Every finding on record at OC Reading Center LLC

Based on observations and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically, the facility failed to ensure medications were stored according to manufacturer's guidelines in three of three medication carts observed. Findings include: Review of the facility policy titled, Storage of Medications, dated as revised August 2025, indicated that medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the suppliers. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. I. General Guidance 8. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. II: Temperature 4. Medications requiring refrigeration are kept in a refrigerator at temperatures between 36 F (2 C) and 46 F (8 C) with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. Controlled substances that require refrigeration are stored within a locked box within the refrigerator that is attached to the inside of the refrigerator or in accordance with state regulations and facility policy.III: Expiration Dating (Beyond-Use Dating) 1. Expiration dates (beyond-use dates) of dispensed medications shall be determined by the pharmacist at the time of dispensing.2. Drugs dispensed in the manufacturer's original container will be labeled with the manufacturer's expiration date.3. Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmic, nitroglycerin tablets, and blood sugar testing solutions and strips require an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency.5. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated.a. The nurse shall place a date opened sticker on the medication and record the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days from opening, unless the manufacturer recommends another date or regulations/guidelines require different dating.b. If a vial or container is found without a stated date opened, the date opened will automatically default to the date dispensed and the expiration date will be calculated accordingly, unless otherwise indicated in a facility-specific 1. On 12/29/25 at 10:46 A.M., the surveyor observed the following on the second-floor front cart: - one bottle of acidophilus capsules opened, manufacturer's guidelines indicate to refrigerate once opened.- one glargine insulin vial, unopened, manufacturer's guidelines indicated to refrigerate until opened. - three insulin lispro vials, opened and undated, manufacturer's guidelines indicated good for 28 days once opened.- one tirzepatide injection pen, opened and undated, manufacturer's guidelines indicate good for 30 days once opened. - two umeclidinium inhalers, opened and undated, manufacturer's guidelines indicated good for 6 weeks once opened. - one tresiba injection pen, opened and undated, manufacturer's guidelines indicated good for 8 weeks once opened. During an interview on 12/29/25 at 10:52 A.M., Nurse #1 said nursing should label and date medications based on manufacture's guidelines. 2. On 12/29/25 at 10:53 A.M., the surveyor observed the following on the second-floor back cart: - two bottles of acidophilus capsules opened, manufacturer's guidelines indicated to refrigerate once opened. - one umeclidinium and vilanterol, opened and undated, manufacturer's guidelines indicated good for 6 weeks once opened. - one insulin glargine pen, opened and undated, manufacturer's guidelines indicated good for 28 days once opened.- one fluticasone furoate, umeclidinium and vilanterol inhaler, opened and undated, manufacturer's guidelines indicated good for 6 weeks once opened. During an interview on 12/29/25 at 10:59 A.M., Nurse #2 said nursing should label and date medications based on manufacture's guidelines. 3. On 12/29/25 at 11:01 A.M., the surveyor observed the following on the third-floor front cart: - one bottle of acidophilus capsules opened, manufacturer's guidelines indicated to refrigerate once opened.- one glargine insulin vial, opened and undated, manufacturer's guidelines indicated good for 28 days once opened.- one insulin lispro vial, opened and undated, manufacturer's guidelines indicated good for 28 days once opened.- one glargine insulin pen, unopened, manufacturer's guidelines indicated refrigerate until opened. - two bottles of liquid lorazepam, opened and not refrigerated, manufacturer's guidelines indicated to refrigerate. During an interview on 12/29/25 at 11:08 A.M., Nurse #3 said nursing should label and date medications based on manufacture's guidelines. During an interview on 12/29/25 at 11:11 A.M., the Director of Nursing said that nursing should label and date medications according to manufacturer's recommendations. The DON said that medications should be discarded according to manufacturer's guidelines.

Based on observations and interviews, the facility failed to ensure that Residents were provided with a dignified existence on two of two units. Specifically, the facility failed to:1. Ensure that staff members were not using their personal cellphones in Resident areas with Residents present. 2. Ensure that staff members were not speaking a foreign language to each other in front of Residents who do not speak that language.Findings include: Review of the facility policy titled Resident Rights, dated and revised January 2025, indicated the following: - All residents will be treated with kindness, respect, and dignity based on established Resident Rights. - Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness and dignity. 1. The surveyor made the following observations: On 12/29/25 at 2:08 P.M. in the second-floor dining room, a Certified Nursing Assistant (CNA) was sitting in the corner of the room using her personal cell phone with multiple Residents in the dining room within view of the CNA, the CNA was not engaging with the Residents. On 12/29/25 at 2:28 P.M., the surveyor walked past a Resident's room who was on a one-to-one observation, there were two CNA's sitting in the room with the Resident present and lying in his/her bed. One CNA was sitting with a bedside table in front of her with her personal cell phone on it. A second CNA was standing next to the sitting CNA leaning over looking at the cell phone. At 2:30 P.M., as the surveyor was walking past the room again, one of the CNA's left the room holding her cell phone and was observed putting it in her side pant pocket. During an interview on 12/30/25 at 2:07 P.M., the Director of Nursing (DON) said staff members should not be on their personal cell phones in Resident areas. The Surveyor showed the DON the photos of staff on their cell phones and she said it was unacceptable. 2. a. During an observation on 12/29/2025 at 10:22 A.M., A.M., on the third-floor unit, a housekeeper entered Resident 20's room. Resident #20 was observed to be seated in a specialized recliner with Certified Nursing Assistant #2 next to him/her. CNA #2 and the housekeeper began speaking in a language that was not English, with Resident #20 in between them as they conversed. The conversation was observed between CNA #2 and the housekeeper and not with Resident #20. Review of Resident #20's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #20's preferred language as English. Further, the MDS indicated Resident #20 scored a 10 out of 15 on the Brief Interview for Mental Status exam, indicating he/she as having moderately impaired cognition. b. On 12/30/25 at 3:15 P.M., on the third-floor unit, two staff were on the opposite side of the nursing desk and could be heard speaking in a language that was not English. The staff were positioned near the entrance to a resident's room, and another resident was observed sitting in a wheelchair right next to the staff, as the staff conversed in another language. During an interview on 12/30/25 at 2:08 P.M., the Director of Nursing (DON) was made aware by the surveyor of staff speaking a language that was not English in front of and in Resident #20's room. The DON said staff should not be speaking to each other in another language around residents, unless it is their preferred language. On 12/30/25 after 3:15 P.M., the DON was made aware of staff speaking a language that was not English at the desk near the entrance to a resident room, which was occupied, and with a resident at wheelchair height right next to the staff. The DON said staff should not speaking in a language that is not English around residents.

Based on observation, record review and interview, the facility failed to ensure professional standards for nutrition were implemented for one Resident (#54), out of a total sample of 19 residents. Specifically, for Resident #54, the facility failed to address a significant weight loss in a timely manner resulting in Resident #54 continuing to lose weight resulting in a severe total loss of body weight of 11.97% in approximately 2 months. Findings include:Review of the facility's policy titled, Weight Assessment and Intervention, revision date March 2022, indicated Resident's weights are monitored for undesirable or unintended weight loss.Weight AssessmentResidents are weighed upon admission and at intervals established by the interdisciplinary team.Weights are recorded in each unit's weight record chart and the individual's medical record.Any weight change of 5% (percent) or more since the last weight assessment is retaken the next day for confirmation. A If the weight is verified, nursing will immediately notify the dietician in writing. Unless notified of significant weight change, the dietician will review the weight record monthly to follow individual weight trends over time.The threshold for significant weight unplanned and undesired weight loss will be based on the following criteria (where percentage of body weight loss+ (usual weight-actual weight/ (usual weight) x 100):1 month- 5% weight loss is significant; greater than 5% is severe.3 months- 7.5% weight loss is significant; greater than7.5% is severe.6 months- 10% weight loss is significant; greater than 10% is severe. Resident #54 was admitted to the facility in May 2025 and has diagnoses that include but are not limited to pain in left hip, difficulty walking, other symptoms and signs involving cognitive functions and awareness, muscle weakness and history of falling.Review of Resident #54's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #54 scored 12 out of 15 on the Brief Interview for Mental Status exam indicating he/she has moderately impaired cognition. Further, the MDS indicated Resident #54 required set up or clean up assistance for eating, is 70 inches in height, weighed 195 pounds and had a weight loss of 5% or more in the last month or 10% or more in the last 6 months and is not on a physician-prescribed weight loss regimen.On 12/29/25 Resident #54 was observed sitting up in a chair in his/her room. Resident #54 had an ensure supplement drink (a nutrition supplement) in front of him/her. When asked about his/her weight he/she said I do not know about my weight. Review of Resident #54's clinical record indicated the following:-A physician's order dated 5/15/25 and discontinued order dated 10/23/25: Regular diet, regular texture, thin liquids consistency. -a [NAME]-Nutritional Assessment Comprehensive dated 5/16/25 type: Admission, which indicated Resident #54's most recent weight dated 5/15/25 as 232.2 with a BMI of 33.3. Goal/Intervention, 1. maintain weight free from significant changes, 2. PO (by mouth) intake to meet daily nutrition and hydration needs, 3. tolerate diet textures as ordered 4. nutritional related labs WNL (within normal limits)Review of Resident #54's documented weights under the results tab in the electronic medical record indicated the following:5/15/25: 232.2 lbs. (pounds)(standing)5/15/25: 232.2 duplicate Lbs. (standing)6/4/25: 215.6 Lbs. (standing)7/14/25: 204.4 Lbs. (standing)7/29/25: 198.8 Lbs. (standing)8/5/25: 198.2 Lbs. (standing)Review of the documented weight dated 5/15/25 of 233.2 Lbs., and the next documented weight dated 6/4/25 of 215.6 Lbs., indicated Resident #54 lost 16.6 pounds, equaling a total loss of body weight of 7.15% in 20 days.Review of the documented weight dated 6/4/25 of 215.6 Lbs., and the next documented weight dated 7/14/25 of 204.4 Lbs., indicated Resident #54 lost 27.8 pounds equaling a total loss of body weight of 11.97% in 60 days, which meets the criteria of severe weight loss.Review of the medical record indicated the next recorded weight on 7/29/25 of 198.8 Lbs. indicated Resident #54 continued to lose weight equaling a total body weight loss of 14.35% since Resident #54's admission to the facility.Review of Resident #54's care plan, date initiated 5/16/25 and revised on 9/23/25 indicated the Resident is at risk for malnutrition related risk d/t (due to) elevated BMI (body mass index) and PMH (past medical history) TBI (traumatic brain injury), falls, OA (osteoarthritis), BPH (benign prostatic hyperplasia), and Asperger's syndrome, Goal: maintain a weight free from significant changes. Interventions include weigh a/o (as ordered), provide diet texture a/o and record % intake-regular with regular texture and thin liquids, PBJ and ice cream [NAME]/DI (lunch and dinner) The interventions were revised dated 9/23/25 which was over 4 months after Resident #54's admission to the facility and over 3 months after the significant weight loss occurred and documented on 6/4/25.The medical record failed to indicate a reweigh was obtained after the 6/4/25 documented weight loss or that a reweigh was documented after further weight loss documented on 7/14/25. Review of the progress notes in Resident #54's medical record from 5/15/25 through 7/13/25 failed to indicate any documentation of the Resident's weight loss, nor did the progress notes indicate the registered dietitian or medical provider were notified of Resident #54's weight loss documented on 6/4/25. A progress note dated 7/14/25 indicated the NP (nurse practitioner) was made aware of weight loss NNO (no new orders) at this time. This note was documented 41 days after Resident #54 experienced a significant total loss of body weight of 7.15% documented on 6/4/25.Review of Resident #54's active and discontinued physician's orders failed to indicate an order to weigh Resident #54 after admission to the facility until 7/21/25, when weekly weights were ordered and after the Resident experienced severe weight loss. Further review of the orders indicated Resident did not have interventions to prevent further weight loss until after 41 days of the significant weight loss documented on 6/4/25.Further review of the medical record failed to indicate Resident #54 was assessed by a registered dietitian until 9/23/25.During an interview on 12/30/25 at 11:43 A.M., Certified Nursing Assistant #2 said the nurses tell them how often to weigh a resident. CNA #2 said some residents are weighed monthly, some weekly and a few daily. CNA #2 said if a resident has a weight loss it is reported to the nurse and a reweight may be taken.During an interview on 12/30/25 at 3:35 P.M., with Unit Manager (UM) #2, who was the nurse who entered the 6/4/25 weight of 215.6 into the medical record, said residents are weighed each month unless they are on hospice. UM #2 said if there is a weight difference of a three-pound loss or gain then a re-weigh is obtained to verify the weight. UM #2 said the medical record will also flag if there is a weight change/loss/gain. UM #2 said the nurse practitioner is informed and an order to be seen by the dietitian would be entered, and they (Registered Dietitian (RD)) will take it from there to assess when a resident is identified for weight loss. UM #2 reviewed Resident #54's weights in the medical record and said at the time she was not the Unit Manager and the Resident was not her primary patient. UM #2 said she entered the weight and did not provide any further follow up.During an interview on 12/30/25 at 4:31 P.M., the Registered Dietitian said she just started at the facility about one month ago. She said generally, the practice for the RD is to assess a resident when they are admitted determining risk factors and develop the plan of care. The RD said some facilities will weigh a resident weekly for 4 weeks then determine a further weight order. The RD said there are many factors that can contribute to changes in a resident's weight. The RD said if a weight loss occurred, she would ask for a re-weigh to verify the weight loss. The RD said if a significant weight loss is identified an assessment should be conducted to dive into the causes, review the care plan and determine interventions. The RD said it would be concerning if a resident continued to trend down in weight loss. The RD said she did not know Resident #54 and that it was her understanding that there was an RD covering at the time.During an interview on 12/30/25 at 4:52 P.M., and 5:41 P.M., the Director of Nursing said she is recently new to the facility and that typically residents are weighed on admission and weekly for the first 4 weeks. The DON said previous weights should be reviewed for any losses or gains and any changes addressed timely. The DON said the weights documented for Resident #54 indicated a significant weight loss. The DON said it was an unexpected weight loss and it should have been addressed when documented on 6/4/25. The DON said Resident #54's weight loss should have been assessed by a registered dietitian, and the medical provider should have been made aware sooner. The DON said the Resident continued to lose weight and could have plateaued earlier with interventions and assessment.

Based on observation, record review, and interviews, the facility failed to provide care and services consistent with professional standards of practice for 1 Resident (#17), out of three applicable residents who require renal dialysis (a life sustaining treatment that helps the body remove extra fluids and waste products from the blood when the kidneys are not able to) out of a total sample of 19 residents. Specifically, the facility failed to ensure for Resident #17 who had a tunneled femoral hemodialysis line (type of vascular access used for hemodialysis, allowing access to the bloodstream for blood filtration in the thigh area), the facility failed to ensure nursing implemented storage of a clamp at bedside in case of emergency in accordance with the physician's order. Findings include: Review of the facility policy titled, End-Stage Renal Disease, Care of a Resident with, dated as revised September 2025, indicated residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care.5. The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis. Resident #17 admitted to the facility in April 2023 with diagnosis including end stage renal disease, dependence on renal dialysis, diabetes, and atrial fibrillation. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/10/25, indicated that Resident #17 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS indicated Resident #17 was independent with activities of daily living and he/she required dialysis. Review of Resident #17's plan of care related to dialysis, dated 9/25/23, indicated:- Observe access site for bleeding every shift.- Assess dialysis access site location/skin integrity every shift. Notify physician of any signs and symptoms of site infection. Review of Resident #17's physician's orders included:- Pressure dressing and clamp at bedside, dated 6/20/24.- Dialysis Catheter Site: a right tunneled femoral hemodialysis line. Monitor every shift for signs and symptoms of bleeding/infection every shift for prevention. Notify physician of abnormal findings, dated 4/10/23.On 12/29/25 at 8:07 A.M., 12/29/25 at 4:14 P.M., and 12/30/25 at 10:13 A.M., the surveyor observed Resident #17 in his/her bed. Resident #17 had a right tunneled femoral hemodialysis line. There was a bag with gauze above Resident #17's bed but there was no clamp inside the bag.During an interview on 12/30/25 at 10:15 A.M., Unit Manager #1 said that Resident #17 has a right tunneled femoral hemodialysis line. Unit Manager #1 said that Resident #17 should have an emergency kit at the bedside including a clamp incase Resident #17's hemodialysis line breaks. Unit Manager #1 said that if hemodialysis line breaks it is a medical emergency and Resident #17 could bleed out (excessive bleeding) and Unit Manager #1 said that if bleeding occurred nursing would need to immediately clamp the hemodialysis line and apply pressure until emergency medical service (EMS) arrives.On 12/30/25 at 10:19 A.M., the surveyor and Unit Manager #1 were unable to locate the clamp in Resident #17's room. Resident #17 said he/she would allow the clamp to be stored in his/her room in the event of an emergency.During an interview on 12/30/25 at 2:12 PM Director of Nursing said that nursing should have ensured that there was a clamp in Resident #17's bedside according to the physician's order. The DON said that the clamp is used in an emergent situation in case the catheter line begins to bleed.

Based on observation, interviews, and record review, the facility failed to ensure a resident with pressure ulcers receives the necessary care and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for one Resident (#2) out of a total sample of 19 residents. Specifically, the facility failed to:Ensure weekly skin checks were being completed for Resident #2 who has a stage 2 pressure ulcer 2. Ensure assessment of a pressure ulcer was being completed. Findings include:Review of the facility policy titled Pressure Ulcers/Skin Breakdown, dated as revised March 2014, indicated:-The nursing staff will assess and document an individual's significant risk factors for developing pressure sores.-The nurse shall describe and document/report the following:a. Full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue. Resident #2 was admitted to the facility in April 2025 with diagnoses including peripheral vascular disease (a circulation disorder), history of cerebral infarction (type of stroke), and vascular dementia.Review of the Minimum Data Set (MDS) assessment dated , 11/26/25, indicated that Resident #2 had a severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 7 out of 15. This MDS also indicated that Resident #2 had a pressure ulcer that was not present on admission. 1.Review of Resident #2's active physician's orders include the following:-Weekly skin checks on Thursdays. Complete weekly skin check UDA (user-defined assessment).-May admit to Hospice as of 8/14/25.Review of Resident #2's plan of care related to falls, dated as initiated on 4/15/25, indicated:-Monitor skin during care and weekly during skin assessments.Review of Resident #2's Norton Scale for prediction risk of pressure ulcer, dated 5/20/25, indicated Resident was a moderate risk for pressure ulcer development as evidenced by a score of 11.Review of Resident #2's skin checks from May 2025 until December 2025 indicated skin checks were performed on:5/4/25,5/6/25, 8/4/25,9/11/25, 9/13,25, 9/15/25, 9/22/25, 10/2/25, 10/16/25,10/24/25, and 12/28/25. Resident #2 had 11 weekly skin checks completed, out of 35 weekly skin checks documented from May 2025 until December 2025. 2. Review of Resident #2's physician orders, dated 10/24/25, indicated:-To area on right heel, cleanse with wound cleanser, pat dry, apply Calcium alginate (a treatment used in highly absorbent, gel-forming wound dressings for moderate to heavy exudate (wound drainage) , promoting moist healing, controlling bleeding, and filling deep wounds), cover with ABD (a large highly absorbent gauze dressing used for heavy-draining wounds) and wrap with Kling (absorbent bandage) daily and as needed.Review of Resident #2's plan of care related to stage 2 pressure ulcer, dated as initiated 10/27/25, indicated:-Administer treatments as ordered and monitor for effectiveness.-Assess/record/monitor wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the physician.Review of Resident #2's wound assessment reports indicated the last report was completed on 10/23/25. The report indicated Resident #2 had a stage 2 pressure ulcer to his/her right heel that measured length=2.50 centimeters (cm) x width=2.50 cm and had no depth. The wound was described as having moderate serosanguineous (mix of blood and fluid from a wound) drainage.Review of Resident #2's wound care specialist's progress note, dated 10/23/25, indicated that the right heel scab had been mechanically debrided (removed tissue from a wound) to better assess the underlying tissue. The wound bed revealed non-granulating tissue (lacks healthy tissue) with areas of purple discoloration, suggestive of early ischemic (lack of blood flow) changes or persistent deep tissue involvement.Review of Resident #2's wound-weekly observation tool, dated 10/23/25, indicated the stage 2 pressure ulcer was worsening and had slough and necrotic (dead tissues) tissue present.Review of Resident #2's medical record failed to indicate any further documentation to describe the stage 2 pressure ulcer to Resident's right heel.During an interview on 12/30/25 at 1:41 P.M., Unit Manager #2 said that Resident #2 was no longer being seen by the wound care specialists as he/she was now on Hospice. Unit Manager #2 said since Resident #2 was on hospice she had been doing wound rounds with Unit Manager #1. Unit Manager #2 said they were not aware that they were supposed to document in the weekly observation tool. Unit Manager #2 said she was not aware that skin checks had not been completed for Resident #2, and they should be.During an interview on 12/31/25 at 8:00 A.M., the Director of Nursing (DON) said that weekly skin checks should be completed so that staff are aware if a Resident is developing any new open areas. The DON said that residents with wounds should also have a weekly wound assessment completed and documented so that staff is monitoring if the wound is improving or getting worse.

Based on record review and interview, the facility failed to develop and implement an effective baseline person-centered care plan within 48 hours from admission to the facility for one Resident (#76) out of a total sample of 19 residents. Specifically, Resident #76 was admitted to the facility due to a fall, Resident #76 sustained a fall four days after admission, and a falls care plan was not developed or implemented until four days after admissionFindings include: Review of the facility policy titled Care Plans - Baseline, dated and revised 2017, indicated the following:- A preliminary plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission.- To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. The baseline care plan must include the minimum healthcare information necessary to properly care for a resident including, but not limited to - Initial goals based on admission ordersResident #76 was admitted to the facility in December 2025 with diagnoses including myocardial infarction, repeated falls and unsteadiness on feet.Review of Resident #76's admission Brief Interview for Mental Status exam dated 12/24/25 indicated that the Resident scored a 0 out of 15 indicating he/she as having severe cognitive impairment.Review of Resident #76's in-progress Minimum Data Set assessment dated [DATE] under Section V: Care Area Assessment indicated that Falls were triggered for the Resident.Review of Resident #76's admission Fall Risk assessment dated [DATE] indicated that the Resident's last known fall was documented as during current stay/within past month.Review of Resident #76's nursing note dated 12/24/25 at 10:45 P.M., indicated the following: Resident #76 was brought to acute care hospital after he/she had experienced a fall with LOC (loss of conscious). Patient has a PMH (prior medical history) of Obesity, Chronic Afib (Atrial Fibrillation) not on AC (anti-coagulants) due to recurrent falls.Review of Resident #76's nursing progress note dated 12/26/25 at 6:43 A.M., indicated the following: Resident is here due to s/p (status post) fall.Resident #76's falls care plan with person-centered interventions was not implemented until 12/28/25.Review of Resident #76's Nursing Progress note dated 12/28/25 at 11:21 P.M., indicated the following: Resident s/p (status post) fall on 12/28/25 @ (at) 4:52 P.M.Review of Resident #76's care plan dated 12/28/25 indicated the following:I am at risk or have the potential to fall r/t (related to) poor safety awareness, confusion, behaviors, impaired mobility h/o (history of) falls. Review of the Falls care plan interventions are all dated 12/28/25.Review of Resident #76's Social Service Progress Note dated 12/30/25 at 7:32 A.M., indicated the following: 48HR (48 hour) meeting yesterday 12/29 as family requested. Resident admitted STR (short-term rehab) from [NAME] Hospital after having lightheadedness and s/p fall at home.Review of Resident #76's Nursing Progress Note dated 12/31/25 at 6:53 A.M., indicated the following: The resident had an unwitnessed fall on 12/28 at 4:52. Neuros was [sic] taken and recorded. The resident is now on Ativan 2x a day. When the resident wakes up, he/she starts yelling and he/she does get wild and he/she will lash out.During an interview on 12/30/25 at 10:02 A.M., Unit Manager #1 said baseline care plans should be made within 48 hours of admission and they are typically done by the MDS nurse. Unit Manager #1 said baseline care plans should be created for anything relevant to a Resident's admission diagnoses including history of falls.During an interview on 12/30/25 at 10:15 A.M., MDS Nurse #1 said baseline care plans should be created within 48 hours of admission, and anything flagged on the nursing admission assessment would result in a baseline care plan being created. MDS Nurse #1 said Resident #76 had a fall at home and he/she should have had a falls care plan created within 48 hours of admission. MDS Nurse #1 said a falls baseline care plan with interventions could have alerted staff of his/her falls history to help prevent further falls.During an interview on 12/30/25 at 10:36 A.M., MDS Nurse #2 said she put in Resident #76's falls care plan on 12/28/25 because she knew the Resident was at risk of falls and it was coincidental he/she had a fall the same day. MDS Nurse #2 said Resident #76 should have had a falls baseline care plan developed within 48 hours since he/she was admitted due to a fall.During an interview on 12/30/25 at 2:07 P.M., the Director of Nursing (DON) said Resident #76 should have had a baseline care plan developed upon admission since the Resident was admitted due to a fall.

Based on observations, interviews, and record review, the facility failed to identify and assess the use of pillows tucked underneath a fitted sheet and on top of the raised edges of the perimeter mattress on both sides of the bed as a potential restraint for one Resident (#42) out of a total sample of 19 residents. Findings include:Review of the facility's policy titled, Restraint Free Environment, dated as revised March 2025, indicated:-It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of physical or chemical restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of such restraints.-Physical Restraint refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints may include, but are not limited to: -Tucking in a sheet tightly so that the resident cannot get out of bed. -Using devices such as cushions that the resident cannot remove and prevents the resident from rising. -Placing a resident on a concave mattress so that the resident cannot independently get out of bed.-The resident has the right to be treated with respect and dignity, including the right to be free from any physical and chemical restraint imposed for the purpose of discipline or staff convenience, and not required to treat the resident's medical symptoms.-Behavioral interventions should be used and exhausted prior to the application of a physical restraint or administration of medications that could be perceived as a chemical restraint.-Before a resident is physically restrained, the facility will determine the presence of a specific medical symptom that would require the use of restraints, and determine: a. How the use of the restraints would treat the medical symptom. b. The length of time the restraint is anticipated to be used to treat the medical symptom, who may apply the restraint, and the time and frequency that the restraint will be released. c. The type of direct monitoring and supervision that will be provided during use of the restraint. d. How the resident will request staff assistance and how his/her needs will be met while the restraint is in place. e. How to assist the resident in attaining or maintaining his or her highest practicable level of physical and psychosocial well-being. Resident #42 was admitted to the facility in July 2025 with diagnoses including Parkinson's Disease, diabetes, and malnutrition.Review of the Minimum Data Set (MDS) assessment, dated 9/30/25, indicated the staff assessment of the Brief Interview for Mental Status (BIMS) indicated Resident #42 as having severe cognitive impairment. Further the MDS indicated Resident #42 was dependent on staff for mobility and did not utilize a restraint.On 12/29/25 at 7:30 A.M., the surveyor observed Resident #42 lying in bed on a perimeter mattress (a mattress with raised edges, acting as a barrier to prevent residents from rolling or falling out of bed). There were two pillows tucked under the fitted sheet and on top of the edges of the perimeter mattress on his/her left side and one pillow tucked under the fitted sheet and on top of the edges of the perimeter mattress on his/her right side. There were fall mats on each side of the bed.On 12/29/25 at 11:54 A.M., the surveyor observed Resident #42 lying in bed on a perimeter mattress. There were two pillows under the fitted sheet and on top of the edges of the perimeter mattress on his/her left side from knee to shoulder area and one pillow under the fitted sheet and on top of the edge of the perimeter mattress on his/her right side in the knee area.On 12/29/25 at 4:28 P.M., the surveyor observed Resident #42 in bed with pillows tucked under both sides of the fitted sheet on top of the perimeter mattress.On 12/30/25 at 6:29 A.M., the surveyor observed Resident #42 lying sideways in bed, with his/her legs over the right side of the bed, with pillows under both sides of fitted sheet on top of the edges of the perimeter mattress. CNA #3 came into the room and repositioned the Resident in bed and did not remove the pillows. CNA #3 said Resident #42 has raised sides on the mattress to prevent him/her from falling out of bed, and that the pillows under the sheet are to keep him/her in bed as he/she falls out of bed no matter what they do.On 12/30/25 at 7:57 A.M., the surveyor observed Resident #42 lying sideways in bed with pillows under the fitted sheet on both sides of the bed. Unit Manager #2 came into room and repositioned Resident in bed and did not remove the pillows.On 12/30/25 8:03 A.M., the surveyor observed Resident #42 lying in bed with a pillow under the fitted sheet on left side of the bed.Review of the plan of care related to falls, dated as initiated 7/10/25 and revised 12/30/25, indicated:-Perimeter mattress, keep resident in center.Further review of Resident #42's clinical record including the active care plans, paper chart, the electronic medical record, completed assessments and physician's orders failed to include any documentation to support the use of pillows tucked under Resident #42's fitted sheet.During an interview on 12/30/25 at 1:52 P.M., Unit Manager #2 said Resident #42 is a fall risk and has a scoop mattress, floor mats, and his/her bed in a low position. Unit Manager #2 said she has seen pillows tucked under the fitted sheets. Unit Manager #2 said the pillows should not be used as they are a restraint.During an interview on 12/31/25 at 7:50 A.M., the Director of Nursing said if nursing is putting pillows under a fitted sheet, it should be assessed for a restraint and care planned, but it should not be used as it is a restraint.

Based on interviews and records reviewed, for one of four sampled residents (Resident #2), who was alert oriented and able to make his/her needs know, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when it was reported that during an overnight shift (8/20/25 into 8/21/25) that Certified Nurse Aide (CNA) #2, while interacting with Resident #2, roughly grabbed him/her by wrist, was rude and disrespectful while providing care and when Resident #2 asked CNA #2 for his name, CNA #2 laughed at him/her and walked out of the room. Findings include:Review of the Facility's policy titled Resident Rights, revised dated January 2025, indicated all residents will be treated with kindness, respect, and dignity based on established Resident Rights. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the residents are always treated with respect, kindness and dignity. Resident #2 was admitted to the Facility in July 2025, diagnoses included multiple sclerosis, paraplegia, colostomy, chronic wounds, anxiety, and depression. Review of Resident #2's Minimum Data Set (MDS) Assessment, dated 07/11/25, indicated he/she scored a 15 out of 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). The MDS also indicated that he/she was dependent for bathing, dressing, hygiene, transfers, incontinent care, and was non-ambulatory. The Facility's Internal Investigation, dated 08/21/25, indicated that during early morning care, Resident #2 reported to Nurse #1 that he/she was roughly handled during care by a male CNA (on the overnight shift). The Investigation indicated Resident #2 reported that at approximately 5:30 A.M., he/she put the call light on to be changed, a male staff member (later identified as Certified Nurse Aide #2) came into the room, and he/she told CNA he/she needed to be changed. The Investigation indicated Resident #2 reported that male aide (CNA #2) grabbed him/her by the left wrist and squeezed. The Investigation indicated that Resident #2 reported that when CNA #2 asked him/her to turn, he/she informed CNA #2 that he/she could not turn, that CNA #2 again asked Resident #2 to turn, and he/she pointed his/her right-hand index finger in the air and asked CNA #2 if he did not hear him/her. The Investigation indicated that Resident #2 said that CNA #2 responded by grabbing his/her left wrist and said to him/her You do not talk to people that way! You do not point your finger at people! The Investigation indicated that Resident #2 reported when he/she asked CNA #2 what his name was, he laughed at him/her and when he/she asked CNA #2 a second time for his name, CNA #2 laughed again as he left the room. The Investigation indicated that Resident #2 reported that CNA #2 was angry when he came into the room. During an interview on 09/29/25 at 2:00 P.M., Resident #2 said that early in the morning (during the overnight shift) on 08/21/25, when CNA #2 asked him/her to turn, he/she informed CNA #2 that he/she could not turn, and he ignored him/her. Resident #2 said that he/she pointed his/her right-hand index finger in the air and asked CNA #2 if he did not hear him/her, and that CNA #2 responded by grabbing his/her left wrist and stated You do not talk to people that way! You do not point your finger at people! Resident #2 said that CNA #2 raised his voice and continued to being rude and disrespectful. Resident #2 said when he/she asked CNA #2 his name was, he laughed at him/her and when he/she asked for his name a second time, CNA #2 laughed again as he left the room. Resident #2 said who speaks to people like that disrespectful manner.During an interview on 09/29/25 at 3:30 P.M., Nurse #1 said on 08/21/25 she received a report from the 11:00 P.M. to 7:00 A.M. shift (during change of shift report) Nurse that Resident #2 had just made allegations during her final round check at 7:00 A.M. that CNA #2 was rough and rude during care. Nurse #1 said she immediately assessed Resident #2, and he/she reported to her that CNA #2 had been rough with him/her around 5:30 A.M., while providing care, and squeezed his/her left wrist. Nurse #1 said she immediately reported the allegation to the Unit Manager and Administrator. During an interview on 09/29/25 at 1:30 P.M., the Director of Social Services (DSS) said that Resident #2 reported that CNA #2 was rough and rude when he was providing care. The DSS said Resident #2 reported that when he/she complained to CNA #2 that he was being too rough and was hurting him/her, that CNA #2 responded by continuing to squeeze his/her left wrist and said, You do not talk to people that way! and when he/she asked for his name, CNA #2 started laughing at him/her and walked of his/her room. The Director of Social Services (DSS) said that Resident #2 requested that CNA #2 not provide care to him/her. The DSS said she validated Resident #2's feelings and provided support, and Resident #2 told her that he/she feels safe. During a telephone interview on 10/02/25 at 12:47 P.M., Nurse #2 said that at the time of the incident, she was the Unit Manager, and Nurse #1 reported Resident #2's allegation on 08/21/25 in the morning. Nurse #2 said she went to interview Resident #2. Nurse #2 said Resident #2 told her that CNA #2 told him/her to roll over in a demanding tone, and when he/she told him that he/she was unable to roll over independently, CNA #2 got upset and then squeezed his/her left wrist. Nurse #2 said Resident #2 told her that CNA #2 was rude and had no manners. During a telephone interview on 10/01/25 at 12:17 P.M., CNA #2 said he worked the overnight shift (11:00 P.M. to 7:00 A.M.) on 08/20/25 into 08/21/25. CNA #2 said that while providing care for Resident #2 around 5:30 A.M., Resident #2 complained that he was being rough, and said he apologized to Resident #2. CNA #2 denied being physically or verbally abusive to Resident #2 during care.During a telephone interview on 10/02/25 at 1:30 P.M., Administrator #2 (previous) said that she conducted an interview with Resident #2 on 08/21/25 at 11:30 A.M. and believed what Resident #2 had reported. Administrator #2 said the Facility substantiated the allegation, and CNA #2 was terminated.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was found unresponsive by staff, the Facility failed to ensure that Licensed Nursing Staff had adequate training, and the necessary skill set needed to initiate life saving measures in an effective and efficient manner when responding during an emergency situation.Findings include:The Facility Policy, Emergency Procedure - Cardiopulmonary Resuscitation (CPR), dated February 2018, indicated the chances of surviving a sudden cardiac arrest may be increased if CPR is initiated immediately upon collapse and early delivery of a shock with a defibrillator plus CPR within 3-5 minutes of collapse can further increase chances of survival.The Policy indicated if an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR and do the following:-Instruct a staff member to activate the emergency response system (Code).-Instruct a staff member to retrieve the automatic external defibrillator (AED).-Initiate the basic life support (BLS) sequence, C-A-B (chest compressions, airway, breathing).-When the AED arrives, assess for need and follow AED protocol as indicated.-Continue with CPR/BLS until Emergency Medical Services (EMS) arrive.Review of the Facility's Internal Investigation's Final Report, dated [DATE], indicated around 2:00 A.M., Nurse #1 found Resident #1 without wearing his/her Bilevel Positive Airway Pressure (BiPAP, helps people to breathe by providing pressurized air through a mask), and Nurse #1 provided education to Resident #1 to leave the BiPAP on. The Report indicated around 4:00 A.M. Resident #1 was found unresponsive, cardiopulmonary resuscitation (CPR) initiated, 911 was called and CPR continued until 4:55 A.M. The Report indicated EMS took over and pronounced Resident #1 dead, while still at the Facility.The Report indicated, per Nurse Practitioner (NP) Resident #1 was hospitalized 25 times since [DATE], Resident #1's death was unavoidable, and NP said the cause of death was Respiratory Failure (lungs cannot properly exchange gases, causing abnormal levels of Carbon Dioxide and/or Oxygen in the arteries) with contributing factor of nonadherence to BiPAP. Resident #1 was admitted to the Facility in [DATE], diagnoses included but was not limited to the following: Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), Congestive Heart Failure (the heart does not pump blood as well as it should), Pulmonary Hypertension (high blood pressure that affects arteries in the lungs and in the heart), Atrial Fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and Obstructive Sleep Apnea (intermittent airflow blockage during sleep).Resident #1's Advanced Directives indicated he/she was a Full Code (patients has opted for all available life-saving measures to be used if their heart stops beating and/or they stop breathing).During interview on [DATE] at 1:24 P.M. and 4:30 P.M., Nurse #1 said on [DATE], sometime around 4:00 A.M. - 4:30 A.M. (unable to recall exact time), she walked into Resident #1's room, observed Resident #1's head in an upward position, his/her facial skin color was bluish, his/her eyes and mouth were wide open, and his/her skin was warm to touch. Nurse #1 said she also noted that Resident #1, who required the use of a BiPAP (Bilevel Positive Airway Pressure machine), that the BiPAP, was not on his/her face. Nurse #1 said she called Resident #1's name several times and tried shaking him/her, without getting any response. Nurse #1 said she screamed for Certified Nurse Aide (CNA) #1 to retrieve the Code Cart, said she started chest compressions immediately on Resident #1, could not recall how many sets of chest compressions or cycles she completed before leaving Resident #1 to go to the Nursing station to inform Nurse #2, who worked on another unit, that she needed help.Nurse #1 said she called the other Nursing Unit via telephone, spoke to CNA #2 and informed her to tell Nurse #2 immediately that she needed help. Nurse #1 said she ran back to Resident #1's room, started chest compressions again. Nurse #1 said Nurse #2 and CNA #1 arrived, helped place the back board under Resident #1 and then she continued with chest compressions. Nurse #1 said Nurse #2 assisted with performing chest compression, CNA #1 assisted with the Ambu bag, but she was unaware of how many cycles were completed. Nurse #1 said the automatic external defibrillator (AED) was not applied to Resident #1 and said she could not recall if the AED was in Resident #1's room.Nurse #1 said while Nurse #2 and CNA #1 continued performing CPR on Resident #1, she left to call 911 and then returned to Resident #1's room. Nurse #1 said shortly thereafter Emergency Medical Services (EMS) arrived at Resident #1's room and took over the code.During a telephone interview on [DATE] at 3:19 P.M., Certified Nurse Aide (CNA) #1 said on [DATE] she observed Resident #1 sleeping around 3:00 A.M. with his/her BiPAP on his/her face and he/she did not look like he/she was having problems at that time. CNA #1 said she started her safety rounds around 4:00 A.M. and shortly thereafter Nurse #1 called her to get the Code Cart because she (Nurse #1) found Resident #1 unresponsive. CNA #1 said she obtained the Code Cart but did not bring the AED to Resident #1's room. CNA #1 said she was not sure where the AED was located on the unit, and that this had been her first Code Blue.During a telephone interview on [DATE] at 8:24 A.M., CNA #2 said on [DATE] sometime during the overnight shift (exact time unknown), Nurse #1 telephoned the unit looking for Nurse #2 (in an urgent voice), saying she needed Nurse #2's help on her unit and hung up the phone. CNA #2 said Nurse #1 did not tell her what the emergency was.During a telephone interview on [DATE] at 8:19 A.M., Nurse #2 said on [DATE], she was administering medications, had been informed by CNA #2, that Nurse #1 called on the telephone to inform her that she had an emergency. Nurse #2 said she had not heard the phone ring, did not know where Nurse #1 was located on the third floor and when she had arrived at the unit, she had to call out her name to find her location.Nurse #2 said when she got to the room, CNA #1 had already arrived with the Code Cart, Nurse #1 was performing chest compressions on Resident #1 and Nurse #1 stopped briefly while they placed the back board under Resident #1. Nurse #2 said she then applied the Ambu bag (located on the Code Cart) to Resident #1's face. Nurse #2 said Nurse #1 then stopped administering chest compressions briefly, and said she was going to call 911.Nurse #2 said she continued performing the Ambu bag on Resident #1 until EMS arrived. Nurse #2 said she did not perform any chest compressions on Resident #1, including while Nurse #1 was calling 911. Nurse #2 said Resident #1 did not have the AED applied to him/her and said she was unaware if the AED was in Resident #1's room at the time of the Code Blue. Nurse #2 said she was unaware of how many cycles of CPR were completed prior to EMS arrival. Nurse #2 said when Nurse #1 returned to Resident #1's room she started chest compressions again. Nurse #2 said the EMS came shortly after Nurse #1 called 911 and took over the code.During interview on [DATE] at 3:48 P.M., the Unit Manager said it is her expectation when a Nurse finds an unresponsive resident, who is a Full Code Status to complete the following:-Never leave the resident alone.-Staff member should yell for help.-A Staff member calls Code Blue via Facility's overhead page, including location three times.-A Staff member call 911. -A Staff member to retrieve the Code Cart and AED. -The Nurse to assess the resident, obtaining vital signs and initiating CPR immediately.-The Staff to apply the AED to the resident when available and follow directions that are provided. The Unit Manager said once chest compressions are started, they do not stop chest compressions until EMS takes over.During interview on [DATE] at 6:12 P.M., the Administrator and Director of Nursing (DON) said they were not affiliated with the Facility when this incident occurred. However, the Administrator and DON said the expectation is that Staff are to follow the Facilities Policy and Procedures relating to Emergency Procedure - Cardiopulmonary Resuscitation (CPR).

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was found unresponsive by staff, and required staff to initiate a Code Blue, the Facility failed to ensure that Licensed Nursing Staff were competent in process of calling and responding in the event of a Code Blue situation.Findings include:According to the Board of Registration in Nursing, 244 CMR9.00: Standards of Conduct, competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a Nurse Licensed by the Board and for the delivery of safe Nursing care in accordance with accepted Standards of Practice.Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully.Resident #1 was admitted to the Facility in [DATE], diagnoses included Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), Congestive Heart Failure (the heart does not pump blood as well as it should), Pulmonary Hypertension (high blood pressure that affects arteries in the lungs and in the heart), Atrial Fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and Obstructive Sleep Apnea (intermittent airflow blockage during sleep).During interview on [DATE] at 1:24 P.M. and 4:30 P.M., Nurse #1 said on [DATE], sometime around 4:00 A.M.- 4:30 A.M., she walked into Resident #1's room, observed Resident #1's head in an upward position, his/her facial skin color was bluish, his/her eyes and mouth were wide open, and his/her skin was warm to touch. Nurse #1 said Resident #1's BiPAP was not on his/her face. Nurse #1 said she called Resident #1's name several times and shaking him/her without getting a response.Nurse #1 said that she was unaware of the Facility's Emergency Procedure-Cardiopulmonary Resuscitation Procedure and Policy. Nurse #1 said she has never seen the Facility's Emergency Documentation Record (located on the Code Cart) to be completed during a Code Blue. Nurse #1 said she has not participated in a Code Blue or any Mock Code Blue Drills, since she has worked at the Facility (approximately 3 years).Nurse #1 said she has never used the Facility's overhead paging system and therefore did not know how to use it, so she called the other Nursing Unit via telephone (located at the Nursing Station) spoke to CNA #2 and told CNA #2 to let Nurse #2 she needed help.Nurse #1 said she could not recall if the Facility's automatic external defibrillator (AED) was in Resident #1's room during the Code Blue. Nurse #1 said the AED was not applied to Resident #1 and said she was unaware if it was part of the Facility's Policy to bring the AED to a Code Blue along with the Code Cart. Nurse #1 said once cardiopulmonary resuscitation (CPR) was initiated, she left to call for help and left again once the other nurse arrived to call 911.During a telephone interview on [DATE] at 8:19 A.M., Nurse #2 said there has not been any staff development personnel at the Facility for a while. Nurse #2 said the Facility has not provided any Mock Code Blue Drills or trainings since she has worked at the Facility (approximately 6 months). Nurse #2 said there has been no education provided to staff regarding Policy and Procedures related to Emergent Events, Code Blue, CPR, the AED and the Code Carts. Nurse #2 said she was unaware her CPR certification had expired on 01/2025, until the Facility called her on [DATE] (the day of the survey) to inform her she needed to renew it. Nurse #2 said the Facility does not provide CPR classes and that she immediately completed a CPR course on [DATE] after receiving Facility's phone call.During interview on [DATE] at 3:48 P.M., the Unit Manager said she could not recall any Facility education provided to staff relating to Policy and Procedures for Emergent Events, Code Blue, CPR, and AED. The Unit Manager said there has not been any Mock Code Blue Drills or trainings conducted since she has worked at the Facility (approximately 1 year). The Unit Manager said employees are only provided information during their orientation.The Unit Manager said if a Code Blue is initiated, Nursing will document the event in the residents' Progress Note and said staff do not use the Facility's Emergency Documentation Record form (located on the Code Cart) which indicates it needs to be completed during the Code Blue.The Unit Manger said on [DATE], she was informed of the Resident #1's Code Blue but said she had not reviewed the Code Blue event and did not speak to the nursing staff who had responded, regarding the incident. The Unit Manger said that she usually speaks with the nursing staff and reviews the documentation but said she had not. The Unit Manager said when she arrived at the Facility on [DATE], Resident #1 had already been transported to the Funeral Home.During interview on [DATE] at 11:53 A.M., the Director of Nursing (DON) said the Facility Staff on 11:00 P.M. to 7:00 A.M. shift are responsible daily to check the Code Cart to ensure all the required Code equipment is on the Code Cart, locked and to ensure on the 15th of every month the Code Cart is opened to ensure all of the Code equipment is located in the drawers.The DON said since she has been at the Facility the Code Carts located on the second and third floor have been found unlocked or at times they were found locked with a twist tie. The DON said it was the responsibility of the Unit Manager to oversee that the Code Carts are being properly maintained.During a tour on [DATE] at 1:04 P.M., the DON, accompanied by the Surveyor, observed and said the following: The DON said the Code Cart and the AED that staff would use during an emergency situation (Code Blue) were located on the second and third floors. The DON said the Oxygen tank attached to the Code Carts should always be full and ready for use. The DON, and the Surveyor, observed that the Oxygen tanks on the code carts, were empty on both the second and third floor. carts. The Code Cart located on the second floor was unlocked, needed to be organized, labeled and there were missing items. The Code Cart located on the third floor was locked and observed missing staff signatures on the Emergency Crash Cart Checklist. The DON said nursing staff needed to ensure they completed the Code Cart check and documentation accurately daily. The DON said the staff were educated to not take items off the Code Cart and not to use the Oxygen tank if it is not an emergency. The DON said staff were educated to obtain medical supplies and oxygen that are needed from the Facility's supplies. The DON said there are plenty of supplies and Oxygen tanks, and that staff do not need to use the Code Cart supplies.During interview on [DATE] at 3:30 P.M., the Director of Nursing (DON) said she was unable to find any Facility documentation to support that Nursing Staff were provided education and/or training related to Emergent Events, Code Blue, CPR, the AED and the maintenance of the Code Cart.The DON said the Facility does not have a Staff Educator / Staff Development Coordinator at this time and that she was currently providing staff education and training.

Based on record review and interview, the facility failed to maintain the highest practicable physical, mental, and psychosocial well being for one Resident's (#55) with a history of suicidal ideation (SI) and depression, out of a total sample of 27 residents. Specifically, Resident #55 was not provided with appropriate behavioral health services following verbalization of SI, and attempted to kill him/herself at the facility. Findings include: Review of the facility policy titled Suicidal Ideation/Risk for Harming Self, dated 10/2016, indicated but is not limited to the following: PURPOSE: To act as a guideline for residents who express/exhibits suicidal ideation or risk to harm self during their stay at the facility in assuring their safety. 2. Care plan initiated and communicated to relevant staff and family member. (sic) Review of the facility policy titled Behavioral Health Services, revised 12/7/21, indicated the following: PURPOSE: To provide our residents with the necessary Behavioral Health Services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. POLICY: It is the policy of the facility to provide Behavioral Health Services in accordance with State and Federal regulations. PROCEDURE: 1. The facility will ensure that a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post traumatic stress disorder, receives appropriate treatment and services. 2. The resident will receive, and the facility will provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. 3. Behavioral health encompasses a resident's emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance abuse disorders. 4. The facility will initiate referrals to psychiatric services, having the resident or responsible party sign consent, as behavioral concerns are identified. Review of the facility assessment, dated as reviewed 7/25/24, indicated the facility is able to manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior and identify and implement interventions, including non-pharmalogical interventions, to help support individuals with issues such as dealing with anxiety, cognitive impairment, depression, trauma/PTSD, and other psychiatric diagnoses. According to the facility assessment, the facility manages 40-65 residents with behavioral health needs at a time. Resident #55 was admitted to the facility in February 2023 and had diagnoses that include depression and dementia. Review of the admission Minimum Data Set (MDS) assessment, dated 2/23/23, indicated Resident #55 scored a 13 out of a possible 15 on the Brief Interview for Mental Status exam, indicating intact cognition. Review of the Resident's hospital discharge paperwork, dated February 2023, given to the facility upon admission, indicated Resident #55 was admitted to the facility after vocalization of passive SI without a plan. Review of the psych discharge summary, dated February 2023, recommended the facility obtain a psych consult and med recommendations Review of the progress note, dated 8/5/23, indicated: Resident sent out at 7pm for suicidal ideations w/ active plan. Reported to this writer that today was going to be his/her last day here I'm going out one way or another. Resident reported that he/she wants to end his/her life today and has a plan to do so. Resident declined to tell this writer what the plan is but repeatedly stated Anyway I can I'm getting it done tonight, there's lots of ways to do it. This writer stayed with resident and discussed further, Resident #55 voiced frustration with being in a LTC (long term care) facility and that at his/her age he/she should be able to end his/her life if he/she wants. Resident #55 further voiced being alone pertaining to his/her children and that they lied to get him/her here and now he/she is stuck. This writer was able to talk with Resident #55 and he/she agreed to a hospital evaluation this evening d/t (due to) his/her current thoughts. He/she remained adamant about ending his/her life t/o (throughout) the conversation and was placed on a 1:1 until EMT's arrived for transport Review of the medical record failed to indicate a care plan was implemented for SI after Resident #55 returned from the hospital on 8/5/23. Further, the medical record failed to indicate a referral was made, or that Resident #55 was assessed by the behavioral health team for psychotherapy to address his/her feelings of SI. Review of the Behavioral Health Group note for medication management, dated 9/20/23, 34 days after his/her return from the hospitalization , indicated Resident #55 was alert and oriented and reports periods of anxiety, sadness and frustration around aspects of institutional living. The report indicates patient can benefit from behavior management, however; fails to indicate that a referral was made for talk therapy or that the plan of care was updated with specific behavioral management interventions. Review of the Social Work progress note dated 10/16/23 indicated the Social Worker met with Resident #55 after the death of his/her friend. Review of the medical record failed to indicate the care plan was reviewed, updated, or any interventions, to monitor Resident #55 for SI, were developed. Review of the Behavioral Health Group note for medication management, dated 10/18/23, indicated Resident #55 was seen by the Psych NP (Nurse Practitioner) due to increased anxiety and paranoia with recommendation to increase Buspar from 5mg to 10 mg BID for anxiety/agitation. The Psych NP recommended the following goals for nursing to monitor: - Short Term Goals: client/staff will report no more than 1-2 episode of anxiety per day - Long Term Goals: client/staff will report no more than 2-3 episode of anxiety per week. Review of the record failed to indicate that the Psych NP's 10/18/23 recommended treatment plan was communicated to staff, implemented or tracked or that the plan of care was updated with specific behavioral management interventions to achieve these goals. On 12/18/23, Resident #55 attempted to commit suicide at the facility by attempting to jump over the second floor balcony, which was intervened by the Maintenance Director and Resident #55 was pulled to safety and sent to the hospital. Review of the clinical record indicated Resident #55 was psychiatrically hospitalized [DATE]-[DATE]. Review of the clinical record failed to indicate that upon readmission to the facility, Resident #55's plan of care was reviewed or updated, despite Resident #55's suicide attempt on 12/18/23. Review of the Behavioral Health Group note for Therapy, dated 1/23/24, 15 days after his/her return from the hospital, indicates a LICSW initial assessment note : Requested by nursing home SW to assess resident because of recent suicide attempt. According to the note Resident #55 declined services and the LICSW will only see the resident again if requested by the facility. During an interview on 10/30/24 at 12:19 P.M., with the facility Social Worker (SW) #1 she said that she has worked at the facility for 2 months. SW #1 said that the facility has psych services for both med management and talk therapy and for a resident that verbalizes SI she would refer them to be evaluated for talk therapy. SW #1 said that she is the only social worker in the building and that she does not know Resident #55 and that she was not aware that he/she had attempted to commit suicide while residing at the facility/ SW #1 said that she would expect to have been told because that is a resident she would have followed to provide nonpharmacological types of interventions such as regular visits and encouraging him/her to spend time them out of his/her room at activities. During an interview on 10/30/24 at 12:35 P.M., with the Nurse Unit Manager #1 said Resident #55 had a history of verbalizing SI and should have been evaluated by psych therapy for talk therapy and she is not sure why that did not happen, as they are in the building once a week and a referral can be made at any time. During an interview on 10/31/24 at 9:02 A.M., with the facility's current Psych Nurse Practitioner (NP) #2 she said that she provides the medication management at the facility and that if the facility wants someone seen by psych services they place a referral in the book on the unit which she checks weekly. Psych NP #2 said she relies on the referrals in the green book rather than asking staff if they have new referrals because most of the time there is agency staff. NP #2 said that she was not the NP at the time of the incidents and that possibly Resident #55 would have benefited from supportive talk therapy services because of his/her history, but that those services are provided by another provider. The Psych NP said that she can directly refer residents for talk therapy and that if she feels a resident would benefit from those services she communicates this directly to the Behavioral Health Group's LICSW that provides that service. During an interview on 10/31/24 at 12:34 P.M., with Resident #55's Physician, he said that it is his expectation that residents admitted with a history of SI be seen by both the psych services NP as well as be assessed for psychotherapy services. The physician said that he was under the impression that Resident #55 was being followed closely by the facility's Social Worker and was surprised to hear that the Social Worker learned only the day prior from the surveyor that Resident #55 had both a history of verbalizing SI and of an actual suicide attempt at the facility. During an interview on 10/31/24 at 1:01 P.M., the Director of Nursing said when a resident is admitted with a history of suicidal ideation, they should be assessed upon admission by psych services for both medication management and psychotherapy. As well, she said that she would expect the resident to be followed closely by social service and that the visit notes would be documented in the medical record. The DON was surprised to learn that the current facility social worker was unaware that Resident #55 had a history of SI and actual suicide attempt at the facility, and would have expected that to have been important information for her to receive when she was trained 2 months prior.

Based on record review and interview, the facility failed to provide the appropriate treatment and services for one Resident (#55), with a known history of depression, suicidal ideation, and adjustment difficulty, out of a total sample of 27 residents. Specifically, the facility failed to develop, implement, and update the plan of care, resulting in an attempted suicide after the vocalization of suicidal ideation (SI). Findings include: Review of the facility policy titled Suicidal Ideation/Risk for Harming Self, dated 10/2016, indicated but is not limited to the following: PURPOSE: To act as a guideline for residents who express/exhibits suicidal ideation or risk to harm self during their stay at the facility in assuring their safety. 2. Care plan initiated and communicated to relevant staff and family member. Review of the facility policy titled Behavioral Health Services, revised 12/7/21, indicated the following: PURPOSE: To provide our residents with the necessary Behavioral Health Services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. POLICY: It is the policy of the facility to provide Behavioral Health Services in accordance with State and Federal regulations. PROCEDURE: 1. The facility will ensure that a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post traumatic stress disorder, receives appropriate treatment and services. 2. The resident will receive, and the facility will provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. 3. Behavioral health encompasses a resident's emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance abuse disorders. 4. The facility will initiate referrals to psychiatric services, having the resident or responsible party sign consent, as behavioral concerns are identified. Review of the facility assessment, dated as reviewed 7/25/24, indicated the facility is able to manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior and identify and implement interventions, including non-pharmalogical interventions, to help support individuals with issues such as dealing with anxiety, cognitive impairment, depression, trauma/PTSD, and other psychiatric diagnoses. According to the facility assessment, the facility manages 40-65 residents with behavioral health needs at a time. Resident #55 was admitted to the facility in February 2023 and had diagnoses that include depression and dementia. Review of the admission Minimum Data Set (MDS) assessment, dated 2/23/23, indicated Resident #55 scored a 13 out of a possible 15 on the Brief Interview for Mental Status exam, indicating intact cognition. Review of the Resident's hospital discharge paperwork, dated February 2023, given to the facility upon admission, indicated Resident #55 was admitted to the facility after vocalization of passive SI without a plan. Review of the psych discharge summary, dated February 2023, recommended the facility obtain a psych consult and med recommendations Review of the progress note, dated 8/5/23, indicated: Resident sent out at 7pm for suicidal ideations w/ active plan. Reported to this writer that today was going to be his/her last day here I'm going out one way or another. Resident reported that he/she wants to end his/her life today and has a plan to do so. Resident declined to tell this writer what the plan is but repeatedly stated Anyway I can I'm getting it done tonight, there's lots of ways to do it. This writer stayed with resident and discussed further, Resident #55 voiced frustration with being in a LTC (long term care) facility and that at his/her age he/she should be able to end his/her life if he/she wants. Resident #55 further voiced being alone pertaining to his/her children and that they lied to get him/her here and now he/she is stuck. This writer was able to talk with Resident #55 and he/she agreed to a hospital evaluation this evening d/t (due to) his/her current thoughts. He/she remained adamant about ending his/her life t/o (throughout) the conversation and was placed on a 1:1 until EMT's arrived for transport Review of the medical record failed to indicate a care plan was implemented for SI after Resident #55 returned from the hospital on 8/5/23 Review of the Behavioral Health Group note for medication management, dated 9/20/23, 34 days after his/her return from the hospitalization , indicated Resident #55 was alert and oriented and reports periods of anxiety, sadness and frustration around aspects of institutional living. The report indicates patient can benefit from behavior management, however; fails to indicate that a referral was made for talk therapy or that the plan of care was updated with specific behavioral management interventions. Review of the Social Work progress note dated 10/16/23 indicated the Social Worker met with Resident #55 after the death of his/her friend. Review of the medical record failed to indicate the care plan was reviewed, updated, or any interventions, to monitor Resident #55 for SI, were developed. Review of the Behavioral Health Group note for medication management, dated 10/18/23, indicated Resident #55 was seen by the Psych NP (Nurse Practitioner) due to increased anxiety and paranoia with recommendation to increase Buspar from 5mg to 10 mg BID for anxiety/agitation. The Psych NP recommended the following goals for nursing to monitor: - Short Term Goals: client/staff will report no more than 1-2 episode of anxiety per day - Long Term Goals: client/staff will report no more than 2-3 episode of anxiety per week. Review of the record failed to indicate that the Psych NP's 10/18/23 recommended treatment plan was communicated to staff, implemented or tracked or that the plan of care was updated with specific behavioral management interventions to achieve these goals. On 12/18/23, Resident #55 attempted to commit suicide at the facility by attempting to jump over the second floor balcony , which was intervened by the Maintenance Director and Resident #55 was pulled to safety and sent to the hospital. Review of the clinical record indicated Resident #55 was psychiatrically hospitalized [DATE]-[DATE]. Review of the clinical record failed to indicate that upon readmission to the facility, Resident #55's plan of care was reviewed or updated, despite Resident #55's suicide attempt on 12/18/23. The medical record indicated that an SI care plan was developed on 1/9/24, 4 days after readmission to the facility. The SI care plan developed on 1/9/24 indicated the following: Review of the Behavioral Health Group note for Therapy, dated 1/23/24, 15 days after his/her return from the hospital, indicates a LICSW initial assessment note : Requested by nursing home SW to assess resident because of recent suicide attempt. According to the note Resident #55 declined services and the LICSW will only see the resident again if requested by the facility. During an interview on 10/30/24 at 12:19 P.M., with the facility Social Worker (SW) #1 she said that she has worked at the facility for 2 months. She said that if a resident admits to the facility with a history of verbalizing SI, whether remote or recent, she would meet with the resident upon admission and determine the history in order to develop a person centered care plan. SW #1 said that for any resident that voices SI while at the facility or if they are hospitalized for SI while at the facility, she would review the care plan and update it when this occurs. SW #1 said that the facility has psych services for both med management and talk therapy and for a resident that verbalizes SI she would refer them to be evaluated for talk therapy. SW #1 said that she is the only social worker in the building and that she does not know Resident #55 and that she was not aware that he/she had attempted to commit suicide while residing at the facility. SW #1 said that she would expect to have been told because that is a Resident she would have followed to provide nonpharmacological types of interventions such as regular visits and encouraging him/her to spend time them out of his/her room at activities. During an interview on 10/30/24 at 12:35 P.M., with the Nurse Unit Manager #1 she said that she has been a nurse unit manager for 7 years and knows Resident #55 well. According to Nurse Unit Manager #1 a baseline care plan, and then a comprehensive care plan, regarding Resident #55's SI should have been developed at admission and she is not sure why it was not. She said that it is the expectation that the team continuously update all SI care plans with any changes in SI status. She said that while she could not recall the SI in August 2023, that at that time an SI care plan should have already been in place and would have been reviewed and updated. As well, Nurse Unit Manager #1 said Resident #55 should have been evaluated by psych therapy for talk therapy and she is not sure why that did not happen, as they are in the building once a week and a referral can be made at any time. During an interview on 10/31/24 at 9:02 A.M., with the facility's current Psych Nurse Practitioner (NP) #2 she said that she provides the medication management at the facility and that if the facility wants someone seen by psych services they place a referral in the book on the unit which she checks weekly. Psych NP #2 said she relies on the referrals in the green book rather than asking staff if they have new referrals because most of the time there is agency staff. NP #2 said that she was not the NP at the time of the incidents and that possibly Resident #55 would have benefited from supportive talk therapy services because of his/her history, but that those services are provided by another provider. The Psych NP said that she can directly refer residents for talk therapy and that if she feels a resident would benefit from those services she communicates this directly to the LICSW that provides that service. During an interview on 10/31/24 at 12:34 P.M., with Resident #55's Physician he said that it is his expectation that residents admitted with a history of SI be seen by both the psych services NP as well as be assessed for psychotherapy services. Additionally, it is his expectation that the facility would develop and implement a care plan, that includes nonpharmacological interventions, for all residents with a history of SI. The physician said that he was under the impression that Resident #55 was being followed closely by the facility's Social Worker and was surprised to hear that the Social Worker learned only the day prior from the surveyor that Resident #55 had both a history of verbalizing SI and of an actual suicide attempt at the facility. During an interview on 10/31/24 at 1:01 P.M., the Director of Nursing said when a resident is admitted with a history of suicidal ideation, they should be assessed upon admission, or shortly thereafter, by psych services for both medication management and psychotherapy and that a care plan should be developed that includes nonpharmacological interventions to keep the Resident safe. The DON said that the care plan should be followed and updated any time the resident voices SI or requires intervention related to SI. As well, she said that she would expect the resident to be followed closely by social service and that the visit notes would be documented in the medical record. The DON was surprised to learn that the current facility social worker was unaware that Resident #55 had a history of SI and actual suicide attempt at the facility, and would have expected that to have been important information for her to receive when she was trained 2 months prior.

Based on observations, interviews and record review, the facility failed to provide necessary treatment, services, interventions to promote healing and prevent new ulcers from developing for one Resident (#4), who was assessed to be at risk for pressure ulcer development, out of 27 total sampled residents. Specifically, for Resident #4: a.) the facility failed to implement physician ordered pressure ulcer prevention interventions to offload heels and ensure correct air mattress settings were implemented consistently resulting in new skin breakdown including the re-opening of a previously healed pressure ulcer on the left upper Achilles heel; b.) the facility failed to obtain wound care orders for the newly re-developed pressure ulcer on the left upper Achilles heel; c.) the facility failed to ensure a right heel pressure related deep tissue injury (DTI) was assessed and measured weekly; and d.) the facility failed to ensure the weekly skin assessments were completed and documented. Findings include: Review of the facility policy titled Pressure Ulcer Prevention, revised 12/22/22, indicated: - The facility will implement interventions to minimize and/or eliminate contributing factors for pressure ulcer development on patients/residents at risk. - A weekly body audit will be completed on residents. - Wounds will have weekly assessments and documentation of each area until healed. Review of the facility policy titled Skin Body Audit, revised 3/12/13, indicated: - Purpose: To identify changes in skin integrity through weekly skin audits (head to toe) on all residents. - Licensed nurses will perform skin body audits on a weekly basis. - Any significant abnormal findings are reported to the resident's physician. Resident #4 was admitted to the facility in December 2023 with diagnoses including end stage renal disease and diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/11/24, indicated Resident #4 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 15 out of 15. This MDS indicated Resident #4 required partial/moderate assistance with transferring from bed to chair, moving from a sitting to a standing position, and with lower body dressing. This MDS also indicated the Resident had one deep tissue pressure injury (DTI) and was at risk for developing pressure ulcers. During an interview on 10/31/24 at 12:35 P.M., The MDS Nurse said the DTI on the MDS, dated [DATE], was for Resident #4's right heel. Review of Resident #4's assessment titled Norton Scale for Predicting Risk of Pressure Ulcer, dated 9/20/24, indicated the Resident was at high risk for pressure ulcer development as evidenced by a score of 10. Review of Resident #4's assessment titled Weekly Skin Checks, dated 10/18/24, failed to indicate a pressure related wound on his/her left upper Achilles heel. Review of Resident #4's plan of care related to potential for new skin breakdown, revised 9/19/24, indicated: - Resident #4 has the potential for new skin breakdown due to impaired mobility, episodes of incontinence, and diagnosis of type 2 diabetes. - Assist with turning/ redistributing weight per facility protocol. - Complete skin checks weekly per facility protocol. Pay particular attention to the bony prominences. - Notify MD if any skin breakdown occurs. a.) The facility failed to implement physician ordered pressure ulcer prevention interventions to offload heels and ensure correct air mattress settings were implemented consistently, resulting in new skin breakdown including the re-opening of a previously healed pressure ulcer on the left upper Achilles heel, as evidenced by the following: Review of Resident #4's physician's orders indicated: - Offload both heels at all times, every shift, initiated 8/13/24. - Offload right heel with 2-3 pillows under calf or apply offloading boots at all times while in bed, every shift, initiated 8/13/24. - Low air loss mattress - settings at 250 lbs. (pounds) alternating pressure. Check function and setting each shift, initiated 8/13/24. Review of Resident #4's medical record failed to indicate any refusal or rationale for his/her heels not being offloaded or the air mattress being set at 200 lbs. (instead of 250 lbs.) alternating pressure. On 10/29/24 at 9:01 A.M. and 10:34 A.M., 10/30/24 at 7:37 A.M., 9:16 A.M., and 10:01 A.M., and 10/31/24 at 8:09 A.M. and 10:18 A.M., the surveyor observed Resident #4 in bed with his/her heels directly on the mattress without any pillows or offloading boots. Resident #4 was on an air mattress which was set at 200 lbs. alternating pressure (instead of 250 lbs.). During an interview on 10/31/24 at 8:09 A.M., Resident #4 said staff used to help offload his/her heels with pillows and offloading boots, but they haven't in a long time. Resident #4 said he/she isn't sure why staff doesn't help offload his/her heels anymore because he/she has a new left heel wound. Resident #4 said he/she would like to have his/her heels offloaded and would never decline because he/she thinks it would make his/her sore heels feel better. Resident #4 said his/her air mattress is often not comfortable. During an interview on 10/31/24 at 8:23 A.M., CNA (Certified Nurse Assistant) #6 said she was currently assigned to care for Resident #4 and was unaware his/her heels should be offloaded. CNA #6 said the CNAs are made aware of specific interventions through report from nurses and the care card. CNA #6 said the nurse never reported that Resident #4 needed to have heels offloaded and his/her care card had no interventions to offload heels. During an interview on 10/31/24 at 8:28 A.M., CNA #7 said he was previously assigned to care for Resident #4 recently and was unaware his/her heels should be offloaded. CNA #7 said the CNAs are made aware of specific interventions to prevent skin breakdown through report from nurses and the care card. CNA #7 said the nurse never reported that Resident #4 needed to have heels offloaded. CNA #7 reviewed Resident #4's care card with the surveyor and said there were no interventions listed to offload heels. During an interview on 10/31/24 at 8:33 AM, Nurse #2 said she was a consistently assigned day shift nurse for Resident #4 during the last two weeks. Nurse #2 said she was unaware his/her heels should be offloaded. Nurse #2 observed Resident #4's heels with the surveyor and said the right heel is dark red and probably had pressure related damage and there is an unstageable pressure ulcer on his/her left upper Achilles heel that had been there since she started two weeks ago. Nurse #2 said there is no treatment in place for the pressure ulcer on left upper Achilles heel. Nurse #2 said she applies skin prep (a topical medication used to prevent skin breakdown) to the medial aspect of the heel only and never applies to the pressure ulcer on left upper Achilles heel because there is no order for it to be applied to that anatomical location. During an interview on 10/31/24 at 10:48 A.M., Nurse Unit Manager #1 said Resident #4 needed to have his/her heels offloaded to prevent skin breakdown because he/she was at high risk for skin breakdown relating to a history of pressure wounds on both heels. Nurse Unit Manager #1 said Resident #4 has a DTI on the right heel and a history of a healed pressure ulcer on the left upper Achilles heel, which in spring 2024. Nurse Unit Manager #1 also said Resident #4 is on an air mattress to prevent the development of pressure ulcers and nurses should check to ensure the correct air mattress settings are in place each shift. Nurse Unit Manager #1 observed Resident #4's heels with the surveyor. Nurse Unit Manager #1 said Resident #4's right heel is a pressure related DTI and the left Achilles is a new unstageable pressure ulcer where a past pressure ulcer had previously healed in spring 2024. Nurse Unit Manager #1 said she was unaware the pressure ulcer had re-developed, and this is exactly why his/her heels needed to be offloaded. During an interview on 10/31/24 at 12:30 P.M., the Director of Nursing (DON) said Resident #4's heels should have been offloaded and the air mattress should have been set to correct settings, and if he/she refused it should be documented. The DON said the nurses are responsible for check air mattress settings each shift and if found not at the physician ordered setting then should be adjusted and/or clarified. b.) The facility failed to obtain wound care orders for a new pressure ulcer, as evidenced by the following: Review of Resident #4's physician's orders indicated: - Wound: left medial heel, apply skin prep to area daily, imitated 8/13/24. Review of Resident #4's current physician's orders failed to indicate any wound orders for the left upper Achilles heel. During an interview on 10/31/24 at 8:33 AM, Nurse #2 said she was a consistently assigned day shift nurse for Resident #4 during the last two weeks. Nurse #2 observed Resident #4's heels with the surveyor and said there is an unstageable pressure ulcer on his/her left upper Achilles heel that has been there since she started two weeks ago. Nurse #2 said there is no treatment in place for the pressure ulcer on left upper Achilles heel. Nurse #2 said she applies skin prep (a topical medication used to prevent skin breakdown) to the medial aspect of the heel only and never applies to the pressure ulcer on left upper Achilles heel because there is no order for it to be applied to that anatomical location. During an interview on 10/31/24 at 10:48 A.M., Nurse Unit Manager #1 said Resident #4 had a history of a healed pressure ulcer on the left upper Achilles heel, which healed in spring 2024. Nurse Unit Manager #1 observed Resident #4's left upper Achilles heel and said there is now an unstageable pressure ulcer that she was unaware of. Nurse Unit Manager #1 said the order for skin prep to the left medial heel does not cover the left upper Achilles heel, and the provider should have been notified to obtain wound orders but had not been. During an interview on 10/31/24 at 12:30 P.M., the Director of Nursing (DON) said the provider should have been notified to obtain wound orders for the pressure ulcer on Resident #4's left upper Achilles heel. c.) The facility failed to ensure a pressure related deep tissue injury (DTI) was assessed and measured weekly, as evidenced by the following: Review of Resident #4's medical record failed to indicate any wound assessments or measurements for his/her right heel DTI in the past three months. During an interview on 10/31/24 at 10:48 A.M., Nurse Unit Manager #1 said Resident #4 had a DTI on his/her right heel. Nurse Unit Manager #1 observed Resident #4's right heel and said it currently is a pressure related DTI. Nurse Unit Manager #1 said the Resident had this DTI since at least August 2024 and it should have been assessed and measured weekly. Nurse Unit Manager #1 said the consultant wound physician should do this but is unsure why the consultant wound physician had not been following this Resident. Nurse Unit Manager #1 reviewed the record and said that since the consultant wound physician was not following Resident #4 then nursing should have been completing weekly wound assessments with measurements but had not been. During an interview on 10/31/24 at 12:30 P.M., the Director of Nursing (DON) said it was the expectation that if the consultant wound physician was not following Resident #4's right heel DTI, then Nurse Unit Manager #1 should have assessed and measured the heel weekly. d.) The facility failed to ensure weekly skin assessments were being completed, as evidenced by the following: Review of Resident #4's physician's orders indicated: - Weekly skin checks, initiated 8/16/24 and discontinued 10/15/24. - Weekly skin checks on Fridays, initiated 10/18/24 and discontinued 10/18/24. - Weekly skin checks on Fridays, initiated on 10/25/24. Review of Resident #4's medical record, dated 8/13/24 to 10/31/24, indicated skin assessments were only documented on 9/27/24, 10/4/24, and 10/18/24. Skin assessments were not completed eight out of the eleven weeks. During an interview on 10/31/24 at 10:48 A.M., Nurse Unit Manager #1 said skin assessments should be completed and documented every week. During an interview on 10/31/24 at 12:30 P.M., the Director of Nursing (DON) said skin assessments should be completed and documented every week. The DON said weekly skin assessments not being completed was an ongoing concern in the facility.

Based on observation, record review, and interview, the facility failed to develop a comprehensive person centered care plan and implement the plan of care for two Residents (#55 and #13) out of a total sample of 27 residents. Specifically: 1. for Resident #55, the facility failed to develop a Suicidal Ideation (SI) care plan, after vocalization of suicidal ideation, which resulted in the Resident attempted to commit suicide at the facility and; 2. for Resident #13, the facility failed to develop and implement a plan of care for incontinence. Findings include: The facility policy titled Comprehensive Care Plan, undated, indicated the following: - Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. - Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments) before interventions are added to the care plan. - The resident's comprehensive care plan is developed within seven (7) days of completion of the resident's comprehensive assessment (MDS) and no more than twenty-one (21) days after admission. 1. For Resident #55, the facility failed to develop a comprehensive person centered care plan for a Resident who admitted with a recent history of verbalizing Suicidal Ideation (SI). Resident #55 had another incidence of verbalizing SI and the facility failed to develop a plan of care related to SI, which resulted in an attempted suicide in December 2023. The facility policy titled Suicide Threats, dated 12/6/21, indicated the following: PURPOSE: To ensure residents that make suicide threats have timely intervention to ensure safety. POLICY: Resident suicide threats shall be taken seriously and addressed appropriately. PROCEDURE: - If the resident remains in the facility, the resident will remain on 1:1 observation. Staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined and documented that a risk of suicide does not appear to be present. Review of the facility assessment, reviewed 7/25/24, indicated the facility is able to manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care for someone with cognitive impairment, care for individuals with depression, trauma/PTSD, other psychiatric diagnoses, and intellectual or developmental disabilities. The facility is able to care for and implement nonpharmacological interventions. On average, the facility manages about 40-65 residents with behavioral health needs at a time. Resident #55 was admitted to the facility in February 2023 and had diagnoses that include depression and dementia. Review of the Nurse Practitioner's admission note indicated that Resident #55 had a question of some passive suicidal ideation, reporting that he/she feels useless and cannot do much. Review of the admission Minimum Data Set (MDS) assessment, dated 2/23/23, indicated Resident #55 scored a 13 out of a possible 15 on the Brief Interview for Mental Status exam, indicating intact cognition. Review of the Mood Interview indicated Resident #55 self-reported a PHQ9 score of 5, which indicates mild depression (score of 0-4=minimal depression, 5-9=mild depression). Review of the Resident's hospital discharge paperwork, given to the facility upon admission, indicated: -Resident's daughter states that her father/mother has been dosing [sic] some passive suicidal ideations, without any plans. I had asked patient about this as well, he/she does not have any active plans. He/she states that he/she feels 'useless and that he/she cannot do much'. He/she states that when it is time to go just let him/her go. He/she does not have any active plans, especially in the hospital. He/she states that he/she has been seeing things that other people may not see. DC instructions included: Patient does not have active SI and will not act upon thoughts. Therefore, I don't think he needs a 1:1 or safety tray at this time. Again, it may be reasonable to obtain psych consult for med recommendations for some of patient's hallucinations. At the time of admission to the facility, a psychosocial well-being care plan was developed for Resident #55 and indicated the following: Focus: Resident #55 has a potential for psychosocial well-being problem r/t Inability to meet role expectations, Recent Admission and current COVID status (initiated 2/15/23). Interventions: -Consult with: Pastoral care, Social services, Psych services, Other: (initiated 2/15/23) -Increase communication between resident/family/caregivers about care and living environment: Explain all procedures and Treatments, Medications, Results of labs/tests, Condition, All changes, Rules, Options. (initiated 2/15/23) -Initiate referrals as needed or increase social relationships: Invite and encourage Resident #55 to participate in activities. (initiated 2/15/23) -Monitor/document residents feelings relative to (isolation, unhappiness, loss). (initiated 2/15/23) -Provide opportunities for I and family to participate in care. (initiated 2/15/23) -Provide support to Resident #55 in setting realistic goals. (initiated 2/15/23) -When conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. (initiated 2/15/23) Review of Resident #55's other comprehensive care plans failed to indicate a care plan was developed for the Resident's history of suicidal ideation (SI), interventions related to the safety of Resident #55, or nonpharmacological interventions to manage thoughts of suicidal ideation. Review of the progress note, dated 8/5/23, indicated: Resident sent out at 7 PM for suicidal ideations w/ active plan. Reported to this writer that today was going to be his/her last day here i'm going out one way or another. Resident reported that he/she wants to end his/her life today and has a plan to do so. Resident declined to tell this writer what the plan is but repeatedly stated Anyway I can I'm getting it done tonight, there's lots of ways to do it. This writer stayed with resident and discussed further, Resident #55 voiced frustration with being in a LTC (long term care) facility and that at his/her age he/she should be able to end his/her life if he/she wants. Resident #55 further voiced being alone pertaining to his/her children and that they lied to get him/her here and now he/she is stuck. Resident #55 was teary eyed when discussing and also voiced concerns about his/her financial status and he/she feels his/her daughter lied to him/her and took over his/her money after agreeing placement here was only going to be temporary. This writer was able to talk with Resident #55 and he/she agreed to a hospital evaluation this evening d/t (due to) his/her current thoughts. He/she remained adamant about ending his/her life t/o (throughout) the conversation and was placed on a 1:1 (one to one supervision) until EMT's arrived for transport. Left in stable condition via stretcher accompanied by 2 EMT's, 2 police officers and local fire department. MD aware. HCP aware. (sic) Review of the hospital progress note, dated 8/5/23, indicated a Behavioral Health Crisis Consult-Initial Assessment: Reason for Consult: Patient made suicidal statement. According to the assessment presented to the hospital on 8/5/23, for Psychiatric evaluation. Behavioral health is consulted after he/she made suicidal statement, per staff from nursing home (Nurse named) patient told her that he/she is going to kill him/herself and did not share any specific plan, but patient denies making this specific statement. The trigger includes that the patient doesn't want to stay at the nursing program and he/she said that he/she wants to stay at his/her home. According to the assessment Resident #55 denied SI and then said that if he/she could get his/her hands on a gun then he/she would kill him/herself. Resident did not meet inpatient criteria and was to send back to the nursing facility with no new orders. Review of the clinical record failed to indicate that, upon readmission to the facility, Resident #55's plan of care was reviewed or updated, despite Resident #55's vocalization of suicidal ideation in the hospital and a section 12. The facility failed to develop a care plan related to suicidal ideation, that included nonpharmacological interventions, and interventions related to resident safety. Review of the Behavioral Health Group note for medication management, dated 8/9/23, indicated: Patient can benefit from: Behavior mgmt; Psychiatric meds. Review of the record failed to indicate any changes were made to the plan of care at that time to include behavioral management interventions. Review of the social service progress note, dated 10/16/23 indicated: On this date, SS met with resident and offered emotional support as resident is grieving the death of his friend. SS provided active listening and validated resident's feelings. SS reminded the resident to reach out with any additional support needed. SS to remain in place for continued support and advocacy. Review of the record fails to indicate any changes were made to the plan of care at that time to address this loss, psychosocial stressors, or potential for SI. Review of the Behavioral Health Group note for medication management, dated 10/18/23, indicated Resident #55 was seen by the Psych NP due to increased anxiety and paranoia with recommendation to increase Buspar from 5mg to 10 mg BID for anxiety/agitation. Treatment Plan (completed today): Treatment Goal / Personal Family Vision: rt will remain stable with mood/behaviors Goals: 1. Problem: anxiety - Short Term Goals: client/staff will report no more than 1-2 episode of anxiety per day - Long Term Goals: client/staff will report no more than 2-3 episode of anxiety per week. Client unable to review treatment plan due to cognitive deficit. Review of the record failed to indicate that the recommended treatment plan was communicated to staff, implemented or tracked. Review of the behavior monitoring sheets since admission failed to indicate that the facility was monitoring for any change in Resident #55's daily mood and depression. Review of the progress note dated 12/18/23 indicated: During dinner this evening patient ambulated out to the second floor balcony, climbed up on a chair and attempted to jump off the balcony. Maintenance manager witnessed patient during this attempt and pulled him/her to safety. Patient became extremely agitated screaming at manager for stopping him/her. Patient returned to his/her room with a sitter . Patient continued making suicidal ideations stating I will try and try until I succeed .FD (fire department) transported patient to hospital .etc. Review of the clinical record indicated Resident #55 was psychiatrically hospitalized [DATE]-[DATE]. Review of the clinical record failed to indicate that upon readmission to the facility, Resident #55's plan of care was reviewed or updated, despite Resident #55's suicide attempt on 12/18/23. The record indicates that an SI care plan was developed on 1/9/24, 4 days after readmission to the facility. The SI care plan developed on 1/9/24 indicated the following: FOCUS: Resident #55 has a mood problem r/t dx's (diagnoses) of Depression and Anxiety d/o (disorder), as well as recent re-admission. He/she has also had a recent suicide attempt, more specifically on 12/18/23 where he attempted to jump off the facility balcony. INTERVENTIONS: -Start 1/9/24: Administer medications as ordered. Monitor/document for side effects and effectiveness. -Start 1/9/24: Assist I (individual) in developing /Provide I with a program of activities that is meaningful and of interest. Encourage and provide opportunities for exercise, physical activity. -Start 1/9/24: Assist I, family, caregivers to identify strengths, positive coping skills and reinforce these. -Start 1/9/24: Behavioral health consults as needed (psycho-geriatric team, psychiatrist etc.) -Start 1/9/24: Educate I/family/caregivers regarding expectations of treatment, concerns with side effects and potential adverse effects, evaluation, maintenance. -Start 1/9/24: Resident #55 needs encouragement to maintain as much independence and control as possible. Resident #55's strength's are: (he/she is. strong advocate for him/herself, he/she can ask for help, can express feelings etc.) -Start 1/9/24: Monitor/document/report PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. -Start 1/9/24: Monitor/record mood to determine if problems seem to be related to external causes, i.e. medications, treatments, concern over diagnosis. -Start 1/9/24: Monitor/record/report to MD (physician) prn (as needed) acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/ eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills -Start 1/9/24: Monitor/record/report to MD prn mood patterns s/sx of depression, anxiety, sad mood as per facility behavior monitoring protocols. -Start 1/9/24: Monitor/record/report to MD prn risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons -Start 1/9/24: Observe for signs and symptoms of mania or hypomania racing thoughts or euphoria; increased irritability; frequent mood changes; pressured speech; flight of ideas; marked change in need for sleep; agitation or hyperactivity. Review of a progress note dated 3/17/24: Receptionist informed nurse that she delivered a package to resident and offered to open package for resident. Resident said yes. Package was a plastic and when receptionist offered to throw it away resident stated no, I'm [NAME] to put it over my head.Resident refuse to give the plastic, was adamant but not aggressive. This nurse approached resident and sat on the bed beside resident and gently asked for the bag. Resident laughed and stated I was joking; I want to use it for trash This nurse explained to resident why the bag needed to be taken resident laughed and stated you don't want to go to my funeral? this nurse stated No sir Resident apologized stating the joke was in poor taste and handed the bag over to this nurse. Resident was pleasant, kind, and calm. Night shift staff made aware to keep an eye of resident for any further remarks or behaviors. Review of the record failed to indicate any changes had been made to Resident #55's plan of care, care plan, or that notification to the Physician, NP or family occurred after the Resident verbalized SI. Further review failed to indicate that the facility's policy regarding SI was implemented. Review of the record failed to indicate that the physician was aware or addressed Resident #55's suicidal ideation in March 2024. During an interview on 10/30/24 at 12:19 P.M., with the facility Social Worker (SW) #1 she said that she has worked at the facility for 2 months. She said that if a resident admits to the facility with a history of verbalizing SI, whether remote or recent, she would meet with the resident upon admission and determine the history in order to develop a person centered care plan. SW #1 said that for any resident that voices SI while at the facility, or if they are hospitalized for SI while at the facility, she would review the care plan and update it when this occurs. SW #1 said that she is the only social worker in the building and that she does not know Resident #55 and that she was not aware that he/she had attempted to commit suicide while residing at the facility. SW #1 said that she would expect to have been told thus so that she could have ensured a plan of care, including nonpharmacological interventions, was in place for Resident #55. During an interview on 10/30/24 at 12:35 P.M., with the Nurse Unit Manager #1 she said that she has been the nurse unit manager for 7 years and knows Resident #55 well. According to Nurse Unit Manager #1, a comprehensive care plan regarding Resident #55's SI should have been developed at admission and she is not sure why it was not. She said that it is the expectation that the team continuously update all SI care plans with any changes in SI status. Nurse Unit Manager #1 said that while she could not recall the SI in August 2023, that at that time an SI care plan should have already been in place and would have been reviewed and updated. During an interview on 10/31/24 at 12:34 P.M., with Resident #55's Physician he said that it is his expectation that the facility would develop and implement a care plan, that includes nonpharmacological interventions, for all residents with a history of SI. The physician said that he was under the impression that Resident #55 was being followed closely by the facility's Social Worker and was surprised to hear that the Social Worker learned only the day prior from the surveyor that Resident #55 had both a history of verbalizing SI and of an actual suicide attempt at the facility. During an interview on 10/31/24 at 1:01 P.M., the Director of Nursing said when a resident is admitted with a history of suicidal ideation, they should be assessed upon admission, and a care plan should be developed that includes nonpharmacological interventions to keep the Resident safe. The DON said that the care plan should be followed and updated any time the resident voices SI or requires intervention related to SI. The DON was surprised to learn that the current facility social worker was unaware that Resident #55 had a history of SI and actual suicide attempt at the facility, and would have expected that to have been important information for her to receive when she was trained 2 months prior. 48990 2. Resident #13 was admitted to the facility in June 2024 with diagnoses including diabetes and heart failure. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/11/24, indicated Resident #13 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 15 out of 15. The MDS further indicated Resident #13 was always incontinent of bowel and bladder. Review of the most recent comprehensive MDS assessment, dated 6/13/24, indicated Resident #13 triggered for incontinence and the care area assessment indicated a need to develop an incontinence care plan. Review of Resident #13's medical record failed to indicate a care plan had been developed for incontinence care. Review of Resident #13's Documentation Survey Report, dated 10/24/24 to 10/30/24, indicated Resident #13 was incontinent six out of the seven days. On 10/29/24 at 9:21 A.M., the surveyor observed Resident #13 in bed and the room smelled strongly of stool. Resident #13 said he/she was incontinent, and that staff were aware. Resident #13 said he/she had told staff many times over the last few months that he/she would like to have incontinence care before meals, but staff said they were unable to. Resident #13 said that the staff change him/her after breakfast. On 10/30/24 at 7:45 A.M., the surveyor observed Resident #13 in bed and the room smelled strongly of stool. Resident #13 expressed being very upset because he/she had no choice but to sit in feces for the breakfast meal. Resident #13 said he/she had told staff but was told they could not provide incontinence care because it was during mealtime. Resident #13 said he/she had not had any incontinence care this shift and asked the surveyor to ask staff for assistance with incontinence care stating please, I don't want to eat breakfast in my own feces again. During an interview on 10/30/24 at 9:45 A.M., the surveyor observed Resident #13 tell Nurse #3 that she was tired of not having incontinence care provided before meals and during the night and that she had asked for many times before. Resident #13 asked Nurse #3 to change the rule that residents were not allowed to have incontinence care during meals. Nurse #3 said she didn't think staff was allowed to provide incontinence care during meals, but that she would make sure staff assisted Resident #13 with incontinence care before meals. On 10/31/24 at 7:51 A.M., the surveyor observed Resident #13 in bed with breakfast tray. Resident #13 said that she was incontinent of urine and waiting for incontinence care to be provided. Resident #13 said that he/she had asked for the care before the breakfast tray arrived, but that it had not occurred. During an interview on 10/31/24 at 9:15 A.M., Certified Nurse Assistant (CNA) #5 said Resident #13 requires assistance with incontinence care and toileting needs and never refuses care. CNA #5 said that although Resident #13 did not have any specific incontinence care interventions that she was aware of, that it was the facility expectation to provide incontinence care promptly when necessary. During an interview on 10/31/24 at 12:24 P.M., the Director of Nursing (DON) said the MDS Nurse was responsible for developing incontinence care plans that triggered on an MDS, but that nurses on the floor can also create and update care plans when needed. The DON said she was surprised there was no incontinence care plan or interventions in Resident #13's medical record as the Resident had been incessant about incontinence care not being provided. The DON said because of the Resident's past concerns with incontinence care she had told staff Resident #13 should have incontinence care before each meal, and that this is an intervention that should be on an incontinence care plan. During an interview on 11/1/24 at 8:42 A.M., the MDS Nurse said Resident #13's comprehensive MDS triggered for incontinence and that an incontinence care plan should have been developed but never was.

Based on interviews, record review, staff education review, and facility assessment review, the facility failed to ensure the nursing staff were trained and demonstrated the competencies and skill sets necessary to provide the level and types of care and services needed as outlined in the Facility Assessment. Specifically, the facility failed to ensure licensed nursing staff were trained and demonstrated competency related to wound care. Findings include: According to the Board of Registration in Nursing, 244 CMR 9.00: Standards of Conduct, a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. Review of the Facility Assessment Tool, dated 7/25/24, included but was not limited to the following: - The facility accepts residents who may develop the following common diseases, conditions, physical and cognitive disabilities or combinations of conditions that require complex medical care and management, including, but not limited to the following: integumentary system: skin ulcers, injuries. - They type of care for residents that the facility provides includes the following: Skin Integrity: Pressure injury prevention and care, skin care, wound care (surgical, other skin wounds). - Staff training/education and competencies: Consider the following competencies: wound care/dressings. Review of the facility document titled Competency Assessment, dated 2/18/22, indicated the following required competencies must be completed by licensed nurses during initial orientation, 30/60/90 days after hire, and annually thereafter: - Knowledge and understanding of physical assessment as follows: Wound assessment and dressing techniques. - Identifies and utilizes the following Documentation Tools: Wound documentation, Skin and wound care protocols. Throughout the recertification survey (10/29/24 through 11/1/24 and 11/5/24) the surveyors identified multiple concerns regarding wound care including: - failure to implement pressure ulcer prevention interventions. - failure to assess and measure wounds weekly. - failure to perform hand hygiene during wound care. - failure to obtain treatment orders for wounds. - failure to notify provider of new wounds. - failure to transcribe new wound care orders. - failure to complete weekly skin checks. The surveyor reviewed staff education files for wound competencies for three licensed nurses with identified concerns relating to wound care during the recertification survey. - 0 out of 3 had wound competencies completed within the last year. During an interview on 11/1/24 at 11:30 A.M., the Director of Nursing (DON) said the document titled Competency Assessment is the policy the facility follows. The DON said the wound competencies should have been completed annually, but there was not a staff development nurse employed from November 2023 to April 2024, and then again from August 2024 to present.

Based on record review and interviews, the facility failed to investigate allegations of neglect for two Residents (1a. discharged Resident #1 and 1b. discharged Resident #2) out of a total sample of 27 residents. Findings include: Review of the facility policy titled, Abuse Prohibition, dated as last revised 7/13/22, indicated the following: -Neglect - any failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness. -Allegations of abuse will be promptly and thoroughly investigated. -The Administrator and Director of Nursing are responsible for investigation and reporting. -The investigation will begin immediately after reporting the actual or suspected incident. -Initiate the investigation using factual data. The investigation should be thorough with witness statements from staff, residents, visitors, and family members who may be interviewable and have information regarding the allegation. -The results of the investigation will be documented. -Conclusion must include whether the allegation was substantiated or not and what information supported the decision. The conclusion/summary must take into account an objective overview of the facts and a reason or basis for the decision, to substantiate or not substantiate the allegation. 1a. discharged Resident #1 was admitted to the facility in March 2024 with diagnoses including quadriplegia. Review of discharged Resident #1's most recent Minimum Data Set (MDS) dated [DATE], had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, which indicated he/she was cognitively intact. The MDS also indicated discharged Resident #1 was dependent on staff for toileting tasks. Review of the Grievance/Concern Form, dated 3/25/24 indicated the following: -Incontinence request for change. When (he/she) asked the aid (name) to change (him/her) that (he/she) was wet, (he/she) was told that they would change (him/her) when they go around and do everyone else later. -The Action Taken section of the grievance form was left blank. -Summary of Findings or Conclusions section of the grievance from said Incident was a miscommunication between the CNA (Certified Nursing Assistant) and the resident. 1b. discharged Resident #2 was admitted to the facility in September 2023 with diagnoses including congestive heart failure. Review of discharged Resident 2's most recent Minimum Data Set (MDS) dated [DATE], had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, which indicated he/she was cognitively intact. The MDS also indicated discharged Resident #2 required substantial/dependent. Review of the Grievance/Concern Form, dated 1/23/24 indicated the following: -Left without assistance to be put back to bed. I requested to be put back to bed more than 3 times each time I was told that I had to wait. I was in the chair for 9 hours. This is not the first time I was left in the chair for a long period of time. -Action Taken - spoke with CNAs on the unit - reviewed expectations. If issue arise that they are delayed, it needs to be communicated to the resident. Review of the Grievance/Concern Form, dated 3/29/24 indicated the following: -(he/she) did not get back to bed until PM. The 7-7 aid said (he/she) could get back to bed once the 2nd aid came. That did not happen and (he/she) is upset. -Action Taken - only listed the CNAs on duty. -Follow-Up - Educated staff regarding hoyer return to bed. Ask for help if necessary. -Additional steps - CNAs to be educated on customer service and patient care. Ask for assistance if necessary. During an interview on 10/30/24 at 1:27 P.M., the Director of Nursing (DON) said she has been responsible for handling the grievance in the building since the facility had been without a social worker for some months. The DON said she reads all grievances and if there is something she feels rises above the level of a grievance she would report this incident to the State Agency. The DON said she would consider it neglect if a resident was told to wait for incontinence care such as discharged Resident #1's grievance indicated. The DON also said it is not acceptable for any residents to wait for the next shift to be assisted back to bed. The DON said discharged Resident #2 was a bariatric resident and required up to three staff members at times to get back into bed. The DON said there may not have been enough staff at that time to assist the Resident. The DON said she looked at these grievances as more of a customer service concern. The DON said she may have paperwork on the follow-up she did with staff and would bring it to the surveyor. The DON was unable to provide any investigations for any of the three grievances listed.

Based on record review and interview, the facility failed to follow their abuse policy for one Resident (#38) out of a total sample of 27 residents. Specifically, the facility did not implement the corrective actions after an abuse investigation was conducted. Findings include: Review of the facility policy titled Abuse Prohibition, dated 2/20/23, indicated the following: - Policy: Allegations of abuse will be reported promptly and thoroughly investigated. - The Administrator and Director of Nursing are responsible for investigating and reporting. They are also ultimately responsible for the following as they relate to abuse, neglect, and/or misappropriation of property standards and procedures: - Implementation - Ongoing monitoring - Implementation of corrective actions and measures to prevent recurrence. Resident #38 was admitted to the facility in August 2022 with diagnoses including depression and unsteadiness on feet. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/4/24, indicated that Resident #38 had severe cognitive impairment. Review of the MDS indicated Resident #38 required substantial to maximal assist with transfers. Review of the incident report for Resident #38, dated 10/18/24, indicated a staff member alleged physical abuse by another nurse on Resident #38 when the staff member incorrectly transferred Resident #38. Review of the corrective measures for the allegation of abuse included updating the resident's care plan and follow up from the Social Worker for Resident #38. Review of the clinical record failed to indicate the care plan was updated or that the social worker assessed Resident #38 after an allegation of physical abuse. During an interview on 10/31/24 at 12:53 P.M., the Director of Nursing said that it was her fault for not updating the care plan, but that she provided education to staff. The Director of Nursing said she was not sure if the Social Worker followed up, but would find out. Review of the Social Worker's notes failed to indicate that a follow up occurred for Resident #38.

Based on interview, record review, and policy review, the facility failed to ensure one Resident's (#31) grievances were addressed, out of 27 total sampled residents. Specifically, the facility failed to follow their grievance policy when Resident #31 expressed concern multiple times about the staff behavior of sleeping while on duty. Findings include: Review of the facility policy titled Grievances/Concerns, revised 12/6/21, indicated: - Residents or their representatives may file a grievance or complaint concerning treatment, medical care, behavior of other residents, or staff members. Employees of the facility will assist residents and their representatives in the grievance/complaint process when such requests are made. - Grievances/concerns may be submitted orally or in writing. The person/staff receiving an oral grievance/concern will fill out the Grievance/Concern Form for submission to leadership. - The grievance/concern investigation will be initiated upon receipt and a written report/resolution will be made available to the Administrator within five (5) days. - Grievances/Concerns will be recorded in the Grievance Log. Grievance/Concern forms will be kept for a minimum of three (3) years. Resident #31 was admitted to the facility in September 2023 with diagnoses including end stage renal disease and hypotension. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/24/24, indicated Resident #31 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 15 out of 15. On 10/29/24 at 8:03 A.M., Resident #31 told the surveyor that there is an ongoing problem with staff sleeping during the night shift. Resident #31 said he/she has complained to the Director of Nursing (DON), a social worker who is no longer employed at the facility, many nurses, and Certified Nursing Assistants (CNAs) for close to a year. Resident #31 said when he/she continued to see staff sleeping instead of working over the summer he/she took a picture of the staff member sleeping. Resident #31 said after he/she complained to administration and showed them the picture, the social worker at the time, came to his/her room and asked him/her to delete the photograph. Resident #31 said that the staff member continued to be employed and sleep on the unit during the night. Resident #31 said he/she saw the staff member, who he/she had taken the picture of sleeping, again asleep in a chair in the hallway as recently as two weeks ago. Resident #31 said he/she again complained to the nurses on the floor about observing staff sleeping on the unit when it happened two weeks ago, but he/she feels like no matter how many times he/she complains it never gets resolved. Review of the facility's Grievance Log failed to indicate any grievances had been filed in the past year regarding Resident #31's complaints of staff sleeping on the unit instead of working. During the Resident Group interview on 10/30/24 at 10:03 P.M., six out of twelve residents were in attendance and reported that recently staff were sleeping when they were supposed to be working on the night shift. They said call lights do not get answered at night. Two of these residents had seen staff sleeping recently. - One resident said he/she came back from the hospital at night recently and two CNAs were sleeping on the unit. - Another resident said on Sunday morning he/she saw staff sleeping at 4:45 A.M. in the day room. During an interview on 11/1/24 at 6:32 A.M., CNA #9 said if a resident had a concern about staff behavior, such as sleeping, they would let the nurse know so they could follow up. CNA #9 said grievance forms are filled out by nurses. During an interview on 11/1/24 at 6:40 A.M., Nurse #4 said if a resident had a concern about staff behavior, such as sleeping, they would fill out a grievance form, which is kept at the nurse's station. During an interview on 10/30/24 at 1:28 P.M., the Director of Nursing (DON) said grievances forms should be completed when residents have complaints about inappropriate staff behavior, such as sleeping. The DON said she knew about the concerns Resident #31 had with staff sleeping and had spoken to him/her about his/her concerns. The DON said she had fired a few staff for sleeping at the time and thought the issue was resolved. The DON could not locate any grievance forms or investigations related to Resident #31's repeated concerns regarding a specific staff person sleeping. During an interview on 10/30/24 at 2:04 P.M., the Administrator said he would expect a grievance to have been completed for Resident #31 if he/she voiced concerns about staff sleeping.

Based on observations, interviews and record review, the facility failed to notify the physician of a significant change in the resident's skin condition and obtain wound treatment orders for two Residents (#4 and #269) out of a total sample of 27 residents. Specifically; 1a.) for Resident #4, the facility failed to notify the provider and obtain wound care orders for the newly re-developed pressure ulcer on the left upper Achilles heel; 1b.) for Resident #4, the facility failed to notify the provider and obtain wound care orders for a skin tear on his/her left hand; and 2.) for Resident #269, the facility failed to notify the provider and obtain wound care orders for a skin condition on his/her buttocks. Findings include: Review of the facility policy titled Skin Body Audit, revised 3/12/13, indicated: - Any significant abnormal findings are reported to the resident's physician. 1.) Resident #4 was admitted to the facility in December 2023 with diagnoses including end stage renal disease and diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/11/24, indicated Resident #4 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 15 out of 15. This MDS indicated Resident #4 required partial/moderate assistance with transferring from bed to chair, moving from a sitting to a standing position, and with lower body dressing. This MDS also indicated the Resident had one deep tissue pressure injury (DTI) and was at risk for developing pressure ulcers. Review of Resident #4's plan of care related to potential for new skin breakdown, revised 9/19/24, indicated: - Resident #4 has the potential for new skin breakdown due to impaired mobility, episodes of incontinence, and diagnosis of type 2 diabetes. - Assist with turning/ redistributing weight per facility protocol. - Complete skin checks weekly per facility protocol. Pay particular attention to the bony prominences. - Notify MD if any skin breakdown occurs. a.) Review of Resident #4's assessment titled Weekly Skin Checks, dated 10/18/24, failed to indicate a pressure related wound on his/her left upper Achilles heel. Review of Resident #4's current physician's orders indicated: - Wound: left medial heel (the inner side of the heel below the Achilles heel), apply skin prep to area daily. Review of Resident #4's medical record failed to indicate the provider had been notified or that wound orders were obtained for his/her left upper Achilles heel unstageable pressure ulcer within the last three months. During an interview on 10/31/24 at 8:09 A.M., Resident #4 said he/she likes his/her heels elevated because of the wound on his/her left heel. During an interview on 10/31/24 at 8:33 A.M., Nurse #2 said she was a consistently assigned day shift nurse for Resident #4 during the last two weeks. Nurse #2 observed Resident #4's heels with the surveyor and said there was an unstageable pressure ulcer on his/her left upper Achilles heel that had been there since she started two weeks ago. Nurse #2 said there is no treatment in place for the pressure ulcer on left upper Achilles heel. Nurse #2 said she applies skin prep (a topical medication used to prevent skin breakdown) to the medial aspect of the heel only and never applies to the pressure ulcer on left upper Achilles heel because there is no order for it to be applied to that anatomical location. Nurse #2 said she never notified the provider or obtained wound orders because it had been there since she started. During an interview on 10/31/24 at 10:48 A.M., Nurse Unit Manager #1 said Resident #4 had a history of a having a healed pressure ulcer on the left upper Achilles heel, which healed in the Spring of 2024. Nurse Unit Manager #1 observed Resident #4's left upper Achilles heel and said there is now an unstageable pressure ulcer that she was unaware of. Nurse Unit Manager #1 said the order for skin prep to the left medial heel does not cover the left upper Achilles heel, and the provider should have been notified to obtain wound treatment orders, but had not been. During an interview on 10/31/24 at 12:30 P.M., the Director of Nursing (DON) said the provider should have been notified of the newly re-developed left upper Achilles heel unstageable pressure ulcer and wound orders should have been obtained. b.) Review of Resident #4's progress notes, assessments, and physician notes fail to indicate the presence of wound on his/her left hand. Review of Resident #4's medical record failed to indicate the provider had been notified or that wound orders were obtained for his/her left hand wound in the last month. On 10/29/24 at 9:01 A.M., and 10:34 A.M., 10/30/24 at 7:37 A.M., 9:16 A.M., and 10:01 A.M., and 10/31/24 at 8:09 A.M., the surveyor observed Resident #4 in bed with a white undated dressing on his/her left hand. There was dark brown drainage visible through the dressing in the same location during each observation. During an interview on 10/31/24 at 8:09 A.M., Resident #4 said staff applied the dressing to his/her hand because he/she bumped the left hand on a door last week. Resident #4 said he/she was still wearing the original dressing from when the incident occurred. During an interview on 10/31/24 at 8:28 A.M., Certified Nurse Assistant (CNA) #7 said Resident #4 had a dressing on his/her right hand since at least Monday (10/28/24). During an interview on 10/31/24 at 8:33 A.M., Nurse #2 said all wound dressings require orders from the physician. Nurse #2 reviewed Resident #4's physician's order and said there was no physician's order for the dressing on his/her left hand but there should be. On 10/31/24 at 10:48 A.M., the surveyor observed Resident #4's left hand with Nurse Unit Manager #1. There was a new dressing in place, dated 10/31/24. Nurse Unit Manager #1 said she had just changed the dressing because she realized Resident #4 did not have an order in place. Nurse Unit Manager #1 said the physician had not been notified to obtain wound orders but should have been. During an interview on 10/31/24 at 12:21 P.M., the Director of Nursing (DON) said the provider should have been notified to obtain wound orders at the time the wound was identified, as all treatments require a physician's order. 2.) Resident #269 was admitted to the facility in October 2024 with diagnoses including diabetes and a right arm fracture. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/27/24, indicated Resident #269 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 14 out of 15. The MDS indicated that Resident #269 did not have any wounds. Review of Resident #269's Admission/ Readmission Nursing Assessment, dated 10/21/24, indicated the Resident had a pressure wound on his/her buttocks upon admission. Review of Resident #269's assessments titled Weekly Skin Checks, dated 10/22/24 and 10/28/24, indicated - Right and left buttock pressure wounds. Review of Resident #269's assessment titled Weekly Skin Checks, dated 10/30/24, indicated: - Reddish, darkened discoloration of inner right and left buttock and perianal area. Areas non-blanchable and non-painful. Review of Resident #269's medical record failed to indicate the provider had been notified of the wounds or that wound orders were obtained for his/her right and left buttocks and/or perianal area. During an interview on 10/30/24 at 9:38 A.M., Nurse Unit Manager #1 said the nurse told her on 10/28/24 that upon admission on 10/21/24 Resident #269 had two pressure areas on his/her buttocks. Nurse Unit Manager #1 said she had not had a chance to investigate yet and that there were no wound orders in place for the buttocks. On 10/30/24 at 9:48 A.M., the surveyor observed Resident #269's buttocks and perianal area with Nurse Unit Manager #1 and the MDS Nurse. The buttocks and perianal area were discolored deep purple/red. Nurse Unit Manager #1 and MDS Nurse said they did not believe it was pressure related because the discoloration extended throughout the entire perianal area and were unsure what they would describe this wound to be. During a follow-up interview on 10/30/24 at 10:05 A.M., Nurse Unit Manager #1 said she was not sure what type of wound this was but that the physician should have been notified of the skin condition on admission and wound orders should have been obtained, such as a topical cream or offloading, but were not. During an interview on 10/31/24 at 12:21 P.M., the Director of Nursing (DON) said the provider should have been notified of Resident's buttocks/perianal wound and wound orders should have been obtained. Refer to F686.

Based on observation, record review and interview the facility failed to provide a dignified existence for one Resident (#13) out of a total sample of 27 residents. Specifically, the facility failed to provide requested incontinence care before meals resulting in Resident #13 repeatedly eating breakfast while sitting in a soiled brief, on multiple days of survey, in a room that smelled strongly of feces. Findings include: Review of the facility policy titled Dignity/Quality of Life, revised 12/6/21, indicated: - Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. - Demeaning practices and standards of care that compromise dignity is prohibited. Staff shall promote dignity and assist residents as needed by: promptly responding to the resident's request for toileting assistance. Resident #13 was admitted to the facility in June 2024 with diagnoses including diabetes and heart failure. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/11/24, indicated Resident #13 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 15 out of 15. The MDS further indicated Resident #13 was always incontinent of bowel and bladder. Review of the most recent comprehensive MDS assessment, dated 6/13/24, indicated Resident #13 triggered for incontinence and the care area assessment indicated a need to develop an incontinence care plan. Review of Resident #13's medical record failed to indicate a care plan had been developed for incontinence care. Review of Resident #13's Documentation Survey Report, dated 10/24/24 to 10/30/24, indicated Resident #13 was incontinent six out of the seven days. On 10/29/24 at 9:21 A.M., the surveyor observed Resident #13 in bed and the room smelled strongly of feces. Resident #13 said he/she was very upset because he/she had no choice but to sit in feces for the breakfast meal, which he/she had finished eating. Resident #13 said that staff were aware as he/she had told them before his/her breakfast tray came that he/she had a bowel movement and needed incontinence care. Resident #13 said that staff said they couldn't assist him/her because they were passing meal trays to other residents. Resident #13 said he/she had told staff many times over the last few months that he/she would like to have incontinence care before meals, but staff said they were unable to. On 10/30/24 at 7:45 A.M., the surveyor observed Resident #13 in bed and the room smelled strongly of feces . Resident #13 expressed being very upset because he/she had no choice but to sit in feces for the breakfast meal. Resident #13 said he/she had told staff but was told they could not provide incontinence care because it was during mealtime. Resident #13 said he/she had not had any incontinence care this shift and asked the surveyor to ask staff for assistance with incontinence care stating please, I don't want to eat breakfast in my own feces again. During an interview on 10/30/24 at 9:45 A.M., the surveyor observed Resident #13 tell Nurse #3 that he/she was tired of not having incontinence care provided before meals and during the night and that he/she had asked for it many times before. Resident #13 asked Nurse #3 to change the rule that residents were not allowed to have incontinence care during meals. Nurse #3 said she didn't think staff was allowed to provide incontinence care during meals, but that she would make sure staff assisted Resident #13 with incontinence care before meals. On 10/31/24 at 7:51 A.M., the surveyor observed Resident #13 in bed with breakfast tray. Resident #13 said he/she was upset and said he/she did not have a bowel movement yet this morning but was incontinent of urine and waiting for incontinence care to be provided that he/she had asked for before his/her breakfast tray arrived. During an interview on 10/31/24 at 9:15 A.M., CNA #5 said Resident #13 requires assistance with incontinence care and toileting needs and never refuses care. During an interview on 10/31/24 at 12:24 P.M., the Director of Nursing (DON) said that no resident should have to sit in a soiled brief for meals. Further, the DON said that she was aware that Resident #13 was upset about this exact concern in the past and had addressed the need for this Resident to have incontinence care provided promptly and before meals with staff, so this should not be happening to Resident #13.

Based on interviews and records reviewed, for one of three sampled residents (Resident #2), the Facility failed to maintain an environment free from accident hazards to prevent a burn injury sustained by Resident #2. - On 12/03/17 Resident #2 asked a Certified Nurse Aide (CNA) for a cup of tea, the CNA brought the cup of tea to Resident #2, told him/her that it was very hot, that the water had been heated in a microwave, Resident #2 let the tea steep for approximately 15 minutes, and while removing the tea bag from the cup, it dropped on to his/her abdomen, resulting in a second degree burn (area appears red and blistered). Findings include: The Surveyor interviewed Resident #2 at 12:43 P.M. on 1/24/18. Resident #2 said he/she had asked a CNA (name unknown) to heat up his/her water for tea, and said the CNA brought the cup of water back and told him/her to be very careful, because the water was hot and had come out of the microwave. Resident #2 said he/she was not sure who the CNA was. Resident #2 said he/she let the tea steep for approximately 15 minutes while he/she ate lunch, then removed the tea bag and tried to toss it onto the tray, but it bumped something and landed on his/her abdomen, scalding it through the sheet. Resident #2 said he/she swiped the tea bag away quickly, said it was only on his/her abdomen for a second, and had not made a mark at that time. Resident #2 said he/she reported it to the nurse later in the day, when the area began to peel. Resident #2 showed the Surveyor a scarred area on his/her abdomen approximately 5 centimeters (cm) by 3.5 (cm), the size of a tea bag. Resident #2's Quarterly Minimum Data Set, dated dated [DATE], indicated he/she was cognitively intact, could feed him/herself, but was completely dependent on staff for transfers and mobility. Review of Resident #2's Activity of Daily Living (ADL) Flow sheet, dated 12/01/17 through 12/31/17, indicated Resident #2 was non-ambulatory and use of wheelchair, geri-chair, or recliner, was coded as does not apply, (indicating Resident #2 does not get out of bed and could not have heated the water for the cup of tea on his/her own). The Nurse's Note, dated 12/3/17 on the 3:00 P.M. to 11:00 P.M. shift, indicated Resident #2 reported a tea bag had fallen onto his/her abdomen earlier that day, and a reddened, tender area was observed on Resident #2's abdomen. Resident #2's physician's orders [REDACTED]. The Nurse Practitioner (NP) progress note, dated 12/05/17, indicated Resident #2 had a self-inflicted burn on his/her abdomen. Review of Resident #2's Treatment Administration Record (TAR), dated 12/08/17, indicated new orders to keep burn area on abdomen clean and dry, minimize skin exposure to moisture until healed, avoid shearing residents skin during positioning, transfer and turning until burn is healed, and monitor burn site on abdomen for signs and symptoms of infection. The TAR indicated Resident #2 required treatment to the burn on his/her abdomen from 12/03/17 until 12/21/17, when it was documented as healed. The Facility policy titled Microwave Policy, dated 9/6/17, indicated staff would not reheat any foods or beverages in the microwaves on the units. The Surveyor interviewed the Director of Nurses (DON) at 8:33 A.M. on 1/24/18. The DON said Resident #2 was known to stay in bed throughout the day with only a sheet covering him/her, and would eat in bed per his/her preference. The DON said that during the Facility's internal investigation, Resident #2 declined to identify which staff member (CNA) had brought him/her the tea and said Resident #2 would not say how the tea was heated. The DON said staff who worked the 7:00 A.M. to 3:00 P.M. shift on 12/3/17 were interviewed and all denied serving Resident #2 tea at lunch time. The DON said staff were not allowed to heat food or beverages for residents in the microwaves on the units, and were to bring the food or beverages to the dietary department to be heated, because heating in the microwave could result in the food or beverage becoming too hot, and potentially causing burns. The DON said all staff were educated to the Microwave Policy, and said all agency staff were educated to the Microwave policy before working their first shift at the Facility. The Facility's staffing sheet, dated 12/3/17 indicated Certified Nurse Aide (CNA) #1, CNA #2, CNA #3, and CNA #5 worked on the second floor unit during the 7:00 A.M. to 3:00 P.M. shift on 12/3/17. The Surveyor interviewed CNA #2 at 10:48 P.M. and CNA #1 at 12:58 P.M. on 1/24/18. CNA #2 and CNA #1 said they did not serve Resident #2 lunch or bring him/her tea on 12/3/17. CNA #2 and CNA #1 said staff are not allowed to heat food or beverages for residents in the microwave per Facility policy. The Surveyor interviewed CNA #3 at 12:01 P.M. on 1/26/18. CNA #3 said she did not serve Resident #2 lunch or bring him/her tea on 12/3/17. CNA #3 said if a resident asked her to heat up food or beverages she would heat it in the microwave located on the unit and bring it back to the resident. CNA #3 said she never asked if heating food in the microwave was allowed, and said it was just how she did it, or words to that effect. This was not consistent with the Facility's Microwave use Policy or with information provided by the DON during her interview. The Surveyor interviewed CNA #5 at 9:45 A.M. on 2/6/18. CNA #5 denied serving any food or tea to Resident #2 on 12/3/17. CNA #5 said the 7:00 A.M. to 3:00 P.M. shift on 12/3/17 was the first shift she worked at the Facility, and said she was not educated to the Microwave policy before beginning her shift. CNA #5 said if a resident asked for their food to be heated up, she would heat it in the microwave and return it to the resident, and said if it was a beverage she would tell the resident to give it a few minutes to cool off, or words to that effect. This was not consistent with the Facility's Microwave use Policy or with information provided by the DON during her interview.