Every finding on record at Sancta Maria Nursing Facility

Based on records reviewed, interviews and observations, for one of three sampled residents (Resident #1) who was assessed as being at high risk for falls and required staff assistance for bed mobility, the Facility failed to ensure his/her safety was adequately maintained during the provision of care to prevent an incident resulting in serious injury, when on 04/22/26, Certified Nurse Aide (CNA) #1 assisted and rolled Resident #1 onto his/her side, turned away to get a towel and Resident #1 rolled off the bed and fell to the floor. Resident #1 was transferred to the Hospital's Emergency Department (ED) for evaluation and was diagnosed with a left knee laceration measuring seven centimeters (cm) long which required a running lock suture (a continuous suturing technique) to close the wound.Findings include: Review of the Facility's policy, titled Falls Management, dated as revised, October 2023, indicated that a fall is defined as any incident in which a resident unintentionally has a change in elevation/plane, an occasion where the resident would have lost their balance without staff intervention, or an incidence where a resident rolls off a bed or mattress close to the floor.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 04/22/26, indicated that while providing care to Resident #1 on 04/22/27 around 6:20 A.M., Certified Nurse Aide (CNA) #1 raised Resident #1's bed up to provide care, then from Resident #1's left side, assisted and rolled Resident #1 onto his/her right side (rolling Resident #1 away from herself). The Report indicated that CNA #1 turned away from Resident #1 to get a towel, and Resident #1's leg shifted and caused him/him to roll out of the bed onto the floor, which caused a left knee laceration and head strike.Review of the Facility's Post Fall Investigation Report, dated 04/22/26, indicated that according to CNA #1 and Resident #1, on 04/22/26 at about 6:20 A.M., CNA #1 had raised Resident #1's bed up to provide care, and while she provided assistance from Resident #1's left side, CNA #1 assisted and rolled Resident #1 onto his/her right side. The Report indicated that CNA #1 said that when she turned around to get a towel, Resident #1's left leg shifted off the side of the bed, which caused him/her (Resident #1) to roll out of bed onto the floor. The Report indicated that Resident #1 was sent to the Hospital's ED for a left knee laceration and returned with a running lock suture measuring seven cm in length, to close the laceration. Resident #1 was admitted to the Facility in April 2026, diagnoses included nontraumatic intracranial hemorrhage (stroke) and heart failure.Review of Resident #1's admission Fall Risk Assessment, dated 04/17/26, indicated he/she was at high risk for falls.Review of Resident #1's admission Brief Interview for Mental Status (BIMS) evaluation, dated 04/17/26, indicated he/she had moderate cognitive impairment.Review of Resident #1's Activities of Daily Living (ADL) Care Plan, dated 04/17/26, indicated that Resident #1 required assistance from one to two staff members to turn and reposition in bed.Review of a Nurse's Note, dated 04/22/26, indicated Resident #1 had a witnessed fall with a head strike during care, sustained a left knee laceration and required transfer to the Hospital's Emergency Department (ED).Review of the Hospital ED Discharge Report, dated 04/22/26, indicated Resident #1's left knee laceration measured seven centimeters (cm) long, two cm deep, and required a running lock suture, (measuring seven cm in length), to close the wound. Review of an Interview documented by the Director of Nurses (DON), dated 04/24/26, indicated that Resident #1 said CNA #1 was providing morning care when he/she (Resident #1) rolled out of bed. The Interview indicated that Resident #1 said CNA #1 was on his/her left side when CNA #1 helped him/her (Resident #1) roll over to his/her right side (rolling him/her away from herself). The Interview indicated that Resident #1 said his/her leg went over the side of the bed, and he/she rolled out onto the floor and hit his/her head.During an interview on 05/07/26 at 12:36 P.M., Resident #1 said that after CNA #1 raised his/her bed up, CNA #1 stood on his/her left side and told him/her (Resident #1) to roll onto his/her right side (away from CNA #1). Resident #1 said she told CNA #1 he/she was too close to the edge of the bed to roll over, but CNA #1 told him/her he /she was fine, and that CNA #1 then helped him/her roll onto his/her right side (away from CNA #1, and not towards her). Resident #1 said once he/she was on his/her right side, his/her left leg somehow moved off the bed, which caused him/her to roll off the bed onto the floor.During a telephone interview on 05/19/26 at 4:02 P.M., (which included a review of her written witness statement, dated 04/22/26,) CNA #1 said that before she provided morning care to Resident #1, she raised the height of his/her bed, and while she stood on Resident #1's left side, she assisted him/her to roll onto his/her right side, which was away from her. CNA #1 said that once Resident #1 was on his/her right side, she turned away to get a towel and when she did, Resident #1 pulled on the small bed rail by his/her head, quickly shifted his/her body in the bed, and rolled off his/her bed onto the floor. CNA #1 said she was unable to prevent Resident #1 from falling out of bed because she was on the opposite side of the bed and could not reach him/her. CNA #1 said she should have assisted and rolled Resident #1 toward her, not away from herself.During a telephone interview on 05/19/26 at 4:19 P.M., Nurse #1 said that CNA #1 told her that Resident #1 fell out of bed. Nurse #1 said that when she walked into Resident #1's room, she saw him/her (Resident #1) on the floor between his/her bed and the window, lying on his/her left side. Nurse #1 said she assessed Resident #1, and due to a left knee laceration, he/she (Resident #1) was transferred to the Hospital's ED.During an interview 05/07/26 at 2:13 P.M., the Unit Manager said Resident #1 could roll in bed with assistance of one staff person. The Unit Manager said that Resident #1 told her that CNA #1 had him/her (Resident #1) roll onto his/her right side (away from CNA #1). The Unit Manager said Resident #1 struck his/her head during the fall and suffered a left knee laceration, which required sutures. The Unit Manager said that for safety reasons, CNAs were always expected to roll a resident toward themselves, never away. The Unit Manager said this is part of CNA basic training for their certificate and is considered basic knowledge.During an interview on 05/07/26 at 2:33 P.M., the Director of Nurses (DON) said that based on his investigation, while providing morning care on 04/22/26, CNA #1 assisted and had Resident #1 roll away from herself (CNA #1) instead of toward herself (CNA #1), and when CNA #1 turned to get a towel, Resident #1 rolled off of the opposite side of the bed from where CNA #1 was standing. The DON said that as a result of the fall from his/her bed, Resident #1 suffered a head strike (no injury) and a left knee laceration and was sent to the ED for evaluation. The DON said Resident #1 returned to the Facility the same day with sutures in place to repair his/her left knee laceration. The DON said that CNA #1 should not have rolled Resident #1 away from herself, but she had and was therefore not able to prevent Resident #1 from rolling off his/her bed onto the floor.

Based on record review and interview, the facility failed to electronically submit direct care staffing data to Centers for Medicare and Medicaid Services (CMS) for the entire reporting period, Fiscal Year (FY) Quarter 1 2026 (October 1 - December 31) in accordance with the schedule specified by CMS.Findings include:The surveyor requested, but the facility was unable to provide, a policy regarding Payroll Based Journal (PBJ) reporting. Review of the PBJ Staffing Data Report, Fiscal Year Quarter 1 (October 1- December 31) indicated the following:-Failed to submit data for the quarter: Triggered.-One star staffing rating: Triggered.-Excessively Low Weekend Staffing: This metric is suppressed for this facility and quarter.-No RN (Registered Nurse) Hours: This metric is suppressed for this facility and quarter.-Failed to have Licensed Nursing Coverage 24 hours per day: This metric is suppressed for this facility and quarter. During an interview on 3/24/26 at 1:24 P.M., the Administrator said that he was responsible for submitting the PBJ reports and that when he reported for the above quarter, there was an error that he was not aware of, resulting in a missing report for the quarter.

Based on observations and interview, 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 transmission of communicable diseases and infections. Specifically, the facility failed to maintain Enhanced Barrier Precautions (EBP) as indicated for four Residents (#85, #40, #59 and #119) out of a total sample of 29 residents.Findings include: Review of the facility policy titled Enhanced Barrier Precautions, not dated, indicated that Personal Protective Equipment (PPE) staff must don gloves and gowns during high-contact care activities, such as bathing or showering, wound care or dressing changes. Review of the Centers for Disease Control (CDC) website indicated the following, dated June 28, 2024:-Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). 1. Resident #85 was admitted to the facility in January 2026 with diagnoses including kidney failure on dialysis, fall with major injury and pneumonia. Review of the Minimum Data Set, dated [DATE] indicated that Resident #85 was cognitively intact scoring a 15 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #85 required assistance with all activities of daily living. Review of the physician orders indicated an order for enhanced barrier precautions, requires gown and glove use during high contact resident care activities due to increased risk of MDRO (multidrug resistant organism) acquisition due to dialysis catheter. On 3/25/26 at 9:12 A.M., the surveyor observed a sign on the room door indicating that Resident #85 was on enhanced barrier precautions (EBP). On 3/25/26 at 9:12 A.M., the surveyor and the Director of Nursing observed Certified Nurse's Aide (CNA) #1 providing direct contact care to Resident #85. The surveyor also observed that CNA #1 was not wearing a protective gown during the high-contact procedure. During an interview on 3/25/26 at 9:12 A.M., the Director of Nursing said that Resident #85 is on EBP, and the staff should be wearing gowns during high contact care. 2. Resident #40 was admitted to the facility in March 2026 with diagnoses including glaucoma, heart failure and anxiety. Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #40 was cognitively intact scoring a 15 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #40 required assist with all activities of daily living. Review of the physician orders dated March 2026 indicated the following order: enhanced barrier precautions, requires gown and glove use during high contact resident care activities due to increased risk of MDRO (multidrug resistant organism) acquisition due to chronic LLE (left lower leg) vascular wound. On 3/25/26 at 9:12 A.M., the surveyor observed a sign on the room door indicating that Resident #85 was on enhanced barrier precautions (EBP). On 3/25/26 at 9:12 A.M., the surveyor and the Director of Nursing observed CNA #2 providing direct contact care to Resident #40. The surveyor also observed that CNA #2 was not wearing a protective gown during the high-contact procedure. During an interview on 3/25/26 at 9:16 A.M., the Director of Nursing said that staff were to wear protective gowns whenever providing direct contact care to a resident who had been placed on enhanced barrier precautions. The Director of Nursing said that Resident #40 was on EBP and staff should be wearing gowns during high contact care. 3. Resident #59 was admitted to the facility in March 2026 with diagnoses including surgical wound to right foot, sepsis and congestive heart failure. Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #59 was cognitively intact, scoring a 14 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #59 required assistance with activities of daily living. Further review indicated that Resident #59 had a surgical wound. On 3/25/26 at 9:23 A.M., the surveyor observed a sign on the room door indicating that Resident #85 was on enhanced barrier precautions (EBP). On 3/25/26 at 9:23 A.M., the surveyor and Nurse #2 observed Nurse #1 performing a wound treatment to Resident #59's right foot. The surveyor and Nurse #2 also observed that Nurse #1 was not wearing a protective gown during the high-contact procedure. During an interview on 3/25/26 at 9:23 A.M. Nurse #1 said that he should have been wearing a gown during the treatment to Resident #59's foot. During an interview on 3/25/26 at 9:24 A.M. Nurse #2 said that Nurse #1 should have been wearing a gown during Resident #59's wound care. 4. Resident #119 was admitted to the facility in March 2025 with diagnoses including muscle weakness and retention of urine. Review of the Minimum Data Set, dated [DATE], indicated a Brief Interview for Mental Status score of 12 out of 15, indicating moderate cognitive impairment. The MDS further indicated that the Resident had an indwelling urinary catheter On 3/25/26 at 7:59 A.M., the surveyor observed a staff member in the room with the Resident. The staff member said she was providing morning ADL care for the Resident. The staff member did not have a gown on, only gloves. The surveyor observed a sign on the Resident's door that indicated the need for Enhanced Barrier Precautions. Review of the Resident care plan, dated 2/24/25, indicated the following: -Resident requires Enhanced Barrier Precautions= EBP require gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO (Multidrug resistant organism) as well as those at increased risk of MDRO acquisition due to indwelling medical device, even if NOT infected or colonized with a MDRO. -Interventions included: Gown and gloves to be worn during high contact activities: ie: Bathing, Showering, Hygiene, Toileting, Incontinence care, Dressing, Transferring -[Resident] has Indwelling Suprapubic Catheter, 18french 30ml due to Urinary retention/obstructive uropathy, revised 1/28/25. Review of physician's orders indicated the following: -Resident requires Enhanced Barrier Precautions = EBP requires gown and glove use during high-contact resident care activities due to known risk of MDRO acquisition due to suprapubic catheter, dated 2/24/25. During an interview on 3/25/26 at 9:16 A.M., the Director of Nursing said that staff are to wear protective gowns whenever providing direct contact care to a resident who has been placed on enhanced barrier precautions. During an interview on 3/25/26 at 11:38 A.M., the Administrator said that he would expect that staff were implementing enhanced barrier precautions as required.

Based on record review and interview, the facility failed to ensure that residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Specifically, for Resident #25 the facility failed to determine if the Resident had specific triggers and interventions that might mitigate the response to the triggers should they occur. Findings include:Review of the facility policy titled Trauma Informed Care dated revised January 2023 indicated that the facility must ensure that residents who were trauma survivors received culturally competent, trauma informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Further review indicated that the facility will:1. Identify a resident's past history of trauma. 2. Identify triggers which cause re-traumatization. Resident #25 was admitted to the facility in February 2026 with diagnoses including Post Traumatic Stress Disorder (PTSD), major depression and status post left knee replacement. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #25 is cognitively intact scoring a 14 out of 15 on the Brief Interview for Mental Status exam. Further review indicated a diagnosis of PTSD. Review of the current care plan indicated a focus for Trauma Informed Care failed to indicate triggers that might cause re-traumatization or interventions to mitigate potential reactions to the triggers. Further review failed to indicate if the Resident either refused to discuss his/her PTSD or whether the Resident indicated that there were no triggers he/she was aware of. Review of the social service progress notes failed to indicate Resident #25 had PTSD or that the Resident's PTSD was discussed with the Resident. Review of the medical record failed to indicate Resident #25 was assessed for PTSD and potential triggers. During an interview on 3/25/26 at 9:30 A.M., Resident #25 said that no one has asked her about his/her PTSD since he/she was admitted . Resident #25 then said that the loud talking of the staff at night can bring him/her back to his/her living situation as a child. Resident #25 said that it just makes him/her sad. During an interview on 3/25/26 at 9:58 A.M., the Director of Nursing said that the care plan should include triggers and interventions specific to the Resident.

Based on record review and interview, the facility failed to ensure Advance Directives (written documents that instruct health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) were accurately documented for one Resident (#14) out of a total sample of 29 residents. Specifically, for Resident #14, the facility failed to ensure that Advanced Directives indicated on the MOLST form (Massachusetts Medical Order for Life-Sustaining Treatment form) were consistently documented in the medical record.Findings include: Review of the facility policy titled Advanced Directives, dated 1/20/23, indicated the facility will inform, document, and honor resident preferences regarding advance directives and MOLST orders. All staff will follow valid medical orders reflecting resident wishes. MOLST orders must match facility code status orders. Ensure consistency across all records. Staff must follow MOLST and physician orders. Any discrepancies must be clarified immediately. Definitions: Advanced Directives: Written Healthcare Instructions.MOLST: Medical Order for Life-Sustaining Treatment.DNR/DNI: Orders regarding resuscitation and ventilation. Resident #14 was admitted to the facility in February 2026 with diagnoses that included cognitive communication deficit, major depressive disorder, repeated falls, and traumatic subdural hemorrhage. Review of Resident #14's most recent Minimum Data Set (MDS) assessment, dated 2/22/26, indicated he/she scored a 6 out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments. Review of the MDS dated [DATE], indicted the Resident was a DNR (Do Not Resuscitate) and DNI (Do Not Intubate) code status. Review of Resident #14's physician order, dated 2/17/26, indicated DNR/DNI STATUS. Review of Resident #14's Advanced Directives care plan, dated 2/9/26, indicated DNR/DNI. Review of Resident #14's Medical Doctor (MD) progress note, dated 2/10/26, indicated Code Status: DNR/DNI. Review of Resident #14's social services progress note, dated 2/9/26, indicated MOLST reads DNI, DNR. Review of Resident #14's MOLST, dated 2/14/22, indicated DNR only signed by the Resident. During an interview on 3/25/26 at 7:51 A.M., Unit Manager #1 said that if a Resident had a MOLST then it should match the doctors order that was in place. Unit Manager #1 said Resident #14's MOLST only indicated that he/she was a DNR because the DNI spot had been left blank. The Unit Manager reviewed the Residents orders with the surveyor and said the doctors order reads as DNR and DNI. During an interview on 3/25/26 at 9:55 A.M., the Director of Nurses said the physician order should match exactly what was on the Resident's MOLST form. During an interview on 3/25/26 at 11:15 A.M., Social Services #1 said the Residents MOLST should always match the doctors order, so it was consistently documented on what the Residents wishes are.

Based on record review and interviews, the facility failed to ensure that appropriate information was communicated to the receiving health care institutions or providers for one Resident (#130) out of a sample of 29 residents. Specifically, the facility failed to contact the Resident's health care provider and elder at-risk services in the community after the Resident provided verbal intent to leave the facility earlier than outlined in the care plan.Findings include:A review of the facility policy titled 'Discharges and Transfers' last updated 9/21/23 indicated the following:-Resident-initiated transfer or discharge means the resident or, if appropriate, the resident representative has provided verbal or written notice of intent to leave the facility (leaving the facility does not include the general expression of a desire to return home or the elopement of residents with cognitive impairment.Resident #130 was admitted to the facility in March 2026 with diagnoses including Parkinsons disease.A review of the most recent Minimum Data Set (MDS) dated [DATE] did not indicate a documented Brief Interview for Mental Status (BIMS) score.Further review of the medical record indicated Resident #130 signed his/her own MOLST (Medical Orders for Life-Sustaining Treatment) on 3/11/26 indicating he/she was his/her own responsible party.Review of hospital discharge summary progress notes dated 3/11/26 indicated that Resident #130 presented to the Emergency Department on 3/6/26 with acute delirium resulting in a motor vehicle collision.A review of Nursing progress notes dated 3/11/26 indicated the following:-Resident left AMA tonight. Resident was admitted this evening for a rehabilitation stay. Spouse was not pleased with some aspects of the stay. Resident's spouse was requesting all medications on order to be given to the Resident this evening. The Resident's spouse was informed that there was no in-house pharmacy, and we were awaiting delivery by the pharmacy. Meanwhile, a call was placed to the physician to address the issues. The Resident left before any resolution could be made.During an interview on 3/25/26 at 9:55 A.M., the Director of Nurses said when residents choose to leave the facility AMA, the Social Worker should notify the Resident's primary care provider in the community and notify elder at-risk services in the community.During an interview on 3/25/26 at 10:54 A.M., Social Worker #1 said Residents do have the right to leave the facility AMA. The Social Worker said she did not meet the Resident after he/she was admitted on [DATE]. The Social Worker said she was not aware that the Resident had left the facility AMA. The Social Worker said she expects to be informed when Residents leave AMA so she can call their primary care provider in the community and inform them that the Resident left the facility AMA. The Social Worker said she would also need to call and inform elder services in the community that the Resident may be at risk because the Resident wished to be discharged earlier than outlined in the plan of care.

Based on observation, record review and interview, the facility failed to follow a physician's order for one Resident (#118) out of a total sample of 29 residents. Specifically, the facility failed to ensure multipodus booties were implemented as ordered.Findings include: Review of the facility policy titled Care Plan dated reviewed 2/25/25 indicated the care plan guides the care and treatment provided by all caregivers. Resident #118 was admitted to the facility in January 2026 with diagnoses including liver disease, kidney disease and mild neurocognitive disorder. Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #118 was cognitively intact, scoring a 13 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that he/she required extensive assistance with lower body dressing. Review of the physician order dated 2/22/26 indicated an order to offload heels with multipodous boots (pressure relieving boots) every shift. Review of the current care plan indicated a focus of potential for pressure ulcer development r/t decreased strength and endurance, Diabetes, Anemia, HTN with an intervention to off load both heels with multipodus boots when in bed. Further review failed to indicate Resident #118 refused care.On 3/24/26 at 8:41 A.M., the surveyor observed Resident #118 lying in bed. The surveyor also observed a pair of pressure relieving booties on the mattress at the end of the bed. During an interview on 3/24/26 at 8:41 A.M. Resident #118 said that the staff have not put them on yet today. Resident #118 then said that he/she was not able to put the booties on by him/herself. On 3/24/26 at 3:26 P.M., the surveyor observed Resident #118 lying in bed. The surveyor also observed a pair of pressure relieving booties on a chair across from the bed. During an interview on 3/24/26 at 3:26 P.M., Resident #118 said that staff never put the booties on today. When asked if he/she refused to wear the booties or did not like them on, Resident #118 said no. During an interview on 3/25/26 at 8:10 A.M., Certified Nurse's Aide (CNA) #1 said that nurses give report in the morning to let them know what the residents required. CNA #1 said that she wasn't aware that Resident #118 didn't have his/her booties on. During an interview on 3/25/26 at 9:24 A.M. Nurse #2 said that the CNAs were supposed to put the multipodus booties on and physician orders were supposed to be followed. On 3/25/26 at 12:54 P.M., the surveyor observed Resident #118 sitting in a wheelchair without multipodus boots on his/her feet.

Based on observation, record review and interview, the facility failed to ensure that a resident who is unable to carry out activities of daily living received the necessary services needed for two Residents (#24 and #125) out of a total sample of 29 residents. Specifically for Residents #24 and #125 the facility failed to provide supervision or assistance during meals for safety with eating. Findings include:Review of the facility policy titled Care Plan dated reviewed 2/25/25 indicated the care plan guides the care and treatment provided by all caregivers. 1. Resident #24 was admitted to the facility in March 2026 with diagnoses including dysphagia (difficulty swallowing), aspiration pneumonia and blood clots in the left leg. Review of the minimum Data Set assessment dated [DATE] indicated that Resident #24 was cognitively intact scoring a 13 out of 15 on the Brief Interview for Mental Status exam. Further review of the MDS indicated that Resident #24 pockets food in the mouth, coughs or chokes during meals and complains of difficulty when swallowing. Review of the current care plan indicated a focus for at risk for swallowing difficulty due to dysphagia. Further review indicated an intervention of during and/or after each meal if s/s (signs/symptoms) of aspiration are observed such as SOB (shortness of breath), watery eyes, labored breathing, choking, coughing, pocketing food notify the nurse and SLP (speech language pathologist). Further review indicated a focus for activities of daily living with an intervention; the Resident requires assist with eating. Review of the facility document titled Functional Abilities and Goals - admission - V 2 dated 3/5/26 indicated that Resident #24 required supervision/touching assistance with eating. On 3/24/26 at 8:53 A.M., the surveyor observed Resident #24 alone in his/her room eating breakfast. On 3/25/26 at 8:31 A.M., the surveyor observed Resident #24 alone in his/her room eating breakfast. Review of the Speech Therapy (ST) notes dated 3/22/26, 3/23/26 and 3/24/26 indicated that Resident #24 was being treated for dysphagia targeting tolerance of current diet (puree, thin). Further review failed to indicate the level of assistance with eating Resident #24 required. During an interview on 3/25/26 at 8:10 A.M., Certified Nurse's Aide (CNA) #2 said she wasn't aware that Resident #24 was supposed to be supervised at every meal. During an interview on 3/25/26 at 9:24 A.M. Nurse #2 said that she was not aware that Resident #24 was supposed to be supervised with meals. 2. Resident #125 was admitted to the facility in December 2025 with diagnoses including pneumonitis related to aspiration of food, dysphagia (difficulty swallowing) and degenerative disease of nervous system.Review of the Minimum Data Set assessment (MDS) dated [DATE] indicated that Resident #125 is severely cognitively impaired, scoring a 4 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #125 requires substantial/maximal assistance with eating. Further review of the MDS indicated that Resident #125 pockets food in the mouth and coughs or chokes during meals. Review of the current care plan indicated a focus for at risk for swallowing difficulty due to dysphagia. Further review indicated an intervention of during and/or after each meal if s/s of aspiration are observed such as SOB, watery eyes, labored breathing, choking, coughing, pocketing food notify the nurse and SLP (speech language pathologist). Further review indicated a focus for activities of daily living with an intervention to assist the Resident requires assist with eating. Review of the progress notes dated March 2026 indicated that Resident #125 had a history of aspiration pneumonia. During an interview on 03/24/2026 12:31 PM Family member (FM) #1 said that she was here with her son every day for lunch. FM #1 then said that Resident #125 coughed occasionally when eating. She said that Resident #125 was being trained to cough when needed during meals to try and prevent aspiration. During an interview on 3/25/26 at 8:10 A.M., Certified Nurse's Aide (CNA) #2 said that Resident #125 was supposed to be supervised at every meal. During an interview on 3/25/26 at 8:10 A.M., Certified Nurse's Aide (CNA) #1 said that nurses give report in the morning to let them know what the residents required. CNA #1 said that Resident #125 was supposed to be supervised at all meals. During an interview on 3/25/26 at 9:24 A.M. Nurse #2 said that Resident #125 was supposed to be supervised at every meal.

Based on observation, interviews and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#3) out of sample of 29 residents. Specifically, the facility failed to ensure that nursing consistently administered oxygen in accordance with the physician's orders. Findings include: Review of facility policy titled Oxygen Administration, updated October 2019, indicated, but was not limited to, the following:-Oxygen shall be administered to a resident by a licensed nurse upon order of the physician.Procedure: -Verify physician order.-Apply cannula/mask as ordered and secure for comfort. Resident #3 was admitted to the facility in March 2026 with diagnoses that included respiratory failure and pneumonia. Review Resident #3's Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating severe cognitive impairment. Further review of the MDS indicated the use of continuous oxygen therapy. On 3/24/26 at 8:25 A.M., the surveyor observed Resident #3 in bed receiving supplemental oxygen at 2.5 liters per minute via nasal cannula, the adjustment controls for the supplemental oxygen were out of reach of the Resident. On 3/24/26 at 12:20 P.M., the surveyor observed Resident #3 in bed receiving oxygen at 2.5 liters per minute via nasal cannula, the adjustment controls for the supplemental oxygen were out of reach of the Resident. On 3/24/26 at 3:15 P.M., the surveyor observed Resident #3 in bed receiving oxygen at 2.5 liters per minute via nasal cannula, the adjustment controls for the supplemental oxygen were out of reach of the Resident. On 3/25/26 at 9:17 A.M., the surveyor observed Resident #3 in bed receiving oxygen at 2.5 liters per minute via nasal cannula, the adjustment controls for the supplemental oxygen were out of reach of the Resident. On 3/25/26 at 12:04 P.M., the surveyor observed Resident #3 in bed receiving oxygen at 2.5 liters per minute via nasal cannula, the adjustment controls for the supplemental oxygen were out of reach of the Resident. Review of Resident #3's active physician's orders indicated the following:- Maintain O2 saturation > 90% below apply 2L O2 via NC (sic), initiated 3/4/26.Further review of the physicians' orders failed to indicate additional instruction regarding Resident #3's supplemental oxygen rate. Review of Resident #3's care plans indicated the Resident used supplemental oxygen due to a recent hospitalization for aspiration pneumonia with respiratory failure and had the following intervention:-Oxygen Settings: O2 via NC (nasal canula) as ordered. Date Initiated: 03/04/2026Review of Resident #3's progress notes failed to indicate a justification for increasing the Resident's oxygen beyond the physician prescribed rate.Review of Resident #3's vitals summary failed to indicate the Residents oxygen saturation had ever dropped below 90%.During an interview and observation on 3/25/26 at 12:06 P.M. Nurse #4 said oxygen should be administered in accordance with the physicians' orders and that nurses check to ensure the correct rate of supplemental oxygen was being administered twice per shift and as needed throughout the day. Nurse #4 said that if a Resident required a different rate of supplemental oxygen than what was ordered that the physician would be notified and the order would be changed. Nurse #4 said that in an emergency the nurse could increase the rate of oxygen, notify the physician and then an order would be put in afterwards which would be documented, however, this was not the case for Resident #3 whose supplemental oxygen should be administered at 2 liters per minute. Nurse #4 observed Resident #3's current oxygen rate with the surveyor, Nurse #4 said the oxygen was being administered at 2.5 liters per minute which was the incorrect rate based on the physician's order. Nurse #4 said the Resident would not be able to adjust the rate him/herself. During an interview on 3/25/26 at 12:14 P.M. Unit Manager #2 said she would expect supplemental oxygen to be administered per the physician's order. Unit Manager #2 said Resident #3 should receive supplemental oxygen at 2 liters per minute and that she doubts the Resident would be able to change the setting him/herself. Unit Manager #2 said if the Residents' oxygen saturation had dropped that the nurse could increase the Resident's rate of supplemental oxygen and notify the physician who would then provide a new order with the new rate; Unit Manager #2 said if the rate needed to be changed, she would expect this to be documented.During an interview on 3/25/26 at 12:24 P.M. the Director of Nurses (DON) said supplemental oxygen should be administered per the physician order. The DON said he would expect Resident #3 to receive supplemental oxygen at a rate of 2 liters per minute based on the Residents physician order. The DON said that if the Residents' oxygen saturation was lower than 90% then a nurse could increase the rate of oxygen to return the Resident to baseline but should also contact the physician and receive a new order with an updated rate; the DON said this would be documented. The DON observed Resident #3's oxygen setting from earlier that day and interpreted the reading as a rate of 2.5 liter per minute and for that reason not reflective of his/her physicians' order. The DON said if the Resident was doing well on a rate of 2.5 liters per minute that the provider should have been contacted and the order formally changed.

Based on observation, record review and interview, the facility failed to ensure medication was secured in locked compartments for two Residents (#40 and #59) out of a total sample of 29 residents. Specifically,1. For Resident #40 the facility failed to ensure eye drops were secured in a locked compartment.2. For Resident #59 the facility failed to ensure an inhaler was secured in a locked compartment. Findings include:Review of the facility policy titled Medication Storage indicated that all medications are to be safely stored and locked up when not in use. Further review indicated that only authorized staff are to have access to medications. 1. Resident #40 was admitted to the facility in March 2026 with diagnoses including glaucoma, heart failure and anxiety. Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #40 was cognitively intact scoring a 15 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #40 required assistance with all activities of daily living. On 3/24/26 at 8:00 A.M., the surveyor observed a bottle of Latanoprost eye drops (used to treat glaucoma) on the windowsill. Review of the medical record failed to indicate that Resident #40 was assessed to safely administer medications. Review of the physician orders failed to indicate an order to self-administer medications. Review of the care plan failed to indicate that the Resident may self-administer medications. During an interview on 3/24/26 at 12:25 P.M., Resident #40 said that someone came in and took the eyedrops from me. They said that I couldn't have them in my room. Resident #40 then said that he/she had brought them in from the hospital at admission to the facility and had had the eye drops in his/her room ever since and no one had said anything about it before. Resident #40 said that he/she had been self-administering the eye drops daily since he/she was admitted . 2. Resident #59 was admitted to the facility in March 2026 with diagnoses including asthma, sepsis and congestive heart failure. Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #59 was cognitively intact, scoring a 14 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #59 required assistance with activities of daily living. On 3/24/26 at 8:23 A.M., and 10:35 A.M., the surveyor observed an Advair inhaler (used to treat asthma) on top of Resident #59's bedside cabinet. During an interview on 3/24/26 at 8:23 A.M., Resident #59 said that the nurses leave the inhaler with him/her to use. Resident #59 then said that he/she had been self-administering the medication since he/she was admitted . Resident #59 said that no one has told him/her that the medication needs to be locked up when not using. Review of the medical record failed to indicate that Resident #59 was assessed to safely administer medications. Review of the physician orders failed to indicate an order to self-administer medications. Review of the care plan failed to indicate the Resident may self-administer medications.During an interview on 3/25/26 at 12:00 P.M., Nurse #2 said that residents are not to have medications at the bedside unless they have been assessed to safely self-administer their medications. Nurse #2 said that neither Resident #40 or Resident #59 had been approved to self-administer medications and all medications should be securely locked at all times.

Based on observation, record review and interview, the facility failed to provide treatment and care in accordance with professional standards of practice for one Resident (#41), out of a total sample of 29 residents. Specifically, for Resident #41 the facility failed to ensure wound provider recommendations were implemented for his/her arterial wounds.Findings include:Resident #41 was admitted to the facility in February 2023 with diagnoses that included chronic kidney disease, gout, adult failure to thrive, and falls. Review of Resident #41's most recent Minimum Data Set (MDS) assessment, dated 2/25/26, indicated he/she scored a three out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Further review of the MDS indicated the Resident had one arterial ulcer. Review of Resident #41's wound care plan, dated 2/26/26, indicated Analgesia as ordered. Monitor/document side effects and effectiveness. Wound MD consult as ordered. Wound care as ordered. Review of Resident #41's Wound Care Provider Program assessment notes, dated 2/24/26, 3/3/26, 3/10/26, 3/17/26, and 3/24/26, indicated the Resident complained of moderate associated pain and had moderate bilateral lower extremity edema. Left heel arterial wound and sacral wound. The Wound notes further indicated:-May apply 4% Lidocaine gel to the wound daily and as needed (PRN) for pain.-LE (lower extremities) elevation and gentle compression therapy with gentle Ace wrap daily.-Offloading discussed.-Plan of care was discussed and coordinated with members of medical team present at bedside. Review of Resident #41's Wound Care Provider Program assessment note, dated 3/17/26, indicated Procedure: Surgical Excisional Debridement of subcutaneous tissue of the left heel. Review of Resident #41's Wound Care Provider Program assessment note, dated 3/24/26, indicated non-palpable pulses bilaterally. Suggest pre-medicating patient 30 minutes prior to wound rounds. Not improved. Review of Resident #41's physician orders failed to indicate any of the above recommendations were put into place. On 3/25/26 at 9:10 A.M., the surveyor observed Unit Manager #1 enter Resident #41's room with treatment supplies to complete his/her dressing changes. On 3/24/26 at 9:00 A.M. and 3/25/26 at 10:56 A.M., the surveyor observed Resident #41 in his/her chair with their feet flat on the ground not offloaded. During an interview on 3/25/26 at 10:56 A.M., Resident #41 said he/she was in pain during dressing changes every day and that it was not an enjoyable experience. During an interview on 3/25/26 at 11:02 A.M., Nurse #3 said Resident #41 had pain in his/her wounds and was on scheduled pain medications at 8:00 A.M., but they have not been given yet. Nurse #3 said the Unit Manager completes the treatments for this Resident and should tell her prior to completing them so she could medicate the Resident before the dressing changes. Nurse #3 was unaware that the dressings were completed and said that the Unit Manager puts in orders for the wound provider recommendations. During an interview on 3/25/26 at 11:06 A.M., Unit Manager #1 said the Resident should be medicated prior to the dressing changes and communication with the nurse did not happen today. He said the Resident did have pain during dressing changes and recommendations should be put in from the wound notes weekly by the Assistant Director of Nurses (ADON). During an interview on 3/25/26 at 11:27 A.M., Nurse Practitioner #1 said she was aware that Resident #41 had pain during wound changes and said she ordered pain medication that she expected to be given prior to the wound changes. Nurse Practitioner #1 said she goes to the facility frequently and expects nursing to put the wound recommendations in timely including the lidocaine, ace wrap and offloading of the lower extremities as she defers to the Wound Provider for wound orders. During an interview on 3/25/26 at 11:33 A.M., the ADON said the provider defers to the wound team and that staff were expected to put in all wound recommendations timely. The ADON said the Resident did have pain in his/her wounds and the plan of care had been communicated to staff for premedicating the Resident. The ADON said usually the Unit Managers puts in the new wound orders the same day as they round with the wound provider, and she helps with the wound orders at times but did not notice the lidocaine, and ace wraps orders were not in place.

Based on interviews, record review, staff education review, and Facility Assessment review, the facility failed to ensure the nursing staff were trained and demonstrated the competencies and skill sets necessary to provide the level and types of care and services needed as outlined in the Facility Assessment. Specifically, the facility failed to ensure licensed nursing staff were trained and demonstrated competency related to wound care. Findings include: According to the Board of Registration in Nursing, 244 CMR 9.00: Standards of Conduct, a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. Review of the comprehensive Facility Assessment Tool, updated and reviewed August 2024, included but was not limited to the following: - Services and Care We Offer Based on our Residents' Needs: Skin integrity: Pressure injury prevention and care, skin care, wound care (surgical, other skin wounds.) - Staff training/education and competencies: Ongoing staff training and education is provided to all departments within the facility specific to each discipline. We also provide annual training along with annual competencies that are required for all departments in the facility according to DPH regulations. - Annual Competencies for Nurses (subject to change): Clean Dressing Change. Review of the summarized Facility Assessment Tool, updated and reviewed February 2025, included but was not limited to the following: - Services and Care We Offer Based on our Residents' Needs: Skin integrity: Pressure injury prevention and care, skin care, wound care (surgical, other skin wounds). Weekly wound rounds with physician. - Staff training/education and competencies: Additional full day staff orientation, depending on position, for specific skill and competencies. Annual Education Fair and Core Competency evaluations. - Competencies: Specialized Care - wound care/dressings. During an interview on 2/26/25 at 1:11 P.M., the Administrator said both the above referenced Facility Assessment Tools are current, but one is more comprehensive and the other is a summary. The Administrator said both should be followed. Throughout the recertification survey (2/24/25 through 2/26/25) the surveyors identified multiple concerns regarding wound care including: - failure to implement wound treatments following physician's orders. - failure to obtain new treatment orders for a pressure wound when the wound status changed and current treatment order was no longer appropriate. - failure to complete weekly skin checks. The surveyor reviewed staff education files for wound competencies for three licensed nurses who provided wound care during the recertification survey. - 0 out of 3 nurses had evidence of wound care competencies completed since hire. During an interview on 2/26/25 at 1:21 P.M., the Assistant Director of Nursing (ADON) said she was responsible for staff competencies and training. The ADON said she was unaware wound or wound dressing competencies were required annually or upon hire. The ADON said if wound or wound dressing competencies are indicated as required on the Facility Assessment, then they should have been completed. The ADON said she has not done any wound related competencies that include return demonstration since she started the position in September 2024. The ADON said she was unable to locate any wound competencies for the three licensed nurse files requested since they were hired. During an interview on 2/26/25 at 1:50 P.M., the Director of Nursing (DON) said wound care competencies should completed as indicated in the Facility Assessment.

Based on observations, interviews and policy review, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically, 1. The facility failed to ensure treatment carts and medication carts were locked while a nurse was not present on the fourth floor. 2. The facility failed to ensure nursing staff secured medications in the medication cart prior to leaving the cart unattended on the fourth and fifth floor units. Findings include: Review of the facility policy titled Medication Administration and Charting Policy, dated as revised November 2024, indicated Medication carts must always remain locked, unless the nurse who is administering the medication is in direct control of the medication cart. If the medication cart is left unattended it must be locked. Review of the facility policy titled Mediation Storage, not dated, indicated it is the policy of the facility to store all medications in a safe and orderly manner. Unlocked medication carts are not left unattended by the nurse with carts keys. 1. On 2/24/25 from 7:37 A.M. to 7:46 A.M., the surveyor observed the treatment cart unlocked and unsupervised on the 4th floor unit. The surveyor observed a resident and staff members walking by the unlocked treatment cart multiple times. On 2/24/25 at 8:12 A.M., the surveyor observed a medication unlocked and unsupervised on the 4th floor unit. No staff were present. During an interview on 2/26/25 at 9:06 A.M., Unit Manager #2 said she expects nursing staff to lock the medication carts and treatment carts when the nurse is not present at the carts. On 2/26/25 at 9:30 A.M., the surveyor observed a 4th floor treatment cart unlocked in the hallway. The nurse was not within sight line of the treatment cart. The surveyor observed multiple prescription topical medications within this treatment cart. During an interview on 2/26/25 at 9:34 A.M., Unit Manager #2 came within view of the treatment cart and locked it. Unit Manager #2 said the treatment cart should have been locked when not within the nurses' view. 2. On 2/25/25 at 12:00 P.M., the surveyor observed a Trelegy inhaler on top of a medication cart on the 4th floor. The nurse was not present at the cart or in the hallway. During an interview on 2/26/25 at 9:06 A.M., Unit Manager #2 said medications should never be left unattended on top of the medication cart. 15016 On 2/25/25 at 9:27 A.M., during the medication pass on the fifth floor unit, the surveyor observed Nurse #1 remove a blister pack of Escitalopram 5 milligram tablets (antidepressant) from the medication cart drawer and place the pack on top of the cart. Nurse #1 then told the surveyor she needed to leave and get additional medications from the medication room. Nurse #1 then locked the medication cart and walked down the hallway and around a corner. The surveyor observed there were 13 tablets of Escitalopram in the blister pack. No other nursing staff were within eyesight of the cart. On 2/25/25 at approximately 9:31 A.M., Nurse #1 returned to the medication cart. Nurse #1 then unlocked the cart and returned the blister pack of escitalopram to the cart drawer and then locked the cart. Nurse #1 said she should not have left the Escitalopram unsecured and unattended on top of the medication cart while she was getting additional medications from the medication storage room.

Based on observation, record review and interview, the facility failed to ensure physician orders were implemented for 8 Residents (#42, #328, #133, #54, #48, #89, #27, and #30), out of a total sample of 27 residents. Specifically, 1a. For Resident #42, 1b. Resident #328 and 1c. Resident #133, 1d. Resident #54, 1e. Resident #48 the facility failed to complete weekly skin assessments, as per the physician order. 2. For Residents #89, #27 and #30 the facility failed to follow physician orders as written. Findings include: 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 prescriber's 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 policy titled Weekly Skin Check Documentation, not dated, indicated it is the policy of the facility to evaluate all resident's skin for evidence of breakdown, wounds, or impaired skin integrity. Those being followed by the wound care team or have weekly wound assessments are still required to have skin checks performed as ordered. Orders for weekly skin checks are placed on admission and assessments are to be documented as ordered. Procedure: 2. Weekly skin check orders are placed in the TAR and scheduled according to the order. 3. Licensed Nursing staff are to acknowledge the weekly skin check order after the weekly skin assessment has been completed. 4. The assessment utilized for weekly skin checks is the N Adv Skin Check Assessment, located in the assessment tab in PCC (electronic medical record). 1a. Resident #42 was admitted to the facility July 2019 with diagnoses that included Alzheimer's disease, aphasia, dysphagia, dementia, and anxiety. Review of Resident #42's most recent Minimum Data Set (MDS) assessment, dated 1/22/25, indicated he/she was assessed by nursing staff to have severe cognitive impairment. Further review of the MDS indicated he/she is at risk for developing pressure ulcers. Review of Resident #42's physician order dated 6/11/20, indicated Weekly Skin check every Thurs (Thursday) 11-7 (11:00 P.M. to 7:00 A.M.). Review of Resident #42's Braden Scale (Scale for Predicting Pressure Ulcer Risk Evaluation), dated 1/16/25, indicated he/she scored a 13 indicating the Resident is at moderate risk for developing pressure ulcers. Review of Resident #42's at risk for pressure ulcers care plan, dated 8/23/22, indicated Skin assessments weekly and prn (as needed), pay special attention to bony prominences. Review of Resident #42's medical record assessments and nursing progress noted failed to indicate that a completed skin assessment was completed since 1/16/25. During an interview on 2/25/25 at 9:53 A.M., the Director of Nurses (DON) said the weekly skin assessment should be completed under the assessment tab or write a progress note that a full body skin check was done by the nurse. During an interview on 2/25/25 at 10:38 A.M., Charge Nurse #2 said weekly skin assessments should be completed as ordered and the nurse completing them should document the skin check under the assessment tab. 1b. Resident #328 was admitted to the facility in February 2025 with diagnoses that included scabies, end stage renal disease, and toxic encephalopathy. Review of Resident #328's Brief Interview for Mental Status (BIMS), dated 2/14/25, indicated he/she scored a 11 out of a possible 15 indicating moderate cognitive impairment. Review of Resident #328's potential for pressure ulcer development, dated 2/14/25, indicated Skin assessments weekly and prn (as needed), pay special attention to bony prominences. Review of Resident #328's Braden Scale (Scale for Predicting Pressure Ulcer Risk Evaluation), dated 2/14/25, indicated he/she scored a 13 and is at risk for developing a pressure ulcer. Review of Resident #328's physician order, dated 2/17/25, indicated Weekly skin checks on Monday night. Review of Resident #328's medical record assessments and nursing progress noted failed to indicate that a completed skin assessment was completed since admission. During an interview on 2/25/25 at 9:53 A.M., the Director of Nurses (DON) said the weekly skin assessment should be completed under the assessment tab or write a progress note that a full body skin check was done by the nurse. The DON reviewed Resident #328's medical record with the surveyor and the DON said he/she does not have any skin assessments completed since admission. During an interview on 2/25/25 at 10:38 A.M., Charge Nurse #2 said weekly skin assessments should be completed as ordered and the nurse completing them should document the skin check under the assessment tab. 1c. Resident #113 was admitted to the facility in December 2024 with diagnoses that included type 2 diabetes, dysphagia, altered mental status, and cognitive communication deficit. Review of Resident #113's most recent Minimum Data Set (MDS) assessment, dated 12/11/24, indicated he/she scored a 11 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. Further review of the MDS indicated he/she is at risk for developing pressure ulcers and had an unhealed pressure ulcer. Review of Resident #113's physician order, dated 12/15/24, indicated Weekly skin checks on Sunday night. Every night shift every Sun for weekly skin check. Review of Resident #113's Braden Scale (Scale for Predicting Pressure Ulcer Risk Evaluation), dated 12/9/24, indicated he/she scored a 13 indicating the Resident is at moderate risk for developing pressure ulcers. Review of Resident #113's medical record assessments and nursing progress noted failed to indicate that a completed skin assessment was completed since 1/27/25. During an interview on 2/25/25 at 9:53 A.M., the Director of Nurses (DON) said the weekly skin assessment should be completed under the assessment tab or write a progress note that a full body skin check was done by the nurse. During an interview on 2/25/25 at 10:38 A.M., Charge Nurse #2 said weekly skin assessments should be completed as ordered and the nurse completing them should document the skin check under the assessment tab. During an interview on 2/26/25 at 9:56 A.M., Unit Manager #2 said weekly skin checks should be completed as ordered and nursing staff should document that under the assessment tab in the electronic medical record. 36431 1d. Resident #54 was admitted to the facility in August 2017 and has diagnoses that include but are not limited to cerebral infarction, hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side, contracture of left upper arm, and contracture, left hand. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #54 scored a 13 out of 15 on the Brief Interview for Mental Status exam indicating he/she as cognitively intact. Further, the MDS indicated Resident #54 had functional limitation in range of motion on both his/her upper and lower extremities on one side and is at risk for developing pressure ulcers/injuries. On 2/24/25 at 7:56 A.M., Resident #54 was observed in bed, with an air mattress mechanism affixed to the footboard. Resident #54 was observed to have his/her left hand held in a fist. Review of Resident #54's physician's orders indicated an order dated 8/13/2019, Weekly Skin check every day shift every Tue (Tuesday), complete skin only assessment. Review of Resident #54's Braden Scale (Scale for Predicting Pressure Ulcer Risk Evaluation), dated 1/10/25, indicated he/she scored an 11 indicating the Resident is at high risk for developing pressure ulcers. Review of Resident #54's care plan, dated 11/1/2024 indicated Resident #54 has potential for pressure ulcer development r/t (related to) decreased strength and endurance, immobility, incontinence, with the intervention/task, Skin assessments weekly and prn (as needed), pay special attention to bony prominences. Review of Resident #54's medical record assessments failed to indicate a weekly skin assessment was completed in accordance with the physician's order. The last documented weekly skin check was dated 11/12/24. During an interview on 2/25/25 at 3:57 P.M., Nurse #9 said all residents requires weekly skin checks. Nurse #9 said she signed off the weekly skin assessment on the TAR (treatment administration record) for Resident #54 for today. Review of the medical record with Nurse #9 failed to indicate a weekly skin assessment was completed. During an interview on 2/25/25 at 4:24 P.M., Unit Manager (UM) #3 said Resident #54 has an order for a weekly skin check every Tuesday. UM #3 said the nurse should document the weekly skin check on the weekly skin assessment. During an interview on 2/25/25 at 4:38 P.M., the Director of Nursing said signing the TAR off for the weekly skin check is acknowledging the order and that the nurse should be completing a skin assessment in the medical record. 48990 1e. Resident #48 was admitted to the facility in January 2017 with diagnoses including a stage three pressure ulcer and diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/12/25, indicated Resident #48 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS also indicated he/she was at risk for developing pressure ulcers. Review of Resident #48's active physician's order, initiated 8/1/19, indicated: - Skin check in the evening every Wed (Wednesday) (Document in skin and wound module). Review of Resident #48's Braden Scale (Scale for Predicting Pressure Ulcer Risk Evaluation), dated 2/12/25, indicated he/she was at high risk for developing pressure ulcers as evidenced by a score of 11. Review of Resident #48's plan of care related to potential for pressure ulcer development, revised 9/14/24, indicated: - Skin assessments weekly and prn (as needed), pay attention to bony prominences. Review of Resident #48's medical record assessments and nursing progress notes failed to indicate that a completed skin assessment was completed since 4/29/24. During an interview on 2/25/25 at 9:50 A.M., Nurse #4 said skin checks should be completed weekly and the nurse completing them should document the skin check under the assessment tab in the medical record. During an interview on 2/25/25 at 9:53 A.M., the Director of Nurses (DON) said the weekly skin assessment should be completed under the assessment tab or write a progress note that a full body skin check was done by the nurse. During an interview on 2/25/25 at 2:02 P.M., the Assistant Director of Nursing (ADON) reviewed Resident #48's medical record. The ADON said there are no skin checks in the medical record since 4/29/24. The ADON said even if it's marked as implemented on the treatment administration record, it's not considered completed unless there is a skin check assessment completed under the assessment tab. During an interview on 2/25/25 at 2:17 P.M., the DON said Resident #48 should have had a skin check completed weekly but was not able to locate one in the Resident's medical record since April 2024. The DON said there was a change in their medical record system, and they were missed. 41456 2a. Resident #89 was admitted to the facility in November 2021 with diagnoses including epilepsy. Review of Resident #89's most recent Minimum Data Set, dated dated dated [DATE] indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 7 out of a possible 15 which indicated the Resident had severe cognitive impairment. The MDS also indicated Resident #89 is dependent on staff for all functional daily tasks. On 2/24/25 at 8:50 A.M., and 4:45 P.M., Resident #89 was observed lying in bed with both side rails elevated without padding on either side rail. On 2/25/25 at 07:14 A.M., and 10:04 A.M., Resident #89 was observed lying in bed with both side rails elevated without padding on either side rail. Review of Resident #89's physician orders indicated the following: -Seizure Precautions: Maintain Padded Top Side rails on Bed at all times for injury protection due to Seizures, initiated 4/18/24. During an interview on 10/6/25 at 10:06 A.M., Certified Nursing Assistant #1 said he had just completed Resident #89's morning care and was not aware if the Resident required padded side rails to his/her bed. During an interview on 10/6/25 at 10:09 A.M., Nurse #1 said she was unaware of Resident #89's risk of seizures and examined the Resident's orders. Nurse #1 said the Resident should have padded side rails. She then went into the Resident's room, looked at the Resident's bed and said the padded side rails were not in place. During an interview on 10/6/25 at 10:20 A.M., Unit Manager #1 said Resident #89 has an order for padded side rails on his/her bed. Unit Manager #1 said she was not aware the Resident did not have the padded side rails in place. Unit Manager #1 said she expects all orders to be followed. During an interview on 2/25/25 at 10:37 A.M., the Director of Nursing said he expects all orders to be followed as ordered. 2b. Resident #27 was admitted to the facility in February 2025 with diagnoses including Parkinson's Disease and toxic encephalopathy. Review of the Brief Interview For Mental Status (BIMS) assessment dated [DATE], indicated Resident #27 scored a 4 out of 15, which indicated he/she had severe cognitive impairment. On 2/24/25 at 8:36 A.M., Resident #27 was observed lying in bed with both heels lying directly on the mattress. There were two prevalon boots (heel protecting boots) on the chair next to the bed. Resident #27 was unable to be interviewed regarding the boots. On 2/25/25 at 8:11 A.M., Resident #27 was observed lying in bed with both heels lying directly on the mattress. There were two prevalon boots (heel protecting boots) on the chair next to the bed. A Certified Nursing Assistant (CNA) entered the Resident's room to provide care. When the CNA left the Resident's room at 8:19 A.M., the Resident was still lying in bed without the heel protective boots on. Review of Resident #27's physician orders indicated the following order: -Off-load boots to bilateral heels while in bed, initiated on 2/18/25. Review of the Skin Observation Tool dated 2/24/25 indicated Resident #27 had bilateral heel pressure wounds. Review of the Wound Documentation dated 2/24/25 indicated a recommendation from the wound physician to have soft booties for pressure protection. During an interview on 2/26/25 at 11:53 A.M., CNA #5 said Resident #27's boots are supposed to be on while he/she is lying in bed. During an interview on 2/26/25 at 12:00 P.M., Nurse #7 said she was unaware if Resident #27 had wounds on his/her bilateral heals and said the Resident is supposed to have heel protective boots on while in bed. During an interview on 2/26/25 at 12:05 P.M., Unit Manager #2 said she expects orders to be followed as written. During an interview on 2/25/25 at 10:37 A.M., the Director of Nursing said he expects all orders to be followed as ordered. 2c. Resident #30 was admitted to the facility in September 2022 with diagnoses including Alzheimer's Disease. Review of Resident #30's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident was unable to complete the Brief Interview for Mental Status and the staff had assessed him/her to have severe cognitive impairment. The MDS also indicated Resident #30 is dependent on staff for all functional tasks. On 2/24/25 at 8:55 A.M., Resident #30 was observed with a skin tear to his/her right lower arm. The Resident was not wearing any protective coverings to either arm. On 2/24/25 at 12:35 P.M., Resident #30 was observed sitting in the dining room without any protective coverings to either arm. On 2/25/25 at 7:03 A.M., Resident #30 was observed sitting in the dining room without any protective coverings to either arm On 10/26/25 at 10:28 A.M., Resident #30 was observed sitting in the dining room without any protective coverings to either arm. Review of Resident #30's physician orders indicated the following order: -Every shift -Geri Gloves (a skin protective garment) to both arms, initiated on 9/25/24. Review of nursing notes and the Treatment Administration Record (TAR) failed to indicate Resident #30 refused to wear the geri-gloves. During an interview on 10:32 A.M., Unit Manager #1 said Resident #30 has fragile skin and has an order for geri-gloves for this reason. Unit Manager #1 said Resident #30 often refuses the geri-gloves and if a refusal occurs it would be documented on the TAR. Unit Manager #1 said all orders should be followed as written. During an interview on 2/26/25 at 10:55 A M., the Director of Nursing said all orders should be followed as written. 52138

Based on observations, record reviews and interviews, the facility failed to maintain accurate medical records for two Residents (#89 and #30) out of a total sample of 27 residents. Findings include: 1a. Resident #89 was admitted to the facility in November 2021 with diagnoses including epilepsy. Review of Resident #89's most recent Minimum Data Set, dated dated dated [DATE] indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 7 out of a possible 15 which indicated the Resident had severe cognitive impairment. The MDS also indicated Resident #89 is dependent on staff for all functional daily tasks. On 2/24/25 at 8:50 A.M., and 4:45 P.M., Resident #89 was observed lying in bed with both side rails elevated without padding on either side rail. On 2/25/25 at 07:14 A.M., and 10:04 A.M., Resident #89 was observed lying in bed with both side rails elevated without padding on either side rail. Review of Resident #89's physician orders indicated the following: -Seizure Precautions: Maintain Padded Top Side rails on Bed at all times for injury protection due to Seizures, initiated 4/18/24. Review of the Treatment Administration Record for 2/24/25 and 2/25/25, indicated the nursing staff had marked the order as complete, indicating the padded siderails were present on Resident #89's bed. During an interview on 2/26/25 at 10:55 A.M, the Director of Nursing said orders should not be marked as complete if not done b. Resident #30 was admitted to the facility in September 2022 with diagnoses including Alzheimer's Disease. Review of Resident #30's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident was unable to complete the Brief Interview for Mental Status and the staff had assessed him/her to have severe cognitive impairment. The MDS also indicated Resident #30 is dependent on staff for all functional tasks. On 2/24/25 at 8:55 A.M., Resident #30 was observed with a skin tear to his/her right lower arm. The Resident was not wearing any protective coverings to either arm. On 2/24/25 at 12:35 P.M., Resident #30 was observed sitting in the dining room without any protective coverings to either arm. Review of Resident #30's physician orders indicated the following order: -Every shift -Geri Gloves (a skin protective garment) to both arms, initiated on 9/25/24. Review of the Treatment Administration Record (TAR) indicated the nursing staff had marked the order as complete on 2/24/25, indicating Resident #30 had worn the geri-gloves. During an interview on 10:32 A.M., Unit Manager #1 said Resident #30 has fragile skin and has an order for geri-gloves for this reason. Unit Manager #1 said Resident #30 often refuses the geri-gloves and if a refusal occurs it would be documented on the TAR. Unit Manager #1 said all orders should be followed as written and not marked as complete if not done. During an interview on 2/26/25 at 10:55 A.M, the Director of Nursing said orders should not be marked as complete if not done.

Based on observation, record review, and interview, the facility failed to notify the physician of a change in condition related to a 12.6 pound (lbs.) weight gain in one day for one Resident (#328) out of a total sample of 27 residents. Findings include: Review of the facility policy titled Notification of Change in Resident Condition, not dated, indicated Nursing Leadership/Primary Nurse shall notify the resident, consult with the resident's physician and notify family/responsible party when any of the following occurs: i. Examples of Change in Condition that require notification: 2. Change in condition- vital signs, abnormal lab values. If contact is successful, Nursing Leadership/Primary Nurse shall document in the resident's medical record date and time contact was made and information conveyed. If contact is initially unsuccessful, Nursing Leadership/Primary Nurse shall document subsequent attempts to contact resident, physician and family/responsible party in the medical record. - When there is a significant change in treatment required that is, a need to discontinue an existing form of treatment due to adverse consequences or to commence a new form of treatment; A need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences, such as an adverse drug reaction, or begin a new form of treatment to deal with a problem that has not been used on that resident before. Resident #328 was admitted to the facility in February 2025 with diagnoses that included chronic diastolic congestive heart failure, scabies, end stage renal disease, and toxic encephalopathy. Review of Resident #328's Brief Interview for Mental Status (BIMS), dated 2/14/25, indicated he/she scored an 11 out of a possible 15 indicating he/she as having moderate cognitive impairment. Review of Resident #328's weights indicated: - 2/15/25 161.2 Lbs. - 2/16/25 160.8 Lbs. - 2/17/25 173.4 Lbs. - 2/18/25 174.5 Lbs. - 2/19/25 174.6 Lbs. - 2/20/25 172.4 Lbs. - 2/21/25 170.8 Lbs. - 2/24/25 167.6 Lbs. - 2/25/25 170.2 Lbs. Review of Resident #328's Congestive Heart Failure (CHF) care plan, dated 2/14/25, indicated Daily weight, record in log, if weight 3# or greater in 2 days or 5# or greater in one week, notify MD/NP (Medical Doctor/Nurse Practitioner). Review of Resident #328's physician order, dated 2/17/25, indicated CHF: Daily weight. Notify MD/NP if weight is > or equal to 3 lbs. (pounds) in 2 days or 5 lbs./week. Review of Resident #328's nursing progress notes 2/16/25 to 2/24/25 failed to indicate that the MD was notified with the 12.6 lbs. weight gain in one day or any weight gain thereafter. Review of Resident #328's MD/NP assessments dated from 2/16/25 to 2/24/25 failed to indicate that the MD or NP assessed the Resident's weight gain. Review of Resident #328's nursing weight change note, dated 2/25/25, indicated both feet noted with 1+ pitting edema. During an interview on 2/25/25 at 2:15 P.M., Charge Nurse #2 said the Resident gained over 10 lbs. last week over many days and the MD should have been notified before today but was not. During an interview on 2/26/25 at 2:20 P.M., the Director of Nursing (DON) said he expects nursing to follow the doctors order and to notify the MD of Resident #328's weight gain and write a progress note.

Based on observations, record reviews and interviews, the facility failed to 1) implement a skin integrity care plan for one Resident (#89) and 2) failed to develop a care plan for antipsychotic medication use for one Resident (#27) out of a total sample of 27 residents. Findings include: 1. Resident #89 was admitted to the facility in November 2021 with diagnoses including stroke, hemiplegia and diabetes. Review of Resident #89's most recent Minimum Data Set, dated dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 7 out of a possible 15 which indicated the Resident had severe cognitive impairment. The MDS also indicated Resident #89 is dependent on staff for all functional daily tasks. On 2/24/25 at 8:50 A.M., Resident #89 was observed lying in bed with both heels directly on the mattress. There was no heel protectors observed in the Resident's room. On 2/24/25 at 12:36 P.M. Resident #89 was observed lying in a reclining chair with both heels directly on the footrest of the chair. The Resident was not using any foot protectors. On 2/25/25 at 7:00 A.M., Resident #89 was observed lying in bed with both heels directly on the mattress. There was no heel protectors observed in the Resident's room. On 2/25/25 at 10:04 A.M., Resident #89 was observed in a reclining chair with bilateral heels directly on the footrest and was not wearing bilateral heel protectors. Review of Resident #89's potential for skin impairment care plan last revised 11/8/24, indicated the following intervention: -Bilateral heel protectors to both heels every shift. During an interview on 10/6/25 at 10:06 A.M., Certified Nursing Assistant #1 said he had just completed Resident #89's morning care and was not aware of any heel protectors the Resident should wear on his/her feet. During an interview on 10/6/25 at 10:09 A.M., Nurse #1 said she was unaware of Resident #89's risk of pressure ulcers and any skin protective equipment that is care planned for the Resident. During an interview on 10/6/25 at 10:20 A.M., Unit Manager #1 said Resident #89 has a care plan for bilateral heel protectors and was unaware the Resident did not have the heel protectors in place. Unit Manager #1 said she expects all care plans to be followed. During an interview on 2/25/25 at 10:37 A.M., the Director of Nursing said he expects all care plans to be followed as written. 2. Resident #27 was admitted to the facility in February 2025 with diagnoses including Parkinson's Disease and toxic encephalopathy. Review of the Brief Interview for Mental Status (BIMS) assessment, dated 2/15/25, indicated Resident #27 scored a 4 out of 15, which indicated he/she had severe cognitive impairment. Review of Resident #27's physician orders indicated the following orders: -Aripiprazole (An antipsychotic medication) oral tablet 5 MG (milligrams), initiated on 2/18/25. -Olanzapine (An antipsychotic medication) oral tablet 2.5 MG (milligrams), initiated on 2/21/25. Review of Resident #27's interdisciplinary care plans failed to indicate a care plan was developed for the Resident's antipsychotic medication use. During an interview on 2/25/25 at 12:22 P.M., Charge Nurse #1 said the Unit Manager is responsible for developing care plans and he was unsure if residents taking antipsychotics should have a care plan developed for this care area. During an interview on 2/25/25 at 12:34 P.M., Unit Manager #2 said residents who are taking antipsychotic medications do not require a care plan to be developed for this care area. During an interview on 2/25/25 at 12:50 P.M., the Director of Nursing said antipsychotic care plans should be developed for any resident who is taking an antipsychotic medication. The Director of Nursing said this type of care plan would be separate from the general psychotropic medication care plan. 52138

Based on observation, record review and interview the facility failed to ensure standards of quality of care for 1 Resident (#54), out of a sample of 25 residents. Specifically, for Resident #54 the facility failed to ensure the medical plan of care was implemented by failing to apply an abdominal pad to his/her left-hand and failing to ensure the left-hand discoloration was monitored for wound development. Findings include: Resident #54 was admitted to the facility in August 2017 and has diagnoses that include but are not limited to cerebral infarction, hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side, and contracture of left upper arm, contracture, left hand. Review of the Minimum Data Set assessment, dated 1/15/25, indicated Resident #54 scored a 13 out of 15 on the Brief Interview for Mental Status exam indicating he/she as cognitively intact. Further, the MDS indicated Resident #54 has functional limitation in range of motion on both his/her upper and lower extremities on one side and is at risk for developing pressure ulcers/injuries. Review of Resident #54's active physician orders indicated the following: -Skin check every day shift every Tue (Tuesday) complete skin only assessment date 8/13/2019. -Left hand roll splint after AM care as tolerated for up to 6 hours for contracture management dated 9/8/2021 -Apply abdominal pad to left hand contracture to offload palm from fingers daily. Keep area dry and clean. Until discoloration resolves. Every shift dated 11/15/2024. Review of the MD/NP (medical doctor/nurse practitioner) progress note, dated 11/14/24, indicated: Exam Skin: left middle fingernail with sings (sic) of onchomycosis (sic) (nail fungus) and skin of that finger a bit boggy, area of indentation on palm where the nail rests against the skin due to his/her contracture, no open wounds on fingers or hand. Assessment and Plan Today also noted onchomycosis (sic) of left middle fingernail and some bogginess of the finger pad, as well as indentation on palm skin. No open wounds noted but fingers and palm both at risk for wound formation. Abd pad in contracted hand to protect skin and keep the area dry. Close monitoring for wound development, ensure nails trimmed regularly. During the survey the following observations were made by the surveyor: -On 2/24/25 at 7:56 A.M., Resident #54 was observed in bed. Resident #54 was observed to have his/her left hand held in a fist. There was nothing in Resident #54's left hand to offload the fingers from his/her palm. -On 2/24/25 at 12:39 P.M., Resident #54 was in his/her bed. Resident #54's left hand fingers were folded around a rolled terry cloth towel. No abdominal pad was observed. -On 2/24/25 at 4:08 P.M., Resident #54 was in his/her bed. A blue hand roll was resting on top of his/her fingers. His/her fingers were folded in toward his/her palm, making the palm not visible. There was no abdominal pad present in or around the blue hand roll, nor was the fingers offloaded from his/her palm. During an observation and interview on 2/25/25 at 8:06 A.M., Resident #54 said he/she has pain in his/her left arm and hand. Resident #54 had a blue hand roll in his/her left hand. No abdominal pad was present. During an observation on 2/25/25 at 8:32 A.M., Resident #54 was observed with Nurse #9 and Unit Manager #3. Resident #54 had a blue hand roll and did not have an abdominal pad in his/her left hand. Nurse #9 said an area of discoloration was a small yellowing area on the outer bottom of his/her thumb. Review of Resident #54s care plan, dated 11/1/2024, indicated Resident #54 has potential for pressure ulcer development r/t (related to) decreased strength and endurance, immobility, incontinence, with the intervention/task, Skin assessments weekly and prn (as needed), pay special attention to bony prominences. Review of LTC (long term care) evaluation, dated 1/14/25, indicated Resident #54 had no skin issues. Review of Resident #54's medical record assessments failed to indicate a weekly skin assessment was completed in accordance with the physician's order. The last documented weekly skin check was dated 11/12/24. Review of the Treatment Administration Record (TAR) with the order start date 11/15/24 indicated apply abdominal pad to left hand contracture to offload palm from fingers daily. Keep area dry and clean. Until discoloration resolves and was signed by nursing staff with a check mark and failed to indicate any monitoring of the the discoloration. Review of the TARs dated for December 2024, January 2025, and February through 2/25/25 indicated apply abdominal pad to left hand contracture to offload palm from fingers daily. Keep area dry and clean. Until discoloration resolves and was signed by nursing staff with a check mark and failed to indicate a description or status of the discoloration. The record review did not indicate any care plan, or established monitoring of the discoloration in Resident #54's left hand. During an interview on 2/25/25 at 8:24 A.M., Certified Nursing Assistant (CNA) #5 said Resident #54 is dependent for daily care. CNA #5 said Resident #54's left side is weak, and he/she is unable to open his/her left hand. CNA #5 said she puts a blue hand roll in the Resident's left hand. During an interview on 2/25/25 at 3:44 P.M., CNA #4 said she cares for Resident #54 on the 3:00 P.M.-11:00 P.M. shift. CNA #4 said Resident #54 does not always cooperate with care, is unable to use his/her left hand and sometimes she will see the hand roll in the Resident's left hand at the start of her shift. During an interview on 2/25/25 at 4:07 P.M., Nurse #5 reviewed Resident #54's orders and said there is an order for an abdominal pad for his/her left hand. Nurse #5 said she did not know what the discoloration was and that the pad was used for the left-hand contracture. Nurse #5 said she did not know how the skin discoloration was monitored. During an interview on 2/25/25 at 4:53 P.M., the Director of Nursing was told by the surveyor that the Resident was observed without the abdominal pad in his/her left hand and was asked about what the discoloration written in the physician's order was. The Director of Nursing said he did not know about the discoloration or how it was being monitored. During an interview on 2/26/25 at 9:11 A.M., Unit Manager #3 said the doctor gave the order for the abdominal pad for Resident #54 and said the Resident was being treated with an antifungal treatment to his/her hand. Unit Manager #3 said the order for the abdominal pad should be followed and that staff are to report any changes in a resident's skin. Review of the medical record failed to indicate how the discoloration area on Resident's left hand was monitored for wound development.

Based on observations, interviews and record review, the facility failed to provide care, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for one Resident (#428) out of a total sample of 27 residents. Specifically, a.) the facility failed to implement physician ordered pressure ulcer prevention intervention for an air mattress. b.) the facility failed to ensure an air mattress was at the correct settings. c.) the facility failed to follow wound care orders to apply adaptic (a non-adherent wound dressing) to a pressure wound as ordered by the physician. d.) the facility failed to ensure nursing clarified the documented stage of a pressure wound and ensure the wound care treatment order was consistent with professional standards (wound care for a stage two pressure wound was performed instead of wound care for a deep tissue injury). Findings include: Resident #428 was admitted to the facility in February 2025 with diagnoses including hypertension and pressure-induced deep tissue damage of sacral region. Review of the Brief Interview For Mental Status (BIMS) Evaluation assessment, dated 2/20/25, indicated Resident #428 scored a 14 out of 15, which indicated he/she was cognitively intact. a.) The facility failed to implement physician ordered pressure ulcer prevention intervention for an air mattress. On 2/24/25 at 10:15 A.M. Resident #428 was observed lying in bed with his/her family member present in the room. The Resident was observed lying on a standard mattress and the Resident's family member said the Resident had not had an air mattress since admission to the facility. On 2/24/25 at 12:31 P.M., Resident #428 was observed lying in bed on an air mattress. Review of Resident #428's hospital discharge summary indicated Resident #428 was admitted to the facility with a sacral deep tissue injury. Review of Resident #428's physician orders indicated the following order: -Air mattress to bed, set dial to Alternating and 200# (pounds). Check for placement and function every shift, initiated 2/21/25. During an interview on 2/25/25 at 12:50 P.M., the Director of Nursing said Resident #428 was admitted with multiple skin impairments and was prescribed and air mattress on admission. The Director of Nursing said the Resident did not receive the air mattress until 3 days after admission. b.) The facility failed to ensure an air mattress was at the correct settings. On 2/24/25 at 12:31 P.M., Resident #428 was observed lying in bed on an air mattress. The air mattress was set to level 3 and did not indicate a specific weight setting. On 2/25/25 at 6:53 A.M., 8:20 A.M. and approximately 12:30 P.M., Resident #428 was observed lying in bed on an air mattress. The air mattress was set to level 3 and did not indicate a specific weight setting. Review of Resident #428's physician orders indicated the following order: -Air mattress to bed, Set dial to Alternating and 200# (pounds). Check for placement and function every shift, initiated 2/21/25. During an interview on 2/25/25 at 12:34 P.M., Unit Manager #2 said Resident #428 has a skin impairment on his/her sacral area and requires an air mattress. Unit Manager #2 said the Resident's air mattress should be set to his/her weight and that would be setting number 2. Unit Manager #2 said an air mattress on a firmer setting than what is prescribed for a resident's weight would not be beneficial. During an interview on 2/25/25 at 12:50 P.M., the Director of Nursing said the facility has three different types of air mattresses in the facility and that not all can be set to a resident's weight. The Director of Nursing said Resident #428 has an order to set the mattress specific to his/her weight and the air mattress he/she is on is not the right type. The Director of Nursing said Resident #428's air mattress should be set to setting 2 and was unaware that it had been on setting 3 for the past two days. The Director of Nursing said an air mattress on a firmer setting would not be as beneficial and could potentially cause worsening of a wound. 48990 c.) The facility failed to ensure Charge Nurse #1 followed wound care orders when he did not apply adaptic (a non-adherent wound dressing) to a pressure wound as ordered by the physician. Review of facility policy titled 'Dry Clean Wound Dressings', undated, indicated: - Steps in the Procedure: 17. Apply the ordered dressing and secure with tape or bordered dressing per order. Review of Resident #428's active physician order, initiated 2/21/25, indicated: - Wound Care - Cleanse Coccyx Stage 2 pressure wound with Vashe (a type of wound cleanser) or any antibacterial wound cleanser. Pat dry, apply Adaptic, then Calcium Alginate and then cover with dry protective dressing, every day shift. On 2/26/25 at 9:14 A.M., the surveyor observed Charge Nurse #1 perform a wound dressing change to Resident #428's coccyx. Charge Nurse #1 cleansed a large, discolored area of intact skin on his/her coccyx with antibacterial wound cleanser. Charge Nurse #1 patted the area dry and then applied calcium alginate followed by a dry protective dressing. Charge Nurse #1 failed to apply adaptic. During a follow-up interview on 2/26/25 at 9:37 A.M., Charge Nurse #1 said he was unaware the physician had ordered adaptic, and that he applied only calcium alginate followed by a dry protective dressing. Charge Nurse #1 reviewed the active physician order and said he should have applied adaptic but did not. During an interview on 2/26/25 at 9:42 A.M., Unit Manager #2 said Resident #428 had a physician's order for adaptic followed by calcium alginate and a dry protective dressing. Unit Manager #2 said Charge Nurse #1 should have been implemented adaptic as ordered by the physician or else clarified the order if there were any concerns. During an interview on 2/26/25 at 1:50 P.M., the Director of Nursing (DON) said Charge Nurse #1 should have implemented adaptic, in addition to the calcium alginate and dry protective dressing, because that was the physician order or else clarified the order if there were any concerns. d.) The facility failed to ensure nursing clarified the documented stage of a pressure wound and ensure the wound care treatment order was consistent with professional standards (wound care for a stage two pressure wound was performed instead of wound care for a deep tissue injury). Review of facility policy titled 'Dry Clean Wound Dressings', undated, indicated: - Report other information in accordance with facility policy and professional standards of practice. Review of the facility policy titled 'Notification of Change in Resident Condition', dated 1/13/25, indicated Nursing Leadership/Primary Nurse shall notify the resident, consult with the resident's physician and notify family/responsible party when any of the following occurs: i. Examples of Change in Condition that require notification: - When there is a significant change in treatment required that is, a need to discontinue an existing form of treatment due to adverse consequences or to commence a new form of treatment; A need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences, such as an adverse drug reaction, or begin a new form of treatment to deal with a problem that has not been used on that resident before. Review of Resident #428's hospital discharge paperwork, dated 2/20/25, indicated: - Wound care on discharge: Sacral DTIs (deep tissue injuries): BID (twice daily): cleanse with soap and water, pat try, apply triad paste (a paste used on wounds). Review of Resident #428's assessment titled 'N Adv - Clinical Admission', dated 2/20/25, indicated there was a sacrococcygeal pressure ulcer/injury that was present on admission without any exudate (drainage). This assessment failed to indicate the stage of this pressure wound. Review of Resident #428's active physician order, initiated 2/21/25, indicated: - Wound Care - Cleanse Coccyx Stage 2 pressure wound with Vashe (a type of wound cleanser) or any antibacterial wound cleanser. Pat dry, apply Adaptic, then Calcium Alginate and then cover with dry protective dressing, every day shift. On 2/26/25 at 9:14 A.M., the surveyor observed Charge Nurse #1 perform a wound dressing change to Resident #428's coccyx. The Resident had a large, discolored area of intact skin on his/her coccyx, which Charge Nurse #1 said was a deep tissue injury. Charge Nurse #1 said this was not a stage two pressure wound. Charge Nurse #1, who had provided Resident #428's wound care the previous four days, said each time he had performed this wound dressing change the wound has looked the same. Charge Nurse #1 cleansed the discolored area of intact skin on his/her coccyx with antibacterial wound cleanser. Charge Nurse #1 patted the area dry and then applied calcium alginate followed by a dry protective dressing. Review of Resident #428's treatment administration record, dated 2/22/25, 2/23/25, 2/24/25, and 2/25/25, indicated the following physician order documented as completed by Charge Nurse #1: - Wound Care - Cleanse Coccyx Stage 2 pressure wound with Vashe (a type of wound cleanser) or any antibacterial wound cleanser. Pat dry, apply Adaptic, then Calcium Alginate and then cover with dry protective dressing, initiated 2/21/25. During a follow-up interview on 2/26/25 at 9:37 A.M., Charge Nurse #1 said the coccyx wound treatment order was for a stage two pressure wound. Charge Nurse #1 said during each wound dressing change he had completed the wound had not been a stage two pressure wound, but always a deep tissue injury with intact skin. Charge Nurse #1 said he was not aware if calcium alginate or adaptic were appropriate treatments for intact skin or deep tissue injuries. Charge Nurse #1 said this should have been clarified, but it's not his job. Charge Nurse #1 said it was Unit Manager #2's job to clarify orders with the physician if they don't match during the weekly wound rounds. During an interview on 2/26/25 at 9:42 A.M., Unit Manager #2 said on admission she reviewed Resident #428's hospital discharge paperwork for wound care orders. Unit Manager #2 said the hospital discharge paperwork recommended triad paste, which they do not use in the facility, so she called the physician and asked for an alternative treatment. Unit Manager #2 said she never visualized the wound herself, but since triad is usually for stage two pressure wounds, she told the physician Resident #428 had a stage two pressure wound on his/her coccyx. Unit Manager #2 said the physician ordered adaptic and calcium alginate for a stage two pressure wound. Unit Manager #2 said she would have expected Charge Nurse #1 to clarify the order when he first noted the wound status did not match the treatment order. Review of Resident #428's hospital discharge paperwork and admission paperwork, both dated 2/20/25, failed to indicate Resident #428 had a stage two pressure wound. The hospital discharge paperwork, dated 2/20/25, indicated sacral deep tissue injuries. During an interview on 2/26/25 at 11:15 A.M., the Regional Nurse Consultant said adaptic and calcium alginate are not appropriate wound treatments for intact skin or deep tissue injury and Charge Nurse #1 should have stopped the dressing change with the surveyor and clarified the wound treatment orders. During an interview on 2/26/25 at 1:50 P.M., the Director of Nursing (DON) said adaptic and calcium alginate are not appropriate wound treatments for intact skin or deep tissue injury and Charge Nurse #1 should have clarified the physician order when he first noted the wound status did not match the treatment order. Refer to F726. 52138

Based on record review and interview the facility failed to ensure for 1 Resident (#92) out of a total sample of 27 residents, that 72-hour neurological checks were conducted after Resident #92 sustained unwitnessed falls. Findings include: Review of the facilities policy titled, Falls Management, last updated October 2023, indicated the facility will utilize resident/patient related information made available upon admission and ongoing to determine resident/patient at risk for fall status. Procedure: A fall risk evaluation will be conducted by the nurse on duty/supervisor on any resident/patient sustaining a fall with or without injury. Once the resident/patient is clinically evaluated as being stable, vital signs, neurological signs, range of motion, and evaluation of cognitive status will be documented. Neurological checks, to be documented on the neurological flow sheet for 72 hours in the following circumstances, resident/patient states that he/she hit head, physical evidence resident hit head, and unwitnessed fall. Resident #92 was admitted to the facility April 2022 and has diagnoses that include but are not limited to legal blindness, repeated falls, cataracts, acute on chronic systolic heart failure and cognitive communication deficit. Review of Resident #92's Minimum Data Set (MDS) assessment, dated 12/18/24, indicated that he/she scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she as having intact cognition. Review of Resident #92's care plans indicated a care plan with the focus: Resident #92 is at risk for falls D/T (due to) unsteady gait, decreased balance, generalized weakness and impaired mobility due repeated falls, legally blind, poor safety awareness, use of antidepressant and antianxiety medications, diuretic medication, opioid use for pain, confusion, oxygen use, incontinence, date initiated 1/2/2024. Review of the following fall risk evaluations indicated Resident #92 was at risk for falls: 9/23/24 comprehensive, 10/8/24 quarterly,10/8/24 other, 11/7/24 other, 12/3/24 quarterly,12/4/24 admission,12/16/24 other,12/18/24 quarterly, 12/22/24 other, 12/24/24 other, 2/5/25 quarterly, 2/6/25 other, 2/19/25 other, and 2/21/25. Review of the incident reports provided to the surveyor by the Director of Nursing indicated Resident #92 sustained 12 falls between 9/6/2024 through 2/21/2025. Of the 12 falls, 10 were not witnessed. Review of the 10 not witnessed fall incident reports, indicated 6 did not include 72-hour neurological assessment low sheets. Review of the incident reports indicated the following: -Fall date 9/8/24, at 5:31 P.M., Fall was not witnessed. Fall occurred bedside. An initial Neurological focused evaluation was conducted. Review of the incident report failed to indicate a 72-hour neuro flow sheet was completed. -Fall date 10/6/24, 06:00 (6:00 A.M.) fall was not witnessed. Fall occurred in Resident's room. Resident was attempting to self-toilet at the time of the fall. Further review of the incident report failed to indicate 72-hour neurological checks were conducted. -Fall 11/7/24 at 5:45 P.M., Fall was not witnessed. Fall occurred in the bathroom. An initial focused neurological focused evaluation was completed, no further 72-hour neurological flow sheet was completed. -Fall 11/13/25, at 7:36 P.M., fall was not witnessed. Fall occurred in the Resident's room. A neurological focused evaluation was conducted. Further review failed to indicate a 72-hour neurological flow sheet was completed. -Fall date 12/22/24, at 6:30 A.M., Fall not witnessed. Fall occurred in the bathroom. Initial neuro check conducted; no further 72-hour neurological flow sheet was completed. -Fall 2/19/25, 12:00 P.M., Fall was not witnessed. Fall occurred in Resident's room. Further review failed to indicate a 72-hour neurological check was completed. During an interview on 2/26/25 at 11:20 A.M., Unit Manager #3 said Resident #92 is at high risk for falls and has had multiple falls. Unit Manager #3 said all falls Resident #92 has sustained are reviewed and the care plan revised. Unit Manager #3 said all falls that are not witnessed require 72-hour neuro checks that are documented on paper neuro flow sheets. Unit Manager said once completed the neurological flow sheets are given to the Director of Nursing as part of the incident report. During an interview on 2/26/25 at 11:44 A.M. The Director of Nursing said neuro checks were required on falls with head strikes or falls that are not witnessed. The DON said the Neurological checks are completed on paper and that the nursing staff and Unit managers are responsible to ensure the neuro checks are conducted. The DON said he was not entirely sure where the missing neuro checks were for Resident #92.

Based on observation, record review, and interview, the Facility staff failed to protect 1 Resident (#96) out of a total sample of 25 residents from neglect by failing to assess and document changes to the resident's toenails despite daily diabetic foot care and being totally dependent on staff for bathing and needing extensive assistance with dressing and grooming. The facility failed to obtain podiatry services per a physician order [REDACTED]. Findings include: Resident #96 was admitted to the facility in 5/2013 with [DIAGNOSES REDACTED]. Review of most recent quarterly Minimum Data Set assessment dated [DATE], Resident #96 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated the Resident was cognitively intact, and he/she requires extensive assist for all aspects of his/her activities of daily living (ADLs), except eating and is dependent for bathing. Review of the policy and procedure titled Weekly Body Audit dated (MONTH) (YEAR) indicates the following: *All residents will have a body audit to address any skin issues on a weekly basis. *The Certified Nursing Assistant is to report any skin impairment to the Charge Nurse when initially identified. *If a new area is discovered, the Charge Nurse is responsible to start appropriate documentation and notify Unit Manager or Supervisor, and will add this information to the 24 hour report. *Monitoring of any area will continue until area is resolved. Review of Resident #96's Diabetic Care plan initiated on 8/24/2017 includes and intervention for diabetic foot care daily. The Diabetic care plan was reviewed on 8/8/18, 10/31/18 and 1/31/19 with no revisions made. On 2/12/19, at 1:15 P.M., Resident #96 was observed lying in bed on his/her back. The Surveyor observed Resident #96's right foot. He/she had long, thick, yellow curling toenails that were curled underneath his/her toe and into the skin of the bottom of his/her toe, causing a discoloration to the skin. The skin to the top of the great toe was thick, yellow, peeling and scaly with dark purple discoloration. On 2/14/19, at 8:15 A.M., the Surveyor observed Resident #96's right foot with the Assistant Director of Nursing (ADNS) and Unit Manger #1. The Surveyor observed Resident #96's right foot had toenails that were thick, yellowed and curling underneath his/her right two toes and into the skin on the bottom of the toe with the skin to the top and bottom of the great toe to have thick, peeling, scaly and crusted yellow skin with dark purple discoloration. The toenail had snapped from bending underneath the toe. The toe itself was observed with dark discoloration at the breaking point where the toenail bent and dark discoloration on the underside of the toe where jagged edges were observed resting against the skin. After looking at Resident #96's right foot, the ADNS and Unit Manger #1 both said they were unaware of the condition of Resident #96's toenails. The ADNS said Resident #96's toenails must have been growing for a long time as this condition of his/her toenails could not have happened in a short period of time. During an interview on 2/14/19, at 1:34 P.M., the Director of Nursing confirmed that Resident #96 had a physician's orders [REDACTED].#96 to be seen by a podiatrist and this had not yet happened. During an interview on 2/14/19, at 12:30 P.M., Certified Nursing Assistant (CNA) #2 said she has been taking care of Resident #96 for years. CNA #2 said that she provided foot care to Resident #96 when he/she allows, however has never reported a change of condition in Resident #96's toenails to the nurse.

Based on observation, record review and staff interviews, the Facility staff failed to provide proper foot care to a diabetic Resident (#96) out of a total of 25 sampled residents, by failing to assess and document changes to the resident's toenails despite daily diabetic foot care and being totally dependent on staff for bathing and needing extensive assistance with dressing and grooming. The facility failed to obtain podiatry services per a physician order written [REDACTED]. Findings include: Resident #96 was admitted to the facility in 5/2013 with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set assessment dated [DATE], Resident #96 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated the Resident was cognitively intact, he/she requires extensive assist for all aspects of his/her activities of daily living (ADLs), except eating and is dependent for bathing. On 2/12/19, at 1:15 P.M., Resident #96 was observed lying in bed on his/her back. The Surveyor observed Resident #96's right foot. He/she had long, thick, yellow curling toenails that were curled underneath his/her toe and into the skin of the bottom of his/her toe, causing a discoloration to the skin. The skin to the top of the great toe was thick, yellow, peeling and scaly with dark purple discoloration. The toenail had snapped from bending underneath the toe. The toe itself was observed with dark discoloration at the breaking point where the toenail bent and dark discoloration on the underside of the toe where jagged edges were observed resting against the skin. Review of the Resident's Skin Integrity Care Plan initiated 8/24/17, included the following interventions: * Frequent skin checks - notify MD/NP of any signs and symptoms of skin breakdown * Pressure relieving devices for bed - air mattress * Reposition every 2 hours as needed * Monitor right leg for further vascular problems Review of Resident #96's Diabetes Care Plan initiated 8/24/17, indicated an intervention of diabetic foot care as needed. Further review of the Resident's record indicated a telephone order written and dated 10/17/18, for podiatry to see pt. - has right toenails that need attention, with the word need underlined. Further, there was no documentation that this had occured 119 days after the order was initiated. An interview and observation of Resident #96's right foot with Unit Manger #1 and Assistant Director of Nursing (ADNS) was completed on 2/14/19, at 8:15 A.M. Both the Unit Manger #1 and the ADNS said they were unaware of the resident's toenails being this long. The ADNS said the Certified Nursing Assistants and Nurses are to monitor foot care for Resident #96. She also said that an order should have been obtained to treat Resident #96's right toe and the Primary care physician should have been notified of the changes. The ADNS and Unit Manager #1 then said the Resident's toenails length and skin discoloration did not develop quickly and must have grown over a period of time. The ADNS additionally said that Resident #96 has never been seen by a Podiatrist because he/she refused podiatry care in (YEAR). The ADNS said the expectation of the Nursing staff would be to re-approach the Resident regarding podiatry services explaining the risks and benefits at least monthly. During an interview on 2/14/19 at 8:00 A.M., Resident #96 voiced concern and said, what is wrong with my foot, why are you looking at it? Review of the Facility Policy, Diabetic Foot Care dated 10/2018 indicated: Diabetic foot care is provided by qualified nursing staff. Foot condition is noted and changes reported as warranted. Procedure * Identify resident/patient, explain procedure and provide privacy. * Perform hand hygiene and don gloves, if applicable. * Wash both feet thoroughly with soapy water and rinse well, giving particular attention to areas between and under the toes. If appropriate, gently clean under nails with soft nail brush. If feet are soiled, it may be necessary to soak 10-15 minutes. * Examine feet carefully for evidence of discoloration, redness, blisters, or skin tears. * Dry feet, also emphasizing areas between and under toes. * Nurse to contact physician for podiatry consult re: trimming of nails. * Podiatry will be scheduled to trim toe nails. * Gently massage foot with lotion, unless contraindicated. * Discard equipment or return it to the appropriate location. * Perform hand hygiene and remove gloves. * Report any irregularities to charge nurse. * Document changes in condition in medical. * Any pertinent findings should be reported to physician and/or appropriate practitioner. Review of the Treatment Administration Records for (MONTH) and (MONTH) 2019 indicated an order for [REDACTED]. On 2/14/19, at 8:27 A.M., the ADNS and Unit Manger #1 re-approached Resident #96 regarding the condition of his/her foot and the need for podiatry services. Resident #96 agreed to have podiatry services.

Based on record review and interview, for one of three sampled residents (Resident #1), the Facility failed to ensure that Resident #1, who had a history of [REDACTED]. The Director of Nurses (DON) said Resident #1 fell on [DATE] at 12:45 P.M. because Certified Nurse Assistant (CNA) #1 shut off the safety alarm, left Resident #1 alone on the toilet with the bathroom door closed, and walked approximately 40 feet away from Resident #1 to obtain his/her walker. The DON said Resident #1 was transferred to the Hospital; he/she sustained displacement of a previous cervical fracture due to the fall at the Facility, and Resident # 1 was required to wear a hard cervical collar for approximately three months. Findings include: The Hospital Discharge Summary, dated 5/15/13, indicated Resident #1 sustained a cervical fracture due to a fall at another facility, was stabilized, and transferred to the Facility with recommendations for a cervical collar for approximately 4 weeks or until discontinued by Orthopedic Consultant #1. The Discharge summary recommended strict fall precautions due to Resident #1's history of falls, a current severe cervical fracture following a fall, imbalance, ataxia, and severe dementia. The Face Sheet indicated that Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The admission resident fall risk assessment, dated 5/24/13, indicated that Resident #1 had fallen 3 or more times during the last ninety days, and his/her last fall was on 5/17/13. The admission fall risk assessment indicated that Resident #1 was at risk for falls because he/she had an impaired cognitive status, required the physical assistance (hands on) of staff during toileting, standing, ambulation with an assistive device. The plan of care, dated 6/12/13, indicated that Resident #1 was at risk for falls due to a history of falls, decreased safety awareness, impaired cognition, and a recent fall that resulted in a cervical fracture and required a cervical collar at all times. The plan of care interventions included: provide physical assistance with all transfers, ambulation, and toileting needs. The Surveyor interviewed the Director of Nurses (DON) at 8:15 A.M. and 4:00 P.M. on 8/12/13. The Director of Nurses (DON) said Resident #1 fell while getting off the toilet unassisted when left alone in the bathroom; Certified Nurse Assistant (CNA) #1 shut off the safety alarm, left Resident #1 alone on the toilet with the bathroom door closed, and walked approximately 40 feet to the dining room to obtain Resident #1's walker. The DON said Resident #1 had a history of [REDACTED]. The DON said Orthopedic Consultant #1 discontinued the collar on 6/19/13 because the cervical fracture had since healed. The day shift nurse's note, dated 7/18/13, indicated that Physician #1 was notified that Resident #1 had a fall, was lying on his/her back on the bathroom floor with his/her head leaning against the wall. The nurse's note indicated that Resident #1 sustained a laceration on the back of his/her head with a small amount of bleeding, and he/she had no complaints of pain. The nurse's note indicated that orders were obtained from Physician #1 to transfer Resident #1 to the Hospital for an evaluation. The Surveyor interviewed Certified Nurse Assistant (CNA) #1 at 12:30 P.M. on 8/12/13. CNA #1 said he was assigned to Resident #1's personal care needs during the day shift on 7/18/13. CNA #1 said Resident #1 required safety alarms at all times and required physical assistance (hands on) when ambulating, transferring, and during toileting. CNA #1 said he routinely remained at Resident #1's side or within reach during toileting to ensure he/she did not attempt to stand without physical assistance. CNA #1 said he left Resident #1 seated alone on the toilet while he walked to the combined dayroom/dining room on the unit to get his/her rolling walker. The Hospital Discharge Summary, dated 7/18/13, indicated that Resident #1 sustained a large hematoma with an abrasion, a shallow laceration on the back of the scalp, and displacement of the previous cervical fracture. The Hospital Discharge Summary indicated that Resident #1 returned to the Facility in 2 days (on 7/20/13) with recommendations to wear a hard cervical collar at all times until otherwise specified by the Orthopedic Consultant, weekly cervical x-rays, and follow up appointment with the Orthopedic Consultant in 2 to 4 weeks The Orthopedic Consultation Report, dated 7/19/13, indicated Resident #1 had an unwitnessed fall at the Facility, had a contusion on the right side of his/her forehead, had mildly increased neck pain in the emergency room , and a CAT (computed axial tomography)Scan indicated that he/she sustained a mild displacement of the previous cervical fracture (that occurred in May 2013) due to the fall at the Facility. The Orthopedic Consultation Report indicated that recommendations included a hard cervical collar immobilization at all times for approximately 3 months, weekly x-rays for one month to follow any further displacement, and strict fall precautions because any further falls could be catastrophic. The Orthopedic Consultation Report further indicated that there was a risk of continued nonunion with the cervical collar and if there was any further displacement of the fracture, surgery may be required. The Surveyor interviewed Orthopedic Consultant #2 at 11:20 A.M. on 8/19/13. Orthopedic Consultant #2 said he first examined Resident #1 following his/her fall at the Facility (on 7/18/13). Orthopedic Consultant #2 said Resident #1 sustained displacement of a previous cervical fracture due to a fall at the Facility; Resident #1 wore a hard cervical collar for approximately three months and received weekly x-rays to follow any further displacement. Ortopedic Consultant #2 said, if further displacement occurred or the nonunion did not fully heal with conservative treatment (hard collar), then surgery might be necessary.

Based on record review and interviews, for 1 of 2 sampled residents (Resident #1), who was assessed to be at high risk for falls, the Facility failed to implement effective interventions and adequate supervision to prevent falls. Resident #1 was admitted to the facility on the evening of 4/8/11 at which time Resident #1's Family Member informed staff of Resident #1's restlessness and risk for potential falls, and requested an alarm be placed on Resident #1's bed. Although the Admission Fall Risk Assessment indicated Resident #1 was at high risk for falls, no interim plan of care for fall prevention was developed and the bed alarm was not implemented. The following morning, at approximately 7:15 AM, Resident #1 was found lying on the floor in another resident's room and Resident #1 sustained a fractured left elbow. Findings included: A Hospital Discharge Referral, dated 4/7/11, indicated Resident #1 was hospitalized and treated for [REDACTED]. Resident #1 was admitted to the Facility in April 2011 and [DIAGNOSES REDACTED]. An Admission Nursing Observation Record, dated 4/8/11, indicated Resident #1 was alert but confused, bed fast and had bilateral half side-rails on the bed. The Observation Record indicated Resident #1 was usually continent and was oriented to the call light system and bathroom. An Admission Falls Risk Assessment, dated 4/8/11, indicated Resident #1 was assessed to be at high risk for potential falls. The Facility's Policy on the Prevention of Falls indicated that a resident identified at risk for falls would have a care plan developed which would reflect the risk for injury and a plan of approach to promote resident safety. A Nurse's Progress Note, dated 4/8/11 at 11:15 PM, indicated Resident #1 was found attempting to go to the bathroom and pulled out an Intravenous Line (IV) inserted in Resident #1 arm used to administer antibiotics. A Nurse's Progress Note, dated 4/9/11 at 4:29 AM, indicated Resident #1 was not adjusting well to the Facility, was given Trazodone (an antidepressant medication with known side effects including dizziness and confusion) with good effect and was able to sleep. The Note indicated that staff would get a bed and chair alarm for Resident #1. Nurse #2 was interviewed at 11:30 AM on 4/28/11. Nurse #2 said at the change of shift report at 11 PM on 4/8/11, Nursing Supervisor #1 reported that Resident #1 was a fall risk and asked Nurse #2 to get an alarm and place it on Resident #1's bed. Nurse #2 said during the course of the report, a Certified Nurse Aide (CNA) called for help with Resident #1 and when Nurse #2 and Nursing Supervisor #1 responded, they found Resident #1 standing by the door to the bathroom and the IV tubing was lying on the floor. Nurse #2 said Resident #1 was helped back to bed, was given a urinal and the call light was placed within Resident #1's reach. Nurse #2 said there was an order to administer Trazodone if needed and because Resident #1 appeared a little anxious, Nurse #2 gave Resident #1 the Trazodone. Nurse #2 said Resident #1 slept throughout the remainder of the night and said the CNAs did not report any problems with Resident #1's care. Nurse #2 said there were no extra bed alarms on the unit. Nurse #2 said Nurse #2 did have keys to the store room on the ground floor where extra alarms were kept and although Nurse #2 did have every intention of going down to the store room to get an alarm, the night just got so busy that Nurse #2 forgot. Nurse #2 did not put an alarm on Resident #1's bed. Nurse #2 said Nurse #2 last saw Resident #1 asleep in bed at approximately 6:30 AM on 4/9/11. Nurse #2 said during the change of shift report sometime between 7 AM and 7:15 AM, someone called out that Resident #1 had fallen. Nurse #2 said Nurse #2 did not respond as this was the end of Nurse #2 assigned shift and that staff assigned on the 7 AM to 3 PM shift took over. A Nurse's Progress Note, dated 4/9/11 at 1 PM, indicated Resident #1 was transferred to the Hospital for evaluation following a fall during morning rounds. An X-ray Report, dated 4/9/11, indicated Resident #1 had a fractured left elbow. Review of Resident #1's medical record indicted there was no documented safety plan of care for the prevention of falls/ injury. The Assistant Director of Nurses (ADON) was interviewed throughout the day of 4/28/11. The ADON said it was the Facility's practice that an Admission Observation Record would be initiated by nursing staff at the time of a resident's admission which would in turn drive an interim plan of care. The ADON said if the assessment or plan of care was not completed on the admitting shift, the oncoming shift would follow through and complete. The ADON confirmed that a Plan of Care for the Prevention of Falls had not been developed on Resident #1. Attempts by the Surveyor to interview Nursing Supervisor #1 and Nurse #1 who worked on the evening of Resident #1 ' s admission, were unsuccessful. A documented statement written by Nursing Supervisor #1 as part of the Facility's Internal Investigation indicated the Family Member had reported to Nursing Supervisor #1 that Resident #1 was a little disoriented and the Family Member requested an alarm be placed on Resident #1's bed and that Resident #1 be given a sedative to help Resident #1 sleep. The ADON said during the course of the Facility's Investigation it was determined that the Family Member reported to Nursing Supervisor #1 on the evening of Resident #1's admission, that Resident #1 was restless and would attempt to get out of bed without help. The ADON said the Family Member had asked Nursing Supervisor #1 to put an alarm on Resident #1's bed, but somehow Nursing Supervisor #1 had become distracted and did not place an alarm on Resident #1's bed.