Every finding on record at Odd Fellows Home of Massachusetts

Based on observations, interviews, and record review, the facility failed to assist three Residents (#30, #62, and #88), with signed consents, out of a total sample of 19 residents, in obtaining routine dental care, increasing the Residents' risks for unidentified dental disease and deteriorating oral health.Findings include:Review of the facility's Dental Services Policy, last revised [DATE], indicated the following: -Residents and/or their responsible party are responsible for the selection of a dentist or dental service to be used by the resident for dental supervision while in the facility. -Residents are assisted in obtaining regular and emergency dental care through the dentist or the dental service indicated at the time of admission. -Each resident may have an annual oral examination by a licensed dentist, and this examination shall be recorded on the resident's record. Review of the American Dental Association (ADA) guidance titled Your Top Nine Questions About Going to the Dentist - Answered, dated 2026 and located at Common Questions About Going to the Dentist | MouthHealthy - Oral Health Information from the ADA included the following: -Regular dental visits are important because they can help spot dental health problems early . -See a dentist if you have a medical condition such as Diabetes, Cardiovascular Disease, . -Even if you don't have any symptoms, you can still have dental health problems that only a dentist can diagnose. -Regular dental visits will also help prevent problems from developing. 1. Resident #30 was admitted to the facility in [DATE] with diagnoses including Diabetes, Hypertension, and gastro-esophageal reflux disease (GERD). Review of Resident #30's Minimum Data Set (MDS) Assessment, dated [DATE], indicated: -The Resident has clear speech (distinct intelligible words). -The Resident usually makes self understood (difficulty communicating some words or finishing thoughts but is able if prompted or given time). -The Resident usually understands others (misses some part/intent of message but comprehends most conversations). -The Resident has no facial pain, discomfort or difficulty with chewing. Review of Resident #30's Dental Consent Form, dated [DATE], indicated the Resident consented to dental care services. Review of Resident #30's Nursing Note, dated [DATE], indicated: -The Resident complained of tooth pain. -The Nurse Practitioner (NP) assessed the Resident and prescribed Amoxicillin (antibiotic medication) to be administered for seven days. -The NP placed a referral for the Resident to see a dentist. Review of Resident #30's NP Note, dated [DATE], indicated: -The Resident was assessed for tooth pain. -The Resident complained of severe pain in the molars. -The Resident's second molar was red and swollen on both sides of his/her mouth. -The Resident was diagnosed with a tooth infection and the NP ordered Amoxicillin to be administered to the Resident for seven days. Review of Resident #30's Nursing Note, dated [DATE], indicated the Resident went to the dentist that same day and the dentist did not see the Resident due to the Resident's insurance being expired. Review of an [Insurance] Note, dated [DATE], indicated . no eligibility [DATE] to [DATE]. Now elig (eligible) [DATE] to current. Review of Resident #30's clinical record did not include any evidence the facility assisted the Resident in obtaining routine dental care between the date the Resident consented to dental services ([DATE]) and when the Resident went to the dentist on [DATE] (six years). Further review of the Resident's clinical record did not include any evidence that the facility assisted the Resident in obtaining a dental appointment after the facility was notified of the Resident's eligibility for insurance on [DATE]. During an interview on [DATE] at 9:29 A.M., Resident #30 said he/she has not been seen by a dentist for oral cavity inspection and his/her teeth have not been cleaned in over a year. Resident #30 said he/she thinks he/she may have some cavities that need fillings because he/she had a toothache a while ago. Resident #30 said he/she wants to see a dentist. Resident #30 said his/her teeth do not bother him/her currently. During an observation at this time, the surveyor observed Resident #30 with areas of brown discoloration on his/her front top teeth. During an interview on [DATE] at 5:15 P.M., Nurse Manager #1 said Resident #30 consented to dental services in 2019. Nurse Manager #1 reviewed Resident #30's clinical record and said that the Resident went to see a dentist recently due to having a toothache, and that he located no evidence the Resident had been provided routine dental care since the Resident consented to dental services in 2019. During an interview on [DATE] at 7:50 A.M., Nurse Manager #1 said Resident #30 went to the dentist on [DATE] due to experiencing a toothache. Nurse Manager #1 said the dentist did not see the Resident because the Resident's insurance had expired. Nurse Manager #1 said the Resident's insurance had been renewed but that the facility had not yet provided the Resident assistance to obtain a dental appointment. Nurse Manager #1 said it is important to obtain routine dental care services for residents to prevent dental health problems. 2. Resident #62 was admitted to the facility in February 2026 with diagnoses including Unspecified Dementia, Type 2 Diabetes Mellitus, Deficiency of other Vitamins, other Vitamin B12 Deficiency Anemias and Essential Primary Hypertension. Review of Resident #62's [DATE] Physician's Orders indicated the following:-Dental consult as needed, initiated [DATE]. Review of Resident #62's admission record dated [DATE] indicated the Resident wears both full upper and lower dentures. Review of Resident #62's Care Plan did not include any problems, goals, or interventions for dental care. Review of the Dental Services Contract indicated that Resident #62 requested dental services on [DATE]. Review of the MDS Assessment, dated [DATE], indicated Resident #62:-had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15 points.-was able to make him/herself understood and understands others-had no natural teeth or tooth fragments. On [DATE] at 8:18 A.M., the surveyor observed the Resident with no teeth in his/her mouth. During an interview on [DATE] at 12:52 P.M., the Resident said that he/she had no natural teeth or dentures. The Resident said that he/she would like to see a dentist for an oral exam. The Resident said that he/she consented upon his/her admission to the facility and requested dental services but had not been given a date and or a time of an appointment. During an interview on [DATE] at 1:42 P.M., the Administrator said that ancillary physician services included a dental provider which was available to residents who reside in the facility every six months and as needed. The Administrator said that 'as needed' indicated that the facility would schedule the service and put Resident #62 on the list to be seen upon his/her request. The Administrator said that dental services were last provided in the facility on [DATE]. During an interview on [DATE] at 3:30 P.M., with the Administrator and Unit Manager (UM) #1, the Administrator said that she was unable to provide evidence that Resident #62 was currently on the list to be seen for dental services. The Administrator also said that dental services should have been scheduled for Resident #62 but it was not. The Administrator further said that Resident #62 was currently not on the list to be seen for dental services and should have been put on the list for the next scheduled dental services. During an interview on [DATE] at 8:22 A.M., admission Coordinator #1 said that she was responsible in ensuring that all consent forms for ancillary services were signed upon admission to the facility by residents and the resident HCP. admission Coordinator #1 also said that she uploads the consent forms into the electronic medical records and gives the hard copy of the consent forms to nursing staff. The admission Coordinator said that nursing staff were responsible for ensuring that residents had been put on dental services vendor list to be seen. During an interview on [DATE] at 8:48 A.M., the Director of Nursing (DON) said that when a resident or a resident representative signs a request for dental services, the resident was then put on a list to be seen by the dental services vendor and arrange for a resident's transportation to their own dental provider outside the facility. The DON said that nursing staff were responsible for ensuring that residents who had consented for dental services were put on the next list to be seen. The DON said Resident #62 was recently admitted to the facility, but he/she should have been put on the dental services vendor list to be seen for the next scheduled visit but was not. 3. Resident #88 was admitted to the facility in [DATE] with diagnoses including Dysphagia, Oropharyngeal Phase, Pulmonary Hypertension, and Anemia. Review of Resident #88's [DATE] Physician Orders indicated the following:-Dentists consult as needed, initiated [DATE]. Review of the Dental Services Contract indicated that Resident #88's HCP requested dental services on [DATE]. Review of the MDS Assessment, dated [DATE], indicated Resident #88:-had cognitively intact as evidenced by a BIMS score of 13 out of a possible 15 points. -usually makes him/herself understood and usually understands others. Further review of MDS Section L: Oral/Dental Status, failed to identify any concerns with Resident #88's dental condition. During an interview on [DATE] at 8:55 A.M., the Resident said that he/she had not seen a dentist since he/she had been in the facility and he/she would like to be examined. The Resident said he/she had no teeth or dentures and wanted to be evaluated for dentures. The Resident said that he/she had mentioned that he/she wanted to see a dentist to a staff member but had not heard a response back with an appointment date and time. During an interview on [DATE] at 4:00 P.M., the Administrator said that Resident #88's HCP had consented to dental services on [DATE]. The Administrator said that Resident #88 consent forms were not followed when the vendor for dental services was in the facility on [DATE]. The Administrator said that Resident #88 was not put on the list to be evaluated for dentures until the surveyor brought it to their attention. The Administrator said that Resident #88 should have been evaluated by dental services on [DATE] when the dental services vendor was in the facility and had not been.

Based on observations, interviews, and record review, the facility failed to implement infection control practices to prevent transmission of infections for three Residents (#64, #13, and #32), out of a total sample size of 19 residents. Specifically, the facility failed:1. For Resident #64, to implement Contact precautions (the use of protective equipment such as gowns and gloves to prevent the spread of parasites from one person to another) in accordance with Resident's plan of care plan increasing the risk to other residents, staff and visitors for contracting scabies (tiny mites that burrow under a person's skin, lay eggs and trigger an allergic reaction that causes itching). 2. For Resident #13, to implement Contact Precautions when the Resident became symptomatic and tested positive for Clostridioides difficile (C. diff: a bacterium causing severe diarrhea and colitis), which increased the risk for transmission of C. diff among residents and staff. 3. For Resident #32, to ensure that Enhanced Barrier Precautions (EBPs - the use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing), were appropriately utilized when providing high contact care for the Resident, to mitigate the risk of organism transmission and the spread of infection to the Resident and other residents within the facility. Findings include: 1. Review of the facility's policy titled Contact Precautions, dated 4/15/25, included but was not limited to: Contact Precautions are indicated for those residents known to be infected/colonized with an infectious organism that could be transmitted through direct contact with a resident or by direct contact with the environmental surfaces/equipment. -Diseases requiring contact precautions include: >Scabies >Clostridium Difficile (C. diff- a highly contagious bacterial infection that causes severe diarrhea) Resident #64 was admitted to the facility in January 2026. Review of Resident #64's person centered care plan indicated the following: -Problem: Residents [sic] have skin rashes, suspected Scabies, start date 2/20/26. -Goal: Staff will maintain Contact Precautions. -Approach: >Maintain Contact Precautions at all times, start date 2/20/26 Review of Resident #64's March 2026 Physician's Orders indicated the following: Permethrin (a topical medication used to treat Scabies) 5% cream, apply cream than [sic] shower after eight (8) to 12 hours. Repeat the same process in seven (7) days once a day every seven days, with a start of 2/21/26 and an end date of 3/9/26. Scabies examination once-one time, effective 3/3/26. Scabies examination once-one time, effective 3/11/26. During an observation on 3/25/26 at 10:15 A.M., the surveyor observed signage posted to Resident #64's room that included but was not limited to: CONTACT PRECAUTIONS REPORT TO NURSE BEFORE ENTERING >Don (put on) gloves upon entry into the room. >Remove gloves before leaving patient room. >Don gown upon entry into the room. >Remove gown and preform hand hygiene before leaving the patient care environment. During an observation and interview on 3/25/26 at 10:20 A.M., the surveyor observed Housekeeping Staff #1 holding clothing in her arms and enter Resident #64's room without performing hand hygiene or donning a gown and gloves. Housekeeping Staff #1 opened the Resident's top dresser drawer, placed clothing inside, then closed the drawer. Housekeeping Staff #1 then opened the Resident's closet door, placed clothing into the Resident's closet then closed the closet door. Housekeeping Staff #1 then exited the room without performing hand hygiene. Housekeeping Staff #1 said Resident #64 was on Contact Precautions for a rash. Housekeeping Staff #1 said that because she did not touch the Resident, she did not need to wear a gown and gloves or clean her hands in the Resident's room. Housekeeping Staff #1 then continued to deliver clothing to other resident rooms on the unit. During an observation and interview on 3/25/26 at 10:22 A.M., the surveyor observed Certified Nurse Aide (CNA) #1 enter Resident #64's room without performing hand hygiene or donning a gown and gloves. CNA #1 then pushed the Resident's privacy curtain at the center of the room back to the wall and turned off the Resident's call light. The privacy curtain was observed to make contact with CNA #1's right and left hands as well as her shirt. CNA #1 then pulled the Resident's bed linens up to the head of the bed while making contact with the Resident's bed against her legs, exited the room and did not perform hand hygiene. CNA #1 said that she was not giving care to the Resident, so she did not need to put on a gown and gloves. CNA #1 said that the Resident had Contact Precautions for scabies but did not have scabies any longer. During an interview on 3/25/26 at 10:24 A.M., the Infection Preventionist (IP) said Resident #64 had been started on Contact Precautions and treated with Permethrin for suspected scabies starting on 2/21/26. The IP said that Resident #64 still had a rash remaining to the thighs, so Contact Precautions needed to continue until the Resident was seen by Dermatology to be cleared of the suspected scabies infection. The IP said that all staff should don a gown and gloves before entering Resident #64's room. The IP said that when staff failed to follow Contact Precautions scabies could be spread to other residents, staff, and visitors in the facility. 2. Resident #13 was admitted to the facility in October 2025 with diagnoses including Toxic Gastroenteritis and Colitis, and Clostridioides difficile (C. diff: a bacterium causing severe diarrhea and colitis). Review of the Centers for Disease Control and Prevention (CDC) guidance titled C. diff. Facts for Clinicians, dated 3/5/24, indicated the following: -C. diff is spore-forming. -C. diff sheds in feces. -Any surface, device or material that becomes contaminated with feces could serve as a reservoir for C. diff spores. -C. diff spores can transfer to patients by the hands of healthcare personnel who have touched a contaminated surface or item. -Gloves are important because hand sanitizer doesn't kill C. diff. Review of the CDC guidance titled Transmission-Based Precautions (TBPs), dated 4/3/24, indicated the following: -TBPs are the second tier of basic infection control and are to be used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. -Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission. -Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. -Donning PPE (personal protective equipment) upon room entry and properly discarding before exiting the patient room is done to contain pathogens. Review of the CDC Infection Control guidance under Appendix A for Preventing Transmission of Infectious Agents in Healthcare Settings: Type and Duration of Precautions Recommended for Selected Infections and Conditions, last reviewed 2/7/25, indicated the following for C. diff: -Contact Precautions plus Standard Precautions for duration of illness. Review of Resident #13's Nursing Note, dated 1/30/26, indicated: -The Resident was having diarrhea. -The physician ordered for a stool C. diff test. Review of Resident #13's Nursing Note, dated 2/2/26, indicated: -Lab results (C. diff) came back and were reviewed by the physician. -An order to start Vancomycin 125 milligrams (mg) QID (four times a day) was given to start on 2/3/26. Review of Resident #13's Nursing Progress Note, dated 2/3/26, indicated the Resident was taking Vancomycin for C. diff. Review of Resident #13's clinical record indicated the following Physician's Orders: -Enhanced Barrier Precautions (EBP) for wound every shift (10/29/25 and no end date). -Vancomycin Capsule; 125 mg, one tab, give one tablet 4 (four) times a day (2/3/26-2/16/26). -Vancomycin recon (reconstituted) soln (solution); 50 mg/milliliter (mL); amt (amount): 2.5 mL oral. Give 2.5 mL TID (three times a day) x 2 (two) weeks (2/26/26-3/12/26) -Vancomycin recon soln; 50 mg/mL; amt: 2.5 mL oral. Give 2.5 mL (125 mg) BID (twice a day) x 2 weeks (3/12/26-3/26/26). -Vancomycin recon soln; 50 mg/mL; amt: 2.5 mL oral. Give 2.5 mL QD (daily) x 2 weeks (3/26/26-4/9/26). The physician's orders failed to indicate Contact Precautions for active treatment of C.diff. Review of Resident #13's March Bowel Log indicated the Resident was incontinent of stool and that the Resident's stool was loose and fatty (last recorded on 3/25/26). On 3/24/26 at 10:45 A.M., the surveyor observed the following posted outside of Resident #13's door: -Enhanced Barrier Precautions (EBP). -Everyone must: -Clean hands, including before and when leaving the room (picture on sign indicated use of alcohol-based hand rub [ABHR]). -Providers and staff must also: -Wear gloves and gown for the following high contact care activities: Dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, . wound care. -No signage for Contact Precautions was posted. On 3/25/26 at 8:12 A.M., the surveyor observed the same EBP signage posted outside of Resident #13's door. No signage for Contact precautions was posted. During an interview on 3/25/26 at 4:40 P.M., the IP said Resident #13 was being treated and was symptomatic for C. diff. The IP said Resident #13 required Contact Precautions. At this time, the IP and surveyor reviewed the EBP sign posted outside of the Resident's door. The IP said the requirements indicated on the EBP sign were not the same as the requirements for Contact Precautions and that staff were required to wash their hands with soap and water when exiting the room. The IP said staff were required to wear a gown and gloves when entering the room, not only when providing high contact care activities for the Resident. On 3/26/26 at 8:00 A.M., the surveyor observed a Contact Precaution Sign posted outside of Resident #13's door as follows: -Everyone must: -Clean their hands, including before entering and when leaving the room. -Providers and staff must also: -Put on gloves and gown before room entry. -Discard gloves and gown before room exit. During an interview on 3/26/26 at 8:00 A.M., Nurse #1 said she was responsible to provide care for Resident #13 on 3/25/26 and also on 3/26/26. Nurse #1 said the Contact Precautions sign posted outside Resident #13's door was new that morning and that EBP signage was present during her shift on 3/25/26. Nurse #1 said when she cared for Resident #13 on 3/25/26, she was not required to wear a gown and gloves on room entry. Nurse #1 said she provided medications to Resident #13 on 3/25/26 while the Resident was in his/her room. Nurse #1 said she did not wear a gown and gloves when she entered Resident #13's room on 3/25/26 to administer medications. Nurse #1 said CNAs who provided care to Resident #13 were only required to wear a gown and gloves when providing high contact care for Resident #13 and that they were not required to wear a gown and gloves when they entered the Resident's room prior to the Contact Precautions sign being posted. During an interview on 3/26/26 at 11:10 A.M., the IP said Resident #13 had a history of C. diff. The IP said Resident #13 became symptomatic for C. diff and positive results for C. diff were confirmed with the facility on 2/2/26. The IP said Resident #13 began antibiotic treatment with Vancomycin upon the positive C. diff result and that the Resident was still being treated for C. diff. At this time, the IP reviewed the facility's February 2026 Infection Surveillance Tracker, which indicated the Resident's C. diff infection had resolved. The IP said the Resident's C. diff infection was resolved accidentally on the February 2026 Infection Surveillance Tracker, but this was not accurate and the C. diff infection was not resolved. The IP said that as of 3/25/26, Resident #13 continued to be symptomatic for C. diff infection, with loose fatty stools. The IP said Contact Precautions should have been implemented and required for all staff to follow for Resident #13 when the Resident was identified as positive for C. diff, but Contact Precautions were not implemented until after the surveyor's inquiry on 3/25/26 at 4:40 P.M. 3. Review of the facility's policy titled Enhanced Barrier Precautions, undated, included but was not limited to:It is the policy of this facility to adhere to the Centers for Disease Control and Prevention (CDC) guidelines as related to Enhanced Barrier Precautions (EBPs) to prevent the transmission of multidrug-resistant organisms (MDROs) while promoting resident quality of life by addressing the need for psychosocial well-being of residents who are colonized with MDROs.-EBPs is a CDC recommendation to provide guidance for use of personal protective equipment (PPE) in facilities for preventing the spread of MDROs. It is a relatively new approach that falls between standard and contact precautions and employs targeted gown and glove use during high contact resident care activities. According to the CDC, more than 50 percent (%) of residents may be colonized with an MDRO in skilled nursing facilities so enhanced infection control may help reduce the transmission of these organisms. EBP may be used when contact precautions do not otherwise apply. Unlike contact precautions, when placed on EBP residents are not restricted to their rooms, do not require placement in a private room, and may participate in group activities. -The facility will implement EBP during high contact resident care activities for those residents who are colonized with an MDRO unless otherwise ordered by healthcare provider.-Examples of high contact resident care activities:>dressing>bathing/showering>transferring>changing linens>changing briefs or assisting with toileting>device care or use- central line, urinary catheter, feeding tube, tracheostomy/ventilator>wound care- any skin opening requiring a dressing-The facility may choose to implement enhanced barrier precautions to include any resident with an indwelling medical device or wound, regardless of MDRO colonization or infection status.-The Infection Preventionist (IP)/Designee will provide staff, residents and/or resident representatives with education regarding the purpose of EBP. -Staff will perform hand hygiene and don PPE before entering the resident's room.-Staff will remove PPE and perform hand hygiene before exiting resident's room. Resident #32 was admitted to the facility in July 2017 with diagnoses including Neuromuscular Dysfunction of Bladder, Hypertensive Chronic Kidney Disease with Stage 1 through Stage 4 Chronic Kidney Disease, and Stage 3 Pressure Ulcer on Right Heel. Review of the Minimum Data Set (MDS) Assessment, dated 2/19/26, indicated Resident #32:-had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 0 out of a possible 15 points.-had an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine outside the body).-had stage 3 pressure ulcer (a full thickness skin injury extending through the dermis into the subcutaneous fat tissue). Review of Resident #32's March 2026 Physician's Orders indicated: -EBP every shift with high contact care. Bathing, dressing, transferring, wound care, device management. Hand hygiene pre- and post-high contact care. Special instructions: Foley. Every shift: Day 7:00 A.M.-3:00 P.M., Eve (Evening) 3:00 P.M.-11:00 P.M., Night 11:00 P.M.-7:00 A.M., initiated 11/20/24.-Change Foley catheter 18 French (Fr)/10 milliliters (ML) monthly on the 23rd 3-11; once a day on the 23rd of the month; eve 3:00P.M. -11:00 P.M., initiated 10/30/25.-Cleanse stage 3 on right heel with normal saline, pat dry apply cal alg (calcium alginate- highly absorptive, non-woven, and non-adhesive primary dressings made from natural brown seaweed fibers)/Santyl (medicine used for debriding chronic dermal ulcers) then cover with border dressing and wrap with kerlix daily, once a day; day, initiated 2/14/26. On 3/24/26 at 3:20 P.M., the surveyor observed a sign posted outside of Resident #32's door. The signage indicated the following:-ENHANCED BARRIER PRECAUTIONS >EVERYONE MUST: -clean their hands including before entering and when leaving the room. > providers and staff must also:-wear gloves and a gown for the following high contact resident care activities: -dressing-bathing/showering-transferring-changing linens-providing hygiene-changing brief or assisting with toileting-device care or use: central line, urinary catheter, feeding tube, tracheostomy -wound care: any skin opening requiring a dressing On 3/26/26 from 9:28 A.M. to 9:31 A.M., the surveyor observed the following:-CNA #4 exited Resident #32's room with a hydraulic lift, no hand hygiene or PPE was observed.-CNA #3 was next to Resident #32's bed covering the Resident with a blanket. -CNA #3 was wearing gloves while handling the Resident's linens. No gown was observed. -CNA #3 exited the room and was observed to doff gloves and perform hand hygiene. -CNA #3 re-entered the room, pulled and repositioned the Resident's blanket. CNA #3 was not observed to perform hand hygiene or don (put on) any PPE when re-entering the room and handling the bed linens and blanket. During an interview on 3/26/26 at 9:34 A.M., CNA #3 said that she and CNA #4 transferred Resident #32 to bed. CNA #3 said that the Resident has a wound and a catheter and required a gown during bathing. CNA #3 and the surveyor reviewed the EBP signage posted outside the Resident room door together. CNA #3 said that she should have put on a gown when transferring Resident #32 to bed and when handling the Resident's linens, but she did not. CNA #3 said that it was important for her to wear a gown to prevent the transfer of germs from herself to Resident #32 and from the Resident to her and other residents. During an interview on 3/26/26 at 10:09 A.M., CNA #4 said that he had worn gloves when he and CNA #3 transferred Resident #32 back to bed. CNA #4 and the surveyor reviewed the EBP signage posted outside Resident #32's door together. CNA #4 said that he should have worn a gown when transferring Resident #32 to bed to prevent the spread of infection to the Resident and other residents. CNA #4 said he was aware that Resident #32 has a catheter and he should have worn a gown. During an interview on 3/26/26 at 1:15 P.M., the IP said that all nursing staff have been educated and trained on EBP upon hire and annually. The IP said that each time a resident is placed on any type of precaution, all staff are educated on the proper use of gown and gloves during high contact care to prevent the spread of infection. The IP said that nursing staff should have worn a gown when transferring Resident #32 to prevent the spread of infection.

Based on observations, record review, and interviews, the facility failed to maintain a clean and homelike environment for two Residents (#52 and #70), out of a total sample of 19 residents, on one unit (Second Floor-South) out of five units observed. Specifically, the facility staff failed to ensure that: -Resident #52's bedroom floor was maintained in a clean and sanitary manner. -Resident #70's bed frame, bed rail, mattress, floor mat and bedroom floor were maintained in a clean and sanitary manner. Findings include: Review of the facility's Resident Handbook, last revised 3/24/26, indicated: >Environment- The Healthcare Center must provide a safe, clean, comfortable and home-like environment, allowing each resident the opportunity to use his/her personal belongings to the greatest extent, provide housekeeping and maintenance services, and assuring clean bath and bed linens that are in good repair. A. Resident #52 was admitted to the facility in December 2025 with diagnoses including benign prostatic hyperplasia and obstructive and reflux uropathy. Review of the Minimum Data Set (MDS) Assessment, dated 12/16/25, indicated Resident #52: -was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of 15. -required substantial/maximal assistance from staff for toileting. -had an indwelling catheter. Review of Resident #52's progress notes indicated: -On 2/24/26, the Resident's Foley catheter was changed due to leakage, and the urine was clear orange colored due to Pyridium (a pain medication used to treat urinary urgency, pain and discomfort. A common side effect is orange-red colored urine). -On 1/28/26, the Resident's Foley catheter was changed due to leakage. -On 1/22/26, the Resident's Foley catheter was changed due to leakage. On 3/24/26 at 9:11 A.M., the surveyor observed three large, dried, bright yellow/orange-colored stains on the Resident's floor. On 3/24/26 at 3:53 P.M., the surveyor observed three large, dried, bright yellow/orange-colored stains on the Resident's floor. On 3/25/26 at 9:57 A.M., the surveyor observed the three bright yellow/orange-colored large stains on the Resident's bedroom floor. During an interview at this time, Resident #52 said that his/her catheter frequently leaks and that the stains on his/her floor have been there for weeks. On 3/25/26 at 2:06 P.M., the surveyor and the Administrator observed the stains on Resident #52's floor. During an interview at this time, the Administrator said that the Resident's bedroom environment was not home-like. B. Resident #70 was admitted to the facility in October 2021 with diagnoses including dementia, lack of coordination, and unsteadiness on feet. Review of the MDS Assessment, dated 2/26/26, indicated Resident #70: -was severely cognitively impaired as evidenced by a BIMS score of 0 out of 15. -was dependent on staff for Activities of Daily Living (ADLs). -was always incontinent of urine and bowel. On 3/24/26 at 9:39 A.M., the surveyor observed Resident #70's room to have a strong odor of feces. There were dried, dark brown colored stains on the left side of the Resident's bed frame, on the left bed rail, the right side of the mattress, on the tile floor to the right of the bed, and on the floor mat. On 3/24/26 at 3:38 P.M., the surveyor observed Resident #70's room, and there were dried, dark brown colored stains on the left side of the Resident's bed frame, on the left bed rail, the right side of the mattress, on the tile floor to the right of the bed, and on the floor mat. On 3/25/26 at 9:56 A.M., the surveyor observed Resident #70's room, and there were dried, dark brown colored stains on the left side of the Resident's bed frame, on the left bed rail, the right side of the mattress, on the tile floor to the right of the bed, and on the floor mat. On 3/25/26 at 2:10 P.M., the surveyor and the Administrator observed the stains that remained in Resident #70's room on the bed frame, the bed rail, the mattress, the tile floor, and the floor mat. During an interview at this time, the Administrator said that the stains were an infection control concern and that the Resident's room was not a home-like environment.

Based on observation, interview, and record review, the facility failed to coordinate vision care services for one Resident (#62), out of a total sample of 19 residents, increasing the Resident's risk for further deterioration of vision when the Resident, who was diagnosed with diabetes and hypertension, had bilateral cataracts and left eye blindness. Specifically, for Resident #62, the facility failed to schedule vision care appointments and ensure that the Resident was seen and received appropriate treatment to maintain vision abilities, when the Resident consented to and requested vision care services. Findings include:Review of the facility's policy titled Ancillary Physician Services, revised 4/2024, included but was not limited to:-Routine and emergency Optometry services are available to meet the resident's health services by the resident's assessment and plan of care.-Routine and emergency Optometry services are provided to our residents through:>A contract agreement with a licensed optometrist that comes to the facility routinely.>Referral to the resident's personal optometrist.>Referral to community Optometrist or>Referral to health care organizations that provide Optometry services.-The Residents have the right to select an Optometrist of their choice when services are needed.-Selected Optometrist will be available to provide follow-up care per resident's request.-Social services or nursing representatives will assist residents with appointments, transportation arrangements, and for reimbursement of an Optometrist's services under the state plan, if eligible.-All services provided are recorded in the resident's medical records. A copy of the resident's record is provided to any facility to which the resident transferred. Resident #62 was admitted to the facility in February 2026 with diagnoses including Type 2 Diabetes Mellitus, Age-Related Nuclear Cataract Bilateral, Essential Primary Hypertension, and Blindness Left Eye Category 4. Review of Resident #62's current March 2026 Physician's Orders indicated the following: -Atropine drops (drops used to treat eye conditions by blocking the chemical acetylcholine, which relaxes the ciliary muscle of the eye and causes the pupil to dilate) 1 percent (%); amount (amt) 1 drop into Left (L) eye, ophthalmic (eye) twice a Day, 8:00 A.M., 8:00 P.M., initiated 2/2/26.-Brimonidine drops 0.2% (eye drops used to lower high eye pressure associated with open angle glaucoma or ocular hypertension, preventing potential vision loss), amt 1 drop into Right (R) eye, ophthalmic (eye) twice a day, 8:00 A.M., 8:00 P.M., initiated 2/2/26.-Prednisolone Acetate (eye drops used to lower high eye pressure associated with open angle glaucoma or ocular hypertension, preventing potential vision loss) drops suspension 1% amt 1 drop into (L) eye, ophthalmic (eye) four times a day, 8:00 A.M., 12:00 P.M., 4:00 P.M., 8:00 P.M., initiated 2/2/26. -Timolol drops (associated with open angle glaucoma or ocular hypertension, preventing potential vision loss) 0.5%; amt: 1 drop into (R) eye; ophthalmic (eye) twice a day, 8:00 A.M., 8:00 P.M., initiated 2/2/26.-Optometrists consult as needed, initiated 2/2/26. Review of the Resident's clinical record included a Request for Service for Eye Care Services signed by the Resident dated 2/2/26.Further review of Nursing admission Record, dated 2/2/26, indicated Resident #62's left pupil was unreactive, due to left eye problem. Review of the Minimum Data Set (MDS) Assessment, dated 2/9/26, indicated Resident #62:-was able to make him/herself understood and understood others. -had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15 points.-had severely impaired vision and used corrective lenses.On 3/24/26 at 8:18 A.M., the surveyor observed Resident #62 seated in a stationary chair in his/her bedroom wearing eyeglasses. The Resident said that he/she would like to see the eye doctor for an exam and was blind in his/her left eye. Resident #62 said it was difficult to see with his/her left eye, and he/she required the use of eyeglasses. The Resident said he/she needs an eye examination to get his/her eyeglasses replaced with a different prescription strength to accommodate his/her visual needs. During an interview on 3/25/26 at 12:52 P.M., the Resident said that he/she consented for vision services and treatment upon his/her admission to the facility due to his/her left eye blindness and cataracts in his/her bilateral eyes and had not been provided with an appointment to be seen and he/she is still waiting to see the eye doctor to be evaluated for an eyeglasses replacement. During an interview on 3/25/26 at 1:42 P.M., the Administrator said that the facility provides vision services through an outside vendor every four months and as needed. The Administrator said 'as needed' indicated the facility would schedule the service for residents if the resident had consented for the services and has medical conditions that required the resident to be seen and examined earlier than the scheduled routine vision services timeframes. The Administrator further said the vendor for vision services was last in the facility on 10/21/25 and Resident #62 should be on the next scheduled list, but Resident #62 was not.During an interview on 3/25/26 at 3:30 P.M., with the Administrator and the Unit Manager (UM), the Administrator provided a consent form for vision services signed by Resident #62 upon his/her admission to the facility. The Administrator said Resident #62 was not currently on the list for routine vision care services and should have been put on the list for vision service when the Resident consented for vision care. During an interview on 3/26/26 at 8:48 A.M., the Director of Nursing (DON) said nursing staff were responsible for ensuring Resident #62 was added to vision services vendor's list to be seen for the next visit if the Resident had consented for the services. The DON also said that if the residents had their own provider outside the facility, nursing staff would arrange transportation for residents to see the outside provider. The DON said Resident #62 was recently admitted to the facility and he/she should have been put on the vision services vendor list to be seen for the next scheduled visit. The DON said she was unable to provide evidence that Resident #62 was put on the next scheduled vision services list.

Based on observation, interview, and record review, the facility failed to provide respiratory care and services in accordance with professional standards of practice for one Resident (#88), out a total sample of 19 residents. Specifically, for Resident #88, the facility failed to obtain a physician's order for a baseline oxygen flow rate, oxygen titration liter flow range, and portable oxygen flow rate when the Resident was diagnosed with chronic obstructive pulmonary disease (COPD) and dependence on supplemental oxygen use placing the Resident at risk for respiratory complications related to oxygen use.Findings include:Review of the facility's policy titled Oxygen and Nebulizer Setup/Tubing Infection Control Policy & Plan, undated, included the following:*To provide guidelines to prevent the spread of health care acquired infections associated with respiratory therapy equipment and to prevent transmission of infections to residents and staff.-Oxygen Administration>A practitioner's order is required to initiate oxygen therapy, except in an emergency situation.>A practitioner's order should include:-Oxygen (O2) flow rate or fraction of inspired oxygen (FiO2), and, a titration of the oxygen flow rate in order to achieve an acceptable range of peripheral oxygen saturation (SpO2) values, i.e. 88-92 percent (%). In most cases, pulse oximetry is the preferred method of measuring blood oxygen values. -A practitioner is to be contacted as soon as possible after initiation of oxygen therapy in emergency situations for verification and documentation of the necessity for oxygen therapy and to obtain any further orders. Resident #88 was admitted to the facility in June 2025 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Dependence on Supplemental Oxygen, and Unspecified Diastolic Congestive Heart Failure. Review of Resident #88's current Physician's Orders indicated the following:-Oxygen (O2) via Nasal Cannula (NC); maintain O2 above 90 percent (%) PRN (as needed); PRN 1; PRN 2; PRN 3, initiated 9/7/25.-No prescribed baseline oxygen flow rate relative to the use of oxygen and portable oxygen use. Review of the Minimum Data Set (MDS) Assessment, dated 3/5/26, indicated Resident #88:-was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 points. -received oxygen therapy.Review of the February and March 2026 Medication and Treatment Administration Records (MAR/TAR) failed to indicate documentation of the oxygen flow rate being administered to the Resident. Review of Resident #88's Nursing Progress Notes for February and March 2026, indicated the Resident was administered Oxygen at 2 liters per minute (LPM) via NC. Review of Resident #88's Nursing Admission/readmission Assessment, dated 2/20/26, indicated a respiratory status as Oxygen at 2 liters. Review of Resident #88's Comprehensive Person-Centered Care Plan, initiated 6/12/25, and last revised dated 3/24/26, indicated the following:-May use O2 via NC/Mask to maintain O2 Sat above 90% as needed.-Monitor lung sounds as needed.-Monitor/document respiratory status as needed.On 3/24/26 at 9:00 A.M., the surveyor observed Resident #88 seated in a wheelchair in the common area with Oxygen being administered to the Resident via NC with the oxygen tubing hanging on the side of the wheelchair and not connected to the portable oxygen concentrator. During an interview at this time, the Resident said that he/she does not feel that he/she was receiving Oxygen through the NC. Unit Manager (UM) #1 was present and got Nurse #3. During an interview at the time, Nurse #3 said that Resident #88 was ordered 1.5 LPM of Oxygen as needed. Nurse #3 checked the status of the Resident's oxygen tubing and said that the Resident's portable oxygen concentrator was in use as ordered. The surveyor requested that Nurse #3 review Resident #88's portable oxygen concentrator positioned behind the Resident's wheelchair with the oxygen tubing hanging on the right side of the Resident's wheelchair, not connected to the portable oxygen concentrator. At that time, Nurse #3 connected the oxygen tubing to the portable oxygen concentrator. Nurse #3 said that Resident #88 was at risk for low blood oxygen levels leading to shortness of breath if his/her oxygen tubing was not properly connected to the concentrator. UM #1 said at that time that Resident #88's Oxygen was scheduled as PRN and not as continuous.On 3/24/26 at 3:46 P.M., the surveyor observed Resident #88 seated in a wheelchair in the day room participating in activities with O2 via NC set to 2 LPM. On 3/25/26 at 12:29 P.M., the surveyor observed Resident #88 seated in the dining room in a wheelchair with his/her O2 on via NC and tubing connected to the portable concentrator with the O2 rate set to 2 LPM. The Resident said the O2 was flowing through his/her nose with no concerns. During an interview on 3/25/26 at 12:25 P.M., the Director of Nursing (DON) said Resident #88's oxygen administration orders added should include the flow rate and the tubing connected to the portable concentrator to ensure that the Resident was being administered the Oxygen as ordered. The DON said that nursing staff should document a respiratory assessment when oxygen was being administered to Resident #88. The DON said Resident #88 was at risk for low blood oxygen levels leading to shortness of breath if he/she did not receive Oxygen at the rate ordered by the Physician or if the tubing was not properly connected. On 3/26/26 at 9:20 A.M., the surveyor observed Resident #88 seated in a wheelchair in the common area with his/her portable oxygen concentrator running at 2LPM via the NC. During an interview on 3/26/26 at 9:25 A.M., Certified Nurse Aide (CNA) #5 said Resident #88 uses his/her portable oxygen concentrator and a bedside concentrator every day and continuously during the night hours. During an interview on 3/26/26 at 10:25 A.M., Nurse #3 said she assessed Resident #88's oxygen saturation level prior to the start of her shift and had a reading of 88 to 90% that morning. Nurse #3 said that she administered Oxygen to Resident #88 at 2LPM PRN and should have documented a respiratory assessment for the Resident, but she did not. Nurse #3 and the surveyor reviewed Resident #88's physician's orders and Nurse #3 said that the physician's orders did not include the oxygen flow rate, and it should. Nurse #3 said that she administered Oxygen at 2LPM for Resident #88 and the Resident required the use of Oxygen during both day and night to maintain his/her oxygen saturation rate above 90%. Nurse #3 further said that documentation of respiratory assessment for Resident #88 helps to identify if the oxygen treatment was effective. During an interview on 3/26/26 at 10:35 A.M., the DON said that Resident #88 should have his/her oxygen flow rate included with the physician's orders and a respiratory assessment should be documented on the TAR as administered.

Based on interview and record review, the facility failed to offer pneumococcal immunization to one Resident (#119), out of five applicable residents reviewed for pneumococcal immunization in a total sample size of 19 residents. Specifically, the facility staff failed to offer pneumococcal immunization to Resident #119 who was at high risk for pneumococcal infection complications due to a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), had no evidence of prior pneumococcal immunizations in his/her medical record, and pneumococcal immunization had not been identified as medically contraindicated. Findings include: Review of the facility's policy titled Pneumococcal Vaccinations, undated, included but was not limited to the following: -All residents are provided the opportunity and encouraged to receive the pneumococcal vaccinations. -Pneumococcal vaccine will be administered according to the latest guidelines from the Massachusetts Department of Public Health issued each year. -The program coordinator .will be responsible to research the medical record and history to determine if the pneumococcal vaccinations have ever been given. -The program coordinator maintains a file of current residents showing status of vaccination. >after determining the resident has no history of receiving the pneumococcal vaccine, the nursing staff will obtain an order for the vaccine from the resident's Physician. >for residents previously vaccinated, record date in resident's comprehensive assessment. Resident #119 was admitted to the facility in November 2018 with diagnoses including COPD and Dependance on Supplemental Oxygen.Review of Resident #119's Minimum Data Set (MDS) Assessment, dated 1/2/26 included but was not limited to the following: -the Resident's Pneumococcal vaccination was not up to date and pneumococcal vaccination had not been offered to the Resident. Review of Resident #119's March 2026 Physician's Orders indicated: -the Resident had an invoked Health Care Proxy (HCP- an appointed person to make health care decisions for someone when they cannot do so for themselves), with a start date of 7/22/22. Review of the Resident's medical record failed to indicate that pneumococcal vaccination had been offered, declined, or contraindicated. During an interview on 3/25/26 at 2:54 P.M., the Infection Preventionist (IP) said that she was responsible to oversee the vaccination status for Resident #119. The IP said Resident #119 did not have evidence in the medical record that pneumococcal vaccination had been offered, declined or contraindicated. The IP said Resident #119's HCP should have been contacted for pneumococcal immunization consent so the vaccine could be administered. The IP said Resident #119 was at high risk for pneumonia complications due to the diagnosis of COPD.

Based on interview and record review, the facility failed to offer COVID-19 immunization to one Resident (#119), out of five applicable residents reviewed for COVID-19 vaccination in a total sample size of 19 residents. Specifically, the facility staff failed to offer COVID-19 immunization to Resident #119 who was at high risk for COVID-19 infection complications due to a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), had no evidence of prior 2025-2026 COVID-19 variant immunizations in his/her medical record, and COVID-19 vaccinations had not been identified as being medically contraindicated. Findings include: Resident #119 was admitted to the facility in November 2018 with diagnoses including COPD and Dependance on Supplemental Oxygen.Review of Resident #119's Minimum Data Set (MDS) Assessment, dated 1/2/26, included but was not limited to the following: -the Resident's COVID-19 vaccination was not up to date. Review of Resident #119's March 2026 Physician's Orders indicated: -the Resident had an invoked Health Care Proxy (HCP- an appointed person to make health care decisions for someone when they cannot do so for themselves), with a start date of 7/22/22. Review of the Resident's medical record indicated the following: -Resident #119 had last received COVID-19 immunization on 3/2/23. Further review of the Resident's medical record failed to include that COVID-19 Spikevax immunization had been offered, declined, or contraindicated. During an interview on 3/25/26 at 2:54 P.M., the Infection Preventionist (IP) said that she was responsible to oversee the vaccination status for Resident #119. The IP said Resident #119 did not have evidence in the medical record that COVOID-19 vaccination had been offered, declined, or contraindicated for the 2025-2026 Spikevax variant. The IP said Resident #119's HCP should have been contacted for COVID-19 immunization consent so the vaccine could be administered. The IP said Resident #119 was at high risk for COVID-19 complications due to the diagnosis of COPD.

Based on observation, record review, and interview, the facility failed to provide and environment as free of accident hazards as possible for three Residents (#83, #35, and #53) out of a total sample of 18 residents. Specifically, facility failed to: 1. implement safe swallow strategies for Resident #83 when the Resident had a history of swallowing difficulty, oropharyngeal (middle part of the throat and back of the mouth) dysphagia (difficulty swallowing), Dementia, and had an overall decline in function requiring dependence on staff for eating, which increased the Resident's risk for choking and/or aspiration (when food or liquids enters one's airway or lungs). 2. complete fall risk assessments for Resident #35 when the Resident was readmitted to the facility following hospitalization s, including one hospitalization resulting from a fall with fracture that required surgical intervention, putting the Resident at risk for further falls, injury and abnormal bleeding resulting from anticoagulation (medication used to prevent blood clots) medication use. 3. For Resident #53, complete a fall risk assessment when the Resident was readmitted to the facility following a hospitalization for a fall with fracture and surgery, putting the Resident at risk for further falls and injury and increased risk for abnormal bleeding from anticoagulant use. Findings include: 1. Resident #83 was admitted to the facility in August 2023 with diagnoses of Dementia and Muscle Weakness. Review of Resident #83's Nutrition Care Plan, initiated 8/14/23 and last revised 10/11/24, indicated the following: -The Resident presented as potential nutrition risk related to medical conditions requiring long term care placement. -The Resident was independent with set up at meals. -Registered Dietician (RD)/Speech Language Pathologist (SLP) screen and treat PRN (as necessary). Review of Resident #83's Minimum Data Set (MDS) Assessment, dated 10/21/24, indicated: -The Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of 15 total possible points. -The Resident required supervision or touching assistance for eating. -The Resident had no signs or symptoms of a possible swallowing disorder. -The Resident had experienced no significant weight loss in the prior six months. Review of Resident #83's Nurse Practitioner (NP) Progress Note, dated 10/25/24, indicated: -The Resident was seen for intermittent cough with meals. -The Resident was on a regular texture diet with thin liquids. -Nursing staff reported that the Resident was coughing with meals and that the Resident was attempting to clear his/her throat after eating. Further review of the NP Progress Note indicated the following assessment and plan: -Cough - . downgraded diet to ground soft diet . Review of Resident #83's NP Order, dated 10/25/24, indicated: -Downgrade diet to ground soft diet. Review of Resident #83's interdisciplinary Facility Weight - Initial Focus Note, dated 11/14/24, indicated: -The Resident was on a minced/moist texture diet. -A recommendation was made for consultation/evaluation by the SLP. Review of Resident #83's Rehab (Rehabilitation) Request/Screen Form, dated 11/21/24, indicated: -The Resident's diet had been downgraded on 10/25/24. -Intervention recommended was for the SLP to assess the Resident. Review of Resident #83's SLP Evaluation and Plan of Treatment, dated 11/27/24, indicated the following: -The Resident's diet was downgraded on 10/25/24 due to concerns with coughing. -The Resident had not previously received speech therapy services. -The Resident's mandibular (lower jaw bone) range of motion, strength, and coordination were impaired. -The Resident's lingual (various components of tongue movement) function was impaired. -The Resident presented with moderate oropharyngeal (middle part of the throat and back of the mouth) dysphagia (difficulty swallowing). -The Resident presented with decreased ability for breaking down and clearing bolus' (rounded mass of a substance, especially of chewed food at the moment of swallowing) from his/her mouth and decreased attention to task during meals. -The Resident presented with moderate lingual residue and residuals in the anterior portion of his/her oral cavity that accumulated over time. -Food residuals were eventually cleared by liquid wash. -The Resident presented with limited attention to bolus in the oral cavity. -Treatment of swallowing dysfunction and/or oral function for feeding was recommended at a frequency of eight times over four weeks. -The long term goal was for the Resident to have safe and adequate intake on the least restrictive diet without signs/symptoms of aspiration (when something that is meant to be swallowed enters one's airway or lungs) and use of strategies. Further review of Resident #83's SLP Evaluation and Plan of Treatment indicated the following relative to swallowing strategies recommended: -Upright positioning during all meals and 30 minutes following meals. -Alternate solids and liquids t assist with oral and pharyngeal clearing of bolus. -Rate modification. -Bolus size reductions. -General safe swallow techniques. Review of Resident #83's SLP Discharge Summary, dated 12/3/24, indicated the following: -The Resident had experienced an overall decline in function. -The Resident had become dependent on staff for meal intake and use of safe swallow strategies. -The Resident's meal intake had reduced due to the Resident becoming increasingly confused and having decreased attention to task during meals. -Skilled interventions provided during speech therapy sessions included education provided to facility staff. -Speech therapy services were being discontinued for the Resident as the Resident was being admitted to Hospice services on 12/3/24. -Discharge Strategies recommended for the Resident included: > upright positioning for all meals and greater than 30 minutes following intake >bolus size reductions >rate modifications >alternating solids and liquids with a two to one ratio to assist with oral and pharyngeal clearing of bolus >general safe swallow precautions On 12/4/24 at 9:42 A.M., the surveyor observed the following: -the surveyor entered Resident #83's room and observed the privacy curtain was pulled between the beds in the room and the Resident was sitting upright in bed. -The surveyor observed that there were no staff in the Resident's room at this time. -The surveyor spoke to the Resident and the Resident responded verbally and softly so that the surveyor had to ask the Resident to repeat what he/she said. -The Resident then smiled and began to speak, and the surveyor observed scrambled eggs in the Resident's mouth, in between the Resident's front teeth and lips and over the top of the Resident's tongue. -The surveyor asked the Resident about having scrambled eggs in his/her mouth, and the Resident said, No. -The surveyor asked the Resident again about the eggs in his/her mouth and the Resident swallowed the eggs. -The surveyor observed that there was no meal tray in the Resident's room. During an interview on 12/5/24 at 9:00 A.M., CNA #2 said that she worked at the facility three days per week and that frequently assisted Resident #83 with eating. CNA #2 said that she had noticed a few days prior that the Resident was having difficulty swallowing and was unable to swallow any lumpy food. CNA #2 said she had assisted Resident #83 with eating over the previous three days and the Resident required his/her food to be ground up so that it was really smooth. CNA #2 said that she thought the SLP was supposed to see the Resident for swallowing and she was not sure if the SLP had seen the Resident yet. CNA #2 also said that she had not received any education or instructions from the Nurse or the SLP relative to swallowing strategies for the Resident. When the surveyor inquired about the scrambled eggs observed in Resident #83's mouth on 12/4/24 at 9:42 A.M., CNA #2 said, I'm glad you were here to see that. During an interview on 12/5/24 at 9:07 A.M., Nurse #1 said that Resident #83 had trouble when drinking and would cough when drinking. Nurse #1 said that the SLPs had been treating the Resident, and the treatment was being discontinued due to the Resident being admitted to Hospice services. Nurse #1 said that Hospice personnel had been in the facility on 12/3/24 to admit the Resident to Hospice services, and she had not seen Hospice personnel with the Resident since 12/3/24. Nurse #1 said that Hospice personnel would be responsible to further assess Resident #83's swallowing function. During an interview on 12/5/24 at 9:20 A.M., Unit Manager (UM) #1 said Resident #83 had been evaluated by the SLP and that speech therapy services were discontinued on 12/3/24 when the Resident was admitted to Hospice services. When the surveyor discussed the observation of Resident #83 from 12/4/24 at 9:42 A.M., UM #1 said she was not aware the Resident had been pocketing food in his/her mouth and that she would need to notify Hospice personnel so that the Resident could be assessed. The surveyor and UM #1 reviewed the results of the Resident's SLP Evaluation and Plan of Treatment from 11/27/24, which indicated the Resident had decreased awareness of food in his/her mouth and that the Resident held food in his/her mouth during the evaluation. UM #1 said she did not know the Resident had been holding food in his/her mouth and she could not recall any recommendations made by the SLP for Resident #83 relative to safe swallowing strategies. UM #1 further said Resident #83 was very confused and would not be aware of food left in his/her mouth. UM #1 further said if Resident #83 held food in his/her mouth, he/she would need to be cued by staff to swallow the food. UM #1 said that staff who assisted residents to eat knew to check residents' mouths for residual food before leaving them alone, and that staff who assisted Resident #83 on 12/4/24 should have made sure the Resident was not left with food in his/her mouth. During an interview on 12/5/24 at 9:49 A.M., SLP #1 said she evaluated Resident #83's swallowing function on 11/27/24, when the facility's Director of Rehabilitation (DOR) had informed her that a referral for speech therapy had been made by nursing staff due to the Resident having experienced weight loss. SLP #1 said when she evaluated the Resident, the Resident was very confused. SLP #1 said that the Resident was unable to pay attention to his/her meal, unable to feed him/herself, and was unaware of the presence of food in his/her mouth. SLP #1 said Resident #83 held food in his/her mouth and could eventually clear the food with alternating solids and liquids and with cues provided by SLP #1. SLP #1 said that after she completed Resident #83's evaluation, she spoke with one CNA and instructed the CNA to alternate solids and liquids for Resident #83. SLP #1 said she could not recall who the CNA was and that she did not discuss safe swallow strategies for the Resident with any other staff at that time. SLP #1 said she saw the Resident again on 12/3/24 and the Resident required full assistance from staff to eat at that time. SLP #1 said that she was informed on 12/3/24 that Resident #83 was being admitted to Hospice services and that she was to discontinue speech therapy services. SLP #1 said that she would normally complete a written staff education sheet with recommendations for safe swallowing strategies to be implemented for residents when they were discharged from speech therapy services, but that she did not complete a written staff education sheet for Resident #83 because she had to discontinue services due to Hospice admission. SLP #1 further said that she was not made aware Resident #83 was being admitted to Hospice until after she treated the Resident that same day, so education to staff for safe swallow strategies had not been completed prior to discontinuing speech therapy services. SLP #1 said that she could not speak to how CNAs were educated regarding swallowing safety for residents, but she thought they would know not to leave a Resident with confusion and swallowing impairments, who required assistance and cues to eat, alone with food in their mouth. During an interview on 12/5/24 at 10:15 A.M., the Staff Development Coordinator (SDC), who was also the Infection Preventionist (IP) said that Certified Nurse Aides' training included assisting residents to eat and feeding residents. The SDC said that she provided education to CNAs during orientation, regarding feeding residents and that a portion of the training was to remind staff to check residents' mouths, to ensure no food was left, for the residents' safety. Immediately following the interview with the SDC/IP, the SDC/IP provided CNA #2's Orientation Checklist to the surveyor which indicated the following: -The Orientation Checklist had been completed for CNA #2 on 4/4/24. -The CNA had been provided education and deemed competent relative to assisting residents with feeding. During an interview on 12/5/24 at 10:27 A.M., the Director of Rehabilitation (DOR) said that Resident #83 was evaluated by the SLP on 11/27/24, following a nursing staff referral for difficulty swallowing and weight loss. The DOR said that the SLP had to discontinue services for Resident #83 on 12/3/24, because the Resident was being admitted to Hospice services. The DOR said that he did not think the SLP would have been required to educate staff on safe swallowing strategies for Resident #83 upon discontinuing speech therapy services because the Resident transitioned to Hospice services. The DOR said it would now be the Hospice personnel's responsibility to assess the Resident and make recommendations relative to safe swallowing. When the surveyor asked who was responsible to ensure interventions were put in place for the Resident to ensure the Resident's safety with swallowing until Hospice personnel assessed the Resident's swallowing abilities, the DOR said, That is a good question. The DOR further said that education had not been completed with nursing staff relative to recommendations for safe swallowing strategies for Resident #83. Please refer to F842. 48206 2. Review of the facility policy titled Falls Accident/Accident Policy and Procedure, dated 2/24/24, indicated: -The Fall Risk Assessment Tool .will be completed on all residents immediately upon admission, quarterly, annually, and whenever there is a significant change in resident status. The Tool will be completed by the Unit Nurse or designee. -New admissions: Any new admissions who have had a fall previously, and/or who are a known risk for falls will have an appropriate intervention initiated on admission. -Nursing will document in the nursing notes for 72 hours after admission if the intervention implemented on admission is effective and if any new intervention has been implemented. Resident #35 was admitted to the facility in October 2023 with diagnoses including difficulty in walking, Atrial Fibrillation (irregular and rapid heart rhythm), and Dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #35: -was mildly cognitively impaired as evidenced by Brief Interview for Mental Status (BIMS) score of 12 out of a possible total of 15. -was able to ambulate short distances independently. -needed supervision to ambulate greater than 50 feet. -was prescribed an anticoagulant medication. Review of the current Physician's orders for Resident #35 included: -Eliquis (anticoagulant medication) 5 mg (milligrams), twice a day at 8:00 A.M. and 8:00 P.M. for diagnosis of atrial fibrillation, initiated 3/15/24 Review of the Nursing Progress notes indicated the following: -4/29/24: Resident #35 complained of chest pain and orders were obtained from the Nurse Practitioner (NP) to send to the emergency room (ER) for further evaluation. -5/2/24: Resident #35 returned to the facility from hospitalization where he/she was admitted for increased confusion and UTI (urinary tract infection). -5/7/24: Resident #35 sustained a fall around 2:40 P.M. at the nurses station .tripped on his/her roller walker and fell on his/her right side .stated he/she hit his/her head. The Resident complained of hip pain, sustained three skin tears .vomited undigested food twice .orders were obtained from the NP to send to ER for further evaluation. -5/13/24: Resident #35 returned from hospital where he/she had been a admitted for closed displaced comminuted (sic) fracture of shaft of right femur (broken thigh bone) and he/she underwent fixation surgery. Review of Resident #35's Care Plan for Risk of Falls, initiated 10/12/23, indicated: -Resident is at risk for fall related injury due to history of fall with fracture (right leg), history of dizzy spells leading to falls (per Resident), generalized weakness, limited range of motion to right arm and leg, and altered mobility. -Intervention of Fall Risk Assessment quarterly and PRN (as needed), initiated 10/12/23 Review of Resident #35's care plan for risk for Abnormal Bleeding, initiated 10/12/23, indicated: -Resident is at risk for abnormal bleeding due to use of [anticoagulant] for Atrial Fibrillation -Goal that Resident will not have excessive bleeding related to anticoagulant therapy -Intervention to handle Resident carefully when turning, positioning, or transferring to avoid injury, initiated 10/12/23. Further review of Resident #35's medical record did not indicate evidence of a fall risk assessment relative to 5/2/24 and 5/13/24 when the Resident returned from hospitalization . During an interview on 12/6/24 at 8:20 A.M., UM #1 said that a falls assessment would evaluate neurological status, vital signs, medication review, ambulation status, changes in skin, and include any care plan interventions implemented to prevent falls. The surveyor and UM #1 reviewed Resident #35's medical record and UM #1 said that Resident #35 should have been assessed for falls risk on re-admission after each hospitalization s but had not been. During an interview on 12/6/24 at 9:50 A.M., Nurse #4 said that when a resident is readmitted to the facility, Nursing will conduct evaluations for pain, elopement, falls, and a Norton Scale and those evaluations are documented in the resident records under observations. Nurse #4 further said that she closely monitors residents on anticoagulant medications due to the higher risk of internal bleeding should a fall or injury occur. Nurse #4 said if a fall occurs, she would contact the Doctor or NP immediately and obtain an order for emergency room evaluation if indicated by the medical practitioner. No additional evidence of post-hospitalization fall risk assessments for Resident #35 were provided to the survey team at the time of survey exit. 3. Resident #53 was admitted to the facility in April 2024 with diagnoses including Dementia with other behavioral disturbance, Vestibular Neuritis (inner ear disorder that causes symptoms such as sudden, severe vertigo [a sudden internal or external spinning sensation, often triggered by moving your head too quickly], dizziness, balance problems, nausea and vomiting), and Atrial Fibrillation. Review of the MDS assessment dated [DATE], indicated Resident #53 was moderately cognitively impaired as evidenced by a BIMS score of 9 out of a total possible 15. Review of the current Physician's orders for Resident #53 included: -Eliquis 2.5 mg (milligrams), twice a day at 8:00 A.M. and 8:00 P.M. for diagnosis of atrial fibrillation, initiated 11/21/24. -LSO (Lumbar Sacral Orthosis, specialty device) Brace to lumbar spine every shift while out of bed, remove during care and inspect skin integrity every shift, once a day, initiated 12/2/24. Review of the Nursing Progress notes indicated: -11/30/24: Resident was out on loa (leave of absence) since 11/28 and was due to return tonight. [Spouse] called the facility at 6:00 P.M., and stated that the Resident fell at home this morning and has been in the ER since then .writer called the hospital for an update .testing revealed an L3 burst compression fracture (severe break in the spine when the vertebrae are crushed in all directions) .Patient is to be evaluated by physical therapy and they will acquire an LSO brace. -12/1/24, Resident returned from hospital where he/she was admitted following a fall while away with family. Hospital discharge notes indicated L3 Fracture with recommendation of LSO brace and ambulation with therapy. Review of Resident #53's Care Plan for Risk for Falls, initiated 4/19/24, indicated: -Resident was at risk for fall related injury due to altered mobility, use of psychotropic medications, Meniere's disease (inner ear problem that can cause dizzy spells, also called vertigo, and hearing loss), and Dementia with behavioral disturbances. -Intervention for fall risk assessment quarterly and PRN (as needed), initiated 4/19/24 During an interview on 12/5/24 at 9:07 A.M., Nurse #5 said that Resident #53 had a recent fall which occurred outside of the facility, and he/she is now wearing an LSO brace to promote healing of the fracture. Nurse #5 said that the Resident is to wear the brace while out of bed and the Resident is receiving physical therapy treatments as well. Nurse #5 further said Resident #53 is at risk of bruising or bleeding due to his/her use of anticoagulant medication. Nurse #5 said that if a fall were to occur, she would immediately complete a falls assessment, monitor the Resident's vitals closely, complete an incident report and skin check, and contact the Doctor or NP immediately as the Resident may need transfer to hospital for emergency evaluation due to risk of internal bleeding with the anticoagulant use. Further review of Resident #53's medical record did not indicate evidence of a falls risk assessment relative to 12/1/24 when the Resident returned to the facility from hospitalization . During an interview on 12/5/24 at 12:04 P.M., UM #1 said that Resident #53 was not re-assessed for fall risk when he/she was readmitted to the facility, and should have been.

Based on observation, record review, and interview, the facility failed to provide routine dental services for one Resident (#46), out of a total sample of 18 residents. Specifically, the facility failed to schedule dental appointments when consent was given, to ensure that Resident #46 received routine dental services as requested, resulting in complications related to dental deterioration for the Resident. Findings include: Review of the facility policy titled Dental Services dated 11/28/17, indicated but was not limited to the following: - residents are assisted in obtaining regular and emergency dental care through the dentist or dental services indicated at the time of the admission Resident #46 was admitted to the facility in January 2020, with diagnoses including Dementia and Dysphagia. On 12/4/24 at 10:29 A.M., the surveyor observed Resident #46 lying in bed. The Resident was observed to have several missing and broken teeth in his/her mouth. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #46: -was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15. -required substantial /maximal assistance with oral hygiene. Review of the medical record indicated a Physician order dated 3/25/21, that indicated: -Dentist Consult as needed. Review of Resident #46's Dental Care Plan indicated but not limited to: -Problem Start Date: 8/11/21, revised 11/5/24 -Resident #46 is assessed with cavity or broken teeth. -Approach Start Date: 8/11/21 - refer to dental as indicated. Review of the medical record indicated a completed Dental Consent Form (a check off form indicating a resident's interest in receiving dental services) for Resident #46. The Dental Consent Form directed the Resident check the statement for which he/she wished to apply. The statement - I would like Dentist to provide dental care was checked off. The form was signed by Resident #46 and was dated 1/20/20. Resident #46 was the responsible party at that time. Further review of the medical record failed to indicate that Resident #46 received any dental services from the Dentist as requested. During an interview on 12/6/24 at 2:20 P.M., Unit Manager (UM) #1 said that she looked through the medical record and cannot find anything about Resident #46 being seen by dental services. UM #1 said that Resident #46 refuses care a lot. UM #1 said she will reach out to the dental provider to see whether the Resident has ever been seen for routine dental services. During an interview on 12/9/24 at 1:10 P.M., UM #1 said she talked with the dental provider's office and Resident #46 had never been seen by that Dentist since signing the consent and was not on the list to be seen. UM #1 said that Resident #46 was seen after the surveyor asked about dental services last week. UM #1 said the Resident allowed the Dentist to take some x-rays and consented to cleaning during the next visit. UM #1 said there were no other visits attempted prior to this visit. On 12/9/24 at 2:57 P.M., UM #1 provided the surveyor with the recent dental visit information. The form indicated but was not limited to the following: -the Resident was given a Comprehensive Oral Evaluation and x-ray by the Dentist. -the text note indicated the Resident was sitting up in bed and consented to be seen. -Findings: very poor dentition with fractured teeth/multiple roots/poor oral hygiene/limited occlusal stop (the point where opposing teeth touch). Obvious decay/ moderate to severe gingivitis/Patient (Pt) refuses any extractions then dentures. -the Resident Ok'd (agreed to) a cleaning which I will put him/her on the list. Review of the dental x-rays dated 12/7/24, indicated: -13 teeth were fractured to the root (Tooth #1, 3, 4, 8, 9, 10, 11, 12, 14, 15, 22, 23, 26) -8 teeth were decayed (Tooth #6, 7, 18, 21, 24, 25, 27, 28) During an interview on 12/9/24 at 3:27 P.M., UM #1 said that once a consent is signed by a Resident, he/she should be added to the list to see the Dentist. UM #1 said she is surprised that this consent was signed so long ago and Resident #46 was never seen by the Dentist. UM #1 said Resident #46 should have been seen right after the consent was signed. During an interview on 12/9/24 at 3:52 P.M., the Director of Nursing (DON) said her expectation is that when a Resident requests dental services and signs a consent, he/she should receive services as soon as possible.

Based on record review and interview, the facility failed to accurately complete a Level I PASRR for one Resident (#83) out of a total sample of 18 residents, which resulted in the Resident not receiving a Level II PASRR Evaluation to determine whether the Resident met criteria for serious mental illness (SMI) and whether specialized services were required to treat the Resident's SMI. Specifically, the facility failed to: -Identify Resident #83's diagnosis of Schizophrenia on the Resident's Level I PASRR when the Resident had a diagnosis of Schizophrenia. -Indicate legal involvement within two years prior to admission to the facility when the Resident had a legal guardian appointed through the court system within two years prior to admission to the facility. Findings include: Resident #83 was admitted to the facility in August 2023 with a diagnosis of Schizophrenia. Review of Resident #83's Hospital Patient Health Summary, dated 1/20/23, indicated the following: -The Resident had been admitted to the hospital for steadily worsening Dementia and developing hallucinations and violent behavior. -The reason for the hospital visit was Schizophrenia. Review of Resident #83's Decree and Order of Appointment of Guardian for an Incapacitated Person, dated 5/5/23, indicated the powers and duties of the Guardian included the following: -Authorization to admit the Incapacitated Person to a nursing facility. The Court found that such admission was in the Incapacitated Person's best interest. Further review of the Resident's Decree and Order of Appointment of Guardian for an Incapacitated Person indicated: -The Court authorized treatment of the Incapacitated Person with antipsychotic medication Review of Resident #83's Level I PASRR, dated 8/3/23, indicated the following: -The Resident had a court appointed Legal Guardian. -The Resident did not have a documented diagnosis of a mental illness or disorder (MI/D) . that may lead to chronic disability. -Question Number Six was completed with an answer of No indicating that the Resident did not require legal intervention that was, or may have been, due to MI/D within the previous two years. -If the answer to Question Number Six was Yes, check Positive SMI screen. Otherwise, check Negative SMI screen. Further review of the Resident's Level I PASRR indicated: -Negative SMI screen was checked. -A Level II PASRR Evaluation was not indicated due to no diagnosis or suspicion of SMI. Review of Resident #83's Physician order dated 8/4/23, with no stop date, indicated the following: -Olanzapine (antipsychotic medication) tablet, one 2.5 milligram (mg) tablet once a day for Psychosis . During an interview on 12/5/24 at 9:33 A.M., the Social Worker (SW) said that Resident #83 had a court appointed Guardian. The SW said that the Resident having a court appointed Guardian within two years of admission to the facility would indicate legal involvement, and that legal involvement within two years prior to the Resident being admitted to the facility would result in a positive SMI screen and referral to the PASRR Office for a Level II PASRR evaluation to be completed for the Resident. During a follow-up interview on 12/5/24 at 12:27 A.M., the SW said Resident #83's Level I PASRR was not completed accurately. The SW said that the Resident had a diagnosis of Schizophrenia prior to being admitted to the facility, was being treated with antipsychotic medication, and had a legal Guardian appointed through the court less than two years prior to admission to the facility. The SW said that the Level I PASRR should have been completed to indicate the Resident had a diagnosis of Schizophrenia and legal involvement through the court. The SW further said that the Level I PASRR should have been completed to indicate the Resident had a positive SMI screen and that the Resident should have been referred to the PASRR Office for a Level II PASRR evaluation to determine whether the Resident met criteria for SMI and to determine whether the Resident required specialized services for SMI.

Based on observation, and interview, the facility failed to provide a clean and homelike environment for one Resident (#35) out of a total sample of 18 residents. Specifically, the facility failed to provide Resident #35 with a wheelchair that was maintained in a clean manner and address promptly any cleaning needs as required. Findings include: Resident #35 was admitted to the facility in October 2023 with diagnoses including Dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was mildly cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15 total possible points. On 12/4/24 at 8:30 A.M., Resident #35 was observed seated in a wheelchair next to the bed in his/her room eating his/her breakfast meal. The surveyor observed the wheelchair was dusty with crumbs and debris on the frame of the chair and cushion. During an interview at the time, Resident #35 said that he/she uses the wheelchair at times because he/she was worried about falling. Resident #35 said that the wheelchair had not been cleaned since he/she had been using it. The Resident further said that his/her family member visited regularly and were involved in his/her care. During an interview on 12/4/24 at 12:04 P.M., Family Member #1 said he/she had asked staff several times to have Resident #35's wheelchair cleaned but the wheelchair had not be cleaned as requested. During an observation and interview on 12/5/24 at 8:59 A.M., Resident #35 said his/her wheelchair was still filthy and had been that way since he/she was admitted to the facility. The surveyor observed that the wheelchair remained dusty with debris. During an interview and observation on 12/5/24 at 12:38 P.M., the Housekeeping Manager (HM) said that there is a schedule to clean the wheelchairs wing by wing. The HM further said she did not have a log to track the cleaning process but she would let the Unit Managers (UM) know to make the wheelchairs available so they can be cleaned. The HM said that she did not have evidence of when the wheelchair used by Resident #35 had last been cleaned. The surveyor and HM observed that the wheelchair in Resident #35's room remained dusty with debris. The HM said that the wheelchair was unacceptable and would be cleaned right away. During an interview on 12/6/24 at 1:13 P.M., the Administrator said the facility did not have a policy relative to wheelchair cleaning, but that a policy and procedure would be developed.

Based on observation, record review, and interview, the facility failed to provide services that met professional standards of quality for two Residents (#83 and #37) out of a total sample of 18 residents. Specifically, the facility failed to: 1. assess Resident #83's swallowing ability in a timely manner, as ordered by the Nurse Practitioner (NP) when the Resident had experienced a decline in swallowing function and weight loss, and required a diet texture downgrade, resulting in a delayed treatment for the Resident. 2. ensure Resident #37 had the correct Physician ordered size indwelling urinary catheter (a soft flexible tube that drains urine from the bladder) in place, placing the Resident at risk for complications related to the urinary catheter. Findings include: 1. Resident #83 was admitted to the facility in August 2023 with diagnoses including Dementia and Muscle Weakness. Review of Resident #83's Nutrition Care Plan, initiated 8/14/23 and last revised 10/11/24, indicated: -The Resident presented at potential nutrition risk related to medical conditions requiring long term care placement. -The Resident was independent with set up at meals. -Registered Dietician (RD)/Speech Language Pathologist (SLP) screen and treat PRN (as necessary). Review of Resident #83's Nursing Progress Note, dated 10/15/24, indicated: -The Resident was in the supervised dining area for his/her meal. -Nursing staff observed that the Resident had some difficulty with the meal. -A rehabilitation screen was submitted for Speech [sic]. Review of Resident #83's Minimum Data Set (MDS) Assessment, dated 10/21/24, indicated: -The Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of 15 total possible points. -The Resident required supervision or touching assistance for eating. -The Resident had no signs or symptoms of a possible swallowing disorder. -The Resident had experienced no significant weight loss in the prior six months. Review of Resident #83's Dietary Progress Note, dated 10/24/24, indicated the following: -The Resident was seen by the Registered Dietician (RD) for a significant change in status assessment related to changes in activities of daily living (ADLs). -The Resident's diet was a Regular Texture House Diet. -The Resident received a four- ounce House Supplement twice daily. -The Resident received diuretic (used to remove excess fluid from the body) medication daily. -The Resident fed him/herself independently after set- up. -The Resident's weight was stable over 30 days and the Resident had experienced an 8.3% weight gain over the previous six months. -No changes were recommended. Review of Resident #83's Nurse Practitioner (NP) Progress Note, dated 10/25/24, indicated: -The Resident was seen for intermittent cough with meals. -The Resident was on a regular texture diet with thin liquids. -Nursing staff reported that the Resident was coughing with meals, and that the Resident was attempting to clear his/her throat after eating. Further review of the NP Progress Note indicated the following assessment and plan: -Cough: New order for chest x-ray, downgraded diet to ground soft diet with a referral to be evaluated by Speech Therapy. Review of Resident #83's NP orders, dated 10/25/24, indicated the following: -Chest x-ray -Downgrade diet to ground soft diet. -Refer Resident to Speech Therapy for cough with eating. Review of Resident #83's clinical record indicated: -A chest x-ray had been completed as ordered. -The Resident's diet had been downgraded to a ground soft diet, as ordered. -There was no evidence the Resident had been referred to Speech Therapy for cough while eating, as ordered by the NP. Review of Resident #83's interdisciplinary Facility Weight - Initial Focus Note, dated 11/14/24, indicated: -The Resident was on a minced/moist texture diet. -The Resident received house supplements twice daily. -The Resident received diuretic medication. -Use of diuretic medication may have contributed to the Resident's weight loss. -A recommendation was made for consultation/evaluation by the SLP. Review of Resident #83's NP Progress Note, dated 11/16/24, indicated: - . referral to be evaluated by Speech Therapy . Review of Resident #83's interdisciplinary Facility Weight - Initial Focus Note, dated 11/21/24, indicated: -The Resident was on a minced/moist texture diet. -The Resident received house supplements twice daily. -The plan included adding fortified food and drink, continuing use of the house supplement twice daily, and discontinuing use of the diuretic medication. Further review of the plan indicated whether a consult with Hospice was appropriate for the Resident. Review of Resident #83's clinical record indicated that a referral for consultation by the SLP was not completed until 11/21/24. Review of Resident #83's Rehab Request/Screen Form, dated 11/21/24, indicated the following: -The Resident had weight changes (166.4 pounds (lbs) 30 days prior; current weight 141.4 lbs) -The Resident's diet had been downgraded on 10/25/24. Review of Resident #83's SLP Evaluation and Plan of Treatment, dated 11/27/24, indicated: -The Resident was referred for evaluation of swallowing due to recent weight loss of 23 pounds since the Resident's diet was downgraded on 10/25/24. -The Resident's diet was downgraded due to concerns with coughing. -The Resident had not previously received Speech Therapy services. -The Resident weighed 151.5 lbs on 10/31/24 and 139.6 lbs on 11/26/24 (significant weight loss). -The Resident's mandibular (lower jaw bone) range of motion, strength, and coordination were impaired. -The Resident's lingual (various components of tongue movement) function was impaired. -The Resident presented with moderate oropharyngeal (middle part of the throat and back of the mouth) dysphagia (difficulty swallowing). -Strategies for safe swallowing were recommended. -Treatment of swallowing dysfunction and/or oral function for feeding was recommended at a frequency of eight times over four weeks. -The long term goal was for the Resident to have safe and adequate intake on the least restrictive diet without signs/symptoms of aspiration (when something that is meant to be swallowed enters one's airway or lungs) and use of strategies. On 12/4/24 at 9:42 A.M., the surveyor observed Resident #83 sitting upright in bed. When the surveyor spoke to the Resident, the Resident responded verbally, and the surveyor observed scrambled eggs in the Resident's mouth, in between the Resident's front teeth and lips and over the top of the Resident's tongue. During an interview on 12/5/24 at 9:49 A.M., SLP #1 said she evaluated Resident #83's swallowing function on 11/27/24, when the facility's Director of Rehabilitation (DOR) had informed her that a referral for Speech Therapy had been made by nursing staff due to the Resident having experienced weight loss. SLP #1 said that she did not know when the referral was submitted because she had just started working at the facility the week prior to completing the Resident's evaluation. During an interview on 12/5/24 at 10:27 A.M., the DOR said that there were two SLPs with time available to work at the facility. The DOR said that the SLPs did not work full time, and that the SLPs were available on an as necessary (Per Diem) basis. The DOR said that SLP #1 recently began working at the facility and that the other SLP was available to work during the time that the NP ordered a Speech Therapy evaluation on 10/25/24. The DOR said that he was not made aware of the NP's order for a speech therapy evaluation for Resident #83 because a referral had not been submitted to him from facility staff. The DOR further said that if he had known the Resident required an evaluation to be completed by an SLP, he would have scheduled the evaluation with the SLP that was available, and the evaluation would have been completed timely. The DOR said that the evaluation with an SLP should have been completed when the evaluation was ordered by the NP on 10/25/24 and that the Resident should not have had to wait until 11/27/24 to be evaluated by the SLP. The DOR said he was not sure why a referral had not been submitted for a speech therapy evaluation when the NP ordered the evaluation to be completed. During an interview on 12/5/24 at 2:36 P.M., the Director of Nursing (DON) said that she recently began working at the facility and had initiated weekly interdisciplinary team (IDT) Risk Meetings where the IDT discussed residents at risk for changes in condition, including weight loss. The DON said the first time Resident #83 was discussed at the Risk Meeting was on 11/14/24. The DON said that the referral for the SLP to evaluate Resident #83 was not completed and submitted to the DOR until 11/21/24. The DON also said that the NP was unavailable for interview and that the RD would be available to speak with the surveyor. During an interview on 12/5/24 at 3:46 P.M., the RD said she participated in weekly interdisciplinary team (IDT) Risk Meetings to identify residents at risk for changes in condition. The RD said that she participated in the Risk Meeting on 11/21/24 and that during this same meeting, the IDT identified that Resident #83 had not been evaluated by the SLP, as ordered by the NP on 10/25/24. The RD said that a referral for the SLP to see the Resident was not completed and submitted to the Therapy Department until 11/21/24. Please refer to F689 and F842. 50138 2. Resident #37 was admitted to the facility in October 2018 with diagnoses including Unspecified Neuromuscular Dysfunction of Bladder (condition caused by damage to the brain, spinal cord or nerves that control bladder function). Review of Resident #37's November 2024 Physician's orders indicated: -Foley (a type of indwelling urinary catheter) 16 Fr (Fr-French, a form of measurement for indwelling urinary catheters [16 French - 5.3 millimeters (mm) circumference])/ 10 (10 milliliter (ml) balloon [a saline inflated balloon used to anchor the indwelling urinary catheter in the bladder]) to bedside drainage at all times. -Foley catheter care every shift. -Change Foley catheter 16 Fr/10 ml monthly on the 1st of the month. -Irrigate (flush) Foley catheter with 50 ml of normal saline for blockage/drainage every shift day, evening, and night. During an interview on 12/4/24 at 3:56 P.M., Nurse #3 said she had irrigated Resident #37's Foley catheter during the day shift (7:00 A.M. to 3:00 P.M.) on 12/4/24 but had not noticed if the correct catheter size was in place. Nurse #3 said she had not changed the Foley catheter during her shift. During an interview and observation on 12/4/24 at 4:00 P.M., Nurse #2 said that she had not changed the Foley catheter for Resident #37. The surveyor and Nurse #2 observed that Resident #37 had an 18 French/ 30 ml balloon Foley catheter in place. Nurse #2 said that Resident #37 had a Physician order for a 16 French/ 10 ml balloon. Nurse #2 said that Resident #37 did not have the correct size Foley catheter in place. Nurse #2 said that Physician's orders should be followed so that the Resident had the correct Foley catheter in place. Nurse #2 further said that all Nurses in the facility had access to the central supply room (room in the facility where supplies are stored before use) and could obtain any size Foley catheter ordered by the Physician. During an interview and observation on 12/4/24 at 4:30 P.M., the facility Staff Educator said all residents with Foley catheters should have Physician orders followed for the correct size. The Staff Educator said size was important because if the catheter and balloon size were too small, the Foley catheter could leak urine and/or fall out of the bladder. The Staff Educator said if the Foley catheter and balloon size were too big, the Foley catheter could cause pain and discomfort to the resident. The surveyor and the Staff Educator observed the stock in the central supply room, and the Staff Educator located 16 French/ 10 ml balloon Foley catheters readily available for use. The Staff Educator said Nurses had access to the central supply office and should have had the correct catheter size in place for Resident #37. During an interview on 12/5/24 at 8:50 A.M., the Director of Nursing (DON) said that Nurses should insert Foley catheters as ordered by the Physician. The DON said the 18 French/ 30 ml balloon was too big for Resident #37 and could cause trauma. The DON said that the facility did not have a policy and procedure relative to the insertion of indwelling Foley catheters but inserting the correct size as ordered by the Physician was a professional standard of practice.

Based on observation, record review, and interview, the facility failed to ensure that one Resident (#46) out of a total sample of 18 residents with contractures received services and treatment to increase range of motion and/or prevent further decrease in range of motion. Specifically, the facility failed to timely assess, monitor and/or treat Resident #46's right third and fourth finger mild contractures. Findings include: Review of the facility's policy titled Resident Mobility and Range of Motion (ROM) Policy (undated) indicated but was not limited to the following: >Residents with limited ROM will receive treatment and services to increase and/or prevent a further decrease in ROM. >As part of the residents' comprehensive assessment, the nurse will identify the residents': -Current ROM of his or her joints >As part of the comprehensive assessment, the nurse will also identify conditions that place the residents at risk for complications related to ROM and mobility, including: -Contractures . >The care plan will be developed by the interdisciplinary team based on the comprehensive assessment and will be revised as needed. >The care plan will include specific interventions, exercises, and therapies to maintain, prevent avoidable decline in, and/or improve mobility and ROM. Resident #46 was admitted to the facility in January 2020, with diagnoses including Dementia and generalized muscle weakness. On 12/4/24 at 10:31 A.M., the surveyor observed Resident #46 lying in bed and his/her right hand was contracted with the third and fourth digits (fingers) in flexion (bending at the joint). There was no positioning device/splint seen in the Resident's area or room. During an interview at the time, Resident #46 said he/she had no pain and has never had a positioning device. Resident #46 said staff do not provide any ROM exercises and he/she does not know if the contractures have gotten worse. The Resident was unable to open his/her hand when the surveyor asked if he/she was able to do so. On 12/9/24 at 2:23 P.M., the surveyor and Unit Manager (UM) #1 observed Resident #46's right upper extremity with the Resident's third and fourth digits in a flexed state. UM #1 asked the Resident if he/she could flex or extend those two fingers and he/she said no. UM #1 said she was unaware of any issues. UM #1 also said she was unsure if Resident #46 was seen by therapy at any point during his/her admission to the facility. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/31/24, indicated that Resident #46 had no impairment in functional limitation in range of motion (ROM) to upper extremities (shoulder, elbow, wrist, hand). Review of the medical record indicated a Visit Note from Physician Assistant (PA) #1 dated 9/5/24. Further review of the PA Visit Note indicated the following in the Additional Notes section: -Musculoskeletal: Right third and fourth finger mild contractures. Further review of the medical record failed to indicate any follow-up to the PA Visit Note or reference to the contractures or limited ROM to the right third and fourth fingers for Resident #46. During an interview on 12/10/24 at 10:06 A.M., the Director of Rehabilitation (DOR) #1 said he has not treated Resident #46. The DOR reviewed the Rehab notes and evaluations and said there was nothing about service for the Resident. The DOR said he received a Rehab request for screen this morning for the third and fourth digit trigger finger (a condition that makes the fingers or thumb difficult to move, and can freeze the fingers in a flexed position) for the Resident and he would screen Resident #46 today. Review of the medical record indicated a Physician Interim/Telephone order dated 12/10/24, for the following new order: -add dx (diagnosis) trigger finger. -PT (Physical Therapy) screen. During a telephone interview on 12/10/24 at 10:33 P.M., PA #1 said she noticed the mild contractures to Resident #46's third and fourth fingers during her evaluation on 9/5/24. PA #1 said the Resident had no functional limitations, pain or skin integrity issues and she had never noticed the contractures before. PA #1 said she discussed with nursing and had no new orders. PA #1 said the treatment (for contractures) is surgical and Resident #46 refuses most interventions. PA #1 said she did not feel rehab would be needed at that time, but expected nursing to monitor for pain, skin integrity issues, decrease in function/ROM and to notify her if anything has changed. Review of the medical record failed to indicate any assessment and/or intervention to monitor the Resident's right third and fourth finger or hand for a decrease in function or ROM. During an interview on 12/10/24 at 10:48 A.M., DOR #1 said he screened Resident #46's right hand and the Resident agreed to the evaluation and treatment. DOR #1 said the Resident's active ROM (the range of motion of a joint that occurs when a person uses their muscles to move without assistance) was impaired. DOR #1 said the Resident would benefit from therapy treatment for the contractures and evaluation for a splint to prevent the contractures from worsening and possibly help improve ROM and use. DOR #1 further said the contractures are noticeable when you see him/her and if it had not been evaluated today, it could have gotten worse. Review of the Physical Therapy (PT) Evaluation and Plan of Treatment dated 12/10/24, indicated: -diagnosis of trigger finger. -Plan of treatment including therapeutic exercises, manual therapy techniques, PT evaluation: moderate complexity and therapeutic activities. >Frequency: Three times/week >Duration: Eight Weeks >Intensity: Daily -Short Term Goal: Patient will tolerate hand splint or roll for 2 hours without signs or symptoms of skin issues to reduce the risk of contracture development. During an interview on 12/10/24 at 11:15 A.M., UM #1 said that after PA #1 found Resident #46's contractures, nursing should have started monitoring the Resident's fingers to ensure there were no complications and that it did not get worse. UM #1 said she would expect Nurses to evaluate the area, complete a pain assessment, assess skin integrity and mobility. UM #1 said Resident #46's contractures were profound but she had not noticed it until it was pointed out to her by the surveyor. UM #1 said she has provided care for Resident #46 multiple times, asking him/her to roll and grab the side rail and she just never saw the contractures. During an interview on 12/10/24, at 11:34 A.M., the Director of Nursing (DON) said that she would have expected a rehab screen to be performed in September when the PA identified that Resident #46 had contractures. The DON said she would have expected nursing to monitor, assess, establish baseline, and try to prevent the contractures from worsening.

Based on observation, record review and interview, the facility failed to maintain complete and accurate medical records for three Residents (#46, #69, and #83), out of a total sample of 18 residents. Specifically, the facility failed to: 1. accurately document measurements of urinary output as ordered when Resident #46 was identified as having a urinary catheter drainage system that provided numerical output measurements. 2. accurately document 24-hour fluid intake and urinary output (I & O) for Resident #69 when the Physician ordered 24-hour I & O monitoring to be completed and documented by staff. 3. maintain a complete clinical record for Resident #83 to include the Resident's Speech Therapy Evaluations, Speech Therapy Treatment Notes, and Speech Therapy Discharge Summary when the Resident had been evaluated, treated, and discharged from speech therapy services and recommendations for safe swallowing strategies were included in the Resident's Speech Therapy Discharge Summary. Findings include: Review of the Facility Policy titled Intake, Measuring and Recording Policy, undated, indicated the following: -The purpose of procedure is to accurately determine the amount of liquid a resident consumes in a 24-hour period. -Record all fluid intake on the intake and output record in cubic centimeters (cc or milliliters [mls]). -Post an intake and output record form in the resident's room. Review of the Facility Policy titled, Nutrition/Hydration Status Maintenance revised 10/6/23, indicated the following: -Based on a resident's comprehensive assessment, the facility will ensure that a resident is offered sufficient fluid intake to maintain proper hydration and health 1. Resident #46 was admitted to the facility in January 2020, with diagnoses including Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms, and Chronic Kidney Disease (CKD), Stage 3. Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #46: -was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of a total score of 15. -had an indwelling foley catheter (a thin, flexible tube that is inserted into the bladder to drain urine into a collection bag). Review of the Comprehensive Person-Centered Care Plan dated 11/25/24, indicated: -Indwelling Catheter, active 11/25/24 -Assess the drainage system every shift and PRN (as needed). Record the amount, type, color, odor. Observe for leakage, active 12/4/24 -Document urinary output every shift. Record the amount, type, color, odor. Observe for leakage, active 11/25/24 Review of Resident #46's December 2024 Physician orders indicated: -24-hour total intake and output to be calculated daily on the 11:00 P.M. to 7:00 A.M. (11-7) shift. Please indicate totals here, initiated 11/25/24. -Encourage fluids every shift, initiated 11/26/24. Review of Resident #46's November 2024 and December 2024 Nursing Documentation of Urine Output indicated no exact measurements of urine output were documented on the following dates: -urine output was documented as 'medium' on: 11/19/24, 12/2/24, 12/4/24 and 12/5/24 -urine output was documented as 'large' on: 11/30/24 and 12/1/24 -urine output was documented as 'none' on: 11/27/24 and 11/28/24 During an interview on 12/6/24 at 10:30 A.M., Nurse #1 said that residents who are on antibiotics and have Foley catheters are placed on intake and output (I&O) monitoring. Nurse #1 also said that the 11:00 P.M. to 7:00 A.M. (11-7) shift tallies the totals for the 24-hour period by adding the total fluid amounts from the 7:00 A.M. to 3:00 P.M. (7-3) and the 3:00 P.M. to 11:00 P.M. (3-11) shifts from the prior day and then add their 11-7 shift which includes supplements, meal fluids, medications fluids. During an interview on 12/6/24 at 10:45 A.M., the Director of Nursing (DON) said that the process for monitoring intake and output totals was as Nurse #1 described, and that this process was something that she had wanted to change since she has been at the facility. The DON said she did not believe that residents who were stable with an indwelling catheter needed to be on intake and output monitoring. The DON further said that staff would monitor output but not necessarily the intake if the resident were eating and drinking well and the Foley catheter were chronic (long term use). The DON said that the intake and output totals should indicate an accurate amount of intake and output for monitoring purposes. The DON said that Resident #46's Physician's order for intake and output monitoring was confusing and she had never seen an intake and output order like that. The DON said she knows that the intake and output process needed to be revised. 42761 2. Resident #69 was admitted to the facility in October 2021, with diagnoses including Obstructive (blockage) and Reflux (backward flow) Uropathy (in the urinary tract) and Retention of Urine. Review of Resident #69's clinical record indicated the Resident had an indwelling urinary catheter. Review of Resident #69's Indwelling Catheter Care Plan, initiated 4/10/24 and last reviewed/revised on 10/3/24, indicated: -The Resident required an indwelling urinary catheter related to Obstructive Uropathy. -Assess the drainage system every shift and PRN (as necessary). -Record the amount . Review of Resident #69's Minimum Data Set (MDS) assessment dated [DATE], indicated: -The Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of five out of 15 total possible points. -The Resident was dependent on staff for toileting. -The Resident had an indwelling urinary catheter. Review of Resident #69's November 2024 Physician Orders indicated the following order, dated 11/2/23 with no stop date: -24-hour total intake and output to be calculated daily on 11:00 P.M. to 7:00 A.M. (11-7) shift. -Please indicate totals . Review of Resident #69's November 2024 Treatment Administration record (TAR) indicated: -The Resident's 24-hour intake total on 11/1/24 was recorded as 640 milliliters (ml) +. -There was no 24-hour total intake and output recorded on 11/3/24. -The Resident's 24-hour output total was recorded as 850 +, medium on 11/13/24. -The Resident's 24-hour intake total was recorded as 620 + and 24 hour output total was recorded as 800 + on 11/25/24. -There was no 24-hour total intake and output recorded on 11/27/24. On 12/4/24 at 9:54 A.M., the surveyor observed Resident #69 lying in bed with a catheter tube extending out from under the sheets, leading to a covered bedside drainage bag visible on the right side of the Resident's bed. During an interview at the time, Resident #69 said he/she did not have an indwelling urinary catheter. During an interview on 12/6/24 at 10:30 A.M., Nurse #1 said that all Residents with indwelling urinary catheters were placed on I & O monitoring. Nurse #1 said that Nurses who worked on the 11-7 shift were responsible to tally the 24-hour intake and output totals for Residents on I & O monitoring and to record the totals on the TAR. Nurse #1 said that the totals recorded for intake and output were supposed to be exact measurements. During an interview on 12/6/24 at 10:45 A.M., the Director of Nursing (DON) said that Nurses who worked on the 11-7 shift were responsible to tally and record the 24-hour intake and output totals for Residents with indwelling urinary catheters. The DON said that the totals recorded were to accurately reflect the total amount of fluid taken in and put out during the 24 hour period. The surveyor and the DON reviewed Resident #69's November 2024 TAR and the DON said that she did not know what the use of the + sign following recorded mls meant. The DON further said that she did not know how the measurements for I & O using the + sign should be interpreted relative to how much liquid the Resident took in and how much urine was put out. The DON said that none of the 24-hour totals for I & O should have been left blank. The DON said I & O monitoring was not recorded accurately in Resident #69's clinical record. 3. Resident #83 was admitted to the facility in August 2023 with diagnoses including Dementia and muscle weakness. Review of Resident #83's Rehabilitation Request/Screen Form, dated 11/21/24, indicated: -The Resident had experienced weight loss. -The Resident's diet had been downgraded on 10/25/24. -Intervention recommended was for the Speech Language Pathologist (SLP) to assess the Resident. Review of Resident #83's clinical record on 12/4/24, did not include any evidence the Resident had been assessed by the SLP. On 12/4/24 at 9:42 A.M., the surveyor observed Resident #83 room sitting upright in bed and that there were no staff or meal tray present in the Resident's room at this time. The surveyor spoke to the Resident who responded verbally and softly so the surveyor had to ask the Resident to repeat what he/she said. Resident #83 smiled and began to speak, and the surveyor observed scrambled eggs in his/her mouth, in between the Resident's front teeth and lips and over the top of the Resident's tongue. When the surveyor asked the Resident about having scrambled eggs in his/her mouth, the Resident said, No. When the surveyor asked the Resident again about the eggs in his/her mouth, the Resident swallowed the eggs. During an interview on 12/5/24 at 9:00 A.M., CNA #2 said that she assisted Resident #83 frequently with eating. CNA #2 said she had noticed that the Resident was having difficulty swallowing. CNA #2 said that she thought the SLP was supposed to see the Resident for swallowing and that she was not sure if the SLP had seen the Resident yet. When the surveyor asked how CNA #2 would know whether any recommendations had been made by the SLP relative to swallowing for Resident #83, CNA #2 said that the SLP would normally provide verbal education and a written education sign-in sheet for staff. CNA #2 said she had not yet received any education relative to safe swallowing strategies for Resident #83. During an interview on 12/5/24 at 9:07 A.M., Nurse #1 said that Resident #83 had difficulty swallowing and would cough when drinking. Nurse #1 said that the SLPs had evaluated and treated the Resident and that the treatment was being discontinued due to the Resident being admitted to Hospice services. Nurse #1 said she was not sure if the Resident's speech therapy services had been discontinued yet. Nurse #1 also said that alternating solids and liquids when assisting Resident #83 to eat was important for safety with swallowing and that she was not aware of any other recommendations made for safe swallow strategies for the Resident. During an interview on 12/5/24 at 9:20 A.M., Unit Manager (UM) #1 said Resident #83 had been evaluated by the SLP and that speech therapy services were discontinued on 12/3/24 when the Resident was admitted to Hospice services. The surveyor asked about any recommendations relative to safe swallow strategies that were made by the SLP upon discontinuing speech therapy services and UM #1 said that she did not recall any recommendations made by the SLP relative to safe swallow strategies for Resident #83. UM #1 reviewed Resident #83's electronic health record (EHR) and paper record on the Unit and said that there was no documentation in the Resident's record relative to speech therapy services. UM #1 further said that she did not know how to access the SLP's documentation for Resident #83. During an interview on 12/5/24 at 9:49 A.M., SLP #1 said she completed an evaluation for Resident #83 on 11/27/24. SLP #1 said that the evaluation was completed in an electronic format and she did not know if the evaluation automatically became part of the Resident's electronic health record (EHR) or if the evaluation needed to be scanned into the Resident's EHR. SLP #1 said she printed a copy of the evaluation on 11/27/24 and left the copy for the Director of Rehabilitation (DOR), but she was not sure if the DOR filed the printed copy of the evaluation in the Resident's paper record located on the Unit. SLP #1 said she treated Resident #83 for two visits and discharged the Resident from speech therapy services on 12/3/24. Review of Resident #83's clinical record on 12/5/24 did not include the evaluation completed by SLP #1, nor did the clinical record include any speech therapy treatments notes and speech therapy discharge summary. During an interview on 12/5/24 at 10:27 A.M., the DOR provided copies of the speech therapy evaluation, progress notes, and discharge summary completed for Resident #83 from 11/27/24 through 12/3/24. The DOR said evaluations, progress notes, and discharge summaries completed by Rehabilitation Therapists were completed electronically in a separate system from the Residents' EHRs that facility staff had access to. The DOR said that once each of the evaluations, progress notes and discharge summaries were completed, the electronic submissions were supposed to automatically transfer into the Residents' EHRs. The DOR said that he did not know Resident #83's speech therapy evaluation, progress notes, and discharge summary did not transfer into the Resident's EHR and that since the surveyor inquired about the notes, he identified other residents whose notes also did not transfer into their EHRs. The DOR said that SLP #1 did leave a printed copy of Resident #83's speech therapy evaluation on 11/27/24 and that the DOR had not yet placed the copy into the Resident's clinical record because the evaluation had not been signed by the Physician yet. The DOR also said he did not place copies of therapy evaluations into residents' clinical records until the evaluations were signed by the Physician. The DOR further said that facility staff did not have access to the electronic system used by the Therapists. Following the interview with the DOR that occurred on 12/5/24 at 10:27 A.M., the surveyor reviewed the Speech Therapy Evaluation, Speech Therapy Progress Notes, and Speech Therapy Discharge Summary provided by the DOR which indicated: -The Resident was evaluated by SLP #1 on 11/27/24. -The Resident has difficulty swallowing. -The Resident received two speech therapy sessions following the evaluation. -The Resident was discharged from speech therapy services on 12/3/24 with recommendations for safe swallowing strategies. -Safe swallowing strategies recommended for the Resident included upright positioning during all intake and greater than 30 minutes following intake, bolus size reductions, rate modifications, alternate solids with liquids at a two to one ratio to assist with oral and pharyngeal clearing of bolus, . During a follow-up interview on 12/5/24 at 4:30 P.M., the DOR said that Resident #83's Speech Therapy Evaluation, Speech Therapy Progress Notes, and Speech Therapy Discharge Summary should have been available in Resident #83's record, but they were not.

Based on observation, record review and interview, the facility failed to complete an inspection of the bed rails, to identify areas of possible entrapment, for one Resident (#49) out of a total sample of 18 residents. Specifically, the facility failed to assess the side rails and mattress in active use for entrapment when Resident #49 had limited mobility and utilized bilateral side rails, placing the Resident at risk for possible entrapment. Findings include: Review of the facility policy titled Side Rail Policy, undated, indicated: -An assessment will be made to determine the resident's symptoms, risk of entrapment, and reason for using side rails . -The resident will be checked periodically for safety relative to side rail use. -When said rail usage is appropriate, the facility will assess the space between the mattress and the side rails to reduce the risk for entrapment . Review of the facility policy titled Falls Accident/Accident Policy and Procedure, dated 2/24/24, indicated: -All mattresses and side rails do require specific measurements to be obtained to rule out the risk of entrapment and does utilize a specific weighted apparatus. -The side rail and mattress measurements are performed and maintained by Maintenance personnel. -Measurements are to be obtained on an annual basis or with any new bedframe, new mattress application, weight changes in a resident, changes noted with resident physical abilities and/or whenever a resident is newly admitted . Resident #49 was admitted to the facility in July 2020 with diagnoses including Vascular Dementia, Polyneuropathy, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #49: -was cognitively intact as evidenced by Brief Interview for Mental Status (BIMS) score of 14 out of a total possible 15. -had range of motion impairment to the lower extremities on both sides -required maximum assistance by staff for upper body bathing and dressing -was dependent on staff for lower body bathing and dressing -was dependent with staff to roll left and right in bed -was unable to go from lying to sitting -did not ambulate. On 12/4/24 at 9:17 A.M., the surveyor observed Resident #49 lying in bed, with the head of the bed elevated and bed in a low position with bilateral side rails in place. During an interview at the time, Resident #49 said that he/she was bed bound and was unable to ambulate or transfer out of bed. On 12/6/24 at 12:04 P.M., the surveyor observed the Resident lying in bed sleeping, with the bed in low position and the head of the bed elevated with bilateral side rails in place. Review of the Care Plan for Risk of Pressure Ulcer/Injury, initiated 7/27/20, indicated Resident #49: -used 2 quarter side rails to enable him/her to participate in bed mobility. During an interview on 12/6/24 at 1:47 P.M., the Maintenance Director (MD) said that he utilizes an entrapment assessment machine, and demonstrated to the surveyor how it is used to evaluate side rails and mattresses for entrapment risk. The surveyor requested evidence of any side rail assessments for Resident #49's current bed and mattress. The MD said that he did not have an assessment on file and was unable to provide evidence of past assessments for entrapment risk for Resident #49.

Based on observation, interview, and record review, the facility failed to adhere to infection control standards of practice for one Resident (#69) out of a total sample of 18 residents. Specifically, for Resident #69, the facility failed to: -appropriately follow Enhanced Barrier Precautions (EBP's: the use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing), when providing high contact care for the Resident, increasing the risk of contamination and spreading infections to the Resident and other Residents within the facility. Findings include: Review of the facility policy titled Enhanced Barrier Precautions (EBP), indicated the following: -The facility will implement EBP during high contact resident care activities for those residents who are colonized with an MDRO (multi-drug-resistant organisms) unless otherwise ordered by healthcare provider. >Examples of high-contact resident care activities: -Dressing -Bathing/Showering -Transferring -Changing Linens -Changing Briefs or Assisting with Toileting -Device Care or Use: - central line, urinary catheter, feeding tube, tracheostomy/ventilator -Wound care-any skin opening requiring a dressing >The facility may choose to implement EBP to include any resident with an indwelling medical device or wound, regardless of MDRO colonization or infection. >The Infection Preventionist (IP)/Designee will provide staff, residents and/or resident representatives with education regarding the purpose of enhanced barrier precautions. >Staff will perform hand hygiene and don personal protective equipment (PPE) before entering resident's room. >Staff will remove PPE and perform hand hygiene before exiting resident's room. Resident #69 was admitted to the facility in October 2021, with diagnoses including Obstructive and Reflux Uropathy, Urinary Tract Infection (UTI) and Urethral Fistula (an opening between the urethra and perineum that causes incontinence and recurrent urinary tract infections(UTIs). Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #69: -was severely cognitively impaired as evidenced by a score of 5 out of a total score of 15 on the Brief Interview for Mental Status (BIMS) exam. -had an indwelling urinary catheter (also referred to as a Foley catheter). Review of Resident #69's Comprehensive Person-Centered Care Plan dated 4/10/24, indicated: -indwelling urinary catheter. Review of Resident #69's Nursing Progress Note, dated 11/20/24, indicated: -EBP for indwelling medical device. On 12/5/24 at 9:10 A.M., the surveyor observed EBP signage posted outside of Resident #69's room which indicated for Everyone: -to cleanse hands before entering and when leaving the room. -wear gloves and a gown for high contact resident care activities including transferring and changing linens. On 12/5/24 at 9:12 A.M., the surveyor observed two staff members transferring Resident #69 from the bed into a wheelchair with no protective gowns being worn by either staff. Certified Nurses Aide (CNA) #2 was observed to pick up Resident #69's Foley catheter and hang the Foley catheter containing urine in the bag on the Resident's wheelchair. CNA #2 then proceeded to handle the Resident's bed linen by making the bed with no protective gown on. The surveyor observed CNA #2 exit the Resident's room and re-entered a few minutes later and continued to assist the Resident without donning or doffing the appropriate PPE. During an interview immediately following the observation on 12/5/24 at 9:19 A.M., CNA #2 said that she was getting the Resident up from bed to go to the dayroom. CNA #2 further said that the Resident was already dressed and that she did not need to utilize a gown. CNA #2 said she believed she had to sanitize her hands and utilize gloves when handling the Resident's Foley catheter. CNA #2 also said that the Resident was on the EBP because he/she had a Foley catheter but she did not need to use a gown when getting the Resident out of bed because the Resident was already dressed for the day. During an interview on 12/5/24 at 10:19 A.M., the Staff Development Coordinator/Infection Preventionist (SDC/IP) said that EBP signage and PPE were used for any Resident that had an indwelling medical device. The SDC/IP also said the use of EBP's were for any high contact care for a Resident who had an indwelling medical device and required care from staff such as transferring, and when handling Resident bed linens. The SDC/IP said that the expectation for staff following EBP signs depended on what staff were doing for the Resident. The SDC/IP also said that staff should know what to do, and the expectation was that staff utilize PPE supplies provided when caring for a Resident on EBP if transferring, handling a Foley catheter, and/or making the bed of a Resident's that has a Foley catheter. During a follow-up interview on 12/5/24 at 1:50 P.M., the SDC/IP said that Residents were placed on EBP either upon admission or when something else comes up after the Resident had been admitted , such as a Foley catheter insertion and/or a Gastrostomy Tube (G-tube: a tube inserted through the abdomen that provides nutrition directly to the stomach). The SDC/IP said the Physician would enter an order in the Resident's records and a care plan would be developed for Residents who have been placed on EBP's so that staff were able to know what the expectations were. The SDC/IP further said that she was responsible for educating staff on EBP for Resident's and that she just did an education for staff and the expectation on PPE requirements.

Based on interview and record review, the facility failed to ensure that Skilled Nursing Facility Advanced Beneficiary Notices of Non-coverage (SNF ABN- notice issued to a resident when a facility determines the beneficiary no longer qualifies for Medicare Part A skilled services and the resident has not used all his/her Medicare benefit days) were issued for three Residents (#17, #35 and #38), out of three applicable residents, so that the Residents could decide if they wished to continue receiving skilled services that may not be paid for by Medicare, and were aware of the financial responsibility they may have to assume. Specifically, the facility failed to issue a SNF ABN: 1. For Resident #17, when the Resident no longer qualified for Medicare Part A skilled services and chose to remain in the facility. 2. For Resident #35, when the Resident no longer qualified for Medicare Part A skilled services and chose to remain a Resident in the facility. 3. For Resident #38, when the Resident no longer qualified for Medicare Part A skilled services and chose to remain in the facility. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) website for SNF ABN last modified 9/10/24, https://www.cms.gov/medicare/forms-notices/beneficiary-notices-initiative/ffs-snf-abn indicated: -Skilled Nursing Facilities (SNFs) must issue a notice to Original Medicare (fee for service - FFS) beneficiaries in order to transfer potential financial liability before the SNF provides: >an item or service that is usually paid for by Medicare, but may not be paid for in this particular instance because it is not medically reasonable and necessary, or >custodial care (non-medical assistance with daily tasks and basic living needs for those who are not sick or disabled). 1. Resident #17 was admitted to the facility in February 2024, with diagnoses including Hypertension, Depression, and Hyperlipidemia. Review of Resident #17's medical record indicated that the Resident's Medicare Part A benefit ended on 5/31/24. The facility was unable to provide any SNF ABN notice corresponding with the Resident ending his/her Medicare benefit on 5/31/24, for review. 2. Resident #35 was admitted to the facility in October 2023, with a diagnosis of Diabetes Mellitus. Review of Resident #35's medical record indicated that the Resident's Medicare Part A benefit ended on 7/5/24. The facility was unable to provide any SNF ABN notice corresponding with the Resident ending his/her Medicare benefit on 7/5/24, for review. 3. Resident #38 was admitted to the facility in January 2020, with diagnoses including Anemia, Coronary Artery Disease, and Heart Failure. Review of Resident #38's medical record indicated that the Resident's Medicare Part A benefit ended on 7/5/24. The facility was unable to provide any SNF ABN notice corresponding with the Resident ending his/her Medicare benefit on 7/5/24, for review. During an interview on 12/5/24 at 3:14 P.M., the Social Worker (SW) said that the previous Physical Therapy (PT) Director assisted with Medicare Part A beneficiary notices, and the SW began doing them when the PT Director left. The surveyor and the SW reviewed Resident's #17, #35, and #38, SNF ABN forms and the SW said that SNF ABN forms were not issued for the three Residents.

Based on record review and interview, the facility failed to ensure that the required members were included in the Quality Assessment and Performance Improvement (QAPI) committee quarterly meetings. Specifically, the facility failed to provide evidence that the Medical Director attended two out of the four quarterly QAPI meetings as required. Findings include: Review of the facility document titled Facility QAPI Plan dated 1/16/2019, indicated the following: -Medical Director must attend at least quarterly, preferred monthly. -All attendees present sign in. If a member is unable to attend in person, due to an occasional schedule conflict, or vacation, indicate the reason they are not in attendance at the meeting. Review of the facility QAPI meeting schedule indicated the QAPI Team met quarterly on 1/18/24, 4/18/24, 7/18/24 and 10/18/24. During an interview on 12/10/24 at 3:15 P.M., the Administrator said the Medical Director is required to attend the quarterly QAPI meetings and that all attendees of the QAPI meeting were required to sign the attendance sheet. The surveyor and the Administrator reviewed the attendance sheets for the quarterly QAPI meetings held at the facility, and the Administrator said that the Medical Director had signed the attendance sheet for the QAPI meetings in April 2024 and October 2024, but did not sign the attendance sheets for the QAPI meetings that took place in January 2024 and July 2024. The Administrator further said that the Medical Director had not attended the quarterly QAPI meetings in January 2024 and July 2024, but should have attended the meetings as required.

Based on records reviewed, review of surveillance camera video footage and interviews, for one of three sampled residents (Resident #1) who had moderate cognitive impairment, history of behaviors and was dependent on staff for care, the Facility failed to ensure he/she was free from physical and verbal abuse when on 12/06/23/23, during the day shift, Certified Nurse Aide (CNA) #1 was seen on video footage pulling Resident #1 backward out of the elevator, then he hit/slapped him/her on the left side of the back of his/her head/neck/face area, and can then be seen standing over him/her engaging verbally and physically as he moves his arms/hands in front of Resident #1's face. The altercation between Resident #1 and CNA #1 was witnessed by another resident and other staff members, who said CNA #1 was antagonizing and threatening Resident #1 and that he/she was visibly upset by the incident. Findings include: Review of the Facility's Policy titled, Abuse Prohibition, dated as revised February 2023, indicated the following: -The Facility has the responsibility to ensure that each resident has the right to be free from abuse, mistreatment, neglect and misappropriation of their personal property, -physical abuse is includes hitting, slapping, kicking, and control of behaviors through corporal punishment, and -mental abuse includes humiliation, harassment, threats of punishment or deprivation. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted 12/06/23, indicated that on 12/06/23 staff witnessed an altercation between a staff member (later identified as CNA #1) and a resident (later identified as Resident #1). The Report indicated Resident #1 was being redirected out of the elevator when he/she became agitated and CNA #1 pulled his/her wheelchair back and put his hand on the side of Resident #1's head. Review of the Facility's Investigation Report, undated, indicated that on 12/06/23, residents were accompanied by staff and were in the basement level of the Facility when Resident #1 attempted to get on the elevator in his/her wheelchair without staff. The Report indicated that another resident's (later identified as Resident #2) Written Witness Statement indicated that CNA #1 pulled Resident #1 out of the elevator and as he (CNA #1) was turning him/her (Resident #1) around, he (CNA #1) hit Resident #1 on the side of the head. The Report indicated that Resident #1 was angry and yelled at CNA #1 which immediately drew the attention of other staff members who were in the basement level. The Report indicated CNA #1 was suspended immediately and then terminated on 12/07/23 for this incident. Resident #1 was admitted to the Facility in March 2020, diagnoses included dementia with behavioral disturbances and right sided hemiparesis (weakness) and hemiplegia (paralysis). Review of Resident #1's Quarterly Minimum Set Data (MDS) Assessment, dated as completed on 12/08/23, indicated Resident #1 had moderate cognitive impairment. Review of Resident #1's Behavior Care Plan, reviewed and renewed with his/her December 2023 MDS, indicated that staff should not confront, argue, or deny his/her belief system. Review of Resident #1's Fall Care Plan, reviewed and renewed with his/her December 2023 MDS, indicated he/she required assist of two staff members for transfers. The Surveyor reviewed Facility surveillance camera video footage from the basement camera in the area of the elevator, with the Administrator and the Director of Nurses (DON) who identified Resident #1 and staff seen in the video. The video footage dated and time stamped 12/06/23 from 14:21:44 to 14:23:01 (2:21 P.M. to 2:23 P.M.) illustrated the following: (14:21:47) CNA #1 walks over to the basement elevator and looks in. (14:21:49) CNA #1 enters the elevator. (14:21:52) CNA #1 is seen pulling the wheelchair Resident #1 is seated in backward out of the elevator. (14:21:55) CNA #1 turns the wheelchair so Resident #1 is facing the camera as he backs him/her up. Then, with his right hand, CNA #1 hits Resident #1 on the left side of his/her face/head/neck area. As CNA #1's hand makes contact with Resident #1's face/head/neck, his/her head jerks backward and to the right. Resident #2 enters into the cameras view, he/she walks toward the elevator assisting (pushing) another resident in a wheelchair. Resident #2 turns his/her head and looks in the direction of Resident #1 and CNA #1, as CNA #1 hits Resident #1. (14:21:57) CNA #1 (who is tall and large in stature), stands over Resident #1 and points his finger in Resident #1's face. Resident #1 raises his/her left arm/hand to cover his/her face. (14:21:59) CNA #1 continues to stand over Resident #1 and swings his arms at Resident #1 in an aggressive manner. Resident #1's moves his/her head and neck backwards and to the right, moving away from CNA #1's reach. Resident #1 raises his/her arms up as if he/she is attempting to protect him/herself. (14:22:05) CNA #2 enters the camera's view and she walks toward CNA #1 and Resident #1, who are still by the basement elevator. (14:22:12) CNA #2 approaches CNA #1 and Resident #1 as CNA #1 continues to stand over him/her. Resident #1 continues to extend (position) his/her upper body back in his/her wheelchair as if he/she is trying to move or keep away from CNA #1. (14:22:19) CNA #1 can be seen pointing down the hall and Resident #1's upper body is still pulled or extended back in his/her wheelchair, away from CNA #1. CNA #2 is standing close to CNA #1 and Resident #1. (14:22:24) Resident #1 moves his/her wheelchair backward, away from CNA #1, and now CNA #1 is no longer standing over him/her in a threatening manner. Resident #1 straightens his/her posture so he/she is seated more upright in his/her wheelchair. (14:22:27) CNA #1 backs away from Resident #1. (14:22:42) The Director of Admissions enters the cameras view and looks toward the direction of CNA #1, CNA #2 and Resident #1 who are near the elevator. (14:22:54) CNA #1 walks away from Resident #1, gets another resident in a wheelchair and pushes him/her onto the elevator. Review of a Disciplinary Action Form, dated 12/08/23, indicated that on 12/06/23 at approximately 2:23 P.M., CNA #1 struck Resident #1 on the neck after taking him/her off the elevator. The Form indicated that the incident was on captured on video surveillance and witnessed by Resident #2. The Form indicated that the incident constitutes physical abuse and assault and battery. The Form indicated that CNA #1 was terminated on 12/07/23. During an interview on 12/20/23 at 3:32 P.M., Resident #1 said he/she could not recall an altercation with CNA #1. Although Resident #1's understanding and/or ability to recall of the incident was limited due to his/her impaired cognitive status, an unimpaired individual would have experienced physical pain and mental anguish after being treated by a caregiver in this manner. The Facility was unable to provide a Written Witness Statement and/or Interview from Resident #1, so there was no documentation of Resident #1's account of incident. During an interview on 12/20/23 at 2:54 P.M. and review of Resident #2's Written Witness Statement, dated 12/06/23, Resident #2 said he/she was downstairs with other residents after they went out to smoke and that they were waiting by the basement elevators to go back upstairs. Resident #2 said he/she saw CNA #1 pull Resident #1 out of the elevator and then smack/slap him/her on the left side of his/her face. Resident #2 said Resident #1 was very upset and was screaming but he/she could not remember what Resident #1 said. Resident #2 said he/she was also very upset, and said, If CNA #1 did that to Resident #1, what is he (CNA #1) doing to other residents that cannot say anything? During an interview on 12/20/23 at 10:48 A.M., and review of her Written Witness Statement, dated 12/06/23, the Director of Admissions said on 12/06/23 at approximately 2:20 P.M., she was in her office (which is in the basement of the Facility) when she heard screaming. The Director of Admissions said she heard Resident #1 yell, fuck you, I will fuck you up for hitting me in the face! The Director of Admissions said she walked around the corner and said when Resident #1 saw her, he/she said, he really did it! The Director of Admissions said CNA #1 was antagonizing Resident #1 and that Resident #1 looked very anxious. The Director of Admissions said Resident #1 was swinging his/her fists at CNA #1 and he (CNA #1) kept pushing Resident #1's hands down. The Director of Admissions said in response to Resident #1 saying, he really did it!, CNA #1 kept saying, no I didn't, let's go up (in the elevator). The Director of Admissions said Resident #1 was very upset. During an interview on 12/20/23 at 11:52 P.M., and review of her Written Witness Statement, dated 12/06 (year not documented), CNA #2 said that after she and CNA #1 had taken residents out to smoke, she heard Resident #1 yelling and that he/she said you slapped me to CNA #1. CNA #2 said she told CNA #1 to stop fighting with Resident #1. CNA #2 said that CNA #3 and CNA #4 came out of the break room and also tried to stop CNA #1 from fighting with Resident #1. CNA #2 said Resident #1 was very angry and he/she kept saying that CNA #1 slapped him/her in the face. During an interview on 12/20/23 at 2:13 P.M., CNA #3 said she was in the break room downstairs which is near the basement elevator when she heard very loud yelling in the hallway. CNA #3 said she went out into the hallway and told CNA #1 to stop yelling at Resident #1. CNA #3 said Resident #1 told her three times that CNA #1 had slapped him/her. CNA #3 said CNA #1 was yelling and arguing with Resident #1. CNA #3 said she and CNA #4 helped Resident #1 calm down. During an interview on 12/20/23 at 2:26 P.M., CNA #4 said she was in the break room with CNA #3 when she heard Resident #1 screaming. CNA #4 said she left the break room and saw Resident #1 sitting in his/her wheelchair near the elevator. CNA #4 said Resident #1 was yelling that CNA #1 had slapped him/her. CNA #4 said she and CNA #3 were tried to calm Resident #1 down. CNA #4 said she told CNA #1 to stop arguing with Resident #1. CNA #4 said that Resident #1 was very upset and angry. During an interview on 12/20/23 at 3:59 P.M., Unit Manager #1 said she heard Resident #1 screaming in the elevator and that he/she was surrounded by staff trying to calm him/her down when he/she returned to the unit. Unit Manager #1 said Resident #2 came to her and said, it really happened, he (CNA #1) slapped Resident #1. During a telephone interview on 12/20/23 at 3:10 P.M., CNA #1 said he knew Resident #1 well and that he/she sometimes plays with the elevators. CNA #1 said he dragged Resident #1 out of the elevator in his/her wheelchair and put his hand on the front of his/her (Resident #1's) face to stop him/her from yelling. CNA #1 said he had been trained to back away from residents if they exhibit behaviors, but said, This time it was too much, and I put my hand on the front of his/her face. During an interview on 12/20/23 at 4:12 P.M., the Administrator said that on 12/06/23 the Director of Admissions called him and said there was a disruption in the basement. The Administrator said he looked at surveillance camera video footage and saw CNA #1 pull Resident #1 out of the elevator. The Administrator said he saw CNA #1 put his fist up to Resident #1's temple. The Administrator said Resident #1 looked angry, and that CNA #1 kept putting his hands up. The Administrator said CNA #1 should have deescalated the situation or walked away, but he had not. The Administrator said he substantiated the allegation of physical abuse and CNA #1 was terminated.

Based on records reviewed, interviews and review of surveillance camera video footage, for one of three sampled residents (Resident #1) who was physically abused by a staff member, the Facility failed to ensure they reported a reasonable suspicion of a crime, when although the Administrator was aware on 12/06/23, that Certified Nurse Aide (CNA) #1 hit Resident #1 in the head/neck/face area, and substantiated the incident as physical abuse, the Facility did not notify local law enforcement until 12/20/23, the day of survey. Findings include: Review of the Facility's Policy titled, Abuse Prohibition, dated as revised February 2023, indicated the following: - Physical abuse is defined as hitting, slapping, pinching, kicking, and control of behavior through corporal punishment, -The Facility will ensure reporting of a reasonable suspicion of crimes against a resident or individuals receiving care from the Facility within prescribed timeframes to the appropriate entities within two hours after forming suspicion if serious bodily arm or if the allegation involves abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriations of resident property, and - When a facility has identified abuse, the facility must immediately take all appropriate steps to remediate the noncompliance and protect the resident from additional abuse. This includes reporting the alleged violation and investigation within the required timeframes. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted 12/06/23, indicated that on 12/06/23 staff witnessed an altercation between a staff member (later identified as CNA #1) and resident (later identified as Resident #1). The Report indicated Resident #1 was being redirected out of the elevator when he/she became agitated, CNA #1 pulled his/her wheelchair back and put his hand on the side of Resident #1's head. Review of the Facility's Investigation Report, undated, indicated that on 12/06/23 residents were accompanied by staff in the basement level of the Facility when Resident #1 attempted to get on the elevator in his/her wheelchair without staff. The Report indicated that another resident's (later identified as Resident #2) Written Witness Statement indicated that CNA #1 pulled Resident #1 out of the elevator and as he was turning him/her (Resident #1) around, he (CNA #1) hit Resident #1 on the side of the head. The Report indicated that Resident #1 was angry and yelled at CNA #1 which immediately drew the attention of other staff members who were in the basement level. The Report indicated CNA #1 was suspended immediately and then terminated on 12/07/23 for this incident. Resident #1 was admitted to the Facility in March 2020, diagnoses included dementia with behavioral disturbances and right sided hemiparesis (weakness) and hemiplegia (paralysis). Review of Resident #1's Quarterly Minimum Set Data (MDS) Assessment, dated 12/08/23, indicated Resident #1 had moderate cognitive impairment. The Surveyor reviewed Facility surveillance camera video footage with the Administrator and the Director of Nurses (DON) who identified Resident #1 and staff seen in the video. Review of the basement elevator area video footage dated and time stamped 12/06/23 from 14:21:44 to 14:23:01 (2:21 P.M. to 2:23 P.M.) illustrated the following: (14:21:47) CNA #1 walks to the basement elevator and looks in. (14:21:49) CNA #1 enters the elevator. (14:21:52) CNA #1 is seen pulling the wheelchair Resident #1 is seated in backwards out of the elevator. (14:21:55) CNA #1 turns the wheelchair so Resident #1 is facing the camera as he backs him/her up. Then, with his right hand, CNA #1 hits Resident #1 on the left side of his/her face/head/neck area. As CNA #1's hand makes contact with Resident #1's face/head/neck, his/her head jerks backward and to the right. Resident #2 enters the cameras view, as he/she walks toward the elevator assisting (pushing) another resident in a wheelchair. Resident #2 turns his/her head and looks in the direction of Resident #1 and CNA #1, as CNA #1 hits Resident #1. (14:21:57) CNA #1 (who is tall and large in stature), stands over Resident #1 and points his finger in Resident #1's face. Resident #1 raises his/her left arm/hand to cover his/her face. (14:21:59) CNA #1 continues to stand over Resident #1 and swing his arms at Resident #1 in an aggressive manner. Resident #1's moves his head and neck backward and to the right, moving away from CNA #1's reach. Resident #1 raises his/her arms up as if he/she is attempting to protect him/herself. (14:22:05) CNA #2 enters the camera's view and she walks toward CNA #1 and Resident #1, who are still by the basement elevator. (14:22:12) CNA #2 approaches CNA #1 and Resident #1 as CNA #1 continues to stand over him/her. Resident #1 continues to have his/her upper body extended (positioned) towards the back of his/her wheelchair as if he/she is trying to move away from CNA #1. (14:22:19) CNA #1 is pointing down the hall and Resident #1's upper body is still extended (positioned) back in his/her wheelchair, away from CNA #1. CNA #2 is standing close to CNA #1 and Resident #1. (14:22:24) Resident #1 moves his/her wheelchair backward, away from CNA #1, and now CNA #1 is no longer standing over him/her in a threatening manner. Resident #1 straightens his/her posture so he/she is seated more upright in his/her wheelchair. (14:22:27) CNA #1 backs away from Resident #1. (14:22:42) The Director of Admissions enters the camera view and looks towards the direction of CNA #1, CNA #2, and Resident #1 who are near the elevator. (14:22:54) CNA #1 walks away from Resident #1, gets another resident in a wheelchair and pushes him/her onto the elevator. Review of a Disciplinary Action Form, dated 12/08/23, indicated that on 12/06/23 at approximately 2:23 P.M., CNA #1 struck Resident #1 on the neck after taking him/her off the elevator. The Form indicated that the incident was on video surveillance and witnessed by Resident #2. The Form indicated that the incident constitutes physical abuse. The Form indicated that CNA #1 was terminated on 12/07/23. The Form indicated that Resident #1's Guardian did not want law enforcement to be notified, and that the incident was assault and battery. During an interview on 12/20/23 at 3:32 P.M., Resident #1 said he/she could not recall an altercation with CNA #1. The Facility was unable to provide a Written Witness Statement and/or Interview from Resident #1, therefore there was no documentation of Resident #1's account of incident after it happened. During an interview on 12/20/23 at 2:54 P.M. Resident #2 said he/she was downstairs with other residents after they went out to smoke and that they were waiting by the elevators to go back upstairs. Resident #2 said she saw CNA #1 pull Resident #1 out of the elevator and then smack him/her on the left side of his/her face. Resident #2 said Resident #1 was very upset and was screaming but he/she could not remember what Resident #1 said. During an interview on 12/20/23 at 10:48 A.M., and review of her Written Witness Statement, dated 12/06/23, the Director of Admissions said on 12/06/23 at approximately 2:20 P.M., she was in her office when she heard screaming. The Director of Admissions said she heard Resident #1 yell, fuck you, I will fuck you up for hitting me in the face! The Director of Admissions said she walked around the corner and said when Resident #1 saw her, he/she said, he really did it! The Director of Admissions said CNA was antagonizing Resident #1 and that Resident #1 looked very anxious. The Director of Admissions said Resident #1 was swinging his fists at CNA #1 and he (CNA #1) kept pushing Resident #1's hands down. During an interview on 12/20/23 at 11:52 P.M., and review of her Written Witness Statement, dated 12/06 (year not included), CNA #2 said that after she and CNA #1 had taken residents out to smoke, she heard Resident #1 yelling and that he/she said you slapped me to CNA #1. CNA #2 said Resident #1 was very angry and he/she kept saying that CNA #1 slapped him/her in the face. During an interview on 12/20/23 at 2:13 P.M., CNA #3 said she was in the break room downstairs which is near the elevator when she heard very loud yelling in the hallway. CNA #3 said Resident #1 told her three times that CNA #1 had slapped him/her. CNA #3 said CNA #1 was yelling and arguing with Resident #1. During an interview on 12/20/23 at 2:26 P.M., CNA #4 said she was in the break room with CNA #3 when she heard Resident #1 screaming. CNA #4 said Resident #1 was yelling that CNA #1 had slapped him/her. During an interview on 12/20/23 at 3:59 P.M., Unit Manager #1 said she heard Resident #1 screaming in the elevator and was surrounded by staff trying to calm him/her down when he/she returned to the unit. Unit Manager #1 said Resident #2 came to her and said, it really happened, he (CNA #1) slapped him/her (Resident #1). During an interview on 12/20/23 at 3:41 P.M., the Director of Nurses (DON) said she was not in the Facility at the time the allegation was made and said the Administrator conducted the investigation. The DON said the allegation could have been a reasonable suspicion of a crime. The DON said she called Resident #1's guardian and asked if he would like the Police to be involved and he (Resident #1's guardian) declined, so she did not notify them. The DON said she called the Police at the time of the survey (12/20/23). During an interview on 12/20/23 at 4:12 P.M., the Administrator said he looked at surveillance camera video footage immediately after the Director of Admissions notified him that there was a disruption in the basement. The Administrator said upon review of the footage, he saw CNA #1 pull Resident #1 out of the basement elevator in his/her wheelchair, and then saw CNA #1 put his fist up to Resident #1's temple. The Administrator said Resident #1 looked angry, and that CNA #1 kept putting his hands up near Resident #1. The Administrator said he substantiated the incident as physical abuse and that CNA #1 had been terminated. The Administrator said he had not called the Police because Resident #1 had not been injured. The Administrator also said Resident #1's guardian declined Police involvement, so he did not notify them.

Based on observations, records reviewed, and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice and the Resident's/Resident Representative's (RRs) choices for one Resident (#27), out of a total sample of 19 residents. Specifically, the facility failed to adequately assess Resident #27's acute change in condition and accurately monitor his/her food intake or fluid intake and fluid output when the Resident demonstrated frequent refusal of medications, had reduced food and fluid intake, had a history of constipation, and complained of abdominal pain, which resulted in rectal fecal impaction and hospitalization . Findings include: Review of the facility's policy titled, Change of Resident Condition, revised June 2020, included the following: -The purpose was to ensure timely communication of a resident's change in condition between nursing staff and the prescriber to better evaluate and manage residents in the facility and to thereby avoid transfer to an acute care setting. -The facility recognized that timely communication of a resident's change of condition to the prescriber (Physician [MD]/Nurse Practitioner [NP]) was essential to the initiation of therapeutic interventions. -The facility also recognized the important role filled by family, surrogate, and representatives in the care of each resident . -A change in condition was a sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains. -Clinically important meant a deviation, that without intervention, might result in complications . Review of the facility's policy titled, Intake and Output Policy, undated, indicated: -The Nursing personnel would keep an accurate record of a resident's fluid balance when the resident had a drainage collection device and/or per the Physician's order. -Fluid output includes all fluid that leaves a resident's body, including urine . -Whenever possible, output will be measured versus estimated. -A resident's fluid output was to be documented in the intake and output form. -The 11:00 P.M. through 7:00 A.M. (11-7) shift would total the intake of fluids for the previous 24-hour cycle and document in the 24-hour total intake space. -The Nurse was required to notify the Physician if any one of the following occurred: 1. A resident's fluid intake fell below 1000 milliliters (mls)/24 hours for a period of greater than 72 hours. 2. A resident's 24-hour fluid intake fell below 500 mls. Review of the facility's policy titled, Nutrition/Hydration Status Maintenance, undated, indicated: -The facility would provide nutrition/hydration status maintenance services in accordance to State and Federal Regulations. -Residents would be offered sufficient fluid intake to maintain proper hydration and health. -Residents would be offered a therapeutic diet when there was a nutritional problem and the health care provider ordered a therapeutic diet. Resident #27 was admitted to the facility in August 2023 with diagnoses including Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), Oropharyngeal (the area of the throat behind the mouth and the tonsils) Phase Dysphagia (difficulty in swallowing food or liquid), and Muscle Weakness. Review of Resident #27's Nursing Admission assessment dated [DATE], indicated the Resident: -had muscle weakness -was alert and confused -had fair appetite -difficulty swallowing. Further review of the Nursing Admission Assessment indicated the Resident had an indwelling urinary catheter (a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag). Review of Resident #27's Discharge Plan Care Plan initiated 8/23/23, indicated the Resident was to remain in the facility for long term care due to requiring 24-hour supervision and care. Review of Resident #27's Behavioral Symptom Care Plan initiated 8/23/23, indicated the Resident could be resistive to care and staff were to reiterate the purpose and advantages of treatment for the Resident. Review of Resident #27's Nutritional Status Care Plan initiated 8/24/23, indicated: -The Resident had a potential nutrition risk related to medical condition requiring a mechanically altered diet. -Staff were to monitor intakes and weights. -Registered Dietician (RD)/Speech Language Pathologist (SLP) screen (brief meeting with an individual to determine strengths and weakness through informal measures) and treat PRN (as the situation demands). Review of an RD Note dated 8/24/23, included the following: -House (a healthy meal plan that includes a variety of healthy foods from all the food groups), soft and bite-sized diet. Allow soft bread products and soft salad sandwiches. -Appetite was 75-100% -No supplements were in place. -The Resident and Health Care Proxy (HCP: someone designated to make choices about one's care if they are unable to make those decisions for themselves) were happy with the diet texture. -No interventions were required at that time. -Will monitor intakes, weights . Review of a Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #27 was severely cognitively impaired as evidenced by a score of five out of 15 possible points on the Brief Interview for Mental Status (BIMS). Further review of the MDS assessment indicated the Resident had inattention and disorganized thinking, and required supervision and set-up for eating. Further review of Resident #27's active Comprehensive Care Plan dated 9/1/23, included: -The Resident had tooth decay and staff were to encourage enough fluid consumption to keep his/her mouth moist and provide diet as ordered. -The Resident had communication difficulties and staff were to allow him/her time to process information. -The Resident was unable to perform activities of daily living (ADLs) independently and required continuous supervision at a ratio of one staff to eight residents for eating. *ADLs could vary in the course of the day due to disease process of Parkinson's Disease with delusions (fixed, false conviction in something that is not real or shared by other people) and hallucinations (experience in which one sees, hears, feels, or smells something that does not exist). *Assess Resident and carry out ADLs as needed. *Evaluate Resident ability to perform ADLs. *Notify MD/NP, Rehab of any decline if noted. *Provide assistance as needed . -The Resident had an indwelling urinary catheter and preferred a leg drainage bag at all times. -The Resident's urinary catheter drainage system was to be assessed every shift and as needed. The amount, color, and odor of urinary output was to be recorded. Review of Resident #27's Speech Therapy Discharge Summary dated 9/20/23, indicated the Resident was able to swallow thin consistency liquids from an open cup using compensatory strategies (techniques used to help an individual perform tasks in a manner to be more independent) from trained staff. Review of a Physician's order, dated 9/26/23, indicated: Downgrade (reduce) thin liquids to nectar liquid consistency until further evaluation is done. Review of Resident #27's clinical record included no evidence of a referral to the RD or SLP for further evaluation after the liquid downgrade was ordered. On 9/29/23 from 8:58 A.M. through 9:11 A.M., the surveyor observed the following: -Resident #27 was lying in bed with the head of the bed slightly elevated. -The Resident's breakfast tray was placed on a rolling overbed table, to the left of the Resident's bed, beside the window. -All food and drink items on the tray were covered. Resident #27 pointed toward the breakfast tray and said he/she was hungry, continued to point at the breakfast tray and said, It's over there. -The surveyor observed the items on the tray included one full cup of juice, one full cup of coffee, one full cup of milk, one full covered bowl of cereal, and one covered plate of scrambled eggs and toast. -the surveyor did not observe any staff members enter the Resident's room to offer or assist with breakfast for the Resident. Review of Resident #27's fluid intake and output on the September 2023 Treatment Administration Record was as follows: -Intake was 600 mls and urine output was 700 mls on 9/29/23. Intake and output was not recorded for the 11:00 P.M. through 7:00 A.M. shift. -Intake was 840 mls and urine output was 400 mls on 9/30/23. Urine output was recorded as Medium on the 7:00 A.M. through 3:00 P.M. shift and the 11:00 P.M. through 7:00 A.M. shift. Review of a Nursing Progress Note, dated 10/1/23, indicated Resident #27's HCP expressed a noted decline in the Resident's eating and drinking to the Director of Nursing (DON) and that the HCP wanted to give the Resident thin liquids. Further review of the Nursing Progress Note indicated the DON explained the Resident's risk for aspiration/choking and Pneumonia to the HCP and that the NP would follow-up on this [sic]. On 10/3/23 between 8:40 A.M. and 8:53 A.M., the surveyor observed the following: -Resident #27 was lying in bed sleeping. -The Resident's breakfast tray was resting on a rolling overbed table to the Resident's left side, within reach of the Resident, and contained scrambled eggs, one piece of toast that was cut in half, one bowl of oatmeal, and one bowl of rice cereal. -There were four individual unopened coffee creamers on the tray and one plastic cup which was positioned upside down. There was no remnants of liquid in the cup. There was one covered metal mug on the tray that was full of thin consistency ice water. There were no other drinks on the tray and no staff were in the room assisting the Resident. During an interview on 10/3/23 at 8:46 A.M., outside the Resident's room with Nurse #2, she said that Resident #27's liquid consistency had recently been downgraded to nectar thick from thin due to difficulty swallowing. Nurse #2 said the Resident's HCP had been attempting to provide thin consistency water to the Resident over the previous week or so due to the HCP having concerns that the Resident was not drinking enough liquids since the downgrade to nectar thick, but she did not think the HCP had been in as yet that day. The surveyor, Nurse #2 and CNA #11 entered the Resident's room together and Nurse #2 said the Resident could not have thin liquids. Nurse #2 instructed CNA #11 to dump it and the CNA removed the metal mug from the tray, entered the bathroom and emptied the metal cup of ice water. -the surveyor did not observe any food or liquids being offered to the Resident during this time and CNA #11 removed Resident #27's tray from his/her room. During an interview on 10/3/23 at 11:30 A.M., Resident #27's HCP said he/she noticed the Resident had a recent decline in eating and drinking over the previous week, since the Resident's liquid consistency had been changed from thin to nectar thick. The HCP said he/she had concerns the Resident was not eating or drinking enough and that he/she would lose weight and become dehydrated. Resident #27's HCP also said the Resident had been refusing medications frequently, including medications used to treat symptoms of Parkinson's Disease and medications to regulate the Resident's bowels. On 10/4/23 between 12:10 P.M. and 12:26 P.M., the surveyor observed the following: -Resident #27 was lying in bed. His/her lunch tray was resting on a rolling overbed table that was positioned against the wall by the window, to the left of the Resident. -The meal tray contained one covered cup of thickened milk, one covered mug of water with a packet of unopened thickened coffee, one covered bowl with applesauce, and one covered plate that contained a stuffed pepper. -The Resident pointed toward the meal tray but did not vocalize out loud to the surveyor. When the surveyor asked the Resident if anyone had offered him/her lunch, the Resident shook his/her head, indicating no. When the surveyor asked if the Resident wanted lunch, he/she nodded his/her head, indicating yes. -At 12:26 P.M., CNA #7 entered Resident #27's room. CNA #7 spoke to the Resident's roommate, then approached Resident #27 and asked if he/she wanted to get up out of bed. Resident #27 said no, and CNA #7 left the room. -No staff were observed offering Resident #27 assistance with his/her meal during this time and the Resident's tray remained on the rolling overbed table against the wall by the window. Review of Resident #27's Meal Intake Monitoring Record for 10/4/23 indicated the Resident ate 76-100% of his/her lunch meal that day, despite the surveyor's observation that the meal tray was untouched. On 10/4/23 at 2:45 P.M., the surveyor observed Resident #27's HCP standing at the nurses station. The Resident's HCP said he/she was looking for a Nurse to assess the Resident and that the Resident was requesting to go to the hospital with complaints of feeling impacted (inability to evacuate large hard stool, most commonly found in the rectum). At this time, Nurse #7 came out of the office located behind the nurses station and introduced himself to the surveyor as the 3:00 P.M. to 11:00 P.M. shift Supervisor. Nurse #7 further said that he had a rapport with the HCP and walked down the hallway with him/her. Review of a Nursing Note dated 10/4/23, indicated Resident #27's indwelling urinary catheter was changed due to blockage. The Nursing Note did not include any information relative to the Resident having had abdominal pain, feeling impacted, or requesting to go to the hospital. During a telephone interview on 10/5/23 at 10:30 A.M., the NP said she was unavailable to come to the facility during the previous week, but she was available to the facility by phone. The NP said she returned to work onsite on 10/2/23 and was aware the Resident had been having trouble with his/her urinary catheter becoming blocked and had been refusing indwelling urinary catheter care and medications. The NP also said she was aware Resident #27's HCP requested to be able to provide the Resident with thin liquids, but was not aware that the Resident had reduced food and thickened fluid intake. The NP further said she was not aware that the Resident had expressed feeling impacted on 10/4/23 or that he/she had requested to go to the hospital. The NP said she had not assessed Resident #27's status that week as this was new information. She said she would want to obtain a urinalysis for the Resident to rule out a urinary tract infection (UTI) and that she needed to review the Resident's record and see the Resident in order to develop a clinical plan. Review of Resident #27's Meal Intake Monitoring Record for 10/5/23 indicated the Resident ate no lunch that day and the surveyor observed that the documentation was completed at 10:53 A.M., which was prior to the lunch meal being served. On 10/5/23 at 11:45 A.M., the surveyor observed Resident #27 seated in a wheelchair beside his/her bed and the Resident's HCP was present. The Resident did not respond to his/her HCP's verbal cues or physical touch. The Resident's head was positioned downward, his/her eyes were closed, and his/her mouth was open. The surveyor observed that the Resident's lips were dry, there was a light grey tint to the skin surrounding the Resident's lips, darkened grey circles around the Resident's eyes, and the Resident's face had a greyish hue. Resident #27's HCP talked to the Resident and touched the Resident on his/her arms and hands, but the Resident did not respond. During an interview at the time, Resident #27's HCP said the Resident had a scheduled outside appointment that afternoon and that transportation services were booked to pick the Resident up at 12:00 P.M. The Resident's HCP also said the Resident had not yet received a lunch even though the Resident was not going to be at the facility for lunch that day. The HCP said he/she did not know if the facility planned to send a lunch with Resident #27, so he/she brought some food from home for the Resident. The HCP then opened a container of yogurt and attempted to provide a spoonful to Resident #27, which fell from the Resident's mouth. The HCP then attempted to provide a drink of water from an open cup which also fell from the Resident's mouth. When the HCP made a second attempt, the Resident accepted and swallowed one spoon of yogurt and one sip of water provided by the HCP while the Resident was cued for the yogurt, water, and to swallow. The Resident's HCP told the Resident he/she needed to wake up so that he/she could talk with the Provider at the scheduled appointment that day, but the Resident did not respond. The HCP said he/she had helped the Resident get dressed that morning and that the Resident's clothes no longer fit as they were too big. The HCP also said she thought the Resident had lost weight and was afraid he/she may have been dehydrated. Resident #27's HCP also said he/she requested the Nurse to check the Resident's rectum for impaction the prior day (10/4/23) as the Resident expressed feeling impacted and requested hospital transfer, but the rectum assessment did not occur because when the Nurse assessed the Resident, the Resident's indwelling urinary catheter was blocked and the drainage bag was empty, so the urinary catheter was changed. The HCP said when the catheter was changed, a large amount of urine flow occurred and the Resident's abdominal pain decreased. The HCP said the Resident's rectum was not assessed for impaction. The HCP then told the surveyor the Resident's community Physician was located in the same building where the Resident was scheduled for an appointment that afternoon, and he/she was hoping that the Physician could assess the Resident. On 10/5/23 at 11:55 A.M., the surveyor observed CNA #7 remove Resident #27's lunch meal tray from the meal cart. When the surveyor asked whether the Resident had been provided lunch as yet that day, CNA #7 said no, pointed to the tray on top of the cart, and said that the tray was Resident #27's lunch meal. CNA #7 said he was going to bring the meal to the Resident at that time. When the surveyor asked why the Resident's Meal Intake Monitoring Record was already completed for the lunch meal, CNA #7 said it should not have been. CNA #7 also said Resident #27 did not eat lunch the previous day, on 10/4/23, so it should not have been recorded as 76-100% consumed on the Meal Intake Monitoring Record. During an interview on 10/5/23 at 12:45 P.M., Nurse #9 said she worked through a staffing agency and that this was the first time she worked on the Unit and was assigned to Resident #27. Nurse #9 said she could not provide an accurate assessment of Resident #27's baseline status because it was the first time she had seen the Resident and had nothing to compare it to, but that the Resident was very sleepy when she went in to provide his/her medications. Nurse #9 also said she did not know the facility's policy for monitoring fluid intake and output (I & O) for Residents on I & O monitoring. Review of the clinical record included a photograph of Resident #27 taken on admission to the facility. The Resident's eyes were slightly sunken and his/her mouth was open in the photograph, but the surveyor did not observe any grey tint to the skin surrounding the Resident's lips, no darkened grey circles around the Resident's eyes, and the Resident had no grey hue to his/her face. During an interview on 10/5/23 at 12:50 P.M., with Nurse #5 (who was covering for the Unit Manager), she said that when a resident had an outside appointment during meal time, the facility was supposed to provide an early meal for the resident. Nurse #5 said Resident #27 left the facility for a scheduled appointment at 12:00 P.M. that day, that she checked on him/her prior to leaving and saw a lunch tray in the room. Nurse #5 said she did not know if the Resident had an opportunity to eat lunch, but she did see the Resident's HCP attempting to feed him/her some yogurt. When the surveyor asked whether five minutes was an adequate amount of time for Resident #27 to eat lunch prior to leaving for his/her appointment, Nurse #5 said she did not know why the Resident did not receive an early lunch tray. Nurse #5 also said that the Resident experienced a recent decline in ability to swallow, so she contacted the NP to obtain an order to downgrade the Resident's liquid consistency from thin to nectar thick. Nurse #5 further said Resident #27 required someone to sit and talk with him/her, and take their time when providing food and fluids. During a telephone interview on 10/5/23 at 2:52 P.M., the RD said if a resident had a change in nutrition, including eating or drinking, she would expect to be notified so she could assess the change. The RD said she was in the facility on 10/4/23, but was not asked to see Resident #27. The RD said that the fact that Resident #27 had a recent downgrade in liquid consistency and had reduced food and fluid intake would be cause for her to have assessed him/her. The RD further said if she had been made aware of Resident #27's status, she would absolutely have seen him/her. Review of Resident #27's fluid intake and output on the October 2023 Treatment Administration Record was as follows: -Intake was 790 mls and urine output was 790 mls on 10/1/23. Urine output measurement for the 7:00 A.M. through 3:00 P.M. shift was indicated as Not administered: Refused. -Intake was 280 mls and urine output was 700 mls on 10/2/23. Urine output measurement for the 7:00 A.M. through 3:00 P.M. shift was indicated as Not administered: Refused. -Intake was 720 mls and urine output was indicated as Medium on the 7:00 A.M. through 3:00 P.M. shift and Large on the 3:00 P.M. through 11:00 P.M. shift on 10/3/23. Urine output on the 11:00 P.M. through 7:00 A.M. shift was not recorded. -Intake was 940 mls and urine output was 500 mls combined from the 7:00 A.M. through 3:00 P.M. and 3:00 P.M. and 11:00 P.M. shift on 10/4/23. Urine output on the 11:00 P.M. through 7:00 A.M. shift was recorded as Medium. -No entry for fluid intake or urine output was recorded for 10/5/23. On 10/5/23 at 4:55 P.M., the surveyor observed the NP seated at the nurses station. During an interview at this time, the NP said she had planned to see Resident #27, but the Resident had not returned to the facility since he/she left for an appointment. During an interview on 10/5/23 at 5:00 P.M., the DON said Resident #27 had been transferred to the hospital Emergency Department (ED) directly from his/her appointment due to the Resident being under-responsive while at the appointment. Review of the hospital ED Note dated 10/5/23, indicated: -Resident #27 presented to the ED with abdominal pain and question of worsening mental status. -The Resident was provided with one liter of intravenous (IV- administered directly into a vein) fluids, Sinemet (medication used to treat symptoms of Parkinson's Disease) that was dissolvable under the tongue as the Resident was not swallowing well, and Zosyn (antibiotic medication used to treat infection). -A computed tomography (CT- computerized x-ray imaging procedure) scan was completed, notable for Stercoral Colitis (rare and severe condition where feces causes blockages within the colon) with possible rectal Pneumatosis (gas found within the wall of the bowel) and inflammatory changes around the bladder consistent with cystitis (inflammation of the bladder). -Per general surgery, air was more likely surrounding stool, and rectal enemas (technique used to stimulate stool evacuation, usually to relieve constipation) and by mouth bowel regimen was recommeded. -Manual disimpaction (removal of stool from the rectum using a gloved finger or retractor. Procedure performed when a person is unable to pass stools due to severe constipation or fecal impaction) was performed in the ED. -Plan was to admit the Resident to the hospital for further bowel regimen management. During an interview on 10/6/23 at 8:24 A.M., Nurse #7 said he spoke with Resident #27's HCP on 10/4/23 and that the HCP was concerned about whether the Resident had been moving his/her bowels as the Resident was complaining of impaction. Nurse #7 said he reported this to Nurse #5 who was assigned to care for Resident #27 at that time. During an interview on 10/6/23 at 8:38 A.M., Nurse #5 said prior to 10/4/23, earlier in the week, Resident #27's HCP questioned whether the Resident had been moving his/her bowels. Nurse #5 said she reviewed the Resident's bowel records which did not indicate a three-day period of no bowel movements, and she also assessed the Resident for bowel sounds, which were present, and abdominal distention, which was not present. Nurse #5 said when the Resident reported feeling impacted on 10/4/23, she assessed the Resident and found that the Resident's urinary catheter collection bag was empty and his/her catheter was blocked. Nurse #5 said she was unable to flush the catheter, so she had to change it. Nurse #5 said once the catheter was changed and urine flow occurred, the Resident's discomfort decreased. Nurse #5 said she assessed the Resident's bowel sounds, which were present, and abdominal distension, which was not present, then offered the Resident an as needed (PRN) dose of Milk of Magnesia, but the Resident refused. Nurse #5 did not say whether she checked the Resident's rectum for fecal impaction. At this time, the surveyor and Nurse #5 reviewed the facility's policy relative to I & O and also reviewed Resident #27's I & O monitoring on the September 2023 and October 2023 Treatment Administration Records (TARs). Nurse #5 said recording fluid intake and urine output on the TAR was the facility's process for accurately monitoring a Resident's fluid I & O. She said that upon review of Resident #27's I & O monitoring and the facility's policy, the NP should have been notified of the Resident's reduced fluid intake, but she could not speak to what the NP knew[sic]. During an interview on 10/6/23 at 9:30 A.M., the Administrator said the facility did not have an SLP as of 9/21/23. During a telephone interview on 10/6/23 at 9:48 A.M., Resident #27's HCP said that at the Resident's baseline, he/she fed him/herself. The HCP said at times the Resident would not want to taste his/her meal, but if a taste of the meal was provided for him/her, he/she would then eat the whole meal. Resident #27's HCP said the Resident responded best to gentle talking and entering his/her reality when talking with him/her to engage the Resident in daily activities. Resident #27's HCP said the Resident was unable to respond to the Provider during his/her appointment on 10/5/23, so the Resident's community Physician was contacted by the Provider to assess the Resident at that time. Resident #27's HCP said the community Physician assessed the Resident and sent him/her to the hospital ED via ambulance. The HCP said the Resident was assessed at the hospital ED and was provided with one liter of IV fluids, a half-dose of antibiotic, and medication to treat symptoms of Parkinson's Disease that dissolved under his/her tongue. The HCP also said when the Resident was assessed at the ED, he/she was diagnosed with fecal impaction and ED staff manually disimpacted the Resident. Resident #27's HCP said he/she left the ED around midnight, and by that time the Resident had been admitted to the hospital for further assessment and was waiting in the ED for an inpatient bed. The HCP said when he/she left the hospital, Resident #27's mental status had improved, his/her eyes were open, and he/she was asking to drink liquids. During an interview on 10/6/23 at 11:09 A.M., the DON said CNAs and Nurses documented resident fluid intake, and that if a resident was on I & O monitoring, the Nurses were responsible to total all fluid intake for their shift and document it on the resident's Treatment Administration Record. The DON said the TAR would indicate all the fluids the resident received on that shift. The surveyor and the DON reviewed Resident #27's fluid intake recorded on the TAR from 9/29/23 through 10/5/23, as listed above. The DON also reviewed the Resident's food intake for 9/29/23 through 10/5/23 with the surveyor with the following findings: -Of 20 meals provided during that timeframe (9/29/23 through 10/5/23), six meals had no record of monitoring. -The lunch meal on 10/4/23 was recorded as the Resident having consumed 76-100% when the Resident did not eat any of the meal. -Record of the lunch meal for 10/5/23 was also reviewed as it indicated the Resident ate no lunch, the documentation was completed prior to the lunch meal being provided. When asked how Resident #27's food and fluid intake and urine output could be accurately assessed based on the facility's system for monitoring, the DON said the Nurses and CNAs needed to communicate more clearly about documenting fluid intake and if a resident's fluid intake fell below the amount stated in the facility policy, the Physician/NP should be notified as required. The DON also said food intake is supposed to be monitored for each meal and documented by the CNAs. The DON said accurately completing the Meal Intake Monitoring Record and Treatment Administration Record were the facility's means for tracking nutrition and hydration. Please Refer to F692.

Based on observations, records reviewed, and interviews, the facility failed to provide necessary nutrition and hydration treatment, services, assessment and monitoring for one Resident (#27) out of a total sample of 19 residents. Specifically, the facility failed to: Provide necessary treatment and services to promote food and fluid consumption, and accurately monitor food and fluid intake for Resident #27 when the Resident was identified as having potential nutrition and swallowing problems. The facility also failed to assess and manage changes in the Resident's functional status pertaining to eating and drinking and an unidentified rectal fecal impaction (inability to evacuate large hard stool, most commonly found in the rectum), and provide required assistance from facility staff to eat and drink. Findings include: Review of the facility's policy titled, Intake and Output (I & O) Policy, undated, indicated: -The Nursing personnel would keep an accurate record of a resident's fluid balance when the resident had a drainage collection device and/or per the Physician's order. -Nursing personnel under the following circumstances and/or per the physician's order will keep an accurate record of a resident's fluid balance: On admission for 72 hours (3 days). -Fluid output includes all fluid that leaves a resident's body, including urine . -Whenever possible, output will be measured versus estimated. -A resident's fluid output was to be documented in the intake and output form. -The 11:00 P.M. through 7:00 A.M. (11-7) shift would total the intake of fluids for the previous 24-hour cycle and document in the 24-hour total intake space. -The Nurse was required to notify the Physician if any one of the following occurred: >1. A resident's fluid intake fell below 1000 mls (milliliters)/24 hours for a period of greater than 72 hours. >2. A resident's 24-hour fluid intake fell below 500 mls. Review of the facility's policy titled, Nutrition/Hydration Status Maintenance, undated, indicated: -The facility would provide nutrition/hydration status maintenance services in accordance to State and Federal Regulations. -Residents would be offered sufficient fluid intake to maintain proper hydration and health. -Residents would be offered a therapeutic diet when there was a nutritional problem, and the health care provider ordered a therapeutic diet. 1. Resident #27 was admitted to the facility in August 2023 with diagnoses including Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), Oropharyngeal (the area of the throat behind the mouth and the tonsils) Phase Dysphagia (difficulty in swallowing food or liquid), and Muscle Weakness. Review of Resident #27's Nursing Admission assessment dated [DATE], indicated the Resident had muscle weakness, was alert and confused, had fair appetite and difficulty swallowing. Review of Resident #27's Discharge Plan Care Plan initiated 8/23/23 indicated the Resident was to remain in the facility for long term care due to requiring 24-hour supervision and care. Review of Resident #27's Behavioral Symptom Care Plan, initiated 8/23/23, indicated: - The Resident could be resistive to care . - Staff were to reiterate the purpose and advantages of treatment for the Resident. Review of Resident #27's Nutritional Status Care Plan, initiated 8/24/23, indicated: -The Resident had a potential nutrition risk related to medical condition requiring a mechanically altered diet. -Staff were to monitor intakes and weights. -Registered Dietician (RD)/Speech Language Pathologist (SLP) screen (brief meeting with an individual to determine strengths and weakness through informal measures) and treat PRN (as the situation demands). Review of an RD Note, dated 8/24/23, included the following: -House (a healthy meal plan that includes a variety of healthy foods from all the food groups), soft and bite-sized diet. Allow soft bread products and soft salad sandwiches. -Appetite was 75-100% -No supplements were in place. -The Resident was independent after set-up for feeding. -The Resident and Health Care Proxy (HCP-someone designated to make choices about one's care if they were unable to make those decisions) were happy with the diet texture. -No interventions were required at that time. -Will monitor intakes, weights . Review of a Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #27 was severely cognitively impaired as evidenced by a score of five out of 15 possible points on the Brief Interview for Mental Status (BIMS). Further review of the MDS assessment indicated the Resident had inattention and disorganized thinking, and required supervision and set-up for eating. Further review of Resident #27's active Comprehensive Care Plan, dated 9/1/23, included: -The Resident had tooth decay and staff were to encourage enough fluid consumption to keep his/her mouth moist and provide diet as ordered. -The Resident had communication difficulties and staff were to allow him/her time to process information. -The Resident was unable to perform activities of daily living (ADLs) independently and required continuous supervision at a ratio of one staff to eight residents for eating. >ADLs could vary in the course of the day due to disease process of Parkinson's Disease with delusions (fixed, false conviction in something that is not real or shared by other people) and hallucinations (experience in which one sees, hears, feels, or smells something that does not exist). >Assess Resident and carry out ADLs as needed. >Evaluate Resident ability to perform ADLs. >Notify MD/NP, Rehab of any decline if noted. >Provide assistance as needed . Review of Resident #27's Speech Therapy Discharge Summary dated 9/20/23, indicated the Resident was able to swallow thin consistency liquids from an open cup using compensatory strategies (techniques used to help and individual perform tasks in a manner to be more independent) from trained staff. Review of a Physician's order dated 9/26/23, indicated: Downgrade (reduce) thin liquids to nectar liquid consistency until further evaluation is done. Review of Resident #27's clinical record included no evidence of a referral to the RD or SLP for further evaluation after the liquid downgrade was ordered. On 9/29/23 from 8:58 A.M. through 9:11 A.M., the surveyor observed the following: -Resident #27 was lying in bed with the head of the bed slightly elevated. -The Resident's covered breakfast tray was sitting on a rolling overbed table, to the left of the Resident's bed, beside the window. -Resident #27 pointed toward the breakfast tray and said he/she was hungry, pointed at the breakfast tray and said, It's over there. -The surveyor observed the items on the tray included one full cup of juice, one full cup of coffee, one full cup of milk, one full covered bowl of cereal, and one covered plate of scrambled eggs and toast. -The surveyor did not observe any staff entering the Resident's room to offer breakfast to the Resident or assist him/her with breakfast. Review of a Nursing Progress Note, dated 10/1/23, indicated that Resident #27's HCP expressed a noted decline in the Resident's eating and drinking to the Director of Nursing (DON) and that the HCP wanted to give the Resident thin liquids. Further review of the Nursing Progress Note indicated the DON explained the Resident's risk for aspiration/choking and Pneumonia to the HCP and that the NP would follow-up on this [sic]. On 10/3/23 between 8:40 A.M. and 8:53 A.M., the surveyor observed the following: -Resident #27 was lying in bed sleeping. -The Resident's breakfast tray was resting on a rolling overbed table to the Resident's left side, within reach of the Resident, and contained scrambled eggs, one piece of toast that was cut in half, one bowl of oatmeal, and one bowl of rice cereal. There were four individual unopened coffee creamers on the tray and one plastic cup which was positioned upside down. The surveyor did not observe any remnants of liquid in the cup. There was one covered metal mug on the tray that was full of thin consistency ice water. There were no other drinks on the tray. -The surveyor did not observe any staff in the room assisting the Resident. During an interview on 10/3/23 at 8:46 A.M. outside the Resident's room, Nurse #2 said Resident #27's liquid consistency had recently been downgraded to nectar thick from thin due to difficulty swallowing. Nurse #2 said the Resident's HCP had been attempting to provide thin consistency water to the Resident over the previous week or so due to the HCP having concerns that the Resident was not drinking enough liquids since the downgrade to nectar thick. The surveyor, Nurse #2 and CNA #11 entered the Resident's room, and Nurse #2 further said the Resident could not have thin liquids and instructed CNA #11 to dump it. The CNA then removed the metal mug from the tray, entered the bathroom, and emptied the metal cup of ice water. The surveyor did not observe any food or liquids being offered to the Resident during this time, and CNA #11 removed Resident #27's tray from his/her room. During an interview on 10/3/23 at 11:30 A.M., Resident #27's HCP said he/she noticed the Resident had a recent decline in eating and drinking over the previous week, since the Resident's liquid consistency had been changed from thin to nectar thick. The HCP said he/she had concerns the Resident was not eating and drinking enough and that he/she would lose weight and become dehydrated. Resident #27's HCP also said the Resident had been refusing medications frequently, including medications used to treat symptoms of Parkinson's Disease and medications to regulate the Resident's bowels. On 10/4/23 between 12:10 P.M. and 12:26 P.M., the surveyor observed the following: -Resident #27 was lying in bed. His/her lunch tray was resting on a rolling overbed bedside table that was positioned against the wall by the window, to the left of the Resident. -The surveyor observed that the meal tray contained one covered cup of thickened milk, one covered mug of water with a packet of unopened thickened coffee, one covered bowl with applesauce, and one covered plate that contained a stuffed pepper. -The Resident pointed toward the meal tray but did not vocalize out loud to the surveyor. When the surveyor asked the Resident if anyone had offered him/her lunch, the Resident shook his/her head, indicating no. When asked if the Resident wanted lunch, he/she nodded his/her head, indicating yes. -At 12:26 P.M., CNA #7 entered Resident #27's room. CNA #7 spoke to the Resident's roommate, then approached Resident #27 and asked if he/she wanted to get out of bed. Resident #27 said no and pointed at the overhead light in the room. CNA #7 asked the Resident if he/she wanted the light on, turned the light on, and left the room. -The surveyor did not observe any staff offering Resident #27 assistance with his/her meal during this time, and the Resident's tray remained on the rolling overbed beside table against the wall by the window, to the left of the Resident. Review of Resident #27's Meal Intake Monitoring Record for 10/4/23 indicated the Resident ate 76-100% of his/her lunch meal that day, when the surveyor's observation was the lunch tray was left in the room and no staff assisted the Resident with eating. During a telephone interview on 10/5/23 at 10:30 A.M., the Nurse Practitioner (NP) said she was available to the facility by phone. The NP said she was aware Resident #27's HCP requested to be able to provide the Resident with thin liquids, but was not aware that the Resident had reduced food and thickened fluid intake. The NP said she had not assessed Resident #27's status that week as this was new information and that she would need to review the Resident's record and see the Resident in order to develop a clinical plan. Review of Resident #27's Meal Intake Monitoring Record for 10/5/23 indicated the Resident ate no lunch that day and the Meal Intake Monitoring Record was completed at 10:53 A.M., which was prior to the lunch meal being served to the Resident. On 10/5/23 at 11:45 A.M., the surveyor observed Resident #27 seated in a wheelchair beside his/her bed and the Resident's HCP was present and providing care to the Resident. Resident #27's HCP talked to the Resident and touched the Resident on his/her arms and hands, but the Resident did not respond. During an interview at the time, Resident #27's HCP told the surveyor the Resident had a scheduled outside appointment that afternoon and that transportation services were booked to pick the Resident up at 12:00 P.M. The Resident's HCP stated concern that the Resident had not yet received lunch since he/she would not be at the facility for the lunch meal. The HCP further said he/she did not know if the facility planned to send a lunch with Resident #27, so he/she brought some food from home for the Resident. The HCP then attempted to provide a spoonful of yogurt to Resident #27 which fell from the Resident's mouth. The HCP also attempted to provide a drink of water from an open cup, which also fell from the Resident's mouth. During a second attempt, the Resident accepted and swallowed one spoon of yogurt and one sip of water provided by the HCP while the HCP cued the Resident to swallow for the yogurt and water. Resident #27's HCP was observed encouraging the Resident to wake up so that he/she could talk with the Provider at the scheduled appointment later that day, but the Resident did not respond. The HCP said he/she had helped the Resident to get dressed that morning and that the Resident's clothes no longer fit and were too big on him/her. The HCP also said she thought the Resident had lost weight and was afraid he/she may have been dehydrated. Resident #27's HCP also said that he/she requested the Nurse to check the Resident's rectum for impaction on 10/4/23, as the Resident expressed feeling impacted and requested hospital transfer, but checking the rectum as requested did not occur. The HCP then told the surveyor the Resident's community Physician was located in the same building where the Resident was scheduled for an appointment that afternoon and he/she was hoping that the Physician could assess the Resident. On 10/5/23 at 11:55 A.M., the surveyor observed CNA #7 remove Resident #27's lunch meal tray from the meal cart. When asked whether the Resident had been provided lunch as yet that day, CNA #7 said no, pointed to the tray on top of the cart, and said that the tray was Resident #27's lunch meal. CNA #7 said he was going to bring the meal to the Resident at that time. When the surveyor asked why the Resident's Meal Intake Monitoring Record was already completed for the lunch meal currently being served, CNA #7 said it should not have been. CNA #7 also said Resident #27 did not eat lunch the previous day on 10/4/23, so it should not have been recorded as 76-100% consumed on the Meal Intake Monitoring Record. During an interview on 10/5/23 at 12:45 P.M., with Nurse #9 who was assigned to Resident #27, she said she worked through a staffing agency and that this was the first time she worked on the Unit. Nurse #9 said she could not provide an accurate assessment of Resident #27's baseline status because it was the first time she had seen the Resident and had nothing to compare it to, but that the Resident was very sleepy when she went in to provide his/her medications. Nurse #9 also said she did not know the facility's policy for monitoring fluid intake and output (I & O) for Resident's on I & O monitoring or where the policy could be located. During an interview on 10/5/23 at 12:50 P.M., Nurse #5 (who was covering for the Unit Manager [UM]) said that when a resident had an outside appointment during meal time, the facility was supposed to provide an early meal for the resident. Nurse #5 said Resident #27 left the facility for a scheduled appointment at 12:00 P.M. that day, that she checked on him/her prior to leaving and saw a lunch tray in the room. Nurse #5 said she did not know if the Resident had an opportunity to eat lunch, but she did see the Resident's HCP feeding him/her some yogurt. When the surveyor asked whether five minutes was an adequate amount of time for Resident #27 to eat lunch prior to leaving for his/her appointment, Nurse #5 said she did not know why the Resident did not receve an early lunch tray. Nurse #5 also said that the Resident experienced a recent decline in ability to swallow, so she had contacted the NP and obtained an order for his/her liquid consistency to be downgraded from thin to nectar thick. Nurse #5 further said Resident #27 required someone to sit and talk with him/her, and take their time when providing food and fluids. During a telephone interview on 10/5/23 at 2:52 P.M., the RD said if a resident had a change in nutrition, including eating or drinking, she would expect to be notified so she could assess the change. The RD said she was in the facility on 10/4/23, but was not asked to see Resident #27. The RD said that the fact that Resident #27 had a recent downgrade in liquid consistency and had reduced food and fluid intake would be cause for her to have assessed him/her (reason for a RD referral). The RD further said if she had been made aware of Resident #27's status, she would absolutely have seen him/her. During an interview on 10/6/23 at 9:30 A.M., the Administrator said the facility did not have an SLP as of 9/21/23. During an interview on 10/5/23 at 5:00 P.M., the DON said Resident #27 had been transferred to the hospital Emergency Department (ED) directly from his/her appointment due to the Resident being under-responsive while at the appointment. Review of the hospital ED Note, dated 10/5/23, indicated Resident #27 presented to the ED with abdominal pain and question of worsening mental status. The Resident was provided with one liter of intravenous (IV: administered directly into a vein) fluid, Sinemet (medication used to treat symptoms of Parkinson's Disease) that was dissolvable as the Resident was not swallowing well, and Zosyn (antibiotic medication used to treat infection). A computed tomography (CT - computerized x-ray imaging procedure) scan was completed, notable for Stercoral Colitis (rare and severe condition where feces causes blockages within the colon) with possible rectal Pneumatosis (gas found within the wall of the bowel). Manual disimpaction (removal of stool from the rectum using a gloved finger that is used when a person is unable to pass stools due to severe constipation or fecal impaction) was performed in the ED and the plan was to admit the Resident to the hospital for further bowel regimen management. During an interview on 10/6/23 at 8:38 A.M., Nurse #5 said prior to 10/4/23, earlier in the week, Resident #27's HCP questioned whether the Resident had been moving his/her bowels. Nurse #5 said she reviewed the Resident's bowel records which did not indicate a three-day period of no bowel movements, and she also assessed the Resident for bowel sounds, which were present, and abdominal distention, which was not present. Nurse #5 said when the Resident reported feeling impacted on 10/4/23, she again assessed the Resident for bowel sounds, which were present, and abdominal distension, which was not present. Nurse #5 said she offered an as needed (PRN) dose of Milk of Magnesia (medication that reduces stomach acid, and increases water in the intestines which may induce bowel movements), but the Resident refused. Nurse #5 did not say she checked the Resident's rectum for fecal impaction. At this time, the surveyor and Nurse #5 reviewed the facility's policy relative to I & O and also reviewed the Resident #27's I & O monitoring on the September 2023 and October 2023 Treatment Administration Record (TAR). Nurse #5 said recording fluid intake on the TAR was the facility's process for accurately monitoring a Resident's fluid I & O. She said that upon review of Resident #27's I & O monitoring and the facility's policy, the NP should have been notified of the Resident's reduced fluid intake, but she coud not speak to what the NP knew. During a telephone interview on 10/6/23 at 9:48 A.M., Resident #27's HCP said that at the Resident's baseline, he/she fed him/herself. The HCP said at times the Resident would not want to taste his/her meal, but if a taste of the meal was provided for him/her, he/she would then eat the whole meal. Resident #27's HCP said the Resident responded best to gentle talking and entering his/her reality when talking with him/her to engage the Resident in daily activities. Resident #27's HCP said the Resident was unable to respond to the Provider during his/her appointment on 10/5/23, so the Provider contacted the Resident's community Physician to assess the Resident which resulted in the Resident being sent to the hospital ED via ambulance. The HCP said the Resident was assessed at the hospital ED and was provided with one liter of IV fluid, a half-dose of antibiotic, and medication dissolved under his/her tongue to treat symptoms of Parkinson's Disease. The HCP also said the Resident was identified as having fecal impaction and ED staff manually disimpacted the Resident. Resident #27's HCP said he/she left the ED around midnight, and by that time the Resident's mental status had improved, his/her eyes were open, and he/she was asking to drink liquids. During an interview on 10/6/23 at 11:09 A.M., the DON said CNAs and Nurses documented resident fluid intake, and that if a resident was on I & O monitoring, the Nurses were responsible to total all fluid intake for their shift and document it on the resident's TAR. The DON said the TAR would indicate all the fluids the resident received on that shift. The surveyor and the DON reviewed Resident #27's fluid intake recorded on the TAR from 9/29/23 through 10/5/23 with the following findings for the total 24-hr period: -600 milliliters (mls) on 9/29/23 -840 mls on 9/30/23 -790 mls on 10/1/23 -280 mls on 10/2/23 -720 mls on 10/3/23 -940 mls on 10/4/23 -No entry for fluid intake on 10/5/23 At this time, the surveyor and the DON reviewed food intake monitoring records for Resident #27 from 9/29/23 through 10/5/23 with the following findings: -Of 20 meals provided during that timeframe, six meals had no record of monitoring. -The lunch meal on 10/4/23 was recorded as the Resident having consumed 76-100% when the Resident did not eat. -Record of the lunch meal for 10/5/23 was also reviewed as it indicated the Resident ate no lunch and was completed prior to the lunch meal being provided to the Resident. When the surveyor asked how Resident #27's food and fluid intake could be accurately assessed based on the facility's system for monitoring, the DON said the Nurses and CNAs needed to communicate more clearly about documenting fluid intake and if a resident's fluid intake fell below the amount stated in the facility policy, the Physician/NP should be notified as required. The DON also said food intake was supposed to be monitored for each meal and documented by the CNAs. The DON said accurately completing the Meal Intake Monitoring Record and Treatment Administration Record were the facility's means for tracking nutrition and hydration.

Based on record review and staff interview, the facility staff failed to notify the Physician about a change of condition as ordered by the Physician (poor intake by mouth) resulting in [DIAGNOSES REDACTED] (low blood sugar) and requiring the resident's emergent transfer to the hospital, for 1 Resident (#47) out of a total sample of 20 Residents. Findings include: Resident #47 was admitted to the facility in 11/2018 with [DIAGNOSES REDACTED]. Review of Resident #47's physician's orders [REDACTED]. -Hold insulin if poor intake by mouth, then notify the Physician. -Humalog 100-unit/ml (a rapid-acting human insulin used to lower blood glucose), inject subcutaneously (SC) according to sliding scale four times daily. -Humalog 100-unit/ml, inject 15 units SC with breakfast at 8 [NAME]M. -Humalog 100-unit/ml, inject 12 units SC with lunch at 12:00 P.M. -Humalog 100-unit/ml, inject 12 units SC with dinner at 5:00 P.M. -[MEDICATION NAME] 100-unit/ml (long acting insulin) 13 units SC at 8:00 P.M. Review of Resident #47's nursing progress note dated 8/24/19 indicated the resident refused dinner multiple times including night time snacks. It also indicated that Resident #47's 8:30 P.M. blood sugar was 218 and humalog insulin coverage was administered. At 10:05 P.M., the resident's blood sugar was 183 and he/she continued to refuse to eat anything. There was no evidence in the note that the physician had been notified. On 8/25/19 at 8:00 [NAME]M., the resident received 15 units of Humalog insulin with a blood sugar of 108. Review of Resident #47's nursing progress note dated 8/25/19 at 10:30 [NAME]M. indicated the Resident was found unresponsive in his/her room. His/her blood sugar was 54. [MEDICATION NAME] (an injectable hormone medication used to raise blood sugars) was administered and the Resident #47's blood sugar rose up to 60. The resident opened his/her eyes but remained non-responsive. Resident #47 was sent to the Emergency Department for evaluation after notifying the Nurse Practitioner. Resident #47 was hospitalized from [DATE] to 8/27/19. Review of Resident #47's hospital discharge summary dated 8/27/19 indicated Resident #47 presented to the Emergency Department on 8/25/19 having severe hypoglycemic event requiring [MEDICATION NAME] and oral glucose replacement with severe altered level of consciousness. Further review of the discharge summary indicated the patient stated that he/she had not eaten much but was given a full dose of insulin, which caused him/her to become hypoglycemic. Upon arrival to the Emergency Department the patient was noted to be hypoxic (lack of oxygen) requiring up to 100% O2 (oxygen therapy) by a non-rebreather mask to maintain adequate oxygen saturations. On 9/11/19 at 1:10 P.M., Nurse #5 was interviewed and said that on 8/24/19 she was the evening nurse that was assigned to Resident #47. She said Resident #47 had refused dinner and night snacks despite multiple attempts. Nurse #5 said that she administered scheduled [MEDICATION NAME] 13 units and Humalog 2 unit's insulin that evening. The surveyor asked Nurse #5 if she had notified the Physician that Resident #47 had refused meals that night and Nurse #5 answered no, I should have. Nurse #5 said that she continued to monitor the Resident and told the 11:00 P.M. to 7:00 [NAME]M. shift nurse that Resident #47 refused to eat dinner and snacks. On 9/11/19 at 1:20 P.M., Unit Manager (UM) #1 was interviewed. He reviewed Resident #47's (MONTH) 2019 MAR and nursing progress notes and acknowledged Resident #47's morning blood sugar was 108 at 8:00 [NAME]M. on 8/25/19. He further said if the resident refused a meal, it should be reported to the Physician.

Based on records review, and interviews, for one of three sampled residents (Resident #1), the Facility failed to provide adequate supervision to prevent injury when, on 12/2/17 a Certified Nurse Assistant left a cigarette lighter outside with residents, then left the designated smoking area while residents were outside smoking, and when Resident #1 attempted to light his/her cigarette, his/her hair caught on fire. Resident #1 sustained second [MEDICAL CONDITION] his/her head, face, and neck. Findings Include: A Policy, titled Facility Smoking Policy, indicated that all residents would be supervised while smoking and all residents would be accompanied by a staff member when going out to smoke in the designated smoking area. The Policy indicated that there was a two-cigarette limit for each resident and only one cigarette would be handed out at a time. A Procedure Sheet, undated and titled Assisting Residents with Smoking, indicated that Certified Nurse Assistants (CNA's) were to be outside at all times with the residents while they were smoking, CNA's were supposed to light the cigarettes for residents, and residents should not hold their own lighter. A quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated that Resident #1's medical [DIAGNOSES REDACTED]. A Resident Event Report, dated 12/2/17, indicated that at 7:15 P.M. Resident burned part of his/her hair on the left side of his/her face while smoking. A hand written statement, dated 12/2/17, and signed by CNA #1, indicated that when CNA #1 opened the door that lead to the smoking area to help a resident inside the Facility, CNA #1 saw Resident #1's hair burning and CNA #1 used his hands to stop the fire. A Witness Statement Form, dated 12/2/17 and signed by CNA #2, indicated that while the residents were smoking, CNA #2 was seated in front of the door waiting for them to finish when she heard CNA #1 calling for help and then she noticed that there was fire in Resident #1's hair. The Facility Investigation Resident interviews, conducted by the Facility and dated 12/4/17, indicated that CNA #2 gave a resident a lighter, went inside the Facility, and when Resident #1 lit his/her cigarette, his/her hair fell forward and Resident #1's hair started smoking, had red/orange flecks in it and it was making a crackling sound. The Resident interviews indicated that CNA #1 and CNA #2 were inside the Facility sitting in the window and a resident had to yell loudly for them because the CNA's never looked upwards. A Nurse's Note, dated 12/2/17, indicated that when Resident #1 returned from smoking, Resident #1 said his/her hair had been burned while she/she was using the lighter. The Note indicated that Resident #1 was examined by the nurse and no [MEDICAL CONDITION] noted at that time. A Nurse's Note, dated 12/3/17, indicated that Resident #1 had [MEDICAL CONDITION] blisters to the left side of his/her face, neck, and left ear. The note indicated that Resident #1's Physician was notified and a medication treatment order was obtained for Resident #1's burns. A Clinician's Progress Note, dated 12/5/17, indicated that Resident #1 would be referred to a Dermatologist for his/her facial burns. A Dermatology Consult, dated 12/7/17, indicated that Resident #1 had second [MEDICAL CONDITION] his/her head, face, and neck. The Consult indicated that Resident #1's scalp, face, eyelids, and ears had shallow red erosions on most of the left face, left forehead, and his/her left ear had thin brown crusting. A Wound Care Specialist Physician Initial Visit, dated 12/29/17, indicated that Resident #1 had second [MEDICAL CONDITION] on his/her left cheek, left neck, and left ear. The Note indicated that the wound size was 14.0 centimeters in length x 9.0 centimeters in width x 0.1 centimeter in depth. The Surveyor interviewed Resident #1 at 10:20 A.M. on 5/9/18. Resident #1 said CNA #1 gave him/her cigarettes and a lighter and went inside the Facility. Resident #1 said when he/she tried to light his/her cigarette it was windy outside and his/her hair caught on fire. The Surveyor interviewed CNA #1 at 9:23 A.M. on 5/11/18. CNA #1 said on the evening when Resident #1 was burned, CNA #2 took the residents from her unit down to the smoking area before he was ready to go, Resident #1 was on CNA #2's unit so he/she went down to the smoking area with CNA #2. CNA #1 said when arrived at the smoking area with the resident he brought down, there were three or four residents that CNA #2 had taken down who were already outside smoking and CNA #2 was inside the Facility seated to the left of the door of that leads to the outside smoking area. CNA #1 said he brought the resident from his unit outside, gave the resident a cigarette, lit it for him/her, and went inside the Facility and stood in front of the glass door to watch the residents. CNA #1 said when he opened the door to assist a resident inside, he noticed Resident #1 standing with his/her hair on fire and put out the fire in Resident #1's hair with his hands. CNA #1 said he was not aware that CNA #2 left a lighter outside with the residents and said although he was watching the residents while they were smoking, he never saw Resident #1 attempt to light his/her cigarette because he was assisting a resident back into the Facility. CNA #1 said he went inside because it was cold outside. CNA #1 said two aides were supposed to be with residents at all times when they smoked, but there was no Policy that he was aware of that indicated that Staff must stay outside with Residents while they smoked. This was not consistent with the Policy titled Facility Smoking Policy. The Surveyor interviewed CNA #2 at 9:54 A.M. on 5/11/18. CNA #2 said, on the evening when Resident #1 was burned, she brought Resident #1 and the other residents from her unit out to smoke and said she lit everyone's cigarette except for an alert and oriented resident, who asked for extra cigarettes and a lighter for her boyfriend who would be there shortly to smoke. CNA #2 said she gave the cigarettes and a lighter as the resident requested and went inside because she doesn't smoke and it was cold and windy. CNA #2 said although she watched the residents smoke from inside the building, she did not see Resident #1 obtain the lighter from the other resident, nor did she see Resident #1 attempt to light his/her cigarette. CNA #2 said CNA #1 was the one who saw Resident #1's hair on fire and he put the fire out. CNA #2 said residents each get two cigarettes and it was okay to give them both cigarettes at a time. CNA #2 said if a resident was alert it was okay to give the resident a cigarette lighter and the Smoking Policy indicated that if staff does not smoke they can stay inside the Facility at the door. This was not consistent with the Policy titled Facility Smoking Policy. The Surveyor observed the 11:00 A.M. smoking session on 5/9/18. The Surveyor observed a total of five residents outside in the designated smoking area. The Surveyor observed two CNA's outside with the residents and the CNA's were observed handing out two cigarettes at one time to four of the five residents. This was not consistent with the Policy titled Facility Smoking Policy. The Surveyor Interviewed the Director of Nursing (DON) at 3:00 P.M. on 5/9/18. The DON said Staff were supposed to hand out one cigarette at a time to each resident, light each cigarette for the residents, and they were not supposed to give any residents a lighter to use. The DON said Staff was supposed to remain outside with the residents while they smoked.

Based on records reviewed, interviews, and observation for one of three sampled residents (Resident #1), the Facility failed to supervise and prevent Resident #1, who was at risk for elopement, from leaving the facility through the front door, and on 11/12/16, Resident #1 went missing from the Facility for approximately 3 hours. Resident #1 left the Facility undetected by staff and was found by Certified Nurse Aide (CNA) #2 sitting on the ground on the adjacent property, approximately 200 feet from the main entrance. Resident #1 was transferred to the hospital for an evaluation and returned to the Facility the next day with a [DIAGNOSES REDACTED]. Findings include: The Health Care Proxy Invocation Form, dated 8/20/14, indicated Resident #1's Nurse Practitioner activated Resident #1's Health Care Proxy related to Resident #1's cognitive impairments, which were severe and the probable duration of Resident #1's incapacity was permanent. The Resident Wandering and Elopement Assessment Policy, reviewed 1/26/16, indicated the safety and security of all residents admitted to the Facility would be ensured at all times. The Elopement Risk Assessment form, dated 8/31/16, indicated Resident #1 was at risk for elopement. Resident #1's Quarterly Minimum Data Set (MDS) Assessment, completed 9/7/16, indicated Resident #1's [DIAGNOSES REDACTED]. The MDS Assessment indicated Resident #1 was cognitively intact (The Brief Interview for Mental Status (BIMS) score of 15/15). The MDS Assessment indicated Resident #1 required supervision walking on and off the unit, his/her balance during transitions and walking was not steady, but he/she was able to stabilize without staff assistance, and he/she used a cane. The Licensed Nursing Monthly Summary, dated 10/18/16, indicated Resident #1 walked with continual redirection/supervision due to poor safety awareness and hemiparesis. Resident #1's physician's orders [REDACTED].#1's wanderguard every shift, on his/her left ankle. Resident #1's Treatment Record, dated 11/1/16 through 11/30/16, indicated Resident #1's left ankle placement of his/her wanderguard was checked every shift, per physician's orders [REDACTED]. The Nurse's Note, dated 11/12/16, indicated the Nurse Supervisor received a phone call that Resident #1 could not be located and she returned to the Facility at approximately 10:00 P.M. on 11/12/16, to assist in the search efforts of Resident #1. The Nurse's Note indicated that the Nurse Supervisor was present when Resident #1 was located and she gave him/her a sweatshirt and the police officer gave Resident #1 his jacket, awaiting arrival of the EMS (Emergency Medical Services). The Nurse's Note indicated the Nurse Supervisor asked Resident #1 what his/her sister was going to think and Resident #1 said, she is going to be pissed off, or words to that effect. The Nurse's Note indicated the Nurse Supervisor asked Resident #1 how he/she got out of the building and he/she said, I walked out the door, or words to that effect. The Surveyor interviewed Nurse #1 at 2:50 P.M. on 1/9/17. Nurse #1 said at approximately 6:55 P.M. on 11/12/16, he observed Resident #1 sitting in the hallway near the nurses' station on Resident #1's unit. The Surveyor interviewed Certified Nurse Aide (CNA #1) at 4:05 P.M. on 1/6/17. CNA #1 said sometime after 7:00 P.M. on 11/12/16, she heard the alarm to the front door of the Facility sound, and she went to look to see what set the alarm off. CNA #1 said there were no residents or family members in the lobby and she looked outside, approximately 10 feet from the front door, but did not see anyone there. CNA #1 said she never saw Resident #1 on 11/12/16 prior to his/her elopement. The Surveyor interviewed Charge Nurse #1 at 3:45 P.M. on 1/9/17. Charge Nurse #1 said at approximately 5:00 P.M. on 11/12/16, she observed Resident #1 waiting to go downstairs to the dining room as a group for dinner. Charge Nurse #1 said Resident #1 could not be on the elevator alone and the elevator doors would not close (due to the wanderguard bracelet). Charge Nurse #1 said at approximately 7:30 P.M. Resident #1 was supposed to get a finger stick (to obtain a small amount of blood for testing of blood sugar levels), and she did not see Resident #1 in his/her room, so she continued her medication pass. Charge Nurse #1 said she addressed a resident in the hallway and said, Resident #1, you need a finger stick, or words to that effect, but she kept her face looking down, in the medication cart and she heard a resident say [***] you or words to that effect. Charge Nurse #1 said she did not see who the resident was at that time but when she went to give Resident #1 his/her medications at approximately 9:30 P.M. on 11/12/16, Resident #1 was not in his/her room. Charge Nurse #1 said she did a room search and got the certified nurse aides together to do a search of the building and pulled the Amber Alert (a report of a missing resident) through the intercom and called the Director of Nurses (DON). Charge Nurse #1 said Resident #1's wanderguard had been checked that night and it was working properly. The Surveyor interviewed Certified Nurse Aide (CNA) #2 at 3:45 P.M. on 1/6/17. CNA #2 said, at approximately 9:45 P.M. on 11/12/16, an Amber Alert was called (to indicate that a resident was missing). CNA #2 said he was familiar with Resident #1 and went downstairs to look for him/her in the main dining room. CNA #2 said, at approximately 10:15 P.M. he went searching for Resident #1 outside and walked around the building, and police officers were also outside. CNA #2 said it was very cold outside and he went around with another certified nurse aide and with a flashlight and called out Resident #1's name. CNA #2 said shortly after 10:15 P.M., he went to the back parking lot, near the new building (construction site next to the Facility), and found Resident #1 sitting on the ground on his/her buttocks, with his/her knees bent and his/her arms on his/her knees. CNA #2 said he asked Resident #1, what are you doing over here? or words to that effect, and Resident #1 replied, I was looking for my sister, or words to that effect. CNA #2 pointed out to the Surveyor to the area where the back Parking lot was, the stairs he went up, and the construction site near the new building, and where he found Resident #1 sitting on the ground on 11/12/16. The Surveyor interviewed the Director of Nurses (DON) at 11:30 A.M. on 1/6/17. The DON said she received a call from Charge Nurse #1 at approximately 9:43 P.M. on 11/12/16, and she told the DON that Resident #1 may have gotten out of the Facility. The DON said she told Charge Nurse #1 to have the Facility grounds checked and to call Resident #1's family member. The DON said the police were called by the Facility and when she arrived at the Facility, Resident #1 was found by staff off the Facility property, approximately 200 feet from the Facility, near the new building (construction site). The DON said Resident #1 was transported via ambulance to the hospital and returned the next day with a [DIAGNOSES REDACTED].#1 showed her how he/she overrode the system so that Resident #1 successfully circumnavigated the security system by lifting the plastic protective encasement lid and by pressing the enclosed handicap accessible button. The Surveyor interviewed the Complainant at 2:50 P.M. on 1/6/17. The Complainant said that at approximately 9:30 P.M. on 11/12/16, the Facility called two of Resident #1's family members to see if Resident #1 was with any of the family members because the staff could not locate Resident #1 at that time. The Complainant said Charge Nurse #1 told her that the last time she observed Resident #1 was at approximately 5:00 P.M. - 5:30 P.M. that day. The Complainant said she got into her car and drove around the streets near the Facility to look for Resident #1, but she was unable to locate Resident #1. The Complainant said at approximately 10:20 P.M., a staff member located Resident #1 on the construction site across the parking lot from the Facility, and Resident #1 was shaking from the cold weather and his/her speech was slow. The Complainant said the Facility was unable to say when staff last saw Resident #1, or what he/she was wearing. Complainant said it took almost 5 hours for Resident #1's body temperature to get back to normal, and the doctor at the hospital told her, you found him/her (Resident #1) just in time. The Surveyor interviewed Resident #1 at 12:50 P.M. on 1/6/17. Resident #1 said he/she left the faciity on [DATE] because he/she wanted to get some fresh air, or words to that effect. Resident #1 said he/she he took the elevator from the second floor to the first floor and he/she said, I pushed the button and the elevator went down. Resident #1 said the elevator doors did not lock, and he/she said, the elevator should have locked, but the elevator did not lock, or words to that effect. Resident #1 said, I went to the door in the front lobby and pushed the handicapped button, the door opened and then I walked outside, or words to that effect. Resident #1 said, I did not tell anyone I left the building, or words to that effect. Resident #1 said, No one else was on the elevator, no alarm went off, and no one saw him/her leave the building, or words to that effect. Resident #1 said, I started to go for a walk, and I was walking around on the property but I was too tired to walk anymore, so I said the Hell with this and I sat down, or words to that effect. Resident #1 said he/she did not try to go back to the Facility because I could not see the Facility, or words to that effect. Resident #1 said, I was not dressed to go outside and it was cold and dark outside, or words to that effect. Resident #1 said, I did not have any food or drink with me, or words to that effect. Resident #1 said, I was not scared. I was free! I was free! or words to that effect. The Police Report, dated 11/12/16, indicated that the police were dispatched to the Facility at approximately 10:00 P.M. on 11/12/16 for a report of a missing male (resident) who suffered from dementia. The Report indicated that Family Member #1 said she came to visit Resident #1 and noticed that he/she was not there and the staff nurses could not give her an answer as to where Resident #1 was. The Report indicated that the staff searched the entire building for Resident #1 but were unable to locate him/her. The Report indicated that a BOLO (be on the look out) for Resident #1 was broadcast on the East and West side as well as surrounding towns, and local hospitals were checked as well as local buses and (taxi) cabs. The Report indicated that at approximately 10:45 P.M., a staff member saw Resident #1 behind the new building (construction site for a new building next to the Facility, and adjacent to the parking lot), sitting on the ground. The Report indicated the Police Officer saw Resident #1 sitting in the dirt, moaning in pain, and the Officer picked up Resident #1 and carried Resident #1 to the Police Cruiser. The Report indicated two Police Officers swaddled Resident #1 with police jackets, sweatshirts and anything they could find to warm him/her up. The Report indicated that ambulance arrived and treated Resident #1 for cold weather injuries and he/she was transported to the local hospital. The Report indicated that the K-9 (canine) unit was on scene to help track Resident #1, if needed. The Hospital Emergency Department Record, dated 11/12/16, indicated Resident #1 had a [DIAGNOSES REDACTED]. The Record indicated Resident #1 was started on a blanket warmer, his/her body temperature was 33.0 Celsius (which was equal to 91.4 Fahrenheit. The standard for normal body temperature was 37 degrees Celsius (or 98.6 Fahrenheit) and Resident #1's primary [DIAGNOSES REDACTED].

Based on record review, observation, and staff interviews, the facility failed to provide adequate supervision and effective interventions to prevent accidents for 1 of 6 applicable residents (#2), out of a total sample of 16 residents. Findings include: Resident #2, with [DIAGNOSES REDACTED]. The falls care plan of 7/18/12 included the following interventions: bed and chair pad alarms, call bell/personal articles within reach and safety checks, as indicated. During interview with Unit Manager (UM) #2 (on 1/24/13 at 8:40 A.M.), she said safety checks were to be completed every 15 minutes, according to the resident's CNA (Certified Nursing Assistant) Care Plan (written 7/18/12). Review of the 9/4/12 Nurse's Note indicated the resident experienced an unwitnessed fall (found on bedroom floor), sustaining a 7 cm(centimeter) rib cage abrasion. Further review indicated the resident was very confused and was found in front of the wheelchair. Review of the falls investigation with UM #2 (on 1/24/13 at 8:40 A.M.) indicated the following: a. a CNA statement indicated the resident's bed alarm sounded although the investigation documented the resident slid out of the wheelchair, and b. a CNA statement indicated the resident was barefoot although a Nurse statement indicated the resident had slipper socks on. During an interview with UM #2 (on 1/24/13 at 8:40 A.M.), she said she was unable to explain the contradictory statements documented by the CNA and Nurse. The falls care plan was updated to include: resident sent to hospital (admitted due to mental status change). On 9/13/12 the falls care plan included: Physical Therapy (PT) evaluation. Review of the quarterly Minimum Data Set (MDS) assessment of 9/26/12 identified the resident as having impaired vision, exhibiting inattention; requiring assistance during transfers and ambulation and exhibiting unsteady balance during transitions and ambulation. The falls care plan was reviewed by the facility's interdisciplinary team on 10/10/12 and remained unchanged. Review of the 12/20/12 Nurse's Note indicated the resident had hit her/his head sustaining a 2.0 cm. laceration to the back of the head requiring 5 staples to close the wound. Review of the falls investigation with UM #2 (on 1/24/13 at 8:40 A.M.) indicated the following: a. the resident was found sitting on the edge of the bed and stated that she/he had fallen; b. a CNA statement (from the CNA who found the resident) indicated the resident's call bell was not ringing although a Nurse statement indicated the call bell was ringing, and c. a CNA statement (from the CNA who found the resident) indicated the resident was barefoot although a Nurse statement indicated the resident had socks/slippers on. During an interview with UM #2 (on 1/24/13 at 8:40 A.M.), she said she was unable to explain the contradictory statements documented by the CNA and Nurse. She further said the resident was confused and exhibited poor safety awareness. Review of the 15 minute safety checks (with UM #2) indicated the checks had not been completed on 12/20/12 between 7:15 A.M. and 2:45 P.M., as planned (resident found with injury at 1:00 P.M.), however, a CNA statement indicated the resident had been seen 5 minutes before (eating in her/his room) finding the resident sitting on the bed. During further discussion with UM #2, she was unable to explain the contradiction regarding the safety checks. UM #2 said confirmation of a fall was inconclusive as there was no supporting evidence during the facility investigation of a fall (although per facility documentation the facility did treat the incident as a fall). The falls care plan was updated to include: motion sensor alarm placed over bed and supervised dining room for meals (will need encouragement). Review of the quarterly MDS assessment of 12/24/12 remained essentially unchanged from the previous assessment except to note that the resident had experienced a fall with injury since the prior assessment. Review of the 15 minute safety check sheets with UM #2 (on 1/24/13 at 8:40 A.M.) indicated the following checks were not completed, as planned: 12/24/12 - between 3:00 P.M. and 10:45 P.M. 12/25/12 - between 7:15 A.M. and 2:45 P.M. 12/26/12 - between 12:00 P.M. and 2:45 P.M. and between 11:00 P.M. and 11:45 P.M. 12/27/12 - between 12:00 A.M. and 2:45 P.M. 12/28/12 and 12/29/12 - between 7:15 A.M. and 2:45 P.M. 12/30/12 - between 7:00 A.M. and 11:45 P.M. 12/31/12 - between 12:00 A.M. and 2:45 P.M. 1/1/13, 1/2/13, 1/6/13 and 1/8/13 - between 7:00 A.M. and 2:45 P.M. 1/9/13 and 1/10/13 - between 10:00 A.M. and 2:45 P.M. 1/11/13 and 1/12/13 - between 7:30 A.M. and 2:45 P.M. 1/18/13 - between 7:00 A.M. and 10:45 P.M. 1/21/13 - between 12:00 A.M. and 7:00 A.M., between 7:00 A.M. and 3:00 P.M. and between 3:00 P.M. and 11:00 P.M. On 1/22/13 at 9:05 A.M., the surveyor observed the resident in her/his bedroom, behind the privacy curtain, sitting in a wheelchair. Review of the 1/22/13 Nurse's Note indicated the resident experienced an unwitnessed fall (found on bedroom floor), sustaining a forehead abrasion. Further review indicated the resident was found next to the wheelchair. Review of the falls investigation with UM #2 (on 1/24/13 at 8:40 A.M.) indicated the following: a. the resident was confused and a contributing factor to the fall was the resident's poor safety awareness, and b. the resident was barefoot. Review of the 15 minute safety checks (with UM #2) indicated the checks had not been completed on 1/22/13 between 10:00 A.M. and 2:45 P.M., as planned (fall at 2:00 P.M.), however, a CNA statement indicated the resident had been seen 15 minutes before the fall (sitting in her/his wheelchair). During further discussion with UM #2, she was unable to explain the contradiction regarding the safety checks. The falls care plan was updated to include: non-skid strips to floor and encourage out of room activity. On 1/22/13 at 4:35 P.M., the surveyor observed the resident's bedroom door half way closed and the privacy curtain was drawn so that when staff passed by the resident's room they were unable to observe the resident from the hallway. The surveyor entered the resident's room and observed the resident lying in bed, barefoot. On 1/23/13 at 6:45 A.M., the surveyor observed the resident ambulating in the bedroom, barefoot, with a CNA. On 1/23/13 between 8:00 A.M. and 8:04 A.M., the surveyor observed the resident in the unit Day/Dining Room, rocking back and forth in her/his wheelchair. Further observation revealed the resident's shoelaces were untied and there was no staff in the Day/Dining Room. The resident informed the surveyor that she/he was waiting to go out to the emergency room because "I fell flat on my face yesterday." During an interview with CNA #1 on 1/23/13 at 8:05 A.M., he said the resident: a. attempts to stand up alone and she/he is unsafe to transfer without staff assistance, b. keeps the bedroom door half way closed and the privacy curtain drawn so that when staff pass by the resident's room they are unable to observe the resident from the hallway, and c. the resident was not on 15 minute safety checks (on 1/21/13, as planned). Review of the hospital radiology consultation of 1/23/13 indicated the resident had bilateral old nasal fractures. Review of the 15 minute safety check sheets with UM #2 on 1/23/13 at 4:10 P.M. indicated the following checks were not completed, as planned: 1/23/13 - between 3:00 P.M. and 4:00 P.M. On 1/24/13 at 8:15 A.M., the surveyor observed the resident's privacy curtain drawn and the resident could not be observed from the hallway. Upon the surveyor entering the bedroom, the surveyor observed the resident, sitting on the edge of the bed, getting ready to eat breakfast. The resident's moccasins were on the floor, in the corner of the bedroom (and not within reach, as planned), and the resident was barefoot. The resident was not in a supervised dining room for her/his meal, as planned. During an interview with UM #2 on 1/24/13 at 8:40 A.M., she said the resident has a long history of falls, exhibits poor safety awareness and should have non-skid socks on in bed. UM #2 further said that more clarity is needed regarding the investigations being contradictory (thus the facility did not gain a clear picture of the details surrounding the resident's falls). It was also discussed with UM #2 that the facility failed to provide effective interventions and adequate supervision to prevent falls for this resident. During an interview with the Director of Nursing Services (DNS) on 1/24/13 at 11:05 A.M., she said the facility plans on speaking with the resident's Health Care Proxy Agent (invoked on 9/14/11) regarding additional interventions the facility would like to implement in order to increase the resident's supervision.

Based on observation, record review, and interview, for one of three sampled residents (Resident #1), the Facility failed to ensure that tea served from the kitchen was at an appropriate temperature to reduce the potential for a burn. On 2/17/11, at 7:30 A.M., the Hospice Home Health Aide obtained a cup of tea from the kitchen; the temperature of the hot water used to make the tea was 193 degrees Fahrenheit; the Hospice Home Health Aide left the cup of tea on Resident #1's table with no staff member present to obtain thick-it, milk, and sugar; Resident #1 spilled the tea on Resident #1's self, and sustained a second degree burn (The first layer of skin has been burned through, the second layer of skin (dermis) is burned, blisters develop and the skin takes on an intensely reddened, splotchy appearance, and second-degree burns produce severe pain and swelling.) on the right leg, hip, and buttock, and the left leg. Findings included: The Admission record indicated that Resident #1 was admitted to the Facility in April, 2009 and Resident #1's [DIAGNOSES REDACTED]. The plan of care, dated 9/30/10, related to Resident #1's risk for aspiration, included: out of bed for all meals, snacks, and drinks, and supervise and assist with meals. The Director of Nurses (DON) was interviewed on 2/24/11, at 8:30 A.M. The DON said Resident #1 was on aspiration precautions and was not to be left alone with hot beverages. The Certified Nursing Assistant Care Plan that was not dated included: independent with eating; breakfast in the dayroom, lunch and dinner in the dining room; nectar thickened liquids, and cut food in small pieces. Unit Manager #1 was interviewed on 2/24/11, at 2:55 P.M.; CNA #2 was interviewed on 2/24/11, at 11:35 A.M.; CNA #3 was interviewed on 2/24/11, at 11:20 A.M., and CNA #4 was interviewed on 2/27/11, at 6:45 A.M. Unit Manager #1, CNA #2, CNA #3, and CNA #4 said sometimes Resident #1 was anxious, impulsive, and grabbed food or liquids that were placed on the table, and they gave Resident #1 only 1 food item or beverage at a time. CNA #3 said Resident #1 spilt milk in the past related to grabbing the milk on the table. Unit Manager #1, CNA #2, CNA #3, and CNA #4 said for this reason and due to Resident #1's history of dysphagia, Resident #1 was supervised at meal time and when given snacks and fluids, and never left alone with food or liquids. CNA #2, CNA #3, and CNA #4 said sometimes Resident #1 consumed fluids independently with supervision, sometimes Resident #1 required physical assistance with consuming fluids, and sometimes Resident #1 was dependent on the staff for consuming fluids. The Hospice documentation indicated that Resident #1 was admitted to Hospice Services on 12/20/10. The Hospice Aide care plan indicated that Resident #1 was to be assisted with meals and the head of the bed was to be elevated due to Resident #1's risk for aspiration. The Hospice Case Manager was interviewed on 2/28/11, at 4:00 P.M. The Hospice Case Manager said when the Hospice Case Manager reviewed Resident #1's clinical record on 12/20/10, there was no information that indicated that Resident #1 was not to use a Styrofoam cup for hot beverages or that Resident #1 was impulsive and received one food item or beverage at a time as Resident #1 sometimes grabbed for items on the tray or table and therefore, the information was not added to the Home Health Aide plan of care. The Significant Change in Status Minimum Data Set assessment, completed on 12/26/10, indicated that Resident #1: was usually understood; was sometimes able to understand; had impaired vision; had cognitive impairment; required set up and supervision with eating, and had difficulty or pain with swallowing. The Dietician was interviewed on 2/24/11, at 1:00 P.M. The Dietician said the hot water in the kitchen usually ranged between 190 and 193 degrees Fahrenheit. The Dietician said the hot water and the coffee were poured prior to starting the steam table; the food was placed from the steam table onto the plates, and the trucks were transported to the resident units. The Dietician said when the food trucks arrived on the resident units, the temperature of the coffee and hot water served to the residents ranged between 140 degrees Fahrenheit and 150 degrees Fahrenheit, which was an appropriate temperature. The Food Service Supervisor (FSS) was interviewed on 2/24/11, at 10:25 A.M. The FSS said in the morning, the temperature of the hot water and coffee that was poured into a carafe for the first floor ranged between 190 degrees Fahrenheit and 193 degrees Fahrenheit. The FSS said the carafe of coffee and hot water remained in the kitchen for 15 minutes prior to bringing to the first floor to ensure the temperature of the coffee and hot water were not too hot for the residents. The FSS said a carafe of hot water and coffee were not brought to Resident #1's unit. The FSS said when the staff requested hot water for a resident, the kitchen staff told the nursing staff that the hot water was very hot and was not to be given immediately to a resident. The plan of care related to Resident #1's alteration in nutrition, dated 12/29/10, included: likes tea, nectar thickened liquids, and do not give hot liquids in Styrofoam cup. The Hospice Case Manager said the Hospice Case Manager attended the care plan meeting related to Resident #1's significant change in status and information regarding Resident #1's impulsiveness around food and the plan not to use a Styrofoam cup for hot beverages was not discussed. The Hospice Home Health Aide was interviewed on 2/24/11, at 12:30 P.M. The Hospice Home Health Aide said Resident #1 had periods of confusion, had dysphagia, and was not to be left alone with food and fluids. The Hospice Home Health Aide said the Hospice Home Health Aide was not aware that Resident #1 was not to use Styrofoam cups for hot beverages. CNA #2, CNA #3, and CNA #4 said sometimes Resident #1 requested tea outside of meal times. CNA #2 and CNA #3 said when Resident #1 requested tea, the kitchen was called and a dietary staff member brought hot water to Resident #1's unit. CNA #2 and CNA #3 said the hot water brought from the kitchen was too hot for Resident #1 to drink. CNA #2 and CNA #3 said sometimes the dietary staff told CNA #2 to let the water cool prior to giving the tea to Resident #1. CNA #2 and CNA #3 said they removed some of the hot water from the cup, placed the tea bag, sugar, thick-it, and milk in the coffee cup, let the tea cool, and sat with Resident #1 while Resident #1 had the tea. CNA #4 said when Resident #1 requested tea, CNA #4 heated water in the microwave in a regular coffee cup to an appropriate temperature. CNA #2, CNA #3, and CNA #4 said they never served hot fluids to Resident #1 in a Styrofoam cup. The physician order [REDACTED]. The Hospice Home Health Aide said the Hospice Home Health Aide never served a meal to Resident #1. The Hospice Home said the Hospice Home Health Aide was not aware Resident #1 was not to be served hot beverages in a Styrofoam cup and was not aware that Resident #1 was impulsive and sometimes grabbed for beverages or food. The Hospice Home Health Aide said when Resident #1 requested tea, the Hospice Home Health Aide heated hot water in a Styrofoam cup in the microwave as the regular coffee cups with handles were not kept on Resident #1's unit. The Hospice Home Health Aide said Resident #1 had dysphagia and needed to be supervised when drinking fluids. The Hospice Home Health Aide said the Hospice Home Health Aide supervised Resident #1 as Resident #1 drank the hot tea in bed with the head of the bed elevated and there were no issues. . The Hospice Home Health Aide said on 2/17/11, Resident #1 requested to be assisted out of bed, which was unusual for Resident #1 and Resident #1 requested a cup of tea. The Hospice Home Health Aide said Resident #1 was assisted out of bed and transported to the day room. The Hospice Home Health Aide said there were no cups or tea bags on Resident #1's unit; the Hospice Home Health Aide went to the kitchen; the Dietary Person placed a tea bag and hot water in a coffee cup with a handle and a lid, and the Dietary Person did not tell the Hospice Home Health Aide that the tea was too hot to serve to a resident. The Hospice Home Health Aide said the Hospice Home Health Aide went to the day room on Resident #1's unit and realized that the Home Health Aide needed to obtain thick-it, milk, and sugar. The Hospice Home Health Aide said the Hospice Home Health Aide placed the tea with the cover across from Resident #1 on the table in the dining room, told Resident #1 that the tea was hot, not to touch the tea, and the Hospice Home Health Aide left the room to obtain thick-it and milk. CNA #4 said on 2/17/11, CNA #4 was in the dayroom, heard Resident #1 scream, and ran to Resident #1. CNA #4 said there was hot tea on Resident #1's lap; there was steam coming from Resident #1's clothing and CNA #4 immediately pulled the clothing away from Resident #1's skin. The nurse's note, dated 2/17/11, indicated that Resident #1 was given a cup of tea and the tea spilt on Resident #1. The nurse's note indicated that Resident #1's clothing and brief was immediately removed and Resident #1 had a large red area on the right outer hip and bilateral inner thighs with blistering. The Facility temperature log indicated that on 2/17/11, the temperature of the water used to make Resident #1's tea was 193 degrees Fahrenheit. The Food Temperature Log, dated 1/30/11 to 2/24/11, indicated that the temperature of the coffee ranged between 185 degrees Fahrenheit to 200 degrees Fahrenheit. The FSS said the temperature of the hot water used for tea was the same temperature as the coffee. The Surveyor accompanied by the Nurse Practitioner (NP) observed Resident #1's burn at 1:00 P.M. The NP's progress note, dated 2/24/11, indicated that Resident #1 had stage 2 wounds on Resident #1's bilateral groins, the right hips that extended to the rights thigh, and the right hip with a dark wound base, no odor, and no surrounding [DIAGNOSES REDACTED]. On the day of the survey visit, at 7:30 A.M., the Surveyor asked the kitchen staff to place a tea bag and hot water in the same type of cup used for Resident #1 on 2/17/11. The Surveyor and the dietary staff obtained the temperature of the hot water, which was 193 degrees Fahrenheit. The Surveyor did not place thick-it, sugar, or milk in the tea as on the day of the incident, the tea that spilt on Resident #1 did not contain these items. The Surveyor took the cup of hot tea to Resident #1's unit and obtained temperatures as follows: 7:35 A.M. 182.8 degrees Fahrenheit, tea was too hot for the Surveyor to drink 7:40 A.M. 177 degrees Fahrenheit, tea was too hot for the Surveyor to drink 7:45 A.M. 167 degrees Fahrenheit, tea was hot, but able to be sipped by Surveyor 7:50 A.M. 154 degrees Fahrenheit, tea was at an acceptable temperature to drink Unit Manager #1 and the DON said prior to the incident on 2/17/11, they were not aware that the temperature of the hot water served from the kitchen to Resident #1 when Resident #1 requested tea was between 190 degrees Fahrenheit and 193 degrees Fahrenheit. The Unit Manager and the DON said they were not aware that the Hospice Home Health Aide used a Styrofoam cup to heat hot water for Resident #1's tea in the microwave oven. The Unit Manager and the DON said they were not aware that some of the staff heated water for Resident #1's tea in a coffee cup in the microwave oven. The DON said heating water in the microwave oven was not a safe practice.