Every finding on record at Sarah S Brayton Center

Based on observations, interviews, and record review, the facility failed to implement nutritional interventions to maintain acceptable parameters of nutritional status for two Residents (#12, #50), with unplanned gradual weight loss, and one Resident with significant weight gain (#95), in a total sample of 33 residents. Specifically, the facility failed:1. For Resident #12, to identify and develop interventions to prevent and address a 12.4% significant weight loss between 8/1/25 and 2/2/26;2. For Resident #50, to identify and develop interventions to prevent and address a 17.57% significant weight loss between 11/4/25 and 2/12/26; and3. For Resident (#95), to implement dietitian recommendations to address a weight gain and ensure the Resident's preference to lose weight was met.Findings include:Review of the facility's policy titled Weight Assessment and Intervention, dated March 2022, indicated but was not limited to: - Resident weights are monitored for undesirable or unintended weight loss or gain. - Unless notified of significant weight change, the dietitian will review the unit weight record monthly to follow individual weight trends over time. - The threshold for significant unplanned and undesired weight loss will be based on the following criteria: 1 month – 5% weight loss is significant, greater than 5% weight loss is severe; 6 months – 10% weight loss is significant, greater than 10% is severe. - Care planning for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, the dietitian, the consultant pharmacist and the resident or resident's legal surrogate. Review of the facility's policy titled Nutritional Assessment, dated October 2017, indicated but was not limited to: - As part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. - The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition. 1. Resident #12 was admitted to the facility in November 2024 with diagnoses including Parkinson's disease and dysphagia (difficulty swallowing). Review of Resident #12's Minimum Data Set (MDS) assessment, dated 1/15/26, indicated he/she was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 7 out of 15. Furthermore, the MDS assessment indicated Resident #12 had experienced a weight loss of 10% or more in the last six months, was not a physician-prescribed weight loss regimen and received a mechanically altered diet. Review of Resident #12's Physician's Orders indicated but was not limited to the following: - 9/9/25: weight weekly - 10/16/25: Regular Diet, Puree Texture, Thin Consistency Review of Resident #12's nutrition care plan indicated but was not limited to the following interventions: - Monitor/record/report to MD PRN (as needed) s/sx (signs/symptoms) of malnutrition: Emaciation (cachexia), muscle wasting, significant weight loss: >5% in 1 month, >7.5% in 3 months, >10% in 6 months. - Monitor weights as ordered. - RD (dietitian) to evaluate and make diet change recommendations PRN (as needed). Review of Resident #12's weights in the medical record indicated but were not limited to the following: - 8/1/25: 208.9 pounds (lbs.) - 9/10/25: 196.8 lbs. - 10/6/25: 198.0 lbs. - 11/4/25: 188.0 lbs. - 12/2/25: 190.0 lbs. - 12/30/25: 187.2 lbs. - 1/6/26: 186.2 lbs. - 1/13/26: 185.7 lbs. - 2/2/26: 183.0 lbs. Review of Resident #12's weights indicated he/she had an 11.11% weight loss from 8/1/25 to 1/13/26. Furthermore, Resident #12's weights indicated he/she had further weight decline and a 12.4% weight loss in six months (8/1/25 to 2/2/26). Review of Resident #12's medical record failed to indicate any Nutrition Assessments were completed after the admission assessment on 11/19/24. Review of Resident #12's weight change note progress note completed by the dietitian on 8/7/25 indicated but was not limited to: - Resident had significant weight gain related to excessive PO (by mouth) intake. - Resident orders take out often and orders side sandwiches/burgers with meals. - Weight has been stable x 1 month. - Will continue to monitor and provide interventions as needed (PRN). Further review of the 8/7/25 weight change progress note failed to indicate any interventions put in place to promote weight loss or if weight loss was desired. Review of Resident #12's weight change progress note completed by the dietitian on 12/31/25 indicated but was not limited to: - 10.3% weight loss triggered. - Weight stabilizing with minor fluctuations. - Resident continues with weekly weight monitoring. - Resident will continue to monitor and provide nutrition interventions PRN. Further review of the 12/31/25 weight change progress note failed to indicate if the weight loss was desired. Review of Resident #12's progress note, dated 1/23/26, completed by the dietitian indicated but was not limited to: - Resident continues on regular diet with pureed texture and thin liquids. - Appetite variable at mealtimes with recorded intakes < 25-100% - Supervision with meals. - Weight has been stable with minor fluctuations this quarter. - Will continue to monitor and provide nutrition interventions PRN, care plan updated. Further review of Resident #12's 1/23/26 progress note failed to indicate he/she had sustained a 10% or more weight loss in less than six months. The progress note also failed to indicate if weight loss was desired. Review of Resident #12's nursing progress notes failed to indicate documentation related to his/her significant weight loss. Review of Resident #12's physician (MD) and nurse practitioner (NP) progress notes failed to indicate documentation related to his/her significant weight loss over six months. During an interview on 2/19/26 at 9:27 A.M., Nurse #5 said when a resident has a weight loss or weight gain it is indicated in the electronic medical record. Nurse #5 said nursing staff would notify the provider and/or the dietitian of the triggered weight loss or weight gain. Nurse #5 said the nursing staff would document the weight loss or weight gain in a progress note. During an interview on 2/19/26 at 9:48 A.M., the Dietitian said she checks weight triggers in the electronic medical record at least weekly. The Dietitian said residents who trigger for a significant weight loss are followed in the facility weekly risk meeting. The Dietitian said Resident #12's weights had been leveling out, and she was not certain if he/she was followed in the weekly risk meeting for weight loss. The Dietitian said the Resident had had some hospitalizations and was not sure if that had impacted his/her weight. During an interview on 2/19/26 at 10:30 A.M., the Dietitian said she had reviewed Resident #12's weights for the past six months today and identified a significant weight loss from August 2025. The Dietitian said the Resident had had a weight gain in August 2025 due to increased PO intake. The Dietitian said due to a change in diet texture, the Resident was no longer ordering additional food items at mealtimes. During an interview on 2/19/26 at 3:48 P.M., the Director of Nursing (DON) said weights for residents who are noted to have lost weight are reviewed at the facility's weekly risk meeting with the dietitian. The DON said the dietitian should complete a nutrition assessment for a resident on admission, quarterly, and with a significant change or weight loss. The DON said she did not believe Resident #12 was added to the weekly risk meeting for weight loss but would have to check. During an interview on 2/19/26 at 4:43 P.M., the DON said Resident #12 was not currently being monitored for weights at the facility's risk meeting. The DON said the Resident's weights had been stable for the past three months on the diet prescribed. 2. Resident #50 was admitted to the facility in September 2025 with diagnoses including end stage renal disease and dependence of dialysis. Review of the MDS assessment, dated 12/18/25, indicated that Resident #50 was moderately cognitively impaired as evidenced by a BIMS exam score of 11 out of 15. Further review of the MDS indicated Resident #50 was 68 inches tall, weighed 149 pounds, had experienced a weight loss of 5% or more in the last month or 10% or more in the last 6 months, not on a physician-prescribed weight-loss regimen, and received a therapeutic diet. Review of Resident #50's medical record indicated he/she had progressive weight loss as evidenced by the following post-dialysis weights:-11/1/25: 167 lbs.-11/4/25: 169lbs.-11/6/25: 167.4 lbs.-11/12/25: 167.1 lbs.-11/13/25: 164.7 lbs.-11/15/25: 167.3 lbs.-11/19/25: 160 lbs.-11/20/25: 160.1 lbs.-11/24/25: 158.9 lbs.-11/26/25: 156.6 lbs.-12/2/25: 158 lbs.-12/6/25: 155.8 lbs.-12/9/25: 152.1 lbs.-12/11/25: 151.3 lbs.-12/13/25: 148.7 lbs.-12/16/25: 151.4 lbs.-12/18/25: 149 lbs.-12/20/25: 147.8 lbs.-12/22/25: 150.6 lbs.-12/24/25: 148.5 lbs.-12/27/25: 152.7 lbs.-1/3/26: 147.2 lbs.-1/6/26: 147.9 lbs.-1/8/26: 148.8 lbs.-1/15/26: 155.4 lbs.-1/17/26: 154 lbs.-1/20/26: 149.9 lbs.-1/22/26: 149.5 lbs.-1/24/26: 147.1 lbs.-1/29/26: 145.3 lbs.-1/31/26: 155.5 lbs.-2/3/26: 146.1 lbs.-2/5/26: 145.5 lbs.-2/10/26: 146.2 lbs.-2/12/26: 142.4 lbs. On 11/4/25, the Resident weighed 169 lbs. On 12/6/25, the Resident weighed 155.8 lbs., which was a 7.81% weight loss in one month. On 12/6/25, the Resident weighed 155.8 lbs. On 1/6/26, the Resident weighed 147.9 lbs., which was a subsequent 5.07% weight loss in one month. On 1/15/26, the Resident weighed 155.4 lbs. On 2/12/26, the Resident weighed 142.4 lbs., which was a subsequent 8.37% weight loss in one month. Between 11/4/25 and 2/12/26, Resident #50 experienced a total weight loss of 24.6 pounds, or 14.73% of his/her body weight. Review of Resident #50's Comprehensive Nutrition Assessment, dated 9/29/25, indicated the Resident was overweight and that weight fluctuations were noted, likely related to fluid shifts with dialysis. The Resident was on Nepro (a therapeutic nutrition supplement designed to help meet the nutritional needs of people on dialysis) and a liquid protein supplement for increased protein and calories to promote weight stability and wound healing and to meet the Resident's increased protein needs due to dialysis. Review of Resident #50's care plan indicated, but was not limited to, the following:Focus: Nutrition: [Resident #50] has nutritional problem or potential nutritional problem r/t dx (diagnosis) ESRD (end stage renal disease), dependence on renal dialysis, T1DM (type 1 diabetes mellitus), T2DM (type 2 diabetes mellitus), COPD (chronic obstructive pulmonary disease), asthma, anemia, dysphagia, GAD (generalized anxiety disorder), depression, hypo-osmolality/natremia, heart failure, HTN (hypertension), HLD (hyperlipidemia), hypothyroidism, GERD (gastroesophageal reflux disease), h/o (history of) lung CA (cancer)Therapeutic diet1.5 L (liter) fluid restrictionInterventions:-Monitor weights as ordered-Monitor/record/report to MD PRN (as needed) s/sx (signs/symptoms) of malnutrition: Emaciation (cachexia), muscle wasting, significant weight loss: >5% in 1 month, >7.5% in 3 months, >10% in 6 months-RD (Registered Dietitian) to evaluate and make diet change recommendations PRN (as needed) Review of Resident #50's Physician's Orders indicated, but was not limited to, the following:-CCHO (consistent-carbohydrate) Renal Liberal diet, Regular texture, Thin consistency (order date 9/18/25)-Document post-dialysis weight every evening shift every Tue, Thu, Sat for weight monitoring (order date 9/25/25)-Liquid protein sugar free (SF) 30 milliliters (ml) twice daily (order date 9/26/25)-Nepro 237 ml two times a day for supplement (order date 2/13/26)-Nepro 237 ml one time a day for supplement (order date 9/27/25 to 2/13/26)-1500 ml Fluid Restriction per 24 hours (order date 2/13/26)-1200 ml Fluid Restriction per 24 hours (order date 12/29/25 to 2/13/26)-Zofran (a medication used to treat nausea and vomiting) 4 milligrams (mg) every eight hours as needed for nausea/vomiting (order date 10/10/25)-Humalog (a fast-acting insulin to control high blood sugar) sliding scale before meals (order date 12/24/25)-Lantus (a long-acting insulin to treat high blood sugar) 11 units at bedtime (order date 12/24/25)-Mirtazapine (an antidepressant medication that may also stimulate appetite) 7.5 mg at bedtime (order date 9/18/25)-Offer diabetic snack at bedtime (order date 9/18/25)-Offer meal/snack prior to dialysis (order date 9/27/25) Review of Resident #50's meal intake percentage documentation 1/20/26 through 2/19/26 indicated Resident #50 consumed less than 51% of his/her meal on 11 occasions, was not available for the meal on 10 occasions, and refused his/her meal once. Review of Resident #50's progress notes indicated, but was not limited to, the following:-12/9/25 Weight Change Note: Weight fluctuations r/t fluid shifts with dialysis. Resident continues on Nepro QD and liquid protein SF 30ml BID r/t variable appetite and increased protein needs r/t dialysis. Will continue to monitor and provide nutrition interventions PRN. -12/31/25 Nutrition/Dietary Note: [Resident #50] continues on a CCHO renal liberal diet with regular textures and thin liquids. 1200cc (cubic centimeter, 1 cc = 1 ml) fluid restriction in place. Appetite varies at mealtimes with most recorded intakes 50-100%. Resident eats independently with set up assistance. CBW (current body weight) 152.7#, BMI of 23.2 indicates healthy weight status, and resident is currently 109% IBW (ideal body weight). 1 month ago: 156.5#. 3 months 166.1#. Weights are recorded post-dialysis sessions Tu/Th/Sat. Weight fluctuates often r/t fluid shifts. Resident continues on Nepro QD as well as SF liquid protein 30ml BID for increased nutrition and calories r/t fair appetite and increased protein needs with dialysis. Meds reviewed- continues on insulin r/t DM (diabetes mellitus), and Mirtazapine which may stimulate appetite. Skin is intact. Labs from 12/22/25 reviewed. Results: TSH (thyroid-stimulating hormone, the lab test measures the level of thyroid-stimulating hormone in the blood to assess thyroid function and detect thyroid disorders): >150.000 H (high) T4 (a test that measures the level of thyroxine, a thyroid hormone, in the blood): 0.80 L (low) Will continue to monitor and provide nutrition interventions PRN. CP (care plan) updated. -1/16/26 Weight Change Note: Weight fluctuations r/t fluid shifts with dialysis. Will continue to monitor and provide nutrition interventions PRN. -2/11/26 Nutrition/Dietary Note: RD spoke with dialysis dietitian to discuss intakes and supplements. Dialysis dietitian in agreement to liberalize fluid restriction from 1200cc to 1500cc, will send order in dialysis binder. Recommend increasing Nepro from QD (daily) to BID once order is received, and to continue with liquid protein SF (sugar-free) 30ml BID r/t (related to) increased protein needs r/t receiving dialysis and to promote wound healing. Will continue to monitor.-2/13/26 Clinical Nurses Note: Resident returned from HD (hemodialysis) center on 2/12/26 with new recommendations to increase fluid restriction to 1500ml/day and increase Nepro to BID (twice daily). Provider in agreement- orders transcribed. RD (Registered Dietitian) made aware for FR (fluid restriction) breakdown. HCP (health care proxy) aware and in agreement. -2/19/26 Weight Change Note: Weight fluctuations r/t (related to) fluid shifts with dialysis. Will continue to monitor and provide nutrition interventions PRN (as needed). Further review of Resident #50's progress notes indicated the Resident experienced multiple days with nausea/vomiting episodes and low/high blood sugar levels between 11/30/25 and 2/19/25. On 2/18/26 at 11:26 A.M., the surveyor observed Resident #50 sitting in his/her Broda chair (positioning chair). Resident #50 was observed to have vomit on his/her person and on the floor beside him/her. Resident #50 said his/her stomach was upset and he/she was assisted back to bed by staff. During an interview on 2/19/26 at 8:41 A.M., Unit Manager #1 said when a resident triggers for weight loss, the triggered weight shows on the electronic health record's dashboard and the dietitian can see it. Unit Manager #1 said the dietitian will then put interventions in place to prevent further weight loss, if needed. Unit Manager #1 said in Resident #50's case, his/her weight fluctuates with dialysis, but his/her Nepro supplement was recently increased. Unit Manager #1 said Resident #50 is particular about his/her likes and dislikes but generally eats well and is able to feed themselves. Unit Manager #1 said Resident #50 is sent to dialysis with a lunch, but she is not sure how much of it Resident #50 eats because she is not there to see it, but dialysis usually reports that Resident #50 eats his/her sandwich. Unit Manager #1 said she was aware that Resident #50 had lost weight but did not know how significant his/her weight loss was. During an interview on 2/19/26 at 2:44 P.M., the Dietitian said Resident #50 had some weight fluctuations due to being on dialysis. The Dietitian said she had spoken to the dietitian at the dialysis center the week prior and she was able to liberalize the Resident's fluid restriction from 1200 ml per day to 1500 ml per day so that she could increase the Resident's Nepro supplement to twice daily. The Dietitian did not identify any other interventions put in place to address the Resident's weight loss prior to the increasing the Resident's supplement. During an interview on 2/19/26 at 3:04 P.M., Physician #1 said he was aware of Resident #50's weight loss. Physician #1 said since the Resident is on dialysis, he would expect that he/she would lose some weight because he/she likely admitted to the facility while fluid-overloaded. During an interview on 2/19/26 at 3:48 P.M., the DON said weights for residents who are noted to have lost weight are reviewed at the facility's weekly risk meeting with the dietitian. The DON said the Dietitian should complete a Nutrition Assessment for a resident on admission, quarterly, and with a significant change or weight loss. During a subsequent interview on 2/19/26 at 4:43 P.M., the DON said Resident #50 is weighed three times weekly at dialysis and has not been reviewed at the facility's weekly risk meeting. The DON said Resident #50's fluid restriction was recently increased because he/she was more stable and that the facility's Dietitian communicates with the Resident's Dietitian at dialysis. The DON said Resident #50's supplement was increased to twice daily on 2/17/26. 3. Review of the facility policy titled Therapeutic Diets, dated as revised 10/2017, indicated but was not limited to: -Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. Resident #95 was admitted to the facility in August 2024 with diagnoses which included Parkinson's disease and congestive heart failure (CHF, a condition where the heart cannot pump blood effectively, leading to fluid buildup in the lungs, legs and other areas of the body). Review of the MDS assessment, dated 2/5/26, indicated Resident #95 scored 15 out of 15 on the BIMS, indicating he/she was cognitively intact. Further review of the MDS indicated he/she was 63 inches and weighed 178 pounds and had a weight gain of 5% or more in the last month or 10% or more in last 6 months while not on a physician-prescribed weight-gain regimen. Review of Resident #95's Physician's Orders indicated but were not limited to: -Heart healthy diet, regular texture, thin consistency with large portions for nutrition, 10/24/24 through 2/19/26 -Resolve malnutrition diagnosis, 11/5/25 During an interview on 2/17/26 at 12:36 P.M., the surveyor observed Resident #95 eating breakfast, his/her meal ticket indicated an alert for large portions. Resident #95 said they were trying to lose weight because they gained too much weight and were overweight. Resident #95 said they had recently spoken with the dietitian and requested regular portion sizes at meals, but he/she continued to receive large portions for all meals. Review of Resident #95's Weight Summary indicated his/her weights had been steadily increasing: -2/1/26: 185.5 lbs. -1/5/26: 179.4 lbs. -12/5/25: 177.4 lbs. -11/2/25: 177.4 lbs. -10/3/25: 179.4 lbs. -9/3/25: 177 lbs. -8/525: 174.2 lbs. -7/2/25: 168 lbs. -6/2/25: 161 lbs. -5/7/25: 158 lbs. -4/2/25: 153.8 lbs. -3/3/25: 150.2 lbs. -2/7/25: 136.8 lbs. -1/2/25: 134 lbs. -12/4/24: 132 lbs. -11/4/24: 132 lbs. -10/1/24: 120.3 lbs. -9/5/24: 118.6 lbs. -8/12/24: 112.6 lbs. Review of the Quarterly Nutrition Note, dated 2/13/26, indicated but was not limited to:-Resident #95 continued a heart healthy, regular texture, thin liquids diet with large portions. -Resident #95 consumed approximately 75% of most of their meals. -Resident #95's current weight was approximately 150% of his/her ideal body weight and his/her body mass index (BMI, a measure of a person's body fat based on their height and weight, used as a tool for assessing body weight) was 32.9 indicating he/she was obese. -Discussed weight gain trend with Resident who agreed to discontinue the large portions to help promote weight maintenance and weight loss. -Recommendations to discontinue large portions. On the following dates and times, the surveyor observed Resident #95 with their meal, large portions on their tray, and a meal ticket on their tray indicating large portions had been served: -2/18/26 at 8:04 A.M., 11:53 A.M., and 4:55 P.M. -2/19/26 at 7:57 A.M. During an interview on 2/18/26 at 8:04 A.M., Resident #95 said he/she wanted to lose weight, but the facility continued to send him/her too much food. During an interview on 2/19/26 at 8:25 A.M., Certified Nursing Assistant #1 said Resident #95 was trying to lose weight and was trying to eat less of his/her meals. During an interview on 2/19/26 at 8:27 A.M., Nurse #4 said Resident #95 had a great appetite and enjoyed snacks. Nurse #4 said she was unaware if Resident #95 had gained weight. Nurse #4 said Resident #95 had a history of CHF but he/she did not have swelling or symptoms indicating weight gain would be related to CHF. During an interview on 2/19/26 at 8:32 A.M. Nurse Practitioner #1 said she was not aware of Resident #95's weight gain and was not aware that he/she wished to lose weight. Nurse Practitioner #1 said she was not aware of the Dietitian's recommendations to discontinue the large portions. During an interview on 2/19/26 at 8:35 A.M., the Assistant Director of Nurses (ADON) said when the Dietitian made recommendations they were electronically sent to the management team, and she was not aware of any recent recommendations for Resident #95. During an interview on 2/19/26 at 8:54 A.M., the Dietitian said Resident #95 came into the facility under his/her ideal body weight and their goal weight was 150 pounds. The Dietitian said since admission Resident #95 had gained a significant amount of weight, past their goal of 150 pounds and had been receiving large portions. The Dietitian said on 2/13/26 Resident #95 was seen by another dietitian who addressed their weight gain and their desire to lose weight and made a recommendation to discontinue the large portions. The Dietitian said electronic communication was sent to the nursing leadership team that day. During an interview on 2/19/26 at 3:48 P.M., the DON said Resident #95's dietary recommendation to discontinue large portions was not completed timely.

Based on review of Resident Council Minutes, a resident group meeting, interviews, and record reviews, the facility failed to ensure grievances brought forward from the Resident Council were addressed and promptly resolved to ensure the residents felt their concerns were acted upon timely and included the facility response to the group.Findings include:Review of the facility's policy titled Resident Council, dated 2001, indicated but was not limited to the following:-The purpose of the Resident Council is to provide a forum for: a. Residents to have input in the operation of the facility; b. Discussion of concerns and suggestions for improvement; c. Consensus building and communication between residents and facility staff; and d. Disseminating information and gathering feedback from interested residents.-A Resident Council Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the item(s) of concern.-The Quality Assurance and Performance Improvement (QAPI) committee will review information and feedback from the resident council as part of their quality review. Issues documented on council response forms may be referred to the QAPI committee, if applicable (i.e., the issue is serious in nature or if there is a pattern, etc.)Review of Resident Council minutes provided by the facility, from September 2025 to February 2026, indicated resident complaints as follows: -9/10/25: There was no follow up to complaints raised during the August meeting (staff not speaking English, agency staff talking loud in hallways) to indicate the complaints were address or resolved. Residents complained about agency staff do not always wear name badges on the 3:00 P.M. to 11:00 P.M. shift on the [NAME] unit.-10/8/25: There was no follow up to the complaints raised during the August and September meetings to indicate the complaints were addressed or resolved. Residents complained again about staff talking loudly in the hallways on the [NAME] unit at 2:00 A.M.-11/12/25: There was no follow up to the complaints raised during the August, September and October meetings to indicate the complaints were addressed or resolved. One resident complained that staff on the 3:00 P.M. to 11:00 P.M. shift are slow to respond to call lights; 11:00 P.M. to 7:00 A.M. shift staff do not turn off lights in the hallway, staff name badges are missing on all three shifts on the [NAME] unit, 3:00 P.M. to 11:00 P.M shift staff who pass out the evening meal do not wear badges, they cough on uncovered plates and the meatballs are terrible tasting and gray.-12/10/25: There was no follow up to the complaints raised during the August through November meetings to indicate if any of the complaints were addressed or resolved. One resident complained that new agency nurses don't introduce themselves when giving medication and one resident complained that staff do not knock before entering his/her room.-1/21/26: There was no follow up to the complaints raised during the August through December meetings to indicate if any of the complaints were addressed or resolved. Residents complained that staff are talking loudly outside their doors on the 3:00 P.M. to 11:00 P.M. and 11:00 P.M. and 7:00 A.M. shifts.-2/11/26: There was no follow up to the complaints raised during the August through January meetings to indicate if any of the complaints were addressed or resolved. Residents said the complaint of staff not speaking English continue and agency staff not wearing name badges continues on the 3:00 P.M. to 11:00 P.M. shift on the [NAME] unit.Review of the Grievance book failed to indicate any complaints voiced by residents during the August 2025 through February 2026 Resident Council meetings were documented, addressed, acted upon or any follow-up was conducted.During a group meeting held on 2/18/26 at 1:45 P.M., the 12 residents in attendance shared the following information with the surveyors:-The residents said the temperature of the food is cold/lukewarm; the coffee is terrible and cold/lukewarm.-Complaints brought up during the Resident Council meetings are not addressed.-Ongoing concerns include staff not speaking English while providing care and/or in their presence, staff speaking loudly outside of their rooms on the 11:00 P.M. - 7:00 A.M. shift waking them up, agency staff not wearing name badges and refusing to put them on when asked by residents. -The residents said there has been no follow-up to most of the complaints brought up during their monthly meetings and that is frustrating.During an interview on 2/18/26 at 1:10 P.M., the Activity Director (AD) said she facilitates the monthly Resident Council meeting and documents the minutes. She said that some of the same issues are brought up by the residents month after month. The AD said when residents identify an issue during Resident Council, she brings it up during the morning meeting the next day and will follow up with an email to the appropriate department head. She said often when she brings the concerns forward during morning meeting, the department head will tell her that it is an old issue that was addressed weeks ago. The AD said that often, the residents talk about complaints during the council meetings because they like to have the floor and it is just gossip. She said she does not use a Resident Council Response Form or a grievance form for any complaints voiced during the Resident Council meetings and never has. She said she uses these forms for maintenance issues and missing items only.During an interview with the Administrator and Assistant Administrator on 2/19/26 at 3:00 P.M., the Administrator said she is the Grievance Officer, and it is her expectation that the AD would complete a Resident Council Response Form for issues brought forward during Resident Council meetings and provide it to the appropriate department head to address. The Administrator said she was not aware of any recent staff education related to any of the issues brought forward by the Resident Council, but the Director of Nursing (DON) may have some information.During an interview on 2/19/26 at 3:10 P.M., the DON said she is not aware of any issues, complaints or education provided to staff in response to complaints brought forward from the Resident Council recently. During an interview on 2/19/26 at 3:27 P.M., the Administrator and Assistant Administrator said they were unable to provide evidence of any education provided to staff, follow up or attempts to resolve the ongoing complaints brought forward during Resident Council meetings from August 2025 through February 2026.

Based on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards for five Residents (#81, #108, #12, #136 and #132), out of a total sample of 33 residents. Specifically, the facility failed:1. For Residents #81 and #108, to implement physician's orders for air mattress settings;2. For Residents #12 and #136, to implement physician's orders for oxygen; and 3. For Resident #132, to ensure physician's orders were in place upon admission for a continuous positive airway pressure (CPAP) machine (uses air pressure to hold the airway open while sleeping). Findings include:Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following:-The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice.Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated:-Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error.-In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber.1A. Resident #81 was admitted to the facility in November 2024 with diagnoses including hemiplegia (one-sided paralysis or weakness) and hemiparesis (one-sided muscle weakness) following cerebral infarction (type of stroke caused by a blood clot in the brain) and scoliosis (side-to-side curvature of the spine). Review of Resident #81's Minimum Data Set (MDS) assessment, dated 1/22/26, indicated the Resident was cognitively intact, as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Further review of the MDS assessment indicated the Resident was at risk for developing pressure ulcers and had a pressure-reducing device for his/her bed. Review of Resident #81's Physician's Orders indicated, but was not limited to, the following:-Air Mattress to bed at all times. (Weight Range Setting: 200-220 pounds (lbs.)). Check setting and function every shift, for skin integrity (12/27/25) The surveyor made the following observations of Resident #81 lying in bed: -On 2/17/26 at 9:10 A.M., his/her air mattress was on and set to 490 lbs. -On 2/17/26 at 11:59 A.M., his/her air mattress was on and set to 490 lbs. -On 12/18/25 at 8:19 A.M., his/her air mattress was on and set to 490 lbs. Review of the February 2026 Treatment Administration Records (TAR) indicated nursing documented that Resident #81's air mattress was in place, functioning and set according to between 200 – 220 lbs. on the dates and times of the surveyor's observations of it set to 490 lbs. B. Resident #108 was admitted to the facility in December 2025 and had diagnoses including catatonic disorder (a condition that affects how the brain controls the body) and Alzheimer's dementia. Review of Resident #108's MDS assessment, dated 1/31/26, indicated the Resident had severely impaired cognitive skills for daily decision making, was at risk for developing pressure ulcers and had a pressure reducing device for his/her bed. Review of Resident #108's Physician's Orders indicated, but was not limited to, the following:- Air Mattress to bed at all times. Weight Range Setting:120-140 lbs. Check setting and function every shift, every shift for skin integrity (1/27/26) The surveyor made the following observations of Resident #108 lying in bed: -On 2/17/26 at 9:08 A.M., his/her air mattress was on and set to 220 lbs. -On 2/17/26 at 11:58 A.M., his/her air mattress was on and set to 220 lbs. -On 2/18/26 at 8:19 A.M., his/her air mattress was on and set to 220 lbs. Review of the February 2026 TAR indicated nursing documented that Resident #108's air mattress was in place, functioning and set according to between 120 – 140 lbs. on the dates and times of the surveyor's observations of it set to 220 lbs. During an interview on 2/18/26 at 8:30 A.M., Unit Manager (UM) #2 reviewed Resident #108 and #81's medical record and said the physician's order for Resident #108's air mattress indicates it should be set between 200 – 220 lbs. to maintain the Resident's skin integrity and for Resident #81's air mattress should be set between 120 – 140 lbs. to maintain skin integrity. UM #2 and the surveyor observed Residents #108 and #81 lying asleep in bed with their air mattresses inflated and set to 490 lbs. and 220 lbs. respectively. UM #2 said the air mattresses are not set correctly. She said nursing is responsible for verifying the air mattress is set correctly and document it on the TAR. She said if an air mattress is not set correctly, it could lead to skin breakdown. During an interview with Nurse #7 and UM #2 on 2/18/26 at 8:34 A.M., Nurse #7 said both Residents #108 and #81 are on her assignment. She said she verifies the air mattress is on and functioning before documenting on the TAR but does not verify the air mattress setting is accurate according to physician's orders. During an interview on 2/18/26 at 2:40 P.M., the Director of Nursing (DON) said nursing staff are to set air mattresses according to the physician's order, verify the functioning and accuracy of the settings, and document it in the medical record. 2. Review of the facility's policy titled Oxygen Administration, dated October 2010, indicated but was not limited to the following: - The purpose of this procedure is to provide guidelines for safe oxygen administration. - Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. A. Resident #12 was admitted to the facility in November 2024 with diagnoses including chronic respiratory failure and chronic obstructive pulmonary disease (COPD). Review of Resident #12's MDS assessment indicated he/she was severely cognitively impaired as evidenced by a BIMS score of 7 out of 15. Furthermore, the MDS assessment indicated he/she required oxygen therapy and assistance for activities of daily living. Review of Resident #12's Physician's Orders indicated but were not limited to the following: - 11/5/24: Oxygen 3 liters (L) per minute via nasal cannula (NC) every shift for chronic respiratory failure with hypoxia (insufficient oxygen reaching the body). On the following dates and times, the surveyor observed Resident #12 with his/her oxygen on via NC and his/her oxygen concentrator set to 2.5 L per minute: - 2/17/26 at 9:55 A.M., 1:08 P.M., and 4:33 P.M. - 2/18/26 at 8:14 A.M. Review of Resident #12's February 2026 TAR indicated his/her Oxygen was checked every shift by nursing and set to 3 L per minute. During an interview on 2/18/26 at 8:51 A.M., Nurse #1 said Resident #12 was on oxygen therapy and his/her orders were for 3 L per minute. Nurse #1 said oxygen monitoring including checking oxygen concentrators for accurate settings was completed by nursing staff each shift. Nurse #1 and the surveyor assessed Resident #12's oxygen concentrator. Nurse #1 said the oxygen concentrator was set to 2.5 L and should be at 3 L and adjusted the settings. During an interview on 2/18/26 at 9:19 A.M., the DON said nursing assesses residents utilizing oxygen therapy throughout the day. The DON said concentrators are checked for proper settings by nursing staff throughout the shift to ensure they match physician's orders. The DON said the oxygen settings should match the physician's orders. B. Resident #136 was admitted to the facility in January 2026 with diagnoses including chronic respiratory failure and COPD. Review of Resident #136's MDS assessment indicated he/she was moderately cognitively impaired as evidenced by a BIMS score of 12 out of 15. Furthermore, the MDS assessment indicated he/she required oxygen therapy and assistance for activities of daily living. Review of Resident #136's Physician's Orders indicated but were not limited to the following: - 1/30/26: Oxygen at 1-2 L per minute via NC continuous, every shift. On the following dates and times, the surveyor observed Resident #136's with oxygen on via NC and his/her oxygen concentrator set to 3 L per minute: - 2/17/26 at 9:34 A.M., and 4:33 P.M. - 2/18/26 at 8:15 A.M. Review of Resident #136's February 2026 TAR indicated his/her oxygen was checked every shift by nursing and set to 1-2 L per minute. During an interview on 2/18/26 at 8:51 A.M., Nurse #1 said Resident #136 was on oxygen therapy and his/her orders were for 1-2 L per minute. Nurse #1 said oxygen monitoring, including checking oxygen concentrators for accurate settings, was completed by nursing staff each shift. Nurse #1 and the surveyor assessed Resident #136's oxygen concentrator. Nurse #1 said the oxygen concentrator was set to 3 L and should be at 2 L and adjusted the settings. During an interview on 2/18/26 at 9:19 A.M., the DON said nursing assesses residents utilizing oxygen therapy throughout the day. The DON said concentrators are checked for proper settings by nursing staff throughout the shift to ensure they match physician's orders. The DON said the oxygen settings should match the physician's orders. 3. Review of the facility's policy titled CPAP/BiPAP Support, dated March 2015, indicated but was not limited to the following: -To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen -To improve arterial oxygenation (PaO2) in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease -To promote resident comfort and safety -Document the following in the resident's medical record: -General assessment (including vital signs, oxygen saturation, respiratory, circulatory and gastrointestinal status) prior to the procedure; -Time CPAP was started and duration of therapy -Mode and settings for the CPAP -Oxygen concentration and flow, if used; -How the resident tolerated the procedure; and -Oxygen saturation during therapy. -Reporting: notify the physician if the resident refuses the procedure, experiences any adverse consequences, including (but not limited to) respiratory distress and marked change in vital signs. Resident #132 was admitted to the facility in January 2026 with diagnoses including obstructive sleep apnea. Review of Resident #132's MDS assessment, dated 1/20/26, indicated he/she was cognitively intact as evidenced by a BIMS score of 15 out of 15. Furthermore, the MDS assessment indicated Resident #132 had obstructive sleep apnea. On the following dates/times, the surveyor observed Resident #132's CPAP machine on their bedside table in his/her room: - 2/17/26 at 10:10 A.M. - 2/19/26 at 1:54 P.M. During an interview on 2/19/26 at 2:32 P.M., Resident #132's family member, with Resident #132 present, said the CPAP machine was provided on the first day of admission. Resident's family member said the nursing staff were aware of the CPAP machine and that the Resident would need nightly assistance. Review of Resident #132's Physician's Orders failed to indicate orders for Resident #132's use and maintenance of the CPAP machine, nor did the orders indicate monitoring Resident #132's respiratory status during CPAP therapy. Review of Resident #132's TAR failed to indicate the staff was monitoring during Resident #132's use of the CPAP machine. During an interview on 2/19/26 at 2:38 P.M., the surveyor, with Nurse #10 present, observed Resident #132's CPAP machine at the bedside and reviewed Resident #132's medical record. Nurse #10 said Resident #132 has a diagnosis of obstructive sleep apnea but does not have orders in place for the CPAP machine and there should have been orders in place. During an interview on 2/19/26 at 3:16 P.M., Physician #3 said with a diagnosis of obstructive sleep apnea, Resident #132 should have had orders in place on admission for the CPAP machine at hours of sleep. Physician #3 said he would have expected to be notified at the time of admission to put the orders in place. During an interview on 2/19/26 at 4:40 P.M., the DON said Resident #132 has a diagnosis of obstructive sleep apnea, however, did not have orders in place for the CPAP machine. The DON said she does not know how they missed it and orders should have been in place for the CPAP machine.

Based on record review and interview, the facility failed to ensure physician visits were completed as required for three Residents (#6, #13 and #7), out of a total of 33 sampled residents. Findings include: Review of the facility's policy titled Physician Services, revised 2/2021, indicated, but was not limited to, the following:-Physician orders and progress notes are maintained in accordance with current OBRA regulations and facility policy.-Physician visits, frequency of visits, emergency care of residents, etc., are provided in accordance with current OBRA regulations and facility policy. 1. Resident #6 was admitted to the facility in July 2024 and had diagnoses including polymyalgia rheumatica, congestive heart failure, major depression and anxiety. Review of the Minimum Data Set (MDS) Assessment, dated 2/8/26, indicated Resident #6 was cognitively intact evidenced by a score of 14 out of 15 on the Brief interview for Mental Status Exam (BIMS) and had limited range of motion in both upper and lower extremities. Review of Resident #6's clinical record indicated that between December 2024 and February 2026, the Resident had been seen by the Physician on two occasions, 12/24/24 and 12/17/25, for a span of 12 months between Physician visits. 2. Resident #13 was admitted to the facility in October 2023 and had diagnoses including heart failure, hypertension, dementia, anxiety and depression. Review of the MDS assessment, dated 1/13/26, indicated Resident #13 had moderately impaired skills for daily decision making and was dependent on staff for all activities of daily living. Review of Resident #13's clinical record indicated that between December 2024 and February 2026, the Resident had been seen by the Physician on two occasions, 12/24/24 and 5/17/25 for a span of five months between these two visits and a span of nine months between the last visit on 5/17/25 and 2/20/26. 3. Resident #7 was admitted to the facility in July 2025 with diagnoses including diabetes and heart failure. Review of Resident #7's MDS assessment, dated 11/6/25, indicated the Resident was cognitively intact, as evidenced by a BIMS score of 15 out of 15 and required assistance from staff for activities of daily living. Review of Resident #7's Physician's Progress notes indicated he/she had not been seen by a physician since 9/9/25. All subsequent visits after 9/9/25 were conducted by the nurse practitioner. Telephone calls made to Resident #6, #7 and #13's Physician (Physician #2) were unsuccessful. During a telephonic interview on 2/20/26 at 9:46 A.M., the Medical Director said it is his expectation that Physicians make visits to their residents every 30 to 60 days alternating with the Nurse Practitioner or more frequently depending on the resident's needs. He said it is unacceptable that Physician #2 has not made the required visits to Residents #6, #7 and #13. During an interview on 2/20/26 at 7:58 A.M., the Director of Nursing said following the first 90 days after a resident is admitted to the facility, the Physician would then be expected to see the resident every 60 days for long term residents.

Based on observations, test tray results, and interviews, the facility failed to serve food that was palatable, and at a safe and appetizing temperature, for two of two test trays on two different units. Findings include: During the initial tour of the facility on 2/17/26, the surveyors received multiple food complaints from the residents on four out of five units. Their major concerns were related to cold food temperatures and the taste of the food served. During the Resident Council Meeting on 2/18/26 at 1:45 P.M., 14 residents attended the meeting and complained about the food. They described the food as horrible, the cold beverages were warm when served and the hot foods were not always served hot.On 2/19/26 at 7:40 A.M., the surveyor observed the breakfast tray line. The [NAME] Unit food truck left the kitchen at 7:43 A.M. and arrived at the unit at 7:45 A.M. Nursing staff began passing trays at 7:53 A.M. and the last tray was passed at 7:58 A.M., 15 minutes after the trays arrived on the Unit. On 2/19/26 at 7:59 A.M., the surveyor conducted a test tray with Nurse #4 present. Food temperatures were recorded in degrees Fahrenheit (F) with the following results:-Egg Casserole- 111.8 F, lukewarm, no flavor-Toast- 93.6 F, cold and soggy-Hot Cereal- 123.8 F, lukewarm, no flavorNurse #4 declined tasting the food items on the tray. On 2/19/26 at 7:52 A.M., the [NAME] Unit food truck left the kitchen and arrived at the Unit at 7:54 A.M. Nursing staff began passing trays at 7:55 A.M. and the last tray was passed at 8:03 A.M., 13 minutes after the trays arrived on the Unit.On 2/19/26 at 8:05 A.M., the surveyor conducted a test tray with the Food Service Director (FSD) with the following results: -Fortified Cream of Wheat- 124 F, not palatable -Oatmeal- 145 F, not palatable-Muffin- cold to taste, not palatable-Coffee- 118.6 F, cold to taste-Orange Juice- 46.0 F, warm to taste During an interview on 2/19/26 at 8:05 A.M., while completing the test tray, the FSD said the hot cereals should be hotter. He said the dietary staff pre-pour a whole rack of oatmeal and cream of wheat portions when doing the tray line, and that is why it gets cold. The FSD said the muffins are always served at room temperature. The FSD said the coffee should be warmer and will need to watch if the staff is pre-pouring too many cups in advance. The FSD said the staff put the orange juice in the freezer prior to service for a little bit of time to make it cold but take it out so it doesn't build up ice. The orange juice should be colder. During an interview on 2/19/26 at 1:30 P.M., the FSD said the results of the test trays validated the residents' concerns.

Based on observation, interview, and record review, the facility failed to ensure one Resident (#185), out of a total sample of 33 residents, was treated with respect and dignity. Specifically, the facility failed for Resident #185, to ensure a cholecystostomy tube drainage system (a drainage bag connected to a catheter inserted through the skin into the gallbladder to drain bile, or infected fluid) was consistently covered with a privacy cover. Findings Include:Review of the facility's policy titled Dignity, dated February 2021, indicated but was not limited to:-Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem-Residents are treated with dignity and respect at all times-Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: helping the resident keep urinary catheter bags covered.Resident #185 was admitted to the facility in February 2026 and had diagnoses including sepsis due to E.coli (life-threatening emergency related to the bodies dysfunctional response to an infection), obstruction of bile duct (blockage in the tubes that carry bile from the liver and gallbladder to the small intestines), and calculus of gallbladder with acute cholecystitis with obstruction (occurs when a gallstone [calculus] becomes trapped in the cystic duct [tube which bile travels in and out of the gallbladder] causing obstruction).Review of the Minimum Data Set (MDS) assessment, dated 2/16/26 (in process), indicated Resident #185 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and had obstruction of bile duct, and calculus of gallbladder with acute cholecystitis with obstruction.Review of the Physician's Orders indicated but was not limited to:-Drain right lower quadrant gastrostomy tube every shift (2/10/26)On 2/17/26 at 10:40 A.M., the surveyor observed Resident #185 sitting in a wheelchair in his/her room visiting with family members. A cholecystostomy drainage bag was observed on Resident #185's right side. The drainage bag was visible as the surveyor entered the room, contained clear/yellow drainage, and was not covered by a privacy bag.On 2/18/26 at 12:51 P.M., the surveyor observed Resident #185 sitting upright in bed visiting with his/her family member. A cholecystostomy drainage bag was observed on the Resident's right side with clear yellow drainage in the drainage bag and was not covered by a privacy cover.During an interview on 2/17/26 at 10:41 A.M., Resident #185's family member, with Resident #185 present, said the drainage bag has been without a privacy cover since admission. Resident #185 and the family member said they felt as though the drainage bag should have been covered for dignity. During an interview on 2/19/26 at 4:23 P.M., Certified Nursing Assistant (CNA) #2 said Resident #185 should have had a privacy cover on the drainage bag and forgot to put one on it.During an interview on 2/19/26 at 4:11 P.M., Nurse #8 said Resident #185 should have had a privacy cover covering the cholecystostomy drainage bag and he/she did not have one.During an interview on 2/20/26 at 8:49 A.M., the Director of Nursing (DON) said Resident #185 should have had a privacy cover on his/her cholecystostomy drainage bag for dignity.

Based on observation, interview, and record review, the facility failed to develop, implement, and individualize a comprehensive care plan for one Resident (#132), out of a total sample of 33 residents. Specifically, the facility failed to ensure a comprehensive care plan related to Resident #132's obstructive sleep apnea (where throat muscles relax and block the airway) with use of a continuous positive airway pressure (CPAP) machine (uses air pressure to hold the airway open) was developed and implemented. Findings include:Review of the facility's policy titled CPAP/BiPAP Support, dated March 2015, indicated but was not limited to the following:-To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen-To improve arterial oxygenation (PaO2) in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease-To promote resident comfort and safetyResident #132 was admitted to the facility in January 2026 with diagnoses including obstructive sleep apnea.Review of Resident #132's Minimum Data Set (MDS) assessment, dated 1/20/26, indicated he/she was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Furthermore, the MDS assessment indicated Resident #132 had obstructive sleep apnea and he/she was an assist with self-care needs.On the following dates/times, the surveyor observed Resident #132's CPAP machine on their bedside table in his/her room:- 2/17/26 at 10:10 A.M., and- 2/19/26 at 1:54 P.M.Review of Resident #132's comprehensive care plans failed to indicate an altered respiratory status of obstructive sleep apnea was developed or implemented to include CPAP interventions.During an interview on 2/17/26 at 10:10 A.M., Resident #132 said sometimes the staff assist putting the mask on him/her at bedtime, but sometimes he/she forgets to ask for help. Resident #132 said since admission he/she has not been using the machine consistently.During an interview on 2/19/26 at 1:54 P.M., Resident #132 said he/she did not use the CPAP machine last night, saying he/she forgot to ask for help again. Resident said his/her spouse usually provides help and always reminds him/her to use the machine at bedtime.During an interview on 2/19/26 at 2:32 P.M., Resident #132's Family Member, with Resident #132 present, said the CPAP machine was provided on the first day of admission and nursing staff were notified that the Resident would need nightly assistance. During an interview on 2/19/26 at 2:38 P.M., the surveyor, with Nurse #10 present, observed Resident #132's CPAP machine at the bedside and reviewed Resident #132's medical record. Nurse #10 said Resident #132 has a diagnosis of obstructive sleep apnea but does not have a care plan in place and there should have been one in place. During an interview on 2/19/26 at 3:16 P.M., Physician #3 said he would have expected Resident #132 to have a care plan in place for the obstructive sleep apnea, and it should have been in place to include the CPAP machine.During an interview on 2/19/26 at 4:40 P.M., the Director of Nursing (DON) said Resident #132 did not have a care plan in place for obstructive sleep apnea to include the CPAP machine and there should have been one in place. The DON said she does not know how they missed it, but they did.

Based on observations, record review, and interviews, the facility failed to provide care and services consistent with professional standards of practice for one Resident (#50) who required renal dialysis (a life sustaining treatment that helps the body remove extra fluids and waste products from the blood when the kidneys are not able to), out of a total sample of 33 residents. Specifically, the facility failed to ensure emergency supplies were kept with the Resident in accordance with the plan of care and the physician's orders in case of emergency.Findings include: Review of the facility's policy titled Hemodialysis Catheters - Access and Care of, dated as revised 2/2023, indicated, but was not limited to, the following:-Hemodialysis catheters are surgically placed in the jugular, subclavian, or femoral veins and end in the vena cava. Removal of the catheter is a surgical procedure.-Dialysis catheters should be marked for dialysis use only so they are not confused with central venous access devices.Review of the American Journal of Kidney Diseases article titled Hemodialysis Emergencies: Core Curriculum 2021, published 3/23/21, indicated, but was not limited to, the following:-Vascular access hemorrhage is a rare but life-threatening complication of HD (hemodialysis) access. -Clinical presentation of vascular access hemorrhage includes rapid blood loss and exsanguination.-Vascular access hemorrhage should be managed by applying direct continuous pressure to the site until emergency medical personnel arrive. Resident #50 was admitted to the facility in September 2025 with diagnoses including end stage renal disease and dependence of dialysis. Review of the Minimum Data Set (MDS) assessment, dated 12/18/25, indicated that Resident #50 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status exam score of 11 out of 15. Further review of the MDS assessment indicated Resident #50 required dialysis. Review of Resident #50's plan of care indicated, but was not limited to, the following:Focus: The resident is receiving dialysis through right internal jugular central catheterInterventions: Ensure that resident has [NAME] clamp (a tool used to clamp blood vessels to control bleeding), gauze and tape at bedsideReview of Resident #50's Physician's Orders indicated, but was not limited to, the following:-Ensure that resident has [NAME] clamp, gauze and tape at bedside every shift for maintenance. If bleeding noted, apply pressure and notify practitioner as per orders (order date 9/25/25)On 2/17/26 at 8:29 A.M., the surveyor observed Resident #50's room and was unable to locate emergency supplies at the Resident's bedside.On 2/18/26 at 8:12 A.M., the surveyor observed Resident #50 in his/her room and there were no emergency supplies ([NAME] clamp, gauze, tape) at the bedside. On 2/18/26 at 11:58 A.M., Unit Manager #1 and the surveyor observed Resident #50 in his/her room. Unit Manager #1 attempted to locate the emergency supplies in Resident #50's room. Unit Manager #1 searched all over Resident #50's room; including behind the bed, on top of the nightstand and in the nightstand and dresser drawers; but was unsuccessful in locating any emergency supplies. Unit Manager #1 said emergency supplies should always be at the Resident's bedside in case of emergency.

Based on record review and interview, the facility failed to maintain medical records in accordance with accepted professional standards and practices that are complete and readily accessible for facility staff for three Residents (#6, #13 and #16), out of a total sample of 33 residents. Specifically, for Residents #6, #13 and #16, the facility failed to ensure the Physician's progress notes were available in the Residents' medical record.Findings include:1. Resident #6 was admitted to the facility in July 2024 and had diagnoses including polymyalgia rheumatica, congestive heart failure, major depression, and anxiety. Review of the Minimum Data Set (MDS) assessment, dated 2/8/26, indicated Resident #6 was cognitively intact as evidenced by a score of 14 out of 15 on the Brief Interview for Mental Status Exam (BIMS) and had limited range of motion in both upper and lower extremities. Review of Resident #6's entire medical record indicated that the Physician examined the Resident on 12/27/24 and 12/17/25. Further review of the medical record failed to indicate any documentation that the Physician visited Resident #6 between 12/27/24 and 12/17/25.2. Resident #13 was admitted to the facility in October 2023 and had diagnoses including dementia, depression, anxiety, and atrial fibrillation (irregular heart rhythm).Review of the MDS assessment, dated 1/13/26, indicated Resident #13 had moderately impaired skills for daily decision making and was dependent on staff for all activities of daily living. Review of the entire medical record indicated that the Physician examined the Resident on 12/24/24 and 5/17/25.Further review of the medical record failed to indicate any documentation that the Physician visited Resident #13 any other time between 12/27/24 and 5/17/25 and 5/17/25 to 2/20/26.3. Resident #16 was admitted to the facility in July 2025 and had diagnoses including a history of falls, schizoaffective disorder, and coronary artery disease.Review of the MDS assessment, dated 2/13/26, indicated Resident #16 had severe cognitive impairment as evidenced by a score of 5 out of 15 on the BIMS and required assistance with all activities of daily living.Review of the entire medical record indicated that the Physician examined the Resident on 7/18/25.Further review of the medical record failed to indicate any documentation that the Physician visited Resident #16 any other time between 7/18/25 and 2/20/26.During an interview on 2/19/26 at 9:39 A.M., Unit Manager #2 reviewed Residents #6, #13 and #16's entire medical record and said there were no additional Physician progress notes in their records, but there may be some notes still in her email that have not been printed out or scanned into the medical record yet.During an interview on 2/19/26 at 1:48 P.M., Unit Manager #2 provided the surveyor with Physician progress notes for Residents #6 (dated 2/25/25, 3/4/25 and 5/27/25), #13 (dated 3/4/25 and 5/27/25) and #16 (dated 7/22/25, 9/16/25 and 1/27/26). She said she found the Physician progress notes in her email, and they had not been printed out and scanned into the medical record.

Based on record review and interview, the facility failed to ensure three Residents (#74, #117, and #155) were offered or provided a summary of their baseline care plans, out of a total sample of 33 residents. Findings include: Review of the facility's policy titled Care Plans - Baseline, dated as last revised March 2022, indicated but was not limited to the following: -A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission. -A comprehensive care plan may be used in place of the baseline care plan providing the comprehensive care plan is developed within 48 hours of the resident's admission and meets the requirements of a comprehensive assessment. -The resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) that includes, but is not limited to the following: the stated goals and objectives of the resident, a summary of the resident's medications and dietary instructions, any services and treatments to be administered by the facility and personnel acting on behalf of the facility, and any updated information based on the details of the comprehensive care plan, as necessary. -Provision of the summary to resident and/or the resident representative is documented in the medical record. a. Resident #74 was admitted to the facility in March 2024 with diagnoses including encounter for surgical aftercare following surgery and diabetes mellitus. Review of the Minimum Data Set (MDS) assessment, dated 9/19/24, indicated Resident #74 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. Review of the Comprehensive Care Plan indicated it had been developed upon admission. Review of the medical record including assessments, nursing and social service progress notes, and scanned documents failed to indicate the baseline care plan had been provided to the Resident. During an interview on 12/19/24 at 12:30 P.M., Resident #74 said he/she never had a care plan meeting after admission, and he/she was never provided a copy of the baseline care plan. b. Resident #117 was admitted to the facility in November 2023 with diagnoses including Chronic Obstructive Pulmonary Disease, diabetes with foot ulcer, and dementia. Review of the MDS assessment, dated 10/17/24, indicated Resident #117 scored 11 out of 15 on the BIMS indicating he/she had mild cognitive impairment. Review of the Comprehensive Care Plan indicated it had been developed upon admission. Review of the medical record including assessments, nursing and social service progress notes, and scanned documents failed to indicate the baseline care plan had been provided to the Resident. During an interview on 12/19/24 at 12:39 P.M., Resident #117 said he/she did not recall if there was a meeting or if the care plan was provided. c. Resident #155 was admitted to the facility in September 2024 with diagnoses including encounter osteoporosis, scoliosis, and encounter for surgical aftercare following surgery on the nervous system. Review of the MDS assessment, dated 9/11/24, indicated Resident #155 scored 13 out of 15 on the BIMS indicating he/she was cognitively intact. Review of the Comprehensive Care Plan indicated it has been developed upon admission. Review of the medical record including assessments, nursing and social service progress notes, and scanned documents failed to indicate the baseline care plan had been provided to the Resident. During an interview on 12/19/24 at 12:02 P.M., Resident #155 said he/she never had a care plan meeting after admission and never got or was offered a copy of their care plan. The Resident said he/she only had one meeting and it was a couple weeks ago for discharge planning. During an interview on 12/19/24 at 10:20 A.M., Unit Manager #4 said they usually have care plan meetings and provide the care plan to the resident and then the social worker writes a note indicating the meeting had occurred. During an interview on 12/19/24 at 10:30 A.M., Social Worker #3 said she has only been here a few months and could not speak if these care plan meetings took place or if the resident was provided with a copy of the baseline care plan. She said they usually have the meeting on Mondays, Wednesdays, and Fridays and then would put a note in the medical record. During an interview on 12/19/24 at 10:35 A.M., the Director of Social Service said she was coordinating the meetings during the time frame these meetings should have occurred. She said the meetings are documented in the electronic medical record in a progress note. She said there is no assessment or paper document in the charts, the proof of the meeting would be the progress note. She said for Resident #74 she was unable to locate a note indicating the meeting had occurred and a copy of the baseline care plan had been provided. She said for Resident #155 the progress note dated 9/12/24 was a late entry for 9/6/24, but it was not a care plan meeting note, it was the initial social service interview note. She said there was not a progress note indicating the meeting had taken place or that the baseline care plan was provided to the resident. Additionally, she said for Resident #117 there was not a progress note indicating the meeting had occurred and a copy of the care plan was provided, but Social Worker #2 manages the meetings for that unit. During an interview on 12/19/24 at 11:17 A.M., Social Worker #2 said she uses a version of a care plan meeting form to log attendance and would locate the meeting document. During an interview on 12/19/14 at 1:18 P.M., Social Worker #2 provided the surveyor with a quarterly care plan meeting form from October 2024 (not the baseline care plan meeting) and said she did not do the initial care plan meeting for Resident #117 and was unable to locate any documentation of that meeting or if the baseline care plan was provided to the resident and/or family. During an interview on 12/19/24 at 12:52 P.M., the Director of Nurses said the baseline care plan is generated on admission and the team usually has the meeting 48-72 hours after admission on Mondays, Wednesdays, and Fridays. She said the meeting includes the resident and the health care proxy (HCP), if applicable, and after they review the plan of care, they are given a copy of the care plan if they want it. She said the meeting should be documented in the electronic medical record under progress notes. During an interview on 12/19/24 at 1:56 P.M., the Director of Social Service said the Social Worker that was doing the meetings at the time of Resident #117's admission is no longer employed and there was not a note indicating the meeting took place or that the HCP was provided a copy on the baseline care plan. She said at the time of admission Resident #117's HCP was invoked and the baseline care plan should have been provided to the HCP. Additionally, she said she did not have an audit system in place to ensure the meetings occurred, the baseline care plan was provided, and it was documented in the medical record and was unable to provide any documentation for Residents #74, #117, or #155 indicating the meetings had occurred and a copy of the baseline care plan was provided to the Resident and/or HCP.

Based on observation, record review, and interviews, the facility failed to provide services to ensure that proper treatment to maintain hearing ability was provided for one Resident (#115), out of a total sample of 33 residents. Specifically, the facility failed to notify the consultant provider to address Resident #115's non-functioning hearing aids for more than two months, resulting in a delay in the process of repairing them. Findings include: Review of the facility's policy titled Hearing Aid, Care of, last revised February 2018, indicated but was not limited to: -The purpose of this procedure is to maintain the resident's hearing at the highest attainable level. Care of the hearing aid: -Never clean or immerse any part of a hearing aid (other than the ear mold) in water. The device must be returned to the dealer or to an audiologist to be cleaned properly. Documentation: The following information should be recorded in the resident's medical record: -The date and time the hearing aid was checked and/or battery was replaced. -The name and title of the individual(s) who checked the hearing aid and changed the battery. -If the resident refused the procedure, the reason(s) why and the intervention taken. -The signature and title of the person recording the task. Reporting: -Notify the supervisor if hearing aid is damaged or needs to be sent to the dealer for cleaning. -Report other information in accordance with facility policy and professional standards of practice. Resident #115 was admitted to the facility in July 2022 and had diagnoses including diabetes mellitus. Review of the Minimum Data Set (MDS) assessment, dated 10/10/24, indicated Resident #115 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 7 out of 15, and had highly impaired ability to hear. Review of the medical record indicated a referral was made for the consultant Audiologist on 1/10/24 due to complaints of newly decreased hearing. Review of the medical record indicated the following documentation from the consultant Audiologist: -A hearing evaluation was performed for Resident #115 on 4/1/24. The progress note indicated clinical findings that Resident #115 had mild to severe hearing loss in both ears and the Audiologist recommended bilateral hearing aids. -An Audiology progress note, dated 4/15/24, indicated Resident #115 was provided bilateral hearing aids and a charger unit. The hearing aids fit well, and the Resident was noted to hear well with the hearing aids. On 12/17/24 at 8:30 A.M., the surveyor observed Resident #115 seated in a chair at the bedside. The Resident's spouse was sitting on the bed writing on a whiteboard with a pen. The spouse said that Resident #115's hearing aids stopped working a few months ago when the hospital mistakenly placed them in a denture cup with water, and now needs to write on the white board to communicate with him/her. The Resident's spouse said he/she has not worn the hearing aids since being in the hospital and wears wireless headphones while watching television to be able to hear the shows. The surveyor attempted to engage Resident #115 in conversation, and he/she kept pointing to his/her ears and shaking his/her head back and forth. Review of the medical record indicated Resident #115 was admitted to the hospital in September 2024 and was readmitted to the facility in October 2024. Review of Nursing Notes indicated but was not limited to: -10/4/24: Resident returned from the hospital with his/her hearing aids in a green denture cup with water. The hearing aids were removed from the water and attempts were made to dry them. -10/5/24: Resident's hearing aids are not turning on. -10/10/24: Unable to find hearing aids. -11/18/24: Hearing aids are waiting for repair; on the charger in the med room. -11/19/24: Hearing aids not working at this time; appropriate people made aware. Review of the medical record indicated the following Physician's order, initiated more than six weeks after staff identified Resident #115's hearing aids were not functioning: -Bilateral hearing aids stored in medication room-ON HOLD PENDING REPAIR (11/20/24) Further review of the medical record failed to indicate the supervisor or Audiologist/dealer was notified the hearing aids were not functioning to determine if the damaged devices needed to be sent to the dealer for cleaning or repair. During an interview on 12/17/24 at 8:37 A.M., Unit Manager #1 said Resident #115 returned from the hospital in October with his/her hearing aids in a denture cup submerged in water. She said they tried to dry out the hearing aids, but they still didn't work. She said the hearing aids are now kept in the medication room. She said she thinks the hearing aids are under warranty and said the Audiologist was in the process of replacing them. During a subsequent interview on 12/18/24 at 1:09 P.M., Unit Manager #1 reviewed Resident #115's medical record and said she could not find any evidence that she notified the Audiologist or dealer that Resident #115's hearing aids were not functioning. She said she called the Audiologist's office today and found out that the hearing aids may not be covered under the warranty. She said she was told the hearing aids need to be sent out to [NAME] for testing to determine if they can be repaired. She confirmed that the non-functioning hearing aids were not addressed until 12/18/24, more than six weeks after nursing documented the hearing aids were not functioning and following surveyor intervention. During an interview on 12/19/24 at 10:13 A.M., Social Worker #1 and Social Worker #2 said they were not aware that Resident #115's hearing aids were not functioning until recently. They said they have not been involved in any efforts to get them repaired. During an interview on 12/19/24 at 11:10 A.M., the Administrator said she thinks the Admissions Director called the hospital to see if they would pay to replace the broken hearing aids since they are responsible for what happened. She said she did not know anything else about the non-functioning hearing aids, but the Admissions Director would know. During an interview with the Admissions Director and Chief Operations Officer (COO) on 12/19/24 at 11:49 A.M., the Admissions Director said she did not make any calls to the hospital regarding Resident #115's hearing aids. She said the Regional Admissions Director called them, but she is away and unavailable for an interview. The COO said he did not know where to find any information about efforts made to have Resident #115's hearing aids repaired but would find out and inform the survey team. During an interview on 12/19/24 at 12:55 P.M., Resident Representative #1 (RR #1) said Resident #115 received new hearing aids in April of this year, and they worked really well. He said he was told that when Resident #115 returned from the hospital in October, the hearing aids were in a denture cup with water and did not work anymore. He said he last spoke with Unit Manager #1 about a month ago but hasn't heard any more about it. RR #1 said prior to getting the hearing aids, they had to write on a dry erase board to communicate with him/her and ever since the hearing aids have broken, he needs to use the whiteboard to communicate with him/her again. No further information regarding efforts to repair Resident #115's non-functioning hearing aids was provided to the survey team by the time of exit on 12/19/24.

Based on observation, interview, and record review, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles on four of four units. Specifically, the facility failed: 1. On the [NAME] Unit to date insulin pens with an open and discard date; 2. On the Sagamore Unit to date ophthalmic ointment with a discard date; 3. On the Pocasset Unit to maintain a medication cart free from loose pills; and 4. On the [NAME] Unit to date eye drops with an open and discard date. Findings include: Review of the facility's policy titled Storage of Medications, last revised November 2020, indicated but was not limited to: - Policy heading: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. - Policy Interpretation and Implementation: 3. The nursing staff is responsible for maintaining medication storage and preparation area clean, safe, and sanitary manner. 4. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Review of the facility's policy titled Miscellaneous Medications with shortened Expiration Dates Requiring Refrigeration, undated, indicated but was not limited to: - All medications will include an open/discard (expire) sticker affixed to the unit. - The date opened and date to discard (expire) will be documented on the sticker as referenced below per manufacturer specifications once the medication is opened and/or removed from the refrigerator. - It is the responsibility of the nurse opening and/or removing the medication from the refrigerator to document the date opened/date discard (expire) on the sticker affixed to the medication unit. - Latanoprost eye drops (Xalatan)- Expiration date (once opened): 42 days (6 weeks) once opened (refrigerator storage unopened, room temperature once opened) 1. On 12/17/24 at 11:18 A.M., the surveyor completed a review of the medication storage room on the [NAME] Unit with Nurse #6 and observed the following in the refrigerator: - Two Admelog (fast-acting insulin) pens, opened not marked with the opened/discard date. During an interview on 12/17/24 at 11:24 A.M., Nurse #6 said insulin pens should have been labeled with the date opened and the discard date. Nurse #6 said the two open insulin pens should not have been in the refrigerator but discarded because they belonged to a resident that had passed away. 2. On 12/17/24 at 1:00 P.M., the surveyor completed a review of the medication cart (Side 1) on the Sagamore Unit with Nurse #2 and made the following observations: - One Erythromycin (antibiotic) Ophthalmic Ointment tube, date opened 10/17/24 - One Erythromycin Ophthalmic Ointment tube, date opened 10/29/24 During an interview on 12/17/24 at 1:04 P.M., Nurse #2 said the two tubes of the Erythromycin were both prescribed for a limited time and should have been discarded after the antibiotics had been completed. 3. On 12/17/24 at 1:09 P.M., the surveyor completed a review of the medication cart (South Side) on the Pocasset Unit with Nurse #9 and made the following observations: - Second drawer of the medication cart with multiple loose pills During an interview on 12/17/24 at 1:16 P.M., Nurse #9 said medication carts should not contain loose pills and medication carts should be kept clean. During an interview on 12/17/24 at 1:39 P.M., Unit Manager (UM) #4 said medication carts should be kept clean and free of loose medications. UM #4 said the expectation was if a pill fell into the drawer, it would be discarded immediately. 4. On 12/17/24 at 1:39 P.M., the surveyor completed a review of the medication cart (Side 1) on the [NAME] Unit with Nurse #10 and made the following observations: - One bottle of Dorzolamide Hydrochloride and Timolol Maleate Ophthalmic Solution (eye drops used to treat glaucoma), opened not marked with the opened/discard date - One bottle of Latanoprost Ophthalmic Solution (eye drops used to treat glaucoma), opened not marked with the opened/discard date - One bottle of Ofloxacin Ophthalmic Solution (eye drops used to treat eye infections), date dispensed 9/14/24 - One bottle of Lubricating Eye Drops, opened not marked with the opened/discard date or a resident's name - One bottle of Ketorolac Ophthalmic Solution (eye drops used to treat itching caused by seasonal conjunctivitis) During an interview on 12/17/24 at 1:53 P.M., Nurse #10 said she was unaware that she was supposed to label eye drops with an open/discard date and she did not date them when she would open them. Nurse #10 said she was unaware to which resident the lubricating eye drops belonged to. During an interview on 12/17/24 at 1:57 P.M., UM #2 and the surveyor reviewed the contents of the medication cart. UM #2 said eye drops should always be labeled with a Resident's name and open/discard date because once they are opened, they have a shortened expiration date. UM #2 said the Ofloxacin Ophthalmic Solution and Ketorolac Ophthalmic Solution should have been discarded after the course of the medication was completed. During an interview on 12/17/24 at 4:05 P.M., the Director of Nursing (DON) said the expectation was for medication rooms and carts to be kept clean. The DON said eye drops and insulin pens should have been labeled with a name and the opened/discard date.

Based on observation, interview, and document review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to: 1. Ensure environmental cleaning was maintained in the laundry room including flooring and surfaces and properly store linens; 2. For Resident #154, who has chronic wounds, putting him/her at increased risk for infection, to ensure that staff implemented Enhanced Barrier Precautions (EBP-an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities. Findings include: 1. Review of the Centers for Disease Control and Prevention Core Infection Prevention and Control Practices for Safe Health Care Delivery in All Settings, last reviewed 11/29/22, indicated but was not limited to: Environmental Cleaning and Disinfection require routine targeted cleaning of environmental surfaces as indicated by the level of patient contact and degree of soiling. Review of a facility document titled 5-Step Daily Routine Cleaning, revised October 2016, indicated but was not limited to the following: Purpose: To teach Environmental Services employees the proper cleaning method to sanitize a patient room or any area in a healthcare facility. Review of a facility document titled Quality Control Inspection-Laundry, undated, indicated but was not limited to the following: Other: -Machines clean -Floors clean -Behind machines On 12/18/24 at 8:07 A.M., the surveyor toured the laundry room with the Housekeeping Manager and observed the following: -One tower fan along the back wall and one tabletop fan on top of a washer in the off position, both significantly laden with dust. Clean linens stored nearby and potentially exposed to any environmental pathogens if fans in use. -Top surface of three washing machines laden with dust. One pillow and a pillowcase stored on top exposed. -Floor drain in front of the washers with a buildup of debris, lint, and other unidentified accumulated particles partially obstructing the drain. -Area behind washing machines with numerous unidentified deteriorating paper and cloth like objects on the floor and against wall, one with numerous blackened areas on the surface, various debris, lint, plastic wrappers, and hoses. A large rectangular floor cage was observed with a buildup of debris, lint and other unidentified accumulated particles partially obstructing the cage. During an interview on 12/18/24 at 8:07 A.M., the Housekeeping Manager said she was responsible for housekeeping in the facility and said staff clean the laundry room around 11:30 A.M. every morning and wash the floor and all the machines but said there was no checklist or log to show the surveyor. The Housekeeping Manager removed the fans and said laundry staff use the fans because it gets hot in there. She said the top surfaces of the washers needed to be cleaned and the pillow and pillowcase should not have been stored there. She said she was not responsible for cleaning behind the washing machines, maintenance was. During an interview on 12/18/24 at 9:59 A.M, the Infection Preventionist (IP) said her expectation is that laundry is stored properly and in a sanitary way and laundry room staff were responsible for the cleanliness of the fans and environmental cleaning. During an interview on 12/18/24 at 10:14 A.M., the Maintenance Director said he usually pulls stuff out of the drain on the floor and sweeps behind the washers. He said he's also responsible for cleaning the cage on the floor behind the washers, so lint doesn't build up and sometimes he'll see diapers back there. The Maintenance Director said he does this monthly, but it should be cleaned as needed as well if staff complain or if he goes back there and sees it. He said he saw it today after surveyor intervention and it was a mess back there, but he's seen worse. He said he found broken hoses and gloves and crumbling sheetrock that had fallen off the wall from all the chemicals. He said the expectation is that the floor drain and cage be clean and free of debris and lint so water can drain but wasn't sure when they were last cleaned and had no record of it. He said lint and gloves may have been swept towards there. 34145 2. Review of the Centers for Medicare and Medicaid Services (CMS) guidance titled Enhanced Barrier Precautions in Nursing Homes, dated 3/20/24, indicated but was not limited to: -Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities. -EBP are used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning (putting on) of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing -EBP are indicated for residents with any of the following: a. Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or b. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO -EBP should be used for any residents who meet the above criteria, wherever they reside in the Facility Review of the facility's policy titled Enhanced Barrier Precautions, last revised March 2024, indicated but was not limited to: -EBPs are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms to residents. -EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply a. gloves and gown are applied prior to performing the high contact resident care activity -Examples of high contact resident care activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care -EBPs are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization -Signs are posted in the door or wall outside the resident room indicating the type of precaution and PPE required -PPE is available outside of the residents' rooms Resident #154 was admitted to the facility in November 2024 and had two stage 2 pressure ulcers. Review of the Minimum Data Set assessment, dated 11/28/24, indicated Resident #154 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status score of 7 out of 15, had functional limitation in range of motion on one side of his/her upper extremity, required partial to moderate assistance for bed mobility, and had two stage 2 pressure ulcers. Review of Physician's Orders indicated but was not limited to: -Maintain enhanced barrier precautions with high contact care-wounds, every shift for prevention (11/25/24) Review of comprehensive care plans indicated but were not limited to: -Focus: The resident is on enhanced barrier precautions due to increased risk to acquire infection related to wounds (11/25/24) -Interventions: Maintain enhanced barrier precautions: clean hands before entering and leaving the room. [NAME] (put on) gloves and gown prior to providing high contact care and discard prior to exiting room (11/25/24) -Goal: The resident will remain free of healthcare acquired infection through the review date (last revised 12/13/24) On 12/17/24 at 8:20 A.M., the surveyor observed an EBP sign posted on the wall outside Resident #154's room. A three-tiered PPE cart was outside the door to the Resident's room and contained gowns and gloves. Resident #154 was sitting upright in bed but slouched down and leaning to his/her right side. On 12/17/24 at 8:25 A.M., the surveyor observed Nurse #2 and Speech Therapist (ST) #1 enter Resident #154's room. Nurse #2 and ST #1 repositioned the Resident in bed. Neither Nurse #2 nor ST #1 wore PPE during high contact care. During an interview on 12/17/24 at 8:27 A.M., ST #1 said she should have worn PPE when she assisted Nurse #2 to boost the Resident and did not. During an interview on 12/17/24 at 8:28 A.M., Nurse #2 said Resident #154 is on EBP and she should have worn a gown and gloves when repositioning the Resident. During an interview on 12/19/24 at 9:31 A.M., Unit Manager #1 said for residents on EBP, staff are to follow what is printed on the sign posted at the resident's door. She said Nurse #2 and ST #1 should have worn a gown and gloves when repositioning Resident #154.

Based on record review, document review, and interview, the facility failed to ensure residents were screened for eligibility to receive the recommended influenza and/or pneumococcal vaccinations, residents/residents' representatives were educated on the benefits and potential side effects of the vaccine, and were offered and administered (if applicable) the vaccine in a timely manner for one Resident (#117), out of a total sample size of five residents reviewed for immunizations. Findings include: Review of the Centers for Disease Control and Prevention (CDC) document titled Pneumococcal Vaccine Timing for Adults, dated October 2024, indicated the following: -Make sure your patients are up to date with pneumococcal vaccination. Adults >= [AGE] years Old, Complete Pneumococcal Vaccine Schedules: -PPSV23 only at any age - give PCV20 or PCV21 >= 1 year later Review of the facility's policy titled Pneumococcal Vaccine, revised March 2023, indicated but was not limited to the following: -All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. -Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated/available, are offered the vaccine series within the facility unless medically contraindicated, awaiting shipments of vaccines, or the resident has already been vaccinated. -Assessments of pneumococcal vaccination status are conducted within thirty (30) days of the resident's admission if not conducted prior to admission. -Before receiving a pneumococcal vaccine, the resident or legal representative receives information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of education is documented in the resident's medical record. -Pneumococcal vaccines are administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician-approved pneumococcal vaccination protocol. -Administration of the pneumococcal vaccines are made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. Review of the facility's policy titled Influenza Vaccine, revised September 2024, indicated but was not limited to the following: -All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. -Between as early as August 1st through March 31st of the following year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated, or the resident or employee has already been immunized. -Prior to the vaccination, the resident (or resident's legal representative) or employee will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. Provision of education shall be documented in the resident's/employee's medical record. Resident #117 was admitted to the facility in November 2023 and was [AGE] years old. Review of the Resident's Immunization record indicated the following: -Resident #117/Resident's representative refused the Influenza vaccine on 9/9/24. The record indicated vaccination education was not provided. -Prevnar-23 vaccine administered 7/31/17, outside of the facility Further review of the medical record failed to indicate documentation of follow up screening, an assessment for eligibility to receive the recommended Pneumococcal vaccine dose (PCV20 or PCV21), the provision of education related to the Influenza and Pneumococcal vaccines, signed consent to either receive or refuse the vaccines, and offering and/or administration of the vaccines. During an interview on 12/18/24 at 9:29 A.M., the Infection Preventionist (IP) said the facility had infection control policies and procedures that were current and based on national standards. She said they follow CDC, Massachusetts Department of Public Health (DPH), or Centers for Medicare and Medicaid Services (CMS) guidance for vaccines, whichever is most stringent. During an interview on 12/18/24 at 9:46 A.M., the IP said she finally got a hold of the Resident's son yesterday, after surveyor intervention, who consented to receive the recommended Influenza and Pneumococcal vaccinations. During an interview on 12/18/24 at 9:48 A.M., the IP said the expectation is to ensure all residents are provided education, offered the vaccines, and either consent to receive the vaccines or decline them.

Based on record review and interview, the facility failed to provide education and/or offer the COVID-19 vaccination as required or appropriate per the Centers for Disease Control and Prevention (CDC) recommendations for two Residents (#153 and #117), out of a total sample size of five residents reviewed for immunizations. Findings include: Review of Centers for Disease Control and Prevention (CDC) guidance titled Use of COVID-19 Vaccines in the U.S. revised October 2024, indicated but was not limited to the following: -People ages 5-[AGE] years should receive 1 dose of an age appropriate 2024-2025 COVID-19 vaccine. Ages 12-[AGE] years (Previous COVID-19 vaccination before 2024-2025 vaccine): -Receive 1 dose of 2024-2025 vaccine -People ages [AGE] years and older, vaccinated under the routine schedule, are recommended to receive 2 doses of an 2024-2025 COVID-19 vaccine (i.e., Moderna, Novavax, or Pfizer-BioNTech) separated by 6 months (minimum interval 2 months) regardless of vaccination history, with one exception: Unvaccinated people who initiate vaccination with 2024-2025 Novavax COVID-19 Vaccine are recommended to receive 2 doses of Novavax followed by a third dose of any COVID-19 vaccine 6 months (minimum interval 2 months) later. Review of the facility's policy titled Coronavirus Disease (COVID-19) - Vaccination of Residents, revised April 2023, indicated but was not limited to the following: -Each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated, or the resident has already been immunized. -Residents who are eligible to receive the COVID-19 vaccine are strongly encouraged to do so. -The resident (or resident representative) has the opportunity to accept or refuse a COVID-19 vaccine, and to change his/her decision. -COVID-19 vaccine education, documentation and reporting are overseen by the infection preventionist. -Vaccines are administered in accordance with CDC, ACIP, FDA and manufacturer guidelines. -Before the COVID-19 vaccine is offered, the resident is provided with education regarding the benefits, risks, and potential side effects associated with the vaccine. -Residents or HCP/guardian must sign a consent to vaccinate form prior to receiving the vaccine. -The resident's medical record includes documentation that indicates, at a minimum, the following: a. That the resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine; b. Signed consent; and c. Each dose of COVID-19 vaccine that was administered to the resident. -If the resident did not receive the COVID-19 vaccine due to medical contraindications, prior vaccination or refusal, appropriate documentation is made in the resident's record. 1. Resident #153 was admitted to the facility in August 2024 and was [AGE] years old. Review of the Resident's Immunization record indicated the following: -Resident #153 refused the 2023-2024 formula COVID-19 vaccine. The record indicated vaccination education was not provided. -COVID-19 Dose 1 received 2/5/21, Dose 2 received 5/24/21 Review of Resident #153's Immunization Consent Form, dated 8/27/24, indicated he/she had declined the vaccine with the reason documented as received. No date was provided. Education on the form indicated the following: -COVID-19 Vaccine/Booster: Soreness, swelling, redness of the arm, fever, muscle aches and pains; rarely allergic reaction. The form did not indicate education regarding the type of COVID-19 vaccine being offered or benefits and risks associated with the vaccine. During an interview on 12/18/24 at 9:41 P.M., the Infection Preventionist (IP) said she did the COVID-19 education with the Resident yesterday, after surveyor intervention, and the Resident refused. She said the only documented COVID-19 vaccinations the Resident received were from 2021 and the Resident did not have anything recent that she knew of. She said there had been no follow up on if the Resident had received a more recent dose as indicated on the consent form. 2. Resident #117 was admitted to the facility in November 2023 and was [AGE] years old. Review of the Resident's Immunization record indicated the following: -Resident #117/Resident's representative refused the COVID-19 Pfizer Booster on 12/15/23. The record failed to indicate that vaccination education was provided. -COVID-19 Dose 1 received 5/10/22, Dose 2 received 6/7/22 Further review of the medical record failed to indicate documentation of follow up screening, an assessment for eligibility to receive the recommended 2024-2025 COVID-19 vaccine dose, the provision of education related to the COVID-19 vaccine, completed consent to either receive or refuse the vaccine in the medical record, and offering or administration of the vaccine. During an interview on 12/18/24 at 9:29 A.M., the IP said the facility had infection control policies and procedures that were current and based on national standards. She said they follow CDC, Massachusetts Department of Public Health (DPH), or Centers for Medicare and Medicaid Services (CMS) guidance for vaccines, whichever is most stringent. During an interview on 12/18/24 at 9:46 A.M., the IP said she finally got a hold of the Resident's son yesterday, after surveyor intervention, who consented for Resident #117 to receive the recommended COVID-19 vaccination. During an interview on 12/18/24 at 9:48 A.M., the IP said the expectation is to ensure all residents are provided education, offered the vaccine, and either consent to receive the COVID-19 vaccination or decline it.

Based on interview and record review, the facility failed to implement policies and procedures for alleged misappropriation of resident property for one Resident (#413), out of a total sample of 33 residents. Specifically, the facility failed to investigate and report an allegation of misappropriation of Resident #413's fifty dollars and a store credit card. Findings include: Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, last revised April 2021, indicated but was not limited to: - Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. - Policy Interpretation and Implementation: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone. 2. Develop and implement policies and protocols to prevent and identify: c. theft, exploitation, or misappropriation of resident property. 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 9. Investigate and report any allegations within timeframes required by federal requirements. Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation- Reporting and Investigating, last revised September 2022, indicated but was not limited to: -Policy Statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. -Reporting Allegations to the Administrator and Authorities 1. If the abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegations immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; e. Law enforcement officials 3. Immediately is defined as: b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 6. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. - Investigating Allegations 1. All investigations are thoroughly investigated. The administrator initiates investigations. - Follow-up Report 1. Within five (5) business days of the incident the administrator will provide a follow-up investigation report. 2. The follow-up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation is verified. 3. The follow-up investigation report will provide as much information as possible at the time of submission of the report. 4. The residents and/or representative are notified of the outcome immediately upon the conclusion of the investigation. Resident #413 was admitted to the facility in December 2024. Review of Resident #413's Admission Assessment, dated 12/12/24, indicated he/she was alert and oriented to person, place, and time. During an interview on 12/16/24 at 8:59 A.M., Resident #413 said he/she was admitted to the facility on the previous Thursday. Resident #413 said upon admission he/she completed an inventory sheet with Certified Nursing Assistant (CNA) #4 and showed CNA #4 that he/she had fifty dollars in cash in his/her personal bag. Resident #413 said when he/she looked in his/her personal bag the next day, he/she realized the fifty dollars and a store credit card were gone. Resident #413 said he/she had reported the missing money and store credit card to CNA #4 and the Social Worker (SW). Review of Resident #413's Personal Inventory List, undated, indicated the Resident had one personal bag and fifty dollars in cash. Further review of the Personal Inventory List failed to indicate Resident #413 had a store credit card. Review of the Health Care Facility Reporting System (HCFRS- State agency reporting system), on 12/16/24, failed to indicate that the facility reported an allegation of misappropriation to the Department of Public Health (DPH). During an interview on 12/17/24 at 3:50 P.M., SW #1 said she was notified on 12/13/24 about Resident #413's missing fifty dollars and store credit card. SW #1 said she notified the Administrator and started an investigation. SW #1 said the fifty dollars and store credit card had gone missing some time during the 11:00 P.M. to 7:00 A.M. shift of Thursday into Friday. SW #1 said Resident #413 had the personal bag tucked under his/her hip while he/she slept and was only able to describe the person who took the money and store credit card as wearing all black. SW #1 said she wasn't sure how Resident #413 couldn't feel someone taking his/her money and store credit card but was able to see their clothes. SW #1 said she offered to call the police, but Resident #413 declined. SW #1 said missing money and missing credit card should be reported to state agencies and the police within two hours. SW #1 said she was going to finish the investigation on Monday, 12/16/24, but lost track of time. During an interview on 12/17/24 at 4:02 P.M., the Director of Nursing (DON) said she had not been aware Resident #413 was missing fifty dollars in cash and a store credit card. During an interview on 12/18/24 at 7:38 A.M., the Administrator said the investigation into the missing fifty dollars cash and store credit card had not been completed yet or reported in HCFRS. The Administrator said the facility had two hours to report the allegation of abuse and five days to complete the investigation. The Administrator said the facility had not implemented their policy.

Based on observation, interview, and record review, the facility failed to ensure for one sampled Resident (#7) with an indwelling nephrostomy tube (a catheter inserted through the skin into the kidney draining urine into a collection bag outside of the body), out of a total sample of 33 residents, that the Resident's dignity was maintained. Specifically, the facility failed to consistently place the Resident's nephrostomy tube drainage bag in a privacy bag. Findings include: Review of the facility's policy titled Resident Rights, dated as revised February 2021, indicated but was not limited to the following: - Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents. - Helping the resident to keep urinary catheter bags covered. Resident #7 was readmitted to the facility in October 2024 with a diagnosis of obstructive nephropathy (a blockage in the urinary tract), hydronephrosis (back up of urine in one or more kidneys), and had a right nephrostomy tube. Review of the Minimum Data Set (MDS) assessment, dated 11/23/24, indicated Resident #7 was cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. Further review of the MDS indicated Resident #7 required maximum assistance with transfers and ambulation and had an indwelling catheter. On 12/16/24 at 3:29 P.M., the surveyor observed Resident #7 sitting up in his/her wheelchair in the threshold of the doorway to their room, with a urinary drainage bag placed on their lap with visible urine in the bag. The drainage bag was fully exposed and not placed in a privacy bag to conceal it from public view. On 12/18/24 at 9:41 A.M., the surveyor observed Resident #7 sitting in his/her chair with an overbed table placed in front of him/her. Directly on the table was a urinary drainage bag with visible urine in the bag. The drainage bag was fully exposed and not placed in a privacy bag to conceal it from public view. During an interview on 12/18/24 at 9:48 A.M., Certified Nurse Aide (CNA) #1 said urinary drainage bags should always be in a privacy bag so the urine is not visible to others. On 12/18/24 at 10:58 A.M., the surveyor observed Resident #7 sitting in a chair next to the doorway with a urinary drainage bag hanging down on his/her right side with visible urine in the bag. The drainage bag was fully exposed and not placed in a privacy bag to conceal it from public view. During an interview on 12/18/24 at 11:02 A.M., Nurse #4 said all drainage bags should be placed in a privacy bag. During an interview with observation on 12/18/24 at 11:04 A.M., Unit Manager (UM) #2 said drainage bags must be placed in a privacy bag. The surveyor and UM #2 observed Resident #7 sitting in his/her chair next to the doorway with a urinary drainage bag hanging down on his/her right side, with visible urine in the bag. UM #2 approached the bed, lifted the blankets, and showed the surveyor a privacy bag attached to the bed frame. UM #2 said the staff should have taken the privacy bag off the bed and attached it to the Resident's chair, when they transferred him/her to the chair, and placed the drainage bag inside. During an interview on 12/18/24 at 4:18 P.M., the Director of Nursing (DON) said the urinary drainage bag should have been placed inside of a privacy bag to maintain the Resident's dignity.

Based on record review and interview, the facility failed to notify the Physician/Nurse Practitioner when one Resident (#30), out of a total sample of 33 residents, did not keep medical appointments with his/her consultant cardiologist and urologist as scheduled. Findings include: Review of the facility's policy, Change in a Resident's Condition or Status, dated February 2022, indicated but was not limited to: -Our facility notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Resident #30 was admitted to the facility in December 2021 and had diagnoses including sick sinus syndrome (a condition where the heart's natural pacemaker, known as the sinus node, does not function properly), hypertensive heart disease with heart failure, presence of a cardiac pacemaker (a small, battery-powered implanted device used to correct a slower-than-normal heart rate), retention of urine, and a Foley catheter (a thin, flexible tube inserted into the bladder to drain urine). Review of the Minimum Data Set (MDS) assessment, dated 10/31/24, indicated Resident #30 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status score of 10 out of 15, and had an indwelling urinary catheter. During an interview on 12/18/24 at 2:03 P.M., Unit Manager #1 said Resident #30's health insurance had lapsed and he/she had missed a few appointments. She said the Resident was due to see his/her cardiologist on 10/24/24 and the urologist on 11/25/24, but the appointments were cancelled because he/she does not currently have health insurance. Review of the medical record indicated Resident #30 had appointments scheduled with his/her cardiologist on 10/24/24 and his/her urologist on 11/25/24. Review of the entire medical record failed to indicate Resident #30 went to his/her 10/24/24 cardiology appointment. During a telephone interview on 12/19/24 at 10:06 A.M., the Resident's cardiology office staff said Resident #30 was a no show for the 10/24/24 appointment with the cardiologist for a pacemaker check and evaluation. Review of a Clinical Nurse's Note, dated 11/25/24, indicated the nurse called the Resident's Urologist's office and cancelled the 11/25/24 appointment and did not reschedule it. Further review of the entire medical record, including Physician/Nurse Practitioner visit notes, failed to indicate the Physician/Nurse Practitioner was notified that Resident #30 did not go to a cardiology appointment scheduled for 10/24/24 and a urology appointment on 11/25/24. During a telephone interview on 12/19/24 at 11:15 A.M., Nurse Practitioner #1 said she was not notified that the Resident did not go to the 10/24/24 cardiology appointment and the 11/25/24 urology appointment as scheduled but would have expected staff to inform her. Attempts to reach Resident #30's attending Physician on 12/19/24 were unsuccessful.

Based on interview and record review, the facility failed to protect one Resident (#413) from misappropriation of resident property, out of a total sample of 33 residents, when fifty dollars and a store credit card were taken from his/her personal bag. Findings include: Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, last revised April 2021, indicated but was not limited to: - Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. - Policy Interpretation and Implementation: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone. 2. Develop and implement policies and protocols to prevent and identify: c. theft, exploitation, or misappropriation of resident property. 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 9. Investigate and report any allegations within timeframes required by federal requirements. Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation- Reporting and Investigating, last revised September 2022, indicated but was not limited to: -Policy Statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. - Reporting Allegations to the Administrator and Authorities 1. If the abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegations immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; e. Law enforcement officials 3. Immediately is defined as: b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 6. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. - Investigating Allegations 1. All investigations are thoroughly investigated. The administrator initiates investigations. - Follow-up Report 1. Within five (5) business days of the incident the administrator will provide a follow-up investigation report. 2. The follow-up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation is verified. 3. The follow-up investigation report will provide as much information as possible at the time of submission of the report. 4. The resident and/or representative are notified of the outcome immediately upon the conclusion of the investigation. Resident #413 was admitted to the facility in December 2024. Review of Resident #413's Admission Assessment, dated 12/12/24, indicated he/she was alert and oriented to person, place, and time. During an interview on 12/16/24 at 8:59 A.M., Resident #413 said he/she was admitted to the facility on the previous Thursday. Resident #413 said upon admission he/she completed an inventory sheet with Certified Nursing Assistant (CNA) #4 and showed CNA #4 that he/she had fifty dollars in cash in his/her personal bag. Resident #413 said when he/she looked in his/her personal bag the next day, he/she realized the fifty dollars and a store credit card were gone. Resident #413 said he/she reported the missing money and store credit card to CNA #4 and the Social Worker. Review of Resident #413's Personal Inventory List, undated, indicated he/she had one personal bag and fifty dollars in cash. Further review of the Personal Inventory List failed to indicate Resident #413 had a store credit card. Review of the Health Care Facility Reporting System (HCFRS- State agency reporting system), on 12/16/24, failed to show the facility had reported an allegation of misappropriation to the Department of Public Health (DPH). During a telephonic interview on 12/18/24 at 2:14 P.M., CNA #4 said she completed the Personal Inventory List for Resident #413 on 12/12/24. CNA #4 said Resident #413 had fifty dollars folded in a piece of paper in his/her personal bag. CNA #4 said she was not aware Resident #413 had a store credit card on admission but found out about it the next day. CNA #4 said when she came into work on 12/13/24, Resident #413 told her that someone had taken his/her store credit card and the fifty dollars. CNA #4 said she searched Resident #413's room and notified Social Worker (SW) #1. During an interview on 12/17/24 at 3:50 P.M., SW #1 said she was notified on 12/13/24 about Resident #413's missing fifty dollars and store credit card. SW #1 said she notified the Administrator and started an investigation. SW #1 said the fifty dollars and store credit card had gone missing some time during the 11:00 P.M. to 7:00 A.M. shift of Thursday into Friday. SW #1 said Resident #413 had the personal bag tucked under his/her hip while he/she slept and was only able to describe the person who took the money and store credit card as wearing all black. SW #1 said she wasn't sure how Resident #413 couldn't feel someone taking his/her money and store credit card but was able to see their clothes. SW #1 said she offered to call the police, but Resident #413 declined. SW #1 said missing money and missing credit card should be reported to state agencies and the police within two hours. SW #1 said she was going to finish the investigation on Monday, 12/16/24, but lost track of time. During an interview on 12/17/24 at 4:02 P.M., the Director of Nursing (DON) said she had not been aware Resident #413 was missing fifty dollars and a store credit card. During an interview on 12/18/24 at 7:38 A.M., the Administrator said the investigation into the missing fifty dollars and store credit card had not been completed yet.

Based on record review and interviews, the facility failed to ensure an allegation of misappropriation of resident property was reported timely to the state agency and to the police as required, for one Resident (#413), of 33 sampled residents. Findings include: Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, last revised April 2021, indicated but was not limited to: 9. Investigate and report any allegations within timeframes required by federal requirements. Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation- Reporting and Investigating, last revised September 2022, indicated but was not limited to: -Policy Statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. -Reporting Allegations to the Administrator and Authorities 1. If the abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegations immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; e. Law enforcement officials 3. Immediately is defined as: b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Resident #413 was admitted to the facility in December 2024. Review of Resident #413's Admission Assessment, dated 12/12/24, indicated he/she was alert and oriented to person, place, and time. During an interview on 12/16/24 at 8:59 A.M., Resident #413 said he/she was admitted to the facility on the previous Thursday. Resident #413 said that upon admission to the facility he/she completed an inventory sheet with Certified Nursing Assistant (CNA) #4. Resident #413 said he/she showed CNA #4 that he/she had fifty dollars in cash in his/her personal bag. Resident #413 said when he/she looked in his/her personal bag the next day, he/she realized the fifty dollars in cash and a store credit card had been taken. Resident #413 said she had reported the missing money and store credit card to CNA #4 and the Social Worker. Review of the Health Care Facility Reporting System (HCFRS- State agency reporting system), on 12/16/24, failed to indicate that the facility reported an allegation of misappropriation to the Department of Public Health (DPH). During an interview on 12/17/24 at 3:50 P.M., SW #1 said she was notified on 12/13/24 about Resident #413's missing fifty dollars in cash and missing credit card. SW #1 said she notified the Administrator and started an investigation. SW #1 said she offered to call the police and report the missing money and credit card but Resident #413 declined. During an interview on 12/17/24 at 4:02 P.M., the Director of Nursing (DON) said she had not been aware Resident #413 was missing fifty dollars in cash and a credit card. During an interview on 12/18/24 at 7:38 A.M., the Administrator said the investigation into the missing fifty dollars in cash and store credit card had not been reported timely in HCFRS as it should have and the incident was not reported to the police because Resident #413 declined to have them notified.

Based on observation, record review, and staff interview, the facility failed to provide adequate supervision and accident prevention interventions to maintain the safety of one Resident (#76), out of a total sample of 32 residents. Specifically, the facility failed to provide adequate supervision to maintain the Resident's safety and prevent falls, and/or injury, resulting in Resident #76 sustaining a total of 14 falls from the time of their admission (January 2023) to 8/27/23; 12 of which were unwitnessed, and one resulted in the Resident being transported to the emergency room for a head laceration that required three staples. Findings include: Review of the facility's policy titled Falls and Fall Risk Managing, revised March 2018, included but was not limited to: -The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. -If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). -If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. -If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. -In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. Monitoring Subsequent Falls and Fall Risk -The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. -If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g., dizziness or weakness) had resolved. -If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change interventions. As needed, the attending physician will help the staff reconsider possible causes that may not have been identified. -The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. Resident #76 was admitted to the facility in January 2023 with diagnoses which included status post wedge compression fracture of the 3rd lumbar vertebra, wedge compression fracture of the thoracic, T11-T12 vertebrae, status post left and right hip fractures following previous falls, anxiety, depression, and Alzheimer's dementia. Review of the Minimum Data Set (MDS) assessment, dated 9/14/23, indicated that Resident #76 experienced severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 5 out of 15, required extensive assistance with bed mobility/transfers, was not steady during walking or moving from seated to standing position, had wandering behaviors, and experienced two or more falls without injury since admission/entry or reentry on the prior assessment. The Resident was assessed to be at high risk for falls r/t (related to) confusion, deconditioning, gait/balance problems, incontinence, poor communication/comprehension, psychoactive drug use, and unaware of safety needs. Review of the Comprehensive Care Plan on 9/15/23 included, but was not limited to: -Focus: Falls, 1/3/2023 -Goals: -Monitor resident every 2 hours to help prevent falls. -The Resident will be free of minor injury through the review date -Side effects of psychoactive drugs, antihypertensives etc. (contributing to gait disturbance, balance, syncope, movement disorders) and increasing the resident's fall risk will be reduced by the review date. -Resident will not sustain serious injury through the review date. Interventions: -1/13/23- Patient (pt) to be in view of staff when out of bed. -1/16/23-Staff member is to be educated not to leave patient in the bathroom alone. -7/6/23- 11-7 staff on first rounds to offer resident toileting while awake. -8/2/23- Anti-tippers applied to w/c (wheelchair). -7/14/23- Antiroll backs on w/c. -8/8/23- Call before you fall placed in room. -7/14/23- Dycem to cushion under w/c. -3/23/23- Handheld bell to ring for assistance any time resident is in bed. -1/3/23- Resident needs activities that minimize the potential for falls while providing diversion and distraction. -1/3/23- Resident needs to be evaluated for, and supplied appropriate adaptive equipment or devices as needed. Re-evaluate and as needed for continued appropriateness and to ensure least restrictive device or restraint. -1/3/23- Resident needs a safe environment with even floors free from spills and/or clutter, adequate, glare-free light, a working and reachable call light, the bed in low position at night, side rails as ordered, handrails on walls, personal items within reach. -8/27/23- Offer toileting at midnight to resident. -5/23/23- OT evaluation for use of reacher. -7/14/23- PT evaluate and treat as ordered or PRN. -6/19/23- Rehab to screen status post (s/p) Covid. -4/19/23- Sign placed in bathroom (BR) to call for assistance. Review of the Falls and Incident Reports for Resident #76 indicated the Resident sustained 14 falls, 12 of which were unwitnessed, and one resulted in the Resident being transported to the emergency room for a head laceration that required three staples as follows: 1. On 1/12/23 at 9:30 A.M., the Resident had an unwitnessed fall. A Certified Nursing Assistant (CNA) found the Resident on the floor in the Resident's room and went to get the nurse. When the Registered Nurse (RN) arrived to the room, the Resident was found in a chair. The Resident stated that he/she did not know how he/she fell or what he/she was doing prior to the fall. No injuries were reported. An immediate intervention was listed as, Patient to be outside nurse station when up in chair for observation. 2. On 1/14/23 at 7:30 P.M., the Resident had an unwitnessed fall in the bathroom. The incident report indicated that the Resident tried to get off the toilet independently. The incident report indicated that the CNA had left the Resident unattended in the bathroom. The plan of care was updated to include, Staff member to be educated not to leave patient in the bathroom alone. No other interventions were implemented to prevent falls. 3. On 1/18/23 at 10:00 A.M., the Resident was being transferred by the CNA, from the side of the bed to the wheelchair. The Report indicated that the Resident began to lean to the right and the CNA was unable to maintain the Resident in an upright position. The CNA lowered the Resident to the floor. The Resident sustained a skin tear to the right arm that required four steri-strips. The plan of care was revised to require two staff members for transferring the Resident. 4. On 3/3/23 at 11:41 A.M., the Resident sustained an unwitnessed fall and was found sitting on the floor of his/her bedroom near the dresser. The report indicated that the Resident had removed his/her pants and non-skid socks. The Resident told the nurse that he/she was getting ready for bed. No injuries were discovered, the MD (medical doctor) was notified, and a new order was obtained to monitor every 2 hours to prevent falls. 5. On 3/22/23 at 10:50 A.M., the Resident sustained an unwitnessed fall. The Resident was found sitting on the floor near his/her bed, and the call light was not functioning. The Resident stated he/she had been pressing the call light for assistance with toileting, however, the call bell was not sounding, and no assistance was noted for a period of time. The Resident attempted to toilet himself/herself. No injuries were reported. There was no evidence that the malfunctioning call light was addressed or investigated. Intervention added to care plan on 3/23/23 of handheld bell to ring for assistance any time resident is in bed. The care plan did not address the Resident's impaired memory and the continued inability of the Resident to follow and retain safety information. 6. On 4/18/23 at 13:56 (1:56 P.M.), the nurse was called to the Resident's room as the Resident was found sitting on the floor in his/her bathroom. The Resident attempted to toilet him/herself without assistance. The Resident was reminded to ask for help to use the restroom. A sign was posted in the BR [bathroom] to call for assistance, however the Resident had severely impaired cognition. 7. On 5/14/23 at 21:27 (9:27 P.M.), the Resident sustained an unwitnessed fall. The Resident was found on the floor beside his/her bed and was confused. No injuries were observed at the time of the incident. The report indicated that the Resident needs activities to minimize potential for falls, however the type of activities were not described. There were no additional interventions listed to address the Resident's poor safety awareness, his/her impaired memory, or the risk for further falls and potential for injury. 8. On 5/23/23 at 15:36 (3:36 P.M.), the Resident sustained an unwitnessed fall in his/her room. The incident report indicated that the Resident was found on his/her knees by his/her chair and told staff that he/she was reaching for something. Staff used a Hoyer (mechanical lift device) lift to get the Resident up off the floor. No injuries were reported. Intervention added of PT/OT to evaluate for Resident ability to utilize a grabber. 9. On 6/7/23 at 17:00 (5:00 P.M.), the Resident sustained an unwitnessed fall in his/her room and sustained a head injury. The incident report indicated that the Resident told staff that he/she was trying to get off his/her chair when he/she fell and hit the back of the head on the bureau and was bleeding. The Resident was transported to the emergency department and received three staples to close a head laceration. Gait imbalance was listed as a causative factor. The care plan did not list any additional interventions to address the Resident's continued risk for falls while attempting to self-transfer. 10. On 6/19/23 at 21:41 (9:41 P.M.), the Resident sustained an unwitnessed fall in his/her room. The report indicated that the Resident was found face down on the floor with no injuries. The Resident told staff that he/she wanted to leave his/her room. The Resident was reportedly Hoyer lifted off the floor and brought to the nurses' station for his/her safety. 11. On 7/6/23 at approximately 12:15 A.M., nursing staff reportedly heard a bang from the North side and walked to the Resident's room. The Resident was found on the floor with no visible injuries. The care plan was revised to include, 11-7 staff to offer Resident to be toileted while awake. 12. On 7/13/23 at approximately 20:10 (8:10 P.M.), the Resident sustained an unwitnessed fall. The incident report indicated that a CNA heard the Resident calling out for help. The Resident was found sitting on the floor in his/her room in front of his/her wheelchair and had previously been in bed. The plan of care was revised for a PT (physical therapy) screen and treatment as needed (PRN). 13. On 8/8/23 at 11:00 A.M., the incident report indicated that the Resident sustained an unwitnessed fall. The CNA responded to calls for help from the Resident. The report indicated that the Resident was found on the floor halfway in the bathroom door. The Resident was incontinent of bowels. The Resident stated that he/she did not use the walker or call light. No injuries were reported. Causative factors included, gait imbalance, incontinent, and impaired memory. Call before you fall sign posted in the Resident's room. This intervention could not be effectively relied upon due to the Resident's severe cognitive impairment and memory impairment. 14. On 8/27/23 at 1:00 A.M., the incident report indicated that the Resident experienced an unwitnessed fall while in his/her room. The nurse and CNA heard a noise and went to the Resident's room to investigate. The Resident was found sitting on the floor between the bed and the bathroom door. Mild redness was found on the left scapula. The Resident was assisted to the toilet without difficulty. Causative factors included, gait imbalance, incontinent, impaired memory, and ambulating without assist. No additional interventions were noted to address the Resident's fall risk, impaired memory, and poor safety awareness. Review of the medical record indicated that a number of the falls occurred due to the inconsistent implementation of the plan of care and the lack of effective interventions and supervision by nursing staff (i.e., Resident left unattended in the bathroom, staff not in view of Resident when Resident out of bed, call light not functioning, etc.). Although interventions were developed to address the Resident's risk for falls, the plan of care was not effective in preventing falls and maintaining the Resident's safety, and interventions were not evaluated for effectiveness. Record review on 9/15/23, indicated a note by the nurse practitioner (NP) in reference to the Resident's multiple falls. The NP note indicated, He/She has poor memory issues, he/she is impulsive and poor safety awareness. No recommendations or causative factors were noted by the NP to address the Resident's falls. The Resident was observed on multiple times throughout the survey including the following: On 9/13/23 at 11:14 AM, the surveyor observed the Resident leaning forward from a soft chair in a sitting area across from the nurses' station. The Resident was observed leaning forward, attempting to stand, and reaching for a wheelchair positioned immediately across from him/her. The Resident was off balance and at risk for falling. The surveyor responded immediately, went over to stand by the Resident, and called out to Corporate Nurse #1 (who couldn't hear the surveyor initially as she had earbuds in her ears) and Nurse #5, who were both sitting at a table behind the nurses' station and were unaware of the Resident's attempt to stand and walk unassisted. Both staff members were looking down and did not view the Resident or the Resident's unsafe behavior until the surveyor called out for their help. Neither staff member were near enough to help the Resident if he/she began falling. Corporate Nurse #1 and Nurse #5 encouraged the Resident to sit back down in the soft chair. During an interview on 9/13/23 at 11:20 A.M., Unit Manager #2 said, Oh yeah, he's/she's a fall risk. He's/She's had multiple falls. During an interview on 9/13/23 at 11:14 A.M., the surveyor made the Director of Nursing (DON) aware of the Resident's near fall when the Resident attempted to stand up and walk unassisted. The DON said that she understood that staff were unaware of the Resident's unsafe behavior, at that time, and would not have been able to help the Resident if he/she started to fall. The DON said, We'll have to figure out a safe plan to keep the Resident safe. During an interview on 9/15/23 at 9:15 A.M., the DON said the Resident had sustained multiple falls, and that the care plan interventions had not been effective in preventing falls, injury, or in maintaining the Resident's safety. The DON said that she was aware of the 14 falls (12 unwitnessed), two with injury that the resident had sustained since admission in January 2023.

Based on observation, interview, and record review, the staff failed to ensure that Residents with pressure ulcers receive the necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent new ulcers from developing for one Resident (#35) out of 26 sampled Residents. Specifically, the facility failed to ensure nursing assessed and measured pressure wounds per facility policy, failed to provide pressure relieving devices as recommended and per facility policy, failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. For Resident #35, the facility staff failed to accurately assess and measure a coccygeal (relating to the coccyx/tailbone) pressure ulcer per facility policy, failed to provide a pressure relieving mattress as recommended by the wound clinic, and failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #35 was admitted to the facility in January 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS), dated [DATE], indicated that Resident #35 had a Stage II pressure injury (present on admission), and required extensive assist with bed mobility and transfers. The MDS further indicated that Resident #35 has a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated that he/she has moderately impaired cognition. Review of the skin integrity report for Resident #35 indicated that he/she was admitted to the facility with an unstageable pressure injury due to the presence of slough (necrotic (dead) tissue that is green, yellow, tan, or brown and may be moist, loose, or stringy) that measured 5.8 centimeters (cm) in length, 4.6 cm in width and undetermined depth. There was no undermining (occurs when tissue under the wound edges becomes eroded resulting in a pocket beneath the skin and the wound edge) present. Unstageable pressure injury is defined as full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (dry, thick, leathery tissue). Review of Nurse Practitioner (NP) #1's progress note, dated 1/15/21, indicated that Resident #35 had a Stage II pressure ulcer on his/her coccyx with some slough on wound bed with a dark center according to nursing. The NP's progress note further indicated the plan was to start Santyl (a topical [MEDICATION(S)] agent that helps remove dead tissue from the wound) daily and to keep pressure off the area. Stage II pressure ulcer is defined as a wound with partial thickness loss of skin with dermis (inner layer of the two main layers of the skin) exposed. Review of Resident #35's care plans indicated that a comprehensive pressure ulcer care plan was not developed until 3/15/21, 66 days after the area was identified. A. The facility staff failed to assess and measure Resident #35's pressure wound per facility policy. The facility's policy titled Wound Dressings (revision date of 11/1/19) indicated the following: 7.2 Measure the wound depth: Insert a sterile, cotton tipped applicator moistened with NSS (Normal Saline Solution) into the deepest part of the wound. Grasp the fully inserted applicator with your thumb and forefinger at the skin surface. Withdraw the applicator while maintaining the grasp with your thumb and forefinger at the point indicating depth. Measure from the tip of the applicator to the position of your thumb. 7.3 Measure undermining and tunneling: Insert a sterile, cotton tipped applicator moistened with NSS as described in depth measuring. Describe the undermining using the clock system. Measure the extent of the undermining clockwise (e.g., 2:00 to 8:00), then the deepest part (e.g., undermining at 2 cm at 4:00). On 03/15/21 at 02:05 P.M., the surveyor observed Resident #35's dressing change, by Unit Manager #1 after receiving approval by the Resident. Unit Manager #1 identified herself as the nurse on the unit responsible for weekly wound rounds, which includes measuring and assessing wounds on the unit. Unit Manager #1 collected materials, washed her hands and proceeded to undress the current dressing. Upon removal of the current dressing, thick yellowish/white drainage was observed and a strong odor was present. Skin surrounding the wound was reddish/purple in color, blanchable, and measured 8 cm in length, and 9.4 cm in width. Unit Manager #1 said the red surrounding tissue was new from the previous week. The surveyor observed slough covering 100% of the wound bed and undermining was present from approximately 7 o'clock to 1 o'clock. Unit Manager #1 then measured the wound at 2.7 cm in length, 2.4 cm in width and 0.9 cm for depth. Unit Manager #1 then began packing the dressing as ordered but failed to measure for any undermining present. The surveyor asked the Unit Manager #1 how she measures the wound for undermining. Unit Manager #1 then stopped packing the wound and said she forgot to measure for undermining. Unit Manager #1 then measured undermining at 6 o'clock, using a dry sterile cotton tip applicator, and did not moisten the applicator per facility policy. The Unit Manager measured undermining with a depth of 0.4 cm at 6 o'clock and did not measure the wound undermining further. The wound was then cleaned and dressed as ordered. There was no further assessment or measurements taken of the remaining areas of undermining. During an interview on 3/15/21 at 2:36 P.M., Unit Manager #1 said this wound was the first wound she has measured with undermining and was unclear on the exact procedure. Unit Manager #1 said she does not recall receiving education on wound care since she started, despite being responsible for measuring wounds on her unit. She further said, she just compares her measurements to the wound clinic's measurements to make sure they are accurate. Review of the wound clinic documentation, dated 3/16/21, indicated Resident #35's pressure ulcer was measured as 2.7 cm in length by 1.5 cm in width by 1.0 cm in depth. Undermining was present from 7 o'clock to 2 o'clock with a maximum depth of 1.5 cm. The pressure injury was now classified as a Stage III, with new undermining present indicating a decline in the wound status. B. The facility failed to ensure that Resident #35 had the appropriate pressure relieving devices and failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility's policy titled Pressure Injury/Ulcer Guidelines, undated, indicated the following: - Treat: 1. Implement prevention interventions 2. Implement actions to redistribute pressure from area, observe for tissue tolerance and any new interventions (devices, surfaces, turning schedules, etc.) 3. Evaluate for pain and medicate as indicated 4. Cleanse area and apply treatment as ordered 5. Monitor site daily for placement of dressing, status of surrounding tissue, and pain. - Re-evaluate/Follow-up: Continue to re-evaluate for healing and/or anticipated deterioration. If deterioration occurs at any time or if not improving in two to four weeks, re-evaluate risk factors and plan of care and notify physician/mid-level provider to report current Skin Integrity Report and current treatment. Review of NP #1's progress note, dated 2/16/21 indicated that Resident #35 is having increased pain in his/her coccyx wound, it is deeper and has a foul odor and a large amount of slough in the center. The NP's progress note further indicated that Resident #35 was currently receiving Santyl which was not improving the wound and that the plan was to continue the use of Santyl, get a wound clinic evaluation, position the patient off his/her buttocks and begin medication for a wound infection and pain management. Resident #35 was seen by the wound clinic on 2/23/21. The wound clinic documentation indicated that Resident #35 had an unstageable pressure injury 2.7 cm in length, 2.0 cm in width and now had a depth of 1.0 cm. Undermining was also present, 1.0 cm at 12 o'clock, which was a new finding. The wound clinic documentation from 2/23/21 further indicated a recommendation for a gel mattress over-lay and gel wheelchair cushion for Resident #35 to off-load pressure to the coccyx. Resident #35 should be turned and repositioned every two hours and should not sit for more than one hour at a time. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/11/21 at 11:42 A.M., the surveyor observed Resident #35 to be out of bed, sitting in his/her wheelchair. A standard mattress was observed on the bed. Resident #35 remained out of bed until 2:45 P.M., approximately three hours later. On 3/15/21 at 11:45 A.M., the surveyor observed Resident #35 to be out of bed, sitting in his/her wheelchair. The Resident told the surveyor that he/she gets into his/her wheelchair to go to wound care appointments. The Resident had an appointment scheduled that day at 1:45 P.M. The Resident said he/she is usually out for a bit and sits for a few hours in his/her wheelchair. During an interview on 03/15/21 at 11:42 A.M., Resident #35 said, The wound clinic nurse wants me to get a new mattress for my bed, but I still haven't gotten one. He/She further said there is still pain at the wound site and pain medication helps a little but the pain is still there, especially when lying in bed. During an interview on 3/15/21 at 11:50 A.M., Unit Manager #1 said Resident #35 did not have an upgraded mattress on his/her bed as recommended by the wound clinic, because the mattress needed to be approved by the facility and to her knowledge this had not been done. Unit Manager #1 could not tell the surveyor why there was a delay in getting the mattress. The Unit Manager further said that Resident #35 goes to his/her weekly appointments in his/her wheelchair and said he/she is usually out for a few hours at a time. During an interview on 3/15/21 at 3:26 P.M., the Director of Nurses said the gel overlay mattress recommended by the wound clinic was not available so we had ordered him/her something similar. She said when mattresses are ordered, they usually come in within a few days but did not have an explanation as to why Resident #35 did not have the recommended mattress. Resident #35 did not receive a pressure relieving mattress until 3/16/21, a total of 22 days after the wound clinic's recommendations. During an interview on 3/17/21 at 12:57 P.M., Nurse Practitioner #1 said Resident #35's wound is now a Stage III and is getting worse based on the size, undermining, drainage and odor. She further said Resident #35 needs to reduce pressure to that area, and should not be out of bed for more than one hour but he/she seems to always be in the chair when I see him/her, this puts pressure on the wound and is likely the reason for the new undermining. C. The facility failed to assess, treat and monitor a pressure wound for infection. Review of NP #1's progress note, dated 2/16/21 indicated that Resident #35 is having increased pain in his/her coccyx wound, it is deeper and has a foul odor and a large amount of slough in the center. The NP progress note further indicated that Resident #35 was currently receiving Santyl which was not improving the wound and that the plan was to continue the use of Santyl, get a wound clinic evaluation, position the patient off his/her buttocks and begin [MEDICATION(S)] (an antibiotic used to treat infections) 100 milligrams (mg) twice per day for ten days for a wound infection. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the wound clinic documentation, dated 2/23/21, indicated that a wound culture was obtained for Resident #35. During an interview on 3/15/21 at 11:50 A.M., Unit Manager #1 said she was unaware that a wound culture was obtained for Resident #35 and could not tell the surveyor if there was an infection present. This was 21 days after the wound culture was first obtained. During an interview on 3/17/21 at 12:57 P.M., NP #1 said she assessed Resident #35 today and the coccyx wound has a strong odor and appears to be infected. She further said, she feels Resident #35's wound is not getting better because of an underlying infection that is not being treated and ordered a wound culture to be obtained.

Based on interview, observations and record review, the facility staff failed to prevent an accidental burn from a hot liquid provided to 1 Resident (Resident 34), from a total of 24 sampled Residents. The facility staff failed to follow their own policy guidelines for re-heating beverages and monitoring temperatures, prior to providing a hot beverages to the Resident. Findings include: Resident #34 was admitted to the facility in 3/2019 with the following pertinent Diagnoses: [REDACTED]. (Resident #34 also has a documented allergy listed to Sulfa antibiotics.) A review of the admission Minimum Data Set (MDS) assessment dated [DATE] indicate a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicates Resident #34 is cognitively intact. The facility policy on Food Handling revision date of 8/8/2018 indicated, hot beverages are to be served at a temperature pleasing to the patients/residents, but in a manner, that reduces the risk for burns, as outlined in the Guidelines for Hot Beverages. The facility Guidelines for Hot Beverages dated 4/1/14 indicated, please observe the following guidelines when heating or reheating liquids in the microwave. Beverages should be heated in the microwave for no more than 30 seconds on full power. Additional heating should be done in 30 second intervals or less. The Facility Guidelines for reheating Food and Beverages Brought in for Patients/Residents dated 11/28/16, indicated to please follow these safety guidelines: -Heat for 30 seconds to 1 minute; stir and check temperature. (heat for additional 30 second intervals and stir, as needed) The facility Reheating Chart indicated, beverages heated in microwave on high power for 1 1/2 to 2 minutes. Do not heat liquid longer than 2 minutes to avoid overheating. A review of the following nurse's notes related to the Resident's burn indicated: On 4/17/19 at 11:30 P.M. a CNA reported to this writer that hot chocolate was spilled on the patient. Upon assessment, it was noted that the patient has a 1st degree burn on her left leg, left hand and right knee. Areas are red, skin intact. Patient reports burning pain on areas. Nurse Practitioner was contacted and ordered cold compresses every hour on areas to prevent blistering. About two hours later, several blisters were noted on areas on the right knee and left leg. Nurse Practitioner contacted and ordered Silverine on areas. Cream applied on areas. Pain medication given to patient with positive effects. On 4/18/19 at 3:27 P.M., patients burn areas assessed the morning. Areas on right knee and left shin noted with intact clear serous filled blisters, no surrounding redness, no surrounding tenderness. Left hand is free from any redness or blistering. Patient was complaining of right wrist pain, status [REDACTED]. Patient able to recount the event of the burn, stating that he/she asked the certified Nursing Assistant CNA) to heat up water for his/her own hot chocolate packet for 3 minutes. He/she acknowledged that the CNA told her it would be very hot, that 3 minutes was a longtime and he/she again stated this morning that she liked it hot. He/she said that the event happened very fast, the CNA brought the hot water back, placed the it on the bedside table in front of him/her, stated it was very hot and before putting in the hot chocolate power in the cup tipped and spilled on him/her. He/she did not know what tipped the cup as it happened very fast, but stated she/he did not think either of them touched the cup. I (the nurse) educated her (the CNA) on guidelines for reheating liquid and 3 minutes was too long. I told her that we will reheat according to the recommendations guideline and serve at the recommended temperature between 160-185 degrees. If she felt that temp was not warm enough, the nurse would use their clinical judgement to heat for additional time to satisfy her. She agreed with the plan. On 4/18/2019 at 3:35 P.M., Patient has bilateral blisters on bilateral lower extremities blisters are fluid filled, patient reported 7/10 pain on both lower legs today. On 5/8/2019 at 2:20 P.M., Patient requested to speak with me this afternoon as he/she had some questions about the copy of her medical record he/she received. She asked me to recount my interview with her the morning after the burn incident. I recalled our conversation and referenced the note I wrote about his/her account of the event. At time, he/she no longer believes he/she asked the CNA to heat his/her water for 3 minutes. I did let him/her know that was his/her statement the morning after the event and that I would note his/her change of the account. I asked if he/she had any other questions, he/she said yes, but would ask other people. A review of the facility investigation dated 4/19/2019 indicates the following: Incident narrative includes the following: The CNA heated the water per resident's request and chose not to check the temperature, as she knew it would be higher than the acceptable temperature. She brought the water to the room and placed it on the bedside table to mix powder, when the cup tipped and hot water spilled onto the patient's right knee and left shin. Internal investigation narrative indicates: The CNA is aware of the reheat policy but acted on patient's insistence. Summary of investigation: Water temperature above facility policy per patient request. On 06/04/19 at 10:28 [NAME]M., Resident #34 was interviewed and said he/she suffered 2nd [MEDICAL CONDITION] the right knee and left front of the lower leg. The Resident stated, he/she developed an infection and had to take antibiotics. The Resident had to attend to personal matters and asked if this surveyor would return to discuss his/[MEDICAL CONDITION]. On 06/06/19 at 09:30 [NAME]M., Resident #34 was again interviewed and stated that on 4/17/19 he/she asked CNA # 2 to take a packet of his/her personnel hot chocolate mix and make a cup of hot chocolate. The Resident states, the CNA left the packet and went to get hot water. When CNA #2 returned to the room, she placed the cup of hot water on the bedside table and Resident #34 said he/she could see the water bubbling. Resident #34 said, when CNA #7 reached for hot chocolate packet she knocked the cup over spilling hot water onto his/her legs. Resident #34 showed this surveyor both his/her legs, which were observed with discoloration of the skin to both the right knee and left lower leg. Resident #34 then showed this surveyor pictures of both his/her legs with multiple fluid filled areas ranging in size from small to large. The front of the left lower leg was noted to have large area of redness from below knee to above the ankle, and front and inside of the right knee was noted to have red area. On 06/06/19 at 3:56 P.M., CNA #2 was interviewed and stated Resident #34 asked her to make a cup of hot chocolate and the resident requested it to be very hot. She went and heated up water in brown cup in the microwave and returned to room placing the cup of hot water on the bedside table. CNA #2 states the Resident had a cast on her left hand and she thinks the Resident hit the table spilling the water. CNA #2 was asked if Resident #34 requested she heat the water for 3 minutes and she responded no. CNA #2 said that she thinks she heated the water for 2 minutes. She was asked if she could see steam or bubbles coming from the cup and she said no. CNA #2 stated, she usually makes hot chocolate in the kitchenette, but they were out of hot chocolate on the floor so she made in Resident's room using his/her personal hot chocolate. CNA #2 acknowledges she did not take the temperature of the water after heating it up in the microwave. On 06/06/19 at 4:28 P.M., the Food Service Director was interviewed by two surveyors and was asked about the reheating policy posted in the nourishment kitchenettes on the resident's floors. He stated a resident was burned 3 months ago by a nurse reheating in the microwave. He admits they used to just have a guideline for temperatures taped on the microwave. Now they have new charts posted, purchased thermometers and put in a log book for the staff to take temperatures and write them down.

Based on Resident observation, Resident and staff interviews and medical record review, the facility failed to offer and provide timely dental care to one Resident (#32), with a fractured, decaying and painful right molar. Findings include: Resident #32 was admitted to the facility in 6/2018 with a recent history of right lower molar abscess (3/26/19 and same molar with current pain), depression and anxiety. Review of the Minimum Data Set (MDS) upon admission (6/23/18) indicates a Brief Interview for Mental Status (BIMS) score of 15 out of 15 or cognitively intact with no oral/dental concerns (Section L). On 6/4/19 at 9:30 [NAME]M., the surveyor observed Resident #32 in bed. The Resident said that he/she was having trouble eating on the right side of mouth because he/she had a toothache which was very painful. The Resident said that the pain was usually about an 8 on a scale of 0-10 (10 being the most painful) and it interfered with sleep at night. The surveyor asked the Resident how the staff are helping him/her with managing the pain. Resident #32 said that he/she saw a dentist a while ago (1/3/19, but had no issues at that time). Review of the Pain Evaluation dated 3/27/19 indicates a pain description (section C) as aching and worse on movement of jaw. Under category E. or What makes the pain better? indicates not moving jaw. Section H indicates Resident started on antibiotics related to abscess in tooth. Review of the Nurse Practitioner's Patient Progress Note (dated 3/26/19) indicates the following: Resident seen today for right tooth pain. Right molar has been hurting for a few days and right cheek is swollen and does appear to have a decaying molar. Assessment and Plan indicates: [MEDICATION NAME] 250 mg. three times per day for 5 days, Tylenol 650 mg. every 6 hours for pain whenever necessary, ice pack to right cheek and if no improvement, consider oral surgeon referral. (A referral for an oral surgeon was not initiated until 6/4/19 and after surveyor inquiries to the Unit Manager.) Review of the Pain Monitoring section of the electronic Medication Administration Record [REDACTED]. Review of the Medication Administration Record [REDACTED]. (give 2 tabs) by mouth every 4 hours as needed for mild pain and do not exceed 3Grams/day with days administered 5/18 for pain level of 1, 5/20 for pain level of 8, 5/29 for pain level of 10, 5/30 for pain level of 8 and 5/31 for pain level of 3 for a total of 5 doses during the month of May. The Resident did not receive ice packs, despite a physician's orders [REDACTED].>Review of the Nursing Progress Note dated 5/29/19 at 6:42 [NAME]M. (59 days after the completion of antibiotics for the right molar abscess) complaining of right jaw pain and teeth, but with no follow-up about a dental evaluation until survey date of 6/4/19. Review of the Dietician's progress note, dated 3/21/19, indicates weight warning and -7.5% change and weight changes due to diuretic adjustments. (The Resident told the surveyor during the initial interview that he/she was not eating well because he/she could not chew on right side of mouth.) Review of the Resident's Care Plans indicates that a Dental Plan of Care was not developed until 6/6/19 following surveyor inquiry. The newly developed Dental Care Plan indicates: assess for signs of pain, inflammation, changes in nutritional status, monitor for discomfort or broken/loose teeth and obtain dental consult or referral as ordered. On the morning of 6/7/19, the Resident was interviewed again. The Resident said that the lowest level his/her pain has ever been, especially at night, is an 8. The Resident said it's been going on for weeks. The surveyor and Nurse #3 observed the right bottom molar to be cracked down the middle with what appeared to be a decaying tooth (completely black in the center) and a reddened gum surrounding the black molar. Nurse #3 asked the Resident if he/she was having pain and the Resident said yes and it's about an 8. Nurse #3 said that she would administer some Tylenol. On 6/18/19, review of the dental evaluation (report faxed to facility on 6/10/19 and therefore, not available during survey) indicated the following treatment notes: Patient reports pain right side especially while chewing. Tooth #31 (rear right molar) very reactive to percussion and appears to be distal fractured tooth and will need extraction with an oral surgeon. The reason for visit indicated toothache. The surveyor interviewed the Unit Manager (UM) throughout the survey. The UM said that the most recent dental evaluation of 6/4/19 indicates that the dentist could not manage the Resident's molar and recommended an oral surgeon referral. The UM started the oral surgeon referral process on 6/4/19 following the dentist's recommendation. On the morning of 6/7/19 Resident #32 was sent out to the hospital for further evaluation of his/her jaw and tooth pain. The emergency room Report indicates the Resident's pain level at 11:36 [NAME]M. at an 8. The Resident received [MEDICATION NAME] at 12:06 P.M. and follow-up pain assessment at 1:18 P.M. dropped to a pain level of 4. The Resident returned to the facility with a prescription for 1.) [MEDICATION NAME] 250 mg/5 ml. oral solution, 5 mls every 8 hours for 7 days and 2.) [MEDICATION NAME] 5-325 mg. tab every 8 hours for pain control.

Based on records reviewed and interviews, for one of five sampled residents (Resident #1), the Facility failed to ensure that nursing staff monitored Resident #1, who was cognitively impaired, and whose care needs were dependent upon staff, had adequate bowel elimination, received appropriate interventions and that physician orders [REDACTED].#1 experienced constipation and documentation indicated he/she did not have a bowel movement for nine consecutive days. Resident #1, who developed changes in condition, was transferred to the hospital, and when evaluated it was determined Resident #1 had abdominal distension and hard masses in the belly, which were determined to be a result of a massive fecal impaction and distension of the colon. Resident #1 died following admission to the Hospital. Findings include: The Facility Policy, titled Change in Condition: Notification of, dated [DATE], indicated that the facility must immediately consult with the patient's physician and notify the patient's Health Care Decision Maker when there is a significant change in the patient's physical, mental or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications. The Policy indicate to report to the physician signs and symptoms of constipation when there is less than one bowel movement in a week. The Facility Policy, titled Physician/Advanced Practice Provider Notification, dated [DATE], indicated upon identification of a patient who has a change in condition, a licensed nurse will perform appropriate clinical observations, collect pertinent patient information and report to the physician or advanced practice provider. Resident #1's medical [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], indicated that Resident #1 was rarely or never understood, was non-ambulatory, incontinent of bowel and bladder and dependent on staff for all toileting needs. The Physicians Orders and Medication Administration Records dated (MONTH) (YEAR), indicated the following: - Milk of Magnesia (MOM) Suspension 400 mg. (milligram) / 5 ml. (milliliter) give 30 ml. by mouth every 24 hours as needed for constipation at bedtime if no bowel movement in 3 days - [MEDICATION NAME] suppository insert one suppository rectally every 24 hours as needed for constipation if no result from MOM from previous shift - Fleet Enema ,[DATE] GM (gram) / 118 ML (milliliter) Sodium [MEDICATION NAME] - Insert one dose rectally every 24 hours as needed for constipation if no result call MD - Polyethylene [MEDICATION NAME] Powder 1450 give 17 gram by mouth as needed for constipation The Bowel Continence Documentation Record, dated (MONTH) 1, (YEAR) through (MONTH) 28, (YEAR), indicated Resident #1 was incontinent of a bowel and last bowel movement was recorded as a medium bowel movement on [DATE] at 10:08 A.M. The Record indicated Resident #1 had no bowel movement from [DATE] through [DATE]. Upon review of Resident #1's MAR, there was no documentation to indicate Resident #1 received any of the physician ordered laxative medications for the treatment of [REDACTED]. There was no documentation in the medical record to indicate the physician was notified that Resident #1 did not have a bowel movement for nine consecutive days. A Progress note, dated [DATE], indicated Resident #1 had inadequate oral intake. A Progress note, dated [DATE] at 4:00 A.M., indicated Resident #1 had oxygen saturation (extent to which hemoglobin is saturated with oxygen. Normal oxygen saturation range is usually between 95 % (percent) and 100 %) of 88% and was short of breath. The note indicated oxygen at 2 Liters/ minute via nasal cannula was to be administered to maintain oxygen saturation levels above 92% as needed for shortness of breath. A Progress note, dated [DATE] at 7:54 A.M., indicated Resident #1 had an episode of coughing up frothy sputum, Vital Signs - Temperature 100.6, Pulse 124 (Normal Range 60 -100), Respirations 24 (Normal Range 12 - 20), Blood Pressure ,[DATE] (Normal Range ,[DATE]-,[DATE]), oxygen saturation 84 - 88 %, was suctioned, oxygen applied at 2 Liters/minute, had audible wheezes, MD was called and made aware, chest x-ray ordered for the morning and nebulizer (device used to administer medication in the form of a mist inhaled into the lungs) was given. A Progress note, dated [DATE] at 2:57 P.M., indicated Nurse Practitioner was in, new orders for [MEDICATION NAME] (steroid medication) taper and Duo-Nebulizer (product containing 2 medications used to treat and prevent symptoms of wheezing and shortness of breath) every 4 hours while awake. A Progress note, dated [DATE] at 11:01 P.M., indicated chest x-ray was negative, reported to Nurse Practitioner who was in the facility at the time. A Progress note, dated [DATE] at 7:51 A.M., indicated Temperature 99.6, oxygen saturation 93 - 94 % on oxygen at 2 Liters/minute, suctioned twice for moderate amounts of frothy sputum, nebulizer given for wheezes and shortness of breath. A Progress note, dated [DATE] at 2:15 P.M., indicated resident noted with a decline in function, difficulty with oral intake, gurgling, suctioned once, oxygen at 5 Liters/minute via nasal cannula, oxygen saturation 83% on room air, 93 % on oxygen, Temperature 101.1 rectally, family and nurse practitioner aware, an order obtained to send resident to emergency room for evaluation. A Progress note, dated [DATE] at 11:45 P.M., indicated Resident #1 was admitted to the Intensive Care Unit at the Hospital with [MEDICAL CONDITION] (low oxygen saturation levels) and question of a bowel obstruction. Although a Nurse Practitioner Progress Note, dated [DATE], indicated a review of systems revealed no bloating, no nausea, no diarrhea and no abdominal pain and examination revealed a normal abdomen, bowel sounds present, soft, nontender and nondistended, the hospital emergency department note, dated [DATE] indicated on physical exam Resident #1's abdomen was tender, hard, significantly distended with hypoactive bowel sounds as well as hard masses felt in the right upper quadrant, right lower quadrant, left upper quadrant and left lower quadrant in his/her belly and a CT scan of the abdomen revealed severe fecal impaction and pneumatosis (gas cysts in the bowel wall consistent with necrotizing [MEDICATION NAME] - death of tissue in the intestine). The Nurse Practitioner was unavailable to interview. Review of the Nurses Progress Notes, dated [DATE] through [DATE], indicated there was no documentation to indicate nursing staff at the Facility assessed Resident #1 for a bowel movement, assessed for bowel sounds, provided any interventions or notified the nurse practitioner or physician that Resident #1 did not have a bowel movement for nine consecutive days. A Progress note, dated [DATE] at 3:19 P.M., indicated social worker informed that Resident #1 passed away on [DATE] while at the hospital. The Surveyor interviewed Nurse #2 at 10:43 A.M. on [DATE]. The Surveyor asked Nurse #2 about the Facility's Bowel Protocol. Nurse #2 said that the night nurse makes a laxative list and gives it to the day shift nurse. The Surveyor asked Nurse #2 to show the Surveyor the laxative list for today. Nurse #2 said that the night nurse did not give her a laxative list today and she did not have a laxative list. The Surveyor interviewed Nurse #2 again at 2:15 P.M. on [DATE]. Nurse #2 said Resident #1 was transferred to the hospital on [DATE] for a decline in condition related to respiratory issues, lethargy, not eating, low oxygen levels and said Resident #1's family wanted to him/her to be transferred to the hospital. Nurse #2 said she did not remember giving Resident #1 any laxatives because he/she always had loose stools. Nurse #2 said she was unaware that Resident #1 did not have a bowel movement for nine consecutive days while at the Facility. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 2:55 P.M. on [DATE]. CNA #1 said Resident #1 was incontinent of bowel, frequently soiled the brief, said when she wiped Resident #1, it seemed like something was there and wanted to come out, but nothing came out. CNA #1 said she reported this to the nurse. The Surveyor interviewed CNA #2 at 3:20 P.M. on [DATE]. CNA #2 said Resident #1 had watery brown stools for approximately two weeks before he/she went to the hospital. CNA #2 said she reported this to the nurse. The Surveyor interviewed the Nursing Supervisor at 3:55 P.M. on [DATE]. The Nursing Supervisor said he completed Resident #1's quarterly nursing assessment on [DATE]. The Nursing Supervisor said he documented that bowel sounds were present but said he did not assess Resident #1's abdomen or bowel sounds. The Nursing Supervisor said he was helping the nurses with assessments and said he asked a nurse if Resident #1 had bowel sounds. The Nursing Supervisor said Family Member #1 called him on [DATE] and asked him the date of Resident #1's last bowel movement. The Nursing Supervisor said he checked Resident #1's (MONTH) (YEAR) Bowel Documentation Record and noted that [DATE] was the last documented bowel movement. The Nursing Supervisor said that Resident #1 had not had a bowel movement in nine consecutive days, said this alarmed him and said that he reported this to the Director of Nurses. The Surveyor interviewed the Director of Nurses (DON) at 3:30 P.M. on [DATE]. The DON said she did not know why staff did not notice Resident #1 went nine consecutive days without a bowel movement and said she did not know why staff did not administer laxatives according to physician's orders [REDACTED]. The Surveyor interviewed Physician #2 at 11:07 A.M. on [DATE]. Physician #2 said he was unaware that Resident #1 had watery stools, said he was unaware Resident #1 had gone nine consecutive days without a bowel movement, said he was unaware that the staff did not administer any laxatives or follow the Facility's constipation protocol. Physician #2 said he was unaware that Resident #1 was transferred to the hospital in (MONTH) (YEAR). Physician #2 said the Nurse Practitioner who wrote Resident #1's progress note on [DATE] was unavailable to be interviewed due being out on a medical leave of absence. The Hospital Discharge Summary, dated [DATE], indicated Resident #1 presented to the emergency roiagnom on [DATE] and on physical examination presented with significant abdominal distension as well as hard masses in the belly. The Hospital Discharge Summary indicated a CT scan was obtained which showed sigmoid and rectal fecal impaction and pneumatosis with ischemic (insufficient blood flow) [MEDICAL CONDITION]. The Hospital Discharge Summary further indicated Resident #1 was placed on [MEDICAL CONDITION] (Bilevel Positive Airway Pressure - a device that helps with breathing) for respiratory distress secondary to abdominal distension, had hypoxemic [MEDICAL CONDITION] in the setting of abdominal distension and pneumonia, was septic secondary to urinary tract infection and [MEDICAL CONDITION]. The Hospital Discharge Summary indicated the renal and breathing issues were due to the distension of the sigmoid colon. Resident #1 was placed on comfort measures and subsequently died .

Based on records reviewed and interviews, for one of five sampled residents (Resident #1), the Facility failed to notify the Physician that Resident #1 experienced constipation and did not have a bowel movement for nine consecutive days and that Physician orders [REDACTED]. Resident #1, who was cognitively impaired, incontinent and dependent on staff for all toileting needs, developed changes in condition and was transferred to the hospital. When evaluated, it was determined Resident #1 had abdominal distension and hard masses in the belly, which were determined to be a result of a massive fecal impaction and distension of the colon. Resident #1 died following admission to the Hospital. Findings include: The Facility Policy, titled Change in Condition: Notification of, dated [DATE], indicated that the facility must immediately consult with the patient's physician and notify the patient's Health Care Decision Maker when there is a significant change in the patient's physical, mental or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications. The Policy indicate to report to the physician signs and symptoms of constipation when there is less than one bowel movement in a week. The Facility Policy, titled Physician/Advanced Practice Provider Notification, dated [DATE], indicated upon identification of a patient who has a change in condition, a licensed nurse will perform appropriate clinical observations, collect pertinent patient information and report to the physician or advanced practice provider. Resident #1's medical [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], indicated that Resident #1 was rarely or never understood, was non-ambulatory, incontinent of bowel and bladder and dependent on staff for all toileting needs. The Physicians Orders and Medication Administration Records, dated (MONTH) (YEAR), indicated the following: - Milk of Magnesia (MOM) Suspension 400 mg. (milligram) / 5 ml. (milliliter) give 30 ml. by mouth every 24 hours as needed for constipation at bedtime if no bowel movement in 3 days - [MEDICATION NAME] suppository insert one suppository rectally every 24 hours as needed for constipation if no result from MOM from previous shift - Fleet Enema ,[DATE] GM (gram) / 118 ML (milliliter) Sodium [MEDICATION NAME] - Insert one dose rectally every 24 hours as needed for constipation if no result call MD - Polyethylene [MEDICATION NAME] Powder 1450 give 17 gram by mouth as needed for constipation The Bowel Continence Documentation Record, dated (MONTH) 1, (YEAR) through (MONTH) 28, (YEAR), indicated Resident #1 was incontinent of bowel and last bowel movement was recorded as a medium bowel movement on [DATE] at 10:08 A.M. The Record indicated Resident #1 had no bowel movement from [DATE] through [DATE]. Upon review of Resident #1's MAR, there was no documentation to indicate Resident #1 received any of the physician ordered laxative medications for the treatment of [REDACTED]. There was no documentation in the medical record to indicate the physician was notified that Resident #1 did not have a bowel movement for nine consecutive days. The Surveyor interviewed Nurse #2 at 2:15 P.M. on [DATE]. Nurse #2 said Resident #1 was transferred to the hospital on [DATE] for a decline in condition related to respiratory issues, lethargy, not eating, low oxygen levels and said Resident #1's family wanted to him/her to be transferred to the hospital. Nurse #2 said she did not remember giving Resident #1 any laxatives because he/she always had loose stools. Nurse #2 said she was unaware that Resident #1 did not have a bowel movement for nine consecutive days while at the Facility and said she did not notify the nurse practitioner or physician. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 2:55 P.M. on [DATE]. CNA #1 said Resident #1 was incontinent of bowel, frequently soiled the brief, said when she wiped Resident #1, it seemed like something was there and wanted to come out, but nothing came out. CNA #1 said she reported this to the nurse. The Surveyor interviewed CNA #2 at 3:20 P.M. on [DATE]. CNA #2 said Resident #1 had watery brown stools for approximately two weeks before he/she went to the hospital. CNA #2 said she reported this to the nurse. The Surveyor interviewed the Nursing Supervisor at 3:55 P.M. on [DATE]. The Nursing Supervisor said Family Member #1 called him on [DATE] and asked him the date of Resident #1's last bowel movement. The Nursing Supervisor said he checked Resident #1's (MONTH) (YEAR) Bowel Documentation Record and noted that [DATE] was the last documented bowel movement. The Nursing Supervisor said that Resident #1 had not had a bowel movement in nine consecutive days, said this alarmed him and said that he reported this to the Director of Nurses. The Nursing Supervisor said he did not notify the nurse practitioner or physician. The Surveyor interviewed the Director of Nurses (DON) at 3:30 P.M. on [DATE]. The DON said she did not know why staff did not notice Resident #1 went nine consecutive days without a bowel movement and said she did not know why staff did not administer laxatives according to physician's orders [REDACTED]. The DON said the physician should have been notified of the change in condition. The Surveyor interviewed Physician #2 at 11:07 A.M. on [DATE]. Physician #2 said he was unaware that Resident #1 had watery stools, said he was unaware Resident #1 had gone nine consecutive days without a bowel movement, said he was unaware that the staff did not administer any laxatives or follow the Facility's constipation protocol. Physician #2 said he was unaware that Resident #1 was transferred to the hospital in (MONTH) (YEAR). Physician #2 said the Nurse Practitioner who wrote Resident #1's progress note on [DATE] was unavailable to be interviewed due being out on a medical leave of absence. The Hospital Discharge Summary, dated [DATE], indicated Resident #1 presented to the emergency roiagnom on [DATE] and on physical examination presented with significant abdominal distension as well as hard masses in the belly. The Hospital Discharge Summary indicated a CT scan was obtained which showed sigmoid and rectal fecal impaction and pneumatosis with ischemic (insufficient blood flow) [MEDICAL CONDITION]. The Hospital Discharge Summary further indicated Resident #1 was placed on [MEDICAL CONDITION] (Bilevel Positive Airway Pressure - a device that helps with breathing) for respiratory distress secondary to abdominal distension, had hypoxemic [MEDICAL CONDITION] in the setting of abdominal distension and pneumonia, was septic secondary to urinary tract infection and [MEDICAL CONDITION]. The Hospital Discharge Summary indicated the renal and breathing issues were due to the distension of the sigmoid colon. Resident #1 was placed on comfort measures and subsequently died .

Based on records reviewed and interviews, for one of five sampled residents (Resident #1), the Facility failed to provide services that met professional standards related to assessing, intervening and following physician orders [REDACTED].#1 experienced constipation for nine consecutive days and documentation indicated he/she did not have a bowel movement for nine consecutive days. Resident #1, who developed changes in condition, was transferred to the hospital, and when evaluated it was determined Resident #1 had abdominal distension and hard masses in the belly, which were determined to be a result of a massive fecal impaction and distension of the colon. Resident #1 died following admission to the Hospital. Findings include: Standard Reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered and practical nurse incorporated into the plan of care, and implement prescribed medical regimens. The rules and regulations 9.03 defined standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. M.G.L. 244 CMR 3.02: Responsibilities and Functions - Registered Nurse A registered nurse shall bear full and ultimate responsibility for the quality of nursing care he/she provides to individuals and groups. Included in such responsibility is health maintenance, teaching, counseling, collaborative planning and restoration of optimal functioning and comfort or for the dignified death of those they serve. A registered nurse, within the parameters of his/her generic and continuing education and experience, may delegate nursing activities to their registered and/or health care personnel, provided that the delegating registered nurse shall bear full and ultimate responsibility for: (3) the outcomes of that delegation. A registered nurse shall act, within his/her generic and continuing education and experience to: (e) evaluate outcomes of nursing intervention, and initiate change when appropriate; (f) collaborate, communicate and cooperate as appropriate with other health care providers to ensure quality and continuity of care. The Facility Policy, titled Change in Condition: Notification of, dated [DATE], indicated that the facility must immediately consult with the patient's physician and notify the patient's Health Care Decision Maker when there is a significant change in the patient's physical, mental or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications. The Policy indicate to report to the physician signs and symptoms of constipation when there is less than one bowel movement in a week. The Facility Policy, titled Physician/Advanced Practice Provider Notification, dated [DATE], indicated upon identification of a patient who has a change in condition, a licensed nurse will perform appropriate clinical observations, collect pertinent patient information and report to the physician or advanced practice provider. Resident #1's medical [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], indicated that Resident #1 was rarely or never understood, was non-ambulatory, incontinent of bowel and bladder and dependent on staff for all toileting needs. The Physicians Orders and Medication Administration Records dated (MONTH) (YEAR), indicated the following: - Milk of Magnesia (MOM) Suspension 400 mg. (milligram) / 5 ml. (milliliter) give 30 ml. by mouth every 24 hours as needed for constipation at bedtime if no bowel movement in 3 days - [MEDICATION NAME] suppository insert one suppository rectally every 24 hours as needed for constipation if no result from MOM from previous shift - Fleet Enema ,[DATE] GM (gram) / 118 ML (milliliter) Sodium [MEDICATION NAME] - Insert one dose rectally every 24 hours as needed for constipation if no result call MD - Polyethylene [MEDICATION NAME] Powder 1450 give 17 gram by mouth as needed for constipation The Bowel Continence Documentation Record, dated (MONTH) 1, (YEAR) through (MONTH) 28, (YEAR), indicated Resident #1 was incontinent of bowel and last bowel movement was recorded as a medium bowel movement on [DATE] at 10:08 A.M. The Record indicated Resident #1 had no bowel movement from [DATE] through [DATE]. Upon review of Resident #1's MAR, there was no documentation to indicate Resident #1 received any of the physician ordered laxative medications for the treatment of [REDACTED]. There was no documentation in the medical record to indicate the physician was notified that Resident #1 did not have a bowel movement for nine consecutive days. A Progress note, dated [DATE], indicated Resident #1 had inadequate oral intake. A Progress note, dated [DATE] at 4:00 A.M., indicated Resident #1 had oxygen saturation (extent to which hemoglobin is saturated with oxygen. Normal oxygen saturation range is usually between 95 % (percent) and 100 %) of 88% and was short of breath. The note indicated oxygen at 2 Liters/ minute via nasal cannula was to be administered to maintain oxygen saturation levels above 92% as needed for shortness of breath. A Progress note, dated [DATE] at 7:54 A.M., indicated Resident #1 had an episode of coughing up frothy sputum, Vital Signs - Temperature 100.6, Pulse 124 (Normal Range 60 -100), Respirations 24 (Normal Range 12 - 20), Blood Pressure ,[DATE] (Normal Range ,[DATE]-,[DATE]), oxygen saturation 84 - 88 %, was suctioned, oxygen applied at 2 Liters/minute, had audible wheezes, MD was called and made aware, chest x-ray ordered for the morning and nebulizer (device used to administer medication in the form of a mist inhaled into the lungs) was given. A Progress note, dated [DATE] at 2:57 P.M., indicated Nurse Practitioner was in, new orders for [MEDICATION NAME] (steroid medication) taper and Duo-Nebulizer (product containing 2 medications used to treat and prevent symptoms of wheezing and shortness of breath) every 4 hours while awake. A Progress note, dated [DATE] at 11:01 P.M., indicated chest x-ray was negative, reported to Nurse Practitioner who was in the facility at the time. A Progress note, dated [DATE] at 7:51 A.M., indicated Temperature 99.6, oxygen saturation 93 - 94 % on oxygen at 2 Liters/minute, suctioned twice for moderate amounts of frothy sputum, nebulizer given for wheezes and shortness of breath. A Progress note, dated [DATE] at 2:15 P.M., indicated resident noted with a decline in function, difficulty with oral intake, gurgling, suctioned once, oxygen at 5 Liters/minute via nasal cannula, oxygen saturation 83% on room air, 93 % on oxygen, Temperature 101.1 rectally, family and nurse practitioner aware, an order obtained to send resident to emergency room for evaluation. A Progress note, dated [DATE] at 11:45 P.M., indicated Resident #1 was admitted to the Intensive Care Unit at the Hospital with [MEDICAL CONDITION] (low oxygen saturation levels) and question of a bowel obstruction. Although a Nurse Practitioner Progress Note, dated [DATE], indicated a review of systems revealed no bloating, no nausea, no diarrhea and no abdominal pain and examination revealed a normal abdomen, bowel sounds present, soft, nontender and nondistended, the hospital emergency department note, dated [DATE] indicated on physical exam Resident #1's abdomen was tender, hard, significantly distended with hypoactive bowel sounds as well as hard masses felt in the right upper quadrant, right lower quadrant, left upper quadrant and left lower quadrant in his/her belly and a CT scan of the abdomen revealed severe fecal impaction and pneumatosis (gas cysts in the bowel wall consistent with necrotizing [MEDICATION NAME] - death of tissue in the intestine). The Nurse Practitioner was unavailable to interview. Review of the Nurses Progress Notes, dated [DATE] through [DATE], indicated there was no documentation to indicate nursing staff at the Facility assessed Resident #1 for a bowel movement, assessed for bowel sounds, provided any interventions or notified the nurse practitioner or physician that Resident #1 did not have a bowel movement for nine consecutive days. A Progress note, dated [DATE] at 3:19 P.M., indicated social worker informed that Resident #1 passed away on [DATE] while at the hospital. The Surveyor interviewed Nurse #2 at 10:43 A.M. on [DATE]. The Surveyor asked Nurse #2 about the Facility's Bowel Protocol. Nurse #2 said that the night nurse makes a laxative list and gives it to the day shift nurse. The Surveyor asked Nurse #2 to show the Surveyor the laxative list for today. Nurse #2 said that the night nurse did not give her a laxative list today and she did not have a laxative list. The Surveyor interviewed Nurse #2 again at 2:15 P.M. on [DATE]. Nurse #2 said Resident #1 was transferred to the hospital on [DATE] for a decline in condition related to respiratory issues, lethargy, not eating, low oxygen levels and said Resident #1's family wanted to him/her to be transferred to the hospital. Nurse #2 said she did not remember giving Resident #1 any laxatives because he/she always had loose stools. Nurse #2 said she was unaware that Resident #1 did not have a bowel movement for nine consecutive days while at the Facility. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 2:55 P.M. on [DATE]. CNA #1 said Resident #1 was incontinent of bowel, frequently soiled the brief, said when she wiped Resident #1, it seemed like something was there and wanted to come out, but nothing came out. CNA #1 said she reported this to the nurse. The Surveyor interviewed CNA #2 at 3:20 P.M. on [DATE]. CNA #2 said Resident #1 had watery brown stools for approximately two weeks before he/she went to the hospital. CNA #2 said she reported this to the nurse. The Surveyor interviewed the Nursing Supervisor at 3:55 P.M. on [DATE]. The Nursing Supervisor said he completed Resident #1's quarterly nursing assessment on [DATE]. The Nursing Supervisor said he documented that bowel sounds were present but said he did not assess Resident #1's abdomen or bowel sounds. The Nursing Supervisor said he was helping the nurses with assessments and said he asked a nurse if Resident #1 had bowel sounds. The Nursing Supervisor said Family Member #1 called him on [DATE] and asked him the date of Resident #1's last bowel movement. The Nursing Supervisor said he checked Resident #1's (MONTH) (YEAR) Bowel Documentation Record and noted that [DATE] was the last documented bowel movement. The Nursing Supervisor said that Resident #1 had not had a bowel movement in nine consecutive days, said this alarmed him and said that he reported this to the Director of Nurses. The Surveyor interviewed Physician #2 at 11:07 A.M. on [DATE]. Physician #2 said he was unaware that Resident #1 had watery stools, said he was unaware Resident #1 had gone nine consecutive days without a bowel movement, said he was unaware that the staff did not administer any laxatives or follow the Facility's constipation protocol. Physician #2 said he was unaware that Resident #1 was transferred to the hospital in (MONTH) (YEAR). Physician #2 said the Nurse Practitioner who wrote Resident #1's progress note on [DATE] was unavailable to be interviewed due being out on a medical leave of absence. The Hospital Discharge Summary, dated [DATE], indicated Resident #1 presented to the emergency roiagnom on [DATE] and on physical examination presented with significant abdominal distension as well as hard masses in the belly. The Hospital Discharge Summary indicated a CT scan was obtained which showed sigmoid and rectal fecal impaction and pneumatosis with ischemic (insufficient blood flow) [MEDICAL CONDITION]. The Hospital Discharge Summary further indicated Resident #1 was placed on [MEDICAL CONDITION] (Bilevel Positive Airway Pressure - a device that helps with breathing) for respiratory distress secondary to abdominal distension, had hypoxemic [MEDICAL CONDITION] in the setting of abdominal distension and pneumonia, was septic secondary to urinary tract infection and [MEDICAL CONDITION]. The Hospital Discharge Summary indicated the renal and breathing issues were due to the distension of the sigmoid colon. Resident #1 was placed on comfort measures and subsequently died .

Based on interview, observations and record review, the Facility staff failed to ensure that Residents were provided an environment that was free from accident hazards and provided supervision and assistive devices to prevent avoidable accidents for 3 Resident (#52, #53, #153), in a total sample of 39 Residents. Findings include: 1. For Resident #153, the facility failed to ensure that the Resident's environment was free from accident hazards, and adequate interventions were implemented, monitored for effectiveness and modified when necessary to prevent 9 falls in a 7 month period, 2 of which resulted in lacerations to the Resident's right eye. Review of the facility's Falls Management Policy (last revised 3/15/16), included the following: -Residents would be assessed for falls risk as part of the nursing assessment process -those determined to be at risk would receive appropriate interventions to reduce risk and minimize injury -Individualized careplans will be developed, reviewed and revised regularly -If the Resident falls, document the accident/incident, and update the care plan to reflect new interventions Resident #153 was admitted to the facility in 9/2017 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) with a reference date of 9/8/17, indicated that Resident #153 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 6 out of 15, required assistance for activities of daily living, and was incontinent of urine. Review of the medical record indicated the following care plans: -Falls (initiated 9/3/17): Offer/assist Resident with urinal/commode as needed, monitor and assist with toileting needs, place all necessary personal items within reach, remind Resident to use call light when attempting to ambulate or transfer -Activity of Daily Living (initiated 9/19/17): Assist with toileting Falls: 1. Review of the medical record indicated that Resident #153 had an unwitnessed fall out of bed on 9/7/17 at 9:00 P.M. Review of the fall investigation indicated that the Resident was sitting in bed watching television with his/her significant other (SO). When the SO left the room, Resident #153 fell out of bed. The Resident said that he/she was getting up to get a urinal when the fall occurred. The Resident did not sustain injury as a result of the fall. Corrective actions were to educate the Resident to use the call light for assistance prior to getting out of bed. 2. Review of the medical record indicated that Resident #153 had another unwitnessed fall on 9/11/17 at 9:00 P.M. Review of the fall investigation indicated that he/she was found on the floor of the bathroom by a CNA (certified nursing assistant). The sound of the bed alarm was faint as it was found beneath a pillow. The Resident said that he/she had to use the bathroom and no one came to help. The Resident did not sustain an injury. Corrective actions were to re-educate the Resident to use call light prior to attempt to ambulate/need for assistance, and wear non-skid socks. Re-education was an intervention that was already in place prior to the fall. 3. Unwitnessed fall on 9/25/17 at 3:30 P.M. Review of the fall investigation indicated that he/she was found by a CNA lying on the floor at the foot of his/her bed. The Resident said that he/she was trying to get up to use the bathroom. The Resident did not sustain an injury. The report indicated that the Resident's SO was in to visit earlier, but left because the Resident fell asleep. The bed alarm did not sound because it was not plugged in properly. Corrective actions were to re-educate the Resident's family to no leave the Resident unattended without notifying staff, and move the bed alarm box to the lower end of the bed out of the Resident's reach. 4. Unwitnessed fall on 9/28/17 at 2:20 A.M. Review of the fall investigation indicated that Resident #153 was found by a CNA lying on the floor. The Resident said that he/she was walking back from the bathroom when he/she fell . The bed alarm did not sound and was found to be non-functioning. The Resident did not sustain an injury. Corrective actions were to replace the bed alarm and re-educate the Resident to call for assistance (not a new intervention) 5. Witnessed fall on 10/7/17 at 3:25 A.M. Review of the fall investigation indicated that he/she was found by a nurse in his/her bathroom, after hearing a faint bed alarm sound and not finding the Resident in bed. The nurse opened the bathroom door and witnessed the Resident slide down the wall to the floor in front of the toilet. The Resident did not sustain an injury. The report indicated that the bed alarm was found under the blankets. Corrective actions included moving the bed alarm box out of the Resident's reach (not a new intervention) , and adding a motion sensor to the Resident's room for use while he/she is in bed. The bed alarm was discontinued on 10/9/17 due to the Resident's continuous behavior of disengaging alarm and hiding it under blankets and pillows. 6. Unwitnessed fall on 2/14/18 at 7:00 P.M. Review of the fall investigation indicated that Resident #153 was found on the floor of the unit hallway bathroom after being left unattended by a CNA. The resident sustained [REDACTED]. Corrective actions included disciplinary action given to staff member, and education provided on safety awareness. Review of the medical record indicated that the motion sensor was discontinued on 2/27/18. 7. Unwitnessed fall on 3/20/18 at 1:30 A.M. Review of the fall investigation indicated that Resident #153's roommate alerted staff the he/she was on the floor. The Resident said that he/she was going to the bathroom and fell when getting out of bed, bumped his/her chest/ribs on the foot board, sustained an abrasion/redness on the front left side of his/her chest. Corrective actions included to keep the call light within the Resident's reach, encourage the Resident to use a urinal every 2 hours while in bed (not new interventions). 8. Unwitnessed fall on 3/22/18 at 11:00 A.M. Review of the fall investigation indicated that Resident #153's roommate alerted staff that he/she was on the floor. The Resident said that he/she wanted to get up out of bed. The Resident did not sustain an injury. Corrective actions indicated that bolsters were added to the Resident's bed. 9. Unwitnessed fall on 4/3/18 at 5:00 A.M. Review of the fall investigation indicated that Resident #153 was found on the floor at his/her bedside. The Resident said that he/she wanted to move his/her bowels and slipped when getting out of bed. The Resident bumped his/her head on the bed frame, and sustained a laceration to the Right eyebrow. Corrective actions indicated the Resident would be encouraged to be brought to the toilet on rounds. During interview with Nurse #4 on 4/4/18 at 10:46 A.M., she said that the Resident used to have a motion sensor, but it was discontinued on 2/27/28, and the only intervention in place right now are the bolsters which were put on the Resident's bed after the bed rails were removed on 3/22/18. She said that the Resident fell out of bed yesterday (4/3/18) and hit his/her head on the footboard of his/her roommate's bed, and he/she has a cut to the Right eyebrow with 2 steri strips in place. The Resident was interviewed on 4/4/18 at 11:00 A.M. while he/she was seated in a wheelchair in the unit dayroom. The Resident said that he/she fell out of bed and hit his/her head when he/she tried to get out of bed. 2 steri strips were noted on the Residents' Right eyebrow with dark blue bruising noted on the eyebrow/temple area. The skin surrounding the Resident's right eye was noted to be reddened and swollen. Unit Manager #3 (UM#3) was interviewed on 4/4/18 at 11:59 A.M. She said that on 4/3/18, Resident #153 scooted to the end of the bolster on his/her bed and fell out while trying to get out of bed. UM#3 said that the bolsters were added to the Resident's bed once the bedrails were removed in March. 2. For Resident #53, who had an above the knee amputation of the Right leg, and a chronic ulcer of the great toe of the Left foot, the facility failed to ensure that assistive devices were provided to prevent the Resident from falling out of bed and sustaining multiple abrasions to the left knee. Resident #53 was admitted to the facility in 1/2016 with [DIAGNOSES REDACTED]. Review of the most recent Annual MDS with a reference date of 1/11/18, indicated that Resident #53 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15, required extensive assistance for bed mobility and transfers, and no falls. During interview with Nurse #4 on 3/29/18 at 8:37 A. M., she said that Resident # 53 was very upset when facility removed his/her bedrails, and has told her that he/she wants them back. She said the Resident is an [MEDICAL CONDITION] and relies on them to reposition and get up out of bed and transfer to a wheelchair. She said that without rails, he/she struggles to maneuver him/herself to sit up using his/her elbows. Nurse #4 said that Resident #53 fell out of bed 2 days ago while trying to transfer to a wheelchair because the bed rails had been removed and he/she had nothing to hang on to. She said he/she sustained abrasions to the left knee. On 3/29/18 at 3:20 P.M., Resident # 53 was observed seated in his/her wheelchair assembling a puzzle at a table outside of the main dining room. Several dark red, irregular shaped scabs were noted on his left kneecap and on the skin below the kneecap. During interview on 3/30/18 at 9:15 A.M., Resident #53 said that he/she wants the side rails reattached to his/her bed. The Resident said that they were removed about 3 weeks ago and was told that the State ordered that they be removed. The Resident said that he/she used the rails for positioning and to adjust from a lying to sitting position, and that he/she does not have the abdominal strength to sit up on his/her own. Resident # 53 said that on Tuesday (3/27/18), he/she was trying to transfer from the bed to the wheelchair, and he/she wound up slipping off the mattress and onto the floor between the bed and wheelchair. The Resident showed the Surveyor three dark red scabs on his/her Left kneecap. He /she said that staff heard him fall, and two staff came into his/her room to assist him/her. They helped him/her up off the floor and cleaned the wounds. Resident said again that he/she wants the siderails back. Review of the the medical record indicated Resident #53 had an active physician's orders [REDACTED]. Review of the medical record indicated a bed rail evaluation dated 3/2/18, indicated that Resident #53 was able to perform the following bed mobility tasks and transfers independently with bed rails in place: turn side to side, move up and down in bed, pull self from laying to sitting position, balance self while transferring to and from bed, support self, enter/exit bed safety (including for toileting), and transfer safely to and from bed. Review of documentation provided by the facility's Maintenance Director on 4/3/18, indicated that Resident #52's bed rails were removed from his/her bed on 3/9/18. Review of the medical record indicated a 3/27/18 nursing progress note which indicated that Nurse #7 was in another Resident's room next to Resident #53 and heard a noise. The nurse indicated that she went next door to check on the Resident and found him/her on the floor on his/her knee. The nursing note indicated that the Resident had three small abrasions to Right knee. The wounds were cleansed and dried. Review of the fall incident report dated 3/27/18, indicated that Resident #53 had an unwitnessed fall out of bed while attempting to get out of bed. The summary of the investigation indicated that Resident #53 fell while trying to get out of bed. The Resident told staff that if he/she had bed rails, the fall would not have happened. A Care Plan Evaluation Note dated 3/28/18, indicated the Resident's mattress was changed to defined perimeter mattress, a rehab screen was sent for bed mobility and weakness, and a bed rail evaluation was completed. Review of bed rail evaluation dated 3/28/18 (nearly two weeks after the bed rails were removed), indicated that Resident #53 was unable to pull him/herself from laying to sitting position, unable to balance self while transferring to and from bed, unable to enter/exit the bed safely (including for toileting), and was unable to transfer safely to and from bed. The facility failed to ensure that Resident #53 was provided assistive devices to prevent a fall out of bed with injury. 3. For Resident #52, the facility failed to ensure that Curad Normal Saline Solution and Santyl (a topical ointment used to remove dead tissue from a wound) was not left at the bedside and accessible to other Residents on a unit which wandering Residents lived. Resident # 52 was admitted to the facility in 5/2010 with [DIAGNOSES REDACTED]. During his/her stay at the facility, the Resident developed a facility acquired pressure ulcer to his/her right heel. Review of the most recent quarterly Minimum Data Set (MDS) with a reference date of 1/11/18, indicated that Resident #52 had impaired short and long term memory, had severely impaired skills for daily decision making, and was dependent on staff for all activities of daily living. Review of the medical record indicated a 3/16/18 Nurse Practitioner's progress note which identified a non-healing, unstageable wound on right heel with an order for [REDACTED]. On 3/24/18 at 8:00 A.M. and 11:34 AM, Curad Saline Wound Wash and a prescription box containing a tube of Santyl ointment was observed in an opened box of gauze pads on the nightstand next to Resident #52's bed. During interview with Unit Manager #2 (UM#2) on 4/4/18 at 12:30 P.M., she said that treatments should not be left at the bedside.

Based on record review and interview, the facility staff failed to provide appropriate treatment and services to prevent a decline in continence for 1 Resident (#82) out a total of 39 sampled residents. Findings include: Resident #82 was admitted to the facility in 10/2017 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) with a reference date of 10/25/17, indicated that Resident #82 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15, required limited assistance with activities of daily living including an assist of 1 for toileting, was continent of bowel and bladder and was administered a diuretic (medication that causes increased excretion of urine) daily. During interview with the facility's Ombudsman on 3/27/18 at 10:47 A.M., she said that Resident #82 told her that he/she was upset and cried because he/she had wet the bed because the facility had removed his/her bed rails. The Resident told her that he/she used the bed rails to reposition and get him/herself up and out of bed and go the the bathroom independently, but is not able to do so anymore and now wets him/herself. During interview on 3/27/18 at 8:32 A.M., Resident #82 said that since his/her bed rails were removed a few weeks ago, he/she is no longer able to get up out of bed independently to use the bathroom and wets the bed. The Resident became tearful and said that he/she takes 100 mg(milligrams) of [MEDICATION NAME] (diuretic), which makes him/her urinate more frequently. The Resident said that the staff are busy and can't assist him/her in time, because now it takes 2 staff members to help and there often is not enough staff. Therefore, he/she often wets the bed. The Resident began to cry and said that he/she was humiliated and sad that he/she is no longer able to make it to the bathroom independently. Review of physician's orders [REDACTED].#82 is administered the following medications with diuretic properties: [MEDICATION NAME] 40 mg daily (antihypertensive with diuretic), [MEDICATION NAME] 60 mg two times daily. Review of the medical record indicated Bed Rail Evaluations dated 3/2/18 and 3/6/18 which identified the Resident's medical conditions related to the need for a bed rails as [MEDICAL CONDITION] and obesity, and recommended bed rails for bed mobility. Review of Nursing Progress Notes indicated that on 3/7/18, a bed rail assessment was completed, a rehab screen was sent for bed mobility, and new urinary incontinence related to difficulty transferring self out of bed was identified. Review of the Occupational Therapy (OT) Initial Evaluation dated 3/5/18, indicated that Resident #82 was referred for skilled OT in order to assess independence in room and in and out of bed to determine need for bed rails. The evaluation noted the Resident's prior level of function with bed mobility and toileting was independent utilizing bed rails. The Resident's current level of function with bed mobility and toileting without the use of a bed rail is maximum assistance. Review of the medical record indicated a 3/22/18 Social Service progress note. The note indicated that the facility social worker met with Resident #82 on 3/22/18 and the Resident reported feeling depressed related to his/her decrease in independence. The Resident expressed concern about the removal of his/her bed rails and said that he/she felt trapped in his/her bed and had episodes of incontinence. The Resident told the social worker that he/she used to bed rails for leverage to get him/herself out of the bed. During interview with Nurse #4 on 3/29/18 at 8:37 A.M., she said that Resident #82 used to be able to get him/herself up out of bed and go to the bathroom independently during the day. But now that the bed rails have been removed, the Resident requires the assistance of 2 staff now and often wets him/herself before staff can arrive to assist. She said that Resident #82 is very upset about not being able to make it to the bathroom anymore and cries. During interview with CNA #2 on 4/4/18 at approximately 1:30 P.M., she said that Resident #82 is on her assignment and provides care for him/her everyday. CNA #2 said that up until the bed rails were removed a few weeks ago, she would assist the Resident up to the bathroom when he/she woke up, but the Resident was independent with toileting during the day. She went on to say that after the bed rails were removed, the Resident now requires assistance of 2 staff for toileting all the time. A care plan for urinary incontinence due to slow mobility was developed on 3/28/18. However, there were no interventions or strategies identified to assist the Resident in regaining independence in toileting.

Based on record review and staff interview, the facility failed for 1 resident (#3) of a total sample of 27 residents, to ensure that each resident have proper supervision to prevent accidents. For Resident #3, the facility failed to ensure that safety equipment, implemented to alert staff that the resident was attempting unsafe ambulation, was present and functioning. At the time of all three falls, the device was not working. The fall on 1/8/11 resulted in a fractured elbow and a hip fracture. The findings included: Resident #3 had [DIAGNOSES REDACTED]. The resident's most recent quarterly Minimum Data Set Assessment (MDS) with a reference date of 3/5/11 indicated that the resident was cognitively impaired and was dependent on facility staff to complete the activities of daily living. On 2/7/10, the resident was assessed as high risk for falls. A care plan, developed 10/28/09, included interventions that included; motion sensor in the room (initiated 2/8/10) personal alarm in wheelchair (2/8/10,) crash mat by the bed (2/8/10,) verbal cues for safety (10/28/09). These interventions remained in effect. On 8/14/10 at 2:15 PM, the resident was found on the floor at the end of the "Northside" hallway on the Unit. Per review of the incident report, the resident was confused and reported wanting to go outside. A statement about the fall, completed by nurse aide #1, reported that the personal alarm "wasn't ringing." A "Patient Fall Investigation Form," completed by the Unit Manager after the fall, wrote "not applicable" to a question about whether an alarm was "on and functioning" at the time of the fall. "New interventions" to be completed included inservicing staff "re: alarms." On 9/30/10 at 4:15 PM, the resident was found on the floor of the Unit hallway after attempting to get up out of the wheelchair. Statements gathered at the time of the fall investigation from four of facility staff indicated that the resident did not have a functioning alarm in place at the time of the fall. The "Patient Fall Investigation Form," completed by the Unit Manager who wrote: "on but not working" to a question about whether an alarm was "on and functioning" at the time of the fall. "New interventions" to be completed included inservicing staff "re: alarms." Further investigation by the Unit Manager indicated that a day shift nurse aide was aware that the equipment was missing and forgot to report it to the nurse. Per interview with the Unit Manager #1 on 4/20/11 at 11 AM and review of the investigation, the inservicing took place on 10/2/10 with Unit Manager discussing with facility staff the importance of immediately reporting missing safety equipment. On 1/8/11 at 5:05 PM, the resident fell to the floor in the Unit dining room after attempting to get up from the wheelchair. The incident report indicated that the resident landed on his/her buttocks and right elbow. Statements gathered from staff indicated that the resident did not have a functioning alarm in place at the time of the fall. An X-ray, ordered by the primary physician at the time of the fall after the resident complained of pain, determined the resident had a right elbow fracture. The resident was subsequently sent to the hospital where a fracture of the right hip was discovered. The resident required surgery to repair both fractures. Per interview with Unit Manager #1 on 4/20/11 at 11 AM, facility nurse aides are solely responsible for ensuring that safety devices were in place. Facility nurses would need to consult the CNA care card to determine what safety devices a resident utilized. The investigation of the 1/8/11 fall, completed by the Unit Manager, determined that facility staff were aware that the alarm had been broken on 1/6/11. Despite that the alarm was removed and brought to the nursing station, facility nurse aides continued to sign that the alarm was present on the "Safety Alarm Checklist." The alarm was not replaced and an effective alternate safety plan was not instituted between 1/6/11 and the fall on 1/8/11. Per interview with the Unit Manager #1 on 4/20/11 at 11 AM, after the 1/8/11 fall, the facility implemented a plan that extra back-up devices would be available on the nursing units in case any device malfunctioned.