Every finding on record at Regalcare at Harwich

Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose Advanced Directives indicated he/she was a full code (attempt resuscitation), the facility failed to ensure nursing provided care and services that met professional standards of nursing practice, when after Nurse #1 found Resident #1 unresponsive, without respirations and without a pulse, the physician was not made aware of Resident #1's change in condition, a Code Blue was not announced, 911 was not activated, therefore other nursing staff in the facility and Emergency Medical Service were not alerted to and could not respond to provide necessary assistance to Nurse #1 with attempts at resuscitation, as a result, the care and treatment provided to Resident #1 by Nurse #1 had not meet acceptable standards of practice. Findings include:Review of the Facility's Policy titled, Code Blue, dated as revised 4/2022, indicated the following:-residents/victims found to be unresponsive or who becomes unresponsive under observation, staff will call a Code Blue and code Blue will be paged overhead two times, the page will include the unit, location, and room number.-the nurse who is the first responder to the situation will determine the code status, lead the code, and remain with the patient throughout the code.Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Review of the Report submitted by the facility, via the Health Care Facility Reporting Systems (HCFRS), dated [DATE], indicated on [DATE] around 5:00 A.M., Resident #1 was found unresponsive by staff, Nurse A (identified as Nurse #1) initiated CPR and CPR was discontinued prior to notifying Resident #1's Physician. The Report indicated that Nurse B (identified as Nurse #2) was contacted by Nurse A (Nurse #1) to complete an RN Pronouncement on Resident #1 and the pronouncement was completed at approximately 5:20 A.M by Nurse B (Nurse #2). The Report further indicated that Nurse A (Nurse #1) did not follow the Facility's policies related to Code Blue, Emergency Code activation, change of condition notification and AED utilization.Resident #1 was admitted to the Facility in [DATE], diagnoses included dementia, Alzheimer's, adult failure to thrive, osteomyelitis of right ankle and foot, hyperlipidemia (high cholesterol), anxiety, severe protein-calorie malnutrition, and pressure ulcers (right heel, left heel and sacral region.Review of Resident #1's Medical Orders for Life Sustaining Treatment (MOLST) Form, dated [DATE], indicated he/she was elected to be a Full Code, for nursing to attempt resuscitation (administer Cardiopulmonary Resuscitation).Review of Resident #1's Physician's Order, dated [DATE], indicated he/she was a Full Code. During an interview on [DATE] at 3:39 P.M., (which included review of her written statement), Certified Nurse Aide (CNA) #1 said she worked the 11:00 P.M. to 7:00 A.M. (night shift) on [DATE] into [DATE] on Resident #1's unit. CNA #1 said around 4:45 A.M. during rounds she checked on Resident #1, he/she was in bed lying on his/her back, his/her eyes were half open, and he/she did not look good. CNA #1 said she called Resident #1's name, he/she did not respond, and said she asked CNA #2 to come look at Resident #1. CNA #1 said that CNA #2 looked at Resident #1 and she (CNA #2) also said he/she did not look well, and said they needed to tell Nurse #1. CNA #1 said CNA #2 went to get Nurse #1 and that Nurse #1 came right away. CNA #1 said Nurse #1 did not instruct her to call a Code Blue or 911.During an interview on [DATE] at 1:25 P.M., (which included review of her written statement), Certified Nurse Aide (CNA) #2 said on [DATE] around 4:45 A.M. she was doing rounds and CNA #1 asked her to take a look at Resident #1. CNA #2 said she went and looked at Resident #1, he/she did not look well and said she told Nurse #1 that Resident #1 looked like he/she was dead. CNA #2 said Nurse #1 asked her to get the crash cart and bring it to Resident #1's room.Review of Resident #1's Progress Note, dated [DATE], (written by Nurse #1) indicated that around 5:00 A.M., he was notified by a CNA that there was a resident unresponsive (identified as Resident #1). The Note indicated Nurse #1 observed Resident #1 lying in bed, unresponsive to verbal and tactile stimuli, had no response to sternal rub, he/she was not breathing, had no pulse, was cold to the touch and stiff. The Note indicated Nurse #1 verified Resident #1's code status, (which was a full code) and proceeded to give CPR. The Note indicated that Nurse #1 sent a text message to the Physician, the Director of Nursing (DON, and Unit Manager.During an interview on [DATE] at 12:49 P.M., Nurse #1 said around 5:00 A.M. CNA #2 called for him to go to Resident #1's room. Nurse #1 said when he entered the room, Resident #1 was lying in bed on his/her back, he/she was unresponsive, not breathing, had no pulse and his/her body was cold to the touch and stiff. Nurse #1 said he checked Resident #1's code status, noted he/she was a full code, and he asked CNA #2 to bring the crash cart (mobile cart stocked with life-saving equipment and medication, designed for rapid deployment during medical emergencies) to Resident #1's room. Nurse #1 said he went back to Resident #1's room and started CPR on him/her. Nurse #1 said while he was doing CPR on Resident #1 another resident came into the room, tried to touch Resident #1's body so he stopped performing CPR to redirect the resident out of the room. Nurse #1 said he had not called a Code Blue, had not called 911 and had not directed one of the CNAs to do so prior to starting CPR on Resident #1. Nurse #1 said he knew what the Facility's policies were for calling a Code Blue and administering CPR. Nurse #1 said you are not supposed to stop CPR once you start and have to wait for Emergency Medical Services (EMS) or other staff to arrive.Nurse #1 said he sent a text message to the Director of Nursing (DON) informing her that Resident #1 had passed away. Nurse #1 said he called the DON because he realized that he had messed up by not calling a Code Blue and 911 before starting CPR on Resident #1.Further Review of Resident #1's Medical Record indicated that, although Nurse #1 asked Nurse #2 to do an RN Pronouncement there was no documentation to support that Nurse #1 spoke with the Physician to obtain an order for the RN Pronouncement.During an in-person interview on [DATE] at 4:13 P.M. and a telephone interview on [DATE] at 10:22 A.M., the Director of Nursing (DON) said when Nurse #1 found Resident #1 unresponsive and not breathing, Nurse #1 should have made sure a called Code Blue was called so that there would have been other staff member respond to assist him. The DON said Nurse #1 could not process what to do and had not followed the Facility's policies for calling a Code Blue and performing CPR. The DON said it is her expectation that all nurses follow the Facility's Policies and process.On [DATE], the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction with an effective date of [DATE], which addressed the area(s) of concern as evidenced by:A. On [DATE] Nurse #1 was suspended pending investigation.B. On [DATE], the Administrator conducted a Root Cause Analysis to determine why the staff member (Nurse #1) had not followed protocol to perform CPR or call a Code Blue, or 911 per the Facility's policies.C. On [DATE], the Nursing Administration conducted a Facility wide audit on all residents' Advanced Directives to verify that resident's code status documentation was present, current and readily accessible in the medical record.D. On [DATE], the Human Resource Director conducted an audit on all Licensed Nursing staff to determine their Basic Life Support (BLS)/CPR certifications were current.E. On [DATE], Nursing Administration conducted an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting to discuss the Facility's Improvement Plan.F. On [DATE], Nursing Administration provided education to all Licensed Nursing staff and Certified Nurse Aides on the Facility's Policies and Procedures for Emergency Code Activation, Code Blue Response, Change of Notification and AED (Automated Electronic Defibrillator) use.G. Nursing Administration staff conducted Mock Code Blue drills on all shifts for 72 hours ([DATE] through [DATE]) after the incident on [DATE], to reinforce appropriate emergency procedures.H. Nursing Administration staff will continue to conduct Mock Code Blue drills weekly for four weeks and then monthly for four months. I. The results of the Mock Code Blue drills will be presented and reviewed at the monthly QAPI meeting for a minimum of four months or until substantial compliance is achieved.J. The Director of Nursing and/or designee are responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was found unresponsive by nursing staff and whose Physician's orders indicated he/she was a full code (in the event of cardiac or respiratory arrest, attempts at resuscitation will be initiated), the Facility failed to ensure nursing staff provided appropriate and necessary basic life saving measures to him/her that were consistent with his/her Advanced Directives and Physician orders. Findings include:Review of the Facility's Policy titled, Code Blue, dated as revised 4/2022, indicated the following:-residents/victims found to be unresponsive or who becomes unresponsive under observation, staff will call a Code Blue and code Blue will be paged overhead two times, the page will include the unit, location, and room number.-the nurse who is the first responder to the situation will determine the code status, lead the code, and remain with the patient throughout the code.-for a Full Code patient/victim: upon arrival to the scene the nursing staff will assess victims who are unconscious, not breathing normally and showing no sign of circulation, such as normal breathing, coughing, and movement and if the victim is noted to have neither pulse nor respiration, the staff will initiate CPR.Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, titled Nursing Practice and Cardio-Pulmonary Resuscitation (CPR), revised [DATE], indicated that to guide the decision making of the nurse, in context of practice in all settings where healthcare is delivered require initiating cardio-pulmonary resuscitation when a patient has been found unresponsive and has not yet been declared dead by a provider authorized pursuant to M.G.L c. 469 except when a patient has a current valid Do Not Resuscitate (DNR) order/status.Review of the Report submitted by the facility, via the Health Care Facility Reporting Systems (HCFRS), dated [DATE], indicated on [DATE] around 5:00 A.M., Resident #1 was found unresponsive by staff, Nurse A (identified as Nurse #1) initiated CPR and CPR was discontinued prior to notifying Resident #1's Physician. The Report indicated that Nurse B (identified as Nurse #2) was contacted by Nurse A (Nurse #1) to complete an RN Pronouncement on Resident #1 and the pronouncement was completed at approximately 5:20 A.M by Nurse B (Nurse #2). The Report further indicated that Nurse A (Nurse #1) did not follow the Facility's policies related to Code Blue, Emergency Code activation, change of condition notification and AED utilization.Resident #1 was admitted to the Facility in [DATE], diagnoses included dementia, Alzheimer's, adult failure to thrive, osteomyelitis of right ankle and foot, hyperlipidemia (high cholesterol), anxiety, severe protein-calorie malnutrition, and pressure ulcers (right heel, left heel and sacral region.Review of Resident #1's Medical Orders for Life Sustaining Treatment (MOLST) Form, dated [DATE], indicated he/she was elected to be a Full Code, for nursing to attempt resuscitation (administer CPR).Review of Resident #1's Physician's Order, dated [DATE], indicated he/she was a Full Code. Review of Resident #1's Progress Note, dated [DATE], (written by Nurse #1) indicated that around 5:00 A.M., he was notified by a CNA that there was a resident unresponsive (identified as Resident #1). The Note indicated Nurse #1 observed Resident #1 lying in bed, unresponsive to verbal and tactile stimuli, had no response to sternal rub, he/she was not breathing, had no pulse and was cold to the touch and stiff. The Note indicated Nurse #1 verified Resident #1's code status, (which was a full code) and proceeded to give CPR. The Note indicated that during the incident another resident was in and out of Resident #1's room, became aggressive and Nurse #1 terminated CPR on Resident #1. The Note further indicated a Registered Nurse (later identified as Nurse #2) was notified of Resident #1's death.During an interview on [DATE] at 12:49 P.M., Nurse #1 said around 5:00 A.M. CNA #2 called for him to go to Resident #1's room. Nurse #1 said when he entered the room, Resident #1 was lying in bed on his/her back, he/she was unresponsive, not breathing, had no pulse and his/her body was cold to the touch and stiff. Nurse #1 said he checked Resident #1's code status, verified he/she was a full code, and he asked CNA #2 to bring the crash cart (mobile cart stocked with life-saving equipment and medication, designed for rapid deployment during medical emergencies) to Resident #1's room. Nurse #1 said he went back to Resident #1's room and started CPR on him/her. Nurse #1 said while he was doing CPR on Resident #1 another resident came into the room. Nurse #1 said he stopped performing CPR on Resident #1 because he needed to redirect the resident out of the room. Nurse #1 said after he had redirected the other resident, he went to another unit and asked Nurse #2 to do an RN Pronouncement on Resident #1.Nurse #1 said he had not called a Code Blue, had not called 911, and had not told one of the CNAs to do so prior to starting CPR on Resident #1 by himself. Nurse #1 said he did not have another staff member helping him while he was performing CPR. Nurse #1 said he started and stopped performing CPR on Resident #1, that night. Nurse #1 was unable say how long he had attempted to perform CPR on Resident #1 before deciding to stop. Nurse #1 said he knew that he was not supposed to stop CPR once it's started and needed to wait for Emergency Medical Services (EMS) or other staff to arrive.During an interview on [DATE] at 3:39 P.M., (which included review of her written statement), Certified Nurse Aide (CNA) #1 said she worked the 11:00 P.M. to 7:00 A.M. (night shift) on [DATE] into [DATE] on Resident #1's unit. CNA #1 said around 4:45 A.M. during rounds she checked on Resident #1, he/she was in bed lying on his/her back, his/her eyes were half open, and he/she did not look good. CNA #1 said CNA #2 went to get Nurse #1 and that Nurse #1 came right away. CNA #1 said that Nurse #1 did not instruct her to call a Code Blue or 911.During an interview on [DATE] at 1:25 P.M., (which included review of her written statement), Certified Nurse Aide (CNA) #2 said on [DATE] around 4:45 A.M. CNA #1 asked her to take a look at Resident #1. CNA #2 said she went and looked at Resident #1, he/she did not look well and said she told Nurse #1 that Resident #1 looked like he/she was dead. CNA #2 said Nurse #1 only asked her to get the crash cart and bring it to Resident #1's room.During an interview on [DATE] at 3:04 P.M., (which included review of her written statement), Nurse #2 said on [DATE] sometime after 5:00 A.M. Nurse #1 informed her that Resident #1 was deceased and asked her (Nurse #2) to do an RN Pronouncement on him/her. Nurse #2 said she assessed Resident #1 and pronounced him/her deceased at 5:15 A.M. Nurse #2 said she thought Resident #1's code status was a Do Not Resuscitate (DNR) because she had not heard anyone call a Code Blue that morning. Nurse #2 said that Nurse #1 never told her that he had started and stopped CPR on Resident #1.During an in-person interview on [DATE] at 4:13 P.M. and a telephone interview on [DATE] at 10:22 A.M., the Director of Nursing (DON) said on [DATE] Nurse #1 notified her that Resident #1 had passed away and that Nurse #2 had done the RN Pronouncement. The DON said she asked Nurse #1 what Resident #1's code status was, and Nurse #1 told her he/she was a full code. The DON said she asked Nurse #1 if he had called a Code Blue, called 911 and if he started CPR. The DON said Nurse #1 told her that he had not called a Code Blue. The DON said Nurse #1 said he had started CPR on Resident #1 then stopped because another resident had become problematic for the CNAs and he had to help them.The DON said when Nurse #1 found Resident #1 unresponsive and not breathing, he should have called Code Blue to have other staff arrive to assist him and should have had a staff member call 911, so EMS could respond. The DON said Nurse #1 could not process what to do and had not followed the Facility's policies for performing CPR. On [DATE], the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction with an effective date of [DATE], which addressed the area(s) of concern as evidenced by:A. On [DATE] Nurse #1 was suspended pending investigation.B. On [DATE], the Administrator conducted a Root Cause Analysis to determine why the staff member (Nurse #1) had not followed protocol to perform CPR or call a Code Blue, or 911 per the Facility's policies.C. On [DATE], the Nursing Administration conducted a Facility wide audit on all residents' Advanced Directives to verify that resident's code status documentation was present, current and readily accessible in the medical record.D. On [DATE], the Human Resource Director conducted an audit on all Licensed Nursing staff to determine their Basic Life Support (BLS)/CPR certifications were current.E. On [DATE], Nursing Administration conducted an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting to discuss the Facility's Improvement Plan.F. On [DATE], Nursing Administration provided education to all Licensed Nursing staff and Certified Nurse Aides on the Facility's Policies and Procedures for Emergency Code Activation, Code Blue Response, Change of Notification and AED (Automated Electronic Defibrillator) use.G. Nursing Administration staff conducted Mock Code Blue drills on all shifts for 72 hours ([DATE] through [DATE]) after the incident on [DATE], to reinforce appropriate emergency procedures.H. Nursing Administration staff will continue to conduct Mock Code Blue drills weekly for four weeks and then monthly for four months. I. The results of the Mock Code Blue drills will be presented and reviewed at the monthly QAPI meeting for a minimum of four months or until substantial compliance is achieved.J. The Director of Nursing and/or designee are responsible for overall compliance.

Based on record review and interview, the facility failed to provide care and services consistent with professional standards of practice for one Resident (#11) who required hemodialysis (a life sustaining treatment that helps the body remove extra fluids and waste products from the blood when the kidneys are not able to), out of a total sample of 17 residents. Specifically, the facility failed:a. To ensure nursing staff did not obtain blood pressures from the Resident's right arm, where his/her AV fistula (arteriovenous fistula, where an artery and vein connect directly, allowing blood to flow) used for hemodialysis access was located; andb. To obtain and implement physician's orders for the care and maintenance of the Resident's hemodialysis catheter (a surgically placed catheter connected to a central vein that exits the skin and attaches to the tubing on the dialysis machine) upon his/her return from the hospital.Findings include:Review of the facility's policy titled Care of a Resident with End-Stage Renal Disease, revised 4/2022, indicated, but was not limited to, the following:-Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care.-Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents.-Education and training of staff include, specifically:g. The care of grafts and fistulas-Agreements between this facility and the contracted dialysis facility include all aspects of how the resident's care will be managed, including:a. How the care plan will be developed and implemented-The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care.Resident #11 was admitted to the facility in July 2025 with diagnoses including end stage renal disease.Review of Resident #11's Minimum Data Set (MDS) assessment, dated 10/9/25, indicated the Resident was cognitively intact, as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Further review of the MDS assessment indicated the Resident received dialysis treatment.a. Review of Resident #11's Physician's Orders indicated, but was not limited to, the following:-Dialysis: [Dialysis-Center Name Redacted] Days: Mon-Wed-Fri Chair time: 12-4p every day shift every Mon, Wed, Fri for Dialysis (7/8/25)-Monitor and document thrill/bruit of RUE (right upper extremity) dialysis/fistula QS (every shift) (7/8/25)-Monitor Dialysis access site RUE dressing every shift (7/8/25)-No blood pressure/blood draws to be taken on right upper extremity every shift for dialysis/fistula (7/8/25)Review of Resident #11's Care Plans indicated, but was not limited to, the following:-Focus: The resident needs hemodialysis r/t (related to) ESRD (initiated 7/7/25)-Interventions: *Do not draw blood or take B/P (blood pressure) in arm with graft. (initiated 7/7/25)*Protect access site from injury. Site: RUE; Avoid constriction on affected arm, such as carrying purse and constrictive clothing. No BP on limb with fistula. (initiated 7/7/25)Review of Resident #11's Weights and Vitals Summary indicated the Resident's blood pressure was taken in his/her right arm on 21 occasions since the physician's order for no blood pressure in the arm with graft was initiated on 7/7/25. During an interview on 12/3/25 at 9:25 A.M., Nurse #4 said there was a physician's order in place for no blood pressure or lab draws in the Resident's right upper extremity because of the fistula and that only the left side should be used for these tasks.During an interview on 12/3/25 at 9:36 A.M., the Director of Nursing (DON) said if an order is in place for no blood pressure or lab draws on Resident #11's right upper extremity, staff should not be taking blood pressures on the Resident's right arm. b. Review of Resident #11's Progress Notes indicated, but was not limited to, the following:-11/25/25 at 7:48 P.M.: Patient sent out to [hospital] from dialysis center r/t clogged fistula. Dialysis not performed. Dialysis scheduled for tomorrow. Dialysis center will call for pick up time. Blood pressure recorded at [hospital] 133/78. Returned to facility at 7:50 P.M.-11/26/25 at 10:14 P.M.: Resident left the facility via Uber to dialysis at 1030. Dialysis unable to access fistula sent patient to [hospital] for further evaluation. This nurse contacted patient at 7 pm via his/her mobile phone. Resident stated that he/she was about to receive dialysis tx (treatment) and that a ride to return to the facility was arranged by the Hospital.-11/28/25 at 11:08 P.M.: Patient returned from dialysis. No new recommendations noted. Vital signs stable. Patient stable. Safety maintained. Review of Resident #11's hospital After Visit Summary, dated 11/26/25, indicated, but was not limited to, the following:-Reason for visit: Vascular Access Problem-Diagnoses: Thrombosis of arteriovenous fistula, hemodialysis patientIncluded with Resident #11's 11/26/25 After Visit Summary was a Bedside Handoff Post-Procedure document, noting the Resident had a 23-centimeter-long tunneled catheter. Also included was the Patient Implant Card, indicating a Bard Access System Hemostar Long-Term Hemodialysis Catheter had been placed.Review of Resident #11's medical record failed to indicate physician's orders were obtained for care and maintenance of the Resident's hemodialysis catheter until 12/2/25. During an interview with observation on 12/1/25 at 10:05 A.M., Resident #11 said he/she has a right upper arm AV fistula for dialysis. The Resident showed the surveyor a gauze dressing secured with a transparent dressing over top on his/her right upper arm and indicated that was where his/her AV fistula was located. The Resident said he/she also had a catheter in his/her right chest that was placed at the hospital the week before because his/her AV fistula was clotted. Resident #11 said the dialysis center is now using the chest catheter for his/her dialysis access. The Resident showed the surveyor a dual-lumen catheter on his/her right chest with a dressing in place. The Resident said staff at the facility had not done anything with the dressing on his/her right arm or right chest since he/she returned from the hospital 11/26/25.During an interview on 12/2/25 at 12:39 P.M., the DON said no new physician's orders were in place for care and maintenance of Resident #11's hemodialysis catheter because he/she returned from the hospital 11/26/25 with limited paperwork and the facility's Admissions Director was not present until 12/2/25 to pull additional documentation from the hospital's electronic system. During an interview on 12/3/25 at 9:25 A.M., Nurse #4 said Resident #11 had been having trouble with the dialysis access in his/her right arm and had been recently sent to the hospital because the dialysis center was unable to use the access for treatment. Nurse #4 said the Resident returned from the hospital the week prior with a chest catheter in place.

Based on observation, interview, and record review, the facility failed to ensure residents were provided care in accordance with professional standards of practice for two Residents (#95, #5), out of a total sample of 17 residents. Specifically, the facility failed:1. For Resident #95, to ensure administration of antipsychotic and psychotropic medications were properly documented in the Resident's medical record; and2. For Resident #5, to ensure physician's orders were in place for the provision of Hospice services. Review of [NAME], Manual of Nursing Practice 11ed, dated 2019, indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. -In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber. Review of Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered nurse and Practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. 1. Resident #95 was admitted to the facility in March 2021 with diagnoses including dementia, delusional disorders, and depression. Review of Resident #95's Minimum Data Set (MDS) assessment, dated 9/11/25, indicated he/she was cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of 15. Furthermore, the MDS assessment indicated he/she was administered antipsychotic and antidepressant medications on a routine basis. Review of Resident #95's Physician's Orders indicated but were not limited to the following: - 2/15/23: Duloxetine (antidepressant) HCl Oral Capsule Delayed Release Sprinkle 20 milligrams (MG); give one capsule by mouth two times a day; and - 4/29/25: Risperidone (antipsychotic) Oral Tablet 0.25 MG; give one tablet by mouth two times a day Review of Resident #95's psychotropic drug care plan, initiated 8/1/22, indicated but was not limited to the following interventions: - Administer medications per physician order. Review of Resident #95's Medication Administration Record (MAR) for September 2025 indicated but was not limited to the following: - Risperidone 0.25MG Oral Tablet: six missing administrations - Duloxetine 20MG Oral Tablet: six missing administrations Review of Resident #95's MAR for October 2025 indicated but was not limited to the following: - Risperidone 0.25MG Oral Tablet: nine missing administrations - Duloxetine 20MG Oral Tablet: nine missing administrations Review of Resident #95's MAR for November 2025 indicated but was not limited to the following: - Risperidone 0.25MG Oral Tablet: 12 missing administrations - Duloxetine 20MG Oral Tablet: 12 missing administrations Review of Resident #95's medical record failed to indicate documentation related to the blank/missing administrations on the MAR. Furthermore, the medical record failed to indicate documentation related to the refusal of medications. During an interview on 12/3/25 at 8:28 A.M., Nurse #3 said all medications are checked off on the MAR as they are being administered to the residents. Nurse #3 said if a resident refuses a medication or a nurse is unable to administer a medication it can be documented on the MAR as such. Nurse #3 said there should not be any blanks on the MAR and if medication is not administered it should always be documented in the record. During an interview on 12/3/25 at 8:40 A.M., the Director of Nursing (DON) said all medications should be signed off on the MAR in real time during a nurse's medication pass. The DON said if a medication is not administered it should be documented in the MAR and/or medical record as to the reasoning. The DON and the surveyor reviewed Resident #95's MAR. The DON said there should not be any blank spots on Resident #95's MAR. 2. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling #9324, titled Accepting, Verifying, Transcribing and Implementing Orders, dated as last revised 4/11/2018, indicated but was not limited to the following: - It is the responsibility of the licensed nurse to ensure there is a proper patient care order from a duly authorized prescriber prior to the administration of any prescription or non-prescription medication or activity that requires which order in accordance with accepted standard of practice and in compliance with the Boards regulations. - Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. - The nurse is accountable for ensuring that any orders he or she implements are reasonable based on the nurse's knowledge of that particular patient's care. -It is the responsibility and obligation of the nurse to question a patient care order that is deemed inappropriate by a nurse according to his/her educational preparation and clinical experience. Resident #5 was admitted to the facility in August 2025 and had diagnoses including Alzheimer's disease and dementia with behavioral disturbance. Review of the MDS assessment, dated 8/25/25, indicated Resident #5 had severe cognitive impairment as evidenced by a BIMS score of 1 out of 15, and required partial/moderate assistance from staff for activities of daily living. Review of the medical record indicated Certification of Terminal Illness, admission documents, a Plan of Care Summary and visit documentation from the facility's contracted Hospice provider with services commencing on 10/16/25. Review of comprehensive care plans included, but was not limited to: -Focus: Resident is receiving Hospice related end stage dementia (10/16/25) -Approach: Allow and encourage resident to eat at own leisure (10/16/25); Discontinue all unnecessary medications per physician's order (10/16/25); End of Life and is on comfort measures (10/16/25); Hospice/Palliative and facility team to review the plan of care to ensure integration (10/16/25); Monitor for signs and symptoms of discomfort (10/16/25) -Goal: Resident will remain comfortable through end of life with necessary support needed through next review (10/16/25; Target Date: 5/18/26) Further review of the medical record failed to indicate a physician's order was obtained for the provision of Hospice services. During an interview on 12/2/25 at 9:36 A.M., Unit Manager #1 reviewed Resident #5's medical record and said there was not a physician's order to screen and admit the Resident for Hospice services but there should be an order. During an interview on 12/3/25 at 1:45 P.M., the DON said residents receiving Hospice services must have a physician's order.

Based on observation and interview, the facility failed to ensure that medications were labeled and stored in accordance with accepted professional principles. Specifically, the facility failed:1. For Resident #121, to ensure the Resident's Insulin Lispro (a fast-acting insulin used to manage blood sugar levels) 100 units/milliliter (u/ml) Kwikpen was labeled with the date opened; and2. To ensure an open Lantus Solostar (a long-acting insulin used to manage blood sugar levels) insulin pen was labeled with a resident's name; and3. To ensure two bottles of Acidophilus (a probiotic over-the-counter medication) were stored in the refrigerator after opening as indicated by the manufacturer's label in two of three medication carts inspected.Findings include: Review of the facility's policy titled Medication Storage, revised 3/2022, indicated, but was not limited to, the following:-The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner.-The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals.-Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location.1. Resident #121 was admitted to the facility in November 2025 with diagnoses including diabetes. Review of Resident #121's Physician's Orders indicated, but was not limited to, the following:-Insulin Lispro 100 u/ml - Inject subcutaneously before meals as per sliding scaleReview of Resident #121's Medication Administration Record (MAR) indicated Resident #121 had received Lispro sliding scale insulin daily since admission.On 12/1/25 at 3:12 P.M., the surveyor observed an open Insulin Lispro 100 u/ml Kwikpen for Resident #121 in the Arborview Unit B-Side medication cart. The Insulin Lispro Kwikpen was not labeled with the date opened. Per manufacturer's instructions, the Insulin Lispro Kwikpen should not be used for more than 28 days after opening.During an interview on 12/1/25 at 3:24 P.M., Nurse #5 said insulin pens should be labeled with the date opened and/or use by date.During an interview on 12/2/25 at 11:07 A.M., the Director of Nursing (DON) said all insulin pens should be labeled with the date opened and the use-by date.2. On 12/1/25 at 3:12 P.M., the surveyor observed an open Lantus Solostar insulin pen in the Arborview Unit B-Side medication cart with no patient name label. Per manufacturer's instructions, Lantus Solostar is a disposable single-patient-use prefilled insulin pen and should not be shared.During an interview on 12/1/25 at 3:24 P.M., Nurse #5 said insulin pens should be labeled with a resident's name.During an interview on 12/2/25 at 11:07 A.M., the DON said all insulin pens should be labeled with a resident's name.3. On 12/1/25 at 3:12 P.M., the surveyor observed an open bottle of Acidophilus in the Arborview Unit B-Side medication cart.On 12/1/25 at 3:43 P.M., the surveyor observed an open bottle of Acidophilus in the Bayview Unit A-Side medication cart. Per manufacturer's instructions, Acidophilus should be stored in the refrigerator once opened. During an interview on 12/1/25 at 3:24 P.M., Nurse #5 said she did not know the bottle of Acidophilus in the Arborview Unit B-Side medication cart required refrigeration. Nurse #5 said in the past, the facility had used a type of Acidophilus that did not require refrigeration after opening.During an interview on 12/2/25 at 11:07 A.M., the DON said the facility had switched to ordering a non-refrigerated brand of Acidophilus and she was unaware that the staff member maintaining the facility's central supply had been ordering a brand requiring refrigeration.

Based on record review and interviews, the facility failed to review and revise the care plan for one Resident (#5), out of a total sample of 17 residents. Specifically, the facility failed to ensure the care plan for disposition was revised to reflect the Resident Representative's decision for the Resident to remain in the facility for long term care. Findings include:Review of the facility's policy titled Comprehensive Care Plans, last revised 4/2022, indicated but was not limited to:-The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.-The comprehensive, person-centered care plan will include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire.-Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.Resident #5 was admitted to the facility in August 2025 and had diagnoses including Alzheimer's disease and dementia with behavioral disturbance.Review of the comprehensive Minimum Data Set (MDS) assessment, dated 8/25/25, indicated Resident #5 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 1 out of 15, wished to be discharged to the community and had an activated Health Care Proxy (health care agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions).Review of comprehensive care plans included, but was not limited to:-Focus: Disposition: Plans to discharge to community (8/8/25)-Approach: Allow Resident and health care representative to express goals and any barriers that are concerning my safety for a safe discharge (8/8/25); Make the appropriate referrals to the community for me (8/8/25); Appropriately assist me with discharge planning (8/8/25)Goal: Resident and health care representative will participate in discharge planning prior to discharge through next review (8/8/25; Target date: 5/18/26)Review of a Social Services Note, dated 9/9/25, indicated the facility Social Worker met with Resident #5's Health Care Proxy who indicated he was unable to care for the Resident at home and wanted Resident #5 to remain at the facility for long term care.Review of interdisciplinary care plan meeting documentation indicated a care plan meeting was held on 11/18/25 without a revision to the care plan to reflect the change in disposition status to long term care.During an interview with Social Worker #1 and Unit Manager #1 on 12/2/25 at 9:40 A.M., they said the disposition care plan should have been revised to reflect the change to long term care at the care plan meeting held on 11/18/25 if not sooner and was not.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure he/she was treated in a dignified and respectful manner by a staff member when 07/27/25, Certified Nurse Aide (CNA) #1 teased Resident #1 and sat on his/her lap. Findings include:Review of the Facility Policy titled Resident Rights, dated as revised April 2022, indicated that employees shall treat all residents with kindness, respect, and dignity. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS) dated 07/28/25, indicated that Resident #1's family (Family Member #1) was concerned with CNA #1's interaction with Resident #1, and that Family Member #1 thought his (CNA #1) behavior was bizarre in nature. During an interview on 08/28/25 at 7:22 A.M., Family Member #1 said she went to the Facility to visit Resident #1 and did not see him/her in his/her room, but could hear Resident #1 yelling, don't! Family Member #1 said she followed Resident #1's voice to Resident #2's room, opened the door, and saw CNA #1 sitting on Resident #1's lap. Family Member #1 said Resident #1 was upset and ran to her (Family Member #1). Family Member #1 said that CNA #1 and CNA #2 followed her and Resident #1 back to Resident #1's room, where CNA #1 apologized and said it was a joke. Review of the Facility's Internal Investigation Report Summary, undated, indicated that on 07/27/25, Resident #1 followed CNA #1 and CNA #2 into Resident #2's room. The Summary indicated that while Resident #1 was seated on an unoccupied bed in Resident #2's room, CNA #1 briefly engaged Resident #1 in a lighthearted interaction in an apparent attempt to redirect and comfort him/her. The Summary indicated that during this exchange, Family Member #1 arrived and misinterpreted CNA #1's behavior as inappropriate, specifically noting that it appeared that CNA #1 was sitting on Resident #1's lap. Resident #1 was admitted to the Facility in March 2024, diagnoses included dementia and psychotic disorder with delusions. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 06/05/25, indicated that Resident #1 had severe cognitive impairment, was independent with ambulation, and dependent on staff for self-care. During an interview on 08/28/25 at 3:01 P.M. (which included a review of his Written Witness Statement, dated 07/28/25), CNA #2 said that Resident #1 followed him and CNA #1 into Resident #2's room, and sat on an unoccupied bed. CNA #2 said CNA #1 joked around with Resident #1 and bent forward to sit on his/her lap. CNA #2 said that Resident #1 yelled each time CNA #1 moved to sit on his/her lap. CNA #2 said that CNA #1 moved to sit on Resident #1's lap three times, and after each time he/she told him (CNA #1) to stop, but he did not. CNA #2 said that Family Member #1 walked into Resident #2's room and asked why CNA #1 was sitting on Resident #1's lap. During an interview on 08/28/25 at 12:48 P.M. (which included a review of his undated Written Witness Statement), Nurse #1 said that Family Member #1 reported to him that she went room to room looking for Resident #1 and could hear him/her screaming from behind Resident #2's room door. Nurse #1 said that Family Member #1 told him that when she opened the door, she saw Resident #1 in Resident #2's room and was upset because she saw CNA #1 sitting on Resident #1's lap. During an interview on 08/28/25 at 3:19 P.M., the Director of Nurses (DON) said that during her investigation, CNA #2 told her that Resident #1 followed him and CNA #1 into Resident #2's room where he/she sat on an unoccupied bed. The DON said that CNA #2 told her that CNA #1 was pretending to sit on Resident #1's lap and that when Family Member #1 opened the door to Resident #2's room, she became very upset and said, what if this was your parent? The DON said that she suspended CNA #1 and CNA #2 pending an internal investigation and then determined that this incident was a customer service and professionalism issue.

Based on observation and interview, the facility failed to ensure the residents' environment was clean, comfortable, and homelike. Specifically, the facility failed to ensure the residents' rooms and environment were maintained in good repair and homelike on two (Bayview and Cranview) of three resident care units. Findings include: Review of the facility's policy titled Accommodation of Needs and Preferences and Homelike Environment, dated as last revised 4/20/22, indicated but was not limited to the following: -Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas, and activity areas. -Orderly is defined as an uncluttered physical environment that is neat and well-kept. -The resident's environment will be maintained in a homelike manner to ensure appropriate housekeeping, clean linens in good repair, private closet space for each resident. Between 8/7/24-8/8/24, the surveyor observed the following on the Bayview unit: -The entrance to the Bayview unit had unpainted areas near the baseboard and the door and molding were chipped and discolored. -The breakfast dining room on Bayview had pieces of wood floor approximately eight to ten inches chipped and missing, the baseboard heating unit was missing the top cover, was bent and appeared in disrepair. The wall had an approximately four-foot scuff visible on the wall. -room [ROOM NUMBER]: The television cable and power plug were hanging from the television unplugged on the floor. The walls had oily drip marks over the walls on both resident sides, in addition to scuff marks and chipped paint. -room [ROOM NUMBER]: The thermostat was broken with internal wires exposed; the bathroom had a soap dispenser sized area unpainted with multiple layers of wall exposed. The heating unit in the room was observed to be dirty and discolored. -room [ROOM NUMBER]: The blinds for the window were broken, the corner of the wall was dented with parts of the molding lifting. -room [ROOM NUMBER]: The molding on the floor connecting the hallway and the resident room was broken and exposed cracked tiles. The blind on the window was broken. -room [ROOM NUMBER]: Five ceiling tiles were discolored from water stains, there was a crack in the window glass. -room [ROOM NUMBER]: The wall had holes, scuffs, and a large unpainted area. -room [ROOM NUMBER]: The ceiling tile had a discolored water stain visible. -room [ROOM NUMBER]: The thermostat was broken exposing the internal parts including wires. The closet was missing doors. -room [ROOM NUMBER]: The heating unit was discolored and cracked. The closet was missing doors. -room [ROOM NUMBER]: The room had a large black scuff on the wall about four feet in width. The closet doors were not attached and leaning against the closet. -room [ROOM NUMBER]: The ceiling tile had a discolored water stain visible. -room [ROOM NUMBER]: The bottom of the wall near the bathroom was missing molding, scratched, and discolored. -room [ROOM NUMBER]: The ceiling tile had two discolored water stains visible. -room [ROOM NUMBER]: The wall had multiple areas of unpainted areas visible, missing molding, and the heating unit appeared dirty, and the cover was on the ground. -room [ROOM NUMBER]: The wall had broken molding on the bottom of the wall exposing wood. -room [ROOM NUMBER]: The wall had holes visible and broken molding that was lifting from the wall. -room [ROOM NUMBER]: The wall had an area visible where the painting was cracked and peeling. The ceiling tiles had two discolored water stains. There was an area of the wall that was peeling. There was an area of molding missing and plaster was crumbled at the bottom of the wall with an unpainted area and wood exposed. On 8/12/24 at 1:00 P.M., the surveyor observed the following on the Cranview Unit: -The residents' shower room had a hole of approximately 12 inches wide on the corner of the wall with pieces of the inner plaster crumbled and a wood stud being exposed. -room [ROOM NUMBER]: The room was dirty with dozens of pieces of trash on the floor, the blind was broken, the headboard and footboard were broken. The dresser drawer was also broken. -The hallway window was cracked, and the screen frayed with a five-inch hole in the screen exposed. During an interview on 8/7/24 at 12:14 P.M., Resident #56's Representative said she wished the building looked better. She said the rooms were in disrepair and the bathrooms were gross. She said there are holes and scratches in the rooms and dining areas. She said the appearance of the unit's upstairs is depressing. During an interview on 8/7/24 at 2:43 P.M., the family member of a resident on Bayview said she was surprised by the environment and how much work was needed compared to the first floor. During an interview on 8/12/24 at 2:56 PM., Resident #75's Representative said the place has not had a lot of attention cosmetically since she had been visiting the Resident for a few months. During an observation with an interview on 8/12/24 at 3:12 P.M., the Regional Plant Manager said there was a gap of about three weeks where the building did not have a full time Maintenance Director. He said at that time he and another building's maintenance director were covering and attending to emergent issues that arose. He said the issues appeared to have been neglected for more than three weeks and his expectation is that all the issues identified would be fixed and walls painted. He said he would expect the wall to be repaired and paint to match. During an interview on 8/12/24 at 3:20 P.M., the Administrator said she has hired a maintenance director, and her expectation is that all these identified concerns are fixed and that he is rounding to ensure issues are identified quickly and responded to. She said during her lapse in coverage preventative maintenance was not being done.

Based on observation, record review, and staff interview, the facility failed to ensure food was stored, in accordance with professional standards. Specifically, the facility failed to ensure 2 out of 3 kitchenettes were maintained in a sanitary manner to store food. Findings include: Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: -A permanent temperature measuring device is required in any unit storing time/temperature control for safety food because of the potential growth of pathogenic microorganisms should the temperature of the unit exceed Code requirements. In order to facilitate routine monitoring of the unit, the device must be clearly visible. 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; On 8/8/24 at 11:25 A.M., the surveyor observed the following in the Bayview kitchenette with the Unit Manager: -August 2024 refrigerator temperature log did not include a place to document temperatures for the freezer and none had been recorded between 8/1/24 and 8/8/24. The surveyor and Unit Manager observed the freezer full of small individual ice creams. The Unit Manager had to move multiple ice creams to find the thermometer which was observed covered in ice particles. -the surveyor and Unit Manager observed the counter drawers in the kitchenette to have a sticky substance when attempting to open them. One of the drawers had a brown sticky substance inside the drawer and on condiment packets. -the surveyor observed a baseball sized tin foil in the cabinet. The Unit Manager opened the tin foil and revealed a hamburger on a bun. The Unit Manager said she did not know who this belonged to and it was not made by the facility. - the surveyor observed an open, undated when opened, bottle of ranch dressing in a cabinet. The bottle indicated it should be refrigerated after opening. The expiration year on the bottle had been torn on the label and unable to read. During an interview on 8/8/24 at 11:25 A.M., Unit Manager #2 said she was not sure who was responsible for cleaning the cabinets, drawers or handles in the kitchenette. She said the cheeseburger and the ranch dressing should not have been kept in the cabinets. 15214 On 8/8/24 at 8:43 A.M., the surveyor observed the following in the Cranview Unit nourishment kitchen: - The freezer had a significant amount of frost built up throughout all surfaces. The freezer contained multiple individual portion sized cups of ice cream. The ice cream containers were coated with frost and soft when squeezed. Additionally, there was a half-gallon sized container of ice cream that was also soft. - There was no thermometer in the freezer, and no log for monitoring freezer temperatures. During an interview on 8/8/24 at 2:00 P.M., the Food Service Director (FSD) said that frozen items in the freezer should not be soft. She also said that the freezer temperatures should be monitored/recorded and acknowledged that there was no thermometer in the Cranview Unit freezer. The FSD said that food quality and safety can be affected by improper temperatures.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections for five Residents (#24, #19, #82, #16, and #57). Specifically, the facility failed: 1. For Resident #24, to ensure staff wore personal protective equipment (PPE) as required for Isolation/Droplet Precautions (infection control precautions used for residents who are infected with certain infectious agents including COVID-19 for which additional precautions are needed to prevent infection transmission) while entering the room for medication administration; 2. For Residents #19 and #82, to ensure staff wore PPE as required for Isolation/Droplet Precautions while entering the room and providing morning coffee/snack and daily activity Chronicle; 3. For Resident #16, to ensure staff wore PPE as required for Contact Precautions (infection control precautions used for patients who may be infected with certain infectious agents for which additional precautions are needed to prevent infection transmission) while entering the room to provide housekeeping services; and 4. For Resident #57, to ensure staff wore PPE as required for Contact Precautions while entering the room to provide housekeeping services. Findings include: Review of the facility's policy titled Isolation: Categories of Transmission Based Precautions, dated as last revised 2/2024, indicated but was not limited to the following: -Standard Precautions shall be used when caring for residents at all times regardless of their suspected or confirmed infection status. Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. -Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent or control the spread of infection. -Based on Center for Disease Control (CDC) definitions, three types of Transmission-Based Precautions (airborne, droplet, and contact) have been established. DROPLET PRECAUTIONS: -In addition to Standard Precautions, implement droplet precautions for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large particles (larger than 5 microns) that can be generated by the individual coughing, sneezing, and talking). -Examples of infections requiring Droplet Precautions include but are not limited to COVID-19. -Resident Placement: private room if possible, residents with the same infection may be cohorted, if private room is not achievable, use a curtain and maintain at least three feet of space between the infected resident and other residents. -Masks to be used when entering the room. -Eye protection to be used when entering the room. -Resident Care Equipment: when possible, dedicate the use of equipment to avoid sharing between residents. If use of common items is unavoidable, then adequately clean and disinfect them before use for another resident. -Signs: The facility will implement a system to alert staff and visitors to the type of precaution the resident requires. -The facility will also ensure that the resident's care plan and care specialist communication system indicated the type of precautions implemented for the resident. Review of the RED Isolation/Droplet Precaution signage posted indicated but was not limited to the following: STOP: ISOLATION-In addition to Standard Precautions Staff and Providers MUST: -Clean Hands when entering and exiting -Gown: Change between each Resident -N 95 Respirator (respiratory protective device designed to achieve a very close facial fit to filtrate airborne particles; the edges form a seal around the nose and mouth) -Eye Protection (goggles or face shield) -Gloves: Change between each Resident 1. Resident #24 was admitted to the facility in November 2023. Review of the medical record including progress notes, physician orders, and care plan indicated but were not limited to the following: -He/she tested positive for COVID-19 on 8/7/24 and COVID protocol was implemented. -Droplet Precautions for COVID-19 every shift. -Resident has an active infection and is being treated in an attempt to prevent the spread, Droplet Precautions. On 8/8/24 at 9:05 A.M. the surveyor observed the following: -There was a RED ISOLATION SIGN Posted on the doorway outside Resident #24's room and a plastic cart containing PPE outside the doorway. -Nurse #3 poured the morning medications for Resident #24. -Nurse #3 had a surgical mask on (being used on the unit by all staff for source control). -Nurse #3 put gloves on, opened the Lidoderm Patch (adhesive pain patch). -Nurse #3 picked up the medication cup, Lidoderm Patch, a cup of water and entered the room. -Resident #24 was observed coughing. -Nurse #3 administered the cup of medications to Resident #24, put the Lidoderm Patch on the overbed table and exited the room. -Nurse #3 removed gloves, performed hand hygiene, looked at her report sheet and said Resident #24 is positive for COVID-19. -Nurse #3 walked down the hallway to wash her hands. -Upon returning to the medication cart, Nurse #3 opened the plastic cart to get PPE. She put a gown on, put an N-95 over the surgical mask she had on, and put gloves on. -Nurse #3 entered the room and applied the Lidoderm Patch to Resident #24's back. -Nurse #3 removed the PPE, exited the room, performed hand hygiene, and put a new surgical mask on. Nurse #3 failed to put on a gown, N-95, or eye protection prior to entering the room with the medications. (The surveyor stood at the doorway and did not enter the room.) Nurse #3 failed to ensure the N95 had a close facial fit and failed to put on eye protection when she entered the room the second time. During an interview on 8/8/24 at 9:17 A.M., Nurse #3 said she should have had full PPE (gown, gloves, eye protection, and N-95) on to enter the room and to administer medications. During an interview on 8/8/24 at 9:20 A.M., Nurse #3 said she always put the N-95 over her surgical mask for extra protection because she does not want COVID again. Additionally, she said the eye protection/face shield is optional. She said she usually wears one if the resident is coughing a lot, but you do not have to wear it. During an interview on 8/8/24 at 9:55 A.M., Minimum Data Set (MDS) Nurse #2 said there are three residents positive for COVID, there is a Red Sign outside the door, and everyone needs to wear full PPE to enter the room. She said they had been fit tested and the N-95 does not go over the surgical mask, she said it must be fitted to your face to work properly. During an interview on 8/8/24 at 1:30 P.M., the Director of Nurse (DON) said if there is a Red Sign at the door everyone needs full PPE to enter the room regardless of which resident they are providing care for. Additionally, she said the N-95 does not go over the surgical mask, it needs to be fitted directly to the face or it is ineffective, and the eye protection/ face shield is not optional. She said everyone should have eye protection on to enter the room. 2. Resident #19 was admitted to the facility in August 2016. Review of the medical record including progress notes and physician's orders indicated but were not limited to the following: -He/she tested positive for COVID-19 on 7/30/24 and was on droplet precautions. -Droplet Precautions for COVID-19 every shift. Resident #82 was admitted to the facility in July 2023. Review of the medical record including progress notes and physician's orders indicated but were not limited to the following: -He/she tested positive for COVID-19 on 7/26/24 and was on droplet precautions through 8/5/24 During an interview on 8/7/24 at 10:00 A.M., Nurse #1 and MDS Nurse #2 said Resident #19 and #82's room had a red sign on it and everyone needed to wear full PPE to enter the room. On 8/7/24 at 10:50 A.M., the surveyor observed the following: -There was a RED ISOLATION SIGN Posted on the doorway to Resident #19 and #82's room and a plastic cart containing PPE outside the doorway. -Activity Assistant #2 was standing at the doorway to the room with a coffee cart. -Activity Assistant #2 entered the room without putting PPE on and was observed delivering coffee, a snack, and the Daily Chronicle to Residents #19 and #82. The Activity Assistant failed to put on PPE to enter the room and failed to perform hand hygiene between resident interaction. During an interview on 8/7/24 at 10:52 A.M., Activity Assistant #2 said she did not need PPE for either Resident and she did not know why the sign was still up, as they were both negative now. During an interview on 8/7/24 at 10:53 A.M., Nurse #1 said Resident #19 is still positive and everyone needs to wear full PPE to enter the room to provide care or see either resident in the room while the red sign is still up. During an interview on 8/8/24 at 2:55 P.M., the DON said if there is a Red Isolation Sign at the doorway everyone needs full PPE to enter the room regardless of which resident they are going to see or providing care for. Additionally, she said if staff are unsure why a sign is posted they should be checking with the nurse prior to entering the room. 46862 3. Resident #16 was admitted to the facility in July 2024 with diagnoses including Extended Spectrum Beta Lactamase (ESBL a Multidrug Resistant Organism) and urinary tract infection (UTI). Review of the Centers for Disease Control and Prevention (CDC) guidance titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 8/1/23, indicated but was not limited to: -Contact Precautions are one type of Transmission-Based Precaution that are used when pathogen transmission is not completely interrupted by Standard Precautions alone. Contact Precautions are intended to prevent transmission of infectious agents, like MDROs, that are spread by direct or indirect contact with the resident or the resident's environment. -Contact Precautions require the use of gown and gloves on every entry into a resident's room. Review of Resident #16's current care plan indicated but was not limited to: -Resident has active infection and is being treated in attempt to prevent the spread. Is symptomatic and/or has a positive test indicating contagious stage urine: ESBL UTI, dated 8/5/24 -Transmission based precautions of contact, dated 8/5/24 The surveyor observed a contact precaution sign posted on the door entrance of Resident #16's room on: -8/7/24 at 10:20 A.M. -8/8/24 at 7:54 A.M. Further review of the facility posted contact precautions sign indicated but was not limited to: -Everyone must: -Clean their hands, including before entering and when leaving the room Providers and Staff must also: -Put on gloves before room entry. Discard gloves before room exit. -Put on gown before room entry. Discard gown before room exit. -Do not wear the same gown and gloves for the care of more than one person. On 8/7/24 at 10:20 A.M., the surveyor observed a contact precaution sign posted on Resident #16's doorway. Housekeeper #2 was in the room and was observed emptying Resident #16's trash. Housekeeper #2 was not wearing a gown. Housekeeper #2 exited the room and placed trash in a large bin. Housekeeper #2 removed her gloves and did not wash her hands. On 8/7/24 at 10:28 A.M., Nurse #2 said any staff entering Resident #16's room needed to wash their hands and put on gloves and a gown. Nurse #2 said Housekeeper #2 needed to wear a gown in the room and wash her hands when she left the room. 4. Resident #57 was admitted to the facility in July 2024 with diagnoses including Enterocolitis due to Clostridium Difficile (C-diff an infection that can be spread by direct contact with an infected person's bowel movements. The infection can also spread through contact with equipment or surfaces that have been contaminated by the germs). The surveyor observed a contact precaution sign posted on the door entrance of Resident #57's room on: -8/7/24 at 10:20 A.M. -8/8/24 at 7:54 A.M. On 8/8/24 at 7:54 A.M., the surveyor observed a contact precaution sign posted on Resident #16's and Resident #57's doorway. Housekeeper #2 was observed putting on gloves and entering Resident #16's room. Housekeeper #2 did not put on a gown. Housekeeper #2 emptied the trash and exited Resident #16's room. Housekeeper #2 placed the trash in a large bin. Housekeeper #2 then was observed to enter Resident #57's room without washing her hands and replacing her gloves. Housekeeper #2 emptied the trash and exited the room. During an interview on 8/8/24 at 8:10 A.M., Housekeeper #2 said she did not need a gown. Housekeeper #2 said she forgot to wash her hands and change her gloves. During an interview on 8/8/24 at 9:49 A.M., the Unit Manager (UM) #1 said Resident #16 was on contact precautions for ESBL and Resident #57 was on contact precautions for C-diff. UM #1 said staff entering a contact precaution room need to wash their hands and use appropriate PPE. Staff need to remove their PPE when leaving the room and wash their hands. UM #1 said Housekeeper #2 should have been wearing a gown and washed her hands when she exited Resident #16's room. The UM #1 said Housekeeper #2 should not have entered Resident #57's room wearing the same gloves. UM #1 said Housekeeper #2 did not follow the proper procedure for contact precautions. During an interview on 8/9/24 at 1:00 P.M., the Director of Nurses (DON) said Resident #16 had ESBL and Resident #57 had C-diff. The DON said she was aware Housekeeper #2 did not follow the contact precaution signage on either room. The DNS said Housekeeper #2 should have followed the signage for contact precautions.

Based on interview and record review, the facility failed to ensure a [NAME] Treatment Plan (court approved treatment plan for the administration of antipsychotic medications) was obtained prior to the administration of an antipsychotic medication for one Resident (#24), in a total sample of 20 residents. Findings include: Review of the website (www.mass.gov/[NAME]-guardianships) indicated but was not limited to the following: -A guardian for an adult is a person appointed by a judge in the Probate and Family Court who is responsible for making decisions for an individual after a judge has decided they aren't competent to make their own informed choices. Some guardians can make decisions about medical treatment for a person with mental illness that is considered extraordinary. These are called [NAME] guardianships. -At a [NAME] guardianship hearing, the person asking for the [NAME] guardianship asks the court to approve extraordinary medical treatment for an incapacitated person. This usually refers to treatment with antipsychotic medication . -If an incapacitated person is prescribed antipsychotic medications, the incapacitated person will need a guardian who has been given [NAME] authority by the court. Resident #24 was admitted to the facility in November 2023 with diagnoses which included traumatic subdural hemorrhage, traumatic brain injury, strange inexplicable behavior, and dementia with behavioral disturbances. Review of the medical record indicated Resident #24 was transferred to the facility from another nursing facility without Guardianship documents. The medical record indicated a Health Care Proxy was in effect upon admission in November 2023. Review of a progress note, dated 6/27/24, indicated the facility was notified that Resident #24 had a Guardian and the Guardian was unaware Resident #24 was residing in the facility. Additionally, the note indicated the Guardian had very little paperwork regarding the Guardianship and Treatment Plan. Review of the medical record included the letter, dated 6/26/24, which indicated the legal Guardian hereby revoked any and all past and/or current Health Care Proxies previously signed by Resident #24. Review of the medical record indicated Resident #24 was appointed a Guardian by the Commonwealth of Massachusetts Probate and Family Court on 1/25/23. The document further indicated that the legal guardian had authority to authorize treatment of the incapacitated person with antipsychotic medication in accordance with the treatment plan dated 1/25/23 which shall be reviewed on or before 1/23/24 and if not sooner extended, shall expire on 1/23/24. The document failed to include the Treatment Plan for the administration of antipsychotic medication and failed to include any subsequent review of the authorization. Review of the Physician's Orders indicated the following: -Risperidone 1 milligram (mg). Give 0.5 mg one time a day (11/1/23) (antipsychotic medication) -Risperidone 1mg two times a day (11/1/23) Review of the Medication Administration Records (MAR) for June, July, and August 2024 indicated the Risperidone was administered as ordered by the physician. Review of the Informed Consent for Psychotropic Administration Form for administration of the medication Risperidone, dated 7/1/23, indicated the consent form was signed by the legal guardian. Additional information on the consent form indicated the legal guardian checked off the box which attested to being the guardian with substituted judgement authority and the [NAME] Monitor has been informed and authorized this medication. Further review of the Informed Consent indicated if the proposed medication is an antipsychotic, and the resident has a guardian, evidence of [NAME] substituted judgement is required. The surveyor had requested a copy of the [NAME] Treatment Plan on 8/8/24 at 2:00 P.M and the facility was unable to provide the document. Further review of the medical record failed to indicate a current Court Ordered [NAME] Treatment Plan and failed to indicate the facility had tried to obtain such documentation since 6/27/24 when they were notified of the Guardianship (>40 days). On 8/13/24, the facility provided the surveyor with a copy of a fax transmittal timestamped 8/8/24 at 4:02 P.M. The fax indicated the facility was requesting authorization to treat with antipsychotic medication. During an interview on 8/13/24 at 12:00 P.M, Nurse #1 said every psychotropic medication needed consent and he was unsure of the process if a resident had a Guardian in place and deferred further questions to the Director of Nurses (DON). During an interview on 8/13/24 at 1:52 P.M., the DON said Resident #24 was on Risperidone, an antipsychotic, and had a Guardian. Additionally, she said there should be a [NAME] Treatment Plan in the record for the use of the antipsychotic and he/she did not have one in the medical record. The DON said they did not find out Resident #24 had a Guardian until June 2024; the Administrator was dealing with it and deferred further questions to the Administrator. During an interview on 8/13/24 at 2:21 P.M., the Administrator said there should be a [NAME] Treatment Plan in place for the Risperidone. She said when the Guardian surfaced in June, they should have submitted the documents requesting the Treatment Plan, but they did not. She said the form was faxed over last week (8/8/24) after the Treatment Plan was requested by the surveyor and she had no further information regarding the Treatment Plan at this time.

Based on observations, interviews, and record review, the facility failed to ensure one Resident's comprehensive and individualized plan of care was implemented, for one Resident (#60), out of a total sample of 20 residents. Specifically, for Resident #60, the facility failed to place a padded floor mat to the left side of his/her bed. Findings include: Review of the facility's policy titled Comprehensive Person-Centered Care Plan, dated 4/17, included but was not limited to: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. -The Interdisciplinary Team must review and update the care plan when there has been a significant change in the resident's condition. Resident #60 was admitted to the facility in March 2022 with diagnoses including history of falling and fracture of the right femur. Review of the Minimum Data Set (MDS) assessment, dated 6/20/24, indicated Resident #60 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15. Review of the care plan, initiated 3/8/22, indicated Resident #60 was at high risk for falls. The goal identified was that Resident #60 will be free of falls through the review date. Interventions included but were not limited to the following: -4/2/24 Padded floor mat to left side of bed. On 8/7/24 at 10:11 A.M., the surveyor observed Resident #60 lying in bed. There was a blue padded floor mat standing straight up against the wall opposite the foot of the bed. During an interview on 8/7/24 at 10:30 A.M., Nurse #2 and the surveyor observed the blue padded floor mat standing straight up against the wall. Nurse #2 said the mat should have been on the floor on the left side of the Resident's bed. On 8/8/24 at 11:09 A.M., the surveyor observed Resident #60 lying in bed. There was a blue padded floor mat standing straight up against the wall opposite the foot of the bed. During an interview on 8/8/24 at 11:15 A.M., Certified Nursing Assistant (CNA) #1 and the surveyor observed the blue padded floor mat standing straight up against the wall. CNA #1 said she had put Resident #60 in bed for a nap. CNA #1 said the blue mat was used because the resident falls, and she should have put the mat on the floor before she left the room. On 8/9/24 at 7:43 A.M., the surveyor observed Resident #60 lying in bed sleeping. There was a blue padded floor mat standing straight up against the wall opposite the foot of the bed. During an interview on 8/9/24 at 7:55 A.M., Unit Manager #1 (UM) and the surveyor observed the blue padded floor mat standing straight up against the wall. UM #1 said, I see they are not in use. UM #1 said the mat should have been on the floor on the left side of the Resident's bed. UM #1 said staff had not followed Resident #60's fall care plan.

Based on record review and staff interview, the facility failed to ensure that for one Resident (#2), of a total sample of 20 residents, the pharmacy's monthly medication regimen review with recommendations for the Resident was reported to the attending physician and director of nursing and acted upon timely. Findings include: Review of the facility's policy titled Medication Regimen Review, dated November 2021, included but was not limited to the following: Policy: 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 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. Resident #2 was admitted with diagnoses which included Type 2 diabetes mellitus and chronic systolic heart failure. Review of a Pharmacy Consultant Note, dated 6/2/24, indicated Resident #2's medications were reviewed and Please see the Consultant Pharmacist report for the recommendations. Review of the Consultant pharmacist's recommendations on 6/2/24 indicated to decrease the potassium chloride from 40 milliequivalents (meq) total per day, to 20 meq per day. During an interview on 08/09/24 at 12:57 P.M., the Director of Nurses (DON) said the facility missed it, in reference to the consultant pharmacist's recommendation on 6/2/24 to decrease the potassium chloride. Review of a separate report submitted by the consultant pharmacist on 7/4/24, titled Recommendations With No Response-DNS, the pharmacist indicated the resident currently receives potassium 20 meq ER (extended release) tablets twice daily. The K (potassium) lab most recent noted K-4.6 (potassium blood level) suggests decrease to 20 meq daily since this formulation is a 24-hour medication. The recommendation status from the physician was listed as no response and the Resident continued to receive potassium chloride 20 meq twice daily, for a total of 40 meq until the omission was discovered and the potassium chloride was decreased to 20 meq daily on 7/12/24.

Based on record review and staff interview, the facility failed to maintain medical records that are complete, accurate, and systemically organized within accepted professional standards and practice for one Resident (#91), out of a total sample of three closed records. Specifically, the facility failed to ensure the physician's order for destination of discharge was accurate. Findings include: Resident #91 was admitted to the facility in July 2024 with diagnoses including hypertension, heart failure, chronic kidney disease, and dementia. Review of a nurse's progress note, dated 7/22/24, indicated the Healthcare Proxy requested that referral be sent to Local skilled nursing facility (SNF) A for transfer as it was closer to family. Documents were sent to Local SNF A. Review of a Social Service's progress note, dated 7/23/24, indicated the social worker had reached out to Local SNF A who confirmed a bed offer had been approved for Resident #91. Resident #91 was transferring to Local SNF A by stretcher . by Ambulance company. Review of the Transfer/Discharge Evaluation-V7, dated 7/23/24, indicated Resident #91 was transferred to a SNF. Family request for transfer to Local SNF A to be close to family. Review of the July 2024 Physician's orders included but was not limited to: May discharge to Local SNF B During an interview on 8/13/24 at 10:44 A.M., Unit Manager (UM) #1 reviewed the Physician's order for discharge. UM #1 said Resident #91 had been discharged to Local SNF A not to Local SNF B. UM #1 said that was her error, in transcribing the order, as she had a few residents being discharged that week.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed for one Resident (#3), in a sample of 20 residents, and one Resident (#91), in a sample of three closed record reviews. Specifically, the facility failed: 1. To ensure the accurate admitted was reflected on three MDSs and limited range of motion was reflected on two MDSs for Resident #3; and 2. To ensure the accurate discharge location was reflected on the MDS for Resident #91. Findings include: 1. Resident #3 was admitted to the facility in October 2018 and developed a contracture. Review of the MDSs, dated 2/5/24, 5/2/24, and 8/1/24, indicated Resident #3 had an admitted [DATE]. During an interview on 8/13/24 at 10:15 A.M., MDS Nurse #1 said the MDSs inaccurately reflected the admitted for Resident #3 and would be updated to indicate the Resident was admitted in 2018. On 08/07/24 at 2:53 P.M., the surveyor observed Resident #3 wearing bilateral hand splints. Review of the Occupational Therapy Discharge Summary indicated services initiated 4/22/24 indicated the prior level of function of Resident #3's bilateral hands were fisted with a gauze roll in the left hand and a baseline of significant contractures to bilateral hands/wrists on 4/22/24. Review of the MDSs, dated 5/2/24 and 8/1/24, indicated Resident #3 had no functional impairment to range of motion on the upper extremities. During an interview on 8/13/24 at 1:14 P.M., MDS Nurse #2 said she had not seen the Occupational Therapy notes, did not know the Resident had a contracture, and the MDSs were inaccurate. 46862 2. Resident #91 was admitted to the facility in July 2024 with diagnoses including hypertension, heart failure, chronic kidney disease, and dementia. Review of Resident #91's clinical record indicated a Physician's Order, dated 7/23/24, may discharge to [Name of local skilled nursing facility (SNF)]. Review of the Transfer/Discharge Evaluation-V7, dated 7/23/24, indicated Resident #91 was transferred to a SNF. Family requested for transfer to [Name of local SNF] to be close to family. Review of the Discharge MDS assessment section A, dated 7/23/24, indicated Resident #91 was discharged to acute care hospital. During an interview on 8/9/24 at 11:08 A.M., MDS Nurse #2 said the discharge status of Resident #91 was incorrectly coded and should have been coded as discharged to a skilled nursing facility.

Based on observation, interview, and Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure facemasks were used by staff in the long term care setting as a method of source control during the Department of Health and Human services Federal public health emergency for COVID-19. Findings include: Review of the CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated September 2022, indicated but was not limited to the following: - Source control refers to use of respirators or well-fitting facemasks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. - Source control options for healthcare providers (HCP) include a well-fitting facemask. On 4/30/23 at 7:49 A.M., the surveyor observed signs posted at the entrance reception desk and in both elevators that indicated but was not limited to the following: - Attention staff and guests, we are happy to provide you with a surgical mask that must be worn at all times within the facility On 4/30/23 at 9:09 A.M., the surveyor observed Certified Nurse Assistant (CNA) #1 sitting beside Resident #84 assisting him/her with eating his/her breakfast meal. CNA #1 had his mask pulled down, not covering his nose or mouth. When the surveyor asked about mask use the CNA said he is supposed to have his nose and mouth covered by the mask at all times in the facility. During an observation with interview on 4/30/23 at 1:51 P.M., the surveyor observed Nurse #1 in the large common room on the Cranview unit assisting Resident #8 to a table for activities. Nurse #1 was observed to have his mask pulled down resting on his [NAME] not covering his nose or mouth during this time. Nurse #1 said he is supposed to have his mask covering both his nose and mouth at all times when in resident areas. During an observation with interview on 4/30/23 at 1:53 P.M., the surveyor observed CNA #1 standing at a computer kiosk in the hallway of the Cranview unit outside of room [ROOM NUMBER]. His mask was pulled down to his [NAME], not covering his nose or mouth. He said, Oh, I'm sorry you got me again and adjusted his mask. He said he is supposed to have his mask up covering his nose and mouth at all times. During an interview on 4/30/23 at 1:57 P.M., Nurse #3 said all staff are required to wear a mask on any nursing unit or in any resident setting covering both their noses and their mouths and she expects that all staff keep their masks on while on the unit. During an observation with interview on 5/2/23 at 1:48 P.M., the surveyor observed Activity Assistant #1 in the large common room on the Cranview unit with her surgical mask pulled down covering only her mouth, leaving her nose exposed. She said she is supposed to have both her nose and mouth covered at all times with a surgical mask in the facility. During an observation with interview on 5/2/23 at 1:54 P.M., the surveyor observed CNA #2 walking in the hallway on the Cranview unit with her mask hanging below her nose exposing it. She said the mask keeps slipping down and she should get a new one because she is supposed to keep both her nose and mouth covered with a surgical mask at all times while working. During an interview on 5/2/23 at 2:02 P.M., the Infection Preventionist and Director of Nurses were made aware of the surveyors observations. They said staff are to wear masks at all times in all resident areas and the expectation was not met.

Based on interview, policy review, and document review, the facility failed to implement a policy to grant COVID-19 vaccination exemptions for staff that included all the required components that were current and based on national standards for 2 of 2 reviewed exempt employees. Specifically, the facility failed to: 1. Ensure documentation was complete for Activity Assistant #2 with a length of time the exemption was granted, and which authorized or licensed COVID-19 vaccine was clinically contraindicated for the staff member; and 2. Maintain completed documentation for Certified Nurse Assistant (CNA) #3 indicating which authorized or licensed COVID-19 vaccine was clinically contraindicated for the staff member. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) Quality Safety and Oversight memo: QSO-23-07-ALL, Attachment A, dated 10/26/22, indicated but was not limited to the following: - Vaccination Exemptions: Facilities must have a process by which staff may request exemption from COVID-19 vaccination based on an applicable Federal law. -To protect long term care (LTC) residents from COVID-19, each facility must develop and implement policies and procedures as specified in S483.80(i) to ensure that all LTC staff are fully vaccinated against COVID-19. - The facility must track and securely document staff who have been granted an exemption from vaccination (this should include the type of exemption and supporting documentation) and staff for whom COVID-19 vaccination must be temporarily delayed. For temporary delays, facilities should track when the identified staff can safely resume their vaccination. *Note: Staff who are unable to furnish proper exemption documentation must be vaccinated or the facility must follow the actions for unvaccinated staff. - Medical Exemptions: Certain allergies or recognized medical conditions may provide grounds for a medical exemption. In general, CDC considers a history of a severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a component of the COVID-19 vaccine, or an immediate (within 4 hours of exposure) allergic reaction of any severity to a previous dose, or known (diagnosed ) allergy to a component of the COVID-19 vaccine, to be a contraindication to vaccination with COVID-19 vaccines. Medical exemption documentation must specify which authorized or licensed COVID-19 vaccine is clinically contraindicated for the staff member and the recognized clinical reasons for the contraindication. The documentation must also include a statement recommending that the staff member be exempted from the facility's COVID-19 vaccination requirements based on the medical contraindications. -Facilities must have a process to track and secure documentation of the vaccine status of staff whose vaccine is temporarily delayed. CDC recommends a temporary delay in administering the COVID-19 vaccination due to clinical considerations, including known COVID-19 infection until recovery from the acute illness (if symptoms were present) and criteria to discontinue isolation have been met. Review of the facility's policy titled: Employee COVID-19 vaccination, dated as revised March 2023, indicated but was not limited to the following: - Staff for whom COVID-19 vaccination must be temporarily delayed: for temporary delays facilities should track when the identified staff can safely resume vaccination - Medical exemption documentation must specify which authorized or licensed COVID-19 vaccine is clinically contraindicated for the staff member and the recognized clinical reason for the contraindication. Review of the facility's Staff COVID-19 Vaccination Matrix indicated two staff were granted medical exemptions. 1. Review of the COVID-19 vaccination medical exemption request form for Activity Assistant #2 indicated the following: - a medical exemption was requested by the staff member and granted on 12/8/22 - the form did not include information to which authorized or licensed COVID-19 vaccine is clinically contraindicated for the staff member - the form indicated to see attached document by the physician - the provided physician note indicated in May 2021 the staff member had an anaphylaxis reaction to COVID-19 vaccination, but did not indicate to which authorized or licensed COVID-19 vaccination - the physician note indicated: at this time, she cannot continue with said vaccines Neither the form nor physician note included information on whether the exemption would be temporary or permanent. 2. Review of the COVID-19 vaccination medical exemption request form for CNA #3 indicated the following: - a medical exemption was requested by the staff member on 10/5/20 and granted on 10/5/21 - the form did not include information to which authorized or licensed COVID-19 vaccine is clinically contraindicated for the staff member. During an interview with the Infection Preventionist (IP), Director of Nurses (DON) and Administrator on 5/2/23 at 2:02 P.M., the IP and DON reviewed the exemption forms and regulatory guidelines and said the forms were not complete as they should be. The Administrator said she understood that the documents needed to be complete and more specific to meet the requirements.

Based on observations, interviews, and record review, the facility failed to ensure an individualized plan of care was followed for two Residents (#53 and #45), in a total sample of 22 residents. Specifically, the facility failed: 1. For Resident #53, to follow the care plan of not providing paper products to the Resident who had a history of eating non-edible items; and 2. For Resident #45, to develop an individualized comprehensive plan of care following a new left clavicle fracture. Findings include: 1. Resident #53 was admitted to the facility in May 2021 with a diagnosis of dementia. Review of the Care Plans for Resident #53 included a Focus of behavioral problems including putting non-edible items in his/her mouth with a goal of not putting items in their mouth and interventions of removing all non-edible items from the food trays, supervising while eating to ensure he/she does not eat non-edible items and removing any non-edible objects from the room. Review of the printed meal tickets, provided by the kitchen to ensure correct dietary restrictions were followed on meal trays, included diet order, notes, and alerts. The meal tickets for Resident #53 failed to indicate that the Resident was not to have non-edible items on the food trays. On 4/30/23 at 11:25 A.M., the surveyor observed Resident #53 in the large activity room ripping up a Styrofoam cup into tiny pieces and placing a piece in his/her mouth and chewing. All residents in the room were observed to have Styrofoam cups. At 11:49 A.M. Resident #53 started to tear up the Daily Chronicle (a one-page facility newsletter). At 11:50 A.M., Activity Assistant #1 approached the Resident and started picking up the pieces of the cup and the pieces of the Daily Chronicle and said to Resident #53, What's in your mouth? Spit it out. The surveyor observed Resident #53 spit a piece of Styrofoam into the hand of the Activity Assistant. On 5/2/23 at 9:08 A.M., the surveyor observed Resident #53 in the small unit dining room feeding his/herself breakfast. The Resident's meal tray had a Styrofoam take-out container, a Styrofoam bowl and a Styrofoam cup. The surveyor observed one nurse walking around the room, supervising 10 residents. On 5/2/23 at 12:55 P.M., the surveyor observed Resident #53 in the large unit activity room having lunch. Certified Nursing Assistant (CNA) #3 was seated next to the Resident. During an interview at this time, CNA #3 said Resident #53 had started to rip up his/her meal ticket and eat it and the Resident had a history of eating non-edible items which was why the CNA was sitting with the Resident. During an interview on 5/3/23 at 9:56 A.M., Unit Manager #2 said Resident #53 had a history of eating non-edible items and it was noted on the Care Plan and on the Kardex (resident information card for CNAs). The Unit Manager said the Therapeutic Activity Director for the unit was aware that Resident #53 was not to have disposable items such as Styrofoam. She said she was not sure how Activity Assistant #1 would have been made aware of the behavior as she wouldn't review the Care Plan or the Kardex. During an interview on 5/3/23 at 12:25 P.M., Activity Assistant #1 said every day a Diet Type Report is printed from the electronic medical record and kept with the activity staff to ensure the proper diet is provided to residents. Review of the Diet Type Report printed on 5/3/23 indicated additional directions for Resident #53 of no paper products on trays. During an interview on 5/3/23 at 12:35 P.M., the Activity Assistant said she had not seen the alert indicating Resident #53 could not have paper products. During an interview on 5/3/23 at 12:38 P.M., the Food Service Director said she was unaware that Resident #53 could not have paper products and that was why it was not on the meal ticket and why Resident #53 had not been given regular and non-disposable dishes on 5/2/23. She said the alert should have been written on the meal ticket to alert the kitchen staff. 43935 2. Resident #45 was admitted to the facility in June 2020 with diagnoses including syncope and collapse, unspecified dementia, and post-traumatic stress disorder. Review of the medical record indicated Resident had four falls since December 2022. Review of the Incident Report and Investigation for the 12/24/22 fall indicated but was not limited to the following: - at 1:00 A.M., the Resident informed the staff he/she had rolled out of bed landing on their left side and placed themselves back to bed - the Resident was oriented to person, situation, place and time - there was no evidence of injury at the time of the fall and Resident #45 declined hospital evaluation Review of the progress notes following the incident indicated the following: - 12/24/22 at 1:40 A.M., Resident used call light to report he/she had rolled out of the bed onto his/her left side. Full assessment done, no new pain swelling or bruising in shoulder. Resident denied dizziness or head strike and declined hospital transfer. - 12/24/22 at 1:45 P.M., Resident stated he/she fell out of bed last night, complaint of increased left shoulder pain, refused to go to the hospital for evaluation. Physician (MD)aware and ordered x-ray of the left shoulder. - 12/24/22 at 10:51 P.M., (late entry) x-ray obtained awaiting results - 12/25/22 at 8:00 A.M., (late entry) MD notified of x-ray results, small fracture to left distal clavicle. - 12/25/22 at 12:52 P.M., two new MD orders received: one is for sling to the left arm and the second patient needs an orthopedic consult - call this in on 12/26/22 There are no further notes following the 12/25/22 at 12:52 P.M. entry to address the left clavicle fracture, orthopedic follow up or use of the sling from the date of the injury to 5/2/23. Review of Resident #45's current care plans indicated a care plan for the following: At risk for fall related to confusion, gait/balance problems, incontinence, unaware of safety needs (last revised 3/13/23). The new intervention following the 12/24/22 fall was found on an old care plan last revised on 1/3/23 (11 days after the fall) that indicated an intervention of medical work up and Physical Therapy (PT) evaluation. Review of the signed Radiology report from 12/25/22 indicated the following: - left complete shoulder, two views Results: - views indicate a left shoulder plate and screw fixation of an old healed fracture - there is a small fracture of the distal clavicle, lateral to the coracoclavicular joint, without visible callous, suggesting an acute or recent injury Conclusion: - small left distal clavicle fracture, acute or recent in appearance, correlate for recent trauma to this area Review of the Minimum Data set (MDS) with assessment reference date 14 days prior to the fall indicated the following: Functional abilities and goals, Section GG: - Eating: independent - Oral hygiene: independent - Toilet hygiene: independent - Shower/bathe self: partial/moderate assistance - Upper body dressing: independent - Lower body dressing: independent - Putting on/taking off footwear: independent Mobility, Section G: - Roll left and right: independent - Sit to lying position: independent - Lying to sitting position: independent - Sit to stand ability: independent - Chair to bed/bed to chair transfer: independent - Toilet transfers: independent - Walk 10 feet & 50 feet: independent - Walk 150 feet: supervision or touch assistance - Bend or stoop to pick up objects: independent Review of the Stern PT/OT Screen, completed on 12/26/22 at 2:37 P.M., indicated the following: - Reason for screen is status post fall - Device normally used by Resident - rolling walker, change noted in functional mobility area - comments for mobility indicated: Resident navigating without assistive device in room during care - patient unable to use rollator (rolling walker) at this time secondary to sling on left upper extremity (LUE). - ADL: hygiene and grooming: limited assist with one caregiver - upper body and lower body dressing: limited assist with one caregiver - comments for change in function indicate Resident will benefit from set up of meal tray, will require increase assistance from staff for grooming and upper body dressing until further assessment with orthopedic is completed secondary to sling - change in fall risk: increase risk secondary to inability to use rollator with sling - presence of orthotic: therapist provided left upper extremity sling per MD orders - no full evaluation necessary - overall: patient does not need further evaluation at this time, may need following orthopedic consult if new weight bearing or movement restrictions are ordered. During an interview on 5/3/23 at 10:56 A.M., the Director of Rehabilitation said rehabilitation(rehab) screens are completed for every person after a fall by viewing the 24-hour report for falls on point click care (PCC). She said if a person is picked up on services they will go straight to a full evaluation and Occupational Therapy (OT) & Physical Therapy (PT) split up screens and/or evaluations for each day. She said Resident #45 did not require a full evaluation and services by a skilled therapist following the fall with clavicle fracture as per the results of the screen that was completed on 12/26/22. Further review of the Resident's care plans failed to indicate a comprehensive individualized care plan was developed for the use of the sling to the LUE or for treatment of the new fracture. Review of the physician progress notes following the fall on 12/24/22, failed to indicate the Resident had a fall resulting in a new clavicle fracture, was using a sling to the LUE or any follow up recommendations or consults for orthopedics. During an interview on 5/3/23 at 9:38 A.M., Unit Manager (UM) #3 reviewed the medical record and said Resident #45 had a history of poor safety awareness and falls. She said the Resident had a self-reported fall on 12/24/22 and a coinciding x-ray result of new left distal fracture of the clavicle and new orders to wear a sling and see orthopedics for a consult. She said there was no follow up documentation in the progress notes, care plans, or medical record to indicate whether the Resident saw orthopedics, or why the sling use and orthopedic consult orders were discontinued on 12/27/22, 3 days following the fall. She viewed the calendars for Resident appointments and said she has no record of the Resident having an appointment or going to see the orthopedic doctor. She reviewed the resolved and canceled care plans for the Resident with the surveyor and said she could not locate a care plan that would indicate the Resident ever wore the sling to the LUE for the new clavicle fracture or that they were ordered to see orthopedics. During an interview on 5/3/23 at 10:27 A.M., Nurse #4 and Consulting staff #1 said the Resident's fall care plan had been updated with an intervention of medical work-up following the fall on 12/24/22 on 1/3/23. They could not locate a care plan for the new clavicle fracture or use of the sling to the LUE and said they would look further and provide the surveyor with their findings. No further documents were provided prior to the survey exit. During a follow up interview on 5/3/23 at 11:40 A.M., Unit Manager #3 said she spoke with the Resident's representative who had made a decision not to pursue an orthopedic consult at the time of the fall. She said she completed a second thorough review of the medical record for Resident #45, including all resolved and canceled care plans and could not find any documentation regarding the decision to not seek orthopedic consult, any progress notes or reason for the discontinuation of the sling use or any care plan for the treatment of the left clavicle fracture. During an interview on 5/3/23 at 11:48 A.M., the Director of Nurses said there is no documentation or individualized comprehensive care plan that could be located for the treatment of the left clavicle fracture and sling use. She said there should be a care plan, but it was missing. She said she believed the Resident may have been non-compliant with the LUE sling and declined orthopedic consult, but she couldn't find any documentation to support that notion.

Based on record review, observation, interview, and policy review, the facility failed to ensure quality care and services were provided for one Resident (#46), out of a total sample of 22 residents. Specifically, the facility failed to ensure diabetic care was provided as ordered and documented correctly in the medical record. Findings include: Review of the facility's policy titled Diabetes Protocol, dated as revised April 2022, indicated but was not limited to the following: - the staff and physician will manage hypoglycemia appropriately - it is important to avoid over-treatment of hypoglycemia, which can result in rebound hyperglycemia and hamper subsequent glucose control Resident #46 was admitted to the facility in March 2023 with diagnoses including type 2 diabetes mellitus. Review of the medical record indicated Resident #46 was transferred to the hospital on 4/20/23 following a period of unresolved hypoglycemia (low sugar levels in the blood). Review of the progress note, dated 4/20/23 at 6:15 P.M. (18:15 military time), indicated the Resident was transferred in an immediate transfer to the hospital for urgent medical needs. Fingerstick blood sugar of 67, juice given; 5:00 P.M., Resident yelling out, capillary blood glucose, a fingerstick blood sugar test (CBG) was 54, then the CBG was 53 at 5:45 P.M., with altered mental status. No other progress notes were available detailing the hypoglycemic episode. Review of the Resident care plan for: Potential for hyperglycemia/hypoglycemia related to Diabetes mellitus type 2 included the following interventions: - administer insulin according to established parameters by physician - administer medications as ordered, see Medication Administration Record (MAR), monitor for signs and symptoms of effectiveness and side effects - check blood glucose levels per physician's order Review of the active Physician's Orders for Resident #46 at the time of transfer on 4/20/23 included but were not limited to the following: - Tresiba (diabetic insulin injectable medication) 18 units once daily at 9:00 A.M. - Glipizide (an oral medication for diabetes that helps lower blood sugar) 5 mg twice a day at 9:00 A.M., and 5:00 P.M. - Lispro insulin administered per a sliding scale (dosage depends on the CBG prior to administration) before meals daily at 6:30 A.M., 11:30 A.M., and 4:30 P.M. - Monitor for signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) every shift - If fingerstick blood sugar less than or equal to 70 and resident is responsive and able to swallow offer 8 milliliters (ml) of orange juice, recheck fingerstick blood sugar in 15 minutes as needed for hypoglycemia - Glucagon (a medication to treat severe low blood sugar) 1 mg injected as needed for blood sugar less than 70 if resident is not able or not willing to swallow - Check fingerstick blood sugar every 15 minutes until emergency medical services (EMS) arrive as needed for hypoglycemia Review of the blood sugar summary for the Resident on 4/20/23 indicated the following in regard to the hypoglycemic episode: - 4:51 P.M., CBG = 67 - 5:52 P.M., CBG = 54 (1 hour and 1 minute after the initial blood sugar below 70) - 6:03 P.M., CBG = 71 (11 minutes later) - 6:08 P.M., CBG = 59 (5 minutes later) - 6:14 P.M., CBG = 53 (6 minutes later) - 6:20 P.M., CBG = 71 (6 minutes later) There were no further documented CBG's beyond the 6:20 P.M. time. Review of the Medication Administration Record (MAR) for Resident #46 on 4/20/23 at the time of the incident indicated the following: - Glipizide was administered as ordered at 5:00 P.M. - Lispro insulin was held at 4:30 P.M. for CBG = 67 The MAR did not indicate that either the juice or Glucagon had been administered as ordered for hypoglycemia, nor did the MAR indicate CBG's were monitored every 15 minutes until EMS arrived. During an interview on 5/3/23 at 2:41 P.M., the Director of Nurses (DON) reviewed the medical record and said there was no documentation the Resident had CBGs every 15 minutes. She said she did look into whether or not a Glucagon kit was removed from the facility emergency medication bank and the pharmacy has notified her that a Glucagon kit was removed for the Resident on 4/20/23 at 6:08 P.M. She said upon viewing the documentation that it appears the process for hypoglycemia was not documented as it should have been. Review of the facility mealtimes indicated the evening meal would be delivered to Resident #46 sometime between 4:45 P.M. and 5:05 P.M. During an interview on 5/3/23 at 3:27 P.M., the infection prevention nurse (IP) and Unit manager (UM) #1 said they treated Resident #46 on 4/20/23 during the episode of hypoglycemia. The IP nurse said the Resident's CBG prior to dinner was 67 and he/she was asymptomatic. She said she had provided Resident #46 with juice as ordered and then stepped away. Unit Manager #1 said she was alerted by a Certified Nursing Assistant (CNA) that Resident #46 was confused, and the Unit Manager checked the Resident's blood sugar, and it was somewhere in the 50's. She said at that time, she gave the Resident 1 tube of Glutose Gel (an oral gel medication used to treat low blood sugar in diabetics). She said after about five minutes she rechecked the Resident's CBG and believes it elevated about 10 points, she said she then checked it again (timeframe uncertain) and the CBG was again lower than it should be, she said she then removed a Glucagon kit from the emergency medication bank and provided it to the IP nurse for administration to the Resident, estimating the time to be around 6:15 P.M., but she was unsure. She said she did not document the administration of the Glutose Gel, the checks of the CBG's or the administration of the Glucagon because she was just helping the IP nurse who was the nurse responsible for the Resident. She said she was unaware that there were no orders for the administration of the Glutose Gel. The IP nurse said she simply forgot to document the administration of the Glucagon following the incident but that she did provide the Glucagon injectable medication to the Resident at the time she was provided it by Unit Manager #1. The IP nurse said the documented times of the CBG's do not match her note because they were not entered into the system at the time of the emergency and the times had to be estimated. She said she believes the Resident left the facility between 6:23 P.M. and 6:30 P.M. She said when the Resident left the facility, he/she seemed to be more alert. She said she should have documented the administration of the medications and interventions on the MAR and written a more detailed timed out nurses note but did not and it was her error. Unit Manager #1 said she was unaware of what the policy was for hypoglycemic and diabetic management of a resident and used her best nursing judgement to treat the Resident. She said she was unaware that CBG's were to be completed at 15-minute intervals and once she began doing them used her nursing judgment and did them in shorter intervals. She said she should have documented the administration of Glutose Gel and a note to indicate the treatment of the Resident but did not. During an interview on 5/3/23 at 4:16 P.M., the DON was made aware of the information provided to the surveyor and reviewed the documentation. Unit Manager #1 was present and said she was unaware that the facility protocol did not include the administration of Glutose Gel and provided it without a physician's order. The DON said the situation and interventions, including 15-minute CBGs, were not documented as they should have been, and it appears the facility protocols were not followed.

Based on observation, interview, record review, and policy review, the facility failed to ensure one Resident (#65), out of a total sample of 22 residents, received care and services consistent with professional standards of practice to prevent and/or promote healing of pressure injuries. Specifically, the facility failed to conduct a comprehensive skin assessment including the size of a newly identified right outer ankle wound and initiate a (pressure or non-pressure) form per facility policy. Findings include: Review of the facility's policy titled Pressure Ulcer/Injury Risk Assessment, revised March 2022, indicated but was not limited to the following: -Risk factors that increase a resident's susceptibility to develop or to not heal PU/PIs include but are not limited to impaired/decreased mobility and decreased functional ability -Once the assessment is conducted and risk factors are identified and characterized, a resident-centered care plan can be created to address the modifiable risks for pressure ulcers/injuries -Conduct a comprehensive skin assessment with every risk assessment -The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate Documentation: -The type of assessment conducted -Any change in the resident's condition, if identified -The condition of the resident's skin (i.e., the size and location of any red or tender areas), if identified -Initiation of a (pressure of non-pressure) form related to the type of alteration in skin 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 -Report other information in accordance with facility policy and professional standards of practice Resident #65 was admitted to the facility in October 2022 with diagnoses including unspecified fracture of upper end of right tibia, fracture of upper and lower end of right fibula, status post ORIF (open reduction and internal fixation) revision nonunion right proximal tibial fracture on 2/22/23, Type 2 diabetes mellitus with diabetic neuropathy, and chronic peripheral venous insufficiency. Review of the Minimum Data Set (MDS) assessment, dated 2/22/23, indicated Resident #65 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15, was at risk for developing pressure ulcers, and had no unhealed pressure ulcers. The MDS also indicated Resident #65 was an extensive assist for bed mobility, transfer, and personal hygiene. Review of the [NAME] Plus Assessment (an assessment used to determine a person's risk for developing pressure injuries), dated 1/26/23, indicated a score of nine, which indicated a high risk of developing a pressure injury (high risk scores range from zero to ten). Review of the Activities of Daily Living (ADL) care plan indicated Resident #65 had a self-care deficit as evidenced by fractures and limited mobility, weakness, visual impairment, pain, and was post ORIF surgical repair to RLE (right lower extremity) fractures, revised 2/27/23. Interventions included a knee immobilizer to RLE, and skin checks as per MD orders, 2/27/23. Review of Physician's Orders indicated the following: -check skin integrity to RLE every shift, 2/25/23 During an interview on 5/1/23 at 9:18 A.M., Resident #65 said he/she broke the big bone in his/her leg and had to have surgery. Resident #65 said he/she was wearing a leg brace and had to keep it on day and night. The Resident said he/she got a wound on his/her right outer ankle, it's from the brace and said it was painful. The Resident said he/she could not recall staff removing the brace to look at his/her skin (MD order 2/25/23, may remove knee immobilizer to check for skin integrity every shift). Review of a Nursing Progress Note, dated 3/19/23 at 0:01 A.M., indicated Resident RLE outer shin has small open area, larger area is scabbed no signs or symptoms of infection. Peripheral skin is slightly pink. No drainage noted. No odor. New order for cleanse and DPD (dry protective dressing) daily and to monitor for infection every shift. Incision to RLE is CDI (clean, dry, intact) with no signs of infection. Review of the Skin Observation Tool, dated 3/16/23, did not indicate any open areas on the Resident's right outer ankle. Review of the Physician's Electronic Verbal Orders indicated the following: -monitor RLE open area for signs and symptoms of infection every shift until resolved, 3/19/23 -cleanse RLE outer shin with normal saline, pat dry, apply DPD daily until resolved, start 3/19/23 Further review of Resident #65's medical record failed to indicate a comprehensive skin assessment was conducted upon identification of the wound to include the type of injury (pressure-related versus non-pressure related), size (perpendicular measurements of the greatest extent of length and width of the PU/PI), and depth per facility policy. The medical record also failed to indicate a (pressure or non-pressure) form related to the type of alteration in skin was initiated per facility policy. During an interview on 5/2/23 at 5:21 P.M., Nurse #6 said, aside from the surgical wound, she noticed the Resident had another area on his/her right outer ankle that was open during her 3:00 P.M.-11:00 P.M. shift on 3/18/23 and was concerned about it. She said the Resident had some sort of brace from surgery on the right leg. She said she made an order on her own just after midnight on 3/19/23 to clean and dress it every night shift. She said she could not remember a description of the wound but said it was open and it looked like the brace was irritating it, pressing up on it or pushing it a bit. Nurse #6 said, I didn't contact a doctor that night or speak to a physician and thought she could write her own order for wound treatment per her nursing judgement. She said she asked the 11:00 P.M.-7:00 A.M. nurse (Nurse #5) to notify the physician for her. Nurse #6 said she did not do an incident report or a full skin assessment upon identification of the wound. During an interview on 5/3/23 at 10:02 A.M., Nurse #5 said she was familiar with the Resident but didn't know much about the wound because she worked the night shift 3/18/23 into 3/19/23 (11:00 P.M.-7:00 A.M.) and did not do a lot of treatments. Nurse #5 said Nurse #6 did report to her at change of shift at 11:00 P.M. about the wound and that it probably came from the brace. She said it was on the Resident's right outer ankle and Nurse #6 said she would put some orders in. Nurse #5 said she did not look at the wound herself. She said she assumed Nurse #6 wanted her to report it off to Unit Manager (UM) #1 at change of shift (7:00 A.M.) so she did, but said she did not notify the physician, she only reported it to UM #1. Review of a physical therapy Summary of Daily Skilled Services note, dated 3/20/23, indicated the patient had small sores along the ankle due to friction of the inferior boarder of the knee immobilizer. 4 cotton stockinette -2 feet long for potential use to block shearing forces of the inferior brace against the right ankle. The note indicated a call was placed to the orthopedist's office regarding the need to protect the right ankle against the brace. Review of Skilled Nursing Notes indicated the following: 3/20/23: -No right ankle wound skin assessment documented 3/21/23: -Scabbed wound noted on RLE ankle region, MD aware. Follow up appointment today with (Ortho). New order for wound management and knee immobilizer discontinuation. Skin good. No skin related concerns. Wound: N/A. -No documentation of size per facility policy 3/22/23: -No right ankle wound skin assessment documented Review of the Weekly Wound Rounds document, dated 3/23/23, indicated Resident #65 acquired a right ankle pressure area on 3/19/23. Review of the Wound Nurse Practitioner's (NP) Initial Progress Note, dated 3/23/23, indicated Resident #65 had an unstageable right lateral ankle pressure ulcer with 100% eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like dead tissue). The wound measured 6 cm (centimeters) x 2 cm x 0.1 cm (no previous measurement by staff for comparison). Debridement was performed (removal of necrotic (dead) tissue from a wound to improve or facilitate the healing process). Treatment recommendations included to wash the wound, dry, apply Santyl (ointment that removes dead tissue from wounds so they can start to heal) to eschar, cover with double xeroform and cover with clean dry dressing daily and as needed and pressure relief/off-loading per the patient's plan of care. During an observation with interview on 5/2/23 at 2:55 P.M., the surveyor observed Nurse #7 perform a dressing change to the Resident's right outer ankle pressure ulcer with the assistance of Nurse #2. The surveyor observed a small amount of yellow drainage on the old dressing. The wound bed had minimal yellow slough (dead tissue, usually cream or yellow in color) and was approximately 2.5 cm (centimeters) long by 1.25 cm wide. The surrounding skin/margins were pink. No eschar, exudate (fluid), tunneling (opening underneath the skin/channels), undermining (significant erosion underneath wound margins), or purulent odor were observed. Resident #65 denied pain. Nurse #7 measured the wound and said it was 2 cm long x 1 cm wide x 0.1 cm depth. Nurse #7 said the surrounding skin was slightly red and inflamed. During an interview on 5/3/23 at 1:16 P.M., UM #1 said the wound was discovered during the 3:00 P.M.-11:00 P.M. shift on 3/18/23 but would have to look at the notes on it. She said it was reported verbally to her between shifts when she came on at 7:00 A.M. on 3/19/23. UM #1 said she did not recall Nurse #5 asking her to notify the physician and did not. UM #1 said the wound was put in the MD communication book on 3/21/23 (2 days later) after the Resident's ortho appointment who had recommended the immobilizer be discontinued and a recommendation made for wound care. UM #1 said the nursing progress notes should have had a full description of the wound including a baseline measurement and said a full skin assessment should have been completed. During an interview on 5/3/23 at 2:55 P.M., Nurse #6 said again she did not speak to the physician herself to obtain the 3/19/23 treatment orders but said a nurse told her it was okay to enter the orders but could not be sure. She said she is not familiar with writing orders in the computer and has to get help from other nurses. Nurse #6 said the wound bed during the initial finding looked clean that night and she was more alarmed by the dark tissue on the outside, a black scab around it, because she knew the Resident was diabetic. During an interview on 5/3/23 at 4:18 P.M., the Director of Nurses (DON) said staff should be documenting in a wound note what the wound is and what it looks like including a full description of the wound with measurements. She said once a new wound is identified, a wound rounds note should be done initially, then weekly. She said a weekly wound note was not completed for Resident #65's right outer ankle pressure area until 3/23/23, four days later, and a full skin assessment was not done until 3/24/23, five days later. The DON said a full skin assessment was not done when the area was first identified on 3/19/23 but should have been.

Based on record review and interviews, for one of three sampled Residents (Resident #1), who had a history of developing deep vein thrombosis (DVT, blood clots), the Facility failed to ensure staff notified his/her physician regarding a significant change in condition, when on 11/03/22 Resident #1 complained of right lower extremity discomfort, edema, swelling, and drainage was noted, however his/her physician was not notified. Resident #1 was discharged home the next day (11/04/22), complained of right lower extremity pain within an hour of being home and his/her right lower extremity was noted with redness and swelling. Resident #1 was transferred to the hospital where he/she was diagnosed with a DVT of the right lower extremity and required surgical intervention to implant an inferior vena cava (IVC) filter (a small device that can stop blood clots from going up into the lungs). Findings include: Review of the Facility's Policy titled, Change of Condition in a Resident Status, dated March 2017, indicated that the Nurse will notify the resident's physician where there has been a significant change in the resident's physical, emotional and mental condition. The Policy indicated that the Nurse will assess the resident's change of condition and document the findings in the medical record. Review of the Facility's Policy titled, Charting and Documentation, dated as revised April 2022, indicated that any changes in the resident's medical, physical, functional or psychosocial condition shall be documented in the medical record and notification of the physician and family. Resident #1 was admitted to the Facility in October 2022, diagnoses included history of deep vein thrombosis (DVT), rheumatoid arthritis, colitis (inflammatory reaction in the colon), gastroenteritis (stomach flu), and osteoporosis. During an interview on 1/17/23 at 11:55 A.M., Nurse #1 said that on 11/02/22, she completed a skin assessment on Resident #1. Nurse #1 said that she did a full head to toe assessment on Resident #1 and said that he/she did not have any edema, swelling, and did not voice any complaints of pain to his/her right lower extremity. Review of a Physical Therapy Treatment Encounter Note, dated 11/03/22 at 12:31 P.M., written by Physical Therapist Assistant (PTA) #1, indicated that Resident #1 had a slow shuffled gait during therapy session, complained of right lower extremity discomfort and requested to sit down. The Note indicated that increased edema and drainage was noted to Resident #1's right lower extremity and nursing was informed. During an interview on 1/19/23 at 12:14 P.M., Physical Therapy Assistant (PTA) #1 said that during a therapy session on 11/03/23, Resident #1 complained of pain in her/his right lower extremity. PTA #1 said that when she looked at Resident #1's right lower extremity, she noticed edema, swelling and some drainage. PTA #1 said that she had treated Resident #1 a few days prior and said that his/her right lower extremity was not edematous or swollen and said that Resident #1 did not complain of pain at that time. PTA #1 said there was definitely a change in condition with Resident #1, from when she last saw him/her. PTA #1 said she reported this to the 7:00 A.M. to 3:00 P.M. nurses working on Resident #1's unit. PTA #1 said she assisted Resident #1 into his/her wheelchair and transported him/her to the nursing station on his/her unit. PTA #1 said there were two nurses seated at the nursing station on the unit at that time, and said that she told them about Resident #1's right lower extremity, and then left Resident #1, seated in the wheelchair with the nurses at the nursing station. Review of an Occupational Therapy Treatment Encounter Note, dated 11/03/22 at 1:22 P.M., written by Occupational Therapist (OT) #1, indicated that the therapist attempted to assist Resident #1 with donning socks and Resident #1's right lower extremity was extremely edematous compared to the left lower extremity. The Note indicated that nursing was notified. During an interview on 1/19/23 at 11:53 A.M., Occupational Therapist (OT) #1 said that during a therapy session on 11/03/22, Resident #1's right lower extremity was very edematous and swollen compared to his/her left lower extremity. OT #1 said that she reported this to the 7:00 A.M. to 3:00 P.M. nurse working on Resident #1's unit. During an interview on 1/19/22 at 1:00 P.M., Nurse #2 (who was assigned to care for Resident #1 on the 7:00 A.M. to 3:00 P.M. shift on 11/03/22) said he did not recall any of the Rehabilitation Therapists reporting to him that Resident #1 complained of right lower extremity pain or that he/she had edema and swelling. Nurse #2 said he did not assess Resident #1 and said he did not notify the physician. During an interview on 1/19/23 at 12:32 P.M., Nurse #3 (who worked the 7:00 A.M. to 3:00 P.M. shift on Resident #1's unit on 11/03/22) said she did not recall any of the Rehabilitation Therapists reporting to her that Resident #1 complained of right lower extremity pain or that he/she had edema and swelling. Nurse #2 said she did not assess Resident #1 and said she did not notify the physician. Review of Resident #1's medical record indicated there was no documentation to support that any assessments were performed by nursing on 11/03/22 related to a change in condition that was reported to nursing by PTA #1 and OT #1. Furthermore, there was no documentation in Resident #1's medical record to support that the physician was notified of a change in condition on 11/03/22. During an interview on 1/17/23 at 2:15 P.M., the Administrator said that PTA #1 and OT #1 told her that during a therapy session, they noticed that Resident #1 had swelling and edema to his/her right lower extremity and that they reported the change in condition to nursing. The Administrator said that she could not determine what happened other than there was a miscommunication between therapy and nursing about a change in Resident #1's condition. Review of a Hospital Discharge Summary, dated 11/04/22, indicated that Resident #1 presented with significant swelling of the entire right lower extremity with warmth, erythema, tenderness and an ecchymotic area at right lateral calf. Resident #1 was in pain and was unable to walk. Resident #1 was admitted to the hospital where he/she was diagnosed with extensive deep vein thrombosis (DVT) with occlusion of all major deep vessels of the right lower extremity. The Summary indicated that an acute DVT of the right lower extremity, unspecified vein and an acute DVT of proximal vein of the right lower extremity, unspecified laterally was noted on Ultrasound of the right lower extremity. Resident #1 required hospitalization for four days and surgery to implant an inferior vena cava (IVC) filter that can stop blood clots from going up into the lungs.

Based on record review and interviews, for one of three sampled Residents (Resident #1), who had a history of developing deep vein thrombosis (DVT, blood clots), the Facility failed to ensure nursing provided care and services that met professional standards of practice, related to a change in condition, when on 11/03/22, it was reported to nursing that Resident #1 complained of discomfort to his/her right lower extremity and was noted to have edema, swelling and drainage. However, there is no documentation to support Resident #1 was assessed by nursing after being notified of his/her change in condition. Resident #1 was discharged home the next day (11/04/22), complained of right lower extremity pain within an hour of being home and his/her right lower extremity was noted with redness and swelling. Resident #1 was transferred to the hospital where he/she was diagnosed with a DVT of the right lower extremity and required surgical intervention to implant an inferior vena cava (IVC) filter (a small device that can stop blood clots from going up into the lungs). Findings include: Review of the Facility's Policy titled, Change of Condition in a Resident Status, dated March 2017, indicated that the Nurse will notify the resident's physician where there has been a significant change in the resident's physical, emotional and mental condition. The Policy indicated that the Nurse will assess the resident's change of condition and document the findings in the medical record. Review of the Facility's Policy titled, Charting and Documentation, dated as revised April 2022, indicated that any changes in the resident's medical, physical, functional or psychosocial condition shall be documented in the medical record and notification of the physician and family. Resident #1 was admitted to the Facility in October 2022, diagnoses included history of deep vein thrombosis (DVT), rheumatoid arthritis, colitis (inflammation reaction in the colon), and osteoporosis. During an interview on 1/17/23 at 11:55 A.M., Nurse #1 said that on 11/02/22, she completed a skin assessment on Resident #1. Nurse #1 said that she did a full head to toe assessment on Resident #1 and said that he/she did not have any edema, swelling or any complaints of pain to his/her right lower extremity. Review of a Physical Therapy Treatment Encounter Note, dated 11/03/22 at 12:31 P.M., written by Physical Therapist Assistant (PTA) #1, indicated that Resident #1 had a slow shuffled gait during therapy session, complained of right lower extremity discomfort and requested to sit down. The Note indicated that increased edema and drainage was noted to Resident #1's right lower extremity and nursing was informed. During an interview on 1/19/23 at 12:14 P.M., Physical Therapy Assistant (PTA) #1 said that during a therapy session on 11/03/23, Resident #1 complained of pain in her/his right lower extremity. PTA #1 said that when she looked at Resident #1's right lower extremity, she noticed edema, swelling and some drainage. PTA #1 said that she had treated Resident #1 a few days prior and said that his/her right lower extremity was not edematous or swollen and said that Resident #1 did not complain of pain at that time. PTA #1 said there was definitely a change in condition with Resident #1, from when she last saw him/her. PTA #1 said she reported this to the 7:00 A.M. to 3:00 P.M. nurses working on Resident #1's unit. PTA #1 said she assisted Resident #1 into his/her wheelchair and transported him/her to the nursing station on his/her unit. PTA #1 said there were two nurses seated at the nursing station on Resident #1's unit at that time, that she told them about Resident #1's right lower extremity, and then left Resident #1, seated in the wheelchair with the nurses at the nursing station. Review of an Occupational Therapy Treatment Encounter Note, dated 11/03/22 at 1:22 P.M., written by Occupational Therapist (OT) #1, indicated that the therapist attempted to assist Resident #1 with donning socks and Resident #1's right lower extremity was extremely edematous compared to the left lower extremity. The Note indicated that nursing was notified. During an interview on 1/19/23 at 11:53 A.M., Occupational Therapist (OT) #1 said that during a therapy session on 11/03/22, Resident #1's right lower extremity was very edematous and swollen compared to his/her left lower extremity. OT #1 said that she reported this to the 7:00 A.M. to 3:00 P.M. nurse working on Resident #1's unit. During an interview on 1/19/22 at 1:00 P.M., Nurse #2 (who was assigned to care for Resident #1 on the 7:00 A.M. to 3:00 P.M. shift on 11/03/22) said he did not recall any of Rehabilitation Therapists reporting to him that Resident #1 complained of right lower extremity pain and that he/she had edema and swelling noted. Nurse #2 said he did not assess Resident #1 and said he did not notify the physician. During an interview on 1/19/23 at 12:32 P.M., Nurse #3 (who worked the 7:00 A.M. to 3:00 P.M. shift on Resident #1's unit on 11/03/22) said she did not recall any of the Rehabilitation Therapists reporting to her that Resident #1 complained of right lower extremity pain and that he/she had edema and swelling noted. Nurse #2 said she did not assess Resident #1 and said she did not notify the physician. Review of Resident #1's medical record indicated there was no documentation to support that any assessments were performed by nursing on 11/03/22 related to a change in condition that was reported to nursing by PTA #1 and OT #1. Furthermore, there was no documentation in Resident #1's medical record to support that the physician was notified of a change in condition on 11/03/22. During an interview on 1/17/23 at 2:15 P.M., the Administrator said that PTA #1 and OT #1 told her that during their therapy sessions (on 11/03/22) with Resident #1, they noticed he/she had swelling and edema to his/her right lower extremity and said they reported the change in condition to the nurse on his/her unit. The Administrator said that she could not determine what happened other than that there had been a miscommunication between therapy and nursing about a change in Resident #1's condition. Review of a Hospital Discharge Summary, dated 11/04/22, indicated that Resident #1 presented with significant swelling of the entire right lower extremity with warmth, erythema, tenderness and an ecchymotic area at right lateral calf. Resident #1 was in pain and was unable to walk. Resident #1 was admitted to the hospital where he/she was diagnosed with extensive deep vein thrombosis (DVT) with occlusion of all major deep vessels of the right lower extremity. The Summary indicated that an acute DVT of the right lower extremity, unspecified vein and an acute DVT of proximal vein of the right lower extremity, unspecified laterally was noted on Ultrasound of the right lower extremity. Resident #1 required hospitalization for four days and surgery to implant an inferior vena cava (IVC) filter that can stop blood clots from going up into the lungs.

Based on record reviews, interviews, and observations for one of four sampled Residents, (Resident #1), the Facility failed to ensure resident safety and failed to provided adequate supervision to prevent an incident of elopement that resulted in serious harm. On [DATE] at approximately 6:15 A.M., Resident #1 was found outside the Facility in the cold, laying on the ground in a patio area, unresponsive, and was pronounced dead by Emergency Medical Services personnel who responded to the Facility's 911 call. Staff were unaware Resident #1 had exited the Facility and the last time staff recalled seeing him/her on the unit was at 11:30 P.M. on [DATE], when he/she was resting in bed. - On [DATE] during the 11:00 P.M. to 7:00 A.M. shift, during the first set of resident care rounds, Certified Nurse Aide (CNA) #1 entered Resident #1's room at approximately 2:30 A.M., to provide assistance with care as needed to Resident #1 and his/her roommate (Resident #2). CNA #1 assisted Resident #2 with toileting needs, and noted at that time that Resident #1 was not in his/her bed and was not in the bathroom. CNA #1 did not report this to the nurse on duty (Nurse #1) and did not stop to go look for Resident #1, but instead continued on with resident care rounds. - Nurse #1, who worked the 11:00 P.M. to 7:00 A.M. shift that night with CNA #1, was responsible for completion of the [DATE] midnight census, which required Nurse #1 to actually have eyes on the resident at the time of completing the census. Nurse #1 said that although he indicated Resident #1 was accounted for on the midnight census report that night, said he got busy and never actually saw Resident #1 that night. Nurse #1 said when he checked Resident #1's room that night, Resident #1 was not in bed, but that the light was on in the bathroom and said he assumed Resident #1 was in bathroom. - At 5:45 A.M. Family Member (FM) #1 arrived at the Facility to take Resident #1 to an outside appointment. Nurse #1 went to Resident #1's room, noted he/she was not there, and that is when CNA #1 reported to Nurse #1 that Resident #1 had not been in his/her room at 2:30 A.M., during resident care rounds. This is when staff began look for Resident #1 and a Code Yellow (missing resident) was initiated. - Sometime between 6:10 A.M. and 6:15 A.M., Resident #1 was found by staff, laying on the ground in a partially enclosed patio area directly outside of the Rehabilitation Gym Exit door, that was unlocked and unalarmed. Once outside Resident #1 was unable to get back into the Facility through the exit door, because when the exit door is closed, it automatically locks from the inside, and Resident #1 would have needed someone from inside the Facility to let him/her back in. Resident #1 was assessed, noted to be unresponsive and cold to the touch (outside temperature at the time was 35 degrees Fahrenheit), 911 was called, local police and fire departments immediately responded, and Resident #1 was pronounced dead at the scene. Findings include:. Review of the Facility Policy titled, Elopement: Resident Elopement Program, undated, indicated the Facility will follow the Missing Resident Policy in the event a resident elopes from the Facility. Review of the Facility's protocol for a Missing Resident, Elopement Policy and Procedures, indicated if a resident is not found at their usual location, do not assume the resident is safe, take extra steps to look for the resident. Check with other staff members immediately and if needed elicit help in search of the resident. Notify the nurse as soon as possible and activate missing resident protocols. Notify the Director of Nurses and/or Administrator as soon as possible. Review of Facility Policy titled, Emergency Code Calls, dated ,d+[DATE], indicated the purpose of the Policy would ensure all staff are familiar with and know how to call an emergency code. The Policy indicated it is designed to help communicate a dangerous situation quickly and mobilize resources in the event of an emergency. The Policy indicated Emergency Codes in effect included the following; Code Red - Fire, Code Blue - heart or respirations stopping, Code Orange - hazardous material spill or release, Code Gray -combative person, Code Silver - person with weapon, hostage situation, Code Green - internal triage, and Code Name Clear- to clear a code. During interviews on [DATE] at 9:30 A.M. with Certified Nurse Aide #1 and at 12:38 P.M. with Nurse #1, they both said they had received education in the Facility prior to [DATE], on what to do when a resident is noted to be missing, and said they would call a Code Yellow. Although, staff interviewed said when resident cannot be located, that they would follow Facility Policy and call a Code Yellow (Missing Resident), further review of the Facility's Emergency Code Policy, provided to the surveyors at the time of the initial survey ([DATE]), indicated the Policy did not include Code Yellow with procedures for staff to implement and follow. Review of the report submitted by the Facility via the Health Care Facility Reporting Systems (HCFRS), dated as submitted [DATE], indicated Resident #1 was not found in his/her room, however, after a perimeter check Resident #1 was discovered outside of the rehabilitation room exit door, he/she was unresponsive. Review of the Facility Incident Report, dated [DATE], indicated Resident #1 was not seen in his/her room and a Code Yellow was called at approximately 6:00 A.M. (exact time unknown). The Report indicated the search led to finding Resident #1 outside the rehabilitation door in a courtyard, and that Resident #1 was unresponsive. Review of Fire Department Incident Report, dated [DATE], indicated at 6:25 A.M., Emergency Medical Services (EMS) and the Fire Department arrived at the scene. Resident #1 was found outdoors lying on his/her right side with his/her feet appearing to be stuck underneath the metal fence. The Report indicated Resident #1 was pulseless and apneic (cessation of respirations) with fixed pupils. The Report also indicated Resident #1 was extremely cold to touch, had rigor mortis (stiffening of the joints and muscles of the body a few hours after death) of the jaw, and possible dependent lividity (reddish-blue discoloration of the skin resulting from the gravitational pooling of blood in the blood vessels) noted on his/her right side. The Report indicated Electrocardiogram (ECG) monitor was applied and showed asystole (state of total cessation of electrical activity from the heart). The Report also indicated Resident #1's lung sounds and heart sounds were auscultated (examining patient by listening to sounds from heart or lungs with a stethescope) for one minute with no sounds heard. The Report indicated Resident #1 had advanced directives in place and was a Do Not Resuscitate (DNR), documentation was produced by the Facility and resuscitation was withheld. The Report indicated that at 6:40 A.M., Resident #1 was pronounced dead. Review of the Police Department Incident Report, dated [DATE], indicated Police were called to the Facility at 6:17 A.M. on [DATE] regarding the discovery of an unconscious and unresponsive subject laying on the ground outside of the Facility. The Report indicated that the subject was identified as Resident #1, and resided in the Facility. The Report indicated Resident #1 was found lying on his/her right side on a concrete patio at the eastern side of the Facility. The Report indicated Resident #1 was wearing blue cotton pants and a T-shirt, and his/her feet were protruding underneath the patio's 8-foot-high metal fence. The Report indicated Resident #1's sneakers were located on the opposite side of the fence. The Report indicated that at approximately 6:40 A.M., a Paramedic determined Resident #1 to be deceased . Resident #1 was admitted to the Facility in February 2022, diagnosis included end stage [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], malnutrition, a stage two pressure injury to his/her and buttocks, and depression. Resident #1 was alert, oriented, was able to make his/her needs known to staff, and was assessed to have a BIMS (Brief Interview Mental Status) score of 11, which indicated he/she had moderate cognitive impairment. Resident #1's Health Care Proxy was not activated. Review of Resident #1's Plan of Care, dated as initiated [DATE], indicated he/she required the use of a rolling walker or cane for ambulation, depending on his/her status on any given day. Review of Resident #1's Hospital Discharge Summary Emergency Department (ED) Nursing Progress Notes, dated [DATE], indicated Resident #1 made several attempts to leave the Emergency Department, and required redirection from ED staff. The Summary indicated the following; - 11:13 A.M., Resident #1 was found outside (outdoors) of the Emergency Department, confused and disoriented; - Clinical Leader was notified that he/she may require constant observation to avoid this in the future; - 3:38 P.M., ED Nurse went to check in on him/her and he/she was not present in his/her room; - previous ED Nurse reported he/she had been wandering outside of his/her room that shift; - 4:30 P.M., Resident #1 was found in the lobby area of the ED, and Resident #1 said he/she went down the street and came back. Review of Resident #1's Elopement Assessment, completed upon admission to the Facility, indicated he/she was not considered to be at increased risk for elopement, at that time. Review of Resident #1's Certified Nurse Aide (CNA) Documentation Survey Report, dated [DATE], indicated he/she had exhibited wandering behaviors on both the 7:00 A.M. 3:00 P.M. (day) shift and the 3:00 P.M. to 11:00 P.M. (evening) shift. The Report indicated Resident #1 was wandering, required redirection, and his/her behaviors were unchanged. Further review of the Documentation Survey Report, for Resident #1's entire admission stay from February 2022 to [DATE], indicated staff documented behaviors on only one other occasion, [DATE], which also occurred on the 11:00 P.M. to 7:00 P.M., that indicated he/she wandered during that shift and required redirection. Review of Resident #1's Medical Record indicated there was no documentation to support that Resident #1's change in behavior on [DATE] (that occurred on the both the day and evening shifts), with increased agitation, wandering, and exiting the Facility, were reported to oncoming staff on the night shift. There was no documentation to support an incident report was completed or that the physician was notified of his/her change in behavior. During an interview on [DATE] at 10:17 A.M., the Director of Rehabilitation (DOR) said on [DATE] during the 7:00 A.M. to 3:00 P.M. (day) shift, she was treating a resident and said she heard Resident #1 yelling out and looking for his/her significant other. The DOR said Resident #1 appeared agitated, as if he/she was searching for someone. The DOR said Resident #1 told her that he/she was in pain, and said she attempted to re-direct Resident #1 back to his/her room on the unit. The DOR said instead of going into his/her room, Resident #1 walked past her, opened the Rehabilitation Gym Room door, which was unlocked, and he/she went into the gym. The DOR said Resident #1's room on the unit was only about 10 feet away from the Rehabilitation Gym Room. The DOR said Resident #1 began to head for the Exit door located within the Gym. The DOR said she placed her body between Resident #1 and the exit door trying to re-direct Resident #1 so he/she would not exit the building. The DOR said Resident #1 went around her and was able to exit the building into the patio area. The DOR said at that time the Rehabilitation Gym exit door (which was equipped with an alarm that is activated when the door handle, push bar is depressed to open it) did not sound because the alarm had been deactivated some time ago. The DOR said she could not give a specific date the alarm was deactivated, but said construction in the Facility started in [DATE], and she said it was deactivated prior to that. The DOR said the Rehabilitation Gym had not been in use for months. The DOR said she reported Resident #1's exit seeking behavior to the Unit Manager and said the Unit Manager told her it was probably terminal agitation (anxious, restless or distressed behaviors that can occur at the end of life). The DOR said she immediately locked the inside rehabilitation gym door (the door between the unit and the gym) and in-serviced the rehabilitation staff on duty regarding the importance of locking the inside rehabilitation gym door. The DOR said she did find the inside rehabilitation gym door unlocked one more time during the remainder of her shift that day. During an interview on [DATE] at 3:02 P.M., the Unit Manager said the Director of Rehabilitation (DOR) had reported to her sometime on [DATE] during the day shift of the interaction she had between Resident #1 and herself (DOR). The Unit Manager said she immediately informed the Director of Nurses (DON) so that she (DON) could speak directly to the DOR. The Unit Manager said she was told by the Director of Nurses that it was nothing, so she did not investigate the incident any further. During an interview on [DATE] at 2:22 P.M., the Director of Nurses (DON) said the Unit Manager did inform her of the incident on [DATE], between Resident #1 and the Director of Rehabilitation (DOR). The DON said the way the incident was described to her by the Unit Manager, she thought Resident #1 was working outside with a physical therapist. The DON said the DOR would always go directly to her with important issues, and said when the DOR did not report the specifics directly to her, said she thought nothing of it. During an interview on [DATE] at 12:18 P.M., the (acting) Assistant Director of Nurses (ADON) said on [DATE] she worked the 3:00 P.M. to 11:00 P.M. (evening) shift. The ADON said she did not receive any information during shift change report about Resident #1 getting through the Rehabilitation Gym Exit Door and making it to the outside patio area. The ADON said she last saw Resident #1 at 11:30 P.M. (at the end of the evening shift) and said Resident #1 was in bed with his/her eyes closed. During an interview on [DATE] at 9:30 A.M., Certified Nurse Aide (CNA) #1 said he went into work at 11:00 P.M. on [DATE], for the overnight shift and was assigned to work on Resident #1's unit. CNA #1 said he did not receive shift change report from either the off going CNA or Nurse #1. CNA #1 said he went to visibly checked the Fall Risk residents and then began stocking carts with linens. CNA #1 said at approximately 2:00 A.M. on [DATE], he began resident care rounds. CNA #1 said he started his rounds with room #101 and worked his way through to the end of the unit. CNA #1 said when he reached Resident #1 (A bed) and Resident #2's (B bed) room, he emptied Resident #2's urinal in the bathroom. CNA #1 said he did not see Resident #1 in bed or in the bathroom. CNA #1 said he was not surprised or concerned about Resident #1 not being in his/her room because Resident #1 was generally independent with his/her care. CNA #1 said he did not inform Nurse #1 that Resident #1 was not in his/her room at that time. CNA #1 said that sometime between first and second rounds, Nurse #1 informed him that Resident #1 had an early appointment in Boston and he/she needed to be ready. CNA #1 said at approximately 4:40 A.M. he began his last set of rounds, again starting with room #101 working his way to the end of the unit, where Resident #1's room was located. CNA #1 said at approximately 5:40 A.M., he entered Resident #1's room to ensure he/she was ready for his/her appointment and said he did not find him/her in the room. CNA #1 said Nurse #1 was entering the room at the same time to get Resident #1 because Family Member #1 had arrived. CNA #1 said that was when he told Nurse #1 that Resident #1 was not in his/her room during first rounds. CNA #1 said he and Nurse #1 began to search for Resident #1, after about ,d+[DATE] minutes of searching, he said Nurse #1 called a Code Yellow and other staff members also help started to look for him/her. During an interview on [DATE] at 12:38 P.M., Nurse #1 said he was working the 11:00 A.M. to 7:00 A.M. shift on [DATE] in to [DATE]. Nurse #1 said he received report from the 3:00 P.M. to 11:00 P.M. nurse, and said there was no mention of anything unusual regarding Resident #1 except that he/she had an early appointment the following morning and he/she needed to be up, dressed and ready to go early. Nurse #1 said after he received shift report, CNA #1 went to do resident care rounds and said he stayed with the high-risk/fall residents. Nurse #1 said one of his responsibilities on the 11:00 P.M. to 7:00 A.M. shift is to complete the midnight census on his assigned unit. Nurse #1 said on [DATE], he started the midnight census rounds at room #101, at some point he was called away while completing the census, so his process was interrupted. Nurse #1 said when he went back to doing the midnight census, (exact time unknown) and got to the other side of the unit (Resident #1's hallway) said he only saw the bathroom light on in Resident #1's room, and since Resident #1 was not in his/her bed, he said he assumed Resident #1 was in the bathroom. Nurse #1 said he knows he completed the midnight census in the earlier part of his shift (exact time unknown). Nurse #1 said he included Resident #1 on the midnight census, but said he never visually put eyes on Resident #1 at any time during his shift. Review of Facility Policy titled, Census Report, dated ,d+[DATE], indicated the following: - a daily census must be maintained and completed by the Facility; - a dated and signed census report must be submitted to the administrative office daily; - the Nurse Supervisor or Charge Nurse on the third shift (11:00 P.M. to 7:00 A.M.), is responsible for completing and signing the census report; and -the daily census report must reflect the resident count at midnight each night and include the names of all residents admitted or discharged during the previous twenty-four-hour period. Review of the Facility Midnight Census Report, for [DATE] into [DATE], for Resident #1's Unit, indicated Nurse #1 certified and signed that there were thirty residents, including Resident #1 on the unit. Nurse #1 said at approximately 5:40 A.M. he let Family Member #1 into the building and returned to the unit to get Resident #1. Nurse #1 said upon entering Resident #1's room along with CNA #1, and said they did not find Resident #1 in his/her room. Nurse #1 said they both began to look and said after searching room to room and other places, he said he called a Code Yellow. Nurse #1 said a nurse from another unit went outside, conducted a perimeter search of the Facility and the grounds and said Resident #1 was found inside the fenced in area of the rehabilitation patio by Nurse #3. Nurse #1 said upon assessment of Resident #1, he/she was unresponsive to verbal or tactile stimuli, no pulse was noted, and said Resident #1 was absent of respirations. Nurse #1 said he did not have his cell phone on his person and said the unit secretary dialed 911 at 6:17 A.M. and reported to dispatch that a resident was found outside the Facility, unresponsive. Review of Resident #1's Medication Administration Record (MAR), dated for [DATE], indicated Nurse #1 also documented and signed as completed, an assessment of Resident #1's pain, an assessment of the use of his/her side-rails, and that Resident #1 was encouraged to elevate his/her feet during the 11:00 A.M. to 7:00 A.M. (night) shift. However, based on Nurse #1's interview in which he admitted to not seeing Resident #1 at all during the night shift, these assessments would not be considered a reliable indicator of trying to determine when Resident #1 walked away from the unit and exited the building. During an interview on [DATE] at 11:40 A.M., the Director of Maintenance said when he started his employment at the Facility on [DATE], he was told the Rehabilitation Gym Exit door leading to the patio was used to come and go by staff members and was not alarmed. The Director said if any employee or resident were to try and go through that door, that it would not be locked and not alarmed and said they would be able to go right outside through to the patio area. Review of the Facility Door Alarm Status Form, dated for the months of [DATE] and February 2022, indicated that the Rehabilitation Exit door was locked, however, the Alarm status is recorded as Not Applicable (N/A). During an observation of the Facility Rehabilitation Gym on [DATE] at 11:10 A.M., the Surveyor observed the inside Rehabilitation Gym Door (door between the unit and gym) was locked with a keypad code. Upon entering the gym, the Surveyor went to the Exit Door leading to the outside patio, depressed the bar handle and pushed on it, the surveyor was able to open the door and exit the gym to the outside. The Surveyor noted the Exit Door alarm did sound. The Director of Maintenance said the Rehabilitation Gym Exit door alarm had been reactivated as a result of the [DATE] incident. Approximately 20 feet away from the exit door to the right, was a solid black door leading to a closet, there was no locking mechanism of any kind on this door. The Surveyor was able to open the closet door and once in the closet, about 5 feet to the right was an exit door leading into the partially enclosed patio, this door was also unlocked. The Director of Nurses said she was called early in the morning on [DATE] by the ADON, who informed her that a resident had been found outside. The DON said she was unaware that both Nurse #1 and CNA #1 had not seen Resident #1 at all on the 11:00 P.M. to 7:00 A.M. shift until both staff were interviewed by the Police Department. The DON said it is her expectation that the nurse must complete the midnight census while seeing each resident and it should be done at the beginning of the shift. During an interview on [DATE] at, 3:02 P.M., the Administrator said she received a phone call early in the morning on [DATE] from the ADON saying there had been an event at the Facility and that she needed to come to the Facility immediately. The Administrator said the Police, Fire Department, and Emergency Medical Services were present getting statements and she said she was counseling staff and entered the Department of Public Health reportable Event. The Administrator said she was unaware that Resident #1 had exited the Facility earlier in the day on [DATE] and had required redirection from the Director of Rehabilitation. The Administrator said she was unaware that the Rehabilitation Room Exit Door alarm had been deactivated.

Based on observation, interviews and record review , the Facility failed to ensure for 1 Resident (#67) of a total sample of 22 Residents, that there was adequate supervision and assistance devices to prevent falls including revision of the comprehensive care plan to create an environment free from accident hazards resulting in 6 falls including 2 with injury. Findings include: Review of the Facility's policy titled, Fall Management Guideline, indicated the following: *Residents will have a Fall Risk Evaluation completed upon admission. *Residents will be considered high risk for falls if they meet the following criteria: a. have fallen within the last 3 months b. have a score of 10 or above on the Fall Risk Evaluation form *Residents identified as high risk for falls will have an interim fall care plan developed upon admission. a. use Fall Care Plan Intervention Tool for suggested interventions based on identified risk factors b. update certified nursing assistant (CNA) care card/plan of care (POC) with appropriate interventions c. residents identified as high risk for falls, including new admissions, will be reviewed and care plans and CNA care cards updated as necessary *After the resident has been evaluated, the licensed nurse: f. updates the resident's care plan with identified interventions Resident #67 was admitted to the facility in October of 2019 and had [DIAGNOSES REDACTED]. Review of Resident #67 admission Fall Risk Evaluation form dated 10/05/19, indicated staff failed to follow the written instructions as the fall risk assessment was incomplete and ,therefore, did not accurately reflect the Resident's fall risk. Review of the Baseline Care Plan dated 10/5/19 indicated assistive devices of 1/4 upper bilateral bedrails, a rolling walker, and a wheelchair to prevent falls. Review of the Minimum Data Set (MDS) with a reference date of 10/10/19, indicated that Resident #67 had a score of 0 of 15 on the Brief Interview for Mental Status (BIMS), indicating that the Resident was severely cognitively impaired. The Resident required extensive assist for bed mobility, transfer, walking, toileting, and locomotion on unit. Mobility devices included a walker and a wheelchair and the Resident had a fall in the last month prior to admission, 2-6 months prior to admission, and a fracture related to a fall in the 6 months prior to admission. Review of Resident #67 Comprehensive Care Plan dated 10/15/19 indicated the following: 1. Keep call light and most frequently used personal items within reach 2. Provide verbal reminders to resident to call when needing assistance 3. Maintain room and pathways free of clutter, and insure adequate lighting-provide night light if needed 4. Toilet resident frequently or upon request 5. PT/OT evaluation as indicated 6. Make sure that all staff members are aware that resident is at high risk for falls 7. Make sure resident's shoes are well fitting with non-slip soles 8. Modify clothing if necessary 9. Instruct resident to sit on side of bed for one minute before standing 10. Assess need for fall interventions such as: low bed, gripper socks, raised toilet seat, padded floor next to bed 11. Provide chair with arms to assist with rising 12. Educate resident in safety awareness 13. Assess medications for contributing factors 14. Maintain record of falls, and evaluate for patterns Review of the clinical record indicated the following 6 incident/falls: (Fall #1) Review of the 10/23/19 fall Event/Incident Report indicated that at 11:30 P.M., Resident #67 had an unwitnessed fall in the room of another resident. (Fall #2) Review of the #1 of 2 fall on 11/08/19 Event/Incident Report indicated that at 12:00 P.M., Resident #67, during transfer with staff assistance, slid out of the wheelchair without injury. (Fall #3) Review of the #2 of 2 fall on 11/08/19 Event/Incident Report indicated that at 3:45 P.M., Resident #67 fell at the nurse's station while self-transferring. The fall was witnessed and resulted in a laceration above the Resident's left eyebrow after the Resident's face hit the floor, breaking his/her glasses. The Resident was transported to the emergency department for evaluation and returned the same day with 6 sutures. Immediate interventions included the Resident to be in supervised areas, a referral to physical therapy for gait training and balance, and to increase the Resident's ambulation to walking with a rolling walker (not added to the comprehensive care plan). (Fall #4) Review of the 11/15/19 fall Event/Incident Report indicated that at 1:00 P.M., Resident #67 had an unwitnessed fall in the dining room. Resident #67 was not in a supervised area. Immediate new interventions included a referral to physical therapy (PT) and occupational therapy (OT) to adjust the arms on the Broda chair, to secure the wheelchair at the table and approach from the front with explanation which were all added to the comprehensive care plan. (Fall #5) Review of the 11/16/19 fall Event/Incident Report indicated that at 7:05 A.M., Resident #67 was found lying on the floor of Resident #67's room in a prone position with the Resident's foot under the bed and he/she faced toward the dresser. Resident #67 was not in a supervised area. The Resident was transported to the hospital and admitted with an acute right [MEDICAL CONDITION]. Upon readmit to the Facility, fall interventions included maintaining the bed in a low position, and placing mats on the floor along the sides of the bed (already listed on the comprehensive care plan). (Fall #6) Review of the 11/23/19 fall Event/Incident Report indicated that at 1:30 P.M., Resident #67 was found on the floor next to the bed with the floor mat in place. During an interview on 1/6/19 at 2:18 P.M., the surveyor asked Unit Manager #1 (UM) about interventions for falls. The UM #1 said interventions are documented in the care plan or the fall risk packets after each fall and the Certified Nursing Assistant (CNA) care cards (which had not been updated despite 6 falls). During an interview on 1/7/19 at 1:05 P.M., the Administrator said a resident's comprehensive care plan and CNA care card should be revised after each fall with interventions written accordingly after each fall. The Facility failed to provide adequate supervision and assistance devices and create an environment free from accident hazards to prevent falls during a 4 week period which resulted in this resident sustaining 6 falls including 2 with injury.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), the Facility failed to ensure that after becoming aware of Resident #1's burns, that the physician was immediately notified. On 11/13/2017 it was discovered by nursing that Resident #1 spilled hot coffee onto his/her left and right thigh, resulting in full thickness (third-degree)[MEDICAL CONDITION] partial thickness (second-degree) burns, spilled hot coffee onto his/her left lower extremity and groin, resulting in partial thickness (second degree) burns. - Resident #1 was transferred to the hospital on [DATE], approximately 16 hours after the Facility became aware of his/her burns. Resident #1 was admitted to the ICU (Intensive Care Unit) Burn Unit with superimposed cellulits (serious bacterial infection of the skin), required IV (Intravenous) antibiotics and surgical management of his/[MEDICAL CONDITION] excisional debridement and skin grafting. Findings include: A Quarterly Minimum Data Set (MDS), dated [DATE], indicated that Resident #1 was alert, oriented and totally independent with all aspects of care. Resident #1's medical [DIAGNOSES REDACTED]. The Facility Policy, titled Notification of Changes, dated 10/2000, indicated the facility will promptly notify the appropriate individuals regarding changes which directly involve the resident and immediately inform the physician when there is an accident involving the resident, a need to alter treatment significantly and document in the clinical record when notification is given. The Facility Policy titled, Skin Integrity and Wound Care, dated 11/2015, indicated it is Facility policy to provide a systematic approach and monitoring process for skin integrity. The Policy indicated the physician will be contacted to obtain treatment orders as indicated. The Policy further indicated that the licensed nurse will be responsible to assess the resident's skin and document any findings. The Policy further indicated the physician, nurse manager, dietician, rehab and skin team leader will be notified of any skin impairments. The Facility Policy, titled Event and Incident Report, dated 11/2015, indicated it was the center's policy to provide an environment that is free from hazards over which the center has control. The Policy further indicated in the event of an accident, the licensed nurse notifies the provider, responsible party and center Administrative staff. An Incident/Accident Report, dated 11/14/17, indicated that at approximately 9:00 P.M. on 11/13/17, Nurse #1 noted red areas on Resident #1's legs, questioned him/her and was informed by Resident #1 that he/she was making a pot of coffee, the glass pot cracked and the hot coffee burnt his/her left leg and right stump. There was no documentation to indicate when Nurse #1 observed Resident #1'[MEDICAL CONDITION] 11/13/17 that the physician was notified. A Situation Background Appearance Review and Notify (SBAR) Note, dated 11/14/17 at 12:55 P.M., indicated Resident #1 reported spilling coffee on self and was noted with [MEDICAL CONDITION] his/her bilateral lower extremities including two fluid filled intact blisters on his/her left calf and his/her right inner thigh, reported his/her pain to be an eight on a scale of one through ten (ten representing the worst pain possible), the physician was notified and Resident #1 was transferred to the hospital. A Physician's Interim Order, dated 11/14/17 at 1:00 P.M., indicated to send Resident #1 to the hospital for evaluation of his/her burn. An Investigation Statement, dated 11/15/17, indicated that two days prior at 9:00 P.M. on 11/13/2017, Nurse #1 noted fluid filled blisters to Resident #1's left inner knee and thigh, Nurse #1 asked Resident #1 what happened and Resident #1 said he/she spilled hot coffee on him/herself three days ago. The Surveyor interviewed Nurse #1 at 12:58 P.M. on 12/15/17. Nurse #1 said that on 11/13/17 at approximately 9:00 P.M. she saw redness and a blister on Resident #1's left leg, left knee, left thigh and the back of his/her left calf. Nurse #1 said she asked Resident #1 what happened and Resident #1 said that he/she burned him/herself with hot coffee a few days ago. Nurse #1 said she did not assess Resident #1'[MEDICAL CONDITION] passed the information on to Nurse #2. There was no documentation to indicate Nurse #1 completed a full skin assessment of Resident #1'[MEDICAL CONDITION] that Nurse #1 notified Resident #1's physician. The Surveyor interviewed Nurse #2 at 1:16 P.M. on 12/15/17. Nurse #2 said that on 11/13/17 at approximately 9:30 P.M., Nurse #1 told her that she [MEDICAL CONDITION] Resident #1's legs. Nurse #2 said she did not notify Resident #1's physician because she misunderstood Nurse #1 and did not understand that Nurse #1 had not called Resident #1's physician to obtain treatment orders and said she did not understand the severity or urgency, or words to that effect, of Resident #1's burns. Nurse #2 said she never saw Resident #1, did not assess Resident #1'[MEDICAL CONDITION] notify the physician of his/her burns. The Surveyor interviewed the Director of Nurses at 4:15 P.M. on 12/15/17. The DON said she was not notified of Resident #1'[MEDICAL CONDITION] sometime late in the morning on 11/14/17 by the Unit Manager. The DON said she and the Unit Manager assessed Resident #1'[MEDICAL CONDITION] 11/14/17, notified the physician and Resident #1 was transferred to the hospital. The DON said that on 11/13/17, when Nurse #1 became aware of Resident #1's burns, Nurse #1 should have assessed Resident #1's burns, and notified the physician of Resident #1's burns. The Hospital Discharge Summary, dated 12/4/17, indicated Resident #1 presented on 11/14/17 after a scald burn to the groin and bilateral thighs from coffee spilled, resulting in full thickness (third-degree)[MEDICAL CONDITION] bilateral thighs and partial thickness (second degree)[MEDICAL CONDITION] bilateral thighs, lower left leg and groin. The Hospital Discharge Summary further indicated, Resident #1 required excisional debridement and skin grafting of his/her burns. The Hospital Discharge Summary, dated 12/20/2017, indicated Resident #1 was readmitted to the hospital on [DATE] for treatment of [REDACTED].

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), the Facility failed to ensure that after becoming aware of Resident #1's burns, nursing assessed his/her burns, took appropriate actions to provide care and treatment for [REDACTED].#1 to the hospital for evaluation and treatment of [REDACTED]. Resident #1 spilled hot coffee onto his/her left and right thigh, resulting in full thickness (third-degree)[MEDICAL CONDITION] partial thickness (second-degree) burns, his/her left lower extremity and groin, resulting in partial thickness (second degree) burns. Resident #1 was transferred to the hospital approximately 16 hours after the Facility became aware of his/her burns, where he/she was admitted to the ICU (Intensive Care Unit) Burn Unit with superimposed cellulits (serious bacterial infection of the skin), required IV (Intravenous) antibiotics and surgical management of his/[MEDICAL CONDITION] excisional debridement and skin grafting. Findings include: A Quarterly Minimum Data Set (MDS), dated [DATE], indicated that Resident #1 was alert, oriented and totally independent with all aspects of care. Resident #1's medical [DIAGNOSES REDACTED]. The Facility Policy, titled Notification of Changes, dated 10/2000, indicated the facility will immediately inform the physician when there is an accident involving the resident, a need to alter treatment significantly and document in the clinical record. The Facility Policy, titled Event and Incident Report, dated 11/2015, indicated in the event of an accident, the licensed nurse renders immediate assistance as necessary, completes an evaluation of the resident and the environment, notifies the provider, responsible party and center Administrative staff, documents a factual account of the event in the interdisciplinary progress notes, completes incident report and additional assessments, documents each shift for 72 hours post incident and initiates measures to prevent re-occurrence. An Investigation Statement, dated 11/13/17, indicated Nurse #2 was informed by Nurse #1 that, at approximately 9:00 P.M. on 11/13/2017, Nurse #1 observed what appeared to be a healing burn on Resident #1's leg. The Statement indicated Nurse #2 did not notify Resident #1's physician because she misunderstood Nurse #1 and did not understand that Nurse #1 had not called Resident #1's physician to obtain treatment orders and she did not understand the severity or urgency of Resident #1's burns. An Incident/Accident Report, dated 11/14/17, indicated Nurse #1 noted, on 11/13/17, red areas on Resident #1's legs, questioned him/her and was informed by Resident #1 that he/she was making a pot of coffee, the glass pot cracked and the hot coffee burnt his/her left leg and right stump. The Report indicated Resident #1 did not report the incident to anyone and Resident #1 was sent to the hospital, at approximately 1:00 P.M. on 11/14/17, for treatment of [REDACTED]. A Situation Background Appearance Review and Notify (SBAR) Note, dated 11/14/17 at 12:55 P.M., indicated Resident #1 reported spilling coffee on self and was noted with [MEDICAL CONDITION] his/her bilateral lower extremities including two fluid filled intact blisters on his/her left calf and his/her right inner thigh, reported his/her pain to be an eight on a scale of one through ten (ten representing the worst pain possible), the physician was notified and Resident #1 was transferred to the hospital. An Investigation Statement, dated 11/15/17, indicated that two days prior, at 9:00 P.M. on 11/13/2017, Nurse #1 noted fluid filled blisters to Resident #1's left inner knee and thigh, Nurse #1 asked Resident #1 what happened and Resident #1 said he/she spilled hot coffee on him/herself three days ago. The Facility was unable to provide supporting documentation to indicate a full skin assessment was completed on Resident #1 and the Facility was unable to provide supporting documentation that a description of [MEDICAL CONDITION] size of Resident #1'[MEDICAL CONDITION] assessed. There was no documentation to indicate the nurse notified the physician or administration, documented the incident in the interdisciplinary progress note, completed an incident report or initiated measures to prevent re-occurrence. This was not consistent with the Facility Policy titled Event and Incident Report and Notification of Changes. The Surveyor interviewed Nurse #1 at 12:58 P.M. on 12/15/17. Nurse #1 said on 11/13/17 at approximately 9:00 P.M. she saw redness and a blister on Resident #1's left leg, left knee, left thigh and the back of his/her left calf. Nurse #1 said she asked Resident #1 what happened and Resident #1 said that he/she burned himself/herself with coffee a few days ago. Nurse #1 said she did not assess Resident #1'[MEDICAL CONDITION] passed the information on to Nurse #2. Nurse #1 said she did what she thought was appropriate and passed the information about Resident #1'[MEDICAL CONDITION] to Nurse #2. Nurse #1 said Nurse #2 should have taken care of it, or words to that effect. Nurse #1 said it was Nurse #2's responsibility to assess Resident #1 and notify the physician. There was no documentation to indicate Nurse #1 or Nurse #2 completed a full skin assessment on Resident #1 and no indication that a description of [MEDICAL CONDITION] size of Resident #1'[MEDICAL CONDITION] assessed. The Surveyor interviewed Nurse #2 at 1:16 P.M. on 12/15/17. Nurse #2 said that on 11/13/17 at approximately 9:30 P.M., Nurse #1 told her that she [MEDICAL CONDITION] Resident #1's legs [MEDICAL CONDITION] to be healing and did not need a treatment. Nurse #2 said she did not notify Resident #1's physician because she misunderstood Nurse #1 and did not understand that Nurse #1 had not called Resident #1's physician to obtain treatment orders and she did not understand the severity or urgency of Resident #1's burns. Nurse #2 said she never saw Resident #1, did not assess Resident #1'[MEDICAL CONDITION] notify the physician of his/her burns. The Surveyor interviewed the Director of Nurses at 4:15 P.M. on 12/15/17. The DON said she was not notified of Resident #1'[MEDICAL CONDITION] sometime late in the morning on 11/14/17 by the Unit Manager. The DON said she and the Unit Manager assessed Resident #1'[MEDICAL CONDITION] 11/14/17, notified the physician and Resident #1 was transferred to the hospital. The DON said that on 11/13/17, when Nurse #1 became aware of Resident #1's burns, Nurse #1 should have assessed Resident #1's burns, notified the supervisor and the physician of Resident #1'[MEDICAL CONDITION] document her observations. The DON said Nurse #1 did not follow acceptable standards of practice, did not follow facility policy and made a big error in professional judgement, or words to that effect. The Hospital Discharge Summary, dated 12/4/17, indicated Resident #1 presented on 11/14/17 after a scald burn to the groin and bilateral thighs from coffee spilled, resulting in full thickness (third-degree)[MEDICAL CONDITION] bilateral thighs and partial thickness (second degree)[MEDICAL CONDITION] bilateral thighs, lower left leg and groin. The Hospital Discharge Summary further indicated, Resident #1 required excisional debridement and skin grafting of his/[MEDICAL CONDITION] 11/16/2017 and further surgical skin grafting on 11/22/2017. The Hospital Discharge Summary, dated 12/20/2017, indicated Resident #1 was readmitted to the hospital on [DATE] for treatment of [REDACTED].

Based on records reviewed and interviews, the Facility failed to provide adequate supervision to prevent accidents, when Resident #1 had access to a coffee maker, brewed coffee unsupervised, and as a result of the coffee pot breaking, spilled hot coffee onto his/her left and right thigh resulting in full thickness (third-degree)[MEDICAL CONDITION] partial thickness (second-degree)[MEDICAL CONDITION] on his/her left lower extremity and groin resulting in partial thickness (second degree) burns. Resident #1 was transferred to the hospital approximately 16 hours after the Facility became aware of his/her burns, where he/she was admitted to the ICU (Intensive Care Unit) Burn Unit with superimposed cellulits (serious bacterial infection of the skin), required IV (Intravenous) antibiotics and surgical management of his/[MEDICAL CONDITION] excisional debridement and skin grafting. - Although Resident #1, who had a [DIAGNOSES REDACTED].#1's ability to safely operate the coffee maker, no indication Resident #1 was provided with education about the risks [MEDICAL CONDITION] skin trauma from hot liquid and no indication of education provided to Resident #1 about the potential risk of the inability to feel temperature changes, which could increase his/her risk [MEDICAL CONDITION] hot water, as a result of his/her [DIAGNOSES REDACTED]. Findings include: A Quarterly Minimum Data Set (MDS), dated [DATE], indicated that Resident #1 was alert, oriented and totally independent with all aspects of care. Resident #1's medical [DIAGNOSES REDACTED]. The Burn Foundation's Fact Sheet, published in 2017 and titled Safety Facts on [MEDICAL CONDITION]: the two highest risk populations for [MEDICAL CONDITION] children under the age of 5 and adults over 65; hot liquids can cause life-threatening burn injuries; coffee, tea, soup and hot tap water can be hot enough to cause serious burn injury and when tap water reaches 140º F it can cause a third degree (full thickness) burn in just five seconds. A Mayo Foundation for Medical Education and Research (MFMER) fact sheet, dated 8/9/2017 and titled Peripheral [MEDICAL CONDITION] indicated: Complications of [MEDICAL CONDITION] can include: -[MEDICAL CONDITION] skin trauma. You might not feel temperature changes or pain on parts of your body that are numb. - Infection. Your feet and other areas lacking sensation can become injured without your knowing. The Facility Policy, titled Event and Incident Report, dated 11/2015, indicated it was the center's policy to provide an environment that is free from hazards over which the center has control. A Facility report in the Health Care Facility Reporting System (HCFRS), dated 11/14/2017, indicated Resident #1 was making a pot of coffee in the main dining room with no staff present, the glass coffee pot cracked and hot coffee burnt Resident #1's left leg and right stump. The BUNN Coffee Maker (identified by the Facility as the coffee maker used in the main dining room at the time of Resident #1's incident) Installation and Operating Guide, dated 11/2015, indicated the brew water temperature is factory set at 200 degrees Fahrenheit. The Facility Food Temperature/Sanitation Record, dated 11/11/17 through 11/14/17, indicated the coffee temperature readings were consistently 150 degrees Fahrenheit for the trays tested . The Surveyor observed, at 9:10 A.M. on 12/15/2017, the area where the BUNN Coffee Maker, which utilized glass coffee pots, had been located. This area was observed to be around a corner in the main dining room, was easily accessible to residents; however, a resident in this area would not be visible to staff from the main dining room entrance door. This was not consistent with the Facility's Policy titled Event and Incident Report which indicated it was the center's policy to provide an environment that is free from hazards over which the center has control. An Investigation Statement, dated 11/13/17, indicated Nurse #2 was informed by Nurse #1 that, at approximately 9:00 P.M. on 11/13/2017, Nurse #1 found what looked to be a healing burn on Resident #1's leg. An Incident/Accident Report, dated 11/14/17, indicated Nurse #1 noted red areas on Resident #1's legs, questioned him/her and was informed by Resident #1 that he/she was making a pot of coffee, the glass pot cracked and the hot coffee burnt his/her left leg and right stump. The Report indicated Resident #1 did not report the incident to anyone and Resident #1 was sent to the hospital for treatment of [REDACTED]. A Situation Background Appearance Review and Notify (SBAR) Note, dated 11/14/17 at 12:55 P.M., indicated Resident #1 reports spilling coffee on self and was noted with [MEDICAL CONDITION] his/her bilateral lower extremities including two fluid filled intact blisters on his/her left calf and his/her right inner thigh, reports pain to be an eight on a scale of one through ten (ten representing the worst pain possible), the physician was notified and Resident #1 was transferred to the hospital for evaluation. There was no documentation to indicate the nurse notified the physician, administration, documented the incident in the interdisciplinary progress note, completed an incident report or initiated measures to prevent re-occurrence. This was not consistent with the Facility Policy titled Event and Incident Report. There was no indication the Facility staff removed the coffee maker and glass coffee pots from the main dining room after staff became aware of Resident #1's incident. The Surveyor interviewed the Director of Nurses (DON) at 4:15 P.M. on 12/15/17. The DON said she was not notified of Resident #1's incident with coffee maker until sometime late in the morning on 11/14/17 by the Unit Manager. The DON said Resident #1 had not been assessed for his/her ability to safely operate the coffee maker because the Facility was unaware he/she had been using it. The Hospital Discharge Summary, dated 12/4/17, indicated Resident #1 presented on 11/14/17 after a scald burn to the groin and bilateral thighs from coffee spilled, resulting in full thickness (third-degree)[MEDICAL CONDITION] bilateral thighs and partial thickness (second degree)[MEDICAL CONDITION] bilateral thighs, lower left leg and groin. The Hospital Discharge Summary further indicated, Resident #1 required excisional debridement and skin grafting of his/[MEDICAL CONDITION] 11/16/2017 and further surgical skin grafting on 11/22/2017. The Hospital Discharge Summary, dated 12/20/2017, indicated Resident #1 was readmitted to the hospital on [DATE] for treatment of [REDACTED].

Based on record review, staff interview and observation, the facility failed to ensure that for one resident (#9) of 22 sampled residents necessary treatment and services were provided to promote healing for 3 pressure ulcers. Findings include: Resident #9 had [DIAGNOSES REDACTED]. According to the initial minimum data set (MDS) with a reference date of 3/1/14, this resident was alert with some difficulty understanding and being understood. Extensive assistance was required for bathing, grooming and dressing and this resident was incontinent of both bowel and bladder. The resident was listed as being at risk for pressure ulcers, but none were coded as present on admission. According to the admission nursing note, this resident's right elbow was in a soft cast with ace bandage from the recent fracture repair. Twenty five staples were noted in the right hip following surgical repair of a right [MEDICAL CONDITION]. This resident was receiving [MEDICATION NAME] (an anticoagulant) for the treatment of [REDACTED]. There was two plus [MEDICAL CONDITION] noted in both lower extremities as well as in the right hand. The admission assessment noted the resident's ankles were red, fragile and tender and the coccyx area was red and fragile. There was a notation of a 3 cm (centimeters) by 3 cm boggy area on the left heel. This resident was evaluated for skin conditions and it was determined the resident was at high risk for developing a pressure ulcer however, there was no treatment obtained and no care plan to address red, fragile heel areas including the left 3 cm by 3 cm boggy area noted as well as the red and fragile coccyx area. Although there was a care plan to address the resident's at risk status for developing pressure ulcers, there was no plan with approaches specific to the areas present on admission to the facility. On 2/24/14, the weekly skin integrity check sheet was reviewed. There as a notation that the right outer ankle was red/blanchable however, there was no notation of the previous red, fragile areas. On 3/3/14, the weekly skin integrity check sheet was reviewed. There was a notation that the coccyx, right and left heels were red. Nurses's notes from 2/22/14 through 3/4/14 were reviewed. There was no documentation of the resident's red and fragile coccyx or the red, fragile, boggy heels or right outer ankle as originally noted in the initial nursing assessment. On 3/5/13, a skin integrity check sheet was completed. There were notations that the coccyx had 2 small open areas and the surrounding skin was red and raw. The left heel was noted to have a 4 cm x 4 cm circumference of red soft tissue. The right heel had a 3 cm by 4 cm red area with with a white center, fragile. Both lower extremities had two plus [MEDICAL CONDITION]. On 3/5/14, nurses' notes documented the following: Skin breakdown on coccyx 0.5 cm open area. The physician was notified and a new order was obtained for [MEDICATION NAME] (topical ointment with zinc oxide and menthol to treat minor skin irritations) to be applied every shift. There was a new order for skin prep to be applied to the left heel and right outer ankle as well as every 2 hour positioning and off loading the heels and ankles. The resident was to be out of bed for all meals. On 3/5/14, the initial documentation of the areas were noted on the pressure ulcer weekly log. The resident had two stage 1(intact skin with non-blanchable redness of a localized areas usually over a bony prominence) areas noted. The first was the left heel which measured 4 cm in diameter and the second was the right outer ankle measuring 4 cm by 3 cm. There was a stage II (partial thickness with loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, with out slough) area noted on the coccyx measuring 1 cm by 0.5 cm. On 3/17/14 at 2:45 P.M., the facility Director of Nurses (DON) was interviewed by the surveyor. She explained that when the resident was admitted , the staff nurse who did the assessment failed to ensure that the physician and staff were aware of the areas she noted on the assessment. On 3/5/14 (12 days after admission) the unit manager noted the areas when she cared for the resident. It was at that time that the physician was notified and weekly documentation including stage, size and appearance of the wounds was started. The wound physician was also notified. On 3/20/14 at 9:00 A.M., a treatment observation was conducted by the surveyor. With the resident's permission, the surveyor entered the resident's room. The resident was in bed and found to be alert and cooperative. The noted areas included: *The coccyx wound was noted as a stage II measuring .25 cm in diameter with a pink center. *The left heel was noted a unstageable area with dark tissue measuring 3 cm by 3 cm. *The right heel was noted to have dark red intact tissue measuring 1 cm by 0.5 cm. *The right outer ankle was an intact darkened area measuring 1 cm by 0.5 cm. with the surrounding discolored skin 3 cm in diameter. The facility failed to ensure that pressure areas noted on admission were promptly treated and services were provided to promote healing of the noted areas for 12 days after admission to the facility.

Based on record review and interviews, for one of four sampled residents, (Resident #1), the Facility failed to provide supervision with ambulation, per care plan, when on 10/3/12 Resident #1 walked into another resident's bathroom unobserved, and fell . Resident #1 was transferred to the Hospital, treated for [REDACTED]. Findings include: Resident #1 was admitted to the Facility May of 2012, and [DIAGNOSES REDACTED]. The falls care plan, dated 9/6/12, indicated that Resident #1 was at risk to fall and he/she required supervision for ambulation on the unit. The certified nurse aide (CNA) flow sheet, dated 9/1/12 to 9/31/12, and 10/1/12 to 10/3/12 indicated that Resident #1 required continual supervision during ambulation. The Surveyor interviewed Nurse #1 on 12/13/12 at 11:00 A.M. Nurse #1 said Resident #1's plan of care for ambulation included supervision in the hallway and independence in his/her room. The Surveyor interviewed the Director of Nurses (DON) on 12/13/12 at 8:20 A.M. The DON said Resident #1's usual routine included ambulation on a secure dementia unit, and he/she was observed by staff as he/she ambulated around the unit with a cane. The DON said on 10/3/12, Resident #1 ambulated unobserved into another resident's room, and fell while using the toilet. The DON said Resident #1 was transferred to the Hospital where it was determined he/she had a fractured left ankle. The nurse's note, dated 10/3/12 for the 7:00 A.M. to 3:00 P.M. shift, indicated that Resident #1 was ambulating on the unit when at approximately 8:15 A.M., Resident #1 was observed by the housekeeping staff on the floor of another resident's bathroom. The nurse's note indicated that Resident #1 was assessed, and he/she complained of left lower extremity pain that ranged 10 (out of a scale of 1 to 10, and 10 represented the worst pain) The nurse's note indicated that Resident #1 also had a laceration over the right eye, and complained of right shoulder pain. The nurse's note indicated that the Physician was notified and Resident #1 was transferred to the Hospital, per physician's orders [REDACTED]. The nurse's note, dated 10/3/12 at 7:00 P.M. indicated that the Hospital notified the Facility that Resident #1 had a fractured left ankle. The nurse's note, dated 10/3/12 at 10:00 P.M., indicated that Resident #1 returned to the Facility after treatment for [REDACTED].

Based on record review and interviews for one of four sampled residents, (Resident #1) the Facility failed to ensure that the personal alarms used as an intervention for falls were in place and functioning properly, per plan of care. Resident #1 fell on [DATE] at 6:45 P.M. Although staff heard the alarm sounding in Resident #1's room after Resident #1 fell and hit his/her head on the wall with enough force to crack the wall, staff were not near enough to Resident #1's room to prevent the fall. The Physician gave staff an order to have Resident #1 evaluated at the Hospital. On 10/24/11, Resident #1 fell at 1:30 P.M. in the bathroom. Per Facility internal investigation Statement, Resident #1's chair alarm did not sound when Resident #1 fell . Resident #1 sustained an abrasion/scrape on the right elbow and right forearm. On 11/7/11 at 6:30 P.M., staff did not attach the chair alarm to Resident #1's dining room chair, Resident #1 fell in the dining room, and Resident #1 sustained a fractured right elbow. Findings include: Resident #1 was admitted to the facility August of 2011, and [DIAGNOSES REDACTED]. The care plan for falls, dated 8/17/11, indicated that Resident #1 was at risk for falls, and interventions included rolling walker with a gait belt and limited assist. The Unit Manager, The Director of Nurses, and Certified Nurse Aide (CNA) #1 were interviewed on 1/3/12, The DON at 8:30 A.M. The Unit Manager at 10:40 A.M. and CNA #1 at 2:00 P.M. The DON, Unit Manager and CNA #2 said that Resident #1 had a chair alarm as an intervention for fall prevention on 10/17/11, 10/24/11 and 11/7/11 at the time of Resident #1's falls. CNA #2 said on 10/17/11, CNA #2 was assigned to provided care to Resident #1, who required contact guard with his/her walker for ambulation. CNA #2 said after dinner, she was in a room providing care to another resident when CNA #2 heard a loud bang, an alarm was sounding in Resident #1's room, and Resident #1 was on the floor of the room. The nurse's note, and incident report, dated 10/17/11, indicated that Resident #1 fell in his/her room at 6:45 P.M. and was found lying against the wall, which was noted to have a large crack in the wall. The nurse's note indicated that the Physician assessed Resident #1 and ordered him/her to the Hospital for evaluation, and Resident #1 returned from the Hospital at approximately 2:00 A.M. The Hospital Nursing procedure:Transfer, dated 10/17/2011, included the [DIAGNOSES REDACTED]. The fall focus note, dated 10/18/11, indicated that the intervention to Resident #1's fall was to ask Resident #1 prior to leaving his/her room, if furniture was set up as he/she wanted. The Rehabilitation Manager was interviewed on 1/3/12 at 1:15 P.M. The Rehabilitation Manager said that Resident #1 had poor safety awareness, and required at the least, close supervision. The nurse's note, dated 10/24/11, indicated that Resident #1 had another fall at approximately 1:30 P.M., when he/she fell in the bathroom, and the chair alarm was not working. The fall focus note, dated 10/25/11, indicated that interventions to Resident #1's fall included change of staff assignment, and motion sensor on bathroom floor. The DON said it appeared that Resident #1 may have turned the chair alarm on "reset" because the alarm was turned on and working after the fall on 10/24/11. The Rehabilitation Manager said that the change of assignments was to be more efficient around lunch breaks and patient care. The quarterly Minimum Data Set (MDS) assessment, completed 11/9/11, indicated that Resident #1 required supervision with ambulation, and was unsteady moving from seated to a standing position, on and off the toilet and between bed and chair. CNA #1 was interviewed on 1/3/12 at 3:15 P.M. CNA #1 said that on 11/7/11, she was assigned to the dining room with other staff persons. CNA #1 said at approximately 6:30 P.M., all residents had eaten, and she and Resident #1 were the only people left in the dining room. Nurse #1 said Resident #1 asked for more ice cream, she gave Resident #1 the ice cream and she turned to put dirty linen away when Resident #1 fell out of the chair. CNA #1 said she called for Nurse #1 immediately to assess Resident #1. Nurse #1 was interviewed on 1/3/12 at 3:00 P.M. Nurse #1 said on 11/7/11, Resident #1 fell in the dining room at approximately 6:30 P.M. Nurse #1 said that Resident #1 was ambulated to the dining room, ate his/her meal, and was the last resident in the dining room. Nurse #1 said that the staff did not bring Resident #1's chair alarm into the dining room, and Resident #1 fell out of the straight backed chair in the dining room . The nurse's note, dated 11/7/11, indicated that at approximately 6:30 P.M. Resident #1 fell in the dining room, after dinner. The nurse's note indicated that Resident #1 complained of right elbow pain, vital signs were within normal limits, the Physician was notified, neurological checks were ordered, an x-ray was done, and indicated that Resident #1 had a right elbow fracture. The nurse's note indicated that both the Physician and Health Care Agent were notified and the Physician ordered a splint for Resident #1. The fall focus note, dated 11/8/11, indicated that Resident #1 would be transferred back to the room right after eating and the chair alarm would go with resident #1. The nurse's note, dated 11/8/11 for the 11:00 P.M. to 7:00 A.M. shift, indicated that Resident #1 was transferred to the Hospital for evaluation and returned to the Facility with the right arm splinted for immobility.