Every finding on record at OC Milford Gardens LLC

Based on records reviewed and interviews, for two of three sampled residents (Resident #2 and Resident #3), who had limited mobility and required staff assistance to complete Activities of Daily Living (ADLs), the facility failed to ensure their ADL Care Plans were individualized, with interventions that clearly identified the necessary number of staff assistance required to adequately and safely meet their needs.Findings include:Review of the facility's policy, titled Care Plans-Comprehensive, with a revision date of 07/2023, included the following:-An individual comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, emotional and psychological needs is developed for each resident.-The comprehensive care plan is based on thorough assessment that includes but is not limited to the Minimum Data Set (MDS) assessment.-Each resident's comprehensive care plan is designed to:*Incorporate identified problem areas*Incorporate risk factors associated with identified problems*Reflect treatment goals, timetables and objectives in measurable outcomes*Aid in preventing or reducing declines in resident's functional status and/or functional levels1) Resident #2 was admitted to the facility in March 2026, diagnoses included hemiplegia (complete or near complete paralysis of one side of the body) and hemiparesis (mild to moderate weakness on one side of the body) following cerebral infarction (stroke).Review of Resident #2's Minimum Data Set (MDS) assessment, dated 03/19/26, indicated his/her ADL status was assessed as follows:-Non-ambulatory-Maximum assistance for chair to bed transfers-Moderate assistance for upper body dressing and dependent for lower body dressing-Moderate assistance for bathingReview of Resident #2's ADL Care Plan, reviewed and renewed with the most recent MDS assessment, indicated the following:-Focus: The resident has an ADL self-care performance deficit activity intolerance, fatigue.-Interventions included the following:*Toilet schedule: around 6:00 A.M., before meals, prior to bed and as needed*Encourage the resident to use the call bell for assistance*Praise all efforts and self-care*Physical Therapy (PT), Occupational Therapy (OT) referrals as ordered and as neededFurther review of the ADL Care Plan indicated it was not individualized or specific to Resident #2's care needs with respect to the necessary number of staff required to adequately and safely meet his/her care needs. Review of Resident #2's CNA Kardex (used by CNAs to indicate the specific level of care required for each resident) indicated his/her ADL section on the Kardex was left blank. Therefore, CNA's reviewing Resident #2's care Kardex prior to providing care would not find individualized information on if he/she required one, two (or more) staff members to adequately and safely meet his/her care needs related to care areas such as (but not limited to) bathing, bed mobility, repositioning or transfers.2) Resident #3 was admitted to the facility in November 2025 diagnoses included unspecified convulsions, altered mental status, and generalized muscle weakness.Review of Resident #3's MDS assessment, dated 03/20/26, indicated his/her ADL status was as follows:-Dependent for chair to bed transfers-Maximum assistance for upper body dressing and dependent for lower body dressing-Dependent for hygiene-Maximum assistance for bathingReview of Resident #3's ADL Care Plan, reviewed and renewed with the most recent MDS assessment, indicated the following:-Focus: The resident has an ADL self-care performance deficit [due to] limited mobility.-Interventions included the following:*Half side rails for assistance with bed mobility*Encourage the resident to use the call bell for assistance*Praise all efforts at self-care*PT, OT referrals as ordered and as neededReview of Resident #3's Falls Care Plan, reviewed and renewed with the most recent MDS assessment, indicated the following:-Focus: Risk for falls-Interventions included (but not limited to) the following:*Assist the resident with ambulation and transfers, utilizing therapy recommendationsFurther review of the ADL Plan indicated it was not individualized or specific to Resident #3's care needs with respect to the necessary number of staff required to adequately and safely meet his/her care needs.Review of Resident #3's CNA Kardex indicated his/her ADL section on the Kardex was left blank. Therefore, CNA's reviewing Resident #3's care Kardex prior to providing care would not find individualized information on if he/she required one, two (or more) staff members to adequately and safely meet his/her care needs related to care areas such as (but not limited to) ambulation, dressing, bed mobility, or transfers.During an interview on 06/17/26 at 1:41 P.M., Certified Nurse Aide (CNA) #2 said he accessed each resident's care plan (Kardex) electronically to determine the level of assistance needed to provide care. CNA #2 said that if the specific level of assistance was not listed on a resident's care plan (Kardex), he would ask the nurse. CNA #2 said when a resident was new to him, that he would have to go and ask the nurse the level of assistance he/she required. During an interview on 06/17/26 at 3:09 P.M., CNA #3 said that the nurses usually write the resident's level of assistance on a piece of paper and give it to the CNAs at the start of their shift. CNA #3 said if a staff member worked at the facility for a long time or knew the residents, they would not get the paper. During an interview on 06/17/26 at 3:20 P.M., the Director of Nurses (DON) said that any member of the clinical staff can put a resident care plan in place. The DON said the CNAs can use the resident's care plans/Kardex's, or they can get shift reports from the nurses to determine the level of assistance each resident needs. The DON said the nurses and CNAs communicate about the residents' statuses, but it is not always reflective on their written care plans/Kardex's.The DON said it was not within the CNAs scope of practice to determine a resident's required level of assistance. However, when asked why the individualized ADL statuses for Resident #2 and Resident #3 were not indicated on the CNA Kardex's for them to readily reference, a response was not provided.

Based on record reviews and interviews for one of three sampled residents (Resident #1), who was newly admitted to the facility, the Facility failed to ensure he/she was free from a significant medication error, when medications from his/her Hospital Discharge Summary were not accurately reconciled by Nursing and he/she was administered Buspirone (anxiolytic medication) and Benzonatate (cough suppressant) in error.Findings include:Review of the Facility Policy titled, Reconciliation of Medications on Admission, dated as revised 04/2025, indicated the following:-medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route and indication for use for the purpose of preventing unintended changes or omissions at transition points in care;-obtain a medication history from the resident or family, complete this first;-gather the information needed to reconcile the medication list - Discharge Summary from referring facility;-find a quiet place that is free from distractions;-review the list carefully to determine if there are any discrepancies;-if there is a discrepancy or conflict in medications, dose, route or frequency, contact the nurse and physician from the referring facility, discuss with the resident or family, and contact the admitting physician;-document findings and actions of the medication discrepancy.Review of the Facility Policy titled Adverse Consequences and Medication Errors, dated as revised 7/2025, indicated that a medication error is defined as the administration of drugs which is not in accordance with physician's orders or accepted professional standards and principles of the professional's providing services.Resident #1 was admitted to the Facility in March 2026, diagnoses included acute renal failure on top of chronic kidney disease, benign prostatic hyperplasia with lower urinary tract symptoms, hyponatremia, hypomagnesemia, hypocalcemia, atrial fibrillation, hyperlipidemia, hypertension, chronic gout due to renal impairment, and Wegener's granulomatosis with renal involvement (autoimmune disease that can affect your whole body, but especially affects your lungs and kidneys).Review of the Report submitted by the Facility via Health Care Reporting System (HCFRS), dated 3/18/26, indicated that Resident #1 was on a medication that he/she did not give consent to be administered. The Report indicated that Resident #1's medication list was reviewed and a discrepancy related to Buspirone was identified. The Report indicated that the nurse who reviewed Resident #1's admission medications accidentally made a mistake during the transcription of the medications and made a medication error due to having two admissions at the same time and being interrupted during the medication reconciliation. The Report indicated that Resident #1 received several doses of Buspirone in error while at the facility.Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated to administer the following:-Calcitriol (Vitamin D Supplement) 0.25 micrograms (mcg) by mouth daily;-Prednisone (corticoid steroid) 5 milligrams (mg) by mouth daily;-Carvedilol (beta-blocker) 12.5 mg by mouth twice daily;-Docusate Sodium (stool softener) 100 mg by mouth daily at bedtime;-Docusate Sodium (stool softener) 200 mg by mouth daily;-Famotidine (histamine-2 blocker) 20 mg by mouth twice daily;-Calcium Carbonate (Mineral Supplement) 500 mg chewable tablet by mouth daily;-Cholecalciferol (Vitamin D3 Supplement) 2000 Unit by mouth daily;-Atorvastatin (statin) 20 mg by mouth daily;-Mycophenolate Mofetil (immunosuppressive) 500 mg by mouth daily at bedtime;-Mycophenolate Mofetil 1000 mg by mouth daily;-Tamsulosin (alpha blocker) 0.4 mg by mouth daily at bedtime;-Eliquis (anticoagulant) 2.5 mg by mouth twice daily;-Lactobacillus Acidophilus (probiotic) one capsule by mouth daily;-Fosfomycin Tromethamine (antibiotic) 3 gram packet by mouth every week on Friday;-Amlodipine (calcium channel blocker) 5 mg by mouth daily;-Metoclopramide HCL (dopamine receptor antagonist) 5 mg by mouth daily;-Allopurinol (antigout) 100 mg by mouth daily.However, further review of Resident #1's Facility Physician's Orders, dated 03/11/26, indicated that it included the administration of two additional medications: -Buspirone HCL (anxiolytic) 10 mg by mouth three times daily;-Benzonatate (cough suppressant) 100 mg by mouth three times daily.Further review of Resident #1's Hospital Discharge summary, dated [DATE], indicated the medication list did not include the administration of Buspirone and Benzonatate.Review of Resident #1's Medical Record indicated that there was no documentation to support that nursing clarified, reconciled or obtained new orders regarding the Buspirone and Benzonatate medications from his/her Physician upon admission.Review of a Nurse Practitioner Progress Note, dated 3/11/26, indicated that Resident #1 arrived today for admission, medications reviewed with Unit Manager, will see [resident] tomorrow for full assessment and note.Review of a Nurse Practitioner Progress Note, dated 3/12/26, indicated that per discharge papers and patient, the hospital had issues confirming medication dosing and patient confirms dosing in the hospital discharge paperwork and we will continue through his/her stay. During an interview on 5/19/26 at 1:20 P.M., Nurse Practitioner (NP) #1 said that she reviewed Resident #1's Hospital Discharge summary dated , 3/11/26, with the Unit Manager and said that everything looked appropriate. NP #1 said that she did not add any new medications [Buspirone and/or Benzonatate] to the medications listed on Resident #1's Hospital Discharge Summary.Review of Resident #1's March 2026 Medication Administration Record (MAR), indicated that he/she received the following medications in error:-Buspirone HCL 10 mg was administered three times a day from 3/11/26 until 3/16/26, for a total of 16 doses;-Benzonatate 100 mg was administered three times a day from 3/11/26 until 3/16/26, for a total of 16 doses.During a telephone interview on 5/20/26 at 10:58 A.M., Nurse #1 said that on 3/11/26 there were three new admissions/re-admissions to her Unit. Nurse #1 said that the Unit Manager completed the medication reconciliations from the Hospital Discharge Summary and entered the medications into the Electronic Medication Administration Record (EMAR) for the three admissions.Nurse #1 said that she did not review the medication list on the Hospital Discharge Summary for Resident #1 and administered the medications to Resident #1 that were on the EMAR. Nurse #1 said that the NP did not order any new medications for Resident #1.During a telephone interview on 5/20/26 at 12:12 P.M., the Unit Manager said that on 3/11/26 she had three new admissions/re-admissions to her Unit. The Unit Manager said that she reviewed all the three admissions Hospital Discharge Summary's and completed the medication reconciliations.The Unit Manager said that she was interrupted many times during the medication reconciliations and entered the Buspirone medication into Resident #1's Medication Administration Record in error. The Unit Manager said that she must have mixed up Resident #1's medication list with one of the other two admissions medication lists in error. The Unit Manager said that she verified Resident #1's medications with the NP on 3/11/26 and said that the NP did not order any new medications for Resident #1.Although the Unit Manager acknowledged that she transcribed the Buspirone error, the Surveyor identified during the survey that Benzonatate had also been entered and transcribed into Resident #1's Medication Administration Record during medication reconciliations on 3/11/26, in error. The Facility's Internal Investigation into the transcription error related to the Buspirone, however failed to identify that a second medication [Benzonatate] had also been transcribed onto Resident #1's EMAR in error.During an in-person interview on 5/19/26 at 3:00 P.M. and a subsequent telephone interview on 5/21/26, the Director of Nurses (DON) said the facility was notified by Resident #1's family member that Resident #1's medication list was wrong and that he/she received a medication (Buspirone) at the facility in error. The DON said that upon this notification, she immediately reviewed Resident #1's Hospital Discharge summary dated [DATE] and noticed that the Buspirone was not on his/her medication list from the Hospital Discharge Summary. The DON said that there were multiple admissions on 3/11/26, that the Unit Manager had reviewed Resident #1's Hospital Discharge Summary medication list, completed the medication reconciliation, and entered the Buspirone in error into Resident #1's EMAR. The DON said that the Unit Manager had multiple interruptions and transcribed the Buspirone from another resident's Hospital Discharge Summary medication list onto Resident #1's EMAR in error.The DON said that she reviewed Resident #1's admission the following day and verified that all of the medications that were listed on the Hospital Discharge Summary were on the EMAR. The DON said that she did not check to see if there were any additional medications on the EMAR and did not notice that the Buspirone was not listed on the Hospital Discharge Summary.During the survey on 5/21/26, while reviewing Resident #1's MAR, the Surveyor noted that Resident #1 also received Benzonatate, which was also not listed on his/her Discharge Summery, and he/she therefore had also received that medication in error. The DON, when informed of the additional transcription/medication error, said that she was unaware that Benzonatate was administered in error and said she would look into it.The DON said that she completed another chart audit on Resident #1's Medical Record after she was notified of the medication error and said that she did not notice that Resident #1 had also received Benzonatate in error. The DON said that it was her expectation that residents receive medications according to the providers orders, that medication reconciliation is completed accurately upon admission and any discrepancies clarified with the provider and documented in the Medical Record.

Based on record reviews and interviews for one of three sampled residents (Resident #1), who was alert, oriented and newly admitted to the facility, the Facility failed to ensure that they obtained signed written informed consent for the administration of psychotropic medication, Buspirone, which include providing the resident with information related to the risks and benefits of the medication, prior to it being administered.Findings include:Review of the Facility Policy Psychotropic Consent, dated as last revised 02/2021, indicated the following:-the facility will obtain informed written consent prior to administration of any psychotropic medication;-psychotropic medications include: antipsychotic, antidepressant, antianxiety and hypnotic medications;-prior to the administration of a psychotropic medication, the prescribe must discuss the purpose for administering the psychotropic drug, the prescribed dosage and any known effect or side effect of the psychotropic medication with the resident;-prior to administration of a psychotropic medication, the facility representative must complete the Informed Consent for Psychotropic Administration Form;-prior to administration of a psychotropic medication, the resident must sign and date the Informed Consent for Psychotropic Administration Form;-after verifying completion of the Informed Consent for Psychotropic Administration Form and verifying all required signatures have been obtained, the facility representative will sign and date the form and notify nursing of the fully approved consent;-the completed Informed Consent for Psychotropic Administration Form will be maintained in the resident's medical record.Resident #1 was admitted to the Facility in March 2026, diagnoses included acute renal failure on top of chronic kidney disease, benign prostatic hyperplasia with lower urinary tract symptoms, hyponatremia, hypomagnesemia, hypocalcemia, atrial fibrillation, hyperlipidemia, hypertension, chronic gout due to renal impairment, and Wegener's granulomatosis with renal involvement (autoimmune disease that can affect your whole body, but especially affects your lungs and kidneys).Review of Resident #1's admission Minimum Data Set (MDS) Assessment, dated 03/16/26, indicated he/she was alert, oriented, was his/her own decision maker, and had scored a 15/15 on his/her Brief Interview for Mental Status (BIMS) Assessment (0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired cognition, and 12-15 suggests a resident is cognitively intact).Review of Resident #1's Physician's Orders, dated 03/11/26 through 03/16/26, indicated to administer the following;-Buspirone HCL (anxiolytic) 10 mg by mouth three times daily;Review of Resident #1's March 2026 Medication Administration Record (MAR), dated 3/11/26 through 3/16/26, indicated that he/she had been administered 16 doses of Buspirone HCL.Further review of Resident #1's Medical Record indicated there was no documentation to support that a written informed consent was obtained from Resident #1 for administration of Buspirone HCL. During a telephone interview on 5/20/26 at 10:58 A.M., Nurse #1 said that Buspirone is an antianxiety medication and requires completion of an informed written consent before being administered to the resident. Nurse #1 said she administered Buspirone to Resident #1 as ordered by the physician and documented it in the MAR. Nurse #1 said that it is the facility's policy to obtain written informed consent for the administration of all psychotropic medications prior to the administration of the medication and said she thought that the Unit Manager had obtained written informed consent from Resident #1 for the administration of Buspirone. Nurse #1 said she did not check Resident #1's medical record for an informed consent prior to administering him/her Buspirone.During a telephone interview on 5/20/26 at 12:12 P.M., the Unit Manager said that Buspirone is an antianxiety medication and requires completion of an informed written consent before being administered to the resident. The Unit Manager said that it is the staff nurse's responsibility and facility policy to obtain written informed consent for any psychotropic medication prior to the administration of the medication. The Unit Manager said that she did not obtain written informed consent from Resident #1 for the Buspirone and said she was unaware that Resident #1's psychotropic medication consent had not been obtained by the staff nurse.During an interview on 5/19/26 at 3:00 P.M., the Director of Nurses (DON) said it is the Facility's policy that a written informed consent be obtained prior to the administration of psychotropic medication. The DON said she was unable to locate documentation to support that the Facility had obtained an informed written consent for the administration of Resident #1's psychotropic medication Buspirone HCL. The DON said it was her expectation that an informed written consent be obtained prior to the administration of any psychotropic medication.

Based on review of Resident Council Minutes, a resident group meeting, interviews, and document review, the facility failed to ensure grievances brought forward from the Resident Council were addressed and promptly resolved to ensure the residents felt their concerns were acted upon timely.Findings include:Review of the facility's policy titled Resident Council, undated, indicated but was not limited to the following:-the purpose of resident council is to provide a forum for residents to have input into the facility operation, discuss concerns, communication and dissemination of information-a resident council response form will be utilized to track issues, and their resolution will be discussed at the next meeting Review of the facility's policy titled: Grievances/Complaints, dated as revised 7/2025, indicated but was not limited to the following:-the resident or persons filing a grievance will be informed of findings of the investigation and actions taken to correct identified problems, by the Administrator within 10 working days of filing the grievance; a written summary will be kept in the grievance book. Review of Resident Council Minutes, dated 9/26/25, indicated but were not limited to:-3:00 P.M. to 11:00 P.M. (3-11) staff are not speaking EnglishReview of the corresponding departmental response form indicated but was not limited to:-Staff not always speaking English on the units - will in-service; in-service with the 3-11 staff ongoing Review of Resident Council Minutes, dated 10/27/25, indicated but were not limited to:-Agency nursing staff continue to not speak EnglishReview of the corresponding departmental response form indicated but was not limited to:Staff continues to not speak English in resident areas - ongoing in-service and audits through Resident Council Review of Resident Council Minutes, dated 11/26/25, indicated but were not limited to: Still having agency staff speaking non-English on unitReview of the corresponding departmental response form indicated but was not limited to:Staff continues to not speak English in resident areas - ongoing in-service and audits through resident council; always having new staff hired and new agency Review of Resident Council Minutes, dated 12/22/25, indicated but were not limited to:-Staff not speaking English on units is getting betterReview of the corresponding departmental response form indicated but was not limited to:Improvement, but staff is not speaking English on the units at times - continue in-service and recommend residents participate in identifying individuals who fail to follow policy Review of Resident Council Minutes, dated 1/28/26, indicated but were not limited to:-Staff continuing to not speak English in resident area (grievance in process)Review of the corresponding departmental response form indicated but was not limited to:Staff continues to not speak English in resident areas - ongoing in-service, new staff are hired and they need to be in-serviced On 2/27/26 at 11:04 A.M., the surveyor held a group meeting with 11 residents in attendance. The residents shared the following information:-9 out of 11 residents in attendance said staff are still not speaking English on the units or in resident areas and they expressed a feeling of the staff speaking negatively about them and trying to be sneaky. This concern remains unresolved since September 2025.- 10 out of 11 residents said they feel unheard by the facility when repeatedly bringing forth concerns and the facility had offered nothing but in-servicing as an attempt to solve concerns, which was ineffective in resolving their concern about staff speaking a foreign language.-9 out of 11 residents in attendance said they don't feel that the facility tries to resolve the issues that they bring forward in Resident Council or provide a plan to resolve the issue. During an interview on 2/27/26 at 12:25 P.M., the Activity Director said she manages the Resident Council meeting minutes and assists the residents with the process. She said when issues arise in Resident Council, she completes the Departmental response form, and it is discussed at morning meeting the next day. She said issues that the residents feel strongly about or are repetitive or severe in nature go directly onto a grievance form. She said the Resident Council had an ongoing unresolved concern about staff not speaking English for many months and she had initiated a grievance for it a few months ago, but the residents continue to voice it as an ongoing concern. She said the grievance was provided to the Administrator who is the grievance officer in the facility. She said the only feedback that she had been able to report to the residents in response to their ongoing concern is in-servicing and she was unaware of any other attempted interventions to solve the Resident Council's concern. She said she agreed with the residents' statement that issues are not always resolved through the Resident Council process as they should be in a timely manner and that the process needed work to resolve the Resident Council concern for staff not speaking English on the units. Review of the facility's Grievance Book from February 2025 to March 2026 indicated but was not limited to the following:-9/26/25: Resident Council concern of: Employees not speaking English on the unitsInvestigation: provide in-services to staff starting 9/26/25Resolution: survey Resident Council regarding this issue at next meeting (21 working days after the initiation of the grievance)The grievance form failed to indicate the grievance was resolved, a date of resolution, or that the plan was communicated to the Resident Council within 10 working days, in accordance with the facility practice/policy. During an interview on 3/4/26 at 12:03 P.M., the Staff Development Coordinator provided all in-services completed in the facility from August 2025 to March 4, 2026, for review.Only one in-service was completed regarding staff speaking a foreign language in resident areas on 9/26/25.The facility could not provide the survey team with any follow up education on this topic by the time of exit. During an interview on 2/27/26 at 1:11 P.M., the Administrator said he is the grievance official for the facility and reviews all concerns brought forth by the Resident Council. He said the concern of staff speaking a foreign language in resident areas may never be resolved as it is a behavior and changing other people's behavior is an ongoing situation that may not be fixed at all. He said he was not aware that the residents felt unheard by the facility in regard to this ongoing concern. He said the facility was attempting to in-service staff on the issue and he wasn't aware that there was no ongoing improvement. He said the facility had initiated audits and considered a performance improvement plan for this unresolved concern, but again there is potential the issue will remain unresolved. He said he should probably have communicated more detailed interventions and attempts to resolve the concern with the Resident Council, and he can see how this lack of communication would make the residents feel like the process was not working as intended.

Based on observations, interviews, and record review, the facility failed to ensure one Resident (#28), out of a total sample of 23 residents, received care and treatment in accordance with professional standards. Specifically, the facility failed to obtain a physician's order and/or include a left heel boot in the plan of care. Findings include: Review of the facility's policy titled Resident Mobility and Range of Motion, undated, indicated the care plan will include specific interventions, exercises, and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. And the care plan will include type, frequency, and duration of interventions. Review of the facility's policy titled Charting and Documentation, undated, indicated but was not limited to the following:-All services provided to the resident, progress toward care plan goals, or any changes on the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.-The following information is documented in the medical record: Treatments or services performed.-Documentation of procedures and treatments will include specific details including date/time provided, assessment data, how the resident tolerated the procedure/treatment. Review of the Lippincott Manual of Nursing Practice, 11th Ed. (2019) indicated: Scope of Practice, Licensure, and Certification: The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. The National Council of State Boards of Nursing and the National League of Nursing have developed standards that guide each State Board in the development of their licensure requirements and scope of practice rules. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice dated as revised April 11, 2018, indicated but was not limited to the following:Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Resident #28 was admitted to the facility in December 2025 with diagnoses which included cerebral infarction (CVA/Stroke), hemiplegia (paralysis on one side) and hemiparesis (weakness on one side) following a CVA affecting left non-dominant side, and a fractured left heel. Review of the Minimum Data Set (MDS) Assessment, dated 1/4/26, indicated he/she scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she was cognitively intact. Additionally, Resident #28 had a CVA with hemiparesis and was at risk for pressure ulcers. Review of the Physician's Orders indicated but were not limited to the following:-Left CAM boot (hard orthotic boot to immobilize and protect foot/ankle while allowing limited walking during recovery from injuries like fractures) on for transfers and when out of bed (OOB) every day and evening shift for fractured left heel and toes. (12/30/25)-Apply left resting hand splint per patient's tolerance daily and remove daily to assess skin for skin integrity. (1/12/26) Review of the Comprehensive Care Plan indicated but was not limited to the following:-Resident has Activities of Daily Living (ADL) self-care performance deficit functional limitations, limited mobility. (12/29/25)-Apply left resting hand splint per patient's tolerance daily and remove daily to assess for skin integrity. (2/27/26)-Resident has potential for skin breakdown due to decreased mobility and impaired circulation. (12/25/25) The surveyor made the following observations:-2/25/26 at 4:00 P.M., Resident lying in bed with soft left heel boot on.-2/26/26 at 1:13 P.M., Resident lying in bed with soft left heel boot on.-2/27/26 at 1:20 P.M., Resident lying in bed with soft left heel boot on. During an interview on 2/25/26 at 4:00 P.M., Resident #28 said he/she wears the CAM boot when out of bed and the soft boot while in bed every day. The Resident said someone from Occupational Therapy (OT) gave it to him/her, and he/she has had it for a while. Resident #28 said the staff never put the soft boot on correctly and OT did some education of how to put it on, but staff still don't do it right. Review of the OT treatment notes failed to indicate he/she had a soft heel boot or any treatment plan for a soft heel boot. During an interview on 2/27/26 at 1:23 P.M., Certified Nursing Assistant (CNA) #2 said Resident #28 has had the soft boot for a while, at least a few weeks, and he/she wears it in bed every day. She said the CNA Assignment sheet doesn't say anything about a brace, so if we have questions then we ask the nurse. She said there is no other place they can get resident specific care information and they do not have a Care Card or anything like that to give instructions. During an interview on 2/27/26 at 1:25 P.M., Nurse #4 said there is no written communication tool for the CNAs. She said if they have questions about a brace or splint they must ask the nurse. She said the nurses get information when things change from therapy and there would be a physician's order for any brace or splint, so the nurse would know when they should be applied and removed. During an interview on 2/27/26 at 1:30 P.M., Rehab Staff #1 said if a resident has a splint or brace given by OT then they enter the order in the computer and the nurse gets it approved by the physician. She said we do an education sheet with the staff and keep that form in the binder in the Rehab Office. She said soft boots usually do not come from OT and was unsure who gave it to Resident #28. She was unable to provide an education form for any splint/brace/boot education that may have been done as there was nothing for Resident #28 in the binder. During an interview on 2/27/26 at 1:33 P.M., the Director of Rehab said the therapists will enter the orders in the computer and nursing completes the order and updates the care plan. She said Resident #28 wears the CAM boot out of bed because of the heel and toe fractures. She said it comes off in bed, but she was unaware of a soft boot. She said when therapy does education with a device it is documented on this Transition of Care from Rehab to Nursing form and she did not have one for Resident #28. She said he/she came to the facility with the CAM boot but was unsure where the soft boot came from. During an interview on 2/27/26 at 1:42 P.M, Rehab Staff #2 said she did not provide Resident #28 with the soft boot. She said Resident #28 has asked her to put it on him/her sometimes and he/she does wear it in bed. During an interview on 3/3/26 at 10:13 A.M., Nurse #3 said there should be an order for any device, so the nurses know when to put it on and when to remove it. She said Resident #28 has two devices for the left leg. She said the CAM boot has an order in the computer, but the soft boot does not, and it should. She said she was going to check with therapy because the Resident does wear it every day. During an interview on 3/3/26 at 12:55 P.M., the Director of Nurses (DON) said sometimes there may not be an order for a brace/splint, but it should at least be in care plan if it's not an order. She said staff are educated by therapy on how to put them on/off and the schedule of what to do should be documented somewhere so staff know what to do, but there was nothing about the soft boot on the care plan or in the orders. During an interview on 3/3/26 at 1:55 P.M., Unit Manager (UM) #2 said there probably should have been an order for the soft boot, as staff would look in the orders to find out when to put braces/splint on and when to take them off. He said the order for the CAM boot has been there, but the order for the soft boot is new, it was not there previously, and Resident #28 has been wearing it in bed.

Based on observation, record review, and interview, the facility failed to ensure one Resident (#59), out of a total sample of 23 residents, was provided an environment as free of accident hazards as possible and received adequate supervision and assistance to prevent accidents. Specifically, the facility failed to ensure person-centered interventions were developed and implemented related to the root cause of the falls to mitigate the risk of future falls and/or injury resulting in five falls in three months after he/she had sustained a fall with fracture and had a change in mobility and continence. Findings include: Review of the facility's policy titled Falls-Clinical Protocol, undated, indicated but was not limited to the following:-While many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause.-Examples of risk factors include musculoskeletal abnormalities, gait and balance disorders, weakness, environmental hazards, and medical conditions.-The staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risk of clinically significant consequences of falling. Review of the facility's policy titled Care Plans-Comprehensive, dated as last revised 7/2023, indicated but was not limited to the following:-Each resident's comprehensive care plan is designed to incorporate risk factors associated with identified problems.-Care plan interventions are designed after careful consideration of the relationship between the resident's problem area(s) and their causes.-The Care Planning/Interdisciplinary Team (IDT) is responsible for the review and updating of care plans when there has been a significant change in the resident's condition, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay, and at least quarterly. Resident #59 was admitted to the facility in December 2024 with diagnoses which included mild cognitive impairment, protein calorie malnutrition, spinal stenosis, repeated falls, and fracture of the right femur. Review of the Minimum Data Set (MDS) Assessment, dated 12/23/25, indicated he/she scored 8 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she had moderate cognitive impairment, had orthopedic surgery to repair a fracture, did not have any falls since the last assessment, used a wheelchair, was occasionally incontinent, not on a toileting program, and required supervision/touching assistance with transfers and toileting. During an observation with interview on 2/25/26 at 9:55 A.M., the surveyor observed Resident #59 sitting in his/her wheelchair self-propelling around their bedroom. The Resident said he/she fell and broke their hip a while ago and had a few other falls because he/she was clumsy. Review of the Comprehensive Care Plan indicated but was not limited to the following:PROBLEM: Resident is a risk for falls/recent falls.INTERVENTIONS: Low Bed, Divert Resident with alternate activities, encourage to sit in chair instead of on the edge of the bed, obtain resident input, reposition items as needed, therapy eval for multiple falls, call for assistance and encourage to attend activities. PROBLEM: Resident is frequently incontinent of urine with potential for improved control or management of urinary elimination.INTERVENTIONS: Provide access to the bathroom, provide privacy and comfort, and provide verbal cues and physical assistance as needed. PROBLEM: Resident is at risk for decreased ability to perform Activities of Daily Living (ADLs) related to fall with hip fracture and surgical repair.INTERVENTIONS: Resident requires staff participation with bathing, dressing, transfers, and toileting needs. Review of the Resident Care Card/Kardex indicated but was not limited to the following:-Transferring: Resident requires staff participation.-Dressing: Resident requires staff participation.-Bathing/Showering: Resident requires staff participation.-Personal Hygiene: Resident requires staff participation.-Bladder/Bowel: Resident requires staff participation. Review of the medical record indicated Resident #59 had a fall on 10/8/25 resulting in a hip fracture. He/she had subsequent falls on 11/13/25, 12/25/25, 12/29/25, 1/14/26, and 1/18/26. Review of the Incident Reports indicated but were not limited to the following: FALL 10/8/25 at 3:30 A.M., Resident #59 heard a noise at night and jumped out of bed, resulting in a fall with a hip fracture.-Prior to this fall he/she was independent with transfers and ambulation and was continent of their bowel/bladder.-He/she was transferred to the hospital. FALL 11/13/25 at 7:00 P.M., Resident #59 called for help and was found in the bathroom on the floor and stated they had to use the bathroom. -On 11/17/25 the Falls Care Plan was updated to Divert Resident by giving alternative objects or activities as needed. FALL 12/25/25 at 6:45 P.M., Resident #59 was sitting on the bathroom floor barefoot and told staff they were trying to transfer off the toilet and slid to the floor.-Therapy eval was ordered for multiple falls and self-transferring. FALL 12/29/25 at 6:30 A.M., Resident #59 called for help and was observed sitting on the floor next to the bed. He/she stated they had to go to the bathroom and slid out of wheelchair. The wheelchair was not locked and moved back during the transfer.-Falls Care Plan was updated to reposition items as needed to location within visual field. FALL 1/14/26 at 3:30 A.M., Resident #59 observed sitting on the floor. They were trying to use the bathroom, did not lock the wheelchair, and fell self-transferring from the bed to the chair.-Falls Care Plan was updated to obtain resident input on strategies to anticipate needs and to prevent future falls. They reported they need to position the wheelchair properly next to the bed prior to transfer. FALL 1/18/26 at 9:30 P.M., Resident #59 was observed sitting on the floor next to the bed. They said they were transferring to the wheelchair and slid to the floor.-Falls Care Plan was updated to include floor mats. The intervention was discontinued the next day at the resident's request. Review of the Therapy Evaluation and Treatment notes indicated but were not limited to the following:-Occupational Therapy (OT) Discharge summary, dated [DATE], indicated he/she required supervision with all aspects of ADLs. Specifically, supervision or touching assistance with toileting and transfers.-Physical Therapy (PT) Discharge summary, dated [DATE], indicated he/she needed one assist to transfer, ambulate daily, and required supervision or touching assistance for toilet transfer and bed to chair transfers.-PT Evaluation and Plan of Treatment, dated 12/30/25, indicated he/she was ambulating with contact guard assist with walker when discharged from PT but has not walked with staff since discharge on [DATE]. At time of discharge, he/she required supervision level for transfers and contact guard for gait. Presenting today with decreased balance, standing tolerance, impaired safety awareness/insight, and decreased tolerance secondary to minimal mobility since discharge.-PT Discharge summary, dated [DATE], indicated he/she needed 24-hour care and required supervision with all transfers, and supervision/touching assistance for bed to chair and toileting transfers. Review of the Toilet Transfer, Toilet Hygiene, Toilet Use, and Bed/Chair Transfer documentation log for 2/1/26 though 3/3/26 indicated he/she was coded as Independent/No assistance from a helper greater than 50% of the time. The surveyor made the following observations:-2/27/26 at 9:51 A.M., Resident #59 was sitting in his/her wheelchair self-propelling around the unit. He/she approached the nurses' station and stood up at the desk without locking the wheelchair brakes.-2/27/26 at 10:52 A.M., Resident #59 was sitting in his/her wheelchair self-propelling around the unit. He/she told the Activities staff they needed to use the bathroom and then wheeled past the desk in the direction of their room and asked a staff member if they could get into their bathroom now. The staff member told the Resident he/she could get into the bathroom in their room, and then she walked away in the other direction. Resident #59 proceeded to self-propel to their room unassisted to use the bathroom.-3/3/26 from 9:08 A.M. until 10:01 A.M.: At 9:08 A.M., Resident #59 was in the bathroom inside their bedroom. Resident #59 exited the bathroom at 9:59 A.M., seated in the wheelchair, self-propelling to the other side of the room. The Resident was barefoot, dragging a towel from the wheelchair, carrying three hangers and a pair of socks. The Resident told the roommate they had to go back into the bathroom to clean up the mess from getting ready. At 10:01 A.M., the Resident was sitting in the wheelchair putting their socks on. Throughout the observation, no staff entered the bathroom to assist Resident #59 with toileting, dressing, or cleaning up the bathroom after he/she was done. During an interview on 3/3/26 at 10:14 A.M., Nurse #3 said when a resident falls, they complete the assessments, incident report, and then the care plan is updated with a new intervention related to the fall. She said the Director of Nurses (DON) is notified and they review the falls at risk meeting. During an interview on 3/3/26 at 1:55 P.M., Unit Manager #2 said after a fall the incident report and assessments are done and then the nurse should be updating the care plan. He said Resident #59 is stubborn and falls all the time, but in reviewing the incident reports he would expect interventions to be related to toileting and transfers. He said he/she requires assistance with toileting and transfers, and he/she should not be toileting self or left in the bathroom alone, and staff should not be telling him/her they can go alone. During an interview on 3/3/26 at 1:10 P.M., the DON said after a fall the post fall and risk management is done. She said they try to figure out the cause of the fall and anyone who is clinical can update the care plan. The surveyor reviewed the five falls with the DON and the intervention added if any at the time of the fall. The DON said the fall on 11/13/25 was related to toileting and transfers and the intervention does not address that. She said at the time she thought maybe the self-toileting was a behavior. She said after the fall on 12/25/25 was also related to toileting and nothing was added until they fell again on 12/29/25 attempting to transfer to use the bathroom and a therapy eval was ordered, but the toileting was not addressed. She said Resident #59 had two more falls in January. She said the fall on 1/14/26 the intervention was added to obtain resident input and wheelchair positioning was added to the care plan. The DON said the care plan indicates he/she needed staff participation, which is assistance, so that intervention does not address the issue of toileting and transfers either because they require assistance with both. After the fall on 1/18/26 floor mats were added but then resolved the next day because they did not work for the Resident. She said after they were resolved nothing else was added. The DON said she can see now how the interventions do not address the cause of the fall and a way to try and prevent future falls because all five falls were around toileting and transfers The surveyor reviewed the medical record with the DON which indicated Resident #59 was independent and continent of urine prior to the fall with hip fracture and since then they have required assistance. The MDS indicated occasional incontinence, and they have had five falls related to toileting with no toileting interventions implemented. The DON said she didn't realize the Resident was continent prior to the hip fracture so maybe the toileting was not a behavior and said they would need to start a diary. The surveyor reviewed the observation from 2/27/26 when staff advised Resident #59 he/she could go to the bathroom and from earlier in the morning when he/she was in the bathroom for 55 minutes alone. The DON said she would expect staff to assist Resident #59 with toileting and transfers and not tell them they could go alone or leave them in the bathroom for an hour alone.

Based on observations and interviews, the facility failed to ensure activity of daily living (ADL) care was provided to maintain good personal grooming for one Resident (#63), in a total sample of 23 residents. Specifically, the facility failed to ensure nail care was performed for Resident #63. Findings include: Review of the facility's policy titled Activities of Daily Living (ADL), undated, indicated residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, and personal hygiene. Resident #63 was admitted to the facility in January 2026 with diagnoses which included intervertebral disc degeneration and weakness. Review of the Minimum Data Set (MDS) Assessment, dated 2/16/26, indicated he/she scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) Assessment, indicating he/she was cognitively intact and was dependent on staff for assistance with ADLs. Review of the Comprehensive Care Plan indicated Resident #63 had an ADL self-care performance deficit due to weakness and degenerative disc disease.During an interview on 2/25/26 at 8:49 A.M., Resident #63 said he/she had a pair of toenail clippers, the big ones, that he/she used for fingernails because the little ones are too hard to manipulate. The Resident said the staff took them and put them somewhere; staff said they could not be in his/her room. The Resident said since then he/she has been asking to have their nails cut and no one will do it. The Resident said he/she was unsure where the nail clippers are now because staff took them before he/she moved units. Resident #63 said they have asked multiple nurses and Certified Nursing Assistants (CNAs) to cut them, and no one will do it.The surveyor made the following observations of Resident #63 sitting in their room:-2/25/26 at 8:49 A.M., nails on both hands long and dirty with dark substance underneath the nails.-2/26/26 at 9:45 A.M. and 1:17 P.M., nails on both hands long and dirty with dark substance underneath the nails.-2/27/26 at 9:12 A.M., nails on both hands long and dirty with dark substance underneath the nails.-3/3/26 at 10:03 A.M., nails on both hands clean and trimmed. Review of the shower schedule indicated Resident #63 was scheduled for a shower on Thursdays on the 7-3 shift. (2/26/26 was a Thursday) During an interview on 2/27/26 at 11:20 A.M., CNA #1 said every Resident is showered weekly. He said they do the shower and weight, and the nurse does the rest. During an interview on 2/27/26 at 1:12 P.M., Nurse #1 said Resident #63 cannot cut their own nails. She said the CNAs or a nurse will do it. She said they are cut whenever they are long, dirty, or if someone asks. During an interview on 2/27/26 at 1:15 P.M., Unit Manager (UM) #1 said she recalled Resident #63's nail clippers being locked in the cart but was unsure where they were now since he/she moved units. She thought they moved with him/her. She said the CNAs do nail care weekly on the shower day and as needed if they are long, dirty, or if the resident asks. During an interview on 3/3/26 at 10:07 A.M., Nurse #3 said nail care should be done on the shower day and whenever it is needed. During an interview on 3/3/26 at 1:00 P.M., the Director of Nurses (DON) said nail care should be done on shower days, as needed if they are dirty, and when a resident asks. She said if a resident asked for fingernails to be trimmed she would expect it to be done as soon as possible that day. During an interview on 3/3/26 at 2:00 P.M., UM #2 said nail care should be done on the shower day. He said staff can cut fingernails but not toenails. He said he would expect nails to be clean and trimmed if requested.

Based on observation, record review, and interviews, the facility failed to ensure staff provided appropriate care and services for one Resident (#12) with a Gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication), out of 23 sampled residents. Specifically, the facility failed to ensure enteral feedings (provide nutrition directly into gastrointestinal tract) were administered via G-tube in accordance with physician's orders.Findings include:Review of the facility's policy titled Enteral Tube Feeding via Continuous Pump, dated as revised 7/2025, included but was not limited to:- The purpose of this procedure is to provide a guideline for the use of a pump for enteral feedings.- Preparation: Verify that there is a physician's order for this procedure.- General Guidelines: Check the enteral nutrition label against the order before administration. Check the following information: Resident name, ID, and room number; type of formula; date and time formula was prepared; route of delivery; access site; method (pump, gravity, syringe); and rate of administration (milliliters (mL)/hour).-Steps in the Procedure:-Verify placement of tube-When correct tube placement has been verified, flush tubing with at least 30ml warm water (or prescribed amount).- Initiate Feeding: On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order. Resident #12 was admitted to the facility in January 2026 with diagnoses including cerebral infarction (type of stroke caused by a blockage in an artery that restricts blood flow to the brain) and aphasia (difficulty speaking).Review of the Minimum Data Set (MDS) assessment, dated 1/8/26, indicated Resident #12 had a Brief Interview for Mental Status (BIMS) score of 10 of 15, indicating he/she was moderately cognitively impaired. Review of Section K: Swallowing/Nutritional Status of the MDS assessment indicated Resident #12 was receiving nutritional support through a feeding tube and he/she received 51% or more of total calories through the feeding tube. The assessment also indicated the Resident was averaging 501 cubic centimeters (cc) per day or more of fluid intake.Review of Resident #12's current Physician's Orders indicated but were not limited to:- Start Date 1/8/26: NPO (nothing by mouth) - tube feeding only diet: NPO texture, NPO consistency.-Start Date 1/21/26: Enteral Feed Order Up 12:00 P.M., Down 10:00 P.M., Jevity 1.5 Cal Administer continuous via Pump 150 milliliters per hour (ml/hr).-Start Date 1/21/26: Free Water: 80ml/hr while running tube feeding Up 12:00 P.M., Down 10:00 P.M.-Start Date 1/12/26 Check placement of feeding tube prior to each use.Review of Resident #12's Nutrition Assessment, dated 1/14/26, indicated the Resident was receiving tube feeding through G-tube placement. The Dietitian documentation indicated recommendations were made to adjust the tube feeding to 150 ml/hour x 10 hours. On 2/26/26 at 12:58 P.M., the surveyor observed Resident #12 resting in bed. The enteral feeding pump was placed on a pole next to the bed without any feeding, water, or tubing present.On 2/26/26 at 1:26 P.M., the surveyor observed Resident #12 resting in bed. The enteral feeding pump was placed on a pole next to the bed without any feeding, water, or tubing present.During an observation with interview on 2/26/26 at 1:29 P.M., the surveyor observed Nurse #6 seated behind the nursing station having a snack. Nurse #6 said she has not hung Resident #12's tube feeding yet because she is running late and has had many interruptions on her medication pass. She said the tube feeding runs in very slowly so it should not be a problem for the Resident that it is late.On 2/26/26 at 1:43 P.M., the surveyor observed Nurse #6 enter Resident #12's with a feeding bottle, bag of water, and tube feeding supplies. Nurse #6 hung the feeding and programmed the pump at a rate of 150 ml/hour and programmed the water flush with rate of 80 ml/hour. She flushed the feeding tube with 60ml/water via a piston syringe (device used to inject fluids) and then connected the feeding tubing to the G-Tube and started the pump. Nurse #6 did not check residual aspirate (volume of fluids withdrawn from the stomach to assess digestion and gastric emptying), or placement of the feeding tube prior to the start of the feeding. On 3/2/26 at 1:26 P.M., the surveyor observed Resident #12 resting in bed with enteral feeding running. Written on the bottle in black marker was the date of 3/2/26, time of 12:00P.M., and a rate of 50ml/hr. The feeding pump was programmed at 80ml/hr. The water flush was also programed for 80ml/hr.On 3/2/26 at 4:25 P.M., the surveyor observed Resident #12 resting in bed with enteral feeding running. Written on the bottle in black marker was the date of 3/2/26, time of 12:00P.M., and a rate of 50ml/hr. The feeding pump was programmed at 80ml/hr. The water flush was also programed for 80ml/hr. During an interview on 3/2/26 at 4:33 P.M., Unit Manager (UM) #1 said she prepared and administered Resident #12's feeding because she is the nurse providing care today. The Surveyor and UM #1 reviewed Resident #12's physician's order and observed Resident #12's feeding pump together. The pump was set to 80ml/hr with a rate written on the bottle of 50ml/hr. UM #1 said the pump should be set to 150ml/hr per the physician's order. UM #1 said she did not check the order prior to administering the feeding. She said she is not sure why she wrote a different rate on the bottle than what she set the pump at. UM #1 said both rates are incorrect.During an interview on 3/3/26 at 10:36 A.M., Nurse #6 said she did not check placement of Resident #12's feeding tube the other day because she is not required to do so. Nurse #6 reviewed the physician's order to check placement prior to use and said she did not realize Resident #12 had an order to do so.During an interview on 3/3/26 at 10:50 A.M., the Dietitian said Resident #12 was receiving bolus feedings when she first came to the facility. She said Resident #12's family requested the feedings be changed to continuous because the Resident was saying he/she was hungry. The Dietitian said she is not notified by nursing if the feeding is administered late or at the wrong rate. She said she monitors the Resident's nutritional status by his/her weekly weights.During an interview on 3/3/26 at 4:02 P.M., the Assistant Director of Nursing (ADON) said all nurses must demonstrate competency of caring for a G-tube prior to having a resident with one on their assignment. The ADON said the competency consists of checking the tube for placement and residual.During an interview on 3/4/26 at 9:18 A.M., the Director of Nursing (DON) said enteral feeding should be given at the time ordered to ensure the Resident is receiving adequate nutrition. She said all physician's orders should be double checked prior to setting up the feeding to ensure it is given at the ordered rate. The DON said her expectation is for placement of the feeding tube to be checked prior to use if there is a physician's order to do so.

Based on record review and interviews, the facility failed to ensure staff maintained accurate medical records for one Resident (#5), out of a total sample of 23 residents. Specifically, the facility failed to ensure nursing staff accurately documented the use of an as needed (PRN) medication on the medication administration record (MAR).Findings include:Review of the facility's policy titled Administering Medications, last revised 7/2025, indicated but was not limited to:-The individual administering the medication initials the resident's Medical Administration Record (MAR) on the appropriate line after giving each medication and before administering the next ones.-As required or indicated for a medication, the individual administering the medication records [sic] in the resident's medical record: -the date and time the medication was administered. Resident #5 was admitted to the facility in January 2026 with diagnoses including osteoarthritis and pressure ulcer of the sacral (base of the spine) region. Review of the Minimum Data Set assessment (MDS), dated [DATE], indicated Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating he/she was cognitively intact. Further review indicated Resident #5 had received an opioid (a strong prescription pain reliever) medication during the review period. Review of Resident #5's Physician's Orders indicated but was not limited to:- Oxycodone tablet (opioid pain reliever) 5 milligrams (mg), give 1 tablet by mouth every 4 hours as needed for pain, give one tab for moderate pain of 4-6 and two tabs for severe pain 7-10 (start date: 1/18/2026) Review of the MAR indicated Resident #5 received Oxycodone 21 times from 2/7/26 to 3/3/26. Review of the Narcotic Book (a record book used in healthcare settings to track and document the administration and handling of controlled substances) indicated Resident #5 had received his/her Oxycodone 38 times from 2/7/26 to 3/3/26. Further review of Resident #5's MAR indicated the use of his/her Oxycodone had not been documented 17 out of 38 times (44.7% of the time). During an interview on 3/3/26 at 3:03 P.M., Nurse #5 said when a resident receives a PRN medication that is a narcotic, it should be documented the time it is given in the MAR and in the narcotic book. During an interview on 3/3/26 at 4:09 P.M., Unit Manager (UM) #1 said when a PRN medication is administered it must be documented on the MAR. She said if it is a narcotic, it must be signed out of the narcotic book as well. UM #1 and the surveyor reviewed Resident #5's Oxycodone MAR and narcotic book together. She said she administered Oxycodone to Resident #5 and got busy and forgot to document on the MAR. She said the documentation did not match as it should and is inaccurate. During an interview on 3/4/26 at 9:18 A.M., the Director of Nursing (DON) said it was her expectation for nurses to document all narcotic PRN medication administration on the MAR as well as in the narcotic book. She said the MAR reflects what has been given to the Resident and if it is not documented it could potentially lead to a medication error.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment and was dependent on staff to meet his/her care needs, the Facility failed to ensures staff consistently implemented and followed their abuse policy, when on 12/13/25 after Nurse #1 was made aware of an allegation that Resident #1 was abused by a staff member, and the following day the Nursing Supervisor was also made aware of the same allegation, however neither of them immediately reported it to facility administration, as required.Findings include: Review of the Facility's Policy titled, Abuse, dated as revised March 2023, indicated that;- the Facility must ensure that alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property and exploitation are reported immediately to the administrator and Director of Nurses of the facility utilizing the chain of command,-staff will follow [Facility Name] Policy and Procedure on investigation of abuse, mistreatment, or neglect, and-reporting timeline requirements for all allegations:1.immediate supervisor2. two-hour requirement to report to the Department of Public Health and local law enforcement.Resident #1 was admitted to the Facility in December 2025, diagnoses included dementia, and generalized muscle weakness.Resident #1's Minimum Data Set (MDS) Comprehensive Assessment, dated 12/10/25, indicated he/she had severe cognitive impairment, and was dependent on staff to meet his/her care needs.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted 12/15/25, indicated that the Administrator received report that Resident #1's family member complained about rough handling by Certified Nurse Aide (CNA) #1 during care that caused bruising on his/her arm. The Report indicated that CNA #1 was suspended [on 12/15/25] pending the investigation.Review of the Facility's Internal Investigation Report, undated, indicated that a Police Officer came to the facility on [DATE] and reported that Resident #1's family reported to the Police yesterday (12/14/25), that Resident #1 was handled roughly during care by CNA #1. The Report indicated that CNA #1 was interviewed [12/15/25] and then suspended.During an interview on 01/13/26 at 12:45 P.M., Nurse #1 said that on 12/13/25, she heard Family Member #1 yelling and swearing at CNA #1 saying that he (CNA #1) was abusing him/her (Resident #1) and that he (CNA #1) caused bruises on Resident #1's arms. Nurse #1 said she stepped away from the situation because Family Member #1 was yelling at CNA #1 and she did not want to be involved.There was no documentation to support Nurse #1 notified her supervisor or administrative staff of the altercation between Resident #1's family member and CNA #1 or of the allegation of abuse that the family member made at that time. During a telephone interview on 01/14/26 at 1:01 P.M., which included review of her written witness statement, undated, the Nursing Supervisor said that on 12/13/25, Family Member #1 told her that CNA #1 had not properly cleaned Resident #1.The Nursing Supervisor said that the next day (12/14/25), Family Member #1 told her that she (Family Member #1) wanted to talk to CNA #1 because she thought he (CNA #1) was responsible for bruises on Resident #1's arms. The Nursing Supervisor said she did not contact the Administrator but had instead put a written statement under his door that day (Sunday 12/14/25).During a telephone interview on 01/29/26 at 11:25 A.M., the Director of Nurses (DON) said the Facility Policy indicates that all staff must immediately report any suspicion or allegation of abuse to their supervisor or administration. The DON said she was not aware of any staff knowing about the allegation of abuse involving CNA #1 and Resident #1 on 12/13/25, but said the weekend Nursing Supervisor was aware of the allegation on 12/14/25 and should have immediately reported to either her (DON) or the Administrator, but she had not.During a telephone interview on 01/28/26 at 3:50 P.M, the Administrator said that it is the policy of the Facility that when any staff member that is made aware of an allegation of abuse, or has a suspicion of abuse, they must immediately report it to their immediate supervisor, and the supervisor must immediately report the allegation or suspicion to Administration. The Administrator said that he was not made aware of an allegation of abuse by staff involving Resident #1 until 12/15/25, when the Police arrived at the Facility and told him.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment and was dependent on staff to meet his/her care needs, the Facility failed to ensure that after being made aware of an allegation of abuse that staff immediately reported it to the administration, so it could then be reported to their state agency, timely as required. On 12/13/25, Nurse #1 became aware that Resident #1's family member was angry and alleged that he/she had been physically abused by a Certified Nurse Aide (CNA), however as a result of not immediately reporting the allegation to Administration, the allegation was not reported to the state survey agency until two days later. Findings include:Review of the Facility's Policy titled, Abuse, dated as revised March 2023, indicated the following:-the Facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown origin, misappropriation of resident property, and exploitation, are reported immediately to the administrator and Director of Nurses of the facility utilizing the chain of command,-all abuse allegations require immediate action, and-the Facility will notify the Department of Public Health (DPH) and local law enforcement no later than two hours after an abuse allegation was received.Resident #1 was admitted to the Facility in December 2025, diagnoses included dementia, and generalized muscle weakness.Resident #1's Minimum Data Set (MDS) Comprehensive Assessment, dated 12/10/25, indicated he/she had severe cognitive impairment and was dependent on staff to meet his/her care needs.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted 12/15/25, indicated that the Administrator received report that Resident #1's family member complained about rough handling by Certified Nurse Aide (CNA) #1 during care that caused bruising on his/her arm. The Report indicated that CNA #1 was suspended [12/15/25] pending the investigation.Review of the Facility's Internal Investigation Report, undated, indicated that a Police Officer came to the facility on [DATE] and reported that Resident #1's family told Police that Resident #1 was handled roughly during care by CNA #1 yesterday (12/14/25). The Report indicated that CNA #1 was interviewed and then suspended.During an interview on 01/13/26 at 12:45 P.M., Nurse #1 said that on 12/13/25, she heard Family Member #1 yelling and swearing at CNA #1 saying that he (CNA #1) was abusing Resident #1 and that he (CNA #1) caused bruises on Resident #1's arms. Nurse #1 said she stepped away from the situation because Family Member #1 was yelling at CNA #1 and she did not want to be involved and said that she did not do anything about it.There was no documentation to support that on 12/13/25, Nurse #1 notified her supervisor or administrative staff of the altercation between Resident #1's family member and CNA #1 or of the allegation of abuse that the family member made at that time. During a telephone interview on 01/14/26 at 1:01 P.M., (which included review of her written witness statement, undated), the Nursing Supervisor said that on 12/13/25, Family Member #1 had told her that CNA #1 had not properly cleaned Resident #1 but did not mention anything about rough care or abuse. The Nursing Supervisor said that the next day (12/14/25), Family Member #1 told her that she (Family Member #1) wanted to talk to CNA #1 because she thought he (CNA #1) was responsible for bruises on Resident #1's arms. The Nursing Supervisor said she did not immediately notify administration.During a telephone interview on 01/29/26 at 11:25 A.M., the Director of Nurses (DON) said that staff are expected to report any suspicion or allegation of abuse to their supervisor or administration immediately, and then administration reports to DPH and the police immediately or within two hours once they are aware of the allegation.During a telephone interview on 01/13/25 at 3:50 P.M., the Administrator said on 12/15/25 he was made aware of the allegation of physical abuse by CNA #1 involving Resident #1 when the Police showed up at the Facility with Resident #1's family. The Administrator said the Police told him that Resident #1's family was alleging that CNA #1 was rough during care and caused bruising on Resident #1's arms.The Administrator said he reported to the Massachusetts Department of Public Health immediately on 12/15/25 once he was made aware. The Administrator said he was not aware that other staff were notified about the abuse allegation [Nurse #1 on 12/13/25, Nursing Supervisor on12/14/25] prior to 12/15/25 when the Police showed up at the Facility.The Administrator said it is the expectation and policy of the Facility that all staff report any allegation or suspicion of abuse immediately to their supervisor and Administration. The Administrator said all allegations of abuse must be reported to the Massachusetts Department of Public Health within two hours of when the allegation is made.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment and was dependent on staff to meet his/her care needs, the Facility failed to ensure that Resident #1 and other residents on his/her unit were protected from potential further abuse by a staff member, when although Nurse #1 and the Nursing Supervisor were made aware of an allegation of physical abuse by a family member on 12/13/25 and 12/14/25, neither of them reported the allegation as required which resulted in the staff member continuing to care for and interact with the residents, and as well as a two day delay in facility initiating an investigation into the allegation.Findings include: Review of the Facility's Policy titled, Abuse, dated as revised March 2023, indicated that when any allegations of abuse, mistreatment, neglect, misappropriation of resident property is observed, reported or suspected by an employee, the following steps will be implemented:-immediately protect the residents from alleged abuse, and-immediately suspend the employee pending an investigation.Resident #1 was admitted to the Facility in December 2025, diagnoses included dementia, and generalized muscle weakness.Resident #1's Minimum Data Set (MDS) Comprehensive Assessment, dated 12/10/25, indicated he/she had severe cognitive impairment, and was dependent on staff to meet his/her care needs.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted 12/15/25, indicated that the Administrator received report that Resident #1's family member complained about rough handling by Certified Nurse Aide (CNA) #1 during care that caused bruising on his/her arms. The Report indicated that CNA #1 was suspended (12/15/25) pending the investigation.Review of the Facility's Internal Investigation Report, dated 12/15/25, indicated that a Police Officer came to the facility on [DATE] and reported that Resident #1's family reported to the Police yesterday (12/14/25), that Resident #1 was handled roughly during care by CNA #1. The Report indicated that CNA #1 was interviewed and then suspended.During an interview on 01/13/26 at 12:45 P.M., Nurse #1 said that on 12/13/25, she heard Family Member #1 yelling and swearing at CNA #1 saying that he (CNA #1) was abusing Resident #1, and that he (CNA #1) caused bruises on Resident #1's arms. Nurse #1 said she removed herself from the situation because Family Member #1 was yelling at CNA #1 and she did not want to be involved, so she did nothing about it.There was no documentation to support Nurse #1 notified her supervisor or administrative staff of the altercation between Resident #1's family member and CNA #1 or of the allegation of abuse that the family member made at that time. During a telephone interview on 01/14/26 at 1:01 P.M.,( which included review of her written witness statement, undated), the Nursing Supervisor said that on 12/13/25, Family Member #1 told her that CNA #1 had not properly cleaned Resident #1 but did not mention anything about abuse.The Nursing Supervisor said that the next day (12/14/25), Family Member #1 told her that she (Family Member #1) wanted to talk to CNA #1 because she thought he (CNA #1) was responsible for bruises on Resident #1's arms. The Nursing Supervisor said she did not immediately report the allegation to administration.There was no documentation to support that the Nursing Supervisor initiated and investigation into Family Member #1's allegation of abuse, including have CNA #1 removed from the schedule, pending an investigation.During a telephone interview on 01/29/26 at 11:25 A.M., the Director of Nurses (DON) said that on 12/15/25 the Administrator informed her about the allegation of abuse involving Resident #1 and CNA #1. The DON said any time an allegation of abuse is made against a staff member, that the accused staff member must be suspended from the Facility immediately in order to protect the resident involved, as well as other residents.The DON said because a staff member (Nursing Supervisor) was made aware of the allegation on 12/14/25, that she should have immediately reported the allegation to administration, but she did not. The DON said CNA #1 should have been suspended on 12/14/25 but had not suspended until 12/15/25. The DON said that as far as she knew, the Nursing Supervisor was the first staff member to be aware of the allegation.During a telephone interview on 01/28/26 at 3:50 P.M. the Administrator said that CNA #1 was not working at the Facility on 12/15/25 when he (Administrator) became aware that CNA #1 had been accused of physical abuse involving Resident #1, so he called CNA #1 and requested a statement and suspended him pending an investigation. The Administrator said any staff member accused of abuse should be suspended immediately, and until the Facility's investigation is complete.

Based on interview and record review, the facility failed to promote and manage the delivery of safe nursing care in accordance with accepted Standards of Nursing Practice by failing to identify and address a change in condition and provide necessary care and treatment for one Resident (#65), out of a total sample of 18 residents. Specifically, the facility failed to implement treatment recommendations and orders to initiate a 40-day Vancomycin (antibiotic) taper due to a diagnosis of Enterocolitis due to Clostridium Difficile (C. diff - an infection of the large intestine often resulting in diarrhea or loose stools) for 19 days after a hospitalization resulting a decline in the Resident's stage IV pressure injury (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) on the sacrum. Findings include: Resident #65 was admitted to the facility in June 2024 with diagnoses including C. diff, pressure ulcer of sacral region, and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment, dated 9/26/24, indicated Resident #65 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. Furthermore, the MDS assessment indicated he/she was being treated for a stage IV pressure ulcer and had a medical diagnosis of C. diff. Review of Resident #65's nursing progress note, dated 7/29/24, indicated Resident #65 was seen by the physician who recommended a transfer to the hospital due to a change in medical status. Review of the hospital Discharge Summary, dated 7/31/24, indicated but was not limited to the following: - Resident had diarrhea on the overnight of 7/29/24. - Resident tested positive for C. diff on 7/30/24. - The Resident was seen by Infectious Disease (ID) during the hospitalization . - ID recommended Fidaxomicin (antibiotic) 200 milligrams (mg) twice a day for five days (7/30/24 to 8/4/24), then 200 mg every 48 hours for 20 days. - ID also alternatively recommended a 40-day Vancomycin taper instead of the Fidaxomicin. - The recommendation for the 40-day Vancomycin taper included: 125 mg by mouth four times a day for 10 days, followed by 125 mg by mouth twice a day for 10 days, followed by 125 mg by mouth once daily for 10 days, followed by 125 mg by mouth once every other day for 10 days. Review of Resident #65's nursing progress note, dated 7/31/24, indicated the Resident returned to the facility from the hospital on this date. Further review of the nursing progress note indicated a Vancomycin taper was recommended for the treatment of C. diff. The nursing progress note indicated the antibiotic treatment options needed to be reviewed with the in-house physician. Review of nursing progress notes, from 7/31/24 to 8/18/24, failed to indicate the antibiotic recommendations were reviewed and/or implemented with the in-house physician. Review of Physician progress notes, from 7/31/24 to 8/18/24, failed to indicate the antibiotic recommendations from the Resident's hospital discharge on 7/31/24 were reviewed or implemented. Review of Resident #65's Physician's Orders failed to indicate an order for the 40-day Vancomycin taper or Fidaxomicin taper were implemented following his/her return from the hospital on 7/31/24. Review of the Certified Nursing Assistant (CNA) Documentation Survey Report for the task of Bowel Continence, dated August 2024, indicated Resident #65 was incontinent of large/medium loose stools on the following dates/shifts: - 8/1/24: Night shift - 8/2/24: Night shift - 8/3/24: All shifts - 8/4/24: Night shift - 8/5/24: All shifts - 8/6/24: Day shift - 8/7/24: Day shift - 8/8/24: Day/Evening shifts - 8/9/24: All shifts - 8/10/24: Day shift - 8/11/24: Night shift - 8/13/24: Evening shift - 8/15/24: Day shift - 8/16/24: Day/Evening shifts Review of the Wound Consultant Documentation, dated 8/9/24, indicated but was not limited to the following: - Resident had been hospitalized since last wound evaluation. - Wound measurements increased, mild odor noted. - Wound status: worsening. Review of the Wound Consultant Documentation, dated 8/16/24, indicated but was not limited to the following: - Wound measurements increased. - Increased odor and drainage. - Wound status: worsening. During an interview on 12/5/24 at 11:58 A.M., Wound Consultant #1 said Resident #65 has been followed for a chronic stage IV sacral pressure ulcer since being admitted to the facility. Wound Consultant #1 said Resident #65 has a history of recurrent C. diff. Wound Consultant #1 said in her experience when Resident #65 has C. diff he/she typically has large, loose stools which would require dressing changes of the chronic stage IV sacral pressure ulcer. Wound Consultant #1 said large amounts of loose stool would negatively impact the wound healing process. During an interview on 12/5/24 at 12:35 P.M., the Physician said loose stools and C. diff would have a negative impact on the Resident's wound status. Review of Resident #65's nursing progress note, dated 8/18/24, indicated the Resident was transferred to the hospital for abnormal test results. Review of the Hospital Discharge Summary, dated 8/19/24, indicated but was not limited to the following: - Resident had a history of recent C. diff (discharged [DATE]). - Resident presented to the hospital with decubitus ulcer, pain and diarrhea. - Resident still had diarrhea, unfortunately the Vancomycin was stopped. - ID suggested a 40-day Vancomycin taper during last hospitalization [DATE] to 7/31/24. - Communication with the nursing facility indicated there was a misunderstanding by the facility on placing the Resident on the Vancomycin taper. - Communicated with them that when leaving the hospital this time the Resident should definitely be on a 40-day taper of Vancomycin. - ID recommendation for the 40-day Vancomycin taper included: 125 mg by mouth four times a day for 10 days, followed by 125 mg by mouth twice a day for 10 days, followed by 125 mg by mouth once daily for 10 days, followed by 125 mg by mouth once every other day for 10 days. Review of the medical record indicated Resident #65 was placed on the recommended 40-day Vancomycin taper on 8/19/24, 19 days after it was initially recommended. During an interview on 12/5/24 at 12:35 P.M., the Physician said when a resident returns from the hospital the facility typically will call him or a nurse practitioner (NP) to review the discharge medications and recommendations. The Physician said he almost always accepts the recommendations for medications and treatments from the hospital discharge. The Physician said he does not recall being notified of recommendations for a 40-day Vancomycin taper after Resident #65's hospitalization from [DATE] to 7/31/24. The Physician said he would have addressed the recommendations and documented them in his progress notes. During an interview on 12/9/24 at 8:26 A.M., Unit Manager (UM) #1 said when a resident returns from the hospital the discharge summary is reviewed by the nurse. UM #1 said all discharge medications and recommendations would then be reviewed by the physician or NP either in the facility, if they were present, or by phone. UM #1 reviewed Resident #65's hospital discharge summary from 7/31/24 and said the Vancomycin taper was not listed on the discharge medication list from the hospital. UM #1 said the hospital discharge summary does clearly indicate the recommendation for a Fidaxomicin or Vancomycin taper to be initiated due to the Resident's diagnosis of C. diff. UM #1 said the hospital discharge summary recommendations should have been reviewed with the physician or NP so they could be implemented. UM #1 said no Vancomycin taper was started until Resident #65 returned from the hospital on 8/19/24. During an interview on 12/9/24 at 11:20 A.M., the Director of Nursing (DON) said when a resident returns from the hospital the discharge summary is reviewed by the nurse. The DON said all discharge medications and recommendations would then be reviewed by the physician or NP either in the facility, if they were present, or by phone. The DON said she reviewed Resident #65's medical record and noted the 40-day Vancomycin taper was not implemented when he/she returned from the hospital on 7/31/24 as it should have been. The DON said the hospital discharge summary should have been reviewed and clarified with the Physician. The DON said there should not have been a delay in starting the 40-day Vancomycin taper for Resident #65.

Based on observation, interview, and record review, the facility failed to notify the Physician and/or responsible party of recommendations or changes in condition for four Residents (#65, #13, #58, and #70), out of a total sample of 18 residents. Specifically, the facility failed: 1. For Resident #65, to notify the Physician of treatment recommendations and orders to initiate a 40-day Vancomycin (antibiotic) taper due to a diagnosis of Enterocolitis due to Clostridium Difficile (C. diff - an infection of the large intestine often resulting in diarrhea or loose stools) for 19 days after a hospitalization resulting in a decline in the Resident's stage IV pressure injury (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) on the sacrum; 2. For Resident #58, to notify the Physician of his/her significant weight loss; 3. For Resident #70, to notify the Physician of his/her significant weight loss; and 4. For Resident #13, to notify his/her Guardian of a fall that required transfer to the hospital. Findings include: Review of the facility's policy titled Change in a Resident's Condition, Acute Care Transfer and Notification, dated 2024, indicated but was not limited to: - Should a change in condition be suspected or noted, the nurse(s) shall be promptly alerted, shall promptly assess the resident, notify his or her Attending Physician of changes in the resident's medical/mental condition and/or status asking for orders/guidance and/or initiate life sustaining supportive measures accordingly to one's presenting condition in accordance with one's advance directives, and notify the resident's representative appropriately. - The Nurse Supervisor/Charge Nurse shall be notified of a change in a resident's condition, presentation, disposition or routine that may serve as an early warning sign of clinical events by staff or other concerned parties. Those may include but are not limited to: (g) a need or request to alter the resident's medical treatment, (k) Instructions to notify the Physician of changes in the resident's condition. 1. Resident #65 was admitted to the facility in June 2024 with diagnoses including C. diff, pressure ulcer of sacral region, and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment, dated 9/26/24, indicated Resident #65 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. Further review of the MDS assessment indicated he/she was being treated for a stage IV pressure ulcer and had a medical diagnosis of C. diff. Review of Resident #65's nursing progress note, dated 7/29/24, indicated Resident #65 was seen by physician who recommended a transfer to the hospital due to a change in medical status. Review of the Hospital Discharge Summary, dated 7/31/24, indicated but was not limited to the following: - Resident had diarrhea on the overnight of 7/29/24. - Resident tested positive for C. diff on 7/30/24. - The Resident was seen by Infectious Disease (ID) during the hospitalization . - ID recommended Fidaxomicin (antibiotic) 200 milligrams (mg) twice a day for five days (7/30/24 to 8/4/24), then 200 mg every 48 hours for 20 days. - ID also alternatively recommended a 40-day Vancomycin (antibiotic) taper instead of the Fidaxomicin. - The recommendation for the 40-day Vancomycin taper included: 125 mg by mouth four times a day for 10 days, followed by 125 mg by mouth twice a day for 10 days, followed by 125 mg by mouth once daily for 10 days, followed by 125 mg by mouth once every other day for 10 days. Review of Resident #65's nursing progress note, dated 7/31/24, indicated the Resident returned to the facility from the hospital on this date and a Vancomycin taper was recommended for the treatment of C. diff. The nursing progress note indicated the antibiotic treatment options needed to be reviewed with the in-house Physician. Review of nursing progress notes from 7/31/24 to 8/18/24 failed to indicate the antibiotic recommendations were reviewed and/or implemented with the in-house physician. Review of physician progress notes from 7/31/24 to 8/18/24 failed to indicate the antibiotic recommendations from the Resident's hospital discharge on 7/31/24 were reviewed or implemented. Review of Resident #65's Physician's Orders failed to indicate an order for the 40-day Vancomycin taper or Fidaxomicin taper were implemented following his/her return from the hospital on 7/31/24. Review of the Certified Nursing Assistant (CNA) Documentation Survey Report for the task of Bowel Continence, dated August 2024, indicated Resident #65 was incontinent of large/medium loose stools on the following dates/shifts: - 8/1/24: Night shift - 8/2/24: Night shift - 8/3/24: All shifts - 8/4/24: Night shift - 8/5/24: All shifts - 8/6/24: Day shift - 8/7/24: Day shift - 8/8/24: Day/Evening shifts - 8/9/24: All shifts - 8/10/24: Day shift - 8/11/24: Night shift - 8/13/24: Evening shift - 8/15/24: Day shift - 8/16/24: Day/Evening shifts Review of the Wound Consultant Documentation, dated 8/9/24, indicated but was not limited to the following: - Resident had been hospitalized since last wound evaluation. - Wound measurements increased, mild odor noted. - Wound status: worsening. Review of the Wound Consultant Documentation, dated 8/16/24 indicated but was not limited to the following: - Wound measurements increased. - Increased odor and drainage. - Wound status: worsening. During an interview on 12/5/24 at 11:58 A.M., Wound Consultant #1 said Resident #65 has been followed for a chronic stage IV sacral pressure ulcer since being admitted to the facility. Wound Consultant #1 said Resident #65 has a history of recurrent C. diff. Wound Consultant #1 said in her experience when Resident #65 has C. diff he/she typically has large, loose stools which would require dressing changes of the chronic stage IV sacral pressure ulcer. Wound Consultant #1 said large amounts of loose stool would negatively impact the wound healing process. During an interview on 12/5/24 at 12:35 P.M., the Physician said loose stools and C. diff would have a negative impact on the Resident's wound status. Review of Resident #65's nursing progress note, dated 8/18/24, indicated that the Resident was transferred to the hospital for abnormal test results. Review of the Hospital Discharge Summary, dated 8/19/24, indicated but was not limited to the following: - Resident had a history of recent C. diff (discharged [DATE]). - Resident presented to the hospital with decubitus ulcer pain and diarrhea. - Resident still has diarrhea, unfortunately the Vancomycin was stopped. - ID suggested a 40-day Vancomycin taper during last hospitalization [DATE] to 7/31/24. - Communication with the nursing facility indicated there was a misunderstanding by the facility on placing the Resident on the Vancomycin taper. - Communicated with them that when leaving the hospital this time the Resident should definitely be on a 40-day taper of Vancomycin. - ID recommendation for the 40-day Vancomycin taper included: 125 mg by mouth four times a day for 10 days, followed by 125 mg by mouth twice a day for 10 days, followed by 125 mg by mouth once daily for 10 days, followed by 125 mg by mouth once every other day for 10 days. Review of the medical record indicated Resident #65 was placed on the recommended 40-day Vancomycin taper on 8/19/24, 19 days after it was initially recommended. During an interview on 12/5/24 at 12:35 P.M., the Physician said when a resident returns from the hospital the facility typically will call him or a nurse practitioner (NP) to review the discharge medications and recommendations. The Physician said he almost always accepts the recommendations for medications and treatments from the hospital discharge. The Physician said he reviewed each of his residents' medical records when evaluating him/her in the facility. The Physician said he does not recall being notified of recommendations for a 40-day Vancomycin taper after Resident #65's hospitalization from [DATE] to 7/31/24. The Physician said he would have addressed the recommendations and documented them in his progress notes. During an interview on 12/9/24 at 8:26 A.M., Unit Manager (UM) #1 said when a resident returns from the hospital the discharge summary is reviewed by the nurse. UM #1 said all discharge medications and recommendations would then be reviewed by the physician or NP either in the facility, if they were present, or by phone. UM #1 reviewed Resident #65's hospital discharge summary from 7/31/24 and said the Vancomycin taper was not listed on the discharge medication list from the hospital. UM #1 said the hospital discharge summary does clearly indicate the recommendation for a Fidaxomicin or Vancomycin taper to be initiated due to the Resident's diagnosis of C. diff. UM #1 said the hospital discharge summary recommendations should have been reviewed with the physician or NP so they could be implemented. UM #1 said no Vancomycin taper was started until Resident #65 returned from the hospital on 8/19/24. During an interview on 12/9/24 at 11:20 A.M., the Director of Nursing (DON) said when a resident returns from the hospital the discharge summary is reviewed by the nurse. The DON said all discharge medications and recommendations would then be reviewed by the physician or NP either in the facility, if they were present, or by phone. The DON said she reviewed Resident #65's medical record and noted the 40-day Vancomycin taper was not implemented when he/she returned from the hospital on 7/31/24 as it should have been. The DON said the hospital discharge summary should have been reviewed and clarified with the Physician. The DON said there should not have been a delay in starting the 40-day Vancomycin taper for Resident #65. 48695 2. Resident #58 was admitted to the facility in September 2024 with diagnoses including obesity and pleural effusion (fluid builds up in the pleural space, the thin cavity between the lungs and the chest wall). Review of Resident #58's Minimum Data Set (MDS) assessment, dated 9/26/24, indicated he/she was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of Resident #58's Registered Dietitian's notes indicated but was not limited to: - 11/21/24: Resident #58 continues to trigger for significant weight loss over 180 days. Resident #58 down approximately 13 pounds. - 10/22/24: Reweight obtained 10/18 of 354.8 pounds which verifies weight loss. - 10/18/24: Weight on 10/14 reordered in electronic medical 358.6 pounds. Weight on 10/9 410.9 pounds. This reflects a weight loss of 43 pounds in 5 days. Further review of Resident #58's medical record failed to indicate his/her Physician or Physician Extender had been notified of his/her weight loss. During an interview on 12/9/24 at 9:50 A.M., Resident #58 said he/she had lost about 99 pounds since his/her hospitalization and facility admission. Resident #58 said he/she was happy with weight loss. During an interview on 12/5/24 at 10:36 A.M., Nurse #11 said if it was identified that a resident had a weight loss the nurse would notify the Dietitian and if the Dietitian made a recommendation the nurse would notify the Physician. Nurse #11 said if the Physician had been notified then it would be documented in the medical record in a nurse's note. During an interview on 12/5/24 at 10:40 A.M., Unit Manager (UM) #2 said the Dietitian was notified for all significant weight loss. UM #2 said the Dietitian would make recommendations, if appropriate, and then the doctor would be called to approve the recommendation. UM #2 said the Physician would often be verbally notified of changes in resident conditions. UM #2 said the nurses do not document Physician notification anywhere. UM #2 said there is not a system in place to notify the Physician of a significant weight loss and there should be a process for Physician notification, but there isn't one in place. During an interview on 12/5/24 at 11:06 A.M., the Dietitian said she did not notify the physician if a resident had a significant weight loss. The Dietitian said her expectation was for the nurses to notify the physician of a significant weight loss. During an interview on 12/5/24 at 11:30 A.M., Physician #1 said he was not aware of Resident #58's significant weight loss. Physician #1 said regardless of if a resident is on prescribed weight loss regimen or had an unplanned weight loss he should be notified of all weight loss. During an interview on 12/9/24 at 3:40 P.M., the Director of Nursing (DON) said the Physician should have been notified of Resident #58's weight loss and the notification should have been documented in his/her medical record but was not. 3. Resident #70 was admitted to the facility in August 2024 with diagnoses including heart failure and obesity. Review of Resident #70's MDS assessment, dated 10/21/24, indicated he/she had a mild cognitive deficit as evidenced by a BIMS score of 10 out of 15. Further review of Resident #70's MDS assessment indicated he/she had a five percent weight loss and he/she was not on a prescribed weight loss regimen. Review of Resident #70's Registered Dietitian's notes indicated but was not limited to: -12/3/24: Resident #70 continues to trigger for significant weight loss. Review of Resident #70's care plan titled Resident #70 is at nutritional risk, last revised 10/21/24, indicated but was not limited to: - Intervention: Weight a/o (as ordered) and alert the dietitian and physician to any significant loss or gain, revision date 8/8/24 During an interview on 12/5/24 at 10:32 A.M., Physician #1 said he was not aware of Resident #70's significant weight loss. Physician #1 said regardless of if a resident is on prescribed weight loss regimen or had an unplanned weight loss he should be notified of all weight loss. During an interview on 12/5/24 at 10:36 A.M., Nurse #11 said if it was identified that a resident had a weight loss the nurse would notify the Dietitian and if the Dietitian made a recommendation the nurse would notify the Physician. Nurse #11 said if the Physician was notified then it would be documented in the medical record in a nurse's note. During an interview on 12/5/24 at 10:40 A.M., UM #2 said the Dietitian was notified for all significant weight loss. UM #2 said the Dietitian would make recommendations, if appropriate, and then the doctor would be called to approve the recommendation. UM #2 said the Physician would often be verbally notified of changes in resident conditions. UM #2 said the nurses do not document Physician notification anywhere. UM #2 said there is not a system in place to notify the Physician of a significant weight loss and there should be to a process for Physician notification, but there isn't one in place. During an interview on 12/5/24 at 11:06 A.M., the Dietitian said she did not notify the physician if a resident had a significant weight loss. The dietitian said her expectation was for the nurses to notify the physician of a significant weight loss. During an interview on 12/9/24 at 3:40 P.M., the DON said the Physician should have been notified of Resident #70's weight loss and the notification should have been documented in his/her medical record but was not. 50740 4. Resident #13 was admitted to the facility in September 2023 with diagnoses including dementia, fracture of the second cervical vertebra (a broken bone in the neck), and mild cognitive impairment. Review of Resident #13's MDS assessment, dated 9/10/24, indicated that the Resident was severely cognitively impaired as evidenced by a BIMS score of 6 out of 15. Review of Resident #13's medical record indicated that a guardian was appointed by the Court on 8/13/24. Review of the facility's fall incident report completed for Resident #13 on 10/30/24 indicated that the Resident sustained an unwitnessed fall and was transported to the hospital for evaluation. The report failed to indicate that the Resident's guardian was notified of the fall or subsequent transfer. Review of a progress note written for Resident #13, dated 10/20/24 7:00 P.M., indicated that the Resident was found on the floor in the dining room and complained of right hip pain, right-sided head pain, and back pain. The progress note indicated the provider was notified and an order was obtained to send the Resident to the emergency department for evaluation. The progress note failed to indicate that the Resident's guardian was notified of the fall or subsequent transfer. Review of an eINTERACT Change in Condition Evaluation completed for Resident #13 on 10/31/24 indicated the Resident returned from the hospital with no new orders and the physician was aware. The Evaluation indicates that the name of family/healthcare agent notified was self. The Evaluation failed to indicate that the Resident's guardian was notified. During an interview on 12/5/24 at 1:09 P.M., the DON reviewed the Resident's record and said that there is no documentation that facility staff notified Resident #13's guardian of the fall and transfer to the hospital. The DON said that the Resident's guardian should have been notified of the fall and transfer. During a telephonic interview on 12/5/24 at 2:52 P.M., Resident Representative #1 said that he was not notified of the Resident's fall and transfer to hospital. Refer to F684

Based on observations, interviews, and record review, the facility failed to ensure two Residents (#65, #68), out of a total sample of 18 residents, received care and treatment to promote healing of pressure injuries. Specifically, the facility failed: 1. For Resident #65, to implement wound care orders per physician recommendations for a stage IV pressure injury (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) on the sacrum; and 2. For Resident #68, to implement orders for a change in treatment for the care of an unstageable pressure ulcer injury (full thickness tissue loss that is covered by a layer of dead tissue that prevents the stage from being determined) to the left heel. Findings include: Review of the facility's policy titled Prevention of Pressure Injuries, undated, included but was not limited to: - The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. - Review of the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. - Monitoring: (1) Evaluate, report and document potential changes in the skin; (2) Review the interventions and strategies for effectiveness on an ongoing basis. Review of the facility's policy titled Wound Care, undated, included but was not limited to: - The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. - The following information should be recorded in the resident's medical record: (1) the type of wound care given, (2) the date the wound care was given, (3) the name and title of the individual performing the wound care, (4) any change in the resident's condition, (5) all assessment date (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound, (6) any problems or complaints made by the resident related to the procedure, (7) if the resident refused the treatment and the reason(s) why, (8) the signature and title of the person recording the data. - Reporting: (1) notify the supervisor if the resident refuses the wound care, (2) report other information in accordance with facility policy and professional standards of practice. 1. Resident #65 was admitted to the facility in June 2024 with diagnoses of Enterocolitis due to Clostridium Difficile (C. diff - an infection of the large intestine often resulting in loose stools/diarrhea), osteomyelitis, stage IV pressure ulcer of the sacral region, and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment, dated 9/26/24, indicated Resident #65 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. Further review indicated that Section M: Skin Conditions of the MDS assessment indicated he/she was being treated for a stage IV pressure ulcer. The assessment also indicated Resident #65 was receiving pressure ulcer/injury care including application of non-surgical dressings and ointments. Review of Resident #65's comprehensive care plans indicated the Resident had a stage IV pressure injury to the sacrum with interventions to provide wound care per treatment order, measure ulcer on at (sic) regular interval and monitor for signs of infection. Review of Resident #65's medical record indicated he/she was hospitalized from 7/29/24 to 7/31/24. Review of the Hospital Discharge Summary indicated the Resident had a chronic sacral wound with osteomyelitis since January 2024. The Hospital Discharge Summary also indicated the Resident was positive for C. diff and required a Fidaxomicin (antibiotic) or Vancomycin (antibiotic) taper for the treatment of C. diff. Review of Resident #65's medical record failed to indicate an order for a Fidaxomicin or Vancomycin taper was obtained on 7/31/24 upon return from his/her hospitalization . Review of Resident #65's nursing Wound - Weekly Observation Tool, dated 7/31/24, indicated but was not limited to the following: - UM (Unit Manager) wound measurements on admission: Stage 4 pressure ulcer sacrum 7.5 centimeters (cm) x 8.0 cm x 0.3 cm, 25% slough (necrotic (dead) tissue that is green, yellow, tan, or brown and may be moist, loose, or stringy) and 75% granulation (pink-red moist tissue that fills an open wound, when it starts to heal), moderate amount serous sanguinous drainage (yellow serous fluid mixed with blood). - Visible Tissue overall impression - unchanged; granulation tissue, slough tissue - Visible Tissue Comments: 7.0 cm x 8.0 cm x 1.0 cm, 50% slough and 50% granulation. - Drainage: Moderate serous - Odor: NO - Treatment: Santyl (a medication used to treat and debride pressure ulcers), Alginate (fibrous, water insoluble dressing that forms a gel that absorbs drainage), Bfoam (bordered foam), once daily and PRN (as needed). - Evaluation: wound progress - improved Review of Resident #65's Physician's Orders indicated but were not limited to the following: - 7/31/24 to 8/9/24: cleanse with wound cleanser; Santyl, Alginate, border foam change daily. Review of the medical record indicated Resident #65 was seen by the Consulting Wound Nurse Practitioner (NP) on 8/9/24. Review of the Consulting Wound NP's progress note from 8/9/24 indicated but was not limited to the following: - Per staff Resident had been hospitalized since last wound evaluation. - Wound measurements increased. - Mild odor noted. - Will switch to cleansing wound with 1/2 strength Dakins. - Duration: Area first evaluated on 3/27/24 - Etiology: Pressure - Stage/Severity: Stage IV - Wound Status: Worsening - Odor Post Cleansing: Mild - Size: 8.0 cm x 9.5 cm x 0.8 cm - Wound Base: 75% granulation, 25% slough - Exudate (Drainage): Moderate amount of yellow - Recommendations: cleanse with 0.25% Dakins (1/2 strength), apply Santyl, Calcium Alginate to base of the wound, secure with bordered foam. Change daily, PRN (as needed) for soiling, saturation or accidental removal. Review of Resident #65's Physician's Orders indicated the following: - 8/9/24 to 8/26/24: Sacral Dakims (sic), alginate, bordered foam; every day shift Further review of the Physician's Orders failed to include the Santyl portion of the treatment as recommended by the Consulting Wound NP on 8/9/24. Furthermore, the Physician's Orders failed to indicate the Dakin's strength or clarify calcium alginate versus an alginate dressing. Review of the August 2024 Treatment Administration Record (TAR) indicated the following treatment was completed daily to the sacrum between 8/9/24 and 8/16/24: - Sacral Dakims (sic), alginate, bordered foam; every day shift Further review of the August 2024 TAR failed to include the Santyl portion of the treatment as recommended by the Consulting Wound NP on 8/9/24. Furthermore, the TAR failed to indicate the Dakin's strength or clarify calcium alginate versus an alginate dressing. Review of the medical record indicated Resident #65 was seen by the Consulting Wound Nurse Practitioner (NP) on 8/16/24. Review of the Consulting Wound NP progress note from 8/16/24 indicated but was not limited to the following: - Per staff Resident went to the hospital yesterday due to abnormal labs and received one unit of packed red blood cells (PRBCs). - Wound measurements increased. - Increased odor and drainage. - Will switch treatment to Dakin moist gauze. - Recommend x-ray and labs to evaluate for osteomyelitis. - Duration: Area first evaluated on 3/27/24 - Etiology: Pressure - Stage/Severity: Stage IV - Wound Status: Worsening - Odor Post Cleansing: Malodorous - Size: 8.0 cm x 10.0 cm x 1.5 cm - Wound Base: 75% granulation, 25% slough - Exposed Tissue: Bone - Exudate (Drainage): Large amount of yellow - Recommendations: irrigate with wound cleanser, apply 1/2 strength Dakins moist gauze to base of wound, secure with silicone border foam. Change twice daily and PRN for soiling, saturation, or accidental removal. - Further Recommendations: X-ray of wound site and labs. Review of Resident #65's nursing progress notes, dated 8/16/24, indicated the Resident was seen by the Consulting Wound NP. The nursing progress notes further indicated the recommended labs and x-ray were reviewed with the NP and ordered. Review of Resident #65's telehealth NP progress note, dated 8/17/24, indicated a sacral x-ray was concerning for osteomyelitis. Further review of the telehealth NP progress note indicated the Resident was ordered to be transferred to the hospital for further follow-up. Review of Resident #65's Hospital Discharge Summary, dated 8/19/24, indicated but was not limited to the following: - The Resident had a history of chronic osteomyelitis and chronic decubitus ulcer. - The Resident presented to the hospital with decubitus ulcer pain and diarrhea. - The Resident was positive for C. diff and a 40-day Vancomycin taper for treatment was never initiated as recommended on previous hospital discharge (7/31/24). - It was recommended for the Resident to begin the 40-day Vancomycin taper for treatment of C. diff upon discharge from the hospital on 8/19/24. - The Resident has a chronic decubitus ulcer and osteomyelitis. - A Computed Tomography Angiography of the Pulmonary Arteries (CTAP) completed on 8/17/24 demonstrated worsening soft tissue ulceration overlying the distal sacrum and coccyx with open bone exposure. The CTAP also showed increased fragmentation of the coccyx favoring chronic osteomyelitis. - The Resident was seen by Infectious Disease (ID) who suggested no antibiotics for now. - Wound treatment recommendations included: cleanse with normal saline and pat dry; paint periwound skin with 3M Vailon No String Barrier Film to protect and help Mepilex to better adhere to skin; cover with a piece of Exufiber Ag (silver) to absorb drainage, promote moist would healing and offer broad spectrum topical antimicrobial control through the use of sustained release silver; cover with Mepilex Border Sacrum; and change every other day and PRN (as needed). Review of Resident #65's medical record indicated he/she returned from the hospital on 8/19/24. Review of the medical record indicated the wound treatment recommendations as well as the 40-day Vancomycin taper were implemented. During an interview on 12/5/24 at 11:58 A.M., Wound Consultant #1 said Resident #65 has been followed for a chronic stage IV sacral pressure ulcer since being admitted to the facility. Wound Consultant #1 said Resident #65 has a history of recurrent C. diff. Wound Consultant #1 said in her experience when Resident #65 has C. diff he/she typically has large stools which would require dressing changes of the chronic stage IV sacral pressure ulcer. Wound Consultant #1 said large amounts of loose stool would negatively impact the wound healing process. During an interview on 12/5/24 at 12:35 P.M., the Physician said recommendations for medications and treatments from the Consulting Wound NP are reviewed with himself or his NP. The Physician said Consulting Wound NP recommendations are generally accepted by the providers. The Physician said he does not recall being notified of recommendations for a 40-day Vancomycin taper after Resident #65's hospitalization from [DATE] to 7/31/24. The Physician said loose stools and C. diff would have a negative impact on the Resident's wound status. During an interview on 12/9/24 at 8:26 A.M., Unit Manager (UM) #1 said the Consulting Wound NP rounds on Fridays with the other UM and herself. UM #1 said the Consulting Wound NP will typically undress and evaluate the wound. UM #1 said the Weekly - Wound Observation Tool is updated based on the Consulting Wound NP's observations and recommendations. UM #1 said if any treatment recommendations are changed, they are reviewed with the resident's Physician or NP and orders are updated in the electronic medical record. UM #1 reviewed Resident #65's medical record and said Resident #65's wound treatment orders from 8/9/24 to 8/16/24 did not match the recommendations made by the Consulting Wound NP. UM #1 said the order was missing the Consulting Wound NP's recommendation for Santyl. UM #1 said recommendations for a Fidaxomicin or Vancomycin taper for the treatment of C. diff was not implemented upon return from the hospital on 7/31/24. During an interview on 12/9/24 at 11:20 A.M., the Director of Nursing (DON) said she reviewed Resident #65's medical record and noted the 40-day Vancomycin taper was not implemented when he/she returned from the hospital on 7/31/24 as it should have been. The DON said there should not have been a delay in starting the 40-day Vancomycin taper for Resident #65. The DON reviewed the Consulting Wound NP's recommendations and documentation and said the orders from 8/9/24 to 8/16/24 did not include Santyl as recommended by the Consulting Wound NP. 49425 2. Resident #68 was admitted to the facility in May 2024 with diagnoses including cerebral vascular accident (damage to the brain from interruption of blood supply) and spinal fusion. Review of the MDS assessment, dated 9/3/24, indicated Resident #68 was cognitively intact as evidenced by a score of 15 out of 15 on the BIMS. Additionally, Resident #68 had two unstageable pressure ulcers/injuries which were receiving skin treatments and he/she was dependent on staff for assistance with bed mobility. Review of the comprehensive care plan indicated but was not limited to the following: - Resident has unstageable pressure ulcers to bilateral heels related to immobility - Administer treatments as ordered and monitor for effectiveness - Notify MD/NP and obtain treatment Review of the medical record indicated Resident #68 was followed by a Wound Care Nurse Practitioner at the facility. Review of the Wound Assessment Report, completed by the Consulting Wound NP, dated 11/22/24, indicated but was not limited to the following: -Unstageable Pressure Wound of the Left Heel - Treatment: Cleanse with normal saline (NS), apply Santyl, Calcium alginate, cover with abdominal (ABD) pad and rolled gauze. Change daily and as needed for soiling, saturation, or accidental removal. Review of the Wound Care Specialist's progress note, dated 11/22/24, indicated but was not limited to the following: - Left heel wound no longer with eschar (thick adherent black dead tissue), slough, and granulation to wound bed. Will update treatment plan. - Wound Status: improving without complications. Review of the Wound Assessment Report, completed by the Consulting Wound NP, dated 12/06/24, indicated but was not limited to the following: - Unstageable Pressure Wound of the Left Heel - Treatment: Cleanse with NS, apply Santyl, Calcium alginate, cover with ABD pad and rolled gauze. Change daily and as needed for soiling, saturation, or accidental removal. Review of the Wound Care Specialist's progress note, dated 12/06/24, indicated but was not limited to the following: - Left heel wound continue with treatment plan. - Wound Status: improving without complications. Review of the November and December 2024 Physician's Orders and TARs indicated an order was implemented on 9/13/24 as follows: Left heel: Cleanse with NS and pat dry. Apply Iodosorb (ointment applied to wound bed to remove bacteria and slough). Cover with ABD pad and wrap with kling. Change daily and as needed for dislodgement. Further review of the Physician's Orders failed to include the wound treatment recommendations from 11/22/24. Review of the nursing and physician progress notes failed to indicate the physician declined the recommendation of the wound nurse practitioner. During an interview on 12/9/24 at 11:42 A.M., UM #1 said she rounds with the wound NP weekly on Fridays. She said the wound NP assesses and measures the wounds and provides treatment recommendations. She said she receives the recommendations verbally, and the wound NP follows up with faxing over a Wound Assessment Report and documenting the visit under progress notes in the Resident's medical record. UM#1 said then she implements the orders. She said the medical director defers treatment plans to the wound NP. UM#1 reviewed the Wound Assessment Report, dated 11/22/24, with the active physician order in the medical record and said the treatment was never changed as it should have been. She said she was not in the facility on 11/22/24, and someone else completed rounds with the wound NP, and must have missed the treatment change. UM#1 said the treatment order is incorrect and will notify the physician of the error. During an interview on 12/9/24 at 2:43 P.M., the DON said her expectation is for the facility staff member who rounds with the wound NP to initiate the recommendations the date received. She said the order was incorrect.

Based on a resident group meeting, Resident Council Minutes, and interview, the facility failed to ensure staff promptly addressed and resolved grievances brought forward during Resident Council Meetings held on 9/29/24 and 10/18/24. Findings include: Review of the facility's policy titled Resident Council, undated, indicated but was not limited to the following: The purpose of the resident council is to provide a forum for: a. residents, families, and resident representatives to have input in the operation of the facility; b. discussion of concerns and suggestions for improvement; and c. disseminating information and gathering feedback from interested residents. -A Resident Council Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the item(s) of concern. Review of Resident Council Minutes, dated 9/29/24, indicated the following grievance/complaint was brought forward: -Residents complained that evening snacks were not being offered at times. Review of the Resident Council Departmental Response Form, dated 9/29/24, indicated the form was signed by the Administrator as complete on 9/30/24. Further review of the form failed to indicate the Administrator, or his designee provided any follow up to the Resident Council regarding efforts the facility made to address their grievance brought forward during the 9/29/24 Resident Council Meeting. Review of Resident Council Minutes, dated 10/18/24, indicated the following grievance/compliant was brought forward: -Residents complained that there were too many agency staff and staff were not speaking English. Review of the Resident Council Departmental Response Form, dated 10/18/24, indicated that the form was signed by the Administrator as complete on 10/18/24, the same day. Further review of the form failed to indicate the Administrator, or his designee provided any follow up to the Resident Council regarding their grievances brought forward during the 10/18/24 Resident Council Meeting. During a resident group meeting held on 12/4/24 at 1:29 P.M., 11 residents were in attendance representing two of three units. Ten of 11 residents said their complaint from September of not being offered evening snacks is unresolved and continues to be a problem. Five out of 11 residents said their complaint from October of staff not speaking English is unresolved and has gotten worse. During an interview on 12/5/24 at 11:11 A.M., the Activities Director (AD) said she facilitates the monthly resident council meetings and writes the minutes. She said resident council is another forum for residents to express their concerns. She said if resident concerns are not resolved during the meeting, then she'll complete the Department Response Form, write who is responsible for addressing the issue and come up with a plan. She said she did not follow up on the residents' concerns regarding evening snacks, too many agency staff, and staff not speaking English, but should have. She said she assumed it was okay and didn't put it in her discussion of old business at the next monthly meetings. The AD said the grievance process was not followed for the grievances brought forward during the 9/29/24 and 10/18/24 Resident Council Meetings. During an interview on 12/5/24 at 12:00 P.M., the Administrator said he is the grievance official, and all grievances come to him for review to ensure issues are resolved as soon as possible and signed in a timely manner. The Administrator said resident council grievances follow the same process as other grievances. He said he investigated the complaints brought forward during the 9/29/24 and 10/18/24 Resident Council meetings. However, he was unable to provide the surveyor with documented evidence that resolutions to the complaints were provided to the group. He said the grievances brought forward during the resident council meetings should have been reviewed at the next month's meetings, but if the AD said she didn't do it, then it wasn't done.

Based on grievance book review and interview, the facility failed to ensure that staff documented all the steps of the grievance resolution and/or reasonable attempts were made to provide a satisfactory resolution for five Residents' (#29, #278, #277, #47, and #72) grievances filed. Findings include: Review of the facility's policy titled Resident and Family Concerns and Grievances Policy and Procedure, dated 2024, indicated but was not limited to the following: Purpose: -To provide for the prompt resolution of medical and non-medical grievances while maintain confidentiality, in accordance with applicable federal and state statutes and regulations. Filing of Grievances: -Residents or their family members, guardian, or representative may voice a grievance to the Facility staff in person, by telephone, or via written communication. -The facility shall provide the attached Grievance Report Form to facilitate the voicing of a grievance if requested by the resident or family member. Investigation of Grievances: Responses to and Resolution of Grievances: -The facility will follow up with the resident or their family members, guardian, or representative within 72 hours of the filing of the grievance. -The facility will advise the resident of the outcome of the grievance investigation and shall make reasonable efforts to contact the resident's family members to advise them of the outcome of the grievance investigation. -The facility will provide the resident with a written grievance decision, which shall include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of pertinent findings or conclusions regarding the resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued. -The facility will document all steps of the grievance resolution in the facility's records, including whether or not the resident/family was satisfied with the resolution. The documentation will be kept for a minimum of 3 years. During an interview on 12/5/24 at 12:00 P.M., the Administrator said he is the grievance official, and all grievances come to him for review to ensure issues are resolved as soon as possible and signed in a timely manner. During a subsequent interview on 12/5/24 at 12:29 P.M., the Administrator and Consultant Staff #1 reviewed the Grievance Book with the surveyor as follows: a. A grievance form, dated 10/7/24, indicated that Resident #29 reported to the Administrator that an agency Certified Nursing Assistant (CNA) ignored a request in the hallway to get him/her a chair. The Resident stated the CNA continued to walk away. The Resident further stated, agency staff are lousy. The grievance was signed as complete on 10/7/24 by the Administrator. Further review of the grievance form failed to indicate that an investigation was conducted regarding agency staff including pertinent findings or conclusions, a statement as to whether the grievance was confirmed or not, any corrective action taken or to be taken by the facility in response, or that a resolution provided to the Resident. The Administrator said Resident #29 has a certain pattern of accusatory behavior, comments, and complaints of which the majority are not accurate. He said it doesn't mean they don't follow through with a complaint, but he considered this a comment not a complaint. The Administrator said he asked the Resident about the incident but did not document it. b. A grievance form, dated 10/15/24, indicated that Resident #278 reported to the Administrator that he/she had some cheese packages that were left in the unit's refrigerator but were now missing. The action taken included to have the family member bring a receipt for its replacement and would be reimbursed by the facility. The grievance was confirmed and signed as complete by the Administrator on 10/15/24. Further review of the grievance failed to indicate follow up on whether or not the Resident was reimbursed, and if he/she was satisfied with the resolution. The Administrator said the Resident was okay with not being reimbursed for the missing cheese packets and that was the resolution, but he did not document this on the grievance form. c. Review of an email sent by Resident #277 to the Administrator, dated 10/20/24, indicated he/she had been subjected to a roommate who had been talking loudly, yelling, singing, and cursing so he/she had not received a full night's sleep since he/she came to the unit six weeks prior. The Resident stated nothing was done and could have been easily rectified, but it was ignored and compounded by threats to send him/her to a psychiatric ward. Review of the Administrator's email response to Resident #277, dated 10/21/24, indicated he would follow up on his/her comment and address the issue. A grievance form, dated 10/21/24, indicated that Resident #277 reported to the Administrator that his/her roommate was making noise during the night and why the roommate wasn't moved to another room when the Resident first complained about it to staff. The grievance indicated the Resident was offered a room change and denied the request expecting the roommate to be moved. The form indicated based on staff's observation, the roommate does not make noise too often and unit managers confirmed that the Resident's comment was not accurate. The grievance was confirmed and signed as complete by the Administrator on 10/21/24. The grievance form failed to indicate a formal investigation was completed with a summary of pertinent findings and conclusions. The Administrator said he could not get satisfaction with this Resident regardless and the roommate was not making noise, he/she was just speaking softly before falling asleep. He said the Resident declined a room change and just wanted a private room and was told that that wasn't the right way to do it. The Administrator said he confirmed the Resident's grievance and felt he did a formal investigation. He said to the lay reader it may not be clear, but to him the investigation was adequate. The Administrator could not provide the names of the staff he spoke to, and no further documentation was provided to the surveyor. d. A grievance form, dated 10/24/24, indicated that Resident #47's son reported to the Administrator that the Resident had developed a bed sore within the past two weeks from lying on his/her back. The form indicated that the unit manager was going to do a skin assessment and was adding the Resident to wound rounds for assessment. The grievance was signed as complete on 10/25/24 by the Administrator. Further review of the grievance failed to indicate documentation of all the steps of the grievance resolution including a statement as to whether the grievance was confirmed or not confirmed, and whether or not the resident/resident's son was satisfied with the resolution. The Administrator said the form should have indicated whether or not the grievance was confirmed. He said there was no summary of the corrective actions taken or documentation of a resolution. The Administrator said the purpose of the grievance form is to serve as a reminder that more information can be accessed in the record but could not provide documentation to the surveyor of pertinent findings, a conclusion, and a resolution. Consulting Staff #1 was present for the interview and said the documentation should be on the grievance form in the event the Administrator is not there. e. A grievance form, dated 10/30/24, indicated that Resident #47's daughter-in-law reported to the Administrator that the Resident should be a two-person assist for care. The form indicated rehab would evaluate the Resident. The grievance was signed as complete on 10/30/24 by the Administrator. Further review of the grievance failed to indicate documentation of all the steps of the grievance resolution including a summary of pertinent findings and whether or not the resident/resident's son was satisfied with the resolution. During an interview on 12/5/24 at 2:29 P.M., the Administrator said he can follow up to see if the rehab evaluation was done because it isn't documented on the form. He said there wasn't a follow up summary done or documentation of whether or not the Resident/representative was satisfied with the resolution. He said the old rule was, if you didn't document it, you didn't do it. f. A grievance form, dated 11/20/24, indicated in the summary of the grievance that Resident #72's sister reported that the Resident's colostomy bag had not been changed for the past three days. The form indicated the colostomy bag was changed as ordered by the physician. The grievance was signed as completed on 11/20/24 by the Administrator. Further review of the grievance failed to indicate documentation of all the steps of the grievance resolution including the steps taken to investigate the grievance, a summary of pertinent findings or conclusions regarding the resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and whether or not the Resident/Resident's sister was satisfied with the resolution. The form also did not indicate who the Resident's sister reported to or when. During an interview on 12/4/24 at 3:15 P.M., Resident #72 said he/she has a hard time changing the colostomy bag and needs staff's help to do it but said he/she has to tell them how to do it. The Resident said if it isn't done right there would be a blow out of liquid stool on the side which has happened before. The Resident said there is mostly agency staff, and they don't know how to do it. The Resident said staff were changing it every few days, just not right. He/she said the Administrator never came in to speak with him directly about the grievance filed and was never provide a resolution. The Resident said it's gotten a little better but still sometimes must wait three or four hours for the bag to be changed. The Administrator said he confirmed the colostomy bag was being changed but did not confirm it was being changed late, so he asked staff to date the bag when changed. He said he asked the Unit Manager who said it was being done after checking the documentation. The Administrator said he didn't document if it was confirmed or not because there were multiple issues on the same grievance form. He said he did meet face to face with the Resident to discuss his/her concerns but did not document it. He said there is no documentation of a resolution because he didn't confirm the grievance. g. A grievance form, dated 11/26/24, indicated that Resident #72's sister reported to the Administrator that two Saturdays ago when his/her friend sat on the Resident's bed, the bed was wet. The form indicated specific staff would be called in for a statement. The form also indicated the Administrator was unable to verify and signed the form as completed on 11/26/24. Further review of the grievance failed to indicate documentation of all the steps of the grievance resolution including a summary of pertinent findings or conclusions from the identified staffs' statements, any corrective action taken or to be taken by the facility as a result of the grievance, a resolution, and whether or not the Resident/Resident's sister was satisfied with the resolution. The Administrator said he documented that he interviewed the staff but didn't get statements from them because no one remembered the incident. He said he did not document this on the form or as part of the investigation. He said there was no corrective action because it could not be confirmed. He said there was no documentation of satisfaction or dissatisfaction because no one remembered what happened or knew a cause for the bed being wet. The Administrator said the form should still have something documented that it was discussed and what the findings were.

Based on observation, interview, and record review, for two Residents (#330 and #64), of 18 sampled residents, the facility failed to provide indwelling catheter (a flexible tube inserted into the bladder to drain urine outside of the body) care consistent with professional standards related to infection control prevention. Specifically, the facility failed: 1. For Resident #330, to maintain/secure the Resident's Foley catheter drainage bag away from contaminated surfaces; and 2. For Resident #64, to ensure his/her catheter drainage bag was positioned in a manner to prevent potential complications. Findings include: Review of Centers for Disease Control and Prevention's Guidelines for Prevention of Catheter-Associated Urinary Tract Infections, page last reviewed November 2015, indicated but was not limited to: - Do not rest the catheter bag on the floor. Review of the facility's policy titled Catheter Care, Urinary, last revised August 2024, indicated but was not limited to: - Purpose: The Purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. - Infection Control: Be sure the catheter tubing and drainage bag are kept off the floor. - Maintaining Unobstructed Urine Flow: Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder. 1. Resident #330 was admitted to the facility in November 2024 with diagnoses including dementia and neuromuscular dysfunction of the bladder. Review of Resident #330's Minimum Data Set (MDS) assessment, dated 11/26/24, indicated he/she had a severe cognitive deficit as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15 and he/she had an indwelling catheter. Review of Resident #330's current Physician's Orders indicated but was not limited to: -Indwelling catheter 16 FR (French) with 10 cc (milliliter) balloon to bedside straight drainage (dated 11/20/24) -Empty catheter drainage bag at least once every eight hours to when it becomes 1/2 to 2/3 full every 8 hours and as needed (dated 11/20/24) -May use leg bag if desired when out of bed (dated 11/20/24) -Perform indwelling catheter care every shift and as needed (dated 11/20/24) -Change indwelling catheter when occluded or leaking as needed (dated 11/20/24) The surveyor observed Resident #330's catheter drainage bag in direct contact with the floor as follows: - 12/4/24 at 7:43 A.M. - 12/4/24 at 8:06 A.M. - 12/4/24 at 9:55 A.M. - 12/4/24 at 12:25 P.M. - 12/4/24 at 1:33 P.M. - 12/4/24 at 3:47 P.M - 12/4/24 at 4:20 P.M. - 12/5/24 at 7:49 A.M. During an interview on 12/5/24 at 7:49 A.M., Certified Nursing Assistant (CNA) #1 said catheter drainage bags should not be on the floor. CNA #1 said if a resident was in bed, then his/her catheter drainage bag should be hung on their bed frame, and if the resident was in their wheelchair, the catheter should be secured off the floor. During an interview on 12/5/24 at 7:50 A.M., Nurse #1 said catheter drainage bags should be secured off the floor. During an interview on 12/5/24 at 10:58 A.M. Unit Manager (UM) #2 said catheter drainage bags should always be kept below the resident's bladder and off the floor. During an interview on 12/5/24 at 12:28 P.M., the Occupation Therapy Assistant said Resident #330's catheter drainage bag should have been secured off the floor. During an interview on 12/9/24 at 3:40 P.M., the Director of Nursing (DON) said the expectation was for catheter drainage bags to be positioned below the resident's bladder and should not be in direct contact with the floor. 43935 2. Resident #64 was admitted to the facility in December 2023 with diagnoses including: cerebral infarction (stroke) and obstructive uropathy. Review of Resident #64's BIMS, dated 9/12/24, indicated he/she was severely cognitively impaired with a score of 0 out of 15. Review of the current orders for Resident #64 indicated but were not limited to the following: -Foley catheter 22 French with 30 milliliter balloon: may change Foley as needed due to blockage (5/24/24) -Empty catheter drainage bag at least once every eight hours every shift (5/3/24) The surveyor made the following observations as follows: 12/3/24 at 9:20 A.M., Catheter drainage bag laying on the floor on the right side of the Resident's bed, while the Resident was in the bed. 12/3/24 at 1:14 P.M., Catheter drainage bag hanging off the right side of the Resident's bed, on the floor face down, while the Resident was in the bed. 12/3/24 at 2:27 P.M., Catheter drainage bag on the right side of the Resident's bed, lying on the floor face up, while the Resident was in the bed. 12/4/24 at 7:37 A.M., Catheter drainage bag hanging off the right side of the Residents bed on the upper 1/4 siderail, above the Resident's bladder level. 12/4/24 at 9:54 A.M., Catheter drainage bag hanging on the right upper 1/4 siderail of the Resident's bed, above the Resident's bladder level. During an interview on 12/5/24 at 7:59 A.M., Nurse #2 said residents with catheters are required to have their drainage bags kept off the floor for infection control reasons and the bag should be positioned below the bladder level at all times to prevent potential backflow of urine into the resident's bladder. During an interview on 12/5/24 at 10:02 A.M., CNA #2 said when the CNAs are providing care to residents with catheters, they are to make sure that the drainage bag is hung below the waist (bladder level) of the resident either on the edge of the bed frame or under the wheelchairs, and the bag may not touch the floor. During an interview on 12/5/24 at 10:07 A.M., Nurse #3 said residents with catheters are to have the drainage bags positioned below bladder level and the bags cannot be placed on the floor for infection control reasons. She said both the CNAs and Nurses are responsible for providing catheter care and ensuring the drainage bags are maintained in the appropriate manner. During an interview on 12/5/24 at 10:09 A.M., Unit Manager #1 said that Resident #64 should have had his/her drainage bag kept off the floor and positioned below bladder level at all times. She said having the drainage bag on the floor is a potential infection control issue for contamination and if the bag is positioned above the bladder it could result in the back flow of urine into the bladder causing potential complications. She said the process for positioning this Resident's catheter drainage bag does not appear to have been followed. During an interview on 12/5/24 at 4:36 P.M., the Infection Preventionist said that residents with catheters are to have their drainage bags positioned below the bladder level to prevent potential back flow of urine into the bladder and complication. She said the drainage bag should never be placed on the floor as it could cause a potential complication with infections. She said based on the surveyor's observations the facility did not follow their process for ensuring Resident #64's catheter drainage bag was positioned in a manner to prevent complications.

Based on document review and interview, the facility failed to ensure the monthly medication regimen review (MRR) for one Resident (#13), out of a total sample of 18 residents, was included in the medical record or readily available for review to indicate the Physician's response to the recommendations made by the Pharmacist. Findings include: Review of the facility's policy titled Pharmacy Consultant/Medication Orders, revised 2024, indicated but was not limited to the following: -The consulting pharmacist will ensure that a record of the observations and recommendations is made available in an easily retrievable to [sic] the Director of Nursing/Designee who is the process manager and who will ensure that the information is available to the nurses, prescribers, and the care planning team. -All recommendations received from the pharmacy consultant should be addressed prior to the next medication regimen review. -Recommendations will be acted upon and documented by the facility licensed nurse and/or the prescriber. Resident #13 was admitted to the facility in September 2023 with diagnoses including dementia, fracture of the second cervical vertebra (a broken bone in the neck), and mild cognitive impairment. Review of the medical record for Resident #13 indicated the Consultant Pharmacist had completed a MRR with recommendations to the physician as follows: 1/23/24: MD rec (recommendation) to reeval (re-evaluate) prn (as needed) trazodone (an antidepressant medication) 2/22/24: md rec for tsh (a laboratory test to evaluate thyroid function) 4/29/24: MD rec for lipid panel (a laboratory test to evaluate cholesterol levels in the blood) 5/22/24: MD rec to consider reduction of Pravachol (a medication used to lower cholesterol levels) 6/17/24: MD rec to consider reduction of Pravachol. 7/25/24: MD rec to consider reduction of Pravachol. 9/23/24: MD rec to reeval prn Ativan (an anti-anxiety medication) Review of the Consultant Pharmacist Recommendation to Prescriber form for the MRR, dated 6/18/24, indicated that the Physician declined the Consultant Pharmacist's recommendation to consider a dose reduction of Pravachol for Resident #13. The facility failed to provide copies of the Review of the Consultant Pharmacist Recommendation to Prescriber forms for MRRs completed 1/23/24, 2/22/24, 4/29/24, 5/22/24, 7/25/24, and 9/23/24 indicating they were reviewed by the Resident's provider as requested by the surveyor. During an interview on 12/05/24 at 2:29 P.M., the Director of Nurses (DON) said the Resident's medical record was reviewed and only one of the requested MRR forms was found. The DON said the completed forms should be retained in the Resident's medical record.

Based on observation, interview, and record review, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed to: 1. For Resident #41, ensure a portable nebulizer device (turns liquid medicine into a mist that can be inhaled to treat lung conditions) and a bottle of Tums (antacid that treats heartburn, indigestion, and upset stomach) were not left unsecured in the Resident's room; 2. Ensure that once opened, a Lantus (long-acting insulin) pen was labeled with the date opened/date to be discarded; and 3. Ensure that once opened, Liquid Protein supplements were labeled with the date opened and/or date to be discarded. Findings include: Review of the facility's policy titled Self-Administration of Medications, dated as revised February 2024, indicated but was not limited to the following: -Medications are stored in a safe and secure place, which is not accessible by other residents. -Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. Review of the facility's policy titled Medication Labeling and Storage, undated, indicated but was not limited to the following: -Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Review of the facility's policy titled Insulin Storage, dated 2024, indicated but was not limited to the following: -Facility shall store insulin in accordance with pharmaceutical standards. -To ensure that your insulin remains effective, stable and undamaged you should discard your 'in use' insulin after 28 days, whether in a vial or cartridge. -Insulin has a 'use by' date as well as an expiration date. Insulins removed from the refrigerator and/or opened shall be dated as such with the use by date not to exceed 28 days. 1. Resident #41 was admitted to the facility in July 2022 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD- lung condition causing airflow obstruction). Review of the Minimum Data Set (MDS) assessment, dated 11/7/24, indicated that Resident #41 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she was cognitively intact. During an observation with interview on 12/3/24 at 9:56 A.M., the surveyor observed the following in Resident #41's room: - a portable handheld nebulizer device, unsecured, uncovered, tucked in the elastic humidifier holder on the oxygen concentrator machine -a large bottle of Tums on the floor at the edge of Resident #41's bed, unsecured. Resident #41 said the staff are aware of the nebulizer device and have watched him/her use it. Resident #41 said his/her son brings in the Albuterol (treats wheezing, difficulty breathing) solution to refill the device, however he/she is uncertain how to clean or manage the device. Resident #41 said he/she keeps the bottle of Tums in his/her room in case he/she needs to use them, and no one from the facility has ever said he/she cannot obtain medications from his/her family. During an observation on 12/9/24 at 9:20 A.M., the surveyor observed the following in Resident #41's room: - a portable handheld nebulizer device, unsecured, uncovered, tucked in the elastic humidifier holder on the oxygen concentrator machine -a large bottle of Tums sticking out of a bag, next to the edge of the Resident's bed, unsecured. Review of Resident #41's active Physician's Orders indicated the following: -Albuterol Sulfate Nebulizer Solution 0.083% inhale orally via nebulizer every 4 hours as needed for shortness of breath/wheezing -Tums tablet chewable 500 milligrams (mg) one tablet by mouth every 8 hours as needed for heartburn Review of the Medication Administration Record (MAR) for the months of September, October, November, and December 2024 indicated Albuterol Sulfate nebulizer or Tums had not been administered. Review of the medical record indicated a Self-Administration of Medications assessment was completed on 11/15/24, indicating Resident #41 wished to self-administer inhaled/nebulized medications and had the ability to manage and maintain safe storage of the medication at the bedside. Further review of the assessment failed to indicate an assessment had been completed for the self-administration of any oral medications. Review of the comprehensive care plan indicated the following: -may self-administer inhalers at bedside -monitor quantity of medications to validate Resident is taking medications -provide locked storage compartment for medications approved for unsupervised self-administration -Resident educated by nursing to ensure inhalers are locked in bedside drawers after use, verbalized understanding. During an interview on 12/5/24 at 2:04 P.M., Nurse #2 said she is not sure if residents may keep medications unlocked at the bedside. She said she would have to ask a nurse manager. During an observation with an interview on 12/5/24 at 2:10 P.M., Nurse #6 said Resident #41 may self-administer his/her Albuterol inhaler, he/she has a physician's order to do so. She said inhalers do not need to be in a locked container. The surveyor and Nurse #6 entered Resident #41's room and observed a portable handheld nebulizer device, not secured, uncovered, tucked in the elastic humidifier holder on the oxygen concentrator machine and a large bottle of Tums, sticking out of a bag, next to the edge of the Resident's bed. She said she was not aware of the Resident having a handheld nebulizer, or Tums in the room, she has never seen it before. Resident #41 said he/she uses the nebulizer throughout the day when he/she feels short of breath but has not taken any of the Tums in a long time. The Resident said the doctor put him/her on a different medication that he/she takes twice a day for heartburn. Resident #41 said he/she has never told anyone that he/she had the Tums in his/her room. During an observation on 12/9/24 at 8:04 A.M., the surveyor observed the following in Resident #41's room: -a portable handheld nebulizer device, unsecured, uncovered, tucked in the elastic humidifier holder on the oxygen concentrator machine. During an interview on 12/10/24 at 1:02 P.M., the Director of Nursing (DON) said Resident #41 should not have medications at the bedside which are not locked. She said her expectation would be for any residents who self-administer medications, to have an assessment completed, physician's order in place, and the medications to be stored in a locked container or drawer. 50740 2. On 12/4/24 at 12:50 P.M., the surveyor completed a review of the medication cart (High) on the Elm Unit with Nurse #5 and made the following observation: -One Lantus (a long-acting insulin) pen opened but not marked with the date opened/date to be discarded. During an interview on 12/4/24 at 12:52 P.M., Nurse #5 said that the insulin pen should have been labeled with the date opened/date to be discarded. 3. On 12/4/24 at 9:06 A.M., the surveyor observed Nurse #6 administer Liquid Protein 30 milliliters (ml) to Resident #68. The bottle of Liquid Protein was opened prior to Nurse #6 using it. The bottle was not marked with the date opened. The surveyor and Nurse #6 reviewed the label on the bottle of Liquid Protein which indicated that the product had a three month shelf life from the date opened. During an interview on 12/4/24 at 9:16 A.M., Nurse #6 said that the bottle of Liquid Protein she had used during the medication pass should have been marked with the date it was opened but was not. On 12/4/24 at 12:50 P.M., the surveyor completed a review of the medication cart (High) on the Elm Unit with Nurse #5 and made the following observation: -One bottle of Liquid Protein, opened, not dated with the date opened or date to be discarded. During an interview on 12/4/24 at 12:52 P.M., Nurse #5 said no one told her the Liquid Protein needed to be labeled with the date opened. During an interview on 12/5/24 at 1:09 P.M., the DON said that the Liquid Protein should be marked with the date opened.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who required extensive assist with transfers and assist with toileting, the Facility failed to ensure staff provided adequate assistance and supervision during toileting, to prevent an injury or accident. Resident #1 was left unattended on the toilet and was found lying on the floor in the bathroom bleeding from the top of his/her head. Resident #1 sustained a laceration to the top of his/her head, was transferred to the hospital emergency department and required eight sutures to close the wound. Findings include: The Policy titled, Falls Management, dated as revised on 3/14/16, indicated patients will be assessed for falls risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. The Policy indicated to identify patient's fall risk by reviewing the Nursing Assessment and develop individualized plan of care. Resident #1 was admitted to the Facility in (MONTH) 2019 and [DIAGNOSES REDACTED]. Resident #1's Visual/Bedside Certified Nurse Aide (CNA) Kardex Report (Care Plan), undated, indicated he/she required extensive assist for transfers and required assist with toileting. An Admission Progress Note, dated 7/2/19, indicated Resident #1 was having confusion, was very hard of hearing with two hearing aids in place, had a past medical history of [REDACTED]. A Therapy Mobility Admission Assessment, dated 7/2/19, indicated Resident #1 required partial/moderate assistance with toilet transfers. An Occupational Therapy Initial Evaluation, dated 7/3/19, indicated Resident #1 presented with a new onset of impaired balance, impaired functional mobility, impaired strength, impaired coordination and impaired transfers. The Evaluation indicated Resident #1 required assistance with toileting and was a fall risk. A Physical Therapy Initial Evaluation, dated 7/3/19, indicated Resident #1 had a decline in ability to perform functional activities without physical assistance. The Evaluation indicated Resident #1 required assistance with transfers and was a fall risk. The Surveyor interviewed the Occupational Therapist (OT) and Physical Therapist (PT) at 1:45 P.M. on 7/18/19. The PT and OT said Resident #1 had poor safety awareness and was a fall risk. The PT and OT said Resident #1 required assistance with toilet transfers, had cognitive and physical deficits as well as severe hearing loss, could not call for help and should not have been left alone on the toilet. The PT and OT said Resident #1's plan of care was reviewed with Nursing. An Admission Functional Abilities Form, dated 7/4/19, indicated Resident #1 required substantial/maximal assistance with toileting and toilet transfer. A Nursing Home to Hospital Transfer Form, dated 7/7/19, indicated that Resident #1 was in the bathroom, fell on the floor and was noted to be bleeding from the head. The Health Care Facility Reporting System (HCFRS) Report, dated 7/9/19, indicated that on 7/7/19 at 6:58 A.M., a CNA heard a noise and saw Resident #1 lying on the floor in the bathroom. The Report indicated Resident #1 was bleeding from the top of his/her head and was transferred to the hospital. The Surveyor interviewed CNA #3 at 9:31 A.M. on 7/22/19. CNA #3 said he transferred Resident #1 onto the toilet in the bathroom and said he heard a noise coming from across the hallway and said he left Resident #1 alone on the toilet to go and see where the noise was coming from. CNA #3 said he knew Resident #1 required supervision during toileting, but said he thought that Resident #1 would be safe alone on the toilet. CNA #3 said while he was across the hallway, he heard a bang from Resident #1's bathroom, said he went back to check on Resident #1's, and found Resident #1 on the floor bleeding from his/her head. CNA #3 said he called the nurse. Nurse #2's written witness statement, dated 7/7/19 at 7:55 A.M., indicated Resident #1 was on the toilet and CNA #3 informed her that Resident #1 had fallen and hit his/her head. The Surveyor interviewed Nurse #2 on 7/31/19 at 2:03 P.M. Nurse #2 said that Resident #1 was at risk for falls and required assistance with toileting and transfers. Resident #1's physician's orders [REDACTED]. The Surveyor interviewed the Director of Nurses (DON) at 2:30 P.M. on 7/18/19. The DON said Resident #1 was a fall risk. The DON said she did not know if Resident #1 should have been left alone in the bathroom or not. A Hospital Emergency Department Report, dated 7/7/19, indicated Resident #1 was seen after a fall at the Nursing Home. The Report indicated Resident #1 struck his/her head and sustained a laceration to his/her forehead and required eight sutures to close the wound.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), the Facility failed to prevent incidents of abuse and ensure that staff were not verbally abusive toward residents, when it was alleged that Certified Nurse Aide (CNA #1) yelled at Resident #1. Findings include: Resident #1's Minimum Data Set (MDS) Assessment, completed 8/1/18, indicated that his/her cognitive patterns were intact. The Surveyor interviewed Resident #1 at 9:45 A.M. on 11/2/18. Resident #1 said that CNA #1 screamed and yelled at him/her about having too much stuff in his/her room. Resident #1 said that CNA #1's temper was [MEDICAL CONDITION] she slammed a walker into a wall in his/her room. Resident #1 said that when he/she went to the nurses' station and reported that CNA #1 screamed and yelled at him/her, CNA #1 yelled at him/her again and told him/her (Resident #1) that he/she should not be discussing this incident. Resident #1 said that CNA #1 tried to intimidate him/her. Resident #1 said that he/she retreated from the situation because he/she was afraid further conversation would escalate CNA #1. Resident #1 said staff at the nurses' station witnessed CNA #1 yell at him/her. Nurse #2's written statement, dated 8/13/18, indicated that Resident #1 came to the nurses' station and asked who his/her nurse was because he/she wanted to make a complaint about CNA #1. Nurse #2's written statement indicated that CNA #1 came down the hall and started yelling at Resident #1 not to talk about him/her. The Surveyor interviewed Nurse #2 at 6:00 P.M. on 11/8/18. Nurse #2 said that in hindsight she did not think CNA #1 yelled at Resident #1. Nurse #2 said that when she discussed the alleged incident with the Director of Nurses and wrote her statement, she chose her words poorly. Nurse #2 said that in hindsight, although CNA #1 raised her voice and spoke in frustration toward Resident #1, she did not think CNA #1 yelled at Resident #1, The Surveyor interviewed the Director of Nurses at 11:00 A.M. on 11/5/18. The Surveyor and the Director of Nurses' reviewed her written statement regarding an interview with Nurse #2 at 2:30 P.M. on 8/13/18. The Director of Nurses' said and her written statement indicated, that Nurse #2 said that she witnessed CNA #1 abuse Resident #1 and did not immediately report the incident. Review of the Facility's Internal Investigation indicated it contained documentation of the Director of Nurses' interview with Resident #3. The Director of Nurses documentation indicated that Resident #3 told her that CNA #1 was angry and yelled at Resident #1. The Statement indicated that Resident #3 told the Director of Nurses that CNA #1 banged a walker against the wall and that he/she felt scared of CNA #1. Review of Resident #3's clinical record indicated he/she shared a room with Resident #1. Resident #3's most recent Minimum Data Set Assessment completed 8/16/18 indicated that his/her cognitive patterns were intact. The Surveyor interviewed CNA #1 briefly by telephone on 11/6/18. CNA #1 said any allegation was an unreal fishing expedition and abruptly terminated the telephone call. On 11/5/18, the Facility was found to be in past non-compliance. The Facility provided the Surveyor with a plan of correction which addressed the concerns as evidenced by: A) The Facility Social Worker provided Resident #1 with weekly visits for support following the alleged incident through to his/her discharge on 8/21/8. B) The Facility terminated Certified Nurse Aide #1 for the allegation of verbal abuse on 8/15/18. C) On 8/10/18 the Unit Manager interviewed other residents who were cared for by CNA #1, and there were no additional complaints or concerns identified. D) The Facility provided enhanced education to its all staff members about responding to incidents of abuse by immediately intervening to protect residents and reporting incidents which may be abuse immediately. Education was completed by 11/1/18. E) The Facility developed a program of post abuse training group and individual staff interviews by the Nurse Practice Education to assess the effectiveness of the enhanced abuse training. Twenty-seven interviews had been completed by 11/1/18. F) The status of the enhanced abuse training was reviewed the Quality Assurance (QA) Committee at a QA Meeting on 10/15/18.

Based on record review and interviews, for 1 of 12 sampled residents (Resident #4), the Facility failed to ensure that following an unwitnessed fall, at approximately 3:30 P.M. on 8/4/15, that a pain assessment was accurately completed or that Resident #1's complaints of pain were addressed in a timely manner. The Neurological Assessment Flow Sheet, documented between 4:00 P.M. and 8:50 P.M. indicated Resident #4 complained of right leg and arm pain a total of 7 times. Resident #4 did not receive Tylenol (an oral [MEDICATION NAME]) until 9:00 P.M., and at 10:10 P.M. was transferred to the emergency room (ER) where he/she was diagnosed with [REDACTED]. Findings include: The Facility's Policy titled Pain Management, dated as revised on 1/2/14, included patients will be evaluated as part of the nursing assessment process for the presence of pain with any change in condition or change in pain status by utilizing a Pain Screen and Evaluation Tool. The Policy indicated that staff will document the effectiveness of any pain medication given and any side effects. A Nurse Progress Note, dated 8/4/15, indicated at approximately 3:30 P.M. Resident #4's roommate alerted staff that Resident #4 had fallen in his/her room. On assessment Resident #4 had pain in his/her right hip and right shoulder, the covering Nurse Practitioner (NP) was notified and an order for [REDACTED].M. Resident #4 had increased pain and was transferred to the ER for further evaluation. The Neurological Assessment Flow Sheet, documented by Nurse #1 between 4:00 P.M. and 8:50 P.M. indicated Resident #4 complained of right leg and arm pain a total of 7 times. A Nurse Progress Note, dated 8/4/15, indicated at approximately 9:00 P.M. Resident #4 had increased pain, he/she received Tylenol, the covering NP was notified and an order was obtained to transfer Resident #4 to the ER for further evaluation. A Risk Management Assessment Record, dated as completed on 8/10/15, as part of the Facility's Internal Investigation indicated Resident #4 was transferred to the ER at 10:10 P.M. on 8/4/15. The Surveyor interviewed Nurse #1 at 12:10 P.M. on 10/20/15. Nurse #1 said following Resident #4's fall staff placed him/her back in to bed. Nurse #1 said that although he documented on the Neurological Assessment Flow Sheet, timed 4:00 P.M. through 8:50 P.M. a total of 7 times that Resident #4 complained of right leg and arm pain, he did not complete a pain assessment on Resident #4 in accordance with the Facility's Pain Management Policy. Nurse #1 said, words to the effect, that to the best his recollection Resident #4 blamed him/herself for falling and that he/she was sore but did not use the word pain until approximately 8:30 P.M. (5 hours after his/her fall). Nurse #1 said by 9:00 P.M. the mobile X-ray company had not arrived to perform an X-ray on Resident #4 so at that time he gave Resident #4 Tylenol and called the covering NP and obtained an order to transfer Resident #4 to the ER for evaluation. The Hospital ER Report, dated 8/4/15, indicated on assessment Resident #4 had pain in his/her right femur, knee and lower leg, and on movement he/she had limited range of motion with worsening diffuse pain and tenderness in the right hip. Resident #4 received 2 milligrams (mg) of [MEDICATION NAME] via IV push, following an X-ray which was performed indicating Resident #4 had a fractured right hip.

Based on record review and interviews, for 2 of 12 sampled residents (Resident #3 and #4), the Facility failed to ensure that bed and/or chair alarms were in place and functioning properly per the Physician's Treatment orders and Care plan documentation. On 7/25/15, Resident #3 had an unwitnessed fall and and sustained lacerations on his/her forehead and back of head and a olecranon (elbow) fracture. On 8/4/15, Resident #4 had an unwitnessed fall and sustained a fractured right hip. Staff interviewed said at the time of Resident #3's and Resident #4's unwitnessed falls, bed and or chair alarms did not sound. Findings include: 1. An Admission Fall Risk Assessment, dated 7/16/15, identified Resident #3 at risk for falls. The Physician's Treatment Order, dated 7/16/15, indicated Resident #3 was to have a bed alarm which staff were to check was in place and functioning on each shift. Nurse Progress Notes, dated 7/25/15, indicated at 4:30 P.M. Resident #3 was found on the floor with his/her head and shoulders leaning against the bedside bureau. Resident #3 was bleeding from lacerations on his/her forehead and back of head, and he/she had skin tears on his/her arms. Resident #3 was transferred to the Hospital for treatment and was admitted for further observation. A Risk Management Assessment Record, dated 7/26/15 and completed by Nurse #1 as part of the Facility's Internal Investigation, indicated at the time of Resident #3's fall no safety measures were in place and Resident #3's alarm did not sound. The Surveyor interviewed Nurse #1 at 11:40 A.M. on 10/20/15. Nurse #1 said at approximately 3:00 P.M. on 7/25/15, he saw Resident #3 lying in bed. Nurse #1 said to the best of his recollection the light on Resident #3's bed alarm was blinking but he did not check to see if the alarm was functioning correctly at that time. The Surveyor interviewed Nurse Practitioner (NP) #1 at 4:00 P.M. on 10/25/15. NP #1 said she was standing in the room across the hall from Resident #3's room speaking with a visitor. NP #1 said the visitor said words to the effect OMG he's falling. NP #1 said she heard a thud and when she turned around she saw Resident #3 lying on the floor in his/her room wedged between the bed and the bedside bureau. NP #1 said she called out for help and instructed staff to call 911 to transfer Resident #3 to the Hospital for evaluation and treatment. NP #1 said Resident #3's alarm did not sound at the time of his/her fall. The Hospital Discharge Summary, dated 7/28/15, indicated Resident #3 had an olecranon (elbow) fracture. The Nurse Progress Note, dated 7/29/15, indicated that in addition to Resident #3's fracture, he/she has staples to the wound on the back of his/her head. 2. The Quarterly Minimum Data Set (MDS) assessment, dated 5/27/15, indicated Resident #4 had mild cognitive impairment, he/she ambulated independently but required extensive assistance from one person for bed mobility, transfers and toilet use, and he/she was unsteady when moving from a seated to a standing position. The Plan of Care, dated 7/29/15, indicated Resident #4 was to have bed and chair alarms to alert staff of his/her need to ambulate. Nurse Progress Notes, dated 8/4/15, indicated at approximately 3:30 P.M. Resident #4's roommate alerted staff that Resident #4 had fallen in his/her room. On assessment Resident #4 had pain in his/her right hip and right shoulder, the covering NP was notified and an order for [REDACTED].#4's right shoulder and hip were obtained. Later that evening, at approximately 9:00 P.M. Resident #4 had increased pain, the covering NP was called and an order was obtained to transfer Resident #4 to the ER for further evaluation. A Risk Management Assessment Record, dated as completed on 8/10/15 as part of the Facility's Internal Investigation, indicated at the time of Resident #4's fall, he/she was not assigned an alarm. The Surveyor interviewed Nurse #2 at 10:28 A.M. on 10/20/15. Nurse #2 said at the time of Resident #4's fall, Resident #4's bed and chair alarms were not in place. A Nurse Progress Note, dated 8/8/15, indicated Resident #4 was readmitted to the Facility following surgical repair of a fractured right hip.

Based on record review, observation, and interview, the facility failed for 1 resident (#10) of 3 applicable residents with pressure sores, out of a total sample of 22 residents, to provide all necessary treatment and services to keep the resident, who entered the facility without pressure sores, from developing pressure sores, and to provide measures to promote healing and the prevention of new pressure sores from developing. Findings include: For Resident #10, the facility failed to provide effective interventions to keep the resident from developing pressure sores on the left and the right heels. Resident #10 was admitted to the facility in 9/2014 with [DIAGNOSES REDACTED]. Review of the Norton Plus Pressure Ulcer Scale completed on 9/10/14 identified the resident as scoring "3". (Score 10 or less = High Risk for skin breakdown). Review of a plan of care for the risk for skin breakdown as evidenced by limited mobility and incontinence, dated 9/11/14, included the following interventions: - Apply barrier cream with each cleansing, - Evaluate for any localized skin problems, i.e. dryness, redness, pustules, inflammation, - Monitor skin for signs/symptoms of skin breakdown, i.e. redness, cracking, blistering, decrease sensation, and skin that does not blanche easily, - Norton/Braden assessments per policy, - Pressure redistribution surfaces to bed and chair per protocol, - Weekly skin assessment by licensed nurse. A Foot Assessment, completed on 9/11/14, indicated the resident had no foot pain, no redness, maceration or breakdown on the heels, between toes, or on any bony prominence. There was no evidence of ingrown toenails. Review of an Initial Minimum Data Set (MDS) assessment of 9/17/14 identified the resident as having moderately impaired cognition. The resident required extensive assistance of two for bed mobility, transfers, and toilet use, and required extensive assistance of one for walking, locomotion, dressing, hygiene, and bathing. The resident utilized a walker and a wheelchair, was at risk for developing pressure ulcers and had no pressure ulcers or foot problems. Review of the Norton Plus Pressure Ulcer Scale completed on 9/18/14 identified the resident as scoring "7". (Score 10 or less = High Risk for skin breakdown). Review of the Treatment Administration Records (TARs) of 9/2014 through 10/4/14 indicated that licensed nursing conducted weekly skin checks. Review of a Skin Integrity Report indicated that on 10/5/14 the resident's left heel had Deep Tissue Injury (DTI). The area was a serous blister which measured 8 centimeters (cm) long by 4 cm wide with no depth, with a minimum amount of serous drainage. The surrounding tissue was documented as deep purple. The Skin Integrity Report, dated 10/5/14, indicated that the resident's right heel had a DTI. The appearance was Intact/Deep purple. The area measured 4.5 cm long by 1 cm wide with no depth. The surrounding tissue was deep purple. Review of a nursing note, dated 10/6/14, indicated that the resident's left heel was deep purple with skin intact, and the right heel had an open blister. Review of the Norton Plus Pressure Ulcer Scale, completed on 10/6/14, identified the resident as scoring "6". (Score 10 or less = High Risk for skin breakdown). Review of an investigation completed on 10/5/14 at 11:30 P.M. indicated, Pressure Ulcer (PU) New in House Acquired. The report indicated that the nurse assessed the resident's heels and found on the left heel, an opened blister, purplish color with serous drainage, measuring 8 cm. x 4 cm. Cleanse with [MEDICATION NAME], pat dry, apply skin prep, followed by [MEDICATION NAME] dressing. Right heel measured 4.5 cm x 1 cm, deep purple color with skin intact. Nurse Practitioner was aware. "It appears the hard rubber on the resident's diabetic shoes is causing area of friction as resident is moving wheelchair with feet/heel motion." On 10/6/14 a care plan was developed for actual skin breakdown related to limited mobility and Diabetes (pressure areas on left and right heels). Interventions included: - Encourage resident to consume all fluids during meals, - Float heels while in bed, resident refuses to elevate heels at times, - Norton/Braden Assessment per policy, - Offer/encourage fluids of choice, - Provide wound treatment as ordered, - Weekly skin assessment by licensed nurse. The plan of care did not indicate an intervention to reduce/relieve friction caused by the resident's mobility, as noted by the Nurse Practitioner on 10/5/14 as a cause for the pressure ulcer. A new order for the right heel was obtained on 10/6/14 for skin prep each shift daily. On 10/7/14 a new order was obtained for the right heel. Nutrishield each shift daily. On 10/8/14 a new order for the left heel was obtained which indicated, [MEDICATION NAME] spray, pat dry, Nourished followed by [MEDICATION NAME] dressing daily on 7:00 A.M. - 3:00 P.M. shift, until healed. On 10/20/14 the Wound Care Specialist evaluated Resident #10 and found the Pressure Ulcer of the right heel to have unstageable necrosis and measured 1.5 cm long x 1.2 cm wide with no exudate. The area contained thick adherent black necrotic tissue (eschar) 100%. The Pressure Ulcer of the left heel had unstageable necrosis and measured 3.0 long x 4.0 wide with light serous drainage and thick adherent black necrotic tissue (eschar). On 11/20/14 the treatment to the right heel changed to [MEDICATION NAME] spray, pat dry, apply Hydrogel followed by [MEDICATION NAME] dressing daily, until healed. The treatment to the left heel changed to Skin Integrity spray, pat dry, apply Hydrogel dressing with multipodus boot and walking sole daily every day shift for left heel decubitus ulcer. The plan of care for actual skin breakdown to the left and right heels, dated 10/6/14 to the present, included the following updated interventions on 11/21/14: - Monitor for verbal/non-verbal signs of pain related to wound or wound treatment and medicate as ordered, - Observe skin condition with ADL care daily and report abnormalities - Provide peri-care/continence care as needed, - Weekly wound assessment to include measurements and description of wound status, - Follow up with wound doctor as scheduled, - Multipodus boot to left lower extremity. On 11/24/14 the Wound Care Specialist evaluated the Pressure Ulcer of the right heel which measured 1.0 cm long x 1.6 cm wide x 0.1 cm deep with no exudate. The left heel remained with unstageable necrosis and measured 4.0 cm long x 4.5 cm wide with light serous drainage and thick adherent black necrotic tissue (eschar) 100% - Wound progress - deteriorated, as indicated by the wound specialist. On 12/1/14 at 10:35 A.M., the surveyor observed the treatments to the resident's heel ulcers. Nurse #3 removed the multipodus boot and sock from Resident #10's left foot. The Kling dressing was removed, then the foam dressing which contained a moderate amount of sero-sanguineous drainage. The area on the left heel measured 5 cm long x 4 cm wide. The area was 100% black necrotic tissue. The resident's right heel measured 1.9 cm long x 2.2 cm wide x 0.2 cm depth. There were no issues with the dressing change. On 11/25/14 at 3:00 P.M. the surveyor observed the resident sitting in the wheelchair in the hallway near the nursing station. The resident had an alarm on in the wheelchair, and the left multipodus boot on. On 12/1/14 at 10:30 A.M., the resident was lying in bed with the left multipodus boot on. On 12/1/14 at 4:40 P.M., the resident was sitting in the wheelchair with the alarm on. The multipodus boot was on the left foot as planned. The resident had a slipper on the right foot. On 12/4/14 at 10:45 A.M., the surveyor interviewed the resident's family member. The family member was aware of the resident's pressure ulcers on the left and the right heels. The family member stated to the surveyor that he/she believed the cause of the pressure ulcers was that the resident removed the insoles from the diabetic shoes which caused the shoes to be a little too big and caused friction.

Based on observation, record review, and staff interviews, the facility failed to provide adequate supervision and effective interventions to prevent accidents for 2 of 11 applicable residents (#1, and #2) out of a total sample of 22 residents. Findings include: 1. For Resident #1, the facility failed to provide effective interventions and adequate supervision to prevent falls in order to provide an effective falls intervention program. The resident had 4 falls between 6/11/14 and 8/14/14, two of which resulted in fractures and lacerations requiring sutures. Resident #1 was admitted to the facility in 4/2013 with [DIAGNOSES REDACTED]. Review of an Annual Minimum Data Set (MDS) Assessment, completed on 4/21/14, indicated that the resident had severely impaired cognition, required extensive assist of one for transfers, ambulation, locomotion in the room, dressing, toilet use, hygiene and bathing, utilized a walker and a wheelchair, was continent of bowel and bladder, had no falls since the last assessment, and received antianxiety and antidepressant medications. Review of the plan of care for falls due to the resident's impaired mobility, use of psychotropic medications, visual deficit, and generalized weakness, dated 3/25/14, included the following interventions: - Assess for changes in medical status, pain status, mental status and report to MD as indicated, - Dycem in wheelchair at all times, - Low bed and fall mats, - Weight Bearing As Tolerated (WBAT) right lower extremity, - Resident to wear non-slip footwear, - Evaluate effectiveness and monitor for side effects of psychotropic drugs as needed (prn), - Educate resident on safety risks, - Fall assessment quarterly and prn, - Assist resident with ambulation providing extensive assistance using a rolling walker and gait belt, - Place call light within reach at all times, - Remind resident to use call light when attempting to ambulate or transfer, resident transfers self frequently, - Maintain a clutter free environment in the resident's room and consistent furniture arrangement, - When the resident is in bed, place all necessary personal items within reach. Review of a Fall Risk Evaluation, dated 6/11/14, indicated that the resident scored "9". (Score of 12 or above indicates high risk for fall). Review of a nursing note, dated 6/11/14, indicated that the resident slipped and fell at 11:05 A.M. while self transferring from the bed to the chair. The bed/chair alarms had been discontinued on 1/24/14 due to the resident turning them off consistently. The resident was complaining of pain to the right shoulder and the right hip, so was sent to the hospital for an x-ray. The resident returned at 3:30 P.M. X-rays were negative. The resident did sustain a large bruise to the right forearm and bruising and swelling to the right hip, with complaints of discomfort. Scheduled Ultram was given with positive effect and a intervention for the bed and chair alarms were added to the plan of care. Review of a nursing note, dated 6/30/14, indicated that the bed and chair alarms were discontinued due to the resident's non-compliance and increased agitation from the noise of the alarm. The note indicated that the resident continued to attempt to ambulate independently and disconnect alarms. the nursing note continued with, "Discussed with pt (patient) risk and benefit of alarms. Grip tape applied to floor between bed and bathroom as alternate intervention." Review of a nursing note of 7/15/14 indicated that at 4:35 A.M. the resident was screaming, "Help Me". The resident was found on the floor in the room face down. Staff turned the resident over on his/her back. The resident stated he/she did not lock the wheelchair. Resident required 1 assist from bed to chair to transfer. The resident was complaining of excruciating pain all over. A laceration and hematoma was noted to the left eyebrow with left facial bruising, and a left knee abrasion. The Paramedics transferred the resident to the hospital at 4:50 A.M. The resident returned to the facility on [DATE] at 12:30 P.M. with 6 sutures for closure to the left forehead laceration, a left side hematoma, and the left eye closed shut. The resident also had a Left TMJ (Temporomandibular Joint) displacement (broken jaw). New interventions added to the plan of care included: - Bed alarm to bed to alert staff members of resident's need to ambulate, - Chair alarm to chair/wheelchair to alert staff members of resident's need to ambulate, - PT (Physical Therapy) Evaluation, and Therapy to assess for the need for automatic brake locking mechanism, - Follow up with Cardiology, - Monitor neurological checks. Review of a Fall Risk Evaluation, dated 7/15/14, indicated that the resident scored "18". (Score of 12 or above indicates high risk for fall). Review of a Quarterly MDS Assessment, completed on 7/18/14, indicated that the resident had impaired vision and wore glasses, required extensive assist of two for transfers and ambulation, had 1 fall with injury except major, 1 fall with major injury, had occasional pain, and received antidepressant medications. A Significant Change of Status MDS was completed on 8/1/14 due to the above decline in the resident's status. The MDS remained basically the same. The resident had no falls since the MDS of 7/18/14. Nursing note of 7/23/14 indicated the resident remained non-compliant with alarms, trying to get out of bed and up from the wheelchair. Increased supervision required. On 7/25/14 the resident was admitted to hospice services. On 8/10/14 at 10:30 P.M., the resident had an unwitnessed fall in his/her room. The alarm was sounding, the CNA responded and found the resident on the floor beside the bed. The resident stated he/she had to go to the bathroom. The resident had been checked at 10:00 P.M. Upon toileting the resident, a bruise was assessed on the resident's mid left lateral back measuring 8 cm x 4 cm. Review of a nursing note of 8/14/14 indicated that the resident had an unwitnessed fall while alone in the room in the wheelchair at 2:30 P.M. The nurse was notified by the CNA after the CNA, "...came down the hall to find (the resident) on the floor." Further review of the investigation revealed that the chair pad alarm did not sound, because the alarm pad was placed under the pressure reduction cushion. The resident was on the floor with his/her head leaning against the wall. The resident was bleeding from the right ear, and a skin tear was noted to the right elbow. The resident was complaining of neck, right wrist, and right ear pain. The resident was sent to the emergency room for an evaluation. The resident was re-admitted to the facility on [DATE] at 9:40 P.M. with a right wrist fracture, right hand splint with immobilizer, and follow-up appointment with wrist surgeon on 8/18/14. The resident also had 3 sutures to the right ear for closure with bleeding, and an order to hold the anti-platelet medication Plavix, until the right ear bleeding stopped and no non-steroidal anti-inflammatory drugs until further notice. The resident also had a right elbow skin tear with dressing change orders. The resident was diagnosed with [REDACTED]. The care plan was updated to include: - Perimeter mattress to bed, - Staff to provide increased supervision at nursing station while not in bed, - Provide diversional activities as tolerated. Review of a Fall Risk Evaluation, dated 8/14/14, indicated that the resident scored "21". (Score of 12 or above indicates high risk for fall). On 9/4/14 the falls care plan was updated to include an alarmed Velcro belt when in wheelchair, resident is able to self release per assessment. Review of a Fall Risk Evaluation dated 10/31/14 indicated that the resident scored "27". (Score of 12 or above indicates high risk for fall). Review of a Quarterly MDS Assessment completed on 10/31/14 indicated that the resident had moderately impaired cognition, adequate vision with glasses, required extensive assist of one for transfers, bed mobility, dressing, and bathing, required limited assist of one for ambulation, locomotion, and hygiene, had 1 fall with injury except major, and 1 fall with major injury, and received antianxiety and antidepressant medications. The surveyor observed the resident on 11/25/14 at 9:00 A.M. sitting in the wheelchair in the room by the bed. The resident had a Velcro self release seat belt on. On 12/1/14 at 9:45 A.M., the surveyor observed the resident sitting in the room with the self releasing Velcro belt on. The resident was watching television. The resident was able to release the alarmed Velcro seat belt. During an interview on 12/4/14 at 1:50 P.M. with the Director of Nursing (DON), she said the resident had 4 falls between 6/11/14 and 8/14/14. The DON indicated that the resident was non-compliant with the bed and chair alarms, and would transfer him/herself independently without assistance. The DON was not able to provide the surveyor with any other information. 2. For Resident #2, the facility failed to provide adequate supervision and assistive devices to prevent 7 unwitnessed falls in the bedroom, 3 of which resulted in injuries. Resident # 2 was admitted to the facility in 10/2013 with [DIAGNOSES REDACTED]. Review of the facility's Fall Management Policy, dated 6/1/96 and revised 9/1/13, indicated the following; -Reduce the risk for falls and minimize the actual occurrence of falls. -Identify patients fall risk by reviewing the Fall Risk Evaluation and those with scores of 12 or greater are at a high risk of falls. -Develop an individualized plan of care, and review and revise it regularly. Review of the Admission Nursing assessment dated [DATE], indicated the resident was not steady and only able to stabilize with human assistance when; -moving from seated to standing position, -walking, -turning around, -moving on and off the toilet, and -surface-to-surface transfer. Review of the care plan, "Risk for Falls....", dated 10/29/13, indicated the following interventions; -Assist resident getting in and out of bed with 1 assistance using a rolling walker, -Assist resident with ambulation providing 1 assistance using a rolling walker, -Resident to wear non slip footwear, and -Place call light within easy reach of resident. Review of the Fall Risk Evaluation, dated 10/29/13, indicated a score of 6 (a score of 12 or above indicates a high risk for fall). Review the Risk Management System form, dated 11/3/13, indicated the resident had an unwitnessed fall in his/her room at 1:45 P.M. The report indicated the resident was trying to self transfer from the wheel chair to the bed when the wheel chair rolled back and he/she fell to the floor. The resident was not injured. The resident was educated on safety risks, reminded to use the call light prior to ambulating or transferring, and had dycem added to the wheelchair. Review of the Fall Risk Evaluation, dated 11/3/13, had a score of 7 (a score of 12 or above indicates a high risk for fall). Review of the Admission MDS Assessment, dated 11/4/13, indicated the resident had moderate cognitive impairment, required extensive assistance for transfer, dressing, toilet use, hygiene and bathing and required limited assistance for bed mobility. Review of the Activity of Daily Living (ADL) Care Area Assessment (CAA) Worksheet, dated 11/8/13, indicated the resident had physical limitations for dressing, bathing, toileting, locomotion, transfer and eating due to weakness, limited range of motion, poor coordination and balance, visual impairment and pain. Review the Risk Management System form, dated 1/13/14, indicated the resident had an unwitnessed fall in his/her room at 11:50 A.M. The report indicated the resident was ambulating in his/her room, and attempted to sit in the wheel chair which moved and he/she fell to the floor. The resident sustained [REDACTED]. The resident was re-educated to lock both sides of the wheel chair, and was referred to therapy. Review of the Fall Risk Evaluation, dated 1/8/14, had a score of 9 (a score of 12 or above indicates a high risk for fall). Review of the Quarterly MDS Assessment, dated 2/4/14, indicated the resident had moderate cognitive impairment, required extensive assistance for toilet use and bathing, required limited assistance for transfers, walking in room/corridor, dressing and personal hygiene. Review of the Risk Management System form, dated 2/27/14, indicated the resident had an unwitnessed fall in his/her room at 9:15 A.M. The report indicated the resident lowered the bed to the lowest position and was attempting to put on his/her stockings. The bed moved and he/she slid to the floor. The resident was not injured. The resident was instructed on the use of the bed controls and to not lower the bed to the floor. Additionally, a referral was made to maintenance to see if the equipment could be altered to decrease slipping. Review of the Fall Risk Evaluation, dated 2/27/14, had a score of 11 (a score of 12 or above indicates a high risk for fall). Review of the Fall Risk Evaluation, dated 3/8/14, had a score of 13 (a score of 12 or above indicates a high risk for fall). Review of the Interdisciplinary Therapy Screen form, dated 3/9/14, indicated the resident was screened by therapy and was educated on the importance of non-skid socks. Review the Risk Management System form, dated 4/2/14, indicated the resident had an unwitnessed fall in his/her room at 6:45 P.M. The report indicated the resident was found lying on the floor and said he/she tripped over something, but nothing was obstructing the area. The resident was not injured. The resident's environment was to be maintained as clutter-free, and staff were to assist the resident getting in and out of bed. Review of the Fall Risk Evaluation, dated 4/29/14, had a score of 13 (a score of 12 or above indicates a high risk for fall). Review of the Interdisciplinary Therapy Screen form, dated 5/1/14, indicated the resident was reapproached to assess balance and safety inside the room secondary to frequent falls. The report indicated the patient declined therapy and therapy discussed the importance of clearing any clutter around the bedside and importance of wearing non-skid socks or shoes when out of bed. (Per the same Therapy Screen form, therapy attempted to see the patient on 2/4/14 and 4/3/14 but was unable as he/she was at dialysis). Review of the Quarterly MDS Assessment, dated 5/2/14, indicated the resident was cognitively intact, required extensive assistance for dressing, toilet use, personal hygiene and bathing and required limited assistance for transfers and walking in room/corridor. Review of the Fall Risk Evaluation, dated 5/29/14, indicated a score of 13 (a score of 12 or above indicates a high risk for fall). Review the Risk Management System form, dated 5/29/14, indicated the resident had an unwitnessed fall in his/her room at 3:45 P.M. The report indicated the resident was found lying on the floor and said he/she sat on the floor. The resident sustained [REDACTED]. Shurtape (non-skid adhesive strip tape) was applied to the floor at the bedside. Review of the Fall Risk Evaluation, dated 7/18/14, had a total score of 13 (a score of 12 or above indicates a high risk for fall). Review of the Quarterly MDS Assessment, dated 8/5/14, indicated the resident had moderate cognitive impairment, required extensive assistance for dressing, personal hygiene and bathing, required limited assistance for transfers, toilet use and walking in room/corridor. Review of the Fall Risk Evaluation, dated 8/5/14, had a total score of 16 (a score of 12 or above indicates a high risk for fall). Review the Risk Management System form, dated 8/10/14, indicated the resident had an unwitnessed fall in his/her room at 9:00 A.M. The report indicated the resident was found sitting on the floor. The resident's shoes were on the floor in front of him/her. The resident was not injured. The resident was referred to rehabilitation services. Review of the clinical record indicated there was no further therapy interventions at this time. Review of the Change in Condition Progress note, dated 9/15/14, indicated the resident had a unwitnessed fall at 6:55 A.M. in his/her room. The note indicated the resident was found on the floor beside the bed. The resident said he/she tripped over something while making the bed. The resident complained of leg and rib pain, and sustained a skin tear to the right wrist and two skin tears to the left elbow. The resident was transferred to the hospital where it was determined he/she had a left hip fracture that required surgical repair. On 11/25/14 at 1:30 P.M., Resident #2 was observed lying in his/her bed on an air mattress. The head of the bed was elevated, the resident's eyes were closed and a wheelchair was near the right side of the bed. The surveyor observed non-skid strips on the floor, on the right side of the bed. During an interview on 12/2/14 at 1:30 P.M. with the DON, she said the resident had been educated to help maintain safety but he/she wasn't compliant. The DON said that she did not think the resident would like having anyone watch and supervise her while he/she was in her room. During an interview on 12/2/14 at 1:45 P.M. with the Assistant DON and UM #1, they said the resident was at risk of falls due to his/her non-compliance with previously implemented interventions and education after the falls, and his/her poor safety awareness. They could not answer how supervision and effective interventions were provided, or how his/her non-compliance to safety interventions were addressed to prevent 7 unwitnessed falls in the bedroom.

Based on record review and interviews, for one of three sampled residents (Resident #1), the Facility failed to 1) on 11/2/13, adequately monitor Resident #1 per plan of care for [MEDICAL CONDITION] activity while in his/her bedroom with the door closed per his/her request; 2) properly position Resident #1 in a recovery position when found on the floor in a a [MEDICAL CONDITION] state, 3) immediately call Advanced Life Support (911) and the on call Physician on 11/2/13 at 6:15 A.M. when Resident #1 experienced a [MEDICAL CONDITION] about 25 minutes, 4) have staff remain at the bedside while Resident #1 actively seized from 6:32 A.M. until the ambulance arrived at 7:13 A.M. and transferred Resident #1 to the Hospital at 7:19 A.M. The Hospital Discharge Instructions, dated 11/5/13, indicated Resident #1 was treated for [REDACTED]. Findings include: The Admission Record, dated 7/10/13, indicated that Resident #1 was admitted to the Facility June 2013 and had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment (MDS), dated [DATE], indicated that Resident #1 was alert and oriented. The MDS indicated that Resident #1 had behavioral symptoms that included behavioral symptoms toward others. The MDS indicated that Resident #1 required limited assistance when ambulating while using a walker. The MDS indicated that Resident #1 was independent during bed mobility, transfers, toileting, and all personal hygiene needs. Nurse #1 was interviewed at 7:10 A.M. on 11/20/13. Nurse #2 was interviewed at 8:00 A.M. on 11/20/13. Nurse #1 and Nurse #2 said they were assigned to Resident #1's nursing care needs during the night (11:00 P.M. to 7:00 A.M.) shift. Nurse #1 said she was assigned to Resident #1's nursing care needs during the night (11:00 P.M. on 11/1/13 to 7:00 A.M. on 11/2/13) shift. Nurse #1 said she had not cared for Resident #1 in the past. Nurse #1 said she did not instruct staff to check on Resident #1, even though his/her bedroom door was closed, per his request between 11:00 P.M. and 5:00 A.M., because she was told by Nurse #2 Resident #1 requested his/her door shut at bedtime. Nurse #2 said he told Nurse #1 that Resident #1 was allowed to keep his/her door shut during the night shift, per his/her request, but denied that he told Nurse #1 not to open Resident #1's door to do safety rounds and provide care as needed. Nurse #2 said he had staff open Resident #1's door every 45 minutes to ensure he/she was safe due to his/her history of [MEDICAL CONDITION]. Certified Nurse Assistant (CNA) #1 was interviewed at 11:25 A.M. on 11/20/13. CNA #2 was interviewed at 4:00 P.M. on 11/20/13. CNA #1 and CNA #2 said they worked as a team on the night (11:00 P.M. to 7:00 A.M.) shift. CNA #1 and CNA #2 said they were told not to open Resident #1's door during the night shift per his/her request. Nurse #1 said she told CNA #2 to check on Resident #1 during morning (5:00 A.M.) rounds because she was concerned that he/she was not supervised all shift and was on [MEDICAL CONDITION] precautions. Nurse #1 said she did not maintain [MEDICAL CONDITION] precautions, between 11:00 P.M. and 5:15 A.M., per the plan of care because Resident #1 requested that his/her door remain closed. CNA #2 said she found Resident #1 face down on his/her bedroom floor when she opened his/her bedroom door at 5:15 A.M. on 11/1/13. CNA #2 said Resident #1 had right sided facial twitching and Nurse #1 was summoned for assistance. The night (11:00 PM on 11/1/13 - 7:00 AM on 11/2/13) shift nurse's note indicated that at 5:15 A.M. Resident #1 was found face down on the floor by his/her bed in a postictal state The nurse's note indicated that Resident #1 was, initially unresponsive, his/her eyes were unfocused, but equal and reactive to light.The nurse's note indicated that Resident #1 had an abrasion on the left elbow, and no other apparent injury. The nurse's note indicated Nurse #2 was summoned for assistance and he and Nurse #3 responded and assisted with the assessment and the transfer of Resident #1 back to bed. The nurse's note indicated that the on call physician's answering service was notified of the fall at 5:55 A.M. Nurse #1 said that the fall and postictal state (confusion that followed a [MEDICAL CONDITION]) was reported to the answering service and that she told the answering service the on call physician did not have to call back, because there was no injury that required treatment and the unwitnessed [MEDICAL CONDITION] had resolved. Nurse #1 said she positioned Resident #1 on his/her back in bed and at 5:30 A.M. directed CNA #1 to remain at Resident #1's bedside for one hour to monitor for further [MEDICAL CONDITION] activity and maintain his safety. CNA #1 said she remained at Resident #1's bedside for about one hour and that he/she had continual right sided twitching and she reported the [MEDICAL CONDITION] activity to Nurse #1. The night (11:00 PM on 11/1/13 - 7:00 AM on 11/2/13) shift nurse's note indicated that at 6:10 A.M. Resident #1 was alert, verbal, and unaware of the incident. Nurse #1 denied that Resident #1 had right sided facial twitching or any witnessed [MEDICAL CONDITION] activity before 6:15 A.M. The night (11:00 PM on 11/1/13 - 7:00 AM on 11/2/13) shift nurse's note indicated that at 6:15 A.M. Resident #1's neurological signs were within normal limits (WNL) and at that time he/she began to have right sided facial twitching and right sided upper body twitching that lasted for 15 minutes, stopped for two minutes, and [MEDICAL CONDITION] re-started (at 6:32 A.M.). CNA #1 said Nurse #1 said she had to assist CNA #2 with other residents' care needs at about 6:30 A.M. and she left Resident #1 alone at that time. CNA #1 said Resident #1 was actively seizing when she left him lying alone in bed. Nurse #1 said the [MEDICAL CONDITION] that re-started at 6:32 A.M. included Resident #1's right leg. The night (11:00 PM on 11/1/13 - 7:00 AM on 11/2/13) shift nurse's note indicated that at 6:40 A.M. a message was left for the on call physician and the on call physician returned the call at 6:55 A.M. with new orders to transfer Resident #1 to the emergency room . The nurse's note indicated that the ambulance was called at 7:00 A.M., arrived at 7:15 A.M., and Resident #1 transferred to the emergency room at 7:20 A.M. Nurse #1 said Resident #1 was left alone in bed from approximately 6:32 A.M. until the Ambulance arrived at about 7:15 A.M. Nurse #1 said she had to complete paperwork for the transfer. Nurse #1 said she would have called 911 (ALS) rather than the contracted ambulance if Resident #1 had grand mal (a loss of consciousness and the body's muscles have rhythmic contractions alternately flexing and relaxing) [MEDICAL CONDITION] because she did not believe that one sided (rhythmic jerking of the face, one arm, and one leg) [MEDICAL CONDITION] were life threatening. Emergency Medical Technician (EMT) #1 was interviewed at 11:00 A.M. on 11/20/13. EMT #1 said 911 (Advanced Life Support) should have been called by the Facility because when he arrived at 7:13 A.M. he found Resident #1 lying on his/her back, with no staff present, while having a grand mal [MEDICAL CONDITION] and EMT #1 said he was told by Nurse #1 that he/she had been actively seizing for 45 minutes. The Director of Nurses (DON) was interviewed at 8:30 A.M. and 4:30 P.M. on 11/20/13. The Medical Director was interviewed at 9:00 A.M. on 11/25/13. The DON and Medical Director said Resident #1 should have been monitored (door should have been opened as needed) for [MEDICAL CONDITION] precautions during rounds between 11:00 A.M. and 5:15 A.M.) per the plan of care. The emergency room Report, dated 11/2/13, indicated that Resident #1 arrived in the emergency room at 7:26 A.M. actively seizing with [MEDICAL CONDITION](an abnormal rapid heart rate of greater than 100 beats per minute), was administered [MEDICATION NAME] (anxiolytic medication used to treat [MEDICAL CONDITION] activity) 2 milligrams intravenously with a good effect, and was admitted for further evaluation. The Hospital Discharge Instructions, dated 11/5/13, indicated that Resident #1 was treated for [REDACTED]. The Medical Director said Resident #1's [MEDICAL CONDITION] was most likely due to the effects of the prolonged [MEDICAL CONDITION] activity that occurred at the Facility and enroute to the Hospital without necessary treatment provided.

Based on observation, record review and staff interview, the facility failed to ensure that one resident (#21) in a total sample of 24, received medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Resident #21 was cognitively impaired with [DIAGNOSES REDACTED]. The resident received Zoloft (antidepressant), 75 milligram (mg.), Ativan (anti-anxiety) .5 mg. three times a day and Ambien (sedative) 10 mg. daily at hours of sleep. A review of the medical record revealed that on 4/4/13, the physician ordered a psychiatric consult for increased depression/crying. On 4/10/13, during an Initial Evaluation with the psychiatric consultant the resident stated that appetite was, "not too good," sleep was, "fair" and mood was effecting functioning. The resident stated, "I'm discouraged. I was doing good." The consultant's report stated a psychopharmacology evaluation would be scheduled and questioned whether the resident needed another medication. The resident had said, "I'm not sure if the medicine is working." Also, the consultant recommended that his/her agency follow the resident for support for 4 - 6 sessions over the next 90 days (pending resident's insurance). A review of the medical record revealed that the physician was not notified of the above recommendations and the resident did not receive the services. The resident had an annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 3/12/13 that indicated the following: the resident had the lowest possible mood score of, "1" and no behavioral problems. Also, the resident scored, "12" in cognition. (A score of 15 is the highest possible score and indicate the resident is alert and oriented.) The significant change MDS with an ARD of 6/10/13 indicated the resident had a mood score of, "0" (minimal depression) and no behavioral problems. The resident declined to a score of " 8" (moderately impaired) in cognition. A nursing note dated 6/28/13 at 1:30 P.M., indicated that a Care Plan Meeting was held and that the "resident has had a significant decline in ADL's, refuses to get out of bed, has had increased depression and is requiring more assist from staff. Will continue to monitor." Care Plans for psychosocial issues and psychiatric medication were as follows: (A) The Care Assessment Area for the MDS dated [DATE], stated psychosocial issues would be addressed in activities. The Activity Care Plan dated 4/12/12, stated that the resident had decreased involvement in activities and prefers to stay in the room. The care plan was not updated following the significant change MDS of 6/10/13. The interventions were as follows: activity staff to visit 1:1, 3 times a week; assist resident in planning leisure-time activities. Encourage resident to plan own leisure time activities; encourage resident to participate in activities; and give resident verbal reminders before activities start. This was the only care plan to address mood and psychosocial issues despite the resident's increased depression documented in the psychiatric consultants evaluation and the nursing note of 6/28/l3. As indicated below, the resident's activity level did not increase with this plan. Activity notes of 2/8/13, 5/3/13 and 6/29/13, all indicated that the resident prefers to stay in the bedroom, refuses group activities, gets along well with roommate and accepts 1:1 visits from activity staff. A review of the quarterly MDS with an ARD of 9/4/13, revealed a mood score was, "2" (minimally depressed), and improved cognition of "11" (moderately impaired). (2) The care plan dated 9/17/13, for psychiatric drugs had the following intervention: "psych consults as needed." On 9/26/13, Resident #21 was observed in bed throughout the day. At 2:10 P.M. the resident stated that she/he prefers to stay in bed. During interview on 9/26/13 at 12:00 P.M., the Director of Social Services (DSS) contacted the psychiatrist for the consultant agency who was in the building. The psychiatrist stated follow-up services were not provided to the resident in April 2013 as recommended because the resident had a hospitalization around the time of the Initial Evaluation (4/10/13) so the agency discontinued services to the resident. A review of the the medical record on 9/26/13 at 12:15 P.M., with the DSS revealed that the resident did not have a hospitalization during that time period. The last social service note in the medical record was dated 9/14/12. Following interview with the DSS, social worker (SW) #2 provided a note dated 9/4/13. Both social workers stated there had not been a full time social worker in the facility from January 2013 to April 2013. The facility had used an agency to provide two temporary social workers. SW #2 said that the temporary social workers were there when she started in April 2013 and one would work some days and two would work other days. During interview on 9/26/13 at 1:45 P.M., social worker #2, who was hired around 4/1/13, was asked whether she was aware of Resident #21's increase in depression that occurred during April 2013 and the recommendations of the psychiatric consultant agency. She stated she was not aware. She stated that it was difficult coming into the facility with no steady SW to work with and 2 agency SW staff. She stated that communication with the consultant psychiatric agency suffered without regular staff in the SW department. She stated that this resident was someone who "slipped though the cracks." A review of the medical record revealed there were no social service notes in the chart from 9/14/12 through 9/4/13. There was no indication the resident received supportive counseling or advocacy from any social worker at that time. The assessment of 9/4/13 indicated the resident spent most of the time alone or watching TV per the resident request. The resident was assessed as being, very social with the other residents when he/she does choose to come out of the room and socialize; the resident gets along with roommate; and that long term placement is anticipated due to overall decline. On 9/26/13, Resident #21 was observed in bed throughout the day. At 2:10 P.M. the resident was observed in bed and stated that she/he prefers to stay in bed. Resident #21 had a decline in mood and an increase in depression during April 2013. The social work staff did not develop a care plan to address these declines. According to the medical record, the social work staff did not provide supportive counseling/interventions to address the declines. The social work staff did not ensure that the resident received a needed psychopharmacology evalution and consultant supportive counseling to address depression. The resident declined further, refusing to get out of bed. The facility failed to provide medically related social services to ensure that a resident who evidenced a decline in mood received the necessary services to attain their highest level of well-being.

Based on observation, record review and staff interview, the facility failed to ensure that one resident (#21) in a total sample of 24, who displayed mental or psychosocial adjustment difficult received appropriate treatment and services to correct the assessed problem .Findings included: Resident #21 was cognitively impaired with [DIAGNOSES REDACTED]. The resident received [MEDICATION NAME] (antidepressant), 75 milligram (mg.), [MEDICATION NAME] (anti-anxiety) .5 mg. three times a day [MEDICATION NAME](sedative) 10 mg. daily at hours of sleep. A review of the medical record revealed that on 4/4/13, the physician ordered a psychiatric consult for increased depression/crying. On 4/10/13, during an Initial Evaluation with the psychiatric consultant the resident stated that appetite was, "not too good," sleep was, "fair" and mood was effecting functioning. The resident stated, "I'm discouraged. I was doing good." The consultant's report stated a psychopharmacology evaluation would be scheduled and questioned whether the resident needed another medication. The resident had said, "I'm not sure if the medicine is working." Also, the consultant recommended the his/her agency follow the resident for support for 4 - 6 sessions over the next 90 days (pending resident's insurance.) A review of the medical record revealed that the physician was not notified of the above recommendations and the resident did not receive the services. The resident had an annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 3/12/13 that indicated the following: a) minimum assistance with transfer; b) non-ambulatory in the bedroom, minimum staff assistance with ambulation in the hallway, minimum staff assistance with wheelchair ambulation on the unit and extensive staff assistance with wheelchair ambulation off the unit; and extensive staff assistance with Activities of Daily Living (ADL's). The MDS indicated the resident had a mood score of, "1" (minimally depressed) and no behavioral problems. Also, the resident scored, "12" (moderately impaired) in cognition. The significant change MDS with an ARD of 6/10/13 indicated a decline in the following areas: a) extensive assistance with transfer; b) non-ambulatory in the bedroom, non-ambulatory in the hallway, extensive staff assistance with wheelchair ambulation on the unit and non-ambulatory in wheelchair ambulation off the unit. In addition, the MDS indicated the resident had a mood score of, "0" and no behavioral problems. The resident declined to a score of " 8" (moderately impaired) in cognition. A nursing note dated 6/28/13 at 1:30 P.M., indicated that a Care Plan Meeting was held and that the "resident has had a significant decline in ADL's, refuses to get out of bed, has had increased depression and is requiring more assist from staff. Will continue to monitor." Care Plan for psychosocial issues, decline and ADL's and psychiatric medications were as follows: (A) The Care Assessment Area for the MDS dated [DATE], stated psychosocial issues would be addressed in activities. The Activity Care Plan dated 4/12/12, stated that the resident had decreased involvement in activities and prefers to stay in the room. The interventions were as follows: activity staff to visit 1:1, 3 times a week; assist resident in planning leisure-time activities. Encourage resident to plan own leisure time activities; encourage resident to participate in activities; and give resident verbal reminders before activities start. This was the only care plan to address mood and psychosocial issues despite the resident's increased depression documented in the psychiatric consultants evaluation and the nursing note of 6/28/l3. Activity notes of 2/8/13, 5/3/13 and 6/29/13, all indicated that the resident prefers to stay in the bedroom, refuses group activities, gets along well with roommate and accepts 1:1 visits from activity staff. (B) The care plan for ADL's stated the resident had a self care deficit secondary to legally blind, pain related to chronic [DIAGNOSES REDACTED]s and chronic interstitial [MEDICATION NAME]. On 4/11/13, the resident was screened by the physical therapist, for the second time in April 2013, and the resident refused services saying, she/he was not, "interested", in therapy at this time due to both knees buckling and she/he prefers 2 staff assists with transfers due to a fear of falling. The plan was to rescreen as needed pending change in resident's motivation to participate. During interview on 9/26/13, the Director of Nurses (DON) stated that the physical therapy department had not rescreened the resident due to past refusal of services. The DON stated that the resident was reviewed during August 2013 during rehabilitation rounds due to a decline in ADL's and rehabilitation services were not provided due to the resident's desire to stay in bed and refusal of rehabilitation services in the past. A review of the quarterly MDS with an ARD of 9/4/13, revealed that the resident no longer ambulated at all in the facility. His/her mood score was, "2", and cognition had improved to "11". (C) The care plan for psychiatric drugs had the following intervention: "psych consults as needed." On 9/26/13, Resident #21 was observed in bed throughout the day. At 2:10 P.M. the resident stated that she/he prefers to stay in bed. Resident #21 experienced an increase in depression and a subsequent decline in ADL's. The facility failed to provide services to address the depression and the resident experienced further decline in mood and ambulation. The resident refused services to address declines in ambulation and chose to stay in bed.