Every finding on record at Sachem Center for Health and Rehabilitation

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed:1. For Residents #22 and #6, who were on enhanced barrier precautions due to wounds, to ensure staff wore appropriate personal protective equipment (PPE) while providing care;2. For Residents #11 and #9, to ensure proper infection control practices were maintained during a dressing change;3. For Resident #37, who was on contact precaution for Vancomycin Resistant Enterococcus Faecalis (VRE, a species of enterococcus bacteria that have developed resistance to the antibiotic vancomycin) to ensure staff wore appropriate PPE while providing care; and4. To ensure proper infection control practices were followed during the smoking activity. Findings include: Review of the facility's policy titled Precautions to Prevent Infection, revised 12/2023, indicated but was not limited to the following: - Transmission-Based Precautions are for patients who are known or suspected to be infected or colonized with infectious agents, including certain epidemiologically important pathogens, which require additional control measures to effectively prevent transmission. - Enhanced Barrier Precautions, which falls between Standard and Contact Precautions, and requires gown and glove use for certain residents during specific high-contact resident care activities that have been found to increase risk for MDRO (Multi Drug Resistant Organism) transmission. Residents defined at risk are those with indwelling medical devices or wounds who reside on units with residents known to be colonized with a novel or targeted MDRO. - High risk Resident care activities are identified as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of a device: central line, urinary catheter, feeding tube, tracheostomy/ventilator. - Contact Precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or patient's environment. - Contact Precautions also apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission. - Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination. - Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE. - Make PPE, including gowns and gloves available immediately outside of the resident room. Ensure access to alcohol-based hand rub (except in the use of C.difficle and during outbreak). Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. Review of the facility's policy titled Handwashing/Hand Hygiene, revised 7/2025, indicated but was not limited to the following: - This facility considers hand hygiene the primary means to prevent the spread of infections. - All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. - Use of an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before handling clean or soiled dressing, gauze, etc.; after handling used dressings, contaminated equipment, etc.; after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; before moving from a contaminated body site to a clean body site; after contact with resident's skin, and after removing gloves. - Single-use disposable gloves should be used when anticipating contact with blood or bodily fluids and when in contact with a resident who is on precautions. - Hand hygiene is the final step after removing and disposing of personal protective equipment. - The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 1A. Resident #22 was admitted to the facility in April 2026 with diagnoses including dementia and chronic obstructive pulmonary disease (COPD). Review of Resident #22's Minimum Data Set (MDS) assessment, dated 4/25/26, indicated he/she was cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 1 out of 15. Furthermore, the MDS assessment indicated he/she was at risk for pressure ulcers/injuries and was being treated for skin tears. Review of Resident #22's Physician's Orders indicated but were not limited to: - 4/10/26: Enhanced Precautions – wounds; every shift. On 5/17/26 at 8:55 A.M., the surveyor observed an Enhanced Barrier Precaution (EBP) sign outside Resident #22's room, which indicated the following: - EVERYONE MUST: clean their hands, including before entering and when leaving the room. - Providers and staff must also wear gloves and a gown for the following High-Contact Resident Care Activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy), wound care (any skin opening requiring a dressing). - Do not wear the same gown and gloves for the care of more than one person. On 5/18/26 at 9:19 A.M., the surveyor made the following observations: - Certified Nursing Assistant (CNA) #3 entered Resident #22's room with linens without donning any PPE or completing hand hygiene. - CNA #3 assisted Resident #22 with a transfer from the EOB (edge of bed) to his/her wheelchair. CNA #3 did not have a gown on during the transfer and was only wearing gloves. - At 9:35 A.M., CNA #3 assisted Resident #22 with oral hygiene while he/she was seated in their wheelchair. CNA #3 did not have a gown on while completing the tasks and was only wearing gloves. - At 9:45 A.M., CNA #3 removed and changed linens from Resident #22's bed. CNA #3 was not wearing a gown while completing the removal/changing of linens. During an interview on 5/18/26 at 11:25 A.M., CNA #3 said residents with EBP signs outside of their room require staff to wear a gown and gloves when completing high contact tasks. CNA #3 said a gown and glove needed to be worn when transferring, performing care or changing linens. During an interview on 5/19/26 at 2:27 P.M., Nurse #1 said any resident who has EBP signage requires staff to wear a gown and gloves when performing tasks such as changing linens, providing care or transferring. During an interview on 5/20/26 at 10:14 A.M., the Director of Nursing (DON) said staff should have worn a gown and gloves when providing care and transfers with Resident #22. B. Resident #6 was admitted to the facility in August 2024 with diagnoses including dementia and type II diabetes. Review of Resident #6's MDS assessment, dated 4/25/26, indicated he/she was cognitively impaired as evidenced by a BIMS score of 3 out of 15. Furthermore, the MDS assessment indicated he/she was at risk for pressure ulcers/injuries and was being treated for a diabetic foot ulcer. Review of Resident #6's Physician's Orders indicated but were not limited to: - 1/29/26: Enhanced Precautions; every shift. On 5/17/26 at 8:55 A.M., the surveyor observed an EBP sign outside Resident #6's room, which indicated the following: - EVERYONE MUST: clean their hands, including before entering and when leaving the room. - Providers and staff must also wear gloves and a gown for the following High-Contact Resident Care Activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy), wound care (any skin opening requiring a dressing). - Do not wear the same gown and gloves for the care of more than one person. On 5/18/26 at 9:46 A.M., the surveyor made the following observations: - CNA #3 entered Resident #6's room and put dirty linens from his/her bed in a bag and brought them out to the hallway. CNA #3 did not put on a gown prior to entering Resident #6's room. CNA #3 did not perform hand hygiene prior to entering the Resident's room. - CNA #3 then brought clean linens into Resident #6's room. CNA #3 did not perform hand hygiene prior to entering the room. - At 9:50 A.M., CNA #3 entered Resident #6's room and put new linens on their bed. CNA #3 did not don (put on) a gown prior to completing the linen change. During an interview on 5/18/26 at 11:25 A.M., CNA #3 said residents with EBP signs outside of their room require staff to wear a gown and gloves when completing high contact tasks. CNA #3 said a gown and glove needed to be worn when transferring, performing care or changing linens. During an interview on 5/19/26 at 2:27 P.M., Nurse #1 said any resident who has EBP signage requires staff to wear a gown and gloves when performing tasks such as changing linens, providing care or transferring. During an interview on 5/20/26 at 10:14 A.M., the DON said staff should have worn a gown and gloves when completing linen changes in Resident #6's room. 2A. Resident #11 was admitted to the facility in December 2025 with diagnoses including cerebral infarction and stage 4 pressure ulcer of heel (stage 4 pressure ulcer is characterized by full-thickness tissue loss that exposes underlying muscle, tendon or bone). Review of Resident #11's MDS assessment indicated he/she was cognitively impaired as evidenced by a BIMS score of 3 out of 15. Furthermore, the MDS assessment indicated he/she was dependent for functional mobility, was at risk for pressure ulcers/injuries and had two stage four pressure ulcers. Review of Resident #11's Physician's Orders indicated but were not limited to the following: - 5/26/26: To right heel wound: NSW (normal saline wash) followed by hydrofera blue foam, cover with ABD pad (abdominal pad), wrap with kling; every day shift every Tuesday, Thursday, and Saturday and as needed. - 5/5/26: To left heel wound: NSW followed by hydrofera blue foam, cover with ABD pad, wrap with kling; every day shift every Tuesday, Thursday, and Saturday and as needed. On 5/19/26 at 9:09 A.M., the surveyor observed a dressing change with the Assistant Director of Nursing (ADON), who is also the wound round nurse. The following observations were made: - ADON completed hand hygiene prior to donning PPE (gown/gloves) before entering Resident #11's room. - After donning a gown and gloves, the ADON used her gloved hands to touch her laptop computer to confirm the Resident's dressing orders. With the same gloved hands, the ADON then opened two drawers of the treatment cart to gather the supplies for the dressing changes. - The ADON then entered Resident #11's room and placed the dressing supplies down on Resident #11's bedside dresser. - The ADON used her scissors to remove the old dressings from the right and left heels, removed her gloves, completed hand hygiene and put on new gloves. - With the new gloves donned, the ADON returned to the treatment cart and opened a drawer to gather more supplies (gauze pads) to complete the dressing changes. The ADON did not change her gloves after opening the cart and did not perform hand hygiene. - The ADON used her scissors to cut the hydrofera blue dressing to the shape of Resident #11's wound. The scissors used were not cleaned in between removing the old dressings and cutting the new treatment. - The ADON applied the dressing to the right heel and then applied the dressing to the left heel. The ADON did not change her gloves between the right heel and left heel dressings, nor did she perform hand hygiene. - The ADON grabbed linens (hand towels placed under each heel) used during the dressing changes from Resident #11's bed and then grabbed the treatment supplies with the same gloved hands used to pick up the linens. - The ADON placed the used linens down on a chair in Resident #11's room and brought the treatment supplies back to the cart outside of the Resident's room and placed them on top of the cart. The ADON then removed her PPE and completed hand hygiene. During an interview on 5/19/26 at 12:12 P.M., the ADON said she should have changed gloves between touching the treatment cart and removing Resident #11's old dressings. The ADON said she does not typically change her gloves when putting on Resident #11's new dressings because they are the same treatment. The ADON said she should have put the dirty linens in a bag and changed her gloves before bringing the treatment supplies back to the treatment cart. During an interview on 5/20/26 at 10:14 A.M., the DON said hand hygiene and glove changes are expected after removal of old dressings, when a staff member comes in contact with a surface such as a computer or treatment cart, as well as when there is contact with dirty linens. B. Resident #9 was admitted to the facility in December 2023 with diagnoses which included protein-calorie malnutrition, Peripheral Vascular Disease (PVD-circulation disorder), Diabetes Mellitus with diabetic neuropathy (nerve damage commonly affecting the feet and legs causing numbness/pain). Review of the MDS assessment, dated 5/4/26, indicated Resident #9 scored 14 out of 15 on the BIMS Assessment indicating he/she was cognitively intact, had PVD, a Multi-Drug-Resistant Organism (MDRO-bacteria resistant to multiple standard antibiotics), septicemia (serious life-threatening bloodstream infection), a wound infection, and had a surgical wound. Review of the Physician's Orders indicated but were not limited to the following: -Enhanced Barrier Precautions every shift related to wound. -Left Transmetatarsal Amputation (TMA-surgical procedure that removes the front part of the foot) Normal Saline Wash (NSW), pat dry, apply mupirocin ointment (prescription strength topical antibiotic) followed by bordered gauze dressing every day. On 5/20/26 at 1:15 PM., the surveyor observed Nurse #3 perform wound care to Resident #9 as follows: -Nurse #3 donned (put on) a gown and gloves at the doorway to Resident #9's room, entered the room with the wound care supplies and set the supplies on the table. -Resident #9 was lying in bed, the left leg was exposed, and the TMA site was covered with a visibly soiled dressing, and there was a foul odor. The non-skid sock that had been over the dressing was visibly soiled with brown/yellow drainage. -Nurse #3 poured the NSW onto the bordered gauze dressing, removed the soiled dressing, and set it aside. The dressing had brown and yellow drainage on it and the wound had a foul odor. The wound bed was red with grey slough (necrotic (dead) tissue that may be moist, loose, or stringy), the peri wound (surrounding skin) was red, tender, and edematous (swollen due to excess fluid). -Nurse #3 cleansed the wound with NS and then patted the wound dry. Nurse #3 did not change her gloves and used the same ones she used to remove the soiled dressing. -Nurse #3 measured the wound with a disposable tape measure using the same gloves used to remove the soiled dressing. -Nurse #3 picked up the tube of Mupirocin Ointment, opened the cover, and started to squeeze the ointment out of the tube directly onto the wound. She stopped before touching the wound, placed the tube back on the table and removed her soiled gloves. -Nurse #3 put clean gloves on without performing hand hygiene after removing the soiled gloves. -Nurse #3 picked the Mupirocin Ointment up from the table and squeezed the ointment onto her gloved fingers and spread the ointment on the wound bed. -Nurse #3 removed her gloves (did not perform hand hygiene) and then removed a permanent marker from her pocket and wrote the date on the bordered gauze dressing that was open on the table. -Nurse #3 applied the bordered gauze dressing to the TMA wound site with her bare ungloved hands, rubbing all 4 sides to fully secure the adhesive border, then applied tape to two of the sides to further secure the dressing. -Nurse #3 picked up a non-skid sock from the pile, confirmed the sock Resident #9 wanted to wear, and walked to the bathroom. Nurse #3 got a pair of gloves from the bathroom and applied them without performing hand hygiene, walked back to the bedside and put the sock over the dressing, disposed of the trash, and bagged the soiled linen. -Nurse #3 removed the soiled gloves, the gown had thumb loops to hold the sleeves in place, the loops were still on her hands, hand sanitizer was applied and rubbed in with the plastic gown thumb loops still on her hands. The gown was then removed, rolled, and disposed of in the trash. The surveyor did not observed Nurse #3 perform hand hygiene after removing the gown. The table used during the dressing change was wheeled out of the room and down the hallway to be cleaned. During an interview on 5/20/26 at 1:35 P.M., Nurse #3 said Resident #9 is on EBP for their wounds and staff must wear a gown and gloves when they do care. She said when doing wound care you should sanitize your hands, remove the old dressing, clean the wound, change your gloves to put the new dressing on, and then sanitize or wash your hands when you are done. She said you should do hand hygiene between glove changes, but she did not. She said sometimes she forgets. Additionally, she said she should have put clean gloves on to apply the new dressing and not done that with her bare hands. During an interview on 5/20/26 at 1:41 P.M., Unit Manager #2 said everyone should have a gown and gloves on to perform any high contact care for Resident #9, including dressing changes. She said hands should be sanitized between glove changes, gloves should be worn to apply a dressing, and hands should be sanitized or washed after removing the gown before exiting the room. During an interview on 5/20/26 at 2:03 P.M., the ADON/Wound Nurse said hand hygiene should be done when you enter/exit a room and between glove changes. Additionally, staff should wear gloves when applying a dressing to a wound. During an interview on 5/20/26 at 2:37 P.M., the DON said gloves should be worn during dressing changes and hand hygiene should be done when entering/exiting a room and between glove changes. 3. Review of the Centers for Disease Control Management of Multidrug-Resistant Organisms in Healthcare Settings, last revised 2/15/17, indicated but not limited to: - Contact precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are transmitted by direct or indirect contact with the patient or the patient's environment. -Healthcare Personnel caring for patients on Contact Precautions should wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. - Donning gown and gloves upon room entry and discarding before exiting the patient room is done to contain pathogens (example VRE). Resident #37 was admitted to the facility in April 2026 with diagnoses including benign prostatic hyperplasia (BPH - is a noncancerous enlargement of the prostate gland) and presence of urogenital implants (surgical placement of medical devices within the urinary tract). Review of the MDS Assessment, dated 4/17/26, indicated Resident #37 had a moderate cognitive deficit as evidenced by a BIMS score of 10 out of 15 and he/she had a suprapubic catheter (a flexible tube inserted through the abdomen directly into the bladder to drain urine when natural urination isn't possible). Review of Resident #37's Physician's Orders indicated but was not limited to: - Maintain VRE precautions (contact precautions) urine every shift, dated 4/29/26 - Suprapubic Catheter Site Care- maintain Enhanced Precautions every shift, dated 5/7/26 Review of Resident #37's Urine Culture results, dated 5/15/26, indicated but was not limited to: - Organism: Vancomycin Resistant Enterococcus Review of the CDC Contact Precautions sign, undated, posted outside of Resident #37's room indicated but was not limited to: - Everyone must: Clean their hands, including before entering and when leaving the room. - Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Review of the CDC EBP sign, undated, posted outside of Resident #37's room indicated but was not limited to: - EVERYONE MUST: clean their hands, including before entering and when leaving the room. - Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, and wound care: any skin opening requiring a dressing On 5/17/26 at 8:38 A.M., the surveyor observed CNA #2 providing morning care to Resident #37 as follows: - CNA #2 donned gloves but failed to don a gown. - CNA #2 assisted Resident #37 in applying his/her shoes. - CNA #2 doffed her gloves, performed hand hygiene and exited Resident #37's room. - CNA #2 returned to Resident #37's room, performed hand hygiene and donned gloves. - CNA #2 failed to don a gown prior to entering Resident #37's room. - CNA #2 removed soiled linen from Resident #37's bed and placed them in the soiled linen cart. During an interview on 5/17/26 at 8:43 A.M., CNA #2 said Resident #37 was on EBP because he/she had a catheter. CNA #2 said she only needed to wear a gown when doing care. On 5/18/26 at 7:06 A.M., the surveyor observed CNA #1 assisting Resident #37 with activities of daily living as follows: - CNA #1 donned gloves. - CNA #1 failed to don a gown prior to entering Resident #37's room. On 5/18/26 at 7:16 A.M., CNA #1 said he was not sure why Resident #37 was on contact precautions. CNA #1 said he had donned gloves prior to providing care but had not donned a gown. On 5/18/26 at 7:15 A.M., the surveyor made the following observations: - CNA #4 performed hand hygiene and donned gloves. - CNA #4 put shoes on Resident #37. - CNA #4 failed to don a gown prior to entering Resident #37's room. During an interview on 5/19/26 at 3:04 P.M., CNA #4 said he was not aware why Resident #37 was on contact precautions. CNA #4 and the surveyor reviewed CDC Contact Precaution sign outside Resident #37's room. CNA #4 said he did not don a gown prior to providing care to Resident #37, but he should have. On 5/19/26 at 8:10 A.M., the surveyor made the following observations: -Unit Manager #1 entered Resident #37's room and removed his/her breakfast tray. -Unit Manager #1 failed to don gloves or a gown. During an interview on 5/20/26 at 10:14 A.M., the DON, who is also the facility's Infection Preventionist (IP), said if there is an EBP sign and a Contact Precaution sign outside of a resident's room then staff must follow the higher precautions. During an interview on 5/20/26 at 11:50 A.M., Unit Manager #1 said Resident #37 had VRE in his/her urine. She said Resident #37's urine was contained in his/her catheter drainage bag. She said she would only don gloves and a gown if emptying Resident #37's catheter drainage bag, providing care, or when there is a risk of coming into contact with Resident #37's urine. During an interview on 5/20/26 at 12:07 P.M., the IP said Resident #37 had VRE in his/her urine. She said staff, prior to entering or exiting Resident #37's room, must perform hand hygiene, and don/doff gloves and a gown. 4. Review of the facility's policy titled Smoking Policy- Residents, revised July 2025, indicated but was not limited to: - The facility shall establish and maintain safe resident smoking practices. - Residents are not permitted to give smoking articles to other residents. On 5/18/26 at 1:02 P.M., during the 1:00 P.M. smoking time, two surveyors observed the following breaches in infection control: - Activity Aide #3 put a cigarette in his/her mouth, lit it, and passed it to Resident #58 who smoked it. On 5/19/26 at 8:50 A.M., during the 8:45 A.M. smoking time, the surveyor observed the following breaches in infection control: - Activity Aide #4 put a cigarette in his/her mouth, lit it, and gave it to Resident #28 who smoked it. On 5/19/26 at 1:09 P.M., during the 1:00 P.M smoking time, two surveyors observed the following breaches in infection control: -Activity Aide #1 put a cigarette in his/her mouth, lit it, and passed the cigarette to Resident #29 who smoked it. -Resident #28 smoked a vape and passed it to Resident #58 who took a puff of the vape 3 different times. During an interview on 5/19/26 at 3:08 P.M., Activity Aide #1 said the Activity staff were responsible for lighting the residents' cigarettes. Activity Aide #1 said sometimes if a resident cannot ignite their own cigarette from a lighter then staff would do it for them. Activity Aide #1 said he/she would put the cigarette in their mouth and light/ignite it, then pass it to the resident to smoke. During an interview on 5/19/26 at 9:50 A.M., Activity Aide #2 said residents should not share any smoking or vaping materials. Activity Assistant #2 said if he/she saw residents sharing smoking or vaping materials he/she would intervene. Activity Assistant #2 said he/she would not intervene when Resident #28 and Resident #58 shared smoking or vaping materials because they were friends. During an interview on 5/20/26 at 9:59 A.M., Activity Aide #5 said staff should never put resident smoking materials in their mouth because it is unsanitary. Activity Aide #5 said residents should not share smoking/vaping materials for infection control reasons. During an interview on 5/20/26 at 10:05 A.M., the Activity Director said all residents must be supervised. The Activity Director said staff should intervene if residents are sharing smoking/vaping materials. The Activity Director said staff should never put residents' smoking materials into their mouth and light it. During an interview on 5/20/26 at 11:52 A.M., Unit Manager #1 said residents should never share smoking/ vaping materials and staff should never put residents smoking materials into their mouth for infection control reasons. During an interview on 5/20/26 at 12:07 P.M., the DON, who is also the facility's IP, said for infection control concerns staff should never put smoking materials that belong to residents into their mouth and residents should not be sharing smoking materials.

Based on observation, interview, and test tray results, the facility failed to ensure staff served palatable, attractive, and flavorful food at appetizing temperatures for two out of two test trays conducted. Findings include: Review of the facility's policy titled General Food Preparation and Handling, undated, indicated but was not limited to: -Food items will be prepared to conserve maximum nutritive value, develop and enhance flavor, and keep free of harmful organisms and substances. On 5/18/26 at 1:30 P.M., the Resident Council meeting was conducted with 18 residents in attendance. During the meeting the residents collectively expressed having ongoing food concerns, with specific complaints including the following: -The facility frequently used canned food for majority of food items; -Foods provided were not appealing, with 17 out 18 residents stating, You should see the appearance and It is terrible and has no taste. During an observation with an interview on 5/18/26 at 11:40 A.M., the surveyor observed the lunch tray line and noted the Mexican rice to be white in color. Dietary Staff #1 said the Mexican rice was made without the red spices because residents said it was too spicy and did not like the rice with the red spices. On 5/18/26 at 11:42 A.M., the food truck containing Test Tray #1 left the kitchen for the Sachem unit and arrived at 11:45 A.M. At 11:59 A.M., the last tray was delivered to a resident. At 12:00 P.M., the surveyor completed a regular texture test tray with the following results in degrees Fahrenheit (F): - Fish taco: 126F, good temperature, good flavor; - Corn: 120F, warm temperature, plain flavor; - Mexican rice: 125F, white in color, lukewarm temperature, rice tasted plain - could not detect any herbs or spices. On 5/19/26 at 11:38 A.M., the food truck containing Test Tray #2 left the kitchen for the Sachem unit and arrived at 11:42 A.M. At 11:57 A.M., the last tray was delivered to a resident. On 5/19/26 at 12:04 P.M., the surveyor and Nurse #3 completed the regular texture test tray with the following results: -Pierogi casserole: 144F, warm, soft texture, flavorful; -Peas: 120F, warm temperature, texture soft and flavor bland; -Cabbage: 123F, lukewarm temperature, flavor bland - no seasoning; Nurse #3 said the peas and cabbage tasted plain with no seasoning. On 5/19/26 at 12:04 P.M., the surveyor completed the mechanical soft test tray with the following results: -Pierogi casserole: 125F, temperature warm not hot, soft texture easy to chew, flavorful; -Peas: 118F, lukewarm temperature, flavor bland with no spices; -Cabbage: 122F, lukewarm, flavor bland with no spices. During an interview on 5/20/26 at 2:33 P.M., the Administrator said food items should be prepared per policy and served at appropriate temperatures.

Based on observation, record review, and interview, the facility failed to ensure it provided an environment free of potential safety hazards for supervised residents who smoke, out of a total sample of 19 residents. Specifically, the facility failed:1. To ensure safe smoking practices were implemented for supervised residents who smoke; and2. For Resident (#58), to ensure the appropriate protective equipment was applied while smoking.Findings include:Review of the facility's policy titled Smoking Policy- Residents, revised July 2025, indicated but was not limited to:-The facility shall establish and maintain safe resident smoking practices.-The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision.-Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking.-Residents are not permitted to give smoking articles to other residents.Review of the facility's policy titled Smoking Policy, undated, indicated but was not limited to:-Smoking is prohibited in any area that would create a hazardous or unsafe condition.1. On 5/18/26 at 8:46 A.M., during the 8:45 A.M. smoking time, the surveyor observed the following:- Two Activity Assistants supervising the residents during the designated smoking time- Resident #69 dropped ash from his/her cigarette onto the ground- Resident #58 used his/her first cigarette to light his/her second cigarette- Resident #69 used his/her first cigarette to light his/her second cigarette- Resident #77 handed his/her lit cigarette to Resident #34 to light their cigaretteOn 5/18/26 at 1:02 P.M., during the 1:00 P.M. smoking time, two surveyors observed the following:- Two Activity Assistants supervising the residents during the designated smoking time- Resident #58 handed a cigarette butt to Resident #12, who put it out and put it into an ashtray- Activity Aide #3 put a cigarette in his/her mouth, lit it, and passed it to #58 who smoked it- Resident #34 used his/her first cigarette to light his/her second cigarette- Resident #10 used his/her first cigarette to light his/her second cigarette- Resident #34 snuffed out his/her cigarette on their wheelchairDuring an interview on 5/19/26 at 8:09 A.M., Resident #12 said the Activity Staff supervise smoking. Resident #12 said residents cannot have lighters on them and the activity staff was responsible for lighting residents' cigarettes. Resident #12 said they are aware they are not supposed to light their second cigarette with their first cigarette, but he/she does it anyway. Resident #12 said when staff see him/her using their first cigarette to light their second cigarette they do not say anything to him/her.On 5/19/26 at 8:50 A.M., during the 8:45 A.M. smoking time, the surveyor observed the following:- Activity Aide #4 put a cigarette in his/her mouth, lit it, and passed it to Resident #28 who smoked it- Resident #34 used Resident #58's cigarette to light his/her first cigarette- Resident #34 used his/her first cigarette to light his/her second cigarette- Resident #7 and Resident #28 flicked their cigarette ash onto the patio, no ashtray was near the residents-The designated smoking area was left unattended and unsupervised for approximately four minutes, with two Residents (#28 and #29) smoking out of a total of nine present with access to a lighter.On 5/19/26 at 1:00 P.M., during the 1:00 P.M. smoking time, two surveyors observed the following:- Two Activity Aides (#1 and #4) were smoking while supervising the designated smoking time- Resident #7 flicked cigarette ash onto the patio; there was no ashtray near him/her- Activity Aide #1 put a cigarette in his/her mouth, lit it, and passed the cigarette to Resident #29 who smoked itDuring an interview on 5/19/26 at 3:08 P.M., Activity Aide #1 said the Activity Department was responsible for supervising the three designated smoking times. Activity Aide #1 said the Activity Staff was responsible for lighting the residents' cigarettes. Activity Aide #1 said residents are not supposed to use their previous cigarettes or other residents' cigarettes to light another cigarette. On 5/20/26 at 8:51 A.M., during the 8:45 A.M. smoking time, the surveyor observed the following:- One of three activity staff members were vaping- One of three activity staff members were smoking- Two Residents (#28 and #58) were sharing a vape- Resident #34 used his/her first cigarette to light his/her second cigarette - Resident #34 snuffed out two cigarettes on his/her wheelchairDuring an interview with observation on 5/20/26 at 9:09 A.M., the surveyor observed Activity Aide #1 assisting Resident #34 back to his/her unit. Activity Aide #1 and the surveyor observed two cigarette butts on Resident #34's wheelchair where the footrest connects to it. Activity Aide #1 said Resident #34 should have extinguished their cigarette and disposed of the cigarette butts in an ashtray. Activity Aide #1 said he/she did not see the extinguished cigarette butts on Resident #34 wheelchair until the surveyor had pointed them out.During an interview on 5/20/26 at 9:10 A.M., Resident #34 said he/she uses his/her first cigarette to light his second cigarette, but the activity staff should light their cigarettes. Resident #34 said if there was not an ashtray near them then they would flick the cigarette ash onto the ground and snuff out his/her cigarette on their wheelchair. Resident #34 said if there was an ashtray near them, then he/she would use it to snuff out his/her cigarette in it.During an interview on 5/20/26 at 9:59 A.M., Activity Aide #5 said residents cannot be left unattended during the designated smoking times and at least one staff member should be present to supervise the residents. Activity Aide #5 said staff members are supposed to light all of the residents' cigarettes especially since some residents are sneaky and will try to take the lighter with them. Activity Aide #5 said some residents do use their first cigarette to light their second cigarette, but they are not supposed to.During an interview on 5/20/26 at 10:05 A.M., the Activity Director said all residents must be supervised if they are a supervised smoker and must not be left unattended and unsupervised while smoking. The Activity Director said all the residents' cigarettes must be lit by a staff member for safety. The Activity Director said while supervising smoking no staff members should be smoking, they are supervising not taking a break.During an interview on 5/20/26 at 11:52 A.M., Unit Manager #1 said there were not any independent smokers in the facility and all of the residents who smoke were supervised. Unit Manager #1 said while supervising the smoking, Activity Staff absolutely should not be smoking, they are supervising smoking not smoking themselves.During an interview on 5/20/26 at 12:07 P.M., the Administrator and the Director of Nursing (DON) said all cigarette ashes and cigarette butts must be disposed of in an ashtray. The Administrator and the DON said cigarettes must be extinguished in an ashtray and not on resident wheelchairs. The Administrator and the DON said residents must be supervised during the designated smoking times and staff needed to light all of the residents' cigarettes. The Administrator and the DON said, If you are smoking, then how are you supervising the residents who are smoking?2. Resident #58 was admitted to the facility in February 2025 with diagnoses including executive function deficit following cerebral infarction (stroke) and nicotine dependence. Review of the Minimum Data Set assessment, dated 3/11/26, indicated Resident #58 was cognitively intact as evidenced by Brief Interview for Mental Status score of 14 out of 15. Review of Resident #58's current Physician's Orders indicated but was not limited to:- Smoker. Resident may smoke with supervision, dated 4/22/25. Review of Resident #58's Smoking and Safety Assessment, dated 5/1/26, indicated but was not limited to:-Which of the following products does the Resident use: Tobacco-Does the Resident display any of the following? Drops ashes on self.-Smoking Safety Notes: -Resident #58 will continue as a supervised smoker but will have to wear the smoking apron on his/her lap. Review of Resident #58's Smoking Safety care plan indicated but was not limited to:-Focus: Resident is a smoker Date Initiated: 02/23/25 Revision on: 08/14/25-Intervention: Resident #58 will wear an apron on his/her lap when smoking, Date Initiated: 5/1/26.On 5/19/26 at 1:09 P.M., two surveyors observed Resident #58 in the designated smoking area, smoking a cigarette, with two staff members present. Resident #58 did not have his/her smoking apron donned (on).During an interview on 5/19/26 at 3:08 P.M., Activity Assistant #1 said the Activity Department was responsible for supervising residents during smoking times. Activity Assistant #1 said Resident #58 recently started wearing a smoking apron because he/she had been dropping cigarette ashes on themselves. Activity Assistant #1 said Resident #58 must wear a smoking apron every time he/she smoked. Activity Assistant #1 said Resident #58 did not have a smoking apron on during the 1:00 P.M. smoking time and Activity Assistant #1 and Activity Assistant #4 forgot to put Resident #58's apron on. During an interview on 5/20/26 at 11:52 A.M., Unit Manager #1 said Resident #58 was recently re-evaluated for smoking safety because he/she was observed to put cigarette ashes on his/her chest. She said Resident #58 needed to be supervised and to wear a smoking apron every time he/she smoked for safety.During an interview on 5/20/26 at 12:07 P.M., the DON said residents who smoke needed to wear the required protective clothing/equipment every time they went outside to smoke for safety. The DON said Resident #58 should have had his/her smoking apron on while smoking.

Based on record review and interview, the facility failed to ensure for one Resident (#9), out of a total sample of 19 residents with an alteration in skin integrity, specifically a Left Transmetatarsal Amputation (TMA-surgical procedure that removes the front part of the foot) received necessary treatment and services to promote healing. Specifically, the facility failed to monitor, assess, and identify wound deterioration and signs/symptoms of an infection until he/she was seen by the Wound Care Physician, and the clinical signs of infection were identified and a treatment implemented. Findings include: Review of the facility's policy titled Charting and Documentation, dated as last revised 7/2023, indicated but was not limited to the following:-The following information is to be documented in the medical record: observations, treatments performed, changes in the residents' condition, and progress toward or changes in the care plan goals and objectives.-Documentation of procedures and treatments will include care specific details including the assessment data and/or any unusual findings obtained during the procedure/treatment. Review of the facility's policy titled Change in Resident's Condition or Status, undated, indicated but was not limited to the following:-The nurse will notify the resident's attending physician when there has been a significant change in the condition, and the medical treatment plan needs to be altered.-A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention.-The nurse will record in the medical record information relative to the change in condition. Resident #9 was admitted to the facility in December 2023 with diagnoses which included protein-calorie malnutrition, Peripheral Vascular Disease (PVD-circulation disorder), Diabetes Mellitus with diabetic neuropathy (nerve damage commonly affecting the feet and legs causing numbness/pain). Review of the Minimum Data Set assessment, dated 5/4/26, indicated Resident #9 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) Assessment indicating he/she was cognitively intact, had PVD, a Multi-Drug-Resistant Organism (MDRO-bacteria resistant to multiple standard antibiotics), septicemia (serious life-threatening bloodstream infection), a wound infection, and had a surgical wound. Review of the Comprehensive Care Plan indicated but was not limited to the following:-Resident #9 has potential and actual impaired skin integrity. Interventions include Monitor for skin breakdown, Measure area weekly, Weekly Skin Assessment, Monitor for worsening skin tissue, Treatment as ordered, and Update Physician with changes in wound status. Review of the medical record including progress notes and transfer documents indicated Resident #9 was transferred to an acute care hospital in March 2026 for a fever and elevated heart rate. Review of the Hospital Discharge paperwork indicated Resident #9 was treated for fever and cellulitis (bacterial skin infection causing redness, swelling, and pain) of the left foot, to continue antibiotics and follow up with the wound clinic. The Wound Description indicated the left foot at the bottom of the foot, below amputation site was spongy, draining, and had black skin. Review of the Treatment Administration Record (TAR) for March 2026 indicated three of 12 days prior to the transfer, the treatment to the left TMA site was not signed off as administered. Review of the progress notes, skin assessments, and skilled evaluations in March 2026 leading up to the transfer failed to indicate an assessment and condition of the TMA surgical site wound or any signs/symptoms of deterioration/infection of the wound. Review of the Wound Physician Notes for March through May 2026 indicated but were not limited to the following:-3/3/26 Left TMA site, duration >444 days, wound size: 1.3 x 0.8 x 0.1 centimeters (cm), 100% granulation tissue (pink/red healing tissue), moderate serous drainage (clean/pale yellow thin/watery), no signs of infection.-3/10/26 Left TMA site, wound size: 1.2 x 0.8 x 0.2 cm, 30% thick devitalized necrotic tissue (dead tissue)/70% granulation tissue, moderate serous drainage, no signs of infection.-4/7/26 Left TMA site, wound size: 0.9 x 0.6 x 0.2 cm, 80% granulation tissue/20% dermis (middle layer of skin), moderate serous drainage, no signs of infection. Improved evidenced by decreased necrotic tissue.-4/28/26 Left TMA site, wound size: 1 x 0.6 x not measurable cm, dried fibrinous exudate (scab), no signs of infection.-5/5/26 Left TMA site, wound size: 0.8 x 0.5 x 0.4 cm, 50% thick devitalized necrotic tissue/50% granulation tissue, moderate serous drainage, no signs of infection. Treatment changed to include Mupirocin 2% Ointment (prescription topical antibiotic cream to treat bacterial skin infections by stopping the growth).-5/12/26 Left TMA site, wound size: 5 x 3 x 0.4 cm, 40% granulation tissue/60% dermis, moderate serous drainage, exacerbated due to infection. One or more signs of clinical infection. Treatment changed to include Doxycycline 100 milligrams (mg) twice daily for 10 days (antibiotic). Review of the progress notes, skin assessments and skilled evaluations from March through May 2026 failed to indicate a change in condition of the TMA site, an assessment of the site, or any signs/symptom of infection until evaluated by the Wound Physician on 5/12/26 during the routine weekly visit. Furthermore, the Skilled Evaluations routinely indicated Skin Tissue had not been evaluated and the Weekly Skin Evaluations failed to indicate wound description and status of the wound. The wound was six times larger than the week prior (5/5/26 through 5/12/26), was exacerbated, and had clinical signs of infection. Review of the current Physician's Orders indicated but were not limited to the following:-Left TMA Site Normal Saline Wash (NSW), pat dry, apply Mupirocin ointment followed by bordered gauze dressing every day (5/5/26). On 5/20/26 at 1:15 PM., the surveyor observed Nurse #3 perform wound care to Resident #9 as follows:-Resident #9 was lying in bed, the left leg was exposed, and the TMA site was covered with a visibly soiled dressing, and there was a foul odor. The non-skid sock that had been over the dressing was visibly soiled with brown/yellow drainage.-The wound bed was red with grey slough (moist dead tissue), the peri wound (surrounding skin) was red, tender, and edematous (swollen).-Nurse #3 measured the wound at 8 x 4.5cm. Review of the progress notes, skin assessments and skilled evaluations from May 12-20, 2026, failed to indicate the further deterioration of the TMA site. The wound was larger than the week prior (5/12/26 through 5/20/26) and had clinical signs of infection. During an interview on 5/20/26 at 1:35 P.M., Nurse #3 said weekly skin checks are done by the managers, usually the Unit Manager or the Director of Nurses (DON) and the nurses on the floor don't routinely do them. Additionally, she said the Skilled Evaluations are assigned by shift and should address the wound status, but they do not. She said if there is a change in condition of a wound it should be documented and the provider should be called. During an interview on 5/20/26 at 1:41 P.M., Unit Manager #2 said the weekly skin checks and skilled evaluations should discuss wound care, progress or deterioration and then follow up with the provider as needed. She said the weekly measurements are from the Wound Doctor notes but the description of the wound should be documented by nursing and they are not. She said the notes are a generic template and incomplete. Additionally, she said she has never seen Resident #9's wound. She said she does some of the weekly skin checks, but the DON does a lot of them. During an interview on 5/20/26 at 12:55 P.M., Resident #9 said the medicine nurse is the one that does the treatment to their foot. He/she said they do the treatment and look at my skin. He/she said the managers don't do the treatment and do not check their skin. During an interview on 5/20/26 at 2:03 P.M., the Assistant Director of Nurses (ADON)/Wound Nurse said she expects the weekly skin checks to be complete and accurate. She said the weekly measurements are done by the wound doctor, but a description of the wound and any changes should be documented by the nurse and the physician notified of any changes. She said the Skilled Notes should also include wound information related to description, drainage, size, redness, and change in condition. She said she does weekly rounds with the Wound Doctor so the terminology she uses from the Doctor's note may be different than what the nurses generally document, but they should be describing what is going on with a wound in the evals and notes and should have picked up on the signs of infection, notified the provider, and not waited for the Wound Doctor to identify the deterioration and infection. During an interview on 5/20/26 at 2:37 P.M., the DON said the weekly skin checks are scheduled during the week. She said active wounds have measurements done by the wound doctor weekly, new areas should be noted on the skin checks, and any changes in the current wound like drainage, redness, swelling, odor etc. should be documented. She said Skilled Evaluations are a template note and the system lets you bypass sections and complete the note. She said she reviews that the notes are done but does not review them for content. She said residents that have wounds should have the wound assessment documented. She said Resident #9's notes and evaluations do not discuss the status of his/her wound or when it started to show changes. Additionally, she said the change in wound condition and signs of infection should have been addressed by the nurses before he/she went out to the hospital with a fever in March and before they were seen by the Wound Doctor in May. She said the wound is significantly larger in size now than it was and the notes do not reflect that change in wound status. The DON said the nurses are doing the treatment, but there is no documentation except from the Wound Doctor about the wound and there should be. She said the process needs improvement as they are not capturing the change in the wound condition by skipping the skin area of the notes, not evaluating the wound, and simply writing followed by wound doctor on the skin assessment.

Based on observation and interviews, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to:-Ensure food items were properly dated and stored in the main kitchen; and-Ensure the main kitchen and food storage areas were maintained in a sanitary and safe condition. Findings include:Review of the 2022 Food Code by the United States Food and Drug Administration (FDA) indicated, but was not limited to: 3-305.11 (A) Except as specified in paragraphs (B) and (C) of this section, food shall be protected from contamination by storing the food (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. 3-305.12 Food Storage, Prohibited Areas. FOOD may not be stored:(G)Under leaking water lines, including leaking automatic fire sprinkler heads, or under lines on which water has condensed;(I) Under other sources of contamination. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. Except when PACKAGING FOOD using a reduced oxygen packaging method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 Celsius (41 Fahrenheit) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request. 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A food specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3- 501.17(A), except time that the product is frozen; (2) Is in a container or package that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3-501.17(A). 6-101.11 Surface Characteristics. (A) Except as specified in (B) of this section, materials for indoor floor, wall, and ceiling surfaces under conditions of normal use shall be: (1) SMOOTH, durable, and EASILY CLEANABLE for areas where FOOD ESTABLISHMENT operations are conducted. Smooth means: (3) A floor, wall, or ceiling having an even or level surface with no roughness or projections that render it difficult to clean. Review of the facility's policy titled General Food Preparation and Handling, undated, indicated but was not limited to:-Food items will be prepared to conserve maximum nutritive value, develop and enhance flavor and keep free of harmful organisms and substances;-Leftovers must be dated, labeled, covered, cooled and stored (within 1/2 hour after cooking or service) in a refrigerator;-Use leftovers within 7 days per 2013 Food Code or discard. Check state regulations for more details. Review of the facility's policy titled Food Storage, undated, indicated but was not limited to:-Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination;-Storage areas will be free from rodent and insect infestation;-All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods;-Leftover food will be stored in covered containers or wrapped carefully and securely. Each item will be clearly labeled and dated before being refrigerated. Leftover food is used within 7 days or discarded as per the 2017 Federal Food Code;-Refrigerated food storage: all foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. Review of the facility's policy titled Dry Storage Areas, undated, indicated but was not limited to:-Dry storage areas will be maintained to keep food safe and free of infestation or contamination;-floors, walls, shelves and other storage areas will be kept clean;-canned and dry foods should be labeled with date of receipt so that they will be used within six months of delivery (or according to the manufacturer's guidelines). -the storeroom will be cleaned on a regular basis. Floors will be swept and mopped at least weekly and more often as needed. On 5/17/26 at 7:25 A.M., the surveyor observed the following in the refrigeration units:-one container of prepared turkey with a use by date of 5/16/26;-one container of prepared rice with a use by date of 5/16/26;-Shredded lettuce wilted and slightly brown with no label or date;-one container of prepared tuna salad with use by date of 5/15/26;-one plastic container of beets wrapped in plastic with use by date of 5/14/26;-one open carton of nectar thickened apple juice, dated 5/5, with manufacturer's instructions to discard 7 days after opening;-one open carton of nectar thickened cranberry juice, dated 5/7, with manufacturer's instructions to discard 7 days after opening;-one open carton of nectar thickened orange juice, dated 5/7, with manufacturer's instructions to discard 7 days after opening;-one clear pitcher containing yellow thickened fluid labeled puree covered with plastic wrap with no date;-honeydew melon covered in plastic wrap with no date;-one small cup of diced cucumber with no label or date;-one small cup of diced ham with no label or date;-one small cup labeled turkey salad with no date;-one container of frozen egg product covered in plastic wrap with use by date of 5/6/26 with manufacturer instructions indicated: Thawed product at 40 F (degrees Fahrenheit) or below, use within 3 days after opening. Thawing instructions: place frozen container in refrigerator at 40 F or below up to 3 days; and,-one tray holding many small single serve sized cups of condiments with no label or date on the tray or cups. On 5/17/26 at 7:25 A.M., the surveyor observed mouse droppings underneath food storage shelving in the dry storage room. On 5/18/26 at 7:45 A.M., the surveyor observed in the main kitchen:-one container of opened teriyaki sauce on dry storage shelf in prep area, half full and warm to touch, with manufacturer best by date of 1/14/22 and manufacturer instructions to refrigerate after opening;-one container of refrigerated liquid egg product dated 5/3/26-5/6/26; -boxes of vegetables open to air in the walk-in refrigerator housed on shelves that were extensively rusted; and-ceiling grid (metal rails that hold the drop ceiling in place) throughout the main kitchen were peeling- located over food prep and food service areas and in areas where clean kitchenware and cookware were held and stored. On 5/18/26 at 1:40 P.M., the surveyor observed the following in the dry storage room: -three bags of crispy onion topping, one with best by date of 9/30/23 and two with best by date of 9/18/24;-three cans of diced chili peppers dated as received on 5/31/19 with no discernable use by or best by date;-large, dried splotch of red liquid substance on the floor underneath the shelving that held containers of barbecue sauce; -mouse droppings in one area near a white sticky pad underneath the food shelves. During an interview on 5/20/26 at 2:15 P.M., Dietary Aide #1 said all prepared and opened food should be labeled and dated and dated food items should be discarded once they are beyond their use by date. During an interview with Dietary Aide #1 and the Registered Dietitian (RD) on 5/20/26 at 2:15 P.M., Dietary Aide #1 said the Food Service Director, who was not in the facility during survey, typically oversees the dry storage area though staff operate on a first in, first out method of food rotation. She said she was unsure of the storage protocol for foods several years past their best by dates, such as the bags of crispy onion topping, however she discarded them just to be safe. The RD said any food that is several years beyond its best by date should be discarded. Dietary Aide #1 also said she was unsure of the protocol for canned foods that were dated as received approximately six years ago with no manufacturer date on item, however she discarded them to be safe. During the same interview and observation on 5/20/26 at 2:15 P.M., the RD, Dietary Staff #1, and the Surveyor observed the spilled red residue and mouse dropping on the floor in the dry storage room. Dietary Aide #1 said the dry storage room floor should be swept and mopped daily but it does not appear that staff are doing that. The RD and Dietary Aide #1 said they would expect the floor to be clean of debris and pest droppings. During an interview on 5/20/26 at 2:15 P.M., the RD, Dietary Aide #1, and the Surveyor observed the rusted walk-in refrigerator shelves and the peeling ceiling rails throughout the main kitchen. Dietary Aide #1 said despite the shelves being rusty, they were cleaned regularly. The RD said she expected the ceiling rails to be smooth and not peeling. During an interview on 5/20/26 at 2:33 P.M., the Administrator said shelving in the main kitchen should not be rusted, the ceiling rails should be smooth, not peeling, and the floors in the kitchen and food storage areas should be clean with no spills or debris or mouse droppings.

Based on observations, interviews, and record reviews, the facility failed to provide care and services consistent with professional standards for one Resident (#5), out of a total sample of 19 residents. Specifically, the facility failed to implement a physician's order for a left-hand roll. Findings include:Review of Lippincott Manual of Nursing Practice 11th edition, dated 2019, indicated the following:- The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated:- Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error.- In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber. Review of the facility's policy titled Resident Mobility and Range of Motion (ROM), undated, indicated but was not limited to the following:- Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM.- Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable.- The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion.- Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts. Resident #5 was admitted to the facility in January 2024 with diagnoses including Alzheimer's disease and muscle weakness. Review of Resident #5's Minimum Data Set (MDS) assessment, dated 5/7/26, indicated he/she was cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. Furthermore, the MDS assessment indicated Resident #5 required assistance from staff for functional mobility and had a range of motion impairment of one upper extremity affecting function. Review of Resident #5's Physician's Orders indicated but were not limited to the following:- 11/18/25: [NAME] (put on) hand roll to L (left) hand after A.M. care and doff (remove) with P.M. care. Check skin daily after removing; every shift. Review of Resident #5's Self-Care Performance Care Plan, last revised 7/17/25, indicated the following intervention:- Left hand roll on in A.M. and remove at HS (nighttime) - monitor skin for breakdown due to use (initiated 4/8/26). On the following dates/times, the surveyor observed Resident #5 without a left-hand roll donned:- 5/17/26 at 8:56 A.M.,- 5/18/26 at 10:05 A.M.,- 5/18/26 at 11:20 A.M.,- 5/18/26 at 2:49 P.M., and- 5/19/26 at 10:10 A.M. Review of Resident #5's May 2026 Treatment Administration Record (TAR) indicated his/her left-hand roll was administered as ordered by the physician. During an interview on 5/19/26 at 2:29 P.M., Nurse #1 said orders for adaptive equipment such as a hand roll come up on the TAR for administration. Nurse #1 said the nurse assigned to the resident when the order populates would make sure the device is put on appropriately and check the skin if applicable. Nurse #1 reviewed Resident #5's physician's orders with the surveyor and said Resident #5 had an order for a left-hand roll and it was to be placed on each morning. During an interview on 5/20/26 at 8:25 A.M., the Director of Nursing (DON) said she would expect any physician's orders for a hand roll to be administered as ordered. The DON said nursing staff should complete the treatment so they can also ensure there are no changes in skin integrity. The DON and the surveyor reviewed the observations made during the survey process and reviewed the TAR. The DON said the nurses did not indicate the Resident refused the left-hand roll and it should have been put on as ordered.

Based on observation, interview, and record review the facility failed to ensure a resident at high risk for developing pressure ulcers received the necessary care, treatment, and services consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for one Resident (#10) out of 18 sampled residents. Specifically, the facility failed to complete wound care as ordered, complete skin check/assessment as ordered, complete Norton Assessments as ordered, and to offload his/her heels, resulting in the worsening of a Stage 3 Pressure Ulcer (full thickness skin loss, exposing subcutaneous tissue, not bone, muscle, or tendon) to the coccyx (tailbone) and the development of a new Unstageable Deep Tissue Injury (DTI: depth of the tissue damage is obscured due to dark purple/maroon color-develops from intense and/or prolonged pressure) to the left heel. Findings Include: Review of the facility's policy titled Pressure Injury Risk Assessment, undated, indicated but was not limited to the following: -The purpose of a pressure injury risk assessment is to identify all risk factors and then to determine which can be modified and which cannot, or which can immediately be addressed, and which will take time to modify. -Risk factors that increase a resident's susceptibility to develop or to not heal pressure injuries are not limited to nutrition, malnutrition, impaired/decreased mobility, the presence of existing pressure injuries, altered skin status over pressure points, impaired sensory perceptions, and cognitive impairment. -Documentation should include the type of assessment performed, the condition of the resident's skin (size and location of areas), and initiation of a pressure or non-pressure form related to the type of alteration in the skin. Review of the facility's policy titled Pressure Injuries Overview, undated, indicated but was not limited to the following: -Pressure Ulcer/Injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence. -Avoidable means that the resident developed a pressure ulcer/injury and that one or more of the following was not completed: Evaluation of the resident's clinical condition and risk factors, implementation of interventions that are consistent with resident needs, resident goals and professional standards of practice, and revision of the interventions as appropriate. Review of the facility's policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, undated indicated but was not limited to the following: -The nurse shall describe and document/report the following: Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue, current treatments, including support surfaces and active diagnoses. Review of the facility's policy titled Charting and Documentation, undated 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, shall be documented in the resident's medical record. -The following information is to be documented in the residents medical record: objective observations, medications administered, treatments or services administered, change in the resident's condition, and progress toward or changes in the care plan goals and objectives. -Documentation of procedures and treatments will include care-specific details, including the date and time the procedure/treatment was provided, the assessment data and/or any unusual findings obtained during the procedure/treatment. Review of the facility's policy titled Care Plans - Comprehensive, dated as last revised 7/2023, indicated but was not limited to the following: -Each resident's comprehensive care plan is designed to incorporate identified problem areas, incorporate risk factors associated with identified problems, reflect treatment goals timetables, aid in preventing or reducing declines in the resident's functional status, and reflect currently recognized standards of practice for problem areas and conditions. Resident #10 was admitted to the facility in January 2025 with diagnoses which included Stage 3 pressure ulcer, Down Syndrome, and malnutrition. Review of the Minimum Data Set (MDS) assessment, dated 3/6/25, indicated he/she was rarely/never understood, had memory impairment, rarely/never made decisions, was dependent on staff for activities of daily living, had a Stage 4 pressure ulcer (full thickness skin and tissue loss, potentially exposing muscle, tendons, ligaments, cartilage, or bone, with a high risk of infection and slow healing) and had an Unstageable DTI. Review of the Comprehensive Care Plan indicated but was not limited to the following: PROBLEM: Resident has potential for impaired skin integrity. (2/1/25) GOAL: Resident will have no further skin breakdown. INTERVENTIONS: -Complete Braden Scale (pressure risk assessment) upon admission, weekly x 4 weeks, and quarterly. -Weekly Skin Assessment. PROBLEM: Resident impaired skin integrity: Coccyx Pressure Injury. (2/1/25) GOAL: Area will not worsen as disease process progresses. INTERVENTIONS: -Measure area weekly. -Treatment as ordered. PROBLEM: Resident impaired skin integrity: Left Medial Heel Stage 3 Pressure Injury (2/18/25) GOAL: Area will resolve without complications. INTERVENTIONS: -Measure area weekly. -Treatment as ordered. Review of the Discharge Summary from January 2025 indicated but was not limited to the following: -Stage 3 to Coccyx -Seen by Wound Nurse-Follow wound care Recommendations. -Wound Nurse Note: Pressure Ulcer measures 2 centimeters (cm) x 1.2cm x 0.5cm Cleanse with Vashe (antimicrobial wound cleanser), dress with Aquacel AG (antimicrobial dressing) and cover with Mepilex dressing. -Turn and reposition resident as tolerated and heel lift boots. Review of the Nursing Admission Evaluation and Skin Assessment, dated 1/31/25, indicated Resident #10 had a Stage 3 pressure area to buttocks/coccyx/sacrum. Further review failed to indicate measurements and a description of the Stage 3 pressure ulcer to the coccyx. Review of the January 2025 Physician's Orders, Medication Administration Record (MAR) and Treatment Administration Record (TAR) indicated but were not limited to the following: -Coccyx Wound: Wound cleanser followed by calcium alginate (dressing to absorb drainage) and cover with foam dressing daily. (1/31/25) -Norton Assessment (pressure risk assessment) every Friday for 4 weeks. (1/31/25) -Air Mattress to bed set at (left blank) check function and settings every shift. (1/31/25) -Skin Integrity Check- complete weekly. (1/31/25) The facility failed to order heel lift boots per the January 2025 Discharge Summary. The facility failed to indicate the appropriate settings for the air mattress (air mattress should be set to patient weight and/or comfort to ensure proper inflation, eliminating a stiff mattress if set too high and one that is bottoming out on the bed frame if set too low). Review of the Norton Scale for Predicting Risk of Pressure Ulcer, dated 1/31/25, indicated a score of 6, indicating Resident #10 was very high risk for skin breakdown. Review of the nursing progress notes indicated but were not limited to the following: -1/31/25: Stage 3 sacrum pressure ulcer measured 2cm x 1.2cm x 0.5cm, area was cleansed and dressing applied. -2/1/25: Risk Note: admitted with wound on buttocks and will be followed by the wound doctor. Air Mattress in place. The progress notes failed to indicate the physician reviewed and declined the recommendation for heel lift boots. Review of the Physical Therapy Evaluation, dated 2/1/25, indicated but was not limited to the following: -Patient to tolerate out of bed to wheelchair with proper equipment to increase posture for skin integrity. -Patient exhibits exacerbation of decreased postural alignment and increased need for assistance from others to facilitate wound healing. The surveyor made the following observations: -4/1/25 at 9:00 A.M., Resident #10 was lying in a Broda/Reclining chair, in frog leg position (his/her legs pulled up, hips flexed, knees bent, and legs relaxed outward/abducted causing lateral legs to rest on the chair surfaces and feet/heels to be touching/almost touching each other or touching the other leg/calf). No offloading device was present on the chair for his/her heels. -4/1/25 at 10:15 A.M., Resident #10 was lying in a Broda/Reclining chair, in frog leg position. No offloading device was present on the chair for his/her heels. -4/1/25 at 11:20 A.M., Resident #10 was lying in a Broda/Reclining chair, in frog leg position. No offloading device was present on the chair for his/her heels. -4/1/25 at 11:35 A.M., Resident #10 was lying in a Broda/Reclining chair, in frog leg position. No offloading device was present on the chair for his/her heels. -4/2/25 at 8:15 A.M., Resident #10 was lying in bed, in frog leg position, being fed breakfast. Air mattress was in place on the bed. No offloading device was present on the bed for his/her heels. (Due to the lateral rotation, heels were pressing on each other and not being offloaded by the air mattress). -4/3/25 at 12:13 P.M., Resident #10 was lying in a Broda/Reclining chair, in frog leg position. No offloading device was present on the chair for his/her heels. -4/4/25 at 10:37 A.M., Resident #10 was lying in a bed, in frog leg position. Left heel was resting on his/her right leg/calf. No offloading device was present on the bed for his/her heels. -4/4/25 at 1:30 P.M., Resident #10 was lying in a bed, in frog leg position. Left heel was resting on his/her right leg/calf. No offloading device was present on the bed for his/her heels. Review of the February 2025 Physician's Orders, MAR, and TAR indicated but were not limited to the following: -The treatment to the Coccyx was not signed off as administered on 2/1/25 or 2/2/25. -The Skin Integrity Check on 2/3/25 was signed off as administered. Review of the Skin Integrity Assessments failed to indicate one had been completed on 2/3/25. Review of the nursing progress note, dated 2/3/25, indicated the coccyx wound measured 3.5cm x 2cm x 0.5cm and wound bed was completely covered in yellow slough (non-viable tissue, yellowish, moist, and stringy in the wound bed often hinders the healing process and potentially increasing the risk for infection). Review of the documented wound measurements from 1/31/25 and 2/3/25 indicated the coccyx wound had nearly doubled in size (wound had increased in size by 192%) and wound bed was now obscured by yellow slough. Further review of the nursing note, dated 2/3/25, failed to indicate the physician had been notified of the change/decline of the wound. Further review of the February 2025 TAR indicated but was not limited to the following: -The treatment to the coccyx was not signed off as administered on 2/4/25. -A new order, adding Santyl (a debriding agent) to the coccyx wound care was initiated on 2/5/25. -The treatment to the coccyx was not signed off as administered on 2/5/25. -The Norton Assessment was signed off as administered on 2/7/25, 2/14/25, and 2/21/25. Review of the Norton Assessments failed to indicate they had been completed on 2/7/25, 2/14/25, or 2/21/25. Review of the nursing progress note, dated 2/9/25, indicated Resident #10 had a blister noted under the left foot. It was covered with a dressing to prevent further break in skin and infection. MD and wound nurse notified. The facility failed to document measurements and description of the new facility acquired wound. Review of the physician's orders failed to indicate a treatment order for the left heel was obtained. The facility failed to provide wound care or further assessment of the area to the left heel on 2/10/25. Review of the Wound Physician's Initial Evaluation, dated 2/11/25, indicated but was not limited to the following: -Patient presents with wound on coccyx and left medial heel. -Review of systems: Deconditioning, Contractures. -Support Surface: Bed: Group 2 (air mattress); Chair: Pressure Reduction Cushion; Feet: Pillow. Site 1: Stage 4 Pressure Wound Coccyx Full Thickness -Etiology: Pressure -Size: 1.9cm x 0.8cm x 0.4cm with moderate serous drainage (thin watery clear/pale yellow). -Surgical Excisional Debridement to remove necrotic (dead) tissue and establish margins of viable tissue. -Treatment Plan: Calcium Alginate and Santyl followed by a bordered gauze dressing daily. -Offload wound (relieve pressure-often with repositioning and/or air mattress). Site 2: Unstageable DTI of the Left Medial Heel Undetermined Thickness. Etiology: Pressure Size: 3.5cm x 3.8cm x not measurable cm with light serous drainage, intact with purple/maroon discoloration, fluid filled. -Additional Wound Notes: from contracture against right calf. -Treatment Plan: Xeroform gauze followed by a bordered gauze dressing daily. -Off-load wound (relieve pressure often with booties or pillows). Review of the February Physician's Orders indicated the wound care orders were implemented per physician recommendations. The facility failed to ensure the air mattress had an appropriate setting for pressure from 1/31/25 until 2/19/25 when the order was rewritten with a setting of 100. The facility failed to offload Resident #10's heels and failed to indicate the physician declined the recommendation to offload the heels per wound physician recommendation. During an interview on 4/3/25 at 12:49 P.M., Nurse #3 said Resident #10 always has their left leg pulled up like that (frog leg position resting on right leg). She said you can straighten it for care, but he/she always pulls it right back up, both in bed and in the chair. During an interview on 4/3/25 at 12:51 P.M., Certified Nursing Assistant #3 said he/she is always in that (frog leg) position. She said you can straighten them to do care, but they are always up like that resting on each other. During an interview on 4/4/25 at 10:54 A.M., Nurse #2 said Resident #10 seems to pull legs up like that (frog leg position). She said he/she does it in the bed and in the chair. During an interview on 4/4/25 at 12:43 P.M., the Assistant Director of Nurses (ADON) said she does wound rounds on Tuesdays with the Wound Doctor. She said after they do rounds, she reviews the notes, updates the Primary Care Physician (PCP), and writes the new orders. She said on Admission the wound should have been described and measured and when the new area was discovered, staff should have called the PCP to get a treatment order. She said Weekly Skin Checks, Norton Assessments, and Treatments should all be done per the physician orders and was unable to speak as to why these treatments were not done, and said if it wasn't documented, it wasn't done. She said Resident #10 has weird body positioning, always tucking one leg up and under the other. She said you can straighten his/her legs, but they always revert back to that frog leg position. She said there was not an order to offload the heels specifically, and the booties were never ordered from admission. She said it's possible they were not ordered due to the air mattress, but it was not documented anywhere, so she was not sure. Additionally, she acknowledged the frog leg position, lateral rotation, and heels resting on one another as his/her routine position and said sometimes they would offload with pillows, but that too was not documented anywhere. She said usually booties would have a specific order, but offloading with pillows might not, but it should at least be on the care plan, and it was not. She said they should be doing weekly wound/skin notes, and they haven't been doing those. She said it is hard with all the agency nurses to ensure they are doing everything they should be. During an interview on 4/4/25 at 1:33 P.M, the Director of Nurses (DON) said the new Admission Evaluation touches on everything, and wound measurements and description should be noted on the assessment. She said Weekly Skin Checks, Norton Assessments, and Treatments should all be done per physician orders and she could not speak to why these treatments were not done as ordered. Additionally, she said any new facility acquired wounds should have a Skin Assessment done, a note written, nurse should notify the PCP, obtain a treatment order, and notify myself and/or ADON to add to wound rounds. After they are seen by the wound physician, we would follow his recommendations from there. She said typically you would not order booties in bed if they were on an air mattress, but he/she spends a lot of time in the Broda chair and doesn't have typical positioning, so can see that being of concern, as is the missing documentation, wound care, and assessments. She said it is hard with all the agency to ensure they are doing everything they should be.

Based on observation, interview, and test tray results, the facility failed to provide food to residents that was palatable and served at appetizing temperatures for both food and drinks for one of three test trays. Findings include: On 4/3/25 at 7:50 A.M., the surveyor requested a test tray, which left the kitchen at 7:47 A.M. The last tray was served off the meal cart at 8:16 A.M. The surveyor tested the tray with Medical Records Staff #1 with the following results: -Scrambled eggs were 111 degrees Fahrenheit (F). The eggs had a rubbery texture, were dry and cold. -Oatmeal was 119 degrees F, tepid (lukewarm) and pasty to taste. -Plastic cup of apple juice, which was served from the kitchen was 48.6 degrees F. It was not cold. -Milk carton 36.3 F. It was palatable and cold. -Cup of coffee served on the unit was 152.9 F. It was palatable and hot. During interviews with Residents after the completion of the breakfast meal pass on 4/3/25, the Residents made the following comments: -Resident #38 said he/she didn't like breakfast and sent it back, and he/she was given a couple of yogurts from the certified nursing assistant. -Resident #30 said he/she didn't like the eggs. -Resident #1A said the eggs were so-so. -Resident #53 said he/she didn't like the eggs, he/she said, look at my plate I didn't eat any of them. -Resident #7 said the eggs are terrible, he/she just had the toast and orange juice. -Resident #52 said he/she is not a fan of the eggs, they are liquid. Resident #52 said he/she doesn't understand why they can't just put onion and/or garlic powder in the eggs to try to make them taste better. He/she said they are over scrambled and leathery. The results of the test tray validated the Residents' complaints of unpalatable, unappetizing, and cold food.

Based on observation, meal ticket review, and interview, the facility failed to ensure residents were receiving the correct therapeutic diets. Specifically, the facility failed to: 1. Ensure during tray service in main kitchen that the dietary aides calling out the diets off the meal tickets were including the resident specific therapeutic diets, including heart healthy, no salt added, and low concentrated sugar diets for three meals observed; and 2. Ensure the residents were being offered and choosing the correct therapeutic diet off the menu and the alternative menu. Findings include: 1a. Review of the therapeutic diets for 4/2/25 dinner meal included the following: -Heart Healthy: Pork loin, no garlic mushroom gravy, no salt added white rice, and no salt added zucchini and onions. -Low concentrated sweet: sugar substitute On 4/2/25 at 4:50 P.M. the surveyor observed the main kitchen dinner tray line service and made the following observations: -Dietary staff was only calling out resident's diets as regular, ground, or mechanical soft diets and not calling out the resident specific therapeutic diets such as heart healthy, LCS, and NAS diets. -Residents with heart healthy diets served pork loin with the garlic mushroom gravy. -Residents with NAS diets with packets of salt on their trays. -Only one pan of white rice and one pan of zucchini and onion. b. Review of the therapeutics diets for 4/3/25 breakfast meal included the following: -Heart Healthy: Egg substitution, no added salt. -Low concentrated sweet (LCS)/No salt added (NAS): Biscuit instead of white toast, sugar substitute. On 4/3/25 at 7:50 A.M., the surveyor observed the main kitchen breakfast tray line service and made the following observations: -Dietary staff was only calling out resident's diets as regular, ground, or mechanical soft diets and not calling out the resident specific therapeutic diets such as heart healthy, LCS, and NAS diets. -Residents with heart healthy diets served regular scrambled eggs, not egg substitute. -Residents with NAS diets with packets of salt on their trays. -Only one pan of regular scrambled eggs, no egg substitute. -No biscuits on tray line. c. Review of the therapeutics diets for 4/3/25 lunch meal included the following: -Heart Healthy: Cube steak, no onion gravy, no salt added peas, sugar and pepper one package each. On 4/3/25 at 11:50 A.M., the surveyor observed the main kitchen lunch tray line service and made the following observations: -Dietary staff was only calling out resident's diets as regular, ground, or mechanical soft diets and not calling out the resident specific therapeutic diets such as heart healthy, LCS, and NAS diets. -Residents with heart healthy diets served cube steak with onion gravy. -Residents with NAS diets with packets of salt on their trays. -Green beans, carrots and cauliflower, there were no peas on the tray line. On 4/4/25 at 11:35 A.M., the surveyor observed the Corporate Food Service Manager on the lunch tray service line calling the correct therapeutic diets including heart healthy, NAS, and LCS, the correct texture, and removing salt packets from trays in which the resident was on a NAS diet. During an interview on 4/4/25 at 11:35 A.M., the Corporate Food Service Manager said he was working on the tray line today to ensure the trays were accurate. He said when asked by the surveyor he did notice the dietary staff was calling out regular diets and not including specific therapeutic diets such as heart healthy and NAS to the cooks. He said the cooks would not know to make a substitution unless they were told the therapeutic diet. 2. Review of the therapeutics diets for 4/4/25 lunch meal included the following: -Heart Healthy: Oven fried fish instead of the main meal BBQ rib patty and one slice of bread instead of cornbread. On 4/4/25 at 9:10 A.M., the surveyor reviewed diet slips filled out by Activity Staff #1 and made the following observations: -Resident #3A's diet slip indicated Heart Healthy, LCS regular. Resident #3A selected Cheeseburger with tomato for lunch and dinner. -Resident #4A's diet slip indicated Heart Healthy regular, NAS. Resident #4A selected Cheeseburger for lunch and dinner. -The following Resident's diet slips all indicated heart healthy diets: Resident #19, #324, #323, #65's, and Resident #1A's. Their diet slips indicated they were to be served for lunch BBQ Rib patty for lunch. During an interview on 4/4/25 at 9:10 A.M., Activity Staff #1 said he goes around to the resident rooms and tells them what is on the menu for lunch and dinner and encourages the residents to pick their meals. He said if they don't like the main meal, they could pick from the alternate menu. He said he is not aware of the difference when the meal ticket says heart healthy, NAS, or low concentrated sweets. Activity Staff #1 said he offered all the residents today BBQ rib patty for lunch. He said he was not aware the healthy heart substitution today was oven fried fish. He said if a resident doesn't like the main meal, he lets them pick anything off the alternate menu. Review of the menu Activity Staff #1 was offering residents on 4/4/25 for lunch included: BBQ rib patty, creamy coleslaw, spiced pear bar, cornbread, margarine, coffee/tea, and condiments. There were no choices for heart healthy or NAS/LCS. Review of the alternate menu taped on the clipboard Activity Staff #1 was offering to residents for lunch on 4/4/25 included: Grilled cheese/tomato, peanut butter and Jelly, cheeseburger, hamburger, chef salad, tuna salad, chicken salad, egg salad, ham salad, deli sandwich, and cottage cheese fruit plate. Activity Staff #1 said he was not aware if any of the choices were heart healthy, NAS, or LCS. He said they can pick anything off the alternate menu. During an interview on 4/4/25 at 11:35 A.M., the Corporate Food Service Manager said the cooks would not know to make the correct therapeutic substitutions unless they were told during the line if a resident was on a heart healthy or low concentrated sweets diet or if the menu was filled out to include the correct therapeutic diet. When asked by the surveyor, the Corporate Food Service Manager said residents on a heart healthy diet should have been offered the pan fried fish today. He said a cheeseburger instead of the BBQ ribs would not be an appropriate substitution for a heart healthy diet.

Based on interview and record review, the facility failed to ensure the medication Metformin (diabetic medication) was discontinued per the Resident's request which had been documented in the Nurse Practitioner Progress Notes multiple times for one Resident (#65), out of a sample size of 18 residents, resulting in Resident #65 receiving 100 extra doses of Metformin. Findings include: Resident #65 was admitted to the facility in July 2024 with diagnoses which included: Type ll diabetes and diabetic neuropathy. Review of the Minimum Data Set (MDS) assessment, dated 2/18/25, indicated Resident #65 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating Resident #65 was cognitively intact. During an interview on 4/4/25 at 12:45 P.M., Resident #65 said he/she met with Nurse Practitioner (NP) #1, and requested he/she stop taking Metformin and NP #1 agreed. Resident #65 said it took two to three months for the nurses to take it off his/her daily medication list. Review of the Physician's Orders indicated Metformin HCI oral tablet 500 milligrams (mg), give one tablet by mouth two times a day for diabetes mellitus, initiated on 7/3/24 and discontinued on 1/10/25. Review of Physician and NP's telephone orders in the medical record and maintained in overflow, indicated only one telephone order, dated 1/10/25, discontinuing Metformin 500 mg daily. Review of Resident #65's Medication Administration Record (MAR) from 11/19/24 through 1/10/25 indicated Resident #65 was administered 100 doses of Metformin during this timeframe. Review of NP #1's Progress Note, dated 10/28/24, indicated: -Assessment and plan: 4. Type 2 diabetes mellitus (DM), A1C (blood test that measures your sugar level over the past 2-3 months) 5.2% (normal A1C is below 5.6%), continue oral agents. Review of NP #1's Progress Note, dated 11/19/24, indicated: - Patient has requested that his/her Metformin be placed on hold. Despite several attempts to educate patient, we are in agreement to hold oral agent. -Assessment and Plan: 4. Type 2 DM, A1C 5.2%, oral agents placed on hold per patient's request. Continue to trend blood glucose levels. Review of NP #1's Progress Note, dated 12/5/24, indicated: -Assessment and Plan: 4. Type 2 DM, A1C 5.2%, oral agents placed on hold per patients request. Continue to trend blood glucose levels. Review of NP #1's Progress Note, dated 12/10/24, indicated: -Assessment and Plan: 4. Type 2 DM, A1C 5.2%, oral agents placed on hold per patients request. Continue to trend blood glucose levels. Review of NP #1's Progress Note, dated 12/27/24, indicated: -Assessment and Plan: 7. Type 2 diabetes managed by diet monitor A1C. Review of NP #1's progress note, dated 1/3/25, indicated: -Assessment and Plan: 3. Type 2 DM, A1C 5.2%, Oral agents placed on hold per patient's request. Continue to trend glucose levels. Review of NP #1's Progress Note, dated 1/10/25, indicated: -Extensive discussion with medications discontinued including Metformin due to gastrointestinal upset. -Assessment and Plan: 7. Type 2 DM. Metformin discontinued secondary to gastrointestinal (GI) issues. Continue glimepiride. Monitor A1C. Recent A1C 5.2%. During an interview on 4/4/25 at 2:20 P.M., the Director of Nurses (DON) said the NP needs to write an order for the nurses to stop the medication. The DON said the nurses are not going to read all of the notes. During a telephonic interview on 4/10/25 at 9:52 A.M., NP #1 said she had a conversation with Resident #65 and to the best of her recollection she gave a verbal order to a nurse, but she can't remember which nurse. NP #1 said Resident #65 wants to be in control of his/her medications. NP #1 said at some point he/she complained of loose stools which was one of the reasons for stopping the medication.

Based on record review and interviews, the facility failed to ensure staff maintained accurate documentation for two Residents (#1 and #65), out of a total sample of 18 residents. Specifically, the facility failed: 1. For Resident #1, to ensure Medication Administration Records (MAR) and Treatment Administration Records (TAR) were accurate and reflected the administration of medications and treatments per physician's orders; and 2. For Resident #65, to accurately record the resident's weight in the medical record. Findings include: Review of the facility's policy titled Charting and Documentation, undated, indicated but was not limited to the following: -Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. -Entries may only be recorded in the resident's clinical record by licensed personnel (e.g. registered nurse, licensed practical nurse, physicians, therapist, etc.) in accordance with state law and facility policy. Certified nursing assistants may only make entries in the resident's medical chart as permitted by facility policy. -Documentation in the medical record may be electronic, manual or a combination. -The following information is to be documented in the resident medical record as warranted: -Objective observations. -Medications administered. -Treatments or services performed 1. Resident #1 was admitted to the facility in January 2023 with diagnoses including Type 2 diabetes mellitus with hyperglycemia and use of insulin. Review of the Physician's Orders included but was not limited to: - Free style Libre 2 Reader Device (Continuous Glucose System Receiver) Apply 1 device transdermally one time a day for diabetes management. - Lantus (to treat elevated blood sugar) Solostar Subcutaneous Solution Pen-injector 100 Unit/ML (Insulin Glargine) Inject 30 Unit subcutaneously one time a day related to Type 2 diabetes Mellitus with Hyperglycemia alternate sites. - Anticoagulant medication (monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea joint pain, lethargy bruising and sudden change in mental status), every shift. - Novolog Flex Pen Subcutaneous Solution Pen Injector 100 Unit/ML (Insulin Aspart) Inject six units before meals related to type 2 diabetes mellitus with hyperglycemia. - Novolog Flex Pen Subcutaneous Solution Pen Injector 100 Unit/ML (Insulin Aspart) Inject as per sliding before meals daily. Review of Resident #1's January 2025 through March 2025 MARs indicated the following medications were not signed off as administered on 66 occasions as evidenced by several blank, unsigned boxes as follows: Free style Libre 2 Reader Device: (Day) 1/27/25, 2/9/25 Lantus Insulin: (day shift) 1/2/25, 1/3/25, 1/17/25, 1/22/25, 1/25/25, 1/29/25, 1/30/25, 1/31/25; 2/2/25, 2/3/25, 2/5/25, 2/16/25, 2/17/25, 2/19/25, 2/20/25, 2/25/25; 3/7/25. Anticoagulant medication: (Night) 1/16/25, 1/21/25, 1/24/25, 1/28/25, 1/29/25, 1/30/25; 2/1/25, 2/2/25, 2/4/25, 2/16/25, 2/19/25, 2/24/25, 3/4/25. Novolog Flex Pen: (every shift) 1/2/25, 1/3/25, 1/8/25, 1/10/25, 1/15/25, 1/17/25, 1/19/25, 1/22/25, 1/23/25, 1/25/25, 1/29/25, 1/30/25, 1/31/25 Novolog Flex: (morning) 1/2/25, 1/3/25, 1/8/25, 1/10/25, 1/15/25, 1/17/25, 1/19/25, 1/22/25, 1/23/25, 1/25/25, 1/29/25, 1/30/25, 1/31/25; 2/2/25, 2/3/25, 2/16/25, 2/17/25, 2/19/25, 2/20/25, 2/25/25, and 3/4/25 Review of Resident #1's January through March 2025 Physician's Treatment Orders included but was not limited to: -Coccyx pressure wound cleanser: Cleanse with wound cleanser, pat dry, apply Silver Sulfadiazine house barrier cream every day shift for wound healing -Diabetic foot care for prevention every evening shift for prevention, write a progress note if abnormal findings Review of the Resident #1's January 2025 through March 2025 TARs indicated the following medications were not signed off as administered on 12 occasions as evidenced by several blank, unsigned boxes as follows: -Coccyx pressure wound cleanser: (day shift) 1/2/25, 1/3/25, 2/9/25. -Diabetic foot care: (evening shift) 1/14/25, 1/18/25, 1/19/25, 1/29/25, 1/30/25; 2/1/25, 2/2/25, 2/5/25; 3/4/25. During an interview on 4/02/25 at 11:30 A.M., Nurse #5 said anytime a medication or treatment is administered it should be documented to prove it was done. During an interview on 4/03/25 at 10:25 A.M., Nurse #1 said the nurses are to document anytime a medication or treatment is administered. During an interview on 4/03/25 at 2:45 P.M., Nurse #3 said the nurses are to document anytime a treatment or medication is administered. During an interview on 4/04/25 at 2:30 P.M., the Assistant Director of Nurses (ADON) said she was not aware there was an issue with the documentation of MARs and TARs. She said the nurses might have administered the medications and provided the treatment but forgot to document. 41106 2. Resident #65 was admitted to the facility in July 2024 with diagnoses which included: displaced fracture of the neck of left femur and surgical after care of left hip. Review of the Minimum Data Set (MDS) assessment, dated 2/18/25, indicated Resident #65 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating Resident #65 was cognitively intact. During an interview on 4/4/25 at 12:45 P.M., Resident #65 said at his/her last physical before being hospitalized in June, he/she weighed 180 pounds (lbs.). Resident #65 said while in the hospital he/she lost about 60 lbs., and they even put him/her on a medication to stimulate his/her appetite. Resident #65 said he/she has never weighed over 200 lbs. Review of Resident #65's weights indicated the following weights since admission: -7/3/24 weight: 208.7 lbs. sitting -7/3/24 weight: 208.7 lbs. mechanical lift -7/24/24 weight: 210.2 lbs. standing -8/12/24 weight: 211.6 lbs. wheelchair -8/20/24 weight: 211.1 lbs. wheelchair -9/11/24 weight: 211.8 lbs. mechanical lift -9/17/24 weight 211.1 lbs. mechanical lift -9/24/24 weight 212.3 lbs. wheelchair -10/1/24 weight 212.9 lbs. wheelchair -11/1/1/24 weight: 213 lbs. wheelchair -11/2/24 weight: 213 lbs. wheelchair -11/3/24 weight: 213 lbs.-last weight obtained-refusal -12/1/24 weight: 213 lbs.- last weight obtained-refusal -12/4/24 weight: 213 lbs. wheelchair -12/7/24 weight:157 lbs. wheelchair Review of the nutritional evaluation comprehensive, dated 7/5/24, indicated but was not limited to the following: -Resident #65's admission weight was 208.7 lbs. -Usual body weight 200# per resident. -Current body weight 208.7 lbs., body mass index (BMI) 30.8 (Overweight). -Resident believes he/she lost weight but unsure of amount, admit weight consistent with hospital weight and he/she is overweight per BMI. Review of nutritional evaluation comprehensive, dated 8/28/24, indicated but was not limited to the following: -Resident weight 211.1 lbs. (8/20/24) -Resident readmitted following a medical leave of absence. -Current body weight represents mild gain of 2.4 lbs. 1% increase since admission. Review of a Nutrition Dietary Note, dated 9/27/24, indicated current body weight 212.3 lbs. (9/24/24). Resident has had a mild weight gain of plus 3.6 lbs. since admission and per chart has excellent meal take. Review of a Nutrition Dietary Note, dated 10/25/24, indicated current body weight 212.9 lbs. (10/1/14). Weight is stable over last 30 days and current body weight represents a mild gain plus 4.2 lbs. since admission. Review of a Nutrition Dietary Note, dated 12/28/24, indicated current body weight 155 lbs. (12/19/24). Resident flagging for significant weight change and continues with wounds. Regarding weight, Resident noted with a sudden large drop from 213 lbs. to 157 lbs. in early December. Resident #65 was re-weighed and found that previous weights in 200's were including wheelchair weight (approximately 60 lbs.), which were falsely elevating true body weight. During an interview on 4/04/25 at 12:20 P.M., the Dietitian said Resident #65 did not have a significant weight loss, they found in December that Resident #65's recorded weight included the weight of the wheelchair. The Dietitian said when Resident #65's weight went from 213 lbs. to 157 lbs. in three days, the only conclusion was the weights in the 200's was wrong, and the CNAs were not subtracting the weight of his/her wheelchair.

Based on observations, interviews, and records reviewed, for one Resident (#1), of seven sampled residents, the facility failed to ensure care was provided to residents in accordance with professional standards of practice. Specifically, for Resident #1, the facility failed to ensure insulin was administered per physician's orders. 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 the following: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber 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. Review of the facility's policy titled Diabetes- Clinical Protocols, undated, indicated but was not limited to: - The Physician will follow up on any acute episodes associated with a significant sustained change in blood sugars or significant deterioration of previous glucose control and document resident status at subsequent visits until the acute situation is resolved. -The staff will identify and report issues that may affect, or be affected by, a patient's diabetes and diabetes management such as foot infections, skin ulcerations, increase thirst, or hypoglycemia. Review of the facility's policy titled Administering Medications, undated, indicated but was not limited to: - Medications are administered in a safe and timely manner, as prescribed. - Medications are administered in accordance with prescribed orders. Resident #1 was admitted to the facility in January 2023 with diagnoses including type 2 diabetes mellitus with hyperglycemia (high blood sugar) and long-term use of insulin. Review of the Minimum Data Set (MDS) assessment, dated 3/25/25, indicated Resident #1 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Further review of Resident #1's MDS indicated he/she had a diagnosis of diabetes mellitus and received insulin daily. Review of Resident #1's current Physician's Orders indicated but were not limited to: - If blood sugar (BS) remains below 70 after the second Glucose Gel administration, notify the doctor and follow directions as needed for hypoglycemia below 70, dated 1/6/23 - If Resident is awake and able to swallow give four ounces of rapid acting carbohydrate (regular juice or Glucose Gel tub). As needed for hypoglycemia, also if Resident has signs and symptoms of hypoglycemia with blood sugar near 70, dated 1/9/23 - If blood sugar is less than 70 after the first dose of Glucose Gel and symptomatic, notify the doctor to review diabetic medications for possible adjustment as needed for hypoglycemia below 70, dated 1/9/23 - Glucagon Emergency Kit 1 milliliter (ml) Inject 1 ml intramuscularly as needed for hypoglycemia blood sugar below 70 or resident is unresponsive with inability to swallow and call the doctor, recheck blood sugar in 15 minutes, dated 11/27/23 - Novolog (a fast-acting insulin analog used to manage blood sugar) Inject 6 units subcutaneously before meals, dated 10/11/24 Review of Resident #1's April 2025 MAR indicated but was not limited to: - Novolog Inject 6 units subcutaneously before meals, dated 10/11/24 - 4/18/25 at 4:00 P.M., Signed of as a 5 - 4/19/25 at 6:30 A.M., Signed of as a 5 - 4/19/25 at 4:00 P.M., Signed of as a 5 - 4/21/25 at 6:30 A.M., Signed of as a 5 - 4/22/25 at 6:30 A.M., Signed of as a 5 - 4/24/25 at 11:00 A.M., Signed of as a 9 - 4/29/25 at 4:00 P.M., Signed of as a 5 Further review of Resident #1's April MAR indicated his/her Novolog was not given per physician's orders 7 times out of 60 opportunities. Review of Resident #1's May 2025 Medication Administration Record (MAR) indicated but was not limited to: - Novolog Inject 6 units subcutaneously before meals, dated 10/11/24 - 5/2/25 at 4:00 P.M., Signed off as 10 (no sliding scale insulin required per order) - 5/3/25 at 4:00 P.M., Signed off as a 9 (other see progress note) - 5/4/25 at 6:00 A.M., Signed off as a 9 - 5/4/25 at 11:00 A.M., Signed off as a 5 (hold see nurse notes) - 5/4/25 at 4:00 P.M., Signed off as a 5 - 5/5/25 at 11:00 A.M., Signed off as a 5 - 5/8/25 at 6:30 A.M., Signed off as a 10 - 5/12/25 at 6:30 A.M., Signed off as a 10 Further of Resident #1's May MAR indicated his/her Novolog was not given per physician's orders 8 times out of 38 opportunities. Review of Resident #1's Nursing Notes indicated but was not limited to: - 4/18/25 at 4:00 P.M., failed to indicate a note was written - 4/19/25 at 6:34 A.M., low blood sugar - 4/19/25 at 5:46 P.M., blood sugar 74 - 4/21/25 at 7:04 A.M., blood sugar 74 - 4/22/25 at 6:45 A.M., blood sugar 79, snack given - 4/24/25 at 11:38 A.M., blood sugar 129 - 4/29/25 at 5:06 P.M., blood sugar 75 - 5/2/25 at 4:00 P.M., failed to indicate a note was written - 5/3/25 at 6:00 P.M., blood sugar 87 - 5/4/25 at 5:38 A.M., low blood sugar - 5/4/25 at 12:43 P.M., blood sugar 72 - 5/4/25 at 5:05 P.M., blood sugar 90 - 5/5/25 at 11:00 A.M., failed to indicate a note was written - 5/8/25 at 6:30 A.M., failed to indicate a note was written - 5/12/25 at 6:30 A.M., failed to indicate a note was written During an interview on 5/13/25 at 2:28 P.M., Nurse #1 said insulin should be given as ordered by the Physician and if it needed to be held then the Physician should have been called and a note would need to be written. During an interview on 5/13/25 at 2:48 P.M., Nurse Practitioner (NP) #1 said Resident #1 did not have an order or parameter to hold his/her Novolog insulin. NP #1 said if the insulin needed to be held then he or the Physician should have been notified, and documentation should have been available in the Resident's record. NP #1 said the facility calls often and he was unable to recall if they had called about these incidents. That's why it should have been documented in a nursing note. During an interview on 5/13/25 at 3:24 P.M., the Director of Nurses (DON) reviewed Resident #1's medical record and said Resident #1 did not have any parameters to hold his/her Novolog insulin. The DON said the insulin should have been given as ordered and if it needed to be held then the nurse should have notified the Physician or NP and documented it in a note. The DON said the expectation was for nurses to follow physician's orders.

Based on observation, interview, and record review, the facility failed to provide care and maintenance of a Peripherally Inserted Midline Catheter (PICC) (type of catheter inserted into a peripheral vein, typically in the arm, near the armpit, used to deliver medications intravenously (IV)), consistent with professional standards of practice for one Resident (#65), out of a total sample of seven residents. Specifically, the facility failed to complete a PICC dressing change by discarding or replacing the antimicrobial disc with a new one during dressing changes dated 5/4/25 and 5/11/25. Findings include: Review of the facility's policy titled Central Venous Catheter Care and Dressing Changes, undated, indicated but was not limited to the following: -The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter related infections that are associated with contaminated, loosened, soiled, or wet dressings. -Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g., damp, loosened or visibly soiled). -Maintain Sterile dressing (transparent semi-permeable membrane (TSM) dressing or sterile gauze) for all central vascular access devices. The type of dressing is based on the condition of the resident and his or her preference. -Change the dressing if it becomes damp, loosened or visibly soiled and: a. At least every 7 days for transparent semi-permeable membrane (TSM) dressing; b. at least every 2 days for sterile gauze dressing (including gauze under the TSM unless the site is not obscured). -Adhere to aseptic non touch technique (ANTT) when performing this procedure. Adhere to standard or surgical ANTT based on the ability to prevent touching key parts or key sites. -Assess the integrity of securement devices with each dressing change. -Removal of old dressing is an aseptic, non-sterile procedure. -While stabilizing the catheter, remove the dressing in the direction of the catheter insertion site (from the hub of the catheter toward the head) to avoid dislodging the catheter. Discard dressing, remove gloves and wash hands. -Visually inspect and/or palpate the insertion site as described above. -Use sterile gloves if there is a need to touch the insertion site. -Documentation: -Date and time dressing was changed -Location and objective description of insertion site -Any complications, interventions that were done -Signature and title of person recording the data. Resident #65 was admitted to the facility in July 2024 with diagnoses which included: left hip fracture, failed left total hip replacement, septicemia requiring intravenous antibiotics through PICC line. Resident #65 had a readmission in April 2025 with added diagnoses which included: Left hip conversion of prior hip surgery to total hip arthroplasty (hip replacement), left revision total hip arthroplasty with closed treatment for left greater trochanter fracture, and PICC placement. Review of the Minimum Data Set (MDS) assessment, dated 5/4/25, indicated Resident #65 scored 13 out of 15 on the Brief Interview for Mental Status (BIMS), indicating Resident #65 was cognitively intact. Review of the Hospital documentation of Resident #65's PICC insertion record, dated 4/14/25, indicated the Resident had a Bard power injectable PICC single lumen PICC line inserted on 4/14/25, with an external catheter length of 0 centimeters (cm), and a post right arm circumference of 26 cm. During an interview on 5/13/25 at 8:26 A.M., Resident #65 said he/she had a hip surgery which was complicated and now receives intravenous (IV) antibiotics and has this line in his/her arm (pointing to his/her PICC in the right upper arm). The surveyor observed the right PICC line in Resident #65's arm to have a round disc around the insertion site and a white square item blocking the visualization of the PICC insertion site. Review of the Physician's Orders indicated but was not limited to the following: -Change PICC line dressing weekly and as needed (PRN), initiated 5/4/2025 and discontinued 5/4/2025. -Change PICC line weekly and as needed, initiated 5/5/2025 and discontinued 5/13/2025. Review of the May 2025 Medication Administration Record (MAR) indicated but was not limited to the following: -Resident #65's PICC line dressing was changed by Nurse #2 on 5/4/25 and 5/11/25. Review of all nursing progress notes, dated 5/4/25 and 5/11/25, and provided to the surveyor during the survey, failed to include any documentation of the PICC line dressing change. During an interview on 5/13/25 at 12:25 P.M., Nurse #2, with Nurse #3 present, said she changed Resident #65's PICC line dressing twice on 5/4/25 and 5/11/25. Nurse #2 said she saw the white disc around the insertion site of the PICC line and was not sure what to do with the white disc, so she cleaned the surfaces with an alcohol prep pad and left the white disc in place and covered the area with a clear dressing. Nurse #2 said she was the last one to change the PICC line dressing on 5/11/25 and the white disc has remained over the PICC insertion site since admission. She said she signed the last dressing and dated it 5/11/25. On 5/13/25 at 12:33 P.M., the surveyor requested from Nurse #2, with Nurse #3 present, all of the facility's PICC line items required for a dressing change. Nurse #2 provided the surveyor with a package titled Dressing Change Kit with Chloraprep swabs and the contents included the following: 1 3M Tegaderm dressing 1 gauze 4 inches () by 4 1 gauze 2 by 2 1 Slit, non-woven gauze, 2 x 2 2 Alcohol prep pads 1 tape measure 1 chloraprep swab stick, 3 pack 1 roll of tape 1 towel 2 pairs of gloves 1 mask There was no antimicrobial disc included in the PICC dressing kit or shown to the surveyor. During an interview on 5/13/25 at 3:22 P.M., Nurse Practitioner (NP) #1 said if the Resident had an anti-microbial disc from the hospital, it should have been removed with the first dressing change and discarded. NP #1 said if the nurse had a new anti-microbial disc, it could have been applied to the PICC insertion site, but the old one should not be left on the PICC line insertion site. During an interview on 5/13/25 at 4:12 P.M., Nurse #2 said both times she changed the PICC line dressing, she cleaned the white antimicrobial disc and left it in place. Nurse #2 said she knows the external length of the PICC was zero. Nurse #2 confirmed she signed and dated the last dressing on Resident #65 on 5/11/25. During an interview on 5/13/25 at 5:05 P.M., the Director of Nurses (DON) said the antimicrobial disc should have been removed and discarded when the PICC line was changed and the clear Tegaderm dressing applied. The DON said she had no further documentation of the PICC dressing change on 5/4/25 or 5/11/25.

Based on observations, interviews, and records reviewed, for one Resident (#1), of seven sampled residents, the facility failed to ensure care was provided to residents in accordance with professional standards of practice. Specifically, for Resident #1, the facility failed to ensure insulin was administered per physician's orders. 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 the following: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber 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. Review of the facility's policy titled Diabetes- Clinical Protocols, undated, indicated but was not limited to: - The Physician will follow up on any acute episodes associated with a significant sustained change in blood sugars or significant deterioration of previous glucose control and document resident status at subsequent visits until the acute situation is resolved. -The staff will identify and report issues that may affect, or be affected by, a patient's diabetes and diabetes management such as foot infections, skin ulcerations, increase thirst, or hypoglycemia. Review of the facility's policy titled Administering Medications, undated, indicated but was not limited to: - Medications are administered in a safe and timely manner, as prescribed. - Medications are administered in accordance with prescribed orders. Resident #1 was admitted to the facility in January 2023 with diagnoses including type 2 diabetes mellitus with hyperglycemia (high blood sugar) and long-term use of insulin. Review of the Minimum Data Set (MDS) assessment, dated 3/25/25, indicated Resident #1 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Further review of Resident #1's MDS indicated he/she had a diagnosis of diabetes mellitus and received insulin daily. Review of Resident #1's current Physician's Orders indicated but were not limited to: - If blood sugar (BS) remains below 70 after the second Glucose Gel administration, notify the doctor and follow directions as needed for hypoglycemia below 70, dated 1/6/23 - If Resident is awake and able to swallow give four ounces of rapid acting carbohydrate (regular juice or Glucose Gel tub). As needed for hypoglycemia, also if Resident has signs and symptoms of hypoglycemia with blood sugar near 70, dated 1/9/23 - If blood sugar is less than 70 after the first dose of Glucose Gel and symptomatic, notify the doctor to review diabetic medications for possible adjustment as needed for hypoglycemia below 70, dated 1/9/23 - Glucagon Emergency Kit 1 milliliter (ml) Inject 1 ml intramuscularly as needed for hypoglycemia blood sugar below 70 or resident is unresponsive with inability to swallow and call the doctor, recheck blood sugar in 15 minutes, dated 11/27/23 - Novolog (a fast-acting insulin analog used to manage blood sugar) Inject 6 units subcutaneously before meals, dated 10/11/24 Review of Resident #1's April 2025 MAR indicated but was not limited to: - Novolog Inject 6 units subcutaneously before meals, dated 10/11/24 - 4/18/25 at 4:00 P.M., Signed of as a 5 - 4/19/25 at 6:30 A.M., Signed of as a 5 - 4/19/25 at 4:00 P.M., Signed of as a 5 - 4/21/25 at 6:30 A.M., Signed of as a 5 - 4/22/25 at 6:30 A.M., Signed of as a 5 - 4/24/25 at 11:00 A.M., Signed of as a 9 - 4/29/25 at 4:00 P.M., Signed of as a 5 Further review of Resident #1's April MAR indicated his/her Novolog was not given per physician's orders 7 times out of 60 opportunities. Review of Resident #1's May 2025 Medication Administration Record (MAR) indicated but was not limited to: - Novolog Inject 6 units subcutaneously before meals, dated 10/11/24 - 5/2/25 at 4:00 P.M., Signed off as 10 (no sliding scale insulin required per order) - 5/3/25 at 4:00 P.M., Signed off as a 9 (other see progress note) - 5/4/25 at 6:00 A.M., Signed off as a 9 - 5/4/25 at 11:00 A.M., Signed off as a 5 (hold see nurse notes) - 5/4/25 at 4:00 P.M., Signed off as a 5 - 5/5/25 at 11:00 A.M., Signed off as a 5 - 5/8/25 at 6:30 A.M., Signed off as a 10 - 5/12/25 at 6:30 A.M., Signed off as a 10 Further of Resident #1's May MAR indicated his/her Novolog was not given per physician's orders 8 times out of 38 opportunities. Review of Resident #1's Nursing Notes indicated but was not limited to: - 4/18/25 at 4:00 P.M., failed to indicate a note was written - 4/19/25 at 6:34 A.M., low blood sugar - 4/19/25 at 5:46 P.M., blood sugar 74 - 4/21/25 at 7:04 A.M., blood sugar 74 - 4/22/25 at 6:45 A.M., blood sugar 79, snack given - 4/24/25 at 11:38 A.M., blood sugar 129 - 4/29/25 at 5:06 P.M., blood sugar 75 - 5/2/25 at 4:00 P.M., failed to indicate a note was written - 5/3/25 at 6:00 P.M., blood sugar 87 - 5/4/25 at 5:38 A.M., low blood sugar - 5/4/25 at 12:43 P.M., blood sugar 72 - 5/4/25 at 5:05 P.M., blood sugar 90 - 5/5/25 at 11:00 A.M., failed to indicate a note was written - 5/8/25 at 6:30 A.M., failed to indicate a note was written - 5/12/25 at 6:30 A.M., failed to indicate a note was written During an interview on 5/13/25 at 2:28 P.M., Nurse #1 said insulin should be given as ordered by the Physician and if it needed to be held then the Physician should have been called and a note would need to be written. During an interview on 5/13/25 at 2:48 P.M., Nurse Practitioner (NP) #1 said Resident #1 did not have an order or parameter to hold his/her Novolog insulin. NP #1 said if the insulin needed to be held then he or the Physician should have been notified, and documentation should have been available in the Resident's record. NP #1 said the facility calls often and he was unable to recall if they had called about these incidents. That's why it should have been documented in a nursing note. During an interview on 5/13/25 at 3:24 P.M., the Director of Nurses (DON) reviewed Resident #1's medical record and said Resident #1 did not have any parameters to hold his/her Novolog insulin. The DON said the insulin should have been given as ordered and if it needed to be held then the nurse should have notified the Physician or NP and documented it in a note. The DON said the expectation was for nurses to follow physician's orders.

Based on observation, interview, and record review, the facility failed to provide care and maintenance of a Peripherally Inserted Midline Catheter (PICC) (type of catheter inserted into a peripheral vein, typically in the arm, near the armpit, used to deliver medications intravenously (IV)), consistent with professional standards of practice for one Resident (#65), out of a total sample of seven residents. Specifically, the facility failed to complete a PICC dressing change by discarding or replacing the antimicrobial disc with a new one during dressing changes dated 5/4/25 and 5/11/25. Findings include: Review of the facility's policy titled Central Venous Catheter Care and Dressing Changes, undated, indicated but was not limited to the following: -The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter related infections that are associated with contaminated, loosened, soiled, or wet dressings. -Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g., damp, loosened or visibly soiled). -Maintain Sterile dressing (transparent semi-permeable membrane (TSM) dressing or sterile gauze) for all central vascular access devices. The type of dressing is based on the condition of the resident and his or her preference. -Change the dressing if it becomes damp, loosened or visibly soiled and: a. At least every 7 days for transparent semi-permeable membrane (TSM) dressing; b. at least every 2 days for sterile gauze dressing (including gauze under the TSM unless the site is not obscured). -Adhere to aseptic non touch technique (ANTT) when performing this procedure. Adhere to standard or surgical ANTT based on the ability to prevent touching key parts or key sites. -Assess the integrity of securement devices with each dressing change. -Removal of old dressing is an aseptic, non-sterile procedure. -While stabilizing the catheter, remove the dressing in the direction of the catheter insertion site (from the hub of the catheter toward the head) to avoid dislodging the catheter. Discard dressing, remove gloves and wash hands. -Visually inspect and/or palpate the insertion site as described above. -Use sterile gloves if there is a need to touch the insertion site. -Documentation: -Date and time dressing was changed -Location and objective description of insertion site -Any complications, interventions that were done -Signature and title of person recording the data. Resident #65 was admitted to the facility in July 2024 with diagnoses which included: left hip fracture, failed left total hip replacement, septicemia requiring intravenous antibiotics through PICC line. Resident #65 had a readmission in April 2025 with added diagnoses which included: Left hip conversion of prior hip surgery to total hip arthroplasty (hip replacement), left revision total hip arthroplasty with closed treatment for left greater trochanter fracture, and PICC placement. Review of the Minimum Data Set (MDS) assessment, dated 5/4/25, indicated Resident #65 scored 13 out of 15 on the Brief Interview for Mental Status (BIMS), indicating Resident #65 was cognitively intact. Review of the Hospital documentation of Resident #65's PICC insertion record, dated 4/14/25, indicated the Resident had a Bard power injectable PICC single lumen PICC line inserted on 4/14/25, with an external catheter length of 0 centimeters (cm), and a post right arm circumference of 26 cm. During an interview on 5/13/25 at 8:26 A.M., Resident #65 said he/she had a hip surgery which was complicated and now receives intravenous (IV) antibiotics and has this line in his/her arm (pointing to his/her PICC in the right upper arm). The surveyor observed the right PICC line in Resident #65's arm to have a round disc around the insertion site and a white square item blocking the visualization of the PICC insertion site. Review of the Physician's Orders indicated but was not limited to the following: -Change PICC line dressing weekly and as needed (PRN), initiated 5/4/2025 and discontinued 5/4/2025. -Change PICC line weekly and as needed, initiated 5/5/2025 and discontinued 5/13/2025. Review of the May 2025 Medication Administration Record (MAR) indicated but was not limited to the following: -Resident #65's PICC line dressing was changed by Nurse #2 on 5/4/25 and 5/11/25. Review of all nursing progress notes, dated 5/4/25 and 5/11/25, and provided to the surveyor during the survey, failed to include any documentation of the PICC line dressing change. During an interview on 5/13/25 at 12:25 P.M., Nurse #2, with Nurse #3 present, said she changed Resident #65's PICC line dressing twice on 5/4/25 and 5/11/25. Nurse #2 said she saw the white disc around the insertion site of the PICC line and was not sure what to do with the white disc, so she cleaned the surfaces with an alcohol prep pad and left the white disc in place and covered the area with a clear dressing. Nurse #2 said she was the last one to change the PICC line dressing on 5/11/25 and the white disc has remained over the PICC insertion site since admission. She said she signed the last dressing and dated it 5/11/25. On 5/13/25 at 12:33 P.M., the surveyor requested from Nurse #2, with Nurse #3 present, all of the facility's PICC line items required for a dressing change. Nurse #2 provided the surveyor with a package titled Dressing Change Kit with Chloraprep swabs and the contents included the following: 1 3M Tegaderm dressing 1 gauze 4 inches () by 4 1 gauze 2 by 2 1 Slit, non-woven gauze, 2 x 2 2 Alcohol prep pads 1 tape measure 1 chloraprep swab stick, 3 pack 1 roll of tape 1 towel 2 pairs of gloves 1 mask There was no antimicrobial disc included in the PICC dressing kit or shown to the surveyor. During an interview on 5/13/25 at 3:22 P.M., Nurse Practitioner (NP) #1 said if the Resident had an anti-microbial disc from the hospital, it should have been removed with the first dressing change and discarded. NP #1 said if the nurse had a new anti-microbial disc, it could have been applied to the PICC insertion site, but the old one should not be left on the PICC line insertion site. During an interview on 5/13/25 at 4:12 P.M., Nurse #2 said both times she changed the PICC line dressing, she cleaned the white antimicrobial disc and left it in place. Nurse #2 said she knows the external length of the PICC was zero. Nurse #2 confirmed she signed and dated the last dressing on Resident #65 on 5/11/25. During an interview on 5/13/25 at 5:05 P.M., the Director of Nurses (DON) said the antimicrobial disc should have been removed and discarded when the PICC line was changed and the clear Tegaderm dressing applied. The DON said she had no further documentation of the PICC dressing change on 5/4/25 or 5/11/25.

Based on observation, interview, and record review, the facility failed to ensure the proper size mattress was on the bed for one Resident (#323), out of a sample of 18 residents. Specifically, the facility failed to ensure the Mattress Bolster/Extender (an object used to fill gaps between the mattress and footboard of a bed) was put on the bariatric (obesity) bed, leaving a gap of approximately 10 inches between the end of the mattress and the footboard with the metal bed frame exposed, leaving the Resident at risk for entrapment and/or injury. Findings include: Review of the facility's policy titled Bed Safety, undated, indicated but was not limited to the following: -The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. -To try and prevent death/injuries from beds and related equipment. -Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems, including potential entrapment risks. -Review that gaps within the bed system are within the dimensions established by the Food and Drug Administration (FDA). Review shall consider situations that could be caused by the resident's weight, movement, or bed position. -Ensure that when bed system components are worn and need to be replaced, components meet the manufacturer specifications. Review of the Guidance for Industry and FDA Staff Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment Document, dated March 10, 2006, indicated but was not limited to the following: -Exclusions: The dimensional criteria described on pages 15-21 are recommended for a number of products, but not all types of hospital beds. We are listing those products below for which some, or all, of the dimensional criteria are not recommended. Please note that the products listed below are not free from risk of entrapment. We continue to suggest that users identify and address areas of potential entrapment for each patient or resident through a comprehensive bed safety program. Total exclusion from the scope of this guidance: Bariatric beds, pediatric beds and infant cribs are excluded because we did not use anthropometric (a person's size, form, and functional capacities) data for these groups in determining the recommended dimensional limits of the entrapment zones in this guidance. -Vulnerable patients are defined in A Guide to Bed Safety, developed by the Hospital Bed Safety Workgroup (described on pages 3-4), as: Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement or who get out of bed and walk unsafely without assistance. -Zone 7 - Between the Head or Foot Board and the End of the Mattress Zone 7 is the space between the inside surface of the head board or foot board and the end of the mattress. This space may present a risk of head entrapment when taking into account the mattress compressibility, any shift of the mattress, and degree of play from loosened head or foot boards. FDA recognizes this area as a potential for entrapment and encourages facilities and manufacturers to report entrapment events at this zone. Review of the Manufacturer Instructions for the Drive P750 Long Term Care Bariatric Bed indicated but were not limited to the following: -Mattresses must fit bed frame and assist rail snugly to prevent patient entrapment. Please follow the manufacturer instructions and monitor patient frequently. -Incompatible mattresses can create hazards. -Do not let any body parts protrude over the side or between parts, especially when the bed is being operated. -Entrapment issues can still arise when components and accessories are not properly installed. -Make sure the mattress is the correct size for bed frame to decrease the risk of entrapment. -It is recommended that a 39, 42 or 48 wide mattress that is made to fit an 80, 84 or 88 length bed frame is used. -Standard Features: 80, 84, 88 adjustable sleep surface. -Adjustable Mattress retainers. -Possible injury or death may occur of the bed is not adjusted to the proper length for the mattress being used. -Assembly: There are mounting positions for 3 different mattress lengths, 80, 84, and 88. Choose the appropriate one for your mattress. -Mattress retainer stops are designed to keep the mattress in place on the sleep surface. -Make sure the mattress fills the length and width between mattress retainer stops. Review of the Relief Max mattress manufacturer guidelines, undated, indicated but were not limited to the following: -Standard Dimensions: 36 x 80; Also Available 36 x 84 and Bariatric 42 and 48 width. Resident #323 was admitted to the facility in March 2025 with diagnoses which included metabolic encephalopathy (impaired brain function due to an underlying condition affecting cognition), dementia, anxiety, and morbid obesity. Review of the Nursing Admission Evaluation indicated he/she was 76.8 inches tall and weighed 343 pounds, was dependent on staff or personal care, transfers, and ambulation. Review of the Nursing Side Rail Evaluation indicated he/she had problems with balance, poor trunk control, and was deconditioned. Review of the Comprehensive Care Plan indicated but was not limited to the following: -He/She had an Actual Fall on 3/29/25 and 4/2/25. Review of the Nursing progress notes indicated but were not limited to the following: -3/29/25: He/She was found on the floor lying face down near the roommate's bed at 7:05 A.M. -4/2/25: He/She was found on the floor lying in a supine (face up) position at 4:30 A.M. Surveyor Observations include: -On 4/1/25 at 9:45 A.M., Resident #323 was lying in bed with his/her feet dangling off the bed; metal bed frame exposed, gap approximately 10 from end of mattress to the footboard. One pillow (standard bed pillow for head) was bunched up partially under heels. No mattress bolster/extender was installed on the bed. -On 4/1/25 at 11:02 A.M., Resident #323 was lying in bed with his/her feet hanging off the end of the mattress. There was one pillow stuffed in part of the gap between the mattress and the footboard. No mattress bolster/extender was installed on the bed. -On 4/2/25 at 8:29 A.M., Resident #323 was sitting in bed, his/her feet were hanging off the end of the mattress touching the footboard. Multiple pillows were stuffed in part of the gap between the mattress and the footboard, no mattress bolster/extender was installed on the bed. Health Care Proxy (HCP) at bedside. During an interview on 4/1/25 at 9:45 A.M., Resident #323's HCP said the bed has had a large gap since he/she was admitted . She said she was told the bed was delivered without the extender, so she had been stuffing pillows in there so his/her feet didn't get stuck in the big gap. During an interview on 4/1/25 at 11:36 A.M., Resident #323's HCP said she asked if she could stuff more pillows in the gap and was told that it was okay because they didn't have anything else to put there. She proceeded to stuff 4-5 pillows in the opening. During an interview on 4/2/25 at 10:28 A.M., Nurse #4 said the regular bed was too small, which is why he/she is in the big bed, but the mattress is too small. There is no extender for it, so that is why his/her HCP stuffed the pillows in there. During an interview on 4/2/25 at 10:39 A.M., the Housekeeping Supervisor said the facility owned one bariatric bed and deferred any questions relating to the bed to the Maintenance Supervisor. During an interview on 4/2/25 at 3:15 P.M., the Director of Maintenance said the facility had two bariatric beds in the facility. He said one is extended, so it's longer than the other one. He said they had a couple different mattresses for the beds, and they were not the same length. He was unable to provide the surveyor with an inspection of the bed and mattress in question. He said the gap on the bed should not be that big. Additionally, he said he thought the bed used to have a longer mattress on it, but the residents did not like it, so there was different mattress on it. He said he had not looked at the bed/mattress closely, they just moved it into that room last week for this Resident. During a telephone interview on 4/2/25 at 3:15 P.M., Maintenance Staff #1 said the beds have annual inspections but the bariatric beds did not have any entrapment assessments because they did not have to be tested . He said the gap on the bed should not be that big and advised the Director of Maintenance to see if they had a [NAME] Wedge (bed extender/bolster) and to look at the bed. The surveyor and the Director of Maintenance went upstairs to look at Resident #323's bed. During inspection of the bed and interview on 4/2/25 at 3:40 P.M., the Director of Maintenance said the gap in the bed from end of the mattress to the footboard should not be that big. He installed the extender/bolster on the bed, closing the gap from approximately 10 to 4-5. During an interview on 4/2/25 at 3:45 P.M., Resident #323 and his/her HCP said that was much better than the big, huge gap that had been there for the last five days. During an interview on 4/4/25 at 9:55 A.M., the Director of Maintenance said they did not have an inspection log for the bed/mattress. At 10:49 A.M., he provided a mechanical inspection of the bed dated 10/29/24, however this was for the bed mechanics and not the mattress fitting the bed. He said they did not have any log indicating the mattress was the correct size for the bed frame. During an interview on 4/4/25 at 10:54 A.M., Nurse #2 said she did not know why the extender was not on the bed for five days. She said she thought they had the extenders in the facility and said it should have been put on last week and the gap should not have been filled with pillows. She said the extender is on there now, but it was not there on 4/1/25. During an interview on 4/4/25 at 1:33 P.M., the Director of Nurses said the mattress should fit the bed properly and the gap should not be that large. She said usually there is an extender/bolster in place if the bed is extended and did not know why it was not in place since Resident #323 was put into that bed.

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 dispose 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: -The Life Safety Code (NFPA 101, 2000 ed., 19.7.4) requires each smoking area be provided with ashtrays made of noncombustible material and safe design. -Metal containers with self-closing covers into which ashtrays can be emptied must be readily available. -The facility is obligated to ensure the safety of designated smoking areas which includes protection of residents from weather conditions and non-smoking residents from secondhand smoke. Review of the facility's policy titled Smoking Policy-Residents Version 2.0, undated, indicated but was not limited to: -This facility shall establish and maintain safe resident smoking practices -Smoking is only permitted in designated resident smoking areas, which are located outside of the building -Metal containers, with self-closing cover devices, are available in smoking area -Ashtrays are emptied only into designated receptacles On 4/2/25 at 8:30 A.M., the surveyor observed the smoking area with a small ashtray, on a table, for cigarette butts but noted numerous cigarette butts in the crevices of the pavement and scattered in the mulch in front of the smoking area. Cigarette butts were noted in and on top of the trash can lined with a plastic bag containing empty cigarette boxes and various paper items. There was a tall black receptacle for cigarette butts noted in the corner of the smoking area which was blocked by a table and chair. During an interview on 4/2/25 at 9:10 A.M., Maintenance staff (MS) #1 said residents were not allowed to smoke without a staff member present. MS #1 said all cigarettes should be disposed of in the receptacle. MS #1 said he had not been at the facility for a couple of days. MS #1 said he would usually clean the area once a week. MS #1 said there was no schedule to clean the smoking area. On 4/3/25 at 8:55 A.M., the surveyor observed the smoking area with numerous cigarette butts in the crevices of the pavement. There was a half-smoked cigar on the pavement under a table next to the back wall of the smoking area. During an interview on 4/3/25 at 10:44 A.M., the Maintenance Director (MD) said someone would clean the smoking area on Mondays. The MD said there were a lot of cigarette butts on the ground yesterday. The MD said all cigarettes should be disposed of in the ashtray. The MD said he did not have a schedule to clean the smoking area. On 4/4/25 at 9:53 A.M. the surveyor observed the smoking area with several cigarette butts in the crevices of the pavement. During an interview on 4/4/25 at 10:05 A.M., the MD said he would clean the area on Monday. The MD said he did not have any additional days to clean the smoking area. The MD said staff should be monitoring that residents use the smoking receptacles to dispose of their cigarette butts. On 4/4/25 at 2:49 P.M., the Director of Nurses (DON) and surveyor observed the smoking area with several cigarette butts in the crevices of the pavement and in the mulch in front of the patio. The DON said the residents were supervised during smoking times. The DON said the staff should be making sure cigarette butts are disposed of properly to prevent a possible fire. On 4/4/25 at 3:05 P.M., the Administrator said staff and family members also used the smoking area. The Administrator said the smoking area should be cleaned frequently and that cigarette butts should not be on the ground. The Administrator said the expectation was for cigarette butts to be extinguished and disposed of in the receptacle.

Based on observation, interview, and record review, the facility failed to protect one Resident's (#33) right to be free from neglect. Specifically, for Resident #33, the facility failed to respond to requests for pain medications for at least 75 minutes for a Resident with a Stage 4 pressure injury (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle tendon, ligament, cartilage, or bone) of the sacral region. Findings include: Review of the facility's policy titled Abuse, dated March 2023, indicated but was not limited to the following: -Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Resident #33 was admitted to the facility in April 2022 with diagnoses which included but were not limited to osteomyelitis (infection of the bone) and a Stage 4 pressure injury of the sacral region. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/17/24, indicated Resident #33 had intact cognitive function as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of the January 2024 Physician's Orders included the following pain medication: -Dilaudid Oral Tablet 2 MG give 1 tablet by mouth every 12 hours as needed for pain On 1/31/24 at 7:10 A.M., the surveyor observed Resident #33 request pain medication from Nurse #4. The surveyor observed Nurse #4 tell Resident #33 that he/she would have to wait because the breakfast meal was on the way up from the kitchen. The surveyor observed the Resident shifting his/her weight in the wheelchair, had a furrowed brow, and was grimacing. The surveyor observed the Resident tell Nurse #4 that he/she was in a lot of pain. On 1/31/24 at 7:18 A.M., the surveyor observed Unit Manager #2 tell Nurse #4 to give Resident #33 his/her pain medication. Nurse #4 responded the breakfast trays were going to be on the unit shortly. On 1/31/24 at 7:18 A.M. through 7:58 A.M., the surveyor observed Nurse #4 distribute breakfast trays, feed a resident breakfast, provide cigarettes to the Maintenance Assistant for residents who were going out to smoke. On 1/31/24 at 7:59 A.M., the surveyor observed Nurse #4 engage in non-resident related conversation with Unit Manager #2. On 1/31/24 at 8:03 A.M., the surveyor observed Nurse #4 get water for another resident. During an interview on 1/31/24 at 8:09 A.M., Nurse #4 said Resident #33 had requested pain medications before breakfast, and she was going to give the requested medication with his/her morning medication. She said she was not supposed to give medications or take vital signs during breakfast. On 1/31/24 at 8:17 A.M., the surveyor observed Resident #33 yell out from his/her room What is taking so long? I'm in so much pain and so sore, I asked for pain medication a while ago. Nurse #4 responded, I know, I'm coming. On 1/31/24 at 8:23 A.M., the surveyor heard Resident #33 yelling out Please, I'm in pain! On 1/31/24 at 8:25 A.M., the surveyor observed Nurse #4 give Resident #33 the requested pain medication. The surveyor observed Resident #33 wait at least 75 minutes for the requested pain medication. During an interview on 1/31/24 at 8:26 A.M., the Resident said he/she asked for pain medications before breakfast and had been in pain since he/she got out of bed at 5:30 A.M. Resident #33 said his/her pain was a 9 out of 10 (on a pain scale of 1-10 with 10 being the worst pain) and if it was any higher he/she would have to go to the hospital. During a telephone interview on 1/31/24 at 3:18 P.M., Unit Manager #2 said she did hear Resident #33 request pain medication and she had told Nurse #4 to give the medication to Resident #33 since he/she was in pain. She said her expectation was that the Nurse would have administered the medication when requested, as she was told because the Resident was in pain. During an interview on 1/31/24 at 3:27 P.M., the Director of Nurses (DON) said her expectation was that the Resident would have received his/her medication when they asked and not have to wait until after breakfast to receive his/her requested pain medication since Resident #33 was in pain. During an interview on 2/1/24 at 7:15 A.M., Resident #33 said he/she was in pain and was waiting for pain medication that was requested an hour ago and that he/she did not know why it was taking so long. On 2/1/24 at 7:25 A.M., the surveyor observed Nurse #5 tell the Assistant Director of Nurses (ADON) that he/she was waiting for the next nurse to come relieve her and only one additional resident needed medication and indicated which resident (not Resident #33). On 2/1/24 at 7:39 A.M., the surveyor observed Nurse #5 give Resident #33 the requested pain medication at least 24 minutes after he/she asked for it. During an interview on 2/1/24 at 4:36 P.M., the DON said that she met with Resident #33 who told her that he/she had a lengthy delay (over an hour) for pain medication administration on 1/31/24 and 2/1/24 and on 1/31/24 the Resident said he/she was told to wait for the medication until after breakfast. The DON said the Resident should not have to wait for pain medication. The DON said the incident did meet the definition of neglect. During an interview on 2/1/24 at 4:48 P.M., the ADON said these two incidents with Resident #33 met the definition for neglect. Refer to F607, F609, F610, F697

Based on record review, interviews, and observations, the facility failed to manage and effectively treat two Residents (#33 and #69), out of a total sample of 21 residents for pain. Specifically, the facility failed: 1. For Resident #33, to ensure staff provided requested as needed pain medication timely when the Resident had a 9 out of 10 pain level (based on a pain scale of 1-10 with 10 being the worst pain); and 2. For Resident #69, to implement Benzocaine spray (a topical anesthetic) when recommended to assist with pain during wound dressing changes of a Stage 4 pressure injury (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone) to the coccyx and a Deep Tissue Injury (DTI- pressure related injury to subcutaneous tissue under intact skin) to the left buttock. Findings include: Review of the facility's policy titled Administering Medications, undated, indicated but was not limited to the following: -Medications are administered in a safe and timely manner, and as prescribed. -Medication administration times are determined by the resident need and benefit, not staff convenience. Factors that are considered include: enhancing optimal therapeutic effect of medication; preventing potential medication or food interactions; and honoring resident choices and preferences consistent with his or her care plan. Review of the facility's policy titled Pain-Clinical Protocol, undated, indicated but was not limited to: -The nursing staff will assess everyone for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new or worsening existing pain. -The staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity. -The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated; for example wound care, ambulation, or repositioning. -The staff and physician will evaluate how pain is affecting mood, activities of daily living, sleep, and the resident's quality of life, as well as how pain may be contributing to complications such as gait disturbances, social isolation, and falls. -The staff will evaluate and report the resident's use of standing and PRN (as needed) analgesics (medications used to treat and manage pain); if there are more than occasional analgesic requests, the physician will consider changing to regular administration of at least one analgesic with another medication for PRN use, increasing the standing dose of an existing analgesic, switching to another analgesic, and/or adding non-pharmacological measures. Resident #33 was admitted to the facility in April 2022 with diagnoses of osteomyelitis (infection of the bone), a stage 4 pressure ulcer of sacral region, and spinal stenosis. Review of the Minimum Data Set (MDS) assessment, dated 1/17/24, indicated Resident #33 had intact cognitive function as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of the Comprehensive Care Plans included but was not limited to: Focus: Resident has actual pain relating to pressure ulcer of sacral region, history of osteomyelitis, and spinal stenosis. Goal: Resident will not have an interruption in normal activities due to pain throughout the review date (date-initiated April 2022) Interventions: Administer medications Tylenol, Dilaudid per orders; evaluate the effectiveness of pain interventions routinely; anticipate resident's need for pain relief and respond immediately to any complaint of pain; identify and record previous pain history and management of that pain and impact of function; identify previous response to analgesia including pain relief, side effects, and impact on function. Review of the January 2024 Physician's Orders indicated the following pain medications: -Acetaminophen Tablet 325 milligrams (MG) give two tablets by mouth every 6 hours as needed for pain -Acetaminophen Extra Strength Tablet 500 MG give two tablets by mouth three times a day for pain -Dilaudid (an opioid) Oral Tablet 2 MG give 1 tablet by mouth every 12 hours as needed for pain Review of Resident #33's Pain Assessment Interview, dated 1/16/24, indicated over the past five days, pain had made it hard to sleep at night; had limited day to day activities over the past five days due to pain and had shown evidence of pain daily. On 1/31/24 at 7:10 A.M., the surveyor observed Resident #33 request pain medication from Nurse #4. The surveyor observed Nurse #4 tell Resident #33 that he/she would have to wait because the breakfast meal was on the way up from the kitchen. The surveyor observed the Resident shifting his/her weight in the wheelchair, had a furrowed brow, and was grimacing. The surveyor observed the Resident tell Nurse #4 that he/she was in a lot of pain. On 1/31/24 at 7:18 A.M., the surveyor observed Unit Manager #2 tell Nurse #4 to give Resident #33 his/her pain medication. Nurse #4 responded that the breakfast trays were going to be on the unit shortly. On 1/31/24 at 7:18 A.M. through 7:58 A.M., the surveyor observed Nurse #4 distribute breakfast trays, feed a resident breakfast, and provide cigarettes to the maintenance assistant for residents who were going out to smoke. On 1/31/24 from 7:59 A.M. through 8:03 A.M., the surveyor observed Nurse # 4 engage in non-resident related conversation with her coworkers and assist another resident by bringing them a beverage. During an interview on 1/31/24 at 8:09 A.M., Nurse #4 said Resident #33 had requested pain medications before breakfast, and she was going to give the requested medication with his/her morning medication. She said she was not supposed to give medications or take vital signs during breakfast. On 1/31/24 at 8:17 A.M., the surveyor heard Resident #33 yell out from his/her room, What is taking so long? I'm in so much pain and so sore; I asked for pain medication a while ago. Nurse #4 responded, I know, I'm coming. On 1/31/24 at 8:23 A.M., the surveyor heard Resident #33 yelling out Please, I'm in pain! On 1/31/24 at 8:25 A.M., the surveyor observed Nurse #4 give Resident #33 the requested pain medication. The surveyor observed Resident #33 wait at least 75 minutes for the requested pain medication (Dilaudid). During an interview on 1/31/24 at 8:49 A.M., Resident #33 said his/her pain was a 9 out of 10 and if the pain was any worse, he/she would have to go to the hospital. Resident #33 said he/she felt that the pain was severe and said he/she did not know why he/she waited so long in pain before the nurse came with his/her medication. Resident said he/she was waiting for the small pain pill not the Acetaminophen. Resident #33 said that he/she received the as needed pain medication last night around 7:30 P.M. and the medication did not last 12 hours. During the interview, the surveyor observed Resident #33 fidget in his/her wheelchair, attempt to weight shift, and grimace with a furrowed brow. Review of the Medication Administration Record (MAR) indicated Resident #33 received the as needed Dilaudid administered on 1/30/24 at 7:37 P.M. During an interview on 1/31/24 at 3:18 P.M., Unit Manager #2 said she did hear Resident #33 request pain medication before breakfast and she told Nurse #4 to give the medication since the Resident was saying he/she was in pain. She said that if a patient is requesting pain medication and has a physician's order it needs to be given when requested regardless of the time. During an interview on 1/31/24 at 3:27 P.M., the Director of Nurses (DON) said that her expectation was that the Resident would have received his/her medication when they asked and not have to wait until after breakfast to receive his/her requested pain medication since Resident #33 was in pain. Review of the January 2024 MAR indicated Resident #33 received the as needed Dilaudid 16 times during the month and each medication administration was coded as E for effective. During an interview on 2/1/24 at 7:15 A.M., Resident #33 said that he/she was in pain and was waiting for pain medication that was requested an hour ago and that he/she did not know why it was taking so long. On 2/1/24 at 7:25 A.M., the surveyor observed Nurse #5 tell the Assistant Director of Nurses (ADON) that she was waiting for the next nurse to come relieve her and only one additional resident needed medication and indicated which resident (not Resident #33). On 2/1/24 at 7:39 A.M., the surveyor observed Nurse #5 give Resident #33 the requested pain medication (Dilaudid) at least 24 minutes after he/she asked for it. During an interview on 2/1/24 at 10:15 A.M., the Resident said that his/her pain was often a 9 (out of 10) in the morning and that he/she had to ask for medication because the pain comes back. He/she said the medication helps for only a few hours. Review of the Medication Administration Record (MAR) for January 2024 indicated Resident #33 received Dilaudid oral tablet 2 MG on 1/31/24 at 8:25 A.M., and on 2/1/24 at 7:31 A.M. (observed to be given at 7:39 A.M.) On 2/1/24 at 12:40 P.M., the surveyor observed the Resident tell the DON that he/she had over an hour wait again today for pain medication. During an interview on 2/1/24 at 2:33 P.M., the Nurse Practitioner said that she was not aware that Resident #33 has had complaints of pain and she had not been contacted by staff regarding Resident #33's pain. During an interview on 2/1/24 at 4:36 P.M., the DON said that she met with Resident #33 who did tell her he/she had a lengthy delay for pain medication administration on 1/31/24 and 2/1/24 and on 1/31/24 the Resident said he/she was told to wait for the medication until after breakfast. The DON said the Resident should not have to wait for pain medication. 36542 2. Resident #69 was admitted to the facility in January 2024 with diagnoses of rectal cancer, Stage 4 pressure injury to the coccyx, and Deep Tissue Injury (DTI) to the left buttock. Review of the MDS assessment, dated 1/18/24, indicated Resident #69 was cognitively intact as evidenced by a BIMS score of 13 out of 15. Review of the care plans for Resident #69 indicated the Resident was at risk for pain related to rectal cancer with mets (metastasis- spreading of a pathogenic agent from one site in the body to another) to the bone and liver and wounds to the coccyx and left buttock. The pain interventions included: administering analgesics as per orders, anticipate need for pain relief, observe resident during care for signs of pain. Review of the Wound Evaluation and Management Summary, dated 1/23/24, from the Wound Physician indicated Resident #33 had an unstageable DTI of the left buttock measuring 4 centimeters (cm) in length by 2.5 cm in width by 0.5 cm in depth, with 7.5 cm of undermining at 3 o'clock and a Stage 4 pressure injury on the coccyx measuring 4 cm in length by 2 cm in width by 3.5 cm in depth. Review of the Wound Physician's treatment plan indicated to add Benzocaine spray to both wound treatments. Review of the Physician's Progress Note, dated 1/23/24, indicated Resident #33 was being followed by the Wound Physician, continued on Morphine and Oxycodone for pain management, and the Wound Physician was trialing a topical Lidocaine (a local anesthetic used to prevent pain by blocking the signals at the nerve endings in the skin) prior to dressing changes. During an interview on 2/6/24 at 10:21 A.M., Resident #69 said the wounds were very painful, crawl out of my skin painful, when treatments were performed. The Resident said the Wound Physician was supposed to order some spray to help with pain, but the staff had not been using it. He/she said the nurses knew how bad the treatments hurt and were giving an oral medication prior to the dressing change, which helped a little, but it was still very painful. During an interview on 2/6/24 at 12:34 P.M., Unit Manager #2 said Resident #69 experienced pain with the dressing changes and the nurses knew to give an as needed opioid medication prior to the treatments, but no other interventions had been initiated. She said she did not use Benzocaine spray that morning when completing the dressing changes. Review of the January and February 2024 MARs and TARs failed to indicate the Benzocaine spray was added to the treatment. During an interview on 2/6/24 at 1:20 P.M., the Assistant Director of Nurses said she regularly conducted wound rounds with the Wound Physician. She said the Wound Physician had recommended Benzocaine spray to both the coccyx and the left buttock wounds on the most recent visit and had suggested that the staff obtain it from a local store instead of waiting for the item to be ordered. She said Benzocaine spray was used to make the Resident more comfortable during a dressing change and had not been implemented for Resident #69 and the Resident continued to experience pain during dressing changes.

Based on document review and interview, the facility failed to provide their staff training on facility ethic standards, policies, and procedures. Findings include: Review of the Facility Assessment, dated May 2023, indicated but was not limited to the following: Staff training/education and competencies: - Throughout the year employees receive training and education on topics related to patient care and services. - Some trainings provided during general orientation is repeated at least annually. - Other topics are provided during the year based on Quality assurance performance improvement initiatives, ensuring regulatory compliance, best practices, clinical competencies and program development. The Facility Assessment failed to indicate ethics and compliance training were required in accordance with the regulations. Review of annual mandatory training content titled Round [NAME] Annual Education, dated 9/21/23, indicated the following trainings were mandatory for staff, included but were not limited to the following and were provided during the 9/21/23 in-service: -Corporate compliance Review of the In-service Education Attendance Record for the Round [NAME] training, dated 9/21/23, failed to indicate ethics as a topic of education. Review of the 2023 and 2024 staff education and in-service sign-in sheets provided by the facility failed to indicate any trainings had been completed on the topic of ethics. During an interview on 2/6/24 at 4:33 P.M., the Assistant Director of Nurses said there were no other in-service sign-in sheets or trainings available for the surveyors to review.

Based on interview and medical record review, the facility failed to arrange transportation to outside specialist medical consultants, therefore delaying essential medical care for two Residents (#45 and #82), out of a total sample of 19 residents. Specifically, the facility 1. Failed to arrange transportation to a neurologist appointment for evaluation and treatment of neck pain with radiating pain into the left arm and hand for Resident #45 which resulted in ongoing pain requiring narcotic medication, and a 5-week delay and potential change in treatment; and 2. Failed to arrange transportation to an orthopedic physician's office for an initial one week follow up appointment for evaluation and x-rays for recent humerus (upper arm) and pubic rami (pelvis) fractures for Resident #82 resulting in a 2.5-week delay in potential progression of weight bearing status. Findings include: During an interview on 04/20/22 at 09:38 A.M., Unit Manager #3 said she does not know why the transportation was not booked for Resident #45's neurology appointment or for Resident #82's orthopedic appointment, because she had been on vacation. She said when she goes on vacation, the nurses can book the transportation through the online account and all the information is posted at the nursing station and she pointed to the instructions. Unit Manager #3 and the surveyor reviewed the Passport Unit's resident appointment scheduling book and both appointments were recorded in the scheduling book, but neither transportation box was checked off indicating transportation was booked. 1. Resident #45 was admitted to the facility in February 2022 with a diagnosis of wedge compression fracture thoracic (mid) spine. Review of the Minimum Data Set (MDS) assessment, dated 2/24/22, indicated Resident #45 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she was cognitively intact. Review of the Passport Unit's schedule book indicated the following: -Scheduled appointment with spinal surgeon 4/15/22 at 10:00 A.M. Transportation arranged box not checked as completed. Review of current Physician's Orders indicated the following: -Pain evaluation every shift, 0= none, 1-2 (mild), 3-4 (moderate), 5-6 (severe, 7-8 (very severe), and 9-10 (worst possible). If pain greater than 0 please refer to as needed medication action every shift. -Gabapentin capsule 300 milligrams (mg), give one capsule by mouth three times a day for pain. -Lidocaine Pain relief patch 4%, apply to left arm one time per day. -Lidocaine Pain relief patch 4%, apply to lower back (2 patches) one time per day. -Oxycodone HCl tablet 5 mg, Give 2.5 mg by mouth every 12 hours as needed for severe pain 7-10. -Tylenol tablet 325 mg, give two tablets by mouth three times per day for pain. Review of Medication Administration Record (MAR) for April 1 through April 20, 2022, indicated the Resident received the following medication interventions for pain: -Lidocaine Pain relief patch 4% to left arm and lower back (2 patches) as ordered -Gabapentin capsule 300 mg, one capsule three times a day as ordered -Tylenol tablet 325 mg, two tablets by mouth three times a day as ordered -Oxycodone HCl tablet 5 mg, give 2.5 mg every 12 hours as needed for severe pain was administered 28 times out of possible 39 administrations with the following recorded pain levels: 0/10- 5 times 5/10- 1 time 7/10- 13 times 8/10- 6 times 9/10- 3 times Review of the Orthopedic Consult Note, dated 3/30/22, indicated but was not limited to the following: - Left arm pain: Acute (new) - Resident #45 had ongoing neck pain associated with left upper extremity radiculopathy (pinched nerve causing pain) of two month duration. - Neck pain associated with left upper extremity radiculopathy. - I will send the patient to the spine clinic for evaluation and treatment concerning his/her neck pain and radiculopathy. Review of the Passport Unit's Out-Patient Referral Form received from the orthopedic consult on 3/30/22 indicated the following recommendations: -Consult spine service -Appointment booked Friday, April 15,2022 at 10:30 A.M. with x-rays at 10:00 A.M. During an interview on 04/12/22 at 09:14 A.M., Resident #45 said he/she has a lot of pain, and the nurses are pretty good about getting him/her pain medication. The Resident said, I can't sit up for long periods of time because the pain gets too much. During an interview on 04/20/22 at 09:34 A.M., Resident #45 said he/she was very upset the 4/15/22 spine doctor's appointment was canceled the day of the appointment, because the facility didn't have transportation. The Resident said he/she now has to wait until 5/20/22 for the new appointment. Resident #45 said he/she went to see an orthopedic doctor last month for the pain and he said he could not do anything to help with the pain and said he/she would need to see the spine doctor, because he thinks it's a pinched nerve. Resident #45 said he/she has pain/burning in his/her 4th and 5th finger that goes up into his/her forearm and it limits his/her ability to use the left arm. During an interview on 04/20/22 at 09:38 A.M., Unit Manager #3 said Resident #45's appointment with the neurologist was canceled because no transportation was booked and when they called the day of the appointment, the contracted transportation company could not provide transportation on short notice. She said the neurologist appointment had to be canceled and the earliest it could be rescheduled was for 5/20/22. During an interview on 04/20/22 at 02:21 P.M., Unit Manager #3 confirmed Resident #45's transportation was never booked in the computer system for the Neurologist (spine) appointment on 4/15/22. On 04/20/22 at 01:35 P.M., Resident #45 said it's not the pain, it's the burning in my 4th and 5th finger and wrist; sometimes he/she gets pain into the elbow. The surveyor asked Resident #45 to rate the pain on a scale on 0-10 and the Resident said the pain is a 20 and he/she can't stand it. 2. Resident #82 was admitted to the facility in March 2022 with diagnoses of right pubic rami fracture (pelvis), right humeral neck (upper arm) fracture, and Alzheimer's dementia. Review of the Minimum Data Set (MDS) assessment, dated 3/29/22, indicated Resident #82 was unable to complete the Brief Interview for Mental Status (BIMS). The MDS did indicate the Resident had short-term and long-term memory problems. Review of the Passport Unit's schedule book indicated the following: -Resident #85 had a scheduled appointment with an Orthopedic physician on 4/8/22 at 01:15 P.M. Transportation arranged box not checked. Review of the Hospital Discharge Summary, dated 3/23/22, indicated the following: Plan: -Right humeral fracture and right pubic ramus fracture- found on plan films post fall. -Orthopedic recommended non-operative conservative management. -A sling should be placed for comfort but should be removed several times a day for elbow, wrist, and finger range of motion to prevent stiffness. -No shoulder range of motion or weight bearing through the right extremity (arm). -Weight bearing as tolerated with the pubic rami (pelvis) fracture. -Follow up with Orthopedic physician in one week for repeat x-rays of the right shoulder. Review of nursing notes indicated there was no documentation indicating Resident #82 had an orthopedic appointment or missed the scheduled orthopedic appointment 4/8/22. In addition, a note dated 4/14/22 indicated Resident #82 was discharged home with his/her family via private transportation. During an interview on 04/20/22 at 09:38 A.M., the surveyor asked Unit Manager #3 if Resident #82 attended his/her scheduled orthopedic appointment on 4/8/22, and she said she was not sure because she was on vacation that week. She reviewed the nursing documentation and said there was no note indicating if Resident #82 went to the orthopedic appointment or not. During an interview on 04/20/22 at 10:01 A.M., Rehab Staff #1 said she knows Resident #82 did not attend the scheduled orthopedic appointment because Resident #82's Family Representative #1 called the facility from the orthopedic physician's office looking for his/her parent. Rehab Staff #1 said there was no transportation booked to take Resident #82 to his/her orthopedic appointment, so the appointment had to be canceled and rescheduled. During an interview on 04/20/22 at 02:21 P.M., Unit Manager #3 reviewed the online transportation booking website and said Resident #85 is not even registered to book an appointment with the company they use. During a telephonic interview on 04/20/22 at 01:42 P.M., Family Representative #1 said he/she was supposed to meet Resident #82 at the orthopedic physician's office. He/She said they waited 30-45 minutes and my mother/father did not show up, so he/she called the facility. He/She said a facility staff member (could not remember the name) told him/her the transportation did not show up to pick up Resident #82 and the appointment would have to be rescheduled. Family representative #1 said he/she was upset because the facility never called him/her and now his/her parent was discharged home and has still not been seen by the orthopedic doctor and won't be until the rescheduled appointment on 4/26/22.

Based on record review and staff interview, the Facility failed to ensure that for 3 Residents (#2, #20 and #308), of a total sample of 21 residents, that the residents maintained acceptable parameters of nutrition and hydration. For Resident #308, the Facility failed to monitor and accurately record the Resident's intake and output and failed to address a significant weight loss. Findings include: 1. Resident #20 was admitted in 1/2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review on 4/18/18, indicated that the Resident's admission weight was listed as 183.6 lbs (pounds). The Resident was 68 inches tall. No issues were noted on admission regarding the Resident's nutritional intake, and no weight gain or loss was reported. The Monthly/Weekly Weight Sheet indicated a significant decline in the Resident's weight over the following three months as listed below: 1/24/18 Weight = 183.6 2/5/18 Weight = 185 3/12/18 Weight = 183.3 4/9/18 Weight = 170.2 4/13/18 Weight = 168.7 4/20/18 Weight = 167 The Resident lost a total of 16.6 lbs (9.04 %) of body weight from the time of admission in late 1/2018, until 4/20/18, and with no evidence that the Resident's significant weight loss was addressed in a timely manner by the Registered Dietician once identified. Per interview with UM #3 (Unit Manager #3) on 4/19/18 at 11:24 A.M., on 4/8/18 UM #3 identified the Resident's significant weight loss. She obtained a new order for weekly weights and a Dietician Consult. UM#3 said she wrote a Dietician consult request in the RD's (Registered Dietician's) consult request book. Per interview with UM #3, as of 4/19/18, there was no response by the RD to the consult request, to address the Resident's 13.3 lb (8.89 %) weight loss over the course of four weeks. The RD was interviewed on 4/19/18 at 11:24 A.M. The RD said, she wasn't aware of the Resident's significant weight loss until 4/19/18. The RD said that the consult request book wasn't flagged and she acknowledged the delay in addressing the Resident's weight loss. The RD recommended weekly weights, Glucerna 240 mls (milliliters) twice daily, and large portions at each meal, in response to the Resident's significant weight loss. 2. Resident #308 was admitted to the Facility in 4/2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident's BIMS (Brief Interview of Mental Status) score was 15 out of 15, indicating no cognitive deficits. The MDS indicated the Resident required extensive assistance in his/her activities of daily living. The Resident was hospitalized from 12/3/17 to 4/7/18. The 4/7/18 hospital discharge summary indicated the hospitalization was complicated due to prolonged acute respiratory failure which necessitated intubation and other complex medical conditions and infections. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/9/18, the physician's admission note indicated the Resident required treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record indicated that the staff were not documenting the Resident's intake and output in the medical record. Review of the 4/2018 MAR/TAR (Mediation/Treatment Administration Record) indicated daily weights were documented from 4/7/18 through 4/12/18. The weights were as follows: 4/7/18 - 345.8 lbs, 4/8/17 -344.4 lbs, 4/9/18 - 330.5 lbs, 4/10/18 - 330.5 lbs and 4/12/18 - 331 lbs. On 4/12/18, the nursing progress note indicated the weights were changed from daily weights to weekly. The nursing progress note did not identify the weight loss of 15 pounds in 5 days. The note did not indicate a reason the order was changed. The Resident was observed on multiple occasions in his/her room and in bed. The Resident was usually in an upright (90 degrees) position and had oxygen on at 2.5 to 3 liters. Observations were completed on 4/18/18 at 1:15 P,M., 4/20/18 at 8:40 P.M., and on 4/23/18 at 1:30 P.M. The Resident was observed with his/her morning meal and on 2 occasions with a urinal filled on his/her night table. On one occasion (4/23/18) a staff was observed removing the urinal and disposing the contents in the toilet. There was no indication she documented the output. On 4/23/18 at 1:30 P.M., Resident #308 said he/she was unaware of any fluid needs and/or monitoring of weights and that his/her legs had swelling. During interview on 4/23/18 at 2:00 P.M., Nurse #2 was asked if she could locate the intake and output record and weights for Resident #308. The Nurse looked into the electronic record and no intake and output records were located. Unit Manager #2 assisted the Nurse and Surveyor and could not find the records. He said he would see if the staff were documenting on paper and get back to the Surveyor. The weights were located on the MAR/TAR but no explanation was provided for not identifying the weight loss of 15 lbs. On 4/25/18 at 1:45 P.M., the Director of Nurses provided a copy of the Facility's intake and output policy. She said that the staff had not and were not obtaining and recording the intake and output for this resident . She said that as of 2/2018, the transition from paper to electronic records had been implemented. She said that staff were not completing their documentation in the electronic record and had not supported the treatment on paper. 3. Resident #2 was admitted to the Facility in 9/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE], indicated the Resident's BIMS score was 9 out of 15, indicating moderate cognitive impairment. The MDS indicated the Resident required extensive assistance in his/her activities of daily living. The 4/2018, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the intake and output records for 1/2018 and 2/2018 indicated that staff documented the Resident's intake and output on a paper form. The staff documentation indicate that the intake amount was under the 1200 ml fluid amount daily. For example, according to the 1/2018 intake record, the staff documented that the Resident's fluid intake was below 900 ml on 21 occasions and above 1000 ml 6 times. Further review failed to find documentation of the Resident's intake and output for 3/2018 and 4/2018 and staff's monitoring for fluid imbalance. During interview on 4/23/18 at 2:00 P.M., Nurse #2 was asked if she could locate the intake and output record and weights for Resident #2. The Nurse looked into the electronic record and located 16 days of the Resident's intake (4/8/18 - 4/23/18). The Unit Manager was unable to navigate the electronic record to determine if staff had been monitoring and documenting the Resident's intake and output from 3/1/18 through 4/7/18. In addition, review of the intake and output determined that staff were not consistently documenting the shift intake and that there was no documentation of the Resident's output. The Unit Manager said he would see if the staff were documenting on paper and get back to the Surveyor. The Unit Manager provided no additional information. On 4/25/18 at 1:45 P.M., the Director of Nurses provided a copy of the Facility's intake and output policy. She said that she was unable to locate intake records from 3/1/18 - 4/7/18 and could not locate any output records. The Director said that as of 2/2018, the transition from paper to electronic records had been implemented. She said that staff were not completing their documentation in the electronic record and had not supported the treatment on paper.

Based on observation, record review and interviews, the facility failed to identify and provide the necessary care and services to attain or maintain the highest practible physical, mental, and psychosocial well-being for 1 Resident (#5) in a sample of 30 Residents. For Resident #5, the facility failed to obtain a physician's order for treatment to a left heel area identified on weekly skin checks 6 weeks prior (identified on 7/4/14 as documented on a weekly skin check). Resident #5 was admitted to the facility in 3/2010 with [DIAGNOSES REDACTED]. Review of a recent annual Minimum Data Set (MDS) assessment completed on 5/16/14 indicated the Resident was alert, oriented and required extensive assistance for all activities of daily living. The MDS indicated the Resident was at risk for developing pressure ulcers, and currently had one venous stasis ulcer. During the initial tour on 8/13/14 at 8:30 A.M., Unit Manager (UM) #1 said the Resident had a healing "left lateral pressure sore" (not a venous stasis ulcer). UM #1 said the Resident had been admitted with the pressure sore and that it was currently a small scabbed area. UM #1 said a treatment to the left lateral foot was done daily. Resident #5 was observed in bed and a bed cradle was in place. During the initial tour, the Surveyor interviewed Resident #5 about his/her pressure sore on the left lateral foot. Resident #5 said that area was almost healed, but that the sore on his/her left heel was the area that was painful and bothersome. The Surveyor inquired if the bed cradle was helpful and if there was a device to float his/her heels. Resident #5 said he/she crossed his/her legs to keep the heel off the mattress and from hurting. The Resident said that there was nothing but the mattress under the cradle. Following the Surveyor interview of Resident #5, UM #1 again said the Resident had only one area on the left lateral foot, despite the Resident's complaint of the left heel being bothersome. Review of the pressure sore risk assessment on 8/14/14 indicated the Resident was at risk for developing a pressure ulcer. The pressure ulcer (as defined by the UM) or area on the left lateral foot had developed in 1/2013 and the Resident had been treated and followed by a wound clinic. Review of the current signed physician's orders for August 2014 indicated the following orders: monitor integrity of skin around left lateral foot dressing daily for redness, drainage or signs and symptoms of infections, document daily on back of treatment sheet; heel lifter when in bed to off load heels every shift; Seaclens wash (a saline based wound cleaner) to left lateral foot, follow by a dry protective dressing and kling and heel cap, twice weekly on Tuesday and Thursday (not daily as indicated by UM #1) and as needed; lambs wool between toes daily, weekly skin assessments; diabetic foot care daily; and slipper socks on at bedtime. Review of the plan of care for Resident #5 indicated the following three care plan areas 1.) venous stasis ulcer, 2.) circulation impairment and 3.) at risk for potential pressure ulcer. 1) Resident has a venous stasis ulcer on left heel, initiated in 10/2011 and rewritten in 5/2014. Goal: to heal the area by next review. The interventions included the following: complete weekly skin checks, report changes in skin status to physician, discuss non-compliance issues with resident, educate resident about risk factors, complete Norton Risk Assessment, monitor laboratory results as ordered, provide diet as ordered and monitor nutritional status and dietary needs, assist in, as needed, positioning, provide air mattress, heel protectors, position with pillows for proper body alignment, float heels, heel lifters in bed, lambs wool between toes and bed cradle to foot of bed, provide incontinent care, reposition, and provide treatments as ordered (despite the Resident's interview which stated no heel protectors). 2) Alteration in peripheral circulation, initiated 7/2012 and rewritten 5/2014. Goal: to not develop further complications from peripheral venous stasis. The interventions included; assess affected extremities for color, temperature, sensation to pain, assess peripheral pulses and document, assess for [MEDICAL CONDITION] and document, report abnormalities, apply anti-[MEDICAL CONDITION] stockings as ordered and vascular follow-up. (There was no order for anti-embolism stockings or a follow-up visit with a vascular clinic). 3) Resident was at risk for developing a pressure ulcer, initiated 10/2012 and rewritten 5/2014. Goal: skin to be intact and free of redness, blisters or discoloration. The interventions were the same as for the care plan for the venous stasis ulcer. Review of the weekly skin checks from 3/2014 through 8/2014 indicated the following: -3/2014 through 6/2014, the weekly skin checks identified an area on the left lateral foot and that the left heel was fragile but intact. No new issues were identified -7/2014, the 4 weekly skin checks identified that the "left heel" was open and had a small amount of drainage. Although, it identified the left heel, no new orders were obtained and the treatment record indicated the staff were treating the left lateral foot only. There was no documentation to indicate that the physician was called regarding the left heel ulcer.. -On 8/1/14, the weekly skin check indicated the Resident's left foot skin area was warm, dry and intact. The 8/8/14 skin check indicated the left foot had a small open area. It did not denote the location of the open area and the treatment records indicated staff were treating the left lateral foot. Review of the March, April, May, June, July and August 2014 Treatment Administration Record (TARs) indicated that there was no treatment for [REDACTED]. The staff documented the heel and/or lateral area of foot or just foot. The documentation did not include a description, (size, color, depth, location) of the separate area(s) or the effectiveness of treatments for the possible revision of the plan of care. During observation by Surveyor #2, on 8/15/14 at 10:15 A.M., Nurse #1 changed the dressing on the Resident's left foot which was observed to be a 4 inch x 4inch piece of gauze and a Kling wrap to the left heel. The Interim Director of Nurses and Nurse #1 assessed the foot. Nurse #1, UM #1 and the Interim Director said they were unaware of an area on the Resident's left heel. Resident #5 told staff that the "heel hurts so be careful ... and the other area (lateral left foot) doesn't bother him/her." Nurse #1 removed a gauze wrap and a 4 x 4 gauze square from the Resident's left heel. Neither the gauze covering or the 4 x 4 had been placed on or covered the left lateral scabbed area of the Resident's foot. The Interim Director said the heel area was 4 cm (centimeters) by 3.5 cm, with a small scab area and that the area surrounding the scab was reddened, mushy and involved a large portion of the heel area. The Director said the area was an unmeasurable pressure sore because it was under the scab. The nursing staff said that there were no physician orders to treat the heel and that they would notify the physician and obtain orders. The Director said that she would see if the physician wanted to order an antibiotic due to the inflammation and pain. In response to the call out to the physician about the heel on 8/15/14, the physician ordered a treatment, antibiotic administration and wound clinic evaluation for the Resident.

Based on observation, record review and interview with resident and staff, the facility failed to provide the appropriate treatment and services to increase the range of motion to prevent the development of a contracture for one Resident (#9), in a sample of 30 Residents. Findings include: Resident #9 was admitted in 4/2014 for short term rehabilitation services after a hospitalization for weakness. Resident #9 had [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS) assessment with a reference date of 4/23/14, indicated the Resident was alert and oriented and required assistance from staff for activities of daily living. The assessment indicated the Resident needed extensive assistance for transfers and other activities of daily living and did not ambulate. The MDS indicated the Resident had functional limitation in range of motion of his/her upper extremity on one side. There was no identified limitations of the lower extremities. A review of the plan of care dated 4/19/14 indicated the resident was at risk for a decline in ADL's (Activities of Daily Living) and a review of the approaches had no information specific for this resident with a range of motion limitation of the upper extremity. The approaches listed to turn and reposition the resident and to report changes in ADL's to the nurse. A review of the next quarterly MDS assessment,with a reference date of 7/11/14, indicated the Resident had a decline in transfers, dressing and hygiene and was assessed as totally dependent on staff. The Resident had functional limitation in range of motion of his/her upper extremity and a new limitation of the lower extremities. Record review indicated on 4/17/14, a physical therapy evaluation and treatment plan was completed. The Resident's mobility, balance and safety was assessed. The goal was for the Resident to return home at his/her maximal functioning potential. The physical therapy plan was the Resident to receive physical therapy 5 to 6 times per week from 4/17/14 - 5/28/14. The assessment indicated the resident had some lower extremity weakness and was at risk for further decline, but that direct physical therapy services would increase lower extremity strength and functional mobility. The assessment did not identify a lower leg contracture. Upon discharge of physical therapy services on 5/27/14, the Resident had met his/her goals and did not have a left knee contracture. During record review on 8/15/14, the physical therapy progress notes, dated 6/27/14 - 7/3/14 and 7/4/14 - 7/10/14, indicated the resident was now receiving direct services for a left knee contracture management. The progress note indicated that a contracture of the resident's left knee was identified on 6/24/14 and the note indicated the the Resident was to wear a knee extension splint on his/her left knee. The progress note indicated the the time the knee extension splintwas worn would be increased, as the Resident was able to tolerate. Concerns were to monitor for pain, discomfort, redness or swelling. The monthly physician's order for June, July and August 2014 listed a no orders for a knee extension splint/brace and no plan of care for treatment for [REDACTED]. The medical record had no plan of care to review from physical therapy for the impaired lower extremity, after starting this second course of therapy 6/27/14, regarding the knee brace. Interview with the Director of Rehabilitation on 8/19/14 at 9:05 A.M., reviewed the record and said there was no plan of care for the brace and told the surveyor she would write one. The surveyor was given a physical therapy plan of care later that day that she had completed and dated it 6/27/14 and not 8/19/14. During surveyor observations on 8/15/14 at 11:00 A.M. and two subsequent observations on 8/18/14 at 12:10 P.M. and 1:30 P.M. and 8/19/14 at 8:45 and 10:00 A.M., the Resident was not wearing a left knee extension splint/brace. During interview on 8/18/14 at 1:30 P.M., Resident #9 said that he/she received physical therapy and that they sometimes put a knee brace on him/her. Resident #9 said he/she did not know where the brace was. The surveyor observed no knee brace in the Resident's closet and/or in bedside table. During interview on 8/19/14 at 8:30 A.M., Physical Therapy Assistant #1 said the Resident received physical therapy 5 times per week, the medical record had no physician's orders for the therapy. She said that they were treating the Resident's knee contracture using a knee extension splint. She said that the therapist applied the brace and took it off. The goal was to increase the Resident's ability to wear the brace 6 hours daily. She said that the therapy staff did not monitor during the time the Resident was wearing the brace and was not sure who was. During interview on 8/19/14 at 8:45 A.M., Unit Manager (UM) #2 said that the Resident had developed a contracture and staff recognized this due to the Resident's complaints of pain. The staff made a referral to rehabilitation services. UM #2 said she was had been aware that a knee extension splint had been ordered, but was not sure if it was being used. She said the splint was in the Resident's bureau and that she thought it had to be refitted. UM #2 said she and the nursing staff had not been educated or trained by the physical therapist to monitor the splint and that, as far as she knew, if and when the Resident was wearing the splint no one was monitoring for adverse effects of the treatment. During interview on 8/19/14 at 9:05 A.M., Director of Rehabilitation Services said that the Resident was suppose to receive physical therapy 5 times per week to treat the contracture. She said that she had been notified by the nursing staff in June 2014, that the Resident had developed a left knee contracture after Resident #9 had been discharged from therapy in May 2014. She said that she did not know why there were no current specified orders for treatment, that included the knee splint, or a plan of care in the medical records. She said that nursing staff had not been trained and that the staff had not been monitoring the Resident when he/she was wearing the knee splint. There was no information in the medical record on how the staff were to prevent this lower extremity contracture, no specific plan of care, no information on the care cards, no information for positioning the Resident, and no nursing documentation. The physical therapy treatment plan indicated the Resident was to receive treatment 5 times weekly and the therapy documentation after 6/27/14 indicated he/she did not receive therapy 5 times a week. The weekly therapy notes indicated treatment provided as follows: Week 6/29/14 - 7/5/14 the resident received 3 therapy treatments. Week 7/6/14 - 7/12/14, 5 treatments. Week 7/13/14 - 7/19/14, 3 treatments. Week 7/20/14 - 7/26/14, 3 treatments. Week 7/27/14 -8/2/14, 2 treatments. Week 8/3/14 - 8/9/14, 2 treatments. Week 8/10/14 - 8/16/14, 1 treatment. During interview on 8/19/14 at 9:30 A.M., the Interim Director of Nurses was notified of the facility acquired contracture and she could offer no information. There was no information provided by the facility that indicated how the resident, who was identified at risk, developed the left knee contracture and why the treatment was not implemented to treat and prevent further decline.

Based on interview, observation and record review, for one of four sampled residents (Resident #2), the Facility failed to monitor Resident #2, per the plan of care, to prevent Resident #2 punching Resident #1 in the face, ear and chest. Resident #2, who had a history as the aggressor in previous altercations and a [DIAGNOSES REDACTED].#2's interactions with his peers. On 9/24/10 at 11:40 PM, Resident #2 hit Resident #1 on the nose, right eye, left jaw, left ear and chest. Resident #1 was transferred to the hospital, where Resident #1 was diagnosed with [REDACTED]. Findings included: The admission Minimum Data Set (MDS), dated [DATE], indicated that Resident #1 had problems with short and long-term memory, and that Resident #1 had severely impaired cognitive skills for decision-making (never/rarely made decisions). The Nurse's Note, dated 9/24/10 at 12:00 AM, indicated that Resident #2 was upset because the light was on over Resident #1's bed. The note indicated that Resident #1 was lying on the bed, when Resident #2 came over and started punching and scratching Resident #1. The note indicated: the right side of Resident #1's nose was red; Resident #1's right eye was starting to bruise; there was a cut behind Resident #1's left ear; Resident #1 had a scratched middle finger on the left hand; and Resident #1's lip was bleeding. The Nurse's Note, dated 9/24/10 (7:00 AM to 3:00 PM), indicated that Resident #1 had increased swelling on the right side of the face; Resident #1 had an abrasion on the left ear; Resident #1's right eye was swollen and ecchymotic (bruised); a small amount of bruising was noted on Resident #1's left inner eyelid; bruising was noted on Resident #1's chest; and two bumps were noted on the back of Resident #1's head. The note indicated that Resident #1 was transferred to the hospital at 9:00 AM. The quarterly Minimum Data Set (MDS), dated [DATE], indicated that Resident #2 had no problem with short or long-term memory, and that Resident #2 had moderately impaired cognitive skills for decision-making. The MDS indicated that Resident #2 exhibited socially inappropriate behavior (noisiness, screaming, self-abusive acts, hoarding, rummaging through others' belongings) on a daily basis. The Functional Maintenance Program Note, dated 5/3/10 indicated that Resident #2 was deaf, and used a combination of sign language, gestures, finger spelling and writing to express self. The Decree of Permanent Guardianship, dated 4/6/10, indicated that Guardians were appointed for Resident #2 on that date. The care plan for actual alteration in mood or behavior, dated 3/5/10, indicated that Resident #2's interaction with peers should be monitored. The care plan indicated that Resident #2 had a history of [REDACTED]. The Psychiatric Progress Note, Dated 5/7/10, indicated that Resident #2 had diagnoses, which included status [REDACTED]. The note indicated that Resident #2 was deaf and mute (ie, speech was unintelligible). The note indicated that Resident #2 was intrusive and teased other residents, and that some of these behaviors had come close to physical assault. The note indicated that staff were good at monitoring Resident #2's behavior and intervening before the situation escalated. The care plan for resident to resident altercation, dated 7/8/10, indicated that Resident #2 was involved in a resident to resident altercation. The plan of approach included: identify potential residents that do not get along well and monitor proximity to each other. The Nurse's Note, dated 7/9/10, indicated that Resident #4 accused Resident #2 of stealing pants. The note indicated that Resident #3 alleged that Resident #2 grabbed a hand and bent the fingers back. The note indicated that the alleged incident was unwitnessed. The Fax Reporting Form, dated 9/9/10, indicated that on 9/7/10 at 4:30 PM, Resident #2 was walking down the hallway with a nurse, when Resident #2 reached out and pulled Resident #3's hand. The report indicated that Resident #2 immediately released Resident #3's hand and continued walking down the hallway. The report indicated that Resident #3 did not receive any injuries. The report indicated that the incident was observed by the Psychiatrist. The Psychiatrist's Note, dated 9/7/10, indicated that Resident #2 was agitated and threatening, and that staff intervened to settle Resident #2 down. The note indicated that Resident #2 responded well to supportive and behavioral interventions and that a Section 12 (emergency hospitalization ) was averted. The Psychiatrist's Note, dated 9/8/10, indicated that the Psychiatrist met with Resident #2's Guardian. The note indicated that there were no residuals to the event on 9/7/10, but Resident #2 became distressed and impulsive at times, which led to intermittent escalation of behaviors. Recommendations included adding a [DIAGNOSES REDACTED]. Resident #1 was interviewed on 9/28/10 at 11:45 AM. Resident #1 said Resident #2 liked to control what went on in the room. Resident #1 said Resident #2 went through Resident #1's personal belongings, which angered Resident #1. Resident #1 recalled the events leading up to the incident with Resident #2 on 9/24/10. Resident #1 reported sitting in bed with the television and over the bed light on, and with the privacy curtain drawn. Resident #1 said Resident #2 got up and tried to turn the television off. Resident #1 said Resident #2 wanted everything shut off, so Resident #2 could sleep. Resident #1 said Resident #2 began punching. Resident #1 reported having a broken bone in the nose and bruising on the right arm. . Nurse #1 was interviewed on 9/28/10 at 2:50 PM and wrote a statement, dated 9/23/10, for the Facility's internal investigation. Nurse #1 reported hearing Resident #2 yelling in the hallway at about 11:40 PM. Nurse #1 walked down the hall to investigate. Nurse #1 indicated that Resident #2 expressed, using hand gestures, that Resident #2 could not sleep because Resident #1's overhead light was on. Nurse #1 entered the room shared by Resident #1 and Resident #2 and went around the drawn privacy curtain to talk to Resident #1. Nurse #1 observed Resident #1 sitting on the side of the bed. Nurse #1 indicated that during the conversation with Resident #1, Resident #1 was wiping the corners of the mouth and lips. Nurse #1 reported seeing blood on the tissue. Nurse #1 said Resident #2 reported punching Resident #1. Nurse #1 verified this information with Resident #1. Nurse #1 said Resident #1 pointed to the area below the right eye, the left jaw and the left ear. Nurse #1 indicated that Resident #1's left ear had three superficial open areas and was bleeding slightly. Certified Nursing Assistant (CNA) #1 was interviewed on 9/28/10, and wrote a statement, dated 9/23/10, for the Facility's internal investigation. CNA #1 said Resident #2 was protective of the room, and did not like staff entering the room to provide care to the other residents. The Unit Manager was interviewed on 9/28/10 at 11:25 AM. The Nurse Manager reported assessing Resident #1 on 9/24/10 and observing widespread bruising on the chest, swelling on Resident #1's left jaw, bruising on the right eye and a left ear abrasion. The Unit Manager said that on two occasions, Resident #1 reported not liking Resident #2. According to a written statement, dated 9/24/10, Resident #1 was unable to provide specific information about why Resident #1 did not like Resident #2. On 9/28/10, the Surveyor observed that Resident #2 shared the room with three residents, including Resident #1. The Unit Manager said the other two residents required total care and had little interaction with Resident #2. The Facility failed to provide adequate supervision to protect Resident #1 from assault by Resident #2. Resident #2 was diagnosed with [REDACTED].#2's interaction with peers was monitored, in compliance with Resident #2's care plan.