Every finding on record at Regalcare at Glen Ridge

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), the Facility failed to ensure they provided an environment free from safety hazards and adequate supervision to prevent an elopement. On 04/14/26 Resident #2 eloped from the Facility unbeknownst to staff. Facility staff were notified by local Hospital Emergency Department (ED) staff that he/she was there being evaluated. Staff were unaware he/she was missing from the Facility for over four hours.Findings include:The Facility Policy, titled Wandering Resident, dated as revised 04/2022, indicated a missing resident was considered a facility-wide emergency, and if a resident was missing the elopement emergency procedure would be initiated.The Facility Policy, titled Missing Resident/Elopement, dated as revised 03/2022, indicated staff would investigate and report all cases of missing residents. The Policy indicated staff were to attempt to locate any resident that was identified as missing.Review of the Report submitted by the facility via the Health Care Facilities Reporting System (HCFRS), dated 04/22/26, indicated that on 04/14/25 around 05:45 P.M., the Facility was notified by the Hospital Emergency Department (ED) that Resident #2 was being evaluated in the ED. The Incident Report indicated staff were unaware that Resident #2 had left the Facility earlier that day.The Facility's Investigation Report include a statement, dated 4/15/26, provided by the facility where Resident #2 was located, which indicated that on 04/14/26 at 1:30 P.M., the Director of Facility Operations for the Specialized Psychiatric Hospital located next door to the Facility was alerted that a resident (later identified as Resident #2) who was unknown to the Psychiatric Hospital, was found seated in a wheelchair near the loading dock area.Resident #2 was admitted to the Facility in September 2025, diagnoses included dementia, depression, anxiety, and diabetes.During an interview on 06/03/26 at 09:23 A.M., the Activities Director said that on 04/14/26 around 1:30 P.M., he was asked by Resident #2's family member to check on him/her because he/she was in the bathroom located on the ground floor across from the Cafe where he/she had been seen during the diabetic foot clinic. The Activities Director said he knocked on the bathroom door and Resident #2 said he/she was almost done, so he thought whoever helped Resident #2 get to the bathroom would come back and help him/her, so he left the area and returned to his office.The Activities Director was the last known Facility staff member to interact with Resident #2 that day.Review Certified Nurse Aide (CNA) #6's written witness statement, dated 04/14/26, indicated CNA #6 was assigned to care for Resident #2 on the 3:00 P.M., to 11:00 P.M., shift on 04/14/26. The Statement indicated CNA #6 could not locate Resident #2 on the unit at dinner time and thought he/she was in the Hospital.During an interview on 06/02/26 at 04:15 P.M., Nurse #5 said that on 04/14/26 she worked the 3:00 P.M., to 11:00 P.M., shift. Nurse #5 said at the beginning of her shift she noticed that Resident #2 was not on the unit but said he/she was often at activities so that's where she thought he/she was. Nurse #5 said she was not aware that Resident #2 was not in the Facility until 06:00 P.M., when she was notified via telephone by the Hospital that Resident #2 was in the Emergency Department.Nurse #5 said CNA #6 did not tell her that Resident #2 was not on the unit for dinner. Nurse #5 said she would have initiated the Facility's Elopement Procedure if she knew Resident #2 was missing.During an interview on 06/03/26 at 10:05 A.M., the Director of Nursing (DON) said at the time Resident #2 eloped, there was no system in place to sign residents on and off the unit. The DON said staff should have been aware of where Resident #2 was after the diabetic foot clinic or should have looked for him/her when he/she was not on the unit for dinner but had not.During an interview on 06/02/26 at 3:00 P.M., the Administrator said through an investigation, the Facility had determined that on 04/14/26 around 2:00 P.M., Resident #2 left the Facility through a side door located down a hallway from the bathroom where he/she had last been known to be. The Administrator said the side door did not have an alarm and was unlocked from the inside, however the door locked from the outside once closed. The Administrator and the Surveyor observed that there was a walkway located outside the side door that led down a slope and over to the loading dock area of the Facility next door, where Resident #2 was located by staff at that Facility.

Based on interview and record review, the facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted within 14 days after a resident assessment was completed for six Residents (#49, #4, #10, #86, #123 and #7), out of a total sample of 34 residents.Findings include:Review of Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual, Version 3.0, indicated assessments must be completed no later than 14 calendar days after the assessment reference date (ARD) and transmitted and encoded within 7 days of assessment completion. 1a. Resident #49 was admitted to the facility in July 2024 with diagnoses that included contracture of the muscle and bilateral primary osteoarthritis of the knee.Review of Resident #49's most recent Minimum Data Set (MDS) Assessment, dated 7/30/25, indicated a Brief Interview for Mental Status (BIMS) score of 5 out of a possible 15 indicating that the Resident has severe cognitive impairment.Further review of the MDS Assessment, with an ARD of 7/30/25, indicated that it was completed on 8/28/25 and submitted on 9/2/25, 34 days after the ARD date. 1b. Resident #4 was admitted to the facility in November 2024 with diagnoses that included follicular lymphoma and ischemic cardiomyopathy.Review of Resident #49's most recent MDS Assessment, dated 7/30/25, indicated a BIMS score of 15 out of 15, indicating that the Resident is cognitively intact.Further review of the MDS Assessment, with an ARD of 7/30/25, indicated that it was completed on 8/29/25 and submitted on 9/2/25, 34 days after the ARD date. 1c. Resident #10 was admitted to the facility in April 2025 with diagnoses that included muscle weakness and diabetes.Review of Resident #10's most recent MDS Assessment, dated 7/30/25, indicated a BIMS score of 11 out of 15, indicating the Resident had moderate cognitive impairment.Further review of the MDS Assessment, with an ARD date of 7/30/25, indicated that it was completed and submitted on 9/2/25, 35 days after the ARD date. 1d. Resident #86 was admitted to the facility in October 2024 with diagnoses that included diabetes and radiculopathy.Review of resident #86's most recent MDS Assessment, dated 4/9/25 indicated a BIMS score of 11 out of 15, indicating the Resident had moderate cognitive impairment.Further review of Resident #86's medical record on 9/4/25 indicated an MDS Assessment in progress, but not yet completed, dated 7/9/25. 1e. Resident #123 was admitted to the facility in January 2025 and has diagnoses that include spinal stenosis, chronic kidney disease, and vascular dementia.Review of Resident #123's most recent MDS Assessment, dated 7/30/25, indicated a BIMS score of 4 out of a possible 15 indicating that Resident #123 has severe cognitive impairment.Further review of the MDS Assessment, with an ARD of 7/30/25, indicated that the MDS was completed on 8/29/25 and submitted 9/2/25, 34 days after the ARD date. 1f. Resident #7 was admitted to the facility in April 2025 with diagnoses that included dysphagia and diabetes.Resident #7's most recent Minimum Data Set, dated [DATE], indicated a BIMS score of 9 out of a possible 16, indicating moderate cognitive impairment.Review of Physician's orders indicated the following order dated 9/1/25:-Admit to hospice- 6/16/25, Dx (diagnosis) Primary Biliary cirrhosis.Review of the Significant Change MDS, dated [DATE], indicated that the MDS was completed on 7/23/25 and submitted on 7/24/25, 31 days after the ARD date. During an interview on 9/5/25 at 8:18 A.M., the MDS nurse said that she started working in the facility at the end of July. She said that when she started working here there was a big back log of MDS assessments that had not been completed because no one was in the position prior to her arrival. She said that the expectation is that MDS assessments are completed and submitted as indicated in the RAI manual. She said all MDS assessments should be submitted timely within the 14 days. During an interview on 9/9/25 at 9:56 A.M., the Director of Nurses said she would expect that MDS Assessments were submitted timely as per the RAI manual.

Based on resident interviews and test tray results, the facility failed to ensure foods provided to the residents were prepared by methods that conserve palatability and are at appetizing temperatures on four of four units.Findings include:During the resident screening process, numerous residents of the facility expressed concern to the surveyors regarding the quality and the temperature of the food, especially the breakfast meals.On 9/8/25, the surveyors conducted test tray audits for the breakfast meals on all units of the facility, the results were as followed: On the [NAME] Unit, the meal carts arrived on the unit at 8:17 A.M., the surveyor received the test tray at 8:33 A.M., 16 minutes later. The following was recorded:- The Banana French Toast Casserole was 110 degrees Fahrenheit, was lukewarm but not hot, and tasted unappetizing.- The Oatmeal was 113 degrees Fahrenheit, was warm to taste, not hot, and tasted very bland.- The Sausage was 110 degrees Fahrenheit, was warm but not hot, and was hard to chew and was dry.- The milk was 50 degrees Fahrenheit, was cool but not cold.- The juice was 50 degrees Fahrenheit, was cool but not cold. On the Oakgrove Unit, the meal cart arrived on the unit at 8:40 A.M., the surveyor received the test tray at 8:49 A.M., the following was recorded:- The Banana French Toast Casserole was 141 degrees Fahrenheit, was warm but not hot, and tasted bland.- The oatmeal was 109 degrees Fahrenheit, was warm but not hot, and tasted very bland.- The milk was 48 degrees Fahrenheit, was cool but not cold.- The juice was 53 degrees Fahrenheit, was cool but not cold. On the Maplewood Unit, the meal cart arrived at 8:51 A.M., the surveyor was informed the test tray was arriving on a rolling cart, not the meal cart. At 9:09 A.M., the surveyor received the test tray, 18 minutes later. The following was recorded:- The Banana French Toast Casserole was 102 degrees Fahrenheit, was lukewarm but not hot, and tasted unappetizing.- The oatmeal was 90 degrees Fahrenheit, was warm to taste, not hot, and tasted very bland.- The Sausage was 100 degrees Fahrenheit, was warm but not hot, and was hard to chew on the ends.- The milk was 52 degrees Fahrenheit, was cool but not cold.- The juice was 52 degrees Fahrenheit, was cool but not cold. On the [NAME] Unit, the meal cart with the test tray arrived on the unit at 9:09 A.M., the surveyor received the test tray at 9:29 A.M., 20 minutes later. The following was recorded:- The Banana French Toast Casserole was 66 degrees Fahrenheit, was cool and not warm, and tasted unappetizing with no banana flavor detected.- The Oatmeal was 97 degrees Fahrenheit, was warm to taste, not hot.- The Sausage was 101 degrees Fahrenheit, was warm but not hot, and was hard to cut in half.- The milk was 50 degrees Fahrenheit, was cool but not cold.- The juice was spilled on the tray. The surveyor received a new cup of juice and was 59 degrees Fahrenheit, was cool but not cold and tasted sour. During an interview on 9/8/25 at 1:58 P.M. with the facility's Food Service Director and the Corporate Food Service Director, the surveyors shared the test tray results. Both Food Service Directors said they would expect the residents to have palatable meals that taste good and to be at an appropriate temperature. The Food Service Directors agreed that the temperatures were not satisfactory.During an interview on 9/9/25 at 9:14 A.M., the Director of Nursing said she would expect Residents to have palatable meals at an acceptable temperature.

Based on observation, record review and interviews, the facility failed to ensure for one Resident (#121), out of 34 sampled residents, that his/her dignity was maintained at the highest practical level of wellbeing. Specifically, the facility failed to maintain Resident #121's dignity by failing to provide incontinence care timely resulting in Resident #121 walking around the unit with a soiled brief with his/her pants visibly wet, emitting an odor and eating a meal with a soiled brief. Findings include: Review of the facility's policy, titled, 'Dignity' includes but is not limited to the following: Policy Statement: Each Resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem. Policy Interpretation and Implementation 1. Residents are treated with dignity and respect at all times. Resident #121 was admitted to the facility in August 2025 with diagnoses that include but not limited to adult failure to thrive, dementia, adjustment disorder with mixed anxiety and depressed mood, and incontinence without sensory awareness. Review of the Minimum Data Set (MDS) indicated it was not completed at the time of the review. Review of the most recent Nursing assessment dated [DATE] indicated Resident #121 was oriented to person and had short term memory issues. Further, the Nursing Assessment indicated Resident #121 bladder history as always incontinent and always incontinent of bowels. Review of Resident #121's care plans failed to indicate a care plan to address Resident #121's incontinence of bowel and bladder. On 9/3/25 at 8:13 A.M., the surveyors made the following observations on the [NAME] Unit: -Resident #121 was in the hallway walking and when he/she walked by the surveyor, a foul odor was emitted from the Resident. The backside of Resident #121's green pants was dark in color consistent with being wet, which extended down the top of the right and left pant legs. Resident #121's brief was bulged on the right side. Resident #121 had a flat, furrowed brow and fiddled with his/her shirt. Resident #121 continued to walk between the medication carts that were parked across from the nursing desk. Nurses were at each medication cart. -At 8:15 A.M., Resident #121 was observed reaching back around his/her pants, with a flat facial expression. -At 8:20 A.M., another resident approached Resident #121 and gave him/her a hug. Resident #121 continued to walk back and forth between the medication carts and observed to be wet on his/her backside. A hospice nurse was present at the nursing desk and was seen looking at Resident #121. In addition, other residents were walking or wheeling in their wheelchairs by Resident #121. -At 8:22 A.M. a resident walked up to Resident #121 and took him/her by the hand and walked down the hallway together. -At 8:25 a Nurse Practitioner (NP) said he was the psych NP and was observing Resident #121 walk and was reviewing his/her medication. The psych NP said the Resident had an odor and needed to be changed. -At 8:31 Resident #121 and another resident continued to walk together in the hallway. When Resident #121 walked by there was a foul odor and the back of his/her pants was dark with a wet area. Staff walked by the Resident several times. -From 8:33 A.M., to 8:39 A.M., Resident #121 continued to walk in the hallway exposed to staff and others with wet and likely a soiled brief as evidenced by the foul odor. -At 8:39 A.M., a Certified Nursing Assistant (CNA) approached Resident #121 took him/her by the hand and walked him/her to the dining room, which was occupied by other residents. Resident #121 did not stay in the room and continued to walk with his/her wet/soiled pants on the unit. - At 8:44 A.M., Nurse #8 walked right by Resident #121 near the doorway of the dining room. Resident #121 then walked near the medication cart and another resident standing close to the Resident said to Nurse #8 what is that smell? -At 8:56 A.M. Nurse #8 asked Resident #121 to sit down on the bench next to the medication cart where he/she remained with a flat distressed facial expression, and slightly rocking in his/her seated position until 9:09 A.M., -At 9:09 A.M., Nurse #8 approached Resident #121 and said it is time to eat and walked Resident #121 into the dining room and assisted him/her to sit at a table, failing to recognize that Resident #121 needed care, resulting in Resident #121 eating his/her breakfast with wet/likely soiled brief from 9:09 A.M. 9:56 A.M. -At 9:56 A.M., Resident #121 finished with his/her breakfast.- At 9:57 A.M., a Nurse provided Resident #121 with a boost nutritional drink and left the Resident in the dining room.-At 10:11 A.M., Resident #121 repositioned him/herself in the chair in the dining room, going from sitting to standing, now standing and attempting to ambulate around dining room holding the hand of another resident. Resident #121's brief is bulged in back of his/her pants and is wet. -At 10:14 A.M., Resident #121 remains standing in the dining room.-At 10:15 A.M., another resident is trying to help, saying he/she is hungry and trying to get him/her food. Resident #121 moved to and is sitting in another chair. -At 10:19 A.M., a CNA provided a snack to Resident #121.-At 10:24 A.M., a staff member was observed talking to Resident #121, pushing his/her chair in closer to the table. -At 10:30 A.M., the Assistant Director of Nursing entered the dining room and greeted residents in the room-At 10:31 A.M., Resident #121 was trying to stand up and a staff member said please sit down. -At 10:46 A.M., the nurse administered medications to Resident #121 standing on his/her right side. -At 10:48 A.M., three staff were standing around Resident #121. CNA #7 asked Resident #121 to come with her. There was a foul strong odor around Resident #121. CNA #7 was encouraging Resident #121 to go into the shower area. Using the reasonable person standard under the circumstances of having a wet, soiled brief and emitting an odor, being exposed to others in the community would not be in alliance with a dignified living experience for Resident #121. During an interview on 9/3/25 at 11:00 A.M., CNA #7 said she started her shift at 7 (A.M.) and is assigned to care for Resident #121. CNA #7 said this was her first time caring for Resident #121. CNA #7 said she had not provided care including incontinence care since she started her shift. CNA #7 said residents who require incontinence care should be changed when needed and twice during the shift. CNA #7 said it would not be comfortable to have a wet/soiled brief, and it would not be comfortable to eat while in a wet/soiled brief. During an interview on 9/8/25 at 4:26 P.M., CNA #6 said residents who have incontinence are changed when they are wet or soiled, checked before and after meals and changed if needed, and when the resident is helped to bed. CNA #6 said a resident should not walk around with a visible wet or soiled brief and should not eat a meal with a wet or soiled brief. During an interview on 9/8/25 at 4:43 P.M., Nurse #8 who was present during the observation of Resident #121 said she did not recall the Resident being visibly wet. Nurse #8 said it should have been addressed, and it would not be comfortable or appropriate for residents to be walking around wet and soiled. During an interview on 9/9/25 at 11:46 A.M., Nurse #3 said if a resident was observed with wet pants and with an odor they should be changed. Nurse #3 said that Resident #121 did have an odor that she smelled later, when she helped the CNA with Resident #121 care. Nurse #3 said it would not be comfortable to eat a meal while wet or soiled. During an interview on 9/8/25 at approximately 5:30 P.M., the surveyor relayed the observation of Resident #121 to the Administrator, with an Administrator in Training (AIT) #1 present for part of the interview. The Administrator said he was sad to hear the observation, that activities of daily living and care with dignity had been a focus for the facility and that the Resident should have been provided care and dignity.

Based on observation, record review and interviews, the facility failed to implement policies and procedures to protect one Resident (#101) from potential abuse, out of 34 sampled residents. Specifically, for Resident #101, who is assessed with severe cognitive impairment, the facility failed to identify a facial injury, report the facial injury to administration, and failed to implement a timely and thorough investigation of the facial injury. Findings include: Review of the facility's policy titled Abuse Prevention, dated revised 3/2022 indicated the Purpose: to allow residents freedom from the risk of abuse, neglect, involuntary seclusion, and misappropriation and exploitation of resident property. Abuse: Identification and Reporting Purpose to proactively identify any event that may be potential abuse, neglect, involuntary seclusion, or misappropriation of resident property and report that event to the appropriate agencies. MA: Each facility shall immediately report to the Department of Public Health suspected of resident abuse, neglect mistreatment or misappropriation of resident property. Federal Regulations: All alleged violations are reported immediately to the administrator and to other officials in accordance with state law. All alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in process. Procedure 2. Resident injuries of unknown etiology, as well as occurrences, patterns and trends that may constitute abuse will be fully investigated to determine the cause. Resident #101 was admitted to the facility in June 2022 with diagnoses that include but are not limited to major depressive disorder, unspecified dementia severe, with other behavioral disturbance, presbyopia (a gradual loss of the eye to focus on nearby objects) and Alzheimer's disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/25/25, indicated that the Resident was unable to participate in the Brief Interview for Mental Status exam, and was assessed by staff as having severe cognitive impairment. The MDS further indicated that Resident #101 required substantial/maximal assistance for activities of daily living including bathing, toileting, hygiene and lower body dressing. Further, the MDS indicated Resident #101 exhibited physical and verbal behaviors on 4-6 days of the look back period, rejected care 1-3 days of the look back period and wandered 4-6 days. During an observation on 9/3/25 at 8:31 A.M., Resident #101 was walking with another resident down the hallway holding hands. Resident #101's head was bent forward, was petite and frail in stature and had a faded area descending down the left side of his/her face consistent with a fading bruise. Resident #101 did not respond to the surveyor's greeting and could not participate in an interview. Resident #101 was observed to continue to walk around the unit freely. The surveyor requested and received incident reports for Resident #101. Review of the incident report 'Falls Incident Packet' dated 8/17/25, time of incident was left blank, indicated: Un-witnessed fall dated 8/17/25 at 20:04 (8:04 P.M.) location resident's room. Incident description: Resident was in bed sleeping, he/she was found on the floor in front of his/her bed. Large redness noted on the left side of his/her face from his/her head to his/her mouth 13 cm (centimeter) long and his/her chin 5 cm long. Resident unable to give description. Was the incident witnessed: N (No). Mental Status: disoriented x 3 (person, place and time) No injuries observed at time of incident. The statement of no injury conflicts with the identification of the large redness noted on Resident #101's face. Further review of the incident report included Incident Investigation Statements. Nurse #10's Incident Investigation Statement, signed and dated 8/19/25 two days after the fall incident report, indicated the following: I was (Resident #101's) nurse on Sunday August 17, 2025, on the 3-11 PM shift. Upon my arrival on the floor Pt (patient) was in deep sleep until 8:35 P.M., Pt came out of his/her room with a bruise shown on his/her face which wasn't new. When I asked couple of staff members that was regular on the unit, they claim that it wasn't new and it had been there. I've (sic) also asked if the pt had recently been to the hospital. I was told that they had no idea. Pt got assistance from his/her nurse in order to use the bathroom Pt got fed his/her dinner by primary nurse. Pt got cleaned up took his/her med (medication) and went to bed for the night.' (sic) Review of the medical record failed to indicate Nurse #10 documented a progress note regarding the bruise on Resident #101 or that a fall occurred, which is in conflict with the fall incident report, indicating Resident #101 was found on the floor in front or his/her bed.Further review of the documented progress notes from 8/6/25 through 8/17/25 failed to indicate that Resident #101 sustained an injury/bruise or large redness on his/her face as a result of a fall. The last previous Incident Report was dated 6/25/25. Review of a statement emailed by Nurse #11, dated 8/19/25 indicated the following written by Nurse #11, 'Having gotten to work early on Sunday, and after doing my rounds. Resident #101 was noted sitting on the bench by the Nurse Station with a bruised face and alone. Answering my questions as to why the resident had bruises and why he/she was not in bed at 11pm, the outgoing nurse (Nurse #10) explained that because the Resident had fallen a few shifts prior, that she was trying to write report/note on him/her. Since I hadn't worked on [NAME] (facility unit) for Months, I said ok.'(SIC) Review of Resident #101's medical record failed to indicate that Resident #101 sustained a fall or any injury a few shifts prior to 8/17/25. Review of Incident Investigation Statements provided by staff members failed to indicate any statement indicating staff were aware of any fall or incident resulting in Resident #101's large redness or bruise on Resident #101's face. One staff member statement dated 8/19/25 indicated the following: I saw him/her (Resident #101) when I coming on Sunday, the morning the CNA (certified nursing assistant) (7:00 A.M.-3:00P.M.) who took care of clean him/her up and put him/her to bed. He/She .all day sleeping until 11 PM night when I was about to leave I overheard the other Nurse tell him (Nurse #11) he/she fall 2-3 days ago, he/she has bruise on his/her face but I did not see his/her face I was asking the nurse how did she know he/she had a fall 2-3 days ago cause you wasn't here if that happened don't say that and I left the floor. (sic)The surveyor made a call to Nurse #10 on 9/9/25 at 1:08 P.M. and did not reach Nurse #10 and was unable to leave a voice message for a call back. During an interview on 9/9/25 at 9:48 A.M. Nurse #3 said she worked on 8/18/25 on the day shift, and said Resident #101 was sleeping at the beginning of the shift and when he/she got up around 10:00 A.M., she saw a big bruise on his/her face. Nurse #3 said she did not get anything on report from the 11:00 P.M.-7:00 A.M. nurse about any incident, fall, or injury to Resident #101's face. Nurse #3 said she told Unit Manager #1. During an interview with the Director of Nursing (DON) on 9/9/25 at 8:53 A.M. she said the [NAME] Unit is challenging. The DON said Resident #101 is a fall risk, bumping into things, touching other residents and wandering a lot. The DON said the outgoing nurse on 8/17/25 did not fill out a fall incident report but reported to the 11:00 P.M.-7:00 A.M. nurse that the bruise was from a fall. The DON said there should be an incident report filled out at the time of any incident. The DON said the bruise is not an injury of an unknown source. When asked how it was determined the Resident sustained a fall the DON said because the Nurse (#10) said it was a fall but did not do the required incident report. The DON said it was investigated, and they obtained statements from staff. The DON said Nurse #10 has not been on the schedule since 8/17/25. Review of the notes in the medical record with the DON failed to indicate there was a fall, a known source of the injury or any documentation of how Resident #101 sustained the large bruise on the left side of Resident #101's face. During an interview on 9/9/25 at 9:58 A.M., Unit Manager #1 said an investigation was started on 8/18/25 after Nurse #3 brought the large bruise on Resident #101's face to her attention (which was over 13 hours after Nurse #10 documented in her statement that she saw a bruise on 8/17/25 at 8:35 P.M on Resident #101's face.) Unit Manager #1 said Nurse #10 failed to validate through record review that the facial bruise was not new. Unit Manager #1 said Nurse #10 did not document in the medical record about the bruise, did not call the medical provider or family, failed to complete nursing assessments and did not complete an incident report for the facial bruise. Unit Manager #1 said all injuries of unknown source need to be reported within two hours and investigated. When asked how it was determined and documented by her, on the incident report dated 8/18/25 that Resident #101 sustained a fall, was found in his/her room on the floor, resulting in a large redness area on his/her face, Unit Manager #1 said because Resident #101 is a high fall risk, Nurse #10 who worked on the 3:00 P.M.-11:00 P.M. shift on 8/17/25, said to Nurse #11 that the Resident had a fall, and because one CNA heard Nurse #10 tell Nurse #11 that the bruise was from a fall 2-3 days ago she assumed/believed that Nurse #10 saw a fall and did not do anything. Unit Manager #1 said Nurse #10 could not be reached to obtain further information and has not continued to work at the facility. The statement written by Nurse #10 said the bruise was not new and failed to indicate Resident #101 had a fall with a facial injury on 8/17/25. Resident #101's medical record did not indicate Resident #101 sustained a fall resulting in a facial injury the 2-3 shifts prior to 8/17/25. This failure resulted in the facility failing to identify, report, and thoroughly investigate a large facial bruise on Resident #101. During a telephone interview on 9/11/25 at 1:21 P.M., the Administrator said he was familiar with the incident report for Resident #101, and he sees it as sloppy documentation, and said staff did not follow policy.

Based on observations, record review and interviews, the facility failed to accurately code three Minimum Data Set (MDS) assessments, for one Resident (#144), out of a total sample of 34 residents. Specifically, the facility failed to accurately reflect Resident #144's status related to his/her left upper extremity range of motion. Findings include:Resident #144 was admitted to the facility in November 2021 and has diagnoses that include but are not limited to cerebral infarction, hemiplegia (a condition characterized by paralysis that affects only one side of the body) and hemiparesis (a one-sided muscle weakness) following a cerebral infarction affecting right dominant side, type 2 diabetes mellitus, and unspecified dementia. Review of the Minimum Data Set assessment, dated 5/28/25, indicated Resident #144 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS) exam, indicating he/she as having severely impaired cognition. During an observation on 9/3/25 at 12:35 P.M., Resident #144 was sitting at a table in the dining room. Resident #144's left arm was held in a position by his/her side and left forearm was held across his/her body with his/her hand bent around a crayon that was in his/her palm. Resident #144 was reaching his/her right hand down to his/her shoe and his/her left arm remained against his/her chest. On 9/4/25 the surveyor made the following observations: -At 7:34 A.M., Resident #144 was lying in his/her bed with his/her left arm against his/her side and forearm across his/her body and his/her fingers folded in. Resident #144 when asked, unfolded his/her fingers. Resident #144 said his/her arm is stiff and has pain when he/she moves his/her arm. -At 8:24 A.M., the surveyor entered Resident #144's room and the bathroom door was open and a Certified Nursing Assistant (CNA) was present providing care. Resident #144 was observed sitting on the toilet with his/her left arm positioned against his/her body and his/her forearm held across his/her body against his/her chest. -At 9:09 A.M., staff set up Resident #144's breakfast tray in the dining area. Resident #144's left arm was held against his/her body and his/her forearm held across his/her chest. During an observation and interview on 9/8/25 at 5:11 P.M., Resident #144 was observed walking in the hallway with his/her arm against his/her body and forearm across his/her chest. CNA #6 walked with Resident #144 to his/her room. At approximately 5:14 P.M., CNA #6 said the Resident always keeps his/her arm held like that and demonstrated with her own arm how he/she holds his/her arm against his/her body and across his/her chest. CNA #6 said Resident #144's arm is impaired, that he/she does not move it on his/her own and is total assistance for dressing. CNA #6 said she did not get any instructions or made aware of any plan of care for Resident #144's left arm. During an interview on 9/4/25 at approximately 9:15 A.M., CNA #5 said Resident #144 holds his/her left arm the same way all the time. CNA #5 said during care she can move the Resident's arm, but it is stiff. CNA #5 said the Resident used to be able to move it more and now it is harder to move. During an interview on 9/8/25 at 12:12 P.M., Nurse #8 said Resident #144 always holds his/her left arm against his/her side and forearm across his/her body. Nurse #8 said this is not new and he/she has been like that for a long time. Review of the MDS assessments indicated the following: -A comprehensive MDS, dated [DATE] Resident #144 was not coded as having upper extremity (shoulder, elbow, wrist, hand) impairment -A quarterly MDS, dated [DATE] Resident #144 was not coded as having upper extremity impairment. -A quarterly MDS, dated [DATE] Resident #144 was not coded as having upper extremity impairment. Review of the MDS assessments failed to indicate that Resident #144 was accurately assessed and coded as having an upper extremity impairment. Review of the Occupational Therapy (OT) Evaluation dated 11/19/24 included but was not limited to the following: LUE (left upper extremity) shoulder = Moderately impaired-demonstrated 25-50% of full range; elbow/forearm = Moderately Impaired-demonstrates 26-50% of full range. The OT evaluation was performed and dated prior to the three MDS assessments and indicates Resident #144 as having impaired upper extremity range of motion on his/her left upper extremity. During an interview on 9/9/25 at 10:42 A.M., the MDS nurse said she is new to the facility and new at doing MDS assessments. The MDS nurse said the sources for completing an MDS would be observation of a resident, reviewing clinical documentation, consulting with PT (physical therapy) or OT. The MDS nurse said if a resident has a range of motion impairment it would be documented on the MDS. During this interview Unit Manager #1 joined the interview and said rehab (rehabilitation) saw the Resident many times. Unit Manager #1 said the way the Resident holds his/her left arm is his/her baseline. During an interview on 9/9/25 at 11:16 A.M., with Nurse #9, Unit Manager #1, MDS nurse and the Director of Rehabilitation (DOR), the MDS nurse said Resident #144 was coded on his/her admission MDS as having an impaired upper extremity. Nurse #9 reviewed the last three MDS assessments and said the last three MDS assessments were not accurate and need to be modified to accurately reflect the Resident upper extremity impairment. The DOR said the Resident's arm is fixed at the elbow, which is an impairment.

Based on observation, record review, and interview, the facility failed to follow professional standards of nursing practice for one Resident (#68) out of a total sample of 34 residents. Specifically, for Resident #68, the facility failed to administer medication via the correct route as stated in the physician's orders.Findings include:Resident #68 was admitted to the facility in December 2024 with diagnoses including Amyotrophic Lateral Sclerosis and dysphagia. Review of Resident #68's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 15 out of 15 indicating intact cognition. Further review of the MDS indicated that the Resident is dependent on staff for activities of daily living and does not reject care.During an observation on 9/3/25 at 9:34 A.M., Resident #68 was laying in his/her bed with his/her stomach exposed showing a percutaneous endoscopic gastrostomy (PEG) tube (a tube that provides direct route for the administration of medications, food and fluids). Resident #68 told the surveyor (while using his/her phone for speaking assistance) that he/she takes some of his/her medicine through the PEG tube as he/she prefers it that way.Review of Resident #68's physician's orders indicated the following:- Lasix Oral Tablet 20 MG (milligrams) (Furosemide) Give 20mg by mouth one time a day for edema.- IBU Oral Tablet 600 MG (Ibuprofen) Gibe 600 mg by mouth two times a day for painDuring a medication administration observation on 9/5/25 at 10:19 A.M., the surveyor observed Nurse #3 administer IBU Oral Tablet 600 MG via feeding tube despite the physician's order indicating by mouth.During an interview on 9/8/25 at 6:55 A.M., the overnight Nurse (Nurse #4) said Resident #68 receives his/her Lasix Oral Tablet 20 MG via feeding tube at 6:00 A.M., Nurse #4 confirmed with the surveyor that she administered the medication via the feeding tube. During a follow up interview at 7:06 A.M., Nurse #4 and the surveyor reviewed Resident #6''s physician's orders and she said she was not aware that the order indicated by mouth. Nurse #4 said physician's orders should be followed as ordered and if she were to question the order she would let the Director of Nursing know.During an interview on 9/8/25 at 9:57 A.M., Nurse #3 said she was not aware that the IBU 600 mg was ordered to be given by mouth and she thought the Resident took all medications via feeding tube. Nurse #3 said she thinks the order was put in incorrectly and she should have questioned it. During an interview on 9/9/25 at 9:14A.M., the Director of Nursing (DON) said she would expect all physician's orders to be administered as written and if a nurse has any doubts about an order then they should reach out to the DON or the physician. The DON said the medications were administered via the incorrect route.

Based on observations, record reviews and interviews, the facility failed to provide activities of daily living (ADL) timely to 1 Resident (#121), out of 34 sampled residents. Specifically, the facility failed to provide incontinence care timely to Resident #121, who is assessed as incontinent and is dependent on staff for daily care, resulting in Resident #121 walking around the unit and eating his/her breakfast with a soiled brief. Findings include: Resident #121 was admitted to the facility in August 2025 with diagnoses that include but not limited to adult failure to thrive, dementia, adjustment disorder with mixed anxiety and depressed mood, and incontinence without sensory awareness. Review of the Minimum Data Set (MDS) indicated it was not completed at the time of the review. Review of the most recent Nursing assessment dated [DATE] indicated Resident #121 was oriented to person and had short term memory issues. Further, the Nursing Assessment indicated Resident #121 bladder history as always incontinent and always incontinent of bowels. Review of Resident #121's care plans failed to indicate a care plan to address Resident #121's incontinence of bowl and bladder. Review of the 'Documentation Survey Report V2' a document that the Certified Nursing Assistants use to document data regarding a resident's ADLS indicated Resident #121 was dependent on staff for shower/bath, dependent for toileting hygiene, and incontinent of bladder and bowel from 9/1/25 through 9/8/25. On 9/3/25 at 8:13 A.M., the surveyors made the following observations on the [NAME] Unit: Resident #121 was in the hallway walking and when he/she walked by the surveyor a foul odor was emitted from the Resident. The backside of Resident #121's green pants was dark in color consistent with being wet, which extended down the top of the right and left pant legs. Resident #121's brief was bulged on the right side. Resident #121 had a flat, furrowed brow and fiddled with his/her shirt. Resident #121 continued to walk between the medication carts that were parked across from the nursing desk. Nurses were at each medication cart. -At 8:15 A.M., Resident #121 was observed reaching back around his/her pants, with a flat facial expression. -At 8:20 A.M., another resident approached Resident #121 and gave him/her a hug. Resident #121 continued to walk back and forth between the medication carts and observed to be wet on his/her backside. A hospice nurse was present at the nursing desk and was seen looking at Resident #121. In addition, other residents were walking or wheeling in their wheelchair by Resident #121. -At 8:22 A.M. a resident walked up to Resident #121 and took him/her by the hand and walked down the hallway together. -At 8:25 a Nurse Practitioner (NP) said he was the psych NP and was observing Resident #121 walk and was reviewing his/her medication. The psych NP said the Resident had an odor and needed to be changed. -At 8:31 Resident #121 and another resident continue to walk together in the hallway. When Resident #121 walked by there was a foul odor and the back of his/her pants was dark with a wet area. Staff walked by the Resident several times. -From 09/03/2025 8:33 A.M., to 8:39 A.M., Resident #121 continued to walk in the hallway exposed to staff and others with wet and likely a soiled brief as evidenced by the foul odor. -At 8:39 A.M., a Certified Nursing Assistant approached Resident #121 took him/her by the hand and walked him/her to the dining room, which was occupied by other residents. Resident #121 did not stay in the room and continued to walk with his/her wet/soiled pants on the unit. - At 8:44 A.M., Nurse #8 walked right by Resident #121 near the doorway of the dining room. Resident #121 then walked near the medication cart and another resident said to Nurse #8 'what is that smell' -At 8:56 A.M. Nurse #8 asked Resident #121 to sit down on the bench next to the medication cart where he/she remained with a flat distressed facial expression, and slightly rocking in his/her seated position until 9:09 A.M., -At 9:09 A.M., Nurse #8 approached Resident #121 and said it is time to eat and walked Resident #121 into the dining room and assisted him/her to sit at a table, failing to recognize that Resident #121 needed care, resulting in Resident #121 eating his/her breakfast with wet/likely soiled brief from 9:09 A.M. 9:56 A.M. eating his/her breakfast. -At 9:56 A.M., Resident #12 finished with his/her breakfast.- At 9:57 A.M., a Nurse provided Resident #121 with a boost nutritional drink and left the resident in the dining room.-At 10:11 A.M., Resident #121 repositioned him/herself the chair in the dining room, going from sitting to standing. now standing and attempting to ambulate around dining room holding the hand of another resident. Resident #121's brief is bulged in back of his/her pants and is wet. -At 10:14 A.M., Resident #121 remains standing in the dining room.-At 10:15 A.M., another resident is trying to help, saying he/she is hungry and trying to get his/her food. Resident #121 moved to and is sitting in another chair. -At 10:19 A.M. a CNA provided a snack to Resident #121.-At 10:24 A.M., a staff member was observed talking Resident #121, pushing his/her chair in closer to the table. -At 10:30 A.M., the Assistant Director of Nursing entered the dining room and greeted residents in the room-At 10:31 A.M. Resident #121 was trying to stand up and a staff member said please sit down. I -At 10:46 A.M., the nurse administered medications Resident #121 standing on his/her right side. -At 10:48 A.M., three staff were standing around Resident #121. CNA #7 asked Resident #121 to come with her. There was a foul strong odor around Resident #121. CNA was encouraging Resident #121 to go into the shower area. During an interview on 9/3/25 at 11:00 A.M., CNA #7 said she started her shift at 7 (A.M.) and is assigned to care for Resident #121. CNA #7 said this was her first time caring for Resident #121. CNA #7 said she had not provided care including incontinence care since she started her shift. CNA #7 said residents who require incontinence care should be changed when needed and twice on the shift. CNA #7 said it would not be comfortable to have a wet/soiled brief, and it would not be comfortable to eat while in a wet/soiled brief. During an interview on 9/08/2025 4:26 P.M., CNA #6 said residents who have incontinence are changed when they are wet or soiled and need to be checked before and after meals and changed if needed and cleaned and changed when a resident is helped to go to bed. CNA #6 said a resident should not walk around with a visible wet or soiled brief and should not eat a meal with a wet or soiled brief. During an interview on 9/8/25 at 4:43 P.M., Nurse #8 who was present during the observation of Resident #121 said she did not recall the Resident being visibly wet. Nurse #8 said it should have been addressed, and it would not be comfortable or appropriate for residents to be walking around wet and soiled. During an interview on 9/9/25 at 11:46 A.M., Nurse #3 said if a resident was observed with wet pants and with an odor they should be changed. Nurse #3 said she did smell Resident #121 when she helped the CNA with Resident #121 care. Nurse #3 said it would not be comfortable to eat a meal while wet or soiled. During an interview on 9/8/25 at approximately 5:30 P.M., the surveyor relayed the observation of Resident #121 to the Administrator, with an Administrator in Training (AIT) #1 present for part of the interview. The Administrator said he was sad to hear the observation, that activities of daily living and care with dignity had been a focus for the facility and that the Resident should have been provided care and dignity.

Based on observations, record reviews and interviews, the facility failed to develop a comprehensive person-centered care plan with individualized interventions for a range in motion impairment for one Resident #144, out of a total sample of 34 residents. Specifically, the facility failed to develop a care plan for Resident #144 who displayed and was assessed with an impaired left upper extremity impairment. Findings include:Review of the facility's policy titled 'Resident Range of Motion dated revised 4/2022 included but not limited to the following: 1. Residents will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent further decrease in ROM. Policy Interpretation and Implementation, 2. As part of the comprehensive assessment, the nurse will also identify conditions that place the resident at risk for complications related to ROM and mobility. 4. The Care Plan will be developed by the interdisciplinary team based on comprehensive assessment and will be revised as needed. 5. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline, in, and/or improve mobility and range of motion. Resident #144 was admitted to the facility in November 2021 with diagnoses that include but are not limited to cerebral infarction, hemiplegia (a condition characterized by paralysis that affects only one side of the body) and hemiparesis (a one-sided muscle weakness) following a cerebral infarction affecting right dominant side, type 2 diabetes mellitus, and unspecified dementia.Review of the Minimum Data Set (MDS) assessment, dated 5/28/25, indicated Resident #144 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS) exam, indicating he/she had severe cognitive impairment. Further, the MDS indicated Resident #144 requires substantial/maximal assistance for bathing/showering and upper body dressing. During an observation on 9/3/25 at 12:35 P.M., Resident #144 was sitting at a table in the dining room. Resident #144's left arm was held in a position by his/her side and left forearm was held across his/her body with his/her hand bent around a crayon that was in his/her palm. Resident #144 was reaching his/her right hand down to his/her shoe and his/her left arm remained against his/her chest. On 9/4/25 the surveyor made the following observations: -At 7:34 A.M., Resident #144 was lying in his/her bed with his/her left arm against his/her side and forearm across his/her body and his/her fingers folded in. Resident #144 when asked, unfolded his/her fingers. Resident #144 said his/her arm is stiff and has pain when he/she moves his/her arm. -At 8:24 A.M., the surveyor entered Resident #144's room and the bathroom door was open and a Certified Nursing Assistant (CNA) was present providing care. Resident #144 was observed sitting on the toilet with his/her left arm positioned against his/her body and his/her forearm held across his/her body against his/her chest. -At 9:09 A.M., staff set up Resident #144's breakfast tray in the dining area. Resident #144's left arm was held against his/her body and his/her forearm held across his/her chest. During an observation and interview on 9/8/25 at 5:11 P.M., Resident #144 was observed walking in the hallway with his/her arm against his/her body and forearm across his/her chest. CNA #6 walked with Resident #144 to his/her room. At approximately 5:14 P.M., CNA #6 said the Resident always keeps his/her arm held like that and demonstrated with her own arm how he/she holds his/her arm against his/her body and across his/her chest. CNA #6 said Resident #144's arm is impaired, that he/she does not move it on his/her own and is total assistance for dressing. CNA #6 said she did not get any instructions or made aware of any plan of care for Resident #144's left arm. During an interview on 9/4/25 at approximately 9:15 A.M., CNA #5 said Resident #144 holds his/her left arm the same way all the time. CNA #5 said during care she can move the Resident's arm, but it is stiff. CNA #5 said the Resident used to be able to move it more and now it is harder to move. During an interview and observation on 9/8/25 8:18 A.M., Resident #144 was in the sitting room holding his/her left forearm hand across his body. Resident #144 tried to raise/move his/her arm and said it was stiff. He/she was observed as having limited mobility in his/her left arm. During an interview on 9/8/25 at 12:12 P.M., Nurse #8 said Resident #144 always holds his/her left arm against his/her side and forearm across his/her body. Nurse #8 said the Resident does not use his/her left arm and needs staff to move his/her arm when he/she gets dressed by staff. Nurse #8 said they added scheduled Tylenol a few months ago for pain. Nurse #8 said Occupational Therapy would tell the nursing staff what to do for his/her arm. Nurse #8 said the way the Resident holds his/her arm is not new and he/she has been like that for a long time. During an interview on 9/8/2025 at 12:09 P.M., Activities Assistant #1 said the Resident will use his/her right hand to hit a ball. Activities Assistant #1 said the Resident holds his/her left arm against his/her body and does not move it at all. During an interview and observation on 9/9/25 at 10:09 A.M., Unit Manager #1 said the Resident could move and use his/her left arm. The surveyor and Unit Manager #1 went to see Resident #144 who was sitting at a table with his/her left arm held at his/her side and forearm across his/her chest. Unit Manager #1 asked Resident #144 to raise his/her arm and he/she moved his/her arm partially away from his/her body and stopped and said it was tight. Unit Manager #1 said she would describe his/her left arm as weak. Unit Manager #1 said that rehab (rehabilitation) has seen him/her in the past. During an interview on 9/9/25 at 10:23 A.M., Nurse #3 said the Resident always holds his arm against his/her chest which limits his use of the arm. Nurse #3 said she did not know if it (the arm) was a deformity or from a stroke. Review of the MDS assessments indicated the following: -A comprehensive MDS, dated [DATE], Resident #144 was not coded as having an upper extremity (shoulder, elbow, wrist, hand) impairment -A quarterly MDS, dated [DATE], Resident #144 was not coded as having an upper extremity impairment. -A quarterly MDS, dated [DATE], Resident #144 was not coded as having an upper extremity impairment. Review of the Occupational Therapy (OT) Evaluation dated 11/19/24 included but was not limited to the following: LUE (left upper extremity) shoulder = Moderately impaired-demonstrated 25-50% of full range; elbow/forearm = Moderately Impaired-demonstrates 26-50% of full range. Review of the OT Discharge summary dated [DATE] goal # 4 Patient will safely and efficiently perform UB (upper body) dressing SBA (standby assist) with use of for initiation/termination of tasks in order to perform ADLs. discharge: Min x 1 (minimal) (patient is able to perform 75% or more of the activity but requires weight bearing assistance from one caregiver to complete.) Review of OT Discharge summary dated [DATE] indicated the following:-Patient will safely and efficiently perform UB dressing Mod x 1 (moderate) with use of proper sequencing and for use of compensatory strategies in order to perform ADLs with increased (I) independence and safety. At Discharge Mod x 1 (patient is able to perform 50% to 75% of the activity but requires weight bearing assistance from one caregiver to complete.) -Patient will tolerate 10 minutes of progressive stretching and PROM (passive range of motion) to LUE (left upper extremity) to increase ROM (range of motion) and facilitate functional use of UE (upper extremity) with ADLs. Discharge 2/6/25 5-10 minutes. The OT discharge summary indicated team communication/Collaboration reviewed patient's plan of treatment and treatment services with interdisciplinary team members. Discharge recommendations: 24-hour care. Restorative program not indicated at this time. The discharge summary failed to indicate how 24-hour care staff would implement stretching and PROM. Review of the 'Therapy Referral form' dated 8/25/25 indicated PT (patient) with continued baseline of ADLS and mod (moderate) impairments with left shoulder and elbow ROM, refusing evaluation at this time. Nursing staff aware of PROM exercises. Review of Resident #144's care plans failed to indicate a person-centered care plan with interventions for his/her left upper impairment was developed, including specific interventions of stretching or passive range of motion. Further review of Resident #144 care plans including the Activities of Dailly Living Care Plan Indicated, Resident is at risk for decreased ability to perform ADL (activities of daily living) bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion and toileting related to CVA (cerebral vascular accident) with right hemiplegia. The ADL care plan failed to have interventions for Resident #144's' identified left upper extremity impairment. Review of the Kardex (a document used by Certified Nursing Assistants as a guide for resident's specific care giving needs), indicated, walks using a walker with continued supervision to assist at times due to impaired cognition and weakness. The Kardex did not indicate any interventions including stretching or passive range of motion for Resident #144's left upper extremity impairment. Review of Resident #144's active physician's order indicated the following: -Nursing monitoring for hemiplegia/hemiparesis and potential signs and symptoms of complications supplementary documentation legend for signs symptoms included but not limited to muscle spasticity, dated 3/12/25. During an interview on 9/8/25 at approximately 12:02 P.M., the Director of Rehabilitation said he was not the OT who provided treatment to the Resident. The DOR said the left upper extremity impaired range of motion may have been his/her baseline and that the Resident could do the passive range of motion on his/her own. The DOR said the impairment could be from deformity and not hemiparesis and he did not know why the OT did not recommend a care plan to maintain and prevent further decline in range of motion in the Resident's left upper extremity. During an interview on 9/9/25 at 11:16 A.M., with Nurse #9, Unit Manager #1, MDS nurse and the Director of Rehabilitation (DOR), the MDS nurse said Resident #144 was coded on his/her admission MDS as having an impaired upper extremity. Nurse #9 reviewed the last three MDS assessments and said the last three MDS assessments were not accurate and need to be modified to accurately reflect the Resident's upper extremity impairment. The DOR said the Resident's arm is fixed at the elbow, which is an impairment and should have a care plan for risk of further decrease in ROM. Nurse #9 said developing care plans is a team effort and that coding Resident #144's impaired upper range of motion on the MDS would trigger the team to review and develop a care plan to address the risk associated with the upper extremity impairment. Nurse #9 said the upper extremity impairment may not be hemiparesis, it may be another source of spasticity and that Resident #144 should have a care plan to address the impaired left upper extremity.

Based on observations, record reviews and interviews, the facility failed to adequately maintain the nutrition and hydration status of one Resident (#22) out of a total sample of 34 residents. Specifically, for Resident #22 the facility failed to:a. Address a significant weight loss timely, andb. Implement interventions for weight loss as indicated in physician's orders. Findings include: Review of facility policy titled Weight Management, dated as revised 4/22, indicated the following:-Purpose: To monitor the resident's weight from time of admission and to provide interdisciplinary support and/or intervention to avert adverse trends.-Weekly weights should be done on residents who are assessed as high nutritional risk.-Weight change is defined as any unplanned weight gain or loss as follows:+/- 5% weight change in 1 month+/- 7.5 % weight change in 3 months+/- 10% change in 6 months-Weight change protocol: -2. The dietitian will assess the residents and will communicate any recommended changes to the DNS (Director of Nursing) and supervisor. The Dietitian will follow up to ensure that the recommendation has been addressed. Resident #22 was admitted to the facility in July 2025 with diagnoses that included frontotemporal neurocognitive disorder, Alzheimer's disease and adult failure to thrive. Review of Resident #22's most recent Minimum Data Set (MDS) Assessment, dated 7/22/25, indicated a Brief Interview for Mental Status Exam could not be completed and the Resident was assessed by staff as having severe cognitive impairment. a. Review of Resident #22's the most recent comprehensive nutritional evaluation, completed by the Registered Dietitian, dated 7/17/25, indicated the following:-admit weight 100 lbs.-Summary, Recommendations & plan: (in part indicated) Patient admitted with significant dx (diagnosis) of severe protein calorie malnutrition . Current weight 100 lbs. BMI of 19.5 depicts. Fair appetite noted; will monitor for supplementation needs. Review of Resident #22's weights in the electronic medical record indicated the following:7/16/25: 100 lbs. (pounds)7/21/25: 99.5 lbs.7/28/25: 95.6 lbs.8/4/25: 95 lbs. (5% weight loss since admission)8/11/25: 95.6 lbs.8/19/25: 94.1 lbs.8/29/25: 92.6 lbs.9/3/25: 90.4 lbs. (9.6% weight loss since admission) On 8/4/25 the Resident weighed 95 lbs., indicating a significant 5% weight loss over 19 days. Review of the Nurse Practitioner progress note, dated 8/5/25, indicated the following:-Adult Failure to thrive- Patient with protein mental (sic) nutrition, poor p.o. (oral) intake, requires assistance with meals, will monitor weights closely, however followed up by the dietitian. (sic) Review of the active nutrition care plan dated as created on 7/21/25 indicated that the [Resident] is at risk for nutritional decline related to severe protein calorie malnutrition with a goal that indicated that the [Resident] will consume adequate calories through safe swallow of diet texture and liquids to maintain weight through next review.-Interventions included: monitor weight, PO intake, skin, labs, notify MD of weight loss added 7/21/25, provide meals per MD orders added 7/21/25 and fortified foods added 9/6/25. Review of the care plan failed to indicate that new interventions to prevent ongoing weight loss were implemented between 7/21/25 and 9/6/25. Review of the medical record failed to indicate that when the Resident had a significant weight loss on 8/4/25, the facility implemented interventions or revised the plan of care. Review of the Nurse Practitioner progress note dated 9/2/25 indicated the following:-Chronic diastolic (chronic) heart failure, currently 92 lbs., monitor closely, goal maintain current weight. (sic)-Adult Failure to Thrive: Patient with protein mental malnutrition, poor p.o. intake, requires assistance with meals, will monitor weights closely, however followed up by the dietitian. (sic) Review of Resident #22's active physician's orders, as of 9/4/25, indicated the following:-Dietary Consult r/t weight loss, dated 8/29/25.-weights weekly x 4 weeks, dated 8/12/25.-Diet: regular diet, puree texture, Nectar consistency, 7/16/25. Review of the medical record as of 9/5/25 failed to indicate that a dietary consult had been completed as ordered on 8/29/25. Review of Certified Nurse Aide (CNA) documentation, dated 8/7/25-9/4/25, indicated the following meal consumption percentages:0-25% consumed on five occasions26-50% consumed on 26 occasions51-75% consumed on 20 occasions76-100% consumed on 16 occasions From 8/7/25 through 9/4/25, there were nine days when percentages of intake for meals were only documented for one or two meals per day and not all three meals. During an interview on 9/5/25 at 1:01 P.M., CNA #1 said that she often assists Resident #22 with meals. CNA #1 said that the Resident does well with the breakfast meal and that lunch and dinner he/she doesn't often eat as well. She said that Resident #22 will drink fluids, but not always eat the food. During a phone interview on 9/5/25 at 12:25 P.M., the Registered Dietitian said that she resigned from her position about a month ago in the facility and is currently working remotely for the facility to help out right now. The Registered Dietitian said that she was aware that Resident #22's weight had gone down to 95 lbs., which she said is a significant loss, but was not aware that it had become as significant as it had as of 9/3/25 weighing 90.4 lbs. She said she was not aware of the order on 8/29 for the dietitian to evaluate the weight loss, and if she was, she could have reviewed the weights remotely and made recommendations. She said that intervening in Resident #22's weight loss now, that became significant on 8/4/25, is a delay in care at this point. During an interview on 9/5/25 at 12:59 P.M., Unit Manager #3 said that the Dietitian is in the facility three days a week so when there is an order for an evaluation the staff let her know. She said that she was not sure if the Dietitian had seen Resident #22 in response to the physician's order dated 8/29/25 for an evaluation for weight loss. During an interview on 9/8/25 at 9:02 A.M., Nurse Practitioner (NP) #1 said that interventions should have been put into place when the 5% significant weight loss was noted, before it became an almost 10% significant weight loss. She said that she would have expected for the dietary consult requested on 8/29/25 to be acted upon sooner than one week later. She said weight loss trends should be acted upon before they become significant losses. During an interview on 9/9/25 at 9:28 A.M., The Director of Nurses was unable to say if an intervention should have been implemented after the 5% weight loss noted for Resident #22 in less than a month before it progressed to further weight loss. She said she would have to look into it and get back to the surveyor with an answer. On 9/09/25 at 11:01 A.M., the Director of Nurses provided the surveyor with the NP note from 8/5/25 indicating that the NP was aware of the current weight. The Progress note was reviewed indicating for the Dietitian to follow, which did not occur until 9/5/25, following a surveyor interview with the Dietitian. At this time, the Director of Nurses still did not indicate whether interventions should have been implemented sooner to prevent further weight loss for Resident #22. b. Following the surveyor's interview with the Dietitian on 9/5/25 the following orders were implemented:-Fortified foods with meals, dated 9/5/25-Encourage PO fluids and document intakes, dated 9/5/25.-[Nutritional] supplement two times a day for weight loss, dated 9/8/25. On 9/8/25 at 9:17 A.M., the surveyor observed Resident #22 in his/her room being assisted by a CNA with breakfast. Review of the Resident's meal ticket did not indicate the need for fortified foods on his/her tray. On 9/8/25 at 1:25 P.M., the surveyor observed Resident #22's lunch meal in his/her room. The meal ticket on the tray did not indicate the need for fortified foods. On 9/9/25 at 8:57 A.M., Review of Resident #22's breakfast tray and meal ticket did not indicate the need for fortified foods. During an interview and observation on 9/9/25 at 9:01 A.M., the surveyor observed Nurse #6 assisting the resident with his/her breakfast. Nurse #6 said that she was made aware late last week of Resident #22's weight loss and said an order for supplements was put into place. Nurse #6 reviewed the meal ticket and said it was not indicated for Resident #22 to receive fortified foods. She looked at the Resident's meal, specifically the cream of wheat and said it did not appear to be fortified. She said typically the kitchen finds out about the need for fortified foods when nursing filled out a communication slip, and she was not sure if one had been filled out. She said she is not sure how the Dietitian communicates those recommendations to the kitchen. Nurse #6 further said that if the need for fortified foods was not indicated on the meal ticket, then the Resident would not be receiving it. During an interview on 9/8/25 at 1:55 P.M., the Food Service Director (FSD) said that they do make fortified foods in the kitchen and have a number of residents who receive them on their trays. She said the Dietitian lets her know when residents are started on fortified foods. Fortified foods include oatmeal, cream of wheat and mashed potatoes. She said if a resident is to receive fortified foods from the kitchen it would be indicated on their meal ticket. She said fortified foods add calories to the meal by adding ingredients like margarine, brown sugar, vanilla, cinnamon and whole milk to the foods. On 9/8/25 at 1:55 P.M., the surveyor requested a list or report of residents who are to receive fortified foods on their meal trays. Review of the list provided to the surveyor by the FSD failed to indicate that Resident #22 was to receive fortified foods on his/her tray. During an interview on 9/9/25 at 9:07 A.M., Nurse #5 said she was told that the Dietitian saw Resident #22 to address weight loss but was not sure what the recommendations were. When the recommendations were reviewed with her, she said she was not aware of the recommendation for fortified foods, and that a communication slip should have been sent to the kitchen so that the Resident could receive the fortified foods. During an interview on 9/8/25 at 10:02 A.M., NP #1 said that she would expect all physician's orders to be implemented as written. During an interview on 9/9/25 at 11:05 A.M., the FSD said that Resident #22 was added to the list of residents who are to receive fortified foods. During an interview on 9/9/25 at 9:28 A.M., the Director of Nurses said she would expect all orders to be implemented as written. She said the purpose of fortified foods or supplements is to try to prevent further weight loss.

Based on record review and interview, the facility failed to ensure recommendations from the Monthly Medication Review (MRR) conducted by the pharmacist were addressed and acknowledged by the physician in a timely manner for two Residents (#11, #81) out of five residents reviewed out of a total sample of 34 Residents. Findings include: Review of the facility policy titled Consultant Pharmacist Reports, dated November 2021, indicated the following: -The consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. The medication regimen review (MRR) includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy. The MRR also involves a thorough review of the resident records, and may include collaboration with other members of the interdisciplinary team, collaboration with the resident, family members or other resident representatives. MRR also involves reporting of findings with recommendations for improvement. All findings and recommendations are reported to the director of nursing and the attending physician, the medical director and the administrator. - Recommendations are acted upon and documented by the facility staff and/or the prescriber. Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing. -Resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented in the resident's active record and reported to the Director of Nursing, Medical Director and/or prescriber as appropriate. - The Director of Nursing or designated licensed nurse address and document recommendations that do not require a physician intervention. - At least monthly, the consultant pharmacist reports any irregularities to the attending physician, medical director and director of nursing, at a minimum. -The consultant pharmacist or designee, e.g., clinical pharmacist at the provider pharmacy, works with facility personnel and electronic records to gather pertinent information related to the resident's status and/ or request for consultation. -The findings are phoned, faxed, or e-mailed within (24 hours) to the director of nursing or designee and are documented and stored with the other consultant pharmacist recommendations in the resident's active record. 1. Resident #11 was admitted to the facility in January 2025 with diagnoses including schizoaffective disorder and heart failure. Review of Resident #11's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 14 out of 15 indicating intact cognition. Further review of the MDS indicated that the Resident does not reject care. Review of Resident #11's medical record indicated the following progress notes written by the pharmacist on 4/9/25 and 6/6/25: - Medication regiment reviewed. Recommendations made; please see report for details Review of Resident #11's MRR Consultant Pharmacist Recommendations Reports to the Provider dated 4/9/25 and 6/6/25 indicated the following: - Resident is receiving quetiapine and risperidone (antipsychotic medications), atypical antipsychotics which may affect metabolic profile. Recommend including lipid panel and A1c (a lab test that measures blood values over time) on next lab day and every 6 months thereafter. The section for Physician/Prescriber Response for both recommendations were blank. Review of Resident #11's Medication Administration Record for April, May and June of 2025 indicated that the Resident was documented as receiving Quetiapine and Risperidone. Review of Resident #11's Lab Results Report from 4/11/25 and 7/2/25 failed to indicate that a lipid panel or A1c lab was requested. During an interview on 9/5/25 at 9:45 A.M., the Director of Nursing (DON) provided the surveyor with the pharmacist recommendations for April and June. The DON said they were missed by the facility, and they were not acknowledged and therefore not completed. The DON said her expectation is that pharmacist recommendations are acknowledged and acted upon as soon as possible and the second one was recommended because the first one never got reviewed. 2. Resident #81 was admitted to the facility in October 2024 with diagnoses including pneumonia and chronic obstructive pulmonary disease (COPD). Review of Resident #81's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated the Resident scored a 15 out of possible 15 on the Brief Interview for Mental Status, indicating he/she was cognitively intact. Review of Resident #81's medical record indicated the following monthly pharmacy review, dated 8/8/25: -Pharmacy Consultant note: Medication regimen reviewed. Recommendations made; please see report for details. On 9/5/25 at 1:00 P.M., the surveyor asked the Director of Nursing for Resident #81's pharmacy recommendation report conducted on 8/8/25. Review of Resident #81's pharmacy recommendation report, dated 8/8/25 indicated the following: -Consultant Pharmacist: MRR (medication regimen review) Date 8/8/25: Resident is receiving fluticasone-salmeterol inhaler (a combination medication used to treat asthma and COPD). In order to help prevent the development of thrush, please update order to instruct resident to rinse mouth after use. Review of Resident #81's active physician's orders indicated: -Fluticasone-salmeterol inhalation Aerosol Powder breath activated 250-50 MCG/ACT (micrograms per actuation) (Fluticasone-Salmeterol) 1 puff inhale orally two times a day for shortness of breath related to chronic obstructive pulmonary disease. Instruct resident to rinse mouth after use, dated 9/5/25. Review of the medical record failed to indicate that the recommendation had been implemented by the facility prior to the surveyor's request to review the monthly medication review. Review of Resident #81's discontinued orders indicated the following: -Fluticasone-Salmeterol inhalation Aerosol Powder breath activated 250-50 MCG/ ACT 1 puff inhale orally two times a day for shortness of breath related to chronic obstructive pulmonary disease, dated as active from 7/29/25 through 9/5/25. Review of Resident #81's August 2025 medication administration record indicated Resident #81 received Fluticasone-Salmeterol from 8/1/25 to 8/31/25 without instructions to have the Resident rinse their mouth after use. Review of Resident #81's September 2025 medication administration record indicated Resident #81 received Fluticasone-Salmeterol from 9/1/25 to 9/5/25 at 8:00 A.M., without instructions to have the Resident rinse their mouth after use. During an interview on 9/9/25 at 9:52 A.M., the Director of Nursing said the facility policy does not state a time frame for when pharmacy recommendations need to be followed up on. The Director of Nursing said she gets to the pharmacy recommendations as soon as possible, meaning as soon as she sees them. During a follow up interview on 9/9/25 at 11:01 A.M., the Director of Nursing said the risk for a resident not rinsing their mouth after using an inhaler is an oral infection. During an interview on 9/9/25 at 11:55 A.M., Nurse #7 said the risk for a resident not rinsing mouth after using an inhaler is developing candidiasis which can cause pain to the resident.

Based on observations, record review and interviews, the facility failed to provide dental services for one Resident (#40) out of a total sample of 34 Residents. Specifically, the facility failed to provide dental care to Resident #40 for an improper fitting upper denture that was documented by facility staff.Findings include:Resident #40 was admitted to the facility in July 2024 with diagnoses including chronic obstructive pulmonary disease and, rheumatoid arthritis. Review of Resident #40's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated that the Resident had a Brief Interview for Mental Status score of 14 out of 15 indicating intact cognition. Further review of the MDS indicated that the Resident required substantial/maximal assistance for activities of daily living and does not reject care.During an interview on 9/3/25 at 9:14 A.M., Resident #40 said to the surveyor that he/she is waiting to see a dentist because his/her dentures are too big and do not fit and he/she wants them fixed so he/she can chew food more easily. The surveyor observed Resident #40's teeth, he/she had no upper teeth and was missing some bottom teeth. Resident #40 said he/she just wants to be able to chew food again.During a follow up interview on 9/5/25 at 8:46 A.M., Resident #40 was eating his/her breakfast. He/she was not wearing his/her dentures while eating breakfast. Resident #40 said to the surveyor I just want to be able to chew food, it has been such a long time to get my dentures fixed, I don't know why it is taking so long.Review of Resident #40's progress notes indicated the following:- Dated 1/8/25 at 9:40 P.M., - Nurses Note: late entry for 1/6/25, Follow up after discussion with dietitian, spoke to resident and oral assessment completed, resident confirms tooth discomfort.- Dated 1/23/25 at 11:58 A.M., - Care Plan Meeting Note: He/She has no upper teeth, one loose tooth on the bottom, denture do not fit well.During an interview on 9/5/25 at 11:28 A.M., Unit Manager #2 said the facility obtains consent from the Residents upon admission to the facility if they want to see dental services. Unit Manager #2 and the surveyor reviewed Resident #40's medical record and found the consent form which Resident #40's requested to be seen by dental. The Consent form was dated 8/14/25. The surveyor asked Unit Manager #2 why the consent was obtained over a year since the Resident was admitted and eight months after Resident #40 expressed denture issues. Unit Manager #2 said she was not sure. Unit Manager #1 then said Resident #40 should have been seen by the dentist a while ago since he/she has been expressing denture issues.Review of Resident #40's Nutrition Assessment documented by the Registered Dietitian dated 7/9/25, indicated the following:- Resident #40 is at nutritional risk. Diet: regular texture, thin liquids, reports dentition impacts intake.During a telephone interview on 9/5/25 at 12:26 P.M., the Registered Dietitian (RD) said Resident #40's bottom teeth are poor, and the RD said that his/her top dentures do not fit well. The RD said he/she gums a lot of food due to not being able to wear his/her dentures and that he/she wanted his/her dentures fix as soon as possible and he/she has been waiting to be seen.During a follow up interview on 9/8/25 at 10:40 A.M., Unit Manager #2 submitted Resident #40's consent to be seen by the dentist. Unit Manager #2 then said she agrees with the concern about Resident #40 not being seen by the dentist to fix his/her dentures.During an interview on 9/9/25 at 9:14 A.M., the Director of Nursing (DON) said Resident #40 should have been assessed by the dentist if a concern was identified in January and the dentist should have been notified sooner. The DON said the whole idea of a care plan meeting is to identify, assess and act upon any concerns that are identified. The DON then said consent to be seen by the dentist should be obtained on admission to the facility.

Based on record review and interview, the facility failed to ensure medical records were completed for two Residents (#101 and #10) out of a total sample of 34 Residents. Specifically, the facility failed to:1. Ensure the medical providers (nurse practitioner and physician's) clinical encounter notes were accessible in the medical record and 2. Ensure that Resident #10's daily care performed by the Certified Nursing Assistants (CNA) was documented as completed.Findings include: 1.Resident #101 was admitted to the facility in June 2022 and has diagnoses that include but are not limited to major depressive disorder, Alzheimer's disease, unspecified dementia and hyperlipidemia. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/25/25, indicated staff assessed Resident #101 as having severe cognitive impairment, requires substantial/maximal assistance for activities of daily living including bathing, toileting, hygiene and lower body dressing. During review of Resident #101's clinical record including the EMR (electronic medical record) and chart failed to indicate visit notes from the physician or nurse practitioner. During an interview on 9/9/2025 at 8:28 A.M., the Director of Nursing said the Resident is on the PACE (Program of All-Inclusive Care for the Elderly) program and the facility is working on the medical providers to document in the EMR and that the Nurse Practitioner and Physician's notes should be accessible in the Resident's medical record. On 9/9/25 at 11:05 A.M., the surveyor reviewed the Nurse Practitioner's notes that were faxed dated 9/9/25. 2. Resident #10 was admitted to the facility in April 2025 with diagnoses including severe protein calorie malnutrition, muscle weakness and type 2 diabetes. Review of Resident #10's most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status score of 12 out of 15 indicating the Resident has moderate cognitive impairment. Further review of the MDS indicated that the Resident requires partial/moderate to substantial/maximal assistance for all activities of daily living and does not reject care. During an interview on 9/3/25 at 11:59 A.M., 9/5/25 at 8:32 A.M. and 9/8/25 at 10:34 A.M., Resident #10 said he/she is not sure if he/she has been offered a shower recently. Review of Resident #10's daily care documentation completed by the CNAs for the months of June through September 2025 indicated the following: June: Behavior Symptoms: 17 of 30 days are missing CNA documentation. Bladder Functions: 17 of 30 days are missing CNA documentation. Bowel Movement: 17 of 30 days are missing CNA documentation. Lower Body Dressing: 17 of 30 days are missing CNA documentation. Lying to Sitting on Side of Bed: 17 of 30 days are missing CNA documentation. Oral Hygiene: 17 of 30 days are missing CNA documentation. Personal Hygiene: 17 of 30 days are missing CNA documentation. Putting on/Taking Off Footwear: 17 of 30 days are missing CNA documentation. Roll Left and Right: 17 of 30 days are missing CNA documentation. Shower/Bathe Self: 17 of 30 days are missing CNA documentation. Sit to Lying: 17 of 30 days are missing CNA documentation. Sit to Stand: 17 of 30 days are missing CNA documentation. Toilet Transfer: 17 of 30 days are missing CNA documentation. Toileting Hygiene: 17 of 30 days are missing CNA documentation. Tub/Shower Transfer: 17 of 30 days are missing CNA documentation. Upper Body Dressing: 17 of 30 days are missing CNA documentation. Intake and Output: 17 of 30 days are missing CNA documentation. Personal Hygiene: 17 of 30 days are missing CNA documentation. Skin Observation: 17 of 30 days are missing CNA documentation. Toilet Use: 17 of 30 days are missing CNA documentation. Snacks: 5 of 30 days are missing CNA documentation. Amount Eaten: 6 of 30 days are missing CNA documentation. Eating: 6 of 30 days are missing CNA documentation. Positioning: 17 of 30 days are missing CNA documentation. July: Behavior Symptoms: 16 of 31 days are missing CNA documentation. Bladder Functions: 16 of 31 days are missing CNA documentation. Bowel Movement: 16 of 31 days are missing CNA documentation. Lower Body Dressing: 16 of 31 days are missing CNA documentation. Lying to Sitting on Side of Bed: 16 of 31 days are missing CNA documentation. Oral Hygiene: 16 of 31 days are missing CNA documentation. Personal Hygiene: 16 of 31 days are missing CNA documentation. Putting on/Taking Off Footwear: 16 of 31 days are missing CNA documentation. Roll Left and Right: 16 of 31 days are missing CNA documentation. Shower/Bathe Self: 16 of 31 days are missing CNA documentation. Sit to Lying: 16 of 31 days are missing CNA documentation. Sit to Stand: 16 of 31 days are missing CNA documentation. Toilet Transfer: 16 of 31 days are missing CNA documentation. Toileting Hygiene: 16 of 31 days are missing CNA documentation. Tub/Shower Transfer: 16 of 31 days are missing CNA documentation. Upper Body Dressing: 16 of 31 days are missing CNA documentation. Intake and Output: 16 of 31 days are missing CNA documentation. Personal Hygiene: 16 of 31 days are missing CNA documentation. Skin Observation: 16 of 31 days are missing CNA documentation. Toilet Use: 16 of 31 days are missing CNA documentation. Snacks: 11 of 31 days are missing CNA documentation. Amount Eaten: 11 of 31 days are missing CNA documentation. Eating: 11 of 31 days are missing CNA documentation. Positioning: 16 of 31 days are missing CNA documentation. August: Behavior Symptoms: 22 of 31 days are missing CNA documentation. Bladder Functions: 22 of 31 days are missing CNA documentation. Bowel Movement: 22 of 31 days are missing CNA documentation. Lower Body Dressing: 22 of 31 days are missing CNA documentation. Lying to Sitting on Side of Bed: 22 of 31 days are missing CNA documentation. Oral Hygiene: 22 of 31 days are missing CNA documentation. Personal Hygiene: 22 of 31 days are missing CNA documentation. Putting on/Taking Off Footwear: 22 of 31 days are missing CNA documentation. Roll Left and Right: 22 of 31 days are missing CNA documentation. Shower/Bathe Self: 22 of 31 days are missing CNA documentation. Sit to Lying: 22 of 31 days are missing CNA documentation. Sit to Stand: 22 of 31 days are missing CNA documentation. Toilet Transfer: 22 of 31 days are missing CNA documentation. Toileting Hygiene: 22 of 31 days are missing CNA documentation. Tub/Shower Transfer: 22 of 31 days are missing CNA documentation. Upper Body Dressing: 22 of 31 days are missing CNA documentation. Intake and Output: 22 of 31 days are missing CNA documentation. Personal Hygiene: 22 of 31 days are missing CNA documentation. Skin Observation: 22 of 31 days are missing CNA documentation. Toilet Use: 22 of 31 days are missing CNA documentation. Snacks: 15 of 31 days are missing CNA documentation. Amount Eaten: 15 of 31 days are missing CNA documentation. Eating: 15 of 31 days are missing CNA documentation. Positioning: 22 of 31 days are missing CNA documentation. September: Behavior Symptoms: Two of the seven elapsed days are missing CNA documentation. Bladder Functions: Two of the seven elapsed days are missing CNA documentation. Bowel Movement: Two of the seven elapsed days are missing CNA documentation. Lower Body Dressing: Two of the seven elapsed days are missing CNA documentation. Lying to Sitting on Side of Bed: Two of the seven elapsed days are missing CNA documentation. Oral Hygiene: Two of the seven elapsed days are missing CNA documentation. Personal Hygiene: Two of the seven elapsed days are missing CNA documentation. Putting on/Taking Off Footwear: Two of the seven elapsed days are missing CNA documentation. Roll Left and Right: Two of the seven elapsed days are missing CNA documentation. Shower/Bathe Self: Two of the seven elapsed days are missing CNA documentation. Sit to Lying: Two of the seven elapsed days are missing CNA documentation. Sit to Stand: Two of the seven elapsed days are missing CNA documentation. Toilet Transfer: Two of the seven elapsed days are missing CNA documentation. Toileting Hygiene: Two of the seven elapsed days are missing CNA documentation. Tub/Shower Transfer: Two of the seven elapsed days are missing CNA documentation. Upper Body Dressing: Two of the seven elapsed days are missing CNA documentation. Intake and Output: Two of the seven elapsed days are missing CNA documentation. Personal Hygiene: Two of the seven elapsed days are missing CNA documentation. Skin Observation: Two of the seven elapsed days are missing CNA documentation. Toilet Use: Two of the seven elapsed days are missing CNA documentation. Snacks: One of seven elapsed days are missing CNA documentation. Amount Eaten: One of seven elapsed days are missing CNA documentation. Eating: One of seven elapsed days are missing CNA documentation. Positioning: Two of the seven elapsed days are missing CNA documentation. During an interview on 9/8/25 at 10:55 A.M., CNA #2 said all care should be documented in the electronic medical record at the end of every shift. During an interview on 9/8/25 at 10:59 A.M., CNA #3 said all documentation for care is done in the electronic medical record. During an interview on 9/9/25 at 7:53 A.M., Nurse #2 said CNA's are expected to document all care provided in the electronic medical record and it is a big issue that there are holes in CNA documentation. Nurse #2 said if nothing is documented then we do not know what care a resident has received. During an interview on 9/9/25 at 8:02 A.M., CNA #4 said her expectation is that CNAs document all care provided every shift so everyone knows the type of care each resident has received. CNA #4 said if a resident refuses care it still needs to be documented and not left blank. During an interview on 9/9/25 at 9:14 A.M., the Director of Nursing (DON) said CNAs need to document care provided every shift and without any documentation we cannot tell what care was provided to the residents. The DON said Resident #10's CNA care needs to be completely documented.

Based on observation, record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically,For one Resident (#54) with a wound, out of a total sample of 34 residents, the facility failed to implement Enhanced Barrier Precautions (EBP).The facility failed to handle clean linen to prevent possible contamination.Findings include:Review of the facility assessment, dated August 2025, indicated the following:-The goal of the infection prevention program is to:decrease risk of infection to residents and personal.maintain compliance with state and federal regulations related to infection prevention. Review of the Centers for Disease Control (CDC) website indicated the following, dated June 28, 2024:-Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). 1.Resident #54 was admitted to the facility in June 2025 with diagnoses including dysphagia, sleep apnea and chronic kidney disease. Review of Resident #54's Minimum Data Set (MDS) Assessment, dated 7/9/25, indicated a Brief Interview for Mental Status score of 10 out of 15 indicating that the Resident had moderate cognitive impairment. On 9/3/25 at 8:52 A.M., the surveyor observed Resident #54 receiving morning care from a staff member. The staff member did not utilize a gown while performing care. On 9/5/25 at 8:05 A.M., the surveyor observed that the doorway entry of Resident #54's room failed to indicate that staff should utilize EBP when providing high contact care to the Resident. Review of Resident #54's Wound care progress note, dated 9/4/25, indicated the following:-Patient was seen for evaluation and treatment recommendation regarding facility acquired stage 3 pressure ulcers to the coccyx, distal and proximal.-PU (pressure ulcer) to coccyx proximal has slightly increased in size. Review of Resident #54's active care plan indicated an actual alteration in skin integrity: Stage III (stage III pressure ulcer), last updated 8/1/25. Further review of Resident #54's active plan of care indicated that the Resident should be on Enhanced Barrier Precautions due to wounds, dated as created 8/15/25. Review of Physician's orders indicated the following:-Coccyx proximal: Wash with normal saline, pat dry, skin prep to peri skin, Collagen to wound bed, cover with silicone border dressing, zinc paste to peri skin, QD/PRN. Document on wound bed, odor, drainage, surrounding skin, wound outcome, every day shift for wound care, dated 8/1/25. Review of Physician's orders failed to indicate orders for EBP. During an interview on 9/5/25 at 11:47 A.M., Nurse #1 said that any resident with an ostomy, wound or chronic infection requires enhanced barrier precautions. She said that Resident #54 has wounds to his/her coccyx requiring treatments. Nurse #1 said that the Resident should have a sign on the doorway and a precaution cart with gowns and gloves outside of his/her room for staff use but he/she did not. Nurse #1 further said that EBP are utilized to prevent the spread of infection to high-risk residents, for example, through their wounds. During an interview on 9/8/25 at 2:18 P.M., the Infection Preventionist (IP) said that for any resident with an indwelling medical device, ostomy or wounds, staff are required to utilize enhanced barrier precautions. The IP said that enhanced barrier precautions are designed to protect higher risk residents from the development of infections, for example through a wound. She said that Resident #54 should have been on the precautions, but he/she was not. During an interview on 9/9/25 at 10:00 A.M., the Director of Nurses said that all residents who have wounds should be on enhanced barrier precautions. 2. On 9/5/25 at 11:35 A.M., the surveyor rounded in the laundry with the Housekeeping Director. The surveyor observed a laundry staff member folding blankets. While the staff member was folding the blankets, the blankets were coming in contact with the floor. During an interview on 9/5/25 at 11:35 A.M., the Housekeeping Director said that the blankets should not come in contact with the floor while the staff are folding them. During an interview on 9/8/25 at 2:18 P.M., the IP said that when folding laundry, it should not come into contact with the floor because that would be an infection control concern. During an interview 9/9/25 at 10:00 A.M., the Director of Nurses said that when staff are folding laundry it should not come into contact with the floor.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure they developed and implemented a baseline plan of care within 48 hours of his/her admission.Findings include:The Facility's Policy, titled, Baseline Care Plan, dated as revised 04/2022, indicated a baseline plan of care to meet the resident's immediate needs would be developed for each resident within 48 hours of admission.The Facility's Policy, titled Elopement Risk Scale, undated, indicated newly admitted residents would be evaluated by nursing to determine elopement risk, and indicated an interdisciplinary plan of care would be developed for residents assessed at risk for elopement.Resident #1 was admitted to the Facility in May 2025, diagnoses included diabetes, vascular dementia, chronic kidney disease, and dysphagia.Review of Resident #1's admission Elopement Risk Evaluation, dated 05/30/25 and timed 01:01 P.M., indicated he/she was exit seeking, wandering without purpose, wanted to leave the unit, was watching others go through the doors, was only oriented to person, and was assessed at risk for elopement by nursing. However, the section of the Elopement Risk Evaluation which indicated to check boxes for nursing to include interventions and develop a plan of care were left blank.Review of Resident #1's Nurse Progress Note, dated 06/01/25, timed 05:30 P.M., indicated Resident #1 eloped from the Facility.Review of Resident #1's Care Plan Report indicated there were no identified areas or interventions for care developed before 06/02/25.Further review of Resident #1's Medical Record indicated there was no documentation to support that a Baseline Plan of Care was developed within 48 hours of his/her admission.During an interview on 07/15/25 at 08:17 A.M., the Director of Nurses (DON) said nursing should have developed an elopement plan of care for Resident #1 upon the assessment that he/she was at risk for elopement, but did not, and said a baseline plan of care should be developed within 48 hours of admission for all residents.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was alert, oriented, and able to make his/her needs known, the Facility failed to ensure he/she was free from physical and emotional abuse from a staff member, when on 08/26/24, although Resident #1 was asleep, the Facility's contracted Podiatrist began to provide care to his/her feet, Resident #1 woke up abruptly, was startled by the Podiatrist touching his/her feet, told the Podiatrist to stop, they became engaged in a verbal and physical altercation, during which Resident #1 was struck on the left side of his/her face and left arm. Resident #1 was transferred and evaluated in the Hospital Emergency Department for an injury to his/her left cheek. Resident #1 said as a result of the altercation, he/she was fearful and anxious about the Podiatrist being in the building. Findings include: The Facility Policy, titled Abuse Prohibition, dated revised 03/2022, indicated: -Each resident had 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 would always be treated with respect and dignity, and residents would 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. -Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical hurt or pain or mental anguish to a resident. -Physical abuse included, but was not limited to, hitting, slapping, pinching, kicking, and so on. -Staff would refrain from all actions that could be considered abuse, mistreatment, neglect, exploitation, and/or misappropriation. Resident #1 was admitted to the Facility in February 2023, diagnoses included dementia, insomnia, and anxiety. Review of Resident #1's Quarterly Minimum Data Set Assessment, dated 08/21/24, indicated he/she had a Brief Interview for Mental Status (BIMS, structured interview to assess attention, orientation and recall) score of 15/15, which indicated he/she was cognitively intact. Review of Resident #1's Nurse Progress Note, dated 08/26/24, indicated Nurse #1 was in the hallway on Resident #1's unit, and heard loud screaming come from Resident #1's room. The Note indicated Nurse #1 immediately went to Resident #1's room, discovered him/her sitting on his/her bed, he/she was bleeding from his/her left hand, the left side of his/her face and was anxious and scared. During a telephone interview on 10/30/24 at 01:08 P.M., Nurse #1 said that on 08/26/24 she was at the medication cart down the hall from Resident #1's room when she heard loud screaming come from Resident #1's room. Nurse #1 said she immediately went to Resident #1's room and saw him/her lying on his/her bed and the Podiatrist was standing at the foot of the bed. Nurse #1 said Resident #1 said he/she told the Podiatrist not to cut his/her toenails and said that the Podiatrist had hit him/her. Nurse #1 said Resident #1 was bleeding from a cut on the left side of his/her face and a cut on his/her left hand, and was transferred to the Hospital Emergency Department. Nurse #1 said she was familiar with Resident #1 and said he/she could be confused at times but was mostly alert and oriented. Nurse #1 said she had never heard Resident #1 make accusations against anyone before this incident. Nurse #1 said Resident #1 became anxious and fearful, would ask if the Podiatrist was coming back, would talk about the incident nonstop, and required reassurance from staff and family. During an interview on 10/30/24 at 02:06 P.M., Resident #1 said that about two months ago (exact date unknown), he/she was napping in bed in the middle of the morning, and he/she woke up because he/she felt someone pulling at his/her leg. Resident #1 said when he/she saw the Podiatrist at the foot of his/her bed, touching his/her feet, he/she told the Podiatrist not to clip his/her toenails. Resident #1 said the Podiatrist ignored him/her and continued to clip his/her toenails. so he/she then tried to get up from the bed. Resident #1 said the Podiatrist then hit him/her with a closed fist on the left side of his/her face, which resulted in a cut and bruising on the left side of his/her face and ear and a cut on his/her hand. Resident #1 said He hit me so hard. He just hauled off and whaled me! Who does he think he is hitting an old (person)? I was so afraid he would come back and hurt me again. Review of the Local Police Department Report, dated 08/26/24, indicated Resident #1 said he/she woke up and found the Podiatrist attempting to clip his/her toenails, and said he/she told the Podiatrist he/she did not want his/her toenails touched. The Police Report indicated Resident #1 said the Podiatrist then struck him/her on the left side of his/her face with a closed fist, and he/she had a visible laceration on his/her left cheek. The Police Report indicated the Podiatrist said that when he attempted to clip Resident #1's toenails, he/she lunged forward at him, that he put his hands out and had his clippers in his right hand. The Police Report indicated the Podiatrist said he was unsure if his hand made contact with Resident #1's face. Review of Resident #1's Interdisciplinary Team Discharge and Recapitulation Summary Note, dated 08/26/24, indicated Resident #1 stated that when the Podiatrist went to cut his/her toenails, he/she said no, and the Podiatrist punched him/her on the left side of his/her face and cut his/her left hand. The Summary indicated Resident #1 was transferred to the Hospital Emergency Department and was alert, oriented at the time of transfer. Review of Resident #1's Hospital Emergency Department Encounter Note, dated 08/26/24, indicated he/she was evaluated and treated for a dime sized abrasion to the left side of his/her face, left ear redness and reported an altercation with the Facility's Podiatrist. The Encounter Note indicated Resident #1 reported that the Podiatrist struck him/her on the left side of his/her face, and that he/she had full recall of the event. Review of Resident #1's Skin Observation Tool, dated 08/26/24, indicated he/she had an abrasion on the left side of his/her face and a laceration on his/her left lower arm, which were new. Review of Resident #1's Nurse Progress Note, dated 08/27/24, indicated Resident #1, who was normally social, was withdrawn, isolating in his/her room, expressing concerns about his/her safety, and refused to take a shower which he/she was usually very eager for. Review of Resident #1's Nurse Progress Note, dated 08/28/24, timed 06:57 A.M., indicated he/she expressed fear over the incident with the Podiatrist from two days prior. Review of Resident #1's Nurse Progress Note, dated 08/28/24, timed 10:26 A.M., indicated he/she was anxious regarding the incident and required reassurance from staff. Review Resident #1's Psychological Progress Note, dated 08/28/24, indicated he/she was generally oriented to self, time, place and situation. The Note indicated Resident #1 discussed the recent incident where the Podiatrist had reportedly hit him/her in the face. The Report indicated Resident #1 said I am so scared of him. I am fearful he will come back and hurt me again. Review of Resident #1's Nurse Progress Note, dated 08/31/24, indicated Resident #1 called the Local Police Department because he/she was in fear that the Podiatrist would be coming in that day. Review of Resident #1's Nurse Progress Note, dated 09/04/24, indicated he/she was very anxious to know when the Podiatrist was coming back to the Facility. Review of the Podiatrist's written statement, that he provided to the facility but was unsigned, indicated that on 08/26/24, he went to see Resident #1 in his/her room, introduced himself, pulled back his/her open toe stockings, and Resident #1 lunged at him, yelled stop stop stop, and grabbed his clippers. During a telephone interview on 10/30/24 at 10:50 A.M., The Podiatrist said that on 08/26/24 at 10:00 A.M., he entered Resident #1's room and found him/her sleeping. The Podiatrist said he made two or three attempts to wake Resident #1, however he/she did not wake up, and said he did not ask a staff member to come to help wake Resident #1 up. The Podiatrist said he then proceeded to pull back Resident #1's open toe stockings and started clipping his/her toenails, without ensuring Resident #1 knew he was there, who he was, or what he was doing. The Podiatrist said as he was clipping his/her toenails, Resident #1 suddenly woke up and lunged at him. The Podiatrist said he never left the foot of Resident #1's bed, and could not recall if he moved his right hand (which was holding the toenail clippers) to the left, right, forward, or backward. The Podiatrist said it was possible, but he could not recall if Resident #1's face or arm came in contact with his clippers, and said they are very sharp and could easily cause a cut. Although the Podiatrist denied hitting/punching Resident #1 in the face, the Podiatrist's written statement conflicted with the statement he made to the Police on 08/26/24 and conflicted with his account of the incident on 10/30/24 during his telephone interview with the surveyor. During an interview on 10/29/24 at 01:18 P.M., the Director of Nurses (DON) said that on 08/26/24, some time in the morning, she was called to Resident #1's unit by Nurse #1 who reported that Resident #1 said the Podiatrist had punched him/her. The DON said Resident #1 had fresh blood on his/her left cheek and left lower arm near his/her hand that were from new injuries, and that he/she said the Podiatrist had hit him/her with a closed fist. The DON said Resident #1 was consistent with his/her story, and said she believed that something did happen, but she was not there to witness the incident. The DON said that during an interview with the Podiatrist, he said he had begun clipping Resident #1's toenails while he/she was sleeping and that's when Resident #1 was startled awake and lunged forward, causing his/her injuries. The DON said she was unsure how Resident #1's face could have come in contact with the Podiatrist's clippers if he was at the foot of the bed.

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who had an ileostomy (surgical procedure that creates an opening in the abdominal wall to direct the small intestine and allow waste to exit the body), the Facility failed to ensure they provided care consistent with professional standards of practice, when on 09/23/24, although nursing was aware Resident #2 did not have ostomy appliances in place over his/her stoma, which was actively secreting stool, no additional nursing interventions were implemented to protect his/her abdominal wound, resulting in fecal matter contamination of his/her abdominal incision, excoriation of surrounding skin, and he/she required transfer and re-admission to the Hospital for treatment. Findings include: The Facility's Policy, titled, Ostomy Care, dated 04/2022, indicated an ileostomy was a surgically created opening from the small bowel which was brought through the abdominal wall and used to create a stoma. The Ostomy Care Policy did not indicate any professional procedure for the appliance or maintenance of placement of an ostomy device. The Facility's Policy, titled Dry/Clean Dressings, dated 03/2022, indicated wound care and dressings would be applied as ordered by the physician. Resident #2 was admitted to the Facility in September 2024, diagnoses included intestinal obstruction and ileostomy. Review of Resident #1's Treatment Administration Record (TAR) for September 2024 indicated he/she had physician's orders for the following: -9/20/24, Ileostomy Care every shift, -Change Abdominal Incision dressing every shift, cleanse with wound spray, pack middle of incision with sterile gauze, and cover with abdominal pad (large absorbent pad) or telfa (nonstick gauze) and secure with paper tape. Review of Resident #2's Physician's Note, dated 09/23/24, indicated that at 11:00 A.M., Physician #1 assessed Resident #2, in person. The Physician's Note indicated Physician #1 removed a dressing from Resident #2's abdomen and found that he/she did not have an ostomy appliance in place at all, and that his/her abdomen, dressing, and abdominal incision were covered in fecal matter, the gauze that was within the abdominal incision was soaked in fecal matter, and the wound edges and peristomal skin (area of skin around the stoma) were red and inflamed. The Physician's Note indicated that Nurse #2 said she had been aware that Resident #2 did not have an ostomy appliance on, that his/her supplies were ordered and would be arriving later that day. Resident #2's Physician's Note indicated he/she was transferred to the Hospital Emergency Department for further care of his/her abdominal wound and high risk of infection due to the presence of fecal matter in his/her open wound. Review of Resident #2's Hospital Emergency Department Admission Note, dated 09/23/24, indicated he/she was diagnosed with abdominal wound dehiscence (opening) and was admitted to the Hospital. During a telephone interview on 10/30/24 at 01:23 P.M., Physician #1 said that on 09/23/24 at 11:00 A.M., she assessed Resident #2, who was in his/her bed at the Facility, and when she removed the dressing that was in place on Resident #2's abdomen, she discovered that he/she did not have an appliance on his/her ostomy stoma. Physician #1 said there was one large dressing taped down covering Resident #2's entire abdominal incision and the ileostomy stoma, that there was fecal material covering his/her entire abdomen, the dressing, and soaked into the gauze that was in his/her abdominal incision. Physician #1 said she asked Nurse #2 to look at Resident #2's abdomen as well, and that Nurse #2 said she knew Resident #2 did not have an ostomy appliance in place when she took over that morning at 07:00 A.M., as Resident #2's nurse. During an interview on 10/29/24 at 02:16 P.M., Nurse #2 said that on 09/23/24 she was the nurse assigned to Resident #2, and said she was told at 07:00 A.M., during change of shift report that Resident #2 did not have an ostomy appliance in place, and that supplies had been ordered. Nurse #2 said she did not assess Resident #2's abdomen or stoma until Physician #1 called her in to Resident #2's room. Nurse #2 said the skin surrounding Resident #2's abdominal incision and stoma was red, excoriated, and the incision had dehisced (opened). Nurse #2 said although Resident #1's specific ostomy supplies had not been delivered, there were ostomy supplies that could be used temporarily in the Facility at the time, and that she applied the ostomy appliance after Physician #1 assessed Resident #2. During an interview on 10/29/24 at 01:18 P.M., the Director of Nurses (DON) said she received a call from the Director of Care at Physician #1's practice and was told that Physician #1 had found Resident #2 without an ostomy appliance with fecal material in his/her wound. The DON said Resident #2 should have had an ostomy appliance in place and his/her abdominal incision should have been protected from fecal contamination.

Based on observations, record review, policy review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs), for six Residents (#63, #10, #3, #37, #94, and #2) out of a total sample of 46 residents. Specifically: 1a. For Resident #63, the facility failed to ensure incontinence care was provided for 17 hours resulting in the development of new pressure ulcers. 1b. For Resident #10, the facility failed to ensure incontinence care was provided for 17 hours resulting in the development of new pressure ulcers. 2. For Resident #3, the facility failed to provide assistance with meals as per the plan of care. 3. For Resident #37 and #94, the facility failed to provide assistance with nail care. 4. For Resident #2, the facility failed to provide assistance with facial hair removal. Findings include: Review of the facility policy titled Activities of Daily Living (ADLs), dated 3/22, indicated Residents who are unable to carry out activities of daily living independently will receive the services necessary for activities of daily living. Appropriate care and services will be provided for residents who are unable to carry out ADLs including appropriate support and assistance with: Dining (meals and snacks). Hygiene (bathing, dressing, grooming and oral care). Elimination (toileting). 1 a. Resident #63 was admitted to the facility in May 2024 with diagnoses including morbid severe obesity, type two diabetes, congestive heart failure, muscle weakness, localized edema, anemia in chronic kidney disease, and hereditary and idiopathic neuropathy. Review of Resident #63's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #63 had a Brief Interview for Mental Status exam score of 15 out of a possible 15, which indicated the Resident had intact cognition. The MDS also indicated Resident #63 is dependent on staff for all functional tasks. Review of Resident #63's current Activity of Daily Living (ADL) care plan, last revised 6/4/24, indicated Resident #63 required assistance with toilet use, bed mobility, personal hygiene and turning/repositioning. Review of Resident #63's current incontinence care plan, last revised 5/30/24, indicated the following interventions: Brief worn, change every 2-3 hours and PRN (as needed). Review of Resident #63's Kardex (a form indicating the level of assistance a resident requires) indicated Resident #63 is always incontinent. During an observation on 8/8/24, at 1:50 P.M., Resident #63 was observed laying in bed. The Resident said his/her incontinent brief had not been changed since 9:00 P.M. the night before, (a total of 17 hours since his/her brief was change), and that he/she was wet and uncomfortable. On 8/8/24 at 1:58 P.M., Corporate Nurse #1, Corporate Nurse #2 and Nurse #9 observed the Resident laying in bed. Corporate Nurse #1 removed the blankets to provide incontinence care. The Resident was observed wearing two incontinent briefs. Corporate Nurse #1 asked the Resident why he/she was wearing two incontinent briefs and the Residents said, I ask them to put two on me because no one comes and changes me. Resident #63 said the last time he/she was provided incontinence care or was repositioned occurred the night before at 9:00 P.M. Corporate Nurse #2 and Nurse #9 turned the Resident on to his/her left side and removed the two incontinence briefs. The two incontinence briefs were soaking wet with dark yellow, foul-smelling urine and contained pink, red, and brownish spots of discoloration throughout the brief, along the coccyx and buttocks area. The Resident had dried feces on his/her skin along the coccyx and buttocks area as well with excoriation throughout the buttock. The surveyor also observed a shallow open ulcer with red wound bed, bloody drainage and slough on the left buttock, a shallow open ulcer with red wound bed, bloody drainage and slough on the posterior thigh, and intact skin with localized area of persistent non-blanchable erythema and maroon discoloration on the coccyx. Corporate Nurse #1 said the Resident has three Stage II wounds. (In spite of slough being present in the wounds indicating wounds are a stage III). During an interview on 8/8/24, at 2:00 P.M., CNA #4 said that Resident #63 had not been provided incontinent care because Resident #63 required an assist of two people to turn and reposition and there was not enough staff to care for all 24 residents on the unit. During an interview on 8/8/24 at 2:30 P.M., Corporate Nurse #1 said the expectation of the facility is that incontinent residents be toileted every two hours and as needed. During an interview on 8/8/24 at 2:48 P.M., Unit Manager #1 said Residents who require incontinence care and turning an repositioning are at risk for skin breakdown and should not be left sitting in urine without care. Review of the facility document titled Documentation Survey Report v2 (Activities of Daily Living (ADL) documentation sheet), dated August 2024, indicated Resident #63 was dependent on staff for toileting, and incontinent of bowel and bladder. Further review failed to indicate that ADL care was provided during the following shifts: On 8/7/24, 7:00 A.M. to 3:00 P.M. On 8/7/24, 11:00 P.M. to 7:00 A.M. On 8/8/24, 7:00 A.M. to 3:00 P.M. On 8/8/24, 3:00 P.M. to 11:00 P.M. During an interview on 8/12/24 at 10:19 A.M., the Director of Nurses (DON) said it is her expectation that staff reposition residents and provide incontinence care every two hours. 36797 1 b. Resident #10 was admitted to the facility in July 2024 with diagnoses including pain, spinal stenosis and osteoarthritis. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #10 scored a 15 out of 15 on the Brief Interview for Mental Status, indicating intact cognition. Further review indicated that Resident #10 is totally dependent on staff for toileting needs and is always incontinent of bowel and bladder. Review of the care plan dated 7/31/24, indicated that Resident #10 is dependent on staff for toileting needs. During an observation on 8/8/24, at 2:00 P.M., Resident #10 said that his/her incontinent brief had not been changed since 9:00 P.M. the night before; a total of 17 hours without incontinence care. The surveyor and Unit Manager #1 observed Resident #10 lying in bed in a saturated incontinent brief. The surveyor and Unit Manager #1 observed the incontinent brief to be saturated and the color of the contents to be a dark reddish brown, with a strong smell of stale urine. Unit Manager #1 said that he could tell that there was no feces present but was concerned about the dark color of the urine. Unit Manager #1 said that Resident #10 should have had his/her incontinent brief checked and changed as needed but at least every 2 to 3 hours. He then said that he could tell that it had been many hours since the incontinent brief had been changed. Unit Manager #1 said that with the number of residents on the unit that require an assist of two staff members to provide care, one Certified Nurse's Aide (CNA) and one nurse is not enough to get the job done. The surveyor and Unit Manager #1 then observed a non-blanchable area on the coccyx measuring 7L cm x 2W cm (centimeters). Unit Manager #1 said that the non-blanchable area on the coccyx was a stage one pressure area and was new. Unit Manager #1 said that leaving a resident in a saturated incontinent brief for an extended period of time could lead to skin breakdown. During an interview on 8/8/24, at 2:00 P.M., CNA #4 said that Resident #10 had not been provided incontinent care because Resident #10 required an assist of two people to turn and reposition and there was not enough staff to care for all 24 residents on the unit. During an interview on 8/12/24 at 10:19 A.M., the Director of Nurses (DON) said it is her expectation that staff reposition residents and provide incontinence care every two hours. 43846 2. Resident #3 was admitted to the facility in January 2024 with diagnoses that included Alzheimer's disease, depression, and lymphedema. Review of Resident #3's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS). Further review of the MDS indicated the Resident required supervision or touching assistance for eating. On 8/6/24 at 8:44 A.M. to 8:53 A.M., the surveyor observed Resident #3 in bed with their breakfast tray in front of them on the over the bed table not set up. The surveyor observed the Resident struggle to uncover their food and drinks. No staff were present in the room. During an interview on 8/6/24 at 8:53 A.M., Resident #3 said he/she needs help to eat and cannot uncover her meal and drinks with out help. On 8/6/24 from 12:19 P.M. to 12:28 P.M., the surveyor observed Resident #3 in bed with their lunch tray, the Resident was not initiating eating. No staff were present in the room. On 8/7/24 from 8:39 A.M. to 8:46 A.M., the surveyor observed Resident #3 in bed asleep with their breakfast tray on their over the bed table. The Resident was behind the privacy curtain and unable to be visualized from the hallway. No staff were present in the room. On 8/7/24 from 12:40 P.M. to 12:48 P.M., the surveyor observed Resident #3 in bed with their lunch tray, the Resident was not initiating eating. The Resident was behind the privacy curtain and unable to be visualized from the hallway. No staff were present in the room. On 8/8/24 from 8:46 A.M. to 8:56 A.M., the surveyor observed Resident #3 in bed asleep with their breakfast tray on their over the bed table. The Resident was behind the privacy curtain and unable to be visualized from the hallway. No staff were present in the room. On 8/9/24 at 8:54 A.M. to 8:58 A.M., the surveyor observed Resident #3 in bed with their breakfast tray in front of them on the over the bed table not set up. The surveyor observed the Resident asleep behind the privacy curtain. No staff were present in the room. Review of Resident #3's Activity of Daily Living (ADL) care plan failed to indicate the level assist the Resident requires for eating. Review of Resident #3's nursing progress note, dated 7/17/24, indicated downgrade diet to puree d/t (due to) difficulty swallowing. During an interview on 8/9/24 at 8:57 A.M., Nurse #5 said if a resident's plan of care is supervised or assist at meals then a staff member should be present in the room with the resident. During an interview on 8/9/24 at 8:58 A.M., CNA #5 said Resident #3 needs assistance to eat and said no one is in the room currently with the Resident. During an interview on 8/12/24 at 10:17 A.M., the Director of Nurses (DON) said if a resident is coded on the MDS as needing supervision or assistance with meal then the expectation is that staff are in the room assisting that resident. 45343 3 a. Resident #37 was admitted to the facility in August 2021, with diagnoses including atrial fibrillation, cerebral infarction, and hemiplegia and hemiparesis affecting the right dominant side. Review of Resident #37's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15, indicating he/she has severe cognitive impairments. The MDS also indicated Resident #37 requires substantial/maximal to dependent assistance for all self-care activities. On 8/6/24 at 8:13 A.M., and 12:16 P.M., 8/7/24 at 12:27 P.M., 8/8/24 at 8:59 A.M., and 8/12/24 at 8:28 A.M., Resident #37 was observed lying in bed with long dirty fingernails. Resident #37 said he/she always kept his/her fingernails clean and would like his/her fingernails cut and cleaned. Resident said he/she has not been offered to have his/her fingernail cut or cleaned. Record review on 8/8/24 at 8:32 A.M., Resident #37's care plan last updated on 3/2/24 indicated the following: Grooming: x 1 assist, dependent at times due to fatigue. Further review of Resident #37's Kardex (a form indicating level of assistance a resident requires) indicated the following: Grooming: x 1 assist, dependent at times due to fatigue. During an interview on 8/12/24 at 9:53 A.M., Nurse #14 said nail care is part of a resident's morning care and if she notices long nails, she will ask the Resident if they would like their nails to be cut. Nurse #14 said she was not aware that Resident #37 had long dirty nails but said she will ask the CNA to go back and clean his/her nails as it was not done during this morning's care. During an interview on 8/12/24 at 12:59 A.M., Corporate Nurse #1 said she would expect Resident's nails to be cleaned and cut as needed during morning care and if a resident refuses care, it should be documented. Review of Resident #37's medical record failed to indicate he/she refused care. 3 b. Resident #94 was admitted to the facility in June 2022, with diagnoses including hemiplegia and hemiparesis affecting left non-dominant side and hypertension. Review of Resident #94's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, indicating he/she is cognitively intact. The MDS also indicated Resident # 94 requires supervision to touch assistance for self-care activities. On 8/6/24 at 8:07 A.M., 8/7/24 at 12:26 P.M., and 8/8/24 at 9:03 A.M., Resident #94 was observed lying in bed with long fingernails on his/her left hand. Resident #94 said he/she normally keeps his/her nails short, but said you have to practically beg to get your nails cut. Resident #94 was asked if he/she was offered to have his/her fingernails cut today, he/she said no. Record review on 8/7/24 at 12:26 P.M., Resident #94's care plan last updated on 7/12/24 indicated the following: Grooming: x 1 assist. Further review of Resident #94's Kardex (a form indicating level of assistance a resident requires) indicated the following: Grooming: x 1 assist. During an interview on 8/12/24 at 9:53 A.M., Nurse #14 said nail care is part of a resident's morning care and if she notices long nails, she will ask the Resident if they would like their nails to be cut. Nurse #14 said she was not aware that Resident #94 needed his/her fingernails cut. During an interview on 8/12/24 at 12:59 A.M., Corporate Nurse #1 said she would expect Resident's nails to be cut as needed during morning care and if a resident refuses care, it should be documented. Review of Resident #94's medical record failed to indicate he/she refused care. 4. Resident #2 was admitted to the facility in May 2018, with diagnoses including Neurocognitive disorder with Lewy body, paranoid schizophrenia, and anxiety disorder. Review of Resident #2's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 4 out of a possible 15, indicating he/she has severe cognitive impairments. The MDS also indicated Resident #2 requires partial/moderate assistance for personal hygiene and does not display any behaviors impacting care. On 8/6/24 at 8:37 A.M., 8/7/24 at 9:30 A.M., 8/8/24 at 8:04 A.M., 8:34 A.M., and 12:42 P.M., and 8/12/24 at 7:56 A.M., Resident #2 was observed with long chin and upper lip hair. Resident #2 said he/she normally does not have facial hair. Record review on 8/6/24 at 3:33 P.M., Resident #2's care plan last updated 3/2/24 indicated the following: assist of 1 to independent for personal hygiene (grooming). During an interview on 8/12/24 at 10:10 A.M., Nurse #13 said we normally shave Resident #2 after asking his/her permission. Nurse #13 said she has not heard that the Resident is refusing care as the staff will normally come find me to assist with his/her care. During an interview on 8/12/24 at 12:59 P.M., Corporate Nurse #1 said she would expect facial hair to be removed with the residents permission during routine care and any refusals should be documented in the medical record. Ref. F684, F686, F725

Based on observation, record review, and interview, the facility failed to ensure residents received treatment and care to maintain the highest practicable well-being for six Residents (#99, #42, #81, #41, #49, and #263) out of a total of 46 sampled residents. Specifically, 1. For Resident #99, the facility failed to ensure staff identified and address a deteriorating skin injury. 2. For Resident #42 the facility failed to obtain a culture and sensitivity (C&S) as ordered by the MD for 10 days after the order was initially given and failed to notify the MD that they were unable to fulfill the order. 3. For Resident #81, the facility failed to ensure it monitored or identified a Stage 2 calf wound or seek treatment to promote healing and prevent infection. 4. For Resident #41, the facility failed to ensure nursing staff completed his/her physician ordered wound treatment. 5. For Resident #49, the facility failed to ensure nursing staff completed his/her physician ordered wound treatment. 6. For Resident #263, the facility failed to ensure physician orders were implemented for his/her wound. Findings include: 1. Review of the facility's Care of Skin Tears - Abrasions and Minor Breaks, dated April 2022 indicated: Obtain a physicians order as needed. Document physician notification in the medical record. Report other information in accordance with facility policy/guideline and professional standards of practice. Resident #99 was admitted to the facility in August 2023 with diagnoses including Alzheimer's disease, dysphagia and legal blindness. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #99 scored 3 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS) indicating severe cognitive impaired. The MDS also indicated Resident #99 requires assistance with bathing, dressing and transfers. Review of Resident #99's Activities of Daily Living (ADL) care plan indicated the following interventions: Provide resident/patient with assist of one for dressing. Provide resident/patient with assist of two for bed mobility. Provide resident/patient with assist for ambulation, toileting. (3/2/24). Review of Resident #99's clinical record indicated the following progress note written by Nurse #8 : 6/19/2024, at 11:37 A.M., while nurse was passing meds, CNA (Certified Nursing Assistant) assign (sic) to resident reported to the nurse, she noted blood on resident leg, and when she looks (sic), resident has a skin tear on the left leg shin area. Nurse assess resident for pain, resident denies any pain or discomfort. assess the skin tear, clean with normal saline and apply sterile strip and sterile border gauze applied. Nurse notified unit manager, HCP and resident physician. Review of the physicians note dated 7/11/24 indicated: [Resident #99] was seen at the facility for follow up where he/she is a long term care resident. [Resident #99] was seen to follow up a skin tear on his/her RLE (right lower extremity).Wound was cleaned with wound spray cleaner by RN (Registered Nurse), old dressing removed, and new dressing placed with santyl (an ointment used to treat wounds). Skin: RLE wound: 10 cm linear skin tear with some scar tissue formed at wound edges. Minimal erythema of the edges of the wound bed where it appears to be attempting to heal. No tenderness to palpation. Minimal warmth as compared to the adjacent leg, no surrounding erythema, some slough (dead tissue within a wound, often appearing as a yellow, tan, or white fibrous material), upon removal of dressing unclear amount of time present on leg. Neurological: At baseline. Responds with inconsistently intelligible speech. States that it hurts when dressings were changed. Assessment/Plan: Open wound of right lower extremity. Skin tear initially noted 6/2024. Unclear if dressing was changed, removed at visit with some slough present, minimal warmth compared to L (left) leg, minimal edema, no pain on palpation, no fevers. Skin tear RLE with delayed healing, no signs of infection at this time. Wound care orders placed: Cleanse with normal saline, pat dry, apply bacitracin, cover with bordered gauze. Change daily - NP (Nurse Practitioner) follow up next week, will initiate antibiotics at that time if signs of cellulitis. Review of the physicians orders failed to indicate any orders for treatments were implemented for Resident #99's skin tear until 7/11/24; after the physician documented the wound had deteriorated evidenced by the presence of slough. During an interview on 8/8/24 at 11:26 A.M., Physician #2 said he had seen Resident #99's skin tear on his/her leg in June 2024 and a dressing was applied, but he did not write a note. Physician #2 said he spoke with nursing staff regarding caring for Resident #99's skin tear but he did not input orders to treat Resident #99's in the clinical record. Physician #2 said he came in to see Resident #99 again (on 7/11/24) and saw that he/she had a dressing on that was undated, saturated and visibly soiled. Physician #2 said that it appeared that the dressing had not been changed for an unknown period of time and was at risk for infection. Physician #2 said that Resident #99 is dependent for care and staff should have noticed that Resident #99's skin tear and dressing needed attention. Physician #2 said that Resident #99's skin tear had deteriorated since he had seen it in June 2024. Multiple calls were placed to Nurse #8 for interview which were unanswered. Unit Manager #2 was unavailable for interview. During an interview on 8/9/24 at 11:27 A.M., Corporate Nurse #1 said that attending physicians have access to the electronic record and will input treatment orders for residents which nurses are supposed to confirm. During an interview on 8/9/24 at 11:27 A.M. and 8/12/24 at approximately 12:30 P.M., The Director of Nursing (DON) said that nurses are to monitor and alert the physician with changes in resident skin condition and change dressings when they are visibly soiled. 41105 2. For Resident #42 the facility failed to obtain a culture and sensitivity (C&S) as ordered by the physician for 10 days after the order was initially given, and failed to notify the physician that they were unable to fulfill the order. Resident #42 was admitted to the facility in July 2022 and has diagnoses that include Multiple Sclerosis and chronic venous hypertension (Idiopathic) with ulcer of right lower extremity. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/10/24, indicated that on the Brief Interview for Mental Status exam Resident #42 scored a 15 out of 15, indicating intact cognition. The MDS further indicated Resident #42 had no wounds or skin issues. Review of the clinical record indicated the following: -A skin assessment, dated 7/22/24, indicated Resident #42 had no skin issues. -A nurses note dated 7/26/24: Area skin flaking and moist with pus filled skin to RLE (history of areas). New order to obtain wound C&S, NSW, pat dry, apply Bacitracin and cover with DPD until healed. -A skin assessment, dated 7/29/24, indicated Resident Resident #42's skin was not intact and had the following area to the front of his/her right lower leg: open areas present with purulent and serosanguineous drainage. -A Nurse Practitioner (NP) Progress note, dated 7/30/24, indicated: Chronic venous ulceration on right lower extremity, protein-calorie malnutrition, generalized muscle weakness. Noted on the patient's right lower extremity are multiple scattered shallow ulcerations with irregular borders. Some areas are reddened with granulation tissue and others are with slough, none tunneling, with large amounts of serous drainage, mild odor. (a deterioration from 7/6/24). Wound culture ordered, Venous Doppler Ultrasound. Continue health supplements. Continue daily dressing changes with NS (normal saline) and wrap with kerlix. We will order topical after results of wound culture is available. Review of the July 2024 Medication Administration Record (MAR) indicated the following order: Obtain wound C & S RLE wound. Start date 7/26/24 at 15:00. The MAR further indicates that after the order was obtained nursing failed to follow the order: -7/26/24 evening shift was left blank (not completed); -7/26/24 night shift was left blank; -7/27/24 day shift was left blank; -7/27/24 evening shift was left blank; -7/27/54 night shift was left blank; -7/28/24 day shift was left blank; -7/28/24 evening shift was left blank; -7/28/24 night shift was left blank; -7/29/24 day shift was coded 9=other/see progress notes. The record indicated a progress note Unable to obtain d/t (due to) no culture swab. -7/29/24 evening shift was coded 2=drug refused; -7/29/24 night shift was left blank; -7/30/24 day shift was coded 9. The record failed to indicate a progress note; -7/30/24 evening shift was left blank; -7/30/24 night shift was coded 9. The record indicated a progress note unavailable. -7/31/24 day shift was coded 9. The record indicated a progress note having technical difficulties. -7/31/24 evening shift was coded with a check mark=drug administered; -7/31/24 night shift was coded with a check mark; -8/01/24 day shift was coded 9. The record indicated a progress note refused. -8/01/24 evening shift was coded 9. The record failed to indicate a progress note; -8/01/24 night shift was coded with a check mark; -8/02/24 day shift was coded 2=drug refused; -8/02/24 evening shift was coded 9. The record failed to indicate a progress note; -8/02/24 night shift was coded 9. The record failed to indicate a progress note; -8/03/24 day shift was coded with a check mark; -8/03/24 evening shift was coded with a check mark; -8/03/24 night shift was coded with a check mark; -8/04/24 night shift was coded with a check mark; -A nurses note dated 8/4/24 indicated the C&S was obtained on 8/4/24; 10 days after the order was initially ordered. -A nurses note dated 8/8/24: Wound C&S results had come back and Resident #42 was positive for the following infection in the wound: + Proteus Mirabilis and Staphylococcus. During an interview on 8/12/24 11:42 A.M., Nurse #4 said that she was the nurse that initially obtained the order to get a C&S. Nurse #4 said that when the change to Resident #42's leg was noted the new orders should have been implemented on that day, however, the facility had no culture kits available, (which are provided by the lab) for a period of time. Nurse #4 said that she called the lab and the kits were delivered the end of the next week. She said that she should have notified the physician and written a progress note but that she has been very busy and must have forgotten. The record failed to indicate that the physician or Nurse Practitioner were notified that the kits were unavailable and that therefore the facility was unable to obtain the C&S for Resident #42's new wound. During an interview on 8/12/24 at 12:21 P.M., the Director of Nursing (DON) said that there was an issue with running out of kits and it took about a week to get them from the lab. The DON said that the physician should have been notified they could not fulfill an order. 15016 3. Resident #81 was admitted to the facility in May 2021 and had a primary diagnosis of stroke. Review of Resident #81's Norton Plus Pressure Ulcer Scale dated 7/30/24, indicated a score of 15, signifying a moderate risk for the development of pressure ulcers. Review of Resident #81's Minimum Data Set Assessment (MDS) dated [DATE], indicated a Brief Interview for Mental Status score of 1 out of 15; signifying severe cognitive impairment. The MDS indicated the Resident is completely dependent on staff for all bed mobility and required substantial assistance for all other activities of daily living. The MDS indicated the Resident was at-risk for pressure injuries but had no skin wounds and required pressure relieving devices for the bed and chair. Resident #81's care plan dated as revised 6/19/24, indicated: Focus: He/she was at-risk for skin breakdown due to decreased mobility and incontinence, staying in his chair for longer periods and refusing to go to bed. The care plan indicated, 3/23/24 multiple scabs to both legs - open to air. Goal: The resident will not show signs of skin breakdown x 90 days. Interventions included: - Monitor scabs on bilateral lower extremities and report changes to MD. - Resident at-risk for skin breakdown due to decreased mobility and incontinence, staying in his/her chair for longer periods and refusing to go to bed. - Independent bed mobility. - Pat (do not rub) skin when drying. - Provide preventative skin care i.e. lotions, barrier creams as ordered. - Apply barrier cream with each cleansing. Review of Resident #81's skin observation tool dated 7/18/24, indicated he/she had no wounds or pressure areas. Review of Resident #81's physician orders and notes and nursing notes dated prior to 8/8/24, did not indicate he/she had a skin wound. On 8/8/24 at 2:10 P.M., the surveyor and Nurse #9 observed that Resident #81 had a 1 centimeter (cm) x 1 cm wound located on the left calf. A dressing or other treatment was absent. Nurse #9 said this was a Stage 2 wound because of its depth and drainage, and the skin around the wound was erythematous. Nurse #9 said she would contact the physician to report the wound and obtain treatment orders. On 8/8/24 at approximately 2:20 P.M., Corporate Nurse #1 accompanied the surveyor and observed Resident #81's calf wound. Corporate Nurse #1 said this was only a scab and it did not need to be reported to the physician because treatment was not required. On 8/8/24 at 2:35 P.M., Unit Manager #1, accompanied by two surveyors, observed Resident #81's calf wound. Unit Manager #1 said the wound was a Stage 2 pressure injury due to its depth and surrounding erythema. Unit Manager #1 said none of the Certified Nurses Aides or nurses who provide care to the Resident and who are supposed to monitor the Resident for skin wounds, told him about this wound. Unit Manager #1 said he would notify Nurse Practitioner (NP) #2 about the wound and obtain treatment orders. Review of Resident #81's skin observation tool dated 8/8/24 and completed at 11:02 P.M. by Corporate Nurse #1, indicated a treatment was applied to a 1 cm x 1 cm wound located on the left calf. The assessment did not indicate the depth of the wound, or the type of treatment. Review of the Resident's nursing and physician progress notes and orders failed to indicate any reference to the Resident's wound or that staff notified the physician or NP #2 about the calf wound, or reference to a treatment. Review of Resident #81's medical record on 8/9/24 at approximately 8:50 A, M., indicated there was no documentation to indicate Nurse #9, Unit Manager #2, Corporate Nurse #1, or any other staff notified the physician or NP #2 about his/her calf wound. On 8/9/24 at approximately 8:15 A. M., 8:57 A.M. and 10:50 A.M., the surveyor observed Resident #81 in the dining room and that no dressing covered his/her exposed calf wound. During an interview with Certified Nurse Aide (CNA) #9 on 8/9/24 at 8:59 A.M., she said she regularly provides care to Resident #81 because he/she is dependent on staff for activities of daily living. CNA #9 said she was unaware the Resident had an open wound on his/her calf. The surveyor observed that the skin surrounding the Resident's calf wound was now purple. On 8/9/24 at 12:50 P.M., the surveyor telephoned NP #2 to determine if she was aware of Resident #81's calf wound. A voice mail message was left but as of 8/15/24 there was no call back. On 8/9/24 at 1:00 P.M., the surveyor observed Resident #81 in the dining area, sitting in a chair. The Resident's left calf wound was exposed and there was no dressing covering it. During an interview with the DON and Corporate Nurse #1 on 8/9/24 at 1:15 PM., the surveyor told them that Resident #81's skin assessment dated [DATE] and completed after the surveyor's observations of the wound earlier in the day, indicated a 1 cm x 1 cm wound on the left lower leg and that a treatment was applied. The surveyor told them there was no documentation in the record to indicate staff notified the physician or NP #2 about Resident #81's calf wound or obtained a physician's order for wound treatment. The surveyor informed them that, despite the assessment indicating a treatment was applied, as of this time Resident #81 did not have a dressing over the open wound. Corporate Nurse #1 said she telephoned the physician during the night of 8/8/24 and notified him that Resident #81 had a scab on the left calf. Corporate Nurse #1 said the physician told her to only apply skin prep because it was not an open wound. Corporate Nurse #1 said she forgot to document the conversation and treatment order. The surveyor told Corporate Nurse #1 that Unit Manager #1, a staff nurse and two surveyors observed the wound on 8/8/24 and determined it was an open wound, not a scab. On 8/9/24 at 1:20 P.M., the DON and surveyor observed Resident #81's calf wound. The DON said it was either a Stage 2 or an unstageable wound and not a scab. The DON said the skin surrounding the wound was purple and the wound had signs of drainage. The DON said skin prep was not an appropriate treatment for the wound and that it should be covered with a medicated dressing to encourage healing and prevent infection. The DON said staff had not made her aware of the wound. 43846 4. Resident #41 was admitted to the facility in April 2022 with diagnoses that included type 2 diabetes, chronic venous hypertension, and chronic kidney disease. Review of Resident #41's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated he/she scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident is cognitively intact. On 8/6/24 at 8:15 A. M., the surveyor observed Resident #41 in bed with exposed wounds on the left lower leg, no dressing was in place. During an interview on 8/6/24 at 8:16 A. M., Resident #41 said that the nurses are busy and do not do his/her leg treatment daily. Review of Resident #41's physician order, dated 7/2/24, indicated Left front calf: Wash with WC (wound cleanser), pat/dry, skin prep, cover the open area with collagen, puracol plus, and silicone border dressing QD/prn (daily/as needed). Review of Resident #41's skin breakdown care plan, dated 3/2/24, indicated: Treatment as ordered. Review of Resident #41's nursing progress notes failed to indicate the Resident refused the left leg treatment. During an interview on 8/9/24 at 1:05 P.M., Nurse #6 said treatments should be completed as ordered and if a resident refuses a treatment, the doctor should be called and a nurses note should be written. During an interview on 8/12/24 at 10:37 A.M., the Director of Nurses (DON) said the expectation is the nurses complete their treatments as ordered. 5. Resident #49 was admitted to the facility in June 2016 with diagnoses that included multiple sclerosis, type 2 diabetes, dementia and legally blind. Review of Resident #49's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated he/she scored a 7 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident has severe cognitive impairments. The MDS further indicated the Resident is at risk for developing pressure ulcers and has a skin tear. The MDS also indicated that the Resident does not reject care. On 8/6/24 at 8:06 A.M., the surveyor observed Resident #49 in bed with wounds exposed on the right shin, no dressing was in place. Review of Resident #49's skin breakdown care plan, dated 3/2/24, indicated: Treatment as ordered. Review of Resident #49's physician order, dated 7/30/24, indicated: Right LE (lower extremity) wound care; Cleanse with NS (normal saline) and pat dry. Apply woundgel/ hydrogel, DPD (dry protective dressing) and kling daily. Review of Resident #49's skin observation tool, dated 7/31/24, indicated the Resident has right lower leg abrasions. Review of Resident #49's nursing progress notes did not indicate that the Resident refused the right lower extremity treatment. During an interview on 8/9/24 at 1:05 P.M., Nurse #6 said treatments should be completed as ordered and if a resident refuses a treatment the doctor should be called and a nurses note should be written. During an interview on 8/12/24 at 10:37 A.M., the Director of Nurses (DON) said the expectation is the nurses complete their treatments as ordered. 6. Resident #263 was admitted to the facility in August 2023 with diagnoses that included acute and chronic respiratory failure, dementia, hypertensive heart and chronic kidney disease. Review of Resident #263's Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 10 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident has a moderate cognitive impairment. On 8/6/24 at 8:01 A.M. and 12:18 P.M., the surveyor observed Resident #263 with a dressing on their right forearm with a date of 8/2/24. During an interview on 8/6/24 at 8:02 A.M., Resident #263 said he/she was not sure why they has a dressing on their forearm. Resident #263 said he/she has had it on their arm since being in the hospital. On 8/7/24 at 6:56 A.M., the surveyor observed Resident #263 with a dressing on their right forearm with a date of 8/6/24. Review of Resident #263's Comprehensive Nutritional Evaluation, dated 8/6/24, indicated a forearm skin tear. Review of Resident #263's active physician orders did not indicate a treatment order for the right forearm. During an interview on 8/9/24 at 1:05 P.M., Nurse #6 said there needs to be a doctors order in place for dressings to be done on any resident. During an interview on 8/12/24 at 10:25 A.M., the Director of Nurses (DON) said there should be a doctors order in place for any dressing treatment. Ref. F686, F725

Based on observations, interviews, policy review, and record review, the facility failed to provide care and treatment to prevent the development and worsening of pressure ulcers (wounds that occur when the skin and tissue are damaged by prolonged pressure, usually on bony areas like the coccyx, hips, heels, or elbows) for six Residents (#30, #14, #63, #10, #81, #3) out of a total sample of 46 residents. Specifically: 1. For Resident #30 the facility failed to implement interventions to prevent pressure ulcer development for a resident who is dependent on staff. The Resident developed an unstageable deep tissue injury on the right heel. 2. For Resident #14, the facility failed to implement treatments recommended by the Wound Nurse Practitioner resulting in the deterioration of a stage II pressure ulcer to an Unstageable pressure ulcer. 3. For Resident #63 and Resident #10, the facility failed to provide incontinence care resulting in the development of pressure ulcers. 4. For Resident #81, the facility failed to treat and promote the healing of a pressure injury. 5. For Resident #3, the facility failed to implement treatment recommendations made by the Wound Nurse Practitioner. Findings include: According to the National Pressure Injury Advisory Panel, a Stage 2 Pressure Injury is defined as a partial-thickness skin loss with exposed dermis and may present as an intact or ruptured serum-filled blister. A Deep Tissue Injury (DTI) is defined as a persistent non-blanchable deep red, maroon or purple discoloration, intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. Review of the facility's policy Pressure Ulcer/Injury Risk assessment dated as revised 3/20/22, indicated Notify attending MD if new skin alteration noted. Documentation in the medical record addressing MD notification if new skin alteration noted with change of plan of care, if indicated. 1. Resident #30 was admitted to the facility in June 2024 with diagnoses including schizoaffective disorder bipolar type, dementia and heart failure. Review of the Minimum Data Assessment (MDS) dated [DATE], indicated that Resident #30 scored a 10 out of 15 on the Brief Interview for Mental Status exam, indicating moderately impaired cognition. Further review indicated that Resident #30 requires substantial to maximal assistance with all activities of daily living. Further review indicated that Resident #30 was at risk for developing pressure ulcers. Review of the care plan dated 6/19/24, with a focus of Potential alteration in skin integrity included the following interventions: -dietary interention/evaluation as indicated -Protective skin care with incontinent care -Rehab screen for positioning/seating as needed -Skin assessments weekly Further reveiw failed to indicate that pressure ulcer prevention interventions were implemented. Review of the facility document titled SKIN OBSERVATION TOOL - (Licensed Nurse) - V 4 dated 7/2/24, indicated that Resident #30's skin is intact. Review of the facility document titled RC Norton Plus Pressure Ulcer Scale and dated 7/9/24, indicated that Resident #30 scored a 10, indicating high risk for pressure ulcer development, (completed one month after Resident #30 was admitted to the facility and only after the development of a pressure ulcer on the right heel on 7/9/24). Review of the doctor's orders with an initiation date of 7/9/24 at 11:00 P.M., indicated an order for Prevalon boot to R (right) heel, off-load R heel every shift for R heel pressure ulcer. Review of the facility document titled SKIN OBSERVATION TOOL - (Licensed Nurse) - V 4 dated 7/10/24, indicated that Resident #30's right heel now has an intact blister. Review of the medical record indicated that Resident #30 was admitted to the hospital on 7/16/24 with pneumonia. Further review of the medical record failed to indicate the condition of the right heel since 7/10/24. Review of the facility document titled SKIN OBSERVATION TOOL - (Licensed Nurse) - V 4 dated 7/28/24, indicated that Resident #30 had a deep tissue injury (DTI) to the right heel and was readmitted from the hospital with a new open area on the Sacrum and a new DTI to L (left) heel. No measurements or staging were included in assessment. Review of the hospital discharge summary dated 7/28/24, failed to indicate Resident #30 had pressure ulcers or non-intact skin. Review of the care plan indicated a focus problem for alteration in skin integrity dated 8/6/24, with an intervention for Prevalon Boots to the right heel. Further review of the care plan failed to indicate that Resident #30 refused to wear the Prevalon boot. On 8/6/24 8:58 A.M., and 12:44 P.M., the surveyor observed Resident #30 laying in bed with both heels flat on the mattress. On 8/7/24, at 12:50 P.M., the surveyor observed Resident #30 laying in bed with his/her heels directly on the mattress. The surveyor observed that Resident #30 was not wearing a Prevalon boot to the right heel. The surveyor observed multiple reddish/brown spots of blood on the sheet under the right heel. The surveyor observed a dark maroon area, approximately the size of a half dollar, on the right heel that had sanguineous drainage. The surveyor was unable to locate a Prevalon boot in the Resident's room. Review of Nurse Practitioner (NP) #1 note dated 7/9/24, indicated a new pressure area to right lateral heel measuring 2.0 x 1.5 CM (centimeters). Further review indicated new order for skin prep to heel and Prevalon boots and off load both heels. Review of NP #1's notes dated 7/11/24 and 7/30/24 failed to indicate she had been notified of the wounds deteriorating. Further review failed to indicate that NP #1 evaluated the deteriorating wounds. Review of Physician #1's notes dated 7/12/24 and 8/2/24, failed to indicate he was aware of the pressure area on the right heel, left heel and sacrum. Review of the medical record failed to indicate any measurements or any process in place to monitor the progression of the wounds. During an interview on 8/8/24, at 9:38 A.M., the Director of Operations said that Resident #30 had not been seen by the wound doctor. On 8/8/24 at 9:26 A.M., the Director of Nursing (DON) said that it is the expectation for the nurse practitioner to be notified of a new pressure area and the wound doctor to see the resident within one week of the development of a new pressure area. The DON then said that she expects that the doctor's orders are followed. During an interview on 8/8/24, at 11:25 A.M., Unit Manager (UM) #1 said that he was not aware of Resident #30's wounds and would expect that a draining wound would be covered, and that the heels should be off loaded as ordered. UM #1 said that he would expect that wounds would be measured at least weekly to determine if treatments were effective. UM #1 then measured the wounds on both heels and said they each measured 3 CM x 3 CM, a deterioration since the 7/9/24, measurements taken by NP #1. UM #1 said that he was not aware that Resident #30 was supposed to have Prevalon boots on and was unable to locate them in the room. During an interview on 8/8/24, at 11:25 A.M., Certified Nurse's Aide (CNA) #4 said that she was not aware that Resident #30 was supposed to have Prevalon boots on. She then said that she had never seen the Resident with the boots on and could not find them in his/her room. During an interview on 8/12/24 at 8:50 A.M., the Wound Nurse Practitioner (NP) said that she was made aware of the Resident #30's wounds on the heels and sacrum today. The Wound NP then said that the wounds are significant. She also said that the wounds have been in place for more than a week based on their severity. The Wound NP then said that she comes in to the building once a week and said she would have expected to be have been notified of the wounds. Review of the Wound NP's note dated 8/8/24, indicated that Resident #30 has the following wounds: Pressure ulcer buttock left; stage 3, 5.4 x 3.6 x 0.3 cm (centimeters) 40% slough, 60% granulation. Pressure ulcer heel left; unstageable, 2.6 x 1.6 x 0 cm intact, boggy to touch, non-blanching maroon. Pressure ulcer heel right; unstageable, 3.7 x 2.4 x 0 cm boggy to touch, non-blanching maroon, small tear in tissue that produces drainage. Further review indicated that the Wound NP wrote and discussed with staff the following treatment recommendations: Pressure ulcers to left and right heel- skin prep to wounds, cover with ABD and wrap in Kerlex, Qday/PRN (every day and as needed). Off-loading in bed at all times, frequent repositioning, avoid pressure and trauma. Monitor for changes. Air Mattress recommended. Pressure ulcer buttock left- Wash with wound cleanser, pat dry, and skin prep to peri skin. Santyl to the area of the slough. Calcium alginate to entire wound with sacral dressing QD and PRN. Prompt pericare, frequent repositioning. Air mattress recommended. Review of the progress notes dated 8/8/24 through 8/12/24 failed to indicate that the doctor had been notified of the Wound NP recommendations. During an interview on 8/12/24, at 11:37 A.M., Unit Manager #1 said that it is the expectation that the nurse taking the recommendation from the Wound NP would call the primary doctor to review the recommendations and obtain the orders. During an interview on 8/12/24 at 11:44 A.M., the DON said that it is the expectation that the nurse taking the recommendation from the Wound NP would call the primary doctor to review the recommendations and obtain the orders. The DON also said that the facility has the nurse complete rounds with the Wound NP so that the nurse is aware of the recommendations at the time of the evaluation of the Wound NP and can then notify the primary doctor and obtain orders because sometimes it takes 24 hours to obtain the Wound NP's written evaluation. 36876 2. Resident #14 was admitted to the facility in May 2023 with diagnoses including peripheral vascular disease and type 2 diabetes. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #14 is cognitively intact as evidenced by a score of 15 out of a possible 15 on the Brief Interview for Mental Status Exam. The MDS also indicated he/she had pressure injuries and required assistance with bathing, dressing and transfers. Review of the clinical record indicated Resident #14 was readmitted to the facility after a hospitalization on [DATE] with closed unstageable pressure ulcer to his/her right heel. Review of Resident #14's Skin Integrity care plan dated as revised 3/25/24 indicated: Focus: Resident is at risk for skin breakdown related to diabetes, decreased mobility. Actual wounds; wound to right heel. ( Interventions: pressure re-distribution surfaces to chair as per guidelines. Provide wound treatment as ordered. Provide supplements as ordered. Weekly skin check by license nurse. Weekly wound assessment to include measurements an description of wound status. Review of the Wound Nurse Practitioner visit note dated 5/16/24 indicated: Unstageable: 1 centimeters (CM) x 0.9 CM x 0 0.9 CM Exudate: None. 100% Closed. Note: Dry. Instruction: Skin prep Q shift (every shift) and prn (as needed). Avoid trauma and pressure. Boots in bed QD (every day) and prn. Monitor for changes . Review of the May 2024 Treatment Administration Record (TAR) indicated the following: Right heel pressure ulcer: Wash with soap and water pat dry apply skin prep, every shift and as needed. Review of the Wound Nurse Practitioner visit note dated 5/23/24 indicated: Pressure ulcer to right heel has opened up. Patient denies pain. Subsequent progress: Deteriorating Stage II, Exudate (fluid released through wounds): Light Serosanguinous (drainage that is typically thin and watery with a light red or pink hue) Note: 1 CM (centimeter) x 0.9 CM x 0.1 CM total area non-blanchable erythema and maroon. Instruction: Clean with wound cleanser open area pat dry, skin prep to peri skin and closed area of wound. Cover open area with collagen matrix, (a dressing for use on partial and full thickness wounds) silicone foam dressing, offload pressure booties in bed QD and prn. The May 2024 TAR indicated the Wound Nurse Practitioner's recommendations for the use of wound cleanser and collagen sheet were never implemented. 5/30/24: Pressure ulcer to right heel continues to open. No new complaints reported. Stage II, 3.5 CM x 4 CM x 0.1 CM. Exudate: Light Serosanguinous. Subsequent progress Deteriorating: Instruction: Cleanse with wound cleanser pat dry, skin prep to peri skin and closed non-blanchable area. Medi honey, (a treatment that supports the removal of necrotic tissue and aids in wound healing), to open area with necrotic tissue (tissue that is dead and indicative of a deterioration and is present on Stage III, Stage IV or Unstageable wounds.) Cover with collagen sheet. ABD (abdominal dressing) wrap in kerlix, booties in bed and frequent reposition. Q day/PRN. The presence of necrotic tissue and the increase in wound size on 5/30/24 indicated a deterioration from the previous visit on 5/23/24. The May 2024 TAR indicated the Wound Nurse Practitioner's recommendations for the use of wound cleanser, medi-honey, and collagen sheet were never implemented. During an interview on 8/13/24 at 12:56 P.M., the Wound Nurse Practitioner said that she documented Resident #14's wound a Stage II on 5/30/24 because the necrotic tissue was on the edges of the wound and not the wound bed. Review of the Wound Nurse Practitioner visit note dated 6/13/24 indicated: Stage II, 2 CM x 2 CM x 0.1 CM. Exudate: Moderate Serosanguinous. Instruction: Cleanse with wound cleanser pat dry, skin prep to peri skin and closed non-blanchable area. Cover with a collagen sheet, ABD, wrap in kerlix, booties in bed and frequent reposition. Q day/PRN. Review of the June 2024 TAR indicated: Right heel pressure ulcer: Wash with soap and water pat dry apply skin prep, every shift and as needed. The June 2024 TAR indicated that the recommendations for the use of wound cleanser and collagen were not implemented. Review of the Wound Nurse Practitioner visit note dated 6/20/24 indicated: Stage II, 2.2 CM X 2 CM X 0 CM. Exudate: Light Serosanguinous Note: hard non-blanching eschar (a type of necrotic tissue that can develop on severe wounds which typically dry, black, firm, and usually adhered to the wound bed and edges). Instruction: Cleanse with wound cleanser pat dry, cover hard eschar with Santyl, and cover whole wound with collagen, ABD, and wrap in kerlix, offload, and pressure booties in bed QD and prn. The June 2024 TAR indicated that the recommendations for the use of wound cleanser, Santyl and collagen were not implemented. Review of the Wound Nurse Practitioner visit note dated 6/27/24 indicated: Unstageable, 2.5 CM x 2 CM x 0 CM. Exudate: None. Tissue Type: 100% Eschar. Instruction: Cleanse with wound cleanser pat dry, cover hard eschar with Santyl, and cover whole wound with collagen, ABD, and wrap in kerlix, offload, and pressure booties in bed QD and prn The June 2024 TAR indicated that the recommendations for the use of wound cleanser, Santyl and collagen were not implemented. Review of the Wound Nurse Practitioner visit note dated 7/4/24 indicated: Unstageable, 2.4 CM x 1.8 CM x 0 CM. Exudate: None. Tissue Type 100% Eschar. Note: Hard necrotic tissue. Peri skin fragile Instruction: Cleanse with wound cleanser pat dry, cover hard eschar with Santyl, and cover whole wound with collagen, ABD, and wrap in kerlix, offload, and pressure booties in bed QD and prn. Review of the July 2024 TAR indicated: Right heel pressure ulcer: Wash with soap and water pat dry apply skin prep every shift, 5/15/24 through 7/15/24. Right heel pressure ulcer: Cleanse with wound cleanser pat dry, Santyl to eschar, collagen to wound bed, ABD and wrap in kerlix, daily & prn. Document on wound bed, odor, drainage, surrounding skin, wound outcome, initiated 7/16/24. The July 2024 TAR indicated that the treatment recommendations for collagen and Santyl were not implemented until 7/16/24. Review of the Wound Nurse Practitioner visit note dated 7/11/24 indicated: Unstageable, 2.5 CM x 1.8 CM x 0 CM. Exudate: None. Tissue Type: 100% Eschar. Note: Hard eschar. Instruction: Cleanse with wound cleanser pat dry, cover hard eschar with Santyl, and cover whole wound with collagen, ABD, and wrap in kerlix, offload, and pressure booties in bed QD and prn. The July 2024 TAR indicated that the treatment recommendations for collagen and Santyl were not implemented until 7/16/24. During an interview on 8/9/24 at 9:21 A.M., Resident #14 said that he/she does not like wearing booties as they irritate his/her heel, then said: I told them I am okay with using a pillow. Resident #14 showed the surveyor his/her right heel offloaded on a pillow in the bed. Resident #14 said that the Wound Nurse Practitioner comes in weekly to look at his/her wound and facility staff had been using Santyl on his/her heel wound for about a month. Resident #14 said that before using Santyl, staff would wash his/her wound and use lotion (skin prep). During an interview on 8/9/24 at 9:33 A.M., Nurse #9 said that when the wound nurse or attending physician makes recommendations or treatment orders, they input the orders themselves into the resident record and the nurse staff has to confirm them. During an interview on 8/9/24 at 9:50 A.M., Unit Manager #1 said that the wound nurse or physician puts orders into the computer as pending orders which are then confirmed by nursing staff. During an interview on 8/9/24 at 11:27 A.M., Corporate Nurse #1 said that the Wound Nurse Practitioner and attending physicians have access to the clinical record and they input orders and pending orders that nursing staff then confirms. During an interview on 8/9/24 at 12:13 P.M., the Wound Nurse Practitioner said that she rounds the facility weekly and does not input orders into the resident's electronic medical record. The Wound Nurse Practitioner said that she will write her note which is then uploaded individual medical record with the treatment recommendations. The Wound Nurse Practitioner said Resident #14 was non-compliant with wearing his/her bootie but she was not aware Resident #14's treatment recommendations were not implemented until July 2024. During an interviews on 8/12/24 at 11:44 A.M. and approximately 12:30 P.M., the Director of Nursing (DON) said she was not aware that Resident #14's treatment recommendations made by the Wound Nurse Practitioner were not implemented. 48671 3. Resident #63 was admitted to the facility in May 2024 with diagnoses including morbid severe obesity, type two diabetes, congestive heart failure, muscle weakness, localized edema, anemia in chronic kidney disease, and hereditary and idiopathic neuropathy. Review of Resident #63's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #63 had a Brief Interview for Mental Status exam score of 15 out of a possible 15, which indicated the Resident had intact cognition. The MDS further indicated Resident #63 is high risk for pressure ulcers, always incontinent of bowel and bladder and dependent on staff for toileting. Further review of the MDS indicated use of a pressure reducing device for his/her bed. Review of Resident #63's medical record indicated he/she scored a 10.0 on the Norton Plus Pressure Ulcer Scale, dated 6/14/24, indicating Resident #63 is high risk for pressure ulcers. Review of the physicians orders indicated: -Skin Assessment Weekly on Tuesday evening every evening shift every Tuesday. Dated 5/28/24. -Diabetic foot care daily. Check feet, toes, heels, report any redness or discolored area to the MD. Every evening shift. Dated 5/25/24. -Barrier Cream: Apply House Barrier Cream to bony prominences ever shift and as needed to prevent skin breakdown. Every shift for Preventative Measures. Dated 5/24/24. Review of the current care plan, included the following focuses: a. Skin Integrity- with interventions including; -Protective skin care with incontinent care. -Turn and reposition every 2-3 hours and PRN (as needed). b. Activity of Daily Living (ADL) care plan- with interventions including; -Assistance with toilet use, bed mobility, personal hygiene, and turning/repositioning. c. Incontinence care plan- with interventions including; -Brief worn, change every 2-3 hours and PRN. Review of the facility document titled Skin Observation Tool - (Licensed Nurse) - V4, indicated the following: -An assessment dated [DATE]: Rash, Right Scapula. Skin is intact otherwise. -An assessment, dated 6/8/24: Refused -An assessment, dated 7/10/24: Skin intact -An assessment, dated 7/17/24: Skin intact -An assessment, dated 7/31/24: Skin intact Review of Resident #63's nurse practitioner progress note dated 8/1/24 indicated the following: -Skin: No skin lesions or rashes noted in b/l UE or LE (bilateral upper extremities or lower extremities). Further review of the progress note indicated Resident #63 is at high risk for developing pressure ulcers. During an observation on 8/8/24, at 1:50 P.M., the surveyor observed Resident #63 laying in bed. Resident #63 said his/her incontinent brief had not been changed since 9:00 P.M. the night before, (for a total of 17 hours without incontinence care) and that he/she was wet and uncomfortable. During an interview on 8/8/24, at 1:55 P.M., CNA #4 said that Resident #63 had not been provided incontinent care because Resident #63 required an assist of two people to turn and reposition and there was not enough staff to care for all 24 residents on the unit. On 8/8/24 at 1:58 P.M., Corporate Nurse #1, Corporate Nurse #2 and Nurse #9 observed the Resident laying in bed. Corporate Nurse #1 removed the blankets to provide incontinence care. The Resident was observed wearing two incontinent briefs. Corporate Nurse #1 asked the Resident why he/she was wearing two incontinent briefs and the Residents said, I ask them to put two on me because no one comes and changes me. Resident #63 said the last time he/she was provided incontinence care or was repositioned occurred the night before at 9:00 P.M. Corporate Nurse #2 and Nurse #9 turned the Resident on to his/her left side and removed the two incontinence briefs. The two incontinence briefs were soaking wet with dark yellow, foul-smelling urine and contained pink, red, and brownish spots of discoloration throughout the brief, along the coccyx and buttocks area. The Resident had dried feces on his/her skin along the coccyx and buttocks area as well with excoriation throughout the buttock. The surveyor also observed a shallow open ulcer with red wound bed, bloody drainage and slough on the left buttock, a shallow open ulcer with red wound bed, bloody drainage and slough on the posterior thigh, and intact skin with localized area of persistent non-blanchable erythema and maroon discoloration on the coccyx. Corporate Nurse #1 said the Resident has three Stage II wounds. (In spite of slough being present in the wounds indicating wounds are a stage III). During an interview on 8/8/24 at 2:24 P.M., Corporate Nurse #2 said any open areas require recommendation for wound consultation and to notify the physician due to a change in condition. During an interview on 8/8/24 at 2:30 P.M., Corporate Nurse #1 said the expectation of the facility is that incontinent residents be toileted every two hours and as needed. During an interview on 8/8/24 at 2:48 P.M., Unit Manager #1 said Residents who require incontinence care and turning and repositioning are at risk for skin breakdown and should not be left sitting in urine without care. Review of the facility document titled Documentation Survey Report v2 (Activities of Daily Living (ADL) documentation sheet), dated August 2024, indicated Resident #63 was dependent on staff for toileting, and incontinent of bowel and bladder. Further review failed to indicate that ADL care was provided during the following shifts: On 8/7/24, 7:00 A.M. to 3:00 P.M. On 8/7/24, 11:00 P.M. to 7:00 A.M. On 8/8/24, 7:00 A.M. to 3:00 P.M. On 8/8/24, 3:00 P.M. to 11:00 P.M. Further review of the ADL Documentation Sheet indicated there were no documented refusals of care during the month of August 2024. During an interview on 8/12/24 at 8:39 A.M., the Wound Nurse Practitioner said best practice interventions in place include skin prep, floating his/her heels, an air mattress and said not following preventative measures can cause skin breakdown. During an interview on 8/12/24 at 10:19 A.M., the Director of Nurses (DON) said it is her expectation that staff reposition residents and provide incontinence care every two hours and said preventative measures upon admission should have been implemented and reviewed weekly to prevent skin breakdown. The DON said preventative measures include offloading heels, applying booties and an air mattress. The DON said weekly skin checks include assessment and documentation in the medical record. The DON said wound rounds are scheduled weekly and wounds are measured and documented by the Wound Nurse Practitioner. During an interview on 8/12/24 at 11:15 A.M., the Corporate Nurse #1 said, Nurses will describe open skin areas, but they would not measure them because they measure them wrong. We follow the facility policy, and the nurses notify the DON to add the resident to the wound rounds for the following Thursday. The wound nurse does the measuring and puts in orders. Corporate Nurse #1 said the physician would be notified and treatment orders would be adjusted after the wound nurse sees the residents the following Thursday. Corporate Nurse #1 said she expects staff to document care provided and document refusals of care in the chart. 15016 4. Resident #81 was admitted to the facility in May 2021 and had a primary diagnosis of stroke. Review of Resident #81's Norton Plus Pressure Ulcer scale dated 7/30/24, indicated a score of 15, signifying a moderate risk for the development of pressure ulcers. Review of Resident #81's Minimum Data Set (MDS) assessment dated [DATE], indicated a Brief Interview for Mental Status score out 1 of 15 signifying severe cognitive impairment. Resident #81's MDS indicated he/she is completely dependent on staff for all bed mobility and required substantial assistance for all other activities of daily living. The MDS also indicated Resident #81 was at-risk for pressure injuries but had no skin wounds and required pressure relieving devices for the bed and chair. Resident #81's care plan dated as revised 6/19/24, indicated: Focus: He/she was at-risk for skin breakdown due to decreased mobility and incontinence, staying in his chair for longer periods and refusing to go to bed. The care plan indicated, 3/23/24 multiple scabs to both legs- open to air. Goal: The resident will not show signs of skin breakdown x 90 days. Interventions included: - Independent bed mobility. - Monitor scabs on bilateral lower extremities and report changes to MD. - Pat (do not rub) skin when drying. - Provide preventative skin care i.e. lotions, barrier creams as ordered. - Apply barrier cream with each cleansing. - Resident at-risk for skin breakdown due to decreased mobility and incontinence, staying in his/her chair for longer periods and refusing to go to bed. Review of Resident #81's skin observation tool dated 7/18/24, indicated he/she had no wounds or pressure areas. Review of Resident #81's physician orders and notes and nursing notes dated prior to 8/8/24, did not indicate he/she had a skin wound on the left calf. On 8/8/24 at 2:10 P.M., the surveyor and Nurse #9 observed that Resident #81 had a 1 centimeter (cm) x 1 cm wound located on the left calf. A dressing or other treatment was absent. Nurse #9 said this was a Stage 2 wound because of its depth and drainage, and the skin around the wound was erythematous. A pressure-redistribution mattress was in use. On 8/8/24 at approximately 2:20 P.M., Corporate Nurse #1 accompanied the surveyor and observed Resident #81's calf wound. Corporate Nurse #1 said this was only a scab and it did not need to be reported to the physician because treatment was not required. On 8/8/24 at 2:35 P.M., Unit Manager #1, accompanied by two surveyors, observed Resident #81's calf wound. Unit Manager #1 said the wound was a Stage 2 pressure injury due to its depth and surrounding erythema. Review of Resident #81's skin observation tool dated 8/8/24 and completed at 11:02 P.M. by Corporate Nurse #1, indicated a treatment was applied to a 1 cm x 1 cm wound located on the left calf. The assessment did not indicate the depth of the wound, or other description, or the type of treatment. Review of the Resident's nursing and physician progress notes and orders failed to indicate any reference to the Resident's wound or that staff notified the physician or NP #2 about the calf wound, or reference to a treatment. Review of Resident #81's medical record on 8/9/24 at approximately 8:50 A.M., indicated there was no documentation to indicate Nurse #9, Unit Manager #2, Corporate Nurse #1, or any other staff notified the physician or NP #2 about Resident #81's calf wound. On 8/9/24 at approximately 8:15 A.M., 8:57 A.M. and 10:50 A.M., the surveyor observed Resident #81 in the dining room and that no dressing covered his/her exposed calf wound. On 8/9/24 at 12:50 P.M., the surveyor telephoned NP #2 to determine if she was aware of Resident #81's calf wound. A voice mail message was left but as of 8/15/24 there was no call back. On 8/9/24 at 1:00 P.M., the surveyor observed Resident #81 in the dining area, sitting in a chair. The Resident's left calf wound was exposed and there was no dressing covering it. During an interview with the DON and Corporate Nurse #1 on 8/9/24 at 1:15 PM., the surveyor told them that Resident #81's skin assessment dated [DATE] and completed after the surveyor's observations of the wound earlier in the day, indicated a 1 cm x 1 cm wound on the left lower leg and that a treatment was applied. The surveyor told them there was no further description of the wound or documentation in the record to indicate staff notified the physician or NP #2 about Resident #81's calf wound or obtained a physician's order for wound treatment. The surveyor informed them that, despite the assessment indicating a treatment was applied, as of this time Resident #81 did not have a dressing covering the open wound. Corporate Nurse #1 said she telephoned the physician during the night of 8/8/24 and notified him that Resident #81 had a scab on the left calf. Corporate Nurse #1 said the physician told her to only apply skin prep because she told him it was a scab and not an open wound. Corporate Nurse #1 said she forgot to document the conversation and treatment order. The surveyor told Corporate Nurse #1 that Unit Manager #1, a staff nurse and two surveyors observed the wound on 8/8/24 and determined it was an open wound, not a scab. On 8/9/24 at 1:20 P.M., the DON and surveyor observed Resident #81's open calf wound. The DON said it was either a Stage 2 or an unstageable wound and not a scab. The DON said the skin surrounding the wound was purple and the wound had signs of drainage. The DON said skin prep was not an appropriate treatment for the wound and that it should be covered with a medicated dressing to encourage healing and prevent infection. 43846 5. Resident #3 was admitted to the facility in January 2024 with diagnoses that included Alzheimer's disease, depression, and lymphedema. Review of Resident #3's most recent Minimu [TRUNCATED]

Based on record review, interview, and observation, the facility failed to notify the physician of changes in medical status for five Residents (#81, #42, #30, #99 and #78) of 46 sampled Residents. Specifically: 1. For Resident #78 the facility failed to ensure the physician was notified when: a.) pain medication was unavailable upon admission to the facility, and for the 19 hours following admission, resulting in worsening pain; and b.) when Resident #78's scheduled pain medication ran out, resulting in worsening pain. 2. For Resident #42 the facility failed to ensure the physician was notified when they were unable to fulfill an order to obtain a culture and sensitivity of a new wound for over a week from when the order was given. 3. For Resident #81, the facility failed to notify the physician or nurse practitioner that Resident #81 had a Stage 2 pressure wound on the left calf. 4. For Resident #30, the facility failed to notify the physician or nurse practitioner of deteriorating wounds and the recommendations of the wound nurse practitioner in a timely manner. 5. For Resident #99, the facility failed to ensure the physician was alerted to a skin injury. Findings include: According to the National Pressure Injury Advisory Panel, a Stage 2 Pressure Injury is defined as a partial-thickness skin loss with exposed dermis and may present as an intact or ruptured serum-filled blister. A Deep Tissue Injury (DTI) is defined as a persistent non-blanchable deep red, maroon or purple discoloration, intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. 1. Resident #78 was admitted to the facility in May 2024 and has diagnoses that include contracture of muscle of right upper arm and Marfan Syndrome with Skeletal Manifestation. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/28/24, indicated that on the Brief Interview for Mental Status exam Resident #78 scored a 15 out of a possible 15, indicating intact cognition. The MDS further indicated Resident #78 requires pain management on a scheduled basis as well as PRN (as needed), and that his/her pain was coded as almost constantly. During an interview on 8/6/24 at 9:01 A.M., with Resident #78 he/she said that he/she has had a terrible experience at the facility. Resident #78 explained that he/she has a diagnosis that causes significant pain and that the pain has not been managed by the facility. Resident #78 said I made a complaint to DPH after here a week (of being at the facility) and things have gotten progressively worse. Review of Resident #78's current Pain care plan indicated initiated on 6/4/24 indicated: Focus: Chronic pain due to contractures and Marfan's syndrome. Interventions include: Administer and monitor for effectiveness and possible side effects from: Routine pain medication. PRN (as needed) pain medication. See [Medication Administration Record] (MAR). Monitor and report to nurse: Signs and symptoms of pain. Worsening of pain. Report changes in pain location /type frequency intensity to physician. a.) Review of the Emergency Department documentation one day prior to Resident #78's admission to the facility indicated: Patient states that he/she has a history of Marfan's and with this does have chronic pain for which he/she uses a patch. The documentation also indicated that the patch was removed at the hospital on the date of transfer to the facility. The discharge orders from the hospital to the facility included the following orders for pain management: Fentanyl 100 Mcg/hr, apply 2 patches every 72 hours. Review of the May 2024 MAR indicated that Resident #78 first had the Fentanyl 100 mcg/hr patch applied on 5/25/24 at 4:15 P.M.; nearly 19 hours after admission to the facility. Review of the record indicated a progress note dated 5/25/24 at 8:45 A.M., approximately 12 hours after the Resident's admission to the facility: Writer this morning found a resident agitated, crying and stated he/she does not feel good because since yesterday he/she came haven't received any medication, sated (sic) that in pain and requesting to be transferred back to hospital, writer called pharmacy to request start orders of Dilaudid and Fentanyl patch because patient stated that he/she is in pain, Pharmacy phones goes to voice mail for 4 times, On call supervisor notified the situation, in about 30 minutes resident called 911 and taken back to hospital. (sic) Review of the Narcotic book indicated that all of Resident #78's admission medications, including the Fentanyl 100 mcg/hl patch were received from the pharmacy on 5/25/24 at 3:20 P.M.; nearly 18 hours after Resident #78's admission to the facility. Review of the facility's MedWiz (an emergency medication supply system for medications not in stock) report failed to indicate the system was accessed to provide any pain medication for Resident #78 on 5/24/24 or 5/25/24. The record failed to indicate that the Physician was notified that the pain medication was unavailable. During an interview on 8/12/24 at 8:35 A.M., with the Director of Nursing (DON) and Corporate Nurse #1, Corporate Nurse #1 said that the admitting nurse should have discussed with the MD what they should provide the resident for pain management coverage until the Resident's medication is available and that this should be documented in the clinical record. b.) Review of the August 2024 Physician orders included the following orders: Fentanyl Transdermal Patch 72 hours 100 MCG/HR (Fentanyl) Apply 2 patch transdermally every 72 hours for pain and remove per schedule. Fentanyl Transdermal Patch 72 hours 12 MCG/HR (Fentanyl) Apply 1 patch transdermally every 72 hours for chronic pain Apply together with the two 100 mcg/hr patches. For total dose of 212 mcg/hour of Fentanyl and remove per schedule. Pain assessment Q (each) shift using pain scale 1-3 Mild Pain, 4-6 Moderate pain, 7-9 Severe Pain, 10 Very severe pain During an observation and interview on 8/7/24 at 12:06 P.M., Resident #78 was observed in bed with his/her right upper arm exposed. 2 patches were applied to the right upper arm that were dated 8/6/24, 7-3. Resident #78 voiced being upset and in pain and presented with significant facial grimacing. Resident #78 said that he/she is supposed to have three pain patches applied but that the facility ran out of one of them yesterday. Resident #78 said that last night the nurses said they had to order more patches from the pharmacy and that they should be in by midnight last night. Resident #78 said that the patches never came in last night and that the nurse today said they are still waiting for the pain patches to come in from the pharmacy. Review of the August 2024 Medication Administration Record (MAR) indicated the following: -The order for Fentanyl Transdermal Patch 72 hours 100 MCG/HR (Fentanyl) Apply 2 patch transdermally every 72 hours for pain was administered on 8/6/24. -The order for Fentanyl Transdermal Patch 72 hours 100 MCG/HR (Fentanyl) Apply 1 patch transdermally every 72 hours was blank. There was no progress note to indicate why the medication was not administered as ordered. -The most recent pain assessed on the 7-3 shift on 8/7/24 indicated Resident #78 reported a pain level of 5. Review of the clinical progress notes failed to indicate the Physician was notified that the Fentanyl Transdermal Patch 72 hours 12 MCG/HR (Fentanyl) patch was not administered as ordered on 8/6/24 or that alternate pain management was provided. During an interview with Nurse #1 on 8/7/24 at 1:00 P.M., she verified that the facility had run out of Resident #78's Fentanyl Transdermal Patch 72 hours 12 MCG/HR (Fentanyl) patch and that it was not available for application as ordered on 8/6/24. Nurse #1 said the following: -The nurse on each shift is responsible to monitor their medication supply and when they are low to reorder it through the computer system. -If it is a narcotic that needs to be refilled it is the nurse's responsibility to notify the MD who will send a prescription directly through the system to the pharmacy and that the Physician's at the facility were very good about doing this. -If a medication is not available the nurse must notify the MD and write a note. In Resident #78's case she said the note should indicate the MD's plan for pain management while waiting for the needed medication to come in from the pharmacy. -Resident #78's Fentanyl Transdermal Patch 72 hours 12 MCG/HR (Fentanyl) patch came in last night (8/6/24) but that the night nurse didn't give it and she did not know why. -Nurse #1 said that she did not apply the Fentanyl Transdermal Patch 72 hours 12 MCG/HR (Fentanyl) patch that day and planned to ask the Director of Nursing if it was okay to apply it late, but had not yet had a chance to try to speak with her that day. Nurse #1 said she did not notify the physician. -Resident #78 reported to her that his/her was a 5 on a scale of 1-10 that day. Nurse #1 said that Resident #78 is probably reporting that his/her pain level is a 10 now because of the patch not being on. During an Interview on 8/7/24 at 1:24 P.M., with the facility's Corporate Nurse #1 she would have expected the MD to notified yesterday when the pain patch was not available, a progress note written about the medication not being applies and what the MD wanted to do to address pain pending receipt of the patch. 2. For Resident #42 the facility failed to ensure the physician was notified when they were unable to fulfill an order to obtain a culture and sensitivity of a new wound for over a week from when the order was given. Resident #42 was admitted to the facility in July 2022 and has diagnoses that include Multiple Sclerosis and chronic venous hypertension (Idiopathic) with ulcer of right lower extremity. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/10/24, indicated that on the Brief Interview for Mental Status exam Resident #42 scored a 15 out of 15, indicating intact cognition. The MDS further indicated Resident #42 had no wounds or skin issues. Review of the clinical record indicated the following: -A nurses note dated 7/26/24: Area skin flaking and moist with pus filled skin to RLE (history of areas). New order to obtain wound C&S, NSW, pat dry, apply Bacitracin and cover with DPD until healed. -A Nurse Practitioner Progress note, dated 7/30/24, indicated: Chronic venous ulceration on right lower extremity, protein-calorie malnutrition, generalized muscle weakness. Noted on the patient's right lower extremity are multiple scattered shallow ulcerations with irregular borders. Some areas are reddened with granulation tissue and others are with slough, none tunneling, with large amounts of serous drainage, mild odor (a deterioration from 7/26/24). Wound culture ordered, Venous Doppler Ultrasound. Continue health supplements. Continue daily dressing changes with NS and wrap with kerlix. We will order topical after results of wound culture is available. Review of the July 2024 Medication Administration Record (MAR) indicated the following order: Obtain wound C & S RLE wound. Start date 7/26/24 at 15:00. -A nurses note dated 8/4/24 indicated the C&S was obtained on 8/04/24, 10 days after the order was initially ordered. -A nurses note dated 8/8/24: Wound C&S results had come back and Resident #42 was positive for the following infection in the wound: + Proteus Mirabilis and Staphylococcus. During an interview with the Nurse #4 on 8/12/24 11:42 A.M., she said that she was the nurse that initially obtained the order to get a C&S but that the facility had run out of the kits that are provided by the lab. Nurse #4 said that the kits were delivered the end of the next week. She said that she should have notified the MD and written a progress note when she was unable to fulfill the MD order, but did not. The record failed to indicate that the MD/NP were notified that the kits were unavailable and that therefore the facility was unable to obtain the C&S for Resident #42's new wound. During an interview on 8/12/24 at 12:21 P.M., the Director of Nursing (DON) said that the MD should have been notified they could not fulfill an order when they were unable to obtain the C&S of a new wound as ordered by the MD. 15016 3. Resident #81 was admitted to the facility in May 2021 and had a primary diagnosis of stroke. Review of Resident #81's Minimum Data Set Assessment (MDS) dated [DATE], indicated a Brief Interview for Mental Status score of 1 of 15 points, indicating severe cognitive impairment. The MDS indicated that Resident #81 is dependent on staff for all bed mobility and requires substantial assistance for all other activities of daily living. The MDS also indicated was at-risk for pressure injuries but had no skin wounds. The Resident required pressure relieving devices for the bed and chair. Review of the facility's policy Pressure Ulcer/Injury Risk assessment dated as revised 3/20/22, indicated the following information should be recorded in the resident's medical record utilizing facility forms. This included but was not limited to: Notify attending MD if new skin alteration noted. Documentation in the medical record addressing MD notification if new skin alteration noted with change of plan of care, if indicated. According to the National Pressure Injury Advisory Panel, a Stage 2 Pressure Injury is defined as a partial-thickness skin loss with exposed dermis and may present as an intact or ruptured serum-filled blister. A Deep Tissue Injury (DTI) is defined as a persistent non-blanchable deep red, maroon or purple discoloration, intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. Resident #81's care plan dated as revised 6/19/24, indicated: Focus: He/she was at-risk for skin breakdown due to decreased mobility and incontinence, staying in his chair for longer periods and refusing to go to bed. The care plan indicated, 3/23/24 multiple scabs to both legs- open to air. Goal: The resident will not show signs of skin breakdown x 90 days. Interventions: - Independent bed mobility. - Monitor scabs on bilateral lower extremities and report changes to MD. - Pat (do not rub) skin when drying. - Provide preventative skin care i.e. lotions, barrier creams as ordered. - Apply barrier cream with each cleansing. - Resident at-risk for skin breakdown due to decreased mobility and incontinence, staying in his/her chair for longer periods and refusing to go to bed. Review of Resident #81's skin observation tool record dated 7/18/24, indicated he/she had no wounds or pressure areas. Review of Resident #81's physician orders and notes and nursing notes dated prior to 8/8/24, did not indicate he/she had a skin wound. On 8/8/24 at 2:10 P.M., the surveyor and Nurse #9 observed that Resident #81 had a 1 centimeter (cm) x 1 cm open wound located on the left calf. There was a small amount of serosanguinous drainage. A dressing or other treatment was absent. Nurse #9 said this was a Stage 2 pressure ulcer because of its depth and the skin around the wound was erythematous. Nurse #9 said she would contact the physician to report the wound and obtain treatment orders. On 8/8/24 at approximately 2:20 P.M., Corporate Nurse #1 accompanied the surveyor and observed Resident #81's calf wound. Corporate Nurse #1 said this was only a scab and it did not need to be reported to the physician because no treatment was required. On 8/8/24 at 2:35 P.M., two surveyors, accompanied by Unit Manager #1, observed Resident #81's calf wound. Unit Manager #1 said the wound was a Stage 2 pressure injury due to its depth and surrounding erythema. Unit Manager #1 said he was unaware of the wound until now. Unit Manager #1 said he would notify NP #2 about the wound and obtain treatment orders. Review of Resident #81's skin assessment dated [DATE] and completed at 11:02 P.M. by Corporate Nurse #1 indicated: Wound 1 x 1 cm to the rear left lower leg, treatment applied. The assessment did not indicate the depth of the wound, type of treatment or if the physician or NP #2 was notified about the wound. On 8/9/24 at approximately 8:15 A.M., 8:57 A.M. and 10:50 A.M., the surveyor observed Resident #81 in the dining room sitting in a chair and his/her calf wound was exposed without a dressing. Review of Resident #81's medical record on 8/9/24 at approximately 8:50 A.M., indicated there was no documentation to indicate Nurse #9, Unit Manager #1, Corporate Nurse #1, or any other staff notified the physician or NP #2 about the Resident's calf wound. On 8/9/24 at 12:50 P.M., the surveyor telephoned NP #2 to determine if she was aware of Resident #81's calf wound. A voice mail message was left but as of 8/15/24 there was no call back. On 8/9/24 at 1:00 P.M., the surveyor observed Resident #81 in the dining area, sitting in a chair. The Resident's left calf was exposed and there was no dressing covering the open wound. During an interview with the DON and Corporate Nurse #1 on 8/9/24 at 1:15 PM., the surveyor told them that Resident #81's skin assessment dated [DATE] indicated a 1 cm x 1 cm wound on the left lower leg and that a treatment was applied. The surveyor told them there was no documentation in the record to indicate staff notified the physician or NP #2 about Resident #81's calf wound. Corporate Nurse #1 said she telephoned the physician during the night of 8/8/24 and notified him that Resident #81 had a scab on the left calf. Corporate Nurse #1 said the physician told her to only apply skin prep because it was not an open wound. Corporate Nurse #1 said she forgot to document the conversation and treatment order. On 8/9/24 at 1:20 P.M., the DON and surveyor observed Resident #81's calf wound. The DON said this was either a Stage 2 or an unstageable wound and not a scab. The DON said the skin surrounding the wound was purple and the wound had signs of drainage. The DON said skin prep was not an appropriate treatment for the wound and that it should be covered with a medicated dressing to encourage healing and prevent infection. The DON said staff had not made her aware of the wound. She said she would immediately notify NP #2 about the wound and obtain treatment orders. 36797 4. Resident #30 was admitted to the facility in June 2024 with diagnoses including schizoaffective disorder bipolar type, dementia and heart failure. Review of the Minimum Data Set Assessment (MDS) dated [DATE], indicated that Resident #30 scored a 10 out of 15 on the Brief Interview for Mental Status exam, indicating moderately impaired cognition. Further review indicated that Resident #30 requires substantial to maximal assistance with all activities of daily living. Review of the facility document titled SKIN OBSERVATION TOOL - (Licensed Nurse) - V 4 dated 7/2/24, indicated that Resident #30's skin was intact. Review of the Nurse Practitioner (NP) #1 note dated 7/9/24, indicated a new stage one pressure area to right lateral heel measuring 2.0 CM x 1.5 CM (centimeters). Further review indicated a new order for skin prep to heels, Prevalon boots and to off load both heels. Review of the facility document titled SKIN OBSERVATION TOOL - (Licensed Nurse) - V 4 dated 7/10/24, indicated that Resident #30's right heel now has an intact blister. ( stage 2 pressure ulcer, a deterioration) Review of NP #1's notes dated 7/11/24 failed to indicate she had been notified of the wound deteriorating or that she assessed Resident #30's wound. There is no documentation to support she is aware the stage one is now a blister. Review of Physician #1's notes dated 7/12/24, failed to indicate he was aware of the pressure area on the right heel. There is no documentation to support he is aware of the blister on Resident #30's right heel. On 8/8/24 at 9:26 A.M., the Director of Nursing (DON) said that it is the expectation for the nurse practitioner or doctor to be notified of a deteriorated pressure area. 36876 5. Resident #99 was admitted to the facility in August 2023 with diagnoses including Alzheimer's disease, dysphagia and legal blindness. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #99 scored 3 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS) indicating severe cognitive impaired. The MDS also indicated Resident #99 requires assistance with bathing, dressing and transfers. Review of the nurse progress note dated 6/30/2024 indicated: CNA (Certified Nursing Assistant) informed this nurse of an old scab on the left upper extremity discovered not intact and opened. Area cleansed, bacitracin antibiotic ointment applied, and covered with bordered dressing. The clinical record failed to indicate the physician was notified and orders were obtained to provide treatment to Resident #99's skin injury. Review of the physicians note dated 7/11/24 indicated: Skin tear of left elbow without complication Unclear when this initially occurred, however old steri strips present on two locations of L (left) elbow removed. Some pain on palpation, no signs of infection. Wound care orders placed: QOD dleanse (sic) with normal saline, pat dry, apply bacitracin, cover with bordered gauze. During an interview on 8/8/24 at 11:26 A.M., Physician #2 said he was not aware of a skin injury to Resident #99's arm until he observed it on 7/11/24. Unit Manager #2 was unavailable for interview. During an interview on 8/8/24 at 12:15 P.M., Nurse #7 said on 6/30/24, a CNA alerted her that Resident #99 had an injury on his/her arm so she provided treatment. Nurse #7 said she is a new nurse and did not call the physician to alert him about Resident #99's arm because she didn't know she needed to. During an interview on 8/12/24 at approximately 12:30 P.M., the Director of Nursing (DON) said that the expectation is for nurses to communicate with the physician regarding changes in resident skin condition. Ref. F658, F684, F686, F697

Based on observation, record review, and interview, the facility failed to protect three Residents (#5, #63, and #10) from abuse and neglect out of a total sample of 46 residents. Specifically: 1. For Resident #5, (who is cognitively impaired), the facility failed to ensure he/she was free from abuse, when the surveyor witnessed a staff member squeeze Resident #5 cheeks and force feed medications. Using the reasonable person concept, this would result in emotional distress. 2. For Resident #63 and #10, the facility failed to ensure they were free from neglect after staff failed to provide incontinence care for 17 hours, resulting in the development of a new pressure ulcers. Findings include: Review of the facility's policy titled Abuse Prohibition dated 7/1/13, and revised 10/24/22, indicated the following: To ensure that center staff are doing all that is within their control to prevent occurrences of abuse, mistreatment, neglect, exploitation, involuntary seclusion, injuries of unknown source, and misappropriation of property for all patients. Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injury of unknown origin, or misappropriation of patient property, must also report to outside agencies, if required. Injuries of unknown origin will be investigated. If abuse or neglect is suspected, report allegations to the appropriate state and local authorities involving neglect, exploitation, or mistreatment, including injuries of unknown source, suspected criminal activity, and misappropriation of patient property, no later than two hours after the allegation is made if the event results in serious bodily injury. Report allegations to the appropriate state and local authorities involving neglect, exploitation, or mistreatment, including injuries of unknown source, suspected criminal activity, and misappropriation of patient property within 24 hours, if the event does not result and serious bodily injury. Provide subsequent reports to the department as often as necessary to inform the department of significant changes in the status of affected individuals or changes in material facts originally reported. Initiate an investigation within 24 hours of an allegation of abuse that focuses on whether abuse or neglect occurred, and to what extent. Interventions implemented to prevent further injury. The investigation will be thoroughly documented within risk management portal. Failure to report in the required time frames may result in disciplinary action up to and including termination. 1. Resident #5 was admitted to the facility in March 2023 with diagnoses including dementia, selective mutism, heart failure, diabetes, and major depressive disorder. Review of Resident #5's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #5 was unable to complete a Brief Interview for Mental Status (BIMS) assessment due to impaired cognition. The MDS also indicated Resident #5 requires assistance with Activities of Daily Living tasks. During an observation on 8/7/24 at 8:30 A.M., the surveyor observed Nurse #3 attempting to administer oral medications to Resident #5 in the dining room during the breakfast meal while other residents were present in the dining room. The surveyor observed Nurse #3 holding a plastic spoon containing whole pills and attempting to place them into Resident #5's mouth. Nurse #3 was not engaging with the Resident and at no time during the observation did Nurse #3 explain what she was doing or attempt to communicate with Resident #5. Nurse #3 was observed squeezing Resident 5's cheeks and attempting to pry open his/her lips with the plastic spoon. The Resident continued to keep his/her mouth closed and the Nurse continued to push the spoon into his/her mouth while squeezing the Resident's cheeks in an attempt to force open his/her mouth. The Resident was pulling back and Nurse #3 continued to squeeze the Residents cheeks. The Resident was observed with one large white oval pill hanging out of his/her mouth, the pill then fell out of the Residents' mouth and back on to the spoon. Review of Resident #5's medical record failed to indicate any nursing notes prior to 8/7/24 that indicated this was typical behavior during medication administration for Resident #5 and there were no documented refusals of medication or care. Review of Resident #5's behavior care plan dated as revised on 8/6/24, indicated the following interventions: Explain care to resident in advanced, in terms resident understands. Review of Resident #5's communication care plan dated as revised on 10/25/23, indicated the following interventions: Speak in normal tone voice clearly and slowly. Provide preferred (aka, primary) language interpreter services such as language line as indicated. Gain attention and eye contact before speaking to the resident/patient. Break tasks down into smaller steps. Review of Resident #5's activities care plan dated as revised on 1/19/24, indicated the following: (The Resident) is Italina (sic) speaking. I would benefit from accommodation for cognitive limitation by using demonstration, reminders, physical prompts, single step activity, time limited, verbal prompts and/or personalized/individual engagement. During an interview on 8/7/24 at 8:30 A.M., Nurse #3 said she was not familiar with the Resident and she was unsure if the Resident requires medication crushed or whole. Nurse #3 said the Resident was refusing to take the medication and that he/she has an appointment at 9:00 A.M. Nurse #3 said that the Resident needed to take the medication, so she squeezed his/her cheeks open. Nurse #3 said she should have asked the Resident if she could administer the medication and said she should not have squeezed the Residents cheeks to make him/her open his/her mouth. During an interview on 8/7/24 at 9:28 A.M., Unit Manager #1 said Nurse #3 should not squeeze the Residents cheeks or try to open the Residents mouth with the spoon during medication administration and that Nurse #3 should communicate with the Resident appropriately. Unit Manager #1 said forcing a resident to take medications is abuse and that he was going to report this to administration right away. During an interview on 8/7/24 at 10:50 A.M., Corporate Nurse #1 said Nurse #3 should not be squeezing any Residents cheeks or forcing a resident to take oral medications. Corporate Nurse #1 said Nurse #3 was removed immediately from the unit. During an interview on 8/12/24 at 10:27 A.M., The Director of Nursing (DON) said Nurse #3 was removed from the schedule and that the nurse should not have squeezed the residents' cheeks to try to force medications into his or her mouth. Based on the reasonable person concept, a person who is cognitively impaired and unable to understand or verbalize refusal, would experience emotional distress being physically forced to accept medications. 2. Resident #63 was admitted to the facility in May 2024 with diagnoses including morbid severe obesity, type two diabetes, congestive heart failure, muscle weakness, localized edema, anemia in chronic kidney disease, and hereditary and idiopathic neuropathy. Review of Resident #63's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #19 had a Brief Interview for Mental Status exam score of 15 out of a possible 15, which indicated the Resident had intact cognition. The MDS also indicated Resident #63 is dependent on staff for all functional tasks. Review of the current care plan, included the following focuses: a. Skin Integrity- with interventions including; -Protective skin care with incontinent care. -Turn and reposition every 2-3 hours and PRN. b. Activity of Daily Living (ADL) care plan- with interventions including; -Assistance with toilet use, bed mobility, personal hygiene, and turning/repositioning. c. Incontinence care plan, last revised 5/30/24, indicated the following interventions: -Brief worn, change every 2-3 hours and PRN. Review of Resident #63's current Activity of Daily Living (ADL) care plan, last revised 6/4/24, indicated Resident #63 required assistance with toilet use, bed mobility, personal hygiene and turning/repositioning. Review of Resident #63's Kardex (a form indicating the level of assistance a resident requires) indicated Resident #63 is always incontinent. The Kardex failed to indicate the level of assistance required. On 8/8/24, at 1:50 P.M., the surveyor observed Resident #63 lying in bed. The Resident said his/her incontinent brief had not been changed since 9:00 P.M. the night before, (a total of 17 hours since his/her brief was change), and that he/she was wet and uncomfortable. On 8/8/24 at 1:58 P.M., Corporate Nurse #1, Corporate Nurse #2 and Nurse #9 observed the Resident laying in bed. Corporate Nurse #1 removed the blankets to provide incontinence care. The Resident was observed wearing two incontinent briefs. Corporate Nurse #1 asked the Resident why he/she was wearing two incontinent briefs and the Residents said, I ask them to put two on me because no one comes and changes me. Resident #63 said the last time he/she was provided incontinence care or was repositioned occurred the night before at 9:00 P.M. Corporate Nurse #2 and Nurse #9 turned the Resident on to his/her left side and removed the two incontinence briefs. The two incontinence briefs were soaking wet with dark yellow, foul-smelling urine and contained pink, red, and brownish spots of discoloration throughout the brief, along the coccyx and buttocks area. The Resident had dried feces on his/her skin along the coccyx and buttocks area as well with excoriation throughout the buttock. The surveyor also observed a shallow open ulcer with red wound bed, bloody drainage and slough on the left buttock, a shallow open ulcer with red wound bed, bloody drainage and slough on the posterior thigh, and intact skin with localized area of persistent non-blanchable erythema and maroon discoloration on the coccyx. Corporate Nurse #1 said the Resident has three Stage II wounds. (In spite of slough being present in the wounds indicating wounds are a stage III). During an interview on 8/8/24, at 2:00 P.M., CNA #4 said that Resident #63 had not been provided incontinent care because Resident #63 required an assist of two people to turn and reposition and there was not enough staff to care for all 24 residents on the unit. Review of the facility document titled Documentation Survey Report v2 (Activities of Daily Living (ADL) documentation sheet), dated August 2024, indicated Resident #63 was dependent on staff for toileting, and incontinent of bowel and bladder. Further review failed to indicate that ADL care was provided during the following shifts: On 8/7/24, 7:00 A.M. to 3:00 P.M. On 8/7/24, 11:00 P.M. to 7:00 A.M. On 8/8/24, 7:00 A.M. to 3:00 P.M. On 8/8/24, 3:00 P.M. to 11:00 P.M. During an interview on 8/8/24 at 2:30 P.M., Corporate Nurse #1 said the expectation of the facility is that incontinent residents be toileted every two hours and as needed. During an interview on 8/8/24 at 2:48 P.M., Unit Manager #1 said Residents who require incontinence care and turning and repositioning are at risk for skin breakdown and should not be left sitting in urine without care. During an interview on 8/12/24 at 10:19 A.M., the Director of Nurses (DON) said it is her expectation that staff reposition residents and provide incontinence care every two hours. 36797 3. Resident #10 was admitted to the facility in July 2024 with diagnoses including pain, spinal stenosis and osteoarthritis. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #10 scored a 15 out of 15 on the Brief Interview for Mental Status, indicating intact cognition. Further review indicated that Resident #10 is totally dependent on staff for toileting needs and is always incontinent of bowel and bladder. Review of the care plan dated 7/31/24, indicated that Resident #10 is dependent on staff for toileting needs. During an observation on 8/8/24, at 2:00 P.M., Resident #10 said that his/her incontinent brief had not been changed since 9:00 P.M. the night before, (a total of 17 hours without receiving incontinence care.) The surveyor and Unit Manager #1 observed Resident #10 laying in bed in a saturated incontinent brief. The surveyor and Unit Manager #1 observed the incontinent brief to be saturated and the color of the contents to be a dark reddish brown, with a strong smell of stale urine. Unit Manager #1 said that he could tell that there was no feces present but was concerned about the dark color of the urine. Unit Manager #1 said that Resident #10 should have had his/her incontinent brief checked and changed as needed but at least every two to three hours. He then said that he could tell that it had been many hours since the incontinent brief had been changed. Unit Manager #1 said that with the number of residents on the unit that require an assist of two staff members to provide care, one Certified Nurse's Aide (CNA) and one nurse is not enough to get the job done. The surveyor and Unit Manager #1 then observed a non-blanchable area on the coccyx measuring 7L cm x 2W cm (centimeters). Unit Manager #1 said that the non-blanchable area on the coccyx was a stage one pressure area and was new. Unit Manager #1 said that leaving a resident in a saturated incontinent brief for an extended period of time could lead to skin breakdown. During an interview on 8/8/24, at 2:00 P.M., CNA #4 said that Resident #10 had not been provided incontinent care because Resident #10 required an assist of two people to turn and reposition and there was not enough staff to care for all 24 residents on the unit. During an interview on 8/12/24, at 12:40 P.M., the Corporate Nurse said that not providing incontinent care to an incontinent resident for 17 hours is considered neglect. Ref. F609, F610, F677, F725

Based on observations, record review, policy review and interviews, the facility failed to identify and address a newly developed contracture for one Resident (#63) out of a total sample of 46 residents. Findings include: Resident #63 was admitted to the facility in May 2024 with diagnoses including morbid severe obesity, type two diabetes, congestive heart failure, muscle weakness, localized edema, anemia in chronic kidney disease, and hereditary and idiopathic neuropathy. Review of Resident #63's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #63 had a Brief Interview for Mental Status exam score of 15 out of a possible 15, which indicated the Resident had intact cognition. The MDS also indicated Resident #63 was dependent on staff for all functional tasks. Section GG of the MDS indicated the Resident did not have any impairments in range of motion. On 8/7/24 at 8:41 A.M., Resident #63 was observed laying in bed with both feet on the bed. The Resident said he/she was unable to turn or get up unassisted because of loss of feeling in his/her feet. Review of the discharge summary from the hospital, dated 5/23/24, failed to indicate contractures of the Resident #63's lower extremities were present. Review of Resident #63's admission nursing assessment dated [DATE], failed to indicate the Resident had an impairment of range of motion to his/her extremities. Review of Resident # 63's podiatry visit note dated, 7/2/24, indicated the following: - Patient was seen bedside at nursing facility today for consult for podiatric evaluation and at-risk foot care. -There is dry skin and severe fissuring left, right foot, which does not show any cardinal signs of cutaneous malignancy or significant irritation. - skin temp cool to touch skin thin, atrophic, dry, cracked, scaly feet. -Monitor pressure areas and continue offloading modalities as needed for OA (osteoarthritis)/foot deformities. - Pedal joints bilaterally are noted to have limited passive ROM (range of motion), there is atrophy of the fat pad noted with flexion of the PIPJs (Proximal Interphalangeal joint, is the first joint of the small toes) of the lesser toes and contracture noted at the corresponding MTPJs (the joints between the metatarsal bones of the foot and the proximal bones (proximal phalanges) of the toes, there are no gross obvious deformities present. Muscle strength is noted to be diminished in all 4 quadrants bilaterally. -Recommend Vitamin A&D/barrier cream as needed for xerosis/skin protection. Follow up 2-3 months or as needed Review of the Occupational Therapy evaluation dated 7/11/24 indicated Resident #63's failed to indicate the Resident had a lower extremity contracture. Calls placed to the physical therapy department for interview were not returned during the time of the survey. During an interview on 8/14/24 at 3:45 P.M., Occupational Therapist (OT) #1 said she was never told about a decline in Resident #63's range of motion or that a contracture was reported. OT #1 said Resident #63 has no physical therapy evaluation on file since admission. OT #1 said the facility does not have a Director of Rehabilitation and that they are running short staffed. During an interview on 8/15/24 at 2:02 P.M., Corporate Nurse #1 said new recommendation, or new contractures required notification to the physician and a change in condition protocol is to be followed. The Corporate Nurse #1 said the expectation is that the unit manager and Director of Nurses review all recommendations and notify the interdisciplinary team, obtain new orders, and update the plan of care. Corporate Nurse #1said she was unaware that the resident had a contracture, and all new contractures need follow up. Corporate Nurse #1said she expects recommendations to be reviewed the next day and expects notes in the medical record for recommendations as reviewed and or declined and said she would expect communication of any changes in range of motion to the therapy department so an evaluation could be completed.

Based on interview, observation, record review and policy review, the facility failed to ensure that pain management, consistent with professional standards of practice, the comprehensive person-centered care plan, and the Resident's goals and preferences was provided for one Resident (#78) out of a total sample of 46 residents. Specifically the facility failed to: a.) ensure pain management was provided upon admission to the facility resulting in worsening pain after 19 hours without any medication available or administered and b.) provide effective pain management when Resident #78's scheduled pain medication ran out resulting in worsening pain. Findings include: The facility policy titled Pain Management, dated as revised April 2022, indicated the following: General Guidelines: 1. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. 2. Pain Management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. 3. Pain Management is a multidisciplinary care process that includes the following: a. Assessing the potential for pain; b. Recognizing the presence of pain; c. Identifying the characteristics of pain; d. Addressing the underlying causes of pain; e. Developing and implementing approaches to pain management; f. Identifying and using specific strategies for different levels and sources of pain; g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary. 4. Cognitive, cultural, familial, or gender-specific influences on the resident's ability or willingness to verbalize pain are considered when assessing and treating pain. Comprehensive pain assessments are conducted upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. 5. Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained. 6. For stable chronic pain, the resident's pain and consequences of pain are assessed at least weekly. Reporting: -Report the following information to the physician or practitioner: 1. Significant changes in the level of the resident's pain; Resident #78 was admitted to the facility in May 2024 and has diagnoses that include contracture of muscle of right upper arm and Marfan Syndrome with Skeletal Manifestation. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/28/24, indicated that on the Brief Interview for Mental Status exam Resident #78 scored a 15 out of a possible 15, indicating intact cognition. The MDS further indicated Resident #78 requires pain management on a scheduled basis as well as PRN (as needed), and that his/her pain was coded as almost constantly. During an interview on 8/06/24 at 9:01 A.M. Resident #78 said that he/she has had a terrible experience at the facility. Resident #78 explained that he/she has a diagnosis that causes significant pain and that the pain has not been managed by the facility. Resident #78 said I made a complaint to DPH after a week (of being at the facility) and things have gotten progressively worse. Review of Resident #78's current Pain care plan, initiated on 6/4/24, indicated: Focus: Chronic pain due to contractures and Marfan's syndrome. Interventions include: Administer and monitor for effectiveness and possible side effects from: Routine pain medication. PRN (as needed) pain medication. See [Medication Administration Record] (MAR). Monitor and report to nurse: Signs and symptoms of pain. Worsening of pain. Report changes in pain location /type frequency intensity to physician a.) Review of the Emergency Department documentation one day prior to Resident #78's admission to the facility indicated: Patient states that he/she has a history of Marfan's and with this does have chronic pain for which he/she uses a patch. The documentation also indicated that the patch was removed at the hospital on the date of transfer to the facility. The discharge orders from the hospital to the facility included the following pain management orders: Fentanyl 100 Mcg/hr (micrograms/hour), apply 2 patches every 72 hours Review of the May 2024 Medication Administration Record (MAR) indicated that Resident first had the Fentanyl 100 mcg/hr patch applied on 5/25/24 at 4:15 P.M.; nearly 19 hours after admission to the facility. Review of the medical record indicated a progress note dated 5/25/24, in the morning, approximately 12 hours after the resident's admission to the facility: Writer this morning found a resident agitated, crying and stated he/she does not feel good because since yesterday when he/she came, haven't received any medication, sated (sic) that in pain and requesting to be transferred back to hospital, writer called pharmacy to request start orders of Dilaudid and Fentanyl patch because patient stated that he/she is in pain, Pharmacy phones goes to voice mail for 4 times, On call supervisor notified the situation, in about 30 minutes resident called 911 and taken back to hospital. Review of the Narcotic book indicated that all of Resident #78's admission medications, including the Fentanyl 100 mcg/hl patch were received from the pharmacy nearly 18 hours after Resident #78's admission to the facility. Review of the facility's MedWiz (an emergency medication supply system for medications not in stock) report failed to indicate the system was accessed to provide any pain medication for Resident #78 on 5/24/24 or 5/25/24. During an interview on 8/12/24 at 8:35 A.M., with the Director of Nursing (DON) and Corporate Nurse #1, Corporate Nurse #1 said that medication cannot be ordered from the pharmacy until a new admission is physically in the building. The admitting nurse should call the physician to get an order to order the resident's medication from the pharmacy upon the resident's admission. If the resident requires a narcotic, Corporate Nurse #1 said that the the physician will send a prescription directly to the pharmacy through the computer system. Corporate Nurse #1 said in the meantime, the nurse should either obtain the medication from the MedWiz system and if it is not available in the MedWiz, discuss with the MD what they should provide the resident for pain management coverage until the Resident's medication is available. The DON said that Resident #78 should not have had to wait 19 hours after admission to the facility to be medicated or have his/her pain addressed. b.) Review of the August 2024 Physician orders included the following orders: Fentanyl Transdermal Patch 72 hours 100 MCG/HR (Fentanyl) Apply 2 patch transdermally every 72 hours for pain and remove per schedule. Fentanyl Transdermal Patch 72 hours 12 MCG/HR (Fentanyl) Apply 1 patch transdermally every 72 hours for chronic pain Apply together with the two 100 mcg/hr patches. For total dose of 212 mcg/hour of Fentanyl and remove per schedule. Pain assessment Q (each) shift using pain scale 1-3 Mild Pain, 4-6 Moderate pain, 7-9 Severe Pain, 10 Very severe pain During an observation and interview on 8/07/24 at 12:06 P.M., Resident #78 was observed in bed with his/her right upper arm exposed. 2 patches were applied to the right upper arm that were dated 8/6/24, 7-3. Resident #78 voiced being upset and in pain and presented with significant facial grimacing. Resident #78 said that he/she is supposed to have three pain patches applied but that the facility ran out of one of them yesterday. Resident #78 said that last night the nurses said they had to order more patches from the pharmacy and that they should be in by midnight last night. Resident #78 said that the patches never came in last night and that the nurse today said they are still waiting for the pain patches to come in from the pharmacy. Review of the August 2024 Medication Administration Record (MAR) indicated the following: -The order for Fentanyl Transdermal Patch 72 hours 100 MCG/HR (Fentanyl) Apply 2 patch transdermally every 72 hours for pain was administered on 8/6/24. -The order for Fentanyl Transdermal Patch 72 hours 12 MCG/HR (Fentanyl) Apply 1 patch transdermally every 72 hours was blank. There was no progress note to indicate why the medication was not administered as ordered. -The most recent pain assessed on the 7-3 shift on 8/7/24 indicated Resident #78 reported a pain level of 5 Review of the clinical progress notes failed to indicate the Physician was notified that the Fentanyl Transdermal Patch 72 hours 12 MCG/HR (Fentanyl) patch was not administered as ordered on 8/6/24 or that alternate pain management was provided. During a follow-up interview on 8/7/24 at 12:53 P.M., Resident #78 was grimacing and said that her pain level was a 10 out of 10 and has been all day. The surveyor asked Resident #78 if he/she had reported this to the Nurse (#1) and he/she said she didn't ask me, they never ask me. Review of the facility's MedWiz report failed to indicate the system was accessed to provide any pain medication for Resident #78 on 8/06/24 or 8/7/24. During an interview with Resident #78's Nurse #1 on 8/07/24 at 1:00 P.M., she verified that the facility had run out of Resident #78's Fentanyl Transdermal Patch 72 hours 12 MCG/HR (Fentanyl) patch and that it was not available for application as ordered on 8/6/24. Nurse #1 said the following: -The nurse on each shift is responsible to monitor their medication supply and when they are low to reorder it through the computer system. -If it is a narcotic that needs to be refilled it is the nurse's responsibility to notify the MD who will send a prescription directly through the system to the pharmacy and that the Physician's at the facility were very good about doing this. -If a medication is not available the nurse must notify the MD and write a note. In Resident #78's case she said the note should indicate the MD's plan for pain management while waiting for the needed medication to come in from the pharmacy. -Resident #78's Fentanyl Transdermal Patch 72 hours 12 MCG/HR (Fentanyl) patch came in last night but that the night nurse didn't give it and she does not know why. -Nurse #1 said that she did not apply the Fentanyl Transdermal Patch 72 hours 12 MCG/HR (Fentanyl) patch that day and planned to ask the Director of Nursing if it was okay to apply it late, but had not yet had a chance to try to speak with her that day. Nurse #1 said she did not notify the physician. -Resident #78 reported to her that his/her was a 5 on a scale of 1-10 that day. Nurse #1 said that Resident #78 is probably reporting that his/her pain level is a 10 now because of the patch not being on. On 8/8/24 at 1:49 P.M., Nurse #1 and the surveyor reviewed the narcotic book together. The Fentanyl 12 mg patch was logged in as received 8/7/24 but the nurse who received the medication failed to indicate what time it was received; rather in the section where the time was supposed to be written the nurse wrote received. During an Interview on 8/07/24 at 1:24 P.M., with the facility's Corporate Nurse #1 she would have expected the MD to notified yesterday when the pain patch was not available, a progress note written about the medication not being applies and what the MD wanted to do to address pain pending receipt of the patch. Corporate Nurse #1 said that the patch should have been applied when it came in last night, and that the nurse today should have told someone in administration and the MD that it had not been applied so that the pain could be addressed and possibly a PRN ordered obtained to cover the pain while waiting for the patch.

Based on observation, record review and interview, the facility failed to ensure there was sufficient staffing to provide necessary treatment and care to Residents on one of four nursing units ([NAME]). Subsequently, multiple residents were not provided incontinent care for 17 hours and skin checks revealed newly developed pressure areas for two Residents (#10 and #63). Findings include: Review of the Facility Assessment Tool, dated, 7/29/24, indicated: The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Staffing plan: Licensed nurses providing direct care: 16-18 per day; Nurse aides: 20-28 per day. Direct care staff Nurses 1:21 ratio (days and evenings) 1:41 nights. CNA: 1:13 ratio days. 1:14 ratio evenings. 1:21 ratio nights. Staff assignments are based on resident and need and census. The goal is to maintain consistent assignments for continuity of care. Review of of the facility's HPPD (Hours Per Patient Day) Report indicated that the facility budgeted 3.30 hours of direct patient care. Additional review of the HPPD report indicated that for 12 out of 30 the previous days the facility was below budget. During an interview with the Scheduling coordinator on 8/12/24 at 9:38 A.M., she said that it can be difficult to staff the units and that there are often call outs. The Scheduling Coordinator said that it is very difficult to staff the 7:00 A.M. - 3:00 P.M. shift when there is a call out. The Scheduling coordinator said that the [NAME] Unit goals for staffing on the 7:00 A.M. - 3:00 P.M. shift are for one nurse and two Certified Nursing Assistants (CNAs). On 8/8/24, the surveyor observed one nurse and one Certified Nurse's Aide (CNA) on the [NAME] unit to care for 24 residents until approximately 11:00 A.M., when another CNA was asked to float to the floor. During an interview on 8/8/24, at 8:30 A.M., Nurse #9 said that there is only her and one CNA on the unit and she cannot pass medication, complete treatments, pass food trays, supervise dining and help the CNA provide care. Nurse #9 said that it was too much and the residents on the unit are the ones that are suffering because of the low staffing. During an interview on 8/8/24, at 11:00 A.M., Unit Manager #1 said that there is not enough staff on the unit to care for 24 residents. During an interview on 8/8/24, at 11:30 A.M., CNA #4 said that she is not capable of providing care for 24 residents with only one nurse to help. CNA #4 then said that she had not provided care to some of the residents, had not changed their soiled briefs and had not repositioned those that needed assist. She then said that some of the residents require an assist of two people and several of those residents had not received care this morning. During an interview on 8/8/24 at 12:34 P.M., the Director of Nursing (DON) said that she was aware of the the staffing on [NAME] unit and believed that there were 22 total residents on the unit, (there were 24). Corporate Nurse #1 said that a CNA did not show up for work and another CNA from another unit was asked to float to the [NAME] unit. Corporate Nurse #1 was made aware that the CNA did not go to the [NAME] unit until approximately 11:00 A.M The Corporate Nurse said that staff would begin rounding to perform skin checks on Residents who had still not received morning care. On 8/8/24 the surveyors joined staff nurses in performing skin checks and the following was observed: On 8/8/24 at 1:58 P.M., Corporate Nurse #1, Corporate Nurse #2 and Nurse #9 observed the Resident laying in bed. Corporate Nurse #1 removed the blankets to provide incontinence care. The Resident was observed wearing two incontinent briefs. Corporate Nurse #1 asked the Resident why he/she was wearing two incontinent briefs and the Residents said, I ask them to put two on me because no one comes and changes me. Resident #63 said the last time he/she was provided incontinence care or was repositioned occurred the night before at 9:00 P.M. Corporate Nurse #2 and Nurse #9 turned the Resident on to his/her left side and removed the two incontinence briefs. The two incontinence briefs were soaking wet with dark yellow, foul-smelling urine and contained pink, red, and brownish spots of discoloration throughout the brief, along the coccyx and buttocks area. The Resident had dried feces on his/her skin along the coccyx and buttocks area as well with excoriation throughout the buttock. The surveyor also observed a shallow open ulcer with red wound bed, bloody drainage and slough on the left buttock, a shallow open ulcer with red wound bed, bloody drainage and slough on the posterior thigh, and intact skin with localized area of persistent non-blanchable erythema and maroon discoloration on the coccyx. Corporate Nurse #1 said the Resident has three Stage II wounds. (In spite of slough being present in the wounds indicating wounds are a stage III). During an interview on 8/8/24, at 1:55 P.M., CNA #4 said that Resident #63 had not been provided incontinent care because Resident #63 required an assist of two people to turn and reposition and there was not enough staff to care for all 24 residents on the unit. At 2:00 P.M., the surveyor and Unit Manager #1 observed Resident #10 lying in bed in a saturated incontinent brief. The surveyor and Unit Manager #1 observed the incontinent brief to be saturated and the color of the contents to be a dark reddish brown, with a strong smell of stale urine. Unit Manager #1 said that he could tell that there was no feces present but was concerned about the dark color of the urine. Unit Manager #1 said that Resident #10 should have had his/her incontinent brief checked and changed as needed but at least every two to three hours. Unit Manager #1 said that with the number of residents on the unit that require an assist of two staff members to provide care, one CNA and one nurse is not enough to get the job done. The surveyor and Unit Manager #1 then observed a non-blanchable area on the coccyx measuring 7L cm x 2W cm (centimeters). Unit Manager #1 said that the non-blanchable area on the coccyx was a stage one pressure area and was new. Unit Manager #1 said that leaving a resident in a saturated incontinent brief for an extended period of time could lead to skin breakdown. During an interview on 8/8/24, at 2:00 P.M., CNA #4 said that Resident #10 had not been provided incontinent care because Resident #10 required an assist of two people to turn and reposition and there was not enough staff to care for all 24 residents on the unit During an interview on 8/9/24 at 9:29 A.M., Nurse #6 said that she typically works on the [NAME] Unit and there is never enough staff. Nurse #6 said staff often call out or do not show up and she then has to work a double. Nurse #6 said that the unit should be staffed with 2 nurses and 3 CNA's. Nurse #6 said that there have been times where it is one nurse and one CNA and it is difficult to pass medications, obtain resident blood sugars, pass trays, assist with resident care, contact physicians and do treatment orders and that on these days, sometimes treatments and tasks do not get done. 36797 During an interview on 8/12/24, at 11:10 A.M., Unit Manager #1 said that he was the only nurse on the unit for the 7:00 A.M. - 3:00 P.M. shift. Unit Manager #1 said that even with one nurse and two CNA's it was hard to provide the needed care for 24 residents when he is responsible for all medications, all treatments, all contact with doctors, dealing with changes to doctor's orders, and checking and passing all meal trays. Unit Manager #1 said that at least 6 of the residents on the unit require an assist of two staff members to provide care and two CNA's and one nurse on the unit is just not enough. Review of the nursing schedules and time sheets from 7/9/24 through 8/9/24 indicated that there was one nurse and one CNA working on 7/9/24, 7/14/24, 7/25/24 and 8/8/24 on the [NAME] Unit.

Based on record review and interview, the facility failed to protect residents from abuse after one Resident (#67) alleged that Nurse #15 yelled at him/her out of a total of 35 sampled Residents. Specifically, the facility failed to remove Nurse #15 after the alleged abuse resulting in Resident #67 experiencing emotional distress. Findings include: Review of the facility's policy titled Abuse Prohibition dated 7/1/13, and revised 10/24/22, indicated the following: To ensure that center staff are doing all that is within their control to prevent occurrences of abuse, mistreatment, neglect, exploitation, involuntary seclusion, injuries of unknown source, and misappropriation of property for all patients. Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injury of unknown origin, or misappropriation of patient property, must also report to outside agencies, if required. Injuries of unknown origin will be investigated. If abuse or neglect is suspected, report allegations to the appropriate state and local authorities involving neglect, exploitation, or mistreatment, including injuries of unknown source, suspected criminal activity, and misappropriation of patient property, no later than two hours after the allegation is made if the event results in serious bodily injury. Report allegations to the appropriate state and local authorities involving neglect, exploitation, or mistreatment, including injuries of unknown source, suspected criminal activity, and misappropriation of patient property within 24 hours, if the event does not result and serious bodily injury. Provide subsequent reports to the department as often as necessary to inform the department of significant changes in the status of affected individuals or changes in material facts originally reported. Initiate an investigation within 24 hours of an allegation of abuse that focuses on whether abuse or neglect occurred, and to what extent. Interventions implemented to prevent further injury. The investigation will be thoroughly documented within risk management portal. Failure to report in the required time frames may result in disciplinary action up to and including termination. Resident #67 was admitted to the facility in January 2021 with diagnoses including left hemiparesis, diabetic nephropathy, major depressive disorder, and falls. Review of Resident #67's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, indicating he/she has intact cognition. Further review indicated Resident #67 requires supervision for functional tasks. During an interview on 10/24/23, at 7:50 A.M., Resident #67 reported that staff ignore his/her requests for assistance with showers and that he/she often feels ignored. Resident #67 said staff don't respond when he/she tells them the temperature of the water is too hot. Resident #67 said Certified Nursing Assistant (CNA) #6 and CNA #5 tells him/her the water is not too hot, the water is fine, and will spray him/her with the hot water. Resident #67 said he/she reported to Nurse #15 about the water temperature, and Nurse #15 ignores me. Resident #67 said when he/she asks for ice, water, or help with tasks, staff ignore him/her because they are mad at him/her for speaking up. On 10/24/23, the surveyor notified the Assistant Administrator and Social Worker #1 of Resident #67's allegations. During an interview on 10/24/23, at 12:25 P.M., Resident #67 said Nurse #15 came into his/her room and was mad, raising her voice, and angry that Resident #67 told the surveyor about the shower issues and concerns with lack of care. Resident #67 said Nurse #15 was waving her arms saying, I care for you all the time and get you what you want, why would you bring up things that are old? Resident #67 said he/she told Nurse #15 he/she feels abused and the issues are not old to him/her. Resident #67 said Nurse #15 continued waving her arms and clapping her hands saying that is it, I am done. [I am] no longer going to care or help you. Resident #67 said When she does that, I know she is mad. Staff ignore you when they are mad at you for speaking up. Resident #67 said he/she was upset that Nurse #15 came into his room. On 10/24/23, at 12:30 P.M., the surveyors alerted Corporate Nurse #1 of Resident #67's allegations that Nurse #15 had gone into his/her room and yelled at him/her. During an interview on 10/24/23, at 12:40 P.M., Nurse #15 was observed on the unit assisting residents. Nurse #15 said she should have told the Director of Nursing (DON) when the hot shower incident occurred, but didn't think she needed to. Nurse #15 said she asked CNA #5 about the hot water and she was told it wasn't hot. Nurse #15 said [Resident #67] is always complaining about something When Nurse #15 was asked if she has Resident #67 on her assignment today, Nurse #15 said no. Nurse #15 said she went to talk to Resident #67 because she was mad that he/she said she doesn't care for him/her. Nurse #15 said, I do care for him/her because I always get what he/she needs. Nurse #15 said she clapped her hands in front of the resident. Nurse #15 then showed the surveyor by clapping her hands in front of her body as she said the words, why would you tell them I didn't provide good care. I always care for you and bring you water, I'm the only one who helps you. Nurse #15 said I was upset, and waving, using my hands and maybe he/she didn't like it. Review of the facility's investigation included a written statement by Social Worker #1 which indicated at on 10/24/23, at approximately 10:30 A.M., Social Worker #1 and the Assistant Administrator met with Resident #67. The witness statement indicated Nurse #15 had yelled at Resident #67 for making allegations regarding the hot shower. The initial investigation included a note indicating that Resident #67 had felt retaliated against when Nurse #15 came into his/her room and yelled at him/her. Review of Nurse #15's time card dated 10/25/23, indicated he/she punched out at 1:51 P.M.; approximately three hours and twenty minutes after the facility was made aware that Nurse #15 had confronted Resident #67 in his/her room. During an interview on 10/25/23, at 10:19 A.M. Social Worker #1 said that on 10/24/23, at approximately 10:30 A.M. she and the Assistant Administrator met with Resident #67 who reported Nurse #15 had yelled at him/her. During interviews on 10/25/26, at 10:10 A.M. and 10/26/23, at 9:18 A.M., the Assistant Administrator said that after she learned of the allegation, she told Nurse #15 to finish her med pass and come to the office to see her. The Assistant Administrator said she did not think that much time had passed between the time that Resident #67 reported Nurse #15 had yelled at him/her and when Nurse #15 left the unit. The Director of Nursing and Assistant Administrator said that Nurse #15 did not tell them she intended to speak with Resident #67 and Nurse #15 should have been removed from the unit. During an interview on 10/25/23, at 9:15 A.M., Resident #67 said, Nurse #15 was very mad yesterday when she came in and was waving her hands, and he/she felt terrible. The facility failed to ensure Nurse #15 was removed immediately from the nursing unit after Resident #67 reported she yelled at him/her; exposing Resident #67 and other residents on the unit to emotional harm.

Based on record review and interview, the facility failed to ensure 1 Resident's (#231) significant change in condition was reported to the nurse on duty out of a total of 38 sampled Residents. While providing care to Resident #231, Certified Nurses Aide (CNA) #2 and CNA #4 observed Resident #231 to have a change in condition evidenced by vomiting and difficulty breathing. CNA #2 and CNA #4 continued to provide care for Resident #231 and then left the Resident alone without alerting Unit Manager #2. Resident #231 was found deceased approximately one hour later. Findings include: Review of the Facility's Change in Condition policy, revised [DATE] indicated: *The center must immediately inform the resident/patient, consult with the patient's physician notify consistent with his/her authority, the patient's health care decision maker wherein there is: *a significant change in the patient's physical, mental, or psychosocial status (that is, a deterioration in health mental or psychosocial status in either life threatening conditions or clinical complications) Review of the Facility's CNA Job Description, revised [DATE] indicated: Responsibilities/Accountabilities: -Reports changes in patient's condition, patient/family concerns or complaints to charge nurse and/or supervisor. Resident #231 was admitted to the facility in [DATE] with diagnoses including type 1 diabetes, ketoacidosis (a serious diabetic reaction where there is not enough insulin in the body), upper gastrointestinal (GI) bleed and kidney failure. Review of the hospital discharge paperwork, dated [DATE] indicated that Resident #231 had a previous hospital admission due to diabetic ketoacidosis and was found unresponsive in his/her home with coffee ground emesis. Review of Resident #231's Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) dated [DATE], indicated he/she was a Do Not Resuscitate (DNR), and wished to be transferred to the hospital in an urgent event. Review of CNA #2's employee record included an education sheet dated [DATE] which indicated: -It is the primary duty of a CNA to report any change in condition of a patient/resident to the nurse in charge. CNA's should never make Resident assessments on their own. It's not in a CNA scope of practice to assess. Review of CNA #2's hand written witness statement signed and dated [DATE] indicated that on [DATE] Resident #231 was assigned to CNA #4. CNA #2 was asked by CNA #4 to help change Resident #231. When CNA #2 arrived in the room, Resident #231 had vomited, the bed was soiled and Resident #231 was gasping for air (originally written as help but was crossed out and written to air.) The statement indicated: I stated the Resident is dying, lets do this quick before [he]/she dies on me. I did my best to finish and set up everything and I left. It was around 6:30 A.M. I check on the resident before the new shift started and I found him/her dead. During an interview with CNA #2 on [DATE] at 8:29 A.M., he said that on [DATE] CNA #4 asked for help changing Resident #231. CNA #2 said that when he got into the room he was surprised because Resident #231 had vomited a brownish color, he/she was gasping for air and looked like he/she was dying. CNA #2 said he told CNA #4 that Resident #231 was dying and we needed to clean him/her quick. CNA #2 said they positioned Resident #231 on his/her back with the head of the bed propped up. CNA #2 said that when they left Resident #231's room, his/her mouth was open and he/she was still gasping for air. CNA #2 said he thought that because Resident #231 was assigned to CNA #4 that she would alert the nurse on duty (Unit Manager #2). CNA #2 said around 7:15 A.M., he went to check on Resident #231. CNA #2 said that Resident #231 was dead and went to tell Unit Manager #2. However, the written statement from CNA #2 indicated he found Resident #231 dead at 6:30 A.M. Review of CNA #4's statement dated [DATE] indicated that Resident #231 was assigned to CNA #2 on [DATE]. The statement indicated she assisted CNA #2 in changing Resident #231 and did not include any details of Resident #231's status. Review of Resident #231's Activities of Daily Living (ADL) sheets indicated that CNA #4 had provided care for Resident #231 on [DATE]. During an interview with CNA #4 on [DATE] at 1:27 P.M., she said that she was doing her rounds and saw Resident #231 vomiting. CNA #4 said she made CNA #2 aware that Resident #231 needed assistance and she provided him clean linen for Resident #231. CNA #4 said she did not provide care for Resident #231 on [DATE]. However, CNA #4's interview does not support her written and signed witness statement from [DATE] and clinical documentation in Resident #231's medical record. Review of the facility investigation indicated Unit Manager #2's typed and signed witness statement dated [DATE], indicated that she observed Resident #231 in bed after 6:00 A.M. Unit Manager #2 walked by Resident #231's room around 6:15 A.M. and heard CNA #2 and CNA #4 providing Resident #231 care and overheard CNA #2 and CNA #4 discussing who Resident #231 was assigned to. The statement indicated that on [DATE] at 7:15 A.M., CNA #2 informed Unit Manager #2 that Resident #231 was dead. The statement indicated that CNA #2 made Unit Manager #2 aware at 7:15 A.M., that while he was providing care to Resident #231 there was vomit around his/her mouth and chest and he realized that he/she was dying at that time. Unit Manager #2's statement indicated that she was shocked and went to assess Resident #231 who was found to have no vital signs and he/she had some coffee ground vomit around his/her mouth, he/she was laying flat in the bed. During an interview with Unit Manager #2 on [DATE] at 8:53 A.M., she said that on [DATE] Resident #231 was assigned to CNA #4. She said that sometime after 6:00 A.M., she had observed Resident #231 and he/she was ok. Unit Manager #2 said sometime after that she observed CNA #4 in Resident #231's room and CNA #2 in the hallway discussing who was assigned to the resident, and then they both went into Resident #231's room. Unit Manager #2 said sometime after that, CNA #2 came to her and said that Resident #231 was dead. Unit Manager #2 said she then ran to the room and found the resident without vitals and had vomit on his/her chest. Unit Manager #2 said that she then notified the provider to obtain a death pronouncement order. Unit Manager #2 said that Unit Manager #1 performed the pronouncement. Unit Manager #2 said that she told CNA #2 and CNA #4 that if they are taking care of a Resident, they need to leave right away and are required to report a change in condition to the nurse. Unit Manager #2 said I was beside myself, I was crying. Unit Manager #2 said both CNA #2 and CNA #4 had the responsibility to notify her of Resident #231's change in condition. Unit Manager #2 said that had she been made aware, she would have been able call 911 and maybe [Resident #231] would not have died here in the building. I did not have a chance to do anything to prevent it. Unit Manager #2 said that Resident #231's death was not expected. Review of CNA #4's employee record included an education sheet dated [DATE] which indicated: -It is the primary duty of a CNA to report any change in condition of a patient/Resident to the nurse in charge. CNA's should never make Resident assessments on their own. It's not in a CNA scope of practice to assess. During an interview with Director of Nursing (DON) #2 on [DATE] at 10:03 A.M., she said that both CNA #2 and CNA #4 had the responsibility to notify Unit Manager #2 of Resident #231's change in condition, regardless of who was assigned to the Resident. DON #2 said she could not say if Resident #231's death was expected or if it was reported to the medical examiner and she would have to review the record. During an interview with Resident #231's physician on [DATE] at 11:50 A.M., she said that she was not aware of a change in Resident #231's medical status prior to being found deceased . During an interview with Nurse Practitioner #1 on [DATE] at 10:46 A.M., she said that when she is called by facilities looking for RN pronouncement orders, they usually do not give details surrounding the Resident deaths. She said that she was not informed by the facility that Resident #231 had had a change in condition which was not reported to the nurse prior to being found deceased . Nurse Practitioner #1 said that if she had, she would have recommended the case to the office of the medical examiner. The facility failed to ensure CNA #2 and CNA #4 notified Unit Manager #2 of a significant change in condition in Resident #231's status when he/she had vomited (deterioration of health). Unit Manager #2 was unable to immediately inform his/her physician or implement his/her treatment plan. On [DATE] at 3:00 P.M., the Administrator was provided with the Immediate Jeopardy Template. On [DATE], the facility submitted, and the Department accepted, a Removal Plan and allegation of removal of the Immediate Jeopardy effective [DATE]. On [DATE], it was determined that the Immediate Jeopardy was removed by the facility providing education to all staff regarding the change of patient/resident condition policies and procedures. The Immediate Jeopardy for F580 was removed effective [DATE].

Based on record review and interview, the facility failed to provide quality care in accordance with professional standards of practice for 1 Resident (#231) out of a total of 38 sampled Residents. While providing care to Resident #231, Certified Nurse Aide (CNA) #2 and CNA #4 observed Resident #231 to have a change in condition as evidenced by vomiting and difficulty breathing. CNA #2 and CNA #4 continued to provide care for Resident #231 and then left him/her alone in bed without alerting licensed nursing staff (Unit Manager #2). Resident #231 was found deceased approximately one hour later. Findings include: Resident #231 was admitted to the facility in [DATE] with diagnoses including type 1 diabetes, ketoacidosis (a serious diabetic reaction where there is not enough insulin in the body), upper gastrointestinal (GI) bleed and kidney failure. Review of the hospital discharge paperwork, dated [DATE] indicated that Resident #231 had a previous hospital admission due to diabetic ketoacidosis and was found unresponsive in his/her home with coffee ground emesis. Review of Resident #231's Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) dated [DATE], indicated he/she was a Do Not Resuscitate (DNR), and wished to be transferred to the hospital in an urgent event. Review of CNA #2's hand written witness statement signed and dated [DATE] indicated that on [DATE] Resident #231 was assigned to CNA #4. CNA #2 was asked by CNA #4 to help change Resident #231. When CNA #2 arrived in the room, Resident #231 had vomited, the bed was soiled and Resident #231 was gasping for air (originally written as help but was crossed out and written to air.) The statement indicated: I stated the Resident is dying, lets do this quick before she dies on me. I did my best to finish and set up everything and I left. It was around 6:30 A.M. I check on the resident before the new shift started and I found him/her dead. During an interview with CNA #2 on [DATE] at 8:29 A.M., he said that on [DATE] CNA #4 asked for help changing Resident #231. CNA #2 said that when he got into the room he was surprised because Resident #231 had vomited a brownish color, he/she was gasping for air and looked like he/she was dying. CNA #2 said he told CNA #4 that Resident #231 was dying and we needed to clean him/her quick. CNA #2 said they positioned Resident #231 on his/her back with the head of the bed propped up. CNA #2 said that when they left Resident #231's room, his/her mouth was open and he/she was still gasping for air. CNA #2 said he thought that because Resident #231 was assigned to CNA #4, she would alert the nurse on duty (Unit Manager #2). CNA #2 said around 7:15 A.M., he went to check on Resident #231. CNA #2 said that Resident #231 was dead and went to tell Unit Manager #2. Review of CNA #4's statement dated [DATE] indicated that Resident #231 was assigned to CNA #2 on [DATE]. The statement indicated she assisted CNA #2 in changing Resident #231 and did not include any details of Resident #231's status. Review of Resident #231's Activities of Daily Living (ADL) sheets indicated that CNA #4 had provided care for Resident #231 on [DATE]. During an interview with CNA #4 on [DATE] at 1:27 P.M., she said that she was doing her rounds and saw Resident #231 vomiting. CNA #4 said she made CNA #2 aware that Resident #231 needed assistance and she provided him clean linen for Resident #231. CNA #4 said she did not provide care for Resident #231 on [DATE]. However, CNA #4's interview does not support her written and signed witness statement from [DATE] and clinical documentation in Resident #231's medical record. Review of Unit Manager #2's typed and signed witness statement dated [DATE], indicated that she observed Resident #231 in bed after 6:00 A.M. Unit Manager #2 walked by Resident #231's room around 6:15 A.M. and heard CNA #2 and CNA #4 providing Resident #231's care and overheard CNA #2 and CNA #4 discussing who Resident #231 was assigned to. The statement indicated that on [DATE] at 7:15 A.M., CNA #2 informed Unit Manager #2 that Resident #231 was dead. The statement indicated that CNA #2 made Unit Manager #2 aware at 7:15 A.M., that while he was providing care to Resident #231 there was vomit around his/her mouth and chest and he realized that he/she was dying at that time. Unit Manager #2's statement indicated that she was shocked and went to assess Resident #231 who was found to have no vital signs and he/she had some coffee ground vomit around his/her mouth and he/she was laying flat in the bed. During an interview with Unit Manager #2 on [DATE] at 8:53 A.M., she said that on [DATE] Resident #231 was assigned to CNA #4. She said that sometime after 6:00 A.M., she had observed Resident #231 and he/she was ok. Unit Manager #2 said sometime after that she observed CNA #4 in Resident #231's room and CNA #2 in the hallway discussing who was assigned to the resident, and then they both went into Resident #231's room. Unit Manager #2 said sometime after that, CNA #2 came to her and said that Resident #231 was dead. Unit Manager #2 said she then ran to the room and found the resident without vitals and had vomit on his/her chest. Unit Manager #2 said that she then notified the provider to obtain a death pronouncement order. Unit Manager #2 said that Unit Manager #1 performed the pronouncement. Unit Manager #2 said that she told CNA #2 and CNA #4 that if they are taking care of a Resident they need to leave right away and are required to report a change in condition to the nurse. Unit Manager #2 said I was beside myself, I was crying. Unit Manager #2 said both CNA #2 and CNA #4 had the responsibility to notify her of Resident #231's change in condition. Unit Manager #2 said that had she been made aware, she would have been able call 911 and maybe [Resident #231] would not have died here in the building. I did not have a chance to do anything to prevent it. Unit Manager #2 said that Resident #231's death was not expected. During interviews with Director of Nursing (DON) #2 on [DATE] at 10:03 A.M., and again at 2:33 P.M., she said that both CNA #2 and CNA #4 had the responsibility to notify Unit Manager #2 of Resident #231's change in condition, regardless of who was assigned to the Resident. She said that it is not within the scope of practice for a CNA to assess a resident's condition. On [DATE] at 3:00 P.M., the Administrator was provided with the Immediate Jeopardy Template. On [DATE], the facility submitted, and the Department accepted, a Removal Plan and allegation of removal of the Immediate Jeopardy effective [DATE]. On [DATE], it was determined that the Immediate Jeopardy was removed by the facility providing education to all staff regarding the change of patient/resident condition policies and procedures. The Immediate Jeopardy for F684 was removed effective [DATE]. See F580

Based on observation, record review and interview, the facility 1.) failed to ensure Resident #231 was not left alone and neglected in bed by Certified Nurses Aide (CNA) #2 and CNA #4 after experiencing a significant change in condition, 2.) failed to ensure CNA #1 was immediately removed from the facility after allegations of abuse/neglect were alleged (and substantiated) for Resident #4 and Resident #88 and 3.) failed to ensure CNA #4 was immediately removed from the facility after allegations of abuse and neglect were alleged for Resident #82 out of a total of 38 sampled Residents. Findings include: Review of the facility's Abuse Prohibition Policy, updated [DATE] indicated: *Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, injury, or mental anguish. *Neglect is defined as the failure, indifference, or disregard of the Center, its employees or service providers to provide care, comfort, safety, goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish or emotional distress. *The employee alleged to have committed the act of abuse will be immediately removed from duty pending investigation. 1. CNA #2 and CNA #4 neglected to ensure Resident #231 was assessed by Unit Manager #2 after experiencing a significant change in condition evidenced by vomiting and difficulty breathing during care and was left alone in bed. Resident #231 was found deceased approximately 1 hour later. Resident #231 was admitted to the facility in [DATE] with diagnoses including type 1 diabetes, ketoacidosis (a serious diabetic reaction where there is not enough insulin in the body), upper gastrointestinal (GI) bleed and kidney failure. Review of Resident #231's Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) dated [DATE], indicated he/she was a Do Not Resuscitate (DNR), and wished to be transferred to the hospital in an urgent event. Review of CNA #2's hand written witness statement signed and dated [DATE] indicated that on [DATE] Resident #231 was assigned to CNA #4. CNA #2 was asked by CNA #4 to help change Resident #231. When CNA #2 arrived in the room, Resident #231 had vomited, the bed was soiled and Resident #231 was gasping for air (originally written as help but was crossed out and written to air.) The statement indicated: I stated the Resident is dying, lets do this quick before she dies on me. I did my best to finish and set up everything and I left. It was around 6:30 A.M. I check on the resident before the new shift started and I found him/her dead. During an interview with CNA #2 on [DATE] at 8:29 A.M., he said that on [DATE] CNA #4 asked for help changing Resident #231. CNA #2 said that when he got into the room he was surprised because Resident #231 had vomited a brownish color, he/she was gasping for air and looked like he/she was dying. CNA #2 said he told CNA #4 that Resident #231 was dying and we needed to clean him/her quick. CNA #2 said they positioned Resident #231 on his/her back with the head of the bed propped up. CNA #2 said that when they left Resident #231's room, his/her mouth was open and he/she was still gasping for air. CNA #2 said he thought that because Resident #231 was assigned to CNA #4, she would alert the nurse on duty (Unit Manager #2). CNA #2 said around 7:15 A.M., he went to check on Resident #231. CNA #2 said that Resident #231 was dead and went to tell Unit Manager #2. Review of CNA #4's statement dated [DATE] indicated that Resident #231 was assigned to CNA #2 on [DATE]. The statement indicated she assisted CNA #2 in changing Resident #231 and did not include any details of Resident #231's status. Review of Resident #231's Activities of Daily Living (ADL) sheets indicated that CNA #4 had provided care for Resident #231 on [DATE]. During an interview with CNA #4 on [DATE] at 1:27 P.M., she said that she was doing her rounds and saw Resident #231 vomiting. CNA #4 said she made CNA #2 aware that Resident #231 needed assistance and she provided him clean linen for Resident #231. CNA #4 said she did not provide care for Resident #231 on [DATE]. However, CNA #4's interview does not support her written and signed witness statement from [DATE] and clinical documentation in Resident #231's medical record. Review of Unit Manager #2's typed and signed witness statement dated [DATE], indicated that she observed Resident #231 in bed after 6:00 A.M. Unit Manager #2 walked by Resident #231's room around 6:15 A.M. and heard CNA #2 and CNA #4 providing Resident #231's care and overheard CNA #2 and CNA #4 discussing who Resident #231 was assigned to. The statement indicated that on [DATE] at 7:15 A.M., CNA #2 informed Unit Manager #2 that Resident #231 was dead. The statement indicated that CNA #2 made Unit Manager #2 aware at 7:15 A.M., that while he was providing care to Resident #231 there was vomit around his/her mouth and chest and he realized that he/she was dying at that time. Unit Manager #2's statement indicated that she was shocked and went to assess Resident #231 who was found to have no vital signs and he/she had some coffee ground vomit around his/her mouth and he/she was laying flat in the bed. During an interview with Unit Manager #2 on [DATE] at 8:53 A.M., she said that on [DATE] Resident #231 was assigned to CNA #4. She said that sometime after 6:00 A.M., she had observed Resident #231 and he/she was ok. Unit Manager #2 said sometime after that she observed CNA #4 in Resident #231's room and CNA #2 in the hallway discussing who was assigned to the resident, and then they both went into Resident #231's room. Unit Manager #2 said sometime after that, CNA #2 came to her and said that Resident #231 was dead. Unit Manager #2 said she then ran to the room and found the resident without vitals and had vomit on his/her chest. Unit Manager #2 said that she told CNA #2 and CNA #4 that if they are taking care of a Resident they need to leave right away and are required to report a change in condition to the nurse. Unit Manager #2 said I was beside myself, I was crying. Unit Manager #2 said that had she been made aware, she would have been able call 911 and maybe [Resident #231] would not have died here in the building. I did not have a chance to do anything to prevent it. Unit Manager #2 said that Resident #231's death was not expected. 2. A. Resident #4 was admitted to the facility in February 2019 with diagnoses including chronic obstructive pulmonary disease, heart failure and diabetes. Review of Resident #4's most recent Minimum Data Set assessment dated [DATE] indicated he/she is cognitively intact and required assistance with bathing, dressing and toileting. During an interview with Resident #4 on [DATE] at 1:43 P.M., he/she said that CNA #1 refused to provide care after he/she had soiled himself/herself and that he/she sat in his/her own feces for hours. Resident #4 said he/she was so upset and ended up calling the police. Review of the facility's investigation dated [DATE] included witness statements from nurses indicating that between 8:00 P.M. and 8:30 P.M., CNA #1 was asked by nursing staff to assist Resident #4 with care after he/she had soiled himself/herself in bed. Both witness statements indicated that CNA #1 initially said that she would provide care after she finished her documentation, then when approached again said she was on break. One of the witness statements indicated that CNA #1 told the nurse she had already changed Resident #4 (when she had not) and to leave her alone. During an interview with Nurse #1 on [DATE] at 9:10 A.M , she said that on [DATE] Resident #4 had put on his/her call light and needed to be changed. Nurse #1 said she went to find CNA #1 who was in the TV room and she asked CNA #1 to change Resident #4. Nurse #1 said CNA #1 replied that she was doing her documentation and she would change Resident #4 after. Nurse #1 said that she went a few minutes later to ask CNA #1 again and CNA #1 then said she was on break. Nurse #1 said that the other nurse on that night had also asked CNA #1 to assist in changing Resident #4 but she was not sure how many times. Nurse #1 said that they had to call the nurse supervisor to intervene. CNA #1 had then assisted Resident #4. Nurse #1 said CNA #1 worked the rest of her shift that night. Nurse #1 said she was not sure how long Resident #4 was waiting but it was a long time and Resident #4 was continuously putting on his/her call light while waiting. During an interview with DON #2 on [DATE] at 12:31 P.M., she said that she was not informed of the incident until the day after on [DATE]. During an interview with DON #1, Administrator #1 and Corporate Nurse #1 on [DATE] 11:34 A.M., Corporate Nurse #1 said that the refusal to provide care to is neglectful. B. Resident #88 was admitted to the facility in [DATE] with diagnoses including Alzheimer's disease and malnutrition. Review of Resident #88's most recent Minimum Data Set assessment dated [DATE] indicated that he/she is severely cognitively impaired and requires assistance with eating, dressing and toileting. Review of the Unit Manager #2's witness statement dated [DATE] indicated that on [DATE] Resident #88's roommate reported that Resident #88 was not fed his/her dinner meal by CNA #1. CNA #1 was asked to leave the facility pending an investigation but went to Resident #88's room and then questioned Resident #88's roommate about the lies he/she told when he/she alleged that CNA #1 did not feed Resident #88 his/her meal. Unit Manager #2's statement indicated that Resident #88's roommate reported to her 3 times that CNA #1 questioned him/her and he/she felt anxious about it. Unit Manager #2's statement also indicated that she informed CNA#1 she could not question Resident #88's roommate as it was intimidation and CNA #1 kept refusing to leave the building. During an interview with DON #2 on [DATE] at 12:31 P.M., she said that she was called on [DATE] because CNA#1 refused to leave the building pending an investigation after he/she was alleged to have neglected Resident #88. DON #2 acknowledged that CNA #1 was terminated effective [DATE] from the facility for the neglect of a Resident. 43807 3. Resident #82 was admitted to the facility in [DATE] with diagnoses including muscle weakness, unsteadiness on feet and difficulty in walking. Review of the most recent Minimum Data Set, dated dated dated [DATE] indicated that the Resident had a brief interview for mental status (BIMS) score of 15 out of a possible 15 indicating intact cognition. Review of the fall packet completed on [DATE] indicated the following: Nurse's description: Resident #82 was observed by Nurse #12 soaking wet, Nurse #12 told CNA #4 to change him/her, CNA #4 refused, Resident #82 was found on the floor soaking wet. Resident's description: Resident #82 was trying to go to the bathroom, when he/she lost control and slid on the floor, denied hitting his/her head. Review of a progress note completed by Nurse #12 on [DATE] indicated the following: She observed Resident #82 with some confusion, she last saw him/her around 6:25 A.M., to give him/her a synthroid dose, the nurse noticed his/her feet hanging by the side of the bed, Nurse #12 helped Resident #82 get comfortable, Nurse #12 then asked CNA #4 who was assigned to the Resident to change him/her, CNA #4 told Nurse #12 that the 7A-3P staff will do it. At 7:15 A.M., another CNA from the 7A-3P shift came to notify Nurse #12 that Resident #82 was found on the floor next to his bed. Nurse #12 proceeded to complete an incident report. During an interview with Unit Manager (UM #2) on [DATE] at 9:24 A.M., she said when she reported for work on [DATE], 7A-3P shift, Nurse #12 informed her of the incident that occurred with Resident #82 after CNA #4 was asked to change him/her and refused to. UM #2 said she completed a fall incident report, UM #2 reported the incident to the Director of Nurses (DON#2). UM #2 said CNAs should take care of Residents on their assignments. During an interview with DON#2 on [DATE] at 9:47 A.M., she said she did not initiate an abuse and neglect investigation after UM #2 informed her of the incident but looking at the incident at this moment, she should have suspended CNA #4 and initiated an abuse and neglect investigation. Review of CNA #4's work schedule indicated that she worked on the following dates after the incident was reported on [DATE], [DATE], 3:30P-11:15P, [DATE], 3:30P-11:15P, [DATE], 3:,d+[DATE]:15P, [DATE], 2:45P-11:15P, [DATE], 3:30P-11:15P, [DATE], 3:30P-11:15P, [DATE], 3:30P-11:15P. During an interview with DON #1, Administrator #1, and Administrator #2, on [DATE] at 11:05 A.M., DON#1 said the expectation after UM #1 reported the incident would have been to immediately suspend her, get her off the schedule pending an abuse and neglect investigation, report the incident to the Department of Public Health (DPH) within 2 hours, start an investigation with the staff on the shift, collect witness statements, check on the Resident, inform the responsible party and physician, transport the Resident to the emergency room if ordered by the physician, and start an abuse and neglect education with staff in the facility. DON#1 acknowledged that since CNA #4 was not suspended and no abuse and neglect investigation was completed, having her on the schedule after the incident put all Residents in the facility at possible risk and harm.

Based on record review, interview, and observation, the facility failed to ensure 1 Resident (#30) of 38 residents was free of an unnecessary physical restraint. On 12/8/22 and 12/9/22, staff placed Resident #30 (a resident who is severely cognitively impaired) in a wheelchair between a wall and table, preventing him/her from rising. Using the reasonable person concept, a person would experience distress having their movement restricted without the ability to understand why. Findings include: Resident #30 was admitted to the facility in June 2021 and had diagnoses which included neurocognitive disorder with Lewy Bodies, Parkinson's disease, muscle weakness (generalized), and difficulty walking. Review of Resident #30's quarterly Minimum Data Set (MDS) assessment, dated 11/16/22, indicated: a Brief Interview for Mental Status Score of 1 (indicating severe cognitive impairment), required extensive two-person assist with mobility on the unit, and had no functional impairment in his/her upper or lower body range of motion. Review of Resident #30's medical record indicated there was no assessment or physician's order for a physical restraint, and no signed consent for a physical restraint. Review of Resident #30's plan of care, dated 7/27/22, indicated he/she had the potential to exhibit physical behaviors and verbal behaviors: Kicking and punching, cursing, screaming and threatening staff related to cognitive loss/dementia, and he/she was at risk for falls related to cognitive loss, and lack of safety awareness. Resident #30's plan of care did not identify restraints as an issue or intervention. During observations on 12/8/22 at 10:59 A.M., 11:20 A.M. to 11:45 A.M., and at 12:15 P.M., Resident #30 was sitting in his/her wheelchair at the [NAME] Unit dining room. Staff had placed the back of his/her wheelchair against a side wall and pushed a dining table above his/her knees. Due to the placement of the wheelchair between the wall and table, Resident #30 was unable to rise from the wheelchair. Resident #30 made multiple attempts to rise from the wheelchair but was unable to stand due to the placement of the wheelchair. During the observation, Resident #30 yelled, Nobody can get out!, and I want to get out of here. At 11:20 A.M., Resident #30 told staff he/she needed to use the toilet. Staff pulled the table away from him/her and then pulled the wheelchair away from the wall. Resident #30 cursed and tried multiple times to kick staff as they wheeled him/her to the bathroom. During observations on 12/9/22 at 9:41 A.M., 10:10 A.M., and 10:17 A.M., Resident #30 was in his/her wheelchair at the [NAME] Unit dining room. Staff had placed the back of his/her wheelchair against a side wall and pushed a dining table above his/her knees. Due to the placement of the wheelchair between the wall and table, Resident #30 was unable to rise from the wheelchair. During an interview with Unit Manager #3 on 12/9/22 at 10:20 A.M., she said Resident #30 had the functional ability to rise from his/her wheelchair. During an observation and interview with Corporate Nurse #1 on 12/9/22 at 10:45 A.M., in view of the [NAME] Unit dining room and Resident #30, she said the table and wall prevented Resident #30 from rising from the wheelchair.

Based on record reviews and interviews, for one of 38 sampled Residents (Resident #124) the facility failed to ensure its staff developed and implemented a baseline care plan that included the instructions needed to provide effective and person-centered care for him/her, resulting in a fall, spinal injury and hospitalization . Findings include: Review of the facility policy titled, Person-Center Care Plan, dated as reviewed 10/22, indicated: -the Center must develop and implement a baseline person-centered care plan with-in 48 hours of admission for each resident that includes instructions needed to provide effective and person-centered care that meets professional standards of quality care. -a comprehensive, individualized care plan will be developed with-in 7 days after completed of a comprehensive assessment. Resident #124 was admitted to the facility in October 2022 with a diagnosis of hemiplegia (paralysis on one side of the body) following cerebral infraction (stroke) affecting the right dominant side and left humerus (bone in the upper arm) fracture. Review of Resident #124's discharge summary transfer form, dated 10/7/22, indicated he/she required an assistance of two and was non-weight bearing to his/her left upper extremity. Review of Resident #124's lift transfer reposition assessment, dated 10/8/22, indicated he/she required two staff members for repositioning in bed. Review of Resident #124's Occupational Therapy Evaluation, dated 10/8/22, indicated he/she had a prior level of function of a maximum assistance of two for bed mobility. Review of Resident #124's Physical Therapy Evaluation, dated 10/10/22, indicated he/she required maximum assist for bed mobility including rolling from the left to the right. The evaluation indicated he/she was non-weight bearing on his/her left shoulder because of a fracture and wore a sling and had right sided hemiparesis (inability to move). Review of Resident #124's Social Services Assessment, dated 10/11/22, indicated he/she was alert and oriented. The assessment indicted he/she could make self understood and could understand others. Review of the nursing progress note, dated 10/22/22, indicated Resident #124 was readmitted after a cervical spine 5 and cervical spin 6 anterior cervical discectomy and fusion (ACDF) on 10/16/22. Review of Resident #124's medical record indicated there was no documentation to support a baseline care plan was developed and implemented, that included the instructions needed to provide effective and person-centered care related to activities of daily living was developed until 10/30/22. Review of Resident #124's incident report, dated 10/15/22, indicated Resident #124 rolled off the bed while receiving care from Certified Nurse Aide (CNA) #1. During a phone call to interview CNA #1 on 12/13/22 at 4:14 P.M., CNA #1 answered her phone, she identified herself and declined an interview with the surveyor. During an interview on 12/13/22 at 5:16 A.M., Nurse #2 said that Resident #124 required two people for bed mobility. Nurse #2 said she didn't know why CNA #1 provided care alone and said that Resident #124 could not move his/her left or his/her right side. During an interview on 12/14/22 at 8:11 A.M., Director of Nursing (DON) #2 said that nursing should have developed and implemented a baseline care plan for Resident #124.

Based on observation, record review, and interview, the facility failed to identify and assess a decline in ambulation status for 1 Resident (#109), out of a total sample of 38 residents. Findings include: Resident #109 was admitted in March 2022 with diagnoses including chronic kidney disease and type II diabetes. Review of the Minimum Data Set (MDS) assessment, dated 9/21/22, indicated that Resident #109 scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated moderate cognitive impairment. Review of the MDS indicated that Resident #109 requires extensive assist with all activities of daily living and supervision with meals. Review of the care plan for Resident #109 indicated that Resident #109 is at risk for a decreased ability to perform activities of daily living due to limited mobility. During an observation and interview on 12/8/22 at 8:15 A.M., Resident #109 was lying in bed and said that he/she used to be able to walk but is now bedbound or in a wheelchair. Resident #109 said that he/she wants to be able to walk again. During an interview on 12/09/22 at 9:43 A.M., Unit Manager #1 said that Resident #109 can stand and pivot and sits in the wheelchair. Unit Manager #1 said the Resident #109 is currently working with therapy for a new chair. During an interview on 12/9/22 at 1:18 P.M., Occupational Therapist #1 said that Resident #109 is on therapy regarding a new chair, but not for ambulation. Review of the Physical Therapy Discharge Summary, dated 4/26/22, indicated that Resident #109 was able to ambulate 100 feet with contact guard assistance from staff. During an interview on 12/13/22 at 10:35 A.M., Physical Therapist #1 said that Resident #109 was on therapy case load in June 2022 and was able to walk 50 feet with moderate assistance from staff. Physical Therapist #1 said that if staff notice a decline and a resident is willing to work with therapy, then a referral to therapy should be made. Physical Therapist #1 said that she had not received a referral for Resident #109 but would do an evaluation in the morning. Review of the Physical Therapy evaluation, dated 12/13/22, indicated that Resident #109 was dependent at baseline and presents with gross deconditioning and decreased strength throughout bilateral extremities. Resident #109 was put on therapy caseload.

Based on interview, observation and record review, the facility failed to 1.) ensure Resident #124 received adequate supervision and assistance to prevent a fall with injury and failed to 2.) provide appropriate supervision to Residents on 3 of 4 units as evidenced by staff sleeping during the overnight shift (11:00 P.M. - 7:00 A.M.) on 3 of 4 units. Findings include: 1.) For Resident #124, who had a diagnosis of right sided hemiplegia (paralysis on one side of the body), had a broken left humerus (bone in the upper arm) which required a sling and who was also non-weight bearing to his/her left side and required assistance of two staff members for bed mobility, the facility failed to ensure Resident #124 was provided adequate staff assistance as required to maintain his/her safety to prevent incidents and/or accidents resulting in a fall. -On 10/15/22, Certified Nurse Aide (CNA) #1 provided Resident #124 care in bed and CNA #1 turned to get a washcloth Resident #124 rolled off the bed and onto the floor. Resident #124 was transferred to the hospital and diagnosed with cervical disc herniation with developing spinal cord injury of the cervical spine 5 and cervical spine 6 (C5-6). Review of the facility policy titled, Falls Management, dated as revised 6/15/22, indicated Residents who experience falls will receive appropriate care and post fall interventions will be implemented. Resident #124 was admitted to the facility in October 2022 with diagnoses including hemiplegia (paralysis on one side of the body) following cerebral infraction (stroke) affecting the right dominant side and left humerus (bone in the upper arm) fracture. Review of Resident #124's Discharge Summary Transfer form, dated 10/7/22, indicated he/she required an assistance of two and was non-weight bearing to his/her left upper extremity. Review of Resident #124's Treatment Administration Record, dated October 2022, indicated the following physician's orders: -avoid range of motion of the shoulder (not specified which shoulder), dated as initiated 10/7/22 -wear sling at all times to the left arm, dated as initiated 10/7/22 Review of Resident #124's Lift Transfer Reposition assessment, dated 10/8/22, indicated he/she required two staff members for repositioning in bed. Review of Resident #124's Occupational Therapy Evaluation, dated 10/8/22, indicated he/she had a prior level of function of a maximum assistance of two for bed mobility. Review of Resident #124's Physical Therapy Evaluation, dated 10/10/22, indicated he/she required maximum assist for bed mobility including rolling from the left to the right. The evaluation indicated he/she was non-weight bearing on his/her left shoulder because of a fracture and wore a sling and had right sided hemiparesis. Review of Resident #124's Social Services Assessment, dated 10/11/22, indicated he/she was alert and oriented. The assessment indicted he/she could make self understood and could understand others. Review of Resident #124's medical record indicated there was no documentation to support a plan of care related to activities of daily living (how staff should provide and the level of assistance required) was not developed until 10/30/22. Review of Resident #124's incident report, dated 10/15/22, indicated Resident #124 rolled off the bed while being provided care by Certified Nurse Aide (CNA) #1. Review of CNA #1's written statement, dated 10/15/22, indicated she turned to get a washcloth from the bedside table and Resident #124 rolled off the bed. During a phone call to CNA #1 for interview on 12/13/22 at 4:14 P.M., CNA #1 answered her phone identified herself, and she declined an interview with the surveyor. During an interview on 12/13/22 at 5:16 A.M., Nurse #2 said that she worked the evening shift on 10/15/22 when Resident #124 fell on the floor. Nurse #2 said that she went into Resident #124's room where she found CNA #1 adjusting Resident #124 on the floor. Nurse #2 said she did not know why CNA #1 did not immediately notify her that Resident #124 was on the floor. Nurse #2 said she had observed Resident #124 laying on his/her right side on the floor and that the CNA #1 had moved the nightstand away from Resident #124's head. Nurse #2 said she should have assessed Resident #124 before CNA #1 moved Resident #124 around on the floor. Nurse #2 said she was not sure why CNA #1 was providing care to him/her alone and said that Resident #124 could not move his/her left or his/her right side. Nurse #2 said that CNA #1 said Resident #124 did not hit his/her head on the floor and Nurse #2 did not believe CNA #1 and sent Resident #124 to the hospital. During an interview on 12/9/22 at 10:15 A.M., CNA #5 said that when Resident #124 was first admitted he/she wore a sling and could not do anything with his/her left arm. CNA #5 said that Resident #124's right side was paralyzed, and he/she could not move it. CNA #5 said he/she required two staff to assist Resident #124 with bed mobility. During an interview on 12/14/22 at 10:55 A.M., CNA #6 said that when Resident #124 was first admitted he/she wore a sling and could not do anything with his/her left arm. CNA #6 said that Resident #124's right side was paralyzed and he/she could not move it. CNA #6 said he/she required two staff to assist Resident #124 with bed mobility and he/she was essentially helpless. During an interview on 12/8/22 at 8:08 A.M. and again on 12/14/22 at 10:30 A.M., Resident #124 said that the day he/she had fallen out of bed he/she was receiving care from CNA #1. Resident #124 said CNA #1 was alone and rolled him/her on his/her left side to change his/her brief. Resident #124 said he/she began to slide off of the bed when CNA#1 had him/her positioned on his/her left side and said he/she smashed his/her face on the nightstand and landed face first on the the floor. Review of the nursing progress note, dated 10/22/22, indicated Resident #124 was readmitted after a C5-6 Anterior Cervical Discectomy and Fusion (ACDF) on 10/16/22. During an interview on 12/14/22 at 8:11 A.M., Director of Nursing (DON) #2 said she completed the investigation into Resident #124's fall. DON #2 said that she received conflicting information from Nurse #2 and CNA#1. DON #2 said that CNA #1 had Resident #124 sitting on the edge of the bed when CNA #1 lowered Resident #124 to the floor. DON #2 said she was not really sure what actually happened to Resident #124 and said that CNA #1 should not have moved Resident #124 until Nurse #2 evaluated him/her. 36876 2. The facility failed to provide appropriate supervision to residents on 3 of 4 units as evidenced by staff sleeping during the 11:00 P.M. - 7:00 A.M. shift on 3 of 4 units. Review of the Employee Handbook dated April 2019 indicated that staff sleeping or failure to remain alert and oriented while on duty constitutes as immediate grounds for dismissal. A. During an early morning visit on 12/13/22 the surveyors observed the following on the [NAME] Unit (a secured unit which houses residents with dementia): -At 4:01 A.M., Nurse #2 was awake and seated behind the nurses station. -2 CNA's were observed asleep in the activity room. They were both under blankets and lounging in reclining positions in chairs. -Resident #30 was observed awake and seated in the same room as the two staff members who were observed asleep. -There were two residents awake and wandering the unit. -The door to lounge area was ajar, and the surveyor attempted to push the door open which hit a chair propped against it. -A CNA was observed laying in total darkness on the sofa in the lounge under blankets with a pillow and jerked upright when the door hit the chair. During an interview with Nurse #2 on 12/13/22 at approximately 5:42 A.M., she said that Resident #30 had been agitated earlier in the night and kept standing up with his/her alarm sounding. Nurse #2 said that Resident #30 had been placed in the activity room to be supervised and acknowledged that the two CNA's in the activity room who were supposed to be supervising him/her were asleep. B. During an early morning visit on 12/13/22 the surveyor observed the following on the Maplewood Unit, (a Rehabilitation Unit housing Resident's for short term rehabilitation requiring subacute medical care after hospitalization s): -At 4:02 A.M., Certified Nurse Aide (CNA) #7 was in a chair wrapped in a blanket with her eyes shut. CNA#7 had her personal computer device in front of her and was wearing headphones. The surveyor observed a call bell turned on behind CNA #7's head. -At 4:03 A.M., Nurse #8 was observed at the nurses station, and her head was down and she had her personal cell phone in her lap. The surveyor observed a call bell turned on immediately to Nurse #8's right. -At 4:03 A.M., CNA #2 was observed in a chair with his eyes shut and mouth open. CNA #2 was not wearing a mask. The surveyor observed a call bell turned on behind CNA #2 and directly in front of CNA #2. -At 4:10 A.M., CNA #7 is observed waking up CNA #2. CNA #7 said to CNA #2 that there is a surveyor in the building. During an interview on 12/13/22 at 4:48 A.M., Nurse #8 said that the overnight shift (11:00 P.M.- 7:00 A.M.) is an awake shift. Nurse #8 said staff should not be sleeping. C. During an early morning visit on 12/13/22 the surveyor observed the following on the Oak Grove Unit, (a unit housing Residents with COVID-19): -At 4:05 A.M., CNA#3 was observed sleeping in the hallway, blocking herself with a linen cart. -At 4:10 A.M., Nurse #3 was observed leaving an empty Resident's room, she was incoherent, had sleeping lines on her face. She stated she was tired and she said she has been working a lot of double shifts. During an interview on 12/13/22 at 6:27 A.M. with Director of Nursing (DON) #1, DON #2, and Administrator #1, they said that staff should not be sleeping in Resident areas or while on duty during their assigned shifts.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required an assist of two staff persons for bed mobility and repositioning, the Facility failed to ensure staff implemented interventions from his/her comprehensive plan of care for bed mobility, when Certified Nurse Aide (CNA) #1 rolled Resident #1 over in bed, without another staff member's assistance, Resident #1 fell off the side of his/her bed, sustained a right knee fracture, and was admitted to the Hospital. Findings include: Review of the Facility's Policy, titled, Person Centered Care Plan, dated 7/01/19, indicated the purpose of the care plan was to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being, and eliminate or mitigate triggers that may cause re-traumatization of the resident. Review of Resident #1's Medical Record indicated he/she was admitted to the Facility in December 2016, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly Minimum Data Set assessment, dated 4/23/21, indicated Resident #1 required extensive assistance of two or more staff for bed mobility. Review of Resident #1's Activities of Daily Living Care Plan, dated 12/09/16 and revised on 7/07/21, indicated he/she required extensive assistance of two staff for bed mobility. Review of Resident #1's Change in Condition Note, dated 7/15/21, indicated Resident #1 had fallen out of bed during care, complained of right knee pain, the Nurse Practitioner was notified, and an X-ray of his/her right knee was ordered. Review of Resident #1's Radiology Report, dated 7/15/21, indicated there was an acute fracture of his/her right distal femur (bone at the top of the knee joint). The Facility's Internal Investigation Summary, dated 7/15/21, indicated that at 8:30 P.M., on 7/15/21, CNA #1 was providing care to Resident #1 in bed, and when she rolled Resident #1 towards his/her left side, Resident #1 slid off the mattress onto the floor, sustained a right knee fracture, and required admission to the Hospital. Review of CNA #1's written statement, dated 7/15/21, indicated that while she was providing care for Resident #1 in his/her bed, Resident #1 was laughing and jovial, and was moving around in the bed, and when she rolled Resident #1 in the bed, he/she fell off the side of the bed and onto the floor. CNA #1 was not available to be interviewed at the time of this survey. Review of Resident #1's Hospital History and Physical, dated 7/16/21, indicated Resident #1 was admitted to the Hospital on 7/16/21 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview on 8/16/21 at 3:40 P.M., Nurse #1 said that on 7/15/21, CNA #1 told him that Resident #1 was on the floor. Nurse #1 said he went to Resident #1's room and saw him/her lying on his/her back on the floor, and he/she was complaining of right knee pain. Nurse #1 said CNA #1 told him that while she provided care for Resident #1, she had rolled him/her onto his/her side facing away from her, and Resident #1 fell off the opposite side of the bed. During interview on 8/16/21 at 9:46 A.M., the Director of Nurses said CNA #1 should have had a second staff member with her to provide care to Resident #1.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required an assist of two staff members with bed mobility, the Facility failed to ensure his/her safety was maintained to prevent incidents or accidents resulting in an injury, when on 7/15/21, Certified Nurse Aide (CNA) #1 rolled Resident #1 over in his/her bed without assistance from another staff member, resulting in him/her falling off the bed, sustaining a right knee fracture, was transferred and admitted to the Hospital. Findings include: Review of the Facility's Policy, titled, Accidents and Incidents, dated 5/02/18, indicated an incident was defined as any occurrence not consistent with the routine operation of the center or normal care of the resident. Review of Resident #1's Medical Record indicated he/she was admitted to the Facility in December 2016, diagnoses included history of stroke with [CONDITION(S)] (paralysis of half of the body) of the left side, and dementia. Review of Resident #1's Quarterly Minimum Data Set assessment, dated 4/23/21, indicated Resident #1 required extensive assistance of two or more staff for bed mobility. Review of Resident #1's Licensed Nursing Summaries, dated 5/26/21 and 6/27/21, indicated Resident #1 was essentially helpless, had decreased strength and endurance, contractures, and required assist of two staff members for repositioning in bed. Review of Resident #1's Lift Transfer Reposition assessment, dated 6/01/21, indicated Resident #1 required extensive assistance of two staff members for bed mobility. Review of Resident #1's Activities of Daily Living Care Plan, dated as revised on 7/07/21, indicated he/she required extensive assistance of two staff members for bed mobility. Review of Resident #1's Change in Condition Note, dated 7/15/21, indicated Resident #1 had fallen out of bed during care, complained of right knee pain, the Nurse Practitioner was notified, and an X-ray of his/her knee was ordered. Review of Resident #1's Radiology Report, dated 7/15/21, indicated there was an acute fracture of his/her right distal femur (bone at the top of the knee joint). The Facility's Internal Investigation Summary, dated 7/15/21, indicated that at 8:30 P.M., on 7/15/21, CNA #1 was providing care to Resident #1 in bed, and when she rolled Resident #1 towards his/her left side, Resident #1 slid off the mattress onto the floor, sustained a right knee fracture, and required admission to the Hospital. Review of CNA #1's written statement, dated 7/15/21, indicated that while she was providing care for Resident #1 in his/her bed, Resident #1 was laughing and jovial, and was moving around in the bed, and when she rolled Resident #1 over in the bed, he/she fell off the side of the bed and onto the floor. CNA #1 was not available to be interviewed at the time of this survey. Review of Resident #1's Hospital History and Physical, dated 7/16/21, indicated Resident #1 was admitted to the Hospital with diagnosis of right distal femur (knee) fracture as the result of a fall. During interview on 8/16/21 at 3:40 P.M., Nurse #1 said that on 7/15/21, CNA #1 told him that Resident #1 was on the floor. Nurse #1 said he went to Resident #1's room and saw him/her lying on his/her back on the floor, and was complaining of right knee pain. Nurse #1 said CNA #1 told him that while she provided care for Resident #1, she had rolled him/her onto his/her side facing away from her, and Resident #1 fell off the opposite side of the bed. During interview on 8/16/21, at 9:46 A.M., the Director of Nurses said CNA #1 should have had a second staff member with her to provide care to Resident #1.

Based on record review and interview, the facility failed to ensure 1 Resident (#423), out of a sample of 28 residents, received the necessary treatment to promote the healing of a pressure ulcer and prevent infection, resulting in hospitalization s for surgical debridement of the wound and [CONDITION(S)] (bone infection) requiring antibiotic treatment. Findings include: Resident #423 was admitted to the facility in 3/2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurse's notes dated 3/6/21, indicated a skin check was completed upon admission and included a finding of a healing pressure ulcer 2.5 x 3.5 centimeters (cm) on Resident #423's buttocks. Review of the facility document titled Skin Check -V4 and dated, 3/6/21, indicated that Resident #423 had a pressure area on the buttocks measuring 3.5 x 2.5 cm. Review of the facility document titled Skin Integrity Report and dated 3/6/21, indicated resident #423 had a pressure ulcer on his/her buttocks measuring 3.5 cm L x 2.5 cm W., no drainage and the wound edges were healthy. Further review indicated that the tissue surrounding the wound was not evaluated, there was no evaluation of the depth of the wound or if there was tunneling or undermining of the wound. Review of the facility document titled Skin Integrity Report and dated 3/13/21, indicated resident #423 had a pressure ulcer on his/her buttocks measuring 3.5 cm L x 2.5 cm W., no drainage and the wound edges were now macerated. Further review indicated that the tissue surrounding the wound was not evaluated, there was no evaluation of the depth of the wound or if there was tunneling or undermining of the wound. Review of the doctor's orders dated 3/6/21 through 3/13/21 failed to indicate a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility treatment record dated for the month 3/2021 indicated that no treatment to the pressure ulcer was initiated until 3/13/21. Review of the nurse's notes 3/6/21 through 3/13/21, failed to indicate a treatment to the pressure ulcer was initiated. Further review failed to indicate that the pressure area on Resident #423's buttocks was monitored for changes. Review of the doctor's orders dated 3/16/21, indicated to send Resident #423 to Massachusetts General Hospital (MGH). Review of the document titled MGH wound Clinic and dated 5/3/21, indicated that on 3/16/21, Resident #423 presented to the hospital with a sacral wound of enlarged size and development of devitalized tissue since discharge on 3/6/21. Further review indicated that Resident #423 required sharp excisional debridement of the wound to a size of 5 cm. x 5 cm. and down to bone, in the operating room (OR) on 4/9/21, was placed on VAC therapy (negative pressure wound therapy) and was discharged back to the facility on [DATE] with a clean, granulating wound. Review of the facility treatment record dated for the month 4/2021 failed to indicate the facility was monitoring the wound and the tissue surrounding the wound for signs and symptoms of infection. Review of the doctor's orders dated for 4/13/21 through 4/23/21, failed to indicate an order to monitor the wound for signs and symptoms of infection. Review of the document titled MGH wound service and dated 5/3/21, indicated that Resident #423 then presented to MGH wound clinic on 4/23/21, without a dressing to the sacral wound and with the wound covered by a towel. Further review indicated that Resident #423 had a temperature and a markedly deteriorated sacral wound (6.5 x 6.5 x 2.7 cm. with circumferential undermining) malodorous, enlarged, now with necrotic tissue and was subsequently admitted to the hospital with [CONDITION(S)] from the sacral wound. The document then indicated that Resident #423 had debridement of the wound on 4/24/21 and 4/26/21 in the OR with a bone biopsy which resulted in the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurse's notes dated 4/23/21 failed to indicate the VAC dressing had been removed or became dislodged prior to sending to MGH wound clinic. Review of the facility policy titled Skin Integrity Management and dated revised 1/31/20, indicated to perform daily monitoring of wounds or dressings for presence of complications or declines and document. Further review indicated that for wounds that did not require a daily dressing change monitor status of tissue surrounding the dressing (free of new redness or swelling). Review of the facility policy titled Skin/Wound Management dated 2005, indicated that the plan of care for all patients who have wounds will include routine evaluations and daily monitoring of the wound site (covered or uncovered). Further review indicated that daily monitoring for a dressing site not scheduled to be changed includes the evaluation of: status of dressing (intact, not leaking); status of tissue surrounding dressing (no new redness or swelling). Review of the medical record failed to indicate that the wound VAC dressing was monitored for the presence of wound decline or the status of the tissue surrounding the dressing (free of new redness or swelling). During an interview on 5/24/21, at 9:45 A.M., the Director of Nursing said that she had not seen the wound. She said that the unit managers usually call her to come and see the wounds when they change the dressings but she didn't have the chance until Resident #423's last re-admission to the facility on [DATE]. During an interview of 5/24/20, at 11:35 A.M., Unit Manager #1 said that there was no documentation of the wound having been monitored daily.

Based on records reviewed and interviews for two of four sampled residents (Resident #2 and Resident #3), the Facility failed to ensure that both residents were free from significant medication errors, when nursing failed to accurately transcribe Physicians orders for medications, and nursing staff on subsequent shifts failed to identify the errors as well. When for more than one week Resident #3 did not receive medications to treat his/her chronic medical conditions, that were ordered by his/her physician, and subsequently experienced a decline in condition, and Resident #2 was administered multiple medications daily for greater than one week, that were not ordered by his/her physician, he/she experienced a significant decline in status, and was transferred and admitted to the Hospital. - On 1/8/19, Resident #3's physician's orders [REDACTED]. - On 5/12/19, Nurse #6, in error, transcribed another resident's admission Medication Orders into Resident #2's Medication Administration Record [REDACTED]. Findings Include: Resident #3's medical record Face sheet indicated that he/she had medical [DIAGNOSES REDACTED]. Resident #3's admission orders [REDACTED]. The Facility Event Report, dated 1/19/19, indicated that Resident #3's [MEDICATION NAME] 20 milligram tablets were not administered. The Report indicated that the root cause for the error was because the order for the [MEDICATION NAME] was on the last page of the Hospital Discharge Summary and it was not transcribed into Resident #3's Medication Orders when Resident #3 was admitted to the Facility. Review of Resident #3's Medication Administration Record [REDACTED]. A Nurse Progress Note, dated 1/19/19 indicated that Resident #3 was observed to have increased [MEDICAL CONDITION] (excess fluid trapped in the body's tissues) to both of his/her legs and his/her lung sounds were diminished with fine crackles (associated with inflammation or fluid in the lungs due to heart failure). The Note indicated that Resident #3's Physician was notified and the Physician questioned why Resident #3's [MEDICATION NAME] was not listed on his/her Medication Orders when he/she was readmitted to the Facility and Orders were obtained for the omitted medications. A Nurse Progress Note, dated 1/22/19, indicated that Resident #3's condition had deteriorated and Resident #1 had difficulty breathing, required increased oxygen administration, was administered medication to improve his/her difficulty breathing which were ineffective and Resident #3 was transferred to the Hospital. The Hospital Emergency Department (ED) Note, dated 1/22/19, indicated that Resident #3 presented with [MEDICAL CONDITION], likely due to [MEDICAL CONDITIONS] (a condition caused by excess fluid in the lungs) and missed [MEDICATION NAME] doses and he/she required diuresis (administered medication for removal of excess fluid from body). The Surveyor interviewed Nurse #5 at 11:35 A.M. on 6/27/19. Nurse #5 said another nurse should have done a check of the physician's orders [REDACTED]. 2. Resident #2's medical record Face Sheet indicated that his/her medical [DIAGNOSES REDACTED]. The Facility Event Summary Report, dated 5/24/19, indicated that Resident #2 was administered medications that were prescribed for another resident from 5/12/19 to 5/20/19. The Report indicated that MEDICATION ORDERS FOR [REDACTED]. The Facility Report, dated 5/28/19, submitted to the Department of Public Health via the Health Care Facility Reporting System, indicated that, on 5/20/19, Resident #2 experienced a change in condition, was transferred to the Hospital, and indicated that the Facility discovered, on 5/24/19, that the wrong medications were transcribed into Resident #2's Medical Record. Review of Resident #2's Hospital Admission Medication Orders compared to Resident #2's Medication Administration Record [REDACTED] -Apixaban 2.5 milligram tablet by mouth twice daily (a blood thinner). Review of Resident #2's MAR indicated [REDACTED]. -[MEDICATION NAME] 10 milligram tablet by mouth daily (used to treat [MEDICAL CONDITION]). Review of Resident #2's MAR indicated [REDACTED]. -Aspirin 81 milligram tablet by mouth daily. Review of Resident #2's MAR indicated [REDACTED]. -Atorvastatin Calcium 20 milligram tablet by mouth daily (lowers high cholesterol). Review of Resident #2's MAR indicated [REDACTED]. -Calcium [MEDICATION NAME] 1000 milligram tablet by mouth twice daily (used to treat [MEDICAL CONDITION] and/or gastric hyperacidity). Review of Resident #2's MAR indicated [REDACTED]. -[MEDICATION NAME] 100 milligram capsule by mouth daily (stool softener). Review of Resident #2's MAR indicated [REDACTED]. -[MEDICATION NAME] Propionate Suspension 50 microgram spray in each nostril daily (corticosteroid used to treat allergic and non-allergic nasal symptoms). Review of Resident #2's MAR indicated [REDACTED]. -Ibandronate Sodium 150 milligram tablet by mouth every 30 days (treats bone loss). Review of Resident #2's MAR indicated [REDACTED]. -[MEDICATION NAME] Sodium 137 microgram tablet by mouth daily (used to treat under-active [MEDICAL CONDITION]). Review of Resident #2's MAR indicated [REDACTED]. -Losartan Potassium 50 milligram tablet by mouth daily (lowers blood pressure). Review of Resident #2's MAR indicated [REDACTED]. -[MEDICATION NAME] 20 milligram 2 tablets by mouth daily (treats fluid retention for [MEDICAL CONDITION], liver disease, kidney disease, and lowers blood pressure). Review of Resident #2's MAR indicated [REDACTED]. -[MEDICATION NAME] Extended Release 240 milligram tablet by mouth daily (treats high blood pressure, chest pain, and certain heart rhythm disorders). Review of Resident #2's MAR indicated [REDACTED]. -[MEDICATION NAME] 25 milligram tablet half tablet by mouth twice daily (treats high blood pressure and chest pain). Review of Resident #2's MAR indicated [REDACTED]. A Nurse Progress Note, dated 5/20/19, indicated that Resident #2 had a change in mental status, low heart rate, low body temperature, cold, pale skin, and he/she was transferred to the Hospital for further evaluation. A Hospital Emergency Department (ED) Note, dated 5/20/19, indicated that Resident #2 was lethargic, with a blood pressure of 70/50 (normal blood pressure range is 120/80), heart rate of 40 beats per minute (bpm) (average heart rate is 60-100 bpm). The ED Note indicated that Resident #2 had acute renal (kidney) failure and the ED Nurse Practitioner considered possible overdose to beta-blockers (cardiac medication that reduces heart rate and blood pressure, such as [MEDICATION NAME]) due to his/her symptoms because it could not be determined how Resident #1 developed the heart rhythm or low blood pressure that he/she presented with (at that time, the Hospital and Facility had not discovered the multiple medication errors that occurred at the Facility). The Note indicated that Resident #3 was admitted to the Hospital. The Surveyor interviewed Nurse #6 at 11:35 A.M. on 7/9/19. Nurse #6 said that he worked on 5/12/19 and Resident #2 was on his assignment. Nurse #6 said that at 2:30 P.M, he assisted with admitting a new resident to the facility and said he was not sure how the newly admitted resident's Medication Orders were transcribed into Resident #2's Medical Record. Nurse #6 said he thought that it was because the day was busy and he may have transcribed the new resident's Medication orders into Resident #2's Medical Record without checking which resident profile he was in when, before he started typing in the new admission's Medication Orders. The Surveyor interviewed the Unit Manager at 12:31 P.M. on 6/19/19. The Unit Manager said the Facility discovered that the medications for the other resident were transcribed into Resident #2's Medical Record after he/she was transferred to the Hospital for a change in condition and the Hospital called to question them about Resident #2's medications. The Unit Manager said she did not recall much about Resident #3's medication error. The Unit Manager said that when Medication Orders were transcribed another nurse was supposed to verify that the Orders were transcribed correctly. The Surveyor re-interviewed the Unit Manager at 12:07 P.M. on 7/16/19. The Unit Manager said that, prior to Resident #2 and Resident #3's medication transcription errors, the Facility did not have a system in place to check accuracy of admission orders [REDACTED]. On 6/18/19 the Facility provided the Surveyor with a plan of correction which addressed the concerns as evidenced by: A. Resident #3 was assessed on 1/19/19, Physician order [REDACTED]. B. Resident #2 no longer resides at the Facility. B. On 6/02/19, an accuracy audit of all new admission and re-admission Physician Orders, going back 30 days, was completed by the Clinical Reimbursement Coordinator, Unit Manager, and Nurses. C. The Facility developed a new Procedure for Admission & Readmission Medication Reconciliation. D. Starting 5/24/19-5/26/19, the Nurse Practice Educator provided In-Services to Nurses regarding the correct process for the following; verifying medication orders upon admission and readmission, Physician order [REDACTED]. E. The Unit Manager and/or designee will continue to review new admission and re-admission Physician order [REDACTED]. F. Results of the audits will be reported to Quality Assurance Performance Improvement Committee until determined. G. The Director of Nurses and/or Designee is responsible for overall compliance.

Based on record review and interview, the Facility staff failed to obtain weights as ordered by the physician, inform the physician and revise the plan of care to address a significant weight loss, and failed to notify the registered dietician of a significant weight loss in a timely manner for 2 of 28 sampled residents (#123 and #87). a) Resident #123 had a 5.52% weight loss between 2/25/19 and 3/4/19, and a 10.43% weight loss between 2/25/19 and 3/27/19. b) Resident #87 had a 8.67 percent weight loss between 11/4/18 and 2/7/19. Findings include: Review of the Facility's Weight and Height Policy, revised 8/1/18, indicated the following: -Residents are weighed at admission and/or re-admission, then weekly for four weeks and monthly thereafter. -A licensed nurse or designee will weigh the resident. -If a resident's weight is less than or greater than five pounds from the previous weight, the resident will be re-weighed and the weight verified by a licensed nurse to determine accuracy. -The verified weight will be entered into the (electronic medical record) that shift. -Significant weight changes will be reviewed by the licensed nurse for assessment. -The licensed nurse will notify the physician and dietician of significant weight changes. -The interdisciplinary care plan will be updated to reflect individualized goals and approaches for managing the weight change. The policy indicated that a significant weight change is defined as 5% in one month and 10% in six months. a) For Resident #123, the Facility staff failed to inform the physician and reassess Resident #123's dietary status after significant weight losses occurred in (MONTH) and (MONTH) 2019. Resident #123 was admitted to the Facility in 2/2019 with [DIAGNOSES REDACTED]. Resident 123's medical record indicated a physician's orders [REDACTED]. Resident #123's physician order, dated 2/25/19, indicated [MEDICATION NAME] (an antidepressant medication often used to promote weight gain) 7.5 milligrams (mg) at bedtime for appetite, and [MEDICATION NAME] 20 mg, 2 tablets per day for [MEDICAL CONDITION] (a diuretic used to reduce swelling from multiple causes such as heart failure and [MEDICAL CONDITION]). Resident #123's dietary order, dated 2/25/19, indicated he/she required a regular diet. The dietary orders did not indicate any other interventions to address Resident #123's nutritional needs. Resident #123's physician order, dated 2/28/19, indicated nursing staff were to telephone the physician, if his/her weight changes 2-3 pounds every day shift related to unspecified combined systolic (congestive) and diastolic (congestive) heart failure. Resident #123's Dietary Nutritional Assessment, dated 3/1/19, indicated a weight of 163 pounds. taken on 2/25/19. The assessment indicated that Resident #123 had a good appetite and recommended a . consistent carbohydrate diet appropriate per need to control BG (blood glucose). Will continue to monitor for significant weight change. The Dietary Nutritional Assessment did not indicate any other interventions to address Resident #123's nutritional needs. Resident #123's admission Minimum Data Set (MDS) assessment, dated 3/4/19, indicated active [DIAGNOSES REDACTED]. Review of Resident #123's clinical record indicated there were no other dietary or nutritional assessments, as of 3/27/19. The clinical record indicated there were no dietary progress notes. Resident #123's Weight and Vitals Summary, recorded the following weights: 2/25/19 at 163 pounds (lbs) 3/4/19 at 154 lbs 3/11/19 at 152.8 lbs 3/16/19 at 153.2 lbs 3/22/19 at 146 lbs 3/27/19 at 146 lbs The Weights and Vitals Summary indicated that Resident #123 had a 5.52% weight loss occurred within one week and a 10.43% weight loss within 30 days. Resident #123's nurse's note, dated 3/4/19, indicated nursing staff informed the Nurse Practitioner that his/her weight measured 163 lbs on 2/25/19 and then measured 154 lbs on 3/4/19 (5% weight loss), but no indication that the Dietician was informed of the weight loss. There were no additional notes in the medical record to indicate that staff informed the Physician or Dietician that Resident #123 weighed 146 lbs on 3/22/19, which resulted in an additional 9.5% weight loss. Resident #123's physician notes, dietary notes and and nursing notes did not reference his/her significant weight loss, or if Facility staff communicated his/her continued weight loss that occurred after 3/4/19. Resident #123's 14 day MDS assessment, dated 3/11/19 indicated he/she weighted 153 lbs and triggered a weight loss of 5% or more in one month. Resident #123's care plan meeting note, dated 3/12/19, indicated he/she was nutritionally stable and there was no reference to his/her significant weight loss or of any interventions to address the loss. Review of Resident #123's 14-day comprehensive care plan, dated 3/11/19, indicated that a dietary care plan was not developed. The care plan did not include interventions to address Resident #123's dietary needs or significant weight loss. The Surveyor entered Resident #123's bedroom on 3/26/19 at approximately 1:00 P.M. Resident #123 was lying under the bed sheets so that the Surveyor was unable to see his/her body condition. Resident #123 refused to be interviewed. The Surveyor interviewed the Unit Manager on 3/27/19 at 12:33 P.M. The Unit Manager said that she was aware that Resident #123 had a weight loss and requested that the Dietician evaluate him/her for nutritional risk. The Unit Manager said that the Dietician's evaluation was the nursing intervention for Resident #123's weight loss, and she referred the Surveyor to the Dietician's Dietary Nutritional Assessment (dated 3/1/19). The Surveyor interviewed the Dietician on 3/27/19 at 12:33 P.M. and again at 12:53 P.M. The Dietician reviewed Resident #123's Weights and Vitals Summary and commented that he/she had over a 10% weight loss between his her/admission on 2/25/19 and today. The Dietician said she and the interdisciplinary team had discussed Resident #123's weight at the care plan meeting held on 3/12/19 and was aware that he/she had a weight loss but thought it might be due to water loss. The Dietician said she had not reassessed Resident #123 since the initial risk assessment on 3/1/19, had not introduced new dietary interventions to address the weight loss, or discussed the continued weight loss with his/her physician or nurse practitioner. Review of Nursing and Dietician progress notes failed to indicate that Resident #123's weight loss had been evaluated and was related to fluid or [MEDICAL CONDITION]. b) For Resident #87, the Facility staff failed to obtain weights as ordered by the physician, failed to inform the physician of a significant weight loss and failed to notify the registered dietician of a significant weight loss in a timely manner. Resident #87 was admitted to the Facility in 7/2014 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set Assessment (MDS), with an assessment reference date of 2/22/19, indicated that Resident #87 had a severe cognitive impairment and required extensive assistance of 2 staff for bed mobility, hygiene and extensive assistance of 1 staff for transfers, dressing and eating. Review of the physician's orders [REDACTED]. Review of the electronic medical record on 3/28/19 indicated the following weights: * 11/04/18 129.2 pounds * 02/07/19 118 pounds * 02/14/19 119.2 pounds The medical record failed to indicate weights were obtained for the months of 12/2018 and 1/2019 as ordered by the physician. Review of the recorded weights indicated that Resident #87 had a weight loss of 11.2 pounds from 11/4/18 through 2/7/19, which is a 8.67 percent weight loss in 90 days. During an interview on 3/28/19 at 10:45 A.M., the Unit Manager (UM#1) said he may be able to find weights that were recorded on paper (this was never provided). UM #1 said he became aware of Resident #87's weight loss on 2/7/19 and said the plan was to check the weight again on 2/14/19,. UM#1's plan was is conflict with the Facility policy. Review of the medical record failed to indicate a progress note was written by nursing on 2/7/19 about the 11.2 pound weight loss or that the registered dietician, physician or nurse practitioner was notified per facility policy. During an interview on 3/28/19 at 10:51 A.M., the Registered Dietician (RD) said Resident #87 lost 8.7 percent of weight in 3 months from 11/4/18 through 2/7/19 which she said was significant. She said she was not made aware of the 11.2 pound weight loss until 2/19/19, 13 days after the 11.2 pound weight loss was recorded for Resident #87. She said she reviews a weekly weight summary report from the weights recorded in the electronic medical record and that Resident #87 did not come up as a weight loss if the weights were not entered. The RD updated the care plan and put in interventions for the significant weight loss 13 days after the weight loss was recorded. Review of the nutritional assessment, dated 2/19/19, indicated that Resident #87 had a significant weight loss in 3 months which was unintended. Review of the physician's progress note dated 1/25/19 did not address Resident #87's weight status and the nurse practitioner's progress note dated 3/26/19 indicated Resident #87 eats well. During an interview on 3/28/19 at 12:21 P.M., the Director of Nurses said when there is a 2 to 3 pound variance in weight, a new weight should be done and the registered dietician, physician and /or nurse practitioner should be notified to assess for significant weight loss.