Every finding on record at Royal Nursing Center, LLC

Based on observations, interviews, and meal test tray results, the facility failed to serve meals that were palatable and at appetizing temperatures on one (Vineyard Sound) of three units.Using the reasonable person concept, a person would not find the food temperatures palatable and appetizing.Findings include:Review of the facility's Matrix (used to identify pertinent care categories for residents) provided to surveyors by the Director of Nursing on 12/16/25 indicated 36 out of 40 residents residing on the Vineyard Sound Unit had a diagnosis of Alzheimer's disease or dementia. On 12/17/25 at 8:13 A.M., the surveyor made the following observations on the Vineyard Sound Unit:-At 8:13 A.M., the first breakfast truck arrived on the unit.-At 8:23 A.M., the first tray is served to residents in the dining area from the first truck.-At 8:27 A.M., the second truck arrives on the unit.-At 8:33 A.M., the first tray is served to residents in the dining area from the second truck.-Staff continue to serve residents off the first truck.-At 8:54 A.M., the final breakfast tray is removed off the first breakfast truck, 41 minutes after the first meal truck was delivered on the unit.-Staff continue to serve residents from the second truck.-At 9:27 A.M., the final breakfast tray is removed from the second breakfast truck, 60 minutes after the second meal truck was delivered on the unit.-Meals were observed delivered directly to residents and not heated prior to delivery. On 12/18/25 at 8:17 A.M., the surveyor made the following observations on the Vineyard Sound Unit:-At 8:17 A.M., the first breakfast truck arrived on the unit.-At 8:21 A.M., the first tray is served to residents in the dining area from the first truck.-At 8:29 A.M., the second truck arrives on the unit.-Staff continue to serve residents off the first truck.-At 8:33 A.M., the first tray is served to residents in the dining area from the second truck.-At 8:41 A.M., the final breakfast tray is removed off the second breakfast truck, 8 minutes after the second meal truck was delivered on the unit.-Staff continue to serve residents from the first truck.-At 8:49 A.M., the final breakfast tray is removed from the first breakfast truck, 32 minutes after the first meal truck was delivered on the unit.-Meals were observed delivered directly to residents and not heated prior to delivery. On 12/17/25 at 8:55 A.M., a test tray from the first breakfast truck was conducted with Nurse #5 observing and confirming temperatures (in degrees Fahrenheit (F)). The results were as follows:-Scrambled Eggs: 105 F, cold to taste-Ham Slices: 96.3 F, lukewarm to taste-Biscuit: 102.2 F, lukewarm to taste-Oatmeal 120 F, warm to taste in the middle of the bowl but lukewarm on the sides of the bowl-Orange Juice 67.3 F, warm to touch/taste-Milk 59.9 F, warm to touch/tasteDuring an interview on 12/17/25 at 8:59 A.M., Nurse #5 said the eggs were cold, the biscuit was supposed to be hot, and it was not, the oatmeal could have been warmer, and the milk and orange juice could have been colder. On 12/17/25 at 9:28 A.M., a test tray from the second breakfast truck was conducted with Nurse #5 observing and confirming temperatures. The results were as follows:-Ham Slices: 94.8 F, lukewarm to taste-Biscuit: 96.2 F, lukewarm to taste-Orange Juice 63.9 F, warm to touch/taste-Milk 62.9 F, warm to touch/tasteOn 12/17/25 at 9:32 A.M., Nurse #5 said she liked her milk cold and if this was her breakfast tray she would send it back and get a new one. On 12/18/25 at 8:50 A.M., a test tray from the first breakfast truck was conducted with the Food Service Manager (FSM) observing and confirming temperatures. The results were as follows:-Scrambled Eggs: 110 F, lukewarm to taste-Muffin: 100.6 F, not warm to taste-Oatmeal: 118 F, warm to taste in the middle of the bowl but lukewarm on the sides of the bowlDuring an interview on 12/18/25 at 8:53 A.M., the FSM said the eggs, oatmeal, and muffin should be warmer. The FSM said when meal carts come up from the kitchen they should not be sitting for an extended time. The trays should be passed out in 10 minutes. The FSD said his expectation was for food to be served at the appropriate temperatures. During an interview on 12/17/25 at 11:06 A.M., Certified Nursing Assistant #2 said most of the residents on the Vineyard Sound unit eat breakfast in the dining room. She said the 11:00 P.M. to 7:00 A.M. shift had a list of residents to get out of bed and the 7:00 A.M to 3:00 P.M. shift would get the rest of the residents up and bring them to breakfast. During an interview on 12/18/25 at 10:58 A.M., the District Food Service Manager said the expectation was for meal trays to be passed in a timely manner and foods should be served at appropriate temperatures. During an interview on 12/18/25 at 11:46 A.M., Unit Manager #3 said most residents on the Vineyard Sound Unit eat in the dining room. She said housekeeping goes in first thing in the morning and vacuums the dining room floor. She said then the staff start to bring residents into the floor dining room as they are getting up and they get their meal trays as soon as they come to the dining room. She said food should be served at appropriate temperatures. During an interview on 12/18/25 at 12:01 P.M., the Director of Nursing and the Administrator said mealtimes are posted and the expectation would be for residents to be in the dining room and for staff members to be ready to help pass out meal trays. They said food should be served at appetizing temperatures.

Based on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards for one Resident (#4), out of a total sample of 20 residents. Specifically, the facility failed to implement physician's orders for air mattress settings. Findings include:Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following:-The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice.Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated:-Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error.-In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber.Review of the facility's policy titled Medication and Treatment Orders, dated 2/2024, indicated, but was not limited to, the following:-Orders for medications and treatments will be consistent with principles of safe and effective order writing.Resident #4 was admitted to the facility in September 2009 with diagnoses including dementia.Review of Resident #4's Minimum Data Set (MDS) assessment, dated 11/14/25, indicated the Resident was cognitively impaired, as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. Further review of the MDS assessment indicated the Resident had one stage 3 pressure ulcer, not present on admission, and had a pressure reducing device for his/her bed.Review of Resident #4's Physician's Orders indicated, but was not limited to, the following:-Air Mattress - Pressure set per resident's most recent weight; +/- 10 lbs. Document weight. Check placement and function every shift. (order date 12/4/25)Review of Resident #4's medical record indicated that he/she weighed 162.5 pounds on 12/2/25.During the course of the survey, the surveyor made the following observations:-On 12/16/25 at 3:03 P.M., Resident #4 was lying in bed, and his/her air mattress was on and set to 72 kilograms (or 158.7 pounds).-On 12/17/25 at 8:08 A.M., Resident #4 was lying in bed, and his/her air mattress was on and set to 143 kilograms (or 315.3 pounds).-On 12/17/25 at 1:47 P.M., Resident #4 was lying in bed, and his/her air mattress was on and set to 143 kilograms (or 315.3 pounds).-On 12/18/25 at 7:47 A.M., Resident #4 was lying in bed, and his/her air mattress was on and set to 143 kilograms (or 315.3 pounds).During an interview on 12/17/25 at 4:21 P.M., Nurse #3 said Resident #4's air mattress should be set for his/her body weight, which was most recently documented at 162.5 pounds.During an interview on 12/18/25 at 7:52 A.M., Unit Manager #2 said Resident #4's air mattress should be set at about 72 kilograms, not 143 kilograms.

Based on record review and interviews, the facility failed to ensure staff provided residents an environment free from accident hazards for one Resident (#17), out of a total sample of 20 residents. Specifically, the facility failed to implement fall prevention interventions to prevent future falls for Resident #17.Findings include:Review of the facility's policy titled Fall Prevention Program, last revised May 2025, included but was not limited to:-Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.-A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force (e.g. resident pushes another resident). The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere.-Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk.-The nurse will indicate on the resident's care plan in the resident's medical record the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk.-Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care.Resident #17 was admitted to the facility in July 2025 and had diagnoses including fusion of the spine cervical region, history of falling, muscle weakness, and ataxia (a neurological condition characterized by poor muscle control that leads to clumsy movements).Review of the Minimum Data Set (MDS) assessment, dated 7/21/25, indicated Resident #17 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15 and required partial to moderate assistance with transfers from bed to chair.Review of the initial Fall Risk Evaluation, dated 7/15/25, indicated Resident #17 had a fall risk score of 14 (at risk).Review of the medical record indicated Resident #17 had multiple falls from July 2025 to October 2025.Review of the fall investigations indicated:-7/27/25 at 9:40 A.M., Resident #17 had an unwitnessed fall without injury and was found sitting on the floor in his/her room. The Resident reported that he/she was done using the bathroom and did not use the call light, got up to walk and did not realize that his/her underwear was around his/her ankles. Immediate action taken: Range of motion, vitals and assessment.A care plan for falls was developed on 7/28/25 as follows:Focus: I am at risk for falls as evidenced by scoring tool (7/28/25)Interventions: Anticipate and meet the resident's needs; Assist resident with ambulation and transfers when therapy recommendations are made; Be sure the resident's call light is within reach and encourage the resident to use it for assistance to all requests; Determine the resident's ability to transfer; Educate on importance of maintaining a safe environment, free of potential fall hazards (7/28/25)Goal: I will not sustain serious injury through the review date; I will be free of minor injury through the review date; I will be free of falls through the review date (7/28/25, Target date: 1/22/26)-8/17/25 at 12:00 P.M., Resident #17 was transferring from a shower chair with a Certified Nursing Assistant (CNA), stood up and immediately fell to the floor. Resident is usually an assist of one. Immediate action taken: Use two staff members to transfer Resident until cleared by therapy. This fall intervention was added to the care plan on 8/17/25. Review of the medical record, including but not limited to Physical Therapy and Occupational Therapy notes, failed to indicate Resident #17 was cleared by therapy.-9/2/25 at 2:00 P.M., Resident #17 was self-transferring to bed from a wheelchair and fell to the floor. The fall was witnessed by the Resident's visitor. The investigation found the wheels on the Resident's bed were not locked at the time of the fall. Immediate action taken: Bed put in locked position. This fall intervention was added to the care plan on 9/3/25.Review of the Kardex (quick reference summary of a resident's care plan, orders, history, and needs utilized by care providers) indicated Resident #17 required moderate assistance of two staff members for transfers with a rolling walker.-10/1/25 at 7:30 A.M., Resident #17 sustained a fall in his/her bedroom while being assisted to the bathroom. The CNA reported to the nurse that the Resident attempted to get his/her walker when the CNA opened the bathroom door and he/she fell to floor face down and was bleeding from the lip. The Resident was assessed by the nurse and found to have abrasions to the left side of his/her lip and bilateral knees. The investigation revealed that at the time of the fall, Resident #17 was assisted by one staff member and not two as indicated on the fall care plan. Immediate action taken: bilateral floor mats on both sides of the bed. This fall intervention was added to the care plan on 10/1/25.-10/2/25 at 10:00 A.M., Resident #17 sustained a fall during a transfer from his/her bed to wheelchair. The investigation revealed that at the time of the fall, Resident #17 was assisted by one staff member and not two as indicated on the fall care plan. Immediate action taken: Resident was assessed with no noted injury; orders to follow facility protocol. The fall risk care plan was updated on 10/3/25 to indicate staff are to utilize sit to stand lift (a mobility device used to safely move someone with limited strength from a seated position (like a wheelchair or bed) to a standing position and back again, or transfer between surfaces) until cleared by therapy.Review of a Health Status Note, dated 10/1/25 and written by Nurse #1, indicated Resident #17 sustained a fall in his/her bedroom while being assisted by one CNA. Nurse #1 indicated Resident #17 was an assist of two.During an interview on 12/17/25 at 12:54 P.M., Nurse #1 reviewed the Resident's medical record and said at the time of the falls on 10/1/25 and 10/2/25, two staff members should have been assisting the Resident but was not.During an interview on 12/17/25 at 1:39 P.M., CNA #1 said she works on all units in the facility and usually receives information about residents on her assignment from the previous shift, or by reviewing their Kardex. She said Resident #17 was on her assignment on 10/2/25 and remembers assisting him/her with a transfer. She said his/her legs got weak and fell onto his/her butt. She said she was not told about the Resident's fall the previous day, did not review the Kardex prior to providing care to Resident #17 and was not aware he/she was an assist of two.During an interview on 12/18/25 at 11:25 A.M., the Director of Nursing (DON) reviewed Resident #17's medical record and fall incident reports. She said Resident #17 is a fall risk and the care plan and Kardex indicated Resident #17 was an assist of two at the time of the falls on 10/1/25 and 10/2/25. She said Resident #17 should have been assisted/transferred by two CNAs on 10/1/25 and 10/2/25 and not one.

Based on observation, interview, and document review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed:1. For Resident #4,a. to perform hand hygiene as indicated during a dressing change, andb. to doff (remove) personal protective equipment (PPE) as indicated for a resident on Enhanced Barrier Precautions (EBP); and2. To disinfect shared vital signs equipment after use.Findings include1. Review of the facility's policy titled Hand Hygiene, revised 12/2024, indicated, but was not limited to, the following:-Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice.-The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.Review of the facility's policy titled Enhanced Barrier Precautions, revised 12/2024, indicated, but was not limited to, the following:-Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities.-High-contact resident care activities include wound care.-Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room.Review of the Centers for Disease Control and Prevention (CDC) document titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrugresistant Organisms (MDROs), updated 7/2022, indicated, but was not limited to, the following:-Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs.-Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room)-Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same roomResident #4 was admitted to the facility in September 2009 with diagnoses including dementia.Review of Resident #4's Minimum Data Set (MDS) assessment, dated 11/14/25, indicated the Resident was cognitively impaired, as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. Further review of the MDS assessment indicated the Resident had one stage 3 pressure ulcer.Review of Resident #4's Physician's Orders indicated, but was not limited to, the following:- Staff to maintain Enhanced barrier precautions related to G-tube (gastrostomy tube, a tube inserted through the abdomen that provides direct access to the stomach for nutrition) and wounds (order date: 8/14/25)a. On 12/17/25 at 1:47 P.M., the surveyor observed Nurse #4 perform a dressing change to Resident #4's sacral pressure ulcer and gastrostomy tube insertion site. The surveyor observed Nurse #4 remove her gloves after removing the Resident's soiled gastrostomy tube dressing and don (apply) new gloves without performing hand hygiene. The surveyor then observed Nurse #4 remove her gloves after removing the Resident's soiled sacrum dressing and don new gloves without performing hand hygiene. During a telephonic interview on 12/18/25 at 11:42 A.M., Nurse #4 said she should have sanitized or washed her hands every time she removed her gloves.During an interview on 12/18/25 at 10:48 A.M., the Infection Prevention Nurse/Assistant Director of Nursing said it was her expectation that staff perform hand hygiene after removing gloves.b. On 12/17/25 at 2:05 P.M., the surveyor observed Nurse #4 remove her gloves, perform hand hygiene, and leave Resident #4's room to retrieve additional dressing supplies from the treatment cart out in the hallway. Nurse #4 failed to remove her gown before exiting Resident #4's room. Nurse #4 returned to the room at 2:06 P.M. with the same gown on.During an interview on 12/18/25 at 10:48 A.M., the Infection Prevention Nurse/Assistant Director of Nursing said it was her expectation that staff remove all PPE when exiting the room for a resident on Enhanced Barrier Precautions.2. Review of a facility document titled [Corporate Health Group], undated, indicated, but was not limited to, the following:-Standard Precaution:Properly handle and properly clean and disinfect patient care equipment and instruments/devices. On 12/17/25 at 9:36 A.M., the surveyor observed Nurse #4 retrieve a portable vital signs machine from the unit's sitting room and use it to obtain Resident #67's blood pressure. After obtaining the Resident's blood pressure, Nurse #4 returned the vital signs machine to the sitting room but failed to disinfect the shared vital signs machine after it was used. During an interview on 12/17/25 at 4:27 P.M., Unit Manager #2 said Nurse #4 should have disinfected the vital signs machine after using it.During a telephonic interview on 12/18/25 at 11:42 A.M., Nurse #4 said she should have disinfected the blood pressure cuff after she used it.During an interview on 12/18/25 at 10:48 A.M., the Infection Prevention Nurse/Assistant Director of Nursing said it was her expectation that staff disinfect shared equipment after it is used.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), the facility failed to ensure that upon admission, nursing developed and implemented a baseline care plan with interventions, treatments, goals and outcomes that addressed the residents' overall immediate care needs.Findings include:Review of the Facility Policy titled Baseline Care Plans, dated as revised May 2023, indicated that a baseline care plan will be developed for each resident within 48-hours of admission to assure the resident's immediate care needs are met and maintained.The Policy further indicated the baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan. The baseline care plan is updated as needed to meet the residents' needs until the comprehensive care plan is developed.Resident #1 was admitted to the Facility in June 2025, diagnoses included hepatic encephalopathy, severe sepsis with septic shock, alcoholic cirrhosis of liver without ascites, type 2 diabetes mellitus, anemia in chronic kidney disease stage 2, opioid dependence, chronic pain syndrome, hereditary and idiopathic neuropathy, idiopathic gout, obstructive sleep apnea, lumbar region radiculopathy and primary hypertension.Review of Resident #1's Acute Rehabilitation Discharge summary, dated [DATE], indicated his/her immediate care needs were identified as followed;-fall, generalized weakness;-cirrhosis - hepatic encephalopathy;-pneumonia - vs- pulmonary edema;-Group G strep bacteremia;-chronic kidney disease;-chronic anemia;-heart failure;-chronic pain;-obstructive sleep apneaReview of Resident #1's Medical Record indicated there was no documentation to support that Baseline Care Plans were developed and implemented, or that Comprehensive Care Plans that addressed these areas of concern were in place within 48 hours of his/her admission or prior to 09/10/25 (day of survey).During an interview on 09/10/25 at 3:35 P.M., the Unit Manager said that the Minimum Data Set (MDS) Nurse was responsible for creating the Baseline Care Plans for the residents within 48 hours after admission. The Unit Manager said that she was not aware that the baseline care plans for Resident #1 had not been completed.During an interview on 09/10/25 at 4:10 P.M., the Assistant Director of Nurses (ADON) said that the MDS Nurse was responsible for creating the resident's baseline care plans within 48 hours after admission. The ADON said that she was not aware that the baseline care plans for Resident #1 had not been completed.During an interview on 09/10/25 at 4:35 P.M., the Director of Nurses (DON) said that it was her expectation that every resident has a baseline care plan completed within 48 hours after admission and said she was not aware that Resident #1's baseline care plans were not completed.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who was newly admitted to the facility and whose Physician's orders included PRN (as needed) pain medication to manage chronic pain, the Facility failed to ensure that his/her pain was adequately treated and effectively managed.Findings include:Review of the Facility's Policy titled, Pain Management, dated as revised May 2025, indicated the following:-The Facility must ensure that pain management is provided to residents who require such services consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences;-chronic pain refers to pain that typically lasts greater than 3 months and can be the result of an underlying medical disease or condition, injury, medical treatment, inflammation or unknown cause;-opioid use disorder refers to a problematic pattern of opioid use leading to clinically significant impairment or distress;-The Facility will utilize a systematic approach for recognition, assessment, treatment and monitoring of pain;-manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences;Review of the Facility's Policy titled, Controlled Substances Administration and Accountability, dated as revised March 2025, indicated the following:- it is the policy of the facility to promote safe, high quality patient care, compliant with State and Federal regulations regarding monitoring the use of controlled substances;- ordering and receiving controlled substances, the pharmacy maintains the supply of controlled substances in automated dispensing system;Resident #1 was admitted to the Facility in June 2025, diagnoses included hepatic encephalopathy, severe sepsis with septic shock, alcoholic cirrhosis of liver without ascites, type 2 diabetes mellitus, anemia in chronic kidney disease stage 2, opioid dependence, chronic pain syndrome, hereditary and idiopathic neuropathy, idiopathic gout, obstructive sleep apnea, lumbar region radiculopathy and primary hypertension.Review of a Hospital Discharge summary, dated [DATE], indicated that Resident #1 had chronic pain and discharge medications included Oxycodone (opioid analgesic used for moderate to severe pain) IR (immediate release) 10 milligrams (mg) by mouth PRN (as needed) for severe pain (pain score 7 - 10) and further indicated that Resident #1's spouse stated that Resident #1 takes up to 50 mg of Oxycodone a day.Review of the Report submitted via the Health Care Facility Reporting System (HSCFRS), dated 7/03/25, (on behalf of Resident #1) indicated that on 6/29/25, Resident #1 told Family Member #1 that he/she was in terrible pain and that he/she had not received any pain medication. The Report indicated that Family Member #1 asked the nurse when Resident #1's pain medication would be available, and Family Member #1 was told by 2:00 P.M. The Report indicated that Resident #1 told Family Member #1 that he/she did not get his/her pain medication until 4:45 P.M.Review of Resident #1's Physician's Order Summary Report, dated 06/28/25, indicated his/her orders included Oxycodone IR 10 mg tablet by mouth every six hours PRN as needed for severe pain (pain score 7-10) and Acetaminophen tablet 325 mg, give two tablets by mouth every four hours as needed for pain.Review of Resident #1's Clinical Admission, dated 6/28/25, (completed by Nurse #2), indicated he/she had no indicators of pain, the pain level and pain scale were left blank.During an interview on 9/10/25 at 3:05 P.M., Nurse #2 said on the day of admission, Resident #1 was admitted to the facility from the hospital at approximately 4:30 P.M. Nurse #2 said that she sent all of Resident #1's hospital physician's orders to the on-call service provider (Third Eye) for verification. Nurse #2 said that Resident #1 requested pain medication upon arrival to the facility and said she told Resident #1 that the only medication she could give him/her was Acetaminophen. Nurse #2 said that she told Resident #1 that it was not easy to get oxycodone from the pharmacy and it would take some time to get the oxycodone.Nurse #2 said that she called the on-call provider to request that a prescription for oxycodone be faxed to the pharmacy for authorization for her to obtain the oxycodone from the Cubex (emergency medication kit). Nurse #2 said that once she got the authorization to obtain the oxycodone from the Cubex, she gave Resident #1 the oxycodone. Nurse #2 could not recall if she gave Resident #1 any Acetaminophen to Resident #1 prior to the oxycodone. Nurse #2 said that she gave Resident #1 one oxycodone 5 mg tablet and said that was all that was dispensed from the Cubex. Nurse #2 said that the Cubex only dispensed one oxycodone 5 mg tablet and said Resident #1's physician's orders were oxycodone 10 mg tablet. Nurse #2 said she could not explain why she did not notify the on-call provider or pharmacy that only one oxycodone 5 mg tablet was available. Nurse #2 said she could not recall exactly what time she administered the oxycodone to Resident #1 and said it was shortly before she went home at approximately 1:00 A.M. on 6/29/25. Nurse #2 said that she did not document that she administered the oxycodone 5 mg tablet to Resident #1 in his/her MAR, nor in his/her progress note and did not document Resident #1's pain assessment but said she should have.Review of an e-mail from the pharmacy, dated 07/07/25, indicated that on 6/29/25 at 12:35 A.M. and 12:36 A.M., a total of two Oxycodone IR 5 mg tablets were removed from the Cubex (emergency medication kit) by Nurse #2 for Resident #1.Review of Resident #1's Medical Record indicated there was no documentation to support that Nurse #2 administered a PRN dose of Oxycodone IR 5 mg to Resident #1 on 6/29/25.Resident #1 was administered Oxycodone IR 5 mg tablet on 6/29/25 at approximately 12:36 A.M. and did not receive any further Oxycodone PRN pain medication until 4:05 P.M. on 6/29/25, 16 hours after he/she received the last dose. Resident #1 had a Physician's Order to receive Oxycodone IR 10 mg every six hours PRN.Review of the Facility's Internal Investigation, dated 7/07/25 indicated the following:-6/28/25 at 11:04 P.M., Nurse contacted on-call provider for a new prescription of two oxycodone 5 mg tablets to be obtained from Cubex;-6/29/25 at 12:35 A.M., Nurse accessed Cubex to retrieve oxycodone for Resident #1. First drawer opened providing one oxycodone 5 mg tablet. The Nurse did not complete the removal process to obtain the second oxycodone 5 mg table and exited out of removal process before continuing onto second compartment for second tablet and was unaware that the remaining dose of oxycodone 5 mg tablet was located in the second compartment. Nurse administered only one oxycodone 5 mg tablet to Resident #1;6/29/25 at 6:02 A.M., Resident #1 medicated with Acetaminophen PRN as well as Diclofenac (topical anti-inflammatory pain medication) gel;-6/29/25 at 3:59 P.M., Resident #1's oxycodone 10 mg tablets arrived at the facility from the pharmacy;-6/29/25 at 4:05 P.M., Resident #1 medicated with oxycodone 10 mg;-7/01/25 at 2:26 A.M., Resident #1 medicated with oxycodone 10 mg;-7/01/25 at 8:00 A.M., Resident #1 requesting oxycodone, Nurse informed him/her that oxycodone was last administered at 4:00 A.M. and medication is ordered every six hours as needed and that medication is not due until 10:00 A.M.However, review of Resident #1's Medical Record indicated there was conflicting documentation in the MAR administration time (2:26 A.M.) (electronic time stamped) and the Narcotic Book administration time (4:00 A.M.) (handwritten entries by Nursing). The Record indicated that Resident #1 became angry and refused all 8:00 A.M. medications including the scheduled Acetaminophen, stated he/she was leaving Against Medical Advice (AMA). Nurse Practitioner was notified and saw Resident #1. Unit Manager obtained oxycodone 10 mg from the Cubex and administered oxycodone 10 mg to Resident #1.Review of Resident #1's Medication Administration Record (MAR), dated June 2025, (time stamped by entries made by Nursing in Electronic Medical Record) indicated he/she had a Physician's Order for Oxycodone IR 10 mg by mouth every six hours PRN for pain and Acetaminophen 325 mg, two tablets by mouth every four hours PRN for pain. The MAR indicated that Resident #1 did not receive any Acetaminophen until 6:02 A.M. on 6/29/25. The MAR also indicated that Resident #1 did not receive any oxycodone until 4:05 P.M. on 6/29/25 and was assessed with a pain level of 10 (highest level of pain) at that time.Review of a Nurse Progress Note, dated 6/29/25 at 9:12 A.M., written by Nurse # 4 (who was the 11:00 P.M. through 7:00 A.M. Nurse), indicated that Resident #1 awoke and requested pain medication. The Note indicated that Resident #1 was assessed, and Diclofenac was applied to lower back and abdomen, Resident #1 became agitated, called Family Member #1 and asked him/her to bring him/her pain medication that was stronger. The Note indicated that the Nurse told Family Member #1 that he/she cannot do that. The Note indicated that the pharmacy was contacted multiple times and Resident #1's medications would be arriving on the first run.The Surveyor was unable to interview Nurse #4 as she did not respond to the Department of Public Health's multiple telephone requests for an interview.Review of a Controlled Substance Register page specific to Resident #1's medications indicated that on 6/29/25, the facility received five Oxycodone IR 10 mg tablets from the pharmacy for Resident #1 and he/she was administered Oxycodone IR 10 mg by mouth PRN (handwritten entries by Nursing) during the following dates and times:-6/29/25 at 4:04 P.M.-6/29/25 at 10:37 P.M.-6/30/25 at 5:00 A.M.-6/30/25 at 4:32 P.M.-7/01/25 at 4:00 A.M.The Controlled Substance Register page specific to Resident #1's Oxycodone IR 10 mg tablet indicated there were zero Oxycodone IR 10 mg left for administration.During an interview on 9/10/25 at 3:35 P.M., the Unit Manager said that Resident #1 was admitted to the facility on [DATE] with a Physician's Order for Oxycodone IR 10 mg by mouth every six hours PRN. The Unit Manager said that Resident #1's medications were called into the pharmacy after 4:00 P.M. on 6/28/25 and would not be delivered to the facility until the next day because the pharmacy cut off time was 4:00 P.M. for same day delivery. The Unit Manager said that the nurses can order medications STAT from the pharmacy and the pharmacy will deliver the medications within four hours of being ordered. The Unit Manager said that nurses can obtain necessary medications from the Cubex until the resident's medications arrive from the pharmacy. The Unit Manager said that Nurse #2 did not access the Cubex correctly and missed the second Oxycodone IR 5 mg tablet for Resident #1 and said Resident #1 did not receive the correct dose of Oxycodone IR on 6/29/25 at 12:36 A.M. The Unit Manager said that Nurse #2 did not document in Resident #1's Medical Record the administration of Oxycodone IR 5 mg to him/her on 6/29/25 at 12:36 A.M. and said it was her expectation that nurses document all medications administered to resident's in the Medical Record.The Unit Manager said that on 7/01/25, Resident #1 requested Oxycodone IR 10 mg PRN at 8:00 A.M. and said when the nurse looked at Resident #1's Controlled Substance Register page, it indicated that Resident #1 had received Oxycodone IR 10 mg at 4:00 A.M. and was therefore not due for oxycodone until 10:00 A.M. The Unit Manager said that when she reviewed Resident #1's MAR, it indicated that Resident received Oxycodone IR 10 mg at 2:26 A.M. and he/she could have received the medication at 8:26 A.M. not 10:00 A.M. The Unit Manager said that the nurse notified her that Resident #1 was upset and was going to sign out AMA.The Unit Manager said that the nurse then notified her that Resident #1 was out of Oxycodone and said she (Unit Manager) contacted the Nurse Practitioner (NP) and the NP sent a prescription to the pharmacy so she could access the Cubex for the Oxycodone. The Unit Manager said that she obtained two Oxycodone IR 5 mg tablets from the Cubex and administered the two Oxycodone IR 5 mg tablets to Resident #1 prior to him/her leaving the facility. The Unit Manager said that she did not document in Resident #1's Medical Record that she administered the Oxycodone to Resident #1.During an interview on 9/10/25 at 4:35 P.M., the Director of Nurses (DON) said that it is her expectation that resident's medications are available from the pharmacy and that residents receive their PRN pain medication when they ask for them. The DON said that the nurses have access to the Cubex to obtain medications including narcotics (Oxycodone) for the residents until their own medication supply comes in from the pharmacy.

Based on records reviewed and interviews for one of three sampled residents, (Resident #1), the facility failed to ensure they maintained complete and accurate medical record when nursing documentation in Resident #1's Medication Administration Record (MAR) and documentation in the Controlled Substance Register (record/log book used by the facility for maintaining accurate records of narcotics ordered and administered to each resident) related to the administration of Oxycodone conflicted, and therefore making on of them accurate.Findings include:Review of the facility's policy titled, Administering Medication, undated, indicated the following:- medications are administered in a safe and timely manner, as prescribed;-medications administration times are determined by resident need and benefit, not staff convenience;- the individual administering the medication initials the resident's MAR on the appropriate line after giving each medication;-as required for a medication the individual administering the medication records in the resident's medical record: the date and time the medication was administered, the dosage, the rout of administration, any complaints or symptoms for which the drug was administered, any results achieved and when those results were observed and the signature and title of the person administering the drug;Review of the facility's policy titled, Charting and Documentation, dated May 2023, indicated the following:- All services provided to the resident, progress toward the care plan goals or changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record;- medications administered shall be documented in the resident medical record.Review of the facility's policy titled, Control Substance Administration and Accountability, dated as revised March 2025, indicated the following:-all controlled substances are recorded on the designated usage form;-in all cases, the dose noted on the usage form must match the dose recorded on the MAR, Controlled Drug Record, or other facility specified form and placed in the patient's medical record;-the Controlled Drug Record (or other specified form) serves the dual purpose of recording both narcotic disposition and patient administration;-the Controlled Drug Record is a permanent medical record document and in conjunction with the MAR is the source form documenting any patient-specific narcotic dispensed from the pharmacy.Resident #1 was admitted to the Facility in June 2025, diagnoses included hepatic encephalopathy, severe sepsis with septic shock, alcoholic cirrhosis of liver without ascites, type 2 diabetes mellitus, anemia in chronic kidney disease stage 2, opioid dependence, chronic pain syndrome, hereditary and idiopathic neuropathy, idiopathic gout, obstructive sleep apnea, lumbar region radiculopathy and primary hypertension.Review of Resident #1's Physician's Order Summary Report, dated 06/28/25, indicated his/her orders included Oxycodone (opioid analgesic used for moderate to severe pain) 10 milligrams (mg) immediate release (IR) tablet by mouth every six hours PRN (as needed) for severe pain (pain score 7-10) and Acetaminophen tablet 325 mg, give two tablets by mouth every four hours as needed for pain.Review of the MAR, dated 7/01/25, indicated that Resident #1 received Oxycodone IR 10 mg at 2:26 A.M. for pain level of 7. Review of a Controlled Substance Register page specific to Resident #1's medications indicated that on 6/29/25, Resident #1 was administered Oxycodone IR 10 mg at 4:04 A.M., and on 7/01/25 he/she received Oxycodone 10 mg at 4:00 A.M.Review of Resident #1's Medical Record indicated there was no documentation to support that Nurse #2 administered a PRN dose of Oxycodone IR 5 mg to Resident #1 on 6/29/25 at 12:35 A.M. The Record further indicated that on 7/01/25 at 8:00 A.M., Resident #1 requested oxycodone, Nurse informed him/her that oxycodone was last administered at 4:00 A.M. and medication is ordered every six hours as needed and that medication is not due until 10:00 A.M. However, per Resident #1's MAR he/she had received Oxycodone at 2:26 A.M., and therefore could have been administered the medication again, at the time of his/her request. During an interview on 9/10/25 at 3:35 P.M., the Unit Manager said that Nurse #2 did not document in Resident #1's Medical Record the administration of Oxycodone IR 5 mg to him/her on 6/29/25 at 12:36 A.M. and said it was her expectation that nurses document all medications administered to residents in the Medical Record.The Unit Manager said that on 7/01/25, Resident #1 requested Oxycodone IR 10 mg PRN at 8:00 A.M. and said when the nurse looked at Resident #1's Controlled Substance Register page it indicated that Resident #1 had received Oxycodone IR 10 mg at 4:00 A.M. and was not due for Oxycodone until 10:00 A.M. The Unit Manager said that when she reviewed Resident #1's MAR, it indicated that Resident received Oxycodone IR 10 mg at 2:26 A.M. and he/she could have received the medication at 8:26 A.M. not 10:00 A.M., which was why it was necessary for nurses to accurately document administration times of medications within the Medical Record. During an interview on 9/10/25 at 4:35 P.M., the Director of Nurses (DON) said that it is her expectation that all medications that are administered to residents be documented in the medical record and said that she expects that the MAR and Controlled Substance Register are accurate and have the same time of medication administration.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had severe cognitive impairment and was unable to identify him/herself, the Facility failed to ensure he/she was free from a significant medication error, when on 03/13/25, Resident #1 was administered another resident's medications in error. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation, he/she remained in the Hospital overnight for monitoring and treatment to stabilize his/her blood pressure, which included administration of intravenous fluids and medications. Findings Include: Review of the Facility's Policy titled, Administering Medications, dated as revised October 2022, indicated the following: -only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so; -medications are administered in accordance with prescriber orders; -the individual administering medications verifies the resident's identity before giving the resident his/her medications; -the individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication; -medications ordered for a particular resident may not be administered to another resident, unless permitted by State law and facility policy, and approved by the Director of Nurses. Review of the Facility's Policy titled, Medication Error, dated March 2025, indicated the following: -it is the policy of the facility to ensure residents receive care and services safely in an environment free of significant medication errors; -the facility shall ensure medications will be administered according to physician's orders; -to prevent medication errors and ensure safe medication administration, nurses should verify the right medication, dose, route and time of administration, right resident and right documentation. Resident #1 was admitted to the Facility in April 2024, diagnoses included late onset Alzheimer's disease, dementia, anemia, hypertension, hyperlipidemia, anxiety disorder paroxysmal atrial fibrillation and osteoarthritis of right and left knees. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated that he/she was severely cognitively impaired. Review of Resident #1's Medication Variance Report, dated 03/13/25, indicated that at 9:45 A.M. he/she was administered medications ordered for another resident (later identified as Resident #2, his/her roommate) in error, which included the following medications: -Celexa (antidepressant) 10 milligrams (mg); -Eliquis (anticoagulant) 5 mg; -Haldol (anti-psychotic) 5 mg ; -Isosorbide Extended Release (ER) (nitrate- dilates blood vessels) 30 mg ; -Protonix (proton pump inhibitor - reduces stomach acid) 40 mg; -Miralax (laxative) 17 grams; -Senna (treats constipation) 17.2 mg; -Digoxin 125 micrograms (cardiac glycoside - treats arrythmias); -Labetalol (antihypertensive) 800 mg; -Trazadone (antidepressant) 25 mg; -Amlodipine (antihypertensive) 2.5 mg. Further review of Resident #1's Physician's Orders indicated he/she did not have physician's orders for any of these medications. Review of Resident #1's Medication Administration Record (MAR), dated 03/13/25 indicated he/she was scheduled to have the following medications administered to him/her between 09:00 A.M. and 10:00 A.M.: -Sertraline (antidepressant) 100 mg; -Metoprolol ER (beta blocker) 25 mg. Review of the Facility's Internal Investigation Report, dated 03/13/25, indicated that Agency Nurse #1 administered Resident #2's morning medications to Resident #1 in error. The Report indicated that Resident #1 was transferred to the Hospital ED, where he/she required telemetry (continuous tracking of your hearts electrical activity) monitoring and returned to the Facility the following day. Review of Resident #2's Physician's Orders, dated March 2025, indicated that he/she had Physician's Orders for the following medications: -Celexa (antidepressant) 10 milligrams (mg); -Eliquis (anticoagulant) 5 mg; -Haldol (anti-psychotic) 5 mg ; -Isosorbide Extended Release (nitrate- dilates blood vessels) 30 mg ; -Protonix (proton pump inhibitor - reduces stomach acid) 40 mg; -Miralax (laxative) 17 grams; -Senna (treats constipation) 17.2 mg; -Digoxin 125 micrograms (mcg) (cardiac glycoside - treats arrythmias); -Labetalol (antihypertensive) 800 mg; -Trazadone (antidepressant) 25 mg; -Amlodipine (antihypertensive) 2.5 mg. The Report further indicated that Agency Nurse #1 approached Resident #1 called him/her by name and administered morning medications. The Report indicated that while Agency Nurse #1 was leaving Resident #1's room, a Certified Nurse Aide (CNA) entered the room, approached Resident #1 and addressed him/her by name. The Report indicated that Agency Nurse #1 confirmed Resident #1's name with the CNA and immediately realized she had administered Resident #2's medication to Resident #1 in error. Review of Resident #1's Hospital Discharge Summary, dated 03/14/25, indicated that on 03/13/25, Resident #1 presented to the ED for an accidental overdose of his/her roommate's medications. The Summary indicated that Resident #1 was supposed to receive: Metoprolol and Sertraline in the morning and instead received the following medications in error: Celexa 10 mg, Eliquis 5 mg, Haldol 5 mg, Isosorbide ER 30 mg, Protonix 40 mg, Miralax, Senna, Digoxin 125 mcg, Labetalol 800 mg, Trazodone 25 mg and Amlodipine 2.5 mg. The Summary indicated that after the medication error, Resident #1's blood pressure was 85/42 (normal range 120/80) and that his/her normal blood pressure was 150/60. The Summary indicated that during Resident #1's hospital stay, he/she required telemetry monitoring, 1000 milliliters of normal saline intravenous fluids, Magnesium sulfate 2 grams intravenous fluid, and four doses of Potassium Chloride 10 Milliequivalent (mEq) intravenous fluids for electrolyte repletion. The Summary further indicated that nursing staff had difficulty getting Resident #1 to take activated charcoal (used to treat overdose), plan was to have an Naso Gastric (NG) tube ( a thin, soft tube made of rubber that is passed through the nose, down through the throat, and into the stomach) inserted, he/she was agitated and unable to tolerate the NG tube, and NG tube was removed. Review of Resident #1's Nurse Progress Note, written by Nurse #1, dated 03/13/25, indicated that during morning medication pass, he/she was administered incorrect medications, physician was notified and he/she was transferred to the hospital. Review of Nurse #1's Written Witness Statement, dated 03/13/25, indicated that she approached Resident #1 by name and administered medication to him/her. The Statement indicated that upon departing Resident #1's room, a CNA approached Resident #1 (calling him/her by another name), she immediately realized that she had made a medication error, notified the physician and Resident #1 was transferred to the hospital. During an interview on 04/15/25 at 2:37 P.M., Nurse #1 said that on 03/13/25, she was assigned to work the dementia unit and said it was the first time she had worked on that unit. Nurse #1 said that she prepared Resident #2's morning medications and went into his/her room to administer them. Nurse #1 said that there was only one resident in the room, the other bed linens were stripped from that bed, so she believed that there was only one resident living in the room at that time. Nurse #1 said that she approached Resident #1, who was in the room and addressed him/her using Resident #2's name, and that Resident #1 shook his/her head in an up and down motion like he/she was saying yes and then administered the medications to Resident #1. Nurse #1 said that a CNA entered the room and said good morning to Resident #1 by another name. Nurse #1 said that she asked the CNA what Resident #1's name was and the CNA told her Resident #1's name and that is when she realized she administered Resident #2's medications to Resident #1 in error. Nurse #1 said that she had not positively identified who Resident #1 was with another staff member, and said she did not look at Resident #2's or Resident #1's pictures on the MAR prior to administering medications to Resident #1. Nurse #1 said she was unaware that Resident #1 was unable to understand or recognize his/her own name, or that he/she responded to any name when addressed. Nurse #1 said that she did not follow the five rights of medication administration. During an interview on 04/08/25 at 1:31 P.M., the Unit Manager said that on 03/13/25, Nurse #1 notified her that she had made a medication error. The Unit Manager said that Nurse #1 was from an Agency and that it was the first time that Nurse #1 worked on the Dementia Unit. The Unit Manager said that Nurse #1 said that she called Resident #1 by (Resident #2's) name and said that Resident #1 shook his/her head nodding up and down, in a yes motion, and she administered medications to him/her. The Unit Manager said that Nurse #1 said that after she administered medications to Resident #1, a CNA entered the room and called Resident #1 by another name, and realized she had administered Resident #2's medications to Resident #1 in error. The Unit Manager said that Resident #1 had dementia and severe cognitive impairment and would not be able to understand if he/she was called by another name. During an interview on 04/08/25 at 1:47 P.M., the Assistant Director of Nurses (ADON) said she was made aware of Resident #1's medication error on 03/13/25 by the Unit Manager. The ADON said that it was Nurse #1's first time working on the Unit and said she did not verify Resident #1's identity with another staff member. The ADON said that it was her expectation that nurses follow the five rights of medication administration, and positively identify a resident before administering any medications. The ADON said that Resident #1 had dementia, with severe cognitive impairment and would not be able to understand if he/she was called by another name. During an interview on 04/08/25 at 2:05 P.M., the Director of Nurses (DON) said that it was her expectation that nurses follow the five rights of medication administration and positively identify each resident before administering medication to any resident. The DON said that Resident #1 had severe cognitive impairment and would not be able to understand if he/she was called by another name. On 04/08/25, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. On 03/13/25, Resident #1 was assessed by nursing and transferred to the Hospital ED for evaluation and treatment. Resident #1 returned to the facility the next day, and was monitored by nursing. B. On 03/13/25 Nurse #1 was educated by the Assistant Director of Nurses on the Facility's Policy and Procedure on Medication Administration. C. On 03/13/25, a Quality Assurance Performance Improvement (QAPI) Committee meeting was held regarding medication administration, reduction of medication errors, resident identification, name band implementation for residents unable to confirm their identity. D. On 03/13/25, all Licensed staff were educated by the Corporate Nurse on the Facility's Medication Administration Policy, Resident Identification and the Five Rights of Medication Administration. E. 03/24/25, Random Medication Administration Competencies were conducted by Director of Nurses with licensed nursing staff. F. 04/01/25, An Audit was completed by the Unit Managers of Residents who were unable to identify themselves and those Residents had an identification wristband placed on their wrist. G. The Director of Nurses / Assistant Director of Nurses will conduct random medication administration competencies/audits with nursing staff three times weekly for four weeks, then they will audit 10% of nursing staff monthly for three months or until substantial compliance is met. H. The results of the audits will be presented and reviewed at the monthly QAPI Committee meeting for three months or until compliance is achieved. I. The Director of Nursing and/or designee are responsible for overall compliance.

Based on record review, policy review, and interview, the facility failed to accurately execute Advance Directives (written documents that tells your health care providers who should speak for you and what medical decisions should be made if you become unable to speak for yourself) for one Resident (#44), out of a total sample of 22 residents. Specifically, for Resident #44 the facility failed to ensure the MOLST (Massachusetts Medical Order for Life-Sustaining Treatment) form was valid and reflected the signature of Resident #44's invoked (made active by a Physician) Health Care Proxy (HCP- a legal document that allows you to appoint someone you trust to make medical decisions on your behalf if you are unable to do so). Findings include: Resident #44 was admitted to the facility in November 2019 with diagnoses including Alzheimer's disease. Review of the facility's policy titled Advanced Directives, undated, indicated but was not limited to the following: -If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. -The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. -The interdisciplinary team will conduct ongoing review of the resident's decision-making capacity and communicate significant changes to resident's legal representative. Such changes will be documented in the care plan and medical record. Review of Resident #44's medical record indicated: -a HCP, dated 7/23/19, appointing Resident Representative #1 as the primary HCP, if that person is unwilling or unavailable to serve there is a Resident Representative #2 named, if that person is unwilling or unavailable to serve as HCP there is a Resident Representative #3 named. -a HCP activation form, dated 5/17/19, indicating that the Resident's dementia is so severe that the Resident lacks capacity to make or to communicate health care decisions. -a MOLST completed by Resident Representative #3 on 4/7/19. Review of Resident #44's Advance Directive care plan, initiated on 10/11/21, and revised on 4/1/24 indicated: Focus: I am unable to make health care decisions due to dementia. A MD has documented my incapacity. Primary HCP: Resident Representative #1, Alt HCP: Resident Representative #2, MOLST in place DNR, DNI, no dialysis, no artificial nutrition. Goal: Healthcare decisions made by my designated HCP will be honored and followed. Interventions: MOLST/Advanced Directives will be discussed with my HCP at quarterly care plan meetings to ensure decisions are accurately documented. -My Health care agent will be informed of their right to formulate advanced healthcare to guide facility staff and their attending physician in the provision of my care. During an interview on 9/12/24 at 11:18 A.M., Social Worker #1 said the MOLST was initiated at the hospital but should be reviewed quarterly at the facility. She said it should have been reviewed multiple times since Resident #44's admission in 2019 and most recently reviewed on 7/25/24. She said it was not identified that the primary or the first alternative HCP did not complete the MOLST. She said the Resident's HCP is available and willing to serve as the primary HCP. During an interview on 9/12/24 at 2:50 P.M., Social Worker #1 said she spoke with the primary HCP and that she was unsure why she wasn't asked to complete the MOLST and the person who completed it was Resident Representative #3. She said the Resident Representative would be in to initiate a new valid MOLST and this should have been identified sooner. During an interview on 9/16/24 at 12:33 P.M., the Assistant Director of Nursing (ADON) said the only time they would obtain a signature different than the primary HCP is if they were not available. She said Resident Representative #1 signs all the Resident's consents and the MOLST should have been reviewed multiple times and revised to have Resident Representative #1 complete the MOLST. She said that she is aware that Resident Representative #1 is available and willing to serve as the primary HCP.

Based on observation, interview, and record review, the facility failed to develop and implement a person-centered comprehensive care plan for one Resident (#11), out of a total sample of 18 residents. Specifically, the facility failed to: a. Implement a care plan to ensure Resident #11 was transferred with the assistance of two people; and b. Develop and implement a care plan for pressure injury prevention for Resident #11, who was assessed to be at risk for skin breakdown, resulting in a facility acquired unstageable (actual depth of ulcer is completely obscured by slough and/or eschar in the wound bed) right heel ulcer. Findings include: Resident #11 was admitted to the facility in June 2024 with diagnoses which included: cellulitis right lower extremity (LE), muscle weakness, unsteadiness on feet, delirium, and metabolic encephalopathy (brain dysfunction due to chemical imbalance). Review of the Minimum Data Set (MDS) assessment, dated 6/19/24, indicated Resident #11 scored 10 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she had moderate cognitive impairment. a. Review of the facility's policy titled Safe Lifting and Movement of Residents, undated, indicated but was not limited to the following: -In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. -Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe transfer and moving of residents. -Manual lifting of residents shall be eliminated when feasible. -Nursing staff, in conjunction with the rehabilitation staff, shall assess individual resident needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. -Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. -Mechanical lifting devices shall be used for heavy lifting including lifting and moving residents when necessary. Review of the MDS assessment, dated 6/19/24, indicated Section GG indicated sit to lying down and lying down to sit was substantial/maximal assistance, sit to stand was not applicable, chair to bed transfer was dependent. Review of Resident #11's Care Plan indicated but was not limited to the following: -I require assistance with activities of daily living care related to metabolic encephalopathy, acute delirium, shortness of breath, and weakness. -Transfers: dependent on two people with mechanical lift; date initiated 6/21/24. Revised to current transfer: Provide sub maximal/maximum assist of two people, left ankle foot orthosis to be worn for all transfers. During an interview on 9/11/24 at 12:20 P.M., Resident #11 said a Certified Nursing Assistant (CNA) was trying to transfer him/her out of a shower chair to a wheelchair which was blocked behind the bathroom door. Resident #11 said the CNA picked him/her up (demonstrated the motion of the CNA picking him/her up for the surveyor) and he/she told the CNA to put him/her down on the bed because he/she was never going to make it to the wheelchair; he/she didn't want to be dropped on the floor. Resident #11 said, The CNA put me on the bed and the CNA told me that she noticed I was bleeding, and she went out and got the nurse. Resident #11 said he/she was told he/she had to go to the hospital. Review of a Physical Therapy progress note, dated 7/2/24, indicated but was not limited to the following: -Resident #11 was dependent for functional transfers with partial to moderate assist, patient unable to ambulate, weight bearing is tolerated, transfer sit to stand not attempted due to medical condition and safety concerns chair to bed transfers, dependent toilet transfer others dependent, interventions bilateral lower extremities and supine. -Transfers to edge of bed Max assist times 2, remains fearful and complains of pain with gentle range of motion to bilateral knees. -Can resident sit unsupported times 30 seconds with feet flat on the floor with no back support?: No. During an interview on 9/17/24 at 8:40 A.M., Rehabilitation (Rehab) Staff #1 said Resident #11 was maximal (max) assist times 2 person to get to the edge of bed because he/she has retropulsion (leaning backwards). She said Resident #11 has been a mechanical lift since his/her re-admission in June 2024, and has never been upgraded, and remains a mechanical lift. Rehab Staff #1 said she has not assessed the Resident for showers, but if Resident #11 was to have a shower even now, Resident #11 would be a mechanical lift in/out of the shower chair. Rehab Staff #1 said the nurses have never been trained in any other transfer mode, including stand/pivot or squat/pivot, and the Resident remains a mechanical lift. During an interview on 9/17/24 at 9:23 A.M., Rehab Staff #2 said Resident #11 is a max assist and still is max assist for transfers. He said back in July, at the time of injury, Rehab was still working on bed mobility and transferring to edge of bed because of his/her strong severe retropulsion. Rehab Staff #2 said Resident #11 was a mechanical lift back in July and remains a mechanical lift now. Rehab Staff #2 said he was aware of the leg injury in July 2024 and his recollection was that Resident #11 hit his/her leg on something during a shower transfer. Rehab Staff #2 said the Resident has fragile skin, and it was a pretty significant injury of which he has never seen from a transfer. Rehab Staff #2 said Resident #11's only safe transfer out or into bed is a mechanical lift; a one person transfer with Resident #11 would not be safe even today. Review of the Facility Investigation Packet, dated 7/9/24, indicated but was not limited to the following: -Incident description: This writer responded to a call to help from CNA in the above resident's room. Upon entry, CNA stated that the resident had just gotten out of the shower and pointed out that he/she had a cut on his/her right lateral lower leg. Resident was assisted onto bed. Upon assessment, a large skin tear like wound was noted to the right lateral lower shin approximately 7 x 8 x 0.4 centimeters. This area was noted to be an existing large bruise (present on admission). On call physician was notified. Health care proxy was called and left a voicemail. Resident was sent to the emergency room for further evaluation and treatment per physician orders. -Resident unable to give description. Immediate Action Taken: -Resident was assisted back into bed. First aid applied. -Shower chair was inspected for any cracks, broken pieces, or sharp edges. None were found. Residents' nails were assessed and found to be longer in length with sharp edges. Nail care was provided to ensure not sharp edges. -Resident taken to hospital: N -Injuries Observed at Time of Incident: No injuries observed at time of incident. -Level of Pain: 0 -Mobility: Ambulatory with assistance -Mental status: Oriented person and place. -Injuries Reported Post Incident: Skin tear right lower leg (front) Other information: -Post shower. Skin very fragile and thin at baseline. Increase edema. Bruising to area (present on admission). -Residents fingernails noted to have sharpened edges with presumed blood under them. Witnesses: 1. CNA #1, dated 7/8/24, indicated but not limited to: - I turned to the dresser to grab the johnny and returned to the Resident to place the johnny on the person. Resident then stated, be careful my leg has a cut on it put and to put me in the bed It just needs a Band-Aid. At that time, I looked at his/her leg and noticed the skin was broken open. I immediately called out for the nurse. I assisted the resident onto the bed in a seated position. The nurse and I then assisted in getting both legs into bed. The nurse proceeded to complete first aid. Resident #11 was sent to the emergency room (ER). Resident #11 did not complain of any pain or discomfort in the area. 2. Nurse #2, dated 7/5/24 indicated but was not limited to: - I went to assist the CNA. Upon arrival to the room, the Resident was sitting upright on his/her bed. I quickly wrapped the wound with a clean towel and ran to get wound supplies. Upon return, the assigned nurse was also present in the room. I assisted with transferring Resident #11's legs into the bed. During an interview on 9/12/24 at 11:45 A.M., with the surveyor, Director of Nurses (DON), and Corporate Nurse #1 present, Resident #11 said he/she completed the shower, and the CNA wheeled him/her out of the bathroom in the shower chair, pushing the bathroom door open with the chair as they exited the bathroom. Resident #11 said the black wheelchair was behind the bathroom door, and the CNA lifted him/her up out of the chair (Resident demonstrated extending both arms in front of him/her making a lifting motion). Resident said he/she told the CNA, he/she was not going to make it to the wheelchair, and he/she needed to put him/her down before she dropped him/her. Resident #11 said the CNA threw/dropped him/her onto the bed and he/she rolled over to his/her left side. Resident #11 said that is when he/she hit the right leg because that is when it hurt. Resident #11 said CNA told her Oh my God you're bleeding and the CNA went to get help. Resident #11 said he/she never saw the blood because he/she was lying back to his/her left side on the bed. During an interview on 9/12/24 at 3:30 P.M., Nurse #2 said she was getting food out of the nourishment kitchenette across the hallway from Resident #11's room when she heard the call for help from CNA #1. Nurse #2 said she was the first one in the room and Resident #11 was sitting on the edge of the bed. During a telephonic interview on 9/12/24 at 3:45 P.M., CNA #1 said she had given Resident #11 a shower and wheeled him/her out of the shower room and positioned the shower chair by the bed. CNA #1 said she dried off Resident #11 and he/she said he/she was cold. CNA #1 said she turned to get a johnny off the dresser and Resident #11 complained his/her leg was burning and that he/she had a small cut on the leg. CNA #1 said she looked at Resident #11's leg and saw a large cut on the leg and went and notified the nurse. CNA #1 said she knew Resident #11 was a two person transfer and waited for Nurse #2 to assist her transferring Resident #11 from the shower chair to the bed. CNA #1 stated again, she did not transfer Resident #11 back to bed alone, she would never have attempted that because Resident #11 was not dressed, and she said she never hit Resident #11's legs on anything. During an interview on 9/17/24 at 12:25 P.M., the DON said they re-enacted the incident with the involved staff, and they found CNA #1 did not understand what a two-person transfer meant. She said CNA #1 thought a two-person transfer meant only two people had to be in the room. Corporate Nurse #1 said the CNA told them she only transferred Resident #11 into bed after she saw the wound on the leg to help the nurses. b. Review of [NAME](R) NURSING PROCEDURES -11th Ed. (2019), indicated but was not limited to the following: Review Factors in the Development of Pressure ulcers. -Edema, anemia, hypoxia, or hypotension. -Neurologic impairment or immobility. -Altered mental status, including delirium or dementia. -Areas susceptible to pressure ulcers: Heel -Nursing Assessment -Assess for risk factors for pressure ulcer development and alter those factors, if possible. -Assess skin of the older adult frequently for the development of pressure ulcer. The Braden Scale for Predicting Pressure Sore Risk is one of the most commonly used instruments for predicting the development of pressure ulcers. -Stage the ulcer so appropriate treatment can be started. The National Pressure Ulcer Advisory Panel advocates the following staging system. -Unstageable-full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed. - Prevent Pressure Ulcer Development -Provide meticulous care and positioning for immobile patients. -Inspect skin several times daily. Relieve the Pressure -Avoid elevation of head of bed greater than 30 degrees. -Reposition every 2 hours. -Use special devices to cushion specific areas (especially bony areas), such as flotation rings, lamb's wool or fleece pads, convoluted foam mattresses, booties, or elbow pads. Lift heels off the bed in bedbound patients. Do not use donut devices. Review of the facility's policy titled Prevention of Pressure Ulcers/Injuries, undated, indicated but was not limited to the following: -The purpose of this procedure is to provide information regarding identification of pressure ulcer injury risk factors and interventions for specific risk factors. Preparation: -Review of the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Risk Assessment: -Assess the resident on admission (within 8 hours) for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. -Choose a frequency for repositioning based on resident's mobility, the support surface in use, skin condition and tolerance, and the resident's stated preferences. -Reposition residents who are chair bound or bed bound. -Reposition resident regularly based on the condition of the skin and the resident's comfort Monitoring: -Evaluate report and document potential changes in skin -Review the intervention strategies for effectiveness on an ongoing basis. Review of the facility's policy titled Skin Integrity Management, undated, indicated but was not limited to the following: -Residents with pressure ulcer risk factors are identified, assessed, and provided treatment according to standard practice. -To provide safe and effective care to prevent the occurrence of pressure ulcers, manage the treatment and promote healing of all wounds. Procedure: -Following admission, the [NAME] plus pressure ulcer or Braden scale is completed quarterly, changing condition, or changing skin integrity. -Resident skin integrity status and need for prevention interventions or treatment modalities is identified through review of assessment information. a. Identify resident's risk level. b. Care plan for residents at high risk for skin breakdown c. Perform skin inspections at admission and weekly. Document in resident record. Comprehensive care plan developed to include prevention and wound treatments, as indicated: a. Implement pressure ulcer prevention for identified risk factors. b. Evaluate the need for support services. Review of Resident #11's admission progress note, dated 6/2024, indicated but was not limited to the following: -Right toes blackened toes throughout all toes. -Right lower leg discoloration: length 12 cm, width 18 cm -Skin is ashen (pale gray or white color). Skin is dry/cracked. Decrease skin turgor (elasticity). -Resident has bilateral edema with excessive dry thick scaly skin covering the lower extremities. Review of the MDS assessment, dated 6/19/24, indicated: -Section M0150 Risk for pressure ulcers: Yes. -Section M0300 Unhealed pressure ulcers: No. -Section M1200 Skin and ulcer treatments: Pressure reducing bed. -Section GG0170 Mobility: roll left and right substantial/maximal assistance. Review of a progress note, dated 6/19/24 at 2:44 P.M., indicated Braden scale for predicting pressure ulcer risk evaluation score of 15, indicating a mild risk for pressure ulcer. Further review indicated Resident was chairfast (ability to walk is limited) and is very limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. Friction and shear: potential problems. Review of the medical record indicated that on 7/5/24, Resident #11 sustained a large trauma wound to the right lower leg requiring emergency room treatment and weekly wound care by a consultant wound physician. Review of the Wound Care Clinic progress note, dated 7/15/24, indicated but was not limited to the following: -Traumatic open wound of right lower leg, initial encounter -No heel pressure wound at this visit. Review of the Wound Care Clinic progress note, dated 7/22/24, indicated but was not limited to the following: -Pressure injury right posterior lateral heel. -Peri-wound assessment: Intact -Exposed structure: Other (Comment) -Wound length: 3.5 centimeters (cm) -Wound width: 2.5 cm -Wound Depth: 0.1 cm -Wound surface area: 8.75 cm2 -Drainage amount: Moderate -Drainage description: serosanguineous Pressure ulcer of right heel, unstageable: -Continue skin prep daily, intensify offloading with offloading boot. -Showering-no showering right heel; unstable pressure wound cannot get wet Review of wound doctor appointments referral form, dated 7/22/24, indicated the following: -Wound follow-up -* note unstageable pressure wound right, posterior lateral heel. Must offload heel boot NOW. Further review of the medical record indicated no additional Braden risk assessments were performed after Resident #11 returned from the emergency room with a traumatic soft tissue injury to the right lower extremity 7/5/24. Further review of the care plan indicated there was no care plan developed or implemented for a resident at risk for skin breakdown or pressure ulcers upon admission or post traumatic soft tissue injury to right leg. During an interview on 9/12/24 at 12:00 P.M., the DON said Resident #11 had a facility acquired pressure ulcer that started out as a blister and is seen by the outside wound doctor for management. During an interview on 9/17/24 at 11:42 A.M., the Assistant Director of Nurses (ADON) said the nurses should be doing a weekly skin assessment of the whole body, looking to identify areas of potential skin breakdown, fragile skin areas and areas that may need attention or preventative treatment. She said she reviewed Resident #11's medical record and said the skin assessment, dated 7/17/24, indicated bilateral legs and feet have thick, dry skin that has been previously documented. The ADON said there was no additional documentation of skin concerns until the outside Consultant Wound Doctor identified the right heel pressure on 7/22/24. The ADON said she has not found any interventions for pressure relief to the right lower extremity at admission or after the Resident sustained the injury on 7/5/24. During an interview on 9/17/24 at 12:58 P.M., the ADON said the only pressure relief/prevention for Resident #11's right lower extremity was CNA repositioning logs which are standard for all residents. The ADON said there is no new orders for pressure relief interventions after the injury to the right leg. The ADON provided the surveyor with the CNA repositioning documentation. Review of the CNA documentation for Positioning Q (every) shift: Was the resident repositioned every two hours? Y-yes, N-No, indicated between 7/17/2024 through 7/22/2024, Resident #11 was not repositioned every two hours on the following shifts: -7/19/2024-11:00 P.M. through 7:00 A.M. -7/20/2024- 3:00 P.M. through 11:00 P.M. -7/21/2024- 3:00 P.M. through 11:00 P.M.

Based on observation, interview, and policy review, the facility failed to ensure that infection control and prevention measures were followed during preparation of medication for administration. Findings include: Review of the facility's Policy Statement for Administering Medications, undated, indicated that medications are administered in a safe and timely manner, and as prescribed. The policy statement included but was not limited to the following: -Staff follows established facility infection control procedures (e.g., handwashing, antiseptic (sic) technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. On 9/13/24 at 10:10 AM, on the Nantucket Unit, the surveyor observed Nurse #1 preparing Resident #22's morning medications. Nurse #1 touched multiple medication cards and the medication cart drawer handle with her bare hands. The Resident had an order for mirtazapine 7.5 milligrams (mg) by mouth every morning. Nurse #1 obtained a card of mirtazapine 30 mg from the medication cart, and in error, popped the pill into the med (medication) cup. After realizing she had poured the incorrect dose of mirtazapine, Nurse #1 inserted her bare finger into the med cup to remove the 30 mg tablet of mirtazapine. Nurse #1 did not sanitize her hands or apply a protective barrier to her hand to prevent contaminating the rest of the nine medications she had already poured for the Resident. During an interview with observation on 9/13/24 at 10:11 AM, the surveyor said to Nurse #1 that she had potentially contaminated the medications that were in the med cup, by scooping the mirtazapine 30 mg out of the med cup with her bare finger. She acknowledged that she did not adhere to accepted practices for infection control by her actions. Nurse #1 commented, That's bad. She then discarded the mirtazapine 30 mg tablet, poured mirtazapine 7.5 mg into the med cup, and administered all the Resident's morning medications. During an interview on 9/17/24 at 7:33 AM, the Director of Nursing (DON) said that Nurse #1 should not have inserted her finger into the med cup to scoop out the mirtazapine 30 mg tablet. The DON said that it was an infection control issue.

Based on observations, interviews, and record review, the facility failed to provide one Resident (#21), out of a total sample of 18 residents, an activity program that engaged the Resident and supported their physical, mental, and psychosocial well-being. Findings include: Resident #21 was admitted to the facility in March 2023 with diagnoses which included diabetes mellitus, dementia, and cognitive-communication deficit. Review of the Minimum Data Set (MDS) assessment, dated 4/29/23, indicated Resident #21 scored a 9 out of 15 on the Brief Interview for Mental Status, indicating moderate cognitive impairment. Review of the care plan for Resident #21 indicated: Focus of Activities - Long Term Care Resident indicated he/she needed encouragement and reminders. Interventions included but were not limited to: -need for social prompts/cues in group settings -encourage and invite to structured programs daily -resident room interests include: folk music, outdoors, and chatting Review of the Recreation Admission Assessment, dated 3/10/23, indicated Resident #21 enjoyed music (specifically, folk music), walking/[NAME] outdoors, and talking/conversing. The assessment also indicated it was very important for Resident #21 to listen to music and to go outdoors. Review of the Recreation Quarterly/Annual Assessment, dated 6/5/23, indicated entertainment appliances or material that were in Resident #21's room included a phone, television, magazines, and books. The plan of care included: lunch social Monday through Friday in the Nantucket Unit dining room. Review of the One-on-One Activity Log indicated the Resident had received a one-on-one visit on three occasions: -4/15/23 -5/11/23 -5/27/23 Review of the Documentation Survey Report, on 6/8/23, for Activity Participation for June 2023 included documentation for 6/5/23 through 6/7/23. Review of Resident #21's activity participation record indicated he/she: -actively participated in activities on 6/7/23, -refused activities on 6/6/23, and -participation was not applicable on 6/5/23. The surveyor observed the following throughout the survey: -6/6/23 at 9:30 A.M., Resident #21 sitting in his/her wheelchair in the unit day room with breakfast tray in front of him/her with no staff or resident engagement/interaction -6/6/23 at 2:15 P.M., Resident #21 sitting in his/her wheelchair in the unit day room not facing the television with no staff or resident engagement/interaction -6/7/23 at 9:35 A.M., Resident #21 sitting in his/her wheelchair in the unit day room not facing the television, fidgeting at a table with no staff or resident engagement/interaction -6/7/23 at 1:19 P.M., Resident #21 sitting in his/her wheelchair in the unit day room not facing the television, he/she was grimacing and fidgeting at a table with no staff or resident engagement/interaction -6/8/23 at 8:04 A.M., Resident #21 sitting in his/her wheelchair in the unit day room at a table with no staff or resident engagement/interaction During a telephonic interview on 6/6/23 at 12:19 P.M., Family Member #1 said Resident #21 sits around and does nothing. Family Member #1 said when she comes in to visit, she finds Resident #21 in the day room idle and not interacting with staff or other residents. During an interview on 6/8/23 at 1:11 P.M., the Activities Director (AD) said the expectation is for staff to log attendance on the daily participation log. She said she could not find a participation log for Resident #21. The AD said Resident #21 is never just sitting in his/her room, he/she typically socializes in a small group, he/she stays in the unit dining room with the television and other residents. The AD said the activities department checks in on Resident #21 throughout the day and during mail delivery. The AD said Resident #21 sometimes goes to coffee social and has gone to two music entertainment activities. She said that usually, Monday through Friday, the Resident goes to the dining room for lunch. The AD said eating in a dining room is considered a social event because there are other residents and music in that room. During a follow up interview on 6/8/23 at 2:34 P.M., the AD said the process for ensuring the documentation of a residents' participation in activities is not fully in place. She said she has provided education for her staff, but the process needs more work to improve the documentation. The AD said there is no documentation that indicates Resident #21 has participated in any activities for the months of March, April, or May and that although the facility does work with him/her it is not documented in the medical record.

Based on document review and interview, the facility failed to ensure the activities program was directed by a qualified professional who has completed a state approved training course. Findings include: During an interview on 6/8/23 at 2:34 P.M., the Activity Director said she is newer to the role and still learning and trying to train the staff she supervises in the department. Review of the employee file for the Activity Director (AD) indicated the following: - she was offered and accepted the role of AD in November 2021 - she did not possess the completed training and qualifications of an AD - she signed a job description indicating she was the AD on 11/24/21 - she was offered and started a self-paced modular educational program to become a trained qualified AD in January 2023 During an interview on 6/8/23 at 3:00 P.M., the AD said she received some training from the previous AD who still currently works in the facility in another department. She said she trained briefly at a sister facility and then for a month or two in this facility at the end of 2021 into early 2022 and has been the activity director ever since. She said she is responsible for formulating, implementing and developing activity programs in the facility and in the community for all the residents residing at the facility. She said she supervises and trains the other staff within the activities department and has the previous activity director in the facility available for questions, but she is responsible for the activities department and is the director. She said she has not completed her course work to be a fully trained and certified activity director at this time, but if she stays on course with the program outline, she should be finished in 6 to 8 weeks and then would have the capability of sitting for the test to complete her training. During an interview on 6/8/23 at 3:18 P.M., the Administrator said he was aware the AD was not fully trained and qualified to serve as the facility AD and she has not yet completed her training. He said he was aware the facility is out of compliance with this requirement.

Based on observation, record review, policy review, and interview, the facility failed for two Residents (#75 and #185), out of a total sample of 18 residents, to maintain professional standards in the managing and care for urinary catheter devices. Specifically, the facility failed: 1. For Resident #75, to ensure the drainage bag and tubing were positioned to lessen the likelihood of complications; and 2. For Resident #185, to maintain the catheter in a manner to prevent the possibility of infection. Findings include: Review of the facility's policy titled Urinary Catheter Care, undated, indicated but was not limited to the following: - the purpose of the policy is to prevent catheter associated complications and infections - the drainage bag must be held or positioned lower than the bladder at all times to prevent urine in the tubing or drainage bag from flowing back into the urinary bladder - be sure the catheter tubing and drainage bag are kept off the floor Review of the facility's policy titled Suprapubic Catheter Care, undated, indicated but was not limited to the following: - the purpose is to prevent skin irritation at the insertion site and infection - the drainage bag must be held or positioned lower than the bladder at all times to prevent urine in the tubing or drainage bag from flowing back into the urinary bladder 1. Resident #75 was admitted to the facility in April 2023 with diagnoses including: retention of urine, enlarged prostate, and Parkinson's disease. Review of the medical record indicated Resident #75 had a suprapubic (SP) tube (a catheter used to drain urine that is inserted into the bladder and exits through the abdomen) placed on 6/5/23 by his/her urologist at the local hospital. During an interview on 6/6/23 at 11:40 A.M., the Resident said he/she did not know where the SP tube drainage bag was or how it worked. He/she also said they had not gotten out of bed at any point during the day so far. During an interview on 6/6/23 at 11:44 A.M., Certified Nursing Assistant (CNA) #2 said she had performed care on the Resident earlier but did not get them out of bed for the day yet. During an observation with interview on 6/6/23 at 11:48 A.M., the surveyor observed Resident #75 ask Nurse #1 where the urine is draining to. The surveyor observed Nurse #1 looking on both sides of the Resident's bed and heard Nurse #1 say she does not see a drainage bag. Nurse #1 removed the covers and a urinary drainage bag was observed by the Resident's right lower leg and about one third of the way full. The drainage bag was not observed to be positioned lower than the bladder to prevent urine in the tubing and drainage bag from flowing back into the bladder. Nurse #1 said the drainage bag should not be lying flat on the bed and it needed to remain below the catheter insertion site/bladder to prevent complications such as infection. On 6/7/23 at 8:04 A.M., the surveyor observed the urinary drainage bag connected to Resident #75 attached to the right side of the Resident's bed, with the bottom of the bag resting on the floor, placing the Resident at an increased risk of infection. During an interview on 6/7/23 at 8:06 A.M., Nurse #3 observed the urinary drainage bag touching the floor and said the drainage bag should not be touching the floor as doing so could potentially contaminate the bag or allow germs to enter the system resulting in an infection. During an interview on 6/7/23 at 3:52 P.M., the Director of Nurses (DON) was made aware of the surveyor's observations. The DON said a urinary drainage bag should not be lying flat on the bed next to a resident, nor should any part of the urinary drainage system tubing or bag be touching the floor at any time. She said the expectations set forth in the urinary catheter care policy were not met. 36542 2. Resident #185 was readmitted to the facility in May 2023 following a hospitalization with the insertion of a Foley catheter. Review of the care plans indicated Resident #185 was at risk for infection related to the indwelling Foley catheter. On 6/6/23 at 8:30 A.M., the surveyor observed Resident #185 lying in bed with their eyes closed. The surveyor observed a catheter drainage bag lying directly on the floor next to the bed, which increases the risk for infection. On 6/8/23 at 7:35 A.M., the surveyor observed Resident #185 lying in bed with their eyes closed. The surveyor was unable to see the catheter bag on either side of the bed. On 6/8/23 at 7:40 A.M., the surveyor and the Director of Nurses (DON) observed Resident #185 lying in bed. The DON lifted the blanket off of Resident #185 and found a catheter drainage leg bag (a bag which straps to the leg to allow for limited restrictions for mobility and for privacy). The leg bag was not positioned lower than the bladder to prevent urine in the tubing and drainage bag from flowing back into the urinary bladder. During an interview on 6/8/23 at 7:42 A.M., Nurse #5 said the CNA was responsible for changing the type of catheter bag and could have switched the bag to a leg bag in anticipation of the Resident getting out of bed. During an interview on 6/8/23 at 7:45 A.M., CNA #2 said she had not been in to care for Resident #185 since she had come in this morning at 7:00 A.M. During an interview on 6/8/23 at 7:46 A.M., the DON said the catheter drainage bag should not be on the floor due to the risk for infection and the bag should be below the bladder. She said the expectation was for staff to remove the leg bag when the Resident was going to bed at night and hang the catheter bag from the side of the bed, and Resident #185 should not be lying in bed with the leg bag on.

Based on record reviews, policy review, and interviews, the facility failed to ensure required physician visits (every 30 days for the first 90 days and at least once every 60 days after) alternated between the Physician and the Nurse Practitioner (NP) for five Residents (#10, #19, #21, #30, and #70), in a total sample of 18 residents. Findings include: Review of the facility's policy titled Physician Services, undated, indicated but was not limited to: - The Physician will perform pertinent, timely medical assessments. - The Physician will visit the Resident at appropriate intervals. - Physician visits, frequency of visits, emergency care of residents, etc., are provided in accordance with current OBRA (Omnibus Budget Reconciliation Act) regulations and facility policy. 1. Resident #10 was admitted to the facility in December 2022 with diagnoses which included Alzheimer's dementia. The Resident's Health Care Proxy (HCP) was activated 12/12/22. Review of the medical record indicated Resident #10 was not seen by his/her attending physician. Resident #10 was visited by the NP for all visits and was last seen on 2/7/23. 2. Resident #19 was admitted to the facility in July 2017 with diagnoses which included dementia. Resident #19's HCP was activated on 7/14/17. Review of the medical record indicated Resident #19 was seen by his/her attending physician on 5/15/23, with no previous or subsequent visits by the attending physician. Resident #19 was visited by the NP for all previous and subsequent visits. 3. Resident #21 was admitted to the facility in March 2023 with diagnoses which included dementia. Resident #21's HCP was activated on 5/22/23. Review of the medical record indicated Resident #21 was visited by his/her attending physician on 5/8/23, 5/15/23, and 5/22/23. Resident #21 was visited by the NP for all previous and subsequent visits. 4. Resident #30 was admitted to the facility in February 2023 with diagnoses which included: hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage affecting the left non-dominant side (bleeding in the brain resulting in weakness to the left side of his/her body). Review of the medical record indicated Resident #30 was not visited by his/her attending physician throughout his/her stay at the facility. Resident #30 was visited by the NP for all visits. 5. Resident #70 was admitted to the facility in April 2022 with diagnoses which included type II diabetes. Review of the medical record indicated Resident #70 was visited only once by his/her attending physician on 4/10/23. Resident #70 was visited by the NP for all previous and subsequent visits. During an interview on 6/8/23 at 12:05 P.M., Unit Manager (UM) #1 said the physicians in the facility changed on 12/1/22. UM #1 said she does not track physician visits. She said she believed the physicians' computer system indicated when a resident needed to be visited and by which provider. UM #1 said that residents should be visited by their attending physician once per month for the first 90 days and then once every 60 days thereafter. During an interview on 6/8/23 at 12:55 P.M., the Director of Nursing (DON) said the expectation for Physician visit frequency was every 30 days for the first 90 days after admission and then once every 60 days thereafter. The DON said she was under the impression the physicians' group was tracking visits to ensure the proper provider saw the residents as needed. The DON said her expectation was that the physician would provide the initial history and physical visit for the residents at the facility. The DON said she would reach out to the physician's office for documentation of the physician's visits. The facility failed to provide evidence of the physician's visits prior to the conclusion of the survey. 48362

Based on observations, interviews, and review of the meal truck delivery schedule, the facility failed to offer a nourishing evening snack when there was greater than 14 hours between dinner and breakfast service. Findings include: Review of the facility's policy titled Food and Nutrition Services, undated, indicated but was not limited to: -Nourishing snacks are available to the residents 24 hours a day. The resident may request snacks as desired, or snacks may be scheduled between meals to accommodate the resident's typical eating patterns. Review of the April 2023 Resident Council Minutes indicated residents had requested snacks in the evenings. Review of the Food Truck Delivery Times, undated, provided by the Food Service Director, indicated there was 15 hours between dinner and breakfast service on the Vineyard Sound Unit. The food truck delivery schedule indicated: -Dinner schedule: VS (Vineyard Sound) East 5:10 P.M. VS (Vineyard Sound) [NAME] 5:20 P.M. -Breakfast schedule: VS (Vineyard Sound) East 8:10 A.M. VS (Vineyard Sound) [NAME] 8:20 A.M. On 6/6/23 at 11:25 A.M., the surveyor observed the Vineyard Sound Unit kitchenette and observed it to be sparsely stocked with snacks and food. Specifically, the following observations were made: -The refrigerator contained 1 bottle of Boost (nutritional supplement), 2 bottles of Ensure (nutritional supplement), 1 carton of Almond Breeze non-dairy milk product, a package of string cheese (labeled for a specific resident) and 1 can of ginger ale - A cabinet contained a box of Sanka (instant decaffeinated coffee) and a bag of sugar On 6/7/23 at 7:55 A.M., the surveyor observed the Vineyard Sound Unit Kitchenette and observed it to be sparsely stocked with snacks and food. Specifically, the following observations were made: -The refrigerator contained 1 bottle of Boost, 2 bottles of Ensure, 1 carton of Almond Breeze, package of string cheese (labeled for a specific resident), 1 can of ginger ale, 2 individual cartons of milk, and 2 food containers (labeled for specific residents) -A cabinet contained a box of Sanka and a bag of sugar On 6/7/23 at 4:38 P.M., the surveyor observed the activity room snack area which consisted of minimal amounts of crackers, cookies, and peanut butter packets. During an interview on 6/7/23 at 4:29 P.M., Certified Nursing Assistant (CNA) #1 said snacks were brought up by the kitchen staff after dinner and passed to all residents before bed. CNA #1 said there was nowhere to document that a snack had been provided or how much of it a resident may have consumed. During an interview on 6/7/23 at 4:33 P.M., Nurse #2 said the kitchen brought snacks up after supper. She said supplements are stored in the clean utility room, and snacks are stored in the activity room. She said for residents who are diabetic the evening snack was documented, but for others there was not documentation to demonstrate whether an evening snack was offered and consumed. On 6/8/23 at 8:15 A.M., the surveyor heard Resident #73 say they have not announced breakfast yet this morning. At 8:25 A.M., the Administrator asked Resident #73 if he/she was ready for breakfast and he/she responded, Yes. On 6/8/23 at 8:48 A.M., the surveyor observed 18 residents in the Vineyard Sound dining room with residents asking Unit Manager #2 where breakfast was, stating I'm hungry and other residents yelling out non-sensible words. Unit Manager #2 answered, informing the residents that breakfast would arrive any minute. No residents were provided snacks while waiting for meal delivery. On 6/8/23 at 8:52 A.M., the surveyor observed the first food truck arrive on the Vineyard Sound Unit, for the east side residents. According to the food truck delivery schedule, breakfast arrived 42 minutes after it was due at 8:10 A.M. On 6/8/23 at 8:57 A.M., the kitchen announced all hands-on deck for Vineyard [NAME] truck. At this time there were 20 residents in the Vineyard Sound dining room and none of those residents had been served any food. During an interview on 6/8/23 at 8:59 A.M., Unit Manager #2 said the first meal truck delivery was for the residents who are in their rooms and the second meal truck delivery was for residents in the dining room. On 6/8/23 at 9:03 A.M., the surveyor observed the first meal tray being served in the Vineyard Sound unit dining room. The first meal was served in the dining room [ROOM NUMBER] minutes after the scheduled time of 8:20 A.M. On 6/8/23 at 9:15 A.M., the surveyor observed the last tray being delivered in the Vineyard Sound Unit dining room. According to the truck delivery time schedule this resulted in a 15-hour and 55-minute gap between the delivery of the evening meal on 6/7/23 and breakfast on 6/8/23. During an interview on 6/8/23 at 10:26 A.M., the Administrator and Director of Nurses (DON) said they were not sure why the Vineyard Sound Unit had 15 hours between the scheduled last meal (dinner) and first meal (breakfast) delivery but did acknowledge there had been many changes in kitchen staff. The Administrator said there was a staffing issue that morning in which the scheduled cook did not report to work and resulted in the residents on the Vineyard Sound Unit not having their meal at the planned time, creating a gap in meals of almost 16 hours. The DON said there is no documentation the facility could provide to ensure that a substantial snack was being provided in the evening for anyone who is not diabetic. The DON said she considers a substantial snack more than a small pack of crackers, and gave an example of a half sandwich, ice cream, or something similar. The surveyor, the Administrator, and the DON reviewed that those types of snacks were not observed in the nourishment kitchen or activity room throughout the survey and they agreed the snacks needed to be more sufficient and nourishing.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to handle prepared foods during plating utilizing gloves and proper hand hygiene to prevent cross contamination. Findings include: Review of the 2013 Food Code (a model for safeguarding public health and ensuring food is unadulterated and honestly presented when offered to the consumer) indicated If used, SINGLE-USE gloves shall be used for only one task such as working with READY-TO-EAT FOOD or with raw animal FOOD, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. On 6/6/23 at 7:36 A.M., the surveyor observed Cook #1 while plating the meals at the prep station. Cook #1 was wearing gloves to pick up the food and plate it with the use of tongs and scoops. Cook #1 used his gloved hand to pick up biscuits, toast and orange slices. Cook #1 left the prep station with his gloves on and proceeded to the oven, opened the oven door and removed a tray of bacon, he then returned to the prep station and continued plating other meals. Cook #1 did not perform hand hygiene or change his gloves prior to returning to the prep station and continued to touch the tongs, scoops and prepared foods with the same gloves he wore while handling the oven door and tray of bacon resulting in potential cross contamination. On 6/7/23 between 11:41 A.M. and 11:52 A.M., the surveyor observed Cook #1, while plating the meals at the prep station. Cook #1 was wearing gloves to pick up the food and plate it with the use of tongs and scoops. Cook #1 left the prep station with his gloves on, went to the oven, opened the oven door and removed a plated grilled cheese. Cook #1 returned to the prep station, removed the grilled cheese from the plate, and placed it on the prep station to cut it and then placed it on a plate. Cook #1 was observed using the same gloved hands to pick up herbs, rolls, and slices of bread. Cook #1 was not observed to change his gloves or perform hand hygiene in between any of these tasks. During an interview on 6/7/23 at 10:21 A.M., the Regional Food Service Director said food should only be handled with clean gloves and gloves should be changed and hand hygiene performed when a cook moves between each station in the kitchen.

Based on record review, policy review, and interview, the facility failed to complete a Level I Preadmission Screening and Resident Review (PASRR- screen to determine if a resident had an intellectual or developmental disability and/or serious mental illness and needed further evaluation) for one Resident (#46), out of a total sample of 18 residents. Findings include: Review of the facility's policy titled Admission Criteria, last reviewed October 2022, indicated but was not limited to: -All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASRR) process. -The facility conducts a Level I PASRR screen for all potential admissions, regardless of payor source, to determine if the individual meets the criteria for a MD, ID, or RD. Resident #46 was admitted to the facility in November 2022 with diagnoses of vascular dementia, major depressive disorder, and cerebral vascular accident (CVA). Review of Resident #46's Level 1 PASRR indicated it was signed and not dated by Social Worker (SW) #1, and Sections A1, A2, A3, and A4 which screen for intellectual or development disability (ID/DD) were not completed. During an interview on 6/8/23 at 7:19 A.M., the Director of Nurses (DON) said Social Services was responsible to oversee the process and complete the PASRRs. During an interview on 6/8/23 at 8:14 A.M., Social Worker #1 said the PASRR Level I was not completed.

Based on record review, policy review, and interview, the facility failed to ensure staff developed and implemented a baseline care plan within 48 hours of the Resident's admission for one Resident (#46), in a total sample of 18 residents, to ensure that the Resident's immediate care needs were met. Findings include: Review of the facility's policy titled Care Plans-Baseline, not dated, included but was not limited to: -To ensure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. Resident #46 was admitted to the facility in November 2022 with diagnoses of vascular dementia, major depressive disorder, and cerebral vascular accident (CVA). Review of the admission Minimum Data Set (MDS) assessment indicated Resident #46 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 00 out of 15, and was dependent for bed mobility, dressing, bathing, and toileting. Review of the medical record failed to indicate a baseline care plan had been developed within 48 hours for the Resident's care to address his/her immediate needs as required. During an interview on 6/8/23 at 11:11 A.M., Unit Manager #1 could not explain why a baseline care plan had not been developed within 48 hours to address Resident #46's immediate needs as required. During a record review on 6/8/23 at 11:24 A.M., the Director of Nurses (DON), Social Worker #1 (SW) and surveyor reviewed Resident #46's medical record. The DON said the 48-hour base line care plan was not present. During an interview on 6/8/23 at 11:41 A.M., SW #1 said a 48-hour care plan should have been completed. During an interview on 6/8/23 at 12:35 P.M., the DON said a 48-hour care plan was not developed.

Based on record review, policy review, and interview, the facility failed to ensure that individualized, comprehensive care plans were developed for one Resident (#46), out of a total sample of 18 residents. Specifically, the facility failed to ensure that Resident #46 had a care plan developed for the care of a blister formation on top of his/her left foot and left middle toe infection. Findings include: Review of the facility's policy titled Comprehensive Person-Centered Care Plan, not dated, included but was not limited to: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. -The Interdisciplinary Team must review and update the care plan when there has been a significant change in the resident's condition. Resident #46 was admitted to the facility in November 2022 with diagnoses of vascular dementia, major depressive disorder, and cerebral vascular accident (CVA) with hemiplegia (paralysis of one side of the body) affecting the left non-dominant side. Review of the Minimum Data Set (MDS) assessment, dated 5/26/23, indicated Resident #46 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 8 out of 15, was dependent for bed mobility, dressing, bathing, and toileting, and no coded pressure areas. Review of a progress note written by Nurse #6 on 6/6/23 indicated: -Apply Bactroban ointment to left reddened crusty toe twice a day (BID) x 7 days. Review of the current Physician's Orders indicated treatment orders: -Mupirocin External Ointment 2% (an ointment to treat secondarily infected traumatic skin lesions due to bacteria). Apply to left middle toe topically every day and evening shift for skin for seven days. -Left top of foot blister apply skin prep while intact every day and evening shift. Review of the comprehensive care plans failed to indicate a care plan had been developed to address the identified blister of the Resident's left foot or the left middle toe. During an interview on 6/8/23 at 11:15 A.M., Unit Manager (UM) #1 said Resident #46 had impaired skin. UM #1 could not explain why the comprehensive care plan had not been updated to address Resident #46's skin condition and treatment. UM #1 said nursing should have implemented a wound care plan. During an interview on 6/8/23 at 12:35 P.M., the Director of Nurses (DON) said a care plan was not implemented for preventative skin care or current wound care.

Based on record review and staff interviews, the facility failed to provide adequate supervision and effective interventions to prevent falls with major injury and elopements per facility policy for 3 Residents (#10,#7, and #21) out of a total sample of 21 Residents. Findings include: 1. For Resident #10, the facility failed to provide adequate supervision and effective interventions to prevent falls, one of which resulted in a fracture. Resident #10 was admitted in May 2017 with [DIAGNOSES REDACTED]. The Resident was transferred from the Facility to the Hospital in 6/2017, following an unwitnessed fall, was treated at the Hospital for a fractured left hip, and readmitted to the Facility at the end of 6/2017. During the initial tour of Unit 1 on 8/1/17 with the ADON (Assistant Director of Nursing), the ADON said that the Resident had been admitted for rehabilitation following a fall that resulted in the Resident fracturing his/her neck. The ADON said that the Resident had resided with a family member and had a history of [REDACTED]. According to the most recent MDS (Minimum Data Set), signed as being completed 5/22/17, the Resident had clear speech, was understood, could understand, had sleep trouble, wandered, displayed behavioral symptoms directed toward others, and scored a 10/15 (moderate cognitive impairment) on the BIMS (Brief Interview for Mental Status). The MDS indicated that the Resident required extensive assistance with bed mobility, transfers, ambulation (in room and corridor), dressing, and bathing. The MDS also indicated that the Resident was continent of bowel and bladder and had experienced a fall/fracture in the past 6 months prior to admission and a fall in the past month. A Fall Risk Assessment was conducted on 5/9/17 which indicated a score of #10, indicating that the Resident was at High Risk for falls (Total score of 10 or above represents HIGH RISK). A Care Plan for Falls was dated 6/5/17 and reviewed/revised on 7/11/17, after the Resident fell and fractured his/her hip at the Facility. The Care Plan listed the following interventions to address the Resident's Risk for falls. -Assure the floor is free of glare, liquids, foreign objects. -Encourage Resident to assume a standing position slowly. -Give Resident verbal reminders not to ambulate/transfer without assistance. -Keep call light in reach at all times. -Keep personal items and frequently used items within reach. -Leave night light on in room. -Obtain PT (Physical Therapy) consult for strength training, toning, positioning, transfer training, gait training, mobility devices, etc. -Provide proper, well-maintained footwear. -Provide Resident an environment free of clutter -Alarms A/O (as ordered). 7/13/17 - No satin night gowns -Keep call bell in reach while in room (education) Although the Facility developed a Care Plan to address the Resident's Risk for Falls, the plan proved ineffective in addressing the Resident's unique individual behaviors and safety needs, i.e. frequently removed alarms and attempted ambulation/transfers without staff assistance. Review of the medical record indicated nursing notes from 5/10/17 - 6/12/17 that documented the Resident's repeated removal of bed/chair alarms, attempts to rise unassisted by staff, wandering, confusion, agitation and anxiety. On 6/10/17 at 11:24 P.M., the nurse wrote that the Resident was alert and agitated. The nurse's note indicated that the Resident's walker was left by the Resident at the bottom of the stairwell (outside the door to Unit 1), and the Resident went up to Unit 2 on the second floor (1 flight above). The nurse failed to document how the Resident was able to leave the first floor unit, unassisted, without anyone from Unit 1 noticing he/she was missing. A Wanderguard and multiple safety alarms were supposed to be in place, however there was no documentation of their status at the time of the elopement, and no incident investigation had been conducted by the Facility. No additional interventions were added to the Resident's Safety Plan of Care to address his/her Risk for potential elopement and/or the need for increased supervision, following his/her wandering from Unit 1 to Unit 2 without staff awareness on 6/10/17. On 6/17/17, a nurse's note indicated that Resident #7 was found next to his/her bed on all fours at approximately 4:30 A.M. The Resident was yelling out that his/her left leg was hurting. The Resident was assisted back to bed with max assist of two, not able to straighten the leg, not externally or internally rotated, tender to touch, denied neck pain, cervical collar on as ordered. Bleeding was noted from the Resident's left upper eyelid from a laceration. 911 was called and the Resident was sent to the local hospital for evaluation where he/she was diagnosed with [REDACTED]. The family was notified and the Resident was transferred from the local hospital to a Boston hospital where he/she underwent surgical repair of the fractured hip. The Resident returned to the Facility. On 6/29/17 at 11:31 P.M., a nurse's note indicated that the Resident had returned to the Facility following treatment for [REDACTED]. The Resident was noted to be pleasant and cooperative. No changes in the Resident's Care Plan for Falls and/or safety, dated 6/5/17, were noted following the 6/17/17 fall with resulting fractured left hip. A handwritten entry on the Care Plan indicated Alarms A/O (as ordered). Upon return to the Facility following surgical repair of the left hip, nurse's notes documented frequent successful attempts by the Resident to remove the Aspen surgical collar intended to treat her fractured neck (which occurred prior to admission in 5/2017) in spite of reminders from nursing to keep the collar in place, and attempts to rise without staff assistance. Further review of nurse's notes indicated the Resident had 2 more falls: -On 7/13/17 at approximately 4:30 P.M., the Resident was found in his/her room on floor between wheelchair and bed. The Resident stated he/she was trying to get from the wheelchair to bed. The note indicated that the Resident was wearing satin night clothes that could cause him/her to slip (this was not in accordance to the resident's plan of care for falls). Non-skid socks were reportedly on at the time. The Resident denied pain and denied hitting his/her head. The Resident was brought to the dining room in the wheelchair for dinner. -On 7/22/17, at 5:40 P.M., the Resident was in the dining room, stood up from the wheelchair, and fell on his/her right side onto the floor hitting the right side of his/her head on the door. The Director of Nursing was interviewed on 8/2/17 at 10:00 A.M. The DON said that there were not effective measures in place to ensure the Resident's safety, prevent falls, and address the Resident's unsafe behaviors such as removing safety alarms, ambulating unassisted, wandering off the unit unnoticed by staff. Additionally, the DON said that the Facility failed to conduct an investigation and did not know the status of the Resident's safety devices a the time of the incidents. 2. For Resident #7, the facility failed to ensure that their Elopement Prevention program was implemented according to facility policy, and was effective to prevent the Resident from eloping from the building on 3 occasions. Resident #7 was admitted to the facility in 1/2017 with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) with a reference date of 4/28/17, indicated that Resident #7 had moderate cognitive impairment as evidenced by a score of 10 out of 15 on the Brief Interview for Mental Status (BIMS), was independent with all activities of daily living and used a walker for ambulation. The MDS also indicated that Resident #7 had an activated Health Care Proxy. The facility's Elopement Prevention Policy (Reviewed 6/2017) included the following: It is the policy of the facility to take appropriate steps to identify the risk of, prevent, detect and respond promptly to Resident Wandering and Elopement. Assessment 1. All Residents shall have an Elopement Assessment done and Immediate Plan of Care for risk of wandering and elopement developed on admission if appropriate 2. Any Resident with episodes of Elopement who has not been previously identified as being a risk for Elopement shall be immediately assessed using the At Risk for Elopement Resident Form 3. Also, any Resident demonstrating behavior indicating a risk for Elopement (i.e. episodes of wandering and conversation/behavior indicating inappropriate need to suddenly leave the building) shall be assessed using the At Risk for Elopement Resident Form 4. If a Resident who has been assessed as being at risk for Elopement has an incident of elopement, despite precautions being in place, a post elopement evaluation shall be done Prevention 1. A facial photograph of an at risk Resident shall be taken at admission and placed onto a completed Missing Resident Profile Form and kept in yellow Elopement binders located at the reception desk, Director of Nursing Services office, and on each unit 2. Resident door label and CNA (certified nursing assistant) care card will be printed on yellow paper 3. Upon hire and annually, each new employee, of all departments, shall be informed of this Elopement Policy and Procedure and each employee shall be informed of their responsibility regarding: a. Door alarms b. code yellow and reporting Elopement c. reporting behavior of Residents which may indicate a risk for elopement d. being aware of Residents who are at risk for Elopement, their photos, Resident specific indications of potential Elopement and individual care plans, approaches, including yellow binders, door labels and CNA care cards Response to Elopement When the Resident is located 1. Nursing to assess the Resident thoroughly and document findings in the medical record/nurses notes 2. Notify MD, Executive Director, Director of Nursing (DON), Nursing Supervisor, Resident's Legal Representative/Family 3. Investigate for causal factors related to the Elopement 4. Complete the Post Elopement Evaluation Form and Incident Report 5. Update Care Plan Reporting-The Executive Director, or designee, shall notify: 1. State Agency, as required by law 2. Medical Director Monitoring 1. Risk for Elopement will be reassessed quarterly for all Residents 2. The Nursing Department shall identify and implement interventions to prevent Elopement, as necessary, which may include transfer of a Resident to another facility to provide and maintain necessary safety for the Resident 3. The Management Team shall discuss incidents of Elopement and identify patterns, trends, causal factors, requiring further interventions. The results should be presented to QAPI Committee. Review of the nursing progress notes indicated that Resident #7 eloped from the facility on 2/7/17 to a Rite Aid Store (walked across Main Street which has heavy traffic) and was brought back to the facility by the Admission officer. The Resident left the facility unnoticed by staff. Upon the Resident's return to the facility, a Wanderguard was applied to his/her left ankle for safety. Further review of the medical record indicated the facility failed to do the following according to facility policy: - conduct a thorough nursing assessment and document findings in the medical record - update the CNA care card with elopement risk status - Notify MD, Medical Director, Executive Director, Director of Nursing, Nursing Supervisor, Resident's Legal Representative/Family - Investigate for causal factors related to the Elopement - Complete the Post Elopement Evaluation Form and Incident Report - Report the elopement to the State Agency, as required by law Review of Resident #7's At Risk for Elopement Assessment Form completed on 2/7/17, indicated that the Resident was identified as being at risk for elopement. Review of care plans failed to indicate that an individualized, person-centered care plan for elopement was developed. Further review of the medical record indicated that Resident #7 had a neuropsychological evaluation on 3/3/17. The psychiatric clinician documented that the Resident had severe deficits in memory, was unable to retain new information, and was unable to make healthcare decisions. During the course of the evaluation, Resident #7 expressed to the clinician that he/she felt that they were being held at the facility against their will and wanted to live independently. The clinician recommended that Resident's healthcare proxy remain activated and that he/she receive intervention and assistance to work through issues with his/her family. Review of a nursing note dated 5/3/17 (with a time stamp of 09:08 A.M.), indicated that the Resident had been at the facility since January with no attempts to elope. The nurse documented that she had completed an elopement assessment (dated 5/3/17), identified that the Resident had no previous attempts to elope, determined that the Resident was not an elopement risk, and subsequently removed the Wanderguard. Later that day, a nursing note indicated that Resident #7 again eloped from the facility on 5/3/17. The Resident exited the facility unnoticed by staff and was observed walking down Main Street. Staff retrieved the Resident and brought him/her back to the facility. The nurses note indicated that Nurse #1 (N#1) discussed safety concerns with the Resident and had the Resident sign a contract that he/she would not leave the premises without a responsible person and informing staff, despite the psychiatric clinician's determination that the Resident had severe deficits in memory and was unable to retain new information. No other appropriate interventions were put into place to prevent the Resident from leaving the facility unattended and without staff knowledge. Further review of the medical record indicated the facility failed to do the following according to facility policy: - conduct a thorough nursing assessment and document findings in the medical record - update the CNA care card with elopement risk status - Notify MD, Medical Director, Executive Director, Director of Nursing, Nursing Supervisor, Resident's Legal Representative/Family - Investigate for causal factors related to the Elopement - Complete the Post Elopement Evaluation Form and Incident Report - Report the elopement to the State Agency, as required by law Review of the care plan failed to indicate that an individualized care plan for elopement had been developed. Review of nursing progress notes dated 5/13/17, indicated that Resident #7 continuously attempted to leave the facility grounds. The Resident was weepy and told staff that he/she could not take this, I am a prisoner here, I have already walked to the bank twice this week, it's only two blocks, who do you people think you are, locking me up like I was in jail. Again, an individualized, person-centered care plan was not developed to reflect the Resident's elopement attempts, actual elopements, or verbalizations of desire to leave. Review of the medical record including a nursing note dated 7/13/17, indicated that Resident #7 again eloped the facility. The Resident left the facility unnoticed by staff and was observed ambulating outside alone on the sidewalk, along the busy street in front of the building. A visitor driving by the building noticed the Resident walking down the sidewalk, stopped and alerted staff that the Resident was off the property. Staff then went outside to get the Resident After much encouragement, the Resident returned to the building. Review of the medical record indicated that on 7/14/17, following the Resident's third elopement from the facility, facility management told the Resident that he/she would be transferred to a secured unit to maintain his/her safety related to the elopement. The Resident became extremely agitated and began to cry out. Ultimately, the Resident was sent out to the hospital for evaluation. Review of hospital documentation indicated that Resident #7 had dementia with behavioral disturbance and severe depression. Upon return to the facility, he/she was admitted to a room on the secure unit. Further review of the medical record indicated the facility failed to do the following according to facility policy: - conduct a thorough nursing assessment and document findings in the medical record - update the CNA care card with elopement risk status - Notify MD, Medical Director, Executive Director, Director of Nursing - Investigate for causal factors related to the Elopement - Complete the Post Elopement Evaluation Form and Incident Report Review of the care plan failed to indicate that an individualized, person-centered care plan for elopement had been developed. During interview with the DON on 8/3/17 at 2:10 P.M., she said that incident reports and investigations were not completed for Resident #7's elopements on 2/7/17 and 5/3/17 according to facility policy. Additionally, the elopements were not reported to the State Agency as required. The DON said that the current assistant DON (ADON) was the unit manager at the time of the elopements and would be able to provide more specific information. On 8/8/17 at 1:35 P.M., the ADON was interviewed. She said that after Resident #7's first elopement, despite the Resident's cognitive impairment, she had the Resident sign a contract stating that he/she would not leave the premises without a responsible person and informing staff. No other interventions were put into place to prevent the Resident from eloping again. The ADON said that after the second elopement, the staff kept an eye on him/her. She said that 15 minute checks annoyed the Resident, so they just kept an eye out for him/her. No other interventions were put into place to prevent the Resident from eloping again. During subsequent interview with the DON on 8/8/17 at 10:30 A.M., she said that yellow elopement binders containing Missing Resident Profile Forms are kept at the receptionist's desk, on each unit and in the DON's office. The Missing Resident forms contain characteristic information about the Resident as well as a photograph of the Resident, although he photographs are grainy and not easy to distinguish who it is. The DON was asked if the receptionist had specific training relative to her responsibilities for utilizing the elopement binder and ensuring Residents identified in the binder do not leave the facility without a responsible person. The DON said No. 3. For Resident #21, the facility failed to ensure that their Elopement Prevention program was implemented according to facility policy, and was effective to prevent the Resident from eloping from the building. Resident #21 was admitted to the facility in 6/2017 after a two week hospitalization for pneumonia, [DIAGNOSES REDACTED] and sepsis. Admission [DIAGNOSES REDACTED]. During hospitalization , the Resident was disoriented and required repeated doses of an antipsychotic medication for behaviors. Review of the medical record indicated that on 6/10/17 (one day after admission) Resident #21 had eloped from the facility unnoticed by staff, and was found alone in the parking lot seated in his/her wheelchair. The Resident was brought back inside and a Wanderguard was placed on his/her right ankle. Further review of the medical record indicated the facility failed to do the following according to facility policy: - conduct a thorough nursing assessment and document findings in the medical record - Notify MD, Medical Director, Executive Director, Director of Nursing, Nursing Supervisor, Resident's Legal Representative/Family - Investigate for causal factors related to the Elopement - Complete the Post Elopement Evaluation Form and Incident Report - Report the elopement to the State Agency, as required by law During interview with the DON on 8/8/17 at approximately 1:00 P.M., she said that an incident report was not completed for the elopement, it was not investigated, and it was not reported to the State Agency per facility policy and as required by law. The ADON was interviewed on 8/8/17 at 1:35 P.M. She said that she only remembers that the Resident was found in the parking lot in the back of the building. She could not say how the Resident, whom requires assistance with propelling a wheelchair, could have left the building unnoticed by staff.

Based on record review and interview, for one of three sampled residents (Resident #1), who were at risk for falls, the Facility failed to ensure a restorative aide used a gait belt when she assisted Resident #1 during ambulation per the restorative/nursing program plan of care. Restorative Aide #1 said she was aware Resident #1 required physical assistance during ambulation while using a rolling walker and a gait belt, and on 4/26/14 she ambulated Resident #1 to the elevator while using the rolling walker with the use of a gait belt, and did not maintain hold of the gait belt and Resident #1 fell . The Hospital record indicated and Nurse Practitioner #1 said Resident #1 sustained a laceration that required 7 staples to close as a result of the fall. Findings include: The admission fall risk assessment, dated 2/14/14, indicated that Resident #1 was at high risk for falls due to disorientation, 3 or more falls in the past 3 months, a non-ambulatory status, a balance problem when walking or standing while using an assistive device, and the effects of medications. The Admission Minimum Data Set (MDS) assessment, completed on 2/27/14, indicated that Resident #1 required extensive assistance of 2 staff members for transfer activities, was not steady during transfers, and was only able to stabilize with staff assistance. The physical therapy discharge summary, dated 4/16/14, indicated that Resident #1 required contact guard (the resident required the staff member to maintain contact with their body for needed support) by 1 staff member while using a rolling walker due to a risk for falls and was referred to the restorative nursing program for continued therapy. The Surveyor interviewed the Rehabilitation Manager at 10:45 A.M. on 6/9/14. The Rehabilitation Manager said the Facility used the restorative/rehabilitation nursing program plan which was used and signed by the restorative aide that was assigned to the resident's restorative care to ensure the assigned restorative aide knows the resident's restorative care needs. The restorative/rehabilitation nursing program plan used and signed by Restorative aide #1, dated 4/16/14, indicated Resident #1 required physical assistance of one staff member while using a rolling walker and a gait belt during ambulation. The Gait Belt Policy and Procedure indicated that during ambulation staff should maintain a hold on the gait belt at all times. The Surveyor interviewed Restorative Aide #1 at 3:50 P.M. on 6/9/14. Restorative Aide #1 said she was assigned Resident #1's restorative care needs and was familiar with Resident #1's restorative/rehabilitation nursing program plan of care. Restorative Aide #1 said she was educated and signed Resident #1's restorative/rehabilitation nursing program plan, and was told that Resident #1 required the physical assistance of one staff member and the use of a gait belt during transfers and ambulation while using a rolling walker. The Surveyor interviewed the Director of Clinical Services at 2:00 P.M. and 4:30 P.M. on 6/9/14. The Director of Clinical Services said Resident #1 required the physical assistance of one staff member while using a gait belt and a rolling walker during transfers and ambulation. The nurse's incident note, at 9:30 A.M. on 4/26/14, indicated that Resident #1 fell while being ambulated by the restorative aide, the physician was notified that he/she sustained a laceration on the back of his head, and was transferred to the Hospital. Restorative Aide #1 said at about 9:15 A.M. on 4/26/14 she let go of the gait belt during ambulation, left him/her standing alone about 3.5 feet from the elevator door, walked about 10.5 feet to reach a key inside the kitchenette, exited the kitchenette and saw him falling sideways to the floor. Restorative Aide #1 said she was unable to reach Resident #1, he/she hit the back of his/her head on a corner molding, and sustained a laceration on the back of his/her head Restorative Aide #1 said she could not prevent the fall because she did not maintain hold of the gait belt during ambulation per the plan of care, as well as, the Facility policy. Restorative Aide #1 said Nurse #1 was immediately summoned for assistance. The Surveyor interviewed Nurse #1 at 12:10 P.M. on 6/9/14. Nurse #1 said she was assigned to Resident #1's nursing care needs during the day shift on 4/26/14. Nurse #1 said she was summoned to the back elevator because Resident #1 had fallen to the floor nearby the elevator door while being ambulated to the elevator by Restorative Aide #1. Nurse #1 said Resident #1 sustained about a 2 inch laceration on the back of his/her head and was transferred to the Hospital for treatment. The Hospital report, dated 4/26/14, indicated Resident #1 sustained a 2 inch laceration on the back of his head that required 7 staples to close.

Based on observation, record review, and staff interview, the facility failed to ensure for 1 (#2) of 6 sampled residents reviewed for falls, from a total sample of 18, that the facility provided care for Resident #2 in accordance with the resident's care plan. The facility failed to use two staff when repositioning Resident #2 which resulted in a significant injury requiring transfer and treatment in the emergency room . Findings included: Resident #2 was admitted with [DIAGNOSES REDACTED]. According to the most recent MDS (Minimum Data Set), signed as being completed 7/25/12, the resident experienced short and long-term memory impairment, severely impaired cognitive skills for daily decision making, incontinence of bowel and bladder, and was totally dependent for bed mobility, transfers, and (ADLs) activities of daily living. Record review on 10/10/12, revealed that the resident had experienced a fall on 9/29/12 at 6:40 PM, which resulted in head trauma with multiple lacerations and contusions to the head requiring staples and sutures at the emergency room . According to the incident report, completed by the Director of Nursing on 9/29/12 at 6:40 PM, the resident was sitting in a chair receiving care from the CNA (Certified Nursing Assistant). The CNA had changed the resident's hospital-type gown while the resident sat in the chair. The report documented that the CNA noticed that the resident was sitting forward in the chair and described the resident as "slouching" forward, in spite of the Dycem (non-slip material) in place on the chair at that time. The report documented that the CNA repositioned the chair at a sixty degree angle in order to prevent the resident from falling. The CNA then pulled the shoulder high Hoyer pad up and back with the intent that the resident's buttocks slide back to the back of the seat. As the CNA pulled up and back on the Hoyer pad, the pad slid partially out from under the resident's buttocks, which propelled the resident forward and out of the chair onto the floor. The CNA said in a statement said that it happened so fast that she did not have time to call for assistance but tried to prevent the resident from falling. Further review of the resident's CNA Care Card documented that the resident required the assistance of two staff members for positioning. The resident was transported via ambulance to the local hospital emergency room . According to the facility incident statement, the resident sustained [REDACTED]. The resident's mental status following the fall was alert and confused which is the resident's usual level of cognition, according to the report. The resident was observed on 10/11/12 at 9:10 A.M., seated upright in a Broda chair in the back dining room on Unit 3. The resident's eyes were closed at that time. A dime-sized, raised, oval-shaped, black scab was observed on the right side of the forehead. An approximately 1-inch long, pink, healing scar was visible on the left side of the forehead. The resident's hair covered the laceration to the left scalp near the ear that had been closed with seven staples in the emergency roiagnom on [DATE]. Review of the facility Accident Prevention Recap dated 10/11/12, emphasized to "Ensure you follow resident's individualized care plan (CNA Care Card)." During interview with the DON (Director of Nursing) on 10/11/12 at 8:25 AM, the DON said yes, when asked if the CNA should have sought help to reposition the resident. The DON also said that the CNA failed to follow the CNA Care Card, and failed to follow the facility's policy (Long Term Care Nursing Assistant training book) of repositioning residents using two staff members. The Hospice registered nurse assigned to provide care to this resident was interviewed on 10/11/12 at 10:12 A.M. in regards to the positioning needs of the resident. The Hospice nurse said they always have two CNAs for transfers or repositioning. The CNA involved was re-educated on 9/28/12 by the facility Staff Development Coordinator. The content of the inservice included making sure two staff are utilized when repositioning a resident in a chair, and, follow the CNA Care Card when providing care to residents.