Every finding on record at Serenity Hill Nursing Center

Based on observation, interview and document review, the facility failed to maintain kitchen equipment in safe operating condition. Specifically, the facility failed to promptly repair or replace a broken dish machine.Findings include:Review of the facility's policy titled Maintaining Food Service Equipment, last reviewed 1/1/25, indicated but was not limited to:-The facility shall maintain all food preparation, storage, and service equipment in good repair and condition to prevent foodborne illness, ensure resident safety, and comply with federal and state regulatory requirements.-Equipment shall be: -Cleaned and sanitized per manufacturer guidelines -Inspected regularly -Preventatively maintained -Removed from service if unsafePreventative Maintenance-Documentation includes: -Malfunctioning equipment immediately removed from service -Food safety impact assessed -Alternate procedures implemented if necessary -Repair order generated and trackedReview of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: 4-5 Maintenance and Operation 4-501 Equipment 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. During breakfast and lunch meals of the entire survey period from 2/25/26 through 3/3/26, residents were observed eating their meals out of aluminum and Styrofoam take-out containers.On 2/25/26 at 9:00 A.M., the surveyor observed the following in the main kitchen:-Dish machine door (clean side) missing a handle. In its place was a piece of metal attached to the door. At the base of the handle a carabiner clip held a thin cable that extended upward, through a pulley and ran along a bracket mounted to the ceiling, ran through another pulley and was attached to a long piece of PVC pipe wrapped in white tape that hung down and served as a weight to open the dish machine door.-Dietary Aide #2 using the dish machine on the rinse cycle and manually pulling out a drain plug to prevent water from spilling onto the floor.During the kitchen walk-through on 2/25/26 at 9:00 A.M. and a subsequent visit to the kitchen at 2:23 P.M., Dietary Aide #1 and Dietary Aide #2 said the dish machine has not worked properly for at least a year. They said the handle to the door on the clean side of the dish washer broke last March and the former Maintenance Director improvised a repair late last summer. Dietary Aide #3 said the dish machine is no longer dispensing sanitizer because the drain mechanism is not functioning to activate the sanitizer. He said the functioning of the machine had been declining for a while before it finally broke a few months ago. He said they use the machine to rinse the cups and flatware, but they have had to serve residents all of their meals in disposable to-go containers.During the Resident Group Interview on 2/26/26 at 11:00 A.M., 8 out of 8 residents said they were told a few months ago that the dishwashing machine is broken and they are waiting for a part to repair it. They said they were told that they will be eating their meals from to-go containers until the machine is fixed.During an interview on 2/26/26 at 7:35 A.M. and 9:35 A.M., the Food Service Manager (FSM) said the handle on the dish machine broke last year and the former Maintenance Director improvised a repair to make the door function, but it has never been properly repaired. She said she has a concern with infection control because she cannot ensure the components the Maintenance Director used to repair the door can be kept clean and sanitized. She said sometime in late December or early January, the dish machine stopped functioning properly and failed to sanitize the dishes. She said they immediately began serving food to residents in take-out containers. The FSM said she notified the Administrator immediately when the dish machine broke and was told a company was contacted for a repair quote. However, no one has come out to inspect the machine, and it still has not been repaired. She said dish machine water temperatures have been an issue for quite a while and she notified the Administrator of this. She said when someone came out to look at the dish machine's broken door assembly last August, the technician also recommended a hot water booster because the water temperature was low. The FSM said she has kept the Administrator informed of her ongoing concerns through email and verbal communication.During an interview on 2/26/26 at 11:24 A.M., the Administrator said he lost his Maintenance Director a few weeks ago and hired a new Maintenance Director last week. He provided the survey team with information related to the dish machine including contacts for dish machine repair, repair documentation, email communication, invoices and recommendations regarding the dish machine in the main kitchen from May 2025 to February 2026.Review of all documentation provided to survey team by the Administrator and FSM from May 2025 through February 2026 failed to indicate any preventative maintenance records, repair work orders or any evidence that concerns with the facility's dish washing machine were addressed timely. A quote for the door assembly repair and dish machine replacement was provided to the facility on 5/20/25 and 8/1/25. There was no evidence that the dish machine vendor was notified, assessed or repairs made to the dish machine once the Administrator or Maintenance Director were made aware it was not functioning in late December/early January2026.During a telephonic interview on 3/1/26 at 2:55 P.M., Vendor #1 said he does not work for the dish machine company the facility uses, rather he works for the lending company the dish machine vendor uses. He said he has never spoken to the Administrator, and the only communication was via email when he sent financing information and a credit application link to him in August 2025.During a telephonic interview on 3/2/26 at 10:38 AM., the dish machine repair Vendor #2 said last August he inspected the facility's dish machine and found there was a lot wrong with the machine. He said he also identified that the water temperature was not adequate. Vendor #1 said he recommended the facility replace the dish machine and get a hot water booster to ensure adequate temperatures. He said he wrote up and provided the Administrator with a proposal for a new dish machine, a hot water booster and provided contact information for a financing company and has not heard from him since that time.During an interview with the Administrator on 3/2/26 at 10:47 A.M., the Administrator could not explain why there was no preventative maintenance records, no repair work orders, a three month delay in repairing the dish machine door assembly and more than a two month delay in addressing the non-functioning sanitizing cycle of dish machine resulting in residents in the facility eating all of their meals in disposable take-out containers.

Based on record review and staff interview, the facility failed to ensure that the resident representative had information in advance to exercise their rights for two Residents (#24 and #30), out of a total sample of 12 residents. Specifically, the facility failed to ensure:1. For Resident #24, a [NAME] Treatment Plan (court approved treatment plan for the administration of antipsychotic medications) was active and current for administration of an antipsychotic medication; and2. For Resident #30, the Health Care Proxy (HCP: health care agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions) was informed in advance and provided information necessary to make healthcare decisions, including the risk and benefits and dose change of psychotropic medications.Findings include:Review of the facility's policy titled Informed Consent, last revised 1/1/20, indicated but was not limited to:-It is the policy of this facility that the resident must be given the opportunity to be given informed consent prior to the administration of psychotropic drugs.-Written verification of the informed consent must be on the resident's chart prior to initiation of any procedures.-An informed consent must be obtained before the order may be carried out by the nursing staff.1. Resident #24 was admitted to the facility in November 2016 with diagnoses including dementia and schizophrenia.Review of the Minimum Data Set (MDS) assessment, dated 1/10/26, indicated Resident #24 had a severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 99. Further review of the MDS indicated Resident #24 had received an antipsychotic medication and had a Guardian (a person who has been appointed by a court or otherwise has the legal authority to care for the personal and property interests of another person who is deemed incapacitated).During a telephonic interview on 2/25/26 at 2:04 P.M., Guardian #1 said Resident #24 was restarted on their antipsychotic medication in 2024. She said Resident #24 did not have a current [NAME] treatment plan. Guardian #1 said they had been after the facility for them to go back to court and put a [NAME] treatment plan in place for Resident #24 since their medication was restarted in 2024, but the facility has not done so.Review of Resident #24's current Physician's Orders indicated but was not limited to:-Risperidone (antipsychotic) Oral Solution 1 milligram (mg)/milliliter (ml), give 1.5 ml by mouth two times a day for Schizophrenia, dated 9/18/24Review of Resident #24's medical record failed to indicate a current [NAME] treatment plan was in place.During an interview on 2/26/26 at 10:41 A.M., the Director of Social Service said Resident #24 had been receiving an antipsychotic medication since 2024 and did not have an active [NAME] treatment plan. She said she had been working with an Attorney's office on Resident #24's [NAME] treatment plan since 2024. She said when she would reach out to the Attorney's office by phone or email and they would not return her calls/emails. She said there were gaps in communication between her to the Attorney and from the Attorney to her and sometimes there would be months before they would get in touch. She provided the surveyor with communication between herself and the Attorney's office. She said she had notified the Administrator about the difficulty in getting information from the Attorney's office. She said there were life events she had that delayed the process. She said there have not been any attempts to transition to another Attorney to move the process along.During a telephonic interview on 2/26/26 at 11:24 A.M., the Paralegal said one set of documents had been provided to the court, but the court lost them. She said the court also had changed the process in how to obtain a [NAME] treatment plan. She said the Attorney had some life events which delayed the process. She said there were delays on both the facility's side and the Attorney's side with the process of obtaining a [NAME] treatment plan for Resident #24.During an interview on 3/3/26 at 6:01 P.M., the Administrator and Director of Nursing (DON) said Resident #24 should have had an active [NAME] treatment plan in place prior to being started on Risperidone.2. Resident #30 was admitted to the facility in February 2020 with diagnoses including dementia and major depressive disorder.Review of the MDS assessment, dated 2/21/26, indicated Resident #24 had a moderate cognitive impairment as evidenced by a BIMS score of 11 out of 15. Further review of the MDS indicated Resident #30 was prescribed antipsychotic and antidepressant medication and had an invoked HCP.Review of Resident #30's current Physician's Orders indicated but was not limited to:- Abilify (antipsychotic) 5 mg, give 1 tablet by mouth in the morning, dated 9/05/25 - Trazodone (antidepressant) 50 mg, give 3 tablets (150 mg) in the evening, dated 1/16/26- Venlafaxine extended release (antidepressant) 150 mg cap daily, dated 1/11/26Review of Resident #30's psychotropic consent forms:-Abilify, dated 1/2/26, signed by Resident #30-Trazodone, dated 11/23/25, signed by Resident #30-Venlafaxine, date 1/11/26, signed by Resident #30Review of Resident #30's advanced directives indicated his/her HCP was activated on 1/31/24.Further review of Resident #30's medical record failed to indicate Resident # 30's HCP was notified of the medication changes.During an interview on 3/3/26 at 12:05 P.M., Nurse #2 reviewed Resident #30's Abilify, Trazodone, and Venlafaxine consents and medical record. She said Resident #30's HCP was activated and should have been called to obtain consent for the changes in Resident #30's psychotropic medications. She said she did not see any documentation of Resident #30's HCP being notified about the medication changes.On 3/3/26 at 9:31 A.M., the surveyor called and left a message for Resident #30's HCP, without a return call back.

Based on observation, record review, and interview, the facility failed to ensure staff provided care and services consistent with accepted standards of clinical practice for four Residents (#2, #4, #8 and #32), out of a total sample of 12 residents. Specifically, the facility failed to ensure:1. For Resident #2,a. care and treatment to the Resident's implanted cardiac pacemaker met professional standards of care;b. a physician's order for the use of an air mattress, including settings, was obtained prior to its use; and 2. For Resident #4, a physician's order for the use of an air mattress, including settings, was obtained prior to its use;3. For Resident #8, a physician's order for the use of an air mattress, including settings, was obtained prior to its use;4. For Resident #32, care and treatment to the Resident's implanted cardiac pacemaker met professional standards of care.Findings include:According to the National Institute of Health, Treatment/Management of permanent pacemakers-Postoperatively, monitor rhythm and device function, obtain interrogation of the device, and restore settings as appropriate. (September 12/2022) Review of the American Heart Association guidance titled Living with Your Pacemaker, dated 10/29/24, indicated but was not limited to: -Pacemakers should be checked every six months or one year to assess the battery and find out how the wires are working. -Pacemaker batteries usually last 10-15 years -Carry a pacemaker identification card signifying: -Type of pacemaker -Type of leads -Manufacturer -Date of Implant -Paced rate -Model -Serial number Review of the facility's policy titled Care of Resident with a Pacemaker, dated revised 9/17/20, indicated but was not limited to: -Purpose of the Procedure: The purpose of this procedure is to provide information about and guidance for the care of a resident with pacemaker. -Monitoring: 3. The pacemaker battery will be monitored remotely through the telephone or an internet connection. The resident's cardiologist will provide instructions on how and when to do this. -Documentation: 1. For each resident with a pacemaker, document the following in the medical record and on a pacemaker identification card upon admission: a. The name, address and telephone number of the cardiologist; b. Type of pacemaker c. Type of leads d. Manufacturer and model; e. Serial number; f. Date of implant; and g. Paced rate. Review of the facility's policy titled Air Mattress, last revised 7/20/20, indicated but was not limited to: -Air mattresses are medical support devices that assist in pressure redistribution and skin integrity preservation. -Their use must be based on individualized resident assessments and integrated into the resident's comprehensive care plan. -Staff must ensure the air mattress is not overly inflated or deflated, which can pose a risk of falls or impaired healing. -Implementation: Nursing staff will ensure the air mattress is in place, properly functioning, and adjusted to the resident's weight and needs. 1. Resident #2 was admitted to the facility in February 2025 with coronary artery disease, heart failure, and a stage three pressure ulcer (a full-thickness loss of skin extends to the subcutaneous tissue but does not cross the fascia beneath it. Slough or eschar may be visible, and the lesion may be foul-smelling) and had a pacemaker. Review of the Minimum Data Set (MDS) assessment, dated 11/21/25, indicated Resident #2 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15, had limitation in range of motion in his/her lower extremities and was at risk for developing pressure ulcers. The MDS failed to indicate Resident #2 had a pacemaker. a. Review of hospital discharge summary documentation, dated 2/5/25, indicated but was not limited to: -X-ray (medical imaging that uses radiation to take pictures of the inside of your body) examination: left-sided dual lead pacemaker is noted; 2 leads appear unremarkable. Monitoring wires present. Review of Physician's Orders indicated but was not limited to: -Pacemaker (2/12/25) Further review of the medical record failed to indicate any additional information about the pacemaker as well as any care and services required, and no care plan was developed for Resident #2's pacemaker device. b. On 2/25/26 at 2:45 P.M., the surveyor observed Resident #2 lying in bed awake. An air mattress was on the bed and set to 150 pounds (lbs.). On 2/26/26 at 2:30 P.M., the surveyor observed Resident #2 lying in bed awake. An air mattress was on the bed and set to 150 lbs. Review of the medical record failed to indicate an order for an air mattress. Review of the medical record failed to indicate a Physician's order, documentation that the air mattress is in place, properly functioning, and adjusted to the resident's weight and needs or a care plan was developed for the use of an air mattress. During an interview on 2/27/26 at 1:37 P.M., Unit Manager (UM) #1 reviewed Resident #2's medical record and said the Resident is at risk for pressure ulcer development has had an air mattress on his/her bed ever since he/she was admitted in February 2025. She said there was no physician's order for its use and there should be. The UM said she was aware the Resident has a pacemaker but was unable to find any information in the medical record about the device or care and services needed to maintain it. During an interview on 2/27/26 at 2:50 P.M., the Director of Nursing (DON) said she was unable to find any information about Resident #2's pacemaker. During a telephonic interview on 3/4/26 at 12:28 P.M., Physician #1 said he does not remember anything about the Resident's pacemaker, who the cardiologist is, or how the device is being monitored. 2. Resident #4 was admitted to the facility in November 2025 with three unstageable deep tissue pressure injuries (depth of wound is unknown because slough or eschar obscures the extent of tissue damage; this injury occurs with prolonged pressure and shear forces at the bone-muscle interface. The result is intact or non-intact skin with persistent, non-blanched, deep red, maroon, or purple discoloration). Review of the MDS assessment, dated 3/4/25, indicated Resident #4 was cognitively intact as evidenced by a BIMS score of 15 out of 15, and had a pressure reducing device in bed. On 2/25/26 at 8:45 A.M., the surveyor observed Resident #4 sitting upright in bed eating breakfast. An air mattress was on the bed and set to 100 lbs. On 2/25/26 at 2:47 P.M., the surveyor observed Resident #4 lying in bed awake. An air mattress was on the bed and set to 100 lbs. Review of the medical record indicated the following Physician's Orders: -Air mattress at all times while in bed-check placement and function every shift to promote skin integrity (12/16/25) Review of the care plan indicated, but was not limited to: -Air mattress used to promote skin integrity, check placement and functioning every shift (12/16/25) Further review of the medical record failed to indicate a physician's order with weight settings to ensure it was neither over inflated nor under inflated to preserve the Resident's skin integrity. 3. Resident #8 was admitted to the facility in February 2026 and was admitted with a stage 1 pressure area (the skin is intact with non-blanchable superficial reddening of the skin). Review of the MDS assessment, dated 2/9/26, indicated Resident #2 had severe cognitive impairment as evidenced by a BIMS score of 99 (unable to complete interview), was dependent of staff for all activities of daily living and was at risk for developing pressure ulcers. On 2/25/26 at 11:50 A.M., the surveyor observed Resident #8 lying in bed awake. An air mattress was on the bed and set to 240 lbs. On 2/26/26 at 1:10 P.M., the surveyor observed Resident #8 lying in bed awake with bilateral side rails up and in use. An air mattress was on the bed and set to 240 lbs. On 2/27/26 at 9:04 A.M., the surveyor observed Resident #8 in sitting upright in bed being fed by a Certified Nursing Assistant (CNA). An air mattress was on the bed and set to 240 lbs. Review of the medical record failed to indicate a physician's order, documentation that the air mattress is in place, properly functioning, and adjusted to the resident's weight and needs or a care plan was developed for the use of an air mattress. Review of the Hospice provider's documentation (Hospice binder) indicated a note written by Hospice Nurse #1 indicating she ordered a low air loss mattress for the Resident's bed on 2/15/26. During a telephonic interview on 2/27/26 at 12:54 P.M., Hospice Nurse #1 said she has seen Resident #8 twice since he/she had been admitted to the facility: 2/3/26 the day he/she was admitted and 2/25/26. She said while visiting Resident #8 on 2/15/26, she ordered an air mattress for his/her bed because he/she was using a standard mattress and had developed a skin injury. She said the air mattress was delivered right away and placed on the Resident's bed while she was with the Resident on 2/15/26. During an interview on 3/3/26 at 3:00 P.M., the DON said every resident that has an air mattress needs physician's orders with settings according to their weight. She said air mattresses are to be checked by nursing for functioning and accuracy of settings and documented in each resident's medical record. She said she did not know why Residents #2, #4 and #8 do not have physician's orders/physician's orders with settings for their air mattresses, but they should have them. 4. Resident #32 was admitted to the facility in February 2026 with diagnoses including orthostatic hypotension (a sudden, significant drop in blood pressure) and hypertension (high blood pressure). Review of the MDS assessment, dated 2/8/26, indicated Resident #32 had intact cognition as evidenced by a score of 14 out of 15 on the BIMS. Further review of MDS, Section I diagnosis, did not indicate presence of a cardiac pacemaker (diagnosis code Z95.0). During an interview on 2/25/26 at 3:55 P.M., Resident #32 said he/she had a pacemaker. Resident #32 said he/she had fallen a lot because his/her blood pressure would go low. Review of Resident #32's hospital discharge paperwork indicated but was not limited to: -He/she had a history of orthostatic hypotension and bifascicular block (a heart conduction disorder where two of the three main electrical pathways below the atrioventricular (AV) node are blocked) status post pacemaker in 1/24. In terms of his/her bifasicular block, cardiology was consulted on last admission due to concerns for repeat falls and syncope. His/her device was reprogrammed/increased by [company name] to 60 beats per minute (BPM). Review of Resident #32's medical record failed to indicate he/she had an implanted pacemaker. During an interview on 2/27/26 at 3:00 P.M., Nurse #1 said she did not know that Resident #32 had a pacemaker. During an interview on 2/27/26 at 3:04 P.M., Unit Manager (UM) #1 said the admitting nurse would identify on admission if a resident had a pacemaker and then notify the physician and obtain orders for care and management of the device. UM #1 said Resident #32's pacemaker was omitted from the admission orders. During an interview on 2/27/26 at 3:09 P.M., the DON said the pacemaker was missed. It should have been identified on admission that Resident #32 had a pacemaker and orders for care should have been obtained along with information about the pacemaker.

Based on observations and interviews, the facility failed to maintain an environment free of accident hazards. Specifically, the facility failed to ensure a resident care area was free from a portable radiator (space heater), a burn/fire hazard risk.Findings include:On 2/25/26 at 10:32 A.M., the surveyor observed a black portable radiator, plugged in, on, and hot to touch in Resident #7, #24, and #34's room. During an interview at this time, Resident #34 said he/she did not know where the portable radiator came from, but he/she liked having it in their room because they liked their room hot.On 2/25/26 at 1:08 P.M., the surveyor observed a black portable radiator, plugged in, on, and hot to touch in Resident #7, #24, and #34's room.On 2/25/26 at 4:09 P.M., the surveyor observed Resident #7, #24, and #34 in their room with the portable radiator plugged in, on, and hot to touch.On 2/26/26 at 9:04 A.M., the surveyor observed Resident #7 and #34 in their room, the portable radiator was plugged in, on, and hot to touch. During an interview at this time, Resident #7 said he/she did not know where the portable radiator had come from but an employee from the facility put it in their room the other day because it was cold in their room.During an interview with observation on 2/26/26 at 9:13 A.M., Certified Nursing Assistant (CNA) #1 observed the portable radiator plugged in and said she was not sure when the portable space heater had been placed in Resident #7, #24, and #34's room. She said the Residents would always complain it's cold in their room, though she personally thought it was warm in there. She said she was not sure if the portable radiator should be in their room; she had never seen one anywhere she had worked before.During an interview with observation on 2/26/26 at 9:18 A.M., Nurse #1 observed the portable radiator plugged in and on. She said the previous Maintenance Director had placed it in Resident #7, #24, and #34's room because they would complain it was cold in their room. She placed her hand on top of the portable radiator and pulled it back quickly. She said it was warm and she would not want to keep her hand on it long.During an interview with observation on 2/26/26 at 9:29 A.M., the Maintenance Director said he had just started working at the facility about a week ago and was not sure if portable radiators were allowed in resident care areas. He said prior to bringing in new electrical equipment it should been checked to ensure there were no loose wires, it was grounded (provides a path for excess electricity to escape in case of a fault, preventing potential electric shock), turn off if it was knocked over, and in safe operational order. He said he did not see any evidence on the portable radiator that it was checked to ensure it functioned properly. He placed his hand on the portable radiator and said it was hot to touch.During an interview with observation on 2/26/26 at 9:33 A.M., the Director of Nursing (DON) observed the portable radiator. She said the portable radiator was placed in Resident #7, #24, and #34's room when it was bitterly cold and the temperature outside was 0 degrees Fahrenheit (F) and Resident #7's family member demanded a portable radiator be placed in their room. She said she believed the previous Maintenance Director inspected the portable radiator but was not sure.During an interview on 2/26/26 at 2:58 P.M., the Administrator said it was against the facility's policy to have portable radiators in resident care areas because they were fire hazards. He said he was aware Residents #7, #24, and #34 had a portable radiator in their room, but Resident #7's family member insisted on it. He said the previous Maintenance Director brought up the portable radiator and he was under the impression the portable radiator had been inspected prior to being placed in Resident #7, #24, and #34's room. He said the portable radiator should have been marked with a label indicating it had been inspected and safe to use but it was not.

Based on employee record review and interview, the facility failed to complete performance reviews of Certified Nursing Assistants (CNAs) at least once every 12 months and provide regular in-service education based on the outcome of these reviews for five out of five CNAs' (#1, #2, #3, #4, #5) employee records reviewed. Findings include:Review of the facility's policy titled Nurse Aide In-Service Training, revised 9/17/20, indicated but was not limited to:-The facility will complete a performance review of nurse aides at least every 12 months.-In-service training will be based on the outcome of the annual performance reviews, addressing weaknesses identified in the reviews. Review of the Facility Assessment, last reviewed 10/22/25, indicated but was not limited to:-Each clinical staff member is provided with an annual performance review and if education is needed to enhance performance in a certain area, then targeted educational in-services are provided. Review of the following five CNAs' personnel files, who had been employed by the facility for over 12 months, failed to indicate a performance evaluation was completed in 2025:-CNA #1, date of hire 11/23/22-CNA #2, date of hire 9/15/14-CNA #3, date of hire 7/22/21-CNA #4, date of hire 6/8/22-CNA #5, date of hire 9/4/19 During an interview on 3/2/26 at 1:10 P.M., the Director of Nursing (DON) said she was behind on her annual reviews and had not completed them for the last year. She said in-services were not based off annual performance reviews but off if she saw something. She said in-servicing should be based on annual performance reviews.

Based on observations, records reviewed, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. Specifically, the facility failed to:1. Maintain an accurate surveillance system that reflected potential illnesses and infections in the facility; and2. Ensure resident hand hygiene was implemented during meal service.Findings include:1a. Review of the revised 2024 McGeer criteria indicated but was not limited to the following: Syndrome: Cellulitis, soft tissue, or wound infection Must fulfill at least 1 criterion: Pus at wound, skin, or soft tissue At least four of the following new or increasing signs or symptoms -Heat -Redness (erythema) at affected site -Swelling at affected site -Tenderness or pain at affected site -Serous drainage at the affected site At least one of the following: -Fever -Leukocytosis -Acute changed mental status -Acute functional decline Review of the facility's monthly surveillance line listings for January 2026 indicated but was not limited to the following: Resident #30: Category: Right Lower Extremity Cellulitis; Date of Onset: 1/5/26; Symptoms Red/Warm; Site: Right Lower Foot; Final Status: Healthcare Acquired Infection (HAI); Counted: Yes Review of Resident #30's Medical Record indicated but was not limited to the following: -1/3/26 7:52 P.M., Nurse's Note Right leg red, swollen, and hot when ace wrap removed. -1/5/26 6:13 P.M., Nurse's Note Right leg red, swollen, and warm to touch. The January surveillance line listing did not have enough symptoms documented to indicate any McGeer infection for skin had been met in accordance with the facility pre-defined criteria and, therefore, should not have been counted as an HAI infection within the facility. b. Review of the revised 2024 McGeer criteria indicated but was not limited to the following: Respiratory Tract Infection Syndrome: Bronchitis or Tracheobronchitis Must fill 1, 2, and 3 1. Chest X-ray not performed, or negative for pneumonia or a new infiltrate 2. At least two of the following criteria: -New or increased cough -New or increased sputum production -Oxygen saturation level less than 94% on room air, or greater than a 3% decrease from baseline Oxygen saturation level -New or changed lung exam abnormalities -Pleuritic (inflammation of the lung lining (pleura), causing sharp chest pain, particularly when breathing or coughing) chest pain -Respiratory rate greater than 25 breaths a minute Review of the facility's monthly surveillance line listings for February 2026 indicated but was not limited to the following: Resident #1: Category: Congested Cough; Date of Onset: left blank; Symptoms: Congested cough/Wheeze; Result: negative chest x-ray; Final Status: left blank; Counted: left blank Review of Resident #1's Medical Record indicated but was not limited to the following: -12/19/25 1:17 P.M., Nurse's Note Resident #1 has been experiencing cold symptoms for 4 days, repeat 4-plex swab (a nasal swab test to simultaneously detects and differentiates for different types of respiratory viruses COVID-19, influenza A and D and Respiratory Syncytial Virus) and chest x-ray ordered this shift. No complaints of pain or discomfort. Vital signs stable. -12/20/25 6:50 P.M., Nurse's Note Increased coughing, complaining of chest hurting from cough, Oxygen Saturation level 87% to 89% room air. This evening Oxygen Saturation level 85% on room air after nebulizer treatment, oxygen applied Oxygen Saturation 92% on 2 Liters of Oxygen via nasal cannula. The December surveillance line listing did not have enough symptoms documented to indicate any McGeer infection for a respiratory tract infection had been met in accordance with the facility pre-defined criteria. During an interview on 3/3/26 at 2:14 P.M., the Director of Nursing (DON)/Infection Preventionist (IP) said the Infection Surveillance Logs were used to track potential infections in the facility. She said the facility used McGeer criteria to define infections. The infection DON and the surveyor reviewed the December 2025 and January 2026 surveillance line listings. She said her expectation was for them to be complete, fully, accurately, and to meet McGeer criteria, but they did not. 2. Review of the facility's policy titled Dining Services, last revised 1/1/20, indicated but was not limited to the following: -[Facility name] shall provide dining and nutrition services that promote resident health, safety, dignity, independence, and quality of life in accordance with Centers for Medicare and Medicaid Services (CMS) Requirements of Participation. -Purpose: To ensure safe food handling practices -Food Safety and Sanitation: The facility shall ensure hand hygiene compliance On 2/26/26 from 12:00 P.M. to 12:20 P.M, the surveyor observed staff serving meals to 24 residents in the main dining room with no hand hygiene offered to residents prior to meal delivery or between residents. On 2/27/26 from 8:30 A.M. to 8:46 A.M., the surveyor observed staff serving meals to 21 residents in the main dining room with no hand hygiene offered to residents prior to meal service and no staff performed hand hygiene between passing trays to residents. On 2/27/26 from 12:04 P.M. to 12:25 P.M., the surveyor observed staff serving meals to 22 residents in the main dining room with no hand hygiene offered to residents prior to meal service and no staff performed hand hygiene between passing trays to residents. On 3/2/26 at 8:31 A.M., the surveyor observed staff serving meals to 24 residents in the main dining room with no hand hygiene offered to residents prior to meal service and no staff performed hand hygiene between passing trays to residents. On 3/2/26 at 12:08 P.M. to 12:36 P.M., the surveyor observed staff serving meals to 22 residents in the main dining room with no hand hygiene offered to residents prior to meal service and no staff performed hand hygiene between passing trays to residents. On 3/3/26 from 12:10 P.M. to 12:15 P.M., the surveyor observed staff serving meals to 27 residents in the main dining room with no hand hygiene offered to residents prior to meal service and no staff performed hand hygiene between passing trays to residents. During an interview on 3/3/26 at 3:00 P.M., the DON said staff must sanitize their hands and the residents' hands prior to meals. During an interview with Unit Manager #1, Nurse #3 and Nurse #4 on 3/3/26 at 2:30 P.M., they said they did not know that residents should be offered/provided hand hygiene prior to meals. During an interview on 3/3/26 at 3:00 P.M., the DON said she was not aware that staff were not assisting residents with hand hygiene prior to eating meals and it should be done for infection control.

Based on record review and interview, the facility failed to implement an antibiotic stewardship program which included antibiotic use protocols and monitoring of antibiotic use in accordance with the facility's antibiotic stewardship program. Findings include:Review of the Centers for Disease Control and Prevention (CDC) guidance titled The Core Elements of Antibiotic Stewardship for Nursing Homes, undated, indicated but was not limited to the following:- The purpose of an antibiotic stewardship program is to improve the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance.- Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.- The CDC recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use.- Any action taken to improve antibiotic use is expected to reduce adverse events, prevent emergence of resistance, and lead to better outcomes for residents in this setting. Review of the facility's policy for Antibiotic Stewardship, revised 9/17/2020, indicated but was not limited to:-Antibiotics will be prescribed and administered to residents under the guidance of the Facility's Antibiotic Stewardship Program.-Orientation, training, and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and overall community.-If an antibiotic is prescribed, prescribers will provide complete antibiotic orders, including the following elements: -Drug name; -Dose; -Frequency of administration; -Duration of treatment; -Root of administration; and -Indication for use.-When antibiotics are prescribed over the phone, the primary care practitioner will assess the resident within 72 hours of the telephone order. Review of the facility's policy for Antibiotic Stewardship-Orders for Antibiotics, revised 9/17/2020, indicated but was not limited to:-Appropriate indications for use of antibiotics include: -Criteria met for clinical definition of active infection or suspected sepsis; and -Pathogen susceptibility, based on culture and sensitivity, to antimicrobial or therapy begun. Wall culture is pending. Review of the facility's policy for Antibiotic Stewardship- Review and Surveillance of Antibiotic Use and Outcomes, revised 9/17/2020, indicated but was not limited to:-Antibiotic usage and outcome data will be collected and documented using a facility approved antibiotic surveillance tracking log. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide antibiotic stewardship.-As part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist, or designee.-At the conclusion of their review, the provider will be notified of the review findings.All resident antibiotic regimens will be documented on the facility-approved Antibiotic Surveillance Tracking Log. The information gathered will include: -Resident name; -Date symptoms appeared; -Name of Antibiotic; -Site of infection -Date of culture; -Stop date; and -Outcomes 1. Review of Resident #25's October 2025 Physician's Orders indicated but was not limited to:-Ciprofloxacin (antibiotic) 500 milligrams (mg), give one tablet once daily seven days, dated 10/7/25 Further review of Resident #25's medical record failed to indicate:-signs and symptoms for antibiotic use;-laboratory results;-primary care physician's documentation; or-nursing documentation from 10/4/25 to 10/9/25. Review of Resident #25's Nurse's Note, dated 10/9/25, indicated but was not limited to:-Continues on antibiotics for Urinary Tract Infection, no dysuria (pain, burning, or discomfort during urination), no hematuria (blood in the urine), no ill effects from antibiotic treatment. Review of Resident #25's October 2025 Medication Administration Record (MAR) indicated he/she received seven doses of Ciprofloxacin as ordered. Review of the facility's October 2025 Infection Tracking Log sheet failed to indicate Resident #25 had received an antibiotic. During an interview on 3/3/26 at 2:14 P.M., the Infection Preventionist (IP)/Director of Nursing (DON) said orders for antibiotic therapy are discussed daily during morning meeting. She said when a resident had a new order for an antibiotic their medical record should contain documentation including a diagnosis, signs and symptoms, a progress note associated with the physician's order and indication and should be tracked on the monthly Infection Tracking Log. She reviewed the October 2025 Infection Tracking Log and reviewed Resident #25's medical record. She said there was no documentation in Resident #25's medical record indicating why he/she was started on an antibiotic or any documented symptoms of infection. The IP/DON said Resident #25's antibiotic was not tracked or monitored by the facility on the facility-approved Antibiotic Surveillance Tracking Log. 2. Review of the revised 2024 McGeer criteria indicated but was not limited to the following:-Syndrome: Cellulitis, soft tissue, or wound infection-Must fulfill at least 1 criterion: -Pus at wound, skin, or soft tissue-At least four of the following new or increasing signs or symptoms -Heat -Redness (erythema) at affected site -Swelling at affected site -Tenderness or pain at affected site -Serous drainage at the affected site-At least one of the following: -Fever -Leukocytosis -Acute changed mental status -Acute functional decline Review of the facility's January 2026 surveillance sheet indicated but was not limited to:January 2026:-Resident- Resident #30-Date of onset: 1/5/26-Symptoms: Red and warm-Site: Right Lower Foot-Treatment: Keflex (antibiotic) 1/5/26 to 1/12/26-Category: Healthcare Associated Infection-Counted: Yes Review of Resident #30's January Physician's Orders indicated but was not limited to:-Keflex 500 mg tab twice daily for seven days, dated 1/5/26. Further review of Resident #30's medical record indicated but was not limited to:-1/3/26 Nurse's Note- Right leg red, swollen, and hot when ace wrap (elastic [NAME] used for compression and support) removed.-1/5/26 Nurse's Note- Right leg red, swollen, and warm. Review of concerns failed to indicate Resident #30's symptoms, with an onset date of 1/5/26, met McGeer criteria for infection however an antibiotic was prescribed and administered twice daily for seven days (for total of 14 doses). During an interview on 3/3/26 at 2:14 P.M., the IP/DON reviewed Resident #30's symptoms and the McGeer criteria for a skin infection and said Resident #30's signs and symptoms did not meet McGeer criteria for a skin infection. She said the expectation was for prescribed antibiotics to meet McGeer criteria.

Based on record review and interview, the facility failed to provide education and/or offer the COVID-19 vaccination as required or appropriate per the Centers for Disease Control and Prevention (CDC) recommendations for five of five employee records reviewed for immunizations.Findings include:Review of the Centers for Disease Control (CDC) COVID-19 Vaccination for Long-term Care Residents, dated 6/11/25, indicated but was not limited to:-Vaccine recommendations: -CDC recommends an updated COVID-19 vaccine for most adults ages 18 years and older, including people who live and work in long-term care (LTC) settings, get 1 dose of an updated COVID-19 vaccine. -CDC recommends everyone ages 65 years and older, including people who live and work in LTC settings, get 2 doses of an updated COVID-19 vaccine 6 months apart.Review of the facility's policy titled COVID-19 Personnel vaccination requirement, dated as revised 10/1/25, indicated but was not limited to the following: -To reduce the risk of COVID-19 transmission within the facility and protect residents, staff, and visitors through vaccination promotion, documentation, infection control practices, and compliance with federal regulatory requirements.-Education: -The facility will provide staff with education consistent with CDC guidance. -Documentation of education will be maintained.-Documentation Requirements: -The facility will maintain confidential documentation of vaccination status, dates of doses, booster status, and declination if applicable. -Records will be maintained in employee health files in accordance with confidential standards.Review of Certified Nursing Assistants (CNA) #6, #7, #8, Nurse #5, and Maintenance Director's employee files and employee health records failed to indicate the facility assessed and offered the COVID-19 vaccine, provided them with education, and had proof the vaccination was offered and either accepted or declined.During an interview on 2/26/26 at 2:29 P.M., the Director of Nursing said she was responsible for maintaining employee records and providing education to staff members about vaccinations and offering vaccinations. She reviewed CNAs #6, #7, #8, Nurse #5, and Maintenance Director's employee files and employee health records. She said all five of the employees' health records or personnel records did not have any documentation of being provided education or offered the COVID-19 vaccine, and whether they had declined or accepted it. She said she did offer and provide education to all employees about the COVID-19 vaccine annually and on orientation, but the facility did not have a form for consent or declination for staff to sign.

Based on observation, record review, and interview, the facility failed to complete a new assessment of the bed, side rails and mattresses in active use for potential entrapment when the bed mattress was changed from the previously assessed mattress, placing two Residents (#2 and #8), out of a sample of 12 residents, who had limited mobility and utilized bilateral side rails, at risk for possible entrapment. Findings include:Review of the facility's policy titled Proper Use of Siderails, revised 2/1/2018, indicated but was not limited to the following:- Manufacturer instructions for the operation of side rails will be adhered to.- When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment (the amount of space may vary, depending on the type of bed and mattress being used).Review of the Food and Drug Administration (FDA) Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated 03/10/2006, indicated the following: The term entrapment describes an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Resident entrapments may result in deaths and serious injuries. There are seven zones of bed entrapment: Zone One (within the rail), Zone Two (under the rail), Zone Three (between rail and mattress), Zone Four (Under the rail, at the ends of the rail), Zone Five (between split bed rails), Zone Six (between the End of the Rail and the Side Edge of the Head or Foot Board) and Zone Seven (Between the Head or Foot Board and the Mattress End). The hospital bed dimensional limit recommendations are as follows:-Zone One: 4.75 inches-Zone Two: 4.75 inches-Zone Three: 4.75 inches-Zone Four: 2.375 inches and 60-degree angle Review of the facility's policy titled Air Mattress, last revised 7/20/20, indicated but was not limited to:-Air mattresses are medical support devices that assist in pressure redistribution and skin integrity preservation.-Implementation: Ensure that the resident's bed frame and mattress are compatible and meet fire safety and electrical requirements. 1. Resident #2 was admitted to the facility in February 2025 with a stage three pressure ulcer (a full-thickness loss of skin extends to the subcutaneous tissue but does not cross the fascia beneath it. Slough or eschar may be visible, and the lesion may be foul-smelling).Review of the Minimum Data Set (MDS) assessment, dated 11/21/25, indicated Resident #2 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15, had limitation in range of motion in his/her lower extremities and was at risk for developing pressure ulcers.On 2/25/26 at 2:45 P.M., the surveyor observed Resident #2 lying in bed awake with bilateral side rails up and in use. An air mattress was on the bed and set to 150 pounds (lbs.). On 2/26/26 at 2:30 P.M., the surveyor observed Resident #2 lying in bed awake with bilateral side rails up and in use. An air mattress was on the bed and set to 150 lbs.Review of the medical record failed to indicate an order for bilateral side rails or an air mattress.During an interview on 2/27/26 at 1:37 P.M., Unit Manager #1 said Resident #2 is at risk for pressure ulcer development and the Resident has had an air mattress on his/her bed ever since he/she was admitted in February 2025.Review of the facility's Bed Safety Check documentation indicated the Administrator checked Resident #2's bed for safety on 2/12/25. The document indicated Resident #2 had 2 half side rails to his/her bed and had a standard mattress and not an air mattress.2. Resident #8 was admitted to the facility in February 2026 and was admitted with a stage 1 pressure area (the skin is intact with non-blanchable superficial reddening of the skin). Review of the MDS assessment, dated 2/9/26, indicated Resident #2 had severe cognitive impairment as evidenced by a BIMS score of 99 (unable to complete interview), was dependent of staff for all activities of daily living and was at risk for developing pressure ulcers.On 2/25/26 at 11:50 A.M., the surveyor observed Resident #8 lying in bed awake with bilateral side rails up and in use. An air mattress was on the bed and set to 240 lbs.On 2/26/26 at 1:10 P.M., the surveyor observed Resident #8 lying in bed awake with bilateral side rails up and in use. An air mattress was on the bed and set to 240 lbs.On 2/27/26 at 9:04 A.M., the surveyor observed Resident #8 sitting upright in bed being fed by a Certified Nursing Assistant (CNA). Bilateral side rails up and in use and an air mattress was on the bed and set to 240 lbs.Review of the medical record indicated the following Physician's order:-May use bilateral side rails for turning and repositioning (2/3/26)Review of the medical record indicated a Hospice Nurse ordered a low air loss mattress for the Resident's bed on 2/15/26.During a telephonic interview on 2/27/26 12:54 P.M., Hospice Nurse #1 said she has seen Resident #8 twice since he/she had been admitted to the facility: 2/3/26 the day he/she was admitted and 2/25/26. She said while visiting Resident #8 on 2/15/26, she ordered an air mattress for his/her bed because he/she was using a standard mattress and had developed a skin injury. She said the air mattress was delivered right away and placed on the Resident's bed while she was with the Resident on 2/15/26. Review of the facility's Bed Safety Check documentation indicated the Administrator checked Resident #2's bed for safety on 2/2/26 (one day prior to the Resident's admission). The document indicated that Resident #8's mattress was an air mattress and not a standard mattress as indicated by Hospice Nurse #1.During an interview on 3/3/26 at 3:36 P.M., the Administrator said he conducted side rail bed safety checks for Residents #2 and #8. He said he's not sure what happened and that the bed safety checks were inaccurate. He said mattresses and bedframes should have been assessed when the air mattresses were applied to the beds.

Based on records reviewed and interviews, the facility failed to ensure Comprehensive Care Plans were reviewed and revised by the interdisciplinary team (IDT) after each assessment, including both the comprehensive and quarterly review assessments, for three Residents (#2, #4, and #16), out of a sample of 12 residents.Findings include:Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated as last revised 9/16/2020, indicated but was not limited to:-The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.-The IDT includes: -The Attending Physician; -A registered nurse (RN) who has responsibility for the resident; -A nurse aide who has responsibility for the resident; -A member of the food and nutrition services staff; -The resident and the resident's legal representative (to the extent practicable); and -Other appropriate staff or professionals as determined by the resident's needs or as requested by the resident.-The IDT must review and update the care plan: -When there has been a significant change in the resident's condition; -When a desired outcome is not met; -When a resident has been readmitted to the facility; and -At least quarterly, in conjunction with the required quarterly MDS. 1. Resident #2 was admitted to the facility in February 2025 with coronary artery disease, heart failure, and a stage three pressure ulcer (a full-thickness loss of skin extends to the subcutaneous tissue but does not cross the fascia beneath it. Slough or eschar may be visible, and the lesion may be foul-smelling) and had a pacemaker.Review of the Minimum Data Set (MDS) assessment, dated 11/21/25, indicated Resident #2 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15, had limitation in range of motion in his/her lower extremities and was at risk for developing pressure ulcers.Review of Resident #2's MDS Schedule indicated that MDS assessments had been completed with an Assessment Reference Dates (ARD) of 5/21/25 (quarterly), 8/21/25 (re-admission), 11/21/25 (quarterly).Review of Care Plan Conference documentation indicated the following:-5/29/25 Attendees: Registered Dietitian (RD), Licensed Practical Nurse (LPN). No other IDT members attended or otherwise participated in the comprehensive care plan review as required.-9/18/25 Attendees: RD, Activity Director. No other IDT members attended or otherwise participated in the comprehensive care plan review as required.-12/1/25 Attendees: RD, Activity Director. No other IDT members attended or otherwise participated in the comprehensive care plan review as required.2. Resident #4 was admitted to the facility in November 2025 with three unstageable deep tissue pressure injuries (depth of wound is unknown because slough or eschar obscures the extent of tissue damage; this injury occurs with prolonged pressure and shear forces at the bone-muscle interface. The result is intact or non-intact skin with persistent, non-blanched, deep red, maroon, or purple discoloration). Review of the MDS assessment, dated 3/4/25, indicated Resident #4 was cognitively intact as evidenced by a BIMS score of 15 out of 15, and had a pressure reducing device in bed.Review of Care Plan Conference documentation indicated the following:-3/2/26 Attendees: RD, Social Worker. No other IDT members attended or otherwise participated in the comprehensive care plan review as required.3. Resident #16 was admitted to the facility in October 2024 and had diagnoses including Alzheimer's disease, anxiety, and depression.Review of Resident #16's MDS Schedule indicated that MDS assessments had been completed with an ARD of 7/17/25 (quarterly), 10/15/25, and 1/15/26.Review of Care Plan Conference documentation indicated the following:-No evidence that a Care Plan Conference was held in conjunction with the 7/17/25 quarterly MDS assessment.-10/20/25 Attendees: RD, Activity Director, Social Worker and Resident #16's Health Care Proxy (health care agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions). No other IDT members attended or otherwise participated in the comprehensive care plan review as required.-1/20/26 Attendees: RD, Activity Director. No other IDT members attended or otherwise participated in the comprehensive care plan review as required.During an interview on 3/3/26 at 11:20 A.M., the Director of Social Services (DSS) said she is responsible for coordinating care plan meetings. She said she is usually the only one in attendance and sometimes the RD or Activity Director will participate. She said she is not good about doing the meetings and making sure the required staff participate and she needs to get better at that.During an interview on 3/3/26 at 3:00 P.M., the Director of Nursing (DON) said the DSS sets up care plan meetings, and the IDT should be reviewing and revising each resident's care plan after each MDS assessment. She said she was not aware the care plan conferences were not being conducted with the required attendees.

Based on document review and interview, the facility failed to develop and implement their facility assessment (a document assessing the capability of the facility and its resources to provide both emergency and day-to-day care of the population the facility currently serves). Specifically, the facility failed to ensure active involvement of all required members when conducting the facility assessment.Findings include:Review of the Centers for Medicare and Medicaid Services (CMS) guidance, dated 6/18/24, indicated but was not limited to the following:-In conducting the facility assessment, the facility must ensure active involvement of the following participants in the process:a. Nursing home leadership and management, including but not limited to, a member of the governing body, the medical director, an administrator, and the director of nursing; andb. Direct care staff, including but not limited to, Registered Nurses, Licensed Practical Nurses/Licensed Vocational Nurses, Nursing Assistants, and representatives of the direct care staff, if applicablec. The facility must also solicit and consider input received from residents, resident representatives, and family members. Review of the Facility Assessment, last reviewed 10/22/25, indicated but was not limited to:-Names/Titles of individuals involved in completing the assessment: Administrator, Director of Nursing, Medical Director, Social Service Director, Maintenance Director, and Business Office Manager. The Facility Assessment failed to solicit input from direct care staff or residents, resident representatives, or family members. During an interview on 3/3/26 at 5:08 P.M., the Administrator said only himself, the Director of Nursing, Medical Director, Social Service Director, Maintenance Director, and Business Office Manager were involved in completing the facility assessment which was last updated 8/12/25 and last reviewed 10/22/25. He said no one else was involved in updating the facility assessment including the Governing Body.

3. On 4/25/25 at 8:49 A.M., the surveyor entered the open door of the clean utility room in the nursing unit hallway. Inside the room were two unlocked cabinets with several items noted inside including: -11 bottles of Antifungal powder with Miconazole Nitrate 2% -28 tubes of moisture barrier antifungal cream mupirocin ointment 2% -9 bottles of DermaCream During an interview on 4/29/25 at 1:29 P.M., the Director of Nursing said the clean utility room has a keypad lock on it and the door should be closed and locked at all times to prevent residents from accessing the hazardous items inside. 4. Resident #22 was admitted to the facility in December 2024 with a stage four pressure ulcer (full-thickness skin loss that extends through the fascia with considerable tissue loss due to prolonged pressure exerted over specific areas of the body). On 4/25/25 at 8:54 A.M., 9:07 A.M., 11:12 A.M. and 12:00 P.M., the surveyor observed a bottle of Daikin solution (a strong antiseptic solution that contains bleach used in wound care), with a prescription label affixed to it with the Resident's name on it, on Resident #22's bureau. During an interview on 4/19/25 at 1:29 P.M., the DON said that all treatments are to be securely stored in the treatment cart and not left out at the Resident's bedside. Based on observation, interview, and document review, the facility failed to ensure all drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. Specifically, the facility failed to: 1. Ensure the facility medication room was locked at all times when not in use or in direct view of a licensed nurse to prevent the potential unauthorized access to medications; 2. Make sure licensed staff locked one of one treatment carts, which contained numerous topical treatments and biologicals, when it was not in use and left in the hallway where it could be accessed by residents or passersby; 3. Ensure the clean utility room, which contained topical treatments, was locked when not in direct supervision of a licensed nurse on one of one units; 4. For Resident #22, ensure their prescribed Daikin solution (a strong antiseptic solution that contains bleach used in wound care) was properly stored, and secured to ensure safe administration; and 5. For Resident #10, provide secure, safe storage for their triamcinolone cream (a prescription corticosteroid cream used to treat skin conditions). Findings include: Review of the facility's policy titled Storage of Medications, dated as revised 9/17/2020, indicated but was not limited to the following: - the facility shall store all drugs and biologicals in a safe, secure, and orderly manner - the nursing staff shall be responsible for maintaining medication storage in a safe manner - only persons authorized to prepare and administer medications shall have access to the medication room, including any keys - compartments (including, but not limited to, drawers, cabinets, rooms, carts, and boxes) containing drugs or biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others 1. During an initial tour of the facility on 4/25/25 at 7:50 A.M., the surveyor observed the facility medication room, which is behind the nurses' station and directly next to the time clock where all staff punch in and out, with a padlock on the door that was not secured in the locked position. On 4/25/25 at 8:25 A.M., the surveyor observed Nurse #1 passing medications. Nurse #1 entered the medication room behind the desk to retrieve a medication from the emergency kit (E-Kit). He was observed to twist the padlock but not use a key to unlock it and open the medication room door. Upon exiting the medication room, he was observed to place the padlock on the door and turn it to line up the shackle to the lock body but not secure the shackle down into the lock body engaging the locking mechanism of the padlock and securing the medication room door. On 4/25/25 at 8:45 A.M., the surveyor observed Nurse #2 passing medications. Nurse #2 entered the medication room to retrieve a medication from the E-Kit. She was observed to twist the padlock but not use a key to unlock it and open the medication room door. Upon exiting the medication room, she was observed to place the padlock on the door and turn it to line up the shackle to the lock body but not secure the shackle down into the lock body engaging the locking mechanism of the padlock and securing the medication room. She said she doesn't know why the medication room isn't kept locked and was unsure if the licensed nurses had a key on the very full key rings they carried. The door remained unlocked following the conversation with the surveyor. At 9:01 A.M., Nurse #2 returned to the medication room to retrieve another medication from the E-Kit. She removed the padlock without using the key to unlock it and upon exiting the room, placed the padlock back on the door, but was not observed to engage the lock, leaving the door unlocked and unsecured. On 4/25/25 the surveyor made the following observations: - 12:43 P.M., the medication room unlocked with the padlock unsecured on the door and no licensed nurses in direct view of the room. The shackle of the lock was lined up to the lock body but not closed to engage the lock. - 1:04 P.M., Nurse #2 was exiting the medication room and said she was leaving to go to lunch. She was observed to place the padlock on the door and line up the shackle to the lock body but not close it to engage the locking mechanism. During an interview on 4/25/25 at 1:06 P.M., Nurse #1 observed the unlocked padlock on the medication room door with the surveyor and said he isn't sure why the medication room doesn't lock but assumes the padlock was placed on the door in an effort to secure the room. He said the padlock was not locked on the door and should be locked at all times when a licensed nurse is not actively in the medication room. He could not explain why the door had remained unlocked and unsecured throughout the day. During an interview on 4/29/25 at 8:36 A.M., the Director of Nurses (DON) said the expectation is that staff lock the medication room when they are not actively using it and that the door should be locked at all times and based on the surveyor's observations on 4/25/25 that had not occurred. 2. Throughout the survey the surveyors made the following observations of the treatment cart, which contained topical creams, sprays and ointments, and was left in the hallway outside of room [ROOM NUMBER]: 4/25/25: the treatment cart was unlocked, unsecured and unattended by a licensed nurse at 7:57 A.M., 8:23 A.M., and 12:45 P.M. 4/28/25: the treatment cart was unlocked and unattended by a licensed nurse at 8:17 A.M., 9:55 A.M., and 12:19 P.M. 4/29/25: the treatment cart was unlocked, unsecured and unattended by a licensed nurse at 7:32 A.M. and 8:04 A.M. During an interview on 4/29/25 at 8:05 A.M., Nurse #1 said the treatment cart is supposed to be locked at all times when not in use or attended by the licensed nurse. It should not be left unlocked in the hallway where anyone has access to it as there were sprays, creams and other biological products in the cart. During an interview on 4/29/25 at 8:36 A.M., the DON said the treatment cart should be locked and the items in it secured at all times when not in direct use by the licensed nurses during a treatment. 5. Resident #10 was admitted to the facility in February 2022 with diagnoses including dementia and bullous pemphigoid (chronic, autoimmune skin condition that causes large fluid-filled blisters). Review of the Minimum Data Set (MDS) assessment, dated 4/15/25, indicated Resident #10 had a moderate cognitive deficit as evidenced by staff interview. On the following days and times, the surveyor observed a container of Triamcinolone Acetonide Cream on Resident #10's dresser: - 4/28/25 at 8:04 A.M., - 4/28/25 at 8:58 A.M., - 4/28/25 at 9:51 A.M., - 4/28/25 at 2:06 P.M., - 4/28/25 at 3:52 P.M., - 4/28/25 at 4:15 P.M., and - 4/29/25 at 7:08 A.M. During an interview on 4/29/25 at 7:20 A.M., Nurse #4 and the surveyor observed a container of Triamcinolone Acetonide Cream on Resident #10's dresser. Nurse #4 said the Triamcinolone Acetonide Cream should be stored in a secure place out of the reach of residents and not on Resident #10's dresser. During an interview on 4/29/25 at 11:04 A.M., Nurse #1 said the Triamcinolone Acetonide Cream should be stored in secure place out of the reach of residents and not on Resident #10's dresser. Nurse #1 said it was not safe to store the Triamcinolone Acetonide Cream because someone could get into it and eat it. During an interview on 4/29/25 at 3:18 P.M., the DON said all medication and treatments should not be left out and unattended and not left in residents' rooms.

Based on observation, record review, and interview, the facility failed to complete a new assessment of the bed, side rails and mattresses in active use for potential entrapment when the bed mattress was changed from the previously assessed mattress, placing two Residents (#22 and #34), out of a sample of 12 residents, who had limited mobility and utilized bilateral side rails, at risk for possible entrapment. Following an interview with the facility's Maintenance Director, it was determined that 38 of 38 beds in use in the facility were affected. Findings include: Review of the facility's policy titled Proper Use of Siderails, revised 2/1/2018, indicated but was not limited to the following: - Manufacturer instructions for the operation of side rails will be adhered to. - When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment (the amount of space may vary, depending on the type of bed and mattress being used). Review of the Food and Drug Administration (FDA) Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated 03/10/2006, indicated the following: The term entrapment describes an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Resident entrapments may result in deaths and serious injuries. There are seven zones of bed entrapment: Zone One (within the rail), Zone Two (under the rail), Zone Three (between rail and mattress), Zone Four (Under the rail, at the ends of the rail), Zone Five (between split bed rails), Zone Six (between the End of the Rail and the Side Edge of the Head or Foot Board) and Zone Seven (Between the Head or Foot Board and the Mattress End). The hospital bed dimensional limit recommendations are as follows: -Zone One: 4.75 inches -Zone Two: 4.75 inches -Zone Three: 4.75 inches -Zone Four: 2.375 inches and 60-degree angle 1. Resident #22 was admitted to the facility in December 2024 with a stage four pressure ulcer (full-thickness skin loss that extends through the fascia with considerable tissue loss due to prolonged pressure exerted over specific areas of the body). Review of the Minimum Data Set (MDS) assessment, dated 3/13/25 indicated Resident #22 was cognitively intact as evidenced by a BIMS score of 15 out of 15, had a stage four pressure ulcer and utilized a pressure reducing device in bed. On 4/25/25 at 8:54 A.M., the surveyor observed Resident #22 lying in bed asleep with bilateral side rails up and in use. An air mattress was on the bed and set to 350 pounds (lbs.). On 4/27/25 at 11:20 A.M., the surveyor observed Resident #22 sitting upright in bed with bilateral side rails up and in use. An air mattress was on the bed and set to 350 lbs. On 4/29/25 at 9:15 A.M., the surveyor observed Resident #22 sitting upright in bed with bilateral side rails up and in use. An air mattress was on the bed and set to 350 lbs. Review of the medical record indicated the following Physician's Orders: - May use bilateral siderails for turning and repositioning (12/5/24) 2. Resident #34 Resident #34 was admitted to the facility in February 2025 and had diagnoses including Alzheimer's disease and a history of falls. Review of the MDS assessment, dated 2/12/25 indicated Resident #34 had severe cognitive impairment as evidenced by a BIMS score of 99, indicating he/she was unable to complete the assessment, and had a pressure reducing device in bed. On 4/25/25 at 9:02 A.M., the surveyor observed Resident #34 lying in bed awake with bilateral side rails up and in use. An air mattress was on the bed and set to 400 lbs. On 4/28/25 at 8:12 A.M., the surveyor observed Resident #34 lying in bed asleep with bilateral side rails up and in use. An air mattress was on the bed and set to 400 lbs. Review of the medical record indicated the following Physician's Orders: - May use bilateral siderails for turning and repositioning (2/6/25) During an interview on 4/30/25 at 12:05 P.M., the Maintenance Director said he has not conducted bed entrapment checks of any beds in the facility since the start of his employment in early 2024. He said he was never told by the Administrator that bed entrapment assessments had to be conducted and there is currently no process in place. On 4/30/25, the facility Administrator faxed the survey team a list of residents in the facility that utilize side rails. Review of the document indicated that 38 of 38 residents in the facility utilize side rails. No additional information was provided by the facility to ensure beds were being assessed for risk of entrapment.

Based on a resident group meeting, interviews, and record reviews, the facility failed to ensure concerns from the Resident Council were thoroughly documented to ensure the residents felt their concerns were acted upon timely and included the facility response to the group. Findings include: Review of the facility's policy titled Resident Council, dated 1/2025, indicated but was not limited to the following: - [Facility name] supports a resident council. - Resident council meets on a monthly basis. Those residents who cannot or do not want to attend a council meeting may submit their concerns to a council member for discussion at the meeting. - The Activities Director is there to take the meeting minutes. Review of the facility's policy titled Grievance, revised 12/2021, indicated but was not limited to: - It is the policy of [Facility name] to provide a communication system whereby residents and/or their significant others or representative, can voice concerns about the quality of care received at the facility. - Residents have the right to voice complaints and make suggestions for change without the fear of reprisal, discrimination, coercion or unreasonable interruption of care, treatment and services. - All grievances are to be submitted to the Administrator, whose office is located in the Business Office. - Upon notification of a resident grievance, information sufficient to identify the individual registering the concern, the name of the resident (if not the individual submitting the information), date of receipt, nature of the concern, resident's attending physician and location of the resident will be recorded. - All grievances receive immediate priority and must be investigated with efforts made toward resolution in 72 hours. Review of the Resident Council meeting notes with response indicated but were not limited to the following: January Meeting: 1/28/25 - Nine residents in attendance - Laundry Concerns: two residents reported missing clothing items. - Physician (MD)/Nurse Practitioner (NP) Concerns: one resident expressed concerns about the MD's response to her medical concerns; one resident expressed not seeing the MD in a long time. January Response: - Laundry Response: Continuing to work with laundry to resolve the issue. - MD/NP Response: no response given about MD/NP concerns. February Meeting: 2/25/25 - Eight residents in attendance - Nursing Concerns: three residents expressed concerns regarding long call wait times for care from Certified Nursing Assistants (CNA); one resident expressed further concerns related to CNAs only answering call lights if they were assigned to the resident. February Response: - Nursing Response: The Director of Nursing (DON) went to speak with one resident regarding call light wait times, but the resident could not remember when the incident occurred. The DON's written response also included that she would speak during her staff meetings about answering call lights. The DON's written response included that nursing departments try very hard to answer call lights quickly and that support staff, including nurses, also answer call lights too and if staff are busy with other residents, it may take longer to respond. The DON's written response indicated she had spoken with staff about answering call lights regardless of being assigned to a specific resident. March Meeting: 3/31/25 - Six residents in attendance - Laundry Concerns: two residents reported missing clothing - Housekeeping Concerns: two residents said items were missing or moved from their room without consent. - Miscellaneous Concerns: three residents expressed concerns regarding the smell of cigarette smoke in their rooms during the evening. - MD/NP Concerns: two residents reported concerns regarding lack of follow up to their concerns about medical care by the MD. March Response: - Laundry Response: When clothes get damaged or too heavily stained, they are disposed of and the resident's health care proxy (HCP) are made aware; however, occasionally due to dementia sometimes it is forgotten. - Housekeeping Response: Residents are always made aware when items are going to be stored and they are moved with consent; however, due to dementia sometimes it is forgotten. When they would like the items bought (sic) back to their room, they are always bought (sic) back. - Miscellaneous Concerns: no response given regarding concerns about the smell of cigarette smoke in rooms in the evenings. - MD/NP Response: no response given regarding resident concerns about MD/NP. On 4/28/25 at 11:00 A.M., the surveyor held a group meeting with four residents in attendance. The residents shared the following information: - Two of four residents said they do not believe their concerns are thoroughly addressed when issues are brought forward. - Two of four residents said they have not had any outcome or follow up regarding reports of missing items or items moved from their room. The residents said they have not had discussions with staff about items being replaced or reimbursed. - Two of four residents said they have not had follow up regarding their concerns about meeting with their facility physician. - Three of four residents said they frequently bring up concerns related to call lights and - Two of four residents said they believe Resident Council is not as effective as it should be because they have to consistently bring up the same concerns over and over. During an interview on 4/29/25 at 10:00 A.M., the Activities Director said Resident Council meetings are held on a monthly basis. The Activities Director said she encourages all residents to attend the meetings throughout the month including the day of the meeting during morning rounds. The Activities Director said the residents run the Resident Council meeting and she takes notes regarding the comments, questions or concerns. The Activities Director said the previous month's concerns are reviewed with the Resident Council at the start of each meeting unless they were already addressed individually with a particular resident. The Activities Director said after the meeting is completed, she types up the concerns and sends them to the department heads in the facility. The Activities Director said responses to the concerns are then sent back to her from the specific department heads and reviewed at the next Resident Council meeting. The Activities Director said depending on the concern, a resident may also have an individual follow up. During an interview on 4/29/25 at 10:15 A.M., the Administrator said all Resident Council concerns are reviewed by department heads and a response is given to the Activities Director to review at the next meeting. The Administrator said he reviews all grievances reported from the Resident Council meetings. The Administrator and the surveyor reviewed the concerns brought forward from the previous Resident Council meetings and the group response during the Resident Council meeting held during the survey process. The Administrator said he did not know why there was not a response regarding the residents' concerns about the MD/NP. The Administrator said a lot of the concerns are handled verbally and he did not have any evidence of the resolutions for missing clothing items or other items removed from resident rooms. The Administrator said the facility typically replaces or reimburses for missing items, but did not have evidence of what items were replaced or reimbursed. The Administrator said call light concerns were an on-going issue but did not provide any further evidence related to the responses given to the Resident Council. The Administrator said the facility needed to be clearer and more specific in their responses to resident concerns.

Based on interviews and observations, the facility failed to ensure grievance forms were available in resident care and public areas, so residents and/or visitors were able to access forms without requesting staff assistance. Findings include: Review of the facility's policy titled Grievance, revised 12/2021, indicated but was not limited to: - It is the policy of [Facility Name] to provide a communication system whereby residents and/or their significant others or representative, can voice concerns about the quality of care received at the facility. - Residents have the right to voice complaints and make suggestions for change without the fear of reprisal, discrimination, coercion or unreasonable interruption of care, treatment and services. - All grievances are to be submitted to the Administrator, whose office is located in the Business Office. - Upon notification of a resident grievance, information sufficient to identify the individual registering the concern, the name of the resident (if not the individual submitting the information), date of receipt, nature of the concern, resident's attending physician and location of the resident will be recorded. - All grievances receive immediate priority and must be investigated with efforts made toward resolution in 72 hours. On 4/25/25 at 9:00 A.M., the surveyor toured the facility including all resident care areas and was unable to locate grievance forms. On 4/28/25 at 11:00 A.M., the surveyor held a resident group meeting with four residents in attendance representing one of one unit. One resident slept throughout the meeting. Three of three residents said they were unaware it was possible to file a grievance anonymously. Furthermore, three of three residents said they were unaware of the location of grievance forms in the facility. Two of three residents said they report any concerns directly to a staff member or bring concerns to a Resident Council meeting. During an interview on 4/29/25 at 10:00 A.M., the Activities Director said concerns or grievances are brought up during the monthly Resident Council meeting and brought to the appropriate department heads or Administrator for response. The Activities Director said she encourages residents during morning rounds each day to bring up any concerns or grievances they may have so she can ensure they are addressed. The Activities Director said there used to be a box and forms for grievances in the front lobby by the resident telephone, but she was not sure if it was there anymore. During an interview on 4/29/25 at 10:15 A.M., the Administrator said grievance forms are available on the unit by the resident telephone in the front lobby as well as by the nurses' station. The Administrator and the surveyor reviewed the observations made as well as the response from the Resident Council meeting. The Administrator said he was unaware forms were not available throughout the facility. The Administrator said residents should have the ability to file a grievance anonymously.

5. Resident #12 was admitted to the facility in October 2021 with diagnoses including epilepsy (a brain disorder characterized by recurrent seizures, which are caused by abnormal electrical activity in the brain). Review of the MDS assessment, dated 11/3/24, indicated Resident #12 was cognitively intact as evidenced by a BIMS score of 15 out of 15 and had a diagnosis of epilepsy. Review of Resident #12's comprehensive care plans failed to indicate a care plan had been developed and implemented for the Resident's diagnosis of epilepsy. During an interview on 4/29/25 at 1:29 P.M., the Director of Nursing said a care plan should have been developed for Resident #12's diagnosis of epilepsy but was not. 6. Resident #37 was admitted to the facility in October 2024 and had diagnoses including Alzheimer's disease, dementia with mild with agitation, major depression disorder (single episode, mild), and anxiety. Review of the comprehensive MDS assessment, dated 10/14/24, indicated Resident #37 had moderate cognitive impairment as evidenced by a BIMS score of 11 out of 15, had Alzheimer's disease, dementia, anxiety, depression and received antipsychotic medication on a routine basis. Review of Resident #37's medical record indicated Physician's Orders for the following antipsychotic medication: -Seroquel 25 mg one time a day for Alzheimer's disease (initiated 10/8/24, discontinued 3/31/25) -Seroquel 12.5 mg one time a day for Alzheimer's disease (initiated 4/1/25, discontinued 4/21/25) -Seroquel 6.25 mg one time a day for Alzheimer's disease (initiated 4/21/25) Review of October 2024 through April 2025 Medication Administration Records indicated Seroquel was administered as ordered by the physician. Review of comprehensive care plans indicated, but was not limited to: -Focus: The resident uses psychotropic medications Quetipaine (Seroquel) related to disease process Alzheimer's disease (10/07/2024) -Intervention: Administer psychotropic medications as ordered by physician; monitor for side effects and effectiveness every shift; consult with pharmacy, physician to consider dosage reduction when clinically appropriate at least quarterly; discuss with MD, family regarding ongoing need for use of medication; review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy; Psychiatric consult as needed. -Goal: The resident will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date (target date: 5/22/25) The care plan failed to identify Resident-specific targeted behaviors, signs/symptoms, resident specific interventions, including non-pharmacological approaches, and measurable goals for the use of antipsychotic medication to meet the Resident's needs. During an interview on 4/28/25 at 1:35 P.M., the Social Worker said nursing is responsible for developing care plans for psychotropic medications. During an interview on 4/29/25 at 1:29 P.M., the Director of Nursing said a care plan should have been developed for Resident #37's use of Seroquel that identifies the Resident's targeted behaviors and appropriate interventions, including non-pharmacological interventions and measurable goals but was not. 3. Resident #8 was admitted to the facility in February 2025 with diagnoses including Parkinson's Disease, heart failure, and hypertension. Review of Resident #8's MDS assessment, dated 2/18/25, indicated he/she was cognitively intact as evidenced by a BIMS score of 15 out of 15. Furthermore, the MDS assessment indicated Resident #8 received anticoagulant (prevents blood from clotting) medication. Review of Resident #8's Physician's Orders indicated by were not limited to the following: - 2/19/25: Eliquis Oral Tablet 5 mg give 5 mg by mouth two times a day for anticoagulation therapy. - 2/12/25: Anticoagulant Medication - monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and or vision, shortness of breath, nose bleeds; every shift. Review of Resident #8's comprehensive care plans failed to include an individualized care plan related to anticoagulant usage. During an interview on 4/29/25 at 9:14 A.M., the Director of Nursing (DON) said care plans are initiated by the admitting nurse and each department develops any care plan related to their specific services. The DON said resident's receiving anticoagulant medication should have an individualized care plan related to its use. The DON said Resident #8 should have a care plan for his/her anticoagulant use. 4. Resident #29 was admitted to the facility in March 2025 with diagnoses including Parkinson's Disease, dementia, and history of falling. Review of Resident #29's MDS assessment, dated 3/18/25, indicated he/she had moderately impaired short term and long term memory. Furthermore, the MDS assessment indicated he/she required moderate assistance with activities of daily living (including toileting and personal hygiene) and was always incontinent of urine. On 4/28/25 at 10:33 A.M., the surveyor observed Resident #29 seated in a wheelchair in his/her room. A urinal was noted to be on the bedside dresser filled with dark amber colored urine and was visible from the hallway. On 4/28/25 at 1:01 P.M., the surveyor observed Resident #29 seated in a wheelchair in his/her room. A urinal was noted to be on the bedside dresser filled with dark amber colored urine and was visible from the hallway. Review of Resident #29's comprehensive care plans failed to include an individualized care plan related to bladder patterns and preferences. During an interview on 4/29/25 at 12:44 P.M., the Director of Nursing (DON) said Resident #29 prefers to put his urinal on his/her bedside dresser after use. The DON said Resident #29 has been educated by staff on calling for assistance after utilizing the urinal so they can discard or clean it. The DON said preferences regarding the Resident's bladder patterns should be documented in the care plan, but she has not gotten around to updating it yet. Based on observations, interviews, and records reviewed, for six Residents (#10, #15, #8, #29, #12, and #37), of 13 sampled residents, the facility failed to ensure that individualized, comprehensive care plans were developed, consistently implemented, and revised as needed. Specifically, the facility failed: 1. For Resident #10, a. to develop and implement a care plan intervention after he/she sustained a fall, and b. to implement the Resident's falls care plan for a floor mat while in bed at all times; 2. For Resident #15, a. to identify non-pharmacological interventions for the use of an antipsychotic medication; and, b. to develop a comprehensive care plan related to hospice services; 3. For Resident #8, to develop a comprehensive care plan related to anticoagulation use; 4. For Resident #29, to develop a comprehensive care plan related to bladder preferences; 5. For Resident #12, to develop a comprehensive care plan to address the Resident's diagnosis of epilepsy (a brain disorder characterized by recurrent seizures, which are caused by abnormal electrical activity in the brain), and 6. For Resident #37, to develop a comprehensive care plan for the use of antipsychotic medication with identified target behaviors, non-pharmacological interventions and measurable goals of treatment. Findings include: Review of the facility's policy titled Comprehensive Careplan [sic], last revised 1/1/2020, indicated but was not limited to: -Policy Statement- a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological, and financial needs is developed and implemented for each resident. -Policy Interpretation and implementation - The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. - The comprehensive, person-centered care plan will: - Include measurable objectives and timeframes; - Include the resident's stated goals upon admission and desired outcomes; - Incorporate identified problem areas; - Incorporate risk factors associated with identified problems; - Reflect treatment goals, timetables, and objectives in measurable outcomes; - Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. - The comprehensive, person-centered care plan is developed within 14 days after admission. - Assessments of the residents are on going care plans are revised as information about the residents and the residents' conditions changes. - The Interdisciplinary Team must review and update the care plan: - At least quarterly, in conjunction with required quarterly MDS assessment. 1. Resident #10 was admitted to the facility in February 2022 with diagnoses including dementia. Review of the Minimum Data Set (MDS) assessment, dated 4/15/25, indicated Resident #10 had a moderate cognitive deficit as evidenced by staff interview. Review of Resident #10's care plans indicated but was not limited to: - Focus: Resident is a risk for falls status post unwitnessed fall 3/17/25, 1/23/25, and 6/26/24 (Revised 3/19/25) - Goal: Resident will remain free of major injury status post falls (Revised 2/7/25, Target date 4/23/25) - Interventions: - Floor mat while in bed at all times (Initiated 3/19/25) - Refuses alarms (Revised 3/19/25) - Resident will use his/her call light to ask for assistance with ADLs/ambulation (Initiated 4/23/24) - Focus: The resident is at risk for falls (revised 12/2/23) - Goal: The resident will have no major injuries due to falls through next review (Revised 2/7/25, Target date 5/29/25) - Interventions: - Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed (Initiated 8/2/22) - Follow fall protocol (Initiated 8/2/22) - The resident needs a safe environment (Initiated 8/2/22) - The resident uses chair electronic alarm (Initiated 7/5/23) a. Review of Resident #10's medical record indicated he/she sustained an unwitnessed fall. Review of Resident #10's Post Fall Investigation, dated 3/29/25, indicated he/she was found sitting on the floor in front of their chair. Further review Resident #10's Post Fall Investigation, dated 3/29/25, indicated but was not limited to: - New interventions/preventative measures added to care plan: was left blank. Further review of Resident #10's fall risk care plans failed to indicate new interventions were added to prevent future falls following the unwitnessed fall on 3/29/25. During an interview on 4/29/25 at 3:18 P.M., the Director of Nursing (DON) reviewed Resident #10's Post Fall Investigation, dated 3/29/25, and medical record. The DON said she did not see an intervention implemented after Resident #10's fall. The DON said after a resident had a fall the nursing staff should develop and implement an intervention to help prevent further falls or decrease potential injury. The DON said Resident #10 should have had an intervention put in place after his/her fall but did not. b. On 4/28/25 at 2:06 P.M., the surveyor observed the following: - Resident #10 in bed, awake, and conversing with the surveyor. - The floor mat on Resident #10's right side was folded up and leaning against his/her dresser. - The floor mat on Resident #10's left side was folded up and leaning against the wall with a box of gloves resting on top of the floor mat. On 4/28/25 at 3:52 P.M., the surveyor observed the following: - Resident #10 in bed and awake. - The floor mat on Resident #10's right side was folded up and leaning against his/her dresser. - The floor mat on Resident #10's left side was folded up and leaning against the wall with a box of gloves resting on top of the floor mat. On 4/28/25 at 4:15 P.M., the surveyor observed the following: - Resident #10 in bed and awake. - The floor mat on Resident #10's right side was folded up and leaning against his/her dresser. - The floor mat on Resident #10's left side was folded up and leaning against the wall with a box of gloves resting on top of the floor mat. On 4/29/25 at 7:05 A.M., the surveyor observed the following: - Resident #10 in bed and awake. - The floor mat on Resident #10's right side was folded up and leaning against his/her dresser. - The floor mat on Resident #10's left side was folded up and leaning against the wall with a box of gloves resting on top of the floor mat. During an interview on 4/29/25 at 7:08 A.M., Certified Nursing Assistant (CNA) #1 said Resident #10 was a fall risk and should have a floor mat on the floor next to either side of his/her bed. CNA #1 and the surveyor observed Resident #10 in bed. CNA #1 said Resident #10 did not have the floor mats on either side of his/her bed but should. CNA #1 then left Resident #10's room and failed to place the floor mats on either side of his/her bed. During an interview on 4/29/25 at 7:20 A.M., Nurse #4 said Resident #10 was a fall risk and when in bed he/she should have a floor mat on either side of his/her bed. Nurse #4 and the surveyor observed Resident #10 in bed and awake. Nurse #4 said Resident #10's floor mats should have been on either side of his/her bed when he/she was in bed, but the floor mats were folded up and not next to their bed. 2. Resident #15 was admitted to the facility in October 2024 with diagnoses including Alzheimer's disease, depression, and anxiety. Review of the MDS assessment, dated 2/24/25, indicated Resident #15 had a severe cognitive deficit as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. Further review of Resident #15's MDS indicated he/she received an antipsychotic medication on a routine basis and was receiving hospice services. Review of Resident #15's current Physician's Orders indicated but was not limited to: - Seroquel 25 milligrams (mg) give 25 mg daily in the morning for behaviors, dated 10/29/24 - Seroquel 50 mg daily in the evening for behaviors, dated 10/29/24 - May be evaluated and admit to Hospice 2/18/2025 a. Review of Resident #15's, March 2025 and April 2025, Medication Administration Record (MAR) indicated Seroquel was administered as ordered by the Physician's orders. Review of Resident #15's comprehensive care plans indicated but was not limited to: - Focus: The resident uses psychotropic medications related to Alzheimer's Dementia with behaviors, depression, anxiety, (Initiated: 10/30/2024) - Goal: The resident will receive least restrictive dose of medication to lessen the following: (specify) (Revised: 02/24/2025, Target Date: 05/16/2025) - Interventions: - Administer psychotropic medications as ordered by the physician. Monitor for side effects and effectiveness every shift. (Initiated: 10/30/2024) - Monitor/document/report as needed any adverse reactions of PSYCHOTROPIC medications. (Initiated: 10/30/2024) - Monitor/record occurrence of for target behavior symptoms (SPECIFY: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document per facility protocol. (Initiated: 10/30/2024) - Psych consult as needed. (Initiated: 10/30/2024) - Focus: The resident has a psychosocial well-being problem related to Alzheimer's Dementia with behaviors, depression, anxiety, (Initiated: 10/30/2024) - Goal: Resident will be free of acute symptoms (Revised: 02/24/2025, Target Date: 05/16/2025) - Interventions: - Allow the resident time to answer questions and to verbalize feelings perceptions, and fears. (Initiated: 10/30/2024) - Identify strengths and supports. (Initiated: 10/30/2024) - Medication as ordered: Seroquel. (Initiated: 10/30/2024) - Provide activities of interest. (Initiated: 10/30/2024) Further review of Resident #15's care plans failed to include non-pharmacological interventions for his/her Seroquel use. b. Further reviewed of Resident #15's medical record indicated he/she was admitted to Hospice on 2/19/25. Further review of Resident #15's care plans failed to indicate a hospice care plan had been developed and implemented. During an interview on 4/29/25 at 10:48 A.M., the Social Worker said she was not responsible for developing care plans for psychotropic medications or hospice services. The Social Worker said she was responsible for psychosocial and mood care plans. The Social Worker and the surveyor reviewed Resident #15's care plans. The Social Worker said the interventions on Resident #15's care plans did not include non-pharmacological interventions for the use of his/her Seroquel, but they should have. The Social Worker said Resident #15's did not have a care plan developed and implemented for their hospice services. During an interview on 4/29/25 at 11:17 A.M., Nurse #1 and the surveyor reviewed Resident #15's care plans. Nurse #1 said Resident #15's care plans did not include non-pharmacological interventions for the use of his/her Seroquel, but they should have. Nurse #1 said said Resident #15's did not have a care plan developed and implemented for their hospice services. During an interview on 4/29/25 at 3:18 P.M., the DON said the expectation was for psychotropic care plans to include non-pharmacological interventions. The DON said Resident #15 should have non-pharmacological interventions on his/her psychotropic care plan but he/she did not. The DON said all residents who receive hospice services should have a individualize comprehensive care plan developed for them but Resident #15 did not.

Based on observation, record review, and interview, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team for four Residents (#12, #22, #37, and #15), out of a total sample of 13 residents . Specifically, the facility failed to review and revise the care plan after comprehensive, significant change, and quarterly assessments were completed to reflect the current status of the Residents. Findings include: Review of the facility's policy titled Comprehensive Care Plan, last revised 1/1/20, indicated but was not limited to: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. -The Interdisciplinary Team (IDT) must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS) assessment. -The IDT includes: a. The attending physician; b. A registered nurse who has responsibility for the resident; c. A nurse aide who has responsibility for the resident; d. A member of the food and nutrition services staff; e. The resident and the resident's legal representative (to the extent practicable); and f. Other appropriate staff or professionals as determined by the resident's needs or as requested by the resident. 1A. Resident #12 was admitted to the facility in October 2021 with diagnoses including epilepsy (a brain disorder characterized by recurrent seizures, which are caused by abnormal electrical activity in the brain). Review of the MDS assessments, dated 8/3/24, 11/3/24, and 2/3/25 indicated Resident #12 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and had a diagnosis of epilepsy. Review of Resident #12's entire medical record failed to indicate IDT care plan meetings had been conducted after each MDS assessment to review the Resident's total program of care and revise the care plan if needed. B. Resident #22 was admitted to the facility in December 2024 with a stage four pressure ulcer (full-thickness skin loss that extends through the fascia with considerable tissue loss due to prolonged pressure exerted over specific areas of the body). Review of the MDS assessment, dated 3/13/25, indicated Resident #22 was cognitively intact as evidenced by a BIMS score of 15 out of 15 and had a stage four pressure ulcer. Review of Resident #22's entire medical record failed to indicate an IDT care plan meeting had been conducted after the MDS assessment to review the Resident's total program of care and revise the care plan if needed. During an interview on 4/27/25 at 11:20 A.M., Resident #22 said he/she has not participated in any care plan meetings to review his/her plan of care. C. Resident #37 was admitted to the facility in October 2024 and had diagnoses including Alzheimer's disease, dementia with mild agitation, major depression disorder (single episode, mild), and anxiety. Review of the MDS assessments, dated 1/14/25 and 4/16/25, indicated Resident #37 had moderate cognitive impairment as evidenced by a BIMS score of 10 out of 15 and 11 out of 15 respectively, and had an activated healthcare proxy (healthcare agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions). Review of Resident #37's entire medical record failed to indicate an IDT care plan meeting had been conducted after each MDS assessment to review the Resident's total program of care and revise the care plan if needed. During a telephone interview on 4/28/25 at 10:15 A.M., Resident #37's Health Care Proxy said that she has never heard of or been invited to participate in a care plan meeting to review Resident #37's plan of care. During an interview on 4/28/25 at 1:35 P.M., the Social Worker said she is responsible for coordinating IDT care plan meetings. She said she has not worked consistently and was out for an extended period of time over the past six to eight months and was not coordinating and conducting any care plan meetings as required. During an interview on 4/29/25 at 1:29 P.M., the Director of Nursing (DON) said she is aware care plan meetings have not been happening for quite some time. She said there have been a lot of staffing challenges and required care plan meetings have not been occurring. 2. Resident #15 was admitted to the facility in October 2024 with diagnoses including Alzheimer's disease. Review of the MDS assessment, dated 2/24/25, indicated Resident #15 had a severe cognitive deficit as evidenced by a BIMS score of 3 out of 15. Further review of Resident #15's MDS indicated but was not limited to the following: - Always incontinent of bowel and bladder; - Walking 10 feet: not attempted - Toileting: Dependent - Bathing: Dependent - Eating: substantial/maximum assistance Review of Resident #15's Activity of Daily Living flow sheets indicated but was not limited to: - Always incontinent of bowel and bladder; - Walking: Dependent - Toileting: Dependent - Bathing: Dependent - Eating: requires assistance Review of Resident #15's comprehensive care plans indicated but was not limited to: - Occasionally incontinent of bowel (initiated 10/30/24) - Occasionally incontinent of bladder (initiated 10/30/24) - Walking: requires assistance by one staff member to walk with a walker (initiated 10/30/24) - Toileting: assist (initiated 10/30/24) - Bathing: assist (initiated 10/30/24) - Eating: independent with set-up (initiated 10/30/24) During an interview on 4/29/25 at 3:18 P.M., the DON said when a resident has a significant change of condition their care plans should be reviewed and revised to accurately reflect each resident's needs then reviewed at the care plan meeting. The DON reviewed Resident #15's care plans and said they were not updated or reviewed to reflect the Resident's significant change in condition. The DON said because of staffing challenges, care plan meetings were not occurring as they should have been.

2. Review of the facility's policy titled Air Mattress, last revised 7/20/20, indicated but was not limited to: -Nursing staff will ensure the air mattress is in place, properly functioning, and adjusted to the resident's weight and needs. -Staff must ensure the air mattress is not overly inflated or deflated, which can pose a risk of falls or impaired healing. Resident #22 was admitted to the facility in December 2024 with a stage four pressure ulcer (full-thickness skin loss that extends through the fascia with considerable tissue loss due to prolonged pressure exerted over specific areas of the body). Review of the MDS assessment, dated 3/13/25 indicated Resident #22 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and had a stage four pressure ulcer and had a pressure reducing device in bed. On 4/25/25 at 8:54 A.M., the surveyor observed Resident #22 lying in bed asleep. An air mattress was on the bed and set to 350 pounds (lbs.). On 4/27/25 at 11:20 A.M., the surveyor observed Resident #22 sitting upright in bed. An air mattress was on the bed and set to 350 lbs. On 4/29/25 at 9:15 A.M., the surveyor observed Resident #22 sitting upright in bed. An air mattress was on the bed and set to 350 lbs. Review of December 2024 through April 2025 Physician's Orders failed to indicate an order for an air mattress. Review of the medical record indicated Resident #22 weighed 180.8 lbs. on 4/1/25. Further review of the medical record failed to indicate any evidence that nursing staff ensured Resident #22's air mattress was in place, properly functioning, adjusted to the resident's weight and was not overly inflated or deflated. During an interview on 4/29/25 at 1:29 P.M., the DON said Resident #22's air mattress should not be set to 350 lbs. She said residents with air mattresses need to have physician's orders for their use that include settings for each resident according to their weight, and staff need to monitor them to ensure the mattresses are set correctly. 3. Resident #34 was admitted to the facility in February 2025 and had diagnoses including Alzheimer's disease and a history of falls. Review of the MDS assessment, dated 2/12/25, indicated Resident #34 had severe cognitive impairment as evidenced by a BIMS score of 99, indicating he/she was unable to complete the assessment, and had a pressure reducing device in bed. On 4/25/25 at 9:02 A.M., the surveyor observed Resident #34 lying in bed awake. An air mattress was on the bed and set to 400 lbs. On 4/28/25 at 8:12 A.M., the surveyor observed Resident #34 lying in bed asleep. An air mattress was on the bed and set to 400 lbs. Review of February 2025 through April 2025 Physician's Orders failed to indicate an order for an air mattress. Review of the medical record indicated Resident #34 weighed 121.9 lbs. on 4/1/25. Further review of the medical record failed to indicate any evidence that nursing staff ensured Resident #34's air mattress was in place, properly functioning, adjusted to the resident's weight and was not overly inflated or deflated. During an interview on 4/29/25 at 1:29 P.M., the DON said Resident #34's air mattress should not be set at 400 lbs. She said residents with air mattresses need to have physician's orders for their use that include settings for each resident according to their weight, and staff need to monitor them to ensure the mattresses are set correctly. Based on observations, interviews, and records reviewed, for three Residents (#10, #22, and #34), of 13 sampled residents, the facility failed to ensure care was provided to residents in accordance with professional standards of practice. Specifically, the facility failed: 1. For Resident #10, to ensure a physician's order was obtained prior to sending him/her to the hospital; 2. For Resident #22, to ensure a physician's order for the use of an air mattress, including settings, was obtained prior to its use; and 3. For Resident #34, to ensure a physician's order for the use of an air mattress, including settings, was obtained prior to its use. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. 1. Resident #10 was admitted to the facility in February 2022 with diagnoses including dementia and bullous pemphigoid (chronic, autoimmune skin condition that causes large fluid-filled blisters). Review of the Minimum Data Set (MDS) assessment, dated 4/15/25, indicated Resident #10 had a moderate cognitive deficit as evidenced by staff interview. Review of Resident #10's medical record indicated he/she was transferred to the hospital for a change in his/her condition on the following days: - 3/17/25; - 4/5/25; and, - 4/15/25. Further review of Resident #10's medical record failed to indicate a physician's order was obtained to transfer him/her to the hospital on 3/17/25, 4/5/25, and 4/15/25. During an interview on 4/29/25 at 11:04 A.M., Nurse #1 said when a resident needed to be sent out to the hospital an order for the transfer must be obtained from the physician or physician's extender and transcribed into the resident's medical record. Nurse #1 reviewed Resident #10's medical record and said he could not find any orders to send Resident #10 to the hospital on 3/17/25, 4/5/25, and 4/15/25. Nurse #1 said there should have been orders, but there wasn't. During an interview on 4/29/25 at 3:18 P.M., the Director of Nursing (DON) reviewed Resident #10's medical record and said she did not see an order to transfer Resident #10 to the hospital on 3/17/25, 4/5/25, and 4/15/25 but he/she should have had an order. The DON said all residents must have an order to be transferred to the hospital.

2. Resident #37 was admitted to the facility in October 2024 and had diagnoses including Alzheimer's disease, dementia with mild with agitation, major depression disorder (single episode, mild), and anxiety. Review of the MDS assessment, dated 10/14/24, indicated Resident #37 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status score of 11 out of 15, had Alzheimer's disease, dementia, anxiety, and depression. Further review of Resident #22's medical record failed to indicate a Social Service assessment or evaluation had been completed on or since admission to the facility. Resident #22's electronic medical record indicated a Social Service assessment was 200 days overdue. During an interview on 4/28/25 at 1:35 P.M., the Social Worker said she has not been working in the facility consistently over the past six to eight months and has not been able to keep up with social service assessments, trauma assessments and care plans. She said she met with Resident #37 and his/her family at the time of admission in October 2024 and took handwritten notes, but did not enter them into the Resident's medical record. The Social Worker said during her initial visit with the Resident she was made aware that Resident #37 had trauma from significant losses of his/her spouse and a child. She said she should have conducted a trauma assessment and developed a care plan with approaches to care that meet his/her needs when she identified the trauma in October 2024 but didn't. Based on record review and interview, the facility failed to ensure a person-centered plan of care with individualized interventions for trauma-informed care was developed for two Residents (#29 and #22), out of a total sample of 13 residents. Specifically, the facility failed to assess and implement care plan interventions for: 1. Resident #29 with a history of a traumatic and violent event; and 2. Resident #22 with a history of traumatic events. Findings include: Review of the facility's policy titled PTSD (Trauma), revised 7/2020, indicated but was not limited to the following: - This policy is designed to ensure that residents with actual or suspected Post-Traumatic Stress Disorder (PTSD) received appropriate screening, diagnosis, care planning and treatment in accordance with CMS regulations and clinical best practices. - PTSD is a recognized mental health condition that may affect residents' quality of life, safety, and functional abilities. - All new residents shall be screened for history of trauma or PTSD as part of the admission assessment by nursing and/or social services. - Veterans and individuals with a known psychiatric history shall receive further evaluation by the interdisciplinary team (IDT). - A personalized care plan shall be developed for each resident diagnosed with PTSD, addressing identified triggers and strategies to minimize them, behavioral symptoms and appropriate interventions, trauma-informed communication methods, medication regimen (if applicable), and counseling or psychotherapy goals. - The care plan shall be reviewed quarterly and as needed based on changes in condition. 1. Resident #29 was admitted to the facility in March 2025 with diagnoses including Parkinson's disease and dementia. Review of Resident #29's Minimum Data Set (MDS) assessment, dated 3/18/25, indicated their short- and long-term memory was moderately impaired. The MDS assessment further indicated Resident #29 experienced periods of verbal behavioral symptoms towards others and rejected care. Review of Resident #29's paper medical record included an article in his/her chart indicating a traumatic and violent life event occurring in his/her youth resulting in physical injuries. Further review of Resident #29's medical record failed to indicate a Social Service assessment or evaluation had been completed on or since admission to the facility. Resident #29's electronic medical record indicated a Social Service assessment was 46 days overdue. Review of Resident #29's comprehensive care plans failed to indicate he/she had a history of a traumatic/violent event. During an interview on 4/28/25 at 2:11 P.M., the Social Worker said she is responsible for completing Social Service assessments on residents when they are admitted to the facility. The Social Worker said she was behind on completing the assessments and was trying to get caught up. The Social Worker said she has met with all the residents since they were admitted but has not input any information into their medical records. The Social Worker said she was not completing trauma assessments for any residents in the facility. She said she was recently educated by the consulting Social Worker on needing to complete trauma assessments but has not implemented the forms at this time. The Social Worker said she had met with Resident #29, and she put the article related to his/her traumatic/violent life event in the paper medical record. The Social Worker said she considered this event a history of trauma. The Social Worker said she should have completed a trauma assessment and updated the care plan to reflect this information but did not.

Based on record review and interview, the facility failed to provide the appropriate treatment and services for one Resident (#29), with a history of a traumatic and violent life event, out of a total sample of 13 residents. Specifically, the facility failed to make a referral to Behavioral Health Services upon admission resulting in a 46-day delay of services. Findings include: Review of the facility's policy titled PTSD (Trauma), revised 7/2020, indicated but was not limited to the following: - This policy is designed to ensure that residents with actual or suspected Post-Traumatic Stress Disorder (PTSD) received appropriate screening, diagnosis, care planning and treatment in accordance with CMS regulations and clinical best practices. - PTSD is a recognized mental health condition that may affect residents' quality of life, safety, and functional abilities. - All new residents shall be screened for history of trauma or PTSD as part of the admission assessment by nursing and/or social services. - Veterans and individuals with a known psychiatric history shall receive further evaluation by the interdisciplinary team (IDT). - A qualified mental health professional (psychiatrist, psychologist, psychiatric NP (Nurse Practitioner), etc.) will evaluate residents with suspected PTSD and document findings in the medical record. - A personalized care plan shall be developed for each resident diagnosed with PTSD, addressing identified triggers and strategies to minimize them, behavioral symptoms and appropriate interventions, trauma-informed communication methods, medication regimen (if applicable), and counseling or psychotherapy goals. - The care plan shall be reviewed quarterly and as needed based on changes in condition. Resident #29 was admitted to the facility in March 2025 with diagnoses including Parkinson's disease and dementia. Review of Resident #29's Minimum Data Set (MDS) assessment, dated 3/18/25, indicated their short- and long-term memory was moderately impaired. The MDS assessment further indicated Resident #29 experienced periods of verbal behavioral symptoms towards others (threatening others, screaming at others, cursing at others) and rejected care. Review of Resident #29's paper medical record included an article in his/her chart indicating a traumatic and violent life event occurring in his/her youth resulting in physical injuries. Review of Resident #29's Physician's Orders indicated but were not limited to: - 3/11/25: May have psych consult/treatment Review of Resident #29's medical record failed to indicate a referral to a psychiatrist or psychologist were made on or after admission. Further review of Resident #29's medical record failed to indicate a Social Service assessment or evaluation had been completed on or since admission to the facility. Resident #29's electronic medical record indicated a Social Service assessment was 46 days overdue. Review of Resident #29's comprehensive care plans indicated: - Focus: The Resident uses psychotropic medications (Divalproex, Gabapentin, Quetiapine) related to delirium and agitation (initiated 3/11/25); Goal: The resident will receive least restrictive dose of medication to lessen the following: aggressive and compulsive behaviors (target date 6/29/25); Interventions: psych consult as needed (initiated 3/11/25), monitor/document/report PRN (as needed) any adverse reactions to psychotropic medications (initiated 3/12/25), administer psychotropic medications as ordered by physician and monitor for side effects and effectiveness every shift (initiated 3/11/25) - No care plan was developed to include a treatment plan for Behavioral Health Services. - No care plan was developed related to Resident #29's history of a traumatic/violent event. During an interview on 4/28/25 at 2:11 P.M., the Social Worker said Resident #29 had a history of trauma related to an incident which occurred in his/her youth. The Social Worker said the appropriate assessments and care plans were not developed on admission. The Social Worker said she makes the referrals to consulting psychiatric services. The Social Worker said based on Resident #29's history and behaviors a referral to psychiatric services should have been made but was not.

Based on interviews and record reviews, for two of four sampled residents (Resident #1 and Resident #2), the Facility failed to provide adequate supervision to prevent Resident #1's burn and Resident #2's multiple elopements. On 11/27/17, Resident #1 moved from his/her low bed onto safety mats positioned next to the bed and leaned against a baseboard heater immediately adjacent to one of the safety mats sustaining a second degree burn measuring 10 centimeters (cm) by 20 cm on his/her neck, shoulder and back. On 10/9/17, Resident #2 eloped from the Facility three times, twice being found standing on the sidewalk in front of the Facility adjacent to Route 1A. Findings include: 1. Resident #1's Quarterly Minimum Data Set (MDS) Assessment Form, dated 10/22/17, indicated that his/her speech was unclear and he/she rarely made him/herself understood verbally or non-verbally. The MDS indicated that Resident #1's ability to see in adequate light was highly impaired. The MDS indicated that Resident #1's short and long term memory was impaired and his/her decision making skills were severely impaired. The MDS indicated Resident #1 was totally dependent on the assistance of two or more staff members for bed mobility and transfers between surfaces. The MDS indicated Resident #1 was not steady and could only stabilize balance when transferring between surfaces with staff member assistance and had impaired range of motion of upper and lower extremities on his/her right and left side. Resident #1's care plan concern initiated January 2016 indicated that he/she was at risk for falls due to dementia and [MEDICAL CONDITION] and interventions included a low bed, floor mats on the floor next to the bed and a body alarm at all times. Resident #1's care plan concern initiated April 2016 indicated that he/she was at risk of impaired communication and interventions included anticipating his/her needs as indicated. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 6:00 P.M. on 12/12/17. The Surveyor interviewed CNA #2 at 6:30 P.M. on 12/12/17. CNA #1 said that she and CNA #2 put Resident #1 into bed between 7:00 P.M. and 7:30 P.M. on 11/27/17 with CNA #3. CNA #1 and CNA #2 said that after they completed Resident #1's evening care, they placed Resident #1's bed in its lowest position and moved floor mats onto the floor next to both sides of Resident #1's bed. CNA #1 and CNA #2 said that they attached a body alarm to the back of Resident #1's Johnny. CNA #2 said that the body alarm was placed onto Resident #1's(NAME)to alert staff members when Resident #1 moved in bed or moved onto the mats next to his/her low bed. CNA #1 and CNA #2 said that Resident #1's personal alarm sounded twice after they put him/her into bed and they responded. CNA #1 said that the first time, they found Resident #1 on the mat next to his/her bed. CNA #1 and CNA #2 said that the second time Resident #1's personal alarm sounded about five minutes later, Resident #1's body was half on his/her bed and half on the mat next to his/her bed. CNA #1 said that Resident #1 had been incontinent and she and CNA #2 provided incontinence care and put Resident #1 back into his/her bed. CNA #1 said that about five or seven minutes later, she walked past Resident #1's bed room door and saw Resident #1's legs on the floor. CNA #1 said she called to CNA #2 for help with Resident #1 and, when they entered Resident #1's room, CNA #1 said she could smell something burning. CNA #1 and CNA #2 said that they saw Resident #1's upper body leaning against the baseboard heater next to her bed. CNA #1 and CNA #2 said they realized that the baseboard heater was hot and CNA #1 said I think (Resident #1) is burning. CNA #1 and CNA #2 said they called to Nurse #1 for help. CNA #1 and CNA #2 said that Resident #1's personal alarm was not sounding. CNA #1 and CNA #2 said that Resident #1's(NAME)had come off and the personal alarm was still clipped to the(NAME)on Resident #1's bed. The Surveyor interviewed Nurse #1 at 1:00 P.M. on 12/11/17. Nurse #1 said that she was Resident #1's nurse on 11/27/17. Nurse #1 said that around 9:30 P.M., CNA #1 and CNA #2 called her to Resident #1's room because Resident #1's back was against the base board heater. Nurse #1 said she assessed Resident #1. Nurse #1 said that the right side of Resident #1's back was blistered with skin shearing and some oozing. Nurse #1 said that from the back of Resident #1's neck toward his/her left shoulder was red. Nurse #1 said she called Physician #1 for orders, cleansed the area and applied [MEDICATION NAME] cream ([MEDICATION NAME] Cream is a topical cream used to prevent infections in burns) and a dressing. Physician #1's note, dated 11/29/17, indicated that he saw Resident #1. Physician #1's note indicated that Resident #1 developed a second degree burn on his/her upper back which measured 10 cm by 20 cm. Physician #1's note indicated that on 11/29/17 he observed the burn to have loose skin and a broken blister. Physician #1's note indicated that Resident #1 sustained the burn after leaning against a baseboard heater. 2. Resident #2's Admission MDS Assessment Form, completed 9/7/17, indicated that his/her vision was impaired and his/her abilities to make his/herself understood and understand others were impaired. Resident #2's MDS Assessment indicated that his/her cognitive patterns were severely impaired. The MDS indicated Resident #2 required limited assistance of one staff member when ambulating on his/her unit and extensive assistance of one staff member when ambulating off of his/her unit. Resident #2's clinical record contained a Health Care Proxy which was activated during July 2017. The Elopement Risk Assessment Form in Resident #2's clinical record, dated 8/28/17, indicated that he/she was at risk for elopement due to his/her [DIAGNOSES REDACTED]. An Elopement Care Plan, dated 8/25/17, indicated interventions for Resident #2 which included monitoring for verbalized desire or intent to elope or wander, one to one supervision as needed, frequent visual check for safety, redirection of any elopement attempts and notification of nursing of every elopement attempt. The Surveyor interviewed Family Member #1 at 7:00 A.M. on 12/12/17. Family Member #1 said that around 7:30 A.M. on 10/9/17, he pulled into the Facility driveway and observed Resident #2 on the side of the road walking away from the Facility. Family Member #1 said that he approached Resident #2 and asked Resident #2 to walk with him and Resident #2 did. Family Member #1 said that as he walked with Resident #2 toward the Facility, a Certified Nurse Aide (CNA) exited the Facility and assisted him with bringing Resident #2 inside. The Surveyor interviewed CNA #2 at 6:15 P.M. on 12/12/17. CNA #2 said that Resident #2 exited the Facility twice during the 7:00 A.M. to 3:00 P.M. shift on 10/9/17. CNA #2 said that around 7:30 A.M. on 10/9/17, Family Member #1 brought Resident #2 back into the Facility and around 9:30 A.M., Resident was observed by a staff member stepping outside of the back door. Nurse #1 said that she worked at the Facility during the 7:00 A.M. to 3:00 P.M. shift on 10/9/17. Nurse #1 said that she was aware that Resident #1 stepped out the back door, but she was not aware that Family Member #1 found Resident #1 standing outside on the sidewalk. Nurse #1 said that around 4:30 P.M. someone told her that Resident #2 was inside of someone's car in front of the Facility. Nurse #1 said that when she exited the Facility, a motorist was parked in front of the Facility and Resident #2 was in the car. Nurse #1 said that the motorist yelled at her and said she had found Resident #2 outside and asked why the Facility doors weren't locked. The Surveyor interviewed the Nurse Manager at 11:00 A.M. on 12/11/17 . The Nurse Manager said that on 10/9/17, she was aware that Resident #1 attempted to exit the Facility once during the 7:00 A.M. to 3:00 P.M., but she was not aware of the incident in which Resident #2 exited the Facility and was found outside by Family Member #1. The Nurse Manager said that around 4:30 P.M., she heard that there was someone out front of the Facility with Resident #2. The Nurse Manager said that she went outside and saw Resident #2 in a woman's car. The Nurse Manager said that the woman told her she stopped to assist Resident #2 because he/she looked lost on the side of the road and she realized that Resident #2 resided at the Facility because he/she was wearing a Facility identification bracelet.

Based on observation, record review and staff interview, the facility failed to ensure that one sampled Resident (#6) in a total sample of 10 residents, received appropriate range of motion exercises to prevent an avoidable decline of range of motion (ROM). Findings include: Resident #6 was admitted in 10/2015 for continued rehabilitation in transfer from another facility where he/she was receiving rehabilitation services following surgery for [REDACTED].) Additional [DIAGNOSES REDACTED]. Review of the initial and quarterly Minimum Data Set (MDS) assessments (working copy provided), with reference dates of 11/6/15 and 5/7/16 respectively indicated that the Resident was cognitively impaired, was unable to ambulate and required extensive assistance from facility staff for all activities of daily living (ADL). No impairment in functional range of motion was coded for the lower extremities. A review of care plans for self care deficits [MEDICAL CONDITION] initiated on 10/29/15 and last reviewed on 5/16/16, identified the goal was for Resident #6 to function at the highest level of capability and listed the following approaches: - Assess and document skills - Assist with ADL's .encourage to self participate to optimum level - Rehab consults as ordered/indicated Review of the clinical record indicated that the Resident was followed by the Rehabilitation Service from 10/28/15 through 12/17/16 for therapeutic exercises, gait training and wheel chair mobility and again from 1/6/16 through 1/22/16 to address proper bed and wheelchair positioning. Although the Resident was unable to ambulate, his/her range of motion for both bilateral extremities was determined to be within functional limits. The physical therapy note indicated that the Resident and caregivers were educated about proper positioning in order to maintain skin/joint integrity. Review of the 3/13/16 evening shift Nurse's note indicated that the Resident complained of right knee pain and said that it hurt to try and straighten it out so he/she bent it and it felt better. The Resident was medicated for pain with a positive effect. On 3/16/16 the physician saw the Resident due to the family concerns of right knee pain. The physician indicated that the knee was not swollen, but there was a marked decrease in the range of motion with pain. The physician ordered scheduled [MEDICATION NAME] ([MEDICATION NAME]) three times daily. Despite the physician and nursing's observations of decreased range of motion a request for a Rehab screen was not obtained as per the facility procedure. On 5/25/16 at 10:30 A.M. and at 1:15 P. M, Resident #6 was observed in bed with his/her eyes open and lying face up with head of the bed slightly elevated and the Resident's legs raised at the knee level and covered with a sheet and a blanket. On 5/26/16 at 8:55 A.M., the Surveyor entered the room and observed the Resident positioned in bed as observed the previous 2 occasions (see above). The Resident smiled and said hello when greeted. A family member then entered the room. The family member said that he/she visits every morning and other family members visit daily. During interview the family member said that the Resident was having knee pain and that the Resident could not straighten the knee without pain. The Surveyor requested the assistance of staff to observe the Resident's lower extremities. CNA #2 (who was covering for another assigned CNA) removed the blankets and the Resident's right knee was observed raised and flexed inward toward the opposite knee. The Resident was then prompted by the CNA to extend his/her knee which he/she attempted and was unable to complete without complaining about pain and quickly pulling the knee into the raised position. On 5/26/16 at 1:05 P.M. the Resident's assigned CNA #3 was interviewed. CNA #3 said that the facility does not have consistent CNA assignments. CNA #3 said if there are any changes in the Resident's status they are informed by the nurses. CNA #3 was asked to describe the care she provides for Resident #6 said that the Resident is totally dependent for care and receives a daily bed bath, uses a bedpan for toileting, transfers to and from the bed with a mechanical lift, and naps in the morning and afternoon. CNA #3 said that she typically rolls the Resident from side to side because it is too painful for him/her to sit on the edge of the bed. CNA #3 was asked if she provides any range of motion exercises and she said no. CNA #3 was asked about the Resident's knee flexion and said that the Resident has not been able to straighten out his/her leg for over 2 weeks. CNA #3 said that she did not report her observations to the nurse. Nurse #3 was interviewed on 5/26/16 at 2:00 P.M. and observed the Resident's right knee in a flexed position. Nurse #3 prompted the Resident to straighten her leg and the Resident attempted and was unable to do so and complained of pain. Nurse #3 said that she assumed that the Resident pulled the leg up in response to pain but was unaware that the Resident could not extend her leg when prompted. Nurse #3 said that the CNA staff provide range of motion daily and that PT comes in daily. Nurse #3 was informed about the previous interview with the assigned CNA, said she was unable to explain why CNA staff do not provide ROM exercises. Nurse #3 reviewed existing documentation and said that there was no evidence that PT actively followed the Resident as thought. Nurse #3 said that she would file a request for Rehabilitation Screen due to the Resident's decline in range of motion. On 5/26/16 at 3:30 P.M. the Director of Physical Therapy (DPT) was interviewed. The DPT said that he had previously followed the Resident and he/she was able to complete active assistive ROM with improvements observed in range and within functional limits at the conclusion of therapy in January. The DPT said that he was unaware that Resident #6 was not receiving any ROM exercises. The DPT said that a request for a Rehab screen was never submitted when the Resident began complaining of pain and decline in mobility. The DPT said that he planned to screen the Resident. At 4:30 P.M. the DPT returned and indicated that the Resident was unable to actively extend the knee when prompted. The DPT said he observed new right knee flexion and planned to fully assess the resident on 5/27/16 as the Resident required skilled therapy for a decline in ROM. Review of the 5/27/16 PT Initial Plan of Care indicated that the Resident's bed mobility had declined from a prior level of minimum to moderate with staff assistance to the current level of moderate to maximum with staff assistance. The Resident was assessed with [REDACTED].