Every finding on record at Park Avenue Health Center

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required the use of a mechanical lift with transfers, the Facility failed to ensure his/her safety was maintained during a mechanical lift transfer to prevent an incident/accident resulting in serious injury. On [DATE], during a transfer the mechanical lift stopped functioning with Resident #1 suspended up in the air in lift sling, staff tried to physically move the mechanical lift to position him/her over the bed, Resident #1's body began to sway in the lift sling, and his/her head struck the bedrail. Resident #1 sustained a head laceration, was transferred to the Hospital Emergency Department for evaluation and he/she required five staples to close the wound. Findings include:The Facility Policy, titled Safe Lifting and Movement of Residents, dated as revised [DATE], indicated staff responsible for direct resident care would be trained in the use of mechanical lift devices, and only staff with documented training on the safe use and care of the machines and equipment used in the Facility would be allowed lift or move residents.A Mechanical Lift is a device that allows caregivers to safely transfer an individual between a bed, wheelchair, shower chair, or another surface. A sling lift is comprised of a base on casters, a boom, and a cradle that supports the sling.The Facility Policy, titled Using a Mechanical Lifting Machine, dated as revised [DATE], indicated staff would ensure that the lift's battery was charged and ensure the emergency release feature was functioning prior to initiating a lift transfer.Review of the Owner's Manual for the F550 Floor Lift, dated as revised [DATE], indicated the Mechanical Lift was equipped with an emergency lowering system which could be used to safely lower the resident in the event of a power failure.Review of the Report submitted by the Facility via the Health Care Facilities Reporting System (HCFRS), dated [DATE], indicated that during a mechanical lift transfer, the mechanical lift malfunctioned, resulting in Resident #1's head striking the bedrail and him/her sustaining a laceration.Review of Resident #1's Emergency Department Hospital Discharge summary, dated [DATE], indicated he/she was diagnosed with a scalp laceration and required five staples to close the wound.Review of Resident #1's Nurse Progress Note, dated [DATE], indicated he/she returned from the Hospital Emergency Department to the Facility and had received five staples to the laceration on his/her head.Resident #1 was admitted to the Facility in [DATE], diagnoses included progressive multiple sclerosis (an autoimmune disease that affects the central nervous system, leading to damage of the myelin sheath that protects nerve fibers, resulting in a range of physical and cognitive symptoms).During a telephone interview on [DATE] at 3:33 P.M., Certified Nurse Aide (CNA) #1 said that on [DATE] at 05:30 P.M. she and CNA #2 were transferring Resident #1 from his/her reclining wheelchair to his/her bed using the mechanical lift device. CNA #1 said once Resident #1 was suspended above the reclining wheelchair, the mechanical lift stopped working.CNA #1 said she then attempted to physically move the lift to position Resident #1 over his/her bed, but she was unable to close the legs of the lift, because the battery was dead. CNA #1 said as she moved the lift with Resident #1 suspended up in the air over the bed, the open legs of the lift prevented good alignment with the bed. CNA #1 said Resident #1 was unable to hold up his/her own head, which was hanging downward in the sling, and as the sling moved, his/her head struck the bedrail on the right side of his/her head during the transfer and he/she began bleeding.CNA #1 said she was not aware that there was an emergency release system on the mechanical lift, and said she would have used it and lowered Resident #1 back into his/her chair safely when the battery died on the lift.During a telephone interview on [DATE] at 10:40 A.M., CNA #2 said that on [DATE] at 5:30 P.M. she was assisting CNA #1 transfer Resident #1 from his/her wheelchair to his/her bed when, in the middle of the transfer, the lift's battery died with Resident #1 suspended up in the air.CNA #2 said she moved the wheelchair out of the way while CNA #1 attempted to move the mechanical lift and Resident #1, who was suspended up in the lift sling by the bed, and during that movement, Resident #1's head struck the bedrail and began to bleed. CNA #2 said she worked at the Facility through a staffing agency, and although she had experience using mechanical lifts, she had not had any training by this Facility on the use of mechanical lifts. CNA #2 said she did not think to look for an emergency release on the lift to safely lower Resident #1 back into his/her wheelchair.During an interview on [DATE] at 3:17 P.M., Nurse #1 said that on [DATE] at 5:30 P.M. he was called to Resident #1's room by CNA #2. Nurse #1 said he immediately went to Resident #1's room and observed that he/she was suspended over his/her bed in the mechanical lift sling and was bleeding from the back of his/her head. Nurse #1 said he applied pressure to the wound while Nurse #2 called 911, and Resident #1 was transferred to the Hospital Emergency Department. Nurse #2 said, prior to Emergency Medical Services (EMS) arriving, CNA #1 and CNA #2 somehow lowered Resident #1 down onto his/her bed but said he was not sure how they did it.During an interview on [DATE] at 09:17 A.M., The Staff Development Coordinator (SDC) said she was unable to provide any documentation to support CNA #1 and CNA #2 were trained on the use of the mechanical lift. On [DATE] at 09:20 A.M. The SDC and the Surveyor observed the Mechanical Lift together on the unit. The SDC said she was not aware that the mechanical lift had an emergency release lever on the piston which lowered the boom (where the sling straps are hooked to and connected to the lift) in the event of a power failure.During an interview on [DATE] at 08:05 A.M., the Director of Nurses (DON) said there should have been documented competencies for all staff for the use of the mechanical lift prior to use of the lift. The DON said she did not know if instructions related to the mechanical lifts emergency release system was part of the education provided to staff for use of the mechanical lift. The DON said staff should have used the emergency release to safely lower Resident #1 back down into his/her wheelchair when the battery died.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who per staff interviews has always been transferred via two person assist with the use of a mechanical lift, the Facility failed to ensure his/her comprehensive person-based plan of care related to transfer status indicated his/her dependence on the use of a mechanical lift device, that included interventions, goals and outcomes.Findings include:The Facility Policy, titled Comprehensive Person-Centered Care Plans, dated as revised in March 2022, indicated the comprehensive person based care plan would describe the services that were to be furnished to the resident.The Facility Policy, titled Safe Lifting and Movement of Residents, dated as revised July 2017, indicated nursing staff would document resident transferring and lifting needs in the care plan.Resident #1 was admitted to the Facility in March 2023, diagnoses included progressive multiple sclerosis (an autoimmune disease that affects the central nervous system, leading to damage of the myelin sheath that protects nerve fibers, resulting in a range of physical and cognitive symptoms).Review of Resident #1's Activities of Daily Living (ADL) Care Plan, dated as reviewed and revised with his/her Quarterly Minimum Data Set (MDS) assessment, dated 06/04/26, indicated he/she was dependent for and required assistance for all transfers.Further review of Resident #1's ADL Care Plan indicated there was no documentation to support that he/she required two staff members assistance and the use of the mechanical lift for all transfers.During a telephone interview on 06/22/26 at 3:33 P.M., Certified Nurse Aide (CNA) #1 said Resident #1 was always transferred using the mechanical lift and two staff members to assist.During a telephone interview on 06/22/26 at 10:40 A.M., CNA #2 said Resident #1 was always transferred using the mechanical lift and two staff members to assist.During an interview on 06/22/26 at 3:17 P.M., Nurse #1 said Resident #1 was always transferred using the mechanical lift and two staff members to assist.During an interview on 06/22/26 at 11:41 A.M., Nurse #2 said Resident #1 was always transferred using the mechanical lift and two staff members to assist.During an interview on 06/22/26 at 08:05 A.M., The Director of Nurses (DON) said Resident #1's ADL Care Plan should have included details of his/her transfer status including the use of the mechanical lift and number of staff required for transfers but did not.

Based on observation, record review, and interview the facility failed to maintain accurate medical records for three residents (#35, #5 and #69), out of a total sample of 18 residents. Specifically,1. For Resident #35 the facility failed to ensure Certified Nursing Assistants (CNAs), accurately documented a. wandering and b. walking on his/her activities of daily living (ADLs) flow sheets. 2. For Resident #5, the facility failed to ensure CNAs, accurately documented wandering on his/her ADLs flow sheets. 3. For Resident #69 the facility failed to ensure CNAs, accurately documented his/her wandering behaviors, resulting in the development of an inaccurate Minimum Data Set (MDS) assessment. Findings include: Review of the facility's policy titled, Charting Errors and/or Omissions, dated as revised December 2006, indicated that accurate medical records shall be maintained by this facility. 1. Resident #35 was admitted to the facility in April 2025 with diagnoses including major depression, anxiety, and failure to thrive. Review of the most recent Minimum Data Set assessment, dated 10/16/25, indicated Resident #35 was cognitively intact as evidenced of a Brief Interview of Mental Status exam score of 15 out of 15. This MDS indicated that Resident #35 did not have any behaviors, did not reject care, and required assistance with activities of daily living. a. On 12/1/25 at 7:54 A.M., the surveyor observed Resident #35 in bed. Resident #35 said he/she does not walk and has not walked for a while and uses a wheelchair if he/she needs to go places. Review of Resident #35's Documentation Survey Report V2 (ADL sheets), indicated that CNAs documented Resident #35 wandered the following: September 2025: 1 shift. October 2025: 6 shifts. November 2025: 1 shift. During an interview on 12/2/25 at 3:13 P.M., CNA #3 said she is familiar with Resident #35 and said that he/she does not wander. CNA #3 said she must have coded the wandering on the ADL sheets incorrectly. During an interview on 12/3/25 at 8:21 A.M. CNA #4 said she is familiar with Resident #35 and said that he/she does not wander. CNA #4 said she must have coded the wandering on the ADL sheets incorrectly. During an interview on 12/3/25 at 8:25 A.M., Nurse #2 said that she is familiar with Resident #35 and he/she doesn't wander and never has wandered. During an interview on 12/3/25 at 9:05 A.M., the Director of Nursing (DON) said CNAs should code ADL documentation correctly. b. On 12/1/25 at 7:54 A.M., the surveyor observed Resident #35 in bed. Resident #35 said he/she does not walk and has not walked for a while. Review of Resident #35's Documentation Survey Report V2, indicated CNAs documented Resident #35 walked the following: - September 2025: 19 shifts walked 10 feet; 19 shifts walked 150 ft with 2 turns; 15 shifts walked 50 feet with 2 turns. - October 2025: 22 shifts walked 10 feet; 25 shifts walked 150 ft 2 turns; 22 shifts walked 50 feet with 2 turns. - November 2025: 23 shifts walked 10 feet; 26 shifts walked 150 feet with 2 turns; 25 shifts walked 50 feet with 2 turns. During an interview on 12/2/25 at 3:14 P.M., CNA #3 said she is familiar with Resident #35 and said that he/she does not walk. CNA #3 said she must have coded the walking on the ADL sheets incorrectly. During an interview on 12/3/25 at 8:22 A.M. CNA #4 said she is familiar with Resident #35 and said that he/she does not walk. CNA #4 said she must have coded the walking on the ADL sheets incorrectly. During an interview on 12/3/25 at 8:26 A.M., Nurse #2 said that she is familiar with Resident #35 and he/she doesn't walk. During an interview on 12/3/25 at 9:38 A.M., the Director of Rehabilitation said that she had worked with Resident #35 for therapy and he/she has never walked. During an interview on 12/3/25 at 9:06 A.M., the Director of Nursing (DON) said CNAs should code ADL documentation correctly. 2. Resident #5 was admitted to the facility with diagnoses including Huntington's disease, anxiety, and apraxia. Review of Resident #5's Minimum Date Set assessment, dated 10/16/25, indicated he/she was rarely/never understood, experienced wandering 1-3 days, and was dependent on staff for activities of daily living. On 12/1/25 at 11:51 A.M. and at 4:25 P.M., the surveyor observed Resident #5 reclined in a tilted chair utilizing a seatbelt to restrict his/her movement. Review of Resident #5's Documentation Survey Report V2, CNAs documented he/she wandered the following: - September 2025: 12 shifts. - October 2025: 10 shifts. - November 2025: 5 shifts. During an interview on 12/2/25 at 3:25 P.M., CNA #3 said that she is familiar with Resident #5 and he/she does not wander, and he/she uses a seatbelt to prevent him/herself from sliding in the titled chair. CNA #3 said she must have coded the wandering in error on the ADL sheets. During an interview on 12/3/25 at 8:20 A.M., CNA #4 said that Resident #5 does not wander and she must have documented wandering in error on the activities of daily living sheets. During an interview on 12/2/25 at 12:45 P.M., the Assistant Director of Nursing said that she is familiar with Resident #5, and he/she does not wander and that the CNAs should document accurately. During an interview on 12/3/25 at 9:14 A.M., the DON said that ADL sheets should be coded accurately. 3. Resident #69 was admitted to the facility in November 2019 and has diagnoses that include but are not limited to unspecified protein-calorie malnutrition, dysphagia (swallowing disorder), adult failure to thrive, other seizures, major depressive disorder, and dementia. Review of the most recent Minimum Data Set assessment, dated 9/20/25 indicated Resident #69 scored a 6 out of 15 on the Brief Interview for Mental Status exam, indicating he/she as having severe cognitive impairment. Further, the MDS indicated Resident #69 wandered (wandering is the act of moving (walking or locomotion in a wheelchair) from place to place with or without a specified course or known direction) in the last 4 to 6 days. During an observation and interview on 12/2/25 at 7:58 A.M., Resident #69 was in bed. Resident #69 said he/she does not get out of bed too often. Review of the document titled, Documentation Survey Report indicated the following: -September 2025, documented Resident #69 wandered on 23 out of 30 days on the 3:00 P.M.-11:00 A.M., shift. -October 2025, documented Resident #69 wandered on 20 out of 31 days on the 3:00 P.M.-11:00 P.M., shift. -November 2025, documented Resident #69 wandered 20 out of 30 days on the 3:00 P.M.-11:00 P.M., shift. During an interview on 12/2/25 at 10:36 A.M., Nurse #3 said she cares for Resident #69 and knows him/her well. Nurse #3 said Resident #69 spends his/her day in bed and refuses to get out of bed. Nurse #3 said the Resident is unable to move on his/her own and does not wander. During an interview on 12/2/25 at 10:47 A.M., Certified Nursing Assistant (CNA) #6 said she cares for Resident #69 and that he/she does not get out of bed. CNA #6 said the Resident is offered to go to the dining room or go to activities and he/she declines. CNA #6 said she has not seen Resident #69 wander, and it has never been reported to her that he/she has the behavior of wandering. During an interview on 12/2/25 at 2:35 P.M., CNA #5 said Resident #69 has behaviors of refusing care and he/she does not like to get out of bed, and he/she does not wander. Further, CNA #5 said she documents in the POC (Plan of Care), using a tablet. CNA #5 reviewed the documentation and said the Resident does not move on his/her own and does not wander and it should not have been documented. During an interview on 12/3/25 at 9:07 A.M., Nurse Consultant #1 said the CNA documentation is reviewed daily for completion versus accuracy. Nurse Consultant #1 said the MDS relies on accurate documentation to have an accurate picture of a resident.

Based on observation, interview, and record review the facility failed to ensure a therapeutic diet was provided for one Resident (#4) out of a total sample of 18 residents. Specifically, for Resident #4 the facility failed to ensure a 1200 mL (milliliter) fluid restriction was followed.Findings include:Review of the facility policy titled Encouraging and Restricting Fluids, dated as revised October 2010, indicated the purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. This may include encouraging or restricting fluids. Restricting fluids:-Record the amount of fluid consumed on the intake side of the intake and output record. Record fluid intake in milliliters (mLs). Resident #4 was admitted to the facility in August 2025 and has diagnoses that include stroke, dysphagia, gastrostomy status (nutrition provided through a tube inserted into the stomach), and congestive heart failure. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/6/25, indicated Resident #4 was rarely/never understood and a staff assessment for Brief Interview for Mental Status indicated severe cognitive impairment. The MDS further indicated Resident #4 receives his/her nutrition through a feeding tube. Review of Resident #4's active physician orders indicated:-Nothing By Mouth (NPO) diet.-Enteral Feed Order: [NAME] Farms Peptide 1.5 Cal liquid via feeding tube pump set at 55 mLs/ hour for 18 hours, total volume 990 mL/day. Pump on at 2 P.M. and off at 8 A.M.-Enteral Feed Order: every four hours 100 mL of water for hydration/ total 600 mL.-Fluid Restriction: 1200 mL total in 24 hours; Nursing: 300 mL/24 hours (100 mL on 7-3, 100 mL on 3-11, 100 mL on 11-7); Dietary 900 mL/24 hours (420 mL at breakfast, 240 mL at lunch, 240 mL at dinner).-Flush PEG (feeding) tube with 30mL of warm water before each medication pass. Flush with at least 15mL of warm water between each medication. Final flush with 30 mL of warm water after administering last medication every shift for enteral medication administration.-Protein liquid 30 mL in the morning via gastrostomy tube for wound healing. Review of Resident #4's plan of care, dated as revised 8/6/25, indicated The resident requires tube feeding related to dysphagia, swallowing problem.Interventions include:-provide tube feed per physician orders.-Dietitian to evaluate and monitor caloric intake and make diet change recommendations as needed.-Monitor/document any signs and symptoms of aspiration.-Obtain and monitor labs as ordered. Review of Resident #4's plan of care failed to indicate Resident #4 was on a fluid restriction. Review of Resident #4's Quarterly Nutrition Assessment, dated 11/7/25, indicated the following assessment/plan:-he/she remains on enteral feedings at rate of 55 mL/hour for 18 hours which provides 752 mL free water daily.- he/she continues a 1200 mL fluid restriction to help manage electrolytes.-flush and free water meet restriction parameters. Review of the [NAME] Farms 1.5 Peptide formula nutrition label indicates that the formula provides 70% free water (amount of water in the formula). The ordered tube feeding regime at 55 ml/hour for 18 hours would provide a total of 693 mL of free water. Water flushes and medication flushes add over 600 ml of extra free water, exceeding the 1200 mL fluid restriction ordered by the physician. On 12/1/25 at 12:07 P.M., the surveyor observed Resident #4's tube feeding infusing at 55 mL/hour, four hours after the tube feeding was supposed to be taken down at 8:00 A.M. On 12/2/25 at 8:57 A.M., 10:24 A.M., 11:26 A.M., 12:36 P.M., and 2:21 P.M., the surveyor observed Resident #4's tube feeding was infusing at 55 mL/hour, over six hours after the tube feeding was supposed to be taken down. On 12/3/25 at 8:38 A.M., the surveyor observed Resident #4's tube feeding infusing at 55 mL/hour 38 minutes after the tube feeding was to be taken down. During an interview on 12/3/25 at 9:20 A.M., the Assistant Director of Nursing said that she knows that tube feeding comes down during the day and that when a new bag is hung the pump should be cleared so nursing can monitor how much feeding has infused. She said that she had turned the feeding off on 12/1/25 as she realized Resident #4's nurse had not turned it off. She said that anytime orders are not followed then the practitioner should be notified. She said Resident could be at risk related to receiving extra fluids. During an interview on 12/3/25 at 9:39 A.M., Nurse #4 said that she had not received any report about what time the tube feeding bag was hung and she said the orders were for the Resident to receive the tube feeding for 24 hours each day. During an interview on 12/3/25 at 9:59 A.M., the Dietitian said that she works with the practitioner to determine the appropriate orders to maintain Resident #4's nutrition and fluid restriction of 1200 ml. She said that she calculated the amount of fluid Resident #4 received by adding the 752 ml (she multiplied 55 ml/hour x 18 hours x 70% = 752 ml) of free water that the Resident received from [NAME] Farms 1.5 Peptide formula to the 400 ml (she multiplied 100 ml flush x 4) of flushes Resident received daily for a total of 1152 ml. She said that she would expect nursing to follow the fluid restriction and if it is not followed that Resident could be at risk for fluid overload. On 12/3/25 at 10:29 A.M. the surveyor, Nurse Consultant #1, and the Director of Nursing observed Resident #4's tube feeding running at 55 ml/hour and Resident #4's order for the tube feeding to be turned off at 8:00 A.M. They both said the Resident was at risk for fluid overload by receiving more than the 1200 mL fluid restriction and that the physician should be notified. During an interview on 12/3/25 at 10:35 A.M., Nurse Practitioner #1 said she was not aware that Resident #4 had been receiving tube feeding outside of the ordered times. She said she would expect that the physician orders be followed and that she be notified if they were not. She said that Resident is on a fluid restriction and is at high risk for fluid overload related to his/her diagnoses of Congestive Heart Failure.

Based on record review and interview, the facility failed to revise the plan of care after two Minimum Data Set assessments for one Resident (#7) out of a total sample of 5 Residents selected for the unnecessary medication review. Specifically for Resident #7, the facility failed to revise three separate care plans related to diuretic use (medication used to decrease fluid) when his/her diuretic was discontinued on 5/19/25 and nursing documented his/her care plans were reviewed on 8/12/25 and 10/27/25. Findings include: Review of the facility policy titled, Care Planning - Interdisciplinary Team, dated as revised March 2022, indicated the interdisciplinary team is responsible for the development of resident care plans.1.Resident care plans are developed according to the timeframes and criteria established by S483.21. Resident #7 was admitted to the facility in November 2022 with diagnoses including Alzheimer's disease, atrial fibrillation, diabetes, and muscle weakness. Review of the Minimum Data Set assessments, dated 7/10/25 and 10/7/25, indicated the Resident #7 was not administered a diuretic medication. Review of Resident #7's provider progress note, dated 5/13/25, indicated:-We will discontinue to torsemide (diuretic medication). Review of Resident #7's discontinued physician's orders, dated 5/19/25, indicated:-Torsemide 10 milligrams, give one tablet by mouth in the morning every other day for congestive heart failure. (Discontinued) Review of Resident #7's Medication Administration Record, dated July 2025, August 2025, September 2025, and through October 2, 2025, failed to indicate that Resident #7 received a diuretic medication since the torsemide was discontinued on 5/19/25. Review of Resident #7's care plan reviews dated 8/12/25 and 10/27/25 indicated nursing reviewed and revised his/her care plan to ensure the most accurate information was included in his/her care plan was in place. Review of Resident #7's plan of care on 12/2/25, included the following care plan focus:- The resident is on diuretic therapy, dated as revised on 5/25/23.- The resident has potential for dehydration or fluid deficit related to cognitive function, mental state, diuretic use, dated as revised 10/15/24.- The resident is at risk for falls related to cognitive deficit, potential for alteration in functional ability, mental state (history of major depression, generalized anxiety disorder, insomnia), occasional bowel and urinary incontinence, and medications (diuretics, psychotropics), syncope, dated as revised on 8/13/25. During an interview on 12/2/25 at 12:55 P.M., the Assistant Director of Nursing (who completed the care plan reviews) said that the care plan for diuretic use should have been resolved (revised) during the care plan reviews but was not. During an interview on 12/3/25 at 9:16 A.M., the Director of Nursing said that care plans need to be revised after the MDS assessment to reflect the most current status of the Resident.

Based on observation, interview, and record review the facility failed to ensure that the administration of enteral nutrition is consistent with and follows the practitioner's orders for one Resident (#47) out of a total sample of 18 residents. Specifically, for Resident #47 the facility failed to ensure the tube feeding was delivered at the frequency it was ordered.Findings include:Review of the facility's policy titled, Enteral Nutrition, dated as revised November 2018, indicated that adequate nutritional support through enteral nutrition is provided to residents as ordered. Resident #4 was admitted to the facility in August 2025 and has diagnoses including stroke, dysphagia, gastrostomy status (nutrition provided through a tube inserted into the stomach), and congestive heart failure. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/6/25, indicated Resident #4 was rarely/never understood and a staff assessment for Brief Interview for Mental Status indicated severe cognitive impairment. The MDS further indicated Resident #4 receives his/her nutrition through a feeding tube. Review of Resident #4's physician order, dated 9/9/25, indicated Enteral Feed Order: [NAME] Farms Peptide 1.5 Cal liquid via feeding tube pump set at 55 milliliters (ml)/ hour for 18 hours, total volume 990 ml/day. Pump on at 2 P.M., and off at 8 A.M. Review of Resident #4's plan of care, dated as revised 8/6/25, indicated The resident requires tube feeding related to dysphagia, swallowing problem.Interventions include:-provide tube feed per physician orders.-Dietitian to evaluate and monitor caloric intake and make diet change recommendations as needed.-Monitor/document any signs and symptoms of aspiration.-Obtain and monitor labs as ordered. Review of Resident #4's Quarterly Nutrition Assessment, dated 11/7/25, indicated he/she remains on enteral feedings at rate of 55ml/hour for 18 hours. Review of physician's progress note, dated 11/25/25, indicated Resident #4 continued [NAME] Farms Peptide 1.5 Cal liquid at 55 ml/hour x 18 hours, up at 2 P.M. and off at 8 A.M. Review of Resident #4's Medication Administration Record (MAR), dated 12/1/25 through 12/3/25, indicated a box for the nurse to initial when she hung the feeding at 2 P.M., but not a box to initial when the feeding was turned off at 8 A.M. On 12/1/25 at 12:07 P.M., the surveyor observed Resident #4's tube feeding infusing at 55 ml/hour. The tube feeding bag was dated 12/1. On 12/1/25 at 12:57 P.M., the surveyor observed Resident #4's tube feeding being turned off by Assistant Director of Nursing. On 12/2/25 at 8:57 A.M., 10:24 A.M., 11:26 A.M., and 12:36 P.M., the surveyor observed Resident #4's tube feeding was infusing at 55 ml/hour. On 12/3/25 at 8:38 A.M., the surveyor observed Resident #4's tube feeding infusing at 55 ml/hour. The tube feeding bag was dated 12/3. During an interview on 12/3/25 at 9:20 A.M., the Assistant Director of Nursing said that she knows that tube feeding comes down during the day and that when a new bag is hung the pump should be cleared so nurse can monitor how much feeding has infused. She said that she had turned the feeding off on 12/1/25 after she realized Resident #4's nurse had not turned it off. She said that anytime orders are not followed that the practitioner should be notified. She said Resident could be at risk related to receiving extra fluids. During an interview on 12/3/25 at 9:39 A.M., Nurse #4 said that she had not received any report about what time the tube feeding bag was hung and she said the orders were for the Resident to receive the tube feeding for 24 hours/day. On 12/3/25 at 10:29 A.M. the surveyor, Nurse Consultant #1, and the Director of Nursing observed Resident #4's tube feeding running at 55 ml/hour and Resident #4's order for the tube feeding be turned off at 8 A.M. They both said the Resident was at risk for fluid overload by not following the physician orders and that the physician should be notified. During an interview on 12/3/25 at 10:35 A.M., Nurse Practitioner #1 said she was not aware that Resident #4 had been receiving tube feeding at any time other than according to orders. She said she would expect that the physician orders be followed and that she be notified if they are not. She said that Resident is on a fluid restriction and is at high risk for fluid overload related to his/her diagnoses of Congestive Heart Failure.

Based on observation, interview, and record review the facility failed to ensure assistance with Activities of Daily Living (ADLs) was provided for one Resident (#47) out of a total sample of 18 residents. Specifically, for Resident #47 the facility failed to ensure one-to-one staff assistance was provided with meals.Findings include: Resident #47 was admitted to the facility in April 2023 and has diagnoses that include Alzheimer's disease, dysphagia, and dementia with psychotic disturbance. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/25/25, indicated Resident #47 had severe cognitive impairment as evidence by a Brief Interview for Mental Status (BIMS) score of 6 out of 15. The MDS further indicated Resident #47 requires set-up or clean-up with assistance with eating. Review of the active physician orders indicated Resident #47 is a 1:1 (one-to-one) feed as of 8/29/25. Review of the Activities of Daily Living care plan, dated as revised 10/1/25, indicated Resident #47 had the following interventions:-Eating: The resident is assist- totally dependent on staff for eating. Will assist 1:1 and encourage adequate PO (by mouth) intake. Review of the Nutrition care plan, dated as revised 9/3/25, indicated Resident #47 had the following interventions:-Feeding assistance with all meals.-observe for signs and symptoms of aspiration, especially during meals. Review of Dietitian progress note, dated 10/24/25, indicated Resident #47 was at risk for weight loss as he/she was spitting out foods. Interventions included downgrading texture of his/her diet to a full liquid diet and 1:1 feeding assist. On 12/1/25 at 8:55 A.M., the surveyor observed Resident #47 seated in bed with the head of bed elevated. Staff set up his/her breakfast tray on table in front of him/her then left the room and continued to pass other trays. The surveyor continued to make the following observations:-Between 8:55 A.M., and 9:10 A.M. The Resident continued to drink or use a spoon to deliver fluids to his/her mouth, but there were no staff in sight of Resident #47 as he/she drank his/her fluid diet and no staff returned to the room to assist with the meal. On 12/1/25 at 12:39 P.M., the surveyor observed Resident #47 being set up for lunch in bed by a staff member, the staff then left room. He/she was able to drink independently. The surveyor continued to make the following observations:-Between 12:39 P.M., and 1:02 P.M. various staff members passed by the room or stood in doorway for a moment, but there were no staff that sat with Resident or assisted with his/her meal. On 12/2/25 at 8:58 A.M., the surveyor observed Resident #47 being set up for breakfast in bed by a staff member, the staff then left room. He/she did not attempt to drink any breakfast.Throughout the observation between 8:58 A.M., and 9:15 A.M., the Resident fell asleep and was leaning towards the right in bed. Staff did not offer to wake Resident and just removed the tray. On 12/2/25 at 12:42 P.M., the surveyor observed Resident #47 being set up for lunch in bed and then staff left the room. The surveyor observed Resident between 12:42 P.M. and 1:08 P.M. There were no staff in or in sight of his/her room during this time. On 12/3/25 at 8:28 A.M., the surveyor observed Resident #47 being set up for lunch in bed and then staff left the room. The surveyor observed Resident between 8:28 A.M. and 8:37 A.M. The were no staff in or in sight of his/her room during this time. During an interview with Resident #47's Certified Nursing Assistant (CNA) #7 on 12/3/25 at 8:45 A.M., she said that Resident only needs to be set up for meals. She does not require any supervision or assistance with meals. During an interview with Resident #47's Nurse #4 on 12/4/25 at 8:48 A.M., she said that the Resident only needs to be set up for meals and that he/she can eat alone. During an interview with the Assistant Director of Nursing (ADON) on 12/3/25 at 9:10 A.M., she said that Resident #47's level of assistance required for eating varies according to his/her level of alertness and his/her dementia therefore staff should observe Resident and offer the amount of assistance he/she needs. The ADON said she does not know if Resident has any aspiration issues. She said that staff learn the level of assistance each Resident needs by reading the Kardex (a form indicated the type of care a resident needs). During an interview with the Registered Dietitian on 12/3/25 at 9:59 A.M., she said that Resident #47 requires 1:1 feeding assistance related to his/her impaired cognition and history of spitting out foods. She said that Resident is discussed in risk meetings and any interventions that the interdisciplinary team determine are communicated to direct care staff by the Director of Nursing or any Nursing staff that is present at the meeting. During an interview with Nurse Practitioner #1 on 12/3/25 at 10:43 A.M., she said that if Resident #47 has an order for 1:1 assistance for eating then the order should be followed. She said the Resident is at risk for aspiration if the assistance is not provided for eating.

Based on observations, record reviews, and interviews, the facility failed to implement the facility's abuse policy for one Resident #35 out of a total sample of 18 residents. Specifically, for Resident #35 the facility failed to ensure Certified Nurse Assistant (CNA #1), who was accused of neglect, left the facility after she was suspended (placed on leave). Findings include:Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated as revised September 2022, indicated that all reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies, and thoroughly investigated by facility management. -Reporting Allegations to the Administrator and Authorities:6.Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions are needed for the protection of residents. -Investigating Allegations: 5. The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility. 6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. Resident #35 was admitted to the facility in April 2025 with diagnoses including major depression, anxiety, and failure to thrive. Review of the most recent Minimum Data Set assessment, dated 10/16/25, indicated Resident #35 was cognitively intact as evidenced of a Brief Interview of Mental Status exam score of 15 out of a possible 15. This MDS indicated that Resident #35 did not have any behaviors, did not reject care, and required assistance with activities of daily living. On 12/1/25 at 7:51 A.M., the surveyor observed Resident #35 in his/her bedroom yelling at CNA #1 saying I don't want you in my room, I called the cops on you this weekend, don't come in my room again. CNA #1 exited Resident #1's room, and she said that she was not sure why Resident #35 was screaming at her. The Resident requested the surveyor to get him/her some help to be boosted for breakfast. On 12/1/25 at 7:54 A.M., the surveyor stood outside Resident #35's door where he/she reported to two staff members I don't want her anywhere near me she neglected me, I want her reported, I don't want her anywhere near me. Review of Resident #35's progress note, dated 11/30/25 at 4:50 A.M., indicated:- At around 4:45 A.M., a call received from a caller (a man voice) identified as being from the police department reporting that resident called the police to report that he/she wants to be changed. This nurse went to resident's room to inquiry about what the matter was. Resident complained of not wanting the overnight staff CNA to touch him/her. Resident stated that they have being putting the same staff to work every night on purpose. Resident reported that he/she wants to leave the facility and wants someone to help him/her do that. Resident appears to be very agitated and frustrated. Resident stated: I can buy all of you and sell you a hundred times over. You should do as I say. Resident refused to calm down and expressed desire to report the facility for the way he/she has been treated since he/she got admitted . After 10 mins another caller (a woman voice) from the police department reporting the same complaint from resident. The caller stated that resident seems to have several ongoing issues at the same time. Resident was advised to talk to social service worker in the morning as this is not a matter for the police department to handle. (sic) On 12/1/25 at 8:32 A.M. the surveyor and the Administrator entered Resident #35's room. Resident #35 said She (CNA #1) neglects me, she doesn't meet my needs, and she thinks things are comical the surveyor offered to close Resident #35's door and Resident #35 said the staff should hear this, so they know there are repercussions to neglect. Resident #35 identified CNA #1 as the accused and the Administrator said that he would take care of things. Review of the Health Care Facility Reporting System, indicated on 12/1/25 at 9:18 A.M., the Director of Nursing created and submitted a case on 12/1/25 at 10:15 A.M., that stated:-Resident reported that neglect was experienced during care. CNA suspended until further investigative findings. CNA #1 was identified as the accused. On 12/1/25 at 9:09 A.M., the surveyor observed CNA #1 on the unit providing care to a Resident. On 12/1/25 at 10:17 A.M., the surveyor observed CNA #1 exiting a resident room. On 12/1/25 at 11:55 A.M., two surveyors observed CNA #1 exiting the elevator on the ground floor (next to the Director of Nursing's office) with a Resident. On 12/1/25 at 12:57 P.M., two surveyors observed CNA #1 at the second-floor nursing station. CNA #1 identified herself and she said she was going to complete her activities of daily living documentation. During an interview on 12/1/25 at 4:20 P.M., Nurse #2 said that CNA #1 worked the entire day shift on 12/1/25. Nurse #2 said that when she receives an allegation of neglect, she is to report the allegation to her supervisor. During an interview on 12/1/25 at 4:54 P.M., the Director of Nursing (DON) said that she was made aware of the allegation of neglect by the Administrator. The DON said that she reported the event to the state agency and she and Nurse Consultant #2 suspended CNA #1 pending investigation on 12/1/25 at 9:30 A.M., and she had thought that CNA #1 had left the facility at that time. The surveyor shared the observations of the CNA in the building after 9:30 A.M., and the DON said that CNA #1 was supposed to leave the facility pending investigation. The surveyor and the DON reviewed CNA's #1 timecard that indicated that she left the faciity on [DATE] at 3:41 P.M., the DON then said she was not sure if Nurse Consultant #1 or Human Resources sent CNA #1 home. During an interview on 12/2/25 at 1:02 P.M., Human Resources said she wasn't made aware that CNA #1 was suspended until 12/1/25 around 5:30 P.M., she said she is typically made aware of suspensions, but she was not aware. During an interview on 12/3/25 at 9:00 A.M., Nurse Consultant #2 said that she sat with CNA #1 and the DON on 12/1/25 at 9:30 A.M., she said that she suspended CNA #1 and she expected her to leave the building pending investigation. During an interview on 12/1/25 at 5:24 P.M., the Administrator said that CNA #1 should have been suspended and left the building immediately pending the neglect investigation at 9:30 A.M. During an interview with the Nurse Consultant #1 and the Administrator on 12/2/25 at 10:00 A.M., they said that there was a breakdown in communication with staff during the suspension of CNA #1 pending the allegation of neglect and that CNA #1 should have left the building, but she did not. Nurse Consultant #1 said that CNA #1 thought she did nothing wrong and she returned back to the unit on 12/1/25 to finish her workday.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was found unresponsive by staff, and required staff to initiate a Code Blue, the Facility failed to ensure that Licensed Nursing Staff were competent in the process of calling and responding in the event of a Code Blue situation. Findings include:Review of the Facility Policy titled, Emergency Procedure, Cardiopulmonary Resuscitation (CPR), dated as last revised 02/2018, indicated that personnel have completed training on the initiation of CPR and Basic Life Support (BLS).The Policy further indicated that if an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR;-Instruct a staff member to activate the emergency response system (CODE BLUE) and call 911;-Instruct a member to retrieve that automatic external defibrillator;-Verify or instruct a staff member to verify the Do Not Resuscitate (DNR) or code status of the individual; and-Initiate the BLS sequence of events, C-A-B (chest compressions, airway, breathing).According to the Board of Registration in Nursing, 244 CMR9:00: Standards of Conduct, competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a Nurse Licensed by the Board and for the delivery of safe Nursing care in accordance with accepted Standards of Practice.Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully.Resident #1 was admitted to the Facility in [DATE], diagnoses included Chronic Obstructive Pulmonary Disease (COPD, airflow is blocked and makes it difficult to breath), End Stage Renal Disease (ESRD, kidneys no longer function to rid the body of waste) requiring hemodialysis (medical procedure that cleans the blood when kidneys fail), and recent amputation of a right below the knee amputation (BKA).During an interview on [DATE] at 1:47 P.M., Nurse #1 said that on [DATE] at 6:30 A.M., he went into Resident #1's room, obtained his/her Capillary Blood Sugar (CBG), result was 123 and said he/she appeared fine. Nurse #1 said he went to the medication cart (at the Nurses Station), recorded the CBG (6:44 A.M.), made a phone call to the Dialysis Center for a time related to Resident #1''s treatment, and then obtained morning medication for Resident #1.Nurse #1 said upon return to Resident #1's room, around 6:45 A.M, he observed that he/she was in his/her wheelchair and was unresponsive. Nurse #1 said he called his/her name multiple times with no response, performed a sternal rub without effect, and that Resident #1 was turning a bluish color.Nurse #1 said he then called out for help, that CNA #1 and CNA #2 responded, they lowered Resident #1 to the floor, and he began chest compressions. Nurse #1 said he called 911/ Emergency Medical Services (EMS) from his personal mobile phone, applied the AED pads, with no shock advised, and re-initiated chest compressions until EMS arrived. Nurse #1 said that he does not recall who retrieved the Code Cart or the AED.Nurse #1 said that he did not overhead page a Code Blue or delegate the task to one of the CNA's to call a Code Blue. Nurse #1 said that this was his first actual Code Blue event and said that he should have had someone overhead page a Code Blue so other nursing staff could have responded in the emergent situation.During a telephone interview (which included a review of her written statement) on [DATE] at 12:35 P.M., CNA #1 said Resident #1 was on her assignment for the 11:00 P.M. - 7:00 A.M. shift on [DATE] into [DATE]. CNA #1 said around 6:00 A.M. Resident #1 had put his/her call bell on and asked to get into his/her wheelchair. CNA #1 said when she left Resident #1's room he/she appeared to be fine, then she left the unit and went down to the basement to get some briefs.CNA #1 said upon return to the unit, while at the nurse's station Nurse #1 said to her that Resident #1 did not appear to be breathing so she went to his/her room with Nurse #1. CNA #1 said that Nurse #1 left the room to get the Code Cart and AED while she stayed with Resident #1 and when Nurse #1 returned, they placed him/her onto the floor, applied the AED pads, called 911 and Nurse #1 began compression. CNA #1 said she does not recall hearing a Code Blue being paged overhead and said she was not asked to overhead page a Code Blue by Nurse #1.During a telephone interview on [DATE] at 9:22 A.M., CNA #2 said that on [DATE] she was working on the second floor (Resident #1's unit) that shift, however Resident #1 was not on her assignment. CNA #2 said that she heard Nurse #1 yell her name for help and said when she entered the room, Resident #1 was still sitting in his/her wheelchair, and she helped CNA #1 and Nurse #1 transfer and lower Resident #1 onto the floor. CNA #2 said she was not asked to call a Code Blue and does not remember hearing a Code Blue being paged overhead. CNA #2 said when a Code Blue is called other staff come and help.During an interview on [DATE] at 12:12 P.M., CNA #4 said that he was working on the third floor for the 11:00 P.M. (night shift) on [DATE] into the (morning shift) 7:00 A.M. of [DATE]. CNA #4 said he does not remember hearing a Code Blue called over the intercom and said if he had, he would respond to help and do what was asked of him.During an interview on [DATE] at 1:03 P.M., Nurse #2 said she was working the overnight shift that the incident occurred, however she was on the third floor. Nurse #2 said she did not recall hearing a Code Blue be paged at any time during the shift.Nurse #2 said that if she had heard a Code Blue being paged, she would have responded immediately to help. During a telephone interview on [DATE] at 11:44 A.M., Nurse #4 said that she came to work on [DATE] at approximately 6:15 A.M., however said she does not recall ever hearing a Code Bue being paged.Nurse #4 said that if she had heard a Code Blue, she would have stopped what she was doing and go to the location announced to help with whatever was needed. Nurse #4 said that the nurse needs to call a Code Blue so that other staff can assist with the emergency.During an interview on [DATE] at 3:53 P.M., the Assistant Director of Nurses (ADON) said that the Facility has not had a Staff Development Coordinator for some time and Mock Code Blue's were not being done on a regular basis.The ADON said that she was not aware Nurse #1 had not called a Code Blue and said if he had, licensed staff would have responded to assist.During an interview on [DATE] at 1:40 P.M., the Interim Director of Nurses (DON, who also serves as the Regional Clinical of Operations), said that she was not aware that Nurse #1 had not called or instructed anyone else to call a Code Blue.The interim DON said that she assumed that a Code Blue was paged and had not realized only three (3) staff members (1 Nurse and 2 CNA's) were involved with the emergency incident. The interim DON said that if Nurse #1 had called a Code Blue other licensed staff would have been available to help.The interim DON said the Facility's expectation is that if a resident is found unresponsive, the responding Nurse is to assess the resident, call out for help, and instruct the first staff member to arrive to page a Code Blue.The interim DON said as staff arrives to assist, the Nurse should instruct each staff member as what to do, retrieve the code cart, AED, resident's chart, call 911, and anything else needed until EMS arrives and takes over the situation.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was an elopement risk and resided on a secured unit, the Facility failed to ensure he/she was provided with an adequate level of staff supervision to prevent an incident of elopement, when on 04/08/25 around 2:15 P.M. Resident #1 was able to exit his/her unit and the Facility, undetected by staff and was found sitting on the curb in front of the Facility. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation and was diagnosed with a fractured left elbow. Findings include: Review of the Facility Policy titled Wandering and Elopements, dated as last revised 03/2019, indicated that the Facility would identify residents who are at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for the residents. Review of the Facility Policy titled, Safety and Supervision of Residents, dated as last revised 07/2017, indicated that the Facility strives to make the environment as free from accidents hazards as possible. The Policy further indicated that resident supervision is a core component of the systems approach to safety, the type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment; and Review of the Facility Job Description titled Receptionist, dated as last revised 10/2020, indicated that one of the jobs responsibilities is to track visitors signing in and out of the Facility. Review of the report submitted by the Facility via Health Care Facility Reporting System (HCFRS), dated 04/14/25, indicated that on 04/08/25 around 2:20 P.M., an employee looking out a second floor window saw a person sitting on the ground. The Report indicated Resident #1 was found outside sitting in front of the Facility. The Report indicated that Resident #1 had been found to have some discoloration to his/her left elbow, and was sent to the Hospital ED for evaluation. Review of Resident #1's Hospital ED Report, dated 04/08/25, indicated he/she sustained a left epicondylar (elbow) fracture. The Report indicated Resident #1 was returned to the facility on [DATE], with a sling and recommendations to follow up with orthopedics. Resident #1 was admitted to the Facility in July 2020 diagnoses included Alzheimer's Disease, a cognitive communication deficit, other amnesia, and dementia with moderate agitation. Review of Resident #1's Document of Resident Incapacity Form, dated 07/29/20, indicated his/her Health Care Proxy (HCP) had been activated. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 02/13/25, indicated he/she scored an 9 out of 15 on his/her Brief Interview for Mental Status (BIMS) Assessment (0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired cognition, and 12-15 suggests a resident is cognitively intact). Review of Resident #1's Care Plan titled Risk for Elopement/Wanderer, dated as last revised 02/09/25, indicated that his/her safety would be maintained by distracting him/her with alternative activities and increasing his/her supervision when needed. During an interview on 04/29/25 at 12:31 P.M., the Housekeeping Supervisor said that on 04/08/25 around 2:20 P.M., she was cleaning a room on the second floor when she looked out the window, which faced the front entrance of the building, saw a stopped car and a woman standing next to someone (possibly a resident) who was sitting on the curb in front of the Facility. The Supervisor said that she ran down to the front reception desk, told Receptionist #1 that a resident might be outside, then ran outside and discovered it was a resident (later identified as Resident #1). The Supervisor said the woman stayed with Resident #1 while she ran back into the Facility to get help. During a telephone interview on 04/29/25 at 2:33 P.M., Receptionist #1 said that on 04/08/25 around 2:20 P.M., she was sitting at the front desk talking with a visitor, when the Housekeeping Supervisor came running downstairs and told her that she saw someone outside who looked as if he/she could have been a resident. Receptionist #1 said anyone who walks through the front door, either coming into or wanting to leave, must be buzzed (releasing of electronic lock) in/out by an employee. Receptionist #1 said Resident #1 must have looked like a visitor and been hidden behind someone leaving the building, when he/she got out of the building past her. Receptionist #1 said that she did not realize that anyone walked through the front door without her knowing it. During an interview on 04/29/25 at 12:00 P.M., the Director of Social Services said that on 04/08/25 around 2:15 P.M., she was on the third floor (Resident #1's unit) at the nurse's station but said she did not see Resident #1. The Director said that a visitor had been touring the third floor for a potential room change for another resident and said she saw a Certified Nurse Aide (CNA, exact name unknown) punch in the security code to the elevator (only way visitors can access and exit the unit) allowing it to move to the lower level where the front entrance and reception areas were located. The Surveyor interviewed CNA's #1, #2, #3, #4 and #5, who were scheduled to work during the day shift on 4/08/25 on Resident #1's unit, and they all denied entering the security code to the elevator and letting a visitor out around the time that Resident #1 eloped from the secure unit. During an interview on 04/29/25 at 3:13 P.M., the Administrator said upon investigation, he noted that on 04/08/25, a visitor had been touring a resident room on the third floor around the time of Resident #1's elopement and he called the visitor to try to get some information. The Administrator said the facility determined that the visitor was let onto the third-floor elevator by a staff member and that Resident #1 followed the visitor onto the elevator (that the visitor had not known he/she was a resident). The Administrator said that when the visitor to went to sign out at the reception desk, the visitor turned around, Resident #1 was no longer in sight, and the visitor had no idea where he/she had gone. During an interview on 04/29/25 at 2:37 P.M., the Director of Nurses (DON) said that it is the Facility's expectation that when a visitor, vendor, or provider requests to leave the third floor (secured unit), they must wait for a staff member to enter the access code (while shielding the code to conceal it from them) into the keypad stationed at the elevator, and the staff is suppose to remain at the elevator until it closes to ensure no residents have left the secured unit. The DON said that all visitors are supposed to sign in and out at the reception desk, and the receptionist is supposed to ensure no residents are allowed out of the Facility without the appropriate level of supervision and assistance. On 04/29/25, the Facility was found to be in past non-compliance. In response to the incident, the Facility took the following corrective action: A) On 04/08/25, Resident #1 was assessed by nursing staff, transferred to the Hospital Emergency Department and treated for a left elbow fracture. B) On 04/09/25, Resident #1 returned to the Facility, a new elopement assessment was completed and his/her plan of care was reviewed and updated as needed. C) On 04/09/25 and 04/11/25 an Ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held to review the elopement incident, as well as their implementation of corrective action plan. D) On 04/09/25, the Facility implemented an elevator monitor (staff member) 24 hours per day to monitor the elevator on the third floor (which will be in place until a Wander Guard System is installed). E) On 04/09/25, the Maintenance Director ensured all secured doors were functioning properly and will continue weekly checks indefinitely. F) On 04/10/25 the DON and/or designee completed An Elopement Risk Evaluation on all residents to determine their risk for elopement and all resident care plans were updated to ensure those at risk for elopement had a plan of care. G) On 04/10/25, the Elopement Books were updated with current picture of residents and an elopement alert notice. Colored photographs were placed at the front reception desk. H) On 04/10/25, the Elevator Code for the third floor was changed and will continue to be changed every 4 weeks, then monthly indefinitely thereafter and PRN. I) On 04/11/25, an Elopement Drill was conducted and random drills will continue for four weeks, then monthly or until substantial compliance is met. J) On 4/12/25, the DON and/or designee provided all staff education regarding; -Elopement/wandering, exit seeking residents and increased supervision required; -Elevator and or Door codes, are not to be given out to any non-staff persons at any time, shield the code when entering, and the need to wait until the elevator door closes completely before leaving the area, ensuring residents remain on the secured unit. K) Ongoing, the DON will be responsible for ensuring on-going audits and present the findings to the Quality Assurance Performance Improvement Committee monthly for three quarters. L)The Administrator and/or designee are responsible for the implementation and follow-up of the Facility POC.

Based on records reviewed and interviews, for one of three sampled residents (Resident #3), the Facility failed to ensure they maintained a complete and accurate medical record, when there was no nursing documentation related to wound measurements for six days following his/her readmission on 3/13/25, after a hospital stay. Findings include: The Facility Policy, titled Charting and Documentation, dated as revised 07/2017, indicated all services provided to the resident, progress towards the care plan goals, or any changes in the resident's medical, physical, functional or psychological condition would be documented in the resident's medical record. The Facility Policy, titled Admission Assessment and Follow Up: Role of the Nurse, dated as revised 09/2012, indicated nursing would conduct an admissions assessment upon admission which included a skin assessment. The Facility Protocol, titled Pressure Ulcers/Skin Breakdown, dated as revised 04/2028, indicated nursing would describe and document a full assessment of pressure injuries including location, stage, width and depth, and presence of exudates or necrotic tissue. Resident #3 was admitted to the Facility in December 2024, diagnoses included chronic osteomyelitis (infection of the bone), polyneuropathy (damage to the peripheral nerves), and stage four pressure injury at his/her sacral region. Review of Resident #3's Wound Assessment Details Reports, dated 03/05/25, indicated he/she had three wounds, which measured as follows: -Sacral stage four (extends past the sebaceous tissue and effects the underlying muscles and deep tissue) wound, which measured 0.40 centimeters (cm) long by 0.40 cm wide by 0.10 cm deep. -Right Ischium (hip) stage four wound, which measured 4.0 cm long by 2.0 cm wide by 1.8 cm deep. -Left Ischium stage four wound, which measured 2.0 cm long by 2.0 cm wide by 6.0 cm deep. Review of Resident #3's Nurse Progress Note, dated 03/05/25, indicated he/she was transferred to the Hospital Emergency Department (ED). Further review of Resident #3's Medical Record indicated he/she was admitted to the Hospital on 03/05/25 and was readmitted to the facility on [DATE]. Review of Resident #3's Admission/Readmission assessment, dated 03/13/25, indicated he/she had pressure injuries on his/her coccyx, left buttock, and right buttock. Further review of the assessment indicated that for all three pressure injuries listed, the section on the assessment designated for documenting measurements of length, width, depth and stage of the pressure injuries was left blank. Further review of Resident #3's medical record indicated there was no documentation to support nursing had measured his/her pressure injuries/wounds at all upon or after his/her readmission to the facility on [DATE]. During an interview on 03/19/25 at 01:23 P.M., the Director of Nurses (DON) said wound (pressure injury) measurements were important for tracking the progression of wounds. The DON said nursing should measure and document all wounds on admission and readmission. The DON said nursing should have documented Resident #3's wound measurements upon readmission on 03/13/25.

Based on records reviewed, interviews and observations for one of six sampled residents (Resident #1), the Facility failed to ensure they provided an adequate level of staff supervision to prevent an incident of elopement, resulting in injuries. 1) On 11/02/24, Resident #1 who had severe cognitive impaired, and was assessed as being at increased risk for elopement, exhibited increased exit seeking behaviors including making multiple attempts to leave the Facility through alarmed exit doors on the unit, asked staff members for a ride home and required constant redirection by staff. Sometime before lunch, Resident #1 was redirected by a staff member to go to an activity going on in the day room. However, that was the last time staff recall seeing Resident #1, and it was not until staff noticed that his/her lunch tray was untouched that staff determined he/she was no longer in the Facility. Resident #1 was found the next day at a convenience store located in the next town (3.6 miles away from the Facility). Resident #1 was transferred to the Hospital Emergency Department for evaluation, was noted to have cuts to the back of both his/her hands and feet, abnormal blood laboratory work, bruises and was admitted . 2) The Facility also failed to ensure that the fenced in patio area located just off the day room utilized by residents for smoking and/or outside activities was secured, so that residents at risk for elopement could not easily access the area unsupervised. Per the facility a designated staff member must enter a security code in the keypad to unlock the patio door to let residents out to smoke, the staff member must stay outside to supervise the smoking group and use the code again to open to door to escort the residents back into the building. However, on 11/15/24, during the survey, multiple residents were observed entering the keypad code number by themselves and exit the day room to go out to the patio area to smoke. During the observation, there were no staff members present in the day room or out on the patio to provide supervision. It was also observed that one of the gates out on the patio that led to the facility parking lot was wide open, and unsecured, therefore making it easy for any resident to elope undetected. Findings include: Review of the Facility's Policy titled Safety and Supervision of Residents, dated as last revised 07/2017, indicated that the Facility strives to make the environment as free from accident hazards as possible and safety, supervision, and assistance to prevent accidents are a facility-wide priority. The Policy further indicated the following; -Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting process; -Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards; -The facility-oriented and resident-oriented approaches to safety are used together implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors; and -Resident supervision is a core component of the systems approach to safety. 1) Review of the Report submitted by the Facility via the Health Care Facility Reporting system (HCFRS), dated as submitted 11/08/24, indicated that on 11/02/24 at approximately 11:50 A.M., Resident #1 was unable to be located despite searching his/her room, unit, Facility (both inside and out) and surrounding neighborhoods. Resident #1 was admitted to the Facility in October 2024, diagnoses included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), alcohol abuse, polysubstance abuse, acute Pulmonary Embolism (PE, blood clot located in the lungs), Deep Vein Thrombosis (DVT, blood clots) to both lower extremities and bipolar disorder. Resident #1's Hospital Discharge Summary, dated 10/31/24, included progress notes related to poor safety awareness and exit seeking behaviors exhibited by him/her while in the hospital, with the need for additional safety measures that were implemented during his/her admission, as follows: -Hospital Physical Therapy Progress Note, dated 10/24/24, indicated he/she required one to one (1:1) continuous monitoring for safety. - Hospital Nurse Progress Notes, dated 10/24/24 and 10/25/24, indicated he/she required a 1:1 sitter and a bed alarm for safety. - Hospital Nurse Progress Note, dated 10/27/24, indicated that a Code Gray (missing person) was called due to Resident #1 trying to leave. -Hospital Nurse Progress Note, dated 10/28/24, indicated he/she required a 1:1 sitter and a bed alarm for safety. Review of Resident #1's Brief Interview Mental Status (BIMS), dated 11/01/24, indicated he/she scored a 4, indicating he/she was severely cognitively impaired (0-7 indicated severe cognitive impairment, 8-12 indicates moderate cognitive impairment, and 13-15 indicates intact cognition). Review of Resident #1's Nurse Progress Note, dated 11/01/24 at 1:09 P.M., indicated that he/she was experiencing increased agitation, increased mood and increased pacing. Review of Resident #1's Care Plan titled Wandering, dated 11/01/24, indicated he/she was at risk for wandering related to his/her impaired cognition. During an interview on 11/14/24 at 12:27 P.M., the Activity Assistant said that on 11/01/24 at approximately 10:45 A.M., she was conducting a group activity (playing trivia and other games) in the day room and Resident #1 was one of five (5) residents in attendance. The Activity Assistant said that two residents entered the day room and asked her if they could go out to smoke (the designated smoking area entrance/exit is in that day room) and said she let the smokers out into the designated smoking area by entering the code into the keypad that releases the door. The Activity Assistant said when she went to let the two residents back inside, Resident #1 followed her to the door, he/she went out onto the patio and when she asked him/her to go back inside through the day room door to the activity table, Resident #1 refused and said no. The Activity Assistant said she remained with Resident #1, that they walked around the building and entered again through the front entrance door to the Facility. The Activity Assistant said she had texted a staff member to meet her at the front entrance to help encourage Resident #1 to go back inside the building. Review of Resident #1's Elopement/Exit Seeking Evaluation, dated 11/01/24, (completed after the incident with the Activity Assistant) indicated he/she was at an increased risk for elopement. During a telephone interview on 11/27/24 at 9:22 A.M., Certified Nurse Aide (CNA) #3 said that on 11/02/24, there were three CNA's working the day shift on Unit 2 (Resident #1's unit) and she was floating back and forth between the two sides of the unit (upper and lower side). CNA #3 said just as she was getting to work at 7:00 A.M., she noticed Resident #1 pacing back and forth on the unit, that he/she appeared very confused, disoriented and was asking to go home. CNA #3 said that she last saw Resident #1 while she was assisting another resident with care in the room directly next to the alarmed exit door on the second floor. CNA #3 said she could hear someone trying to open the exit door so she went to see who it was. CNA #3 said she saw Resident #1 at the door, asked Resident #1 what he/she was doing and that he/she said he/she was just looking outside. CNA #3 said that she redirected Resident #1 away from the exit door, walked him/her down the hallway back towards the opposite direction on the unit and returned to her assignment. During an interview on 11/14/24 at 12:43 P.M., Certified Nurse Aide (CNA) #1 said on 11/02/24 she worked the 7:00 A.M. to 3:00 P.M., shift on Unit #2, which is split up into lower and upper sides, that she was assigned to work on the side of the unit where Resident #1 resided and that he/she was on her assignment. CNA #1 said Resident #1 had already been dressed in regular street clothes at the start of the shift. CNA #1 said starting around 7:30 A.M., Resident #1 continuously asked her and Nurse #1 for a ride home. CNA #1 said that she had been in another room providing care to a different resident and said she could hear someone trying to push through the exit door at the end of the hall. CNA #1 said she went to check it out, saw Resident #1 at the door, asked him/her what he/she was doing and that Resident #1 said he/she was trying to get out. CNA #1 said Resident #1 had been pacing back and forth up and down the hallway, kept trying to exit out the alarmed, locked exit door at the end of the hallway and that Resident #1 somehow broke the alarm mechanism of the door, so that the alarm kept sounding. CNA #1 said it was difficult to monitor Resident #1 that day, and that she had redirected Resident #1 multiple times (between 7:00 A.M. and 11:20 A.M.) away from the exit door at the end of the hall. CNA #1 said that around 11:20 A.M., she told Nurse #1 that she was going on a short break and when she left the unit, she saw Resident #1 talking with Nurse #1 at the medication cart. CNA #1 said she returned from break at approximately 11:40 A.M., started to help pass lunch trays, that as she walked by Resident #1's room she noticed that he/she was not there, and she did not see him/her anywhere in the hallway, so she went into Resident #1's room to look for him/her and he/she was not in there. CNA #1 said that she immediately went and told Nurse #1 that she thought Resident #1 was missing. CNA #1 said she did not know how Resident #1 exited the unit. Review of Resident #1's Nurse Progress Note (written by Nurse #1), dated 11/02/24, indicated that Resident #1 appeared unsettled, was wandering from room to room and he/she was asking to have someone book him/her a ride. The Note indicated that Resident #1 had been exit seeking through one of the locked, alarmed exit doors at the end of the hallway and at one point he/she broke the alarm on the door. During a telephone interview on 11/14/24 at 1:59 P.M., Nurse #1 said on 11/02/24 from 7:00 A.M. to 3:00 P.M., he was Resident #1's nurse. Nurse #1 said Resident #1 had been pacing back and forth, hanging out at the medication cart with him and repeatedly saying he/she wanted a ride home. Nurse #1 said that by approximately 9:00 A.M., Resident #1 had broken the locked, alarmed exit door at the end of the hallway from repeatedly trying to open the door, so the alarm would not stop sounding, and was unable to be shut off for a few hours. Nurse #1 said he notified Nurse #2 (who was working on another unit in the facility) and Nurse #3 (who was working on the other side of Unit 2) that the exit door was broken and asked them what to do. Nurse #1 said that both Nurse #2 and Nurse #3 said that they were too busy and did not have time to help him. Nurse # 1 said when CNA #1 informed him that she was going to take a break, he directed Resident #1 to go into the day room to join an activity that was happening and said he saw Resident #1 going toward that direction. Nurse #1 said that at approximately 11:45 A.M., CNA #1 notified him that Resident #1 was missing. Nurse #1 said they began to search for him/her immediately. Nurse #1 said when he went to check outside in the designated smoking area (which was fenced in), he noticed that there were two gates and said the gate leading to the back parking lot was not secured and was wide open. Nurse #1 said it was only after the fact of Resident #1's elopement, that he was made aware that Resident #1 had tried to exit the building the day before. Nurse #1 said that he was not aware that there was a Weekend Supervisor in the building or that the Director of Maintenance had been in the building as well that day. Nurse #1 said the Director of Maintenance only came up to Unit 2 to try and fix the alarm on door that would not stop sounding, after Resident #1 had already been noted as missing. During an interview on 11/14/24 at 10:13 A.M., the Director of Maintenance said that he had been in the Facility on 11/02/24 and was unaware that the alarm had been broken on the exit door at the end of the hallway on Resident #1's unit. The Director said when he was made aware that the exit door had been broken, Resident #1 was already identified as missing. The Director said that when he went to check the exit door on Resident #1's unit, the alarm was still sounding, and that a staff member had to enter the access keycode number to let him onto the unit. During a telephone interview on 11/22/24 at 10:15 A.M., the Weekend Supervisor said that on 11/02/24, she went into work that day at 7:00 A.M. and said she rounded on the second floor (Resident #1's unit), said hello to Nurse #3, two of the three CNA's and then headed to the third floor where she was assigned to be the second nurse for the 7:00 A.M. to 3:00 P.M. shift. The Supervisor said that she was unaware that the second floor had a challenging resident (Resident #1) that had been exit seeking and said she never heard any alarms going off. The Supervisor said right around 12:00 P.M., she was exiting a resident's room, saw staff running around, that she was then made aware Resident #1 was missing and that she announced a Missing Person Emergency Code, called to informed the police, Director of Nurses and the Administrator. During an interview on 11/14/24 at 11:43 A.M., Nurse #2 said that on 11/02/24 around lunch time, a nurse from the second floor came up to the third floor looking for Resident #1. Nurse #2 said that he began helping with the search and that the Missing Person Emergency Code (announced over the Facility intercom with location and directions) announcement was made. During an interview on 11/14/24 at 2:33 P.M., Resident #1 told the surveyor that he/she had taken a trip a few days ago, went for a long walk, and somehow ended up back at the Facility. Resident #1 said that he/she walked all the way to Woburn, that his/her feet hurt, and he/she had blisters and sores on them because it had been such a long walk (3.6 miles). Resident #1 said someone had picked him/her up and brought him/her to a hospital to be evaluated. Resident #1 said he/she could not remember how he/she got out of the building. Review of the website Weather.com, for weather conditions on 11/02/24 into 11/03/24 for Arlington and Woburn, indicated the during the day on 11/02/24 the daytime temperature on days in both cities and was between 50-55 degrees Fahrenheit (F), however the overnight temperature in both cities on 11/03/24 was between 30-31 degrees (F). Although staff members recall seeing Resident #1 dressed in street clothes at the start of the day shift on 11/02/24, there is no evidence to support he/she had on a winter or heavy warm coat to protect him/her from the cold overnight/early morning temperatures on 11/03/24. Review of Resident #1's Hospital Discharge Summary, dated 11/05/24, indicated he/she had been transferred and admitted to the Hospital after being found by police at a convenience store. The Summary indicated Resident #1 was diagnosed with leukocytosis (increased number of white blood cells, that could be caused by an infection, inflammation, an injury, or immune system disorders), Acute Kidney Injury (AKI) from dehydration, and wounds to both feet and toes. During an interview on 11/14/24 at 2:50 P.M., the Director of Nurses (DON) said that despite all their search efforts, they were unable to locate Resident #1. The DON said that Resident #1 was found the next day by the police in a different town, more than three miles away in a grocery store. The DON said they were unable to determine exactly how Resident #1 got off the unit or how he/she exited the facility. 2) Review of the Facility Policy titled Smoking, undated, indicated that those residents who desire to smoke are allowed the privilege to do so outside, while supervised by a designated staff member. The Policy also indicated that there were designated smoking times at scheduled predetermined intervals (at the discretion of the Facility); -9:00 A.M.,11:30 A.M., 1:00 P.M., 4:00 P.M., 6:00 P.M., and 11:30 P.M. During a tour of the facility on 11/15/24 at 7:55 A.M., the Surveyor conducted observations in the designated smoking area utilized by the residents and they were as follows: -The designated smoking area is in the back of the building and is located just outside of the day room on the second floor (Resident #1's unit). -The smoking area is fenced in by a chain link fence (about 3 feet high) and there were two (2) gates, one on each end of the smoking area. -One of the gates, if you exit through it, leads to the front side of the building. -The other gate, if you exit through it, leads to the side of the building. - However, both gates allow anyone going out through them to access the facility parking lot, which take you to the front of the building, which is off a main road, and allows anyone to walk away from facility grounds. -The gate leading to the back of the building was unsecured and was wide open. -There was one resident out in the patio area smoking a cigarette, unsupervised by staff. -The were no staff members present in the day room or out in the smoking area. During an interview on 11/14/24 at 12:27 P.M., the Activity Assistant said on 11/02/24 (the day Resident #1 went missing) sometime before lunch, while she was doing an activity in the day room, two residents entered the day room and asked her if they could outside to smoke (the door used by staff/residents to go in/out to the designated smoking area is located in the day room). The Activity Assistant said she let the two residents out into the designated smoking area by entering a code into the keypad that releases the door. The Activity Assistant said she did not go outside to the smoking area to supervise the two residents, that she stayed in the day room and continued doing an activity with the other residents. The Activity Assistant said from inside the day room, she watched the residents smoking outside and monitored the residents participating in the activity in the day room, at the same time. The Activity Assistant said that is what she usually does when there is an activity running at the same time there is a scheduled smoking break going on. However, this was not consistent with the facility's Smoking Policy, which indicated that residents could go outside to smoke while under the supervision of a designated staff member. During an observation on 11/15/24 at 7:55 A.M., the Surveyor also noted the following in the day room on Unit 2, which is where the door with access to the designated smoking area is located: - Inside the day room, there was a keypad mounted on the wall to the left of the door that exits out into the smoking area. The keypad requires an access code be entered into it, in order for the locking mechanism to release and open the door. -On the wall on the outside the door, (in the smoking area) there is another keypad mounted on the wall next to door, which also requires an access code to be entered into it, in order to be able to open the door and re-enter the building. During an interview on 11/15/24 at 8:00 A.M., Resident #4 said that the designated smoking area is located off the main dining room/day room on the second floor. Resident #4 said he/she smokes, can smoke alone, and that he/she does not need anyone to be with him/her while smoking. The Surveyor asked Resident #4 if he/she had the code number to the keypad to open the door to exit and enter, he/she said yes and he/she provided the keypad code numbers to the Surveyor. During an interview on 11/15/24 at 8:25 A.M., Resident #5 said that he/she was a smoker and was independent with smoking. Resident #5 said a staff member watches them from inside of the building. Resident #5 said that he/she did not know the codes to get out or back in from the designated smoking area. During an observation on 11/15/24 at 8:31 A.M., the Surveyor saw Resident #6 out in the designated smoking area smoking a cigarette, however there was no staff member present in the smoking area providing supervision. At 8:34 A.M. the Surveyor observed Resident #6 enter numbers into the keypad from the outside, the lock on the disengaged, and he/she came back into the building. During an observation on 11/15/24 at 8:37 A.M., the Surveyor observed Resident #5, (who previously stated that he/she did not know the codes to the doors keypads) enter the day room on the second floor, he/she went to the keypad, entered numbers into it and was able to exit the day room out to the designated smoking area independently. There were no staff members present in the day room to let the Resident #5 out or back in from the smoking area. There were no staff members present out in the smoking area to provide supervision for Resident #5 when he/she went outside to smoke. Resident #5 was outside alone for about 20 minutes unsupervised by staff while smoking, until 8:57 A.M., when the Activity Director arrived. During an interview on 11/15/24 at 8:59 A.M., the Unit Manager said that she was not aware that any residents had the access codes to exit the building to go out to the smoking area, and said there should always be a staff member outside with the smokers until the smoking break is over. During an interview on 11/15/24 at 2:00 P.M., the Director of Nurse (DON) said that he was unaware that some of the residents knew the access codes to the keypad to exit out to the designated smoking area. The DON said that it is the Facility's expectation that none of the residents are provided with the keypad codes to any exit doors. The DON said that the gates outside in the designated smoking area are supposed to be kept locked at all times. The DON said residents are not allowed to be in the designated smoking area unless they are supervised by a Facility employee, and that the staff member must be outside while the residents are out there. The DON said it was not acceptable for the designated staff member to stay inside in the day room to monitor the residents who are outside, as that would leave the residents outside smoking unsupervised.

Based on observation, policy review, and interview, the facility failed to handle food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure that staff did not contaminate ready to eat food during service. Findings include: Review of the facility's policy titled Food Preparation and Services, revised April 2022, indicated, but was not limited to, the following: - Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. - Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single-use items and are discarded after each use. The surveyor made the following observations on 10/17/24 from 11:34 A.M. until 11:52 A.M. during the lunch tray line: - The cook contaminated his gloves by taking lids off pans and by grabbing pan lids stored under the table. The cook then further contaminated his gloves by removing the plastic wrap from the top of two pans, and by grabbing the handles of serving utensils. - Using the same contaminated gloves the cook grabbed edible flowers and placed them on 12 resident plates to be served. Using the same contaminated gloves the cook also grabbed five hot dog buns and placed them on resident plates to be served. During an interview on 10/18/24 at 8:27 A.M., the Food Service Director (FSD) said it was important for staff to avoid contaminating food and that staff should handle food in a way that avoids contaminating ready-to-eat food with contaminated gloves.

Based on record review and interview, the facility failed to obtain a signed psychotropic informed consent for one Resident (#67) out of a total sample of 23 residents. Findings include: Resident #67 was admitted in 06/2024 with diagnoses including bipolar disorder and schizophrenia. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #67 scored a 2 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Review of the medical record indicated Resident #67 has a guardian in place (a court appointed designated individual who makes decisions on behalf of the Resident). Review of the medication administration record for October 2024 indicated Resident #67 was receiving Lithium Carbonate 600 milligrams (a medication used to treat bipolar disorder), which was initiated on 6/21/24. Review of the psychotropic consent form, undated, failed to indicate that it was signed by the resident representative or healthcare representative. During an interview on 10/18/24 at 8:09 A.M., the Director of Nursing said that he has been trying to contact the healthcare proxy and guardian, but they have been difficult to contact. The Director of Nursing said that the facility will provide the medication without consent if it would be more harmful to stop the medication.

Based on observations, record review and interview the facility failed to provide a clean and comfortable homelike environment to one Resident (#21) out of a total sample of 23 residents. Specifically, the facility failed to ensure that Resident #21's room was free from strong odors. Findings Include: Resident #21 was admitted to the facility in August 2021 with diagnoses that include cerebral infarction and diabetes. Review of Resident #21's most recent Minimum Data Set (MDS) Assessment, dated 9/5/24, indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating that Resident #21 is cognitively intact. The MDS further indicated that the Resident is dependent for ADLS and toileting and is frequently incontinent of bowel and bladder. On 10/16/24 at 8:48 A.M., the surveyor entered Resident #21's room, which had a strong odor. The Resident was in bed and eating breakfast. The Resident said, my room smells horrible, but it doesn't get cleaned well. It's not fair to have to keep smelling it, especially while I'm eating breakfast. On 10/17/24 at 8:14 A.M., the Resident was observed sleeping in bed. A strong odor was noted in the room. On 10/17/24 at 9:57 A.M., the Resident was observed eating breakfast in his/her bed. The surveyor asked if he/she felt like the odor in the room was improved and he/she said, no it's not, it's sickening especially while I am here eating my breakfast. The Resident indicated that no one had been in to thoroughly clean the room. Review of physician's orders indicated the following order: -Change purewick [an external catheter] catheter head every 12 hours and as needed when soiled. Empty container, wash container and elbow tubing with soap and water, pat dry. Reapply, hook up machine and check for function, dated 5/24/23. Further review of the medical record failed to indicate documentation regarding management and maintenance of the purewick system as ordered by the physician. During an interview on 10/17/24 at 10:13 A.M., Nurse #3 said it was hard to keep Resident #21's room odor free because of the purewick system that he/she used for incontinence management. During an interview on 10/17/24 at 10:33 A.M., the Housekeeping Manager said it was difficult to prevent odors in Resident #21's room because of the bathroom devices he/she used. She said she was aware of the strong odor, but that staff had never asked to increase the cleaning frequency of the room. She said housekeeping was going into the room daily, and the last time that the room was deep cleaned was 9/28/24. During an interview on 10/18/24 at 7:07 A.M., Unit Manager #1 said that she was aware of Resident #21's concerns about the odor in his/her room. She said the cover of the purewick canister builds up with urine and that she cleaned it out yesterday but it needed ongoing maintenance, which was not previously ordered to be completed. During an interview on 10/18/24 at 7:33 A.M., the Director of Nurses said he was aware of the odor in Resident #21's room. He said there should not be odors in resident's rooms.

Based on record review and interview, the facility failed to provide a resolution to a grievance filed, specifically related to staff members sleeping on shift. Findings include: Review of the facility policy titled Grievance Policy, dated 12/29/22, indicated the following: - Upon the receipt of the written grievance and/or complaint, the grievance officer will refer it to the appropriate department head for investigation. The department head will submit a written report of the findings to the grievance officer within 72 hours of receiving the grievance and/or complaint. - Receipt of the grievance log/complaint will be logged by the Grievance officer in the grievance log. - The person filing the grievance and/or complaint will be informed of the findings and actions taken. This report will be completed by the grievance officer or designee within 3-5 working days. Review of the grievance log indicated that on 5/16/24, a grievance was filed stating staff asleep 11-7 am Friday night. Review of the resolution on the grievance form failed to indicate that any resolution was determined. During an interview on 10/18/24 at 10:30 A.M., the Director of Nursing said that a resolution should be documented on the form and that there were audits completed after that grievance was filed. The facility failed to provide any documentation of resolution for the grievance filed regarding staff sleeping.

Based on observations, record review and interview, the facility failed to identify and assess the use of mattress bolsters underneath a fitted sheet to bilateral head and foot of the bed as a potential restraint for one Resident (#62) out of a total sample of 23 residents. Findings Include: A physical restraint, as defined in the State Operations Manual, Appendix PP - Guidance to surveyors for Long Term Care Facilities, is any manual method, physical or mechanical device, equipment or material that limits a resident's freedom of movement and cannot be removed by the resident in the same manner as it was applied by staff. Resident #62 was admitted to the facility in May 2023 with diagnoses that include cognitive communication deficit and chronic kidney disease. Review of Resident #62's most recent Minimum Data Set (MDS) Assessment, dated 8/1/24, indicated a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating that the Resident had severe cognitive impairment. On 10/16/24 at 8:16 A.M., the surveyor observed Resident #62 lying in bed. The Resident had mattress bolsters in place bilaterally at the head of the bed as well as foot of bed under the fitted sheet. An approximately eight inch gap was present between the upper and lower bolster. On 10/16/24 at 8:44 A.M. and 1:02 P.M., the surveyor observed Resident #62 sitting in bed at an approximately 45-degree angle. The elevated head of the bed erased the gap that was present between the bolsters at the head and the foot of the bed which were under the fitted sheet. On 10/17/24 at 6:58 A.M., and 9:10 A.M., and 12:49 A.M., the surveyor observed Resident #62 in bed with mattress bolsters in place bilaterally at the head of the bed as well as the foot of the bed. The bolsters were under the fitted sheet and an approximately eight inch gap was present between the upper and lower bolsters. On 10/18/24 at 6:47 A.M., the surveyor observed Resident #62 sleeping in bed on his/her back with mattress bolsters in place bilaterally at the head of the bed as well as at the foot of the bed under the fitted sheet. Review of Resident #62's medical record failed to indicate a restraint assessment has been completed to determine whether the mattress bolsters would be a potential restraint for the Resident. Review of Resident #62's medical record failed to indicate a physician's order for the mattress bolsters. Review of Resident #62's care plan failed to indicate the use of mattress bolsters. During an interview on 10/17/24 at 1:20 P.M., Certified Nurse Aide (CNA) #1 said that Resident #62 tries to climb out of bed every day and that is why he/she has bolsters on their mattress. CNA #1 said that Resident #62 tries to swing his/her legs over the bolsters and stand up, even though the Resident is unable to stand. She said this helps to keep her in bed. During an interview on 10/18/24 at 6:26 A.M., CNA #2 said that he works the overnight shift. He said that the bolsters are on Resident #62's bed to keep him/her in bed and prevent him/her from getting out of bed. He said that sometimes the Resident attempts to get out of bed, so the bolsters help to stop him/her. CNA #2 said that he also rounds and checks in frequently on the Resident. During an interview on 10/18/24 at 7:11 A.M., Unit Manager #1 said that to her knowledge, no restraint assessment was completed to determine whether the mattress bolsters would be a potential restraint for Resident #62. During an interview on 10/18/24 at 7:52 A.M., the Regional Clinical Director said that she did not see a restraint assessment completed on Resident #62 but if they thought it was potentially inhibiting the Resident's movement, they would complete one. She said officially no assessment was completed but there was a conversation among the team before utilizing the mattress bolsters.

Based on record review and interview, the facility failed to report allegations of potential abuse for 3 Residents (#55, #78, and #DC1) out of a total sample of 23 residents. Findings include: Review of the facility policy titled Abuse and Neglect- Clinical Protocol, revised March 2018, indicates the following: - Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes deprivtion by an individual, including a caretaker, of goods or services that are necessary to attain or maintain mental and physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. 1. Resident #55 was admitted in 07/2023 with diagnoses including anxiety and depression. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #55 scored a 13 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the grievance concern report, dated 3/13/24, indicated Resident #55 filed a grievance because a nurse made a comment to his/her roommate saying that Resident #55 was always drugged up. 2. Resident #DC1 was admitted in October 2022 with diagnoses including dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident DC#1 scored a 9 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Review of the grievance concern report, dated 2/12/24, indicated Resident #DC1 complained that a certified nursing aide said to him/her this is why your spouse [sic] doesn't want to visit you. 3. Resident #78 was admitted in July 2024 with diagnoses including anxiety and communication deficit. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #78 scored a 7 out of 15 on the Brief Interview for Mental status (BIMS), indicating severe cognitive impairment. Review of the MDS indicated Resident #78 was dependent on staff for care. Review of the grievance concern report, dated 4/2/24, indicated Resident #78's representative reported that certified nursing aides are rough when handling the Resident and the Resident was told on three separate dates to go to the bathroom in his/her bed or brief instead of being assisted to the bathroom. During an interview on 10/18/24 at 7:20 A.M., the Social Worker said that she is responsible for filing grievances for the residents. The Social Worker said that if she feels anything rises to the level of abuse then she would notify the Director of Nursing immediately. The Social Worker said that when there is an allegation of abuse, then an investigation is initiated and the residents and staff are interviewed. During an interview on 10/18/24 at 7:40 A.M., the Director of Nursing said if there is an allegation of abuse, then an investigation is conducted and a 2 hour reportable is sent to the state agency. The Director of Nursing said that abuse is constituted as physical, verbal, emotional harm, and neglect. The Director of Nursing said that refusing to change someone's incontinence brief is neglect. Yelling at a resident would be considered verbal abuse, as well as, saying no wonder your spouse doesn't want to visit you. Review of the Healthcare Facility Reporting System (HCFRS) failed to indicate that any of the allegations were reported to the state agency.

Based on record review and interview, the facility failed to investigate allegations of potential abuse for 3 Residents (#55, #78, and #DC1) out of a total sample of 23 residents. Findings include: Review of the facility policy titled Abuse and Neglect- Clinical Protocol, revised March 2018, indicates the following: The staff, with physician's input as needed, will investigate alleged abuse and neglect to clarify what happened and indentify possible causes. - Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes deprivtion by an individual, including a caretaker, of goods or services that are necessary to attain or maintain mental and physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Review of the facility policy titled Grievance Policy, dated 12/19/2022, indicates the following: - If a grievance or complaint rises to the level of potential abuse, neglect, or misappopriation the Administrator should be notified immediately. Otherwise, the information should be given to the Administrator within 24 hours. 1. Resident #55 was admitted in 07/2023 with diagnoses including anxiety and depression. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #55 scored a 13 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the grievance concern report, dated 3/13/24, indicated Resident #55 filed a grievance because a nurse made a comment to his/her roommate saying that Resident #55 was always drugged up. 2. Resident #DC1 was admitted in October 2022 with diagnoses including dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident DC#1 scored a 9 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Review of the grievance concern report, dated 2/12/24, indicated Resident #DC1 complained that a certified nursing aide said to him/her this is why your spouse [sic] doesn't want to visit you. 3. Resident #78 was admitted in July 2024 with diagnoses including anxiety and communication deficit. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #78 scored a 7 out of 15 on the Brief Interview for Mental status (BIMS), indicating severe cognitive impairment. Review of the MDS indicated Resident #78 was dependent on staff for care. Review of the grievance concern report, dated 4/2/24, indicated Resident #78's representative reported that certified nursing aides are rough when handling the Resident and the Resident was told on three separate dates to go to the bathroom in his/her bed or brief instead of being assisted to the bathroom. During an interview on 10/18/24 at 7:20 A.M., the Social Worker said that she is responsible for filing grievances for the residents. The Social Worker said that if she feels anything rises to the level of abuse then she would notify the Director of Nursing immediately. The Social Worker said that when there is an allegation of abuse, then an investigation is initiated and the residents and staff are interviewed. During an interview on 10/18/24 at 7:40 A.M., the Director of Nursing said if there is an allegation of abuse, then an investigation is conducted and a 2 hour reportable is sent to the state agency. The Director of Nursing said that abuse is constituted as physical, verbal, emotional harm, and neglect. The Director of Nursing said that refusing to change someone's incontinence brief is neglect. Yelling at a resident would be considered verbal abuse, as well as, saying no wonder your spouse doesn't want to visit you. The facility failed to provide any internal investigations for the allegations.

Based on observations, record review and interview the facility failed to ensure Minimum Data Set (MDS) Assessments were accurately completed to reflect the status of one Resident (#21) out of a total sample of 23 residents. Specifically, the facility inaccurately documented the use of an indwelling catheter. Findings Include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, indicates that an indwelling catheter is a catheter that is maintained within the bladder for the purpose of continuous drainage of urine. Resident #21 was admitted to the facility in August 2021 with diagnoses that include cerebral infarction and diabetes. Review of Resident #21's most recent Minimum Data Set (MDS) Assessment, dated 9/5/24, indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating that Resident #21 was cognitively intact. Further review of the MDS indicated that the Resident utilized an indwelling catheter. Review of the medical record failed to indicate the use of an indwelling catheter. Review of physician's orders indicated the following order: -Change purewick [an external catheter] catheter head every 12 hours and as needed when soiled. Empty container, wash container and elbow tubing with soap and water, pat dry. Reapply, hook up machine and check for function, dated 5/24/23. Review of Resident #21's active urinary incontinence care plan, dated as revised on 8/15/23, indicated to use purewick as ordered. During an interview on 10/18/24 at 7:07 A.M., Unit Manager #1 said that a purewick catheter is not an indwelling catheter and should not be coded as one. During an interview on 10/18/24 at 7:26 A.M., the Director of Nursing (DON) said that Resident #21 uses a purewick catheter, but a purewick catheter is not an indwelling catheter. He said it was an inaccurate coding on the MDS.

Based on record review, and interview the facility failed to protect one Resident (#2) from neglect out of a total sample of 22 Residents. Specifically, the facility failed to ensure that nursing staff identified multiple treatment orders for one wound and neglected to implement treatments ordered by the physician as instructed by the Wound Clinic for his/her coccyx wound from May 2023 through September 2023. Subsequently, Resident #2's wound deteriorated significantly. In July 2023 Resident #2 was hospitalized and was diagnosed with Stage IV decubitus ulcer with osteomyelitis (an infection of the bone) and erosion of the distal sacrum and proximal coccyx. Findings include: Neglect, as defined at S483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The American Nurses Association (ANA), Scope of Nursing Practice, Third Edition, indicated Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations. Resident #2 was readmitted to the facility in March 2023 with diagnoses including an amputation of the right leg below the knee, peripheral artery disease, diabetes and dementia. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #2 scored 10 out of a possible 15 on the Brief Interview for Mental Status Exam indicating moderate cognitive impairment. Review of the MDS also indicated Resident #2 required physical assist of two staff members for bed mobility. Review of Resident #2's nursing progress note dated 3/27/23, indicated the Resident developed a stage II pressure ulcer at the facility on his/her coccyx. Review of Resident #2's pressure ulcer care plan dated 6/15/23, indicated interventions including: monitoring nutritional status, weekly treatment documentation to include measurements of each area of skin breakdown width, length, depth, type of tissue and exudate, and to administer treatments as ordered and monitor for effectiveness and weekly wound physician evaluation and treatment. Review of Resident #2's medical record indicated his/her wound was being monitored by both the contracted wound physician at the facility and the Wound Clinic from March, 2023 to June, 2023. During an interview on 10/2/23 at 8:58 A.M., Unit Manager #1 said that orders from the Wound Clinic are relayed to a Resident's attending physician or Nurse Practitioner which are then approved and implemented. Unit Manager #1 said Physician #1 and Nurse Practitioner #1 have not declined any treatment recommendations from the Wound Clinic for Resident #2. Review of the Wound Clinic Summary dated 5/4/23, indicated Resident #4 had a Stage IV pressure ulcer: [Resident's] sacral ulcer extends to muscle and there was a fair amount of necrosis (dead tissue) today with undermining requiring extensive debridement (a surgical procedure to remove dead tissue). I am very concerned about [Resident #2's] sacral ulcer. Dressings: Mesalt packing/adhesive foam 1-2 times daily. (Mesalt helps manage heavily discharging wounds in the inflammatory phase. It can be used for deep cavity pressure ulcers. Mesalt absorbs wound exudate and the sodium chloride is released, exudate, bacteria and necrotic material is drawn into the dressing, facilitating the natural wound healing process.) Review of the Wound Clinic Summary dated 5/18/23, indicated: [Resident's] sacral ulcer Dressings: Mesalt packing/adhesive foam 1- 2 times daily. Review of the May 2023 Treatment Administration Record (TAR) for Resident #2 indicated: *Wound care left coccyx cleanse with normal saline, pat dry. Apply Santyl to wound bed followed by calcium alginate. Cover with bordered gauze island dressing every day shift for wound care. Active 4/27/23 through 6/22/23 *Santyl external ointment 250 Unit (collagenase) apply to left coccyx topically every day shift for wound care. apply Santyl to left coccyx as per TAR treatment order. Active 4/21/23 through 6/22/23. The May 2023 TAR for Resident #2 indicated both treatments were documented as being completed every day shift from 5/1/23 through 5/31/23. The treatments administered to Resident #2 for May 2023 did not include packing the wound with Mesalt or the use of adhesive foam per the Wound Clinic. Review of the Wound Clinic summary dated 6/1/23 indicated: [Resident #2's] sacral ulcer Dressings: Dakins irrigation (a dilute solution of sodium hypochlorite (0.4% to 0.5%) used as an antiseptic to cleanse wounds in order to prevent infection) then Mesalt packing/Adhesive foam 1-2 X daily. Review of the Wound Clinic Summary dated 6/22/23 indicated: Hopefully [Resident #2's] sacral wound has stabilized. Dressing: Dakins irrigation then Mesalt packing/adhesive foam 1-2 times daily. Review of the June 2023 TAR indicated: *Wound care left coccyx cleanse with normal saline, pat dry. Apply Santyl to wound bed followed by calcium alginate. Cover with bordered gauze island dressing every day shift for wound care. Active, 4/27/23 through 6/22/23 *Santyl external ointment 250 Unit (collagenase) apply to left coccyx topically every ay shift for wound care. apply Santyl to left coccyx as per TAR treatment order. Active 4/21/23 through 6/22/23. *Wound care: coccyx. cleanse with normal saline pat dry. Apply Mesalt to wound bed. Cover with bordered gauze island dressing every day shift for wound care. Active 6/23/23 - 7/28/23. The June 2023 TAR indicated that two treatments were administered daily to Resident #2 from 6/1/23 through 6/22/23. The orders implemented on 6/23/23 failed to include the Dakins solution, instructions to pack the wound, or the use of absorbent foam per the Wound Clinic. Review of the Wound Clinic summary dated 7/13/23 indicated: [Resident] is a candidate for wound vac (a machine used to pull fluid from the wound over time to help reduce swelling, clean the wound and remove bacteria) for better wound management. Dressings: Alginate with silver/Adhesive foam 1-2 times daily. Wound Vac when available. Review of the July 2023 TAR indicated: *Change wound vac Monday, Wednesday Friday every day shift in the morning for wound care, active 7/14/23 - 7/28/23. *Wound care: coccyx. cleanse with normal saline pat dry. Apply Mesalt to wound bed. Cover with bordered gauze island dressing every day shift for wound care. Active 6/23/23 - 7/28/23 *Normal Saline wash pat dry alginate to wound bed border gauze to coccyx wound change daily in the morning for wound care 7/29/23 - 9/25/23. The use of alginate with silver and the use of adhesive foam per the Wound Clinic were not implemented. Review of the Wound Clinic Summary dated 8/17/23 indicated: hospitalization occurred the day after [Resident #2's] wound vac was placed. Decubitius ulcer has demarcated but there are signs of pressure that still remain in the surrounding skin. I would like to reinitiate the wound vac to [Resident #2's] sacral wound. Dressing: moist packing gauze/adhesive foam 1-2 times daily. Wound vac when available. Review of the August 2023 TAR indicated: *[Normal Saline] wash pat dry alginate to wound bed border gauze to coccyx wound. Change daily in the morning care 7/29/23 - 9/25/23. The orders for the use of a wound vac and moist packing gauze/adhesive foam per the Wound Clinic were not implemented. During an interview on 10/2/23 at 8:58 A.M., Unit Manager #1 reviewed the Wound Clinic's 8/17/23 summary. She said that she was not aware of the Wound Clinic had ordered the use of a Wound Vac in August 2023. Unit Manager #1 said she did not call and was not aware if anyone else had called to verify orders or to follow up on obtaining a wound vac for Resident #2. Review of the Wound Clinic summary dated 9/21/23 indicated: I would like to reinitiate the wound vac to [Resident #2's] sacral wound. Dressings: Moist Packing gauze/adhesive foam 1-2 times daily. Please start wound vac as ordered to sacrum. Review of the September 2023 TAR indicated: *[Normal Saline] wash pat dry alginate to wound bed border gauze to coccyx wound. Change daily in the morning care. Active 7/29/23 - 9/25/23 *Start wound vac as ordered to the sacrum settings 125 mmhg. Change 3 times a week M, W, F every day shift for stage IV wound to the sacrum, initiated 9/23/23. The use of moist packing gauze/adhesive foam per the Wound Clinic were not implemented. During interviews on 10/2/23 at 8:58 A.M., and 10/5/23 at 10:26 A.M., Unit Manager #1 reviewed Resident #2's TAR's and said she was not aware of the double orders in June 2023 and May 2023. Unit Manager #1 said that errors should have been caught during the facility's 24 hour chart review or the monthly edits. Unit Manager #1 said that the Wound Clinic's orders were not implemented for Resident #2. During an interview on 10/2/23 at 8:36 A.M., Physician #1 said that Resident #2's wounds are monitored at the Wound Clinic. Physician #1 said that treatment orders are relayed to him or his nurse practitioner for approval. Physician #1 said that he defers to the wound clinic physician's recommendations and said he has never declined a recommendation from the Wound Clinic. During an interview on 10/2/23 at 9:42 A.M., Nurse Practitioner #1 said she has not declined any treatment recommendations made by the Wound Clinic for Resident #2. During an interview on 10/5/23 at 10:32 A.M., the Assistant Director of Nurses (ADON) said that risk meetings are held weekly to review residents with skin issues. The ADON said that at risk, measurements, treatments and the progression of wounds are reviewed. The ADON said that he was now aware that there were discrepancies between treatments implemented versus treatment orders from the Wound Clinic. The ADON said there needs to be a better system in place to ensure wound treatment orders are put in the record correctly. Review of the facility risk minutes indicated risk meetings where Resident #2's wounds were discussed were held on 5/4/23, 5/11/23, 5/18/23, 6/23/23, 6/29/23, 7/10/23, 8/10/23, 9/7/23 and 9/15/23. During an interview on 10/2/23 at 12:41 P.M. the Wound Clinic Physician said that Resident #2 has detailed orders that are put on a communication sheet and are also faxed over to the facility after his/her visits. The Wound Clinic Physician said that there have been times that there has been a dressing on Resident #2's sacrum/coccyx that was not the dressing he had ordered. The Administrator was provided with the Immediate Jeopardy Template on 10/6/23 at 11:25 A.M. and 10/13/23 at 12:15 P.M. See F658 and F686.

Based on observation, record review, and interview the facility failed to implement physician orders related to pressure ulcers for one Resident (#2) out of a total sample of 22 residents. Specifically, the facility failed to implement treatments ordered by the physician as instructed by the Wound Clinic for his/her coccyx wound from May 2023 through September 2023. Subsequently, Resident #2's wound deteriorated. In July 2023 Resident #2 was hospitalized and was diagnosed with Stage IV decubitus ulcer with osteomyelitis (an infection of the bone) and erosion of the distal sacrum and proximal coccyx. Findings include: Review of the [NAME] Manual of Nursing Practice, 11th Ed. (2019) indicated: Scope of Practice, Licensure, and Certification: The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. The National Council of State Boards of Nursing and the NLN have developed standards that guide each State Board in the development of their licensure requirements and scope of practice rules. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice dated as revised April 11, 2018 indicted: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Review of the facility's Pressure Ulcers/Skin Breakdown Clinical Protocol policy dated April 2018 indicated: *The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings and application of topical agents. *The physician will help identify medical interventions related to wound management, for example, treating a soft tissue infection surrounding an ulcer, removing necrotic (dead) tissue, addressing comorbid medical conditions, managing pain related to the wound or wound treatment. *During resident visits, the physician will evaluate and document the progress of wound healing - especially for those with complicated, extensive or poorly healing wounds. *The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. *Current approaches should be reviewed for whether they remain pertinent to the resident's/patient's medical conditions, are affected by factors influencing wound development or healing and the impact of specific treatment choices made by the resident/patient or a substitute decision-maker. Resident #2 was readmitted to the facility in March 2023 with diagnoses including an amputation of the right leg below the knee, peripheral artery disease, diabetes and dementia. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #2 scored 10 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS) indicating moderate cognitive impairment. Review of the MDS also indicated Resident #2 requires physical assist of two for bed mobility. On 9/28/23 at 7:59 A.M. Resident #2 was observed to be thin and frail resting in bed on an air mattress (a device utilized to redistribute pressure on the body) set at 320 lb. The air mattress pump had hand written instructions indicating the setting should be at 150 lbs. Review of Resident #2's medical record indicated a weight obtained on 9/15/23 was 109.6 lbs (pounds). During an interview on 10/5/23 at 8:31 A.M. Resident #2 was resting in bed. Resident #2 said he/she was having pain from the wound on his/her backside. Resident #2 said he/she goes out to the doctor for his/her wound treatment and was not sure if his/her wound was improving or worsening. During interviews on 10/2/23 at 7:28 A.M., and 10/5/23 at 8:35 A.M., CNA #1 said Resident #2 has wounds which are uncomfortable for him/her. CNA #1 said that Resident #2 is repositioned every two hours and does not refuse treatment or being turned. Review of Resident #2's clinical record indicated: *A nurse progress note dated 3/27/23 indicating Resident #2 developed a Stage II pressure injury at the facility on his/her coccyx measuring 1 Centimeter (CM) X 1 CM X .2 CM *Resident #2 was hospitalized from 4/11/23 through 4/14/23 and was noted to have returned with deterioration of the coccyx wound with slough (dead tissue). Measurements indicated by the facility's contracted wound physician on 4/27/23 indicated: 3.5 CM X 2.2 CM X not measurable depth. *Resident #2's wound was sporadically documented at Weekly Risk Meetings. *A care plan regarding Resident #2's coccyx pressure injury dated 6/15/23 with interventions including: monitoring nutritional status, weekly treatment documentation to include measurements of each area of skin breakdown width, length, depth, type of tissue and exudate, and to administer treatments as ordered and monitor for effectiveness and weekly wound physician evaluation and treatment. *Resident #2's wound was being monitored by both the contracted wound physician in the facility and the Wound Clinic from March 2023 to June 7, 2023. Resident #2 then began to receive wound care treatment solely through the Wound Clinic 1-2 times per month. During an interview on 10/2/23 at 8:36 A.M. Physician #1 said that Resident #2's wounds are monitored at the Wound Clinic. Physician #1 said that treatment orders are relayed to him or his nurse practitioner for approval. Physician #1 said that he cannot recall ever declining any wound treatments ordered by the Wound Clinic for Resident #2. During an interview on 10/2/23 at 9:42 A.M., Nurse Practitioner #1 said that for patient's who have wounds monitored at the Wound Clinic, she will review the Wound Clinic's orders and approve them. Nurse Practitioner #1 said she has not declined any treatment recommendations made by the Wound Clinic for Resident #2. During an interview on 10/2/23 at 8:58 A.M., Unit Manager #1 said that it is the responsibility of the assigned nurse to review orders from the Wound Clinic and then relay them to a Resident's attending physician or Nurse Practitioner. Unit Manager #1 said that the attending will then approve the orders and the nurse will then put them in the electronic record. Unit Manager #1 said that Physician #1 and Nurse Practitioner #1 have not declined any treatment orders from the Wound Clinic. A. Review of Resident #2's treatment care for May 2023 indicated: Review of the Wound Clinic Summary dated 5/4/23 indicated Resident #2 had a Stage IV pressure ulcer: [Resident's] sacral ulcer extends to muscle and there was a fair amount of necrosis (dead tissue) today with undermining requiring extensive debridement (a surgical procedure to remove dead tissue). I am very concerned about [Resident #2's] sacral ulcer. Post Debridement Measurements: 4.5 CM X 4 CM X .02 CM Type of tissue removed: subcutaneous fat, skin, necrotic eschar (a type of necrotic tissue that can develop on severe wounds). Structure exposed: Other. Dressings: Mesalt packing/adhesive foam 1-2 times daily. (Mesalt helps manage heavily discharging wounds in the inflammatory phase. It can be used for deep cavity pressure ulcers.) Review of the May 2023 risk notes indicated three total entries: 5/4/23: Unstageable due to necrosis of the left coccyx full thickness: Wound Size: 3.5 X 1.4. Depth is unmeasurable due to presence of nonviable tissue. (The measurements and staging of the wound differed from the Wound Clinic's documented measurements the same day; 5/4/23). Exudate: Light serosanguinous (drainage) Eschar thick adherent black necrotic tissue: 50% (The note failed to indicate what treatment was in place.) 5/11/23: Unstageable due to necrosis of the left coccyx full thickness: Wound size: 4 CM X 4 CM. Depth not measurable due to presence of nonviable tissue and necrosis. Exudate: Light serosanguineous. Eschar thick adherent black necrotic tissue: 10% Slough: 30% Interventions: NS (Normal Saline) wash Santyl gauze sponge daily to coccyx. (The staging of the wound differed from the Wound Clinic and the treatment indicated was not ordered by the Wound Clinic.) 5/18/23: Unstageable due to necrosis of the left coccyx full thickness: Wound size: 5 CM X 5 CM X 1 CM. Exudate: Serosanguinous. Eschar thick adherent black necrotic tissue: 10% Slough: 30% Interventions: NS wash Santyl gauze sponge daily to coccyx. (The staging of the wound differed from the Wound Clinic and the treatment indicated was not ordered by the Wound Clinic.) Review of the Wound Clinic Summary dated 5/18/23 indicated: [Resident's] sacral ulcer extends to muscle and there still was a fair amount of necrosis today with undermining requiring moderate debridement. Post Debridement Measurements: 6.8 CM X 6 CM X 2 CM Type of tissue removed: subcutaneous fat, skin, necrotic eschar, fascia (stringy connective tissue), muscle. Structure exposed: fat layer, bone (Resident #2's bone was now exposed) Dressings: Mesalt packing/adhesive foam 1 - 2 times daily. Review of the May 2023 Treatment Administration Record (TAR) indicated: *Wound care left coccyx cleanse with normal saline, pat dry. Apply Santyl to wound bed followed by calcium alginate. Cover with bordered gauze island dressing every day shift for wound care. Active 4/27/23 through 6/22/23 *Santyl external ointment 250 Unit (collagenase) apply to left coccyx topically every day shift for wound care. apply Santyl to left coccyx as per TAR treatment order. Active 4/21/23 through 6/22/23. The May 2023 TAR indicated both treatments were documented as being completed every day shift from 5/1/23 through 5/31/23. The treatments administered to Resident #2 for May 2023 did not include packing the wound with Mesalt or the use of adhesive foam per the Wound Clinic. During an interview on 10/5/23 at 8:12 A.M., Nurse #4 said Unit Manager #1 is responsible for measuring the wounds weekly and the weekly assessment of the wound. Nurse #4 said there should only be one treatment in place for each wound. During an interview on 10/5/23 at 8:13 A.M., Nurse #5 said there should only be one treatment in place for each wound. During an interview on 10/5/23 at 8:14 A.M., Nurse #6 said if there are two orders for the same wound she is not sure which one would be the correct order. Nurse #6 said there should only be one order for each wound in place. During interviews on 10/2/23 at 8:58 A.M., and 10/5/23 at 10:26 A.M., Unit Manager #1 reviewed the May 2023 TAR and said she was not aware of the double orders. Unit Manager #1 said that the errors should have been caught during the facility's 24 hour chart review or the monthly audits. Unit Manager #1 said she thought there had been a delay in obtaining the Mesalt, but it was not for long. Unit Manager #1 said she did not contact the Wound Clinic and did not know if anyone else had contacted the Wound Clinic to alert them of a delay in getting the Mesalt. Unit Manager #1 said the orders from the wound clinic, including the use of Mesalt, packing the wound or the use of the adhesive foam dressing were not implemented for May 2023. B. Review of Resident #2's treatment care for June 2023 indicated: Review of the Wound Clinic summary dated 6/1/23 indicated: [Resident's] sacral ulcer extends to muscle and there is even more necrosis today with undermining and foul odor/drainage. I could not debride the wound today because of [Resident #2's] discomfort despite 4% lidocaine in the wound. [Resident #2] looks gaunt and is crying constantly. I am very concerned about [Resident #2's] sacral ulcer. Dressings: Dakins irrigation (an antiseptic to cleanse wounds to prevent infection) then Mesalt packing/Adhesive foam 1-2 X daily. The clinic summary failed to indicate measurements of Resident #2's wound. Review of Resident #2's Skin Notes dated 6/8/23 and 6/16/23 both indicated: Coccyx 6 CM x 7 CM x 3 CM undermines 12 to 6 o'clock 3 CM. 50% necrotic tissue. NS wash Santyl gauze pack border gauze. (The treatment indicated was not the treatment ordered by the Wound Clinic.) Review of the Wound Clinic Summary dated 6/22/23 indicated: Hopefully [Resident #2's] sacral wound has stabilized. Post Debridement Measurements: 6.9 CM x 9.4 CM by 3 CM. Types of tissue removed: subcutaneous, muscle, skin, fascia, eschar. Structure exposed: fat layer, bone. Dressing: Dakins irrigation then Mesalt packing/adhesive foam 1-2 times daily. Review of the June 2023 TAR indicated: *Wound care left coccyx cleanse with normal saline, pat dry. Apply Santyl to wound bed followed by calcium alginate. Cover with bordered gauze island dressing every day shift for wound care. Active, 4/27/23 through 6/22/23 *Santyl external ointment 250 Unit (collagenase) apply to left coccyx topically every ay shift for wound care. apply Santyl to left coccyx as per TAR treatment order. Active 4/21/23 through 6/22/23. *Wound care: coccyx. cleanse with normal saline pat dry. Apply Mesalt to wound bed. Cover with bordered gauze island dressing every day shift for wound care. Active 6/23/23 - 7/28/23. The June 2023 TAR indicated that two treatments were administered daily to Resident #2 from 6/1/23 through 6/22/23. The orders implemented on 6/23/23 failed to include the Dakins solution, instructions to pack the wound, or the use of absorbent foam per the Wound Clinic. During interviews on 10/2/23 at 8:58 A.M., and 10/5/23 at 10:26 A.M., Unit Manager #1 reviewed the June 2023 TAR and said she was not aware of the double orders. Unit Manager #1 said that the errors should have been caught during the facility's 24 hour chart review or the monthly audits. Unit Manager #1 said that the Wound Clinic orders, including the Dakins solution, instructions to pack the wound, and the use of adhesive foam per were not implemented. Review of the June 2023 Risk notes indicated two entries: 6/23/23: Stage IV Coccyx: 6 CM x 7 CM x 3 CM. (The measurements differed from the Wound Clinic's documentation the day before; 6/22/23.) Undermines 3 CM from 12 to 6 O'clock. Large serous drainage. 30% non-viable tissue 70% bone, dermis, muscle. Interventions: NS wash to coccyx wound bed followed by border gauze daily. [Resident] goes to Wound Clinic. (The treatment failed to indicate instructions to pack the wound, the use of Dakins solution or the use of an absorbent dressing per the Wound Clinic.) 6/29/23: Stage IV Coccyx: 6 CM x 7 CM x 3 CM. Undermines 3 CM from 12 to 6 O'clock. (The measurements differed from the Wound Clinic's measurements on 6/22/23). Large serous drainage. 30% non-viable tissue 70% bone, dermis, muscle. Interventions: Normal Saline (NS) wash to coccyx wound bed followed by border gauze daily. Resident goes to Wound Clinic. (The treatment failed to indicate instructions to pack the wound, the use of Dakins solution or the use of an absorbent dressing per the Wound Clinic.) During an interview on 10/2/23 at 8:58 A.M., Unit Manager #1 said she does the measurements weekly for Risk Meeting and she understood that there were differing measurements between the facility and Wound Clinic documentation. C. Review of Resident #2's treatment for July 2023 indicated: Review of the July 2023 Risk notes indicated one entry: 7/10/23: Stage IV coccyx: 7 CM X 6 CM X 3 CM. Undermines 3 CM from 12 to 6 o'clock. Large serous drainage. 100% beefy red tissue. Interventions: NS wash Mesalt to coccyx followed by border gauze daily. (The treatment failed to indicate instructions to pack the wound, the use of Dakins solution or the use of an absorbent foam dressing per the Wound Clinic.) Review of the Wound Clinic summary dated 7/13/23 indicated: [Resident] is a candidate for wound vac (a machine used to pull fluid from the wound over time to help reduce swelling, clean the wound and remove bacteria) for better wound management. Post Debridement Measurements: 6.9 CM X 7.8 X 3 CM. Type of tissue removed: subcutaneous, muscle, fascia, skin, eschar. Structure exposed: fat layer, bone. Dressings: Alginate with silver/Adhesive foam 1-2 times daily. Wound vac when available. Review of the July 2023 TAR indicated: *Change wound vac Monday, Wednesday Friday every day shift in the morning for wound care, active 7/14/23 - 7/28/23. *Wound care: coccyx. cleanse with normal saline pat dry. Apply Mesalt to wound bed. Cover with bordered gauze island dressing every day shift for wound care. Active 6/23/23 - 7/28/23 *Normal Saline wash pat dry alginate to wound bed border gauze to coccyx wound change daily in the morning for wound care 7/29/23 - 9/25/23 The use of alginate with silver and the use of adhesive foam per the Wound Clinic were not implemented. Review of the clinical record indicated Resident #2 was sent to the hospital on 7/15/23. Review of the hospital records indicated Resident #2 was diagnosed with sepsis (potentially related to UTI), Stage IV decubitus ulcer with osteomyelitis and erosion of the distal sacrum and proximal coccyx. The hospital records included recommendations to continue the use of Dakins solution for his/her coccyx wound (which was not initiated upon his/her return to the facility.) Resident #2's clinical record included a progress note dated 7/28/23 indicated that upon his/her return to the facility on [DATE], his/her wound vac had been left behind at the hospital and hospital staff were asked to contact the facility if it was located. The clinical record failed to indicate any attempts were made by the facility to replace the wound vac or notify the Wound Clinic. During interviews on 10/2/23 at 8:58 A.M., and 10/5/23 at 10:26 A.M., Unit Manager #1 said that she was aware that the wound vac had been lost at the hospital. Unit Manager #1 said that she did not call or make any attempts to replace Resident #2's wound vac. Unit Manager #1 said she thought the facility wanted Resident #2 assessed again at the wound clinic to see if they wanted to continue the use of wound vac. Resident #2 was not seen at the wound clinic again until 8/17/23. D. Review of Resident #2's treatment care for August 2023 indicated Review of the August 2023 Risk notes indicated one entry: 8/10/23: Stage IV coccyx 6 CM X 7 CM X 3 CM undermines 3 CM from 12 to 6 o'clock. Large serous drainage 100% beefy red tissue. Interventions: NS wash to Mesalt to coccyx wound bed followed by border gauze daily. Review of the Wound Clinic Summary dated 8/17/23 indicated: hospitalization occurred the day after [Resident #2's] wound vac was placed. Decubitius ulcer has demarcated but there are signs of pressure that still remain in the surrounding skin. I would like to reinitiate the wound VAC to [Resident #2's] sacral wound. (Resident #2's wound was not debrided at this visit) Measurements: 7 CM X 9 CM X 2.1 CM. Structure exposed: fat layer, bone. Dressing: moist packing gauze/adhesive foam 1-2 times daily. Wound Vac when available. Review of the August 2023 TAR indicated: *[Normal Saline] wash pat dry alginate to wound bed border gauze to coccyx wound . Change daily in the morning care 7/29/23 - 9/25/23 The orders for the use of a wound vac and moist packing gauze/adhesive foam per the Wound Clinic were not implemented. During an interview on 10/2/23 at 8:58 A.M., Unit Manager #1 reviewed the Wound Clinic's 8/17/23 summary. She said that she was not aware of the Wound Clinic had ordered the use of a Wound Vac in August 2023. Unit Manager #1 said she did not call and was not aware if anyone else had called to verify orders or to follow up on obtaining a wound vac for Resident #2. E. Review of Resident #2's treatment care for September 2023 indicated Review of the September 2023 Risk notes indicated two entries: 9/7/23: Stage IV Coccyx: 7 CM X 7.7 CM X 2.3 CM large serous drainage, 80% beefy red tissue 20% slough. Interventions: NS wash to coccyx wound bed followed by border gauze daily. 9/15/23: Stage IV Coccyx: 7 CM X 7.7 CM X 2.3 CM large serous drainage, 80% beefy red tissue with 20% slough. Interventions: NS wash Mesalt to coccyx wound bed followed by border gauze daily. Review of the Wound Clinic summary dated 9/21/23 indicated: I would like to reinitiate the wound vac to [Resident #2's] sacral wound. Post Debridement measurements: 7 CM X 9 CM X 2.5 CM. Type of Tissue Removed: subcutaneous, fascia, eschar. (The summary failed to indicate structure exposed) Dressings: Moist Packing gauze/adhesive foam 1-2 times daily. Please start wound vac as ordered to sacrum. Review of the September 2023 TAR indicated: *[Normal Saline] wash pat dry alginate to wound bed border gauze to coccyx wound. Change daily in the morning care. Active 7/29/23 - 9/25/23 *Start wound vac as ordered to the sacrum settings 125 mmhg. Change 3 times a week M, W, F every day shift for Stage IV wound to the sacrum, initiated 9/23/23. The use of moist packing gauze/adhesive foam per the Wound Clinic were not implemented. During an interview on 10/5/23 at 10:32 A.M., the Assistant Director of Nursing (ADON) said that risk meetings are held weekly to review residents with skin issues. The ADON said that at risk meetings, measurements, treatments and the progression of wounds are reviewed. The ADON said that he was now aware that there were discrepancies in measurements and treatments implemented versus measurements and treatment ordered from the Wound Clinic. The ADON said there needs to be a better system in place to ensure wound treatment orders are put in the record correctly. During an interview on 10/2/23 at 12:41 P.M. the Wound Clinic Physician said that Resident #2 has detailed orders that are put on a communication sheet and are also faxed over to the facility after his/her visits. The Wound Clinic Physician said he was not aware his/her wound vac had been left at the hospital in July 2023. The Wound Clinic Physician said that they had been trying to have Resident #2 seen every two weeks but transportation has been an issue. The Wound Clinic Physician said that there have been times when there has been a dressing on Resident #2 sacrum/coccyx that was not the dressing he had ordered. On 10/2/23 at approximately 7:00 A.M. at the surveyor requested to observe Resident #2's dressing change. The surveyor was told staff had already completed the treatment. The Administrator was provided with the Immediate Jeopardy Template on 10/6/23 at 11:25 A.M.

Based on observation, record review, and interview the facility failed to implement interventions related to pressure ulcers for two Residents (#2, #27) out of a total sample of 22 Residents. Specifically: 1. For Resident #2, the facility failed to implement treatments to promote healing ordered by the physician as instructed by the Wound Clinic for his/her coccyx wound from May 2023 through September 2023. Subsequently, Resident #2's wound deteriorated. In July 2023, Resident #2 was hospitalized and was diagnosed with Stage IV pressure injury with osteomyelitis (an infection of the bone) and erosion of the distal sacrum and proximal coccyx. Additionally: 2. For Resident #27, the facility failed to follow the recommendations from the wound physician related to his/her heel wound. Findings include: Review of the facility's Pressure Ulcers/Skin Breakdown Clinical Protocol policy dated April 2018 indicated: *The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings and application of topical agents. *The physician will help identify medical interventions related to wound management, for example, treating a soft tissue infection surrounding an ulcer, removing necrotic (dead) tissue, addressing comorbid medical conditions, managing pain related to the wound or wound treatment. *Although poor nutritional status is associated with increased risk of pressure ulcer development, no specific nutritional interventions clearly prevent or heal pressure ulcers. *During resident visits, the physician will evaluate and document the progress of wound healing - especially for those with complicated, extensive or poorly healing wounds. *The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. *Current approaches should be reviewed for whether they remain pertinent to the resident's/patient's medical conditions, are affected by factors influencing wound development or healing and the impact of specific treatment choices made by the resident/patient or a substitute decision-maker. 1. Resident #2 was readmitted to the facility in March 2023 with diagnoses including an amputation of the right leg below the knee, peripheral artery disease, diabetes and dementia. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #2 scored 10 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS) indicating moderate cognitive impairment. Review of the MDS also indicated Resident #2 requires physical assist of two for bed mobility. On 9/28/23 at 7:59 A.M. Resident #2 was observed to be thin and frail resting in bed on an air mattress (a device utilized to redistribute pressure on the body) set at 320 lb. The air mattress pump had hand written instructions indicating the setting should be at 150 lbs. Review of Resident #2's medical record indicated a weight obtained on 9/15/23 was 109.6 lbs (pounds). During an interview on 10/5/23 at 8:31 A.M. Resident #2 was resting in bed. Resident #2 said he/she was having pain from the wound on his/her backside. Resident #2 said he/she goes out to the doctor for his/her wound treatment and was not sure if his/her wound was improving or worsening. During interviews on 10/2/23 at 7:28 A.M., and 10/5/23 at 8:35 A.M., Certified Nurse Aide (CNA) #1 said Resident #2 has wounds which are uncomfortable for him/her. CNA #1 said that Resident #2 is repositioned every two hours and does not refuse treatment or being turned. Review of Resident #2's clinical record indicated: *A nurse progress note dated 3/27/23 indicating Resident #2 developed a Stage II pressure injury at the facility on his/her coccyx measuring 1 Centimeter (CM) X 1 CM X .2 CM *Resident #2 was hospitalized from 4/11/23 through 4/14/23 and was noted to have returned with deterioration of the coccyx wound with slough (dead tissue). Measurements indicated by the contracted wound physician on 4/27/23 indicated: 3.5 CM X 2.2 CM X not measurable depth. *Resident #2's wound was sporadically documented at Weekly Risk Meetings. *A care plan regarding Resident #2's coccyx pressure injury dated 6/15/23 with interventions including: monitoring nutritional status, weekly treatment documentation to include measurements of each area of skin breakdown width, length, depth, type of tissue and exudate, and to administer treatments as ordered and monitor for effectiveness and weekly wound physician evaluation and treatment. *Resident #2's wound was being monitored by both the contracted wound physician in the facility and the Wound Clinic from March 2023 to June 7, 2023. Resident #2 then began to receive wound care treatment solely through the Wound Clinic 1-2 times per month. During an interview on 10/2/23 at 8:36 A.M. Physician #1 said that Resident #2's wounds are monitored at the Wound Clinic. Physician #1 said that treatment orders are relayed to him or his nurse practitioner for approval. Physician #1 said that he cannot recall ever declining any wound treatments ordered by the Wound Clinic for Resident #2. During an interview on 10/2/23 at 9:42 A.M., Nurse Practitioner #1 said that for patient's who have wounds monitored at the Wound Clinic, she will review the Wound Clinic's orders and approve them. Nurse Practitioner #1 said she has not declined any treatment recommendations made by the Wound Clinic for Resident #2. During an interview on 10/2/23 at 8:58 A.M., Unit Manager #1 said that it is the responsibility of the assigned nurse to review orders from the Wound Clinic and then relay them to a Resident's attending physician or Nurse Practitioner. Unit Manager #1 said that the attending will then approve the orders and the nurse will then put them in the electronic record. Unit Manager #1 said that Physician #1 and Nurse Practitioner #1 have not declined any treatment orders from the Wound Clinic. A. Review of Resident #2's treatment care for May 2023 indicated: Review of the Wound Clinic Summary dated 5/4/23 indicated Resident #4 had a Stage IV pressure ulcer: [Resident's] sacral ulcer extends to muscle and there was a fair amount of necrosis (dead tissue) today with undermining requiring extensive debridement (a surgical procedure to remove dead tissue). I am very concerned about [Resident #2's] sacral ulcer. Post Debridement Measurements: 4.5 CM X 4 CM X .02 CM Type of tissue removed: subcutaneous fat, skin, necrotic eschar (a type of necrotic tissue that can develop on severe wounds). Structure exposed: Other. Dressings: Mesalt packing/adhesive foam 1-2 times daily. (Mesalt helps manage heavily discharging wounds in the inflammatory phase. It can be used for deep cavity pressure ulcers. Mesalt absorbs wound exudate and the sodium chloride is released, exudate, bacteria and necrotic material is drawn into the dressing, facilitating the natural wound healing process.) Review of the May 2023 risk notes indicated three total entries: 5/4/23: Unstageable due to necrosis of the left coccyx full thickness: Wound Size: 3.5 X 1.4. Depth is unmeasurable due to presence of nonviable tissue. (The measurements and staging of the wound differed from the Wound Clinic's documented measurements the same day; 5/4/23). Exudate: Light serosanguinous (drainage) Eschar thick adherent black necrotic tissue: 50% (The note failed to indicate what treatment was in place.) 5/11/23: Unstageable due to necrosis of the left coccyx full thickness: Wound size: 4 CM X 4 CM. Depth not measurable due to presence of nonviable tissue and necrosis. Exudate: Light serosanguineous. Eschar thick adherent black necrotic tissue: 10% Slough: 30% Interventions: NS (Normal Saline) wash Santyl gauze sponge daily to coccyx. (The staging of the wound differed from the Wound Clinic and the treatment indicated was not ordered by the Wound Clinic.) 5/18/23: Unstageable due to necrosis of the left coccyx full thickness: Wound size: 5 CM X 5 CM X 1 CM. Exudate: Serosanguinous. Eschar thick adherent black necrotic tissue: 10% Slough: 30% Interventions: NS wash Santyl gauze sponge daily to coccyx. (The staging of the wound differed from the Wound Clinic and the treatment indicated was not ordered by the Wound Clinic.) Review of the Wound Clinic Summary dated 5/18/23 indicated: [Resident's] sacral ulcer extends to muscle and there still was a fair amount of necrosis today with undermining requiring moderate debridement. Post Debridement Measurements: 6.8 CM X 6 CM X 2 CM Type of tissue removed: subcutaneous fat, skin, necrotic eschar, fascia (stringy connective tissue), muscle. Structure exposed: fat layer, bone (Resident #2's bone was now exposed) Dressings: Mesalt packing/adhesive foam 1 - 2 times daily. Review of the May 2023 Treatment Administration Record (TAR) indicated: *Wound care left coccyx cleanse with normal saline, pat dry. Apply Santyl to wound bed followed by calcium alginate. Cover with bordered gauze island dressing every day shift for wound care. Active 4/27/23 through 6/22/23 *Santyl external ointment 250 Unit (collagenase) apply to left coccyx topically every day shift for wound care. apply Santyl to left coccyx as per TAR treatment order. Active 4/21/23 through 6/22/23. The May 2023 TAR indicated both treatments were documented as being completed every day shift from 5/1/23 through 5/31/23. The treatments administered to Resident #2 for May 2023 did not include packing the wound with Mesalt or the use of adhesive foam per the Wound Clinic. During an interview on 10/5/23 at 8:12 A.M., Nurse #4 said Unit Manager #1 is responsible for measuring the wounds weekly and the weekly assessment of the wound. Nurse #4 said there should only be one treatment in place for each wound. During an interview on 10/5/23 at 8:13 A.M., Nurse #5 said there should only be one treatment in place for each wound. During an interview on 10/5/23 at 8:14 A.M., Nurse #6 said if there are two orders for the same wound she is not sure which one would be the correct order. Nurse #6 said there should only be one order for each wound in place. During interviews on 10/2/23 at 8:58 A.M., and 10/5/23 at 10:26 A.M., Unit Manager #1 reviewed the May 2023 TAR and said she was not aware of the double orders. Unit Manager #1 said that the errors should have been caught during the facility's 24 hour chart review or the monthly audits. Unit Manager #1 said she thought there had been a delay in obtaining the Mesalt, but it was not for long. Unit Manager #1 said she did not contact the Wound Clinic and did not know if anyone else had contacted the Wound Clinic to alert them of a delay in getting the Mesalt. Unit Manager #1 said the orders from the wound clinic, including the use of Mesalt, packing the wound or the use of the adhesive foam dressing were not implemented for May 2023. B. Review of Resident #2's treatment care for June 2023 indicated: Review of the Wound Clinic summary dated 6/1/23 indicated: [Resident's] sacral ulcer extends to muscle and there is even more necrosis today with undermining and foul odor/drainage. I could not debride the wound today because of [Resident #2's] discomfort despite 4% lidocaine (a topical pain medication) in the wound. [Resident #2] looks gaunt and is crying constantly. I am very concerned about [Resident #'s] sacral ulcer. Dressings: Dakins irrigation (a dilute solution of sodium hypochlorite (0.4% to 0.5%) used as an antiseptic to cleanse wounds in order to prevent infection) then Mesalt packing/Adhesive foam 1-2 X daily. The clinic summary failed to indicate measurements of Resident #2's wound. Review of Resident #2's Skin Notes dated 6/8/23 and 6/16/23 both indicated: Coccyx 6 CM x 7 CM x 3 CM undermines 12 to 6 o'clock 3 CM. 50% necrotic tissue. NS wash Santyl gauze pack border gauze. (The treatment indicated was not the treatment ordered by the Wound Clinic.) Review of the Wound Clinic Summary dated 6/22/23 indicated: Hopefully [Resident #2's] sacral wound has stabilized. Post Debridement Measurements: 6.9 CM x 9.4 CM by 3 CM. Types of tissue removed: subcutaneous, muscle, skin, fascia, eschar. Structure exposed: fat layer, bone. Dressing: Dakins irrigation then Mesalt packing/adhesive foam 1-2 times daily. Review of the June 2023 TAR indicated: *Wound care left coccyx cleanse with normal saline, pat dry. Apply Santyl to wound bed followed by calcium alginate. Cover with bordered gauze island dressing every day shift for wound care. Active, 4/27/23 through 6/22/23 *Santyl external ointment 250 Unit (collagenase) apply to left coccyx topically every ay shift for wound care. apply Santyl to left coccyx as per TAR treatment order. Active 4/21/23 through 6/22/23. *Wound care: coccyx. cleanse with normal saline pat dry. Apply Mesalt to wound bed. Cover with bordered gauze island dressing every day shift for wound care. Active 6/23/23 - 7/28/23. The June 2023 TAR indicated that two treatments were administered daily to Resident #2 from 6/1/23 through 6/22/23. The orders implemented on 6/23/23 failed to include the Dakins solution, instructions to pack the wound, or the use of absorbent foam per the Wound Clinic. During interviews on 10/2/23 at 8:58 A.M., and 10/5/23 at 10:26 A.M., Unit Manager #1 reviewed the June 2023 TAR and said she was not aware of the double orders. Unit Manager #1 said that the errors should have been caught during the facility's 24 hour chart review or the monthly audits. Unit Manager #1 said that the Wound Clinic orders, including the Dakins solution, instructions to pack the wound, and the use of adhesive foam per were not implemented. Review of the June 2023 Risk notes indicated two entries: 6/23/23: Stage IV Coccyx: 6 CM x 7 CM x 3 CM. (The measurements differed from the Wound Clinic's documentation the day before; 6/22/23.) Undermines 3 CM from 12 to 6 O'clock. Large serous drainage. 30% non-viable tissue 70% bone, dermis, muscle. Interventions: NS wash to coccyx wound bed followed by border gauze daily. [Resident] goes to Wound Clinic. (The treatment failed to indicate instructions to pack the wound, the use of Dakins solution or the use of an absorbent dressing per the Wound Clinic.) 6/29/23: Stage IV Coccyx: 6 CM x 7 CM x 3 CM. Undermines 3 CM from 12 to 6 O'clock. (The measurements differed from the Wound Clinic's measurements on 6/22/23). Large serous drainage. 30% non-viable tissue 70% bone, dermis, muscle. Interventions: Normal Saline (NS) wash to coccyx wound bed followed by border gauze daily. Resident goes to Wound Clinic. (The treatment failed to indicate instructions to pack the wound, the use of Dakins solution or the use of an absorbent dressing per the Wound Clinic.) During an interview on 10/2/23 at 8:58 A.M., Unit Manager #1 said she does the measurements weekly for Risk Meeting and she understood that there were differing measurements between the facility and Wound Clinic documentation. C. Review of Resident #2's treatment care for July 2023 indicated: Review of the July 2023 Risk notes indicated one entry: 7/10/23: Stage IV coccyx: 7 CM X 6 CM X 3 CM. Undermines 3 CM from 12 to 6 o'clock. Large serous drainage. 100% beefy red tissue. Interventions: NS wash Mesalt to coccyx followed by border gauze daily. (The treatment failed to indicate instructions to pack the wound, the use of Dakins solution or the use of an absorbent foam dressing per the Wound Clinic.) Review of the Wound Clinic summary dated 7/13/23 indicated: [Resident] is a candidate for wound vac (a machine used to pull fluid from the wound over time to help reduce swelling, clean the wound and remove bacteria) for better wound management. Post Debridement Measurements: 6.9 CM X 7.8 X 3 CM. Type of tissue removed: subcutaneous, muscle, fascia, skin, eschar. Structure exposed: fat layer, bone. Dressings: Alginate with silver/Adhesive foam 1-2 times daily. Wound vac when available. Review of the July 2023 TAR indicated: *Change wound vac Monday, Wednesday Friday every day shift in the morning for wound care, active 7/14/23 - 7/28/23. *Wound care: coccyx. cleanse with normal saline pat dry. Apply Mesalt to wound bed. Cover with bordered gauze island dressing every day shift for wound care. Active 6/23/23 - 7/28/23 *Normal Saline wash pat dry alginate to wound bed border gauze to coccyx wound change daily in the morning for wound care 7/29/23 - 9/25/23 The use of alginate with silver and the use of adhesive foam per the Wound Clinic were not implemented. Review of the clinical record indicated Resident #2 was sent to the hospital on 7/15/23. Review of the hospital records indicated Resident #2 was diagnosed with sepsis (potentially related to UTI), Stage IV decubitus ulcer with osteomyelitis (an infection of the bone) and erosion of the distal sacrum and proximal coccyx. The hospital records included recommendations to continue the use of Dakins solution for his/her coccyx wound (which was not initiated upon his/her return to the facility.) Resident #2's clinical record included a progress note dated 7/28/23 indicated that upon his/her return to the facility on [DATE], his/her wound vac had been left behind at the hospital and hospital staff were asked to contact the facility if it was located. The clinical record failed to indicate any attempts were made by the facility to replace the wound vac or notify the Wound Clinic. During interviews on 10/2/23 at 8:58 A.M., and 10/5/23 at 10:26 A.M., Unit Manager #1 said that she was aware that the wound vac had been lost at the hospital. Unit Manager #1 said that she did not call or make any attempts to replace Resident #2's wound vac. Unit Manager #1 said she thought the facility wanted Resident #2 assessed again at the wound clinic to see if they wanted to continue the use of wound vac. Resident #2 was not seen at the wound clinic again until 8/17/23. D. Review of Resident #2's treatment care for August 2023 indicated: Review of the August 2023 Risk notes indicated one entry: 8/10/23: Stage IV coccyx 6 CM X 7 CM X 3 CM undermines 3 CM from 12 to 6 o'clock. Large serous drainage 100% beefy red tissue. Interventions: NS wash to Mesalt to coccyx wound bed followed by border gauze daily. Review of the Wound Clinic Summary dated 8/17/23 indicated: hospitalization occurred the day after [Resident #2's] wound vac was placed. Decubitius ulcer has demarcated but there are signs of pressure that still remain in the surrounding skin. I would like to reinitiate the wound VAC to [Resident #2's] sacral wound. (Resident #2's wound was not debrided at this visit) Measurements: 7 CM X 9 CM X 2.1 CM. Structure exposed: fat layer, bone. Dressing: moist packing gauze/adhesive foam 1-2 times daily. Wound Vac when available. Review of the August 2023 TAR indicated: *[Normal Saline] wash pat dry alginate to wound bed border gauze to coccyx wound . Change daily in the morning care 7/29/23 - 9/25/23 The orders for the use of a wound vac and moist packing gauze/adhesive foam per the Wound Clinic were not implemented. During an interview on 10/2/23 at 8:58 A.M., Unit Manager #1 reviewed the Wound Clinic's 8/17/23 summary. She said that she was not aware of the Wound Clinic had ordered the use of a Wound Vac in August 2023. Unit Manager #1 said she did not call and was not aware if anyone else had called to verify orders or to follow up on obtaining a wound vac for Resident #2. E. Review of Resident #2's treatment care for September 2023 indicated: Review of the September 2023 Risk notes indicated two entries: 9/7/23: Stage IV Coccyx: 7 CM X 7.7 CM X 2.3 CM large serous drainage, 80% beefy red tissue 20% slough. Interventions: NS wash to coccyx wound bed followed by border gauze daily. 9/15/23: Stage IV Coccyx: 7 CM X 7.7 CM X 2.3 CM large serous drainage, 80% beefy red tissue with 20% slough. Interventions: NS wash Mesalt to coccyx wound bed followed by border gauze daily. Review of the Wound Clinic summary dated 9/21/23 indicated: I would like to reinitiate the wound vac to [Resident #2's] sacral wound. Post Debridement measurements: 7 CM X 9 CM X 2.5 CM. Type of Tissue Removed: subcutaneous, fascia, eschar. (The summary failed to indicate structure exposed) Dressings: Moist Packing gauze/adhesive foam 1-2 times daily. Please start wound vac as ordered to sacrum. Review of the September 2023 TAR indicated: *[Normal Saline] wash pat dry alginate to wound bed border gauze to coccyx wound. Change daily in the morning care. Active 7/29/23 - 9/25/23 *Start wound vac as ordered to the sacrum settings 125 mmhg. Change 3 times a week M, W, F every day shift for Stage IV wound to the sacrum, initiated 9/23/23. The use of moist packing gauze/adhesive foam per the Wound Clinic were not implemented. During an interview on 10/5/23 at 10:32 A.M., the Assistant Director of Nursing (ADON) said that risk meetings are held weekly to review residents with skin issues. The ADON said that at risk meetings, measurements, treatments and the progression of wounds are reviewed. The ADON said that he was now aware that there were discrepancies in measurements and treatments implemented versus measurements and treatment ordered from the Wound Clinic. The ADON said there needs to be a better system in place to ensure wound treatment orders are put in the record correctly. During an interview on 10/2/23 at 12:41 P.M. the Wound Clinic Physician said that Resident #2 has detailed orders that are put on a communication sheet and are also faxed over to the facility after his/her visits. The Wound Clinic Physician said he was not aware his/her wound vac had been left at the hospital in July 2023. The Wound Clinic Physician said that they had been trying to have Resident #2 seen every two weeks but transportation has been an issue. The Wound Clinic Physician said that there have been times that there has been a dressing on Resident #2 sacrum/coccyx that was not the dressing he had ordered. On 10/2/23 at approximately 7:00 A.M. at the surveyor requested to observe Resident #2's dressing change. The surveyor was told staff had already completed the treatment. The Administrator was provided with the Immediate Jeopardy Template on 10/6/23 at 11:25 A.M. and 10/13/23 at 12:15 P.M. 41456 2. Resident #27 was admitted to the facility in September 2016 with diagnoses including diabetes and venous insufficiency. Review of Resident #27's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status score of 10 out of a possible 15, which indicated the Resident had moderate cognitive impairment. The MDS also indicated Resident #27 required extensive assistance from staff for all bed mobility tasks. During an interview on 9/28/23 at 7:43 A.M., Resident #27 was observed lying in bed with both heels directly on the bed. There was a waffle boot (pressure relieving boot) on the wheelchair across from the bed. Resident #27 said his/her left heel was painful and he/she has pain when the heel is directly on the bed and not offloaded from pressure. Resident #27 said his/her left heel was supposed to be in a boot when he/she is lying in bed. On 9/29/23 at 8:09 A.M., Resident #27 was observed lying in bed with both heels directly on the bed. On 10/2/23 at 8:10 A.M., Resident #27 was observed lying in bed with both heels directly on the bed. Review of Resident #27's medical record indicated the Resident has an unstageable left, posterior heel wound for the past 45 days. Review of the wound physician notes from 8/30/23, 9/6/23, 9/13/23 and 9/20/23 indicated the following recommendations were made after each visit: *Offload wound *Float heels in bed *Pressure off-loading boot Review of Resident #27's physician orders indicated the following orders: *Air Mattress to bed set to comfort. Check setting and function every shift, every shift, initiated on 8/25/23. *Off load Heels at all times, initiated 7/29/23. Review of Resident #27's skin integrity care plan last revised 4/28/23, indicated the following intervention: *Heels offloaded when in bed. *Skin prep to heels and off load. During an interview on 10/2/23 at 8:11 A.M., Nurse #1 said she was unaware of any skin integrity interventions Resident #27 may need while in bed. During an interview on 10/2/23 at 8:16 A.M., the Assistant Director of Nursing (ADON) said Resident #27 had a left heel wound that has been improving. The ADON said the recommendation is to have Resident #27 offload his/her heel whenever he/she is in bed. The ADON said the facility currently has a waffle boot for the Resident, but the wound doctor does not like this type of boot, so the staff just offload the heel by placing pillows underneath the leg. The ADON said the facility has not ordered a different type of boot.

Based on observation, interview, and record review, the facility failed to ensure one Resident (#126) was free from abuse, out of a total of 19 sampled residents. Findings include: Review of the facility's policy titled Abuse Policy, revised 3/2021, indicated the following: * The facility prohibits the mistreatment, neglect and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends etc. * Verbal abuse: Oral, written, or gestured language, that willfully includes disparaging and derogatory terms, to the resident/patient or their families, or within their hearing distance, to describe resident/patient, regardless of their age, ability to comprehend or disability. * Provide for the immediate safety of the resident/patient, upon identification of suspected abuse, neglect, mistreatment, and/or misappropriation of property. - Move resident/patient to another room or unit; - Provide 1:1 monitoring as appropriate; - Immediate suspension of suspected employee(s), pending outcome of the investigation; Resident #126 was admitted to the facility in November 2021, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical progress notes indicated Resident #126 was alert and oriented. During a record review on 11/18/21 at 11:12 A.M., the following was indicated: * A Social Services Progress Note, dated 11/9/21, documenting that Resident #126 was upset about an incident regarding a Certified Nursing Assistant (CNA) that had been reported earlier. Administration was aware. He/she was so upset he/she wanted to leave Against Medical Advice (AMA). * A Physician's Progress Note, dated 11/10/21, that documented Social Worker (SW) reported incident yesterday where homophobic comments were made to Resident #126. During an interview on 11/19/21 at 2:17 P.M., the facility Social Worker (SW) #1 said Resident #126's mood fluctuates because last week he/she had an issue that made him/her extremely upset. SW #1 said that she did not know much about the situation and referred the surveyor to speak with the Director of Nursing (DON) and Nursing Home Administrator (NHA) who were investigating the situation. On 11/19/21 at 2:25 P.M., the DON provided the surveyor with a file for Resident #126's investigation regarding the allegation made on 11/9/21. The DON said that he had not yet completed the investigation and he was still waiting for psych services to see Resident #126. During a review of Resident #126's abuse investigation on 11/19/21 at 2:27 P.M., the following was included: * A copy of the initial report submitted to the Health Care Facility Reporting System (HCFRS), dated 11/9/21. * A statement from SW #1, dated 11/9/21, that indicated: -Resident #126 was emotionally drained from this issue; -Resident #126 said that the CNA stated his/her condition is his/her own fault; -Resident #126 said multiple times why would anyone say this to a patient. * A statement from the Admissions Director (AD) #1, dated 11/9/21, that indicated: - Resident #126 said to AD#1 I have something to tell you. An aide was taking care of me and asked me how I got [CONDITION(S)]. Resident #126 reported to AD #1 that he/she told the CNA that at one point in my life I was gay, and she replied with that is what you get for living that lifestyle and jump around as a baboon. -While AD #1 was speaking with Resident #126, CNA #1 entered the room and Resident #126 confronted her by asking her if she was in his/her room yesterday and asked if he/she had ([CONDITION(S)]) [CONDITION(S)]. AD #1 documented that Resident #126 was very upset by seeing her (CNA #1) and asked for her not to come in again. * A statement from CNA #1, dated 11/10/21, that indicated she had cared for the Resident on 11/8/21. The statement made no mention of a negative interaction with Resident #126 on 11/9/21. During an interview on 11/19/21 at 2:58 P.M., the DON and NHA said the following: * The DON stated that on 11/9/21, he had received an allegation of abuse to investigate; * The NHA said that Resident #126 was very upset to the point of being tearful because a CNA had made homophobic remarks to him/her and said that's how you people get AIDS; * The NHA said that Resident #126 identified the CNA by face and name and she therefore suspended the CNA but that the next day Resident #126 retracted the statement and the CNA came back to work. During a follow-up interview with Resident #126 on 11/22/21 at 10:50 A.M., he/she presented as alert and oriented X3. Resident #126 stated to the surveyor that on the date of the incident CNA #1 was taking care of him/her. Resident #126 said CNA #1 asked him/her how he/she contracted AIDS and said that CNA #1 responded that's what you get and made girating body gestures like he/she was an animal for being gay. Resident #1 said at first I was dumbfounded, and didn't say anything to her, but couldn't believe that she was standing over me and supposed to be taking care of me and instead talked about me like I was not human. Resident #126 said clearly, Oh no, I never said it wasn't her, because I know it was CNA #1.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), the Facility failed to ensure Resident #1 was free from abuse, when on 8/29/21 around 1:00 P.M., Nurse #1 was witnessed engaging in a verbal altercation with Resident #1, was heard threatening him/her, and said words to the effect of, I can get physical with you all I want, and I will [OBSCENITY] you up, and Nurse #1 was also witnessed making physical contact with Resident #1 several times in the area of his/her left shoulder, during the altercation. Resident #1 said Nurse #1 punched him/her and said it hurt. Findings include: Review of the Facility Abuse Policy, revised 10/2017, indicated that the Facility prohibits the mistreatment, neglect and abuse of residents. Review of Resident #1's Medical Record indicated that Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's most recent Minimum Data Set Assessment, dated 8/17/21, indicated Resident #1's cognitive patterns were severely impaired. During an interview on 9/20/21 at 12:00 P.M., Resident #1 said that Nurse #1 punched him/her in the shoulder. Resident #1 said that he/she had no idea why Nurse #1 punched him/her and said although he/she was not injured, said the punch hurt. The Police Report, dated 8/29/21 at 1:44 P.M., indicated that Resident #1 told police officers that he/she did not listen to Nurse #1 when he (Nurse #1) told him/her that he/she could not use the telephone to call 911 and said Nurse #1 punched his/her left shoulder. During an interview on 9/28/21 at 9:30 A.M., the Maintenance Assistant said that on 8/29/21 around 1:00 P.M., he saw Resident #1 and Nurse #1 in the dining room. The Maintenance Assistant said he heard Nurse #1 ask Resident #1 why he/she called the police. The Maintenance Assistant said Resident #1 responded to Nurse #1, and said he/she called the police because he (Nurse #1) had gotten physical with him/her. The Maintenance Assistant said Nurse #1 then said to Resident #1, words to the effect of, I can get physical with you all I want, and said that Nurse #1 then shoved Resident #1 on the shoulder. The Maintenance Assistant said Resident #1 then said to Nurse #1, words to the effect of, there you go, you did it again. The Maintenance Assistant said Nurse #1 shoved Resident #1's shoulder two more times and Nurse #1 said to Resident #1, words to the effect of, I will [OBSCENITY] you up, I will [OBSCENITY] you up, I will [OBSCENITY] you up. During an interview on 9/20/21 at 12:30 P.M., the Activity Director said that on 8/29/21, Resident #1 told her that Nurse #1 punched him/her in the shoulder. The Activity Director said that Resident #1 told her that he/she and Nurse #1 argued after he/she told Nurse #1 he/she was calling the police. The Activity Director said Resident #1 told her that Nurse #1 punched him/her in the shoulder during the argument. The Activity Director said that Resident #1 told her that he/she was OK and his/her shoulder hurt. During an interview on 9/20/21 at 1:30 P.M., the Director of Nurses said that on 8/29/21, the Activity Director reported that Resident #1 alleged that Nurse #1 hit him/her. The Director of Nurses said that he interviewed Resident #1 about the alleged incident. The Director of Nurses said that Resident #1 told him that Nurse #1 hit him/her on the shoulder. The Director of Nurses said that Resident #1 told him that although he/she was not injured, the area on his/her shoulder hurt.

Based on record review, observation and staff and resident interview, the facility failed to ensure that there was a policy and procedure for administering disposable hot packs and that a hot pack was administered appropriately to 1 resident (#2), resulting in [MEDICAL CONDITION] the right leg in a total sample of 17 residents. Findings include: During tour, on 7/20/11 at 8:30AM, it was reported to this surveyor that Resident #2 had 2 burns, one on the right knee, which presented as a blister, and one on the inner right thigh, which started as a blister but had since opened. It was further reported to this surveyor that this resident been burned by an uncovered disposable hot pack which had been applied on the 11-7 shift and was found in the bed on the day shift by CNA #1, who also reported the 2 blisters on the right leg to unit manager #2. Resident #2 was admitted to this facility in May, 2011 with [DIAGNOSES REDACTED]. The initial Minimum Data Set (MDS), dated [DATE], identified this resident as alert and oriented and capable of making health care decisions but requiring assistance with transfers, ambulation, bathing and dressing. Review of the physician's orders [REDACTED]. A hot pack as needed for right knee pain for arthritis, initiated on 7/11/11 at 2:30PM and, on 7/12/11 at 11:30AM, an additional physician's orders [REDACTED]. a. For Resident #2, the facility failed to ensure that a disposable hot pack was administered appropriately. Review of the nurses notes revealed a notation, dated 7/12/11 at 12 PM, which revealed that there were 2 fluid filled blisters, one 2 x 1 centimeter (cm) and the other 7 x 4 cm with surrounding skin slightly reddened. The physician was notified and treatment orders were obtained for [MEDICATION NAME] ointment and cover with dry sterile dressing (DSD) till healed. The resident's family member was notified when s/he came in to visit resident. Interview with the Assistant Director of Nurses, on 7/20/11 at 10:30AM, revealed that Nurse #5 was never interviewed subsequent to the development of [MEDICAL CONDITION] by Resident #2. Interview with Resident #2, on 7/20/11 at 1:15 PM, confirmed that s/he had been burned with a disposable hot pack which had been applied on 7/12/11 at 2AM without a cover. This resident stated that s/he had also been medicated with pain medication around the same time and had fallen asleep until morning. When CNA #1 was assisting this resident with morning care, 2 blisters were discovered, one on the right knee and the other on the right inner thigh. Interview with Unit manager #2, on 7/21/11 at 10AM, confirmed that the disposable hot pack had been found in this resident's bed on the morning of 7/12/11 but no towel was either wrapped around it or found in the bed with the hot pack. Interview with the Staff Development Coordinator (SDC), on 7/21/11 at 10:15 AM, stated that the licensed staff had been inserviced regarding the use of disposable hot packs after Resident #2 was burned but did not provide the written materials that were utilized during the inservice. It was discovered, at this time, that there was no policy developed for the use of disposable hot packs in this facility. The facility failed to ensure a disposable hot pack was administered following professional standards of practice to ensure that Resident #2 maintain his/her physical well-being, which resulted in this resident sustaining 2 second [MEDICAL CONDITION] the right leg. b. For Resident #2, the facility failed to ensure that a policy was developed for the application of a disposable hot pack. Interview with Unit manager #2, on 7/21/11 at 10AM, confirmed that disposable hot packs are used in the facility and that the only hydroculator machine in the facility is in the physical therapy room and used exclusively by the therapists. When asked by this surveyor for a policy for the use of the disposable hot pack, Unit manager #2 provided facility policies regarding the administration of Hot Compress (Hot Packs) and Compress (Warm), which were found in the policy and procedure books on the nursing unit. Subsequent review of these facility policies revealed that the Hot Compress policy was developed for a hydroculator pack, which was no longer in use on the nursing units, and the Warm Compress, which involved the use of warm towels. There was no policy available on the unit for the administration of the disposable hot packs which were currently in use at this facility. Interview with the Staff Development Coordinator (SDC), on 7/21/11 at 10:15 AM, revealed that all new hires receive a general orientation on the units which includes the use of packs, both hot and cold. However, the SDC confirmed that there was no policy for the administration of the disposable hot packs, which had been in use for at least 5 years. The facility had failed to ensure that a policy and procedure be developed for a product, the disposable hot pack, that had been in use for 5 years.