Every finding on record at Pine Knoll Nursing Center

Based on observations, interviews, and record review, the facility failed to ensure three Residents (#24, #6, and #11) received appropriate treatment and services to prevent a decrease in range of motion. Specifically:1.For Resident #24, the facility failed to implement interventions to prevent a new contracture of the left fifth finger from developing and then worsening resulting in the amputation of this left fifth finger. The facility failed to:1a.) Ensure Occupational Therapy (OT) evaluated Resident #24 timely and provided therapy at the frequency ordered. In addition, the nursing staff failed to implement the contracture management devices as recommended by OT, and1b.) Ensure the Resident received recommended contracture treatment for botox injections (a medical procedure for contractures where the muscles are intentionally paralyzed) after being recommended by multiple physicians,2. For Resident #6, the facility failed to implement a splint for the Resident's left hand which resulted in a stage four pressure wound and failed to identify and treat a new contracture of the Resident's right hand; and3. For Resident #11, the facility failed to implement a physician's order for bilateral hand grips for contracture management. Findings include:Review of the facility policy titled 'Contractures', undated, indicated: -Residents of this facility will be given care to prevent formation and progression of contractures and deformities. -If a contracture is assessed on a resident, the physician will be notified. If indicated, orders will be received from the physician specific to the contracture and the resident. -The Nurse Manager or designated RN (registered nurse) will monitor compliance and notify the attending physician if progression of the contracture occurs. Review of the facility policy titled 'Splints, revised 1/3/26, indicated: -All splints require a physician's order. The order will include the type of splint and wearing schedule. -Application and Removal: Splints will be applied and removed according to the physician's order. -Documentation: Nursing staff will document splint use, skin condition, and resident tolerance. -Responsibility: Nursing and therapy staff are responsible for the safe application, monitoring, and documentation of splint use. 1.) Resident #24 was admitted to the facility in December 2024 with diagnoses including osteoarthritis, heart failure and hypertension. The list of Resident #24's diagnoses failed to include a neurological diagnosis that would cause an unpreventable contracture. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/29/25, indicated Resident #24 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS also indicated Resident #24 had impairment of functional range of motion in one upper extremity. Review of Resident #24's discharge paperwork from previous facility, dated as faxed 12/3/24, at the time of his/her initial admission to this facility, indicated: -Annual Physical Examination Form: Musculoskeletal: No joint abnormality. -Physician Progress note: Musculoskeletal: feels stiff, no obvious joint swelling or tenderness. -Neurological: Moves all 4 extremities. Review of Resident #24's assessment titled Pre-admission Notification, dated 12/12/24, and completed by the facility failed to indicate Resident #24 was assessed to have any joint abnormalities, including contractures of the left hand or fingers. On 1/14/25, Resident #24 went out to the hospital with a question of a neurological event. Review of Resident #24's hospital paperwork, dated 1/15/25, indicated: -Alert, moving all four extremities. -Left upper extremity: nondeformed, motor and sensation grossly intact. -An occupational therapy evaluation that indicated Resident #24's left upper extremity had range of motion that was within function limits without impairment. -All hospital paperwork failed to indicate a contracture of the left hand or fingers was present at this time. Review of Resident #24's [Re]admission Assessment completed by the facility, dated 1/17/25, failed to indicate any contractures. During an interview on 2/13/26 at 8:24 A.M., the surveyor reviewed the Pre-admission notification, dated 12/12/24; the admission assessment dated [DATE]; and the Hospital [Re]admission assessment dated [DATE] with Unit Manager #1. Unit Manager #1 said there was no indication Resident #24 had any contractures at the time of these admissions/re-admissions. During an interview on 2/10/26 at 7:47 A.M., Resident #24's health care proxy (HCP) said she had concerns that the facility was not providing necessary therapy and interventions for Resident #24's left-hand contracture. Resident #24's HCP said the Resident developed a new contracture in July 2025 and it continued to worsen between July and December of 2025. Resident #24's HCP said it worsened because the facility did not provide necessary therapy and because Resident #24 never received botox (a medical procedure for contractures where the muscles are intentionally paralyzed), which the physician recommended back in September 2025. Resident #24's HCP said she kept telling the facility he/she needed botox, but his/her appointments kept being cancelled. Resident #24's HCP also said that the Resident had developed a pressure wound from the contracted fingers digging into his/her palm, and the wound appeared concerning but the facility wasn't doing anything about it. Resident #24's HCP said because of these concerns not being addressed by the facility she became frustrated and called the hospital herself to arrange for them to admit Resident #24 for his/her contracture and related concerns. Resident #24's HCP said the hospital had to amputate the Resident's left fifth finger because the contracture did not have appropriate interventions earlier and had worsened to a point where the only treatment intervention was amputation of the finger. During an observation and interview on 2/10/26 at 1:10 P.M., the surveyor observed Resident #24 with a palm guard (a device for contracture management) in his/her left hand with the scar tissue from a left fifth finger amputation visible. Resident #24 said he/she had to have his/her fifth finger amputated because he/she developed a new contracture last summer and it kept getting worse. Resident #24 said that prior to the amputation the staff often did not help him/her with contracture management devices that had been recommended by therapy, even though they were supposed to. Resident #24 further said he/she wished he/she could have had more therapy, but it wasn't available. Resident #24 said he/she wished more could have been done so that his/her finger did not have to be amputated. During an interview on 2/11/26 at 8:38 A.M., Certified Nurse Assistant (CNA) #6 said he had known Resident #24 since he/she was admitted in December 2024. CNA #6 said Resident #24 did not have any contractures when he/she was admitted , and that it appeared in the summer of 2025. CNA #6 said in the summer of 2025 Resident #24 was able to open his/her left hand to put things inside of it, like a hand carrot (a contracture management device), but it progressively got worse until he/she couldn't open the left hand at all in December 2025. CNA #6 said that was when his/her finger had to be amputated. During an interview on 2/11/26 at 8:56 A.M., Nurse #6 said Resident #24 had some stiffness in his/her left hand since admission in December 2024, but the left hand became contracted in July 2025. Nurse #6 said in July 2025 Resident #24 could open his/her left hand, but by December 2025 the contracture had worsened to the point Resident #24 could not open his/her hand at all and required hospitalization for amputation of the left fifth finger. Review of Resident #24's medical record indicated the Resident was discharged to the hospital on [DATE]. Review of the hospital discharge paperwork, dated 12/16/25, indicated: -Left hand pointer/index finger (digit 2) contracted straight outward with thumb touching. Able to visualize skin to palm next to these two digits only. Digit 3, 4, and 5 contracted and unable to visualize the nailbed of the 5th (pinky) finger. Pinky Finger appears swollen and pink. This clinician, along with wound colleague, was unable to extend digits to see the palm of the hand. Unable to visualize if there was a wound or not. Fingers tightly contracted. -The patient reports he/she has had difficulty moving his hand for months. He/she has also had associated hand pain, particularly in his/her pinky. -If the patient elects not to pursue amputation, alternative options such as Botox injections may be reconsidered, though per inpatient orthopedic discussion this may not be indicated at this time and would require outpatient reassessment. -His/her left fifth finger was amputated on 12/19/25. a.) The facility failed to ensure Occupational Therapy (OT) evaluated Resident #24 timely and provided therapy at the frequency ordered. In addition, the nursing staff failed to implement the contracture management devices as recommended by OT. Review of Resident #24's Nurse Practitioner progress notes, dated 7/21/25, 7/23/25, 7/28/25, 8/6/25, 8/11/25, 8/25/25, 9/8/25, indicated: -Stiffness of finger joint of right hand and right wrist pain: Occupational therapy (OT) evaluation (eval) pending. During an interview on 2/11/26 at 2:08 P.M., Nurse Practitioner (NP) #1 said Resident #24 had stiffness and a contracture developed in his/her left hand, not right hand, and the documentation from NP #1's above noted progress notes, dated 7/21/25, 7/23/25, 7/28/25, 8/6/25, 8/11/25, 8/25/25, 9/8/25, were inaccurate. Review of Resident #24's medical record indicated an order for Occupational Therapy written on 8/6/25. The evaluation was completed on 9/8/25, 34 days after the order was written and 49 days after the Nurse Practitioner first documented the need for an OT evaluation in his note on 7/21/25. Review of Resident #24's medical record, dated 7/17/25 to 9/8/25, failed to indicate any rationale for why occupational therapy evaluation was delayed 49 days. Review of Resident #24's occupational therapy evaluation, dated 9/8/25, indicated the following: -Pt (patient) referred to OT services after concern over increased tightness in L (left) hand, assessment for brace and positioning. -Contracture: Tightness to left hand (2nd digit fixed in extension (straightened finger), 3-5th digits tighter in a flexed (bent finger) position. -Device = Other: rolled up wash cloth or carrot orthosis (an orthotic device in the shape of a carrot that can progressively widen a person's grasp) recommended. -Plan of Treatment: 10 time(s)/period; Cert. (Certification) Period: 9/8/25 – 10/7/25. Review of Resident #24's medical record indicated the Resident was re-evaluated by OT three more times and each time the OT ordered the Resident to be seen 10 times in a 30-day period. In the time period from the initial OT evaluation on 9/8/25 to when the Resident was discharged from services on 12/12/25, the Resident was ordered to receive 30 visits. Review of the OT notes indicated Resident #24 had been seen by OT 13 times, not even half the ordered frequency. Review of Resident #24's occupational therapy progress notes for the entirety of the treatment period of 9/8/25 to 12/12/25 indicated the following: -OT treatment was focused on manual manipulation (stretching/range of motion) of Resident #24's left hand and fingers. The treatment notes indicated Resident #24's range of motion to his/her fifth finger improved with treatment visits, however regressed between treatments. -At the end of every visit, the OT recommended an orthotic device for the Resident to wear, and the Resident was in agreement. -The initial orthotic device recommended was a rolled towel. This was recommended on 9/8/25 and 10/2/25. The notes from these days indicated the OT recommended 24- hour wear of the rolled towel, however, failed to indicate if nursing was educated regarding the placement and use of the towel. -On 10/8/25, the OT recommended the use of a hand carrot. The note indicated Resident #24 was in agreement and the nursing staff were educated on the use and wearing schedule of the carrot (24 hours a day). -On 10/15/25, the OT again recommended the hand carrot and indicated the carrot had only been used one time since 10/8/25. The note again indicated Resident #24 was in agreement and the nursing staff were educated on the use and wearing schedule of the carrot (24 hours a day). -On 10/22/25, the OT indicated he observed Resident #24 without the hand carrot and the Resident had informed him he/she had not been wearing the orthotic. The note also indicated nursing was unaware if the Resident had worn the hand carrot and was again educated that the Resident should be wearing the carrot 24 hours a day. -On 10/29/25 the OT continued to recommend Resident #24 wear the hand carrot 24 hours a day and that nursing had reported the Resident had success wearing the carrot for a 24-hour period. -On 11/5/25, the OT continued to recommend Resident #24 wear the hand carrot 24 hours a day and that nursing had reported the Resident had only worn the carrot for 2 days since previous treatment session (2 days in a week). -On 11/12/25, the OT indicated that due to nursing lack of follow-through with the hand carrot and Resident #24's increased left hand pain, he discontinued the use of the hand carrot. The OT instead recommended a palm guard, however the Resident refused due to increased left-hand pain. -On 11/19/25, the OT indicated he once again recommended the use of a hand carrot with Resident #24 in agreement and nursing educated and in agreement to place orthotic in the Resident's hand. -On 12/3/25, the OT again discontinued the use of the carrot and recommended the use of a palm guard and Resident #24 was now in agreement with the orthotic change. The OT failed to indicate nursing was educated on the use of this orthotic. -Resident #24 was discharged from OT services with the last treatment date of 12/12/25 secondary being admitted to the hospital. Throughout this time period, there were never written orders for any of the orthotic devices recommended by the OT, there were no nursing notes that indicated nursing was utilizing the orthotic devices and there were no nursing notes that indicated Resident #24 was resistive to the use of orthotic devices. During an interview on 2/11/26 at 11:33 A.M., the Director of Rehab (DOR) said during July 2025 to December 2025 there was only one OT, (Occupational Therapist (OT) #1), available as needed for OT evaluations and treatments in the facility. The DOR said she was unaware OT #1 was delayed in completing the initial OT evaluation for Resident #24. The DOR said that once the evaluation was completed, OT #1 was responsible for monitoring and completing treatments at the frequency indicated on the initial evaluation and recertifications. The DOR said she was unaware OT #1 had not completed treatments at the frequency indicated of 10 time(s)/period for each certification period. The DOR said the risk of delay of treatment and not treating at necessary frequency would be Resident #24's contracture worsening. During an interview on 2/11/26 at 1:29 P.M., OT #1 said he was the OT responsible for treating Resident #24 from 9/8/25 until his/her finger was amputated in December 2025. OT #1 said his specialty was contractures, and that when he met Resident #24, his/her left-hand contractures was one of the worst contractures he had ever seen. OT #1 said the evaluation was delayed because that was the soonest he could see the Resident as he was the only OT working in the building and he only comes to the building on an as needed (PRN) basis. OT #1 said when he completed the initial evaluation and recertifications he indicated Resident #24 required 10 time(s)/period for each certification period because the Resident needed it. OT #1 said since he was the only OT available and he was only available once a week, so the Resident did not receive the OT treatments he required. OT #1 said Resident #24 would have benefitted from more therapy sessions for the manual techniques and joint mobility exercises, but since he was the only OT available it didn't happen. OT #1 said he did not report the missed frequencies to the DOR or ask if another OT could complete the visits he was unable to do. OT #1 said he documented improvements after his direct treatments but, since his recommendations weren't followed by nursing, when he'd come back the next week Resident #24's contracture was back in the original spot and had to start from scratch. OT #1 said nursing often was unable to replace the hand carrot when it fell out, so the contracture didn't get better. OT #1 said he downgraded from the hand carrot to the palm guard in December 2025 for this reason, because the palm guard straps in and would not as easily fall out. OT #1 said nursing never requested a back-up hand carrot for when it was missing. During an interview on 2/11/26 at 8:38 A.M., Certified Nurse Assistant (CNA) #6 said he took care of Resident #24 frequently and knew him/her well. CNA #6 said sometimes he saw Resident #6 with a rolled towel or hand carrot in his/her left hand, but it often wouldn't fit back in when it fell out, so he/she usually didn't wear it. CNA #6 said OT had told the staff Resident #24 required orthotic devices, but often they didn't have it available or couldn't open his/her hand enough to apply it. CNA #6 said the left-hand contracture kept getting worse and by December he/she couldn't open to put anything in the left hand at all. During an interview on 2/12/26 at 7:44 A.M., Nurse #6 said he took care of Resident #24 frequently and knew him/her well. Nurse #6 said OT communicates instructions for hand orthotics, including rolled carrots, hand carrots, or palm guards, by giving orders to the Director of Nursing (DON). Nurse #6 said the DON then enters the orders into the medical record so that each nurse is alerted to complete the order on each required shift. Nurse #6 said he doesn't remember if orders were in place for Resident #24 for any hand orthotic, including rolled carrots, hand carrots, or palm guard, but there should have been. Nurse #6 said hand contractures would get worse if they are not treated using hand orthotics. Nurse #6 said Resident #24 required assistance to apply any ordered hand orthotics. Nurse #6 said Resident #24 wanted to use hand orthotics, but often staff were unable to apply them because they had fallen out, it was missing, or because his/her hand was too contracted to reapply it. Nurse #6 said he wasn't aware if any staff member alerted therapy for a back-up hand orthotic. Nurse #6 said the reason Resident #24's left hand contracture worsened was because they were often unable to put the hand orthotics back in, and that therapy only came into the building once a week. During an interview on 2/11/26 at 2:08 P.M., Nurse Practitioner (NP) #1 said Resident #24 developed a contracture in his/her left hand in July 2025 and an OT evaluation referral was put in at that time. NP #1 said his expectation is that OT should complete an evaluation as soon as possible. NP #1 said the risk for delaying OT evaluation/treatment would be the contracture worsening. NP #1 said he was unaware there was a delay in Resident #24's OT evaluation and he should have been notified. Nurse Practitioner (NP) #1 further said his expectation is that OT provide the treatments they indicate are necessary. NP #1 said the risk of not providing the necessary frequency of OT treatments would be the Resident's contracture worsening. NP #1 said he was unaware that OT was not providing treatments at the frequency they noted were necessary (10 time(s)/period for each certification period) but should have been. NP #1 said Resident #24's left hand contracture worsened between July 2025 and December 2025 and it required amputation because of it. During an interview on 2/12/26 at 12:56 P.M., the Medical Director said his expectation is that OT should complete an evaluation as soon as possible after referral so OT treatment can begin if indicated. The Medical Director said he was unaware that the OT evaluation/treatment was delayed from 7/21/25 to 9/8/25 for Resident #24, but a provider should have been notified if it had not been completed. The Medical Director said his expectation is that OT provides the treatments they indicate are necessary and said he was unaware that OT was not providing treatments at the frequency they noted were necessary (10 time(s)/period for each certification period). The Medical Director said the risk of not evaluating a contracture timely and not providing the necessary frequency of OT treatments would be the Resident's contracture worsening. During an interview on 2/12/26 at 1:59 P.M., the Director of Nursing (DON) said contractures require treatment to prevent decline. The DON said his expectation is that OT should complete an evaluation as soon as possible after the referral is made so OT treatment can begin if indicated. The DON said Resident #24 should have been evaluated by OT after first referred to OT on 7/21/15 and that not evaluating until 9/8/26 was a delay and that he was unaware of this delay in OT treatment. The DON further said that if the OT was unable or had not evaluated Resident #24 he should have been notified, as well as the physician, and they were not. The DON said his expectation is that OT provides the treatments they indicate are necessary. The DON further said that if the OT was unable or was not providing treatments at the frequency they noted were necessary (10 time(s)/period for each certification period) he should have been notified, as well as the physician. The DON said he was unaware OT was not providing treatment at the necessary frequency indicated on the initial evaluation and recertifications. The DON said he was responsible for monitoring if therapy referrals or treatments were being completed but had not been monitoring this for Resident #24 and he did not. The DON said that if the OT is trialing an orthotic device such as a hand carrot or palm guard, there should be a treatment form in the chart and the nurses should put in orders for the orthotic on the Medication Administration Record (MAR) so all nurses know to put the orthotic in place. The DON said Resident #24's left fifth finger contracture definitely became worse while at the facility and his/her left fifth finger was amputated because of this. 1b.) The facility failed to ensure Resident #24 received recommended contracture treatment for botox (a medical procedure for contractures where the muscles are intentionally paralyzed) after being recommended by multiple physicians. Review of Resident #24's Wound Physician's wound evaluation and management summary progress notes, dated 9/23/25, 9/30/25, 10/7/25, and 10/14/25, all indicated the following: -The patient is extremely contracted on his/her left hand. The patient would need either derm[atology] or plastic for botox injection to help with the contractures. -The wound physician recommendations after each visit was for Resident #24 to have botox treatments scheduled. Review of Resident #24's Nurse Practitioner Progress notes, dated 9/26/25, 10/6/25, 10/19/25 and 10/17/25 all indicated the Nurse Practitioner asked nursing to make a referral to a surgeon or plastics for botox injection treatment per the wound physician's recommendations. Review of Resident #24's nursing progress note, dated 10/22/25, 27 days after the first time botox was recommended by the Wound Physician indicated: -Have patient see orthopedic surgery for management of contracture. Review of Resident #24's nursing progress note, dated 10/30/25, indicated: -Today, the resident attended an orthopedic appointment, during which Botox was prescribed for the left forearm. The order is pending Nurse Practitioner (NP) approval. The orthopedic specialist also recommended scheduling a follow-up appointment. Review of Resident #24's medical record failed to indicate the follow-up appointment was scheduled. Review of the Nurse Practitioner Progress notes dated 11/12/25, 11/17/25, 11/24/25, 12/1/25, and 12/8/25, indicated botox injections to Resident #24's left forearm should still be considered and the orthopedic appointment is still pending. Review of Resident #24's occupational therapy treatment progress note, dated 11/25/25, indicated: -Consulted with DON (Director of Nursing) regarding pending botox injections to LUE (left upper extremity) to maximize therapy efforts to achieve digit extension secondary current tone limitations inhibiting tolerated joint mobility. Review of Resident #24's medical record, dated 9/23/25 to 12/16/25, failed to indicate the Resident was offered or received botox injections. During an interview on 2/10/26 at 7:47 A.M., Resident #24's health care proxy (HCP) said the physician had been saying Resident #24 should get botox injections since September 2025 and the facility kept trying to arrange the appointment, but it kept getting cancelled. Resident #24's HCP said because the left-hand contracture was getting worse and the botox appointment never happened, she became frustrated and called the hospital herself to arrange for them to admit Resident #24 for his/her contracture and get the contracture care he/she required, including the botox. Resident #24's HCP said the hospital had to amputate his/her left fifth finger because the contracture did not have appropriate interventions earlier. During an interview on 2/10/26 at 1:10 P.M., Resident #24 said he/she was not sure why his/her orthopedic appointment never happened, and that he/she was just told it was cancelled. During a telephone interview on 2/12/26 at 8:36 A.M., a staff member at the orthopedic surgeon office said Resident #24 was seen on 11/5/25, and that the office prescribes, but does not administer botox injections, and referred him/her to their neurology department to receive the botox on 11/10/25. The staff member said it is noted in his/her record that the facility cancelled that appointment on 11/10/25, and another appointment was rescheduled for 11/24/25. The staff member said the facility cancelled that appointment as well and never rescheduled, so Resident #24 never had any botox injections. During an interview on 2/11/26 at 11:01 A.M., Nurse #6 said Resident #24's had an appointment to get botox injections, but there was a problem with transportation and the appointment was cancelled. Nurse #6 said he was unaware if the appointment was ever rescheduled because it's not his responsibility. Nurse #6 said the nurses on the floor are not responsible for scheduling or rescheduling appointments. Nurse #6 said the Director of Nursing (DON) or Unit Manager were responsible for scheduling appointments. Review of Resident #24's medical record, dated 11/10/25 to 11/24/25, failed to indicate any mention of neurology appointments or any rationale regarding why the facility cancelled these appointments. During an interview on 2/11/26 at 11:22 A.M., the Director of Nursing (DON) said he and the Unit Manager are responsible for scheduling/rescheduling appointments. The DON said the previous Unit Manager left at the beginning of November and a new Unit Manager started on 12/1/26. The DON said he was unaware that Resident #24 had missed any botox appointments because he had never been notified it was something Resident #24 required. The DON said there is no record in the facility of Resident #24 having or missing this appointment. The DON said he was unaware that the Wound Physician had recommended botox injections on 9/23/25, 9/30/25, 10/7/25, 10/14/25, and 10/21/25. The DON said he was unaware of the facility cancelling the neurology appointment for Resident #24 on 11/10/25 and 11/24/25 and that it should have been rescheduled but was not. During an interview on 2/11/26 at 11:25 A.M., Unit Manager #1 said her first day was 12/1/25. Unit Manager #1 said she was unaware that Resident #24 was supposed to have any appointments for botox injections scheduled. During an interview on 2/11/26 at 2:08 P.M., Nurse Practitioner (NP) #1 said he had put a referral in to have Resident #24 to have botox injections beginning 9/26/25 as a treatment to manage his/her left-hand contracture. NP #1 said it was his expectation that the facility would obtain the first available appointment for Resident #24 to receive botox at an outpatient office. NP #1 said he would have expected to be notified if the facility was unable to make this appointment so he could reassess treatment plan but was never notified. NP #1 said the risk of Resident #24 not receiving the botox injections would be worsening of his/her contracture. NP #1 said Resident #24's left hand contracture worsened between July 2025 and December 2025 and it required amputation because of it. During an interview on 2/12/26 at 12:56 P.M., the Medical Director said he was unaware the botox appointment was cancelled and never rescheduled. The Medical Director said it should not have been cancelled by the facility, and that he would have expected them to notify himself or Nurse Practitioner #1 if for any reason Resident #24 couldn't make the appointment so they could reassess the treatment plan. 2). For Resident #6, the facility failed to implement a splint for the Resident's left hand which resulted in a stage four pressure wound and failed to identify and treat a new contracture of the Resident's right hand. Resident #6 was admitted to the facility in May 2020 with diagnoses including dementia and muscle weakness. Resident #6's diagnoses did not include a neurological disorder that would lead to contracture. Review of Resident #6's Minimum Data Set (MDS) assessment, dated 1/16/26, indicated the Resident scored a zero out of total 15 on the Brief Interview for Mental Status indicating severe cognitive impairment. Section GG of this MDS indicated Resident #6 has no impairment to his/her range of motion of his/her bilateral upper and impairment to one side of his/her lower extremities. On 2/5/26 at 8:56 A.M., the surveyor observed the Resident #6 lying in his/her bed. The Resident's right hand third to fifth fingers were bent forward towards the palm and the pointer finger and thumbs were sticking straight out. The left-hand fingers were all bent forward towards the palm in a fist. The Resident did not have a splint in either hand. On 2/9/26 at 7:17 A.M., the surveyor observed the Resident #6 lying in his/her bed. The Resident's right hand third to fifth fingers were bent forward towards the palm and the pointer finger and thumbs were sticking straight out. The left-hand fingers were all bent forward towards the palm in a fist. The Resident did not have a splint in either hand. On 2/9/26 at 7:30 A.M., the surveyor and Certified Nursing Assistant (CNA) #5 observed Resident #6 lying in his/her bed. Resident #5 was not wearing a splint in either hand at this time. CNA #5 said she is Resident #6's primary care giver and said

Based on observations, record review and interviews, the facility failed to notify four Resident's (#24, #6, #21 and #9) physicians and legal guardian of a change in condition out of a total sample of 34 residents. Specifically:1.) For Resident #24, who developed a left-hand contracture in July 2025, the facility failed to notify the provider that the Resident's occupational therapy (OT) evaluation was delayed 49 days, that OT treatment was not being completed at necessary frequency, that his/her hand orthotic was not being tolerated because of increased pain and decreased range of motion, or that left-hand contracture was worsening, resulting in the amputation of the left fifth finger.2.) For Resident #6, the facility failed to notify the legal guardian of a worsening contracture of the left hand with development of a stage 4 pressure ulcer, development of a new contracture to the right hand and failed to notify the physician of the worsening of the left-hand contracture and development of a new contracture to the right hand.3.) For Residents #21 and #9, the facility failed to notify the physician of a change in respiratory status. Findings include: Review of the facility policy titled 'Change in a Resident's Condition or Status or Injury of Unknown Origin', dated 3/25/25, indicated: -The nurse will notify the resident's Attending Physician or physician on call when there has been a significant change in the resident's physical condition. -A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting). 1.) Resident #24 was admitted to the facility in December 2024 with diagnoses including osteoarthritis, heart failure and hypertension. The list of Resident #24's diagnoses failed to include a neurological diagnosis that would cause an unpreventable contracture. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/29/25, indicated Resident #24 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS also indicated Resident #24 had impairment of functional range of motion in one upper extremity. Review of Resident #24's Pre-admission notification, dated 12/12/24; the admission assessment dated [DATE]; and the Hospital [Re]admission assessment dated [DATE] all indicated Resident #24 did not have any contracture of the left hand upon admission/readmission. During an interview on 2/13/26 at 8:24 A.M., the surveyor reviewed the above assessments with Unit Manager #1. Unit Manager #1 said there was no indication Resident #24 had any contractures at the time of these admissions/re-admissions. During an interview on 2/10/26 at 7:47 A.M., Resident #24's health care proxy (HCP) said the Resident developed a new contracture in July 2025 and it continued to worsen between July and December of 2025. Resident #24's HCP said the Resident's left fifth finger was amputated because the contracture did not have appropriate interventions earlier and had worsened to a point where the only treatment intervention was amputation of the finger. During an observation and interview on 2/10/26 at 1:10 P.M., the surveyor observed Resident #24 with a palm guard (a device for contracture management) in his/her left hand with the scar tissue from a left fifth finger amputation visible. Resident #24 said he/she had to have his/her fifth finger amputated because he/she developed a new contracture last summer and it kept getting worse. Review of Resident #24's Nurse Practitioner progress notes, dated 7/21/25, 7/23/25, 7/28/25, 8/6/25, 8/11/25, 8/25/25, 9/8/25, indicated the Resident had stiffness/pain in his/her fingers/wrist and that an Occupational therapy (OT) evaluation (eval) pending. Review of Resident #24's medical record indicated the occupational therapy (OT) evaluation was completed on 9/8/25, 49 days after the Nurse Practitioner first documented the need for an OT evaluation in his note on 7/21/25. This OT evaluation indicated: -Pt (patient) referred to OT services after concern over increased tightness in L (left) hand, assessment for brace and positioning. -Plan of Treatment: 10 time(s)/period; Cert. (Certification) Period: 9/8/25 – 10/7/25. Review of Resident #24's medical record failed to indicate the physician was notified of the delay in the completion of the OT evaluation. Review of Resident #24's medical record indicated the Resident was re-evaluated by OT three more times and each time the OT ordered the Resident to be seen 10 times in a 30-day period. In the time period from the initial OT evaluation on 9/8/25 to when the Resident was discharged from services on 12/12/25, the Resident was ordered to receive 30 visits. Review of the OT notes indicated Resident #24 had been seen by OT 13 times, not even half the ordered frequency. Review of Resident #24's medical record failed to indicate the physician was aware the OT was not meeting the frequency of treatments ordered. Review of Resident #24's occupational therapy (OT) progress notes for the entirety of the treatment period of 9/8/25 to 12/12/25 indicated the following left-hand contracture concerns: -OT treatment indicated Resident #24's range of motion to his/her fifth finger improved with treatment visits, however regressed between treatments. -On 10/15/25, the OT recommended hand carrot had only been used one time since 10/8/25. This note indicated that the Resident was in agreement to use the hand carrot and that nursing staff were educated on the use and wearing schedule of the carrot (24 hours a day). -On 10/22/25, the OT indicated he observed Resident #24 without the hand carrot and the Resident had informed him he/she had not been wearing the orthotic. The note also indicated nursing was unaware if the Resident had worn the hand carrot and was again educated that the Resident should be wearing the carrot 24 hours a day. -On 11/5/25, the OT continued to recommend Resident #24 wear the hand carrot 24 hours a day and that nursing had reported the Resident had only worn the carrot for 2 days since previous treatment session (2 days in a week). -On 11/12/25, the OT indicated that due to nursing lack of follow-through with the hand carrot and Resident #24's increased left hand pain, he discontinued the use of the hand carrot. The OT instead recommended a palm guard, however the Resident refused due to increased left-hand pain. -Resident #24 was discharged from OT services with the last treatment date of 12/12/25 secondary being admitted to the hospital. Review of Resident #24's medical record throughout the treatment period of 9/8/25 to 12/12/25 failed to indicate the physician was notified of recommendations for hand orthotics or that any physician orders had been obtained for their use. Further review of the medical record failed to indicate the physician was notified of any concerns of pain, inability to wear hand orthotic, or lack of improvement/decline in contracture. Review of Resident #24's medical record indicated the Resident was discharged to the hospital on [DATE]. Review of the hospital discharge paperwork, dated 12/16/25, indicated: -Left hand pointer/index finger (digit 2) contracted straight outward with thumb touching. Able to visualize skin to palm next to these two digits only. Digit 3, 4, and 5 contracted and unable to visualize the nailbed of the 5th (pinky) finger. Pinky Finger appears swollen and pink. This clinician, along with wound colleague, was unable to extend digits to see the palm of the hand. Unable to visualize if there was a wound or not. Fingers tightly contracted. -The patient reports he/she has had difficulty moving his hand for months. He/she has also had associated hand pain, particularly in his/her pinky. -If the patient elects not to pursue amputation, alternative options such as Botox injections may be reconsidered, though per inpatient orthopedic discussion this may not be indicated at this time and would require outpatient reassessment. -His/her left fifth finger was amputated on 12/19/25. During an interview on 2/11/26 at 1:29 P.M., Occupational Therapist (OT) #1 said he was the OT responsible for treating Resident #24 from 9/8/25 until his/her finger was amputated in December 2025. OT #1 said his specialty was contractures. OT #1 said he documented improvements after his direct treatments but, since his recommendations weren't followed by nursing, when he'd come back the next week Resident #24's contracture was back in the original spot and had to start from scratch. OT #1 said nursing often was unable to replace the hand carrot when it fell out, so the contracture didn't get better. OT #1 said it was nursing's responsibility to communicate Resident #24's worsening contracture or intolerance of hand orthotics, so he did not notify any physician regarding his concerns, late eval or missed treatments. During an interview on 2/11/26 at 8:38 A.M., Certified Nurse Assistant (CNA) #6 said Resident #24's left hand contracture worsened between July 2025 and when the left fifth finger was amputated in December 2025. CNA #6 said Resident #24 often didn't use his/her hand orthotic because he/she wasn't tolerating it because of increased pain and worsening range of motion. CNA #6 said he told many nurses that the contracture was getting worse and that Resident #24 was not tolerating the hand orthotics. During an interview on 2/12/26 at 7:44 A.M., Nurse #6 said he never notified any physician of Resident #24's worsening contracture, increased left hand contracture pain, or that Resident #24 was no longer tolerating his/her hand orthotics. Nurse #6 said he didn't think anyone had notified the physician, because since the Resident wasn't wearing the orthotic of course it was going to get worse. During an interview on 2/11/26 at 2:08 P.M., Nurse Practitioner (NP) #1 said Resident #24 developed a contracture in his/her left hand in July 2025 and he expected OT to evaluate promptly as he recommended it in July. NP #1 said he expected that the facility follow-up with OT evaluation, treatment, and recommendations. NP#1 said he would have been expected to be notified if there were any delays in therapy treatment, inability to provide therapy treatment, and/or changes in contractures so the Resident's plan of care could be re-evaluated. NP #1 said he was never notified of Resident #24's worsening contracture, increased left hand contracture pain, or that Resident #24 was not tolerating his/her hand orthotics but should have been. NP #1 said he was only aware it had worsened after Resident #24's left fifth finger was amputated. During an interview on 2/12/26 at 12:56 P.M., the Medical Director said a physician should have been notified if Resident #24's therapy treatment was delayed or not being completed, if hand orthotics were not being tolerated, and/or if there were any signs of the left-hand contracture worsening. During an interview on 2/12/26 at 1:59 P.M., the Director of Nursing (DON) said Resident #24's left fifth finger contracture definitely became worse while at the facility and his/her left fifth finger was amputated because of this. The DON said a physician should have been notified if Resident #24's therapy treatment was delayed or not being completed, if hand orthotics were not being tolerated, and/or if there were any signs of the left-hand contracture worsening. 2.) For Resident #6, the facility failed to notify the legal guardian of a worsening contracture of the left hand with development of a stage 4 pressure ulcer, development of a new contracture to the right hand and failed to notify the physician of the worsening of the left-hand contracture and development of a new contracture to the right hand. Resident #6 was admitted to the facility in May 2020 with diagnoses including dementia. Review of Resident #6's Minimum Data Set (MDS) assessment, dated 1/16/26, indicated Resident #6 scored 0 out of 15 on the Brief Interview for Mental Status, indicating severe cognitive impairment. Further review of the MDS indicated the Resident was dependent on staff for all activities of daily living (ADLs). Review of the medical record indicated Resident #6 had a legal guardian. On 2/9/26 at 7:30 A.M., the surveyor and Certified Nursing Assistant (CNA) #5 observed Resident #6 lying in his/her bed. Resident #5 was not wearing a splint in either hand at this time. CNA #5 said she is Resident #6's primary care giver and said Resident #6 has a splint ordered to be worn in his/her left hand but she has not seen the Resident's hand splint in a very long time. CNA #5 said the Resident used to wear the left-hand splint at night and it would be removed in the morning. The Resident's left hand was observed to be contracted inwardly, and the thumbs were overlapping the third finger. The right hand was also observed with the third to fifth fingers bent forward towards the palm of the hand. CNA #5 attempted to pry open the fingers on both hands and the Resident was observed saying ouch indicating pain. CNA #5 said the Resident's left hand has become progressively more contracted since they stopped applying his/her splint and his/her right hand has a new contracture. CNA #5 said she has a difficult time cleaning the Resident's hands due to the worsened contractures on both hands. On 2/9/26 at 9:56 A.M., Nurse #2 told the Surveyor that CNA #5 reported an open area to the Resident's left hand third finger. The surveyor and Nurse #2 went to Resident #6 and when Nurse #2 pried open the Resident's left fingers, the surveyor observed an open area to the third finger. The middle of the wound bed was covered in a whitish substance, and the surroundings were reddened and inflamed. The Resident was attempting to pull back his/her had saying ouch indicating pain. Nurse #2 said that it was a new stage 2 pressure ulcer and had notified the Nurse Practitioner and obtained orders including referral to the wound care physician. Nurse #2 said the wound had developed due to the worsening of the contracture as it was getting difficult to open the Resident's fingers. Review of Resident #24's [Re]admission Assessment completed by the facility, dated 4/23/25, failed to indicate any contractures. Resident #6 medical record indicated he/she was treated by Occupational Therapy (OT) from 5/14/25 to 6/25/25 for contracture management of the left hand. Review of the Wound Care Specialist note, dated 2/10/26, indicated Resident #6 had a new stage 4 wound with the etiology of pressure. Review of the medical record failed to indicate the legal guardian was notified of a change in condition, when the Resident's left arm contracture worsened causing a development of a stage 4 pressure ulcer to the left hand third digit and the new contracture to the right hand. Review of medical record failed to indicate the facility notified the physician of the worsening of the left-hand contracture and the development of a new right-hand contracture. During an interview on 2/11/26 at 7:39 A.M., Resident Representative #1 said he was not notified of the worsening left-hand contracture, the development of a new contracture of the right hand and a new stage 4 pressure ulcer to the third finger. During an interview on 2/11/26 at 1:32 P.M., Occupational Therapist (OT) #1 said Resident #6 had been seen by OT back in June and left-hand splint was initiated for contracture management and he said it was nursing responsibility to carry through the splint application after the Resident had been discharged from OT. He further said if the splint was not being applied consistently the contractures would worsen. OT #1 said that at the time he was treating Resident #6 from May to June 2025, the Resident did not have a contracture of his/her right hand. During an interview on 2/11/26 at 3:00 P.M., Nurse #2 said when there is a change in condition, the physician and resident representative would be notified and documented in the progress notes. She said Resident #6 had a legal guardian. Nurse #2 said she believed the unit manager notified the legal guardian. During an interview on 2/11/26 at 3:06 P.M., Unit Manager #2 said she left the guardian a message about a skin tear but did not mention the worsened contracture or the stage 4 pressure ulcer to the left third finger. She said the nurse who found the pressure area should have notified the guardian. During an interview on 2/11/26 at 2:02 P.M., Nurse Practitioner #1 said staff never informed him of the worsening of the left-hand contracture or the development of a new contracture to the right hand. He said if he was aware he would have put in an occupational therapy referral. He further said staff should notify physicians with any changes in resident's status. During an interview on 2/12/26 at 1:59 P.M., the Director of Nursing said the nurse who finds a change in condition on a resident should be the one to notify the resident representative and the physician. 3). Resident #21 was admitted to the facility in February 2022 with diagnoses including chronic obstructive pulmonary disease (COPD), dementia and heart failure. Review of Resident #21's most recent Minimum Data Set (MDS) dated [DATE] indicated Resident had a score of 0 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she is severely cognitively impaired. The MDS also indicated Resident #21 is dependent on staff for activities of daily living. Review of Resident #21's physician orders, indicated the following order: -Oxygen 2 liters continuous via nasal cannula to keep o2 sat at or above 90%. Call MD/NP (medical doctor/nurse practitioner) if O2 (oxygen) sat (saturation) is below 90%. every shift for Hypoxemia Oxygen 2 liters continuous via nasal cannula to maintain sat at or above 90%. Call MD if sat is below 90%. On 2/6/26 at 7:34 A.M., Resident #21 was observed being brought to dining room by staff without his/her oxygen on. The portable oxygen tank was attached to the back of his/her wheelchair, however the tubing was wrapped around the tank and not placed on the Resident's nose. At 8:44 A.M., the Resident was observed with the oxygen nasal cannula on his/her nose, however the portable tank was observed to be empty. From 8:44 A.M. until 12:13 P.M., Resident #21 continued to sit with the nasal cannula on but with an empty tank. Throughout this observation time, Resident #21 was never observed attempting to take of the nasal cannula and was compliant with his/her oxygen wearing. On 2/6/26 at 12:13 P.M., the surveyor asked Nurse #9 to check Resident #21's portable oxygen tank. Nurse #9 checked the portable tank and told the surveyor it was empty. Nurse #9 said he did not know the level of oxygen Resident #21 was ordered to be receiving and had not assessed the Resident's oxygen yet today. Nurse #9 said the Certified Nursing Assistants (CNAs) are supposed to monitor the tanks throughout the day and refill them as needed. At 12:18 P.M., Nurse #9 said he should check Resident #21's oxygen level, however he did not have a working oximeter on the unit. Nurse #9 then left the Resident and the unit to obtain an oximeter on a different nursing unit. At 12:20 P.M., Nurse #9 returned to the unit, placed the oximeter on Resident #21's index finger and his/her oxygen level reading was 85%. At 12:25 P.M., the Director of Nursing entered the unit and was informed of the above observations by the surveyor. During an interview at this time, the Director of Nursing said the CNAs should be filling the portable oxygen tanks and the nurse should be checking Resident #21's oxygen level throughout the shift and ensuring the oxygen is being provided at the level ordered by the physician. At 12:32 P.M., the Director of Nursing took Resident #21's oxygen level with the oximeter again, and his/her reading at this time was 74%. At 12:33 P.M., the Director of Nursing said the level may be low because the oximeter may need a new battery and he left the unit to obtain a new battery for the oximeter. At 12:38 P.M., the Director of Nursing returned to the unit with the oximeter and again took Resident #21's oxygen level and the reading was now 80%. At this time, the Director of Nursing said oxygen levels should be above 90% unless otherwise stated by the physician. During an interview on 2/6/26 at 12:37 P.M., Nurse #9 said if a resident's oxygen level is low, specifically if it is below 90%, he would need to notify the provider. During an interview on 2/6/26 at 12:39 P.M., the Director of Nursing said oxygen should always be provided to residents as ordered by the physicians. The Director of Nursing said if a resident's oxygen level drops below 90%, as Resident #21's dropped to as low as 80%, the physician or nurse practitioner should be notified to see if oxygen rate should be increased or other interventions added. During an interview on 2/9/26 at 9:59 A.M., the Nurse Practitioner said he was never notified of Resident #21's change in respiratory status and lowered oxygen saturation levels on 2/6/26. The Nurse Practitioner said he would need to be notified in case further assessment or interventions are required. 4). Resident #9 was admitted to the facility in June 2020 with diagnoses including chronic obstructive pulmonary disease (COPD), pulmonary nodule and heart failure. Review of Resident #9's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident score 0 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #9 is dependent on staff for all activities of daily living and mobility tasks. Review of Resident #9's care plan indicated the following interventions: - Monitor for s/sx (signs and symptoms) of respiratory distress and report to MD (medical doctor) PRN (as needed): Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, -OXYGEN SETTINGS: I have O2 (oxygen) via nasal cannula 2L continuously. On 2/6/26 at 12:10 P.M. Resident #9 was observed sleeping in dining room. He/she had a portable oxygen tank attached to his/her recliner and a nasal cannula in his/her nose. The portable oxygen tank was observed to be empty. On 2/6/26 at 12:13 P.M., the surveyor asked Nurse #9 to check Resident #9's portable oxygen tank. Nurse #9 checked the portable tank and told the surveyor it was empty. Nurse #9 said he did not know the level of oxygen Resident #9 was ordered to be receiving and had not assessed the Resident's oxygen yet today. Nurse #9 said the Certified Nursing Assistants (CNAs) are supposed to monitor the tanks throughout the day and refill them as needed. At 12:18 P.M., Nurse #9 said he should check Resident #9's oxygen level, however he did not have a working oximeter on the unit. Nurse #9 then left the Resident and the unit to obtain an oximeter on a different nursing unit. At 12:21 P.M., Nurse #9 returned to the unit, placed the oximeter on Resident #21's index finger and at 12:26 P.M., five minutes later, Nurse #9 was able to get an oxygen reading of 74%. At 12:25 P.M., the Director of Nursing had entered the unit and was informed of the above observations by the surveyor. The Director of Nursing said the CNAs should be filling the portable oxygen tanks and the nurse should be checking Resident #9's oxygen level throughout the shift and ensuring the oxygen is being provided at the level ordered by the physician. At 12:33 P.M., the Director of Nursing said the level may be low because the oximeter may need a new battery and he left the unit to obtain a new battery for the oximeter. At 12:38 P.M., the Director of Nursing returned to the unit with the oximeter and again took Resident #9's oxygen level at 12:40 P.M., and the reading was now 80%. At this time, the Director of Nursing said oxygen levels should be above 90% unless otherwise stated by the physician. During an interview on 2/6/26 at 12:37 P.M., Nurse #9 said if a resident's oxygen level is low, specifically if its below 90%, he would need to notify the provider. During an interview on 2/6/26 at 12:39 P.M., the Director of Nursing said oxygen should always be provided to residents as ordered by the physicians. The Director of Nursing said if a resident's oxygen level drops below 90%, as Resident #9's dropped to as low as 74%, the physician or nurse practitioner should be notified to see if oxygen rate should be increased or other interventions added. During an interview on 2/9/26 at 9:59 A.M., the Nurse Practitioner said he was never notified of Resident #9's change in respiratory status and lowered oxygen saturation levels on 2/6/26. The Nurse Practitioner said he would need to be notified in case further assessment or interventions are required.

Based on observation, record review and interview the facility failed to ensure two Residents (#36 and #24) were free from abuse out of a total sample of 34 residents. Specifically,1.) For Resident #36, despite repeated emails sent by the Resident to the facility Administrator, Director of Nursing and Social Worker, the facility failed to prevent sexual abuse and protect the Resident from psychological harm due to the fear he/she lived with from this abuse and lack of protection provided by the facility. 2.) For Resident #24, the facility failed to ensure the Resident was free from abuse, when the facility failed to ensure after Resident #24 reported that another Resident (#47) kept entering his/her room to climb into his/her bed, exposing his/her private areas, and touching him/her and his/her belongings, which made him/her feel afraid and unsafe. Findings include:Review of the policy titled Suspected Adult, Disabled Resident or Elderly Abuse/Neglect/Exploitation, dated as revised 6/26/25, indicated the following: Sexual Abuse: Failure to make a reasonable effort to prevent sexual contact, sexual intercourse, sexual conduct, sexual assault or sodomy inflicted on, shown to or intentionally practiced in the presence of a resident. -Compelling or encouraging the resident to engage in sexual contact Neglectful Supervision: -Placing in, or failing to remove, the resident from a situation that a reasonable individual would realize required judgment or actions beyond that physical condition or mental abilities and that results in bodily injury or substantial risk of immediate harm to the resident. Procedure: -Management of Suspected Abuse/Neglect: Cases of suspected sexual assault, physical abuse or neglect will be given priority and will be investigated thoroughly. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. -To protect the resident from real or suspected mental, physical, sexual and verbal abuse, neglect and/or exploitation, staff will safeguard the resident from the offending individual(s). This safeguarding may be over tor covert, dependent upon the resident's mental and physical sense of well-being. If any type of abuse or exploitation is proven legitimate (witnessed and obvious), the offending individual will be restricted from access to the resident. Resident to Resident Altercations: -It is the policy of (the facility) to create and maintain a safe environment for all residents. -An altercation free culture will be promoted through appropriate staff and resident screenings, staff and resident training, education, supervision and support. -The reporting of resident to resident altercations will adhere to the Department of Public Health guidelines. 1. Resident #36 was admitted to the facility in April 2025 and has diagnoses that include anxiety disorder, paraplegia and depression. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/2/26, indicated that on the Brief Interview for Mental Status exam Resident #36 scored a 15 out of 15, which indicated he/she had intact cognition. The MDS further indicated that Resident #36 had no behaviors and is dependent on staff for self-care and transfers. During the Resident Group Meeting with the Surveyors on 2/6/26 at 10:30 A.M., Resident #36 said that there is a resident in the building that is a pervert, he/she walks up to him/her and says nasty things and has even pulled his/her genitals out. Resident #36 said that one time he/she had to call the police because of it and that it is an ongoing issue that he/she has reported to the Director of Nursing on multiple occasions. During a follow-up interview on 2/10/26 at 8:22 A.M., Resident #36 said the following:-He/she has an ongoing issue with another resident who he/she describes as a disgusting pervert. Resident #36 said that on October 15, 2025 he/she was seated in the hall with several other residents when the resident approached him/her and said, you know you want me to **** you, you want this **** in your mouth and other vulgar things. -That at that time he/she emailed the Director of Nursing (DON) and Nursing Home Administrator (NHA) to tell them what was happening and said that if it was not stopped he/she would call the cops. Resident #36 said that shortly after sending the email he/she called the cops. Resident #36 said that later that same day the DON and the Operational Director (OD) came to the unit to speak with him/her. Resident #36 relayed to them what the resident had said, and Resident #36 said that the OD did not believe him/her and responded, I can't believe he/she could put that many words together in a sentence. Resident #36 said that the resident making these threats was taken by the responding police offers to the hospital but returned the next day, and the behaviors have continued since then. -Resident #36 said that he/she lives in fear the other resident will take it further and hurt me and touch me and I can't protect myself or get up and run. Resident #36 provided the surveyor with emails from October 2025 between him/herself and the NHA and DON:1. Email #1, dated 10/15/25, from Resident #36 to the NHA and DON: Something has got to be done with (the other resident). Today he/she drops his/her pants in the Hallway and then walks up to me later and said to me YOU Know you want my *** in your **** and right now he/she just took out his/her (genitals) in front of me and said you know you want this. If he/she does this in front of me or anyone else again, I'm calling the cops on him/her. Its lewn (sic) and obnoxious behavior. Please d something!!! (sic).2. Email #2, dated 10/15/25, from Resident #36 to the NHA and DON: Sorry but I called the cops, he/she wouldn't stop coming and bothering us men/ladies.3. Email #3, dated 10/16/25, from the DON to Resident #36: I understand. Resident #36 provided the surveyor with emails from January 2026 between him/herself and the NHA, DON and facility Social Worker (SW):1. Email #1, dated 1/18/26, from Resident #36 to the NHA, DON and SW: (the resident) and (another resident): THESE TWO NEED TO BE REMOVED FROM THIS AREA. They are out of control. You have (the resident) constantly speaking nasty to you. I had to call the cops on him one night because he/she was so bad. Neither one of them should be allowed down in our area. You have the Nurse and Certified Nursing Assistants (CNAs) take them away a couple of times but then they just let them go and ignore them because they are tired of dealing with them. Then you have days when the two of them are hanging in the hallway dancing around naked. 2. Email #2, dated 1/20/26, from the facility SW to Resident #36, the DON and NHA: We try to redirect the wanderers that are in and out of rooms and dressed inappropriately on a daily basis. It takes redirection and reattempting to address the concerns throughout the day. They have rights too, however, we will try to do better with supervising them, especially when they are roaming the hallways. It is hard to make everyone happy, but we are trying to address many of these concerns so that everyone feels safe and comfortable in their home. Resident #36 said that although the SW responded by email on 1/20/26, the SW never came to speak with him/her regarding the concerns he/she had reported in the 10/15/25 or 1/18/26 emails. Review of Resident #36's care plans failed to indicate any care plans regarding the abuse Resident #36 has reported to the facility. There is an unrelated psychosocial care plan in place that was last reviewed and revised in April 2025, which indicated: Focus: psycho-social well-being: (Resident #36) is at risk for an alteration in psychological well-being due to self-isolation, adjustment to a nursing home environment, progression of disease process, depression. cognitive decline/ deficit, mobility decline/ deficit, relocation (revised 4/25/25). Interventions: -Encourage loved ones to keep in contact. (4/25/25) -Encourage self-control and problem-solving skills including; imitating new behavior, awareness of behavior, directing/ redirecting energies into stress-reducing activities and behaviors. (4/25/25) -Explain procedures before beginning them (4/25/25) -Observe and report any changes in mental status (4/25/25) Review of the care plans fails to indicate any resolved or current care plans regarding the incident on 10/15/25. Review of Resident #36's clinical progress notes from October 2025 through February 2026 failed to indicate the sexual abuse sustained by Resident #36 on 10/15/25, was addressed by the facility SW, the Nurse Practitioner (NP), the nursing staff or Behavioral Services. During an interview on 2/10/26 at 11:17 A.M., the Psychiatrist said that he was never told about the abuse sustained by Resident #36, and that he would consider this sexual abuse. The Psychiatrist said that he would want to have this type of abuse reported to him because it can cause fear and be frightening for Resident #36 to have these things occur. The Psychiatrist said that he is the only psychiatric service in the building and that his role is to manage medication. He said that he has never been asked to see Resident #36 regarding the incident on 10/15/25 or after subsequent reports made by him/her to the facility. The Psychiatrist said that it has been over a year since the building had talk therapy available and that Resident #36 would be the type of resident who would benefit from talk therapy to address his/her feelings regarding the abuse. During an interview on 2/10/26 at approximately 12:00 P.M., Certified Nursing Assistant (CNA) #1 said that she is Resident #36's regular CNA. CNA #1 said that Resident #36 requires two-person assistance with his/her care and transfers with a mechanical lift in and out of bed. CNA#1 said that Resident #36's mood is generally stable except whenever CNA #1 is providing care to him/her, Resident #36 will hear the (accused resident) in the hallway and ask CNA #1 to stop care and make sure he/she goes away because Resident #36 is scared and uncomfortable. CNA #1 did not report this to anyone because it is a regular occurrence that she manages during care. During an interview on 2/10/26 at 1:59 P.M., the SW said that Resident #36 has been upset with the accused resident for a long time because the resident has predatory behavior, is sexually inappropriate and wanders in and out of Resident #36's room regularly. The SW said that she was never informed about the incident on 10/15/25 or that Resident #36 called the police because of the abuse and that if she had been possibly the facility could have prevented its reoccurrence. The SW said that communication is lacking in the building and therefore she does not always find out about things like this but should. During an interview on 2/10/26 at 2:21 P.M., the DON said that in hindsight the 10/15/25 sexual abuse Resident #36 had experienced and reported to the facility should have been addressed and a plan made to adequately prevent recurrence but had not. He said that it is his expectation that when a behavior continues, and staff are aware that the behavior is upsetting the resident, that he be informed The DON said that he was not aware that Resident #36 was fearful of the other resident or that the resident's voice in the hall triggers Resident #36 to have his/her CNA stop care and send the resident away. During an interview on 2/11/26 at 12:02 P.M., the NHA said that at the time of the sexual abuse on 10/15/25 and in the months following, safeguards should've been put in place to protect Resident #36 and other residents, and he could not say why that did not happen. During an interview on 2/12/26 at 12:55 P.M., the Medical Director said all allegations of abuse need to be taken seriously and addressed. The Medical Director said he was unaware of the allegations of sexual abuse made by Resident #36. 2.) Resident #24 was admitted to the facility in December 2024 with diagnoses including osteoarthritis, heart failure and hypertension. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/29/25, indicated Resident #24 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS also indicated Resident #24 was dependent on staff for dressing, transfers, and mobility. On 2/6/26 at 2:12 P.M., the surveyor observed Resident #24 in his/her bed with the door to the hallway closed. Certified Nurse Assistant (CNA) #6 was also in the room behind a closed curtain with the Resident's roommate, not within view of Resident #24. Another Resident (#47), who did not reside in this room, walked out of the shared bathroom. Resident #47 walked through the room to Resident #24's bed, where he/she attempted to get into the bed with Resident #24. Resident #47 then stood back up and pulled down his/her pants exposing his/her buttocks while attempting to pull back the sheets that were covering Resident #24. Resident #24 appeared frightened with wide eyes and grimace. CNA #6, who was still behind the closed curtain with the roommate, did not intervene or interact in any way. The Activities Director then entered Resident #24's room to see another roommate and the surveyor alerted her to the situation. The Activities Director responded Oh yeah, he/she does that. Let me get him/her out of here. The Activities Director was unable to redirect Resident #47, so she left to get Nurse #6, who came and was able to redirect Resident #47 out of the room. On 2/6/26 at 2:19 P.M., CNA #6, who was behind the closed curtain with the roommate, told the surveyor not to worry about Resident #47 because nothing ever happens and he/she wanders into Resident #24's room all the time. During an interview on 2/6/26 at 2:25 P.M., Resident #24 said Resident #47 comes into his/her room every day without permission. Resident #24 said Resident #47 often climbs into bed with him/her, pulls down his/her own pants to exposes private areas, and touches him/her and his/her belongings. Resident #24 said one time he/she got socked in the face by accident when he/she was trying to get into my bed. Resident #24 said he/she doesn't feel safe because he/she isn't able to move from the bed himself/herself and is afraid Resident #47 would overtake him/her. Resident #24 said staff continues to let Resident #47 wander into his/her room even though he/she's told many staff members he/she doesn't want Resident #47 there and that it makes him/her feel afraid. Resident #24 said he/she feels staff could do more to keep Resident #47 out of his/her room and the only thing they have done is tell him/her to press the call light if Resident #47 comes in, but they often don't answer timely and he/she just wants Resident #47 to stay out. Resident #24 said he/she often must shout at Resident #47 to leave, but he/she doesn't listen. Resident #24 said he/she has told staff he/she wishes he/she had something to throw at Resident #47 to protect himself/herself. Resident #24 said he/she does not feel safe. During an interview on 2/6/26 at 3:15 P.M., the Administrator and Director of Nursing (DON) said they were unaware Resident #24 did not feel safe and that based on the incident they would put interventions in place to ensure the other Resident did not enter Resident #24's room. Review of Resident #24's entire plan of care, reviewed by surveyor on 2/9/26, which was three days after the surveyor's observation of incident on 2/6/26, failed to indicate the Resident's concern of another Resident repeatedly entering his/her room or any interventions to deter intrusive wandering. During a follow-up interview on 2/9/26 at 11:04 A.M., which was three days after the surveyor's observation of incident on 2/6/26, Resident #24 said Resident #47 continued to come into his/her room over the weekend and still has free access to his/her room. Resident #24 said he/she had to shout at Resident #47 to get out of his/her room over the weekend. Resident #47 said he/she is fearful of Resident #47 because he/she takes my things, removes his/her clothes, and I feel like I'm going to get mugged or hurt all the time or he/she's going to get into my bed with me. Resident #24 said he/she does not sleep at times because he/she is fearful Resident #47 will come into his/her room. During an interview on 2/9/26 at 11:15 A.M., Certified Nurse Assistant (CNA) #6 said he wasn't aware of any new interventions to prevent Resident #47 from entering Resident #24's room over the weekend or during the current shift. CNA #5 said they provide general, intermittent oversight and redirection to Resident #47. During an interview on 2/9/26 at 11:19, Nurse #6 said they have been unable to stop Resident #47 from entering Resident #24's room, even after the incident on 2/6/26. Nurse #6 said he knew nobody on the floor likes when another Resident wanders into their room but they can't force Resident #47 to leave because it's Resident #47's right to be in whatever room he/she wants. During an interview on 2/9/26 at 11:28 A.M., CNA #5 said she wasn't aware of any new interventions to prevent Resident #47 from entering Resident #24's room over the weekend or during the current shift. CNA #5 said they provide general, intermittent oversight and redirection to Resident #47. During an interview on 2/10/26 at 7:47 A.M., Resident #24's health care proxy (HCP) said Resident #24 has not felt safe since March 2025, when Resident #47 began coming into his/her room. Resident #24's HCP said she's seen signs of psychological distress since March 2025, such as being on edge and not sleeping. Resident #24's HCP said she told staff that both she and Resident #24 did not want Resident #47 in his/her room in March or April of 2025 but stopped asking because it seemed staff was just unable to keep Resident #47 from going into everyone's room. During an interview on 2/10/26 at 11:17 A.M., the Psychiatrist said he was unaware Resident #24 had any concerns of psychosocial distress or psychological effects from being fearful from another Residents behaviors, but he/she should have been referred. During an interview on 2/10/26 at 1:59 P.M., the Social Worker (SW) said she was unaware Resident #24 was distressed by Resident #47 repeatedly entering his/her room since March 2025 but should have been. The SW said repeatedly wandering into their room could cause distress and anxiety. The SW said if behaviors cause distress, such as trying to get into bed or pulling down pants, these are considered resident to resident altercations and interventions should be put into place immediately specific to the Resident effected. The SW said she was first made aware 2/6/26 after the incident occurred, and when she followed up Resident #24 told her he/she was distressed. The SW said the facility did not put any interventions into place specific for Resident #24 but should have. During an interview on 2/10/26 at 2:21 P.M., the Director of Nursing (DON) said repeatedly wandering into their room could cause distress. The DON said if behaviors cause distress, such as trying to get into bed or pulling down pants, these are considered resident to resident altercations and interventions should be put into place immediately specific to the Resident effected. The DON said there were no interventions specifically implemented for Resident #24, but looking back there probably should have been. The DON further said staff should have notified himself and the physician/Psychiatrist of Resident #24's fearfulness and psychological distress but they had not. The DON said over the weekend through Monday (2/6/26 through 2/9/26), the staff was supposed to completed 15 minute face checks for Resident #47 and redirect him/her from entering any other resident rooms until 2/10/26. The DON was unaware that Resident #24 had ongoing concerns of Resident #47 entering his/her room or that CNAs were not aware of Resident #47's 15 minute face checks. During a follow-up interview on 2/11/26 at 8:26 A.M., CNA #5 said any resident to resident altercations, including wandering causing any resident distress, should be reported to the nurse and interventions should be put into place immediately. CNA #5 said Resident #24's family reported Resident #24 was distressed by Resident #47 wandering into his/her room a long time ago in March or April 2025 and had requested Resident 47 never enter his/her room. CNA #5 said she didn't think any interventions were put into place and that staff just redirects if we see it. CNA #5 further said that not providing necessary supervision to prevent resident to resident altercations would be considered neglect and is a form of abuse. During a follow-up interview on 2/11/26 at 8:38 A.M., CNA #6 said Resident #24 had not wanted Resident #47 in his/her room since they were admitted in March 2025. CNA #6 said Resident #24 always tells staff to get Resident #47 out of his/her room and the Social Worker is always talking to him/her about it. CNA #6 said he believes the repeated wandering into his/her room had caused emotional distress to Resident #24. CNA #6 said he often sees Resident #24 shout at Resident #47 to get out and gets very emotional and upset that Resident #47 keeps coming in because he/she doesn't like him at all. CNA #6 said Resident #24 told him he/she doesn't want Resident #47 in his/her room because he will beat him up. CNA #6 said he has told management and the social worker many times that the current general oversight with redirection isn't enough and that they can't keep Resident #47 from wandering into other Resident's rooms, including Resident #24, and has requested 1:1 but the facility does not have enough staff for it. CNA #5 further said that not providing necessary supervision to prevent resident to resident altercations would be considered neglect and is a form of abuse. During an interview on 2/11/26 at 12:01 P.M., the Administrator said he was unaware of Resident #24's concerns or emotional distress related to repeated wandering from Resident #47. The Administrator said he would expect staff to notify administration immediately if Resident #24 was distressed or that interventions were not working so they could attempt alternate interventions promptly. During a follow-up interview on 2/11/26 at 8:56 A.M., Nurse #6 said any resident to resident altercations, including wandering that causes another resident distress or resident's shouting at other residents, should be immediately reported to administration. Nurse #6 said administration was aware of the concern of not being able to keep Resident #47 out of all other resident rooms, including Resident #24's room, and that even 15 minutes was too long in between checks but they did not want to put any other interventions into place because they did not have the staff for 1:1. Nurse #6 said he can only do interventions he is directed to do. Nurse #6 said they never attempted any interventions specific to Resident #24 but should have. Nurse #6 further said that not providing necessary supervision to prevent resident to resident altercations would be considered neglect, which is a form of abuse. During an interview on 2/11/26 at 2:08 P.M., Nurse Practitioner (NP) #1 said he would have expected to be notified immediately if any resident was experiencing emotional distress so they could figure out what they could do to help them. NP #1 said he should have been told about Resident #24's distress when it first was reported back in March or April 2025 and interventions should have been put into place to prevent it but was not. During an interview on 2/12/26 at 12:55 P.M., the Medical Director said he would expect interventions to be put into place for Resident #24 if there was a reoccurring issue with another Resident's behaviors causing emotional distress.

Based on record review and interview the facility failed to ensure two Resident (#36 and #24) were provided with the necessary behavioral health service to attain the highest level of psych-social well-being out of a total sample of 34 residents. Specifically:for Resident #36, the facility failed to provide psychotherapy or necessary behavioral health services when the Resident expressed fear and anxiety related to the intrusive wandering and sexual threats of another resident and despite Resident #36 sending multiple emails to the facility's Administrator, Director of Nursing and Social Worker regarding the ongoing concern. Resident #24, the facility failed to provide behavioral health services when the Resident expressed fearfulness and emotional distress related to another Resident's repeated intrusive wandering, indecent exposure, unwanted touching and attempts to enter his/her bed. Findings include: Resident #36 was admitted to the facility in April 2025 and has diagnoses that include anxiety disorder, paraplegia and depression. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/2/26, indicated that on the Brief Interview for Mental Status exam Resident #36 scored a 15 out of 15, which indicated he/she had intact cognition. The MDS further indicated that Resident #36 had no behaviors and is dependent on staff for self-care and transfers. During the Resident Group Meeting with the Surveyors on 2/6/26 at 10:30 A.M., Resident #36 said that there is a resident in the building that is a pervert, he/she walks up to him/her and says nasty things and has even pulled his/her genitals out. Resident #36 said that one time he/she had to call the police because of it and that it is an ongoing issue that he/she has reported to the Director of Nursing on multiple occasions. During a follow-up interview on 2/10/2026 at 8:22 A.M., Resident #36 said the following:-He/she has an ongoing issue with another resident who he/she describes as a disgusting pervert. Resident #36 said that on October 15, 2025 he/she was seated in the hall with several other residents when the resident approached him/her and said, you know you want me to **** you, you want this **** in your mouth and other vulgar things. Resident #36 said that since that incident the behaviors of his/her peer have continued and he/she therefore lives in fear the other resident will take it further and hurt me and touch me and I can't protect myself or get up and run. Resident #36 said that he/she does not receive any type of talk therapy but would accept it if offered. Resident #36 provided the surveyor with emails from October 2025 and January 2026 between him/herself, the Nursing Home Administrator (NHA), Director of Nursing (DON) and facility Social Worker (SW). Resident #36 detailed the abuse he/she was experiencing from a peer and pleaded for the facility to help him/her. During an interview on 2/10/2026 at approximately 12:00 P.M., Certified Nursing Assistant (CNA) #1 said that she is Resident #36's regular CNA. CNA #1 said that Resident #36 requires two-person assistance with his/her care and transfers with a mechanical lift in and out of bed. CNA#1 said that Resident #36's mood is generally stable except whenever CNA #1 is providing care to him/her, Resident #36 will hear the (accused resident) in the hallway and ask CNA #1 to stop care and make sure he/she goes away because Resident #36 is scared and uncomfortable. Review of Resident #36's care plans failed to indicate behavioral health services as an intervention to maintain Resident #36's psychosocial well-being following the sexual abuse on 10/15/25. Review of Resident #36's medical record failed to indicate he/she was ever evaluated or treated by behavioral health services after the 10/15/25 incident or subsequent incidents thereafter. During an interview on 2/10/2026 at 11:17 A.M., the Psychiatrist said that he was never told about the abuse sustained by Resident #36, and that he would consider this sexual abuse. The Psychiatrist said that he would want to have this type of abuse reported to him because it can cause fear and be frightening for Resident #36 to have these things occur. The Psychiatrist said that he is the only psychiatric service in the building and that his role is to manage medication. He said that he has never been asked to see Resident #36 regarding the incident on 10/15/25 or after subsequent reports made by him/her to the facility. The Psychiatrist said that it has been over a year since the building had talk therapy available and that Resident #36 would be the type of resident who would benefit from talk therapy to address his/her feelings regarding the abuse. During an interview on 2/10/2026 at 1:59 P.M., the SW said that Resident #36 has been upset with the accused resident for a long time because the resident has predatory behavior, is sexually inappropriate and wanders in and out of Resident #36's room regularly. The SW said that the psychological effect of someone repeatedly wandering in their room could cause distress and anxiety. The SW said that she does not personally provide talk therapy to residents in the facility and that the facility's psychotherapist left in December of 2024 and has not been replaced. She said that her LICSW consultant comes in once a month and that at that time he has started to see a few residents for psychotherapy needs, but that she had never referred Resident #36 to receive that service. The SW said she thinks that the facility needs more psychiatric support to adequately manage the behaviors and support the residents in the facility. The SW added, that in hindsight she should have checked in on Resident #36 and provided support, knowing that Resident #36 was distressed by a peer's behavior toward him/her. During an interview on 2/10/2026 at 2:21 P.M., the DON said that in hindsight the 10/15/25 sexual abuse Resident #36 had experienced and reported to the facility should have been addressed and a plan made to emotionally support him/her by providing behavioral health services. The DON said that the facility has been without a psychotherapist (talk therapy) since December 2024 and that as situations arise, such as Resident #36's, we try to deal with them and sit down and talk but that there was no formal therapy available. The DON was unable to say if Resident #36 was receiving psychotherapeutic support but said that if he/she was it should be documented in the medical record. During an interview on 2/11/2026 at 12:02 P.M., the NHA said that Resident #36's experience with the peer on 10/15/25 was sexual abuse and that his/her continued distress validates this abuse. The NHA said that if a resident does not feel safe they should receive psychotherapy support to talk through the process. The NHA said that he was not aware that Resident #36 was not receiving psychotherapy. During an interview on 2/12/26 at 12:55 P.M., the Medical Director said he was unaware of the allegations of sexual abuse made by Resident #36 and that it is his expectation that a resident receive support from psych services to address being distressed by the sexual and intrusive behavior of his/her peer. The Medical Director said that he has not seen talk therapy available at the facility since the therapist providing it left over a year ago, and that it is a service that would be beneficial here. 2.) Resident #24 was admitted to the facility in December 2024 with diagnoses including osteoarthritis, heart failure and hypertension. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/29/25, indicated Resident #24 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS also indicated Resident #24 was dependent on staff for dressing, transfers, and mobility. On 2/6/26 at 2:12 P.M., the surveyor observed Resident #24 in his/her bed with the door to the hallway closed. Certified Nurse Assistant (CNA) #6 was also in the room behind a closed curtain with the Resident's roommate, not within view of Resident #24. Another Resident (#47), who did not reside in this room, walked out of the shared bathroom. Resident #47 walked through the room to Resident #24's bed, where he/she attempted to get into the bed with Resident #24. Resident #47 then stood back up and pulled down his/her pants exposing his/her buttocks while attempting to pull back the sheets that were covering Resident #24. Resident #24 appeared frightened with wide eyes and grimace. CNA #6, who was still behind the closed curtain with the roommate, did not intervene or interact in any way. The Activities Director then entered Resident #24's room to see another roommate and the surveyor alerted her to the situation. The Activities Director responded Oh yeah, he/she does that. Let me get him/her out of here. The Activities Director was unable to redirect Resident #47, so she left to get Nurse #6, who came and was able to redirect Resident #47 out of the room. On 2/6/26 at 2:19 P.M., CNA #6, who was behind the closed curtain with the roommate, told the surveyor not to worry about Resident #47 because nothing ever happens and he/she wanders into Resident #24's room all the time. During an interview on 2/6/26 at 2:25 P.M., Resident #24 said Resident #47 comes into his/her room every day without permission. Resident #24 said Resident #47 often climbs into bed with him/her, pulls down his/her own pants to exposes private areas, and touches him/her and his/her belongings. Resident #24 said one time he/she got socked in the face by accident when he/she was trying to get into my bed. Resident #24 said he/she doesn't feel safe because he/she isn't able to move from the bed himself/herself and is afraid Resident #47 would overtake him/her. Resident #24 said staff continues to let Resident #47 wander into his/her room even though he/she's told many staff members he/she doesn't want Resident #47 there and that it makes him/her feel afraid. Resident #24 said he/she feels staff could do more to keep Resident #47 out of his/her room and the only thing they have done is tell him/her to press the call light if Resident #47 comes in, but they often don't answer timely and he/she just wants Resident #47 to stay out. Resident #24 said he/she often must shout at Resident #47 to leave, but he/she doesn't listen. Resident #24 said he/she has told staff he/she wishes he/she had something to throw at Resident #47 to protect himself/herself. Resident #24 said he/she does not feel safe. During an interview on 2/10/26 at 7:47 A.M., Resident #24's health care proxy (HCP) said Resident #24 has not felt safe since March 2025, when Resident #47 began coming into his/her room. Resident #24's HCP said she's seen signs of psychological distress since March 2025, such as being on edge and not sleeping. Resident #24's HCP said she told staff that both she and Resident #24 did not want Resident #47 in his/her room in March or April of 2025 but stopped asking because it seemed staff was just unable to keep Resident #47 from going into everyone's room. During an interview on 2/6/26 at 3:15 P.M., the Administrator and Director of Nursing (DON) said they were unaware Resident #24 did not feel safe and that based on the incident they would put interventions in place to ensure the other Resident did not enter Resident #24's room. Review of Resident #24's entire plan of care, reviewed by surveyor on 2/9/26, which was three days after the surveyor's observation of incident on 2/6/26, failed to indicate the Resident's concern of another Resident repeatedly entering his/her room or any interventions to deter intrusive wandering. Review of Resident #24's entire medical record, dated 3/1/25 to 2/9/26, failed to indicate the Resident was referred to or evaluated for the need for any behavioral health services during this time frame. During a follow-up interview on 2/9/26 at 11:04 A.M., which was three days after the surveyor's observation of incident on 2/6/26, Resident #24 said Resident #47 continued to come into his/her room over the weekend and still has free access to his/her room. Resident #24 said he/she had to shout at Resident #47 to get out of his/her room over the weekend. Resident #47 said he/she is fearful of Resident #47 because he/she takes my things, removes his/her clothes, and I feel like I'm going to get mugged or hurt all the time or he/she's going to get into my bed with me. Resident #24 said he/she does not sleep at times because he/she is fearful Resident #47 will come into his/her room. Resident #24 said a lady came to follow-up with him/her on 2/6/26 after the incident and he/she told her that he/was afraid and did not feel safe. During an interview on 2/11/26 at 8:26 A.M., CNA #5 said Resident #24's family reported Resident #24 was distressed by Resident #47 wandering into his/her room a long time ago in March or April 2025 and had requested Resident #47 never enter his/her room. CNA #5 said she didn't think any interventions were put into place and that staff just redirects if we see it. During an interview on 2/11/26 at 8:38 A.M., CNA #6 said Resident #24 had not wanted Resident #47 in his/her room since they were admitted in March 2025. CNA #6 said Resident #24 always tells staff to get Resident #47 out of his/her room and the Social Worker is always talking to him/her about it. CNA #6 said he believes the repeated wandering into his/her room had caused emotional distress to Resident #24. CNA #6 said he often sees Resident #24 shout at Resident #47 to get out and gets very emotional and upset that Resident #47 keeps coming in because he/she doesn't like him at all. CNA #6 said Resident #24 told him he/she doesn't want Resident #47 in his/her room because he will beat him up. CNA #6 said he has told management and the social worker many times that the current general oversight with redirection isn't enough and that they can't keep Resident #47 from wandering into other Resident's rooms, including Resident #24, and has requested 1:1 but the facility does not have enough staff for it. During an interview on 2/11/26 at 8:56 A.M., Nurse #6 said if staff were aware of any emotional distress the provider should have been notified. Nurse #6 said he was unaware if anyone had notified the provider regarding Resident #24's emotional distress. During an interview on 2/10/26 at 11:17 A.M., the Psychiatrist said he was unaware Resident #24 had any concerns of psychosocial distress or psychological effects from being fearful from another Residents behaviors, but he/she should have been referred. The Psychiatrist said Resident #24 should have promptly been referred to behavioral health services to address any emotional distress from Resident #47's behaviors as soon as staff identified the concern but was not. The Psychiatrist said that it has been over a year since the building had talk therapy available and that Resident #24 would be the type of resident who would benefit from talk therapy to address his/her feelings of emotional distress. During an interview on 2/10/26 at 1:59 P.M., the Social Worker (SW) said she was unaware Resident #24 was distressed by Resident #47 repeatedly entering his/her room since March 2025 but should have been. The SW said repeatedly wandering into their room could cause distress and anxiety. The SW said if behaviors cause distress, such as trying to get into bed or pulling down pants, these are considered resident to resident altercations and interventions should be put into place immediately specific to the Resident effected. The SW said she was first made aware 2/6/26 after the incident occurred, and when she followed up Resident #24 told her he/she was distressed. The SW said the facility did not put any interventions into place specific for Resident #24 but should have, including making a referral to behavioral health services. The SW further said staff should have notified herself and the Psychiatrist promptly when they identified emotional distress or fearfulness from Resident #47's behaviors so he/she could have been referred to behavioral health services but did not. The SW said that she does not personally provide talk therapy to residents in the facility and that the facility's psychotherapist left in December of 2024 and had not been replaced. The SW said thinks that the facility needs more psychiatric support to adequately manage the behaviors and support the residents in the facility. During an interview on 2/10/26 at 2:21 P.M., the Director of Nursing (DON) said repeatedly wandering into their room could cause distress. The DON said if behaviors cause distress, such as trying to get into bed or pulling down pants, these are considered resident to resident altercations and interventions should be put into place immediately specific to the Resident effected. The DON said there were no interventions specifically implemented for Resident #24, but looking back there probably should have been. The DON further said staff should have promptly notified himself and the physician/Psychiatrist of Resident #24's fearfulness and psychological distress and been referred to behavioral health services but they had not. The DON said that the facility has been without a psychotherapist (talk therapy) since December 2024 and that as situations arise we try to deal with them and sit down and talk but that there was no formal therapy available. During an interview on 2/11/26 at 12:01 P.M., the Administrator said he was unaware of Resident #24's concerns or emotional distress related to repeated wandering from Resident #47. The Administrator said he would expect staff to notify administration immediately if Resident #24 was distressed or that interventions were not working so they could attempt alternate interventions promptly. The Administrator said if a resident does not feel safe they should receive psychotherapy support to talk through the process. During an interview on 2/11/26 at 2:08 P.M., Nurse Practitioner (NP) #1 said he would have expected to be notified immediately if any resident was experiencing emotional distress so they could figure out what they could do to help them, including referring to behavioral health services. NP #1 said he should have been told about Resident #24's distress when it first was reported back in March or April 2025 and interventions should have been put into place to prevent it but was not. During an interview on 2/12/26 at 12:55 P.M., the Medical Director said he would expect interventions, including referral to behavioral health services, to be put into place for Resident #24 if there was a reoccurring issue with another Resident's behaviors causing emotional distress. The Medical Director said that it is his expectation that a resident receive support from psych services to address being distressed by the sexual and intrusive behavior of his/her peer. The Medical Director said that he has not seen talk therapy available at the facility since the therapist providing it left over a year ago, and that it is a service that would be beneficial here.

Based on observations, record review and interviews, the facility failed to provide specialized rehabilitative services for two Residents (# 24 and #3) out of a total sample of 34 residents. Specifically,1. For Resident #24, the facility failed to obtain a timely Occupational Therapy (OT) evaluation and failed to provide OT treatments at the frequency ordered to treat a left-hand contracture. The Resident's contracture worsened and he/she required an amputation of the left fifth finger. 2. For Resident #3, the facility failed to obtain a Physical Therapy (PT) evaluation as ordered by the Nurse Practitioner. Findings include: Review of the facility's policy titled Scheduling Therapy and Treatment Services, undated, indicated but was not limited to the following: -Therapy Services shall be scheduled in accordance with the residents' treatment plan. -Therapy is scheduled in coordination with Nursing Service and is documented in the resident's medical records. 1. Resident #24 was admitted to the facility in December 2024 with diagnoses including osteoarthritis, heart failure and hypertension. The list of Resident #24's diagnoses failed to include a neurological diagnosis that would cause an unpreventable contracture. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/29/25, indicated Resident #24 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS also indicated Resident #24 had impairment of functional range of motion in one upper extremity. Review of Resident #24's medical record indicated the Resident was admitted to the facility without any contractures and in July 2025, he/she developed a new contracture to the left hand. Review of Resident #24's Nurse Practitioner progress notes, dated 7/21/25, 7/23/25, 7/28/25, 8/6/25, 8/11/25, 8/25/25, 9/8/25, indicated: -Stiffness of finger joint of right hand and right wrist pain: Occupational therapy (OT) evaluation (eval) pending. During an interview on 2/11/26 at 2:08 P.M., Nurse Practitioner (NP) #1 said Resident #24 had stiffness and a contracture developed in his/her left hand, not right hand, and the documentation from NP #1's above noted progress notes, dated 7/21/25, 7/23/25, 7/28/25, 8/6/25, 8/11/25, 8/25/25, 9/8/25, was inaccurate. Review of Resident #24's medical record indicated an order for Occupational Therapy written on 8/6/25. The evaluation was completed on 9/8/25, 34 days after the order was written and 49 days after the Nurse Practitioner first documented the need for an OT evaluation in his note on 7/21/25. Review of Resident #24's medical record, dated 7/17/25 to 9/8/25, failed to indicate any rationale for why occupational therapy evaluation was delayed 49 days. Review of Resident #24's occupational therapy evaluation, dated 9/8/25, indicated the following: -Pt (patient) referred to OT services after concern over increased tightness in L (left) hand, assessment for brace and positioning. Contracture: Tightness to left hand (2nd digit fixed in extension (straightened finger), 3-5th digits tighter in a flexed (bent finger) position. -Plan of Treatment: 10 time(s)/period; Cert. (Certification) Period: 9/8/25 – 10/7/25. Review of Resident #24's medical record indicated the Resident was re-evaluated by OT three more times and each time the OT ordered the Resident to be seen 10 times in a 30-day period. In the time period from the initial OT evaluation on 9/8/25 to when the Resident was discharged from services on 12/12/25, the Resident was ordered to receive 30 visits. Review of the OT notes indicated Resident #24 had only been seen by OT 13 times, not even half the ordered frequency. Review of Resident #24's medical record indicated the Resident was discharged to the hospital on [DATE]. Review of the hospital discharge paperwork, dated 12/16/25, indicated: -Left hand pointer/index finger (digit 2) contracted straight outward with thumb touching. Able to visualize skin to palm next to these two digits only. Digit 3, 4, and 5 contracted and unable to visualize the nailbed of the 5th (pinky) finger. Pinky Finger appears swollen and pink. This clinician, along with wound colleague, was unable to extend digits to see the palm of the hand. Unable to visualize if there was a wound or not. Fingers tightly contracted. -The patient reports he/she has had difficulty moving his hand for months. He/she has also had associated hand pain, particularly in his/her pinky. -If the patient elects not to pursue amputation, alternative options such as Botox injections may be reconsidered, though per inpatient orthopedic discussion this may not be indicated at this time and would require outpatient reassessment. -His/her left fifth finger was amputated on 12/19/25. During an interview on 2/10/26 at 7:47 A.M., Resident #24's health care proxy (HCP) said she had concerns that the facility was not providing necessary therapy for Resident #24's left-hand contracture. Resident #24's HCP said the Resident developed a new contracture in July 2025 and it continued to worsen between July and December of 2025. Resident #24's HCP said it worsened partly because the facility did not provide necessary therapy. Resident #24's HCP said the Resident eventually was admitted to the hospital resulting in an amputation of the Resident's left fifth finger. The Resident's HCP said she felt the amputation occurred because the contracture did not have appropriate interventions earlier and had worsened to a point where the only treatment intervention was amputation of the finger. During an observation and interview on 2/10/26 at 1:10 P.M., the surveyor observed Resident #24 with a palm guard (a device for contracture management) in his/her left hand with the scar tissue from a left fifth finger amputation visible. Resident #24 said he/she had to have his/her fifth finger amputated because he/she developed a new contracture last summer and it kept getting worse. Resident #24 said he/she wished he/she could have had more therapy, but it wasn't available. Resident #24 said he/she wished more could have been done so that his/her finger did not have to be amputated. During an interview on 2/11/26 at 11:33 A.M., the Director of Rehab (DOR) said during July 2025 to December 2025 there was only one OT, (Occupational Therapist (OT) #1), available as needed for OT evaluations and treatments in the facility. The DOR said she was unaware OT #1 was delayed in completing the initial OT evaluation for Resident #24 and there should not have been a delay. The DOR said that once the evaluation was completed, OT #1 was responsible for monitoring and completing treatments at the frequency indicated on the initial evaluation and recertifications. The DOR said she was unaware OT #1 had not completed treatments at the frequency indicated of 10 time(s)/period for each certification period. The DOR said the risk of delay of treatment and not treating at necessary frequency would be the Resident's contracture worsening. During an interview on 2/11/26 at 1:29 P.M., OT #1 said he was the OT responsible for evaluating and treating Resident #24. OT #1 said his specialty was contractures, and that when he met Resident #24, his/her left-hand contracture was one of the worst contractures he had ever seen. OT #1 said the evaluation was delayed because that was the soonest he could see the Resident as he was the only OT working in the building and he only comes to the building on an as needed (PRN) basis. OT #1 said when he completed the initial evaluation and recertifications he indicated Resident #24 required 10 time(s)/period for each certification period because the Resident needed it. OT #1 said since he was the only OT available and he was only available once a week, so the Resident did not receive the OT treatments he required. OT #1 said Resident #24 would have benefitted from more therapy sessions for the manual techniques and joint mobility exercises, but since he was the only OT available it didn't happen. OT #1 said he did not report the missed frequencies to the DOR or ask if another OT could complete the visits he was unable to do. During an interview on 2/11/26 at 2:08 P.M., Nurse Practitioner (NP) #1 said Resident #24 developed a contracture in his/her left hand in July 2025 and an OT evaluation referral was put in at that time. NP #1 said his expectation is that OT should complete an evaluation as soon as possible. NP #1 said the risk for delaying OT evaluation/treatment would be the contracture worsening. NP #1 said he was unaware there was a delay in Resident #24's OT evaluation and he should have been notified. Nurse Practitioner (NP) #1 further said his expectation is that OT provide the treatments they indicate are necessary and said the risk of not providing the necessary frequency of OT treatments would be the Resident's contracture worsening. NP #1 said he was unaware that OT was not providing treatments at the frequency they noted were necessary (10 time(s)/period for each certification period) but should have been. NP #1 said Resident #24's left hand contracture worsened between July 2025 and December 2025 and it required amputation because of it. During an interview on 2/12/26 at 12:56 P.M., the Medical Director said his expectation is that OT should complete an evaluation as soon as possible after referral so OT treatment can begin if indicated. The Medical Director said he was unaware that the OT evaluation/treatment was delayed from 7/21/25 to 9/8/25 for Resident #24, but a provider should have been notified if it had not been completed. The Medical Director said his expectation is that OT provides the treatments they indicate are necessary and said he was unaware that OT was not providing treatments at the frequency they noted were necessary (10 time(s)/period for each certification period). The Medical Director said the risk of not evaluating a contracture timely and not providing the necessary frequency of OT treatments would be the Resident's contracture worsening. During an interview on 2/12/26 at 1:59 P.M., the Director of Nursing (DON) said therapy at the facility was being provided by an outside, contracted rehabilitation company and the facility had been having difficulty for months with the therapy services being provided. The DON said therapy was often not in the building and the facility would have to repeatedly call the therapy company to ask for therapists to come treat the residents of the facility. The DON said his expectation is that OT should complete an evaluation as soon as possible after the referral is made so OT treatment can begin if indicated. The DON said Resident #24 should have been evaluated by OT after first referred to OT on 7/21/15 and that not evaluating until 9/8/26 was a delay and that he was unaware of this delay in OT treatment. The DON said contractures require treatment to prevent decline. The DON also said his expectation is that OT provides the treatments they indicate are necessary. The DON said he was unaware OT was not providing treatment at the necessary frequency indicated on the initial evaluation and recertifications. The DON said he was responsible for monitoring if therapy referrals or treatments were being completed but had not been monitoring this for Resident #24 and he did not. The DON said Resident #24's left fifth finger contracture definitely became worse while at the facility and his/her left fifth finger was amputated because of this. During an interview on 2/11/26 at 2:53 P.M., the Administrator said the facility had noticed that the staffing of the therapy company had been getting worse and that, specifically, the therapy staffing between September 2025 and December 2025 was spotty. The Administrator said nursing was responsible for checking the therapy evaluations and ensuring the frequency ordered was being completed. The Administrator said he expects all therapy evaluations to be completed in a timely manner and, subsequently, all therapy visits be completed at the frequency ordered. The Administrator said he was unaware that the OT eval was delayed for Resident #24 and that the Resident was not receiving the amount of treatments ordered. 2. Resident #3 was admitted to the facility in September 2022 with diagnoses including dementia, osteoarthritis, left shoulder pain, fatigue, and major depressive disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/7/25, indicated that Resident #3 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 13 out of a possible 15. The MDS further indicated the Resident required moderate to maximum assistance for performing activities of daily living (ADLs). Review of Resident #3's physician orders indicated: -Schedule physical therapy evaluation, dated 12/9/25. Review of the clinical record failed to indicate that Resident #3 was evaluated by PT (Physical Therapy) consistent with the physician orders. During an interview on 2/5/26 at 12:08 P.M., Resident #3 said he/she has pain in both shoulders that limits his/her ability to lift his/her arms. During a further interview on 2/6/26 at 7:35 A.M., Resident #3 said he/she is depressed about the pain and fed up with it because of his/her inability to use his/her arms. Resident #3 said he/she has not seen a Physical Therapist recently and is not actively receiving PT. During an interview on 2/11/26 at 4:56 P.M., Resident #3's activated Health Care Proxy (HCP) #2 said he feels Resident #3 has declined as evidenced by the Resident staying in bed more. The HCP said he was not aware Resident #3 was ordered for a PT evaluation or that the evaluation did not take place. During an interview on 2/9/26 at 10:13 A.M., Unit Manager #1 said when the provider orders a PT consult, she or one of the nurses confirms the order in the Electronic Health Record and she will either email the PT company to notify them of the consult or will verbally tell the PT lead if he/she is on-site. During an interview on 2/10/26 at 11:27 A.M., Nurse Practitioner (NP) #1 said pain management has been a big issue for Resident #3 despite increasing his/her pain medications. NP #1 said Resident #3 has pain in his/her shoulders and knees, and he/she is immobile due to uncontrolled pain. NP #1 said he feels Resident #3's pain cannot be managed alone by pain medication, leading him to make referrals to multiple specialties including PT. The NP said the PT evaluation is still pending, but he would have preferred for the Resident to be evaluated as soon as possible to prevent decline. During an interview on 2/10/26 at 3:03 P.M., the Director of Nursing (DON) said the absence of a PT evaluation when ordered by the Provider is considered a delay in care and can lead to decline. The DON provided the surveyor with a copy of his email from 12/10/25 requesting a PT consult for Resident #3 without additional follow-up. The DON said nursing is responsible for ensuring consults, including PT evaluations, are completed. During an interview on 2/11/26 at 11:33 A.M., the Director of Rehabilitation said she never received a therapy evaluation referral for Resident #3. During an interview on 2/11/26 at 2:53 P.M., the Administrator said the facility had noticed that the staffing of the therapy company had been getting worse and that, specifically, the therapy staffing between September 2025 and December 2025 was spotty. The Administrator said nursing was responsible for checking the therapy evaluations were being completed as ordered. The Administrator said he expects all therapy evaluations to be completed in a timely manner.

Based on record review and interview the facility failed to report allegations of abuse within the required two hour time frame to the Health Care Facility Reporting System for 5 Residents (#36, #47, #25, #55, #45 and #10) out of a total sample of 34 residents. Specifically, 1. For Resident #36 the facility failed to report an allegation of sexual abuse.2. For Resident #47 the facility failed to report an allegation of sexual abuse. 3. For Resident #25 the facility failed to report a resident-to-resident altercation. 4. For Resident #55 the facility failed to report an allegation of sexual abuse.5. For Resident #10 the facility failed to report a resident-to-resident abuse.6. For Resident #45 the facility failed to report an allegation of physical abuse by staff. Findings include: Review of the policy titled Suspected Adut, Disabled Resident or Elderly Abuse/Neglect/Exploitation, dated as revised 6/26/25, indicated the following: -All allegations of abuse will be reported to the Department of Public Health within 2 hours after the allegation is made. Sexual Abuse: Failure to make a reasonable effort to prevent sexual contact, sexual intercourse, sexual conduct, sexual assault or sodomy inflicted on, shown to or intentionally practiced in the presence of a resident. -Compelling or encouraging the resident to engage in sexual contact Neglectful Supervision: -Placing in, or failing to remove, the resident from a situation that a reasonable individual would realize required judgment or actions beyond that physical condition or mental abilities and that results in bodily injury or substantial risk of immediate harm to the resident. Procedure: -Management of Suspected Abuse/Neglect: Cases of suspected sexual assault, physical abuse or neglect will be given priority and will be investigated thoroughly. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Resident to Resident Altercations: -It is the policy of Pine [NAME] to create and maintain a safe environment for a residents. -An altercation free culture will be promoted through appropriate staff and resident screenings, staff and resident training, education, supervision and support. -The reporting of resident-to-resident altercations will adhere to the Department of Public Health guidelines. 1. Resident #36 was admitted to the facility in April 2025 and has diagnoses that include anxiety disorder, paraplegia and depression. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/2/26, indicated that on the Brief Interview for Mental Status exam Resident #36 scored a 15 out of 15, indicating intact cognition. The MDS further indicated that Resident #36 has no behaviors and is dependent on staff for care and transfers. During the Resident Group Meeting with the Surveyors on 2/6/26 at 10:30 A.M., Resident #36 said that there is a resident in the building that is a pervert, he/she walks up to him/her and says nasty things and has even pulled his/her genitals out. Resident #36 said that one time he/she had to call the police because of it and that it is an ongoing issue that he/she has reported to the facility on multiple occasions. Review of the HCFRS report on 2/6/26, failed to indicate Resident #36's allegation of sexual abuse was reported. During a follow-up interview on 2/10/26 at 8:22 A.M., Resident #36 said the following:-He/she has an ongoing issue with another resident who he/she describes as a disgusting pervert. Resident #36 said that on October 15, 2025 he/she was seated in the hall with several other residents when the resident approached him/her and said you know you want me to **** you, you want this **** in your mouth and other vulgar things. -That at that time he/she emailed the Director of Nursing (DON) and Nursing Home Administrator (NHA) to tell them what was happening and said that if it was not stopped he/she would call the cops. Resident #36 said that shortly after sending the email he/she called the cops. Resident #36 said that later that same day the DON and the Operational Director (OD) came to the unit to speak with Resident #36. Resident #36 relayed to them what the resident had done and said the OD did not believe him/her and responded, I can't believe he/she could put that many words together in a sentence. Resident #36 said that the resident making these threats was taken by the responding police offers to the hospital but returned the next day, and the behaviors have continued since then. -Resident #36 said that he/she lives in fear the other resident will take it further and hurt me and touch me and I can't protect myself or get up and run. Resident #36 provided the surveyor with emails from October 2025 between him/herself and the NHA and DON:1. Email #1, dated 10/15/25, from Resident #36 to the NHA and DON: Something has got to be done with (specific resident named). Today he/she drops his/her pants in the hallway and then walks up to me later and said to me YOU Know you want my *** in your **** and right now he/she just took out his/her (genitals) in front of me and said you know you want this. If he/she does this in front of me or anyone else again, I'm calling the cops on him/her. Its lewn (sic) and obnoxious behavior. Please d something!!! (sic).2. Email #2, dated 10/15/25, from Resident #36 to the NHA and DON: Sorry but I called the cops, he/she wouldn't stop coming and bothering us men/ladies.3. Email #3, dated 10/16/25, from the DON to Resident #36: I understand. During an interview on 2/10/26 at 2:21 P.M., the DON said that in hindsight the 10/15/25 sexual abuse Resident #36 reported to the facility should have been reported to the Health Care Facility Reporting System (HCFRS) within 2 hours. The DON said that would include resident-to-resident altercations and that a resident-to-resident altercation can be either verbal or physical in nature. The 10/15/25 sexual abuse sustained by Resident #36 was discussed and the DON said that it should've been reported to HCFRS but it was not. During an interview on 2/11/26 at 12:02 P.M., the NHA said an event or allegation of abuse should be reported to the HCFRS within in two hours if there is harm or injury. The 10/15/25 altercation between Resident #36 and a peer was discussed and the NHA said that it should've been reported to HCFRS. 2. Resident #47 was admitted to the facility in March 2025 and has diagnoses that include Dementia with other behavioral disturbance, wandering in diseases classified elsewhere and traumatic brain injury. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/19/25, indicated that on the Brief Interview for Mental Status exam Resident #47 scored a 1 of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #47 had no behaviors aside from wandering 1-3 days a week. Review of Resident #47's clinical progress notes indicated the following notes: 10/16/25: Patient is seen today after he/she was sent to the emergency room on 10/16 for provocative hypersexual behavior with aggression which he/she exhibited towards peers. 10/15/25: Resident #47 was down and was exposing him/herself to (a peer) while he/she was close, uttering words such as you want this, do you want this inside of you. Psychiatrist #1 was present during this episode and was informed that the male/female resident's do not feel safe in their rooms with Resident #47 wandering and being sexually disgusting as the male/female residents stated. During the Resident Group Meeting with the Surveyors on 2/6/26 at 10:30 A.M., a resident said that Resident #47 is a pervert, he/she walks up to him/her and says nasty things and has even pulled his/her genitals out. The resident said that one time he/she called the police because of Resident #47's behavior. During an interview on 2/10/26 at 8:22 A.M., another resident said the following:-He/she has an ongoing issue with Resident #47 who he/she describes as a disgusting pervert. The other resident reported that Resident #47 approached him/her and said you know you want me to **** you, you want this **** in your mouth and other vulgar things. -That at that time he/she emailed the Director of Nursing (DON) and Nursing Home Administrator (NHA) to tell them what was happening and said that if it was not stopped he/she would call the cops. During an interview on 2/10/26 at 2:21 P.M., the DON said that in hindsight the 10/15/25 sexual abuse Resident #47 had been accused of should have been reported to the Health Care Facility Reporting System (HCFRS) within 2 hours. The DON said that would include resident-to-resident altercations and that a resident-to-resident altercation can be either verbal or physical in nature. The 10/15/25 altercation between Resident #47 and a peer was discussed and the DON said that it should've been reported to HCFRS. Review of the HCFRS on 2/11/26 at 8:08 A.M., failed to indicate the facility had reported the allegation of sexual abuse reviewed with DON on 2/10/26. During an interview on 2/11/26 at 12:02 P.M., the NHA said an event or allegation of abuse should be reported to the HCFRS within two hours if there is harm or injury. The 10/15/25 altercation between Resident #47 and a peer was discussed and the NHA said that it should've been reported to HCFRS. 3. Resident #25 was admitted to the facility in July 2022 and has diagnoses that include bipolar and Alzheimer's disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/18/25, indicated Resident #25 was unable to participate in the Brief Interview for Mental Status exam and was assessed by staff to have severely impaired cognition. The MDS further indicated Resident #25 has daily behavior of physical behavior directed toward others and wandering and has no verbal behaviors and no other behaviors such as pacing or disrobing. Review of Resident #25's clinical progress notes indicated the following: -A progress note dated 1/6/26: Alert and confused. Screaming heard this writher ran to former activities office to find Resident #25 soaked in water. walking around, unable to give an accurate account of what had happened. The other resident would not say ether. No s/s (signs or symptoms) of trauma noted, no bruises, refused vital signs. Resident #25 was cleaned and changed had a 100% of super, po (by mouth) fluids tolerated well. Otherwise, stable. -A social work note dated 1/12/26: SW attempted to meet with Resident #25 s/p (status/post) resident altercation. Resident #25 was not able to report what led to the altercation. Resident #25 was observed in his room with his roommates and the aggressor. No concerns were observed at this time. -A progress note dated 1/13/26: Resident #25 had a brief altercation with a female resident. During an interview on 2/11/26 at 7:58 A.M., the DON said that allegations of abuse should be reported to the Health Care Facility Reporting System (HCFRS) within 2 hours. The DON said that would include resident-to-resident altercations and that a resident-to-resident altercation can be either verbal or physical in nature. Review of the HCFRS on 2/11/26 at 8:08 A.M., failed to indicate the facility had reported the any resident-to-resident altercations regarding Resident #25. During an interview on 2/11/26 at 12:02 P.M., the NHA said a resident-to resident altercation should be reported to the HCFRS within two hours if there is harm or injury. 4. Resident #55 was admitted to the facility in May 2024 with diagnoses including anxiety, depression and mild cognitive impairment. Review of Resident #55's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident scored a 15 out of a total 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. The MDS further indicated the Resident required supervision from staff to perform activities of daily living. During an interview on 2/5/26 at 9:40 A.M., Resident #55 said another resident had jumped in his/her bed and grabbed his/her breast on multiple occasions. The Resident said he/she got sexually assaulted by this other resident and had reported to staff but nothing was done about it. The Resident further indicated that the other resident was no longer at the facility. On 2/5/26 at 9:49 A.M., the surveyor reported this allegation from Resident #55 to the Director of Nursing (DON). The DON said this was the first time he heard of this allegation and was going to investigate it. On 2/6/26 at 7:53 A.M., the surveyor inquired from the DON of any investigations completed from the reported allegations. The DON said the Social Worker had the paperwork as this was an old allegation that had been reported. During an interview on 2/6/26 at 1:52 P.M., the Social Worker (SW) said she did not have any paperwork from this reported allegation and said it was her first time hearing about it. The SW said any allegations of abuse should be reported to the department of public health within two hours of knowledge. Review of the health care reporting system on 2/10/26 indicated the facility did not report the allegations within the required two hours. On 2/10/26 at 2:21 P.M., the Director of Nursing said he should have reported to the state agency within the required two hours. He said that he reported the allegation the following day. Review of the heath care reporting system n 2/11/26 indicated the report was initiated on 2/6/26 at 11 A.M., approximately 14 hours after the allegation was [NAME] to the Director of Nursing attention. During an interview on 2/11/2026 at 12:02 P.M., the Administrator said allegations of abuse should be reported within two hours if there is harm or injury, or within 24 hours if there is no harm or injury. The Administrator said that when in doubt, the facility should report allegations within two hours. 5. Resident #10 was admitted to the facility in July 2020 with diagnoses including Alzheimer's disease with late onset and anxiety disorder. Review of Resident #10's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident scored an 8 out of a total 15 on the Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. The MDS further indicated that the Resident exhibited behaviors directed towards others, for example verbal or vocal occurred daily. During an interview on 2/5/26 at 8:47 A.M., the surveyor met with the Resident in his/her room. The Resident said to the surveyor you can call my daughter she will tell you what's happening here. Review of a Social Worker (SW) progress note dated 12/9/25 indicated the following: 'SW met with Resident to follow up on staff report that he/she spilled water on roommate. Upon arriving at the room, Resident presented angry. When SW asked what had happened he/she reported he needs to stop messing with me. He is over there peeing in his thingy (urinal) and trying to climb into my bed. I don't sleep with men. SW observed water on the bedside table, floor and on the roommate's clothing. Residents have a history of spilling water on previous roommates and making the same alleged report. SW reached out to the Healthcare Proxy (HCP) regarding this incident, notified DON (Director of Nursing) and reached out to Dr Skewer to follow up with an assessment. SW will remain available for support. Review of the health care reporting system on 2/5/26, failed to indicate the facility reported this resident-to-resident altercation to the state agency. During an interview on 2/6/26 at 2:01 P.M., the Social Worker said that the Resident had a history of spilling water on other roommates and it was because he/she wanted to have a private room. The Social Worker said she reported this incident to the Director of Nursing as it was a resident-to-resident altercation and should be reported. During an interview on 2/9/26 at 9:52 A.M., Resident Representative (HCP) said the facility had notified her that the Resident was being moved out of the room as he/she had spilled water on another resident. During an interview on 2/10/26 at 2:35 P.M., the Director of Nursing said by Resident throwing water at another resident would be considered a resident-to- resident altercation, and that it should have been investigated and reported. The Director of Nursing the incident was not investigated or reported to the state agency. During an interview on 2/11/26 at 12:45 P.M., the Administrator said a report should have been filed with the state agency. 6. Resident #45 was admitted to the facility in August 2020 with diagnoses including Alzheimer's Disease and schizophrenia. Review of Resident #45's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #45 required partial to moderate assistance from staff for functional daily tasks. During an interview on 2/5/26 at 8:08 A.M, Resident #45 said she was recently grabbed by a staff member and was treated roughly, resulting in black and blue bruises on his/her arm. Resident #45 said he/she everybody knows about it and that he/she had told a lot of people about this incident. Resident #45 said no staff members have come to talk about the incident with him/her. On 2/5/26 at approximately 8:20 A.M., the surveyor reported this allegation from Resident #45 to the Corporate Operations Director. On 2/6/26, the surveyor asked the Director of Nursing for any investigation that had begun for this allegation. The Director of Nursing provided the surveyor with an incident report that indicated the following incident description: -Nursing description: Went to the resident this morning because (he/she) stated (today) that 'a couple of weeks ago, (he/she) was rough handled by a female aide and had bruises on (his/her) right arm. I (the Director of Nursing) spoke with (him/her) and at first, (he/she) was not understanding what I was asking. I explained a 3rd time and (he/she) responded yes and look at my arm. I call her Hitler. (He/She) was asked when this happened and (his/her) response was I don't know, a couple of weeks ago. There were no bruises or any other skin abnormality observable when examined. -Resident description: Was unable to explain at first. (I had to request the information three times), (he/she) then answered, yes and she was rough. Look at my arm it's all bruised because of it. Review of the health care reporting system on 2/10/26, failed to indicate the facility reported this allegation of abuse to the state agency within the two hour time frame of receiving the report of the allegation. During an interview on 2/10/26 at 2:21 P.M., the Director of Nursing said he did not report this allegation to the state agency but that he should have. The Director of Nursing said he made the decision to not report this allegation because he felt he could not substantiate the abuse; however, he now realizes that he needs to report allegations while the investigation is still ongoing to ensure he is within regulatory compliance. During an interview on 2/11/2026 at 12:02 P.M., the Administrator said allegations of abuse should be reported within two hours if there is harm or injury, or within 24 hours if there is no harm or injury. The Administrator said that when in doubt, the facility should report allegations within two hours.

Based on record review and interview the facility failed to investigate allegations of abuse for 5 Residents (#36, #47, #25 and #45 and #10) out of a total sample of 34 residents. Specifically,1. For Resident #36, the facility failed to investigate an allegation of sexual abuse.2. For Resident #47, the facility failed to investigate an allegation of sexual abuse.3. For Resident #25, the facility failed to investigate an allegation of resident-to-resident altercation. 4. For Resident #45, the facility failed to investigate an allegation of physical abuse by staff. 5. For Resident #10, the facility failed to investigate an allegation of resident-to-resident altercation. Review of the policy titled Suspected Adult, Disabled Resident or Elderly Abuse/Neglect/Exploitation, dated as revised 6/26/25, indicated the following: Sexual Abuse: Failure to make a reasonable effort to prevent sexual contact, sexual intercourse, sexual conduct, sexual assault or sodomy inflicted on, shown to or intentionally practiced in the presence of a resident. -Compelling or encouraging the resident to engage in sexual contact Neglectful Supervision: -Placing in, or failing to remove, the resident from a situation that a reasonable individual would realize required judgment or actions beyond that physical condition or mental abilities and that results in bodily injury or substantial risk of immediate harm to the resident. Procedure: -Management of Suspected Abuse/Neglect: Cases of suspected sexual assault, physical abuse or neglect will be given priority and will be investigated thoroughly. 1). Resident #36 was admitted to the facility in April 2025 and has diagnoses that include anxiety disorder, paraplegia and depression. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/2/26, indicated that on the Brief Interview for Mental Status exam Resident #36 scored a 15 out of 15, indicating intact cognition. The MDS further indicated that Resident #36 had no behaviors and is dependent on staff for care and transfers. During the Resident Group Meeting with the Surveyors on 2/6/26 at 10:30 A.M., Resident #36 said that there is a resident in the building that is a pervert, he/she walks up to him/her and says nasty things and has even pulled his/her genitals out. Resident #36 said that one time he/she had to call the police because of it and that it is an ongoing issue that he/she has reported to the Director of Nursing on multiple occasions. Review of the HCFRS report on 2/6/26, failed to indicate Resident #36's allegation of sexual assault was reported as required. During a follow-up interview on 2/10/26 at 8:22 A.M., Resident #36 said the following:-That he/she has an ongoing issue with another resident who he/she describes as a disgusting pervert. Resident #36 said that on October 15, 2025 he/she was seated in the hall with several other residents when the resident approached him/her and said you know you want me to **** you, you want this **** in your mouth and other vulgar things. -That at that time he/she emailed the Director of Nursing (DON) and Nursing Home Administrator (NHA) to tell them what was happening and said that if it was not stopped he/she would call the cops. Resident #36 said that shortly after sending the email he/she called the cops. Resident #36 said that later that same day the DON and the Operational Director (OD) came to the unit to speak with Resident #36. Resident #36 relayed to them what the resident had done and said the OD did not believe him/her and responded, I can't believe he/she could put that many words together in a sentence. Resident #36 said that the resident making these threats was taken by the responding police offers to the hospital but returned the next day, and the behaviors have continued since then. -Resident #36 said that he/she lives in fear the other resident will take it further and hurt me and touch me and I can't protect myself or get up and run. Resident #36 provided the surveyor with emails from October 2025 between him/herself and the Nursing Home Administrator (NHA) and Director of Nursing (DON):1. Email #1, dated 10/15/25, from Resident #36 to the NHA and DON: Something has got to be done with (the other resident). Today he/she drops his/her pants in the Hallway and then walks up to me later and said to me YOU Know you want my *** in your **** and right now he/she just took out his/her (genitals) in front of me and said you know you want this. If he/she does this in front of me or anyone else again, I'm calling the cops on him/her. Its lewn (sic) and obnoxious behavior. Please d something!!! (sic).2. Email #2, dated 10/15/25, from Resident #36 to the NHA and DON: Sorry but I called the cops, he/she wouldn't stop coming and bothering us men/ladies.3. Email #3, dated 10/16/25, from the DON to Resident #36: I understand. During an interview on 2/11/26 at 7:58 A.M., the DON said that allegations of abuse should be investigated. The DON said that would include resident-to-resident altercations and that a resident-to-resident altercation can be either verbal or physical in nature. He said that the 10/15/25 altercation between Resident #36 and a peer was not investigated but should have been. The facility's OD was present for this interview. During an interview on 2/10/26 at 2:21 P.M., the DON said that in hindsight the 10/15/25 sexual abuse Resident #36 had experienced should have been investigated but had not. During an interview on 2/11/26 at 12:02 P.M., the NHA said an event or allegation of abuse should be investigated. The NHA said that a thorough investigation includes interviewing the residents involved, any staff that were present and possibly staff from previous shifts. The 10/15/25 altercation between Resident #36 and a peer was discussed and the NHA said that it should've been investigated but it was not. 2). Resident #47 was admitted to the facility in March 2025 and has diagnoses that include Dementia with other behavioral disturbance, wandering in diseases classified elsewhere and traumatic brain injury. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/19/25, indicated that on the Brief Interview for Mental Status exam Resident #47 scored a 1 of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #47 had no behaviors aside from wandering 1-3 days a week. Review of Resident #47's clinical progress notes indicated the following notes: 10/16/25: -Patient is seen today after he/she was sent to the emergency room on 10/16 for provocative hypersexual behavior with aggression which he/she exhibited towards peers. 10/15/25: -Resident #47 was down and was exposing him/herself to (a peer) while he/she was close, uttering words such as you want this, do you want this inside of you. -Psychiatrist #1 was present during this episode and was informed that the male/female resident's do not feel safe in their rooms with Resident #47 wandering and being sexually disgusting as the male/female residents stated. During the Resident Group Meeting with the Surveyors on 2/6/26 at 10:30 A.M., a resident said that Resident #47 is a pervert, he/she walks up to him/her and says nasty things and has even pulled his/her genitals out. The resident said that one time he/she called the police because of Resident #47's behavior. During an interview on 2/10/26 at 8:22 A.M., another resident said the following:-That he/she has an ongoing issue with Resident #47 who he/she describes as a disgusting pervert. The other resident reported that Resident #47 approached him/her and said you know you want me to **** you, you want this **** in your mouth and other vulgar things. -That at that time he/she emailed the Director of Nursing (DON) and Nursing Home Administrator (NHA) to tell them what was happening and said that if it was not stopped he/she would call the cops. During an interview on 2/10/26 at 2:21 P.M., the DON said that in hindsight the 10/15/25 sexual abuse Resident #47 had been accused of should have been investigated but it had not. During an interview on 2/11/26 at 12:02 P.M., the NHA said an event or allegation of abuse should be investigated. The NHA said that a thorough investigation includes interviewing the residents involved, any staff that were present and possibly staff from previous shifts. The 10/15/25 altercation between Resident #47 and a peer was discussed and the NHA said that it should've been investigated but it was not. 3). Resident #25 was admitted to the facility in July 2022 and has diagnoses that include bipolar and Alzheimer's disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/18/25, indicated Resident #25 was unable to participate in the Brief Interview for Mental Status exam and was assessed by staff to have severely impaired cognition. The MDS further indicated Resident #25 has daily behavior of physical behavior directed toward others and wandering and has no verbal behaviors and no other behaviors such as pacing or disrobing. Review of Resident #25's clinical progress notes indicted the following: -A progress note dated 1/6/26: Alert and confused. Screaming heard this writher ran to former activities office to find Resident #25 soaked in water. walking around, unable to give an accurate account of what had happened. The other resident would not say ether. No s/s (signs or symptoms) of trauma noted, no bruises, refused vital signs. Resident #25 was cleaned and changed had a 100% of super, po (by mouth) fluids tolerated well. Otherwise, stable. -A social work note dated 1/12/26: SW attempted to meet with Resident #25 s/p (status/post) resident altercation. Resident #25 was not able to report what led to the altercation. Resident #25 was observed in his room with his roommates and the aggressor. No concerns were observed at this time. -A progress note dated 1/13/26: Resident #25 had a brief altercation with a female resident. During an interview on 2/11/26 at 7:58 A.M., the DON said that allegations of abuse should be investigated. The DON said that would include resident-to-resident altercations and that a resident-to-resident altercation can be either verbal or physical in nature. The 1/6/26, 1/12/26 and 1/13/26 progress notes were reviewed with the DON. He said that he was unaware of those notes and that there had not been an investigation into what had occurred, but there should have been. During an interview on 2/11/26 at 12:02 P.M., the NHA said an event or allegation of abuse should be thoroughly investigated. The NHA said that a thorough investigation includes interviewing the residents involved, any staff that were present and possibly staff from previous shifts. The 1/6/26, 1/12/26 and 1/13/26 progress notes were reviewed with the DON. He said that he was unaware of those notes and that there had not been an investigation into what had occurred, but there should have been. 4). Resident #45 was admitted to the facility in August 2020 with diagnoses including Alzheimer's Disease and schizophrenia. Review of Resident #45's most recent Minimum Data Set (MDS0 dated 12/2/25, indicated the Resident sore a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she had server cognitive impairment. The MDS also indicated Resident #45 requires partial to moderate assistance from staff for functional daily tasks. During an interview on 2/5/26 at 8:08 A.M, Resident #45 said she was recently grabbed by a staff member and was treated roughly, resulting in black and blue bruises on his/her arm. Resident #45 said he/she everybody knows about it and that he/she had told a lot of people about this incident. Resident #45 said no staff members have come to talk about the incident with him/her. On 2/5/25 at approximately 8:20 A.M., the surveyor reported this allegation from Resident #45 to the Corporate Operations Director. On 2/6/25, the surveyor asked the Director of Nursing for any investigation that had begun for this allegation. The Director of Nursing provided the surveyor with an incident report that indicated the following incident description: -Nursing description: Went to the resident this morning because (he/she) stated (today) that 'a couple of weeks ago, (he/she) was rough handled by a female aide and had bruises on (his/her) right arm. I (the Director of Nursing) spoke with (him/her) and at first, (he/she) was not understanding what I was asking. I explained a 3rd time and (he/she) responded yes and look at my arm. I call her Hitler. (He/She) was asked when this happened and (his/her) response was I don't know, a couple of weeks ago. There were no bruises or any other skin abnormality observable when examined. -Resident description: Was unable to explain at first. (I had to request the information three times), (he/she) then answered, yes and she was rough. Look at my arm it's all bruised because of it. The incident report failed to indicate any further investigation was completed, including other staff interviews, other resident interviews, a full skin check or any other resident assessments were completed. During an interview on 2/10/26 at 2:21 P.M., the Director of Nursing said after an allegation of abuse an investigation should take place immediately. The Director of Nursing said the investigation would include interviewing the resident, other staff members and potentially other residents. The Director of Nursing said resident assessments such as skin or pain assessments would also be part of a thorough investigation. The Director of Nursing said the incident report he provided to the surveyor was the only investigation he did into Resident #45's allegation of abuse. The Director of Nursing said because there were no current bruises on the Resident's arms or because the Resident was unable to recall full specifics of the incident, he did not feel it necessary to complete any further investigation. During an interview on 2/11/2026 at 12:02 P.M., the Administrator said an investigation is started immediately if there is an event or allegation of abuse. The Administrator said the investigation would include an interview with the resident making the allegation, staff present and possibly previous shift, and the resident's roommate if they are a witness. The Administration also said assessments would be done if there is an injury. 5). Resident #10 was admitted to the facility in July 2020 with diagnoses including Alzheimer's disease with late onset and anxiety disorder. Review of Resident #10's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident scored an 8 out of a total 15 on the Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. The MDS further indicated that the Resident exhibited behaviors directed towards others, for example verbal or vocal occurred daily. During an interview on 2/5/26 at 8:47 A.M., the surveyor met with the Resident in his/her room. The Resident said to the surveyor you can call my daughter she will tell you what's happening here. Review of a Social Worker (SW) progress note dated 12/9/25 indicated the following: 'SW met with Resident to follow up on staff report that he/she spilled water on roommate. Upon arriving at the room, Resident presented angry. When SW asked what had happened he/she reported he needs to stop messing with me. He is over there peeing in his thingy (urinal) and trying to climb into my bed. I don't sleep with men. SW observed water on the bedside table, floor and on the roommate's clothing. Residents have a history of spilling water on previous roommates and making the same alleged report. SW reached out to the Healthcare Proxy (HCP) regarding this incident, notified DON (Director of Nursing) and reached out to Dr Skewer to follow up with an assessment. SW will remain available for support. Review of the health care reporting system on 2/5/26, failed to indicate the facility reported this resident-to-resident altercation to the state agency. During an interview on 2/6/26 at 2:01 P.M., the Social Worker said that the Resident had a history of spilling water on other roommates and it was because he/she wanted to have a private room. The Social Worker said she reported this incident to the Director of Nursing as it was a resident-to-resident altercation and should be reported. The Social Worker said she does her part and documents in the progress noted and the Director of Nursing is responsible for completing the full investigation. During an interview on 2/9/26 at 9:52 A.M., Resident Representative (HCP) said the facility had notified her that the Resident was being moved out of the room as he/she had spilled water on another resident. During an interview on 2/10/26 at 2:35 P.M., the Director of Nursing said by Resident throwing water at another resident would be considered a resident-to- resident altercation, and that it should have been investigated and reported. The Director of Nursing the incident was not investigated or reported to the state agency. During an interview on 2/11/26 at 12:45 P.M., the Administrator said a report should have been investigated and filed to the state agency.

Based on observation and interview, the facility failed to store and prepare food in accordance with professional standards for food service safety. Specifically, the facility failed to:1) Ensure food was labeled and stored under sanitary conditions without significant signs of decomposition. 2) Practice proper food handling during meals in the [NAME] Unit dining room. Findings include: Review of the facility's policy titled Food Storage, dated April 2020, indicated, but was not limited to, the following: -All foods stored in walk-in refrigerators and freezers shall be stored above the floor on shelves, racks, dollies, or other surfaces that facilitate thorough cleaning. -Perishable items are stored as follows: Sliced and shredded cheeses will be used within seven days of opening and labeled with a use-by date noting seven days from opening as according to the Date Marking Policy/ Reference sheet. Milk and other dairy products such as yogurt and cottage cheese, unopened, are good until the use by date noted by the manufacturer. Produce will be stored covered. Fruit and vegetables stored in the original box and labeled/dated with a vendor delivery sticker are acceptable. Products in covered storage bins will require a date of delivery. This is relative to all un-refrigerated and refrigerated produce. Fruits and vegetables will be checked for wholesomeness and/or spoiledness upon delivery and prior to use. (sic.) Refrigerated, ready-to-eat, potentially hazardous food opened or prepared shall be clearly marked at the time of preparation to indicate the date of preparation. Ready-to-eat food items shall be discarded within 72 hours of the date opened. On 2/5/26 at 7:20 A.M., the surveyor made the following observations during the initial walkthrough of the kitchen: -A case of acorn squash in the walk-in refrigerator with significant signs of decomposition including color changes, textural changes and the presence of a white wispy growth. -A case of sweet potatoes in the walk-in refrigerator with significant signs of decomposition including textural changes and the presence of a blueish-white wispy growth. -An undated bag of shredded cabbage in the walk in refrigerator with significant signs of decomposition including brown discoloration and textural changes. -A container of oranges in the walk-in refrigerator with significant signs of decomposition including color changes, textural changes, and the presence of a blueish-white wispy growth. -There was a black wispy growth present on the shelving in the walk-in refrigerator; food was stored on top of and below the black wispy growth. -Two undated bags of shredded mozzarella cheese in the walk-in refrigerator, there was irregular blue coloring throughout one of the bags of cheese consistent in appearance with mold. -A container of salsa in the walk-in refrigerator; the salsa was dated opened 8/26 and had a blueish-white wispy growth on the outside of the bottle as well as the presence of a slimy white substance on the inside of the bottle in the salsa. -A box of raw fish fillets stored on the shelf above opened ready-to-eat ham in the walk-in refrigerator. -A box of chicken stored directly on the freezer floor. -Two bottles of juice opened but undated in the reach-in refrigerator. -Sliced deli turkey opened but undated in the reach-in refrigerator. -Salami open and dated 1/10/26 in the reach-in refrigerator. -The fan located in the reach-in refrigerator was covered in a brownish stringy debris, there was food stored below the fan. -Undated brownies in the reach-in refrigerator. During an interview on 2/5/26 at 7:37 A.M. the Food Service Director (FSD) said he noticed the acorn squash yesterday and should have thrown it out yesterday. The FSD said kitchen staff were supposed to label and date all prepared and opened foods and discard them after seven days. The FSD said he did not know when the shredded cabbage was opened and that it should have been dated. The FSD said staff should have gone through the sweet potatoes and discarded the ones showing signs of decomposition. The FSD said that the black wispy growth present on the shelving could be mold and that food should not be stored on top or below it. The FSD said the raw fish should not have been stored above the opened ready-to-eat ham. The FSD said the salsa should have been thrown away and that the chicken in the freezer should not have been stored on the floor. The FSD said he would have expected the open juice in the reach-in refrigerator to be dated when it was opened and that the deli turkey and salami should have been discarded. The FSD said food should not be stored below the fan in the reach-in refrigerator because the debris could fall and contaminate the food. 2. Review of the facility policy titled, Food Handling – Preventing Foodborne Illness, dated 10/10/25, indicated the following: -Food at (the facility) will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. -All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents. The following was observed in the [NAME] Unit during the breakfast meal on 2/6/26 at 7:31 A.M.: -The Corporate Operations Director (COD) was assisting with serving meals to residents. While assisting, she touched seven pieces of toast with her bare hands to spread jelly and peeled a banana and with her bare hands took the banana out of the peel and placed it on a plate. The following was observed in the [NAME] Unit during the lunch meal on 2/9/26 at 11:42 A.M.: -The COD was opening a milk container and put her finger inside the spout of the container to open it. The COD was not wearing gloves. -The COD picked up a dinner roll, a ready to eat food item, with her bare hands to butter it for two different residents. The COD failed to apply gloves or wash her? Hands between tasks. -Two different Certified Nursing Assistants (CNAs) picked up dinner rolls with their bare hands to butter them for six different residents. -A nurse picked up a dinner roll with her bare hands to butter it for two different residents. -One resident took a glass of juice from a tablemate's tray and drank it. The juice had already been partially drunk by the other resident. This same resident also took food from the resident's plate with her bare hands and ate it. The Survey told the nurse at the time and the nurse did not stop the resident from eating the food from another resident's plate. The following was observed in the [NAME] Unit during the breakfast meal on 2/10/26 at 7:38 A.M.: -A nurse peeled a banana and with her bare hands took the banana out of the peel and placed it on a plate. This same nurse then touched two slices of bread with her bare hands to spread jelly and opened a milk container by putting her finger inside the spout of the container to open it. The following was observed in the [NAME] Unit during the breakfast meal on 2/12/26 at 7:38 A.M.: -A CNA peeled a banana and with her bare hands took the banana out of the peel and placed it on a plate. This same nurse then touched two slices of bread with her bare hands to spread jelly. -The COD removed a muffin wrapped with her bare hands, touching the muffin and then touched several pieces of toast with her bare hands to spread jelly. -A CNA removed a muffin wrapped with her bare hands, touching the muffin. During an interview on 2/12/26 at 1:36 P.M., the Director of Nursing said food should not be touched by staff and if staff are assisting with the setting up of meals, they should be wearing gloves when touching food. The Director of Nursing said staff should be aware of this and should know not to touch food because this could potentially contaminate the food.

Based on observations and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically:1.) The facility failed to ensure medications with shortened expiry dates were dated once opened in two out of three medication carts and to ensure insulin that required refrigeration was refrigerated in one out of two medication rooms observed.2.) The facility failed to properly secure medication carts when unattended on one of three units.3.) The facility failed to ensure the medication room was locked when unattended.4.) The facility failed to ensure unauthorized staff did not have access to medication room.5.) The facility failed to ensure lorazepam, a controlled drug, was separately locked in a permanently affixed compartment for storage of controlled drugs. Findings include:Review of the facility policy titled 'Storage of Medications', dated 8/12/25, indicated:-Drugs and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they are received. -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.-The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.-Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. -Only persons authorized to prepare and administer medications shall have access to the medication room, including any keys. 1.) On 2/5/26 at 11:28 A.M., the surveyor and Nurse #7 observed the following in the [NAME] Wing medication room:-One unopened lantus solostar insulin pen, not refrigerated. This insulin pen felt room temperature. The manufacturers guidelines listed on the label indicated to refrigerate unopened product. During an interview on 2/5/26 at 11:30 A.M., Nurse #7 said the lantus solostar insulin pen was unopened and unrefrigerated. Nurse #7 said based on the manufacturers' guidelines on the label, it should have been stored in the refrigerator. On 2/5/26 at 12:24 P.M., the surveyor and Nurse #7 observed the following in the [NAME] Wing medication cart:-One opened, undated fluticasone propionate and salmeterol inhaler. The manufacturers guidelines listed on the label indicated to discard one month after opening.-One opened, undated airsupra inhaler. The manufacturers guidelines listed on the label indicated to discard 12 months after removal from foil pouch.-One opened, undated symbicort inhaler. The manufacturers' guidelines listed on the label indicated to discard three months after opening.-Two opened, undated bottles of latanoprost eye drops. The manufacturers' guidelines listed on the label indicated to discard after six weeks.-Three opened, undated artificial tears eye drops. There were no manufacturers guidelines listed on the label indicating when to discard. During an interview on 2/5/26 at 12:34 P.M., Nurse #7 said all the medications with shortened expiry dates should be dated when opened so they can be discarded appropriately following the facility policy and manufacturers guidelines. On 2/6/26 at 8:11 A.M., the surveyor and Nurse #6 observed the following in the Central Wing medication cart:-One opened and undated bottle of latanoprost eye drops. The manufacturers' guidelines listed on the label indicated to discard after six weeks.-Two opened, undated fluticasone propionate and salmeterol inhaler. The manufacturers guidelines listed on the label indicated to discard one month after opening.-One opened, undated symbicort inhaler. The manufacturers' guidelines listed on the label indicated to discard three months after opening.-One opened, undated bottle of prosource liquid protein. The manufacturers' guidelines listed on the label indicated to discard three months after opening.-Three opened, undated artificial tears eye drops. One of these bottles was not labeled with a resident name or stored in the box, but directly in the drawer. There were no manufacturers guidelines listed on the label indicating when to discard.-Greater than 30 loose, unlabeled pills.-Multiple medications stored touching a sticky, brown liquid on the bottom of one of the drawers. During an interview on 2/6/26 at 8:15 A.M, Nurse #6 said all the medications with shortened expiry dates should be dated when opened so they can be discarded appropriately following the facility policy and manufacturers' guidelines. Nurse #6 said there should not be loose, unlabeled pills or any brown sticky substances touching the medications. During an interview on 2/12/26 at 1:59 P.M., the Director of Nursing (DON) said all the medications, including eye drops, inhalers, and liquid protein with shortened expiry dates should be dated when opened so they can be discarded appropriately following the facility policy and manufacturers' guidelines. The DON said eye drops should always be stored in the original box and not loose in the medication cart. The DON said eye drops should be dated once opened and discarded after 30 days unless the manufacturers guidelines indicate otherwise. The DON said lantus solostar should be stored in the refrigerator until it is opened. The DON said there should not be loose, unlabeled pills or any brown sticky substances touching the medications. 2.) On 2/6/26 at 7:28 A.M., the surveyor observed the [NAME] Wing medication cart unlocked and unattended in the hallway. The nurse was not within sight line of the medication cart. During an interview on 2/6/26 at 7:30 A.M., the Unit Manager said that it was Nurse #13's medication cart and that he should have locked it whenever it was unattended. During an interview on 2/6/26 at 8:41 A.M., Nurse #13 said his medication cart should be locked whenever it was unattended. On 2/25/26 at 9:13 A.M., the surveyor observed the [NAME] Wing medication cart unlocked and unattended in the hallway. The nurse was not within sight line of the medication cart. The surveyor was unable to locate Nurse #13, who was assigned to this medication cart. During an interview on 2/25/26 at 9:16 A.M., the Unit Manager said that it was Nurse #13's medication cart and that he should have locked it whenever it was unattended. During an interview on 2/12/26 at 1:59 P.M., the Director of Nursing (DON) said medication carts should be locked when unattended and not within the nurse's view. 3.) On 2/5/26 at 7:06 A.M. and 8:05 A.M., the surveyor observed the [NAME] Wing medication room ajar greater than a foot. There was no nurse within view of the medication room. There were two residents wandering around the desk in front of the open medication room. During an interview on 2/5/26 at 8:07 A.M., Nurse #7 said the medication room should never be left unlocked when unattended. During an interview on 2/5/26 at 11:54 A.M., the Director of Nursing (DON) said the medication room should never be left unlocked when unattended. 4.) On 2/5/26 at 11:34 A.M., the surveyor observed Nurse #7 give keys to person who was not wearing a facility name badge and was not wearing any type of staff uniform. The person used the keys to open and enter the medication room, not within view of Nurse #7. During an interview on 2/5/26 at 11:25 A.M., Nurse #7 said the person was an off-duty nurse who needed to retrieve his/her forgotten personal belongings in the medication room. During an interview on 2/5/26 at 11:50 A.M., Nurse #1 said nurses should never share keys with other staff members or store any personal items in the medication room. Nurse #1 said the facility had staff lockers available to store any of their personal items. During an interview on 2/5/26 at 11:54 A.M., the Director of Nursing (DON) said nurses should never share their keys with anyone. The DON said Nurse #7 should not have let any off duty nurse borrow her keys. The DON further said nurses should never store personal items in the medication room. The DON said the facility had staff lockers available to store any of their personal items. 5.) On 2/5/26 at 11:50 A.M., the surveyor and Nurse #1 observed the following in the North/Central medication room:-Two bottles of lorazepam in the shared medication refrigerator. These bottles were stored with a variety of other non-controlled drugs and not separately locked in a permanently affixed compartment for storage of controlled drugs. During an interview on 2/5/26 at 11:50 A.M., Nurse #1 said both herself and the other medication cart nurse have access to this refrigerator. Nurse #1 said those two bottles of lorazepam should be locked separately in a permanently affixed compartment, but that the facility doesn't have one. Nurse #1 said it didn't matter because they weren't being used as both residents the lorazepam was prescribed for passed away last year. During an interview on 2/5/26 at 11:54 A.M., the Director of Nursing (DON) said lorazepam should always be locked separately in a permanently affixed compartment that the other medication cart nurse did not have access to.

Based on observations, interviews and record review, the facility failed to maintain a safe environment for one Resident (#38) out of 34 total sampled residents. Specifically, the facility failed to ensure that Resident #38 was not left unattended in his/her room in accordance with plan of care. Findings include:Review of the facility policy titled 'Falls Policy', revised 9/15/18, indicated:-The Fall Committee may suggest several preventative measures that will be individually tailored to meet each resident's needs.-These procedures will stay in place to ensure that the resident is safe from falls until such a time that the resident can be fully evaluated by the Director of Nursing. Resident #38 was admitted to the facility in March 2025 with diagnoses including dementia and hemiplegia (one-sided paralysis). Review of the most recent Minimum Data Set (MDS) assessment, dated 1/27/26, indicated Resident #38 was rarely/never understood and a Staff Assessment for Mental Status indicated he/she had severe cognitive impairment. Review of Resident #38's plan of care related to falls, revised 2/2/26, indicated:-Focus: I am high risk for falls r/t (related to) to right side paralysis.-Intervention: Do not leave Resident unattended in the room by himself/herself. On 2/5/26 at 8:19 A.M., the surveyor observed Resident #38 in bed without any staff in his/her room or visible from the hallway. At 8:21 A.M., Nurse #1 entered the Resident's room and said she was checking on him because he should never be left alone in the room. Nurse #1 said staff must stay with him/her because he/she is a fall risk and is always trying to get out of bed. On 2/5/26 at 10:26 A.M., the surveyor observed Resident #38 in bed without any staff in his/her room or visible from the hallway. On 2/5/26 from 7:48 A.M. to 7:58 A.M., the surveyor observed Resident #38 in bed without any staff in his/her room. During this time the door to the hallway was closed. On 2/10/26 at 1:12 P.M., the surveyor observed Resident #38 in bed without any staff in his/her room. At this time the door to the hallway was closed. During an interview on 2/10/26 at 1:13 P.M., Certified Nurse Assistant (CNA) #6 said any interventions in a resident's fall care plan should always be followed. CNA #6 said he was unaware Resident #38's care plan indicated he/she should not be left unattended in his/her room, and they often leave him/her unattended there. During an interview on 2/10/26 at 1:15 P.M., Nurse #7 said any interventions in a resident's fall care plan should always be followed. Nurse #7 said she was unaware Resident #38's care plan which indicated he/she should not be left unattended in his/her room. During an interview on 2/12/26 at 1:59 P.M., the Director of Nursing (DON) said any fall interventions in a resident's care plan should be implemented. The DON further said if any interventions were not appropriate, they should be clarified and/or resolved before stopping the intervention. The DON said Resident #38 should not have been left unattended in his/her room if his/her care plan indicated this was an intervention.

Based on observation, record review and interview, the facility failed to ensure that one Resident (#48) out of a total sample of 34 residents received proper treatment and assistive devices to maintain hearing abilities. Specifically, the facility failed to facilitate an audiology appointment for Resident #48 who was hard of hearing routinely and when his/her hearing aids went missing. Findings include: Review of the facility policy titled, Dental and Audiology Services, dated 3/25/25, indicated the following:-If a resident has an issue with hearing or diagnosis needing hearing aids, (the consulting audiology service) will be notified and tracked. If a hearing tool is found missing, nursing or the assistant administrator will notify (the consulting audiology service) or the appropriate physical found in the resident's record.-Residents have the right to select dentists and audiology doctors of their choice when dental care or audiology services are needed.-Social service representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental or audiology services under the state plan, if eligible.-Direct care staff will assist with inserting hearing aids as needed.-Lost or damaged dentures or hearing aids will be replaced at the resident's expense unless an employee or contractor of the facility is responsible for accidentally or intentionally damaging the dentures. Resident #48 was admitted to the facility in December 2024 with a diagnosis of unspecified hearing loss, bilateral (both sides). Review of the most recent Minimum Data Set (MDS) assessment, dated 12/26/25, indicated that Resident #48 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 0 out of 15. Further review of the MDS indicated the Resident's hearing was highly impaired/had an absence of useful hearing and that hearing aides were not used in completing the assessment. On 2/5/26 at 8:36 A.M., the surveyor observed Resident #48 in his/her room, the Resident was dressed and sitting in a chair but did not have any hearing assistive devices on. Resident #48 said he/she could not hear the surveyor and that his/her hearing aides were not present. During an observation on 2/6/26 at 8:11 A.M., the surveyor observed Resident #48 in his/her room, the Resident was dressed and sitting in a chair but did not have any hearing assistive devices on. During an observation on 2/6/26 at 1:30 P.M., the surveyor observed Resident #48 in his/her room, the Resident was dressed and sitting in a chair but did not have any hearing assistive devices on. During an observation on 2/10/26 at 7:37 A.M., the surveyor observed Resident #48 walking with a staff member to a common area, the Resident did not have any hearing assistive devices on. During an observation on 2/10/26 at 10:46 A.M., the surveyor observed Resident #48 in the common area participating in activities, the Resident did not have any hearing assistive devices on. During an observation on 2/10/26 at 11:52 A.M., the surveyor observed Resident #48 leaving the common area with a staff member, the Resident did not have any hearing assistive devices on. During an observation on 2/10/26 at 2:21 P.M., the surveyor observed Resident #48 in his/her room, the Resident was dressed and sitting in a chair but did not have any hearing assistive devices on. Review of Resident #48's progress note, dated 7/2/25 and written by the Director of Nursing (DON), indicated the following: Will check to make sure he/she (Resident #48) has his/her hearing aids in his/her ears. The Resident is very hard of hearing and does not hear without the aids. Review of Resident #48's Nurse Practitioner progress note, dated 7/7/25, indicated the Resident had hearing loss and used hearing aids. Review of Resident #48's care plans indicated the Resident had hearing deficits with the following intervention:Speak to the Resident with a louder voice as he/she is HOH (hard of hearing). Review of Resident #48's Request of Service form, signed 12/11/24, indicated the Resident requested to be seen for the following services:Audiology, dental, eye care and podiatry. Review of Resident #48's physician orders indicated the following active orders:Dental consult as needed, initiated on 12/11/24.Ophthalmology consult as needed, initiated 12/11/24.Optometry consult as needed, initiated 12/11/24.Podiatry consult as needed, initiated 12/11/24.May be seen, evaluated, and treated by services for services by Audiology, as necessary (sic.), initiated 2/6/26.Further review of Resident #48's physician orders indicated the order for audiology services was initiated after the surveyor brought concerns regarding audiology services to the facilities' attention. Review of Resident #48's physical and electronic medical record failed to indicate the Resident had ever been seen by audiology services or that the Resident had ever refused his/her hearing aids. Review of the Audiology Group Schedule with a visit date of 2/20/26 indicated Resident #48 was not scheduled to be seen by audiology services during the upcoming visit. During an interview on 2/6/26 at 10:41 A.M., Resident #48's Health Care Proxy (HCP) said she made Resident #48's medical decisions. The HCP said Resident #48 would not be able to hear people without an assistive hearing device and that she did not like the idea of Resident #48 not being able to hear as this could be isolating; the HCP said the Resident was friendly and enjoyed talking with people. The HCP said the last time she visited, around October of last year, the Resident could not hear at all. The HCP said the Resident had hearing aids when he/she was admitted to the facility but that they had gone missing at some point, that she was not notified that the hearing aids went missing and that the Resident had not been seen by audiology services while admitted to the facility. The HCP said she had bought the Resident a pocket amplifier but that the Resident had refused to use it. The HCP said her biggest concern about Resident #48's care was his/her hearing, and that she used to be able to call to speak with the Resident but now can't because he/she can't hear her. During an interview on 2/10/26 at 4:48 A.M., Resident #48 said he/she would be willing to receive and use a pair of hearing aids. During an interview on 2/6/26 at 10:55 A.M., Certified Nursing Aide (CNA) #6 said Resident #48 could not hear all the time and that the Resident did not currently have any hearing devices. CNA #6 said the Resident previously had a pocket amplifier but that the Resident had refused to wear it. During an interview on 2/10/26 at 10:46 A.M., CNA #2 said he was currently assigned to Resident #48 and that the Resident was sometimes hard of hearing. CNA #2 said the Resident did not use hearing assistive devices because the Resident did not have any. During an interview on 2/6/26 at 10:19 A.M., Nurse #6 said that when a Resident needs audiology services somebody upstairs will place the Resident on a list to be seen and that audiology services come every few months. Nurse #6 said that if a Resident lost hearing aids he would tell the Unit Manager and that the Unit Manager would follow up and notify the family. Nurse #6 said he was not sure if Resident #48 had ever been seen by audiology or if the Resident had an upcoming audiology appointment. Nurse #6 said he did not remember if Resident #48 used assistive hearing devices but that if the Resident did it would be listed in the Resident's treatment orders; after looking through Resident #48's treatment records, Nurse #6 said Resident #48 did not have a treatment order for any assistive hearing devices. Nurse #6 said Residents assistive hearing devices should be listed in the care plan and physician orders so that nurses would be aware of them. During an interview on 2/10/26 at 10:42 A.M., Nurse #7 said if a Resident's hearing aids went missing that she would look for them and if she could not find them, she would tell the Unit Manager who would reach out to the family. Nurse #7 said she was Resident #48's nurse today. Nurse #7 said the Resident was hard of hearing, but she did not know if the Resident used any assistive hearing devices. Nurse #7 checked the medication and treatment cart which did not contain Resident #48's hearing aids. During an interview on 2/6/26 at 10:29 A.M., Unit Manager #1 said the next time audiology services were coming to the building was on 2/20/26. Unit Manager #1 said if a Resident needed to be seen by audiology services that they would need a physician order and that the Unit Manager could email the audiology services if a Resident had an issue and needed to be seen, such as if the Resident had lost his/her hearing aids. Unit Manager #1 reviewed the upcoming appointments and said that Resident #48 did not have an upcoming audiology appointment and that she was not sure if the Resident used assistive hearing devices but that she would check with the DON. During an interview on 2/6/26 at 1:35 P.M., the DON said there should have been a physician order and care plan for Resident #48's assistive hearing devices. The DON said he had checked Resident #48's room and could not find hearing aids but that he did find hearing aid batteries in the Residents drawer; the DON said that the hearing aid batteries indicated the Resident used to have hearing aids. The DON said staff should have notified him when the hearing aids went missing but didn't, as they could have signed the Resident up to be seen by audiology on their next facility visit. During an interview on 2/10/26 at 11:59 A.M., the Operational Director said Resident #48 had never been seen by audiology services during his/her admission. During an interview on 2/10/26 at 2:13 P.M., the Social Worker said any Resident who mentions concerns, is hard of hearing and/or uses an assistive hearing device, would be seen by audiology services. The Social Worker said Resident #48 was hard of hearing and had hearing aids and that if the Resident's hearing aids had gone missing that she would have contacted audiology services. The Social Worker said she was not aware that the Resident's hearing aids had gone missing and that she would have expected staff to have notified her when the hearing aids went missing. The Social Worker said any staff member could place a request for a Resident to be seen by audiology. The Social Worker said that Resident #48 would need assistance with his/her hearing devices and that staff should help put on the Resident's assistive hearing devices in the morning and that they should look for the hearing devices each night to remove them; the Social Worker said Resident #48 did not refuse his/her hearing aids and that any refusals would be documented. The Social Worker said she would expect a physician order for the use of hearing aids. The Social Worker said there was no reason for the Resident to have not been seen by audiology services and that the Resident was not referred to audiology services but should have been. During a follow-up interview on 2/10/26 at 2:57 P.M., the DON said he was not sure why Resident #48 was not seen by audiology services but that the Resident should have been referred to audiology services.

Based on observations and interviews, the facility failed to provide an activities program for residents on the [NAME] Unit. Findings include: Review of the facility policy titled, Activities, dated 5/10/25, indicated the following:-It is the policy of (the facility) to provide an activities program that is appropriate to the needs and interests of each resident that will encourage self-care, resumption of normal activities, maintenance of optimal cell functioning and contact with the environment.-The planned activities program shall be suited to the needs, abilities and interests of each resident. Activities shall be provided in individual and group settings for ambulatory and non ambulatory residents.-The activities program shall include a variety of activities both inside and outside the facility. Planned activities shall include, but not be limited to, exercise classes, recreational or social activities, literary or educational activities, community activities, spiritual activities and continuing life experiences that allow the resident to maintain his or her present life cycle.-A member of the staff shall be assigned responsibility for developing, documenting and maintaining an activities program. Sufficient support staff must be available to meet the activity needs of all residents. Review of the activities calendar for 2/5/26 indicated the following activities were scheduled:-Refreshments at 10:15 A.M.-Animal [NAME] at 11:00 A.M. On 2/5/26, from when breakfast ended at approximately 9:30 A.M. to when lunch began at approximately 11:45 A.M., the surveyor observed the activity room. The activities listed on the activity calendar did not take place. There were three residents that were provided with individual activities on the table. The rest of the residents were lined up in front of the television while cat videos were playing and several of the residents were sleeping. The Certified Nursing Assistants (CNAs) who were supervising the room throughout this time period did not engage with the residents and there was not an activity staff member present during this time. Review of the activities calendar for 2/6/26 indicated the following activities were scheduled:-Refreshments at 10:15 A.M.-[NAME] at 11:00 A.M. On 2/6/26, from when breakfast ended at approximately 9:30 A.M. to when lunch began at approximately 11:45 A.M., the surveyor observed the activity room. The activities listed on the activity calendar did not take place. There were three residents that were provided with individual activities on the table. The rest of the residents were lined up in front of the television while the Golden Girls sitcom was playing. This show played for the entirety of the time. Several of the residents were observed to be sleeping. The Certified Nursing Assistants (CNAs) who were supervising the room throughout this time period did not engage with the residents and there was not an activity staff member present during this time. Review of the activities calendar for 2/10/26 indicated the following activities were scheduled:-Refreshments at 10:15 A.M.-Animal [NAME] at 11:00 A.M. On 2/10/26, from when breakfast ended at approximately 9:30 A.M. to when lunch began at approximately 11:45 A.M., the surveyor observed the activity room. The activities listed on the activity calendar did not take place. There were three residents that were provided with individual activities on the table. The rest of the residents were lined up in front of the television while a movie played and several of the residents were sleeping. The Certified Nursing Assistants (CNAs) who were supervising the room throughout this time period did not engage with the residents and there was not an activity staff member present during this time. During an interview on 2/13/26 at 10:45 A.M., the Activity Director said she has been working at the facility for a month, and she is the only activity staff member. The Activities Director said there is an activity assistant, but she is out on medical leave, and she does not know when she will be returning to work. The Activities Director said she primarily spends her time on the North and Central Units, and the [NAME] Unit activities are supposed to be run by the CNAs when she is not on that unit. The Activity Director said she cant be everywhere at once so she typically will set up residents on the [NAME] Unit with activities but then leaves to go to the other units to run activities. The Activity Director said the [NAME] Unit has a lot of residents who have dementia and has its own activity calendar to meet the cognitive needs of those residents. The Activity Director said since she is the only staff member she has not been able to spend as much time on the [NAME] Unit to learn the needs of those residents and has not trained any of the CNAs to run the activities while they are supervising the room. The Activity Director said the [NAME] Unit residents are not having their activity needs met.

Based on observation, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs) for 3 Residents (#69, #67 and #45) out of a total sample of 34 residents. Specifically, the facility failed to:1) Provide incontinence care for Residents #69 and #67. 2) Provide assistance to Resident #45 for grooming tasks and removal of unwanted facial hair. Findings include:Review of the facility policy titled, Activities of Daily Living (ADLs), dated 11/6/24, indicated the following:-Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).-Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.-Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming and oral care), c. Elimination (toileting). Review of the facility policy titled, Incontinent Care, dated 3/5/25, indicated the following:-All residents are to be given incontinent care after each episode of incontinence. Residents are to be checked for incontinence every two hours and as needed.-Each resident's care plan is specific to the needs of the individual resident. 1a. Resident #69 was admitted to the facility in April 2019 with diagnoses including Alzheimer's Disease. Review of Resident #69's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 00 out of a possible 15, which indicated he/she had severe cognitive impairment. The MDS also indicated Resident is dependent on staff for toileting tasks and is frequently incontinent of both bowel and bladder. Review of Resident #69's most recent bowel and bladder assessment dated [DATE], indicated Resident #69:-never voids appropriately without incontinence,-has daily incontinence of stool, and-is never mentally aware of need to toilet. Review of Resident #69's incontinence care plan, last revised on 8/1/25 indicated the following intervention: -check and change every 2 hours and as needed apply barrier cream to coccyx buttocks area after each incontinent episode. Routine toileting q (every) 2 hours and PRN (as needed). Review of Resident #69's ADL care plan, last revised 8/1/25, indicated the following intervention:-Bladder-incontinent, provide incontinent care after each episode. Bowel-incontinent, provide incontinent care after each episode. Toilet every 2 hours and as needed. On 2/5/26 at 8:18 A.M., Resident #69 was observed sitting in his/her wheelchair in the dining room. Resident #69 sat in the same position in the dining room until he/she was taken to the bathroom at 12:29 P.M., over four hours later. During this time period, no staff were observed checking the Resident for possible incontinence. On 2/6/26 at 7:30 A.M., Resident #69 was observed sitting in his/her wheelchair in the dining room. Resident #69 sat in the same position in the dining room until 12:00 P.M., over four hours later. During that time period, Resident #69 was not assisted to the bathroom and was not checked for incontinence. On 2/9/26 at 7:43 A.M., Resident #69 was observed sitting in his/her wheelchair in the dining room. Resident #69 sat in the same position in the dining room until he/she was taken to the bathroom at 12:38 P.M., almost five hours later. The surveyor observed Certified Nursing Assistant #11 provide toileting assistance to Resident #69 and the Resident's incontinence brief was observed to be saturated with urine. During an interview on 2/9/26 at 12:04 P.M., Certified Nursing Assistant (CNA) #11 said the majority of residents on the unit, including Resident #69, are incontinent. CNA #11 said the nursing staff typically assist residents with toileting after breakfast and after lunch or as needed. CNA #11 said she cares for Resident #69 regularly and usually toilets him/her before breakfast and after lunch. During an interview on 2/10/26 at 9:43 A.M., the Unit Manager said all residents should be checked every two hours and have incontinence care provided if needed. The Unit Manager said it is a nursing standard that any resident who is incontinent of either bowel or bladder is provided with incontinence care every two hours. The Unit Manager said Resident #69 is incontinent of both bowel and bladder and nursing should be providing care to him/her every two hours. The Unit Manager said if incontinent care is not provided every two hours there is a risk of infection, rash or skin breakdown. During an interview on 2/10/2026 at 10:36 A.M., the Director of Nursing said all residents who are incontinent should be toileted every two hours. The Director of Nursing said Resident #69 is incontinent and should be checked and changed every two hours and the length of time the surveyor observed the Resident without being toileted was not acceptable. The Director of Nursing said the risk of not having timely incontinence care is skin breakdown. 1b. Resident #67 was admitted to the facility in January 2020 with diagnoses including Alzheimer's Disease, Review of Resident #67's most recent Minimum Data Set, dated [DATE], indicated the Resident was unable to complete the Brief Interview for Mental Status and the staff had assessed him/her to have severe cognitive impairment. The MDS also indicated Resident #67 is dependent on staff for all functional tasks and is always incontinent of both bowel and bladder. Review of Resident #67's most recent bowel and bladder assessment dated [DATE], indicated the Resident:-never voids without incontinence,-has daily incontinence of stool, and -is not usually aware of need to toilet. Review of Resident #67's incontinence care plan last revised 6/12/25, indicated the following intervention:-Incontinent program: check and change every 2 hours Assist me to toilet every 2 hours and as needed Review of Resident #67's ADL care plan last revised 6/12/25, indicated the following intervention: -Preventative skin care every shift and as needed. Bladder- incontinent, provide incontinent care after each episode Bowel- incontinent, provide incontinent care after each episode. On 2/5/26 at 7:59 A.M., Resident #67 was observed lying in a recliner in the dining room. Resident #67 was in the same position in the dining room until 12:30 P.M., over four hours later. During that time period, Resident #69 was not assisted to the bathroom and was not checked for incontinence. On 2/6/26 at 7:30 A.M., Resident #67 was observed lying in a recline in the dining room. Resident #67 was in the same position in the dining room until 12:00 P.M., over four hours later. During that time period, Resident #69 was not assisted to the bathroom and was not checked for incontinence. On 2/9/26 at 7:43 A.M., Resident #67 was observed lying in a recliner in the dining room. Resident #67 was in the same position in the dining room until he/she was taken to the bathroom at 12:46 P.M., five hours later. The surveyor observed Certified Nursing Assistant #11 provide toileting assistance to Resident #67 and the Resident's incontinence brief was observed to be saturated with urine. During an interview on 2/9/26 at 12:04 P.M., Certified Nursing Assistant (CNA) #11 said the majority of residents on the unit, including Resident #67, are incontinent. CNA #11 said the nursing staff typically assist residents with toileting after breakfast and after lunch or as needed. CNA #11 said she cares for Resident #67 regularly and usually toilets him/her before breakfast and after lunch. During an interview on 2/10/26 at 9:43 A.M., the Unit Manager said all residents should be checked every 2 hours and have incontinence care provided if needed. The Unit Manager said it is a nursing standard that any resident who is incontinent of either bowel or bladder is provided with incontinence care every two hours. The Unit Manager said Resident #67 is incontinent of both bowel and bladder and nursing should be providing care to him/her every two hours. The Unit Manager said if incontinent care is not provided every two hours there is a risk of infection, rash or skin breakdown. During an interview on 2/10/2026 at 10:36 A.M., the Director of Nursing said all residents who are incontinent should be toileted every two hours. The Directof of Nursing said Resident #67 is incontinent and should be checked and changed every two hours and the length of time the surveyor observed the Resident without being toileted was not acceptable. The Director of Nursing said the risk of not having timely incontinence care is skin breakdown. 2. Resident #45 was admitted to the facility in August 2020 with diagnoses including Alzheimer's Disease and schizophrenia. Review of Resident #45's most recent Minimum Data Set (MDS) dated [DATE], indicated Resident #45 had a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15, which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #45 required moderate assistance from staff for grooming tasks. On 2/5/26 at 11:31 A.M., Resident #45 was observed lying in bed. The Resident had significant, long chin hair. During an interview at this time, Resident #45 said he/she would like to have his/her chin hair removed and prefers to have a smooth chin without hair. On 2/12/26 at 7:25 A.M., Resident #45 was observed lying in bed with significant long chin hair still present. During an interview at this time, Resident #45 said staff had not offered to remove his/her chin hair and he/she would very much like it removed. Review of Resident #45's activity of daily living care plan, last revised on 7/2/25, indicated the following interventions:-I am an assist of one with Bathing, dressing and grooming. -Staff will offer me positive reinforcement for accomplishments and efforts. grooming assist of 1 During an interview on 2/12/26 at 7:29 A.M. Certified Nursing Assistant (CNA) #8 said removing unwanted facial hair is a part of daily care. CNA #8 said Resident #45 will at times refuse showers and washing his/her hair, however, never refuses grooming assistance, including removing chin hair. CNA #8 said Resident #45 prefers to have all chin hair removed. During an interview on 2/12/26 a1:36 P.M., the Director of Nursing said all unwanted facial hair should be removed as part of daily grooming. The Director of Nursing said if a resident were to refuse care, the nursing staff would document the refusal. Review of Resident #45' medical record failed to indicate the Resident refused assistance with grooming tasks.

Based on observation, record review and interview, the facility failed to provide care in accordance with professional standards of practice for one Residents (#74) out of a total of 34 sampled residents. Specifically:1. For Resident #74, the facility failed to ensure a physician's order was implemented for padded side rails. Findings include: Review of [NAME], Manual of Nursing Practice 11ed, dated 2019 indicated the following:- The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following:Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize errors.1.Resident #74 was admitted to the facility in January 2026 with diagnoses including seizure and epilepsy. Review of Resident #74's Brief Interview for Mental Status (BIMS) indicated the Resident scored a 13 out of 15 indicating intact cognition. Review of the medical record indicated Resident #74 was dependent on staff for activities of daily living. On 2/5/26 at 9:06 A.M., the surveyor observed Resident #74 lying in his/her bed with two quarter side rails up. The side rails were not padded. On 2/6/26 at 7:49 A.M., the surveyor observed tResident #74 lying in his/her bed with two quarter side rails up. The side rails were not padded. On 2/6/26 at 9:02 A.M., the surveyor observed Resident #74 lying in his/her bed with two quarter side rails up. The side rails were not padded. On 2/9/26 at 7:14 A.M., the surveyor observed Resident #74 lying in his/her bed with two quarter side rails up. The side rails were not padded. Review of the active physician's order indicated the following:Padded side rails while in bed secondary to seizures activities, dated 2/28/23. During an interview on 2/9/26 at 7:24 A.M., Nurse #2 said based on the physician orders the Resident should have padded side rails. During an interview on 2/10/26 at 10:19 A.M., Certified Nursing Assistant (CNA) #4 said he has not seen the Resident's bed with padded side rails. He further said if the Resident required padded side rails the nurses would be the one to place them. During an interview on 2/12/26 at 1:59 P.M., the Director of Nursing said physician orders should be followed as ordered and that Resident #74 was ordered to have padded side rails and those should have been in place.

Based on record review and interviews, for 2 Residents (#47 and #50) out of a total sample of 34 residents, the facility failed to ensure they reviewed and revised the Comprehensive Care Plan following the completion of his/her scheduled Quarterly Minimum Data (MDS) assessment. Specifically,For Resident #47 the facility failed to update the care plan to remove interventions of 15-minute checks when they were no longer being implemented.For Resident #50, the facility failed to revise the comprehensive care plan relating to communication problem, which did not include any interventions related to his/her language barrier.Findings include: Review of the facility policy titled 'Resident-Centered Comprehensive Careplan (AIMS)', revised 9/22/24, indicated: -The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family and legal representative, develops and implements a comprehensive, person-centered care plan for each resident. -The care plan interventions are derived from the thorough analysis of the information gathered as part of the comprehensive assessment. -The care planning process will incorporate the resident's personal and cultural preferences in developing the goals of care. -The comprehensive, person-centered care plan will: describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and incorporate identified problem areas. 1. Resident #47 was admitted to the facility in March 2025 and has diagnoses that include Dementia with other behavioral disturbance, wandering in diseases classified elsewhere and traumatic brain injury. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/19/25, indicated that on the Brief Interview for Mental Status exam Resident #47 scored a 1 of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #47 had no behaviors aside from wandering 1-3 days a week. Review of Resident #47's active physician orders include the following orders: -Please check resident status every 15 minutes, start date 8/8/25. Review of Resident #47's active care plans includes the following care plans: 1. FOCUS: I have the potential for becoming physically aggressive with other residents when I may not understand what is happening. Resident has a physical aggressive altercation with another resident (last updated 7/9/25) Interventions include: -Resident shall be monitored every 15 minutes and documented by staff members to prevent him from entering other residents' rooms and to be able to recognize when his mood/behavior changes. (start date 7/18/25) Review of the Clinical progress notes includes a note dated 2/6/26 that indicated Resident #47 was behavioral and the intervention implemented was to put him/her on 15-minute checks, despite this already being an active MD order that was on Resident #47's care plan. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) failed to indicate that the 15-minute checks were done at any time from July 2025 until they were implemented on 2/6/26. During an interview on 2/10/26 at 2:21 P.M., the Director of Nursing (DON) said that the 15-minute checks on Resident #47's care plans since 7/18/25 and ordered by the Physician on 8/8/25 were not actually being done. The DON said that it was an outdated intervention and should have been caught during each quarterly care plan meeting after that date and the care plan revised to reflect the current plan of care. As well, the MD order should have been discontinued. During an interview on 2/11/26 at 12:02 P.M., the Nursing Home Administrator said that if 15-minute checks were on the care plan since July 2025 and ordered by the MD since August 2025, he would have expected the 15-minute checks to be done, or the care plan revised to reflect that the checks were no longer in place. 2. Resident #50 was admitted to the facility in March 2025 with diagnoses including Alzheimer's dementia and failure to thrive. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/11/25, indicated Resident #50 spoke Swahili and needed or wanted an interpreter to communicate with a doctor or health care staff. This MDS indicated he/she was usually understood and usually understands in Section B. On 2/5/26 at 8:10 A.M., the surveyor observed Resident #50 in his/her room eating breakfast. Resident #50 was unable to answer the surveyor's questions such as how are you? and how is your breakfast but instead shrugged and spoke in another language. During a follow-up interview on 2/6/26 at 11:14 P.M., Resident #50 conversed with a surveyor, who spoke Swahili. Resident #50 was able to respond to questions about his/her care such as that he/she prefers tea over coffee and discussed his/her personal past with the surveyor. Review of Resident #50's plan of care related to communication problem, dated 1/21/26, indicated: -Focus: Resident #50 has a communication problem related to language barrier; his/her primary language is Swahili. -Intervention: Anticipate and meet needs. -Intervention: Ensure/provide a safe environment. Resident #50's plan of care failed to indicate any interventions used to assist with communicating in Swahili, such as communication board or use of translator services. During an interview on 2/6/26 at 10:40 A.M., Certified Nurse Assistant (CNA) #9 said she cannot communicate with Resident #50 because he/she speaks Swahili. CNA #9 said there are no staff in the building on the current shift that speak Swahili, but that there are a few staff employed on other shifts that speak Swahili, so if Resident #50 needs something he/she can tell them on other shifts. CNA #9 said Resident #50 often urinates on the floor and before doing so will often be attempting to communicate in Swahili, but she doesn't know what he/she is saying because there was no way to understand him/her. CNA #9 was unaware of any interventions, such as a communication board or electronic translator services. During an interview on 2/6/26 at 10:49 A.M., the Administrator said he was unaware there was Resident #50's language barrier. The Administrator said Resident #50 has a communication board and he expected staff would utilize an electronic translator program. The Administrator said Resident #50 should have had interventions, such as the communication board and electronic translator, included in his/her care plan to ensure staff were aware of how to communicate with the Resident but they were not. During an interview on 2/9/26 at 8:24 A.M., Nurse #8 said she frequently cares for Resident #50. Nurse #8 said she does not speak Swahili, so she is unable to communicate with Resident #50. Nurse #8 said they anticipate his/her needs the best they can and rely on a few staff members who work evening shift to communicate in Swahili with Resident #50 when they are scheduled if needed. Nurse #8 said she was unaware of any interventions, such as communication board or use of electronic translator, used to communicate with Resident #50. Nurse #8 said if these were supposed to be used, she would expect them to be in Resident #50's care plan but they were not. During an interview on 2/9/26 at 10:06 A.M., the Social Worker (SW) and MDS Coordinator said the interdisciplinary team meets quarterly to review Resident #50's care plan. They both said since staff are unable to communicate with Resident #50 when Swahili speaking staff is unavailable they are expected to utilize a communication board and electronic translator services. They said these interventions should have been included in Resident's care plan. They said the care plan should have been revised to include these interventions following the last MDS assessment, which was dated 12/11/25, but was not. During an interview on 2/12/26 at 1:59 P.M., the Director of Nursing (DON) said Resident #50 should have had interventions in his/her care plan, such as the use of a communication board and electronic translator services but did not. The DON said that these interventions should have been added to the care plan during review of the most recent MDS on 12/11/25.

Based on record review and interviews, the facility failed to develop a care plan for suicidal ideation for one Resident (#33) out of a total sample of 34 residents. Findings include: Review of the facility policy titled, Oxygen Administration, dated 2/23/26, indicated the following:-Place appropriate oxygen device on the resident. -Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated. Resident #33 was admitted to the facility in December of 2025 with diagnoses including schizoaffective disorder and schizophrenia. Review of Resident #33's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview of Mental Status (BIMS) score of 14 out of a possible 15 which indicated he/she is cognitively intact. The MDS also indicated Resident #33 required substantial assistance with activities of daily living. Throughout survey, Resident #33 was not agreeable to an interview. Review of the Psychiatrist note from 12/29/25 indicated Resident #33 had experienced suicidal ideation previously in the day, however at the time of his visit with the Resident, the Resident no longer expressed any suicidal ideation. Review of the medical provider note on 1/25/25 indicated the following:- Patient called Police at facility requesting to leave facility, expressed suicidal ideation with a plan, put on 1-1 to monitor for safety. NO Suicidal ideation and ideation on assessment today.Review of Resident #33's interdisciplinary care plans failed to indicate a care plan for suicidal ideation was created after 12/29/25. During an interview on 2/10/26 at 10:36 A.M., the Director of Nursing said any resident who has expressed suicidal ideation should have a care plan developed to address this concern. The Director of Nursing said the care plan would assist the staff to identify interventions to assist a resident is managing feeling of suicidal ideation. The Director of Nursing said Resident #33 should have had a suicidal ideation care plan developed and was unaware it had not been developed. During an interview on 2/10/26 at 1:44 P.M., the Social Worker said any resident who expresses suicidal ideation in present or past should have a suicidal ideation care plan developed. The Social Worker said such a care plan would be important to develop in order to identify possible triggers for the suicidal ideation as well as appropriate interventions for the resident. The Social Worker said she does not remember Resident #33 expressing suicidal ideation on 12/29/25, however, a care plan should have been developed for this.

Based on record review and interview, the facility failed to ensure that its staff completed a quarterly Minimum Data Set (MDS) assessment in a timely manner for one Resident (#27), out of 34 sampled residents. Findings include:Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) version 3.0 Manual, dated October 2025, indicated:-A Quarterly MDS Assessment is due every quarter unless the resident is no longer in the facility. There must be no more than 92 days between OBRA assessments. -The Quarterly MDS Assessment must be completed no later than 14 calendar days after the Assessment Reference Date. Resident #27 was admitted to the facility in April 2022. Review of Resident #27's most recent Minimum Data Set (MDS) assessment was a quarterly MDS assessment with an assessment reference date of 10/2/25, which was 127 days prior. No further MDS assessments for Resident #27 were completed or transmitted to CMS since that date. During an interview on 2/5/26 at 2:12 P.M., the MDS Coordinator said Resident #27 was supposed to have a quarterly MDS completed on 12/26/25 but it was missed. The MDS Coordinator said Resident #27 should have had a quarterly MDS within 92 days, and it was overdue. During an interview on 2/12/26 at 1:59 P.M., the Director of Nursing (DON) said he would expect the MDS Coordinator to complete all MDS assessments following the RAI manual instructions.

Based on record review and interviews, the facility failed to inform residents or their representatives of charges for services available in the facility not covered under Medicare/Medicaid or by the facility's per diem rate for two out of two applicable records reviewed. Findings include: The SNF ABN (CMS-10055) notice is administered to a Medicare recipient when the facility determines that the beneficiary no longer qualifies for Medicare Part A skilled services and the resident has not used all the Medicare benefit days for that episode. The SNF ABN provides information to residents/beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility. Review of the notices provided to two residents who came off their Medicare Part-A Benefit, who had benefit days remaining and stayed at the facility, were provided Advanced Beneficiary Notices that did not include an estimated cost of services should they choose to pay privately. During an interview on 2/12/26 at 10:28 A.M., the Social Worker said she was responsible for providing the SNF ABN notices to residents or their representatives. The Social Worker said she left the cost breakdown sections blank because she does not know what the individual costs are, but the resident or their representative should have been provided with a cost breakdown in the event they assume financial responsibility for skilled services. During an interview on 2/12/26 at 10:39 A.M., the Operations Director said she was unsure of the cost breakdown for skilled services, but it should be listed on the SNF ABN.

Based on observation and interview, the facility failed to provide a dignified existence for one Resident (#74) out of a total sample of 34 residents. Specifically, staff failed to pull the privacy curtain for Resident #74 when he/she was in bed receiving assistance with bathing, which exposed Resident #74 to his/her roommates.Findings include:Review of the facility policy titled Quality of Life-Dignity, undated, indicated the following:Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment and procedures. Resident #74 was admitted to the facility in January 2026 with diagnoses including dysphagia, unspecified dementia and seizures. Review of Resident #74's Brief Interview for Mental Status (BIMS) indicated the Resident scored an 8 out of 15 indicating moderate cognitive impairment.Review of medical records indicated the Resident was dependent on staff for all activities of daily living. Review of Resident #74's current care plan indicated the following:Focus: Resident has potential or actual alteration in selfcare (initiated 7/30/25)Intervention: Assist resident to the extent required with bathing, dressing and grooming. During an observation on 2/6/26 at 9:02 A.M., Resident #74 was in his/her bed, naked receiving morning care by Certified Nursing Assistant (CNA) #4. His/her privacy curtain was open and two other residents were in the room able to see Resident #74 being bathed. During an interview on 2/6/26 at 9:53 A.M., CNA #4 said he should provide privacy to the residents when providing care. He further said residents should not be able to see other residents receiving personal care. During an interview on 2/12/26 at 1:59 P.M., the Director of Nursing said staff should pull privacy curtains when providing personal care.

Based on observations and interviews, the facility failed to maintain a home-like environment. Specifically, the facility failed to ensure that the [NAME] Wing was free from odors. Findings include:Review of the facility policy titled 'Home-like Environment Policy', dated 2/4/26, indicated:-Purpose: To provide a safe, comfortable, and dignified environment that reflects a home-like atmosphere and promotes resident choice, independence, and well-being. On 2/5/26 at 7:59 A.M., 10:55 A.M., and 2:24 P.M.; and on 2/6/26 at 6:57 A.M., 7:47 A.M., 8:37 A.M., and 9:03 A.M., the surveyors noted the west wing hallway had a strong odor of stale urine. During the resident group meeting conducted on 2/6/26 at 10:30 A.M., half of the participating residents (4 out of 8 residents) reported unpleasant odors within the facility. Residents reported the following:-A resident said there was a poor odor present like somebody used the bathroom.-Another resident said there was a constant smell of doo-doo.-Another resident said that housekeeping doesn't really stay on top of the odors in the facility. During an interview on 2/6/26 at 9:04 A.M., Nurse #13 said staff uses a deodorizing spray to cover odors frequently on the [NAME] Wing. During an interview on 2/6/26 at 9:45 A.M., Housekeeper #1 said she is the primary housekeeper for [NAME] Wing. Housekeeper #1 said she has to wash the floors 3 to 4 times a day because urine had soaked into the flooring in two resident rooms on the [NAME] Wing. Housekeeper #1 said since the urine is within the flooring, she is unable to remove the odor, and her cleaning only covers up the smell. Housekeeper #1 further said she uses deodorizing spray frequently to cover up the odor. During an interview on 2/6/26 at 9:59 A.M., Certified Nurse Assistant (CNA) #7 said there is often strong odors of urine on the [NAME] Wing, especially in the morning before housekeeping comes. CNA #7 showed the surveyor a deodorizing spray, which he pulled out of his pocket, and said I carry this room spray to use whenever I need it. During an interview on 2/6/26 at 10:25 A.M., the Administrator said the [NAME] Wing smells of urine because there is a resident who urinates on the floor. The Administrator said the urine may have soaked into the floor causing the odor. During an interview on 2/9/26 at 8:29 A.M., Nurse #8 said the [NAME] Wing often smells of urine. Nurse #8 said it is expected to smell like urine because it's a dementia unit. During a follow-up interview on 2/9/26 at 8:46 A.M., Housekeeper #1 said she had been telling administration for over a year that she couldn't get the smell out of the floor in the [NAME] Wing. During an interview on 2/13/26 at 8:12 A.M., the Director of Facilities (DOF) said if staff suspected urine had soaked into the floor, he would expect the flooring to be replaced promptly. The DOF said he had extra flooring in the building. The DOF said, after the surveyor brought the concern to the facility's attention, he went down to the room Housekeeper #1 said had urine soaked into the floor. The DOF said the smell of urine was strong and he thought it might be in the radiator, so he removed the radiator covering and could see that urine had soaked into the flooring. The DOF said staff should have notified him of the ongoing odor concern on the [NAME] Wing and it should have been fixed promptly but was not.

Based on observation, record review, and interviews the facility failed to ensure the nursing staff were trained and demonstrated the competencies and skill sets necessary to provide the level and types of care and services needed as outlined in the Facility Assessment. Specifically, the facility failed to: 1. Ensure licensed nursing staff were trained and demonstrated clinical competency related to pressure injury/wound care, including recognizing and reporting wound deterioration, evaluation and measurements for one resident (#20), out of a total sample of 26 residents. For Resident #20 the facility staff failed to implement treatments and physician orders recommended by the consulting wound physician resulting in the wound requiring antibiotic therapy, resulting in the deterioration of an unstageable pressure injury wound progressing to a Stage 4 pressure injury. 2. Ensure that 13 nursing staff employee files reviewed received the appropriate competencies, and skill sets necessary for the care and treatment of residents. 3. Ensure two scheduled and actively working nurses were clinically competent in providing pressure injury/wound care. 4. Ensure licensed nurses completed wound care competency by failing to be observed for the application of knowledge for delivering safe nursing care related to wound care and treatment. Findings include: Review of the Board of Registration in Nursing, 244 CMR 9.00 &10.00: Standards of Conduct, Definitions and Severability; a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice. Review of the facility's document titled Facility Assessment Tool date of assessment or update April 5, 2024, indicated the following: Our Resident Profile indicated the average daily census: 1/1/24 - 3/31/24 as 65.25. Review of the common diagnoses include but are not limited to, Psychiatric/Mood Disorders, Congested Heart Failure, Coronary Artery Disease, Parkinson's Disease, Hemiparesis, Alzheimer's Disease, Visual Loss, Hearing Loss, Fractures, Osteoarthritis, Prostrate Cancer, Breast Cancer, Lung Cancer, Diabetes, Thyroid Disorders, Chronic Obstructive Pulmonary Disease (COPD), Pneumonia, Asthma, Chronic Lung Disease, Renal Insufficiency, Ulcerative Colitis, Gastroenteritis, Bowel Incontinence, Skin Injury, Injuries, Skin Infections, Respiratory Infections. Part 2: Services and Care We Offer Based on our Residents' Needs Pressure injury preventions and care, skin care, wound care (surgical, other skin wounds) Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies. Staff training/education and competencies. Staff members are provided inservices (sic) throughout the year and as needed on topics (see attached list of inservice (sic) types). Training and Inservice review at the Facility: included but not limited to - Specialized Care - catheterization insertion/care, colostomy care, diabetic blood glucose testing, oxygen administration, suctioning, pre-op and post op care, trach care/suctioning, ventilator care, tube feedings, wound care/dressings, dialysis care. Throughout the Recertification Survey on 9/3/24 through 9/6/24 and 9/9/24, 9/12/24, 9/16/24 and 9/24/24, the surveyors identified multiple concerns regarding the repeated failure to implement wound care recommendations, notify the physician of wound care recommendations and failure to transcribe the physician's orders related to wound care. As well as failures in respiratory care practices and communicating changes to the medical provider of residents change in conditions. 1. Resident #20 was admitted to the facility in June 2024 with diagnoses including Alzheimer's disease, anemia, vitamin D deficiency, overactive bladder and cognitive communication deficit. Review of Resident #20's Minimum Data Set (MDS) assessment, dated 6/14/24, indicated that the Resident had severely impaired cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15, and required assistance with activities of daily living. Further review of the MDS indicated that Resident #20 was at risk for developing pressure injuries. Review of Resident #20's medical record indicated that Resident #20's new unstageable DTI (Deep Tissue Injury) wound to the right heel, identified on 7/16/24, required antibiotic therapy, resulting in the wound deteriorating and developed into a Stage 4 pressure injury on 8/1/24. Further review of the medical record failed to indicate that nursing staff implemented treatment and physician orders recommended by the Consultant Wound Physician to Resident #20's right heel, or that staff notified the physician that the right heel wound progressed from an unstageable DTI pressure injury to a Stage 4 pressure injury. Further review of Resident #20's medical record indicated the following: Nurse #7 completed a Skin Only Evaluation dated 7/17/24, indicated that Resident #20 had open lesions of the foot with a right heel area measuring 2 cm (centimeters) x 2.5 cm, with documented granulation, exudate, purulent, thin, thick, opaque, tan/yellow drainage, erythema. Tissue documented as painful and warm. Skin note indicated Right heel area with open wound injury 2 cm x 2.5 cm. Stage 3. Further review of the provider notification section of the Skin Only Evaluation form dated 7/17/24, failed to indicate the provider was contacted as the form was blank and contained no notification information. Review of the medical record failed to indicate that the (MD)/(NP) were notified of the right heel open wound. Review of the medical record indicated Resident #20 was seen by the Consultant Wound Physician, dated 7/18/24, and indicated one right heel unstageable DTI (Deep Tissue Injury), closed, surface area 30 cm, length 5 cm, width 6 cm, no depth. Nurse #4 completed a Skin Only Evaluation, dated 7/31/24, which indicated, skin was warm/dry. Skin turgor normal. Does the resident have current skin issues? Documented answer is No. Skin Note indicated, Stage 4 wound right heel with copious drainage, no foul odor. The evaluation did not contain detailed information regarding the wound. Review of the medical record indicated Resident #20 was seen by the Consultant Wound Physician on 8/1/24, and indicated an undefined, Stage 4 wound on the right heel, measurements: surface area 18.4 cm, 4 cm x 4.6 cm. Further review of Resident #20's medical record failed to indicate any wound assessments were documented on the Skin Only Evaluation form on the following dates: 8/7/24, 8/14/24, 8/21/24, and 8/28/24 and indicated: Does the resident have current skin issues? Documented answer is No. During an interview on 9/5/24 at 9:04 A.M. Nurse #5 said Resident #20 has a right heel wound and that measurements and skin checks are done weekly. Nurse #5 said the wound physician comes out weekly and he will send the wound report to the facility. Nurse #5 said he will round with the wound physician and look at wounds, but he does not document the information in a skin check. Nurse #5 said there is no unit manager or Director of Nurses (DON), so he reports issues to the (NP). Nurse #5 said he has not completed any clinical training or competencies here at this facility and said he signed a packet on orientation for new hire documents but has not been trained on wounds or any other clinical competencies. During an interview on 9/5/24 at 8:11 A.M., Nurse #4 said she will document information on the skin assessment but does not include measurements because the wound physician will do that. Nurse #4 said she has not completed any training aside from her new hire paperwork that was not related to wounds and has not completed any competencies. Review of Nurse #7 education files failed to include any demonstrated competencies necessary to provide the level and types of care needed for the resident population as required per the facility assessment. Review of the education files failed to include recognizing and reporting wound deterioration, evaluation, measurements, and hands-on clinical competency evaluations. Nurse #7's education files indicated he/she did not have the necessary skills to properly evaluate Resident #20's unstageable DTI that deteriorated to a Stage 4 pressure injury. Review of Nurse #4's education files failed to include demonstrated competencies necessary to provide the level and types of care needed for the resident population as required per the facility assessment. Review of the education files failed to include recognizing and reporting wound deterioration, evaluation, measurements, and hands-on clinical competency evaluations. Nurse #4's education files indicated he/she did not have the necessary skills to properly evaluate Resident #20's unstageable DTI that deteriorated to a Stage 4 pressure injury. Review of Nurse #5's education files failed to include demonstrated competencies necessary to provide the level and types of care needed for the resident population as required per the facility assessment. Review of the education files failed to include recognizing and reporting wound deterioration, evaluation, measurements, and hands-on clinical competency evaluations. Nurse #5's education files indicated he/she did not have the necessary skills to properly evaluate Resident #20's unstageable DTI that deteriorated to a Stage 4 pressure injury. During an interview on 9/9/24 at 9:21 A.M., the Consulting Nurse said staff should report skin conditions and document findings as well as report new or worsening skin areas. The Consultant Nurse said all licensed clinical staff should have documented clinical competencies and know how to complete a skin assessment and document findings. The Consulting Nurse said nursing staff should know how to assess a pressure wound and apply treatment orders appropriately including how to do a sterile dressing change and follow appropriate infection control protocol. 2. Review of 10 personnel files of actively working clinical nursing staff including 4 Licensed Nurses and 6 Certified Nursing Assistants (CNA) on 9/3/24 and 9/4/24 indicated the facility failed to conduct training that included an evaluation of demonstrated competencies necessary to provide the level and types of care needed for the resident population as required per the facility assessment. Further review of the education files indicated licensed clinical staff did not have the necessary skills to evaluate, document, or recognize a change in condition related to skin integrity and proper wound management. Review of additional 3 personnel files of actively scheduled and working licensed nurses failed to indicate any competencies related to the specialized care areas outlined in the Facility Assessment including wound care/dressings. In all, 7 licensed nurses failed to have clinical competencies including care of pressure injuries, skin and wound assessments, and wound care dressing changes. During an interview on 9/6/24 at 9:40 A.M., the Administrator and Assistant Administrator (AA) said all newly hired employees come to the facility for about three hours and review policies and procedures, they do a skills fair annually, but they do not review any clinical topics. The AA said the Director of Nursing (DON) would determine when the staff are competent enough to work. The AA continued to say historically, the facility has used word of mouth and verbal confirmation to track newly hired employees' status of staff shadowing and training. The AA then said the facility has no training curriculum. The Administrator and AA said the facility provides clinical in-services for all staff. The surveyor requested to see the in-services for the last year. Upon review of the in-services, no clinical topics relating to wound/skin care, or oxygen care were provided. During an interview on 9/9/24 at 7:38 A.M., Nurse #6 said she did an orientation with the DON when she was hired a few months ago. Nurse #6 said they reviewed mostly administrative things, sensitivity training, abuse training, HIPPA over anything clinical. Nurse #6 said wound care/skin care was very limited and only verbal educations was done, nothing written. During an interview on 9/9/24 at 9:21 A.M., the Consulting Nurse said all licensed clinical staff should have documented clinical competencies. 3. Review of the facility's document titled Removal Plan indicated at: 7. As part of the training and re-education, the MDS (Minimum Data Set)/Educator Nurse has developed nursing competencies specific to wound care to be provided to all clinical team members to ensure that this practice does not recur. These competencies are for Registered Nurses and Licensed Practical Nurses. Wound Care competencies will be completed by September 13, 2024. The nursing competencies evaluate the nurse on identifying, assessing and treating wounds, wound care testing regarding sterile dressing changes, Decubitus care, knowledge of and review of each nurse's documentation, evaluations of careplan knowledge, lifting and positioning knowledge, transfer technique, incontinent skin relation to skin integrity, medication evaluations and many other skilled nursing techniques. On 9/16/24 at 8:18 A.M., Review of the working schedule of licensed nurses and the completed wound care competency check list for licensed nurses, failed to indicate two nurses currently working a shift that began at 7:00 A.M., had a completed wound care competency checklist. During an interview on 9/16/24 at 8:20 A.M. the Administrator said one nurse (Nurse #8) is being put through the competency now and the other nurse is an agency nurse and did not have the competency done and will have it done now. The Administrator said all nursing staff were to have the competencies completed by 9/13/24. During an interview and observation on 9/16/24 at 7:47 A.M., the surveyor along with Nurse #8, the MDS Nurse, and Nurse #6 observed Resident #20 during a wound dressing change. Nurse #8 was observed removing old treatment dressings from Resident #20's right hip, right heel, and right toe. Nurse #8 did not perform hand hygiene, remove her gloves or maintain infection control standards throughout the observation. The MDS nurse had to verbally remind Nurse #8 to follow proper infection control measures throughout the observation. Nurse #8 said she would follow proper infection control protocol, but she did not have time to perform all the dressing changes and would return later to complete the treatments. Nurse #8 said she should have worn the proper PPE (personal protection equipment) and removed her gloves and performed hand hygiene when removing the old dressings. Nurse #8 said she has not completed any wound training or clinical competencies in the building. During an interview with the MDS nurse on 9/16/24 at 8:18 A.M., she said she did not complete clinical wound competencies with Nurse #8 or with any nurses in the facility. The MDS nurse said she completed verbal education with nursing staff about following wound treatment recommendations, but no clinical competencies have been done. During an interview on 9/16/24 at 8:22 A.M., Nurse #6 said she has not completed any clinical competencies or had any clinical in-services since training she started working in the facility and continued to say that the DON (Director of Nursing) would verbalize how things should be documented but that was it. During a follow up interview on 9/16/24 at 9:38 A.M., with the MDS Nurse and Nurse #6, the MDS nurse said she just started working with the company last week and that she has not received any clinical training or in-services. The MDS nurse said she does not have a clinical competency on file and said the Administrator asked her to educate the nursing staff about wounds. The MDS nurse said she does not have any formal training on wound care. Nurse #6 said she does not have any clinical in-service or clinical competency on file and that she does not have any formal training on wound care. During an interview on 9/16/24 at 9:41A.M., the Administrator said he did not have any outside clinical training or hands-on clinical competencies completed for the MDS nurse or Nurse #6 and said staff providing education need to be competent and have the necessary training and clinical competencies on file. 4. Review of the facility's policy entitled Wound Care, not dated, indicated the following: -All nurses will need to perform a wound care competency by the nurse trainer before starting a shift. All external agency staffing will need to check in with nursing leadership and perform a wound care competency before starting their shift. Review of the document titled Wound Care Competency for 15 out of 15 licensed nurses reviewed indicated the following: - Two licensed nurses had an incomplete page, indicating an incomplete wound care competency. - Fourteen out of fifteen licensed nurse competencies failed to be checked off as 'Cleaning a wound and applying a dry non-sterile dressing skill checklist requirement met/or Cleaning wound and applying a dry non-sterile dressing skill checklist requirement NOT met. During an interview on 9/24/24 at 8:07 A.M., Nurse #6 said she provided one-to-one education using the wound care competency document with each licensed nurse before they started a shift. Nurse #6 said the second part of the wound care competency would include observing the nurse completing wound care, then they would determine if the nurse met or not met wound care competency. During an interview on 9/24/24 at 10:10 A.M., the Director of Nursing (who recently started at the facility) said education was provided and that no clinical observation wound competency was conducted with the licensed nurses, except for two licensed nurses. Twelve of fifteen licensed nurses failed to have wound care competency to include the evaluated by a trained observer. 36431 45984

Based on observations, interviews and record review the facility failed to ensure its administration used its resources effectively to provide appropriate wound care. Specifically, the facility administration failed to: 1. Provide nursing staff education and training to provide competent, safe, and effective wound care management. 2. Provide continuation of the pressure injury prevention and care services following the absence of the Director of Nursing (DON) and implement an effective system for pressure injury (wounds that occur when the skin and tissue are damaged by prolonged pressure, usually on bony areas like the hips, heels, or elbows) prevention and care per the Facility Assessment Tool. These failures resulted in the development of an infected Stage 4 pressure injury for one Resident (#20) out of a total sample of 26 residents. Findings Include: During the survey process it was identified that the Administration's failure to perform wound care competencies for nursing staff that were delegated to assume the responsibilities of wound care management in the absence of a wound nurse resulted in a failure to perform skin checks and wound evaluations, implement physician orders, updated the physician and plan of care when significant changes occurred, and the development of an infected stage 4 pressure injury. Review of the Facility Assessment Tool, dated as reviewed with the QAPI (Quality Assurance Performance Improvement) committee in April 2024, indicated the facility offers pressure injury prevention and care, skin care, wound care (surgical, other skin wounds). Further review of the Facility Assessment Tool indicated, but was not limited to, the following: Licensed Nurses providing direct care - Plan 1 DON (Director of Nurses) RN full-time Days; if has other responsibilities, add X more RN as Asst. DON to equal one FTE (full time employee). RN or LPN Charge Nurse: 1 for each shift. 1-X residents DON may be Charge Nurse. Staff training/education and competencies. - Staff members are provided in-services throughout the year and as needed on topics (see attached list of in-service types). Infection control-handy hygiene, isolation standard universal precautions including use of personal protective equipment, MRSA/VRE/ CDI precautions, environmental cleaning. Resident assessment and examinations- admission assessment, skin assessment, pressure injury assessment, neurological check, lung sounds, nutritional check, observations of response to treatment, pain assessment. Caring for persons with Alzheimer's or other dementia. Specialized care catheterization insertion/care, colostomy care, diabetic blood glucose testing, oxygen administration, suctioning, pre-op care, trach care/suctioning, ventilator care, tube feedings, wound care/dressings, dialysis care. The facility provides an Infection Control Committee and an Infection Preventionist in the Director of Nursing. Areas Facility Assessment Informed: Training, Competencies - Up to date. 1. The facility failed to provide nursing staff education and training to provide competent, safe, and effective wound care management. According to the Board of Registration in Nursing, 244 CMR 9.00 &10.00: Standards of Conduct, Definitions and Severability; a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. Resident #20 was admitted to the facility in June 2024 with diagnoses including Alzheimer's disease, anemia, vitamin D deficiency, overactive bladder and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment, dated 6/14/24, indicated that Resident #20 had severely impaired cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15, and required assistance with activities of daily living. Further review of the MDS indicated that Resident #20 was at risk for developing pressure injury. Review of the medical record indicated that Resident #20's new unstageable DTI (Deep Tissue Injury) wound to the right heel, identified on 7/16/24, required antibiotic therapy resulting in the deterioration and developed into a Stage 4 pressure injury on 8/1/24. The medical record failed to indicate that nursing staff implemented treatment and physician orders recommended by the Consultant Wound Physician to Resident #20's right heel, or that staff notified the physician that the right heel wound progressed from an infected unstageable DTI to a Stage 4 pressure injury. Review of the nursing notes, physician notes and wound evaluations failed to indicate nursing staff evaluated and monitored the wound, implemented preventative interventions and treatments, or notified the physician of a change in condition to prevent the worsening of Resident #20's wound. According to the Mayo Clinic, complications and outcomes of Stage 4 pressure injuries include: - Osteomyelitis, which is characterized by a mixture of inflammatory cells, fibrosis, bone necrosis, and new bone formation. It is associated with nonhealing wounds, surgical flap complications, and an increased length of hospitalization . It may develop within the first 2 weeks of pressure injury formation and despite treatment may require amputation in lower extremity cases. - Joint infections (septic arthritis) can damage cartilage and tissue. - Bone infections (osteomyelitis) can reduce the function of joints and limbs. - Long-term, nonhealing wounds can develop into a type of squamous cell carcinoma. - Sepsis (blood infection). Further review of Resident #20's medical record indicated the following: Nurse #7 completed a Skin Only Evaluation dated 7/17/24, that indicated Resident #20 had open lesions of the foot with a right heel area measuring 2 cm (centimeters) x 2.5 cm, with documented granulation, exudate, purulent, thin, thick, opaque, tan/yellow drainage, erythema. Tissue documented as painful and warm. Skin note indicated Right heel area with open wound injury 2 cm x 2.5 cm. Stage 3. Further review of the provider notification section of the Skin Only Evaluation form failed to indicate the provider was contacted as the form was blank and contained no notification information. Review of the medical record failed to indicate that the (MD)/(NP) were notified of the findings on the 7/17/24 Skin Only Evaluation. Further review of the medical record indicated Resident #20 was seen by the Consultant Wound Physician, dated 7/18/24, indicated one right heel unstageable DTI (Deep Tissue Injury), closed, surface area 30 cm, length 5 cm, width 6 cm, no depth. Nurse #4 completed a Skin Only Evaluation, dated 7/31/24, indicated, skin was warm/dry. Skin turgor normal. Does the resident have current skin issues? Documented answer is No. Skin Note indicated, Stage 4 wound right heel with copious drainage, no foul odor. The evaluation did not contain detailed information regarding the wound. Review of the medical record indicated Resident #20 was seen by the Consultant Wound Physician on 8/1/24, and indicated undefined right heel wound, Stage 4, measurements: surface area 18.4 cm, 4 cm x 4.6 cm. Further review of Resident #20's medical record failed to indicate any wound assessments were documented on the Skin Only Evaluation form on the following dates: 8/7, 8/14, 8/21, and 8/28 and indicated: Does the resident have current skin issues? Documented answer is No. During an interview on 9/5/24 at 8:11 A.M., Nurse #4 said she will document information on the skin assessment but does not include measurements because the wound physician will do that. Nurse #4 said she has not completed any training aside from her new hire paperwork that was not related to wounds and has not completed any competencies. During an interview on 9/5/24 at 8:11 A.M., the Consultant Wound Physician said he expects staff to have demonstrated competencies on file, know how to implement physician recommendations and treatment orders to care for residents in the facility. During an interview on 9/5/24 at 9:04 A.M., Nurse #5 said Resident #20 has a right heel wound and that measurements and skin checks are done weekly. Nurse #5 said the wound physician comes out weekly and he will send the wound report to the facility. Nurse #5 said he will round with the wound physician and look at wounds, but he does not document the information in a skin check. Nurse #5 said there is no unit manager or Director of Nurses (DON), so he reports issues to the (NP). Nurse #5 said he has not completed any clinical training or competencies here at this facility and said he signed a packet on orientation for new hire documents but has not been trained on wounds or any other clinical competencies. Review of Nurse #7, Nurse #4 and Nurse #5 education files failed to include any demonstrated competencies necessary to provide the level and types of care needed for the resident population as required per the facility assessment. Review of the education files failed to include recognizing and reporting wound deterioration, evaluation, measurements, and hands on clinical competency evaluations. The education files indicated Nurse #7, Nurse #4 and Nurse #5 did not have the necessary skills to properly evaluate Resident #20's unstageable DTI that deteriorated to a Stage 4 pressure injury. During an interview on 9/9/24 at 9:21 A.M., the Consulting Nurse said staff should report skin conditions and document findings as well as report new or worsening skin areas. The Consultant Nurse said all licensed clinical staff should have documented clinical competencies and know how to complete a skin assessment and document findings. The Consulting Nurse said nursing staff should know how to assess a pressure wound and apply treatment orders appropriately including how to do a sterile dressing change and follow appropriate infection control protocol. 2. The facility failed to provide continuation of the pressure injury prevention and care services following the absence of the Director of Nursing and implement an effective system for pressure injury (wounds that occur when the skin and tissue are damaged by prolonged pressure, usually on bony areas like the hips, heels, or elbows) prevention and care per the Facility Assessment Tool. During an interview on 9/4/24 at 8:48 A.M., Project Manager #1 said the DON has been out of the building since last month, the facility has been without a unit manager since last September, and they have been without a supervisor. The Project Manager #1 said he helps around the building with various tasks and worked as the Director of Rehab prior to this role. During an interview on 9/4/24 at 8:51 A.M. Nurse #4 said when she got back from vacation around 8/19/24 the Director of Nursing was already out. Nurse #4 said resident care plans were only updated by the DON. Nurse #4 said if a resident experienced a change, she would notify the Nurse Practitioner. When asked who would be notified in the facility during the DON's absence, Nurse #4 said she would inform the Minimum Data Set (MDS) nurse. During an interview on 9/4/24 at 9:43 A.M., NP #1 said the DON would review wound and other treatment recommendations, and staff would call regarding updates to wounds in the facility but in the absence of the DON she does not have access to any wound recommendations and treatment plans unless staff call her with updates and new orders. During an interview on 9/4/24 at 4:16 P.M., the Administrator said in the absence of the DON the charge nurse is responsible for the clinical decision making in the building. The Administrator said the charge nurse on the [NAME] unit is Nurse #7 and the North Unit is Nurse #5. The Administrator said the charge nurse does rounding on the residents, provides medications, supervises the CNAs (Certified Nursing Assistants), updates care plans, reviews recommendations, puts in new orders, responds to pharmacy recommendations, and reviews admissions. During an interview on 9/5/24 at 9:06 A.M., Nurse #5 said staff contact the Nurse Practitioner (NP) since there is no unit manager or charge nurse available to help and said the former MDS Nurse was available on weekends only but has since left. Nurse #5 said he was never told that he was a charge nurse and that he does not have access to the wound recommendations. and does not have a login. Nurse #5 said he is not sure who is looking at the recommendations in the absence of the DON. During an interview on 9/5/24 at 9:50 A.M., the Consultant Nurse said the Administrator called her two days ago and asked if she could be a contact person for the facility and said she was not aware that the DON had been out of the building and that she is not familiar with this facility. During a follow up interview on 9/5/24 at 10:12 A.M., the Administrator said he is not clinical, had no knowledge of wounds, infections or treatment recommendations not being followed and said he would not be notified unless it's relevant and that information is discussed at QAPI meetings. The Administrator said the facility has been without a Director of Nurses since 8/23/24 and she was responsible for oversight of wounds in the building and has access to the wound treatment recommendations and visit summaries. The Administrator said the facility does not have an assistant director of nurses, infection preventionist, unit managers or supervisors at this time. The Administrator said no outside services were consulted or contracted to provide clinical oversite and that staff nurses were expected to follow up with wound recommendations and update the Nurse Practitioner and Medical Director with concerns. The Administrator said the facility hired a new Minimum Data Set (MDS) Nurse that will be a clinical support person and was scheduled to start this week but was unable to be in the building. The Administrator said there is a covering Director of Nurses at another facility that is available, and staff can call with questions. During an interview on 9/5/24 at 12:25 P.M., the Medical Director said he was notified on 9/4/24 that the DON was out on leave and said he went on vacation on 8/22/24. The Medical Director said he expects the facility to assign someone to cover for the DON because we do not have an assistant director, infection preventionist, or a staff development coordinator, and the new MDS Nurse is not here. The Medical Director said the building must have clinical oversite of areas such as infections, reporting wounds, implementing orders and clinical oversight. The Medical Director said every building must have a DON. The Medical Director said senior members are responsible for clinical oversite and he expects the Administrator to delegate and implement measures to ensure no lapse in clinical oversite. The Medical Director said he expects a tracking system in place, and wound recommendations to be reviewed and implemented. During an interview on 9/6/24 at 11:11 A.M., the MDS Nurse said it is her second day here and she was made aware today that she would be point person for clinical questions. The MDS Nurse said she was told the DON was out sick when she was hired two weeks ago but did not know she was the point of contact for clinical questions and said she is not familiar with the building because she is new.

Based on record review and interview, the facility failed to protect three Residents (#20, #23, #26), from neglect, out of a total sample of 26 residents. Specifically, 1. For Resident #20, the facility neglected to a.) implement wound treatments as recommended by the Consultant Wound Physician resulting in the deterioration of a closed unstageable pressure injury to a Stage 4 pressure injury and b.) failed to follow up on a progress note indicating right hip redness dated 8/28/24, and implement the use of an air mattress. 2. For Resident #23, the facility neglected to implement treatment recommendations by the Wound Consultant Physician for wound care. 3. For Resident #26, the facility neglected to implement the treatments as recommended by the Consultant Wound Physician resulting in treatment being implemented without active physician's orders resulting in undocumented wound treatment being implemented and not implementing the Consultant Wound Physician's treatment orders on a newly identified pressure ulcer to the right hip and trauma area to the right, second toe. It was determined the Immediate Jeopardy began on 7/16/24 and was identified on 9/6/24. The Department of Public Health sent a Notice of Determination of Immediate Jeopardy to the Facility Administrator on 9/6/24, including the Immediate Jeopardy Templates. 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. Review of the facility's policy Pressure Ulcer/Injury Risk Assessment undated, indicated the following: - The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing pressure ulcers/injuries. The risk assessment should be conducted as soon as possible after admission, but no later than eight hours after admission is completed. Repeat the risk assessment weekly for the first four weeks, if there is a significant change in condition, or as often as is required based on the resident's condition. - Conduct a comprehensive skin assessment with every risk assessment. Once inspection of skin is completed document the findings on a facility-approved skin assessment tool. If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin. Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments. The effects of the interventions must be evaluated. 1. Resident #20 was admitted to the facility in June 2024 with diagnoses including Alzheimer's disease, anemia, vitamin D deficiency, overactive bladder and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment, dated 6/23/24, indicated that Resident #20 had severely impaired cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15, and required assistance with activities of daily living. Further review of the MDS indicated that Resident #20 was at risk for developing pressure injuries and indicated the use of a pressure reducing device for chair and pressure reducing device for bed. Review of Resident #20's Braden Scale for Predicting Pressure Injury Risk, dated 6/17/24, indicated a score of 15 indicating the resident is at risk for pressure injury development. On 9/3/24 at 8:58 A.M. and 9/4/24 at 8:05 A.M., the surveyor observed Resident #20 laying in bed with one prevalon boot (Prevalon Heel Protectors help reduce the risk of bedsores by keeping the heel floated, relieving pressure), placed on the right heel. His/her left heel was directly on the mattress and not elevated. There was no air mattress applied to the bed. Review of the facility document titled Skin Only Evaluation (Assessment tool used to evaluate resident's skin for any abnormalities, including the presence of any open areas or lesions) dated 7/3/24, indicated that Resident #20's skin was intact, no issues noted. Further review of the medical record indicated physician orders were implemented on 7/16/24 which included obtain pedal pulse every shift for wound ulcer and booties while in bed every shift for wound. The medical record failed to indicate any further documentation that a wound was identified on Resident #20, including the assessment, location, size of wound. Review of the facility document titled Skin Only Evaluation dated 7/17/24, indicated that Resident #20 had open lesions of the foot with a Right heel area measuring 2 cm(centimeters) x 2.5cm, with documented granulation, exudate, purulent, thin, thick, opaque, tan/yellow drainage, erythema. Tissue documented as painful and warm. The skin note indicated Right heel area with open wound injury 2cm x 2.5cm. Stage 3. New order: Wash with NS (normal saline). Apply Xeroform every day then cover with dry dressing and wrap as ordered. Booties at Hs (hour of sleep). Review of the medical record indicated Resident #20 was seen by the Consultant Wound Physician, on 7/18/24, and indicated one right heel unstageable DTI (Deep Tissue Injury), closed, surface area 30 cm, length 5 cm, width 6 cm, no depth, intact with purple/maroon discoloration. Treatment plan: Alginate calcium cover with ABD pad and kerlix daily. Off-load wound, float heels in bed. Review of the medical record failed to indicate the facility notified the attending providers of the recommendations from the wound consultant and failed implement the above wound treatment recommendations of the newly identified pressure injury on the right heel until 7/24/24; six days after the wound consultant first saw the Resident. Review of Nurse Practitioner #1's (NP) progress note dated 7/24/24, (nine days after the right heel pressure injury was first identified and six days after the Resident was first seen by the Consultant Wound Physician) indicated the following: Suspected deep tissue injury to right heel. Acute on chronic Right heel due to elevated wbc (white blood cells) with wound odor swelling. I will order Keflex 500mg by mouth for wound infection X 10 days, Probiotic 250 mg capsule twice daily X 15 days. Repeat lab 7/30 for CBC, CMP. continue in house wound team follow up. Review of the medical record indicated orders for Celphalexin 500 mg every 12 hours for infected right heel wound were not implemented until 8/2/24; 10 days after NP #1's note. Review of Resident #20's Skin Only Evaluation, dated 7/24/24, (the same date of NP's assessment and progress note indicating right heel infection) indicated no signs and symptoms of infection. The assessment further indicated wound exudate: purulent thin, thick, opaque, tan/yellow drainage. Peri wound condition: Erythema Dressing saturation moderate 26-75%. Tissue: Painful, warm. Skin note indicated Right heel area with open wound injury 2cm x 2.5cm. Stage 3. New order: Wash with NS. Apply Xeroform every day then cover with dry dressing and wrap as ordered. Booties at Hs. The skin only evaluation dated 7/24/24 indicated a new order for Xeroform dressing every day for the right heel pressure injury, however, this order had already been implemented on 7/17/24 and was inconsistent with the Wound Consultant recommendations for the use of Alginate Calcium on 7/18/24. Review of the Consultant Wound Physician note dated 7/25/24 indicated: undefined, exacerbated, wound is unstageable with necrosis (the death of tissues of the body due to lack of blood flow or oxygen) thick adherent devitalized necrotic tissue 100%. The progress of this wound and context surrounding the progress were considered in greater detail today. Patient not following repositioning or offloading recommendations and counseling provided. Reviewed off-loading surfaces and discussed surfaces care plan. Treatment plan: Apply hydrogel with silver and xeroform gauze cover with ABD pad and kerlix daily. Off-load wound, float heels in bed. Review of the medical record failed to indicate nursing implemented the above wound treatment recommendations until 7/27/24; two days after the recommendation was made. Review of the physician order, dated 7/27/24 through 9/3/24, indicated: right heel full thickness wash with NS, pat dry, apply xeroform gauze then hydrogel with silver change daily then ABD pad wrap with kerlix change daily. Off load wound, float heel in bed one time a day for wound care. Review of the NP's's note dated 7/29/24, indicated the following: Right heel cellulitis. Patient was recently evaluated for new right heel DTI infection and elevated WBC Keflex was added to medication list. Today follow up visit reviewed inhouse wound team visit summary agreed with plan. Review of the Resident #20's Skin Only Evaluation, dated 7/31/24, indicated: skin was warm/dry and indicated a Stage 4 wound to the right heel with copious drainage, no foul odor. The skin only evaluation failed to indicate any measurements or any further assessment of the wound. The medication administration record contained two active physician orders in place for the same right heel wound from 7/31/24 through 9/2/24 as follows: -right heel full thickness unstageable wash with normal saline padded dried apply xerofoam gauze then hydrogel with silver change daily then abd pad wrap with kerlix change daily offload wound float heel in bed one time a day for wound care. Dated (7/27/24-9/3/24). -site unstageable due to necrosis of the right heel full thickness wash with normal saline apply xerofam gauze hydrogel one daily Abd bad [SIC] wrap with kling [NAME] [SIC] daily one time a day for tage [SIC] 4 wound in right heel. Dated (7/31/24-9/3/24). Further review of the MAR (Medication Administration Record) indicated the nursing staff documented both orders as administered to Resident #20's right heel for 34 days. (One order containing hydrogel with silver and one order containing hydrogel only- both being signed off on the same day). Review of the medical record indicated Resident #20 was seen by the Consultant Wound Physician on 8/1/24, and 8/8/24, and indicated Stage 4 pressure wound of the right heel full thickness. Treatment recommendation is: Apply hydrogel with silver and xeroform gauze cover with ABD pad and kerlix daily. Review of NP's note dated 8/5/24, indicated the following: Nursing report poor appetite with poor wound healing. Pt (patient) recently completed antibiotic for right heel cellulitis with good effect. Today follow up visit reviewed inhouse wound team visit summary agreed with plan. Notify provider with acute suspected deep tissue injury. Acute on chronic site unstageable due to necrosis of the right heel full thickness. This documentation was inconsistent as the Resident now has a Stage 4 right heel wound as documented by the Consultant Wound Physician on 8/1/24 and 8/8/24. Review of the medical record indicated Resident #20 was seen by the Consultant Wound Physician on 8/14/24, 8/22/24, and 8/29/24, which indicated granulation, stage 4 pressure injury. Treatment recommendation indicated: Start Alginate calcium once daily cover with ABD pad and kerlix. Off load wound, float heels in bed. Review of the medical records indicated that the Wound Consultant's recommendations for the use of alginate calcium was not implemented until 9/4/24; a total of 22 days since his/her recommendations. Additionally, staff continued to document the administration of the two additional orders for the use of hydrogel with and without silver. During an interview on 9/4/24 at 9:01 A.M. Nurse #5 said Resident #20 has a right heel wound and that measurements are done weekly by the Wound Consultant. Nurse #5 said there is no unit manager or Director of Nurses (DON) currently and he does not have access to the wound recommendations and visit notes. Nurse #5 said the DON is the only one who had access to the wound recommendations and treatments visit notes. During an interview on 9/4/24 at 9:28 A.M Project Manager #1 said the DON is the only person with access to the Consultant Wound Physician visit and recommendation visit notes and that she has been out of the building since 8/22/24. Project Manager #1 said he would need to call the company to get access to the visit notes. During an interview on 9/5/24 at 8:12 A.M., the Consultant Wound Physician said he expects recommendations to be followed, and that Resident #20 should not have duplicate treatment orders for the same wound because hydrogel and hydrogel with silver are two different treatment orders. The Consultant Wound Physician said Hydrogel with silver helps to stop the growth of microorganisms and regular hydrogel does not contain the antimicrobial barrier. The Consultant Wound Physician said Resident #20 requires and air-mattress and prevalon booties to both heels because he/she is at risk for pressure areas and requires turning and repositioning. The Consultant Wound Physician said he has recommended these preventative measures to the nursing staff and clinical management and expects them to be implemented and said Residents who are high risk for pressure ulcers require off-loading interventions. During an interview on 9/5/24 at 12:25 P.M., the Medical Director (MD) said he expects the wound treatment recommendations and orders to be implemented and followed. MD #1 said he expects a tracking system to be in place and reviewed by clinical management to update the plan of care and to track wound progression. MD #1 said he expects senior management to be diligent and implement measures for clinical oversight for all residents. MD #1 said clinical oversight is needed and must have access to the wound treatment recommendations and status of wounds. During an interview on 9/5/24 at 11:56 A.M., the Administrator said he has no knowledge of wounds, infections, or any recommendations not being followed and that he was not aware that Resident #20 had an infected wound that progressed to a Stage 4. The Administrator said the DON should have known orders were not followed and treatment recommendations not implemented correctly and said he would not be notified of wounds unless its relevant and that wounds and infections are discussed only if there are concerns during the quarterly QAPI meeting. The Administrator said nursing staff should have access to the wound recommendations and that orders should be updated. 1b. Resident #20 developed a right hip wound as indicated on a skin check dated 9/11/24. The facility failed to implement the use of an air mattress and failed to follow up on a progress note indicating right hip redness dated 8/28/24. Review of the facility policy titled Bed Safety-Air Mattress-Side Rails undated, indicated but was not limited to the following: - It is the policy of the facility to provide air mattress, with a physician's order, to residents who are bedridden, have limited mobility, are at high risk for pressure sores on the buttocks/hips or who are recovering from a wound. Nursing will follow these procedures: - Obtain a physicians order for an air mattress. - Apply air mattress to residence bed. - Follow manufacturers instructions for use in care of the mattress. - The mattress should be pumped in accordance with their residence weight. - Document all skin assessments. - Maintenance will audit quarterly or as needed to determine proper usage of the air mattress. Review of medical record indicated Resident #20 was being followed weekly by the Wound Consultant Physician as of 7/18/24, for the development of a DTI to the right heel. Further review of the medical record indicated the Wound Consult Physician made recommendations to off load wound, float heels while in bed and the use of pressure relieving boots and an air mattress. Review of the Care Plan's for Resident #20 included but was not limited to the following: - I need heels kept off bed by and prevent direct contact between bony prominences keep heels off load. - Evaluate wound for: Size, Depth, Margins: peri-wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated. 7/25/24 prevalon boot at all times keep elevated at all times keep feet off load feet off load keep elevated and off load. (Dated: 7/26/24). - Booties while in bed (Dated 7/16/24) - ADL Self- Care Performance Deficit, included the following interventions dated 7/10/24, and revised on 8/31/24: - Bed Mobility: I required, 2 staff participation to reposition and turn in bed. I required an Air Mattress d/t (due to) stage 4 ulcer on my heel, and I am at risk for further skin breakdown. - Skin Inspection: I required, SKIN inspection daily. Observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse. - Wound Management due to DTI care plan, initiated on 8/2/24 and last revised 8/31/24: - Provide wound care per treatment order. I require an air mattress. (Dated 8/2/24). On 9/3/24 at 8:58 A.M., 9/4/24 at 8:05 A.M., 9/4/24 at 1:03 P.M., 9/6/24 at 8:05 A.M., and 9/9/24 at 8:00 A.M., the surveyor observed Resident #20 lying in bed on his/her left side with one prevalon boot placed on the right heel. The left heel was directly on the mattress and was not elevated. There was no air mattress applied to the bed. The observations made by the surveyor during the survey revealed that Resident #20's care planned interventions related to the use of prevalon boots to bilateral feet, offloading and the use of an air mattress were not implemented. Review of the physician's orders for Resident #20 indicated the following: - May use prevalon boot every shift for use for skin protection (7/26/24). - May have booties all the time every shift (9/5/24). Further review of the medical record failed to indicate an order was in place for the use of an air mattress. Review of NP's note dated 8/28/24, indicated the following: Nursing requested right hip redness, and in house wound visit with rec (recommendation). Pt (patient) recently completed antibiotic for right heel cellulitis with good effect. Today follow up visit reviewed in house wound team visit summary agreed with plan. Cellulitis right heel suspected DTI. Further review if the medical record failed to indicate Nurse #4 documented the right hip redness to Resident #20 hip, despite being reported to NP. Review of Resident #20's Skin Only Evaluation, dated 9/11/24, (15 days after right hip redness was first documented in NP #1's note) indicated the following: - Pressure Ulcer/ Injury Right Hip, Stage 2 (Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible). -Pressure Ulcer / injury Right Heel, Stage 4 Full thickness tissue loss. Area on right heel, moderate serosanguineous drainage on old dressing, no foul odor, wound measuring 3.8cm x 2.6cmx no depth; wound bed remains red with healthy tissues surrounding the area; skin pink. Wound washed with NS, applied Calcium Alginate, cover with ABD and wrap with Kerlix as ordered. Further review of the medical record indicated Resident #20 was seen by the Consultant Wound Physician on 9/12/24, and indicated the following: - Wound 1 Stage 4 Pressure Right Heel - Wound 2 Unstageable (due to necrosis) of Right Hip Full Thickness - Wound 3 Unstageable DTI of the Right, First Toe Undetermined Thickness - Wound 4 Unstageable DTI of the Right Ankle Undetermined Thickness The nursing skin assessments completed on 9/11/24 and 9/12/24 indicated Resident #20 developed three additional areas on right 1st toe, right ankle and right hip. Resident #20 had a total of 4 wounds identified, 3 identified as new wounds. During an interview on 9/5/24, at 8:09 A.M., Certified Nurse's Aide (CNA) #7 said that he was not aware that Resident #20 should have his/her legs elevated and that Resident #20 does not have an air-mattress. During an interview on 9/5/24 at 8:11 A.M., Nurse #5 said Residents with skin issues will have an air mattress and heel botties in place to prevent skin breakdown and the plan of care will be updated so staff know what the resident needs for care. During an interview on 9/4/24 at 9:44 A.M., NP said she was notified by staff that Resident #20 had right hip redness and that she did not visualize the resident's skin. NP said she was not aware that Resident #20 did not have an air mattress in place and said Residents at high risk for pressure ulcers should have an air mattress and heel booties in place and she expects staff to notify her of any new skin issues or if wounds are getting worse and that she expects preventative measures to be implemented and followed to prevent the wounds from deteriorating. The NP said she would expect the orders and care plan interventions be followed and said resident #20 requires and air mattress and prevalon booties to both feet. During an interview on 9/5/24 at 8:02 A.M., Nurse #4 said if a new skin area is observed there should be a skin check indicating the new area and the NP or MD will be notified. Nurse #4 said she notified NP #1 that Resident #20 had redness to his/her right hip and that he/she was seen by the wound physician but was not aware of any new orders or follow up because the DON has been out. During an interview on 9/5/24 at 8:09 A.M., the Consultant Wound Physician said Resident #20 requires an air mattress and prevalon boots to both heels because he/she is high risk for wounds and has wounds that need preventative measures. The Consultant Wound Physician said wound recommendations have not been implemented on admission and said he expects recommendations and preventative measures to be followed. The Consultant Wound Physician said Resident #20 is high risk for more pressure areas and prevalon booties, air-mattress and elevation of the legs at all times are needed and should have been implanted because he/she is dependent on staff and can't turn and reposition without staff assistance. During an interview and observation on 9/16/24 at 7:47 A.M., the surveyor along with Nurse #8, The MDS Nurse, and Nurse #6 observed Resident #20 during a wound dressing change. Nurse #8 said Resident #20 has wounds to his/her right hip, right heel, and right toe. Nurse #6 said the resident does not have any other skin areas and that a skin check was completed, and these new areas were identified. The surveyor asked Nurse #8 and the Nurse #6 to turn and reposition the Resident to look observe the Residents skin. The Resident was repositioned and the surveyor asked Nurse #8 to open the brief covering the left hip, observed was intact pink/maroon skin with a localized area of non-blanchable erythema. The Nurse #6 said the area is a pressure area on his/her left hip bone in the same location as the pressure area to the right hip bone. Upon further skin inspection, Resident #20 was observed to have an open skin area to the left ankle, with pink and red drainage. Nurse #6 said the area to the left ankle is a Stage 2 wound that should have a dressing in place due to drainage. During an interview on 9/16/24 at 8:05 A.M., the Nurse #6 said the open wound is a Stage 2 and the area on the left hip bone is pressure that needs to be reported and documented. Nurse #6 said staff should have reported and documented any new areas observed when providing care and during any skin checks or dressing changes. 43846 2. Resident #23 was admitted to the facility in January 2013 with diagnoses that included traumatic brain injury, hemiplegia and hemiparesis and major depressive disorder. Review of Resident #23's most recent Minimum Data Set (MDS) assessment, dated 8/15/24, indicated a Brief Interview for Mental Status (BIMS) score of 5 out of a possible 15 indicating he/she has severe cognitive impairment. Further review of the MDS indicated that the Resident is at risk for developing pressure ulcers. Review of Resident #23's Braden Scale for Predicting Pressure Ulcer Risk, dated 2/21/24, indicated the Resident scored 12 indicating he/she is at high risk for developing pressure ulcers. On 9/3/24 at 8:10 A.M., the surveyor observed Resident #23 in bed with his/her heels directly on the mattress, no dressing was observed to be on the Resident's left heel. Resident #23 said his/her heels hurt. On 9/3/24 at 12:14 P.M., the surveyor observed Resident #23 in the dining room without socks on wearing sneakers on both feet. Review of Resident #23's wound doctor evaluation and management summary, dated 8/22/24 and 8/29/24, indicated the Resident has a stage two pressure wound of the left lateral heel with partial thickness, measured 2.5 cm by 2.5 cm. Further review of the wound summary indicated the wound dressing treatment plan: apply calcium alginate once a day cover with ABD (large wound dressing) pad and then gauze roll daily. Off-load wound and float heels in bed. The summary further indicated the Resident's plan of care was discussed with nursing staff member. Review of Resident #23's skin evaluation, dated 8/23/24, indicated seen by wound md (medical doctor) new order for wash with normal saline pat dry apply calcium alginate cover with ABD pad and kerles [sic] until healed. Review of Resident #23's physician orders failed to indicate that a treatment was put in place for his/her stage two pressure ulcer of the left heel. On 9/5/24 at 7:39 A.M., the surveyor with Certified Nurse Aide (CNA) #1 observed the Resident's heels, the surveyor observed a round wound with a dark center on the Resident's left heel. No dressing was observed to be on the left heel wound. CNA #1 said his/her wound has been there for a few weeks and she cannot remember seeing a dressing on the Resident's left heel. Resident #23 was observed in bed with his/her heels directly on the mattress the Resident said his/her heels hurt. Review of Resident #23's wound doctor evaluation and management summary dated 9/5/24, indicated stage two pressure wound to the left lateral heel treatment plan: skin prep apply twice daily. Off-load wound, float heels in bed. The summary further indicated the Resident's plan of care was discussed with nursing staff member and patient. Review of Resident #23's physician orders failed to indicate that a treatment was implemented for his/her stage two pressure ulcer of the left heel. On 9/6/24 at 7:54 A.M., the surveyor observed Resident #23 in bed with his/her heels directly on the mattress. During an interview on 9/3/24 at 2:17 P.M., Nurse #7 said Resident #23 does not have wound orders in place for his/her left heel wound. Nurse #7 said the Wound Physician comes to the facility weekly and provides new treatment orders for wound care. During an interview on 9/5/24 at 7:46 A.M., the Consultant Wound Physician said Resident #23 has a pressure ulcer on his/her left heel. The Consultant Wound Physician said he expects for nursing to call and relay his recommendations to the provider at the facility. The Consultant Wound Physician said Resident #23 should be wearing a boot on his/her left foot and not sneakers without socks as that would cause more pressure. The Consultant Wound Physician said he would expect there to be treatment and interventions put into place for Resident #23's left heel wound. During an interview on 9/5/24 at 12:04 P.M., Medical Doctor (MD) #1 said she was not told by nursing staff that the resident had a wound nor did they tell her they had wound recommendations. MD #1 said she would expect to be called when the Resident was found with a new pressure area. 45984 3. Resident #26 was admitted to the facility in July 2024 with diagnoses including pressure ulcer of left buttock stage 2, pressure ulcer of right upper back, non-pressure chronic ulcer of skin of other sites and dementia. Review of Resident #26's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 4 out of a possible 15 indicating severe cognitive impairment. Further review of Resident #26's MDS under section M indicated that the Resident is at risk for developing pressure ulcers and has one or more unhealed pressure ulcers/injuries. Review of Resident #26's physician's orders indicated the following: - Dated 8/1/24: weekly skin assessment on Thursday 7-3 shift one time a day every Thu (Thursday). - Dated 7/30/24: May be seen by the wound doctor. - Dated 7/31/24: wash left wound heel with normal saline apply Santyl Ointment cover with 4x4 then wrap with kling as of 7/19/24. Review of Resident #26's assessment titled Admit/Readmit Screener, dated 7/18/24 under Section C. Skin Integrity indicated the following: - Site: left mid-back, Type: Pressure, Length: 3, Width: 3, Stage: II - Site: Coccyx, Type: Pressure, Length: 4, Width: 5, Stage: IV - Site: Left Heel, Type: Scar, Length: 4, Width: 4, Stage: IV - Site: Right Heel, Type: Scar, Length: 3, Width: 3, Stage: Unstageable - Site: Ischial Chronic Wound, Type: Pressure, Length: 1, Width: 1, Depth: 2,3, Stage: IV - Details/Comments: Tunneling 7.2 cm (centimeters) nsw aquacel AGrope packing 3x week cover with boder [sic] gauze. Bilateral heel escar apply skin prep daily cover with boarder from dgs (dressings). Review of Resident #26's document titled Braden Scale for Predicting Pressure Ulcer Risk, dated 7/18/24 indicated that the Resident was at a Moderate Risk for developing pressure ulcers. Review of Resident #26's Wound Evaluation & Management Summary developed by the Consultant Wound Physician during his weekly visits with Resident #26 indicated the following: - Dated 8/1/24: -Stage 3 Pressure Wound of the Left Heel, Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 30 days; Hydrogel gel w/silver apply once daily for 30 days. Secondary Dressing(s): ABD pad apply once daily for 30 days; Gauze roll (kerlix) 4.5 apply once daily for 30 days - Wound of left foot, fourth toe, Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 30 days; Hydrogel gel w/silver apply once daily for 30 days. Secondary Dressing(s): Gauze Island w/ bdr (border) apply once daily for 30 days - Dated 8/8/24: -Stage 3 Pressure Wound of the Left Heel, Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 23 days; Hydrogel gel w/silver apply once daily for 23 days. Secondary Dressing(s): ABD pad apply once daily for 23 days; Gauze roll (kerlix) 4.5 apply once daily for 23 days - Wound of left foot, fourth toe, Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 23 days; Hydrogel gel w/silver apply once daily for 23 days. Secondary Dressing(s): Gauze Island w/ bdr apply once daily for 23 days. - Non-Pressure Wound of left buttock, Primary Dressing(s): Alginate Calcium apply once daily for 23 days. Secondary Dressing(s): Gauze Island w/ bdr apply once daily for 23 days. - Non-pressure wound of the right, second toe, Dressing Treatment Plan - Primary Dressing(s): Skin prep once daily for 30 days. - Non-pressure wound of the right shin, etiology: Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 30 days; Hydrogel gel w/silver apply once daily for 30 days. Secondary Dressing(s): Gauze Island w/ bdr apply once daily for 30 days - Dated 8/14/24: -Stage 3 Pressure Wound of the Left

Based on observations, interviews, and record review, the facility failed to provide care and treatment to prevent the development and worsening of pressure injury's (wounds that occur when the skin and tissue are damaged by prolonged pressure, usually on bony areas like the coccyx, hips, heels, or elbows) for three Residents (#20, #23, and #26) out of a total sample of 26 residents. Specifically, 1a. For Resident #20 the facility failed to implement treatments and physician orders recommended by the Consultant Wound Physician resulting in the wound requiring antibiotic therapy resulting in the deterioration of an unstageable pressure wound progressing to a Stage 4 pressure injury. 1b. For Resident #20 the facility failed to implement the use of an air mattress and failed to follow up on a progress note indicating right hip redness dated 8/28/24 resulting in the development of a right hip wound as indicated on a skin check dated 9/11/24. 2. For Resident #23, the facility failed to implement treatment recommendations by the Wound Consultant Physician for wound care. 3. For Resident #26, the facility failed to implement treatment recommendations by the Wound Consultant Physician for wound care. Findings include: According to the National Pressure Injury Advisory Panel, a Stage 4 Pressure Injury is defined as a full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in injury. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and /or tunneling often occur. Depth varies by anatomical location. Review of the facility's policy Pressure Injury/Injury Risk Assessment, undated, indicated the following: - The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing pressure injurys/injuries. The risk assessment should be conducted as soon as possible after admission, but no later than eight hours after admission is completed. Repeat the risk assessment weekly for the first four weeks, if there is a significant change in condition, or as often as is required based on the resident's condition. - Conduct a comprehensive skin assessment with every risk assessment. Once inspection of skin is completed document the findings on a facility-approved skin assessment tool. If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin. Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments. The effects of the interventions must be evaluated. - The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate. - Contact the Medical Director for updated orders. Contact the Wound Doctor for a scheduled visit. Documentation in medical record addressing (MD) notification if new skin alteration noted with change of plan of care, if indicated. Notify attending (MD) if new skin alteration noted. Review of the facility policy, titled Decubitus Prevention, revised 2/4/21, indicated but was not limited to the following: It is the policy of the facility to prevent the formation of pressure sores and other skin breakdowns. - All residents shall be assessed upon admission, quarterly and periodically for the risk of skin breakdown by a licensed staff member. This assessment shall be done using the Norton Scale and by careful review of history, health conditions, environment, medications, nutrition, as well as visualization of the resident's body. The Norton Score will indicate a resident's risk for skin breakdown. To avoid breakdowns a preventative program shall be instituted by the Unit Manager which will include a repositioning schedule, a consult with the Dietician, notification of the attending physician, and use of pressure relieving devices. Skin care treatments will be documented by the licensed nurse and the appropriate areas of the residence chart. All residents at risk for skin breakdown will be care planned quarterly and as needed skin barrier will be used on all residents. 1a. Resident #20 was admitted to the facility in June 2024 with diagnoses including Alzheimer's disease, anemia, vitamin D deficiency, overactive bladder and cognitive communication deficit. Review of Resident #20's Minimum Data Set (MDS) assessment, dated 6/23/24, indicated that Resident #20 had severely impaired cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15, and required assistance with activities of daily living. Further review of the MDS indicated Resident #20 was at risk for developing pressure injuries and indicated the use of a pressure reducing device for chair and pressure reducing device for bed. Review of Resident #20's Braden Scale for Predicting Pressure Injury Risk, dated 6/17/24, indicated a score of 15 indicating the Resident is at risk for developing pressure injuries. On 9/3/24 at 8:58 A.M., the surveyor observed Resident #20 laying in bed with one prevalon boot (Prevalon Heel Protectors help reduce the risk of bedsores by keeping the heel floated, relieving pressure), placed on his/her right heel. The left heel was observed to be directly on the mattress and was not elevated. There was no air mattress applied to the bed. On 9/4/24 at 8:05 A.M., the surveyor observed Resident #20 laying in bed with one prevalon boot placed on the right heel. The left heel was observed to be directly on the mattress and was not elevated. There was no air mattress applied to the bed. Review of the facility document titled Skin Only Evaluation (Assessment tool used to evaluate resident's skin for any abnormalities, including the presence of any open areas or lesions) dated 7/3/24, indicated Resident #20's skin was intact, no issues noted. Further review of Resident #20's medical record indicated physician orders were put into place on 7/16/24 which included obtain pedal pulse every shift for wound ulcer and booties while in bed every shift for wound. The medical record failed to indicate any further documentation that a wound was identified on Resident #20, including the assessment, location, size of wound. During an interview on 9/5/24 at 8:06 A.M., Nurse #5 said treatment orders are entered if staff identify new skin areas until the resident can be seen by the wound doctor. Nurse #5 said the Nurse Practitioner (NP) or MD (medical doctor) will review the orders in the recommendations book and if the provider wants to change them they will let the nurses know. Nurse #5 said if a new skin area is observed there should be a skin check when it was first found. Review of the facility document titled Skin Only Evaluation dated 7/17/24, indicated that Resident #20 had open lesions of the foot with a right heel area measuring 2 cm (centimeters) x 2.5 cm, with documented granulation, exudate, purulent, thin, thick, opaque, tan/yellow drainage, erythema. Tissue documented as painful and warm. The skin note indicated Right heel area with open wound injury 2 cm x 2.5 cm. Stage 3. New order: Wash with NS (normal saline). Apply Xeroform every day then cover with dry dressing and wrap as ordered. Booties at Hs (hour of sleep). Further review of Resident #20's medical record indicated the above order was implemented to the Stage 3 on the right heel on 7/17/24, however the medical record failed to indicate the provider was notified of the newly identified pressure injury on the right heel. During an interview on 9/5/24 at 8:09 A.M., Nurse #4 said the right heel area was identified on Resident #20 on 7/16/24 and an order was entered, however the skin assessment was not completed until 7/17/24. Nurse #4 said nursing staff put in orders until the Resident is seen by the wound doctor. Review of the medical record indicated Resident #20 was seen by the Consultant Wound Physician, dated 7/18/24, and indicated one right heel unstageable DTI (Deep Tissue Injury), closed, surface area 30 cm, length 5 cm, width 6 cm, no depth, intact with purple/maroon discoloration. Treatment plan: Alginate calcium cover with ABD pad and kerlix daily. Off-load wound, float heels in bed. Review of the medical record failed to indicate the facility notified the attending providers of the recommendations from the wound consultant and failed implement the above wound treatment recommendations of the newly identified pressure injury on the right heel until 7/24/24, 6 days after the wound consultant first saw the Resident. Review of Nurse Practitioner (NP) progress note dated 7/24/24, (9 days after the right heel pressure injury was first identified and 6 days after the Resident was first seen by the wound consultant MD) indicated the following: Suspected deep tissue injury to right heel. Acute on chronic Right heel due to elevated wbc (white blood cells) with wound odor swelling. I will order Keflex (antibiotic) 500 mg by mouth for wound infection X (times) 10 days, Probiotic 250 mg capsule twice daily X 15 days. continue in house wound team follow up. Further review of the medical record indicated on 7/24/24 the Resident started Keflex 500 mg every 12 hours for infected wound in the right heel until 8/2/24. During an interview on 9/5/24 at 8:12 A.M., the Consultant Wound Physician said Resident #20 had an unstageable DTI that required antibiotics for an infection and that wound treatments must be followed to promote healing. The Consultant Wound Physician said Alginate Calcium sterile primary dressing for wounds with moderate to heavy exudate /drainage, while maintaining a moist wound environment), is used to promote healing and he expects orders to be followed. Review of Resident #20's Skin Only Evaluation, dated 7/24/24, (the same date of the NP's assessment and progress note indicating right heel infection) indicated no signs and symptoms of infection. The assessment further indicated wound exudate: purulent thin, thick, opaque, tan/yellow drainage. Peri wound condition: Erythema Dressing saturation moderate 26-75%. Tissue: Painful, warm. Skin note indicated Right heel area with open wound injury 2 cm x 2.5 cm. Stage 3. New order: Wash with NS. Apply Xeroform every day then cover with dry dressing and wrap as ordered. Booties at Hs (hour of sleep). The skin only evaluation dated 7/24/24, indicated a new order for Xeroform dressing every day for the right heel pressure injury however this order had already been implemented on 7/17/24 and was inconsistent with the wound consultant recommendations on 7/18/24. During an interview on 9/4/24 at 9:42 A.M., NP #1 said staff must document skin checks accurately at the time of the assessment and when skin issues are identified, they must document findings and notify providers for any new treatment or medication orders before implementing them. Review of the medical record indicated Resident #20 was seen by the Consultant Wound Physician, dated 7/25/24, and indicated undefined, exacerbated, wound is unstageable with necrosis, thick adherent devitalized necrotic tissues 100%. Expanded evaluation performed: The progress of this wound and the context surrounding the progress were considered in greater detail today. Patient not following repositioning or off-loading recommendations and counseling provided. Reviewed off-loading surfaces and discussed surfaces care plan. Treatment plan: Apply hydrogel with silver and xeroform gauze cover with ABD pad and kerlix daily. Off-load wound, float heels in bed. Review of the medical record failed to indicate nursing implemented the above wound treatment recommendations until 7/27/24, 2 days after the recommendation was made. During an interview on 9/5/24 at 8:10 A.M., the Consultant Wound Physician said Resident #20 requires and air-mattress and prevalon booties to both heels because he/she is at risk for pressure areas and requires turning and repositioning. The Consultant Wound Physician said an air mattress should have been in place when Resident #20 first developed the skin issue to the right heel and, he has recommended these preventative measures to the nursing staff as well as clinical management and expects them to be implemented and said Residents who are high risk for pressure ulcers require off-loading interventions. Review of Resident #20's physician order, dated 7/27/24 through 9/3/24, indicated right heel full thickness wash with NS, pat dry, apply xeroform gauze then hydrogel with silver change daily then ABD pad wrap with kerlix change daily. Off load wound, float heel in bed one time a day for wound care. Review of NP #1's note dated 7/29/24, indicated the following: Right heel cellulitis. Patient was recently evaluated for new right heel DTI infection and elevated WBC Keflex was added to medication list. Today follow up visit reviewed inhouse wound team visit summary agreed with plan. During an interview on 9/4/24 at 9:42 A.M., NP said she does not have access to wound recommendation or visit notes and she relies on the nursing staff to notify her of any new or worsening skin issues. The NP said she may have been told by staff that Resident #20 had cellulitis and that is why she documented it in her note. Review of the Resident #20's Skin Only Evaluation, dated 7/31/24, indicated, skin was warm/dry and indicated a Stage 4 wound to the right heel with copious drainage, no foul odor. The skin only evaluation failed to indicate any measurements or any further assessment of the wound. Further review of the medical record indicated a second wound treatment order was implemented on 7/31/24 to the right heel. Which indicated site unstageable due to necrosis of the right heel full thickness, wash with normal saline, apply Xeroform gauze, hydrogel once daily ABD pad wrap with Kling change daily. The medication administration record contained two active physician orders in place for the same right heel wound from 7/31/24 through 9/2/24 as follows: - right heel full thickness unstageable wash with normal saline padded dried apply xerofoam gauze then hydrogel with silver change daily then abd pad wrap with kerlix change daily offload wound float heel in bed one time a day for wound care. Dated (7/27/24-9/3/24). - site unstageable due to necrosis of the right heel full thickness wash with normal saline apply xerofam gauze hydrogel one daily Abd bad [SIC] wrap with kling [NAME] [SIC] daily one time a day for tage [SIC] 4 wound in right heel. Dated (7/31/24-9/3/24). Further review of Resident #20's MAR (Medication Administration Record) indicated the nursing staff documented both orders as administered to Resident #20's right heel for 34 days. (One order containing hydrogel with silver and one order containing hydrogel only- both being signed off on the same day). During an interview on 9/5/24 at 8:12 A.M., Nurse #4 said she did not realize that there were two treatments and that she does not recall documenting two different orders even though they are singed off and said most residents receive hydrogel for wounds. Review of the medical record indicated Resident #20 was seen by the Consultant Wound Physician on 8/1/24, and 8/8/24, and indicated Stage 4 pressure wound of the right heel full thickness. Treatment recommendation is: Apply hydrogel with silver and xeroform gauze cover with ABD pad and kerlix daily. Review of the medical record indicated Resident #20 continued to have two active physician orders in place for the same right heel wound. During an interview on 9/5/24 at 8:12 A.M., the Consultant Wound Physician said he expects recommendations to be followed, and that Resident #20 should not have duplicate treatment orders for the same wound because hydrogel and hydrogel with silver are two different treatment orders. The Consultant Wound Physician said Hydrogel with silver helps to stop the growth of microorganisms and regular hydrogel does not contain the antimicrobial barrier. During an interview on 9/5/24 at 12:25 P.M., the Medical Director (MD) said he is not always made aware of orders that are entered under his name and that staff have been told not to enter orders unless they speak directly with providers. The MD said he was not aware that Resident #20 had a pressure area that developed an infection and deteriorated to a Stage 4 wound and he was not aware that Resident #20 was receiving two different treatment orders for the same wound and said he expects nursing staff to follow recommendations by the wound physician and discontinue orders that are no longer recommended by the wound physician. Review of NP's note dated 8/5/24, indicated the following: - Nursing report poor appetite with poor wound healing. Pt (patient) recently completed antibiotic for right heel cellulitis with good effect. Today follow up visit reviewed inhouse wound team visit summary agreed with plan. Notify provider with acute suspected deep tissue injury. Acute on chronic site unstageable due to necrosis of the right heel full thickness. This documentation was inconsistent as the Resident now has a Stage 4 right heel wound as documented by the Consultant Wound Physician on 8/1/24 and 8/8/24. During an interview on 9/4/24 at 9:46 A.M., the NP said she does not have access to wound recommendation or visit notes and she relies on the nursing staff to notify her of any new or worsening skin issues. NP said she was not aware that Resident #20 had a wound that deteriorated to a Stage 4 wound on 8/1/24 and is not aware of recommendations unless she is notified by nursing. Review of the medical record indicated Resident #20 was seen by the Consultant Wound Physician on 8/14/24, 8/22/24, and 8/29/24, which indicated granulation, stage 4 pressure injury. Treatment recommendation indicated: Start Alginate calcium once daily cover with ABD pad and kerlix. Off load wound, float heels in bed. Review of the medical record failed to indicate nursing implemented the above wound treatment recommendations until 9/4/24 (a total of 22 days from the wound consultants first recommendation on 8/14/24) and continued to document the administration of the two previous orders for hydro gel with and without silver. During an interview on 9/5/24 at 12:25 P.M., the Medical Director said he expects the wound treatment recommendations and orders to be implemented and followed. The Medical Director said he expects a tracking system to be in place and reviewed by clinical management to update the plan of care and to track wound progression. The Medical Director said he expects senior management to be diligent and implement measures for clinical oversight for all residents. The Medical Director said clinical oversight is needed and must have access to the wound treatment recommendations and status of wounds. During an interview on 9/4/24 at 9:01 A.M. Nurse #5 said Resident #20 has a right heel wound and that measurements are done weekly by the Wound Consultant. Nurse #5 said there is no unit manager or Director of Nurses (DON) currently and he does not have access to the wound recommendations and visit notes. Nurse #5 said the DON is the only one who had access the wound recommendations and treatments visit notes. During an interview on 9/4/24 at 9:28 A.M., Project Manager #1 said the DON is the only person with access to the Consultant Wound Physician visit and recommendation visit notes and that she has been out of the building since 8/22/24. Project Manager #1 said he would need to call the company to get access to the visit notes. During an interview on 9/5/24 at 11:56 A.M., the Administrator said he has no knowledge of wounds, infections, or any recommendations not being followed and that he was not aware that Resident #20 had an infected wound that progressed to a Stage 4. The Administrator said the DON should have known orders were not followed and treatment recommendations not implemented correctly and said he would not be notified of wounds unless its relevant and that wounds and infections are discussed only if there are concerns during the quarterly QAPI meeting. The Administrator said nursing staff should have access to the wound recommendations and that orders should be updated. 1b. Resident #20 developed a right hip wound as indicated on a skin check dated 9/11/24. The facility failed to implement the use of an air mattress and failed to follow up on a progress note indicating right hip redness dated 8/28/24. Review of the facility policy titled Bed Safety-Air Mattress-Side Rails undated, indicated but was not limited to the following: - It is the policy of the facility to provide air mattress, with a physician's order, to residents who are bedridden, have limited mobility, are at high risk for pressure sores on the buttocks/hips or who are recovering from a wound. Nursing will follow these procedures: - Obtain a physicians order for an air mattress. - Apply air mattress to residence bed. - Follow manufacturers instructions for use in care of the mattress. - The mattress should be pumped in accordance with their residence weight. - Document all skin assessments. - Maintenance will audit quarterly or as needed to determine proper usage of the air mattress. Review of medical record indicated Resident #20 was being followed weekly by the Wound Consultant Physician as of 7/18/24, for the development of a DTI to the right heel. Further review of the medical record indicated the Wound Consult Physician made recommendations to off load wound, float heels while in bed and the use of a pressure relieving boots and an air mattress. Review of the Care Plan's for Resident #20 included but was not limited to the following: - Venous/Stasis Ulcer (abnormal vein function) r/t (related to) CHF (Congestive Heart Failure- heart doesn't pump blood as well as it should), included the following interventions, dated 7/16/24: - I need heels kept off bed by and prevent direct contact between bony prominences keep heels off load. - Evaluate wound for: Size, Depth, Margins: peri-wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated. 7/25/24 prevalon boot at all times keep elevated at all times keep feet off load feet off load keep elevated and off load. (Dated: 7/26/24). - Booties while in bed (Dated 7/16/24). - ADL Self- Care Performance Deficit, included the following interventions dated 7/10/24, and revised on 8/31/24: - Bed Mobility: I required, 2 staff participation to reposition and turn in bed. I required an Air Mattress d/t (due to) stage 4 ulcer on my heel, and I am at risk for further skin breakdown. - Skin Inspection: I required, SKIN inspection daily. Observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse. - Wound Management due to DTI care plan, initiated on 8/2/24 and last revised 8/31/24: - Provide wound care per treatment order. I require an air mattress (Dated 8/2/24). On 9/3/24 at 8:58 A.M., the surveyor observed Resident #20 laying in bed on his/her left side with one prevalon boot placed on the right heel. The left heel was directly on the mattress and was not elevated. There was no air mattress applied to the bed. On 9/4/24 at 8:05 A.M., the surveyor observed Resident #20 laying in bed on his/her left side with one prevalon boot placed on the right heel. The left heel was directly on the mattress and was not elevated. There was no air mattress applied to the bed. On 9/4/24 at 1:03 P.M., the surveyor observed Resident #20 laying in bed on his/her left side with one prevalon boot placed on the right heel. The left heel was directly on the mattress and was not elevated. There was no air mattress applied to the bed. On 9/6/24 at 8:05 A.M., the surveyor observed Resident #20 laying in bed on his/her left side with one prevalon boot placed on the right heel. The left heel was directly on the mattress and was not elevated. There was no air mattress applied to the bed. On 9/9/24 at 8:00 A.M., the surveyor observed Resident #20 laying in bed on his/her left side with one prevalon boot placed on the right heel. The left heel was directly on the mattress and was not elevated. There was no air mattress applied to the bed. The observations made during survey failed to indicate Resident #20 had care planned interventions in place including the use of prevalon boots to bilateral feet, keeping bilateral heels elevated and the use of an air mattress. Review of the physician's orders for Resident #20 indicated the following: - May use prevalon boot every shift for use for skin protection (7/26/24). - May have booties all the time every shift (9/5/24). Further review of the medical record failed to indicate an order was in place for the use of an air mattress. Review of NP #1's note dated 8/28/24, indicated the following: Nursing requested right hip redness, and in house wound visit with rec (recommendation). Pt (patient) recently completed antibiotic for right heel cellulitis with good effect. Today follow up visit reviewed in house wound team visit summary agreed with plan. Cellulitis right heel suspected DTI. During an interview on 9/4/24 at 9:44 A.M., NP said she was notified by staff that Resident #20 had right hip redness and that she did not visualize the resident's skin. The NP said she was not aware that Resident #20 did not have an air mattress in place and said Residents at high risk for pressure ulcers should have an air mattress and heel booties in place and she expects staff to notify her of any new skin issues or if wounds are getting worse and that she expects preventative measures to be implemented and followed to prevent the wounds from deteriorating. The NP said she would expect the orders and care plan interventions be followed and said resident #20 requires and air mattress and prevalon booties to both feet. During an interview on 9/5/24 at 8:02 A.M., Nurse #4 said if a new skin area is observed there should be a skin check indicating the new area and the NP or MD will be notified. Nurse #4 said she notified NP that Resident #20 had redness to his/her right hip and that he/she was seen by the wound physician but was not aware of any new orders or follow up because the DON has been out. During an interview on 9/5/24, at 8:07 A.M., Certified Nurse Aide (CNA) #7 said that he was not aware that Resident #20 should have his/her legs elevated and that Resident #20 does not have an air-mattress. During an interview on 9/5/24 at 8:11 A.M., Nurse #5 said Residents with skin issues will have an air mattress and heel botties in place to prevent skin breakdown and the plan of care will be updated so staff know what the resident needs for care. Further review if the medical record failed to indicate Nurse #4 documented the right hip redness to Resident #20 hip, despite being reported to NP. During an interview on 9/5/24 at 8:09 A.M., the Consultant Wound Physician said Resident #20 requires an air mattress and prevalon boots to both heels because he/she is high risk for wounds and has wounds that need preventative measures. The Consultant Wound Physician said wound recommendations have not been implemented on admission and said he expects recommendations and preventative measures to be followed. The Consultant Wound Physician said Resident #20 is high risk for more pressure areas and prevalon booties, air-mattress and elevation of the legs at all times are needed and should have been implanted because he/she is dependent on staff and can't turn and reposition without staff assistance. Review of Resident #20's Skin Only Evaluation, dated 9/11/24, (15 days after right hip redness was first identified) indicated the following: - Pressure Ulcer/ Injury Right Hip, Stage 2 (Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible). - Pressure Ulcer / injury Right Heel, Stage 4 Full thickness tissue loss. - Area on right heel, moderate serosanguineous drainage on old dressing, no foul odor, wound measuring 3.8 cm x 2.6 cm x no depth; wound bed remains red with healthy tissues surrounding the area; skin pink. Wound washed with NS, applied Calcium Alginate, cover with ABD and wrap with Kerlix as ordered. Further review of the medical record indicated Resident #20 was seen by the Consultant Wound Physician on 9/12/24, and indicated the following: *Wound 1 -Stage 4 Pressure Right Heel (Existing Wound) Treatment Plan- Alginate Calcium apply once daily for 27 days. ABD pad apply once daily for 27 days. Gauze roll Kerlix 4.5cm apply once daily for 27 days. *Wound 2 Unstageable (due to necrosis) of Right Hip Full Thickness - New Wound Pressure, unstageable necrosis, 6x4 depth not measurable due to presence of nonviable tissue and necrosis. 100% thick adherent devitalized necrotic tissue. Treatment Plan- Xeroform gauze once daily for 30 days. Hydrogel with silver apply once daily for 30 days. Gauze island with bdr apply once daily for 30 days. Offload wound, reposition per facility protocol, low air loss mattress. *Wound 3 - Unstageable DTI of the Right, First Toe Undetermined Thickness New Wound. Pressure, unstageable DTI with intact skin 1x1.2 depth not measurable. Skin intact with purple/maroon discoloration. Treatment Plan: Skin prep apply twice daily for 30 days. Offload wound, reposition per facility protocol. *Wound 4 Unstageable DTI of the Right Ankle Undetermined Thickness New Wound Pressure, unstageable DTI with intact skin 1x1 depth not measurable. Skin intact with purple/maroon discoloration. Treatment Plan- Skin prep apply twice daily for 30 days. Off load wound reposition per facility protocol. The skin assessments completed on 9/11/24 and 9/12/24 indicated Resident #20 developed three additional areas on right 1st toe, right ankle and right hip. Resident #20 had a total of 4 wounds identified, 3 identified as new wounds within 2 days. During an interview and observation on 9/16/24 at 7:47 A.M., the surveyor along with Nurse #8, The MDS Nurse, and Nurse #6 observed Resident #20 during a wound dressing change. Nurse #8 said Resident #20 has wounds to his/her right hip, right heel, and right toe. Nurse #6 said the Resident does not have any other skin areas and that a skin check was completed, and these new areas were identified. The surveyor asked Nurse #8 and Nurse #6 to turn and reposition the Resident to look observe the Residents skin. The Resident was repositioned and the surveyor asked Nurse #8 to open the brief covering the left hip, observed was intact pink/maroon skin with a localized area of non-blanchable erythema. Nurse #6 said the area is a pressure area on his/her left hip bone in the same location as the pressure area to the right hip bone. Upon further skin inspection, Resident #20 was observed to have an open skin area to the left ankle, with pink and red drainage. Nurse #6 said the area to the left ankle is a Stage 2 wound that should have a dressing in place due to drainage. During an interview on 9/16/24 at 8:05 A.M., Nurse #6 said the open wound on Resident #20 is a Stage 2 and the area on the left hip bone is pressure that needs to be reported and documented. Nurse #6 said staff should have reported and documented any new areas observed when providing care and during any skin checks or dressing changes. 43846 2. Resident #23 was admitted to the facility in January 2013 with diagnoses that included traumatic brain injury, hemiplegia and hemiparesis and major depressive disorder. Review of Resident #23's most recent Minimum Data Set (MDS) assessment, dated 8/15/24, indicated a Brief Interview for Mental Status (BIMS) score of 5 out of a possible 15 indicating he/she has severe cognitive impairment. Further review of the MDS indicated that the Resident is at risk for developing

Based on observations, record reviews and interviews the facility failed to ensure the physician/nurse practitioner were notified of the recommendations made by the consulting wound physician for two Residents (#23, #26) out of four applicable residents and failed to notify the physician/nurse practitioner of a change in condition for two Residents (#6, #7). Specifically, 1. For Resident #23, the facility failed to notify the provider of the consultant wound physician's treatment recommendations resulting in the wound treatments not being implemented. 2. For Resident #26, the facility failed to notify the provider of the consultant wound physician's treatment recommendations resulting in the wound treatments not being implemented. 3a. For Resident #6, the facility failed to notify the provider that Resident #6 was not provided oxygen therapy resulting in the resident's oxygen saturation to drop to 77% resulting in respiratory distress. 3b. For Resident #6, the facility failed to notify the provider of significant weight loss resulting in a 12% weight loss in one month. 4. For Resident #7, the facility failed to report to the Nurse Practitioner (NP) or physician that Resident #7's right lower extremity's skin was open, discolored, and weeping. Further, the facility failed to report the Resident's left lower extremity had scabs and swelling. Findings include: Review of the facility's policy entitled, 'Change in a Resident's Condition or Status or Injury of Unknown Origin' not dated indicated the following: The facility shall promptly notify the resident, his or Attending Physician and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation 1. The nurse will notify the resident's attending Physician or physician on call when there has been a(an): a. accident or incident involving the resident; b. discover of injuries of unknown source; c. adverse reaction to medication; d. significant change in the resident's physical/emotional condition; e. need to alter the resident's medical treatment significantly. f. refusal of treatment or medication two (2) or more consecutive times); g. need to transfer the resident to the hospital/treatment center; h. discharge without proper medical authority; and/or; i. specific instructions to notify the Physician of changes in the resident's condition. 8. the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 1. Resident #23 was admitted to the facility in January 2013 with diagnoses that included traumatic brain injury, hemiplegia and hemiparesis and major depressive disorder. Review of Resident #23's most recent Minimum Data Set (MDS) assessment, dated 8/15/24, indicated he/she scored a 5 out of a possible 15 on the Brief Interview for Mental status exam indicating he/she has severe cognitive impairment. Further review of the MDS indicated he/she is at risk for developing pressure ulcers. Review of Resident #23's wound doctor evaluation and management summary dated 8/22/24 and 8/29/24, indicated the Resident has a stage two pressure wound of the left lateral heel with partial thickness. Further review of the wound summary indicated the wound dressing treatment plan: apply calcium alginate once a day cover with ABD (large wound dressing) pad and then gauze roll daily. Off-load wound and float heels in bed. The summary further indicated the Resident's plan of care was discussed with a nursing staff member. Review of Resident #23's skin evaluation, dated 8/23/24, indicated seen by wound md (Medical Doctor) new order for wash with normal saline pat dry apply calcium alginate cover with ABD pad and kerles [sic] until healed. Review of Resident #23's wound doctor evaluation and management summary dated 9/5/24, indicated stage two pressure wound to the left lateral heel treatment plan: skin prep apply twice daily. Off-load wound, float heels in bed. The summary further indicated the Resident's plan of care was discussed with a nursing staff member and patient. Review of Resident #23's physician orders failed to indicate that a treatment was put in place for his/her stage two pressure ulcer of the left heel. During an interview on 9/3/24 at 2:17 P.M., Nurse #7 said Resident #23 does not have left heel wound orders in place. During an interview on 9/5/24 at 7:46 A.M., the Consultant Wound Physician said Resident #23 has a pressure ulcer on his/her left heel. The Wound Consultant said he expects for nursing to call and relay his recommendations to the provider at the facility. The Wound Consultant said he would expect their to be treatment and interventions put into place Resident #23's left heel wound. During an interview on 9/5/24 at 12:04 P.M., Medical Doctor (MD) #1 said she was not told by nursing staff that the resident had a wound nor did they tell her they had wound doctor recommendations. MD #1 said she would expect to be called by nursing staff when the Resident was found with a new pressure area and to be told the wound doctor recommendations but was not. 45984 2. Resident #26 was admitted to the facility in July 2024 with diagnoses including pressure ulcer of left buttock stage 2, pressure ulcer of right upper back, non-pressure chronic ulcer of skin of other sites and dementia. Review of Resident #26's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated that the Resident had a Brief Interview for Mental Status score of 4 out of a possible 15 indicating severe cognitive impairment. Further review of Resident #26's MDS under section M indicated that the Resident is at risk for developing pressure ulcers and has one or more unhealed pressure ulcers/injuries. Review of Resident #26's physician's orders indicated the following: - Dated 8/1/24: weekly skin assessment on Thursday 7-3 (7:00 A.M. through 3:00 P.M.) shift one time a day every Thu (Thursday). - Dated 7/30/24: May be seen by the wound doctor. Review of Resident #26's document titled Braden Scale for Predicting Pressure Ulcer Risk, dated 7/18/24 indicated that the Resident was at a Moderate Risk for developing pressure ulcers. Review of Resident #26's assessment titled Admit/Readmit Screener, dated 7/18/24 under Section C. Skin Integrity indicated the following: - Site: left mid-back, Type: Pressure, Length: 3, Width: 3, Stage: II - Site: Coccyx, Type: Pressure, Length: 4, Width: 5, Stage: IV - Site: Left Heel, Type: Scar, Length: 4, Width: 4, Stage: IV - Site: Right Heel, Type: Scar, Length: 3, Width: 3, Stage: Unstageable - Site: Ischial Chronic Wound, Type: Pressure, Length: 1, Width: 1, Depth: 2,3, Stage: IV - Details/Comments: Tunneling 7.2 cm (centimeters) nsw (normal saline wash) aquacel AG (silver- helps with preventing infection in the wound) rope packing 3x (three times) a week cover with boder [sic] gauze. Bilateral heel escar apply skin prep daily cover with boarder from dgs (dressings). Review of Resident #26's Wound Evaluation & Management Summary developed by the wound doctor during his weekly visits with Resident #26 indicated the following: - Dated 8/1/24: -Stage 3 Pressure Wound of the Left Heel, wound size (LxWxD): 2x2x0.2 cm, surface area: 4.00 cm, exudate: light serous, slough: 50%, granulation tissue: 50%. Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 30 days; Hydrogel gel w/silver apply once daily for 30 days. Secondary Dressing(s): ABD pad apply once daily for 30 days; Gauze roll (kerlix) 4.5 apply once daily for 30 days. - Wound of left foot, fourth toe, etiology: infection, wound size: 1x1xnot measurable, surface area: 1.00 cm, exudate: light purulent, thick adherent devitalized necrotic tissue: 40%, granulation tissue: 60%. Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 30 days; Hydrogel gel w/silver (with silver) apply once daily for 30 days. Secondary Dressing(s): Gauze Island w/ bdr (border) apply once daily for 30 days. - Dated 8/8/24: -Stage 3 Pressure Wound of the Left Heel, wound size (LxWxD): 3.2x3x0.2 cm, surface area: 9.60 cm, exudate: light serous, slough: 50%, granulation tissue: 50%. Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 23 days; Hydrogel gel w/silver apply once daily for 23 days. Secondary Dressing(s): ABD pad apply once daily for 23 days; Gauze roll (kerlix) 4.5 apply once daily for 23 days. - Wound of left foot, fourth toe, etiology: infection, wound size: 1x1xnot measurable, surface area: 1.00 cm, exudate: light serous, thick adherent devitalized necrotic tissue: 40%, granulation tissue: 60%. Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 23 days; Hydrogel gel w/silver apply once daily for 23 days. Secondary Dressing(s): Gauze Island w/ bdr apply once daily for 23 days. - Non-Pressure Wound of left buttock, etiology: trauma/injury, wound size: 0.5x1x0.2, surface area: 0.50 cm, exudate: moderate serous, granulation tissue: 100%, abnormal granulation present within the wound margins. Dressing Treatment Plan - Primary Dressing(s): Alginate Calcium apply once daily for 23 days. Secondary Dressing(s): Gauze Island w/ bdr apply once daily for 23 days. - Non-pressure wound of the right, second toe, etiology: trauma/injury, wound size: 1x1xnot measurable, surface area: 1.00 cm, blister: blood filled. Dressing Treatment Plan - Primary Dressing(s): Skin prep once daily for 30 days. - Non-pressure wound of the right shin, etiology: trauma/injury, wound size: 1.2x0.5x0.1, surface area: 0.60 cm, exudate: none, granulation tissue: 100%. Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 30 days; Hydrogel gel w/silver apply once daily for 30 days. Secondary Dressing(s): Gauze Island w/ bdr apply once daily for 30 days. - Dated 8/14/24: -Stage 3 Pressure Wound of the Left Heel, wound size (LxWxD): 3x2.2x0.2 cm, surface area: 6.60 cm, exudate: light serous, slough: 20%, granulation tissue: 80%. Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 17 days; Hydrogel gel w/silver apply once daily for 17 days. Secondary Dressing(s): ABD pad apply once daily for 17 days; Gauze roll (kerlix) 4.5 apply once daily for 17 days. - Wound of left foot, fourth toe, etiology: infection, wound size: 0.3x0.5xnot measurable, surface area: 0.15 cm, exudate: none, thick adherent devitalized necrotic tissue: 100%. Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 17 days; Hydrogel gel w/silver apply once daily for 17 days. Secondary Dressing(s): Gauze Island w/ bdr apply once daily for 17 days. - Non-Pressure Wound of left buttock, etiology: trauma/injury, wound size: 0.5x0.5x0.2, surface area: 0.25 cm, exudate: moderate serous, granulation tissue: 100%, abnormal granulation present within the wound margins. Dressing Treatment Plan - Primary Dressing(s): Alginate Calcium apply once daily for 17 days. Secondary Dressing(s): Gauze Island w/ bdr apply once daily for 17 days. - Non-Pressure Wound of the Right, Second Toe, etiology: trauma/injury, wound size: 0.5x0.3x0.1, surface area: 0.15 cm, exudate: light serous, granulation tissue: 100%, abnormal granulation present within the wound margins. Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 17 days; Hydrogel gel w/silver once daily for 17 days. Secondary Dressing(s): Gauze island w/bdr apply once daily for 17 days. - Non-pressure wound of the right shin, etiology: trauma/injury, wound size: 1.2x0.5x0.1, surface area: 0.60 cm, exudate: none, granulation tissue: 100%. Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 24 days; Hydrogel gel w/silver apply once daily for 24 days. Secondary Dressing(s): Gauze Island w/ bdr apply once daily for 24 days. - Dated 8/22/24: -Stage 3 Pressure Wound of the Left Heel, wound size (LxWxD): 1.6x1.2x0.2 cm, surface area: 1.92 cm, exudate: light serous, granulation tissue: 100%. Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 9 days; Hydrogel gel w/silver apply once daily for 9 days. Secondary Dressing(s): ABD pad apply once daily for 9 days; Gauze roll (kerlix) 4.5 apply once daily for 9 days. - Wound of left foot, fourth toe, etiology: infection, wound size: 0.3x0.3xnot measurable, surface area: 0.09 cm, exudate: none, thick adherent devitalized necrotic tissue: 100%. Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 9 days; Hydrogel gel w/silver apply once daily for 9 days. Secondary Dressing(s): Gauze Island w/ bdr apply once daily for 9 days. - Non-Pressure Wound of left buttock, etiology: trauma/injury, wound size: 0.3x0.3x0.2, surface area: 0.09 cm, exudate: moderate serous, granulation tissue: 100%, abnormal granulation present within the wound margins. Dressing Treatment Plan - Primary Dressing(s): Alginate Calcium apply once daily for 9 days. Secondary Dressing(s): Gauze Island w/ bdr apply once daily for 9 days. - Non-Pressure Wound of the Right, Second Toe, etiology: trauma/injury, wound size: 0.3x0.3xnot measurable, surface area: 0.09 cm, exudate: none, thick adherent devitalized necrotic tissue: 100%. Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 9 days; Hydrogel gel w/silver once daily for 9 days. Secondary Dressing(s): Gauze island w/bdr apply once daily for 9 days. - Dated: 8/29/24: -Stage 3 Pressure Wound of the Left Heel, wound size (LxWxD): 3x3x0.2 cm, surface area: 9.0 cm, cluster wound: open ulceration area of 4.50 cm exudate: light serous, granulation tissue: 50%. Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 30 days; Hydrogel gel w/silver apply once daily for 30 days. Secondary Dressing(s): ABD pad apply once daily for 30 days; Gauze roll (kerlix) 4.5 apply once daily for 30 days. - Wound of left foot, fourth toe, etiology: infection, wound size: 0.2x0.2x0.1, surface area: 0.04 cm, exudate: light serous, slough: 100%. Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 30 days; Hydrogel gel w/silver apply once daily for 30 days. Secondary Dressing(s): Gauze Island w/ bdr apply once daily for 30 days. - Non-Pressure Wound of left buttock, etiology: trauma/injury, wound size: 0.3x0.3x0.2, surface area: 0.09 cm, exudate: moderate serous, granulation tissue: 100%, abnormal granulation present within the wound margins. Dressing Treatment Plan - Primary Dressing(s): Alginate Calcium apply once daily for 30 days. Secondary Dressing(s): Gauze Island w/ bdr apply once daily for 30 days. - Non-Pressure Wound of the Right, Second Toe, etiology: trauma/injury, wound size: 0.3x0.3xnot measurable, surface area: 0.09 cm, exudate: light serous, thick adherent devitalized necrotic tissue: 100%. Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 30 days; Hydrogel gel w/silver once daily for 30 days. Secondary Dressing(s): Gauze island w/bdr apply once daily for 30 days. - Dated 9/5/24: - Non-Pressure Wound of left buttock, etiology: trauma/injury, wound size: 0.3x0.3x0.2, surface area: 0.09 cm, exudate: moderate serous, granulation tissue: 100%, abnormal granulation present within the wound margins. Dressing Treatment Plan - Primary Dressing(s): Alginate Calcium apply once daily for 23 days. Secondary Dressing(s): Gauze Island w/ bdr apply once daily for 23 days. - Non-Pressure Wound of the Right, Second Toe, etiology: trauma/injury, wound size: 0.3x0.3x not measurable, surface area: 0.09 cm, cluster wound: open ulceration area of 0.05 cm exudate: light serous, thick adherent devitalized necrotic tissue: 100%. Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 23 days; Hydrogel gel w/silver once daily for 23 days. Secondary Dressing(s): Gauze island w/bdr apply once daily for 23 days. - Non-Pressure wound of the right knee, etiology: trauma/injury, wound size: 2x1.4x not measurable, surface area: 2.80 cm, thick adherent devitalized necrotic tissue: 100%. Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 30 days; TRIPLE FOLDED. Secondary Dressing(s): Gauze island w/bdr apply once daily for 30 days. - Non-Pressure wound of the left knee, etiology: trauma/injury, wound size: 1x1.3x0.1, surface area: 1.30 cm, exudate: none, granulation tissue: 100%. Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 30 days; Triple Folded. Secondary Dressing(s): Gauze island w/bdr apply once daily for 30 days. Review of Resident #26's active, discontinued and completed physician's orders in the facility's electronic medical record failed to indicate that the facility implemented or updated any of Resident #26's treatment orders as recommended by the consultant wound physician. During an interview on 9/3/24 at 1:11 P.M., Nurse #6 and the surveyor reviewed Resident #26's active physician's orders. Nurse #6 said there are no orders for the Resident's buttock or back wound. When asked how are the nurses supposed to know what treatment Resident #26 should be getting she said we would have no way of knowing without an order. During an observation on 9/3/24 at 1:20 P.M., the surveyor observed Resident #26's wounds with Nurse #6, the buttock and back wounds were treated and covered with gauze despite no active treatment orders. During an interview on 9/4/24 at 6:41 A.M., Nurse #2 said when the wound doctor puts in a treatment recommendation it first gets sent to the Director of Nursing (DON) and then the Nurse Practitioner (NP) will review the treatment orders and approve them and will then tell nursing staff to put the orders in the electronic medical system. Nurse #2 said he only completed the active order for Resident #26's heel treatment and did not treat the other wounds because there was no order in. Nurse #2 said he would not do a treatment without an order because he would not know how to treat the area. During an interview on 9/4/24 at 8:48 A.M., Nurse #5 said he treated Resident #26's buttock and back wounds with a gauze pad despite no active order, he said he used his best nursing judgement so the wounds do not get worse. Nurse #5 said he does rounds with the wound doctor each week and the wound doctor will let the DON know his treatment recommendations and the NP will approve them and put the orders in. Nurse #5 said he is not sure how the ordering process works with the DON absence from the facility. During an interview on 9/4/24 at 10:02 A.M., the NP said any new treatment orders will get flagged in a binder for her to approve and then the nurses will put the orders in the electronic medical record. The NP said a nurse rounds with the wound doctor and then that nurse should reach out to her with any new wound recommendations so she can review and approve them. The NP continued to say if the wound doctor were to make a recommendation she would approve it. When asked if she was aware of any of the recommendations the wound doctor has made for Resident #26, she said she was unaware and staff never brought them to her for review. During an interview on 9/5/24 at 8:11 A.M., the Consultant Wound Physician said he comes in weekly and he would expect all of his recommendations to be followed by nursing. He continued to say since the DON's absence, none of his wound treatment orders have not been communicated. The Wound Doctor continued to say that he communicates with Nurse #5 about his wound treatments, and he would expect them to be implemented. The Wound Doctor said his treatments clearly have not been implemented and there is a problem with transcribing his recommendations. The Wound Doctor then said Resident #26's active order for Santyl Ointment for his/her left heel is an old order and the Resident should not be treated with that. During an interview on 9/5/24 at 12:44 P.M., the facility's Medical Director said he would expect all the wound doctor's treatment recommendations to be followed and put into the electronic medical system so all staff know what they are so they can be completed as ordered. 48671 3a. Resident #6 was admitted to the facility in March 2022 with diagnoses including chronic obstructive pulmonary disease (COPD), acute respiratory failure, dysphagia, and anxiety. Review of Resident #6 most recent Minimum Data Set assessment (MDS) dated [DATE], indicated that the Resident had a Brief Interview for Mental Status score of 15 out of a possible 15 indicating an intact cognitive status. Further review of the MDS indicated that the Resident requires assistance with activities of daily living and receives respiratory care. On 9/3/24 at 10:01 A.M., Resident #6 was observed sitting in a wheelchair in the dining room. A portable oxygen concentrator was observed hanging off the back of the wheelchair, oxygen tubing attached, the nasal cannula was placed around the Residents head but was not placed in his/her nostrils. Staff could be seen walking around the dining room and one staff member remained seated in the doorway. The Resident's back was to the staff member. Review of Resident #6's physician's orders dated 11/10/23 indicated the following: - O2 (Oxygen) at 2L (liters/minute) via nasal cannula continuously to maintain O2 saturation greater than 90% every shift for interstitial lung disease. Review of Resident #6's care plan for oxygen therapy dated 7/6/22 indicated the following intervention: - Monitory oxygen sat (saturation) every shift. - If the resident is allowed to eat, oxygen still must be given to the resident but in a different manner (e.g., changing from mask to nasal cannula). Return resident to usual oxygen delivery method after the meal. - Monitor for s/sx (signs and symptoms) of respiratory distress and report to MD (medical doctor) PRN (as needed): Respirations, [NAME] oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color. - OXYGEN SETTINGS: I have, O2 via nasal prongs/mask @ 2L continuously as needed. For sob (shortness of breath) respiratory distress. Review of Resident #6's care plan for Emphysema (lung condition causing shortness of breath)/COPD (Chronic Obstructive Pulmonary Disease)/asthma (airway disease) dated 7/6/22 indicated the following intervention: - Give oxygen therapy as ordered by the physician - Monitor for difficulty breathing (Dyspnea) on exertion. Remind resident not to push beyond endurance. During an observation and interview on 9/3/24 at 10:04 A.M., Nurse #1 said Resident #6 is on 2L of oxygen and wears a nasal cannula. Nurse #1 said he/she is using a portable concentrator in the dining room. Resident #6 was observed sitting in the wheelchair in the dining room, with his/her back facing another staff member sitting at the doorway to the dining room. A portable oxygen concentrator was observed hanging off the back of the wheelchair, the dial was turned to 2.5L of oxygen, oxygen tubing was attached, the nasal cannula was placed around the Residents head, but was not placed in his/her nostrils. The surveyor continued to make the following observations in the dining room with Nurse #1 present: - At 10:06 A.M., Nurse #1 observed the Resident with the surveyor. The surveyor observed Resident #6 to be uncomfortable and could visualize the use of accessory muscles, as he/she was leaning forward with his/her mouth open. The surveyor observed the portable oxygen tank on empty as indicated by the arrow pointing to the red indicator section labeled 0 zero, the dial was set at 2.5L. Nurse #1 said He/she is doing good and proceeded to walk out of the dining room. The surveyor stopped Nurse #1 from leaving the dining room and asked Nurse #1 to visualize Resident #6's nasal cannula. - At 10:08 A.M., Nurse #1 checked the nasal cannula by observing it on the Resident's face and then checked the concentrator level and said, Yes she is getting oxygen. Nurse #1 proceeded to walk away from the Resident and the surveyor had to stop Nurse #1 for a second time, from leaving the dining room. The surveyor asked Nurse #1 to again visualize the Resident, and Nurse #1 looked over the Resident and said he was going to get a pulse oximeter machine because he/she is having difficulty breathing. The surveyor asked Nurse #1 to visualize the nasal canula placement and Nurse #1 said he was sorry and said Resident #6 is not wearing the nasal canula correctly, and he adjusted the nasal cannula and placed the prongs into the Residents nose. Nurse #1 visualized the oxygen gauge at 0 zero. Nurse #1 told the surveyor that the machine is not empty and that he will check for air bubbles. Nurse #1 obtained a small plastic cup of water, removed the nasal canula from Resident #6's nostrils and submerged the nasal canula prongs into the water. Nurse #1 said there should be bubbles coming out of the nasal cannula prongs, to indicate the oxygen tank is not empty. Nurse #1 then observed the oxygen concentrator set at level at 2.5L and said the Resident should be on 2 liters. Nurse #1 and the surveyor observed very few bubbles and Nurse #1 said the tank is empty and said he/she is not getting any oxygen. - At 10: 15 A.M., Nurse #1 then exited the dining room leaving Resident #6 without oxygen, to obtain a vital sign machine. Nurse #1 placed the pulse oximeter on to the Residents finger and was unable to obtain a reading. Nurse #1 said the machine was not working or turning on and exited the dining room again to obtain a portable pulse oximeter. - At 10:16 A.M., Resident #6 said I'm having a little bit of trouble but not too bad as Nurse #1 placed the pulse oximeter on the Residents finger. Resident #6's oxygen saturation level was 77%. Nurse #1 said he/she is having difficulty breathing and gasping for air. I need to get him/her on oxygen and left the dining room. Resident #6 continued to remain off oxygen. - At 10:18 A.M Nurse #1 said I will be back I'm going to check something to confirm orders are for 2 liters and get an oxygen tank. - At 10:20 A.M., another staff member wheeled Resident #6 to his/ her room and Nurse #1 carried a new oxygen tank and oxygen tubing into the Residents room. Nurse #1 attached a new nasal cannula to a concentrator that was already set up in Resident #6's room. Resident #6 continued to have difficulty breathing and his/her pulse oxygenation level was 76 %. Nurse #1 said I need to get shorter tubing and the surveyor had to tell Nurse #1 that the he must place the nasal cannula onto the Resident's nose as it was on the Residents bed. The Nurse placed the nasal canula prongs appropriately into the Resident's nose. Nurse #1 said he/she is in respiratory distress and the oxygen is not working and proceeded to recheck the Residents oxygenation status, and its was 78%. - At 10:24 A.M., Nurse #1 said his/her color does not look good and he/she is gasping. Nurse #1 proceeded to unhook the oxygen tubing from the concentrator in the bedroom and connected it to the new portable tank he brought into the room. Resident #6 continued to have labored breathing with the use of accessory muscles as Nurse #1 re-checked the oxygenation levels. Resident #6 continued to receive 2L oxygen via nasal canula and his/her oxygen saturation level went to 80%, 86%, and 93% and remained at 93% during the remainder of the observation. Nurse #1 said the Resident is doing much better and his/her color has improved, and he/she is no longer in respiratory distress. Nurse #1 said the Resident needed oxygen and should not have been using an empty tank and said the nasal canula needs to be applied to the nose correctly. During an interview on 9/3/24 at 10:25 A.M., Nurse #1 said he will check for respiratory treatment orders and call the doctor to report what happened. During an interview on 9/4/24 at 9:47 A.M., Nurse Practitioner (NP) said she was not aware that Resident #6 had respiratory distress yesterday and that she was not notified by the nurse or anyone in the building. During an interview on 9/5/24 at 12:26 P.M., the Medical Director said staff should have notified the NP right away and said he was notified this morning by the NP. The MD said a process needs to be in place in the absence of the Director of Nursing to make sure systems are followed. During an interview on 9/5/24 at 1:35 P.M., the Administrator said he was not aware that the NP or MD was not notified regarding the issue with Resident #6 and said he was told that the Nurse notified the NP. The Administrator said staff should notify the NP because the facility does not have a DON. During an interview on 9/9/24 at 9:56 A.M., the Consulting Nurse said staff must report clinical concerns and medical issues to the NP or MD right away in order to care for the Residents appropriately. 3b. Review of the facility policy titled Weight Management, revised and dated 10/21/19, indicated the following: - In the event where a resident shows a significant weight loss of 3 lbs (pounds) or more or the weight appears inaccurate, the resident shall be weighed again as soon as possible. If the weight loss is verified the following are completed: - Weights are recorded weekly and taken by a Certified Nursing Assistants. - Charge nurses are responsible to ensure that weights are documented appropriately. - Nursing will report weight loss to the Dietitian within 24 hours. - Report weight loss to the physician during physicians next visit. - If weight loss is verified, the Dietitian will seek the appropriate care plan adjustments to include snacks and supplements in order to curtail the weight loss. - Weight losses and gains are addressed quarterly at the QA (Quality Assurance) meeting. - Weights are performed weekly unless weights have been discharged . - If the weight loss is over the CMS guidelines, then a full assessment will be required and performed by the Dietitian. - When nutritional interventions such as supplements and recommended for weight loss, the orders for those interventions will be written within 7 days. Review of the facility policy titled Nutrition (Impaired)/Unplanned Weight Loss- Clinical Protocol, undated, indicated the following: Assessment and Recognition - The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparison over time. - The physician will consider whether any assessment including additional diagnostic testing is indicated to help clarify the severity or consequences of the weight loss and or impaired nutrition. - The staff will report to the physician significant weight gains or losses or food intake. - The physician will review for medical causes of weight gain, anorexia and weight loss before ordering interventions. - For individuals with recent or rapid weight gain or loss (for example a more than a pound a day), the staff and will review for possible fluid and electrolyte imbalance as a cause. - The physician and staff will monitor nutritional status, an individual's response to interventions and possible complications of such interventions. Resident #6 was admitted to the facility in March 2022 with diagnoses including dysphagia, vitamin B12 deficiency anemia, vitamin D deficiency, and dementia. Review of Resident #6 most recent Minimum Data Set (MDS) assessment dated [DATE], indicated that the Resident had a Brief Interview for Mental Status score of 15 out of a possible 15 indicating no cognitive impairment. Further review of the MDS indicated that the Resident is at risk for malnutrition and requires a mechanically altered diet. Review of Resident #6's weight log indicated the following: - 6/7/24: 91.2 lbs. - 6/14/2

Based on observation, record review, and interview, the facility failed to address the nutritional status in a timely manner for one Resident (#6) out of a total sample of 26 residents. Specifically, the facility failed to address a significant weight loss in a timely manner for Resident #6, resulting in a 12% weight loss in one month. Findings include: Review of the facility policy titled Weight Management, revised and dated 10/21/19, indicated the following: - In the event where a resident shows a significant weight loss of 3 lbs (pounds) or more or the weight appears inaccurate, the resident shall be weighed again as soon as possible. If the weight loss is verified the following are completed: - Weights are recorded weekly and taken by a Certified Nursing Assistants. - Charge nurses are responsible to ensure that weights are documented appropriately. - Nursing will report weight loss to the Dietitian within 24 hours. - Report weight loss to the physician during physicians next visit. - If weight loss is verified, the Dietitian will seek the appropriate care plan adjustments to include snacks and supplements in order to curtail the weight loss. - Weight losses and gains are addressed quarterly at the QA (Quality Assurance) meeting. - Weights are performed weekly unless weights have been discharged . - If the weight loss is over the CMS guidelines, then a full assessment will be required and performed by the Dietitian. - When nutritional interventions such as supplements and recommended for weight loss, the orders for those interventions will be written within 7 days. Review of the facility policy titled Nutrition (Impaired)/Unplanned Weight Loss- Clinical Protocol, undated, indicated the following: Assessment and Recognition - The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparison over time. -The staff and physician will define the individual's current nutritional status (weight, food/fluid intake, and pertinent laboratory values) and identify individuals with anorexia, weight loss or gain, and significant risk for impaired nutrition. - The physician will consider whether any assessment including additional diagnostic testing is indicated to help clarify the severity or consequences of the weight loss and or impaired nutrition. - The staff will report to the physician significant weight gains or losses or food intake. - The physician will review for medical causes of weight gain, anorexia and weight loss before ordering interventions. - For individuals with recent or rapid weight gain or loss (for example a more than a pound a day), the staff and will review for possible fluid and electrolyte imbalance as a cause. - The physician and staff will monitor nutritional status, an individual's response to interventions and possible complications of such interventions. -The physician will help identify medical conditions (cancer, cardiac or renal disease, depression, dental problems, etc.) and medications that may be causing weight gain or loss or increasing risk for either gaining or losing weight. -The physician will review carefully, and rule out medical causes of, oral or swallowing problems before authorizing other consults or interventions to modify diet consistency. -Sometimes, an extensive workup may not be appropriate or knowing the cause may not change the interventions, Nevertheless, a systematic review for cause based on an individuals history, comorbidities, risk factors, etc. may be appropriate even if an extensive workups is not. -The physician and staff will collaborate to address any ethical issues related to weight and nutrition (for example, possible use of artificial nutrition and hydration) related to severe or prolonged impairment of nutritional status and weight loss. Resident #6 was admitted to the facility in March 2022 with diagnoses including dysphagia, vitamin B12 deficiency anemia, vitamin D deficiency, and dementia. Review of Resident #6 most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated that the Resident had a Brief Interview for Mental Status score of 15 out of a possible 15 indicating no cognitive impairment. Further review of the MDS indicated that the Resident is at risk for malnutrition and requires a mechanically altered diet. On 9/3/24 at 8:55 A.M., Resident #6 was observed sitting in a wheelchair in the dining room. The breakfast tray was on the table and the Resident was not eating breakfast. Staff were present in the dining room. On 9/4/24 at 12:45 P.M., Resident #6 was observed sitting in a wheelchair in the dining room. The lunch tray was on the table and the Resident was not eating lunch. Staff were present in the dining room. Review of Resident #6's medical record indicated the following documented weights: - 6/7/24: 91.2 lbs. - 6/14/24: 91.5 lbs. - 6/18/24: 91.6 lbs. - 6/26/24: 90.4 lbs. - 7/2/24: 91.2 lbs. - 7/16/24: 83.6 lbs. (Weight was struck-out - see Nutrition note dated 7/29/24) - 7/23/24: 92.8 lbs. - 8/11/24: 84.4 lbs. - 8/25/24 81.2 lbs. From 7/23/24 to 8/25/24, Resident #6 had a significant weight loss of 12.50%. Further review of the medical record failed to indicate that Resident #6 had any additional weights obtained after 8/25/24. Review of Resident #6's medical record failed to indicate a physician's order to obtain weights. Review of Resident #6's PCM (Protein Calorie Malnutrition) care plan, dated and revised 1/8/24 indicated the following: Resident meets criteria for PCM, has a potential for weight loss and further alteration in nutritional status as related to: -Chewing and swallowing difficulty, need for altered diet texture and thickened liquids. - Low body weight, potential for Inadequate oral intake, On planned weight gain program. Interventions Include: - Monitor weights as ordered. - Provide nutritional supplements as ordered - Provide diet as ordered- Puree diet, NTL (Nectar Thick Liquids) - Monitor intake of meal consumed Review of Resident #6's comprehensive Nutrition assessment dated [DATE] indicated the following: - Diet Regular Pureed diet w/NTL (with nectar thick liquids) d/t hx (due to history) of dysphagia and high risk for aspiration. - PO (oral) intake is fair, which is his/her baseline. Resident is thin/underweight w/ BMI (with Body Mass Index) of 17.8, continues to meet criteria for Protein Calorie Malnutrition d/t (due to) severe subcutaneous fat depletion and severe muscle mass depletion. - Weight has remained stable +/- 3% over the past 6 months. On Remeron- which may aid appetite, diet is supplemented w/ 4 oz House Supplement BID (twice daily) and magic cup BID for added kcals (calories) and protein to assist w/ (with) prevention of weight loss. - Continue 4oz (ounces) house supplement and magic cup BID supervision and setup w/meals. Monitor weights, intake, diet tolerance. New Recommendations/Goals: Puree diet/w/NTL continue 4oz house supplement and magic cup BID. Supervision and setup w/meals. Monitor weights, intake, diet tolerance. Review of Resident #6's active physician's orders, indicted the following: - Magic Cup at lunch and dinner two times a day for unplanned weight loss. Dated 5/14/24. - House diet, Pureed texture, Nectar consistency. Dated 1/8/24 - House Supplement every day shift 4 oz at Breakfast and Lunch. Dated 11/14/23. Review of Resident #6's progress notes indicated the following: Nurse Practitioner (NP) progress note dated 7/15/24, indicated: Severe protein-calorie malnutrition. Chronic condition due to his/her progressive dementia his/her appetite has decrease, poor meal and fluid intake. Nutrition progress note dated 7/19/24, indicated: Weight: 83.6 (7/16), significant unplanned weight loss of 8.7% x 1 month, 7.9% x 3 months, and 11.2% x 6 months. Will ask nursing to obtain a reweight to verify weight loss. (Resident) remains on a Pureed diet w/ NTL d/t hx (due to history) of dysphagia and high risk for aspiration. On Remeron - which may aid appetite, diet is supplemented w/ 4 oz House Supplement BID and magic cup BID. Continue to follow. Review of the medical record indicated a reweight was not done until 7/23/24, 4 days after the dietitian requested a re-weight. MD progress note dated 7/25/24: (Resident) has lost about 9 pounds in the last 6 months. (Resident) says he/she does not like the food here sometimes. Unintentional weight loss, Add supplements, Dietary consult. Review of the active orders failed to indicate an order was entered for a dietary consult. Further review of the medical record failed to indicate any new orders were implemented to address the unintentional weight loss since 7/23/24. Review of the Dietician's Nutrition progress note dated 7/29/24, indicated: Wt (weight): 92.8(7/23/24), struck out wt of 83.6 (7/16/24), as it was an erroneous weight. No significant wt loss. Further review of Resident #6's documented weights indicated the Resident did not have another weight documented until 8/11/14, 19 days later. Review of the Nutrition Note dated 8/19/24, indicated: Wt: 84.4 (8/11/24), request a re-weight to verify wt loss. Review of the medical record indicated there was no re-weight until 8/25/24, 6 days after the dietitian requested a re-weight on 8/19/24. Review of the Nutrition Progress note dated 8/30/24, indicated: Wt: 81.2 (8/25), underweight w/ hx (history) of Protein Calorie Malnutrition and significant unplanned wt loss of 11.6# (12.5%) x 1 month. Lost 3.2# x 2 weeks. Recently came off SLP (Speech Language Pathology Therapy), remains on Pureed diet w/ NTL. On Remeron, house supplements BID, and magic cup BID. Will notify NP of wt loss as well. Review of the medical record failed to indicate the NP or MD was notified of the unintentional weight loss. Resident #6's documented significant weight loss was not addressed, and no additional weights were obtained after 8/25/24. The facility was unable to provide documentation of weights obtained after 8/25/24 throughout the survey. During an interview on 9/4/24 at 9:42 A.M., NP #1 said Resident #6 is receiving supplements for a history of weight loss but she was not aware of the significant weight loss of 12% and was not aware that Resident #6 did not have weekly weights completed. The NP said Resident #6 should have had an order for weekly weights and said daily weights should have been implemented to monitor for a decline in status. The NP said she expects reweights to be completed within 24 hours and to be reviewed by the nutritionist. The NP said Resident # 6 is on a weekly weight schedule and there is a binder located on the unit for staff to write weights in. Review of the weight binder indicated the following for Resident #6: -July 2024 weekly weights Week 1 dated 7/2/24 91.2lbs. Week 2 83.6lbs. Week 3 92.8lbs. Week 4 85.6lbs. -August 2024 weekly weights Week 1 dated 8/4/24 85.4lbs. Week 2 84.4lb.s Week 3 81.8lbs. Week 4 82.6lbs. The facility did not have any documented September 2024 weights in the binder durng the time of the survey. Review of Resident #6's Resident Care Kardex (a form indicating care needs), indicated the following: Weight frequency weekly, 7am -3pm, scale-chair. During an interview on 9/4/24 at 12:58 A.M., Resident #6 said his/her lunch was alright and said he/she doesn't care for the food but eats it anyway because he/she had weight loss. The surveyor asked the Resident about the weight loss, but he/she said, I don't know what they do. During an interview on 9/5/24 at 12:25 P.M., the Medical Director said he was not aware that Resident #6 had a significant weight loss and said he would expect the facility to obtain re-weights, check orders in place and to document assessments and re-assessments. The MD said Residents are weighed weekly to monitor for weight loss. The MD said the Resident should have been followed closely to monitor weight loss and daily weights should have been implemented and reviewed. The MD said he expects reweights to be completed within 24hours and reported to the Director of Nursing and Nutritionist. During an interview on 9/09/24 at 8:02 A.M., Nurse #6 said weights are obtained and entered into the electronic medical record system by the dietitian or MDS nurse weekly, and if a re-weight is needed the dietitian will notify staff by verbally telling staff or by leaving a note at the nurses desk. Nurse #6 said if the weight is off more than 2-5lbs the provider should be notified. Nurse #6 said Resident #6 has had some weight loss and is followed by the dietitian. Nurse #6 said the Director of Nursing would review the weight but she has not been in the facility for some time and she is not sure who is monitoring them. During an interview on 9/9/24 at 9:49 A.M., the Consulting Nurse said she expects staff to monitor and document weight loss and to notify appropriate staff if weight loss or gain is suspected. The Consulting Nurse said clinical management should be notified and reweights must be done to ensure accuracy and follow-up. She continued to say that the dietitian and providers must be notified, orders need to be followed and care plan interventions should be documented. During an interview on 9/09/24 at 9:51 A.M., the Registered Dietitian (RD) said she reviews weights weekly on Fridays and enters them into the electronic medical record system and if she identifies a discrepancy of more than a few pounds, she will request a re-weight to be completed within 48 hours. The RD said she reviews the re-weights the following week when she returns to the building, and said if there is a weight loss she is not notified because there is no Director of Nursing. The RD is not made aware of the weights because it is written down and not communicated verbally and said there is a delay because no one else monitors the weights if they were completed or of any weight loss. The RD said she struck out the weight on 7/16/24 because she didn't think that much weight loss was possible and it could not be right and said she wanted a reweight but it was not done. The RD said a reweight should have been done to ensure the weight loss was correct. The dietitian said Resident #6 had a significant weight loss in 4 weeks and that she was waiting to hear back from the family because they mentioned hospice services in July. The RD said she was going to obtain another weight this week and that she notified the provider about the weight loss on 8/30/24.

Based on observations, record review and interview, the facility failed to ensure Residents received respiratory care and treatment according to professional standards of practice and in accordance with physician's orders for one Resident (#6) out of a total sample of 26 residents. Specifically, The facility failed to provide consistent oxygen therapy for Resident #6 who required oxygen continuously resulting in the resident's oxygen saturation to drop to 77% resulting in respiratory distress. Findings include: Resident #6 was admitted to the facility in March 2022 with diagnoses including chronic obstructive pulmonary disease (COPD), acute respiratory failure, dysphagia, and anxiety. Review of Resident #6 most recent Minimum Data Set assessment (MDS) dated [DATE], indicated that the Resident had a Brief Interview for Mental Status score of 15 out of a possible 15 indicating an intact cognitive status. Further review of the MDS indicated that the Resident requires assistance with activities of daily living and receives respiratory care. The surveyor made the following observations: On 9/3/24 at 8:49 A.M., Resident #6 was observed sitting in a wheelchair in the dining room receiving oxygen (O2) at 2.5 liters via nasal cannula. A portable oxygen concentrator was observed hanging off the back of the wheelchair. Staff could be seen walking around the dining room. On 9/3/24 at 8:59 A.M., Resident #6 was observed sitting in a wheelchair in the dining room eating breakfast. The Resident was not utilizing oxygen. A portable oxygen concentrator was observed hanging off the back of the wheelchair, oxygen tubing attached, the nasal cannula was placed around the Residents head but was not placed in his/her nostrils and was off to the side of the nose. Staff could be seen walking around the dining room. On 9/3/24 at 9:16 A.M., Resident #6 was observed sitting in a wheelchair in the dining room. The Resident was not utilizing oxygen. A portable oxygen concentrator was observed hanging off the back of the wheelchair, oxygen tubing attached, the nasal cannula was placed around the Residents head but was not placed in his/her nostrils. Staff could be seen walking around the dining room. Review of Resident #6's physician's orders dated 11/10/23 indicated the following: - O2 (Oxygen) at 2L (liters/minute) via nasal cannula continuously to maintain O2 saturation greater than 90% every shift for interstitial lung disease. Review of Resident #6's care plan for oxygen therapy dated 7/6/22 indicated the following intervention: - Monitor oxygen sat (saturation) every shift. - If the resident is allowed to eat, oxygen still must be given to the resident but in a different manner (e.g., changing from mask to nasal cannula). Return resident to usual oxygen delivery method after the meal. - Monitor for s/sx (signs and symptoms) of respiratory distress and report to MD (medical doctor) PRN (as needed): Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color. - OXYGEN SETTINGS: I have, O2 via nasal prongs/mask @ 2L continuously as needed. For sob (shortness of breath) respiratory distress. Review of Resident #6's care plan for Emphysema (lung condition causing shortness of breath)/COPD (Chronic Obstructive Pulmonary Disease)/asthma (airway disease) dated 7/6/22 indicated the following intervention: - Give oxygen therapy as ordered by the physician - Monitor for difficulty breathing (Dyspnea) on exertion. Remind resident not to push beyond endurance. Review of the medical record indicated Resident #6's last recorded oxygenation saturation level was 86% via nasal cannula, dated 7/6/24, and failed to indicate the use of oxygen. Review of Resident #6's progress notes indicated the following: - 7/15/24 Nurse Practitioner (NP) Progress Note: O2 level 94%. - 7/25/24 Medical Director (MD) Progress Note: O2 level 90%. - 9/5/24 MD Progress Noted: O2 level 94%. Further review of the medial record indicated Resident #6 was hospitalized on [DATE], due to change in mental status and oxygen level 79%. On 9/3/24 at 10:01 A.M., Resident #6 was observed sitting in a wheelchair in the dining room. A portable oxygen concentrator was observed hanging off the back of the wheelchair, oxygen tubing attached, the nasal cannula was placed around the Residents head but was not placed in his/her nostrils. Staff could be seen walking around the dining room and one staff member remained seated in the doorway. The Resident's back was to the staff member. During an observation and interview on 9/3/24 at 10:04 A.M., Nurse #1 said Resident #6 is on 2L of oxygen and wears a nasal cannula. Nurse #1 said he/she is using a portable concentrator in the dining room. The surveyor then asked Nurse #1 to observe Resident #6's oxygen status. The surveyor observed Resident #6 sitting in the wheelchair in the dining room, with his/her back facing another staff member sitting at the doorway to the dining room. A portable oxygen concentrator was observed hanging off the back of the wheelchair, the dial was turned to 2.5 L of oxygen, oxygen tubing was attached, the nasal cannula was placed around the Residents head, but was not placed in his/her nostrils. The surveyor continued to make the following observations in the dining room with Nurse #1 present: - At 10:06 A.M., Nurse #1 observed the Resident with the surveyor. The surveyor observed Resident #6 to be uncomfortable and could visualize the use of accessory muscles, as he/she was leaning forward with his/her mouth open. The surveyor observed the portable oxygen tank on empty as indicated by the arrow pointing to the red indicator section labeled 0 zero, the dial was set at 2.5 L. Nurse #1 said He/she is doing good and proceeded to walk out of the dining room. The surveyor stopped Nurse #1 from leaving the dining room and asked Nurse #1 to visualize Resident #6's nasal cannula. - At 10:08 A.M., Nurse #1 checked the nasal cannula by observing it on the Resident's face and then checked the concentrator level and said, Yes she is getting oxygen. Nurse #1 proceeded to walk away from the Resident and the surveyor had to stop Nurse #1 for a second time, from leaving the dining room. The surveyor asked Nurse #1 to again visualize the Resident, and Nurse #1 looked over the Resident and said he was going to get a pulse oximeter machine because he/she is having difficulty breathing. The surveyor asked Nurse #1 to visualize the nasal cannula placement and Nurse #1 said he was sorry and said Resident #6 is not wearing his/her nasal cannula correctly, and he adjusted the nasal cannula and placed the prongs into the Residents nose. Nurse #1 visualized the oxygen gauge at 0 zero. Nurse #1 told the surveyor that the machine is not empty and that he will check for air bubbles. Nurse #1 obtained a small plastic cup of water, removed the nasal cannula from Resident #6's nostrils and submerged the nasal cannula prongs into the water. Nurse #1 said there should be bubbles coming out of the nasal cannula prongs, to indicate the oxygen tank is not empty. Nurse #1 then observed the oxygen concentrator set at level at 2.5 L and said the Resident should be on 2 liters. Nurse #1 and the surveyor observed very few bubbles and Nurse #1 said the tank is empty and said he/she is not getting any oxygen. - At 10: 15 A.M., Nurse #1 then exited the dining room leaving Resident #6 without oxygen, to obtain a vital sign machine. Nurse #1 placed the pulse oximeter on to the Residents finger and was unable to obtain a reading. Nurse #1 said the machine was not working or turning on and exited the dining room again to obtain a portable pulse oximeter. - At 10:16 A.M., Resident #6 said I'm having a little bit of trouble but not too bad as Nurse #1 placed the pulse oximeter on the Residents finger. Resident #6's oxygen saturation level was 77%. Nurse #1 said he/she is having difficulty breathing and gasping for air. I need to get him/her on oxygen and left the dining room. Resident #6 continued to remain off oxygen. -At 10:17 A.M., the Project Manager observed Resident #6's portable concentrator and said oxygen tanks need to be held a certain way to check for levels to know if the machine is empty and said Nurse #1 will be right back with a new oxygen tank. -At 10:18 A.M., Nurse #1 said I will be back I'm going to check something to confirm orders are for 2 liters and get an oxygen tank. - At 10:20 A.M., another staff member wheeled Resident #6 to his/ her room and Nurse #1 carried a new oxygen tank and oxygen tubing into the Residents room. Nurse #1 attached a new nasal cannula to a concentrator that was already set up in Resident #6's room. Resident #6 continued to have difficulty breathing and his/her pulse oxygenation level was 76 %. Nurse #1 said I need to get shorter tubing and the surveyor had to tell Nurse #1 that the he must place the nasal cannula onto the Resident's nose as it was on the Residents bed. The Nurse placed the nasal cannula prongs appropriately into the Resident's nose. Nurse #1 said he/she is in respiratory distress and the oxygen is not working. Nurse # 1 rechecked the Residents oxygenation status, and its was 78%. Nurse #1 said his/her color does not look good and he/she is gasping. Nurse #1 proceeded to unhook the oxygen tubing from the concentrator in the bedroom and connected it to the new portable tank he brought into the room. Resident #6 continued to have labored breathing with the use of accessory muscles as Nurse #1 re-checked the oxygenation levels. Resident #6 continued to receive 2L oxygen via nasal cannula and his/her oxygen saturation level went to 80%, 86%, and 93% and remained at 93% during the remainder of the observation. Nurse #1 said the Resident is doing much better and his/her color has improved, and he/she is no longer in respiratory distress. Nurse #1 said the Resident needed oxygen and should not have been using an empty tank and said the nasal cannula needs to be applied to the nose correctly. During an interview on 9/3/24 at 10:26 A.M., Nurse #1 said he will check for respiratory treatment orders and call the doctor to report what happened. Nurse #1 said he did not realize he/she was not wearing the nasal cannula correctly and said the resident should not have been placed on an empty portable oxygen concentrator because he/she needs oxygen to breath. During an interview on 9/3/24 at 10:35 A.M., the surveyor notified the Administrator regarding Resident #6 and Nurse #1. The Administrator said the care was unacceptable and that he expects staff to provide appropriate care to all Residents. During an interview on 9/4/24 at 9:48 A.M., Nurse Practitioner (NP) said she was not aware that Resident #6 had respiratory distress yesterday and that she was not notified by the nurse or anyone in the building. The NP said Resident #6 requires oxygen and has an order for 2 liters, and she expects staff to recognize if a resident requires assistance. The NP said she expects staff to be checking oxygen saturation every shift and said orders for oxygenation parameters and level of oxygen requirements should be entered and followed. During an observation on 9/4/24 at 12:25 P.M., Resident #6 was observed sitting in a wheelchair in the dining room eating lunch. The Resident was receiving 2.5 L of oxygen via nasal cannula. A portable oxygen concentrator was observed hanging off the back of the wheelchair, oxygen tubing attached. Staff were in the dining room and able to visualize the Resident. During an observation on 9/4/24 at 1:03 P.M., Resident #6 was observed sitting in a wheelchair in the dining room. The Resident was receiving 2.5 L of oxygen via nasal cannula. A portable oxygen concentrator was observed hanging off the back of the wheelchair, oxygen tubing attached. Staff were in the dining room and able to visualize the Resident. During an interview on 9/4/24 at 1:05 P.M., Nurse #4 said Resident #6 needs oxygen and is on 2 liters continuously and that overnight staff will fill the oxygen tanks. The surveyor and Nurse #4 observed the concentrator setting and Resident #6 was receiving 2.5 L of oxygen. Nurse #4 said he/she should be on 2L and not 2.5 L. During an interview on 9/5/24 at 10:30 A.M., Certified Nursing Assistant (CNA) #8 said Resident #6 requires oxygen all the time to help him/her breath and that staff will fill the oxygen containers during the overnight shift. CNA #8 said staff can check if a tank is full by looking at the gauge on the tank and it is red it is empty. During an interview on 9/5/24 at 12:25 P.M., the Medical Director said he expects staff to follow medication and treatment orders related to oxygen use and he expects staff to be trained and competent to use equipment and monitor for signs and symptoms of respiratory distress. The Medical Director said resident's requiring oxygen must have their oxygen checked at least each shift and as needed if compromised. The Medical Director said Resident #6 should not have been without oxygen due to her diagnosis and respiratory status. The Medical Director said staff should have notified the NP right away. During an interview on 9/9/24 at 9:54 A.M., the Consulting Nurse said Residents requiring oxygen must be placed on oxygen and staff must follow physician orders. The Consulting Nurse said care plan interventions should be followed and staff need to know if an oxygen tank is empty, how to check the oxygen setting and to recognize if a resident is having difficulty. The Consulting Nurse said staff should be aware if a resident is having difficulty breathing and is not wearing nasal cannula correctly. She also said staff must check settings on all types of oxygen systems.

Based on record review and interview, the facility staff failed to provide supervision while eating to prevent injury, resulting in a second degree burn, for 1 resident (Resident #55) out of a total sample of 24 residents. Findings include: Resident #55 was admitted to the facility in 8/2017 with diagnoses including [CONDITION(S)], [CONDITION(S)] and hearing loss. Review of Resident #55's medical record indicated a Minimum Data Set (MDS) assessment dated [DATE]. The MDS indicated the Resident was unable to complete the Brief Interview for Mental Status and the Staff Assessment for Mental Status indicated the resident had short and long term memory problems. The MDS further indicated the resident had moderate impairment making decisions regarding tasks of daily life and required supervision with eating. Review of Resident #55's February 2019 monthly nursing summary (a summary of the care and assistance a resident requires) indicated the resident required continual supervision of 1 staff member for 8 residents or less while eating due to decreased attention span and that the resident required cues and supervision for meals due to cognitive loss. Additionally, Resident #55 had a care plan dated 10/09/2018 reviewed 1/24/19, which indicated that he/she required supervision at meals. Review of Resident #55's Certified Nursing Assistant (CNA) flowsheets for February 2019, indicated the resident had been documented as independent eating for all meals throughout the month of February 2019, which was in conflict with Resident #55's plan of care. Review of Resident #55's medical record indicated the following: - A nursing progress note dated 2/23/19, on the 7:00 A.M. to 3:00 P.M. shift which indicated that during care, a CNA had noticed that the Resident's left upper thigh was pink. Per the nursing progress note, the Resident stated he/she was burned from oatmeal during breakfast. - A nursing progress note dated 2/23/19, on the 3:00 P.M. to 11:00 P.M. shift which indicated that the burn was monitored and a blister was noted. - A nursing progress note dated 2/24/19, at 2:00 P.M. which indicated a new order was obtained from the Nurse Practitioner to wash the area, apply [MEDICATION(S)] (a topical antibiotic cream) with a dry protective dressing to the burn on the Resident's left leg. - A nursing progress note dated 3/1/19, at 2:00 P.M. which indicated the Resident was seen by the Nurse Practitioner and new orders were obtained for Tylenol with [MEDICATION(S)] (a pain reliever) 300 milligrams-30 milligram to be given with Tylenol 325 milligrams orally four times daily for 7 days and for [MEDICATION(S)] (a topical antibiotic used in partial thickness and full thickness burns) to be applied to the left upper thigh with a dry protective dressing twice daily. A Nurse Practitioner (NP) note dated 4/16/19, indicated a follow up to assess the burn and which indicated it was a burn of the second degree (a burn which causes damage to the skin or deeper tissues). Review of Resident #55's medical record failed to include a Nurse Practitioner note from the visit on 3/1/19 during which the Resident's treatment was changed and pain relievers were prescribed. During an interview on 8/19/19, at 1:48 P.M., Certified Nursing Assistant #3 and Certified Nursing Assistant #1 said Resident #55 requires setup for his/her meals. They said he/she eats in his/her room with setup and does not require supervision. Review of Facility policy titled 'All Incidents' Reference #9772 revised 11/08/18 indicated the following: -In the event an incident occurs, Pine [NAME] Nursing Center is to follow procedure and report it in a timely manner -This procedure applies to reporting all incidents such as falls, accidents, altercations, suspected abuse, neglect, mistreatment and misappropriation of resident -Upon any incident, an incident form should be filled out and given to the immediate supervisor. Incident reports should be signed, dated and given a time of the incident -An internal investigation will be opened and completed within 5 days. During an interview on 8/20/19, at 10:42 A.M., the Director of Nursing (DON) said an investigation and incident report should be done anytime there is an injury to a resident. She further said she doesn't remember completing an incident report for Resident #55's burn and that it may have fallen through the cracks. She said she was informed of the incident, but she doesn't recall the circumstances of her notification. She said the resident was burned by eating something that was too hot. She said she notified the kitchen and the Food Service Director (FSD), but that she did not complete a formal investigation. The DON said that the incident should have been investigated. She further said that she did an informal investigation. When asked by the surveyor to clarify what that meant, she said she spoke with her staff and the kitchen staff. She was unable to provide any documentation of this and was unable to recall specifics of what was said. She said she was unsure if the Resident #55 ate in the dining room or in his/her room. She said she was unsure if the resident was supervised or not. She further said the incident was memorable because of the burn that occurred. During an interview on 8/20/19, at 10:59 A.M., the Food Service Director (FSD) said he was never notified of a resident being burned. He said if an adverse event had occurred he would have documented it. He said that food temperatures are taken before food is sent out of the kitchen to residents. During an interview on 8/20/19, at 11:06 A.M., Dietary Staff #1 said that she was never notified of any resident being burned. During an interview on 8/20/19, at 11:10 A.M., Unit Manager #2 said that the Resident was found to have a red mark on his/her thigh during care. Unit Manager #2 further said that Resident #55 had been eating breakfast in his/her room alone. She said the Resident always eats alone and does not require supervision. She said a blister formed after the burn and then the blister opened up and that it took a few months to heal. She acknowledged that the Resident's care plan and nursing summary indicated he/she required supervision while eating. During an interview on 8/20/19, at 11:39 A.M., the DON said the kitchen staff will always monitor the temperatures of foods before serving to residents. Review of the facility daily temperature log failed to indicate that temperatures were obtained for breakfast items, including hot cereal on 2/23/19. During an interview on 8/20/19, at 12:47 P.M., Cook#1 said the kitchen staff will take temperatures of the foods to be served before serving them. She acknowledged that there were no temperatures taken for breakfast on 2/23/19. She said she forgot to take the temperatures. She said that hot cereal, including oatmeal, is usually held for serving at 175 degrees Fahrenheit. During an interview on 8/21/19, at 9:01 A.M., the DON said she was unable to locate the NP progress note from 3/1/19. She said she was told by the NP's office that no note was written and that the NP was away and not available for interview.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was at increased risk for falls due to impaired functional mobility, the Facility failed to ensure that nursing staff maintained Resident #1's safety during a transfer with a mechanical lift, which caused the lift to tip over during the transfer. As a result, Resident #1 was dropped onto his/her bed, hit his/her head on the headboard, and sustained a laceration that required seven sutures to repair. Findings Include: Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated that he/she was admitted in November 2016, had severe cognitive impairment, was non-ambulatory, and required the assistance of two staff members for transfers in and out of bed. Resident #1's Care Plan for self care deficits, dated 5/16/17, indicated that Resident #1 required the use of a mechanical lift when nursing staff transferred him/her into and out of bed. An Incident/Accident Report, timed at 4:30 P.M. and dated 10/1/17, indicated that when Certified Nurse Aide(CNA) #1 and CNA #2 transferred Resident #1 into bed with a mechanical lift, the lift tilted and Resident #1 fell on to the bed. The Report indicated that Resident #1 sustained a laceration to the top of his/her head and was transferred to the Hospital Emergency Department for treatment. A Hospital Emergency Department Report, dated 10/1/17, indicated that Resident #1 was treated for [REDACTED]. Review of the Manufacturers User Manual for the Invacare Reliant Lift (mechanical lift used by CNA #1 and CNA #2 to transfer Resident #1) included a highlighted warning that indicated the legs of the lift must be locked in the maximum open position to ensure safety and stability. The Surveyor interviewed CNA #2 at 3:15 P.M. on 11/2/17. CNA #2 said she was assigned to Resident #1 on 10/1/17 and when she and CNA #1 transferred Resident #1 with the mechanical lift, the lift tipped over and Resident #1 hit his/her head on the headboard and sustained a laceration. CNA #2 said she could not recall if she or CNA #1 opened the legs of the mechanical lift to the widest position. CNA #2 said she was not educated on how to properly use the mechanical lift when she was hired. CNA #2 said it was okay to move the mechanical lift with the legs not fully opened when a resident was suspended from the lift. The Surveyor interviewed CNA #1 at 2:45 P.M. on 11/2/17. CNA #1 said Resident #1 was in his/her seated in a recliner in his/her room on 10/1/17 and CNA #2 asked her to help transfer Resident #1 into bed. CNA #1 said while Resident #1 was suspended up off the chair in the mechanical lift, she and CNA #2 moved the lift next to Resident #1's bed and when they approached the bed the mechanical lift tipped over and Resident #1 fell and hit his/her head on the headboard of the bed. CNA #1 said she was not sure why the mechanical lift tipped over but thought that the legs of the lift were not fully opened when she and CNA #2 transferred Resident #1. CNA #1 said it was not the first time the mechanical lift tipped when she transferred a resident. The Surveyor interviewed the Assistant Director of Nursing (ADON) at 8:35 A.M. on 11/2/17. The ADON said her role included the responsibility for staff development and education. The ADON said Certified Nurses Aides (CNA's) were trained on the correct use of the mechanical lifts during orientation. At the time of the survey, the ADON was unable to provide the Surveyor with supporting documentation that indicated that during orientation that CNA's were trained on how to properly and safely operate the mechanical lifts. The Surveyor interviewed the Director of Nursing (DON) 9:29 P.M. on 11/2/17. The DON said she investigated the incident involving Resident #1 on 10/1/17 and determined that CNA #1 and CNA #2 did not have the legs of the lift opened all the way when they transferred Resident #1. The DON said the Facility had not done any competencies or demonstrations with staff to ensure the lifts were being used according to manufacturer's instructions.