Every finding on record at Seacoast Nursing and Rehabilitation Center

Based on observations, record reviews and interviews, the facility failed to prevent a decline in range of motion leading to the development of a contracture for one Resident (#46) out of a total sample of 26 residents. Findings include: Review of the facility policy titled 'Resident Mobility and Range of Motion, dated September 2024, indicated the following: - Residents will not experience an avoidable reduction in range of motion (ROM). - Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in (ROM). - Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts. Resident #46 was admitted to the facility in November 2020 with diagnoses including dementia, apraxia, polymyalgia rheumatica (a condition that causes muscle pain and stiffness), and abnormal posture. Resident #46's diagnosis list did not include a diagnosis of arthritis. Review of Resident #46's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident scored a 5 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she has severe cognitive impairment. Section GG of this MDS indicated Resident #46 has no impairment to his/her range of motion of his/her bilateral upper and lower extremities. On 5/13/25 at 7:53 A.M., Resident #46 was observed lying in bed with his/her right hand in a closed fisted position. When the surveyor asked the Resident to open his/her hand, the Resident was able to straighten his/her thumb and pointer finger and the third through fifth fingers remained bent. The Resident then attempted to straighten these fingers using his/her left hand and was unable to, saying it was painful, and a facial grimace was observed during the attempt. Resident #46 said his/her fingers have been like this for a while. Review of Resident #46's medical record failed to indicate that the Resident had a documented limit of range of motion of the right hand in any physician, nurse practitioner, or nursing notes or in any nursing assessments. On 5/14/25 at 7:43 A.M., the surveyor again observed Resident #46 lying in bed. The Resident was again observed with his/her right third through fifth fingers bent in a claw position. Resident #46 said his/her right hand hurt, again attempted to open his/her fingers on his/her own and was unable to. The Resident again winced in pain with attempted movement of those fingers. During an interview on 5/14/25 at 7:45 A.M., Certified Nursing Assistant (CNA) #1 said Resident #46 is able to fully open his/her hand sometimes and that the hand is not always stuck closed. CNA #1 then entered Resident #46's room and with the Resident's permission attempted to straighten the Resident's right hand fingers. The Resident grimaced in pain when CNA #1 began to move the fingers, pulled his/her hand back and would not let CNA move the fingers anymore. During an interview on 5/14/25 at 7:51 A.M., Unit Manager #1 said Resident #46 was recently seen by occupational therapy for a change in range of motion to his/her right hand. Unit Manager #1 said the Resident was fully able to open his/her hand at that time. Unit Manager #1 said she was unaware that at this point in time the Resident was unable to open three fingers on his/her right hand. Unit Manager #1 said if any resident were to experience a change in range of motion, the nursing staff should make a referral to therapy and notify the nurse practitioner of this change. On 5/14/25 at 8:05 A.M., the Director of Rehabilitation (DOR) provided the surveyor with a therapy screen completed on 2/3/25. The screen indicated that Resident #46 was referred to therapy for splinting needs and contractures for his/her right ring finger. The screen further indicated that at this time the Resident was able to have full range of motion of the right ring finger and no evaluation or therapy was indicated. The DOR said she was unaware Resident #46 was unable to straighten three fingers during today's observation and said she would have an occupational therapist assess him/her today. On 5/14/25 at 12:25 P.M., the surveyor was provided with an occupational therapy evaluation completed on this date. The evaluation indicated the following: - Reason for referral: pt (patient) is an [AGE] year old (male/female) resident of this setting. pt referred to skilled intervention to address contracture management of right dominant hand. pt was previously screened in 2/25 due to middle right trigger finger. At the time pt was able to perform AROM (active range of motion) of all digits without c/o (complaints of) pain. At this time pts condition has exacerbated involving digits (fingers) 3-5/ pt demonstrates no pain in resting position and is able to use dominant hand for self feeding and other tasks using digits one and two. Pt at this time will benefit from skilled intervention to address decline through positioning, education and manual therapy as pt tolerates. (sic) - Medical history and complexities: Contracture right hand digits 3-5. - UE (upper extremity) ROM: impaired - Clinical impressions: skilled OT (occupational therapy) to address right dominant hand contracture in digits 3-5. During an interview with the DOR and the Occupational Therapist (OT) on 5/14/25 at 12:25 P.M., the DOR said the OT evaluated Resident #46 this morning and found a new contracture to the Resident's right hand. The OT said there was a definite new contracture of Resident #46's third through fifth fingers. The OT said she did not know the cause of the contracture, that he/she previously had a trigger finger and that the Resident does not have a diagnosis of arthritis. The OT said she made a goal for the Resident to tolerate a hand carrot (an orthotic in the shape of a carrot that gets progressively wider at the top of the orthotic. The carrot is labeled in stages, with the wider top being a higher number) and that during the evaluation, the Resident was able to tolerate the carrot at a level 6, but as soon as she attempted to move the carrot to level 7 (increased the opening of the fingers) the Resident experienced pain and removed the carrot. The OT said she recommended skilled intervention to treat the new contracture. During a follow-up interview on 5/14/25 at 12:36 P.M., Unit Manager #1 said she had not noticed Resident #46's hand had gotten worse since February. During an interview on 5/14/25 at 12:54 P.M., Resident #46's Health Care Proxy (HCP) said she had noticed the Resident was unable to open his/her right ring finger about two months ago. The HCP said that therapy saw the Resident at this point and although they said she could straighten his/her finger, his/her hand never fully open. The HCP said that she had noticed that Resident #46's hand had become more claw-like in the past few weeks and she had reported this to the nursing staff. Resident #46's HCP said she was told that the Resident had arthritis but said she has known the Resident for 47 years and has never known him/her to have arthritis. Resident #46's HCP said she has also noticed this decline in range of motion has also affected the Resident's ability to use the hand for everyday tasks such as self-feeding. She said that over the past weekend she noticed the Resident was unable to use a fork and was eating green beans like french fries. During an interview on 5/14/25 at 12:55 P.M., Nurse Practitioner #1 said she expects to be notified of any change in status with residents and was not notified of a change to Resident #46's range of motion of the right hand until today. Nurse Practitioner #1 said Resident #1 does not have a diagnosis of arthritis, but she feels this is a flare up of arthritis. Nurse Practitioner said it was unfair to call it a contracture until you attempted to treat the decline in range of motion, however said that could just be semantics because Resident #46 has had a definite new change in range of motion to his/her right hand. During an interview on 5/14/25 at 1:17 P.M., the Director of Nursing said she would expect any change in status, including a change in range of motion, to be referred to therapy and the Nurse Practitioner to be notified.

Based on observation, interviews, and records reviewed the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, 1.) The facility failed to disinfect shared resident medical equipment and adhere to infection control guidelines during medication pass. 2.) For one Resident (#26) out of a total sample of 26 residents, the facility failed to implement Enhanced Barrier Precautions (EBP). Findings Include: Review of the facility policy titled 'Resident Care and Treatment- Diagnostic Testing Glucose Testing with Glucometer (Assure Platinum)', dated as revised September 2024, indicated: 14. Clean Assure Platinum according to manufacturer's guidelines. Meter shuts down after two minutes. Should use two wipes; the first to clean and the second to disinfect. Review of the manufacturers' guidelines for the Assure Prism Multi Use Glucometer indicated the following: - Cleaning and Disinfecting Procedures: Two disposable wipes will be needed for each cleaning and disinfecting procedure; one wipe for cleaning and a second wipe for disinfecting. Further review of the manufacturer's guidelines indicate only approved FDA (Food and Drug Administration) approved products are to be used on the glucometer and reference the CDC Guidelines for Fingerstick Devices. Review of the facility policy titled 'Infection Control Manual, Blood-Borne Pathogen Standards, Cleaning Equipment', dated as revised September 2024, indicated: 4. DME (durable medical equipment) must be cleaned and disinfected before use by another resident. 1.) On 5/14/25 at 7:34 A.M., the surveyor observed Nurse #4 pickup a white open container from on top of the medication cart, containing a glucometer, several lancets, and alcohol prep pads. Nurse #4 entered the Resident's room and placed the white open container directly on top of his/her uncleaned overbed table. Nurse #4 obtained the Resident's blood sugar and immediately put the glucometer back into the white container without cleaning it and potentially contaminating the contents of the container. Nurse #4 then returned to the medication cart and picked up the contaminated glucometer with her ungloved hand and placed the contaminated glucometer directly on top the medication cart. Nurse #4 obtained an alcohol hand wipe from a container located at the nurse's station and with her ungloved hand proceeded to wipe down the glucometer and placed it back into the white container that was potentially contaminated earlier. -At 7:46 A.M., the surveyor observed Nurse #4 pickup the white open container from on top of the medication cart, containing the potentially contaminated glucometer, several lancets, and alcohol prep pads. Nurse #4 entered a second Resident's room and placed the white open container directly on top of his/her uncleaned overbed table. Nurse #4 proceeded to put on gloves and was about to obtain the Residents blood sugar when the surveyor had to intervene and stop Nurse #4 from using the potentially contaminated glucometer to obtain the Residents blood sugar. During an interview on 5/14/24 at 7:50 A.M., Nurse #4 said the facility has bleach wipes available for cleaning but she uses the alcohol hand wipes because they are easier on the hands and said she was not sure how or when to clean glucometers. Nurse #4 said she wipes the glucometers down with the alcohol wipes when she is finished with her glucose checks. On 5/14/25 at 8:06 A.M., the surveyor observed Nurse #4 pickup the white open container from on top of the medication cart, containing the potentially contaminated glucometer, several lancets, and alcohol prep pads, she removed the glucometer and placed it directly on top of the medication cart, and proceeded to remove the lancets and alcohol prep pads and discarded them into the trash. Nurse #4 used her bare hand to obtain one bleach wipe and proceeded to wipe down the now empty white container and proceeded to use the same bleach wipe to wipe down the glucometer. Nurse #4 placed the wet glucometer directly back into the white container and then added lancets and alcohol prep pads directly on top of the wet glucometer. Nurse #4 then placed the white container on top of her medication cart. During a follow up interview on 5/14/25 at 8:09 A.M., Nurse #4 said she was not aware that the glucometer, lancets and equipment could not go into the Residents rooms and said she was just told to use bleach wipes and to clean the glucometer. Nurse #4 said she was unaware of the contact time for the bleach wipes because she doesn't usually use them. During an interview on 5/14/25 at 9:27 A.M., Unit Manager #1 said staff must clean the glucometer with bleach wipes after each use and said containers containing glucometer equipment should not be taken into resident rooms or placed on bedside tables because they are contaminated. Unit Manager #1 said staff must follow the bleach wipes recommendations for contact time and said the glucometer should be placed on a paper towel and left to dry for two minutes. Review of the bleach wipes used in the facility indicated the following: Super Sani-Cloth Germicidal Disposable Wipe. Contact Time: Use Unfold a clean wipe and thoroughly wet surface. Allow surface to remain went for two minutes. Let air dry. During an interview on 5/14/25 at 11:21 A.M., the Director of Nurses (DON) said staff must use approved bleach wipes to clean and disinfect shared equipment and said she expects staff to follow manufacturer's instructions for wiping and cleaning. The DON said she expects all staff to follow infection control guidelines for proper cleaning and disinfection and said not following recommendations could increase the risk of blood borne pathogens between residents if equipment is not properly cleaned in between use. The DON said alcohol hand wipes should not be used to clean equipment and said bleach wipes must be used and said nurses must follow the contact time of two minutes to allow the surface to dry after wiping it with a bleach wipe. During an interview on 5/14/25 at 1:03 P.M., Nurse Practitioner (NP) #1 said she expects staff to follow infection control guidelines with cleaning and disinfecting according to policy and manufacturers guidelines to prevent the spread of infection. 2.) Review of the Centers for Disease Control (CDC) website indicated the following, dated June 28, 2024: -Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Review of facility policy from the Infection Control Manual, under the subject 'Enhanced Barrier Precautions', dated as reviewed 4/29/24, indicated the following: - Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug- resistant organisms that employs targeted gown and glove use during high contact resident care activities. - EBP are indicated for residents with any of the following: wounds and/ or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO (multidrug resistant organism). Resident #26 was admitted to the facility in March 2024 with diagnoses that included adult failure to thrive, Chronic Obstructive Pulmonary Disease and localized edema. Review of Resident #26's most recent Minimum Data Set (MDS) Assessment, dated 3/12/25, indicated a Brief Interview for Mental Status exam score of 14 out of a possible 15, which indicated that the Resident had intact cognition. The MDS further indicated that the Resident had one stage 3 pressure ulcer that was not present on admission. On 5/13/25 at 7:46 A.M., Resident #26 was observed awake in bed. Resident #26 had an air mattress in place. Resident #26 said that he/she has a wound to his/her heel. There was no signage on the doorway of Resident #26's room indicating the use of Enhanced Barrier Precautions. On 5/14/25 at 6:58 A.M., Resident #26 was observed awake in bed. Resident #26 had a dressing to his/her right heel. There was no signage on the doorway of Resident #26's room indicating the use of Enhanced Barrier Precautions. On 5/14/25 at 7:18 A.M., the surveyor observed Nurse #2 perform a wound dressing change to Resident #26's right heel. Nurse #2 entered the Resident's room and sanitized her hands and applied gloves. The Nurse did not put on a gown during the wound dressing change. For the duration of the dressing change, the nurse utilized gloves only and did not put on a gown at any time. Review of the most recent wound consultant note, dated 5/12/25, indicated the following: - Resident #26 has a stage 3 pressure wound of the right heel, full thickness that measures 1.4 x 1.4 x 0.1 centimeters. Review of Resident #26's active care plan indicated the following: - Resident has an unstageable on [his/her] right heel, and a skin tear to the right calf, dated as revised 5/2/25. Review of the Care plan failed to indicate the use of EBP. Review of Resident #26's physician's orders indicated the following: - Cleanse right heel with wound cleanser, apply calcium alginate and foam dressing, one time a day, dated 4/15/25. - Monitor dressing to right heel every shift, dated 4/8/25. Review of physician orders failed to indicate the use of EBP. During an interview on 5/14/25 at 7:25 A.M., Nurse #2 said that when a resident has a wound, they should be on Enhanced Barrier Precautions. Nurse #2 said that when she changed the dressing on Resident #26's wound, she should have worn a gown, but she did not. She said typically there is a physician's order for Enhanced Barrier Precautions. During an interview on 5/14/25 at 7:28 A.M., Unit Manager #2 said that Resident #26 did not need to be on Enhanced Barrier Precautions because the wound was not infected. He said residents with a wound that is not infected do not require Enhanced Barrier Precautions. During an interview on 5/14/25 at 10:34 A.M., the Director of Nursing said anyone with tubes, IV lines, pressure injuries or surgical incisions should be on Enhanced Barrier Precautions. She said that there is typically a physician's order in place for the use of EBP. The Director of Nurses further said that when changing the dressing for Resident #26's wound, the nurse should have worn a gown and gloves.

Based on observations, record reviews and interviews, the facility failed to ensure that one Resident (#96) was free from significant medication errors out of a total sample of 26 residents. Specifically, the facility failed to ensure medications were not administered when the Resident #96's blood pressure was not within the parameters prescribed by the physician. Findings include: Resident #96 was admitted to the facility in July 2024 with diagnoses including congestive heart failure. Review of Resident #96's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status exam score of 8 out 15 which indicated the Resident had moderate cognitive impairment. The MDS also indicated Resident #96 requires partial to moderate assistance with functional daily tasks. Review of Resident #96's physician orders indicated the following orders: - Lasix Oral Tablet (a diuretic medication) 20 MG (milligrams). Give 20 mg by mouth one time a day for edema Hold for SBP (systolic blood pressure) < (less than) 110 AND Give 20 mg by mouth as needed for edema add 20mg to the scheduled 20mg to equal 40mg if not resolved within 3-5 days, contact the physician, initiated on 11/15/24. - Spironolactone (a blood pressure medication) Oral Tablet 25 MG. Give 25 mg by mouth one time a day for edema related to essential hypertension. Hold for BP less than 110 systolic, initiated on 11/21/24. Review of Resident #96's Medication Administration Report (MAR) for November 2024 indicated the following: - On 11/20/25, Resident #96 had a blood pressure of 102/62 and was given his/her dose of lasix. Review of Resident #96's Medication Administration Report MAR for December 2024 indicated the following: - On 12/12/25, Resident #96 had a blood pressure of 105/49 and was given his/her dose of lasix. - On 12/23/25, Resident #96 had a blood pressure of 99/60 and was given his/her dose of lasix and spironolactone. - On 12/31/25, Resident #96 had a blood pressure of 108/70 and was given his/her dose of lasix and spironolactone. Review of Resident #96's Medication Administration Report MAR for January 2025 indicated the following: - On 1/2/25, Resident #96 had a blood pressure of 106/86 and was given his/her dose of lasix. - On 1/3/25, Resident #96 had a blood pressure of 108/68 and was given his/her dose of lasix and spironolactone. - On 1/13/25, Resident #96 had a blood pressure of 102/65 and was given his/her dose of spironolactone. - On 1/14/25, Resident #96 had a blood pressure of 102/65 and was given his/her dose of lasix and spironolactone. - On 1/18/25, Resident #96 had a blood pressure of 108/68 and was given his/her dose of spironolactone. - On 1/20/25, Resident #96 had a blood pressure of 108/72 and was given his/her dose of spironolactone. - On 1/25/25, Resident #96 had a blood pressure of 102/70 and was given his/her dose of lasix and spironolactone. Review of Resident #96's Medication Administration Report MAR for February 2025 indicated the following: - On 2/1/25, Resident #96 had a blood pressure of 108/68 and was given his/her dose of lasix and spironolactone. - On 2/8/25, Resident #96 had a blood pressure of 88/52 and was given his/her dose of lasix. Review of Resident #96's Medication Administration Report MAR for March 2025 indicated the following: - On 3/15/25, Resident #96 had a blood pressure of 109/60 and was given his/her dose of lasix and spironolactone. - On 3/26/25, Resident #96 had a blood pressure of 108/72 and was given his/her dose of lasix and spironolactone. - On 3/27/25, Resident #96 had a blood pressure of 108/72 and was given his/her dose of lasix and spironolactone. Review of Resident #96's Medication Administration Report MAR for April 2025 indicated the following: - On 4/4/25, Resident #96 had a blood pressure of 108/68 and was given his/her dose of lasix and spironolactone. - On 4/24/25, Resident #96 had a blood pressure of 108/72 and was given his/her dose of lasix and spironolactone. Review of Resident #96's Medication Administration Report MAR for May 2025 indicated the following: - On 5/3/25, Resident #96 had a blood pressure of 108/72 and was given his/her dose of spironolactone. - On 5/4/25, Resident #96 had a blood pressure of 109/61 and was given his/her dose of lasix. During an interview on 5/13/25 at 12:52 P.M., Nurse #1 said if a parameter is written in the physician's order, it would show up when the nurse is providing medications to ensure the parameter is being followed. Nurse #1 said providing lasix and blood pressure medications when a resident's blood pressure is below the parameter could be dangerous because it could further lower the resident's blood pressure. During an interview on 5/13/25 at 1:00 P.M., Unit Manager #1 said nurses are expected to check the parameters of medications prior to administrating the medication. Unit Manager #1 said Resident #96 had parameters for his/her blood pressure and diuretic medications and these should have been followed. During an interview on 5/13/25 at 1:28 P.M., the Director of Nursing said she expects any medications with parameters to be held if the parameters are not met. The Director of Nursing said a resident with low blood pressure has a risk of their blood pressure dropping more if given blood pressure or diuretic medications.

Based on record review and interview, the facility failed to document urinary output as ordered for one Resident (#93) out of a total sample of 26 residents. Findings include: Review of the facility's Nursing Service Documentation, dated September 2024 indicated; 5. Nursing documentation is performed as required by each person responsible for the care of the resident. 6. Every entry is noted by complete date, time and signature. Each set of initials used shall correspond to a complete signature. Review of the facility's policy titled 'Catheter Care', dated September 2024, indicated: 1. Residents with indwelling catheters should have their urinary output assessed at regular intervals to ensure that adequate drainage is occurring. Resident #93 was admitted to the facility in February 2024 with diagnoses including venous insufficiency and polyuria (urinating more than usual). Review of the Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #93 was cognitively intact as evidenced by a score of 15 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS). The MDS also indicated Resident #93 had an indwelling catheter. Review of Resident #93's physicians orders indicated the following orders: - Foley Catheter Size 16fr (french scale) Type 10 ml (milliliter) balloon, dated 3/26/24. - Check placement and provide foley catheter care every shift, dated 3/26/24. - Monitor urine output each shift BLADDER SCAN IF OUTPUT <200ML QSHIFT, dated 3/30/25. Review of Resident #93's Catheter care plan, dated 3/27/24, indicated the following intervention: - Monitor and document intake and output as per facility policy. Review of the April 2025 Treatment Administration Record (TAR) indicated Resident #93's output was not documented on the morning shift on 4/29/25, the evening shift on 4/2/25, and the night shift on 4/2/25, 4/3/25, 4/5/25, 4/6/25, 4/17/25, and 4/30/25. Review of the May 2025 TAR indicated Resident #93's output was not documented on the night shift on 5/4/25, the morning shift on 5/10/25, and the night shift on 5/11/25. During an interview on 5/14/25 at 10:16 A.M., the surveyor and Unit Manager #2 reviewed Resident #93's April 2025 TAR. Unit Manager #2 said staff should be documenting Resident #93's output as ordered.

Based on observation and interview the facility failed to store all drugs and biologicals in accordance with currently accepted professional principles on one of three units. Specifically, the facility failed to secure drugs and biologicals on one of three units during a medication pass when medication was left unattended at the nurse's station. Findings include: Review of facility policy titled 'Medication Management-Medication Storage', dated as revised September 2024, indicated: - The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas and a clean safe and sanitary manner. 8. Drugs shall be stored in an orderly manner in cabinets drawers carts or automatic dispensing systems. On 5/14/25 at 7:28 A.M., the surveyor observed Nurse #4 prepare medications during a morning med pass on the Atlantic [NAME] Unit. Nurse #4 mixed miralax (laxative/stool softener) with a cup of water and placed the cup on top of her medication cart and proceeded to remove medication pills into a medication cup to be administered. The unlabeled cup of water containing the miralax was clear and looked like a clear cup of water. Nurse #4 said she would go back to administer the medication because the Resident was in the restroom and not available to take his/her medications. At 7:32 A.M., Nurse #4 proceeded to pick up the cup of water containing miralax and place it on top of the counter at the nurses' station directly in front of Nurse #4's medication cart. Nurse #4 then poured water into a new cup, picked up the medication cup containing pills and walked back to the Residents room and administered the pills with the cup of water that did not contain the miralax. The cup containing the miralax remained on the counter at the nurses' station and there were no staff present at the nurses station or in the hall. The surveyor continued to make observations from 8:02 A.M. to 8:26 A.M. and the cup containing miralax was left unattended throughout the observation period. The surveyor observed three residents walk by the cup containing miralax. The surveyor observed one resident walking behind the nurses' station and proceeded to touch items on the counter. The surveyor then informed Nurse #4 about the unattended miralax cup at the nurse's station. During an interview on 5/14/25 at 9:11 A.M., Nurse #4 said she did not realize she gave the resident water and said she remembers pouring a new fresh cup of water. The surveyor then pointed out the clear cup of miralax that was placed on the counter at the nurses' station and Nurse #4 said I can tell you if that is miralax or not, and proceeded to take a drink from the cup and said I messed up, I gave him/her water I can taste it, it's miralax. Nurse #4 said she did not give the miralax and said she should not have left the miralax unattended on the counter because residents or staff could have mistaken it for water and said medications must not be left unattended. During an interview on 5/14/25 at 9:30 A.M., Unit Manager #1 said medications should not be left unattended or on the counter at the nurses' station and said staff should not taste medication to confirm what type of medication it is if the medication is found or left unlabeled. The Unit Manager said residents on this unit have dementia and often wander around and could mistake the cup for water. During an interview on 5/14/25 at 11:25 A.M., the Director of Nursing (DON) said medication must be in stored appropriately in locked medication carts and not left out unattended where residents or staff could have access to them. The DON said it is her expectation that nurses would not taste or consume any medication to confirm what it is and said the medication should have been thrown out instead of left unattended on the counter.

Based on record reviews and interviews, the facility failed to ensure one Resident (#69) was free from unnecessary psychotropic medications by ensuring a reassessment of an as needed (PRN) dose of trazodone after 14 days, out of a total sample of 26 residents. Findings include: Review of the facility policy titled 'Psychotropic PRN Medication Use', dated September 2024, indicated the following: - Policy: the following requirements are in place to safeguard the health of our residents, ensure PRN orders for psychotropic medications do not remain in place for an extended period of time without being reviewed by the resident's physician and ensure that benefits and side effects of these medications are evaluated between required physician visits. -Type of PRN order: PRN orders for psychotropic medications excluding antipsychotics. Time Limitations: 14 days. Exception: Order may be extending past 14 days if the physician or prescribing practitioner believes it is appropriate to extend the order. Required actions: Attending physician or prescribing practitioner should document the rationale for the extended time period in the medical record and indicate the specific duration. Resident #69 was admitted to the facility in August 2024 with diagnoses including Alzheimer's Disease and adjustment disorder with mixed anxiety and depressed mood. Review of Resident #69's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 7 out of a possible 15, which indicated he/she has severe cognitive impairment. During an interview on 5/13/25 at 8:08 A.M., Resident #69 said he/she was feeling well. The Resident was unable to answer specific questions about his/her medical diagnoses or medications. Review of Resident #69's physician orders indicated the following order initiated on 12/5/24: - Trazodone HCl (hydrochloride) Oral Tablet (a mood stabilizing medication), give 12.5 mg (milligrams) by mouth every 6 hours as needed (PRN) for anxiety, without a stop date. Review of the Medication Administration Records (MAR) for December 2024 through May 2025 indicated Resident #69 was given the PRN dose of trazodone 19 times on the following days: - In December: 12/19/24, 12/22/24, 12/29/24, 12/30/24 and twice on 12/31/24, - In January: 1/13/25, 1/17/25, 1/19/25, 1/22/25 and 1/30/25, - In February: 2/7/25 and 2/13/25, - In April: 4/26/25 and 4/29/25, - In May: 5/2/25, 5/4/25, 5/9/25 and 5/11/25. Review of the Psychiatric Nurse Practitioner note, dated 1/28/25, indicated the following: -PRN trazodone has been utilized with positive effect and Would recommend adding stop/re-eval date to PRN Trazodone. Review of the Physician and Nurse Practitioner notes from December 2024 to May 2025 failed to indicate any notes that the PRN trazodone was reassessed, or a reassessment date was added to the order. During an interview on 5/13/25 at 12:51 P.M., Nurse #1 said all PRN psychoactive medications need to be reassessed after 14 days and then an end date placed on the order so continued reassessment can be completed. During an interview on 5/13/25 at 12:59 P.M., Unit Manager #1 said all PRN psychoactive medications need to be reassessed after 14 days and then an end date placed on the order so continued reassessment can be completed. During an interview on 5/13/25 at 1:26 P.M., the Director of Nursing said all PRN psychotropic medications need to be reassessed after the first 14 days and then need an end date or reassessment date added to the order to ensure continued reassessment occurs.

Based on observations, interviews, and record review, the facility to ensure that services provided met professional standards for one Resident (#43), out of 26 total sampled residents. Specifically, the facility failed to obtain and implement a physician's order for Resident #43's skin tear for approximately three days. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: - Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized 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. Review of the facility policy titled 'Care and Treatments: Skin/Wound Care: 2-Documentation Guidelines', dated as reviewed September 2024, indicated: - Physician orders will be in place for wounds requiring treatment. Resident #43 was admitted to the facility in April 2020 with diagnoses including Parkinson's disease and dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/6/25, indicated Resident #43 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status exam score of 2 out of 15. On 5/13/25 at 8:27 A.M. and on 5/14/25 at 8:07 A.M., the surveyor observed Resident #43 with an undated foam dressing on his/her right forearm. The foam dressing was visibly soiled with what appeared to be drainage. Resident #43 was unable to say how he/she injured him/herself or when this foam dressing had been applied. Review of Resident #43's medical record, including physician's orders, progress notes, and plan of care, dated 5/10/25 to 5/14/24, failed to indicate the presence of a right arm skin tear, any physician order for the treatment of a right arm skin tear, or documentation that any wound treatment was implemented for a right arm skin tear. During an interview on 5/14/25 at 8:13 A.M., Certified Nurse Assistant (CNA) #2 said Resident #43 recently injured their right arm resulting in a skin tear and the nurse put a dressing on it. CNA #2 was unsure when this injury occured. During an interview on 5/14/25 at 8:15 A.M., Nurse #3 said a few days ago Resident #43 had a skin tear and a nurse put a dressing on it. Nurse #3 said there was not an order for the dressing but there should have been. Nurse #3 was unaware if the dressing had been changed since it was applied a few days ago. On 5/14/25 at 10:21 A.M., the surveyor observed Resident #43's right forearm wound with Nurse #3. Under the visably soiled undated dressing, there was an approximately half inch triangular wound with a red wound bed and dried dark red drainage. During an interview on 5/14/25 at 9:06 A.M., Unit Manager #2 said Resident #43 sustained a skin tear over the weekend on his/her right forearm and the nurse applied a dressing. Unit Manager #2 said a physician's order for the wound treatment was not obtained until this morning, which was at least three days after the skin tear had occurred, and after the surveyor brought it to the facilities' attention. Unit Manager #2 said that the treatment order should have been obtained when the dressing was first applied. Unit Manager #2 further said the danger of not obtaining a physician order for a wound treatment is that the dressing would not be implemented daily as required or completed correctly if it had been done. During an interview on 5/14/25 at 9:56 A.M., the Director of Nursing (DON) said wound treatments, such as dressings, for skin tears require a physician's order.

Based on observation, record review and interview, the facility failed to identify and address a significant weight loss for one Resident (#14) out of a total of 26 sampled residents. Findings include: Review of the facility policy title 'Determining and Addressing Significant Weight Changes', dated September 2024, indicated: - Purpose: The nutritional and hydration status of residents will be maximized with appropriate and timely intervention. 1. A resident experiencing weight loss or gain per guidelines: a. 5% in one month, b. 10% in six months. should be referred to the dietitian for further monitoring. 2. The nurse will notify [Occupational therapy / Speech therapy] for screening as necessary and appropriate recommendations will be communicated by the nursing staff to the physician. Physician orders will be obtained for an evaluation if indicated and for all interventions. Resident #14 was admitted to the facility in December 2023 with diagnoses including unspecified dementia and cognitive communication deficit. Review of the Minimum Data Set Assessment (MDS), dated [DATE], indicated that Resident #14 was severely cognitively impaired as evidenced by a score of 00 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS). The MDS also indicated Resident #14 was dependent on staff assistance for meals. On 5/14/25 at 7:31 A.M., the surveyor observed Resident #14 resting in bed. Resident #14 appeared thin and frail and was unable to participate in the interview process. Review of Resident #14's care plans, initiated 12/22/23, indicated the following: - Focus: The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) pain, generalized weakness. - Interventions: The resident needs set up/clean up assistance with eating. Review of Resident #14's physician orders indicated the following: - Magic Cup (a nutritional supplement) with meals breakfast, lunch, dinner, initiated 10/30/24. - Ensure Enlive, three times a day, initiated 9/5/24. - Fortified Cereal, with meals Super cereal with breakfast and super potato with lunch and supper; initiated 5/28/24. - Mirtazapine Give 15 mg by mouth one time a day for mood and appetite, initiated 9/20/24. Review of Resident #14's weights indicated: - 12/26/24: 126.3 lbs (pounds). - 1/6/25: 123.2 lbs. - 2/24/25: 116.2 lbs; a total loss of 8% of his/her total body weight since 12/26/25. - 3/13/25: 119.8 lbs. - 4/7/25: 114.2 lbs. Review of Resident #14's clinical record indicated Resident #14 was not assessed by the Dietitian for weight loss until 4/4/25; 39 days after Resident #14's significant weight loss was first documented. Review of the Dietitian's note, dated 4/4/25, indicated: - Gradual wt (weight) loss since mid-Dec. Wt fluctuations noted the past few weeks. Variable PO (by mouth) intake at meals, poor at times. Averages ~50-75% this past week. Staff to provide encouragement for adequate intake. Poor acceptance of ONS (ordered nutritional supplements) 25%. Rt (resident) is prescribed medications with known s/e (side effects) of inc (increased) appetite and wt (weight) gain. May need 1:1 supervision at meals for adequate intake. During an interview on 5/14/25 at approximately 8:30 A.M., Certified Nursing Assistant (CNA) #2 said that she did not think Resident #14 had any weight loss. CNA #2 said that Resident #14's appetite and intake would go up and down and within the past two months and that CNA's had started to cue or provide physical assistance to Resident #14 during meals. During an interview on 5/14/25 at approximately 8:35 A.M., Unit Manager #2 said that when a resident experiences weight loss, staff will re-weigh to verify and then the weight is put in the electronic medical record. Unit Manager #2 said that the Dietitian runs a report of the weights and would then assess and put in interventions to address the weight loss. Unit Manager #2 said that there is not much verbal communication regarding weight loss between nursing and the Dietitian because she can access the weights and reports electronically. During interviews on 5/14/25 at 9:06 A.M., and 9:38 A.M., the Dietitian said that she gets reports from the electronic record or verbally from staff when a Resident loses weight. The Dietitian said that within 24-48 hours she will assess the resident, ask for a re-weight, review possible interventions to address the weight loss and document in a progress note. The Dietitian said that Resident #14 was previously reviewed during risk meetings for weight loss but when he/she stabilized, he/she came off risk. The surveyor and the Dietitian reviewed Resident #14's weights and nutritional progress notes and assessments. The Dietitian was not aware that Resident #14 had a significant weight loss in February 2025 and that he/she had not been assessed for weight loss until April 2025. The Dietitian said that she missed Resident #14's February 2025 weight loss.

Based on observation, interviews, and record review, the facility failed to ensure that staff accommodated food preferences for one Resident (#65), out of a total sample of 26 residents. Specifically, the facility failed to honor Resident #65's preferences and served the Resident foods he/she disliked, including eggs, white bread, toast, and broccoli. Findings include: Review of the facility policy titled 'Resident Food Preferences and Choice, dated as reviewed September 2024, indicated: - Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. - When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. - Facility staff may document the residents' significant food and eating preferences in the care plan. During a telephone interview on 5/13/25 at 9:43 A.M., the ombudsman said there is an ongoing concern at the facility regarding food choices being made available to residents. Resident #65 was admitted to the facility in November 2024 with diagnoses including protein-calorie malnutrition and dysphagia (difficulty swallowing). Review of the most recent Minimum Data Set (MDS) assessment, dated 2/19/25, indicated Resident #65 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status exam score of 12 out of 15. Review of Resident #65's plan of care related to nutrition, revised 3/11/25, indicated Resident #65 was at nutritional risk related to a diagnosis of protein-calorie malnutrition and a history of significant weight loss and dysphagia. This care plan indicated the following intervention: - Provide meals in keeping with resident's preferences. Review of Resident #65's assessment titled 'Nutritional Assessment', dated 11/29/24, indicated a problem of unplanned significant weight loss and the following nutrition intervention: - Honor food preferences as able. Review of Resident #65's diet slip, which was visible on the Resident's breakfast and lunch meal trays when they were delivered on 5/13/25, indicated: - Dislikes: broccoli, cheese, corn, eggs group, peas, sausage patty, scrambled egg, spinach, toast, white bread. On 5/13/25 at 8:11 A.M., the surveyor observed Resident #65 eating breakfast. Resident #65 said he/she was upset because he/she often gets food he/she dislikes. Resident #65 was noted to have scrambled eggs and white bread toast that was untouched on his/her meal tray. Resident #65 said he/she was not asked what they would like for breakfast but would never ask for eggs or toast because he/she does not like them. Resident #65 further said eggs cause him/her stomach upset and diarrhea. Resident #65 said staff knows he/she does not like these items and does not offer any substitutions. Resident #65 said he/she does not ask for a substitution because he/she does not want to be a bother. There was a meal slip present on the meal tray that indicated Resident #65 dislikes scrambled eggs, white bread, and toast. On 5/13/25 at 12:17 P.M., the surveyor observed Resident #65 eating lunch. Resident #65 was noted to have broccoli on his/her meal tray. Resident #65 said he/she does not like broccoli and that staff know this because it's written right on my tray. Resident #65 said he/she did not request broccoli. Resident #65 took a bite of broccoli, then spit it out and said he/she does not like broccoli at all. There was a meal slip present on the meal tray that indicated Resident #65 dislikes broccoli. During a follow up interview on 5/14/25 at 8:34 A.M., Resident #65 said he/she wishes the facility would honor his/her food preferences. Resident #65 said foods listed as a dislike on his/her meal slip are served to him/her at least three to four times every week. During an interview on 5/14/25 at 8:37 A.M., Certified Nurse Assistant (CNA) #2 said all residents' food preferences should be honored. CNA #2 said food items listed as a dislike on Resident #65's meal slip should not be served to him/her. CNA #2 said nurses are supposed to check all meal trays to ensure dislikes are not served before they are delivered to the Resident. CNA #2 said disliked food items are sometimes missed and served to residents, and if that happens the staff is expected to send a slip down to the kitchen to remind them not to include it on the meal tray. During an interview on 5/14/25 at 8:46 A.M., Unit Manager #2 said all residents' food preferences should be honored. Unit Manager #2 said a nurse is supposed to check each meal slip to make sure a disliked food is not served to the residents, unless the resident requests that food item. Unit Manager #2 said disliked foods are sometimes missed and served to residents, and if that happens the staff is expected to send a slip down to the kitchen to remind them not to include it on the meal tray. During an interview on 5/14/25 at 9:25 A.M., Dietary Staff #1 said he was responsible for checking disliked foods before putting food on each resident's tray. Dietary Staff #1 said all residents' food preferences should be honored. Dietary Staff #1 said if a food indicated as a dislike on a resident's meal slip then it should not be served to the resident. During an interview on 5/14/25 at 9:46 A.M., the Dietitian said all resident's food preferences should be honored. The Dietitian said Resident #65 doesn't like broccoli, white bread, or toast and that these are listed as dislikes on his/her meal slip. The Dietitian said he/she prefers muffins. The Dietitian was unaware that Resident #65 had concerns of the upset stomach or diarrhea with eggs but said eggs should not have been served because it was listed as a dislike on his/her meal slip. During an interview on 5/14/25 at 9:54 A.M., the Director of Nursing (DON) said food preferences should be honored. The DON said if a food was listed as a dislike on any resident's meal slip then it should not have been served. During a follow up interview on 5/14/25 at 11:04 A.M., the Dietitian said there were no food shortages on 5/13/25 that would have affected what Resident #65 was served.

Based on record reviews, observations and interviews, the facility failed to ensure resident centered care plans were implemented for two Residents (#36 and #59) out of a total sample of 23 residents. Specifically, 1. For Resident #36, the facility failed to implement thigh high TED hose (compression stockings) as ordered by the Physician. 2. For Resident #59, the facility failed to implement pressure relieving boots, as ordered by the Physician. Findings include: 1. Resident #36 was admitted to the facility in January 2024 with diagnoses that included nephrotic syndrome, orthostatic hypotension, and small cell b-cell lymphoma. Review of Resident #36's most recent Minimum Data Set (MDS) assessment, dated 4/17/24, indicated Resident #36 scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. On 5/28/24 at 1:12 P.M., the surveyor observed Resident #36 out of bed in a geri-recliner chair, not reclined. Resident #36 was not wearing compression stockings on his/her legs. On 5/29/24 at 12:44 P.M., the surveyor observed Resident #36 out of bed in a geri-recliner chair, not reclined. Resident #36 was not wearing compression stockings on his/her legs. Review of Resident #36's active physician order, dated 3/28/24, indicated Thigh high [NAME] hose (compression stockings) on before getting out of bed. Every day shift for BLE (bilateral lower extremity) edema, hypotension. Review of Resident #36's Nurse Practitioner progress note, dated 5/9/24, indicated the Resident remains weak, with fluctuating edema. +1 edema of the both lower legs. (sic.) Review of Resident #36's nursing progress notes from 5/27/24 to 5/30/24 did not indicate that the Resident refused to wear the compression stockings. During an interview on 5/30/24 at 7:31 A.M., Unit Manager #1 said the nurses should follow each residents plan of care. During an interview on 5/30/24 at 7:35 A.M., Nurse #1 said nurses should be following each resident's physician orders. Nurse #1 said if the Resident refuses anything then it should be documented in a nursing note. During an interview on 5/30/24 at 10:34 A.M., the Director of Nurses said she expects that the compression stockings are on as ordered when the Resident is out of bed. 2. Resident #59 was admitted to the facility in August 2023 with diagnoses that included Parkinson's disease, dysphagia, hemiplegia and hemiparesis. Review of Resident #59's Minimum Data Set (MDS) assessment, dated 3/17/24, indicated Resident #59 was assessed by nursing staff to have moderately impaired cognition. On 5/28/24 at 7:58 A.M., the surveyor observed Resident #59 in bed without pressure relieving boots on his/her feet. The boots were observed to be on the floor in the closet. On 5/29/24 at 7:43 A.M., the surveyor observed Resident #59 in bed without pressure relieving boots on his/her feet. The boots were observed to be on the floor in the closet. Review of Resident #59's physician order, dated 4/18/24, indicated Pressure relieving boots to bilateral feet AAT's (at all times) while in bed. Review of Resident #59's nursing progress notes from 5/22/24 to 5/30/24 failed to indicate that the Resident refused pressure relieving boots to his/her feet. Review of Resident #59's [NAME] Pressure Ulcer Risk Scale, dated 3/18/24, indicated Resident #59 scored an 11, indicating the Resident was at high risk for developing pressure ulcers. On 5/30/24 at 7:31 A.M., the surveyor and Unit Manager #1 observed Resident #59 in bed without pressure relieving boots on his/her feet. Unit Manager #1 said Resident #59 should have boots on while in bed as ordered by the Physician. Unit Manager #1 said the Resident has a history of having a pressure ulcer on his/her heel/ankle due to positioning issues and that is why the Resident needs boots on in bed. During an interview on 5/30/24 at 7:35 A.M., Nurse #1 said Resident #59 has an order to have pressure relieving boots on while in bed and they should be on while the Resident is in bed. Nurse #1 said if the Resident refuses anything then it should be documented in a nursing note. During an interview on 5/30/24 at 10:34 A.M., the Director of Nurses said she would expect Resident #59's pressure relieving boots on when the Resident is in bed.

Based on observation, interview, and record review, the facility failed to ensure that one Resident (#9) did not self-administer medications out of a total sample of 23 residents. Specifically, Resident #9 was not assessed to be able to safely self administer medication, and was observed self administering medication. Findings include: The facility policy, titled 11 - Self Administration of Medications, dated as reviewed 9/23, indicated the following: -It is the responsibility of the interdisciplinary team (IDT) to determine that it is safe for the resident to self-administer medications before the resident may exercise that right. Procedure: 1. Upon request, assess the resident's ability to meet the criteria outlined above and document outcomes on the form Assessment for the Self-Administration of Medication. 2. If determined that the resident is capable of self-administering medications, obtain order from the MD (Medical Doctor). 3. Document on the resident's care plan. Resident #9 was admitted to the facility in March 2022 with diagnoses including arthritis, heart failure and asthma. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/28/24, indicated that Resident #9 scored a 15 out of 15 on the Brief Interview for Mental Status exam, indicating that the Resident was cognitively intact. Review of Resident #9's active physician orders failed to indicate an order for self-administration of medication. The following orders were in place: -Advair Diskus Aerosol Powder Breath Activated 100-50 Mcg (micrograms)/dose (Fluticasone-salmeterol) 1 puff inhale orally two times a day for COPD (Chronic Obstructive Pulmonary Disease) have resident rinse mouth after each use, initiated 2/21/24. -Biotene Dry Mouth/Throat liquid (mouthwashes) 30 mL (milliliters) by mouth two times a day for mild pain, initiated 2/2/24. -Lidocaine Patch 4% apply to left knee topically one time a day for pain, initiated 5/1/23 -Prostat one time a day for low pre albumin 30 cc (cubic centimeter) po (by mouth) daily, initiated 5/4/24. -Boost plus two times a day for weight loss 240 m boost plus or equiv (sic.), initiated 2/21/24. -Lasix tablet 40 Mg (milligrams) (Furosemide) give 1 tablet by mouth one time a day every Mon (Monday), Wed (Wednesday), Fri (Friday) for fluid retention related to edema, unspecified, initiated 5/1/23. -Aspirin tablet chewable 81 Mg give 1 tablet by mouth one time a day related to heart failure, unspecified, initiated 9/19/23. -Cyanocobalamin (a synthetic form of vitamin B12) Oral Tablet give 500 Mcg by mouth one time a day for supplement, initiated 5/1/23. -Losartan Potassium Tablet give 50 Mg by mouth one time a day related to essential (primary) hypertension, initiated 5/1/23. -Protonix Tablet Delayed Release 40 Mg (Pantoprazole Sodium) give 40 Mg by mouth one time a day for heartburn, initiated 5/1/23. -Norvasc Tablet (Amlodipine Besylate) give 10 Mg by mouth one time a day for HTN (hypertension), initiated 5/1/23. -Cymbalta Oral Capsule Delayed Release Particles 20 Mg (Duloxetine HCl) give 2 capsule (sic.) by mouth one time a day for mood/pain related to major depressive disorder, anxiety disorder, initiated 6/17/23 -Neurontin Capsule (Gabapentin) give 300 Mg by mouth three times a day for pain management, initiated 5/1/23. -Preservision AREDS (Age-Related Eye Disease Study) 2 Oral Tablet Chewable (multiple vitamins with minerals) give 1 tablet by mouth in the morning for vision loss, initiated 3/18/24. Review of Resident #9's most recent Self-Administration of Medication Assessment, dated 2/20/24, indicated that the Resident did not wish to administer his/her medication. Further review of the assessment indicated Resident #9 was not approved to self-administer medication. Review of Resident #9's care plans failed to indicate a care plan for self-administration of medication. On 5/28/24 at 8:25 A.M., the surveyor observed Nurse #2 leave a cup full of medication, a supplemental shake, a small cup of yellow-orange liquid, a small cup of clear liquid, and an Advair inhaler in front of the Resident on a bedside table; Nurse #2 then left the room. The surveyor observed Resident #9 applying a white patch to his/her knee and self-administering medication from the cup without staff present. On 5/29/24 at 8:33 A.M., the surveyor observed Nurse #2 leave a cup full of medication, a supplemental shake, a small cup of yellow-orange liquid, a small cup of clear liquid, and an Advair inhaler on the Resident's bedside table, the Resident was exiting the bathroom; Nurse #2 then left the room. The surveyor observed Resident #9 self-administer his/her medications without staff present. Resident #9 intermittently coughed while swallowing the pills. During an interview on 5/29/24 at 9:50 A.M., Nurse #2 said Resident #9 self-administers all of his/her medication regularly, including self-applying a Lidocaine patch to his/her knee. Nurse #2 said she left the following medications on Resident #9's bedside table for the Resident to self-administer that morning: Advair, Biotene, a Lidocaine patch, Prostat, boost, Lasix, aspirin, Vitamin B12, Losartan potassium, Protonix, Norvasc, Cymbalta, Neurontin, and Preservision. During an interview on 5/29/24 at 8:44 A.M., Resident #9 said he/she self-administers medication without staff present every day. During a follow-up interview on 5/29/24 at 9:50 A.M., Nurse #2 said she did not know if Resident #9 had been assessed for self-administering medication. Nurse #2 said she would expect a resident to be assessed for the ability to self-administer medication before they do so, and that this should be documented in the Resident's physician orders. During an interview on 5/29/24 at 10:14 A.M., the Director of Nursing (DON) said a self-administration of medication assessment should be completed on admission, and quarterly; if a resident chooses to self-administer his/her medication they will be assessed to determine if this is appropriate. The DON said that the resident's care plan and physician's orders would be updated to specify that the resident was able to self-administer medication. During a follow-up interview on 5/29/24 at 10:38 A.M., the DON said a self-administration of medication assessment was completed for Resident #9 on 2/20/24 deeming the Resident unable to self-administer medication.

Based on observations, record review, policy review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs), for one Resident (#59) out of a total sample of 23 residents. Specifically, the facility failed to provide assistance with meals as per the plan of care for Resident #59. Findings include: Review of the facility policy titled Activities of Daily Living (ADLs), dated 9/23, indicated Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: D. Dining (meals and snacks). Resident #59 was admitted to the facility in August 2023 with diagnoses that included Parkinson's disease, dysphagia, hemiplegia and hemiparesis. Review of Resident #59's Minimum Data Set (MDS) assessment, dated 3/17/24, indicated Resident #59 was assessed by nursing staff to have moderately impaired cognition. On 5/28/24 at 7:58 A.M., the surveyor observed Resident #59 in bed eating his/her breakfast. No staff were in the room to provide assistance or supervision. On 5/29/24 at 7:43 A.M. to 7:59 A.M., the surveyor observed Resident #59 in bed eating his/her breakfast. The Resident was observed to fall asleep at times. No staff were in the room to provide assistance or supervision. On 5/29/24 at 12:45 P.M., the surveyor observed Resident #59 seated in a wheelchair in his/her room eating lunch. No staff were in the room to provide assistance or supervision. On 5/30/24 from 7:27 A.M. to 7:31 A.M., the surveyor observed Resident #59 in bed eating his/her breakfast. No staff were in the room to provide assistance or supervision. Review of Resident #59's physician order, dated 9/1/23, indicated Feeding assistance with all meals for manipulation of utensils, opening containers, navigating tray, ID environmental barriers, and ability to bring utensils to his/her mouth for intake of proper nutrition. Review of Resident #59's current Activity of Daily Living care plan, indicated EATING: The resident requires physical assistance by (1) staff to eat. Review of Resident #59's current Nutrition care plan, indicated Pt (patient) has a dx (diagnosis) of Parkinson's, legally blind and requires staff assistance at meals. Provide staff assistance at meals per MD order. Review of Resident #59's active Certified Nurse Aide (CNA) Kardex (resident specific care instructions), dated 5/30/24, indicated EATING: The resident requires physical assistance by (1) staff to eat. Provide diet as ordered: Mech (Mechanical) soft, thin liquids, one person assist. Provide staff assistance at meals per MD order. During an interview on 5/30/24 at 7:31 A.M., Unit Manager #1 said CNA's follow the Resident specific Kardex to know the needs of the Resident on how they eat, transfer, ADL needs etc. Unit Manager #1 said the nurses should follow each residents plan of care and doctors orders. During an interview on 5/30/24 at 10:34 A.M., the Director of Nurses said she would expect nursing to follow Resident #59's physician order and plan of care to be assisted with meals.

Based on observation, record review and interview the facility failed to ensure it was free from a medication error rate of greater than 5 percent. Three out of the four nurses observed made 6 errors in 32 opportunities resulting in a medication error rate of 18.75%. These errors impacted 3 Residents (#33, #69 and #316) out of 4 residents observed. Findings include: Review of facility policy titled 'Administering Medications' revised December 2012 indicated the following: Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: *4. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). *7. The individual administering the medication must check the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 1. On 3/15/23 at 8:27 A.M., the surveyor observed a medication pass on Bayside resident care unit. Nurse #3 prepared and administered medications including the following to Resident #69: *Norvasc 2.5 mg (Milligram) 1 tab *Calcium carbonate 500 mg 1 tab *Celexa 10 mg 1 tab *Aspirin 81 mg chewable 1 tablet * Eliquis 2.5 mg 1 tab *metoprolol tartrate 50 mg 1 tab *Multivitamin with iron 1 tab *Magnesium Oxide 400 mg 1 tab *Prilosec 20 mg 1 cap *Vitamin D3 1000 units 1 tab *Aspercream lidocain 4% patch Review of the current physician's orders indicated the following: * Ecotrin low strength tablet Delayed Release 81 mg (Aspirin). Give 1 tablet by mouth one time a day for cardiac. *Multivitamin tablet (Multiple vitamin) Give 1 tablet by mouth one time a day for supplement. During an interview on 3/15/23 at 11:47 A.M., Nurse #3 acknowledge that she administered the wrong formula of the two medications. On 3/15/23 at 9:05 A.M., the surveyor observed a medication pass on Atlantic [NAME] resident care unit. Nurse #5 prepared and administered medication including the following to Resident #33: *Tylenol 500 mg (Milligram) 2 tablets *Allopurinol 100 mg 2 tablets *Aspirin Enteric Coated 81 mg 1 tablet *Vitamin D3 1000 units 1 tablet *Vitamin B 12 1000 mcg (micrograms) 1 tablet *Lexapro 5 mg 1 tablet *Metoprolol succinate 25 mg 1/2 a tablet (12.5 mg) *Cetirizine 10 mg 1 tablet. Review of the current physician's orders indicated the following medications to be administered at 8:00 A.M.: *Aspirin tablet 81 mg give 81 mg by mouth one time a day for Atrial Fibrillation *Tylenol tablet (Acetaminophen) give 1000 mg by mouth three times a day for discomfort 8:00 A.M., 2:00 P.M., 8:00 P.M. During an interview on 3/15/23 at 12:13 P.M., Nurse #5 said for Aspirin she normally gives the enteric coated because the Resident takes his/her medications whole. For administration outside of the one (1) hour window Nurse #5 acknowledge it was outside of the allocated administration time. On 3/15/23 at 9:23 A.M., the surveyor observed a medication pass on the Cape [NAME] way resident care unit. Nurse #1 prepared and administered medications including the following to Resident #316: *Tylenol 500 mg (milligram) 2 tablets *Calcium Carbonate 750 mg 1 tablet *Vitamin B 12 1000 mcg (Microgram) 1 tablet *Sennakot 8.6 mg 1 tablet *Polyethylene glycol 17 gm (Grams) *Vitamin D 3 1000 units 1 tablet *Metoprolol succinate 25 mg 1 tablet *Lovenox injection 40 mg/ 0.4 ml (Milliter) *Oxycodone 5 mg 2 tablets Review of the current physician's orders indicated the following medications to be administered at 8:00 A.M.: *Acetaminophen oral tablet 500 mg give 1000 mg by mouth three times a day for pain control post surgery for 14 days 8:00 A.M., 2:00 P.M., 8:00 P.M. *Calcium Carbonate Antacid Oral tablet chewable 750 mg. Give 750 mg by mouth two times a day for supplement. During an interview on 3/15/23 at 12:42 P.M., Nurse #1 said medication administration should occur between the 1 hour before and 1 hour after. She further said the workload on her assignment was not realistic to be able to complete task in a timely manner. During an interview on 3/16/23 at 8:51 A.M., the Director of Nursing said the expectation for medication administration is to occur within the 1 hr. before and after window. She further said the nurses are supposed to follow the five rights of medication administration and if medications were to be given late the physician would be notified for further orders.

Based on observation, policy review, and interviews the facility 1) failed to ensure medications were stored in a safe manner and 2) failed ensure outdated needles were not stored and made available for use in 2 out of 2 medications rooms. Findings include: Review of facility policy titled, 'Storage of Medications' dated as revised [DATE] indicated the following: Policy Statement: The facility shall store all drugs and biologicals in a safe, secure and orderly manner. Policy Interpretation and Implementation: *2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner *9. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses's station or other secured location. Medications must be stored separately from food and must be labeled accordingly ** Temperatures must be maintained at less than 41 degrees F (Fahrenheit) (refrigerator) and less than 1 degree (freezer) at all times. (Refrigerator temperatures/Nourishment kitchens, revised ,d+[DATE]) 1. The facility failed to ensure medications were stored in a safe manner During an inspection of Bayside medication room on [DATE] at 12:01 P.M., the surveyor observed the medication refrigerator open with a recording temperature of 58 degrees F. The following medications were available in the refrigerator: -6 insulin pens (medication to treat diabetes) -3 vials of insulin (medication to treat diabetes) -1 box of bisacodly suppository (medication to treat constipation) -1 bottle of lactobacillus (probiotic) -3 boxes of eye drops -1 bottle of liquid ativan (medication to treat anxiety) -1 blister pack of marinol (medication to aide with appetite) -1 bottle of floradix (liquid iron) During an interview on [DATE] at 12:09 P.M., Nurse #4 said the temperature in the refrigerator was too high and all the medications needed to be discarded and replaced. She further said the refrigerator door should be closed before walking away. 2. The facility failed to ensure expired needle syringes were not available for use. During an inspection of the Atlantic shore medication room on [DATE] at 12:24 P.M., the following were observed in the medication room: -1 box of insulin syringes with an expiration date of [DATE] -1 box of 1 ml (milliter) [NAME] point syringes with an expiration date of [DATE]. During an interview on [DATE] at 12:28 P.M., Nurse #5 said the expired needles should not be in the medication room. During an interview on [DATE] at 8:46 A.M., the Director of Nursing acknowledged that she had been made aware of the high refrigerator temperatures, and that nurses should ensure the refrigerator door closed completely to maintain the integrity of the medications. She further said expired needles should not be available for use.

Based on observations, record reviews and interviews, the facility failed to provide needed assist with Activities of Daily Living (ADLs) to 1 Resident (#13) out of a total sample of 26 Residents. Findings include: Review of facility policy titled 'Activities of Daily Living (ADLs), Supporting' reviewed 9/2022 indicated the following: Policy Interpretation and Implementation: *2. Appropriate care and services will be provided for residents who are unable to carry ADLs independently, with consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) Resident #13 was admitted to the facility in February 2023 with diagnoses including Alzheimer's disease, right femur fracture and multiple rib fractures. Review of of Resident #13's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #13 had a Brief Interview for Mental Status (BIMS) score of 99 out of a possible 15 indicating he/she has severe impaired cognition. The MDS further indicated that Resident #13 required extensive assistance of two persons for personal hygiene. On 3/13/23 at 9:16 A.M., the surveyor observed Resident #13 sitting in his/her chair outside of his/her room. The surveyor observed Resident #13's fingernails with dark green matter underneath and around the nail bed. On 3/15/23 at 7:00 A.M., the surveyor observed Resident #13 laying in in his/her bed with his/her fingernails with dark green matter around and underneath nail bed. Review of Resident #13's Activity of Daily Living care plan dated as initiated 2/24/23 indicated the following intervention: *Resident requires extensive assistance by (1) staff with personal hygiene and oral care. Further review of medical record failed to indicate that Resident #13 refused care. During an interview on 3/15/23 at 12:56 P.M., Certified Nursing Assistant (CNA#1) said Resident #13 requires total assistance with grooming, does not refuse care and that grooming is part of ADL care. During an interview on 3/15/23 at 1:03 P.M., Unit Manager #2 said grooming is part of daily tasks and should be completed during ADL care. During an interview on 3/16/23 at 8:53 A.M., the Director of Nursing said residents requiring total care should receive daily grooming with nails cleaned and trimmed, if any issues CNA would report to nurses.

Based on observation, record review and interview the facility failed to ensure for one Resident (#54), out of a total sample of 26 residents that the medical plan of care was implemented for the use of a night guard. Findings include: Resident #54 was admitted to the facility in 12/2017 and has diagnoses that include type 2 diabetes's mellitus, nontraumatic subarachnoid hemorrhage, and mild cognitive impairment. Review of the Minimum Data Set Assessment, with an assessment reference date of 2/8/23 indicated Resident #54 had severe cognitive impairment with a score of 7 out of 15 on the Brief Interview for Mental Status Exam. Further, the MDS indicated Resident #54 required supervision for hygiene and was not coded as exhibiting behaviors. On 3/13/23 Resident #54 was lying on his/her bed. He/she was observed to have missing teeth. Review of Resident #54's medical record indicated the following: *A dental exam dated 1/27/23 and signed by an DMD, action required by nursing home staff: recommend OTC (over the counter) night guard to help prevent lower teeth from hitting extraction areas. Review of the order summary report indicated the following: *A physician's order category other, night guard to be worn HS (at hour of sleep), (when available) at bedtime for mouth comfort, dated 1/27/23. Review of the Medication Administration Record, dated for 3/2023 indicated the Night Guard was administered to Resident #54. On 3/15/23 at 9:46 A.M., Resident #54 said he/she has a night guard and does not wear it and said it's here somewhere (in his/her room.) He/she said he/she had broken teeth and has seen a dentist. During an interview on 3/15/23 at 4:07 P.M. Nurse #2 said that she has not seen the night guard for about two weeks and that Resident #54 will often refuse to wear it. Nurse #2 acknowledged it was being signed off on the MAR as being administered. Nurse #2 said the nursing staff should monitor the use of devices. The surveyor accompanied Nurse #2 to Resident #54's room. Resident #54 and Nurse #2 looked through some belongings/drawers and were not able to locate the night guard. During an interview on 3/15/23 at 4:22 P.M. the Director of Nursing (DON) was made aware that the night guard for Resident #54 could not be located by Nurse #2. The Director of Nursing said the expectation would be for the nursing staff to be aware of any device needed for residents and make sure it is available to administer to the resident and not sign it off as administered if it is not available. During a subsequent interview on 3/15/23 at 4:49 P.M., the DON said she could not locate the night guard for Resident #54 and would expect that the nursing staff to keep track of it.

Based on observation, policy review and interviews the facility failed to ensure a call light was placed within reach of the resident for 1 Resident (#313), out of a total sample of 26 residents. Findings include: Review of facility policy titled 'Call bell Procedure' dated reviewed 12/22 indicated the following: General Guidelines: *5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Resident #313 was admitted to the facility in March 2023 with diagnoses including malignant neoplasm of lower lobe, right bronchus or lung. Review of Resident #313's nursing assessment dated [DATE] indicated Resident #313 was alert, oriented to person, place and situation, indicating intact cognition. On 3/13/23 at 9:27 A.M., Resident #313's call bell was observed on the floor out of reach from the Resident. On 3/15/23 at 9:20 A.M., Resident #313's call bell was observed on the floor out of reach from the Resident, he/she needed assistance in being adjusted in his/her bed but could not call for help. During an interview on 3/15/23 at 9:22 A.M., Nurse #1 said the Resident should have his/her call bell in reach at all times. During an interview on 3/15/23 at 1:08 P.M., Unit Manager #1 said call bells need to be within the Residents' reach at all times. During an interview on 3/16/23 at 8:55 A.M., the Director of Nursing said the call bell should be within Residents reach at all times and if a Resident is unable to use the given call bell, there are alternative call bells that can be provided.

Based on record review and interview the facility failed to ensure professional standards of care for respiratory treatment for one Resident (#64) out of a total sample of 26 residents. Specifically, the facility failed to develop and implement a care plan for nebulizer equipment and failed to change the nebulizer mask and tubing timely. Findings include: Review of the facility's policy, Infection Control Manual, subject Respiratory Equipment, dated as reviewed 9/22. Purpose: to Prevent the transmission of infection associated with respiratory therapy tasks and equipment. Policy 5. Nebulizers should be rinsed and dried after each use. Wipe mouthpiece with a damp gauze or paper towel. Save equipment in clean plastic bag between treatments. Discard the administration set every 7 days. Resident #64 was admitted to the facility in May, 2021 with diagnoses that include chronic obstructive pulmonary disease. Review of the Minimum Data Set Assessment with an Assessment Reference Date of 2/8/23, indicated Resident #64 scored 15 out of 15 on the Brief Interview for Mental Status Exam, indicating intact cognition and requires extensive assistance with daily care activities. On 3/13/23 at 9:12 A.M. Resident #64 was in his/her room sitting in a wheelchair. A nebulizer mask and tubing were uncovered and on the bedside table. A bag on the floor between the bed and bedside table had a sticker on it dated 3/2/23. Resident #64 said he/she has a nebulizer treatment 2 times a day. Resident #64 said the mask and tubing are to be changed every Wednesday, but it does not always happen. On 3/13/23 at 4:48 P.M., Resident #64 was laying in his/her bed. The nebulizer was in the bag with a sticker dated 3/2/23. Review of the Resident #64's current physician's orders indicated the following: *Arformoterol Tartrate Nebulization Solution 15 MCG/2ML inhale orally via nebulizer two times a day, dated 8/12/22. *Pulmicort Suspension 0.5 MG/2ML vial inhale orally two times a day related to Chronic Obstructive Pulmonary Disease, combine with aformoterol via nebulizer, dated 12/9/22. The physician's orders failed to indicate an order for the treatment for the nebulizer equipment. Review of 3/2023 Medication Administration Record and Treatment Administration Record failed to indicate a plan of care or interventions for the nebulizer equipment. Review of Resident #64's care plans dated as initiated 12/10/22 indicated the problem: The resident has c/o respiratory symptoms, with the interventions of bronchodilators via nebulizer as ordered by the physician, dated 12/10/22. The respiratory care plan failed to have interventions for the nebulizer equipment. During an interview on 3/15/23 at 12:39 P.M., Unit Manager #1 said nebulizers are to be wiped down weekly and the tubing and mask are to be changed every 7 days. Unit Manger #1 said a physician order should be in place for the care of the equipment. During a review of Resident #64's record with Unit Manger #1, Unit Manager #1 acknowledged there were no interventions for the nebulizer equipment on either of the physician's orders or care plans.

Based on record review and interview the facility failed to ensure for one Resident (#16) that professional standards of care were implemented out of a total sample of 26 residents. Specifically, the facility failed to 1. complete weekly skin assessments, in accordance with the medical plan of care, 2. failed to follow the physician's order related to documenting on a pressure injury, and 3. failed to complete weekly assessments of the identified pressure ulcer. Findings include: Review of the facility's policy titled 'Care and Treatments'; Skin/Wound Care dated as reviewed 9/22 indicated the following: A complete wound assessment and documentation may be done weekly on all pressure injuries/ulcers until they are healed. The criteria to be included: *Site location *Stage, this applies only to pressure ulcer injuries/ulcers. Wound healing is to be described by changes in the wound appearance and size, not by reverse down staging. *Size-length width and depth measured in centimeters. The length is listed first and identifies the measurement of the wound that is head to toe. The width is second and identifies the measurement of the wound that is side to side. Depth is third and identified the deepest area of the wound bed. *Appearance of the wound bed. *Undermining/tunneling-probe base of wound with gloved finger or cotton tip swab to identify if present. *Peri-wound (surrounding skin) describes the condition of the surrounding skin noting if it is intact, erythematous, indurated, edematous, macerated and the temperature if abnormal. *Drainage/exudate describe the amount, color, consistency, and odor. *Pain-document presence and measures taken to eliminate it or provide analgesia or both. Resident #16 was admitted to the facility in 7/2018 and has diagnoses that include other drug induced secondary Parkinsonism and adult failure to thrive. Review of the Minimum Data Assessment, with an Assessment Reference Date of 2/22/23, indicated Resident #16 had a moderately intact cognition based on a score of 11 out of 15 on the Brief Interview for Mental Status Exam, was dependent on staff for bathing and dressing, was at risk for developing pressure ulcers and had 1 unhealed stage 2 pressure ulcer, that was not present on admission or re-entry. Review of the facility Matrix provided to the surveyors on 3/13/23 indicated Resident #16 had a facility acquired stage 2 pressure ulcer. On 3/13/23 at 11:15 A.M., Resident #16 was observed resting in his/her bed. The bed was equipped with an air mattress. Review of Resident #16's medical record indicated the Norton Plus Pressure Ulcer Risk Scale assessments dated 2/21/23, 11/24/22, 8/24/22 and 5/23/22, indicated Resident #16 was at high risk for developing pressure ulcers. 1. Review of Resident #16's physician order summary report indicated the following: -Weekly skin (assessments) Friday 3-11 every evening shift, every Friday for monitoring, dated 9/23/2020 -weekly skin assessment and vital signs every Sunday 7-3 every day shift every Sunday for monitoring, dated 2/6/23. On 3/13/23 at 2:42 P.M., review of the medical record indicated weekly skin assessments for Resident #16 on the following dates: *1/20/23 *2/3/23 *2/19/23 *3/5/23 Further review of the medical record indicated a one time skin check dated 1/24/23 identifying a stage 2 pressure ulcer on Resident #16's coccyx. During an interview on 3/15/23 at 9:11 A.M., Unit Manger #1 said skin checks are done weekly for all residents including Resident #16. Unit Manager #1 reviewed the medical record and acknowledged that 3 weekly skin assessments were not completed 2/12/23, 2/26/23 and 3/12/23. 2. Review of Resident #16's medical record indicated the following: -A One Time Skin Check, dated 1/24/23, indicated a skin issue was identified as a new pressure ulcer, -Location and description of skin issue site: coccyx 0.5 cm (centimeter) times 0.5 cm x 0.2 deep stage 2. Review of the physician's order summary record indicated the following: -Cleanse area with wound cleanser GENTLY, pat dry. Do not worry about removing all of triad that is on skin, ok to leave thin layer triad to not cause further skin issues. Apply thin layer Triad paste to coccyx wound. Document size and description of wound and report concerns/changes to provider, one time a day for coccyx wound treatment, start date 2/17/23 discontinue date 3/14/23. Review of the Treatment Administration Sheets dated 2/2023 and 3/2023 failed to document the size and description of the wound, per the physician's orders. Review of the progress notes dated from 2/17/23 through 3/14/23 failed to document the size and description of the wound, per the physician's orders. During an interview on 3/15/23 at 9:11 A.M., Unit Manger #1 reviewed the record and said the only description of the pressure ulcer is on the 1/24/23 on the One Time Skin Check. Unit Manager #1 acknowledged there was no documentation of the size and description of the wound per the physician's orders. 3. Review of Resident #16's medical record indicated Resident #16 was identified on 1/24/23, on a One Time Skin Check dated 1/24/23 with a new skin issue, a new pressure ulcer. Location and description of skin issue site: coccyx 0.5 cm (centimeter) times 0.5 cm x 0.2 deep stage 2. Review of the Resident #16's care plan, dated 1/24/23, indicated Resident #16 has an actual skin impairment to skin integrity due to decreased/impaired mobility or function, fragile skin, incontinence, with an intervention: weekly treatment documentation to include measurement of each area of skin breakdown's width, length depth, type of tissue and exudate and any other notable changes or observations. Review of Resident #16's medical record progress notes, Treatment Administration Sheets, Medication Administration Sheets, failed to indicate weekly documentation to include measurement of the pressure area's width, length, depth, type of tissue and exudate and any other notable changes or observations. During an interview on 3/15/23 at 9:11 A.M., Unit Manger #1 reviewed the record and said the only description of the pressure ulcer is on the 1/24/23 One Time Skin Check, which identified the coccyx area with a stage 2 pressure ulcer. Unit Manager #1 said nursing should be reviewing the wound for progress towards healing, is there drainage?, and size of the wound at least weekly. During an interview on 3/15/23 at 9:55 A.M., the Director of Nursing (DON) said weekly skin checks should be completed per the physician's orders. The DON said Resident #16's stage 2 coccyx pressure ulcer healed 3/14/23, and that weekly wound assessments should have been completed, she acknowledged that weekly wound assessments were not completed for Resident #16.

Based on record review and interview the facility failed to ensure professional standards of practice for 1 discharged Resident (#112) out of three discharged records reviewed. Specifically, the facility failed to obtain a physician or nurse practitioner order for the RN (Registered Nurse) to provide the pronouncement of death. Findings include: Review of the facility's policy Care and Treatment, section: 'End of Life', dated as reviewed with no changes 9/22, indicated the following: Purpose: To eliminate substantial delays that may occur waiting for the attending physician or the medical examiner. Procedure: 1. RN (Registered Nurse) responsibilities; pronounce resident/patient) if physician indicates an inability to come to the facility and gives permission for the RN pronouncement. Document this in the nurses' note. Review of Resident #112's medical record indicated in a progress note dated 12/26/22 at 8:14 A.M., that at approximately 8:00 A.M., nursing notified by CNA (certified nursing assistant) patient found unresponsive laying supine in bed. Emergency response activated. Patient skin cool to touch, no pulse or respirations noted. No signs of injury noted. Patient status DNR (Do Not Resuscitate), DNI (Do Not Intubate), DNT (Do not transfer), Nurse Practitioner (NP) notified at 8:05 A.M., The note failed to document the permission/order for the RN to provide the pronouncement of death. During an interview on 3/13/23 at 3:53 P.M., the Director of Nursing said she would expect an order to be obtained for the pronouncement of death by the RN and said she was unable to locate one in the medical record.

Based on record review and interview, the facility failed to alert the physician of a change in status for 1 Resident (#19), out of a total of 26 sampled residents. Subsequently, Resident #19 was hospitalized with a urinary tract infection with [CONDITION(S)]. Findings include: Review of the facility's Change of Condition policy, dated 2/28/17, indicated the nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical, emotional, mental condition, and need to transfer the resident to a hospital/treatment center. Resident #19 was admitted to the facility in June 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the clinical record indicated that Resident #19's health care proxy had been activated in June 2021 due to poor cognitive testing indicating he/she was not his/her own decision maker. Review of Resident #19's most recent Minimum Data Set (MDS) assessment, dated 9/9/21, indicated that he/she is moderately cognitively impaired and requires assistance with bathing and dressing. Additional review of the MDS indicated Resident #19 utilized a catheter (a thin tube passed through the urethra and into the bladder to drain urine). Review of Resident #19's Catheter Care Plan, dated 6/8/21, indicated the following: Goal: Resident #19 will remain free from catheter-related trauma through review date. Interventions: Change catheter as ordered. Flush Foley catheter as ordered. Monitor/document for pain/discomfort due to catheter. Monitor/record/report to MD for signs/symptoms for [CONDITION(S)]: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, foul smelling urine. Review of Resident #19's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)]: 5 milligram (mg) tablets Give 1 tablet by mouth every 6 hours as needed for pain 6/7/21. [MEDICATION(S)] Tablet: (a medication used to treat painful urination) Give 100 mg by mouth every 8 hours as needed. Review of Resident #19's Medication Administration Records for September 2021, October 2021, and November 2021 indicated the following: September 2021: 6 doses of [MEDICATION(S)] were administered on 9/9/21, 9/12/21, 9/16/21, 9/21/21, 9/26/21, 9/30/21 and 11 doses of [MEDICATION(S)] were administered on 9/5/21, 9/7/21, 9/9/21, 9/10/21, 9/12/21, 9/13/21, 9/19/21, 9/20/21, 9/21/21, 9/27/21 and 9/30/21. October 2021: 10 doses of [MEDICATION(S)] were administered on 10/5/21, 10/6/21, 10/7/21, 10/9/21, 10/10/21, 10/15/21, 10/16/21, 10/25/21, 10/27/21, 10/31/21 and 20 doses of [MEDICATION(S)] were administered 10/1/21, 10/4/21, 10/6/21, 10/10/21, 10/11/21, 10/13/21 through 10/18/21, 10/22/21 through 10/27/21, 10/29/21, 10/30/21 and 2 doses on 10/31/21 November 1st through 20th 2021 - 15 doses of [MEDICATION(S)] were administered on 11/5/21, 11/6/21, 11/7/21, 11/11/21, 11/13/21, 11/14/21, 11/15/21, 11/17/21, 2 doses on 11/18/21, 3 doses on 11/19/21 and 8 doses of [MEDICATION(S)] were administered on 11/6/21, 11/7/21, 11/11/21, 11/13/21, 11/14,21, 11/16/21, 11/17/21, and 11/19/21. There was no evidence in the clinical record indicating that the physician or the nurse practitioner was notified of the increased frequency of the PRN medications being administered to Resident #19. Review of Resident #19's nursing progress notes from October 2021 through November 2021 indicated the following: 10/1/21: Complained of burning and pain offered pain pill and he/she stated it would bound him/her up took [MEDICATION(S)], no further complaints of discomfort. 10/4/21: Resident medicated with [MEDICATION(S)] complained of burning with good effect. 10/5/21: Resident anxious throughout the day. In the afternoon stated he/she needed something for pain. Stated back was killing him/her. Gave as needed previously PRN [MEDICATION(S)] previously for burning with good effect. 10/6/21: Resident Foley catheter in place complained of burning gave [MEDICATION(S)] with good effect. pain pill for discomfort gave 5 mg [MEDICATION(S)] effect pending. 10/7/21: Resident complained of burning pain and discomfort. Catheter drainage cloudy yellow urine. PRN [MEDICATION(S)] for complaints of burning and pain. 10/9/21: Resident complained of burning, gave PRN [MEDICATION(S)]. 10/10/21: Resident complained of burning gave PRN [MEDICATION(S)] with good effect, Foley catheter drainage orange urine colored. 10/18/21; [MEDICATION(S)] given this morning and evening. 10/20/21: Resident given [MEDICATION(S)] for burning pain decline offer of pain pill, states it binds him up. Foley drainage cloudy yellow urine. 10/22/21: Nurse Practitioner (NP) Note: Patient seen for his/her concern about snoring. (Note did not indicate any information regarding change of status in pain or cloudy urine per resident's plan of care and per facility's policy) 10/23/21: Resident Foley catheter yellow orange colored urine. Gave [MEDICATION(S)] this morning for complaints of burning with good effects. 10/24/21: Complain of burning this morning gave PRN [MEDICATION(S)] with good effect. 10/26/21: Did give Tylenol 650 mg for moderate pain in groin area. 10/27/21: Resident complains of pain after supper. Previously, before dinner, he /she complained of burning pain in his/her groin. Gave PRN [MEDICATION(S)] and Tylenol while daughter was here. Then after supper continued to complain of pain and offered him/her [MEDICATION(S)] and he/she replied yes. 11/8/21: Foley catheter flushed, drainage orange colored urine, previously have given [MEDICATION(S)] for burning and [MEDICATION(S)] for pain with good effect. 11/11/21: Resident complaining of catheter stating it was coming apart. Inspected catheter and no obvious signs of it coming apart but keeps repeating himself/herself about that. A nurse's aide witnessed him/her twice pulling catheter apart and then stating it came apart. Gave PRN [MEDICATION(S)] and PRN [MEDICATION(S)] given no further complaints of anything. 11/12/21: Resident complaining of burning and pain. Gave [MEDICATION(S)] and [MEDICATION(S)]. No further complaints. 11/14/21: Resident given [MEDICATION(S)] and [MEDICATION(S)] this morning after complaining of burning and pain in the genital area 11/15/21: Resident complained of burning and pain in genital area gave PRN [MEDICATION(S)] per his/her request x 2 these last two shifts with good effect. Foley catheter drainage cloudy yellow urine. 11/17/2: Resident Foley cath drainage bright yellow urine cloudy color. Asked for pain meds for pain. Burning and beyond gave 5 mg [MEDICATION(S)] and [MEDICATION(S)] with good effect. 11/19/21: 6:20 A.M. Resident complained of urinary discomfort due to catheter insertion yesterday. Blood clots noted-medicated with [MEDICATION(S)] x 2 this shift along with [MEDICATION(S)]. 11/19/21: 7:38 P.M. Resident complained of genital and lower abdominal pain complains of burning gave PRN [MEDICATION(S)] at 12 and 6 PM for pain Review of Resident #19's output monitoring for November 2021 indicated Resident #19 had zero output on the 7:00 A.M. - 3:00 P.M. shift: 11/9/21, 11/10/21, 11/12/21, 11/15/21, and 11/20/21 and on the 3:00 P.M. -11:00 P.M. shift on 11/15/21. There was no evidence in the clinical record indicating that the physician or nurse practitioner were notified regarding changes Resident #19's status per care plan and policy when Resident #19: *had increased administration of PRN pain medications administered from September 2021 through November 2021 *had episodes of cloudy urine *blood clots were noted with catheter insertion on 11/18/21 *was given multiple doses of pain medications on 11/18/21 and 11/19/21 *had documented instances with 0 output Additional review of Resident #19's nursing progress notes indicated the following: 11/20/21: 7:36 A.M. PRN [MEDICATION(S)] requested by patient. 11/20/21: 6:07 P.M. Resident requested pain pill and this nurse gave him/her an [MEDICATION(S)]. Foley catheter drainage small amount urine this afternoon encouraged fluids. Resident confused attempting to take shirt off, vital signs taken. Resident refused lunch when daughter was visiting. This nurse asked if she wanted to send Resident to the hospital. She stated no at this time. Resident continues to rest in bed. 11/20/21: 7:41 P.M. Resident continues to lie in bed and complain of being uncomfortable. Second set of vitals has a marked change blood pressure 81/150, temp 99.5 Mental status change remains confused, spoke with daughters and they decided they would like Resident #19 sent to hospital. Call to doctor for transport order for emergency for evaluation and comfort. 11/20: 8:22 P.M., Second call to doctor on call waiting for call back order. Resident #19 was hospitalized for a [CONDITION(S)] with [CONDITION(S)] from 11/20/21 through 11/30/21. During an interview with Unit Manager #1 on 12/2/21 at approximately 9:00 A.M., she said that Resident #19 was always in pain and his/her pain was managed with PRN medications that he/she usually takes every day. Unit Manager #1 said that Resident #19 was noncompliant with his/her catheter and would always pull at it. Unit Manager #1 said that she was not aware if there was a protocol on notifying the physician if there was a concern regarding output for residents with catheters. Unit Manager #1 said that on the day that Resident #19 was hospitalized the nurse on duty had noticed a change in Resident #19 and spoke with Resident #19's daughter about sending him/her out to the hospital and the family declined. When asked if the physician was called regarding Resident #19's change in status, Unit Manager #1 said Why would we call? The family already said no and the physician would have just said to send him/her out. During an interview with the NP on 12/2/21 at 10:31 A.M., she said that she was very familiar with Resident #19 and was surprised when she found out that he/she had been hospitalized . The NP said that while she was aware that genital burning and back pain was a concern for Resident #19 and was aware that he/she was taking PRN [MEDICATION(S)] and [MEDICATION(S)] for pain. The NP said that staff had not informed her the frequency Resident #19 was taking his/her PRN medications. The NP said that she would have expected staff to have alerted the on call physician regarding Resident #19's change of status.

Based on record review and interview for 1 of 3 sampled residents (Resident #1), the Facility failed on 3/11/15, to prevent a burn with multiple blisters to Resident #1's skin caused by the application of an unwrapped hotpack. Findings include: Facility policy and procedure on the Application of Heat, dated 4/28/09, indicated, "Fold towel to provide 3-5 layers of protection. Place folded towel on area to be treated. Place hot pack(s) on top of the towels, and secure with a strap, if available." Resident #1's Nurse Practitioner's note, dated 3/11/15, indicated he/she had a raised abscess with cellulitis, located on the back of his/her neck. Review of the Nurse Practitioner's order, dated 3/11/15, indicated placement of a warm compress to the posterior of Resident #1's neck for a 20 minute period, four times per day, and to apply a dressing over the abscess. Review of the Physician's note, dated 3/12/15, indicated Resident #1 sustained a burn to the neck from a hotpack. The Nurse's note, dated 3/13/15, indicated Resident #1 had a burn to the left side of the upper back and shoulder area with fluid-filled blisters. The Nurse's note indicated the skin around the site was red and Resident #1 said the area was painful. The Surveyor interviewed Nurse #1 at 2:00 P.M. on 5/1/15. Nurse #1 said that at approximately 5:00 P.M., she told CNA #1 to apply a hot pack to an abscess located on Resident #1's upper back. Nurse #1 said she did not tell CNA #1 to wrap the hot pack in a towel. Nurse #1 said she did not know hotpacks were required to be wrapped in a towel before application. Nurse #1 said soon after leaving Resident #1's bedroom, CNA #1 told her that he applied the hot pack without a towel and that Resident #1 complained of burning pain. CNA #1's written statement, dated 5/1/15, indicated a nurse asked him to give a hotpack to Resident #1, who was complaining of neck pain. CNA #1 indicated Resident #1 showed him where he/she was having the pain, and then CNA #1 placed the hotpack on Resident #1. The Surveyor interviewed Resident #1 at 12:00 P.M. on 4/9/15. Resident #1 said that on 3/11/15, in the early afternoon, CNA #1 applied an unwrapped hotpack to his/her back. Resident #1 said the hotpack burned his/her skin and, "it was the most painful experience I've ever had." Resident #1 said as of 4/9/15, his/her back was still in pain from the burn and it was especially painful to lie in bed on his/her back. The Surveyor interviewed Nurse #3 at 3:05 P.M. on 4/9/15. Nurse #3 said at approximately 8:00 A.M. on 3/12/15, she observed blistering on Resident #1's left shoulder. Nurse #3 said Resident #1 told her that someone placed a hotpack on him, which burned his/her skin. The Surveyor interviewed the Unit Manager at 9:00 A.M. on 4/9/15. The Unit Manager said on 3/12/15, at approximately 9:00 A.M., she assessed Resident #1 and determined he/she had 3 fluid-filled blisters on the left shoulder and neck, and the skin around the blisters was red.

Based on record review and interview for 1 of 3 sampled residents (Resident #1), the Facility failed on 3/11/15, to ensure staff properly administered a warm compress to Resident #1's skin abscess, which resulted in burn blisters to his/her left shoulder and upper back. Findings include: 1) Pursuant to Massachusetts General Law (M.G.L.), pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 (3.03) a registered nurse, or licensed practical nurse, may delegate nursing activities to other health care personnel, provided that the delegating nurse shall bear full responsibility for: a) making an appropriate assignment; b) properly and adequately teaching, directing and supervising the delegatee; and c) the outcomes of that delegation (all within the parameters of his/her generic and continuing education and experience. 2) The Surveyor interviewed the Director of Nurses (DON) at 10:00 A.M. on 4/09/15. The DON said it was Facility policy for only licensed nurses to apply heat to residents and that unlicensed staff, such as CNAs, were prohibited from performing this treatment. The DON said that it was not appropriate for Nurse #1 to assign CNA #1 to treat Resident #1 with a hot pack, and that CNA #1 did not have the education or training to safely administer a hot pack. Facility policy and procedure on the Application of Heat, dated 4/28/09, indicated, "Fold towel to provide 3-5 layers of protection. Place folded towel on area to be treated. Place hot pack(s) on top of the towels, and secure with a strap, if available." Resident #1's Nurse Practitioner's note, dated 3/11/15, indicated he/she had a raised abscess with [MEDICAL CONDITION], located on the back of his/her neck. Review of the Nurse Practitioner's order, dated 3/11/15, indicated placement of a warm compress to the posterior of Resident #1's neck for a 20 minute period, four times per day, and to apply a dressing over the abscess. Review of the Physician's note, dated 3/12/15, indicated Resident #1 sustained a burn to the neck from a hotpack. The Nurse's note, dated 3/13/15, indicated Resident #1 had a burn to the left side of the upper back and shoulder area with fluid-filled blisters. The Nurse's note indicated the skin around the site was red and Resident #1 said the area was painful. The Surveyor interviewed Nurse #1 at 2:00 P.M. on 5/1/15. Nurse #1 said that at approximately 3:30 P.M., she observed an abscess on the back of Resident #1's neck. Nurse #1 said the Nurse Practitioner assessed Resident #1 and ordered a warm compress to be applied to the abscess. Nurse #1 said that at approximately 5:00 P.M., she entered Resident #1's bedroom with a chemical heat pack to apply to Resident #1, but that Resident was occupied with CNA #1, who was helping him/her to the toilet. Nurse #1 said she told CNA #1 to apply the hot pack to the abscess after Resident #1 was finished toileting, and she showed CNA #1 the location of the abscess. Nurse #1 said she did not tell CNA #1 to wrap the hot pack in a towel. Nurse #1 said that CNA #1 did not question her as to whether the application of a hot pack was within his scope of practice. Nurse #1 said she did not know application of heat was beyond a CNA's professional scope of practice. Nurse #1 said she did not know hotpacks were required to be wrapped in a towel before application. Nurse #1 said soon after leaving Resident #1's bedroom, CNA #1 told her that he applied the hot pack without a towel and that Resident #1 complained of burning pain. Nurse #1 said CNA #1 told her that he then wrapped the hot pack in a towel and reapplied it to the back of Resident #1's neck. Nurse #1 said she reentered Resident #1's bedroom at approximately 6:00 P.M. and Resident #1 complained that when CNA #1 applied the hot pack it was too hot. Nurse #1 said she assessed the skin on the back of Resident #1's neck and it was intact and at its baseline color. Nurse #1 said the hotpack was no longer on Resident #1's neck. CNA #1's written statement, dated 5/1/15, indicated a nurse asked him to give a hotpack to Resident #1, who was complaining of neck pain. CNA #1 indicated Resident #1 showed him where he/she was having the pain, and then CNA #1 placed the hotpack on Resident #1. The Surveyor interviewed Resident #1 at 12:00 P.M. on 4/9/15. Resident #1 said that on 3/11/15, in the early afternoon, Nurse #1 and CNA #1 were in his/her bedroom and Nurse #1 handed CNA #1 a hotpack. Resident #1 said CNA #1 opened the hotpack and applied it to his/her back (Resident #1 pointed to his/her upper back). Resident #1 said the hotpack burned his/her skin and, "it was the most painful experience I've ever had." Resident #1 said CNA #1 then removed the hotpack and wrapped it "in something" and reapplied it to his/her back. Resident #1 said approximately 10 minutes later he/she removed the hotpack because it was too painful. Resident #1 said as of 4/9/15, his/her back was still in pain from the burn and it was especially painful to lie in bed on his/her back. The Surveyor interviewed Nurse #2 at 11:35 A.M. on 5/1/15. Nurse #2 said she worked the 11:00 P.M. to 7:00 A.M. shift, beginning on 3/11/15 and ending on 3/12/15. Nurse #2 said during the change of shift report Nurse #1 told her that Resident #1 had an order for [REDACTED].#2 said there was no report of an incident involving Resident #1. Nurse #2 said at approximately 6:40 A.M. on 3/12/15, she applied a hotpack, wrapped in a towel, to the abscess on the back of Resident #1's neck. Nurse #2 said she did not observe Resident #1's upper back or left shoulder area, or see any burned skin or blisters. The Surveyor interviewed Nurse #3 at 3:05 P.M. on 4/9/15. Nurse #3 said at approximately 8:00 A.M. on 3/12/15, she entered Resident #1's bedroom to administer his/her medications and change the dressing over the abscess. Nurse #3 said she observed blistering on Resident #1's left shoulder. Nurse #3 said Resident #1 told her that someone placed a hotpack on him, which burned his/her skin. The Surveyor interviewed the Unit Manager at 9:00 A.M. on 4/9/15. The Unit Manager said on 3/12/15, at approximately 9:00 A.M., she assessed Resident #1 and determined he/she had 3 fluid-filled blisters on the left shoulder and neck, and the skin around the blisters was red. The DON said that Nurse #1 had been a [MEDICATION NAME] nurse for approximately one year.

Based on staff interview and record review, the facility failed to prevent the development of a pressure sore on the distal calf for 1 of 2 residents (Resident #2) from a sample of 24 residents. Findings include: Review of Resident #2's clinical record on 7/31/12 indicated that the resident was admitted to the facility during 6/2012 for rehabilitation following a fractured left patella (knee) and a fractured right humerus (shoulder). Review of the resident's admission physician orders, dated 6/24/12, indicated that the resident required a knee immobilizer to the left lower extremity (LLE) at all times and the resident's knee immobilizer was to be removed to check for skin integrity every shift. Review of the resident's admission Minimum Data Set (MDS), dated [DATE], indicated that the resident was alert and oriented to time, place, and person. The MDS further indicated that the resident was dependent for bathing, transfers, toileting, and personal hygiene. Review of the resident's plan of care for activities of daily living, dated 6/24/12, indicated that the resident required total assistance for bathing and personal hygiene. Review of the resident's plan of care for skin integrity, dated 6/24/12, indicated that the resident's skin was to be monitored for signs and/or symptoms of infection. The plan of care did not indicate that the skin under splint devices or braces was to be monitored . Review the resident's nurse's note, dated 7/22/12 at 11:00 A.M., indicated that the resident's left ankle was red and warm; the physician was made aware, and the physician ordered Keflex (an anti-infective medication) 250 milligrams (mg) by mouth three times a day for 5 days. Review of the nurse's note, dated 7/24/12 from 11 P.M. to 7 A.M., indicated that the resident's left shin was pink and warm and the resident continued on Keflex. Review of the nurse's note, dated 7/24/12 at 4:00 P.M., indicated that the resident continued on Keflex for left shin [MEDICAL CONDITION] (an infection of the skin) and the skin on the left shin was blotchy red and warmer than the surrounding skin. The note further indicated that the distal end of the knee immobilizer was making a deep indentation and the knee immobilizer was loosened at the distal aspect. Review of the nurse's note, dated 7/25/12 at 3:00 P.M., indicated that the resident's left shin was blotchy and red and had no increased [MEDICAL CONDITION] (swelling). Review of the nurse's note, dated 7/25/12 at 11:00 P.M., indicated that the resident's left shin was red, slightly warm, and [MEDICAL CONDITION]. Review of the nurse's note, dated 7/26/12 at 4:00 A.M., indicated that the resident's left shin was warm and red and had one plus [MEDICAL CONDITION]. Review of the nurse's note, dated 7/26/12 at 2:45 P.M., indicated that the resident's left shin was blotchy, red, warm, and slightly tender and the resident continued on Keflex for [MEDICAL CONDITION]. Review of the nurse's notes, dated 7/27/12 at 3:00 A.M. and 3:00 P.M., indicated that the resident's left shin remained red, blotchy, and warm and Keflex for the resident's left shin [MEDICAL CONDITION] continued. Review of the nurse's note, dated 7/28/12 at 8:15 A.M., indicated that the resident's left incision was less blotchy with less redness; the incision was healed, and two plus [MEDICAL CONDITION] was present in the left lower extremity. The nurse's note indicated that the resident's Keflex was completed. There was no further documentation in the nurse's notes after 7/24/12 until 7/28/12 of the deep indentation on the left lower extremity. Review of the nurse's note, dated 7/28/12 from 7:00 A.M. to 3:00 P.M., indicated that the physical therapist noted an open wound at the distal, lateral calf (above the ankle) where the edge of the immobilizer touched the resident's skin. The note indicated that the surrounding skin around the open wound was dark red and warm. The note further indicated that the physician was notified of the open wound. The note indicated that the physician ordered Keflex 500 mg three times a day and a dressing to the open wound (pressure sore) daily until healed. Review of the Pressure Ulcer careplan dated 7/28/12 and the nurse's note of 7/28/12 indicated no documentation of pressure ulcer stage or measurements. The Treatment Record also lacked documentation of the pressure ulcer stage and measurements. During an interview on 8/1/12 at 11:25 A.M., the Assistant Director of Nurses (ADON) said there was no Treatment Record documentation and/or documentation in the nurse's notes that redness was present on the resident's left distal calf until the wound became open on 7/28/12. The ADON said because the resident developed [MEDICAL CONDITION] of the left shin and [MEDICAL CONDITION] was observed daily, close monitoring of the resident's left leg was not evident by the documentation completed by the nursing staff.

Based on record review and interviews, for 1 of 7 sampled residents (Resident #1), the Facility failed to prevent at least 5 incidents of abuse, one physical and four verbal, by Certified Nurse Aide (CNA) #1 during approximately a three month period prior to 3/17/12. The incidents included: * On 3/17/12, CNA #2 observed and CNA #3 heard (from behind a privacy curtain) when CNA #1 punched Resident #1 with a closed fist in the chest; * On 3/17/12, CNA #1 was observed to poke Resident #1 until he/she became agitated and CNA #1 laughed in response; the interaction [MEDICATION NAME] approximately 30 seconds until stopped by CNA #2; * During the three months prior to 3/17/12, CNA #5 said CNA #5 observed CNA #1 getting very close to Resident #1's face and calling Resident #1 by name repeatedly until Resident #1 became agitated, and CNA #1 was observed smiling in response to Resident #1's agitation. CNA #5 said that interaction made CNA #5 feel uncomfortable enough to tell CNA #1 to stop; and * CNA #1 was heard by CNA #4 to be taunting Resident #1 by referring to Resident #1 as a, "piece of[***]" or words to that effect, while in Resident #1's presence; and would refer to Resident #1 as a, "bastard,[***] , piece of shift, or pain in the ass," or words to that effect when exiting Resident #1's room. Findings include: 1. Resident #1's [DIAGNOSES REDACTED]. Resident #1's quarterly Minimum Data Set assessment, dated 1/18/12, indicated that Resident #1 had adequate hearing, was rarely understood, and had impaired ability to understand others. The assessment indicated that Resident #1 had physical and verbal behavioral symptoms which were directed at others one to three times per week. The assessment indicated Resident #1 was dependent on two staff for bed mobility, transfers, and personal hygiene; and was non-ambulatory. The Facility report form, dated 3/20/12, indicated that on 3/17/12 at 8:30 P.M., Certified Nursing Assistant (CNA) #1 was observed striking Resident #1 in the right sternal/chest area. A follow-up report, dated 3/22/12, indicated that CNA #1 was asked to assist in the transfer of Resident #1 into bed. The report indicated that prior to the transfer, CNA #1 was observed to try to provoke Resident #1 by trying to '"egg (him/her) on'" by poking Resident #1's arm and when Resident #1 attempted to strike CNA #1, CNA #1 responded by stating, "'That's all you got?''' The report indicated that during the transfer, Resident #1 squeezed his/her arms against his/her sides to "retaliate against care," and tried to pull CNA #1 down. The report indicated that CNA #1 broke free from Resident #1's grip and punched Resident #1 in the chest. The report indicated that as a result of being punched, Resident #1 landed into the bed. CNA #2's written statement, dated 3/17/12, indicated that while providing care to Resident #1, CNA #1 began to "egg (Resident #1) on, trying to provoke him/her." The statement indicated that CNA #1 poked Resident #1 in the arm and when Resident #1 attempted to strike out with his/her hands and feet at CNA #1, CNA #1 responded, "that's all you got"? or words to that effect. The statement indicated that CNA #2 directed CNA #1 to assist in putting Resident #1 into bed. The statement indicated they each put their arms under Resident #1's arms to transfer him/her when Resident #1 squeezed his/her arms. The statement indicated that Resident #1 attempted to pull CNA #1 down and CNA #1 broke free from his/her grip and punched Resident #1 in the chest. The statement indicated that as a result of being punched, Resident #1 fell back into his/her bed. The statement indicated that CNA #1 immediately left the room. The statement indicated that CNA #3 came from around the privacy curtain and informed CNA #2 that she heard a "thud' and wanted to make sure that Resident #1 was okay. The statement indicated that CNA #2 showed CNA #3 that Resident #1 had a red mark on the upper right side of the sternum. The Surveyor interviewed CNA #2 at 11:52 A.M. on 4/11/12 and at 10:05 A.M. on 4/18/12. CNA #2 said that CNA #2 was assigned to provide care to Resident #1 during the evening shift (2:45 P.M. to 11:15 P.M.) on 3/17/12. CNA #2 said that Resident #1 had behavioral issues and could become agitated during care. CNA #2 said that Resident #1 had a slight tremor of the right arm and when Resident #1 was becoming agitated he/she would shake his/her right arm in a more pronounced manner. CNA #2 said that in addition, Resident #1 had a tendency to move his/her mouth, tongue, and lips in a certain manner that let those who knew him/her know that he/she was becoming agitated. CNA #2 said at approximately 8:30 P.M., CNA #2 needed assistance to transfer Resident #2 into bed and asked CNA #1 for assistance. CNA #2 said that they brought Resident #1 to his/her room. CNA #2 said that upon entering the room, CNA #2 observed CNA #3 who was with Resident #1's roommate. CNA #2 said that the privacy curtain was pulled between the beds upon entering the room. CNA #2 said that as CNA #2 was starting to remove Resident #1's shirt, Resident #1 did not seem agitated and did not attempt to strike either CNA #1 or CNA #2, and did not say anything to either CNA. CNA #2 said that CNA #2 started to provide care, CNA #1 tapped with the tips of CNA #1's fingers on the bottom of the forearm in a rapid and repeated poking action, while saying to Resident #1, "that's all you got?" or words to that effect. CNA #2 said that in response, Resident #1 began to get agitated, and attempted to kick out at CNA #1 and attempted to reach out at CNA #1 and try to punch CNA #1. CNA #2 said that when Resident #1 attempted to kick and punch CNA #1, CNA #1 laughed. CNA #1 said that the episode lasted approximately 30 seconds until CNA #2 told CNA #1 to stop. CNA #2 said that CNA #1 stopped and then proceed to assist with the transfer by placing her arm under the arm of Resident #1. CNA #2 said that CNA #1 was on one side of Resident #1 while CNA #2 was on the other side during the transfer and they both assisted Resident #1 to a standing position in preparation of transferring Resident #1 into bed. CNA #2 said that Resident #1 tightened his/her arms toward his/her chest, which resulted in Resident #1 squeezing the arms of both CNA #1 and CNA #2. CNA #2 said that when Resident #1 was positioned in a standing position in front of the bed, Resident #1 started to lean to one side and almost pulled CNA #1 toward the bed. CNA #2 said that CNA #1 pulled her arm away from Resident #1's grip and immediately pulled her arm back and with a closed fist struck Resident #1 in the right side of the chest. CNA #2 said that CNA #2 heard an audible thud when CNA #1 punched Resident #1. CNA #2 said that the punch was so hard that Resident #1 fell back and landed into the bed. CNA #2 said that CNA #1 left the room immediately. CNA #2 said that Resident #1's eyes were watery after the incident, but did not make any comment or response when punched. CNA #2 said that Resident #1 appeared afraid because he/she kept looking at the door and his/her face seemed tighter. CNA #2 said that CNA #3 who was in the room, came from behind the privacy curtain and asked CNA #2 what had happened. CNA #2 said that she informed CNA #3 that CNA #1 punched Resident #1. CNA #2 said that they both looked at Resident #1's chest together and observed a red mark on Resident #1's chest. CNA #2 said that CNA #3 assisted with the remainder of care. CNA #2 said that she reported the incident to a nurse approximately 45 minutes later. CNA #3's written statement, dated 3/17/12, indicated that on this date, CNA #3 was providing care to Resident #1's roommate when she heard a, "thud" and was unsure of what was heard until informed by CNA #2, who said that CNA #1 hit Resident #1. The Surveyor interviewed CNA #3 at 2:45 P.M. on 4/11/12. CNA #3 said she provided care to Resident #1's roommate when Resident #1 was being assisted into bed by CNA #1 and CNA #2. CNA #3 said that while providing care to Resident #1's roommate, she heard a sound which CNA #3 described as a "thud." CNA #3 said that when she heard the sound it was a hollow sound and recalled thinking it sounded as if someone was just hit. CNA #3 said that CNA #1 exited the room immediately after CNA #3 heard the thud. CNA #3 said that CNA #3 came from around the privacy curtain to Resident #1's side of the bed and observed Resident #1 lying diagonally in the bed. CNA #3 said that CNA #2 told her that CNA #1 punched Resident #1 in the chest. CNA #3 said that they both looked at Resident #1's chest and observed a round, red mark on Resident #1's chest which CNA #3 had not observed prior to 3/17/12. CNA #3 said that she assisted CNA #2 to reposition and finish evening care with Resident #1. CNA #1's written statement, dated 3/19/11, indicated that at approximately 9:15 P.M. CNA #1 was asked to assist with providing a transfer to Resident #1. The statement indicated that as CNA #1 walked into the room, she called Resident #1 by name. The statement indicated that while transferring Resident #1 into bed, Resident #1 grabbed the back of CNA #1's arm and squeezed it with his/her "dirty nails." The statement indicated that CNA #1 pushed Resident #1 off of CNA #1, placed Resident #1's legs in the bed, and left the room. The statement indicated that CNA #1 pushed Resident #1 in the chest area. The Surveyor interviewed CNA #1 at 2:24 P.M. on 4/17/12. CNA #1 said that during the evening of 3/17/12, CNA #1 assisted CNA #2 to transfer Resident #1 into bed. CNA #1 said that CNA #1 never tapped or poked Resident #1 in any way prior to the transfer. CNA #1 said that when CNA #1 approached Resident #1 to assist with the transfer, Resident #1 already had an agitated look. CNA #1 described Resident #1 as being very readable with regard to how he/she presented when agitated, and described the presentation as Resident #1 having more pronounced shaking of the right arm, and tongue and lip movements. CNA #1 said that Resident #1 was already agitated when CNA #1 approached Resident #1 and in an effort to not startle Resident #1, CNA #1 said "hi" and referred to Resident #1 by his/her first name. CNA #1 said that during the transfer while Resident #1 was in a standing position, Resident #1 began to squeeze CNA #1's upper arm and within a "split second," or words to that effect, she pulled her arm out from under Resident #1's arm, placed her open palm on Resident #1's chest, and extended her arm which pushed Resident #1 into the bed. CNA #1 said that Resident #1 went from a standing position to landing into the bed as a result of the push. 2. Review of the investigation file regarding an allegation of abuse on 3/17/12, indicated that there were notes from telephone interviews and written statements from direct care staff contained within the file. The notes indicated that when interviewed by the Director of Nurses (DON), CNA #5 told the DON that CNA #1 was observed to antagonize Resident #1 a couple of times prior to 3/17/12. The Surveyor interviewed CNA #5 at 6:20 A.M. on 4/12/12. CNA #5 said that CNA #5 was consistently assigned to provide care to Resident #1 and worked with CNA #1 on a consistent basis during the night (10:45 P.M. to 7:15 A.M.). CNA #5 said that Resident #1's body language was such that it was easy to tell by looking at Resident #1 when Resident #1 was becoming agitated. CNA #5 said that Resident #1 normally had a twitch of the right arm which would become more exaggerated when agitated, and Resident #1 would make facial expressions with his/her tongue when agitated. CNA #5 said that normally when Resident #1 was agitated the staff were able to calm down Resident #1 by talking to him/her. CNA #5 said that CNA #1 appeared aggravated by Resident #1 on a regular basis when coming out of Resident #1's room after providing care to Resident #1. CNA #5 said that on at least two occasions prior to 3/17/12, CNA #1 was observed by CNA #5 attempting to antagonize Resident #1 by placing CNA #1's face very close to Resident #1 and stating, "come on (Resident #1's first name)," or words to that effect or, "what's up (Resident #1's first name)"? or words to that effect. CNA #5 said that there was no need to get that close to Resident #1 and it appeared to CNA #5 that CNA #1 was intentionally getting close to agitate Resident #1. CNA #5 said that the interaction was uncomfortable enough for CNA #5 to tell CNA #1 to stop and to intervene. CNA #5 said it appeared that CNA #1 liked to cause Resident #1 to become agitated because CNA #1 would appear as if it was entertaining and smile. 3. Review of the investigation file regarding an allegation of abuse on 3/17/12, indicated that there were notes from telephone interviews and written statements from direct care staff contained within the file. The notes were identified as being from the DON and indicated that CNA #4 told the DON that CNA #1 was mean to Resident #1, would occasionally taunt Resident #1 by calling Resident #1, "a piece of[***]" or words to that effect, while in Resident #1's presence. The notes indicated that CNA #4 told the DON that CNA #1 was asked why she was mean to Resident #1 and CNA #1 told CNA #4 that it was because CNA #1 thought Resident #1 was a, "piece of[***]" or words to that effect. CNA #4 documented in a written statement, dated 4/12/12, that CNA #1 called Resident #1 a, "piece of[***] when in close proximity to Resident #1. The statement indicated that during rounds and while leaving Resident #1's room, CNA #1 would refer to Resident #1 a "bastard, an[***] , and even a racist piece of[***]" or words to that effect. The Surveyor interviewed CNA #4 at 12:30 P.M. on 4/11/12 and at 7:30 A.M. on 4/12/12 and at 9:59 A.M. on 4/17/12. CNA #4 said that CNA #4 worked with CNA #1 on a consistent basis during the night (10:45 P.M. to 7:15 A.M.). CNA #4 said that CNA #1 called Resident #1 a "piece of[***] " or words to that effect when in close proximity to Resident #1 and Resident #1's roommate. CNA #4 said that during rounds and while leaving Resident #1's room, CNA #1 would refer to Resident #1 as a "bastard, an[***] , and even a racist piece of[***] or words to that effect. CNA #4 said that CNA #1 called residents who were difficult to care for as, "a pain in the ass," or words to that effect, which included Resident #1. CNA #1 said it was possible that Resident #1 was able to hear the comment, but was not certain because CNA #1 was exiting Resident #1's room at the time the comment was made. CNA #4 said that to clarify the comment about Resident #1 being referred to by CNA #1 as a "bastard" or "asshole" or "pain in the ass," or words to that effect, CNA #4 said that combinations of those comments were said by CNA #1 as a matter of routine during the night shift (10:45 P.M. to 7:00 A.M.). CNA #4 said that these comments were not consistently made in the presence of residents or Resident #1. CNA #5 said that CNA #1 appeared aggravated by Resident #1 on a regular basis when coming out of the room after providing care to Resident #1. CNA #5 said that CNA #1 did refer to Resident #1 as a "piece of[***]" or words to that effect but did not recall a time when CNA #5 heard the comment made in Resident #1's presence. CNA #1 said when asked by the Surveyor whether CNA #1 had ever referred to Resident #1 as, "a bastard, an[***] , a piece of[***] and a pain in the ass" or words to that effect, and CNA #1 responded that she had used those terms to describe Resident #1 and other residents to staff but not in the presence of other residents, Resident #1, or family members. Resident #1 was observed by the Surveyor at approximately 12:30 P.M. on 4/11/12. Resident #1 made eye contact when his/her first name was called but did not respond when asked any questions.

Based on record review and interviews, for 1 of 7 sampled residents (Residents #1), the Facility failed to ensure that three of five allegations of abuse, occurring during the three months prior to 3/17/12, were immediately reported to the Administrator and Department of Public Health. Once reported to the Director of Nurses (DON) on approximately 3/21/12, no addition investigation was completed until 4/13/12. Findings include: The Facility had two abuse prevention policies at the Facility, which were identified by the Administrator and Director of Nurses (DON) as being the Facility's current policies. The Facility abuse policy, dated 7/2010, indicates that the staff member who is first aware of an allegation of abuse shall immediately notify the charge nurse, their supervisor, or the administrator. The abuse prevention policy, dated 10/21/08, indicated that the Facility ensures that staff received inservice education regarding how to recognize signs of burnout, frustration, and stress that may lead to abuse. The policy indicated that the Facility would identify, correct, and intervene in situations in which abuse, mistreatment, neglect, and/or misappropriation of resident property are more likely to occur through analysis of... "monitoring residents, visitors, and staff to identify inappropriate behaviors such as using derogatory language, rough handling, etc.." and, "The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect." 1. Review of the investigation file regarding an allegation of physical abuse which occurred on 3/17/12, indicated that there were notes from telephone interviews and written statements from direct care staff contained within the file. The notes indicated that when interviewed by the DON, CNA #5 told the DON that CNA #1 was observed to antagonize Resident #1 a couple of times. The Surveyor interviewed CNA #5 at 6:20 A.M. on 4/12/12. CNA #5 said that CNA #5 was consistently assigned to provide care to Resident #1 and worked with CNA #1 on a consistent basis during the night shift (10:45 P.M. to 7:15 A.M.). CNA #5 said that Resident #1's body language was such that it was easy to tell by looking at Resident #1 when Resident #1 was becoming agitated. CNA #5 said that Resident #1 normally had a twitch of the right arm which would become more exaggerated when agitated, and Resident #1 would make facial expressions with his/her tongue when agitated. CNA #5 said that normally when Resident #1 was agitated the staff were able to calm down Resident #1 by talking to him/her. CNA #5 said that CNA #1 appeared aggravated by Resident #1 on a regular basis, when coming out of the room after providing care to Resident #1. CNA #5 said that on at least two occasions prior to 3/17/12, CNA #1 was observed by CNA #5 attempting to antagonize Resident #1 by placing CNA #1's face very close to Resident #1 and stating, "come on (Resident #1's first name)," or words to that effect or, "what's up (Resident #1's first name)"? or words to that effect. CNA #5 said that there was no need to get that close to Resident #1 and it appeared to CNA #5 that CNA #1 was intentionally getting close to agitate Resident #1. CNA #5 said that the interaction was uncomfortable enough for CNA #5 to tell CNA #1 to stop and to intervene. CNA #5 said it appeared that CNA #1 liked to cause Resident #1 to become agitated because CNA #1 would appear as if it was entertaining and smile. CNA #5 said that CNA #5 was aware of the requirement for reporting abuse, but did not report what she had observed to the Administrator or anyone else until 3/21/12 because CNA #5 thought that CNA #1 would stop when asked to do so. 2. Review of the investigation file regarding an allegation of abuse on 3/17/12, indicated that there were notes from telephone interviews and written statements from direct care staff contained within the file. The notes were identified as being from the DON and indicated that CNA #4 told the DON that CNA #1 was mean to Resident #1, would occasionally taunt Resident #1 by calling Resident #1, "a piece of[***]" or words to the effect, while in Resident #1's presence. The notes indicated that CNA #4 told the DON that CNA #1 was asked why she was mean to Resident #1 and CNA #1 told CNA #4 that it was because CNA #1 thought Resident #1 was a, "piece of[***]" or words to that effect. CNA #4 documented in a written statement, dated 4/12/12, that CNA #1 called Resident #1 a "piece of[***] when in close proximity to Resident #1. CNA #4 said that during rounds and while leaving Resident #1's room, CNA #1 would refer to Resident #1 a "bastard, an[***] , and even a racist piece of[***]" or words to that effect. The Surveyor interviewed CNA #4 at 12:30 P.M. on 4/11/12 and at 7:30 A.M. on 4/12/12 and at 9:59 A.M. on 4/17/12. CNA #4 said that CNA #4 worked with CNA #1 on a consistent basis during the night (10:45 P.M. to 7:15 A.M.). CNA #4 said that CNA #1 called Resident #1 a "piece of[***] " or words to that effect when in close proximity to Resident #1 and Resident #1's roommate. CNA #4 said that during rounds and while leaving Resident #1's room, CNA #1 would refer to Resident #1 as a "bastard, an[***] , and even a racist piece of[***] or words to that effect. CNA #4 said that CNA #1 called residents who were difficult to care for, a "pain in the ass," or words to that effect, which included Resident #1. CNA #1 said it was possible that Resident #1 was able to hear the comment, but was not certain because CNA #1 was exiting Resident #1's room at the time the comment was made. CNA #4 said that to clarify the comment about Resident #1 being referred to by CNA #1 as a "bastard" or "asshole" or "pain in the ass," or words to that effect, CNA #4 said that combinations of those comments were said by CNA #1 as a matter of routine during the night shift. CNA #1 said that these comments were not consistently made in the presence of residents or Resident #1. CNA #5 said that CNA #1 appeared aggravated by Resident #1 on a regular basis, when coming out of the room after providing care to Resident #1. CNA #5 said that CNA #1 did refer to Resident #1 as a "piece of[***]" or words to that effect but did not recall a time when CNA #5 heard the comment made in Resident #1's presence. CNA #4 said that CNA #4 did not report what CNA #4 heard to the Administrator or anyone else unit questioned by the Surveyor on 4/11/12. CNA #4 said that though CNA #4 was aware of the requirements of reporting abuse, CNA #4 was afraid to report the allegation. CNA #1 said that CNA #1 was told by the DON that Resident #1 did not know what Resident #1 was saying to staff, but CNA #1 told the Surveyor that based on Resident #1's actions toward CNA #1 and other staff, that CNA #1 knew Resident #1 was well aware of what he/she was saying. CNA #1 said when asked by the Surveyor whether CNA #1 had ever referred to Resident #1 as a, "bastard,[***] , piece of[***] and pain in the ass" or words to that effect, CNA #1 responded that she had used those terms to describe Resident #1 and other residents to staff but not in the presence of residents, Resident #1, or family members. Resident #1 was observed by the Surveyor at approximately 12:30 P.M. on 4/11/12. Resident #1 made eye contact when his/her first name was called but was unable to answer any basic questions. The DON said that no additional separate investigation was completed in response to the comments made regarding CNA #1 antagonizing, swearing at or about Resident #1, or being rough with residents until after the start of survey dated 4/11/12.

Based on record review and interviews, for 1 of 7 sampled residents, the Facility failed to ensure that the Facility's abuse prevention policy and procedures were implemented when: * On 2/27/12, Nurse #3 reported to the DON that she and other nurses had concerns about CNA #1 and CNA #5 working together during the night shift. CNA #1 was identified as making derogatory comments when questioned by the charge nurse; was heard stating, "[***] this place," or words to that effect when entering the elevator; was observed sleeping on the unit; and of having a general angry appearance when directed or questioned by the nurses. Though the DON met with CNA #1, no plan was developed to ensure that CNA #1's actions and performance were monitored to ensure they did not impact residents. * CNA #4 said that for approximately three months prior to 3/17/12, CNA #4 observed CNA #1 being rough when providing care to 4 of 7 samples residents (Resident #1, Resident #2, Resident #3, Resident #4), but did not report the concerns until 3/21/12; * CNA #5 reported during an unknown period of time prior to 3/17/12, observing five episodes of CNA #1 being rough with Resident #1, but did not report the incidents until 3/21/12; * CNA #6 said she received a complaint of rough handling from Resident #7 approximately seven months prior to 4/11/12, but did not report the concerns. * CNA #4, CNA #5, and CNA #1 told the Surveyor that CNA #1 referred to Resident #1 in a derogatory manner, but CNA #4 and CNA #5 did not report this concern until 3/21/12; * On 3/17/12 CNA #2 witnessed CNA #1 antogonize Resident #1 but did not immediatley take action to protect Resident #1 from further abuse and moments later, CNA #1 was observed to punch Resident #1 in the chest. CNA #2 did not report the incidents until 45 minutes later; and * On 3/18/12, Nurse #3 sent an electronic mail (e-mail) to the DON, which included allegations of abuse reported to Nurse #2 and Nurse #3, but neither nurse completed an incident report or obtained statements in accordance with facility policy; and Findings include: The Facility had two abuse prevention policies at the Facility, which were identified by the Administrator and Director of Nurses (DON) as being the Facility's current policies. The Facility abuse policy, dated 7/2010, indicates that the staff member who is first aware of an allegation of abuse shall immediately notify the charge nurse, their supervisor, or the administrator. The abuse prevention policy, dated 10/21/08, indicated that the Facility ensures that staff received inservice education regarding how to recognize signs of burnout, frustration, and stress that may lead to abuse. The policy indicated that the Facility would identify, correct, and intervene in situations in which abuse, mistreatment, neglect, and/or misappropriation of resident property are more likely to occur through analysis of... "monitoring residents, visitors, and staff to identify inappropriate behaviors such as using derogatory language, rough handling, etc.." and, "The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect." 1. On 2/27/12, Nurse #3 reported to the DON that she and other nurses had concerns about CNA #1 and CNA #5 working together during the night shift. CNA #1 was identified as making derogatory comments when questioned by the charge nurse; was heard stating, "[***] this place," or words to that effect when entering the elevator; was observed sleeping on the unit; and of having a general angry appearance when directed or questioned by the nurses. Though the DON met with CNA #1, no plan was developed to ensure that CNA #1's actions and performance were monitored to ensure they did not impact residents. The Surveyor interviewed the DON at approximately 10 A.M. on 4/11/12, at various times on 4/12/12, at 9:15 A.M. on 4/25/12, and at 8:23 A.M. and 11: 34 A.M. on 4/27/12 . The DON said that she and the Unit Manager met with CNA #1, who did not deny using foul language but denied that CNA #1 was not meeting residents' needs. The DON said that no plan was developed to ensure that CNA #1's actions and performance would be monitored and supervised to ensure that CNA #1's actions did not impact resident care. 2. Review of the investigation file regarding an allegation of physical abuse which occurred on 3/17/12, indicated that there were notes from telephone interviews and written statements from direct care staff contained within the file. The notes indicated that when interviewed by the DON, CNA #5 told the DON that CNA #1 was observed to antagonize Resident #1 a couple of times. The Surveyor interviewed CNA #5 at 6:20 A.M. on 4/12/12. CNA #5 said that CNA #5 was consistently assigned to provide care to Resident #1 and worked with CNA #1 on a consistent basis during the night (10:45 P.M. to 7:15 A.M.). CNA #5 said that Resident #1's body language was such that it was easy tell by looking at Resident #1 when Resident #1 was becoming agitated. CNA #5 said that Resident #1 normally had a twitch of the right arm which would become more exaggerated when agitated, and Resident #1 would make facial expressions with his/her tongue when agitated. CNA #5 said that normally when Resident #1 was agitated the staff were able to calm down Resident #1 by talking to him/her. CNA #5 said that CNA #1 appeared aggravated by Resident #1 on a regular basis, when coming out of the room after providing care to Resident #1. CNA #5 said that on at least two occasions prior to 3/17/12, CNA #1 was observed by CNA #5 attempting to antagonize Resident #1 by placing CNA #1's face very close to Resident #1 and stating, "come on (Resident #1's first name)," or words to that effect or, "what's up (Resident #1's first name)"? or words to that effect. CNA #5 said that there was no need to get that close to Resident #1 and it appeared to CNA #5 that CNA #1 was intentionally getting close to agitate Resident #1. CNA #5 said that the interaction was uncomfortable enough for CNA #5 to tell CNA #1 to stop and to intervene. CNA #5 said it appeared that CNA #1 liked to cause Resident #1 to become agitated because CNA #1 would appear as if it was entertaining and smile. CNA #5 said that CNA #5 was aware of the requirement for reporting abuse, but did not report what she had observed to the Administrator or anyone else until 3/21/12 because CNA #5 thought that CNA #1 would stop when asked to do so. 3. Review of the investigation file regarding an allegation of abuse on 3/17/12, indicated that there were notes from telephone interviews and written statements from direct care staff contained within the file. The notes were identified as being from the DON and indicated that CNA #4 told the DON that CNA #1 was mean to Resident #1, would occasionally taunt Resident #1 by calling Resident #1, "a piece of[***]" or words to the effect, while in Resident #1's presence. The notes indicated that CNA #4 told the DON that CNA #1 was asked why she was mean to Resident #1 and CNA #1 told CNA #4 that it was because CNA #1 thought Resident #1 was a, "piece of[***]" or words to that effect. CNA #4 documented in a written statement, dated 4/12/12, that CNA #1 called Resident #1 a "piece of[***] when in close proximity to Resident #1. CNA #4 said that during rounds and while leaving Resident #1's room, CNA #1 would refer to Resident #1 as a "bastard, an[***] , and even a racist piece of[***]" or words to that effect. The Surveyor interviewed CNA #4 at 12:30 P.M. on 4/11/12 and at 7:30 A.M. on 4/12/12 and at 9:59 A.M. on 4/17/12. CNA #4 said that CNA #4 worked with CNA #1 on a consistent basis during the night (10:45 P.M. to 7:15 A.M.). CNA #4 said that CNA #1 called Resident #1 a "piece of[***] " or words to that effect when in close proximity to Resident #1 and Resident #1's roommate. CNA #4 said that during rounds and while leaving Resident #1's room, CNA #1 would refer to Resident #1 as a "bastard, an[***] , and even a racist piece of[***] or words to that effect. CNA #4 said that CNA #1 called residents who were difficult to care for, a "pain in the ass," or words to that effect, which included Resident #1. CNA #1 said it was possible that Resident #1 was able to hear the comment, but was not certain because CNA #1 was exiting Resident #1's room at the time the comment was made. CNA #4 said that to clarify the comment about Resident #1 being referred to by CNA #1 as a "bastard" or "asshole" or "pain in the ass," or words to that effect, CNA #4 said that combinations of those comments were said by CNA #1 as a matter of routine during the night shift (10:45 P.M. to 7:15 A.M.). CNA #1 said that these comments were not consistently made in the presence of residents or Resident #1. CNA #5 said that CNA #1 appeared aggravated by Resident #1 on a regular basis, when coming out of the room after providing care to Resident #1. CNA #5 said that CNA #1 did refer to Resident #1 as a "piece of[***]" or words to that effect but did not recall a time when CNA #5 heard the comment made in Resident #1's presence. CNA #4 said that CNA #4 did not report what CNA #4 heard to the Administrator or anyone else unit questioned by the Surveyor on 4/11/12. CNA #4 said that though CNA #4 was aware of the requirements of reporting abuse, CNA #4 was afraid to report the allegation. CNA #1 said when asked by the Surveyor whether CNA #1 had ever referred to Resident #1 as a, "bastard,[***] , piece of[***] and pain in the ass" or words to that effect, CNA #1 responded that she had used those terms to describe Resident #1 and other residents to staff but not in the presence of residents, Resident #1, or family members. 4. CNA #4 said that for approximately three months prior to 3/17/12, CNA #4 observed CNA #1 being rough when providing care to 4 of 7 samples residents (Resident #1, Resident #2, Resident #3, Resident #4), but did not report the concerns to anyone until 3/21/12. CNA #5 said that during an unknown period of time prior to 3/17/12, she observed five episodes of CNA #1 being rough with Resident #1, but did not report the incidents to anyone until 3/21/12. CNA #6 said she received a complaint of rough handling from Resident #7 approximately seven months prior to 4/11/12, but did not report the concerns to anyone. The DON said that during the course of the investigation regarding the 3/17/12 allegation of physical abuse involving Resident #1, CNA #4 and CNA #5 reported additional allegations. The DON said no additional investigations were initiated until 4/13/12. 5. The Surveyor interviewed CNA #2 at 11:52 A.M. on 4/11/12 and at 10:05 A.M. on 4/18/12. CNA #2 said that CNA #2 started to provide care, CNA #1 taped with the tips of CNA #1's fingers on the bottom of the forearm of Resident #1 in a rapid and repeated poking action, while saying to Resident #1, "That's all you got?" or words to that effect. CNA #2 said that in response, Resident #1 began to get agitated, and attempted to kick, and reach out and punch CNA #1. CNA #2 said that when Resident #1 attempted to kick and punch CNA #1, CNA #1 laughed. CNA #1 said that the episode lasted approximately 30 seconds until CNA #2 told CNA #1 to stop. CNA #2 said that CNA #1 stopped and then proceed to assist with the transfer by placing her arm under the arm of Resident #1. CNA #2 did not immediately take action to protect Resident #1 from further abuse and did not immediately ask for assistance from another staff member after observing CNA #1 antagonize Resident #1. On 3/17/12, CNA #2 witnessed CNA #1 punch Resident #1 in the chest, and CNA #3 heard the punch; and both CNAs observed a red mark on the chest of Resident #1 after the incident. CNA #2 said that she did not report the incident until 45 minutes later because CNA #2 was afraid of CNA #1 and CNA #2 did not want CNA #1 to know that CNA #2 reported the incident. 6. On 3/18/12, a nurse sent an electronic mail (e-mail) to the DON regarding allegations of abuse that had been discussed in the presence of the nurses (later identified as Nurse #5 and Nurse #3). The e-mail indicated that Nurse #3 said that during the night shift (10:45 P.M. to 7:15 A.M.), staff member (later identified as CNA #4) talked about their interactions with CNA #1 and another CNA, who were observed, "taunting and teasing" Resident #1, "for a while." The e-mail indicated that Resident #1 was called names and sworn at by CNA #1 and another CNA who were also, "bullying" Resident #1. There was no documentation to indicate that either Nurse #5 and Nurse #3 completed an incident report or obtained statements in accordance with Facility policy regarding the allegations of abuse. The Surveyor interviewed Nurse #3 at 9:37 A.M. on 4/17/12. Nurse #3 said that she and Nurse #5 worked the night shift (10:45 P.M. on 3/17/12 to 7:15 A.M. on 3/18/12). Nurse #3 said that at no time prior to 3/18/12 had any CNA or other staff member reported concerns about possible abuse or rough handing involving any resident including Resident #1. Nurse #3 said that she did not follow-up with the DON to ensure that the DON received the e-mail, did not complete and incident report, and did not ask for statements from staff, which was not consistent with the Facility's abuse prevention policy. The Surveyor interviewed Nurse #4 at 11:01 A.M. on 4/17/12. Nurse #4 said that she was present when staff reported to Nurse #3 concerns about how CNA #1 treated Resident #1 and Resident #3. Nurse #4 said that she thought that the incidents occurred approximately one month prior to 3/7/12, but was not certain. Nurse #4 said that prior to 3/18/12 no staff member reported having concerns about the way that CNA #1 or any other staff member treated residents, no one reported rough handling, sweating, or taunting to Nurse #4 prior to 3/18/12. Nurse #4 said that she never reported what she was told because it was her understanding that the information had already been reported to the DON.