chronic obstructive pulmonary disease (lung disease causing restricted air flow). Review of the Brief Interview for Mental Status (BIMS) score for Resident #86, dated 6/25/24, indicated the Resident was cognitively intact with a score of 15 out of 15. During an interview on 11/3/24 at 8:33 A.M., Resident #86 said he/she does not believe he/she is listened to when voicing grievances or concerns and there are times when no one gets back to him/her or the situation goes completely unaddressed. The Resident said at the time of admission he/she voiced a concern about the room temperature and the air conditioner in the room not working well, resulting in the room being very warm throughout the summer. The Resident said he/she told the Administrator about this concern and he/she is still in the same room now without a functioning air conditioner and no resolution to his/her concern. Review of the facility's Grievance Book failed to indicate a grievance was completed for Resident #86. During an interview on 11/4/24 at 3:36 P.M., the Social Worker said she was aware Resident #86 voiced a grievance about a hot room back in June or July of 2024, but that a grievance form was not completed as it should have been. She said the process is for staff to complete a grievance form or provide the Resident with a grievance form and assist them with completing one, but that process was not followed in this circumstance. During an interview on 11/4/24 at 4:00 P.M., the Administrator said he was aware of Resident #86's voiced concern regarding a hot room and he was actively involved in attempting to resolve the concern, but no grievance form was ever completed and there is no documentation about the issue, investigation or resolution. He said the facility does not always complete grievance forms if the issue is something they think they can resolve internally quickly but can see that the process was not followed and now the concern appears unresolved and there is no documentation to indicate otherwise. B. Resident #68 was admitted to the facility in August 2024 with diagnoses including: chronic kidney disease and hypertension. Review of the BIMS score for Resident #68, dated 8/15/24, indicated the Resident was cognitively intact with a score of 14 out of 15. During an interview on 11/3/24 at 1:02 P.M., Resident #68 said he/she had complained to the Administrator about a few certified nurse aides on several occasions but has never received any follow up or feedback. During an interview on 11/4/24 at 2:14 P.M., Resident #68 said he/she had spoken with both the Director of Nurses and the Administrator about poor customer service he/she received from two different nurse aides, most recently a few weeks ago. The Resident said all he/she ever hears is I'll talk to them but then never hears back and the situation is never resolved. Resident #68 said he/she feels that the facility is not listening to his/her concerns and is just trying to appease the staff at the expense of the resident. Review of the facility's Grievance Book failed to indicate a grievance was completed for Resident #68. During an interview on 11/4/24 at 2:54 P.M., the Social Worker said when a resident voices a grievance of concern the staff are supposed to either complete a form or help the resident complete a grievance form. She said from there the form goes to the Administrator, who is the grievance official, and a plan is put in place within 48 hours and communicated to the team for investigation and follow up. During an interview on 11/4/24 at 4:01 P.M., the Administrator said he was aware Resident #68 voiced concerns about receiving poor customer service and there should be grievances and are not. He reviewed the grievance book with the surveyor and there was no documentation available to indicate Resident #68 had voiced concerns about two separate aides on two separate occasions. He said the process for grievances was not being consistently followed by the facility. 2. During a tour of the facility on 11/4/24 at 7:34 A.M., the surveyors did not observe the availability of grievance or concern forms on any of the three nursing units. In the lobby area, the surveyors observed that there was a wall pocket labeled grievances/concerns, but it was empty. During an interview on 11/4/24 at 10:22 A.M., the Director of Nurses said grievance forms are typically available in the activity area, business office, social worker's office and on each nursing unit. During an interview on 11/4/24 at 10:32 A.M., Nurse #3 said she did not know where any grievance forms were kept, but if a resident were to voice a grievance, she would attempt to resolve it and then pass the issue on in nursing report. During an interview on 11/4/24 at 10:57 A.M., Nurse #10 said he was unaware of what to do if a grievance was voiced or received and said he would get the unit manager involved. He said he does not know where any grievance or concern forms are kept. During an interview on 11/4/24 at 11:10 A.M., Certified Nurse Aide #8 said if a resident wants to complete a grievance, then she notifies a nurse and doesn't know what happens after that. She said there may be forms behind the nurses' station in the drawers or filing cabinets but she isn't sure. During an interview on 11/4/24 at 11:12 A.M., Nurse #16 said the unit doesn't have any grievance forms, but she believes forms are kept in a wall pocket outside of the unit in the lobby area. During a group meeting on 11/4/24 at 1:03 P.M., seven out of nine residents in attendance said they do not know where to locate a grievance form to complete a grievance anonymously and that they would need to request a form from staff if they wanted to put in a concern. Three of nine residents in attendance said the facility does not always follow up on grievances and make the residents aware of any resolution. On 11/4/24, the survey team made the following observations: 7:34 A.M., wall pocket in the lobby labeled grievances/concerns did not contain any forms for the residents/their family members 11:13 A.M., a wall pocket in the lobby marked grievances was empty of any available forms 1:32 P.M., the lobby wall pocket marked grievances remained empty of any available forms 2:13 P.M., wall pocket in the lobby marked grievances was empty of any available forms During an interview on 11/4/24 at 3:00 P.M., the Social Worker said each nursing unit and the front lobby all have wall pockets with grievance/concern forms available for residents or their family members to be able to complete a grievance form anonymously or just obtain a form. During a tour on 11/4/24 at 3:01 P.M., the Social Worker and the surveyor toured all three nursing units and the Social Worker said she was unaware that the units did not have grievance forms available for the residents/families to obtain them independently. Further she said the wall pocket in the lobby was empty and the forms needed to be kept in a location in which residents and their families could obtain the forms independently to voice concerns anonymously if they wanted to and for the facility to meet the guidelines. During an interview on 11/4/24 at 4:03 P.M., the Administrator said the process for grievances is for staff to obtain a form for the resident and if necessary assist the resident in completing the form. He said from there the form is discussed with the interdisciplinary team and a plan is put in place to investigate the situation and a resolution is determined. He said the facility will communicate a resolution to a voiced or written grievance within approximately five days. He said he was unaware that residents and their families needed the availability of forms for completing a grievance anonymously and/or independently and there is currently no process in the facility for that to be done. He reviewed the facility policy on grievances and said the process has not been fully implemented as it should be. During an interview on 11/4/24 at 4:39 P.M., Regional Clinical Nurse #1 said there should have been grievance forms completed for both Resident #86 and #68 and forms needed to be available for residents and/or their families to report grievances anonymously if they should wish to do so.

Based on document review and interview the facility failed to ensure Section C (Cognitive patterns) of the Minimum Data Set (MDS) assessment was complete and accurate to reflect the status of seven Residents (#86, #250, #60, #17, #9, #55, #40), out of a sample of 18 current residents and one discharged Resident (#97), who also had an incomplete pain section (Section J), out of a sample of three discharged records reviewed. Findings include: -Resident #86 was admitted to the facility in June 2024 with diagnoses including chronic respiratory failure with hypercapnia (buildup of carbon dioxide in the bloodstream). Review of the MDS assessment, dated 9/20/24, Section C indicated but was not limited to the following: C 0100: Should Brief Interview for Mental Status (BIMS) be conducted: Yes Further review indicated questions C 0200 through C 0400 were not assessed, and there was no BIMS score to determine the Resident's level of cognition. -Resident #250 was admitted to the facility in October 2024 with diagnoses including diabetes mellitus. Review of the MDS assessment, dated 10/28/24, Section C indicated but was not limited to the following: C 0100: Should BIMS be conducted: Yes Further review indicated questions C 0200 through C 0400 were not assessed, and there was no BIMS score to determine the Resident's level of cognition. -Resident #60 was admitted to the facility in October 2024 with diagnoses including unspecified dementia. Review of the MDS assessment, dated 10/14/24, Section C indicated but was not limited to the following: C 0100: Should BIMS be conducted: Yes Further review indicated questions C 0200 through C 0400 were not assessed, and there was no BIMS score to determine the Resident's level of cognition. -Resident #17 was admitted to the facility in August 2018 with diagnoses including quadriplegia. Review of the MDS assessment, dated 10/18/24, Section C indicated but was not limited to the following: C 0100: Should BIMS be conducted: Yes Further review indicated questions C 0200 through C 0400 were not assessed, and there was no BIMS score to determine the Resident's level of cognition. -Resident #9 was admitted to the facility in September 2024 with diagnoses including dementia. Review of the MDS assessment, dated 9/10/24, Section C indicated but was not limited to the following: C 0100: Should BIMS be conducted: Yes Further review indicated questions C 0200 through C 0400 were not assessed, and there was no BIMS score to determine the Resident's level of cognition. -Resident #55 was admitted to the facility in January 2024 with diagnoses including: Acute respiratory failure with hypoxia (deficiency of oxygen to the body). Review of the MDS assessment, dated 10/11/24, Section C indicated but was not limited to the following: C 0100: Should BIMS be conducted: Yes Further review indicated questions C 0200 through C 0400 were not assessed, and there was no BIMS score to determine the Resident's level of cognition. -Resident #40 was admitted to the facility in December 2019 with diagnoses including dementia. Review of the MDS assessment, dated 9/6/24, Section C indicated but was not limited to the following: C 0100: Should BIMS be conducted: Yes Further review indicated questions C 0200 through C 0400 were not assessed, and there was no BIMS score to determine the Resident's level of cognition. -Resident #97 was admitted to the facility in September 2024 with diagnoses including spinal stenosis. Review of the MDS assessment, dated 9/25/24, Section C indicated but was not limited to the following: C 0100: Should BIMS be conducted: Yes Further review indicated questions C 0200 through C 0400 were not assessed, and there was no BIMS score to determine the Resident's level of cognition. Review of section J indicated but was not limited to the following: J 0200: Should pain assessment interview be conducted: Yes Further review indicated questions J 0300 through J 0600 were blank. During an interview on 11/4/24 at 3:28 P.M., the Social Worker said there is not a time she can think of in which Section C of the MDS should not be assessed for a resident. She said the MDSs were incomplete and they should not be and that is not her practice. During an interview on 11/6/24 at 12:01 P.M., the MDS Nurse said the expectation is that all residents have evaluations completed quarterly by the social worker who in turn completes Section C of the MDS. She said Section C is the BIMS assessment for the residents and should not be dashed or marked as not assessed; either the resident interview or staff interview for resident cognition should be completed for that section of the MDS each quarter. She reviewed Section C of the MDS for Residents #86, #250, #60, #17, #9, #55, and #40 as indicated above and said the MDS was incomplete and inaccurate since Section C for all of the reviewed Residents was dashed or marked as not assessed. During an interview on 11/6/24 at 3:00 P.M., the MDS Nurse reviewed Resident #97's (discharged Resident) MDS with the surveyor and said Section C of the MDS was dashed out and therefore incomplete for the Resident. She reviewed section J for pain and said the nursing evaluation was not complete and did not include a pain score. Therefore, she could not use it and that section is incomplete. During an interview on 11/6/24 at 12:58 P.M., Corporate Nurse #2 said the MDS should be complete and accurate including Section C. 48695 34145

Based on observation, record review, and interview, the facility failed to ensure sufficient staffing to assure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed to have sufficient staffing on the weekends as indicated on the payroll-based journal (PBJ) report submitted to Centers for Medicare and Medicaid Services (CMS) for Fiscal Year Quarter 3, 2024. Findings include: Review of the PBJ Staffing Data Report, CASPER Report 1705D FY Quarter 3, 2024 (April 1 - June 30) indicated the following: This Staffing Data Report identifies areas of concern that will be triggered (e.g., requires follow-up during the survey). -One Star Staffing Rating Triggered= Star Staffing Rating Equals 1 Excessively Low Weekend -Staffing Triggered = Submitted Weekend Staffing data is excessively low Review of the facility's healthcare Facility Assessment (FA), revised August 2024, indicated the following: Part 1: Resident Profile 1.1 Number of residents you are licensed to provide care for - 121 -Number of licensed beds on Unit A: 41 -Number of licensed beds on Unit B: 41 -Number of licensed beds on Unit C: 39 -Average daily census: 83 Staffing Plan 3.2 Total Number Needed or Average or Range of Staff: - Licensed nurses providing direct care: 13-16 Nurses daily based on shift and acuity - Nurse Aides: 18-21 daily based on shift and acuity The FA did not include a minimum standard of staffing for hours per patient day (HPPD- staffing hours per resident per day which is the total number of hours worked by each type of staff divided by the total number of residents) of direct nursing care provided to ensure the residents' health and safety. Review of the as worked weekend staffing schedules provided by the Scheduling Coordinator for licensed nurses and nurse aides during FY Quarter 3, 2024, indicated the total number of nurse aides was below the needed or average range, per the FA, for the following dates: 4/6/24 -Total census, 77, (A Unit-7, B Unit-37, C Unit-35) -15 total aides (three less than the minimum required) 4/12/24 -Total census, 82, (A Unit-10, B Unit- 36, C Unit-37) -17 total aides (one less than the minimum required) 4/19/24 -Total census, 82, (A Unit-11, B Unit-36, C Unit-36) -15 total aides (three less than the minimum required) 4/20/24 -Total census, 82, (A Unit-11, B Unit-36, C Unit-36) -14 total aides (four less than the minimum required) 4/21/24 -Total census, 83, (A Unit-12, B Unit-36, C Unit-35) -16 total aides (two less than the minimum required) 4/26/24 -Total census, 84, (A Unit-14, B Unit-35, C Unit-35) -17 total aides (one less than the minimum required) 4/27/24 -Total Census, 82, (A Unit-14, B Unit-35, C Unit-35) -17 total aides (one less than the minimum required) 4/28/24 -Total census, 83, (A Unit-14, B Unit-35, C Unit-35) -15 total aides (three less than the minimum required) 6/16/24 -Total census, 79, (A Unit-15, B Unit-31, C Unit-35) -17 total aides (one less than the minimum required) During the Resident Group conducted on 11/04/24 at 1:03 P.M., nine out of nine residents said call lights are typically not answered timely and it can take, on average, 45 minutes. They said there doesn't seem to be any day or shift that's worse than others and there's no rhyme or reason, but the facility just doesn't consistently have enough staff to answer the lights. During an interview on 11/5/24 at 10:25 A.M., Nurse #12 and Nurse #13 said there are normally three aides on the B and C Wings for day shift, but there are call outs sometimes so then they only have two. They said there is a lot of agency staff that don't show up or call out, with the day shift on the weekends being the worst. They said it happens frequently. During an interview on 11/6/24 at 6:28 A.M., Nurse #14 on the B Wing said she mostly works nights and occasionally there are sick calls, and they have to give up one aide, but it was getting better. She said sometimes on the weekends when there's call outs, they have only one aide overnight, but it was rare. During an interview on 11/6/24 at 6:32 A.M., Nurse #15 on the C Wing said she was agency staff and there were three aides scheduled overnight, but there was a call out, so they lost one to another unit. During an interview on 11/6/24 at 8:15 A.M., the Scheduling Coordinator said she thought the low weekend staffing was triggered due to call outs. She said it was their biggest thing and she could overstaff, but they're still going to do it. She said she used six different agencies for staffing needs, approximately 300-400 hours/week all shifts for nursing and approximately 200 hours/week for aides, but it was down to 50-100 hours/week. She said the facility will be having a job fair and hadn't had one before. The Scheduling Coordinator said they get a lot of call outs the last minute mostly from aides that are facility staff, typically for the 11p-7a shift. She said normal staffing should be as follows, depending on the census: A Wing: -2-3 aides for 7a-3p shift -2 aides for 3p-11p shift, sometimes 2.5 -1-2 aides for 11p-7a shift B and C Wings: -3-4 aides for 7a-3p shift -typically, 3 aides for 3p-11p shift -2 aides for 11p-7a shift The Scheduling Coordinator said, in general, she goes by the census and there should be one aide for every 14 residents (1:14). She said if there's a full census on every unit then there should be 4 aides for each unit during the 7a-3p and 3p-11p shifts and 2 aides during the overnight shift (11p-7a). During an interview on 11/6/24 at 10:05 A.M., the Scheduling Coordinator said staffing requirements, per the FA, to meet the needs of the residents included 18-21 aides daily based on the daily census but did not include a minimum standard for HPPD. She said there wasn't a staffing policy or documentation of staffing needs she could provide to the surveyor other than the facility assessment. During an interview on 11/6/24 at 10:39 A.M., the surveyor reviewed the above staffing schedules (4/6/24, 4/12/24, 4/19/24, 4/20/24, 4/21/24, 4/26/24, 4/27/24, 4/28/24, and 6/16/24) and daily census reports with the Scheduling Coordinator who said the dates reviewed, including on 5/3/24 and 6/29/24, did not meet the standard for nurse aide staffing per the FA and actual schedules worked per census requirement. She said the staffing was insufficient and there should have been a ratio of 1:14, but the facility did not meet this requirement for the dates reviewed. She said the schedules provided to the surveyor by her were all updated and were as worked, and there were no other variations of the schedules. During an interview on 11/6/24 at 11:49 A.M. with the Director of Nursing (DON) and Consulting Staff #2, the DON said A Wing nurse aide staffing should be at a ratio of 1:10 for the day and evening shifts and typical staffing for night shift was 2 aides in general. He said they flex as needed based on admissions, discharges, and acuity level. The DON said the FA should reflect current staffing needs, not hours worked. Consulting Staff #2 said the A Wing required a 1:10 ratio because there was a higher level of acuity and the B and C Wings had a 1:12 ratio, not 1:14, per the Scheduling Coordinator, but the C Wing had more independent residents, so they didn't require as much care. The DON said the goal is to meet the staffing requirement and be as safe as possible.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Handle ready to eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another); and 2. Properly label and date food products, and maintain safe and clean equipment in two of three nourishment kitchenettes. Findings include: Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA), revised ,d+[DATE], indicated but was not limited to the following: - ,d+[DATE].11 Preventing Contamination from Hands. (A) FOOD EMPLOYEES shall wash their hands as specified under S ,d+[DATE].12. (B) Except when washing fruits and vegetables as specified under S,d+[DATE].15 or as specified in (D) and (E) of this section, FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT. - ,d+[DATE].15 Gloves, Use Limitation. (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. 1. On [DATE] at 11:04 A.M., the surveyor made the following observations during the lunch meal service: - Two dietary aides and one cook were preparing and working the lunch service line. - At 11:16 A.M., [NAME] #1 grabbed a dish rag from a bucket of water underneath the service line and tossed it into the sink next to the stove top. [NAME] #1 then returned to the pan on the stove top to cook grilled cheese sandwiches. [NAME] #1 was never observed to perform hand hygiene. - At 11:24 A.M., [NAME] #1 double gloved (put on gloves over her existing gloves) while working the service line. [NAME] #1 touched the broccoli she plated with her gloved hand. [NAME] #1 then continued to work the service line without switching her gloves or performing hand hygiene. - At 11:29 A.M., [NAME] #1 touched carrots she plated. [NAME] #1 then returned to the service line without changing gloves or performing hand hygiene. - At 11:35 A.M., [NAME] #1 reviewed a paper on a cart next to the service line that listed resident specific preferences for the lunch meal service. [NAME] #1 touched her gloved hand to the side of the paper and cart. [NAME] #1 returned to the service line and began plating food items. [NAME] #1 was not observed to change her gloves or perform hand hygiene. - At 11:40 A.M., [NAME] #1 plated spinach and then used her gloved hand to move the spinach on the plate in order to make room for other food items. [NAME] #1 then moved to plating the next food items. [NAME] #1 was not observed to change her gloves or perform hand hygiene. - At 11:44 A.M., [NAME] #1 touched the side of her face with her gloved hand and continued to serve food items on the service line. [NAME] #1 was not observed to change her gloves or perform hand hygiene. - At 11:48 A.M., [NAME] #1 removed plates from the plate warmer and put them on the service line. [NAME] #1 was then observed to lean over the plates, allowing her top to brush over the top and sides of the plates. - At 11:57 A.M., [NAME] #1 plated chicken and then touched the chicken with her gloved hand to make room for fortified mashed potatoes. [NAME] #1 then continued to serve food items on the service line. [NAME] #1 was not observed to change her gloves or perform hand hygiene. - At 12:05 P.M., [NAME] #1 used her gloved hand to grab a grilled cheese sandwich out of a pan on the stove top. [NAME] #1 brought the grilled cheese from the pan to the service line. [NAME] #1 cut the grilled cheese on the counter of the service line using her gloved hands and plated the food. [NAME] #1 was not observed to change her gloves or perform hand hygiene. During an interview on [DATE] at 8:11 A.M., [NAME] #1 said she wears gloves during each meal service. [NAME] #1 said she would change her gloves when leaving the service line and before returning. [NAME] #1 said she would not change her gloves if she touches food items during meal service. During an interview on [DATE] at 8:35 A.M., the Food Service Director (FSD) said gloves should be changed when leaving the service line and before returning to the food service line during mealtimes. The FSD said cooks should not be touching food items that are plated. The FSD said [NAME] #1 should have changed her gloves if she touched food items before continuing to serve lunch meal items. 2. Review of the facility's policy titled Food Brought into Facility, last revised ,d+[DATE], indicated but was not limited to: - It is the policy of the Company that visitors or family members are permitted to bring food to a resident and are encouraged to limit foods to those that meet patient's meal plan and safe food handling practices. - Perishable food must be stored and identified with resident's name, food item and use by date. - These can be stored in the nursing unit kitchen nourishment refrigerator. - The nursing staff is responsible for discarding perishable foods on or before the use by date. On [DATE] at 8:11 A.M., the surveyor made the following observations of the B Wing Unit nourishment kitchenette: - In the freezer there was one hot pocket labeled [NAME] - emergency with no further resident identification or use by date. - Four Healthy Shot Peach Protein and Amino Acid Solution drinks were located on the door of the refrigerator. One drink product had a date of ,d+[DATE] and a second with the date of ,d+[DATE]. None of the drink product bottles were identified with a resident name or other form of identification. - A six-pack of Adirondack Lemon Water was on the shelf of the refrigerator with no resident identification. - One 12-ounce Diet Coke Bottle was located on the door of the refrigerator. The bottle of soda had no resident identification. On [DATE] at 8:34 A.M., the surveyor made the following observations on the A Wing Unit nourishment kitchenette: - A white Styrofoam cup with ice and a red liquid substance was located in the freezer. There was no resident identification or use by date on the cup. - A white paper bag with a takeout food container was labeled only with a use by date of ,d+[DATE]. - A white paper bag with a wrap sandwich with no resident identification and a use by date of ,d+[DATE]. - An open container of individual plain cream cheese with no date or resident identification. - A 16-ounce Diet Coke soda bottle with no resident identification or use by date. - A 7.5-ounce Diet Coke can with no resident identification or use by date. On [DATE] at 3:30 P.M., the surveyor made the following observations on the A Wing Unit nourishment kitchenette: - A white Styrofoam cup with ice and a red liquid substance was located in the freezer. There was no resident identification or use by date on the cup. - A white paper bag with a takeout food container was labeled only with a use by date of ,d+[DATE]. - A 16-ounce Diet Coke soda bottle with no resident identification or use by date. - A 7.5-ounce Diet Coke can with no resident identification or use by date. On [DATE] at 7:22 A.M., the surveyor made the following observations of the B Wing Unit nourishment kitchenette: - In the freezer there was one hot pocket labeled [NAME] - emergency with no further resident identification or use by date. - Three Healthy Shot Peach Protein and Amino Acid Solution drinks were located on the door of the refrigerator. One drink product had a date of ,d+[DATE]. None of the drink product bottles were identified with a resident name or other form of identification. - A six-pack of Adirondack Lemon Water was on the shelf of the refrigerator with no resident identification. - One 12-ounce Diet Coke Bottle was located on the door of the refrigerator. The bottle of soda had no resident identification. On [DATE] at 7:13 A.M., the surveyor made the following observations on the A Wing Unit nourishment kitchenette: - A 16-ounce Diet Coke soda bottle with no resident identification or use by date. - A 7.5-ounce Diet Coke can with no resident identification or use by date. During an interview on [DATE] at 1:30 P.M., the FSD said kitchenettes are stocked twice daily by dietary aides. The FSD said dietary aides are educated to remove any expired food products when stocking the refrigerators. The FSD said nursing staff are also responsible for checking food products in the nourishment kitchenette refrigerators. During an interview on [DATE] at 7:35 A.M., Nurse #7 said items are stocked by dietary staff members daily, at least twice a day. Nurse #7 said typically food items brought in for residents are kept for three days. Nurse #7 said staff will label food items with the resident's name and a use by date. Nurse #7 said if nursing notices that something is expired they will dispose of it. During an interview on [DATE] at 8:35 A.M., the FSD said kitchenettes should be checked daily for expired food products. The FSD said items should be labeled with the resident's name and use by date. The FSD and the surveyor reviewed the observations made out the A Wing and B Wing Unit nourishment kitchenettes. The FSD said food products that are not labeled or expired should not be in the nourishment kitchenettes.

Based on observation, record review and staff interviews, the Facility failed to ensure that professional standards of practice were followed for the care and treatment of [REDACTED].#15 and #19), from a total sample of 23 Residents. Findings include: 1. For Resident #15, who was assessed to be at high risk for the development of pressure areas, the Facility staff did not identify any skin issues using their weekly skin checks, incorrectly identified the wound characteristics for tissue injury, failed to correctly identify the correct site of the pressure injury, failed to have documentation of providing the daily wound treatments and when the Resident was seated on a pressure relieving device it was not used correctly. Resident #15 was a long term care Resident, admitted in ,[DATE], with a [DIAGNOSES REDACTED]. A review of the last annual Minimum Data Set (MDS) assessment, dated [DATE], indicated the Resident had a cognitive BIMS (Brief Interview for Mental Status) score of 6 out of 15, which indicated cognitive impairment. The assessment noted that the Resident needed two person assistance for all activities of daily living (bed mobility, personal hygiene, dressing) and had range of motion functional limitation of both lower extremities. The Resident had no weight loss or gain and was assessed to be at risk for pressure injury but had no identified pressure injury. A review of the plan of care for risk of pressure ulcer noted one of multiple interventions was to provide a pressure reducing wheelchair cushion and conduct weekly skin inspections both dated ,[DATE]. The plan had no information on the type of seat cushion. The nursing documentation on [DATE] indicated that the Resident's skin was clean and intact. Six days later a nurse's note dated, [DATE], indicated that the Resident had a Stage 2 (Staging of a PU/PI is performed to indicate the characteristics and extent of tissue injury. Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis and presents as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister). The note indicated the Stage 2 pressure area was found during morning care and located on the left gluteal fold that measure 2 cm (centimeters) (width) x 4 cm (length). The nurse wrote that the wound bed had granulating tissue with some slough at base of the wound. The Physician was notified and a treatment order was obtained and a requisition form for OT (Occupational Therapy) for wheelchair positioning. An Incident Event Report was completed on [DATE] and signed by the Director of Nurses and the Administrator indicating the same information of the wound's site and wound Staging as documented above and to consult with the Facility's wound Physician. The Wound Physician Consultant's initial wound evaluation completed [DATE] (2 days after it was first observed) indicated the wound was not located on the left gluteal fold but rather on the left ischium. The ischium is one of three lower parts of the hip bone and is a curved bone forming the base of each half of the pelvis (hip bone). The Physician documented that he/she had an unstageable area (due to necrosis) of the left ischium of at least 14 days duration. The Wound Physician noted the wound to be 100 % thick adherent devitalized necrotic tissue and had to surgically excise 4.86 cm of devitalized tissue. On [DATE] at 10:39 A.M., with 2 Surveyors, Unit Manager #3 and the Medical Director who is the Resident's primary care physician where interviewed. Unit Manager #3 said the skin check and the nurses' note for [DATE] where the nurses identified the area as a Stage 2 and on the gluteal fold were incorrect and as far as she can remember there was education done at the time with the staff. The Manager said she was unable to say how the wound went from a Stage 2 to necrotic in 2 days. The Medical Director said that this was not possible and that the nurses who wrote the skin evaluation on [DATE] were incorrect. He further said that there was no way the skin was clean and intact on [DATE] as indicated on the skin check. A review of the treatment administration record for ,[DATE], indicated that the physician's orders [REDACTED]. The remainder of the month of ,[DATE] (19 days) there was no information to review of any treatments administered to the left ischium wound. The Treatment records for ,[DATE] and ,[DATE] continued to list the incorrect site of the wound. The Wound Physician continued to see the Resident and from initial visit of [DATE] through [DATE] the left ischium wound continued to be surgically debrided. The Treatment records in ,[DATE] were corrected to reflect the correct site of the wound (3 months after first observed). During an interview on [DATE] at 12:02 P.M., the Director of Nurses said. everyone was saying it was the gluteal fold when it was found. It initially came through as a gluteal fold Stage 2, 2 x 4 cm. on [DATE]. The Surveyor asked about positioning, and the incident documentation had no type of the cushion used for the wheelchair. She said, we basically contributed it to positioning in chair and time up in chair and referred to rehab. A review of the Occupational Therapy plan of care started [DATE] (4 days after wound observed) noted that he/she was referred to therapy after developing a unstageable necrosis on the left ischium. The therapist documented that the Resident currently used a ROHO cushion (soft, flexible, interconnected air cells that adjust to each individual and the cells are inflated with air). The therapist documented that the Resident was referred to rehab because of the wound developing as a result of improper positioning and the ROHO cushion being deflated. The Therapist documented that the Resident would be monitored to ensure proper positioning and use of the cushion while in the chair. On [DATE] the OT discharged the services with properly inflated ROHO cushion and caregiver instructions had been provided. A review of the plan of care for the pressure risk and wound had no information listed for the specific use of the ROHO cushion. The Resident was seen ,[DATE] by Physical therapy who evaluated the Resident's seating in the wheelchair and changed to another cushion for the chair. The Surveyor did a wound observation on [DATE] at 10:10 A.M., with Unit Manager #3 and the Resident's approval. The left ischium wound dressing was removed. The wound was observed to be open with visible bone, the old dressing had some dark brown drainage. The wound was observed to be a Stage 4, it was clean, no odors and had granulation tissue noted on the perimeter of the wound, with small amount of slough at 6 o' clock. The wound measurements were done by the nurse and she recorded a width of 3.4 cm x length of 3.2 and a depth of 4.0 cm. The Facility staff failed to follow professional standards of practice by not questioning the accuracy of the weekly skin checks, by not following the Standards of Practices for the care and treatment of [REDACTED]. 2. For Resident #19, the Facility staff failed to ensure that the physician orders [REDACTED]. Resident #19 was admitted to the Facility in ,[DATE] with a [DIAGNOSES REDACTED]. A review of the medical record indicated the Resident had an order for [REDACTED]. Resident #19 was interviewed on [DATE] at 10:30 A.M. The Resident said that there was a tear in his/her tail bone from a recent hospitalization . At this time, the Resident's air mattress was observed to be at a setting of 4. On [DATE] at 9:20 A.M. The Resident was observed in bed again and the air mattress was set to 4 (which indicated a weight of about 175 pounds). The Resident said the previous motor for the air mattress died over the weekend and a new one was obtained on [DATE]. On [DATE] at 5:30 P.M. the Resident's air mattress was observed to remain at the setting of 4. A review of the medical record for Resident #19 indicated that the Resident's usual body weight was 235 to 250 pounds. Unit Manager #3 was informed of the observations on [DATE] at 5:35 P.M. She said she would review the appropriate settings for the air mattress.

Based on records reviewed and interviews, for 2 of 3 sampled residents (Resident #1 and Resident #3), the facility failed to provide services in accordance with professional standards of practice by not ensuring proper procedures were followed during the administration of medications and by not ensuring physician's orders [REDACTED].#1 ingested 4 residents unidentified medications and required hospitalization and admission for somnolence, slightly elevated [MEDICATION NAME] level and [MEDICAL CONDITION] (low heart rate) due to medication error. Resident #3 received twice the dosage of [MEDICATION NAME] (an anti-anxiety medication) for 8 days. Standard reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered and practical nurse incorporated into the plan of care, and implement prescribed medical regimens. The rules and regulations 9.03 define standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Findings include: The Facility's Policy and Procedure, titled Storage of Medication, dated 3/7/17, indicated medication supplies are accessible only to licensed nursing personnel, medication supplies are locked and medications are kept in containers in a controlled environment such as medication carts. The Facility's Policy and Procedure, titled Administration Procedures for All Medications, dated 6/2015, indicated for security: all medication storage areas, medication carts, are locked at all times unless in use and under the direct observation of the medication nurse. The Facility's Policy and Procedure, titled Medication Error Reporting and Adverse Drug Reaction Prevention and Detection, dated 9/2010, indicated a medication error is defined as any preventable event that may cause or lead to inappropriate medication use or resident harm while the medication is in the control of the health care professional. Medication errors are considered significant if they require hospitalization . The Facility's Policy and Procedure, titled Narcotic Book, undated, indicated a narcotic book is a permanently bound book with pre-numbered pages used to record the receipt, dispensing/administration and destruction of controlled substances. The Policy indicated for the first entry each page should be co-signed by a second nurse, verifying the right amount was entered for the right patient, right drug and right dose. When the drug is reordered, add the new amount to the same page and have a second nurse co-sign the new entry again. The Facility's Policy and Procedure, titled Control Substance Check Sheet, undated, indicated there is a system of records of receipt and disposition of all controlled substances. The Policy indicated delivery receipts are routinely cross referenced against narcotic book, pharmacy order book, patient record and Physician order. Drug is properly entered into designated controlled substance tracking documentation/index page, two nurses sign and verify receipt of drugs in controlled substance tracking documentation. The Facility's Medication Pass Observation, undated, indicated medications are not left on top of medication cart. A) Resident #1's [DIAGNOSES REDACTED]. The Minimum Data Sheet (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired, wandered daily and required supervision with ambulation. An Individualized Care Plan for eating disorder, PICA (involves eating items that are not typically thought of as food) due to dementia, dated 6/3/16, indicated Resident #1 was found to be eating several different non-food items, staff were to monitor Resident #1 for eating non-food items and intervene as needed. An Individualized Care Plan for short attention span, dated 12/26/16, indicated Resident #1 exhibited wandering behaviors with constant need to keep looking, walking and moving. An Event Report, dated 2/28/17 at 7:45 P.M., indicated Resident #1 took medication from medication cart and was found by staff ingesting medication. Resident #1 was transferred to the hospital. A witness statement, undated, indicated Nurse #1 poured medications into labeled cups for 4 residents and left the medications on top of the medication cart unattended. A Situation Background Assessment Response (BAR) Progress Note, dated 2/28/17, indicated Resident #1 was wandering throughout the unit, took medications from the medication cart, was found chewing the medications and was transferred to the hospital for evaluation. A Nursing Home to Hospital Transfer Form, dated 2/28/17, indicated Resident #1 ingested several medications from the med cart, unable to identify how many, but included [MEDICATION NAME], Trazadone, [MEDICATION NAME], Tylenol and [MEDICATION NAME], and Resident #1 was transferred to the hospital. The Surveyor interviewed Nurse #1 at 1:08 P.M. on 3/31/17. Nurse #1 said she pre-poured 4 residents medications into plastic cups, left the cups on top of the medication cart, walked away from the medication cart without putting the cups in the medication cart and did not lock the medication cart. Nurse #1 said she did not follow facility policy or acceptable nursing practice. Nurse #1 said she made a massive mistake when she pre-poured medications, left medications on top of the medication cart where Resident #1, who had dementia and was a wanderer, ingested the medications and was transferred to the hospital. Nurse #1 said it was an accident that should not have ever happened. The Surveyor interviewed the Director of Nurses (DON) at 2:00 P.M. and throughout the day on 3/31/17. The DON said Nurse #1 did not follow facility policy for medication administration, resident safety and accident prevention when she pre-poured 4 residents medications into cups, left the cups with medications in them on top of the medication cart, and left the medication cart unlocked and unattended. Resident #1, who had dementia and was a wanderer, ingested the medications and was transferred to the hospital. B) Resident #3's [DIAGNOSES REDACTED]. The Minimum Data Sheet (MDS), dated [DATE], indicated Resident #3 was severely cognitively impaired. An Individualized Care Plan for potential for drug related complications associated with use of anti-anxiety medication, dated 2/19/17 indicated provide medications as ordered by the Physician. A physician's orders [REDACTED]. (milligrams) daily at 6:00 P.M. A Pharmacy Shipping Manifest Form, dated 12/6/16, indicated the Facility received thirty tablets of [MEDICATION NAME] (Generic name for [MEDICATION NAME]) 0.25 mg. for Resident #3. There was no signature on the form to indicate who received the medication at the Facility. A Medication Administration Record [REDACTED].M. A Narcotic Book Patient Page, un-numbered, indicated Resident #3 was administered [MEDICATION NAME] 0.5 mg at 6:00 P.M. on 12/7/16, 12/8/16, 12/9/16, 12/10/16, 12/11/16, 12/12/16, 12/13/16, and 12/14/16. A Narcotic Book Patient Page, numbered 146 and dated 12/14/16, indicated [MEDICATION NAME] 0.25 mg. give one tab by mouth at hour of sleep. The first entry indicated the Facility received thirty [MEDICATION NAME] 0.25 mg. tablets for Resident #3 on 12/14/16 with a single nurses signature. There was no co-signature by a second nurse. This was not consistent with the Facility's Narcotic Book Policy. A Medication Error Reporting Form, dated 12/15/16, indicated Resident #3 received [MEDICATION NAME] 0.5 mg. at 6:00 P.M. instead of the [MEDICATION NAME] 0.25 mg. at 6:00 P.M. ordered by the Physician. The form was incomplete and did not indicate resident experienced any negative effects from the error. The Surveyor interviewed the Director of Nurses (DON) and Assistant Director of Nurses (ADON) at 2:00 P.M. and throughout the day on 3/31/17. The DON and ADON said Nurse #4 did not follow the Facility's narcotic book policy, placed the medication card in a locked drawer that was not in use, and did not enter the narcotic, [MEDICATION NAME] 0.25 mg. tablets into the narcotic book index or patient page when it was received from the pharmacy on 12/6/16. The DON and ADON said staff did not follow the Facility's medication administration policy and administered the incorrect dose of [MEDICATION NAME] for 8 days. The ADON said a per diem nurse notified her of the medication error on 12/14/16. The DON said the facility did not reconcile the pharmacy delivery receipts with the narcotic book and did not always require two nurses sign and verify receipt of narcotics. This was not consistent with the Facility's Control Substance Check Sheet Policy.

Based on records reviewed and interviews, for 1 out of 3 sampled residents, (Resident #1), who had the [DIAGNOSES REDACTED].#1 who was found with medications in his/her mouth from 4 other Residents pre-poured medications that were left unattended on top of the medication cart. Resident #1 required hospitalization and admission for somnolence, slightly elevated acetaminophen level and bradycardia (low heart rate) due to medication error. Findings include: The Facility's Accident's Critical Element Pathway, dated 7/2015, indicated to use pathway for residents who require supervision to prevent accidents and ensure the environment is free from accident hazards. The pathway indicated to observe wandering residents by doing routine visual checks, adequately supervising the residents and ensuring the environment is safe. The Facility's Policy and Procedure, titled Storage of Medication, dated 3/7/17, indicated medication supplies are accessible only to licensed nursing personnel, medication supplies are locked and medications are kept in containers in a controlled environment such as medication carts. The Facility's Policy and Procedure, titled Administration Procedures for All Medications, dated 6/2015, indicated for security: all medication storage areas, medication carts, are locked at all times unless in use and under the direct observation of the medication nurse. The Facility's Medication Pass Observation, undated, indicated medications are not left on top of medication cart. Resident #1's [DIAGNOSES REDACTED]. The Minimum Data Sheet (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired, wandered daily and required supervision with ambulation. An Individualized Care Plan for eating disorder, PICA (involves eating items that are not typically thought of as food) due to dementia, dated 6/3/16, indicated Resident #1 was found to be eating several different non-food items, staff were to monitor Resident #1 for eating non-food items and intervene as needed. An Individualized Care Plan for short attention span, dated 12/26/16, indicated Resident #1 exhibited wandering behaviors with constant need to keep looking, walking and moving. An Event Report, dated 2/28/17 at 7:45 P.M., indicated Resident #1 took medication from medication cart and found by staff ingesting medication. Resident #1 was sent to the hospital. A witness statement, undated, indicated Nurse #1 poured medications into labeled cups for 4 residents and left the medications on top of the medication cart unattended. A Situation Background Assessment Response (BAR) Progress Note, dated 2/28/17, indicated Resident #1 was wandering throughout the unit, took medications from the medication cart, was found chewing the medications and was transferred to the hospital for evaluation. A Nursing Home to Hospital Transfer Form, dated 2/28/17, indicated Resident #1 ingested several medications from the med cart, unable to identify how many, but included: -Neurontin ( a medication used for seizures) - Trazadone (an antidepressant medication used for insomnia) - Ativan (a medication used for anxiety) - Tylenol (a medication used for pain, inflammation, fever) - Lopressor ( a beta blocker medication used for high blood pressure). The Surveyor interviewed Nurse #1 at 1:08 P.M. on 3/31/17. Nurse #1 said she pre-poured 4 residents medications into plastic cups, left the cups on top of the medication cart, walked away from the medication cart without putting the cups in the medication cart and did not lock the medication cart. Nurse #1 said she did not follow facility policy and nursing practice. Nurse #1 said she made a massive mistake when she pre-poured medications, left medications on top of the medication cart where Resident #1, who had dementia and was a wanderer, ingested the medications and was transferred to the hospital. Nurse #1 said it was an accident that should not have ever happened. The Surveyor interviewed the Director of Nurses (DON) at 2:00 P.M. and throughout the day on 3/31/17. The DON said Nurse #1 did not follow facility policy for medication administration, resident safety and accident prevention when she pre-poured 4 residents medications into cups, left the cups with medications in them on top of the medication cart, and left the medication cart unlocked and unattended. Resident #1, who had dementia and was a wanderer, ingested the medications and was transferred to the hospital. The Hospital Discharge Summary, dated 3/2/17, indicated Resident #1 was admitted to the hospital for somnolence (drowsiness), elevated acetaminophen level and bradycardia (low heart rate) due to accidental drug ingestion.

Based on record review and interview with staff, the facility failed to adequately monitor weight loss, and failed to provide effective interventions to prevent further loss and stabilize weight, for 1 of 2 residents with weight loss (#3) in a total sample of 22 residents. Findings include: For Resident #3, the facility failed to provide adequate and timely interventions and services to attempt to maintain nutritional parameters and body weight to prevent unplanned severe weight loss of 39 pounds, or a 16% change in body weight. Resident #3 was admitted to the facility on [DATE] for rehabilitation. The resident's [DIAGNOSES REDACTED]. The resident weighed 242 pounds and was 75 inches tall on admission. The medical record was reviewed on 4/8/14 at 4:40 P.M. The nutritional assessment dated [DATE], included Resident #3's estimated daily maintenance needs as 2200-2400 calories, 90-115 grams protein and 3300 cubic centimeters (cc) of fluid for weight and hydration. Admission laboratory serum (blood protein) [MEDICATION NAME] levels were 3.8 d/L (normal range). The resident required supervision and limited assistance to eat. The resident was identified as obese according to a BMI (body mass index) of 30. The BMI is used as an indicator of body fatness. It is calculated based on your height and weight. A normal BMI or healthy weight range 18.5 to 24.9, if falls within the "normal" or Healthy Weight range. Review of the 10/27/13 nutritional assessment and plan of care, the written nutrition goal was not to lose weight, but maintain weight and hydration, provide a house no salt packet diet with regular (thin) liquids. On 11/13/13 the resident weighed 239.5 pounds, and on 11/20/13 the resident had a 4 pound weight loss to 235.5 pounds. The resident's plan of care review date of 11/21/13 continued to include the goal to keep weight within UBWR/IBWR (usual body weight range/ideal body weight range) with weekly weight monitoring, a no salt packet diet and assistance with activities of daily living. In December, the resident experienced another 6.9 pound loss, weighing 235.7 pounds on 12/11/13, to weighing 228.8 pounds on 12/18/13. There was no documentation of a reassessment of this resident's nutritional status needs to address the unplanned weight loss and no evidence of new interventions to halt further weight loss. January (2014) weight records indicated ongoing gradual weight loss as follows: On 1/2/14, the resident's weight was 230.2 pounds; on 1/8/14 weight was 227.5 pounds; on 1/16/14 the resident weighed 226.8 pounds. Review of the most recent quarterly Minimum Data Set (MDS) assessment, dated 1/21/14, indicated the resident's cognition was moderately impaired, with inattention, and wandering behaviors; the resident requires assistance with activities of daily living (hygiene, bathing and dressing). The MDS indicated the resident requires supervision and set up for eating, receives a mechanically altered and therapeutic diet of no salt packet, with no swallowing difficulties at that time. The resident's height was recorded at 75 inches and weight was 228 pounds. The dietician's quarterly nutrition note dated 1/27/14, indicated the resident weighed 226.8 pounds, and had a 6 % weight loss over a three month period and not significant (for a 90 day interval 7.5% weight change is considered a significant change, and greater than 7.5% is considered a severe change). The assessment indicated the resident's serum [MEDICATION NAME] level had decreased from 3.8 (upon admission) to 3.5 d/L, but still within normal parameters. The resident continues to eat with supervision, slight assist and set-up; readily accepts snacks. The plan included to monitor intake, labs and weights. There had been no interventions to halt the weight loss or maintain weight as planned upon admission. Review of the unit B's Dietitian's Communication book on 4/10/14 at 12:45 P.M., with the consultant dietician, revealed and entry dated 1/27/14 which recommended to provide Resident #3 with a nutrition supplement per (Q) shift. Medical record review on 4/8/14 at 4:40 P.M. included a physician's orders [REDACTED]. On 1/30/14 the resident's weight was recorded at 224.8 pounds. Further record review from 1/2/14 to 4/5/13 indicated that the resident continued with weight loss, resulting in a severe loss of 27.1 pounds, or a 11.7% change in body weight. On 2/6/14 the resident's weight is reported at 213.4 pounds. At that time the plan of care was revised to include large portions. The resident had over an 11 pound (5%) weight loss in a one week period, the resident was identified with significant weight loss. The facility failed to implement an effective intervention to halt the resident's weight loss. The dietician's 2/10/14 progress note indicates that resident's food portions were increased to large, to prevent further weight loss, will monitor. However, the resident's intake of food and fluids during this time had been noted as poor. On 2/17/14, nurses' progress note indicated the physician was made aware of the resident's lethargy, therefore, antipsychotic ([MEDICATION NAME]) medication had been reduced and blood pressure ([MEDICATION NAME]) medications were held and discontinued on 2/14/14. Intake was recorded as poor for breakfast and lunch meals, and only eating 50 % at the evening meal. For 2/18/14, the resident's meal intake was recorded as poor. Medical record information indicates the resident was treated for [REDACTED]. On 2/19/14, Resident #3's weight was recorded at 209.7 pounds, with ongoing weight loss. The facility failed to ensure effective care measures were established for this resident for weight maintenance. There was no evidence of comprehensive assessment or evaluation of the resident's consumable calories, nutrition supplementation, and/or whether large portions were an effective approach to halt weight loss when the resident was documented with poor intake and being treated for [REDACTED]. Record review indicates the resident was seen by the facility's rehabilitation Speech and Occupational therapist for evaluations and treatment during February and March 2014 for dysphasia and feeding ability skills to determine possible causative factors for decreased intake. Interventions at that time (2/28/14) included diet texture downgrade to puree foods; with meal assistance prompts and cues, (loading utensil) to initiate self feeding in a quiet environment, and offering one item for less distraction were several approaches recommended. Documentation indicated the resident would permit feeding assistance on occasion; at times will be resistant. There was no evidence of a reevaluation of the resident's nutritional intake to determine whether meals provided were adequate to meet the resident's needs. Weight summary records indicates the resident weighed 207 pounds range for 2/27/14, 3/6/14 and 3/23/14. Review of the resident's plan of care on 4/8/14 indicates the problem of significant weight loss (dated 2/14/14) with the admission goal to maintain weight status and not to lose weight. Interventions and approaches included weekly weights; large portions initiated on 2/6/14 and supplements (2/14/14). Although the resident's plan of care included supplements three times a day as of 2/14/14, there was no evidence that the facility provided the resident with the supplements as planned. For example: Review of medication administration records (MAR) for 2014 January, February, March and April as of 4/7/14, the resident's ordered nutritional supplement was only provided (as ordered) once a day and not three times per day as stated in the revision date of 2/14/14. There was no evidence that the supplement was increased. Additionally, the medical plan of care dated 4/8/14 indicated the resident was at risk for skin impairment due to incontinence status and a new open area on the coccyx. Cleansing and hydrogel treatments were ordered on [DATE]. Interventions for nutrition and hydration support were identified as approaches which were not appropriately implemented. On 4/8/14, the physician's orders [REDACTED]. During interview with the dietician on 4/10/14, at 12:45 P.M. she said that after reviewing the dietitian's communication book that the dated entry on 1/27/14 was not her handwriting and could not offer an explanation as to why her recommendation to increase the resident's nutrition supplement to three times per day was not implemented at that time. The recommendation was written incorrectly for once per day. The dietitian was unaware until 4/10/14, after interview with the surveyor, that the resident's plan of care was not implemented appropriately and not effective to halt the resident's weight loss. On 4/10/14, the plan of care was altered/revised to add fortified foods at each meal and a nutritional supplement at each meal time in addition to the supplement provided each nursing shift; an increase from once a day to six times per day (from approximately 240 to 1440 additional calories). Fortified foods and ready care supplement as ordered (4/7/14) were not implemented until 4/10/14, a delay of three days.

Based on record review and staff interview, the facility failed to develop a comprehensive care plan for bowel and bladder incontinence for 1 resident (#20) from a total sample of 23 residents that included measurable objectives and timetables to meet a resident's specific needs. Findings include: Resident #20 was admitted to the facility following hospitalization for acute [MEDICAL CONDITION], dementia, [MEDICAL CONDITION] disorder, gait dysfunction, fall history, and [MEDICAL CONDITION] due to [MEDICAL CONDITIONS]. Per record review on 1/29/13, review of a bladder assessment form completed on admission on 6/7/12 indicated that the resident was incontinent of bladder as evidenced by clothes or incontinence pad wet; daytime frequency greater than 8 times during waking hours; night time incontinence greater than 2 times per night; and bedwetting. The resident was assessed having a history of [MEDICAL CONDITION] due to prostatitis/[MEDICAL CONDITION] and was identified with functional and urge incontinence. The Treatment Program recommended was for scheduled toileting/habit training. Review of page 3 of the bowel and bladder summary indicated that the resident had moderate to severe dementia that is progressively worsening and was experiencing functional mobility problems with inability to ambulate at this time or to use the bathroom. "Presently would not be a receptive candidate for toilet training program." There was no documented evidence that facility staff attempted any interventions as recommended on 6/7/12. There was no care plan that addressed the resident's incontinence. Continued review of the clinical record indicated that the resident had 9 falls between 6/18/12 and 10/24/12. Review of the incident reports indicated that 7 of the 9 falls were associated with the resident attempting to self toilet. Unit Manager #2 said during interview on 1/30/13 at 2:15 P.M. that there was no documented evidence that a care plan was developed to address the resident's bladder incontinence. See F 315

Based on record review and staff interview, the facility failed for 2 residents (#8, #20) of a total sample of 23 residents, to ensure that each resident receive necessary services to maintain as much bladder function as possible. The findings include: 1. Resident #8 had [DIAGNOSES REDACTED]. The resident's most recent quarterly Minimum Data Set Assessment (MDS), with a reference date of 11/20/12, indicated that the resident was cognitively impaired and needed assistance from facility staff to complete the activities of daily living. The resident's admission MDS, with a reference date of 3/12/12, coded the resident 1- occasionally incontinent of bladder. The facility bladder assessment form, dated 3/5/12, reported that the resident was continent of urine. Per review of the resident's bladder tracking data, from 3/12/12 to 5/1/12 the resident was continent of urine 139 times and incontinent of urine 12 times. A care plan, created 3/16/12, reported that the resident was occasionally incontinent. Goals included that the resident would maintain the current level of bladder function. The interventions included: - prompt and cue upon upon rising, before/after meals, at bedtime and PRN - encourage exercise/ fluids - monitor for symptoms of urinary tract infection - monitor and report changes in ability to toilet or incontinence status The facility bladder assessment form, dated 11/18/12, indicated that the resident was incontinent of urine. The form indicated that the resident had "urge urinary incontinence" and was not appropriate for retraining due to dementia. The form concluded that the resident would wear "pull ups for dignity," and be assisted by staff for cuing and toileting needs. The resident's quarterly Minimum Data Set Assessment (MDS), with a reference date of 11/20/12, coded the resident as 2- frequently incontinent of urine, a decline in urinary function. The care plan was reviewed on 12/4/12. No changes were made. Per review of the resident's bladder tracking data, from 11/29/12 to 1/27/13 the resident was continent of urine 87 times and incontinent of urine 93 times. Despite the decline in urinary continence, the facility failed to modify the plan of care and attempt new interventions to help the resident retain as much bladder function as possible. 2. For Resident #20, the facility failed to implement an appropriate care plan and adequate interventions to allow the resident to attain and maintain normal voiding and continence. Resident #20 was admitted to the facility following hospitalization for acute [MEDICAL CONDITION], dementia, [MEDICAL CONDITION] disorder, gait dysfunction, fall history, and [MEDICAL CONDITION] due to [MEDICAL CONDITIONS]. Review of the 6/14/12 initial and 11/20/12 quarterly Minimum Data Set (MDS) assessments indicated that the resident was cognitively impaired and required extensive assistance of staff to complete activities of daily living. The assessments indicated that the resident was frequently incontinent of bowel and bladder and that no toileting program had been trialed. The assessments also indicated that the resident required extensive assistance for ambulation, transfers and for toilet use due to unsteadiness and only being able to stabilize with human assistance. Per record review on 1/29/13, review of a bladder assessment form completed on admission on 6/7/12 indicated that the resident was incontinent of bladder as evidenced by clothes or incontinence pad wet; daytime frequency greater than 8 times during waking hours; night time incontinence greater than 2 times per night; and bed wetting. The resident was assessed having a history of [MEDICAL CONDITION] due to prostatitis/[MEDICAL CONDITION] and was identified with functional and urge incontinence. The Treatment Program recommended was for scheduled toileting/habit training. Review of page 3 of the bowel and bladder summary indicated that the resident had moderate to severe dementia that is progressively worsening and was experiencing functional mobility problems with inability to ambulate at this time or to use the bathroom. "Presently would not be a receptive candidate for toilet training program." The clinical record did not reflect what receptive candidate meant. There was no documented evidence that facility staff attempted any of the bladder treatment program interventions as recommended on 6/7/12. There was no care plan that addressed the resident's incontinence. The resident was assessed as requiring extensive assistance for toileting but there plan on how this would be accomplished. The 6/7/12 nurse progress note indicated that the resident was unable to use the urinal to void. On 6/12/12 the physician's history and physical indicated that the resident had [MEDICAL CONDITION] and with the addition of [MEDICATION NAME] and [MEDICATION NAME] (used to reduce [MEDICAL CONDITION]) began to void normally. The physician's plan included monitoring for distension/retention; Urology consult as needed; observe closely for signs and symptoms of worsening and adjust treatment as needed. Continued review of the clinical record indicated that the resident had 9 falls between 6/18/12 and 10/24/12. Review of the incident reports indicated that 7 of the 9 falls were associated with the resident attempting to self toilet. Per review of the incident reports, following the falls on 8/5/12 and 9/11/12 a toileting schedule was to be implemented before meals and at bedtime. Review of the nurses' notes indicated no consistent implementation of a toileting program or any attempt to initiate voiding patterns. On 9/12/12, a care plan entry listed for a 3 day bowel and bladder assessment that had been crossed out without explanation. Review of the 9/17/12 bowel and bladder assessment indicated that the resident had impaired mobility/ambulation and was incontinent of bladder with the word occasionally written onto the form. Daytime and nighttime frequency and bed wetting that were previously coded on 6/7/12 were left blank. Review of page 3 of the assessment indicated that the"Resident occasionally incontinent of urine. Continent of bowel. Wears pull-ups. Toileted upon request." On 1/30/13 at 11:45 A.M., Certified Nurses Assistant (CNA #2) was interviewed about the resident's toileting schedule. Review of the CNA Care Card with CNA #2 failed to identify a timed toileting schedule for the resident. When asked about the toileting times CNA #2 said that the resident is alert and oriented and will tell staff when he/she has to go to the bathroom. Unit Manager #2 and the Director of Nurses were interviewed on 1/30/13 at 2:15 P.M. and were unable to explain why the resident's bladder incontinence was not addressed. See F 323

Based on record review, review of incident investigations and staff interview for 1 resident (#20) of a total sample of 23 residents, the facility failed to provide effective safety measures and adequate supervision to prevent falls resulting in injury. Resident #20 sustained 9 unwitnessed falls between 6/18/2012 and 10/24/2012 which resulted in progressive injury to the resident. The facility failed to provide adequate interventions to prevent falls which addressed the resident's cognitive deficits, lack of compliance with asking for assistance and the resident's repeated removal of the alarms applied to the resident. Findings include: Resident #20 was admitted to the facility following hospitalization for acute renal failure, dementia, seizure disorder, gait dysfunction, fall history, and urinary retention due to benign prostatic hyperplasia (BPH). Review of the 6/14/12 initial and 11/20/12 quarterly Minimum Data Set (MDS) assessments indicated that the resident was cognitively impaired and required extensive assistance of facility staff to complete activities of daily living. Both assessments indicated that the resident was frequently incontinent of bowel and bladder and that no toileting program had been trialed. The assessments also indicated that the resident required extensive assistance for ambulation, transfers and for toilet use due to unsteadiness and only being able to stabilize with human assistance. The resident was coded on the 11/20/12 MDS for fall history with injury and pain. Review of a fall care plan initiated on 6/11/12 listed the following interventions: bed/chair alarm; bed in low position; call light within easy reach; foot wear to prevent slipping; gait belt and fall mats. A review of the clinical record on 1/29/13 indicated that the resident had 9 unwitnessed falls that occurred on 6/18/12, 7/20/12, 7/30/12, 8/1/12, 8/5/12, 8/7/12, 9/11/12, 10/23/12 and 10/24/12. Unit Manager #2 was interviewed on 1/30/13 at 2:15 P.M. and reviewed the facility incident reports and facility documentation with the surveyor. The Director of Nurses was also present during the interview. The incident report documentation indicated the following: 1. On 6/18/12 at 10:40 P.M., the resident was found on the bedroom floor on the fall mat with no apparent injury. The resident said she/he walked to the bathroom and was unable to make it back to bed. The nurse documented the resident had poor safety awareness does not like to ask for assistance. Recommendations included replacing the bed alarm that had malfunctioned, continue physical therapy, and follow up with "safety cues". Unit Manager #2 was unable to explain what safety cues were implemented. Review of nurse progress notes from 6/19/12 through 6/28/12 indicated that the resident was non-complaint with alarms, was attempting to self toilet and put him/her to bed. 2. On 7/20/12 at 10:15 P.M., the resident was found sitting on the floor beside the bed. The alarm was not sounding and the resident said she/he rolled out of bed. The resident sustained [REDACTED]." Knee and skull x-rays were negative for fracture. Recommendations included adding half side rails, a perimeter mattress and a fall mat. Unit Manager #2 said that that fall mats should have been in place as they were previously care planned. 3. On 7/30/12 at 11:05 P.M., the resident was found on the bathroom floor after toileting independently. No injury was incurred. The nurse reported that the resident shut the alarm off. Recommendations included ordering non skid slipper socks. During 1/30/13 interview, Unit Manager #2 said that non-skid socks were previously care planned. Unit Manager #2 said that the resident was not on a toileting schedule and there was no documented evidence that a bladder treatment program was implemented. On 7/31/12 the Nurse Practitioner (NP) visited the resident because of increasing right knee pain. The NP indicated that the resident denied injury but had dementia and history of multiple falls so it was likely the knee was injured in a recent fall. Vicodin (narcotic) was ordered for pain with a plan to refer for an orthopedic evaluation if the pain persisted. 4. On 8/1/12 at 6:20 P.M., the resident was found on the floor in the bathroom. The resident told the nurse that she/he the lost his balance and fell . A knee x-ray indicated that there may be a knee joint effusion. New interventions included, resident education regarding the use of the call light. The resident's room was moved closer to the nurse's station. The resident was administered Vicodin for pain. 5. On 8/5/12 at 11:15 A.M., the resident was found sitting on the floor in the bathroom incontinent of bowel and bladder. The resident shut the alarm off and ambulated unassisted to the bathroom. Recommendations included educating the resident regarding the call light and to toilet before meals and at bedtime. There was no documented evidence that the toileting schedule recommended was implemented. 6. On 8/7/12 at 8:20 P.M., the resident was found sitting on the floor in front of a chair. The resident was visited by the Nurse Practitioner as the resident had a temperature of 102.6 and was reported anxious and irritable. Blood work, urine cultures and Tylenol were ordered and the resident was eventually referred for an orthopedic consultation. Intervention included the addition of a self release seat belt and the addition of hipsters. Unit Manager #2 said she was unaware of the recommendation for hipsters and that the intervention was not initiated. Review of the 8/7/12 Nurse Practitioner's progress note indicated that the resident had poor safety awareness due to dementia, "cannot seem to process or remember reasons for alarms or restrictions." The resident was seen by the orthopedic consultant on 8/22/12 who indicated the resident had progressively increasing right knee pain related to falls. The physician documented that following the 8/5/12 fall the resident had increased pain and swelling resulting in a significant effusion of the right knee. The orthopedic physician drained the fluid from the resident's knee followed by a Celestone (steroid) knee injection. 7. On 9/11/12 at 9:00 P.M., the resident was found sitting on the floor in the bathroom with the alarms shut off. Recommendations listed to continue physical therapy and to offer the resident use of bathroom at night. Unit Manager #2 and the Director of Nurses were unable to explain why the toileting schedule previously recommended on 8/5/12 was not implemented or why a 9/12/12 care plan intervention for 3 day bowel and bladder assessment had been crossed out without explanation. 8. On 10/23/12 at 7:40 P.M., a certified nurse aide (CNA) responding to an alarm found the resident on the floor at the side of the bed. The resident told the nurse that he/she wanted to urinate and was provided a urinal. No injury was identified. Recommendations included placing a urinal at the bedside. 9. On 10/24/12 at 7:07 A.M. the resident was found sitting on the floor next to the bed. The resident attempted to self transfer to the bathroom without assistance. The resident told the CNA staff responding to the alarm that he/she had to urinate. The resident complained of left shoulder pain and was medicated. Stat x-rays of the left shoulder and humerus showed no acute fracture. Non-skid strips were applied to the floor. On 10/26/12 a second x-ray was completed and was negative. The resident continued to complain of pain, the left shoulder was reported swollen, warm to touch with bruising noted to the bicep area. On 10/31/12 the physician ordered an MRI. Review of the 11/2/12 Nurse Practitioner's note indicated that the MRI results indicated that the resident sustained [REDACTED]. The resident's arm was immobilized with a sling to be worn at all times and stat orthopedic consult was ordered. The resident was seen by an orthopedic consultant on 11/7/12 but the report was unavailable at the time of survey. Following surveyor inquiry, a physician note dated 1/31/13 indicated that the orthopedic consultant noted a chronic rotator cuff full thickness tear that likely occurred decades prior. The physician indicated that the (shoulder) joint effusion and muscle hematoma were acute as would be expected from an acute injury. The physician indicated that the resident continued with physical therapy and his/her pain improved. The facility failed to provide effective safety measures and adequate supervision to prevent falls resulting in injury for Resident #20 who had a pattern of falls related to self toileting.

Based on record review and staff interview, the facility failed to adequately monitor weight and nutritional parameters for 3 residents (#16, #18 and #20) from a total sample of 24, to implement timely interventions to prevent weight loss and maintain nutritional status. Refer to the following: The facility's weight monitoring policy included to review and monitor residents with weight variances at interdisciplinary meeting, and on a regular scheduled basis. If a weight loss or gain of three pounds is noted, a reweigh is to be obtained the same shift the next day. If the weight variance was accurate the nurse was to notify the physician, the weight committee, and document in the nurses' notes the interventions taken. 1. Resident #16 was admitted to the facility with [DIAGNOSES REDACTED]. The resident was admitted to the facility for rehab therapy after hospitalization for treatment of [REDACTED]. Per review of the clinical record, on 9/30/10, the facility failed to complete a comprehensive assessment of this resident's nutritional needs to improve nutritional parameters and as a result failed to avoid significant weight loss. Review of the Initial Minimum Data Set (MDS) assessment with a reference date of 7/23/10, documented the resident's height as 64 inches and weight as 130 pounds. This resident had short and long term memory loss, with cognitive impairment for decision-making and required staff assistance for activities of daily living. The resident had no skin areas noted. Nutritional status information identified a swallowing problem, with altered dentition requiring a mechanically (puree) altered diet. The resident was noted to leave more than 25 % of meals uneaten and received a nutritional supplement. Discharge plans included returning to the home with family after rehab therapy. The Nutritional Screening & assessment dated [DATE] documented that the resident was admitted from the hospital weighing 160 pounds, and at 133 % of ideal weight range. Meal intake at that time was noted at 50%. Therefore, the house supplements prescribed at meal times were necessary. Admission physician orders [REDACTED]. Hospital referral documentation included the results of this resident's laboratory blood tests which reported abnormal (low) levels for serum [MEDICATION NAME] (2.6), hemoglobin (11.4) and hematocrit (34). Medications prescribed included [MEDICATION NAME] to treat the [MEDICAL CONDITION]. The dietician's assessment acknowledged the resident's low [MEDICATION NAME] stating that it was low due to "dehydration."(Actually dehydration would falsely increase the resident's blood [MEDICATION NAME] level). Further, the initial nutritional screening noted that resident's food preferences can be obtained at a later time, as the resident was out of room when visited. The plan was to monitor and encourage good hydration. Review of the medical care plan indicated the resident had a reddened lower extremity which required an acute hospital evaluation on 7/23/10. The resident was treated for [REDACTED]. According to nursing documentation the resident's right heel had developed a reddened area. prescribed treatments included [MEDICATION NAME] and Prevalon boot to be worn. The resident was seen by speech therapy on 8/3/10, who recommended a puree texture diet with nectar thickened liquids for dysphagia. An entry by the dietician on 8/5/10 noted a correction to the initial nutritional assessment reporting that the resident's admission weight was inaccurate at 160 pounds, as the hospital discharge weight was reported at 133 pounds. There was no facility admission weight referenced. The resident's weight for the week of 8/2 to 8/8/10 was noted at 125 pounds. The dietician acknowledged that the resident had an 8 pound weight loss since admission from the hospital (133 to 125) over a three week period. According to the care tracker, documented by certified nurse aide (CNA) staff, the resident had been recorded to eat 50 % at most meals with some meal intakes at 100%. The recommendation at that time included to add fortified foods at meals, encourage the resident to eat 75% of meals, to continue the regular puree diet with a house supplement at meal times with ice cream and nectar thick liquids, and to monitor weight, meal intake and skin issues. Nursing monthly summary report stated the resident weighed 124 pounds on 8/10/10. Review of the Unit C weight book failed to include weekly or monthly weight measurements for resident #16 during July or August 2010. There was no evidence of weight monitoring during this time period. The resident's unintended weight loss was not reviewed by the weight variance committee consistent with facility policy. A laboratory report dated 8/11/10 included elevated levels for sodium 147 (133-145 mmol/L), chloride 111 (96-108 mmol/L) and BUN 28 (10-24 mg/dL) abnormal values indicative of possible dehydration. Further record review revealed a physician's orders [REDACTED]. This change was implemented after a delay of 2 weeks from the dietician's 8/5/10 recommendation. Interview with food service staff at approximately 12:30 P.M. on 9/29/10, reported that fortified foods consisted of a fortified cereal, fortified mashed potato, and a fortified soup. On 9/9/10 the resident was noted to weigh 115.7 pounds. Another 8.3 pound weight loss (124 to 115.7) in a one month period. There was no evidence of nutritional interventions to halt the resident's weight loss or evidence of "At Risk" communication referral to the Weight Variance Committee for further assessment and interventions. The resident's heel had a noted reddened area. Physician orders [REDACTED]. The laboratory report dated 9/23/10 indicated the resident's [MEDICATION NAME] level was abnormal at a critical low value of 11.9 (normal range of 16 - 40 mg/dL). Medical progress notes of 9/29/10 reported that the area "2.8 x 2" was improving. Further wound consultation on 9/29/10 recommended to start a nutritional supplement [MEDICATION NAME] 2.0 (4 ounces) three times a day. According to the Unit C weight records on 9/30/10 the resident's weight was reported at 114 pounds. The resident had a significant 14.2 % weight loss in two month period. Review of the plan of care dated 7/19/10 included weekly weight monitoring due to the resident's admission [DIAGNOSES REDACTED]. The resident was seen with full plates of foods untouched near the end of the 9/28 and 9/29/10 noon meals. This resident was not provided with ongoing cues or assistance to eat during these observations in the main dining room. The facility failed to identify an effective plan to address initial weight loss for this resident at nutritional risk and failed to consider multiple factors affecting the resident's weight loss, inadequacy of meal intake and increased nutrient needs which resulted in further weight loss. Weight monitoring was not prudent nor followed and communicated according to the facility's "at risk" weight committee procedure. Screening of weights for variances (loss or gain of 3 pounds) was to be done on a routine basis and addressed accordingly and communicated to the physician. This was confirmed through interviews on 10/1/10, at 1:20 P.M., with the Unit C Nurse Manager that there were no prior weight records except the current weekly weight sheet for September for resident #16. The issues regarding this resident's weight loss were also discussed with the Director of Nurses', on 10/1/10 at approximately 1:45 and 2:10 P.M., who could not provide any additional information from "At Risk" minutes to explain the resident's weight loss and planned interventions. 2. For Resident #20, the facility failed to ensure that nutritional parameters such as body weight were appropriately monitored and interventions were implemented timely to avoid unintended weight loss. Recorded reweigh measurements were not assessed timely for accuracy and discrepancies (weight loss) were not always addressed to . Refer to the following: The facility's weight monitoring policy read to notify the charge nurse of all weight changes totaling +/- three pounds weight variance. The nurse would check the resident's weight and then record the weight. If the weight variance was accurate the nurse was to notify the physician, the weight committee, and document in the nurses' notes the interventions taken. Resident #20 had been admitted to the facility for long term placement in May of 2010. The resident's [DIAGNOSES REDACTED]. An Initial MDS assessment completed on 6/2/10 and a subsequent significant change MDS completed on 9/7/10 indicated a decline in the resident's cognitive status and activity of daily living. The Initial MDS indicated the resident weighed 174 pounds, was on a therapeutic diet and required supervision with meals. The Significant change MDS noted the resident to weigh 144 pounds with more that 5% weight loss in the last 30 days, and more than 10% loss in the last 180 days. The resident required required extensive assistance with meals. Review of the permanent weight chart revealed the resident was weighed weekly for four weeks following the resident's May 2010 admission. The weight chart showed the resident's weight was stable for this period of time. The resident's weight status was recorded in the 174 pound range on 5/30/10, 6/6/10, 6/13/10 and 6/20/10. The next documented weight recorded for this resident was on 7/12/10 showing the resident's weight was 162 pounds (a 12 pound weight loss). There was no documentation by the dietician or nursing regarding the resident's weight status acknowledging the change or weight variance according to facility policy. For the next three weeks, the resident's weight remained stable at this 162 pound range. Per record review the resident had two hospitalization s in August 2010. The weight chart and assessments revealed the resident's weight following the second hospitalization was 144 pounds on 8/23/10. An additional 12 pound weight loss in one month and a 17.8% weight loss since the resident's admission to the facility. There was no evidence that nutritional weight loss interventions were implemented at that time. The dietician's quarterly note of 9/2/10 reported this resident with significant weight loss, presenting with a 12% weight loss in 30 days. The dietician indicated the weight loss was significant following the resident's discharge from the hospital in August 2010. The resident's oral intake was poor, now dependent in eating and had a diet change from regular to pureed texture. The plan included fortified foods, protein supplements three times per day, encourage food preferences daily and to encourage better oral intake at meals. 3. The facility failed to identify and address Resident #18's unplanned weight loss over the previous six months. Resident #18 had lived at the facility for 6 years and had [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment was completed on 7/14/10 and indicated the resident required extensive assistance for personal care and mobility, and limited assistance for eating. The resident was noted to have memory loss and severe cognitive deficits. The resident's diet order was for mechanical soft texture, with thin liquids and finger foods at all meals. The resident was also to receive a section plate at all meals. Review of the resident's record revealed that the last nutritional assessment by the dietician was completed on 4/5/10. At that time, the dietician wrote that the resident's weight was stable at 99 pounds. The dietician noted that the resident's intake was 50% - 100% with physical assist and was tolerating the diet and liquid consistency well. The care plan reflected this assessment with the most recent update on 4/8/10. According to the weight record, the resident weighed 99 pounds when weighed on 3/29/10 and 4/5/10, and weighed 90.6 pounds on 9/27/10. This represented a loss of 8.4 pounds or 8.5% of the resident's body weight over the previous 6 months. There was no current documentation by the dietician or nursing regarding the resident's weight status included in the record. On 9/30/10 at 3:45 P.M., the dietician was interviewed and explained that she had begun working at the facility in June 2010 about two weeks after the previous dietician had left. She reviewed the documentation in the resident's record, confirmed that she had not done any assessment of Resident#18 and stated that she had no other explanation other than the resident had been "overlooked" during the transition. At 4:00 P.M., the resident's weight loss was discussed with the Director of Nursing and the Regional Clinical Consultant with a request for any other information related to the resident's weight loss that may have been completed by nursing or other facility staff. On 10/1/10 at 8:45 A.M., the Director of Nurses' reported that no other information had been found, and that there was no evidence that the resident had identified and discussed at the facility's "At Risk" meetings.