Every finding on record at Prescott House

Based on record review and interview, the facility failed to report lab results to the provider timely for one Resident (#82) out of a total of 24 sampled residents. Specifically, the facility failed to notify the on call provider of Resident #82's urine culture which indicated he/she had a urinary tract infection on 1/4/26. Subsequently, antibiotic treatment was not initiated, and Resident was hospitalized and diagnosed with sepsis, (a life threatening illness that develops when an existing infection triggers an extreme immune system response in your body) secondary to a urinary tract infection on 1/6/26; approximately two days after the lab results were completed. Findings include:Review of the policy titled Test Results dated April 2007 indicated: 1. Results of laboratory, radiological and diagnostic tests shall be reported in writing to the resident's attending physician or the facility. 2. Should the test results be provided to the facility, the attending physician shall promptly be notified of the results. 3. The director of nursing services or charge nurse receiving the test results shall be responsible for notifying the physician of such test results. Review of the policy titled Change in a Resident's Condition or Status, dated as revised February 2021 indicated: The nurse will notify the resident's attending physician or physician on call when there has been a(an): d. significant change in the resident's physical/emotional/mental condition. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or implementing standard disease related clinical interventions. Resident #82 was admitted to the facility in January 2025 with diagnoses including type two diabetes, hypertensive heart disease without heart failure and bilateral osteoarthritis of the hip. Review of the Minimum Data Set assessment (MDS) dated [DATE], indicated Resident #82 is moderately cognitively impaired as evidenced by a score of 12 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS). Review of Resident #82's Urinary Care Plan indicated:Focus: Resident is incontinent. At risk for UTI, 2/1/25Goal: Resident will not suffer UTI this review.Interventions: Laboratory tests as ordered. Monitor labs as available. Review of the nurse progress note dated 12/30/25 indicated: New orders obtained for a urine spec for UA/CS (urinalysis with culture and sensitivity) and STAT hematology labs, for weakness, confusion. Labs were drawn this afternoon and are currently pending. The lab technician informed this writer that she will not be available to pick the urine up this evening and will tomorrow if it is obtained, recommendations from lab tech is to use the first morning urine, if possible, since she is unable to retrieve the sample until 12/31/2025. will notify the oncoming nurse during shift report. Resident #82 has been observed this morning walking with staff back from the bathroom; however, sample was not obtained at this time. Review of Resident #82's lab report indicated his/her urine was obtained on 1/1/26 and the results of urine culture indicated an infection as the culture grew greater than 100,000 CFU (colony forming unit) Escherichia coli (a group of bacteria that normally lives in the digestive tract often referred to as E. coli). The lab report indicated the results were reported and available for review on 1/4/26, (a Sunday). The clinical record failed to indicate the lab results were reviewed by nursing staff or reported to the provider on 1/4/26 or 1/5/26. Review of the nurse progress note dated 1/6/25, indicated: At approx. 12:00PM upon returning from the hairdresser back to the c-unit he/she was found to have shaking chills and vomiting. The NP (Nurse Practitioner) as notified and came onto the unit to assess him/her; he/she reported to the NP that he/she felt unwell and would like to be seen in the ER. He/she was transferred to [the hospital]. Review of the Nurse Practitioner note dated 1/6/26, indicated: Seen today per staff request he/she appeared to be in his/her usual state of health this morning, went downstairs to the hairdresser, upon return to floor was found to have shaking chills, dry heaving, states he/she feels generally unwell and would like to be seen in the ER. On 12/23 seen by this NP with fever and general malaise in the setting of Covid-19 infection, CXR (chest x-ray) negative, no hypoxia or other respiratory concerns. On 12/30 nursing reported ongoing weakness and confusion. UACS and labs ordered. BMP CBC unremarkable. On review today it appears UACS was sent on 1/2 with culture resulting on Sunday 1/4 showing greater than 100,000 E. coli, result not reported to provider therefore has not been started on antibiotic. Will proceed with ER evaluation per patient request, high risk for urosepsis. Blood sugar stable, nursing states unable to obtain vital signs due to shaking chills. Review of the hospital Discharge summary dated [DATE] indicated Resident #82 was admitted to the hospital and diagnosed with sepsis secondary to urinary tract infection. During an interview on 1/21/26 at 8:42 A.M., Unit Manager #2 said that the facility is using a new lab service. Unit Manager #2 said that labs are reviewed by nursing staff or the NP online through the lab portal and the facility is working on having the lab results be automatically uploaded to the clinical record. Unit Manager #2 said on weekends the nursing staff are responsible for reviewing and reporting lab results to the on-call practitioner. Unit Manager #2 said she did not know why Resident #82's urine results were not reported to the provider over the weekend (1/4/26). During an interview on 1/21/26 at 11:05 A.M., Resident #82 said he/she went to the hospital a few weeks ago but was not sure why. During an interview on 1/21/26 at 1:26 P.M., Nurse Practitioner (NP) #1 said that lab results are reviewed by nursing staff or she will log into the system and review the results herself. NP #1 said that the facility is in the process of having lab results be automatically uploaded in the resident electronic record. NP #1 said that on weekends, nursing staff are expected to report results to the on-call provider. NP #1 said that Resident #82's urine results were not reported and should have been. NP #1 said antibiotic treatment should have been implemented when the culture and sensitivity were finalized. NP #1 said she documented that Resident #82 was high risk of urosepsis because he/she had the chills which is an indication of a systemic issue. NP #1 said that delaying antibiotic treatment could contribute to sepsis. During an interview on 1/21/2026 1:38 P.M., the Director of Nursing (DON) said that nursing staff are expected to report results of labs to the on-call provider on the weekends. The DON said that Unit Manager #2 told her that the Resident #82's labs were not reviewed or reported to the NP on 1/4/26. The DON said that Unit Manager #2 worked on 1/5/26 and told her she had missed it when Resident #82's results were reviewed and was hospitalized on [DATE].

Based on record review and interview, the facility to ensure that services provided met professional standards for one Resident (#126), out of 24 total sampled residents. Specifically, the facility failed to obtain and implement a physician's order for Resident #126's Sinemet (carbidopa-levodopa, medication used to treat tremors with Residents who have Parkinson's disease) based on the Resident's home schedule.Findings include:Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following:- Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Review of the facility policy titled, Reconciliation of Medication Administration, dated as revised July 2017, indicated the purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission. Review of the Sinemet fact sheet (sinemet.org), dated as 2026, indicated that the timing of Sinemet doses can vary depending on individual factors and the specific needs of each person. There are a few general guidelines to consider:1. Symptom pattern: It is beneficial to take Sinemet at times when you typically experience the most significant Parkinson's symptoms. For example, if you notice that your motor symptoms, such as stiffness or tremors, are more pronounced in the morning, you may consider taking a dose of Sinemet in the morning to help alleviate those symptoms and improve mobility.2. Meal times: Sinemet is typically taken on an empty stomach, as protein-rich foods can interfere with its absorption. Therefore, it is generally recommended to take Sinemet at least 30 minutes before meals or 1-2 hours after meals.3. Consistency: Maintaining a consistent dosing schedule is important to achieve optimal symptom control. Regularly spaced doses help to maintain a steady level of medication in the body and minimize fluctuations in symptom control.4. Nighttime dosing: Some individuals may benefit from a dose of Sinemet taken closer to bedtime if they experience nighttime symptoms or sleep disturbances associated with Parkinson's disease. This can help alleviate those symptoms and improve sleep quality. Resident #126 admitted to the facility in January 2026 with diagnoses including Parkinson's disease without dyskinesia, Alzheimer's disease, and dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/20/26, indicated Resident #126 had a severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 2 out of 15. On 1/20/26 at 8:00 A.M., the surveyor observed Resident #126 in bed, he/she was awake and alert and his/her hands were tremulous. The Resident was unable to participate in an interview. Review of Resident #126's hospital Discharge summary, dated [DATE], indicated: -carbidopa-levodopa 25-100 milligrams (mg) per tablet take 1.5 tablet by mouth 4 times a day. Review of Resident #126's physician's order, dated 1/16/26, indicated:-Carbidopa-Levodopa Oral Tablet 25-100 mg (Carbidopa-Levodopa), give 1.5 tablet by mouth every 6 hours for Parkinson's. Give 30 minutes before meals or 1 hour after meals. Further review of the order indicated the medication was scheduled to be administered at 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M. During an interview on 1/20/26 at 1:09 P.M., the Family Member (Health Care Agent (HCA), which was active) said that Resident #126 takes Sinemet at home. The HCA said that he administers Resident #126 his/her Sinemet four times a day, every four hours starting when he/she is wakes up usually around 9:00 A.M., at home and the facility should do the same. The HCA said that the medication helps with Resident #126's tremors. The HCA said that Resident #126 does not take Sinemet at midnight. During an interview on 1/20/26 at 3:47 P.M., Nurse #1 said she completed the second medication check for Resident #126's admission physician's medication orders. Nurse #1 said on the day Resident #126 was admitted to the facility it was a very busy shift and there were four admissions that day and Nurse #1 said that the Admissions Director did the first transcription for the admission medications from the hospital discharge summary. Nurse #1 reviewed the Sinemet order and she said that Sinemet is not usually given at midnight (12:00 A.M). During an interview on 1/20/26 at 3:54 P.M., the admission Director (a licensed nurse) said that she transcribed the admission physician's orders for Resident #126's Sinemet based on the hospital discharge summary. The Admissions Director said although she was a nurse she had not transcribed physician's orders into the electronic health record in a long time. The Admissions Director said that she was not sure why she put in the Sinemet order for every six hours, when the recommendation was for four times a day, and said she was not sure why there was additional information to administer the medication around meals. The Admissions Director said that the Director of Nursing (DON) was supposed to be the second check to ensure she transcribed all the medications correctly. During an interview on 1/20/26 at 3:59 P.M., the DON said she didn't review Resident #126's admission orders that were transcribed by the Admissions Director, the DON said that Nurse #1 was supposed to review the orders to ensure accuracy of the transcribed physician's orders. The DON said that Sinemet is used for Parkinson's related tremors and the medication times should be individualized to the resident's regime. The DON said that Resident #126 should not receive Sinemet at midnight. During an interview on 1/21/26 at 7:46 A.M. Nurse #2 said she routinely works the overnight shift, and she said Resident #126 receives Sinemet at midnight. Nurse #2 said she questioned the timing of the Sinemet order to herself, and she did not ask a provider for clarification because Sinemet is not normally given at during the middle of the night. During an interview on 1/21/26 at 8:29 A.M., Unit Manager #1 said that the order from the hospital discharge summary was for four times daily and she said that nursing could have transcribed the order for Sinemet as every six hours. Unit Manager #1 said that Resident #126 takes Sinemet for Parkinson's related tremors and the timing for Sinemet administration is individually scheduled according to the Resident's home schedule. During an interview on 1/21/26 at 1:26 P.M., the Nurse Practitioner said that Resident #126 takes Sinemet for his/her Parkinson's and tremors. The Nurse Practitioner said that nursing should have obtained and transcribed Resident #126's Sinemet order from the hospital discharge summary and based on Resident #126's home time schedule.

Based on observations, record review and interview, the facility failed to accurately document in the electronic medical record for one Residents (#30), out of a total sample of 24 residents. Specifically, the facility documented that Resident #30 was wearing an orthotic elbow edge cushion when he/she was not.Findings include:Resident #30 was admitted to the facility in August 2023 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, contracture of the right elbow and neuromuscular dysfunction of bladder. Review of Resident #30's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief interview for Mental Status score of 6 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated that the Resident has upper extremity impairment on one side.The surveyor made the following observations:- On 1/20/26 at 8:04 A.M., Resident #30 was sleeping in his/her bed, his/her right arm was visible and was bent very closely to his/her body with no orthotic observed.- On 1/21/26 at 6:39 A.M., Resident #30 was sleeping in his/her bed, his/her right arm was visible and was bent very closely to his/her body with no orthotic observed.Review of Resident #30's physician's order dated 10/17/26 indicated the following: Right 90 degree elbow wedge cushion to be worn, nightly, as tolerated every evening shift.Review of Resident #30's care plan dated 11/25/24 indicated the following:- Resident #30 has limited physical mobility r/t (related to) CVA with right sided hemiplegia- Maintain usage of wrist/elbow braces to prevent contracturesReview of Resident #30's January 2026 Treatment Administration Record (TAR) indicated that staff documented that Resident #30 was wearing the Right 90 degree elbow wedge cushion on 1/20/26 and 1/21/26 despite the surveyors observations of the Resident not wearing it.During an interview on 1/21/26 at 10:26 A.M., Nurse #7 said Resident #30 only wears a wrist splint when he/she goes into his/her wheelchair and does not use any other orthotic devices.During an interview on 1/21/26 at 10:29 A.M., Certified Nursing Assistant (CNA) #1 said Resident #30 is supposed to wear a splint under his/her arm but he/she refuses. CNA #1 said she will tell therapy that he/she has been refusing whenever they check in with the staff.During an interview on 1/21/26 at 11:02 A.M., the Occupational Therapist (OT) and Director of Rehabilitation (DOR) said Resident #30 has a cushion for his/her elbow but he/she takes it off because he/she does not like it. At 11:34 A.M., the OT and DOR said they found Resident #30's cushion in his/her bedside table drawer, the OT and DOR said staff should be documenting if Resident #30 is refusing to wear the cushion or that he/she takes it off.During an interview on 1/21/26 at 11:50 A.M., Unit Manager #2 said she would expect staff to be accurately documenting the medical record. During an interview on 1/21/26 at 12:32 P.M., the Director of Nursing said she expects staff to documenting in the medical record accurately and if Resident #30 is not wearing his/her cushion they should not be documenting that he/she is.

Based on observations, record review, and interview the facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC), consistent with professional standards of practice for one Resident (#22), out of a total sample of 24 residents. Specifically, for Resident #22, the facility failed to apply a PICC line dressing that did not have gauze obstructing the insertion site. Findings include:Review of the facility policy titled Central Venous Catheter Care and Dressing Changes, dated as revised March 2022, indicated the purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. 3. Change the dressing if it becomes damp, loosened or visibly soiled and:a. at least every 7 days for a transparent semi-permeable membrane (TSM) dressing; orb. at least every 2 days for sterile gauze dressing (including gauze under a TSM unless the site is not obscured). Resident #22 was admitted to the facility in October 2025 with diagnoses including osteomyelitis and diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/4/26, indicated that Resident #22 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS indicated Resident #22 required IV antibiotics. Review of Resident #22's physician's orders, dated 12/29/25, indicated:-Change PICC:(Right arm): change transparent dressing, extension set and cap on admission, weekly, and as needed. every day shift and as needed for dressing change every day shift every Tuesday for IV maintenance date and label dressing and as needed for maintenance change as needed for leakage, infiltration, etc. date and label dressing.-Monitor IV site- PICC and location: Right arm for signs/symptoms of infection and/or infiltration every shift for maintenance monitor IV site each shift, notify practitioner and document if swelling, redness, drainage and/or infiltration noted. Review of Resident #22's physician's orders, dated 12/30/25, indicated:-Meropenem Intravenous Solution Reconstituted 1 GM (Meropenem), Use 1 gram intravenously every 8 hours for osteomyelitis until 2/5/26. Review of Resident #22's Skilled Care Nursing Documentation note, dated 1/18/26, indicated:-Resident receives IV therapy, PICC line dressing changed no signs and symptoms of infection noted. On 1/20/26 at 7:41 A.M., and on 1/21/26 at 8:56 A.M., the surveyor observed Resident #22's PICC line inserted in his/her right arm, the dressing was dated 1/18/26 and there was a gauze dressing obstructing the insertion site. During an interview on 1/21/26 at 8:33 A.M., Unit Manager #1 said that PICC line dressings are to be changed every 7 days and there should be no gauze obstructing the insertion site and nursing should be able to see the insertion site every shift. During an interview on 1/21/26 at 8:39 A.M., Nurse #4 said that PICC line changes require a sterile technique. Nurse #4 said that he will put the gauze over the insertion site during dressing changes if it is available in the kit. During an interview on 1/21/26 at 8:44 A.M., the Staff Development Coordinator (SDC) said that PICC line dressing changes should be completed according to policy. The SDC said that gauze dressing obstructing the PICC line dressing site should be changed every 2 days. During an interview on 1/21/26 at 8:50 A.M. the Director of Nursing said that nursing should not apply gauze underneath the transparent dressing during the PICC line dressing changes. On 1/21/26 at 8:56 A.M., the surveyor and the Director of Nursing observed Resident #22's PICC line dressing dated as 1/18/26 (3 days prior), the DON said that there should not be gauze under the transparent dressing, and she said that the insertion site could not be visualized.

Based on observation, record review, and interview, the facility failed to ensure professional standards of practice for the care of an indwelling Foley urinary catheter (a flexible tube inserted through the urethra into the bladder to drain urine) for one Resident (#30) out of a total sample of 24 residents. Specifically, the facility failed to ensure nursing inserted the correct balloon size in accordance with physician's orders.Findings include:Review of the facility policy titled Indwelling (Foley) Catheter Insertion, Male Resident, dated and revised August 2022, indicated the following:- Preparation: Verify there is a physician's order for this procedure, review the resident's care plan to assess for any special needs of the resident- Equipment and Supplies: The catheter size is specified in the order.Resident #30 was admitted to the facility in August 2023 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, contracture of the right elbow and neuromuscular dysfunction of bladder. Review of Resident #30's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief interview for Mental Status score of 6 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated that the Resident has an indwelling urinary catheter and does not reject care. Review of Resident #30's physician's order dated 8/30/25, indicated the following:- Foley catheter size #16fr (French) with 10cc (cubic centimeters) Balloon- Foley catheter care every day and evening shift for maintenance provide catheter care as neededReview of Resident #30's indwelling foley catheter care plan dated 11/30/23, indicated the following intervention: Catheter: Resident #30 has 16f 10cc (balloon size) Foley Catheter.Review of Resident #30's Kardex (a care card indicating the type of care a resident needs) indicated the following under the Bladder/Bowel section: Resident #30 has 16f 10cc Foley Catheter.During an observation on 1/21/26 at 7:32 A.M., the surveyor observed Resident #30's foley catheter as having a 16 French sized tubing with a 30 cc balloon.During an interview on 1/21/26 at 11:40 A.M., Nurse #7 said Resident #30 either uses a 16 or 18 French sized catheter tubing with a 5 cc balloon. The surveyor disclosed to Nurse #7 that Resident #30 is currently using a 30cc balloon and Nurse #7 said she was not even aware they had balloon that big in the facility and he/she should not be using that big of a balloon as it can cause pressure on the bladder and she missed it when doing catheter care. The surveyor and Nurse #7 then observed Resident #30's catheter together and she confirmed he/she currently had a 30 cc balloon foley catheter.During an interview on 1/21/26 at 11:50 A.M., Unit Manager #2 said Resident #30 should not be using a 30 cc balloon for his/her foley catheter. Unit Manager #2 said the last time she changed Resident #30's catheter was in November 2025 and she is not sure who changed it since then or how long the Resident has been using a 30 cc balloon. Unit Manager #2 said Resident #30 has not been out to urology and all catheter care is done in the facility.Review of the facility's Central Supply room on 1/21/26 at 11:58 A.M., indicated there were foley catheters with 30 cc balloon available for use.During an interview on 1/21/26 at 12:32 P.M., the Director of Nursing (DON) said physician's orders should be followed and Resident #30 should not be using a 30 cc balloon for his/her foley catheter as it could cause some irritation.During a telephone interview on 1/21/26 at 1:20 P.M., the Nurse Practitioner (NP) said Resident #30's physician's orders should be followed, and she had no knowledge of a 30 cc balloon being used for his/her foley catheter. The NP then said Resident #30 has not gone out to Urology recently.

Based on observation, record review, and interview, the facility failed to accurately transcribe wound recommendations and perform wound care appropriately for one Resident (#4) out of a total sample of 24 residents. Findings include: Review of the facility policy titled Dressings, Dry/Clean, dated September 2013, indicated the following: Verify that there is a physician's order for this procedure.Review the resident's care plan, current orders, and diagnoses to determine if there are special treatment needs. Assess the wound and surrounding skin for edema, redness, drainage, tissue healing progress and wound stage.Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually, from the center outward). Resident #4 was admitted in March 2024 with diagnoses including type 2 diabetes and venous insufficiency. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #4 scored a 15 out of 15 of the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the MDS indicates Resident #4 has a stage 4 pressure wound. Review of the care plan for Resident #4 indicated the following: Focus: The resident has pressure ulcer on coccyx (initiated 3/1/24)Interventions: Administer treatments as ordered and monitor for effectiveness (initiated 3/1/24) Review of the current physician's orders indicated the following order:wound care: COCCYX: Cleanse the wound with Full Strength Dakin's solution (an antiseptic used for wound cleaning) moistened gauze, (pack the wound depth and tunnel/s adequately with IODOFORM PACKING), maintain packing in one piece, apply Zinc Barrier Cream to peri wound area, cover with superabsorbent Silicone border foam dressingReview of the wound follow up progress note, dated 1/15/26, indicated the following: Wound Measurements: 0.6 centimeters (cm) length, 0.5 cm width, and 2.4 cm depth. The wound has a tunnel measurement of 2-5 o'clock: 2.9 cm. Instruction: Offer/provide prompt perineal care with incontinence, Cleanse the wound with Full Strength Dakin's solution moistened gauze, allow for Dakin's soak for 1-2 minutes, pack the wound depth and tunnel/s adequately with Iodoform rope/packing. May reinforce with clean gauze, cover with superabsorbent Silicone border dressing daily, as needed (PRN). Turn, reposition, offload every 2 hours PRN and as tolerated. Monitor for changes. Review of the physician's orders failed to indicate that the recommendations for the Dakin's soak were transcribed to the current physician's orders. During an interview on 1/20/26 at 12:36 P.M. and 1/21/26 at 11:17 A.M., Resident #4 said that he/she has had a wound for 3 years now and some of the staff don't pack the wound correctly or with enough Iodoform packing. Resident #4 said that it is certain staff members who do not pack it correctly and he/she can tell which nurses do not perform the wound care correctly. Resident #4 said that he/she has told staff including the Social Worker, Unit Manager, Ombudsman, and Administrator about his/her concerns regarding his/her coccyx wound treatment. On 1/21/26 at 10:59 A.M., the surveyor observed Nurse #8 complete Resident #4's coccyx wound dressing. Nurse #8 cleansed the exterior of Resident #4's coccyx wound with Dakin's solution (not the wound bed). Nurse #8 did not apply any Dakin's solution to the wound bed according to the wound provider's recommendation. After Nurse #8 cleansed the exterior of the coccyx wound Nurse #8 immediately began to pack Resident #4's coccyx wound. Nurse #8 did not apply any zinc cream to the peri wound. During an interview on 1/21/26 at 11:03 A.M., Nurse #8 said that she routinely cares for Resident #4 coccyx wound. Nurse #8 said that she does not insert Dakin's moistened gauze into the wound bed and she does not apply zinc cream to the peri-wound. Nurse #8 said that she put the dressing on Resident #4's coccyx and then puts the zinc cream around his/her rectum. During an interview on 1/21/26 at 11:32 A.M., Unit Manger #2 said that the wound doctor provides a spreadsheet with recommendations for each wound after their visit. Unit Manager #2 said that the wound doctor was in the facility on 1/15/26 and showed the surveyor a spreadsheet with the recommendation to apply the Dakin's solution to Resident #4's wound and let it sit for 1-2 minutes. Unit Manager #2 said that Nurse #8 should have taken a clean piece of gauze and moistened the gauze with the Dakin's solution, and then Nurse #8 should have filled the wound bed with the Dakin's moistened gauze and let the wound soak for 1-2 minutes according to the wound providers recommendations. Unit Manager #2 said that the purpose for the Dakin's solution soak is to help prevent infection and to help remove old dead tissue and drainage from the wound to promote healing. During an interview on 1/21/26 at 12:21 P.M., the Director of Nursing said she would expect the wound doctor's recommendations to be transcribed correctly to the orders and nurses should be following the orders. The Director of Nursing said that the wound bed should have been cleaned as recommended.

Based on observation, record review, and interview, the facility failed to follow the grievance process for one Resident (#4) related to wound care, out of a total sample of 24 residents. Findings include: Review of the facility policy titled Grievance Policy, undated, indicated the following: It is the policy of the facility to follow all regulatory guidance and support that each resident has the right to voice grievances, complaints, and that resolution will be actively pursued in a reasonable amount of time. - The Center must have a grievance officer -- the Grievance officer is the point person responsible for overseeing the grievance process, receiving, and tracking grievances through to their conclusion. - When a resident, representative or other person linked to a resident has a grievance or complaint a staff member should encourage that person to file a written grievance using the facility grievance/complaint report form. The staff member should assist with the completion of the form if necessary. - If the person does not wish to complete the report, the staff member receiving the grievance should ensure the form is filled out and passed along in accordance with the policy. - Receipt of the grievance and/or complaint will be logged by the Grievance officer in the facility grievance log. This log will be utilized for tracking and trending as part of the facility QAPI program. - The Administrator is responsible for overall compliance of the grievance and/or complaint officer. Resident #4 was admitted in March 2024 with diagnoses including type 2 diabetes and venous insufficiency. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #4 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the MDS indicates Resident #4 has a stage 4 pressure wound. Review of a voicemail message from the facility's Ombudsman on 1/20/26 at 8:16 A.M. indicated the following: Resident #4 has been complaining about his/her wound care that he/she receives in the facility and he/she is pretty reliable. On 1/21/26 at 11:17 A.M., Resident #4 said that he/she has been having concerns with his/her wound care, specifically wound packing (a technique for deep or tunneling wounds, involving tightly stuffing gauze into the cavity to control bleeding, absorb drainage, and promote healing from the inside out, preventing premature closure), and feels like it is not being addressed. Resident #4 said that he/she has told the staff and has expressed his/her concern during the quarterly care meetings. Resident #4 said he/she told the Ombudsman about his/her concerns regarding the wound care as well. Resident #4 said he/she feels like staff is not addressing it and has not been approached to file a grievance. Review of the care conference note, dated 1/14/26, indicated Resident #4 had concerns regarding the timing of his/her wound care and getting back into bed in the afternoon. During an interview on 1/21/26 at 11:35 A.M., Unit Manager #2 said that Resident #4 has expressed his/her concerns regarding the packing of his/her wound and knows Resident #4 has contacted the Ombudsman and Unit Manager #2 said she told the Administrator. Unit Manager #2 said she has shown her nurses how to correctly do the wound care but does not have a record of the education. During an interview on 1/21/26 at 12:09 P.M., the Social Worker said that Resident #4 had concerns about his/her wound care not being packed correctly by certain nurses and she feels that the staff did address it with him/her. The Social Worker said that the Administrator was in the care meeting and may have filed a grievance, but she is not sure. The Social Worker said that when a resident has a complaint, then a grievance should be filed about it. During an interview on 1/21/26 at 12:21 P.M., the Director of Nursing said she was aware of Resident #4's wound concerns, but the Administrator is the one that handles grievances. During an interview on 1/21/26 at 12:34 P.M., the Administrator said that he will file a grievance if it is a serious concern or something regarding care. The Administrator said that Resident #4 has a lot of concerns and feels like no matter what the facility does, the Resident is not satisfied. The Administrator said that he feels he addressed the concerns by notifying the Unit Manager and he feels that the notes in the electronic medical record are accurate in reflecting that they have addressed the wound. When the surveyor asked how the Administrator ensures resolution of a grievance, the Administrator said that even though there is not a paper trail, he ensures they get resolved. The Administrator said he does remember Resident #4 bringing up the wound care concern and feels he appropriately addressed the issue with the Unit Manager. On 1/21/26 at 10:59 A.M., the surveyor observed Nurse #8 fail to correctly apply the appropriate treatment to Resident #4's wound, according to the wound doctor's recommendations made on 1/15/26. See F686.

Based on interview and record review, the facility failed to notify the physician of a change in condition for one Resident (#3) out of a total sample of 24 residents. Specifically, the facility failed to notify the physician/nurse practitioner when Resident #3's blood sugar levels went below 70 mg/dL (milligrams per deciliters) as indicated by the plan of care.Findings include:Review of the facility policy titled Change in a Resident's Condition or Status dated and revised February 2021, indicated the following:- The nurse will notify the resident's attending physician or physician on call when there has been a(an): significant change in resident's physical/emotional/mental condition, specific instruction to notify the physician of changes in the resident's condition.Resident #3 was admitted to the facility in August 2024 with diagnoses including type 1 diabetes mellitus with diabetic neuropathy, atherosclerotic heart disease, and dementia. Review of Resident #3's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 13 out of 15 indicating intact cognition. Further review of the MDS indicated that the Resident receives insulin due to hypoglycemia. Review of Resident #3's physician's order dated 8/16/24 indicated the following:- May obtain blood glucose as needed if symptoms of hypo/hyperglycemia (low/high blood sugar) present & notify MD as needed Notify practitioner if blood sugar is less than 70 or greater than 400Review of Resident #3's nursing progress note dated 6/1/25 at 10:33 P.M., indicated the following:- 9:15pm resident called and wanted his/her blood sugar checked because it felt low and he/she had trouble getting onto the toilet from his/her w/c. his/her CBS was found to be 56. He/she was alert and able to drink so he/she requested fruit punch, two puddings, and he/she ate a cupcake. upon recheck 35 minutes later his/her CBS was 89 and he/she reported feeling much better.Review of Resident #3's Blood Sugar Vitals log indicated the following:11/11/25 at 8:20 P.M. - 67 mg/dL (milligrams per deciliter, a unit for measuring blood sugar).11/23/25 at 8:35 A.M. - 64 mg/dL12/4/25 at 12:17 P.M. - 61 mg/dL1/4/26 at 7:56 A.M. - 57 mg/dL1/10/26 at 12:12 P.M. - 69 mg/dLReview of Resident #3's care plan dated 7/23/22 indicated the following:- Resident is at risk for complications related to Diabetes Mellitus - insulin dependent- Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness.Review of Resident #3's medical record failed to indicate any documentation that the Physician or Nurse Practitioner were notified of blood sugars <70, as per the physician's order.During an interview on 1/21/26 at 8:48 A.M., Unit Manager #2 said all physician's orders should be followed. Unit Manager #2 said the Nurse Practitioner (NP) or physician should be contacted if a Resident is experiencing a change of condition or if specified by a physician's order. The surveyor and Unit Manager #2 reviewed Resident #3's blood sugar values and she said the NP should have been notified of Resident #3's low blood sugar values so she was aware of the situation and could provide updates and monitor as needed. Unit Manager #2 then said staff need to be documenting in the medical record when they contact the NP.During an interview on 1/21/26 at 12:32 P.M., the Director of Nursing (DON) said when staff contact the NP of physician they should be documenting it in the medical record. The surveyor reviewed Resident #3's low blood sugar values and the physician's order and she said the NP should have been notified.During a telephone interview on 1/21/26 at 1:16 P.M., the NP said she does not remember being notified about Resident #3's low blood sugar values and she should have been to provide guidance and so she could follow up with the Resident. The NP said if she was unavailable then staff should be contacting the on-call provider. The NP then said she would expect staff to be documenting when they contact or attempt to contact her or the physician.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was dependent on staff for assistance with care, the facility failed to ensure staff consistently implemented and followed their abuse policy related to the reporting of abuse allegations, when in the morning on 09/06/25, although Certified Nurse Aide (CNA) #2 witnessed CNA #1 forcefully remove that call bell cord out of Resident $#1's hand and intentionally place it out of his/her reach, CNA #2 did not immediately report the incident as required, but waited two days to report it. Findings include:Review of Facility Policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated September 2022, indicated if abuse is suspected, the suspicion must be reported immediately to the administrator.Review of Resident #1's admission Record indicated his/her diagnoses included Dementia, Scoliosis, Congestive Heart Failure, and Adjustment Disorder with mixed anxiety and depressed mood.Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 06/30/25, indicated he/she had intact cognitive functioning and was dependent on others for bed mobility, bathing, personal hygiene and transfers.Review of Resident #1's Care Plan, reviewed and renewed with his/her June 2025 MDS, indicated he/she was at risk for decreased ability to perform activities of daily living. Care Plan interventions included that the call bell to be within reach when in bed.During an interview on 11/25/25 at 10:30 A.M., Resident #1 said one day (exact date unknown) when he/she rang the call bell while lying in bed, CNA #1, who was in the room, quickly put her hand on his/her hand squeezing it, pulled the call cord hard out of his/her hand and said you're not going to start this today. Resident #1 said CNA #1 moved the call bell cord out of his/her reach, off the bed and put it behind him/her. Resident #1 said CNA #2 had entered the room, stood by the foot of his/her bed and witnessed the incident. During an interview on 11/25/25 at 12:00 P.M., CNA #2 said in the morning on 09/06/25 she stood at the foot of Resident #1's bed while CNA #1 was with his/her roommate. CNA #2 said CNA #1 complained that Resident #1 always rang the call bell. CNA #2 said she noticed that Resident #1's call light was turned off, and that Resident #1 still held the call bell cord button in his/her hand. CNA #2 said she asked Resident #1 if she could help him/her. CNA #2 said when Resident #1 responded by crying out, CNA #1 pulled back the privacy curtain that was between the two Residents beds and yanked the call bell cord held in Resident #1's fist, forcefully out of his/her grip. CNA #2 said CNA #1 stated Resident #1 called too much. CNA #2 said CNA #1 threw the call bell cord onto the floor between the two beds out of Resident #1's reach. CNA #2 said she did not immediately report the incident but waited and reported the incident a day or two later to Unit Manager #1. CNA #2 said she waited to report the incident to Unit Manager #1 because she was unsure if other nurses (working on the unit that day) would respond to the incident appropriately during the shift. During an interview on 12/02/25 at 1:30 P.M., CNA #1 said on 09/06/25 prior to CNA #2's arrival to assist Resident #1, she unwrapped the call bell cord from Resident #1's side rail and put it on the ground (floor) out of his/her reach and proceeded to care for his/her roommate. During an interview on 09/08/25 at 8:30 A.M., Unit Manager #1 said in the morning on 09/08/25, CNA #2 approached her in tears to report that CNA #1 had pulled the call bell cord away from Resident #1 and tossed it out of his/her reach. Unit Manager #1 said she immediately reported the incident to the Director of Nurses. Unit Manager #1 said while investigating the incident it was determined that the incident occurred on 09/06/25, when both CNA #1 and CNA #2 were assigned to Resident #1's Unit. Unit Manager #1 said the nurses who were scheduled to work on the Unit (on 09/06/25) told her they were unaware that an incident occurred. During an interview on 11/25/25 at 2:50 P.M., the Director of Nurses (DON) said on 09/08/25 Unit Manager #1 informed her that CNA #1 pulled Resident #1's call bell cord out of Resident #1's hand on 09/06/25. The DON said neither herself nor the Administrator had been made aware of the incident prior to being notified of it by Unit Manager #1 (on 09/08/25). The DON said staff members were expected to immediately report allegations of abuse and not wait until two days later.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who was alert, oriented and able to make his/her needs known, the facility failed to ensure he/she was treated in a dignified and respectful manner, when a staff member told Resident #1 that his/her rang the call bell too much, then intentionally took Resident #1's call bell and placed it out of his/her reach to prevent him/her from using it.Findings include:Review of Facility Policy titled Call System, Residents, dated September 2022, indicated that residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or centralized work station.Review of Facility Policy titled Resident Rights, dated February 2021, indicated employees shall treat all residents with kindness, respect and dignity. The Policy indicated a resident's right to a dignified existence, and self determination.Review of Resident #1's admission Record indicated his/her diagnoses included Dementia, Scoliosis, Congestive Heart Failure, and Adjustment Disorder with mixed anxiety and depressed mood.Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 06/30/25, indicated he/she had intact cognitive functioning and was dependent on others for bed mobility, bathing, personal hygiene and transfers.Review of Resident #1's Care Plan, reviewed and renewed with his/her June 2025 MDS, indicated he/she was at risk for decreased ability to perform activities of daily living. Care Plan interventions included that the call bell to be within reach when in bed.During an interview on 11/25/25 at 10:30 A.M., Resident #1 said while lying in bed he/she pushes the call bell button if he/she needed help. Resident #1 said one day (exact date unknown) when he/she rang the call bell, CNA #1, who was in the room, quickly put her hand on his/her hand squeezing it, pulled the call bell cord hard out of his/her hand and said to him/her you're not going to start this today. Resident #1 said CNA #1 moved the call bell cord out of his/her reach, took it off the bed and put it behind him/her. Resident #1 said CNA #2 had entered the room, stood by the foot of his/her bed and witnessed the incident. During an interview on 11/25/25 at 12:00 P.M., CNA #2 said in the morning on 09/06/25 she entered Resident #1's room and stood at the foot of Resident #1's bed while CNA #1 was with his/her roommate. CNA #2 said CNA #1 complained that Resident #1 always rang the call bell. CNA #2 said she noticed that Resident #1's call bell light was turned off, and that Resident #1 still held the call bell cord button in his/her hand. CNA #2 said she asked Resident #1 if she could help him/her. CNA #2 said when Resident #1 responded by crying out, CNA #1 pulled back the privacy curtain that was between the two residents' beds and yanked the call bell cord held in Resident #1's fist, forcefully out of his/her grip. CNA #2 said CNA #1 stated Resident #1 called too much. CNA #2 said CNA #1 threw the call bell cord to the floor between the two beds out of Resident #1's reach. CNA #2 said she gave Resident #1 back the call bell and provided his/her morning care. CNA #2 said she reported the incident a day or two later to the Unit Manager.During an interview on 12/02/25 at 1:30 P.M., CNA #1 said on 09/06/25 she entered Resident #1's room and told him/her that her assigned CNA was busy, but would come to assist him/her, and then she turned off his/her the call bell from sounding on the wall. CNA #1 said she pulled the privacy curtain and proceeded to assist Resident #1's roommate. CNA #1 said she knew the assigned CNA was coming and did not want Resident #1 to ring the call bell again. CNA #1 said prior to CNA #2's arrival, she unwrapped the call bell cord from Resident #1's side rail, put it on the ground (floor) out of his/her reach and proceeded to care for the roommate. During an interview on 09/08/25 at 8:30 A.M., Unit Manager #1 said on 09/08/25, CNA #2 approached her to report that CNA #1 had pulled the call bell cord away from Resident #1 and tossed it out of his/her reach. Unit Manager #1 said she immediately reported the incident to the Director of Nurses. During an interview on 11/25/25 at 2:50 P.M., the Director of Nurses (DON) said she was informed of the incident by Unit Manager #1 in the morning on 09/08/25. The DON said upon interviewing CNA #1 on 09/08/25, CNA #1 stated that Resident #1 had his/her call light turned on, she wanted it to stop sounding, so she pulled it away from his/her reach. The DON said CNA #1's employment was terminated.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had a new Physicians Order on 01/07/2025, for Blood Laboratory work to be conducted on 01/09/25, the Facility failed to ensure Resident #1 was provided with Laboratory Services consistent with his/her Physician Orders, when the laboratory tests were not ordered or obtained, as ordered.Findings include:The Facility Policy titled, Lab and Diagnostic Test Results - Clinical Protocol, dated revised November 2018, indicated the following: the Physician will identify and order diagnostic and laboratory testing based on the Resident's diagnostic and monitoring needs, the staff will process test requisitions and arrange for tests and the laboratory, diagnostic radiology provider, or other testing source will report test results to the facility.The Policy indicated the following: a Nurse will try to determine whether the test was done, as a routine screen or a follow up and if the reason for performing the test cannot be identified, the Nurse should proceed as though the tests were ordered to assess a condition change or recent onset of signs and symptoms.Resident #1 was admitted to the Facility in January 2025, diagnoses included Influenza (flu), Diabetes (too much sugar that stays in the blood), Hypertension (high blood pressure), Hyperlipidemia (high levels of fat in the blood), Heart Block status post Pacemaker (pacemaker placement to manage signals in the heart that are delayed or blocked), Chronic Kidney Disease-stage III (kidneys are moderately to severely damaged and not working as well as they should), Spinal Stenosis (spaces inside the bone of the spine get too small), Epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures) and muscle weakness.Review of Resident #1's Physician Orders, dated 01/07/25, indicated Resident #1's CBC (Complete Blood Count - blood test that analyzes the size and quality of different blood cells) and a BMP (Basic Metabolic Panel - a group of blood tests that measure blood glucose (sugar), electrolytes (like sodium, potassium, and calcium), and kidney function indicators (like blood urea nitrogen (BUN) and creatinine), were to be drawn on 01/09/25.Review of Resident #1's Medication Administration Record (MAR), dated 01/07/2025 through 01/12/2025, indicated there was no documentation to support Resident #1's CBC and BMP had been obtained and completed as ordered by Resident #1's Physician on 01/07/2025.There was no documentation to support Nursing followed up on Resident #1's CBC and BMP, and no documentation to support Nursing Staff informed the Physician/Nurse Practitioner that the laboratory work had not been obtained.Review of the Nurse Practitioner Progress Note, dated 01/09/2025, indicated Resident #1's laboratory results were pending on 01/09/2025.During an interview on 09/23/2025 at 10:25 A.M., the Nurse Practitioner (NP) (which included a review of Resident #1's admission Physician Orders, dated 01/07/2025, the NP said Resident #1's Physicians Orders indicated a CBC and BMP were to be drawn on 01/09/2025.The Nurse Practitioner said on 01/09/2025, she assessed Resident #1, and had documented in her Progress Note, (written on 01/09/2025), that Resident #1's laboratory results were pending on 01/09/2025. The Nurse Practitioner said the laboratory results were not available when she had reviewed Resident #1's Medical Record.The Nurse Practitioner said she was not informed Resident #1's CBC and BMP were not drawn on 01/09/2025, was not informed of the reason why they were not completed and said Resident #1's next laboratory draw had been scheduled for 01/11/2025.During an interview on 09/23/2025 at 2:28 P.M., (which included a review of Resident #1's admission Physician Orders) Nurse #3 said on 01/07/2025 she assisted with Resident #1's admission Orders. Nurse #3 said when a Resident is admitted to the Facility, her focus is to enter the Residents' Medications Ordered by the Physician and the oncoming Shift Nurse will review the Resident's admission Orders to ensure medications and laboratory tests are ordered correctly. Nurse #3 said the Residents' medications and laboratory orders are populated on his/her Medication admission Record after the Nurse enters the Physicians Orders into the computer system.Nurse #3 said on 01/07/25, she does not know why Resident #1's orders for CBC and BMP were not ordered for 1/09/25.During a telephone interview on 09/24/2025 at 1:29 P.M., the Unit Manager said when a new Resident is admitted to the Facility, Nursing will enter the Resident's medication and laboratory orders. The Unit Manager said her practice would be to review the Physicians Orders to ensure they were entered correctly and completely.The Unit Manager said she does the best she can to ensure she checks all new admission Physicians Orders. The Unit Manager said as far as she knew, the Clinical Staff and the Director of Nurses (DON) would check the Physicians' Orders when she was not at the Facility to ensure they were completed.During an interview on 09/23/2025 at 4:20 P.M., the Director of Nurses (DON) said her expectations of staff are when a Physician Orders laboratory tests for a Resident, that Nursing will order the laboratory tests, ensure the laboratory tests are drawn, and if the Resident is unable to be drawn, the staff will notify the Physician/Nurse Practitioner that is was not completed. The DON said the Unit Manager was responsible for ensuring Resident's Physicians Orders are entered and completed. The DON said she was unable to find any documentation to support Resident #1's CBC and BMP had been ordered by Nursing on 01/07/25, or that test samples were drawn by the Laboratory Staff. The DON said she was unable to find documentation to support Nursing followed up with Resident #1's Physician/Nurse Practitioner that Resident #1's tests were not completed as ordered.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Physician's Orders included the administration of an anxiolytic, and an ear drop medication, the Facility failed to ensure Resident #1 was administered the medications, consistent with physicians' orders.Findings include:The Facility Policy titled, Administering Medications, dated revised April 2019, indicated medications are administered in accordance with prescriber orders, including any required time frame. The Policy indicated whether a medication is withheld, refused, or given at a time other than the schedule time, the individual administering the medication shall initial and circle the Medication Administration Record (MAR) space provided for that drug and dose.The Facility's Policy titled, Change in a Resident's Condition or Status, dated revised February 2022, indicated the Nurse will notify the resident's attending Physician or Physician On-Call when there has been a refusal of treatment or medications two (2) or more consecutive times.Resident #1 was admitted to the Facility in January 2025, diagnoses included Influenza (flu), Diabetes (too much sugar that stays in the blood), Hypertension (high blood pressure), Hyperlipidemia (high levels of fat in the blood), Heart Block status post Pacemaker (pacemaker placement to manage signals in the heart that are delayed or blocked), Chronic Kidney Disease-stage III (kidneys are moderately to severely damaged and not working as well as they should), Spinal Stenosis (spaces inside the bone of the spine get too small), Epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures) and muscle weakness.Review of Resident #1's Physician's Orders for January 2025, indicated they included an order for (but was not limited to) the following:-Debrox Otic Solution 6.5% (Carbamide Peroxide (Otic), Instill 8 drop in left ear two times a day for impacted cerumen (earwax) for 4 days, Nursing: irrigate with normal saline when Debrox course completed, initiated, 01/09/25.-Diazepam Oral Tablet 5 milligrams (mg), give 5mg by mouth at bedtime for anxiety, initiated, 01/07/2025.Review of Resident #1's Medication Administration Record (MAR), indicated Resident #1 did not receive the ordered Debrox Otic Solution 6.5% (Carbamide Peroxide (Otic), 8 drop in left ear two times a day for impacted cerumen and the Nurse documented code 9 (other, see nursing note) for the following dates and times:-01/09/25: 6:00 P.M.,-01/11/25: 6:00 P.M.Review of Resident #1's Nurse Progress Notes indicated the following:-01/09/25: 6:00 P.M., No reason given as to why the medication was not given or what steps Nursing took after they were unable to administer the medication.-01/11/25: 6:00 P.M., No reason given as to why the medication was not given or what steps Nursing took after they were unable to administer the medication. Further review of Resident #1's MAR, indicated Resident #1 did not receive the ordered Diazepam Oral Tablet 5 mg by mouth at bedtime for anxiety and the Nurse documented code 9 (other, see nursing note) for the following dates and times:-01/07/25: 8:00 P.M.,-01/08/25: 8:00 P.M.,-01/09/25: 8:00 P.M.Review of Resident #1's Nurse Progress Notes indicated the following:-01/07/25: 8:00 P.M., No reason given as to why the medication was not given or what steps Nursing took after they were unable to administer the medication.-01/08/25: 8:00 P.M., No reason given as to why the medication was not given or what steps Nursing took after they were unable to administer the medication.-01/09/25: 8:00 P.M. No reason given as to why the medication was not given or what steps Nursing took after they were unable to administer the medication.During an interview on 09/23/25 at 3:07 P.M. (which included a review of Resident #1's MAR) Nurse #1 said if a Resident was not given a medication, she would document in the Residents MAR (located in the Point Click Care, EMR-Electronic Medical Record) and would not document in the Residents' Nurses Progress Note. Nurse #1 said if a Resident was not given his/her medication two (2) or three (3) times in a row, the Physician would need to be notified. Nurse #1 said she was assigned to Resident #1 on 01/07/25, 01/08/25, 01/09/25 and 01/11/25, and had administered Resident #1's medications to him/her. Nurse #1 said she had documented code 9, indicates she would have needed to document in Resident #1's Nurses Progress Note the reason why it had not been given.This Surveyor reviewed Resident #1's MAR with Nurse #1, which indicated Resident #1 had not received the ordered Debrox Otic Solution 6.5% (Carbamide Peroxide (Otic), on 01/09/25 and 01/11/25 at 6:00 P.M., and for the Diazepam Oral Tablet 5 mg by mouth at bedtime, on 01/07/25, 01/08/25 and 01/09/25 at 8:00 P.M., all of which were documented as code 9 (other see nursing note).However, review of Resident #1's Nurses Progress Notes, indicated there was no documentation to support why Resident #1 did not receive the medication or what steps Nursing took after they were unable to administer the medication, on these dates.Nurse #1 said she could not recall why Resident #1's medications were not given and why she had not documented in Resident #1's Nurses Progress Note. During an interview on 09/23/25 at 4:20 P.M., the Director of Nurses (DON) said it is her expectation that the Nurse will document the reason why the medication was not given to a Resident, notify the Residents Physician/Nurse Practitioner regarding the Residents status and document in the Residents Progress Note.

Based on policy review, interview and observation, the facility failed to ensure it provided a means for residents to communicate to staff on the A Unit. Findings included: The Facility's policy titled Answering the Call Light dated as revised September 2022, indicated: - The purpose of this procedure (answering the call light) is to ensure timely responses to the resident's requests and needs. - Be sure the call bell is plugged in and functioning at all times. On 1/21/25 at approximately 8:30 A.M., the surveyor observed that the call bell system was broken on the A Unit. The surveyor sampled the call bell system from several bedrooms and noted that the call bell did not sound, either in the hallway of the nursing station, and the call bell board at the nursing station did not illuminate to identify which bedroom requested help. The surveyor observed that in some of the sampled bedrooms the call light button illuminated the light outside the bedroom doorway. The surveyor observed that the call lights in the hallway located on the left wing of the unit, and the end of the hallway of the right wing, were not visible from the nursing station. During the morning of 1/21/25 and the afternoon of 1/22/25, the surveyor observed: - room [ROOM NUMBER]W: No hand bell. The Resident was unaware the call light system was broken. - room [ROOM NUMBER]W: No hand bell. The Resident was unaware call light system was broken. - room [ROOM NUMBER]D and 7W: No hand bells in the bedroom. The Residents said they were unaware the call light system was broken. - room [ROOM NUMBER]D: No hand bell. The Resident was unaware the call light system was broken. - room [ROOM NUMBER]W: Resident lying in bed and a hand bell was located on windowsill, beyond his/her reach. The Resident was aware the call light system was broken. - room [ROOM NUMBER]W: Resident lying in bed and hand bell on windowsill, beyond his/her reach. The Resident was aware call light system was broken. - room [ROOM NUMBER]D: Resident lying in bed and hand bell was located on over bed table, within reach. Resident said light in the hallway outside the bedroom illuminates when the call bed cord button is pushed, but no alarm sounds or light illuminates at the nursing station. The Resident said sometimes staff respond to the hall light, other times he/she needs to call out for help. - room [ROOM NUMBER]D: No hand bell, and the call bell cord was on the floor, beyond the Resident's reach. The Resident was unaware the call light system was broken. - room [ROOM NUMBER]W: No hand bell, and the call bell cord was on the floor, beyond the Resident's reach. The Resident was aware call light system was broken. During an interview with Unit Manager #2 on 1/22/25 at 11:20 A.M., she said the call light system began to stop functioning in some of the residents' bedrooms in November 2024, and that by mid-December 2024 the system stopped functioning in all the bedrooms. Unit Manager #2 said none of the call bells sounded, but that some of the hallway call lights still activated, but not at the nursing station. Unit Manger #2 said she did not when the call system was to be repaired. Unit Manager #2 said she had instructed staff nurses to distribute hand bells to each of the residents and to place them within reach. The surveyor told Unit Manager #2 that many residents did not have handheld bells, and for those that did these were sometimes out of reach. The surveyor told Unit Manager #2 that many of the residents did not know the call light system was broken, yet were still using the call bell, and complained about the late response time. On 1/22/25 at 11:25 A.M., the surveyor was on the A Unit hallway and heard the Resident in room [ROOM NUMBER]D calling for help, from his/her bed. The surveyor entered the bedroom and observed that room [ROOM NUMBER]D still did not have a hand bell. During an interview with the Administrator on 1/23/25 at 9:36 A.M., he said he was aware the call light system was broken, and that staff should have given each resident a hand bell to ring for assistance. During an interview with the Consulting Maintenance Director on 1/23/25 at 1:30 P.M., he said the building has been without a Maintenance Director for approximately a week, and he was not familiar with required repairs in the building. The surveyor and Consulting Maintenance Director reviewed the Maintenance Log, and it indicated staff documented the A Unit call light system needed repairs in October and December 2024. The Log indicated the call light system had not been repaired.

Based on observation, record review and interview, the facility failed to regularly inspect bed frames and mattress spacing to identify areas of potential entrapment. Specifically, the facility failed to regularly inspect and document findings regarding the seven zones of bed entrapment of Residents' beds for potential areas of entrapment as evidenced by a bed bolster (an object used to fill gaps between the mattress and headboard/footboard of a bed) that did not fit properly. Findings include: According to The Guidance for Industry and FDA Staff Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment Document issued on March 10, 2006 by the U.S. Department of Health and Human Services Food and Drug Administration Center for Devices and Radiological Health, The HBSW (Hospital Bed Safety Workgroup) identified 7 potential entrapment zones for hospital beds. Review of the facility policy titled Bed Safety and Bed Rails, revised and dated August 2022, indicated the following: - Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. - Bed frames, mattresses and bed rails are checked for compatibility and size prior to use. - Bed dimensions are appropriate for the resident's size. - Regardless of mattress type, width, length and/or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a resident's head or body. Any gaps in the bed system are within the safety dimensions established by the FDA. - Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks. The surveyor made the following observations on the same resident's bed: - On 1/21/25 at 9:17 A.M., on the B-unit, a resident was observed sleeping in his/her bed. There was a bolster on the foot of the bed between the mattress and the footboard. The bolster was less than half the length of the mattress and the gap between the space above the bolster to the footboard was about six inches. - On 1/22/25 at 10:25 A.M., on the B-unit, there was a bolster on the foot of the bed between the mattress and the footboard. The bolster was less than half the length of the mattress and the gap between the space above the bolster to the footboard was about six inches. The surveyor was able to put his entire arm between the mattress and the footboard. Review of the facility binder titled Bed Inspection indicated that the Maintenance Director completed Bed entrapment measurement tests on nine beds on the A Unit. Review of the nine checks indicated they were incomplete and did not have documentation on all of the entrapment zones. These checks were done on 7/24/24. The facility bed capacity is 126 beds. During an interview on 1/22/25 at 10:15 A.M., the Administrator told the surveyor that the previous Maintenance Director did not complete the yearly bed entrapment rounds. The Administrator continued to say he has a Maintenance Director from another facility completing them today. During an interview on 1/22/25 at 11:17 A.M., the visiting Maintenance Director from a sister facility said bed inspections for entrapment should be done yearly. He said this building's maintenance director never finished them so he was asked to do them. The visiting Maintenance Director said if there is a space between the headboard or footboard of the bed then a bolster that is the same thickness of the mattress should be used and the bolster should be level with the mattress so there are no gaps. The surveyor showed the visiting Maintenance Director photos of the current bolster being used and he said that is the wrong type of bolster being used and it needs to be thicker and higher up to properly fill the gap as a resident can get entrapped in the space. During an interview on 1/22/25 at 2:18 P.M., the Director of Nursing (DON) said bed safety checks for entrapment were not done. The DON said they had a previous Maintenance Director who quit and told the facility they were complete when they were not but she would expect them to still be complete. The surveyor showed the DON the photos of the bed bolster and she said it is the incorrect bolster and needs to be changed as the resident can be entrapped in the spacing with the current bolster.

Based on record reviews, observations and interviews, the facility failed to ensure resident centered care plans were developed and/or implemented for three Residents (#12, #91 and #13) out of a total sample of 24 residents. Specifically, 1. For Resident #12, the facility failed to a. develop a comprehensive resident centered care plan for a pacemaker and b. failed to implement the Resident's fall intervention of non skid strips on the floor next to his/her bed. 2. For Resident #91, the facility failed to implement a right hand splint and arm wedge as per the plan of care. 3. For Resident #13, the facility failed to implement a right hand roll as per the plan of care. Findings include: Review of the facility policy titled Comprehensive Person-Centered Care Plans, dated March 2022, indicated The interdisciplinary team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Review of the facility policy titled Care of a Resident with Pacemaker, dated December 2015, indicated The purpose of this procedure is to provide information about and guidance for the care of a resident with a pacemaker. The pacemaker battery will be monitored remotely through the telephone or an internet connection. The resident's cardiologist will provide instructions on how and when to do this. For each resident with a pacemaker, document the following in the medical record: a. The name, address and telephone number of the cardiologist; g. paced rate. When the resident's pacemaker is monitored by the physician, document the date and results of the pacemaker surveillance, including: a. [NAME] the resident's pacemaker was monitored (phone, office, internet); b. Type of heart rhythm; c. Functioning of the leads; d. Frequency of utilization; and e. Battery life. 1a. Resident #12 was admitted to the facility in July 2023 with diagnoses that included dementia, presence of a cardiac pacemaker, adult failure to thrive, and cognitive communication deficit. Review of Resident #12's most recent Minimum Data Set (MDS) assessment, dated 12/5/24, indicated he/she scored a 6 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments. Review of Resident #12's physician order, dated 9/18/23, indicated Pacemaker check as ordered. Review of Resident #12's pacemaker care plan dated 9/13/23, indicated Pacemaker checks as ordered. The resident's Pacemaker information: was left blank. During an interview on 1/22/25 12:22 P.M., Unit Manager #1 said there should be a comprehensive pacemaker care plan in place so the nurses know how to monitor the pacemaker. Unit Manager #1 said she is not sure how the Residents' pacemaker is being monitored because there is not a monitoring device in his/her room. The Unit Manager said the Resident has not been followed by cardiology. During an interview on 1/22/25 at 12:58 P.M., the Director of Nurses (DON) said she expect a Resident who has a pacemaker to have a complete and comprehensive care plan in place with the paced rate and how the pacemaker is to be monitored. 1b. On 1/21/25 at 12:33 P.M., the surveyor observed Resident #12 in bed, non skid strips were not in place on the floor next to bed. On 1/22/25 at 8:00 A.M. and 12:13 P.M., the surveyor observed Resident #12 in bed, non skid strips were not in place on the floor next to bed. Review of Resident #12's fall care plan, dated 9/30/24, indicated non skid strips to floor- Next to bed. Review of Resident #12's active Certified Nurse Aide (CNA) Kardex (from indicating the Resident needs to staff), dated 1/21/25, indicated non skid strips to floor- Next to bed. During an interview on 1/22/25 at 12:15 P.M., Certified Nurse Aide (CNA) #1 said she has taken care of the Resident multiple times and he/she is a fall risk. CNA #1 said the Resident does not have non skid strips on the floor next to the bed. During an interview on 1/22/25 12:22 P.M., Unit Manager #1 said the Resident is a fall risk and should have non skid strips on his/her floor next to bed if the care plan says they should be there. During an interview on 1/22/25 at 12:58 P.M., the Director of Nurses (DON) said if a resident is care planned to have non skid strips on the floor next to the bed then they should be in place. 45343 2. Review of the facility policy titled Orthotics and Assistive Devices, dated February 2022, indicated the following: - An assistive device is any piece of equipment that assists a resident coping with the effects of his or her disability/limited range of motion due to medical condition. These devices are intended to assist residents maneuver or perform other daily functions of daily life or prevent further complications. - If resident refuses notify nurse/provider and update care plan. - The reason for the use of the joint stabilization device is documented in the medical record. Resident #91 was admitted to the facility in August 2023 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, right wrist contracture, right hand contracture, right shoulder contracture, and right elbow contracture. Review of Resident #91's most recent Minimum Data Set (MDS) assessment, dated 11/21/24, indicated Resident #91 had a Brief Interview for Mental Status (BIMS) exam score of 8 out of a possible 15, indicating moderate cognitive impairment. The MDS further indicated Resident #91 substantial/maximal to dependent assistance with functional daily activities and upper extremity range of motion (ROM) impairment on one side. On 1/21/25 at 8:15 A.M., the surveyor observed Resident #91 was observed laying in his/her bed. Resident #91 was not wearing his/her right-hand splint or right upper extremity wedge. On 1/21/25 at 12:33 P.M., the surveyor observed Resident #91 laying in his/her bed. Resident #91 was not wearing his/her right-hand splint or right upper extremity wedge. Resident #91's hand splint was observed resting on the nightstand and right arm wedge was not visible in the room. On 1/21/25 at 4:32 P.M., the surveyor observed Resident #91 laying in his/her bed. Resident #91 was not wearing his/her right-hand splint or right upper extremity wedge. Resident #91's hand splint was observed resting on the nightstand and right arm wedge was not visible in the room On 1/22/25 at 6:55 A.M., the surveyor observed Resident #91 laying in his/her bed. Resident #91 was not wearing his/her right-hand splint or right upper extremity wedge. Resident #91's hand splint was observed resting on the nightstand and right arm wedge was not visible in the room On 1/22/25 at 7:59 A.M., the surveyor observed Resident #91 laying in his/her bed. Resident #91 was not wearing his/her right-hand splint or right upper extremity wedge. Resident #91's hand splint was observed resting on the nightstand and right arm wedge was not visible in the room. On 1/22/25 at 10:16 A.M., the surveyor observed Resident #91 laying in his/her bed. Resident #91 was not wearing his/her right-hand splint or right upper extremity wedge. Resident #91's hand splint was observed resting on the nightstand and right arm wedge was not visible in the room. On 1/22/25 at 12:39 P.M., the surveyor observed Resident #91 laying in his/her bed. Resident #91 was not wearing his/her right-hand splint or right upper extremity wedge. Resident #91's hand splint was observed resting on the nightstand and right arm wedge was not visible in the room. On 1/23/25 at 6:47 A.M., the surveyor observed Resident #91 laying in his/her bed. Resident #91 was not wearing his/her right-hand splint or right upper extremity wedge. Resident #91's hand splint was observed resting on the nightstand and right arm wedge was not visible in the room. Review of Resident #91's physician order indicated the following order initiated on 11/26/24: - Right flex hand splint to be worn up to 4-6 hrs (hours), daily, as tolerated. Put on in morning, take off in evening. Regular skin checks for any redness, irritation, indication of pain., every day shift. - Right 90-degree elbow wedge cushion to be worn up to 4-6 hrs, nightly, as tolerated. Regular skin checks for any redness, irritation, indication of pain. every evening shift Review of Resident #91's physical mobility care plan interventions indicated the following: - Maintain usage of wrist/elbow braces to prevent contractures, date initiated, 11/25/2024. Review of Resident #91's medical record failed to indicate he/she refused to wear his/her right hand splint or arm wedge. During an interview on 1/23/25 at 8:54 A.M., Unit Manager #1 said Resident #91 has a hand splint and the splint schedule should be followed per the doctor's order and documented if the resident refuses. Unit Manager #1 was not aware that Resident #91 right hand splint and wedge were not on the past two days. During an interview on 1/23/25 9:07 A.M., The Director of Nursing said a splint schedule should be followed as ordered by the physician. The Director of Nursing said if a resident refuses to wear the splint it should be documented in the medical record. 3. Resident #13 was admitted to the facility in November 2022 with diagnoses including quadriplegia, C5-C7 central cord syndrome and right-hand contracture. Review of Resident #13's most recent Minimum Data Set (MDS) assessment, dated 1/9/25, indicated Resident #13 had a Brief Interview for Mental Status (BIMS) exam score of 9 out of a possible 15, indicating moderate cognitive impairment. The MDS further indicated Resident #13 is dependent with functional daily activities and upper extremity range of motion (ROM) impairments on both sides. On 1/21/25 at 7:50 A.M., the surveyor observed Resident #13 seated in his/her wheelchair. Resident #13 was not wearing his/her right-hand roll. On 1/22/25 at 8:00 A.M., the surveyor observed Resident #13 seated in his/her wheelchair. Resident #13 was not wearing his/her right-hand roll. On 1/2/25 at 10:16 A.M., the surveyor observed Resident #13 seated in his/her wheelchair. Resident #13 was not wearing his/her right-hand roll. On 1/22/25 at 12:14 P.M., the surveyor observed Resident #13 laying in his/her recliner chair. Resident #13 was not wearing his/her right-hand roll. On 1/23/25 at 8:31 A.M., the surveyor observed Resident #13 seated in his/her wheelchair. Resident #13 was not wearing his/her right-hand roll. Review of Resident #13's physician order indicated the following order initiated on 8/12/24: - Right hand roll to be worn up to 6-8 hrs (hours), daily, as tolerated. Put on in morning, take off in evening. Regular skin checks for any redness, irritation, indication of pain. Review of Resident #13's skin integrity care plan interventions indicated the following: - The resident needs assistance to apply hand roll, date initiated, 8/12/2024. Review of Resident #13's medical record failed to indicate he/she refused to wear his/her right hand roll. During an interview on 1/23/25 at 8:54 A.M., Unit Manager #1 said Resident #13 has a hand roll, but he/she does not like to wear it all the time. Unit Manager #1 said a hand roll order should be followed per the doctor's order and documented if the resident refuses. Unit Manager #1 was not aware that Resident #13 right hand roll was not on the past two days. During an interview on 1/23/25 9:07 A.M., The Director of Nursing said a hand roll order should be followed as ordered by the physician. The Director of Nursing said if a resident refuses to wear the hand roll it should be documented in the medical record.

Based on interview, observation and record review, the facility failed to ensure a home-like environment on the A Unit. Findings include: On 1/21/25 at approximately 8:30 A.M., the surveyor observed a sample of bedrooms located on the A Unit. - room [ROOM NUMBER]: bed D, bed frame side rail has approximately 12 inches of chipped enamel. - room [ROOM NUMBER]: window shade is missing its draw chain, unable to raise or lower the blind. - room [ROOM NUMBER]: unpainted, unsanded plaster on bedroom wall next to bathroom measuring approximately 13 x 6. - room [ROOM NUMBER]: window shade is missing its draw chain, unable to raise or lower the blind. - room [ROOM NUMBER]: wired wall receptacle for television control is dangling from the wall, wires and wall cavity exposed. Review of the Maintenance Log on 1/23/25 indicated the above items in need of repair were not documented. During an interview with the Consulting Maintenance Director on 1/23/25 at 1:30 P.M., he said the blinds, unpainted wall plaster, chipped bed frame paint, and loose television control were not documented in the log book.

Based on interview, record review and observation, the facility failed to ensure it provided one Resident (#175) with the assistance required for meal setup. Findings include: Resident #175 was admitted to the facility in January 2025 and had active diagnoses which included chronic kidney disease, heart disease, muscle wasting and atrophy, difficulty walking, lack of coordination and dysphagia. As of the date of survey, a Minimum Data Set assessment had not yet been completed for Resident #175, including a Brief Interview for Mental Status exam. Resident #175's Activity of Daily Living care plan dated 1/17/25, indicated he/she required staff assistance with setup or clean-up assistance. Resident #175's Admission Functional Abilities and Goals assessment dated [DATE], indicated he/she required setup or clean-up assistance with meals. Review of Resident #175's Activities of Daily Living care plan dated 1/21/25, indicated he/she has a self-care performance deficit related to activity Intolerance, deconditioning, disease process and spinal stenosis. Interventions included: Required setup and clean-up assistance. On 1/21/25 at 8:00 A.M., the surveyor observed a staff person enter Resident #175's room and place his/her meal tray, which contained pancakes, juice and coffee, on the over bed table. The staff person offered to open the lids covering the food, and Resident #175 was agreeable. The staff person removed the lid from a juice cup, then left the bedroom. Resident #175 then picked up a creamer with his/her right hand and opened the lid with his/her teeth. Resident #175 then picked up a pancake with both hands, brought it to his/her mouth, and took bites from it. Resident #175 said she does not have the use of two of his/her fingers on the left hand and so is unable to open lids or cut up his/her food. Resident #175 said today was the first day since admission to the facility that a staff person was nice and offered to open the lids, and that no one had offered to cut up his/her food. Resident #175 said staff have until now just dropped off the meal trays on his/her table and left without offering any assistance. Resident #175 said she had not asked staff for help because he/she was unsure if this was a service provided. During an interview with Unit Manager #2 on 1/22/25 at 12:22 P.M., she said staff are supposed to offer to cut up Resident #175's meals. Unit Manager #2 said there is a new meal distribution system in place involving more staff but that unfortunately some staff are still learning about individual resident's assistance needs. During an interview with Resident #175 on 1/22/25 at 12:24 P.M., he/she said a staff person cut up his/her lunch meal and that this was the first time this had happened since admission.

Based on record review, interview and observation, the facility failed to follow physician's orders for two Residents (#175 and #68) of 24 sampled residents. Specifically: 1. For Resident #175, the facility failed to change a soiled wound dressing for three days. 2. For Resident #68, the facility failed to change oxygen tubing for approximately three weeks because staff did not obtain a physician's treatment order for the procedure. Findings include: Review of the facility policy titled Dressing, Dry/Clean dated as revised September 2013, indicated, but was not limited to: - Review the physician's order. - Label tape or dressing with date, time and initials. - Document the wound appearance, including wound bed, edges, presence of drainage. - How the resident tolerated the wound change procedure. 1. Resident #175 was admitted to the facility in January 2025 and had active diagnoses which included chronic kidney disease, muscle wasting and atrophy, difficulty walking, and lack of coordination. As of the date of survey, a Minimum Data Set assessment had not yet been completed for Resident #175. Review of Resident #175's physician orders dated 1/19/25, indicated: - Ulcer in left great toe - wash with normal saline apply dry protective dressing daily, every day shift. Review of Resident #175's Treatment Administration Record (TAR) on 1/21/25 indicated staff changed the toe dressing on 1/19/25, 1/20/25 and 1/21/25. Review of Resident #175's care plan dated 1/20/25, indicated he/she had an ulcer on the left great toe and was at-risk for pain. The care plan did not reference dressing changes, or other interventions to address the wound. Review of Resident #175's nursing progress note dated 1/19/25, indicated: - No new changes noted to skin integrity. Resident has treatable wounds present. Dressing(s) changed as per treatment orders. No notable changes to wound(s) observed. Review of the Physician's progress note dated 1/20/25, indicated lesion of the left toe - dressing in place with mild serosanguinous drainage. Review of Resident #175's nursing progress notes dated 1/20/25 and 1/21/25, indicated there was no reference to the ulcer on the Resident's toe, an assessment of the wound, as required by facility policy. The notes did not indicate the Resident was offered or declined a dressing change on these days. On 1/21/25 at 8:50 A.M., the surveyor observed Resident #175's left great toe dressing. The dressing was dated 1/19/25. There was no staff initial on the dressing. The dressing had areas of black color from what appeared to be dirt. During an interview with Resident #175 on 1/21/25 at 8:50 A.M., he/she said he/she fell at home and injured his/her toe. The Resident said a nurse at the facility dressed the wound a few days ago, but staff seemed to have forgotten about the wound. On 1/22/25 at approximately 7:10 A.M., the surveyor observed Resident #175 lying in bed. The Resident had the same dressing covering the toe ulcer, dated 1/19/25. On 1/23/25 at approximately 9:25 A.M., the surveyor observed the Wound Physician had removed the toe dressing and was examining the wound. During an interview with Nurse #1 on 1/23/25 at 9:30 A.M., the surveyor informed her that the surveyor observed Resident #175's left great toe dressing on 1/21/25 and 1/22/25, dated 1/19/25. The surveyor said the physician's order required that it be changed daily but no dressing changes had occurred over the past three days. Nurse #1 said she thought the dressing was to be changed as needed. The surveyor told Nurse #1 that she and another nurse documented in the TAR they had changed the dressing on 1/20/25 and 1/21/25, but that this was not possible because the dressing was dated 1/19/25. Nurse #1 said she did not understand how this error occurred. During an interview with the Director of Nursing (DON) on 1/23/25 at approximately 10:00 A.M., the surveyor informed her of the observation of Resident #175's dressing on 1/21/25 and 1/22/25, yet the dressing was dated 1/19/25 and the TAR indicated dressing changes occurred on 1/20/25 and 1/21/25. The DON said it was nursing staff's responsibility to follow the physician's treatment orders, the facility's wound dressing policy and to document accurately in the clinical record. 2. For Resident #68, the facility failed to change oxygen tubing for approximately three weeks. Resident #68 was admitted to the facility in January 2025 and has active diagnoses which include chronic obstructive pulmonary disorder (COPD), emphysema and chronic respiratory failure with hypoxia. Review of Resident #68's Minimum Data Set assessment indicated he/she was cognitively intact and required the use of continuous oxygen to help with breathing. Review of Resident #68's physician order dated 1/4/25, indicated: - Oxygen 3 liters per minute via nasal cannula, continuous, every shift for COPD. The physician's orders did not include a schedule for changing the oxygen tubing. Review of Resident #68's Treatment Administration Record dated through 1/21/25 failed to indicate the Resident's oxygen tubing had been changed since his/her admission to the facility. Review of Resident #68's progress notes did not reference changing his/her oxygen tubing On 1/21/25 at 10:25 A.M., the surveyor observed Resident #68 lying in bed with a nasal cannula under his/her nose. The oxygen concentrator ran at 3 liters per minute. The surveyor observed the tubing was undated and disconnected from the concentrator. The surveyor left the room and informed Nurse #2 that the tubing was undated and disconnected from the concentrator, resulting in the Resident not receiving concentrated oxygen. Nurse #2 then replaced the tubing and attached it to the concentrator. During an interview with Nurse #2 on 1/21/25 at approximately 11:30 A.M., she said she thought oxygen tubing was changed as needed and not weekly. Nurse #2 said there was no recorded date of if, or when, the tubing was last changed. Following the surveyor's conversation with Nurse #2, a new physician's order was entered into Resident #68's clinical record, dated 1/21/25, at 4:45 P.M. (approximately three weeks after the start of oxygen use): - Oxygen Equipment Maintenance every night shift every Sunday, During an interview with the DON on 1/23/25 at 10:00 A.M., she said it was the standard of practice and facility policy to obtain a physician's order for weekly oxygen tubing changes and to document these changes on the TAR.

Based on interview, record review and observation, the facility failed to ensure one Resident (#175) was able to dine in a dignified manner. Findings include: Review of the facility policy Dignity dated as revised February 2021, indicated, but was not limited to: - Provided with a dignified dining experience. Resident #175 was admitted to the facility in January 2025 and had active diagnoses which included chronic kidney disease, heart disease, muscle wasting and atrophy, difficulty walking, lack of coordination and dysphagia. As of the date of survey, a Minimum Data Set assessment had not yet been completed for Resident #175, including a Brief Interview for Mental Status exam. Resident #175's Activity of Daily Living care plan dated 1/17/25, indicated he/she required staff assistance with setup or clean-up assistance. Resident #175's Admission Functional Abilities and Goals assessment dated [DATE], indicated he/she required setup or clean-up assistance with meals. On 1/21/25 at 8:00 A.M., the surveyor observed a staff person enter Resident #175's room and place his/her meal tray, which contained pancakes, juice and coffee, on the over bed table. The staff person offered to open the lids covering the food, and Resident #175 was agreeable. The staff person removed the lid from a juice cup, then left the bedroom. Resident #175 then picked up a creamer with his/her right hand and opened the lid with his/her teeth. Resident #175 then picked up a pancake with both hands, brought it to his/her mouth, and took bites from it. Resident #175 said she does not have the use of two of his/her fingers on the left hand and so was unable to open lids or cut up his/her food. Resident #175 said today was the first day since admission to the facility that a staff person was nice and offered to open the lids, and that no one has offered to cut up his/her food. Resident #175 said staff have until now just dropped the meal trays off on his/her table and left without offering any assistance. Resident #175 said she has not asked staff for help because he/she was unsure if this was a service provided. During an interview on 1/22/25 at 12:22 P.M., Unit Manager #2 said staff are supposed to offer to cut up Resident #175's meals. Unit Manager #2 said there is a new meal distribution system in place involving more staff but unfortunately some staff are still learning about individual resident's assistance needs. During an interview with Resident #175 on 1/22/25 at 12:24 P.M., he/she said a staff person cut up his/her lunch meal and that this was the first time this had happened since admission.

Based on record review and interview, the facility failed for one Resident (#175) to communicate with the Dialysis Center nurse regarding Resident #175's care, document his/her condition after dialysis treatment, and notify the practitioner of fistula bleeds out of a total sample of 24 residents. Findings include: Review of the facility's policy Hemodialysis Catheters - Access Care of dated as revised February 2023, indicated: - Mild bleeding from the site (post-dialysis) can be expected. Apply pressure to insertion site and contact dialysis center for instructions. - The nurse should document in the resident's medical record every shift as follows: 1. Location of the catheter. 2. Condition of the dressing (interventions if needed). 3. If dialysis was done during shift. 4. Any part of the report from dialysis nurse post-dialysis being given. 5. Observations post-dialysis. Resident #175 was admitted to the facility in January 2025 and had active diagnoses which included dependence on renal dialysis, arteriovenous fistula, chronic kidney disease, muscle wasting and atrophy, and lack of coordination. As of the date of survey, a Minimum Data Set assessment had not yet been completed for Resident #175. Review of Resident #175's physician orders, dated 1/20/25, indicated: - Resident to have dialysis on: Tuesday, Thursday, Saturday. - Right arm with hematoma bleeding - change daily and prn (as needed) until stop bleeding. - Monitor access site for bleeding, redness, tenderness and/or swelling every shift for monitoring. Notify Practitioner of abnormal findings as indicated. If bleeding noted, apply pressure and notify the Practitioner. Review of Resident #175's care plan dated 1/20/25, indicated he/she needs dialysis related to renal failure. Interventions included: - Monitor/document/report PRN for signs and symptoms of bleeding, hemorrhage, bacteremia, or septic shock. Review of Resident #175's nursing progress notes dated 1/19/25, 1/20/25 and 1/21/25 indicated there was no reference to the location of the catheter or condition of the dressing (interventions if needed), as required by facility policy. Review of Resident #175's Treatment Administration Record (TAR) dated 1/19/25, 1/20/25 and 1/21/25, indicated on these days the Resident's fistula site bled, and staff changed the dressing. Review of Resident #175's progress note dated 1/19/25 and 1/20/25 and 1/21/25, indicated there was no reference to staff informing the Practitioner that the Resident's fistula site was bleeding, as required by the order. Resident #175's nursing progress notes dated 1/21/25 indicated he/she went to the Dialysis Center for treatment. After returning to the facility, the nursing progress notes did not document (as required by facility policy): - Location of the catheter. - Condition of the dressing. - Any report from the dialysis nurse post-dialysis. - Observations post-dialysis. Review of Resident #175's Dialysis Center Communication Book on 1/23/25, indicated it consisted of blank communication forms. There was no reference to the Resident's visit to the Dialysis Center on 1/21/25. There was no report from the dialysis nurse post-dialysis, observations post-dialysis, the location of the catheter, or condition of the fistula dressing. On 1/21/25, 1/22/25 and 1/23/25, the surveyor observed Resident #175's covered fistula, located on the right arm. On each of these days, the fistula was covered with a 4 x 4 dry sterile dressing. The dressings were undated and not initialed by staff. During an interview with Resident #175 on 1/21/25 at 8:50 A.M., he/she said the fistula site often bleeds following dialysis. A 4 x 4 dry sterile dressing covered the fistula, and it was undated and not initialed by staff. On 1/22/25 and 1/23/25, during the morning, the surveyor observed a 4 x 4 dry sterile dressing covering Resident #175's fistula, and it was undated and not initialed by staff. During an interview with Nurse #1 on 1/23/25 at 9:30 A.M., she said she had changed Resident #175's fistula dressing on 1/21/25 because of bleeding after his/her return from the Dialysis Center on 1/21/25. Nurse #1 said she did not recall if she notified the Practitioner that the site had been bleeding or that she applied a dressing. Nurse #1 said she did not know if the Dialysis Center had communicated with the facility regarding the Resident's status post-dialysis visit on 1/21/25. During an interview with Unit Manager #2 on 1/23/25 at 9:32 A.M., she reviewed Resident #175's Dialysis Center Communication Book and determined the book did not contain any information about the Resident's visit to the Center on 1/21/25. Unit Manager #2 said that the book did not contain communication from the Center it was nursing staff's responsibility to call the Center to obtain the required information. During an interview with the Director of Nursing (DON) on 1/23/25 at approximately 10:00 A.M., she said it was nursing staff's responsibility to obtain the required information from the Dialysis Center, per facility policy, and follow the physician's treatment orders.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure staff followed Resident #1's care plan for a puree consistency diet and supervision while dining, resulting on 11/2/19 in Resident #1 choking on a piece of bread given to him/her by Resident #3. Resident #1 was transferred to the Hospital Emergency Department and was admitted to the Hospital for three days as a result of the incident. Findings include: The Facility's Internal Investigation Narrative, undated, indicated that at approximately 5:30 P.M. on 11/2/19, Resident #1 was seated in the dining room on the unit eating his/her dinner, when staff observed Resident #1 was choking. The Narrative indicated staff performed the [MEDICATION NAME] Maneuver and used suction to clear his/her airway. The Narrative indicated it was determined that Resident #3 likely handed Resident #1 a piece of bread. The Narrative indicated Resident #1 was transferred to the Hospital Emergency Department for evaluation and admitted to the Hospital as a result of the incident. Resident #1 was admitted to the Facility in (MONTH) (YEAR), with [DIAGNOSES REDACTED]. The Activities of Daily Living Care Plan, dated 8/9/19, indicated Resident #1 was dependent on staff for assistance with eating. The Assistance With Eating Care Plan, dated 8/9/19, indicated Resident #1 required staff to monitor him/her when he/she was eating food for swallowing difficulty and coughing. The Medication Review Report, dated 11/2019 with an order date of 12/06/18, indicated Resident #1 was prescribed a puree texture diet with nectar thick liquids. The Facility's Policy titled, Meal Service in Dining Room, dated 11/1/19, indicated that if a resident required assistance with meals, staff would not serve that resident until assistance was available, and staff would provide assistance and supervision based on the resident's current level of self performance with eating. During an interview on 11/19/19 at 3:13 P.M., Certified Nurse Aide (CNA) #2 said that on 11/2/19, at approximately 5:30 P.M., she was assisting another resident with dinner and noticed Resident #1 appeared to be unable to breathe. CNA #2 said no staff were supervising Resident #1, who had been served his/her meal, and was seated next to Resident #3, who had also been served his/her meal, which was of regular consistency. During an interview on 11/19/19 at 1:14 P.M., Nurse #1 said that on 11/2/19 at approximately 5:30 P.M., she was called to the dining room on the unit and saw staff were performing the [MEDICATION NAME] Maneuver on Resident #1. Nurse #1 said she looked in Resident #1's mouth, saw something in his/her throat, and suctioned Resident #1 to remove the object. Nurse #1 said another staff member was able to manually remove the item from Resident #1's throat and Resident #1 began to breathe more easily. During an interview on 11/19/19 at 3:29 P.M., Nurse #2 said that on 11/2/19 at approximately 5:30 P.M., she was called to the dining room on the unit by staff because Resident #1 was choking. Nurse #2 said the object cleared from Resident #1's throat appeared to be bread, which was not served to Resident #1. Nurse #2 said Resident #1 was at risk for aspiration, was known to put things in his/her mouth, and required staff supervision when eating . During an interview on 11/19/19 at 10:58 [NAME]M., the Director of Nurses said Resident #1 should have been supervised by staff while eating his/her meal.

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), the Facility failed to ensure only qualified staff provided care, when a Unit Assistant ambulated Resident #2 to the bathroom, left him/her alone on the toilet, and as a result, Resident #2 fell and sustained a fractured left wrist. Findings include: A Nurse Progress Note, dated 11/9/19, indicated Resident #2 was ambulated to the bathroom, assisted to a seated position on the toilet, and a staff member (later identified as Unit Assistant #1) exited the bathroom and closed the door. The Note indicated Unit Assistant #1 heard a noise and upon opening the bathroom door, found Resident #2 seated on the floor, and that Resident #2's left wrist was swollen and tender to touch. A Radiology Report, dated 11/9/19, indicated Resident #2 had an acute distal radius fracture (broken wrist). The Facility's Job Description titled Nursing Unit Assistant, dated 6/27/17, indicated a Unit Assistant would assist nursing staff in providing non-patient care activities and related non-professional services essential to caring for the needs and comfort of residents. During an interview on 11/21/19 at 11:34 [NAME]M., Unit Assistant #1 said that during her orientation to the Unit Assistant position she was educated that she was not allowed to provide any personal care to the residents. Unit Assistant #1 said that at approximately 2:15 P.M. on 11/9/19, Resident #2 said he/she had to use the bathroom, and said that she assisted Resident #2 to ambulate to the bathroom, pulled down his/her pants, and sat him/her on the toilet. Unit Assistant #1 said Resident #2 requested privacy, so she exited the bathroom and closed the door. Unit Assistant #1 said that moments later she heard a noise coming from the bathroom, opened the door, and found Resident #2 on the floor. Resident #2 was admitted to the Facility in (MONTH) (YEAR), with [DIAGNOSES REDACTED]. The Activities of Daily Living Care Plan, dated 9/26/19, indicated Resident #2 was dependent on staff for toileting and ambulation using a walker. During interviews throughout the day on 11/19/19, Certified Nurse Aide (CNA) #1, CNA #2, and Unit Manager #1 said Resident #2 was at risk for falls, was known to be impulsive, and would get up from the toilet by his/herself if left alone in the bathroom. During an interview on 11/19/19 at 10:58 [NAME]M. and throughout the day, the Director of Nurses (DON) said Unit Assistants were not allowed to provide direct resident care and said Unit Assistant #1 did not receive training related to ambulating and toileting residents. The DON said a nurse or a CNA should have ambulated and toileted Resident #2, and said he/she should not have been left unsupervised while in the bathroom.

Based on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #2), the Facility failed to provide adequate supervision to Resident #1, who choked on a piece of bread given to him/her by another resident, and Resident #2, who fell and fractured his/her wrist when left on the toilet unattended. Findings include: 1. The Facility's Internal Investigation Narrative, undated, indicated that at approximately 5:30 P.M. on 11/2/19, Resident #1 was seated in the dining room on the unit eating his/her dinner, when staff observed Resident #1 was choking. The Narrative indicated staff performed the [MEDICATION NAME] Maneuver and used suction to clear his/her airway. The Narrative indicated it was determined that Resident #3 likely handed Resident #1 a piece of bread. The Narrative indicated Resident #1 was transferred to the Hospital Emergency Department for evaluation and was admitted to the Hospital as a result of the incident. Resident #1 was admitted to the Facility in (MONTH) (YEAR), with [DIAGNOSES REDACTED]. The Medication Review Report, dated 11/2019, with an order date of 12/06/18, indicated Resident #1 was prescribed a puree texture diet with nectar thick liquids. The Activities of Daily Living Care Plan, dated 8/9/19, indicated Resident #1 was dependent on staff for assistance with eating. The Assistance With Eating Care Plan, dated 8/9/19, indicated staff were to monitor Resident #1 when eating food for swallowing difficulty and coughing. The Facility's Policy titled, Meal Service in Dining Room, dated 11/1/19, indicated that if a resident required assistance with meals, staff would not serve that resident until assistance was available, and staff would provide assistance and supervision based on the resident's current level of self performance with eating. During an interview on 11/19/19 at 3:13 P.M., Certified Nurse Aide (CNA) #2 said that on 11/2/19, at approximately 5:30 P.M., she was assisting another resident with dinner and noticed Resident #1 appeared to be unable to breathe. CNA #2 said no staff were supervising Resident #1, who had been served his/her meal, and was seated next to Resident #3, who had also been served his/her meal, which was of regular consistency. CNA #2 said Resident #1 was known to put objects in his/her mouth, and said that in the past she had witnessed Resident #3 hand his/her food to others, including Resident #1. CNA #2 said she had told the nurses on the unit about Resident #3 giving food to Resident #1, and said she was told to keep an eye on them. CNA #2 said Resident #1 was usually not given his/her tray until a staff member could sit with him/her to supervise him/her. During an interview on 11/19/19 at 1:14 P.M., Nurse #1 said that on 11/2/19 at approximately 5:30 P.M., she was called to the dining room on the unit and saw staff were performing the [MEDICATION NAME] Maneuver on Resident #1. Nurse #1 said she looked in Resident #1's mouth, saw something in his/her throat, and suctioned Resident #1 to remove the object. Nurse #1 said another staff member was able to manually remove the item from Resident #1's throat and Resident #1 began to breathe more easily. During an interview on 11/19/19 at 3:29 P.M., Nurse #2 said that on 11/2/19 at approximately 5:30 P.M., she was called to the dining room on the unit by staff because Resident #1 was choking. Nurse #2 said the object cleared from Resident #1's throat appeared to be bread, which was not served to Resident #1. Nurse #2 said Resident #1 was at risk for aspiration, was known to put things in his/her mouth, and required staff supervision when eating. During an interview on 11/19/19 at 2:53 P.M. CNA #1 said Resident #1 was known to pick up objects and put them in his/her mouth, and said that Resident #3 was known to give others his/her food. CNA #1 said that she has had to take food away from Resident #1 that Resident #3 had given him/her many times. CNA #1 said she had told the nurses on the unit about this concern, and said nurses told her to keep an eye on them. During an interview on 11/19/19 at 10:58 [NAME]M., the Director of Nurses said Resident #1 should have been supervised by staff while eating his/her meal. 2. A Nurse Progress Note, dated 11/9/19, indicated Resident #2 was ambulated to the bathroom, assisted to a seated position on the toilet, and a staff member (later identified as Unit Assistant #1) exited the bathroom and closed the door. The Note indicated Unit Assistant #1 heard a noise and upon opening the bathroom door found Resident #2 seated on the floor, and that Resident #2's left wrist was swollen and tender to touch. A Radiology Report, dated 11/9/19, indicated Resident #2 had an acute distal radius fracture (broken wrist). During an interview on 11/21/19 at 11:34 [NAME]M., Unit Assistant #1 said that at approximately 2:15 P.M. on 11/9/19, Resident #2 said he/she had to use the bathroom, and that she assisted Resident #2 to ambulate to the bathroom, pulled down his/her pants, and sat him/her on the toilet. Unit Assistant #1 said Resident #2 requested privacy, so she exited the bathroom and closed the door. Unit Assistant #1 said that moments later she heard a noise coming from the bathroom, opened the door, and found Resident #2 on the floor. Unit Assistant #1 said that during her orientation to the Unit Assistant position she was educated that she was not allowed to provide any personal care to the residents. Resident #2 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The Activities of Daily Living Care Plan, dated 9/26/19, indicated Resident #2 was dependent on staff for toileting and ambulation using a walker. The Facility's Policy titled Falls Management, dated 11/1/19, indicated residents would be assessed for falls risk, those determined to be at risk for falls would receive appropriate interventions to reduce risk and minimize injury, and a resident's risk for falls would be communicated to caregivers. During interviews throughout the day on 11/19/19, CNA #1, CNA #2, and Unit Manager #1 said Resident #2 was at risk for falls, was known to be impulsive, and would get up from the toilet by his/herself if left alone in the bathroom. During an interview on 11/19/19 at 10:58 [NAME]M. and throughout the day, the Director of Nurses (DON) said Unit Assistants were not allowed to provide direct resident care and said Unit Assistant #1 did not receive training related to ambulating and toileting residents. The DON said a nurse or a CNA should have ambulated and toileted Resident #2, and said he/she should not have been left unsupervised while in the bathroom.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was at significant risk for dehydration, the Facility failed to monitor Resident #1's fluid intake and output when Resident #1 had difficulty swallowing, was not drinking adequate fluids, was administered diuretics, and had significant diarrhea from a [MEDICAL CONDITION] (a bacterium that causes symptoms ranging from diarrhea to life-threatening inflammation of the colon) infection. Resident #1 was transferred to the Emergency Department, was admitted to the Hospital, and died four days later with a [DIAGNOSES REDACTED]. Findings Include: 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. The Facility Policy titled Fluid Balance, revised ,[DATE], indicated that the Facility would provide patients with sufficient amounts of fluids based on individual needs and patients' hydration status would be determined through routine nursing evaluation. The Policy indicated that fluid intake and output would be monitored and documented with a [DIAGNOSES REDACTED]. Resident #1 was admitted to the Facility in (MONTH) of (YEAR) with medical [DIAGNOSES REDACTED]. Resident #1's Facility Admission Paperwork included a Hospital History and Physical, dated [DATE], which indicated that Resident #1's [DIAGNOSES REDACTED].#1's Family, Resident #1 had poor oral intake. A Nurse Practitioner's Progress Note, dated [DATE], indicated that Resident #1 was admitted to the Facility after a three day hospitalization after a fall at home. The Progress Note indicated that Resident #1's chronic medical conditions were stable and the plan was for Resident #1 to return home with Family after he/she was discharged from the Facility. Resident #1's physician's orders [REDACTED]. A Nurse's Progress Note, dated [DATE], indicated that Resident #1's appetite was poor and he/she took sips of drinks but then refused. A Nurse's Progress Note, dated [DATE], indicated that Resident #1's appetite was poor and may take bites of food and sips of drinks. An Occupational Therapy Assistant's Progress Note, dated [DATE], indicated that Resident #1 had significant diarrhea for which nursing was aware and would monitor. A Physical Therapy Assistant Note, dated [DATE], indicated that Resident #1, had watery stool during the Therapy Session. A Nurse's Progress Note, dated ,[DATE], indicated that Resident #1 had loose stools twice during the shift. A Nurse Practitioner's Order, dated [DATE], indicated to send Resident #1's stool sample to the Laboratory to rule out [MEDICAL CONDITION] (a bacterium that causes symptoms ranging from diarrhea to life-threatening inflammation of the colon) infection. A Nurse's Progress Note, dated [DATE], indicated that Resident #1 still had loose stools. A Nurse's Progress Note, dated [DATE] indicated that Resident #1 was lethargic, continued with loose stools, took a sip of fluid. A call was placed to the Nurse Practitioner due to a Family Member's concern about Resident #1's status and laboratory blood work and Tylenol (an [MEDICATION NAME] used for minor aches and pains or to reduce fever) were ordered. A Nurse Practitioner's Progress Note, dated [DATE], indicated that Resident #1's [MEDICATION NAME] was increased for five days. The Progress Note indicated that Resident #1 developed increased frequency of diarrhea and laboratory results were positive for [MEDICAL CONDITION]. A Nurse's Progress Note, dated [DATE], indicated that the Nurse Practitioner was called regarding abnormal laboratory results and orders were obtained which included to push (encourage) fluids to Resident #1. A Nurse's Progress Note, dated [DATE], indicated Resident #1 was lethargic and took small sips of fluid. A Nurse's Progress Note, dated [DATE], indicated that the Nurse attempted to encourage Resident #1 to drink fluids but Resident #1 was sometimes unable to swallow. A Nurse's Progress Note, dated [DATE], indicated Resident #1's condition had declined, was unable to drink fluids, his/her Family was concerned about dehydration, requested IV hydration, and the NP was called. A Nurse Practitioner's Progress Note, dated [DATE], indicated that Resident #1 was not doing well over the weekend with limited intake by mouth. The Progress Note indicated that laboratory results revealed that Resident #1's sodium level was elevated and his/her renal (kidney) function was suggestive of acute [MEDICAL CONDITION] with dehydration. The Progress Note indicated that IV fluids were ordered, fluid intake was encouraged, and Resident #1 remained lethargic and weak. A Nurse's Progress Note, dated [DATE], indicated that Resident #1's Family, after speaking with Resident #1's Primary Care Physician, requested that Resident #1 be transferred to the Emergency Department for further evaluation. Resident #1's Medication Administration Records (MAR) did not include any documentation of fluid intake and output (I & O) monitoring until [DATE] when Resident #1's MAR indicated [REDACTED]. Resident #1's Meal Percentage Sheet (completed by Certified Nurse Aides), dated [DATE] through [DATE] indicated that Resident #1 consumed fluid at only two meals during that time period. A Care Plan, dated [DATE], indicated that Resident #1 was at risk for complications of infection related to [MEDICAL CONDITION]. The Care Plan directed staff to encourage Resident #1 to consume all fluids during meals. A Care Plan, dated [DATE], indicated that Resident #1 was at nutritional risk secondary to dysphagia (difficulty swallowing). The Care Plan directed staff to encourage 100% consumption of all fluids. There was no Care Plan in Resident #1's Medical Record that indicated that Resident #1 was at Risk for Dehydration, and no Care Plan that included nursing interventions to assess and monitor Resident #1 for signs and symptoms of dehydration, address the potential need for IV fluids, or to monitor Resident #1's fluid intake and output as indicated in the Facility's Fluid Balance Policy. The Facility was not able to provide documentation to indicate Resident #1's fluid intake and output was monitored. The Surveyor interviewed Nurse #1 at 10:43 A.M. on [DATE]. Nurse #1 said Resident #1 had difficulty swallowing since he/she was admitted to the Facility. Nurse #1 said Resident #1 began to have increased difficulty swallowing and during the week prior to him/her being sent to the Hospital he/she would not always swallow fluids and staff would swab Resident #1's mouth to keep it moist. Nurse #1 said she attempted to push fluids and Resident #1's Family would try also, but it was not working. Nurse #1 said Resident #1 was diagnosed with [REDACTED].M. to 3:00 P.M. shift. Nurse #1 said she was concerned that Resident 1 was at risk for dehydration. Nurse #1 said that she could not recall if there were any nursing interventions implemented to monitor Resident #1 for dehydration and said Nursing Staff would not have monitored Resident #1's fluid intake and output until he/she was started on intravenous (IV) fluids. The Surveyor questioned Nurse #1 about signs and symptoms of dehydration and Nurse #1 said that decreased skin turgor and dry mouth were signs of dehydration. Nurse #1 said Resident #1 had dry mouth but she did not notice Resident #1's skin turgor. Nurse #1 said she thought that Resident #1's laboratory blood work showed that he/she was dehydrated but said she was unsure of which laboratory tests would determine dehydration. The Surveyor interviewed Certified Nurse Aide (CNA) #3 at 11:15 A.M. on [DATE]. CNA #3 said she cared for Resident #1 several times and she was his/her primary CNA. CNA #3 said Resident #1 had frequent diarrhea. The Surveyor interviewed the Unit Manager at 12:31 P.M. on [DATE]. The Unit Manager said that Resident #1 had increased frequency of diarrhea after he/she was admitted , could not recall if Resident #1 had difficulty swallowing. The Unit Manager said Resident #1's fluid intake and output was not monitored because Nurses would not have recorded Resident #1's fluid intake and output unless he/she had a urinary catheter or if he/she was started on IV fluids. The Unit Manager said that going by the Facility Fluid Balance Policy, she would not have monitored Resident #1's fluid intake and output. The Unit Manager said she spoke with Family Member #1 about Resident #1's condition and Family Member #1 was concerned about Resident #1's fluid consumption. The Surveyor interviewed Family Member #1 at 1:02 P.M. on [DATE]. Family Member #1 said he/she was concerned about Resident #1's rapid decline in condition and said he/she questioned the Facility for three days about administering IV fluids to Resident #1 before IV fluids were implemented by the Facility. The Surveyor interviewed the Director of Nursing (DON) at 3:47 P.M. on [DATE]. The DON said that staff should have monitored Resident #1's fluid intake and output, as indicated in the Facility Policy titled Fluid Balance and Resident #1 was at risk for dehydration. The DON said factors that put Resident #1 was at risk for dehydration included fluid loss from diarrhea, decreased intake of fluids, [DIAGNOSES REDACTED]. The Hospital Emergency Department Report, dated [DATE], indicated that Resident #1 was severely lethargic, unresponsive to verbal stimuli, was dehydrated and [MEDICAL CONDITION] (increased sodium level) with a serum (blood) sodium level of 164 (normal levels are ,[DATE], a severe level is 160 or over). Resident #1 was admitted to the Hospital. The Hospital Discharge Summary, dated [DATE], indicated that Resident #1 was hypernatremic and treated for [REDACTED]. The Discharge Summary indicated that Resident #1 died on [DATE] with the cause of death, [MEDICAL CONDITIONS], acute [MEDICAL CONDITION] (a high blood sodium concentration cause by a disruption in fluid balance) and metabolic [MEDICAL CONDITION] (alteration of all aspects of brain function) due to electrolyte imbalance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was at significant risk for dehydration, failed to establish and implement a care plan with interventions to monitor and prevent Resident #1 from becoming dehydrated. Resident #1 was transferred to the Emergency Department where he/she died four days later with a [DIAGNOSES REDACTED]. Findings Include: The Facility Policy titled Fluid Balance, revised ,[DATE], indicated that the Facility would provide patients with sufficient amounts of fluids based on individual needs and patients' hydration status would be determined through routine nursing evaluation. The Policy indicated that fluid intake and output would be monitored and documented with a [DIAGNOSES REDACTED]. Resident #1 was admitted to the Facility in (MONTH) of (YEAR) with medical [DIAGNOSES REDACTED]. Resident #1's Facility Admission Paperwork included a Hospital History and Physical, dated [DATE], which indicated that Resident #1's [DIAGNOSES REDACTED].#1's Family, Resident #1 had poor oral intake. A Nurse Practitioner's Progress Note, dated [DATE], indicated that Resident #1 was admitted to the Facility after a three day hospitalization after a fall at home. The Progress Note indicated that Resident #1's chronic medical conditions were stable and the plan was for Resident #1 to return home with Family after he/she was discharged from the Facility. Resident #1's physician's orders [REDACTED]. A Nurse's Progress Note, dated [DATE], indicated that Resident #1's appetite was poor and he/she took sips of drinks but then refused. A Nurse's Progress Note, dated [DATE], indicated that Resident #1's appetite was poor and may take bites of food and sips of drinks. An Occupational Therapy Assistant's Progress Note, dated [DATE], indicated that Resident #1 had significant diarrhea for which nursing was aware and would monitor. A Physical Therapy Assistant Note, dated [DATE], indicated that Resident #1, had watery stool during the Therapy Session. A Nurse's Progress Note, dated ,[DATE], indicated that Resident #1 had loose stools twice during the shift. A Nurse Practitioner's Order, dated [DATE], indicated to send Resident #1's stool sample to the Laboratory to rule out [MEDICAL CONDITION] (a bacterium that causes symptoms ranging from diarrhea to life-threatening inflammation of the colon) infection. A Nurse's Progress Note, dated [DATE], indicated that Resident #1 still had loose stools. A Nurse's Progress Note, dated [DATE] indicated that Resident #1 was lethargic, continued with loose stools, took a sip of fluid. A call was placed to the Nurse Practitioner due to a Family Member's concern about Resident #1's status and laboratory blood work and Tylenol (an [MEDICATION NAME] used to treat minor aches, pains, or to reduce fever) were ordered. A Nurse Practitioner's Progress Note, dated [DATE], indicated that Resident #1's [MEDICATION NAME] was increased for five days. The Progress Note indicated that Resident #1 developed increased frequency of diarrhea and Laboratory results were positive for [MEDICAL CONDITION]. A Nurse's Progress Note, dated [DATE], indicated that the Nurse Practitioner was called regarding abnormal Laboratory results and orders were obtained which included to push (encourage) fluids to Resident #1. A Nurse's Progress Note, dated [DATE], indicated Resident #1 was lethargic and took small sips of fluid. A Nurse's Progress Note, dated [DATE], indicated that the Nurse attempted to push fluids but Resident #1 was sometimes unable to swallow. A Nurse's Progress Note, dated [DATE], indicated Resident #1's condition had declined, was unable to drink fluids, his/her Family was concerned about dehydration, requested IV hydration, and the NP was called. A Nurse Practitioner's Progress Note, dated [DATE], indicated that Resident #1 was not doing well over the weekend with limited intake by mouth. The Progress Note indicated that laboratory results revealed that Resident #1's sodium level was elevated and his/her renal (kidney) function was suggestive of acute [MEDICAL CONDITION] with dehydration. The Progress Note indicated that IV fluids were ordered, fluid intake was encouraged, and Resident #1 remained lethargic and weak. A Nurse's Progress Note, dated [DATE], indicated that Resident #1's Family, after speaking with Resident #1's Primary Care Physician, requested that Resident #1 be transferred to the Emergency Department for further evaluation. Resident #1's Medication Administration Records (MAR) did not include any documentation of fluid intake and output (I & O)monitoring until [DATE] when Resident #1's MAR indicated [REDACTED]. Resident #1's Meal Percentage Sheet (completed by Certified Nurse Aides), dated [DATE] through [DATE] indicated that Resident #1 consumed fluid at only two meals during that time period. A Care Plan, dated [DATE], indicated that Resident #1 was at risk for complications of infection related to [MEDICAL CONDITION]. The Care Plan directed staff to encourage Resident #1 to consume all fluids during meals. A Care Plan, dated [DATE], indicated that Resident #1 was at nutritional risk secondary to dysphagia (difficulty swallowing). The Care Plan directed staff to encourage 100% consumption of all fluids. There was no Care Plan in Resident #1's Medical Record that indicated that Resident #1 was at Risk for Dehydration, and no Care Plan that included nursing interventions to assess and monitor Resident #1 for signs and symptoms of dehydration, address the potential need for IV fluids, or to monitor Resident #1's fluid intake and output as indicated in the Facility's Fluid Balance Policy. The Surveyor interviewed Nurse #1 at 10:43 A.M. on [DATE]. Nurse #1 said Resident #1 had difficulty swallowing since he/she was admitted to the Facility. Nurse #1 said Resident #1 began to have increased difficulty swallowing and during the week prior to him/her being sent to the Hospital he/she would not always swallow fluids and staff would swab Resident #1's mouth to keep it moist. Nurse #1 said she attempted to push fluids and Resident #1's Family would try also, but it was not working. Nurse #1 said Resident #1 was diagnosed with [REDACTED]. Nurse #1 said she was concerned that Resident 1 was at risk for dehydration. Nurse #1 said that she could not recall if there were any nursing interventions implemented to monitor Resident #1 for dehydration and said they would not have monitored Resident #1's fluid intake and output until he/she was started on intravenous (IV) fluids. The Surveyor questioned Nurse #1 about signs and symptoms of dehydration and Nurse #1 said that decreased skin turgor and dry mouth were signs of dehydration. Nurse #1 said Resident #1 had dry mouth but she did not notice Resident #1's skin turgor. Nurse #1 said she thought that Resident #1's laboratory blood work showed that he/she was dehydrated but said she was unsure of which laboratory tests would determine dehydration. The Surveyor interviewed Certified Nurse Aide (CNA) #3 at 11:15 A.M. on [DATE]. CNA #3 said she cared for Resident #1 several times and she was his/her primary CNA. CNA #3 said Resident #1 had frequent diarrhea. The Surveyor interviewed the Physical Therapy Assistant (PTA) at 2:15 P.M. on [DATE]. The PTA said that when Resident #1 would attempt standing activity, he/she would be incontinent of loose stool upon standing and some of their therapy sessions ended up in the bathroom as a result. The Surveyor interviewed the Unit Manager at 12:31 P.M. on [DATE]. The Unit Manager said that Resident #1 had increased frequency of diarrhea after he/she was admitted , could not recall if Resident #1 had difficulty swallowing and said Nurse's would not have recorded Resident #1's fluid intake and output unless he/she had a urinary catheter or if he/she was started on IV fluids. The Unit Manager said that going by the Facility Fluid Balance Policy, she would not have monitored Resident #1's fluid intake and output. The Unit Manager said she spoke with Family Member #1 about Resident #1's condition and Family Member #1 was concerned about Resident #1's fluid consumption. The Surveyor interviewed Family Member #1 at 1:02 P.M. on [DATE]. Family Member #1 said was concerned about Resident #1's rapid decline in condition and said he/she questioned the Facility for three days about administering IV fluids to Resident #1. The Surveyor interviewed the Director of Nursing (DON) at 3:47 P.M. on [DATE]. The DON said that staff should have monitored Resident #1's fluid intake and output, as indicated in the Facility Policy titled Fluid Balance and Resident #1 was at risk for dehydration. The DON said factors that put Resident #1 was at risk for dehydration included fluid loss from diarrhea, decreased intake of fluids, [DIAGNOSES REDACTED]. The Hospital Emergency Department Report, dated [DATE], indicated that Resident #1 was severely lethargic, unresponsive to verbal stimuli, was dehydrated and [MEDICAL CONDITION] (increased sodium level) with a serum (blood) sodium level of 164 (normal levels are ,[DATE], a severe level is 160 and over. Resident #1 was admitted to the Hospital. The Hospital Discharge Summary, dated [DATE], indicated that Resident #1 was hypernatremic and treated for [REDACTED]. The Discharge Summary indicated that Resident #1 died on [DATE] with the cause of death documented as: [MEDICAL CONDITIONS], acute [MEDICAL CONDITION] (a high blood sodium concentration cause by a disruption in fluid balance), and metabolic [MEDICAL CONDITION] (alteration of all aspects of brain function) due to electrolyte imbalance.

Based on observation, interview and record review, the facility failed to accept resident refusal of a room change resulting in psychological distress for 1 resident, (#90), out of a total of 22 sampled residents. Findings include: Resident #90 was admitted to the facility in 1/2018 with [DIAGNOSES REDACTED]. Review of Resident #90's most recent Minimum Data Set, (MDS), dated [DATE], indicated that he/she requires assistance with bathing, dressing and ambulation. Additionally the MDS indicated that Resident #90 scored 12 out of 15 on the Brief Interview for Mental Status, indicating moderate cognitive impairment. During interview with Resident #90 on 2/22/18 at 10:19 A.M., he/she said that he/she would like to return to his/her old room on the subacute unit. Resident #90 said that he/she did not understand why the move had to be made and he/she liked being downstairs better and was more familiar with the people on the unit. Review of the facility's Room Transfers policy, dated 2/13/17, indicated the following: -Healthcare staff may initiate room changes based on: medical needs of patients; efforts to comply with room change requests from patients and/or family members or to facilitate appropriateness of patient care. -The patient's physical, social, emotional, and cognitive needs as well as preferences are assessed by the interdisciplinary team and considered prior to relocating the patient. -If patient/resident refuses to transfer, document refusal. Review of Resident #90's clinical record indicated the following nursing notes: 1). 12:24, 2/12/18: Patient brought upstairs to tour new room and meet new nurse. Patient became very upset and quickly got right on the elevator and stated 'I cannot. Get me out of here.' .Explained the plan was for him/her to stay on C unit. Patient very upset and started to weep. Patient's (HCP) called and notified of (resident's) reaction to changing rooms upstairs. Patient's (HCP) agreed to come in for transition. (Resident) was notified his/her (HCP) would be in to discuss changes. Patient returned to his/her old room where he/she is more comfortable. 2). 12:46, 2/12/18: Patient was given tour of his/her new room, floor and new nurse and began to cry. She/he was very anxious and raced off the floor to the elevator. Patient continues to verbalize he/she was not going to live there and did not like that floor. Patient asked if only elderly people lived there.Two social workers spoke with him/her and his/her (HCP) at length discussing transition.(Resident's physician) called and updated regarding how reluctant resident is to move upstairs. New order to activate healthcare proxy.Patient agreed later in shift to go upstairs when this writer explained he/she is unable to stay on the short term floor. Patient and his/her (partner) went upstairs. Patient began to weep and was consoled by (partner) and nursing.(HCP) called and notified (resident) is now upstairs. Further review of Resident #90's clinical record indicated that the Health Care Proxy was activated via physician's telephone order on 2/12/18 at 2:20 PM. There was no evidence indicating that a physician's progress note or assessment was completed addressing the need for resident's Health Care Proxy to be activated. During interview with the Physician on 2/22/18 at 11:29 A.M., she said that Resident #90's HCP was activated due to Resident #90's increased confusion. She said that she had not received any recommendations to activate the HCP prior to 2/12/18, the day the room change was initiated and after the resident declined and became upset. During interview with Unit Manager #1 on 2/22/18 at 10:38 A.M., she said that Resident #90 was transferred from the subacute unit to the long term care unit because it was determined that Resident #90 is not able to live independently and his/her goals changed from short term to long term care. Unit Manager #1 said it was common practice in the facility to transfer residents from the subacute long term care unit after such a determination is made. Review of Resident #90's room change form indicated that he/she did not refuse the transfer on 2/12/18, which contradicts the nursing documentation. During interview with the Administrator and the Director of Nursing on 2/22/18 at 1:20 P.M., the above concerns were reviewed. The Administrator and the Director of Nursing were unable to explain why the room transfer continued despite Resident #90 being visibly emotionally distressed or why the HCP was activated after the resident refused the transfer.