Every finding on record at Royal of Cotuit

Based on interview and record review, the facility failed to maintain a safe environment, free of accident hazards for four Residents (#6, #10, #33, #77), out of eight independent smokers on the Popponesett Unit. Specifically, the facility failed to ensure the Residents' smoking materials were stored securely. Findings include:Review of the facility's policy titled Smoking Policy and Procedure, undated, indicated but was not limited to the following: - It is the policy of [Corporate Name] to provide a safe environment for residents, staff and visitors through the enforcement of a smoking policy designed to reduce risks to residents who smoke tobacco products, reduce the risks of passive smoking for others and reduce the risk of fire. - Independent Smoker: A resident who has been assessed by the IDT (interdisciplinary Team) to be able to smoke safely in the designated area without staff supervision. The Independent Smoker will adhere to all guidelines for safe smoking outlined in this policy and, if there are any infractions, will be re-assessed for safe smoking. The resident must keep all lighting materials at the designated secure area. - Tobacco products will be stored in a box on each unit. Each box will have a written list of residents who need safety measures taped inside the box. - Addendum A – Smoking Times: All lighting materials are kept at the nursing station and distributed per request by the staff. During the entrance conference on 3/25/26 at 8:40 A.M., the facility provided a list of smokers to the survey team which included Residents #6, #10, #33, and #77. During an interview on 3/25/26 at 9:05 A.M., Unit Manager (UM) #1 said the unit had eight independent smokers and one supervised smoker. UM #1 said there was a lock box on the wall for all smokers to store their cigarettes and lighting supplies. UM #1 said independent smokers have a key to their own lock boxes and are able to go out to the smoking unit throughout the day as they choose. UM #1 said nurses also have a key to the lock boxes are supposed to remind any of the smokers as they return from the smoking area to place their supplies back in their lock boxes. UM #1 said some of the independent smokers do not always put their supplies back in the lock boxes. A. Resident #6 was admitted to the facility in May 2025 with diagnoses including chronic obstructive pulmonary disorder (COPD) and nicotine dependence. Review of Resident #6's Minimum Data Set (MDS) assessment, dated 1/15/26, indicated he/she was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of Resident #6's medical record indicated a signed smoking agreement by the Resident and a facility representative on 5/3/25. On 3/25/26 at 4:17 P.M., the surveyor observed the smoking lock boxes on the unit. Resident #6's lock box had three packages of cigarettes and no lighting supplies. During an interview on 3/25/26 at 4:20 P.M., Resident #6 said he/she was an independent smoker. Resident #6 said there was a lock box on the unit for him/her to place his/her smoking supplies, including their lighter and cigarettes, in after use. Resident #6 said he/she does not always remember to use the lock box. Resident #6 said sometimes he/she places his/her supplies in his/her bag, which was observed to be on top of the Resident's bed. On 3/26/26 at 9:19 A.M., the surveyor observed Resident #6 in the smoking area, independently smoking a cigarette. Resident #6's lock box for smoking supplies on the unit contained one cigarette package. On 3/26/26 at 11:52 A.M., the surveyor observed Resident #6 in the smoking area, independently smoking a cigarette. Resident #6's lock box for smoking supplies on the unit was empty. At 11:58 A.M., Resident #6 returned to the unit from the smoking area. Resident #6 was observed to walk down the hallway to their room without placing any smoking supplies in their lock box. A nurse was observed at the nurses' station and did not request the Resident place any supplies in the lock box. On 3/27/26 at 8:10 A.M., Resident #6's smoking lock box on the unit contained one package of cigarettes and no other supplies. Review of Resident #6's comprehensive care plan for smoking included the following interventions: - All light materials are to be kept in designated secure storage at nurses' station. Review of Resident #6's smoking assessments, dated 5/29/25, 11/17/25, and 1/13/26, indicated he/she was safe to smoke independently and followed the facility's policy on smoking. B. Resident #10 was admitted to the facility in June 2024 with diagnoses including tobacco use and emphysema. Review of Resident #10's MDS assessment, dated 2/26/26, indicated he/she was cognitively intact with a BIMS score of 13 out of 15. Review of Resident #10's medical record indicated a signed smoking agreement by the Resident and a facility representative on 9/18/24. On 3/25/26 at 11:27 A.M., the surveyor observed that Resident #10's smoking lock box on the unit contained no smoking supplies or cigarette packages. On 3/25/26 at 4:03 P.M., the surveyor observed Resident #10 outside in the smoking area independently smoking. Resident #10's lock box on the unit for smoking supplies was empty. On 3/26/26 at 9:19 A.M., the surveyor observed that Resident #10's smoking lock box on the unit contained no smoking supplies or cigarette packages. On 3/26/26 at 11:51 A.M., the surveyor observed that Resident #10's smoking lock box on the unit contained no smoking supplies or cigarette packages. On 3/26/26 at 11:52 A.M., the surveyor observed Resident #10 outside in the smoking area independently smoking. Resident #10's lock box on the unit for smoking supplies was empty. On 3/26/26 at 2:57 P.M., the surveyor observed Resident #10 outside in the smoking area independently smoking. Resident #10's lock box on the unit for smoking supplies was empty. On 3/27/26 at 7:56 A.M., the surveyor observed that Resident #10's smoking lock box on the unit contained one package of cigarettes and no other supplies. Review of Resident #10's comprehensive care plan for smoking included the following interventions: - All lighters/cigarettes will be turned into the nurse when not in use. Review of Resident #10's smoking assessments dated 6/2/25, 8/26/25, 11/17/25 and 2/9/26, indicated he/she was safe to smoke independently and followed the facility's policy on smoking. C. Resident #33 was admitted to the facility in November 2025 with diagnoses including tobacco use, weakness, and COPD. Review of Resident #33's MDS assessment, dated 2/26/26, indicated he/she had a moderate cognitive impairment as evidenced by a BIMS score of 13 out of 15. Review of Resident #33's medical record indicated a signed smoking agreement by the Resident and a facility representative on 12/22/25. On 3/25/26 at 9:05 A.M., the surveyor observed Resident #33 return to the unit from the smoking area and walk past the nurses' station. UM #1 asked the Resident to return his/her smoking supplies to their lock box across from the nurses' station. Resident #33 said he/she was getting a sweatshirt from their room and going back outside and continued walking down to his/her room. Resident #33 was not observed to return to the smoking area. During an interview on 3/25/26 at 9:19 A.M., Resident #33 said he/she had been smoking since they were a teenager and was safe to smoke as well as hold their smoking supplies. Resident #33 said he/she did not always put their smoking supplies, including lighters, back in their lock box on the unit. Resident #33 said, I am safe to keep my supplies because I have been smoking for a long time. On 3/25/26 at 10:26 A.M., the surveyor observed Resident #33 independently smoking in the smoking area. No supplies were noted in Resident #33's smoking lock box. On 3/25/26 at 11:37 A.M., the surveyor observed that Resident #33's smoking lock box on the unit contained one package of cigarettes and no other smoking supplies, including a lighter. On 3/25/26 at 4:03 P.M., the surveyor observed that Resident #33's smoking lock box on the unit was empty. On 3/26/26 at 7:11 A.M., the surveyor observed Resident #33 return to the unit from the smoking area and go directly to his/her room without placing any supplies including packages of cigarettes or lighters in his/her smoking lock box. On 3/26/26 at 9:19 A.M., the surveyor observed Resident #33's smoking lock box on the unit to be empty. On 3/26/26 at 10:10 A.M., the surveyor observed Resident #33 leave the unit for the smoking area. Resident #33 did not take any items from their smoking lock box on the unit as it was empty. Resident #33 was observed to pull a lighter and cigarette from their jacket pocket as they entered the smoking area and began independently smoking. On 3/26/26 at 11:51 A.M., the surveyor observed that Resident #33's smoking lock box on the unit contained two packages of cigarettes and no other supplies. At 11:55 A.M., Resident #33 was observed to return to the unit from the smoking area, open his/her lock box, remove all smoking supplies and return to his/her room. The nurse seated at the nurses' station did not ask the Resident to return the supplies to the smoking lock box. On 3/27/26 at 7:56 A.M., the surveyor observed that Resident #33's smoking lock box on the unit contained one package of cigarettes and no other supplies. Review of Resident #33's comprehensive care plan for smoking included the following interventions: - All lighting materials are to be kept in designated secure storage at nurses' station. Review of Resident #33's smoking assessments, dated 11/20/25 and 2/17/26, indicated he/she was safe to smoke independently and followed the facility's policy on smoking. During an interview on 3/25/26 at 4:24 P.M., Certified Nursing Assistant (CNA) #4 said most of the residents on the unit who smoke are independent. CNA #4 said nurses have a key to the lock boxes for storage of smoking supplies. CNA #4 said nurses unlock the boxes for residents to gather and return their supplies before/after smoking. CNA #4 said all lock boxes should contain the residents' cigarettes and lighters. During an interview on 3/26/26 at 2:32 P.M., CNA #1 said residents who smoke independently on the unit have a code to the door to access the smoking area independently. CNA #1 said residents who smoke are supposed to put their cigarettes and smoking supplies back in their lock boxes when they return from the smoking area. D. Resident #77 was admitted to the facility in April 2025 with diagnoses including COPD and tobacco use. Review of Resident #77's MDS assessment, dated 4/25/25, indicated he/she had moderate cognitive impairment with a BIMS score of 11 out of 15. Review of Resident #77's smoking assessments, dated 9/26/25 and 12/22/25, indicated he/she was safe to smoke independently and followed the facility's policy on smoking. Review of Resident #77's comprehensive care plan for smoking included the following interventions: - I need help budgeting my cigarettes and will allow staff to keep cigarettes in med room. One baggie containing six cigarettes given per day. - I will return my cigarettes and lighter to lock box after when finished smoking. Further review of Resident #77's medical record did not indicate that the facility's smoking agreement was reviewed with the resident on admission. On 3/26/26 at 7:22 A.M., the surveyor observed the smoking lock boxes on the unit. Resident #77's lock box did not contain any cigarettes or lighting supplies. The surveyor observed Resident #77 walk by the lock boxes and go to the smoking area. Resident #77 pulled a cigarette and lighter from his/her coat pocket and proceeded to light the cigarette. Resident #77 was noted to return from the smoking area at 7:26 A.M. Resident #77 asked UM #1 for his/her cigarettes. UM #1 gave the Resident a clear plastic bag containing six cigarettes. Resident #77 carried the bag of cigarettes to his/her room. On 3/26/26 at 7:53 A.M., the surveyor observed Resident #77 returning to the smoking area. Resident #77's lock box for smoking supplies was empty. Resident #77 was noted to pull a lighter from his/her coat pocket and light a cigarette. Resident #77 returned to the unit from the smoking area. Resident #77 did not return smoking supplies to his/her lock box. Resident #77 proceeded to return to his/her room. During an interview on 3/26/26 at 10:10 A.M., Certified Nursing Assistant (CNA) #1 said most of the residents on the unit who smoke are independent. CNA #1 said nurses check a few times a day to see if residents return their cigarettes and lighters to the lock boxes. CNA #1 said she was not responsible for reminding or monitoring that residents were using their lock boxes. CNA #1 said nurses would remind residents to place their smoking items in their lock boxes on return from the smoking area. CNA #1 said all lock boxes should contain the residents' cigarettes and lighters. During an interview on 3/26/26 at 10:30 A.M., Nurse #1 said residents who smoke independently on the unit have a code to the door to access the smoking area independently. Nurse #1 said residents who smoke were supposed to put their cigarettes and smoking supplies back in their lock boxes when they return from the smoking area. Nurse #1 said the facility had too many independent smokers who can go out several times a day. Nurse #1 said it was hard to keep track of who was coming in or going out to the smoking area. Nurse #1 said she was not responsible for reminding the residents to put their smoking items in their lock boxes. Nurse #1 said UM #1 would remind the residents to put their smoking items in their lock boxes if she was in the area. On 3/27/26 at 7:45 A.M., the surveyor observed Resident #77's smoking lock box on the unit which contained no smoking supplies or cigarette packages. On 3/27/26 at 8:07 A.M., the surveyor observed Resident #77 outside in the smoking area independently smoking. Resident #77's lock box on the unit for smoking supplies was empty. During an interview on 3/27/26 at 10:06 A.M., the Director of Nurses (DON) said residents who smoke sign a smoking policy. Review of Resident #77's medical record did not include a signed smoking policy. The DON said it should have been obtained the day of admission by the admitting nurse. The DON said residents who independently smoke were given a key to a lock box in which they should house their smoking supplies when not out in the designated smoking area. The DON said staff are responsible for ensuring residents use their lock boxes after smoking. During an interview on 3/27/26 at 11:05 A.M., the Administrator said she was aware that not all independent residents who smoke were using their lock boxes. The Administrator said she and the Activity Director held a meeting in January with the residents who smoke. The Administrator said the smoking policy was reviewed and the residents acknowledged they understood the process. The Administrator said the expectation was for any staff member to monitor and/or cue residents to return their smoking supplies to their lock boxes upon returning from the smoking area.

Based on observation, interview, and document review, the facility failed to ensure medications with a shortened expiration date upon opening were properly labeled once opened, in one medication storage room out of two medication storage rooms observed. Findings include:Review of the facility's policy titled Storage of Medications, dated as revised 8/2020, indicated but was not limited to the following: -Medications and biologicals are stored safely, securely, and properly, following manufacturers' recommendations or those of the supplier. -Certain medications or package types, such as multidose injectable vials require an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency. -When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. -The nurse shall place a date opened sticker on the medication and record the date opened and the new date of expiration. On 3/26/26 at 10:30 A.M., the surveyor observed the medication storage room with Nurse #4 on Santuit Unit and made the following observations: Three bottles of Tuberculin (used in skin tests to detect infection with Mycobacterium Tuberculosis - a contagious disease that affects the lungs) multi dose vials, opened and in use with no opened date. During an interview on 3/26/26 at 3:38 P.M., Nurse #4 said the bottles were open and in use and she did not know when they were opened. She said they should have been labeled with an opened date. During an interview on 3/30/26 at 4:14 P.M., the Director of Nursing (DON) said multi-dose vials have a shortened expiration date and should be labeled with the open and discard date upon opening to ensure they are not used after expiration.

Based on observations, record review, and interviews, the facility failed to implement recommendations from the Occupational Therapy assessments for contracture management for one Resident (#32), out of a total sample of 19 residents. Findings include:Resident #32 was admitted to the facility in October 2024 with diagnoses which included: traumatic brain injury, swan neck deformity of right fingers (a condition where the middle joint of the finger bends backward and the fingertip joint bends down, creating a swan-like shape) and right ring finger trigger finger (a condition where a finger or thumb catches, clicks, or locks in a bent position). Review of the Minimum Data Set (MDS) assessment, dated 1/1/26, indicated Resident #32 scored 7 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she had severe cognitive impairment. Review of the consultation, to the hand specialist, dated February 2026, indicated but not limited to:-right middle and right ring finger triggering-right fingers swan neck deformity-performed steroid shot in right ring finger-OT referral for eval for figure eight splint right ring and middle finger Review of the Occupational Therapy Evaluation, dated 3/3/26, indicated Resident #32 was referred to therapy for evaluation due to new onset of pain, decrease in range of motion (ROM) and decrease in strength. Patient required skilled occupational services to fabricate, establish a splint wearing schedule, for a figure eight to right middle finger and right ring finger, and train caregivers on donning/doffing (putting on/taking off) splint to reduce pain and increase ROM of the right hand. Review of the Occupational Therapy Discharge summary, dated [DATE], indicated the following:-Patient currently fitted for a figure eight splint to right ring finger and middle finger, tolerating well, nursing staff trained with orthotic wear schedule. Review of the Orthotic wearing schedule, dated 3/17/26 indicated the following:-Application instructions, slip onto finger with openings on top of hand (see attached pictures)-Wearing schedule, on: morning before breakfast and off: night before bed-Store orthotic between uses in plastic bag, labeled Review of the Physician's Order Summary report March 2026 indicated there were no orders for Resident #32 to don/doff figure eight splint to right ring finger and middle finger to reduce pain and increase ROM of the right hand. On 3/26/26 at 7:40 A.M., the surveyor observed Resident #32 sitting in the dayroom. Resident #32 was not wearing his/her figure eight splint to right ring finger and middle finger. During an interview on 3/26/26 at 2:07 P.M., Certified Nursing Assistant (CNA) #1 said she regularly cares for Resident #32. She said she was with Rehab when they demonstrated how to put on the figure eight splint to right ring finger and middle finger. CNA #1 said she was not aware staff were to apply the splint. During an interview on 3/26/26 at 2:10 P.M., Nurse #1 said if a resident is seen by rehab and they recommend any splints, they tell us, and we get the physician's orders for treatment. She said Resident #32 does not have any orders for a figure eight splint to right ring finger and middle finger. She said if there is no order then the nurses would not know to put the figure eight splint to right ring finger and middle finger on the resident. On 3/27/26 at 7:53 A.M., the surveyor observed Resident #32 sitting in the dayroom. Resident #32 was not wearing his/her figure eight splint to right ring finger and middle finger. During an interview on 3/27/26 at 9:15 A.M., the Director of Rehab said Occupational Therapist (OT) #2 was unavailable for interview as she was out of the country. She reviewed the Occupational Therapy Discharge summary, dated [DATE], and said there should have been follow-up with the nurses on the use of the figure eight splint to right ring finger and middle finger. The Rehab manager said nursing staff would have been educated by the rehab staff to don/doff any splinting devices. Nursing staff would sign off on the Orthotic Wearing Schedule. The schedule would be given to the primary nurse to obtain a physician's order for donning/doffing. The Rehab manager said that education for Resident #32's splint would be placed in the education book on the floor for staff to review. The Rehab manager said there was no follow up on education or an order obtained. During an interview on 3/27/26 at 12:06 P.M., Nurse #2 said she was educated and took the information from OT #2. Nurse #2 said she would have gotten a physician's order for the splint. Nurse #2 reviewed the medical record and did not see an order for the figure eight splint to right ring finger and middle finger. Nurse #2 said she did not know why she did not follow through with contacting the physician. During an interview on 3/27/26 at 12:12 P.M., Unit Manager (UM) #1 said she was unaware that Resident #32 was discharged from Occupational Therapy and needed an order for splinting of his/her right ring finger and middle finger. UM #1 said the nurse receiving the Orthotic Wearing Schedule should have obtained a physician's order so nursing would know when to don/doff the splint. During an interview with the Director of Nurses (DON) on 3/27/26 at 1:36 P.M., the DON said once Rehab makes a recommendation and it is communicated to the nurses, the nurses should follow-up with obtaining physician's orders if that is what they want. The DON said the order should have been obtained by the nurse receiving the education. As of the end of the survey, the OT who performed the most recent OT evaluation was not available to the surveyor for interview.

Based on observation, interview, and record review, the facility failed to develop, implement and individualize a comprehensive care plan for one Resident (#4), out of a total sample of 19 residents. Specifically, the facility failed to ensure a comprehensive care plan related to Resident #4's use of hearing aids to support a communication deficit was developed and implemented. Findings include:Review of the facility's policy titled Comprehensive Care Plans, dated November 2019 and revised May 2025, indicated but was not limited to the following:-It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.-The comprehensive care plan will describe, at a minimum, the following:-The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. -The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment.Resident #4 was admitted to the facility in February 2026 with diagnoses including unspecified sensorineural hearing loss (hair cells in the cochlea or auditory nerves are damaged causing hearing loss).Review of Resident #4's Minimum Data Set (MDS) assessment, dated 3/2/26, indicated he/she was cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 5 out of 15. Furthermore, the MDS assessment indicated Resident #4 was highly impaired for hearing and utilized hearing aid(s) and was dependent on staff's assistance for daily living needs.During an interview on 3/25/26 at 9:15 A.M., the surveyor observed Resident #4 lying in bed yelling for his/her hearing aids. The surveyor observed the hearing aids on a charging device located on a bedside table out of the Resident's line of sight. Resident #4 indicated he/she needed to have the hearing aids while awake to communicate with others.Review of Resident #4's medical record indicated but was not limited to the following:-2/26/26: History and Physical progress note indicated Resident was hard of hearing; orientation was difficult to assess due to hearing impairment.-2/27/26: Nurse progress note indicated Resident was hard of hearing and had bilateral hearing aids.-2/28/26: Nurse progress note indicated Resident had bilateral hearing aids at bedside.-3/3/26: Physician progress note indicated Resident is difficult to truly assess due to hearing loss.Review of Resident #4's Physician orders failed to indicate orders for Resident #4's hearing aid devices.Review of Resident #4's comprehensive care plans failed to indicate a communication care plan was developed or implemented to include hearing aids device needs.During an interview on 03/31/26 at 10:08 A.M., Nurse #4 said she was the admitting nurse for Resident #4 and was aware of the Resident being hard of hearing and wearing hearing aids. Nurse #4 reviewed Resident #4's medical record and said the Resident does not have a care plan in place for his/her communication impairment and use of hearing aids. Nurse #4 said she should have put a care plan in place for Resident #4 and did not do it. Nurse #4 said all nurses are responsible for updating a care plan however, the leadership team which includes the unit managers, Assistant Director of Nursing (ADON), Director of Nursing (DON), and the MDS nurse are the ones that usually put in the care plans. Nurse #4 said as the admitting nurse she should have taken care of it and it was an oversight.During an interview on 3/31/26 at 10:20 A.M., Unit Manager (UM) #2 said she usually creates the care plan as well as the ADON, DON, and MDS nurse as needed. UM #2 said the Resident did not have a care plan in place for his/her hearing impairment and use of hearing aids. UM #2 said Resident #4 should have had them in place and somehow it was an oversight and not done. During an interview on 3/31/26 at 10:45 A.M., the DON said Resident #4 should have had a communication care plan in place for his/her hearing deficit to include hearing aids and did not.

Based on observation, interview, and document review, the facility failed to coordinate an assessment with the Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) program for one Resident (#3), out of a total sample of 19 residents. Specifically, the facility failed to initiate a new PASRR Level II Assessment following the addition of a schizoaffective disorder diagnosis to the clinical record. Findings include:Review of the MassHealth Nursing Facility Bulletin 186, dated June 2024, included but was not limited to the following:-Post admission Screening: For residents who experience a Significant Change or are newly identified as having a condition that may impact their PASRR status, the appropriateness of their nursing facility placement, or their need for Specialized Services.Review of the facility's policy titled Resident Assessment-Coordination with PASARR Program, dated as revised December 2025, indicated but was not limited to the following: -The Social Services Director shall be responsible for keeping track of each resident PASARR screening status and referring to the appropriate authority.-Any resident who exhibits a newly evident or serious mental disorder or related condition will be referred promptly to the state mental health authority for a level II resident review. Examples include: A resident whose related condition was not previously identified and evaluated through PASARR.Resident #3 was admitted to the facility in January 2026 with diagnoses which included history of falls, compression fractures, dementia, anxiety and depression.Review of the Minimum Data Set (MDS) assessment, dated 2/10/26, indicated Resident #3 scored 11 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was moderately cognitively impaired, and he/she did not have a diagnosis of schizophrenia. Review of the MDS assessment, dated 2/18/26, indicated Resident #3 had a diagnosis of schizophrenia.Review of the Diagnosis List in the electronic medical record indicated the diagnosis of schizoaffective disorder was added to Resident #3's profile on 2/13/26. During an interview on 3/30/26 at 3:43 P.M., Social Worker (SW) #1 stated she oversees the PASARR process. If a resident has a new diagnosis of schizoaffective disorder, she would alert the appropriate authority for a new PASARR II to be completed. Social Worker #1 said she was unaware of the new diagnosis and did not make the referral as she should have.During an interview on 3/30/26 at 4:14 P.M., the Director of Nursing (DON) said a level II PASARR screen should have been completed when Resident #3 acquired the new diagnosis, and it was not done.

Based on record review and interview, the facility failed to ensure two Residents (#7 and #12), out of a total sample of five residents reviewed for immunizations, were screened for eligibility to receive the recommended influenza vaccination, residents/residents' representatives were educated on the benefits and potential side effects of the vaccines, were offered and administered (if applicable) the seasonal vaccine in a timely manner, and appropriately documented in the Resident's medical record.Findings include:Review of the facility's policy titled Influenza Vaccine, dated 5/2023, indicated, but was not limited to, the following:-All residents who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza.-Beginning no later than October 1st and continuing through March 31st each year, the influenza vaccine shall be offered to residents, unless the vaccine is medically contraindicated or the resident has already been immunized.-Prior to the vaccination, the resident (or resident's legal representative) will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. Provision of such education shall be documented in the resident's medical record.-A resident's refusal of the vaccine shall be documented on the Informed consent for influenza vaccine and placed in the resident's medical record.1. Resident #7 was admitted to the facility in March 2021 with diagnoses including type two diabetes and hypertension.Review of Resident #7's medical record indicated a Guardian (someone appointed by the court responsible for making decisions for another person) had been appointed on 6/17/21.Review of Resident #7's Immunization Consent indicated that the Resident's Guardian had consented to annual influenza vaccine administration on 5/18/22.Review of Resident #7's medical record failed to indicate the Resident had received the 2025-2026 influenza vaccine after the Guardian had consented to the administration.During an interview on 3/20/26 at 2:32 P.M., the Infection Control Nurse (ICN) said she is responsible for all residents' immunization tracking. The ICN said Resident #7 did not receive the influenza vaccination and there was no documentation education was provided or that the Resident refused administration of the vaccine.2. Resident #12 was admitted to the facility in August 2025 with diagnoses including heart disease.Review of Resident #12's medical record failed to include documentation that indicated the Resident was provided education regarding the benefits and potential side effects of the influenza vaccination and either consented to receive or refused vaccination for the 2025-2026 influenza season.During an interview on 3/20/26 at 2:40 P.M., the ICN said Resident #12 did not receive the vaccination this season. The ICN said there was no documentation in the Resident's medical record indicating education was provided or that the Resident consented to or refused administration of the vaccine for the 2025-2026 season.During an interview on 3/31/26 at 8:42 A.M., the Director of Nursing (DON) said there should have been documentation for both Resident #7 and Resident #12 in their medical records indicating administration of the vaccine or refusal. The DON said there should be a consent and documented education for every resident.

Based on observation, interview, and record review, the facility failed to provide services that met professional standards of practice for two Residents (#6 and #3), out of a total sample of 19 residents. Specifically, the facility failed to:1. Ensure Resident #6 had an occlusive dressing at bedside as ordered by the physician; and2. Ensure Resident #3, who had a diagnosis of schizoaffective disorder added after admission, had supporting documentation in the medical record. 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. 1. Resident #6 was admitted to the facility in May 2025 with diagnoses including end stage renal disease and dependence on renal dialysis. Review of Resident #6's Minimum Data Set (MDS) assessment, dated 1/15/26, indicated he/she was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Furthermore, the MDS assessment indicated he/she was on dialysis. Review of Resident #6's Physician's Orders indicated but were not limited to: - 5/2/25: may go to Dialysis Center Monday, Wednesday, Friday; may be transported by ambulance service. - 5/14/25: maintain occlusive dressing supplies at bedside in the event the catheter dislodges; every shift. - 1/13/26: remove post dialysis dressing to fistula site every Tuesday, Thursday, Saturday. On the following dates and times, the surveyor failed to observe occlusive dressing supplies at Resident #6's bedside: - 3/25/26 at 10:21 A.M. and 11:45 A.M. - 3/26/26 at 9:30 A.M. Review of Resident #6's Treatment Administration Record for March 2026 indicated nursing staff ensured occlusive dressing supplies were at the bedside every shift from 3/1/26 to 3/26/26. During an interview on 3/25/26 at 11:45 A.M., Resident #6 said nursing staff do not keep any dressings at his/her bedside. During an interview on 3/26/26 at 12:28 P.M., Nurse #1 said Resident #6 had an arteriovenous (AV) fistula (surgically created connection between the artery and vein to provide the safest long-term access for hemodialysis). Nurse #1 said Resident #6 used to have dressings at his/her beside when he/she was on a different unit at the facility but did not currently have an occlusive dressing in their room. Nurse #1 said Resident #6 did have an order for an occlusive dressing at the bedside and it was checked off each shift by the nurse indicating it was in the room. During an interview on 3/26/26 at 12:28 P.M., Unit Manager #1 said the occlusive dressing for Resident #6 should have been discontinued because he/she had an AV fistula site for access. Unit Manager #1 said she would contact the physician to discharge the orders. During an interview on 3/26/26 at 2:29 P.M., Unit Manager #1 said she heard back from the physician, and they wanted to keep the occlusive dressing at the bedside. Unit Manager #1 said an occlusive dressing should have been at the bedside as ordered. During an interview on 3/26/26 at 2:55 P.M., the Director of Nursing (DON) said she would expect an occlusive dressing to be at Resident #6's bedside as ordered by the physician. 2. Review of the Diagnostic and Statistical Manual of Mental Disorders (DSM) IV, last revised March 2022, indicated but was not limited to the following: -Disorder class: Schizophrenia Spectrum and other psychotic disorders: Two or more of the following, each present for a significant portion of time during a 1-month period. -Delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior. Resident #3 was admitted to the facility in January 2026 with diagnoses which included history of falls, compression fractures, dementia, anxiety, and depression. Review of the MDS assessment, dated 2/10/26, indicated Resident #3 scored 11 out of 15 on the BIMS indicating he/she was moderately cognitively impaired, and he/she did not have a diagnosis of schizoaffective disorder. Review of the MDS assessment, dated 2/18/26, indicated Resident #3 had a diagnosis of schizophrenia. Review of the Diagnosis List in the electronic medical record indicated the diagnosis of Schizophrenia was added to Resident #3's profile on 2/13/26. Review of the medical record failed to indicate why the diagnosis was added to his/her profile less than one month after admission. Review of the medical record failed to indicate Resident #3 had this diagnosis on admission and failed to indicate supporting documentation of the diagnosis had been provided to the facility to facilitate adding the diagnosis to his/her profile. Review of the comprehensive care plan failed to indicate behavioral symptoms for the diagnosis of schizoaffective disorder. During an interview on 3/30/26 at 11:18 A.M., Unit Manager (UM) #1 said she added the diagnosis to Resident #3's medical record because she received a verbal order from the physician to do so. She said there is no documentation in the record supporting the diagnosis. Further review of the medical record failed to indicate any supporting documentation of the diagnosis from any historical medical provider. During an interview on 3/30/26 at 3:43 P.M., Social Worker (SW) #1 said she does not know where the diagnosis came from. During an interview on 3/30/26 at 4:14 P.M., the DON said a new diagnosis of schizoaffective disorder requires documentation in the medical record of specific behaviors. The DON said the medical record does not have the proper documentation for the diagnosis.

Based on record review and interview, the facility failed to ensure two Residents (#7 and #12), out of a total sample of five residents reviewed for immunizations, were screened for eligibility to receive the recommended COVID-19 vaccination, residents/residents' representatives were educated on the benefits and potential side effects of the vaccine, were offered and administered (if applicable) the vaccine in a timely manner, and appropriately documented in the Resident's medical record. Findings include: Review of the facility's policy titled COVID-19 Vaccine Policy-Massachusetts, dated September 2025, indicated, but was not limited to, the following:-Before offering the vaccine, all residents or their representatives will receive education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine being offered.-CDC defines Up to Date as received all doses of the current vaccine.-The resident's medical record will include documentation that indicates: -The date the resident or resident representative was provided education regarding benefits and potential risks associated with COVID-19 vaccination. -The resident accepted or refused the vaccination due to medical contraindications, prior vaccination, or refusal. If refused, document if it was related to a medical contraindication. -Each dose of COVID-19 administered to the resident will be recorded in the immunization record.1. Resident #7 was admitted to the facility in March 2021 with diagnoses including type two diabetes and hypertension.Review of Resident #7's medical record indicated a Guardian (someone appointed by the court responsible for making decisions for another person) had been appointed on 6/17/21.Review of Resident #7's medical record failed to include documentation that indicated the Resident's Guardian was provided education regarding the benefits and potential side effects of the COVID-19 vaccination and either consented to receive or refused vaccination.During an interview on 3/20/26 at 2:32 P.M., the Infection Control Nurse (ICN) said she is responsible for all residents' immunization tracking. The ICN said Resident #7 did not receive the vaccination and there was no documentation education was provided to the Resident's Guardian or that the Guardian consented or refused administration of the vaccine.2. Resident #12 was admitted to the facility in August 2025 with diagnoses including heart disease.Review of Resident #12's medical record failed to include documentation that indicated the Resident was provided education regarding the benefits and potential side effects of the COVID-19 vaccination and either consented to receive or refused vaccination for the 2025-2026 season.During an interview on 3/20/26 at 2:40 P.M., the ICN said Resident #12 did not receive the vaccination this season. The ICN said there was no documentation in the Resident's medical record indicating education was provided or that the Resident consented to or refused administration of the vaccine for the 2025-2026 season.During an interview on 3/31/26 at 8:42 A.M., the Director of Nursing (DON) said there should have been documentation for both Resident #7 and Resident #12 in their medical records indicating administration of the COVID-19 vaccine or refusal. The DON said there should be a consent and documented education for every resident.

Based on record review and interview, the facility failed to ensure a person-centered plan of care with individualized interventions for trauma-informed care was developed for one Resident (#5), out of a total sample of 19 residents. Specifically, the facility failed to assess and implement care plan interventions for Resident #5 with a history of post-traumatic stress disorder (PTSD) and a history of a traumatic event. Findings include:Review of the facility's policy titled Trauma Informed Care Policy, last reviewed 11/2024, indicated but was not limited to the following:- [Corporate Name] remains committed to providing the highest quality of care. This commitment includes recognizing events in our residents' past that may have been traumatic and that may continue to have a negative, upsetting or emotionally difficulty impact on their lives.- To that end, a screening process will allow each facility to determine whether a resident might need or wish more specialized counseling or care.- As part of the admission process a specific assessment will be done consisting of several questions that are worded to assess past experiences and not trigger the episode.- If a resident has a history of trauma that is documented or if they have triggered from the assessment, the SW (social worker) and IDT (interdisciplinary team) need to immediately formulate a plan of care to assist the resident in coping within the facility with whatever issue has been identified. - The plan of care needs to be specific and include anything that has been shared that can trigger a memory of the incident.- Staff education should be done to identify any resident reactions that may indicate past trauma and what to do with that information. Resident #5 was admitted to the facility in January 2026 with diagnoses including dementia and PTSD. Review of Resident #5's Minimum Data Set (MDS) assessment, dated 1/29/26, indicated he/she had a moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 8 out of 15. Review of Resident #5's Social Service admission and Cultural Assessment, dated 2/3/26, indicated he/she had a diagnosis of PTSD and was involved in a traumatic accident in his/her adult life. Review of Resident #5's comprehensive care plans failed to indicate he/she had a history of a traumatic life event and/or PTSD. During an interview on 2/25/26 at 4:22 P.M., Certified Nursing Assistant (CNA) #4 said she was not aware of any resident on the unit with a diagnosis of PTSD or any related triggers/restrictions in their care. CNA #4 said she did not know if Resident #5 had PTSD or if he/she required any specific care interventions. During an interview on 3/26/26 at 11:23 A.M., the Social Worker said an assessment is completed for residents on admission related to trauma informed care. The Social Worker said she uses the assessment to determine if a resident has a history of trauma or a PTSD diagnosis. The Social Worker said any information identified during the assessment is put into the care plan for all staff to be able to identify. The Social Worker said Resident #5 did not have a care plan specific to his/her diagnosis of PTSD and/or traumatic life event. During an interview on 3/26/26 at 11:31 A.M., the Director of Nursing (DON) said all residents are assessed by social services on admission for trauma. The DON said if they trigger for a traumatic experience or a diagnosis such as PTSD a care plan should be developed. The DON said Resident #5 should have had a care plan in place for their known diagnosis of PTSD and traumatic life event.

Based on observations and staff interviews, the facility failed to ensure a functional, safe, and clean environment. Specifically, the facility failed to ensure residents and/or staff properly disposed of cigarette butts in designated smoking receptacles.Findings include:Review of the Centers for Medicare & Medicaid Services (CMS) circular letter, dated November 10, 2011, titled Smoking Safety in Long Term Care Facilities indicated but was not limited to the following: -Metal containers with self-closing covers into which ashtrays can be emptied must be readily available.Review of the facility's policy titled Smoking Policy and Procedure, undated, indicated but was not limited to:-It is the policy of [Corporate Name] to provide a safe environment for residents, staff and visitors through the enforcement of a smoking policy designed to reduce risks to residents who smoke tobacco products, reduce the risks of passive smoking for others and reduce the risk of fire.-Employees and residents must dispose of tobacco products in appropriate tobacco receptacles. Residents that are observed leaving tobacco products on the ground or are observed tossing, flicking or throwing tobacco products will be reassessed to determine if they should be considered unsafe smokers.On 3/26/26 at 7:26 A.M., the surveyor observed the designated smoking area and identified two tall receptacles for cigarette butts with numerous cigarette butts scattered across the pavement. The surveyor also observed several cigarette butts scattered in the mulch adjacent to the facility. Three chairs were positioned along the outer perimeter of the smoking area, each with several cigarette butts accumulated underneath. On 3/27/26 at 8:07 A.M., the surveyor conducted a subsequent observation of the designated smoking area and identified the same conditions.During an interview on 3/26/26 at 10:10 A.M., Certified Nursing Assistant (CNA) #1 said the residents are independent smokers and no one is assigned to go outside with them. CNA #1 said sometimes the maintenance staff would clean up the area. CNA #1 said CNAs were not assigned to clean up the area. During an interview and observation of the designated smoking area on 3/27/26 at 8:20 A.M., the Maintenance Director said he tries to go out one to two times a week to clean up the area. The Maintenance Director said he had placed a broom and dustpan outside for the residents to sweep up the area after use. The Maintenance Director said he did not have a cleaning schedule, or anyone assigned to maintain the area. During an interview on 3/27/26 at 10:19 A.M., the Director of Nurses (DON) said the Maintenance Director was responsible for maintaining the smoking area. The DON said she was not sure of a cleaning schedule or why the area had not been maintained. During an interview on 3/27/26 at 11:05 A.M., the Administrator said Maintenance and Activities would usually maintain the area. The Administrator said she was not sure why the area had not been maintained.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed as being at risk for falls, had physical limitations in both upper and lower extremities due to contractures, and was dependent on staff for mobility including bed mobility, the Facility failed to ensure they developed an individualized comprehensive plan of care that included the number of staff members required during care, to appropriately meet his/her care needs. Findings include:Review of the Facility's Policy titled, Comprehensive, Person-Centered Care Plans, dated as revised May 2025, indicated the Facility will develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The Policy further indicated that the comprehensive care plan would include resident specific interventions that reflect the resident's strengths and needs as identified in the resident's comprehensive assessment.Resident #1 was admitted to the Facility in October 2023, diagnoses included Cerebral Palsy, contractures of the right and left hand, and the right and left knee, kyphosis, convulsions, periprosthetic fracture of the right knee, atrial fibrillation, osteoarthritis, congestive heart failure and hearing loss.Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 03/27/25, indicated that Resident #1 had impairments of both upper extremities and lower extremities, and was dependent on staff for activities of daily living, including bed mobility and turning and repositioning.Review of Resident #1's Fall Risk Evaluation, dated 03/21/2025, indicated Resident #1 was at risk for falls.Review of Resident #1's Certified Nurse Aide Activities of Daily Living Flowsheet for May 2025 indicated he/she was dependent on staff for personal hygiene and toilet hygiene. The Flowsheet indicated staff provided varying levels of staff assistance (one or two) with rolling left and right (positioning and bed mobility).Review of Resident #1's Activities of Living (ADL) Care Plan, reviewed and revised with the Quarterly MDS, dated [DATE], indicated he/she required extensive to total dependence with activities of daily living and was dependent on staff with bed mobility, personal hygiene and toileting/incontinence care.However, although Resident #1's ADL Care Plan indicated that he/she was totally dependent on staff with ADL's, there was no documentation to support the level of staff assistance (number of staff required) related to bed mobility, personal hygiene and toileting/incontinence care.Review of the Report submitted by the Facility via Health Care Reporting System (HCFRS), dated 05/24/25, indicated that during morning care on 05/22/25, Certified Nurse Aide (CNA) #1 rolled Resident #1 onto his/her left side when he/she raised his/her right leg which crossed over the left leg and caused his/her legs to slide off the bed. The Report indicated that CNA #1 was unable to reposition Resident #1 back into the bed, held onto his/her upper body and lowered him/her to the floor. The Report indicated that CNA #1 notified Nurse #1 and Resident #1 was transferred back to bed using a mechanical lift. The Report indicated that Resident #1 was transferred to the hospital on [DATE] and on 05/24/25, the Facility was notified that a CT scan of the pelvis revealed an acute comminuted fracture of the right femur (hip fracture resulting from trauma). During a telephone interview on 7/16/25 at 6:30 A.M., CNA #1 said that Resident #1's care plan just states that Resident #1 is dependent with bed mobility and personal hygiene but does not indicate the number of staff required to provide assistance, so she believed he/she was a one person assist with care. CNA #1 said that Resident #1 was a one person assist with care most of the time. CNA #1 said that Resident #1 usually holds onto the side rail when she turns him/her in bed. CNA #1 said that if she needed the assistance of another staff member, she would ask another CNA to help her. During an interview on 7/15/25 at 11:50 A.M., CNA #2 said that Resident #1 was very heavy and required the assistance of two staff with all care, including turning, repositioning, and bed mobility. CNA #2 said that she reviews the resident care plans daily and said she could not recall exactly what Resident #1's care plan stated but said she knows he/she required the assistance of two staff members with all care.During an interview on 7/15/25 at 12:11 P.M., CNA #4 said that Resident #1 was very heavy and required the assistance of two staff with all care, including turning, repositioning, and bed mobility. CNA #2 said that she reviews the resident care plans daily and said she believes the care plan stated that he/she required the assistance of two staff members with all care.During a telephone interview on 7/16/25 at 6:51 A.M., CNA #3 said that Resident #1 usually requires the assistance of one staff because he/she can assist with turning in bed. CNA #3 said that sometimes he/she needs assistance from another staff member and will get someone else to help her with bed mobility and personal care. Review of the CNA Job Description indicated there was no documentation to support that a CNA can make the determination as to what level of staff assistance a resident requires with ADL's.During a telephone interview on 7/16/25 at 9:21 A.M., Nurse #2 said that she could not recall the level of staff assistance Resident #1 required with bed mobility and personal hygiene. Nurse #2 said that the Resident specific ADL Care Plan's indicate the level of assistance the resident requires with ADL's. Nurse #2 said that Resident #1 now requires the assistance of two staff members with all care since the fall.During an interview on 7/15/25 at 2:50 P.M., the Director of Nurses (DON) said Resident #1 required the assistance of one staff member with care and bed mobility at the time of the incident. The DON said that if the Care Plan does not indicate that the resident requires two assists, then it means that the resident requires one assist. The DON said that if a staff member needed the assistance of another staff member with care, they could always ask for assistance from another CNA.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who on 5/22/25 sustained a fall, the Facility failed to ensure care and treatment provided by nursing met professional standards of practice. When after Nurse #1 was notified by Certified Nurse Aide (CNA) #1 that Resident #1 slid out of bed and was on the floor in his/her room, Nurse #1 instructed the CNA's to put Resident #1 back to bed. There was no supporting documentation including assessments or nurse progress notes in Resident #1's medical record related to the fall, no incident report, and the oncoming shift nurse and the Physician were also not notified of the fall. The next day, Resident #1 was noted with swelling to his/her right hip/thigh area and was transferred to the Hospital Emergency Department (ED) for evaluation and was diagnosed with a right hip and femur (thigh bone) fractures and was admitted . Findings Include:Pursuant to Massachusetts General Law (M.I.T.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CRM) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Review of the Facility's Policy titled, Fall Prevention Program, dated as revised May 2025, indicated that a fall is an event in which an individual unintentionally comes to rest on the floor. The Policy indicated that when a resident experiences a fall, the facility will:-assess the resident;-complete a post-fall assessment;-complete an incident report;-notify the physician and family;-review the resident's care plan and update as indicated;-document all assessments and actions;-obtain witness statements in the case of injury.Review of the Facility's Policy titled, Incidents and Accidents, dated as revised May 2025, indicated the following:-it is the policy of the facility for staff to report, investigate and review any accidents or incidents that occur on facility property;-licensed staff will report incident/accidents;-a fall is an accident that requires an incident/accident report;-any injuries will be assessed by the licensed nurse;-the supervisor or designee will be notified of the incident/accident;-the nurse will contact the resident's practitioner to inform them of the incident/accident, report any injuries or other findings and obtain orders, if indicated;-the nurse will enter the incident/accident information into the appropriate form and will document all pertinent information;-documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications and orders obtained or follow-up interventions.Resident #1 was admitted to the Facility in October 2023, diagnoses included Cerebral Palsy, contractures of the right and left hand, and the right and left knee, kyphosis, convulsions, periprosthetic fracture of the right knee, atrial fibrillation, osteoarthritis, congestive heart failure and hearing loss.Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 03/27/25, indicated that Resident #1 had impairments of both upper extremities and lower extremities, and was dependent on staff for activities of daily living.Review of Resident #1's Fall Risk Evaluation, dated 03/21/2025, indicated Resident #1 was at risk for falls.Review of the Report submitted by the Facility via Health Care Reporting System (HCFRS), dated 05/24/25, indicated that during morning care on 05/22/25, Certified Nurse Aide (CNA) #1 rolled Resident #1 onto his/her left side when he/she raised his/her right leg which crossed over the left leg and caused his/her legs to slide off the bed. The Report indicated that CNA #1 was unable to reposition Resident #1 back into the bed, held onto his/her upper body and lowered him/her to the floor. The Report indicated that CNA #1 notified Nurse #1 and Resident #1 was transferred back to bed using a mechanical lift. The Report indicated that Resident #1 was transferred to the hospital on [DATE] and on 05/24/25, the Facility was notified that a CT scan of the pelvis revealed an acute comminuted fracture of the right femur (thigh bone) (hip fracture resulting from trauma). The Report indicated that during change of shift report, Nurse #1 reported to Nurse #2 that Resident #1 needed a wider bed because his/her leg was hanging over the edge of bed during care. The Report indicated that Nurse #1 did not report to Nurse #2 that Resident #1 had a fall. The Report indicated that (on 5/23/25) a CNA reported to Nurse #2 that Resident #1's right upper leg was swollen, and Nurse #2 did not notice any difference in the size of his/her upper legs and there were no signs of redness or bruising. The Report further indicated that Nurse #2 noted that Resident #1's respiratory rate was elevated and that Resident #1 was transferred to the hospital ED on 05/23/25 and on 05/24/25, the Facility was notified that a CT scan of the pelvis revealed an acute comminuted fracture of the right femur (thigh bone) (hip fracture resulting from trauma). Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated that Resident #1 presented to the ED from the nursing home with right leg swelling and a CT of the pelvis was ordered. The Summary indicated that the CT of the pelvis revealed an acute comminuted intertrochanteric fracture of the right femur, an avulsion fracture of the iliopsoas muscle from the right femur, bony demineralization and a dislocation of right knee arthroplasty. The Summary indicated that Resident #1 was admitted to the hospital.During a telephone interview on 07/16/25 at 6:30 A.M., Certified Nurse Aide (CNA) #1 (which also included review of her written witness statement dated 05/30/25) said that on 05/22/25 at approximately 6:30 A.M., she was providing care to Resident #1 in bed, without the assistance of another staff member, rolled him/her onto his/her left side, and his/her right leg crossed over the left leg causing him/her to slide off the bed. CNA #1 said that she held onto Resident #1's upper body and lowered him/her to the floor. CNA #1 said that she notified the nurse (exact name unknown) of the fall.During a telephone interview on 7/16/25 at 9:29 A.M., Nurse #1 said that she worked the 11:00 P.M. to 7:00 A.M (on 5/21/25 into 5/22/25) shift. Nurse #1 said that on 5/22/25 at approximately 6:30 A.M., CNA #1 notified her that Resident #1 had slid out of bed. Nurse #1 said that when she entered Resident #1's room, he/she was lying on the floor on his/her back. Nurse #1 said that Resident #1 denied being in pain and she told the CNA's to transfer him/her into bed. Nurse #1 said that she reported the fall to the day shift nurse. Nurse #1 said she could not recall if she documented the fall in the nurse's note or if she completed an incident report but said she should have. Nurse #1 said that she did not notify the physician of the fall.Review of Resident #1's medical record indicated that there was no documentation to support that Nurse #1 assessed Resident #1 for potential injuries, that she completed an incident report, or that she notified the Physician of a fall.During a telephone interview on 7/16/25 at 9:21 A.M., Nurse #2 said that on 5/22/25 she worked the 7:00 A.M. to 3:00 P.M. shift and received change of shift report from Nurse #1. Nurse #2 said that Nurse #1 told her that Resident #1 needed a bigger bed because he/she was leaning on the side of the bed when the CNA turned and rolled him/her during care. Nurse #2 said that Nurse #1 never reported that Resident #1 had fallen out of bed. During an interview on 7/15/23 at 2:50 P.M., the Director of Nurses (DON) said she expected that all Nurses would assess a resident after a fall, document the assessment in the nurse's notes, complete an incident report, report the fall to the oncoming shift, notify the Physician and family of any falls or incidents and follow the Facility Policy. The DON said that Nurse #1 did not follow the Facility's policy.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who on 05/22/25, slid off the bed onto the floor during care, the Facility failed to ensure that nursing immediately notified the Physician that he/she had experienced a fall.Findings include:Review of the Facility Policy titled, Notification of Changes, dated as revised May 2025, indicated that the Facility promptly consults the resident's physician when there is a change requiring notification including accidents resulting in injury and potential to require physician intervention.Review of the Facility Policy titled, Fall Prevention Program, dated as revised May 2025, indicated that a fall is an event in which an individual unintentionally comes to rest on the floor. The Policy indicated that when a resident experiences a fall the physician is to be notified.Resident #1 was admitted to the Facility in October 2023, diagnoses included Cerebral Palsy, contractures of the right and left hand, and the right and left knee, kyphosis, convulsions, periprosthetic fracture of the right knee, atrial fibrillation, osteoarthritis, congestive heart failure and hearing loss.Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 03/27/25, indicated that Resident #1 had impairments of both upper extremities and lower extremities, and was dependent on staff for activities of daily living.Review of Resident #1's Fall Risk Evaluation, dated 03/21/2025, indicated Resident #1 was at risk for falls.Review of the Report submitted by the Facility via Health Care Reporting System (HCFRS), dated 05/24/25, indicated that Resident #1 was transferred to the hospital on [DATE] and on 05/24/25, the Facility was notified that a CT scan of the pelvis revealed an acute comminuted fracture of the right femur (thigh bone) (hip fracture resulting from trauma). The Report indicated that during morning care on 05/22/25, Certified Nurse Aide (CNA) #1 rolled Resident #1 onto his/her left side when he/she raised his/her right leg, which crossed over the left leg, and caused his/her legs to slide off the bed. The Report indicated that CNA #1 was unable to reposition Resident #1 back into the bed, held onto his/her upper body and lowered him/her to the floor. The Report indicated that CNA #1 notified Nurse #1 and Resident #1 was transferred back to bed using a mechanical lift.During a telephone interview on 07/16/25 at 6:30 A.M., Certified Nurse Aide (CNA) #1 (which also included review of her written witness statement dated 05/30/25) said that on 05/22/25 at approximately 6:30 A.M., she was providing care to Resident #1 in bed without the assistance of another staff member, rolled him/her onto his/her left side, and his/her right leg crossed over the left leg causing him/her to slide off the bed. CNA #1 said that she held onto Resident #1's upper body and lowered him/her to the floor. CNA #1 said that she notified the nurse (exact name unknown) of the fall.During a telephone interview on 7/16/25 at 9:29 A.M., Nurse #1 said that she worked the 11:00 P.M. to 7:00 A.M (from 5/21/25 into 5/22/25) shift. Nurse #1 said that on 5/22/25 at approximately 6:30 A.M., CNA #1 notified her that Resident #1 had slid out of bed. Nurse #1 said that when she entered Resident #1's room, he/she was lying on the floor on his/her back. Nurse #1 said that Resident #1 denied being in pain and she told the CNA's to transfer him/her into bed. Nurse #1 said that she did not notify the physician of the fall.During a telephone interview on 7/16/25 at 9:21 A.M., Nurse #2 said that on 5/22/25 she worked the 7:00 A.M. to 3:00 P.M. shift and received change of shift report from Nurse #1. Nurse #2 said that Nurse #1 never reported to her that Resident #1 had fallen out of bed. Nurse #2 said that she did not notify the physician that Resident #1 had a fall because she was not aware that he/she had a fall.Review of Resident #1's medical record indicated that there was no documentation to support that Nurse #1 completed an incident report, or that she notified the Physician of a fall.During an interview on 7/15/23 at 2:50 P.M., the Director of Nurses (DON) said she expected that all Nurses would notify the Physician of any falls or incidents and follow the Facility Policy.

Based on record review and interview, the facility failed to utilize the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, with no nurse staffing waivers in place as required, placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurse Aides (CNA) that the RN was responsible for overseeing with the provision of resident care. Specifically, the facility failed to provide RN services on 1/11/25 and 1/12/25. Findings include: Review of the facility's policy titled Staffing, undated, indicated but was not limited to the following: -Facility maintains adequate staffing on each shift to ensure that our residents' needs and services are met based on Facility Assessment. Licensed nursing staff are available to provide and monitor the delivery of care services. Review of the as worked nursing schedules for 1/6/25 through 2/6/25 indicated but was not limited to the following: -Saturday, 1/11/25, there was no RN coverage for the 24-hour period. -Sunday, 1/12/25, there was no RN coverage for the 24-hour period. During Entrance Conference on 2/4/25 at 9:02 A.M., the Administrator said the facility did not have any nurse staffing waivers. During an interview on 2/6/25 at 2:00 P.M., the Administrator said there should be RN coverage for at least 8 hours every day. During an interview on 2/7/25 at 11:33 A.M., the Scheduling Coordinator said there should be an RN working every day and on 1/11/25 and 1/12/25 the RN called in and we must not have been able to get another one, because we did not have RN coverage on either of those days. During an interview on 2/7/25 at 4:50 P.M., the Director of Nurses said there should be RN coverage for at least 8 hours every day and she was not aware on 1/11/25 or 11/12/25 the facility did not have RN coverage.

Based on record review and interview, the facility failed to ensure sufficient staffing to assure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed to have sufficient staffing on the weekends as indicated on the payroll-based journal (PBJ) report submitted to Centers for Medicare and Medicaid Services (CMS) for Fiscal Year (FY) Quarter 4, 2024. Findings include: Review of the PBJ Staffing Data Report, CASPER Report 1705D FY Quarter 4, 2024 (July 1 - September 30) indicated the following: This Staffing Data Report identifies areas of concern that will be triggered (e.g., requires follow-up during the survey). -Excessively Low Weekend Staffing - Triggered = Submitted Weekend Staffing data is excessively low. Review of the facility's healthcare Facility Assessment (FA), revised 1/7/2025, indicated the following: Part 1: Resident Profile -Number of residents you are licensed to provide care for - 98 -Average daily census: 88-92 Staffing Plan 3.2 Total Number Needed or Average or Range of Staff: - Licensed nurses (LN) providing direct care: 1:x LN ratio Days and Evenings. - Direct Care Staff (Nurse Aides): 1:x ratio The facility failed to indicate updated staffing patterns on the FA. Review of the facility's previous healthcare FA, revised 10/6/2023, last reviewed 10/29/2024, indicated the following: Part 1: Resident Profile -Number of residents you are licensed to provide care for - 99 -Average daily census (ADC): 85-92 -Current ADC: 72 Staffing Plan 3.2 Total Number Needed or Average or Range of Staff: - Licensed nurses (LN) providing direct care: RN or Unit Manager 1 for each unit (2 units Monday-Friday) Staff Nurse: 2 for each unit per shift; 1 on 11pm -7am. - Direct Care Staff (Nurse Aides-CNA): Nights 2 per unit. Review of the as worked staffing schedules and time sheets provided by the Scheduling Coordinator for licensed nurses and nurse aides during FY Quarter 4, 2024, indicated the total number of LN and nurse aides was below the needed or average range, per the FA, for the following dates: 7/6/24 -Total Census 74 -7pm-11pm one nurse on Popponessett Unit (one less than the minimum required) 7/13/24 Total Census 74 -7pm-11pm one nurse on Popponessett Unit (one less than the minimum required) 7/14/24 Total Census 74 -11pm-7am three total CNAs (one less than the minimum required) 7/20/24 Total Census 78 -7pm-11pm one nurse on Popponessett Unit (one less than the minimum required) 7/21/24 Total Census 79 -7pm-11pm one nurse on Popponessett Unit (one less than the minimum required) 7/27/24 Total Census 78 -7pm-11pm one nurse on Popponessett Unit (one less than the minimum required) -11pm-7am three total CNAs (one less than the minimum required) 7/28/24 Total Census 80 -7pm-11pm one nurse on Popponessett Unit (one less than the minimum required) 8/2/24 Total Census 76 -11pm-7am two total CNAs (two less than the minimum required) 8/10/24 Total Census 75 -11pm-7am two total CNAs (two less than the minimum required) -7pm-11pm one nurse on Popponessett Unit (one less than the minimum required) 8/11/24 Total Census 74 -7pm-11pm one nurse on Popponessett Unit (one less than the minimum required) 8/17/24 Total Census 83 -7pm-11pm one nurse on Popponessett Unit (one less than the minimum required) 8/18/24 Total Census 81 -11pm-7am three total CNAs (one less than the minimum required) 8/24/24 Total Census 87 -11pm-7am one CNA with one trainee (three less than the minimum required) 8/25/24 Total Census 87 -7pm-11pm one nurse on Popponessett Unit (one less than the minimum required) 8/28/24 Total Census 89 -11pm-7am three total CNAs (one less than the minimum required) 8/31/24 Total Census 89 -11pm-7am two total CNAs (two less than the minimum required) -7pm-11pm one nurse on Popponessett Unit (one less than the minimum required) 9/1/24 Total Census 90 -7pm-11pm one nurse on Popponessett Unit (one less than the minimum required) 9/7/24 Total Census 84 -7pm-11pm one nurse on Popponessett Unit (one less than the minimum required) 9/22/24 Total Census 83 -7pm-11pm one nurse on Popponessett Unit (one less than the minimum required) 9/28/24 Total Census 83 -7pm-11pm one nurse on Popponessett Unit (one less than the minimum required) 9/30/24 Total Census 83 -11pm-7am three total CNAs (one less than the minimum required) During an interview on 2/6/25 at 2:00 P.M., the Director of Nurse (DON) said with a Census of 70-80 our staffing pattern on the 3pm-11pm shift would be 2 nurses on each unit and on 11pm-7am shift the staffing pattern would be 2 CNAs on each unit. During an interview on 2/7/25 at 11:33 A.M., the Staffing Coordinator said on a typical day we staff 2 nurses on each unit on the 3pm-11pm shift and 2 CNAs on each unit on the 11pm-7am shift. She said if the census is lower than 70 then they will adjust. She said if there is a call out that can't be covered someone will stay late and/or come in early to cover the shift. She said occasionally there are only 3 CNAs on at night due to call ins and one will float to the other unit to help. She said it's not ideal, but it happens sometimes. She said there should never be one CNA on each unit and did not know how that happened. She said there were a lot of call ins during this time frame which made the schedule difficult to manage. Additionally, she said there is still a hole in the nursing schedule and the 7pm-11pm shift is hard to cover. She said it never used to be like that, but it has been for a while. She said she has been able to cover it more often than during the time frame reviewed. She said sometimes someone will stay until 9:30/10:00pm and leave when it's quiet, but not always, and not on these days, it appears both nurses left between 7pm and 7:30pm on these days. She said the weekend nurse working 7pm-7am was alone after 7pm. She said she tries to schedule a desk nurse to cover it, but she cannot always do that or sometimes the on-call nurse will come in, but during this time frame the previous DON would not even answer the phone. During an interview on 2/7/25 at 4:40 P.M., the Administrator said she was unsure why the staffing pattern did not carry over to the updated FA. She said the staffing pattern is the same as previously noted, 2 staff nurses on each unit for 3pm-11pm shift and there should be 2 CNAs on each unit on the 11pm-7am shift for the census that we have, if the census drops then we would adjust staffing accordingly. She said occasionally due to call out there may only be 3 CNAs in the building on 11pm-7am shift and they would have to help each other, but there should never just be one on each unit. During an interview on 2/7/25 at 4:50 P.M., the DON said if there is a hole in the schedule due to call ins generally, they would piece it together by having one nurse stay late and one come in early. She was unable to speak to FY Quarter 4 as she was not employed by the facility at that time. Additionally, she said there should never be just one CNA on each unit, someone should have been mandated to stay.

Based on a resident group meeting, staff interviews, and document review, the facility failed to ensure grievances and concerns from the Resident Council were documented to ensure they were acted upon timely and included the facility response and rationale for response and to ensure residents were able to hold meetings without staff present unless they desired to invite staff. Findings include: Review of the facility's policy titled Resident Council Meetings, dated as last reviewed/revised [DATE], indicated but was not limited to the following: -The Activity Director shall be designated, if approved by the group, to serve as a liaison between the group and the facility's administration and any other staff members. -The designated liaison shall be responsible for providing assistance with facilitating successful group meetings and responding to written requests from the group. -The facility shall act upon concerns and recommendations of the Council, make attempts to accommodate recommendations to the extent practicable, and communicate its decisions to the Council. Review of the facility's Complaint/Grievance Policy and Procedure, dated [DATE], indicated but was not limited to the following: -All residents and their responsible party will have a mechanism to voice grievances and complaints to the Grievance Official in order to facilitate communication and timely resolution of the matter. -Voiced grievances (e.g. those about treatment, care, management of funds, lost clothing, or violation of rights) are not limited to a formal, written process and may include a resident's verbalized complaint to facility staff. -Staff shall complete a grievance form when resident makes a verbal complaint, if not completed by the complainant. Review of the Resident Council Minutes from [DATE] through [DATE] indicated but were not limited to the following: [DATE] -Meeting was facilitated and moderated by the Ombudsman. No staff members were present. No meeting minutes/notes were compiled. [DATE] -Attendance: Eight Residents, the Activities Director, and six additional staff members. -Review of Old Business: TOPIC: Lack of Communication between Residents and Certified Nursing Assistants (CNAs). STATUS: This is still an issue, there will be education taught on it. -Open Discussion: Laundry isn't coming back. -Concern: Lack of Communication. How will Manager address this: in-service and education with CNA staff. -Concern: Laundry has gone missing. How will Manager address this: We are working on a better solution for labeling and delivering personal (items) and asking family members to bring the personal (items) to us to be labeled before going to the rooms. Further review of the [DATE] Resident Council Minutes failed to indicate that the facility filed grievances for the missing laundry items on behalf of the residents. [DATE] -Attendance: 13 Residents, the Activities Director, and two additional staff members. -Review of Old Business: TOPIC: Some Resident's laundry has gone missing. STATUS: While this is still an issue, some resident's laundry has been found. TOPIC: Lack of Communication between Residents and Certified Nursing Assistants (CNAs). STATUS: This is still an issue. They are the same as before. -Open Discussion: Laundry issue is still a major factor. While some of it has been found, most articles of clothing have gone missing. -Concern: Lack of Communication. How will Manager address this: staff have been in-serviced on greeting/acknowledging residents when they enter rooms. Further review of the [DATE] Resident Council Minutes failed to indicate that the facility filed grievances for the missing laundry items on behalf of the residents, and there was no resolution to the residents' concerns of the lack of communication with the CNAs and the residents' concerns of missing laundry originally brought forward in [DATE]. [DATE] -Attendance: Six Residents, the Activities Director, the Ombudsman, and one additional staff member. -Review of Old Business: TOPIC: Some Resident's laundry has gone missing. STATUS: While this is still an issue, some resident's laundry has been found. TOPIC: Lack of Communication between Residents and Certified Nursing Assistants (CNAs). STATUS: This has been resolved. -Open Discussion: Laundry issue is still a factor. While some of it has been found, most articles of clothing have gone missing. -Concern: Laundry has gone missing. How will Manager address this: We are still working on labeling the new clothes. (There are) a lot of no name clothes that we are trying to find the owners. Further review of the [DATE] Resident Council Minutes failed to indicate that the facility filed grievances for the missing laundry items on behalf of the residents, and there was no resolution to the residents' concerns of missing laundry originally brought forward in [DATE]. [DATE] -Attendance: 18 Residents, the Activities Director, and three additional staff members. -Review of Old Business: TOPIC: Some Resident's laundry has gone missing. STATUS: This has been completely resolved. All articles of clothing have been returned. -Open Discussion: no issues. On [DATE] at 1:30 P.M., the surveyor held a Resident Council Meeting with 11 residents in attendance. During the meeting the residents brought forth the following concerns: -They said during the meetings the Activity Director talks about the previous meeting and goes over their complaints, but they don't really address them. -They said staff are not supposed to come to our meetings, but they always want to, so they do. It was good when they did not come because the other residents would talk about concerns, but when they are all at the meeting, no one says anything, because they don't want the staff to go after them. They said the staff that come are not invited, they just want to come, so they do. They said there was one time we had a meeting with the Ombudsman, and we had to go around and tell everyone no staff was allowed. -4 of 11 Residents said they have had a lot of laundry go missing and the facility doesn't do anything about it. They do not resolve it, follow up with you, or reimburse you for the missing laundry. They said it's just gone. -They said sometimes they give you old unlabeled things, but they are not what went missing, they are donated or from someone that died . -They said the laundry is terrible, they don't resolve any issues, your stuff is just gone. -Resident #6 said he/she has had multiple missing clothing items and his/her cell phone has been missing for months and none of it has been addressed. -Resident #29 said they are missing a lot of clothing, amounting to hundreds of dollars, and a new bottle of perfume and nothing has been done about any of it. During an interview on [DATE] at 11:58 A.M., the Ombudsman said staff is always present at the Resident Council Meetings and she has reminded the group they can meet without staff and that the staff that attends the meeting should be invited by the group and not be inviting themselves. During an interview on [DATE] at 2:06 P.M., the Activity Director said she runs the meetings and sometimes her assistant takes the notes. She said staff is usually present, but they are invited. She said the Department Heads will address the concerns voiced by the residents, although missing laundry is the biggest concern, and they never come. She said the residents voice a lot of complaints about missing laundry. She said sometimes we find it in the no name pile. She said they are trying to make sure everything is labeled and will give them things from the donation pile if they need something. She said she will jot it down on a scrap of paper and look for things, but if she can't find it, the resident must take it up with laundry. She said she does not log anything that is reported missing, does not file a grievance on the resident's behalf, fill out a missing item form, or anything like that, and she never has. She said she thinks the Administrator deals with it and she thinks the facility pays for lost items but was unsure of the process. During an interview on [DATE] at 4:54 P.M., the Administrator said she did not know of specific things reported missing at Resident Council, but she would expect the Activity Director to fill out grievance forms and notify laundry of missing items. She said missing items are not always elevated to a grievance, but they should be, as it is part of the grievance process. She said if unable to find the missing item within 72 hours there should be a form filled out and it should be part of the grievance book. She said the Missing Item Forms are all part of the grievance book, and she did not have any for concerns that came from Resident Council.

Based on observation, record review, and interview, the facility failed to follow the grievance process for resident concerns reported at Resident Council, to ensure all grievances filed were thoroughly investigated with a documented resolution, and for two Residents (#6 and #29), out of a total sample of 18 residents. Specifically, the facility failed: 1. To ensure concerns brought forth during Resident Council including multiple concerns for missing laundry had a grievance filed on their behalf and were investigated through the grievance process; 2. To ensure grievances filed by residents/resident representatives/family/friends were thoroughly investigated with a documented resolution; 3. For Resident #6, to initiate an investigation when his/her cell phone was determined to be missing, file a grievance for the missing cell phone, and follow the grievance process; and 4. For Resident #29, to ensure a grievance was filed for missing clothing and was investigated through the grievance process with an adequate resolution. Findings include: Review of the facility's policy titled Resident Council Meetings, dated as last reviewed/revised [DATE], indicated but was not limited to the following: -The Activity Director shall be designated, if approved by the group, to serve as a liaison between the group and the facility's administration and any other staff members. -The designated liaison shall be responsible for providing assistance with facilitating successful group meetings and responding to written requests from the group. -The facility shall act upon concerns and recommendations of the Council, make attempts to accommodate recommendations to the extent practicable, and communicate its decisions to the Council. Review of the facility's Complaint/Grievance Policy and Procedure, dated [DATE], indicated but was not limited to the following: -All residents and their responsible party will have a mechanism to voice grievances and complaints to the Grievance Official in order to facilitate communication and timely resolution of the matter. -Voiced grievances (e.g. those about treatment, care, management of funds, lost clothing, or violation of rights) are not limited to a formal, written process and may include a resident's verbalized complaint to facility staff. -Staff shall complete a grievance form when a resident makes a verbal complaint, if not completed by the complainant. -The Grievance Official, or designee in his/her absence, will review the grievance within ,d+[DATE] hours. -The Grievance Official will complete the Grievance form to include date received, summary statement, steps taken to investigate, summary of findings, confirmation or no confirmation of grievance, corrective action taken or to be taken, and date written resolution was issued if requested. -The Grievance Official or Social Service Department will review the findings with the resident/responsible party and provide written resolution if requested. 1. Review of the Resident Council minutes from [DATE] through [DATE] indicated but were not limited to the following: [DATE] Concern: Laundry has gone missing. [DATE] Concern: Laundry issue is still a major factor. While some of it has been found, most articles of clothing have gone missing. [DATE] Concern: Resident's laundry has gone missing. While this is still an issue, some resident's laundry has been found. [DATE]. Concern: Some Resident's laundry has gone missing. Status: This has been completely resolved. All articles of clothing have been returned. The facility failed to file grievances on behalf of the residents for the missing laundry items in [DATE], and [DATE] through [DATE]. On [DATE] at 1:30 P.M., the Surveyor held a Resident Council Meeting with 11 residents in attendance. During the meeting, the residents brought forth the following concerns: -10 of 11 residents said they did not know what a grievance form was or how to file a grievance. -4 of 11 residents said they have had a lot of laundry go missing and the facility doesn't do anything about it. They do not resolve it, follow up with you, or reimburse you for the missing laundry. They said it's just gone. -They said sometimes they give you old unlabeled things, but they are not what was missing, they are donated or from someone that died . -They said the laundry is terrible, they don't resolve any issues, your stuff is just gone. During an interview on [DATE] at 2:06 P.M., the Activity Director said the Residents voice a lot of complaints about missing laundry. She said she will jot it down on a scrap of paper and look for things, but if she can't find it the Resident has to take it up with laundry. She said she does not log anything that is reported missing, does not file a grievance on the resident's behalf, fill out a missing item form or anything like that, and she never has. She said she thinks the Administrator deals with it and she thinks the facility pays for lost items but was unsure of the process. During an interview on [DATE] at 4:54 P.M., the Administrator said she did not know of specific things reported missing at Resident Council, but she would expect the Activity Director to fill out grievance forms and notify laundry of missing items. She said missing items are not always elevated to a grievance, but they should be, as it is part of the grievance process. She said if unable to find the missing item within 72 hours there should be a form filled out and it should be part of the grievance book. She said the Missing Item Forms are all part of the grievance book, and she did not have any for concerns that came from Resident Council. 2. Review of the Grievance Book from [DATE] through [DATE] indicated but was not limited to the following: [DATE] - 1 grievance on the log. -[DATE] indicated Missing Dentures, located in room. Form failed to indicate family was updated on resolution. [DATE] - 3 grievances on the log, but only 2 were in the book. -[DATE] indicated education would be done with staff, and the education record attached was dated [DATE]. Form failed to indicate resident was updated on resolution. [DATE]- 6 grievances on the log. -[DATE] indicated missing clothing, family to bring in receipts for reimbursement. Resolution indicated receipts provided did not contain dates. It failed to indicate resident/family was reimbursed. Form failed to indicate resolution was discussed and acceptable to the resident/family. -[DATE] indicated phone was broken. Form failed to indicate resolution was discussed and acceptable to the resident/family. -[DATE] indicated phone was broken. Form failed to indicate resolution was discussed and acceptable to the resident/family. [DATE] - 1 grievance on the log. -[DATE] indicated missing pants. Not found. Summary indicated education regarding labeling of clothing. Form failed to indicate resolution was discussed and acceptable to the resident/family. [DATE] - 2 grievances on the log. 3 forms in the book. -[DATE] indicated family reported resident drowsy and not answering the phone. Form failed to indicate resolution was discussed and acceptable to the resident/family. -[DATE] indicated concern with wounds. Form failed to indicate resolution was discussed and acceptable to the resident/family. -[DATE] indicated crumbs in drawer. Form failed to indicate resolution was discussed and acceptable to the resident/family. [DATE] - No log. 4 grievances in the book. -[DATE] indicated food was thrown away in container. Summary indicated educate families on policy. Staff in-service attached. Form failed to indicate resolution was discussed and acceptable to the resident/family. -[DATE] indicated resident menu complaint. Form failed to indicate resolution was discussed and acceptable to the resident/family. -[DATE] indicated family complaint of menu. Form failed to indicate resolution was discussed and acceptable to the resident/family. [DATE] - No log. 1 grievance in the book. -[DATE] indicated a cell phone was missing. Form failed to indicate phone had been located or that resolution was discussed and acceptable to the resident/family. [DATE] - 3 grievances on the log. -[DATE] indicated a missing item reported by family. Form failed to indicate resolution was discussed and acceptable to the resident/family. -[DATE] indicated complaint of harassment. Form failed to indicate resolution was discussed and acceptable to the resident/family. During an interview on [DATE] at 4:54 P.M., the Administrator said they discuss grievances at morning meeting, they go to the Social Worker and then they come back to my office to note the resolution and sign off on it as completed. They all should have a resolution noted and be signed off as completed and they are not. The surveyor reviewed a grievance form from the grievance book dated [DATE] regarding a missing cell phone with the Administrator. The form failed to include a summary of the findings and failed to include a resolution. During an interview on [DATE] at 4:54 P.M., the Administrator said she did not know the status of the grievance for the missing phone or if the family had been updated. 3. Resident #6 was admitted to the facility in [DATE]. Review of the Minimum Data Set (MDS) assessment, dated [DATE], indicated he/she scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. On [DATE] at 1:30 P.M., the surveyor held a Resident Council Meeting with 11 residents in attendance. During the meeting, Resident #6 said he/she has had multiple missing clothing items, and his/her cell phone has been missing for months and none of it has been addressed. During an interview on [DATE] at 2:00 P.M., Certified Nursing Assistant (CNA) #2 said Resident #6 had a cell phone since at least [DATE] when she started working at the facility, but she has not seen it for a couple months. She said he/she was accusing us of stealing it, everyone knew about it, but we did not find it. Additionally, she said Resident #6 was vocal about it at first but, she has not heard much about it recently, and did not know the status of the investigation. During an interview on [DATE] at 3:45 P.M., Resident #6 said the cell phone has been missing for a couple months. He/she said the phone was on the bed but when he/she returned from the bathroom it was gone. Resident #6 said he/she told the nurse at the desk, but they didn't care. He/she said nothing ever came of it. Additionally, he/she said there were multiple missing undergarments and was told he/she could just buy new ones and was shrugged off when reporting two blouses that were missing around Thanksgiving. Resident #6 said, Things just disappear, so I don't have anything nice anymore and won't buy any new things. During an interview on [DATE] at 4:05 P.M., CNA #2 said laundry is missing a lot. She said they look for it and if they don't find it, it's reported to the Unit Manager and she handles it. She said she was not aware of anything currently missing for Resident #6. During an interview on [DATE] at 4:25 P.M., Unit Manager #1 said if something is reported missing, they do an initial search and then fill out a Missing Item Form. She said they used to fill out the Grievance Form but now there is a Missing Item Form. She said it is all part of the grievance book, and the Administrator handles it. She said missing laundry is frequently a concern but was not aware of Resident #6 missing any laundry. Additionally, she said Resident #6's cell phone has been missing for a few months and did not know the status of the investigation. She said the Missing Item Form would have been filled out when it was deemed missing and then turned into the office. She said she does not keep a copy, nor follow up on the investigation after the forms are turned in. Additionally, she said there were no progress notes indicating a search or resolution for the missing cell phone in the medical record. During an interview on [DATE] at 4:54 P.M., the Administrator said she did not know Resident #6 was missing clothing or a cell phone. She said missing items are not always elevated to a grievance, but they should be, as it is part of the grievance process. She said if unable to find the missing item (clothes) within 72 hours there should be a form filled out and it should be part of the grievance book. She said things like cell phones should be reported right away. The Administrator said the Missing Item Forms are all part of the grievance book, and she did not have any for Resident #6. 41106 4. Resident #29 was admitted to the facility in [DATE]. Review of the MDS assessment, dated [DATE], indicated Resident #29 scored 15 out of 15 on the BIMS which indicated the Resident was cognitively intact. During an interview on [DATE] at 9:09 A.M., Resident #29 said Laundry has lost over $600 worth of his/her clothes. On [DATE] at 3:50 P.M., the surveyor reviewed the Grievance book for 2024 and 2025 and found only one grievance filed on behalf of Resident #29 which included: -Grievance filed [DATE] -Description of Complaint: Resident was missing a pair of pants not found, but all clothes will be labeled at the front desk and distributed to residents. -Summary Statement: Education was done for Resident and encouraged to send clothes to son's house, Salvation Army or throw out. -Steps Taken to Investigate: All clothes that are mailed to patients will be labeled upon arrival. -Summary of Findings (to include statement of whether grievance was confirmed or not confirmed: Patient has lost 50 lbs. (pounds) and will need to process old clothes that are too large and label all. -Corrective Action Taken or To Be Taken: Lost clothing has reduced to 0 for this resident. -Resolution Acceptable to Resident/Responsible person: The boxes yes or no were not checked and the date resolved was left blank. The Staff Development Coordinator (SDC) and Director of Nursing (DON) with Resident; he/she appears to accept the explanation. No evidence of grievance was resolved. During an interview on [DATE] at 4:52 P.M., Resident #29 said he/she had a meeting with the Administrator about his/her missing clothing, and he/she was told to donate some clothes. During an interview on [DATE] at 11:00 A.M., the Administrator said Resident #29's clothes were going missing, but he/she has had nothing missing for the last three months. The Administrator said prior to that we could not keep an inventory because he/she was receiving packages three times a week. The surveyor reviewed the grievance filed [DATE] with the Administrator who said she was not aware of any other missing clothes since the incident of the missing pants in [DATE]. The Administrator said the grievance written for the pants is weak and there was no resolution for the missing pants. The Administrator said there were no other grievances filed for missing clothes for Residents #29. During an interview on [DATE] at 9:09 A.M., Resident #29 said he/she just recently bought $300 worth of new clothes and is already missing a pink sweatshirt with the head of a cat and their paws on the front of it. Resident #29 said it has been missing for weeks. During an interview with the Director of Laundry and Laundry Staff #1 on [DATE] at 12:45 P.M., Laundry Staff #1 said she had been aware for weeks that Resident #29 was missing a pink sweatshirt with a cat's face and their paws on the front of it. Laundry Staff #1 said Resident #29 showed her a picture of the missing sweatshirt which he/she has been looking for and unable to find. Laundry Staff #1 showed the surveyor a picture of the missing sweatshirt on her phone. Laundry Staff #1 said if she can't find an item the resident is missing, then she reports it to the Activity Director. After that she does not know what will happen. During a telephonic interview on [DATE] at10:24 A.M., Family Member (FM) #1 (Resident #29's Health Care Proxy) said he has been in contact with the facility regarding at least ,d+[DATE] pieces of missing clothing, but you (the surveyor) would have to speak directly to Resident #29 to find out how much clothing is missing. FM #1 said they have never been reimbursed for any of the missing clothing, and it is simple if they (the facility) just labelled the clothing there would not be a problem. During an interview on [DATE] at 2:55 P.M., the Activity Director said she was aware Resident #29 was missing the pink sweatshirt with a cat face on the front for a couple of months. She said she never filed a grievance for Resident #29, but she still looks for the sweatshirt.

Based on interviews and record review, the facility failed to ensure one Resident (#64), out of a total sample of 18 residents, received care and treatment to promote healing of pressure injuries. Specifically, the facility failed to implement wound care orders per physician recommendations for a Stage I pressure injury (localized area of non-blanchable redness on intact skin, usually over a bony prominence) to the left medial knee. Findings include: Review of the facility's policy titled Prevention of Pressure Ulcers/Injuries, dated as last revised May 2024, indicated but was not limited to the following: -Identify any signs of developing pressure injuries (non-blanchable erythema) -Inspect pressure points -Evaluate, report and document potential changes in the skin -Review the interventions and strategies for effectiveness Review of the facility's policy titled Charting and Documentation, dated as last revised May 2023, indicated but was not limited to the following: -All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, should be documented in the resident's medical record. -The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care -The following information is to be documented in the resident medical record: -Objective observations -Treatments or services performed -Progress toward or changes in the care plan goals and objectives -Documentation of procedures and treatments will include care-specific details Review of the facility's policy titled Skin Integrity Management, undated, indicated but was not limited to the following: -Residents with actual skin breakdown are identified, assessed, and provided treatment according to standards of practice. -Refer to wound MD/wound clinic as appropriate. -Implement wound care modalities Review of the Wound Clinic Services Agreement, dated January 2024, indicated but was not limited to the following: Facility Responsibilities: -Provide a dedicated nurse to round and communicate with the Provider. -Inform the resident's primary care provider of Provider's recommendation within 24 hours. -Discuss recommendations/wound care plan with the Provider on the day of rounds. Resident #64 was admitted to the facility in December 2023 with diagnoses including type II diabetes, severe protein calorie malnutrition, and pressure ulcers. Review of the Minimum Data Set (MDS) assessment, dated 1/15/25, indicated Resident #64 was mildly cognitively impaired as evidenced by a score of 12 out of 15 on the Brief Interview for Mental Status (BIMS). Additionally, Resident #64 had skin treatments and was dependent on staff for bed mobility. Review of the comprehensive care plan indicated but was not limited to the following: -Resident has a stage 1 pressure ulcer of the left medial knee related to immobility (1/16/25) -Administer treatments as ordered and monitor for effectiveness (1/16/25) Review of the medical record indicated Resident #64 was followed by a Wound Care Physician at the facility. Review of the Wound Evaluation and Management Summary, dated 1/15/25, indicated but was not limited to the following: -Stage 1 Pressure Wound of the Left Medial Knee measured 1.0 x 1.0 x not measurable centimeters (cm) -Dressing treatment plan: Skin prep once daily for 30 days. -Additional wound detail: This is a stage 1 pressure injury at the site of prior stage 2 wound -Pillow between knees -Additional information: The patient is resistant to repositioning and using a pillow between her knees Review of the skin/wound note, dated 1/16/25, written by the Assistant Director of Nursing (ADON), indicated Resident #64 was seen by wound physician and an order was received to apply skin prep to the stage 1 pressure injury on the left medial knee daily. Review of the January and February 2025 Physician's Orders/Treatment Administration Record (TAR) failed to indicate an order was implemented to apply skin prep to the stage 1 pressure injury of the left medial knee. Review of the Wound Evaluation and Management Summary, dated 1/21/25, indicated but was not limited to the following: -Stage 1 Pressure Wound of the Left Medial Knee measured 1.0 x 1.0 x not measurable cm -Dressing treatment plan: Skin prep once daily for 30 days. -Pillow between knees -Additional information: The patient is resistant to repositioning and using a pillow between her knees Review of the skin/wound note, dated 1/22/25, written by the ADON, indicated Resident #64 was seen by wound physician and to continue previously ordered treatment to the stage 1 pressure injury of the left medial knee. Review of the January and February 2025 Physician's Orders/TAR failed to indicate an order was implemented to apply skin prep to the stage 1 pressure injury of the left medial knee. Review of the Wound Evaluation and Management Summary, dated 2/4/25, indicated but was not limited to the following: -Stage 2 Pressure Wound of the Left Medial Knee measured 0.8 x 0.9 x 0.02 cm -Dressing treatment plan: gauze island with border apply every two days for 30 days -Discontinue skin prep -Pillow between knees -Additional information: The patient is resistant to repositioning and using a pillow between her knees Review of the skin/wound note dated 2/5/25, written by Unit Manager (UM) #1, indicated Resident #64 was seen by wound physician and an order was received to cleanse area with normal saline, cover with bordered gauze island dressing, change every two days to the stage II pressure injury of the left medial knee. Review of the February 2025 Physician's Orders/TAR indicated the following: -Left medial knee: Wash with normal saline, pat dry. Apply gauze island with border every other day for wound healing. During an interview on 2/6/25 at 10:09 A.M., UM #1 said she just started completing wound rounds on her unit with the wound physician this week. She said the wound physician communicates his recommendations verbally and then sends them over to the facility electronically the same day. UM #1 said she then notifies the medical director of the recommendations and documents the information in a nursing note. UM #1 said Resident #64's treatment was updated to apply a dressing for protection of the area and she implemented the new order yesterday. She said there was no other treatment order in place to the area, only to encourage a pillow between the knees. During an interview on 2/6/25 at 10:25 A.M., Nurse #1 said she provides care to Resident #64 on a consistent basis. She said Resident #64 did not have an order to apply skin prep to the left medial knee. Nurse #1 said she would place a pillow between the Resident's knees and encourage him/her to keep it in place. During an interview on 2/6/25 at 1:49 P.M., ADON said she completed rounds with the wound physician until last week. She said she would remove the dressings, and the wound physician would take measurements of the areas and give her recommendations verbally. She said she would document his verbal recommendations on a rounding sheet which included current treatment orders. The ADON said the wound evaluations are then sent over electronically to the medical record system. She then implements the orders, and documents it in a nursing note. She said the medical director defers treatment plans to the wound physician. The ADON and the surveyor reviewed Resident #64's wound evaluations, dated 1/15/25 and 1/22/25, nursing progress notes, and physician's orders in the medical record. She said Resident #64 was supposed to have an order to apply skin prep to the left medial knee, and documented it in her nursing note, however it was never put into place. The ADON said the Resident has an abundance of open areas, and it must have been an oversight. The ADON said she was going to notify the physician of the error. During an interview on 2/6/25 at 2:12 P.M., the Director of Nursing (DON) said her expectations are for the nurse who is completing rounds with the wound physician to transcribe and implement all the treatment orders on the day they are received. She said the order was never implemented as it should have been.

Based on interview and record review, the facility failed to report allegations of abuse within the State mandated time frame for two Residents (#29 and #609), in a total sample of 18 residents. Specifically, the facility failed to: 1. For Resident #29, ensure an allegation of misappropriation of resident property by staff of withholding packages until the Resident cleaned out his/her room was reported to the State Survey Agency; and 2. For Resident #609, ensure an allegation of harassment by the Administrator was reported to the State Survey Agency. Findings include: Review of the facility's policy titled Abuse Policy, undated, indicated but was not limited to the following: Policies and procedures regarding investigation and reporting of alleged violations of federal or state laws involving mistreatment, neglect, abuse, injuries of unknown source, and misappropriation of resident's property. -Such violations will also be reported to state agencies in accordance with existing state law. -The facility will investigate each alleged violation thoroughly and report the results of the investigation to the Executive Director or his or her designee, as well as to state agencies as required by state and federal law. -Protection: -If the suspected perpetrator is an employee, the Executive Director shall place the employee on immediate investigatory suspension while completing the investigation. Investigation of suspected resident abuse/ mistreatment/misappropriation/neglect/injury of unknown origin: 1. If a family member, resident, or staff reports an incident of abuse/mistreatment/neglect, it is to be reported to the Director of Nursing or manager immediately and an incident/accident report is to be completed. 2. The supervisor is to initiate the following steps: -Send the initial report to the Department of Public Health via Virtual Gateway immediately but no later than two hours. 1. Resident #29 was admitted to the facility in June 2020. Review of the Minimum Data Set (MDS) assessment, dated 1/9/25, indicated Resident #29 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the Resident was cognitively intact. During an interview on 2/05/25 at 4:52 P.M., Resident #29 said he/she had a meeting with the Administrator about his/her missing clothing, and he/she was told to donate some clothes. During a telephonic interview on 2/6/25 at 10:24 A.M., Family Member (FM) #1 (Resident #29's Health Care Proxy) said Resident #29 was upset and told him, he/she had 11 packages that were not delivered over Christmas until he/she got rid of stuff in his/her room. FM #1 said some of the packages contained Christmas presents for family members. FM #1 said he spoke with the woman in Activities and informed her that Resident #29's packages were not delivered, and it was illegal for them to withhold packages and cited Federal law chapter 8, section 1701 and 1702. During an interview on 2/06/25 at 11:00 A.M., the surveyor informed the Administrator of FM #1's concern of packages being withheld until extra items in Resident #29's room were removed. The Administrator said FM #1 had expressed his concerns to her about Resident #29 not receiving some packages and he did cite the Federal law to her during a meeting in January about mail delivery. The Administrator said she did not keep any notes on the conversations with FM #1 and referred the surveyor to check the social service notes. The Administrator said she did not investigate why Resident #29's packages were held in the business office, and/or file a grievance. During an interview on 2/06/25 at 11:18 A.M., the Front Desk Receptionist (FDR), with the Administrator present, said Resident #29 was complaining about packages not being delivered over Christmas. FDR said she told the Business Office Manager (BOM) about the complaints and never heard any more about the complaint. During an interview on 2/07/25 at 9:02 A.M., Social Worker (SW) #1 said she called FM #1 at the beginning of January and asked him to come in and pick up some of Resident #29's extra belongings the facility was storing. She said at that time FM #1 brought the concerns of Resident #29 not receiving his/her packages, and FM #1 said it violated federal law. SW #1 said she notified the Administrator, and they decided to have a meeting with FM #1. SW #1 said the care plan meeting took place on 1/15/25 and mail delivery concerns were discussed, and they reviewed Resident #29's purchase of clothing and extra clothes in the room. SW #1 said FM #1 brought up the Federal law of delivery of packages and FM #1 was assured Resident #29 would receive his/her packages going forward. During an interview on 2/07/25 at 10:35 A.M., the Corporate Nurse said she was not aware of FM #1's complaint that Resident #29 did not receive packages over Christmas until items were removed from his/her room. On 2/7/25 at 11:30 A.M., the surveyor reviewed Health Care Facility Reporting System (HCFRS) which from 12/24/2024 through 2/7/25 failed to indicate any incidents of alleged misappropriation of Resident #29's property was reported by the facility. 2. Resident #609 was admitted to the facility in March 2024. Review of the MDS assessment, dated 12/19/24, indicated Resident #609 scored 15 out of 15 on the BIMS indicating he/she was cognitively intact. During an interview on 2/4/25 at 9:35 A.M., Resident #609 said he/she was just going to call the Department of Public Health (DPH) and file a complaint of harassment for payment and for ease dropping on his/her private conversation he/she had with their spouse. Resident #609 said the Administrator continues to harass him/her for payment and he/she was told by his/her lawyer to pay what you can. During an interview on 2/4/25 at 8:55 A.M., the Director of Nurses (DON) was notified of Resident #609's alleged complaints of harassment and ease dropping on a phone conversation against the Administrator. The DON said she was aware of Resident #609's complaint of ease dropping but was not aware of the harassment for payment. During an interview on 2/05/25 at 9:13 A.M., the Corporate Nurse said she was aware of the financial concerns relating to Resident #609, but she was not aware he/she made allegations of harassment yesterday. During an interview on 2/05/25 at 9:26 A.M., the Administrator said she was made aware yesterday of Resident #609's complaint of harassment for non-payment against her. She said she is fully aware of Resident #609's current financial issues and last week she called the local police on Resident #609 after he/she received a 30-day discharge notice and then threatened her in the lobby. The Administrator said because she knows what is going on with Resident #609, she did not report the allegations of harassment to the state as they were not substantiated. During an interview on 2/05/25 at 2:01 P.M., Corporate Nurse said a complaint of harassment requires reporting and an investigation. On 2/7/25 at 11:30 A.M., the surveyor reviewed HCFRS which from 2/4/25 through 2/7/25 failed to indicate any incidents of alleged harassment towards Resident #609 were reported by the facility.

Based on interviews and documentation review, the facility failed to ensure packages were delivered in a timely manner to one Resident (#29), out of a total sample of 18 residents. Findings include: Resident #29 was admitted to the facility in June 2020. Review of the Minimum Data Set (MDS) assessment, dated 1/9/25, indicated Resident #29 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the Resident was cognitively intact. Review of Physician's orders indicated Resident #29's Healthcare Proxy (HCP) was invoked 6/15/2023. Review of a Social Service progress note, dated 1/15/25, indicated but was not limited to the following: -Social Service Care Plan meeting, present at the meeting was HCP, dietitian, executive director, assistant director of nurses and director of social services. Review of mail delivery, and review of purchases and extra clothes in the room. During an interview on 2/05/25 at 4:52 P.M., Resident #29 said he/she had a meeting with the Administrator about his/her missing clothing, and he/she was told to donate some clothes. During a telephonic interview on 2/06/25 at 10:24 A.M., Family Member (FM) #1 (Resident #29's HCP) said Resident #29 was upset and told him, he/she had 11 packages that were not delivered over Christmas until he/she got rid of stuff in his/her room. FM #1 said some of the packages contained Christmas presents for family members. FM #1 said he spoke with the woman who worked in Activities and informed her that Resident #29's packages were not delivered, and it was illegal for them to withhold packages and cited Federal law chapter 8, section 1701 and 1702. During an interview on 2/06/25 at 11:00 A.M., the surveyor informed the Administrator of FM #1's concern of packages being withheld until extra items in Resident #29's room were removed. The Administrator said FM #1 had expressed his concerns to her about Resident #29 not receiving some packages and he did cite the Federal law to her during a meeting in January. The Administrator said she did not keep any notes on the conversations with FM #1 and referred the surveyor to check the social service notes. The Administrator said she did not investigate why Resident #29's packages were held in the business office, and she did not file a grievance. During an interview on 2/06/25 at 11:18 A.M., the Front Desk Receptionist (FDR), with the Administrator present, said Resident #29 was complaining about packages not being delivered over Christmas. FDR said she told the Business Office Manager (BOM) about the complaints and never heard any more about the complaint. During an interview on 2/06/25 at 2:55 P.M., the Activity Director (AD) said she has been working with Resident #29 to get rid of some of his/her clothes. The AD said she was aware some of Resident #29's packages went up to the business office over Christmas, but she did not know why. She said after Christmas a lot of packages were brought down and delivered to Resident #29's room and she and Activity Assistant #1 helped Resident #29 put away the new clothes. The AD said she did speak with FM #1 and told him she did not think the packages were withheld on purpose it was just a miscommunication. During an interview on 2/06/25 at 3:05 P.M., Activity Assistant (AA) #1 said he was not aware of any packages being held at Christmas, but after Christmas he delivered a whole bunch of packages to Resident #29's room. AA #1 said he could not say how many packages but said it was a lot. During an interview on 2/06/25 at 3:30 P.M., the FDR said she did receive a couple packages for Resident #29 which she delivered to Resident #29's room. The FDR said packages are never held in the business office, if they are received after hours they are delivered the next day. The FDR said she does not know why Resident #29's packages went to the business office or why. During an interview on 2/07/25 at 9:02 A.M., Social Worker (SW) #1 said she knows around Christmas time the Activity Staff were trying to clean out Resident #29's room. SW #1 said she was aware Resident #29 had some packages that were in the business office, but she was not sure how or why they were in the business office. She said she called FM #1 at the beginning of January and asked him to come in and pick up some of Resident #29's extra belongings the facility was storing. She said at that time FM #1 brought the concerns of Resident #29 not receiving his/her packages, and FM #1 said it violated federal law. SW #1 said she notified the Administrator, and they decided to have a meeting with FM #1. SW #1 said the care plan meeting took place on 1/15/25 and mail delivery concerns were discussed, and they reviewed Resident #29's purchase of clothing and extra clothes in the room. SW #1 said FM #1 brought up the Federal law of delivery of packages and FM #1 was assured Resident #29 would receive his/her packages going forward. During a telephonic interview on 2/7/25 at 10:19 A.M., the BOM said due to staffing limitations around the Christmas holiday they could not process all Resident #29's packages. She said she brought 4-5 packages on 12/24/24, up to her office until they were later delivered to Resident #29 on 12/27/24. The BOM said after FM #1 complained about the delay in the packages being delivered, she said they had a telephonic meeting with FM #1, and no one asked why the packages were held up in her office. She said she did not inform Resident #29 she had packages delivered to the facility and she was holding them in her office. During an interview on 2/07/25 at 10:35 A.M., Corporate Nurse said she was not aware of FM #1's complaint that Resident #29 did not receive packages over Christmas until items were removed from the Resident's room. Refer to F609 and F610

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had a diagnosis of Diabetes with long-term use of insulin, and had a Physician's order with parameters for medication administration by nursing in the event of low blood sugar, the Facility failed to ensure Resident #1 was provided nursing care and treatment in accordance with professional standards of practice, when on 10/01/23, he/she experienced a hypoglycemic (low blood sugar) episode and was found minimally responsive by nursing, however, nursing did not follow Physician's orders related to the treatment of a low blood sugar with Glucagon (hormone that increases blood sugar), and although Resident #1's Physician ordered that he/she be immediately transferred to the Hospital for evaluation, 911 was not contacted by facility staff until an hour and a half after his/her hypoglycemic episode was first observed, at which point he/she was transferred to Hospital Emergency Department (ED). Resident #1 required administration of Glucagon in the ambulance enroute to the ED, and was admitted to the Hospital for management of his/her diabetes. Findings include: Review of the Facility Policy titled, Nursing Care of the Resident with Diabetes Mellitus, undated, indicated the following: -the following conditions are associated with diabetes: hyperglycemia, diabetic ketoacidosis, and hypoglycemia -signs and symptoms of hypoglycemia usually have a sudden onset -approximate reference ranges for hypoglycemia: -mild hypoglycemia 55-70 mg (milligrams)/dl (deciliter); -moderate hypoglycemia 40-55 mg/dl; and -severe hypoglycemia < (less than) 40 mg/dl -management of hypoglycemia: the severity of hypoglycemia is determined by a combination of blood sugar results and clinical symptoms -for asymptomatic and responsive residents with hypoglycemia (<70 mg/dl or less than the physician ordered parameter): give the resident an oral form of rapidly absorbed glucose (4 oz (ounces) of juice or 5-6 ounces of soda); recheck blood glucose in 15 minutes; if no improvement, notify physician for further orders -for symptomatic and unresponsive residents with (<70 mg/dl or less than the physician ordered parameter): administer oral glucose paste to the buccal mucosa (lining of the checks and back of the lips), intramuscular (IM) Glucagon, or IV (intravenous) 50% dextrose (type of sugar), per facility protocol and notify the physician for further orders -medication management: the nurse will closely monitor the diabetes management of cognitively impaired residents Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Resident #1 was admitted to the Facility in September 2023, diagnoses included type II diabetes, long term use of insulin, Alzheimer, dysphagia (difficulty swallowing), hypothyroidism, epilepsy (seizure disorder), and hypertension. Review of Resident #1's Nurse Progress Note, dated 10/01/23, (written by Nurse #1), indicated that at 8:00 A.M. Resident #1 was found by a Certified Nurse Aide (CNA), he/she was difficult to arouse and the CNA notified the nurse. The Note indicated Nurse #1 went to assess Resident #1 and found he/she was only arousable by rubbing his/her sternum. The Note indicated Resident #1 was unable to open his/her eyes or coherently answers yes or no questions, upon assessment his/her CBG (capillary blood glucose) level was 43 mg/dl, negative for covid and the Physician was notified. The Note indicated the Physician ordered Resident #1 to be sent to the Hospital ED for further evaluation, 911 was called and Health Care Proxy (HCP) notified. Review of Resident #1's Physician Order, dated 09/23/23, indicated he/she had a Physician's order with parameters indicating what nursing was to administer in the event of a low blood sugar, the order was as follows: -administer GlucaGen Hypokit Solution (emergency kit) Glucagon (hormone that raises blood sugar) inject 1 milligram (mg) intramuscularly (into the muscle) as needed for severe hypoglycemia if blood sugar is less than 50 and resident is unable to eat or drink safely due to disorientation related to low blood sugar. Review of Resident #1's Medication Administration Record (MAR) and Nurse Progress Notes, dated 10/01/23, indicated there was no documentation to support Nurse #1 administered Glucagon to Resident #1, per physician orders. During a telephone interview on 10/17/23 at 1:30 P.M. and a follow-up telephone interview on 10/23/23 at 11:25 A.M., Nurse #1 said she worked the 7:00 A.M.-3:00 P.M. shift on 10/01/23 and CNA #1 came to her around 8:00 A.M. and told her that Resident #1 was unresponsive. Nurse #1 said she immediately went to Resident #1's room to assess him/her, he/she was lying in bed, she called him/her by name, and he/she did not respond. Nurse #1 said Resident #1 was lethargic, difficult to arouse, that she tried rubbing his/her sternum several times and he/she could barely open his/her eyes or answer questions. Nurse #1 said she obtained Resident #1's vital signs and his/her CBG which was 43 mg/dl. Nurse #1 said she notified Resident #1's Physician and received an order to immediately send him/her to the Hospital ED for evaluation. Nurse #1 said she called 911 Emergency Medical Services (EMS) and notified Resident #1's Health Care Proxy. Although Nurse #1 said the Physician told her to immediately send Resident #1 to the Hospital ED for evaluation, she had not include the need for immediate transfer in Resident #1's Nurse Progress Note. Nurse #1 said that after obtaining Resident #1's CBG reading of 43 mg/dl, she did not administer Glucagon to him/her as ordered, because when she checked his/her MAR for physician's orders, she saw Residents #1's sliding scale insulin order for high blood sugar levels, but had not checked all of the Physician's orders for him/her, but she should have. Nurse #1 said she could not remember the exact time she notified Resident #1's Physician or when she called 911. Nurse #1 said she had spoken to one of the Emergency Medical Technician's (EMT's) upon their arrival to the Facility but could not recall if she told the EMT that no interventions were provided to Resident #1 for his/her hypoglycemia. During a telephone interview on 10/17/23 at 12:58 P.M., Nurse #2 said she worked the 7:00 A.M.-3:00 P.M. shift on 10/01/23 with Nurse #1 and that Nurse #1 had told her Resident #1's blood glucose level was low (exact number unknown) and he/she was sleepy. Nurse #2 said she told Nurse #1 to try to give Resident #1 some orange juice and graham crackers to get his/her blood glucose level up and if that was unsuccessful, said she told Nurse #1 she would have to administered Glucagon to him/her. Review of Resident #1's Facility Transfer Form, dated 10/01/23, indicated that his/her blood glucose was 43.0 mg/dl on 10/01/23 at 8:13 A.M. Review of the Emergency Medical Services (EMS) Pre-hospital Care Report, dated 10/01/23, indicated that EMS were notified of an unresponsive resident on 10/01/23 at 9:30 A.M. and on scene (at the Facility) at 9:35 A.M. (more than an hour and a half after Resident #1 was found to be unresponsive by nursing staff). The Report indicated they were en-route to the hospital at 9:57 A.M., and arrived at 10:16 A.M, at destination (ED). The Report indicated upon arrival to the facility Resident #1 was found lying in his/her bed, unable to open his/her eyes, making incomprehensible sounds and his/her skin was cool and clammy. The Report indicated that staff had found Resident #1 unresponsive that morning and checked his/her glucose level at 7:57 A.M. which was 43 mg/dl. The Report indicated that staff had stated they did not provide any interventions and called EMS at 9:30 A.M. The Report further indicated Resident #1 was placed on a stretcher, moved into the ambulance and the crew obtained a glucose level of 20 mg/dl and he/she was administered Glucagon 1 mg IM. The Report indicated that during transport to the hospital Resident #1's mental status began to improve, he/she was able to sit up, hold a conversation and his/her final glucose level obtained by the crew was 67 mg/dl. Review of Resident #1's Hospital Discharge Summary, dated 10/05/23, and timed at 10:20 A.M., indicated Resident #1 presented to the Hospital Emergency Department on 10/01/23, after he/she was found to be poorly responsive at his/her Long-term Care facility and it was reported Resident #1's blood glucose level had been 43 mg/dl earlier in the day without intervention. The Summary indicated that EMS found Resident #1's blood glucose level to be 20 mg/dl and he/she received IM Glucagon (by EMS en-route) with improvement of his/her blood glucose and mentation. The Summary indicated upon arrival to the ED Resident #1's blood glucose level was 91 mg/dl and he/she was admitted for diabetes management and possible Urinary Tract Infection (UTI). During an interview on 10/16/23 at 2:54 P.M., the Assistant Director of Nurses (ADON) said on 10/02/23 she was made aware that Resident #1 had a hypoglycemic episode on 10/01/23, that he/she was sent to the Hospital ED and that the Unit Manager told her Resident #1's blood glucose was in the 40's and no Glucagon was administered to him/her. The ADON said after she reviewed Resident #1's Physician's orders and nursing progress notes, and that Nurse #1 should have administered Glucagon to Resident #1 per his/her Physician's orders and that she had also not followed the facility's policy. During an interview an in-person on 10/16/23 at 3:21 P.M., and a telephone interview on 10/17/23 at 1:12 P.M., the Director of Nurses (DON) said after being made aware of Resident #1's hypoglycemic episode she reviewed his/her medical record which included his/her progress notes, MAR's, and transfer form. The DON said Resident #1 had a Physician's order to administer Glucagon for low blood sugar. The DON said Nurse #1 told her that Resident #1 did not have a Physician's order for Glucagon because she could not find one. The DON said Nurse #1 had not used critical thinking, had not followed Resident #1's Physician orders or the Facility's Policy and Procedure and that she should have administered Glucagon to him/her. The DON said Nurse #1 told her she had notified Resident #1's Physician right away of his/her change. The DON said to the best of her knowledge there was no delay in when the physician or EMS were notified, because when she reviewed Resident #1's Nurse progress note, it did not indicate there was a delay in notifying them. The DON said she had not obtained a copy of the EMS report. The DON said she expects all nurses to follow the resident's Physician orders, as well as Facility Policies and Procedures.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose diagnoses included Diabetes with long-term use of insulin, and was at risk for hypoglycemia (low blood sugar) for which he/she had Physician's orders in place with parameters specific to the administration of Glucagon (hormone that increases blood sugar), the Facility failed to ensure that nursing staff was competent and had the necessary skill set to appropriately care for residents in the event of a sudden change in condition. On 10/01/23, at approximately 8:00 A.M., Nurse #1 was notified by a Certified Nurse Aide (CNA) that Resident #1 was unresponsive, and after she assessed Resident #1, Nurse #1 determined he/she was experiencing a hypoglycemic (low blood sugar) episode. Nurse #1 did not implement or follow facility policy related to nursing actions to be taken in the event of hypoglycemia, she did not thoroughly review Resident #1's physician's orders and despite there being an order for the administration of Glucagon, she did not administer it to him/her. Furthermore although Nurse #1 had notified the physician of Resident #1's change in condition, and obtained an order to immediately transfer him/her to the hospital, she did not transcribe the order and did not call 911 until an hour and a half later, resulting in a delay in treatment. Resident #1 required administration of Glucagon by Emergency Medical Services (EMS) en-route in the ambulance and was admitted to the Hospital for management of his/her diabetes. Findings include: Review of the Facility Policy titled, Nursing Care of the Resident with Diabetes Mellitus, undated, indicated the following: -the following conditions are associated with diabetes: hyperglycemia, diabetic ketoacidosis, and hypoglycemia -signs and symptoms of hypoglycemia usually have a sudden onset -approximate reference ranges for hypoglycemia: -mild hypoglycemia 55-70 mg (milligrams)/dl(deciliter); -moderate hypoglycemia 40-55 mg/dl; and -severe hypoglycemia < (less than) 40 mg/dl -management of hypoglycemia: the severity of hypoglycemia is determined by a combination of blood sugar results and clinical symptoms -for asymptomatic and responsive residents with hypoglycemia (<70 mg/dl or less than the physician ordered parameter): give the resident an oral form of rapidly absorbed glucose (4 oz (ounces) of juice or 5-6 ounces of soda); recheck blood glucose in 15 minutes; if no improvement, notify physician for further orders -for symptomatic and unresponsive residents with (<70 mg/dl or less than the physician ordered parameter): administer oral glucose paste to the buccal mucosa (lining of the checks and back of the lips), intramuscular Glucagon, or IV (intravenous) 50% dextrose (type of sugar), per facility protocol and notify the physician for further orders -medication management: the nurse will closely monitor the diabetes management of cognitively impaired residents During an interview on 10/19/23 at 11:20 A.M., the Staff Development Coordinator (SDC) said all new hires receive general orientation and nurses are supposed to receive nursing specific orientation that includes being assigned to a nurse preceptor and being signed off on competencies such as medication pass, Physician orders, and pharmacy ordering. The SDC said Nurse #1 worked at the facility as an agency staff person first, was then hired and became a facility staff (exact date of hire unknown) nurse. The SDC said she had not conducted orientation with Nurse #1, because Nurse #1 had been working at the Facility prior to her starting as SDC at the Facility. The SDC said she did not know when or even if Nurse #1 had received facility nursing orientation and did not know when or even if Nurse #1 had been signed off as having completed any of the facility required nursing competencies. Review of the Facility's Staff Nurse (Registered Nurse RN/Licensed Practical Nurse LPN) Job Description, indicated it included but was not limited to the following: -primary purpose of your job description is to provide direct nursing care to residents; -as floor nurse you are delegated the administrative authority, responsibility, and accountability necessary for carrying out assigned duties; -duties and responsibilities: administrative functions, charting and documentation, drug administration functions (prepare and administer medications as ordered by the Physician), personnel functions, nursing care functions (review the resident's chart for specific treatments), medication orders, diets etc, as necessary, staff development, safety and sanitation, equipment and supplies, care plan and assessment functions, resident rights, and miscellaneous. Review of Nurse #1's personnel file, indicated she had received and reviewed a copy of the Staff Nurse RN/LPN Job Description which was a ten page packet of information specific to nurses, and that she signed and dated the Job Description on 5/24/23. Further review of Nurse #1's Job Description packet indicated it had eight pages titled Job Description Floor Nurse, that contained areas of competencies that all newly hired nurses were required to be signed off on as being competent, in order to be able to work independently. However Nurse #1's nursing competencies were not signed off, were blank, and therefore failed to indicate if Nurse #1 performed nursing functions satisfactorily or needed in-service training. Review of the Job Description packet also indicate that on the last page the Director of Nursing Services needed to sign off on and date the competencies were completed, but that was also left blank. There was no additional documentation in Nurse #1's personnel file to support that she had received and passed competency evaluations related to nursing duties and responsibilities. Resident #1 was admitted to the Facility in September 2023, diagnoses included type II diabetes, long term use of insulin, Alzheimer, dysphagia (difficulty swallowing), hypothyroidism, epilepsy (seizure disorder) and hypertension. Review of Resident #1's Physician Order, dated 09/23/23, indicated he/she had a Physician's order with parameters that indicated what nursing was to administer if he/she low blood sugar, the order was as follows: -administer GlucaGen Hypokit Solution (emergency kit) Glucagon (a hormone that raises blood sugar) inject 1 milligram (mg) intramuscularly (into the muscle) as needed for severe hypoglycemia if blood sugar is less than 50 and resident is unable to eat or drink safely due to disorientation related to low blood sugar. Review of Resident #1's Nurse Progress Note, dated 10/01/23, (written by Nurse #1), indicated that at 8:00 A.M. Resident #1 was found by a Certified Nurse Aide (CNA), he/she was difficult to arouse and notified the nurse. The Note indicated Nurse #1 went to assess Resident #1 and found he/she was only arousable by rubbing his/her sternum. The Note indicated Resident #1 was unable to open his/her eyes or coherently answers yes or no questions, upon assessment his/her CBG (capillary blood glucose) was 43 mg/dl (low), he/she was negative for covid and the Physician was notified. The Note indicated the Physician ordered Resident #1 to be sent to the Hospital ED for further evaluation and 911 was called. During a telephone interview on 10/17/23 at 1:30 P.M. and a follow-up telephone interview on 10/23/23 at 11:25 A.M., Nurse #1 said she has only been a nurse for two years, had been working at the Facility since February 2023 as an Agency nurse, and that she was hired and became a facility staff nurse but could not remember the date. Nurse #1 said she had never received nursing specific orientation from the Facility and had only received a general orientation. Nurse #1 said she worked the 7:00 A.M.-3:00 P.M. shift on 10/01/23 and CNA #1 came to her around 8:00 A.M. and told her that Resident #1 was unresponsive. Nurse #1 said she immediately went to Resident #1's room, he/she was lying in bed, she called him/her by name, and he/she did not respond. Nurse #1 said Resident #1 was lethargic, difficult to arouse, she tried rubbing his/her sternum several times and he/she could barely open his/her eyes or answer questions. Nurse #1 said she obtained Resident #1's vital signs, his/her CBG was 43 mg/dl, and she notified Resident #1's Physician and received an order to immediately send him/her to the Hospital ED for evaluation. Nurse #1 said that after obtaining Resident #1's CBG reading of 43 mg/dl, she did not administer Glucagon to him/her as ordered. Nurse #1 said when she checked Resident #1's MAR for physician's orders, said although she saw his/her physician's order for sliding scale insulin for high blood sugars, said she had not checked all of the Physician's orders for him/her, but should have. Nurse #1 said she could not remember the exact time she notified Resident #1's Physician or when she called 911. Nurse #1 said she had spoken to one of the Emergency Medical Technician's (EMT's) upon their arrival to the Facility but could not recall if she told the EMT that no interventions were provided to Resident #1 for his/her hypoglycemia. Nurse #1 said she was not aware the Facility had specific policies for caring for residents with Diabetes. Nurse #1 said she did not know that when you receive a Physician's order to send a resident to the Hospital, that she had to write and transcribe the Physician's order into the resident's medical record. Review of Resident #1's Facility Transfer Form, dated 10/01/23, indicated that his/her blood glucose was 43 mg/dl on 10/01/23 at 8:13 A.M. Review of the Emergency Medical Services (EMS) Pre-hospital Care Report, dated 10/01/23, indicated that EMS were notified of an unresponsive resident on 10/01/23 at 9:30 A.M. and on scene (at the Facility) at 9:35 A.M. (more than an hour and a half after Resident #1 was found to be unresponsive by nursing staff). The Report indicated they were en-route to the hospital at 9:57 A.M., and arrived at 10:16 A.M., at their destination (ED). The Report indicated upon arrival to the facility Resident #1 was found lying in his/her bed, unable to open his/her eyes, making incomprehensible sounds and his/her skin was cool and clammy. The Report indicated that staff had found Resident #1 unresponsive that morning and checked his/her glucose level at 7:57 A.M. which was 43 mg/dl. The Report indicated that staff had stated they did not provide any interventions and called EMS at 9:30 A.M. The Report further indicated Resident #1 was placed on a stretcher, moved into the ambulance and the crew obtained a glucose level of 20 mg/dl and he/she was administered Glucagon 1 mg IM. The Report indicated that during transport to the hospital Resident #1's mental status began to improve, he/she was able to sit up, hold a conversation and his/her final glucose level obtained by the crew was 67 mg/dl. Review of Resident #1's Hospital Discharge Summary, dated 10/05/23, and timed at 10:20 A.M., indicated Resident #1 presented to the Hospital Emergency Department on 10/01/23, after he/she was found to be poorly responsive at his/her Long-term Care facility and it was reported Resident #1's blood glucose level had been 43 mg/dl earlier in the day without intervention. The Summary indicated that EMS found Resident #1's blood glucose level to be 20 mg/dl and he/she received IM Glucagon (by EMS en-route) with improvement of his/her blood glucose and mentation. The Summary indicated upon arrival to the ED Resident #1's blood glucose level was 91 mg/dl and he/she was admitted for diabetes management and possible Urinary Tract Infection (UTI). During an interview on 10/17/23 at 12:58 P.M., Nurse #2 said she worked the 7:00 A.M.-3:00 P.M. shift on 10/01/23 with Nurse #1 and that Nurse #1 had told her Resident #1's blood glucose level was low (exact number unknown) and he/she was sleepy. Nurse #2 said she told Nurse #1 to try to give Resident #1 some orange juice and graham crackers to get his/her blood glucose level up and if that was unsuccessful, she would have to administered Glucagon to him/her. Review of Resident #1's Medication Administration Record (MAR) and his/her Nurse Progress Note, dated 10/01/23, indicated there was no documentation to support that he/she was administered Glucagon, in accordance with Physician's orders. During an interview on 10/16/23 at 2:54 P.M., the Assistant Director of Nurses (ADON) said on 10/02/23 she was made aware that Resident #1 had a hypoglycemic episode on 10/01/23, and he/she was sent to the Hospital ED. The ADON said the Unit Manager told her Resident #1's blood glucose was in the 40's and Glucagon was not administered to him/her. The ADON said Nurse #1 should have administered Glucagon to Resident #1 per his/her Physician's orders and facility's policy. During an in-person interview on 10/16/23 at 3:21 P.M., and telephone interview on 10/17/23 at 1:12 P.M., the Director of Nurses (DON) said she could not recall if Nurse #1 had received nursing orientation with a preceptor and said there was no SDC in place when Nurse #1 became a per-diem staff member at the Facility. The DON said she was not sure if the current SDC had done a nursing orientation with Nurse #1. The DON said she expects all nurses to follow the resident's Physician orders, as well as Facility Policies and Procedures. The DON said after being made aware of Resident #1's hypoglycemic episode she reviewed his/her medical record which included his/her progress notes, MAR's, Physician's orders and transfer form. The DON said Nurse #1 told her that Resident #1 did not have a Physician's order for Glucagon because she (Nurse #1) could not find one. The DON said she reviewed Resident #1's MAR, and said he/she had a current Physician's order in place to administer Glucagon for low blood sugar, and said Nurse #1 should have administered Glucagon to him/her. The DON said that Nurse #1 had not written or transcribed the Physician's order to send Resident #1 to the Hospital ED for evaluation, into the medical record. The DON said Nurse #1 told her she had notified Resident #1's Physician right away of his/her change. The DON said to the best of her knowledge there was no delay in when the physician or EMS were notified, because when she reviewed Resident #1's Nurse progress note, it did not indicate there was a delay in notifying them. The DON said she had not obtained a copy of the EMS report (which showed 911 was not called until an hour and a half later). The DON said she expects all nurses to follow the resident's Physician orders, as well as Facility Policies and Procedures.

Based on meal observations, interview and medical record review, the Facility staff failed to: a.) monitor the provision of recommended dietary interventions (fortified cereal and increased fluids), b.) accommodate the Resident's dietary preferences and c.) provide assistance during meals and d.) follow the physician's recommendations for weekly weights, for one sampled Resident (#76), from a total sample of 18 residents. Resident #76 had a continued, unplanned and significant weight loss of 8.42% from admission to date of survey (3 month time period). Findings include: Resident #76 was admitted to the Facility from the hospital in 1/2019, with a closed left shoulder fracture and dislocation, hearing loss and bilateral visual impairment. Resident #76 was living independently prior to this admission. Review of the admission Minimum Data Set (MDS) indicates the following: * Brief Interview for Mental Status (BIMS) indicates a score of 14 or cognitively intact with no memory problems. * Not on a physician-prescribed weight loss regimen. * no swallowing difficulties, no weight loss and an entry weight of 121 pounds. * requires supervision or oversight/cueing and one person physical assist for eating. Review of the weekly weights and nutrition notes indicated the following: 1/23/19 121.1 pounds 2/18/19 125.2 pounds 3/14/19 116.8 pounds (significant weight loss of 8.4 pounds or 6.7% in 1 month). Review of the Initial Nutrition assessment dated [DATE] indicates a current weight of 121.1 pounds, is on a no added salt regular diet and eats approximately 75% of his/her meals with preferences outlined on the tray ticket. The Resident stated that he/she has a very specific eating pattern, which he/she would like to maintain during his/her stay. A house supplement (Ensure) was started at 120mls 2x/day due to risk of weight loss related to specific menu preferences and limited acceptance of facility meals. Review of the Interim Nutrition Note dated 3/20/19 indicates: weight recorded at 116.8 pounds (4.3 pound loss) with recommendation to increase supplement to 3x/day. Recommend adding fortified cereal at breakfast to maximize caloric intake and help stabilize weight (one month after initial assessment). 4/05/19 113.0 pounds (significant weight loss of 12.2 pounds or 9.7% in less than 3 months) 4/10/19 no weight taken Review of the Interim Nutrition Note of 4/12/19 indicates: Resident weight recorded at 113 pounds and reflects a continued weight loss trend, receiving meals @ 50-75% (down from admission) and will add fortified cereal at breakfast. 4/17/19 no weight taken Review of the Interim Nutrition Note of 4/19/19 (following Surveyor inquiry) indicates: Visited with Resident today to address concerns with breakfast meal. Resident has a preference for Cream of Wheat, but has not been receiving it. The Resident reports lunch and dinner meals are good. 4/24/19 weight taken by RD at 110.9 pounds ( loss of additional 2.1 pounds) and Nurse Practitioner notified. The Resident's total weight loss was 10.2 pounds which reflects a significant weight loss of 8.42% in 3 months. On 4/18/19 at 8:00 A.M. the Surveyor observed Resident #76 in bed with a tray on the bedside table with no assistance from staff. The Surveyor observed the meal ticket which indicated cream of wheat, yogurt and coffee with no extra fluids. The Surveyor observed a small container (5.3 ounces) of yogurt and a cup of coffee, but no fortified cream of wheat cereal. The Resident said that the food was horrible and that he/she never gets what he/she ordered. The Resident said that he/she enjoys soup, but it was rarely offered and was usually just broth which is too salty. The Resident also said that the tray is left on his/her table with no set up help, even though he/she cannot see very well (requires supervision and set up/cueing assistance per MDS). On 4/19/19 at breakfast, the Surveyor observed the breakfast ticket which indicated hard boil egg and apple sauce. The Surveyor observed yogurt, apple sauce, coffee with no hard boiled egg or assistance from staff. The Resident pointed to his/her tray and asked the Surveyor no hard boiled egg and no cereal again can you believe this? On the mornings of 4/23/19 and 4/24/19 the Resident did not receive fortified cereal and the breakfast tray did not reflect the Resident preferences of what was indicated on the meal ticket. The Resident received no assistance from staff during the meal. On 4/23/19 at lunch, the Surveyor observed the lunch meal ticket which indicated prefers fish or chicken entrees for supper, likes soup with crackers and likes mashed potatoes and extra gravy when available. The Resident said that he/she did not get soup or mashed potatoes with gravy. The Resident said that whatever the meat was, he/she returned it because it was too tough and had no flavor and came without gravy. Review of the Certified Nursing Assistant (CNA) Kardex indicated a completely blank form and section 13. Nutrition indicates blanks for supervise, assist, cueing and diet and therefore, no way for the direct care staff to know how to meet the nutritional needs of the Resident. On 4/19/19 the Surveyor asked the Unit Manager (UM) about the CNA assignment for Resident #76. The UM said that Resident #76 had been accidently deleted off of the CNA assignment list for that morning and added the resident's name back to the CNA assignment sheet. The Surveyor asked about the blank Kardex and the UM said that she would take care of it. On 4/24/19 at 2:30 P.M., the Surveyor interviewed the Dietician. The Dietician said that she was not aware that the Resident had not been weighed since 4/5/19 (19 days ago) and returned with a weight of 110.9 pounds. The Dietician said that she was not aware that the Resident was not receiving his/her fortified cereal and said that the recommendation was not transcribed correctly and therefore, never received. The Dietician could not say if the physician/ had been notified about the Resident's continued weight loss, but said that she had recently spoken to the Nurse Practitioner. On 4/26/19 at 11:52 A.M. the Surveyor interviewed the Nurse Practitioner (NP) by telephone. The NP said that he had not received an update from nursing staff about the Resident's weight loss and was unaware that the resident was not receiving his/her fortified cereal or meal preferences. The NP said that he was a little shocked about the weight on 4/24/19 after the Dietician reported the current weight to the NP.

Based on meal observations, interview and medical record review the Facility failed to notify the Resident's physician (Nurse Practitioner/NP) about a change in condition (significant weight loss), to re-evaluate the potential need to alter the treatment plan for one Resident (Resident #76), from a total sample of 18 residents. Resident #76 had a continued, unplanned and significant weight loss of 8.42% from admission to date of survey (3 month time period). Findings include: Resident #76 was admitted to the Facility from the hospital in 1/2019, with a closed left shoulder fracture and dislocation, hearing loss and bilateral visual impairment. Resident #76 was living independently prior to this admission. Review of the admission Minimum Data Set ((MDS) dated [DATE] indicated the following: * Brief Interview for Mental Status (BIMS) indicated a score of 14 or cognitively intact with no memory problems. * Not on a physician-prescribed weight loss regimen. * no swallowing difficulties, no weight loss and an entry weight of 121 pounds. * requires supervision or oversight/cueing and one person physical assist for eating. Review of the Initial Nutrition assessment dated [DATE] indicated a current weight of 121.1 pounds, was on a no added salt regular diet and eats approximately 75% of his/her meals with preferences outlined on the tray ticket. The Resident stated that he/she has a very specific eating pattern, which he/she would like to maintain during his/her stay. A house supplement (Ensure) was started at 120 mls 2 times per day due to risk of weight loss related to specific menu preferences and limited acceptance of facility meals. (Resident #76 did not like the food at the Facility and did not receive his/her preferred alternate choices.) Review of the weekly weights and nutrition notes indicated the following: 1/23/19 121.1 pounds 2/18/19 125.2 pounds 3/14/19 116.8 pounds (significant weight loss of 8.4 pounds or 6.7% in 1 month). Review of the Interim Nutrition Note dated 3/20/19 indicated: weight recorded at 116.8 pounds (4.3 pound loss) from admission with recommendation to increase supplement to 3 times per day. Recommend adding fortified cereal at breakfast to maximize caloric intake and help stabilize weight. 4/05/19 113.0 pounds (significant weight losss of 12.2 pounds or 9.7% in less than 3 months). 4/10/19 no weight taken Review of the Interim Nutrition Note of 4/12/19 indicated: Resident weight recorded at 113 pounds and reflects a continued weight loss trend, meal intake at 50-75% and will add fortified cereal at breakfast. 4/17/19 no weight taken Review of the Interim Nutrition Note of 4/19/19 indicated: Visited with Resident today to address concerns with breakfast meal. Resident had a preference for Cream of Wheat, but had not been receiving it. The Resident reports lunch and dinner meals are good. 4/24/19 weight taken by Registered Dietician (RD) at 110.9 pounds (-2.1 pounds) and Nurse Practitoner notified. From admission (1/2019) to survey exit date (4/24/19) or 91 days/3 months, the Resident's total weight loss = 10.2 pounds which reflected a significant weight loss of 8.42% in 3 months. On 4/19/19 and 4/24/19, the Surveyor interviewed the Dietician. The Dietician said that she was under the impression that the physician had been notified about the Resident's continued weight loss, however no nursing progress notes or Nurse Practitioner notes indicate a change in condition or plan for a change in treatment. On 4/26/19 at 11:52 [NAME]M. the Surveyor interviewed the Nurse Practitioner (NP) by telephone. The NP said that he had not received an update from nursing staff about the Resident's weight loss and was unaware that the resident was not receiving his/her fortified cereal or meal preferences. The NP said that he was a little shocked about the weight on 4/24/19 after the Dietician reported the current weight to the NP. Please refer to F692.

Based on record review, resident observations, resident interviews and interviews with staff, the facility failed to ensure that residents maintained acceptable parameters of nutritional status, particularly by providing adequate interventions and evaluating their effectiveness to maintain body weight and prevent significant weight loss, for 5 of 5 residents (#2, #5, #6, #10 and #13) who had unplanned significant weight loss in a total sample of 17 residents. Findings include: The requirements for completing the standardized Resident Assessment Instrument (RAI) define significant weight change as any loss or gain of 5% or more in the past 30 days or 10% or more in the last 180 days. The RAI guidelines specify that "Weight loss should be monitored on a continuing basis; weight loss should be assessed and care planned at the time of detection and not delayed until the next MDS (Minimum Data Set) assessment." 1. The facility failed to provide adequate interventions and services to attempt to maintain body weight and prevent additional unplanned significant weight loss for Resident #6. In one year the resident lost 40 pounds, or 25% of the resident's body weight. Resident #6 was a long term resident of the facility with [DIAGNOSES REDACTED]. The resident had been receiving Hospice services since 6/21/12. Record review indicated that there had been no physician order to monitor the resident's blood sugar level. The most recent Minimum Data Set (MDS) assessment, dated 3/14/13, indicated the resident was totally dependent on one staff person for eating. The MDS assessment also indicated the resident had unplanned significant weight loss and a Stage II pressure ulcer. Review of the facility weight records revealed the resident's weight status was monitored monthly and had been stable at 159 pounds. Significant weight loss was noted on 6/5/12 (157 to 140 pounds) as the resident had a 17 pounds weight loss, which represent a 10.8% loss in 30 days and an 11.6% loss in 180 days. The resident received a House Consistent Carbohydrate (HCC) diet due to the [DIAGNOSES REDACTED]. When the Dietitian noted the significant weight loss on 6/12/12, the recommendation included to add 4 ounces of health shake supplement and to weigh weekly for 4 weeks. The next recorded weight on 6/20/12 was 138.9 pounds. The weight record showed that the resident gained some weight, up to 145 pounds on 7/9/12, but then began to lose weight again. On 8/9/12, the Dietitian noted a weight of 142.5 pounds and stable for one month. On 9/11/12, the Dietitian noted a weight of 141 pounds, stable for three months, but that the resident continued to trigger for significant weight loss of 11.6% in 6 months. On 11/8/12, the resident weighed 136.5 pounds, and by 2/1/13, the resident's weight was 126.0 pounds. In a note of 4/9/13, recording the most recent weight of 119 pounds, the Dietitian wrote the weight loss was most likely due to end of life process and said to continue the current interventions. Review of the Dietitian's notes from 6/12/12, to the time of survey review on 5/3/13, revealed that no other nutritional interventions other than the health shake supplements were attempted. The weight for May 2013 had not yet been taken at the time of survey. In one year the resident lost 40 pounds, or 25% of the resident's body weight. Despite this acknowledgement of on-going significant weight loss totaling 40 pounds in 12 months, the Dietitian did not make any other recommendations for interventions to address the resident's weight loss. The Dietitian also failed to consider and address the resident's [DIAGNOSES REDACTED]. nutritional condition. On 5/7/13 at 8:25 A.M., the resident was observed during the breakfast meal. A Certified Nurse Aide (CNA #1) was feeding the resident who was sitting up in bed. The resident's eyes were closed, and the resident appeared awake but sleepy, and not interested in eating. The resident took an occasional bite, but generally did not respond to coaxing and encouragement by CNA #1 who said that breakfast was the worst meal for the resident and the resident seldom ate well in the morning, but ate better at other meals. During interview on 5/7/13 at 3:00 P.M., the Dietitian said the resident's weight loss was unplanned and that, after checking the nutrition notes in the resident's record, there had been no additional interventions. She said staff were taking and recording the resident's weights and providing the supplement three times daily. The Dietitian said that no additional information on the resident's nutritional status was available other than what was located in the resident's record. The Dietitian said no consideration was given to developing an individualized meal plan for the resident, taking into account the meals or times when the resident ate more, as identified by CNA or nursing staff. The Dietitian did say that the resident's likes and dislikes were noted at the time of admission, but did not know if they had been updated at any time due to the resident's cognitive status. The Dietitian said the resident was on Hospice, so the weight loss was considered to be due to end of life process. According to review of the Hospice care plan available on the unit, dated 8/15/12, a problem was identified for nutrition and hydration. The approaches included: exploring concerns of decreased appetite; assess nutritional needs and tolerance; "nutritional changes are identified promptly and interventions initiated quickly ..." No specific interventions were identified or recommended. Following discussion with the Administrator, Director of Nurses and Corporate Regional Nurse on 5/7/13 at 3:00 P.M., the Director of Nurses provided notes from the facility's Clinical At Risk Evaluation (C.A.R.E.) meetings for Resident #6 back to August 2012. The only reference to the resident's weight status was on 8/14/12 when it was noted that the resident's weight was stable and was being followed by the dietitian. The Director of Nurses said there was no additional information and that the nursing staff had not initiated any interventions besides the supplement recommended by the dietitian in June 2012. 2. For Resident #2, the facility failed to provide meal assistance and failed to introduce new and timely approaches to prevent weight loss, for this resident who had a 24 pound weight loss since his/her readmission on 1/25/13. Resident #2 had [DIAGNOSES REDACTED]. According to the readmission/significant change Minimum Data Set (MDS) assessment dated [DATE] and the quarterly MDS dated [DATE], indicated the resident had some cognitive loss, and was independent in his/her eating abilities. The readmission MDS (2/1/13) identified the resident's height and weight as 58 inches and 122 pounds and indicated there was no weight loss and he/she required no nutritional interventions. The quarterly MDS (4/25/13) identified the resident's height and weight as 58 inches and 99 pounds and indicated the resident had no significant weight loss and he/she required no nutritional interventions. This assessment failed to identify the resident's 23 pound weight loss. Review of the nutritional care plan initiated on 1/8/13 and updated on 3/5/13 and 5/5/13, indicated the resident was at risk for weight loss due to poor intake, [MEDICAL CONDITION] and taking a long time to eat his/her meals. The interventions were diet as ordered, weekly weights, provide afternoon snacks, supplement as prescribed and respect the resident's decision for no intravenous fluids or tube feeding. Review of the weight record indicated the resident's weight on 1/25/13 was recorded 123 pounds, the 1/29/13 weight was 119.2 pounds and on 2/6/13 the resident's weight was 118.5 pounds, a weight loss of 4.5 pounds in one week. On 2/13/13, the resident's weight was 115 pounds, an additional weight loss of 3.5 pounds and total weight loss of 8 pounds since the resident's readmission on 1/25/13. The resident was not reweighed to check for accuracy on 2/13/13, even though the weight record triggered for a 6.5 % weight loss over the past 30 days. Further review of the weight record indicated the resident continued to lose significant weight and triggered weight loss each time the resident was weighed. The weight loss is as follows: - On 2/20/13, the resident's weight was recorded 110 pounds, an additional 5 pound loss, a 10.6 % loss in 30 days and a 7.6 % loss in 90 days. The resident was not reweighed. - On 2/21/13, the resident's weight was 109 pounds, an additional 1 pound loss and a total of 14 pounds since his/her readmission on 1/25/13. - On 3/1/13, the resident's weight was 103.6 pounds and the resident was reweighed. The reweigh validated an additional 5.4 pounds weight loss in one week. - Between 3/8/13 and 4/23/13, the resident's weight declined from 104.2 to 99 pounds, a weight loss of 24 pounds in approximately 3 months. Review of the medical record revealed the resident had initially been admitted to the facility on [DATE] for short term care following a hospitalization for a [MEDICAL CONDITION]. Following the resident's admission he/she was hosptalized on [DATE] for dehydration, pneumonia and [MEDICAL CONDITION] and readmitted to the facility for long term care on 1/25/13. The admission nursing assessment dated [DATE] indicated the resident was alert and oriented, his/her memory was intact and was able to make his/her own decisions. The resident had upper extremity [MEDICAL CONDITION] (2+), and had multiple skin issues. The nutrition readmission assessment dated [DATE], indicated the resident's height and weight was 58 inches and 122.2 pounds with a desirable body weight of 96 pounds (with a 10 pound variance). The resident's diet was a regular house and his/her intake was 25-50 % for breakfast, 0-50 % for lunch and a 50 % for dinner. The assessment indicated the resident was independent for eating and ate meals in room. The Dietician wrote the resident had a lactose intolerance, and had recommended to decrease the sodium in the resident's diet to 2 grams and recommended a 4 ounce health shake daily. Dietary interventions to address the resident's lactose intolerance, dietary sodium intake and the health shake were not implemented. On 2/14/13, the Dietician's progress note identified the resident had a 3.5 pound weight loss in one week and that the supplement recommended 2 weeks ago had not been implemented. Not only had the supplement not been started, the Dietician failed to identify the total weight loss of 8 pounds in two and half weeks and made no mention of the resident's lactose intolerance and low sodium diet. She attributes the weight loss to the resident's [MEDICAL CONDITION]. On 2/21/13, the Dietician's progress note continued to indicate the diet supplement recommended on 1/29/13 had not been implemented. She indicated the resident's weekly weight is pending and she will monitor and make changes as needed. Review of the weight record indicated the resident's weight of 110 pounds had been recorded on 2/20/13 at 10:00 A.M., and had experienced an overall weight loss of 13 pounds since readmission. Review of the Dietician's 3/5/13 quarterly assessment, and progress notes dated 3/12/13, 4/4/13 and 4/11/13, indicated the resident continued to lose significant weight and that his/her meal and supplement intake was suboptimal. The Dietician attributed the weight loss to diuretics and poor intake. The Dietician's recommendations were as follows: - On 3/5/13, the Dietician recommended adding an afternoon snack. - On 3/12/13, the recommendation was adding a Magic cup to the lunch meal. - On 4/11/13, the recommendation was to increase the daily supplement to twice day. - On 4/26/13, the recommendation included to add two milks on all meal trays. Record review failed to indicate that the afternoon snack, magic cup and extra milks were implemented. The medical record indicated the increase in the nutritional supplement to twice a day was initiated on 4/23/13, 12 days after it was recommended by the Dietician. The resident was observed and interviewed on multiple days of the survey. On 5/3/13 at 8:15 A.M. during the breakfast meal the resident was observed in room. The staff served the resident the meal and assisted with removing covers and utensils. The staff left the resident alone in his/her room. During observations on 5/3/13 and 5/7/13 at 1:00 P.M. and interview with the resident during these two lunch meals, the resident said the meals did not look appetizing to him/her. The meals were bland looking and colorless. There was no magic cup and no extra milks on any of the trays observed. The surveyor inquired about it, and the resident said he/she did not know what a magic cup was and could not tolerate milk. The resident did say that staff would leave drinks for him/her, and that he/she rarely received an afternoon snack. During these meal observations, several half filled cups of milk like drinks were on the resident's tray table. On 5/7/13 at 1:00 P.M. during this lunch meal observation, the resident said that staff left them and did not know how long they had been there. At that time the resident asked the surveyor to move a drink closer to him/her. The resident said his/her shoulders got stiff and needed help. The resident said although he/she did not want anyone feeding him/her, some assistance was okay. The resident said sometimes it was lonely being in the room all the time and he/she would yell for staff assistance. The surveyor inquired about the resident's appetite and food preferences. The resident said his/her appetite varied, and would not mind getting some foods he/she liked. The resident did not remember if anyone had asked his/her preferences. Review of the resident's breakfast and lunch meal tickets dated 5/3/13 and 5/7/13, indicated a house regular diet. The meal tickets failed to include the magic cup or extra milks. During interview on 5/7/13 at 2:30 P.M., the Dietician said she followed the weight summaries to determine weight loss. She said if a resident triggered weight loss, she would recommend weekly weights and monitor for trends. The Dietician said she was aware of Resident # 2's weight loss and had made several recommendations. She said that there was a problem implementing the supplement, but said that it was currently in place. She said she was not aware the magic cup and snack were not being provided and did not know why a lactose intolerant diet had not been implemented and if it affected the resident. The Dietician said she knew the resident ate in his/her room, but did not know if the resident would benefit from any social or physical assistance. During interview on 5/3/13 at 11:00 A.M., Staff Nurse #2 said the resident was alert and oriented and able to make own decisions. The nurse said the resident liked to stay in room, but often yelled and called out. The nurse said when staff responded the resident either did not know what he/she wanted, required repositioning, or just wanted someone to talk to. Staff Nurse #2 said the resident ate alone in room, ate both his/her meals and supplements poorly and other than setting up the tray, there were no other interventions. 3. For Resident #10, the facility failed to address the resident's weight loss by failing to follow the plan of care and failing to introduce new approaches for this resident who currently has a significant weight loss of 13.9 % over the past 180 days and a 17.5 pound weight loss from 3/28/13 through 5/6/13. Resident #10's [DIAGNOSES REDACTED]. According to the medical record the resident had been residing at the facility since December 2011. Review of quarterly MDS dated [DATE], indicated the resident's height and weight was 70 inches and 180 pounds. On 3/31/13, the resident was hospitalized after exhibiting increased destructive behaviors following the loss of a significant family member and an exacerbation of [MEDICAL CONDITION] and pneumonia. The resident was readmitted on [DATE]. Review of readmission weight, dated 4/22/13, indicated the resident's weight was 161 pounds on 4/22/13, a 9.5 % or 17.5 pound weight loss in 30 days; a 10 % or 21 pound weight loss in 90 days; and a 13.7 % or 25 pound weight loss in 180 days. According to the 4/24/13 admission Minimum Data Set (MDS) assessment, the resident was alert and oriented, independent in eating and was noted to have a weight loss of 5 % or more in the last month and or a 10 % or more in last 6 months. The resident's weight and height was recorded at 70 inches and 161 pounds. The readmission MDS failed to indicated any nutritional approaches. On 4/26/13, a nutrition care plan was initiated to prevent weight loss. The following interventions included diet as ordered and weekly weights for 4 weeks. The goals included to not have a significant change in weight in 30 and/or 180 days, and to not have a weight change of 3 pounds in 7 days. On 4/26/13, a focus nurse's note indicated the resident had a weight loss of 7.5 % over 90 days. The nurse compared the resident's readmission weight of 161 pounds on 4/22/13 to a weight of 178 pounds on 3/8/13. The note indicated the resident's health care agent, physician and dietician were made aware of the change. Review of the 4/26/13 medical nutrition assessment indicated the resident was alert, received a house diet (three times per day) in room and was independent in eating. The resident ate 100 % of breakfast, 25-100 % of lunch and 75-100 % of dinner. The Dietician listed the resident's height, but failed to list his/her readmission weight or usual weight, but listed the resident's desirable body weight as 166 pounds with a range of 10 pounds. She indicated the resident lost 9.5 % in 30 days, 10 % in 90 days and 13 % in 180 days. She attributed the significant weight loss to the resident's hospitalization period. The Dietician indicated the resident's intake was fair to good and she would monitor weekly weights per protocol to assess for trends. No additional interventions were recommended by the dietician. Additional review of the weight record failed to find evidence the resident was weighed weekly as dictated by the plan of care. On 5/6/13, two weeks after the facility had identified a significant weight loss, a weight was recorded indicating the resident had lost an additional half of pound. The weight record indicated a significant weight alert was triggered, but record review failed to indicate additional interventions. During interview on 5/7/13 at 2:30 P.M., the Dietician said she followed the weight summaries to determine weight loss. She said if a resident triggered weight loss, she would recommend weekly weights and monitor for trends. The Dietician said Resident # 10's weight loss occurred during the resident's hospitalization . She said she was monitoring for trends, but was unaware that the weights had not been done for 2 weeks and unaware that the resident's weight had slightly declined. During interview on 5/8/13 at 9:45 A.M., the resident said his/her appetite was not very good. The resident said he/she had lost two of his/her children, one in March 2013 and the other 5 years ago. In addition, the resident said he/she lost his/her spouse in May 2012. The resident said he/she was hospitalized and had been real sick both medically and emotionally. The resident said the new medications that helped control his/her mood were making him/her tired. The resident said food didn't interest him/her that much. The resident said the only thing he/she was aware of was that the request to have salt with meals was okay with the staff. The resident said he/she was not aware of anything else, but would not mind getting some of his/her food preferences. 4. For Resident #5 admitted [DATE] with [DIAGNOSES REDACTED]. Medical record review on 5/2/13 at 3:30 P.M. and survey observations (5/2-5/8/13) revealed this resident was fed a house diet consisting of ground meat, puree vegetables and fruit with [MEDICATION NAME] milk. The resident's meal intake percentage was recorded as 25 to 100 %. The resident experienced a change in status since admission to the facility in April of 2012, with decline in functional ability. The resident exhibited periods of agitation and distress with repetitive non sensible speech, and had a 12 pound weight loss (154 to 142). The nutritional progress note dated 8/9/12, reported that the resident's meal intake was good, although continued on a negative weight loss trend, with a body mass index (BMI) of 27 (above a desirable body weight) for the resident's height (60 inches) stature. An intervention plan included to add a 10:00 A.M. and 8:00 P.M. snack to promote weight maintenance. A nutritional assessment dated [DATE], indicated the resident had significant weight loss (9 %) since admission, weighing 140 pounds and meal intake was improved, now that the resident was fed by staff. Hospice services had started, and the dietitian's nutrition plan for this resident was to monitor monthly weights and be available as needed. Monthly nutrition progress notes dated from October 2012 to January 2013, continued to report the resident with continued gradual weight loss, totaling 15.5 pounds. The Dietician's progress note dated 1/8/13, indicated the resident continued to trigger for significant weight loss, consumed fair to good meal intakes, remained on hospice care, the plan was to continue to monitor. There were no new dietary interventions identified to attempt halt the resident's weight loss. The resident's most recent Quarterly Minimum Data Set Assessment (MDS), with a reference date of 2/21/13, indicated that the resident had severe cognitive impairment, and required extensive assistance from facility staff to complete activities of daily living. According to this assessment, the resident exhibited mood, physical, verbal, repetitive and behavioral symptoms, utilized a restraint device, received [MEDICAL CONDITION] medications, had a weight loss and a decline in health condition. The resident's weight loss was insidious without evidence of attention that the facility altered the plan of care in attempt to avoid further weight loss as possible. The resident received a house mechanical altered diet, with a snack at 10:00 A.M. and 8:00 P.M. (pudding), which had been the nutrition intervention plan since August 2012. The nutritional progress note dated 3/12/13, indicated this resident's meal intake varied from fair to good, and noted an additional 4 pound weight loss to 119.5 pounds. After this additional documented weight loss, the Dietitian recommended to add a 2:00 P.M. nutritional supplement (Health Shake) which was prescribed by the physician on 3/12/13. Review of the March 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview with the Dietitian on 5/7/13 at 2:20 P.M. could not offer an explanation for the delay in providing the nutritional supplement, or why other interventions were not attempted prior to the 3/12/13 recommendation considering the resident's continued weight loss. The resident was observed for the supper meal on 5/2/13 as staff fed the resident with good acceptance. At 12:16 P.M. during the 5/3/13 noon meal the resident was fed and ate ate over 50 % of meal. 5. The facility failed to provide adequate assessment and interventions for Resident #13 with fluctuations between significant weight gain and significant weight loss. The resident lost 12 pounds over a five month period, and no nutritional interventions were initiated. Resident #13 had lived at the facility for over three years. The resident suffered from on-going severe depression because of the death of an adult child in March 2012, which had impacted the resident's functional status and overall well-being. The resident was admitted to Hospice services on 12/11/12 due to the resulting decline in the resident's condition. Review of the current Minimum Data Set (MDS) quarterly review, dated 3/7/13, revealed that the resident was 66 inches tall and weighed 130 pounds, with no significant weight gain or loss. Review of the current care plan revealed no specific identified problem for nutrition. Review of the resident's weight history for 2012 revealed a gradual weight gain trend from 128 pounds on 2/28/12 to 138 pounds on 7/3/12. The resident received a "nutritious juice" supplement. On 5/8/12, the Dietitian wrote that the resident had a 3 pound weight gain in one week, that the resident's intake had been very good and that the nutritious juice continued to provide 200 calories and 6 grams of protein. The Dietitian wrote that the weight gain was "ok" and that the weight was within normal limits. On 7/5/12, the Dietitian noted that this was a significant weight gain. The Dietitian recommended that the nutritious juice be discontinued. This recommendation was repeated in the dietitian's note of 9/6/12 and no longer in use as of the 12/6/12 quarterly review. Further review of the weight history revealed that the resident's weight was stable from July through December 2012, ranging from 134 to 138 pounds. On 12/4/12 the resident's weight was recorded as 136 pounds. The next weight, taken twice on 12/31/12, was recorded as 129 pounds. This was noted as a significant loss of 5.1% in 30 days. On 1/8/13, the dietitian noted that the resident had significant weight loss over 30 days from 136 pounds to 129 pounds, and that intake was decreased when the resident was on antibiotics. The Dietitian also wrote that the resident was on hospice care and "weight loss could be related to end of life process. " The most recent documentation by the Dietitian was a note dated 3/5/13, in which the dietitian wrote that the resident weighed 130 pounds and was within the usual body weight (UBW) range of 128 to 138 pounds. The dietitian wrote that no care plan was needed for nutrition as the nutrition care plan was resolved. Review of the hospice care plan, dated 3/11/13, revealed that the resident was provided services due to a decline in function requiring increased assistance with activities of daily living related to [MEDICAL CONDITION] over the child's death The most recent weight noted was 126 pounds on 4/4/13, an additional loss of four pounds, for a total continued loss of 12 pounds over the past 6 months. Review of the current physician orders, dated 4/9/13, revealed that the resident was on a house regular diet with [MEDICATION NAME] milk. The resident did not have any orders for nutritional supplements. The monthly weight for May had not yet been recorded at the time of survey on 5/8/13. During interview on 5/7/13 at 3:00 P.M., the Dietitian said that there was no additional information related to the resident's weight loss. The Dietitian said the resident received hospice services, but provided no information related to any interventions that had been recommended or implemented to prevent additional unplanned weight loss.

Based on record review and interview, for one of three sampled residents (Resident #1), the Facility failed to educate staff to ensure that liquids were heated in the microwave to a safe temperature per Facility guidelines. On 3/26/13 Resident #1 was found with second degree burns (burn in which damage extends through the outermost layer of the skin and into the next layer of skin) on the right thumb. Resident #1 said the coffee had been re-heated in the microwave during the breakfast meal. Resident #1 said an unidentified staff member put the coffee in a double styrofoam cup because it was too hot to hold in one cup; he/she became startled when he/she lifted the cups because the double styrofoam cups were hot to hold, and he/she spilled some hot coffee on his/her right hand. Findings include. The Facility microwave re-heating chart guidelines indicated that when heating warm liquids in the microwave, not to exceed thirty seconds, and perform any additional heating in intervals of 30 seconds or less to reach the desired temperature. The Admission Record Form indicated that Resident #1 was admitted to the Facility February 2013 and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment, completed on 2/28/13, indicated that Resident #1 was understood and he/she understood others. The MDS indicated that Resident #1 had good recall. The MDS indicated that Resident #1 had no behaviors. The MDS indicated that Resident #1 was nonambulatory. The MDS indicated that Resident #1 was totally dependent and required extensive assistance of 2 staff for bed mobility. The MDS indicated that Resident #1 required extensive assistance of 2 staff for transfer activities. The MDS indicated that Resident #1 was able to eat and drink independently after set up. The MDS indicated that Resident #1 received no pain medication during the last five days and had no signs of pain during the last five days. The Surveyor interviewed Occupational Therapist (OT) #1 at 12:45 P.M. on 4/22/13. OT #1 said that Resident #1 was able to feed himself/herself independently and drink hot beverages independently. The Surveyor interviewed the Acting Food Service Director at 11:45 A.M. on 4/22/13. The Acting Food Service Director and OT #1 said since 3/26/13, when Resident #1 was found with a second degree burn on the right thumb, a thermal cup with a secured lid was provided by the kitchen staff to ensure his/her coffee arrived hot enough, and thus re-heating the coffee was no longer required. The Surveyor interviewed Unit Manager #1 at 8:30 A.M. on 4/22/13. The Surveyor interviewed Nurse #1 at 1:40 P.M. on 4/22/13. Unit Manager #1 and Nurse #1 said they were assigned to Resident #1's nursing care needs during the day shift. Unit Manager #1 and Nurse #1 said at times Resident #1 requested that his/her coffee be re-heated in the microwave and the coffee was previously re-heated without causing a burn. Unit Manager #1 said that Resident #1 reported to her on 3/26/13 that she had sustained a burn during the breakfast meal two days earlier. Unit Manager #1 said she immediately had the right thumb burn assessed by the Wound Physician who was on the unit when Resident #1 first reported the incident. Unit Manager #1 said she reported the incident to the previous Director of Nurses who initiated an internal investigation. The Surveyor interviewed the Wound Physician at 8:35 A.M. on 4/23/13. The Wound Physician said he evaluated the wound and said Resident #1 had sustained a second degree burn on his/her right thumb that he/she said was due to hot coffee that he/she spilled on his/her thumb two days earlier. The Wound Physician said he recommended a treatment, observed the area two more times during the next few weeks, and the area had since fully healed. The Wound Physician's report, dated 3/26/13, indicated that Resident #1 sustained a second degree burn on his/her right thumb due to spilling his/her coffee. The Wound Physician's report described the burn as occurring more than 24 hours ago and recommendations included silvadene (treatment for [REDACTED]. The Surveyor interviewed the Manager of Clinical Operations at 12:30 P.M. on 4/22/13. The Manager of Clinical Operations said all nursing staff and dietary staff were interviewed that were on duty when Resident #1 said the burn occurred. The Manager of Clinical Operations said all nursing staff and dietary staff denied they re-heated Resident #1's coffee on 3/24/13; however, nursing staff admitted that they routinely re-heated Resident #1's coffee because he/she liked it hot. The Wound Physician's reports, between 4/9/13 and 4/16/13, indicated the burn was fully healed on 4/16/13. The Surveyor interviewed Nurse #2 at 2:20 P.M. on 4/22/13. Nurse #2 said she was assigned to Resident #1's nursing care needs during the day shift on 3/24/13. Nurse #2 said she was a per diem nurse and was not aware that Resident #1 asked to have his/her coffee reheated. Nurse #2 said she received no reports that Resident #1 sustained a burn on 3/24/13. The Surveyor interviewed Certified Nurse Assistant (CNA) #1 at 4:00 P.M. on 4/24/13. CNA #1 said she was assigned to Resident #1's personal care needs from 7:00 A.M. to 11:00 P.M. on 3/24/13. The Surveyor interviewed CNA #2 at 2:05 P.M. on 4/24/13. CNA #2 said she was assigned to Resident #1's unit during the day shift on 3/24/13. The Surveyor interviewed CNA #3 at 1:50 P.M. on 4/24/13. CNA #3 said she was assigned to Resident #1's unit during the day shift on 3/24/13. The Surveyor interviewed CNA #4 at 2:00 P.M. on 4/24/13. CNA #4 said she was assigned to Resident #1's unit during the day shift on 3/24/13. CNA #1, CNA #2, CNA #3, and CNA #4 denied they reheated Resident #1's coffee on 3/24/13. CNA #2, CNA #3, and CNA #4 said they routinely re-heated Resident #1's coffee for about 1 minute in the microwave. CNA #1, CNA #2, CNA #3, and CNA #4 said they routinely served her coffee in a coffee mug from her meal tray. CNA #1, CNA #2, CNA #3, and CNA #4 said staff were provided the code to open the nutrition kitchen door on the unit to enable staff to use the microwave to reheat items for staff and residents. CNA #1, CNA #2, CNA #3, and CNA #4 said they were not aware that Resident #1 sustained a burn on 3/24/13. The Surveyor interviewed Nurse #3 at 11:00 A.M. on 4/23/13. Nurse #3 said she was assigned to Resident #1's nursing care needs during the night shift (11:00 P.M. on 3/24/13 to 7:00 A.M. on 3/25/13). Nurse #3 said that the night shift staff routinely completed Resident #1's personal morning care because he/she liked to get up early. Nurse #3 said she received no reports that Resident #1 sustained a burn on 3/24/13. Unit Manager #1 and Nurse #1 said they were assigned to Resident #1's nursing care needs during the day shift on 3/25/13. Unit Manager #1 and Nurse #1 said Resident #1 had not reported that a burn had occurred on the previous day and the injury was not reported by staff on 3/25/13. The change of condition documentation, dated 3/26/13, indicated that Resident #1 spilled coffee on his/her right hand a few days ago, sustained a second degree burn, was seen by the Wound Physician who was onsite when the injury was first reported, and Physician #1 was notified, The change of condition documentation indicated that Tylenol was offered for discomfort, but was declined, and a protective dressing was applied before new orders were obtained. The wound condition documentation form, between 3/26/13 and 4/16/13, indicated Resident #1 sustained a burn on the right thumb that was treated and had fully healed on 4/16/13. The Wound Physician's reports, between 3/26/13 and 4/16/13, indicated Resident #1 sustained a second degree burn on his/her right thumb due to spilling coffee on his/her right hand per Resident #1's report of how the injury occurred. The Wound Physician's report described the burn as occurring more than 24 hours prior to Resident #1 reporting the injury on 3/26/13. The Wound Physician's report recommendations included silvadene (treatment for [REDACTED]. The Wound Physician's report, dated 4/16/13, indicated the burn was fully healed on 4/16/13. The Manager of Clinical Operations said he/she completed the internal investigation. The Surveyor interviewed the Staff Development Coordinator (SDC) at 3:40 P.M. on 4/22/13. The Manager of Clinical Operations and SDC said prior to the incident the microwave reheating chart was posted by the microwaves but staff were not educated to ensure directions on the microwave reheating chart were followed. The Manager of Clinical Operations and SDC said staff were not provided thermometers with recommended safe temperature parameters to enable staff to check the temperature of food or liquids prior to serving the heated items to residents. The Manager of Clinical Operations said all nursing staff and dietary staff were interviewed that were on duty when Resident #1 said the burn occurred. The Manager of Clinical Operations said all nursing staff and dietary staff denied that they re-heated Resident #1's coffee on 3/24/13; however, nursing staff admitted that they routinely re-heated Resident #1's coffee because he/she liked it hot. The Surveyor interviewed the Staff Development Coordinator (SDC) at 3:40 P.M. on 4/22/13. The SDC said he/she was recently hired and he/she educated staff on the microwave reheating chart after the burn incident occurred. The Surveyor interviewed the Administrator at 4:15 P.M. on 4/22/13. The Administrator said the microwaves were stored in nutrition kitchens on the units that had a coded door to ensure only staff had access to the area. The Administrator said the Manager of Clinical Operations did the investigation and he since realized that prior to this incident the Facility had not educated staff on the Facility guidelines on heating foods and liquids in the microwave. The Administrator said prior to the burn incident staff, were not provided safe temperature parameters or thermometers to enable staff to check the temperature of food or liquids prior to serving. . The Administrator said the Facility had no previous incidents of burns due to hot liquids or foods that had been re-heated in the microwave. The Surveyor interviewed Resident #1 at 10:00 A.M. on 4/22/13. Resident #1 said he/she routinely asked staff to re-heat his/her breakfast coffee because he/she liked coffee hot. Resident #1 said he/she recalled that an unidentified staff member re-heated his/her coffee on a Sunday morning that he/she spilled on his/her right hand. Resident #1 said that he/she recalled the incident because staff were upset that he/she had not reported the burn for 2 days. Resident #1 said the unidentified staff member put the coffee in a double styrofoam cup because it was too hot to hold in one cup; he/she became startled when he/she lifted the cups because the double styrofoam cups were hot to hold, and he/she spilled some hot coffee on his/her right hand.

Based on interview and record review, for one of nine sampled residents (Resident #1), the Facility failed: 1 ) to ensure that an allegation of abuse was immediately reported to the Administrator. On 10/1/12 around 8:00 P.M. Certified Nursing Assistant (CNA) #1 and CNA #2 dared Resident #1, a mentally ill resident, to flash his/her naked body at CNA #3 and the Visitor. Although CNA #3 and CNA #4 told Nurse #1 that Resident #1 flashed CNA #3 with the coaxing of CNA #1 and CNA #2,, Nurse #1 did not report the alleged incident to the Administrator; 2) to prevent further abuse following the reported incident because, when Nurse #1 did not report the allegation or intervene in any way with CNA #1 and CNA #2, Resident #1 flashed his/her naked body at the Visitor (the spouse of CNA #1). CNA #1 said that, at 11:00 P.M,. she told Resident #1 that the Visitor would need psychiatric help because Resident #1 flashed him; 3) to prevent further potential abuse when the Facility terminated CNA #1 on 10/9/12, CNA #1 roamed the Facility, entered the room shared by Resident #1 and Resident #3 and shouted at and admonished Resident #1, in front of Resident #3, in an intimidating, punitive and retaliatory manner. After staff escorted CNA #1 out of Resident #1's room, CNA #1 returned to Resident #1's room a second time to yell at him/her, and 4) to prevent further potential abuse when CNA #1 called Resident #1 around 5:00 P.M. on 10/9/12 and threatened to tell Family Member #1 about the alleged incident. Findings include: Resident #1's most recent Quarterly Minimum Data Set (MDS) Assessment, dated 9/13/12, indicated that his/her cognitive patterns were intact, he/she ambulated independently in his/her room and used a wheelchair independently for mobility outside of his/her room. Resident #1's care plan concerns, initiated 7/23/10 and most recently updated 9/18/12, were reviewed. A care plan concern indicated that Resident #1's self care abilities were deficient due to [MEDICAL CONDITION] disorder, obesity and [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED] is a genetic disorder which involves the spine or its covering. The care plan interventions included the assistance of two staff members with personal care and encouraging Resident #1 to be as independent as possible. A second care plan concern indicated that Resident #1's decision making abilities were altered due to mental illness with auditory hallucinations and personality disorder. The care plan interventions included: provide care (to Resident #1) in pairs; gently redirect activities when Resident #1's actions are inappropriate; tell Resident #1 the behavior is inappropriate; modify the environment to prevent situations that trigger inappropriate behavior, and observe and report changes in cognitive status. A third care plan concern indicated that Resident #1 received multiple [MEDICAL CONDITION] medications due to mental illness and interventions included observing him/her for the appropriateness of interactions with others, for danger to self and for rapid mood changes. The Surveyor interviewed Resident #1 on 10/23/12 at 6:55 A.M. and at 1:55 P.M. Resident #1 said that, on 10/1/12 during the 3:00 P.M. to 11:00 P.M. shift, CNA #1 and CNA #2 dared him/her to flash the Visitor. Resident #1 said CNA #1 and CNA #2 told him/her that they would get him/her an ice cream if he/she flashed the Visitor. Resident #1 said CNA #1 and CNA #2 told him/her to practice flashing on CNA #3 before the Visitor arrived at the Facility. Resident #1 said that he/she flashed CNA #3 and CNA #3 looked horrified. Resident #1 said, a few minutes later the when Visitor arrived, Resident #1 flashed him. Resident #1 said that he/she did not want to flash and felt embarrassed. Resident #1 said CNA #1 and CNA #2 were on him/her all night about flashing CNA #3 and the Visitor and coached him/her to do it. Resident #2's most recent MDS Assessment Form, completed 7/5/12 indicated that his/her cognitive patterns were intact. The Surveyor interviewed Resident #2 on 11/6/12 at 1:45 P.M. Resident #1 said that he/she witnessed the alleged incident and found it disgusting. Resident #2 said that as he/she walked past Resident #1, Resident #2 saw Resident #1 lift his/her Johnny and expose his/her breasts. Resident #2 said he/she told Resident #1 not to do that CNA #2 approached Resident #2 and stated words to the effect, isn't it funny, (Resident #1) thinks (he/she) is going to get an ice cream for this. Resident #2 said he/she told CNA #2 that the incident was not funny and said it was disgusting. Resident #2 said that CNA #1 said words to the effect, (Resident #1) is going to flash (the Visitor). Resident #2 said that he/she saw Resident #1 flash CNA #3 and CNA #3 walked away disgusted. Resident #2 said CNA #1 stated words to the effect, (Resident #1) do it again, lift up you shirt. Resident #2 said that CNA #1, CNA #2, CNA #4 and Nurse #1 saw Resident #1 flash and laughed. Resident #2 said he/she was 100 % sure that Nurse #1 saw Resident #1 flash and did not intervene. Resident #2 said he/she did not see Resident #1 flash the Visitor, but later on during the 3:00 P.M. to 11:00 P.M. shift, Resident #1 told Resident #2 words to the effect, I think I messed up, I flashed (the Visitor) and I think they are going to get me an ice cream. Resident #2 said he/she told Resident #1 flashing was disgusting and not right and Resident #1 replied words to the effect, they were telling me to do it. The Surveyor interviewed CNA #3 on 10/23/12 at 2:15 P.M. CNA #3 said that, on 10/1/12 around 8:00 P.M., Resident #1 lifted up his/her Johnny above his/her head and exposed his/her naked body. CNA #3 said that he looked away quickly and continued down the corridor toward a sounding call light. CNA #3 said that, after answering the call light, he walked back to the day room and Resident #1 called out to him two more times and raised his/her Johnny over his/her head. CNA #3 said that CNA #1 and CNA #2 were near Resident #1 and laughed so hard that they leaned against the nurses' station for support each time Resident #1 exposed his/herself to him . CNA #3 said that, although he could not recollect the specific words spoken by CNA #1 and CNA #2 to Resident #1, he thought CNA #1 and CNA #2 pushed Resident #1 to expose his/her body to him and were very amused by Resident #1's behavior. CNA #3 said that he immediately reported the alleged incident to Nurse #1. The Surveyor interviewed CNA #4 on 10/23/12 at 6:15 P.M. CNA #4 said that on 10/1/12 around 8:00 P.M, she heard CNA #1, CNA #2 and Resident #1 laugh. CNA #4 said that although she was not attending to the conversation, she heard CNA #1, CNA #2 and Resident #1 refer to the Visitor and someone stated words to the effect of, I dare you and, another voice replied, do you dare me. CNA #4 said that, moments later, CNA #3 walked past Resident #1, CNA #1 and CNA #2 and Resident #1 lifted his/her Johnny to flash his/her naked body to CNA #3. CNA #4 said Resident #1 said something about [MEDICATION NAME]. CNA #4 said CNA #1 and CNA #2 laughed and CNA #3 walked away. CNA #4 said CNA #3 reported the incident to Nurse #1 and CNA #4 joined CNA #3 and told Nurse #1 that she also saw Resident #1 flash CNA #3. CNA #3 and CNA #4 said CNA #3 told Nurse #1 that he thought CNA #1 and CNA #2 pushed Resident #1 to flash him and CNA #3 and CNA #4 told Nurse #1 that CNA #1 and CNA #2 laughed when Resident #1 flashed CNA #3. The Surveyor interviewed Nurse #1 on 10/23/12 at 3:00 P.M. Nurse #1 said that she worked at the Facility on Resident #1's unit during the 3:00 P.M. to 11:00 P.M. shift on 10/1/12, but was not Resident #1's assigned nurse. Nurse #1 said that around 9:00 P.M., CNA #3 and CNA #4 told her that Resident #1 exposed his/her breasts to CNA #3. Nurse #1 said CNA #3 said Resident #1 thought flashing his/her breasts was funny. Nurse #1 said that she told CNA #3 that maybe CNA #3 should report the incident to the Evening Supervisor or the Director of Nurses. The Surveyor asked Nurse #1 about her written statement dated 10/2/12. The written statement indicated that CNA #3 told Nurse #1 that CNA #3 was very offended that they would encourage Resident #1 to (expose his/her breasts to CNA #3). The written statement indicated that Nurse #1 asked CNA #3 who they were and CNA #3 pointed to the staff members at the nurses' station. Nurse #1 told the Surveyor CNA #1 and CNA #2 were at the nurses' station. The Surveyor asked Nurse #1 whether she reported the allegation to the Administrator. Nurse #1 said she did not immediately contact the Administrator, the Director of Nurses or the Evening Supervisor about the incident because she was not Resident #1's assigned nurse, she did not witness the incident herself and she was very busy. Nurse #1 said she decided to address the incident the next day when she came back to work her next scheduled shift. Nurse #1 said she did not report CNA #3's allegation to Nurse #2 ( Resident #1's assigned nurse for the 3:00 PM to 11:00 PM shift) or Nurse #3 ( Resident #1's assigned nurse for the 11:00 PM to 7:00 AM shift). The Surveyor interviewed Nurse #2 on 10/25/12 at 8:00 P.M. Nurse #2 said she saw Resident #1 raise his/her Johnny over head twice during the 3:00 PM to 11:00 PM shift on 10/1/12. Nurse #2 said, on one occasion, she did not see any staff members present and on the other, she heard staff members laugh. Nurse #2 said CNA #1, CNA #2 and CNA #4 were present, but she did not recall words spoken by them or who specifically laughed. Nurse #2 said, on one of the occasions, she told Resident #1 words to the effect, we can't be doing that in the hallway. Nurse #2 said she did not intervene further because she was passing medications, felt stressed and did not want to make a medications error. CNA #4 said that, around 10:00 P.M,. Resident #1 called out the Visitor's name and pulled up his/her Johnny. CNA #4 said that although she heard CNA #1, CNA #2 and Resident #1 discuss the Visitor and a dare earlier during the 3:00 P.M. to 11:00 P.M. shift, when Resident #1 actually flashed Visitor #1, CNA #4 did not see CNA #1 and CNA #2 nearby. The Surveyor interviewed CNA #1 on 10/24/12 at 10:00 A.M. The Surveyor interviewed CNA #2 on 10/23/12 at 12:50 P.M. CNA #1 said that, at some point after dinner on 10/1/12, Resident #1 overheard her say that the Visitor planned to come to the Facility later on during the 3:00 P.M. to 11:00 P.M. shift. CNA #1 said that Resident #1 stated words to the effect, I'm going to flash (the Visitor). CNA #1 said she told Resident #1 words to the effect, you wouldn't dare and Resident #1 said words to the effect, no one should dare me. CNA #1 and CNA #2 said that, at that moment, CNA #2 approached Resident #1 and CNA #1. CNA #1 and CNA #2 said Resident #1 stated words to the effect, (CNA #2) do you double dare me and CNA #2 stated words to the effect, I double dare you to do what. CNA #2 said Resident #1 told them that he/she planned to flash the Visitor, and she and CNA #1 told Resident #1 that they dared him/her (to flash the Visitor.) CNA #1 and CNA #2 said that CNA #1 left the conversation to answer a call light and the conversation between CNA #2 and Resident #1 shifted to a plan for CNA #2 to bring Resident #1 an ice cream before a period of abstinence required for a scheduled medical test. Although CNA #1's statement written the day after the alleged incident indicated that she heard CNA #2 tell Resident #1 that CNA #2 would buy Resident #1 an ice cream if Resident #1 flashed the Visitor, when the Surveyor interviewed CNA #1 on 10/24/12, 23 days after the alleged incident, CNA #1 said did not hear CNA #2 state that she planned to buy Resident #1 an ice cream if Resident #1 flashed the Visitor. CNA #2 said that at the end of the conversation, Resident #1 wheeled his/her wheelchair toward the nurses' station and said that he/she was going to practice. CNA #2 said she asked words to the effect, practice what and Resident #1 did not answer. CNA #2 said that when Resident #1 reached the nurses' station, he/she raised up his/her Johnny over his/her head and exposed his/her naked body to CNA #3. CNA #2 said she laughed in response to Resident #1's behavior, but in a nervous way, not because she found the behavior amusing. CNA #1 said she saw Resident #1 flash CNA #3. CNA #1 said Nurse #1, Nurse #2, CNA #3 and CNA #4 were in the vicinity of the nurses' station and she thought they were in a position to see Resident #1 flash CNA #3 and CNA #1 said she heard several staff members laugh nervously. Although CNA #1 and CNA #2 said that CNA #2 told Resident #1 that it was not appropriate to expose her naked body, Resident #1, CNA #3 and CNA #4 said CNA #2 did not speak to Resident #1 after Resident #1 flashed. CNA #1 and CNA #2 said they did not tell Nurse #1 or Nurse #2 about their earlier conversation with Resident #1 during which they dared Resident #1 to flash the Visitor. CNA #1 said that a short while later, she heard the Visitor's voice on the unit and met the Visitor in the hallway. CNA #1 said the Visitor told her words to the effect, I told (Resident #1) that it was not nice for (him/her) to (flash) and he/she could go to jail for (flashing). CNA #1 said that she did not speak with Nurse #1 or Nurse #2 about Resident #1 flashing the Visitor but Nurse #1 would have to be stupid or crazy not to have known Resident #1 flashed the Visitor because she was right there when the incident occurred. CNA #1 said that as she was exiting the Facility at 11:00 P.M., she stopped by Resident #1's room and warned Resident #1 that the Visitor might need psychological help because Resident #1 flashed him. The Surveyor interviewed Nurse Manager #1 on 10/22/12 at 1:00 P.M. Nurse Manager #1 said that, on 10/2/12, she met with Resident #1 to discuss a report she received from the Director of Nurses that Resident #1 flashed CNA #3 during the 3:00 PM to 11:00 PM shift. Nurse Manager #1 said that during the conversation, Resident #1 told her that he/she exposed him/herself to CNA #3 and the Visitor because CNA #1 and CNA #2 dared him/her to flash them and offered him/her an ice cream if he/she flashed them. The Surveyor interviewed the Regional Director of Clinical Operations on 10/23/12 at 11:30 A.M. The Regional Director of Clinical Operations said that on 10/9/12, she and the Director of Nurses met with CNA #1 and CNA #2 to terminate them after the Facility internal investigation concluded. The Regional Director of Clinical Operations said that after she and the Director of Nurses terminated CNA #1, CNA #2 was already waiting outside of the Director of Nurses' office door and they did not accompany CNA #1 out of the Facility as usual. Resident #1 said that CNA #1 blasted him/her out verbally when the Facility terminated CNA #1. Resident #1 said CNA #1 told him/her words to the effect, I did not know that you would be stupid or dumb enough to flash (the Visitor). Resident #1 said CNA #1 told him/her that Resident #1 was manipulative and CNA #1 cried and yelled at him/her in an angry tone of voice. Resident #1 said she felt afraid. Resident #1 said that the Director of Nurses and Nurse Manager #1 told him/her when he/she first reported the alleged incident that the Facility would protect him/her and the Facility did not. CNA #1 said that, on 10/9/12 after the Facility fired her, she went back to confront Resident #1. CNA #1 said she asked Resident #1 why he/she lied and did not take responsibility for his/her own actions. CNA #1 said that she told Resident #1 that he/she had no accountability for his/her own actions and staff members at the Facility let Resident #1 get away with murder. CNA #1 said told Resident #1 that Resident #1 needed to remember what his/her actions might be doing to someone else. CNA #1 said she told Resident #1 that Resident #1 cost CNA #1 her job over a frivolous matter. CNA #1 said that after Nurse Manager #1 and the Assistant Director of Nursing physically escorted CNA #1 from Resident #1's room, she broke free of their hands and returned to Resident #1's room. CNA #1 said she told Resident #1 that Resident #1 had once told her that she was like a mother to Resident #1 and would Resident #1 (cause his/her own mother) to lose her job. The Surveyor interviewed the Scheduler on 10/24/12 at 10:55 A.M. The Scheduler said that, on 10/9/12,she brought Resident #1 a pitcher of water. The Scheduler said CNA #1 entered Resident #1's room, crying, shaking and upset. The Scheduler said that, in a loud tone of voice, CNA #1 yelled at Resident #1 words to the effect, you need to stop doing this to people, you are costing people their jobs and health insurance, you are effecting peoples families. The Scheduler said CNA #1 spoke to Resident #1 in a reprimanding way and Resident #1 did not respond. The Scheduler said Resident #3 was present in the room while CNA #1 yelled at Resident #1 and, at one point, CNA #1 stopped yelling at Resident #1 and hugged Resident #3 and told Resident #3 that CNA #1 would miss him/her. The Scheduler said Nurse Manager #1 and the Assistant Director of Nurses entered Resident #1's room. Resident #3's most recent Significant Change in Status MDS Assessment, dated 9/20/12, indicated that he/she heard adequately, usually understood others and his/her short term and long term memory skills were impaired. The Surveyor interviewed Nurse Manager #1 on 10/23/12 at 1:00 P.M. Nurse Manager #1 said that, on 10/9/12 shortly after 2:00 P.M., she heard yelling and responded to Resident 1's room. Nurse Manager #1 said CNA #1 was in Resident #1's room hollering and screaming at Resident #1 and the Scheduler was standing next to CNA #1. Nurse Manager #1 said CNA #1 hollered words to the effect, you are a 50 something year old woman, look at me, look at my face, you are making me lose my job. Nurse Manager #1 said Resident #3 was present in the room he/she shared with Resident #1 while CNA #1 yelled at Resident #1. The Surveyor interviewed the Assistant Director of Nurses on 10/24/12 at 10:00 A.M. The Assistant Director of Nurses said that she responded to the sound of yelling in Resident #1's room and found Resident #1, Resident #3, CNA #1, Nurse Manager #1 and the Scheduler in the room Resident #1 and Resident #3 to shared. The Assistant Director of Nurses said that CNA #1 yelled at and berated Resident #1. The Assistant Director of Nurses said CNA #1 stated words to the effect, look at what you have done, you cost me my livelihood. Nurse Manager #1 said she repeatedly told CNA #1 to stop. Nurse Manager #1, the Assistant Director of Nurses and the Scheduler said that, eventually, Nurse Manager #1 and the Assistant Director of Nurses put their hands on CNA 1's shoulders and guided CNA #1 out Resident #1's room. Nurse Manager #1, the Assistant Director of Nurse and the Scheduler said that, once in the corridor, CNA #1 stated words to the effect, I'm not done, broke free of their hands and returned to Resident #1's room again. Nurse Manager #1 said CNA #1 stated to Resident #1 words to the effect, look at my face, I'm crying, I lost my job and the Assistant Director of Nurses said CNA #1 stated words to the effect, you are not a child, you need to hear this, I'm not going to let you do this to anyone else. The Scheduler said CNA #1 stated words to the effect, I've always treated you like a mother and you have turned around and done this to me. The Scheduler said that, about an hour later, she spoke with Resident #1 and Resident #1 cried and said he/she felt scared and intimidated. Resident #1 said that around 5:00 P.M on 10/9/12, CNA #1 called Resident #1 on the telephone in his/her room and told Resident #1 that she was going to call Family Member #1 and tell Family Member #1 the things that Resident #1 did. Resident #1 said she reported CNA #1's telephone call staff members and the Facility changed his/her telephone number.

The facility failed to ensure that all residents were free from abuse and misappropriation of property, failed to thoroughly investigate all alleged abuse and misappropriation and failed to protect residents from further potential abuse and misappropriation, as follows. Based on record review and staff and resident interviews, the facility failed to protect sampled resident (#12), and keep the resident free from harassment and caused emotional distress from mental abuse. Based on the resident group interview, review of documentation and interview with staff, the facility failed to recognize resident allegations of misappropriation of personal belongings, failed to fully investigate all such allegations and failed to report these allegations to the Department of Public Health as required by federal and state regulation, for two residents, Resident #15 and #16, as well as five additional residents (Residents A, B, C and S and an unidentified resident) who were not in the sample. Findings are as follows: 1. For Resident #12, the facility had harassed, threatened and intimidated the resident, causing undo emotional distress and anxiety, by the facility's repeated attempts to transfer the resident out of a private room. The facility repeatedly threatened the resident with discharge and/or additional financial fees. Resident #12 had been admitted to the facility 5 weeks earlier after being diagnosed on [DATE] with the [MEDICAL CONDITION] disease ALS (Amyotrophic Lateral [MEDICAL CONDITION], also known as Lou Gehrig's Disease). The resident had been living at home but the disease had progressed to the point where the resident required palliative care. The initial Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had no cognitive, mood or behavior issues and was totally dependent on staff for all personal care and mobility. The resident had no voluntary use of any of the extremities. A review of the Care Area Assessment (CAA) summary, noted the resident's need for total assistance with activities of daily living was because of the [DIAGNOSES REDACTED]. Additionally, the resident fatigued easily and had shortness of breath. The resident had made two separate requests to speak with the surveyors on the first day of survey [DATE]. The surveyors met with the resident on [DATE] at 1:35 PM in the resident's room. The resident was sitting up in an upholstered chair, with her arms extended and resting on a cushion on the lap. Although the resident was able to converse, speech was slow and breathless. The resident was noted to have restriction of the head and neck movement, and was unable to move the rest of the body at all. The resident shared that this was a first experience with a long term care facility and expressed being very astonished and shocked at the treatment personally received from the people in charge. The resident described initially being admitted to the dementia unit and on the same day being moved to a double room on a the other rehab unit. The resident related being approached by Social Worker #1 on at least 4 separate occasions requested that the resident move from the double room on the other rehab unit to a private room located on the dementia unit. Social Worker #1 offered the private room on the premise that it was larger and would provide more space for necessary medical equipment. The resident described feeling anxious and uneasy about a move to a dementia unit. The resident said that after viewing the private room, the resident agreed to the move. The transfer was completed [DATE] at 9 AM. According to the resident, by 10 AM, an hour after settling into the room, Social Worker #1 came in and told the resident, "Sorry you're going to have to move to a shared room." The shared room was on the dementia unit. The resident described feeling bewildered by the request to move, and refused. The repercussions from this refusal to move were described by the resident as if the intent of the Administrator and Social Worker #1 was to force the resident to move. The resident went on to say that Social Worker #1 "badgered me." The resident said Social Worker #1 repeatedly approached the resident, and informed the resident "that I had to move." The resident was clearly distressed during this description of events. The resident's tone of voice was sad as she pleaded for help from the surveyors. The resident was noted to become more anxious and visibly upset as the resident told how the Administrator started coming to the resident's room and demanding the move. Although the resident was not specific about the time sequence of these events, the resident stated that Social Worker #1 later returned and was accompanied by the facility's business office manager. They told the resident to move. The resident stated he/she was "so angry by them coming to me" and of feeling "so sickened by this almost constant badgering" that "I told them to get out." This was followed by another visit from the Administrator two days later, who the resident described as "rude" and "nasty". The resident said, "He told me that I had no choice, and I had to move out of this room." The resident still attempted to refuse and was told by the Administrator that the consequence was that the resident would have to pay an extra $30.00 per day. When the resident told the Administrator that he/she could not afford this, the Administrator responded that the resident would be discharged if the extra charge wasn't paid. The resident said that in an attempt to protect him/herself, the resident asked the Administrator to put the threat in writing and told him to leave the room. The resident had become more distressed and was gasping for breath as he/she recounted the story of the last few weeks. The resident went on to tell the surveyors, that over the following two weeks they (Administrator and Social Worker) "backed off" and had not returned to the resident's room. This did not relieve the resident's anxiety over what they might do next and what might happen to him/her. Although the resident was not aware at the time, she later found out that the Administrator and Social Worker #1 had been calling and harassing a family member. The resident learned that the Administrator and Social Worker #1 had been calling the resident's family member and "badgering her" with the intent of moving the resident. The resident indicated there were several phone calls over a two week period. The resident said that the family member had been told that the resident had to vacate the room, pay the extra fee of thirty dollars or be discharged out of the facility. The resident reported being very upset that the facility staff had been contacting the family member. The resident added he/she made all his/her own decisions and expressed "my body may not work, but my brain does." The resident continued, "they are trying to wear me down." The resident shared feeling shocked and in disbelief of what had been done to him/her and added, "I don't know what will happen next." An interview was conducted with the Administrator and Social Worker #1 on [DATE] at 3:30 PM. Also present were the facility's Regional Vice President of Operations and the Regional Director of Clinical Operations. Social Worker #1 had been asked to describe the resident's room placement in the private room on [DATE]. Social Worker #1 stated the resident had been offered the room, due to the volume of the medical equipment needed for care. Social Worker #1 was asked if she had gone back to the resident after the resident moved and she stated "once to see how the resident was doing." The Administrator was asked if he had been to see the resident and he replied once. He added he had offered another room because of the resident's self-isolating behavior. He explained that the resident's self-isolating had been discussed at a morning meeting and staff felt the resident would benefit from socialization and a room mate. Per review, the medical record contained no reference to self-isolating, especially considering the resident's end of life care. The Administrator and Social Worker #1 were asked if either had contacted the resident's niece about moving the resident out of the private room. Both denied having contacted the resident's niece. After the interview, the Regional Director instructed the Administrator to go speak to the resident to reassure the resident and alleviate any fears of transfer or discharge. The surveyor was present during this meeting at the request of the resident, and following the Administrator's statement, the resident stated to the surveyor, "This was a different side of him." On [DATE] at 7:50 AM, the Regional Vice President of Operations informed the surveyors, that the Administrator and Social Worker #1 had been suspended. He explained that following the [DATE] meeting, the facility's corporate team had done their own investigation. Social Worker #1 had admitted contacting the resident and niece several times about moving, and stated that at the direction of the Administrator, she also told the resident and niece that an additional daily fee of $30.00 would be required to stay in the private room. He added they had interviewed the resident and the resident's niece and confirmed the resident's allegations of being badgered and harassed by the Administrator and Social Worker #1, and that their interactions with the resident were abusive. The surveyor visited the resident on [DATE] at 11:30 AM. The resident reported relief with finally having been heard and being assured that no move would happen nor would an additional charge occur. The facility had failed to ensure the resident was not subjected to undue mental and emotional harm from harassment and threatening the resident with transfer to a shared room, added room fees or discharge out of the facility. 2. The facility failed to fully investigate all allegations of misappropriation of resident property and failed to report these allegations to the Department of Public Health as required by federal and state regulation. During the group meeting with the residents on [DATE] at 1:30 PM, five of the thirteen residents in attendance complained personal belongings were missing or stolen from their rooms. The property included jewelry, a vase and clothing. The residents stated they had each reported the missing items to staff. On [DATE] at 10:00 AM, a meeting was held with the Administrator, Director of Nursing and Regional Clinical Director and the residents' reports of missing property were discussed. The Administrator stated that these issues were written up by staff on a grievance form and that the Director of Social Service followed through. The Administrator initially provided a log, but then on request the Social Worker provided the actual completed grievance forms. A review of the forms revealed that most of the forms were incomplete and included no information related to any investigation or related action undertaken by the facility. In some cases it was noted that the resident or family was reimbursed for the item, but in most cases no resolution was documented. Most of the forms were blank except for the statement by the resident/family of what was missing. A second interview was held with the Administrator, Director of Social Service, Director of Nurses and Regional Clinical Director the same day at 11:35 AM, after a review of the grievance forms. They were advised of the lack of completeness of the grievance forms. The Administrator responded that everything had been addressed and that each resident had been reimbursed. Upon specific inquiry, the Administrator reported that none of the reports had been considered misappropriation and confirmed that no investigations had been undertaken of any of the reports. When asked, the Director of Social Service stated, the facility policy was to reimburse the resident or family for the missing item only if a receipt of purchase of a replacement item was presented to the facility. She confirmed that many of the items had never been reimbursed because the resident or family had never submitted a receipt. The Administrator confirmed that no reports of misappropriation of resident property had ever been submitted to the state Department of Public Health as required by state and federal mandate. The grievance forms were reviewed and the following were noted to be allegations of potential misappropriation of resident property: a. Resident #15 reported a missing ring on [DATE], a "stolen" ring with pearls and diamonds on [DATE] valued at about $200, and a missing, possibly lost, gold pinky ring with small pearls and diamonds on [DATE]. Interview with Resident #15 on [DATE] at 2:00 PM, confirmed that there were two rings missing, one large ring with diamonds and pearls that had belonged to the resident's deceased spouse's mother and a smaller pinky ring with pearls and diamonds that had been missing for about one week. The resident stated that the nurses on the unit were told when the small ring was missing and the Director of Social Service had been notified of the same ring missing the day before. The resident stated that the resident's brother had been advised that a new ring would have to be purchased to replace the missing one that had been reported in December before they could be reimbursed. The resident stated "How am I supposed to get the $200 to buy a new ring? My brother doesn't have that kind of money either." No investigation had been done following the initial report on [DATE], that ring had never been found and the potential misappropriation had not been reported, as confirmed in the interview noted above. b. Resident #16 was now deceased but the spouse still resided at the facility. According to a grievance form, on [DATE] the resident reported to a nurse on the Santuit unit that $100 was missing from a packet in the resident's room. The Director of Social Service documented that a search was done but the money was not found. The documented follow-up was to replace the money and the facility business office was instructed to do this. The Director of Social Service wrote that she contacted the family to come to the facility to pick up the money on [DATE]. There was no reference to any investigation related to the missing money, and interview with the Director of Social Service and Administrator, as noted above, confirmed that no investigation had been conducted and no report of the misappropriation of the resident's money had been filed with the Department of Public Health. c. At the group meeting Resident A reported a missing watch and cigarettes. These were entered on the Grievance log kept by the Director of Social Service, but no grievance forms were provided. The resident reported 2 packs of cigarettes missing on [DATE] and the watch missing on [DATE]. Upon inquiry, the Director of Social Service provided a copy of a page of Social Service notes with two entries both dated [DATE]. The first note stated that the Resident A spoke with the Director of Social Service about the missing cigarettes. The noted also stated that the Administrator spoke with the resident and directed the resident to have someone get replacements and the resident would be reimbursed with the receipt. The second note was noted to be a late entry and stated that the missing watch had been reported but not found in an immediate search of the area. She wrote "All Departments aware to look out for it." d. On [DATE], Resident B reported multiple items stolen from the resident's room, including several make-up items, snacks, clothing and jewelry. The resident reported the stolen items to a staff nurse who completed the initial part of the grievance form listing the items. The remainder of the grievance form including the follow-up and resolution was blank. During the group meeting, the resident stated that she had made a verbal report to the nurse about many items stolen from the resident's room. The resident stated some had been replaced but not all. Upon inquiry, the Director of Social Service provided copies of receipts dated [DATE] and [DATE] for replacement items and copies of vouchers for reimbursement. However, according to the resident and later to the Director of Social Service, it was confirmed that not all items had been replace or reimbursed at the time of survey. Per interview with the Administrator and Director of Social Service as noted above, there was no investigation into the disappearance of the resident's items and no report of misappropriation made to the Department of Public Health. e. A grievance report was completed on behalf of Resident C, by the Activity Director on [DATE], which stated that $40.00 was taken from the resident's wallet which was in the resident's room. The only other information on the form was that the resident repeated the same story to the Director of Social Service and to the Administrator. There was no documentation of any follow-up or resolution. The Administrator and Director of Social Service did not provide any additional information, but did confirm, as above, that no investigation or reporting had been done. f. One resident at the group meeting, whose identity was not determined, stated during the meeting that a few months ago, the resident's daughter brought in a special dress of her own for the resident to wear to attend the granddaughter's graduation. After the event, the resident had the dress hanging in the closet until the daughter could come to pick it up and take it home. The dress was taken from the closet and could not be found. According to the resident, it was reported to staff that it was taken but the resident stated no response was ever received back and the dress was never found. Review of the grievance logs and forms yielded no report of the resident's missing dress. g. Resident S reported at the group meeting that a vase had been taken from the room. The resident stated that a family member had given a gift of an "Edible Arrangement" which was in a glass vase. Once the arrangement was gone, the resident had kept the vase to use again. The resident could not remember exactly when the vase was taken, but believed it was a few months previous. Upon review, an entry was found on the grievance log, dated [DATE], for the "missing vase" with the notation that "will reimburse when family replaces item. No grievance report was found regarding the vase. During interview, the Administrator was questioned about it and stated he was aware of the situation. He stated that the family was told to replace the vase and submit the receipt to be reimbursed, but did not believe they had done this. During interview as noted above, he confirmed that no investigation or reporting had been done.

Based on record review and staff interview, the facility failed for 2 residents (#7 and #9) of a total sample of 18 residents, to ensure that each resident receive necessary services to maintain range of motion and activities of daily living (ADL). The findings included: 1. The facility failed to provide services in accordance with the medical plan of care to maintain the resident's upper and lower range of motion. Resident #7 had [DIAGNOSES REDACTED]. The resident's annual Minimum Data Set Assessment (MDS) with a reference date of 1/27/11 indicated that the resident's memory was intact and had indicated that daily and activity preferences were important. The resident was identified as requiring from no assistance to supervision from facility staff for bed mobility, transfers, and ambulation, and limited assistance of one assist for dressing, toileting and personal hygiene. Beginning October 2010, the resident's care plan was updated to include a restorative nursing program 6 times per week to prevent declines in bilateral upper and lower extremities, to maintain ambulation, transfers and the use of left metal brace. Per review of the October 2010 monitoring sheet, the resident received the treatment on approximately 7 days per week from 10/5/10 through 11/18/10 during an 8 week period. The plan of care for self care deficits was updated on 11/5/10 and 2/2/11 indicating that the resident was to continue to participate in the restorative nursing program. Record review and discussion with the Assistant Director of Nurses on 2/18/11 at 3 PM could not explain why the resident had not received the treatments in accordance with the medical plan of care for stengthening and functional maintenance The physical and occupational therapy re-assessments, dated 2/2/11 and 2/15/11, reported the resident had last been seen from 9/7/10 through 10/10/10 for skilled services. They stated that at discharge from therapy the resident was independent in bed mobility, supervised with transfers and ambulated 220 feet with a rolling walking. The resident's current status was independent at wheelchair level, contact guard and a stand pivot for transfers and had told the therapist he/she would "like to get back to walking again." 2. The facility failed to provide services in accordance with the medical plan of care to maintain the resident's upper and lower range of motion. Resident #9 was admitted to this facility in September 2010 and had [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] identified the resident as hard of hearing with some short term memory loss. The resident required extensive assistance of two staff for transfers, toileting and bed mobility. In addition, the resident was unable to ambulate, was dependent with personal hygiene and had limited lower extremity range of motion. The resident used a wheelchair for mobility and had a history of [REDACTED]. The resident had a current plan of care dated 1/5/11 to address his/her self care deficits. Included in the interventions was for the resident to receive restorative nursing program 6 days per week. The care plan indicated this program had been initiated on 11/14/10. Record review found no evidence the resident had received the restorative nursing intervention. On 2/23/11 at 12 PM the medical record staff provided copies of flow sheets dated 10/30/10 through 11/26/10 and 12/4/10 through 1/18/11. The plan was for the resident to perform activities of daily living including transfers, dressing and/or grooming with verbal cues and at a seated position. Review of these flow sheets revealed the resident received the treatments approximately 6 to 7 days per week for seven of the twelve weeks and five of the remaining weeks had received the care less than five times and less per week. In addition, there was no evidence the resident was currently receiving the restorative nursing program. There was no flow sheet documentation after 1/18/11. Record review and discussion with the Assistant Director of Nurses on 2/18/11 at 3 PM could not explain why the resident whose current functioning status required extensive assistance of 2 staff for care had not received restorative nursing in accordance with the medical plan of care to maintain or improve the resident's ADL status.

Based on observation, record review and staff interview, the facility failed to identify and assess a pressure ulcer and failed to promptly implement interventions and efforts to treat the pressure ulcer for 1 resident (#2) in a total sample of 18 residents. Findings included: For Resident #2, the facility failed to identify and assess a facility acquired pressure area on the left heel. The facility had not followed the plan of care for skin integrity for prevention of wounds for this resident at high risk for the development of a pressure sore. The resident's pressure ulcer declined with pain and infection, and did not improve due to the failure to provide adequate pressure relief on the area on the resident's heel. Resident #2 was admitted to the facility in January 2011 from an acute care hospital for short term rehabilitation. [DIAGNOSES REDACTED]. The hospital record dated 1/7/11 indicated the resident had recently been treated for [REDACTED]. The resident was diagnosed with [REDACTED]. The resident's hospitalization was complex and addressed electrolyte abnormalities, [MEDICAL CONDITION] (which required blood transfusion), pain management, and wound care management for the lower extremities open wounds. Additionally, the hospital discharge record reported the resident had 3+ to 4+ [MEDICAL CONDITION] of the bilateral lower extremities with weeping. The resident had multiple ecchymotic areas on all four extremities, with scabbed excoriations on both legs. The treatment plan on discharge from the hospital included daily weights; elevate legs and ace wraps or [MEDICAL CONDITION] stockings daily. Per review of the record, the facility's initial nursing admission assessment dated [DATE] and 1/8/11, identified one wound on the resident's right lower arm which measured 2 cm long by .25 cm wide and covered with steri strips. Additionally, the resident had multiple areas with skin discolorations, multiple blemishes and scabbed over areas, but "nothing open and draining. " The admission physician orders [REDACTED]. The ace wraps were to be discontinued when the [MEDICAL CONDITION] stocking became available. The most recent Minimum Data Set (MDS) assessment, dated 1/12/11, indicated the resident was cognitively intact, and required extensive staff assistance for transfers, mobility, toilet use and bathing. The MDS reported the resident was continent of bowel and bladder and the overall goal was to return home after receiving rehabilitation services. In addition, the assessment identified the resident was at risk for developing pressure ulcers and therefore proceeded with a care plan for alteration in skin integrity. A review of the care plan for skin integrity dated 1/12/11, addressed the right arm skin tear and lower extremity [MEDICAL CONDITION]. The multiple interventions included following facility protocol for treating breaks in skin integrity, inspecting and monitoring feet for redness, [MEDICAL CONDITION] and open areas, pressure reducing devices as ordered, treatments as ordered, weekly skin assessments, elevate legs, ace wraps/[MEDICAL CONDITION] boots, monitoring for extremity [MEDICAL CONDITION] and weeping of legs and updating the physician with changes. The nurses' notes from 1/7/11 through 1/17/11, had no documentation of the resident's skin condition. One nurse documented on 1/9/11 that the resident's extremities were elevated in bed. Although this was part of the care plan, there was no entry on the treatment sheet. On 1/18/11, the plan of care for skin integrity was revised and included a new problem of a left heel ulcer. The plan stated to provide a treatment to the left heel ulcer "as ordered", but the treatment was not otherwise specified. Record review failed to find any evidence of a physician's orders [REDACTED]. The January 2011 treatment record had no documentation that a treatment was being done. The medical record had no information or evidence that any assessment of the ulcer and its condition was done, or that other interventions were provided. A review of the physician notes for 1/20/11 noted the left heel as a brown scab but he wrote no new treatment orders for this area. On 1/23/11 he wrote the resident's left heel was not improved and noted an area of eschar. He wrote in the note that the resident should have no weight bearing on the heel but ordered no treatment to the area. On 1/25/11, the nurse reported that the resident, family and staff met to review the plan of care. Although, the note indicated the resident was having difficulty in physical therapy and that a shoe with an open heel would be tried, there was no mention of the reason(s) why. There was no documentation of the left heel pressure sore, or any issues or complications related to the area. A subsequent note for the same day documented that an [MEDICATION NAME] pad would be applied to both heels prior to applying the [MEDICAL CONDITION] boots. On 1/26/11, the nurse wrote that gel pads would be applied prior to the boots being applied. There was no evidence the shoe with an open heel, the [MEDICATION NAME] pad or the gel pads were ever implemented. There was no documentation of the condition of the heel wound. On 1/27/11, the physician reported the left heel was "still quite painful" and there was redness surrounding the wound and the eschar was about the same. The physician ordered an antibiotic to treat [MEDICAL CONDITION] of the foot. Nurses notes and subsequent nurses notes failed to indicate signs and symptoms of infection or the condition of the residents skin. On 2/2/11 the nurses' note indicated the scab was peeling from the left heel with the skin pink and intact beneath. This note was followed by a note stating the physician had assessed the left heel wound and pain was only noted when touched or pressure applied. The physician wrote on 2/3/11 that the eschar was gone from the left heel; the area was clean and there was a shallow ulcer with surrounding redness. There was no other nursing documentation describing the "shallow ulcer." On 2/6/11 the resident was hospitalized and readmitted on [DATE]. The hospital readmission record dated 2/13/11 identified the resident with a Stage 2 left heel pressure ulcer. The left heel was positive for staph aureus and was surgically debrided at the hospital. The pressure wound orders included; to wash the left heel with normal saline, pat dry and apply topical [MEDICATION NAME] ointment with a 4X4 dry protective dressing; [MEDICATION NAME] for pain as needed; keep left extremity elevated; off load both heels with bunny boots and follow up with wound care center in one week. The facility's nursing readmission assessment dated [DATE], documented the resident's left heel had been debrided. The assessment had no information that described, staged and measured the wound. The treatment order from the hospital was incorporated into the current physician orders, but not the use of the bunny boots or other interventions to offload pressure to the resident's heels. On inquiry with the Unit 2 Nurse manager on 2/18/11 at 12:00 PM, she confirmed that the bunny boots had never been implemented as part of the resident's care plan. There was no documentation following any of the dressing changes, which were signed off on the treatment sheet. The care plan remained unchanged, but was revised only to add that the wound was a Stage 2 area on the left heel. On 2/14/11 the nurse's note stated the left heel was .5 cm with minimum drainage. From 2/14/11 through 2/17/11, the daily wound treatment was signed as done on the February treatment record. There was no documentation of the status of the wound. The physician on 2/17/11 described the left heel as 2 cm in size, with a depth of 4 mm. The surveyor on 2/18/11 at 12 PM observed the resident seated in a wheelchair in the room with ace wrapping applied from the toes to the upper legs. The wheelchair had no leg rests on the chair to support the lower extremities. The resident was not wearing shoes or any other protective covering except the ace wraps and both feet were resting on the floor, with both heels on the floor. The [MEDICAL CONDITION] boots were observed on top of a plastic storage container. The bunny boots were not found in the room. Per interview with the resident, he/she now was scheduled to go to the wound clinic. Additionally, following general discussion on 2/18/11 at 10 AM about skin/wound documentation with the Unit 2 Manager, record review on 2/23/11, revealed the facility staff only started using a "Pressure Ulcer Documentation Form" on 2/20/11 for this resident's left heel. The form recorded the onset of the pressure ulcer as 1/12/11 and provided a description. Other than this one assessment (completed 39 days after the onset of the pressure ulcer) there was no full assessment of the resident's pressure sore. Further record review revealed that the resident was sent to the wound clinic on 2/21/11 for an evaluation. The wound physician's orders [REDACTED]. suspended in heel boots. Despite these specific treatment recommendations, review of the current physician orders, treatment sheets and progress notes revealed the resident's plan of care remained unaltered. There was no evidence the staff was following any plan of care for treatment of [REDACTED]. Interview with the Assistant Director of Nurses on 2/23/11 at 1:30 PM, failed to provide any explanation or evidence that the facility staff had identified the pressure wound timely, had assessed, evaluated or reevaluated the resident's skin condition, and implemented interventions to promote healing.