Every finding on record at Regalcare at Courtyard-Medford

Based on observation, record review and interview, the facility failed to ensure medications were stored appropriately for two Residents (#169 and #167) out of a total of 34 sampled Residents. Findings include:Review of the facility's policy titled Medication Storage dated as revised March 2022 indicated:Policy: The facility shall store all drugs and biologicals in a safe, secure and orderly manner. 7. Compartments (including, but not limited to drawers, cabinets, rooms refrigerators, carts and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. 1. Resident #169 was admitted to the facility in August 2025 with diagnoses including other specified disorders of veins, other specified metabolic disorder and adult failure to thrive. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #169 is moderately cognitively impaired evidenced by a score of 8 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS). During observations on 3/30/26 at 9:22 A.M. and 11:57 A.M., Resident #169 was sleeping in bed and a bottle of Vitamin C tablets was on the windowsill. During an observation and interview on 3/31/2026 at 7:31 A.M., Resident #169 was observed in bed. There was a bottle of Vitamin C tablets on the windowsill and a pill on his/her overbed table. Resident #169 said that the pill was a caffeine pill and he/she takes them because he/she can't drink coffee. During an interview on 3/31/26 at approximately 7:35 A.M., Unit Manager #1 said that Resident #169 does not have an assessment for self-administration and she was not aware that the Resident had caffeine pills or Vitamin C in his/her room. 2. Resident #167 was admitted to the facility in February 2022 with diagnoses including malignant neoplasm of spinal cord and urinary retention. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated he/she is moderately cognitively impaired, as evidenced by a score of 12 out of a possible 15 on the Brief Interview for Mental Status Exam. On 3/30/26 at 8:10 A.M., the surveyor observed Resident #167 asleep in bed. Two pills were in a small cup on his/her bedside table. Review of Resident #167's clinical record indicated that there were no physician orders or assessment for the self-administration of medications. During an interview on 3/30/26 at approximately 8:12 A.M., Unit Manager #1 said Resident #167 does not self-administer medications. Unit Manager #1 then joined the surveyor and observed the two pills on his/her bedside table and removed them. Unit Manager #1 said they were left there by the 11-7 nurse and they should not have left the pills at bedside.

Based on record review, interview and observation, the facility failed to provide a routine annual dental examination for one Resident (#54) of 34 sampled residents. Specifically, the Resident was admitted to the facility in October 2024, and the facility had not arranged for dental services as of the date of survey. Findings include: Resident #54 was admitted to the facility in October 2024 and had diagnoses which included heart failure and hypertension.Review of Resident #54's Minimum Data Set assessment dated [DATE] indicated: Brief Interview for Mental Status examination score of 15, signifying intact cognition, required staff supervision or touching assistance for oral hygiene, and did not wear dentures or experience pain or difficulty while chewing. On 3/30/26 at 11:05 A.M., the surveyor observed Resident #54 standing at the entry way to his/her bedroom. Resident #54 appeared to be edentulous. The Resident opened his/her mouth, and he/she had only three teeth located on the right lower jaw. Resident #54 said he/she had lived at the facility for over a year but had never been examined by a dentist. Resident #54 said he/she would like to be seen but did not think he/she could afford the cost.Review of Resident #54's physician orders dated 10/25/24 indicated he/she may be seen by dental as indicated.Review of Resident #54's medical record on 3/31/26 indicated there was no care plan for oral hygiene.Review of Resident #54's medical record on 3/31/26 indicated there was no signed consent or declination for dental services.Review of Resident #54's medical record on 3/31/26 indicated a dentist had not seen the Resident at any time during his/her admission period since October 2024 (approximately 16 months).During an interview with the Director of Nursing (DON) on 3/31/2026 at 8:17 A.M., he said he would review the medical record and contact the dental service to determine if a consent or examination occurred. At approximately 9:00 A.M., the DON said Resident #54 had not been offered a consent form for dental services and that a dentist had not seen the Resident since admission to the facility (October 2024). The DON said it was the facility's policy for the dentist to examine every resident at least annually, unless the resident declined. The DON said Resident #54 had a history of declining care at times, but there was no indication he/she declined dental services.

Based on observation, record review and interviews, the facility failed to ensure one Resident (#148) with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, out of a total sample of 34 residents. Specifically, for Resident #148 the facility failed to implement four recommendations from the Wound Consultant for the treatment of a pressure ulcer.Findings include:Review of the facility policy titled Physician Order, Revised April 2022, indicated the following:-Purpose: The Purpose of the procedure is to establish uniform guidelines in the receiving and recording of the physician orders.-Supervision by a Physician:2. A current list of orders must be maintained in the clinical record of each resident.3. Orders must be written and maintained in the clinical record of each resident. -Treatment Orders: When recording treatment orders, specify the treatment, frequency and duration of the treatment. Resident #148 was admitted to the facility in February 2024 with the diagnoses that included Parkinsonism, type 2 diabetes, dementia and sequelae of cerebral infarction (long-term, chronic, or permanent neurological deficits and complications persisting after a stroke.) Review of the most recent Minimum Data Set (MDS) Assessment, dated 2/23/26, indicated a Brief Interview for Mental Status (BIMS) score three out of 15, indicating the Resident had severe cognitive impairment. The MDS further indicated the following:-Resident #148 was dependent on staff for all activities of daily living-Resident #148 was at risk of developing pressure ulcers/injuries.-Resident #148 had one unhealed pressure ulcer/injury-Resident #148 had a stage 3 pressure ulcerOn 3/30/26 at 9:07 A.M., the surveyor observed Resident #148 lying in bed on an air-mattress (an alternating pressure and low air loss device designed to prevent and treat pressure ulcers by reducing, shifting, and relieving skin pressure) set at 250 pounds. Review of Resident #148's active skin plan of care, dated 1/6/26, indicated the following:-Actual alteration in skin integrity: Location: Stage three left buttock.Related to the following: decreased mobility and urinary incontinence.-Interventions: Follow MD orders for skin care and treatment. Left Buttock open area: cleanse with wound cleanser/normal saline (a sterile solution used to flush the wound), pat dry, skin prep. cover with collagen wafer, border foam dressing (a sterile, primary wound dressing that transforms into a soft gel upon contact with wound exudate, creating a moist environment that accelerates healing) every day and as needed. Review of the wound consultant note, dated 1/15/26, indicated the following:-Initial Progress note: Patient being seen by wound care for an assessment and treatment recommendation for: A pressure ulcer to the left buttock. Treatment recommendations in place. No other wound concern upon assessment.-Treatment recommendations: Pressure ulcer Buttock left. Instruction: Clean with wound cleanser/normal saline, pat dry. Cover with Silvadene (a prescription-strength topical sulfa antibiotic cream used to prevent and treat wound infections) to wound bed, cover with Silicone border dressing (a wound care product featuring a soft silicone adhesive layer that minimizes pain and trauma to the wound bed and surrounding skin during changes). Every day and as needed. Review of the January 2026 physician orders and January 2026 Treatment Administration Record (TAR) failed to indicate that the treatment for the left buttock pressure ulcer was initiated and implemented per the recommendation from the wound consultant. Review of the wound consultant note, dated 1/28/26, indicated the following:- Patient being seen by wound care for an assessment and treatment recommendation for: A pressure ulcer to the left buttock. Treatment recommendations in place. No other wound concern upon assessment. Pressure to left buttock with improvement this week. New change made to treatment recommendation. No new wound concerns. No signs/symptoms of infection. -Treatment recommendations: Pressure ulcer Buttock left. Instruction: Clean with wound cleanser/normal saline, pat dry. Apply Medihoney (a medical-grade, antibacterial honey product used to promote healing in chronic and acute wounds) to slough (a yellow, soft, dead tissue layer commonly found in chronic, non-healing wounds, consisting of bacteria, protein and white blood cells) and cover with a dry protective dressing. Daily and as needed. Review of the January 2026 physician orders and January 2026 TAR failed to indicate that the treatment for the left buttock pressure ulcer was initiated and implemented as per the recommendation from the wound consultant. Review of the wound consultant note, dated 2/26/26, indicated the following:- Patient being seen by wound care for an assessment and treatment recommendation for: A pressure ulcer to the left buttock. Treatment recommendations in place. No other wound concern upon assessment. Wound with no change this week. Treatment recommendation has been updated. No new wound concerns during assessment. No signs/symptoms of infection.-Treatment recommendations: Pressure ulcer Buttock left. Instruction: Clean with wound cleanser/normal saline, pat dry. Apply Skin Prep (a liquid, film-forming protective barrier applied to intact skin to facilitate better adhesion of wound dressings) and leave open to air. Daily. Review of the February 2026 physician orders and February 2026 TAR failed to indicate that the treatment for the left buttock pressure ulcer was initiated and implemented as per the recommendation from the wound consultant. Review of the wound consultant note, dated 3/25/26, indicated the following:-Patient being seen by wound care for an assessment and treatment recommendation for: A pressure ulcer to the left buttock. Treatment recommendations in place. No other wound concern upon assessment. Wound showing some improvement this week. Treatment recommendation has been updated. No new areas of concern. -Treatment recommendations: Pressure ulcer Buttock left. Instruction: Clean with wound cleanser/pat dry. Apply Zinc and Collagen Sprinkles (collagen particles or powder designed for chronic or non-healing wounds with minimal to heavy exudate). Daily and as needed.Review of the March 2026 physician orders and March 2026 TAR failed to indicate that the treatment for the left buttock pressure ulcer was initiated and implemented as per the recommendation from the wound consultant. Review of Resident #148's discontinued orders indicated the following:-Left Buttock open area: cleanse with wound cleanser/normal saline apply Therahoney to wound bed cover with silicon border gauze daily and when soiled, date initiated 1/28/26, discontinued date 2/6/26.-Left Buttock open area: cleanse with wound cleanser/normal saline, pat dry. Apply medihoney to slough, cover with silicone boarder dressing every day and as needed, date initiated 2/6/26, discontinued 2/12/26. Review of the discontinued orders failed to indicate the wound consultant recommendations for the dates 1/15/26, 1/28/26, 2/26/26 and 3/25/26. Further review of the discontinued orders indicated that Resident #148 received treatment orders that were not recommended by the wound consultant and the treatment orders he/she received did not coincide with the correct dates following any of the recommendations from the wound consultant. Review of Resident #148's active Physician orders indicated the following: Left Buttock open area: cleanse with wound cleanser/normal saline, pat dry, skin prep, cover with collagen wafer, border foam dressing every day and as needed, dated 2/12/26. Further review of the Resident's active Physician orders indicated that the Resident received the same treatment order despite recommendations from the wound consultant for the dates 2/26/26 and 3/25/26. Review of Resident #148's February 2026 and March 2026 TAR indicated that the nurses administered the active treatment order, dated 2/12/26, from 2/13/26 through 3/31/26, despite new wound recommendations from the Wound Consultant. During an interview on 4/1/26 at 12:14 P.M., Unit Manger #2 said that the nurse assigned to the resident being followed by the Wound Consultant accompanies the Wound Consultant during the wound rounds and any recommendations following the wound rounds are given to her. Unit Manager #2 said after the recommendations are given to her, she would notify the Provider and if the Provider agrees to the recommendation, she would put the physician treatment order along with the weekly wound assessment into the resident's medical record. During an observation and interview on 4/1/26 at 12:18 P.M., the surveyor and Unit Manager #2 reviewed all Wound Consultant recommendations for the dates 1/15/26, 1/28/26, 2/26/26 and 3/25/26 along with the discontinued and active orders for Resident #148. Unit Manger #2 said she took the recommendations for those dates and did not update the orders. Unit Manger #2 said the initial treatment order from the Wound Consultant was never put in the Resident's medical record. Unit Manager #2 said the orders should have been updated and if new orders are recommended they should be verified by the Nurse Practitioner (NP). During an interview on 4/1/26 at 1:49 P.M., the Wound Consultant said her recommendations are put directly into the Residents medical record, but she does not input actual orders into the medical record. The Wound Consultant said she was not aware that her recommendations were not implemented and it is the responsibility of whoever is in charge at the facility to put the orders into the medical record. During an interview on 4/1/26 at 1:57 P.M., Nurse Practitioner (NP) #1 said the wound recommendations go to the facility and the staff notify her of any recommendations. NP #1 said she can't recall a time she declined a recommendation by the Wound Consultant but if she disagreed with a recommendation, she would document the reason why she disagreed in the Resident's medical record. Review of Resident #148's medical record failed to indicate documentation from NP #1 declining recommendations from the Wound Consultant for the dates 1/15/26, 1/28/26, 2/26/26 and 3/25/26. During an interview on 4/1/26 at 2:43 P.M., the Director of Nurses said he expects recommendations to be approved by the provider should be put in the medical record by the nurse receiving the order.

Based on record review and interview the facility failed to adhere to nursing standards of practice for one Resident (#184) out of three closed records reviewed. Specifically, the facility failed to ensure the Registered Nurse (RN), performed a physical assessment to complete the pronouncement of death after Resident #184 died. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019 indicated the following: - The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of Massachusetts General Law - Part I, Title VII, Chapter 46, Section 9 - indicated: When a patient suffering from a terminal illness or whose death is anticipated and who is receiving the services of a home health agency, as that term is defined in 42 USC 1395x(o), or of a hospice program licensed by the commonwealth, or who resides in a certified nursing home or who is enrolled in a PACE program as defined in 42 U.S.C. 1396u-4, dies, at home, in a hospice, or a nursing home, a registered professional nurse, licensed by the board of registration in nursing and employed by a certified home health agency, hospice, nursing home or a PACE program as defined in 42 U.S.C. 1396u-4, may declare such person dead; provided, however, that said nurse first makes a reasonable effort to contact the attending physician or medical examiner before making such determination or pronouncement; provided, further, that such determination or pronouncement be made in writing on a form approved by the commissioner of public health and subscribed under pain and penalties of perjury; and provided, further, that said physician or medical examiner be notified forthwith of the exact location to which the decedent has been removed. Review of the facility policy titled RN Pronouncement dated as revised [DATE] indicated: Policy: The facility ensures that residents receive appropriate and timely care in the event of cardiopulmonary arrest. RN's, in accordance with state law, may pronounce death when clinical criteria are met. Initial observation: Note the general appearance of the body, and presence of family.Verify identity: Confirm patient identityPhysical Assessment observe for absence of breathing for one full minute (auscultate lung sounds). Check for absence of apical pulse for one full minute. Check for fixed and dilated pupils (no response to light). Confirm no reaction to verbal or tactile stimuli. Document the time the assessment was completed (time of pronouncement). Notify Health Care Representatives. Orders to be obtained by nurse from provider to release the body to funeral home per family choice.Documentation: Record the following in the EMR: Time and date of assessment. Absence of vital signs. Notification of physician/family. Resident #184 was admitted to the facility in [DATE] with diagnoses including stroke, dysphagia, and vascular parkinsonism. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated that Resident #184 died at the facility. Review electronic record included a drafted progress note written by Nurse #1 dated [DATE], indicating the following: After all assessments, patient was pronounced dead by [Nurse #1] per protocol at 17:26 P.M., (5:26 P.M.) Provider notified, family notified, Postmortem care initiated per facility policy. The body was released to [funeral home] and left facility around 19:00 P.M., (7:00 P.M.). During an interview on [DATE] at 10:58 A.M., Nurse #2 said that Resident #184 coded and needed CPR (Cardiopulmonary Resuscitation) which facility staff initiated until EMTs (Emergency Medical Technicians) took over. Nurse #2 said the EMTs were not able to revive Resident #184 and he/she died. Nurse #2 said that Nurse #1 was the only RN in the building at that time and so he was responsible for completing the pronouncement of death. During an interview on [DATE] at 2:03 P.M., Nurse Supervisor #1 said that RNs can complete death pronouncements and not LPNs (Licensed Practical Nurses). Nurse Supervisor #1 said that if Resident #184 died in the facility then Nurse #1 would have been the nurse to complete the death pronouncement. During interviews on [DATE] at approximately 10:00 A.M., and 2:38 P.M., Nurse #1 said that he was the only RN in the building the day Resident #184 died. Nurse #1 said that he was on break in the basement and did not know that Resident #184 had coded so he was not present during the code. Nurse #1 said that Nurse #2 and Nurse Supervisor #1 informed him that Resident #184 had died and he needed to complete the RN pronouncement. Nurse #1 said that by the time he got upstairs after his break, Resident #184's body had been taken by the funeral home so he never saw the body. Nurse #1 said he signed the RN pronouncement without performing a physical assessment of Resident #184's body. During an interview on [DATE] at 2:38 P.M., the Director of Nursing (DON) said that it is not within the scope of an LPN's practice to complete a death pronouncement. The DON said that RNs are expected to perform a physical assessment of the body in order to complete a death pronouncement.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was independent with eating, the Facility failed to ensure they maintained a complete and accurate medical/clinical record, including but not limited to his/her Comprehensive Nutrition Assessment and Nurse Progress Notes.Findings include:Review of the Facility Policy titled Charting and Documentation, dated as last revised 04/2022, indicated that the Medical Record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.The Policy indicated that the documentation in the medical record will be objective, complete and accurate.Resident #1 was admitted to the Facility in 06/2023, diagnoses include history of a traumatic Subarachnoid Hemorrhage (SAH, life threatening emergency caused by bleeding between the brain and its covering membranes) frontal lobe contusions secondary to multiple falls, hypertension and dysphagia.Review of Resident #1 Care Plan titled Activities of Daily Living (ADL), dated as last reviewed 08/27/25, indicated that he/she was able to eat independently after staff set up (helper set-up or cleans up, resident completes the activity).Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 10/08/25, indicated that he/she was independent (completes the activity by themselves with no assistance from a helper) with the task of eating (the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident).Review of Resident #1's Comprehensive Nutritional Evaluation, dated 10/31/25, indicated that he/she required to be fed by the staff.Review of Resident #1's two previous nutrition evaluations dated 08/12/25 and 05/12/25, indicated that he/she feeds self no assist.During a telephone interview on 11/28/25 at 2:15 P.M., the Registered Dietician (RD) said that she had completed Resident #1's Nutritional Assessment remotely while covering for the Facility's regular dietician.The RD said after looking at his/her ADL's and functional ability for eating, she must have accidentally checked off the wrong box on the Nutrition Assessment. The RD said that Resident #1 is independent with eating and said she made a documentation error.Review of Resident # 1's Nurse Progress Notes, dated 11/19/25, written by Nurse #1, indicated that Resident #1 was dependent with eating.During an interview on 11/28/25 at 12:42 P.M., Nurse #1 said that he has taken care of Resident #1 many times and said that he/she is independent for eating, at times the CNA's may provide him/her with a set-up, but Resident #1 is able to eat his/her meals independently.Nurse #1 said that he was not aware that he documented Resident #1 as dependent with meals in his/her latest progress note and said he made an error when checking off the level of assistance that he/she required with eating.During an interview on 11/28/25 at 3:08 P.M., the Director of Nurses (DON) said that he did not realize that there was conflicting documentation in Resident #1's medical record until he had submitted the reportable to the Department of Public Health.The DON said that it is the Facilities expectation that all medical record entries, including but not limited to ADL documentation, Nurse Progress Notes and Nutritional Assessments are complete and accurate.

Based on records reviewed and interviews for one of three sampled residents (Resident #2), the Facility failed to ensure that they completed a quarterly Minimum Data Set (MDS) assessment as required in a timely manner.Findings include:Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual indicated for Quarterly Assessments:The MDS completion date (item Z0500B) must be no later than 14 days after the Assessment Reference Date (ARD + 14 calendar days).Resident #2 was admitted to the Facility in 03/2022, diagnoses include Alzheimer's Disease, bipolar disorder, hypertension and diabetes mellitus.Review of Resident #2's Medical Record indicated that his/her last completed Quarterly MDS had an Assessment Reference Date (ARD) of 08/13/25.Further review of Resident #2's medical record indicated that his/her quarterly MDS, with an ARD of 11/11/25, had not been completed within 14 days of the ARD date (due to be completed by 11/25/25).During a telephone interview on 12/03/25 at 3:23 P.M., the MDS Nurse said the facility has been behind in completing multiple MDS assessments. The MDS Nurse said that she only works remotely for about seven to ten hours per week for the Facility and can only complete so many.During a telephone interview on 12/03/25 at 3:31 P.M., the Regional Clinical Director said that she was currently responsible for overseeing and assisting the Facility with the MDS process.The Regional Clinical Director said that she was aware that the MDS's for the Facility have been behind for some time and said she has been working on getting the Facility back into compliance.During an interview on 11/28/25 at 3:08 P.M., the Director of Nurses (DON) said that he was aware that there are many MDS's that are incomplete and are being completed late.The DON said that the Facility's expectation was to have all MDS's completed in a timely manner as required, and in accordance with the RAI Manual.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had new physician's orders on 3/05/25, for a STAT (without delay, immediately) chest X-ray (two views) due to onset of acute respiratory congestion, the Facility failed to ensure Resident #1 was provided with radiology services consistent with his/her Physician's Orders, when the Radiology Provider was not contacted by nursing on 3/05/25 to order the STAT X-ray, the order was not followed-up on by nursing and as a result, the chest X-ray was not obtained, as ordered. Findings Include: The Facility Policy titled, Labs and Diagnostic, dated as revised 04/2022, indicated the Physician will identify, order diagnostic and lab testing, based on diagnostic and monitoring needs. The Policy indicated the staff will process test requisitions and arrange for tests. The Policy indicated a Nurse will identify the urgency of communicating with the Attending Physician based on the Physician request, the seriousness of any abnormality, and the individual's current condition. Resident #1 was admitted to the Facility in March 2025, diagnoses included Chronic Pulmonary Disease (a group of lung diseases that blocks airflow and make it difficult to breathe), Bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), Emphysema (chronic lung disease that permanently damages the lungs' air sacs, making it difficult to breathe), Chronic Kidney Disease Stage III (the kidneys have mild to moderate damage and are less able to filter waste and fluid out of the body), Anxiety (a feeling of fear, dread, and uneasiness), Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Dementia (a loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), Depression (a serious mental illness that can impact how you think, feel act, and perceive the world), Hypertension (high blood pressure), Left Bundle Branch Block (a delay or blockage of electrical impulses to the left side of the heart), and Neoplasm of Bronchus and Lung (bronchogenic carcinoma or lung cancer). Review of Resident #1's Medication Administration Recorded, dated 03/05/25, indicated Resident #1 had new Physician's Orders (Prescriber Entered) for Diagnostic Management as follows: - Chest X-ray (2 views) STAT (without delay, immediately) for respiratory congestion. During an interview on 04/03/25 at 4:06 P.M., Nurse #1 said on 03/05/25, he worked the 7:00 A.M. to 3:00 P.M. shift and received a change of shift Nurse Report, around 7:00 A.M. Nurse #1 said he was told that Resident #1 was not feeling well and was coughing. Nurse #1 said he informed the Nurse Practitioner (NP), who assessed Resident #1 and provided new orders. Nurse #1 said he was aware there were new orders for the Flu and COVID swabs, but was unaware that the NP wrote orders for a STAT chest X-ray. Nurse #1 said if he had seen the STAT chest X-ray Order, he would have called the Clinical Services (Radiology Company), faxed over the paperwork and then ensure the company was aware it was a STAT Chest X-ray Order. Nurse #1 said if the Radiology Company was unable to obtain the STAT chest X-ray and there would have been a delay, he would have called the Nurse Practitioner to notify her to obtain new orders. Review of Resident #1's Nurse Practitioner's Progress Note, dated 03/05/25 indicated Resident #1 presented with acute cough symptoms, sinus congestion and evidence of chills upon assessment. The Note indicated an Order was provided (written) for Nursing to obtain a Stat Chest X-ray (2 views) on Resident #1. During an interview on 04/03/25 at 2:49 P.M., The Nurse Practitioner (NP) said she had assessed Resident #1 on 03/05/25, that he/she had sinus congestion, was shivering, and had an increased cough with a hoarse voice. The NP said Resident #1 had a history of Lung Cancer, and she was concerned about him/her having the Flu since other residents in the Facility had developed the Flu during this time, so she Ordered a STAT chest X-ray (2 views) for Resident #1. The NP said she did not receive an update from nursing staff regarding Resident #1's STAT chest X-ray and that she would have expected to be informed if the Radiology Company was unable to perform a STAT chest X-ray. The NP said she would have developed an alternate plan to ensure Resident #1 had a STAT chest X-ray completed. During an interview on 04/03/25 at 1:16 P.M., The Unit Manager said she was unaware Resident #1 had a STAT (urgent) Order for a chest X-ray that the Nurse Practitioner (NP) entered into the Electronic Medical Record on 03/05/25. The Unit Manager (during the interview) reviewed Resident #1's Medication Administration Record and said the Provider (NP) wrote an order on 03/05/25, for Resident #1, to have a STAT chest X-ray for his/her respiratory congestion. The Unit Manager said if a Provider orders a STAT X-ray, this indicates it is urgent, that nursing staff need to notify the Radiology Company of the STAT Order, because it can take two to three days for a non-STAT, non-emergent X-ray to be completed. During a telephone interview on 04/14/25 at 8:53 A.M., Nurse #2 said she worked the 3:00 P.M. to 11:00 P.M., shift on 03/05/25, and was unaware of Resident #1's STAT chest X-ray Order until the end of shift when she completed her documentation in Resident #1's medical record, and read that he/she had been seen by the NP earlier in the day, who had ordered labs and a STAT chest X- ray. Nurse #2 said it was late in the shift when she became aware of the STAT X-ray order and that she did not follow-up to see if the STAT chest X-ray had been ordered or obtained. Nurse #2 said a STAT X-ray indicates the X-ray needs to be done right away and if they were unable to get the X-ray, the Nurse Practitioner would need to be informed. Review of Resident #1's Medical Record indicated there was no documentation to support Resident #1's STAT chest X-ray had been obtained and completed as ordered by the Nurse Practitioner on 03/05/25. There was no documentation to support nursing followed up with the Radiology Company (X-ray Department) regarding Resident #1's STAT chest X-ray Order, and no documentation to support nursing staff informed the NP that the STAT chest X-ray had not been completed. During a telephone interview on 04/14/25 at 9:30 A.M., the Supervisor Coordinator of the Radiology Company said they did not receive a call on 03/05/25 from the Facility regarding a STAT chest X-ray for Resident #1. The Coordinator said according to their records, there was no order placed with them by the Facility, for a STAT chest X-ray for Resident #1. During an interview on 04/03/25 at 6:17 P.M., the Director of Nurses (DON) said Resident #1's Nurse Practitioner placed his/her STAT chest-X ray in the Facility's Point Click Care System (an Electronic Health Record) and his expectations was that nursing call the Radiology Company, notify the Company of the STAT chest X-ray Order, inquire about their availability, and if there was going to be any delays in obtaining it, for nursing to inform the Nurse Practitioner to obtain new orders. The DON said the Radiology Company arrived at the Facility on 03/09/25, to obtain Resident #1's STAT chest X-ray, however Resident #1 was no longer at the Facility. The DON said he was unaware when Resident #1's order for the STAT Chest-X-ray was placed, or by whom. The DON said the Radiology Company's documentation indicated Resident #1's chest X-ray did not indicate it was a STAT Order and the X-ray was canceled on 03/09/25 by the facility because Resident #1 was no longer at the Facility.

Based on observations, record review and interviews, the facility failed to ensure four Residents (#138, #110, #106, and #130) were free from abuse and neglect out of a total sample of 42 residents. Specifically, 1.) For Resident #138, the facility failed to ensure staff provided necessary care of repositioning and incontinence care resulting in the deterioration of a pressure wound. 2.) For Residents #110, #106 and #130, the facility neglected to provide the necessary care for incontinence management. Findings include: Review of the facility policy titled, Abuse: Prevention, dated revised 3/2022, indicated the following: Purpose: To allow residents freedom of the risk of abuse, neglect, involuntary seclusion, and misappropriation and exploitation of resident property. Policy: - The facility will be proactive with any type of abuse. - The facility Administrator will be the Abuse Prevention Coordinator. - The Administrator or designee has the ability to delegate actions and tasks to other employees, such as gathering of pertinent data, so that a timely resolution of an event and/or alleged event will occur. Procedure: - 3. The Administrator will ensure that residents, families, and staff have information on how to and whom they may report concerns, incidents, and grievances without fear of retribution, and provide feedback regarding concerns that have been expressed. - 6. Facility specific characteristics will be considered when planning for prevention. Such characteristics may include: a. Features of the physical environment that may make abuse and/or neglect more likely to occur, such as secluded areas of the facility; b. The deployment of staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs; c. The supervision of staff to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their beds; and d. The assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other resident rooms, residents with self-injurious behaviors, residents with communication disorders, those that require heavy nursing care and/or are totally dependent on staff. Review of the facility policy titled, Abuse Prohibition, dated 3/2022, indicated the following: Purpose: - Each resident has the right to be free from verbal, sexual, physical and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of their property, Every resident in the facility will always be treated with respect and dignity, - Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Policy: - Residents will not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants, volunteer staff, family members, friends, or other individuals, - Staff will refrain from all actions that could be considered abuse, mistreatment, neglect, exploitation, and/or misappropriation. 1.) For Resident #138, the facility failed to ensure staff provided necessary care to reposition and provide incontinence care resulting in the deterioration of a pressure wound. Resident #138 was admitted to the facility in June 2024 with diagnoses including functional urinary incontinence and dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/29/25, indicated Resident #138 had severe cognitive impairment based on a Staff Assessment for Mental Status. The MDS further indicated Resident #138 had a stage three pressure ulcer, required substantial/maximal assistance to roll in bed, was always incontinent of bowel and bladder, and was dependent of staff for toileting hygiene and transfers. Review of Resident #138's medical record indicated he/she had been transferred to the hospital on 3/4/25 for deteriorating coccyx wound with increased size, drainage, and foul smell. During a telephone interview on 3/6/25 at 9:07 A.M., Resident #138's health care proxy said she does not believe Resident #138 was repositioned every two hours or was receiving incontinence care timely and that this caused his/her pressure ulcer to worsen. During a follow-up telephone interview on 3/10/25 at 8:56 A.M., Resident #138's health care proxy said she was looking for another facility for Resident #138 because he/she was being neglected at the facility. Resident #138's health care proxy said Resident #138's wound worsened to a stage four pressure ulcer with visible bone in the wound bed because he was not being turned and repositioned every two hours which the physician had ordered. Resident #138's health care proxy said Resident #138 also often did not have necessary incontinence care provided. Resident #138's health care proxy said she had told the Administrator, the Director of Nursing (DON), the Unit Manager, and many nurses and certified nurses assistants (CNAs) that Resident #138 was not being repositioned or having necessary incontinence care, but it continued. Review of Resident #138's plan of care related to actual alteration in skin integrity, initiated 11/7/24, indicated: - Turn and reposition every 2-3 hours every shift. Review of Resident #138's plan of care related incontinence of bladder, initiated 6/4/24, indicated: - Check twice a shift and as needed for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. Review of Resident #138's report titled 'Documentation Survey Report' (a report including certified nursing (CNA) documentation), dated 10/24/24 to 3/4/25, indicated the Resident was always incontinent and always required staff assistance for repositioning. Review of Resident #138's assessment titled 'Skin Observation Tool', dated 10/25/24, indicated the Resident did not have any pressure ulcers on 10/25/24. Review of Resident #138's Wound Nurse Practitioner progress note, dated 10/29/24, indicated initial exams for two new wounds including: - Initial exam: left buttock pressure ulcer, stage 1. - Initial exam: MASD (moisture associated skin damage) coccyx. Review of Resident #138's Wound Nurse Practitioner progress notes, dated 10/29/24, 11/5/24, 11/19/24, 11/26/24, 12/3/24, 12/10/24, 12/17/24, 12/27/24, 12/31/24, 1/7/25, 1/14/25, 1/21/25, 1/28/25, 2/4/25, 2/11/25, 2/18/25, 2/25/25, and 3/4/25, indicated: - Treatment recommendations for left buttock pressure ulcer and MASD coccyx include prompt peri care and frequent repositioning. Review of Resident #138's Wound Nurse Practitioner progress note, dated 11/5/24, indicated: - Deteriorating left buttock pressure ulcer, unstageable. - MASD to coccyx was reclassified as an unstageable pressure ulcer. - Deteriorating pressure ulcer coccyx, unstageable. - New stage three right buttock pressure ulcer. During a review of Resident #138's 'Documentation Survey Report' from time between new wound was noted and when the wound deteriorated, dated 10/30/24 to 11/5/24, indicated: - Toileting hygiene was not provided on 4 shifts. - Turning and repositioning every 2 hours was not provided 12 times. Review of Resident #138's Wound Nurse Practitioner progress note, dated 12/10/24, indicated: - Deteriorating coccyx pressure ulcer which increased in size. During a review of Resident #138's 'Documentation Survey Report' from the timeframe before the wound deteriorated, dated 11/6/24 to 12/10/24, indicated: - Toileting hygiene was not provided on 33 shifts. - Turning and repositioning every 2 hours was not provided 45 times. Review of Resident #138's Wound Nurse Practitioner progress notes, dated 12/17/24, indicated: - Coccyx pressure wound reclassified to a stage three and increased in size. During a review of Resident #138's 'Documentation Survey Report' from the timeframe before the wound deteriorated, dated 12/11/24 to 12/17/24, indicated: - Toileting hygiene was not provided on 7 shifts. - Turning and repositioning every 2 hours was not provided 17 times. Review of Resident #138's nursing progress note, dated 1/27/25, indicated: - (Health care proxy) stated he/she need to be changed right now. The nurse explained that I will notify the nursing aide for you. The resident aide was on break, the nurse was on break, two of the aide was with a resident in shower room. The other one was helping a resident with food. After a couple of minutes, while this writer was verify a dressing order, so that she was going to change when she heard someone was screaming at her: hey you, if you don't want to do your job just (expletive) stay home. This writer reply are you talking to me please do not yelled at me. This family member keep shouting and screaming at the nurse .This writer did not reply, just report it to the aide to change the resident as soon as he returned from break. [sic] Review of Resident #138's Wound Nurse Practitioner progress notes, dated 2/11/25, indicated: - Pressure ulcer to coccyx is deteriorating this week. During a review of Resident #138's 'Documentation Survey Report' from the timeframe before the wound deteriorated, dated 2/1/25 to 2/11/25, indicated: - Toileting hygiene was not provided on 16 shifts. - Turning and repositioning every 2 hours was not provided 31 times. Review of Resident #138's nursing progress note, dated 2/12/25, indicated: - Pressure ulcer to coccyx deteriorating this week. Review of Resident #138's Wound Nurse Practitioner progress notes, dated 2/18/25, indicated: - Deteriorating coccyx pressure ulcer which increased in size. - New stage two right buttock pressure ulcer. During a review of Resident #138's 'Documentation Survey Report' from the timeframe before the wound deteriorated, dated 2/12/25 to 2/18/25, indicated: - Toileting hygiene was not provided on 6 shifts. - Turning and repositioning every 2 hours was not provided 5 times. Review of Resident #138's Wound Nurse Practitioner progress notes, dated 3/4/25, indicated: - Deteriorating coccyx pressure ulcer. - New left buttock maceration. - Stable right buttock stage two pressure ulcer. Review of Resident #138's nursing progress note, dated 3/4/25, indicated: - Coccyx wound in deteriorating, foul smell noted, with increased size and drainage. NP (nurse practitioner) orders to send patient for ED (emergency department) evaluation. During a review of Resident #138's 'Documentation Survey Report' from the timeframe before the wound deteriorated, dated 2/19/25 to 3/4/25, indicated: - Toileting hygiene was not provided on 9 shifts. - Turning and repositioning every 2 hours was not provided 9 times. Review of Resident #138's hospitalist progress note, dated 3/7/25, indicated: - No definite sacral osteomyelitis, but the MRI is not adequate for evaluation due to significant motion artifact. - Recommendations for wound care include to change positions regularly. Review of Resident #138's entire medical record, dated 10/24/24 to 3/4/25, failed to indicate the Resident refused repositioning or incontinence care. During a telephone interview on 3/7/25 at 6:29 A.M., Certified Nurse Assistant (CNA) #7 said the facility has been short staffed several days a week for the past few months. CNA #7 said several days a week there was only one CNA on the overnight shift making it physically impossible to turn and reposition all the residents on the unit. CNA #7 said she does not believe Resident #138 was repositioned every two hours consistently over the past three months. During a telephone interview on 3/7/25 at 8:40 A.M., Nurse Practitioner (NP) #1 said she sees that staff isn't always able to reposition and provide toileting/incontinence care. During an interview on 3/7/25 at approximately 1:00 P.M., the Administrator said not providing services or care to residents when needed is considered neglect. During an interview on 3/7/25 at 1:12 P.M., Certified Nurse Assistant (CNA) #8 said leaving a resident in their feces or urine for hours or not turning and repositioning them is neglect. During an interview on 3/7/25 at 1:17 P.M., Nurse #8 said leaving a resident in their feces or urine for hours or not turning and repositioning them is neglect. Nurse #8 said not providing frequent repositioning or prompt incontinence care could cause a wound to deteriorate. During an interview on 3/7/25 at 1:19 P.M., Unit Manager #2 said Resident #138 should have been repositioned every two hours and incontinence care should have been provided promptly. Unit Manager #2 said repositioning and incontinence care should be documented by the CNAs, which is where the information from the report titled 'Documentation Survey' populates, under repositioning and toileting hygiene. Unit Manager #2 said if a Resident refuses repositioning or incontinence care that should be documented accordingly. Unit Manager #2 said not providing frequent repositioning or prompt incontinence care could cause a wound to deteriorate. During an interview on 3/7/25 at 1:58 P.M., the Director of Nursing (DON) said residents who are incontinent should be changed every 2-3 hours. The DON said he would have to defer to the Administrator's definition of neglect and would not answer if not providing care could be considered neglect. During an interview on 3/7/25 at 2:49 P.M., the Wound Nurse Practitioner (NP) said not providing frequent repositioning or prompt incontinence care could cause a wound to deteriorate. The Wound NP said 50% of the time during weekly wound visits Resident #138's brief was soiled or full of urine. During an interview on 3/10/25 at 10:11 A.M., the Director of Nursing (DON) and the Regional Nurse Consultant said CNA documentation should be completed by the end of each shift, including repositioning and incontinence care. The DON and Regional Nurse Consultant declined to comment on if not providing frequent repositioning or prompt incontinence care can cause a wound to deteriorate. 41456 2a.) Resident #110 was admitted to the facility in April 2022 with diagnoses including dementia. Review of Resident #110's most recent Minimum Data Set (MDS) assessment, dated 1/9/25, indicated the Resident scored a 0 out of a possible 15 on the Brief Interview for Mental Status exam, indicating he/she has severe cognitive impairment. The MDS indicated the Resident requires substantial assistance for toilet transfers and is dependent on staff for toileting tasks. Section H of the MDS indicated Resident #110 is always incontinent of both bowel and bladder. On 3/5/25 at 9:00 A.M., Resident #110 was observed sitting in his/her wheelchair in the dining room. The Resident was observed sitting in the dining room from 9:00 A.M. until 12:00 P.M. Throughout this time Resident #110 was not observed to have either of the two nursing assistants or the nurse working on the floor approach the Resident to check for incontinence or to provide care. On 3/7/25 at 8:05 A.M., Resident #110 was observed sitting in his/her wheelchair in the dining room. The Resident was observed sitting in the dining room from 9:00 A.M. until 11:57 A.M. Throughout this time Resident #110 was not observed to have either of the two nursing assistants or the nurse working on the floor approach the Resident to check for incontinence or to provide care. At 1:12 P.M., the surveyor returned to the unit and Resident #110 was observed lying in bed. Review of Resident #110's most recent Norton Pressure Ulcer assessment dated [DATE], indicated the Resident has double incontinence and is a high risk for pressure ulcer development. Review of Resident #110's ADL care plan indicated the following intervention: - Provide resident/patient with limited assist of 1 for toileting after meals and as needed. Review of Resident #110's incontinence care plan, failed to indicate an intervention of a toileting schedule or how often the Resident should be checked/changed. During an interview on 3/5/25 at 1:48 P.M., Certified Nursing Assistant (CNA) #4 said the unit is very short staffed, and because of this it takes a long time to provide care to residents and ensure that all the care is being completed. During an interview on 3/7/25 at 1:12 P.M., CNA #5 and #6 said they provide incontinence care to residents on the floor in the morning and then again in the afternoon. CNA #5 said the staff on the floor know the residents well on the floor and can predict when they go to the bathroom so there is no need to check for incontinence. CNA #5 said she did not provide care to Resident #110 while the surveyor was off the unit. CNA #5 said Resident #110 requires maximal assistance from staff for toileting and is incontinent of both bladder and bowel. CNA #5 said she provided care to Resident #110 and assisted him/her back to lunch after bed. CNA #5 said she did not provide incontinent care to the Resident when she placed him/her back in bed and she was waiting until after she completed her afternoon paperwork. During interviews on 3/5/25 at 2:03 P.M., and 3/7/25 at 1:22 P.M., Nurse #1 said all residents should be checked for incontinence and have incontinent care provided to them every 2-3 hours. Nurse #1 said there is not enough staff on the floor for the acuity of the residents and because of this people are often left soaking with incontinence because staff cannot get to the residents on time. Nurse #1 said residents are cared for in the morning and then are often not cared for again until the afternoon when the next shift comes in. Nurse #1 said she and the other staff do not have enough time to complete rounds on residents. During an interview on 3/7/24 at approximately 1:00 P.M., the Administrator said not providing services or care to residents when needed is considered neglect. During an interview on 3/7/25 at 1:58 P.M., the Director of Nursing (DON) said residents who are incontinent should be changed every 2-3 hours. The DON said he would have to defer to the Administrator's definition of neglect and would not answer if not providing care could be considered neglect. 2b.) Resident #106 was admitted to the facility in March 2018 with diagnoses including dementia. Review of Resident #106's most recent Minimum Data Set (MDS) assessment, dated 2/6/25, indicated the Resident scored 3 out of a possible 15 on the Brief Interview for Mental Status exam, indicating he/she has severe cognitive impairment. Section H of the MDS also indicated the Resident is always incontinent of bladder and bowel and is dependent on staff for toileting tasks. On 3/5/25 at 9:00 A.M., Resident #106 was observed sitting on the couch in the dining room. The Resident was observed sitting in the dining room from 9:00 A.M. until 12:00 P.M. Throughout this time Resident #106 was not observed to have either of the two nursing assistants or the nurse working on the floor approach the Resident to check for incontinence or to provide care. On 3/7/25 at 8:05 A.M., Resident #106 was observed lying on the couch in the dining room. The Resident was observed sitting in the dining room from 9:00 A.M. until 11:57 A.M. Throughout this time Resident #106 was not observed to have either of the two nursing assistants or the nurse working on the floor approach the Resident to check for incontinence or to provide care. At 1:12 P.M., the surveyor returned to the unit and Resident #106 was observed still sitting on the couch. Review of Resident #106's most recent Norton Pressure Ulcer assessment dated [DATE], indicated the Resident has urinal incontinence and is a moderate risk for pressure ulcer development. Review of Resident #106's ADL care plan indicated the following intervention: -(The Resident) needs assistance of one with bathing, dressing, grooming (needs extra encouragement for hygiene), locomotion, transfers, and toileting. (The Resident) can eat independently with set up of a tray. (He/she) is incontinent of both bowel and bladder. Review of Resident #106's incontinence care plan, failed to indicate an intervention of a toileting schedule or how often the Resident should be checked/changed. During an interview on 3/5/25 at 1:48 P.M., Certified Nursing Assistant (CNA) #4 said the unit is very short staffed, and because of this it takes a long time to provide care to residents and ensure that all the care is being completed. During an interview on 3/7/25 at 1:12 P.M., CNA #5 and #6 said they provide incontinence care to residents on the floor in the morning and then again in the afternoon. CNA #5 said the staff on the floor know the residents well on the floor and can predict when they go to the bathroom so there is no need to check for incontinence. CNA #6 said she did not provide care to Resident #106 while the surveyor was off the unit. CNA #6 said Resident #106 requires maximal assistance from staff for toileting and is incontinent of both bladder and bowel. CNA #6 said she provided care to Resident #106 and will be providing care to the Resident again. On 3/7/25 at 1:22 P.M., CNA #5 transferred Resident #106 from the couch to a wheelchair. When Resident #106 stood, a strong odor similar to urine was observed by the surveyor. CNA #5 then assisted the Resident to the bathroom to provide care. Once care was provided, CNA #5 showed the surveyor Resident #106's brief that had just been removed. The brief was soiled with a significant amount of urine. During interviews on 3/5/25 at 2:03 P.M., and 3/7/25 at 1:22 P.M., Nurse #1 said all residents should be checked for incontinence and have incontinent care provided to them every 2-3 hours. Nurse #1 said there is not enough staff on the floor for the acuity of the residents and because of this people are often left soaking with incontinence because staff cannot get to the residents on time. Nurse #1 said residents are cared for in the morning and then are often not cared for again until the afternoon when the next shift comes in. Nurse #1 said she and the other staff do not have enough time to complete rounds on residents. During an interview on 3/7/24 at approximately 1:00 P.M., the Administrator said not providing services or care to residents when needed is considered neglect. During an interview on 3/7/25 at 1:58 P.M., the Director of Nursing (DON) said residents who are incontinent should be changed every 2-3 hours. The DON said he would have to defer to the Administrator's definition of neglect and would not answer if not providing care could be considered neglect. 2c.) Resident #130 was admitted to the facility in December 2020 with diagnoses including Alzheimer's Disease. Review of Resident #130's most recent Minimum Data Set (MDS) assessment, dated 12/19/24, indicated the Resident was unable to complete the Brief Interview for Mental Status exam and staff had assessed him/her to have severe cognitive impairment. Section H of the MDS also indicated the Resident is always incontinent of bladder and bowel and is dependent on staff for toileting tasks. On 3/5/25 at 9:00 A.M., Resident #130 was observed reclined in his/her reclining Broda chair in the dining room. The Resident was observed sitting in the dining room from 9:00 A.M. until 12:00 P.M. Throughout this time Resident #130 was not observed to have either of the two nursing assistants or the nurse working on the floor approach the Resident to check for incontinence or to provide care. On 3/7/25, Resident #130 was observed in the dining room from 10:26 A.M. until 11:57 A.M. Throughout this time Resident #106 was not observed to have either of the two nursing assistants or the nurse working on the floor approach the Resident to check for incontinence or to provide care. At 1:12 P.M., the surveyor returned to the unit and Resident #130 was observed still reclined in the dining room. Review of Resident #130's most recent Norton Pressure Ulcer assessment dated [DATE], indicated the Resident has both bladder and bowel incontinence and is a high risk for pressure ulcer development. Review of Resident #130's ADL care plan indicated the following intervention: -(The Resident) needs dependent care of 1-2 for all of (his/her) ADLs. Review of Resident #130's incontinence care plan, failed to indicate an intervention of a toileting schedule or how often the Resident should be checked/changed. During an interview on 3/5/25 at 1:48 P.M., Certified Nursing Assistant (CNA) #4 said the unit is very short staffed, and because of this it takes a long time to provide care to residents and ensure that all the care is being completed. During an interview on 3/07/25 at 1:12 P.M., CNA #5 and #6 said they provide incontinence care to residents on the floor in the morning and then again in the afternoon. CNA #5 said the staff on the floor know the residents well on the floor and can predict when they go to the bathroom so there is no need to check for incontinence. CNA #5 said Resident #130 is dependent on staff for all care, including toiling and that the Resident is incontinent of both bladder and bowel. CNA #5 said she did not provide care to Resident #130 while the surveyor was off the unit. CNA #5 said she provided care to Resident #130 this morning and because the Resident did not get up from bed until after breakfast, he/she would not receive care again until the afternoon staff starts their shift. During interviews on 3/5/25 at 2:03 P.M., and 3/7/25 at 1:22 P.M., Nurse #1 said all residents should be checked for incontinence and have incontinent care provided to them every 2-3 hours. Nurse #1 said there is not enough staff on the floor for the acuity of the residents and because of this people are often left soaking with incontinence because staff cannot get to the residents on time. Nurse #1 said residents are cared for in the morning and then are often not cared for again until the afternoon when the next shift comes in. Nurse #2 said she and the other staff do not have enough time to complete rounds on residents. During an interview on 3/7/24 at approximately 1:00 P.M., the Administrator said not providing services or care to residents when needed is considered neglect. During an interview on 3/7/25 at 1:58 P.M., the Director of Nursing (DON) said residents who are incontinent should be changed every 2-3 hours. The DON said he would have to defer to the Administrator's definition of neglect and would not answer if not providing care could be considered neglect. Refer to F686 and F725.

Based on observations, interviews and record review, the facility failed to provide necessary treatment, services, and/or interventions to promote healing and prevent new ulcers from developing for four Residents (#138, #30, #167, and #143), who had pressure ulcers, out of 42 total sampled residents. Specifically, 1a.) For Resident #138, the facility failed to implement multiple wound care orders timely, resulting in the deterioration of the wound. 1b.) For Resident #138, the facility failed to ensure staff provided prompt incontinence care and was repositioned every two hours for pressure ulcer care, resulting in the deterioration of the wound. 1c.) For Resident #138, the facility failed to ensure staff implemented an appropriate support surface based on it's therapeutic benefit for the Resident's specific situation when the Resident, who had multiple worsening pressure ulcers and difficulty communicating needs, utilized an air mattress without specified settings. 2a.) For Resident #30, the facility failed to ensure wound care orders were implemented at the correct frequency. 2b.) For Resident #30, the facility failed to ensure staff implemented an appropriate support surface based on it's therapeutic benefit for the Resident's specific situation when the Resident, who had multiple pressure ulcers and incontinence, utilized an air mattress without specified settings. 3.) For Resident #167, the facility failed to ensure wound care recommendations were implemented timely. 4.) For Resident # 143, the facility failed to obtain physician orders for the use of a support surface (air mattress/overlay). Findings include: 1.) Resident #138 was admitted to the facility in June 2024 with diagnoses including functional urinary incontinence and dementia. Resident #138 did not have any pressure ulcers on admission to the facility. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/29/25, indicated Resident #138 had severe cognitive impairment based on a Staff Assessment for Mental Status. This MDS also indicated Resident #138 had a stage three pressure ulcer, required substantial/maximal assistance to roll in bed, and was dependent on staff for toileting hygiene and transfers. During a telephone interview on 3/6/25 at 9:07 A.M., Resident #138's health care proxy said she was concerned that the Resident was not receiving the wound care he/she needs because his/her wounds kept worsening. Review of Resident #138's medical record indicated he/she had been transferred to the hospital on 3/4/25 for deteriorating coccyx wound with increased size, drainage, and foul smell. 1a.) Review of Resident #138's assessment titled 'Skin Observation Tool', dated 10/25/24, indicated the Resident did not have any pressure ulcers on 10/25/24. Review of Resident #138's Wound Nurse Practitioner progress note, dated 10/29/24, indicated initial exams for two new wounds including: - Initial exam: left buttock pressure ulcer, stage 1. - Initial exam: MASD (moisture associated skin damage) coccyx. - Treatment recommendation for left buttock pressure ulcer and MASD coccyx: Wash with soap and water, pat dry. Apply zinc paste to bilateral buttocks and coccyx QD (every day) and PRN (as needed). Review of Resident #138's physician orders indicated: - Wash with soap and water, pat dry, then apply zinc oxide paste to BL (bilateral) buttocks and coccyx QD and PRN, initiated 10/31/24, which was two days after recommendation was made. Review of Resident #138's treatment administration record (TAR), dated October 2024, failed to indicate any treatment for the Resident's left buttock pressure ulcer or MASD on coccyx on 10/29/24 or 10/30/24. This TAR further indicated that on 10/31/24 the treatment order to Wash with soap and water, pat dry, then apply zinc oxide paste to BL (bilateral) buttocks and coccyx QD and PRN was not marked as implemented, but instead not documented by the nurse. This wound order was not implemented until 11/1/24, which was three days after it was recommended. Review of Resident #138's Wound Nurse Practitioner progress note, dated 11/5/24, indicated: - Deteriorating left buttock pressure ulcer, unstageable. - MASD to coccyx was reclassified as an unstageable pressure ulcer. - Deteriorating pressure ulcer coccyx, unstageable. - New stage three right buttock pressure ulcer. - Treatment recommendation for left buttock pressure ulcer and unstageable coccyx pressure ulcer: Wash with wound cleanser, pat dry. Skin prep to peri skin. Santyl to open area, cover with collagen and sacral dressing, QD and PRN. - Treatment recommendation for right buttock pressure ulcer: Wash with wound cleanser, pat dry, skin prep to peri skin, collagen into open area, cover with sacral dressing, QD and PRN. Review of Resident #138's physician orders indicated: - Rt (Right) Buttock: Wash with wound cleanser, pat dry, skin prep to peri skin, collagen into area, cover with sacral dressing QD/PRN, initiated 11/8/24. This wound order was not implemented until three days after the recommendation was made. - Left buttock/coccyx: Wash with wound cleanser, pat dry, skin prep to peri skin. Santyl to open area, cover with collagen and sacral dressing QD and PRN with peri care, initiated 11/8/24. This wound order was not implemented until three days after the recommendation was made. Review of Resident #138's Wound Nurse Practitioner progress note, dated 12/10/24, indicated: - Deteriorating coccyx pressure ulcer which increased in size. - Treatment recommendation for unstageable coccyx pressure ulcer: Wash with wound cleanser, pat dry. Skin prep to peri skin. Collagen with silver to wound bed, cover with sacral dressing QD/PRN/with peri care. Review of Resident #138's physician orders indicated: - Wash with wound cleanser, pat dry, skin prep to peri skin. Collagen with silver to wound bed. Cover with sacral dressing QD/PRN and with peri care, initiated 12/17/24. This wound order was not implemented until seven days after the recommendation was made. Review of Resident #138's medication administration record (MAR) indicated santyl ointment was applied to his/her coccyx wound from 12/10/24 to 12/18/24, which was eight days after santyl was no longer recommended by the Wound Nurse Practitioner. Review of Resident #138's Wound Nurse Practitioner progress notes, dated 12/17/24, indicated: - Coccyx pressure wound reclassified to a stage three and increased in size. Review of Resident #138's Wound Nurse Practitioner progress notes, dated 2/11/25, indicated: - Pressure ulcer to coccyx is deteriorating this week. - Treatment recommendation for stage three coccyx pressure ulcer: Wash with wound cleanser, pat dry. Skin prep to peri skin. Santyl to slough. Collagen to open area and cover with sacral dressing QD/PRN/with peri care. Review of Resident #138's physician orders indicated: - Pressure coccyx wound: Wash with WC (wound cleanser), pat dry, skin prep to peri skin. Santyl to slough, collagen to open area and cover with sacral dressing QD/PRN with peri care, initiated 2/14/25. This wound order was not implemented until three days after the recommendation was made. Review of Resident #138's nursing progress note, dated 2/12/25, indicated: - Pressure ulcer to coccyx deteriorating this week. Review of Resident #138's Wound Nurse Practitioner progress notes, dated 2/18/25, indicated: - Deteriorating coccyx pressure ulcer which increased in size. - New stage two right buttock pressure ulcer. - Treatment recommendation for stage three coccyx pressure ulcer and stage two right buttock pressure ulcer: Wash with wound cleanser, pat dry. Skin prep to peri skin. Santyl to slough. Collagen to open area and cover with sacral dressing QD/PRN/with peri care. Review of Resident #138's physician orders indicated: - Pressure coccyx wound: Wash with WC (wound cleanser), pat dry, skin prep to peri skin. Santyl to slough, collagen to open area and cover with sacral dressing QD/PRN with peri care, initiated 2/14/25. - No wound treatment order was implemented for the Resident's new stage two right buttock pressure ulcer until 3/4/25. This wound order was not implemented until 14 days after the recommendation was made. Review of Resident #138's Wound Nurse Practitioner progress notes, dated 2/25/25, indicated: - Treatment recommendation for stage three coccyx pressure ulcer and stage two right buttock pressure ulcer: Wash with wound cleanser, pat dry. Skin prep to peri skin. Collagen to open area and cover with sacral dressing QD/PRN/with peri care. Review of Resident #138's physician orders indicated the stage three coccyx pressure ulcer treatment recommendation was never implemented prior to the next scheduled weekly Wound Nurse Practitioner's visit on 3/4/25 during which wound deterioration was noted. Review of Resident #138's Wound Nurse Practitioner progress notes, dated 3/4/25, indicated: - Deteriorating coccyx pressure ulcer. - New left buttock maceration. - Stable right buttock stage two pressure ulcer. Review of Resident #138's nursing progress note, dated 3/4/25, indicated: - Coccyx wound in deteriorating, foul smell noted, with increased size and drainage. NP (nurse practitioner) orders to send patient for ED (emergency department) evaluation. Review of Resident #138's hospitalist progress note, dated 3/7/25, indicated: - No definite sacral osteomyelitis, but the MRI is not adequate for evaluation due to significant motion artifact. - Recommendations for wound care include to change positions regularly. During an interview on 3/7/25 at 1:19 P.M., Unit Manager #2 said she usually completes the weekly wound rounds with the Wound Nurse Practitioner. Unit Manager #2 said the Wound Nurse Practitioner verbally communicates wound treatment changes before she leaves the floor. Unit Manager #2 said the Wound Nurse Practitioner always sends the written progress note with the treatment recommendations the next day, and the latest the facility receives it is the next day. Unit Manager #2 said the treatment recommendations should be communicated to the Resident's provider when the recommendation is received and implemented or documented why it was not. Unit Manager #2 said Wound NP treatment recommendations should be addressed and implemented the day they are received. During an interview on 3/7/25 at 2:49 P.M., the Wound Nurse Practitioner (NP) said she always tells the nurse or unit manager if there are any wound treatment recommendations before she leaves the facility. The Wound NP said she always sends the written progress note with the treatment recommendations the next day. The Wound NP said she expects the treatment recommendation to be implemented or addressed prior to the next scheduled dressing change. The Wound NP said not implementing Resident #138's wound treatment recommendations timely could cause the wound to deteriorate. The Wound NP said santyl is a debriding agent that can damage healthy tissue and applying it when no longer indicated could cause a wound to deteriorate. During an interview on 3/10/25 at 10:11 A.M., the Director of Nursing (DON) and the Regional Nurse Consultant declined to comment on what was an acceptable time frame for Wound NP treatment recommendations to be addressed/implemented. 1b.) Review of the facility policy titled 'Preventative Pressure Ulcer', revised April 2022, indicated: - Prevention: Moisture: Keep skin clean and free of exposure to urine and fecal matter. - Prevention: Mobility/Repositioning: At least every two hours, reposition residents who are reclining and dependent of staff for repositioning. During a telephone interview on 3/6/25 at 9:07 A.M., Resident #138's health care proxy said she does not believe he/she is repositioned every two hours or is receiving incontinence care timely and that it's caused his/her pressure ulcers to worsen. Resident #138's health care proxy said she believed this was related to the facility not having enough staff. Review of Resident #138's plan of care related to actual alteration in skin integrity, initiated 11/7/24, indicated: - Turn and reposition every 2-3 hours every shift. Review of Resident #138's plan of care related incontinence of bladder, initiated 6/4/24, indicated: - Check twice a shift and as needed for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. Review of Resident #138's report titled 'Documentation Survey Report' (a report including certified nursing (CNA) documentation), dated 10/24/24 to 3/4/25, indicated the Resident was always incontinent and always required staff assistance for repositioning. Review of Resident #138's assessment titled 'Skin Observation Tool', dated 10/25/24, indicated the Resident did not have any pressure ulcers on 10/25/24. Review of Resident #138's Wound Nurse Practitioner progress note, dated 10/29/24, indicated initial exams for two new wounds including: - Initial exam: left buttock pressure ulcer, stage 1. - Initial exam: MASD (moisture associated skin damage) coccyx. Review of Resident #138's Wound Nurse Practitioner progress notes, dated 10/29/24, 11/5/24, 11/19/24, 11/26/24, 12/3/24, 12/10/24, 12/17/24, 12/27/24, 12/31/24, 1/7/25, 1/14/25, 1/21/25, 1/28/25, 2/4/25, 2/11/25, 2/18/25, 2/25/25, and 3/4/25, indicated: - Treatment recommendations for left buttock pressure ulcer and MASD coccyx include prompt peri care and frequent repositioning. Review of Resident #138's Wound Nurse Practitioner progress note, dated 11/5/24, indicated: - Deteriorating left buttock pressure ulcer, unstageable. - MASD to coccyx was reclassified as an unstageable pressure ulcer. - Deteriorating pressure ulcer coccyx, unstageable. - New stage three right buttock pressure ulcer. During a review of Resident #138's 'Documentation Survey Report' from time between new wound was noted and when the wound deteriorated, dated 10/30/24 to 11/5/24, indicated: - Toileting hygiene was not provided on 4 shifts. - Turning and repositioning every 2 hours was not provided 12 times. Review of Resident #138's Wound Nurse Practitioner progress note, dated 12/10/24, indicated: - Deteriorating coccyx pressure ulcer which increased in size. During a review of Resident #138's 'Documentation Survey Report' from the timeframe before the wound deteriorated, dated 11/6/24 to 12/10/24, indicated: - Toileting hygiene was not provided on 33 shifts. - Turning and repositioning every 2 hours was not provided 45 times. Review of Resident #138's Wound Nurse Practitioner progress notes, dated 12/17/24, indicated: - Coccyx pressure wound reclassified to a stage three and increased in size. During a review of Resident #138's 'Documentation Survey Report' from the timeframe before the wound deteriorated, dated 12/11/24 to 12/17/24, indicated: - Toileting hygiene was not provided on 7 shifts. - Turning and repositioning every 2 hours was not provided 17 times. Review of Resident #138's nursing progress note, dated 1/27/25, indicated: - (Health care proxy) stated he/she need to be changed right now. The nurse explained that I will notify the nursing aide for you. The resident aide was on break, the nurse was on break, two of the aide was with a resident in shower room. The other one was helping a resident with food. After a couple of minutes, while this writer was verify a dressing order, so that she was going to change when she heard someone was screaming at her: hey you, if you don't want to do your job just (expletive) stay home. This writer reply are you talking to me please do not yelled at me. This family member keep shouting and screaming at the nurse .This writer did not reply, just report it to the aide to change the resident as soon as he returned from break. [sic] Review of Resident #138's Wound Nurse Practitioner progress notes, dated 2/11/25, indicated: - Pressure ulcer to coccyx is deteriorating this week. During a review of Resident #138's 'Documentation Survey Report' from the timeframe before the wound deteriorated, dated 2/1/25 to 2/11/25, indicated: - Toileting hygiene was not provided on 16 shifts. - Turning and repositioning every 2 hours was not provided 31 times. Review of Resident #138's nursing progress note, dated 2/12/25, indicated: - Pressure ulcer to coccyx deteriorating this week. Review of Resident #138's Wound Nurse Practitioner progress notes, dated 2/18/25, indicated: - Deteriorating coccyx pressure ulcer which increased in size. - New stage two right buttock pressure ulcer. During a review of Resident #138's 'Documentation Survey Report' from the timeframe before the wound deteriorated, dated 2/12/25 to 2/18/25, indicated: - Toileting hygiene was not provided on 6 shifts. - Turning and repositioning every 2 hours was not provided 5 times. Review of Resident #138's Wound Nurse Practitioner progress notes, dated 3/4/25, indicated: - Deteriorating coccyx pressure ulcer. - New left buttock maceration. - Stable right buttock stage two pressure ulcer. Review of Resident #138's nursing progress note, dated 3/4/25, indicated: - Coccyx wound in deteriorating, foul smell noted, with increased size and drainage. NP (nurse practitioner) orders to send patient for ED (emergency department) evaluation. During a review of Resident #138's 'Documentation Survey Report' from the timeframe before the wound deteriorated, dated 2/19/25 to 3/4/25, indicated: - Toileting hygiene was not provided on 9 shifts. - Turning and repositioning every 2 hours was not provided 9 times. Review of Resident #138's hospitalist progress note, dated 3/7/25, indicated: - No definite sacral osteomyelitis, but the MRI is not adequate for evaluation due to significant motion artifact. - Recommendations for wound care include to change positions regularly. Review of Resident #138's entire medical record, dated 10/24/24 to 3/4/25, failed to indicate the Resident refused repositioning or incontinence care. During a telephone interview on 3/7/25 at 6:29 A.M., Certified Nurse Assistant (CNA) #7 said the facility had been short staffed several days a week for the past few months. CNA #7 said several days a week there is only one CNA on the overnight shift making it physically impossible to turn and reposition all the residents on the unit. CNA #7 said she does not believe Resident #138 was repositioned every two hours consistently over the past three months. During a telephone interview on 3/7/25 at 8:40 A.M., Nurse Practitioner (NP) #1 said she sees that staff isn't always able to reposition and provide toileting/incontinence care. During an interview on 3/7/25 at 1:17 P.M., Nurse #8 said not providing frequent repositioning or prompt incontinence care could cause a wound to deteriorate. During an interview on 3/7/25 at 1:19 P.M., Unit Manager #2 said Resident #138 should have been repositioned every two hours and incontinence care should have been provided promptly. Unit Manager #2 said repositioning and incontinence care should be documented by the CNAs, which is where the information from the report titled 'Documentation Survey' populates, under repositioning and toileting hygiene. Unit Manager #2 said if a Resident refuses repositioning or incontinence care that should be documented accordingly. Unit Manager #2 said not providing frequent repositioning or prompt incontinence care could cause a wound to deteriorate. During an interview on 3/7/25 at 2:49 P.M., the Wound Nurse Practitioner (NP) said not providing frequent repositioning or prompt incontinence care could cause a wound to deteriorate. The Wound NP said 50% of the time during weekly wound visits Resident #138's brief was soiled or full of urine. During an interview on 3/10/25 at 10:11 A.M., the Director of Nursing (DON) and the Regional Nurse Consultant said CNA documentation should be completed by the end of each shift, including repositioning and incontinence care. The DON and Regional Nurse Consultant declined to comment on if not providing frequent repositioning or prompt incontinence care can cause a wound to deteriorate. 1c.) Review of the facility policy titled 'Preventative Pressure Ulcer', revised April 2022, indicated: - Support Surfaces and Pressure Redistribution: Select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors. Review of Manufacturer's guidelines for Medline Supra APL Mattress System indicated: - To set the Medline Supra APL, first connect the pump and mattress, then power it on and inflate. Adjust the mattress based on the patient's weight. On 3/4/25 at 9:40 A.M. and at 3:04 P.M., the surveyor observed Resident #138 in bed on a Medline Supra APL air mattress. Resident #138 did not respond to the surveyors questions. During both observations the air mattress pump was set to 180 weight (lbs). Review of Resident #138's 'Monthly Weight Report' indicated the following weights: - December 2024: 160.8 lbs. - January 2025: 149.8 lbs. - February 2025: 142 lbs. - March 2025: 141 lbs. Review of Resident #138's physician order, initiated 10/29/24, indicated: - Pressure air pad and pump, every shift, for Dry Skin and limited bed mobility, initated 10/29/24 and discontinued 3/4/25. - Low airloss mattress to bed set to comfort, initiated 3/4/25 without stop date. Review of Resident #138's plan of care related to actual alteration in skin integrity, initiated 11/7/24, indicated: - Therapeutic air mattress to be applied: Setting: set to resident's preference. Review of Resident #138's medical record indicated he/she had been transferred to the hospital on 3/4/25 for deteriorating coccyx wound with increased size, drainage, and foul smell. During a telephone interview on 3/6/25 at 9:07 A.M., Resident #138's health care proxy said Resident #138 often called out because he/she was uncomfortable in bed during the past few months. During an interview on 3/10/25 at 9:35 A.M., Unit Manager #2 said Resident #138's air mattress did not require specific settings because it can be changed based on his/her comfort. Unit Manager #2 said Resident #138 had difficulty communicating and could not communicate discomfort verbally. During an interview on 3/11/25 at 10:52 A.M., Unit Manager #2 said Resident #138 had a physician's order for an air mattress for pressure ulcer management. During an interview on 3/11/25 at 10:59 A.M., the Regional Nurse Consultant said she changed all the orders for any residents on air mattresses to be set related to resident comfort. The Regional Nurse Consultant said air mattresses should be set according to facility policy. The Regional Nurse Consultant there is no system in place to monitor the effectiveness or comfort of each resident on an air mattress, even if they are not able to communicate their needs, but they expect the nurses to be monitoring for signs of discomfort and adjusting the air mattress settings as necessary based on the nurses assessment of each resident's comfort. During an interview on 3/7/25 at 2:49 P.M., the Wound Nurse Practitioner (NP) said if air mattresses are used for wounds they require settings usually related to size and weight. If an air mattresses is set too firm or too soft it puts the resident at risk for skin breakdown or worsening wounds. The Wound NP said Resident #138 was on an air mattress to treat his/her pressure ulcers. 2.) Resident #30 was admitted to the facility in December 2020 with diagnoses including diabetes and pressure ulcers. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/22/25, indicated Resident #30 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS also indicated Resident #30 had a stage three pressure ulcer and a stage four pressure ulcer. 2a.) On 3/10/25 at 2:02 P.M., the surveyor observed Nurse #8 and Unit Manager #2 perform a wound dressing change for Resident #30's left buttock stage four pressure ulcer. Nurse #8 said we always change his/her left buttock dressing twice a day. Review of Resident #30's Wound Nurse Practitioner (NP) progress note, dated 3/4/25, indicated: - Stage four pressure ulcer left buttock. - Treatment recommendation for pressure ulcer left buttock: Wash with wound cleanser, pat dry. Skin prep peri skin, Santyl to slough. Pack entire wound with collagen. Cover with silicone foam dressing QD (every day)/PRN (as needed). Review of Resident #30's physician's order, initiated 3/4/25, indicated the following for his/her left buttock: - Wash with WC (wound cleanser), pat dry. skin prep PS (peri skin), santyl to slough, pack entire wound with collagen, then silicone foam dsg (dressing) QD/PRN, every day shift and every evening shift. Review of Resident #30's treatment administration record (TAR), dated 3/4/25 to 3/9/25, indicated the physician's order to Wash with WC (wound cleanser), pat dry. skin prep PS (peri skin), santyl to slough, pack entire wound with collagen, then silicone foam dsg (dressing) QD/PRN was documented as implemented twice daily. During an interview on 3/10/25 at 2:40 P.M., Unit Manager #2 said she reviewed the Wound NP's treatment recommendation and the physician's order for Resident #30's left buttock. Unit Manager #2 said it was transcribed incorrectly and accidentally scheduled to be completed twice a day, instead of once a day. During an interview on 3/11/25 at 9:15 A.M., the Director of Nursing (DON) said Resident #30's physician's order for his/her left buttock should have been transcribed at frequency recommended, and the left buttock treatment being completed twice day was incorrect. 2b.) Review of Manufacturer's guidelines for Selectis Serenity Air Mattress indicated: - The Selectis Serenity alternating low air loss mattress system helps provide prevention therapy and treatment of multiple stage wounds. - By tailoring the pressure based on the patient's weight and specific ailment, optimal comfort and support can be achieved. On 3/4/25 at 9:45 A.M., the surveyor observed Resident #30 in bed on a Selectis Serenity air mattress. The air mattress pump was set to 300 pounds (lbs.) weight. Resident #30 said his/her air mattress is uncomfortable. Resident #30 said it often feels deflated and that when she tells them it takes a long time to fix it. During observations on 3/4/25 at 3:10 P.M., 3/5/25 at 7:01 A.M., and 3/6/25 at 5:34 A.M., Resident #30 was in bed on a Selectis Serenity air mattress with the pump set to 300 pounds weight. Review of Resident #30's 'Monthly Weight Report' indicated the following weights: - December 2024: 190.5 lbs. - January 2025: 194.5 lbs. - February 2025: 195.5 lbs. Review of Resident #30's physician orders indicated: - Low air mattress to bed check every shift/function every shift. Settings are per weight (192.4), initiated 1/29/24 and discontinued 3/4/25. - Air mattress to bed check every shift/function set to resident comfort level, initiated 3/4/25 without stop date. Review of Resident #30's plan of care related to actual alteration in skin integrity, initiated 10/16/24, indicated: - Air mattress, set to patient comfort. During an interview on 3/10/25 at 9:35 A.M., Unit Manager #2 said residents on air mattresses did not require specific settings because it can be changed based on his/her comfort. During an interview on 3/11/25 at 10:52 A.M., Unit Manager #3 said Resident #30 had a physician's order for an air mattress for pressure ulcer management. During an interview on 3/11/25 at 10:59 A.M., the Regional Nurse Consultant said she changed all the orders for any residents on air mattresses to be set related to resident comfort. The Regional Nurse Consultant said air mattresses should be set according to facility policy. The Regional Nurse Consultant there is no system in place to monitor the effectiveness or comfort of each resident on an air mattress, but they expect the nurses to be monitoring for signs of discomfort and adjusting the air mattress settings as necessary based on the nurse's assessment of each resident's comfort. During an interview on 3/7/25 at 2:49 P.M., the Wound Nurse Practitioner (NP) said if air mattresses are used for wounds, they require settings usually related to size and weight. If an air mattress is set too firm or too soft, it puts the resident at risk for skin breakdown or worsening wounds. 50338 3.) Resident #167 was admitted to the facility in December 2024 with diagnoses including diabetes, prostate cancer, and chronic kidney disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/5/25, indicated that Resident #167 is cognitively intact as evidenced by a Brief Mental Status (BIMS) score of 13 out of 15. The MDS also indicated that he/she was at high risk for pressure ulcers and had two Stage 3 pressure ulcers. Review of Resident #167's Norton Plus Pressure Ulcer Scale, dated, 12/6/24, 12/16/24,12/30/24, 12/31/24, 1/12/25, 1/16/25, and 2/4/25 indicated that he/she was at high risk for pressure ulcers. Review of Resident #167's nursing progress note, dated 12/25/24, indicated Resident sustained a pressure ulcer to coccyx, Nurse Practitioner (NP) #3 notified, area covered pending wound care evaluation. Review of Resident #167's Treatment Administration Record (TAR), dated 12/7/24, indicated Apply triad and DPD to coccyx area daily. Review of Resident #167's Wound care progress note, dated 12/27/24, indicated pressure ulcer coccyx measuring 3 centimeters (cm) x 2.3 cm x 0.1 cm. Treatment Recommendations: wash, dry, apply Med honey to wound bed, cover with dry protective dressing (DPD) daily and as needed. Review of Resident #167's nursing progress note, dated 12/30/24, indicated Resident followed up by wound care consultant on 12/27/24, report on 12/30/24 as follows: evaluated for new area on coccyx, stage 2. Recommended treatment: Wash with wound cleanser, pat dry, apply med [NAME] to wound bed, cover with dry protective dressing (DPD) daily and as needed. NP #3 in agreement. Order in place. Review of Resident #167's plan of care, dated 12/30/24, indicated actual in skin integrity related to stage 3 to coccyx. Interventions include: -wash with wound cleanser, pat dry, skin prep peri skin, apply collagen wafer, then apply silicone border dressing daily and as needed. Review of Resident #167's TAR, dated 12/30/24, indicated Pressure Coccyx wound: wash with wound cleanser, pat dry, apply med honey to wound bed, cover with DPD daily and as needed. Further review of TAR, dated 12/30/24, failed to indicate that treatment was signed as completed on 12/30/24 or 12/31/24. Review of Resident #167's TAR, dated 12/31/24, indicated Pressure Coccyx wound: wash with wound cleanser, pat dry, apply med honey to wound bed, cover with DPD daily and as needed. Further review of TAR, dated 12/31/24, failed to indicate that treatment was signed as completed on 12/31/24 and 1/1/25. During an interview on 3/11/25 at 9:15 A.M., the Director of Nursing (DON) said he would expect wound care recommendations to be followed. 4.) Resident #143 was admitted to the facility in January 2025 with diagnoses including osteomyelitis (bone infection) of right tibia and fibula, diabetes, and peripheral vascular disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/7/25, indicated that Resident #143 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. The MDS indicated Resident #143 was at risk for pressure ulcer, required maximum assist for bed mobility, and had two deep tissue injuries (DTIs). On 3/04/25 at 8:35 A.M., the surveyor observed Resident # 143 sleeping in bed with air mattress set on fi[TRUNCATED]

Based on observation, record review and interview the facility failed to ensure that three Residents (#70, #629, and #130) out of a total sample of 42 residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically: 1. For Resident #70, the facility failed to a) initiate a treatment for a genital wound which subsequently became infected and deteriorated and b) failed to implement the wound Nurse Practitioner's (NP) recommendation for a change in wound treatment. 2. For Resident #629, the facility failed to obtain an antibiotic medication from the pharmacy in a timely manner, resulting in a worsening skin infection. 3. For Resident #130, the facility failed to complete weekly documentation of skin conditions. Findings Include: 1a.) Resident #70 was admitted to the facility in October 2022 with a diagnosis of diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/30/24, indicated that Resident #70 scored a 15 out of 15 on the Brief Interview for Mental Status exam, indicating the Resident was cognitively intact. Review of Resident #70's activities of daily living (ADL) care plan indicated the Resident was at risk for decreased ability to performs ADLs in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting related to weakness. Interventions in the care plan included: -Provide resident/patient with total assist of 1 for personal hygiene (grooming), initiated 10/18/22. Review of Resident #70's most recent [NAME] plus pressure ulcer scale, dated 12/30/24, indicated the Resident was at high risk for developing pressure injuries. Review of Resident #70's hospital discharge paperwork, dated 12/29/24 indicated Resident #70 was hospitalized from 12/26/24 to 12/29/24. Further review of the hospital paperwork indicated the Resident had a genital lesion, that the Resident had first noticed the lesion in his/her nursing facility after his/her most recent admission (13 days earlier) and that the Resident associated the lesion with a cut he/she experienced from his/her urinary catheter. Further review of the hospital paperwork indicated that the hospital assessed the genital wound on 12/28/24, described the wound as scabbed and were cleansing the wound with soap and water. Review of NP #2's progress note dated 12/31/24 indicated Resident #70 returned to the facility from the hospital on 12/29/24 and that the Resident's hospitalization was complicated by a genital lesion. Further review of NP #2's progress note indicated the Resident had a small genital lesion most likely related to pressure from a urinary catheter. Review of the physician note, dated 1/2/25, indicated Resident #70 had a history of foley trauma of his/her urethra with a cut which was slow healing. Review of a nursing progress note, dated 1/8/25, indicated that therapy reported blood dripping from Resident #70's genitals. Review of a nursing note, dated 1/13/25, indicated that the nurse had reported a small pressure area on Resident #70's genitals to the NP. Review of the incident report titled new pressure ulcer, dated 1/13/25, indicated Resident #70 had an area on his/her genitals which was previously seen by the NP and documented as pressure due to the Foley catheter; the wound was noted with slough. Review of NP #2's progress note, dated 1/14/25 indicated Resident #70 had a small ulcer on his/her genitals that was tender and draining purulent discharge. Further review of NP #2's progress note indicated that the lesion appeared bigger than previously observed with a recommendation to continue to clean the lesion daily with NS (normal saline). Review of a nursing progress note, dated 1/14/25, indicated that Resident #70 was started on an antibiotic by the NP for infection. Review of a nursing progress note, dated 1/15/25, indicated Resident #70 was started on an antibiotic due to a pressure area on his/her genitals. Review of NP #2's progress note, dated 1/21/25, indicated Resident #70's genital lesion improved after treatment with antibiotics but remains open with yellow slough with a plan to wash the wound daily with NS. Review of Resident #70's physician orders indicated the following order: Genitals: Cleanse wound area with NS pad dry twice daily, initiated 1/20/25. Genitals: Monitor for bleeding until the end of the month, if bleeding continue, will refer PT (patient) to urology. Notify NP/MD (medical doctor) for excessive bleeding, initiated 1/8/25 Further review of Resident #70's physician orders indicated that the order for cleansing the wound area with NS was initiated 20 days after the facility became aware of Resident #70's genital wound and an order to monitor for genital bleeding was initiated eight days after the facility became aware of Resident #70's genital wound. Review of Resident #70's Medication Administration Records and Treatment Administration Records (MAR/TAR) failed to indicate that the Residents genital wound was being cleansed with normal saline until 1/21/25, 21 days after the facility became aware of Resident #70's genital wound. Review of the wound NP's progress note, dated 1/21/25, indicated Resident #70 had a traumatic wound on his/her genitals measuring 3 x 2.5 x 0.6 cm (centimeters) with 60% soft tissue and 40% slough. Further review of the progress note indicated a recommendation for the following treatment: Wash with wound cleanser, pat dry, medihoney to slough, cover with collagen wafer and ABD (a gauze pad). Prompt peri care and frequent repositioning. Keep area dry. During an interview on 3/6/25 at 12:28 P.M., Nurse # 7 said when a resident had a wound, nursing would notify the provider who would either ask nursing what kind of treatment they think would be appropriate for the wound or would place a treatment order themselves. Nurse #7 said she would expect a treatment to be in place for all wounds. Nurse #7 said Resident #70 had a laceration on his/her genitals. During interviews on 3/6/25 at 3:51 P.M., and 3/7/25 at 8:40 A.M. and 11:48 A.M. NP #2 said all wounds should have treatments in place. NP #2 said that if a treatment was not implemented that it would put the resident at high risk for wound infection. NP #2 said Resident #70 had a wound on his/her genitals which developed from a urinary catheter. NP #2 said she had first noticed that the Resident had an open wound on his/her genitals when she assessed the Resident on 12/31/24 after his/her re-admission from the hospital. NP #2 said she would have expected an order for cleansing the wound with normal saline to have been initiated when the Resident was readmitted from the hospital on 12/29/24. NP #2 said that on 1/14/25 she was concerned the Resident's wound was infected because it was draining pus, white exudate, was red and macerated so she started the resident on antibiotics; NP #2 said that Resident #70's genital wound looked worse on 1/14/25 than it did on 12/31/24. NP #2 said she assessed the Resident again on 1/21/25 and the wound had no pus but was still open and had slough. During an interview on 3/7/25 at 2:17 P.M. the wound NP said she would have expected that someone started a treatment plan before she was consulted to assess Resident #70's genital wound on 1/21/25 as the wound could deteriorate without a treatment and/or become infected. The wound NP said that on 12/31/24 she had noticed that Resident #70 had a small open wound on his/her genitals while she was assessing a different wound in proximity of the genital wound and that the other wound had since resolved. The wound NP said she wasn't consulted to assess the Resident's genital wound until 1/21/25, but would have expected a treatment to cleanse the wound with NS to have been initiated on 12/31/24 and that she had failed to documented her observation of the newer genital wound in her 12/31/24 assessment in error. During an interview on 3/6/25 at 5:06 P.M. Unit Manager #4 said she would have expected a treatment order to be in place for Resident #70's genital wound when he/she first returned from the hospital in December 2024. 1b.) Review of the wound NP's progress note, dated 2/25/25, indicated Resident #70's traumatic genital wound had increased in measurement and that the Resident reported the wound was tender to the touch. Further review of the progress note indicated the genital wound measured 6 x 3.5 x 0.6 cm. with 100% soft tissue with the following recommended treatment: Wash with wound cleanser, pat dry, collagen powder to wound and leave OTA (open to air). Keep wound clean and dry Qday (every day)/PRN (and as needed). During an interview on 3/6/25 at 12:28 P.M., Nurse # 7 said the wound NP saw Resident #7 and that they received the wound NP's report on 2/26/25. Nurse #7 said she was not sure if there were new recommendations but if there were she would expect them to be implemented right away. Review of Resident #70's physician orders indicated the wound NP's recommended treatment was not implemented until 3/6/25, 8 days after the facility received the recommendation and after the surveyor brought the concern to the attention of the facility. During an interview on 3/6/25 at 3:51 P.M. NP #2 said the wound NP comes in on a weekly basis and that she would expect wound NP recommendations to be implemented within 24 hours of the facility receiving them. NP #2 said she was not aware of any new recommendations to change Resident #70's genital wound treatment. During an interview on 3/7/25 at 2:17 P.M. the wound NP said she comes in once a week and that her notes with recommendations were emailed to the facility by the next day; the wound NP said she would expect her recommendations to be implemented as soon as the facility received them. The wound NP said that Resident #70's gauze pad was getting moist, gross and wadded so she recommended to change the treatment to leave the wound open to air to reduce moisture accumulation on 2/25/25. The wound NP said she was unaware that her most recent recommendation was not implemented until 3/6/25. During an interview on 3/6/25 at 5:06 P.M. Unit Manager # 4 said the wound NP's recommendation was implemented today and that if a wound retains too much moisture that it could make the wound worse; UM #4 said the recommendation should have been implemented earlier. During an interview on 3/6/25 at 7:30 P.M., the Director of Nursing (DON) said he would expect an order for a wound treatment and that he would expect wound NP recommendations to be implemented. 41019 2.) For Resident #629, the facility failed to obtain an antibiotic medication from the pharmacy in a timely manner, resulting in a worsening skin infection. Resident #629 was admitted in July 2024 with diagnoses including type 2 diabetes and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment, dated 7/31/24, indicated Resident #629 scored a 13 out of a possible 15 on the Brief Interview for Mental Status exam, indicating intact cognition. During an interview on 3/7/25 at 8:40 A.M., Nurse Practitioner #1 said that she had concerns regarding communication between the facility and the providers. Nurse Practitioner #1 said that she ordered an antibiotic for Resident #629 due to an infection. She said that she was not notified timely by the facility that the order flagged an allergy alert that required her to address, and that therefore the antibiotic was not sent. Nurse Practitioner #1 said that following this incident she filed a safety report with the facility because the infection worsened and the Resident had increased pain because of the delay. Review of the nurse progress note, dated 8/17/24, indicated the following: Spoke to on call NP regarding changes to skin tear to R shin. Noted skin around tear is red, warm to the touch, and mildly painful to the patient. Redness continues throughout the front of the patient's shin. Bilateral swelling, which is baseline for patient noted to both legs. R leg noted to be significantly warmer to the left . New orders for Keflex 500 mg TID x 5 days. Override to penicillin allergy. Order to follow up with MD/NP on Monday 8/19/24. Review of the progress note, dated 8/18/24, indicated Keflex Oral Capsule 500 mg - Pharmacy notified. Unable to pull from Medwhiz. (the facility's contracted pharmacy). Review of the progress note, dated 8/19/24, indicated Keflex Oral Capsule 500 mg- Awaiting clarification for pharmacy to send. The record failed to indicate the Physician or Nurse Practitioner were notified that the facility was unable to obtain the medication on 8/17/24, 8/18/24 or 8/19/24. Review of the Medication Administration Record (MAR) for August 2024 indicated that on 8/18/24 and 8/19/24, Resident #629 did not receive the Keflex of 500 mg. During an interview on 3/10/25 at 11:37 P.M., the Director of Nursing said if there is a delay with a pharmacy then the nurses should notify the provider and then the provider would determine the course of action. The Director of Nursing said that they should also let him know if they are missing a medication because he keeps backup medications in the emergency kit. The Director of Nursing said that all of the actions should be documented in the progress notes, but were not. 41456 3.) Resident #130 was admitted to the facility in December 2020 with diagnoses including Alzheimer's Disease. Review of Resident #130's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) and staff had assessed him/her to have severe cognitive impairment. The MDS also indicated Resident #130 was dependent on staff for all care. On 3/04/25 at 9:02 A.M., Resident #130 was observed lying in bed with the sheets lifted to expose both legs. The Resident was observed to have black scabs on bilateral knees. Review of Resident #130's physician orders indicated the following orders: - Right buttocks area, cleanse with NS (normal saline). Pat dry and apply xeroform dressing. Cover with DPD dressing every day and pm (night), initiated on 2/7/25. - Check skin daily and report if skin irritation is notes, in the evening for skin breakdown, initiated 1/10/25. Review of Resident #130's nursing notes from 2/7/25 to present failed to indicate skin impairment on the right buttocks requiring the above stated order. Review of Resident #130's Treatment Administration Record (TAR) failed to indicate the nursing documented any skin irritation or abnormalities per the order. Review of Resident #130's weekly skin assessments, dated 2/17/25, 2/20/25, 2/22/25 and 3/1/25, failed to indicate the right buttock area or the bilateral knee scabs were observed and documented. During an interview on 3/6/25 at 7:39 A.M., Unit Manager #1 said all skin impairments should be included on the weekly skin assessments. Unit Manager #1 said she was unsure if Resident #130 had a skin impairment on his/her buttocks, however said if there was an impairment this should be included on the skin assessment. Unit Manager #1 then entered the Resident's room and observed the two black scabs on the Resident's bilateral knees and also observed a reddened small opened area on the Resident's buttock. Nurse #1 then entered Resident #130's room, observed the two scabs and buttocks and said these areas have been present for a couple of weeks. Both Nurse #1 and Unit Manager #1 said all three of these skin impairments should have been documented on the past skin assessments. During an interview on 3/6/25 at 9:31 A.M., the Director of Nursing said all skin impairments should be documented on the weekly skin assessment, with descriptions of the impairment included.

2.) Resident #109 was admitted in 5/2021 with diagnoses including dementia and major depressive disorder. Review of the Minimum Data Set (MDS) assessment, dated 1/30/25, indicated Resident #109 could not participate in the Brief Interview for Mental Status exam due to severe cognitive impairment. Review of the facility policy titled Psychotropic Medication, dated 4/2022, indicates the following - The consultant pharmacist reviews the appropriateness of the psychoactive medication order as part of each drug regimen review and monitors for; - Appropriateness of psychoactive administration based on diagnosis, clinical indications and prescribing guidelines and; - Reassessment for trial reduction in dose in accordance with state/federal regulations. On 3/4/25 at 9:55 A.M., Resident #109 was observed lying in bed. The Resident was not interviewable and at the time of observation, his/her mouth was moving with repetitive involuntary movement, similar to tardive dyskinesia. Review of the psychiatric follow up note, dated 1/14/25, indicated the following recommendations: - GDR (gradual dose reduction) recommended for Seroquel (an antipsychotic medication used to treat Schizophrenia), lower to 25 mg (milligrams) in AM (morning) and 50 mg in the evening. Review of the clinical record failed to indicate that the recommendation was reviewed by the Physician or Nurse Practitioner or that it was implemented. Review of the psychiatric follow up note, dated 2/4/25, indicated the following: - Resident #109 was seen on 1/14 and a GDR for Seroquel was recommended at that time but was not completed. There is no accompanying documentation in his/her chart as to why this was not completed. Review of the active physician orders indicated Resident #109's Seroquel order was changed on 2/4/25 to 25 mg in the morning and 50 mg in the evening, 18 days after the initial recommendation. Review of the psychiatric follow up note, dated 2/25/25, indicated the following recommendations: - Depression and agitation with positive response from current medications and no adverse effects from current Seroquel GDR. I would like to continue this dose reduction today and would recommend a lowering of his/her Seroquel to 25 mg 2x daily at this time. Review of the physician's orders failed to indicate that the recommendation from 2/25/25 had been implemented or reviewed. During an interview on 3/10/25 at 10:07 A.M., Unit Manager #1 said that the psychiatric nurse speaks with the charge nurse or nurse on duty when making recommendations. Unit Manager #1 said that the psychiatric nurse also sends an email that all the nurses have access to. The nurse who receives the recommendation will then notify the physician. During an interview on 3/10/25 at 11:42 A.M., the Director of Nursing said that the nurses receive the recommendations from the psychiatric nurse but also need to read the psychiatric nurse progress notes. Once the nurse reads the recommendation, they are to notify the physician and healthcare proxy. The Director of Nursing said that psychiatric nurse recommendations is a process that the facility is working on and is a work in progress. Based on observations, interviews and record review, the facility failed to ensure two Residents (#138 and #109) were free from the administration of unnecessary psychotropic medications (medications that affect brain activity associated with mental processes and behavior) out of a total sample of 42 residents. Specifically, 1.) For Resident #138, upon readmission to the facility, a new physician's order for ramelteon (a hypnotic medication) was implemented without informing the Resident or his/her representative of it's use or risks/benefits. Nurse Practitioner #2 recommended to evaluate the discontinuation of this medication, but it was never done, and as a result, Resident #138 experienced a significant decline in functional and cognitive status that included increased somnolence, decline in ability to self-feed, decline in ability to reposition himself/herself in bed, and the development of pressure injuries. 2.) For Resident #109, the facility failed to implement a gradual dose reduction in a timely manner as recommended by the psychiatric nurse practitioner. Findings include: 1.) Review of the facility policy titled 'Psychotropic Medications', revised April 2022, indicated, but was not limited to: - Policy: To administer and monitor effects of psychoactive medications when prescribed. Monitoring for drug side effects leads to early identification and reporting in accordance with state/federal regulations. - An informed consent from the resident (or legally authorized individual in the case of resident incompetence) is required for administration of psychoactive medication. - Reassessment for trial reduction in dose in accordance with state/federal regulations. Review of the facility policy titled 'Behavioral Management', revised April 2022, indicated, but was not limited to: - The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes. - The resident and/or representatives will be informed of the resident's condition as well as the potential risks and benefits or proposed interventions. - Psychiatric recommendations will be reviewed by the IDT (interdisciplinary team) and will implement as indicated. - When medications are prescribed for behavioral symptoms, documentation will include: potential risks and benefits of medications as discussed with the resident and/or representative, monitoring for efficacy and adverse consequences. - Monitoring: If the resident is being treated for altered behavior or mood, the IDT will observe for changes in the individual's behavior, mood, and function. Resident #138 was admitted to the facility in June 2024 with diagnoses including functional urinary incontinence and dementia. During a telephone interview on 3/6/25 at 9:07 A.M., Resident #138's health care proxy said she was never made aware and never consented to Resident #138 receiving ramelteon. Resident #138's health care proxy said she was very angry because she had told the facility many times that she believed Resident #138 was overmedicated and receiving medications that affected him/her mentally, but the facility denied it. Resident #138's health care proxy said she had asked for a medication list many times, but it was never provided to her. Resident #138's health care proxy said she would have never consented to ramelteon, or any other hypnotic medication. Resident #138's health care proxy said before Resident #138 went to the hospital on [DATE] he/she was able to communicate in full sentences, was able to feed himself/herself, was able to get out of bed, and did not have pressure ulcers. Resident #138's health care proxy said since he/she returned from the hospital on [DATE] he/she has significantly declined. Resident #138's health care proxy said he/she no longer talks, except yes/no questions, and is often difficult to arouse. Resident #138's health care proxy said sometimes she has to shake him/her to wake them up and even then they fall back asleep right away. Resident #138's health care proxy said sometimes she must watch his/her chest to check to see if he/she is breathing because she thinks he/she's dead. Resident #138's health care proxy said he/she has also lost the ability to feed himself/herself or even able to sit up in his/her chair and is now bedbound with multiple pressure ulcers. Review of Resident #138's medical record indicated he/she was discharged to the hospital on [DATE] and did not receive Ramelteon, or any other hypnotic medication, prior to this hospital discharge. Further review of Resident #138 medical record indicated he/she was readmitted to the facility on [DATE]. Review of quarterly Minimum Data Set (MDS) assessment prior to discharge to hospital, dated 9/11/24, indicated Resident #138 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. This MDS indicated Resident #138: - Was understood by staff and usually able to understand staff communication. - Had no pressure ulcers. - Was able to roll in bed with supervision or touching assistance - Was able to feed himself/herself after set-up. This MDS indicated Resident #138 was not receiving hypnotic medication. Review of discharge Minimum Data Set (MDS) assessment, dated 10/24/24, did not include any cognitive assessments and indicated Resident #138: - Had no pressure ulcers - Was able to roll in bed with partial/moderate assistance - Was able to feed himself/herself after set-up. This MDS indicated Resident #138 was not receiving hypnotic medication. Review of Resident #138's hospital Discharge summary, dated [DATE], indicated: - Indication for admission: diarrhea and altered mental status found to have Clostridium difficile (a bacterium that causes diarrhea and inflammation of the colon). - Delirium: Patient has trouble sleeping with intermittent yelling/vocalizations throughout the night during admission. Psych was consulted due to concern for delirium. - Discharge medication list includes: Start taking these medications: Ramelteon 8 milligram (mg) tablet by mouth nightly. Review of Resident #138's physician orders upon readmission to the facility from the hospital, dated 10/24/24, indicated a new physician order for Ramelteon 8 mg once daily for anxiety. Review of Resident #138's medical record failed to indicate the Resident or the Resident's representative was informed of the risks/benefits or gave consent to administer Ramelteon 8 mg. Review of Manufacturer's guidelines for ramelteon indicated: - Ramelteon is a hypnotic (sleep) medicine. - Common side effects include drowsiness and tiredness. - Most common adverse reactions (>3% and more common than with placebo) are: somnolence, dizziness, fatigue, nausea, and exacerbated insomnia. Review of Resident #138's progress note from Nurse Practitioner #1, dated 10/28/24, indicated: - Consider stopping ramelteon next week once settled in if no new issues - this was started because of delirium in the hospital. Review of Resident #138's nursing progress note, dated 10/30/24, indicated: - Significant change identified by IDT today due to decline in ADL (activities of daily living) and mobility function, decline in cognition and increase assistance with decision making. Review of Significant Change in Status Minimum Data Set (MDS) assessment, dated 11/6/24, indicated Resident #138 had severe cognitive impairment based on a Staff Assessment for Mental Status. This MDS indicated Resident #138: - Was rarely/never understood. - Had one new stage three pressure ulcer - Required substantial/maximal assist to roll in bed - Was dependent on staff to feed him/her. This MDS indicated Resident #138 was receiving hypnotic medication. Review of Resident #138's medical record indicated he/she was discharged to the hospital on [DATE]. Further review of medical record indicated Resident #138 had received ramelteon daily as ordered from 10/24/24 until this discharge on [DATE]. Review of Resident #138's hospital Discharge summary, dated [DATE], indicated: - Sent to hospital for hypoxia, more somnolence, and decreased level of alertness and poor po (by mouth) intake. - According to the prior record even though patient has history of dementia his/her baseline mental status is usually very talkative person, very social. Last known well 10/1/24. - Somnolent. Hypoactive since prior hospital discharge (on 10/24/24). Review of Resident #138's medical record indicated he/she was readmitted to the facility on [DATE] and that the ramelteon 8 mg was continued without a re-evaluation by the provider to consider stopping the hypnotic medication. Review of Resident #138's progress note written by Unit Manager #2, dated 11/13/24, indicated: - HCP (health care proxy) came to visit resident, states he/she is sleepy and not arousable. Verbalizes the nurse is overmedicating Resident. This writer reviewed meds (medications) given this morning with HCP, which included Tramadol PRN (as needed) due to pain r/t (related to) wound tx (treatment). During a follow-up interview on 3/6/25 at 9:35 A.M., Unit Manager #2 said she was hired at the facility after Resident #138's October hospitalization and she never knew his/her cognitive/functional status prior to that hospitalization. Unit Manager #2 said since that hospitalization he/she had episodes of somnolence and spoke in yes/no questions only, but she believed that was his/her baseline. Review of Resident #138's nursing progress note, dated 12/2/24, indicated: -(Health care proxy) stating she does not want Resident overmedicated. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/29/25, indicated Resident #138 had severe cognitive impairment based on a Staff Assessment for Mental Status. This MDS also indicated Resident #138: - Had one stage three pressure ulcer. - Required substantial/maximal assistance to roll in bed. - Was dependent of staff on staff to feed him/her. This MDS indicated Resident #138 was receiving hypnotic medication. Review of Resident #138's medical record, dated 10/24/24 to 3/4/25, failed to indicate any re-evaluation to consider stopping ramelteon. During this timeframe Resident #138 was not seen by psychiatric services. Further review indicated Resident #138 received ramelteon daily during this time frame. During an interview on 3/6/25 at 9:31 A.M., Nurse Supervisor #1 said side effects for ramelteon include somnolence, fatigue, drowsiness, and behavior disorders. Nurse Supervisor #1 said was hired at the facility after Resident #138's October hospitalization and she never knew his/her cognitive/functional status prior to that hospitalization and believed this was his/her baseline. Nurse Supervisor #1 said if a family member or health care proxy reported increased somnolence or any mental status change from his/her baseline, she would expect the physician to be notified and a medication review to be completed. During an interview on 3/6/25 at 10:26 A.M., the Social Worker said he had known Resident #138 since he/she was admitted in June 2024. The Social Worker said before his/her October 2024 hospitalization he/she had cognitive deficits but was able to communicate and was more alert. The Social Worker said since his/her hospitalization in October 2024 they completed a significant change in status assessment because he/she had a decline functionally and cognitively. The Social Worker said following the October 2024 hospitalization Resident #138's alertness decreased, and his communication deficit was too poor to complete the Brief Interview for Mental Status (BIMS) assessment anymore, when he/she previously could. During an interview on 3/6/25 at 11:02 A.M., the Director of Nursing (DON) said a consent, including education of risks/benefits of the medication, must be obtained and a consent form signed before administration of psychotropic medication. During a telephone interview on 3/7/25 at 6:29 A.M., Certified Nurse's Assistant (CNA) #7 said she had known Resident #138 since he/she was admitted in June 2024. CNA #7 said before his/her October 2024 hospitalization he/she was able to communicate in full sentences and was more alert. CNA #7 said when he/she returned from the hospital at the end of October 2024 he/she was less alert and required more assistance functionally. CNA #7 said he/she lost the ability to self-feed and became dependent on staff for assistance to eat. CNA #7 said he/she could no longer communicate in full sentences and could only respond to yes/no questions. During an interview on 3/7/25 at 8:40 A.M., Nurse Practitioner #1 said Resident #138 had a cognitive and functional decline after his/her hospitalization in October 2024. Nurse Practitioner #1 said she was not aware Resident #138 was receiving ramelteon. Nurse Practitioner #1 said somnolence or decreased alertness is a common side effect of ramelteon. Nurse Practitioner #1 said if a provider documented consider stopping ramelteon next week once settled in if no new issues - this was started because of delirium in the hospital one of the providers should have re-evaluated the ramelteon the next week and documented it. During an interview on 3/10/25 at 10:12 P.M., the DON said if a provider documented consider stopping ramelteon next week once settled in if no new issues - this was started because of delirium in the hospital the facility would expect the provider to follow up with a re-evaluation of the medication and document it the next week. The DON declined to answer questions regarding the monitoring and reporting of adverse effects of ramelteon and said the facility should be following their policy regarding psychotropic medications. Review of Resident #138's hospitalist progress note, dated 3/9/25, indicated: - Resident #138 is no longer receiving ramelteon. During a follow-up telephone interview on 3/10/25 at 8:56 A.M., Resident #138's health care proxy said the Resident is no longer receiving ramelteon and is more alert during meals and his/her intake is improving.

Based on observation, record review, and interviews, the facility failed to maintain and implement an effective pest control program on six out of six resident units in the facility which included residents reporting mice sightings daily and mice droppings in resident's rooms and resident areas. Findings include: Review of the facility policy title Pest Control, dated 1/2025, indicates the following: - Facility Management * Conduct regular inspections for potential pest entry points and address any issues promptly. * Coordinate with a licensed pest control provider to implement an IPM program. * Maintain records of pest control activities and treatment applications. - Prevention * Seal cracks and crevices around doors, windows, and utilities * Maintain proper sanitation practices, including regular cleaning of spills and debris. * Store food in airtight containers. * Regular inspect incoming deliveries for pests. - Monitoring * Establish pest monitoring stations in key areas. Throughout the survey and during the resident council meeting, multiple residents complained of pests; specifically mice, were running throughout the facility, particularly at night. Review of resident council minutes, dated 11/22/24, indicated the following: - Agenda item three: Maintenance, housekeeping, and exterminator vendor continue to work together to control mouse sightings. (Company name) started after meeting to increase Exterminator Vendor to weekly. Council members continue to report seeing mice in room. Educated residents to inform staff so that it can be documented in the Pest control book at the front desk, 11/22/24. Review of the pest control logs indicated that the pest control company provided services on 12/3/24, 12/20/24, 1/3/25, 2/7/25, 2/21/25, and on 3/7/25. There was no indication that the pest control company had visited weekly in the facility. During an observation on 3/6/25 at 3:04 A.M., a surveyor observed a mouse running in the hallway on the C Unit into a resident's room. During an observation on 3/6/25 at 3:07 A.M., the surveyors observed four mice on the A Unit. One mouse was behind the linen cart, one ran out from under the refrigerator, one ran down a wheelchair, and another ran out from under the kitchenette. 43807 Observations and interviews were conducted on all resident units as follows: A Unit: A 101-During an interview on 3/10/25 at 7:47 A.M., the Resident in bed A reported seeing mice daily from the heater during the night.(The Resident's Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status Score (BIMS) of 15/15 indicating intact cognition). A 103-During an interview on 3/10/25 at 7:57 A.M., the Resident in bed B reported seeing mice daily during the night coming from the heater.(The Resident's Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status Score (BIMS) of 14/15 indicating intact cognition). A 109-On 3/10/25 at 8:09 A.M., the surveyor observed mice droppings in the closet, next to the dresser and air conditioner. A 111- During an interview on 3/10/25 at 8:10 A.M., the Resident in bed B reported seeing mice coming from under the heater, at least 2-4 mice daily. (The Resident's Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status Score (BIMS) of 15/15 indicating intact cognition.) A 112-During an interview on 3/10/25 at 8:12 A.M., both Residents reported seeing mice every night. (The Residents' Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status Score (BIMS) of 13/15 and 15/15 respectively indicating intact cognition). A 113-On 3/10/25 at 8:18 A.M., the surveyor observed mice droppings next to the wheelchair storage area. The Resident in bed A said he/she sees mice daily during the night. (The Resident's Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status Score (BIMS) of 15/15 indicating intact cognition). A 114- On 3/10/25 at 8:19 A.M., the surveyor observed mice droppings in the bathroom. A 116-During an interview on 3/10/25 at 8:25 A.M., the Resident in bed A said he/she has seen mice in the room during the day and night. (The Resident's Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status Score (BIMS) of 13/15 indicating intact cognition). On 3/10/25 at 8:43 A. M, the surveyor observed mice droppings next to the bookshelf in the dining room on unit A. A 120-On 3/10/25 at 8:45 A.M., the surveyor observed mice droppings in the storage room next to the bathroom. A 121-During an interview on 3/10/25 at 8:48 A.M., the Resident in bed B reported seeing mice at night coming from the radiator.(The Resident's Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status Score (BIMS) of 15/15 indicating intact cognition). A 122-During an interview on 3/10/25 at 8:50 A.M., the Resident in B bed reported seeing mice at night. He/she said the mice traps in the room are not working. (The Resident's Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status Score (BIMS) of 15/15 indicating intact cognition). A 124- During an interview on 3/10/25 at 8:55 A.M., the Resident in B bed reported seeing mice coming from the radiator daily. He/she said he/she put a towel under the radiator and the mice are coming into the room less. (The Resident's Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status Score (BIMS) of 15/15 indicating intact cognition). B Unit: B 101-During an interview on 3/10/25 at 9:12 A.M., the Resident in bed B and the Resident's family member said they do see mice in the room daily. They both said the mice traps in the room are not working. (The Resident's Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status Score (BIMS) of 15/15 indicating intact cognition). C Unit: C 101-During an interview on 3/10/25 at 9:52 A.M., the Resident in bed A reported seeing mice in the room daily. (Resident's Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status Score (BIMS) of 15/15 indicating intact cognition). C 102- During an interview on 3/10/25 at 9:54 A.M., the Resident in B bed said mice are present in the room daily and are coming from the radiator. (The Resident's Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status Score (BIMS) of 14/15 indicating intact cognition). C 103-During an interview on 3/10/25 at 9:55 A.M., the Resident in bed B said mice are present in the room daily and they come from the radiator. Mice droppings observed next to the radiator. (The Resident's Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status Score (BIMS) of 14/15 indicating intact cognition). C 104-On 3/10/25 at 9:58 A.M., the surveyor observed mice droppings at the entrance to the room. C 109-During an interview on 3/10/25 at 10:04 A.M., the Resident in bed B reported seeing mice daily coming from the radiator. (The Resident's Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status Score (BIMS) of 11/15 indicating moderate impaired cognition). C 110-During an interview on 3/10/25 at 10:05 A.M., the Resident in bed A reported seeing mice coming into the room from the hallway daily. (The Resident's Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status Score (BIMS) of 14/15 indicating intact cognition). C 118-During an interview on 3/10/25 at 10:17 A.M., the Resident in bed A reports seeing mice in the room yesterday. (The Resident's Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status Score (BIMS) of 11/15 indicating moderate impaired cognition). C 121-During an interview on 3/10/25 at 10:21 A.M., the Resident in bed B reported mice are coming into the room from the radiator daily. (The Resident's Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status Score (BIMS) of 15/15 indicating intact cognition). C 122-On 3/10/25 at 10:22 A.M., the surveyor observed mice droppings under the bathroom sink. C 124-On 3/10/25 at 10:24 A.M., the surveyor observed mice droppings at the bathroom entrance. D Unit: D 108-During an interview on 3/10/25 at 11:08 A.M., both Residents in the room reported seeing mice coming into the room from the radiator daily. (The Residents' Minimum Data Set (MDS) dated [DATE] and 12/30/24 respectively indicated a Brief Interview for Mental Status Score (BIMS) of 13/15 and 15/15 indicating intact cognition). D 114-During an interview on 3/10/25 at 11:17 A.M., the Resident reported there was a mouse in the room today. He/she said staff removed it. (The Resident's Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status Score (BIMS) of 15/15 indicating intact cognition). E Unit: E 108- On 3/10/25 at 11:48 A.M., the surveyor observed a mouse running around in the room. F Unit: F 102- During an interview on 3/10/25 at 11:58 A.M., the Resident in bed A reported seeing mice in the room daily. (The Resident's Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status Score (BIMS) of 14/15 indicating intact cognition). During an interview on 3/11/25 at 7:33 A.M., Certified Nurse's Assistant (CNA) #1 said she continues to see mice and mice droppings in resident's rooms and on the unit. She said the residents have a lot of food in the room that is not stored properly and is left out. During an interview on 3/4/25 at 2:00 P.M., the Ombudsman said that the mice issue has been ongoing and asked the Administrator about implementing sealed plastic containers as storage for resident's food items and snacks. The Ombudsman said she opened a case regarding the mice on October 18th, 2024. During an interview on 3/11/25 at 7:36 A.M., Unit Manager #2 said she continues to see mice and mice droppings on the unit. She said she has tried to help residents store food in sealed containers but some of the residents have refused to use the sealed containers to store food. Unit Manager #2 said she has seen holes in walls in the residents' bathrooms. She said mice can hide and nest in those holes. Unit Manager #2 said there is a pest control book at the front desk. All staff are expected to report any mice sightings so pest control can address the concerns when they come to the building. During an interview on 3/11/25 at 7:20 A.M., the Housekeeping Manager said she expects the housekeeping staff to clean all residents' rooms daily. She said she expects them to wipe all items in the room, sanitize everything, sweep, mop, and take out the trash. The Housekeeping Manager said she expects the housekeepers to move items in the room and clean behind them, clean in room corners and in storage rooms. She said she is aware of the mice problem in the facility and her staff should always be available to clean mice droppings. The House Keeping Manager said keeping all the residents' rooms clean ensures a homelike environment for the residents. During an interview on 3/5/25 at 12:56 P.M., the Maintenance Director said that the facility uses an outside pest control company that he believes comes out once every 10 days. The Maintenance Director said that the mice problem has gotten really bad in the last 3-4 months and a lot of it is self-inflicted because a lot of residents are hoarders with food. The Maintenance Director said that the facility was going to provide plastic containers, but they haven't been given out yet. During an interview on 3/11/25 at 9:24 A.M., the Administrator said the pest control company is coming into the facility weekly due to the mice problem. He said families and residents have been educated to report any mice sightings to the front desk so the pest control company can address the concerns when they visit the facility. He said when holes are identified in walls, the Maintenance Director is notified to plug in the holes in walls with steel wool prior to the pest control company arriving at the facility. He said he expects the pest control company to address and treat the holes in the walls. The Administrator said he then expects the Maintenance Director to patch the holes afterwards. The Administrator said most of the residents on the units do not store their food in sealed containers. He said managers on the units emphasize proper food storage with residents. He said he expects all the residents to store food in sealed Tupperware provided by the facility. He said Tupperware has not been handed out to all residents in the facility because a bulk Tupperware order has not been made yet.

Based on observations and interviews, the facility failed to maintain a homelike environment on: 1) Six out of six resident units (A, B, C, D, E, F, and G) in the facility which included stained ceiling tiles, chipped and loose floor tiles, broken blinds, holes in walls, gouged walls, peeling baseboards, missing baseboards, peeling wallpaper, dark and brown substance on ceiling tiles, streaks of dried soap on the wall, loose fitting ceiling tiles, flickering lights, and missing closet doors. 2) Specifically in Resident #80's room a significant portion of the heater was covered in tape. Findings include: A review of the facility policy titled 'Accommodation of needs and preferences and homelike environment policy', with no revision date, indicated the following: - The facility will provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. - The objective of the accommodation of resident needs and preferences is to create an individualized, home-like environment to maintain and/or achieve independent functioning, dignity, and wellbeing to the extent possible in accordance with the resident's own needs and preference. - Definitions: Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas lobby, outdoor patios, therapy areas and activity areas. - A homelike environment is one that de-emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a homelike environment. A determination of homelike should include the resident's opinion of the living environment. - Orderly is defined as an uncluttered physical environment that is neat and well kept. Procedure: - The resident's environment will be maintained in a homelike manner to ensure, appropriate housekeeping and private closet space for each resident. 1.) On 3/10/25 at 7:47 A.M., to 9:06 A.M., the surveyor observed the following in A Unit and the Dining area: A 101- Stained ceiling tiles. A 102-Stained ceiling tiles, unfinished wall painting. A 103- The Resident told the surveyor his/her toilet was clogged and not flushing. The Resident tried to flush the toilet with the surveyor in the room. The toilet was clogged. A 104-The bathroom sink drainpipe was wrapped in a towel. The towel was wet. A 106- Hole in the wall under the bathroom sink next to the drainpipe. Hole in the wall in the corner of the bathroom, next to the toilet. A 108- Hole in the wall under the bathroom sink next to the drainpipe. A 109- Hole in the wall under the bathroom sink next to the drainpipe. A 114- Stained ceiling tiles next to the bathroom door. A 115- Stained ceiling tile in the closet, gouged wall in the closet, peeling baseboards. Hole in the bottom wall next to the toilet, the toilet appeared not securely fit to the floor. Stained ceiling tile in the bathroom. Dining area- Space underneath the diet kitchen sink cabinet which appeared dirty. Peeled wallpaper behind the ice machine. A 117- Stained ceiling tile in the bathroom. A 118- Stained ceiling tiles above the television and clock. A 119- Stained ceiling tile above the closet, next to the room entrance. Stained ceiling tiles above the tub in the bathroom. A 121- A dark and brown substance next to the ceiling tiles in the bathroom. The wall below the area appeared wet. A 124- Stained ceiling tile at the entrance to the room. Hole in the wall next to the sprinkler in the ceiling. A 125- Broken window blinds. A 126- Stained ceiling tiles above the bathroom sink and above the door. A 127- Streaks of dried soap on the wall under the soap dispenser in the bathroom. A 128- Loose closet door handle and a gouge under the bathroom sink. A 130- Chipped floor tile on the bathroom floor and hole in the bottom wall in the left corner next to the toilet. A 131- Hole in the bottom left wall in the bathroom corner next to the toilet. Peeling and cracked baseboard next to the toilet, chipped ceiling tile in the bathroom. Stained, wet, peeling ceiling tiles at the room entrance. On 3/1025 at 9:12 A.M., to 9:47 A.M., the surveyor observed the following on the B Unit: B 101- Break in baseboard behind the toilet. B 102- Steel wool stuck in a hole under the bathroom sink drainpipe. Stained ceiling tiles above the bed light, next to the privacy curtains in the middle of the room. B 104- Peeling baseboard next to the dresser at the room entrance. Peeling baseboard behind the toilet. B 105- Chipped and cracked floor tiles next to the toilet. Space between ceiling tiles above the toilet. B 106- Space between ceiling tiles above the entrance to the room. B 107- Chipped floor tile next to the toilet. Hole in the bottom wall in the corner of the bathroom next to the bathroom sink. B 109- Cracked floor tile around the toilet. B 110- Loose fitting ceiling tile above the toilet in the bathroom. B 111- Stained ceiling tiles above the entrance to the room. B 113- Hole in the ceiling in the bathroom and storage room next to the bathroom. B 114- Stained ceiling tile in the closet. B 115- Peeling baseboard in the bathroom. B 116- Chipped floor tiles under the bathroom sink next to the trash can. B 117- Stained and cracked ceiling tile above the toilet. B 118- Baseboard off the wall on the floor under the bathroom sink. B 119- Hole in the wall under the heater stuffed with steel wool. On 3/10/25 at 9:52 A.M., to 10:24 A.M., the surveyor observed the following in the C Unit: C 101- Flickering lights in the bathroom. C 102- Closet without a closet door. C 104- Hole in the bottom wall behind the toilet, hole in the wall from the bathroom sink drainpipe. C 105- Chipped floor tile in front of bed B. Chipped floor tile next to the toilet. C 106- Peeled paint above bed A and next to the closet next to bed A. C 108- Missing closet door. C 110- Chipped floor tile in the bathroom and hole in the wall from the bathroom sink drainpipe. C 111- Broken and missing floor tiles in the shower area. C 112- Bumpy cracked floor tiles in front of the dresser. C 114- Broken tile behind the toilet creating a hole. Space under the radiator. C 115- Loose fitting ceiling tile above the bathroom sink. C 116- Crack on wall tile behind the toilet creating a hole. C 118- Cracked floor tiles on both sides of the toilet creating holes. C 119- Hole in the wall behind the toilet drainpipe. C 123- Peeling baseboard behind the toilet. Chipped floor tiles beside bed B. C 124- Stained ceiling tiles above the bed B's dresser. On 3/10/25 at 10:55 A.M., to 11:33 A.M., the surveyor observed the following on the D Unit and the Governor's room: D 101- Bumpy floor tiles at the entrance of the room. Chipped tile in front of the dresser. Peeled baseboard behind the trash can in the bathroom. D 102- Stained ceiling tiles next to the privacy curtains railing. Peeled baseboard behind the toilet next to the trash can. D 103- Cracked floor tile beside the toilet. D 104- Cracked base board and loose floor tile in the bathroom corner next to the toilet. D 105- Hole behind the toilet wall from the toilet drainpipe. Chipped floor tile in front of the toilet. D 106- Loose fitting ceiling tile in the bathroom. D 107- Loose fitting piece of wood nailed to cover a hole in the left bottom wall next to the toilet. D 109- Hole in the wall under the bathroom sink wall from the drainpipe. Hole in the bottom wall behind the toilet on the right side. D 110- Chipped floor tiles next to bed B and under bed B. Peeling baseboards next to the first closet. D 112- Hole in the bottom wall beside the toilet on the right side. D 113- Holes in the bottom wall on both sides of the toilet. Four missing tiles in the bathroom wall in front of the sink. D 114- Cracked floor tiles in the bathroom shower area. Holes in the bottom wall on both sides of the toilet. D 115- Holes in the bottom wall on both sides of the toilet. D 116- Holes in the bottom wall on both sides of the toilet. Chipped floor tile next to the air conditioner. D 117- A part of the baseboard missing on the wall behind both Residents' beds. D 118- Missing baseboard on the side of the radiator. Hole on the side of the radiator. Stained ceiling tiles above the radiator. D 119- Hole in the bottom wall on the right side of the toilet. D 120- Holes in the bottom wall on both sides of the toilet. D 121- Broken window blinds. Holes in the bottom wall on both sides of the toilet. D 122- Stained ceiling tile above the dresser and television next to bed B. Holes in the bottom wall on both sides of the toilet. Chipping on baseboard behind the toilet. Chipped floor tiles in the bathroom. D 123- Peeling wallpaper under the bathroom sink and next to the toilet. Hole in the wall from the bathroom sink drainpipe. Peeling baseboard next to the dresser, television and bed A. Governor's room- Chipped floor tiles at the entry way. On 3/10/25 at 11:37 A.M., to 11:50 A.M., the surveyor observed the following on the E Unit: E 104- Hole in the wall under the bathroom sink from the drainpipe. Holes in the bottom walls on both sides of the toilet. E 105- Hole in the bottom wall on the right side of the toilet. E 106- Broken blinds. Holes on the bottom wall on both sides of the toilet. E 107- Holes on the bottom walls on both sides of the toilet. E 109- Holes on the bottom walls on both sides of the toilet. Hole in the corner of the bathroom. E 110- Hole in the wall from the bathroom sink drainpipe. Hole on the bottom wall next to the toilet on the left side. On 3/10/25 at 11:54 A.M., to 12:13 P. M., the surveyor observed the following on the F Unit: F 101- Chipped tile next to the heater. F 102- Broken blinds. Hole in the wall in the corner of the bathroom. Hole in the wall from the drainpipe from the bathroom sink. F 103- Chipped floor tiles at the bathroom entrance. F 104- Broken blinds. Hole in the bottom left side of the wall next to the toilet. Hole in the wall in the corner in the bathroom. F 105- Hole in the wall from the drainpipe from the bathroom sink. F 106- Hole in the wall from the drainpipe from the bathroom sink. F 107- Space between the wall and ceiling tiles next to the bathroom entrance. Hole in the wall from bathroom sink drainpipe. Broken blinds. F 108- Hole in the wall from drainpipe from the bathroom sink. Small dresser missing the top drawer. F 109- Hole on the bottom wall of the right side of the toilet. Chipped floor tile in front of the bathroom. The hallway in front of room F 109 has a hole in the wooden floor. During an interview on 3/11/25 at 7:36 A.M., Unit Manager #2 said, for repairs on the unit, staff write the repairs needed on a work order book on the unit, the Maintenance Director is responsible for completing rounds daily to work on repairing the concerns written in the work order book. Unit Manager #2 said if the repair is an emergency, the Maintenance Director is called on the phone to respond to the repair immediately. Unit Manager #2 said she has seen holes in walls in residents' rooms. Unit Manager #2 said she has reported these concerns at morning meeting to management. During an interview on 3/11/25 at 10:12 A.M., the Administrator and Maintenance Director said staff communicate repairs needed in the facility in a work order binder on each unit. The Maintenance Director said if there is a repair emergency, staff will call him so he can address the concern immediately. The Maintenance Director said for the repairs added in the work order logbook, he does rounds three times a day, every day, and addresses the repairs. The Maintenance Director said for all completed repairs, he crosses out the concern in the work log. A review of the worklogs on all the units failed to indicate that staff had noted down the concerns identified above except for broken blinds that needed repair in room E-106. The repair concern was dated 3/7/25 and had not been addressed. The Administrator said staff will be educated on how to identify repair concerns on the units. The Administrator and Maintenance Director said there are still a lot more repairs that need to be completed in the facility, especially in the residents' rooms to create a homelike environment. 45763 2.) Resident #80 was admitted to the facility in September 2020 with a diagnosis of hypertension. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #80 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident was cognitively intact. During an interview and observation in room [ROOM NUMBER]d on 3/5/25 at 11:38 A.M., the surveyor observed that a significant portion of the cover for Resident #80's heater was covered in a variety of tape. Resident #80 said the heater cover has been broken for three and a half years and that he/she had been told it was too expensive to repair it. The Resident said he/she had been told to take care of it him/herself so his/her sister bought the tape to hold the cover in place. During an interview on 3/5/25 at 12:50 P.M., the Maintenance Director said there was nothing functionally wrong with the heater just that the cover was broken. The Maintenance Director said he wouldn't be able to buy a separate cover so in order to fix it he would have to replace the entire heater which was expensive. The Maintenance Director said keeping the heater in its current state was the lesser of two evils. During an interview on 3/11/25 at 9:50 A.M. the Administrator said he would not consider the current state of Resident #80's heater to be an appropriate permanent fix, and that he was unaware of the issue. Refer to F925.

Based on observations, record review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when three out of three nurses observed made seven errors out of 29 opportunities, resulting in a medication error rate of 24.14%. Those errors impacted three Residents (#149, #8, and #433), out of three residents observed. Specifically, 1.) For Resident #8, Nurse #4 failed to administer his/her medications within the one-hour time frame. 2.) For Resident #433, Nurse #5 failed to administer his/her medications within the one-hour time frame. 3.) For Resident #149, Nurse #1 failed to administer his/her medications within the one-hour time frame. Findings include: Review of the facility policy titled 'Oral Medication Administration', dated as revised 4/2022, indicated the following: The purpose of this procedure is to provide guidelines for the safe administration of oral medications. - Verify that there is a physician's medication order for this procedure. 1.) Review of Resident #8's physician orders indicated the following: - Phenobarbital 97.2 milligrams (mg) one tablet two times a day for seizures. Scheduled two times daily at 8:00 A.M., and 8:00 P.M. - Carbamazepine 200 mg two tablets a day for seizures. Scheduled two times daily at 8:00 A.M., and 8:00 P.M. - Sodium Chloride (NaCl) one gram (gm) one tablet three times a day for supplement. Scheduled three times daily at 8:00 A.M., 12 P.M., and 4:00 P.M. On 3/5/25 at 9:32 A.M., the surveyor observed Nurse #4 prepare and administer morning medications to Resident #8 including the following: - Phenobarbital 97.2mg one tablet. The medication was administered one hour and 32 minutes after the scheduled time. - Carbamazepine 200 mg two tablets. The medication was administered one hour and 32 minutes after the scheduled time. - NaCl one gram one tablet. The medication was administered one hour and 32 minutes after the scheduled time. 2.) Review of Resident #433's physician orders indicated the following: - Gabapentin 300 mg one capsule two times a day for pain. Scheduled two times daily at 8:00 A.M., and 8:00 P.M. On 3/5/25 at 10:03 A.M., the surveyor observed Nurse #5 prepare and administer morning medications to Resident #433 including the following: - Gabapentin 300 mg one capsule. The medication was administered two hours and three minutes after the scheduled time. 3.) Review of Resident #149's physician orders indicated the following: - Tylenol 500 mg one tablet three times a day for pain. Scheduled three times daily at 9:00 A.M., 1:00 P.M., and 9:00 P.M. - Eliquis 5mg one tablet two times a day for blood thinner. Scheduled two times daily at 9:00 A.M., and 9:00 P.M. - Buspar 5mg one tablet three times a day for anxiety. Scheduled three times daily at 9:00 A.M., 5:00 P.M., and 9:00 P.M. On 3/5/25 at 10:38 A.M., the surveyor observed Nurse #1 prepare and administer morning medications to Resident #149 including the following: - Tylenol 500 mg one tablet. The medication was administered one hour and 38 minutes after the scheduled time. - Eliquis 5mg one tablet. The medication was administered one hour and 38 minutes after the scheduled time. - Buspar 5mg one table. The medication was administered one hour and 38 minutes after the scheduled time. During an interview on 3/5/25 at 9:35 A.M., Nurse #4 said she was late administering medications and medications should be administered within a one-hour window. During an interview on 3/5/25 at 10:06 A.M., Nurse # 5 said she was late administering medications and medications should be administered within a one-hour window. During an interview on 3/5/25 at 10:40 A.M., Nurse #1 said she was late administered medications and medications should be administered within a one-hour window. During an interview on 3/10/25 at 12:24 P.M., the Director of Nursing (DON) said medications should be administered within one hour of the scheduled times.

Based on record review and interview, the facility failed to complete annual Certified Nurse Aide (CNA) performance reviews for 5 out of 5 eligible sampled CNAs. Findings include: During review of 5 CNA employee records, the Surveyor was unable to locate annual performance reviews for 5 out of 5 eligible CNAs. Employee records indicated the following: - A CNA last had an annual review on 7/13/21; - A CNA last had an annual review on 10/23/21; - A CNA last had an annual review on 3/19/20; - A CNA last had an annual review on 2/26/21; - A CNA never had an annual review, but was eligible. During an interview on 3/11/25 at 9:38 A.M., the Director of Nursing (DON) said it is the expectation that annual reviews be done annually and could not say why that was not happening. During an interview on 3/11/25 at 9:48 A.M., the Administrator said that it is the expectation that all staff receive annual performance reviews. The Administrator said that he could not speak to why reviews were not happening in the past but was aware that they were not done.

Based on interviews, record review, staff education review, and Facility Assessment review, the facility failed to ensure the nursing staff were trained and demonstrated the competencies and skill sets necessary to provide the level and types of care and services needed as outlined in the Facility Assessment. Specifically, the facility failed to ensure 5 of 5 nurse records reviewed were trained and demonstrated competency related to wound care. Findings include: According to the Board of Registration in Nursing, 244 CMR 9.00: Standards of Conduct, a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. Review of the comprehensive Facility Assessment Tool, updated and reviewed by the facility in October 2024, indicated the following: - The facility accepts residents with a broad range of diseases and disabilities, primarily including common diseases of the elderly for its long-term care unit. These conditions, physical and cognitive disabilities, or combination of conditions require complex medical care and management. - Listed under common diagnoses the facility treats included skin ulcers, injuries, skin and soft tissue infections. - The type of care that the facility provides includes the following: *Pressure injury prevention and care, skin care, wound care (surgical, other skin wounds). - The facility considers the following competencies (this is not an inclusive list): *Person-centered-care - This should include but not be limited to person-centered care planning, education of resident and family/resident representative about treatment and medications, documentation of resident treatment preferences, end of life care, and advance care planning. *Medication administration - injectable, oral, subcutaneous, topical. *Resident assessment and examinations - admission assessment, skin assessment, pressure injury assessment, neurological check, lung sounds, nutritional check, observations of response to treatment, pain assessment. *Specialized care - wound care/dressings. Throughout the Recertification survey (3/4/25 through 3/7/25 and 3/10/25 through 3/11/25) the surveyors identified multiple concerns regarding wound care. The surveyor reviewed staff education files for wound competencies for five licensed nurses: - 0 out of 5 nurses had evidence of wound care competencies completed in the past year. During an interview on 3/11/25 at 9:38 A.M., with the Director of Nursing (DON) he said that he was unable to provide wound care competencies for 5 of 5 nurse records reviewed. The DON said that on 1/29/25 there was verbal education regarding wound care provided to him and several facility staff. The DON said that the instructor verbally reviewed wound care however there were no competency's assessed. During an interview on 3/11/25 at 9:48 A.M., the Administrator said that is the expectation that nursing staff demonstrate wound competency.

Based on observation, record review, and interview, the facility failed to ensure that there was sufficient qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. Specifically, 1.) The facility failed to maintain sufficient staffing according to the facility assessment and facility staffing requirements. 2.) The facility failed to ensure staff were not sleeping in resident areas during their shifts on three out of six units. Findings include: 1.) Review of the comprehensive Facility Assessment Tool, updated and reviewed by the facility in October 2024, indicated the following staffing ratios for Certified Nursing Aides (CNAs): - 1:12 ratio for days (ratio of CNA to number of residents to care for) - 1:14 ratio for evenings - 1:21 ratio for nights During an interview on 3/10/15 at 12:54 P.M., the Staff Scheduler said that when he makes the schedule, he does it based off the census on the unit. The Staff Scheduler said that he staffs the units as follows: - A unit, C unit, and D unit require 4 certified nursing aides (CNA's) on 7-3 shift, 4 CNA's on the 3-11 shift, and 2 CNA's on the 11-7 shift. - E and F unit requires 2 CNA's on the 7-3 shift, 2 CNA's on the 3-11 shift, and 1 CNA on the 11-7 shift - B unit requires 2-3 CNA's on the 7-3 shift, 2-3 CNA's on the 3-11 shift, and 1 CNA on the 11-7 shift (depending on the census as it is the short term unit) During a telephone interview on 3/7/25 at 6:29 A.M., Certified Nurse Assistant (CNA) #7 said the facility has been short staffed several days a week for the past few months. CNA #7 said several days a week there is only one CNA on the overnight shift making it physically impossible to turn and reposition all the residents on the unit. During a telephone interview on 3/6/25 at 9:07 A.M., one Resident's health care proxy said that she believes that the Resident, who has wounds, had not been turned and repositioned every two hours and is not receiving incontinence care because of lack of staff. During an interview on 3/5/25 at 1:48 P.M., CNA #4 said that she is over worked and that not all staff give showers because there are not enough staff to provide showers. CNA #4 said that some residents require two people to assist and those resident's will go without showers because there is not enough staff. CNA #4 said the facility used to put 3 CNA's on the floor and now they only schedule two. CNA #4 said residents stay in bed longer, food takes a while to pass out, and it takes a longer time to get everyone ready. During an interview on 3/5/25 at 2:03 P.M., Nurse #1 said there is just not enough staff so medications are passed out late. Nurse #1 said that it causes trays to be passed out late and residents that require feeding assistance end up with cold food because there's not enough staff to feed them. Nurse #1 said residents are often soaking wet because we can't get to them in time. Nurse #1 said the staff are unable to provide every 2-3 hour incontinence care because they don't have enough staff and don't have time to go around and do rounds on people. During an interview on 3/7/25 at 1:12 P.M., CNA #5 and CNA #6 said they don't feel like they have enough staff and it affects the residents. CNA #5 and #6 said that low staffing delays residents getting up, being fed, and receiving showers. During a telephone interview on 3/7/25 at 8:40 A.M., Nurse Practitioner (NP) #1 said she sees that staff isn't always able to reposition and provide toileting/incontinence care. During the medication pass on 3/5/25, A unit, B unit, and F unit's medications were all delivered one hour and 30 minutes late. Review of the actual daily schedule report for 1/1/25 indicates the following: - B unit 11-7 shift- No CNA scheduled for a census of 17. - C unit 11-7 shift- 1 CNA scheduled for a census of 39. - D unit 11-7 shift - 1 CNA scheduled for a census of 38. Review of the actual daily schedule report for 1/5/25, indicated the following: - A unit 7-3 shift - 2 CNA's for a census of 42, which is a ratio of 1:21 - B unit 11-7- no Nurse on duty - C unit 11-7 shift- one CNA for a census of 39. Review of the actual daily schedule report for 1/19/25 indicated the following: - A unit 7-3 shift- 3 CNA's for a census of 41, which is a ratio of 1:13.6 Review of the actual daily schedule report for 1/20/25 indicated the following: - A unit 7-3 shift- 3 CNA's for a census of 41, which is a ratio of 1:13.6 - A unit 11-7 shift- 0 CNA's for a census of 41 - B unit 11-7 shift- 0 CNA's for a census of 18 - C unit 11-7 shift- 1 CNA for a census of 37 - D unit 11-7 shift- 1 CNA for a census of 38 Review of the actual daily schedule for 2/1/25, indicated the following: - A unit 7-3 shift- 2 CNA's for a census of 41, which is a ratio of 1:20.5 - A unit 11-7 shift- 1 CNA for a census of 41 - D unit 7-3 shift- 2 CNA's for a census of 38 Review of the actual daily schedule for 2/9/25, indicated the following: - D unit 11-7 shift- 1 CNA for a census of 40 Review of the actual daily schedule for 3/1/25 indicated the following: - C unit 3-11- 2 CNA's for a census of 39, which is a ratio of 1:19.5 During an interview on 3/11/25 at 11:13 A.M., the Staff Scheduler said that if there are call outs then he will try to get other staff to stay for the shift or offer bonuses. The Staff Scheduler says he never has an issue getting staff to cover open shifts. During an interview on 3/11/25 at 9:23 A.M., the Administrator said that staffing has stabilized and was more of an issue when he got here. The Administrator said that the facility was pushed to eliminate agency and that they transitioned those agency staff to the building. The Administrator said that staff have come to him about staffing levels and he has explained the process to them and how the facility is staffed based on acuity. The Administrator said that based on the acuity depends on how many staff each unit gets. 48990 2.) Review of the employee handbook, dated April 2, 2024, indicated, but was not limited to the following: - Standards of Conduct: Any violation of company rules, including the following, may result in disciplinary action: Sleeping on duty. During the initial tour of the facility on 3/4/25 at 8:47 A.M., there were multiple concerns regarding care during the night shift including: - One resident said he/she has seen staff sleeping in the resident dining room. This resident said there is not enough staff at night and the call bell wait time can take up to two hours. - Another resident said there is long call light wait times, especially at night. - Another resident said sometimes it takes up to four hours to answer call lights during the night shift. During the 'Resident Group' meeting on 3/5/25 at 10:05 A.M., 13 residents met with the surveyor and indicated the following: - 13 out of 13 expressed concerns with staffing and prolonged call light wait time. - 3 out of 13 residents expressed concerns that staff were sleeping during the night shift. On 3/6/25 at 3:01 A.M., a surveyor entered the F Unit and observed a certified nurse assistant (CNA) covered in a blanket with her head on a pillow and eyes closed, appearing to be asleep. During an interview on 3/6/25 at 3:03 A.M., Nurse #9 said the CNA on F Unit was asleep, and could not say for how long. On 3/6/25 at 3:04 A.M., a surveyor entered D Unit and observed a CNA covered in a blanket laying on two chairs pushed together in the dining room with her eyes closed, appearing to be asleep. There was another CNA with eyes closed, appearing to be asleep, on a chair in the hallway. During an interview on 3/6/25 at 3:06 A.M., Nurse #10, who was working on D Unit, said staff should not be sleeping on the unit. On 3/6/25 at 2:58 A.M., a surveyor entered the A Unit and observed a CNA in a chair covered with a blanket and head on a pillow with her eyes closed, appearing to be asleep, in the resident dining room. The CNA opened her eyes after a few minutes and said she had been sleeping. During an interview on 3/6/25 at 3:01 A.M., Nurse Supervisor #1 and CNA #7 were sitting at the nurse's station on A Unit. They said there was nobody on break on the A Unit. During an interview on 3/6/25 at 3:12 A.M., Nurse Supervisor #1 said there is an ongoing concern with staff sleeping. Nurse Supervisor #1 said she is suspicious when she walks on a unit and the lights are off that staff might be sleeping. Nurse Supervisor #1 said about two weeks ago a CNA was disciplined by being moved to a different unit because she was caught sleeping. During an interview on 3/6/25 at 4:25 A.M., The Administrator and the Regional Nurse Consultant said staff should not be sleeping in resident areas during their shift. The Administrator and Regional Nurse Consultant said if staff want to sleep on their breaks, it must be in the staff break room.

Based on observations and interviews the facility failed to ensure an environment free from accident hazards for one Resident (#59) out of a total sample of 42 residents. Specifically, the facility failed to ensure that there was not a space heater placed in Resident #59's room on top of a trash can which had a plastic lid and contained paper waste. Findings Include: Review of life safety code K781, Portable Space Heaters, indicated the following: Portable space heating devices shall be prohibited in all health care occupancies. Unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8. Resident #59 was admitted to the facility in November 2023 with a diagnosis of dementia and parapalegia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #59 scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had moderate cognitive impairment. Further review of the MDS indicated the Resident was dependent on staff for transferring out of bed. During an interview and observation on 3/4/25 at 10:07 A.M., Resident #59 said the heater in her room was broken and that the facility provided him/her with a space heater (a small portable heating unit) during the interim to keep the room warm. The surveyor observed the Resident in bed and the space heater, which was plugged in and produced heat, placed on top of a trash can with a plastic lid. On 3/4/25 at 7:23 A.M., the surveyor observed Resident #59 in bed, there was a space heater in his/her room. The space heater was on, producing heat, and placed on top of a trash can with a plastic lid. The surveyor observed paper waste products inside the trash can, below the space heater. Review of the maintenance log indicated the following entry: - Resident #59's heat is not working, dated 11/26/24. During an interview on 3/5/25 at 12:17 P.M., Unit Manager #4 said Resident #59 had a space heater and that facility was in the process of getting Resident #59's heat fixed. During an interview on 3/5/25 at 12:50 P.M., the Maintenance Director said the heat in Resident #59's room was not working and that an outside company was in the process of fixing it. The Maintenance Director said the facility provided the Resident with a space heater during the interim but that it should not be placed on top of a trash can with a plastic lid. During an interview on 3/6/25 at 6:40 P.M., the Administrator said Residents should not have space heaters in their rooms.

Based on observations, record review and interviews, the facility failed to provide an activity program for four Residents (#106, #110, #130 and #148) out of a total sample of 42 residents. Findings include: 1.) Resident #106 was admitted to the facility in March 2018 with diagnoses including dementia. Review of Resident #106's most recent Minimum Data Set (MDS) assessment, dated 2/6/25, indicated the Resident scored 3 out of a possible 15 on the Brief Interview for Mental Status exam, indicating he/she has severe cognitive impairment. The MDS further indicated Resident #106 is always incontinent of bladder and bowel and is dependent on staff for care. Review of Section F on the MDS indicated that staff assessed Resident #106's activity preferences and listed his/her activities of preference are listening to music, being around animals such as pets, keeping up with the news, reading magazines, books and newspapers, doing things with groups of people, participating in group activities and spending time outdoors. On 3/5/25 the following was observed: - At 9:26 A.M., the activity assistant came to the unit and put music on. She was not observed entering resident rooms to the common area were to begin. Resident #106 was already in the common area sitting on the couch. - At 9:30 A.M., the activity calendar had sorting and sequencing as the activity. This did not occur. The activity assistant began a basketball activity. Resident #106 was given one opportunity to roll the basketball into the hoop. - At 9:39 A.M., the activity assistant started a picture game where residents needed to find the missing item in the picture. Resident #106 was not able to participate in this activity. The activity assistant never approached the Resident to offer extra support or provide individual activity materials. - At 10:07 A.M., the activity assistant again put music on and began singing. From 10:07 A.M. until 10:43 A.M., the activity assistant sang music while looking at the lyrics on her phone and did not interact with Resident #106. The Resident was lying down on the couch throughout this time and was in and out of sleep. - At 10:43 A.M., a second activity assistant came to the floor and the first activity assistant left. From 10:43 A.M. until the unit prepared for lunch at 12:00 P.M., the activity assistant sat at a table in the common area with three residents while Resident #106 remained on the couch. Throughout this time, the activity assistant did not attempt to engage Resident #106 in the conversation/coloring activity or provide individual activity materials to him/her. - The activity calendar lists emotion posters for 11:15 A.M. This activity did not occur. - Resident #106 was observed not moving from the couch from 8:00 A.M. to 12:00 P.M. On 3/7/25, the following was observed: - At 9:27 A.M., the activity assistant came to the unit and put music on. She was not observed entering resident rooms to the common area were to begin. Resident #106 was already in the common area sitting on the couch. - The 9:30 A.M. activity listed on the activity calendar was morning stretches. The activity assistant began exercising without explaining the activity to the residents in the room. Resident #106 continued to sit on the couch without exercising and the activity assistant did not approach the Resident to get him/her to engage in the activity. - At 9:45 A.M., the activity assistant began balloon toss without explanation. The activity assistant tossed the balloon to Resident #106 and the balloon bounce off his/her head. - At 10:35 A.M., Resident #106 was given a brief hand massage. - At 11:00 A.M., the activity assistant put on music and began singing. The Residents in the room were not engaged in the song, did not have any individual activity materials in front of them and Resident #106 was observed to be sleeping on the couch. - At 11:30 A.M., a second activity assistant began a coloring activity. Resident #106 was not provided with any activity or coloring materials. - Resident #106 was observed not moving from the couch from 8:00 A.M. to 11:57 A.M. Review of Resident #106's activity care plan indicated the following interventions: - I (the Resident) would benefit from accommodation for cognitive limitations by using demonstrations, reminders, one-to-one settings, small groups, and/or verbal prompts. - I (the Resident) like to use a computer, do crossword/sudoku, listen to classical music, look out the window, lay down/rest, meditate, read on the computer, reading Machinal engineering system, and/or [NAME], spending time by myself in my bedroom, or common spaces. - Compliment (the Resident) for activity participation. - Provide 1:1 (one-on-one) visits that incorporate (the Resident's) past interest: active games (i.e. tennis, soccer, exercising), surfing the web together - looking at machinal engineer systems, listening/watching classical music, watching a soccer/tennis/rowing program, play trivia games, also include sensory therapy, active games/exercise during 1:1 visits. Respect (his/her) right to refuse. - I would benefit from accommodation for hearing loss by using placement near the speaker/leader, and/or written instructions/gestures. During interviews on 3/10/25 at 10:58 A.M., and 1:24 P.M., the Activity Director said she develops the activity calendar based on all cognitive levels and ensures activities range from high and low functioning activities. The Activity Director said she expects the calendar to be followed as written. The Activity Director said low level activities are typically done on the units and include activities such as sensory activities, reminiscing, nails, massage, sorting, and music. The Activity Director said the activity assistants should also be completing one-on-one visits and attempting to invite all residents to the activities. The Activity Director said the activity assistant on Resident #106's unit does not seem to be a good fit for the unit and she may not know how to organize activities for residents with a lower cognitive ability and she should be attempting to engage Resident #106 in all activities. The Activity Director said the facility could do a better job with activities on that unit. 2.) Resident #110 was admitted to the facility in April 2022 with diagnoses including dementia. Review of Resident #110's most recent Minimum Data Set, dated dated dated [DATE], indicated the Resident scored a 0 out of a possible 15 on the Brief Interview for Mental Status, which indicated he/she has severe cognitive impairment. The MDS also indicated the Resident requires substantial assistance for toilet transfers and is dependent on staff for toileting tasks. Review of Section F on the MDS indicated that staff assessed Resident #110's activity preferences and listed his/her activities of preference are reading books, magazines and newspapers, listening to music, being around animals such as pets, keeping up with the news, being in groups of people, participating in favorite activities, spending time outdoors and religious activities. On 3/5/25 the following was observed: - At 9:26 A.M., the activity assistant came to the unit and put music on. She was not observed entering resident rooms to the common area were to begin. Resident #110 was already in the common area sitting in his/her wheelchair. - At 9:30 A.M., the activity calendar had sorting and sequencing as the activity. This did not occur. The activity assistant began a basketball activity. Resident #110 was given one opportunity to roll the basketball into the hoop and was unable to complete this task. The Activity assistant never returned to the Resident for another opportunity to participate. - At 9:39 A.M., the activity assistant started a picture game where residents needed to find the missing item in the picture. Resident #110 was not able to participate in this activity and eventually fell asleep. The activity assistant never attempted to engage the Resident or provide him/her with individual activity materials. - At 10:07 A.M., the activity assistant again put music on and began singing. From 10:07 A.M. until 10:43 A.M., the activity assistant sang music while looking at the lyrics on her phone and did not interact with Resident #110. The Resident was sleeping in his/her wheelchair. - At 10:43 A.M., a second activity assistant came to the floor and the first activity assistant left. From 10:43 A.M. until the unit prepared for lunch at 12:00 P.M., the activity assistant sat at a table in the common area with three residents while Resident #110 remained in his/her wheelchair not engaged. Throughout this time, the activity assistant did not attempt to engage Resident #110 in the conversation/coloring activity or provide individual activity materials to him/her. - The activity calendar lists emotion posters for 11:15 A.M. This activity did not occur. On 3/7/25, the following was observed: - At 9:27 A.M., the activity assistant came to the unit and put music on. She was not observed entering resident rooms to the common area were to begin. Resident #110 was already in the common area sitting in his/her wheelchair. - The 9:30 A.M. activity listed on the activity calendar was morning stretches. The activity assistant began exercising without explaining the activity to the residents in the room. Resident #110 continued to sit in his/her wheelchair without exercising and the activity assistant did not approach the Resident to get him/her to engage in the activity. - At 9:45 A.M., the activity assistant began balloon toss without explanation. The activity assistant tossed the balloon to Resident #110 and he/she was not able to hit the balloon back. - At 10:35 A.M., the activity assistant was providing hand massages. Resident #110 was sleeping and she did not attempt to wake the Resident to give him/her a hand massage. - At 11:00 A.M., the activity assistant put on music and began singing. The Residents in the room were not engaged in the song, did not have any individual activity materials in front of them and Resident #110 was observed to be sleeping. - At 11:30 A.M., a second activity assistant began a coloring activity. Resident #110 was sitting close to the table but was not provided with coloring materials. Review of Resident #110's activity care plan indicated the following interventions: - Compliment (the Resident's) participation and efforts. - Gently attempt to use cueing, demonstration, and/or redirect (the Resident) attention as necessary with (the Resident's) tolerance to remain on task. - Give (the Resident) time to respond, providing simple, clear directions for task with (the Resident's) abilities, giving (the Resident) time to process/respond. - Recreation staff will encourage (the Resident) in activity preferences: Religious services, outdoor programs, bingo, pokeno, musical programs, card games, active games, veteran clubs and movies. Respect (his/her) right to refuse. - Repeat instructions and demonstrate actions on a one-to one basis within group program. Review of Resident #110's most recent activities assessment, dated 1/8/25, indicated the following: - Resident #110 has had a slight decline over the past year and requires more cueing, re-direction and demonstration for active participation. - Resident #110's favorite activities are: playing cards, watching boxing programs and sports programs, touch sensory, active games, spending time outside in good weather, playing mini bingo/table games with staff support, arts and crafts, musical programs, religious services, men's club, sporting programs, and watching movies. - The interventions/approaches for Resident #110 are: giving him/her time to respond, providing simple ,clear directions for task within his/her abilities, and giving him/her time to process/respond. During interviews on 3/10/25 at 10:58 A.M., and 1:24 P.M., the Activity Director said she develops the activity calendar based on all cognitive levels and ensures activities range from high and low functioning activities. The Activity Director said she expects the calendar to be followed as written. The Activity Director said low level activities are typically done on the units and include activities such as sensory activities, reminiscing, nails, massage, sorting, and music. The Activity Director said the activity assistants should also be completing one-on-one visits and attempting to invite all residents to the activities. The Activity Director said the activity assistant on Resident #110's unit does not seem to be a good fit for the unit and she may not know how to organize activities for residents with a lower cognitive ability and she should be attempting to engage Resident #110 in all activities. The Activity Director said the facility could do a better job with activities on that unit. 3.) Resident #130 was admitted to the facility in December 2020 with diagnoses including Alzheimer's Disease. Review of Resident #130's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) and staff had assessed him/her to have severe cognitive impairment. The MDS also indicated Resident #130 was dependent on staff for all care. Review of Section F on the MDS, dated [DATE], indicated that staff assessed Resident #130's activity preferences and listed his/her activities of preference are listening to music, being around animals such as pets, keeping up with the news, being in groups of people, participating in favorite activities, spending time outdoors and religious activities. On 3/5/25 the following was observed: - At 9:26 A.M., the activity assistant came to the unit and put music on. She was not observed entering resident rooms to the common area were to begin. Resident #130 was already in the common area reclined in a Broda chair. The Resident was observed to have bilateral UE (upper extremity) contractions of elbows and shoulders. - At 9:30 A.M., the activity calendar had sorting and sequencing as the activity. This did not occur. The activity assistant began a basketball activity. Resident #130 was not approached to participate and was positioned at the side of the room, not with the other residents who the activity assistant was engaging with. - At 9:39 A.M., the activity assistant started a picture game where residents needed to find the missing item in the picture. Resident #130 was not approached to participate and was positioned at the side of the room, not with the other residents who the activity assistant was engaging with. Resident #130 was given a sensory mat that he/she would be unable to use due to contractures, and the mat was placed on the table a foot away from him/her. - At 10:07 A.M., the activity assistant again put music on and began singing. From 10:07 A.M. until 10:43 A.M., the activity assistant sang music while looking at the lyrics on her phone and did not interact with Resident #130. - At 10:43 A.M., a second activity assistant came to the floor and the first activity assistant left. From 10:43 A.M. until the unit prepared for lunch at 12:00 P.M., the activity assistant sat at a table in the common area with three residents while Resident #130 remained removed from the group. - The activity calendar lists emotion posters for 11:15 A.M. This activity did not occur. On 3/7/25, the following was observed: - At 9:27 A.M., the activity assistant came to the unit and put music on. She was not observed entering resident rooms to the common area were to begin. Resident #130 was still in his/her room and the surveyor did not observe the activity assistant enter the Resident's room to see if he/she could attend the activity. - At 10:35 A.M., the activity assistant was providing hand massages. Resident #130 was reclined in his/her Broda chair and the activity assistant was not observed approaching the Resident to provide a hand massage. -A t 11:00 A.M., the activity assistant put on music and began singing. The Residents in the room were not engaged in the song, did not have any individual activity materials in front of them and Resident #130 was observed to be sleeping. - At 11:30 A.M., a second activity assistant began a coloring activity. Resident #130 was brought closer to the table by the activity assistant, however she did not provide any one-on-one activities to the Resident. Review of Resident #130's activity care plan indicated the following: - Focus: needs one-to-one recreation interventions to help promote sensory, mental and social stimulation - Goal: will make eye contact, follow 1-step directions during one-to-one recreation sensory therapy, physical programs, and social stimulation 3-5 times per week. - Interventions: encourage (the Resident) participation in one-to-one recreation visits 3-5 times per week of (the Resident's) preference of: musical programs, exercising, and socialization, reading (mysteries), pet therapy (dogs and/or cats), praying together, sensory therapy. Respect (his/her) right to refuse. - Offer gentle, hand-over-hand guidance for sensory and physical stimulation. - Provide demonstration, verbal cueing, 1-step direction and giving (the Resident) time to respond to stimuli. Review of Resident #130's most recent activity assessment, dated 12/19/24, indicated the following: - Resident #130's favorite activities are 1:1 visits for sensory, physical stimulation and companionship. - Activity staff should be providing 1:1 visits, providing hand-over-hand guidance, cueing/re-directions, demonstration and 1 step directions. - Resident #130 may have changes in facial expressions at times and can be passive at times. During interviews on 3/10/25 at 10:58 A.M., and 1:24 P.M., the Activity Director said she develops the activity calendar based on all cognitive levels and ensures activities range from high and low functioning activities. The Activity Director said she expects the calendar to be followed as written. The Activity Director said low level activities are typically done on the units and include activities such as sensory activities, reminiscing, nails, massage, sorting, and music. The Activity Director said the activity assistants should also be completing one-on-one visits and attempting to invite all residents to the activities. The Activity Director said the activity assistant on Resident #130's unit does not seem to be a good fit for the unit and she may not know how to organize activities for residents with a lower cognitive ability and she should be attempting to engage Resident #130 in all activities. The Activity Director said the facility could do a better job with activities on that unit. 4.) Resident #148 was admitted to the facility April 2022 with diagnoses including Alzheimer's Disease. Review of Resident #148's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident scored a 2 out of a possible 15 on the Brief Interview for Mental Status (BIMS), which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #148 was dependent on staff for all functional daily tasks. Review of Section F on the MDS indicated that Resident #148's activity preferences are to listen to music, be around animals such as pets, do favorite activities, get fresh air when the weather is good, and participate in religious activities. Throughout all days of survey, Resident #148 was always observed in bed and the television was never on and no music was ever playing in his/her room. On 3/5/24 from 9:27 A.M. to 12:00 P.M., two activity assistants were observed on Resident #148's unit. At no point was either assistant observed entering Resident #148's room to provide a one-on-one visit. On 3/7/25 from 9:30 A.M., to 11:57 A.M., two activity assistants were observed on Resident #148's unit. At no point was either assistant observed entering Resident #148's room to provide a one-on-one visit. Review of Resident #148's activity care plan indicated the following: - Focus: (the Resident) seems to need bed-side sensory/activity stimulation secondary to late-stage terminal diagnosis of Alzheimer's Disease. - Keep stimulation within optimal levels for (the Resident's) tolerance. - Provide hand-over-hand guidance for sensory stimulation within (the Resident's) tolerance level. - Provide one-on-one contacts based on (the Resident's) individual preference: play Italian music, provide sensory stimulation, review (his/her) life story to (him/her). - Re-direct (the Resident's) attention to recreation program, via demonstration, cueing/demonstration, simple single step activity cueing, hand-over-hand guidance, giving (the Resident) time to process and respond. Review of Resident #148's most recent activity assessment, dated 1/23/25, indicated the following: - Resident #148 continues to be responsive to 1:1 activity visits 3 times per week and will make brief eye contact, use verbalization, and may have changes in facial expression. During interviews on 3/10/25 at 10:58 A.M., and 1:24 P.M., the Activity Director said she develops the activity calendar based on all cognitive levels and ensures activities range from high and low functioning activities. The Activity Director said she expects the calendar to be followed as written. The Activity Director said low level activities are typically done on the units and include activities such as sensory activities, reminiscing, nails, massage, sorting, and music. The Activity Director said the activity assistants should also be completing one-on-one visits and attempting to invite all residents to the activities. The Activity Director said the activity assistant on Resident #148's unit does not seem to be a good fit for the unit and she may not know how to organize activities for residents with a lower cognitive ability and she should be attempting to engage Resident #148 in one-on-one bedside sensory activities. The Activity Director said the facility could do a better job with activities on that unit.

Based on observations, record review and interview, the facility failed to provide assistance with activities of daily living (ADLs) for five Residents (#110, #106, #130, #148, and #87) out of a total sample of 42 residents. Specifically, the facility failed to: 1.) Provide incontinence care for Residents #110, #106, and #130; 2.) Provide showers for Residents #106 and #148; and 3.) Provide assistance with self-feeding for Resident #87. Findings include: Review of the facility policy titled, Activities of Daily Living Support, revised April 2022, indicated the following: - Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out their activities of daily living (ADLs). - Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. - Residents will be provided with care, treatment and services to ensure that their activities of daily living do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. - Appropriate care and services will be provided for residents who are unable to carry out their ADL's independently, with the consent of the resident and in coordination with the plan of care, including appropriate support and assistance with: - a. Hygiene (bathing, dressing, grooming, and oral care); - c. Elimination (toileting) - d. dining (meals and snacks) - If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care period approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate. 1a.) Resident #110 was admitted to the facility in April 2022 with diagnoses including dementia. Review of Resident #110's most recent Minimum Data Set (MDS) assessment, dated 1/9/25, indicated the Resident scored a 0 out of a possible 15 on the Brief Interview for Mental Status exam, indicating he/she has severe cognitive impairment. The MDS further indicated Resident #110 requires substantial assistance for toilet transfers and is dependent on staff for toileting tasks. Section H of the MDS indicated Resident #110 is always incontinent of both bowel and bladder. On 3/5/25 at 9:00 A.M., Resident #110 was observed sitting in his/her wheelchair in the dining room. The Resident was observed sitting in the dining room from 9:00 A.M. until 12:00 P.M. Throughout this time Resident #110 was not observed to have either of the two nursing assistants or the nurse working on the floor approach the Resident to check for incontinence or to provide care. On 3/7/25 at 8:05 A.M., Resident #110 was observed sitting in his/her wheelchair in the dining room. The Resident was observed sitting in the dining room from 9:00 A.M. until 11:57 A.M. Throughout this time Resident #110 was not observed to have either of the two nursing assistants or the nurse working on the floor approach the Resident to check for incontinence or to provide care. At 1:12 P.M., the surveyor returned to the unit and Resident #110 was observed lying in bed. Review of Resident #110's most recent Norton Pressure Ulcer assessment, dated 1/8/25, indicated the Resident has double incontinence and is a high risk for pressure ulcer development. Review of Resident #110's ADL care plan indicated the following intervention: - Provide resident/patient with limited assist of 1 for toileting after meals and as needed. Review of Resident #110's incontinence care plan failed to indicate an intervention of a toileting schedule or how often the Resident should be checked/changed. During an interview on 3/5/25 at 1:48 P.M., Certified Nursing Assistant (CNA) #4 said the unit is very short staffed, and because of this it takes a long time to provide care to residents and ensure that all the care is being completed. During an interview on 3/7/25 at 1:12 P.M., CNA #5 and #6 said they provide incontinence care to residents on the floor in the morning and then again in the afternoon. CNA #5 said the staff on the floor know the residents well on the floor and can predict when they go to the bathroom so there is no need to check for incontinence. CNA #5 said she did not provide care to Resident #110 while the surveyor was off the unit. CNA #5 said Resident #110 requires maximal assistance from staff for toileting and is incontinent of both bladder and bowel. CNA #5 said she provided care to Resident #110 and assisted him/her back to lunch after bed. CNA #5 said she did not provide incontinent care to the Resident when she placed him/her back in bed and she was waiting until after she completed her afternoon paperwork During interviews on 3/5/25 at 2:03 P.M., and 3/7/25 at 1:22 P.M., Nurse #1 said all residents should be checked for incontinence and have incontinent care provided to them every 2-3 hours. Nurse #1 said there is not enough staff on the floor for the acuity of the residents and because of this people are often left soaking with incontinence because staff cannot get to the residents on time. Nurse #1 said residents are cared for in the morning and then are often not cared for again until the afternoon when the next shift comes in. Nurse #1 said she and the other staff do not have enough time to complete rounds on residents. During an interview on 3/7/25 at 1:58 P.M., the Director of Nursing said residents who are incontinent should be changed every 2-3 hours. The DON said this is something that is expected and told to nursing staff during their orientation process. 1b.) Resident #106 was admitted to the facility in March 2018 with diagnoses including dementia. Review of Resident #106's most recent Minimum Data Set (MDS) assessment, dated 2/6/25, indicated the Resident scored a 3 out of a possible 15 on the Brief Interview for Mental Status exam, indicating he/she has severe cognitive impairment. Section H of the MDS indicated the Resident is always incontinent of bladder and bowel and is dependent on staff for toileting tasks. On 3/5/25 at 9:00 A.M., Resident #106 was observed sitting on the couch in the dining room. The Resident was observed sitting in the dining room from 9:00 A.M. until 12:00 P.M. Throughout this time Resident #106 was not observed to have either of the two nursing assistants or the nurse working on the floor approach the Resident to check for incontinence or to provide care. On 3/7/25 at 8:05 A.M., Resident #106 was observed lying on the couch in the dining room. The Resident was observed sitting in the dining room from 9:00 A.M. until 11:57 A.M. Throughout this time Resident #106 was not observed to have either of the two nursing assistants or the nurse working on the floor approach the Resident to check for incontinence or to provide care. At 1:12 P.M., the surveyor returned to the unit and Resident #106 was observed still sitting on the couch. Review of Resident #106's most recent Norton Pressure Ulcer assessment, dated 2/5/25, indicated the Resident has urinal incontinence and is a moderate risk for pressure ulcer development. Review of Resident #106's ADL care plan indicated the following intervention: - (The Resident) needs assistance of one with bathing, dressing, grooming (needs extra encouragement for hygiene), locomotion, transfers, and toileting. (The Resident) can eat independently with set up of a tray. (He/she) is incontinent of both bowel and bladder. Review of Resident #106's incontinence care plan failed to indicate an intervention of a toileting schedule or how often the Resident should be checked/changed. During an interview on 3/5/25 at 1:48 P.M., Certified Nursing Assistant (CNA) #4 said the unit is very short staffed, and because of this it takes a long time to provide care to residents and ensure that all the care is being completed. During an interview on 3/07/25 at 1:12 P.M., CNA #5 and #6 said they provide incontinence care to residents on the floor in the morning and then again in the afternoon. CNA #5 said the staff on the floor know the residents well on the floor and can predict when they go to the bathroom so there is no need to check for incontinence. CNA #6 said she did not provide care to Resident #106 while the surveyor was off the unit. CNA #6 said Resident #106 requires maximal assistance from staff for toileting and is incontinent of both bladder and bowel. CNA #6 said she provided care to Resident #106 and will be providing care to the Resident again. On 3/7/25 at 1:22 CNA #5 transferred Resident #106 from the couch to a wheelchair. When Resident #106 stood, a strong odor similar to urine was observed by the surveyor. CNA #5 then assisted the Resident to the bathroom to provide care. Once care was provided, CNA #5 showed the surveyor Resident #106's brief that had just been removed. The brief was soiled with a significant amount of urine. During an interviews on 3/5/25 at 2:03 P.M., and 3/7/25 at 1:22 P.M., Nurse #1 said all residents should be checked for incontinence and have incontinent care provided to them every 2-3 hours. Nurse #1 said there is not enough staff on the floor for the acuity of the residents and because of this people are often left soaking with incontinence because staff cannot get to the residents on time. Nurse #1 said residents are cared for in the morning and then are often not cared for again until the afternoon when the next shift comes in. Nurse #1 said she and the other staff do not have enough time to complete rounds on residents. During an interview on 3/7/25 at 1:58 P.M., the Director of Nursing said residents who are incontinent should be changed every 2-3 hours. The DON said this is something that is expected and told to nursing staff during their orientation process. 1c.) Resident #130 was admitted to the facility in December 2020 with diagnoses including Alzheimer's Disease. Review of Resident #130's most recent Minimum Data Set (MDS) assessment, dated 12/19/24, indicated the Resident was unable to complete the Brief Interview for Mental Status exam and staff had assessed him/her to have severe cognitive impairment. Section H of the MDS indicated the Resident is always incontinent of bladder and bowel and is dependent on staff for toileting tasks. On 3/5/25 at 9:00 A.M., Resident #130 was observed reclined in his/her reclining Broda chair in the dining room. The Resident was observed sitting in the dining room from 9:00 A.M. until 12:00 P.M. Throughout this time Resident #130 was not observed to have either of the two nursing assistants or the nurse working on the floor approach the Resident to check for incontinence or to provide care. On 3/7/25, Resident #130 was observed in the dining room from 10:26 A.M. until 11:57 A.M. Throughout this time Resident #106 was not observed to have either of the two nursing assistants or the nurse working on the floor approach the Resident to check for incontinence or to provide care. At 1:12 P.M., the surveyor returned to the unit and Resident #130 was observed still reclined in the dining room. Review of Resident #130's most recent Norton Pressure Ulcer assessment, dated 12/18/25, indicated the Resident has both bladder and bowel incontinence and is a high risk for pressure ulcer development. Review of Resident #130's ADL care plan indicated the following intervention: - (The Resident) needs dependent care of 1-2 for all of (his/her) ADLs. Review of Resident #130's incontinence care plan, failed to indicate an intervention of a toileting schedule or how often the Resident should be checked/changed. During an interview on 3/5/25 at 1:48 P.M., Certified Nursing Assistant (CNA) #4 said the unit is very short staffed, and because of this it takes a long time to provide care to residents and ensure that all the care is being completed. During an interview on 3/07/25 at 1:12 P.M., CNA #5 and #6 said they provide incontinence care to residents on the floor in the morning and then again in the afternoon. CNA #5 said the staff on the floor know the residents well on the floor and can predict when they go to the bathroom so there is no need to check for incontinence. CNA #5 said Resident #130 is dependent on staff for all care, including toiling and that the Resident is incontinent of both bladder and bowel. CNA #5 said she did not provide care to Resident #130 while the surveyor was off the unit. CNA #5 said she provided care to Resident #130 this morning and because the Resident did not get up from bed until after breakfast, he/she would not receive care again until the afternoon staff starts their shift. During interviews on 3/5/25 at 2:03 P.M., and 3/7/25 at 1:22 P.M., Nurse #1 said all residents should be checked for incontinence and have incontinent care provided to them every 2-3 hours. Nurse #1 said there is not enough staff on the floor for the acuity of the residents and because of this people are often left soaking with incontinence because staff cannot get to the residents on time. Nurse #1 said residents are cared for in the morning and then are often not cared for again until the afternoon when the next shift comes in. Nurse #1 said she and the other staff do not have enough time to complete rounds on residents. During an interview on 3/7/25 at 1:58 P.M., the Director of Nursing said residents who are incontinent should be changed every 2-3 hours. The DON said this is something that is expected and told to nursing staff during their orientation process. 2.) Review of the resident group monthly meeting notes from November 2024 to January 2025 indicated the residents of the facility have been complaining about not being offered showers consistently and feel showers are not occurring as often as they should. 2a.) Resident #148 was admitted to the facility April 2022 with diagnoses including Alzheimer's Disease. Review of Resident #148's most recent Minimum Data Set (MDS) assessment, dated 1/23/25, indicated the Resident scored a 2 out of a possible 15 on the Brief Interview for Mental Status exam, indicating he/she had severe cognitive impairment. The MDS further indicated Resident #148 was dependent on staff for all functional daily tasks. On 3/04/25 at 9:59 A.M., Resident #148 was observed lying in bed with significant dry skin build-up on his/her face and scalp. The Resident was able to say he/she was not in pain but was unable to answer any questions about ADL care. Review of Resident #148's ADL care plan indicated the following: - Focus: (The Resident) requires extensive to dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: Chronic disease/condition: End stage dementia with limited mobility. Further review of Resident #148's care plans indicated a care plan for resistance to care, however, the care plan failed to indicate the Resident refuses showers. Review of the shower schedule indicated Resident #148 is scheduled for showers on Wednesdays and Sundays. Review of the Documentation Survey Report (a report indicating all ADL care provided) for the months of October 2024, November 2024, December 2024, January 2025, February 2025 and March 2025 failed to indicate Resident #106 has been provided a shower in the past six months. Review of the medical record failed to indicate Resident #148 has refused a shower if offered. During an interview on 3/5/25 at 1:48 P.M., Certified Nursing Assistant (CNA) #4 said residents are scheduled to have at least two showers a week. CNA #4 said she is always able to provide showers to residents but not all staff do because the floor is very busy and has a lot of dependent residents so showers cannot be completed. During an interview on 3/11/25 at 9:19 A.M., Unit Manager #1 said showers should be given twice a week to all residents and if a resident refuses, the refusal should be documented by the nursing assistants and nurses. Unit Manager #1 said she believes Resident #148 was given a shower last week but is unable to say why there is no documentation of it. During an interview on 3/11/25 at 9:41 A.M., the Director of Nursing (DON) said showers are provided twice a week or as needed. The DON said nursing has to document the refusal of care. 2b.) Resident #106 was admitted to the facility in March 2018 with diagnoses including dementia. Review of Resident #106's most recent Minimum Data Set (MDS) assessment, dated 2/6/25, indicated the Resident scored 3 out of a possible 15 on the Brief Interview for Mental Status exam, indicating he/she has severe cognitive impairment. Section H of the MDS also indicated the Resident is always incontinent of bladder and bowel and is dependent on staff for toileting tasks. On 3/4/25 at 9:51 A.M., Resident #106 was observed sitting on the couch in the dining room. The Resident has significantly greasy hair with white flakes similar to dandruff. The Resident was unable to be interviewed. Review of Resident #106's ADL care plan indicated the following intervention: - (The Resident) needs assistance of one with bathing, dressing, grooming (needs extra encouragement for hygiene), locomotion, transfers, and toileting. (The Resident) can eat independently with set up of a tray. (He/she) is incontinent of both bowel and bladder. Review of the shower list indicated Resident #106 is scheduled for showers on Tuesdays and Saturdays. Review of the Documentation Survey Report (a report indicating all ADL care provided) for the months of January 2025, February 2025 and March 2025 failed to indicate Resident #106 has been provided a shower in the past three months. Review of the medical record failed to indicate Resident #106 has refused a shower if offered. During an interview on 3/5/25 at 1:48 P.M., Certified Nursing Assistant (CNA) #4 said residents are scheduled to have at least two showers a week. CNA #4 said she is always able to provide showers to residents but not all staff do because the floor is very busy and has a lot of dependent residents so showers cannot be completed. During an interview on 3/11/25 at 9:19 A.M., Unit Manager #1 said showers should be given twice a week to all residents and if a resident refuses, the refusal should be documented by the nursing assistants and nurses. Unit Manager #1 said she was unable to recall the last time Resident #106 was provided with a shower. During an interview on 3/11/25 at 9:41 A.M., the Director of Nursing (DON) said showers are provided twice a week or as needed. The DON said nursing has to document the refusal of care. 45763 3.) Resident #87 was admitted to the facility in December 2020 and had diagnoses of dementia, need for assistance with personal care and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment, dated 2/19/25, indicated that Resident #87 scored a 3 out of a possible 15 on the Brief Interview for Mental Status exam, indicating the Resident had severe cognitive impairment. The MDS further indicated the Resident required substantial/maximal assistance with eating. Review of Resident #87's activity of daily living care plan indicated the following intervention: -Resident #87 is dependent for bathing, grooming, personal hygiene, dressing, bed mobility, transfer, locomotion, toileting related to generalized weakness, dementia with cognitive loss. Mod (moderate) assist with eating. Dressed in bed for dignity. Position with assist of 2 in bed, initiated 12/2/21. Review of Resident #87's comprehensive nutritional evaluation, dated 2/17/25, indicated Resident #87 required total feeding assistance at mealtimes. Review of Resident #87's most recent occupational therapy (OT) discharge summary, dated 3/5/25, indicated the Resident required modx1 (moderate, one staff) assistance with eating. On 3/4/25 at 8:55 A.M., the surveyor observed Resident #87 in bed in his/her room, the Resident's breakfast tray was in front of the Resident and there were no staff or family members in the room or within eyesight of the Resident. On 3/5/25 at 9:03 A.M., the surveyor observed Resident #87 in bed in his/her room, the Resident's breakfast tray was in front of the Resident, there was milk spilled on the Residents tray and there were no staff or family members in the room or within eyesight of the Resident. On 3/5/25 at 12:13 P.M., the surveyor observed Resident #87 in bed in his/her room, the Resident was eating lunch and coughing; there were no staff or family members in the room or within eyesight of the Resident. During an interview on 3/6/25 at 5:48 P.M., Nurse #6 said care plans for eating should be followed and that Resident #87 required feeding assistance with meals. Nurse #6 said that the Resident's son provided feeding assistance when he visited but that staff should provide feeding assistance when the son was not visiting; Nurse #6 said he would expect a staff member to be in the Resident's room throughout the entire meal period if the Resident was being fed by staff. During an interview on 3/6/25 at 5:58 P.M., Resident #87's son said the Resident needed to be fed due to his/her Alzheimer's disease and that he would expect staff to assist with feeding as the Resident can't do too much. During an interview on 3/6/25 at 6:15 P.M., the Registered Dietitian (RD) said Resident #87 required total feeding assistance due to dementia and mobility issues. The RD said she would expect a staff to be with the Resident during the entire meal period. During an interview on 3/6/25 at 6:50 P.M., the Director of Rehabilitation (DOR) said he would expect staff to be with Resident #87 throughout the entire meal period due to the Resident's cognitive fluctuation. During an interview on 3/6/25 at 7:30 P.M., the Director of Nursing (DON) said he would expect staff to provide the level of assistance outlined in the care plan and recommended by rehabilitation services.

Based on record review and interview, the facility failed to prevent abuse for 1 Resident (#157) out of a total sample of 41 residents. Specifically, Resident #157 was physically restrained to a chair by a staff member, causing emotional distress and weepiness. Findings include: Review of the facility policy titled Abuse Prohibition, dated 10/24/22, indicated the following: -Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/patient (hereinafter patient) property, and exploitation for all patients. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptoms. -The center will implement an abuse prohibition program through the following: * Prevention of occurrences * Identification of possible incidents or allegations which need investigation * Investigation of all incidents and allegations * Protection of patients during investigation * Reporting of incidents, investigations, and center response to the results of their investigation. -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with the resulting physical harm, injury, or mental anguish. Resident #157 was admitted in April 2022 with diagnoses including dementia and anxiety. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #157 did not score on the Brief Interview for Mental Status (BIMS), but is severely cognitively impaired. Review of the MDS indicated that Resident #157 requires supervision with mobility. Review of the Incident Report investigation, dated 3/8/24, indicated the following: At about 6:45am today, pt was found by nurse from a different department crying upon examination, pt restrained by clothing on a chair in the common area. Review of a witness statement, dated 3/8/24, indicated the following: Approximately 6:45 AM, I was helping a resident in his/her wheelchair to get to the common area on the unit. After he was set, I noticed Resident #157 sitting in a chair crying, behind me. I walked over to him/her and saw that there was a blanket covering the back of the chair. I pulled the blanket back, and noted that his/her shirt was pulled over the back of the chair he/she was sitting on. It was so far down that I had a hard time pulling it off the back of the chair . During an interview on 3/21/24 at 10:08 A.M., the Director of Nursing said that she was told of the incident by the MDS nurse, who noticed that Resident #157's shirt was up and over the back of the chair and tucked under. The Director of Nursing said that the shirt being tucked under was preventing the Resident from rising and the Resident was teary and whining. The Director of Nursing said that she interviewed the certified nursing aide and nurse that were on the unit, but neither admitted to restraining the Resident. The Director of Nursing said that there was no way the Resident could have tucked his/her shirt behind him/her in the chair. The Director of Nursing notified the Resident's family, police, and terminated both employees. She said that they are doing education shiftly and initiated a quality assurance performance improvement (QAPI) program. On 3/21/24, the facility provided the surveyor with a plan of correction that addressed the areas of concern identified during this survey. The plan of correction is as follows: -Investigation of the circumstances leading up to and including the restraint -Education of restraints and abuse to all employees on every shift, before the beginning of their shift daily for 14 days, then weekly for two weeks, then monthly for 2 months until 3/25/24. -Audit of each unit on 3/12/24 for restraints -The Director of Nursing, Assistant Director of Nursing, Unit Manager, Supervisors, and Facility Educator are responsible for completion of the education. REF to F604.

Based on record review and interview, the facility failed to prevent 1 Resident (#157) from being free from restraints, out of a total of 41 residents. Specifically, Resident #157 was physically restrained to a chair by a staff member. Findings include: Review of the facility policy titled Restraints: Use of, dated 6/15/22, indicated the following: -Patients have the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the patient's medical symptoms. -Physical restraint is defined as any manual method, physical or mechanical device, equipment, or materials that meets all of the following criteria: -Is attached or adjacent to the patient's body -Cannot be removed easily by the patient -Restricts the patients freedom of movement or normal access to their body Resident #157 was admitted in April 2022 with diagnoses including dementia and anxiety. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #157 did not score on the Brief Interview for Mental Status (BIMS), but is severely cognitively impaired. Review of the MDS indicated that Resident #157 requires supervision with mobility. Review of the Incident Report investigation, dated 3/8/24, indicated the following: At about 6:45am today, pt was found by nurse from a different department crying upon examination, pt restrained by clothing on a chair in the common area. Review of a witness statement, dated 3/8/24, indicated the following: Approximately 6:45 AM, I was helping a resident in his/her wheelchair to get to the common area on the unit. After he was set, I noticed Resident #157 sitting in a chair crying, behind me. I walked over to him/her and saw that there was a blanket covering the back of the chair. I pulled the blanket back, and noted that his/her shirt was pulled over the back of the chair he/she was sitting on. It was so far down that I had a hard time pulling it off the back of the chair . During an interview on 3/21/24 at 10:08 A.M., the Director of Nursing said that she was told of the incident by the MDS nurse, who noticed that Resident #157's shirt was up and over the back of the chair and tucked under. The Director of Nursing said that the shirt being tucked under was preventing the Resident from rising and the Resident was teary and whining. The Director of Nursing said that she interviewed the certified nursing aide and nurse that were on the unit, but neither admitted to restraining the Resident. The Director of Nursing said that there was no way the Resident could have tucked his/her shirt behind him/her in the chair. The Director of Nursing notified the Resident's family and police and terminated both employees. She said that they are doing education shiftly and initiated a quality assurance performance improvement (QAPI) program. On 3/21/24, the facility provided the surveyor with a plan of correction that addressed the areas of concern identified during this survey. The plan of correction is as follows: -Investigation of the circumstances leading up to and including the restraint -Education of restraints and abuse to all employees on every shift, before the beginning of their shift daily for 14 days, then weekly for two weeks, then monthly for 2 months until 3/25/24. -Audit of each unit on 3/12/24 for restraints -The Director of Nursing, Assistant Director of Nursing, Unit Manager, Supervisors, and Facility Educator are responsible for completion of the education.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who was newly admitted to the facility after undergoing surgical repair of left hip fracture due do a fall, had severe cognitive impairment with poor safety awareness, and was noted upon admission by nursing to be at increased risk for falls, the Facility failed to ensure he/she was provided with adequate safety measures and supervision to meet his/her immediate safety care needs in an effort to prevent a fall with injury. Resident #1 was in the facility less than 24 hours when he/she had an unwitnessed fall, was found on the floor in his/her room beside the bed, and required emergent transfer to the Hospital Emergency Department for evaluation. Resident #1 was diagnosed with a right hip fracture and subarachnoid hemorrhage (brain bleed), was admitted to the Intensive Care Unit, and required surgical intervention to repair his/her right hip fracture. Findings include: Review of the Facility's Policy titled, Fall Management, dated as revised 6/15/22, indicated all patients (residents) will be assessed for risk of falls upon admission. The Policy indicated that the Facility would implement and document patient-centered interventions according to individual risk factors in the patient's (resident's) plan of care. The Policy indicated that the Facility would educate staff and the patient (resident) as appropriate to increase awareness of at risk patients and to provide possible strategies to minimize risk for falls. Review of Resident #1's Hospital History and Physical, dated 11/15/22, indicated Resident #1 had been admitted to the ED for left hip pain after he/she fell . The History and Physical indicated Resident #1 was diagnosed with a left femoral neck (hip) fracture, and his/her head computerized tomography (CT) scan was negative for intracranial (inside the skull) findings. Review of the Hospitalist's Note, dated 11/18/22, indicated Resident #1 underwent left hip surgery to repair his/her left hip fracture. Resident #1 was admitted to the Facility in November 2022, diagnoses included dementia, and left femur (hip) fracture, secondary to a fall on same level from slipping, tripping, and stumbling without subsequent striking against an object. Review of Nurse #1's Admission Nursing Note, dated 11/19/22, indicated Resident #1 was admitted to the Facility following a left femur (hip) fracture with subsequent surgical repair. The Note indicated Resident #1 required the assistance of two staff members for mobility and he/she had experienced a fall in the last two to six months prior to admission. The Note indicated Resident #1 had a history of dementia, was confused, and was not oriented to place or time. The Note indicated Resident #1's decision making skills were severely impaired and staff needed to anticipate and meet resident's needs. During an interview on 12/21/22 at 2:24 P.M., Nurse #1 said she completed the admission assessments on Resident #1 to help Nurse #2. Nurse #1 said she assessed Resident #1 as being a high fall risk. Nurse #1 said after completing the assessments, she passed care of Resident #1 back to Nurse #2. Nurse #1 said she told Nurse #2 that Resident #1 was a high fall risk. Nurse #1 said typically, an intervention such as an alarm would be added once a resident was determined to be a high fall risk, but said she just helped Nurse #2 by doing the admission assessments. Nurse #1 said she did not know if the Certified Nurse Aides (CNAs) were made aware that Resident #1 was a high fall risk. During an interview on 12/21/22 at 2:44 P.M., Nurse #2 said nurses should add fall prevention interventions to the residents' Falls Care Plan upon admission, but said he did not initiate an admissions care plan or interventions related Resident #1's fall risk or safety concerns. Review of Resident #1's Bed Rail Evaluation, dated 11/19/22, indicated he/she was at high risk for falls. Further review of Resident #1's medical record indicated there was no documentation to support that the CNA Care Kardex (which is were each residents specific care needs are identified and communicated to the CNAs) was updated to indicate he/she was at increased risk for falls and that there were safety concerns. Review of a Nurse's Note, dated 11/20/22, indicated Resident #1 was found (on the floor in his/her room beside the bed) lying on his/her right side with a laceration on the right side of his/her head. The Note indicated Resident #1 was transferred to the Hospital's ED for evaluation. Review of a Nurse's Note, dated 11/20/22, indicated Resident #1 suffered a subarachnoid hemorrhage (brain bleed) and was admitted to the Hospital's ICU. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 11/25/22, indicated Resident #1 had an unwitnessed fall with a head strike in his/her room on 11/20/22 at approximately 11:15 A.M. The Report indicated a nurse responded to the sound of a loud bang and found Resident #1 lying on the ground (floor) with bleeding from his/her face, and a laceration on his/her right eyebrow. The Report indicated it appeared that Resident #1 had attempted to walk by him/herself. The Report indicated Resident #1 was sent to the Hospital's Emergency Department (ED) evaluated, diagnosed with a right hip fracture and subarachnoid hemorrhage (brain bleed) and subsequently admitted to the Intensive Care Unit (ICU) for further care. The Report indicated Resident #1 required surgical repair of his/her right femur (hip) fracture. During an interview on 12/22/22 at 10:15 A.M., Nursing Supervisor #1 said the nurse completing the resident admission, is required to develop a Falls Care Plan upon admission and add appropriate fall prevention interventions to the Care Plan. Nursing Supervisor #1 said Resident #1's Care Plan for Falls and safety concerns was not developed or put into place upon admission. Nursing Supervisor #1 said she developed Resident #1's Falls Care Plan, which is dated 11/20/22, and included interventions to help maintain his/her safety, but said she did so after Resident #1 had already fallen at the Facility and had been transferred to the Hospital's ED. During an interview on 12/21/22 at 11:45 A.M., the Assistant Director of Nurses (ADON) said he had been the acting Director of Nurses (DON) on 11/19/22 when Resident #1 was admitted to the Facility, and when he/she fell the following day. The ADON said there was a breakdown in communication and he was not made aware that Resident #1 was being admitted over the weekend. The ADON said, based on Resident #1's recent fall with a left hip fracture prior to admission, he/she should have been considered a high fall risk, and nursing staff should have implemented a Falls Care Plan upon admission to the Facility, but did not. The ADON said he was unable to locate any documentation to support fall prevention interventions had been put into place upon admission or prior to Resident #1's fall on 11/20/22. The ADON said had he been aware Resident #1 was being admitted over the weekend, based on his/her history of falls, and most recent fall with a left hip fracture, he would have made sure Resident #1's room was located closer to the Nurses' Station if possible, and that he/she was provided with a bed alarm, if needed. The ADON said CNAs refer to the CNA Care Kardex for each resident to determine fall risk and level of staff assistance needed to care for the resident. The ADON said this information does not appear on the CNA Care Kardex until after the nurse adds it to the resident's care plan. The ADON said Resident #1's Falls Care Plan and safety interventions were not initiated until after Resident #1 fell in the facility on 11/20/22. During an interview on 01/04/22 at 10:10 A.M., the Administrator said every resident that is admitted to the Facility should be considered a fall risk. Review of Resident #1's Summary of Hospital Course, dated 11/20/22, indicated Resident #1 presented to the Hospital's ED following a fall at the Facility on 11/20/22, and was found to have a right frontal lobe subarachnoid hemorrhage. The Summary also indicated Resident #1 was found to have a right femoral neck (hip) fracture which required surgical repair.

Based on record review and interview, the facility failed to identify a significant weight loss for 2 residents (#9, #124) out of total sample of 35 residents. Findings include: Review of the facility policy titled NSG244 Weights and Heights, revised date 6/1/2021 indicated; -Policy: Patients are weighed upon admission and/or re-admission, then weekly for four weeks and monthly thereafter. -Purpose: -To obtain baseline weight and identify significant weight change -To determine possible causes of significant weight change. 1.) Resident #9 was admitted to the facility in 4/2015 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's Minimum Data Set (MDS) dated , 5/6/2021 indicated that he/she was severely cognitively impaired and scored 3 out of 15 on the Brief Interview for Mental Status Exam (BIMS). The MDS also indicated the resident required supervision during eating. Review of Resident #9's medical record indicated the following: -On 03/03/2021, Resident #9 weighed 155.8 lbs. On 08/04/2021, Resident #9 weighed 139.8 pounds which is a -10.27 % loss within six months. -Resident #9 was discharged from hospice services in February 2021. During interviews throughout the day on 8/10/21, Unit Manager #2 said a nursing note should be written to document a weight loss or gain. Unit Manager #2 acknowledged Resident #9 had a significant weight loss. Unit Manager #2 gave contradictory statements regarding whether or not the Dietician should be notified for a weight loss. Review of Resident #9's medical chart failed to indicate the Dietician was notified of the weight loss. During an interview on 08/10/21 at 10:57 A.M., the Dietician said she was present in the building 4 days a week. The Dietician said her process to identify weight changes includes reviewing daily reports and weekly facility wide weights. She said a significant weight loss was considered a 5% loss in a month, 7.5% loss in 3 months or 10% loss in 6 months and the expectation was that nursing staff would notify her of any significant weight loss. The Dietician reviewed Resident #9's weights with the Surveyor and acknowledged the resident had a significant weight loss that was not identified by both herself and nursing. The Dietician said that no interventions had been put in place for the weight loss due to not having identified it. 2. Resident #124 was admitted to the facility in March 2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS) dated , 7/1/2021 indicated the Resident #124 was severely cognitively impaired and scored 2 out of 15 on the Brief Interview for Mental Status Exam (BIMS). The MDS also indicated the resident required supervision during eating. Review of Resident #124's medical record indicated the following; -On 7/6/2021, Resident #124 weighed 141.8 lbs. On 08/04/2021, Resident #124 weighed 134.4 pounds which is a -5.22 % Loss. -Care plan, revised on 10/28/2020 indicated a nutritional risk related to history of downward weight trend. Interventions for Resident #124 included; weigh per policy and alert dietician and physician to any significant loss or gain. During interviews throughout the day on 8/10/21, Unit Manager #2 said a nursing note should be written to document a weight loss or gain. Unit Manager #2 further said a reweigh should be done with any discrepancy of 2-5 lbs. between weights. Unit Manager #2 acknowledged a weight loss for Resident #124 and said a reweigh should have been done and the Dietician and physician should have been notified. During an interview on 08/10/21 at 10:57 A.M., the Dietician said she was present in the building 4 days a week. The Dietician said her process to identify weight changes includes reviewing daily reports and weekly facility wide weights. She said a significant weight loss was considered a 5% loss in a month, and the expectation was that nursing staff should notify her of any significant weight loss. The Dietician reviewed Resident #124's weights with the surveyor and acknowledged Resident #124 had a significant weight loss of 5.2% in 1 month that had not been previously identified by either herself or nursing. The Dietician said that no interventions had been put in place for the weight loss due to not having identified it.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure Resident #1's weights were being obtained, he/she was being monitored and assessed for weight loss and that interventions were implemented to prevent weight loss, when it was discovered Resident #1 experienced a significant weight loss of 31 pound over a 4 month period. Findings Include: Review of the Facility Policy titled, Weights and Heights dated as revised on 11/30/15, indicated that patients were weighed upon admission and/or re-admission, then weekly for four weeks and monthly thereafter. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], indicated that Resident #1 was admitted in December of 2018 and he/she had severely impaired cognition. Review of the Weight Summary indicated Resident #1's weights were as follows: - 121.0 pounds on 01/04/21 - 100.6 pounds on 02/23/21 (down 20.4 pounds in over a month) - 90.0 pounds on 05/21/21 (down an additional 10.6 pounds in almost 3 months) Review of Resident #1's Medical Record indicated there was no documentation to support that he/she had been weighed monthly, per Facility policy, between 02/23/21 and 05/21/21. Review of Resident #1's Medical Record indicated that there was no documentation to support that Resident #1 had a Nutritional Evaluation by the Dietician for his/her significant weight loss, until 04/27/2021. Review of the Nutritional Assessment, dated 04/27/21 and signed by the Dietician, indicated that Resident #1 weighed 121.0 pounds on 01/04/21. The Assessment indicated that an updated weight was pending, his/her meal intake varied, and he/she was observed at breakfast ignoring the meal. Review of Resident #1's Medical Record indicated that there was no documentation to support that a weight was obtained for Resident #1 on 04/27/2021. Review of the Nutritional Assessment, dated 05/27/21 and signed by the Dietician, indicated that Resident #1 weighed 90.0 pounds on 05/21/21. The Assessment indicated that Resident #1 was being seen for a significant weight loss of 25.6% of his/her body weight over the last 4.5 months. The Assessment indicated that Resident #1 was underweight and indicated that it was difficult to discern if the meals his/her family brought in for him/her were adequate to meet his/her needs and seemed like they were not. The Assessment indicated that Resident #1 had varied meal intake and protein liquid and house supplements were initiated to increase intake. Review of Resident #1's Medical Record indicated there was no documentation to support that Resident #1's Physician and or Nurse Practitioner were notified or that interventions were implemented for his/her significant weight loss until 05/25/21, which, by that time, was a loss of 31.0 pounds in over a 4 month period. Review of the Nurse Progress Note, dated 05/25/21, indicated that Resident #1's Nurse Practitioner was notified of Resident #1's drastic weight loss from January 2021 to May 25, 2021 (31 pound weight loss). The Note indicated that no weights were found for Resident #1 for the months of March and April 2021. The Note also indicated that Resident #1 had been a poor eater for a while. Review of the Nurse Progress Note, dated 05/26/21, indicated that Resident #1 experienced a change in condition: weight loss. The Note indicated that Resident #1 was noted to have a drastic weight loss from February, and that in March and April, that weights were not done, and his/her weight, taken in May, was 90 pounds. Review of the Incident Report Form submitted to the Massachusetts Department of Public Health via the Health Care Facility Reporting System (HCFRS), dated as submitted 06/03/21, indicated that, it was discovered that Resident #1 had a gradual unexpected significant weight loss of thirty pounds which began in February. The Report indicated that the Facility determined the root cause for Resident #1's weight loss was inadequate caloric intake with a continued decline in cognition. During an interview on 07/30/21 at 9:57 A.M., the Dietician said Resident #1 was supposed to be weighed monthly and that the weights are to be documented into his/her Electronic Medical Record (EMR) by nursing staff. The Dietician said that when a weight is documented into a resident's EMR, a notification comes up that identifies significant weight loss and said that a nurse should notify her. The Dietician said she reviewed weights that flagged for significant weight changes in the computer weekly but said that if weights are not done and entered into the computer, she would not know to evaluate a resident for significant weight loss because it would not flag. The Dietician said she was not aware of Resident #1's significant weight loss in February because she did not think Resident #1's the weight from 02/23/21 was actually documented into his/her EMR in February and therefore was not aware until 05/21/21. The Dietician said she the reason she believed that was because, when she completed Nutritional Evaluations, the computer system always auto-populated the weight section of the evaluation with the last weight documented in the computer. The Dietician said that, on 04/27/21, when she completed Resident #1's quarterly Nutritional Evaluation, his/her weight of 121 pounds from 01/04/21 was pulled onto the form and if another weight had been entered in Resident #1's EMR in February, that weight would have auto-populated and shown up on the Nutritional Evaluation instead. The Dietician said that she was not notified of Resident #1's significant weight loss (of 20.4 pounds) from 01/04/21 to 02/23/21 by nursing staff, and said she was not notified of his/her weight loss until 05/21/21 when he/she was down to a weight of 90 pounds which indicated he/she had a significant weight loss of 25.6% (31 pound loss) in a four and one half month period. The Dietician said that if she was notified about Resident #1's weight loss in February, she could have possibly prevented further weight loss and said that, in February (when he/she experienced a 20.4 pound weight loss) that Resident #1's Physician and or Nurse Practitioner was not notified and there were no new orders obtained to address it at the time. During an interview on 08/03/21 at 12:57 P.M., the Nurse Practitioner said that when weights are put into the computer, if there is a significant weight loss, the computer generates the percentage of body weight lost as well as the number of pounds lost in a period of time, and said staff are expected to let her know when that occurs. The Nurse Practitioner said she was at the Facility full time in January and February of 2021 and said she would have written a note if she had been notified that Resident #1 had a weight loss of 20.4 pounds from 01/04/21 to 02/23/21. The Nurse Practitioner said she reviewed her notes and said that there were no notes that she wrote regarding weight loss for Resident #1. The Nurse Practitioner said, if she had been notified in February, she would have ordered laboratory blood work and contacted the dietician regarding supplements for Resident #1. During an interview on 07/28/21 at 4:48 P.M., the Director of Nurses (DON) said she did not work at the Facility during the time that Resident #1 experienced significant weight loss. The DON said weights should be done upon admission for four weeks, then monthly thereafter unless otherwise noted and said that the Dietician was supposed to inform her about weights that needed to be done so she could follow-up with nursing staff.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure Resident #1 received adequate staff assistance and utilized necessary equipment (gait belt) to prevent an accident with injury, when Certified Nurse Aide (CNA) #1 transferred Resident #1, unassisted by another staff member, and without the use of a gait belt, and Resident #1 fell to the floor. Resident #1 sustained a right [MEDICAL CONDITION], was transferred to the Hospital Emergency Department for further evaluation, and required surgical intervention to repair his/her right [MEDICAL CONDITION]. Findings include: The Facility Policy titled Falls Management, revised 03/15/16, indicated that patients will be assessed for falls risk as part of the nursing assessment process. The Policy indicated those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Resident #1 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 required an extensive assistance of two staff persons for transfers. The MDS indicated Resident #1's balance from surface to surface transfer (transfer between bed and chair or wheelchair) was not steady and was only able to stabilize with staff assistance. A Lift Transfer Reposition Form, dated 05/27/19, indicated Resident #1 required two staff person assistance with a gait belt for transfers. The Activities of Daily Living (ADL) Care Plan, revised on 06/28/18, indicated Resident #1 required two staff person assistance for transfers. The At Risk for Falls Care Plan, revised on 03/23/19, indicated Resident #1 was a stand pivot transfer with a gait belt and two staff person assistance. The Nurse Progress Note, dated 08/10/19, indicated Resident #1 had a fall, the Nurse Practitioner was notified and ordered and x-ray of Resident #1's right hip. The physician's orders [REDACTED]. A Radiology Report, dated 08/10/19, indicated Resident #1 had an acute severely displaced right proximal femoral shaft fracture. The physician's orders [REDACTED]. The Hospital Discharge Summary, dated 08/16/19, indicated Resident #1 was admitted to the hospital with [REDACTED]. The Facility Investigation, dated 08/13/19, indicated CNA #1 was transferring Resident #1 from his/her wheelchair to his/her bed. The Investigation indicated CNA #1 assisted Resident #1 to a standing position, Resident #1 grabbed on to the side rail, turned and pivoted, became shaky and fell to the floor. The Investigation indicated CNA #1 was unable to grab Resident #1 before he/she fell to the floor. The Investigation indicated Resident #1 did not complain of right hip pain until he/she was transferred back to bed using a mechanical lift. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 11:25 A.M. on 08/21/19. CNA #1 said on 08/10/19 she was assisting Resident #1 with transferring from his/her wheelchair to his/her bed. CNA #1 said Resident #1 grabbed onto the siderails of his/her bed, pulled him/her self up out of the wheelchair as she held onto the wheelchair. CNA #1 said Resident #1 became shaky and then fell to the floor on his/her buttocks in a sitting position. CNA #1 said she did not place a gait belt on Resident #1 and did not have her hands on Resident #1 during the transfer. CNA #1 said she was not aware Resident #1 required a two staff person assist with a gait belt for transfers. CNA #1 said she did not review Resident #1's plan of care prior to providing care to him/her, did not see his/her transfer status and did not see the fall risk indicator located on Resident #1's door name tag outside of his/her room. The Surveyor interviewed Nurse #1 at 3:02 P.M. on 08/20/19. Nurse #1 said CNA #1 was transferring Resident #1 alone and that Resident #1 did not have a gait belt on him/her. Nurse #1 said she assessed Resident #1 while on the floor and said he/she had no complaints of pain at that time. Nurse #1 said once they transferred Resident #1 off the floor to his/her bed using a mechanical lift, he/she complained of right leg pain. Nurse #1 said Resident #1 was a two staff person assist with a gait belt for transfers. Nurse #1 said the GB x2 and the green dot outside of Resident #1's room displayed on the door name tag indicated Resident #1 was a fall risk and required a gait belt and two staff person assist for transfers and said that the information was on the door prior to the fall on 08/10/19. The Surveyor interviewed Unit Manager #1 at 10:15 A.M. and at multiples times throughout the survey. Unit Manager #1 said Resident #1 required a two staff person assist with a gait belt for transfers. Unit Manager #1 said resident transfer status was documented on the resident care cards that CNA's have access to on their computers. Unit Manager #1 said the transfer status was also located on the resident door tags outside of the resident's room. Unit Manager #1 said Resident #1's door tag indicated GBx2 and a green dot which indicated he/she required a gait belt with two staff person assist for transfer, was a fall risk, and that this information was on his/her door prior to his/her fall on 08/10/19. The Surveyor interviewed the Assistant Director of Nurses (ADON) at 2:17 P.M. on 08/20/19. The ADON said on 08/10/19 CNA #1 was transferring Resident #1 by herself from his/her wheelchair to his/her bed without a gait belt when Resident #1 fell to the floor. The ADON said Resident #1's plan of care indicated Resident #1 required a two staff person assist with a gait belt for transfers.

Based on record reviews and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure Certified Nurse Aide (CNA) #1 followed Resident #1's plan of care for a two person assist with a gait belt for transfers. CNA #1 transferred Resident #1 by herself, Resident #1 fell to the floor, sustained a right [MEDICAL CONDITION], was transferred to the Hospital Emergency Department for further evaluation, and required surgical intervention to repair his/her right [MEDICAL CONDITION]. Findings include: The Facility Policy titled Falls Management, revised 03/15/16, indicated that patients will be assessed for falls risk as part of the nursing assessment process. The Policy indicated those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Resident #1 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 required an extensive assistance of two staff persons for transfers. The MDS indicated Resident #1's balance from surface to surface transfer (transfer between bed and chair or wheelchair) was not steady and was only able to stabilize with staff assistance. A Lift Transfer Reposition Form, dated 05/27/19, indicated Resident #1 required two staff person assistance with a gait belt for transfers. The Activities of Daily Living (ADL) Care Plan, revised on 06/28/18, indicated Resident #1 required two staff person assistance for transfers. The At Risk for Falls Care Plan, revised on 03/23/19, indicated Resident #1 was a stand pivot transfer with a gait belt and two staff person assistance. The Nurse Progress Note, dated 08/10/19, indicated Resident #1 had a fall, the Nurse Practitioner was notified and ordered an x-ray of Resident #1's right hip. A Radiology Report, dated 08/10/19, indicated Resident #1 had an acute severely displaced right proximal femoral shaft fracture. The Hospital Discharge Summary, dated 08/16/19, indicated Resident #1 was admitted to the hospital with [REDACTED]. The Facility Investigation, dated 08/13/19, indicated CNA #1 was transferring Resident #1 from his/her wheelchair to his/her bed. The Investigation indicated CNA #1 assisted Resident #1 to a standing position, Resident #1 grabbed on to the side rail, turned and pivoted, became shaky and fell to the floor. The Investigation indicated CNA #1 was unable to grab Resident #1 before he/she fell to the floor. The Investigation indicated Resident #1 did not complain of right hip pain until he/she was transferred back to bed using a mechanical lift. The Investigation indicated Nurse #1 notified the Nurse Practitioner, an x-ray of Resident #1's hip was ordered and revealed a displaced right femoral shaft fracture. The Investigation indicated the Nurse Practitioner was notified of the x-ray results and ordered Resident #1 to be transferred to the Hospital Emergency Department for evaluation. The Investigation indicated Resident #1 required surgery for [REDACTED]. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 11:25 A.M. on 08/21/19. CNA #1 said on 08/10/19 she was assisting Resident #1 with transferring from his/her wheelchair to his/her bed. CNA #1 said Resident #1 grabbed onto the siderails of his/her bed, pulled him/her self up out of the wheelchair as she held onto the wheelchair. CNA #1 said Resident #1 became shaky and then fell to the floor on his/her buttocks in a sitting position. CNA #1 said she did not place a gait belt on Resident #1 and did not have her hands on Resident #1 during the transfer. CNA #1 said she was not aware Resident #1 required a two staff person assist with a gait belt for transfers. CNA #1 said she did not review Resident #1's plan of care prior to providing care to him/her, did not see his/her transfer status and did not see the fall risk indicator located on Resident #1's door name tag outside of his/her room. The Surveyor interviewed Nurse #1 at 3:02 P.M. on 08/20/19. Nurse #1 said on 08/10/19 CNA #1 reported to her that Resident #1 had fallen to the floor after he/she became shaky while being transferred from his/her wheelchair to his/her bed. Nurse #1 said CNA #1 was transferring Resident #1 alone and that Resident #1 did not have a gait belt on him/her. Nurse #1 said she assessed Resident #1 while on the floor and said he/she had no complaints of pain at that time. Nurse #1 said once they transferred Resident #1 off the floor to his/her bed using a mechanical lift, he/she complained of right leg pain. Nurse #1 said she notified the Nurse Practitioner, an x-ray of the right hip was ordered and obtained, which revealed a right [MEDICAL CONDITION]. Nurse #1 said Resident #1 was a two staff person assist with a gait belt for transfers. Nurse #1 said the GB x2 and the green dot outside of Resident #1's room displayed on the door name tag indicated Resident #1 was a fall risk and required a gait belt and two staff person assist for transfers and said that the information was on the door prior to the fall on 08/10/19. The Surveyor interviewed Unit Manager #1 at 10:15 A.M. and at multiples times throughout the survey. Unit Manager #1 said Resident #1 required a two staff person assist with a gait belt for transfers. Unit Manager #1 said resident transfer status was documented on the resident care cards that CNA's have access to on their computers. Unit Manager #1 said the transfer status was also located on the resident door tags outside of the resident's room. Unit Manager #1 said Resident #1's door tag indicated GBx2 and a green dot which indicated he/she required a gait belt with two staff person assist for transfer, was a fall risk, and that this information was on his/her door prior to his/her fall on 08/10/19. The Surveyor interviewed the Assistant Director of Nurses (ADON) at 2:17 P.M. on 08/20/19. The ADON said on 08/10/19 CNA #1 was transferring Resident #1 by herself from his/her wheelchair to his/her bed without a gait belt when Resident #1 fell to the floor. The ADON said Resident #1's plan of care indicated Resident #1 required a two staff person assist with a gait belt for transfers.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), the Facility failed to prevent an incident of neglect when Certified Nurse Aide (CNA) #1 knowingly transferred Resident #1 with a sit to stand mechanical lift (which requires two staff) alone and as a result of the inappropriate transfer Resident #1 sustained skin tears to his/her right arm and right leg. Findings include: The Facility policy, titled, Abuse Prohibition, dated 7/1/18, indicated: -Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. -Neglect was defined as the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The Facility's policy titled Accidents and Incidents, dated 5/2/18, indicated any incident that could be considered an allegation of abuse would be managed in accordance with the Abuse Prohibition policy. The Facility policy titled, Safe Resident Handling and Transfer Equipment, dated 5/15/17, indicated use of the sit to stand mechanical lift required two staff members. Resident #1 was admitted to the Facility in (MONTH) 2014, [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment, dated 12/26/18, indicated Resident #1 required extensive assistance from two staff member for transfers and bed mobility. The Care Plan, dated 9/13/2017, indicated Resident #1 required assist of two staff members with the sit to stand mechanical lift device for transfers. The Facility's Event Summary Report, dated 2/10/19, indicated that at 11:30 P.M. on 2/10/19, Resident #1 alleged that CNA #1 transferred him/her roughly, and as a result he/she sustained skin tears to his/her right arm and right leg. The Summary indicated the event was an allegation of physical abuse. The Surveyor interviewed CNA #1 at 11:55 A.M. on 3/5/19. CNA #1 said she knew it was Facility policy to use two staff members for mechanical lift transfers, and said that on 2/10/19, some time at the beginning of the 11:00 P.M. to 7:00 A.M. shift, she transferred Resident #1 from his/her wheelchair to bed using the sit to stand mechanical lift, without a second staff member present. CNA #1 said after she got Resident #1 to bed she tried to roll Resident #1 over in the bed to provide care, and Resident #1 began hitting her on her arms. CNA #1 said Resident #1 was yelling and screaming, and continued to try to hit and kick her, which was when she noticed Resident #1 had skin tears to his/her right arm and leg. The Surveyor interviewed Resident #1 at 2:20 P.M. on 3/4/19. Resident #1 said CNA #1 caused skin tears to his/her right arm and right leg. Resident #1 said he/she was afraid of CNA #1 and wanted her to leave him/her alone. The Surveyor interviewed Nurse #1 at 10:08 A.M. on 3/5/19. Nurse #1 said that on 2/10/19 at approximately 11:30 P.M. CNA #1 told her Resident #1 was bleeding. Nurse #1 said she and CNA #1 went to Resident #1's room and found him/her sitting on the side of the bed, bleeding from skin tears on his/her right arm and right leg. Nurse #1 said Resident #1 told her CNA #1 caused skin tears to his/her right arm and right leg, and he/she was upset. Nurse #1 said she did not ask Resident #1 any questions about the allegation, and reported the injuries and allegation of abuse to Nurse Supervisor #1. The Surveyor interviewed Nurse Supervisor #1 at 2:57 P.M. on 3/4/19. Nurse Supervisor #1 said that on 2/10/19, at approximately 11:30 P.M. she was called to Resident #1's room because Resident #1 was bleeding. Nurse Supervisor #1 said Resident #1 had skin tears to his/her right arm and right leg, and he/she said CNA #1 caused the skin tears, and Resident #1 was visibly upset. Nurse Supervisor #1 said she did not ask Resident #1 any questions about the allegation, and said she entered a report into the Facility's internal reporting system. Nurse Supervisor #1 said CNA #1 was not suspended from duty at that time, and per Facility policy, CNA #1 should have been suspended, however CNA #1 continued working the 11:00 P.M. to 7:00 A.M. shift. The Surveyor interviewed the Administrator at 11:52 A.M. on 3/4/19. The Administrator said there should be two staff for all transfers using the sit to stand mechanical lift. The Surveyor interviewed the Director of Nurses at 2:50 P.M. on 3/4/19. The Director of Nurses said Facility policies indicated staff were required to use two assist for transfers using the sit to stand mechanical lift, and staff accused of abuse would be suspended pending investigation.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), the Facility failed to develop a plan of care to meet Resident #1's bed mobility needs, and failed to ensure staff implemented the plan of care for transfers, when Certified Nurse Aide (CNA) #1 transferred Resident #1 without a second staff member present as required. Resident #1 sustained skin tears to his/her right arm and right leg. Findings include: The Facility policy titled, Person Centered Care Plan, dated 3/1/18, indicated a comprehensive, individualized care plan would be developed within seven days of completion of the comprehensive assessment that would include needs that are identified in the comprehensive assessment, and documentation would show evidence of development of care planning interventions for all care area assessments triggered by the Minimum Data Set (MDS). The Facility policy titled, Safe Resident Handling and Transfer Equipment, dated 5/15/17, indicated use of the sit to stand mechanical lift required two staff members. Resident #1 was admitted to the Facility in (MONTH) 2014, [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment, dated 12/26/18, indicated Resident #1 required extensive assistance from two staff member for transfers. The Care Plan, dated 9/13/2017, indicated Resident #1 required assist of two staff members with the sit to stand mechanical lift for transfers. The Facility's Event Summary Report, dated 2/11/19, indicated Resident #1 sustained skin tears to his/her right upper arm and right thigh. The Report indicated Resident #1 said CNA #1 was rough when putting him/her to bed. The Surveyor interviewed Nurse #1 at 10:08 A.M. on 3/5/19. Nurse #1 said that at approximately 11:40 P.M. on 2/10/19, she asked CNA #1 to help Resident #1 go to bed, and saw CNA #1 bring Resident #1 to his/her room. Nurse #1 said approximately 2-5 minutes after CNA #1 brought Resident #1 to his/her room, CNA #1 came to her and said Resident #1 was bleeding. Nurse #1 said she found Resident #1 sitting on the edge of his/her bed, with the bedside table in front of him/her, and was bleeding from skin tears on his/her right arm and right thigh. Nurse #1 said Resident #1 told her CNA #1 caused the skin tears. The Surveyor interviewed CNA #1 at 11:55 A.M. on 3/5/19. CNA #1 said she knew it was Facility policy to use two staff members for sit to stand mechanical lift transfers. CNA #1 said that on 2/10/19, some time at the beginning of the 11:00 P.M. to 7:00 A.M. shift, she transferred Resident #1 to bed using the sit to stand transfer device, without a second staff member present. CNA #1 said after she got Resident #1 to bed she tried to roll Resident #1 over in the bed to provide care, and Resident #1 began hitting her on her arms. CNA #1 said Resident #1 was yelling and screaming, and continued to try to hit and kick her, which was when she noticed Resident #1 had skin tears to his/her right arm and leg. CNA #1 said she knew all sit to stand mechanical lift transfers should have been performed using a minimum of two staff members. CNA #1 said she should have had another staff member with her while transferring Resident #1 with the sit to stand mechanical lift. The Surveyor interviewed the Director of Nurses at 2:50 P.M. on 3/4/19 and again at 2:37 P.M. on 3/8/19. The Director of Nurses said Facility policies indicated staff were required to use two assist for sit to stand mechanical lift transfers, and said CNA #1 should have had a second staff person with her to do the sit to stand mechanical lift transfer for Resident #1.

Based on record review and interviews for 2 of 3 residents (Residents #1 and #2), the Facility failed to ensure that staff administered prescribed medications in the correct dose and at the correct times as ordered by the Physician. Findings include: The Facility's Policy titled Medication Error dated 1/2/14, indicated a medication error is defined as a discrepancy between what the physician ordered and what the patient received. Types of errors include medication omission; wrong patient, dose, route, rate or time; incorrect preparation; and/or incorrect administration technique. Resident #1 was admitted to the Facility in September 2015 and his/her [DIAGNOSES REDACTED]. The physician's orders [REDACTED].#1 was prescribed [MEDICATION NAME] (a narcotic [MEDICATION NAME] medication) 30 milligrams (mg) every 4 hours as need (PRN) for pain. The Substance Control Record, Page 191, indicated Resident #1 was prescribed one 30 mg tablet of [MEDICATION NAME] every 4 hours PRN for pain. The record indicated that on 10/19/15, a total of 12 tablets of [MEDICATION NAME] 30 mgs were signed out in a 3.5. hour period, between 9:30 A.M. and 1:00 P.M. A Nurse Progress Note, dated 10/19/15, indicated at 12:30 P.M. Resident #1 was discovered lying across his/her bed looking up at the ceiling, he/she had hand tremors and initially was not responding to verbal stimuli. The progress note indicated that within a few minutes Resident #1 blinked his/her eyes and started to speak, but was unaware of the event he/she had just experienced. The progress note indicated Resident #1 was evaluated by the Nurse Practitioner (NP) who instructed staff to monitor Resident #1's blood pressure and obtain blood tests on Resident #1. A Nurse Progress Note, dated 10/19/15 and documented on the 3:00 P.M. to 11:00 P.M. shift, indicated Resident #1 was lethargic but arousable, he/she refused to eat and kept dosing off in to a sleep. The progress note indicated Resident #1's pupils became pin point and non-reactive, the Physician was notified and Resident #1 was transferred to the Hospital. The Facility's Internal Investigation Report indicated Resident #1 received [MEDICATION NAME] (an opioid antagonist used to reverse the side effects of opioids, especially in the case of overdose) in the ER, and following over night observation was discharged back to the Facility without further incident. The Facility's Internal Investigation Report, dated 10/27/15, indicated that when interviewed by the Director of Nurses (DON), Nurse #1 said she popped out 6 pills of [MEDICATION NAME] at 9:00 A.M. which she gave to Resident #1, but when she went back after lunch time, Resident #1 was unable to take his/her pills and she wasted 6 pills of [MEDICATION NAME]. The Surveyor interviewed the Director of Nurses (DON) at 10:55 A.M. on 2/9/16. The DON said Nurse #1 said in the past Resident #1 received [MEDICATION NAME] 5 mg, 6 tablets, for a total dose of 30 mgs, but this order had been changed to [MEDICATION NAME] 30 mg, 1 tablet. The DON said that on 10/19/15, Nurse #1 did not check the dose of the medication against the medication card and the prescribed dose documented on the Substance Control Record, and as a result Resident #1 received [MEDICATION NAME] 30 mgs, 6 tablets , for a total of 180 mgs of [MEDICATION NAME]. Resident #2 was admitted to the Facility in May 2015 and his/her [DIAGNOSES REDACTED]. The physician's orders [REDACTED].#2 was prescribed [MEDICATION NAME] (an antidepressant medication) 7.5 mg daily at 8 :00 A.M. for 7 days, last dose to be administered on 12/28/15, and [MEDICATION NAME] (an opioid pain medication) 25 mgs daily at 8:00 A.M. The physician's orders [REDACTED].#2 was prescribed [MEDICATION NAME] 15 mg daily at hour of sleep. Resident #2's Medication Administration Record [REDACTED]. The DON said she was unsure why Resident #2's [MEDICATION NAME] was not administered on 12/23/15 and 12/26/15, but said Resident #2's [MEDICATION NAME] and [MEDICATION NAME] was omitted on 1/1/16, 1/2/16, and 1/3/16 due to an editing error which was not identified until 1/4/16.

Based on record review and interview, the facility failed to ensure nursing staff provided services in accordance with professional standards of quality, and failed to ensure accurate documentation of narcotics, for 1 of 3 sampled residents (Resident #1). On 10/19/15, Resident #1 was given 180 milligrams (mg) of [MEDICATION NAME] (a narcotic medication ) rather than 30 mgs as prescribed by the Physician. Resident #1 became lethargic and was transferred to the emergency room (ER) where he/she received [MEDICATION NAME] (an opioid antagonist used to reverse the side effects of opioids, especially in the case of overdose) and was admitted to the Hospital for overnight observation. In addition Nurse #2 signed she wasted 6 [MEDICATION NAME] 30 mg tablets on 10/19/15, however, Nurse #2 said she did not actually count the number of tablets or verify the name of the medications which were wasted. Findings included: Standard reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered nurse and Practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered nurse and practical nurse incorporate into the plan of care, and implement prescribed medical regimens. A nurse licensed by the Board shall not administer any prescription drug or non-prescription drug to any person in the course of nursing practice except as directed by an authorized prescriber. A nurse licensed by the Board shall document the handling, administration, and destruction of controlled substances in accordance with all federal and state laws and regulations and in a manner consistent with accepted standards of practice. The Facility's Policy titled General Dose Preparation and Medication Administration dated 3/1/11, indicated that prior to administering medications staff were to verify that the medication name and dose are correct. Resident #1 was admitted to the Facility in September 2015 and his/her [DIAGNOSES REDACTED]. The physician's orders [REDACTED].#1 was prescribed [MEDICATION NAME] (a narcotic [MEDICATION NAME] medication) 30 milligrams (mg) every 4 hours as need (PRN) for pain. The Substance Control Record, Page 191, indicated Resident #1 was prescribed one 30 mg tablet of [MEDICATION NAME] every 4 hours PRN for pain. The record indicated that on 10/19/15 a total of 12 tablets of [MEDICATION NAME] 30 mgs were signed out over a 3.5 hour period, between 9:30 A.M. and 1:00 P.M. An entry signed by Nurse #1 indicated that at 9:30 A.M. there were 103 [MEDICATION NAME] 30 mg tablets on hand. A second entry, signed by Nurse #1, and timed at 1:00 P.M. indicated there were 97 [MEDICATION NAME] 30 mg tablets on hand, amount used was not indicated and a hand written note indicated wasted, popped tablets with a remaining 91 tablets of [MEDICATION NAME] 30 mg on hand. A Nurse Progress Note, dated 10/19/15, indicated that at 12:30 P.M. Resident #1 was discovered lying across his/her bed looking up at the ceiling, he/she had hand tremors and initially was not responding to verbal stimuli. The progress note indicated that within a few minutes Resident #1 blinked his/her eyes and started to speak, but was unaware of the event he/she had just experienced. The progress note indicated Resident #1 was evaluated by the Nurse Practitioner (GNP) who instructed staff to monitor Resident #1's blood pressure and obtain blood tests on Resident #1. A Nurse Progress Note, dated 10/19/15 and documented on the 3:00 P.M. to 11:00 P.M. shift, indicated Resident #1 was lethargic but arousable, he/she refused to eat and kept dosing off in to a sleep. The progress note indicated Resident #1's pupils became pin point and non-reactive, the Physician was notified and Resident #1 was transferred to the Hospital. The Facility's Internal Investigation Report, dated 10/27/15, indicated Resident #1 received [MEDICATION NAME] in the ER, and following over night observation was discharged back to the Facility without further incident. A hand written statement, signed by Nurse #1 on 10/29/15, as part of the Facility's Internal Investigation, indicated that on 10/19/15, at 9:30 A.M. Resident #1 received all of his/her prescribed medications including [MEDICATION NAME]. The statement indicated that at 12:30 P.M. Resident #1 had a possible [MEDICAL CONDITION] and at 1:30 P.M. Resident #1 was lethargic and his/her afternoon medications were not administered and were flushed down the toilet. The Facility's Internal Investigation Report, dated 10/27/15, indicated that when interviewed by the Director of Nurses (DON), Nurse #1 said she popped out 6 pills of [MEDICATION NAME] at 9:00 A.M. which she gave to Resident #1, but when she went back after lunch time, Resident #1 was unable to take his/her pills and she wasted 6 pills of [MEDICATION NAME]. The Surveyor interviewed Nurse #2 at 1:06 P.M. on 2/9/16. Nurse #2 said that on 10/19/15, at approximately 1:30 P.M., she was approached by Nurse #1 who asked her to watch her waste mediations. Nurse #2 said she looked in the medication cup and saw some white pills, but did not pay attentation to the number of pills in the cup and she hurriedly signed the narcotic book without checking what she was signing.

Based on record review, observation and staff interview, the facility failed to adequately monitor and implement effective interventions to avoid weight loss for 1 resident (#7) in a total sample of 30 residents. Findings are: For Resident #7, the facility failed to address the resident's weight loss and implement interventions to prevent further weight loss. Resident #7 was admitted to the facility in 4/2013 with a fractured humerus and dementia. An initial weight for the resident of 139 pounds (lbs) was obtained on the day of admission. On 5/2/13, a nutrition assessment was completed. There were no nutrition concerns identified. An initial minimum data set ((MDS) dated [DATE] indicated the resident had cognitive impairment, needed extensive assistance for transfers, was totally dependent for ambulation and needed supervision for eating. The documented weight for the resident was 139 lbs. The CAA (Care Assessment Area) for nutrition noted no nutritional concerns and the decision was made to not proceed with a care plan for nutrition. On 5/29/13 clinical record review revealed the resident weighed 128.6 lbs, which is a 10.4 lb weight loss. Review of the resident's record indicated there were no interventions put into place when the resident's weight loss was recorded. On 6/6/13, the Nurse Practitioner wrote a progress note that indicated the resident's weight as being 129 lbs and the resident's right arm swelling had decreased, but made no mention of the resident's weight loss. On 6/17/13, the Nurse Practitioner ordered blood work and to be notified if the resident's weight decreased by 2 lbs in the following week. There were no other interventions put into place. The resident was observed eating lunch in the day room on 6/25/13 at 12:10 P.M. The resident only ate small bites of the food on the plate and then stated "I am done". The CNA supervising the day room took the tray away and placed it on the food cart without offering the resident an alternative meal. On 6/26/13, the resident weighed 126 lbs. On 6/26/13 at 12:15 P.M., the resident was observed eating lunch. The resident did not eat any of the food on the plate. The surveyor asked the resident if he/she was going to eat. The resident stated "No, I don't feel like it." When asked by the surveyor if he/she would like something else to eat, the resident stated "No, I'm all set, but I would like a drink". A full glass of milk was observed on the resident's tray. The milk was offered to the resident and the resident stated "Oh yes, I like milk." On 6/26/13 at 2:50 P.M., CNA #1 was interviewed. CNA #1 was stationed in the dayroom for lunch that day. CNA #1 stated the resident is not a big eater, but she eats better at breakfast." On 6/26/13 at 1:30 P.M., the DON (Director of Nurses) was interviewed. She stated she was unaware of the resident's weight list, as the resident did not appear on the weight watch list. On 6/26/13 at 3:00 P.M., an interview was conducted with the dietician. The dietician stated she was unaware of the resident's weight loss. The resident did not show up on her weight watch list. When asked how this may have happened, the dietician stated that if a "0" is entered into the computer a weight for a resident (indicating that for some reason a weight had not been taken on a particular day), the next weight recorded would show up as a weight gain. She stated a "0" should not be entered into the computer as a weight but instead the computer should indicate that a weight had not been taken. On 6/26/13 at 3:15 P.M., the Unit B Charge Nurse was interviewed. The Charge Nurse stated nurses input the weight into the computer. She also stated that the previous weights are not always viewable in the computer. It depends on how you access the program. On 6/26/13 at 3:30 P.M., during an interview, the DON stated the doctor was notified of the resident's weight loss and ordered supplements for the resident.

Based on record review and staff interview, the Facility failed to ensure for one of four sampled residents (Resident #1), that Resident #1 was told the raised toilet seat with side bars was to be removed, and given the option to continue the use of the raised toilet seat with side bars for comfort and safety. Consequently, on 4/8/10 at approximately 7:00 PM, Resident #1, who was legally blind and unaware that the raised toilet seat had been removed from the toilet, reached for the missing raised toilet seat side bars to prevent Resident #1 from falling while Resident #1 attempted to remove wet slacks. Resident #1 lost Resident #1's balance, fell on the buttocks, and complained of right hip pain. A right hip X-ray taken on 4/8/10 was negative for any fractures and Resident #1 had right leg pain which was relieved by pain medication. Unit Manager #1 said that on 4/10/10, the Physician was notified that Resident #1 was unable to bear weight, the Physician ordered Resident #1 sent to the Hospital, where another X-ray showed an undisplaced fracture of the right pubic ramus. Findings included: Resident #1 was admitted to the Facility January of 2010, and [DIAGNOSES REDACTED]. The Care Plan dated 1/14/10, indicated that Resident #1 was at risk to fall due to impaired vision.Care plan interventions included non skid socks, call light within reach, and monitor and assist with all toileting needs. The admission Minimum Data Set (MDS) assessment, dated 1/25/10, indicated that Resident #1: had no memory deficits, was independent in daily decision making, and required extensive assistance in toileting and transfers. Family Member #1 was interviewed on 8/15/11 at 1:00 PM. Family Member #1 said that Resident #1 fell because the staff failed to provide a raised toilet seat for Resident #1, so Resident #1 fell off of the toilet on 4/8/10. The Occupational Therapist was interviewed on 8/15/11 at 1:20 PM.The Occupational Therapist said and the Occupational Therapy notes dated 4/1/10, indicated that Resident #1 required moderate assistance to the bathroom. The Facility's incident report and fall investigation, dated 4/8/10, indicated that Resident #1 was found sitting on the buttocks at approximately 7:00 PM, in the bathroom. The incident report indicated that Resident #1 complained of right hip pain, The Health Care Agent and the Physician were notified, and the Physician ordered a right hip x-ray. The incident report and fall investigation indicated that Resident #1 said that Resident #1 was getting off of the toilet, and was changing wet slacks when Resident #1 fell . The fall investigation indicated that Resident #1 said Resident #1 was unaware that the raised toilet seat was not on the toilet, Resident #1 reached for the side bars, lost Resident #1's balance and fell . The right hip x-ray report, dated 4/8/10, indicated that Resident #1 had no fracture or acute dislocation, and the pubic rami (pelvis) bones were normal. Unit Manager #1 was interviewed on 8/15/11 at 11:15 AM. Unit Manager #1 said a right hip X-ray taken on 4/8/10 was negative for any fractures and Resident #1 had right leg pain which was relieved by pain medication. Unit Manager #1 said that on 4/10/10, the Physician was notified that Resident #1 was unable to bear weight, the Physician ordered Resident #1 to the Hospital, where another X-ray showed an undisplaced fracture of the right pubic ramus. The Hospital Discharge Summary indicated that Resident #1 was admitted on [DATE] for a mechanical fall with inferior pubic ramus fracture after Resident #1 fell off the toilet seat. The Hospital Discharge Summary indicated that Resident #1 was seen by Orthopedics and physical therapy was recommended, and Resident #1 was discharged back to the Facility for Rehabilitation on 4/12/10. The Director of Nurses (DON) was interviewed on 8/15/11 at 9:00 AM. The DON said that Resident #1 used the roommate's raised toilet seat, and it was unknown why on 4/8/10, the raised toilet seat was removed from the bathroom.