Every finding on record at Plymouth Harborside Healthcare

Based on record reviews and interviews for one of three sampled residents (Resident #1), who was receiving Hospice Services, and had physician's orders for the administration of morphine, the Facility failed to ensure he/she was free from a significant medication error, when after nursing obtained new orders to administer a higher dosage of morphine to Resident #1, the previous order for morphine was not discontinued as ordered, and he/she was administered both dosages at the same time in error.Findings include:Review of the Facility Policy titled, Preventing and Detecting Adverse Consequences and Medication Errors, dated 08/2020, indicated the following:-the facility employs a system to ensure that medication usage is evaluated on an ongoing basis;-when a resident has a change in condition, medication-related problems are considered;-significant medication-related problems are assessed, documented and reported as appropriate to the resident's attending physician;-when a resident receives a new medication, the medication order is evaluated for: the dose, route of administration, duration, and monitoring are in agreement with current clinical practice, clinical guidelines and manufacturer's specifications for use, that the resident is not taking other medication that would be incompatible with the prescribed medication;-in the event of a significant medication-related error, immediate action is taken to protect the resident's safety and welfare;-a significant medication-related error is defined as: requiring medication discontinuation or dose modification;-the physician is notified promptly of any significant medication errorReview of the Report submitted by the Facility via Health Care Reporting System (HCFRS), dated 5/07/26, indicated that the facility received a call from a Department of Public Health (DPH) representative to report that a complaint was received regarding an alleged medication error. The Report indicated that an internal investigation was initiated immediately and during the medical record review it was determined that medication transcription errors had occurred during the processing of Hospice recommendations and provider orders. The Report indicated the following:On 5/05/26, during the 3:00 P.M. to 11:00 P.M. shift, Hospice recommendations were made as follows:*Morphine 20 milligrams (mg) / 1 milliliter (ml) - administer 10 mg (0.5) ml sublingually (under the tongue) every two hours as a scheduled dose and*Morphine 20 mg / 1ml - administer 10 mg (0.5) ml sublingually every hour as needed (prn) for severe painThe Report indicated that on 5/06/26, the Hospice Nurse made additional recommendations for Resident #1 as follows:*Discontinue scheduled Morphine 10 mg (0.5) ml every two hours and initiate*Morphine 20 mg / 1 ml - administer 20 mg (1) ml sublingually every two hours scheduledThe Report further indicated that during the transcription of this order, the original scheduled dose of Morphine 10 mg (0.5) ml was not discontinued, resulting in two active scheduled orders totaling Morphine 30 mg (1.5) ml every two hours. The Report indicated that Resident #1 received multiple doses prior to the discrepancy being identified.Resident #1 was admitted to the Facility in September 2021, diagnoses included acute respiratory failure with hypoxia, major depressive disorder, severe protein malnutrition, dementia, sever sepsis with septic shock, anxiety disorder, chronic venous insufficiency and kidney failure.Review of Resident #1's Facility Medication Error Report, dated 5/07/26, indicated that Resident #1's Morphine medication orders were not transcribed correctly, and he/she had two active scheduled orders, one for Morphine 20 mg every two hours and one for Morphine 10 mg every two hours. The Report indicated that the Nurse Practitioner was notified of the medication discrepancy and the scheduled Morphine 10 mg every two hours was discontinued.Review of a Nurse Progress Note, dated 5/05/26, written by Nurse # 5 indicated that Resident #1 was restless and agitated throughout the shift, PRN (as needed) medications were administered with minimal effect. The Note indicated that Hospice was notified and a new order [was recommended] to increase Morphine 20 mg / 1 ml - give 10 mg (0.5) ml every two hours scheduled and give Morphine 10 mg (0.5) ml every hour PRN.During a telephone interview on 6/11/26 at 10:43 A.M. (which included review of her written witness statement, dated 5/05/26), Nurse #5 said that Resident #1 seemed like he/she was in a lot of pain and that she called the Hospice Nurse to report the change in Resident #1's condition and obtain recommendations for pain. Nurse #5 said that the Hospice Nurse recommended scheduling Morphine 10 mg (0.5) ml every two hours and Morphine 10 mg (0.5) ml every hour as needed. Nurse #5 said that she notified the NP of Resident #1's Hospice recommendations and the NP agreed and gave her a new order for the same. Nurse #5 said that she transcribed the orders into Resident #1's Electronic Medication Administration Record (EMAR).Review of Resident #1's Physician's Orders for May 2026 indicated his/her orders related to Morphine were as follows:- 5/05/26, Morphine Sulfate Oral Solution 100 mg / 5 ml, give 10 mg (0.5) ml sublingually every two hours for pain.- 5/06/26, Morphine Sulfate Oral Solution 100 mg / 5 ml, give 10 mg (0.5) ml sublingually every two hours for pain and,-5/06/26, Morphine Sulfate Oral Solution 100 mg / 5 ml, give 20 mg (1) ml sublingually every two hours for pain.There was no documentation to support that the Morphine 10 mg dose was discontinued when the Morphine 20 mg dose was ordered.Review of Resident #1's EMAR, dated 5/06/26, indicated that Resident #1 received both Morphine 10 mg sublingually and Morphine 20 mg sublingually at the same time at 2:00 P.M., 4:00 P.M., 6:00 P.M., 8:00 P.M., and 10:00 P.M., in error.Review of Nurse Progress Note, dated 5/06/26, written by the Unit Manager, indicated that a new order for Morphine 20 mg (1) ml every two hours scheduled was recommended by the Hospice Nurse, the NP was notified and was in agreement with the recommendation.During an interview on 6/08/26 at 1:10 P.M., (which included review of her written witness Statement, undated), the Unit Manager said that she was unaware that Resident #1 already had a scheduled dose of the Morphine 10 mg (0.5) ml every two hours and said she did not discontinue that dose when she transcribed the Morphine 20 mg (1) ml order every two hours scheduled into the EMAR on 5/06/26.The Unit Manager said she should have discontinued Resident #1's scheduled Morphine 10 mg every two hours when she obtained the new order for Morphine 20 mg every two hours. The Unit Manager said that the next day, 5/07/26, the 11:00 P.M. to 7:00 A.M. Nurse informed her that there were two scheduled doses for Resident #1's Morphine and that when she (Unit Manager) reviewed Resident #1's Physician Orders, she saw the error that she made. The Unit Manager said that Resident #1 received several doses of Morphine totaling 30 mg in error instead of Morphine 20 mg.Review of a Nurse Practitioner's Progress Note, dated 5/07/26, indicated that nursing requested that Resident #1 be assessed for pain control. The Note indicated that Resident is currently ordered Morphine every two hours and Hospice recommended to increase Morphine to 20 mg every two hours scheduled. The Note further indicated that nursing endorses, that Resident #1 received Morphine 30 mg every two hours scheduled the previous evening.During a telephone interview on 6/10/26 at 3:09 P.M., the Nurse Practitioner (NP) said that on 5/05/26, during the 3:00 P.M. to 11:00 P.M. shift, a Nurse informed her that Hospice made recommendations for Resident #1's pain management. The NP said that Hospice recommended scheduling Morphine 10 mg every two hours and that she agreed with their recommendation and gave them an order. The NP said that she was informed that Resident #1's pain was not relieved, and Hospice made new recommendations to increase the Morphine to 20 mg every two hours, that she agreed and gave them an order to increase the Morphine to 20 mg every two hours.The NP said that the Morphine 10 mg order should have been discontinued when the Morphine 20 mg order was implemented. The NP said that the facility informed her that the Morphine 10 mg dose was not discontinued when the Morphine 20 mg was implemented and Resident #1 received several doses of Morphine for a total of 30 mg in error, before the medication error was caught.During a telephone interview on 6/10/26 at 11:37 A.M., Nurse #1 said that she administered Resident #1's medications as they appeared on his/her EMAR. Nurse #1 said that she did not question the Morphine dosages and administered a total of 30 mg of Morphine sublingually to Resident #1 on 5/06/26 at 2:00 P.M., 4:00 P.M., 6:00 P.M., 8:00 P.M., and 10:00 P.M. During an interview on 6/08/26 at 3:15 P.M. the Assistant Director of Nurses (ADON) said that Resident #1 was receiving Hospice services and experiencing increased pain. The ADON said that on 5/05/26, Hospice made recommendations for Morphine 10 mg sublingually every two hours scheduled, the NP was notified and gave orders to implement the recommendations. The ADON said that Resident #1 continued to experience pain on the scheduled Morphine, Hospice made recommendations to increase the Morphine to 20 mg sublingually every two hours scheduled, the NP was notified and gave orders to implement the recommendations.The ADON said that during the transcription of the medication orders, the Morphine 10 mg order was not discontinued, and Resident #1 received several doses of Morphine for a total of 30 mg in error. The ADON said that the Morphine 10 mg order should have been discontinued when the Morphine 20 mg order was implemented but was not. The ADON said his expectation was that nurses discontinue the current medication order before implementation of a new medication order.

Based on observations, records reviewed, and interviews, the facility failed to ensure that adequate supervision and interventions were implemented to prevent accidents and failed to maintain an environment free of accident hazards for four Residents (#80, #15, #82, #84) of a total of 20 residents sampled. Specifically, the facility failed to:1. Ensure adequate supervision for Resident #80, a known elopement risk, and enabled access to a designated smoking area with unlocked doors that had access to outside of the facility, thus placing Resident #80 at Immediate Jeopardy risk for serious harm or death.In addition to the Immediate Jeopardy, non-compliance of this requirement also existed because the facility failed to:2. Provide adequate supervision to prevent accidents and to accurately assess Resident #15, who was found to reuse cigarette butts and wore clothing with burn holes; and3. Educate Resident #82 regarding having an oxygen concentrator in a smoking area; and4. Ensure Resident #84, with multiple falls, was utilizing a care planned wheelchair wedge cushion. Findings include:1. Resident #80 was admitted to the facility in September 2022 with diagnoses including alcohol dependence (in remission), cerebral infarction (stroke), aphasia (a disorder that results from damage to areas of the brain that are responsible for language that impairs expression and understanding of language, as well as reading and writing), and bipolar disorder. Review of the Minimum Data Set (MDS) assessment, dated 12/11/25, indicated Resident #80 had moderate cognitive deficit as evidenced by a Brief Interview for Mental Status (BIMS) score of 7 out of 15 and was independent with ambulation. a. On 2/10/26 at 4:14 P.M., the surveyor observed the following:-Resident #80 exit the facility through the patio doors into the unsupervised and unsecured designated smoking area.-A wander guard (an electronic wander management system that includes wearable bracelets and door sensors to ensure residents do not wander or elope) on Resident #80's right wrist.-The surveyor did not hear anything alarm to notify the staff Resident #80 had exited the facility. -Secure smoking area gate opened with open access to the parking lot. Review of weather data obtained from the National Oceanic and Atmospheric Administration indicated the temperatures on 2/11/26 in [Town name], Massachusetts was a maximum of 34 degrees Fahrenheit and a minimum of 3 degrees Fahrenheit. Review of Resident #80's current Physician's Orders indicated but was not limited to:- Check function of wander guard on right wrist weekly on Mondays, dated 12/26/25- Health Care Proxy invoked, dated 9/20/22 Review of Resident #80's medical record indicated but was not limited to: -10/11/25 Nurse's Note:Nurse received call from a Certified Nursing Assistant (CNA) who was leaving for the day to let her know Resident was walking back into the driveway with a paper bag, at the same time a different CNA came up to nursing station to report they had seen the Resident walking on the street coming from direction of liquor store. The bag had bottles of vodka. -10/13/25 Care plan updated to make Resident #80 a supervised smoker in response to the elopement on 10/11/25. -10/13/25 Elopement Risk Evaluation:Resident was oriented to person and place. Resident was wanting to go home or leave; Resident had a history of substance abuse and was independent for mobility with aid (walker). Elopement attempted in the last 30 days. Resident was at risk for elopement. SCORE: 10 Category: High Risk. -Resident #80 was on a leave of absence from the facility from 12/24/25 until 12/26/25. -12/24/25 Alert Note:Phone conversation with Resident's Health Care Proxy regarding continued safety concerns with Resident attempting to leave the facility without proper authorization. The Clinical IDT (interdisciplinary team) including Nursing, Social Services, Administration and DON (Director of Nursing) all agree that this [refers to wander guard] is the least restrictive yet safest way for staff to be alerted to his/her whereabouts. The Resident's Health Care Proxy agrees with our decision and will share that information with the Resident prior to their return from his/her leave. -12/24/25 Nursing Note:New order from the Nurse Practitioner for wander guard to apply when Resident returns from leave of absence. -12/26/25 Elopement Risk Evaluation indicated but was not limited to:Resident was oriented to person, place, and time. Resident was oblivious to needs or safety, wanting to go home or leave, and watching others go out of doors. Resident was at risk for elopement. SCORE: 9 Category: High Risk. Review of Resident #80's Elopement Care Plan indicated but was not limited to:Focus: Elopement: is at risk for elopement, revision on 12/26/25Goal: Resident will remain within the facility unless supervised, remain free of harm, target date 3/5/26Interventions: 12/24/25 When Resident returns from pass (leave of absence), he/she is to have a wander guard placed. Nursing to check placement every shift and check function weekly, revision date 12/24/25; wander guard applied to: right wrist revision date 12/26/25 Review of the Elopement Risk book indicated Resident #80 was an elopement risk and had a wander guard. During an interview with observation on 2/10/26 at 4:22 P.M., Nurse #1 said residents used to go outside out the front door now they would go to the designated smoking area through the first-floor unit patio doors. Nurse #1 said there were two residents on the first who needed to be supervised when outside. Nurse #1 and the surveyor walked down to the first-floor unit patio doors which led to the unsecured designated smoking area and observed Resident #80 outside unsupervised. Nurse #1 said Resident #80 had a wander guard on and needed to be supervised when outside and should not have been outside unsupervised. She said no alarm sounded to notify staff that Resident #80 had exited the facility. She said she was not aware if the patio doors had a wander guard alert system. Nurse #1 said the gate leading from the designated smoking area in the parking lot was usually kept open, but she was not sure it should have been. During an interview on 2/10/26 at 4:34 P.M., the Administrator said the first-floor unit patio doors were newly installed for the residents to have easier access to the designated smoking area. She said the doors did not have a wander guard alarm alert system. She said the doors to the smoking area were unlocked from 7:00 A.M. to 7:00 P.M. daily and the gate leading from the smoking area to the parking lot was initially latched and secured but the facility had decided to leave the gate open in case a resident was outside after 7:00 P.M. without access to get back into the facility. She said Resident #80 had a wander guard and should not have been unsupervised. During an interview on 2/10/26 at 5:06 P.M., CNA #3 said the doors to the designated smoking area were unlocked and unalarmed from 7:00 A.M. to 7:00 P.M. daily. She said if a resident with a wander guard went through the doors, the doors would not alarm to notify the staff someone had exited through the patio doors. She said if someone attempted to exit through the patio doors after 7:00 P.M. and before 7:00 A.M. the doors would alarm if pushed on. She said there was a camera pointed at the smoking area, but it would not alarm if a resident attempted to exit through the patio doors and they are not monitored continuously. During an interview on 2/10/26 at 5:10 P.M., CNA #2 said if Resident #80 attempted to exit the facility through the front doors, the wander guard alarm alert system would sound loudly, the door will lock until a code is put in, and the Resident could not be missed. She said the first-floor unit patio doors did not have a wander guard alarm alert system, so if Resident #80 went outside unsupervised, staff would not have been aware he/she exited the facility unless someone notified them. During an interview on 2/10/26 at 5:18 P.M, the Administrator and Director of Nurses (DON) said Resident #80 required supervision when outside. They said Resident #80 wore a wander guard. They said the first-floor patio doors were still under construction but because of the cold weather and snow the facility had made the decision to open the doors before being fully completed to make it a shorter walking distance to the patio. The Administrator said there needed to be safety measures in place before the newly renovated patio doors were opened and in use. During an interview on 2/11/26 at 7:49 A.M., CNA #5 said there was a binder at the nurse's station which lists the residents who were at risk for elopement. She said Resident #80 was in the book because he/she was an elopement risk because he/she had left the facility before without supervision. She said Resident #80 wore a wander guard. She said the side patio doors which lead to the smoking area were not alarmed, so if no one saw him/her go outside then no one would know. During an interview on 2/11/26 at 7:57 A.M., Nurse #1 said Resident #80 had followed another resident out to the smoking area on 2/10/26 and because the doors which led to the smoking area did not have a wander guard alarm alert system staff were unaware he/she had left the unit unsupervised. Nurse #1 said the Administrator had unlocked the doors leaving them unalarmed. During an interview on 2/11/26 at 8:06 A.M., CNA #6 said Resident #80 would need supervision when he/she would go outside because he/she was an elopement risk. CNA #6 said Resident #80 would sit and wait for someone to go outside so he/she could follow them out. During an interview on 2/11/26 at 9:45 A.M., the Administrator said the doors to the designated smoking area from the first-floor unit were left unlocked on 2/2/26 until 2/10/26. She said she had not provided official education to staff members, just told them to start using the doors for smoking. She said the doors were not ready for use, as still being renovated, but the facility tried to use them because of the weather. She said the facility had not implemented a wander guard alert system on the patio doors. She said she felt confident Resident #80 would continue to sit and wait to go outside like he/she had done with the front door because he/she knew the wander guard system alarm would sound if/she tried to go outside without a staff member. She said she had not realized exiting through the patio doors there was not an alarm sounding to notify staff if a resident had left the facility without the appropriate supervision. She said she had not realized using the patio exit door created confusion for Resident #80. During an interview on 2/11/26 at 3:51 P.M., Activity Assistant #1 said Resident #80 had a wander guard on and needed supervision when he/she was outside. She said Resident #80 had wandered from the facility previously. She said if Resident #80 attempted to leave the facility through the front doors without supervision, the doors would lock and the wander guard alert system would sound notifying staff he/she was attempting to leave and would not turn off until a staff member would go and check the area and reset the alarm. She said the doors leading to the designated smoking area were not alarmed at this time. During an interview on 2/11/26 at 3:54 P.M., CNA #8 said Resident #80 required supervision to go outside because he/she was an elopement risk and was in the elopement book. CNA #8 said when Resident #80 would attempt to go through the from doors the doors would lock and alarm but the new patio doors leading to designated smoking would not alarm if he/she tried to go outside between 7:00 A.M. and 7:00 P.M. During an interview on 2/12/26 at 7:49 A.M., CNA #9 said Resident #80 had a wander guard because he/she would leave the facility unsupervised and would not notify anyone he/she was leaving. She said because the patio door did not have a wander guard alert system no one would be aware if Resident #80 had gone outside. During an interview on 2/12/26 at 12:33 P.M., Resident #80 said he/she had a wander guard alarm bracelet on their right wrist. Resident #80 said he/she would leave the facility once in a while and walk down to the store. During an interview on 2/12/26 at 1:10 P.M., Family Representative #1 said they had received a call from the facility asking for permission to apply a wander guard to Resident #80 and he/she gave permission. Family Representative #1 said Resident #80 needed a wander guard so he/she would not wander off by themselves while outside as he/she had poor safety awareness. During an interview on 2/12/26 at 12:14 P.M. and 1:53 P.M., the DON said Resident #80 needed supervision when outside because he was an elopement risk. She said Resident #80 should not have been outside unsupervised with their history and risk of elopement. She said the gate leading to the parking lot in the designated smoking area should not have been opened. She said the goal was to have a wander guard alert system in place prior to opening the newly installed doors to the designated smoking area, however, there was not a system in place to notify staff if a resident with a wander guard left the facility through the patio door. She said the patio doors should not have been unlocked without them being secure. During an interview on 2/12/26 at 2:22 P.M., the Maintenance Director said the facility unlocked the doors from the first-floor unit to the designated smoking area on 2/2/26. He said the doors did not have a wander guard alert system but should have. During an interview on 2/12/26 at 2:33 P.M., the Administrator said the doors from the first-floor unit patio were opened on 2/2/26 to allow for easier access to the designated smoking area because of the cold weather but the facility had forgotten about the wander guard alert system. She said the wander guard alert system should have been installed prior to unlocking the doors leaving them unsecured and unalarmed. b. On 2/10/26 at 4:14 P.M., the surveyor observed the following: -Resident #52 sitting in the smoking area smoking a cigarette. -Resident #80 walked out into the designated smoking area unsupervised. -Resident #80 take Resident #52's cigarette and use it to light his/her cigarette. -No staff were present. Review of a Smoking Evaluation, dated 12/4/25, indicated Resident #80 was safe to smoke with supervision and was safe to light their own cigarette with staff assistance. Review of Resident #80's Smoking Care Plan indicated but was not limited to: -Focus: Smoking: Resident wishes to smoke and requires supervision due to incident when he/she left the facility grounds during a smoking break 10/11/25, revision on 10/13/25 -Intervention: Resident will be supervised by staff when going outside to smoke, initiated 10/11/25. Review of the Supervised Smoking Times provided to the survey team on 2/9/26 indicated Resident #80 required supervision with smoking. During an interview with observation on 2/10/26 at 4:22 P.M., Nurse #1 said the first-floor unit had two supervised smokers. Nurse #1 and the surveyor walked down to the first-floor unit patio doors and Nurse #1 said Resident #80 should not have been outside unsupervised and he/she had a wander guard on and needed to be supervised when smoking. During an interview on 2/12/26 at 1:53 P.M., the DON said Resident #80 should not have used Resident #52's cigarette to ignite their cigarette instead Resident #80 should have used the electric lighter to light it. 2. Review of the facility's policy titled Smoking Policy-Residents, dated as revised in September 2025, indicated: -the facility shall establish and maintain safe resident smoking practices -ashtrays/cigarettes are emptied only into designated receptacles Resident #15 was admitted to the facility in January 2023 with a diagnosis of nicotine dependence. Review of the MDS assessment, dated 12/5/25, indicated Resident #15 scored 10 out of 15 on the BIMS, indicating he/she had a moderate cognitive impairment and used tobacco products. On 2/9/26 at 10:25 A.M., the surveyor observed Resident #15 seated near the nurses' station wearing navy blue sweatpants with numerous burn holes. Review of the Smoking Evaluation, dated 1/15/26, indicated Resident #15 had no evidence of burn holes on their clothing and was independent with smoking without the need for protective smoking equipment. The Evaluation was completed by the DON. On 2/9/26 at 10:43 A.M., the surveyor observed the smoking gazebo area with multiple already smoked and extinguished cigarette butts on the ground. There was a large amount of cigarette butts scattered on the ground inside the gazebo and in a snowbank. The walkway leading to the gazebo had numerous cigarette butts on the ground and in the snow. There were cigarette butts scattered along the side of the building. During an observation with interview on 2/10/26 at 12:41 P.M., the surveyor observed burn holes in Resident #15's navy blue sweatpants and on his/her t-shirt. Resident #15 said, Maybe ashes fell on them. On 2/10/26 at 12:46 P.M., the surveyor observed Resident #15 pick up a cigarette butt from the ground, bring it to the stationary electronic lighter, light the cigarette, take a puff and then throw it to the ground. On 2/11/26 at 9:20 A.M., the surveyor observed Resident #15 wearing navy blue sweatpants with multiple burn holes, mostly on the left thigh area. On 2/11/26 at 12:40 P.M., the surveyor observed Resident #15 outside in the smoking area picking a cigarette butt up off the ground and lighting it on the stationary electronic lighter. During an interview on 2/11/26 at 12:41 P.M., Resident #15 said he/she did not have their own cigarettes but had picked up the cigarette butt which was not lighting on the electronic lighter. The surveyor inquired about the multiple burn marks on the Resident's clothes, and he/she said the burns were from cigarettes. The surveyor observed multiple cigarettes butts on the ground in the smoking area. During an interview on 2/11/26 at 3:02 P.M., CNA #1 said Resident #15 has had burn holes in his/her clothing since coming to the facility. She said Resident #15 did not like to change clothes and was usually wearing the clothing with burn holes. While the clothes had burn holes when the Resident was admitted , she could not say if all of the burn holes were old. During an interview on 2/11/26 at 3:03 P.M, CNA #7 said Resident #15 has had burn holes in his/her clothes for a while and does not change their clothes. During an interview on 2/11/26 at 3:04 P.M, CNA #10 said Resident #15 did not change his/her clothes and would wear clothes with burn holes. He said he was not sure how they would know which holes were new and which were old. Review of the active care plans failed to include any information regarding Resident #15 wearing clothing with burn holes. During an interview on 2/11/26 at 3:11 P.M., Resident #15 said he/she did not like to change their clothes but probably should. He/she said there was no way for him/her to know if there were any new burn holes in the pants. Resident #15 denied ever having any burns on his/her skin. During an interview on 2/13/26 at 10:55 A.M., the DON said she had not noticed the burn holes in the pants of Resident #15 but should have. She said there was no way to know if the burn holes were new or old. She said there should not be cigarette butts on the ground in the smoking area, and this area was supposed to be maintained. She said she was unaware Resident #15 was picking cigarette butts up from the ground and smoking them. She said she was not sure who was responsible for obtaining cigarettes for Resident #15. During an interview on 2/13/26 at 11:00 A.M., the Staff Development Coordinator said he was going to re-assess Resident #15 for the Smoking Evaluation on 2/12/26 but the Resident had said he/she did not have cigarettes, and he hadn't inquired further about where the Resident was getting cigarettes. He said the Resident's family previously brought in cigarettes, but he had not seen the family member in a while. He said Resident #15 should not be picking cigarette butts up from the ground to smoke them. 3. Review of the facility's policy titled Smoking Policy-Residents, dated as revised in September 2025 indicated oxygen use was prohibited in smoking areas. Resident #82 was admitted to the facility in January 2025 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Review of the MDS assessment, dated 1/30/26, indicated Resident #82 scored 14 out of 15 on the BIMS indicating he/she was cognitively intact, used tobacco products, and used oxygen treatments. Review of the care plans indicated Resident #82 was a smoker and would be educated on safe smoking practices. On 2/10/26 at 12:49 P.M., the surveyor observed Resident #82 exit the facility through the patio door with an oxygen concentrator (a portable device used to take air and convert it into concentrated oxygen) attached to their ambulatory device and a nasal cannula (flexible tubing inserted into the nostrils to deliver supplemental oxygen) in his/her nose. The Resident walked to the gazebo and lit a cigarette. During an interview at this time, Resident #82 said he/she had turned the power off to their oxygen concentrator. Review of the medical record indicated Resident #82 had a physician's order to administer oxygen at 2 liters continuously. Review of the Smoking Evaluation for Resident #82, dated 2/1/26, indicated Resident #82 smoked cigarettes and was educated on the dangers of smoking while on oxygen therapy. The Smoking Evaluation was completed by Unit Manager #1. During an interview on 2/11/26 at 8:17 A.M., Resident #82 said the Staff Development Coordinator (SDC) had watched him/her smoke a long time ago and the SDC had removed their oxygen to watch smoking. The Resident said no staff members had provided education about smoking recently because he/she knew what to do. Resident #82 said they take their oxygen concentrator outside with them because it was difficult to walk without it. He/she said staff had never talked about not having the oxygen concentrator in the smoking area. The Resident said they had bought this particular concentrator because it was not at risk for exploding like an oxygen tank. The Resident was observed to have an Inogen portable oxygen concentrator. Review of the Inogen manufacturer's Safety of Portable Oxygen Concentrators information indicated the following: -oxygen is a key catalyst in many chemical reactions and oxygen users need to be cautious and keep a safe distance from fire, sparks and other flammable materials -keep sources of heat and flame at least five feet away from where oxygen unit is being used or stored -smoking increases the risk of fire when oxygen is in use and puts the user in danger of severe burns or other serious injuries -lighters, matches, cigarettes, cigars and even smoldering ashes are all a fire hazard near supplemental oxygen During an interview on 2/11/26 at 8:28 A.M., Unit Manager #1 said she had completed the Smoking Evaluation for Resident #82. She said she did not go outside with Resident #82 to observe the smoking process but had observed the Resident while walking by the smoking area or front door to come into the facility. She said she was not sure where the Resident put the oxygen concentrator when smoking and had not provided any education regarding this as indicated on the Evaluation on 2/1/26. On 2/11/26 at 9:24 A.M., the surveyor observed Resident #82 smoking in the gazebo with other residents. Resident #82 was actively smoking with their oxygen concentrator hanging from the back of their ambulation device. The Resident did not have their nasal cannula in their nose. During an interview on 2/11/26 at 11:15 A.M., the SDC said Resident #82 was the only Resident who smoked and utilized portable oxygen. He said he had educated Resident #82 about a year ago on stepping away from the oxygen concentrator after turning it off and prior to lighting a cigarette. He said there was no plan for where the Resident would put the oxygen concentrator while smoking. He said the Resident having the oxygen concentrator and/or wearing the nasal cannula which had recently been in use puts the Resident at risk. He said when completing Smoking Evaluations, the staff should be with the residents from the beginning until the end to ensure safety including oxygen safety. During an interview on 2/13/26 at 10:50 A.M., the DON said the Unit Manager should have gone outside with Resident #82 to watch the smoking process from start to finish and should have gone with the Resident to see where the oxygen concentrator was being stored. She said the oxygen concentrator should not be in the smoking area. 4. Review of the facility's policy titled Fall Prevention and Management, dated as revised in November 2024 indicated the following: -develop an individualized care plan based on risk factors -care plans should be updated or revised with any changes in the resident condition and any time a resident experiences a fall Resident #84 was admitted to the facility in October 2025 following recurrent falls. On 2/10/26 at 11:30 A.M., the surveyor observed Resident #84 seated in a wheelchair in the hallway with a regular wheelchair cushion. During an interview on 2/10/26 at 11:30 A.M., Nurse #2 said there were no staff in the unit dining room and the Resident needed supervision related to standing up often. Review of the medical record indicated Resident #84 had seven falls from admission through 11/8/25 and was placed in a wheelchair for use on 11/11/25. Review of the medical record indicated on 11/21/25 Resident #84 slid out of the wheelchair, on 11/25/25 Resident #84 slid out of wheelchair with a note on the incident report indicating therapy would order a wedge cushion for the Resident and on 11/26/25 Resident #84 slid out of the wheelchair. Review of the Care Plan indicated Resident #84 was at risk for falls with an intervention added on 11/25/25 for Therapy to provide the Resident with a wedge cushion. Review of the Occupational Therapy Treatment Encounter notes indicated on 12/9/25 Resident #84 was provided with a new cushion. Review of the medical record indicated Resident #84 did not have any falls in December 2025. Further review indicated Resident #84 fell out of the wheelchair on 1/1/26, 1/6/26, and 1/26/26. Review of the incident reports failed to indicate if the wedge cushion was in place at the time of the falls. On 2/13/26 at 9:05 A.M., the surveyor observed Resident #84 in the unit day room in a wheelchair with a regular cushion, not a wedge cushion. During an interview on 2/13/26 at 9:15 A.M., the Unit Manager and the surveyor reviewed the Resident's falls and interventions. The Unit Manager said Resident #84 was losing his/her balance when ambulating with a rolling walker and a wheelchair was implemented to assist the Resident with further distances. The Unit Manager said the Therapy Department had implemented a wedge cushion for Resident #84 which was still in place. The surveyor and the Unit Manager observed Resident #84 at this time and the Unit Manager confirmed the Resident had a regular cushion and did not have a wedge cushion as indicated on the care plan. During an interview on 2/13/26 at 10:15 A.M., the Director of Rehabilitation said she had ordered a wedge cushion for Resident #84 which had arrived while Resident #84 was in the hospital in early December. She said she placed the wedge cushion on the wheelchair for Resident #84, and the Resident was discharged from services shortly after with a plan to continue the wedge cushion. She said she was not sure where the wedge cushion was at this time. During an interview on 2/13/26 at 11:03 A.M., the DON said when a resident falls the process was to review the Resident and the environment to ensure all interventions were in place. She said following the falls in January 2026, the facility staff should have identified if the wedge cushion was still in place.

Based on interview, policy review, and document review, the facility failed to set priorities for an effective Quality Assurance Performance Improvement (QAPI). Specifically, the facility failed to develop a performance improvement project (PIP) to track, investigate, analyze and use data and information related to:1. The identification of adverse events of residents who required supervision leaving the facility unattended; and2. Resident Council and individual resident identified concerns with call light wait times. Findings include:Review of the facility's policy titled Quality Assurance Performance Improvement (QAPI): Operations Department, dated as revised in June 2019, indicated the following:-the purpose of the Steering Committee was to review and analyze facility related data and direct appropriate actions for the facility response-data is reviewed initially to identify problems and challenges to be addressed through PIPs and then are used to prioritize the challenges to address first-data will be used to set goals for the PIP, monitor progress, and evaluate the effectiveness of intervention(s) implemented during the PIP, then determine how to expand the lessons learned systemically Review of the facility's policy titled Quality Assurance Performance Improvement (QAPI): Clinical Department, dated as revised in June 2019, indicated the following:-the QAPI plan will address Quality of Life through resident/family concerns brought up at Resident or Family Committee meetings-Center leadership, including, but not limited to Administrator, Director of Nurses, Social Services, and Activity Director meet monthly to address life concerns.-the following data is monitored through QAPI: input from caregivers, residents, families and others including adverse events, performance indicators and survey findings-the information gathered is analyzed and compared to benchmarks and/or targets established by the facility 1. Review of the Facility Reported Incidents (FRIs) prior to the survey start indicated in December 2025 the facility had developed a plan of correction for deficient practice related to a resident eloping from the facility. On 2/10/26 at 4:15 P.M., Resident #80 was observed outside in the opened courtyard, adjacent to the parking lot, with a wander guard on his/her wrist. Resident #80 was not supervised or with any staff members. During an interview on 2/10/26 at 4:22 P.M., Nurse #1 said Resident #80 should be supervised and should not be outside alone. Review of the medical record indicated Resident #80 had an activated Health Care Proxy and had previously left the facility unattended in October 2025. During an interview on 2/13/26 at 1:35 P.M., the Administrator said the facility used multiple ways to identify projects for improvement including plans of correction. She said the facility had developed a plan of correction (POC) for residents at risk for elopement in December 2025 which included staff education and audits. She said she did not have a PIP for the surveyor to review because she brought the POC audits to the QAPI committee meeting in January 2026. She reviewed the facility form utilized for PIPs and said there was not one to address the residents at risk for elopement. She said there were no measurable goals for the POC and the goal was to supervise residents who were identified as needing wander guards. She could not say how she was measuring the success of the implemented interventions through the QAPI process. 2. Review of the Resident Council Minutes for November 2025 indicated that when asked, the residents responded that they could not get help or care without waiting a long time and call lights were not always answered in a timely manner. Review of the Resident Council Minutes for January 2026 indicated that when asked, the residents responded that sometimes they could get help or care without waiting a long time and call lights were sometimes answered in a timely manner. During a group meeting with 14 residents on 2/10/26 at 1:30 P.M., the residents said they did not feel call lights were being answered timely. Residents said the call light wait times could vary and the issue was usually during the 3:00 P.M. to 11:00 P.M. shift. Seven out of 14 residents said they had waited over a half hour for call lights to be answered. During an interview on 2/11/26 at 10:30 A.M., the Activities Director said sometimes during Resident Council meetings the residents would say they waited a long time for call lights to be answered, but it was not all the residents, so she verbally provided the information to the Administrator. During an interview on 2/13/26 at 1:30 P.M., the Administrator said the resident's input was used for the QAPI process through resident conversations, grievances, and Resident Council. She said residents had voiced concerns with long call light wait times and she felt this had improved. She said call light wait time was an active QAPI but that she did not have a PIP for the surveyor to review. She reviewed the facility form utilized for PIPs and said there was not one for call light wait times. She said she had done education with the staff and lunch and learns to tell staff to answer the call lights and the weekend Manager on Duty was completing audits. She said there was no documentation to analyze, measure, or track the data from audits and that audits were only being completed on the weekends. She said she felt the call light wait time was improving but did not have any data to indicate the improvements and had not attended Resident Council to receive feedback from the residents on the success of the implemented interventions. During an interview on 2/13/26 at 2:45 P.M., the [NAME] President of Operations and a member of the Governing Body, said these two examples of improvement were missed as part of the QAPI process.

Based on observation, interview, and record review, the facility failed to ensure oxygen (O2) equipment was maintained in a sanitary manner to help decrease the risk of potential contamination and infection for two Residents (#21 and #15), out of a total sample of 20 residents. Findings include:Review of the World Health Organization: Care, Cleaning and Disinfection of Oxygen Concentrators Checklist (2022) indicated:-Inspect and clean air intake filter (1-2 times per week)1. Pull the filter gently out and replace with spare one.2. Put the filter in cool, soapy water and swirl gently to remove debris.3. Remove from soapy water and place it in [NAME] area until completely dry.4. Store the spare filter until next cleaning is needed. Review of the National Library of Medicine (NLM), dated 1/19/22, indicated but was not limited to:-One of the main issues affecting the oxygen concentrators, is that related to the filters, which are designed to filter out dust, particles, bacteria.https://pmc.ncbi.nlm.nih.gov/articles/PMC8768026/ A. Resident #21 was admitted to the facility in October 2024 with diagnoses including chronic obstructive pulmonary disease (COPD, a progressive, irreversible lung disease that causes severe airflow obstruction and breathing difficulties,) and shortness of breath. Review of the Minimum Data Set (MDS) assessment, dated 1/23/26, indicated Resident #21 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15, shortness of breath or trouble breathing with exertion and when lying flat, and utilized oxygen therapy. Review of the User's Technical Manual, dated November 2009, for Resident #21's oxygen concentrator indicated but was not limited to:-Cleaning the Cabinet Filter (external filter)-DO NOT operate the concentrator without the filter installed.- NOTE: There is one cabinet filter located on the back of the cabinet.-Remove the filter and clean at least once a week depending on environmental conditions.-Clean the cabinet filter with a vacuum cleaner or wash in warm soapy water and rinse thoroughly. Review of Resident #21's Physician's Orders indicated but were not limited to:- Administer Oxygen at 2 liters (L)/minute continuously via nasal cannula every shift, dated 10/4/2024-Change oxygen every Tuesday on the night shift. Wipe down concentrator and clean filters, dated 10/25/2025 The surveyor observed Resident #21's oxygen concentrator running and in use without a filter and gray dust-like debris where the filter should have been as follows:-2/9/26 at 10:00 A.M.-2/10/26 at 8:49 A.M. and 4:07 P.M.-2/11/26 at 11:26 A.M. and 2:44 P.M.-2/12/26 at 7:12 A.M. and 12:20 P.M. Review of Resident #21's February Treatment Administration Record (TAR) indicated his/her oxygen concentrator had been wiped down and the filter cleaned on 2/3/26 and 2/10/26. During an interview with observation on 2/11/26 at 2:44 P.M., Nurse #1 and the surveyor observed Resident #21 sitting in his/her wheelchair utilizing his/her oxygen. Nurse #1 said Resident #21 utilized oxygen continuously. Nurse #1 and the surveyor inspected Resident #21's oxygen concentrator. Nurse #1 said she had changed Resident #21's oxygen tubing on 2/3/26 and wiped down their oxygen concentrator. Nurse #1 said she did not know if Resident #21's oxygen concentrator needed a filter. Nurse #21 said the area over the internal filter of the oxygen concentrator had gray dust-like debris over it. During an interview with Nurse #1 present on 2/11/26 at 2:53 P.M., Resident #21 said he/she had utilized oxygen therapy since being admitted to the facility. Resident #21 said his/her oxygen concentrator should have an external filter on it, but it did not. During an observation and interview with Resident #21 present on 2/12/26 at 12:36 P.M., Nurse #3 said the 11:00 P.M. to 7:00 A.M. shift was responsible for changing tubing and cleaning the filters on oxygen concentrators weekly. Nurse #3 observed Resident #21's oxygen concentrator and said she was not sure if it should have had a filter. Resident #21 said there should have been a filter in place on his/her oxygen concentrator but there had not been a filter in place in some time. During an interview with observation 2/12/26 at 1:40 P.M., the Staff Development Coordinator/Infection Preventionist said the filters on oxygen concentrators were cleaned weekly on the overnight shift. He observed Resident #21's oxygen concentrator and said the area where the filter belonged was covered with gray dust-like debris and the filter was not present. B. Resident #15 was admitted to the facility in January 2023 with diagnoses including dependence on supplemental oxygen, COPD, chronic respiratory failure, and shortness of breath. Review of the MDS assessment, dated 12/5/25, indicated Resident #15 had a moderate cognitive deficit as evidenced by a BIMS score of 10 out of 15, had trouble breathing on exertion and when lying flat, and utilized oxygen therapy. Review of the User's Technical Manual, dated July 2022, for Resident #15's oxygen concentrator indicated but was not limited to:- Cleaning the Cabinet Filter-CAUTION! Risk of Damage: To avoid damage to the internal components of the unit: - DO NOT operate the concentrator without the filter installed or with a dirty filter.-There are two cabinet filters located on each side of the cabinet.- Remove the filter and clean as needed. -Environmental conditions that may require more frequent inspection and cleaning of the filter include, but are not limited to high dust, air pollutants, etc.-Clean the cabinet filter with a vacuum cleaner or wash with mild liquid dish detergent and water. Rinse thoroughly.-Thoroughly dry the filter and inspect for fraying, crumbling, tears and holes. Replace filter if any damage is found.-Reinstall the cabinet filter. Review of Resident #15's Physician's Orders indicated but were not limited to:- Administer Oxygen at 3 liters (L)/minute continuously via nasal cannula as needed, dated 9/10/2024-Change oxygen every Tuesday on the night shift. Wipe down concentrator and clean filters, dated 11/12/2024 The surveyor observed Resident #15's oxygen concentrator running and in use with the filters on the left and right side of the oxygen concentrator covered with a thick layer of gray dust-like debris on each side on:-2/9/26 at 9:31 A.M. and 11:19 A.M.-2/10/26 at 8:44 A.M.-2/12/26 at 7:13 A.M. Review of Resident #15's February TAR indicated his/her oxygen concentrator had been wiped down and filter was cleaned on 2/3/26 and 2/10/26. During an interview with observation on 2/12/26 at 12:26 P.M., Nurse #4 said oxygen concentrators were monitored by maintenance. Nurse #4 said the overnight shift was responsible for changing the oxygen tubing weekly and changing and cleaning the filters weekly. Nurse #4 and the surveyor inspected the filters on Resident #15's oxygen concentrator and said they did not look too bad. During an interview with observation 2/12/26 at 1:40 P.M., the Staff Development Coordinator/Infection Preventionist said the filters on oxygen concentrator were cleaned weekly on the overnight shift. He observed Resident #15's oxygen concentrator and said those filters are dirty and should be cleaned. During an interview on 2/12/26 at 1:53 P.M., the Director of Nursing said the 11:00 P.M. to 7:00 A.M. shift was responsible for cleaning the oxygen concentrators and washing the oxygen filters with soap and water weekly. She said she was notified about Resident #15's oxygen filters being dirty and Resident #21's filter being missing and the area where the filter should have been being dirty. She said the expectation was each oxygen concentrator should be clean and have a clean filter in place.

Based on observation, interview and record review, the facility failed to follow professional standards of practice for three Residents (#2, #8, and #39), out of a total sample of 20 residents. Specifically, the facility failed:1. For Resident #2, to inform Nurse Practitioner (NP) #1 timely of medication dosage recommendations following a neurology consult, resulting in a 22-day delay in ordering and implementing the recommendations; 2. For Resident #8, to obtain a urology consultant report per NP #1's order resulting in a 57-day delay in reviewing the recommendations; and3. For Resident #39, to monitor the continuous glucose sensor or hand held reader to ensure they were both working properly and providing accurate blood glucose results, and to ensure the manufacturer's recommendations of changing the sensor every 14 days and rotation of the sensor application site were followed, and to ensure infection control parameters were followed to minimize risk of infection since Resident #39 was admitted to the facility. Findings include: 1. Facility reported no policy for consultant visit recommendations. During an interview on 2/12/26 at 11:22 A.M., Nurse Practitioner (NP) #1 said it can be challenging to get consult reports. She said in a perfect world she refers the residents to see a consultant, they have the consult visit, return to the facility with a visit summary report, and that report is put in her folder. NP #1 said she doesn't always receive the visit summary report. When she does not, she writes an order for the nurses to obtain the report, or she can sometimes see them in the hospital based electronic medical record. NP #1 said it is important to get consultant reports for collaboration of care, medication recommendations or changes. She said there have been some communication issues with getting the consultant summary visits timely. Resident #2 was admitted to the facility in February 2025 with diagnoses which included Parkinson's disease and dementia. During an interview on 2/10/26 at 12:10 P.M., Resident #2's Family Member #3 said the Resident was seen by the neurologist and was never started on the recommended medication until he/she brought in the neurologist report and gave it to a nurse because it was not in his/her medical record. Review of Physician's Orders indicated the Carbidopda-Levodopa ER oral tablet 25-100 milligrams (mg), give by mouth two times a day for Parkinson's disease was initiated on 2/4/26. Review of Resident #2's Neurology Consultant Progress note, dated 1/13/26, indicated but was not limited to the following:-Patient is here for a follow up, at a nursing home but has deteriorated since last visit with us.-His/her Mini-Mental State Examination (screening tool to monitor progression of Parkinson's disease) is much worse and he/she has more Parkinsonian with symmetry which may be related to anti-psychotic medication, but also possibly Parkinson's disease.-We discussed a trial of Carbidopa/ Levodopa (Sinemet- Used to treat Parkinson's disease by reducing symptoms, like muscle stiffness, tremors, spasms, and poor muscle control by increasing dopamine levels in the brain) at 25/100 mg initially twice a day (BID), then increased to three times a day (TID). -Follow up in three months, sooner if needed.-Copy in the chart indicated NP #1 signed reviewing the consultant report on 2/4/26. Review of a Nursing note, dated 1/13/26 at 11:16 P.M., indicated Resident #2 returned from neurology appointment with Consultant Neurologist. Consult notes indicated deterioration in function and memory with recommendations for trial of Carbidopa/Levodopa at 25/100 mg, initially twice a day and then increased to three times a day. Review of Nursing note, dated 1/13/26 at 11:20 P.M., indicated. NP #1 notified of neurology recommendations at 10:21 P.M. During an interview on 2/12/26 at 1:15 P.M., Family Member #3 said the transport driver brought Resident #2 back to the facility and had the paperwork from the neurologist. Family Member #3 said about week and half after the appointment he/she followed up with Nurse #1 to see if the medication was started and Family Member #3 was told by Nurse #1 the neurologist consult report was not in the medical record. Family Member #3 provided Nurse #1 with a copy of the neurology consult report and was told Nurse #1 was going to put it in the medical record. Family Member #3 said he/she followed up with NP #1 on 2/4/26 to inquire how the medication change was and NP #1 told him/her she had not seen the neurology consult. Family Member #3 said NP #1 found the consultation report in the medical record and that's when Resident #2 was started on the medication the neurologist recommended. During an interview on 2/12/26 at 11:22 A.M., NP #1 said she was not aware of the neurologist summary report until FM #3 brought it to her attention on 2/4/26. NP #1 said when she read the report, she started Resident #8 on the medication the neurologist recommended. NP #1 said there was a delay in starting the medication because she was delayed in receiving the report. 2. Resident #8 was admitted to the facility September 2025 with diagnoses which included prostatic hyperplasia (enlargement of prostate gland) with lower urinary symptoms, urinary tract infection(s), and urinary retention. Review of Physician's Orders indicated but were not limited to:-NP #1 on 12/15/25 wrote order to please obtain urology visit summary from 12/12/25 and leave in provider book for review. Every shift for visit summary request needed for coordination of care. Review of Resident #8's Treatment Administration Record (TAR) for December 2025, January 2026, and February 2026 indicated this order was signed off 171 times and signed off as completed and coded 8 (other) 23 times over three shifts. Review of a Nursing note, dated 12/17/25 at 9:59 A.M., indicated Urology Consultant's office was called and a message left to fax over visit summary from last week's visit at NP's request. On 2/11/26, a review of Resident #8's medical record indicated there was no urology consult report for date of service 12/12/25 in the paper or electronic medical record. During an interview on 2/11/26 at 3:42 P.M., Nurse #1 said the Assistant Director of Nurses said Resident #8's Urology report was never received in the facility. Review of a fax received in the facility on 2/12/26 at 2:06 P.M. from the consultant urology office included an office visit note with date of service 12/12/25 which indicated but was not limited to the following: -Resident's Health Care Proxy (HCP) stated Resident #8 had about four urinary tract infections over the last four to five months.-Resident has been on several courses of antibiotics.-I did recommend maybe starting him/her on some cranberry supplements and we will have to consider maybe about suppressive antibiotics in the future as well as maybe Methenamine Hippurate (Antiseptic medication used to prevent recurrent urinary tract infections) moving forward. During an interview on 2/12/26 at 11:22 A.M., NP #1 said she never received Resident #8's urologist's consult report from the visit on 12/12/25, so she wrote orders on 12/17/25 to obtain urology note and leave it in the providers folder. NP #1 said she referred Resident #8 to see the urologist as a follow up to Resident #8's recurrent UTIs and follow-up to his/her hospitalization recommendations. NP #1 said she wrote a second request today for the nurses to obtain the urology note. NP #1 said there are some communication issues on the first floor. Resident #8's consultant urology report, dated 12/12/25, was received in the building on 2/12/26, 57 days after the visit. 3. During an interview on 2/13/26 at 2:14 P.M., the Director of Clinical Services said they do not have a policy for using a continuous glucose monitor (CGM). Review of the manufacturer's guidelines for the use and care of the CGM system used by Resident #39, indicated but was not limited to the following:-Continuous Glucose Monitoring system has 2 main parts: A disposable sensor and either a handheld reader or a mobile app to wirelessly receive and display glucose readings from the sensor.-Failure to use the System according to the instructions for use may result in you missing a severe low blood sugar or high glucose event and or making a treatment decision that may result in injury.-14-day wear duration.-Take standard precautions for transmission of bloodborne pathogens to avoid contamination.-Wash application site on the back of your upper arm using plain soap. Dry, and then clean with an alcohol wipe (Not included in the kit). Allow site to air-dry before proceeding.-Clean hands prior to sensor handling/insertion to help prevent infection.-Change the application site for the next sensor application to prevent discomfort or skin irritation.-Only apply the sensor to the back of the upper arm. If placed in other areas, the sensor may not function properly.-Do not touch inside sensor application as it contains a needle.-Applying the sensor may cause bruising or bleeding.-During the first 12 hours of sensor wear the magnifying glass/drop of blood symbol will display, and you cannot use sensor values to make treatment decisions during this time period. Confirm sensor glucose readings with a blood glucose test before making treatment decisions during the first 12 hours of sensor. There when you see the magnifying glass/blood drop symbol.-If the reader is dropped or subjected to impact, do a reader test to check that it is still working properly. Resident #39 was admitted to the facility in November 2025 with diagnoses which included Type II diabetes mellitus with proliferative diabetic retinopathy with macular edema right eye and traction retinal detachment involving macular left eye, legally blind, and on long-term use of insulin. Review of the Minimum Data Set (MDS) assessment, dated 11/24/25, indicated Resident #39 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating Resident #39 was cognitively intact. Review of Resident #39's Physician's Orders indicated the following orders:- Resident has a continuous glucose monitor, before meals and at bedtime related to diabetes mellitus (DM) (sic), order date 11/24/25. During an interview on 2/13/26 at 12:45 P.M., Resident #39 said the nurses check his/her blood glucose levels using his/her CGM system since he/she was admitted . Resident #39 said they never prick his/her finger to get his/her sugar readings. During an interview on 2/13/26 at 2:13 P.M., the Director of Nurses (DON) said they don't use a CGM system in the building. She said her expectation is that the nurses do a finger stick to monitor a resident's blood glucose levels. The DON said she was not aware the nurses were monitoring Resident #39's blood glucose levels using only the CGM system. The DON reviewed Resident #39's orders and said there were no orders in place for the care of the CGM system or changing of the CGM sensors. During an interview on 2/13/26 at 2:18 P.M., Nurse #1 said she regularly works on the first floor and cares for Resident #39. She said she checks Resident #39's blood glucose level using the Resident #39's CGM monitoring system. Nurse #1 said she does not know who monitors the sensors, changes the sensor unit, how often it is changed, or where Resident #39 gets the supplies to change the sensor. During an interview on 2/13/26 at 2:20 P.M., Nurse #7 said she has worked with Resident #39, and she uses Resident #39's glucose monitor to check his/her blood sugar levels. Nurse #7 said she never does a finger stick to check blood glucose levels. Nurse #7 said she did not know anything about the care or maintenance of the CGM monitoring machine system. Nurse #7 said she just reads the meter for the results; that's the way the patient wants it. During an interview on 2/13/26 at 2:26 P.M., with Consultant Chief Clinical Officer (CCCO) present, Resident #39 said the nurses get his/her blood glucose reading from the meter reading all the time and showed the surveyor the small digital reader on his/her bedside table. Resident #39 said he/she changes the device every two weeks him/herself and proceeded to demonstrate for the surveyor with an actual sensor he/she removed from a box, raised their left arm and said, you just put it against your skin and press down; it is easy. Resident #39 did not demonstrate or state he/she cleans the area or rotates the location of the sensor. During an interview on 2/13/26 at 2:27 P.M., CCCO said Resident #39 said the nurses use his/her CGM system all the time to monitor blood glucose levels. She said she has the CGM package insert and will have to review the manufacturer's instructions.

Based on observation, interview, and record review, the facility failed to ensure a person-centered plan of care with individualized interventions for trauma-informed care was developed for one Resident (#84), out of 20 sampled residents. Specifically, the facility failed to assess and implement care plan interventions for Resident #84 who had a history of trauma. Findings include:Review of the facility's policy titled Trauma Informed Care, dated as revised in October 2019, indicated as part of the comprehensive assessment, identifying history of trauma or interpersonal violence when such information is provided to the facility. Identifying past trauma or adverse experiences may involve record review or the use of screening tools. Resident #84 was admitted to the facility in October 2025 with diagnoses of substance use disorder and cognitive impairment. On 2/10/26 at 11:30 A.M., the surveyor observed Resident #84 sitting across from the nurses' station. Resident #84 said he/she was scared and asked the surveyor for help. During an interview on 2/10/26 at 11:30 A.M., Nurse # 2 said Resident #84 always says they were scared and this was their behavior. Review of the care plans indicated Resident #84 had a focus for behaviors related to wandering, pacing, refusing care, yelling at staff, physically aggressive, verbally abusive, disruptive sounds and disrobing in public with the following interventions: administer and monitor the effectiveness and side effects of medications, anticipate care needs, invite and encourage activity programs, provide non-confrontational environment and to reduce the following stressors that may be contributing to the resident's inappropriate behaviors: calling sister. Review of the medical record indicated on 11/5/25 the Licensed Mental Health Counselor (LMHC) noted Resident #84 had a history of trauma, and all subsequent visits with the LMHC noted a history of trauma. Review of the Social Service Evaluation, dated 1/9/26, which included a Trauma Informed Care Assessment indicated Resident #84 had not ever had an experience so upsetting it changed him/her emotionally, spiritually, physically or behaviorally. No further information was indicated on the trauma assessment. The Behavior section indicated Resident #84 demonstrated agitation, anxiousness, restlessness and tearfulness. The Plan of Care comments indicated Resident was followed by psychiatric services including a most recent visit with the LMHC on 1/6/26. There was no further indication the Social Worker inquired to the Resident or the Resident's sister about the noted trauma on the LMHC visit. During an interview on 2/13/26 at 10:10 A.M., the Administrator said the Social Worker was unavailable for interview this week. During an interview on 2/13/26 at 11:12 A.M., the LMHC said Resident #84 had a cognitive decline over the last few months and he had continued therapeutic sessions with the Resident to offer support. He said Resident #84 had previously alluded to trauma in regard to drug use and living on the streets. He said the Resident cries a lot and would talk about very difficult things including the people he/she associated with during the drug use. He said he had not reached out to the family of Resident #84 regarding the trauma and had not heard if the facility staff had either. He said he communicates with the unit staff regarding residents, including the Unit Manager. During an interview on 2/13/26 at 11:40 A.M., the Unit Manager said she was aware Resident #84 had a history of substance use disorder but did not hear anything about a history of trauma. During an interview on 2/13/26 at 12:00 P.M., the LMHC said he had reached out to the sister of Resident #84 who said Resident #84 had a history of being physically abused. He said with the Resident's cognitive decline, the Resident may be thinking he/she was currently in the unsafe situation, making accepting care difficult. During an interview on 2/13/26 at 12:26 P.M., the Director of Nurses said the history of trauma should have been on the Social Service Evaluation and should have been care planned with interventions.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to:1. Properly label and date food products in the main kitchen walk-in refrigerator, and store food products in the walk-in refrigerator off the floor; and 2. Ensure in two of two kitchenettes, resident food was discarded after three days, and food storage cabinets were kept clean. Findings include: Review of the facility's policy titled Food and Supply Storage, last revised 6/2018, indicated but was not limited to the following:-Food and food supplies are stored to minimize exposure to splash, dust, and other contamination; and stored away from the walls and six inches off the floor and eighteen inches below ceiling and fire sprinkler system.-Food products that are opened and not completely used; transferred from its original package to another storage container; or prepared at the facility and stored should be labeled as to its contents and use by date.-Discard food that exceeds their use by date or expiration date, is damaged, is spoiled, has the time and temperature danger zone requirements, or incorrectly stored such that it is unsafe or its safety is uncertain. On 2/9/26 at 7:21 A.M., the surveyor observed the following in the main kitchen: -One metal container containing sliced tomato and lettuce with a pinkish discoloration, Prep date 1/30/26, and a use by date of 2/4/26.-One metal container, holding four small clear plastic containers dated 1/21 containing white chopped onions.-Two trays with prepared cole slaw and plastic containers, undated.-One pouch of whipped cream, not dated with an open date.-Four boxes containing juice cups stored on the floor, under the bottom shelf. On 2/11/26 at 9:34 A.M., the surveyor observed the following in the main kitchen:Walk-in refrigerator:-Two boxes of half gallon milk products stored on the floor of the walk-in refrigerator (where the four boxes of juice cups were stored on 2/9/26). During an interview on 02/12/26 at 9:00 A.M., the Food Service Manager (FSM) said the boxes of food should not have been stored on the floor in the refrigerator and the food should be discarded after three days. 2. Review of the facility's policy titled Food Brought into Facility, last revised 4/2019, indicated but was not limited to:- It is the policy of the Company that visitors or family members are permitted to bring food to a resident and are encouraged to limit food to those that meet patient's meal plan and safe food handling practices.- Perishable food must be stored and identified with resident's name, food item and use by date.- These can be stored in the nursing unit kitchen nourishment refrigerator. - The nursing staff is responsible for discarding perishable foods on or before the use by date.On 2/12/26 at 8:08 A.M., the surveyor made the following observations in the resident's kitchenette on the second-floor unit:-In the refrigerator was a white takeout container with a resident's name, which was dated 2/7/26. -In the bottom left shelf cabinet was a plastic food container that was soiled with some type of sauce, dirty fork, and particles of debris on the shelf. On 2/12/26 at 8:18 A.M., the surveyor made the following observations in the resident's kitchenette on the first-floor unit:-In the refrigerator was a white bag labeled with a resident's name, which was dated 2/6/26. In the bag was a black banana, white Styrofoam container which contained a piece of cake, various other pre-packaged items orange juice, cake, fruit cups, and numerous packages of condiments. On 2/13/26 at 10:10 A.M., the surveyor and the FSM observed both the first and second floor resident kitchenettes and observed the same resident food as observed on 2/12/26 still in the refrigerator and the same dirty container on the bottom shelf of the second-floor kitchenette. During an interview on 2/13/26 at 10:14 A.M., the FSM said when the staff check the refrigerator temperatures in the morning, they should remove any food stored that is older than three days. He said the cabinets should be kept clean.

Based on record review and interview, the facility failed to ensure the Arbitration Agreement presented to residents as part of the admission packet included the required information for three Residents (#75, #85, and #59), out of a sample of three records reviewed. Specifically, the facility failed to ensure the agreement explicitly granted Residents thirty days after signing to rescind the Agreement and failed to explicitly state that the residents (or representatives) were not required to sign as a condition for admission. Findings include:During the entrance conference interview on 2/9/26 at 8:22 A.M., the Administrator said the facility has asked residents to enter into a binding arbitration agreement. 1. Resident #75 was admitted to the facility in January 2026. During an interview on 2/10/26 at 3:37 P.M., Resident #75 said no one had explained any of the paperwork to him/her when they were admitted . He/she said they were handed paperwork and asked to sign it. Review of the Arbitration Agreement signed by Resident #75 on 1/8/26 failed to explicitly state that the Resident could rescind the agreement within 30 days and failed to indicate the Resident was not required to sign as a condition of admission. 2. Resident #85 was admitted to the facility in December 2025. During an interview on 2/10/26 at 3:43 P.M., Resident #85 said no one had told him/her about arbitration or having 30 days to rescind the agreement, but that hearing it from the surveyor made sense. The Resident said no one had reviewed the admission paperwork with him/her, but he/she had told the staff that he/she understood it. Review of the Arbitration Agreement signed by Resident #85 on 12/16/25 failed to explicitly state that the Resident could rescind the agreement within 30 days and failed to indicate the Resident was not required to sign as a condition of admission. 3. Resident #59 was admitted to the facility in January 2026. During an interview on 2/10/26 at 3:47 P.M., the representative of Resident #59 said someone had reviewed the admission paperwork with her and she did recall reviewing the Arbitration Agreement. Review of the Arbitration Agreement signed by the representative of Resident #59 on 1/23/26 failed to explicitly state that the Resident could rescind the agreement within 30 days and failed to indicate the Resident was not required to sign as a condition of admission. During an interview on 2/10/26 at 4:10 P.M., the Administrator said she was responsible for reviewing admission packets with residents and representatives and had been reviewing Arbitration Agreements as well. The Administrator provided the surveyor with a blank copy of an admission packet that she had been providing to residents, which included Attachment M: Arbitration Agreement. The Administrator reviewed the Arbitration Agreement for all three Residents and said she was unable to find where it stated the Residents could rescind the Agreement within 30 days after signing or where it stated that the Residents (or representatives) were not required to sign as a condition for admission. She said she goes over this information verbally with residents because she knows it is part of the regulation. She said she was not sure why two of the Residents had said no one had gone over the information with them. She said this was the most up to date Arbitration Agreement. During an interview on 2/11/26 at 8:30 A.M., the Administrator said there was a more up to date Arbitration Agreement that was developed in February 2025, but she had not been using the correct one. She said the required components were not listed on the Agreements signed by Residents #75, #85 and the representative for #59.

Based on record review and interview, the facility failed to ensure the Arbitration Agreement presented to residents as part of the admission packet included the required information for three Residents (#75, #85, and #59), out of a sample of three records reviewed. Specifically, the facility failed to ensure the agreement provided for the selection of a neutral arbitrator agreed upon by both parties and the selection of a venue that was convenient to both parties. Findings include:During the entrance conference interview on 2/9/26 at 8:22 A.M., the Administrator said the facility had asked residents to enter into a binding arbitration agreement. 1. Resident #75 was admitted to the facility in January 2026. Review of the Arbitration Agreement signed by Resident #75 on 1/8/26 failed to indicate both parties would agree to a neutral arbitrator and agree to a venue that was convenient to both parties. 2. Resident #85 was admitted to the facility in December 2025. Review of the Arbitration Agreement signed by Resident #85 failed to indicate both parties would agree to a neutral arbitrator and agree to a venue that was convenient to both parties. 3. Resident #59 was admitted to the facility in January 2026. Review of the Arbitration Agreement signed by the representative of Resident #59 on 1/23/26 failed to indicate both parties would agree to a neutral arbitrator and agree to a venue that was convenient to both parties. During an interview on 2/10/26 at 4:10 P.M., the Administrator said she was responsible for reviewing admission packets with residents and representatives and had been reviewing Arbitration Agreements as well. The Administrator provided the surveyor with a blank copy of an admission packet that she had been providing to residents, which included Attachment M: Arbitration Agreement. The Administrator reviewed the Arbitration Agreement for all three Residents and said she was unable to find where it indicated both parties would agree to a neutral arbitrator and would agree to a venue that was convenient to both parties. She said this was the most up to date Arbitration Agreement. During an interview on 2/11/26 at 8:30 A.M., the Administrator said there was a more up to date Arbitration Agreement that was developed in February 2025, but she had not been using the correct one. She said the required components were not listed on the Agreements signed by Residents #75, #85 and the representative for #59.

Based on record review and interview, the facility failed to coordinate an assessment with the Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) program for one Resident (#9), out of a total sample of 20 residents. Specifically, the facility failed to document Resident #9's bipolar disorder diagnosis in Section B at admission and did not initiate a new PASRR Level I Assessment following the addition of a schizoaffective disorder diagnosis to the clinical record. Findings include:Review of the MassHealth Nursing Facility Bulletin 186, dated June 2024, included but was not limited to the following:-Level I Screenings, including Post-admission Screenings, must be performed using the PASRR Level I Screening form via the PASRR Portal. Level I Screenings may not be performed using any other form or screening tool-Post admission Screening:A PASRR screening, using the Level I Screening form submitted via the PASRR Portal, of nursing facility residents that the nursing facility must conduct in the following instances:1) for an individual who is admitted to the facility under an Exempted Hospital Discharge (EHD) or a time-limited Categorical Determination (CD), if the facility determines that the admission will exceed the EHD or CD's permitted duration, or 2) for residents who experience a Significant Change or are newly identified as having a condition that may impact their PASRR status, the appropriateness of their nursing facility placement, or their need for Specialized Services.Resident #9 was admitted to the facility in September 2022 with diagnoses including bipolar disorder, anxiety, and depression. Review of the PASRR assessment, completed 9/22/22, Section B: Screen for Serious Mental Illness (SMI) indicated that the resident had a SMI for anxiety. Further review, of Section B, mood disorder (e.g., Bipolar or Major Depression) was not selected on the intake form.Review of Physician's orders, dated 2/5/24, indicated to add a diagnosis of schizoaffective disorder.Review of the Resident's clinical record included a list of diagnoses which indicated:-bipolar disorder, current episode depressed, mild, dated 9/2022-schizoaffective disorder was added on 2/6/24 During an interview on 2/13/26 at 1:05 P.M., Regional Nurse (RN) #1 said the Social Worker (SW) would oversee the PASRR process. RN #1 said the SW was not available as she was away. RN #1 said the Administrator would be able to retrieve any PASRRs from the portal.During an interview on 2/13/26 at 1:06 P.M., the Administrator reviewed the PASRR Portal for an updated Level I PASRR and said a new Level I PASRR screen had not been submitted to include a diagnosis of bipolar disorder and capture a newly added diagnosis of schizoaffective disorder on 2/6/24. The Administrator said a Level I PASRR should have been completed.During an interview on 2/13/26 at 2:00 P.M., RN #1 said that the Resident should have had a new Level I PASRR screening done to include a SMI diagnosis of bipolar disorder. RN #1 said that a new PASRR Level I screen should have been submitted to the PASRR Portal on 2/6/24 when a diagnosis of schizoaffective disorder was added to the Resident's diagnosis list, but the PASRR screen had not been submitted.

Based on interview, observation, and document review, the facility failed to ensure residents/resident representatives had the right to voice and formulate grievances, have those grievances responded to promptly, and be provided a resolution to their grievance for one Resident (#39), out of a total sample of 20 residents. Specifically, the facility failed to ensure staff followed their policy and procedure when Resident #39 voiced a complaint regarding music playing outside his/her room disrupting his/her ability to be comfortable in his/her room. Findings include: Review of the facility's policy titled Grievances, dated 2/2024, indicated but was not limited to the following:-The Administrator is identified as the grievance official responsible for oversight of the grievance process in the facility. This includes responsibility for reviewing and tracking grievances, necessary investigations, ensuring that grievances are addressed and response provided.-If a resident, and/or health care representative, or another interested family member of a resident has a complaint, a staff member will inform the person of the grievance process and assist the resident, or person acting on the resident's behalf, to file a written grievance with the facility using the grievance form as needed.-Grievances may be submitted orally or in writing.-Upon receipt of written grievance, the Administrator will refer it to the appropriate department head for investigation. The Department head will submit a responsive finding to the Administrator.-The Administrator will review the findings with the person investigating the grievance to determine what corrective actions need to be made.-The Administrator will document receipt of all grievances on the Grievance Log. The Grievance Log will be used for tracking and trending as part of the Facility Quality Performance Improvement Committee as warranted.-The resident, and/or health care representative, or person filing the grievance on behalf of the resident, will be informed of the findings of the investigation and actions that will be taken to correct any identified problems. This report will be completed by the Administrator within 7 working days of receipt of the grievance.-The grievance will be signed by the administrator and will be made available to the resident and/or health care representative, or person acting on behalf of resident. The reports are filed in a binder, labeled Grievances and maintained in the Administrator's office. Resident #39 was admitted to the facility in November 2025 with diagnoses which included depression and legal blindness. Review of the Minimum Data Set (MDS) assessment, dated 11/24/25, indicated Resident #39 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she was cognitively intact.During an interview on 2/9/26 at 10:30 A.M., Resident #39 said he/she keeps the door closed because the radio speaker in the hall is loud, it was turned off for a couple of days but is now turned back on. On 2/12/26 at 11:03 A.M., the surveyor observed Resident #39's door closed. Upon entering the room, the surveyor observed Resident #39 wearing headphones and resting. The surveyor observed the radio speaker in the hallway ceiling located directly outside Resident #39's room and heard the music playing. During an interview on 2/12/26 at 11:03 A.M., Resident #39 said he/she complained to the Administrator about the radio in the hallway ceiling coming on every day at 5:50 A.M. and staying on all day. Resident #39 said it's especially bothersome on the weekend when the music channel has a lot of [NAME]. Resident #39 said they are playing with his/her thyroid medication, and he/she is exhausted and can't sleep because the radio is on all day. Resident #39 said he/she must keep the room door shut all day and often must wear headphones to block out the music. Resident #39 said the Administrator hasn't done anything about it. Review of the facility's 2026 Grievance Log for January and February indicated there were no grievances for Resident #39 recorded for the music playing in the hallway. During an interview on 2/13/26 at 12:15 P.M., the Administrator said Resident #39 has brought up the music playing in the hallway ceiling (Central to whole building) as a complaint. The Administrator said she agreed the music at 6:00 A.M. was too early. She spoke with the Maintenance Director and told him to turn on the music at 9:00 A.M. and shut it off when he leaves for the day. The Administrator said she would have to follow up with the Maintenance Director to check if he is following the schedule for the music. The Administrator said if Resident #39 was still unhappy about the music, he/she would need to communicate that with her. The Administrator said the difference between a complaint and grievance is, if she addresses the complaint right away, it's not a grievance. The Administrator said this was a complaint from Resident #39, not a grievance. During an interview on 2/13/26 at 2:26 P.M., with Consultant Chief Clinical Officer (CCCO) present, Resident #39 said the Administrator never spoke to him/her about the Maintenance Director turning on the music at 9:00 A.M. Resident #39 said the music was on at 6:50 A.M. today. Resident #39 said he/she has spoken to the Administrator four times, and nothing has been done. Both the surveyor and CCCO heard the music coming from the speaker in the hallway.

Based on observations, interviews, and records reviewed, the facility failed to ensure one Resident (#71), out of 20 sampled residents, received care and treatment to promote healing of a pressure ulcer. Specifically, the facility failed to follow physician's orders to offload his/her wound, float his/her heels when in bed, and follow wound orders. Findings include:Review of [NAME], Manual of Nursing Practice 11th edition, 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 prescriber 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. Review of the facility's policy titled Dry/Clean Dressings, dated as revised 11/2024, indicated but was not limited to:-The purpose of this procedure is to provide guidelines for the application of dry, clean dressings-Preparation:1. Verify that there is a physician's order for this procedure2. Review the residents current orders and diagnosis to determine if there are special resident needs3. Assemble the equipment and supplies as needed4. Explain procedure to the resident and provide privacy-Guidelines:23. Apply the ordered dressing and secure or bordered dressing per order as ordered. Resident #71 was admitted to the facility in January 2026 with diagnoses which included dementia and pressure ulcer (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence) of his/her left heel. Review of the Minimum Data Set (MDS) assessment, dated 1/16/26, indicated Resident #71 had one stage three (indicating full thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and rolled wound edges are often present) unhealed pressure ulcer that was present on admission. Further review of the MDS indicated Resident #71 required a treatment/dressing to his/her feet. Review of Resident #71's Physician's Orders indicated but was not limited to:-offload wound every shift, 1/9/26 through 2/12/26-float heels in bed every shift, 1/19/26 through 2/12/26-left lateral heel: wash with normal saline, pat dry, apply iodosorb (a gel used to clean wounds and promote healing) and cover with boarder (sic) foam dressing (a sterile, conformable, and highly absorbent wound dressing made of polyurethane foam with an adhesive, often waterproof, border which acts as a barrier against bacteria and fluid and is suitable for partial- to full-thickness wounds) every day for wound care Review of Resident #71's care plans indicated but was not limited to:-Problem: Pressure Ulcer: Ulceration or interference with structural integrity of layers of skin, left lateral heel-Interventions: Treatment as ordered, 1/6/26 Review of the wound consultant recommendations, on the following dates, indicated part of his/her treatment plan included float heels in bed and offload wounds:-1/7/26,-1/12/26,-1/19/26,-1/27/26,-2/4/26, and- 2/9/26 Review of Resident #71's Treatment Administration Record (TAR) from February 2026 indicated his/her heels were floated in bed every shift and his/her wound was offloaded every shift. Further review of the TAR indicated his/her left lateral heel dressing had been changed as ordered on 2/10/26 and no as needed treatments were documented. On the following dates/times of the survey, the surveyor observed Resident #71:-2/9/26 at 10:28 A.M., lying in bed with both heels flat on his/her bed-2/10/26 at 3:45 P.M., sitting in his/her wheelchair with both feet resting on his/her foot buddy/leg supports-2/11/26 at 7:33 A.M. and 8:21 A.M., lying in bed heels flat on his/her bed-2/11/26 at 10:50 A.M., sitting in his/her wheelchair with both feet resting on his/her foot buddy/leg supports with a white bordered gauze dressing sticking from the top of his/her sock-2/11/26 at 2:40 P.M.: lying in bed with flattened pillow at the top of his/her calves with both heels touching the surface of the bed with a white bordered gauze dressing sticking from the top of his/her sock-2/12/26 at 7:38 A.M., lying in bed with both heels flat on his/her mattress On 2/11/26 at 2:40 P.M., the surveyor observed Unit Manager #1 provide wound care with assistance from the Infection Control Nurse. The surveyor observed Unit Manager #1 remove a white boarded gauze dressing (a sterile, multi-layer, all-in-one adhesive island dressing designed for covering wounds with light to moderate drainage and consists of non-adherent, absorbent gauze pad surrounded by an adhesive border that secures the dressing in place) from the wound and provide wound care as ordered. During an interview on 2/11/26 at 2:59 P.M., Unit Manager #1 and the Infection Prevention Nurse said Resident #71's heels should be offloaded and not resting on the mattress. Unit Manager #1 said the incorrect dressing had been applied and should have been a bordered foam dressing not bordered gauze. During an interview on 2/12/26 at 8:23 A.M., Unit Manager #1 said Resident #71 had orders indicating his/her wound should be offloaded every shift and his/her heels should be floating while in bed. During an interview on 2/12/26 at 1:31 P.M., the Director of Nurses (DON) said physician's orders should be followed as indicated. The DON said heels should be offloaded and/or floating and the correct dressing should have been applied.

Based on observation, record review, and interview, the facility failed to ensure one Resident (#21), out of a total sample of 20 residents, was assessed by the Interdisciplinary Care Team for self-administration of all their medications and had a physician's order to self-administer medications.Findings include:Review of the facility's policy titled Self-Administration of Medications, last revised September 2024, indicated but was not limited to:-Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.-As part of their overall evaluation the staff and/or provider will assess each resident's mental and physical abilities to determine whether self-administering medications are clinically appropriate for the resident. -The staff and/or provider will document their findings and the choices of the residents who are able to self-administer medications.Resident #21 was admitted to the facility in October 2024 with diagnoses including chronic obstructive pulmonary disease (COPD, a progressive, irreversible lung disease that causes severe airflow obstruction and breathing difficulties) and shortness of breath.Review of the Minimum Data Set (MDS) assessment, dated 1/23/26, indicated Resident #21 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. During an interview with observation on 2/9/26 at 10:00 A.M., the surveyor observed Resident #21 sitting on the edge of his/her bed with the following:- A wash basin on his/her bed containing two inhalers - Breztri Aerosphere (maintenance inhaler approved for long-term, twice-daily treatment of COPD), and - Salmeterol Inhaler (used to maintain control of COPD by relaxing airway muscles)Resident #21 said he/she would administer their own inhalers twice a day and preferred to do so themselves. Resident #21 said the nurses knew he/she had had their inhalers at their bedside.On 2/10/26 at 8:49 A.M. and 4:07 P.M., the surveyor observed Resident #21 sitting in his/her wheelchair with two Breztri Inhalers and one Salmeterol Inhaler next to him/her on the bed.On 2/11/26 at 11:19 A.M., the surveyor observed Resident #21 sitting in his/her wheelchair with one Breztri Inhaler next to him/her on the bed.Review of Resident #21's Physician's Orders indicated but was not limited to:- Breztri Aerosphere Inhalation Aerosol 160-9-4.8 micrograms (mcg) per activation inhale two puffs two times a day,1/10/26- Salmeterol Xinafoate Aerosol Powder Breath Activated 50 mcg dose inhale two times a day, dated 8/21/25- Albuterol Sulfate Inhalation Aerosol Solution (used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness) 108 mcg inhale two puffs every four hours as needed, dated 8/16/25Review of Resident #21's medical record failed to indicate:- he/she had a care plan to self-administer their medications, and - a physician's order for self-administration of medications.During an interview with observation on 2/11/26 at 2:44 P.M., Nurse #1 and the surveyor observed one Breztri Inhaler and one Salmeterol Inhaler on Resident #21's bed. Nurse #1 said if a resident voiced a desire to self-administer their medications, they would need an assessment and physician's order, which indicated which medications he/she could self-administer. Nurse #1 said Resident #21 had not been assessed nor had an order to self-administer his/her medications. Nurse #1 said Resident #21 preferred to hold onto their inhalers and administer them himself/herself. Nurse #1 said she took one of Resident #21 Breztri Inhalers this morning and placed it in the medication cart. During an interview with observation on 2/12/26 at 12:24 P.M., the surveyor observed on Resident #21's bed one Breztri Inhaler, one Salmeterol Inhaler, and one Albuterol Inhaler. Resident #21 said he/she wanted to be able to hold onto his/her inhalers and be able to self-administer their own inhalers especially the Albuterol. Resident #21 said he/she did not want to wait on a nurse if they needed their rescue inhaler (Albuterol).During an interview with observation on 2/12/26 at 12:52 P.M., Nurse #3 and the surveyor observed one Breztri Inhaler, one Salmeterol Inhaler, and one Albuterol Inhaler. Nurse #3 said Resident #21 chose to administer their own inhalers. Nurse #3 said she had watched Resident #21 take their Breztri Inhaler and Salmeterol Inhaler this morning. Nurse #3 said Resident #21 did not have an order to self-administer his/her inhalers and had not been evaluated to do so. During an interview on 2/12/26 at 1:53 P.M., the Director of Nursing said if a resident expressed a desire to self-administer his/her medications then they should have been assessed to self-administer their medications. In addition, they need a physician's order to do so prior to the nurses allowing him/her to administer them and prior to storing them in their room.

Based on interview and record review, the facility failed to develop, implement and individualize comprehensive care plans for one Resident (#39), out of a total sample of 20 residents. Specifically, the facility failed to ensure a comprehensive care plan was developed for the care needs and monitoring related to the diagnosis of Type II DM and the use of a continuous glucose monitoring system (CGM). Findings include: Review of the facility's comprehensive care plan titled Care Plans, Comprehensive Person-Centered, last Revised 1/2024, indicated but was not limited to the following:-A comprehensive, person-centered care plan will be developed for each resident. The care plan will include objectives that meet the residents' physical, psychosocial and functional needs that are developed for each resident.-The residents comprehensive care plan will identify problem areas and their causes as warranted and develop interventions that are targeted and meaningful to the residents.-Evaluations of residents are ongoing and care plans are revised as information about the resident and the conditions change. Review of the manufacturer's guidelines for the use and care of the CGM system used by Resident #39, indicated but was not limited to the following:-Continuous Glucose Monitoring system has 2 main parts: A disposable sensor and either a handheld reader or a mobile app to wirelessly receive and display glucose readings from the sensor.-Failure to use the System according to the instructions for use may result in you missing a severe low blood sugar or high glucose event and/or making a treatment decision that may result in injury.-14-day wear duration.-Take standard precautions for transmission of bloodborne pathogens to avoid contamination.-Wash application site on the back of your upper arm using plain soap. Dry, and then clean with an alcohol wipe (Not included in the kit). Allow site to air-dry before proceeding.-Clean hands prior to sensor handling/insertion to help prevent infection.-Change the application site for the next sensor application to prevent discomfort or skin irritation.-Only apply the sensor to the back of the upper arm. If placed in other areas, the sensor may not function properly.-Do not touch inside sensor application as it contains a needle.-Applying the sensor may cause bruising or bleeding. Resident #39 was admitted to the facility in November 2025 with diagnoses which included: Type II diabetes mellitus with proliferative diabetic retinopathy with macular edema right eye and traction retinal detachment involving macular left eye, legally blind, and on long-term use of insulin. Review of Resident #39's Physician's Orders indicated but were not limited to the following orders:-Consistent/controlled carbohydrate diet (diabetic diet), effective 11/24/25-Resident has Continuous Glucose Monitoring device, before meals and at bedtime related to type II diabetes mellitus (DM) (sic), effective 11/24/25.-Jardiance oral tablet 25 milligrams (mg), give one tab by mouth in evening related to DM, effective 1/7/26.-Lantus Solostar subcutaneous solution pen injector, inject 18 units subcutaneously in the evening related to DM, effective 11/24/25.-Metformin tablet extended release 24-hour 750 mg. Give two tablets by mouth one time a day related to DM, effective11/24/25. Review of Resident #39's comprehensive care plans failed to indicate there was a care plan developed for Resident #39's care needs related to the diagnosis of Type II DM and the use of a CGM. During an interview on 2/13/26 at 2:13 P.M., the Director of Nurses (DON) said she would expect a resident with a diagnosis of Type II Diabetes to have a care plan for care and monitoring. The DON said Resident #39 should have a care plan to address their diabetic needs, including the CGM, and does not have one.

Based on record review and interviews for one of three sampled residents (Resident #1), who was moderately cognitively impaired, had a Legal Guardianship in effect, and was known to leave the Facility without notifying staff, the Facility failed to ensure he/she was provided with an adequate level of staff supervision, to prevent him/her from eloping, when on several occasions Resident #1 exited the Facility unbeknownst to staff and they were unaware of his/her whereabouts for extended periods of time. Findings include: Review of the Facility's Policy titled Elopements, dated as revised June 2025, indicated the following:- If an employee discovers that a resident is missing from the facility, he/she shall: a. determine if the resident is out on an authorized leave or pass, and b. if the resident was not authorized to leave, notify the Director of Nursing and/Administrator. Resident #1 was admitted to the Facility in September 2025, diagnoses included paranoid schizophrenia and chronic obstructive pulmonary disease. Review of a Guardianship document (Decree and Order of Appointment of Guardian for an Incapacitated Person), dated 06/02/15, indicated Resident #1 did not retain the right to make and communicate decisions about healthcare. Review of Resident #1's admission Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1 required supervision for ambulation, and had moderate cognitive impairment, evidenced by a Brief Interview of Mental Status (BIMS) score of 8 out of 15 (13-15 indicates intact cognition, 8-12 moderate cognitive impairment, and 0-7 severe cognitive impairment). Review of Resident #1's Elopement Assessment, dated 09/19/25, indicated he/she was at risk for elopement.Review of Resident #1's Nurse's Notes indicated the following: 10/16/25; Resident #1 left the Facility without signing out,10/18/25; Resident #1 was seen in the community, he/she had left without signing out and continues to be noncompliant despite education from staff,10/21/25; Resident #1 was outside walking along the sidewalk, staff met him/her and walked him/her back to the Facility,11/27/25; indicated Resident #1 had been seen along the roadway, and two staff members went to look for him/her but could not locate Resident #1. The Note indicated that staff called the Administrator immediately and the Administrator said Resident #1 typically returns, and if he/she did not, then notify Police. The Note indicated that Resident #1 returned.12/03/25, indicated Resident #1 left the Facility without signing out. Review of a Physician's Note, dated 11/18/25, indicated that nursing had concerns that Resident #1 was frequently noncompliant with supervision, was frequently ambulating outside with his/her walker on his/her own, staying outside in the cold temperatures, and that this was concerning. The Note indicated concerns that Resident #1 was not fully understanding the situation and that cognitive testing was ordered. During a telephone interview on 12/12/25 at 1:21 P.M., Nurse #1 said Resident #1 had left the Facility while he had been working on two separate occasions, that he told Administration that they needed to do something about this because he needed to take care of Resident #1 and he couldn't if he did not know where Resident #1 was.Review of Resident #1's Medical Record, indicated there was a Physician's order, dated 11/18/25, to complete the St. Louis University Mental Status (SLUMS) screening (cognitive exam). During a telephone interview on 12/04/25 at 2:22 P.M., the Nurse Practitioner (NP) said Resident #1 had been going outside alone for extended periods of time. The NP said she ordered the SLUMS to be completed because she needed more detailed information about Resident #1's level of cognition. The NP said she had concerns about Resident #1's ability to make appropriate choices related to safety. During an interview on 12/04/25, Social Worker #1 said that because Resident #1 kept leaving the Facility without letting staff know, which he/she was not safe to do, she was trying to transfer Resident #1 to another facility that had a locked or secured unit in order to keep him/her safe. During an interview on 12/04/25 at 3:46 P.M., the Director of Nurses (DON) said Resident #1 was at a supervision to independent level for ambulation in the facility. The DON said that what the Guardian had in place, as far as what he allowed Resident #1 to do, was not conducive to his/her (Resident #1) safety due to his/her impaired cognitive status, and that the Guardian had been made aware of this. The DON said Resident #1 did not have the cognitive ability to safely leave the Facility alone but had been doing so. During an interview on 12/04/25 at 3:45 P.M., the Administrator said Resident #1 was not consistently redirectable, and that it was unsafe for Resident #1 to remain at the Facility, so she had been working with his/her [NAME] to transfer Resident #1 to a Facility that could keep him/her safe. The Administrator said effective immediately (day of survey), Resident #1 would be placed on 1:1 supervision until he/she was transferred to another Facility.

Based on records reviewed and interviews for one of four sampled residents (Resident #2), who was known to exhibit intrusive, combative and aggressive behaviors towards staff, residents, and visitors, the Facility failed to ensure that other residents residing on his/her unit were free from physical abuse, when between May 2025 and August 2025, Resident #2 was involved in several altercations, which included being witnessed by staff as he/she punched a resident in the stomach, climbed into another residents bed and became combative with attempts to be redirected, and it was alleged that he/she punched a resident on the arm and in the face during an unwitnessed altercation. Resident #2's combative and aggressive behaviors place other residents on his/her unit at increased risk for physical abuse.Findings Include:Review of the Facility Policy titled Abuse Investigation and Reporting, dated as last revised 02/2024, indicated that each resident has the right to be free from verbal, sexual, physical and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of their property. Every resident in the Facility will be treated with respect and dignity. The Policy further indicated that physical abuse includes, but is not limited to, hitting, slapping, pinching, kicking, and so on. Resident #2 was admitted to the Facility in April 2025, diagnoses include Alzheimer's Disease, dementia with behavioral disturbances, and anxiety.Review of Resident #2's admission Minimum Data Set (MDS) dated [DATE], indicated that he/she exhibited both long- and short-term memory loss, severely impaired decision-making abilities, was sometimes understood and was rarely able to understand what was being said by others.The MDS indicated he/she exhibited physical behaviors, (hitting, kicking, pushing, scratching) one (1) to three (3) days per week, verbal behaviors (threatening, screaming, or cursing at others) one (1 ) to three (3) days a week, and other behaviors (hitting or scratching self, pacing, rummaging, disrobing) four (4) to six (6) days per week. The MDS further indicated that Resident #2 rejected care one (1) to three (3) times weekly and wandered four (4 ) to six (6) days per week. 1) Review of the report submitted by the facility via Health Care Facility Reporting System (HCFRS), dated 05/02/25, indicated that at 7:28 P.M., a Certified Nurse Aide (CNA) witnessed Resident #2 punched Non-Sampled Resident (NSR) A in the stomach/chest several times. The Report indicated that Resident #2 was standing in NSR A's doorway and when NSR A attempted to enter his/her room, Resident #2 hit NSR A in the stomach/chest with a closed fist several times.Further review of the Report indicated that the plan for Resident #2 was for staff to monitor him/her while ambulating on the unit and redirect him/her out of other residents' rooms. The Report indicated that staff had identified that Resident #2 had no interest in activities and was essentially non-verbal.2) Review of a Report filed with the Department of Public Health (DPH), dated 07/22/25, indicated that on 05/31/25 Resident #2 had been observed in Resident #3's bed (roommate of Resident #1) by Resident #1's Family Member.The Report indicated that Family Member #2 had gone into Resident #1's room and found Resident #2 sleeping in Resident #3's bed. The Report indicated that Family Member #2 had called out for help, and a CNA (later identified as CNA #1) went to get Resident #2 out of Resident #3's bed.The Report further indicated Family Member #2 said that when CNA #1 woke Resident #2 up from sleeping, he/she displayed aggression and was combative with CNA #1.During an interview on 09/16/25 at 1:43 P.M., CNA #1 said that she has found Resident #2 in other residents' beds multiple times. CNA #1 said that she has assisted with getting Resident #2 out of other resident's rooms, including Resident #1 and Resident #3's room. CNA #1 said Resident #2 has punched her and been combative towards her many times.During an interview on 09/16/25 at 11:03 A.M., Resident #3 said that there is an older resident (later identified as Resident #2) that comes into their room all the time. Resident #3 said that he/she will ask him/her to leave, but that staff usually have to escort him/her out of the room. Resident #3 said that Resident #2 has been found in his/her bed sleeping and said Resident #2 had hit him/her in the past.3) Review of the report submitted by the facility via the Health Care Facility Reporting System (HCFRS) Report, dated 08/25/25, indicated that at 5:15 P.M., yelling was heard coming from a resident's room (identified as Resident #4) and upon entering the room, Resident #4 was observed holding Resident #2's hands (trying to prevent Resident #2 from hitting him/her). The Report also indicated, that although unwitnessed, Resident #4 said that Resident #2 had grabbed his/her arm and punched him/her on his/her right arm and right cheek.Further review of the Report and Facility Investigative Findings indicated that Resident #4 told staff that Resident #2 had wandered into his/her room, picked up his/her lunch tray, removed some clothing from his/her bed and then Resident #2 laid down on his/her (Resident #4's) bed.Review of Resident #4's Behavior Health Group Note, dated 08/26/25, indicated that he/she spoke of an incident involving Resident #2, and that Resident #4 said that he/she was shocked by the incident and said he/she has never been popped in the face before.Review of Resident #4's Behavior Health Group Note, dated 09/03/25, indicated he/she again discussed a recent incident where he/she alleged another resident (Resident #2) struck him/her in the face.During interviews throughout the day of the survey, dated 09/16/25, CNA s #1, #2, #4, #5, and #7 said they have witnessed and have been the recipient of Resident #2's aggressive and combative behaviors. All the CNA's said they were familiar with Resident #2's wandering behaviors and acknowledged that he/she requires supervision and constant redirection.During an interview on 09/16/25 at 12:10 P.M., Nurse #1 said that she was aware that Resident #2 can be very aggressive and combative with staff. Nurse #1 said that she was also aware that Resident #2 wandered throughout the day into other residents' rooms and has a history of being combative with other residents. During a telephone interview on 09/24/25 at 10:52 A.M., Nurse #2 said that she was aware that Resident #2 has been combative with staff and other residents.During an interview on 09/16/25 at 2:04 P.M., Unit Manager #1 said that Resident #2 was known to wander throughout the hallways of his/her unit and has been observed many times in multiple residents' rooms. Unit Manager #1 said that she was aware of Resident #2's aggressive and combative behavior towards staff and other residents. Unit Manager #1 said interventions such as magnetic stop signs and redirection were being implemented to decrease the risk for Resident #2 entering other residents' rooms. Unit Manager #1 said that the staff are aware of Resident #2's behaviors, and they continue to supervise and redirect Resident #2, as needed, when he/she was seen wandering around the unit.During an interview on 06/16/25, the Executive Director (ED) said that she was aware of Resident #2's behaviors, including his/her wandering and being combative with other residents and staff. The ED said that it is the Facility's expectation to maintain the safety of all residents, to accurately report and document behaviors for all residents and follow the plan of care for each resident to ensure a safe environment.

Based on records reviewed, interviews and observation, for two of four sampled residents (Resident #1 and #4), the Facility failed to ensure they developed and/or consistently implemented and followed interventions identified in their plan of care related to the placement and use of a magnetic stop sign across their doorways to minimize the risk of other residents wandering into their rooms. Findings include: Review of the facility Policy titled Care Plans, Comprehensive Person Centered, dated as last revised 01/2024, indicted that a comprehensive, person-centered care plan will be developed for each resident and include objectives that meet the resident's physical, psychosocial and functional needs for each resident.1) Resident #1 was admitted to the Facility in February 2024, diagnoses include legal blindness, history of falls with vertebral fractures, and dementia.Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she scored a six (6) out of 15 on his/her Brief Interview for Mental Status (BIMS, evaluates cognitive impairment and can help dementia diagnosis) (0-7 indicates severe cognitive impairment).Review of Resident #1's Physician's Orders, dated as of 09/16/25, indicated that his/her Health Care Proxy (HCP) was activated and his/her Health Care Agent (HCA) had been invoked since 02/16/24.During a telephone interview on 09/15/25 at 1:42 P.M., Family Member #1 said that she had been in contact with the Facility multiple times in regard to her concerns of maintaining Resident #1's safety from another resident (identified as Resident #2) who had been wandering in and out of his/her room. Family Member #1 said she was concerned because Resident #2 exhibited aggressive and combative behaviors at times. Review of Resident #1's Nurse Progress Note, dated 06/18/25, indicated that Resident #2 had wandered into his/her room and required staff redirection to escort him/her out of Resident #1's room.Review of Resident #1's Nurse Progress Note, also dated 06/18/25, indicated that Unit Manager #1 spoke with Family Member #1 and discussed interventions that the Facility had put into place to help prevent further episodes of intrusive wandering.The Note further indicated that the interventions that had already been in place were redirecting Resident #2 out of other resident's rooms and placing a magnetic stop sign across the doorway of Resident #1's room to inhibit Resident #2 from entering.Review of Resident #1's care plans indicated that although Nursing told Family Member #1 that they had implemented the use of a magnetic stop sign across his/her doorway as an intervention to maintain his/her safety, there was no documentation to support that the intervention was added to his/her care plan.During an interview on 09/16/25 at 10:51 A.M., with Resident #1, the surveyor noted that upon arrival to his/her room, there was no stop sign across the doorway. Resident #1 said that there was a resident here (identified as Resident #2) that walks into his/her room all of the time. Resident #1 said that he/she (Resident #2) will come to the window, look out and then will he/she would sit on his/her (Resident #1's) bed. During interview with Resident #1 (at 11:06 A.M.), the Surveyor observed as Resident #2 wander into Resident #1's room and walk towards his/her bed. The Surveyor stayed with Resident #1 and a CNA then entered Resident #1's room and redirected Resident #2 out of the room.During three observations on 09/16/25 at 9:36 A.M., 10:51 A.M. and 2:47 A.M., the Surveyor observed the magnetic stop sign that should have been secured in place across Resident #1's door, was left hanging off to one side of the doorway and therefore would not stop or inhibit any one from entering his/her room.During an interview on 09/16/25 at 1:43 P.M., Certified Nurse Aide (CNA) #1 said that she does not know why the stop sign was not across Resident #1's doorway and said Resident #1 has had a stop sign across his/her doorway for a while to help prevent Resident #2 from wandering into his/her room.During an interview on 09/16/25 at 1:32 P.M., CNA #2 said that Resident #1 has had a stop sign across his/her doorway for quite some time and that sometimes she finds it hanging on the side of the door and not properly attached.During an interview on 09/16/25 at 1:21 P.M., CNA #3 said that Resident #1 has had a stop sign at his/her door for about 6 months and said it is now broken and does not always stay in place properly,During an interview on 09/16/25 at 12 :10 P.M., Nurse #1 said that she does not know why Resident #1's stop sign was not across his/her doorway during surveyor observations.During an interview on 09/16/25 at 2:04 P.M., Unit Manager #1 said that it was her responsibility to ensure each resident's care plan includes all identified interventions and goals. Unit Manager #1 said she thought she added the intervention of the stop sign to Resident #1's care plan. Unit Manager #1 said she did not know that Resident #1's stop sign was not being consistently utilized.2) Resident #4 was admitted to the Facility in March 2024, diagnoses include dementia with psychotic disturbances, major depression, and anxiety.Review of Resident #4's Physician's Orders, dated 09/16/25, indicated that his/her HCA had been invoked since 03/09/24.Review of the Health Care Facility Reporting System (HCFRS) Report, dated 08/25/25, indicated that at 5:15 P.M., a yell was heard coming from a resident's room (Resident #4) and upon entering the room, Resident #4 was observed holding Resident #2's hands (trying to prevent Resident #2 from hitting him/her). The Report further indicated that staff had provided a magnetic stop sign across Resident #4's doorway in hopes to deter Resident #2 from wandering into his/her room. Review of Resident #4's Care Plan titled Activities of Daily Living (ADL), dated as last revised 08/25/25, indicated that a magnetic stop sign was to be placed across his/her doorway as an intervention to maintain his/her safety.During multiple observations of Resident #4's room, on 09/16/25 throughout the day of the survey, the Surveyor did not observe a magnetic stop sign across Resident #4's doorway at any time that day.Therefore, although Resident #4's care plan indicated he/she required the use of a magnetic stop sign across his/her doorway as an intervention to maintain his/her safety, based on the Surveyor observations the intervention was not consistently implemented by staff.During an interview on 09/16/25 at 1:43 P.M., CNA #1 said she thinks that Resident #4 had a stop sign across his/her doorway but does not know what happened to it. During an interview on 09/16/25 at 1:21 P.M., CNA #3 said that Resident #4 has never had a stop sign going across his/her doorway that she was aware of.During an interview on 09/16/25 at 12 :10 P.M., Nurse #1 said that she thought Resident #4's stop sign was to be placed across his/her doorway, only a temporary intervention and does not know what happened to it. During multiple observations on Resident #2's unit, throughout the day of the survey, the Surveyor frequently observed Resident #2 wandering the unit without purpose or direction. During an interview on 09/16/25 at 2:04 P.M., Unit Manager #1 said that she was aware that Resident #2 wandered around on the unit and that Resident #1 and Resident #4 were to have magnetic stop signs going across their doorways to help prevent Resident #2 from wandering into their rooms.During an interview on 09/16/25 at 2:57 P.M., the Executive Director said that she was not aware that Resident #1 and Resident #4's care plans were missing interventions or that interventions were not consistently being implemented and followed accordingly.The ED said that the Facility's expectation is that nurses are to develop care plans for all residents and the staff are to implement and follow interventions per the residents' care plan as indicated.

Based on records reviewed and interviews, for one of four sampled residents (Resident #2) the Facility failed to ensure they reported and/or investigated incidents/allegations of abuse when 1) a family member reported that he attempted to redirect Resident #2 out of his family members room by pushing on Resident #2 and 2) Resident #2 punched a staff member in the face, neither of which were reported or investigated by the Facility.Findings include:Review of the Facility Policy titled Abuse Investigation and Reporting, dated as last revised 02/2024, indicated that each resident has the right to be free from verbal, sexual, physical and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of their property. Every resident in the Facility will be treated with respect and dignity. The Policy indicated the definition of abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting physical hurt or pain or mental anguish to a resident.The Policy further indicated that physical abuse includes, but is not limited to, hitting, slapping, pinching, kicking, and so on. Resident #2 was admitted to the Facility in April 2025, diagnoses include Alzheimer's Disease, dementia with behavioral disturbances, and anxiety.Review of Resident #2's admission Minimum Data Set (MDS) dated [DATE], indicated that he/she exhibited both long- and short-term memory loss, severely impaired decision-making abilities, was sometimes understood, and was rarely able to understand what is being said.The MDS indicated he/she exhibited physical behaviors, (hitting, kicking, pushing, scratching) one (1) to three (3) days per week, verbal behaviors (threating, screaming, or cursing at others) 1 to 3 days a week, and other behaviors (hitting or scratching self, pacing, rummaging, disrobing) four (4) to six (6) days per week and Resident #2 rejected care 1 to 3 times weekly and wandered 4 to 6 days per week. 1) Review of Resident #2's Nurse Progress Note (written by Unit Manager #1), dated 06/18/25, indicated that Resident #1's son (Family Member #2), informed Unit Manager #1 that Resident #2 wandered into Resident #1's room and Family Member #2 asked Resident #2 to leave. The Note indicated that Family Member #2 said that he pushed Resident #2 with his fingers to direct him/her out of the room and Resident #2 tried to grab him.Review of Resident #2's medical record indicated that there was no documentation to support that the facility initiated an investigation or reported the incident involving a visitor to resident altercation.During an interview on 09/16/25 at 2:04 P.M., Unit Manager #1 said that there was no incident report completed, or report filed to the Department of Public Health (DPH) after the documented incident.Unit Manager #1 said she thought the incident should have been a reportable event, however, said that after the management team discussed the incident with the Corporate Team, it was decided not to investigate the incident or report it.During an interview on 09/16/25 at 3:53 P.M., the Executive Director (ED) said that on 06/18/25 (day of the Incident), Family Member #2 stormed into her office telling her that Resident #2 wandered into Resident #1's room and Family Member #2 said that he pushed Resident #2 out of the room.2) During an interview on 09/16/25 at 11:16 A.M., Certified Nurse Aide (CNA) #4 said that on 08/28/25, during the evening shift (3:00 P.M. to 11:00 P.M.), she was assisting Resident #2 with evening care, that she was standing in front of Resident #2, went to lower his/her pants to get him/her changed into sleep wear and Resident #2 took both of his/her hands, made a fist with each hand and punched her on each side of her face very hard.CNA#4 said that she reported the incident to the nurse on the unit but said she was never asked to write a statement. During a telephone interview on 09/24/25 at 10:52 A.M., Nurse #2 said that she was aware of the incident that had occurred between CNA #4 and Resident #2 on 08/28/25, Nurse #4 said that she had reported it to Unit Manager #2.Nurse #2 said that Unit Manager #2 told her that if CNA #4 did not want to write a statement, then she did not have to.Nurse #2 said she did not know why an incident report wasn't completed and said she just followed what Unit Manager #2 told her and said she never asked CNA #4 for a statement.During a telephone interview on 09/24/25 at 11:20 A.M., Unit Manager #2 said that he does not recall anyone reporting a resident to staff member altercation on 08/28/25.Unit Manager #2 said that if a staff member had reported a resident to staff altercation, he was not certain that he would have initiated an incident report. The Executive Director said that she was not made aware of the 08/28/25 incident involving Resident #2 and CNA #4. The Executive Director said that she does not know why they did not do an incident report for either of these two incidents. The ED said that it was the Facility's expectation that all altercations that occur in the Facility be followed by an incident report and properly reported.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who required continual supervision (staff member to stay with resident during entire task) during meals, the Facility failed to ensure that he/she was provided with the necessary level of staff supervision during meals in an effort to prevent an incident resulting in an injury. On 05/13/25, Resident #1 was served his/her breakfast tray, left unsupervised in his/her room with his/her meal, spilled a hot beverage on his/her upper legs, and sustained second-degree burns (partial thickness, involves both the outer (epidermis) and underlying layer (dermis) of skin, they cause pain, redness, swelling, and blistering) to the front side of his/her left thigh and required daily treatment to the areas for around four weeks.Findings Include: Review of the Facility's Policy tilted, Activities of Daily Living (ADLs), Supporting, dated as revised 11/2024 indicated the following:-residents who are unable to carry out activities of daily living independently will receive the services necessary for activities of daily living.-appropriate care and services will be provided for residents who are unable to carry out ADLs independently, including appropriate support and assistance with: dining (meals and snacks). Resident #1 was admitted to the Facility in August 2019, diagnoses included Dementia, legal blindness, severe stage glaucoma right eye, muscle weakness, atrial fibrillation (irregular heartbeat) and hypertension. Review of Resident #1's Annual Minimum Data Set (MDS), dated [DATE], indicated that he/she had severe cognitive impairment, and required supervision with touching assistance with eating.Review of Resident #1's ADL Deficit Care Plan, renewed and reviewed with his/her May 2025 MDS, indicated that he/she required continual supervision with meals.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 05/20/25, indicated that on 05/13/25 a Certified Nurse Aide (CNA) observed Resident #1 had spilled coffee on him/herself, he/she was washed, assisted back to bed, did not complain of pain and there were no discolorations on his/her left thigh. The Report indicated that on 05/14/25 at approximately 8:00 A.M. while giving care to Resident #1 a CNA observed blisters on his/her left thigh and told the Nurse who was taking care of him/her. The Report further indicated that Resident #1's Primary Care Provider (PCP) was notified, treatment was ordered for mupirocin (Bactroban) 2% ointment (a topical antibiotic used to treat and/or prevent bacterial skin infections) to the area three times a day.Review of Resident #1's Nurse Progress Note, dated 05/14/25, (written by the Unit Manager), indicated that at approximately 8:00 A.M. a CNA called this writer to Resident #1's room, where she observed three blisters on his/her thigh (left or right side not indicated). The Note indicated that while speaking to staff, they stated a CNA told them yesterday (05/13/25) Resident #1 spilled coffee on him/herself. The Note further indicated that first aid was performed, the Nurse Practitioner (NP) was notified, and a new order was placed for Bactroban (topical antibiotic) ointment.Review of Resident #1's Weekly Skin Evaluation, dated 05/14/25, indicated that Resident #1 had three blisters on the front of his/her left thigh, measuring 7.0 centimeters (cm) by 3.0 cm, 4.0 cm by 2.5 cm and 1.5 cm by 2.5 cm.During an interview on 08/05/25 at 2:24 P.M., CNA #3 said she worked the 7:00 A.M. to 3:00 P.M. shift on 05/13/25 and said she did not give Resident #1 his/her breakfast tray that morning. CNA #3 said the CNA that is assigned to Resident #1 would give his/her breakfast tray to him/her after getting him/her out of bed into his/her wheelchair.During an interview on 08/05/25 at 1:10 P.M., (which included review of her written statement) CNA #1 said she worked the 7:00 A.M. to 3:00 P.M. shift on 05/13/25 and was assigned to provide care to Resident #1. CNA #1 said Resident #1 was blind and required set-up with continual supervision for meals. CNA #1 said she would set-up Resident #1's meal tray, then leave to continue passing meal trays to other residents then go back to Resident #1's room. CNA #1 said she could not remember if she gave Resident #1 his/her breakfast meal tray on 05/13/25, but said she might have. CNA #1 said she heard someone yell Ow, from Resident #1's room, ran to his/her room, saw Resident #1's coffee mug on the floor and that there was coffee on his/her upper pants area that was dripping onto the floor. CNA #1 said she asked Resident #1 what happened and he/she told her that his/her hand was shaking, and the cup slipped out of his/her hand. CNA #1 said Resident #1's meal tray was still in his/her room, and he/she was by him/herself that morning (05/13/25), with his/her meal.CNA #1 said she brought Resident #1 into the bathroom to wash and dress him/her and when she removed his/her pants she saw a dime size red spot on his/her left thigh. CNA #1 said that Resident #1 said, my legs feel very, very hot. CNA #1 said she put Resident #1 back into bed, then informed nursing (believed it was Nurse #2) that he/she had spilled hot coffee on him/herself and had a small red area on his/her left thigh.During an interview on 08/05/25 at 3:55 P.M., Nurse #2 said she worked from 7:00 A.M. to 11:00 P.M. on 05/13/25 and was assigned to Resident #1. Nurse #2 said she was not aware that Resident #1 had spilled hot coffee on him/herself that morning and said that the CNA (later identified as CNA #1) that was assigned to Resident #1 did not tell her about the incident.During an interview on 08/06/25 at 11:22 A.M., (which included review of her written statement) Nurse #3 said she worked from 7:00 A.M. to 11:00 P.M. on 05/13/25, on Resident #1's unit. Nurse #3 said she was passing medications in the opposite hallway when CNA #1 walked by her and said Resident #1 had spilled coffee on him/herself. Nurse #3 said she did not tell or ask Nurse #2 (Resident #1's primary nurse) or the Unit Manager if they knew about the incident, because she thought CNA #1 had told them.During an interview on 08/05/25 at 4:11 P.M., (which included review of her written statement) CNA #6 said she worked the 3:00 P.M. to 11:00 P.M. shift on 05/13/25 and the 7:00 A.M. to 3:00 P.M. shift on 05/14/25 and was assigned to Resident #1 on both shifts. CNA #6 said on 05/14/25 she was providing morning care to Resident #1 and saw three blisters with redness on his/her left thigh and immediately informed the Unit Manager.During an interview on 08/05/25 at 3:06 P.M., the Unit Manager said on 05/14/25 CNA #6 called her to Resident #1's room to look at his/her left thigh. The Unit Manager said when she looked at Resident #1's left thigh she saw three blisters, said she cleansed them with normal saline, then notified the Nurse Practitioner (NP) and obtained an order for Bactroban (mupirocin) ointment. The Unit Manager said Nurse #3 told her that on 05/13/25 that CNA #1 had mentioned to her (Nurse #3) that Resident #1 had spilled hot coffee on him/herself. The Unit Manager said that on 05/13/25, she had not been informed that Resident #1 had spilled hot coffee on him/herself. The Unit Manager said she notified the Director of Nursing that Resident #1 had blisters on his/her left thigh, and that he/she had spilled hot coffee on him/herself the day before (05/13/25). During an interview on 08/06/25 at 12:48 P.M., the Nurse Practitioner (NP) said she could not recall the date she was notified that Resident #1 had spilled hot coffee, and that he/she was found with blisters. The NP said if a resident develops blisters after spilling a hot beverage on their self it is considered a second-degree burn (partial thickness, involves both the outer (epidermis) and underlying layer (dermis) of skin, they cause pain, redness, swelling, and blistering).Review of Resident #1's Treatment Administration Records (TARs), dated May 2025 and June 2025, indicated that Bactroban (mupirocin) 2% ointment was applied to Resident #1's left thigh topically three times a day to promote healing from 05/15/2025 through 06/17/25 (for 34 days).During an interview on 08/12/25 at 12:16 P.M., the Former Director of Nursing (DON) said on 05/14/25 the Unit Manager informed her that Resident #1 had spilled hot coffee on his/her leg (could not recall which leg) and that he/she had sustained a burn. The Former DON said she started her investigation which determined that Resident #1 was a set-up with continual supervision for meals and he/she was left unsupervised and unassisted with his/her breakfast meal on 05/13/25. The Former DON said the CNA (later identified as CNA #1) who was assigned to Resident #1 had not informed the Nurse on duty (Resident #1's primary nurse) that he/she spilled hot coffee on his/her legs.During an interview on 08/05/25 at 4:25 P.M., the Director of Nursing (DON) said it is her expectation if a resident requires continual supervision with meals staff must stay with the resident for the entire time during their meal and that staff reports all incidents immediately to the nurse on duty or the Unit Manager.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1) whose Plan of Care related to Activities of Daily living (ADLs) indicated that he/she required continual supervision (staff member to be with him/her during entire task) with meals, the facility failed to ensure that staff consistently implemented and followed his/her care plan interventions, when on 05/13/25, Resident #1 was served his/her breakfast tray, then left unsupervised in his/her room with his/her meal, he/she spilled a hot beverage on his/her upper legs, and sustained second-degree burns (partial thickness, involves both the outer (epidermis) and underlying layer (dermis) of skin, they cause pain, redness, swelling, and blistering) to the front side of his/her left thigh, which required treatment.Findings Include: Review of the Facility's Policy titled, Care Plans, Comprehensive Person-Centered, dated as revised 01/2024, indicated the following:-A comprehensive, person-centered care plan will be developed for each resident; the care plan will include objectives that meet the resident's physical, psychosocial and functional needs is developed for each resident.-The resident comprehensive care plan will identify problem areas, and their causes as warranted and developing interventions that are targeted and meaningful to the resident.-Evaluation of residents is ongoing and care plans are revised as information about the resident and the resident's condition changes.-The Interdisciplinary Team (IDT) reviews and updates the care plan when there has been a significant change in the resident's conditions, when there is a change and at least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS) assessment. Resident #1 was admitted to the Facility in August 2019, diagnoses included dementia, legal blindness, severe stage glaucoma right eye, muscle weakness, atrial fibrillation (irregular heartbeat) and hypertension. Review of Resident #1's Annual Minimum Data Set (MDS) assessment, dated 05/02/25, indicated that he/she had severe cognitive impairment, and required supervision with touch assistance when eating.Review of Resident #1's ADL Deficit Care Plan, renewed and reviewed with his/her May 2025 MDS, indicated that he/she required continual supervision with meals.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 05/20/25, indicated that on 05/13/25, a Certified Nurse Aide (CNA) observed Resident #1 had spilled coffee on him/herself, he/she was washed, assisted back to bed, he/she did not complain of pain and there were no discolorations on his/her left thigh. The Report indicated that on 05/14/25 at approximately 8:00 A.M. while giving care to Resident #1 a CNA observed blisters on his/her left thigh and told the Nurse who was taking care of him/her. Review of Resident #1's Nurse Progress Note, dated 05/14/25, (written by the Unit Manager), indicated that at approximately 8:00 A.M. a CNA called this writer to Resident #1's room, where she observed three blisters on his/her thigh (left or right side not indicated). The Note indicated that while speaking to staff, they stated a CNA told them yesterday (05/13/25) that Resident #1 spilled coffee on him/herself. The Note further indicated that first aid was performed, the Nurse Practitioner (NP) was notified, and a new order was placed for Bactroban (topical antibiotic) ointment.During an interview on 08/05/25 at 1:10 P.M., (which included review of her written statement) CNA #1 said she worked the 7:00 A.M. to 3:00 P.M. shift on 05/13/25 and was assigned to provide care to Resident #1. CNA #1 said she has worked at the Facility for more than a year and said Resident #1 is on her assignment the days she works. CNA #1 said residents' care Kardex's are in Point Click Care (PCC, electronic medical record (EMR) system) under Point of Care (POC) and said she knew how to look at a resident's care Kardex.CNA #1 said Resident #1 was blind and required set-up with continual supervision for meals. CNA #1 said when she provided care for Resident #1 she would set-up Resident #1's meal tray, then leave to continue passing meal trays to other residents and then go back to Resident #1's room. CNA #1 said she could not remember if she gave Resident #1 his/her breakfast meal tray on 05/13/25, but said she might have. CNA #1 said she heard someone yell Ow, from Resident #1's room, ran to his/her room, saw Resident #1's coffee mug on the floor and that there was coffee on his/her upper pants area that was dripping onto the floor. CNA #1 said she asked Resident #1 what happened and he/she told her that his/her hand was shaking, and the cup slipped out of his/her hand. CNA #1 said Resident #1's meal tray was still in his/her room, and he/she was by him/herself that morning (05/13/25), with his/her meal tray.CNA #1 said she brought Resident #1 into the bathroom to wash and dress him/her and when she removed his/her pants she saw a dime size red spot on his/her left thigh. CNA #1 said that Resident #1 said, my legs feel very, very hot. CNA #1 said she put Resident #1 back into bed, then informed a nurse (thinks it was Nurse #2) that he/she had spilled hot coffee on him/herself and had a small red area on his/her left thigh.During interviews throughout the day of the survey, on 08/05/25 with CNA #2, CNA #4, and CNA #5, who all worked on Resident #1's unit, said that Resident #1 ate his/her breakfast meal in his/her room and required continual supervision with eating. CNA #2, CNA #4, and CNA #5 said that they knew where and how to look at a resident's care Kardex on the computer.During an interview on 08/12/25 at 12:16 P.M., the Former Director of Nursing (DON) said on 05/14/25 the Unit Manager informed her that Resident #1 had spilled hot coffee on his/her leg (could not recall which leg) and that he/she had sustained a burn. The Former DON said she started her investigation which determined that Resident #1 was a set-up with continual supervision for meals and he/she was left unsupervised, as well as unassisted with his/her breakfast meal on 05/13/25. The Former DON said that staff did not follow Resident #1's plan of care.During an interview on 08/05/25 at 4:25 P.M., the Director of Nursing (DON) said it is her expectation that if a resident requires continual supervision with meals that staff must stay with the resident for the entire time during their meal. The DON said all CNA's are trained on how to document care provided in the POC EMR system and how to access residents' care Kardex's, that it is part of their orientation after hire.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was helpless, unable to participate in self care, had limited mobility due to left sided hemiparesis (paralysis on one side of the body), and who had been assessed by nursing as being at high risk for falls, the Facility failed to ensure he/she was provided with the necessary level of staff assistance during care to maintain his/her safety, in an effort to prevent incidents/accidents resulting in an injury. On 10/13/23, Certified Nurse Aide (CNA) #1 provided personal care to Resident #1 in bed without another staff member present to assist her, when she turned Resident #1 on his/her side in bed, he/she began to slide, CNA #1 could not manage him/her, and Resident #1 fell out of bed, landing on the floor on his/her right side. Resident #1 was noted to be bleeding from a laceration to the back of his/her head. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation, where he/she received seven staples to close the laceration to the back of his/her head, and was also diagnosed with a right intertrochanteric (hip) fracture which required surgical intervention to repair. Findings include: Review of the Facility's Policy, titled Managing Falls and Fall Risk, dated as revised April 2018, indicated the following: -based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling; -staff will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls; -if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant; -if underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable; -staff will monitor and document each resident's response to interventions intended to reduce falling or the risk of falling; -if interventions have been successfully in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention has resolved; -if the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions; -the staff will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. Review of the Facility's Internal Investigation Report, dated 10/19/23, indicated that on 10/13/23 at 7:20 P.M., CNA #1 provided personal care to Resident #1, rolled him/her towards her (CNA #1) when Resident #1 slid off the mattress and fell out of bed on the right side of bed onto his/her right side. The Report indicated that Resident #1 was bleeding from the back of his/her head and sustained a laceration to the back of his/her head. The Report indicated that Resident #1 was transferred to the Hospital Emergency Department and was diagnosed with a right hip fracture that required surgery. Review of a Nurse Progress Note, dated 10/13/23, as a late entry, written by Nurse #1 indicated that she was called by CNA #1 to Resident #1's room where she found him/her on the floor. Review of a Fall Incident Report, dated 10/13/23, written by Nurse #1 indicated that CNA #1 called her to Resident #1's room where she found Resident #1 on the floor on the right side of the bed on his/her right side. The Report indicated that while providing care to Resident #1, CNA #1 rolled him/her toward her (CNA #1) and suddenly Resident #1's feet went to the floor, CNA #1 could no longer manage him/her and he/she hit the back of his/her head on the bedside table. The Report indicated that Resident #1 sustained an abrasion to the top of his/her scalp. Review of a Hospital Discharge Summary, dated 10/14/23, indicated that Resident #1 sustained a fall at the Facility on 10/13/23 while being changed, rolled off the bed, hit the back of his/her head on the nightstand and sustained a laceration to the back of his/her head. The Discharge Summary indicated that Resident #1 required seven staples to close the laceration to the back of his/her head. The Discharge Summary indicated that a CT Scan of Resident #1's pelvis revealed a mildly comminuted (fragmented) minimally impacted right intertrochanteric (hip) fracture and he/she underwent an open reduction internal fixation (ORIF) surgery to repair his/her right hip. Resident #1 was admitted to the Facility in October 2018, diagnoses included hemiplegia (one sided paralysis) and hemiparesis affecting left non-dominant side, type 2 diabetes mellitus, atrial fibrillation, malignant neoplasm of colon and muscle weakness. Review of the Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired, required extensive physical assistance of two staff members with transfers, bed mobility, hygiene care, toileting (which included incontinence care) and was totally dependent on the physical assistance of two staff members with bathing. Review of Resident #2's Care Plan related to Activities of Daily Living (ADL) and Functional Mobility, reviewed and renewed with his/her August 2023 MDS, indicated he/she was essentially helpless with left sided hemiparesis, required the physical assistance and/or total dependence of one to two staff members with bathing, bed mobility, positioning, dressing, personal hygiene and toileting (which included incontinence care). Review of Resident #1's ADL Flowsheets, dated September 2023 and October 2023, (as documented by the CNA's) indicated that prior to his/her fall on 10/13/23, he/she consistently required extensive physical assistance of two staff members or was totally dependent on the physical assistance of two staff members for bed mobility, positioning, hygiene care, and toileting (which included incontinence care) on all three shifts. However, review of Resident #1's Resident Care Card, (used as a reference guide by CNA's), dated October 12, 2023, indicated he/she required the physical assistance and/or total dependence of one to two staff members with bathing, bed mobility, positioning, dressing, personal hygiene and toileting (which included incontinence care). Review of Resident #1's Fall Risk Assessment, dated 10/06/23, indicated that he/she was at high risk for falls. During an interview on 11/14/23 at 12:05 P.M., Nurse #1 said that CNA #1 called her into Resident #1's room and when she entered the room, Resident #1 was on the floor bleeding from a laceration on the back of his/her head. Nurse #1 said that CNA #1 was providing personal care to Resident #1 without the assistance of another staff member and that Resident #1 fell out of bed, hit the back of his/her head on the bedside table (nightstand). Nurse #1 said that Resident #1 is very stiff, has hemiparesis and is unable to participate in any activities of daily living. Nurse #1 said that Resident #1 requires physical assistance from two staff members with all his/her activities of daily living and said CNA #1 should not have provided care to Resident #1 alone. Nurse #1 said that she believes it was CNA #1's first time taking care of Resident #1. Nurse #1 said that she did not review Resident #1's level of assistance with CNA #1 and said that the CNA's review the level of assistance that each resident's require with each other at the beginning of the shift. Nurse #1 said that nurses don't usually give report to the CNA's regarding the level of assistance the residents require with the CNA's. Review of CNA #1's Written Witness Statement, dated 10/13/23, indicated that at approximately 7:30 P.M., she was providing personal care to Resident #1 in bed, rolled him/her toward her (CNA #1) when his/her feet slid off the side of the bed with the bed sheet and he/she landed on the floor hitting his/her head on the bedside table (nightstand). The Statement indicated that she (CNA #1) was not aware that Resident #1 required the assistance of two staff members with care. During an interview on 11/14/23 at 3:30 P.M., Certified Nurse Aide (CNA) #1 said that on 10/13/23, she was providing personal care to Resident #1 in bed without the assistance of another staff member when his/her legs got caught in the bed sheet, he/she slid off the bed, and fell out of bed hitting the back of his/her head on the bedside table (nightstand). CNA #1 said that at the beginning of the shift, one of the CNA's told her that Resident #1 required the assistance of one staff member with care but said she could not recall which CNA told her. CNA #1 said that she had taken care of Resident #1 once before, and said she thought that he/she required the physical assistance of one staff member with care. CNA #1 said that after the incident, she was made aware that he/she required the physical assistance of two staff members with bed mobility, bathing and personal care. CNA #1 said that the nurse did not inform her at the beginning of the shift the level of assistance Resident #1 required with care. CNA #1 said that she was not aware that each resident had a care card that informed the CNA of the level of assist required when providing care. Review of the CNA job description indicated there is no documentation to support that in the CNA's job description, they can assess the level of assistance a resident requires with each activity of daily living task. Further review of the CNA job description, indicated that assessment of the level of assistance a resident requires is not within the scope of a CNA's practice. During an interview on 11/14/23 at 1:30 P.M., CNA #2 said that even though Resident #1's Care Card indicates that he/she requires extensive physical assistance of one to two staff members with bed mobility, positioning, bathing, personal care and dressing, she always gets the assistance of another staff member. CNA #2 said that Resident #1 has hemiparesis, is very stiff and is difficult to turn in bed. CNA #2 said she is unable to position, turn, bathe, dress, and provide personal hygiene safely without the physical assistance of another staff member. CNA #2 said the only thing you can do alone safely for Resident #1 is wash the front side of him/her, because he/she is laying flat in bed. During an interview on 11/14/23 at 1:45 P.M., CNA #3 said that Resident #1 requires extensive physical assistance of two staff members with bed mobility, positioning, bathing, personal care and dressing. CNA #3 said that Resident #1 has hemiparesis, is very stiff and is difficult to provide care without the assistance of another staff member. CNA #3 said that although Resident #1's Care Card does indicate that she requires extensive physical assistance of one or two staff members said the only thing you can do alone is wash his/her front side in bed. CNA #3 said that for everything else, Resident #1 requires extensive physical assistance of two staff members to care for him/her safely. During an interview on 11/14/23 at 3:05 P.M., the Unit Manager said that CNA's ask another CNA or the nurse what level of assistance each resident requires. The Unit Manager said that every resident has a care card that indicates the level of assistance they require with each activity of daily living task. The Unit Manager said that the care card should be specific as to the level of assistance the resident requires with each activity of daily living. During an interview on 11/14/23 at 4:15 P.M., the Director of Nurses (DON) said that Resident #1's resident care card indicated that he/she required one to two assists with his/her care needs. The DON said this means that when a CNA gives care to Resident #1 and feels they need another staff member to assist them with care needs, they need to ask another staff member for assistance with that resident. The DON said that CNA #1 used poor judgment when she provided care to Resident #1 on 10/13/23 without the physical assistance of another staff member. The DON said that it is his expectation that the nurse lets the CNA's know what level of assistance each resident requires with each activity of daily living task at the beginning of the shift.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was severely cognitively impaired, was essentially helpless, unable to participate in care due to left sided hemiparesis (partial paralysis on one side of the body) and had been assessed by nursing as being at high risk for falls, the Facility failed to ensure that his/her care plan related to activities of daily living was updated and accurately identified his/her individual care needs that he/she required two staff members to assist at all times during the provision of care, due to impaired mobility and safety concerns. Although staff consistently documented that Resident #1 required two staff persons for assistance with care, his/her Care Plan and Resident Care Card, both indicated he/she required one or two staff persons for assistance and on 10/13/23, Certified Nurse Aide (CNA) #1 provided personal care to Resident #1 in bed without another staff member present to assist her, when CNA #1 turned Resident #1 onto his/her side, he/she fell out of bed and landed on the floor on his/her right side. As a result of the fall Resident #1 sustained a laceration to the back of his/her head, was transferred to the Hospital Emergency Department for further evaluation, he/her received seven staples to close the laceration and was also diagnosed with a right intertrochanteric (hip) fracture which required surgical intervention to repair. Findings include: Review of the Facility's Policy, titled Comprehensive Person-Centered Care Plans, dated as revised November 2017, indicated the following: -a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -the Interdisciplinary Team (IDT) develops and implements a comprehensive, person-centered plan for each resident; -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; -the comprehensive, person-centered care plan will incorporate identified problem areas, incorporate risk factors associated with identified problems, build on the resident's strengths, enhance the optimal functioning of the resident, reflect currently recognized standards of practice for problem areas and conditions; -care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. -assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Resident #1 was admitted to the Facility in October 2018, diagnoses included hemiplegia (one sided paralysis) and hemiparesis affecting left non-dominant side, type 2 diabetes mellitus, atrial fibrillation, malignant neoplasm of colon and muscle weakness. Review of the Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired, required extensive physical assistance of two staff members with transfers, bed mobility and toileting and was totally dependent on the physical assistance of two staff members with bathing. However, review of Resident #1's Care Plan related to Activities of Daily Living (ADL) and Functional Mobility, reviewed and renewed with his/her August 2023 MDS, indicated he/she was essentially helpless with left sided hemiparesis, required the physical assistance and/or total dependence of one to two staff members with bathing, bed mobility, positioning, dressing, personal hygiene and toileting (including incontinence care). Review of Resident #1's ADL Flowsheets, dated September 2023 and October 2023, (as documented by the CNA's) indicated that prior to his/her fall on 10/13/23, he/she consistently required and was provided extensive physical assistance of two staff members or was totally dependent on the physical assistance of two staff members for bed mobility, positioning, hygiene and toileting (including incontinence care) care needs on all three shifts. Review of Resident #1's Fall Risk Assessment, dated 10/06/23, indicated that he/she was at high risk for falls. Review of Resident #1's Resident Care Card, (used as a reference guide by CNA's), dated October 12, 2023, indicated he/she required the physical assistance and/or total dependence of one to two staff members with bathing, bed mobility, positioning, dressing, personal hygiene and toileting (including incontinence care). Although Resident #1's Care Plan and CNA Care Card related to ADL's both indicated the need for one to two staff members to assist with care, this was inconsistent with the actual level of assistance that was required and provided to Resident #1 during care, as evidence by documentation completed by nursing staff which clearly indicated he/she required two staff members physical assistance while meeting his/her care needs. There was no documentation to support that Resident #1's ADL Care Plan or resident Care Card were updated by nursing to reflect the need for two staff member to assist and participate during the provision of care. Review of the Facility's Internal Investigation Report, dated 10/19/23, indicated that on 10/13/23 at 7:20 P.M., CNA #1 provided personal care to Resident #1, rolled him/her towards her (CNA #1) when Resident #1 slid off the mattress and fell out of bed on the right side of bed onto his/her right side. The Report indicated that Resident #1 was bleeding from the back of his/her head and sustained a laceration to the back of his/her head. The Report indicated that Resident #1 was transferred to the Hospital Emergency Department and was diagnosed with a right hip fracture that required surgery. Review of a Nurse Progress Note, dated 10/13/23, as a late entry, written by Nurse #1 indicated that she was called by CNA #1 to Resident #1's room where she (Nurse #1) found him/her on the floor. Review of a Fall Incident Report, dated 10/13/23, written by Nurse #1 indicated that CNA #1 called her to come to Resident #1's room where she found Resident #1 on the floor on the right side of the bed on his/her right side. The Report indicated that while providing care to Resident #1, CNA #1 rolled him/her toward her (CNA #1) and suddenly Resident #1's feet went to the floor, CNA #1 could no longer manage him/her and he/she hit the back of his/her head on the bedside table. The Report indicated that Resident #1 sustained an abrasion to the top of his/her scalp. Review of a Hospital Discharge Summary, dated 10/14/23, indicated that Resident #1 sustained a fall at the Facility on 10/13/23 while being changed, rolled off the bed, hit the back of his/her head on a nightstand and sustained a laceration to the back of his/her head. The Discharge Summary indicated that Resident #1 required seven staples to close the laceration to the back of his/her head. The Discharge Summary indicated that a CT Scan of Resident #1's pelvis revealed a mildly comminuted (fragmented) minimally impacted right intertrochanteric (hip) fracture and he/she underwent an open reduction internal fixation (ORIF) surgery to repair his/her right hip. During an interview on 11/14/23 at 12:05 P.M., Nurse #1 said CNA #1 was providing personal care to Resident #1 without the assistance of another staff member and said that Resident #1 fell out of bed. Nurse #1 said that Resident #1 is very stiff, has hemiparesis and is unable to participate in any activities of daily living. Nurse #1 said that Resident #1 requires the physical assistance of two staff members with all his/her activities of daily living. Nurse #1 said that she believes it was CNA #1's first time taking care of Resident #1. Nurse #1 said that she did not review Resident #1's level of assistance with CNA #1. Review of CNA #1's Written Witness Statement, dated 10/13/23, indicated that at approximately 7:30 P.M., she was providing personal care to Resident #1 in bed, rolled him/her toward her (CNA #1) when his/her feet slid off the side of the bed with the bed sheet and he/she landed on the floor hitting his/her head on the bedside table (nightstand). The Statement indicated that she (CNA #1) was not aware that Resident #1 required the assistance of two staff members with care. During an interview on 11/14/23 at 3:30 P.M., Certified Nurse Aide (CNA) #1 said that on 10/13/23, she was providing personal care to Resident #1 in bed without the assistance of another staff member when his/her legs got caught in the bed sheet, he/she slid off the bed, and fell out of bed hitting the back of his/her head on the bedside table (nightstand) causing the back of his/her head to bleed. CNA #1 said that she has taken care of Resident #1 once before, said she thought that he/she required the physical assistance of one staff member with care and said that after the incident, she was made aware that he/she required the physical assistance of two staff members with bed mobility, bathing and personal care. CNA #1 said that the nurse did not inform her at the beginning of the shift the level of assistance Resident #1 required with care. CNA #1 said that she was not aware that each resident had a care card that informed the CNA of the level of assist required when providing care. During an interview on 11/14/23 at 1:30 P.M., CNA #2 said that even though Resident #1's Care Card indicates that he/she requires extensive physical assistance of one to two staff members with bed mobility, positioning, bathing, personal hygiene and dressing, said she always gets the assistance of another staff member. CNA #2 said that Resident #1 has hemiparesis and is very stiff and difficult to turn in bed. CNA #2 said she is unable to position, turn, bathe, dress, and provide personal hygiene safely to him/her without the physical assistance of another staff member. CNA #2 said the only thing you can do alone safely for Resident #1 is wash the front side of him/her, because he/she is laying flat in bed. During an interview on 11/14/23 at 1:45 P.M., CNA #3 said that Resident #1 requires extensive physical assistance of two staff members with bed mobility, positioning, bathing, personal hygiene and dressing. CNA #3 said that Resident #1 has hemiparesis, is very stiff and difficult to provide care without the assistance of another staff member. CNA #3 said that although Resident #1's Care Card indicates that she requires extensive physical assistance of one or two staff members, said the only thing you can do alone is wash his/her front side in bed. CNA #3 said that for everything else, Resident #1 requires extensive physical assistance of two staff members to care for him/her safely. During an interview on 11/14/23 at 3:05 P.M., the Unit Manager said that CNA's will ask another CNA or the nurse what level of assistance each resident requires. The Unit Manager said that every resident has a CNA Care Card that indicates the level of assistance they require with each activity of daily living task. The Unit Manager said that the care card should be specific as to the level of assistance the resident requires with each activity of daily living. During an interview on 11/14/23 at 4:15 P.M., the Director of Nurses (DON) said that Resident #1's resident CNA Care Card indicated that he/she required one to two person assist with his/her care needs and said that when a CNA gives care to Resident #1 and feels they need another staff member to assist them with care needs, they should ask another staff member for assistance with that resident. The DON said that is what one to two assistance with care needs means when indicated on the resident care card. The DON said that CNA #1 used poor judgment when she provided care to Resident #1 on 10/13/23 without the physical assistance of another staff member. The DON said that it is his expectation that the nurse lets the CNA's know what level of assistance each resident requires with each activity of daily living task at the beginning of the shift. Review of a CNA job description indicated that under the direction and supervision of a licensed/registered nurse, the CNA: -delivers efficient and effective nursing care while achieving positive clinical outcomes and patient/family satisfaction; -the CNA will function within the standards of practice accorded by his/her certification; -the CNA performs various patient care activities and related non-professional services essential to caring for personal needs and comfort of patients; -provides patient care in a manner conducive to safety and comfort; -assists patient with or performs activities of daily living; -positions patients in correct body alignment in and out of bed; -reports changes in patient's condition to the charge nurse or supervisor; -promotes a culture of safety; -participates in the care planning process and implements care according to care plan. Review of the CNA job description indicated there is no documentation to support that in the CNA's job description, they can assess the level of assistance a resident requires with each activity of daily living task. Further review of the CNA job description, indicated that assessment of the level of assistance a resident requires is not within the scope of a CNA's practice.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose physicians' orders indicated he/she was a full code (if a person's heart stops beating and/or they stop breathing, all resuscitation procedures will be provided to keep them alive), the Facility failed to ensure nursing staff provided life saving measures to him/her, when on [DATE], at approximately 5:30 A.M., after Nurse #1 found Resident #1 unresponsive, without pulse and without respiration, she did not call a Code Blue, per facility policy, and Resident #1 was not administered cardiopulmonary resuscitation (CPR). Resident #1 was pronounced dead at the facility, approximately two hours after nursing initially found him/her unresponsive. Findings include: Review of the Facility Policy titled, Code Blue, dated as last revised ,d+[DATE], indicated that if a resident is found to be unresponsive or becomes unresponsive under observation, staff will call a Code Blue and would be paged overhead three times, the page will include the unit, location, and room. The Policy also indicated that for a Full Code, upon arrival to the scene the nursing staff will assess victims who are unconscious, not breathing normally and showing no signs of circulation, such as normal breathing, coughing, and movement and if the victim is noted to have neither pulse nor respiration, the staff will initiate CPR. Review of the Massachusetts Board of Registration of Nursing Advisory Ruling on Nursing Practice, titled Nursing Practice and Cardio-Pulmonary Resuscitation (CPR), revised [DATE], indicated that to guide the decision making of the nurse, in context of practice in all settings where healthcare is delivered require initiating cardio-pulmonary resuscitation when a patient has been found unresponsive and has not yet been declared dead by a provider authorized pursuant to M.G.L c. 469 except when a patient has a current valid Do Not Resuscitate (DNR) order/status. Review of the Report submitted by the facility, via the Health Care Facility Reporting Systems (HCFRS), dated [DATE], indicated on [DATE], in the morning, Resident #1 was found with his/her mouth open, chest not moving and nursing was unable to get vital signs. The Report indicated Nurse #1 checked his/her chart for a code status and was unable to do so (could not find code status or physicians' orders) and CPR was not immediately initiated. Resident #1 was admitted to the Facility in [DATE], diagnoses included adult failure to thrive, Alzheimer's type dementia, chronic obstructive pulmonary disease, malnutrition, and dysphagia (difficulty swallowing) with a gastrostomy (tube that brings nutrients directly into the stomach) in place. Review of Resident #1's Decree and Order for Appointment of Guardian for An Incapacitated Person, dated [DATE], indicated he/she had an active Guardianship in place, and Guardian was to make medical decisions. Review of Resident #1's Care Plan titled, Advanced Directives, reviewed and renewed with his/her Minimum Data Set (MDS) assessement completed in [DATE], indicated he/she was a Full Code. Review of Resident #1's History and Physical, dated [DATE], indicated he/she was a Full Code. Review of Resident #1's Physician's Order, dated [DATE], indicated he/she was a Full Code. Review of Resident #1's medical record indicated there was no pink Medical Orders for Life Sustaining Treatment (MOLST) form in place. Review of Nurse #1's written Witness Statement, dated [DATE], indicated she last saw Resident #1 alive at approximately 4:00 A.M. and then on her second set of rounds, (later determined to be at approximately 5:30 A.M.) she found Resident #1 with his/her mouth open, his/her chest was not rising, and she unable to obtain vital signs. The Statement indicated Nurse #1 checked his/her medical record for a code status and it was unspecified, so she called the Registered Nurse (RN, later identified as Nurse #2) who was in the building to pronounce Resident #1. During an interview on [DATE] at 9:20 A.M., Nurse #1 said during her morning rounds (5:30 A.M.) she found Resident #1 unresponsive and said he/she looked like she was completely dead. Nurse #1 said she went to his/her medical record, said she could not located his/her advanced directives and said she called, (later determined that the call was placed at 6:06 A.M.) the on-call Nurse Practitioner (NP). Nurse #1 said she did not call a Code Blue at the time she first noted Resident #1 to be unresponsive, and was unable to offer an explanation as to why. Nurse #1 said the NP asked her what she had found when assessing Resident #1 and Nurse #1 said she told the NP he/she had no blood pressure, no pulse, no respirations, and he/she was cold. During an interview on [DATE] at 8:34 A.M., the Nurse Practitioner (NP) said at 6:06 A.M. she received a phone call from Nurse #1. The NP said Nurse #1 was very difficult to understand, said she was all over the place with her thoughts and that English was not her (Nurse #1's) primary language. The NP said she thought to herself, does this nurse even know what she is talking about? The NP said Nurse #1 told her that Resident #1 was not breathing. The NP said she asked Nurse #1 if she checked him/her for a heartbeat and Nurse #1 said yes. The NP said Nurse #1 also informed her during the call that she (Nurse #1) had already left a message for his/her Guardian and called the funeral home. The NP said she gave Nurse #1 a verbal order for an RN to pronounce Resident #1. During an interview on [DATE] at 5:59 A.M., Certified Nurse Aide (CNA) #1 said Resident #1 was on her assignment on the 11:00 P.M.-7:00 A.M. (night shift) on [DATE] into [DATE]. CNA #1 said at approximately 3:00 A.M., Resident #1 was yelling out and said that was not unusual when he/she was wet and uncomfortable. CNA #1 said she provided incontinent care, and he/she stopped yelling out and was noted to be quiet at approximately 4:00 A.M. CNA #1 said Nurse #1 came to her at around 5:30 A.M., and said she (Nurse #1) could not find Resident #1's pulse and then Nurse #1 said, I think he/she is dead. CNA #1 said Nurse #1 did not call a Code Blue and asked her to go get Nurse #2 (only RN in the facility) to pronounce Resident #1. During an interview on [DATE] at 5:48 A.M., CNA #2 said on [DATE], she was the second CNA on the unit that night and said she did not hear a Code Blue called. CNA #2 said she was unaware that a resident had passed away during the shift until approximately 7:00 A.M., at the end of the shift. Review of Nurse #2's written Witness Statement and during an interview on [DATE] at 12:57 P.M., Nurse #2 (who was the only RN working on the overnight shift that night) said on [DATE] at approximately 6:15 A.M. she was passing her early morning medications when CNA #1 approached her and told her that Nurse #1 wanted her to come up to the second floor and help with an RN pronouncement. Nurse #2 said there was no Code Blue announced that night during the shift. Nurse #2 said she finished medicating the resident she was working on and then went to the second floor to assist Nurse #1. Nurse #2 said she asked Nurse #1 what Resident #1's code status was and said Nurse #1 told her he/she was a DNR. Nurse #2 said she did not check Resident #1's chart for his/her advanced directives and took Nurse #1's word for it. Nurse #2 said Nurse #1 told her she had already called the on-call Nurse Practitioner (NP) and that the NP had given her a verbal order for Resident #1's RN pronouncement. Nurse #2 said she went to Resident #1's room and performed an assessment. Nurse #2 said Resident #1 had no pulse, no respirations, vital signs were unable to be obtained, and he/she was white and cold. Nurse #2 said she was unable to locate the proper RN Pronouncement Form so she could not complete the pronouncement at that time. Nurse #2 said if she had the Form she would have pronounced Resident #1 dead at 6:35 A.M. During an interview on [DATE] at 8:19 A.M., Nurse #6 said she worked the 11:00 P.M.-7:00 A.M. (night) shift on [DATE] into [DATE], and said she did not hear a Code Blue called at all during the shift. During an interview on [DATE] at 11:27 A.M., the Nurse Manager said he knew Resident #1 was a full code, and that he/she had a Guardianship in place. The Nurse Manager said a Code Blue should have been called right away and said that staff should have followed the proper procedures. The Nurse Manager said if a nurse is unable to locate or confirm that a resident is a DNR, that the resident should be treated as a full code and CPR is to be initiated. During an interview on [DATE] at 11:06 A.M., the Assistant Director of Nurses (ADON) said when Resident #1 was found unresponsive a Code Blue should have been called immediately, allowing other staff to assist Nurse #1. The ADON said if a nurse is unable to locate or confirm a DNR status, CPR is to be initiated and 911 called. During an interview on [DATE] at 1:30 P.M., the Director of Nurses (DON) said as soon as Nurse #1 found Resident #1 unresponsive, without a pulse, and without respirations, Nurse #1 should have called a Code Blue and CPR should have been immediately initiated. The DON said on [DATE], after being made aware sometime after the start of the day shift (approximately 7:15 A.M. - 7:30 A.M.) that Resident #1 had been found unresponsive (during the overnight shift), he said he instructed nursing staff to call a Code Blue, call 911 and initiate CPR. Nurse #1 and Nurse #2 said they were made aware after the day shift nurses arrived that Resident #1 was a full code, and that although Resident #1 had been identified as being unresponsive, without a pulse and not breathing for more than an hour and a half before this, said they were directed to call a Code Blue, call 911, and initiate CPR. Nurse #1 said Resident #1 had obvious signs of rigor mortis (stiffening of the joints and muscles of a body a few hours after death), by then, that he/she was stiff. Nurse #1 said they did call 911, but had not started CPR and that EMS arrived right away. Review of the Emergency Medical Services (EMS) Final Report, dated [DATE], indicated EMS arrived at the Resident's room at 7:43 A.M. (more than two hours after Resident #1 was initially found unresponsive by nursing) and met the Fire Department at the door who stated they had findings of lividity (bluish-purple discoloration of skin after death) and resident was cold to the touch. EMS indicated they found Resident #1 in bed, pale, cold, and with lividity noted to the corners of his/her back. Resident #1 was noted to have stiffness in the jaw with minimal movement, he/she was rolled to the side and lividity was noted to the back and top of thighs, pupils were fixed and dilated, and resuscitation was considered futile, and Resident #1 was pronounced dead by EMS staff at 7:45 A.M.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose physicians' orders indicated he/she was a full code (if a person's heart stops beating and/or they stop breathing, all resuscitation procedures will be provided to keep them alive), the Facility failed to ensure nursing staff were competent and had the necessary skill set to respond in an emergency situation which included adequately assessing a resident who was unresponsive with a significant change in condition, calling a Code Blue, and initiating 911 to activate Emergency Medical Services (EMS). On [DATE], at approximately 5:30 A.M., Nurse #1 found Resident #1 unresponsive, briefly assessed him/her, and although Nurse #1 (who was a Licensed Practical Nurse, LPN) was unable to identify Resident #1's code status in his/her medical record, determined him/her to be dead, and did not call a Code Blue or initiate cardiopulmonary resuscitation CPR) and did not call 911. Nurse #2, who was asked by Nurse #1 to complete the RN Pronouncement on Resident #1, did not review Resident #1's medical record for his/her code status, and took Nurse #1's word for it, when she said he/she was a DNR. On [DATE], Resident #1 was pronounced dead at the facility by EMS, approximately two hours after nursing initially found him/her unresponsive, which was when facility staff called a Code Blue and called 911. Findings include: Review of the Facility Policy titled, Code Blue, dated as last revised ,d+[DATE], indicated that if a resident is found to be unresponsive or becomes unresponsive under observation, staff will perform the following: -Call a Code Blue and it would be paged overhead three times, the page will include the unit, location, and room; -For a full code victim, the nurse first responder will give directions to other staff who respond to retrieve the medical record and code cart, record the event, perform CPR, and call 911. Review of the Facility Policy titled, RN Pronouncement, dated as last revised ,d+[DATE], indicated that the documentation in nurses' notes by the RN making the pronouncement should include the following: -Absence of respiration, apical pulse, and blood pressure; -Time of pronouncement; -Notification of the Funeral Home. Review of the Massachusetts Board of Registration of Nursing Advisory Ruling on Nursing Practice, titled Nursing Practice and Cardio-Pulmonary Resuscitation, revised [DATE], indicated that to guide the decision making of the nurse, in context of practice in all settings where healthcare is delivered require initiating cardio-pulmonary resuscitation when a patient has been found unresponsive and has not yet been declared dead by a provider authorized pursuant to M.G.L c. 469 except when a patient has a current valid Do Not Resuscitate (DNR) order/status. Review of the Report submitted by the facility, via the Health Care Facility Reporting Systems (HCFRS), dated [DATE], indicated on [DATE], in the morning, Resident #1 was found with his/her mouth open, chest not moving and nursing was unable to get vital signs. The Report indicated Nurse #1 checked his/her chart for a code status and was unable to do so (could not find code status or physicians' orders), CPR was not immediately initiated and the Registered Nurse (RN) in the building was asked to pronounce Resident #1. The Report further indicated that once Resident #1's code status was verified (as a full code two hours later), nursing staff were directed to call a Code Blue, call 911, and initiate CPR. Resident #1 was admitted to the Facility in [DATE], diagnoses included adult failure to thrive, Alzheimer's type dementia, chronic obstructive pulmonary disease, malnutrition, and dysphagia (difficulty swallowing) with a gastrostomy (tube that brings nutrients directly into the stomach) in place. Review of Resident #1's Decree and Order for Appointment of Guardian for An Incapacitated Person, dated [DATE], indicated he/she had an active Guardianship in place, and his/her Guardian was to make medical decisions. Review of Resident #1's Care Plan titled, Advanced Directives, reviewed and renewed with his/her Minimum Data Set (MDS) assessement completed in [DATE], indicated he/she was a Full Code. Review of Resident #1's History and Physical, dated [DATE], indicated he/she was a Full Code. Review of Resident #1's Physician's Order, dated [DATE], indicated he/she was a Full Code. Review of Resident #1's medical record indicated there was no Medical Orders for Life Sustaining Treatment (MOLST) form in place. During an interview on [DATE] at 9:20 A.M., (which included a review of Nurse #1's written Witness Statement) Nurse #1 said she last saw Resident #1 alive at approximately 4:00 A.M. and then on her second set rounds, (later determined to be at approximately 5:30 A.M.) she found Resident #1 with his/her mouth open and his/her chest not rising. Nurse #1 said she was unable to obtain vital signs, so she checked Resident #1's medical record for a code status and said it was unspecified. Nurse #1 said she called the on-call provider (it was later determined that Nurse #1 placed the call at 6:06 A.M.) for a verbal order for an RN pronouncement. Nurse #1 said the on-call provider was a Nurse Practitioner (NP), and that the NP asked her what she had found when she assessed Resident #1. Nurse #1 said she told the NP he/she had no blood pressure, no pulse, no respirations, and he/she was cold. Nurse #1 said she did not tell the NP she had been unable to locate Resident #1's code status in his/her medical record. Nurse #1 said after she obtained the order, she sent a CNA to get Nurse #2 (the only RN in the building) to complete the pronouncement on Resident #1. Nurse #1 said when the day shift (7:00 A.M. to 3:00 P.M.) nursing staff came in to work, they told her Resident #1 was a full code. Nurse #1 said she was directed by the Director of Nurses (DON) at that time (sometime after 7:00 A.M.) to call a Code Blue and call 911. Review of Resident #1's Nursing Progress Noted, dated [DATE], written by Nurse #1, indicated that Resident #1 was found unresponsive, no pulse, chest not moving and called 911, when ambulance arrived EMS pronounced him/her dead. During an interview on [DATE] at 8:34 A.M., the Nurse Practitioner (NP) said at 6:06 A.M. she received a phone call from Nurse #1. The NP said Nurse #1 was very difficult to understand, she was all over the place with her thoughts and that English was not her (Nurse #1's) primary language. The NP said she thought to herself, does this nurse even know what she is talking about? The NP said Nurse #1 told her that Resident #1 was not breathing. The NP said she asked Nurse #1 if she checked him/her for a heartbeat and Nurse #1 said yes. The NP said Nurse #1 also informed her during the call that she (Nurse #1) had already left a message for his/her Guardian and called the funeral home. The NP said she gave Nurse #1 a verbal order for an RN to pronounce Resident #1. Review of Resident #1's Medical Record indicated there was no documentation to support that when Nurse #1 initially found Resident #1 unresponsive at 5:30 A.M., that she adequately assessed Resident #1 for signs of viable life. There was no documentation to support that Nurse #1 transcribed the order she obtained from the Nurse Practitioner for the RN pronouncement, into Resident #1's medical record. During an interview on [DATE] at 5:59 A.M., Certified Nurse Aide (CNA) #1 said Nurse #1 came to her at 5:30 A.M. and said she could not find Resident #1's pulse and that Nurse #1 said, I think he/she is dead. CNA #1 said Nurse #1 did not call a Code Blue. CNA #1 said Nurse #1 asked her to go get Nurse #2 (only RN in the facility) to do the pronouncement for Resident #1. During an interview on [DATE] at 12:57 P.M., (which included a review of Nurse #2's written Witness Statement) Nurse #2 said on [DATE] at approximately 6:15 A.M. she was passing her early morning medications when CNA #1 approached her and told her that Nurse #1 wanted her to come up to the second floor and help with an RN pronouncement. Nurse #2 said there was no Code Blue announced during their shift that night. Nurse #2 said, when she got to Resident #1's unit, Nurse #1 told her she had already called the on-call Nurse Practitioner (NP) and that the NP had given her a verbal order for Resident #1's RN pronouncement. Nurse #2 said she did not check Resident #1's medical record, before proceeding to do the RN Pronouncement, that Nurse #1 told her he/she was a DNR, and said she took her word for it. Nurse #2 said she went to Resident #1's room, performed an assessment and said Resident #1 had no pulse, no respirations, vital signs were unable to be obtained, and he/she was white and cold. Nurse #2 said she was unable to locate the proper RN Pronouncement Form so she could not complete the pronouncement at that time. Nurse #2 said if she had the Form she would have pronounced Resident #1 dead at 6:35 A.M. Review of Resident #1's Medical Record indicated there was no documentation to support Nurse #2 adequately assessed him/her for any signs of viable life prior to proceeding with pronouncement, there was no nurse progress note or assessment related to Nurse #2's findings in the medical record. During an interview on [DATE] at 11:27 A.M., the Nurse Manager said Resident #1 was a Full Code, a Code Blue should have been called right away, staff should have followed the process for a Code Blue, but said nursing staff did not follow appropriate procedures that night. The Nurse Manager said if a nurse is unable to locate or confirm that a resident is a Do Not Resuscitate (DNR) the resident is then treated as a full code and CPR is to be initiated. During an interview on [DATE] at 11:06 A.M., the Assistant Director of Nurses (ADON) said a Code Blue should have been called immediately, allowing other staff to assist Nurse #1. The ADON said if a nurse is unable to locate or confirm a DNR status, CPR is to be initiated and 911 needs to be called. During an interview on [DATE] at 1:30 P.M., the Director of Nurses (DON) said as soon as Nurse #1 found Resident #1 unresponsive, without a pulse, and without respirations Nurse #1 should have called a Code Blue and CPR should have been immediately initiated. The DON said on [DATE], after being made aware sometime after the start of the day shift (approximately 7:15 A.M. - 7:30 A.M.) that Resident #1 had been found unresponsive (during the overnight shift), that he instructed nursing staff to call a Code Blue, call 911 and initiate CPR. Nurse #1 and Nurse #2 said they were made aware after the day shift nurses arrived that Resident #1 was a full code, and that although Resident #1 had been identified as being unresponsive, without a pulse and not breathing more than an hour and a half before this, said they were directed to call a Code Blue, call 911, and initiate CPR. Nurse #1 said Resident #1 had obvious signs of rigor mortis (stiffening of the joints and muscles of a body a few hours after death), by then, that he/she was stiff. Nurse #1 said they did call 911, but had not started CPR and that EMS arrived right away. Review of the Emergency Medical Services (EMS) Final Report, dated [DATE], indicated EMS arrived at the Resident's room at 7:43 A.M. (more than two after Resident #1 was initially found unresponsive by nursing) and met the Fire Department at the door who stated they had findings of lividity (bluish-purple discoloration of skin after death) and that the resident was cold to the touch. EMS indicated they found Resident #1 in bed, pale, cold, and with lividity noted to the corners of his/her back. Resident #1 was noted to have stiffness in the jaw with minimal movement, he/she was rolled to the side and lividity was noted to the back and top of thighs, pupils were fixed and dilated, and resuscitation was considered futile, and Resident #1 was pronounced dead by EMS staff at 7:45 A.M.

Based on policy review, observation, interview, and record review, the facility failed to ensure one Resident (#70), out of a total sample of 20 residents, received care and treatment to promote healing of a facility acquired deep tissue injury (DTI) (localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) and to help prevent wound deterioration, resulting in worsening of the DTI to a Stage 4 pressure injury (full thickness tissue loss with exposed bone, tendon, or muscle). Specifically, the facility failed to: a. Ensure staff informed the Resident's primary care provider of the wound provider's treatment recommendations after three consecutive wound care visits dated 1/25/23, 1/31/23, and 2/17/23 to help prevent continued deterioration of a left medial ankle pressure wound and implement treatments as ordered; b. Identify and document the condition of the Resident's left medial ankle pressure wound on weekly skin checks; and c. Complete a pressure evaluation form to accurately reflect the date the pressure wound was acquired at the facility. Findings include: Review of the facility's policy titled Pressure Ulcer/Injury Risk Assessment, dated April 2018, indicated but was not limited to the following: -Conduct a structured pressure ulcer/injury risk assessment using a facility-approved tool. -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 a resident centered care plan and interventions based on risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. The following information should be recorded in the resident's medical record utilizing facility forms: -Any change in the resident's condition. -The condition of the resident's skin (i.e., the size and location of any red or tender areas), if identified. -Documentation in medical record addressing MD notification if new skin alteration noted with change of plan of care, if indicated. Review of the wound clinic Services Agreement, dated March of 2015, indicated but was not limited to the following: Facility Responsibilities: -Provide a dedicated nurse to round and communicate with the Provider. -Inform the resident's primary care provider of Provider's recommendation within 24 hours. -Discuss recommendations/wound care plan with the Provider on the day of rounds. Resident #70 was admitted to the facility in November 2022 with diagnoses including adult failure to thrive, diabetes mellitus type 2, difficulty in walking, and weakness. Review of the Minimum Data Set (MDS) assessment, dated 8/21/23, indicated Resident #70 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15 and was an extensive assist for bed mobility, transfer, and personal hygiene. a. Review of the Norton Scale for Predicting Risk of Pressure Ulcers form, dated 11/9/22, indicated Resident #70 was a high risk for developing pressure ulcers. Review of the Pressure Ulcer Care Plan, initiated 11/10/22, indicated a goal to comply with the therapeutic regime. The care plan was resolved on 5/30/23. Review of the Venous Ulcer of the Left Ankle Care Plan, initiated 5/30/23, indicated the Resident's ulcer would be healed by the review date with the following interventions: -document the location of wound, amount of drainage, peri-wound area, edema, and circumference measurements with every dressing change -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. -weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations Review of the Weekly Skin Evaluation, dated 1/12/23, indicated Resident #70 had an old wound present (left heel). No new wounds were identified. Review of the Wound Evaluation and Management Summary, dated 1/17/23, indicated Resident #70 developed a DTI of the left medial ankle greater than three days in duration. The skin was documented as being intact and measured 1.3 centimeters (cm) x 1.8 cm x not measurable. The quality of the wound was documented as a pressure wound with an arterial component. Wound recommendations included the following: -apply skin prep (creates an invisible layer on skin to protect it from friction and shear) to peri-wound once daily for 30 days -elevate legs and off-load the wound Review of the Physician's Orders indicated the following: -off-load heels as tolerated while in bed every shift, 12/15/22 -unstageable DTI of the left, medial ankle, skin prep every day shift, 1/18/23 Review of the January 2023 Treatment Administration Record (TAR) indicated the following: -17 of 93 shifts, heels not documented as being off-loaded -2 of 12 days (1/22/23, 1/23/23), skin prep treatment not documented as being completed Review of the Wound Evaluation and Management Summary, dated 1/25/23, indicated Resident #70's wound had deteriorated and was documented as being an unstageable full-thickness (amount of tissue loss, base of the ulcer is covered by slough/dead tissue, and/or eschar/non-viable tissue in the wound bed) pressure wound. Wound recommendations included the following: -normal saline wash, apply once daily for 30 days; Iodosorb gel (treats wet ulcers to kill bacteria, absorb exudate (pus), and clean out the wound so it heals faster), apply once daily for 30 days -gauze island with border (type of dressing), apply once daily for 30 days -skin prep to peri-wound, apply once daily for 30 days -elevate legs, float heels in bed; off-load wound Review of the medical record failed to indicate staff informed the Resident's primary care provider of the wound provider's recommendations and failed to indicate the recommendations were implemented. Review of the Wound Evaluation and Management Summary, dated 1/31/23, indicated Resident #70's wound had deteriorated and increased in size measuring 3.1 cm x 2.9 cm x 0.3 cm and required surgical debridement to remove necrotic (dead) tissue which revealed a stage 4 pressure wound. Wound recommendations included the following: -normal saline wash, apply once daily for 24 days; Iodosorb gel, apply once daily for 24 days -gauze island with border (type of dressing), apply once daily for 24 days -skin prep to peri-wound, apply once daily for 24 days -elevate legs, float heels in bed; off-load wound Review of the medical record failed to indicate staff informed the resident's primary care provider of the wound provider's recommendations and failed to indicate the recommendations were implemented. Review of the Wound Evaluation and Management Summary, dated 2/17/23, indicated Resident #70's stage 4 pressure wound had deteriorated measuring 3.2 cm x 3.8 cm x 0.3 cm and required surgical debridement to remove necrotic tissue. Wound recommendations included the following: -Iodosorb gel, apply once daily for 30 days, normal saline wash, apply once daily for 30 days, calcium alginate (wound dressing that keeps the wound moist enough for proper healing), apply once daily for 30 days -ABD pad, apply once daily for 30 days, gauze roll stretch 4 inch, apply once daily for 30 days -skin prep to peri wound, apply once daily for 30 days -reposition, elevate legs, float heels in bed, off-load wound Review of the medical record failed to indicate staff informed the resident's primary care provider of the wound provider's recommendations and failed to indicate the dressing treatment recommendations were ordered and implemented until 2/23/23. Review of the February 2023 Treatment Administration Record indicated the following: -19 of 84 shifts, heels not documented as being off-loaded Review of a Nurse Practitioner's Progress Note, dated 2/13/23, indicted Resident #70 had a CT Angio (type of test that combines a CT scan with an injection of a special dye to produce pictures of blood vessels and tissues) on 2/2/23 for a large malleolar (medial ankle) non-healing ulcer which showed no signs of arterial disease. During an interview on 8/24/23 at 8:35 A.M., Unit Manager (UM) #1 said Resident #70 acquired a stage 4 pressure wound on his/her left medial ankle at the facility and was followed by the wound doctor. UM #1 said the facility did not have a dedicated wound care nurse and would just use whoever was available. During an observation with interview on 8/24/23 at 1:43 P.M., the surveyor observed Resident #70 sitting in a wheelchair next to his/her bed. A gauze wrap was observed wrapped around the Resident's left ankle and was dated 8/22/23. Resident #70 said he/she wasn't sure how the wound got there. Review of the current Physician's Orders indicated the following: -Elevate legs and float heels while in bed one time a day, 4/27/23 -Stage 4 pressure wound of the left, medial ankle, normal saline wash, pat dry, apply Iodosorb gel followed by calcium alginate, cover with ABD, skin prep peri area and wrap with gauze roll every day shift, 5/27/23 Review of the August 2023 Treatment Administration Record indicated the following: -3 of 28 days, no documentation the legs were elevated and heels floated -5 of 28 days (8/11/23, 8/18/23, 8/20/23, 8/23/23, 8/27/23), no documentation the stage 4 dressing change was completed On 8/28/23 at 1:25 P.M., the surveyor observed Nurse #5 perform a dressing change on the Resident's left medial ankle wound. Resident #70 said staff were not changing the dressing every day and only did it every now and then. Nurse #5 removed the old dressing which did not have an ABD pad applied per physician's orders and said the wound was a stage 4 pressure ulcer. Nurse #5 said the ABD pad was needed because, without it, the gauze could pull on the skin. The calcium alginate dressing was removed which contained a mild amount of yellow slough. The wound bed was observed covered with yellow slough and the surrounding skin was red and inflamed. The wound was approximately the size of a quarter in circumference with an irregular border. Nurse #5 said the surrounding skin was red and warm to touch. Nurse #5 did not measure the wound prior to completing the dressing change and did not off-load the Resident's heels upon completion of the dressing change. During an interview on 8/29/23 at 11:19 A.M., Nurse #6 said she was assigned to the Resident and was familiar with him/her. She said Resident #70 was admitted with a heel wound and developed a left ankle pressure wound while at the facility. Nurse #6 said the Resident's risk factors included circulation issues and diabetes and needed assistance from staff for bed mobility. She said interventions included putting boots on while in bed and said wound treatments were supposed to be done every day. Nurse #6 said if a new area is identified the wound doctor would come and make recommendations, a nurse would notify the attending physician who would then approve the recommendations, then the nurse would enter the order in the system. She said this should have been done right away but it wasn't. Nurse #6 further said nurses should document in a progress note the presentation of the wound and interventions placed. During an interview on 8/29/23 at 11:42 A.M., UM #1 said the 1/25/23, 1/31/23, and 2/17/23 wound recommendations were not communicated to the attending physician or implemented but should have been. He said there were two days in January when the skin prep was not applied as ordered. UM #1 said a nurse should have called the physician to communicate the wound recommendations to obtain orders but this was not done after the 1/25/23, 1/31/23, and 2/17/23 wound provider's visits. He further said the left medial ankle wound did deteriorate so the Resident was sent to vascular for a stent. UM #1 said the heels should have been consistently off-loaded and the wound started as a DTI on 1/18/23 then was a stage 4 pressure ulcer. He said nursing should write a progress note and complete the required pressure or non-pressure form as indicated. During an interview on 8/29/23 at 12:12 P.M., the Director of Nursing (DON) said the current order was for a left-medial ankle dressing change every day shift and there were five days in August that it was not documented as being done and was a concern. He said he believed one day, on the 18th, the Resident went to the hospital for an ultrasound, but there were no progress notes as to when he/she left and when he/she came back. The DON said the dressing should have been changed daily. b. Review of the Weekly Skin Evaluation forms failed to identify the left medial ankle pressure wound, identified by the wound physician on 1/17/23, as a new area on the 1/19/23, 1/27/23, 2/3/23, 2/21/23, and 2/28/23 forms including documentation of measurements of the skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations per facility policy. During an interview on 8/29/23 at 3:03 P.M., UM #1 said he completed the 1/19/23 skin evaluation and did not complete it correctly as he documented that there was an old wound, so it did not prompt him to document the new skin alteration of the left medial ankle. He said the 1/27/23, 2/3/23, 2/21/23, and 2/28/23 assessments did not reflect it either. c. Review of the Pressure Ulcer Evaluation, dated 1/18/23, indicated the date Resident #70's DTI of the left medial ankle was first observed on 11/4/22. During an interview on 8/29/23 at 3:03 P.M., UM #1 said he completed the 1/18/23 pressure form and documented the date first observed incorrectly. He said it was a facility acquired pressure wound that was first identified on 1/17/23 by the wound doctor and not upon admission to the facility. During an interview on 8/30/23 at 10:04 A.M., Physician #1 said he reviews all the decubitus wounds with staff but could not recall notification back in January of the Resident's new left medial ankle pressure wound. He said he did not recall communication made to him by staff regarding the wound and was not sure how the wound was doing currently as he had not been in to see the Resident. During an interview on 8/30/23 at 12:41 P.M., the Wound Physician said he was following Resident #70. He said he identified the Resident's wound on 1/17/23 and it was a mixed bag of a pressure wound with an arterial component to it. He said the Resident was revascularized on 2/24/23 but the left heel wound was the driving force for that. The Wound Physician said the left medial malleolus wound was facility acquired and in the process of the left heel turning over the medial malleolus went in the wrong direction and, if it continued, he was going to send the Resident back to the vascular surgeon. He said the medial malleolus had gotten worse, so he switched the dressings around. He said when he sees a resident and makes recommendations his preference is to have a dedicated wound care nurse at the facility, but the facility did not have one. He said back in January he had sporadic help from staff so whomever the nurse was would help or it would be an end of the week chore for the DON. The Wound Physician said the wound care recommendations should have been communicated to the attending physician and implemented. During an interview on 8/30/23 at 1:44 P.M, the surveyor reviewed the medical record with the DON and Regional Nurse #2 who said the left medial ankle pressure wound was facility acquired in January of this year. Regional Nurse #2 said treatments should have been completed as ordered. The DON said if there are wound recommendations, then staff should run the recommendations by the physician immediately and, if he agrees, then enter the orders. Regional Nurse #2 said the wound physician treatment recommendations from 1/25/23, 1/31/23, and 2/17/23 were not communicated to the physician or implemented that she could see until 2/23/23. She said the pressure ulcer evaluation form should have had the correct date of acquire and weekly skin checks should have indicated any new areas with a description of the wound.

Based on records reviewed and interviews, for one of three sampled Resident's (Resident #2), the Facility failed to ensure essential equipment was maintained in safe, operating conditions, when on 6/11/19, the head of Resident #2's bed collapsed, Resident #2 complained of severe back pain, was transferred to the Hospital Emergency Department for evaluation, was diagnosed with [REDACTED]. Findings include: Review of Resident #2's medical record indicated [DIAGNOSES REDACTED]. The Admission Nursing Evaluation, dated 6/6/19, indicated, using a pain scale of zero to 10, zero is no pain and 10 being the worst pain, Resident #2 rated his/her level of pain between one and two (hurts a little bit) daily to his/her back and lower extremities. The Admission Minimum Data Set (MDS), dated [DATE], indicated Resident #2 required extensive assist of one staff with activities of daily living. A Resident Incident Report, dated 6/11/19, indicated a Certified Nurse Aide (CNA) was providing morning care to Resident #2 when the head of his/her bed unexpectedly dropped, Resident #2 complained of severe back pain and was transferred to the hospital. A Grievance/Complaint Report, undated, indicated Resident #2's bed piston broke and caused bed to tilt in a 20 degree angle toward head of bed while Resident #2 was in bed. The Health Care Facility Reporting System (HCFRS), dated 6/17/19, indicated that on 6/11/19 at 9:15 A.M., a CNA was providing morning care to Resident #2 while he/she was in bed when she heard a bang and noted that the head of the bed had collapsed. The Report indicated the Maintenance Director was notified of the incident and that it was noted that the head of the bed was approximately 20 degrees below the center of the bed and tilted to the right, while Resident #2 was lying in the bed. The Report indicated that the Maintenance Director noted that the piston extending from the motor, that controls the head of the bed, was at a 90 degree angle from the motor. The Report indicated Resident #2 complained of increased back pain which was worse following the incident and Resident #2 was transferred to the hospital for evaluation. A Lumbar Spine CT Scan Report, dated 6/11/19, indicated Resident #2 had chronic [MEDICAL CONDITION] and or post traumatic change throughout the lumbar spine with chronic associated central canal and foraminal stenoses. The Report indicated there were depressions of the central and left aspects of the L3 and L4 superior endplates (top part of the spine bone known as the vertebral body in the lower back or lumbar region labeled 1 thru 5 has a depression into it due to degeneration, injury related to a disc pushing into the bone) that are probably acute (abrupt onset). A Neurological Consult, dated 6/12/19, indicated Resident #2 had compression deformities of the L3 and L4 and was ordered an LSO (lumbar sacral orthosis - a brace that specifically focuses on immobilizing and supporting your lumbar spine) brace to be worn at all times when standing or in a vehicle. A physician progress notes [REDACTED].#2 complained of lower back pain and leg pain and [MEDICATION NAME] (narcotic [MEDICATION NAME]) was increased to 2 milligrams (mg) twice daily as needed and [MEDICATION NAME] 30 mg Extended Release (narcotic [MEDICATION NAME]) twice daily was added to his/her pain management regime. A physician progress notes [REDACTED].#2 complained of lower back pain which radiates down his/her right leg and [MEDICATION NAME] 5% patch (local anesthetic used to relieve pain) to lumbar spine was ordered. The Surveyor interviewed the Maintenance Director at 11:10 A.M., on 6/25/19. The Maintenance Director said he was called into Resident #2's room and noted that the bed had collapsed with Resident #2 in it. The Maintenance Director said the head of bed was down 20 degrees below the center of the bed and said the electric motor which raises the head of the bed has a bar that attaches to the bed frame, said the bar was bent at a 90 degree angle. The Maintenance Director said the bed frame was damaged from the bent motor rod and said he did not know how that happened. The Maintenance Director said he did not know what a preventative maintenance program was, said the beds were old and said he did not have a manufacturer's manual for the beds for maintenance guidelines. The Surveyor interviewed CNA #1 at 12:50 P.M. on 6/25/19. CNA #1 said that she was providing morning care to Resident #2 when she heard a loud noise and said the head of the bed suddenly collapsed down and the foot of the bed went up. The Surveyor interviewed the Administrator at 10:40 A.M., on 6/26/19. The Administrator said he would look to see if the Facility had a preventative maintenance policy and said the Facility did not have the manufacturer's manual for the Joerns type bed (the type of bed Resident #2 had been in). The Surveyor received an email from the Facility, dated 7/1/19, with the Joerns Bed User-Service Manual attached. The Joerns Bed User-Service Manual, dated (YEAR), indicated that thorough preventative maintenance of the bed should be conducted monthly which includes: visual inspection of the bed frame and accessories for broken welds, cracks, bending or hole enlargement including checking for loose hardware, bolts, nuts, pins and other retaining hardware. The Manual indicated to check wiring for proper connections and damage (fraying, kinking or deterioration) and to check [MEDICATION NAME] (a component of a machine that is responsible for moving parts in the bed) for correct mounting at attachment points and ensure all related pins are mounted securely and properly to the bed frames. The Facility was unable to provide the Surveyor with any documentation to support that preventative maintenance was performed according to the Joerns Bed User-Service Manual Manufacturer's Recommendations to ensure essential equipment was maintained in safe, operating conditions. There was no documentation to support that the facility had a Preventative Maintenance Policy and/or protocol related to essential equipment, to ensure equipment utilized by residents was maintained per manufacturers guidelines.

Based on observation, record review, and interviews, the Facility failed to ensure, that for 6 sampled Residents (#19, #40, #68, #70 #144 and #145) they provided adequate supervision to residents at risk for elopement and who wandered. One resident (Resident #144) wandered down the stairwell on two occasions in November 2017, and although staff said he/she was supposed to be provided one-to-one supervision, this was not consistently provided during the survey and on one occasion the staff member assigned appeared to be sleeping and other residents reported they would awaken at night to find Resident #144 standing in their rooms alone and unsupervised. A second Resident (Resident #68), was found by surveyors in the basement of the facility and staff were not aware of the Resident's location until alerted by surveyors. When interviewed, staff said this resident had a history of [REDACTED]. In addition: -The Facility failed to ensure that exit alert alarms on elevators could not be bi-passed by staff on another floor attempted to use the elevator, - failed to ensure staff responded on a consistent basis to exit alert alarms when activated by residents. During survey, staff were observed to enter the code to silence exit alert alarms on the elevators when activated by residents without redirecting or assisting the resident off the elevator or to a safe location. Surveyors observed that on one occasion, after staff silenced the alarm and did not remove or assist resident from the elevator that the doors closed with the resident alone unsupervised inside and brought the resident to another floor, - failed to ensure that exit alert alarms sounded on a consistent basis when residents with exit alert devices (Wander guard) were in proximity of the system, and - Failed to ensure direct care staff were aware of residents who were at risk for elopement and wandering. Findings include: The Facility Policy titled, Clinical Guideline: Elopement, dated as revised 4/24/06, indicated the purpose of the policy is to identify residents at risk for elopement, minimize episodes of elopement, protect residents that are not capable of protecting themselves, and provide the techniques and equipment to minimize safety risks. The policy included that the frequency of visual checks is established in accordance with the resident's needs and the Facility will identify any external environmental hazards as well as entrances, stairwells or exits that pose a foreseeable danger to residents who wander or have exit seeking behavior. 1. For Resident #68, the Facility failed to respond to exit alert Bracelet Alarm/Device when the Resident exited Unit 2 and was found by Surveyor #2 in the unsupervised basement level of the facility. Resident #68 is a long term care resident admitted ,[DATE] with a [DIAGNOSES REDACTED]. The Resident received Oxygen continuously due to [MEDICAL CONDITION] (Chronic [MEDICAL CONDITION] obstructive Disease) and was observed to have a bracelet alarm/device on his/her wheelchair. A review of the last annual MDS assessment dated [DATE] and the last quarterly MDS dated [DATE] indicated the Resident's BIMS score as 0 (scores range from 0 - 15 with 0 identified as having severe cognitive impairment) and assessed the Resident as needing extensive assistance from one staff person for locomotion on the unit and he/she utilized a wheelchair. At approximately 1:45 P.M. on 12/19/17 Resident #68 was found in the basement of the facility by Surveyor #2. Resident #68 was confused, wandering in his/her wheelchair and stated words to the effect of, (he/she) was lost and did not know where to go. At this time there were no staff around supervising the Resident. The Surveyor entered the Kitchen to obtain assistance for Resident #68. The Food Service Director came out of the kitchen to assist with the return of the Resident to the Second floor. Before being able to assist the Resident to the Second floor the bracelet alarm system within the elevator had to be disabled with a code for the elevator to function. The Unit Manager told Surveyors she was unaware as to how the Resident had eloped from the unit. On 12/21/17 at 1:00 P.M., Surveyor #6 and Surveyor #4 observed Resident #68 getting on the elevator with an Bracelet Alarm/Device on and the elevator alarm did not sound. Surveyor #4 asked the Nurse at the station if the Resident could access the elevator and she said no. There was a 10 to 15 second delay before the Bracelet Alarm/Device sounded. 2. For Resident #19, the Facility failed to ensure the staff responded on a consistent basis when this resident activated the exit alert alarm on the elevator. In response to the activated alarm staff were observed to deactivate and silence the alarm without redirecting or assisting the resident, and the elevator doors closed with the resident inside, sending him/her to the first floor unsupervised. Resident #19 was a long term care resident admitted ,[DATE] an had multiple [DIAGNOSES REDACTED]. A review of the last quarterly MDS assessment dated [DATE] indicated the Resident had a low BIMS score of 7/15 (indicating severe cognitive deficits) and required extensive assistance of one staff person for locomotion on and off the unit. The resident utilized a wheelchair and had not exhibited wandering behaviors. The annual MDS assessment dated [DATE] documented the same except for a lowered BIMS score calculated the Resident at a 3/15 (designating severe cognitive deficits). On 12/20/17 at 11:54 A.M., Surveyor #6, sitting at the second floor nursing desk, observed Resident #19 roll the wheelchair to the elevator door and push the button of the elevator. When the elevator doors opened, the Resident rolled onto the elevator and the exit alert alarm sounded. An activity assistant was observed to come from the day/dining room and turn off /silenced the alarm and the staff member did not assist Resident #19 off the elevator. After being left on the elevator, the elevator doors closed and Resident #19 was brought downstairs in the elevator by his/herself. 3. For Resident #40, the Facility failed to provide adequate supervision when Resident #40 exited the unit unsupervised. Resident #40 was found downstairs (on Unit 1) in another resident's bed on 12/18/17. Resident #40 was admitted ,[DATE] for long term care with multiple [DIAGNOSES REDACTED]. A review of the admission MDS (Minimum Data Set) assessment dated [DATE], indicated the resident had cognitive impairment and scored a 3 out of 15 for the Brief Interview for Mental Status (BIMS) with 3 being severe cognitive impairment. The assessment indicated the Resident exhibited no behaviors and did not wander. The assessment indicated the Resident's functional status with ambulation in the room and corridor was needing the assistance of one staff person for physical assistance. The resident was assessed as having no mobility devices. The initial elopement risk evaluation, dated 10/20/17, indicated Resident #40 was not at risk for elopement and noted the Resident was independent with mobility which was different from the MDS assessment for mobility. A review of the plan of care dated 11/10/17, for Activities of Daily Living, indicated the Resident needed extensive assistance for ambulation but had no information regarding use of assistive devices. The plan of care had no information of the resident exit seeking. The interdisciplinary progress notes indicated the Resident was using a walker on 11/3/17. On 11/26/17 the note at 14:10 (2:10 P.M.) indicated the Resident was wandering around and very confused at times. The medical record indicated the Resident was no longer able to navigate purposefully as of 12/16/17. A note dated 12/16/17 at 8:04 A.M. indicated the Resident was assisted to the bathroom then after was wandering looking for his/her room on the unit. On 12/21/17, the Surveyor #6 observed and heard Unit Nurse Manager #2 call the Resident's Family Member and inform them Resident #6 was found on another unit three days prior (on 12/18/17) and that in response, they were applying an exit alert bracelet device. A review of the nursing documentation for 12/18/17 indicated there was no information of the Resident leaving the second floor and being found on Unit 1 in another Resident's bed on this date. Further observations of Resident #40's room revealed that the staff posted a sign with the Resident's name on the door frame in order to assist the Resident in locating his/her room. During interview on 12/21/17 at 7:37 A.M., the Director of Nurses said Resident #40 wandered out of an activity on the first floor and into another resident's room and said there was no incident report/documentation completed for this wandering episode. 4. For Resident #145, the Facility failed to ensure exit alert alarms sounded when Resident #145 entered the elevator; failed to ensure the direct care staff were aware of Resident #145's exit seeking and wandering behaviors; and, failed to ensure the CNA assignments accurately reflected that this resident used an exit alert (wander guard) device and therefore was an elopement risk. Resident #145's Admission Assessment MDS, dated [DATE], indicated Resident #145 had [DIAGNOSES REDACTED]. The MDS indicated Resident #145 was wheelchair dependent for mobility, and required total dependence of a one person physical assist for locomotion on and off the unit. The MDS indicated Resident #145 did not exhibit wandering behavior. On 12/15/17 at 12:10 P.M., Surveyor #1 observed Resident #145 self propelling in a wheelchair. The Resident was observed with a staff member who identified him/herself as a therapist and was speaking with the Resident and Family. The staff member said Resident #145 had unsafe mobility and wandered without purpose and safety awareness. The Family later said to the Surveyor that they had been informed by Facility staff that the Resident was frequently found trying to get out of the building and/or wandered into other Residents' rooms. a. On 12/21/17 at 12:40 P.M., Resident #145 was observed approaching the elevator, he/she pressed the elevator button and waited for the elevator. The door of the elevator opened and the Resident attempted to enter the elevator. The exit alert bracelet alarm/device did not sound. A staff member walking by redirected the Resident. During the interview with Unit Manager #2 on 12/21/17, Surveyor #1 observed 2 Residents (unidentified at the time) attempting to enter the elevator. At the time, alarms were heard and staff did not intervene. The Surveyor notified the staff of the situation. b. The Wander Guard Listing (the exit alert bracelet alarm device) of Facility residents, which was provided to the Surveyor by the Facility on 12/21/17, indicated Resident #145 was identified as using a wander guard. Surveyor #1 and Surveyor #3 interviewed Certified Nurse Aide (CNA) #1 at 1:45 P.M., on 12/21/17. CNA #1 initially said she received report at the start of her shift from a floor nurse, but then told the Surveyors she received report from the CNA at change of shift and not a nurse. CNA #1 said she was not aware of any residents on her assignment who had a wander guard in place. c. CNA #1 showed the Surveyors the assignment sheet she was given at the start of her shift and although Resident #145 was identified as a resident on her assignment, Resident #145 was not identified as a resident who wore a wander guard, and therefore was an elopement risk. 5. For Resident #70, the staff failed to have knowledge that this Resident who had been identified as an elopement/wander risk, required interventions to ensure his/her safety, and failed to ensure the assignments for the CNA accurately reflected that Resident #70 wore a wander guard and therefore was an elopement risk. Resident #70's Annual Assessment MDS, dated [DATE], indicated Resident #70 had diagnoses, which included dementia and depression, and had severely impaired cognition skills for decision making. The MDS indicated Resident #70 required extensive assistance of a one person physical assist for locomotion on the unit and limited assistance of a one person physical assist for locomotion off the unit. The MDS indicated Resident #70 did not exhibit wandering behavior. The Wander Guard Listing of Facility residents, which was provided on 12/21/17, indicated Resident #70 was identified with a wander guard. a. Surveyor #1 and Surveyor #3 interviewed CNA #2 at 1:55 P.M., on 12/21/17. CNA #2 said she received report from the nurse at change of shift. CNA #2 said she was not aware of any residents on her assignment who were at risk of elopement/wandering behavior. b. CNA #2 showed the Surveyors the assignment sheet she was given at the start of her shift and although Resident #70 was identified as a resident on her assignment, Resident #70 was not identified as a resident with a wander guard (bracelet alarm/device). 6. For Resident #144, Surveyor #1 observed Resident #144 wandering the unit in an attempt to elope and five residents told surveyors that the Resident's wandering behavior was intrusive and they were fearful of Resident # 144. The five residents residents told Surveyors that Resident #144 would enter their rooms at all hours of the day and night, and that they were often awoken and found Resident #144 leaning over their beds, taking items, using their bathrooms, and sitting on the floor of their rooms. Resident #144 was admitted to the Facility in 10/2017 and had [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident had some cognitive loss, scoring an 11 out of 15 on his/her BIMS (Brief Interview of Mental Status). The MD indicated Resident #144 was inattentive, had disorganized thinking, exhibited behavioral symptoms towards others, and wandered most days. The MDS indicated the Resident's wandering posed a significant risk of getting to potentially dangerous places for self and his/her wandering significantly intruded on the privacy and activities of others. A review of the care plan, initiated on 11/6/17, indicated Resident #144's wandering and elopement was a behavior. The goal was to decrease the episodes of wandering and the intervention included medication, anticipate needs, explain care in advance, invite to and encourage activities, provide non-confrontational environment for care, and when agitated approach at later time. a. Record review indicated on 11/14/17, the Resident had exit seeking behaviors and often attempted to leave the Facility. The nurses' notes indicated the Resident became angry by not being allowed to leave the facility and redirection was ineffective. Record review identified Resident #144 exited the Facility on 11/17/17 and that staff were able to bring the Resident back into the building without incident. However, further record review indicated the Social Worker had identified the Resident attempting to leave the building on 2 additional occasions. The Facility indicated the Resident was moved to the second floor for safety and that they would seek alternate nursing home placement. On 11/18/17, the nurse's note indicated the Resident was asking for a knife or scissors to remove the wander guard. On 11/19/17, the nurse's note indicated the Resident was wandering and trying to find the stairwell on 2 occasions, and staff redirected. There were no further interventions put into place. On 11/20/17, the Resident was wandering at 11:00 P.M. per the nurse's note and at 0045 A.M. (one hour and fifteen minutes later), the Staff were alerted by the alarm on the stair well and found the Resident down the stairs. From 11/20/17 through survey, the nurses' notes indicated the Resident wandered without purpose and daily entered other Residents' rooms, taking belongings, attempting to lie in their beds, screaming at staff and refusing assistance, pushing furniture, slamming doors, striking staff, and exit seeking. During interview with Unit Manager #2 on 12/15/17 at 12:00 P.M., Surveyor #1 shared the concerns shared with the surveyors from Residents' interviews and asked about Resident #144's exit seeking and intrusive behavior. Unit Manager #2 said that she was aware of the Resident's exit seeking behavior and other behaviors. She said that the Resident had left the building on one occasion and that there had been several instances the Resident had gotten down the stairwell. Unit Manger said that the Resident was able to read the sign on the stair exit door that said if held for 15 seconds, the door will open. The Unit Manager said that was why the staff had covered the sign with paper. Following this interview and observation on 12/14/17 from 8:00 A.M. through 2:30 P.M., three residents told the Survey Team that Resident #144's wandering behavior significantly affected their sense of safety and well being. In addition, Unit Manager #2 said to Surveyor #6 that Resident #144 had been found on the stairwell 11/19 and 11/20/17 and there were no incident reports or investigations following this exit seeking behavior. There were no new interventions to the care plan. Resident #144 was observed asleep in his/her bed at 9:00 A.M. and 10:00 A.M. on 12/14/17. At 11:00 A.M., the Resident entered the area where the Survey Team was assembled. The Resident wandered around the room and looked in cabinet doors and then sat down. The Resident chattered away for more than 20 minutes and then left the room and wandered towards the exit door across the hall and then walked back towards the nurse's station. At the time of the observation, there was no indication the staff were aware of the Resident's location. On 12/15/17 at 1:25 P.M., the Director of Nurses said Resident #144 was receiving 1 to 1 supervision (it was unknown when this was started and was not observed being provided until 12/15/17) Surveyor #1 shared that the Resident had been observed in his/her room without supervision since 7:00 A.M., and in response, the Director of Nursing said that she had directed the Activity Staff to supervise the Resident and that she would look into it or words to that effect. It was later determined that the Activity Director thought she was asked to encourage additional activities for Resident #144, but told surveyors that none of her staff arrived at 7:00 A.M. and therefore would not have been able to provide the supervision. Resident #144's care plan for fall prevention indicated it was updated on 12/15/17 and indicated the Resident would now be free of falls and that one-to-one was indicated on 12/15/17 to ensure Resident # 144's safety. On 12/20/17 at 6:25 P.M., Resident #144 was observed seated in a chair near the nurse's station. Surveyor #1 and Surveyor #4 approached the area and observed a staff member seated next to the Resident with his head on his palm and the staff member appeared to be dozing. Review of the unit's assignment identified a CNA to be Resident #144's assigned aide to provide one-to-one from 3:00 P.M. to 7:00 A.M. However, during the observation the staff assigned to the Resident had left for the day and the staff providing the care was not certified and was a Nursing Assistant (NA #1). The NA said it was his second shift at the facility. The Resident and NA #1 were observed for more than an hour. The Resident was restless and became easily provoked. The NA stayed close to the Resident, as he/she wandered up and down the hall, in and out of rooms. Review of the personnel file for NA #1 indicated that he had no dementia training and had received no instruction on how to care for this resident. Concerns regarding supervision of Residents who were assessed to be at risk for elopement and who wandered was brought to the attention of the Facility's Director of Nurses and Administrator. In response the team were informed that staff were re-educated regarding the Facility's elopements policies and alarm use. On 12/21/17 review of the inservice sheets for the Facility's alarm device and protocol (on New Elopement Policy) listed multiple staff for day and evening shift, but did not include all staff such as housekeeping, dietary, activities and the night staff. On 12/21/17 at 8:16 A.M., during interview with the Maintenance Director, the Maintenance Director said he checked the wander guards and elevators to ensure they are functioning correctly. He said that on his checks, he approaches the door with a wander guard to verify that it rings and that the door locks. He said that he has logs from the last several months. He said that he can't duplicate every situation, but makes sure that the alarm goes off and that the door locked. The Maintenance Director said that he had originally changed the codes to the elevators on 12/12/17, but found that Elevator #1 and Elevator #2 were overriding and that the codes could not be consistently entered. He said other than this the elevator cars should not move when the alarm is sounding and said that if someone is in the vicinity of the elevator with an exit alert bracelet or device, the elevator should lock. After further discussion on 12/21/17, Surveyor #1, Unit Manager #2 and the Maintenance Director completed an exit alert bracelet alarm/device check. It was observed during the checks that the alarms did not activate as described by the Maintenance Director and that we were able to have the elevators move floor to floor and that the exit alert device did not stop the elevator from moving. After 15 minutes the staff determined the system was not functioning as described and that the Maintenance Director was unaware until 12/21/17. On 12/21/17 at 12:14 P.M., interviews with the Administrator, Director of Nurses and Maintenance Director revealed that the Facility had called the alarm company and were waiting for them to repair the system. The Administrator said that it should be fixed later this afternoon. During the interview, the Administration provided conflicting information about the number of Residents assessed for elopement and who had actually eloped. The Administrator said he was aware that Resident #144 had attempted to leave the building, but said he/she had not actually exited the building.

Based on observation, record review and interviews, for 1 resident (#144) identified living with dementia, the facility failed to provide adequate treatment, supervision and implement interventions to prevent the Resident from exit seeking and prevent wandering behavior that was intrusive and caused 5 residents to be fearful. Five residents told Surveyors that Resident #144 would enter their rooms at all hours of the day and night, and that they were often awoken and found Resident #144 leaning over their beds, taking items, using their bathrooms, sitting on the floor of their rooms and agitated. The total sample included 27 residents. Findings include: Resident #144 was admitted in 10/2017 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident had some cognitive loss, scoring an 11 out of 15 on his/her BIMS (Brief Interview of Mental Status) and displayed inattentive and disorganized thinking, exhibited behavioral symptoms towards others and wandered most days. The MDS indicated the Resident's wandering posed a significant risk of getting to potentially dangerous places for self and his/her wandering significantly intruded on the privacy and activities of others. Record review indicated that the Facility had admitted the Resident (and per the Hospital discharge record dated 10/28/17) as having progressive [MEDICAL CONDITIONS] and agitation. The discharge record indicated the Resident was not able to converse without confabulation. The Resident had exhibited [MEDICAL CONDITION] and agitation while in the hospital. The hospital attempted trials of [MEDICAL CONDITION] medications and had found that some medications had caused and allergic reaction and/or over sedation with an escalation in disinhibited behaviors. The hospital record identified the antidepressant, [MEDICATION NAME] and antipsychotics (medication name was not identified) as causing elevated QTc (prolongation of the heart rate intervals that could cause death). In addition, the antianxiety medication [MEDICATION NAME] caused sedation and caused the Resident to exhibit disinhibited behaviors. On 11/6/17, the facility initiated a care plan for wandering and elopement behaviors. The goal was to decrease the episodes of wandering and the interventions included medication, anticipate needs, explain care in advance, invite to and encourage activities, provide non-confrontational environment for care, and when agitated approach at later time. Further review of the medical record indicated the Resident exhibited wandering and exit seeking behaviors. On 11/10/17, the Resident was transferred for an evaluation for inpatient psychiatric treatment. However, after three days the Resident was ruled out for inpatient care. The hospital record indicated that they informed the Facility that the Resident's intrusive wandering and risk of elopement required interventions to ensure his/her safety. The Resident was transferred back to the facility on [DATE]. The discharge record identified a urinary track infection and ordered an antibiotic for treatment. Record review failed to identify that the Facility reassessed the Resident following the hospital emergency room assessment. The care plan was not revised to included additional safety interventions. The record indicated that the [MEDICAL CONDITION] medications were being managed through the physician and psychiatric service and that prior to the hospital assessment, a plan for discharge to another facility had been initiated on 11/8/17. However, there was no indication why the discharge plan had been initiated. Review of the nurse's notes (11/14/17), indicated the Resident ambulated throughout the halls, exhibited increased anger about not being able to leave the facility, was actively exit seeking and that redirection was ineffective. On 11/14/17, the social worker's progress note indicated the Resident was readmitted to the Facility for skilled care and was awaiting a transfer to another facility. The social worker did not identify the reason for the transfer to another facility and did not identify the Resident's behaviors. The psychiatric consultant's progress note dated 11/14/17 indicated the Resident was found to be both verbally and physically abusive, delusional, confused, attempting to elope and thinking he/she was being kept a prisoner. The assessment indicated the goal was to keep the Resident calm and safe, as is still exit seeking, walking into other residents rooms and waking them from sleep. The recommendations include calling the family to help keep the Resident safe, redirect to a calm and quiet environment, adding [MEDICATION NAME] (a natural supplement) 5 mg and 4 hours prior to sleep, to increase the sleep cycle, and increasing the antipsychotic [MEDICATION NAME] from 12. 5 mg, twice daily to 25 mg twice daily and continuing with [MEDICATION NAME] 50 mg at hour of sleep. Review of the medical record indicated that the staff obtained an order to increase the [MEDICATION NAME], but not for the [MEDICATION NAME]. There was no evidence that staff followed the additional non-pharmalogical interventions. Review of the nurse's notes beginning 11/15/17 indicated the Resident continued to wander up and down the hallways, was confused and attempted to exit the facility. The nurses' notes indicated the Resident was wandering into other resident's rooms, was intrusive, taking other resident's belongings, was insulting and badgering them. The notes indicated redirection was ineffective. On 11/16/17, the nursing staff indicated that they contacted the physician and obtained an order for [REDACTED]. The nurses notes continue to indicate the Resident wandered the halls, was intrusive and went in and out of other resident's rooms. On 11/17/17, Resident #144 was noted to have exited the facility and that staff brought the resident back into the facility. However, further record review indicated the Social Worker had identified the Resident leaving the building on 2 additional occasions. The Facility indicated the Resident was moved to the second floor for safety and that they would seek alternate nursing home placement (on 11/17/17), but did not implement additional interventions to ensure safety for the resident and others. The nurse's notes dated 11/18/17, 11/19/17 and 11/20/17, indicated the Resident was confused, agitated, exit seeking, wandering and was intrusive. The Resident asked for a knife or scissors to remove the wander guard, had attempted to find the stairwell and had been found down the stairwell attempting to leave. The notes indicated the Resident wandered without purpose and (daily) entered other Resident's rooms, taking belongings, attempting to lie in their beds, screaming at staff, refusing assistance, pushing furniture, slamming doors, striking staff and exit seeking. The staff administered the [MEDICATION NAME] at times and obtained a one time order to administer [MEDICATION NAME] on 11/20/17. There was no evidence that the medication had been identified as causing adverse reactions for the resident. No new interventions were put into place and redirection was noted to be ineffective. On 11/21/17, the psychiatric consultant reassessed the Resident. The consultant noted the Resident's behaviors as acute and indicated that the [MEDICATION NAME] was not always being utilized. The recommendations were to schedule the [MEDICATION NAME] 0.5 mg, three times per day and include 0.5 mg as needed, one time during the night. [MEDICATION NAME] was recommended a second time to correct the resident's rhythm disturbance and prevent sundowning. The [MEDICATION NAME] order was for 5 mg for 7 days then increase to 5 mg, twice daily. In addition, it was recommended if the [MEDICATION NAME] was ineffective to increase the dosing of [MEDICATION NAME] to 50 mg, twice a day and 75 mg at hour of sleep, and obtain a EKG (electrocardiography which records activity). Although, the [MEDICATION NAME] (5 mg daily) was started on 11/21/17, there was no indication if the physician had ordered the medication based on 11/6/17 recommendations or the 11/21/17 recommendations and no clarification for the additional recommendations (11/21/17). From 11/21/17 through 11/29/17, the nurse's notes indicated the Resident continued to wander, was intrusive, confused, had disorganized thoughts, anxious, exit seeking and continued to go into other Residents rooms. The notes indicated that the staff were unable redirect the Resident. On 11/29/17, the Resident was noted to wander in and out of other residents room, taking their belongings from 11:00 P.M. to 3:00 A.M. The nurse's note indicated the Resident fell and would not allow the staff to assess him/her. The staff obtained a telephone order for [MEDICATION NAME] 0.5 mg, three times daily. The Social Worker note on 11/29/17 indicated the Admission staff of another Facility was looking at possibility of resident getting bed in their facility as would be more appropriate for resident due to his/her . wandering behavior. From 11/30/17 through 12/4/17, the nurses' notes indicated the Resident continue to wander, was intrusive and took other resident's belonging and would not give back. On 12/4/17, the Resident attempted to go down the stairwell. On 12/6/17, the psychiatric consultant reassessed the Resident. The assessment identified the Resident as having dementia and exhibiting anxious, anxiety and wanting to leave, perseveration, flight of ideas and confusion. The note indicated the Resident escaped off the floor to the outside of the building into the cold dark night while wearing only a johnny. In addition, the consultant indicated the Resident's anxiety increased after family visits (which none of this information was identified in the medical record and could not be corroborated with any type of incident report). The consultant recommended a trial of a few days to week of the family not visiting to see if the Resident remains calm through the day and explore option of genomind [MEDICATION NAME] testing for personalized treatment guidance (used to guide treatment for [REDACTED]. According to the assessment the test kit was not available and there was no indication that staff spoke with the Family and trialed no visits. From 12/7/17 through 12/12/17, the nurse's notes indicated the Resident exhibited agitated, wandering, aggressive and intrusive behaviors. The Resident screamed, threatened the staff with physical violence, sat self on floor and refused to leave another resident's room on 12/17/17. The notes indicated the Resident wandered aimlessly in and out of other resident's rooms and took their belongings. The staff were unable to redirect the Resident. On 12/12/17, the psychiatric consultant reassessed the Resident. The assessment indicated the genomind [MEDICATION NAME] testing was not done and that the staff were not using the [MEDICATION NAME] (PRN/as needed). The assessment indicated she would change the PRN [MEDICATION NAME] from night to day time, continue to explore the option of genomind [MEDICATION NAME] testing, check the Residents amylase (an enzyme that breaks down starch into sugar) and the lipase levels (an enzyme the body uses to break down fat), then consider adding the mood stabilizer [MEDICATION NAME] (125 mg, three times daily) to curb impulsiveness and mood swings. The assessment indicated that she spoke with the psychiatric's agency's physician and he suggested if the [MEDICATION NAME] was ineffective to investigate the neuroleptic medications such as [MEDICATION NAME] or [MEDICATION NAME] (antipsychotic medications). There was no indication that staff notified the physician of these recommendations. During the initial tour of the Facility on 12/14/17 from 8:00 A.M. to 2:30 P.M., five residents identified Resident's #144 wandering behavior as intrusive and that it had a significant adverse impact on their safety, privacy and activities. The Residents said that the Facility staff were aware of the Resident's behavior, but when staff intervened the Resident's agitation became worse and the Resident became more aggressive. The Residents said they were fearful of Resident #144 and did not know when the Resident might appear in their rooms and felt the Staff failed to keep them safe from him/her. In addition, Resident #144 was observed by the Survey Team wandering the unit in an attempt to elope, entering other Resident's rooms and approaching others in an intrusive aggressive manner. The Survey Team did not observe the staff provide any redirection or encouragement to prevent the Resident from unsafe behaviors. The Surveyors interviewed 5 Residents who said Resident #144 exhibited the following behaviors on a consistent basis and said the remained fearful of Resident #144 : - Resident #144 came into other Resident's rooms and used the bathroom. The Resident was not with staff and became agitated if told to get out of the room. - Resident #144 was abusive towards others, wandered and was violent. This had been reported to staff but that the staff were ineffective in redirecting the Resident and that he/she had been awoken by Resident #144 standing over him/her and that Resident #144 had attempted to get into the bed with him/her. - Resident #144 was abusive and the Facility did not prevent the Resident from entering rooms. The Resident said when he/she asked Resident #144 to leave room, the Resident got very close to him/her and pointed finger into face and yelled at him/her. - Resident #144 had been intrusive, agitated and aggressive. The Resident said he/she often awoke with Resident #144 leaning into his/her bed. The Resident said the Resident was creepy and that he/she did not trust the Resident's behavior because of his/her dementia. The staff are not equipped to care for the behaviors and only escalate the situations. The Resident said the behaviors Resident #144 exhibits had taken an effect on his/her sleep and mood. Resident #144 is up all night and sleeps for periods during the day and then back up again. Resident #144 yells and is unable to understand boundaries. Staff are aware of his/her condition and situation, but have not offered an alternative. - A Resident stated that Resident #144 was constantly in his/her room. Resident #144 takes a lot of his/her belongings and that staff will bring them back. The Resident said that staff were to put up a barrier stop sign to prevent the Resident from entering his/her room, but that it had not been done. Resident #144 often enters his/her room at night and it is scary, when staff try to get Resident #144 out his/her room, Resident #144 will sit on floor and not move. The Resident said this would go on for quite a period of time. Resident #144 was observed asleep in his/her bed at 9:00 A.M. and 10:00 A.M. on 12/14/17. At 11:00 A.M., Resident #144 entered the area the Survey Team was assembled. Resident #144 wandered around the room and looked in cabinet doors and then sat down. Resident #144 chattered away for more than 20 minutes and then left the room and wandered towards the exit door across the hall an then back towards the nurse's station. At the time of the observation, there was no indication the staff were aware of the Resident's location. On 12/15/17 from 7:00 A.M. through 10:45 A.M, Resident #144 was asleep in his/her bed. The roommate said Resident #144 had been up most of the night and fought with the staff. Resident #144 clogged the toilet and had fallen. The roommate said he/she reported the incidents to staff and that one staff came into the room to assist the Resident (#144) off the floor. Unit Manager #2 was asked about the Resident's behaviors. Unit Manger #2 said that Resident # 144 did wander into other rooms and would sit on the floor. During a follow-up interview on 12/15/17 at 12:00 P.M., Unit Manager #2 said that Resident #144 was an elopement risk and had attempted to elope from the building on 3 occasions. Unit Manager #2 said the Resident had initially lived on the first floor and had been observed leaving the building, and therefore had been moved to the second floor. Unit Manager #2 said while residing on the second floor Resident #144 had been found on the stairwell twice (in an attempt to elope). Unit Manager #2 said Resident #144 was able to read the sign on the stair exit door that said if held for 15 seconds, the door will open. The Unit Manager said that was why the staff had covered the sign with paper and that the Facility was trying to discharge Resident #144 to another Facility with a secured unit due to elopement risks. Unit Manager #2 did not mention the Resident's intrusive wandering behaviors, even though the Surveyor had informed the Unit Manager of the reports received from the 5 residents and that they were in fear of Resident #144. The Surveyor asked for any investigation and/or incidents related to Resident #144's elopements, resident to resident encounters and fall (which Unit Manager #2 said she was unaware of). In addition, the Surveyor asked for the Facility's plan to ensure the Residents are kept safe from Resident #144's behavior. Subsequent to the interview with Unit Manager #2 on 12/15/17 at 12:00 P.M., at 1:25 P.M., the Director of Nurses said that the Facility had been providing 1 to 1 supervision to Resident #144 by the Activities Department staff. The Surveyor informed the Director that during observations of the Resident from 7:00 A.M. until 1:25 P.M., that no 1 to 1 supervision had been observed. The Director said that there had been. The Surveyor observed Resident #144 after the interview and found a staff member sitting next to the Resident. The Unit Manager #2 said that the Facility had taken one of the CNA (Certified Nursing Assistants) and assigned her to watch Resident #144. Unit Manager #2 said that no one had been providing one to one supervision prior to the observation. She said that at the Facility's morning meeting there had been discussion about providing supervision, but had not been implemented until after she met with the Surveyor at 12:00 P.M. During interview on 12/15/17 at 2:30 P.M., the Activity Director was unaware that her staff were to provide 1 to 1 supervision for Resident #144. She said that she thought that if the Resident would, that her staff would try to engage Resident #144 in more activities. She asked the Surveyors if it was appropriate for her and the activity staff to provide 1 to 1 supervision. Observations of Resident #144 on 12/18/17 through 12/19/17 from 7:00 A.M. through 3:00 P.M. indicated that staff were observed seated next to Resident #144 in his/her room. Staff said they were to sit with Resident #144 and sign the log book indicating where the Resident was. The log book indicated the Resident was sleeping for most of the shifts. Review of the medical record indicated the Resident's care plan for falls was updated on 12/15/17 and indicated the Resident would now be free of falls and that 1 to 1 supervision was initiated on 12/15/17 to ensure safety. The care plan for exiting seeking and intrusive wandering was not updated and there were no additional assessments completed or additional interventions implemented. On 12/20/17 at 6:25 P.M., a staff personwho identified himself as a Certified Nursing Assistant (CNA) was providing 1 to 1 for Resident #144. During the first part of the observation, the Resident was seated and the CNA appeared to be dozing next to the Resident. Resident #144 began actively roaming the unit, taking items off the medication cart, the snack cart and wandering in and out of resident rooms and touching and taking items. The CNA walked either behind the Resident or next to the resident and provided no interventions other than this. It was later determined that the CNA was not certified and had not been trained or been provided any additional education on caring for Resident #144's behaviors and dementia. Subsequently, observations of staff treatment of [REDACTED]. No additional interventions were provided to prevent the Resident from wandering and being intrusive. Additional interviews were conducted with the 5 Residents who had reported their fearfulness of the Resident. The Residents said that the Resident continue to wander into their rooms and that staff just followed the Resident into their rooms.

Based on record review, review of facility incident reports and resident and staff interviews, the facility failed for 1 Resident (#11) in a total sample of 19 residents, to provide adequate supervision and ensure the resident environment was free of accident hazards, for Resident #11, who had a history of [REDACTED]. Findings include: Resident #11 was admitted to the facility in 1/2015 with [DIAGNOSES REDACTED]. Review of the medical record that included discharge hospital records dating 7/2/16 and 6/30/16, indicated that the Resident had substance use disorder. The medical record also indicated Resident #11 experienced overdoses twice in 2015 while at the facility Review of the Quarterly Review of 3/17/16 and the Quarterly Minimum Data Set, with an reference date of 6/7/16, indicated the Resident scored a 15 out of 15 on his/her Brief Interview of Mental Status (BIMS), indicating no cognitive impairment, and did not exhibit behaviors or changes in mood. Further review on 11/4/16 failed to indicate that a substance abuse assessment was conducted at the time of prior overdoses or since, although the Resident was a high risk for behaviors that would affect his/her safety. Record review indicated the Resident was receiving 1 to 1 psychotherapy, which ended on 3/31/16. The care plan indicated that staff were to do random searches of room and items provided from outside the facility, random drug screens and supervision during visits with others, however there was no evidence this was done and there was no evidence staff were educated in substance use disorder. Review of the psychotherapist's progress notes dated 3/24/16 and 3/31/16, indicated the therapist was leaving his/her position and that he/she recommended the continuation of 1 to 1 psychotherapy. The therapist's notes focused on mental health issues (not substance use issues) and indicated the therapy was effective in helping the Resident decrease his/her risk for behaviors that would affect his/her safety. Review of the safety care plan that was in place prior to and on 6/30/16 included, 1 to 1 psychotherapy, random room searches for prohibited paraphernalia, supervised visits from friends and others, outside supervision, random urine drug screens, search items that visitors bring into facility for resident for prohibited paraphernalia, provide emotional support and advocacy to resident and to facilitate continued discharge planning. Following the psychotherapist's termination on 3/31/16, and through 6/30/16, the Resident did not receive any additional psychotherapy and there was no documentation indicating that staff were providing supervision, completing any random searches or offered additional psychotherapy and/or drug counseling. On 7/1/16, the nursing staff entered three notes (one a late entry) at 1:07 A.M., 4:00 A.M. and 4:22 A.M. indicating the Resident had a drug overdose on 6/30/16 at 11:15 P.M. The nurse's note indicated that the Resident's roommate notified staff that the Resident was unresponsive. The Resident was found with abnormal assessment findings that included an oxygen level of 40 % on room air and his/her pupils were pinpoint. The Resident was administered Narcan (a medication to block opioid during an overdose) and transferred to the emergency room . The nurses' notes indicated the Resident returned around 4:00 A.M. and the hospital discharge record indicated the change in Resident #11 was due to a heroin overdose. From 4:00 A.M. to approximately 1:00 P.M. there was no evidence the Facility acted upon a safety plan to ensure the Resident was provided supervision, searched the Resident's room for drugs or contraband to prevent further ingestion of drugs, or investigated how the Resident obtained the heroin as planned. On 7/1/16, at 1:30 P.M., the Director of Nurses (DON) documented (in the medical record) that the Administration staff met with the Resident. The note indicated that the Facility had contacted the Facility's psychiatric service and that they would be in later in the day to evaluate the Resident. The note indicated that Resident #11 said a visitor had brought him/her in heroin and he/she had inhaled it. The progress note indicated that during their meeting with Resident #11, the Facility had offered to obtain drug treatment services, but the Resident refused. The DON indicated that the psychiatrist recommended to implement 1 to 1 direct supervision and implement the current plan until her assessment was completed. The psychiatrist assessment dated [DATE], indicated she spoke with Facility staff and met with the Resident. The Resident was determined to be too sedated to undergo a complete evaluation. The psychiatrist indicated the Facility would implement measures to ensure safety, 1 to 1 direct supervision, room searches and monitoring of visitors. The psychiatrist indicated the staff should closely monitor over the holiday weekend and to seek alternate treatment for [REDACTED]. Review of the medical record documentation from 7/1/16 at 1:30 P.M. through 6:30 P.M., failed to indicate that the staff had implemented any safety measures. The subsequent nurse's note dated 7/1/16 at 6:30 P.M. indicated that the nurse had been checking on the Resident, until 3:00 P.M. when the 1 to 1 direct supervision (for safety) was started. On 7/2/16 at 8:48 A.M., a change of condition note indicated the 1 to 1 staff, who was providing continuous supervision, found the Resident unresponsive and notified the nurse at 6:10 A.M. It was unclear how the Resident was found unresponsive if being provided 1 to 1 supervision per plan of care. The nurse's note indicated that she first applied a sternal rub, then administered Narcan and called for emergency transport. After the arrival of the emergency response team, a second dose of Narcan was administered. The nurse indicated she/she found a bottle of Afrin nasal spray (an over the counter nasal spray used to ease nasal decongestant) on his/her chest, a lighter and the box that held the nasal spray in the open draw of the bedside table. Record review failed to indicate the staff had seen the visitor and if they had seen the visitor, that the staff had provided supervision during the visit and had monitored for outcome after the visit, as planned. The record indicated the Resident remained in bed from 4:00 A.M. until 3:30 P.M., and that direct 1 to 1 supervision was started at 3:00 P.M. There was no documentation what had been found in the Resident's room at the time of the overdose on 6/30/16 or that subsequent searches had identified any additional contraband. Review of the Facility investigation conducted after the the 2 drug overdoses indicated: *The Nurse's statement said she had seen an unknown visitor with the Resident prior to the overdose on 6/30/16 (at 8:30 P.M.) and said (in the Facility investigation) she had supervised from the hallway while giving medications to other residents, and that she saw the Resident after the visit and there was nothing out of the ordinary for the rest of the night. There was no indication the Nurse had directed staff to provide direct supervision during the visit or search the Resident and his/her room following the visit. *The investigation report had no investigative information about what had occurred between the first and second overdose on 7/2/16. The investigation did include the DON's note about the Facility's meeting and to implement 1 to 1 supervision, but failed to monitor the effectiveness of the plan. The 1 to 1 staff was not started until 11 hours after the Resident's readmission from the first overdose and other than staff initialing a piece of paper every 15 minutes,thee was no indication that 1 to 1 supervision was provided. *There was no indication in the investigation that other than the Afrin found on the Resident on 7/2/16, that staff had searched the Resident's room for contraband. *The investigation included the the 1 to 1 staff's statement, in which she said that she had provided care to the Resident had 5:45 A.M. She said that the Resident was watching television and had asked her to put a bag of peanuts on a shelf. The staff said she put the peanuts away and was standing by the door. She said she heard a sniffing sound and the Resident snoring. She said she then observed the Resident unresponsive and called the nurse. Following the review, there was no indication the Facility identified any concerns related to the failure to implement the plan of care or provide adequate supervision. On 7/2/16 the Facility indicated that they had decided, due to the Resident's history of drug overdose and recent incidents, that were a cause of concern for the safety of the Resident and the safety of others, the facility was not accepting the Resident back into the Facility. The physician indicated that the Resident should be referred to drug detox or psych facility. During interview with the Administrator on 11/2/16 at 2:45 P.M. and an additional interview on 11/4/16 at 10:50 A.M., he said he was aware the Resident caused a safety risk to him/herself and others. The Administrator said that the Resident was always remorseful after the overdoses and would become a model patient. The Administrator said that the Facility had maintained supervision by moving the Resident's room so he/she could be monitored by staff from the hallway. During interview with the Director of Social Service (DSS) on 11/2/16 at 1:45 P.M., he knew little about the Resident and was unaware that the Resident had not been receiving 1 to 1 psychotherapy for 3 months prior to the two overdoses. The Director of Nurses (DON) on 11/2/16 at 1:45 P.M., 11/3/15 at 2:00 P.M. and 2:45 P.M and on 11/4/16 at 11:50 A.M. and said that the facility had a plan for safety and that following the 6/30/16 overdose that staff had notified the Administration staff. The DON said he was aware there had been a delay in implementing the 1 to 1 supervision, but thought there had been a room search at the time of the meeting with the Resident around 1:00 P.M. on 7/1/16, but that he would check with the Administrator. On 11/4/16 at 10:50 A.M., the Administrator provided a typed piece of paper indicating that he had done a room search on 7/1/16. The statement (which had not been available before the conclusion of the investigation) did not indicate the time the search was done, but indicated that a cigarette making machine, tobacco, candles, lighters, utility tools and alcohol nips were found (all items that had been considered prohibited paraphernalia according to the medical record). The Administrator said the search had been done after the meeting he and the staff had with the Resident on 7/1/16, which had been conducted midday (approximately 7 hours after his/her return from the emergency room ). There was no supporting evidence that following this search and prior to the second overdose, that additional searches were conducted to ensure the Resident did not have access to additional hazards. The Resident was observed during the survey process and was noted to be in his/her room or independently propelling inside and outside of the building (11/1/16 at 12:50 P.M. 1:20 P.M., 11/3/16 and 11/4/16). The Staff said they supervised the Resident from the hall and that when the Resident went out to smoke a Family Member met the Resident in the parking lot to supervise his/her smoking, which was not consistent with the plan of care for supervision. During interview on 11/4/16 at 11:50 A.M., the Resident was alert and oriented. He shared that he/she was trying to move out of the Facility soon. The Resident said that he/she was making most of the arrangements with outside services. The Surveyor inquired what type of services would be needed and if there were any problems related to substance use. The Resident said he/she was addicted to cigarettes and was trying to quit before he/she is discharged .

Based on observation, record review and interview with residents and staff, the facility failed to identify the loss of function and contractures of the Resident #6's right fingers and hand, and then failed, after the resident requested and was evaluated by a hand surgeon, to treat the contractures for the one sampled resident (#6) with contractures in a total of 19 sampled residents. Findings include: Resident #6 was readmitted in November 2012 and had [DIAGNOSES REDACTED]. The resident had significant shortness of breath and was oxygen dependent. Review of the most recent quarterly Minimum Data Set (MDS) assessment with a reference date of 5/2/13, indicated the resident was cognitively intact, had no mood or behavioral symptoms and required assistance from staff for activities of daily living. The MDS indicated the resident had no functional limitation in range of motion of his/her upper or lower extremities. Review of the nurse's note, dated 4/27/13, indicated the resident reported a change in his/her mobility with his/her right index finger. The resident said he/she could no longer use this finger and therefore he/she could not use the computer (an activity that he/she participated in constantly). The nurse's note indicated the resident had no pain and would notify the physician and request a physical therapy consult. On 5/1/13, the physician ordered the resident be seen by an orthopedic surgeon for his/her right hand. On 5/2/13, the nurse's note indicated the resident complained about his/her decreased mobility to fingers, and having to wait to see the orthopedic surgeon on 5/22/13. The note indicated that therapy was aware and would address it at the next session. Record review on 5/30/13 failed to locate any assessment of the resident's fingers by any staff. According to record review on 5/30/13, from 5/3/13 through 5/21/13, there was no documentation to indicate that any staff assessed and addressed the decrease in the range of motion (ROM) of the resident's right fingers. In addition, there was no evidence the resident was provided with any intervention to prevent further decline. Review of the orthopedic consult, dated 5/22/13, indicated the orthopedic surgeon diagnosed the resident with a right index finger extension tendon rupture and a right middle extension tendon subluxation. The surgeon provided the resident with a splint and recommended it be used with daily activity. The surgeon indicated if the splint was not effective the resident could consider tendon reconstruction and intensive post op therapy. Following the surgeon's evaluation, review of the medical record, including nursing and rehabilitative services, failed to address, identify or implement a treatment plan to address the recommended use of the splint and it's effectiveness. During interview and observation on 5/30/13 at 10:20 A.M., 6/3/13 at 9:45 A.M., 6/4/13 at 11:30 A.M. and on 6/5/13 at 9:30 A.M., the resident was not seen wearing the hand splint and the hand splint was not visible in the room. The resident's right hand was observed, and with his/her hand open the middle finger was touching the palm and the index finger was cocked at an irregular angle. The resident used a computer and Ipad as a form of daily continuous activity and was observed to have difficulty with computer use and with activities around his/her room. The resident said the splint was in a drawer. The resident said he/she did not use the splint because it was cumbersome and made it more difficult to use the computer and perform other activities. The resident said when he/she wore the brace it was difficult to even move around the bed. The resident said the surgeon had given him/her the splint and that no staff had evaluated his/her use of it. The resident said the contractures were getting worse and painful at times, and although the surgeon had discussed surgery, he/she was going to inquire about an injection treatment if the pain got worse. The resident thought surgery would be too difficult for him/her to endure and recover from. He/she said he/she did not know when or if he/she had a follow up appointment with the surgeon. The resident said he/she did not know if the staff was aware he/she was not wearing the splint or of his/her plan. During review of treatment sheets, care plan, therapy notes, physician orders [REDACTED]. There was no documentation to indicate that staff was aware the resident was not wearing the splint. During interview on 5/30/13 at 11:10 A.M., Unit Manager #2 said the resident had requested a consult with an orthopedic surgeon due to a decline in the function of his right fingers. He/she said the resident was seen by the surgeon and a splint was recommended. Unit Manager #2 said he/she thought the resident was wearing the splint, but said if it wasn't effective the resident could have surgery. Unit Manager #2 said a physician's orders [REDACTED]. Unit Manager #2 did not know that there was no plan included for range of motion or any other interventions to the contracted fingers to prevent further decline.

Based on record review, interview with staff and observation of the resident, the facility failed to provide adequate care and treatment of [REDACTED]. Findings include: For Resident #4, the facility failed to obtain physician orders for all treatments applied to the resident's pressure sore, and failed to follow identified interventions for pressure relief to the affected area, resulting in the pressure sore re-opening after healing several times over the period of 4 months to the time of survey. Resident #4 had lived at the facility for several years and had [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) assessment, with a reference date of 3/7/13, indicated the resident had severely impaired cognition and required extensive assistance from staff for all personal care and mobility. This MDS also indicated the resident had an unhealed, unstageable pressure sore. Review of the weekly skin sheets in the resident's record on 5/29/13 indicated that on 2/1/13 staff identified a small pinpoint open area on the resident's left second toe because of pressure from a hammer toe, i.e. the great toe crossing over and resting on the second toe. According to wound monitoring documentation sheets provided by the Director of Clinical Education, who was also responsible for wound management for the facility, an interim physician order was obtained on 2/1/13 for treatment with [MEDICATION NAME], an antibiotic ointment, but did not include a dressing order. The next entry on the wound documentation sheet was undated and indicated the area was healed. On 2/14/13, the wound documentation indicated the area was re-opened and treated with skin prep (cleanser) followed by foam adhesive (padded dressing). No physician order was located for this treatment. The area was described as scabbed with errythema surrounding the area. On 2/21/13, the wound documentation indicated the area was treated with foam adhesive with no physician's order. The area was described as having a small amount of purulent drainage and an interim physician order was given for Keflex, an antibiotic. On 2/22/13, a physician order was obtained to clean the area with normal saline, pat dry, apply skin prep, let dry and cover with foam adhesive on Monday, Wednesday and Friday until healed and as needed. This treatment was signed by staff that it was done as ordered on the Treatment Administration Record (TAR) for February 2013. The wound documentation for 2/26/13 indicated the current treatment was foam adhesive. No physician order was located for this change in treatment, or to discontinue the previous order of 2/22/13. The wound was described as having a small amount of drainage on the dressing around the scab, and it was noted to continue with treatment plan, which was not specified. On 3/6/13, the wound documentation indicated the area was "scabbed and healed." The wound documentation for 3/30/13 indicated a treatment to cleanse the area with normal saline and apply gauze between the toes. The wound was described as showing maceration with yellow exudate in the center, and "peri wound pinkish-red." Review of the TAR for April 2013 included a treatment to apply skin prep and place lamb's wool between the second and great toe daily, noted to have a start date of 3/22/13. However, review of the March 2013 and April 2013 monthly physician order sheets indicated no order for this treatment that was listed on the TAR, and there was no telephone order for this treatment in the resident's record. The nurses signed the TAR every day for the month to indicate the treatment was done. There were no other treatment orders listed on the April 2013 TAR. On 4/4/13, the wound documentation indicated the treatment was to wash the area with normal saline, apply skin prep and [MEDICATION NAME] (anti-fungal). No physician order was located for this treatment. The wound was described as open, surrounding tissue red with slight blanching, center yellow white with small amount of drainage. On 4/9/13, the wound documentation indicated a treatment of [REDACTED]. No physician order was located for this treatment. The wound documentation indicated the wound was closed with a scab. According to review of a Hospice visit note, dated 4/23/13 with no time noted, the Hospice nurse observed the resident resting in bed. The Hospice nurse wrote that the area on the second toe on the left foot was macerated and draining and had no gauze between the toes. The Hospice nurse wrote that the resident had shoes on and was not supposed to wear them. The wound documentation on 4/23/13 indicated the treatment was to use gauze and to remove the shoes. The notes indicated the wound was open because of the shoe. On 4/26/13, the wound documentation sheet indicate the treatment was for [MEDICATION NAME] (film dressing) and foam. There was no physician order for [REDACTED]." The weekly skin check sheet, dated as completed by Unit Manager #2 on 4/26/13, indicated the second left toe was dry and lamb's wool was in place. On 4/27/13 on the night shift, the nurse's note indicated that the left second toe had gauze stuck over the area. The nurse wrote that the gauze was removed with a normal saline soak and that the nurse cleaned the area with normal saline and applied [MEDICATION NAME] and a bandage, and then put gauze between the second and great toes. There was no evidence that a physician was contacted or an order obtained for this treatment. Review of the TAR for May 2013 included the same treatment that was listed on the April 2013 TAR as noted above - to apply skin prep, place lamb's wool between the second and great toe daily, noted to have an order date of 3/22/13. Review of the physician's order sheets revealed no order for this treatment, and there was no telephone order for this treatment in the resident's record. The nurses signed the TAR every day during the month to indicate the treatment was done. There were no other treatment orders listed on the May 2013 TAR. On 5/6/13, the wound documentation indicated a treatment of [REDACTED]. The wound documentation indicated there was a small amount of sero-sanguinous drainage and "peri-wound" of the toe was "red blanchable." On 5/10/13, the wound documentation indicated the wound was closed and gauze was put between the toes. This was the last entry noted on the wound documentation sheets. Review of the weekly skin check sheet, dated 5/10/13, indicated there was "no change" to the area on the toe. Review of the weekly skin check sheet for 5/17/13 revealed that the nurse described the left foot second toe as open and moist. On 5/24/13, Unit Manager #2 wrote a description of the area on the left second toe as pink and moist. There was no evidence that any treatment was provided to the toe after the 5/10/13 wound documentation until the time of survey review on 5/29/13. Review of the Nurses' Treatment Notes sheet revealed the entries for 5/25/13, 5/26/13 and 5/27/13 all indicated that the area was scabbed and lamb's wool was in place. On 5/29/13, the resident was observed at the lunch meal in the unit dining room at 11:40 A.M. The resident was wearing cushioned open booties over stockings for pressure relief to the heel area. During interview on 5/30/13 at 10:45 A.M., the Hospice nurse said there were no specific Hospice orders for wound care and that the Hospice staff follow the orders or protocol of the facility for skin treatment. The Hospice nurse said that he/she did recommend to the Director of Clinical Education that they try [MEDICATION NAME] on the wound. During interview on 5/30/13 at 10:48 A.M., a request was made to Unit Manager #2 for assistance in locating physician orders for the treatments noted on the wound check sheets and treatment sheets in the record. Unit Manager #2 said he/she was not able to find any orders in the printed record or on the electronic record. During interview on 5/30/13 at 10:55 A.M., the Director of Clinical Education, who was also responsible for wound management for the facility, said that the nurses on the unit usually contact the physician to obtain the treatment orders. When asked if he/she had copies of the orders to use for treatment, he/she asked Unit Manager #2 who again said he/she did not find any orders. When asked if he/she verified treatment orders after they were obtained by the nurses, the Director of Clinical Education said he/she did not. Upon inquiry, the Director of Clinical Education said that he/she was not currently providing any treatment to the resident's toe. Upon review of the weekly skin check sheets dated 5/17/13 and 5/24/13, the Director of Clinical Education said that staff had not informed him/her that the area was re-opened. On 5/30/13 at 11:00 A.M., the pressure sore on the resident's left second toe was observed while the Certified Nurse Aide was in the room to provide care to the resident. There was observed to be a 2 cm by 2 cm gauze between the open area on the second toe and the great toe, which was lying on top of the area on the second toe. The gauze was lightly stuck to the wound which was observed to have a thin eschar lifting from the open wound of approximately 2 cm diameter. On 5/30/13 at 11:45 A.M., the Director of Clinical Education brought a copy of a physician order for [REDACTED]. On 5/30/13 at approximately 12:05 P.M., the Director of Nursing was advised of the concerns related to the care and treatment of [REDACTED]. During interview on 5/30/13 at 3:00 P.M., the Administrator and Director of Nurses were advised of the concerns of no orders for treatment and lack of communication related to care of the resident's wounds. No additional information or documentation was provided during the rest of the survey through 6/5/13.