Every finding on record at Regalcare at Lowell

Based on observations, record review and interviews, the facility failed to provide an environment free from accidents and hazards for two Residents (#9 and #39) out of a total sample of 25 residents. Specifically,1. For Resident #9, the facility failed to identify Resident #9's needs to receive 1:1 supervision with meals upon admission, and while eating unsupervised in his/her room, the Resident choked and required the Heimlich maneuver to be administered by facility staff. The Resident was subsequently transferred to the hospital, admitted to the intensive care unit, intubated and required a bronchial scope to remove a piece of chicken from his/her bronchial tube (the main airway leading to the lung), placing the resident at the likelihood of serious harm or death.2. For Resident #38, the facility failed to provide supervision with meals as indicated in his/her care plan. Findings include: Review of the facility policy titled, Activities of Daily Living, dated 3/2002, indicated the following:-Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with dining (meals and snacks). Review of the facility policy titled, Baseline Care Plan, dated 4/2022, indicated the following:-To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within 48 hours of the resident's admission.-The interdisciplinary team will review the health practitioner's orders (e.g dietary needs, medications, routine treatments, etc.) And implement A baseline care plan to meet the resident's immediate care needs including but not limited to: a. Initial goals based on admission orders, c. Dietary orders.-The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. 1. Resident #9 was admitted to the facility in November 2025 with diagnoses including dementia and Wernicke's encephalopathy. Review of Resident #9's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 00 out of a possible 15 on the Brief Interview for Mental Status which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #9 required assistance from staff for meals. Resident #9 was unable to be interviewed during survey due to his/her cognitive status. During an interview on 3/5/26 at 10:23 A.M., Resident #9's Legal Guardian said a social worker on her staff had visited Resident #9 in the facility and had concerns regarding activity of daily living care being provided. She was unable to provide more detailed information. Review of the hospital Discharge summary dated the day prior to the Resident's admission to the facility indicated the following:-Dietary order: Adult Diet, no room service; regular. Comments: 1:1 (one-to-one) feed, please leave tray at nurse's station, initiated on 11/3/25. -Dietary recommendations: Continue current adult regular diet (as listed with the above with comments). -Monitoring/evaluation: PO (by mouth) intake. Review of the Clinical and Alerts paperwork sent from the hospital at the time of the Resident's admission to the facility indicated the following:-Problem area: Swallowing Impairment (stroke/transient ischemic attack). Goal: optimal eating and swallowing without aspiration. Outcome: ongoing, not progressing.-The clinical alert indicated Resident #9 was a 1:1 (one-on-one) feed throughout the document for a total of 10 times. -The nutritional assessment follow-up indicated Resident #9 continued to be a 1:1 feed. -The document failed to indicate the 1:1 feed order was discontinued for Resident #9 at any point of his/her hospitalization or at discharge from the hospital. Upon admission to the facility, Resident #9 was screened by speech therapy. The speech therapy screen, dated 11/28/25, indicated the following:-Pt (patient) continues with severe cognitive impairments since ACF (acute care facility) admission in August 2025 with no improvement. Pt on regular diet/thin liquids with no s/sxs (signs/symptoms) of dysphagia but would benefit from dining room for supervision given safety and cognitive concerns. Review of Resident #9's care plan upon admission failed to include an intervention for the Resident to have supervision with meals despite the hospital discharge paperwork and the speech therapy screen indicating the need for this. Review of the nursing note dated 1/13/26 indicated the following:- Resident (#9) was transferred to the hospital. The reason for transfer is an immediate transfer is required by the resident's urgent medical needs. Resident was choking on (his/her) food at lunch and hellich (sic) maneuver completed. Pieces of food came out and patient was suctioned and oxygen applied. Patient is lethargic and EMS (emergency medical services) in. Review of the incident report dated 1/16/26 indicated the following:- On 1/13/26 at approximately 12:15PM the resident was eating lunch in (his/her) room and was observed by staff having trouble breathing. Nursing Staff immediately started the Heimlich Maneuver and 911 was called. A code blue was called. A first piece of food came but the resident remained unable to fully respond and VSS (vital signs stable) maintaining and 02 (oxygen) stat (saturation) above 90. Staff continued to provide the Heimlich Maneuver and suctioning provided as well with positive effect. A big piece of meat came out; the resident had some eye contact. When asked what happened, staff informed the resident started coughing with color change while eating (his/her) lunch. 911 was called immediately and the provide notified of the incident with the order to transfer the resident to the hospital. Staff continued to provide emergency assistance while waiting for EMS. Oxygen administered at 5L (liters) d/t (due to) oxygen became above 90 on RA. EMS arrived; the resident was transferred to the hospital via stretcher. Guardian made aware of transfer. Per hospital record appears the resident was intubated by EMS while in route due to acute hypoxic respiratory failure due to aspiration. Review of the staff witness statements of the incident indicated the following:-A nurse witness statement: The nurse observed the resident earlier in the shift sitting on a side of (his/her) bed. The nurse was transporting another resident from the dining room at approximately 12:15 PM was informed by the aide that a resident was having trouble breathing. The nurse ran to the room and observed the resident (#9) lethargic (sic) and sliding from bed. The nurse called for assistance. She saw that the resident was choking and started to perform the heimlich (sic) maneuver with the CNA staff. A piece of meat came out and additional staff came to assist and started to suction the resident. With suctioning the staff was able to get a couple more pieces of meat from the residents mouth. EMS arrived and took over assisting the resident and took the resident to the hospital period prior to the incident the nurse never observed the resident having any trouble with eating as he was a regular diet with thin liquids.-A Certified Nursing Assistant (CNA) Statement: The resident is on a regular diet. The resident prefers to eat in his room.Assisting another resident in the day from around 12:15 with dining, notify (sic) by another resident that someone was having trouble breathing in their room. The CNA immediately went to the room and observed the resident wheezing. The CNA tried to get the residents attention by calling his name and the CNA realized that resident was choking and immediately the nurse.(sic) Owners and the CNA started to perform the heimlich (sic) maneuver. Additional staff came to assist the resident as a code was called. Nursing staff took over to assist the resident and started to use the suction machine.-The Scheduler/CNA statement: The CNA was picking trays (sic) in the day room period the CNA heard the nurse scream for help from the resident's room. When arriving to the room CNA and nurse were in the room. The resident was on the floor. The staff were trying to get the resident up off the floor you(sic) assisted on the right side so the nurse could perform the heimlich (sic) maneuver. The nurse was thrusting the resident. The CNA put her fingers in the residence mouth and pulled 1/4 sized piece of meat of the residents mouth. The staff took turns trying to do the heimlich (sic)maneuver. A code was called an additional staff came to assist. The nurses took over and sectioned (sic) the resident in pieces of meat come up. The CNA then left the room as EMS arrived to assist. Review of the hospital paperwork dated 1/13/26, indicated the following:- Patient Is a [AGE] year old with history of alcohol use disorder, SDH (subdural hematoma), major neurocognitive disorder, and HTN (high blood pressure) who presented with acute hypoxic respiratory failure due to aspiration. At facility (he/she) was eating chicken and became hypoxic and unresponsive. Intubated in field with large piece of chicken removed from glottis (the opening of the tube leading to the lung). In the ED (emergency department), (he/she) continued to have desaturations with PIP's in 40's (peak inspiratory pressure indicative of severe acute respiratory distress). Bronchoscopy performed on arrival to ICU with removal of likely piece of chicken from the left main stem. During an interview on 3/4/26 at 9:25 A.M., Nurse #2, who is also the staff educator, said when nurses complete a new admission, they are expected to read all discharge paperwork from the hospital and use the information to develop a comprehensive plan of care for the new resident. During an interview on 3/4/26 at 9:43 A.M., Nurses #1 and #2 said Resident #9 is a very fast eater and needs cuing from staff to slow down and not overstuff his/her mouth. Nurse #1 and Nurse #2 said Resident #9 has presented as an impulsive eater since admission, and Nurse #1 said Resident #9 shovels food into his/her mouth. Nurse #1 said the nurse completing the admission assessment should always read all the discharging hospital paperwork and include any relevant information for patient care into the initial plan of care. During an interview on 3/4/26 at 10:39 A.M., Nurse #8 said that the nurse completing the admission for Resident #9 should have identified the need for 1:1 at meals from the hospital paperwork. Nurse #8 said she completes all admission care plans, and she failed to identify the need for supervision and add this to Resident #9's care plan. Nurse #8 said Resident #9 is a fast eater and shovels food into his/her mouth when he/she eats. Nurse #8 said Resident #9's status has fluctuated since his/her admission, but the one aspect that has not fluctuated is the fast pace that the Resident eats. Nurse #8 said Resident #9 should have been eating in the dining room on the day of the choking incident and is unsure why he/she was eating alone in his/her room. During an interview on 3/04/26 at 10:30 A.M., the Director of Nursing said that when a new admission comes into the facility the nurse reads the hospital paperwork and from this paperwork and the nursing assessments, the initial plan of care is created. The Director of Nursing said she was not employed at the facility at the time of Resident #9's choking incident. During an interview on 3/5/26 at 10:00 A.M., CNA #1 said Resident #9 has been a fast, impulsive eater since admission. CNA #1 said he was not aware of the speech therapy screen that indicated Resident #9 should have supervision with meals and said the Resident preferred to eat in his/her room, so the staff allowed him/her to eat alone. During an interview on 3/5/26 at 12:43 P.M., the Speech Therapist said she screens all new admissions, and she had screened Resident #9 on 11/28/25. The Speech Therapist said she recommended Resident #9 have supervision with meals due to the Resident's cognitive status and for safety concerns. The Speech Therapist said she verbally reported this to the nursing staff working that day and also wrote it in her screen which is available in the Resident's medical record. During an interview on 3/5/26 at 11:58 A.M., Corporate Nurse #1 refused to answer surveyor questions regarding how therapy recommendations are communicated to and implemented by nursing staff, if nurses should review all therapy screens, and if therapy is part of the interdisciplinary team and can make recommendations for residents. During an interview on 3/4/26 at 11:02 A.M., the Nursing Supervisor said she assisted with Resident #9's admission and was the nurse that took the admission phone call from the hospital for the warm hand-off. The NursingSupervisor said she was not aware that the Resident was a 1:1 feed at the hospital and said she was not told this by the hospital and must have missed this information when reading the discharge summary. The NursingSupervisor said Resident #9 had always been a very fast eater since admission. During a follow-up interview on 3/6/26 at 9:20 A.M., the Nursing Supervisor said if staff had observed safety concerns with pacing of eating with Resident #9 at meals, the staff should have discussed this, documented it, and an intervention should have been put into place in the Resident's care plan. The Nursing Supervisor said interventions to eat with supervision due to the Resident's increased pacing with eating should have been in place back when it was noted by the nursing staff and the speech therapist's recommendations in November. The Nursing Supervisor said all speech therapy recommendations should be followed and is not sure why the recommendation for Resident #9 to eat supervised was not. During an interview on 3/6/26 at 11:42 A.M., Physician #1, who also acts as the facility's Medical Director, said that he expects all information from the hospital to be thoroughly read at the time of admission and any pertinent information on the discharge summary be included in a resident's plan of care. Physician #1 said Resident #9's plan of care should have included supervision for dining if both the hospital discharge summary and speech therapist recommended this. 2. Resident #38 was admitted to the facility in March 2022 with diagnoses including stroke and right sided hemiplegia. Review of Resident #38's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 00 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicate he/she had severe cognitive impairment. The MDS also indicated Resident #38 required maximal assistance from staff for self-care tasks. On 3/4/26 at 8:02 A.M., Resident #38 was observed lying in bed, eating breakfast with the privacy curtain half drawn and the Resident not visible from the hallway. There were no staff present while the Residet was eating. On 3/5/26 from 8:15 A.M. to 8:25 A.M., Resident #38 was observed lying in bed, eating breakfast with the privacy curtain half drawn and the Resident not visible from the hallway. There were no staff present while the Residet was eating. On 3/6/26 at 8:07 A.M., Resident #38 was observed lying in bed, eating breakfast with the privacy curtain half drawn and the Resident not visible from the hallway. There were no staff present while the Residet was eating. At 8:11 A.M., a nurse walked by room and stepped in and asked the Resident if he/she was okay and then left within the same minute. The Resident ate alone until 8:12 A.M., when a nursing assistant walked in and then left at 813 A.M. At 8:15 A.M., a nursing assistant went back into the room and remained for the remainder of the meal. Review of Resident #38's Activities of Daily Living care plan indicated the following interventions:-Provide resident/patient with tray and plate set-up for eating. Continual supervision with 1:8 ration, cue and assist as needed. -Provide cueing for safety and sequencing to maximize current level of function. Review of Resident #38's Kardex (a form indicating the level of assistance needed with tasks) indicated:--Provide resident/patient with tray and plate set-up for eating. Continual supervision with 1:8 ration, cue and assist as needed. During an interview on 3/5/26 at 10:05 A.M., Certified Nursing Assistant (CNA) #2 said the CNAs are verbally told how much assistance a resident needs and they are not able to see the care plans or Kardex of any resident. CNA #2 said Resident #38 is independent with meals and she had never been told otherwise. During an interview on 3/5/26 at approximately 1:40 A.M., Corporate Nurse #2 and the Regional Director of Operations said that continual supervision means supervision at all times. Both said if a care plan says continual supervision, the nursing staff should follow this care plan intervention During an interview on 3/6/26 at 9:22 A.M., the Nursing Supervisor said continual supervision means at all times. The Nursing Supervisor said if Resident #38's privacy curtain was drawn, supervision could not be provided from the hallway, and staff would have had to be in the room with the Resident while he/she was eating. The Nursing Supervisor said that Resident #38 should have gotten continual supervision with meals if his/her care plan indicated that.

Based on observations and interviews, the facility failed to maintain a homelike environment on 1 of 2 units. Findings include:Review of the facility policy titled Accommodation of Needs and Preferences and Homelike Environment Policy, dated as revised 4/2022, indicated the following:A homelike environment is one that de-emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a homelike environment. A determination of homelike should include the resident's opinion of the living environment. Orderly is defined as an uncluttered physical environment that is neat and well-kept.7. 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-Adequate and comfortable lighting-Comfortable and safe temperatures-Comfortable sound levels During a tour of the first floor unit on 3/3/26 at 8:27 A.M., the following was observed:Small dining room: the doorway to the room had significant scuff marks and missing paint on the doorway entrance of the room. Along the entire wall there were gouges on the wall with exposed plaster, missing paint on the wall and the radiator had significant dark scuff marks. room [ROOM NUMBER]: there were significant scuff marks and stains on the bottom of the closet door. The wall across from both beds and the wall next to the A bed had had plaster exposed. The wall under the window had significant stains and the radiator had significant scuff marks. room [ROOM NUMBER]: There was a gouge on the wall behind the A bed. The window blinds were broken. There was a black substance on floor, the bulletin board was broken, and the closet doors had a brown stain. The floor was chipped with a piece of the baseboard missing. In the bathroom, there was a loose towel rod, a mirror not attached to the wall resting behind grab bars and the shower did not have a head or handle.room [ROOM NUMBER]: Wallpaper was missing from the wall outside of the room under the number plate. Throughout the interior of the room, the walls had mismatched paint. Outside the bathroom door plaster was exposed on the walls. Stains were observed on the walls above the closet door.The hallway between rooms [ROOM NUMBERS] had plaster exposed and missing wallpaper. room [ROOM NUMBER]: There was a gouge in the wall behind the B bed with plaster exposed. The window blinds were broken. The radiator had significant scuff and stain marks. The hallway between rooms [ROOM NUMBERS] had wallpaper missing from the wall. room [ROOM NUMBER]: There were significant stains on the ceiling above both beds. Plaster was exposed on the wall behind the A bed. The chair across from the A bed was significantly stained and the B bed side table had a missing door to the bottom cabinet. The wallpaper border was peeling from the wall, the walls across from the bed had significant stains, and there was a hole in the wall behind the B bed. The closet doors were broken. Inside the bathroom, there were three small holes in the wall next to the toilet. room [ROOM NUMBER]: The bathroom ceiling had significant yellow and brown stains. There were gouges in the wall behind both walls with drywall exposed. room [ROOM NUMBER]: The bathroom ceiling was stained. The paint in the walls was mismatched. During a tour of the first floor unit on 3/6/26 beginning at 8:07 A.M., the following was observed:room [ROOM NUMBER]: There was dark brown debris covering the walls. A resident in the room said, I already told maintenance about that cause it freaks me out to look at. Additionally, there was paint peeling off the wall by the entryway light switch.room [ROOM NUMBER]: There was paint chipped off the walls and gouges in the walls throughout the room as well as brown stains behind the window bed.room [ROOM NUMBER]: There were gouges of missing paint by the door bed's wall and long dark scuffs/gouges on the bathroom door.room [ROOM NUMBER]: Paint was chipped off the walls and there were gouges in the walls throughout the room. There were long dark scuffs on the bathroom door.The hallway between rooms [ROOM NUMBERS] had a 3-foot (ft) x 1 ft area of missing wallpaper.room [ROOM NUMBER]: There was a long piece of metal falling off underneath the radiator.The hallway beside room [ROOM NUMBER] had peeling wallpaper and three holes in the wall.room [ROOM NUMBER]: An area of 1 ft x 2 ft white paint on the wall, when the room's main color was tan paint. There was also mismatched patches of paint by the window wall.room [ROOM NUMBER]: A long black scuff mark on the walls and brown debris splattered on the walls. There were holes on the bathroom door with missing paint. There were also long dark scuffs on the entryway door. A resident in the room said that it is disgusting and we shouldn't have to live like this. If they hired someone to paint the walls that person would make a killing in this building. room [ROOM NUMBER]: Resident refused access to the surveyor to observe the room.room [ROOM NUMBER]: There were large scuff marks on the walls throughout room and writing in marker all over the closet doors.room [ROOM NUMBER]: There were long black scuff marks on the walls and brown debris on the walls. There were long black scuff marks on bathroom door.room [ROOM NUMBER]: Gouges of paint missing off the wall beside the bathroom door.The hallway between rooms [ROOM NUMBERS], and also between rooms [ROOM NUMBERS] had peeling wallpaper.room [ROOM NUMBER]: Resident refused access to the surveyor to observe the room.room [ROOM NUMBER]: There were large scuff marks on the radiator and gouges in the wall by the door bed.Beside the service elevator there were large pieces of missing wallpaper on the wall.room [ROOM NUMBER]: There were gouges in the bathroom door and paint patches on the walls that are different color than the main wall color of the room.Main dining room: A broken metal plate on the left wall and missing paint on the walls.Outside the main dining room there were large stains on the carpet. During an interview on 3/6/26 at 9:26 A.M., the Maintenance Director said that he tries to do rounding daily to observe the environment and that Thursday is his designated day to do projects and improve on resident rooms. The surveyor shared environmental observations from the 1st floor unit with him and the Corporate Administrator. The Maintenance Director said that he is aware of the mismatched paint on resident walls and that he has brought his concern to the Nursing Home Administrator (NHA). He said that he does not have the paint colors to replace missing paint on the walls in the same color but that the NHA told him to paint with what he has. Additionally, he said that he is aware of the peeling wallpaper in the corridors, but that wallpaper is one of those things you can't just go out and buy.

Based on record review and interviews, the facility failed to ensure they reviewed and revised the Comprehensive Care Plan following the completion of his/her scheduled Quarterly Minimum Data Set (MDS) assessment for 1 Resident (#6) out of a total sample of 25 residents Specifically, for Resident #6 the facility failed to ensure a dementia care plan was developed following a Psychiatric assessment adding the diagnosis to the resident record. Review of the facility policy titled Comprehensive Assessments and the Care Delivery Process, dated as revised 2/2025, indicated:-Comprehensive assessments will be conducted to assist in developing person-centered care plans.-Comprehensive assessments are conducted and coordinated by a registered nurse with appropriate participation of other health professionals. 7. Completed assessments (baseline, comprehensive, MDS, etc.) are maintained in the resident's active record for a minimum of 15 months. These assessments are used to develop, review and revise the resident's comprehensive care plan. Resident #6 was admitted to the facility in October 2025 and has diagnoses that include dementia with psychotic disturbance, Review of the most recent MDS assessment, dated 1/22/26, indicated that on the Brief Interview for Mental Status exam Resident #6 scored a 2 out of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #6 showed signs and symptoms of delirium, with continuous inattention. Review of the Psychiatric Assessment note dated 1/16/26 indicated Resident #6 has a dx. Unspecified dementia, unspecified severity, with psychotic disturbance. Review of the Psychiatric Assessment note dated 12/18/25 indicated Resident #6 has a dx. Unspecified dementia, unspecified severity, with psychotic disturbance. Review of the Psychiatric Assessment note dated 12/4/25 indicated Resident #6 has a dx. Unspecified dementia, unspecified severity, with psychotic disturbance. Review of Resident #6's Care Plan failed to indicate a care plan for Resident #6's dementia diagnoses, or that one was developed at the time of Resident #6's Comprehensive Quarterly assessment in January 2026. During an interview on 3/06/26 at 8:40 A.M., Certified Nursing Assistant (CNA) #3 said that Resident #6 requires total care. CNA # said that Resident #6 is confused and yells out at times because he/she doesn't know how to ring a call bell or tell the staff what he/she needs. During the interview there was a loud yell of help from down the hallway and CNA #3 said that that was Resident #6. She explained that yelling out is what Resident #6 does and that the staff then have to try to figure out what he/she wants or needs. During an interview 3/06/26 at 8:46 A.M., the MDS nurse said that Resident #6 should have a dementia care plan in place with individualized interventions but that she must have missed it. The MDS nurse said during the quarterly assessment review period in January 2026 this should have been caught and a dementia care plan developed at that time. During an interview on the 03/05/26 at 1:03 P.M., the Nurse Supervisor said Resident #6 should have dementia care plan in place and if he/she didn't it should have been developed at that time of the quarterly assessment.

Based on observations, record review and interviews, the facility failed to provide one Resident (#38) with his/her hearing aids to maintain adequate hearing for communication, out of a total sample of 25 residents. Findings include: Review of the policy titled, Ancillary Physician, dated 4/2022, indicated the following:-Direct care staff will assist residents with eyewear and hearing aid care, including removing, cleaning and storage. Resident #38 was admitted to the facility in March 2022 with diagnoses including stroke and right sided hemiplegia. Review of Resident #38's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident scored a 00 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #38 uses bilateral hearing aids. On 3/3/26 at 7:55 A.M., Resident #38 was observed lying in bed. The Resident had a difficult time hearing the surveyor's questions and he/she was not wearing hearing aids. On 3/4/26 at approximately 9:15 A.M., Resident #38 was observed lying in bed and not wearing any hearing aids. On 3/5/26 at 8:43 A.M., Resident #38 was observed lying in bed and not wearing any hearing aids. The Resident was able to answer yes/no questions and said he/she hadn't worn his/her hearing aids in a long time and would be agreeable to wear them. On 3/6/26 at 8:12 A.M., Resident #38 was observed lying in bed and not wearing any hearing aids. Review of Resident #38's nursing assessment, dated 2/19/26, indicated the Resident had adequate hearing with the use of bilateral hearing aids. Review of Resident #38's communication care plan indicated the following intervention:-Ensure hearing aid, glasses or other assistive devices are in place, initiated 4/2/24 Review Resident #38's last audiology visit, dated 10/9/24, indicated the following:-Recommendations: Patient requires assistance with insertion and manipulation for hearing aids daily; patient to wear hearing aids daily; continue with current means of communication. Review of Resident #38's medical record for the dates of survey failed to indicate the Resident was offered and refused the use of his/her bilateral hearing aids. During an interview on 3/6/26 at 8:18 A.M., Nurse #7 said Resident #38 has bilateral hearing aids. Nurse #7 said Resident #38 will refuse his/her hearing aids at times, but if he/she were to refuse the nurses need to document the refusal. During an interview on 3/6/26 at 9:22 A.M., the Nursing Supervisor said Resident #38 has bilateral hearing aids and should have been offered them daily in the mornings. The Nursing Supervisor said if Resident #38 refused his/her hearing aids, the nursing would document the refusal.

Based on record review and interview, the facility failed to identify a significant weight loss in a timely manner for one Resident (#46) out of a total sample of 25 residents. Findings include: Review of the facility policy titled 'Weight Management', dated 4/2022, indicated the following but not limited to:-To monitor the resident's weight from time of admission and to provide interdisciplinary support and/or intervention to avert adverse trends.-Weight change is defined as any unplanned weight gain or loss as follows:+/- 5% weight change in 1 month+/- 7.5% weight change 3 months+/- 10% weight change in 6 months-Reweights must be done within 24 hours.-The dietician will assess the resident and will communicate any recommended changes to the DNS and supervisor. Resident #46 was admitted to the facility in October 2025 with diagnoses including cognitive communication deficit and type 2 diabetes mellitus. Review of Resident #46's Minimum Data Set (MDS), dated [DATE], indicated the Resident scored a 7 out of a total 15 on the Brief Interview for Mental Status exam indicating severe cognitive impairment. Review of the current Nutritional Status care plan indicated that Resident #46 is at risk for nutritional decline related to therapeutic diet. Review of the Weight and Vitals summary indicated the following:-12/11/25: 117.7 lbs (pounds)-1/16/26: 106.2 lbs-2/6/26: 104 lbs Review of the weights indicated that between 12/11/25 and 1/16/26, Resident #46 lost a total of 11.5 lbs., which is a 9.7% clinically significant weight loss. Review of the clinical record failed to indicate that Resident #46 had been assessed by the Dietitian after this weight loss or that the weight loss had been reviewed. Review of the nutrition progress note, dated 2/12/26, indicated that Resident #46 had weight loss from admission and the plan was for weekly weights x 4 weeks and add assorted snack 2x (two times) per day. During an interview on 3/6/26 at 9:12 A.M., Nurse #6 said he was not aware of Resident #46's weight loss. He said if there is a discrepancy in the resident's weight then a reweight would occur the following day and the dietician would be notified. During an Interview on 3/6/26 at 9:18 A.M., Certified Nursing Assistant (CNA) #4 said if a resident was weighed and there is a weight loss they would reweigh the resident and then notify the nurse. CNA #4 said Resident #46 likes foods brought to him/her from home. During an interview on 3/6/26 at 11:10 A.M., the Dietician said she runs the weight reports monthly and that the facility has a weekly risk meeting where they discuss weights. The dietician said that Resident #46 had a significant weight loss, and she believed it was because the Resident had moved floors and was weighed on a different scale. She further said the Resident should have been reweighed to confirm the weight loss and interventions should have been put in place sooner. During an interview on 3/6/26 at 11:30 A.M., the Director of Nursing said residents with weight loss should be reweighed the next day and if it confirms weight loss, it should be reported to the physician and dietician.

Based on observations, record review and interviews, the facility failed to ensure that for 1 Resident (#6), who was diagnosed with dementia, appropriate treatment and services were provided to attain his/her highest practical physical, mental and psychosocial well-being, and that person centered interventions were implemented, out of a total sample of 25 residents. Findings include:Review of the facility policy titled Dementia CP, dated as revised 3/33, indicated:Treatment and ManagementFor the individual with confirmed dementia, the IDT will identify a resident-centered care plan to maximize remaining function and quality of life. The IDT (interdisciplinary team) will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise. Resident needs will be communicated to direct care staff through care plan conferences, during change of shift communications and through written documentation (nurses' notes and documentation tools). Progressive or persistent worsening of symptoms and increased need of staff support will be reported to the IDT. Resident #6 was admitted to the facility in October 2025 and has diagnoses that include dementia with psychotic disturbance, Review of the most recent MDS assessment, dated 1/22/26, indicated that on the Brief Interview for Mental Status exam Resident #6 scored a 2 out of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #6 showed signs and symptoms of delirium, with continuous inattention. Review of the most recent Psychiatric assessment notes indicate the following visit notes: 1.) 2/18/26, Diagnostic assessment: Resident #6 continues to be disruptive, yell out and is difficult to redirect. Since he/she is on low dose of Depakote (a mood stabilizer), will recommend increasing this and adding prn (as needed) Trazadone (as antidepressant) for the time being. 2.) 1/16/26, Diagnostic assessment: Resident #6 with psychosis: continue to yell out through the day and is very anxious and disruptive.Recommendations: start Haldol (an antipsychotic) .5 milligrams (mg) BID (two times a day). Review of the Psychiatric Assessment note dated 12/4/25 indicated Resident #6 has a dx. Unspecified dementia, unspecified severity, with psychotic disturbance. Review of Resident #6's Care Plan failed to indicate a care plan for Resident #6's dementia diagnoses with person centered interventions. During an observation on 3/3/26 at 8:51 A.M., Resident #6 was observed in bed yelling out, I want music, why can't I just get music. The yelling could be heard 30-35 feet away at the nurse's station, and several staff were in the vicinity, however no one responded to the yelling or provided the resident with music. During an observation on 3/4/26 between approximately 1:30 P.M., and 1:50 P.M., the surveyors could here screaming from the floor up above. Upon arriving on the unit, it was the determined that the yelling was Resident #6. He/she was observed in bed, and a Certified Nursing Assistant (CNA) was in the room speaking to the resident. After a few moments, the resident did not respond to the CNA and the CNA left the room. Resident #6 remained alone in the room yelling. During an interview on 3/6/26 at 8:40 A.M., CNA #3 said that Resident #6 requires total care. CNA #3 said that Resident #6 is confused and yells out at times because he/she doesn't know how to ring a call bell or tell the staff what he/she needs. During the interview there was a loud yell of help from down the hallway and CNA #3 said that that was Resident #6. She explained that Resident #6 frequently yells out and that staff then have to try to figure out what he/she wants or needs. CNA #3 could not say interventions that were utilized to support Resident #6 at the time these behaviors presented. During an interview 3/6/26 at 8:46 A.M., the MDS nurse said that Resident #6 should have a dementia care plan in place with individualized interventions in place to address his/her status and care needs. During an interview on the 3/5/26 at 1:03 P.M., the Nurse Supervisor said Resident #6 should have dementia care plan in place with resident specific interventions to address his/her mood and behavior and care needs, as he/she cannot express them him/herself due to dementia.

Based on observation, record review and interviews, the facility failed to ensure that one Resident (#39) was free of significant medication errors out of a total sample of 24 residents. Specifically, the nurse substituted and attempted to administer furosemide (a diuretic- used for removing excess fluids from the body) medication without a physician order.Findings include: Review of the facility policy titled Oral Medication Administration, dated 4/22, indicated the following but not limited to:-Verify that there is a physician's medication order for this procedure.-Check the label on the medication and confirm the medication name and does with the MAR (medication administration record).-Check the medication dose. Re-check to confirm proper does. Resident #39 was admitted to the facility in January 2026 with diagnoses including acute heart failure and coronary artery disease. Review of Resident #39's Minimum Data Set (MDS), dated [DATE] indicated the Resident scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. During a medication observation pass on 3/4/26 at 9:03 A.M., Nurse #3 pulled a blister pack containing one tablet out of the medication cart, the nurse said to the surveyor that the order for Torsemide 20 mg (milligram) (a diuretic) had changed, and the resident was now receiving 40 mg (milligram). Nurse #3 said that she was going to the pyxis machine (an automated locked medication dispensing cabinet used to securely store, manage and dispense medication), to access another dose of torsemide. Nurse #3 walked away and then shortly returned saying she had sent another nurse to bring her the medication. Nurse #2 returned with two pills in a pack and handed it to Nurse #3. Nurse #3 poured the medication into a medication cup then handed the empty packet to the surveyor. The surveyor noted the packet stated Furosemide 20mg tablets. She then proceeded to enter the Resident's room to administer the medication, at this point the surveyor asked Nurse #3 to step out of the room, prior to administering the incorrect medication. During an interview on 3/4/26 at 9:49 A.M., Nurse #3 said she asked Nurse #2 to bring her Lasix (furosemide) form the pyxis. Nurse #3 said that she thought Torsemide and furosemide are the same medication. Nurse #3 said she did not have a physician order to substitute medication, and she should have administered what was ordered which was Torsemide. Review of Resident #39's current physician's order indicated the following order:-Torsemide oral tablet 40 mg give one tablet by mouth one time a day for edema (swelling caused by excess fluid trapped in body tissue, commonly occurring in legs, feet, and ankles). Review of the physician order failed to indicate an order for Furosemide. During an interview on 3/5/26 at 8:07 A.M., Nurse #2 said that Nurse #3 had asked her to retrieve Lasix (Furosemide) 40 mg from the pyxis. She said it was the nurse's responsibility to double-check the medication against the order to ensure she had the right medication. During an interview on 3/4/26 at 2:00 P.M., the Director of Nursing (DON) said the nurses should be doing the five checks when performing medication administration. She further said all medications require a physician order to administer. During an Interview on 3/6/26 at 12:24 P.M., Nurse Practitioner #1 said medication should never be given without a physician order. She said the difference between furosemide and torsemide is that they are metabolized differently.

Based on observations, record review and interview, the facility failed to provide dental services to one Resident (#9) out of a total sample of 25 residents. Specifically, the facility failed to refer Resident #9 to the dentist to repair or replace his/her broken dentures. Findings include:Resident #9 was admitted to the facility in November 2025 with diagnoses including Wernicke's encephalopathy. Review of Resident #9's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident scored a 00 out of a possible 15 on the Brief Interview for Mental Status exam which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #9 required assistance from staff for all functional tasks. On 3/3/26 at 7:58 A.M., Resident #9 was observed lying in bed. The Resident was observed to have a missing front tooth from his/her upper dentures and did not have lower dentures. Resident #9 could not be interviewed due to cognition. On 3/4/26 at 9:43 A.M., Nurse #2 and the surveyor observed Resident #9's broken dentures. Nurse #2 said she was unaware the Resident's dentures were broken and did not know if the dentist had been notified for them to be fixed. Review of Resident #9's admission nursing assessment, dated 11/26/25, failed to indicate the Resident had broken dentures on admission. Review of Resident #9's nursing notes from time of admission to present failed to indicate any documentation of when or how the dentures broke as well as any referral to the dentist to have the denture repaired or replaced. During an interview on 3/5/26 at 10:00 A.M., Certified Nursing Assistant (CNA) #1 said Resident #9's dentures were not broken when admitted and this must have happened at some time during the Resident's stay at the facility. CNA #1 said he was unaware if the facility had contacted the dentist to have the dentures fixed. During an interview on 3/6/26 at 9:20 A.M., the day Nursing Supervisor said she was unaware that Resident #9's dentures were broken. The Nursing Supervisor said the Resident was not admitted with broken dentures and they must have broken at some time since admission. The Nursing Supervisor said the facility refers anyone with broken dentures to the dentist to have the dentures fixed and the facility had not done this for Resident #9. During an interview on 3/6/26 at 7:48 A.M., the Director of Nursing said she was unaware prior to survey that Resident #9's dentures were broken. The Director of Nursing said when a denture breaks, the resident should be referred out to the dentist and this did not occur for Resident #9 and should have. During an interview on 3/5/26 at 10:32 A.M., Resident #9's Legal Guardian said she was unaware Resident #9's dentures were broken and if she had known, she would have wanted them fixed.

Based on interviews and record review, the facility failed to ensure a hospice care plan was present in the medical record and coordinated between facility staff and the hospice agency for one Resident (#48) out of a total sample of 24 residents. Findings include: Review of the facility policy titled Hospice Care, revised April 2022, indicated but was not limited to the following: -In general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions, including: -Determining the appropriate hospice plan of care. -Our facility staff will coordinate care provided to the resident with the hospice staff. He or she is responsible for the following: -Obtaining the following information from the hospice: -The most recent hospice plan of care specific to each resident. -Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental, and psychosocial well-being. Resident #48 was admitted to the facility in June 2022 with diagnoses including vascular dementia. Review of Resident #48's Minimum Data Set (MDS) assessment, dated 1/22/26, indicated the Resident scored a 10 out of a possible 15 on the Brief Interview for Mental Status, indicating he/she had moderate cognitive impairment. Review of Resident #48's medical record indicated the following: -A physician's order, dated 2/12/26: may do hospice evaluation and treat and admit as indicated. -A facility care plan: [Resident #48] is receiving the following care: hospice related to end-stage dementia, initiated 2/12/26. -A Hospice Election Form indicating the Resident was admitted to hospice on 2/19/26. Review of the medical record failed to indicate the hospice agency's plan of care was available to the staff at the facility; furthermore, the medical record failed to indicate appropriate coordination between the facility and hospice agency to create a plan of care that includes both the most recent hospice plan of care and a description of the services furnished by the facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. During an interview on 3/4/26 at 8:27 A.M., Nurse #6 said all hospice residents are supposed to have a binder that includes the hospice plan of care. Nurse #6 said Resident #48 started hospice recently and he/she does not currently have a binder with the hospice plan of care; he said if there is no binder with the hospice plan of care, the Resident is at risk of not receiving the care he/she needs and the facility staff would be unable to follow the hospice care plan. During an interview on 3/4/26 at 1:25 P.M., Day Supervisor #1 said the hospice plan of care is sent from the hospice agency to the facility and uploaded into the Electronic Health Record. Day Supervisor #1 said the facility had not received the hospice plan of care for Resident #48. During an interview on 3/4/26 at 1:49 P.M., the Director of Nursing (DON) said the nursing staff are responsible for coordinating hospice care at the facility. The DON said she would expect a hospice plan of care to be available within one to two weeks of a resident being admitted to hospice, and that Resident #48 should have already had a hospice plan of care available. During an interview on 3/4/26 at 2:23 P.M., Hospice Nurse #1 said all hospice residents have a binder that should include a plan of care at the facility. Hospice Nurse #1 said Resident #48 was recently admitted to hospice, but she was out sick the previous week and was unable to provide the facility with the plan of care timely.

Based on record review and interviews, for one of three sampled Personnel Files (Occupational Therapist #1), the Facility failed to ensure they implemented and followed their abuse prohibition procedures as defined in their policy when a Massachusetts Nurse Aide Registry background check was not conducted prior to hire.Findings include: Review of the Facility's Policy titled Abuse Screening, dated March 2022, indicated all potential employees will be screened to rule out a history of abuse, neglect or mistreating residents which includes attempting to obtain information by checking with appropriate licensing registries. The Policy indicated the Nurse Aide Registry is checked prior to employment for all facility employees. Review of Occupational Therapist (OT) #1's Personnel File indicated she was hired on 05/20/24. There was no documentation to support that the facility had conducted a Massachusetts Nurse Aide Registry background check on OT #1 before hire.During a telephone interview on 02/09/26 at 2:45 P.M., the Director of Nurses (DON) said OT #1 was a contracted employee. The DON said it was determined that a Massachusetts Nurse Aide Registry background check had not been conducted per the facility contract prior to hire, as agreed upon. The DON said per Facility Policy, all employees, irregardless of their position were to have a Massachusetts Nurse Aide Registry background check prior to hire.

Based on record review and interview, the facility failed to maintain the highest practicable physical, mental, and psychosocial well-being for one Resident (#7) with a history of suicidal ideation (SI) and depression, out of a total sample of 28 residents. Specifically, Resident #7 was not provided with appropriate behavioral health services following verbalization of SI and attempted to kill him/herself at the facility by ingesting nail polish remover. Findings include: Review of the facility policy titled Behavior Management, dated ,d+[DATE], indicated the following: - The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. - The IDT staff will identify, document, and inform the physician about specific details regarding changes in an individuals mental status, behavior, and cognition including: * Onset, duration, intensity and frequency of behavioral symptoms * Any precipitating or relevant factors or environmental triggers (e.g., medication changes, infection, recent transfer from hospital) and * New onset or changes in behavior will be documented. - The interdisciplinary team (IDT) will elevate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition. - The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary, to protect the resident and others from harm. - Interventions will be individualized and part of an overall care environment that supports physical, functional, and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities. Psychiatric recommendations will be reviewed by the IDT and will implement as indicated. - Interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior. The care plan will include, as a minimum: * A description of the behavioral symptoms * Targeted and individualized interventions for the behavioral and/or psychosocial symptoms; * The rationale for interventions and approaches; * Specific and measurable goals for targeted behaviors; and * How the staff will monitor for effectiveness of the interventions - Non-pharmacologic approaches will be utilized to the extent possible to avoid or reduce the use of psychoactive medication to manage behavioral symptoms. Review of the facility policy titled Suicide Threats, dated [DATE], indicates the following: - All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. - As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be indicated. - If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present. Review of the facility assessment, dated [DATE], indicated that the facility manages, on average, 30 residents with behavioral health needs. Review of the facility assessment indicated the facility is able to manage the medical conditions and mental health conditions related to psychiatric symptoms and behavior, assessment of gradual dose reduction, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD (post-traumatic stress disorder), other psychiatric diagnoses, intellectual or developmental disabilities, contract with external psychological services, utilize a code system, and trauma informed care planning. The facility assessment indicated the facility had a contracted Social Worker for 16 hours per week for a census of 59 residents. Resident #7 was admitted in [DATE] with diagnoses including major depressive disorder, history of suicidal ideations, post-traumatic stress disorder (PTSD), and bipolar disorder. Review of the Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident #7 scored a 14 out of a possible 15 on the Brief Interview for Mental Status exam, indicating intact cognition. During an interview on [DATE] at 9:49 A.M., Resident #7 said Some staff care and some don't. I am depressed a lot and take medication for that. I have 3 kids but they don't talk to me and this past August I tried to kill myself. I was really low and depressed. When I did what I did, I screamed cause it hurt. My heart stopped and I died on the table at the hospital. Three or four weeks before, I started getting really down, I had no one to talk to and it just got worse I was letting myself go. I wasn't eating and was staying in my room more and more and then I drank nail polish remover. Now I lay in bed a lot and watch tv and cry because I miss my kids and it is sad. Review of the current care plan indicated Resident #7 has a history of suicidal ideation with the following interventions: - Provide a safe environment, free from things that may harm the client (initiated [DATE]) - Encourage the client to avoid decisions during the time of crisis until alternatives can be considered (initiated [DATE]) - Encourage the client to talk freely about feelings and help plan alternative ways of handling disappointment, anger and frustration (initiated [DATE]) - Encourage the client to talk about their feelings and problem solve alternatives (initiated [DATE]) - Monitor resident for signs and symptoms of suicidal ideation (initiated [DATE]) - Social services to check in periodically with the resident to ensure safety (initiated [DATE]) - [DATE] Resident mloa (medical leave of absence) d/t (due to) suicide attempt (initiated [DATE]) - Encourage out of room activities (initiated [DATE]) Review of the psychiatric consultant progress note, dated [DATE], indicated Resident #7 had symptoms of anxiety and depression and indicated the following: Patient reported on his/her mood and stated 'I am always depressed. I just keep to myself and it's easier now that I have the room to myself. I prefer it this way and just to spend some time thinking.' Patient was receptive to offered support and feedback. Review of the progress note indicated a plan to follow up with Resident #7 in two weeks. Review of the nursing progress note, dated [DATE], indicated the following: Resident had suicidal ideation. Told one of the staff that he/she would like to kill him/herself but he/she doesn't have a plan. NP (nurse practitioner) notified and gave an order to send resident to hospital for evaluation. Unable to reach son via phone. Resident transferred to hospital. Review of a nursing progress note, dated [DATE], indicated the following: Resident returned from hospital emergency room at approximately 1900 (7:00 P.M.). There was no medication changes. He/she is to follow up with the physician and psych. Upon returning no vocalization of wanting to die/harm him/herself. He/she continues to deny having a plan. Declined dinner, offered alternate but refused On 20 minute checks. No acute distress note. Physician on call notified of his/her return. HCP (healthcare proxy) called but no answer. Review of the medical record failed to indicate that 20 minute checks were completed or that there was a physician's order for 20 minutes checks. Review of the hospital discharge paperwork, dated [DATE], indicated the following: Pt (patient) tells this writer that he/she did make SI (suicidal ideation) statements; 'wanting to die, take my life, I've just had it and got to a point,' and 'tired of anything.' Pt denies a plan and denies any intent. Pt reports he/she has been feeling this way on and off for the past month and only today did he/she disclose it. This writer stated the nurse said he/she was having a good day up until 2:50 P.M. when the activities lady went into pt's room and pt disclosed SI thoughts to this staff person. Pt cannot recall if he/she took medication for depression . pt had been at his/her current facility for the past 6 years and states it is lonely, 'I'm by myself all the time'. Pt used to have a roommate but states he/she was difficult. Pt denies any history of attempts, gestures, SIB (self injurious behavior) or psych hospitalization s. This writer spoke to the nurse prior to meeting with the pt and the nurse reported pt had a boyfriend at the facility but the relationship ended about ,d+[DATE] months ago . Pt reports being upset that he/she has not heard from his/her children in months. Review of the psychiatric progress note from the hospital, dated [DATE], indicated the following: Discussed talk therapy referral and pt was agreeable stating he/she just needs someone to talk to. Review of the clinical record failed to indicate that social services or psychiatric services; specifically talk therapy, had been provided upon Resident #7's return to the facility after the verbalization of suicidal ideation on [DATE]. Review of the nursing progress note, dated [DATE], indicated the following: Resident seen by physician today. New order received to increase Seroquel (and antipsychotic medication used for Bipolar disorder) to 200 mg (milligrams) twice daily, 150 mg daily at 1 pm, add Wellbutrin xl (a medication used to treat depression) 150 mg daily and psych consult. Review of the consultant psychiatric nurse practitioner note, who provides medication management, dated [DATE], indicated the following: Resident reports he/she has been more depressed starting last week and made end of life statement. Reports he/she still feels this way but with no plan in place . Of note, resident was previously in a relationship with another resident, which did not end well. Since then resident has been more depressed and isolated to his/her room. Review of the note indicated a recommendation to discontinue the Wellbutrin and obtain labs. Review of Nurse Practitioner #1's progress note, dated [DATE], indicated Resident #7 said he/she will not attempt to hurt him/herself, but does not really have much to live for. Review of the plan indicated the following: Depression with attention seeking behavior. Psych does not feel that he/she will harm him/herself. They feel that he/she is confused, although I did sit with him/her today for quite some time. He/she answers questions appropriately, does engage and is able to conduct meaningful conversation. Review of the medical record failed to indicate behavioral health services had provided talk therapy since [DATE] or that a referral was made for talk therapy services, as recommended from the hospital. Review of the medical record failed to indicate that social services had provided any services or initiated any talk therapy after Resident #7's verbalization of suicidal ideation on [DATE]. Review of the nursing progress note, dated [DATE], indicated the following: Resident shouted from his/her room 'help, I'm dying'. When the nurse got to the resident's room, the resident was on a wheelchair and seemed to be weak an not on [sic] his/her baseline, then he/she stated he/she had taken something which he/she does not want to tell. 2 cups were on the table, one had coffee and another one had pink liquid ,d+[DATE] full which immediately we identified as nail polish remover. 911 was activated, vital signs taken and staff stayed with him/her. On call doctor and DON notified, unable to reach son over the phone. Resident transferred to hospital. Review of the hospital discharge paperwork, dated [DATE], indicated the following: presented to hospital for suicide attempt of ingesting nail polish remover in the context of multiple environmental stressors, and worsening of depressive episode. per ED (emergency department) records, the patient is a resident of a Nursing facility. Focal to the SA (suicide attempt), patient reports an increase of hopelessness and loneliness after attempting to contact his/her son multiple times failed. After ingestion of nail polish remover, he/she called for help and was brought to the ED, and transferred to ICU (intensive care unit) after multiple episodes of non-sustained V. Tach (ventricular tachycardia- a heart rate of over 100 beats per minute) and acute encephalopathy (disorder of the brain which can cause confusion) (,d+[DATE]-[DATE]). He/she was diagnosed with Non- STEMI (non- ST- segment myocardial infarction) (heart attack) on presentation thought to be secondary to demand ischemia (decreased blood flow) in the setting of cardiomyopathy (disease of the heart muscle). Patient arrived to hospital .I interviewed the patient on [DATE]. Patient is alert, oriented to person, date, month, year and place. He/she is aware of the admission, and is able to express clearly that he/she took sips of the acetone nail polish remover, in an attempt to end his/her life. He/she expresses regret, remorse over the act stating 'it was stupid'. He/she is not able to clearly say what precipitated the event, but says 'I had just had it'. He/she adamantly denies that he/she would ever do this again stating, 'I would never do this, it scared the hell out of me, I don't want to die'. He/she identifies that his/her thoughts are active in the evening and race impacting his/her sleep and ability to fall asleep. Additionally he/she adds images, or 'flashbacks' to past traumas of previous abusive relationships. He/she denies any AH (actual harm), HI, no longer expressing SI . The patient is oriented x3, has a clear understanding of events leading to his/her admission, is understanding of his/her medications benefits and side effects, is wanting treatment and agreeable to treatment. Review of the Patient Safety Plan provided by the hospital on discharge on [DATE] indicated the following: - Warning signs: feeling depressed and lonely, lack of contact with family, medication issues, nursing home placement, and loss of past roles - Internal coping strategies: Playing bingo and poker with activities department - People and social settings that provide distraction: activities in the dayroom at the facility - People who I can ask for help: the director of nursing - Making environment safe: spending more time in the milieu and less isolating in room. Review of the care plan indicated the following revisions completed after Resident #7's attempted suicide: - [DATE]: [DATE] resident mloa d/t suicide attempt - [DATE] : encourage out of room activities During a follow-up interview on [DATE] at 8:04 A.M., Resident #7 said that he/she had had the nail polish remover in his/her possession since she originally admitted to the facility. During an interview on [DATE] at 10:50 A.M., Certified Nursing Assistant (CNA) #3 said that she has been working at the facility about a year and knows about Resident #7's suicide attempt. CNA #3 said she was taking care of Resident #7 the morning of the suicide attempt, but was not made aware of the incident until after it occurred. During an interview on [DATE] at 10:55 A.M., Nurse #4 said that he knows Resident #7 and that the Resident has on and off days related to his/her mood and has verbalized that he/she is depressed. Nurse #4 said that on the day of the suicide attempt he went into the room when he heard Resident #7 screaming and found the nail polish remover. Nurse #4 said that Resident #7 has a history of being sent out and leading up to that event had been down, but could not tell them why. Nurse #4 remembers Resident #7 was having a down day and was not happy in the morning before the incident and that he did what he normally does when Resident #7 is down and let him/her be. Nurse #4 said he does not remember the social worker seeing Resident #7 on that day, or at all during that time period. During an interview on [DATE] at 12:14 P.M., Social Worker #1 said that she is in the facility two days per week, and that her main role is doing assessments and ensuring the facility is in compliance with necessary things such as care plan reviews. Social Worker #1 said if a Resident expresses suicidal ideation then she would expect to be told of the incident and she would see the resident upon return from the psych hospitalization . Social Worker #1 said that the outside services that are offered from contracted staff are medication management and talk therapy. Social Worker #1 said that although she was in the building on [DATE], following Resident #7's hospital assessment for SI, she was not notified of the suicidal ideation from Resident #7; therefore, she did not see or speak with Resident #7. During an interview on [DATE] at 12:23 P.M., Activities Assistant #1 said that Resident #7 is involved in activities, but that she had noticed a change in Resident #7's attendance to activities leading up to the suicide attempt, as she indicated in a witness statement at the time of the incident. During an interview on [DATE] at 12:42 P.M., the psychiatric Nurse Practitioner (NP) said that she provides strictly medication management in the facility and has a colleague that provides talk therapy to residents. The psychiatric NP said that Resident #7's medications were adjusted after the suicidal ideation incident, but that the therapeutic effects of medications can take up to ,d+[DATE] weeks to take effect. The psychiatric NP said she notified her colleague, who provides talk therapy, the day of her evaluation of Resident #7 on [DATE]. The psychiatric NP said that if a Resident is expressing suicidal ideation, then the environment should be checked and be free of harmful items and the care plan should be updated. During an interview on [DATE] at 8:11 A.M., the contracted psychiatric Social Worker said that she comes in bi-weekly to provide individual psychotherapy to residents. The psychiatric Social Worker said that she was not made aware of Resident #7's suicidal ideation until her colleague told her on [DATE], seven days after the initial SI verbalization. The psychiatric Social Worker said that by the time she came into the facility, Resident #7 had already gone out to the hospital for the suicide attempt. During an interview on [DATE] at 8:46 A.M., Nurse Practitioner #1 said that if a Resident expresses suicidal ideation, then she would expect psychiatric services or the social worker to see the Resident immediately to determine the appropriate action. Nurse Practitioner #1 said she would have expected psych services or social services to be provided for Resident #7 after his/her suicidal ideation on [DATE]. During an interview on [DATE] at 9:05 A.M., the Director of Nursing said that when a Resident expresses suicidal ideation or returns from the hospital after expressing suicidal ideation, then behavioral services, including talk therapy, should be initiated immediately. She said that although the talk therapist comes in every two weeks, that they can reach out to the psychiatric service provider and have someone else come in to see a resident if there is a need. The Director of Nursing said that it should all be documented in the medical record and if 20 or 30 minute checks were done then they should be uploaded in the record. The Director of Nursing said that the Resident's environment should always be assessed for safety. The Director of Nursing said that Resident #7 was previously in a relationship and it was a terrible time and had a huge affect on him/her. The Director of Nursing said that just before the suicidal ideation, Resident #7 was really wrapped up in his/her kids not calling and that it was difficult because he/she already has major depression. The Director of Nursing said that if there is an increase in worsening depression, then there is always someone from psychiatric services they can call.

Based on record review and interview, the facility failed to provide the appropriate treatment and services for one Resident (#7), with a known history of depression and suicidal ideation out of a total sample of 28 residents. Specifically, for Resident #7, the facility failed to implement and update the plan of care, resulting in an attempted suicide after the vocalization of suicidal ideation (SI). Findings include: Review of the facility policy titled Behavior Management, dated ,d+[DATE], indicated the following: -The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. - The IDT staff will identify, document, and inform the physician about specific details regarding changes in an individuals mental status, behavior, and cognition including: * Onset, duration, intensity and frequency of behavioral symptoms * Any precipitating or relevant factors or environmental triggers (e.g., medication changes, infection, recent transfer from hospital) and * New onset or changes in behavior will be documented. - The interdisciplinary team (IDT) will elevate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition. - The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary, to protect the resident and others from harm. - Interventions will be individualized and part of an overall care environment that supports physical, functional, and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities. Psychiatric recommendations will be reviewed by the IDT and will implement as indicated. - Interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior. The care plan will include, as a minimum: * A description of the behavioral symptoms * Targeted and individualized interventions for the behavioral and/or psychosocial symptoms; * The rationale for interventions and approaches; * Specific and measurable goals for targeted behaviors; and * How the staff will monitor for effectiveness of the interventions - Non-pharmacologic approaches will be utilized to the extent possible to avoid or reduce the use of psychoactive medication to manage behavioral symptoms. Review of the facility policy titled Suicide Threats, dated [DATE], indicates the following: - All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. - As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be indicated. - If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present. Review of the facility assessment, dated [DATE], indicated that the facility manages, on average, 30 residents with behavioral health needs. Review of the facility assessment indicated the facility is able to manage the medical conditions and mental health conditions related to psychiatric symptoms and behavior, assessment of gradual dose reduction, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD (post-traumatic stress disorder), other psychiatric diagnoses, intellectual or developmental disabilities, contract with external psychological services, utilize a code system, and trauma informed care planning. The facility assessment indicated the facility had a contracted Social Worker for 16 hours per week for a census of 59 residents. Resident #7 was admitted in [DATE] with diagnoses including major depressive disorder, history of suicidal ideations, post traumatic stress disorder (PTSD), and bipolar disorder. Review of the Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident #7 scored a 14 out of a possible 15 on the Brief Interview for Mental Status exam, indicating intact cognition. During an interview on [DATE] at 9:49 A.M., Resident #7 said Some staff care and some don't. I am depressed a lot and take medication for that. I have 3 kids but they don't talk to me and this past August I tried to kill myself. I was really low and depressed. When I did what I did, I screamed cause it hurt. My heart stopped and I died on the table at the hospital. Three or four weeks before, I started getting really down, I had no one to talk to and it just got worse I was letting myself go. I wasn't eating and was staying in my room more and more and then I drank nail polish remover. Now I lay in bed a lot and watch tv and cry because I miss my kids and it is sad. Review of the current care plan indicated Resident #7 has a history of suicidal ideation with the following interventions: - Provide a safe environment, free from things that may harm the client (initiated [DATE]) - Encourage the client to avoid decisions during the time of crisis until alternatives can be considered (initiated [DATE]) - Encourage the client to talk freely about feelings and help plan alternative ways of handling disappointment, anger and frustration (initiated [DATE]) - Encourage the client to talk about their feelings and problem solve alternatives (initiated [DATE]) - Monitor resident for signs and symptoms of suicidal ideation (initiated [DATE]) - Social services to check in periodically with the resident to ensure safety (initiated [DATE]) - [DATE] Resident mloa (medical leave of absence) d/t (due to) suicide attempt (initiated [DATE]) - Encourage out of room activities (initiated [DATE]) Review of the nursing progress note, dated [DATE], indicated the following: Resident had suicidal ideation. Told one of the staff that he/she would like to kill him/herself but he/she doesn't have a plan. NP (nurse practitioner) notified and gave an order to send resident to hospital for evaluation. Unable to reach son via phone. Resident transferred to hospital. Review of a nursing progress note, dated [DATE], indicated the following: Resident returned from hospital emergency room at approximately 1900 (7:00 P.M.) . There was no medication changes. He/she is to follow up with the physician and psych. Upon returning no vocalization of wanting to die/harm him/herself. He/she continues to deny having a plan. Declined dinner, offered alternate but refused. On 20 minute checks. No acute distress note. Physician on call notified of his/her return. HCP (healthcare proxy) called but no answer. Review of the medical record failed to indicate that 20 minute checks had been initiated or that a physician's order was put in place for 20 minute checks. Review of the hospital discharge paperwork, dated [DATE], indicated the following: Pt (patient) tells this writer that he/she did make SI (suicidal ideation) statements; 'wanting to die, take my life, I've just had it and got to a point,' and 'tired of anything.' Pt denies a plan and denies any intent. Pt reports he/she has been feeling this way on and off for the past month and only today did he/she disclose it. This writer stated the nurse said he/she was having a good day up until 2:50 P.M. when the activities lady went into pt's room and pt disclosed SI thoughts to this staff person. Pt cannot recall if he/she took medication for depression . pt had been at his/her current facility for the past 6 years and states it is lonely, I'm by myself all the time. Pt used to have a roommate but states he/she was difficult. Pt denies any history of attempts, gestures, SIB (self injurious behavior) or psych hospitalization s. This writer spoke to the nurse prior to meeting with the pt and the nurse reported pt had a boyfriend at the facility but the relationship ended about ,d+[DATE] months ago . Pt reports being upset that he/she has not heard from his/her children in months. Review of the psychiatric progress note from the hospital, dated [DATE], indicated the following: Discussed talk therapy referral and pt was agreeable stating he/she just needs someone to talk to. Review of the consultant psychiatric nurse practitioner note, who provides medication management services, dated [DATE], indicated the following: Resident reports he/she has been more depressed starting last week and made end of life statement. Reports he/she still feels this way but with no plan in plan . Of note, resident was previously in a relationship with another resident, which did not end well. Since then resident has been more depressed and isolated to his/her room. Review of the note indicated a recommendation to discontinue the Wellbutrin and obtain labs. Review of Nurse Practitioner #1's progress note, dated [DATE], indicated Resident #7 said he/she will not attempt to hurt him/herself, but does not really have much to live for. Review of the plan indicated the following: Depression with attention seeking behavior. Psych does not feel that he/she will harm him/herself. They feel that he/she is confused, although I did sit with him/her today for quite some time. He/she answers questions appropriately, does engage and is able to conduct meaningful conversation. Review of the clinical record failed to indicate that the care plan was reviewed, updated, or implemented upon Resident #7's return to the facility after the verbalization of suicidal ideation on [DATE]. Review of the medical record failed to indicate a referral for talk therapy services was made or that Resident #7 received talk therapy from psych services or social services. Review of the nursing progress note, dated [DATE], indicated the following: Resident shouted from his/her room 'help, I'm dying'. When the nurse got to the resident's room, the resident was on a wheelchair and seemed to be weak an not on [sic] his/her baseline, then he/she stated he/she had taken something which he/she does not want to tell. 2 cups were on the table, one had coffee and another one had pink liquid ,d+[DATE] full which immediately we identified as nail polish remover. 911 was activated, vital signs taken and staff stayed with him/her. On call doctor and DON notified, unable to reach son over the phone. Resident transferred to hospital. Review of the hospital discharge paperwork, dated [DATE], indicated the following: presented to hospital for suicide attempt of ingesting nail polish remover in the context of multiple environmental stressors, and worsening of depressive episode. per ED (emergency department) records, the patient is a resident of a Nursing facility. Focal to the SA (suicide attempt), patient reports an increase of hopelessness and loneliness after attempting to contact his/her son multiple times failed. After ingestion of nail polish remover, he/she called for help and was brought to the ED, and transferred to ICU (intensive care unit) after multiple episodes of non-sustained V. Tach (ventricular tachycardia- a heart rate of over 100 beats per minute) and acute encephalopathy (disorder of the brain which can cause confusion) (,d+[DATE]-[DATE]). He/she was diagnosed with Non- STEMI (non- ST- segment myocardial infarction) (heart attack) on presentation thought to be secondary to demand ischemia (decreased blood flow) in the setting of cardiomyopathy (disease of the heart muscle). Review of the Patient Safety Plan provided by the hospital on discharge on [DATE] indicated the following: - Warning signs: feeling depressed and lonely, lack of contact with family, medication issues, nursing home placement, and loss of past roles - Internal coping strategies: Playing bingo and poker with activities department - People and social settings that provide distraction: activities in the dayroom at the facility - People who I can ask for help: the director of nursing - Making environment safe: spending more time in the mileu and less isolating in room. Review of the current care plan indicated the following revisions after the attempted suicide: - [DATE]: [DATE] resident mloa d/t suicide attempt - [DATE] : encourage out of room activities During a follow-up interview on [DATE] at 8:04 A.M., Resident #7 said that he/she had had the nail polish remover in his/her possession since she originally admitted to the facility. During an interview on [DATE] at 12:14 P.M., Social Worker #1 said that she is only in the facility two days per week, and that her main role is doing assessment and ensuring the facility is in compliance with needed things such as care plan reviews. Social Worker #1 said if a Resident expresses suicidal ideation then she would expect to be told of the incident and she would see the resident as soon as possible upon return from the psychiatric hospitalization . Social Worker #1 said that the outside services that are offered from contracted staff are medication management and talk therapy. Social Worker #1 said that although she was in the building on [DATE], following Resident #7's hospital assessment for SI, she was not notified of the suicidal ideation from Resident #7. She said that she did not see or speak with Resident #7 and was then away the week after that. Social Worker #1 said that if she had seen or assessed Resident #7, it would be documented in the medical record. Social Worker #1 said that she would expect the care plan to be updated and an interdisciplinary team review of the Resident following a statement of suicidal ideation. During an interview on [DATE] at 12:42 P.M., the psychiatric Nurse Practitioner (NP) said that if a Resident is expressing suicidal ideation, then the environment should be checked and be free of harmful items and the care plan should be updated. During an interview on [DATE] at 9:05 A.M., the Director of Nursing said that when a Resident expresses suicidal ideation or returns from the hospital after expressing suicidal ideation, then behavioral health services, including talk therapy, should be initiated immediately. The Director of Nursing said that the Resident's environment should always be assessed for safety. The Director of Nursing said that Resident #7 was previously in a relationship and it was a terrible time and had a huge affect on him/her. The Director of Nursing said that just before the suicidal ideation, Resident #7 was really wrapped up in his/her kids not calling and that it was difficult because he/she already has major depression. The Director of Nursing said that if there is an increase in worsening depression, then there is always someone from psychiatric services they can call. The Director of Nursing said, after verbalization of suicidal ideation, she updates the care plan and notifies the interdisciplinary team. The Director of Nursing said that anything that was developed at the hospital would be reviewed in the facility and make sure it's appropriate.

Based on observations, interviews and policy review, the facility failed to maintain a homelike environment on 2 out of 2 resident units in the facility. Specifically on 2 of 2 units there were stained ceiling tiles, missing thresholds, broken blinds, holes in walls, gouged walls, peeling baseboards, missing baseboards, peeling wallpaper, dark and brown substance on ceiling tiles, stained floor tiles and missing closet doors. Findings include: A review of the facility policy titled, Resident Rights: Accommodation of Needs and Preferences and Homelike Environment, not dated, indicated that the facility will provide a safe, clean, comfortable and homelike environment. On 3/27/25 between 7:22 A.M. and 8:45 A.M., the surveyor observed the following in the bedrooms on the first floor unit: 100: A hole in the bathroom ceiling next to the vent. 101: The door bed had a brown substance was on the wall and the toilet was continuously running. 102: A wall was patched white and not painted. 103: A wall was patched white and not painted, the bathroom faucet was loose, the bifold closet doors were broken. 104: The bathroom toilet was continuously running, the bathroom radiator was rusted. 105: A wall was patched white and not painted, the bathroom radiator was rusted. 106: The bathroom ceiling was stained brown, the ceiling over the door bed was stained brown, the ceiling over the window had plaster and paint falling down, the top edge of window frame with peeling paint falling onto the window ledge. 107: The bathroom walls had 2 holes and ripped wall paper, the ceiling above the window was stained brown with plaster and paint peeling and the phone jack behind the window bed was pulled out of the wall. 108: The ceiling above the window was stained brown with plaster and paint peeling, and the ceiling above the window bed was stained brown. 109: The door bed's privacy curtain had multiple brown spots, the ceiling above the window had a hole and was stained brown with plaster and paint peeling. The window bed's privacy curtain was stained brown. 110: The ceiling above the window had a hole and was stained brown with plaster and paint peeling. 111: The walls were scuffed and the ceiling above the window was stained brown with paint peeling. 112: The ceiling above the window was stained brown with plaster, wallpaper and paint peeling. 113: The edge of the bathroom radiator was coming off, the ceiling above the window was stained brown with plaster, wallpaper and paint peeling. 114: The wall behind both beds had white patches and were not painted, the bathroom ceiling was stained brown and peeling and the toilet was continuously running. 115: The ceiling above the window was stained brown with plaster and paint peeling. 116: The ceiling above the window was patched white and not painted. 117: The ceiling above the door bed was stained brown. 118: The closet door was missing, corner of the baseboard was missing. 119: The plaster above the window was cracked. 120: The ceiling was stained brown, and the toilet was continuously running. 121: The bathroom shelf was rusted, the ceiling over the tub was coming down, the walls and ceiling was patched white and not painted, and the wall behind the window bed was gauged. Additionally on the unit the following was observed: -Two ceiling tiles in the hallway between rooms [ROOM NUMBERS] were stained brown. -The wall corners in the dining room were gauged. -The wallpaper border in the hallway was peeled off. On 3/27/25 between 9:01 A.M. and 10:15 A.M., the surveyor observed the following in the bedrooms on the second floor unit: 200: The tiles around the toilet were missing and the toilet was being held in place with pieces of cardboard. 201: The bathroom faucet was loose, the window screen has a hole and blind slats were missing. 202: The blind slats were missing and broken. 203: The toilet was continuously running, the faucet was loose and the wall was patched white and not painted. 204: The wall was patched white and not painted. 205: The sink faucet was loose and the wall was patched white and not painted. As well, the wall was gauged behind the window bed. 206: The wall behind the window bed was gauged, the walls were patched without paint, the window blinds were broken, and the sink drain was leaking onto the floor. 207: The blinds were broken, the wall behind the bed was gauged, scuffed and patched without paint. 208: The bathroom faucet was loose. 209: The closet door was broken. 210: The door bed's mattress had hole in the center. 211: The bottom drawer of a dresser was without a handle and would not close, the wallpaper border was peeling in multiple areas and the wall behind the window bed was gauged. 212: The wall behind the door bed was gauged. 213: The bathroom threshold was partially missing and partially held together with green tape, the tiles surrounding the toilet were stained a blackish brown and there were circular brown stains throughout floor of the room. 214: The sink drain was leaking onto the floor, the bathroom threshold was missing with broken tiles. 215: There was a hole in the wall behind the door bed, gauges in the wall behind the window bed, walls were patched but not painted, the corner of the wall next to the bathroom was broken with missing plaster. 216: The window blinds were broken, the walls were scuffed in the room and bathroom. 217: The toilet paper holder was broken and parts missing, the walls were patched and without paint. 218: The walls were scuffed. 219: The window blind slats were missing and the wall was scuffed. 220: The wall was scuffed with paint missing. During an interview on 3/27/25, at 6:55 A.M., the Administrator said that there was not a specific plan in place to fix the environment other than ongoing continued maintenance. During an interview on 3/27/25, at 8:19 A.M., The Director of Maintenance said he is the only member of the maintenance department. He said that he tries to keep up with the needed repairs, but an extra set of hands would help. When asked if he was able to keep up with the needed repairs he said that he was not able to answer that question. The Maintenance Director said that he completes room rounds monthly. By the end of the survey the Maintenance Director was unable to produce documentation to support room rounds were completed.

Based on observations, interviews, and records reviewed, the facility failed to provide an activities program to: 1. Residents on two of two units observed, and 2. One Resident (#2) out of a total sample of 28 residents. Findings include: Review of the facility policy titled Daily Programming, not dated, indicated that it is the policy of the facility to provide meaningful activities appropriate to the Resident's cognitive, physical, and social abilities on a regular basis, to enhance their quality of life. Review of the facility policy titled Activity Program for Residents with Cognitive Impairment, not dated, indicated that it is the policy of this facility to offer meaningful activity programs to residents who display disorientation to time place and/or person. 1. Review of the activity schedule for 3/25/25 indicated the following: 9:45 A.M., a coffee social. 10:15 A.M., Movin N Groovin-1st 10:45 A.M., Stretch and Tone-2nd 1:30 P.M., Room visits 2:00 P.M., Travelogue 3:00 P.M., Bingo 3:45 P.M., Room Visits On 3/25/25 between 9:00 A.M. and 11:33 A.M. the surveyor observed 4 residents sitting in the dining room on the second floor. The television was on but no scheduled activity was taking place. The surveyor also observed that none of the residents were watching the television. Two were sleeping and 2 were staring forward. On 3/25/25 between 1:30 P.M. and 3:30 P.M. the surveyor observed no activity taking place on the second floor. Two residents were sitting in the dining room, there was no music, no TV and no individualized activities for the residents. During an interview on 3/25/25 at 3:30 P.M. supervisor Unit Manager #1 said activities are always happening on the floor. When asked why activities were not occurring on the unit she was not able to give an answer. Review of the activity schedule for 3/26/25 indicated the following: 9:45 A.M., a coffee social. 10:00 A.M., communion 10:45 A.M., Stretch and Tone. 2:00 P.M., Target Practice 3:00 P.M., Family Feud 3:45 P.M., Room Visits On 3/26/25, between 9:30 A.M., and 11:00 A.M. the surveyors observed no activities on the 1st and 2nd floor units all morning. During an interview on 3/26/25, at 11:57 A.M., Certified Nurse's Aide #3 said that mostly bingo happens on the 2nd floor but there are not many activities for residents with dementia. She said that they don't have activities sometimes. During resident group meeting on 3/26/25 at 11:00 A.M., 4 out of 4 residents said that there has been no activities director for awhile and as a result there has been a reduction in the number of activities. They said that the posted activities calendar is not accurate and the activities posted don't happen. 4 out of 4 also said that there are no activities seen for dementia residents, activities are sparse and dementia residents sit in the dining room not doing much. Review of the activity schedule for 3/27/25 indicated the following: 9:45 A.M., a coffee social. 10:15 A.M., Movin N Groovin-1st (sic) 10:45 A.M., Stretch and Tone-2nd 1:00 P.M., Art Group 2:00 P.M., Bingo 3:00 P.M., Men's Group 3:45 P.M., Room Visits On 3/27/25 from 8:30 A.M., to 10:15 A.M., the surveyor observed several residents sitting in the dining room. The surveyor observed the television on but no one was watching. One resident was sleeping, one resident was staring off into space and one resident was trying to engage all passers by in conversation. During an interview on 3/27/25 at 10:20 A.M., Activity Assistant (AA) #1 said that on 3/25/25, she was the only staff in the activity department for the day. AA #1 then said that no activities took place 3/25/25 on the second floor. AA #1 then said that her hours start at 9:45 A.M. and the other Activity Assistant starts her day at 10:00 A.M. AA #1 also said that there has not been an activity director for several months. AA #1 then acknowledged that there are residents with dementia who are sitting in the dining rooms for long periods of time without any activity. 48671 2. Resident #2 was admitted to the facility in January 2023 with diagnoses including hemiplegia and hemiparesis following cerebral infarction effecting right dominant side and weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/27/25, indicated Resident #2 did not have a Brief Interview for Mental Status assessment completed and was assessed by staff to have moderately impaired cognition. The MDS further indicated Resident #2 speaks Cantonese, has clear speech but is rarely/never understood, and is dependent on staff for care. Review of Section F. on the MDS indicated an interview for daily and activity preferences should not be conducted and indicated the Resident is rarely/never understood and family/significant other not available. On 3/25/25 the following was observed: -At 9:30 A.M., Resident #2 was observed sitting in the main dining room in a wheelchair. The television was on. -At 9:45 A.M., the activity calendar had Coffee Social, as the activity. The activity was not observed on the unit and Resident #2 remained in the dining room sitting alone at a table. On 3/26/25 the following was observed: - At 9:24 A.M., Resident #2 was observed sitting in the main dining room in a wheelchair. The television was on. - The activity calendar lists 9:45 A.M., Coffee Social, as the activity. The activity was not observed on the unit and Resident #2 remained in the dining room sitting alone at a table. - At 9:35 A.M., Resident #2 was observed sitting in the main dining room in a wheelchair. The television was on. -At 9:40 A.M., Resident #2 was observed sitting in the main dining room in a wheelchair. The television was on. -The activity calendar lists 10:00 A.M., Communion, as the activity. The activity was not observed on the unit and Resident #2 remained in the dining room sitting alone at a table. -At 10:10 A.M., Resident #2 was observed sitting in the main dining room in a wheelchair. The television was on. -The activity calendar lists 10:45 A.M., Exercise Group, as the activity. The activity was not observed on the unit and Resident #2 remained in the dining room sitting alone at a table. During an interview on 3/26/24 at 10:02 A.M., Family Member #2 said Resident #2 speaks Cantonese and enjoys watching television, listening to music and talking with others and can communicate in Cantonese, but staff do not try to communicate in any way other than speaking English, which the Resident does not understand. Family Member #2 said he/she would enjoy conversation, music or movies in his/her language. Review of Resident #2's activity care plan indicated the following interventions: -Resident has a potential for altered activity patter(n) related to routine involvement with the following: -Introduce to other residents with similar interests, disabilities, and/or limitations. -Invite resident to activities that promote additional intake of food and fluids as allowed. Ensure that all snacks and beverages offered comply with diet restrictions prescribed. -Invite to scheduled activities. -Offer to assist/escort resident to activity functions. During an interview on 3/27/25 12:38 P.M., Activities Assistant #2 said Resident #2 doesn't speak English and can't participate in most activities due to a language barrier. The Activities Assistant #2 said she talks to the resident, but he/she can't understand her. Activities Assistant #2 said she called Resident #2's family member today because she did not know what language the Resident speaks. The Activities Assistant said the television is on in the dining room but Resident #2 does not understand English and just sits in his/her chair. Review of the February 2025 and March 2025 Recreation Participation Record indicated the following: February 2025, 9 out of 28 days indicated Resident #2 was coded as I for Independent with Socializing/Socials/ Talking on Phone/Visits/ Sending Cards and Relaxing/Looking out/People Watching & window/ Resting/Thinking. -Six days indicated S for Sleeping / In Bed during Baking/ Cooking Refreshments Carts. March 1st - March 24th 2025, indicated Likes to sit and watch T.V. in Day Room. Resident #2 was coded as L for limited engagement with Movies/TV, Socializing/Socials/ Talking on Phone/Visits/ Sending Cards and Relaxing/Looking out/People Watching & window/ Resting/Thinking. During an interview on 3/27/25 at 12:41 P.M., the Director of Activities said she expects the calendar to be followed as scheduled and said staff should invite all residents to the activities. The Activities Director said she expects care plans to be implemented and followed and said staff should know how to communicate with the Resident and offer activities he/she may be interested in. During an interview on 3/27/25 at 12:54 P.M., the Director of Nurses (DON) said activities should be conducted and offered to all residents and said if a resident does not enjoy group activities staff should offer other opportunities and attempt to engage with the Residents in ways he/she may enjoy and understand. The DON said an activities assessment should indicate the types of things Resident #2 enjoys doing and should include his/her language needs. Further review of the medical record failed to indicate an activity assessment was completed. During a follow up interview on 3/31/25 at 8:35 A.M., the DON said Resident #2 did not have an activities assessment completed and said all Residents should have an activities assessment completed with care plan interventions specific to his/her needs.

Based on record reviews and interviews, the facility failed to ensure they provided laboratory services to meet the needs of its residents. Specifically, the facility failed to maintain a current Clinical Laboratory Improvement Amendment (CLIA) certificate appropriate for the level of testing performed within the facility. Findings include: On [DATE] at 7:15 A.M., the surveyor observed a CLIA certificate posted on the bulletin board adjacent to the lobby near the Administrator's office with an expiration date of [DATE]. On [DATE] the surveyor requested the facility's CLIA certificate. On [DATE], the Administrator provided the surveyor with a CLIA certificate dated as expired [DATE] and the following document indicating Application Name: CLIA Laboratory Program dated [DATE], which indicated the payment was made on [DATE], for a CLIA renewal application. Further review of the documents provided by the facility indicated that an incomplete application was submitted but not followed up on until the day of survey on [DATE]. During an interview on [DATE] at 1:00 P.M., the Administrator said the facility provides testing that requires a CLIA certificate and said the certificate should have been renewed but was not. The Administrator said she started the application process but did not follow up on additional documents that were needed to renew the certificate.

Based on observations, diet manual review, and interviews, the facility failed to ensure that the [NAME] consistently prepared meals according to the therapeutic diet manual as ordered by the physician. Specifically, the facility failed to ensure the [NAME] consistently served the IDDSI 6 (soft and bite sized) therapeutic diet in accordance with 13 applicable resident's physician's order. Findings include: Review of the facility policy titled Therapeutic Diet, dated as revised 4/22, indicated that therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. 1. Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. Diagnosis alone will not determine whether the resident is prescribed a therapeutic diet. 2. A therapeutic diet must be prescribed by the resident's attending physician (or non-physician provider). The attending physician may delegate this task to a registered or licensed dietitian as permitted by state law 3. Diet order should match the terminology used by the food and nutrition services department. 4. A 'therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example: d. altered consistency diet. 5. If a diet is ordered, the provider will specify the texture modification. The International Dysphagia Diet Standardization Initiative (IDDSI), through consultation and following best practice principles, has developed a global standardized way of describing foods and drinks that are safest for people with feeding, chewing or swallowing problems. Review of the IDDSI Food and Drinks Classification Adults, dated 8/7/24, indicated the following: - Level 7: Regular, includes normal everyday foods of various textures that are developmentally and age appropriate. Biting and chewing ability needed. - Level 6: Soft and Bite- Sized, includes tender and moist throughout, with no thin liquid leaking or dripping from the food. Chewing ability is needed. https://www.iddsi.org/images/Publications-Resources/Poster/posterenglishinternational7aug2024.pdf a. Review of the facility's diet manual titled Therapeutic Breakdowns, dated as revised 9/15/16, indicated the following therapeutic diet breakdown for Tuesday 3/25/25: - IDDSI 7 Regular Texture: Pork, 3 ounces 1/2 inch strips Roasted Potatoes, 4 ounces quartered Mixed Vegetables, 4 ounces sliced carrots - IDDSI 6 Soft and Bite Size: Pork, 3 ounces 1/2 inch diced Roasted Potatoes, 4 ounces 1/2 inch soft mashable, no skin Mixed Vegetables, 4 ounces mashable mixed vegetables (no peas or corn) On 3/25/25 at 12:11 P.M., during a lunch time observation the surveyor observed three different residents who had diet slips which indicated IDDSI 6 Soft and Bite Size. - The residents received pork that served cubed, the cubes were cut greater than 1/2 inch and the cubes of pork were not diced. - The residents received potatoes were the same potatoes served to the IDDSI 7 residents, and there was skin on the potatoes. - The residents received the same mixed vegetables served to the IDDSI 7 residents which included whole green and yellow beans measuring approximately 2-3 inches in length and baby whole carrots approximately 2 inches in length. The surveyor observed one Resident (#4) who was served the IDDSI 6 meal, and he/she was edentulous and he/she was unable to eat his/her meal. b. Review of the facility's diet manual titled Therapeutic Breakdowns, dated as revised 9/15/16, indicated the following therapeutic diet breakdown for Wednesday 3/26/25: - IDDSI 7 Regular Texture: Chicken Pot Pie, 1/24th of a pan Broccoli, 4 ounces - IDDSI 6 Soft and Bite Size: Chicken Pot Pie, 6 oz 1/2 inch diced chicken with mashable vegetable. Broccoli, 4 oz mashable On 3/26/25 during the lunch meal tray line the surveyor observed the [NAME] serve six different residents who had diet slips which indicated IDDSI 6 Soft and Bite Size. - The residents received the same chicken pot pie as the IDDSI 7 residents. - The residents received the same broccoli as the IDDSI 7 residents. On the 3/26/25 at 12:12 P.M., the surveyor conducted a test tray of IDDSI 6 Soft and Bite Size diet, the chicken in the chicken pot pie were long thick pieces of pulled chicken greater than 1 inch in length and the chicken was not diced according to the therapeutic breakdown. The broccoli was served whole (floret, flower buds and stem, stalk) approximately 1 inch in length and 2 inches in diameter, the stems were firm, and the surveyor was unable to mash the broccoli. During an interview on 3/26/25 at 12:15 P.M., the [NAME] said she prepared the meal for lunch on 3/26/25. The [NAME] said that she prepared the IDDSI 7 and IDDSI 6 chicken pot pie in the same manner, she boiled chicken thighs and then shredded the chicken meat with a fork, and she was serving the same pot pie to both the IDDSI 7 and IDDSI 6 diet textures. The surveyor observed five residents who had been served the IDDSI 6 diet, two of the Residents said that the broccoli was too hard to eat. c. Review of the facility's diet manual titled Therapeutic Breakdowns, dated as revised 9/15/16, indicated the following therapeutic diet breakdown for Thursday 3/27/25: - IDDSI 7 Regular Texture: Au Gratin Potato, 4 ounce - IDDSI 6 Soft and Bite Size: Au Gratin Potato, 4 ounce 1 mashable cubes no skin. On 3/27/25 between 11:45 A.M., through 12:05 P.M., during the lunch meal tray line the surveyor observed the [NAME] serve five different residents who had diet slips which indicated IDDSI 6 Soft and Bite Size. The [NAME] was serving au gratin potatoes for both the IDDSI 7 and IDDSI 6 diet from the same pan. The pan contained slices of potatoes, some of which were greater than 1 inch in diameter. The top of the au gratin potatoes was crispy. During an interview on 3/27/25 at 12:05 P.M., the [NAME] said she doesn't always pay attention to the IDDSI numbers, and she said that IDDSI 7 is regular texture and the IDDSI 6 is chopped texture The [NAME] said that the Residents who were receiving IDDSI 7 and IDDSI 6 are receiving the same au gratin potatoes today which included sliced potatoes. On 3/27/25 at 12:15 P.M., the surveyor and the Director of Nursing observed a Resident (#9) who required an IDDSI 6 diet. He/she was served au gratin potatoes that were served greater than 1 inch in diameter and he/she couldn't eat because it was too hard and big. During an interview on 3/27/25 at 12:43 P.M., the Dietitian said the [NAME] should follow meal textures according to the therapeutic diet manual. The surveyor shared the observations of the lunch meals from 3/25/25, 3/26/25, and 3/27/25 and the Dietitian said that the [NAME] did not follow the therapeutic diet breakdown for the IDDSI 6 diets. During an interview on 3/27/25 at 12:51 P.M., the Food Service Director said the [NAME] should follow meal textures according to the therapeutic diet manual. The surveyor shared the observations of the lunch meals from 3/25/25, 3/26/25, and 3/27/25 and the Food Service Director said that the [NAME] did not follow the therapeutic diet breakdown for the IDDSI 6 diets. During an interview on 3/27/25 at 12:59 P.M., the Administrator said the [NAME] should follow meal textures according to the therapeutic diet manual. The surveyor shared the observations of the lunch meals from 3/25/25, 3/26/25, and 3/27/25 and the Administrator said that the [NAME] did not follow the therapeutic diet breakdown for the IDDSI 6 diets. The Administrator provided the surveyor with a list of therapeutic diets, and she said there were 13 residents with physician ordered IDDSI 6 diets on 3/25/25, 3/26/25, and 3/27/25.

Based on observation, interviews, and reviewed records, the facility failed to ensure staff treated residents in a dignified manner to effectively communicate in a language they understand for one Resident (#2) out of a total sample of 28 Residents. Findings include: The facility failed to indicate a language/communication policy was available as requested during the survey. Resident #2 was admitted to the facility in January 2023 with diagnoses including weakness, hemiplegia and hemiparesis following cerebral infarction effecting right dominant side, and weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/27/25, indicated Resident #2 did not have a Brief Interview for Mental Status assessment completed and was assessed by staff to have moderately impaired cognition. The MDS further indicated Resident #2 speaks Cantonese. Review of Resident #2's communication care plan dated, 2/19/25, indicated the following interventions: -Resident has impaired communication related to primary language is Cantonese. -Enlist use of communication devices as needed (i.e.) communication board, sign language specify. -Allow time to process information -Anticipate resident needs if resident is unable to express needs. -Assess body and facial expressions. During an observation on 3/25/25 at 8:33 A.M., Resident #2 was observed sitting in the main dining room in a wheelchair. Certified Nursing Assistant (CNA) #3 entered the dining room and was observed walking over to the Resident, moved the wheelchair closer to the table and then walked out of the dining room. CNA #3 did not speak to Resident #2 during the observation. During an observation on 3/26/25 at 7:46 A.M., Resident #2 was observed sitting in the main dining room in a wheelchair. The surveyor observed a staff member deliver a breakfast tray to Resident #2. The staff member was observed speaking to Resident #2 in English. Resident #2 did not try to engage or acknowledge the staff member. During an observation on 3/26/25 at 8:20 A.M., the survey observed CNA #2 deliver a breakfast tray to Resident #2. The CNA was observed speaking to Resident #2 in English. Resident #2 did not try to engage or acknowledge CNA #2. During an observation on 3/26/25 at 9:24 A.M., Resident #2 was observed sitting in the main dining room in a wheelchair. The surveyor observed a staff member walk into the dining room and was observed speaking English to two other residents seated in the dining room. The staff member did not try to engage or acknowledge Resident #2. During an observation on 3/26/25 at 9:42 A.M., Family Member #2 was observed asking staff if someone could take Resident #2 to the bathroom. Resident #2 was observed engaging, smiling and talking to Family Member #2 in Cantonese. CNA #2 walked over to Resident #2 and began pushing him/her in the wheelchair down the hall to the Residents room without engaging or speaking to Resident #2. CNA #2 and Occupational Therapist (OT) #1 were then observed undressing Resident #2, pulling his/her pants down and placing him/her on the toilet and then both exited the bathroom. CNA #2 and OT #1 did not speak or engage with Resident #2 during the entire observation. During an observation on 3/26/25 at 9:54 A.M., Unit Manager #1 and the Infection Control Nurse entered Resident #2's room and began to assist Resident #2 off the toilet. Unit Manager #1 and the Infection Control Nurse were observed speaking English to Resident #2 and said, Here you can wash your hands, as they turned the wheelchair towards the sink and turned the water on. Resident #2 did not engage or acknowledge the staff members. Family Member #2 was observed speaking to the Resident in Cantonese and the Resident could be heard exchanging in the conversation. Family Member #2 said she would wash the Residents' hands. Unit Manager #1 and the Infection Control Nurse then exited the Residents room. Throughout the observations a communication board was not observed or utilized and staff did not utilize a language line for interpreter services. During an interview on 3/26/24 at 10:00 A.M., Family Member #2 said Resident #2 understands and can communicate in Cantonese, but staff do not understand him/her and do not try to communicate in any way other than speaking English, which the Resident does not understand. During an interview on 3/26/25 at 10:04 A.M., CNA #2 said she does not know what language Resident #2 speaks and said she can't understand Resident #2 because he/she does not speak English. When the surveyor asked CNA #2 how she communicates with Resident #2 she said the family is usually here. When asked how she communicates if the family is not present CNA #2 said I'm not sure. During an interview on 3/26/25 at 10:06 A.M., Nurse #4 said Resident #2 speaks Cantonese and does not understand English and said there is a kitchen staff member who speaks Cantonese that could help if needed. Nurse #2 said he was not aware of a translation or language line in the facility and has never seen or used a communication board for the Resident. During an interview on 3/26/25 at 10:09 A.M., Unit Manager #1 said Resident #2 doesn't speak English and said if he/she is shouting or grimacing staff will know he/she needs to use the bathroom. Unit Manager #1 said staff can use the language line if needed and said staff should communicate with Resident #2 during care. Unit Manager #1 said she has not used the language line and has not seen a communication board used with Resident #2. During an interview on 3/27/25 at 8:34 A.M., Nurse #5 said Resident #2 speaks Cantonese and said if he/she yells out she will know the Resident needs to use the bathroom or is in pain. Nurse #5 said the facility does not use an interpreter line and is not aware of any communication board used for Resident #2. Nurse #2 said she speaks to the Resident in English, but he/she can't understand what she is saying. During an interview on 3/27/25 at 10:27 A.M., Director of Nurses (DON) said Resident #2 requires translation services and said staff should be utilizing the translation line to communicate with the Resident. The DON said the communication care plan should be followed by all staff and she expects staff to use a communication board to assist with communication.

Based on observations, record review, and interviews, the facility failed to ensure a call light was within reach for one Resident (#2) out of a total sample of 28 residents. Findings include: Resident #2 was admitted to the facility in January 2023 with diagnoses including weakness, hemiplegia and hemiparesis following cerebral infarction effecting right dominant side, and weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/27/25, indicated Resident #2 did not have a Brief Interview for Mental Status assessment completed and was assessed by staff to have moderately impaired cognition. The MDS further indicated Resident #2 speaks Cantonese. During an observation on 3/25/25 at 7:27 A.M., Resident #2 was in bed, the call light was located behind the bed on the floor. The call light was out of reach. During an observation on 3/26/25 at 7:12 A.M., Resident #2 was in bed, the call light was located behind the bed on the floor. The call light was out of reach. During an interview on 3/26/25 at 10:05 A.M., CNA #2 said Resident #2 uses the call light and staff will check on him/her during the day. During an interview on 3/26/25 at 10:07 A.M., Nurse #4 said Resident #2 can use the call light if he/she needs to but will yell out if he/she needs something. During an interview on 3/26/25 at 10:10 A.M., Unit Manager #1 said Resident #2 can use the call light and said the call light should be accessible at all times. During an interview on 3/27/25 at 10:28 A.M., Director of Nurses (DON) said she expects all residents to have access to call lights and said call lights should be functioning and within reach of the Resident.

Based on observation, interviews, and reviewed records, the facility failed to implement a communication care plan for one Resident (#2) out of a total sample of 28 Residents. Findings include: Resident #2 was admitted to the facility in January 2023 with diagnoses including weakness, hemiplegia and hemiparesis following cerebral infarction effecting right dominant side, and weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/27/25, indicated Resident #2 did not have a Brief Interview for Mental Status assessment completed and was assessed by staff to have moderately impaired cognition. The MDS further indicated Resident #2 speaks Cantonese. Review of Resident #2's communication care plan dated, 2/19/25, indicated the following interventions: -Resident has impaired communication related to primary language is Cantonese. -Enlist use of communication devices as needed (i.e.) communication board, sign language specify. -Allow time to process information -Anticipate resident needs if resident is unable to express needs. -Assess body and facial expressions. During an observation on 3/25/25 at 8:33 A.M., Resident #2 was observed sitting in the main dining room in a wheelchair. Certified Nursing Assistant (CNA) #3 entered the dining room and was observed walking over to the Resident, moved the wheelchair closer to the table and then walked out of the dining room. CNA #3 did not speak to Resident #2 during the observation. During an observation on 3/26/25 at 7:46 A.M., Resident #2 was observed sitting in the main dining room in a wheelchair. The surveyor observed a staff member deliver a breakfast tray to Resident #2. The staff member was observed speaking to Resident #2 in English. Resident #2 did not try to engage or acknowledge the staff member. During an observation on 3/26/25 at 8:20 A.M., the survey observed CNA #2 deliver a breakfast tray to Resident #2. The CNA was observed speaking to Resident #2 in English. Resident #2 did not try to engage or acknowledge CNA #2. During an observation on 3/26/25 at 9:24 A.M., Resident #2 was observed sitting in the main dining room in a wheelchair. The surveyor observed a staff member walk into the dining room and was observed speaking English to two other residents seated in the dining room. The staff member did not try to engage or acknowledge Resident #2. During an observation on 3/26/25 at 9:42 A.M., Family Member #2 was observed asking staff if someone could take Resident #2 to the bathroom. Resident #2 was observed engaging, smiling and talking to Family Member #2 in Cantonese. CNA #2 walked over to Resident #2 and began pushing him/her in the wheelchair down the hall to the Residents room without engaging or speaking to Resident #2. CNA #2 and Occupational Therapist (OT) #1 were then observed undressing Resident #2, pulling his/her pants down and placing him/her on the toilet and then both exited the bathroom. CNA #2 and OT #1 did not speak or engage with Resident #2 during the entire observation. During an observation on 3/26/25 at 9:54 A.M., Unit Manager #1 and the Infection Control Nurse entered Resident #2's room and began to assist Resident #2 off the toilet. Unit Manager #1 and the Infection Control Nurse were observed speaking English to Resident #2 and said, Here you can wash your hands, as they turned the wheelchair towards the sink and turned the water on. Resident #2 did not engage or acknowledge the staff members. Family Member #2 was observed speaking to the Resident in Cantonese and the Resident could be heard exchanging in the conversation. Family Member #2 said she would wash the Residents' hands. Unit Manager #1 and the Infection Control Nurse then exited the Residents room. Throughout the observations a communication board was not observed or utilized, and staff did not utilize a language line for interpreter services. During an interview on 3/26/24 at 10:00 A.M., Family Member #2 said Resident #2 understands and can communicate in Cantonese, but staff do not understand him/her and do not try to communicate in any way other than speaking English, which the Resident does not understand. During an interview on 3/26/25 at 10:04 A.M., CNA #2 said she does not know what language Resident #2 speaks and said she can't understand Resident #2 because he/she does not speak English. When the surveyor asked CNA #2 how she communicates with Resident #2 she said the family is usually here. When asked how she communicates if the family is not present CNA #2 said I'm not sure. During an interview on 3/26/25 at 10:12 A.M., Unit Manager #1 said staff can use the language line if needed and said staff should communicate with Resident #2 during care. Unit Manager #1 said staff should follow the care plan when providing care. During an interview on 3/27/25 at 10:29 A.M., Director of Nurses (DON) said the communication care plan should be followed by all staff and she expects staff to use a communication board to assist with communication.

Based on observation, record review and interview, the facility failed to provide treatment and care in accordance with professional standards of practice for one Resident (#51), out of a total sample of 28 residents. Specifically, the facility failed to identify a skin wound to the right elbow and document it on a skin assessment. Findings include: Resident #51 was admitted to the facility in January 2025 with diagnoses including sepsis, non-pressure chronic ulcer of lower leg, generalized edema, peripheral vascular disease, and kidney failure. Review of Resident #51's most recent Minimum Data Set (MDS) assessment, dated 2/25/25, indicated the Resident scored a 15 out of total 15 on the Brief Interview for Mental Status indicating intact cognition. The MDS further indicated Resident #51 requires substantial/maximal assistance with activities of daily living tasks. During an observation on 3/25/25 at 12:07 P.M., the surveyor observed Resident #51 in bed with both arms exposed. The Resident was observed to have a dime sized dark pink, raised swollen, circular scabbed area to the right elbow. The center of the scab was yellow and brown with what appeared to be white and yellow dried skin surrounding the center. The skin around the scab was raised, swollen and pink. The Resident reported occasional pain when he/she rubs the area on surfaces and said they know about it, I show them my arms. Review of Resident #51's weekly skin checks, dated 2/28/25, 3/1/25, 3/7/25, and 3/14/25, and 3/21/25 indicated the Residents skin was not intact with open areas documented to right and left shin that were not new areas. No skin impairment to the right elbow was documented on the skin checks. Review of Resident #51's skin integrity care plan dated 1/17/25, indicated the following: Focus area of Vascular wound to r (right) shin, Advanced Age, Decreased/impaired mobility or function and Decrease sensory perception. Interventions include: -Monitor for signs and symptoms of infection. -Protective skin care with incontinent care. -Skin assessments weekly. -Turn and reposition every 2 hours. Review of Resident #51's most recent [NAME] plus pressure ulcer scale, dated 2/9/25, indicated the Resident was at high risk for developing pressure injuries. Review of the active physician orders indicated the following: -Barrier Cream: Apply House Barrier Cream to bony prominences ever [sic] shift and as needed to prevent skin breakdown. Every shift for preventative measures. Start date 1/16/25. Review of Resident #51's Medication and Treatment Administration Record for the month of March 2025 indicated the order for Barrier Cream was documented as administered as ordered during the month. Review of the progress notes entered in Resident #51's medical record failed to indicate any nursing progress note related to changes in Resident #51's skin, specifically the area to his/her right elbow. During an interview on 3/25/25 at 1:36 P.M., CNA #2 said Resident #51 has a lot of swelling to his/her lower legs and said the Resident scratches his/her skin a lot and has an area on the right arm that has been there a while. During an observation on 3/26/25 at 8:39 A.M., Nurse #4 and the surveyor observed Resident #51 sitting up in bed with his/her right arm exposed. Nurse #4 observed the area to the right elbow and said he was not aware of the area to the right elbow and said he would document the area to the right elbow on a skin check and notify the provider for treatment orders. Nurse #4 and the surveyor reviewed Resident #51's medical record and Nurse #4 said he completed the last skin check on 3/21/25 and did not notice the area to the right elbow and said it looked like an old open area that is scabbed over. Nurse #4 said the area must be documented and reported for follow-up and treatment. During an interview on 3/26/25 at 9:05 A.M., Unit Manager #1 said Resident #51 has weekly skin checks and said she was not aware of the area to the right elbow and said the area should have been documented on a skin check and a treatment order should be in place. Unit Manager #1 said she would notify the Nurse Practitioner to get a treatment order and said she would add the right elbow to the weekly wound rounds to keep an eye on it because it could become a pressure area because of the location. During an interview on 3/26/25 at 9:15 A.M., the Director of Nurses (DON) said the area to the Residents' right elbow is not new and said it should have been documented on the weekly skin checks and said a treatment order should have been in place. The DON said the area looks like an unstageable wound because of the scabbed top layer and said she can't see the depth of the wound. The DON said the area should be included in the weekly wound rounds to prevent additional skin breakdown. Review of Resident #51's medical record on 3/27/25 failed to indicate a skin assessment was completed after 3/21/25, and further review of the medical record failed to indicate any nursing progress notes related to the skin area on the right elbow. During a phone interview on 3/27/25 at 10:39 A.M., Nurse Practitioner #2 said she would expect wounds and skin conditions to be assessed and documented and said she was not aware of any open skin areas and would need to check her notes on Resident #51. Review of the active physician orders on 3/27/25 failed to indicate any new treatment orders were implemented to the area on the right elbow. During a follow-up interview on 3/27/25 at 8:25 A.M., the Director of Nurses said a skin check should have been completed when the area to the right elbow was observed and said the physician should have been notified for treatment orders to be implemented.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had dementia, with a history of wandering and exit seeking, but whose nursing admission assessment related to his/her risk for elopement was left incomplete and unfinished, the Facility failed to ensure they developed and implemented a baseline care plan that at a minimum contained the necessary information for staff to properly care for him/her. On 02/22/23, Resident #1 left the Facility, unbeknownst to staff, and was found 0.4 miles away at his/her Family's residence by a Family Member. Resident #1 was noted to be bleeding from his/her head and left elbow, 911 was called, and he/she was transferred to the Hospital Emergency Department for evaluation. Resident #1 was diagnosed with a head injury, an injury to his/her left eyebrow, and having had a fall. Findings include: The Facility was unable to provide any policies regarding the development of baseline care plans and/or policy that addressed the care needs of a wandering or exit seeking resident. Resident #1 was admitted to the Facility in February 2023, diagnoses dementia and a history of falls. The Hospital History and Physical Report, dated 02/10/23, indicated Resident #1 was admitted to the Emergency Department following a fall at home, was assessed to be confused and was wandering. The Report indicated hospital nursing staff placed him/her in a Soma bed (a bed with a mesh enclosure) for safety, and that his/her family was unable to safely keep Resident #1 at home. The Facility Nursing Evaluation, dated 02/17/23, indicated Resident #1 was disoriented and had short term memory issues. Review of Resident #1's facility Elopement Risk Scale Assessment, dated 02/17/23, indicated he/she was ambulatory but was not dependent with ambulation, could not follow instructions, could communicate with staff, and was medically diagnosed with dementia. However further review of the Elopement Risk Assessment indicated it was incomplete, that the section of the assessment form designated for history of wandering, observations, and current behaviors, were left blank. During interview on 03/06/23 at 2:32 P.M., Nurse #3 said she assessed Resident #1 upon his/her initial admission to the facility. Nurse #3 said Resident #1 was confused, and she deferred most of the admissions questions to his/her Family Member. Nurse #3 said Resident #1's Family was mostly concerned about his/her fall risk and said she did not ask questions regarding his/her elopement risk factors. Nurse #3 said she reviewed Resident #1's Hospital discharge paperwork, but did not recall reading that he/she had been wandering while at the Hospital. During interview on 03/08/23 at 1:18 P.M., Nurse #2 said that he was Resident #1's nurse a few times during his/her admission to the Facility and said Resident #1 would become increasingly confused in the evenings, would gather his/her clothes, ambulate around the unit, and ask staff about how to get home. Nurse #2 said he did not report Resident #1's behaviors to anyone and did not complete an Elopement Risk Assessment that included Resident #1's behaviors. The Nurse Progress Note, dated 02/17/23, indicated Resident #1 was confused, ambulated independently, was asking to go home, and staff had to redirect him/her. The Nurse Progress Note, dated 02/19/23, indicated Resident #1 was confused, refused care from staff, and was up several times looking to go home. The Nurse Progress Note, dated 02/21/23, indicated Resident #1 had periods of confusion and forgetfulness, had gathered his/her clothing, and was looking for a way to go home. Review of Resident #1's Medical Record indicated, that despite his/her exit seeking behaviors, that there was no documentation to support they had developed and implemented a baseline care plan for his/her wandering and exit seeking behaviors in an effort to keep him/her safe. During interview on 03/06/23 at 2:13 P.M., the Regional Director of Clinical Operations said Resident #1's Elopement Risk Scale, dated 02/17/23, was incomplete. The Nurse Progress Note, dated 02/22/23, indicated Resident #1's Family Member called the Facility to report that Resident #1 was found at their house at 5:10 P.M., bleeding from his/her head and arm. The Progress Note indicated Resident #1 was transferred from his/her Family's home to the Hospital Emergency Department via 911. Review of the Facility's Security Camera Footage from 02/22/23 and time stamped 4:27 P.M., indicated Resident #1 left the Facility through a back door fire exit. The Facility's Investigation Summary, dated 02/22/23 indicated that on 02/22/23 Resident #1's Family Member called to notify staff that Resident #1 was at his house, 0.4 miles away from the Facility, and was bleeding from a cut on his/her head. The Summary indicated Resident #1 was taken to the Hospital Emergency Department via 911 and returned to the Facility later that day. The Hospital Emergency Department History and Physical, dated 02/22/23, indicated Resident #1 had an injury to his/her left eyebrow, was diagnosed with a fall and head injury, and was discharged back to the Facility that same day. Review of Resident #1's facility Skin Observation Tool, dated 02/23/23, indicated he/she had the following new areas of skin alterations: -Left elbow wound, measuring 18 centimeters (cm) by 7 cm, -Left knee wound, scabbed, no measurements indicated, -Face wound at the corner of his/her right eye, no measurements indicated, -Left lower leg (rear), scabbed, no measurements indicated. During interview on 03/09/23 at 1:27 P.M., Nurse #4 said that on 02/22/23 she worked a double shift on the other hall on the unit from Resident #1. Nurse #4 said Resident #1 was wandering about the unit for most of the day, and said she last saw him/her in the dayroom/dining on the unit at 4:30 P.M. Nurse #4 said Resident #1's Family called the Facility at 5:00 P.M. to report he/she was at their home. During interview on 03/06/23 at 3:03 P.M., Nurse #1 said she was Resident #1's Nurse on 02/22/23 on the 3:00 P.M., to 11:00 P.M., shift, and said she administered Resident #1 medications at 4:33 P.M. in the dayroom on the unit. Nurse #1 said that Nurse #4 told her at 5:00 P.M., that Resident #1's Family had called and said Resident #1 had left the Facility, was at their home, and that they sent him/her to the Hospital Emergency Department via 911. Nurse #1 said she did not know Resident #1 had a history of wandering and asking to go home. During interview on 03/10/23 at 12:51 P.M., the Administrator said the Facility did not have a policy specific to development of baseline care plans. During interview on 03/10/23 at 12:54 P.M., the Director of Nurses (DON) said she could not recall if she was aware of Resident #1's behaviors as noted in his/her Nurse Progress Notes of asking about going home and gathering his/her belongings. The DON said these behaviors should have triggered the Facility to develop a plan of care to prevent elopement.

Based on records reviewed, interviews, and observations, for one of three sampled residents, (Resident #1), had dementia, with a history of wandering and exit seeking behaviors, the Facility failed to ensure he/she was appropriately assessed by nursing for his/her risk of elopement to determine his/her needs related to preventative measures for safety, including the necessary level of staff supervision to maintain his/her safety in an effort to prevent an incident/accident (elopement) resulting in an injury, and failed to ensure alarmed doors were kept secured, with alarms systems sounding and functioning adequately. On 02/22/23, Resident #1, unbeknownst to staff, eloped from the facility by exiting the through a fire exit door, and was found 0.4 miles away at his/her Family's residence by a Family Member. Resident #1 was noted to be bleeding from his/her head and left elbow, 911 was called, and he/she was transferred to the Hospital Emergency Department for evaluation. Resident #1 was diagnosed with a head injury, an injury to his/her left eyebrow, and having had a fall. It was later determined that Resident #1 eloped through an alarmed door that had been left unlocked and then made his/her way through a second alarmed door that should have, but did not, alarm at the nurses station to alert staff. Findings include: The Facility Policy, titled, Missing Resident/Elopement, dated 03/2022, indicated staff would promptly report any resident who tries to leave the premises to the Charge Nurse or Director of Nursing. The Facility was unable to provide any policies regarding alarmed doors or care of a wandering or exit seeking resident. Resident #1 was admitted to the Facility in February 2023, diagnoses included dementia and a history of falls. The Hospital History and Physical Report, dated 02/10/23, indicated Resident #1 was admitted to the Emergency Department following a fall at home, was assessed to be confused and was wandering, The Report indicate hospital nursing staff placed him/her in a Soma bed (a bed with a mesh enclosure) for safety and that his/her family were unable to safely keep Resident #1 at home. The Facility's Nursing Evaluation, dated 02/17/23, indicated Resident #1 was disoriented, and had short term memory issues. Review of Resident #1's facility Elopement Risk Scale Assessment, dated 02/17/23, indicated he/she was ambulatory but was not dependent with ambulation, could not follow instructions, could communicate with staff, and was medically diagnosed with dementia. However further review of the Elopement Risk Assessment indicated it was incomplete, that the section of the assessment form designated for history of wandering, observations, and current behaviors, were left blank. During interview on 03/06/23 at 2:32 P.M., Nurse #3 said she assessed Resident #1 upon his/her initial admission to the facility. Nurse #3 said Resident #1 was confused, and she deferred most of the admissions questions to his/her Family Member. Nurse #3 said Resident #1's Family was mostly concerned about his/her fall risk and said she did not ask questions regarding his/her elopement risk factors. Nurse #3 said she reviewed Resident #1's Hospital discharge paperwork, but did not recall reading that he/she had been wandering while at the Hospital. The Nurse Progress Note, dated 02/17/23, indicated Resident #1 was confused, ambulated independently, was asking to go home, and staff redirected him/her. The Nurse Progress Note, dated 02/19/23, indicated Resident #1 was confused, refused care from staff, and was up several times looking to go home. The Nurse Progress Note, dated 02/21/23, indicated Resident #1 had periods of confusion and forgetfulness, and had gathered his/her clothing and was looking for a way to go home. During interview on 03/08/23 at 1:18 P.M., Nurse #2 said that he was Resident #1's nurse a few times during his/her admission to the Facility and said Resident #1 would become increasingly confused in the evenings, would gather his/her clothes, ambulate around the unit, and ask staff about how to get home. Nurse #2 said he did not report Resident #1's behavior to anyone and did not complete an Elopement Risk Assessment that included Resident #1's behaviors. The Nurse Progress Note, dated 02/22/23, indicated Resident #1's Family Member called the Facility to report that Resident #1 was found at their house at 5:10 P.M., bleeding from his/her head and arm. The Progress Note indicated Resident #1 was transferred from his/her family's home to the Hospital Emergency Department via 911. Review of the Facility's Security Camera Footage from 02/22/23, and time stamped 4:27 P.M., indicated Resident #1 left the Facility through the back door fire exit. During a tour of the Facility with the Director of Nurses (DON) on 03/06/23 at 7:40 A.M., the Surveyor observed there was a set of self-closing swinging doors outside the unit dining room, and on the far right corner of the dining room, there was a fire exit door with a red magnet-style alarm in the shape of a stop sign affixed to the upper right corner of the door, with a key in it, that was turned to the off position. During the Observation, when the door was opened, no alarm sounded. On the other side of this door was a small hallway and another door with a keypad style alarm, which did alarm when opened. Beyond that door, there were seven stairs leading down to an outside door, which opened to a parking lot and was not alarmed. The DON said doors alarmed with a keypad should sound an alarm at a panel located near the Nurses' Station, which would alert staff that someone had opened the door. At 7:56 A.M., at the request of the Surveyor, the DON sounded the keypad alarmed door located at the top of the stairs of the fire exit, while the Surveyor stayed to observe the alarm panel at the first floor Nurses' Station. During the observation the Surveyor noted that when the alarmed door (with the keypad) was opened by the DON and the door alarm sounded, the alarm panel at the Nurses' Station did not sound. The Surveyor also noted that the alarm could not be heard from the outside of the dining room with the doors closed. During interview on 03/06/23 at 7:56 A.M., the Assistant Director of Nurses (ADON) , who was at the Nurse's station with the Surveyor, said she too could not hear the fire exit door alarm sounding, and acknowledged that the door alarm panel at the nurses station was not sounding. The Facility's Investigation Summary, dated 02/22/23, indicated that on 02/22/23 Resident #1's Family Member called to notify staff that Resident #1 was at his house, 0.4 miles away from the Facility, and was bleeding from a cut on his/her head. The Investigation Summary indicated Resident #1 was taken to the Hospital Emergency Department via 911 and returned to the Facility later that day. During interview on 03/06/23, Certified Nurse Aide (CNA) #1 said that on 02/22/23 at 4:30 P.M., she last saw Resident #1 seated in the dayroom on the unit. CNA #1 said she did not see Resident #1 leave the unit and did not hear any door alarms sounding. During interview on 03/09/23 at 1:27 P.M., Nurse #4 said that on 02/22/23 she worked a double shift on the other hall on the unit from Resident #1. Nurse #4 said Resident #1 was wandering about the unit for most of the day, and said she last saw him/her in the dayroom on the unit at 4:30 P.M. Nurse #4 said Resident #1's Family called the Facility at 5:00 P.M. to report he/she was at their home. Nurse #4 said that later that night, someone reviewed the Facility's Security Camera Footage and it revealed that Resident #1 had left the facility through a fire exit door, that he/she had to walk through the unit dayroom/dining room to get to. Nurse #4 said she did not hear a door alarm sound when Resident #1 left, and said when staff tested the alarm that night, staff were unable to hear the alarm on the unit, when outside of the dayroom/dining room doors. During interview on 03/06/23 at 3:03 P.M., Nurse #1 said she was Resident #1's nurse on 02/22/23 on the 3:00 P.M., to 11:00 P.M., shift, and said she administered Resident #1 medications at 4:33 P.M. in the dayroom on the unit. Nurse #1 said that Nurse #4 told her at 5:00 P.M., that Resident #1's Family had called and said Resident #1 had left the Facility and was at their home, and they sent him/her to the Hospital Emergency Department via 911. Nurse #1 said she did not know Resident #1 had a history of wandering and asking to go home. Nurse #1 said she did not hear any door alarms sound when Resident #1 eloped. The Hospital Emergency Department History and Physical, dated 02/22/23, indicated Resident #1 had an injury to his/her left eyebrow, was diagnosed with a fall and head injury, and was discharged back to the Facility that same day. Review of Resident #1's facility Skin Observation Tool, dated 02/23/23, indicated he/she had the following new areas of skin alterations: -Left elbow wound, measuring 18 centimeters (cm) by 7 cm. -Left knee wound, scabbed, no measurements indicated. -Face wound at the corner of his/her right eye, no measurements indicated. -Left lower leg (rear), scabbed, no measurements indicated. During interview on 03/10/23 at 12:54 P.M., the Director of Nurses (DON) said she could not recall if she was aware of Resident #1's behaviors as noted in his/her Nurse Progress Notes of asking about going home and gathering his/her belongings. The DON said these behaviors should have triggered the Facility to develop a plan of care to prevent an elopement. During interview on 03/06/23 at 2:13 P.M., the Regional Director of Clinical Operations said Resident #1's Elopement Risk Scale, dated 02/17/23, was incomplete. During interview on 03/06/23 at 8:45 A.M., the Administrator said the Facility currently did not have a Maintenance Director, and said their other Facilities' Maintenance Departments would come to help out. The Administrator said she did not know if routine door alarm checks were done, and was unable to provide any documentation to support that door alarm checks or maintenance related to the functional status of door alarms, were completed at the Facility prior to 03/06/23. On the day of the survey, there was a contracted Door/Alarm Company on-site at the facility to inspect doors, door alarms, and alarm panels, the Contractor completed any issues found that required repairs.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed at risk for weight loss, the Facility failed to ensure his/her weight remained stable, that weights were obtained as ordered by the Physician, and as a result Resident #1 experienced a weight loss of more than 20 pounds in a 30 day period of time, which was significant. Findings include: The Facility's Policy, titled, Weights and Heights, dated as revised on 6/01/21, indicated: -Residents would be weighed upon admission, then weekly for four weeks, and monthly thereafter. -Additional weights could be obtained at the discretion of the interdisciplinary care team. -Significant weight change was defined as: 5% in one month, or 10% in six months. Resident #1 was admitted to the Facility in June of 2021, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Nutrition Care Plan, dated 6/11/21, indicated, Resident #1 was at nutritional risk related to increased nutritional needs due to skin breakdown, likely inadequate oral intake, and needed a therapeutic diet for wound healing. Interventions included Resident #1 was to be weighed as ordered. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was therefore due to be weighed by nursing on 6/10/21, 6/17/21, 6/24/21, and 7/01/21. Review of Resident #1's medical records indicated his/her weights were recorded as follows: - 6/06/21 documented as 170 pounds - 6/16/21 documented as 170.4 pounds. - 7/01/21 documented as 170.2 pounds. - 7/14/21 documented as 147.3 pounds. There was no documentation to support Resident #1's weight was obtained on 6/10/21, or 6/24/21. Based on Resident #1's weight on 7/01/21 at 170.2 pounds, and 146.4 pounds on 8/06/21, this reflects a very significant weight loss of 13.98%, in one month. Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Medical Record indicated his/her weights were recorded as follows: - 8/06/21 documented as 146.4 pounds. - 8/18/21 documented as 146.3 pounds. There was no documentation to support that Resident #1's weights were obtained daily for seven days starting 8/06/21, as ordered by the Physician. There are no documented weights for Resident #1 on 8/07/21, 8/08/21, 8/09/21, 8/10/21, 8/11/21, 8/12/21, or 8/13/21. During an interview on 10/18/21 at 3:00 P.M., the Dietician said he was aware that Resident #1 had a significant weight loss, and said staff should have weighed and recorded his/her weight as ordered. The Dietician said that was how the Facility monitored whether Resident #1's plan of care was effective in helping to maintain her/her weight and prevent weight loss. During an interview on 10/18/21 at 3:26 P.M., the Director of Nurses said Resident #1's weights should have been measured and recorded as ordered by the Physician.

Based on observation, record review, and interview, the facility failed to prevent a worsening contracture for 1 Resident (#62) out of a total sample of 27 residents. Findings include: Resident #62 was admitted in June 2013 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #62's Minimum Data Set Assessment(MDS) dated [DATE], indicated that Resident #62 was unable to complete the Brief Interview for Mental Status and his/her cognitive skills were assessed as severely impaired. The MDS also indicated that Resident #62 was dependent on staff for all mobility and activities of daily living. On all days of survey, Resident #62 was observed lying in bed and unable to communicate with the surveyor. Resident #62's right foot was turned in towards his/her body with no observable splint or brace in place. Review of Resident #62's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Wear right foot/ankle splint at all times except for hygiene and skin inspection. Every shift for ROM (range of motion) check skin and splint for placement. Review of Resident #62's Progress Notes indicated, - A progress note dated 2/25/2021-splint use was documented as, was not available. - This documentation for the prescribed brace was documented as not available or pending 72 times from 2/25/21 until 7/1/2021 -A note dated 7/2/21 which indicated the brace had been discontinued. Review of Resident #62's Physical Therapy Evaluation dated 12/31/2020, indicated the following: *Resident #62 has developed worsening range of motion in right ankle and great toe after not wearing the prescribed device. *Goals for treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 07/01/21 04:01 P.M., Nurse #4 said that Resident #62 was missing the ordered right foot/ankle splint. Nurse # 4 could not say how long the splint had been missing but said Rehab was aware. During an interview on 7/1/21 and 7/2/21, the Director of Rehabilitation (DOR) said that Resident #62's contracture had worsened. The DOR said orthotic devices are prescribed for a purpose and should be applied as ordered. The DOR said the expectation for missing orthotics is Nursing would inform Rehab and/or put in an order. The DOR said she was unaware of Resident #62's missing orthotic.

Based on interview and record review, the Facility failed to provide adequate supervision to prevent an elopement for 1 Resident (#25) out of a total sample of 27 residents, resulting in a fall down a flight of stairs and a left clavicle fracture. Findings include: Resident #25 admitted to the Facility in 1/2019 with diagnoses which included Alzheimer's Disease, dementia with behavioral disturbance, [CONDITION(S)] with delusions. Review of the most recent Minimum Data Set (MDS), dated [DATE], indicated that Resident #25 used a wheelchair and required limited assistance to move both on and off the nursing unit. Review of the most recent Elopement Evaluation, completed 1 year and 5 months prior on 2/4/20, indicated that Resident #25 had a history of actual elopement or attempted elopement, and had a history of wandering that places the patient at significant risk of getting to a potentially dangerous place, e.g., stairs, outside facility. Review of Resident #25's plan of care for risk for elopement related to cognitive loss/dementia and Health Care Proxy's concern for elopement indicated an intervention was initiated on 4/9/21 to check on Resident #25 frequently to make sure he/she is not attempting to leave. Review of the nurses note written on 7/6/21 at 12:13 A.M., indicated that Resident #25 had been agitated since the morning of 7/5/21, saying somebody stole his/her child. Reassurance and redirecting done with little or no effect. He/she eloped through the back door and had an unwitnessed fall. Transferred out to the hospital for further evaluation. During an interview on 7/7/21, at 12:35 P.M., Unit Manager #1 said that 15 minute checks were initiated whenever Resident #25 became agitated. The checks were documented on 15 minute check forms and kept in the resident record. She reviewed the medical record with the surveyor and was unable to locate a 15 minute check sheet for 7/5/21. During a phone interview on 7/7/21, at 1:30 P.M., Certified Nursing Assistant (CNA) #2 said that on 7/5/21, Resident #25 had been agitated the entire 3-11 shift, attempting to get on the elevator to leave. She said no one was assigned to watch Resident #25, but everyone knows he/she can't be left alone when he/she is agitated like that. CNA #2 said that just after 9:30 P.M. she needed to provide care to another resident and left Resident #25 being supervised by Nurse #2. CNA #2 said that when she came out of the room she could hear Resident #25 yelling for help so she began searching room to room and was not able to locate him/her. CNA #2 said she finally looked in the stairway next to room 100 and saw Resident #25 at the bottom of the stairs and yelled for help. During a phone interview on 7/7/21, at 1:12 P.M., Nurse #2 said that on 7/5/21 at approximately 9:30 P.M., the nurse that was caring for Resident #25 let her know that she would be taking her break off the unit. She said that Resident #25 had been pacing back and forth the entire shift attempting to get on the elevator to leave the unit. She said there was no one assigned to specifically supervise Resident #25, but everyone knew that Resident #25 could not be left alone when he/she was agitated like that. Nurse #2 said that she needed to give medications to another resident down the hallway and left Resident #25 being supervised by CNA #2. Nurse #2 said that when she came out of the other resident's room, CNA #2 was yelling for help and Resident #25 was found at the bottom of the stairs in the stairway outside of room 100. She said Resident #25 was then transferred to the hospital to be evaluated. Review of the hospital discharge summary, dated 7/6/21, indicated a left shoulder x-ray result that showed a [MEDICATION(S)] fracture mid to distal clavicle with minimal displacement and mild to moderate angulation.

Based on observation, record review and interview the facility failed to ensure a resident maintained acceptable parameters of nutritional status for 1 Resident (#4), out of a total sample of 27 residents. Findings include: Review of the facility policy titled Weights and Heights, reviewed 12/20/19, indicated the following: 1. Weights will be obtained on admission, then weekly for four weeks and monthly thereafter. 2. If the body weight is not what is expected then re-weigh the resident. 3. Significant weight changes will be reviewed by the licensed nurse for assessment. 4. For a significant weight change the licensed nurse will notify the physician/nurse practitioner and the dietician. 5. The licensed nurse will notify the physician/nurse practitioner of the dietician recommendations. Resident #4 was admitted to the facility in September 2016 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's medical record indicated that the Resident had a usual body weight of 140-145 pounds (lbs). Review of the Resident #4's medical record indicated the Resident weighed 130 lbs on 2/21/21. Further review of Resident #4's medical record indicated physician orders dated 3/16/21 to reduce the house supplement to one time per day. Further review of the medical record indicated that the next weight obtained wasn't until 4/15/21, at which time Resident #4 weighed 120.6 lbs., a significant weight loss of 9.4 lbs. or 7.23 percent in less than 2 months (a significant weight loss is defined as 5% in one month, 7% in three months and 10% in six months). Review of the medical record failed to indicate a dietician note or a dietary intervention to prevent further weight loss. Review of the medical record indicated that on 5/27/21, Resident #4 lost another pound with a weight of 119 lbs. Review of the Dietician note dated 5/27/21, indicated a recommendation to increase the house supplement back to two times per day. Review of the doctor's orders dated May 2021, June 2021 and July 2021 failed to indicate that the Dietician's recommendation was implemented. Review of the medical record failed to indicate a weight had been obtained in June 2021. Review of the medical record failed to indicate that Resident #4 refuses to be weighed. During an interview on 7/6/21, at 9:35 A.M., Unit Manager (UM) #2 said that Resident #4 is able to be weighed and doesn't know why there are not weights on him/her weekly. UM #2 then ambulated Resident #4 to the scale in the dining room and obtained a weight of 110 lbs., a significant weight loss of 9 lbs. or 7.56 percent in less than 2 months. During an interview on 7/6/21, at 11:00 A.M., the Dietician said that he was aware of the weight loss and the lack of the Resident being weighed weekly. He further said that he had spoken with the Unit Managers and the Director of Nursing but that nothing had changed. The Dietician also said that he wasn't sure why no further interventions had been implemented to prevent further weight loss. During an interview on 7/6/21, at 11:21 A.M., the surveyor asked UM #2 how the doctor or nurse practitioner is informed about a resident's weight. UM #2 responded that the nurse practitioner looks in Point Click Care (PCC) (the computer medical record) and the weights are listed there. During an interview on 7/6/21, at 1:39 P.M., Nurse Practitioner (NP) #1 said that she is supposed to be informed by nursing if a resident has had a significant weight loss. NP #1 then said that she had not been informed of Resident #4's weight loss. NP #1 also said that she was not aware to look in PCC for the weights. NP #1 then said that if the surveyor looked in her notes that the surveyor would not see any mention of Resident #4 having had a weight loss because she didn't know about it. Review of NP #1's notes dated 12/14/20, 2/12/21, 3/5/21, and 3/9/21 failed to indicate a mention of weight loss.

Based on observation, interview, review of facility policy and medical record review, the facility staff failed to implement negative pressure wound therapy consistent with professional standards of practice and facility policy, to prevent the decompensation of a wound for 1 resident (#40) out of a total sample of 19 Residents. Findings include: Review of the facility policy Vacuum Assisted Closer (V.[NAME]C.) Therapy, undated, indicated the following: -Monitor continuously and check and respond to alarms -Failure to consult a physician and carefully read and follow all therapy unit and dressing instructions and safety information prior to each use may lead to improper product performance and the potential for serious or fatal injury. -Do not adjust therapy unit settings or perform therapy application without directions from/or supervision by the treating physician. -Vacuum Assisted Closure (V.[NAME]C.) Therapy is contraindicated for patients with necrotic tissue. -If active bleeding develops suddenly or in large amounts during V.[NAME]C. Therapy, or if frank (bright red) blood is seen in the tubing or in the canister, immediately stop V.[NAME]C. Therapy, leave dressing in place, take measures to stop the bleeding and seek immediate medical assistance. -If significant bleeding occurs, do not remove the foam dressing until the treating physician or surgeon is consulted. -Tubing blockages with the VAC Therapy unit may result in brief vacuum excursion to more than 250 mmHg negative pressure. Resolve alarm conditions immediately. -The V.[NAME]C. Canister should be changed when full (the alarm will sound) or at least once a week to control odor. -V.[NAME]C. Therapy is not a [MEDICATION NAME] tool and is not a substitute for effective surgical and/or other forms of debridement. -The blockage alarm will sound if the canister is full, change the canister if it is full. Resident #40 was admitted to the facility in 11/2017 with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] indicated the Resident had severely impaired cognition. The MDS dated [DATE] indicated the Resident was totally dependent or required assistance with all aspects of his/her activities of daily living. On 7/9/19 at 8:28 [NAME]M., the surveyor observed Resident #40 in his/her bed, a wound V.[NAME]C. for delivering negative pressure wound therapy (NPWT) was in a case at the Resident's bed side. Review of Resident #40's medical record indicated a physician's order dated 6/25/19 for wound V.[NAME]C to coccyx wound NPWT 150 with the use of program directly on the base of wound bed, change dressing Mon-Wed-Fri. Review of Resident #40's care plan indicated an intervention for a chronic sacral wound dated 3/7/19 to provide wound treatment as ordered. Review of Resident #40's hospital wound consult report dated 6/20/19 indicated the following: -Stage 4 pressure injury to the sacrum. -The base of wound bed is red and moist -The wound bed is 100% red, moist, healthy granulating (new vascular tissue forming on healing surface of a wound) tissue -Moderate amount of serosanguinous drainage (yellowish fluid with small amounds of blood) on the old dressing. Review of Resident #40's hospital discharge summary dated 6/24/19 indicated a recommendation for negative pressure wound therapy 150 (mmHg) with use of program directly on the base of the wound bed, change dressing on Monday, Wednesday, and Friday for the sacral wound. On 7/10/19 at 11:45 [NAME]M., the surveyor observed Resident #40 in bed, the wound V.[NAME]C alarm indicating a blockage was sounding. On 7/10/19 at 2:16 P.M., the surveyor observed Resident #40 in bed, the wound V.[NAME]C alarm indicating blockage was sounding. The surveyor observed the wound V.[NAME]C drainage 300 milliliter (ml) canister filled with frank blood. The surveyor notified Nurse #3 of the alarming wound V.[NAME]C. Nurse #3 was interviewed, he told the surveyor the last time he saw Resident #40 was around 12:00 P.M.; he also told the surveyor that he only looked at Resident #40's general appearance, but did not check/assess the functioning of the wound V.[NAME]C. On 7/10/19 at 2:20 P.M., the surveyors observed the wound V.[NAME]C with Nurse #3 and Physical Therapist (PT) #2. During an interview on 7/10/19 at 2:20 P.M., PT #2 said she observed the wound V.[NAME]C on 7/7/19 and she had observed that the canister was filled with frank blood similar to the filled canister she was observing with the two surveyors present. She said the dressing was removed prior to notification of the physician or nurse practitioner on 7/7/19 and bleeding was present to the wound bed. She said the bleeding was a change in the status of the wound. On 7/10/19 at 2:40 P.M., Nurse #3 removed the wound V.[NAME]C. dressing to Resident #40's sacral wound. The surveyor observed the wound to be bleeding with frank blood, and the wound had slough (white/tan dead/necrotic tissue) covering the wound bed with some darkened areas. During an interview on 7/10/19 at 2:43 P.M., PT #2 said the Resident had readmitted to the facility with recommendations for a negative pressure wound therapy. She said the wound did not contain slough upon readmission, the wound was completely granulated with a small area of exposed tendon. During an interview on 7/10/19 at 2:44 P.M., Nurse #3 said on 6/25/19, the wound was completely granulated and had moderate serosanguinous drainage. He said the wound was not bleeding nor was there any slough in the wound. Further inspection of the wound V.[NAME]C device on 7/10/19 at 2:45 P.M., indicated the pump only operated at a pressure setting of 125 mmHg, not the 150 mmHg as ordered on [DATE] (15 days prior) During an interview on 7/11/19 at 11:43 P.M., Unit Manager #2 said she did hold an in-service when the resident was started on the Wound V.[NAME]C. She said usually in services are held for new therapies or procedures. She said the staff should have been in serviced. She said the only pump that had been ordered for Resident #40 was the one that had been in use on 7/10/19. She said that it had not been operating at the pressure for negative therapy wound pressure ordered on [DATE], and a different pump should have been ordered. Review Resident #40's skin integrity report (wound measurements) indicated the following: -6/25/19-100% Granulated, depth 2.1 centimeters, moderate serosanguinous drainage. -6/27/19-100% Granulated, depth 1.5 centimeters, moderate serosanguinous drainage. -7/1/19-100% Granulated, depth 2.4 centimeters, moderate bleeding. -7/10/19-60% Granulated, 40% slough, depth 3 centimeters, heavy bleeding. The facility staff failed to implement negative pressure wound therapy consistent with professional standards of practice and facility policy and prevent the decompensation Resident #40's wound. Refer to F726

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), the Facility failed to provide interventions and supervision necessary to prevent resident to resident sexual abuse, when on 5/17/19, Resident #2, who had known behavior of sexually grabbing others, was seated near the exit of the dining room, and as Resident #1 was passing by, Resident #2 groped Resident #1's breast. Findings include: The Facility's policy, titled Abuse Prohibition, dated 5/1/19, indicated: -Sexual abuse was defined as non-consensual sexual contact of any type with a resident, including sexual assault. -The Facility would provide adequate supervision when risk of resident to resident altercation is suspected. -The Facility was responsible for identifying residents who had a history of [REDACTED]. Resident #1 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. Resident #2 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. Resident #3 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The Nurse's Note, dated 5/15/19, indicated that Resident #2 groped Speech Therapist #1's breasts, and the incident was reported to Director of Nurses #1. The Facility's Investigation Report, dated 5/15/19, indicated that Nurse #1 heard Resident #3 say No to Resident #2, and Nurse #1 saw Resident #2 walk away from Resident #3. The Report indicated Resident #3 said Resident #2 touched his/her ribs, and the incident was reported to the Director of Nurses. The Surveyor interviewed Nurse #1 at 1:07 P.M. on 6/10/19. Nurse #1 said that on 5/15/19, at approximately 3:15 P.M., Resident #2 walked up behind Speech Therapist #1, reached around behind her, and groped her breasts. Nurse #1 said that approximately 3:45 P.M., on the same date, she heard Resident #3 say No and when she turned around saw Resident #2 walk away from Resident #3, and Nurse #1 said Resident #3 said Resident #2 had walked up behind him/her and touched both sides of his/her waist near his/her ribs. Nurse #1 said Resident #2 was placed on one on one supervision after he/she touched Resident #3's waist. The Facility's Investigation Report, date 5/17/19, indicated that at approximately 12:30 P.M., on 5/17/19, Resident #1 was in his/her wheelchair leaving the dining room on the unit, and as he/she went past Resident #2, who was seated in a chair near the door, Resident #2 reached out and groped Resident #1's breast. The Surveyor interviewed CNA #1 at 11:50 A.M. on 6/10/19. CNA #1 said she was assigned to provide one on one supervision for Resident #2 on 5/17/19. CNA #1 said that on 5/17/19, Resident #2 was seated at a table without other residents in the dining room on the unit near the door, and she had walked across the hallway to put a piece of paper on the desk at the Nurses' Station, and said that as she turned back around, she saw Resident #2 reach out with his/her left hand and groped one of Resident #1's breasts. CNA #1 said Resident #1 said Don't touch me or words to that effect, and said Resident #1 was upset. The Surveyor interviewed CNA #2 at 1:23 A.M., on 6/10/19. CNA #2 said that Resident #2 had some sudden onset of sexual behaviors including groping staff and Resident #3. CNA #2 said that at approximately 12:30 P.M., on 5/17/19, she was in the dining room on the unit, and was standing next to Resident #1 as he/she was ambulating in his/her wheelchair past Resident #2. CNA #2 said as Resident #1 passed by Resident #2, Resident #2 reached out and groped Resident #1's breast. CNA #2 said she was not certain if Resident #2 was assigned a one on one staff on 5/17/19. The Surveyor interviewed Resident #1 at 2:10 P.M., on 6/10/19. Resident #1 said that as he/she was leaving the dining room in his/her wheelchair, Resident #2, who was seated next to the door, reached out and groped Resident #1's breast. Resident #1 said he/she was surprised by Resident #2's actions. Resident #1 said he/she had not been told to stay away from Resident #2. The Surveyor interviewed Director of Nurses #1 at 11:37 A.M., on 6/12/19. Director of Nurses #1 said she was notified that Resident #2 groped Resident #1's breast on 5/17/19. Director of Nurses #1 said that when a resident was on one on one supervision, staff should be able to see the resident at all times, and should ensure another staff member would provide one on one supervision if they needed to leave the resident for any reason.

Based on records reviewed and interviews for one of three sampled residents (Resident #2), the Facility failed to ensure that Resident #2, who had medical [DIAGNOSES REDACTED]. As a result, Resident #2 did not receive the respiratory or steroid medications nor was his/her blood work obtained as ordered by the Nurse Practitioner and three days later, Resident #2 was transferred to the Hospital where he/she was admitted with respiratory distress and required treatment for [REDACTED]. Findings Include: The Facility Policy titled Medication Errors, dated as revised on 1/2/14, indicated that a medication error is defined as a discrepancy between what the Physician/Mid-Level Provider ordered and what the patient received which included medication omissions. The Facility Policy titled Transcription of Orders, dated as revised on 10/1/12, indicated that in order to communicate all Practitioner orders to caregivers regarding patient's care and treatment, orders from an authorized licensed Independent Practitioner are transcribed by a licensed nurse. The Facility Policy titled 24-Hour Chart Check, dated 3/1/16, indicated that licensed Nursing Staff were responsible for completing a chart check once every 24 hours on the same shift each day. The Policy indicated that, in order to validate the correctness of orders, proper transcription, and to prevent improper treatment or omission of treatment, medication, ancillary orders, or documentation, the licensed Nurse who completed the 24-hour chart check was required to identify and correct improper orders in the medical record and/or on the Medication Administration Record [REDACTED] Resident #2 was admitted to the Facility in (MONTH) of (YEAR) with medical [DIAGNOSES REDACTED]. A Care Plan, initiated on 1/14/18, indicated that Resident #2 exhibited or was at risk for respiratory complications related to asthma and [MEDICAL CONDITION]. The Care Plan included an intervention that directed Staff to provide respiratory treatment as ordered and monitor for effectiveness. Nurse Practitioner Orders for Resident #2, dated 1/15/18, were written as follows: -[MEDICATION NAME] (inhalation solution to treat respiratory symptoms associated with [MEDICAL CONDITION]) via nebulizer every six hours around the clock -Change [MEDICATION NAME] (used to treat respiratory symptoms associated with [MEDICAL CONDITION]) to two puffs every six hours as needed, for shortness of breath and wheeze -[MEDICATION NAME] (a corticosteroid used to treat [MEDICAL CONDITION] processes) 40 milligrams (mg) by mouth daily for two days, then taper down doses: -[MEDICATION NAME] 30 mg by mouth daily for two days, then -[MEDICATION NAME] 20 mg by mouth daily for two days, then -[MEDICATION NAME] 10 mg by mouth daily for two days -Laboratory Blood Work -Fasting Blood Sugar levels three times daily while on [MEDICATION NAME]. There was no documentation in Resident #2's Medical Record to indicate that the Nurse Practitioner's Orders written on 1/15/18 were transcribed and implemented. An Event Summary Report, dated 1/19/18, indicated that the Nurse Practitioner was in to see Resident #2 early during the 7:00 A.M. to 3:00 P.M. shift on 1/15/18 and the Nurse Practitioner's Orders were never transcribed. The Report indicated that there were multiple errors with 15 doses of medications omitted, and therefore not administered to Resident #2 as ordered by the Nurse Practitioner. The Report indicated that the effect on Resident #2 was a change in condition with medical intervention required and Resident #2 was transferred to the Hospital Emergency Department for respiratory distress. The Surveyor Interviewed the Nurse Practitioner (NP) at 11:21 A.M. on 4/10/18. The NP said she wrote Orders for Resident #2 on 1/15/18 and said she wrote orders for Resident #2 to be transferred to the Hospital, a few days later, due to respiratory issues. The NP said she flagged the New Orders in Resident #2's medical record on 1/15/18 for review by nursing. The Nurse Practitioner said she was informed by the Unit Manager, on the day after she transferred Resident #2 to the hospital, that the Orders she had written, on 1/15/18, were never transcribed or followed by Staff. The NP said the Unit Manager told her that the Nurse put Resident #2's chart, with the flagged Orders, back on the shelf and they missed them. The Nurse Practitioner said she was frustrated about the incident because if the Facility had followed the Orders she wrote, Resident #2 would not have required a Hospital Admission. The Hospital Discharge Summary, dated 1/20/18, indicated that Resident #2 was transferred from the Facility on 1/18/18 and upon arrival, Resident #2 was found to be in respiratory distress with [MEDICATION NAME] (a tightening of the muscles that line the airways in lungs) and Resident #2 was admitted to the hospital with [REDACTED]. Resident #2 was discharged from the hospital on [DATE] and returned to the Facility with MEDICATION ORDERS FOR [REDACTED] The Surveyor interviewed the Unit Manager at 1:44 P.M. on 4/9/18. The Unit Manager said the Nurse Practitioner wrote the Orders for Resident #2 on 1/15/18 but said she could not recall how the medication errors occurred. The Unit Manager said she expected Nurses to check to see if new orders were written anytime a Physician or Nurse Practitioner comes to the Facility to see a resident and said she typically checked Physician's and/or Nurse Practitioner's Orders each morning to make sure they were transcribed. The Unit Manager said Resident #2's medication errors were an isolated incident and said she and the nurse missed it, or words to that effect. The Surveyor Interviewed Nurse #4 at 1:39 P.M. on 4/10/18. Nurse #4 said she worked on the 7:00 A.M. to 3:00 P.M. shift on 1/15/18 and said although she was aware of a medication error that occurred for Resident #2, she could not recall the details about the incident. Nurse #4 said a Nurse on the 11:00 A.M. to 7:00 P.M. shift was responsible for checking physician's orders [REDACTED]. Nurse #4 said when Resident #2's medication error occurred, Nurses only checked Physician and NP Orders that Staff placed in a basket and if an order was overlooked and not placed in the basket, the order would not get checked and verified for accuracy. The Surveyor Interviewed Nurse #5 at 2:14 P.M. on 4/10/18. Nurse #5 worked on the 11:00 P.M. to 7:00 A.M. shift on 1/15/18. Nurse #5 said she was aware that Resident #2's Nurse Practitioner's Orders were not transcribed, but she could not recall what happened that day or if she had seen any orders. Nurse #5 said when Resident #2's medication error occurred, Order checks were completed by Nurses on the 11:00 P.M. to 7:00 A.M. shift, and said they checked orders for the day that were put into baskets but did not go through all the charts to check for Physician or NP Orders that may not have been placed in the baskets. The Surveyor interviewed the Director of Nursing (DON) at 12:45 P.M. on 4/9/18. The DON said she expected nurses to read the Physician's notes and check to see if orders were written when Physician's or Nurse Practitioners came to the Facility to see a resident.