Every finding on record at Plymouth Rehabilitation & Health Care Center

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who required food items to be served in separate containers, the Facility failed to ensure he/she was free from incidents/accidents resulting in serious injury. On 06/13/26, Resident #1's mashed potatoes were portioned and served to him/her in a covered container with an unvented (without steam hole, holds temperature of food item longer) lid, when Resident #1 attempted to eat the mashed potatoes, they were too hot so he/she spit them out and they landed on his/her right thigh, which caused him/her to sustain a second-degree burn (partial thickness, involves both the outer (epidermis) and underlying layer (dermis) of skin, they cause pain, redness, swelling, and blistering) to the top of his/her right thigh, which required daily treatment.Findings Include: Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 06/19/26, indicated that on 06/13/26 at 12:00 P.M. Resident #1 was sitting in the dining room for lunch. The Report indicated that the Nurse (later identified as Nurse #1) heard Resident #1 yell, Nurse #1 entered the dining room and observed Resident #1 standing up with mashed potatoes on the floor in front of him/her. The Report indicated that a Certified Nurse Aide (CNA, later identified as CNA #1) was supervising the dining room and observed mashed potatoes on Resident #1's right thigh, CNA #1 swept them away and reported to Nurse #1 that the mashed potatoes were very hot. The Report indicated that Nurse #1 assessed Resident #1's mouth and no injuries were noted.The Report further indicated that approximately ten minutes later a cluster of blisters formed on Resident #1's right thigh measuring 2.5 centimeters (cm) by 3.0 cm, his/her Physician was notified, treatment was ordered for No-Sting Skin Prep (topical alcohol free liquid protective barrier) to blisters every shift and to monitor for signs and symptoms of infection.Resident #1 was admitted to the Facility in March 2024, diagnoses included schizophrenia, speech and language deficits following cerebral infarction (stroke), anxiety, hypertension, and hyperlipidemia (high cholesterol). Review of the Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of 0 out of 15 (0-7 indicates severe cognitive impairment, 8-12 indicates moderate cognitive impairment, 13-15 indicates cognitively intact). Review of Resident #1's Non-Pressure Skin Injury Report, dated 06/13/26, (completed by Nurse #1) indicated that Nurse #1 heard Resident #1 yell out, she entered the dining room and observed Resident #1 standing up, that there were mashed potatoes on the table, floor, and on him/herself. The Report indicated that CNA #1 used her hand to scoop off mashed potatoes that had landed onto Resident #1's right thigh and that CNA #1 had stated, they (mashed potatoes) were really hot. The Report indicated that Nurse #1 felt the mashed potatoes and other food items, and they were noted to feel hotter than appropriate to eat.The Report indicated that ten minutes later when Resident #1 sat down to eat again, there was an area [burn like] noted to the top of his/her right thigh where CNA #1 had removed the food (mashed potatoes) with her hand. The Report indicated that Resident #1's type of injury was a burn, and he/she had a cluster of blisters that measured 2.5 cm by 3.0 cm on his/her right thigh. The Report further indicated the Physician was notified and a treatment order was obtained for No-Sting Skin Prep.During an interview on 07/21/26 at 2:51 P.M., (which included review of her written statement) Nurse #1 said on 06/13/26 around 12:00 P.M. she heard Resident #1 yell out from the dining room. Nurse #1 said upon entering the dining room she observed Resident #1 standing up, and that there were mashed potatoes on the floor in front of him/her and that it looked like he/she had spit them out.Nurse #1 said CNA #1 was next to Resident #1 with some mashed potatoes in her hand that she (CNA #1) said she had scooped off his/her right thigh, and that CNA #1 had also stated that the mashed potatoes were really hot. Nurse #1 said Resident #1's lunch meal was in three separate paper container bowls; that she tested the temperature of the mashed potatoes by feeling them and said that the mashed potatoes were not an appropriate temperature for eating because they were hotter than they should have been. Nurse #1 said that she took Resident #2's food items away to let them cool.Nurse #1 said she tried to assess Resident #1, but he/she would not cooperate and that he/she left the dining room. Nurse #1 said ten minutes later Resident #1 returned to the dining room to eat his/her lunch meal and said CNA #1 told her that Resident #1 had a mark [burn like] on his/her right thigh.Nurse #1 said she assessed Resident #1's right thigh and observed a cluster of blisters measuring 2.5 cm by 3.0 cm and said she tried to apply a cool cloth to the area but Resident #1 was again uncooperative. Nurse #1 said she notified Resident #1's Physician and obtained a treatment order for No-sting Skin Prep.During an interview on 07/21/26 at 2:07 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 06/13/26 and was passing the lunch meal trays in the unit dining room. CNA #1 said Resident #1 required to be given one food item at a time during meals and said she gave him/her the bowl of mashed potatoes first. CNA #1 said she was standing next to Resident #1, when he/she scooped some of the mashed potatoes into his/her mouth, then he/she stood up, mashed potatoes fell out of his/her mouth, and he/she yelled out. CNA #1 said Nurse #1 immediately came into the dining room; they sat Resident #1 back into the chair and said she (CNA #1) saw some mashed potatoes on Resident #1's right thigh. CNA #1 said she scooped the mashed potatoes off of Resident #1's right thigh with her hand and said that the mashed potatoes were really hot. CNA #1 said she did not see any marks on Resident #1's right thigh after she had scooped the mashed potatoes off with her hand. CNA #1 said that Resident #1 was wearing a pair of shorts that day (06/13/26) and that the mashed potatoes had fallen directly onto his/her bare skin.CNA #1 said the nurse was trying to assess Resident #1, but he/she got up and left the dining room, then about ten minutes later Resident #1 came back to the dining room said he/she wanted to eat, sat in his/her chair, and that's when she (CNA #1) noticed a burn mark on his/her right thigh and immediately told Nurse #1. CNA #1 said she did not know that the mashed potatoes were too hot when she gave them to Resident #1, because she had not seen any steam coming from the bowl after she had removed the lid.Review of the Dietary Department's Daily Temperature Log, dated 06/13/26, indicated the temperature for the mashed potatoes for lunch was 190 degrees Fahrenheit (F).During an interview on 07/21/26 at 1:10 P.M., the [NAME] said he worked on 06/13/26 from 5:00 A.M. until 12:30 P.M. and had cooked the lunch meal. The [NAME] said it is the responsibility of the Cook's to take daily temperatures of all individual food items for every meal and log them onto the Daily Temperature log sheet. The [NAME] said that once a food item is cooked the temperature of the food is taken, then placed onto the steam table before placed on or into the resident's meal plates or bowls.The [NAME] said Resident #1's food items needed to be served in separate containers for his/her meals. The [NAME] said on 06/13/26 he used three separate paper cardboard soup bowls with unvented (without steam holes) lids for Resident #1's lunch meal because he thought that if he used the plastic soup bowls with vented (steam holes allows heat to be released) plastic lids that Resident #1's meal would get too cold. The [NAME] said the paper carboard soup bowls with unvented lids are specifically designed to keep food hotter.The [NAME] said he was told by the Food Service Director that Resident #1 had been burned from the mashed potatoes he/she received for lunch on 06/13/26. The [NAME] said that it was his mistake for deciding to use the paper cardboard bowls with unvented lids and that he should have used the plastic bowls with vented lids that the kitchen always used for residents' meals.During an interview on 07/21/26 at 1:36 P.M., the Food Service Director (FSD) said on 06/13/26 she was notified by the Director of Nursing (DON) that Resident #1 had been burned by mashed potatoes because they were too hot. The FSD said on 06/14/26 she spoke with the [NAME] and asked him what type of container he had used to serve Resident #1's mashed potatoes in. The FSD said the [NAME] told her that he had used paper cardboard bowls with unvented lids for Resident #1's lunch meal that day (06/13/26).The FSD said the paper cardboard bowls with unvented lids keep food items hotter for a longer period of time and said the kitchen does not use paper cardboard bowls with unvented lids for resident's meals. The FSD said the [NAME] should not have used paper cardboard bowls with unvented lids for Resident #1's meal.Review of Resident #1's Physician Orders, dated June 2026 indicated the following:-On 06/13/26, new order for: No-Sting Skin Prep to intact blister right thigh every shift for skin protection. Order was discontinued on 06/26/26.-On 06/13/26, new order for: Intact blister right thigh: monitor for intactness, signs and symptoms of infection every shift for skin protection and report any changes to Physician. Order was discontinued on 06/27/26.-On 06/27/26, new order for: Blister right thigh: Normal Saline wash, pat dry, apply foam dressing and monitor area for signs and symptoms of infection on the day shift (7:00 A.M. to 3:00 P.M.) for skin protection and report any changes to Physician. Review of Resident #1's Treatment Administration records (TARs), dated June 2026 and July 2026, indicated that No-Sting Skin Prep was applied to Resident #1's right thigh every shift for skin protection from 06/13/26 through 06/25/26 (for 13 days). Resident #1's TARs further indicated that the treatment for Resident #1's right thigh blister: Normal Saline wash, pat dry, apply foam dressing and monitor area for signs and symptoms of infection started on 06/28/26 and the treatment was still in place on the day of survey (07/21/26).During an interview on 07/21/26 at 3:41 P.M., the Director of Nursing (DON) said on 06/13/26 she was notified by Nurse #1 that Resident #1 had spit out mashed potatoes during the lunch meal because they were too hot and that the mashed potatoes had landed onto his/her right thigh. The DON said Nurse #1 told her that about ten minutes later a cluster of blisters developed on Resident #1's right thigh, his/her Physician was notified, and a treatment order was obtained. The DON said that the blisters on Resident #1's right thigh were considered a second-degree burn.The DON said she notified the FSD on 06/13/26 of Resident #1's incident and started her investigation. The DON said after her investigation she determined that the kitchen had used paper cardboard containers with unvented lids for Resident #1's lunch meal on 06/13/26. The DON said that because the lids to the paper cardboard container were unvented, the lids held the temperatures of the food and did not allow the food to cool quicker like the vented plastic lids that the kitchen normally used. On 07/21/26, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction with an effective date of 06/20/26, which addressed the area (s) of concern as evidenced by: A. On 06/13/26, Resident #1 was assessed by the Nurse, his/her Physician was notified, and an order was obtained for No-Sting Skin Prep to his/her right thigh every shift and monitor for signs and symptoms of infection. B. On 6/13/26, the facility immediately initiated an investigation into incident to determine the cause of the injury, and they were able identify the use of paper cardboard bowls with unvented lids, when preparing and serving Resident #1's food to him/her, which was not standard practice of the Cooks, as the root cause. C. On 6/14/26, the FSD met with the Cook, who prepared the lunch time meal on 6/13/26 and said he had used paper cardboard bowls with an unvented lid, and provided 1:1 education regarding the appropriate bowls (with vented lids) to be used for resident food items. D. All Resident diet orders were reviewed, and no other residents were identified as requiring food items served in separate containers. E. On 06/15/26, the Administrator, Director of Nursing, Food Service Director and Resident #1's Physician discussed the area of concern to develop and implement a corrective action plan. F. On 06/17/26, the Food Service Director provided additional education to the [NAME] (and kitchen staff) that the Dietary Department cannot not use paper carboard bowls with unvented lids for resident meal and that only plastic bowls with a vented lid will be used for residents' meals. G. The Food Service Director and/or designee will conduct random audits on food temperatures on the food line and on residents' meal trays upon arrival to residents' units weekly for three months. H. The results of the audits will be presented and reviewed at the monthly QAPI meeting for three months or until substantial compliance is achieved. I. The Food Service Director and/or designee (in conjunction with Administration) are responsible for overall compliance.

Based on observations, interviews, and records reviewed, the facility failed to ensure one Resident (#10), out of a total sample of 29 residents, received care and treatment to promote healing of a pressure ulcer. Specifically, for Resident #10, the facility failed to implement treatments from the wound consultant physician for a Stage 4 pressure ulcer (full-thickness loss of skin) on the left ischium/buttock.Findings include:Review of the facility's policy titled Prevention and Management of Pressure Injuries, revised 1/2025, indicated, but was not limited to, the following:-Wound treatments are done per MD order.Resident #10 was admitted to the facility in October 2025 with diagnoses including Stage 4 pressure ulcer of the left buttock.Review of Resident #10's Minimum Data Set (MDS) assessment, dated 1/2/26, indicated the Resident was cognitively intact, as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Further review of the MDS indicated the Resident had one Stage 4 pressure ulcer present on admission to the facility and received pressure ulcer care. Review of Resident #10's Consultant Wound Care Provider's Progress Notes indicated, but was not limited to, the following:-1/2/26 follow-up visit: Stage 4 pressure ulcer located on the left ischium/buttock appears healed. Wound dressing: none. As far as the patient's moisture related dermatitis on groin and buttock areas, suggest house barrier cream daily and PRN (as needed). -1/9/26 follow-up visit: Recurrent stage 4 pressure ulcer is located on the left ischium/buttock. Surgical debridement (removal of dead or damaged tissue) to promote optimal wound healing. Post-debridement wound measurements: 6 cm (centimeters) length by 6 cm width by 0.8 cm depth. Moderate amount of serous exudate (a clear, thin, and watery fluid that is produced by the body in response to tissue damage or inflammation, playing a crucial role in the healing process), wound bed is 100% granulation (a key component of wound healing, consisting of new connective tissue and blood vessels that form in the wound bed). No signs of infection. Wound dressing: Prisma/Puracol/Dermacol (or similar collagen dressing) (collagen dressings promote healing by stimulating new tissue growth, providing structural support, and maintaining a moist environment), Alginate (a dressing that absorbs drainage and forms a gel) and foam to the left ischium/buttock wound changed daily and PRN. -1/16/26 follow-up visit: Stage 4 pressure ulcer on the left ischium/buttock. Surgical debridement to promote optimal wound healing. Post-debridement wound measurements: 4 cm length by 5.8 cm width by 0.6 cm depth. Moderate amount of serous exudate, wound bed is 100% granulation. No signs of infection. Wound dressing: Prisma/Puracol/Dermacol (or similar collagen dressing), Alginate and foam to the left ischium/buttock wound changed daily and PRN.-1/23/26 follow-up visit: Stage 4 pressure ulcer on the left ischium/buttock. Surgical debridement to promote optimal wound healing. Post-debridement wound measurements: 3 cm length by 5 cm width by 0.3 cm depth. Moderate amount of serous exudate, wound bed is 100% granulation. No signs of infection. Wound dressing: Prisma/Puracol/Dermacol (or similar collagen dressing), Alginate and foam to the left ischium/buttock wound changed daily and PRN.-1/30/26 follow-up visit: Stage 4 pressure ulcer on the left ischium/buttock. Post-debridement wound measurements: 3 cm length by 4.5 cm width by 0.3 cm depth. Moderate amount of serous exudate. Wound bed is 30% yellow necrosis (dead tissue) and 70% granulation. There is an odor associated with the wound. Mild periwound redness, no swelling. Wound dressing: Change to Vashe (or similar antibacterial wound cleanser), Bactroban (a topical antibiotic), alginate and foam to the left ischium/buttock wound changed daily and PRN.Review of Resident #10's January 2026 Physician's Orders indicated the following:-10/14/25 through 1/2/26: Wash with wound cleanser, pay dry, apply skin prep to peri wound, collegen [sic] to wound base f/b (followed by) alginate cover with Foam dressing Location: left buttock/ischium every evening shift-1/3/26 through 1/30/26: NSW (normal saline wash), pat dry, apply alginate, cover with foam dressing, change every evening Location: Left lower buttocks-1/30/26: Wash with wound cleanser, pat dry, apply Bactroban f/b alginate, cover with DCD (dry clean dressing), change every evening Location: Left lower buttocksReview of Resident #10's Progress Notes showed a late entry note was entered for 1/2/26 at 1:00 P.M. indicating the Resident was seen on wound rounds and his/her wound was healing well and continue with the current treatment. Further review indicated that on 1/30/26, the Resident was seen by the Consultant Wound Care Provider and the Resident's left ischium wound was measuring smaller, but a new slight odor was present, and the Consultant Wound Care Provider recommended treatment with wound cleanser, Bactroban ointment, alginate and dry protective dressing. Review of Resident #10's medical record failed to indicate the facility implemented pressure ulcer treatment with a collagen dressing as recommended by the Consultant Wound Care Provider from 1/9/26 through 1/30/26 and failed to implement antibacterial wound cleanser and a foam dressing after the Consultant Wound Care Provider's visit indicated a new wound odor on 1/30/26. Review of Resident #10's Physician and Nurse Practitioner Progress Notes failed to indicate the Physician or Nurse Practitioner declined any of the Consultant Wound Care Provider's treatment recommendations.During an interview on 1/29/26 at 11:10 A.M., the Infection Prevention Nurse said she usually rounded with the Consultant Wound Care Provider. The Infection Prevention Nurse said the Consultant Wound Care Provider had recommended discontinuing treatment with collagen and implementing treatment with the alginate dressing only because Resident #10's wound healing had stalled.During an interview on 1/30/26 at 2:01 P.M., the Consultant Wound Care Provider said Resident #10's left ischium treatment recommendation has always included collagen with the treatment. The Infection Prevention Nurse, present during the surveyor's interview with the Consultant Wound Care Provider, reviewed the Consultant Wound Care Provider's progress notes and confirmed the notes indicated collagen should be used. The Consultant Wound Care Provider said the Resident's wound care order should have included treatment with collagen.During an interview on 2/2/26 at 2:16 P.M., Resident #10's Attending Physician said she was not aware the facility had not been following the Consultant Wound Care Provider's recommendations. The Attending Physician said the Consultant Wound Care Provider's recommendations should have been implemented and if she were to disagree with a recommendation, she would document that in a progress note.

Based on observation, record review and interview, the facility failed to ensure medications were labeled and stored in accordance with acceptable professional standards. Specifically, the facility failed to:1. Ensure Resident #50's Prednisolone Acetate 1% and Timolol Maleate 0.5% ophthalmic drops were stored securely; 2. Ensure medication and topical treatments were securely stored and not left at the bedside on 1 out of 5 units in the facility; and3. Ensure that medications in the refrigerator were stored under the proper temperature for 1 out of 3 medication rooms.Findings include:Review of the facility's policy titled Medication Storage Room/Medication Cart Policy, dated 2/2018, indicated, but was not limited to, the following:-Medications are stored primarily in a locked mobile medication cart which is accessible only to licensed nursing personnel.-Storage for other medications will be limited to a locked medication room.-Drugs requiring refrigeration are stored separately in a refrigerator, that is used exclusively for medication and medication adjuncts.-Medication refrigerators/freezers will be cleaned on a weekly basis and daily as needed. 1. On 1/28/26 at 9:54 A.M. on the [NAME] Unit, the surveyor observed Nurse #9 leave Resident #50's Prednisolone Acetate 1% and Timolol Maleate 0.5% ophthalmic drops on top of the medication cart when she left the medication cart parked in the hallway against the wall across from the nurses' station and went to a resident's room down the hallway, out of view of the medication cart. Nurse #9 returned to the medication cart at 10:24 A.M. and put the medications away in the medication cart. During an interview on 1/28/26 at 11:53 A.M., Nurse #9 said she should have put the eye drops away in the medication cart before walking away. During an interview on 2/2/26 at 12:16 P.M., the Director of Nursing (DON) said it was her expectation that medications were not left unattended on top of the medication cart. 2. On 1/27/26 at 9:00 A.M., 1/28/26 at 8:30 A.M. and 1:00 P.M. the surveyor observed multiple topical treatments at the bedside in 7 of 12 resident rooms on the Mayflower South unit: -room [ROOM NUMBER]: two tubes of 2.5 oz tube of Triad Hydrophilic wound dressing Pansement hydrophile (topical zinc oxide), two bottles of Miconozole Nitrate 2% antifungal powder -room [ROOM NUMBER]: two 17.9 oz bottles of polyethylene Glycol 3350 (laxative), one 2.5 oz tube of Triad Hydrophilic wound dressing Pansement hydrophile, one bottle of Miconozole Nitrate 2% antifungal powder -room [ROOM NUMBER]: one tube of 2.5 oz tube of Triad Hydrophilic wound dressing Pansement hydrophile -room [ROOM NUMBER]: one Ventolin HFA inhaler (medication used to treat bronchospasms) -room [ROOM NUMBER]: one tube of Muscle Rub (topical analgesic) -room [ROOM NUMBER]: one Flovent HFA inhaler (corticosteroid medication used to treat asthma attacks) -room [ROOM NUMBER]: one bottle of fluticasone propionate nasal spray (medication used to treat allergies) During an interview on 1/28/26 at 10:00 A.M., Nurse #6 said she didn't notice the items, and they should not be left at the bedside and should be secured. During an interview on 1/28/26 at 2:13 P.M., Unit Manager #1 said these medications and treatments should be secured and not left at the bedside. 3. Review of the United States Pharmacopeia (USP) standards, dated 5/1/17 indicated, but was not limited to: -Safe medication storage includes the provision of appropriate environmental controls. Medications can be altered by exposure to improper temperature; medications should be stored and handled in accordance with manufacturer's specifications. Review of manufacturer guidelines for the following diabetic insulin vials and kwikpens indicated but was not limited to: -Unopened medications Novolog, Levemir, Lantus, Basaglar, Humalog, Humulin, Lispro, Procrit Desmopressin, and Tubersol should be stored in a refrigerator with a temperature between 36 to 46 degrees Fahrenheit. On 1/30/26 at 8:05 A.M., the surveyor, accompanied by Nurse #3, inspected the medication room on the [NAME] Unit, and observed the following: -Refrigerator was open with an internal temperature of 70 degrees. -The following medications were warm to the surveyor's touch: Novolog (treats diabetes) Lantus (treats diabetes) Basaglar (treats diabetes) Humalog (treats diabetes) Lispro (treats diabetes) Procrit (stimulates the bone marrow to produce red blood cells) Desmopressin nasal spray (treats cranial diabetes insipidus) Tubersol (used as a diagnostic agent to detect tuberculosis infection) Review of the facility Medication Refrigerator Temperature Logs from August 2025 through January 2026 failed to indicate the refrigerator temperature was checked on the following dates: 8/2/25, 8/6/25, 8/7/25, 8/12/25, 8/13/25, 8/14/25, 8/16/25, 8/20/25, 8/21/25, 8/23/25, 8/27/25, 8/28/25, 9/3/25, 9/4/25, 9/6/25, 9/10/25, 9/11/25, 9/13/25, 9/18/25, 9/20/25, 9/23,25, 9/24/25, 10/8/25, 10/18/25, 11/1/25, 11/6/25, 11/20/25, 11/22/25, 11/27/25, 11/29/25, 12/6/25, 12/14/25, 12/24/25, 12/31/25, 1/3/26, 1/7/26, 1/10/26, 1/13/26, 1/14/26, 1/15/26, 1/20/26, 1/21/26, 1/31/26. During an interview on 1/30/26 at 8:05 A.M., Nurse #3 said she did not know how long the refrigerator was left open and did not know what the process was for use vs. disposal of the medications in the refrigerator that were warm to touch and would need to check with her supervisor. Nurse #3 said the 11:00 P.M. to 7:00 A.M. shift nurse is in charge of checking the medication refrigerator temperatures and did not know where the Medication Refrigerator Temperature Logs were kept on the unit. During an interview on 1/30/26 at 8:39 A.M., Unit Manager #2 said the 11:00 P.M. to 7:00 A.M. shift nurse is responsible every shift for checking and documenting the medication refrigerator temperatures. Unit Manager #2 said the medication refrigerator should be kept closed at all times and medications not within manufacturer's guidelines for storage temperature should be removed immediately. During an interview on 2/2/26 at 8:57 A.M., the DON said the medication refrigerator should be kept closed and the 11:00 P.M. to 7:00 A.M. shift nurse is responsible for checking and documenting the temperatures at least once per shift, and twice if there are vaccines stored in the refrigerator. The DON said the nurse should be checking at the beginning and end of each shift. The DON said all nurses are responsible for checking the refrigerators.

Based on record review and interviews, the facility failed to report a potential allegation of abuse for one Resident (#18), out of a total sample of 29 residents. Findings include:Review of the facility's policy titled Abuse, Neglect and Exploitation, dated 2/2023, indicated, but was not limited to, the following:-It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.-Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:a. immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, orb. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.-The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.Resident #18 was admitted to the facility in August 2025 with diagnoses including metabolic encephalopathy (a brain dysfunction caused by underlying metabolic disturbances, leading to symptoms like confusion, memory loss, and altered consciousness), dementia, and cognitive communication deficit. Review of Resident #18's Minimum Data Set (MDS) assessment, dated 1/23/26, indicated the Resident was cognitively intact, as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Further review of the MDS assessment indicated that the Resident was dependent on staff for completing activities of daily living. During an interview on 1/28/26 at 12:06 P.M., Resident #18 said there was lots of abuse in the facility and that staff think he/she is crazy. Resident #18 said he/she was not comfortable sharing anything further because he/she did not know the surveyor. Resident #18 said he/she had not shared his/her concerns with any staff at the facility but said he/she would like to discuss it with the police. On 1/28/26 at 12:08 P.M., the surveyor notified the facility's Director of Nursing (DON) of Resident #18's report of abuse in the facility and request to speak with the police.Review of the Health Care Facility Reporting System (HCFRS- system used in Massachusetts by facilities to report suspected abuse/misappropriation) on 1/29/26 failed to indicate the facility submitted a report on 1/28/26 for an allegation of abuse. During an interview on 1/29/26 at 12:01 P.M., the Administrator said the DON was able to complete her investigation of the abuse allegation within two hours and determined that it was not necessarily abuse but more of an educational opportunity for the Certified Nursing Assistant (CNA) and was not reported in HCFRS. During an interview on 1/29/26 at 12:18 P.M., the DON said when an allegation of abuse is reported, the first thing she does is talk to the resident making the allegation to find out what had occurred. The DON said if indicated, she would interview staff and anyone else that may have been witness to what the resident was reporting to determine whether abuse had occurred or not. The DON said that if she determined that abuse had occurred, she would report the allegation to the Department of Public Health within the 2-hour window as required. The DON said the Assistant Director of Nursing (ADON) spoke with Resident #18's roommate on 1/28/26, but no other residents on the unit were interviewed and no other staff were interviewed beyond CNA #9, who had been caring for the Resident on 1/28/26 when the allegation was reported. During an interview on 1/29/26 at 12:35 P.M., the DON said after she spoke with Resident #18, she determined the concern was a care concern, not abuse, so she did not report the allegation in HCFRS or notify the police.

Based on observation, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections for two Residents (#13, #33), out of a total of five residents. Specifically, the facility failed:1. For Resident #13, to ensure his/her indwelling Foley catheter (tube inserted into the bladder to drain urine into a collection bag outside of the body) drainage bag was maintained in a sanitary manner through implementation of infection control practices for resident care; and2. For Resident #33, to ensure his/her indwelling Foley catheter drainage bag was maintained in a sanitary manner. Findings Include:Review of the Centers for Disease Control and Prevention (CDC) Guideline for Prevention of Catheter-Associated Urinary Tract Infections, dated 2009, updated 6/6/19, page 13, section III, Proper Techniques for Urinary Catheter Maintenance, indicated but was not limited to the following criteria: - Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. 1. Resident #13 was admitted to the facility in October 2022. In October 2025, he/she had new diagnoses including urinary retention (bladder does not empty completely during urination) and urinary tract infection. Review of the Minimum Data Set (MDS) assessment, dated 10/3/25, indicated Resident #13 was cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 5 out of 15. Further review of MDS assessments indicated a significant change assessment was completed on 11/14/25 for new diagnoses of urinary tract infection, urinary retention, and indwelling Foley catheter use. Review of Resident #13's Physician's Orders indicated but was not limited to: -Foley catheter care every shift and at night [PM] (12/1/25) -Enhanced Barrier Precautions (prevent spread of infection) for Foley catheter (11/18/25) -May have indwelling catheter in place until follow up urology appt (10/31/25) -Insert Foley catheter #16 French with 10milliliter (ml) balloon (10/30/25) -Call physician if Foley catheter does not drain after replacement (10/29/25) -Irrigate Foley catheter as needed with 30 mL normal saline if not draining as needed (10/29/25) -Replace Foley bag monthly the 29th every month (10/29/25) -Replace Foley catheter as needed if still not draining after irrigation (10/29/25) On 1/27/26 at 10:23 A.M., the surveyor observed Resident #13 holding his/her Foley catheter by the drainage bag in their hand while walking down the hallway with no protective barrier. On 1/27/26 at 10:35 A.M., the surveyor observed Resident #13 sitting on his/her bed. The indwelling Foley catheter bag was not secured to the bedframe, and the bag was lying directly on the floor with no protective barrier. On 1/27/26 at 10:38 A.M., the surveyor observed Resident #13 stand up from his/her bed holding the indwelling Foley catheter by the side of the bag allowing urine to flow back up the urinary collection tube. Resident #13 then sat back on his/her bed placing the indwelling Foley catheter back onto the floor with no protective barrier in place. On 1/29/26 at 8:28 A.M., the surveyor observed Resident #13 lying in bed with the indwelling Foley catheter bag in front of the bedside table on the floor with no protective barrier in place. On 1/29/26 at 9:06A.M., the surveyor observed Resident #13 lying in bed watching television. The indwelling Foley catheter bag was not secured to the bedframe, and the bag was lying directly on the floor with no protective barrier. On 01/30/26 at 7:54 A.M., the surveyor observed Resident #13 holding the indwelling Foley catheter bag by the urinary drainage tube at the top of the bag while walking to the bathroom. During an interview on 1/29/26 at 9:07 A.M., Nurse #3 said sometimes Resident #13 puts the indwelling Foley catheter on the bedside table or floor and when he/she walks around they pick up the indwelling Foley catheter bag and carry it. The surveyor, accompanied by Nurse #3, observed Resident #13 lying in bed with the indwelling Foley catheter on the floor next to the Resident's bed with no protective barrier. During an interview on 1/29/26 at 9:28 A.M. Certified Nursing Assistant (CNA) #6 said Resident #13 handles his/her indwelling Foley catheter and he/she picks the catheter up and puts it down on their own. During an interview on 1/30/26 at 2:54 P.M., Unit Manager (UM) #2 said Resident #13 requires constant reminding to keep the indwelling Foley catheter off the floor. UM #2 said the indwelling Foley catheter should not be on the floor, a table, or on the Resident's lap to prevent infection. During an interview on 1/30/26 at 3:15 P.M., the Infection Control Nurse said indwelling Foley catheter bags should not be on the floor at any time. During an interview on 2/2/26 at 8:53 A.M., the Director of Nursing (DON) said indwelling Foley catheter bags should not be on the floor or a table, the indwelling Foley catheter bag should be below the level of the bladder and secured properly to the bed frame or Resident should use a secured leg bag if tolerated. 2. Resident #33 was admitted to the facility in June 2025 and had diagnoses including urinary retention (bladder does not empty completely or at all when urinating). Review of the MDS assessment, dated 12/12/25, indicated Resident #33 was cognitively intact as evidenced by a BIMS score of 15 out of 15 and had an indwelling urinary catheter. Review of Physician's Orders indicated but was not limited to: -Foley catheter size #16 French with 10 milliliter (ml) balloon (6/27/25) -Catheter to bedside drainage bag while in bed every shift (6/27/25) -Flush Foley catheter with 30 ml normal saline as needed and every shift (9/20/25) -Provide Foley catheter care every shift (6/13/25) -May use leg bag (6/13/25) -Replace Foley bag monthly the 28th of every month (8/4/25) On 1/27/26 at 9:20 A.M., the surveyor observed Resident #33 sitting upright in bed watching television. The indwelling Foley catheter tube was not secured to the bedframe, and the bag was lying directly on the floor with no protective barrier. On 1/28/26 at 10:10 A.M., the surveyor observed Resident #33 being pushed in his/her wheelchair down the hallway. The Foley catheter bag was clearly visible hanging underneath the wheelchair and dragging on the floor with no protective barrier. On 1/28/26 at 10:50 A.M., the surveyor observed Resident #33 sitting in a wheelchair at the bedside. The indwelling Foley catheter bag was hanging down from the wheelchair and lying directly on the floor with no protective barrier. On 1/28/26 at 1:49 P.M., the surveyor observed Resident #33 sitting in a wheelchair in his/her room watching television. The indwelling Foley catheter bag was hanging down from the wheelchair and lying directly on the floor with no protective barrier. During an interview on 1/29/26 at 2:55 P.M., Nurse #7 said Resident #33's catheter bag should have been secured to the bedframe or wheelchair and not lying on the floor. During an interview on 2/2/26 at 12:04 P.M., the DON said Resident #33's catheter bag is supposed to be secured and not allowed to lie directly on the floor.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential for foodborne illness to residents who are at high risk. Specifically, the facility failed to:1. Properly label and date food and beverage products as well as maintain safe and clean equipment in three of four nourishment kitchenettes; and2. Handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another).Findings include: Review of the facility's policy titled Personal Food Policy, dated 11/2016, indicated but was not limited to the following: - Families and visitors of residents are permitted to bring food into the facility for resident use. - The staff person receiving the personal food shall label the container with the date it was brought into the facility and the name of the resident receiving it. - Dietary aides are responsible for checking nourishment refrigerators daily and discarding any unused refrigerated food after 3 days. - Frozen food should be discarded after 3 months. Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: - 3-301.11 Preventing Contamination from Hands. (A) FOOD EMPLOYEES shall wash their hands as specified under 2-301.12. (B) Except when washing fruits and vegetables as specified under 3-302.15 or as specified in (D) and (E) of this section, FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT. - 3-304.15 Gloves, Use Limitation. (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. 1. On 1/28/26 at 10:19 A.M., the surveyor made the following observations of the Hopkins Unit nourishment kitchenette: - Brown/orange food splatter/residue was noted to the top inside portion of the microwave. - One Lean Cuisine Protein Kick Ricotta Cheese and Spinach Ravioli frozen dinner was in the freezer with a manufacturer expiration date of August 2026 but had no resident identification. On 1/28/26 at 3:56 P.M., the surveyor made the following observations of the Mayflower Unit nourishment kitchenette: - Brown/orange food splatter/residue was noted to the top inside portion of the microwave. - One 2-liter (L) bottle of Diet Coca Cola was on the door of the refrigerator, opened with no resident identification. - One 20-ounce bottle of [NAME] Dry Ginger Ale was on the door of the refrigerator with no resident identification. - A white takeaway container with illegible resident name and a date of 12/2025 containing mashed potatoes with gravy and ground meat with gravy and crust. The inside of the container was noted to have water droplets on the inside of the container. On 1/29/26 at 8:45 A.M., the surveyor made the following observations of the [NAME] Unit nourishment kitchenette: - Brown/orange food splatter/residue was noted to the top and sides of the inner portion of the microwave. The white inner plastic component of microwave was peeling with exposure of the metal components on top and bottom. - An opened Vanilla Med Pass 2.0+ Fortified Nutritional Shake was undated on the door of the refrigerator. The manufacturer label on the bottle indicated to discard four days after opening if properly refrigerated. - An opened [NAME] Spicy Chicken Broth container with no resident identification was on the top shelf of the refrigerator. The container was undated. - Two whole milk individual milk cartons with manufacturer expiration date of 1/26/26 located on the top shelf of the refrigerator. - Two whole milk individual milk cartons with manufacturer expiration date of 1/28/26 located on the top shelf of the refrigerator. - Six fat-free individual milk cartons with manufacturer expiration date of 1/28/26 located on the top shelf of the refrigerator. - Two Cosmic Stardust [NAME] Nu Energy Drink cans with no resident identification on the door of the refrigerator. - [NAME] residue observed underneath the bottom drawers of the refrigerator. Residue was sticky and had hair residue on the bottom of the refrigerator. On 1/29/26 at 10:01 A.M., the surveyor made the following observations of the Hopkins Unit nourishment kitchenette: - Brown/orange food splatter/residue was noted to the top inside portion of the microwave. - One Lean Cuisine Protein Kick Ricotta Cheese and Spinach Ravioli frozen dinner was in the freezer with a manufacturer expiration date of August 2026 but had no resident identification. On 1/29/26 at 10:08 A.M., the surveyor made the following observations of the Mayflower Unit nourishment kitchenette: - Brown/orange food splatter/residue was noted to the top inside portion of the microwave. - One 2-liter (L) bottle of Diet Coca Cola was on the door of the refrigerator, opened with no resident identification. - One 20-ounce bottle of [NAME] Dry Ginger Ale was on the door of the refrigerator with no resident identification. On 1/29/26 at 1:00 P.M., the surveyor made the following observations of the [NAME] Unit nourishment kitchenette: - Brown/orange food splatter/residue was noted to the top and sides of the inner portion of the microwave. The white inner plastic component of microwave was peeling with exposure of the metal components on top and bottom. - An opened Vanilla Med Pass 2.0+ Fortified Nutritional Shake was undated on the door of the refrigerator. The manufacturer label on the bottle indicated to discard four days after opening if properly refrigerated. - An opened [NAME] Spicy Chicken Broth container with no resident identification was on the top shelf of the refrigerator. - Two whole milk individual milk cartons with manufacturer expiration date of 1/26/26 located on the top shelf of the refrigerator. - Two whole milk individual milk cartons with manufacturer expiration date of 1/28/26 located on the top shelf of the refrigerator. - Six fat-free individual milk cartons with manufacturer expiration date of 1/28/26 located on the top shelf of the refrigerator. - Two Cosmic Stardust [NAME] Nu Energy Drink cans with no resident identification on the door of the refrigerator. - [NAME] residue observed underneath the bottom drawers of the refrigerator. Residue was sticky and had hair residue on the bottom of the refrigerator. During an interview on 1/30/26 at 9:39 A.M., the Food Service Director (FSD) said dietary staff are responsible for stocking and cleaning nourishment kitchenettes. The FSD said this includes cleaning refrigerators and microwaves, as well as disposing of any expired food products or unlabeled products. The FSD and the surveyor reviewed the observations made throughout the survey. The FSD said the [NAME] Unit microwave should be cleaned and not have plastic and/or metal exposure. The FSD said the [NAME] Unit refrigerator should be clean and free of spills and food residue. The FSD said all food and drink products should be appropriately labeled with resident identification and open dates. The FSD said expired milk products should have been removed from the refrigerators. The FSD said the Med Pass Fortified Drink is opened by nursing staff and should be dated and discarded after four days by the nursing staff. During an interview on 1/30/26 at 10:12 A.M., the Administrator and the surveyor reviewed the observations of the nourishment kitchenettes. The Administrator said all food and beverage products should be appropriately labeled and dated or otherwise discarded. The Administrator said all equipment should be clean, safe and in a sanitary condition. 2. On 1/30/26 between 11:20 A.M. and 12:15 P.M., the surveyor made the following observations during the lunch line service: -11:21 A.M. the FSD washed his hands in the handwashing sink next to the food service line and dried his hands with a paper towel. -11:22 A.M. the FSD began taking temperatures of meat sauce, pasta, puree meat and gravy from the service line. The FSD wiped the thermometer down with the paper towel he used to dry his hands with after washing. - 11:26 A.M., the FSD began putting breaded fish from the oven into a pan on the service line. The FSD had a dirty/stained potholder on one hand that was observed to touch the fish as it was placed into the pan on the food service line. -11:30 A.M., the FSD began pouring broccoli into a pan on the service line. The FSD touched the broccoli with his ungloved left hand and took the temperature without cleaning the thermometer. -11:31 A.M., the FSD used his gloved hands to wipe down the counter next to the service line with the paper towel he previously used to dry his hands. The FSD threw the paper towel away but did not change his gloves or perform hand hygiene. -11:32 A.M., a dietary staff member asked the FSD for keys, the FSD placed his gloved right hand and bare left hand into his pants pocket and did not perform hand hygiene. -11:33 A.M., the FSD touched his gloved hands to his face/nose and did not perform hand hygiene or change his gloves. -11:38 A.M., the FSD checked the temperature of baked fish without cleaning the thermometer. - 11:43 A.M., the FSD checked the temperature of two soups located on the stove top. The FSD didinot clean the thermometer between checking the temperature of each soup. The FSD placed the thermometer on a tray next to the service line without cleaning it. - 11:47 A.M., the FSD took the temperature of potatoes from the oven using the thermometer without cleaning it. - 11:50 A.M., the FSD removed his gloves and put on a new pair of gloves without performing hand hygiene. - 11:52 A.M., the FSD left the service line to review a form on the table next to the service line. The FSD touched the piece of paper with his gloved hands and did not change his gloves or perform hand hygiene prior to returning to the line to plate food items. - 11:52 A.M., the FSD left the service line to review a form on the table next to the service line. The FSD touched the piece of paper with his gloved hands and did not change his gloves or perform hand hygiene prior to returning to the line to plate food items. -11:53 A.M., the FSD touched his gloved hands to the front of his apron without changing his gloves and continued to plate food items on the service line. -11:54 A.M., the FSD used his gloved hand to serve ready-to-eat bread to a resident's food plate. - 12:00 P.M., the FSD touched his gloved hands to the side of his apron/pants, turned to the stove to place more pasta into a pot of boiling water and then returned to the service line without changing his gloves or performing hand hygiene. - 12:05 P.M., the FSD touched his gloved hands to his face/nose and continued to plate food items on the service line without performing hand hygiene or changing his gloves. - 12:06 P.M., the FSD touched his gloved hands to his face and continued to plate food items on the service line without performing hand hygiene or changing his gloves. -12:10 P.M., the FSD left the service line and turned to the stove to stir pasta in a pot of boiling water and returned to the service line without changing his gloves or performing hand hygiene. During an interview on 1/30/26 at 2:27 P.M., the FSD said the thermometer should be cleaned using thermometer probe wipes after performing temperature checks on each food item to prevent cross contamination. The FSD said gloves should be changed when moving from one area of the kitchen to another, changing tasks, performing new tasks, or when touching clothing or aprons indirectly occurs. The FSD said he did not use a utensil to serve ready-to-eat food items, and all food items should have a serving utensil on the serving line. During an interview on 1/30/26 at 2:30 P.M., the Administrator said the thermometer should be cleaned correctly between each use with the designated cleaning wipes. The Administrator said the FSD should have changed his gloves and performed hand hygiene as needed.

Based on observations, records reviewed, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when one of one nurses observed during a medication pass made two errors out of 32 opportunities, resulting in a medication error rate of 6.25%. Those errors impacted two Residents (#50 and #56), out of three residents observed.Findings include:Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated but was not limited to the following:-Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers. 1. Review of Resident #50's Physician's Orders indicated, but was not limited to, the following:-Prednisolone Acetate Ophthalmic Suspension 1% - Instill 1 drop in both eyes two times a day (order date 10/4/24)On 1/28/26 at 10:24 A.M., the surveyor observed Nurse #9 prepare and administer Resident #50's morning medications. Nurse #9 returned to the medication cart, put the Resident's eye drops away, and began preparing medications for another resident. Nurse #9 failed to administer the Resident's prescribed Prednisolone Acetate Ophthalmic Suspension (a steroid medicine used to treat eye inflammation) to both eyes as ordered.During an interview on 1/28/26 at 10:26 A.M., Nurse #9 said she failed to administer Resident #50's Prednisolone eye drops because she must have gotten distracted after administering the Resident's inhaler and forgot.2. Review of Resident #56's Physician's Orders indicated, but was not limited to, the following:-Buprenorphine HCl-Naloxone HCl (a combination medication used primarily to treat opioid use disorder) Sublingual Tablet 8-2 MG- Give 1 tablet sublingually three times a day (order date 6/26/25)On 1/28/26 at 9:48 A.M., the surveyor observed Nurse #9 prepare and administer Resident #56's morning medications. Nurse #9 prepared and administered the sublingual film form of Buprenorphine HCl-Naloxone HC to the Resident. During an interview on 1/28/26 at 10:38 A.M., Nurse #9 said the form of Buprenorphine HCl-Naloxone HCl supplied by the pharmacy for Resident #56 was films, not tabs, as indicated in the Resident's Physician's Orders.During an interview on 2/2/26 at 12:16 P.M., the Director of Nursing said it was her expectation that medications were administered as indicated by the physician's orders.

Based on interview and record review, the facility failed to ensure staff implemented care and services consistent with professional standards of practice for four Residents (#12, #1, #145, and #5), out of 29 sampled residents. Specifically, the facility failed:1. For Resident #12, to administer an antihypertensive medication as ordered on days the Resident left the facility to go to dialysis;2. For Resident #1, to monitor that Certified Nursing Assistants (CNA) were not working out of their scope of practice by adjusting liter flow on oxygen tanks;3. For Resident #145, to administer Ativan according to physician's orders; and4. For Resident #5, to ensure a physician's order was in place for self-administration of Muscle Rub (topical analgesic treatment).Findings include:Review of [NAME], Manual of Nursing Practice 11ed, dated 2019, indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized 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. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber. 1. Resident #12 was admitted to the facility in November 2025 with diagnoses including end stage renal disease (ESRD) and hypertension urgency (a severe elevation of blood pressure generally over 180/120 mmHg, without new or progressive target organ damage). Review of the Minimum Data Set (MDS) assessment, dated 11/21/25, indicated Resident #12 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Further review of the MDS indicated Resident #12 had received dialysis. Review of Resident #12's current Physician's Orders indicated but was not limited to: - Dialysis: Tuesday, Thursday and Saturday 11:30 AM chair- dated 1/23/26 -Labetalol HCL oral tablet 300 milligrams (MG) give one tablet by mouth every eight hours related to hypertensive urgency. Hold for systolic blood pressure (SBP) less than 130-dated 1/23/26 Further review of the Medication Administration Record (MAR) indicated that the Labetalol HCL was scheduled to be given at 6:00 A.M., 2:00 P.M., and 10:00 P.M. The following as ordered 2:00 P.M. doses were marked as not given on dialysis days: 11/18/25, 11/20/25, 11/22/25, 11/29/25, 12/2/25, 12/4/25, 12/6/25, 12/9/25, 12/11/25, 12/22/25, 12/27/25, 12/29/25, 12/31/25, 1/6/26, 1/8/26, 1/10/26, 1/24/26 and 1/27/26 To note Resident #12's dialysis schedule was modified from 12/22/25 through 12/31/25 to accommodate the holidays. Further review of Resident #12's medical record failed to indicate the Physician or Nurse Practitioner (NP) were notified of the missing doses of the Labetalol HCL. During an interview on 1/29/26 at 1:53 P.M., Nurse #2 said she holds the scheduled dose of Labetalol when Resident #12 is at dialysis. Nurse #2 said she does not send any medications to dialysis. Nurse #2 said she does not inform the physician or NP of the missing doses. During an interview on 1/30/26 at 10:15 A.M., Nurse #1 said she does not send any medications with the resident to dialysis. Nurse #1 said she would document the scheduled 2:00 P.M. dose of Labetalol as not given. Nurse #1 said she does not inform the physician or NP of the missing doses. During an interview on 1/30/26 at 11:12 A.M., the surveyor and Unit Manager (UM) #1 reviewed the times that the Labetalol was not given as Resident #12 was out of the facility. UM #1 said the Labetalol should have been scheduled for times that the Resident was in the facility. During an interview on 1/30/26 at 1:14 P.M., the Director of Nurses (DON) said medications should be scheduled around the times Resident #12 was out of the facility at dialysis. The DON said several missed doses of medication should be relayed to the physician or NP. On 1/30/26 at 1:30 P.M. and 2/4/26 at 11:57 A.M., the surveyor attempted to contact the NP but was unsuccessful. 2. Review of the National Institutes of Health (NIH) (.gov) https://www.ncbi.nlm.nih.gov>books>NBK593208, indicated but was not limited to: Oxygen is considered a medication and, therefore, requires a prescription and continuous monitoring by the nurse to ensure its safe and effective use. Review of the facility's policy titled Oxygen Administration Nasal Cannula, dated revised November 2020, indicated but was not limited to: -Policy Statement to deliver low flow oxygen, per the physician's order (generally 1-6 liters per minute (LPM) and 24%-45% concentration) via nasal cannula. -Set the oxygen liter flow to the prescribed liters flow per minute -Verify oxygen is flowing through tips of the cannula -Document flow rate and resident's condition and response in the medical record as indicated Resident #1 was admitted to the facility in December 2025 with diagnoses including chronic obstructive pulmonary disease (COPD) and chronic respiratory failure. Review of the MDS assessment, dated 1/9/26, indicated Resident #1 was cognitively intact as evidenced by a BIMS score of 15 out of 15. Further review of the MDS indicated Resident #1 had received Oxygen. Review of Resident #1's current Physician's Orders indicated but was not limited to: -Evaluate and document respiratory status for change in condition every shift-dated 12/17/25 -Monitor shortness of breath (SOB) q shift: Does the resident with COPD/Asthma/Interstitial lung disease have SOB while lying flat and request or need to have head of bed elevated for respiratory support-dated 12/17/25 -Oxygen as needed via NC at 2 LPM for SOB. May titrate between 1-4 LPM as needed for comfort or to maintain O2 saturation greater than 90%-dated 1/19/26 On 1/29/26 at 1:15 P.M., the surveyor observed Resident #1 tell CNA #1 that he/she was not getting any oxygen through his/her portable oxygen tank. CNA #1 said she would boost it up to six and took her hand and manipulated the setting on the oxygen tank. During an interview on 1/29/26 at 1:16 P.M., CNA #1 said she was able to fill the portable oxygen tanks and turn on the tank for the residents. CNA #1 said on a good day Resident #1 would be on four liters. CNA #1 said when he/she was huffing and puffing, he/she was on five liters. CNA #1 said, if she did not know what setting to use, she would ask the nurse. During an interview on 1/29/26 at 1:37 P.M., Nurse #2 said CNAs were allowed to fill portable oxygen tanks but were not allowed to manipulate the liter flow on the oxygen tanks. The surveyor and Nurse #2 observed the liter flow on Resident #1's portable oxygen tank. Nurse #2 said the liter flow was five liters. Nurse #2 said the liter flow was set at two liters this morning and decreased the flow to two liters. During an interview and observation on 1/30/26 at 10:20 A.M., Resident #1 returned from his/her cigarette break. CNA #2 placed a portable oxygen tank on the back of Resident #1's wheelchair and turned on the oxygen. The surveyor and CNA #2 observed the setting which was set at two liters. CNA #2 said she was allowed to fill the oxygen tanks and turn on the oxygen. During an interview on 1/30/26 at 10:57 A.M., Nurse #1 said CNAs are allowed to fill oxygen tanks and adjust the liter flow. Nurse #1 said if they do not know the liter flow to set the oxygen tank they would ask the nurse. During an interview on 1/30/26 at 11:20 A.M., the Staff Development Coordinator (SDC) said we educate and do competencies with licensed nurses on oxygen delivery. The SDC said CNAs are educated and go through a competency to fill the portable oxygen tanks. The SDC said oxygen is considered a medication and only licensed nurses can administer and manipulate the liter flow with a physician's order. During an interview on 1/30/26 at 12:22 P.M. the DON said all CNAs are educated during orientation on filling a portable oxygen tank. The DON said CNAs should not be adjusting or turning on oxygen tanks. 3. Resident #145 was admitted to the facility in February 2024 with diagnoses including anxiety disorder. Review of Resident #145's MDS assessment, dated 11/14/25, indicated the Resident was cognitively impaired, as evidenced by a BIMS score of 12 out of 15. Further review of the MDS assessment indicated that the Resident had a psychiatric mood disorder of anxiety and received antianxiety medications. Review of Resident #145's Physician's Orders indicated, but was not limited to, the following: -Lorazepam (a medication used to treat anxiety) Oral tablet 1 MG. Give one tablet by mouth three times a day for increased anxiety (order date 8/27/24), at scheduled times of 9:00 A.M., 5:00 P.M., and 10:00 P.M. Review of Resident #145's MAR indicated Nurse #4 administered Lorazepam 1 MG as prescribed on 1/29/26 at 9:00 A.M. On 1/29/26 at 3:18 P.M., the surveyor, with Nurse #4 present, reviewed the narcotic log count and actual medication count for Resident #145's Lorazepam 1 MG. Nurse #4 counted 66 tablets of Lorazepam 1 MG remaining. The narcotic log indicated 65 tablets of Lorazepam 1 MG should have been remaining, a discrepancy of one tablet of Lorazepam 1 MG. During an interview on 1/29/26 at 3:18 P.M., Nurse #4 said she was certain she gave Resident #145 his/her 9:00 A.M. dose of Lorazepam 1 MG and did not know why the narcotic count was incorrect. Nurse #4 said the count was correct earlier and she signed out the 9:00 A.M. dose. Nurse #4 said based on the number of tablets remaining she was unsure if she gave Resident #145 his/her ordered Lorazepam 1 MG. Review of Resident #145's incident report indicated Nurse #4 made a medication error. The report indicated Nurse #4 signed one tablet of Lorazepam 1 MG out of the narcotic log for Resident #145 without giving the medication and the Resident was unaware. During an interview on 2/2/26 at 8:57 A.M., the DON said Resident #145 should have received their medication as ordered. 4. Resident #5 was admitted to the facility in July 2025 and had diagnoses including right upper quadrant pain, osteoarthritis of the right hip and muscle weakness. Review of the MDS assessment, dated 1/14/26, indicated that Resident #5 was cognitively intact as evidence by a BIMS score of 15 out of 15, experienced constant pain over the past five days, and had limited range of motion on one side of his/her lower extremity. On 1/27/26 at 9:31 A.M., the surveyor observed a tube of Muscle Rub (topical analgesic) on the bedside table in full view. During interviews with observation on 1/28/26 at 8:37 A.M. and 10:06 A.M., the surveyor observed Resident #5 seated in a wheelchair at the bedside applying Muscle Rub to his/her legs. The Resident said staff used to leave him/her a small cup of the cream to apply, but it wasn't enough, so they leave the entire tube for him/her to apply on his/her own. Review of Physician's orders failed to indicate Resident #5 had an order to self-administer Muscle Rub and/or to keep the treatment at the bedside. Review of the medical record indicated Self-Administration of Medication assessments, dated 7/25/25, 10/3/25, 12/26/25 and 1/3/26. All the assessments indicated Resident #5 did not want to self-administer any medications and was not assessed to self-administer. Review of comprehensive care plans failed to indicate a care plan for self-administration of medication. During an interview on 1/28/26 at 2:13 P.M., Unit Manager #1 said she said she was not aware Resident #5 had been self-administering and keeping Muscle Rub cream at the bedside. She said treatments should not be left at the bedside and not self-administered without an assessment and Physician's order is obtained to do so. During an interview on 2/2/26 at 12:04 P.M., the DON said Resident #5 should have had an evaluation to self-administer the treatment and a Physician's order to apply the treatment independently and store it at the bedside but did not.

Based on interview and record review, the facility failed to ensure staff thoroughly investigated an allegation of abuse for one Resident (#18), out of a total sample of 29 residents. Findings include:Review of the facility's policy titled Abuse, Neglect and Exploitation, dated 2/2023, indicated, but was not limited to, the following:-It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.- Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property.-An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.-Written procedures for investigations include:1. Identifying staff responsible for the investigation;2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence);3. Investigating different types of alleged violations;4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations;5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation.-The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to:a. Responding immediately to protect the alleged victim and integrity of the investigation;b. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment, if needed;c. Increased supervision of the alleged victim and residents;d. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator;f. Providing emotional support and counseling to the resident during and after the investigation, as needed;g. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. -The facility will have written procedures that include:1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:a. immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, orb. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.-The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.-Accused employee may be placed on administrative leave while the investigation is being conducted.-The resident will be monitored for potential negative outcomes for 72-hours post-incident occurrence and this will be documented in the clinical record.Resident #18 was admitted to the facility in August 2025 with diagnoses including metabolic encephalopathy (a brain dysfunction caused by underlying metabolic disturbances, leading to symptoms like confusion, memory loss, and altered consciousness), dementia, and cognitive communication deficit. Review of Resident #18's Minimum Data Set (MDS) assessment, dated 1/23/26, indicated the Resident was cognitively intact, as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Further review of the MDS assessment indicated that the Resident was dependent on staff for completing activities of daily living. During an interview on 1/28/26 at 12:06 P.M., Resident #18 said there was lots of abuse in the facility and that staff think he/she is crazy. Resident #18 said he/she was not comfortable sharing anything further because he/she did not know the surveyor. Resident #18 said he/she had not shared his/her concerns with any staff at the facility but said he/she would like to discuss it with the police. On 1/28/26 at 12:08 P.M., the surveyor notified the facility's Director of Nursing (DON) of Resident #18's report of abuse in the facility and request to speak with police. During an interview on 1/29/26 at 11:03 A.M., the DON said she had completed a grievance form for Resident #18 on 1/28/26. The DON said when she interviewed the Resident on 1/28/26, she determined the Resident was unhappy with the Certified Nursing Assistant's (CNA) method of positioning him/her with pillows and that she had changed the CNA assignment for the Resident's comfort and the CNA was provided reeducation. CNA #9 was not placed on administrative leave during the DON's investigation. The DON provided a copy of the grievance form she had completed to the surveyor. Review of a Grievance Sheet, dated 1/28/26, completed by the DON and Assistant Director of Nursing (ADON) for Resident #18 indicated the Resident did not like having pillows behind his/her back for positioning and said CNA #9 would not remove the pillows and had a bad attitude. Resident #18 said he/she prefers CNA #9 not provide his/her care going forward. Included with the Grievance Sheet was an Employee Education Report that indicated CNA #9 was educated on refusal of care/customer service/resident's rights on 1/28/26 and a written statement from CNA #9 dated 1/29/26 regarding her provision of care to Resident #18. The grievance form did not include any information the surveyor had reported to the DON on 1/28/26.As of the survey exit on 2/2/26, review of the Health Care Facility Reporting System (HCFRS) failed to indicate the facility had reported any allegations of abuse involving Resident #18 and their investigation findings.During an interview on 1/29/26 at 12:01 P.M., the Administrator said the DON was able to complete her investigation within 2 hours after the initial report was made and, after speaking to Resident #18, the DON determined that it was more of a misunderstanding than abuse. The Administrator did not know if other staff or residents on the unit were interviewed during the course of the DON's investigation.During an interview on 1/29/26 at 12:18 P.M., the DON said when an allegation of abuse is reported, the first thing she does is talk to the resident making the allegation to find out what had occurred. The DON said if indicated, she would interview staff and anyone else that may have been witness to what the resident was reporting to determine whether abuse had occurred or not. The DON said that if she determined that abuse had occurred, she would report the allegation to the Department of Public Health within the 2-hour window as required. The DON said the ADON spoke with Resident #18's roommate on 1/28/26, but no other residents on the unit were interviewed and no other staff were interviewed beyond CNA #9, who had been caring for the Resident on 1/28/26 when the allegation was reported. During a subsequent interview on 1/29/26 at 12:35 P.M., the DON said after she spoke with Resident #18, she determined the concern was a care concern, not abuse, so she did not report it or notify the police. The DON said she had not informed the Resident's Health Care Proxy about the Resident's concern.

Based on observation, interview, and record review, the facility failed to ensure one Resident (#33), out of a total sample of 29 residents, was treated with respect and dignity. Specifically, the facility failed for Resident #33, to ensure a Foley catheter (tube inserted into the bladder to drain urine) drainage bag was consistently covered with a privacy bag. Findings include:Resident #33 was admitted to the facility in June 2025 and had diagnoses including urinary retention (inability to completely empty the bladder leading to frequent urination or leakage of urine).Review of the Minimum Data Set (MDS) assessment, dated 12/12/25, indicated Resident #33 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and had an indwelling urinary catheter.Review of Physician's Orders indicated but was not limited to:-Foley catheter size #16 French with 10 milliliter (ml) balloon (6/27/25)-Catheter to bedside drainage bag while in bed every shift (6/27/25)-Flush Foley catheter with 30 ml normal saline as needed and every shift (9/20/25)-Provide Foley catheter care every shift (6/13/25)-May use leg bag (6/13/25)-Replace Foley bag monthly the 28th of every month (8/4/25)On 1/27/26 at 9:20 A.M., the surveyor observed Resident #33 sitting upright in bed watching television. A urinary drainage bag was observed lying directly on the floor to the side of the Resident's bed. The drainage bag was visible from the doorway, contained clear/yellow urine and was not covered by a privacy bag.On 1/28/26 at 10:10 A.M., the surveyor observed Resident #33 being pushed in his/her wheelchair down the hallway. The Foley catheter bag was not covered by a privacy bag and clearly visible hanging underneath the wheelchair.On 1/28/26 at 10:50 A.M., the surveyor observed Resident #33 seated in a wheelchair at the bedside. The Foley catheter bag was not covered with a privacy bag and clearly visible from the doorway hanging underneath the wheelchair.On 1/28/26 at 1:49 P.M., the surveyor observed Resident #33 sitting in a wheelchair in his/her room watching television. The Foley catheter bag was not covered by a privacy bag, was visible from the doorway hanging underneath the wheelchair and contained clear/yellow urine.On 1/29/26 at 1:18 P.M., the surveyor observed Resident #33 ambulating in the unit hallway with therapy staff. The Foley catheter bag was not covered by a privacy bag and contained clear/yellow urine visible to anyone in the hallway.During an interview on 1/29/26 at 2:55 P.M., Nurse #7 said Resident #33 as well as all residents with catheter bags should have privacy bags to cover the catheter drainage bag.During an interview on 2/2/26 at 12:04 P.M., the Director of Nursing (DON) said Resident #33 is supposed to have had a privacy cover on his/her catheter bag and staff must have forgotten to put it on.

Based on record review and interview, the facility failed to implement written policies and procedures for the investigation of allegations of abuse, protection of residents during investigations and reporting of allegations and investigative findings for one Resident (#18), out of a total sample of 29 residents. Specifically, the facility failed to initiate their abuse policy after an allegation of potential abuse was reported by the surveyor during the survey.Findings include:Review of the facility's policy titled Abuse, Neglect and Exploitation, dated 2/2023, indicated, but was not limited to, the following:-It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.- Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property.-An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.-Written procedures for investigations include:1. Identifying staff responsible for the investigation;2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence);3. Investigating different types of alleged violations;4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations;5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation.-The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to:a. Responding immediately to protect the alleged victim and integrity of the investigation;b. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment, if needed;c. Increased supervision of the alleged victim and residents;d. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator;f. Providing emotional support and counseling to the resident during and after the investigation, as needed;g. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. -The facility will have written procedures that include:1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:a. immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, orb. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.-The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.-Accused employee may be placed on administrative leave while the investigation is being conducted.-The resident will be monitored for potential negative outcomes for 72-hours post-incident occurrence, and this will be documented in the clinical record.Resident #18 was admitted to the facility in August 2025 with diagnoses including metabolic encephalopathy (a brain dysfunction caused by underlying metabolic disturbances, leading to symptoms like confusion, memory loss, and altered consciousness), dementia, and cognitive communication deficit. Review of Resident #18's Minimum Data Set (MDS) assessment, dated 1/23/26, indicated the Resident was cognitively intact, as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Further review of the MDS assessment indicated that the Resident was dependent on staff for completing activities of daily living. During an interview on 1/28/26 at 12:06 P.M., Resident #18 said there was lots of abuse in the facility and that staff think he/she is crazy. Resident #18 said he/she was not comfortable sharing anything further because he/she did not know the surveyor. Resident #18 said he/she had not shared his/her concerns with any staff at the facility but said would like to discuss it with the police. On 1/28/26 at 12:08 P.M., the surveyor notified the Director of Nursing (DON) of Resident #18's report of abuse in the facility and his/her request to speak with the police. During an interview on 1/29/26 at 11:03 A.M., the DON said she had completed a grievance form for Resident #18 on 1/28/26. The DON said when she interviewed the Resident on 1/28/26, she determined the Resident was unhappy with the Certified Nursing Assistant's (CNA) method of positioning him/her with pillows and that she had changed the CNA assignment for the Resident's comfort. The DON provided a copy of the grievance form to the surveyor. Review of a Grievance Sheet, dated 1/28/26, completed by the DON and Assistant Director of Nursing (ADON) for Resident #18 indicated the Resident did not like having pillows behind his/her back for positioning and said CNA #9 would not remove the pillows and had a bad attitude. Resident #18 said he/she prefers CNA #9 not provide his/her care going forward. Included with the Grievance Sheet was an Employee Education Report that indicated CNA #9 was educated on refusal of care/customer service/resident's rights on 1/28/26 and a written statement from CNA #9 dated 1/29/26 regarding her provision of care to Resident #18. During an interview on 1/29/26 at 12:01 P.M., the Administrator said the DON was able to complete her investigation within 2 hours after the initial report was made and, after speaking to Resident #18, the DON determined that it was more of a misunderstanding than abuse. The Administrator did not know if other staff or residents on the unit were interviewed during the course of the DON's investigation.During an interview on 1/29/26 at 12:18 P.M., the DON said when an allegation of abuse is reported, the first thing she does is talk to the resident making the allegation to find out what had occurred. The DON said if indicated, she would interview staff and anyone else that may have been witness to what the resident was reporting to determine whether abuse had occurred or not. The DON said that if she determined that abuse had occurred, she would report the allegation to the Department of Public Health within the 2-hour window as required. The DON said the ADON spoke with Resident #18's roommate on 1/28/26, but no other residents on the unit were interviewed and no other staff were interviewed beyond CNA #9, who had been caring for the Resident on 1/28/26 when the allegation was reported. During an interview on 1/29/26 at 12:35 P.M., the DON said after she spoke with Resident #18, she determined the concern was a care concern, not abuse, so she did not report it or notify the police. The DON said she had not informed the Resident's Health Care Proxy about the Resident's concern.

Based on observations and staff interviews, the facility failed to ensure residents and/or staff properly disposed of cigarette butts in designated smoking receptacles. Findings include:Review of the Centers for Medicare & Medicaid Services (CMS) circular letter, dated November 10, 2011, titled Smoking Safety in Long Term Care Facilities indicated but was not limited to the following:-The Life Safety Code (NFPA 101, 2000 ed., 19.7.4) requires each smoking area be provided with ashtrays made of noncombustible material and safe design.-Metal containers with self-closing covers into which ashtrays can be emptied must be readily available.Review of the facility's policy titled Smoking, dated revised November 2020, indicated but was not limited to:-Purpose to afford residents the privilege of smoking while maintaining a safe and clean environment within the policy of this facility, that is also respectful to the non-smoker.On 1/28/26 at 6:55 A.M., the surveyor observed the temporary designated smoking area and identified a tall black receptacle for cigarette butts with numerous cigarette butts scattered across the pavement. The surveyor also observed cigarette butts protruding from the adjacent snowbank. Seven chairs were positioned along the outer perimeter of the smoking area, each with several cigarette butts accumulated underneath.On 1/28/26 at 5:03 P.M., the surveyor conducted a subsequent observation of the designated smoking area and identified the same conditions.On 1/30/26 at 6:56 A.M., the surveyor observed the designated smoking area and identified numerous cigarette butts scattered across the pavement.During an interview on 1/30/26 at 7:59 A.M., Certified Nursing Assistant (CNA) #2 said the smoking assistant would clean the area after each smoke but we do not have one now. CNA #2 said sometimes the maintenance staff would clean up the area. CNA #2 said she would ask the residents to use the black ash can for their cigarettes after they are finished smoking, but they often would just throw them on the ground. CNA #2 said she was not assigned to clean up the area. During an interview on 1/30/26 at 12:13 P.M., the Maintenance Director said the smoking attendant would clean the area, but we have been without one for three weeks. The Maintenance Director said he did not have a cleaning schedule, or anyone assigned to maintain the area in the absence of the smoking attendant. On 2/2/26 at 9:14 A.M., the surveyor and CNA #2 observed the smoking area and noted several cigarette butts littered on the ground. There was also a snow-covered table with a few cigarette butts embedded in the snow.During an interview on 2/2/26 at 2:05 P.M., the Administrator said the usual smoking area was located in the rear of the building but had been moved to the front temporarily due to snow. The Administrator said maintenance and housekeeping would usually maintain the area. The smoking attendants would also empty ashtrays and clean up the area, but they were down a full-time smoking attendant right now. The Administrator said she was not sure why the area had not been maintained.

Based on observations, interviews, and record reviews, the facility failed to ensure quality of care was provided, according to the plan of care, facility protocols, and professional standards of practice for one Resident (#79), out of 28 sampled residents. Specifically, the facility failed to ensure wound care treatments for Resident #79 were reflective of recommendations from the wound consultant physician and in line with the primary physician's treatment plan. Findings include: Review of the facility's policy titled Treatments, dated April 2015, indicated but was not limited to the following: -in order for residents to achieve an optimum in their physical state, various treatments may be necessary -these treatments may be ordered by the physician or, within the scope of nursing -it is the responsibility of all nursing staff to constantly evaluate the health state of residents as to the need for treatments -once treatments are ordered, they are to be carried out as prescribed -an order is written for each treatment indicating type, frequency and location -treatments are reviewed daily and the physician notified of all healed areas Resident #79 was admitted to the facility in October 2024 with a diagnosis of localized swelling, mass and lump to the right upper limb. Review of the Minimum Data Set (MDS) assessment, dated 11/21/24, indicated Resident #79 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she was cognitively intact. During an interview with observation on 12/19/24 at 9:10 A.M., Resident #79 said he/she had a large mass on their right elbow and showed the surveyor. The surveyor observed the right elbow swollen on all sides, there was no dressing and the area was open to air. The Resident said he/she had an upcoming appointment to have the cyst drained. Review of the care plans indicated the Resident had a right ulnar (elbow) and thigh cyst (initiated 10/23/24) with interventions including but not limited to administering treatments as ordered and wound consult as needed. Review of the Physician Progress Note from the Nurse Practitioner, dated 11/4/24, indicated Resident #79 had a large cyst to the right elbow and thigh with erythema (redness) and a wound from a cyst that opened with a plan to continue antibiotics until seen by the dermatologist, obtain dermatology evaluation, and continue to monitor clinically. Review of the Treatment Administration Record (TAR) indicated Resident #79 had the following treatment to the right elbow cyst from 11/4/24 through 11/18/24: mupirocin ointment (antibiotic ointment, also referred to as Bactroban), apply to right elbow cyst topically every day and evening shift: wash with wound cleanser, pat dry, apply Bactroban, followed by Alginate and dry dressing. Review of the nursing progress notes indicated the following: -11/4/24: Resident seen by consultant wound physician for the right elbow cyst with a new order for wound cleanser, pat dry, apply Bactroban followed by Alginate and dry dressing. -11/9/24: right elbow draining clear fluid -11/12/24: right elbow draining clear fluid -11/14/24: resident sent to hospital for change in mental status -11/20/24: resident returned from hospital -11/22/24: no dressing to right elbow cyst, not needed, no open area -12/2/24: right leg cyst with necrosis (dead tissue) Review of the consultant wound physician Visit Notes indicated the following: 11/11/24: right elbow draining large amount of serous exudate (a clear or pale yellow, watery fluid that drains from a wound as part of the healing process). Treatment: Adaptic (a primary wound contact layer made of knitted cellulose acetate with a woven mesh structure impregnated with petrolatum), Alginate (a highly absorbent dressing) followed by a dry, protective dressing, twice per day. 11/25/24: right elbow draining moderate amount of serous exudate. Treatment: Adaptic, Alginate and dry protective dressing, change daily. Review of the Physician Progress Note from the Nurse Practitioner, dated 12/2/24, indicated the right thigh cyst had opened and started draining and to continue to monitor. Review of the consultant wound physician Visit Notes indicated the following: 12/9/24: right elbow draining moderate amount of serous exudate. Treatment: Adaptic, Alginate and dry protective dressing. New right thigh cyst with moderate amount of purulent exudate (a thick, opaque, milky fluid that drains from a wound and indicates an infection). Treatment: Bactroban, Alginate, and dry protective dressing daily. 12/16/24: right elbow draining moderate amount of serous exudate. Treatment: Adaptic, Alginate and dry protective dressing. Right thigh cyst with moderate amount of purulent exudate (a thick, opaque, milky fluid that drains from a wound and indicates an infection). Treatment: Bactroban, Alginate, and dry protective dressing daily. Review of the medical record for the month of December 2024 failed to include monitoring or treatments to the right elbow cyst or the right thigh cyst. On 12/20/24 at 12:48 P.M., the surveyor observed Resident #79 sitting on the edge of the bed. The surveyor observed the cyst to the right elbow open to air and cyst to the right thigh open to air. During an interview on 12/24/24 at 10:43 A.M., the Nurse Practitioner said the plan for the Resident was to continue treatments as recommended by the consultant wound physician and the treatment could change as indicated by an external dermatologist, if needed. She said she defers treatments to the consultant wound physician and both the right elbow cyst and the right thigh cyst should have treatments. Review of the medical record on 12/19/24 failed to indicate any current treatments, dressings or monitoring of the cysts on the right upper or lower extremities. During an interview on 12/24/24 at 12:50 P.M., Nurse #2 said Resident #79 did not receive any dressing to the elbow or thigh. She said there used to be a treatment to the elbow, but there was not one any longer. During an interview on 12/24/24 at 1:35 P.M., the Assistant Director of Nurses (ADON) said the treatment for the elbow was discontinued in November 2024. She said the process was for the Wound Nurse to review the recommendations from the consultant wound physician, contact the primary physician and implement treatment orders. During an interview on 12/24/24 at 1:55 P.M., the ADON said she reviewed the consultant wound physician recommendations and the recommendations for changes to the treatment of the right elbow had not been implemented and the new treatment to the right thigh had also not been implemented. During an interview on 12/26/24 at 9:55 A.M., the Wound Nurse said the nurse should not have discontinued the treatment to the right elbow on 11/22/24. She said she was not sure why the wound treatment for the right elbow was not changed with the recommended change in treatment on 11/11/24. She said there was a miscommunication on who was entering the orders for the treatment to the right thigh and that was why it had not been implemented. She said the monitoring process included weekly assessments of wounds. She reviewed the medical record and said she was not sure why there were no weekly evaluations for the wounds for Resident #79, but there should have been.

Based on observations, interviews, and record review, the facility failed to provide the necessary respiratory care and services for one Resident (#91), in a total sample of 28 residents. Specifically, the facility failed to administer oxygen at the correct liter flow per physician's orders, failed to ensure oxygen equipment was maintained in a sanitary manner to help decrease the risk of potential contamination and infection, and failed to ensure the Resident was referred to a pulmonologist. Findings include: Review of the facility's policy titled Oxygen Administration, undated, indicated a physician's order is necessary for the administration of oxygen. Review of the facility's policy titled Oxygen Concentrators, undated, indicated but was not limited to the following: -Verify the physicians order and review the patients' chart. -Adjust the liter flow in accordance with the physician's order by rotating the flow selector knob on the flow meter located on the front panel of the unit. Review of the facility's policy titled C-Pap (Continuous Positive Airway Pressure) and Bi-PAP Ventilatory System, undated, indicated but was not limited to the following: -Place the mask or pillows on the patient's face, and explain to the patient that he or she should breathe in and out normally. Resident #91 was admitted to the facility in January 2024 with diagnoses including chronic obstructive pulmonary disease (COPD), pneumonia, acute and chronic respiratory failure with hypoxia (low oxygen levels), and obstructive sleep apnea (airway collapse with an associated decrease in oxygen levels or waking from sleep). Review of the Hospital Discharge Summary, dated 11/20/24, indicated Resident #91's discharge diagnoses included respiratory failure with hypercapnia (too much carbon dioxide in the blood). The Discharge Summary indicated the Resident would need BiPAP at discharge given his/her underlying neurologic disorder and hypercapnia and that per review with the Case Manager, this was delivered to the facility. The Discharge Summary also indicated that the Resident should follow-up with pulmonology on a regular basis. The Resident's most recent vital signs at time of discharge included a pulse oximetry (measurement of oxygen levels in the blood) of 96% on 2 liters/minute (L/min) of oxygen. Review of the Minimum Data Set (MDS) assessment, dated 12/3/24, indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Further review of the MDS assessment indicated the Resident utilized oxygen and a non-invasive mechanical ventilator (CPAP or BiPAP). Review of Resident #91's care plans indicated but was not limited to the following: Focus: Resident has respiratory disease related to resp (respiratory) failure SOB with HOB (head of bed) flat Interventions: -Assist to reposition for maximum airflow -Auscultate lung sounds as indicated -Encourage resident to pace activities to prevent episodes of dyspnea and fatigue -If resident has shortness of breath, adventitious lung sounds, dyspnea or exertion [sic], fever or changes in mental status, this may indicate an infection. -O2 sats and O2 as ordered -Provide gentle touch, reassurance, emotional support as needed -Respiratory conversation technique training -SOB while lying flat elevate HOB to position of comfort for patient Review of Resident #91's Physician's Orders indicated but was not limited to the following: -Change O2 (oxygen) tubing every Sunday on 11:00 P.M.-7:00 A.M. (11/22/24) -Oxygen continuously via NC (nasal cannula) at 2 Liters/minute every shift Check pulse ox and liters per minute (LPM) (11/22/24) -BiPAP - apply at HS (bedtime), remove in AM (morning). Settings: 6 cm (centimeters) H2O (water) (11/21/24) -BiPAP Headgear/Strap hand wash in mild soap and air dry as needed (11/21/24) -BiPAP Humidifier - Change distilled water daily right before bed every evening shift (11/21/24) -BiPAP Humidifier - Clean chamber weekly and let air dry every night shift every Monday (11/21/24) -BiPAP Replace disposable filter per manufacturer's guidelines per order as needed (11/21/24) Review of Resident #91's Medication Administration Record (MAR) for December 2024 indicated that the Resident's BiPAP was administered as ordered every evening shift 12/1/24 through 12/17/24 and 12/19/24-12/23/24 and the Resident refused the BiPAP on the evening shift on 12/18/24. Further review of the MAR indicated the Resident's oxygen liter flow was set at 2-4 L/min, not 2 L/min as indicated in the physician's order. Review of Resident #91's Treatment Administration Record (TAR) for December 2024 indicated the Resident's oxygen tubing was changed on 12/1/24, 12/8/24, 12/15/24 and 12/22/24. On 12/19/24 at 9:39 A.M., the surveyor observed Resident #91 in bed, wearing a nasal cannula. The oxygen concentrator was observed to be set at 3.5 L/min and the oxygen tubing was dated 12/9/24. The Resident's BiPAP machine was on the nightstand. On 12/23/24 at 2:16 P.M., the surveyor observed Resident #91 in bed, wearing a nasal cannula. The oxygen concentrator was observed to be set at 3.5 L/min and the oxygen tubing was dated 12/23/24. The Resident's BiPAP machine was on the nightstand in the same position as it was on 12/19/24. On 12/26/24 at 9:25 A.M., the surveyor observed Resident #91 in bed, wearing a nasal cannula. The oxygen concentrator was observed to be set at 3L/min. The Resident's BiPAP machine was on the nightstand in the same position as it was on 12/19/24. During an interview on 12/19/24 at 2:16 P.M., Resident #91 said that he/she got a BiPAP machine after his/her last hospitalization but he/she had not used it. During an interview on 12/23/24 at 4:02 P.M., Nurse #1 said that Resident #91 should be using a BiPAP machine at night but refused to use it. Nurse #1 said that Resident #91's oxygen concentrator should be set at 2-3 L/min. Nurse #1 said that the Resident's order for oxygen was for 2 L/min, but when he/she returned from his/her last hospitalization she was told he/she was on 3 L/min. During an interview on 12/26/24 at 11:28 A.M., Nurse #4 said she did not work regularly on the unit but was aware that Resident #91 had a BiPAP machine. Nurse #4 said the BiPAP mask was not on the Resident when she arrived for her shift that morning. Nurse #4 said that the Resident's oxygen concentrator should be set at 2 L/min. During an interview on 12/26/24 at 11:49 A.M., Nurse #4 said she checked the Resident's oxygen concentrator and it was set at 3 L/min. During an interview on 12/26/24 at 12:00 P.M., the Director of Nursing (DON) said that physician's orders should be implemented as written. During an interview on 12/26/24 at 2:16 P.M., the DON said Resident #91 had not been scheduled for a pulmonology appointment and she could not find any documentation that the Resident had been seen by a pulmonologist while at the facility but should have been referred to one.

Based on record review and interview, the facility failed to ensure three Residents' (#1, #123, and #87) drug regimen was free from unnecessary psychotropic medications, out of a total sample of 28 residents. Specifically, the facility failed: 1. For Resident #1, to ensure a gradual dose reduction (GDR) of the antipsychotic medications risperidone and chlorpromazine were attempted, unless clinically contraindicated and documented in the medical record, in an effort to discontinue the drug; 2. For Resident #123, to ensure a GDR of the antipsychotic medication olanzapine was attempted, unless clinically contraindicated and documented in the medical record, in an effort to discontinue the drug; and 3. For Resident #87, to ensure a GDR of psychotropic medication was attempted, unless clinically contraindicated and documented in the medical record, in an effort to discontinue the drug. Findings include: Review of the facility's policy titled Psychotropic Medication Management, dated 4/15, included but was not limited to the following: -Each resident's drug regimen will be free from unnecessary drugs. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and review. -Review should include verification that adequate indications for use of the psychotropic medication exist, the medications are not being used for extended duration, and the residents are free of duplicate therapy and being monitored for adverse consequences, per professional standards of practice. Review of the facility's pharmacy policy titled Psychotropic Medication Management, revised 12/19, included the following: -If a Resident is admitted on an antipsychotic medication or the facility initiates antipsychotic therapy, the facility must attempt a GDR in two separate quarters within the first year, unless clinically contraindicated. After the first year, a GDR must be attempted annually. -A GDR is considered clinically contraindicated if target symptoms return or worse after most recent attempt of a GDR and the physician documents the clinical rationale for why any attempted dose reductions would impair the resident's function, or the continued use is in accordance with relevant current standard of practice and the physician documents the clinical rationale for why any attempted GDR would impair the resident's function. 1. Resident #1 was admitted to the facility in May 2019 with diagnoses which included epilepsy (seizure disorder), dementia, traumatic brain injury, and bipolar disorder. Review of the Physician's Orders included the following medications: Risperidone 2 milligrams (mg), dated 5/30/24 Chlorpromazine 25 mg, dated 5/29/24 Review of the medical record indicated Resident #87 was signed on to hospice services on 10/25/24. Further review of the medical record failed to indicate a GDR had been attempted in the previous 12 months. Review of the Minimum Data Set (MDS) assessment, dated 11/11/24, indicated the Resident did not have any symptoms of psychosis including delusions or hallucinations. On 12/20/24 at 12:45 P.M., the surveyor observed the Resident sitting in the hallway with his/her eyes open, quietly watching staff. On 12/23/24 from 10:28 A.M to 12:09 P.M., the surveyor observed the Resident sitting in the hallway in a reclining Broda chair (positioning chair) with no behavioral disturbances. Resident #1 was smiling and waving to staff as they passed by and occasionally closed his/her eyes. On 12/23/24 at 02:16 P.M., the surveyor observed the Resident being invited to attend an activity and nodded to attend in agreement. Resident #1 closed their eyes during the movie and slept in the dining room in a reclining Broda chair. During an interview on 12/24/24 at 8:23 A.M., Nurse #2 said the behavioral health service team will make psychotropic medication recommendations as well as the pharmacy. If it's not an emergency, we put the recommendations in a folder for the doctor to review. She said she was unsure if Resident #1 had a GDR attempted, she said he/she has had a physical decline and is on hospice services and has not had any symptoms of psychosis. During an interview on 12/24/24 at 11:36 A.M., the Director of Nurses (DON) said they have begun to review some residents beginning in October for GDRs as they were not previously being attempted for residents on antipsychotic medication. She said she could not provide evidence that a GDR was discussed or attempted for this Resident in the past year. 2. Resident #123 was admitted to the facility in January 2024 with diagnoses including but not limited to visual hallucinations and dementia. Review of the Physician's Orders indicated: Olanzapine 2.5 mg one time a day, dated 1/15/24 Olanzapine 7.5 mg one time a day, dated 1/15/24 Review of the MDS assessment indicated that the Resident scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident was cognitively intact. Further review of the MDS indicated that the Resident had no signs or symptoms of delirium. Review of the Resident's behavioral health notes indicated the following: no changes in medications were recommended. The Resident had no hallucinations/ paranoia/delusions and no combative or aggressive behaviors. Review of the nursing progress notes from June 2024 through December 2024 failed to indicate Resident #123 exhibited any behaviors or changes in mood. Further review of the medical record failed to indicate a GDR had been attempted since the Resident was admitted to the facility. During an interview on 12/24/24 at 8:23 A.M., Nurse #2 said she wasn't sure how GDRs were reviewed or attempted. She said that Resident #123 is very pleasant with behaviors that are easily redirectable. She was unsure if the Resident's antipsychotic medication had been reviewed for a GDR. During an interview on 12/24/24 at 11:36 A.M., the DON said they have begun to review some residents beginning in October for GDRs as they were not previously being attempted for residents on antipsychotic medication. She said she could not provide evidence that a GDR was discussed or attempted for this Resident in the past year. 36542 3. Resident #87 was admitted to the facility in June 2021 with a diagnosis of dementia, major depressive disorder, post-traumatic stress disorder, developmental disorder of scholastic skills, and traumatic brain injury. Review of the medical record indicated Resident #87 was admitted to hospice services on 3/1/24. Review of the care plans indicated Resident #87 had a Focus for psychotropic medications with Interventions including but not limited to review with the IDT (interdisciplinary team) for GDR as indicated. Review of the Physician's Orders included the following medications: Lorazepam (antianxiety) tablet 0.5 mg- twice per day (4/30/24) Melatonin (supplement to aid in sleep) 3 mg at bedtime (10/6/23) Olanzapine 5 mg in the morning (1/4/23) Olanzapine 2.5 mg twice per day (10/6/23) Sertraline (antidepressant) 25 mg once per day (7/12/23) Trazodone (antidepressant) 50 mg three times per day (7/11/23) Review of the December 2024 Medication Administration Record indicated Resident #87 did not have any behaviors on any shift from 12/1/24 through 12/24/24. During an interview on 12/19/24 at 1:22 P.M., the family member of Resident #87 said the Resident had been putting his/her head on the table for about a year and she was not sure if this was related to his/her mood, the Resident was on a lot of medication to manage his/her mood and she was not sure if the medications were making the Resident tired. The surveyor observed Resident #87 during the following days of survey: 12/19/24 at 10:06 A.M. in the unit day room with his/her head on the table, eyes closed 12/19/24 at 1:00 P.M. in unit day room with head on a pillow on the table 12/20/24 at 8:41 A.M. in unit day room, having breakfast, sitting up right 12/20/24 at 8:53 A.M. in unit day room with a baby doll on the table in front of him/her 12/20/24 at 9:31 A.M. resident with chin tucked to chest and eyes closed 12/20/24 at 10:00 A.M. in unit day room with face hovering over table and staff placed a pillow between the Resident and the table 12/20/24 at 12:59 P.M. in unit day room with head down on a pillow on the table, rubbing nose around in circles 12/20/24 at 1:18 P.M. Resident did not respond when Certified Nursing Assistant (CNA) asked Resident if they would like to go to bed 12/24/24 at 10:15 A.M. in bed sleeping 12/24/24 at 12:51 P.M. in unit day room, head leaning back and forth During an interview on 12/24/24 at 12:55 P.M., CNA #1 said Resident #87 refused care at times, but was easily redirected. She said the Resident mostly sits in the unit day room with his/her head down on the table, rubbing his/her face. She said Resident #87 did not exhibit any other behaviors. Review of the nursing progress notes from June 2024 through December 2024 failed to indicate Resident #87 exhibited any behaviors or changes in mood. Review of the Psychiatric Evaluation and Consultation notes indicated the Resident was seen by the consultant psychiatric Nurse Practitioner for an initial evaluation on 2/14/24. All notes were reviewed and indicated the following: 2/14/24: no acute psychiatric needs or worsening mood/behavior reported 4/12/24: Resident refusing to leave dining room; continue to monitor behaviors and redirect verbally; no changes are indicated 5/18/24: presents overall less agitated and more pleasant; no behaviors observed or reported this visit 6/22/24: presents overall less agitated and more pleasant; no behaviors observed or reported this visit 7/20/24: presents overall less agitated and more pleasant; no behaviors observed or reported this visit 8/17/24: presents overall less agitated and more pleasant; no behaviors observed or reported this visit 9/14/24: presents overall less agitated and more pleasant; no behaviors observed or reported this visit 10/12/24: presents pleasant with minimal agitation, semi-confused and suspicious at times; no behaviors observed or reported this visit 11/9/24: presents pleasant with minimal agitation, semi-confused and suspicious at times; no behaviors observed or reported this visit 12/7/24: presents pleasant with minimal agitation, semi-confused and suspicious at times; no behaviors observed or reported this visit Review of the hospice Plan of Care, dated 10/17/24, indicated Resident #87 was leaning forward and resting their head on the table, and even when repositioned, would rub his/her nose on the table in circles, with increased lethargy and sleeping and would spend an entire day in bed sleeping and the next day be up in a chair but still slept on and off with their head on the table. Review of the medical record failed to indicate a GDR had been attempted in the previous 12 months. During an interview on 12/20/24 at 1:53 P.M., the Hospice nurse said the Resident had recently been recertified for Hospice services. She said the Resident at baseline will sit in the unit day room with his/her head on the table rubbing their nose on the table or sleeping, which was why the Resident was provided with a pillow or towel. She said she had not reviewed the psychotropic medications for GDRs and did not realize the last change in medications occurred in October 2023, prior to signing on to hospice services. During an interview on 12/20/24 at 2:50 P.M., the DON said she reviewed the medical record for Resident #87 and there had been no attempts for a GDR in at least the last 12 months. During an interview on 12/24/24 at 11:32 A.M., the DON said the facility had been attempting to work on GDRs for residents, but Resident #87 had not been discussed at their IDT meetings.

Based on observations, record review, and interviews, the facility failed to maintain accurate medical records in accordance with professional standards and practices for four Residents (#58, #92, #79, and #90), out of 28 sampled residents. Specifically, the facility failed for Residents #58, #92, #79, and #90 to ensure that documentation of wound physician visits was part of the medical record in a timely manner. Findings include: Review of the facility's policy titled Thinning of the Clinical Record, dated September 2015, indicated the following records were to be maintained in the active clinical record: Consultations: Most current year with exception of a one-time only consult. 1. Resident #58 was admitted to the facility in February 2019 with diagnoses including traumatic brain injury and protein calorie malnutrition. Review of Resident #58's current Physician's Orders indicated but was not limited to: -Monitor dressing site: left foot dressing every shift, dated 12/19/24 -Monitor dressing site: right foot dressing every shift, dated 11/21/24 -Treatment order: Wash with wound cleanser, pat dry apply Iodosorb followed by dry protective dressing. Location: right 3rd toe and right 4th toe every day shift, dated 12/19/24 -Treatment order: Wash with wound cleanser, pat dry apply skin prep to peri wound followed by Iodosorb, cover with dry protective dressing. Location: left plantar, left 5th toe every day shift, dated 12/19/24 -Treatment order: Wash with wound cleanser, pat dry, apply skin prep to peri wound, apply adaptic followed by calcium alginate to wound bed and cover with gauze, wrap with Kerlix. Location: right foot web space between 4th and 5th toe, and right lateral foot every day shift, dated 12/26/24 During an interview on 12/20/24 at 10:41 A.M., Nurse #5 said Resident #58 was being followed by the consultant wound physician. The surveyor and Nurse #5 reviewed the medical record and could not locate the wound physician's documentation. Nurse #5 said the Infection Control Preventionist (ICP) made rounds with the wound physician and oversaw the wound program. Nurse #5 said the ICP must keep the wound physician's notes in her office. Review of Resident #58's wound physician's visit notes, provided to the survey team by the Assistant Director of Nurses (ADON), on 12/24/24 at 8:47 A.M., indicated the Resident had been seen on the following days: -12/16/24 -12/9/24 -12/2/24 -11/25/24 -11/18/24 -11/4/24 -10/21/24 -10/14/24 During an interview on 12/26/24 at 12:21 P.M., the ICP said Resident #58's medical record did not contain his/her wound physician's visit notes. The ICP said she had them in a folder in her office. The ICP said they should have been put in Resident #58's medical record. 50740 2. Resident #92 was admitted to the facility in April 2021. Review of the Minimum Data Set (MDS) assessment, dated 12/9/24, indicated Resident #92 had one Stage IV pressure injury and the Resident's care included the application of non-surgical dressings. Review of Resident #92's Physician's Orders indicated but was not limited to the following: -Treatment order: wash with wound wash, pat dry, apply skin prep to wound edge, apply calcium alginate, daily cover with foam dressing Location: sacrum as needed for drainage (9/5/24) - Treatment order: wash with wound wash, pat dry, apply skin prep to wound edge, apply calcium alginate, daily cover with foam dressing Location: sacrum every day and evening shift (9/5/24) Review of Resident #92's care plans indicated but was not limited to the following: Focus: Resident has a stg IV Pressure Ulcer Interventions: -Provide with a pressure relieving mattress -Signs of infection may include purulent drainage, swelling, increased pain, elevated temp, redness of wound, change in drainage. -Skin checks per facility protocol -Treatment as ordered Review of the medical record failed to include visits from the consultant wound physician for the last year. During an interview on 12/24/24 at 8:47 A.M., the ADON said the Wound Nurse (also the ICP) has kept the consultant wound physician's visit paperwork for the last year in her office. The surveyor was provided with the Resident's consultant wound physician visit documentation for the last year, which had not been included in the electronic or paper medical record. 36542 3. Resident #79 was admitted to the facility in October 2024. Review of the medical record indicated Resident #79 had large cysts to the right upper extremity and the right lower extremity. Review of the medical record indicated the Resident was followed by the Nurse Practitioner (NP) and the Primary physician. Review of the Physician Progress Note dated 12/2/24 indicated the right lower cyst had opened and was draining. Review of the medical record on 12/19/24 failed to indicate any current treatments, dressings or monitoring of the cysts on the right upper or lower extremities. During an interview on 12/24/24 at 8:47 A.M., the ADON said the Wound Nurse (also the ICP) has kept the consultant wound physician visit paperwork for the last year in her office. The surveyor was provided with a large stack of papers. During an interview on 12/24/24 at 10:44 A.M., the NP said Resident #79 was being followed by the consultant wound physician for the right upper and lower extremity cysts. Review of all wound consultant physician visits for the last year included wound consultant visits for Resident #79 on the following dates: 10/28/24, 11/11/24, 11/25/24, 12/9/24 and 12/16/24, which had not been included in the electronic or paper medical record. 4. Resident #90 was admitted to the facility in February 2021. Review of the medical record indicated Resident #90 had developed a pressure ulcer on 11/13/24. During an interview on 12/24/24 at 8:40 A.M., the ADON said the Wound Nurse (ICP) does wound rounds with the consultant wound physician on Mondays and the visit summaries are kept in the office of the Wound Nurse. Review of all wound consultant physician visits from the office of the Wound Nurse included wound consultant visits for Resident #90 on the following dates: 11/25/24, 12/2/24, 12/9/24 and 12/16/24, which had not been included in the electronic or paper medical record. During an interview on 12/26/24 at 10:05 A.M., the Wound Nurse (ICP) said the consultant wound physician comes to the facility on Mondays and then sends the visit summaries to her. She said she thought the consultant wound physician was uploading the visit summaries to the electronic medical record and had not realized that none of the visits had been uploaded this year.

Based on observation and interview, the facility failed to provide a clean and homelike environment for six Residents (#82, #93, #96, #59, #104, #54) on the [NAME] Unit. Specifically, the facility failed to provide the Residents with assistive devices (wheelchairs and walkers) that were maintained in a clean and comfortable manner and promptly addressed any repair needs as required. Findings include: Review of the facility's policy titled Rehabilitation Services Policy and Procedure Manual, dated 1/17, indicated but was not limited to the following: -Adaptive devices will be checked with each use. Needed replacement parts will be kept in inventory to ensure timely replacement. Tightening of nuts/bolts will be done when needed as will wiping off of tips to prevent slipping. -All equipment malfunctions are to be reported immediately to the Rehab Program Manager. The equipment will be tagged Do Not Use and stored in a non-patient treatment area until repaired. On 12/19/24 at 9:05 A.M., the surveyor observed the following during the initial tour of the [NAME] unit: -Resident #82's rolling walker had a right arm pad with an approximate 5-inch crack in the foam that was taped together to prevent the foam from falling off. -Resident #93's wheelchair had a loose armrest on the left-hand side along with a ripped seat back and ripped arm rest. -Resident #96's wheelchair had multiple rips in the fabric of the seat back exposing inside foam cushion. -Resident #59's wheelchair was labeled with another Resident's name, had a ripped seat back that was separating the fabric on the back of the wheelchair to the handles, with an observed frayed fabric. -Resident #104's wheelchair was fraying and loose on the seat back where it attached to wheelchair handles. There was an approximate 4-inch rip in the fabric of the wheelchair exposing yellow foam inside cushion. -Resident #54's wheelchair was missing a padded armrest on the left side of the chair. There was a metal bar where there should have been a cushion. Review of the [NAME] Unit's Maintenance Log on 12/19/24 at 2:03 P.M., indicated the last entry in the log was dated 12/6/24, and was not for any of the above Residents' items. During an interview on 12/23/24 at 5:11 P.M., Resident #82 said he/she has put tape along the arm cradle of the walker to prevent it from breaking off. Resident #82 said he/she requested glue from nursing staff to keep it in place more securely. During an interview on 12/24/24 at 8:32 A.M., Nurse #2 said the wheelchairs were not in good condition and she wasn't sure what the process was for routine repairs and upkeep. She said there is a wheelchair washing day, but someone should go around and review the condition of the chairs, some need to be replaced or repaired. She said Resident #59's wheelchair was labeled with another resident's name who was discharged over three months ago. During an interview with observation on 12/24/24 at 8:46 A.M., Rehab Staff #1 toured the unit with the surveyor and said she wasn't sure how the condition of this equipment was overlooked by facility staff. She said the wheelchairs with rips, loose parts, and holes should be replaced or repaired immediately. She said the wheelchairs and equipment should be clean, comfortable, and in good repair at all times.

Based on record review and interview, the facility failed to ensure that a required Preadmission Screening and Resident Review (PASARR) was completed for one Resident (#91) with a diagnosed mental condition, out of a total sample of 28 residents. Findings include: Resident #91 was admitted to the facility in January 2024 with diagnoses including bipolar disorder and alcohol abuse. Review of the Hospital Medical Intensive Care Unit (MICU) Admission Note, dated 1/1/24, indicated the Resident's past medical history included bipolar disorder and alcohol use disorder. Review of the Psychiatric Evaluation and Consultation for Resident #91, dated 2/19/24, indicated the Resident's diagnoses included bipolar disorder and alcohol abuse. Review of the Minimum Data Set (MDS) assessment for Resident #91, dated 12/3/24, indicated under Section I (Active Diagnoses) the Resident had bipolar disorder coded as an active diagnosis. Review of the medical record failed to indicate a Level 1 PASARR was completed for Resident #91. During an interview on 12/23/24 at 4:31 P.M., Social Worker #1 said that the facility's three social workers are responsible for completing the PASARR prior to or at the time of admission to the facility. Social Worker #1 and the surveyor reviewed Resident #91's record and confirmed the only PASARR in the record was completed in 2020 by another facility when he/she was admitted there. Social Worker #1 said another PASARR should have been completed for the Resident when he/she was admitted to this facility. During an interview on 12/23/24 at 5:04 P.M., Social Worker #1 said she confirmed with the PASARR agency that the Resident did not have a Level 1 PASARR completed upon admission to the facility.

Based on record review and interview, the facility failed to have a consistent medical order honoring Advanced Directives for two Residents (#1 and #123), in a total sample of 28 residents. Specifically, the facility failed: 1. For Resident #1, to ensure the physician's order and medical record for Advance Directives matched the court ordered directives; and 2. For Resident #123, to ensure the physician's order and medical record reflected the resident's executed Advance Directives. Findings include: 1. Resident #1 was admitted to the facility in [DATE]. Resident #1 has a legal guardian who is responsible for making healthcare decisions. Review of the medical record indicated Resident #1 was admitted to hospice services on [DATE]. Review of Resident #1's Physician's Orders indicated: Code Status: Full Code revised [DATE]. Review of the Resident's record indicated a decree to authorize the guardian to consent to the following Advanced Directives: Do Not Resuscitate (DNR) and Do Not Intubate (DNI), dated [DATE]. During an interview on [DATE] at 8:35 A.M., Nurse #6 said Resident #1's Advance Directives are a full code at this time. Nurse #6 reviewed the Advanced Directives in the physical chart and the electronic health record (EHR) and said they did not match. During an interview on [DATE] at 8:41 A.M., Unit Manager #1 said the Resident is a DNR/DNI due to the court's order. She said the resident's code status is a DNR and DNI. She said the information in the computer indicated the Resident was a full code. She said this was not accurate and should have been updated. During an interview on [DATE] at 10:14 A.M., Hospice Staff #1 said the Resident is a full code at this time. During an interview on [DATE] at 1:26 P.M., Unit Manager #1 said she would expect that the advanced directives in the physical chart and the EHR match. She said it could get confusing during an emergency if they do not match. During an interview on [DATE] at 1:32 P.M., the Director of Nurses (DON) said her expectation is the physician's orders should match the court decree form. She expects the EHR and the physical chart to have the same advanced directives documented. 2. Resident #123 was admitted to the facility in [DATE]. Review of Resident #123's physical chart indicated a Massachusetts Order for Life Sustaining Treatment (MOLST) form was completed on [DATE], and the Resident's Advance Directives indicated DNR/DNI. Review of Resident #123's Physician's Orders indicated: Code Status: Full Code/CPR, dated [DATE]. During an interview on [DATE] at 1:51 P.M., Unit Manager #1 said the Advance Directives should be the same in the physical chart and the EHR. She said she needed to update the physician's orders in the computer to match the MOLST form. She said it could be confusing in an emergency if there is conflicting information regarding the Advance Directives. During an interview on [DATE] at 1:32 P.M., the DON said when a MOLST is completed the nurse who receives the MOLST should update the physician's orders to match the Advance Directives signed by the physician. She said Resident #123's orders needed to be updated as they incorrectly reflected his/her current code status.

Based on interview and record review, the facility failed to notify the Resident's physician about changes in condition so as to re-evaluate the potential need to alter the treatment plan for one Resident (#90), from a total sample of 28 residents. Specifically, the facility failed to notify the primary physician of a new pressure ulcer in order to alter the treatment plan to prevent deterioration. Findings include: Resident #90 was admitted to the facility in February 2021. Review of the medical record indicated the Resident switched primary care physicians in October 2024. Review of the care plans for Resident #90 indicated the Resident was at risk for alterations in skin integrity related to weakness, poor safety awareness, and diabetes. Review of the current Physician's Orders indicated an order for triad paste (a zinc-oxide based sterile coating designed to manage low to moderate levels of exudate (drainage), while promoting a moist wound healing environment) to the coccyx (base of the spine, near the top of the buttocks) was implemented on 9/2/24. Review of the Pressure Injury Evaluation tool, dated 11/13/24 (locked 11/20/24), indicated Resident #90 had a new facility acquired, unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer on the coccyx. The pressure ulcer measured 2.5 centimeter (cm) in length by 1.8 cm in width by an unmeasurable depth with 100 percent (%) eschar (dead or devitalized tissue that is hard or soft in texture). The evaluation indicated this was the start of treatment and the comment section for treatment was blank. Further review of the Pressure Injury Evaluation tool, dated 11/13/24, indicated the physician and responsible parties were notified. Review of the Pressure Injury Evaluation tool, dated 11/20/24, indicated the unstageable pressure ulcer to the coccyx had 50% healthy tissue and 50% unhealthy tissue, noted as yellow to white. The Pressure Injury Evaluation tool indicated the physician was notified. Review of the Physician's Orders indicated a new treatment began on 11/21/24 for the coccyx. The treatment was to wash with wound cleanser, pat dry, apply Calcium Alginate to wound base and cover with a foam dressing. The treatment was electronically signed by the primary physician on 11/26/24. Review of the medical record on 12/24/24 failed to include any documentation from the consultant wound physician. During an interview on 12/24/24 at 8:39 A.M., the Assistant Director of Nurses (ADON) said the consultant wound physician visit notes were not kept in the medical record and were kept in the office of the Wound Nurse. During an interview on 12/26/24 at 10:05 A.M., the Wound Nurse said on 11/13/24 she was notified of a new pressure ulcer on the coccyx of Resident #90 and went and evaluated it. She said she notified a physician who said to continue the triad paste that had been in place since September 2024. She said she could not remember who she contacted and who ordered the continued Triad paste. She said there was no documentation to indicate who she spoke with. She said the wound changed between 11/13/24 and 11/20/24 but she did not know when because there was no additional documentation from nurses between the weekly Pressure Injury Evaluations. Review of Physician Progress Notes from 11/13/24 through 12/10/24 from the Nurse Practitioner and Primary Physician failed to indicate Resident #90 had a pressure ulcer. During an interview on 12/26/24 at 12:00 P.M., the surveyor inquired about the pressure ulcer for Resident #90 and the Nurse Practitioner replied, The what? The Nurse Practitioner said she had been providing care to the Resident since October 2024 and did not know the Resident had a pressure ulcer. She said she was in the facility twice per week and was on call for all interim needs. She said she had recently discovered that staff were initiating treatment orders without obtaining physician verification of orders. She said she wanted to be actively involved in resident care and wanted to be called to verify recommendations and treatments. During an interview on 12/26/24 at 12:28 P.M., the Primary Physician said she did not recall being told about the pressure ulcer for Resident #90. She said she does not take calls from the facility and calls for orders or treatments were deferred to the Nurse Practitioner, and she addressed issues if she was in the facility. She said she was not in the facility on 11/13/24 or 11/20/24. She said if she had known about the pressure ulcer, she would have documented it in her visit on 12/10/24. During an interview on 12/26/24 at 12:35 P.M., the Wound Nurse said her process was to call the physician following wound rounds, including identification of a new wound. She said she cannot remember who she called on 11/13/24 and who she contacted was not documented anywhere. During an interview on 12/26/24 at 2:10 P.M., the Director of Nurses (DON) said the physicians for Resident #90 are saying they were unaware of the pressure ulcer. She said the consultant wound physician sends their consults to the primary physician. Review of the consultant wound physician visit summaries (11/25/24, 12/2/24, 12/9/24 and 12/16/24) indicated the previous primary physician was notified and not the current physician who started caring for the Resident in October 2024. The DON said she had not noticed that the incorrect primary physician was designated on the visit summaries. She said there was no additional information to verify the physicians were notified of the pressure ulcer.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing at risk for falls, whose Plan of Care indicated he/she required physical assistance of two staff members with toileting, personal hygiene, dressing, bathing and turning side to side in bed, the Facility failed to ensure he/she was provided with the required level of staff assistance during care to maintain his/her safety, in an effort to prevent incidents/accidents resulting in an injury. On 09/26/23, 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, Resident #1 fell out of bed and landed on the floor on his/her left side. On 10/01/23, Resident #1 was noted with bruising to his/her left shoulder, and his/her left ankle was noted to be bruised and swollen. An x-ray was ordered and revealed a nondisplaced left distal tibial (along the length of the bone, below the knee and above the ankle) fracture. Resident #1 was transferred to the Hospital Emergency Department for evaluation, where an x-ray confirmed that he/she had a left tibial shaft fracture and was placed in a splint. Findings include: Review of the Facility's Policy, titled Falls Management, dated as revised August 2018, indicated the following: -the facility will utilize all resident related information mad available upon admission and ongoing to determine resident at-risk for fall status; -information includes: facility to facility referrals, hospital admission, discharge summary, nursing admission evaluation, rehabilitation screening and evaluation, fall risk evaluation; -a fall risk evaluation will be conducted on each resident upon admission, quarterly, significant change, annually and following a fall; -the Interdisciplinary Team (IDT) will develop, initiate and implement an appropriate individualized care plan based on the fall risk evaluation score; -residents who are identified to be at risk on the admission fall risk evaluation will have a fall risk care plan developed with the information made available at the time of admission to implement a safety related care plan; -resident can be screened/evaluated by the rehabilitation services; -residents who are identified to be at risk on subsequent fall evaluations will be evaluated in accordance with nursing, medical and rehabilitative needs; -a fall risk evaluation will be conducted by the nurse on duty/supervisor on any resident sustaining a fall with or without injury; -once resident is clinically evaluated as being stable, vital signs, neurological signs, range of motion and evaluation of cognitive status will be documented; -documentation for 72 hours to assess for latent injury. Resident #1 was admitted to the Facility in September 2017, diagnoses included anoxic brain damage, accidental unintentional poisoning by narcotics, chronic respiratory failure, convulsions and gastrostomy and tracheostomy status. Review of the Quarterly Minimal Data Set Assessment (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired, was totally dependent on the physical assistance of two staff members with transfers, dressing, hygiene, bathing, bed mobility and toileting. 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 dependent on the physical assistance of two staff members with dressing, grooming, bathing, toileting and turning side to side in bed. Review of Resident #1's Resident Care Card, (used as a reference guide by CNA's), dated September 2023, indicated he/she was dependent on the physical assistance of two staff members with toileting, personal hygiene, dressing, bathing, bed mobility and transfers. Review of the Facility's Internal Investigation Report, dated 10/05/23, indicated that on 9/26/23 Resident #1 had a fall from bed during care with no apparent injuries upon assessment. The Report indicated that on 10/01/23 during fall monitoring, staff observed bruising to Resident #1's left shoulder and ankle, the Physician was notified, and an x-ray was ordered. The Report indicated that the x-ray results revealed a left ankle fracture, the Physician was notified, and Resident #1 was transferred to the Hospital Emergency Department for evaluation. The Report indicated that Resident #1 returned from the Hospital Emergency Department where an x-ray confirmed that Resident #1 had sustained a left tibial shaft fracture, a splint was applied and an orthopedic consult was ordered. The Report indicated that staff was providing care to Resident #1 in bed, rolled him/her in bed, he/she coughed and he/she fell over the side of the bed. The Report indicated that the staff member received education and was removed from the schedule. Review of CNA #1's Written Witness Statement, dated 9/26/23, indicated that at approximately 10:00 A.M., she was providing care to Resident #1 in bed, turned him/her on his/her side, he/she started to cough and fell out of bed. During an interview on 10/25/23 at 11:50 A.M., Certified Nurse Aide (CNA) #1 said that on 09/26/23, she was providing personal care to Resident #1 in bed without the assistance of another staff member. CNA #1 said that she turned Resident #1 on his/her side, he/she coughed forcefully and fell out of bed onto the floor on his/her left side. CNA #1 said that she has taken care of Resident #1 before, was aware of his/her care needs that he/she required the assistance of two staff members with bed mobility, bathing and toileting and said she should not have provided personal care without the assistance of another staff member. CNA #1 said that she knew how to access Resident #1's Care Card. Review of a Nurse Progress Note, dated 09/26/23, written by the Assistant Director of Nurses (ADON), indicated that at approximately 10:00 A.M., staff alerted her that Resident #1 had fallen out of bed. The Note indicated that upon entering the room, Resident #1 was noted to be lying on the floor mats next to his/her bed on his/her left side. The Note indicated that Resident #1 was assessed for injuries, none were noted, and he/she was transferred back into bed with the assistance of three staff members and a hoyer lift (mechanical floor lift). During an interview on 10/25/23 at 2:11 P.M., the ADON said that on 9/26/23 she responded to a Code Dixie (internal code to alert staff that a resident has fallen, and staff assistance is needed) and was informed that Resident #1 had fallen out of bed. The ADON said that she went to assess Resident #1 and found him/her lying on his/her left side on the floor mat. The ADON said that Resident #1 did not have any visible injuries at that time, was calm without any signs or symptoms of pain. The ADON said Resident #1's range of motion was limited but that was his/her baseline due to contractures. The ADON said that Resident #1 is totally dependent on two staff members for all aspects of his/her care, said that CNA #1 provided care to Resident #1 without the assistance of another staff member and said Resident #1 was not provided the required level of staff assistance during care. Review of a Nurse Progress Note, dated 10/01/23, indicated that Nurse #2 noted bruising to Resident #1's left shoulder, his/her left ankle was bruised and swollen and had a recent fall on 9/26/23. The Note indicated that Resident #1 grimaced when his/her left extremity was moved, the physician was notified, an x-ray was ordered and revealed a nondisplaced left distal tibial (along the length of the bone, below the knee and above the ankle) fracture. The Note indicated that Resident #1 was transferred to the Hospital Emergency Department for evaluation. During a telephone interview on 10/27/23 at 12:19 P.M., Nurse #2 said that she went to administer medications to Resident #1 when she noticed a bruise to his/her left shoulder, his/her left ankle was bruised and swollen as well. Nurse #2 said that upon movement of his/her left extremity, Resident #1 grimaced, said she remembered that Resident #1 had a recent fall out of bed, said she notified the physician and an x-ray was ordered, Nurse #2 said that the x-ray revealed a fracture of the left distal tibia, said she reported the results to the physician and Resident #1 was transferred to the Hospital Emergency Department for evaluation. Review of the Hospital Emergency Department Discharge Summary, dated 10/01/23, indicated Resident #1 had sustained a fall at the Facility on Tuesday, 9/26/23 and subsequently noted to have bruising of the left shoulder and ankle later in the week. The Discharge Summary indicated that an x-ray was performed at the facility, showed a tibial fracture and Resident #1 was transferred to the Hospital Emergency Department. The Discharge Summary indicated that an x-ray was obtained at the Hospital Emergency Department which revealed a left tibial shaft fracture, a splint was applied to his/her left lower extremity and to follow up with orthopedics outpatient. During an interview on 10/25/23 at 3:15 P.M., the Director of Nurses (DON) said that Resident #1 is at risk for falls and is totally dependent on the physical assistance of two staff members with bed mobility, toileting, hygiene and all personal care. The DON said that CNA #1 provided personal care and turned Resident #1 in bed without the assistance of another staff member, Resident #1 fell out of bed and sustained a fracture of his/her left tibia as a result from the fall. The DON said Resident #1 was not provided the required level of staff assistance during care. On 10/25/23, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, the Plan of Correction is as follows: A) 9/26/23, Resident #1 was immediately assessed by Nursing, no visible injuries were initially observed and Nursing monitored Resident for any injuries after the fall. B) 9/26/23, CNA #1 was immediately educated by the Assistant Director of Nurses (ADON) to follow the plan of care for each resident, CNA #1 provided a statement and was removed from the schedule while the incident was investigated. C) 9/27/23, CNA #1 was again re-educated by the Director of Nurses (DON) about following each resident's plan of care prior to beginning her shift. D) 9/26/23 through 10/01/23, Nursing monitored Resident #1 for any injuries after the fall and documented the observations in his/her medical record. E) 10/01/23, Nursing observed bruising to Resident #1's left shoulder, bruising and swelling to Resident #1's left ankle and grimacing upon movement of his/her left extremity, sign of pain. MD was notified, an x-ray was obtained and revealed a fracture. Resident #1 was transferred to the Hospital Emergency Department, another x-ray was obtained which revealed a fracture of his/her left tibial shaft, a splint was applied to his/her left lower extremity. F) 10/02/23 through 10/09/23, the Director of Nurses, Assistant Director of Nurses and Staff Development Coordinator (SDC) conducted Educational In-services for nursing department staff on following the plan of care/care card when transferring residents, providing personal care and all aspects of care. G) 10/03/23 and 10/04/23, A Facility wide audit of all resident's Care Plans and Care Cards was completed by the DON, ADON and SDC. H) 10/03/23 and 10/04/23, All resident's Care Plans and Care Cards were updated by the DON and ADON to ensure they reflected their current status. I)10/09/23 and 10/16/23, the DON and ADON conducted random care observation audits to ensure staff are providing the level of assistance to residents during care according to their Care Plans and Care Cards. J) DON and ADON will continue to conduct random care observation audits weekly. K) Audits will be conducted weekly for three months or until substantial compliance is achieved. L) Results of the audits will be presented to the Quality Assurance Performance Improvement (QAPI) committee monthly for three months for patterns, trends and continued recommendations for process monitoring and improvement. M) The DON and/or Designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Plan of Care indicated he/she required physical assistance of two staff members with toileting, personal hygiene, dressing, bathing and turning side to side in bed, the Facility failed to ensure nursing staff consistently implemented and followed interventions from his/her Plan of Care while meeting his/her care needs. On 09/26/23, 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, Resident #1 fell out of bed and landed on the floor on his/her left side. On 10/01/23, Resident #1 was noted with bruising to his/her left shoulder, and his/her left ankle was noted to be bruised and swollen. An x-ray was ordered and revealed a nondisplaced left distal tibial (along the length of the bone, below the knee and above the ankle) fracture. Resident #1 was transferred to the Hospital Emergency Department for evaluation, where an x-ray confirmed that he/she had a left tibial shaft fracture and his/her left leg was placed in a splint. Findings include: Review of the Facility's Policy, titled Comprehensive Care Plan, dated as revised November 2017, indicated the following: -the facility is committed to providing residents with all necessary care and services to enable them to achieve the highest quality of life; -care plans are oriented toward preventing avoidable decline in clinical and functional levels and maintaining a specific level of functioning; -care plans are a combination of evaluations done by professionals and other disciplines, data concerning the resident obtained from the physician, clinical records, acute, chronic events, behaviors and/or illness; -the Interdisciplinary Team (IDT) develops a comprehensive care plan for each resident that includes measurable objectives and timelines to accommodate preferences, special medical, nursing and psychosocial needs identified. Resident #1 was admitted to the Facility in September 2017, diagnoses included anoxic brain damage, accidental unintentional poisoning by narcotics, chronic respiratory failure, convulsions and gastrostomy and tracheostomy status. Review of the Quarterly Minimal Data Set Assessment (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired, was totally dependent on the physical assistance of two staff members with transfers, dressing, hygiene, bathing, bed mobility and toileting. 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 dependent on the physical assistance of two staff members with dressing, grooming, bathing, toileting and turning side to side in bed. Review of Resident #1's Resident Care Card, (used as a reference guide by CNA's), dated September 2023, indicated he/she was dependent on and required physical assistance of two staff members with toileting, personal hygiene, dressing, bathing, bed mobility and transfers. Review of the Facility's Internal Investigation Report, dated 10/05/23, indicated that on 9/26/23 Resident #1 had a fall from bed during care with no apparent injuries upon assessment. The Report indicated that on 10/01/23 during fall monitoring, staff observed bruising to Resident #1's left shoulder and ankle, the Physician was notified, and an x-ray was ordered. The Report indicated that the x-ray results revealed a left ankle fracture, the Physician was notified, and Resident #1 was transferred to the Hospital Emergency Department for evaluation. The Report indicated that Resident #1 returned from the Hospital Emergency Department where an x-ray confirmed that Resident #1 had sustained a left tibial shaft fracture, a splint was applied and an orthopedic consult was ordered. The Report indicated that staff was providing care to Resident #1 in bed, rolled him/her in bed, he/she coughed and fell over side of bed. The Report indicated that the staff member received education and was removed from the schedule. Review of a Nurse Progress Note, dated 09/26/23, written by the Assistant Director of Nurses (ADON), indicated that at approximately 10:00 A.M., staff alerted her that Resident #1 had fallen out of bed. The Note indicated that upon entering the room, Resident #1 was noted to be lying on the floor mats next to his/her bed on his/her left side. The Note indicated that Resident #1 was assessed for injuries, none were noted, and he/she was transferred back into bed with the assistance of three staff members and a hoyer lift (mechanical floor lift). During an interview on 10/25/23 at 2:11 P.M., the ADON said that on 9/26/23 she responded to a Code Dixie (internal code to alert staff that a resident has fallen, and staff assistance is needed) and was informed that Resident #1 had fallen out of bed. The ADON said that she went to assess Resident #1 and found him/her lying on his/her left side on the floor mat. The ADON said that Resident #1 did not have any visible injuries at that time, was calm without any signs or symptoms of pain. The ADON said Resident #1's range of motion was limited but said that was his/her baseline due to contractures. The ADON said that Resident #1 is totally dependent on two staff members for all aspects of his/her care, said that CNA #1 provided care to Resident #1 without the assistance of another staff member and said that CNA #1 did not follow Resident #1's plan of care. Review of CNA #1's Written Witness Statement, dated 9/26/23, indicated that at approximately 10:00 A.M., she was providing care to Resident #1 in bed, turned him/her on his/her side, he/she started to cough and fell out of bed. During an interview on 10/25/23 at 11:50 A.M., Certified Nurse Aide (CNA) #1 said that on 09/26/23, she was providing personal care to Resident #1 in bed without the assistance of another staff member. CNA #1 said that she has taken care of Resident #1 before, said she was aware that he/she required the assistance of two staff members with bed mobility, bathing and toileting and said she should not have provided personal care without the assistance of another staff member. CNA #1 said that when she turned Resident #1 on his/her side, he/she coughed forcefully and fell out of bed onto the floor on his/her left side. CNA #1 said she did not follow Resident #1's plan of care, when she tried to provide care to him/her by herself. Review of a Nurse Progress Note, dated 10/01/23, indicated that Nurse #2 noted bruising to Resident #1's left shoulder, his/her left ankle was bruised, swollen and he/she had a recent fall on 9/26/23. The Note indicated that Resident #1 grimaced when his/her left extremity was moved, the physician was notified, an x-ray was ordered and revealed a nondisplaced left distal tibial (along the length of the bone, below the knee and above the ankle) fracture. The Note indicated that Resident #1 was transferred to the Hospital Emergency Department for evaluation. During a telephone interview on 10/27/23 at 12:19 P.M., Nurse #2 said that she went to administer medications to Resident #1 when she noticed a bruise to his/her left shoulder,and that his/her left ankle was bruised and swollen as well. Nurse #2 said that upon movement of his/her left extremity, Resident #1 grimaced, said she remembered that Resident #1 had a recent fall out of bed, so she notified the physician and an x-ray was ordered. Nurse #2 said that the x-ray revealed a fracture of the left distal tibia, said she reported the results to the physician and Resident #1 was transferred to the Hospital Emergency Department for evaluation. Review of the Hospital Emergency Department Discharge Summary, dated 10/01/23, indicated Resident #1 had sustained a fall at the Facility on Tuesday, 9/26/23 and subsequently noted to have bruising of the left shoulder and ankle later in the week. The Discharge Summary indicated that an x-ray was performed at the facility, showed a tibial fracture and Resident #1 was transferred to the Hospital Emergency Department. The Discharge Summary indicated that an x-ray was obtained at the Hospital Emergency Department which revealed a left tibial shaft fracture, a splint was applied to his/her left lower extremity and to follow up with orthopedics outpatient. During an interview on 10/25/23 at 3:15 P.M., the Director of Nurses (DON) said that Resident #1 is totally dependent on the physical assistance of two staff members with bed mobility, toileting, hygiene and all personal care. The DON said that CNA #1 provided personal care and turned Resident #1 in bed without the assistance of another staff member and Resident #1 fell out of bed and sustained a fracture of his/her left tibia as a result from the fall. The DON said that CNA #1 did not follow Resident #1's plan of care and said it was her expectation that staff follow the plan of care. On 10/25/23, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, the Plan of Correction is as follows: A) 9/26/23, Resident #1 was immediately assessed by Nursing, no visible injuries were initially observed and Nursing monitored Resident for any injuries after the fall. B) 9/26/23, CNA #1 was immediately educated by the Assistant Director of Nurses (ADON) to follow the plan of care for each resident, CNA #1 provided a statement and was removed from the schedule while the incident was investigated. C) 9/27/23, CNA #1 was again re-educated by the Director of Nurses (DON) about following each resident's plan of care prior to beginning her shift. D) 9/26/23 through 10/01/23, Nursing monitored Resident #1 for any injuries after the fall and documented the observations in his/her medical record. E) 10/01/23, Nursing observed bruising to Resident #1's left shoulder, bruising and swelling to Resident #1's left ankle and grimacing upon movement of his/her left extremity, sign of pain. MD was notified, an x-ray was obtained and revealed a fracture. Resident #1 was transferred to the Hospital Emergency Department, another x-ray was obtained which revealed a fracture of his/her left tibial shaft, a splint was applied to his/her left lower extremity. F) 10/02/23 through 10/09/23, the Director of Nurses, Assistant Director of Nurses and Staff Development Coordinator (SDC) conducted Educational In-services for nursing department staff on following the plan of care/care card when transferring residents, providing personal care and all aspects of care. G) 10/03/23 and 10/04/23, A Facility wide audit of all resident's Care Plans and Care Cards was completed by the DON, ADON and SDC. H) 10/03/23 and 10/04/23, All resident's Care Plans and Care Cards were updated by the DON and ADON to ensure they reflected their current status. I)10/09/23 and 10/16/23, the DON and ADON conducted random care observation audits to ensure staff are providing the level of assistance to residents during care according to their Care Plans and Care Cards. J) DON and ADON will continue to conduct random care observation audits weekly. K) Audits will be conducted weekly for three months or until substantial compliance is achieved. L) Results of the audits will be presented to the Quality Assurance Performance Improvement (QAPI) committee monthly for three months for patterns, trends and continued recommendations for process monitoring and improvement. M) The DON and/or Designee are responsible for overall compliance.

Based on observations, interviews, and records reviewed, for three Residents (#18, #78, and #97), of 27 sampled residents, the facility failed to ensure quality care was provided. Specifically, 1. For Resident #18, the facility failed to monitor, document, and assess the impaired skin on his/her left lateral ankle, resulting in cellulitis (a serious bacterial infection of the skin); 2. For Resident #78, facility staff moved the Resident with a broken hip off the floor and into a wheelchair prior to the arrival of emergency services; and 3. For Resident #97, the facility failed to follow physician's orders for wound treatments. Findings include: 1. Review of the facility's policy titled, Skin Care Non-Pressure Wound Assessment, undated, indicated but was not limited to: -The facility strives to provide the resident with high quality, consistent, timely wound assessments. If a resident presents with a venous, arterial or diabetic ulcer, the wound will be assessed on a weekly basis. Non-pressure alterations in skin integrity also include skin tears and post op surgical incisions. Ongoing monitoring and evaluation are provided to ensure optimal resident care outcomes. - Residents with non-pressure wounds (arterial, venous & diabetic ulcers, post op surgical incisions and skin tears) are assessed, documented and provided appropriate treatment to promote healing. Care Plans are developed based on individual resident's goals for treatment. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. Review of the facility's policy titled Weekly Body Audit, undated, indicated but was not limited to: -If an alteration in skin integrity (bruise, pressure injury, non-pressure wound, rash, abrasion, skin tear, reddened area, etc.) is discovered it will be documented on the Weekly Skin Audit form as soon as the nurse observes the area. Monitoring of the area will continue until the area is resolved. Resident #18 was admitted to the facility in June 2021 with the following diagnoses: diabetes mellitus, hypertension, muscle weakness, and an unstageable pressure ulcer of left ankle. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/21/23, indicated that Resident #18 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Throughout the survey the surveyor observed a bordered foam dressing on Resident #18's left lateral ankle. The bordered foam dressing had an area in the center that was torn and had faded writing; the surveyor was unable to determine what the writing indicated. The bordered foam dressing remained unchanged and was observed on Resident #18's left lateral ankle on the following days: -9/26/23 at 9:38 A.M. -9/27/23 at 11:47 A.M. -9/28/23 at 11:08 A.M. During an interview on 9/26/23 at 9:38 A.M., Resident #18 said he/she was not sure who put the dressing on his/her left lateral ankle or how long it had been there. Resident #18 said he/she was not sure what had happened. Review of Resident #18's Physician's Orders failed to indicate an order to monitor and/or treat impaired skin integrity to his/her left lateral ankle. Review of Resident #18's care plans included but was not limited to: -Focus: Resident has Potential Alteration in Skin integrity related to: decreased/impaired mobility or function, history of alteration in skin integrity, Location: buttocks, Etiology: moisture related dermatitis (resolved), Incontinence, Moisture, Risk Assessment -Goal: Skin will be free from infection, and skin will remain intact -Interventions: Complete skin condition at 24 hours and then weekly Further review of Resident #18's care plans failed to identify an area of impaired skin integrity to his/her left lateral ankle. Review of Resident #18's September Medication Administration Record (MAR) and Treatment Administration Record (TAR) failed to indicate his/her left lateral ankle had been monitored and/or treated. Review of Resident #18's September 2023 progress notes failed to indicate his/her left lateral ankle had been monitored and/or treated. Further review of Resident #18's September progress notes failed to address his/her skin integrity. Review of Resident #18's weekly skin audits indicated: -On 8/18/23 at 9:46 A.M., a new non-pressure skin impairment had been observed. The left lower extremity had a hematoma with fluid and the right lower extremity had a red scabbed area with small blisters/cellulitis. -On 8/23/23, no new skin impairments since the last review -On 8/30/23, no new skin impairments since the last review -On 9/9/23, no new skin impairments since the last review -On 9/16/23, no new skin impairments since the last review -On 9/25/23, no new skin impairments since the last review Review of Resident #18's Non-Pressure Wound Evaluation, effective date 8/18/23 at 1:08 P.M. (signed date of 9/8/23), indicated the non-pressure wound was healed and the skin was intact with no open areas noted. During an interview on 9/28/23 at 11:08 A.M., Resident #18 said he/she did not know the last time somebody had looked at his/her left lateral ankle. During an interview on 9/28/23 at 11:15 A.M., Nurse #3 said Resident #18 had an ulcer on his/her left ankle at one point, but it had healed and should be open to air. Nurse #3 said she was unaware Resident #18 had a dressing on his/her left lateral ankle. On 9/28/23 at 11:18 A.M., Nurse #3 and the surveyor entered Resident #18's room. Nurse #3 removed the bordered foam dressing from Resident #18's left lateral ankle which revealed a circular open area (approximately 1 centimeter (cm) length by 1 cm width in size with no measurable depth) with a moderate amount of serosanguinous drainage (a type of wound drainage secreted by an open wound in response to tissue damage) on the removed dressing. The skin surrounding the open area was dark pink, tender, and swollen. Nurse #3 said she needed to call the wound nurse to assess the wound and assist in updating the treatment plan. Nurse #3 said if a resident had impaired skin integrity the nurse who identified it should get orders to monitor and treat the area. During an interview on 9/28/23 at 11:27 A.M., Unit Manager #1 said she was unaware Resident #18 had a wound on his/her left lateral ankle. Unit Manager #1 said if there was no treatment ordered then the previous dressing had likely been there for a while. Unit Manager #1 said nurses should write orders for treatment and monitoring when a resident is discovered to have impaired skin integrity. During an interview on 9/28/23 at 12:38 P.M., the Director of Nurses (DON) said she was unaware Resident #18 had an open area on his/her left lateral ankle. The DON said Resident #18 had a history of impaired skin to the left ankle, but it had healed in March. The DON said there was no documentation to indicate Resident #18 had a current wound on his/her left lateral ankle and when a resident had an open area there should be an order for wound care. During an interview on 9/28/23 at 1:00 P.M., the Infection Control Nurse (whose responsibilities include functioning as the facility wound nurse) said she was not aware Resident #18 had impaired skin on his/her left lateral ankle and there were no orders in place for a dressing and/or monitoring. The Infection Control Nurse said a dressing should not have been in place without an order for treatment orders and monitoring. The Infection Control Nurse said she assessed Resident #18's left lateral ankle and was unable to determine the cause of the wound. The Infection Control Nurse said the open area was superficial, but it appeared that the Resident had cellulitis. The Infection Control Nurse said the wound would be assessed by the wound doctor next week but in the meantime Resident #18 should be started on antibiotics. Further review of Resident #18's medical record, specifically the Non-Pressure Wound Evaluation, dated 9/28/23, indicated there was a partial thickness left outer ankle wound that measured 1.1 cm length by 0.8 cm width with intact depth and pain upon palpation. The Wound Evaluation indicated the wound edge was unhealthy (irregular, rolled under, hard/indurated, or macerated) and the surrounding skin was unhealthy (red-warm-swollen-macerated/white or abraded/denuded). During an interview on 9/28/23 at 2:54 P.M., Nurse #3 said she had just received an order from the physician to start Resident #18 on Bactrim (an antibiotic used to treat infection) for his/her left lateral ankle until 10/8/23. Further review of Resident #18's medical record, specifically the nursing progress note, dated 9/28/23, indicated new orders for Bactrim DS (an antibiotic used to treat infection) twice daily for left outer ankle redness and warmth for 10 days and non-sting skin prep to open area on ankle had been obtained. Subsequent review of Resident #18's medical record, specifically the Wound Care Specialist note, dated 10/2/23, indicated a consult had been placed for the management of a left lower extremity wound and the Resident was on Bactrim for the wound until 10/8/23. The Wound Care Specialist identified the wound on Resident #18's left lateral ankle as a venous ulcer (a wound that takes longer than usual to heal and is related to impaired blood flow) and recommended daily and as needed dressing changes. 36542 2. Resident #78 was admitted to the facility in November 2020 with a diagnosis of dementia. Review of the medical record indicated on 8/20/23 Resident #78 fell and obtained a hip fracture. Review of the hospital emergency room Physician Report, dated 8/20/23, indicated Resident #78 was brought in by EMS (Emergency Medical Services) following a fall to the floor in which staff helped the Resident back up to get dressed. Resident was noted to have pain in the left femur/hip. Review of the facility Fall Incident Report for 8/20/23 indicated around 4:30 P.M. Resident #78 was ambulating on the unit when he/she had a mechanical fall in the hallway, reported pain and was sent out to the hospital for more evaluation. Review of the statement from Certified Nursing Assistant (CNA) #6 indicated before dinner on 8/20/23 Resident #78 was found on the floor in the hallway and the CNA reported it to the nurse. No additional information was available in the statement. Review of the statement from Nurse #5, dated 8/20/23, indicated the Nurse was on break when Resident #78 fell and was found on the floor. The statement indicated upon return to the unit patient assessment was made. Vitals stable. Patient reported pain in lower extremities. Patient is sent out for more evaluation. There was no additional information available in the statement. Review of the fall investigation failed to indicate any additional information including who moved Resident #78 off the floor and if a range of motion assessment was completed prior to moving the Resident from the floor. During an interview on 9/27/23 at 5:25 P.M., the Regional Nurse said there was one additional CNA (#8) who had worked on 8/20/23 and she had obtained a statement from him on this day. The Regional Nurse said she spoke with CNA #8, who was working on 8/20/23, and he said the nurse had instructed him to pick up Resident #78 from the floor. She said the nurses should be following the standard of practice to assess the Resident, including a range of motion assessment, prior to moving the Resident off the floor. Review of the statement from CNA #8 indicated Resident #78 fell (on 8/20/23) and the nurse instructed the CNAs to pick up the Resident from the floor. During an interview on 9/28/23 at 11:46 A.M., CNA #6 said she was working the evening Resident #78 fell and she had found the Resident in the hallway. She said the Resident was sitting up on the floor. She said she did not remember if the nurse had assessed the Resident but that the nurse had asked the staff to get the Resident off the floor and put the Resident in a wheelchair. She said the Resident then ate dinner in the wheelchair and the Resident did not have any complaints of pain during the transfer. She said when EMS arrived and attempted to move the Resident from the wheelchair to the stretcher the Resident yelled and could not transfer. She said she did not know why EMS was called if there had been no reports of pain prior to their arrival. During an interview on 9/28/23 at 1:43 P.M., Nurse #5 said she was on break and not on the unit when Resident #78 fell . She said she returned to the unit and the CNAs informed her the Resident had fallen. The Nurse said the CNAs had transferred the Resident to a wheelchair prior to her returning to the unit. She said when she returned, she knew something was wrong, attempted to do a range of motion assessment, and the Resident called out in pain. She said that was when she determined the Resident would go to the hospital and called for transport. She said the CNAs had said someone had told them to put Resident #78 in a wheelchair, but there had been no nurses on the unit at that time. During an interview on 9/28/23 at 4:50 P.M., CNA #8 said on 8/20/23 Resident #78 had fallen in the hallway. He said he could not remember if the nurse had come to see the Resident, but that was the process for the nurse to check the Resident before staff transferred the Resident from the floor. The CNA said he did not remember if Resident #78 was assessed by the nurse prior to being picked up from the floor. He said he assisted in putting Resident #78 in a wheelchair and did not recall the Resident having pain. He said he did not know why EMS would have been called if the Resident did not have any pain. During an interview on 9/29/23 at 10:51 A.M., the Director of Nurses said she did not have any additional information regarding Resident #78's fall including if the nurse provided range of motion to the Resident or when the pain was identified. She said the facility did not have a policy on what staff should do after a resident falls and that staff should follow the standard of practice to assess a resident prior to moving the resident. 3. Review of the facility's policy titled, Skin Care Non-Pressure Wound Assessment, undated, indicated but was not limited to: - Residents with non-pressure wounds (arterial, venous & diabetic ulcers, post op surgical incisions and skin tears) are assessed, documented and provided appropriate treatment to promote healing. Care Plans are developed based on individual resident's goals for treatment. Resident #97 was admitted to the facility in January 2022 with a diagnosis of Guillain-Barre syndrome (a neurological disorder causing muscle weakness and sometimes paralysis). Review of the most recent MDS assessment, dated 7/21/23, indicated Resident #97 was cognitively intact as evidenced by a BIMS score of 15 out of 15. Review of the medical record indicated Resident #97 developed a wound to the right groin area in September 2022. Review of the Non-Pressure Wound Evaluation, dated 9/20/23, indicated the wound to the right groin measured 12.3 centimeters (cm) in length by 6 cm wide by 0.4 cm in depth. Review of Resident #97's Treatment Administration Record (TAR) for September 2023 indicated on 9/5/23 an order was initiated to spray the right groin wound with wound cleanser, pat dry, apply barrier cream, followed by Aquacel, then an ABD dressing taped lightly in place, every day and night shift (once on the 7:00 A.M. to 3:00 P.M. shift and once on the 11:00 P.M. to 7:00 A.M. shift). During an interview on 9/27/23 at 11:08 A.M., Resident #97 said the nursing staff were not changing the dressing twice per day, that there were days the dressing was not changed at all, but mostly the dressing change to the wound was completed once per day. Review of the TAR indicated the wound treatment to the right groin had not been completed 10 out of 44 times. Review of the TAR indicated the wound treatment was not completed on either shift on 9/25/23. During an interview on 9/29/23 at 7:50 A.M., Unit Manager #2 said the treatments for all residents should be completed as ordered and that all nurses should be documenting when the orders were not complete and the reasons. During an interview on 9/29/23 at 10:35 A.M., the Director of Nurses said she was unaware the wound treatments were not being completed for Resident #97. She said the expectation was for nurses to communicate to the next shift nurse when/if they were not able to complete wound treatments.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure nursing staff provided care and services in accordance with professional standards of practice related to medication administration. When on 2/02/23, Resident #1, who did not have Physician ordered medications scheduled to be administered at 9:00 P.M., was administered another residents (Resident #3's) evening medications in error by Nurse #3, who did not follow Facility policy or adhere to nursing standards of practice when dispensing and administering medications to residents. Approximately one hour later, Resident #1 became extremely pale, difficult to arouse, his/her blood pressure and heart rate dropped, he/she was transferred to the Hospital Emergency Department (ED) for evaluation, and was admitted to the Intensive Care Unit (ICU) for treatment. Findings include: Standard Reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered and practical nurse incorporated into the plan of care, and implement prescribed medical regimens. The rules and regulations 9.03 defined standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Review of the Facility Policy titled, Medication Administration - Oral, dated June 2015, indicated the following: -Verify medication order on the medication administration record (MAR), check against physician order -Identify the resident -Avoid distractions and interruptions when preparing and administering medications -Only prepare one resident medication at a time -Compare the medication label to the resident's MAR -Verify that the medication is being administered at the proper time, in the prescribed dose and by the correct route -Document medications administration Resident #1 was admitted to the Facility in June 2009, diagnoses included spastic quadriplegic cerebral palsy, intellectual disabilities, microcephaly, gastrostomy status and epilepsy. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated , 1/06/22, indicated he/she was severely cognitively impaired and required total dependence of two staff members for activities of daily living. Review of Resident #1's Decree of Guardianship of Mentally Retarded Record, dated 7/20/1987, indicated he/she was incapable of caring for him/herself by reason of mental retardation. Review of Facility Medication Incident Report, dated 2/02/23 at 11:00 P.M., indicated Nurse #3 administered Resident #1 the wrong medications, that the medications were ordered for a resident with the same last name. Review of the Facility's Internal Investigation Report, dated 2/03/23, indicated that during the 3:00 P.M. to 11:00 P.M. shift (on 2/02/23), Resident #1 was given medications that were ordered for another resident (Resident #3) with a similar last name. The Report indicated that Resident #1 experienced a noted drop in blood pressure and was transferred to the Hospital (ED) for monitoring of hypotension (low blood pressure). The Report indicated that Resident #1 received the following medications in error: -Escitalopram (antidepressant) 20 milligrams (mg) -Trazadone (antidepressant) 50 mg -Clonidine (antihypertensive) 0.2 mg -Gabapentin (anticonvulsant) 800 mg -Suboxone (opioid narcotic, used to treat narcotic dependence) 8-2 mg -Clonazepam (benzodiazepine sedative) 2 mg -Melatonin (used to treat insomnia) 5 mg During an interview on 2/24/23 at 9:07 A.M., with Nurse #3, (which included a review of her written witness statement, dated 2/03/23, regarding Resident #1's medication error), Nurse #3 said that on 2/02/23 at 9:00 P.M., she was preparing Resident #3's medications at the medication cart, entered his/her room and found him/her asleep. Nurse #3 said Resident #3 did not wake up when she called his/her name and said rather than wake him/her up and possibly upset him/her, she wrote his/her last name on the medication cup and placed it in the top drawer of the medication cart. Nurse #3 said she continued on with her medication pass. Nurse #3 said she prepared Resident #1's roommate's evening medications and when she brought those medications into the room, she also brought in the medication cup (that contained Resident #3's medications) that was labeled with the same last name as Resident #1 with her. Nurse #3 said that she got distracted, was unfocused, and mistakenly thought that the medications in the cup labeled with the same last name as Resident #1 (but contained Resident #3's medications) were Resident #1's medications and said she administered them to Resident #1 in error. Nurse #3 said that when she left Resident #1's room, Resident #3 was in the doorway to his/her room waiting for his/her medications and said that was when she realized that she had administered Resident #3's medications to Resident #1 in error. Nurse #3 said that Resident #1 did not have any medications scheduled at 9:00 P.M., and that she had already administered Resident #1 his/her medications earlier in the evening. Nurse #3 said she could not explain why she administered medications to Resident #1 when she knew he/she did not have any medications ordered at 9:00 P.M. Nurse #3 said she usually prepares the medications of both residents, who are in the same room, at the same time. Nurse #3 said she labels the medication cups with their last name, and brings both medication cups into the room at the same time to save time on her medication pass. Nurse #3 said she did not look at Resident #1's MAR prior to administering him/her the medications and said she did not follow the Facility's policy regarding medication administration. During an interview on 2/22/23 at 11:58 A.M., the Nursing Supervisor said that Nurse #3 reported to her that she had administered the wrong medications to Resident #1. The Nursing Supervisor, who worked the following shift after the medication error occurred, said she monitored Resident #1's blood pressure and heart rate following the medication error. The Nursing Supervisor said that approximately an hour after the medication error, Resident #1 became extremely pale, was difficult to arouse and said his/her blood pressure and heart rate dropped. The Nursing Supervisor said that she notified the Physician and said Resident #1 was transferred to the Hospital ED for evaluation. Review of Resident #1's Medication Administration Record (MAR), dated for 2/02/23, indicated his/her Physician Orders for evening medications to be administered via his/her jejunostomy (surgical opening in the small intestine from outside the body, allowing placement of a feeding tube) included the following: -Levothyroxine (used to treat an underactive thyroid) 25 micrograms (mcg) tablet, give one tablet via jejunostomy tube (J-tube) at 6:00 P.M. -Docusate Sodium (used to treat constipation) capsule 100 mg, give one capsule via J-tube at 6:00 P.M. -Diazepam (benzodiazepine sedative) tablet 5 mg, give one tablet via J-tube at 6:00 P.M. Review of Resident #3's Medication Administration Record, dated 2/02/23, indicated his/her Physician's Orders for evening medication included the following: -Escitalopram (antidepressant) tablet 20 mg, give one tablet by mouth (PO) daily at 9:00 P.M. -Trazodone (antidepressant) tablet 50 mg, give one tablet PO at bedtime at 9:00 P.M. -Clonidine (antihypertensive) tablet 0.2 mg, give one tablet PO at 9:00 P.M. -Gabapentin (anticonvulsant) tablet 800 mg, give one tablet PO at 9:00 P.M. -Suboxone (opioid narcotic, used to treat opioid addiction) 8-2 mg, give one tablet sublingually (under the tongue) at 9:00 P.M. -Clonazepam (benzodiazepine sedative) tablet 2 mg, give one tablet PO at 9:00 P.M. -Melatonin (used to treat insomnia) tablet 5 mg, give one tablet PO at bedtime at 9:00 P.M. During an interview on 2/22/23 at 1:15 P.M., the Director of Nurses (DON) said Nurse #3 told her that she had pre-poured Resident #3's medications and left them in the top drawer of the medication cart labeled with his/her last name. The DON said that Nurse #3 said she administered Resident #3's medications, that were labeled with the same last name as Resident #1, in error, to Resident #1. The DON said that Nurse #3 did not follow the basic nursing practice of medication administration and said she did not follow the Facility's medication administration policy. Review of Resident #1's Hospital Discharge Summary, dated 2/03/23, indicated that at approximately 11:00 P.M. on 2/02/23, Resident #1 received another resident's medications. The Summary indicated that Resident #1 received Narcan (narcotic, can treat narcotic overdose in an emergency situation) 4 mg by Emergency Medical Services (EMS) en route to the emergency room with no appreciable improvement. The Summary indicated that Resident #1 was lethargic, had a depressed respiratory rate, was bradycardic (low heart rate) and received another dose of Narcan in the emergency room with no appreciable improvement. The Summary indicated that Resident #1 received atropine (used to treat a slow heart rate), intravenous fluids, and low dose neosynephrine (used to treat acute low blood pressure) for profound bradycardia, hypotension (low blood pressure) and first-degree AV Block (atrioventricular heart block) and was admitted to the Intensive Care Unit (ICU) for close monitoring.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure he/she was free from significant medication errors that adversely impacted his/her health. On 2/02/23, Resident #1, who did not have any Physician ordered medications to be administered at 9:00 P.M., was administered Resident #3's 9:00 P.M. medications by Nurse #3 in error. Approximately one hour later, Resident #1 became extremely pale, was difficult to arouse, and his/her blood pressure and heart rate dropped. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation and required admission to the Intensive Care Unit (ICU) for treatment and monitoring. Findings Include: Review of the Facility Policy titled, Medication Administration - Oral, dated June 2015, indicated the following: -Verify medication order on the medication administration record (MAR), check against physician order -Identify the resident -Avoid distractions and interruptions when preparing and administering medications -Only prepare one resident medication at a time -Compare the medication label to the resident's MAR -Verify that the medication is being administered at the proper time, in the prescribed dose and by the correct route -Document medications administration Resident #1 was admitted to the Facility in June 2009, diagnoses included spastic quadriplegic cerebral palsy, intellectual disabilities, microcephaly, gastrostomy status and epilepsy. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated , 1/06/22, indicated he/she was severely cognitively impaired and required total dependence of two staff members for activities of daily living. Review of Resident #1's Decree of Guardianship of Mentally Retarded Record, dated 7/20/1987, indicated he/she was incapable of caring for him/herself by reason of mental retardation. Review of Resident #1's Facility Medication Incident Report, dated 2/02/23 at 11:00 P.M., indicated Nurse #3 administered the wrong medications from a resident with the same last name. Review of the Facility's Internal Investigation Report, dated 2/03/23, indicated that on 2/02/23 on the 3:00 P.M. through 11:00 P.M. shift, Resident #1 was given the medications of another resident with a similar last name. The Report indicated that Resident #1 experienced a noted drop in blood pressure and was transferred to the Hospital for monitoring of hypotension (low blood pressure). The Report indicated that Resident #1 received the following medications in error: -Escitalopram (antidepressant) 20 milligrams (mg) -Trazadone (antidepressant) 50 mg -Clonidine (antihypertensive) 0.2 mg -Gabapentin (anticonvulsant) 800 mg -Suboxone (opioid narcotic, used to treat narcotic dependence) 8-2 mg -Clonazepam (benzodiazepine sedative) 2 mg -Melatonin (used to treat insomnia) tablet 5 mg Review of Resident #1's Hospital Discharge Summary, dated 2/03/23, indicated that at approximately 11:00 P.M. on 2/02/23, Resident #1 received another resident's medications. The Summary indicated that Resident #1 received Narcan (narcotic, can treat narcotic overdose in an emergency situation) 4 mg by Emergency Medical Services (EMS) en route to the emergency room with no appreciable improvement. The Summary indicated that Resident #1 was lethargic, had a depressed respiratory rate, was bradycardic (low heart rate) and received another dose of Narcan in the emergency room with no appreciable improvement. The Summary indicated that Resident #1 received atropine (used to treat a slow heart rate), intravenous fluids, and low dose neosynephrine (used to treat acute low blood pressure) for profound bradycardia, hypotension (low blood pressure) and first-degree AV Block (atrioventricular heart block) and was admitted to the Intensive Care Unit (ICU) for close monitoring. During an interview on 2/24/23 at 9:07 A.M., with Nurse #3 and review of Nurse #3's Written Witness Statement, dated 2/03/23, regarding the medication error on 2/02/23, indicated the following: Nurse #3 said that at 9:00 P.M., she was preparing Resident #3's medications at the medication cart, entered his/her room and found him/her asleep. Nurse #3 said that Resident #3 did not wake up when she called his/her name and said rather than wake him/her up and possibly upset him/her, she wrote his/her last name on the medication cup and placed it in the top drawer of the medication cart. Nurse #3 said she continued on with her medication pass. Nurse #3 said she prepared Resident #1's roommate's medications and when she brought in the roommates medications into the room, she also brought in the medication cup (containing Resident #3's medications) that was labeled with the same last name as Resident #1 with her. Nurse #3 said that she got distracted, was unfocused, and mistakenly thought that the medications in the cup (which she had dispensed to administered to Resident #3, who had the same last name as Resident #1) that they were Resident #1's medications and said she administered them to Resident #1 in error. Nurse #3 said that when she left Resident #1's room, Resident #3 was standing in the doorway to his/her room waiting for his/her medications and said that was when she realized that she had administered Resident #3's medications to Resident #1 in error. Nurse #3 said that Resident #1 did not have any medications scheduled to be administered at 9:00 P.M., that his/her medications are administered earlier in the evening. Nurse #3 said she could not explain why she administered medications to Resident #1 when she knew he/she did not have any medications ordered at 9:00 P.M. Nurse #3 said she usually prepares the medications of both residents, who are in the same room, at the same time. Nurse #3 said she labels the medication cups with the residents last name, and brings both medication cups into the room at the same time to save time on her medication pass. Nurse #3 said she did not look at Resident #1's MAR prior to administering him/her the medications and said she did not follow the Facility's medication administration policy. During an interview on 2/22/23 at 11:58 A.M., the Nursing Supervisor said that on 2/02/23, Nurse #3 reported to her that she had administered the wrong medications to Resident #1. The Nursing Supervisor, who worked the following shift after the medication error occurred, said she monitored Resident #1's blood pressure and heart rate following the medication error. The Nursing Supervisor said that approximately an hour after the medication error, Resident #1 became extremely pale, was difficult to arouse and said his/her blood pressure and heart rate dropped. The Nursing Supervisor said that she notified the Physician and said Resident #1 was transferred to the Hospital ED for evaluation. Review of Resident #1's Medication Administration Record (MAR), dated for 2/02/23, indicated his/her Physician Orders for evening medications to be administered via his/her jejunostomy (surgical opening in the small intestine from outside the body, allowing placement of a feeding tube) included the following: -Levothyroxine (used to treat an underactive thyroid) 25 micrograms (mcg) tablet, give one tablet via jejunostomy tube (J-tube) at 6:00 P.M. -Docusate Sodium (used to treat constipation) capsule 100 mg, give one capsule via J-tube at 6:00 P.M. -Diazepam (benzodiazepine sedative) tablet 5 mg, give one tablet via J-tube at 6:00 P.M. Review of Resident #3's Medication Administration Record, dated 2/02/23, indicated his/her Physician's Orders for evening medication included the following: -Escitalopram (antidepressant) tablet 20 mg, give one tablet by mouth (PO) daily at 9:00 P.M. -Trazodone (antidepressant) tablet 50 mg, give one tablet PO at bedtime at 9:00 P.M. -Clonidine (antihypertensive) tablet 0.2 mg, give one tablet PO at 9:00 P.M. -Gabapentin (anticonvulsant) tablet 800 mg, give one tablet PO at 9:00 P.M. -Suboxone (opioid, narcotic used to treat narcotic dependence) 8-2 mg, give one tablet sublingually (under the tongue) at 9:00 P.M. -Clonazepam (benzodiazepine sedative) tablet 2 mg, give one tablet PO at 9:00 P.M. -Melatonin (used to treat insomnia) tablet 5 mg, give one tablet PO at bedtime at 9:00 P.M. During an interview on 2/22/23 at 1:15 P.M., the Director of Nurses (DON) said Nurse #3 told her that she had pre-poured Resident #3's medications and left them in the top drawer of the medication cart labeled with his/her last name. The DON said that Nurse #3 said she administered Resident #3's medications, that were labeled with the same last name as Resident #1, in error to Resident #1. The DON said that Nurse #3 did not follow the basic nursing practice of medication administration and said she did not follow the Facility's medication administration policy.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required the use of adaptive equipment, (an air mattress which included an air mattress cover), the Facility failed to ensure staff inspected the air mattress cover for wear and tear, that the air mattress cover straps were secured and intact, in an effort to maintain a safe environment to prevent incidents or accidents that could result in injury. On 11/29/21, Resident #1 had an unwitnessed fall out of bed and was found on the floor with half of the bed air mattress cover underneath him/her. The straps that held the air mattress cover onto the air mattress, were found to be torn and frayed, and could not hold the air mattress cover securely in place over the air mattress. Resident #1 sustained an acute left femoral head dislocation, an abrasion to the left forehead, a skin tear to the right lateral elbow, a bruise to the right hip bone and right side of face. Findings include: Review of the SUPRA APL Air Mattress Overlay/Replacement Mattress Operating Manual, undated, indicated to read all instructions before use. The Manual indicated to use the straps at the end of the mattress and stretch them around the mattress to prevent it from unraveling and to check the mattress cover for signs of wear or damage. Resident #1 was admitted to the Facility in March 2021, medical diagnoses included pathological fracture of left hip, dementia and [CONDITION(S)]. A Quarterly Minimum Data Set (MDS) Assessment, dated 10/13/21, indicated that Resident #1 had severe cognitive impairment, contractures of the lower extremities and required extensive assist of one staff member for bed mobility. Review of Resident #1's Fall Risk Assessment, dated 10/08/21, indicated that he/she was at high risk for falls. Review of the Facility's Internal Investigation, dated 11/29/21, indicated that Resident #1 had an unwitnessed fall out of bed and that the strap that holds the air mattress cover in place was torn and the air mattress cover was noted half off the bed. The Investigation indicated that Resident #1 stated that he/she just fell out of bed and that he/she sustained an abrasion to the left forehead, a skin tear to the right lateral elbow, a bruise to the right hip bone and right side of face. The Investigation indicated that equipment failure was a contributing factor, that faulty straps caused the air mattress cover to slide off the bed (air mattress), and caused Resident #1 to fall onto the floor. Review of a Nurse Progress Note, dated 11/29/21 at 5:21 A.M., indicated that a Certified Nurse Aide (CNA #1) heard a startling noise from an area close to Resident #1's room and noted that he/she was lying on his/her back on the floor. The Note indicated that Resident #1 was crying and stated I just fell out. The Note indicated that Resident #1 complained of mid and lower back pain and confirmed that he/she hit his/her head on the side of bed as his/her body rolled onto the floor. The Note indicated that bright red blood was dripping from the left side of his/her forehead, he/she had a skin tear to his/her right lateral elbow and a bruise to the right hip. The Note indicated that a torn strap on the air mattress cover with little threading holding two straps together, caused the air mattress cover to slide off the bed. The Note indicated that the Physician was notified and ordered a STAT x-ray. Review of a bilateral hip and pelvis X-ray Report, dated 11/29/21, indicated Resident #1 had an acute left femoral head dislocation and soft tissue swelling. Review of a Nurse Progress Note, dated 11/29/21 at 3:32 P.M., indicated that Resident #1 was transferred to the Hospital due to a fall resulting in a dislocated femur. Review of a Nurse Progress Note, dated 11/30/21, indicated that Resident #1 returned from the Hospital at 12:45 A.M. with a diagnosis of chronic left total hip dislocation, that an attempted closed reduction (procedure for treating a hip dislocation without surgery, using manipulation of thigh bone (femur) to put the hip back in place) was not successful and that the Health Care Proxy (HCP) elected to avoid open surgery for now. The Note indicated that Resident #1 complained of an 8/10 pain in his/her left hip and was medicated with oxycodone 10 milligrams (opioid narcotic used to relieve severe pain). Review of a Hospital Discharge Instructions, dated 11/29/21, indicated that Resident #1 had a chronic left total hip dislocation, an attempted closed reduction was not successful and HCP elected to avoid open surgery for now, with pain control as needed. During an interview on 12/13/21 at 11:15 A.M., Nurse #1 said that on 11/29/21 at 3:00 A.M., CNA #1 heard a startling noise coming from Resident #1's room and notified her. Nurse #1 said that when she entered Resident #1's room, he/she was lying on the right side of the bed on the floor with blood coming from the left side of his/her forehead. Nurse #1 said that upon further assessment, Resident #1 had a bruise to the right hip area, a skin tear to his/her right elbow and said he/she complained of back pain. Nurse #1 said that Resident #1 was found lying on the air mattress cover and said that half of the air mattress cover slid off the bed with Resident #1 on it and said the other half of the air mattress cover was still on the bed. Nurse #1 said that the straps to the air mattress cover were all frayed and torn, said that the air mattress cover slid off the bed with Resident #1 and said the air mattress cover was not secured to the air mattress. During an interview on 12/13/21 at 12:40 P.M., the Director of Maintenance said that he is notified by nursing when a resident requires an air mattress. The Director of Maintenance said that he checks the air mattresses to make sure that the mattress holds air and makes sure that the air mattress is set per the weight of the resident. The Director of Maintenance said that when an air mattress is delivered to a resident, he sets up the mattress cover and makes sure the straps are intact. The Director of Maintenance said that the Facility does not have a preventative maintenance program for air mattresses. The Director of Maintenance said that nursing is responsible for the settings of the air mattress and is responsible for inspecting the air mattress cover and making sure the mattress cover is not defective or in disrepair after the air mattress is delivered to the resident. The Director of Maintenance said that if an air mattress becomes defective or in disrepair, nursing notifies him and he replaces the air mattress. The Director of Maintenance said, after the incident, nursing notified him that Resident #1's air mattress cover was torn and said that when he inspected Resident #1's air mattress cover, the straps to the air mattress cover were broken off the air mattress cover. During an interview on 12/13/21 at 2:13 P.M., the Director of Nurses (DON) said that Resident #1 was on an air mattress and said that the air mattress cover was ripped, that the air mattress cover straps were frayed and said that the air mattress cover slid off the bed with Resident #1. The DON said that they follow the manufacturer's recommendations for maintaining the air mattress cover. The DON said that her expectation is that nursing checks that the air mattress cover is intact and checks the integrity of the air mattress and cover when they check the air mattress for placement and function.

Based on observation, interview, and schedule review, the facility 1) Failed to maintain sufficient staffing to monitor the oral intake and weights for three Residents (#50, #66, #93) resulting in weight loss; 2) Failed to ensure there was clinical staff present to assure resident safety for one Resident (#128); 3) Failed to ensure there was sufficient staff available to provide nursing services and the adequate care required to meet the residents' needs and; 4) Failed to maintain sufficient staff to provide assistance with feeding and timely meal service, out of a total sample of 30 residents. Findings include: Review of the Facility Assessment Tool, dated January 2021, included but was not limited to the following: Resources needed to provide competent support and care for our resident population every day and during emergencies: Nursing: - [NAME] Unit: 0.5 Unit Manager, 1 Nurse (all three shifts), 4 Certified Nursing Assistants (CNAs) (first and second shift), and 1 CNA overnight - Mayflower: 1 Unit Manager, 2 Nurses (all three shifts), 6 CNAs (first and second shift), and 2 CNAs overnight - Hopkins: 0.5 Unit Manager, 1 Nurse (all three shifts), 3 CNAs (first and second shift), and 2 CNAs overnight - [NAME]: 0.5 Unit Manager, 1 Nurse (all three shifts), 5 CNAs (first and second shift), and 2 CNAs overnight - [NAME]: 0.5 Unit Manager, 1 Nurse (all three shifts), 3 CNAs (first and second shift) and 2 CNAs overnight 1A. Resident #50 was admitted to the facility in May 2019 with a history of [CONDITION(S)] [CONDITION(S)] and aspiration pneumonia. Review of the Nutrition Assessment, dated 11/9/21, indicated Resident #50 would meet their nutrition needs through food by mouth and a feeding tube, while maintaining a stable weight. The assessment indicated the last weight obtained for the resident was on 10/13/21 for 138 pounds (lbs.). Review of the Minimum Data Set (MDS) assessment, dated 8/13/21, indicated Resident #50 required a supervision level of eating with oversight, encouragement or cueing. Review of the resident care card indicated Resident #50 was on aspiration precautions, was to be provided continual supervision in a one to eight (1:8) ratio, and ate in the main dining room. Review of the Speech Therapy Discharge Summary, dated 10/29/20, indicated a good prognosis with consistent staff follow through, a plan of taking liquids through teaspoon, alternating of liquids and solids, upright posture during meals and upright posture for at least 30 minutes after meals and to have 1:8 continual supervision for swallowing and self-feeding. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/4/21 at 11:00 A.M., the surveyor observed Resident #50 lying in bed. The Resident's breakfast tray was on the overbed table with individual cups of untouched puree eggs, hot cereal, and a light brown substance. There were two Styrofoam cups on the tray with thickened liquids, one of them half empty, and no other items on the tray had been touched. On 11/5/21 at 9:49 A.M., the surveyor observed Resident #50 lying in bed. The Resident's breakfast tray was on the overbed table, the cup of eggs was empty, the hot cereal was untouched, and another brown substance was untouched. The Resident had a large cup of thickened orange juice that had not been consumed. The Resident was not observed to be out of bed and there were no staff providing supervision. On 11/5/21 at 1:24 P.M., the surveyor observed Resident #50 with his/her eyes closed with the lunch tray on the overbed table. At 1:45 P.M., the Resident was observed to be sitting up, eyes open, and not eating. At 1:54 P.M., the Resident was observed to be sitting up, not eating, and there was no staff there for supervision. During an interview on 11/5/21 at 2:32 P.M., Certified Nursing Assistant (CNA) #6 said staff had not been monitoring meal intake and they were unsure who needed supervision with eating. She said there were not enough staff to take care of all of these residents. She said there was a list of seven residents on the [NAME] unit who needed assistance with feeding and Resident #50 was not one of them. She said they did not monitor intake when picking up the meal trays after the meal. During an interview on 11/12/21 at 9:00 A.M., Registered Dietitian (RD) #1 said Resident #50 received nutrition through food by mouth, house supplements, and through a feeding tube to support the nutritional goals. She said the staff should be monitoring the meal intake of this resident as the supplemental support of drinks and the feeding tube were determined based on the Resident's meal intake, but there was not enough staff to monitor meal intake. She said she was not aware Resident #50 had not been eating, was not aware the Resident had not been receiving the house supplement as ordered, and had not been notified when less than 50% was consumed. She said the Resident should have been weighed weekly, but there was not enough staff to monitor the weights. RD #1 said a weight was obtained for Resident #50 on 11/11/21 and the Resident weighed 129.2 lbs., a loss of 6.38% in one month. B. Resident #66 was admitted to the facility in August 2021 with a history of traumatic [CONDITION(S)] and required a feeding tube. Review of the medical record for Resident #66 included a Medical Nutrition Therapy assessment dated [DATE]. The assessment indicated a diet of [MEDICATION(S)] 1.5, 390 milliliters (ml) bolus four times per day for a total of 1560 ml per day, and water 240 ml four times per day, a weight of 168 lbs. on 10/13/21, and indicated the weight had no significant changes for 30 days. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . As of 11/12/21, the last weight in the medical record was obtained on 10/13/21. Review of the October 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the November 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/12/21 at 8:53 A.M., RD #1 said Resident #66 was supposed to be weighed weekly and the last weight was one month prior. She said there was not enough staff to obtain the weights and, therefore, the weight was unable to be monitored for changes. During an interview on 11/12/21 at 12:26 P.M., RD #1 said Resident #66 was weighed on 11/12/21 and weighed 158.5 lbs., a loss of 5.65% in one month. C. Resident #93 was admitted to the facility in June 2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #93 included a Medical Nutrition Therapy assessment dated [DATE]. The assessment indicated a diet of [MEDICATION(S)] 1.5 at a rate of 63 ml per hour until 1323 ml were infused, a weight of 130.9 lbs. on 8/24/21, and indicated the weight had stabilized. Review of an RD's progress note, dated 10/4/21, indicated Resident #93's weight was 129.8 lbs. and was stable. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #93 was readmitted to the facility in October 2021. Review of the electronic medical record on 11/10/21 indicated the last weight obtained for Resident #93 was on 10/1/21 of 129.8 lbs. Review of the MAR for October 2021 indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .M., and off the following 4:00 P.M. A review of the October 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/12/21 at 8:38 A.M., RD #1 said Resident #93 was supposed to be weighed weekly and, due to the lack of staffing, the weights had not been obtained on a regular basis. She said she was unaware the ordered feedings had not been signed off as administered for eight days in October 2021. During an interview on 11/12/21 at 12:25 P.M., RD #1 said Resident #93 had a current weight of 122.3 lbs., indicating a weight loss of 5.78% since the previous weight on 10/1/21. 2. Resident #128 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 10/4/21, indicated Resident # 128 required extensive assist with toileting and locomotion on the unit, and used a walker and wheelchair. Review of the Falls Care Plan, initiated 9/23/20, indicated Resident #128 was at risk for a fall related injury due to traumatic [CONDITION(S)] with right [CONDITION(S)], [CONDITION(S)] disorder, [CONDITION(S)] in the left eye, neurocognitive disorder with aggression and agitation, and impulse control disorder. The goal was Resident #128 would not sustain a fall related injury by utilizing fall precautions. Interventions to achieve this goal were as follows: - Continual supervision while ambulating in hallways - Provide/monitor use of adaptive devices; walker and wheelchair with assist Review of the clinical record indicated Resident #128 sustained 13 falls between February 2021 and November 2021 without major injury. Seven of the falls were unwitnessed, and six were witnessed. The Resident was transferred to the emergency room for further evaluation after one of the 13 falls. On 11/8/21 at 8:33 A.M., the surveyor observed Resident #128 walk out of his/her room down the hall to the nurses' station unsupervised without a walker. His/her right foot was catching/dragging on the floor and caused him/her to stumble multiple times. Nurse #7 instructed Resident #128 to go back to his/her room, but did not supervise or assist the Resident. On 11/15/21 at 8:28 A.M., the surveyor observed Resident #128 ambulating without assistance in his/her room. He/she then walked out of his/her room down the hall to the nurses' station unsupervised without a walker. His/her right foot was catching/dragging on the floor and caused him/her to stumble multiple times. Nurse #15 was in a resident's room. CNA #16 was passing breakfast trays. No other staff was present at the time. Resident #128 remained standing at the nurses' station and then walked back to his/her room without assistance. Nurse #15 exited another resident's room and asked the surveyor who Resident #128 was and did not assist him/her back to his/her room. Review of the Mayflower North Unit nursing schedules for the months of August 2021 through November 2021 indicated the following: 8/11/21 fall at 11:00 A.M. - 1 nurse, 2 CNAs 9/16/21 fall at 6:13 P.M. - 1 nurse, 1 CNA 10/5/21 fall at 6:15 P.M. - 1 nurse, 1 CNA 11/6/21 fall at 3:02 P.M. - 1 nurse, 2.5 CNAs During an interview on 11/16/21 at 10:41 A.M., Nurse #5 said Resident #128 was very impulsive and non-compliant and was worried he/she would sustain a serious injury from falls. She further said usually there was only one nurse and one aide working each shift. Nurse #5 said there was not enough staff to continually supervise Resident #128 to keep him/her safe, especially if she was in another resident's room and could not hear his/her feet shuffling. By that time, she said, it would be too late. During an interview on 11/15/21 at 4:13 P.M., the Director of Nurses (DON) said, You cannot expect the staff to continually supervise if you only have one nurse and one aide. 3A. During an interview on 11/5/21 at 2:30 P.M. CNA #6 said there was not enough staff on the unit to get the residents out of bed and the staff was doing the best they could to keep the residents washed. She said the CNAs were unable to complete any documentation regarding their care of the residents. B. On 11/12/21 at 1:00 P.M., the surveyor observed CNA #13 assisting Resident #136 with eating. Resident #136 was observed to continue to try to stand up from the chair. CNA #13 and CNA #9 were then observed to recline Resident #136 in the Geri-chair and continue to feed him/her. On 11/12/21 at 1:12 P.M., the surveyor heard CNA #13 say to CNA #5 that she felt she could not leave Resident #136 alone, reclined in the Geri-chair because he/she was going to fall. The surveyor observed the Resident attempting to lift his/her trunk from the reclined chair. The surveyor heard CNA #5 respond that Resident #136 was probably going to fall as it had happened before and it would happen again. On 11/12/21 at 1:18 P.M., the surveyor observed Resident #136 reclining in the Geri-chair and rocking back and forth attempting to get out of the chair. The regional Food Service Director ran over to the Resident and called CNA #9 over for assistance. CNA #9 said someone needed to sit with Resident #136, but there was not enough staff. C. During an interview on 11/8/21 at 3:53 P.M., Nurse #5 said approximately twice a month she received a call at the end of her shift at 3:00 P.M. that she was being mandated to stay because the facility did not have enough staff. She said it was very last minute and was not ready for it. Nurse #5 further said the facility had a difficult time getting agency staff because the facility was not paying their bills and agency staff did not want to work there if they were not getting paid. D. During an interview on 11/9/21 at 7:59 A.M., the surveyor observed Nurse #18 sitting at the nurses' station on Mayflower North unit. She said her shift was supposed to end at 7:00 A.M. and was sitting there waiting for the day nurse to arrive. She said it was her first day working at the facility from an agency and tried calling the staff scheduler who did not answer. She said no one had called to confirm staffing for the shift and did not know who else to call. The surveyor observed two aides working on the unit. During an interview on 11/9/21 at 8:10 A.M., Nurse #18 said the staff scheduler called and said a nurse would arrive from another unit as the scheduled day nurse had worked a double yesterday and was not supposed to be on the schedule. On 11/9/21 at 8:43 A.M., the surveyor observed Nurse #18 giving report to Nurse #7 who had arrived from the [NAME] Unit. E. During an interview on 11/10/21 at 9:36 A.M., Minimum Data Set (MDS) Nurse said there was one licensed nurse and two CNAs on the [NAME] Unit for the 7:00 A.M. to 3:00 P.M. shift. She said she was new to the facility at the start of the COVID-19-19-19-19-19-19-19-19-19-19-19 outbreak in September and she was told to work on the unit that shift instead of her role as an MDS nurse due to lack of staffing. She said she was not oriented to the unit, but a corporate nurse was on the unit overseeing her care of the residents. 4A. On 11/9/21, the Mayflower North unit had one nurse, two CNAs, and another CNA who worked from 7:00 A.M. to 9:00 A.M. on the 7:00 A.M. to 3:00 P.M. shift. On 11/9/21 at 8:17 A.M. the breakfast meal trays arrived to the Mayflower North unit. On 11/9/21 at 8:43 A.M., the surveyor observed Resident #83 lying in bed waiting for his/her breakfast tray. Two CNAs were observed passing trays. Another CNA was answering call bells until 9:00 A.M. Nurse #18 was giving morning report to Nurse #7 who arrived from another unit. On 11/9/21 at 8:48 A.M., the surveyor observed Resident #6 lying in bed waiting for his/her breakfast tray. On 11/9/21 at 9:04 A.M., the surveyor observed CNA #17 deliver Resident #6's breakfast tray, 48 minutes after the food truck arrived to the unit. CNA #17 set the tray down on the Resident's overbed tray table, which was not within reach of the Resident, and exited the room. She walked down the hall then back entering the room next door to Resident #6 to answer a call bell. She exited the room then reentered to provide direct care to a resident. On 11/9/21 at 9:10 A.M., the surveyor observed Resident #83 had not received his/her breakfast tray yet. During an interview on 11/9/21 at 9:10 A.M., the surveyor asked CNA #2 if all the trays were delivered. She said yes and that the food truck was empty, but when CNA #12 looked inside, Resident #83's tray was in there. CNA #12 said she was only working 7:00 A.M. to 9:00 A.M. to answer call bells and had not assisted with delivering the breakfast trays. CNA #2 said there was not enough staff helping to deliver trays that day leaving only two CNAs to do so, and did not know Resident #83's tray was still in the food truck until CNA #12 looked. On 11/9/21 at 9:15 A.M., Resident #83's tray was delivered, 58 minutes after the food truck arrived on the unit. On 11/9/21 at 9:17 A.M., the surveyor observed CNA #17 return to Resident #6's room to assist with his/her feed, 13 minutes after the tray was first delivered to the Resident and one hour after the food truck arrived to the unit. During an interview on 11/9/21 at 9:17 A.M., CNA #17 said she was not sure if Resident #6's food was still warm and he/she was non-verbal. She proceeded to feed Resident #6. CNA #17 said they did not have enough staff helping to pass trays that day while also helping two residents who were feeds. CNA #17 said usually there was more help. During an interview on 11/9/21 at 9:21 A.M., Nurse #7 said she did not help pass the breakfast trays that morning because it was hard for her to do that if she was on the medication cart. During an interview on 11/9/21 at 9:24 A.M., Resident #83 said the French toast was cold when he/she put the syrup on it. During an interview on 11/10/21 at 11:01 A.M., Nurse #5 said on a normal day there was only one nurse and one aide with a census of 28-31 residents and there was not enough staff working in the kitchen. She further said there was no help and not enough staff to provide care to the residents. She said five residents were very demanding and she was frequently pulled away from the medication cart to answer call bells resulting in a delay of medication administration times. During an interview on 11/15/21 at 4:25 P.M., the DON said the delayed meal service and delayed assistance with feeding was unacceptable and there should have been more staff to assist in passing the trays. She further said there was a staffing concern and she had to assign more staff to help. B. On 11/5/21 at 12:34 P.M., the surveyor observed the lunch meal trays arrive on the [NAME] unit. At 12:56 P.M. three staff started passing the meal trays. During an interview on 11/5/21 at 2:00 P.M., CNA #11 said the staff were unsure which residents needed assistance with eating. The last lunch tray was distributed at 2:05 P.M. (90 minutes after it arrived on the unit). On 11/5/21 at 2:26 P.M., the surveyor observed both residents in room [ROOM NUMBER] to have their lunch trays on their overbed tables with the covers still on them. CNA #5 went into room [ROOM NUMBER] to retrieve the meals. During an interview, CNA #5 said neither resident had eaten their meals and had not been offered assistance with eating as they were not known to need assistance. CNA #5 said no one had asked either resident why they were not eating the food. During an interview on 11/5/21 at 2:30 P.M., CNA #6 said there was not enough staff on the unit to provide meals timely and offer feeding assistance to those not listed as needing assistance. C. On 11/12/21 the [NAME] unit had 31 residents, one desk nurse, one medication cart nurse, and three CNAs. On 11/12/21 at 12:37 P.M., the surveyor observed the meal trays arrive on the [NAME] unit. The meal trays were passed starting at 12:47 P.M. through 1:34 P.M. by two CNAs. The medication nurse was observed to be giving medications at that time, the desk nurse was observed to be sitting at the nurses' station and one CNA was assisting a resident with eating. During an interview on 11/12/21 at 1:26 P.M., CNA #5 said there was not enough staff to pass the meal trays on time. D. On 11/5/21 the [NAME] unit had 36 residents, one nurse, and three CNAs. On 11/5/21 at 10:21 A.M., the surveyor observed CNA #11 bring a resident their breakfast. The CNA said the resident needed assistance with eating and the staff had just noticed the resident had not been given his/her breakfast meal. During an interview on 11/5/21 at 10:23 A.M., CNA #6 said there were seven residents who needed assistance with eating and only three CNAs and that was why they were unable to get their meals to them on time. During an interview on 11/4/21 at 4:30 P.M., the scheduler said there had been a lack of staffing in the facility for at least two months. She said she had been working with one staffing agency. She said she contacted additional agencies this week and last week, but had not contacted them prior. She said when she contacted the agencies they were unable to provide staffing due to lack of payment from the facility ownership to the agencies. She provided a list of 13 staffing agencies that were contacted over the past two weeks, despite a staffing shortage for months During an interview on 11/15/21 at 11:09 A.M., the scheduler said, I do not agree with the staffing. She said since July, she was lucky to get two aides per shift and by September she was lucky if she only got one. She said she was unable to get enough staff to work from the facility, sister facility, or agencies and facility staff were overworked with many holes left unfilled. During an interview on 11/16/21 at 1:50 P.M., the Administrator said she was aware that staffing agencies were unable to send staff to the facility due to outstanding bills and the facility was not operating at their designated staffing ratios identified in their facility assessment. She said the operating company/ownership handled all accounts payable.

Based on observations, interviews, record reviews, and policy review, the facility failed to ensure five Residents (#50, #66, #93, #29 and #110) maintained their nutritional status, out of a total sample of 30 residents. Specifically, 1. For Resident #50, the facility failed to ensure the resident received A.) adequate nutrition through food by mouth; B.) tube feeding as ordered; and C.) house supplement as ordered to maintain nutritional status; 2. For Resident #66, the facility failed to ensure a bolus feed and water were administered as ordered and weights were obtained weekly to ensure monitoring of any changes; 3. For Resident #93, the facility failed to ensure tube feedings were administered as ordered and weights were obtained weekly to monitor for changes, as ordered; 4. For Residents #29 and #110 the facility staff failed to ensure weights were obtained weekly to ensure monitoring of any changes. Findings include: 1. Resident #50 was admitted to the facility in May 2019 with a history of [CONDITION(S)] [CONDITION(S)] and aspiration pneumonia. Review of the Nutrition Assessment, dated 11/9/21, indicated Resident #50 would meet their nutrition needs through food by mouth and a feeding tube, while maintaining a stable weight. The assessment indicated the last weight for the Resident was 138 pounds (lbs.) obtained on 10/13/21. A.) Review of the Minimum Data Set (MDS) assessment, dated 8/13/21, indicated Resident #50 was a supervision level of eating with oversight, encouragement or cueing. A review of the resident care card indicated Resident #50 was on aspiration precautions, was to be provided continual supervision in a one to eight (1:8) ratio, and ate in the main dining room. Review of the Care Plans indicated a focus of a swallowing difficulty with interventions including continual supervision during meals, provide safe swallow strategies of feeding slowly, alternating solids and liquids, small bites and sips, discouragement from talking during meals/snacks, and provide verbal/tactile cues when necessary to get Resident to swallow. Review of the Speech Therapy Discharge Summary, dated 10/29/20, indicated Resident #50 tolerated 75-100% of meal without overt signs or symptoms of aspiration. The Discharge Summary included a good prognosis with consistent staff follow through, a plan of taking liquids through teaspoon, alternating of liquids and solids, upright posture during meals and upright posture for at least 30 minutes after meals and to have 1:8 continual supervision for swallowing and self-feeding. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/4/21 at 11:00 A.M., the surveyor observed Resident #50 lying in bed; the Resident's breakfast tray was on the overbed table, with individual cups of untouched puree eggs, hot cereal and a light brown substance. There were two styrofoam cups on the tray with thickened liquids, one of them half empty, no other items on the tray had been touched. On 11/5/21 at 9:49 A.M., the surveyor observed Resident #50 lying in bed; the Resident's breakfast tray was on the overbed table, the cup of eggs was empty, the hot cereal was untouched, and another brown substance was untouched. The Resident had a large cup of thickened orange juice that had not been consumed. The Resident was not observed to be out of bed and there was no staff providing supervision. On 11/5/21 the surveyor observed: - At 1:24 P.M., Resident #50 with his/her eyes closed with the lunch tray on the overbed table. - At 1:45 P.M., Resident #50 sitting up, eyes open, not eating. - At 1:54 P.M., Resident #50 sitting up, not eating, there was no staff there for supervision. During an interview on 11/5/21 at 2:32 P.M., Certified Nursing Assistant (CNA) #6 said the staff had not been monitoring meal intake and they were unsure who needed supervision with eating. She said there was not enough staff to take care of all of these residents. She said there was a list of seven residents on the [NAME] unit who needed assistance with feeding and Resident #50 was not one of them. She said they did not monitor intake when picking up the meal trays after the meal. During an interview on 11/9/21 at 1:52 P.M., the Director of Rehabilitation said Resident #50 was to be served with individual meal items in small bowls and to eat with a teaspoon with supervision. She said the Resident was to be supervised to ensure he/she was using the teaspoon to decrease the risk of aspiration. She said Resident #50 may not have been eating his/her meals because he/she was not in the main dining room and seeing other residents eat as a cue for him/her to eat. B. Resident #50 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the October 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/9/21 at 12:30 P.M., the surveyor observed a 1000 ml feeding tube bottle of [MEDICATION(S)] 1.5 labeled 11/6/21 with approximately 500 ml left in the bottle. A feeding on 11/6/21, 11/7/21, and 11/8/21 should have administered 875 ml, with 175 ml left in the bottle, a difference of 325 ml. On 11/10/21 at 9:28 A.M., the surveyor observed the same feeding tube bottle, dated 11/6/21, to have approximately 225 ml left in the bottle, indicating the Resident was fed 275 ml as ordered on 11/9/21. Review of the precautions listed on the bottle of [MEDICATION(S)] 1.5 cal, observed by the surveyor to be hanging at the beside of the Resident on 11/10/21, indicated to hang product for up to 48 hours after initial connection. The decrease in the amount of feeding in the bottle on 11/10/21 indicated the bottle dated 11/6/21 had been used on 11/9/21, three days after it was hung. On 11/12/21 at 3:35 P.M., the surveyor observed a new 1000 ml [MEDICATION(S)] 1.5 bottle to be connected, which was dated 11/10/21 at 10:00 P.M. with 825 ml left in the bottle. If Resident #50 had been fed as ordered, on 11/10/21 225 ml would have been used from the bottle dated 11/6/21 and 50 ml would have been used from the bottle dated 11/10/21; then on 11/11/21 Resident #50 would have been fed 275 ml for a total of 325 ml from the bottle dated 11/10/21; which would have left 675 ml in the bottle that the surveyor observed on 11/12/21, a difference of 150 ml. C. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M., 2:00 P.M., 6:00 P.M., and to contact the physician and dietitian if less than 50% was consumed. Review of the MARs indicated: - September 2021, the house supplement was not provided 36 out of 90 times; - October 2021, the house supplement was not provided 51 out of 93 times; and - November 2021 (11/1/21 through 11/10/21), the house supplement was not provided 19 out of 27 times. During an interview on 11/12/21 at 9:00 A.M., Registered Dietitian (RD) #1 said Resident #50 received nutrition through food by mouth, house supplements and through a feeding tube to support the nutritional goals. She said the staff should be monitoring the meal intake of this Resident as the supplemental support of drinks and the feeding tube are determined based on the Resident's meal intake, but there was not enough staff to monitor meal intake. She said she was not aware Resident #50 had not been eating, was not aware the Resident had not been receiving the house supplement as ordered, and had not been notified when less than 50% was consumed. She said the Resident should have been weighed weekly but there was not enough staff to monitor the weights. She said her assessment of Resident #50 completed on 11/9/21 had been based on a weight from the previous month. RD #1 further said a weight was obtained for Resident #50 on 11/11/21 and the Resident weighed 129.2 lbs., a significant loss of 6.38% in one month. 2. Resident #66 was admitted to the facility in August 2021 with a history of traumatic [CONDITION(S)] and required a feeding tube. Review of the medical record for Resident #66 included a medical nutrition therapy assessment dated [DATE]. The assessment indicated a diet of [MEDICATION(S)] 1.5, 390 milliliters (ml) bolus four times per day for a total of 1560 ml per day, and water 240 ml four times per day, a weight of 168 pounds (lbs) on 10/13/21 and indicated the weight had no significant changes for 30 days. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record on 11/12/21 indicated the last weight was obtained on 10/13/21. Review of the October 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M., 10/8/21 at 12:00 P.M., 10/13/21 at 12:00 P.M., 10/14/21 at 6:00 P.M., 10/16/21 at 6:00 P.M., 10/17/21 at 12:00 P.M., 10/18/21 at 6:00 P.M., 10/19/21 at 12:00 A.M. and 6:00 A.M., 10/21/21 at 12:00 P.M., 10/26/21 at 6:00 A.M., 12:00 P.M., 6:00 P.M., 10/28/21 at 12:00 P.M., 10/29/21 at 6:00 P.M., and 10/31/21 at 12:00 P.M. and 6:00 P.M. Review of the October 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M., 10/8/21 at 12:00 P.M., 10/13/21 at 12:00 P.M. 10/14/21 at 6:00 P.M., 10/15/21 at 6:00 P.M., 10/16/21 at 6:00 P.M., 10/17/21 at 12:00 P.M., 10/18/21 at 6:00 P.M., 10/19/21 at 12:00 A.M. and 6:00 A.M., 10/21/21 at 12:00 P.M., 10/26/21 at 6:00 A.M., 12:00 P.M., 6:00 P.M., 10/28/21 at 12:00 A.M., 6:00 A.M., 12:00 P.M., 6:00 P.M., 10/29/21 at 6:00 P.M., and 10/31/21 at 6:00 A.M., 12:00 P.M. and 6:00 P.M. Review of the November 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and 6:00 P.M., 11/4/21 at 12:00 P.M., and 11/9/21 at 12:00 P.M. Review of the November 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and 6:00 P.M., 11/4/21 at 12:00 P.M., and 11/9/21 at 12:00 P.M. On 11/12/21 at 8:13 A.M., the surveyor observed Resident #66 lying in bed. There was a bottle of [MEDICATION(S)] 1.5 on the nightstand. The bottle was dated 11/11/21 at 6:00 P.M. and there was approximately 400 ml gone from the bottle (one feeding). During an interview on 11/12/21 at 8:14 A.M., Resident #66 said he/she was hungry and had not received the bolus feed this morning (6:00 A.M.). During an interview on 11/12/21 at 8:53 A.M., RD #1 said Resident #66 was supposed to be weighed weekly and the last weight was one month prior. She said she was unaware staff was not signing off as administering the bolus feeds of Resident #66 and had not been checking the MAR. During an interview on 11/12/21 at 9:00 A.M., Unit Manager #2 said the bolus feed should be signed off for each feeding and if it was not signed off there was no way to determine if the Resident was fed. During an interview on 11/12/21 at 12:26 P.M., RD #1 said Resident #66 was weighed on 11/12/21 and weighed 158.5 lbs., a loss of 5.65% in one month (a significant weight loss). The RD said she had met with the Resident who informed her that he/she had feelings of hunger at times. She said the Resident should have been weighed weekly to monitor for any changes. 3. Resident #93 was admitted to the facility in June 2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #93 included a medical nutrition therapy assessment dated [DATE]. The assessment indicated a diet of [MEDICATION(S)] 1.5 at a rate of 63 milliliters (ml) per hour until 1323 ml were infused, a weight of 130.9 pounds (lbs) on 8/24/21, and indicated the weight had stabilized. Review of an RD's Progress Note, dated 10/4/21, indicated Resident #93's weight was 129.8 lbs and was stable. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #93 was readmitted to the facility in October 2021. A review of the electronic medical record on 11/10/21 indicated the last weight obtained for Resident #93 was on 10/1/21 of 129.8 lbs. Review of the MAR for October 2021 indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and off the following 4:00 P.M. A review of the October 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/16/21 at 11:00 A.M., the Director of Nurses said if the feedings were not documented then it is assumed they were not done. During an interview on 11/12/21 at 8:38 A.M., RD #1 said Resident #93 was supposed to be weighed weekly and due to the lack of staffing the weights had not been obtained on a regular basis. She said she was unaware the ordered feedings had not been signed off as administered for eight days in October 2021. During an interview on 11/12/21 at 12:25 P.M., RD #1 said Resident #93 had a current weight of 122.3 lbs, indicating a significant weight loss of 5.78% since the previous weight on 10/1/21. The RD said the staff should have been obtaining weights for the resident weekly to monitor for weight loss to implement interventions prior to a significant weight loss. 4a. Review of the Facility's Weights Policy, dated August 2015, indicated the following residents are weighed weekly x 4: -newly readmitted residents (unless clinically not indicated) -residents with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -thereafter, residents will be weighed monthly, unless clinically indicated Resident #29 was readmitted to the facility in October 2021. Review of a Nutrition Note, dated 10/11/21, indicated Resident #29 was readmitted to the facility and his/her most recent weight was 162.7 lbs from 8/10/21. The note also indicated the Resident had inadequate meal intakes. Review of Resident #29's medical record, under Weights and Vitals Summary, indicated the following weights, but was not limited to: -162.7 lbs on 8/10/21 -no readmission weight -no weekly weights following readmission Review of the November 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/16/21 at 8:43 A.M., RD #1 said Resident #29 had not been weighed since 8/10/21, when he/she weighed 162.7 lbs. She said the nurse had just weighed Resident #29 twice and his/her current weight was 148.2 lbs. She further said the Resident should have been weighed weekly, but was not, so she was unaware of the 14.5 lb weight loss. b. Resident #110 was readmitted to the facility in July 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the November 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #110's medical record, under Weights and Vitals Summary, indicated the following weights, but was not limited to: - 148 lbs, on 7/21/21, six days after readmission - 148 lbs on 8/11/21 - no weights recorded after 8/11/21 During an interview on 11/16/21 at 9:21 A.M., RD #1 said Resident #110 had not been weighed since 8/11/21, when he/she weighed 148 lbs. She said a nurse had just weighed Resident #110, and his/her current weight was 137 lbs, which was an 11 lb. weight loss. She further said the Resident should have been weighed weekly, but was not, so she was unaware of the weight loss. During an interview on 11/16/21 at 2:12 P.M., RD #1 said that Residents #29 and #110 had not been weighed weekly as ordered by the physician, and/or at least monthly, as per facility policy. She further said without Residents' weights it is not possible to properly assess and monitor the Residents' nutritional status, and implement interventions as needed. Each time weights were not recorded, RD #1 said she asked the nurse, but was told there was not enough nursing staff to weigh the residents, and they had to prioritize things.

Based on observations, interviews, and record review, the facility failed to ensure enteral nutrition and fluids provided via a gastrostomy tube (G-tube- a feeding tube in abdomen used to provide nutrition) were provided in accordance with professional standards and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Resident #50 was admitted to the facility in May 2019 with a history of [CONDITION(S)] [CONDITION(S)] and aspiration pneumonia. Review of the Nutrition Assessment, dated 11/9/21, indicated Resident #50 would meet their nutrition needs through food by mouth and a feeding tube, while maintaining a stable weight. The assessment indicated the last weight for the Resident was 138 pounds (lbs.) obtained on 10/13/21. A) Review of the Minimum Data Set (MDS) assessment, dated 8/13/21, indicated Resident #50 was a supervision level of eating with oversight, encouragement or cueing. A review of the resident care card indicated Resident #50 was on aspiration precautions, was to be provided continual supervision in a one to eight (1:8) ratio and ate in the main dining room. Review of the Care Plans indicated a focus of a swallowing difficulty with interventions including continual supervision during meals, provide safe swallow strategies of feeding slowly, alternating solids and liquids, small bites and sips, discouragement from talking during meals/snacks, and provide verbal/tactile cues when necessary to get resident to swallow. Review of the Speech Therapy Discharge Summary, dated 10/29/20, indicated Resident #50 tolerated 75-100% of meal without overt signs or symptoms of aspiration. The Discharge Summary included a good prognosis with consistent staff follow through, a plan of taking liquids through teaspoon, alternating of liquids and solids, upright posture during meals and upright posture for at least 30 minutes after meals and to have 1:8 continual supervision for swallowing and self-feeding. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/4/21 at 11:00 A.M., the surveyor observed Resident #50 lying in bed; the Resident's breakfast tray was on the overbed table, with individual cups of untouched puree eggs, hot cereal and a light brown substance. There were two styrofoam cups on the tray with thickened liquids, one of them half empty, no other items on the tray had been touched. On 11/5/21 at 9:49 A.M., the surveyor observed Resident #50 lying in bed; the Resident's breakfast tray was on the overbed table, the cup of eggs was empty, the hot cereal was untouched and another brown substance was untouched. The Resident had a large cup of thickened orange juice that had not been consumed. The Resident was not observed to be out of bed and there was no staff providing supervision. On 11/5/21 the surveyor observed: - At 1:24 P.M., Resident #50 with his/her eyes closed with the lunch tray on the overbed table; - At 1:45 P.M., Resident #50 sitting up, eyes open, not eating; - At 1:54 P.M., Resident #50 sitting up, not eating; there was no staff there for supervision. During an interview on 11/5/21 at 2:32 P.M., Certified Nursing Assistant (CNA) #6 said the staff had not been monitoring meal intake and they were unsure who needed supervision with eating. She said there was not enough staff to take care of all of these residents. She said there was a list of seven residents on the [NAME] unit who needed assistance with feeding and Resident #50 was not one of them. She said they did not monitor intake when picking up the meal trays after the meal. During an interview on 11/9/21 at 1:52 P.M., the Director of Rehabilitation said Resident #50 was to be served with individual meal items in small bowls and to eat with a teaspoon with supervision. She said the Resident was to be supervised to ensure he/she was using the teaspoon to decrease the risk of aspiration. She said Resident #50 may not have been eating his/her meals because he/she was not in the main dining room and seeing other residents eat as a cue for him/her to eat. B. Resident #50 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the October Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/9/21 at 12:30 P.M., the surveyor observed a 1000 ml feeding tube bottle of [MEDICATION(S)] 1.5 labeled 11/6/21 with approximately 500 ml left in the bottle. A feeding on 11/6/21, 11/7/21, and 11/8/21 should have administered 875 ml, with 175 ml left in the bottle, a difference of 325 ml. On 11/10/21 at 9:28 A.M., the surveyor observed the same feeding tube bottle, dated 11/6/21, to have approximately 225 ml left in the bottle, indicating the Resident was fed 275 ml as ordered on 11/9/21. On 11/12/21 at 3:35 P.M., the surveyor observed a new 1000 ml [MEDICATION(S)] 1.5 bottle connected, which was dated 11/10/21 at 10:00 P.M. with 825 ml left in the bottle. If Resident #50 had been fed as ordered, on 11/10/21 225 ml would have been used from the bottle dated 11/6/21 and 50 ml would have been used from the bottle dated 11/10/21; then on 11/11/21 Resident #50 would have been fed 275 ml for a total of 325 ml from the bottle dated 11/10/21; which would have left 675 ml in the bottle that the surveyor observed on 11/12/21, a difference of 150 ml. C. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M., 2:00 P.M., 6:00 P.M., and to contact the physician and dietitian if less than 50% was consumed. Review of the Medication Administration Records (MAR) indicated: - September 2021, the house supplement was not provided 36 out of 90 times; - October 2021, the house supplement was not provided 51 out of 93 times; and - November 2021 (11/1/21 through 11/10/21), the house supplement was not provided 19 out of 27 times. During an interview on 11/12/21 at 9:00 A.M., Registered Dietitian #1 said Resident #50 received nutrition through food by mouth, house supplements and through a feeding tube to support the nutritional goals. She said she was not aware Resident #50 had not been eating, was not aware the Resident had not been receiving the house supplement as ordered and had not been notified when less than 50% was consumed. She said the goal for Resident #50 was to be able to discontinue the feeding tube, as previously attempted, but oral intake would need to be able to maintain nutritional status first.

Based on observation, interview, record review, and policy review, the facility failed to provide adequate respiratory care for three Residents (#84, #110, and #66), out of a total sample of 30 residents. Specifically, the facility failed to: 1. Provide adequate care and services for the management of [CONDITION(S)] (breathing tube in neck) tubes for Residents #84 and #110; and 2. Ensure oxygen was administered at a flow rate recommended by a Pulmonologist for Resident #66. Findings include: 1. Review of [CONDITION(S)] Care (Lippincott), dated 2014, indicated the following emergency supplies should be immediately available at the patient's bedside: - a [CONDITION(S)] tube of the same type and size as the one currently in place as well as a [CONDITION(S)] tube one size smaller -suction equipment -bag-valve mask (Ambu bag-used for ventilation) a. Resident #84 was readmitted to the facility in October 2021. On 11/4/21 at 11:25 A.M., the surveyor observed Resident #84 lying in bed. He/she had a [CONDITION(S)] ([CONDITION(S)]) tube. The surveyor observed a suction machine next to the bed, but no tubing or other equipment needed to perform suctioning was present. On 11/8/21 at 1:30 P.M., the surveyor observed Resident #84 lying in bed. There was a suction machine next to the bed, but no tubing or other equipment needed to perform suctioning was present. On 11/10/21 at 3:31 P.M., the Director of Nurses (DON) observed Resident #84 with the surveyor and said Resident #84 had a significant amount of secretions coming out of his/her [CONDITION(S)] tube and it was unacceptable to leave the Resident like this, so she would take care of the him/her. On 11/12/21 at 1:46 P.M., the surveyor observed Resident #84 lying in bed with a pillow under his/her head and neck which pushed his/her head significantly forward causing his/her neck to cover his/her [CONDITION(S)] tube. The surveyor was unable to visualize the [CONDITION(S)] tube because it was covered by the Resident's neck, due to poor positioning. The Resident was diaphoretic (sweating), and appeared to be in distress. The surveyor alerted Nurse #11 who entered the Resident's room and immediately repositioned the Resident. She said the Resident should not have been positioned like that. Review of Resident #84's Comprehensive Care Plan indicated he/she should be positioned to allow for maximum air flow. Review of the November 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the November 2021 Treatment Orders failed to indicated any orders related to Resident #84's [CONDITION(S)] tube. Review of the medical record and an Interim/Telephone order, dated 11/10/21 and not signed by the physician, indicated the following: -please add [CONDITION(S)] size/type to treatment orders -[MEDICATION(S)] 6 mm cuffed -may replace [CONDITION(S)] appliance if dislodged Review of the facility's [CONDITION(S)] Care Policy by Pro2Caire, indicated that the outer tube (main [CONDITION(S)] tube) should be changed by a physician or licensed respiratory therapist only. Review of a Nurse's Note, dated 11/13/21, indicated Resident #84's [CONDITION(S)] tube was changed to a #6 (6 millimeter) [MEDICATION(S)] cuffed (balloon around the outer diameter of the [CONDITION(S)] tube, that when inflated, prevents aspiration (movement of secretions into lungs). Review of a Nursing Note, dated 11/14/21, indicated the following: -Resident #84's [CONDITION(S)] was noted to be abnormally placed and was semi-sideways and the cuff was deflated. -Resident #84 had increased coughing with abnormal breath sounds. -Resident #84 was sent to the emergency department. Review of discharge documentation from the emergency department, dated 11/14/21, indicated Resident #84 had been treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/15/21 at 11:29 A.M., Nurse Consultant #4 said she went to the facility to assess residents with [CONDITION(S)] tubes. She said Resident #84 had yellow drainage from his/her [CONDITION(S)] site, so she changed the [CONDITION(S)] tube to a 6 mm cuffed [MEDICATION(S)] tube. The surveyor asked Consultant Staff #4 about cuff inflation and she said the cuff had not been inflated. During an interview on 11/16/21 at 10:50 A.M., the DON said she was not sure what size or type of [CONDITION(S)] tube Resident #84 had prior to the [CONDITION(S)] change by Consulting Staff #4 on 11/13/21, since there had been no order prior to the Interim Order, dated 11/10/21. She further said there were no Treatment Orders for November related to the Resident's [CONDITION(S)]. During an interview on 11/16/21 at 12:57 P.M., the DON said she found notes from the acute care hospital that Resident #84 had a 6 mm [MEDICATION(S)] [MEDICATION(S)] [CONDITION(S)] that was placed on 3/22/21. She said she could not find any documentation of any [CONDITION(S)] changes since the Resident's initial admission to the facility in July 2021, or why the Resident now had a cuffed [CONDITION(S)]. The DON further said, there had been no orders, prior to the Interim/Telephone order written on 11/10/21, for the size, type of [CONDITION(S)], and whether or not it was cuffed, but there should have been. b. Resident #110 was admitted to the facility in July 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On 11/5/21 at 9:35 A.M., the surveyor observed Resident #110 lying in bed; he/she had a [CONDITION(S)] tube in place. He/she had thick yellow secretions at the end of the [CONDITION(S)] tube with audible congestion and visible labored breathing. There was a suction machine next to the Resident's bed, but there was no collection canister or suction tubing present. On 11/8/21 at 1:54 P.M., the surveyor observed Resident #110 lying in bed. He/she had brownish/yellow secretions coming from his/her [CONDITION(S)] tube. During an observation and interview on 11/9/21 at 9:44 A.M., Nurse #16 said Resident #110 did not have suction tubing in his/her room, but he/she should since staff could not suction the Resident without it. She further said she should not have to hunt for [CONDITION(S)] supplies, they should have been right at the bedside, but were not. On 11/9/21 at 12:41 P.M., the surveyor observer Resident #110 lying in bed with his/her head pressed against the metal bed rail. He/she had copious (significant) amounts of respiratory secretions coming from his/her [CONDITION(S)] tube which were all over the bed sheet. On 11/9/21 at 2:38 P.M., the surveyor observed Resident #110 lying in bed; his/her face was red, and the surveyor heard gurgling from the Resident's [CONDITION(S)]. The surveyor asked Nurse #16 if Resident #110 was typically suctioned and she said she did not know because the Resident's treatment sheets had been taken from the unit, and she did not have access to them. On 11/10/21 at 11:05 A.M., the surveyor observed Resident #110 lying in bed. He/she was gurgling and had a red face. The surveyor observed yellow secretions in the [CONDITION(S)] and on the Resident's chest. Review of the November 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Resident #110 had a 8.0 mm [MEDICATION(S)] [CONDITION(S)] tube with a 7.0 mm inner cannula -May replace [CONDITION(S)] as needed if it becomes dislodged -Change and date suction tubing weekly -suction with a 14 French (suction catheter size) as needed for increased secretions Review of the November 2021 Treatment Record failed to indicate that Resident #110's [CONDITION(S)] tube had been suctioned. On 11/10/21 at 3:38 P.M., the DON observed Resident #110 with the surveyor and said the Resident had a significant amount of secretions and was gurgling, and it was unacceptable to leave the Resident like this. The DON said she was unsure as to whether or not the staff had suctioned the Resident, but there was an order to suction as needed for increased secretions. Review of a Nurse's note from Consulting Staff #4, dated 11/13/21, indicated Resident #110 had a slight blockage in his/her [CONDITION(S)], and she changed the [CONDITION(S)] and used a size 8 mm [MEDICATION(S)] Blueline [MEDICATION(S)] [CONDITION(S)] tube. During an interview on 11/16/21 at 12:57 P.M., the DON said she had not known Consulting Staff #4 was coming to the facility to assess residents' [CONDITION(S)] tubes. She further said she did not know why Consulting Staff #4 had changed Resident #84's [CONDITION(S)] or Resident #110's [CONDITION(S)]. She said neither Resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON further said after she observed the Residents with tracheostomies with the surveyor, she had contacted the respiratory contract company because the nursing staff needed training. 2. Resident #66 was admitted to the facility in August 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record for Resident #66 indicated a new order for a continuous pulse oximeter testing overnight on 9/4/21. Review of the Pulmonologist Consultation, dated 9/28/21, indicated a recommendation to continue oxygen at 2 L (liters) during the day and increase to 3 L at night due to significant hypoxemia (low oxygen) noted on the overnight oximetry. Review of a Nursing Progress Note, dated 9/28/21, indicated the recommendation from the Pulmonologist to increase the oxygen overnight was received. Review of the October 2021 and November 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The administration records failed to include an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/12/21 at 2:45 P.M., the DON said she had reviewed the pulmonary consult from 9/28/21. She said the information should have been reviewed with the physician and oxygen should have been provided to Resident #66 as indicated by the Pulmonologist.

Based on observation, interview, and record review, the facility failed to ensure staff promptly, within three days, referred one Resident (#6) with damaged dentures for dental services, out of a total sample of 30 residents. Findings include: Resident #6 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 10/15/21, indicated Resident #6 had difficulty with chewing, had broken or loosely fitting full or partial dentures, and received hospice services. Review of the facility's policy titled Dental Services/Dentures, revised September 2017, included but was not limited to the following: - Staff will assist residents in obtaining routine and emergency dental care. - The appropriate health care professional will document the provision of dental services and oral hygiene procedures in the resident's clinical record. - The facility must promptly, within three days, refer the resident with damaged dentures for dental services. - An investigation will be conducted to determine the cause for loss or damage to a resident's dentures. Review of the facility's policy titled Consultant Services, dated April 2015, included but was not limited to the following: - The licensed charge nurse will obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] - For .dental .consults, all families will sign a release form upon admission indicating whether they do or do not want the center to make these arrangements - Once the consultant is identified by the physician and after the family has been notified and given the permission for the consult, the staff will call the consultant to notify him/her of the request and document response in the medical record Review of the comprehensive Dental Care Plan, initiated 1/29/20, indicated Resident #6 had upper and lower dentures with the goal that the Resident would have no difficulty chewing. Interventions included the following: - Dental consult as needed - Monitor for difficulty chewing/swallowing - Notify physician if oral intake declines During an interview on 11/9/21 at 12:53 P.M., Hospice Nurse #2 told Unit Manager #1 and the surveyor she had just seen Resident #6 and, because he/she had lost nine pounds, his/her dentures needed to be fixed as they did not fit properly due to weight loss and that four teeth on the upper set were broken. She further said the upper denture was just sitting in there and adhesive would not create the proper fit. Hospice Nurse #2 said she documented her recommendations on the Hospice Communication Sheet for the attending physician a month ago, but it had not been addressed. During an interview on 11/9/21 at 12:53 P.M., Unit Manager #1 said the hospice recommendation from Hospice Nurse #2 was not in Resident #6's medical record and was not sure what happened to it. She further said there was no signed consent in the medical record for dentistry, but should have been done upon admission. Unit Manager #1 said Resident #6 could sign for him/herself, and did not know why it had not been not done yet. On 11/9/21 at 1:09 P.M., the surveyor observed Resident #6 sitting upright in his/her electric wheelchair. His/her upper denture was loose and hanging down from his/her gums. Resident #6 moved it up and down with his/her tongue. Broken/missing teeth were observed on the upper left denture. During an interview on 11/9/21 at 1:10 P.M., Unit Manager #1 said she found the hospice recommendation, written 35 days earlier, in a folder behind the nurses' station, but it was not reviewed or addressed by the attending physician. Unit Manager #1 said a better system was needed for communication with the attending physician. During an interview on 11/10/21 at 8:39 A.M., Nurse #5 said she knew Resident #6's dentures were loose, but did not know they were broken. She further said Hospice Nurse #2 told her the last time she had been there that Resident #6's dentures needed to be replaced. Nurse #5 said she did not refer Resident #6 for dental services because she was waiting for the attending physician to look at the request. On 11/15/21 at 8:12 A.M., the surveyor observed, while Resident #6 was smiling, broken/missing teeth on the left upper denture. Resident #6 shook his/her head yes when the surveyor asked him/her if the dentures were causing him/her pain while eating. During an interview on 11/15/21 at 8:47 A.M., Resident #6 used his/her iPad to communicate with the surveyor and typed that his/her dentures broke after he/she dropped them almost a year ago at the facility. During an interview on 11/15/21 at 9:23 A.M., Certified Nursing Assistant (CNA) #16 said she knew Resident #6's dentures were broken about two weeks ago and told the nurse, but the nurse already knew. On 11/16/21 at 10:08 A.M., the surveyor observed CNA #18 clean and insert Resident #6's dentures with adhesive. The surveyor observed four missing teeth on Resident #6's upper denture, three on his/her left and one on his/her right. CNA #18 said she had been working at the facility for eight months, and the dentures had been like that since that time. She further said she told a nurse who was no longer working at the facility and a CNA who told her she already knew. During an interview on 11/15/21 at 1:00 P.M., the Director of Nurses (DON) said there should have been better communication between the facility and hospice regarding Resident #6's dentures, but there was not. She further said the attending physician should have been notified by means other than by just placing the recommendation in a folder. The DON said an investigation into how the dentures were broken was not done, per facility policy, but should have been. During an interview on 11/15/21 at 4:30 P.M., the DON said the dental signed consent should have been obtained upon admission, but was not. She further said Resident #6 should have received prompt dental services when his/her dentures were first identified as being loose or broken, but did not.

Based on record review, policy review, and interview, the facility failed to ensure that one Resident (#125), out of a total sample of 30 residents, was free from neglect and abuse. Specifically, the facility A) Failed to use two staff to get the Resident out of bed, per the care plan and the facility's policy; B) Failed to provide the Resident Activities of Daily Living (bathing and showers), per the Resident's choice; and C) Failed to complete a thorough skin assessment after hospitalization s with the most recent hospitalization , resulting in multiple pressure areas on the Resident's skin that were not identified until observed by the surveyor. Findings include: Review of the facility's policy titled Abuse Prohibition Policy, dated September 2020, included but was not limited to the following: -Every [NAME] facility has the responsibility to ensure that each resident has the right to be free from abuse, mistreatment, neglect, exploitation, and misappropriation of his or her personal property. ABUSE PREVENTION: -It will be the facility's responsibility to identify, correct and intervene in situations where abuse, mistreatment, neglect, exploitation and or misappropriation of resident property occur, DEFINITIONS: Abuse/Potential Abuse: Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. This also includes the deprivation by an individual, including a caretaker, or goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. Neglect: Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Resident #125 was admitted to the facility in April 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A. Review of the Minimum Data Set (MDS) assessment, dated 9/24/21, indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. It also indicated that the Resident was totally dependent with bed mobility, transfers, bathing, personal hygiene, and dressing and required the assist of two. Review of Resident #125's Care Plan indicated: Transfer Device Mechanical lift (2 staff). During an interview on 11/10/21 at 1:00 P.M., Resident #125 told the surveyor about an incident with a Certified Nursing Assistant (CNA) who was attempting to use the Hoyer (a mechanical lift used to transfer a resident out of bed; always used by 2 staff members, no exceptions) independently. Resident #125 said this happened a couple months ago and that he/she told the CNA that he could not use the Hoyer alone and that he needed two people to use the Hoyer as that is the protocol. Resident #125 said that the CNA told the Resident that he was exempt, and he could do it himself. Resident #125 said the CNA continued to use the Hoyer lift independently and that the CNA then pulled the Resident's wrist so hard that Resident #125 stated he/she heard a pop in his/her shoulder. Resident #125 stated that he told the Administrator. Review of the facility's policy titled Total Lift, dated March 2013, included but was not limited to the following: Overview. The use of a total lift allows nursing staff to safely transport residents that require maximum assistance from one location to another without involving weightlifting. Procedure. 2. Identify yourself and your staff assistant, explain the procedure, provide privacy, and perform hand hygiene. 3.To transfer a resident from a bed to a chair you should: j. Gently lower the resident into the chair while the staff assistant guides the resident to ensure that no entrapment occurs, 4. To put the resident back to bed, you should: e. The staff assistant guides the resident to ensure no entrapment occurs. B. During an interview on 11/10/21 at 1:00 P.M., the Resident asked the surveyor to look at his/her fingernails on the right hand. The surveyor observed that all the fingernails on the right hand were extremely long. The nail on the index finger appeared long and ready to fall off, and the nail on the ring finger was purple, extremely long, and lifting. Resident #125 requested the surveyor look at the suprapubic catheter site. The surveyor observed a brown colored drainage on the skin surrounding the insertion site which had no dressing in place to absorb the drainage, some of the drainage had crusted and dried on the Resident's skin. The surveyor observed Resident #125 had dried blood on the left hand, which the Resident stated was from the hospital and that it has not been washed off since his/her return to the facility on three days ago. Resident #125 requested the surveyor look at his/her feet. The surveyor observed the left foot had dry, dirty scaly skin and in between the Resident's toes was a dirty, yellow colored, moist substance that had a foul odor that could be detected even through the surveyor's N95 mask. Resident #125 told the surveyor that he was supposed to have a shower at least once a week and said since he has not received a shower in long time; and when staff give him a bed bath, the staff don't wash his feet, that's why they look like they do. The surveyor also observed scabs on both knees of Resident #125 and the skin surrounding the areas were reddened and slightly warm to the touch. Resident #125's right heel had a border dressing (large white cloth Band-Aid). Record review indicated that there was no physician's order for this dressing and no documentation as to why the border dressing had been applied. Review of the Resident's care plan indicated the Resident is to be showered twice a week. Review of the ADL flow sheet indicated Resident #125 received a shower weekly in August (showered on 8/28, then on 11/11/21 by the DON), the Resident did not receive any showers in September 2021, and only received a shower on 10/1/21. Resident #125 received no bathing from 10/26/21 through 10/31/21. On 11/1/21, Resident #125 received a partial sponge bath and on 11/6/21 received a bed bath, and then not until 11/11/21 when the Resident was showered by the DON. C. On 11/10/21 at 3:30 P.M., the surveyor notified the Director of Nursing (DON) and with the Resident's permission, the DON, with the surveyor present, did a head-to-toe skin inspection. The DON said she was concerned with the findings the surveyor had brought to her attention. During the DON's assessment, the surveyor observed: -The right index fingernail had fallen off and there was a Band-Aid covering the area (per Resident #125, a Certified Nursing Assistant (CNA) applied a Band-Aid). - The DON removed the border dressing revealing the skin on the right heel to have a Deep Tissue Injury (DTI) ulcer. Record review indicated no documentation or physician's order addressing of any of the above areas. Upon leaving the Resident's room, the DON said that Resident #125 would have a shower in the morning (DON said would give the Resident the shower herself). The DON further said that tomorrow morning an extensive head to toe skin assessment, with measurements of all the areas would be completed and would ensure that the proper treatments were in place addressing the areas. Review of the Pressure Injury Evaluation, dated 11/11/21 with date of origin 11/10/21, included but was not limited to the following: -Right Heel- Pressure Injury, facility acquired, DTI- 7.0 centimeters (cm) x 6.5 cm 75% is healthy tissue and 25% is unhealthy tissue, no drainage surrounding skin is intact. -Left Buttocks-Stage II pressure, facility acquired 2.5 cm x 1.0 cm small amount of drainage, 75% is healthy tissue and 25% is unhealthy tissue, surrounding skin is intact -Right toes-Pressure Injury, facility acquired, DTI- 7.3 cm x 4.0 cm 75% is healthy tissue and 25% is unhealthy tissue, no drainage, surrounding skin is intact -Left lower leg (front)-Pressure Injury, facility acquired-DTI-3.0 cm x 2.8 cm x 0.2 cm, 75% is healthy tissue and 25% is unhealthy tissue, no drainage, surrounding skin is intact -Left lower leg (rear)-Pressure Injury, facility acquired-DTI-2.5 cm x 1.6 cm 75% is healthy tissue and 25% is unhealthy tissue, no drainage, surrounding skin is intact -Other (bruised area on Left toe) -Pressure Injury, Facility acquired-DTI-1.5 cm x 1.0 cm 75% is healthy tissue and 25% is unhealthy tissue, no drainage, surrounding skin is intact The physician was contacted regarding the above areas, treatments and preventative measures were ordered by the physician. Review of the facility's policy titled Prevention and Management of Pressure Injuries, dated July 2017, included but was not limited to the following: Policy: Residents with pressure injuries and those at risk for skin breakdown are identified, assessed, and provided appropriate treatment to encourage healing and/or maintenance of skin integrity. Protocol: Assessment: Ulcer/Risk Factors 1. On admission/readmission, a comprehensive assessment of the resident will be completed which will include the following * A head-to-toe skin assessment in a manner that respects the resident's dignity. * A comprehensive clinical assessment to identify specific physical and functional risks associated with pressure injury development. 2. The resident is assessed for pressure injury risk factors on admission then weekly x three weeks, quarterly, annually and with any significant change in condition. 3. The resident's skin is observed daily with care. 4. Residents will have a weekly body audit completed by the licensed staff. Review of the Hospital Discharge Summary, dated November 2021, indicated the right heel was noted to have a pressure injury, that the treatment performed to the area was an adhesive border foam dressing, due to be changed on 11/10/21. It further indicated that the Resident's skin was not intact and that there was a pressure injury present. Upon return to the facility, review of the November 2021 Nurse's notes indicated that an assessment was done with Vital Signs-Within Normal Limits, no changes in skin integrity prior to leaving Rehab. Resident in stable condition. Record review indicated no documentation that the physician was called upon Resident #125's return to the facility, that the discharge summary had been reviewed and that medications/treatments were checked for any changes and that a head-to-toe skin assessment was completed as per the facility policy. During an interview on 11/15/21 at 9:30 A.M. the DON said the facility failed to provide care and services for Resident #125 by not identifying the pressure injuries upon return to the facility on [DATE] and providing proper ADL care as requested by Resident #125.

Based on interviews and record review, the facility failed to ensure quality care was provided to one Resident (#136), out of a total sample of 30 residents. Specifically, the facility failed to assess and treat the Resident's identified skin impairment, resulting in difficulty ambulating and the Resident reporting tenderness for a few weeks. Findings include: Resident #136 was admitted to the facility in March 2018 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Hospice Communication Book indicated: -On 10/15/21 Hospice requested podiatry for toenails and to look at the area on the bottom of the Resident's foot. -On 10/22/21 the right foot callous was still present. Review of a Hospice Recommendation, dated 10/19/21, indicated to consider a foam cushion with wound window cut out to bottom of right foot and to secure with tape; followed by slipper socks to change as needed; and continue until seen by the wound doctor on 10/25/21. Review of a Hospice Recommendation, dated 11/2/21, indicated to follow up with the wound doctor or podiatrist regarding area on foot. The recommendation form indicated the infection control preventionist, who was responsible for wound care, was aware. Review of the October 2021 and November 2021 Treatment Administration Records (TAR) did not include any treatments orders to the bottom of the right foot. Review of the medical record indicated a Weekly Skin Audit (assessment of skin areas) was conducted on 10/3/21 with no areas and the next Weekly Skin Audit was not conducted until 11/1/21. The Weekly Skin Audit, dated 11/1/21, did not include any information regarding an area to the bottom of the right foot. During an interview on 11/9/21 at 2:40 P.M., the Infection Control Preventionist said she was unaware of the recommendation hospice made on 10/19/21 for a foam wound dressing. She said she reviewed the nursing documentation and was unable to find a skin evaluation to indicate the wound had been assessed and evaluated by the facility staff. She said Resident #136 was not seen by the podiatrist or wound doctor until 11/8/21 (20 days after first identified by hospice). Review of the Wound Care History and Physical, dated 11/8/21, indicated Resident #136 had a neuropathic ulcer with a thick callus on the plantar surface of the right foot. The consultation indicated the Resident had been complaining of the tender callused area on the right foot for a few weeks and ambulation had been difficult. The wound assessment indicated there was a thick callused area on the right mid plantar distal foot, measuring approximately 3 centimeters (cm) x 3 cm x 0.5 cm. The wound doctor wrote a treatment plan for Iodosorb gel (or [MEDICATION(S)] gel) into the wound bed; foam dressing changed approximately every two to three days. During an interview on 11/12/21 at 11:26 A.M., the Director of Nurses said she had just obtained the consultation from 11/8/21 and did not know if the treatment was implemented to the area in the four days since. Review of the medical record, including the TAR, on 11/12/21 at 12:10 P.M., failed to include a treatment to the right foot area, as indicated by the wound consultant on 11/8/21.

Based on observation, interview, policy review, and record review, the facility failed to ensure that residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice to promote healing, prevent new ulcers from developing, and provide ongoing assessment and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Specifically, the facility 1.) Failed to complete a head-to-toe skin assessment as per the facility policy, upon return to the facility from two hospitalization s, resulting in numerous pressure areas that were not identified, for Resident #125; 2.) Failed to complete weekly skin assessments which would identify skin impairments, failed to provide bilateral booties as ordered for prevention and failed to document and evaluate a pressure area to the left lateral forefoot, for Resident #93; and 3.) Failed to complete weekly skin assessments per the physician's order to monitor and assess Resident #6's Stage II pressure area. Findings include: 1. Review of the facility's policy titled Prevention and Management of Pressure Injuries, dated July 2017, included but was not limited to the following: Policy: Residents with pressure injuries and those at risk for skin breakdown are identified, assessed, and provided appropriate treatment to encourage healing and/or maintenance of skin integrity. Protocol: Assessment: Ulcer/Risk Factors 1. On admission/readmission, a comprehensive assessment of the resident will be completed which will include the following: * A head-to-toe skin assessment in a manner that respects the resident's dignity. * A comprehensive clinical assessment to identify specific physical and functional risks associated with pressure injury development. 2. The resident is assessed for pressure injury risk factors on admission then weekly x three weeks, quarterly, annually and with any significant change in condition. 3. The resident's skin is observed daily with care. 4. Residents will have a weekly body audit completed by the licensed staff. Resident #125 was admitted to the facility in April 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/10/21 at 1:00 P.M., Resident #125 requested the surveyor look at his/her feet. The surveyor observed the following on the resident's lower extremities: - scabs on both knees and the skin surrounding the areas were reddened and slightly warm to the touch - right heel had a border dressing (large white cloth Band-Aid). Record review indicated there was no physician's order for this dressing and no documentation as to why the border dressing had been applied. On 11/10/21 at 3:30 P.M., the surveyor notified the Director of Nursing (DON) of her observations. The DON said she was concerned with the findings the surveyor had brought to her attention. With the Resident's permission, and the surveyor present, the DON performed a head-to-toe skin inspection. During the DON's assessment, the surveyor observed the following: - The right index fingernail had fallen off and there was a Band-Aid covering the area (per Resident #125, the Band-Aid was applied by a Certified Nursing Assistant). - The DON removed the border dressing on the right heel revealing a Deep Tissue Injury (DTI) ulcer (Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm mushy, boggy, warmer, or cooler as compared to adjacent tissue). Record review indicated no documentation or physician's order addressing any of the above areas. Upon leaving the Resident's room, the DON said Resident #125 would have an extensive head to toe skin assessment and measurements of all the areas would be completed. The DON said that she would ensure that the proper treatments were in place addressing the areas. Review of the Pressure Injury Evaluation, dated 11/11/21 with Date of origin 11/10/21, included but was not limited to the following: - Right Heel- Pressure Injury, facility acquired, -DTI-7.0 centimeters (cm) x 6.5 cm 75% is healthy tissue and 25% is unhealthy tissue, no drainage surrounding skin is intact. - Left Buttocks-Stage II pressure, facility acquired 2.5 cm x 1.0 cm small amount of drainage, 75% is healthy tissue and 25% is unhealthy tissue, surrounding skin is intact - Right toes-Pressure Injury, facility acquired-DTI--7.3 (cm) x 4.0 cm 75% is healthy tissue and 25% is unhealthy tissue, no drainage, surrounding skin is intact - Left lower leg (front)-Pressure Injury, facility acquired-DTI-3.0 cm x 2.8 cm x 0.2 cm, 75% is healthy tissue and 25% is unhealthy tissue, no drainage, surrounding skin is intact - Left lower leg (rear)-Pressure Injury, facility acquired-DTI-2.5 cm x 1.6 cm 75% is healthy tissue and 25% is unhealthy tissue, no drainage, surrounding skin is intact - Other (bruised area on Left toe) -Pressure Injury, Facility acquired-DTI-1.5 cm x 1.0 cm 75% is healthy tissue and 25% is unhealthy tissue, no drainage, surrounding skin is intact - The physician was contacted regarding the above areas, treatments and preventative measures were ordered by the physician. Record review indicated the following: - Resident #125 was admitted to the hospital in October 2021, and upon return to the facility, no comprehensive skin assessment was completed. Upon return to the facility in October 2021, the Nurse's notes indicated the Resident was readmitted to the facility, however the hospital discharge papers were left at the hospital. Vital signs as follows; Blood pressure 121/89, Temperature 97.9, Oxygen saturation 95% on room air, Pulse 73. Suprapubic catheter intact, patent [CONDITION(S)]. Patient has a Midline at the antecubital fossa. Patient is stable condition and can make needs known. There was no reference to the Resident's skin integrity. - Resident #125 was admitted to the hospital in November 2021, and upon return to the facility, no comprehensive skin assessment was completed. Review of the Hospital Discharge Summary, dated November 2021, indicated the right heel was noted to have a pressure injury; that the treatment performed to the area was an adhesive border foam dressing, due to be changed on 11/10/21. It further indicated that the Resident's skin was not intact and that there was a pressure injury present. Upon return to the facility, November 2021 Nurse's notes indicated that an assessment was done with Vital Signs-Within Normal Limits, no changes in skin integrity prior to leaving Rehab. Resident in stable condition. Record review indicated no documentation upon Resident #125's return to the facility following hospitalization in October 2021 and November 2021 that a head-to-toe skin assessment was completed as per the facility policy and that the discharge summary been reviewed in November 2021. Record review indicated the last weekly skin assessment was completed on 9/23/21. During an interview on 11/15/21 at 9:30 A.M., the Director of Nursing (DON) said the facility failed to provide necessary care and treatment consistent with professional standards of practice for Resident #125. The DON said that the facility failed to ensure a complete a head-to-toe skin assessment as per the facility policy upon return to the facility from two hospitalization s resulting in numerous pressure areas that were not identified and had no treatment orders upon return to the facility in November 2021. 2. Resident #93 was admitted to the facility in June 2021 with contractures (shortening and hardening of tissues leading to the rigidity of joints). Review of the Physician's Orders for October and November 2021 indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/9/21 at 8:09 A.M., the surveyor observed Resident #93 lying in bed; there were no booties on the Resident. Review of the Treatment Administration Record (TAR) for October 2021 indicated the weekly skin checks were not signed off as completed on 10/15/21, 10/22/21, and 10/29/21. Review of the electronic medical record did not indicate a weekly skin audit was completed on 10/8/21 and then not again until 11/5/21, four weeks later. During an interview on 11/9/21 at 2:37 P.M., the Infection Control Preventionist, who provides oversight of the residents with wounds, said skin checks should be conducted weekly for all residents on shower days and an evaluation would be initiated in the electronic medical record. She said she was unaware that weekly skin checks were not being completed until this morning. During an interview with observation on 11/10/21 at 8:53 A.M., the surveyor observed Resident #93 lying in bed with no booties on. The surveyor observed Unit Manager #2 check the skin of the Resident. Unit Manager #2 observed an area to the left lateral forefoot and said the area was non-blanchable (when applying pressure with one's finger on an area the blood is forced out of the capillaries and the skin does not become pale or white); she said this indicated it was a pressure area. During an interview on 11/10/21 at 8:55 A.M., Certified Nursing Assistant (CNA) #9 said she had not been placing booties on the bilateral lower extremities of the Resident and she did not know where booties would be. On 11/10/21 at 3:26 P.M., the surveyor observed Resident #93 in bed, not wearing booties, as ordered. During an interview on 11/12/21 at 9:00 A.M., Unit Manager #2 said she had not completed a skin evaluation form or measured the observed area on the foot of Resident #93. She said she only identified the area of skin impairments. Review of the medical record on 11/16/21 indicated a Weekly Skin Audit was conducted on 11/12/21 and there were no new skin impairments since the previous skin assessment on 11/5/21. On 11/16/21 at 10:01 A.M., the surveyor observed Resident #93 lying in bed not wearing booties; the area to the left lateral forefoot was observed. During an interview on 11/16/21 at 10:30 A.M., Unit Manager #2 said she had not completed a skin evaluation regarding the pressure area observed on 11/10/21, six days prior. On 11/16/21 at 1:45 P.M., Unit Manager #2 provided the surveyor with a Weekly Skin Audit, dated 11/14/21, which indicated new skin areas including a non-blanchable area on the right outer ankle and a scabbed area on the left outer ankle. There was no documentation regarding the left lateral forefoot area observed by the Unit Manager, the CNA, and two surveyors on 11/10/21. 3. Resident #6 was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 10/15/21, indicated Resident #6 required extensive assistance for bed mobility and transfer and was at risk for developing pressure ulcers. Review of the medical record for Resident #6 indicated a current Physician's Order, initiated 2/28/20, to perform weekly skin checks on Mondays during the 7:00 A.M.-3:00 P.M. shift. Review of Nursing Progress Notes, dated 11/4/21, indicated a 3 x 3 (unit of measurement undefined) reddened area on the coccyx. Review of the Weekly Skin Audit, dated 11/5/21, failed to indicate a new suspected pressure ulcer or deep tissue injury. During an interview on 11/9/21 at 12:53 P.M., Hospice Nurse #2 said she had just seen Resident #6 and he/she had a Stage II (partial-thickness skin loss) pressure ulcer on his/her coccyx that had been there for about a week now. During an interview on 11/10/21 at 9:20 A.M., Nurse #5 said Resident #6 developed a Stage II pressure ulcer on his/her coccyx one to two weeks ago and a skin evaluation had not been done yet, but should have been. On 11/10/21 at 4:27 P.M., the surveyor observed a wound assessment with Nurse #5 who said the wound was not improving and she was waiting for new treatment orders from the hospice nurse. Review of the skin care plan indicated interventions toward the goal for Resident #6's skin to remain intact including assessing the Resident's skin condition at 24 hours then weekly, initiated 1/21/20. The care plan failed to indicate Resident #6 had a pressure ulcer. Review of the TARs, dated 10/1/21 through 10/31/21, with the Director of Nurses (DON) failed to indicate weekly skin checks were completed during the 7:00 A.M. - 3:00 P.M. shift for 2 out of 4 weeks as well as for 1 out of 3 weeks on the 11/1/21 through 11/30/21 TAR. On 11/16/21 at 1:11 P.M., the DON said a skin evaluation should have been done immediately after nursing staff discovered it on 11/4/21, but was not. She further said the weekly skin check completed the following day should have included an assessment of the wound, but did not. The DON said the medical record did not contain further documentation of the pressure ulcer after it had developed and weekly skin checks should have been consistently performed, but were not.

Based on observation, interview, and record review, the facility failed to ensure four Residents (#89, #128, #84, and #110), out of a total sample of 30 residents, and 1 out of 5 resident care units were provided with an environment free of accident hazards. Specifically, the facility failed to: 1. Provide fall prevention interventions for Resident #89, resulting in a hip fracture; 2. Provide fall prevention interventions for Resident #128 resulting in multiple falls; 3. Ensure there was an Ambu bag (used for ventilation) on the [NAME] Unit emergency code cart; and 4. Provide emergency [CONDITION(S)] (tube in neck for breathing) equipment for Residents #84 and #110. Findings include: 1. Review of the policy for Falls Management, dated as revised August 2018, indicated the interdisciplinary team will develop, initiate and implement an appropriate individualized care plan based on the fall risk evaluation score. Resident #89 was admitted to the facility in April 2018 with a diagnosis of dementia. Review of the Minimum Data Set (MDS) assessment, dated 6/11/21, indicated Resident #89 needed extensive assist of one with transferring between surfaces, walking in room, walking in corridor and locomotion on unit. Review of the Progress Notes for Resident #89 indicated the Resident fell on [DATE], 7/23/21, and 8/5/21 as follows: Fall 7/6/21: -Review of the Fall Incident Report for 7/6/21 indicated Resident #89 fell at 1:15 P.M. while bending over in the dining room, without injury. -Review of the Fall Risk Assessment, dated 7/6/21, indicated the Resident was at risk for falls, had one to two falls in the past three months, was ambulatory, with balance problems while standing, balance problems while walking, decreased muscular coordination, jerking or unstable when making turns. -Review of the Care Plan indicated an intervention of taking naps after lunch. -Further review of the Care Plan indicated a similar intervention of offering a rest period after lunch was implemented on 4/6/21. Fall 7/23/21: -Review of the Fall Incident Report for 7/23/21 indicated Resident #89 fell at 10:00 A.M. in his/her room after making jerking movements, without injury. The report indicated the intervention to prevent further occurrence was a medication review for assessment. -Review of the Fall Risk Assessment, dated 7/23/21, indicated the Resident was at risk for falls, had one to two falls in the past three months, was ambulatory, with balance problems while standing, balance problems while walking, change in gait pattern when walking through doorway, jerking or unstable when making turns. -Review of the Care Plan indicated an intervention dated 7/29/21 of a medication review. Fall 8/5/21: -Review of the Fall Incident Report for 8/5/21 indicated Resident #89 fell at 5:55 A.M. while near the nurses' station. The fall investigation indicated at 5:30 A.M. the Resident was washed, dressed, toileted and brought out to the nurses' station. The Resident was found on the ground with immediate signs of pain in the left lower extremity, which was shorter than the right and had left foot externally rotated. -Review of the Hospital Discharge Paperwork indicated the Resident had a left hip fracture that required surgical intervention. Review of the Physician's Progress Notes indicated physician visits on 6/23/21 and 8/18/21. There was no indication the physician completed a medication review following the fall on 7/23/21, prior to the next fall on 8/5/21. Review of the Pharmacy Progress Notes in the medical record failed to include a medication review was completed between the falls on 7/23/21 and 8/5/21. During an interview on 11/16/21 at 12:54 P.M., the Director of Nurses said there was no medication review located as part of the fall investigation or part of the medical record and could not determine if a medication review had been conducted following the fall for Resident #89. She said there were no other interventions implemented following the fall on 7/23/21 and the facility policy was for an immediate intervention to be added to the care plan to prevent further falls. 2. Resident #128 was admitted to the facility with diagnoses including neuromuscular disorder, traumatic [CONDITION(S)] accident ([CONDITION(S)]) with right [CONDITION(S)] (paralysis on one side of the body), [CONDITION(S)] disorder, [CONDITION(S)] in the left eye, neurocognitive disorder with aggression and agitation, and impulse control disorder. Review of the MDS assessment, dated 10/4/21, indicated Resident # 128 required extensive assistance with toileting and locomotion on the unit, and used a walker and wheelchair. Review of the Fall Risk Assessment, dated 9/22/20, indicated Resident #128 was at risk for falls. Review of the Falls Care Plan, initiated 9/23/20, indicated Resident #128 was at risk for a fall related injury due to traumatic [CONDITION(S)] with right [CONDITION(S)], [CONDITION(S)] disorder, [CONDITION(S)] in the left eye, neurocognitive disorder with aggression and agitation, and impulse control disorder. The goal was Resident #128 would not sustain a fall related injury by utilizing fall precautions. Interventions to achieve this goal were as follows: - Continual supervision while ambulating in hallways - Edge defining mattress in place at all times - Educate Resident to call for assistance to use the bathroom - Provide/monitor use of adaptive devices; walker and wheelchair with assist Review of the clinical record indicated Resident #128 sustained 13 falls between February 2021 and November 2021 without major injury. Seven of the falls were unwitnessed, and six were witnessed. The Resident was transferred to the emergency room for further evaluation after one of the 13 falls. Review of the Resident Care Card (Clinical Nursing Assistant (CNA) care instructions) for Resident #128 indicated he/she required an assist x 1 for toileting and ambulation. On 11/8/21 at 8:33 A.M., the surveyor observed Resident #128 walk out of his/her room down the hall to the nurses' station unsupervised without a walker. His/her right foot was catching/dragging on the floor and caused him/her to stumble multiple times. Nurse #7 instructed Resident #128 to go back to his/her room, but did not supervise or assist the Resident. On 11/8/21 at 1:15 P.M., the surveyor observed Resident #128 sitting at the side of his/her bed. The call bell was located on the floor underneath his/her bed. It was not within reach of the Resident. He/she then walked unsteadily to the bathroom without calling for help from staff. During an interview on 11/8/21 at 1:20 P.M., Nurse #5 entered the room with the surveyor and said Resident #128's call bell was not within reach, but should have been. She said the Resident was supposed to call for help but did not, and was not supposed to be ambulating independently. On 11/9/21 at 8:12 A.M., the surveyor observed Resident #128 walk out of his/her room down the hall to the nurses' station unsupervised without a walker. His/her right foot was catching/dragging on the floor and caused him/her to stumble multiple times. CNA #17 instructed Resident #128 to go back to his/her room, but did not supervise or assist the Resident. During an interview on 11/9/21 at 8:12 A.M., CNA #17 said Resident #128 did not require assistance with ambulation, only if he/she was in his/her wheelchair. During an interview on 11/9/21 at 8:40 A.M., the surveyor reviewed the resident care card with CNA #17 who said she did not know it said Resident #128 was an assist with ambulation. She said she should have referred to it to determine his/her level of care, but did not. On 11/15/21 at 8:28 A.M., the surveyor observed Resident #128 ambulating without assistance in his/her room. He/she then walked out of his/her room down the hall to the nurses' station unsupervised without a walker. His/her right foot was catching/dragging on the floor and caused him/her to stumble multiple times. Nurse #15 was in a resident's room. CNA #16 was passing breakfast trays. No other staff was present at the time. Resident #128 remained standing at the nurses' station and then walked back to his/her room without assistance. Nurse #15 exited another resident's room and asked the surveyor who Resident #128 was and did not assist him/her back to his/her room. During an interview on 11/15/21 at 8:31 A.M., Nurse #15 said it was her first day working in the facility so she did not know who the residents were, and did not have access to the electronic medical record yet to look them up. She further said she did not receive any safety/fall risk information about Resident #128 during verbal report prior to her shift, thus, did not know Resident #128 required assistance and continual supervision with ambulation to prevent falls. During an interview on 11/16/21 at 10:41 A.M., Nurse #5 said there was no plan she knew of to prevent future falls for Resident #128. She said he/she was very impulsive and non-compliant and was worried he/she would sustain a serious injury. She further said usually there was only one nurse and one aide working each shift. Nurse #5 said there was not enough staff to continually supervise Resident #128 to keep him/her safe, especially if she was in another resident's room and could not hear his/her feet shuffling. By that time, she said, it would be too late. During an interview on 11/15/21 at 4:13 P.M., the Director of Nurses (DON) said fall risk interventions should have been implemented to prevent falls, but were not. She further said, You cannot expect the staff to continually supervise if you only have one nurse and one aide. During an interview on 11/16/21 at 1:01 P.M., the surveyor reviewed the Falls Weekly Risk Meeting notes from February 2021 to present with the DON. The DON said not all of Resident #128's falls were addressed or documented in the risk minutes, but should have been. She further said the facility did not have risk minutes for any resident after July 2021, but should have. 3. Review of the facility's [CONDITION(S)] (breathing tube in neck) Care Policy, undated, by Pro2Caire, failed to indicate any information about emergency equipment that should have been located at the bedside of a resident with a [CONDITION(S)]. Further review indicated that, if the outer cannula did come out (decannulation), a hemostat (surgical tool that may be used to open the airway and allow ventilation) could be used to keep the airway open. Review of [CONDITION(S)] Care (Lippincott), dated 2014, indicated the following emergency supplies that should be immediately available at the [CONDITION(S)] patient's bedside: - a [CONDITION(S)] ([CONDITION(S)]) tube of the same type and size as the one currently in place as well as a [CONDITION(S)] tube one size smaller -suction equipment -bag-valve mask (Ambu bag-used to provide ventilation) During an observation with interview on 11/9/21 at 9:44 A.M., the surveyor observed two Residents (#84 and #110) on the [NAME] unit with [CONDITION(S)] tubes with Nurse #16. Nurse #16 said neither Resident had an Ambu bag, suction tubing, or spare [CONDITION(S)] tubes a size smaller at the bedside, which she would expect to see. Nurse #16 said she should not have to hunt for emergency supplies, they should be right at the bedside, but were not. The surveyor and Nurse #16 then observed the Code Cart for the [NAME] Unit. She said there should be an Ambu bag on every code cart to be used emergently for any resident requiring breathing support, but there was not one on the [NAME] Unit code cart. Nurse #16 reviewed the November Code Cart Checklist with the surveyor and said it indicated the Ambu bag was present, but it was not. During an interview on 11/9/21 at 11:10 A.M., Nurse #17 said he worked the 3:00 P.M. to 11:00 P.M. shift, and the Ambu bag on the code cart on the [NAME] Unit had been used for an emergency about a week and a half ago. He said he had not had a chance to replace it with a new one after the emergency. Nurse #17 said staffing had been horrid recently and there had been times when he was the only staff member on the [NAME] unit, so there was no time for extra tasks. He further said the 11:00 P.M. to 7:00 A.M. shift nurse was responsible for taking inventory of the code cart every night. Nurse #17 said he had had another emergency on the Hopkins Unit recently and the back board was not with the code cart, so he had to break a tray table in half in order to give Cardiopulmonary Resuscitation to a resident. During an interview on 11/9/21 at 2:34 P.M., Nurse #12 said she worked the overnight shift on the [NAME] Unit. She said it was her duty to check the code cart every night. She said she had not checked every part of the code cart on 11/8/21 during the 11:00 P.M. to 7:00 A.M. shift because there had not been enough time. She said she could not be sure the Ambu bag was on the emergency code cart, but she said she knew it used to be there. She further said it may have been used during an emergency on 10/31/21. 4. On 11/10/21 at 10:00 A.M., the surveyor observed Residents #84 and #110 with the Director of Nurses (DON). She said she would have expected to see the same size and type of [CONDITION(S)] tube and a size smaller at the bedside of every [CONDITION(S)] resident. She said Resident #110 had only one spare [CONDITION(S)] at his/her bedside, which was the same size. She said Resident #84 had only one spare [CONDITION(S)] above his/her bed, but she said she could not determine if the spare [CONDITION(S)] above Resident #84's bed was the same size or a size smaller since she was unable to find an order that indicated the type and size of the [CONDITION(S)] the Resident currently had in. The DON said there should have been an order for [CONDITION(S)] tube type and size, but there was not. She also said emergency equipment including an Ambu bag, suction equipment, and a hemostat should have been located at the bedside of every resident with a [CONDITION(S)], including two spare [CONDITION(S)] tubes (same size and a size smaller), but was not. Resident #84 was readmitted to the facility in October 2021. Review of a Physician's Interim/Telephone order dated 11/10/21, indicated Resident #84 had a [MEDICATION(S)] 6 millimeter (mm) cuffed (balloon on outer cannula used to prevent aspiration when inflated) [CONDITION(S)] tube. The order was not signed by the physician, and there was no previous order for the type and size of the [CONDITION(S)] tube. Resident #110 was admitted to the facility in July 2021. Review of November 2021 Physician's Orders, indicated Resident #110 had a [MEDICATION(S)] size 8 mm [CONDITION(S)] tube with a size 7.0 mm inner cannula (smaller, removable tube within [CONDITION(S)] outer cannula). During an interview on 11/15/21 at 11:24 A.M., Nurse #11 said someone told her this past weekend that the spare [CONDITION(S)] tube at a resident's bedside should be one size larger than the one the resident has in place. During an interview on 11/15/21 at 11:29 A.M., Consultant Staff #4 said the same size [CONDITION(S)] tube should be attached to the wall in case a spare [CONDITION(S)] is needed emergently. During an interview on 11/16/21 at 12:57 P.M., the DON said she found an interim/telephone order in Resident #84's medical record, dated 11/10/21, for [CONDITION(S)] type and size. She further said, as far as she was concerned, each resident with a [CONDITION(S)] should always have two spare [CONDITION(S)] tubes at the bedside, one the same size and one a size smaller, an Ambu bag, suctioning equipment and a hemostat, but neither Resident (#110 nor #84) did.

Based on observation, record review, policy review, and interview, the facility failed to provide treatment and services for 2 out of 7 Residents (#100 and #83) with indwelling catheters (tube inserted into the bladder to drain urine), out of a total sample of 30 residents. Specifically, the facility failed to: 1. Provide Foley catheter care and Urology follow up for catheter changes and ongoing assessment, in order to prevent recurrent catheter-related urinary tract infections requiring hospitalization s, for Resident #100; and 2. Provide consistent suprapubic catheter care per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. During an interview on 11/5/21 at 9:18 A.M., Resident #100 said his/her urinary catheter hurt. During an interview on 11/9/21 at 12:37 P.M., Resident #100 said his/her urinary catheter hurt. Resident #100 was admitted to the facility in September 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Urology Office Visit Report, dated 9/13/21, the physician indicated the following: -patient presents with clogged catheter -no documentation from the Skilled Nursing Facility of the last time the catheter was changed -last time it had been changed by urology was August 2020 -excessively calcified tip of Foley catheter consistent with not being changed for an extended period of time -In the Notes section of the report the physician documented the following: -spoke directly with the Director of Nurses at rehab (facility) -discussed how completely unacceptable it was that there was no documentation of the last time the Foley catheter was changed, that no one noticed it had not been changed for an extended period of time, and the state that it was in when it was removed today Review of Resident #100's medical record indicated, he/she had been admitted to the hospital: -September 2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -October 2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the August 2021 Treatment Administration Record (TAR) indicated the Foley catheter protocol was to be implemented. This included, but was not limited to: -Foley catheter care every shift Further review of the August 2021 TAR failed to indicate that Foley catheter care had been provided on 22 out of 93 occasions during the month of August 2021. Review of the September 2021 TAR indicated the Foley catheter protocol was to be implemented. This included, but was not limited to: -Foley catheter care every shift Further review of the September 2021 TAR failed to indicate that Foley catheter care had been provided 34 out of 90 times in the month of September 2021. Review of the October 2021 TAR indicated the Foley catheter protocol was to be implemented. This included, but was not limited to: -Foley catheter care every shift Further review of the October 2021 TAR failed to indicate that Foley catheter care had been provided 44 out of 93 times in the month of October 2021. Review of a Nurse's Note, dated 10/12/21, indicated Resident #100 had an appointment with the Urologist on 10/18/21 for Foley replacement. During an interview on 11/16/21 at 12:25 P.M., Nurse # 11 said Resident #100 had a Urology appointment scheduled for 10/18/21, but it had been rescheduled and she was not sure why. She also said she was unable to determine if the appointment had actually been rescheduled or not, since there was no documentation, and nothing was written on the calendar. During an interview on 11/16/21 at 3:33 P.M., the Director of Nurses (DON) said it was the facility's responsibility to ensure Resident #100 was followed by urology and it had not been done, but it should have been. She said she was unable to determine the last time the catheter had been changed prior to the Urology appointment on 9/13/21. The DON further said, there was no way to ensure catheter care had been done for the Resident, if it had not been marked off on the TAR, and catheter care should have been done on every shift in order to help prevent urinary tract infections. 2a. Resident #83 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #83's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Nursing Progress Notes, dated 9/23/21, indicated Resident #83 had a suprapubic catheter (surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal flow) placed on 9/22/21. On 11/15/21 at 8:54 A.M., the surveyor observed Resident #83's suprapubic catheter bag draining yellow urine. Resident #83 said the catheter was relatively new. On 11/15/21 at 2:40 P.M., the surveyor and Nurse #15, with Resident #83's permission, observed the suprapubic catheter insertion site which was draining a small amount of serosanguinous (both blood and a clear yellow liquid known as blood serum) fluid. Resident #83 said a nurse looked at it that day and said it looked okay, but never returned to clean it with soap and water. Review of the TAR, dated 11/15/21, indicated catheter care for the 7:00 A.M.-3:00 P.M. shift was completed as evidenced by documentation of nursing initials. During an interview on 11/15/21 at 2:55 P.M., Nurse #15 said she signed off that she completed Resident #83's catheter care treatment during her 7:00 A.M.-3:00 P.M. shift, but did not do it. She further said she should not have documented that she completed the treatment when, in fact, she did not. Further review of the TAR from 10/1/21 through 10/31/21 indicated suprapubic catheter care was not completed on 17 of 93 shifts. Review of the TAR from 11/1/21 through 11/15/21 indicated suprapubic catheter care was not completed on 14 of 45 shifts. During an interview on 11/16/21 at 1:00 P.M., the DON said there should have been consistent documentation for catheter care, but there was not. She further said Nurse #15 should not have signed off that she completed suprapubic catheter care if she had not done it. 2b. Review of the [CONDITION(S)] Bladder Care Plan, initiated 12/29/20, indicated Resident #83 was at risk for urinary infection. Interventions included monitoring the amount of urinary output. Review of Resident #83's Intake and Output Worksheets for 11/2/21, 11/3/21, and 11/5/21 through 11/12/21 failed to indicate consistent documentation of urinary output. During an interview on 11/15/21 at 4:01 P.M., the surveyor reviewed the worksheets with the DON who said urinary output should have been consistently documented, but was not.

Based on interviews and records reviewed, for two of three sampled residents (Residents #2 and #3) the Facility failed to ensure residents were free from physical abuse, when on 9/2/20 they failed to prevent Resident #1 from slapping, grabbing and trying to choke Resident #2 and on 9/8/20 while Resident #1 was supposed to be on one to one supervision by a staff member, he/she was left unobserved long enough to wrap his/her hands around Resident #3's neck. Findings include: Resident #1's most recent Minimum Data Set (MDS) Assessment, dated as completed 8/21/20, indicated that his/her cognitive patterns were severely impaired and he/she had a Guardian. Resident #1's care plan concern related to behavioral symptoms, dated as initiated 11/23/19, indicated one of his/her goals included that Resident #1 would not harm him/herself or others. Care plan interventions included staff to address Resident #1's wandering by walking with or redirecting Resident #1 and to intervene as needed to protect the rights and safety of others. Resident #2's most recent MDS Assessment, dated as completed 6/26/20, indicated that his/her cognitive patterns were severely impaired. During an interview on 9/14/20 at 4:00 P.M., Resident #2 said that Resident #1 asked him/her for the face mask he/she had in his/her hands. Resident #2 said that when he/she told Resident #1 that he/she could not have the face mask, Resident #1 slapped him/her in the head and choked him/her. During an interview on 9/14/20 at 2:50 P.M., the Occupational Therapy Assistant said that around 5:30 P.M. on 9/2/20, Resident #1 hit Resident #2 on the forehead and grabbed Resident #2's jaw and squeezed it really hard. During an interview on 9/23/20 at 12:41 PM, Certified Nurse Aide (CNA) #1 said that on 9/2/20 around 5:30 P.M., she saw Resident #1 standing beside Resident #2 with his/her hands around Resident #2's throat or neck. During an interview on 9/24/20 at 3:10 PM, CNA #5 said that on 9/2/20 around 5:30 P.M., she saw Resident #1 standing beside Resident #2 with his/her hands grabbing Resident #2's face. During an interview on 9/21/20 at 4:07 PM, Nurse #1 said that on 9/2/20 around 5:30 P.M., she heard commotion in the dining room and when she responded, CNA #1 and CNA #5 were separating Resident #1 and Resident #2. Nurse #1 said that CNA #1 and CNA #5 told her that Resident #1 tried to choke Resident #2 and grabbed Resident #2's face. During an interview on 9/14/20 at 4:15 P.M., the Director of Nurses said that Resident #1 was sent to the emergency department for an evaluation on 9/2/20 and when he/she returned, he/she was placed on one to one supervision. Resident #1's care plan concern for behaviors included an update on 9/3/20 which indicated that he/she would receive one to one supervision by staff members. Resident #3's MDS Assessment indicated his/her cognitive patterns were severely impaired. Resident #3 was not interviewed by the Surveyor due to Resident #3's cognitive impairment. CNA #1 said that on 9/8/20 during the 3:00 P.M. to 11:00 P.M. shift, she was assigned to provide Resident #1's one to one supervision. CNA #1 said that around 6:00 P.M. she and Resident #1 were seated at a table together in the dining room. CNA #1 said that although she and Resident #1 were alone at the table, residents were seated at other tables in the dining room. CNA #1 said that when the meal trucks were parked in the doorway to the dining room, she stood and walked across the dining room to retrieve Resident #1's meal tray. CNA #1 said while retrieving the tray, she heard yelling and when she turned around, she saw Resident #1 standing next to Resident #3 with his/her hands wrapped around Resident #3's neck. CNA #1 said that she and another CNA separated Resident #1 from Resident #3. In an email dated 9/23/20, the Administrator wrote that the Maintenance Director measured the distance from the dining room table where CNA #1 left Resident #1 to the meal trucks to be 9.5 to 10 feet. The Director of Nurses said Resident #1 was sent to the hospital emergency department on 9/8/20 for evaluation. Although Resident's #2 and #3 were cognitively impaired and unable to communicate physical and mental harm, a reasonable person would experience physical pain and mental anguish when choked and slapped by another resident.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was severely cognitively impaired, resided on a secure locked unit and wandered daily, the Facility failed to ensure staff provided adequate supervision to prevent an injury or accident. - On 08/07/19 Resident #1, who resided on the second floor secured locked unit, was found in the basement, near the kitchen, sitting on the floor by the kitchen staff. Resident #1 was transferred to the Hospital Emergency Department for evaluation, where he/she was diagnosed with [REDACTED]. Findings include: Resident #1 was admitted to the Facility in (MONTH) 2019 and resided on the second floor secured locked unit of the Facility. Resident #1's [DIAGNOSES REDACTED]. Resident #1's Elopement and Wandering Screen, dated 6/17/19, indicated he/she exhibited behaviors of trying to leave the facility, wandered aimlessly and was at risk for wandering and elopement. Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 6/21/19, indicated he/she was severely cognitively impaired, required extensive assist with ambulation and his/her behaviors included wandering daily. Resident #1's Resident Care Card, dated 7/2019, indicated he/she required assist with ambulation and had intrusive wandering behavior. Resident #1's Care Plan, dated as revised on 4/17/19, indicated he/she moved with no direction, destination or purpose, was intrusive and wandered on the unit. The Care Plan indicated to assist Resident #1 in finding his/her room and unit as needed, to use hand in hand assist to direct him/her to a safe area during wandering behavior and to redirect him/her to his/her room. A Nurses Note, dated 8/7/19, indicated at 5:00 [NAME]M. Resident #1 was found downstairs by the kitchen. The Note indicated Resident #1 complained of right elbow pain upon touch and was transferred to the Hospital for evaluation. A Fall Incident Report and Investigation, dated 8/7/19 at 5:00 [NAME]M., indicated Resident #1 was found in front of the kitchen and was transferred to the Hospital. The Health Care Facility Reporting System (HCFRS) Report, dated 8/7/19, indicated that at 4:55 [NAME]M., Resident #1 was found sitting on the floor by a kitchen staff member. The Report indicated Resident #1 had right hip and right shoulder discomfort and was transferred to the Hospital Emergency Department, where he/she was diagnosed with [REDACTED]. A Hospital Emergency Department Report, dated 8/7/19, indicated Resident #1 was seen after an unwitnessed fall at the Nursing Home. The Report indicated Resident #1 complained of right elbow pain, an x-ray was obtained and revealed a right supracondylar fracture. The Surveyor interviewed the Kitchen Staff Member at 11:40 [NAME]M. on 8/28/19. The Kitchen Staff Member said that at 4:55 [NAME]M., she saw Resident #1 sitting on the floor next to the kitchen that is located on the basement level of the Facility. The Kitchen Staff Member said she notified Nurse #2. Nurse #2's written witness statement, dated 8/7/19, indicated that at 5:01 [NAME]M., a kitchen staff member notified her that there was a resident on the floor in front of the kitchen. The Statement indicated Nurse #2 went to investigate and found Resident #1, who was quite confused, unable to identify him/herself and unknown to Nurse #2, sitting on the floor across from the kitchen, leaning on his/her right elbow. The Statement indicated that a Code Dixie (overhead page indicating a resident was found on the floor and all nurses must respond) was called and a Certified Nurse Aide (CNA), who came to the Code Dixie, identified Resident #1 as a resident who resided on the secured locked unit on the second floor. The Statement indicated that two hours prior to this incident, an alarm was heard sounding from the basement level hallway door, the Nursing Supervisor was notified that, she turned off the alarm and directed all units to check all residents to ensure no one was missing from their unit. The Surveyor interviewed Nurse #2 at 2:04 P.M. on 9/5/19. Nurse #2, who worked on the basement level unit, said that at approximately 3:00 [NAME]M. she heard an alarm sound from the basement level hallway door, said she went to reset the alarm but did not know the code and said she called the Nursing Supervisor. Nurse #2 said the Nursing Supervisor came to the basement level, reset the alarm to the hallway door and directed her to check her unit to ensure all residents were accounted for. Nurse #2 said that she did not search the basement level when she heard the alarm sound. Nurse #2 said that at approximately 5:00 [NAME]M. a kitchen staff member notified her that one of her residents was on the floor near the kitchen. Nurse #2 said she went to see who the resident was, said Resident #1 was not one of her residents and said she did not know who Resident #1 was. Nurse #2 said she called a Code Dixie, said several staff members responded to the Code Dixie and said a CNA from another unit identified Resident #1 as a resident who resided on the secured locked unit on the second floor. The Nursing Supervisor's written witness statement, undated, indicated that at 3:00 [NAME]M. an alarm was sounding, all units were asked to do bed checks and everyone said that all residents were accounted for. The Statement indicated that at 5:00 [NAME]M., a Code Dixie was called in front of the kitchen, that she went down to respond and found Resident #1, who resided on the secured locked unit on the second floor, lying on the floor. The Statement indicated Resident #1 complained of right shoulder and right hip pain, and that 911 (Emergency Response) was called. The Surveyor interviewed the Nursing Supervisor at 9:50 [NAME]M. on 9/5/19. The Nursing Supervisor said that approximately 3:00 [NAME]M. the alarm was sounding from the basement level hallway door and said she took the elevator down to the basement level. The Nursing Supervisor said she did a quick glance around the basement hallway, said she did not see anyone, said she reset the alarm and walked up the staircase. The Nursing Supervisor said she called all of the units and directed them to do a head count of all of their residents and said no one reported any resident missing. The Nursing Supervisor said at 5:00 [NAME]M. Nurse #2 called a Code Dixie to the basement and said when she responded, she saw Resident #1 on the floor by the kitchen on the basement level. The Nursing Supervisor said she did not know how Resident #1 got down four flights of stairs to the basement level from the second floor secured locked unit. Nurse #1's written witness statement, dated 8/7/19, indicated Resident #1 was pacing and exit seeking. The Statement indicated that between 1:00 [NAME]M. and 3:00 [NAME]M., Resident #1 tried to go into the other unit on the second floor, was redirected three times and continued to pace the unit. The Statement indicated that at 4:45 [NAME]M., a Code Dixie was called to the basement kitchen area, that Nurse #1 went down the stairs to the basement and found Resident #1 sitting on the floor by the kitchen. The Statement indicated Nurse #1 did not receive a call from the Nursing Supervisor regarding the alarms going off downstairs. The Surveyor interviewed Nurse #1 at 10:11 [NAME]M. on 9/5/19. Nurse #1 said that Resident #1 had been walking around the unit and said he/she walked over to the other unit on the second floor several times during the early morning hours. Nurse #1 said the last time she saw Resident #1 was approximately 3:00 [NAME]M. and said she that at approximately 5:00 [NAME]M., she heard a Code Dixie announced to the basement kitchen area. Nurse #1 said that when she responded to the basement kitchen area, she said she was shocked to see that Resident #1 was sitting on the floor and said she did not know how Resident #1 made it down four flights of stairs. Nurse #1 said she did not receive a call from the Nursing Supervisor regarding the alarm going off downstairs. CNA #1's written witness statement, undated, indicated Resident #1 was walking around the unit and she was notified by Nurse #1 that Resident #1 was found downstairs in the basement level of the Facility. The Statement indicated CNA #1 did not know how Resident #1 got downstairs to the basement level of the Facility. The Surveyor interviewed CNA #1 at 11:01 [NAME]M. on 9/5/19. CNA #1 said that Resident #1 had wandered around the unit and wandered to the other unit on the second floor several times during the early morning hours. CNA #1 said that at approximately 3:00 [NAME]M., she provided care to Resident #1, said she transferred him/her to bed and said that was the last time she saw Resident #1 on the unit. CNA #1 said she was unaware that an alarm had sounded earlier in the basement level hallway door and said she was not instructed to do a head count. The Surveyor interviewed the Administrator at 3:22 P.M. on 8/28/19. The Administrator said that the basement level hallway alarm sounded and the Nursing Supervisor called all of the units to do a head count. The Administrator said that Nurse #1 said she never received a call from the Nursing Supervisor to do a head count after the basement level hallway door alarm sounded. The Administrator said Nurse #1 did not do a head count and said somehow Resident #1 got down to the basement level.

Based on records reviewed, interviews, and observations, for one of five sampled residents (Resident #5) the Facility failed to ensure staff maintained his/her safety to prevent injury, when on 6/18/19, he/she was given a shower by a Certified Nurse Aide (CNA), the shower chair used by the CNA was defective, missing three rubber foot [MEDICATION NAME], and the shower chair was unstable. The CNA asked Resident #5 to stand during the shower, Resident #5 started to lose his/her balance, when he/she went to sit back down and the shower chair slid away from him/her, resulting in Resident #5 to fall. Resident #5 sustained a tow centimeter (cm) laceration to his/her head, was transferred the Hospital Emergency Department for treatment and required four staples to close the wound. Findings include: The Facility's Policy titled, Environmental Rounds dated 7/2017, indicated the following: -The Infection Preventionist or his/her designee, Charge Nurses, Supervisors, and Department Heads participate in environment rounds on a regular basis, but at least quarterly. -Environmental rounds will be an integral part of daily routine and also will be performed regularly throughout the entire facility, with detailed reporting to all units and departments as needed. Although the Facility provided documentation to support shower chairs were inspected starting on 6/20/19, there was no indication of what staff inspected or looked at. The Facility was unable to provide any documentation to support shower chairs were inspected prior to the 6/18/19 incident on a regular basis. Resident #5's Face sheet indicated that he/she was admitted to the Facility in (MONTH) 2019, [DIAGNOSES REDACTED]. The Health Care Facility Reporting System (HCFRS) Report, dated 6/20/19, indicated that on 6/18/19 at 4:20 P.M., while being showered by CNA #7, Resident #5 slipped and fell on to the floor, sustained a laceration to the back of his/her head. The HCFRS Report indicated the Facility's conclusion related to the incident was the following: -The CNA did not inspect the shower chair prior to use. -The shower chair was missing three out of the four rubber [MEDICATION NAME] that are put on the legs, making the chair unstable. A physician's orders [REDACTED].#5 to the hospital emergency department. The Hospital Emergency Department Report, dated 6/18/19, indicated Resident #5 had a right two cm occipital (trapezoidal-shaped bone found at the lower-back are of the head) laceration that required four staples to repair. Surveyor #2 interviewed Resident #5 at 11:20 A.M. on 6/28/19. Resident #5 said the shower chair was unbalanced causing him/her to slip and fall backwards on to the floor. The Facility's Investigation, dated 6/20/19, indicated that the shower chair used by Resident #5 was missing three of the four rubber foot [MEDICATION NAME] making the chair unstable. The Investigation indicated, Certified Nurse Aide (CNA) #7 did not inspect the shower chair prior to use. Surveyor #2 interviewed the Director of Nurses (DON) at 9:00 A.M. on 6/28/19. The DON said she did not look at other shower chairs or equipment after the incident, because the chair Resident #5 preferred, was a specific chair only he/she used. The DON said that the CNA's were responsible for checking shower chairs and said she did not know if maintenance checked shower chairs when they completed environmental rounds. Surveyor #2 interviewed the Nurse Manager at 9:39 A.M. on 6/28/19. The Nurse Manager said the CNA's or any staff should look at equipment before use. The Nurse Manager said the Infection Control Nurse does environmental rounds, looking for hazards and safety, but did not know how often they were done. On 6/28/19, Surveyor #1 and Surveyor #2 conducted observations in the shower rooms for all units in the facility, the findings are as follows: -One of two shower rooms on the(NAME)Unit, contained one shower chair that was missing the right rear chair leg rubber foot [MEDICATION NAME]. -One of two shower rooms on the(NAME)Unit, contained one shower chair that was missing the left rear chair leg rubber foot [MEDICATION NAME]. Surveyor #2 interviewed the Infection Control Nurse (ICN) at 11:45 A.M. on 6/28/19. The ICN said since the incident on 6/18/19, the Facility had done environmental rounds twice on all shower chairs and replaced rubber foot [MEDICATION NAME] if they were missing. The ICN, after she was informed by the Surveyors that there were two shower chairs found on 6/28/19, missing rubber foot [MEDICATION NAME], on the(NAME)and(NAME)Units, said she could not explain why. Surveyor #1 interviewed the Director of Maintenance at 11:46 A.M. on 7/30/19. The Director of Maintenance said that he did weekly environmental rounds prior to Resident #5's fall and said he was not aware that the shower chair was missing three rubber foot [MEDICATION NAME], until he was informed by nursing staff after the incident. Surveyor #2 interviewed the Director of Operations at 10:40 A.M. on 6/28/19. The Director of Operations said he would have expected the Facility to look at all shower chairs, after the incident involving Resident #5 on 6/18/19, to ensure safe working conditions for all shower chairs. The DON, when informed by Surveyor #2 that two shower chairs were observed on 6/28/19, to be missing rubber foot [MEDICATION NAME], on the(NAME)and(NAME)Units, said she was surprised by the observations.

Based on records reviewed and interviews, for one of eight sampled residents (Resident #6), the Facility failed to provide necessary mental health and counseling services as ordered by the physician to address Resident #6's multiple losses, hopelessness and depression. Findings include: Resident #6 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. A Hospital Discharge Summary, dated 10/3/18, indicated Resident #6 had been seen by psychiatry and psychology throughout his/her stay at the hospital from 7/26/18 through 10/3/18. A Physician's Progress Note, dated 10/22/18, indicated Resident #6 stated he/she had not had a shower in over one week, was weepy during our conversation, was upset with the care he/she received at the Facility, had depression and anxiety and to re-consult the Facility's Psychiatric Services Provider. A Physician's Telephone Order, dated 10/23/18, indicated to consult the Facility's Psychiatric Services Provider to see Resident #6 as soon as possible for increased depression and hopelessness. A Physician's Telephone Order, dated 10/26/18, indicated that Resident #6 be seen by the Facility's Psychiatric Services Provider. Review of Resident #6's clinical record indicated there was no documentation to support that the Facility had Resident #6 evaluated by psychiatric services as ordered by the physician. Surveyor #1 and Surveyor #2 interviewed Resident #6 at 11:30 A.M. on 11/13/18. Resident #6 said he/she did not know what counseling services or psychiatric services were available at the Facility and said he/she would like someone to talk to. Surveyor #1 and Surveyor #2 interviewed the Nurse Practitioner at 12:15 P.M. on 11/26/18. The Nurse Practitioner said she had requested and wrote orders to have Resident #6 evaluated by psychiatric services for his/her depression. The Nurse Practitioner said Resident #6 was experiencing mood swings. The Nurse Practioner said it would be beneficial for Resident #6 to be evaluated by psychiatric services because he/she has been through a lot, feels hopeless, is depressed about his/her situation and has experience a lot of losses. Surveyor #1 and Surveyor #2 interviewed the Social Worker at 2:40 P.M. on 11/26/18. The Social Worker said Resident #6 was supposed to be evaluated by psychiatric services at the Facility. The Social Worker said the Facility's psychiatric provider services were in transition and said she was unsure if Resident #6 was ever evaluated by the psychiatric provider. The Social Worker said she was unsure if the Facility currently had a psychiatric provider. The Social Worker said she was unsure of the Facility's referral process for informing the psychiatric provider of a resident consult. The Social Worker said she was new to the Facility and said Resident #6 fell through the cracks. Surveyor #1 and Surveyor #2 interviewed Nurse #5 at 3:35 P.M. on 11/26/18. Nurse #5 said she did not know if Resident #6 was evaluated by psychiatric services and said she did not know if Resident #6 had a physician's orders [REDACTED]. Surveyor #1 and Surveyor #2 interviewed the Director of Nurses (DON) at 4:00 P.M. on 11/26/18. The DON said Resident #6 was not evaluated by psychiatric services, said it was an oversight and said currently the Facility did not have a psychiatric services provider.

Based on observations, records reviewed and interviews, for one of eight sampled residents (Resident # 6), the Facility failed to ensure that Resident #6's individualized care requests related to dependence on staff for eating and getting out of bed daily, were reasonably accommodated. Findings include: Resident #6 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) Assessment, dated 10/8/18, indicated Resident #6 was totally dependent requiring the assistance of one staff member with eating and two staff members with transfers. Resident #6's plan of care for Activities of Daily Living (ADL), dated 10/11/18, indicated he/she had physical deficits related to [MEDICAL CONDITION] and was dependent on staff with eating and two staff assist with transfers in and out of bed. Resident #6's Resident Care Card, used by the Certified Nursing Assistants, dated 11/2018, indicated he/she was a total feed and required a mechanical lift and two staff member for assistance with transfers. Resident #6's plan of care for nutrition, dated 10/10/18, indicated he/she was at risk for nutritional decline related to multiple food intolerances and indicated to allow resident sufficient time to eat. Resident #6's Comprehensive Nutrition Assessment, dated 10/18/18, indicated he/she had physical limitations with eating due to [MEDICAL CONDITION] and was totally dependent on staff with eating. Surveyor #1 and Surveyor #2 interviewed Resident #6 at 11:30 A.M. on 11/13/18. Resident #6 was crying and said he/she requires two staff to get out of bed, said staff tell her/him they are going to find someone to help get him/her out of bed but don't return to get him/her out of bed. Resident #6 said she/he has to stay in bed on multiple occasions because two staff were unavailable to get him/her out of bed. Resident #6 said his/her food is always cold when he/she is fed. Resident #6 said he/she is always the last one to be fed and said staff usually have to reheat his/her meal and said he/she wanted to be transferred to another Facility. On 11/13/18 at 11:50 A.M., Surveyor #1 and Surveyor #2 observed a staff member drop off Resident #6's lunch tray on his/her overbed table in his/her room and leave the room. Resident #6 was lying in bed waiting for a staff member to come in and feed him/her lunch meal. Resident #6 has total loss of use of arms and is unable to reach, pick up or assist in any part of eating. Resident #6 is totally dependent on staff for eating. At 12:20 P.M., a staff member entered Resident #6's room and informed her/him that she was going to feed him/her lunch (tray sat for one half hour and meal did not get re-heated). Surveyor #1 and Surveyor #2 interviewed Nurse #1 at 12:25 P.M. on 11/13/18. Nurse #1 said staff pass out all of the trays on the food trucks first and then staff go back to residents who require help with eating. Nurse #1 said staff were going to get Resident #6 out of bed after lunch because there were multiple residents on the unit who needed to get out of bed before Resident #6. Surveyor #1 interviewed Resident #6 at 4:20 P.M. on 11/13/18. Resident #6 said that his/her lunch meal was cold when he/she was fed by staff. Resident #6 began to cry and said staff feed him/her too fast, rush him/her during meals and shovel food down my throat. Resident #6 said he/she has to tell the staff to wait for him/her to finish chewing and swallowing a bite before giving him/her another bite of food. Surveyor #1 and Surveyor #2 interviewed Resident #6 at 11:50 A.M. on 11/26/18. Resident #6 said he/she had cold French toast for breakfast. Resident #6 said staff told him/her that other residents' trays have to be passed out before he/she is fed. Resident #6 said that staff told him/her that she/he has to be fed last because he/she takes the most time to be fed. Resident #6 said staff make and treat him/her like the last one on the totem pole and said he/she wants out of the Facility. Surveyor #1 and Surveyor #2 interviewed Certified Nurse Aide (CNA) #1 at 3:10 P.M. on 11/26/18. CNA #1 said staff pass out all of the trays on the food trucks before they feed Resident #6. CNA #1 said staff feed Resident #6 as soon as possible, said Resident #6 has complained to her that his/her meal was cold. CNA #1 said staff warm up Resident #6's meal before feeding him/her. CNA #1 said Resident #6 required two staff to transfer out of bed and said she was going to get Resident #6 out of bed after lunch. Surveyor #1 and Surveyor #2 interviewed the Director of Nurses (DON) at 4:00 P.M. on 11/26/18. The DON said that her expectation is that Resident #6 be fed meals that are warm not cold. The DON said Resident #6 should not be rushed when being fed by staff or have to wait until all of the trays on the food trucks are passed before being fed by staff. The DON said staff should get Resident #6 out of bed daily, which is his/her preference.

Based on records reviewed and interviews, for one of eight sampled residents (Resident #6), the Facility failed to ensure that: -Resident #6 who experienced a traumatic cervical spinal cord injury, resulting in [MEDICAL CONDITION] (total paralysis and total loss of use of arms, legs and torso) and expressed concerns related to hopelessness and depression; -a comprehensive psychosocial assessment was completed for traumatic cervical spinal cord injury and depression to determine the appropriateness of treatments and services he/she required related to his/her ability to adjust to major physical limitations and dependence on others. Findings include: Resident #6 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. A Hospital Discharge Summary, dated 10/3/18, indicated Resident #6 had been seen by psychiatry and psychology throughout his/her stay at the hospital from 7/26/18 through 10/3/18. A Physician's Progress Note, dated 10/22/18, indicated Resident #6 stated he/she had not had a shower in over one week, was weepy during our conversation, was upset with the care he/she received at the Facility, had depression and anxiety and to re-consult with the Facility's Psychiatric Services Provider. A Physician's Telephone Order, dated 10/23/18, indicated to consult the Facility's Psychiatric Services Provider to see Resident #6 as soon as possible for increased depression and hopelessness. A Physician's Telephone Order, dated 10/26/18, indicated that Resident #6 be seen by the Facility's Psychiatric Services Provider. Review of Resident #6's clinical record indicated that as of 12/3/18 there was no documentation to support that the Facility had Resident #6 evaluated by psychiatric services as ordered by the physician. Surveyor #1 and Surveyor #2 interviewed Resident #6 at 11:30 A.M. on 11/13/18. Resident #6 said he/she did not know what counseling services or psychiatric services were available at the Facility and said he/she would like someone to talk to. Surveyor #1 and Surveyor #2 interviewed the Nurse Practitioner at 12:15 P.M. on 11/26/18. The Nurse Practitioner said she had requested and wrote orders to have Resident #6 evaluated by psychiatric services for his/her depression. The Nurse Practitioner said Resident #6 was experiencing mood swings. The Nurse Practioner said it would be beneficial for Resident #6 to be evaluated by psychiatric services because he/she has been through a lot, feels hopeless, is depressed about his/her situation and has experience a lot of losses. Surveyor #1 and Surveyor #2 interviewed the Social Worker at 2:40 P.M. on 11/26/18. The Social Worker said Resident #6 was supposed to be evaluated by psychiatric services at the Facility. The Social Worker said the Facility's psychiatric provider services were in transition and said she was unsure if Resident #6 was ever evaluated by the psychiatric provider. The Social Worker said she was unsure if the Facility currently had a psychiatric provider. The Social Worker said she was unsure of the Facility's referral process for informing the psychiatric provider of a resident consult. The Social Worker said she was new to the Facility and said Resident #6 said words to the effect of fell through the cracks. Surveyor #1 and Surveyor #2 interviewed Nurse #5 at 3:35 P.M. on 11/26/18. Nurse #5 said she did not know if Resident #6 was evaluated by psychiatric services and said she did not know if Resident #6 had a physician's orders [REDACTED]. Surveyor #1 and Surveyor #2 interviewed the Director of Nurses (DON) at 4:00 P.M. on 11/26/18. The DON said Resident #6 was not evaluated by psychiatric services, said it was an oversight and said currently the Facility did not have a psychiatric services provider.

Based on observation, record review and interviews, the Facility failed to maintain acceptable nutritional parameters including weights related to tube feedings not administered as ordered for 1 of 3 Residents ( #109) with enteral feedings, from a total sampled of 35 Residents. Findings include: For Resident #109, the facility failed to maintain acceptable nutritional parameters including weights related to tube feedings not administered according to physician's orders [REDACTED]. Resident #109 was admitted to the facility in 2/2013 with [DIAGNOSES REDACTED]. Review of the most recent annual Minimum Data Set (MDS), with a reference date of 8/17/17, indicated that Resident #109 was rarely or never understood, and was dependent on staff for eating, hygiene and bathing. The assessment indicated the Resident received tube feeding and was not on any mechanically altered oral diet, and received 51% or more of his/her nutrition via a parental or feeding tube route. Review of the medical record indicated the following physician's orders [REDACTED].>- NPO (to receive nothing by mouth) - Promote with fiber (nutritional formula) 80 ml (milliliters)/hour over 20 hours - up at 1:00 P.M., down at 9:00 A.M. for a total volume of 1600 ml/day via G Tube ([DEVICE]) - weekly weights Review of the Resident's current Care Plan indicated a Nutritional Care Plan was initiated on 2/25/17 and last revised on 9/5/17. The Care Plan indicated the Resident was dependent on tube feeding related to [DIAGNOSES REDACTED]. The Care Plan also indicated the Resident was NPO (nothing by mouth). Care Plan interventions included administration of tube feeding as ordered and monitor weights. A Nutrition Assessment was completed by the Registered Dietitian on 11/17/17. The assessment indicated the Resident was NPO and received nutrition exclusively via the tube feeding formula (1600 ml daily). The Nutrition Assessment also indicated the Resident's nutritional status would be monitored by weekly weights. Review of the Resident's weights from 11/2017 through 12/2017 indicated the following weights were recorded: 11/13/17 200.5 lbs (pounds) 12/13/17 189.0 lbs (5% weight loss) 12/27/17 189.0 lbs The following observations were made: - On 12/28/17 at 1:17 P.M. Resident # 109 was observed seated in his/her tilt wheelchair in the unit hallway. Tube feeding was not connected and not running. This was not consistent with the physician's orders [REDACTED].>- On 12/28/17 at 1:20 P.M. the Surveyor Observed the agency nurse take Resident #109 into his/her room, flush the G Tube and hook up the tube feeding. The pump was observed to be running at 80 ml/hour. - On 1/02/18 at 1:29 P.M. Resident #109 was observed seated in tilt chair along wall in unit hallway. The tube feeding was not connected and not running. This was not consistent with the physician's orders [REDACTED].>- On 1/02/18 at 1:42 P.M. Resident #109 was observed in his/her room with a staff nurse. The nurse connected tube feed and turned on the pump to initiate the tube feeding. The pump was observed to be running at 80 ml/hour. - On 1/05/18 at 1:22 P.M. Resident #109 was observed sitting in his/her tilt wheelchair to his/her room. Tube feed was not connected and not running. Nurse #2 was observed performing a flush and and then connecting the tube feeding. The pump was observed to be running at 80 ml/hour. - On 1/8/18 at 8:30 A.M. the Surveyor observed Resident #109 lying in bed, G Tube feeding not connected; tubing was observed wound up and hanging from the pump. Nurse #2 was interviewed on 1/8/18 at 8:30 A.M. She said that she had not been in to see Resident #109 yet, and did not know who had discontinued the tube feeding. She said that sometimes the CNAs (certified nursing assistant) will disconnect the tube feeding if they have to provide care, and that they may have forgotten to resume the feeding. During interview with Unit Manager #3 (UM #3) at 8:42 A.M., Surveyor's observations of the [DEVICE] feedings were shared. She said that she was unaware that Resident #109 had weight loss. UM #3 said that she thought that there was a 1 hour window before and after ordered administration time in which the tube feeding could be initiated and discontinued. UM #3 said that it is not within a CNA's scope of practice to disconnect and reconnect G Tubes. In the presence of the Surveyor, UM #3 called nurse #3 (on the telephone) whom was on duty the previous shift. Nurse #3 told UM #3 that the Resident was given medication at 6:00 A.M. through the G Tube, flushed the tube with no problem and the tube feeding was resumed. During subsequent interview with UM #3 on 1/8/18 9:20 A.M., she said that she was unable to determine who disconnected Resident #109's tube feeding. UM #3 said that there is no way to determine that Resident #109 receives the volume of tube feeding as ordered by the physician unless it is going up and down at the specified times. The facility's consultant Dietitian was interviewed via telephone on 1/8/18 at 12:15 P.M. She said that she started working at the facility as a temporary consultant in early (MONTH) (YEAR) and said that staff were not taking Residents' weights consistently. The Dietitian said that Resident #109 had a nutrition assessment on 11/17/17 and his/her weight was reviewed. She documented the Resident's weight as 201.2 on 11/8/17, but said that there was no weight documented in the record from 30 days prior to compare it to and therefore documented the Resident's weight status as stable. Observations of late administration and early discontinuation of tube feeding during survey was shared with the Dietitian. She said she believes the volume of tube feeding formula needs to be monitored, not just that it is going up and going down and has shared her concern with the lead Dietitian at the facility.

Based on document review, staff and Resident interviews, the Facility failed to ensure that Residents were free from abuse, neglect, and misappropriation of personal property for 1 sampled Residents (#107), from a total sample of 35 Residents. Findings include: 1. Resident #107 was admitted in 12/2014. According to the most recent BIMS (Brief Interview for Mental Status) 15 of 15, the Resident was alert and oriented to person, place, and situation. On 12/27/17 at 9:30 A.M., the Resident said to Surveyor #2 that she was mistreated by CNA #5, a couple of weeks prior. The Resident explained, that CNA #5 had volunteered to work a double shift from 3:00 P.M. on 12/17/17, to 7:00 A.M. on 12/18/17. CNA #5 reportedly told the Resident that because she was tired from working her regular shift, that the Resident should not be using his/her call light. The Resident said to Surveyor #2 that the CNA put him/her on the bed pan. The Resident couldn't remember if the CNA stayed with him/her or left. The Resident said that when the CNA took the Resident off the bed pan, the bed pan spilled urine all over the Resident's bed. According to the Resident, the CNA dabbed the wet pad with a towel to soak up the urine. The Resident told the CNA that the pads were still wet. The Resident said that the CNA told the Resident to turn over and the CNA yanked the pads out from under him/her roughly. The CNA reportedly tried to just put a yellow incontinent brief under the Resident but the Resident wanted the more absorbent soaker pad placed underneath her. The CNA got a soaker pad and placed it partially under the Resident. The Resident told the CNA that he/she did not want the soaker pad half way under him/her and that he/she would roll back and forth so that the soaker pad would be flat under the Resident. Next, according to the Resident's statement, the Resident heard the Nurse and CNA #5 having words down the hallway from the Resident's room. When the CNA returned to the Resident's room, the Resident said that the CNA told him/her, I'm tired of this, and you're a piece of[***] The Resident told Surveyor #2 on 12/27/17, that he/she was very upset by the way CNA #5 treated him/her when the CNA refused to provide appropriate incontinent care, and told the Resident, You're a piece of[***] On 12/27/17 at 2:05 PM, Surveyor #2 Informed the DON of the Resident's complaint of neglect/verbal abuse by CNA #5 on 12/17/17, who refused to provide incontinent care to the Resident and allegedly called the Resident a piece of[***] According to the DON, she said she knew about the incident, however as of 12/27/17, the incident had not been reported to the State or investigated, in accordance with the Facility Abuse Prohibition Policy. CNA #5 continued to work at the Facility, providing care to Residents on a different nursing unit without any repercussion as a result of the reported verbal abuse and neglect.

Based on record review, interviews and observation, the Facility failed to ensure a comprehensive plan was implemented to maintain the skin integrity for 1 Resident (#108) identified at risk for impaired skin, from a total sample of 35, and provide and appropriate interventions to promote healing, prevent infection, and prevent new areas from developing. Findings include: For Resident #108, impaired skin areas were not communicated and / or investigated timely according to Facility policy and alternative care plan approaches were not implemented to avoid worsening. Resident #108 was readmitted in 8/2017 after an extended hospitalization for multiple co-morbidities including respiratory distress, aspiration pneumonia and chronic tracheotomy, [MEDICAL CONDITION] and spastic [MEDICAL CONDITION]. Review of the Minimum Data Set (MDS) assessment dated [DATE], Resident #108 had three unhealed stage II pressure areas; with approaches to use a pressure relief device chair and bed and to reposition every 2 hours. The Resident's quarterly 11/14/17 MDS assessment indicated severe cognitive impairment, total dependent for all care areas of daily life, bladder/bowel incontinence, weight loss of 5 % at 155 pounds, with nutrition and hydration provided via feeding tube. For skin care, the assessment indicated one unhealed worsening stage 3 area (1 x 1.5 x. 1) and one healed stage 2 area. Treatments included ointment/medications and pressure devices for bed and chair. Documentation of impaired skin areas were not communicated and / or investigated timely according to Facility policy and alternative care plan approaches were not implemented to avoid impaired skin. 1. During interview on 1/3/18, a Resident representative (family) expressed concern for consistent care, as staff do not communicate or always know how to care for residents. The family member pointed to a bandaged ankle on Resident #108's left lower extremity and said that he/she noticed and reported the broken skin area, staff had not been aware. This was upsetting to the family member. Record review indicated a treatment prescribed on 11/5/17 to an area on the Resident's left ankle. Nursing progress notes for that date (11/5/2017) failed to provide details of what occurred other than an interim order for treatment to the area. Review of Facility incident documentation for bruise/skin tears included the an incident report dated 11/6/17, for the area on the Resident's ankle that was found by family member, and per investigation the a nurse aide had reported the area to nursing (3-11 shift) on 11/5/17. Further review, the incident investigation was incomplete, there was no report from the nurse working the shift. Review of progress notes and interview with Unit Manager #1 on 1/3/18 said that the origin of skin injury was uncertain, said it may have developed from the orthotic boot and or the pressure of the orthotic on skin during repositioning. Further interview with Unit Manager #1 said the ankle area was likely due to a bar on the chair or orthotic devices, used on lower extremities in bed, explaining that they may not have been put on correctly. The orthotic had soft fleece padding over a hard plastic brace. Review of the plan of care for impaired skin integrity and risk of contractures dated 12/11/13, did not included any updated approaches or resident specific. The approaches listed splints/devices as indicated, monitor skin, and PT OT as indicated. The plan of care for impaired skin integrity dated 12/11/13, stated to apply splints/devices as indicated, and rehab screen for seating / positioning; however the approaches to ensure consistent care were vague, and not resident specific. There was no mention that lower extremity orthotic devices were ill fitting, or on hold, nor was there another approach or intervention for skin protection. Resident #108 was observed in bed on 1/2/18, 1/3/18 and 1/5/18 without anything on lower extremities and when in the wheelchair, the resident was observed dressed wearing sneakers. As of 1/5/18, the Resident was still receiving treatment to the left ankle pressure wound area. Observation on 1/5/18 at 12:10 P.M., the skin area was covered with a white dressing, reddish, superficial, irregular shaped approximately 1 centimeter with small amount of serosanguinous drainage. Observation of Resident #108 on 1/2/18 during the afternoon and on 1/3/18 in the morning, no protective devices were in use for lower extremities. 2. Preventative interventions to avoid pressure and skin impairments were not communicated to the physician as recommended by the wound consultant. Review of the plan of care failed to identify specific orthotic devices in use or on hold to ensure consistent appropriate application for skin integrity. Although there was no current order for services to be provided by the wound clinic physician, the wound consultant recommendations were not implemented. For example: lower extremity protective devices recommended by the wound physician on 11/30/17, 12/7/17, 12/14/17 and 12/21/17 were not implemented. Review of Wound Clinic physician's consult note dated 11/30/17, the right buttock (1 x 0.8 x 0.1 cm) area indicated the healing stage III area, improved. The left lateral ankle has a new ulceration (1.5 x 0.8 x non-stageable) area. Treatment to the ischium included to continue Triad cream 3 times a day. Treat the left ankle with Santyl nickel layer, foam dressing and change daily. Although using an air mattress, should be using Protective (Prevalon) boots 24/7 to protect ankles. On 12/7/17, the Wound Clinic consult report indicated the Resident's right buttock ulcer had healed. The left ankle pressure injury measures (1.5 x 1.1 x 0.2 centimeters) with loose brown devitalized tissue, some swelling. Resident was treated for [REDACTED]. The wound consultant physician's recommendation included use of a protective boot to lower extremities (Prevalon boot) when in bed and in the wheelchair. The wound consultant's recommendation for use of a protective boot was noted on 12/14/17, and again on 12/21/17, to use protective boot in bed and in the wheelchair. The medical plan of care failed to indicate that Resident #108 received services from the wound clinic. Record review on 1/2/18 failed to include a current order for consultant wound care. Interview with the Facility's Wound Nurse on 1/3/18 said she can not locate the order, and had no explanation why monthly orders did not include wound clinic consultant services or implementation of a protective boot. During interview at 8:45 A.M. on 1/3/18, the physical therapy assistant said that no devices were in use and that they were on hold due to skin. Interview with the Rehabilitation Manager on 1/3/18 at 10:18 A.M., who was new to the Facility, was unable to clarify what device Resident #108 was suppose to wear in and or out of bed. The Rehabilitation Manager was not aware of the Wound consultant's prior recommendations for use of protective boots for the Resident's lower extremities. A physical therapy assistant note dated 1/2/18, indicated no lower extremity devices were in use. During interview with Unit Manager #1 on 1/3/18 for clarification of what skin prevention approaches were in use, Unit Manager #1 said that she has devices (called multi-podus boots) in her office. Observation of the boots, the boots appeared new and unused. Unit Manager #1 said they were not using them due to the Resident's ankle area. Further interview, Unit Manager #1 said that the Resident wears other foam type boots in bed, however Unit Manager #1 and Surveyor toured the resident unit and room area and Unit Manager #1 could not locate any foam or protective boots that were in use for Resident #108. Interview on 1/3/18 with nurse aide #6, said was not aware of any other devices and none were located in the Resident's room. Unit Manager #1 said that in the past, the practice was to have a photo of the Resident while wearing orthotic / rehab equipment and that the photo was kept in Resident's room (closet) or nurse aide care card to ensure all staff knew how and what devices were used for Residents. However, there was no photo or list of resident specific orthotic or skin prevention equipment in Resident #108's room, nurse aide care card or plan of care to aid in skin integrity and positioning.

Based on observations, records reviewed and staff interviews, the Facility failed to ensure that the environment remained free from accident hazards and the facility failed to provide adequate supervision and assistive devices to prevent elopements for 1 Sampled Resident (#111), from a total sample of 35 sampled Residents. Findings include: Review of the facility policy for elopement (dated 7/2015), indicated the Facility strives to promote Resident safety by maintaining a process to screen all Residents for risk of elopement, implement preventative strategies for those identified at risk and institute measures for Resident identification at the time of admission. The Policy further indicated the licensed nurse will have visual contact with each Resident at the beginning of any shift and/or know the location of each Resident. The Policy indicated in the event of a missing Resident, the Facility is to notify the police and local hospitals. Review of the facility policy entitled Wandering Management System (dated 4/2015), indicated a wander management system is used for Residents at risk for elopement as assessed and determined by the interdisciplinary team. The Policy further indicated the wander management system bracelet will be applied to Resident's wrist or ankle and not removed until replacement is needed, checked and documented every shift for placement, check function daily and wander management system doors check and documented weekly by maintenance. 1. For Resident #111, the facility failed to ensure for a Resident who resides on a secured unit, and is at risk of elopement, did not leave the building unsupervised. On 12/30/17 Resident #111 eloped from the facility and was found by the police approximately one hour later. Resident #111 was transferred to the hospital where he/she remained until 1/2/18. The outdoor temperatures on 12/30/17 registered 19 degrees Fahrenheit was a wind chill of 4 degrees Fahrenheit. Resident #111's was admitted to the facility on ,[DATE], with [DIAGNOSES REDACTED]. Record review indicated that the Resident had a legal Guardian. The Resident was readmitted to the facility on [DATE]. The Admission Minimum Data Set (MDS) signed as completed on 11/16/17, indicated Resident #111 was delusional, had a Brief Interview for Mental Status (BIMS) and scored a 13 of 15 indicating no cognitive impairment, and required supervision for ambulation. Review of the medical record indicated that the a staff nurse completed an Elopement and Wandering Assessment on 12/09/17 due to Resident #111 frequently going to the elevator and packing his/her bags to leave with continued attempts at exit seeking. A second Elopement and Wandering assessment was conduced on 12/20/17, due to Resident's increased behaviors of actively exit seeking. This Assessment indicated that the Resident was at risk for elopement/wandering and an individualized plan of care was developed based on the Resident's assessed needs and risk factors. Review of Resident #111's Care Plan indicated there were no updates after 11/30/17 and no individualized interventions to address his/her increased behaviors related to frequent exit seeking. The facility requested that the consulting psychiatric service evaluate Resident #111 urgently on 12/27/17 due to Resident #111 packing up his/her belongings and stating he/she wanted to leave the facility. The nurse documented that the Resident was unable to be re-directed and refused medications that day as well. Recommendations were to increase medications in accordance with Roger's Guardian. The consulting psychiatric service practitioner documented that the Resident was restless, belongings were packed up on the bed and the Resident was repeatedly stating Mr. D. says I can leave. The psychiatric service documented that the Resident continued to have waxing and waning [MEDICAL CONDITION], agitation, low mood in the setting of chronic mental illness and underlying dementia. Episodes of frustration, delusional thinking, and paranoia were increasing. The recommendation was to increase medications. The Guardian had been called to help de-escalate the Resident and said that the Resident was more paranoid on Christmas and speaking about his/her food being poisoned. Resident #111's treatment record documentation indicated that the wanderguard had not been checked on 12/30 - 7:00 A.M.-3:00 P.M. and 3:00-11:00 P.M. for placement. The Director of Nurses and Administrator were interviewed on 1/2/18 at 7:20 A.M. and said that Resident #111 had eloped from the facility on 12/30/17, however there were still several staff to be interviewed and statements to be obtained. In addition, the facility did not determine how the Resident had access to the secured elevator wearing a wanderguard bracelet. The DON stated that the Resident eloped at approximately 5:00 P.M. and was found at approximately 5:25 P.M. or 5:30 P.M. On 1/2/18 at 9:10 A.M. the DON was again interviewed and said that she had obtained statements and was conducting an investigation. However, she was still unable to determine how the Resident was able to exit the building and could not tell the Surveyor what door the Resident exited. The Surveyor asked the DON who shut off the wanderguard alarm and the DON was not aware that the alarm was sounding. The DON had not asked that question of the staff that she already interviewed. On 1/2/18 at 1:30 P.M. interview continued with DON who confirmed that there had been no elopement drills conducted from 10/2017 to present and no education has been provided since 12/30/17. The Surveyor informed the DON on 1/3/18, at 3:45 P.M. after interviewing several staff members, that Resident #111 had exited thru the front door. This prompting the DON to re-interview/interview staff to complete the investigation. There were three doors in the basement level that were not alarmed and the elevator goes to the basement level. Anyone can exit out these doors without the use of a code. The Surveyor interviewed Charge Nurse #1 (CN #1) on 1/3/18 at 11:00 A.M., and said that the 2 CNAs informed her that Resident #111 had left the unit, and witnessed by Resident #82. The staff had searched the unit and were unable to locate the missing Resident. CN #1 called Dr.(NAME) (code for missing Resident) and left the unit. Nurse went down to the front entrance and heard the alarm was sounding, so she went out the front door and looked around for the Resident. CN #1 then said she got into her car, which was parked in the front of the building, to start looking for the Resident in the area. She immediately noticed the Resident standing across the street, in front of the public library, with his/her belongings. CN #1 approached the Resident and the Resident said she was waiting for her bus. CN #1 offered The Resident a ride, which he/she accepted. As CN #1 took the Resident's hand to assist her to the car, the Resident went willing at first then pulled his/her hand away and started running towards the woods. CN #1 looked around and there were other staff members looking as well using their flashlights. CN #1 stated that this all happened within 30 minutes before the Resident was found. The Surveyor interviewed CNA #1 on 1/3/18 at 11:55 A.M. and she said that at approximately 5:00 P.M. Dr.(NAME)(elopement code) was announced over the loud speaker and went searching for the missing Resident within building. She was unable to locate the Resident and there were staff outside looking as well. She heard a nurse yell, we found his/her and she grabbed three blankets, then heard that Resident #111 was gone again. CNA#1 ran into woods, but was unsuccessful in finding Resident and at that point 911 was called. Fire, Police, Ambulance and dogs arrived. It was approximately 5:30 P.M. now. They were still looking for the Resident, it was approximately 5:50-6:00 P.M. that they found Resident. The Police asked for a staff member to identify the resident, so Police drove me over there to identify Resident. Resident #111 had about 3-4 bags with him/her. Police returned the CNA back to Facility. CNA #1 could not provide an explanation as to how the Resident exited the secured unit. The elevator had a code, Resident had a wanderguard on and the alarm on front entrance door was sounding. CNA #1 stated that the weather was extremely cold, snowy and slippery. The Surveyor interviewed CNA #2 on 1/3/18 at 2:40 P.M. and said that she was walking with CNA #3 when at approximately 5:00 P.M. on 12/30/17, Resident #82 said that Resident #111 had left the unit and when the CNA's asked for an explanation from Resident #82 he/she said that the Resident left the building. CNA #2 notified CN #1 that they both searched for Resident #111 in his/her room and on the unit and were unable to locate the Resident. The Nurse called a Dr.(NAME)(elopement code-missing Resident) over the intercom to alert staff and she left the unit immediately to begin looking for the Resident. CNA #2 stated that she heard the Supervisor cancel the code at approximately 5:45 P.M. CNA #2 confirmed that as of this date, no re-education has been offered since the elopement on 12/30/17. The Surveyor interviewed CNA #3 on 1/3/18 at 3:00 P.M. who stated that she was with CNA #2 when at approximately 5:00 P.M. on 12/30/17 Resident #82 stated I think she left The two CNAs verified Resident #111 was gone off the unit after searching it and notified CN #1. Resident #82 said he/she saw the Resident's bags packed. CN #1 called Dr.(NAME)over the intercom x 3, staff responded and two other CNAs went outside to search the grounds. The weekend Supervisor obtained their statements and cleared the code at approximately 5:30 P.M. CNA #3 was not sure if they had found the Resident or not at that time as CNA #3 was busy with other Residents and no one told them. CNA #3 confirmed that as of this date, no re-education has been offered since the elopement on 12/30/17 The Surveyor interviewed the Weekend Supervisor on 1/8/18 at 11:10 A.M. regarding the elopement of Resident #111 on 12/30/17. The Supervisor stated that she was on the phone with the DON at approximately 5:00 P.M. discussing another Resident and did not hear the code announced Dr.(NAME)(elopement code). A staff member came to her while on the phone with the DON and informed the weekend Supervisor that a Dr.(NAME)was called for Resident #111. The Supervisor asked what exit she went out and was informed the front door. As the Supervisor exited the front door, she grabbed a blanket due to the extreme cold. The Supervisor heard someone yell, they found her so she turned around and came back into the building and canceled the Dr.(NAME)code. Just then, another staff member said they did not find her. The Supervisor then called 911 to be sure they were on their way, as she did not see any Police and/or EMS at the scene and it was now 5:15 P.M., they assured her they were on their way. A Police Officer entered the facility and requested schematics of the building, just in case the Resident had returned to building. The Supervisor had to call the DON to obtain the location of the schematics. During this time, the Supervisor stated that over the Police Officer's radio came an announcement that they found Resident #111. The Police officer stated that they were going to take Resident #111 to hospital for evaluation. The Supervisor stated it was approximately 5:20-5:25 P.M. at this time. The EMS trip sheet documentation indicated that they were enroute to Facility at 17:20 (5:20 P.M.) arrive at 17:25 (5:25 P.M.) and the patient was found at 18:00 (6:00 P.M.) and transported the Resident to the hospital at 18:05 (6:05 P.M.). Review of the hospital emergency room (ER) assessment indicated that Resident #111 arrived in the ER at 18:14 (6:14 P.M.) on 12/30/17. The Hospital admission documentation dated 12/30/17 indicated that Resident #111 stated that he/she would like to return home and does not want to live in a nursing home any longer. Resident #111's family member stated to the ER Physician that he/she was concerned that the Resident may be having worsening psychotic symptoms. Resident #111 remained in the hospital for 3 days until 1/2/18 when he/she was transferred to another facility for worsening psychiatric condition. 2. The facility failed to ensure that the environment, on the(NAME)Unit, was free from accident hazards. On 12/28/17 at 1:26 P.M., observation on the(NAME)unit, a unit which includes Residents with a history of substance abuse and wandering, revealed that a medication cart was positioned at the nursing station, unlocked, unattended and the contents were easily accessible. The unsecured contents of the cart included medication blister packs of the unit's Residents. A narcotic box was unlocked and contained medications such as [MEDICATION NAME], Klonopin, and [MEDICATION NAME]. During the observation, 3 Residents were observed to wander in the vicinity of the unlocked medication cart. During interview with agency nurse #1 at 1:45 P.M., the Surveyor alerted her that the medication cart was unlocked with the contents, including controlled medications, easily accessible. She said that she thought she had locked it.

Based on observation, record review and staff interview, the facility failed to ensure that for 4 of 11 residents reviewed for falls (#4, #19, #21 and #26) from a total sample of 26, that each resident received adequate supervision and assistive devices to prevent accidents. Findings include: 1. Resident #4 was admitted with [DIAGNOSES REDACTED]. According to the most recent MDS (minimum data set), signed as being completed 11/5/12, the resident had documented short and long-term memory impairment, severely impaired cognitive skills for daily decision making, was rarely understood and could rarely understand, and displayed inattention, disordered thinking, altered level of consciousness, feeling tired, hallucinations, physical and verbal behavioral symptoms toward others, and other behavioral symptoms not directed toward others. The MDS indicated that the resident required extensive assistance with bed mobility and transfers, used a chair daily that prevented rising, could eat with supervision, and was totally dependent for all other ADL's (activities of daily living). The resident was coded as always incontinent of bowel and bladder. Record review on 2/7/13; revealed that the resident was assessed to be at high risk for falls according to each Fall Risk Assessment conducted during 2012. A nurse's note indicated that the resident fell on [DATE] at 10:15 P.M. The nurse heard a noise in the dining/activity room and found the resident lying on his/her left side on the floor. The resident had been toileted at 9:15 P.M., and was sitting in a stationary chair watching television prior to the fall. According to the investigation report, the staff were in the room earlier but were not present at the time of the fall as they were doing rounds. The intervention listed in the investigation to prevent reoccurrence, was to have a staff member supervising the dining/activity room whenever there is a resident there. Further record review indicated that on 5/11/12 at 4:30 A.M., the resident was found on the floor on his/her right side next to the roommate's bed. The nurse's note indicated that the resident was incontinent of urine, was able to transfer from the wheelchair to the bed, and had no complaint of pain at that time. The nurse also documented that the resident had a skin tear to the right elbow that measured 3.5 centimeters. The physician and health care proxy were updated about the fall and skin tear to the right elbow. According to the facility accident investigation, reported to the State on 5/17/12 at 4:30 P.M., the resident was reportedly alert and confused and resided on the secured Alzheimer's unit. The resident was supervised for eating, incontinent of bowel and bladder, required two assists for toileting and transferring, and required assistance with bathing, dressing, and grooming. On 5/11/12 the CNA (certified nursing assistant) caring for the resident reported to the RN (registered nurse) the resident's complaint of pain in the right elbow. The registered nurse assessed the resident and discovered "localized ecchymosis, mild swelling, and slight limited range of motion with extension surrounding the skin tear". Acetaminophen (Tylenol) 650 milligrams was given with good effect. On the 3:00 P.M. to 11:00 P.M. shift, the LPN (licensed practical nurse) on duty indicated that the right arm was noted to have bruising and slight swelling, full ROM, and no complaint of pain. On 5/12/12 on the 11:00 P.M. to 7:00 A.M. shift, the LPN noted bruising and swelling to the elbow with baseline ROM and no complaint of pain. On 5/13/12 on 7:00 A.M. to 3:00 P.M. on 5/13/12, the RN on duty assessed the resident's right arm and documented that the forearm to the resident's fingers were ecchymotic and swollen. The RN notified the on-call physician who ordered an x-ray of the right forearm, humerus, and elbow. The mobile x-ray company was called, performed the x-rays, and faxed the findings to the facility as follows: "There is a right elbow fracture present of the olecranon with modest distraction. There is also slight deformity of the radial head consistent with a slight impaction fracture." The on-call physician ordered the resident to go to the orthopedic clinic at the local hospital on [DATE], and to utilize a sling to the right arm. According to the statement from the LPN on duty at the time of the resident's fall with resulting right elbow fracture, the resident was incontinent of bladder during first rounds on the 11:00 P.M. to 7:00 shift. The resident was provided with incontinent care and went back to sleep. The LPN indicated, that while tending to another resident with the CNA, Resident # 4 attempted to self-transfer toward the bathroom at 4:30 A.M. The LPN also indicated hearing an alarm while walking the hallway toward the resident's room, entered the room and found the resident lying on the floor on his/her right side next to the roommate's bed. The follow-up review of the accident dated 5/11/12, indicated that the etiology of the incident/injury included: "The resident self-transferred OOB (out of bed) and ambulated towards the bathroom. Staff were concentrated on other side of unit responding to another resident who fell ." Interventions documented on the investigation report to prevent repeat occurrence included: "We have ordered an edge-defining mattress to help resident identify perimeter of bed. We will avoid concentrating staff in one section of the unit." Resident provided with incontinence care and 1:1 attendance, assess B & B (bowel and bladder pattern. During Interview with the DON, Administrator, and Q.I. Director on 2/13/13 at 4:03 P.M., the lack of adequate supervision and safety interventions to maintain the resident's safety were discussed. The DON said that although the alarm for this resident sounded at the time the resident fell and fractured the right elbow, it was not effective in keeping the resident safe. Also, the DON indicated that while the LPN and CNA were responding to another resident who's alarm was sounding, supervision for Resident #4 was not effective to prevent the resident's fall. 2. For Resident #21, the facility failed to provide effective and appropriate safety interventions and supervision to maintain the resident's safety. Resident #21 was admitted with [DIAGNOSES REDACTED]. According to the most recent MDS (minimum data set), signed as being completed 12/24/12, the resident experienced short and long-term memory deficits and moderately impaired cognitive skills for daily decision making. The MDS indicated that the resident required extensive assistance with bed mobility, transfers, ambulation, was totally dependent for hygiene and bathing, and was always incontinent of bladder. The MDS also indicated that the resident had experienced two or more falls without injury since the prior MDS. Record review on 2/12/13, indicated that the resident was assessed to be at high risk for falls during each fall risk assessment conducted in 2012. Further record review, and review of accident/incident investigations on 2/12/13, indicated that the resident had experienced 9 falls from 9/6/12 to 1/29/13: a. On 9/6/12 at 8:45 P.M., the resident was found by a CNA (certified nursing assistant) lying on the floor near the bed in the resident's room. The nurse documented in the nurse's note that the resident said he/she slipped while trying to get out of bed. No injuries were documented. The facility's accident investigation indicated that at 8:30 P.M. the resident was seated in a chair at the nurse's station. The accident investigation did not determine how the resident was able to get from the chair at the nurses' station to the resident's bedroom into bed without staff observance. The accident investigation indicated that the resident had an alarm in place at the time of the fall. However, the investigation confirmed that the alarm did not sound to alert staff of the resident's independent transfer and ambulation. Additionally, the facility failed to conduct an investigation into why the alarm failed to sound. Review of the accident investigation, interventions implemented to prevent repeat occurrence included, "Resident reminded to use call bell for assistance," "Bed alarm replaced "and "Will offer toileting prior to placing resident to bed." b. On 9/15/12 at 12:00 A.M., the resident's alarm sounded. According to the nurse's note, the nurse responded to the alarm and observed the resident sliding onto the floor from the bed while attempting to self-transfer. The nurse indicated "unable to break fall in time." Review of the nurse's note indicated there were no injuries noted at the time of the fall, an order for [REDACTED]." The resident informed the nurse that he/she did not know why he/she was getting up. Supervisory review of the accident was conducted on 9/16/12. Interventions to prevent re-occurrence included, ask daughter to bring in new slippers, non-skid with backs. Resident to wear slipper socks until available. Fifteen minute checks to be conducted on 11:00 P.M. to-7:00 A.M. shift until edge defining mattress available. c. On 9/29/12 at 6:20 P.M., staff were called to the resident's room as the resident was found sitting on the floor next to the bed. The nurse documented that there were no apparent injuries observed following the fall, the alarm did not sound, and the alarm box was reconnected. According to the nurse, the resident said, "I slipped" while trying to self-transfer from standing with walker to the bed. The nurse documented that the call bell was within reach, alarm placement complete, and that "Continuous reminder needed to maintain safety. The accident investigation noted that "senile dementia-poor safety awareness, confusion, poor sense of direction with instructions, and reminders to call for assist,"were information that would help get to the cause of the incident. The Supervisory Review of the accident on 10/2/12 documented the supervisor's discussion with the nurse regarding the status of the alarm. The discussion revealed the "alarm had become disconnected during fall" and "was checked at beginning of shift and was intact." Interventions to prevent repeat occurrence included urine culture and urinalysis, 30 minute checks until completed, and offer P.M. care after dinner." The supervisory review did not address the failure of the alarm to alert staff of the resident's self-transfer. There was no evidence to support the facility's evaluation of the alarm to ensure that it was functioning properly. d. On 9/30/12 at 2:15 P.M., the nurse documented, "res (resident) fell to buttocks at bedside no apparent injury. Res. attempting self-transfer without calling for assist, alarm sounded clearly." No injuries were documented at the time of the fall. The nurse indicated "Continue to supervise res OOB (out of bed) at nurse's station." Additionally, the nurse wrote in his/her note "Res previously attempted to exit lobby to take care of the baby." The accident investigation indicated that the resident had been lying on the bed, attempted to self-transfer out of bed with the walker, and slipped to the floor landing on the buttocks. Behaviors listed as not normal to resident included "Attempted to go to front door from lobby x 1." Interventions listed to prevent repeat occurrence included 1:1 supervision at nurses' desk for 24 hours, obtain labs, U/A (urinalysis), C & S (urine culture and sensitivity), 30 minute checks until lab work done, and rehab referral screen. The accident investigation indicated that the resident refused the rehab screen three times. e. On 10/5/12 at 1:35 P.M., the resident was found sitting on the floor at the bedside in the resident's room. According to the nurse's note no injuries were sustained during the fall and the alarm was noted to be on and functioning. The accident investigation documented the resident at "baseline decreased safety awareness." Immediately prior to the fall the resident was observed by staff sitting in a chair in the lobby. The investigation listed the resident's transfer status as "self-transfer-supervision." and noted that the resident had felt dizzy and was being treated with antibiotics at the time. Interventions listed to prevent repeat occurrence were orhos (orthostatic blood pressures) twice daily for three days. The investigation failed to address the lack of staff supervision at the time of the fall, and failed to evaluate how the resident ambulated unsupervised from the lobby to the resident's room on the MCN Unit without staff supervision. f. On 10/6/12 at 9:00 P.M., the resident was found sitting on the floor beside the bed. According to the nurse's note, the resident was alert and confused, and did not sustain any injuries from the fall. Review of the accident investigation indicated that prior to the fall in the resident's bedroom, the resident had been observed at 8:30 P.M. lying in bed. The resident told the nursing staff "I fell " while trying to get out of bed. Although the accident investigation and nurse's note indicated that the resident had an alarm in place at the time of the fall, there was no evidence to support that the alarm sounded when the resident attempted to self-transfer from the bed. Interventions to prevent further occurrence included medication review, furniture rearranged, and 30 minute checks until medication review. Additional follow-up required included: On 10/712, 30 minute checks D/C'd (discontinued), clip alarm while in bed. M.D., reviewed orthostatic BP (blood pressures), and the medication review was completed with changes in the resident's Lisinopril, Namenda tapered and then D/C'd, and oxybutynin discontinued once supply was exhausted. g. On 10/21/12 at 4:40 P.M., the resident's bed alarm sounded. The nurse responded to the alarm, entered the room, and witnessed the resident sliding off the bed onto the floor landing on the buttocks. The resident told the nurse that he/she fell while trying to get in bed. No injuries were documented at the time of the fall. According to the accident investigation, the resident's cognitive status was listed as "alert, confused at baseline." The nurse documented that he/she assisted the resident to bed and "reinforced the importance of asking for assistance when transferring. Interventions listed to prevent repeat occurrence included, sensor alarm over bed to alert staff when getting into/out of bed, remind to ask for assistance when transferring, clip alarm on at all times until sensor alarm available. The accident investigation noted that the sensor alarm was put in place on 10/26/12. h. On 11/18/12 at 4:45 P.M., the resident was found lying on his/her left side on the floor in the bathroom. The resident told the nurse that he/she was trying to use the toilet. No clip alarm was noted. The nurse's note indicated that there were no injuries noted. When the nurse asked the resident if he/she had removed the alarm the resident said "yes." The nurse stated in the nurse's note "Resident educated on importance of asking for assistance and compliance with alarms." At 11:00 P.M., the nurse wrote an addendum to the initial note written earlier describing the resident's fall at 4:45 P.M. The addendum indicated "Resident continues non-compliance with alarms-attempt to self transfer x 4. Removed clip alarm x 3, verbally redirected with little effect. Resting in bed at this time alarms intact and functioning." The etiology of the incident was documented to be "removed clip alarm self tx (transfer) to BR (bathroom) and fell ." Interventions listed to prevent repeat occurrence included urinalysis, urine culture and sensitivity, "sensor alarm was working when placed to bed at 4:30 P.M. for nap," 15 minute checks x 24 hours. Although, the clip alarm and sensor alarm were in place at the time the resident was put to bed for a nap at 4:30 P.M., both devices proved ineffective in maintaining the resident's safety. Nursing staff continued to utilize these devices as interventions in the resident's fall prevention plan. Additionally, attempts at reminding this memory impaired resident to call for assistance with transfers and not to remove the safety alarms, continued to be implemented although ineffective. i. On 1/29/13 at 11:45 A.M., the resident sustained [REDACTED]. According to the accident investigation, one minute prior to the fall, the activity staff person observed the resident trying to stand up from the chair. The activity staff person said "I kept reminding him/her to sit down." The activity staff person turned away from supervising the resident, left the resident, and called out from the dining room to ask the nurse if he/she should bring the resident out of the activity room. The resident stood up from the wheelchair, the alarm sounded, and the resident fell to the floor landing on the left side of the face. Assessment of the resident revealed a laceration over the left eye which measured 1 cm (centimeter) long by 0.25 cm wide. The physician was notified and ordered a normal saline wash, pat dry, apply Steristrip, and check placement every shift. The accident investigation noted that the clip alarm was in place and was heard at the time of the fall. However, this device proved ineffective in preventing the resident's fall and continued to be utilized as part of the resident's fall prevention plan. Interventions to prevent repeat occurrence included "When activities is done they are to bring res. (resident) to nurse's station." The resident was observed on multiple days during the survey. On 2/14/13 at 11:30 A.M., the resident was observed sitting in a wheelchair in front of the nurses' station on the MCN Unit. The resident appeared alert and staring blankly towards the nurses' station. The resident was noted to have some discoloration above the left eye with a single Steristrip in place. The resident was neatly groomed and dressed and a clip alarm was observed in place at that time. During interview with the DON (Director of Nursing), Quality Improvement Director, and Administrator, on 2/13/13 at 4:03 P.M., they all said that the use of alarms and other fall interventions for this resident had proven ineffective in preventing falls. Additionally, the Q.I. Director stated that Q.I. fall data is not collected for individual residents, nor does the facility compile data on falls attributed to the failure of a particular device being used for a specific resident. The Q.I. Director, DON, and Administrator also indicated their understanding that the facility's failure to evaluate particular safety interventions following a resident fall, may be contributing to the inappropriate use of a device, or, in some cases, or their failure to recognize that a device may be defective. 3. For Resident #19, the facility failed to provide adequate supervision and effective safety interventions to prevent falls. Resident #19 was admitted with [DIAGNOSES REDACTED]. According to the most recent MDS, signed as being completed 1/30/13, the resident scored 6 out of a possible 15 on the BIMS (Brief Interview for Mental Status), which indicated memory and cognitive deficits. The MDS indicated that the resident displayed physical and verbal behavioral symptoms directed towards others 1 to 3 days per week. The MDS also indicated that the resident required extensive assistance with bed mobility, hygiene, and bathing, was always incontinent of bowel and bladder, required limited assistance with ambulation in the room and corridor, and the resident had fallen in the last month prior to admission. Record review on 2/13/13, indicated that upon admission to the facility, the resident was assessed to be at high risk for falls with a score of 13 (a score of > 10 equals High Risk). Further record review on 2/13/13, indicated that a clip alarm was ordered upon admission. This device was ordered to be in place at all times and to be checked for function and placement every shift. On 1/18/13 at 9:00 P.M., the nurse documented "pt (patient) taking off clip alarm multiple x's (times), non-compliant with alarm, multiple attempts @ (at) redirecting with little effect." No further interventions were listed to address the resident's multiple attempts to remove the clip alarm. Additional documentation from the hospital indicated, that on the day of discharged from the hospital at 8:15 A.M, the resident had slid out of bed landing on the floor. According to the information from the hospital, the resident was assessed by the physician and nurse practitioner, the resident was able to ambulate independently, and offered no complaints of pain prior to being discharged to the nursing home. After reviewing the information about the fall from the hospital discharge summary, the primary care physician at the facility ordered bilateral hip x-rays. The hip x-rays were reported negative for fractures. Further record review on 2/1/13 at 12:30 A.M., indicated that the nurse "heard loud thump noise" from the resident's room. The resident was found sitting on the floor next to the bed with the "clip alarm not attached to resident or alarm box." The nurse's note also indicated that the clip for the clip alarm was clipped onto the back of the resident's clothing. The note documented that the resident did not want "that thing on." No injuries were documented following the fall. Interventions documented on the facility's investigation report to prevent repeat occurrence included, new order for bed alarm and discontinue clip alarm. No additional interventions were added to the resident's fall prevention plan to ensure the resident's safety. The resident was admitted to the facility from the hospital with a history of falls. A clip alarm was implemented that the facility documented the resident removed multiple times. The facility continued to utilize the clip alarm even after the resident demonstrated that he/she was able to remove the alarm. The interventions implemented by the facility failed to effectively maintain the resident's safety. 4. For resident #26, the facility failed to provide adequate supervision and effective safety devices to prevent falls with the potential for injury. Resident #26 was transferred from another facility with [DIAGNOSES REDACTED]. The initial MDS assessment with a reference date of 11/7/12 indicated that the resident was cognitively impaired and required extensive assistance of facility staff for most activities of daily living including ambulation, transfers and toilet use. The resident was coded with balance issues and had a fall history. The resident was assessed at high risk for falls. Review of the 11/2/12 fall care plan identified the following interventions to prevent falls: - Keep environment free from clutter and well lit - Answer calls, anticipate needs - Allow rest periods between activities - Non-skid foot wear - Bed alarm - Clip alarm on at all times - Remind to use helmet and walker (the type of walker was not clarified) The clinical record reviewed on 2/12/13 indicated that the resident sustained [REDACTED]. No injuries were reported. Unit Manager #3 was interviewed on 2/14/13 at approximately 9:45 A.M. and reviewed the facility incident reports and nursing documentation with the surveyor. The incident report documentation indicated the following: A. On 11/2/12 at 10:45 A.M., the housekeeper alerted nurses that the resident had fallen. The nurses found the resident at the doorway to the Alden unit on his/her knees inside the merry walker and actively seizing. The resident was wearing his/her helmet. Staff determined the cause of the fall to be due to a seizure. Unit Manager #2 said during interview that the recommended intervention was to place a clip alarm to the resident's merry walker. Unit Manager #2 said the incident report indicated that the resident was ambulating unsupervised in the hallway even though the resident required supervision for ambulation. Review of the nursing notes from 11/3/12 through 11/14/12 indicated that the resident was noncompliant with wearing the helmet, and was repeatedly observed releasing the clip alarm from the merry walker to walk unassisted. Even though the nurses notes indicated that the resident was noncompliant, there were no additional interventions to keep the resident safe. B. On 11/24/12 at 12:30 A.M., the nurses note indicated that the nurse heard the noise of the rolling walker in the room and turned to observe the resident self transfer and fall to the floor. No injury was incurred. The nurse indicated that the resident had bed slippers on and had removed the clip alarm. New interventions included for the resident to wear slipper socks. On 11/27/12 a bed pad alarm was added. Unit Manager #2 was unable to explain why the non-skid socks were not already available as previously care planned. Unit Manager #2 said that the clip alarm was discontinued because of noncompliance and the bed pad alarm was initiated to alert the staff to respond and not to cue the resident because he/she was deaf. Unit Manager #2 said that the resident was to utilize the rolling walker in the bed room and merry walker in the hallway but said that this information was not listed in the care plan. C. On 12/31/12, the 8:00 P.M. nurse's note indicated that the nurse witnessed the resident fall while standing in the doorway to the bedroom attempting to pick up butter from the floor. No injury was reported. The resident was wearing slippers instead of the non-skid socks. The resident was ambulating without a walker or staff assistance. Review of witness statements indicated that the resident "self toilets." Unit Manager #2 said that the resident was to ambulate with the assistance of one staff. Unit Manager #2 said that on 1/1/13 contact guard (hands on) assistance was "reinstated" to prevent further falls. D. On 1/4/13 at 7:45 PM, the nurse's note indicated that the resident was observed on the bedroom floor between the beds. No injury was reported. The nurse documented that the walker was not near the resident and the resident had his/her slippers on. The nurse listed that the resident's transfer status was "self". The nurse did not address the status of the bed pad alarm. Review of a 1/7/13 care plan intervention indicated that "if pt (patient) found ambulating in the room, staff to attend to the pt and assist with task." On 2/13/13 at 10:15 A.M. the surveyors observed the resident in the bedroom ambulating unassisted. The resident was observed staggering on his/her feet and was not wearing his/her helmet. The resident's bed pad alarm was not sounding. Surveyor #1 immediately assisted the resident while Surveyor #2 entered the closed doors to the dining/activity room to get assistance. Staff were unaware of the issue because the doors were closed. Nurse #1 responded from the dining room and provided assistance to the resident. Nurse #1 said that the bed pad alarm had "malfunctioned." Unit Manager #2 arrived and attended to the resident. Nurse #1 went back into the dining room and before closing the doors told the surveyors to "let us know if there are any other problems." On 2/13/13 at 11:40 A.M. the surveyors observed the resident ambulating unassisted in his/her bedroom. The resident was observed very unsteady on his/her feet. The resident alarm was not sounding. Surveyor #1 responded to the resident and Nurse #1 was summoned from the dining room. Nurse #1 ran to the room and gave the resident the walker and assisted the resident to the bathroom. No other staff members were observed during this time providing supervision to the residents on the unit. Nurse #1 told the surveyor that the alarm had malfunctioned a second time. The surveyors' observations were discussed with facility management on 2/13/12 at 4:00 P.M. The Director of Nurses (DON) said that she was aware that the alarm had malfunctioned. The DON said that the bed alarm was discontinued after surveyor observations and replaced with a wall sensor alarm. The surveyors discussed their observations regarding staff supervision and the reliance on alarms with the facility management. On 2/14/13 at 9:35 A.M., the surveyor entered the Alden unit. Resident #26 was observed halfway between his/her room and the dining room ambulating unsupervised, without a walker and was observed to be very unsteady on his/her feet. The surveyor immediately assisted the resident and called out for staff assistance. There was no response from staff. When the surveyor called out a second time a housekeeper appeared in the doorway to the room adjacent to the nurses desk that she was cleaning. The surveyor asked the housekeeper if there were any staff on the floor and she shrugged her shoulders. Nurse #1 was observed hurriedly rounding the corner from the main corridor to provide assistance. Nurse #1 also called out for help. When there was no response the surveyor obtained the resident's walker from the resident's bedroom. No alarm was heard sounding. Nurse #1 was heard asking a second nurse if the staff were on break because no one had responded to her call for assistance. The surveyor then entered the dining/activity room and observed the room filled with residents who were unsupervised by staff. During this time, a resident's family member was observed approaching the nurse's desk requesting assistance for his wife who was seated in the dining room unsupervised. Unit Manager #2 arrived on the floor at approximately 9:45 A.M., and was informed of the surveyor's observations. Unit Manager #2 was unable to explain who was providing supervision for Resident #26 and the other residents on the Alden unit. The facility failed to provide adequate supervision and effective safety devices to prevent falls with the potential for injury.

Based on record review and interviews, for one of three sampled residents (Resident #2), the Facility failed to ensure that the locking pins on the safety bars to the shower stretcher were present and functional when on 4/12/11, Certified Nurse Aide (CNA) #1 rolled Resident #2 over and the safety bar released. Resident #2 was transported to the Hospital and was diagnosed with [REDACTED]. Findings included: Resident #2 was admitted to the facility on October of 2007 and [DIAGNOSES REDACTED]. The care plan, dated 7/14/10, indicated that Resident #2 was totally dependent the nursing staff for all activities of daily living and interventions included padded siderails for safety, two person mechanical transfer, siderails up while in bed, and Resident #2 required a seatbelt on while in the wheelchair. The quarterly Minimum Data Set (MDS) assessment, dated 3/24/11, indicated that Resident #2: was severely impaired for daily decision making skills; was totally dependent on the nursing staff for all activities of daily living; required two staff persons for bed mobility and transfers; was incontinent of bowel and bladder, and Resident #2 had no falls. The nurse's note, the incident report, and the internal investigation dated 4/12/11, indicated that during the shower, Resident #2 fell from the shower stretcher onto the floor after Certified Nurse Aide (CNA) #1 rolled Resident #2 over and the safety bar released. The nurse's note, internal investigation, and incident report indicated that Resident #2 sustained a bloody nose, chipped tooth, left foot abrasion and bruise, left elbow abrasion, swollen lip and nose, was transferred to the Hospital, and required suctioning in the emergency room after Resident #2 aspirated blood from the nose. CNA #1 was interviewed on 5/10/11 at 2:30 PM. CNA #1 said that on 4/12/11, Resident #2 was on the shower stretcher and was incontinent. CNA #1 said CNA #1 rolled Resident #2 over and reached for supplies, when suddenly the safety bar on the side of the shower stretcher went down and Resident #2 fell over onto the cement floor. CNA #1 said that the Nurse was immediately notified and Resident #1 was transferred to the Hospital. The Hospital records, dated 4/12/11, indicated that Resident #2 sustained a closed head injury. The DON said that on 4/12/11, CNA #1 should have had another staff person to assist with Resident #2's shower because Resident #2 required two persons for bed mobility. The DON said during the course of the investigation, it was determined that the locking pins on the safety bars to the shower stretcher were missing and it was not determined how long the safety bar was broken. The Maintenance Director was interviewed on 6/8/11 at 10:00 AM. The Maintenance Director said that there was no written policy for preventive maintenance or to check the shower stretchers on a routine basis. The Maintenance Director said the staff usually wrote any request in the work order log book to alert the maintenance department when equipment was broken. The Maintenance Director said that on 10/6/10, 11/4/10, and 2/15/11, there were written requests for maintenance to repair the broken safety bar on the shower stretcher.