Every finding on record at Palm Springs Post Acute

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was admitted to the facility with an unstageable pressure injury (full tissue loss covered with slough or dead tissue), the facility failed to ensure they adequately managed his/her pain, when he/she displayed both verbal and non-verbal indicators of pain and analgesics were not offered or administered.Findings include:Review of the facility's Policy, titled Pain Assessment and Management, with a revision date of April 2025, indicated the following:-The purposes of this procedure are to help the staff identify pain in the resident, develop interventions consistent with the resident's goals and needs, and address the underlying causes of pain.-Pain management is a multidisciplinary process that includes the following:*identifying signs and symptoms of existing pain*recognizing situations and conditions with the potential for pain*identifying the underlying causes, intensity, duration, type, and characteristics of pain-Cognitive, cultural, familial, and gender-specific influences on the resident's ability or willingness to verbalize pain are considered when assessing and treating pain.-Possible behavioral signs of pain include:*behaviors such as resisting care, depressed mood-Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain, including:*pressure ulcers-Review the resident's treatment record to identify any situations or interventions where an increase in the resident's pain may be anticipated, for example:*treatments such as wound care or dressing changes*ambulation or physical therapy*turning/repositioningResident #1 was admitted to the facility in January 2026, diagnoses included chronic kidney disease, polyosteoarthritis (affecting multiple joints), and unstageable pressure injury of the sacral region.Review of Resident #1's Minimum Data Set (MDS) assessment, dated 02/02/26, indicated he/she scored a 12 on the Brief Interview for Mental Status (BIMS) - (a score of 13-15 suggests intact cognition, a score of 8-12 suggests moderate cognitive impairment, a score of 0-7 suggests severe cognitive impairment).Review of Resident #1's Physical Therapy (PT) Treatment Note, dated 02/06/26, indicated he/she adamantly declined to mobilize out of bed and was too sore to participate in therapy. Review of Resident #1's PT Treatment Note, dated 02/09/26, indicated he/she rated his/her pain at rest and with movement to be 5 out of 10 (on a scale of 0-10, 0 being no pain - 10 being worst pain ever) constant, affecting his/her lower back.Review of Resident #1's PT Treatment Note, dated 02/10/26, indicated his/her pain level was determined based upon behaviors exhibited and per the note, he/she was agitated and tense.Review of Resident #1's PT Treatment Note, dated 02/11/26, indicated he/she was premedicated (prior to therapy) and he/she rated his/her pain to be 7 out of 10, all over aching and sharp. The Note indicated that nursing was aware, and Resident #1 agreed to participate in light bed mobility activities.Review of Resident #1's PT Treatment Note, dated 02/12/26, indicated he/she rated his/her pain 5 out of 10, affecting his/her bilateral hips, and he/she declined to get out of bed. The Note indicated that a re-visit later in the day was attempted and Resident #1 continued to be in a lot of pain despite being pre-medicated and refused to participate in the PT session.During an interview on 03/26/26 at 1:39 P.M., Physical Therapy Assistant (PTA) #1 said she had PT visits with Resident #1 on 01/29/26, 02/03/26, 02/05/26, 02/09/26, 02/10/26, and 02/12/26. PTA #1 said that the first few visits she had with Resident #1, he/she participated and as time went on, he/she became more agitated, and did not want to participate in therapy and did not want to get out of bed because of pain.PTA #1 said that she reported Resident #1's pain to nursing and she thought he/she was given Tylenol. PTA #1 said after a few visits with Resident #1, he/she avoided touch and complained of low back and whole body pain. PTA #1 said she documented that Resident #1 was premedicated on 02/12/26 because she thought he/she had been.During a telephone interview on 03/27/26 at 10:36 A.M., Nursing Supervisor #2 said he was on duty 02/11/26 and cared for Resident #1. Nursing Supervisor #2 said that if a therapist (PT/OT/PTA) told him Resident #1 was in pain, he would assess him/her and administer pain medications. Nursing Supervisor #2 said he could not remember if he gave Resident #1 any pain medications on 02/11/26 or not, and if he had, it would be documented on his/her Medication Administration Record (MAR). Review of Resident #1's MAR, dated 02/11/26, indicated there was no documentation to support Nursing Supervisor #2 administered pain medication to Resident #1 that day. During an interview on 03/26/26 at 1:56 P.M., the Director of Rehabilitation (DOR) said she was aware Resident #1 refused to participate in therapy at times and it was due to his/her fatigue and low motivation. The DOR said if he/she refused therapy due to pain, they would schedule therapy around pain medication administration and determine if pain was an on-going issue. The DOR said she was only aware of Resident #1's refusals to get out of bed.Review of Resident #1's Physician's Orders for February 2026 indicated he/she had orders for the following:-Methocarbamol (muscle relaxant) 500 milligrams (mg) one tablet by mouth three times per day for muscle spasm- discontinued on 02/05/26.-Acetaminophen (non-prescription analgesic) 325 mg give two tablets every four hours as needed for mild pain.-Acetaminophen 500 mg give one tablet by mouth every six hours as needed for pain.Review of Resident #1's Medication Administration Record (MAR) for the month of February 2026 indicated that although Resident #1 reported and displayed signs and symptoms of pain during several Physical Therapy Treatments and the PT Notes indicated he/she was either premedicated and/or received prescribed medications, there was no documentation to support that nursing administered Resident #1 an analgesic from 02/06/26 through 02/12/26.Review of Resident #1's Nurse Practitioner #1's Progress Note, dated 02/11/26, indicated Resident #1 had increased tenderness to his/her sacral pressure ulcer. The Note indicated that Resident #1 had declined to get out of bed due to bilateral hip pain but did participate in bed exercises with PT and he/she had Tylenol ordered for pain management as needed.During a telephone interview on 03/27/26 at 9:04 A.M., Nurse Practitioner (NP) #1 said that she had visited Resident #1 multiple times during his/her stay at the facility. NP #1 said she was unaware that Resident #1 was reporting pain during several Physical Therapy visits and if she had known she would have initiated a new pain management plan, especially if his/her pain was a barrier for him/her to complete therapy sessions. NP #1 said she had discontinued Resident #1's scheduled Methocarbamol due to him/her having increased lethargy. NP #1 said she was unaware that nursing had not administered Tylenol to Resident #1.Nurse Practitioner (NP) #1 said other indicators of pain included facial grimacing, not getting out of bed or moving as well. NP #1 said if Resident #1 had been displaying those behaviors the nursing staff could have offered him/her Tylenol.During a telephone interview on 03/27/26 at 1:21 P.M., the Director of Nurses (DON) said that the departments should be talking to each other and if Resident #1 had signs and symptoms of pain during PT visits, nursing staff should have been notified and should have followed through. The DON said if there is communication between departments, it should be documented in a progress note.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose physician's orders included wound care and dressing changes to a wound on his/her buttocks, the facility failed to ensure professional standards of practice were maintained when the nursing staff did not document specific wound characteristics, as well as effectiveness of treatment, in accordance with nursing best practice and facility policy.Findings include:Review of the Facility's Policy, titled Wound Care, with a revision date of October 2010, included the following:-The following information should be recorded in the resident's medical record:*The type of wound care given.*The date and time the wound care was given.*The position in which the resident was placed.*All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound.*Any change in the resident's condition.*How the resident tolerated the procedure.Resident #1 was admitted to the facility in January 2026, diagnoses included chronic kidney disease, polyosteoarthritis (affecting multiple joints), and unstageable (full thickness skin loss covered with slough or dead tissue) pressure injury of the sacral region.Review of Resident #1's Nursing admission Assessment, dated 01/28/26, indicated Resident #1 had an unstageable pressure injury on his/her right buttock which measured 5 centimeters (cm) x 1 cm and he/she had a pressure injury (not staged) on his/her left buttock that measured 1.5 cm x 0.3 cm.Review of Resident #1's Physician's Orders, dated 01/28/26, indicated he/she had an order to wash the unstageable wounds with wound wash, apply calcium alginate (used for moderate to heavy wound drainage) and cover with a foam dressing daily and as needed.Review of Resident #1's Wound Nurse Practitioner's Assessment, date 02/04/26, indicated Resident #1 had one unstageable wound on his/her sacrum, which measured 3.9 cm x 3.1 cm and had a moderate amount of serosanguineous (mix of clear and bloody) drainage. The Assessment included a recommendation to change treatment to include Santyl (used to debride wounds) with the daily dressing.Review of Resident #1's Wound Nurse Practitioner's Assessment, dated 02/11/26, indicated Resident #1 sacral wound measured 5.10 cm x 7.80 cm, its status had worsened, and the wound was malodorous with a moderate amount of serosanguineous drainage. The Assessment included a recommendation to change his/her treatment to include crushed Flagyl (antibiotic) to the wound bed with the daily dressing.Review of Resident #1's Treatment Administration Record (TAR) for the months of January and February 2026 indicated that although nurses were changing his/her wound dressings daily, there was no documentation to support that nursing documented the wound appearance, measurements, drainage amount and type, and/or odor, during the daily dressing changes.During a telephone interview on 03/26/26 at 5:08 P.M., Nurse #1 said she had taken care of Resident #1's wound multiple times. Nurse #1 said Resident #1's wounds were on his/her coccyx or buttocks area. Nurse #1 said it was standard practice to include the appearance of the wound, the type of drainage, and if there is an odor, with each dressing change, when documenting the treatment. During an interview on 03/26/26 at 1:00 P.M., Nurse #2 said she was familiar with Resident #1 and had provided his/her wound care. Nurse #2 said there is a template [within the electronic medical record] on the Treatment Administration Record (TAR) that prompts the nurses to enter the wound description, including the wound appearance, drainage, odor, or if the wound has improved or worsened, with each dressing change.During an in-person interview on 03/26/26 at 12:15 P.M., and a telephone interview on 03/27/26 at 1:21 P.M., the Director of Nurses (DON) said that nursing staff should be documenting the appearance and specific characteristics of Resident #1's wounds with each dressing change. The DON said the facility had identified that when nursing staff modified the wound care order within the electronic medical record, the supplementary documentations were mistakenly removed.On 03/26/26, the Facility was found to be in Past Non-Compliance, with an effective date of 03/16/26, and presented the Surveyor with a plan of correction which addresses the areas of concern as evidenced by:A) On 03/15/26 the Director of Nurses educated the nursing staff on Wound Treatment Documentation requirements with mandatory documentation after every wound treatment to include:*Wound Location*Wound Measurements*Wound Appearance*Drainage*Odor*Peri Wound Skin Condition*Signs of InfectionB) On 03/15/26 the Director of Nurses educated the nursing staff on required documentation elements, including supplemental documentation inclusive of wound characteristics.C) On 03/15/26 a facility wide audit was initiated for all residents with wound orders to validate documentation elements in place, and completeness of documentation.D) Weekly wound documentation audits will be conducted weekly x 4 weeks and then monthly x 2 months.E) The Director of Nurses will review audit findings and trends and bring to monthly Quality Assurance Performance Improvement (QAPI) and Wound Committee meetings.F) The Director of Nurses and/or Designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the facility failed to ensure they maintained an accurate and complete medical record related to 1) the anatomical location of a pressure injury and 2) the frequency of repositioning.Findings include:Review of the Facility's Policy, titled Charting and Documentation, with a revision date of July 2017, included the following:-All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.Review of the Facility's Policy, titled Prevention of Pressure Injuries, with a revision date of April 2020, included the following:-Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by their interdisciplinary care team.Resident #1 was admitted to the facility in January 2026, diagnoses included chronic kidney disease, polyosteoarthritis (affecting multiple joints), and unstageable (full tissue loss covered with slough or dead tissue) pressure injury of sacral region.1) Review of Resident #1's Nursing admission Assessment, dated 01/28/26, indicated Resident #1 had an unstageable pressure injury on his/her right buttock which measured 5 centimeters (cm) x 1 cm and he/she had a pressure injury (not staged) on his/her left buttock that measured 1.5 cm x 0.3 cm.Review of Resident #1's Wound Nurse Practitioner's (NP) Assessment, date 02/04/26, indicated Resident #1 had one unstageable wound on his/her sacrum. Review of Resident #1's Treatment Administration Record (TAR) for the month of February 2026, indicated that although the Wound NP identified the anatomical location of Resident #1's unstageable pressure injury to be on his/her sacrum, nursing continued to sign off that they completed wound care for unstageable pressure injuries on Resident #1's right and left buttock.During a telephone interview on 03/26/26 at 5:08 P.M., Nurse #1 said she had taken care of Resident #1's wound multiple times. Nurse #1 said Resident #1's wounds were on his/her coccyx or buttocks area.During an in-person interview on 03/26/26 at 12:15 P.M., and a telephone interview on 03/27/26 at 1:21 P.M., the Director of Nurses (DON) said they identified that nursing documented Resident #1's wounds were on his/her right and left buttocks, when the Wound NP had identified the anatomical site to be his/her sacrum.2) Review of Resident #1's Wound Nurse Practitioner's (NP) Progress Note, dated 02/05/26, included recommendations to offload pressure and reposition him/her every two hours.Review of Resident #1's Wound NP's Progress Note, dated 02/11/26, indicated that strict adherence to pressure injury prevention protocols remains essential, including frequent repositioning.Review of Resident #1's Certified Nurse Aide (CNA) flow sheets for the months of January 2026 and February 2026 indicated there was no documentation to support that Resident #1 was repositioned every two hours as recommended by the Wound NP.During an interview on 03/26/26 at 3:33 P.M., Certified Nurse Aide (CNA) #1 said she had taken care of Resident #1 and he/she required assistance with repositioning. CNA #1 said they were supposed to document the repositioning on his/her flow sheet.During an in-person interview on 03/26/26 at 12:15 P.M., and a telephone interview on 03/27/26 at 1:21 P.M., the Director of Nurses (DON) said they had previously identified that the option to document every two-hour repositioning was not automatically appearing on the CNA flow sheets and had been missed for Resident #1.On 03/26/26, the Facility was found to be in Past Non-Compliance, with an effective date of 03/24/26, and presented the Surveyor with a plan of correction which addresses the areas of concern as evidenced by:A) On 03/02/26 through 03/16/26, the Director of Nurses educated the nursing staff on anatomical wound locations.B) On 03/21/26 the Director of Nurses educated the nursing staff on Repositioning and Offloading, which included the need to ensure completion of daily flow sheet documentation. C) On 3/15/26 an audit was initiated, and is on-going, for all residents with wounds for accurate anatomical location documentation.D) Audits were also initiated, and remain on-going, for all residents for every two-hour repositioning need, documentation accuracy and completion.E) The Director of Nurses will review audit findings and trends and bring to monthly Quality Assurance Performance Improvement (QAPI) and Wound Committee meetings.F) The Director of Nurses and/or Designee are responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the facility failed to ensure they maintained complete and accurate records related to 1) the care and services associated with his/her tracheostomy (a surgical procedure that creates and opening in the neck to facilitate breathing when the usual airway is obstructed or compromised) and 2) the recording of the events during his/her Cardiopulmonary Resuscitation (CPR) Code.Findings include:Review of the Facility's policy, titled Suctioning the Tracheostomy Tube, with a revision date of 10/2023, indicated the following:-The purpose of this procedure is to remove secretions, maintain a patent airway, and prevent infection of the lower respiratory tract.-The following information should be recorded in the resident's medical record: *The date and time the procedure was performed *The type and size of the catheter used. *The amount of negative pressure millimeters per mercury (mmHg) used to suction. *Amount, color and characteristic of secretions. *Oxygen saturation and pulse during the procedure.Resident #1 was admitted to the facility in [DATE], diagnoses included large intracranial hemorrhage, acute hypoxic respiratory failure, and tracheostomy.1) Review of Resident #1's Nursing Progress Note, dated [DATE], indicated Resident #1 was suctioned once and his/her inner (tracheostomy) cannula (removable tube inserted within the outer cannula tracheostomy tube, used to maintain airway patency) was changed.Review of Resident #1's Treatment Administration Record (TAR) for the month of [DATE] indicated the following physician's orders were not signed off as being completed by nursing on [DATE].-Tracheal suctioning as needed.- Change the disposable inner cannula daily.Review of Resident #1's medical record indicated there was no documentation to support that the type and size of the suction catheter or the amount of negative pressure used to suction him/her were documented per the facility's policy.During an interview on [DATE] at 1:46 P.M., Nurse #2 said he was on duty on the [DATE] evening shift (3:00 P.M. through 11:00 P.M.) and was mentoring another nurse. Nurse #2 said they provided Resident #1's care together, that they provided oral and tracheal suctioning and changed his/her inner cannula. Nurse #2 said the orders should have been signed off on Resident #1's TAR as being completed by nursing and he did not know why they weren't.2) Review of the Facility's Procedure Form, titled Emergency Code Documentation Form, indicated a section to document the narrative of the Code.During an interview on [DATE] at 3:09 P.M., Nursing Supervisor (NS) #1 said she was on duty on [DATE] and was in Resident #1's room when she noticed that Resident #1's chest was not going up and down and she did not feel a pulse. NS #1 said she called for help and initiated a Code Blue.Nursing Supervisor #1 said that when they rolled Resident #1 onto the backboard, his/her tracheostomy tube came out. NS #1 said that they covered the stoma (the surgical opening into the airway) with gauze and proceeded to administer breaths with the ambu bag (used to force air into the lungs) placed over Resident #1's nose and mouth. NS #1 said they also applied the AED and Resident #1 received one or two shocks.Review of Resident #1's Nursing Progress Note and Emergency Code Documentation Form, dated [DATE], indicated at 5:55 P.M. Resident #1 ceased to have a pulse, nursing staff called a Code Blue and initiated Cardiopulmonary Resuscitation (CPR). The Note and Form indicated a backboard was placed underneath Resident #1, CPR was initiated at 5:55 P.M., an Automated External Defibrillator (AED- a portable device used to treat individuals in sudden cardiac arrest by delivering electric shock to restore normal heart rhythm) was applied and CPR continued until the police and paramedics arrived and took over.During an interview on [DATE] at 4:10 P.M., the Director of Nurses (DON) said that several of the staff members who were present during Resident #1's Code documented the events on individual pieces of paper and when the Code was done the summary was rewritten on Resident #1's Emergency Code Documentation Form. The DON said all the events that occurred during the Code, along with the times they occurred, should be on the Form.Further review of the Form indicated that the CPR narrative did not include the details provided by Nursing Supervisor #1 and the DON.The DON said that the number of shocks administered to Resident #1 via the AED and that his/her trach dislodgement during the Code should have been documented in both, the Nursing Progress Note and the Emergency Code Documentation Form, but were not.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a tracheostomy (a surgical procedure that creates and opening in the neck to facilitate breathing when the usual airway is obstructed or compromised) and required continual respiratory care and the administration of humidified oxygen, the facility failed to ensure that care and treatment provided were consistent with professional standards of practice, when physician's orders related to his/her respiratory equipment use/monitoring were not obtained by nursing.Findings include:Review of the Facility's Protocol and Procedure, titled Airvo and myAirvo Unit, undated, indicated the following:-Description: A humidifier, with adjustable flow settings, delivering high flow warm and humidified gases.-Fill the water chamber with sterile or distilled water. Do not allow the water chamber to run dry.-Set the airflow setting on the Airvo and the oxygen liters per minute to achieve the prescribed percentage of oxygen.-Documentation: *Airvo flow settings *Oxygen liter flow *Oxygen percentage *Patient's tolerance to therapyResident #1 was admitted to the facility in November 2025, diagnoses included large intracranial hemorrhage, acute hypoxic respiratory failure, and tracheostomy.Review of Resident #1's medical record which included his/her Medication Administration Record (MAR) and Treatment Administration Record (TAR) indicated there was no documentation to support that nursing obtained Physician's orders for:-the Airvo flow settings-the type of water required to fill the water chamber on the Airvo unit-the frequency to monitor the water chamber on the Airvo unit to ensure it did not run dryDuring a telephone interview on 12/10/25 at 10:35 A.M., Respiratory Therapist (RT) #1 said he programmed the settings on Resident #1's Airvo unit upon his/her admission to the facility and nursing was then responsible for monitoring the settings on the unit.During an interview on 12/09/25 at 4:10 P.M., the Director of Nurses (DON) said that nursing had been working on Resident #1's Physician's orders, including the specific orders related to the Airvo unit, and the orders were not complete upon his/her admission to the facility.

Based on observations, record review and interviews, the facility failed to provide supervision during meals for one Resident (#102) with an aspiration risk out of a total sample of 27 residents. Findings include: Review of the facility policy titled, Activities of Daily Living (ADL) Supporting, dated April 2025, indicated the following:-Residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living.-Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.-Appropriate care and services are provided to residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: d. dining (eating, including meals and snacks). Resident #102 was admitted to the facility in July 2025 with diagnoses of cervical spine fusion and muscle weakness. Review of Resident #102's most recent Minimum Data Set (MDS) indicated the Resident had a Brief Interview for Mental Status exam score of 15 out of a possible 15, which indicated he/she has intact cognition. On 11/18/25 at 9:14 A.M., Resident #102 was observed lying in bed with his/her breakfast on the table in front of him/her. Resident #102 was not eating and had only drunk his/her liquids. During an interview at this time, Resident #102 said he/she typically eats alone in his/her room. There were no staff present in the room or in the nearby hallway to provide assistance or supervision if needed. On 11/19/2025 at 8:14 A.M., Resident #102 was provided his/her breakfast tray by the staff who then walked out of the room leaving the Resident alone to eat. The door to the Resident's room was approximately 80% closed and it was difficult to observe the Resident from the hallway. The Resident ate alone in his/her room from 8:14 A.M., to 8:36 A.M., with no staff present to provide supervision or assistance if needed. On 11/20/2025, Resident #102 was observed eating alone in his/her room from 8:25 A.M., to 9:02 A.M. Review of Resident #102's Activity of Daily Living care plan, initiated in July 2025, indicated the following intervention:-EATING: I require supervision with eating and drinking Review of Resident #102's Kardex (a form indicating the level of assistance a resident requires) indicated the following:-EATING: I require supervision with eating and drinking Review of a Modified Barium Swallow (a swallowing test to determine the level of aspiration risk) completed in August 1, 2025 indicated the following:-Strategies recommended During PO (by mouth) feeding: Allow extra time for meals, alternate solids and liquids and follow with dry swallow, avoid impulsivity with rate and amount of intake, controlled sips, cued cough, monitor PO intake rate, multiple swallows, positioned upright, reduce distraction, small bites/sips. -Supervised PC feeding: strategies dependent on caregiver assistance, aspiration precautions, monitor patient for adequate nutrition and hydration. Review of the Speech Therapy Discharge summary, dated [DATE], indicated the following:-discharge recommendations: comp strategies/positions: supervised PO (by mouth) intake, sit up right, slow rate, alternate liquids and solids-supervision for oral intake: Close supervision. Review of the Documentation Survey Report for the month of November 2025, indicated that for 29 out of 54 meals, supervision had not been provided to Resident #102. During an interview on 11/20/2025 at 9:02 A.M., Certified Nursing Assistant (CNA) #3 said the staff providing care have access to review each resident's Kardex so that they provide the level of assistance required to care for the resident. CNA #3 said she is Resident #102's typical CNA and knows the Resident well. CNA #3 said Resident #102 does better eating when someone is next to him/her providing verbal cues helps him/her to have encouragement during the meal for safety and adequate intake. During an interview on 11/20/2025 at 8:36 A.M., Unit Manager #4 said Resident #102 has an aspiration risk and altered diet due to his/her cervical spine fusion. Unit Manager #4 said Resident #102 requires assistance at times for self-feeding because on some days he/she is unable to feed him/herself. Unit Manager #4 said that staff should be checking in on the Resident throughout the meal to see if he/she needs assistance. Unit Manager #4 said all staff have access to review the Kardex and care plans and that these should be followed as written to ensure residents are provided with the level of care the interdisciplinary team had assessed them to need. During an interview on 11/20/25 at 9:25 A.M. the Director of Nursing said care plans and Kardex's should be followed as written. The Director of Nursing said that Resident #102 should have supervision with meals.

Based on observation and interview, the facility failed to store and prepare food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure food was dated, stored off the floor, shelves on which food was stored were clean/free of possible contaminants, and that unpasteurized eggs were cooked thoroughly. Findings include: Review of the facility's policy titled Food Receiving and Storage, dated as revised November 2022, indicated, but was not limited to, the following:- Foods shall be received and stored in a manner that complies with safe food handling practices. - Dry foods that are stored in bins are removed from original packaging, labeled and dated ( use by date). Such foods are rotated using a first in-first out system.- All foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date).- Refrigerators/walk-ins are not overcrowded. Foods in the walk-in are stored off the floor. Review of the facility's policy titled Food Preparation and Service, dated as revised November 2022, indicated, but was not limited to, the following:- Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practice.- Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food means food that requires time/temperature control for safety to limit the growth of pathogens (i.e., bacterial or viral organisms capable of causing a disease or toxin formation). Examples of PHF/TCS foods include ground beef, poultry, chicken, seafood (fish or shellfish), cut melon, unpasteurized eggs, milk, yogurt and cottage cheese.- Only pasteurized shell eggs are cooked and served when:a. Residents request undercooked, soft-served or sunny side up eggs; andb. Preparing foods that will not be thoroughly cooked (e.g., hollandaise sauce, French toast, ice cream, etc.).- Unpasteurized eggs are cooked until all parts of the egg (yolk and whites) are completely firm. Review of the current United States Department of Agriculture (USDA) food safety guidelines indicate that undercooked or raw unpasteurized eggs should not be consumed as they pose a significant risk for Salmonella (a potentially serious bacterial food-borne infection), especially for those who are elderly and/or immuno-compromised (those with a weakened immune systems). The USDA food safety guidelines also indicate that leftover prepared food should not be kept for more than 4 days in the refrigerator. On 11/18/25 at 7:17 A.M., the surveyor made the following observations during the initial walkthrough of the kitchen: - A bag of flour in the dry storage area, open but undated.- A bag of pasta in the dry storage area, open but undated.- A bottle of soy sauce in the dry storage area, open but undated.- Two pound cakes stored directly on the floor in the walk-in freezer.- A box of sub rolls stored directly on the floor in the walk-in freezer. During an interview on 11/18/25 at 8:33 A.M., the Food Service Director (FSD) said the pasta, flour and soy sauce should have been dated when opened and that the pound cakes and sub rolls should not have been on the floor. On 11/19/25 at 7:17 A.M., the surveyor made the following observations during a revisit to the kitchen:- Eight pre-portioned and undated canned fruit cups in the walk-in refrigerator.- Three undated sandwiches in the walk-in refrigerator.- A 25-pound bucket of hard cooked peeled eggs, opened and dated 11/9 in the walk-in refrigerator. Instructions on the egg packaging indicated the eggs should be used within five days of opening.- A wispy white substance on food storage shelves in the walk-in refrigerator; there was food stored on, and below, the wispy white substance. During an interview on 11/19/25 at 7:56 A.M. the FSD said staff should wrap and date all food. The FSD said he did not know when the undated sandwiches were made and that they should have been dated. The FSD said the hardboiled eggs were delivered on 11/9 but he did not know when they were opened and that they should have been labeled when they were opened. The FSD said there was a cleaning schedule but that cleaning the racks was not on the schedule, the FSD said food should not have been stored on top or below the white substance on the shelves. On 11/19/25 at 7:51 A.M., the surveyor observed the cook prepare a fried egg during the tray-line observation. The cook placed the egg on a plate and cut the egg into smaller pieces. When the cook cut the egg the entirety of the eggs' yolk was runny/liquidous indicating the egg was undercooked. The cook then handed the plate with the egg to kitchen staff who placed the plate on a resident tray and covered the plate with a plastic lid to be served to a resident. During an interview and observation on 11/19/25 at 7:52 A.M., the FSD said the eggs were not pasteurized, should not have been served runny and that staff would need to ensure the eggs were fully well done. The surveyor and FSD observed the packaging of shelled eggs in the walk-in refrigerator, the FSD said they were the only shelled eggs in the facility. The packaging and eggs failed to indicate that they were pasteurized. The safe handling instructions on the packaging indicated the following:To prevent illness from bacteria: keep eggs refrigerated, cook eggs until yolks are firm, and cook foods containing eggs Thoroughly.

Based on observations and interviews the facility failed to ensure drugs and biologicals were stored in accordance with acceptable professional standards of practice. Specifically,1.The facility failed to ensure that expired medications were removed from medication carts and medication rooms on 2 out of 3 units.2.The facility failed to ensure medication carts were locked while unattended.Findings include:Review of the facility policy titled Medication Storage, dated August 2021, indicated the following: -Facility will ensure that medications are safely and appropriately stored. -Discontinued or expired medications will be destroyed within 30 days, or if unopened and properly labeled, returned to the pharmacy for credit if allowed. -The storage area will be kept locked when not in use. 1. On 11/19/25 at 6:35 A.M., the surveyor and Nurse#2 observed the following in the C-wing medication cart and medication room. -A bottle of Maalox with expiration date of 10/2025 -A bottle of Metamucil with expiration date of 3/2025 -A bottle of ear wax with expiration date of 10/2025 -A bottle of magnesium citrate with an expiration date of 9/13/2025. During an interview on 11/19/25 at 6:40 A.M., Nurse #2 said the nurses are responsible to ensure that expired medications are removed from the medication cart, and for the medication rooms the central supply staff is responsible of ensuring expired items are removed and discarded. On 11/19/25 at 6:50 A.M., the surveyor and Nurse #5 observed the following expired item in the B-wing medication room. -A bottle of saline nasal spray expiration date of 10/2025. During an interview on 11/19/25 at 6:54 A.M., Nurse #5 said central supply staff is responsible for checking expired items and removing them from the medication room. During an interview on 11/19/25 at 11:05 A.M., the Central Supply Staff said she checks for expired items when restocking and at least once a month. During an interview on 11/19/25 at 12:17 P.M., Unit Manager #2 said she checks medication carts and medication room weekly for expired items. During an interview on 11/19/25 at 12:18 P.M., the Director of Nursing said 11-7 nurses and Central supply staff are responsible for ensuring expired items are removed from the medication rooms. She further said nurses check for expired items in the medication carts daily and the unit manager does weekly. 2. On 11/19/2025 at 9:12 A.M., on the C unit, the surveyor observed an unattended and unlocked medication cart. The surveyor was able to open and access the cart. At 9:14 A.M., Nurse #4 exited a resident room and returned to the medication cart. During an interview with Nurse #4 on 11/19/2025 at 9:14 A.M., she said that the medication cart was supposed to be locked when unattended. During an interview with the Director of Nursing on 11/19/2025 at 12:22 P.M., she said that medication carts should be locked when unattended.

Based on observations, record review, and interviews, the facility failed to ensure one Resident (#87) who was fed by enteral means (artificially via a tube), out of a total sample of 27 residents, received appropriate treatment to prevent complications of enteral feeding. Specifically, the facility failed to ensure that Resident #87's enteral nutrition formula was administered at the physician-prescribed rate. Findings include:Review of the facility policy, titled Enteral Nutrition, revised November 2018, indicated, but was not limited to, the following:- Adequate nutritional support through enteral nutrition is provided to residents as ordered.- The dietitian monitors residents who are receiving enteral nutrition and makes appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings.- Enteral feedings are scheduled to try to optimize resident independence whenever possible (e.g., at night or during hours that do not interfere with the resident's ability to participate in facility activities).- The nurse confirms that orders for enteral nutrition are complete. Resident #87 was admitted to the facility in October 2025 with diagnoses including unspecified protein-calorie malnutrition and gastrostomy (G-tube, a tube surgically placed directly into the stomach through the abdominal wall with the purpose of delivering food, typically in the form of liquid formula). Review of the most recent Minimum Data Set (MDS) assessment, dated 11/10/25, indicated that Resident #87 scored an 11 out of a possible 15 on the Brief Interview for Mental Status exam indicating the Resident had moderate cognitive impairment. Further review of the MDS indicated the Resident received nutrition via a feeding tube. Review of Resident #87's care plan indicated the Resident had a nutritional problem or a potential nutritional problem related to abnormal nutrition-related labs, CHF (congestive heart failure), cognitive loss, diuretic therapy, HTN (hypertension), swallowing problem, PEG (percutaneous endoscopic gastrostomy) tube, and surgical wound with the following intervention:- Administer tube feedings as ordered. Review of Resident #87's physician orders indicated the following orders:- Enteral feed order every shift Jevity 1.5 CAL administer continuous via pump 67 mL (milliliter) per hour for 18 hours per day. Up at 6 a.m., down at 12 a.m. Flush with 30 mL water before and after feedings, initiated on 11/12/25 and discontinued on 11/17/25.- Enteral feed order every shift Jevity 1.5 CAL administer continuous via pump 100 mL per hour for 12 hours per day. Up at 6 a.m., down at 6 p.m. Flush with 30 mL water before and after feeding, initiated 11/17/25 with a start date of 11/18/25. Review of the Medication Administration Record/Treatment administration record (MAR/TAR) indicated a nurse signed off that Resident #87 received continuous enteral feed on the day, evening and night shift on 11/18/25, and 11/19/25. Review of the Health Status Note, dated 11/17/25, indicated the Registered Dietitian (RD) was working with Resident #87 towards a goal of transitioning to bolus feeding (large doses of enteral nutrition formula administered in a short span of time); the RD recommended a new order of Jevity 1.5 to be run at 100 mL per hour for 12 hours. During an observation on 11/18/25 at 9:14 A.M., the surveyor observed Resident #87 receiving enteral nutrition formula via pump, the pump indicated the formula was being administered at a rate of 67 mL per hour. During an observation on 11/18/25 at 11:14 A.M., the surveyor observed Resident #87 receiving enteral nutrition formula via pump, the pump indicated the formula was being administered at a rate of 67 mL per hour. During an observation on 11/19/25 at 7:07 A.M., the surveyor observed Resident #87 receiving enteral nutrition formula via pump, the pump indicated the formula was being administered at a rate of 67 mL per hour. During an observation on 11/19/25 at 3:01 P.M., the surveyor observed Resident #87 receiving enteral nutrition formula via pump, the pump indicated the formula was being administered at a rate of 67 mL per hour. During an observation on 11/20/25 at 7:19 A.M., the surveyor observed Resident #87 receiving enteral nutrition formula via pump, the pump indicated the formula was being administered at a rate of 67 mL per hour. During an interview and observation on 11/20/25 at 9:43 A.M., Nurse #3 said that nurses managing enteral nutrition should check to ensure that the rate provided by the pump was consistent with the physician order. Nurse #3 said nurses should check the pump to ensure the correct rate is being delivered every time the nurse administered medication. The surveyor and Nurse #3 reviewed Resident #87's physician orders; Nurse #3 said Resident #87 was previously receiving enteral nutrition at a rate of 67 mL per hour but that on 11/17/25 the order was changed to 100 mL per hour. The surveyor and Nurse #3 observed Resident #87 receiving enteral nutrition via pump, the pump indicated the formula was being administered at a rate of 67 mL per hour. Nurse #3 said this was incorrect and that the pump should have been set to 100 mL per hour. Nurse #3 said the 11-7 nurse who had initiated the enteral nutrition that morning should have ensured the rate was 100 mL per hour and that Nurse #3 should have also ensured that the rate was correct when his shift started, but that he didn't. Nurse #3 said he had worked on 11/19/25 and was not aware that the order for the Resident's rate had changed from 67 mL per hour to 100 mL per hour. During an interview on 11/20/25 at 10:03 A.M., Unit Manager #3 said nurses should check Resident enteral nutrition rates when they first come in for their shifts and that she would expect nurses to change the rate to be consistent with the physician order if the rate was incorrect. During an interview on 11/20/25 at 10:10 A.M., the RD said Resident #87 was planning to be discharged in December and was interested in transitioning from continuous enteral nutrition to bolus feeding. The RD said the enteral nutrition rate was previously 67 mL per hour for 18 hours but was changed on 11/17/25 to 100 mL per hour for 12 hours in order to give the Residents' stomach time to adjust to the increased volume and decreased feeding time, and to minimize the risk of intolerance, to prepare the Resident for his/her upcoming discharge. The RD said that the Resident should have been receiving enteral nutrition formula at a rate of 100 mL per hour, and that the Resident receiving the incorrect rate would put the Resident at risk for not properly transitioning to bolus feeding. During an interview on 11/20/25 at 10:44 A.M., the Director of Nursing (DON) said she would expect the nurse to ensure the rate was consistent with the physician order when starting an enteral nutrition.

Based on interview and record review, the facility failed to ensure one Resident (#5), out of a total sample of 27 residents, was referred for a Level II Preadmission Screening and Resident Review (PASRR) evaluation (an evaluation to determine if a resident needs specialized services to address his/her new diagnosis of schizoaffective disorder, which is a serious mental illness (SMI)) as required.Findings include: Review of the facility policy titled Behavioral Assessment, Intervention, and Monitoring, dated as revised February 2025, indicated:-New onset or changes in behavior that indicate newly evident or possible serious mental disorder, intellectual disability, or a related disorder are referred for a PASARR Level II evaluation.Resident #5 was admitted to the facility in November 2025 with diagnoses including diabetes and heart failure.Review of the most recent Minimum Data Set (MDS) assessment, dated 11/7/25, indicated Resident #5 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 14 out of 15. This MDS also indicated Resident #5 had a diagnosis of schizophrenia and was not currently considered by the state level II PASRR process to have serious mental illness.Review of Resident #5's PASRR, dated 11/18/25, indicated the Resident did not have a diagnosis of schizophrenia.Review of Resident #5's initial psychological consultation, dated 12/10/24, indicated:-Resident appears to have been suffering in silence with schizoaffective disorder depressive type.-Please add the Schizoaffective diagnosis.Review of Resident #5's nursing progress note, dated 12/10/25, indicated the Resident was seen by the psychological nurse practitioner who recommended to start an antipsychotic medication, Abilify. Review of Resident #5's psychological follow-up notes, dated 9/10/25, 9/23/25, 10/21/25, and 11/4/25, indicated the Resident was receiving care for schizoaffective disorder.During an interview on 11/19/25 at 10:28 A.M., Social Worker #1 said any new diagnosis of schizoaffective disorder would require a referral for Level II PASRR. Social Worker #1 said Resident #5 did not have schizoaffective disorder upon admission in November 2024. Social Worker #1 said she was unaware Resident #5 had a new diagnosis of schizoaffective disorder in December 2024 and a Level II PASRR referral was never completed at that time but should have been. During an interview on 11/19/25 at 12:23 P.M., the Director of Nursing (DON) said any new diagnosis of schizoaffective disorder would require a referral for Level II PASRR. The DON said a Level II PASRR referral should have been completed for Resident #5 when he/she was newly diagnosed with schizoaffective disorder in December 2024 but was not.

Based on observation, interview and record review, the facility failed to accurately code in the Minimum Data Set (MDS) for one Resident (#7) out of 27 total sampled residents. Specifically, for Resident #7, the facility failed to accurately document a fall resulting in a right humeral fracture. Findings include:Review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual, dated October 2025, indicated:-Review any follow-up medical information received pertaining to the fall, even if this information is received after the ARD (e.g., emergency room x-ray, MRI, CT scan results) and ensure that this information is used to code the assessment.-If the level of injury directly related to a fall that occurred during the look-back period is identified after the ARD and is at a different injury level than what was originally coded on an assessment that was submitted to the Internet Quality Improvement and Evaluation System (iQIES), the assessment must be modified to update the level of injury that occurred with that fall Resident #7 was admitted to the facility in November 2024 with diagnoses including diabetes and dementia. Review of the most recent MDS assessment, dated 11/13/25, indicated Resident #7 had severe cognitive deficit as evidenced by a Brief Interview for Mental Status exam score of 6 out of 15. Review of Resident #7's nursing progress note, dated 9/21/25, indicated:-Patient was found the floor at the hallway with the face down bleeding and complaining of pain on the right arm emergency services 911 was called and the patient was transported to the hospital [sic] Review of Resident #7's hospital Discharge summary, dated [DATE], indicated:-Discharge Diagnosis: unwitnessed fall and post-traumatic right humeral fracture. Review of the discharge MDS assessment, dated 9/21/25, failed to indicate a fall with major injury, which would include bone fractures. During an interview on 11/20/25 at 9:38 A.M., the MDS Nurse said all MDS assessments should be coded according to the RAI manual instructions. The MDS Nurse said major injuries include bone fractures. The MDS Nurse said Resident #7's discharge MDS, dated [DATE], the fall was coded incorrectly as it did not indicate the fall resulting in major injury even though the Resident had a fall resulting in a right humeral fracture. During an interview on 11/20/25 at 10:58 A.M., the Director of Nursing said she would expect all MDS assessments to be coded correctly according to RAI manual.

Based on observations, record review and interviews, the facility failed to ensure one Resident (#36) was free from restraints, out of a total sample of 27 residents.Findings include:Review of the facility policy titled, Restraints, dated September 2021, indicated the following:- -All residents have the right to be free of physical and chemical restraint used in violation of applicable regulations and standard of practice.- - Residents may not be physically restrained for discipline or convenience.- - Residents may not be physically restrained without an order from a physician to treat the resident's symptoms or medical conditions.Resident #36 was admitted to the facility in October 2025 with the diagnosis including Parkinson's disease and transient alteration of awareness.Review of Resident #36's most recent Minimum Data Set (MDS) assessment, dated 11/3/25, indicated the Resident scored 7 out of 15 on the Brief Interview for Mental Status exam indicating he/she was severely cognitively impaired. The MDS also indicated Resident #36 was dependent on staff for all care.On 11/18/25 at 9:24 A.M., the surveyor observed Resident #36 lying in his/her bed. The Resident's bed had a perimeter mattress and on the left and the right side of the Resident there were pillows tucked under the fitted sheet.On 11/19/25 at 7:36 A.M., the surveyor observed Resident #36 lying in his/her bed. The Resident's bed had a perimeter mattress and on the left and the right side of the Resident were pillows tucked under the fitted sheet.On 11/19/25 at 8:28 A.M., the surveyor observed Resident #36 lying in his/her bed. The Resident's bed had a perimeter mattress and on the left and the right side of the Resident were pillows tucked under the fitted sheet.Review of Resident #36's care plan for falls indicated the following intervention:-Bolster sheet to air mattress to prevent accidental rolling out of bed.The care plan failed to indicate a plan to place pillows under the fitted sheets on both sides of Resident #36's body.The medical record failed to indicate a restraint assessment had been completed or that a physician's order was in place for the use of restraint.During an interview on 11/19/25 at 8:41 A.M., Certified Nursing Assistant (CNA) #1 said staff put pillows under the fitted sheet for Resident's safety as he/she tries to put his/her feet on the floor.During an interview on 11/19/25 at 8:42 A.M., Unit Manager #1 said Resident #36 is at a high risk for falling and since he/she is on a perimeter mattress staff should not place pillows under the fitted sheet as this restricts the Resident's movement.During an interview on 11/19/25 at 12:20 P.M., the Director of Nursing (DON) said the Resident should not have pillows tucked under fitted sheet as it restrains the Resident from getting out of bed.

Based on interview, record and policy review, the facility failed to ensure that an Influenza (Flu) vaccine was administered to one Resident (#16) out of five applicable residents, out of a total sample of 20 residents. Specifically, the facility failed to administer the Influenza vaccine for Resident #16 who had signed a consent for the vaccine to be administered. Findings include: Review of the facility policy titled Respiratory Protection Program Policy, (not dated), indicated: -The Center will ensure that all center staff and Residents/Patients have the opportunity to receive the respiratory illness vaccinations in accordance with the Centers for Disease Control and Prevention (CDC)recommendations and federal/state regulations . -Provide resident/resident representative with the current vaccine administration sheet as education regarding risks/benefits of vaccination if unvaccinated and document education. -Obtain consent. -Document exemptions/declinations. -Obtain a physician's order. -Administer vaccine. -Document vaccine administration. Review of the CDC guidelines titled Who Needs a Flu Vaccine, dated 10/3/24, indicated the following: -Everyone 6 months and older should get a flu vaccine every season with rare exceptions. Vaccination is particularly important for people who are at higher risk for serious complications from influenza. -Flu vaccination has important benefits. It can reduce flu illnesses, visits to doctor's office's .as well as make symptoms less severe and reduce flu-related hospitalization s and deaths in people who get vaccinated but still get sick. Review of the CDC guidelines titled People at Increased Risk for Flu Complications, dated 9/11/24, indicated some of the people at increased risk for complications of the flu are: -Adults aged 65 and older -People with Chronic lung disease -People with blood disorders -People with heart disease -People with a Body Mass Index (BMI) of 40 Kg (kilograms)/M (meters) 2 or higher -People with a weakened immune system due to .chronic conditions requiring chronic corticosteroids or other drugs that suppress the immune system. Resident #16 was admitted to the facility in March 2019, with diagnoses including Chronic Obstructive Pulmonary Disease (COPD- a chronic lung disease that causes obstructed airflow from the lungs and difficulty breathing), Vitamin B12 Deficiency Anemia (a condition in which your body does not have enough healthy red blood cells), Chronic Diastolic Heart Failure(condition in which the left ventricle [the heart's main pumping chamber] becomes stiff and unable to relax between heartbeats to fill properly with blood), and morbid obesity (a chronic disease in which a person has a body mass index of 40 Kg or higher). Review of the Resident's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15. Review of Resident #16's medical record indicated the Resident received Influenza vaccinations on: 10/07/19, 10/19/20, 10/05/21, 10/06/22, and the Resident signed a consent form on 9/15/22 giving the facility permission to administer the appropriate Influenza vaccine annually. Further review of Resident #16's clinical record indicated a Physician's order, dated 11/27/23, for the following: -Fluzone High-Dose Quadrivalent Suspension Prefilled Syringe 0.7 ML (Influenza Vac High-Dose Quad). Inject 0.7 milliliter (ml) intramuscularly as needed for vaccination yearly per CDC guidelines for patients [AGE] years or older, unless contraindicated. -Check for allergies prior to administration. -Any signs or symptoms of moderate to severe acute illness contact Provider (Physician) prior to administration and document in PN (progress note). Inject 0.7 ml intramuscularly one time only for vaccine, until 11/28/23. Hold 11/30 - 12/1. During an interview on 10/16/24 at 4:01 P.M., Unit Manager (UM) #1 said that the Unit Nursing staff was responsible for administering the flu shots for the Residents on the unit. UM #1 said she knew the Resident was acutely ill in October 2023 and November 2023 and had been on IV antibiotics. UM #1 said the Influenza vaccine would have been held due to the Resident being on antibiotics. UM #1 was unable to say if the Influenza vaccine had been offered when the Resident recovered from the acute illness and was finished with the course of antibiotics. During an interview on 10/18/24 at 10:12 A.M., The Infection Preventionist (IP) said if a resident was acutely ill at the time the facility was administering the flu vaccines the vaccine would be held. The IP said Resident #16's vaccination was held because he/she was on antibiotics and was also receiving steroid injections. The IP said when Resident #16 had recovered and their antibiotic treatment was completed, the facility should have contacted the Physician and get recommendations for administering the flu shot to the Resident. During an interview on 10/18/24 at 11:16 A.M., Resident #16 said he/she could not remember if he/she was administered the flu vaccine in 2023. Resident #16 said he/she always get a flu vaccine if it is offered, and the Doctor says he/she can have the flu vaccine.

Based on observation, policy and record review, and interview, the facility failed to provide respiratory care and services consistent with professional standards of practice for one Resident (#29) out of a total sample of 20 residents. Specifically, the facility failed to obtain Physician's orders for oxygen administration and maintenance of oxygen and respiratory equipment. Findings include: Review of facility policy titled Oxygen Administration, dated 2001 with revision date of 10/2022, indicated: -Verify that there is a physician's order for oxygen administration. -Adjust the Oxygen delivery device so that it is comfortable for the resident and the proper flow of Oxygen is being administered. Review of the facility policy titled Respiratory Equipment/Supply Cleaning/Disinfecting, undated with revision date of 7/15/2024, indicated: -Schedule for supply changes of Nasal Cannula (NC - a clear, soft flexible tube with prongs which are positioned in the nose for oxygen delivery) should occur every seven days and as needed for soiling. Review of the AARC (American Association for Respiratory Care) Clinical Practice Guideline, updated 2014: https://www.aarc.org/wp-content/uploads/2014/08/08.07.1063.pdf indicates: -All oxygen must be prescribed and dispensed in accordance with federal, state, and local laws and regulations. -Oxygen is a medical gas and should only be dispensed in accordance with all federal, state, and local laws and regulations. -Undesirable results or events may result from noncompliance with physicians' orders or inadequate instruction for oxygen therapy. -There is a potential in some spontaneously breathing hypoxemic patients with hypercapnia [high carbon dioxide levels in the blood) and chronic obstructive pulmonary disease that oxygen administration may lead to an increase in PaCO2. -Equipment maintenance and supervision: >All oxygen delivery equipment should be checked at least once daily >Facets to be assessed include proper function of the equipment, prescribed flowrates, remaining liquid or compressed gas content, and backup supply. Resident #29 was admitted to the facility in August 2024, with diagnoses including Acute Hypoxic Respiratory Failure (a life-threatening condition where the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide from the body, with difficulty attaining normal blood oxygen levels) secondary to multifocal Pneumonia (an infection of the lungs that may be caused by bacteria, viruses, fungi or aspiration [when food or liquid is accidentally inhaled into airways and lungs] and characterized by severe cough with phlegm, fever, chills and difficulty breathing), empyema (pockets of pus collection in the pleural space [ area between the lung and the inner surface of the chest wall surrounding the lung]) and Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment). Review of the Resident's comprehensive medical record indicated: -Invocation (made active by Physician) of a Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself), effective 3/27/21. -No Physician orders for Oxygen administration or oxygen and respiratory equipment maintenance. Review of Resident #29's Minimum Data Set (MDS) Assessment, dated 8/30/24, indicated: -that the Resident had moderate cognitive impairment as evidenced by a score of ten out of a total score of 15 on the Brief Interview for Mental Status (BIMS) exam. -that the Resident had been receiving Oxygen therapy. On 10/15/24 at 8:27 A.M., the surveyor observed Resident #29 seated in the Unit dining area with Oxygen flowing at 2.5 LPM (Liters Per Minute- the flow rate set for Oxygen delivery) via nasal cannula (NC). The surveyor observed that the nasal cannula included the date 10/6/24 written on white tape in red ink and attached to the tubing. The surveyor observed Nurse #3 approach the Resident, adjust the oxygen delivery device on the Resident's face, have a short conversation with the Resident and leave the area. On 10/15/24 at 11:29 A.M., the surveyor observed Resident #29 seated in the Unit dining area with Oxygen flowing at 2.5 LPM via NC, and the NC tubing was dated 10/6/24. The surveyor observed Nurse #3 approach the Resident and provided a beverage to him/her. During an observation and interview on 10/15/24 at 12:15 P.M., the surveyor and Nurse #3 observed Resident #29 seated in the Unit dining area with Oxygen flowing at 2.5 LPM and NC tubing in his/her nose. Nurse #3 said Resident #29 was getting 2.5 LPM and had been receiving Oxygen since being admitted from the hospital in August 2024. Nurse #3 said when Residents are admitted to the facility with Oxygen, the admitting Nurse should obtain an order for the Oxygen, and tubing changes were every week on Sundays. Nurse #3 said that Resident #29 did not have Physician orders in place for Oxygen administration or tubing changes, but should have so all the Nurses would know how much Oxygen to administer and change the tubing weekly to prevent germs (contamination). During an interview on 10/16/24 at 12:38 P.M., Unit Manager (UM) #1 said that Resident #29 was admitted from the hospital in August 2024 with the Oxygen already in place. UM #1 said that Resident #29 should have had orders in place for Oxygen administration and tubing changes but did not. UM #1 said it was the responsibility of the admitting Nurse to obtain the orders to ensure proper administration of Oxygen and equipment maintenance.

Based on observation, record and policy review, and interview, the facility failed ensure a Resident who was dependent for activities of daily living (ADL's- personal care activities including but not limited to, eating, grooming, and personal hygiene) received the necessary care and services to maintain grooming for one Resident (#94) out of a total sample of 20 residents. Specifically, for Resident #94, the facility failed to provide assistance for grooming of facial hair per the Resident's preference. Findings include: Review of the facility policy titled Activity of Daily Living (ADL's)- Supporting, dated 2001 with revision date of 3/2018, indicated: -Residents will be provided with care, treatment and services .to carry out ADL's. -Residents who are unable to carry out ADL's independently will receive the services necessary to maintain good .grooming and personal care. Resident #94 was admitted to the facility in June 2024, with diagnoses including fall, fracture (a complete or partial break of a bone) of the neck, and fracture of right radius (a long bone in the forearm that supports movement of the arm and wrist). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #94: -was moderately cognitively impaired as evidenced by a score of 12 out of a total score of 15 on the Brief Interview for Mental Status (BIMS) exam. -required substantial/maximum assistance (the Resident can perform between 25 and 50 percent of the ADL activity, with the remainder performed by the staff member) with personal hygiene which included facial grooming. Review of a Comprehensive Person-Centered Care Plan with a revision date of 10/14/24, indicated that Resident #94: -needed intervention of substantial/maximum assistance with personal hygiene due to decreased strength, decreased endurance and multiple fractures in the upper extremities. During an observation and interview on 10/15/24 at 9:57 A.M., the surveyor observed Resident #94 lying in bed with two patches of approximately one inch long facial hair present on the jaw line. Resident #94 said that he/she had been assisted with a shower that morning but was not offered assistance to remove the facial hair. During an interview on 10/15/24 at 4:45 P.M., the surveyor observed Resident #94 lying in bed with facial hair still present on the jaw line. Resident #94 said he/she liked to remove facial hair at home with an electric razor and prefered not to have any hair on his/her face. Resident #94 said it was not possible to shave his/herself as yet due to weakness in the right arm. Resident #94 said he/she was right hand dominant. During an interview on 10/16/24 at 10:09 A.M., the surveyor observed Resident #94 lying in bed and remained with patches of facial hair on the jaw line/chin. Resident #94 said that he/she would like the hair to be removed from his/her face. Resident #94 said he/she liked to remove the facial hair everyday when he/she was at home, but nobody has offered to remove the facial since being admitted to the facility. Resident #94 said he/she had no way of removing the facial hair his/herself due to the weakness in his/her right arm and removing the facial hair was important to him/her. During an interview on 10/16/24 at 10:10 A.M., Certified Nurses Aide (CNA) #1 said that Resident #94 was dependent for all personal care like washing, dressing and grooming. CNA #1 said that removal of facial hair should be part of daily care not just on shower days, and both male and female Residents should be offered facial hair removal with morning care. During an interview on 10/16/24 at 10:53 A.M., the Assistant Director of Nursing (ADON) said shaving should be offered to all Residents during AM (morning) care, because grooming/shaving was part of good hygiene, personal choices, and dignity.

Based on observation, interview, and record and policy review, the facility failed to ensure that devices utilized for two Residents (#50 and #103), were assessed and consent was obtained by the Resident Representative, when used as physical restraints (defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: is attached or adjacent to the resident's body, cannot be removed easily by the resident; and restricts the resident's freedom of movement or normal access to his/her body), for two applicable Residents who had gastrostomy tubes (G-tube: tube inserted through the stomach that delivers nutrition/hydration), out of a total sample of 20 residents. Specifically, the facility failed to: 1. For Resident #50, obtain written consent for a restraint, and assess the need for an abdominal binder (wide compression belt that hook and loop fastens and encircles the abdomen) to cover Resident #50's G-tube site in order to prevent him/her from pulling on the G-tube. 2. For Resident #103, obtain written consent for a restraint for an abdominal binder and bilateral hand mitts (mitts to cover the hands of a patient who is prone to disrupting medical treatment, picking, or tube pulling) that were being administered to cover Resident #103's G-tube site and bilateral hands in order to prevent him/her from pulling on the G-tube. Findings include: Review of the facility policy titled Use of Restraints, dated 2017, indicated: -Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. -Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. -Examples of devices that are/may be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, geri-chairs, and lap cushions and trays that the resident cannot remove. -Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. -Restraints shall only be used upon the written order of a Physician and after obtaining consent from the resident and or representative (sponsor). Review of the facility form titled Physical Restraints -Record of Informed Consent, last revised 2012, indicated: -that use of restraint will only be necessary/be considered to treat a medical condition or symptom that endangers my physical safety or the safety of other residents. -only be used upon my written consent or the written consent of my representative (sponsor). 1. Resident #50 was admitted to the facility in March 2023, with diagnoses including Cerebral Infarction (stroke: damage to tissues in the brain caused by blood clots, disrupted blood supply and restricted oxygen supply to the specific area), Hemiplegia Unspecified Affecting Right Dominant Side (partial or complete paralysis on one side of the body), and Gastrostomy Status (G-tube placed in the stomach for nourishment). Review of Resident #50's clinical record included a Decree and Order of Appointment of Guardian for an Incapacitated Person, dated 11/15/22, at which time a Guardian (a court appointed person who makes important personal and healthcare decisions for an adult who lacks the capacity to make their own decisions) was appointed for the Resident. Review of Resident #50's Physician's Progress note, dated 5/15/24, indicated that the Nurses had reported to the Nurse Practitioner (NP) that the Resident had pulled on their G-tube and the site was reddened/irritated. The Physician Progress note also included that staff may use an abdominal binder if patient/ Resident keeps pulling on G-tube. Review of Resident #50's current Physician's orders included: -Abdominal Binder, place and check for skin integrity; may remove for ADL (Activities of Daily Living) every shift. Order Active, initiated 5/15/24 Review of Resident #50's Minimum Data Set (MDS) assessment dated [DATE] included: -the Resident was severely cognitively impaired and rarely/never understood or made decisions -the Resident had a range of motion (ROM) deficit on one side -the Resident had G-tube feeding -the Resident was dependent on staff for all upper body dressing tasks Review of Resident #50's September 2024 Treatment Administration Record (TAR) indicated that the Abdominal Binder had been utilized daily for the entire month. Review of Resident #50's October 2024 TAR indicated that the Abdominal Binder had been utilized daily from 10/1/24 through 10/15/24. Review of the Resident's clinical record did not provide any documented evidence of an Informed Consent for the use of restraints that was reviewed with the Resident's Guardian, nor any assessment of the Abdominal Binder restraint. On 10/16/24 at 10:15 A.M., during a G-tube feeding observation, the surveyor observed Nurse #1 remove the bed clothes from the Resident's upper body. The surveyor observed an Abdominal Binder fastened around the Resident's abdomen and the G-tube tubing was not visible. Nurse #1 unfastened the Abdominal Binder to expose the Resident's abdomen and the G-tube tubing. Nurse #1 completed administering the G-tube feeding and then re-applied the Abdominal Binder over the Resident's abdomen, covering the G-tube tubing. During an interview at the time, Nurse #1 said that the Abdominal Binder was applied for the purpose of keeping the Resident from pulling on the G-tube tubing, which the Resident had done in the past, causing irritation to the skin around the G-tube opening and making the skin bleed. Nurse #1 said the Resident has had the Abdominal Binder applied since last May 2024. Nurse #1 said the Resident was not able to remove the Abdominal Binder. During an interview on 10/17/24 at 9:28 A.M., the Director of Nursing (DON) said there was no written informed consent for the use of restraints for the application of the Abdominal Binder obtained from the Resident's Guardian before the application of the Abdominal Binder, but there should have been. The DON also said that there was never an assessment of the restraint when the Abdominal Binder was applied, but there should have been an assessment completed. 45429 2. Resident #103 was admitted to the facility in September 2024, with diagnoses including Gastrostomy and Cerebral Infarction. Review of Resident #103's Nurse Practitioner (NP) progress note, dated 9/20/24, indicated that the Resident was admitted to the facility with bilateral hand mittens and an Abdominal Binder in place. Review of the Minimum Data Set (MDS) Assessment, dated 9/24/24, indicated Resident #103: -was cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. -had a gastrostomy. -had a limb restraint. Review of Resident #103's October 2024 Physician's orders indicated: -Abdominal Binder for prevention of PEG (feeding) tube displacement every shift, start date of 9/19/24 -mittens (glove that covers the hands but does not have individual finger openings) to bilateral hands, remove to check for skin integrity every shift, start date of 9/19/24 Review of Resident #103's September 2024 Treatment Administration Record (TAR) indicated that both the bilateral mittens and Abdominal Binder had been utilized daily. Review of Resident #103's October 2024 TAR indicated that the Abdominal Binder had been utilized daily, and the bilateral hand mittens had been utilized from 10/13/24 to 10/16/24. On 10/15/24 at 9:03 A.M., the surveyor observed Resident #103 lying in bed with mittens on his/her hands and a feeding tube administering Glucerna (liquid enteral feed specially designed for patients with a glucose intolerance). On 10/16/24 at 1:52 P.M., the surveyor and Nurse #2 observed Resident #103 lying in bed with an Abdominal Binder in use. During an interview at the time, Nurse #2 said that the Abdominal Binder and mittens were being used to prevent Resident #103 from dislodging his/her feeding tube. Review of the Resident's clinical record indicated the following: -a Restraint Evaluation was completed on 9/29/24 and 10/13/24, after the Resident's admission to the facility and after the use of restraints had already been administered to the Resident. -no documented evidence that informed consent had been obtained prior to the administration of the bilateral hand mittens or Abdominal Binder. During an interview on 10/16/24 at 2:08 P.M., Resident #103's invoked (made active by a Physician) Health Care Proxy (HCP- a legal document that allows you to appoint someone you trust to make medical decisions on your behalf if you are unable to do so) said that he/she had not signed consent paperwork for the use of restraints for Resident #103. During an interview on 10/17/24 at 9:14 A.M., the Director of Nursing (DON) said that informed consent should have been obtained prior to the administration of the abdominal restraint and mittens to Resident #103 and it had not been obtained.

Based on interview, record and policy review, the facility failed to inform in advance of changes to the plan of care relative to the use of psychotropic (medication that affects how the brain works and causes changes in mood, awareness, thoughts, feelings or behavior) medications for two Residents (#9 and #29) out of a total sample of 20 residents. Specifically, the facility failed to obtain written consent for the use of psychotropic medications before administering Lorazepam (Ativan - anti-anxiety medication) medication to Residents #9 and #29. Findings include: Review of the facility policy titled Psychoactive Medication Use, dated 2015 and revised December 2022, indicated: -A psychotropic medication is any medication that affects the brain activity associated with mental processes and behavior. -Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring and review requirements specific to psychotropic medications .anti-anxiety medications . -Written consent must be obtained prior to the administration of these medications. The consent form must be completed and signed by either the alert and oriented resident or his/her legal representative. 1. Resident #9 was admitted to the facility in November 2021, with diagnoses including Dementia (loss of memory, language, problem-solving, and other thinking abilities severe enough to interfere with daily life activities) and Generalized Anxiety Disorder (mental health condition that causes fear, worry and a constant feeling of being overwhelmed). Review of Resident #9's Minimum Data Set Assessment (MDS) completed 9/5/24, indicated a score of 0 out of a possible total score of 15 on the Brief Interview for Mental Status (BIMS ) exam indicating severe cognitive impairment. Review of Residents #9's Clinical Record indicated: -The Resident's Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself) was activated by the Physician, effective 12/7/21. Review of Resident #9's October 2024 Physician's orders indicated: -Lorazepam (anti-anxiety medication) Oral tablet 0.5 milligrams (mg) (Lorazepam) give 0.5 mg by mouth every 6 hours as needed (PRN) for agitation/restlessness. Start date 9/18/24 and discharge [sic] 10/18/24. Review of Resident #9's September 2024 Medication Administration Record (MAR) indicated the Lorazepam medication was administered once daily on the following dates: -9/20/24 - 9/23/24 -9/27/24 Review of Resident #9's October 2024 MAR indicated the Lorazepam medication was administered once daily on the following dates: -10/1/24 -10/4/24 -10/8/24 -10/10/24 Further review of Resident #9's Clinical Record indicated no evidence of a signed consent for the Lorazepam medication. During an interview on 10/16/24 at 1:19 P.M., the Director of Nursing (DON) said the Nurse who takes the order for a psychotropic medication should fill out a consent form and get it signed. The DON said Resident #9 did not currently have a consent form in place for Lorazepam. The DON said the Resident should have had a consent form in place for Lorazepam. 50138 2. Resident #29 was admitted to the facility in August 2024, with diagnoses including: Dementia and Bipolar Disorder (a mental health condition that causes extreme mood swings that include emotional highs [mania or hypomania] and lows [depression]). Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #29 scored a ten out of a possible total score of 15 on the Brief Interview for Mental Status (BIMS) exam indicating that Resident #29 had moderate cognitive impairment. Review of Resident #29's comprehensive medical record indicated: -Invocation (put into effect) of a Health Care Proxy, effective 3/27/21. Review of Resident #29's Physician orders indicated: -Ativan (Lorazepam - psychotropic, anti-anxiety medication) 1 mg (milligram) by mouth, two times a day for agitation, effective 9/20/24. Review of Resident #29's Medication Administration Record (MAR) indicated: -Ativan medication was administered from 9/20/24 through 10/15/24. Further review of Resident #29's medical record indicated no evidence of written consent prior to the administration of the Ativan medication. During an interview on 10/16/24 at 10:42 A.M., Unit Manager (UM) #1 said all psychotropic medications require written informed consent before administration to a Resident. UM #1 said the Nurse who transcribed (to put data into printed form) the Provider's order was responsible for obtaining consent. UM #1 said Resident #29 had been given scheduled Ativan twice a day without written consent and that consent should have been obtained from the HCP before administration. During an interview on 10/16/24 at 11:05 A.M., the Assistant DON (ADON) said all psychotropic medications required written consent. The ADON said Resident #29 had been administered Ativan without consent being in place. The ADON said consent for psychotropic medication was important because there could be side effects (secondary, undesired effect of a medication).

Based on record review and interview the facility failed to complete an accurate assessment to reflect resident status for one Resident (#106) out of a total sample of 3 closed resident records. Specifically, for Resident #106, the facility failed to accurately enter in Minimum Data Set (MDS) Assessment that the Resident was discharged to the hospital and not to home/community resulting in an inaccurate medical record. Findings include: Resident #106 was admitted to the facility in July 2024. Review of the Resident's comprehensive medical record included: -A Provider order to transfer the Resident to the hospital on 7/22/24. -A Nursing progress note dated 7/22/24 that indicated the Resident was in the hospital due to abnormal laboratory (blood) work. -A Social Service progress note dated 7/23/24, which indicated Resident #106 had a change in condition and was sent to the hospital for evaluation on 7/22/24. -A Minimum Data Set (MDS) assessment dated [DATE], which indicated Resident #106 had been discharged to their home on 7/22/24. During an interview on 10/17/24 at 12:18 P.M., MDS Nurse #1 said that Resident #106 was discharged from the facility to the hospital on 7/22/24. MDS Nurse #1 said the discharge location entered to the MDS dated [DATE], for Resident #106 was inaccurate. MDS Nurse #1 said that the Resident's MDS should have indicated that the Resident was discharged to a short-term hospital, not the home/community and therefore would require modification to accurately reflect the Resident's discharge location.

Based on record review and interview, the facility failed to ensure the Advance Care Planning and Advance Directive rights for one Resident (#79), out of 21 sampled residents, to have a designated Health Care Agent make healthcare related decisions were upheld when the Resident was unable to make his/her own health care decisions. Specifically, the facility failed to arrange for Resident #79 to obtain a legally designated Health Care Agent when the Resident was incapacitated and his/her designated Health Care Agent was permanently unavailable to make healthcare related decisions for the Resident, resulting in facility communication of sharing confidential information and discussing health care related decision making, with an individual who was not the Resident's designated Health Care Agent. Findings include: Review of the facility's policy, titled Guardianship, revised 2/28/21, indicated: - A guardian may be appointed when a patient/resident (hereinafter patient) has been deemed incapacitated. - A court appointed guardian's responsibilities and duties may include, but are not limited to: . Consenting to and monitoring medical treatment . and . making decisions regarding the release of confidential information. - The Social Services Department will provide resource information on guardianship to a resident's family, friend, or interested party when the potential need for a guardian is determined. - In certain circumstances, the Center may initiate a guardianship petition in collaboration with any relevant agency (e.g., Office of Public Guardian, Department of Mental Health, etc.) to the court to appoint a guardian for a patient of the Center. - It will be the responsibility of the Administrator to facilitate appointment of guardian. - Social Services will monitor and document the guardianship process through completion. Review of the facility policy, titled Health Care Decision Making, revised 3/1/22, indicated: - Advance Care Planning is an ongoing process of communication between residents and their healthcare decision makers to understand, reflect on, discuss, and plan for future healthcare decisions for a time when residents are not able to make their own healthcare decisions. - An Advance Directive is written instruction . relating to the provision of health care when the resident is incapacitated. - Advance Directives can be either Instructive or Proxy Directives. - Proxy Directives may include a . Health Care Proxy, Health Care Agent, or Legal Representative who has been appointed by the resident to act in his/her behalf when he/she can no longer express his/her wishes as determined by State requirements. Resident #79 was admitted to the facility in September 2022 with a diagnosis of Dementia (a group of symptoms affecting memory, thinking and social abilities). Review of Resident #79's Massachusetts Health Care Proxy form, dated 1/19/22, indicated the Resident had designated a Health Care Agent to make all health care decisions for him/her if the Resident became unable to make these decisions for him/her self. Further review of the Health Care Proxy form indicated no Alternate Agent was appointed if the Health Care Agent was unwilling or unable to serve. Review of Resident #79's Physician Progress Note to Activate Health Care Proxy/Durable Power of Attorney for Health Care, dated 12/5/22, indicated Resident #79 was incapable of making informed decisions due to moderate cognitive impairment and that the duration of incapacity was indefinite. Further review of the Physician Progress Note indicated the designated health care decision-maker was the Health Care Agent designated by the Resident on the Resident's Health Care Proxy Form. Review of Resident #79's Change in Condition Evaluations indicated that changes in the Resident's medical condition were communicated to an individual who was not a designated Health Care Agent on the following dates: 6/9/23, 7/3/23, 7/23/23, and 8/2/23. Review of Resident #79's Admission Record Contacts, dated 8/23/23, indicated the primary emergency contact for Resident #79 was an individual who had not been designated as a Health Care Agent by the Resident. Further review of the clinical record included no evidence that this individual had been appointed to serve as Resident #79's Health Care Agent. Review of Resident #79's clinical record included no evidence the facility identified an interested party to make health care related decisions or share confidential information pertaining to the Resident. Further review of Resident #79's clinical record included no evidence the facility initiated the process to facilitate the appointment of a Guardian to make health care related decisions or share confidential information regarding the Resident. During an interview on 8/23/23 at 10:13 A.M., Unit Manager (UM) #1 said Resident #79's designated Health Care Agent became permanently unavailable to make health care related decisions for the Resident sometime around February 2023. UM #1 said after that occurred, the facility began to contact another individual regarding Resident #79's health care needs, but she was unsure whether that individual had been designated or appointed as the Health Care Agent for the Resident. During an interview on 8/23/23 at 11:04 A.M., the Social Worker (SW) said if a resident's designated Health Care Agent became unavailable to make health care decisions for a resident, and the resident was incapacitated and unable to designate an alternate Health Care Agent, the facility would need to pursue the legal Guardianship process. The SW said Resident #79's Health Care Agent was permanently unable to make health care decisions for the Resident, and the Resident had no Alternate Health Care Agent designated. The SW also said the individual the facility was currently contacting for health care notifications and decision making was not the Resident's designated Health Care Agent and had not been legally appointed as a Guardian to make health care decisions for the Resident. During an interview on 8/23/23 at 4:14 P.M., the Administrator said the facility had not pursued legal Guardianship proceedings relative to medical decisions for Resident #79 until 8/24/23, after the surveyor's inquiry. The Administrator said the individual the facility had been contacting regarding medical decisions since the designated Health Care Agent became permanently unavailable, was not designated as an Alternate Agent or appointed as an Agent for the Resident, and that he/she did not wish to serve as the Resident's Health Care Agent. The Administrator further said the facility should have initiated legal Guardianship proceedings for Resident #79 when the Resident's designated Health Care Agent became unable to serve, but they did not.

Based on record review and interview, the facility failed to conduct an accurate comprehensive assessment of one Resident's (#79) functional capacity, out of 21 sampled residents according to the Centers for Medicare and Medicaid Services' (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual instructions. Specifically, the facility failed to comprehensively assess Resident #79's cognitive patterns when the Resident did not require an interpreter and was identified to have: clear speech, the ability to make him/her self understood, and the ability to understand others. Findings include: Review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2019, indicated the following for Section C, Cognitive Patterns: -Intent: The items in this section are intended to determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in many care planning decisions. -The Brief Interview for Mental Status (BIMS) should be conducted when the resident is at least sometimes understood verbally, in writing, or using another method, and if an interpreter is needed, one is available. Resident #79 was admitted to the facility in September 2022 with a diagnosis of Dementia (a group of symptoms affecting memory, thinking and social abilities). Review of Resident #79's Minimum Data Set (MDS) assessment dated [DATE], included the following: -The Resident had: >adequate hearing >clear speech >made him/her self understood >had the ability to understand others >and did not need/want an interpreter to communicate with staff Further review of the MDS assessment, Section C for Cognitive Patterns, indicated the Brief Interview for Mental Status (BIMS) was not conducted with the Resident because the Resident was rarely/never understood. During an interview on 8/22/23 at 8:50 A.M., Resident #79 responded verbally to the surveyor's inquiries pertaining to bowel and bladder regimen. The Resident stated that he/she wore special pants that staff at the facility changed for him/her when they became wet or soiled. The Resident spoke softly, but used clear speech when he/she responded to the surveyor's questions. During an interview on 8/23/24 at 4:11 P.M., the Social Worker (SW) said she did not complete the MDS assessments, but she would attempt to contact the other SW who did, as that SW worked Per Diem (an employee who does not have a regular schedule) only and was not available at that time. The SW said she would ask the Per Diem SW whether Resident #79's cognitive patterns should have been assessed through attempt to complete the BIMS with the Resident. During an interview on 8/24/23 at 10:33 A.M., the Administrator said she was responding to the surveyor for the Facility SW, and that the BIMS should have been attempted with Resident #79 for the MDS assessment dated [DATE] as required, but it was not.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed upon admission by nursing to be at high risk for skin breakdown, and was assessed by nursing as not having any open areas upon admission, the Facility failed to ensure he/she receive appropriate care and services in an effort to prevent the development of a pressure injury, and that treatment orders were obtained by nursing after the pressure injury was first observed. On 06/12/23 Resident #1 was left on a bedpan for approximately one hour and twenty minutes, he/she was assessed by nursing after being taken off the bedpan and noted to have subsequently developed a stage 2 (area appears as a shallow crater-like wound or a blister) pressure injury. However although nursing noted the presence of the pressure injury on 06/12/23, the physician was not notified until three days later on 06/15/23, at which point they obtained orders for treatment of Resident #1's pressure injury. Findings include: The Facility Policy, titled, Skin Integrity and Wound Management, dated 02/01/23, indicated: -Nursing staff would provide safe and effective care to promote optimal skin health, prevent pressure injuries, and promote healing. -Identify resident's skin integrity status and need for prevention or treatment interventions through review of all appropriate assessment information. The Facility Protocol, titled Appropriate Bed Pan Usage, undated, indicated the risks for leaving a resident on a bed pan for prolonged time included pressure injuries, ulcers, and neuropathy, and nursing staff were not to leave a resident on the bedpan for more than 15 minutes, unless they were able to remove the bedpan themselves. Resident #1 was admitted to the Facility in June 2023, diagnoses included right ankle fracture, multiple sclerosis, Parkinson's Disease, and dysphagia. Review of the [NAME] Plus Assessment (used to determine skin integrity risk), dated 06/10/23, indicated Resident #1 was assessed by nursing as being at high risk for the development of pressure injuries. Review of the Skin Check, dated 06/10/23, indicated Resident #1 was at risk for skin breakdown related to immobility and reddened areas to his/her buttocks and coccyx. Review of the Skin Integrity Care Plan, dated 06/10/23, indicated Resident #1 was at risk for skin breakdown related to reddened areas at his/her buttocks and coccyx, and interventions included nursing staff would observe his/her skin condition daily with care and report abnormalities. Review of the Situation, Background, Assessment, Recommendation (SBAR) Note, dated 06/12/23, indicated Resident #1 was left on a bedpan for a prolonged amount of time, (more than one hour), and staff would monitor him/her. Review of the Skin Check, dated 06/12/23, indicated Resident #1 had two small open areas/skin tears in the center of his/her coccyx and under his/her left gluteal fold (later clarified that these were not skin tears, but indentations from the bedpan). Review of Resident #1's medical record indicated there was no documentation to support measurements of Resident #1's wounds were obtained on 06/12/23, or any time before 06/15/23. Review of the Wound Specialist Physician Initial Consultation Note, dated 06/15/23, indicated Resident #1 had a pressure injury on his/her sacrum that measured 0.8 centimeters (cm) in length x 0.5 cm in width x 0.1 cm in depth. During interview on 07/12/23 at 9:51 A.M., Certified Nurse Aide (CNA) #1 said that on 06/12/23 at 3:00 P.M., Resident #1 requested the bedpan, so she and CNA #2 helped him/her onto the bedpan, gave Resident #1 the call bell, alerted CNA #3 that Resident #1 was on the bedpan, and then left the unit, as her shift was over. During interview on 07/13/23 at 2:48 P.M., CNA #2 said that on 06/12/23 at 3:00 P.M., Resident #1 requested the bedpan, so she and CNA #1 helped Resident #1 onto the bedpan, gave him/her the call bell, alerted CNA #3 that he/she was on the bedpan, and left the unit, as her shift was over. During interview on 07/12/23 at 12:05 P.M., CNA #3 said that on 06/12/23 at 4:20 P.M., Resident #1's family member told her that Resident #1 was on a bedpan for a long time. CNA #3 said she was not aware that Resident #1 was on the bedpan until that time. CNA #3 said she removed the bedpan, and noticed a red mark where the bedpan had been, on Resident #1's buttocks. CNA #3 said she told Nurse #1 about Resident #1 being left on the bedpan. During interview on 07/13/23 at 12:23 P.M., Nurse #1 said she was the nurse assigned to Resident #1 on the 7:00 A.M., to 3:00 P.M., and 3:00 P.M., to 11:00 P.M., shifts on 06/12/23. Nurse #1 said that on 06/12/23 at 4:20 P.M., CNA #3 told her that she had taken Resident #1 off the bedpan and that it had been under him/her for an extended period (more than one hour). Nurse #1 said she completed a skin check on Resident #1 and said there was an indent in the shape of a bedpan around his/her buttocks and he/she also had a stage two pressure injury on his/her coccyx which was approximately the size of a quarter. Nurse #1 said she thought the pressure injury looked old and had been there previously. Nurse #1 said she did not measure the pressure injury, did not review previous documentation of Resident #1's skin assessments to determine if this was a new pressure injury, and did not notify Resident #1's physician of her findings. Nurse #1 said that in her documentation she indicated Resident #1 had skin tears under his/her left gluteal fold, however said what she meant by this was there were indentations from the bedpan and not actual open areas under his/her gluteal fold. During interview on 07/12/23 at 1:10 P.M., The Director of Nurses (DON) said the Facility was initially aware that Resident #1 had been left on the bedpan for a period of over one hour, and upon submission of the report to the Department of Public Health, she realized that there was documentation of a pressure injury that had not been identified before the incident. The DON said Nurse #1 should have reviewed Resident #1's previous skin check documentation to determine if the injury was new and should have reported it to Resident #1's physician but did not. The DON said Resident #1's pressure injury was reported to the physician on 06/15/23, three days after it was discovered by nursing, and there was no documentation to support that measurements were obtained before 06/15/23. Review of Resident #1's Treatment Administration Record (TAR) for June 2023, indicated a physician's order was obtained on 06/15/23 for treatment of his/her pressure injury. The order indicated for nursing to cleanse the area with antibacterial wound cleanser, and apply Alginate (antibacterial material) and a foam dressing to the sacral wound, change daily and as needed. The DON said nursing staff should not leave residents on bedpans for more than 15 minutes and said CNAs should report to the oncoming shift and the nurse if they are leaving at the end of their shifts. The DON said Resident #1 should not have been left on a bedpan for over one hour, as this could cause pressure injuries. On 07/12/23, the Facility was found to be in Past Non-Compliance and provided the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A. 06/15/23; The Wound Specialist Physician Initial Consultation Note indicated Resident #1 was referred to the Wound Specialist for assessment and a treatment plan was initiated. B. 06/15/23; A Facility wide audit was performed by the DON and Unit Managers to identify any other resident with skin breakdown to ensure Facility Policies and Protocols were being followed. C. 06/16/23; The Individual Performance Improvement Plan indicated Nurse #1 was re-educated by the Nurse Practice Educator on the Facility's Policy titled, Skin Integrity and Wound Management. D. 06/23/23; Nursing staff were re-educated by the Nurse Practice Educator on the Facility's Protocol titled, Appropriate Bed Pan Usage. E. 06/30/23; Facility Nurses were re-educated by the Nurse Practice Educator on the Facility's Policy titled, Skin Integrity and Wound Management F. 06/22/23; The Ad-Hoc Performance Improvement Plan indicated the Facility developed a plan to correct and prevent the deficient practice. G. 06/30/23; shift change audits of each unit were completed for a period from 06/16/23 through 06/30/23 to determine if any residents were left of the bedpan. Audits were completed by the Unit Managers. H. Ongoing monthly audits will be performed, and the results brought to monthly QAPI for three months, or until substantial compliance is determined I. The DON and/or designee are responsible for ongoing compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), the Facility failed to ensure the resident environment was free from accident hazards, when a staff member served him/her a hot coffee in a cup that was worn out on the bottom and unstable, the cup tipped over, with the hot coffee spilling onto the outer side of Resident #2's left thigh, and he/she sustained a second degree (area often looks wet or moist, affects the first and second layers of skin, blisters may develop and pain may be severe) burn. Findings include: The Facility's policy, titled, Accidents and Incidents, dated as revised on 8/01/16, indicated the Facility would provide a safe and healthful environment for residents, visitors, and employees, and incidents included Facility induced physical injuries, including [CONDITION(S)]. The Facility's Incident Narrative Report, dated 5/31/21, indicated that at 8:10 A.M., Certified Nurse Aide (CNA) #1 placed a hot cup of coffee on the table in front of Resident #2, and the cup tipped over, resulting in hot coffee spilling onto his/her left outer thigh, resulting in a burn. The Incident Narrative Report indicated the cup was found to be worn on the bottom and unstable, which resulted in the coffee spilling. Resident #2 was admitted to the Facility May 2021, diagnoses included dementia and muscle weakness. The Norton Plus Assessment for Resident #2, dated 5/25/21, indicated he/she was chair-bound, and had limited mobility. During interview on 6/16/21 at 1:11 P.M., CNA #1 said that on 5/31/21 at 8:10 A.M., she served Resident #2 a hot cup of coffee, and said when she placed it on the table, the cup tipped over, spilling the hot coffee onto Resident #2's left leg. CNA #1 said Resident #2 cried out when the hot coffee spilled onto him/her. CNA #1 said she immediately notified Nurse #1. During interview on 6/16/21 at 3:21 P.M., Nurse #1 said that on 5/31/21 at 8:10 A.M., CNA #1 told her that hot coffee had spilled onto Resident #2's left leg. Nurse #1 said she immediately assessed Resident #2's left outer thigh and saw a reddened area. Nurse #1 said the reddened area measured approximately 5 centimeters (cm) by 4 cm, and said when she assessed the area again later in the shift, said there were small scattered blisters within the reddened area. Review of Resident #2's medical record indicated there was a Physician's order, dated 5/31/21, for Resident #2 to be treated with [MEDICATION(S)] cream to be applied daily, on the 7:00 A.M. to 3:00 P.M, to treat burn. Review of Resident #2's Activity of Daily Living (ADL) plan of care, updated 6/02/21, indicated to apply treatment to blisters, as ordered, until healed. Review of the Care Plan goals, dated as created and initiated 6/14/21, indicated that Resident #2's blisters would resolve by next review. During interview on 6/17/21 at 10:40 A.M., the Director of Nurses (DON) said that the Facility's internal investigation revealed that the cup Resident #2 was served hot coffee in, was warped on the bottom and made the cup unsteady, which caused it to tip over and spill onto Resident #2's left leg. On 6/17/21, the Facility was found to be in Past Non-Compliance and provided the Surveyor with a plan of correction which addressed the area of concern as evidenced by: 1. The Facility's Audit, dated 6/03/21, indicated the Food Service Director inspected all the hot beverage cups, and discarded all that were distorted at the bottom. 2. The Post Incident Interdisciplinary Team Review, dated 5/31/21, indicated the incident was discussed with the Quality Assurance team. 3. The Education Sign in Sheet, dated 5/31/21, indicated staff were educated to inspect hot beverage cups prior to serving beverages to residents, and to discard any hot beverage cups that are bubbled or distorted. 4. The Director of Nurses and/or Designee, will be responsible for monitoring ongoing compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure he/she was free of medication errors and received medications as ordered by his/her Physician. Resident #1's diuretic medication was omitted during transcription of his/her admission physician's orders [REDACTED].#1 did not receive his/her diuretic medication for four days, for a total of eight missed doses, and as a result he/she was admitted to the hospital for treatment for [REDACTED]. Findings Include: The Hospital Discharge Summary, dated 9/28/17, indicated that Resident #1's was discharged back to the Facility after being admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED].). The Summary indicated that Resident #1's Discharge Medication Orders included [MEDICATION NAME] (a diuretic medication, used to treat heart failure, that rids the body of excess fluid) 80 milligrams (mg) by mouth twice daily and included an order for [REDACTED]. Review of the Facility's Medication Review Report, dated 9/28/17, indicated the medications included on Resident #1's Medication Administration Record, [REDACTED]. Review of Resident #1's Medication Administration Record [REDACTED]. A Progress Note, dated 10/2/17, indicated that Resident #1 was short of breath, his/her Physician was called and orders were obtained to transfer Resident #1 to the Hospital Emergency Department. A Hospital Discharge Summary, dated 10/6/17, indicated that on examination Resident #1 was found to be in fluid volume overload. The Summary indicated there was a discrepancy with a history regarding his/her [MEDICATION NAME] intake, and Resident #1 was treated with [MEDICATION NAME] 80 mg intravenously three times daily. The Summary indicated Resident #1 was admitted to a Cardiac Monitoring Unit with a [DIAGNOSES REDACTED]. The Surveyor interviewed Nurse #1 at 10:41 A.M. on 11/3/17. Nurse #1 said she omitted the order for Resident #1's [MEDICATION NAME] when she transcribed the orders into his/her Medical Record. Nurse #1 said Nurse #2 was responsible for doing the second check for Resident #1's Medication Orders to ensure that the orders she transcribed from Resident #1's Hospital Discharge Medication Orders were correct. The Surveyor interviewed Nurse #2 at 11:57 A.M. on 11/3/17. Nurse #2 said she checked Resident #1's Medication Orders against the Hospital Discharge Summary and said she overlooked the order that was omitted for Resident #1's [MEDICATION NAME]. The Surveyor interviewed the Director of Nursing (DON) at 8:07 A.M. on 11/3/17. The DON said when admission orders [REDACTED]. The DON said a third check is done during the 11:00 P.M. to 7:00 A.M. shift when another nurse reviews all orders received over the prior 24 hour period, however the omission of Resident #1's [MEDICATION NAME] was not discovered during any of the checks.

Based on observations, record review, resident and staff interviews, the facility failed to ensure that 1 of 10 applicable sampled residents with falls (#15) out of a total sample of 22 residents received adequate assistive devices and/or supervision to prevent accidents with injury. Findings include: For Resident #15, the facility did not provide supervision/assistance necessary to prevent unwitnessed bed/bathroom falls which resulted in injury (fractured 5th digit to the right hand, fracture of the right femoral neck, and fracture of the right femoral shaft), from 10/25/15 to 12/24/15. Resident #15 was admitted to the facility in 9/2015 with [DIAGNOSES REDACTED]. Clinical Record review indicated the resident had falls at home prior to admission and sustained peri-orbital bruising and a laceration to the left eye. The resident's care plan for Activities of Daily Living (ADL), dated 9/25/15, indicated the resident required maximum assistance in bathing, grooming, dressing, bed mobility, transfers. locomotion, and toileting due to Parkinson's Disease, with impaired mobility, and a history of falls. The resident's care plan to have no falls with injury, dated 9/24/15, had the following interventions; -Assist resident getting in and out of bed with gait belt assist(ance), stands/pivots to chair. Weight bearing as tolerated for right lower extremity, -and assist resident with ambulation providing assistance using platform walker, gait belt., The resident was assessed as a high risk for falls with a score of 16.0 on 9/28/15. The resident's Admission Minimum Data Set (MDS) Assessment, dated 9/30/15, indicated the resident was alert and oriented with a Brief Interview for Mental Status (BIMS) score of 15/15 points, required extensive assistance of one for bed mobility, transfers, ambulation, dressing, toilet use, grooming and bathing, was unsteady with balance during transitions from seated to standing position, moving, walking, turning around, and surface to surface transfers, used a walker, was occasionally incontinent of bladder, and had fallen prior to admission. Progress Notes and Incident Report/Investigation of 10/25/15 at 9:00 A.M. indicated the resident was assisted to the bathroom for toileting by the Certified Nursing Aide (CNA). The CNA left the resident alone in the bathroom to make up the resident's bed, and heard the resident fall in the bathroom. The resident fell to the right side, sustained a fracture of the proximal phalanx of the 5th digit of the right hand and fracture of the right femoral neck. Staff were reminded and inserviced on 10/25/15 to not leave the resident unattended during toileting in the bathroom. Subsequently record indicate the Resident was admitted to the hospital on [DATE]. Review of Hospital Records indicated the resident was required a right hip cannulation with screw fixation and right wrist splint in the hospital on [DATE]. The resident was assessed as a high risk for falls with a score of 13.0 on 11/2/15. The care plan for falls was updated 11/3/15 to include: -Skilled Physical Therapy, as ordered, -Provide verbal cues for safety and sequencing when needed, -Provide verbal cues for proper pacing and energy conservation techniques, -Place call light within reach at all times, -and maintain a clutter-free room and consistent furniture arrangement. Review of the Significant Change MDS Assessment of 11/26/15 indicated the resident had increased mood issues, required extensive assistance for all ADL needs, had impairment on one side for upper and lower extremity, utilized a wheelchair and walker, was frequently incontinent of bladder, had a fall with a major injury and received antianxiety medication daily. Review of Care Plan Progress Notes, dated 12/3/15, indicated the resident was a max assist for ADLs .use(d) a platform walker for transfers and ambulation .need(ed) assist for toileting. Progress Notes and Incident Report/Investigation of 12/23/15 at 11:30 A.M. indicated the resident was confused and on antibiotics for a UTI. The resident went to a Bible study and was returned to the bedroom by the minister. Alone, the resident attempted to lean forward to remove shoes, and fell to the floor from the wheelchair on the right side. A passerby alerted staff that the resident was on the floor. The wheelchair had rolled back from the resident. The resident sustained [REDACTED]. The falls care plan was updated 12/23/15 to include anti-roll back brakes to the wheelchair. Progress Notes and Incident Report/Investigation of 12/24/15 at 2:30 A.M. indicated the resident had been brought to the bathroom for toileting by a CNA. At 2:50 A.M., the resident called out for help to go to the bathroom again. The CNA put the resident on a bedpan, and left the room and the resident during toileting. At 3:05 A.M., the resident screamed for help and the CNA found the resident on the floor, having fallen out of bed. The resident was sent to the hospital, and sustained a right femoral shaft fracture. The care plan was updated on 12/24/15 to include: -alarming floor mat to the left side of the bed, -anti-skid socks, -bolster/wedge pillow applied to right side of the bed, -and a scoop mattress. Observation on 2/18/16 at 9:30 A.M. revealed the resident seated in a wheelchair at the rosary activity with glasses on, hand tremors, and anti-roll back brakes attached to the wheelchair. During interview on 2/18/16 at 11:45 A.M., Nurses #2 and #5 said that the resident's fall on 10/25/15 was due to a new CNA leaving the resident alone in the bathroom during toilet use, and that staff had been inserviced, and reminded not to leave the resident alone during toileting. On 2/18/16 at 1:00 P.M., the resident was observed seated in the wheelchair next to the resident's bed. An alarmed floor mat was on the floor to the left of the bed. During interview on 2/18/15 at 1:15 P.M., the resident said that he/she had had multiple falls at home, particularly when experiencing confusion. The resident said that he/she used to walk with a quad cane/rolling walker, but now had to be pushed in the wheelchair due to falls in his/her bedroom and bathroom when staff were not present. During interview with the resident's primary daytime assigned CNA on 2/18/16 at 1:30 P.M., CNA #3 said that the resident was alert and oriented with periodic confusion, had tremors, needed extensive assistance for ADLs, was incontinent at times, and had fallen in the past with injury. The CNA said that she did not leave the resident alone when toileted (having been inserviced on 10/25/15.) During interview on 2/18/16 at 2:00 P.M., the Director of Nursing and the Manager of Clinical Operations said that staff should not have left the resident alone when being toileted on 10/25/15 and 12/24/15 as these omissions resulted in unwitnessed injurious falls.

Based on record review and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure Certified Nurse Aide (CNA) #1 followed Resident #1's plan of care. On 1/6/15, CNA #1 did not place a gait belt on Resident #1, which was not consistent with the plan of care when ambulating Resident #1 to the bathroom. Resident #1 lost his/her balance when reaching for the bar on the back of the commode, fell to the floor, and required sutures to a laceration on the back of his/her head. Finding include: The Admission record indicated the staff admitted Resident #1 to the Facility in December 2014 and his/her [DIAGNOSES REDACTED]. The Lift-Transfer-Repositioning Evaluation, dated 12/22/14, indicated Resident #1 required the use of a gait belt for transfer activities and ambulation. The Tinetti Balance Assessment Tool, dated 12/23/14, indicated sitting down was not a smooth motion for Resident #1 and Resident #1 was at a high risk for falls. The Safe Resident Handling/Transfer Equipment Policy, dated 12/18/14, indicated the staff were to use a gait belt with residents who can safely ambulate with assistance and/or perform greater than or equal to 50 percent of lift/transfer with stand pivot assistance with one staff member. The Admission Minimum Data Set (MDS) assessment completed on 12/29/14, indicated Resident #1 had minimal cognitive impairment and a history of falls. The MDS Assessment indicated one staff was required to transfer Resident #1 for toilet use and ambulation with a platform walker. The Surveyor interviewed Certified Nurse Aide (CNA) #2 at 11:00 A.M. on 3/18/15. The Surveyor interviewed CNA #5 at 9:00 A.M. on 3/19/15. CNA #2 said sometimes she did not use the gait belt when transferring Resident #1 to the bathroom and instead placed her hand on Resident #1's back. CNA #5 said when Resident #1 had to use the bathroom, he/she usually sat on the edge of the bed and wanted to use the bathroom quickly. CNA #5 said she did not use a gait belt when assisting Resident #1 to ambulate to the bathroom to receive personal care or use the toilet. The Surveyor interviewed CNA #1 at 12:50 P.M. on 3/18/15. CNA #1 said prior to 1/6/15, she observed other CNAs assist Resident #1 to the bathroom without a gait belt. CNA #1 said on 1/6/15, at approximately 6:45 A.M., Resident #1 wanted to use the bathroom. CNA #1 said that in error, she did not check the sticker on Resident #1's door that indicated Resident #1 required the use of a gait belt. CNA #1 said she did not place a gait belt on Resident #1. CNA #1 said she remained behind Resident #1, slightly to the side as Resident #1 walked to the bathroom using the platform walker. CNA #1 said when Resident #1 was in front of the toilet, he/she used his/her right hand to reach for the bar in back of the commode over the toilet. CNA #1 said she did not have her hands on Resident #1 or the commode. CNA #1 said as Resident #1 reached for the bar, the commode moved. CNA #1 said Resident #1 lost his/her balance and fell backward. CNA #1 said she was not able to prevent Resident #1's fall or ease Resident #1 to the floor. The nurse's note, dated 1/6/15, indicated the CNA reported she assisted Resident #1 to the bathroom with a walker; Resident #1 attempted to reach for the commode handle in the bathroom, and fell . The nurse's note indicated the CNA witnessed Resident #1's fall and was not able to keep Resident #1 from falling. The nurse's note indicated Resident #1 had a laceration on his/her head. The nurse's note indicated the staff transferred Resident #1 to the Emergency Department (ED). The Surveyor interviewed the Director of Nurses (DON) at 9:00 A.M. on 3/18/15. The DON said CNA #1 did not follow Resident #1's Plan of Care. The ED documentation, dated 1/6/15, indicated Resident #1 received four sutures to a laceration, which measured 1.5 centimeters (cm) on the posterior scalp.

Based on record review and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure Certified Nurse Aide (CNA) #1 followed Resident #1's plan of care and followed the Facility's Safe Resident Handling/Transfer Equipment Policy. On 1/6/15, CNA #1 did not place a gait belt on Resident #1, which was not consistent with the plan of care when ambulating Resident #1 to the bathroom. CNA #1 did not have her hands on Resident #1 in the bathroom; Resident #1 lost his/her balance when reaching for the bar on the back of the commode, fell to the floor, and required sutures to a laceration on the back of his/her head. Finding include: The Hospital Emergency Department (ED) Physician report, dated 12/22/14, indicated Resident #1 sustained a fall at his/her previous dwelling. The ED Physician report indicated Resident #1 had osteopenia with a right wrist fracture. The ED Physician report indicated Resident #1's dominant hand was his/her right hand. The Admission record indicated the staff admitted Resident #1 to the Facility in December 2014 and his/her [DIAGNOSES REDACTED]. The Lift-Transfer-Repositioning Evaluation, dated 12/22/14, indicated Resident #1 required the use of a gait belt for transfer activities and ambulation. The Tinetti Balance Assessment Tool, dated 12/23/14, indicated sitting down was not a smooth motion for Resident #1 and Resident #1 was at a high risk for falls. The Safe Resident Handling/Transfer Equipment Policy, dated 12/18/14, indicated the staff were to use a gait belt with residents who can safely ambulate with assistance and/or perform greater than or equal to 50 percent of lift/transfer with stand pivot assistance with one staff member. The Surveyor interviewed CNA #1 at 12:50 P.M. on 3/18/15. The Surveyor interviewed CNA #2 at 11:00 A.M. on 3/18/15. The Surveyor interviewed CNA #3 at 11:30 A.M. on 3/18/15. The Surveyor interviewed CNA #4 at 2:30 P.M. on 3/18/15. The Surveyor interviewed CNA #5 at 9:00 A.M. on 3/19/15. CNA #1, CNA #2, CNA #3, CNA #4, and CNA #5 said they were to use gait belts on residents who were able to weight bear and required supervision and/or assistance with transfer activities and/or walking. CNA #1, CNA #2, CNA #3, CNA #4, and CNA #5 said there was a sticker next to each resident's name at the entrance to their door, that noted whether a resident required the use of a gait belt for transfer/ambulation. CNA #1, CNA #2, CNA #3, CNA #4, and CNA #5 said that sometimes when they were transferred a resident from the bed to walk to the bathroom in their room, they did not use a gait belt for residents, who required a gait belt. The Admission Minimum Data Set (MDS) assessment completed on 12/29/14, indicated Resident #1 had minimal cognitive impairment and a history of falls. The MDS Assessment indicated one staff was required to transfer Resident #1 for toilet use and ambulation with a platform walker. The Surveyor interviewed Physical Therapist #1 at 12:20 P.M. on 3/18/15. Physical Therapist #1 said Resident #1 used a platform walker related to his/her right wrist fracture. Physical Therapist #1 said Resident #1 ambulated with the platform walker without difficulty and had some difficulty with the platform walker when turning. Physical Therapist #1 said using the gait belt gave Resident #1 a sense of steadiness and allowed the staff to assist Resident #1 when turning in the bathroom or toward a chair or bed. CNA #2 and CNA #3 said Resident #1 had a cast on his/her right arm and was not able to use the grab bar on the wall near the toilet, which was on Resident #1's right side. CNA #2 and CNA #3 said after they assisted Resident #1 to turn in the bathroom, Resident #1 reached with his/her left hand onto the bar on the commode over the toilet and sat on the toilet. CNA #2 and CNA #3 said they held the commode to prevent the commode from moving while Resident #1 sat on the commode. CNA #2 said sometimes she did not use the gait belt when transferring Resident #1 to the bathroom and placed her hand on Resident #1's back. CNA #3 said she did not always check the sticker outside a resident's room to determine the amount of assistance and the type of support a resident required, such as the use of a gait belt. CNA #5 said when Resident #1 had to use the bathroom, he/she usually sat on the edge of the bed and wanted to use the bathroom quickly. CNA #5 said she did not use a gait belt when assisting Resident #1 to ambulate to the bathroom to receive personal care or use the toilet. CNA #1 said prior to 1/6/15, she observed other CNAs assist Resident #1 to the bathroom without a gait belt. CNA #1 said on 1/6/15, at approximately 6:45 A.M., Resident #1 wanted to use the bathroom and receive personal care. CNA #1 said that in error, she did not check the sticker on Resident #1's door that indicated Resident required the use of a gait belt. CNA #1 said she did not place a gait belt on Resident #1. CNA #1 said she remained behind Resident #1, slightly to the side as Resident #1 walked to the bathroom using the platform walker. CNA #1 said when Resident #1 was in front of the toilet, he/she used his/her right hand to reach for the bar in back of the commode over the toilet. CNA #1 said she did not have her hand on Resident #1 or the commode. CNA #1 said as Resident #1 reached for the bar, the commode moved. CNA #1 said Resident #1 lost his/her balance and fell backward. CNA #1 said she was not able to prevent Resident #1's fall or ease Resident #1 to the floor. The nurse's note, dated 1/6/15, indicated the CNA reported she assisted Resident #1 to the bathroom with a walker; Resident #1 attempted to reach for the commode handle in the bathroom, and fell . The nurse's note indicated the CNA witnessed Resident #1's fall and was not able to keep Resident #1 from falling. The nurse's note indicated Resident #1 had a laceration on his/her head. The nurse's note indicated the staff transferred Resident #1 to the Emergency Department (ED). The Surveyor interviewed the Director of Nurses (DON) at 9:00 A.M. on 3/18/15. The DON said CNA #1 did not look at the sticker on Resident #1's door, which indicated he/she required the use of a gait belt. The DON said CNA #1 did not follow the Safe Resident Handling/Transfer Equipment Policy and Resident #1's Plan of Care. The ED documentation, dated 1/6/15, indicated Resident #1 received four sutures to a laceration, which measured 1.5 centimeters (cm) on the posterior scalp.

Based on interviews and record review, the facility failed for 1 of 4 residents (Resident #2) to notify the physician of the wound specialist physician's 9/25/13 recommendation for wound care needs. On 9/28/13, staff found a wound to the resident's right lower leg that was 15 centimeters by 10 centimeters (cm) with red, beefy tissue and infested by maggots. Findings include: For Resident #2, the facility failed to notify the physician of the recommendations made by the wound specialist physician on 9/25/13 to change the resident's treatment program concerning an open, moist, weepy area to the resident's right lower leg. Resident #2 was admitted to the facility in July 2012 with [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) assessment, dated 9/28/13, indicated Resident #2 was cognitively intact, required extensive assistance with bed mobility, ambulation, transfers and had two stage two pressure ulcers. Documentation on the Wound Care Specialist Evaluation, dated 9/25/13, indicated Resident #2 was noted to have a right lymphademic wound of the right leg, which measured 4 centimeters (cm) by 2 cm, with a surface area of 8 cm. The evaluation indicated the drainage was light serous drainage (did not indicate symptoms of infection) with 100% granulation (new tissue development) tissue. The physician wound specialist indicated that the dressing to the lymphademic wound was to be a foam dressing and changed daily. The physician wound specialist also indicated that the resident's legs are to be elevated and the wound offloaded (no pressure). The evaluation indicated Resident #2's leg was to be covered with [MEDICATION NAME] (soft cotton fabric used to protect fragile skin). Review of the physician orders, dated 9/25/13, indicated no documentation to indicate the recommendations regarding the specialist's evaluation were communicated to Resident #2's physician. The orders indicated there was no order to apply a foam dressing to Resident #2's lower extremities. Review of the facility's agreement with the Wound Care Physician group, dated 5/13/10, indicated the following: * Provide a dedicated nurse to round with the wound care clinician assigned by provider. * Inform primary care provider within 24 hours of clinician's recommendations. During interview with on 10/8/13 at 3:00 P.M., Unit Manager #1 (UM #1) said that the wound doctor comes in every Wednesday. She said that on occasion she will see him, but sometimes she does not as he often sees residents by himself. On this occasion, she said she was told by other staff that he had come in. UM#1 said that she usually will go to the computer and print out his recommendations on Wednesday afternoon. She would then call the primary care physician and obtain new orders for what the wound doctor recommended. She said that because she was so busy that day (9/25/13), she did not have time to print them out. She said she didn't print them out until Friday evening (9/27/13) around 5:00 P.M. She said she didn't look at what she had printed as she was just getting them ready for a meeting that was to be held the following week. She said as of Friday evening she did not know what the wound doctor's recommendations were. She said there was no change in the treatment plan for Resident #2 until 9/28/13, when the maggots were found in the area of the wound. During interview on 10/8/13 at 2:15 P.M., Nurse #1 said that she doesn't usually work that side (where Resident #2 resides), but did that day. She knew the wound specialist doctor was in, but because he is so quick, she was not sure what residents he saw. She said staff don't make any changes in the resident's treatment plan until staff see the wound doctor's written report. She said she knew that UM #1 would be getting the wound doctor's reports from the computer and then UM#1 notify's the primary care physician for new treatment orders when needed. The Facility failed to notify the physician of the recommendations by the physician wound specialist on 9/25/13 to change Resident #2's treatment program concerning the lymphademic wounds. On 9/28/13, Resident #2's wound was assessed as having worsened from the 9/25/13 evaluation, to a wound which was red in color, beefy, measured 15 cm x 10 cm in size, and was infested with maggots.

Based on record review and staff interview, the facility failed to provide services which meet professional standards of quality for treatment administration of 1 Resident (#2) out of 4 sampled residents. Findings include: Standard reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and Practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered nurse and practical nurse incorporate into the plan of care, and implement prescribed medical regimens. The rules and regulations 9.03 define standards of Conduct for Nurses where it is stipulated that a "nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice". For Resident #2, the Facility failed to ensure that the weekly skin check/assessment and nightly application of house lotion with skin monitoring was completed as ordered by the physician. On 9/28/13, the resident was found to have a beefy, red 15 centimeter by 10 centimeter wound that was infested with maggots. Resident #2 was admitted to the facility in July 2012 with [DIAGNOSES REDACTED]. Review of the Physician orders [REDACTED]. * Weekly skin check on Saturday 11-7 shift * House Lotion to bilateral feet and lower extremities at bedtime (monitor skin) A. Review of the Treatment Administration Record (TAR), dated September 2013, indicated an order to perform a weekly skin assessment on Saturdays, during the 11 P.M. -7:00 A.M. shift. Staff are expected to code as follows: 1= no area or injury 2=new area or injury 3=previous noted area or injury On 9/28/13, the TAR was initialed by a licensed nurse as having completed the skin assessment. The code which was documented was "3" (previous noted area or injury) There was no corresponding narrative note on the reverse page of the TAR to determine what the assessment revealed. During interview on 10/8/13 at 10:00 A.M., Nurse #2 said that although she initialed the TAR for 9/28/13, she did not complete the skin assessment as ordered. She said that she knew Resident #2 had an open area on her/his buttocks, and that was why she wrote the "#3" on the TAR. She said that Resident #2 always asks me to come back, she/he is not easy do move at nighttime. The Surveyor asked Nurse #2 if she reported this to her supervisor. and she said "No, I haven't". Nurse #2 said she could see a dressing underneath the [MEDICATION NAME]. She also said she saw dried blood on the [MEDICATION NAME] located at the tip of Resident #2's right toe and detected a terrible odor in the room. She said she thought the odor was body odor and she left a note for the next shift to bathe Resident #2. B. A Review of the Treatment Administration Record (TAR), dated September 2013, indicated an order to apply house lotion to bilateral feet and lower extremities at bedtime (monitor skin). On 9/26/13 and 9/27/13 Nurse #3 initialed the TAR to indicate that the treatment had been completed. There was no corresponding narrative note on the reverse page of the TAR to indicated Nurse #3's findings. During interview on 10/4/13 at 11:05 A.M., Nurse #3 said that on the night of 9/27/13 she went in and looked at Resident #2's legs from a distance. She said she saw the [MEDICATION NAME] and noticed a dressing of some type under the [MEDICATION NAME]. She said she was very busy and did not actually take down the [MEDICATION NAME] and assess Resident #2's lower extremities. She continued to say she did not apply the house lotion to Resident #2's lower extremities as ordered by the physician. She said she knew she initialed it, but she didn't do a narrative note, because she didn't actually do the treatment. During a subsequent interview with Nurse #3 on 10/9/13 at 1:20 P.M., the surveyor asked if she had performed the treatment to Resident #2's legs as ordered on [DATE], she said "I worked that night?, I can't recall". Once she realized that she did work that evening, she said she really could not recall if she did the treatment or not.

Based on observation, record review and interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practible physical, mental, and psychosocial well-being for 1 resident (#2) in a sample of 4 residents. For Resident #2, the facility failed to assess and treat a right lower leg wound which developed into a beefy red, 15 centimeter (cm) by 10 cm wound, with an infestation of maggots. Findings include: Resident #2 was admitted to the facility in July 2012 with [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) assessment, dated 9/28/13, indicated that Resident #2 was cognitively intact, required extensive assistance with bed mobility, ambulation, transfers and had two stage two pressure ulcers. Review of an incident report, dated 9/28/13, 10:00 A.M., indicated the following: "Upon removal of [MEDICATION NAME] (soft cotton fabric, that protects fragile skin) socks for a whirlpool bath, there were maggots noted to the resident's right lower extremity, with red granulated tissue, with a large amount of serous drainage, with odor. Wound area was 10 cm by 15 cm". During interview on 10/8/13 at 8:45 A.M., the Director of Nursing (DON) said that Resident #2 has chronic [MEDICAL CONDITION] and dry flaky skin to her/his lower extremities. She said that his/her skin often opens and becomes weepy from fluid, but heals up quickly. The DON said that when staff removed Resident #2's [MEDICATION NAME] socks from Resident #2's right leg on 9/28/13, they also found an undated foam dressing. The DON said she was in the process of investigating this incident, but as of this date, no nurse has claimed responsibility for applying the dressing or how long the dressing was on Resident #2's right leg. She said that there was not a physician's order for the dressing. The DON said the resident is followed by the wound doctor and is seen almost weekly. The Wound Care Specialist Evaluation form, dated 9/25/13, indicated that the resident had the following: For Resident #2's Right Leg: Lymphademic wound of the right leg. Wound size is 4 cm by 2 cm. The surface area is 8 cm. The exudate (drainage) is light serous (clear fluid) with 100% granulation (new tissue development) tissue. The physician wound specialist recommended that the dressing to the lymphademic wound was to be a foam dressing and changed daily. The physician wound specialist also indicated that the resident's legs are to be elevated and the wound offloaded. He indicated that the resident's leg then be covered with [MEDICATION NAME]. For Resident #2's Left leg: Lymphademic wound of the left leg. Wound size is 2 cm by 2 cm. The surface area is 4 cm. The physician wound specialist indicated that the dressing to the lymphademic wound was to be a foam dressing and changed daily. The physician wound specialist also recommended that the resident's legs are to be elevated and the wound offloaded. He indicated that the resident's leg then be covered with [MEDICATION NAME] Review of the physician orders, dated 9/25/13 through 9/28/13, indicated that there was no order to apply a foam dressing to Resident #2's lower extremities. Treatment observation on 10/8/13 at 10:35 A.M., revealed Resident #2's lower right leg to have an approximately 8 cm by 6 cm area of pink tissue, there was no depth to the area. The surrounding skin was dry, scaly and flaky, not inflamed. There was a pinpoint open moist area located at the left lower corner of the pink tissue. Nurse #7 said the wound was greatly improved with the current treatment plan. During interview on 10/8/13 at 12:50 P.M., Certified Nursing Assistant (CNA) #1 said that on 9/26/13 she was assigned to care for Resident #2. She said that she bathed Resident #2 and noticed an odor that seemed to be coming from his/her right leg. She said she noticed the [MEDICATION NAME] sock seemed to be sticking to the resident's leg. "I have never smelled anything like that before". CNA #1 said she reported her findings to Nurse #4. During interview on 10/8/13 at 2:30 P.M., Nurse #4 said that on 9/26/13 she was floated to the B unit for the 7:00 A.M. -3:00 P.M. shift. She said she doesn't work that unit very often and that the CNA's are always coming to tell her things about the residents. She said that CNA#1 may have come to her, but she couldn't recall the specifics of a conversation. She said she noticed an odor in Resident #2's room, but thought it was from her urinary catheter. Nurse #4 said that she did check both of the resident's legs and found them to be dry and scaly, not weepy. She said she pulled the [MEDICATION NAME] down to Resident #2's ankles, which were swollen. She said she did not take them off completely and that the [MEDICATION NAME] came down with ease. She did say that the [MEDICATION NAME] had dried yellow spots on them, but she did not change them. Nurse #4 does not recall a dressing on Resident #2's right leg. During interview on 10/8/13 at 3:00 P.M., Unit Manager (UM) #1 said that she cared for Resident #2 on 9/27/13 during the 7:00 A.M.- 3:00 P.M. shift. She said it was very busy and just a "bad" morning. She said she went into Resident #2's room and pulled down the [MEDICATION NAME] socks just to check her legs. She said she did not take them off completely because she was rushed. She couldn't see anything weepy or draining and couldn't tell if there was or wasn't a dressing on either leg. During interview on 10/4/13 at 11:05 A.M., Nurse #3 said that during the 3:00 P.M. - 11:00 P.M. shift on 9/27/13, she went in and looked at Resident #2's legs from a distance. She said she saw the [MEDICATION NAME] on both legs and noticed a dressing of some type under the [MEDICATION NAME] on the right leg. She said she was very busy and did not actually take down the [MEDICATION NAME] and assess Resident #2's lower extremities. She continued to say she did not apply the house lotion to Resident #2's lower extremities as ordered by the physician. She said she knew she initialed it on the treatment administration record, but she didn't do a narrative note, because she didn't actually do the treatment. During a subsequent interview with Nurse #3 on 10/9/13 at 1:20 P.M., the Surveyor asked if she had performed the treatment to the resident's legs as ordered on [DATE], she said "I worked that night?, I can't recall" or words to that effect. Once she realized that she did work that evening, she said she really could not recall if she did the treatment or not, but she said she must have. During interview on 10/8/13 at 3:45 P.M, CNA #2 said she cared for Resident #2 during the 3:00 P.M.- 7:00 A.M. shift on 9/27/13. She said she responded to the resident's call light at supper time. She said she could smell something then, but Resident #2 wasn't on her assignment so she did not report the smell to anyone. She said she entered Resident #2's room again at 4:30 A.M. and could smell the odor again. CNA#2 said she reported it to Nurse #2. CNA #2 said Nurse #2 went into Resident #2's room and said Resident #2 needed a shower. During interview on 10/8/13 at 10:00 A.M., Nurse #2 said she worked the 11:00 P.M.-7:00 A.M. shift on 9/27/13. She said that CNA #2 came to her and asked her to go into Resident #2's room. Nurse #2 said she could see a dressing underneath the [MEDICATION NAME] on the right leg. She also said she saw dried blood on the [MEDICATION NAME] located at the tip of Resident #2's right toe and detected a terrible odor in the room. She said she thought the odor was body odor and she left a note for the next shift to bathe Resident #2. Although there was a physician's order to complete a skin assessment during her shift, Nurse #2 said the resident always asks us to come back and she/he is not easy to move. Nurse #2 said she did not assess Resident #2's legs even though she initialed the Treatment Administration Sheet, which would indicate it had been done. During interview on 10/8/13 at 1:20 P.M., CNA #3 said he cared for Resident #2 on 9/27/13 during the 7:00 A.M. -3:00 P.M. shift. He said he noticed a "stench" down near Resident #2's room. He said he wasn't sure where it was coming from and asked maintenance to look into it. CNA #3 said that Resident #2 refused to get washed up that morning, so he just helped her/him wash his/her face and changed his/her nightclothes. CNA #3 continued to say that he noticed the [MEDICATION NAME] sock on Resident #2's right lower leg had some sort of brown drainage on it. He said it was about the size of a quarter. He said he informed a nurse, but couldn't remember which one it was. CNA # 3 said he also cared for Resident #2 on 9/28/13 during the 7:00 A.M.-3:00 P. M. shift. He said Resident #2's complained of throbbing legs and he told Nurse #5. He said Nurse #5 said a whirlpool tub might help. CNA #3 said that the drainage on the right leg [MEDICATION NAME] sock had increased from the day before. It was more like a half dollar size. He said the smell was still there. Once in the whirlpool room, CNA #3 began pulling down Resident #2's [MEDICATION NAME] socks on the right leg and quickly noticed an untaped dressing of some type and saw something moving. He said when he looked closer he thought it was maggots. He said he thought there were at least 100 of them. He said he then pulled the [MEDICATION NAME] sock back up and reported it to Nurse #5. During interview on 10/9/13 at 2:15 P.M., Nurse #5 said that on 9/28/13 at approximately 10:00 A.M., CNA #3 came to her and said that Resident #2's room smells horrible. When Nurse #5 entered Resident #2's room, she concurred that the room smelled. She thought Resident #2 needed a shower. She said she did notice that the [MEDICATION NAME] on the right leg had some drainage on it, but would assess Resident #2 in the whirlpool room. Nurse #5 said that after CNA #3 told her what he saw, she went to the whirlpool room, began taking down the [MEDICATION NAME] sock on the right leg, and found an undated foam dressing (which had no physician order), located near Resident #2's shin, as well as live maggots. She lifted the [MEDICATION NAME] sock back up and she called for assistance from the manager on duty. The manager on duty was a nurse and she cleansed the right leg while Nurse #5 called the nurse practitioner and the family. Once the wound was cleansed it looked red and superficial. She said it was like the brown scaly skin had been lifted off. The Nurse Practitioner was notified and Resident #2's was started on an antibiotic. During interview on 10/8/13 at 3:20 P.M., Nurse #6 said that on 9/28/13 she was the manager on duty. She said that after breakfast, Nurse # 5 asked her to come to the whirlpool room to assess Resident #2's right leg. Nurse #6 said as she walked into the whirlpool room, she detected a strong odor. She continued to say that Resident #2 had [MEDICATION NAME] on both legs, but that the right leg [MEDICATION NAME] was saturated with brown drainage and it had a strong odor. As Nurse #6 pulled down the [MEDICATION NAME] from the right leg, a [MEDICATION NAME] dressing, saturated with brown drainage, fell off Resident #2's right leg (around the shin area), as well as several maggots. She estimated that there were between 100-150 live maggots on the resident's lower right leg. Nurse #6 said she then cleaned the area with warm water and soap. Once the area was clean she said you could better see a 15 cm by 10 cm red, beefy wound. She said she cleansed the wound in such a way as not to alarm Resident #2'. She said that Resident #2's would not want to know about having maggots on her/his leg wound.