Every finding on record at Sherrill House

Based on observations, interviews, and record review, the facility failed to provide necessary treatment, services, or interventions to promote healing and prevent new ulcers from developing a.) ensure treatment orders were transcribed and implemented per the Wound Nurse Practitioner's recommendations and b.) accurately implement a wound intervention of an air mattress for four Residents (#152, #32 , #4, and #5) out of a total sample of 33 residents. 1.For Resident #152, the facility failed to prevent an existing ankle wound that was present on admission to the facility from worsening from a Stage 2 (partial-thickness skin loss- shallow open ulcer with a red-pink wound bed) pressure ulcer to a Stage 4 (full-thickness tissue loss- exposed bone, tendon, or muscle) pressure ulcer by not assessing and monitoring the wound and not implementing physician orders for wound treatment.2.For Resident #32, the facility failed to (a) ensure treatment orders were transcribed and implemented per the Wound Nurse Practitioner's recommendations and (b) accurately implement a wound intervention of an air mattress.3.For Resident #4, the facility failed to (a) follow wound care orders to a pressure wound as ordered by the physician, failed to assess and measure wound weekly, and (b) ensure an air mattress was at the correct setting.4.For Resident #5, the facility failed to ensure treatment was provided according to the physician's order. Findings include:Review of the facility policy titled Pressure Ulcer/Skin Breakdown - Clinical Protocol, revised April 2018, indicated, but was not limited to, the following: -The nursing staff and practitioners will assess and document an individual's significant risk factors for developing pressure ulcers. -In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. b. Pain assessment. d. Current treatments, including support surfaces. -The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings, and application of topical agents. Resident #152 was admitted to the facility in March 2026 with a diagnosis of Parkinson's, Dementia, Anemia, Diabetes, and Malnutrition. Review of Resident #152's most recent Minimum Data Set (MDS) assessment, dated 3/30/26, indicated severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 7 out of 15. The MDS further indicated Resident #152 was dependent for all activities of daily living, had impairment to functional limitation in range of motion to bilateral lower extremities and was assessed to be at risk for developing pressure injuries. Review of Resident #152's plan of care titled I have a potential for pressure ulcer development with a goal of Resident being free from pressure ulcers, dated as initiated 3/30/26, indicated: -Weekly skin check by licensed nurse. -I use a therapeutic mattress on my bed. -Apply barrier lotion to my bony prominences every shift as preventative measure and with incontinent care as needed. -Avoid prolonged positioning on my bony prominences. -I need assistance to turn and reposition at least every 2 hours, and more often as needed or requested. -I need moisturizer applied every shift and as needed to my skin. Do not massage bony prominences and use mild cleansers for peri-care/washing. -Inform me and my family/caregivers and MD/PA/NP of any new area of skin breakdown. -Inspect my skin while providing personal care, paying special attention to boney prominences. -Monitor and report to my MD/PA/NP any change in skin status: appearance, color, wound healing, signs of infection, wound size, stage. -Educate me and my family/caregivers as to the causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Review of Resident #152's plan of care failed to include care for a pressure ulcer. Review of Resident #152's Norton Plus Skin Risk Assessment, dated 3/27/26, indicated Resident #152 scored a four, indicating that he/she was assessed by nursing to be at high risk for skin breakdown. On 4/8/26 at 9:30 A.M., and 4/9/26 at 9:15 A.M., the surveyor observed Resident #152 sitting in his/her recliner. Resident #152's right ankle was exposed and there was a wound dressing in place. Review of Resident #152's hospital discharge paperwork, dated 3/23/26, indicated that the Resident had a Stage 2 pressure injury on his/her right ankle with a treatment of Vaseline gauze covered with an abdominal pad and wrapped with bulky gauze. Review of Resident #152's skin check, dated 3/27/26, indicated: -Right ankle wound. Review of Resident #152's nursing progress note, dated 3/27/26 indicated he/she had a right ankle wound. Further review of Resident #152's medical record, dated 3/27/26 failed to include any further description of his/her right ankle wound. During an interview on 4/9/26 at 9:20 A.M., Unit Manager #2 said that she was Resident #152's assigned nurse and she had done his/her skin check on 3/27/26 and that he/she did have a wound on his/her right ankle with a dressing that she lifted to look at and then returned to cover the wound. Unit Manager #2 said she did not communicate Resident #152's wound to the supervisor or to the doctor and she did not get an order for treatment to the wound. During a telephone interview on 4/9/26 at 12:15 P.M., Nurse #7 (evening supervisor) said she reviewed the hospital paperwork and did not see any wound orders for Resident #152 and had not received any report about Resident #152 needing a wound treatment from Unit Manager #2. Review of Resident #152's medical record failed to indicate the physician was notified of the impairment in skin condition so a treatment could be ordered, if indicated. Review of Resident #152's March 2026 Treatment Administration Record (TAR) failed to indicate any order to monitor or treat Resident #152's wounds. Review of Resident #152's nursing skilled evaluation by Unit Manager #2, dated 3/30/26, indicated: - Rear right malleolus. Pressure ulcer/injury. Wound was present on admission. It is unknown how long the wound has been present. Review of Physician progress note dated 3/30/26, 3/31/26, and 4/1/26 failed to indicate the right ankle wound. Review of Resident #152's nursing skilled evaluation skin note and weekly skin check by Nurse #5, dated 4/3/26, indicated: - Rear right malleolus. Pressure ulcer/injury. Wound was present on admission. It is unknown how long the wound has been present. Review of Physician progress note, dated 4/3/26, indicated: -Stage 4 wound right ankle. -His/hers were documented in wound notes during hospitalization. -Honey Medi (Medi honey is used to manage dry to moderately exuding ulcers), foam dressing. -Air mattress. Review of Resident #152's physician orders, dated 4/3/26, indicated: -PU (pressure ulcer) to right later malleolus; NSW (normal saline wash), pat dry, apply therahoney gel, cover with foam dressing every day shift for wound care. -Low air loss mattress: Ensure air mattress is functioning properly and settings are correct. During an interview on 4/9/26 at 9:04 A.M., Physician #2 said that the first time she was made aware of Resident #152's right ankle wound was 4/3/26 when Nurse #5 was completing a skin check and asked her to assess the wound. Physician #2 said it was a stage 4 pressure injury as it was down to the bone. It was on 4/3/26 that treatment was initiated for Resident's pressure injury. Physician #2 said she had missed the documentation from the hospital paperwork about the stage 2 right ankle pressure injury that was present and had not seen the right ankle wound during physical inspection related to the Resident's contracted lower extremities making it difficult to see the area. Physician #2 said she would have expected nursing to have noticed the skin impairment during daily care and communicated it with her so that a treatment could have been put in place. Physician #2 said that the wound would have worsened without having treatment in place. On 4/9/26 at 11:44 A.M., the surveyor observed Resident #152's wounds with wound nurse consultant and Unit Manager #2. The wound nurse consultant assessed the right outer ankle as stage 4 as it was down to the bone and recommended an x-ray to rule out osteomyelitis (infection of the bone) and lab work. The wound nurse consultant described the wound as having slough and measured it as 3cm (centimeters) x 2.5cm. She recommended pressure to be off-loaded and for treatment to be changed to vashe cleanse followed by honey gel, calcium alginate (absorbent wound dressing for moderate to heavy drainage) and covered with foam. During an interview on 4/9/26 at 12:22 P.M., with the Director of Nursing she said that all new admissions have a skin assessment that includes a chart review, as well as observation. If a wound is found during the physical skin check, the appearance should be documented, and the admitting nurse should either get an order for treatment of the wound or carry over the treatment order from the hospital, if there is one, until the resident can be seen by the doctor. The Director of Nursing said that any new pressure ulcers are referred to the wound consultant and added to risk meeting. The Director of Nursing said that wounds should be looked at daily by licensed nurses and certified nursing aides should be reporting to nurses if there are any changes in residents' skin. The Director of Nursing said that she was aware that Resident #152 was admitted with a wound but was not aware that the admitting nurse did not inform the doctor or get a treatment order in place. The Director of Nursing said the risk of not getting treatment put into place timely for Resident #152's wound was that it would get worse. 2. Review of the facility policy titled 'Pressure Ulcers/Skin Breakdown – Clinical Protocol', dated April 2018, indicated but was not limited to: -The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.) and application of topical agents. Resident #32 was admitted to the facility in January 2023 with diagnoses including Alzheimer's disease, stroke, and functional quadriplegia. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/4/26, indicated that Resident #32 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of a possible 15, and required assistance with activities of daily living including bed mobility. The MDS further indicated that Resident #32 was at risk for developing pressure ulcers/injuries and had a pressure-reducing device for bed. Review of Resident #32's medical record indicated he/she was admitted to hospice services on 1/28/26. Review of the Norton Assessment completed on 2/5/26 indicated Resident #32 had a score of 5, indicating he/she is at a very high risk of skin breakdown. Resident #32 was unable to be interviewed due to his/her cognitive status. During an interview on 4/9/26 at 8:02 A.M., Resident #32's activated Health Care Proxy (HCP) said Resident #32's has wounds, which have been worsening over the last month. Review of Resident #32's wound management care plan, revised 3/3/26, indicated the following interventions: -Provide wound care per treatment order, initiated on 3/2/26. a) Review of the nursing skin assessment, dated 2/2/26, indicated Resident #32 developed new facility-acquired Moisture-Associated Skin Damage (MASD- inflammation or erosion of the skin caused by prolonged exposure to moisture, such as urine, stool, sweat, or wound exudate) on his/her bilateral buttocks. Review of the Wound NP note, dated 3/19/26, indicated Resident #32 had a worsening stage 2 pressure injury to his/her left buttock that had increased in size, with a measurement of 6 cm x 3 cm x 0.1 cm, a calculated area of 18 sq cm, no odor, and a moderate amount of serosanguineous (a common wound drainage that is thin, watery, and light red or pink, combining blood and serum) exudate. The Wound NP note indicated the following updated treatment recommendation: -Cleanse with normal saline. -Apply calcium alginate (a highly absorbent wound dressing) to the base of the wound. -Secure with bordered foam. -Change PRN (as needed) for soiling, saturation, or accidental removal, daily. Review of the Treatment Administration Record (TAR) for March 2026 failed to indicate this recommendation was put into place. Review of the nursing progress notes acknowledged the updated treatment order but failed to indicate the physician was notified to transcribe and implement the recommendation. Review of the nursing skin assessment, dated 3/23/26, indicated overall wound has declined. No measurements were taken. Review of the Wound NP note dated 3/26/26 indicated Resident #32 had a worsening stage 2 pressure injury to his/her left buttock, with a measurement of 8 cm x 5.5 cm x 0.1 cm and a calculated area of 44 sq cm, which is an overall increase of 43.25 sq cm in one month. The note indicated the worsening stage 2 pressure injury had no odor and a moderate amount of serosanguineous exudate. The Wound NP note indicated the following treatment recommendation: -Cleanse with normal saline. -Apply calcium alginate to the base of the wound. -Secure with bordered foam. -Change PRN for soiling, saturation, or accidental removal, daily. Review of the TAR for March 2026, nursing notes, and physician notes failed to indicate this recommendation was put into place. Review of the nursing skin assessment, dated 3/26/26, indicated Resident #32 had a worsening stage 2 pressure wound to his/her buttocks that measured 8.5 cm x 5.5 cm x 0 cm with a treatment to cleanse with normal saline, apply calcium alginate, and cover with bordered foam. Although the skin assessment includes the Wound NP recommendation, the nursing staff failed to implement this recommendation as an order. Review of the nursing skin assessment, dated 3/30/26, indicated Resident #32 had a deteriorating pressure wound to his/her buttocks with foul odor. No measurements were taken and the wound was not staged. Review of the most recent Wound NP note, dated 4/2/26, indicated Resident #32 had a worsening unstageable (a full-thickness wound where the base is obscured by necrotic tissue) pressure wound to his/her left buttock, with a measurement of 5 cm x 5 cm x 0 cm, a calculated area of 25 sq cm, mild odor, and a moderate amount of serosanguineous exudate. The Wound NP note indicated the following treatment recommendation: -Cleanse with Vashe (a professional-grade, sterile wound cleanser containing hypochlorous acid to cleanse, irrigate, and moisten acute and chronic wounds). -Apply 1/4 strength Dakin's moist gauze (a wound care dressing soaked in Dakin's solution, or sodium hypochlorite, that is used to clean, disinfect, and debride wounds) to the base of the wound. -Secure with bordered foam. -Change PRN (as needed) for soiling, saturation, or accidental removal, twice a day. Review of the nursing skin assessment dated [DATE] indicated Resident #32 had an unstageable wound to his/her left buttock, with a measurement of 5 cm x 5 cm and a treatment to cleanse with Vashe, apply 1/4 strength Dakin's moist gauze then cover with bordered foam twice daily and PRN for soilage or accidental removal. During an interview on 4/8/26 at 1:29 P.M., Unit Manager #1 said the Wound Nurse Practitioner (NP) comes in weekly to assess residents with wounds and provides written recommendations, and the nurse is responsible for transcribing and implementing wound care recommendations once they are approved by the physician. Unit Manager #1 said Resident #32 has facility-acquired wounds to his/her bilateral buttocks, and the left buttock wound has been worsening over the last few weeks. Unit Manager #1 said the Wound NP recommended calcium alginate on 3/19/26 and 3/26/26. Unit Manager #1 said the purpose of calcium alginate is to dry out the wound to help with drainage and odor, but the Wound NP's recommendations were never transcribed into an order because they must have been missed. Unit Manager #1 said the wound then developed more odor and drainage resulting in the Wound NP recommending a stronger treatment on 4/2/26. During an interview on 4/8/26 at 2:06 P.M., the Director of Nursing (DON) said she was aware Resident #32 had a pressure injury on his/her left buttock. The DON said she was unaware that the Wound NP's treatment recommendations on 3/19/26 and 3/26/26 for Resident #32 were never transcribed or implemented which could contribute to worsening wounds. The DON said the purpose of calcium alginate is to dry out the wound, and the risk of not implementing calcium alginate as recommended is that the wound will not heal properly. The DON said it was possible the physician declined the Wound NP's recommendations or the recommendations were missed. During an interview on 4/9/26 at 8:21 A.M., Hospice Staff #1 said she was aware Resident #32 had a wound to his/her left buttock. Hospice Staff #1 said she would expect the Wound NP treatment recommendations to be followed and was unaware that the Wound NP's treatment recommendations on 3/19/26 and 3/26/26 were never transcribed or implemented. Hospice Staff #1 said calcium alginate helps to manage wound drainage and has antimicrobial properties, and the risk of not implementing calcium alginate as recommended is the wound would have maceration or not improve. Hospice Staff #1 said she cannot recall a situation where hospice has declined treatment recommendations made by the Wound NP. During an interview on 4/9/26 at 10:09 A.M., Physician #1 said Resident #32 has had a worsening wound to his/her left buttock. Physician #1 said she was unaware that the Wound NP's treatment recommendations on 3/19/26 and 3/26/26 were never transcribed or implemented which could contribute to worsening wounds; she said she cannot recall declining any treatment recommendations the Wound NP made for Resident #32. Physician #1 said the purpose of calcium alginate is to absorb some of the wound exudate, and the risk of not implementing calcium alginate as recommended is the wound could deteriorate. During an interview on 4/9/26 at 10:39 A.M., the Wound NP said she communicates wound treatment recommendations the same day she sees the resident, and the unit manager is responsible for transcribing the order once approved by the physician. The Wound NP said Resident #32 has a worsening pressure wound to his/her left buttocks and she was unaware that her recommendations from 3/19/26 and 3/26/26 were not transcribed or implemented; she said she cannot recall the physician declining these recommendations. The Wound NP said she recommended calcium alginate for Resident #32 to absorb the wound's increased drainage while keeping the wound moist to promote healing and not implementing calcium alginate as recommended could cause deteriorating of the wound regardless of whether the resident is on hospice. The Wound NP said Resident #32's left buttock wound continued to deteriorate as evidenced by increased drainage and odor, which resulted in her recommending a stronger treatment on 4/2/26. During an interview on 4/9/26 at 12:57 P.M., the Clinical Director of Operations said it is possible that Resident #32's wound worsened from not transcribing and implementing the Wound NP's treatment recommendations regardless of hospice status. b) On 4/7/26 at 7:39 A.M. and 10:43 A.M. and 4/8/26 at 6:40 A.M., 9:11 A.M., and 1:20 P.M., the surveyor observed Resident #32 lying in bed on an air mattress that was set to 350 or more pounds. The Resident was non-interviewable and unable to answer any questions about his/her air mattress and whether or not it was comfortable. Review of Resident #32's physician orders indicated the following: -Air flow mattress with bumper pads, monitor functioning and setting according to my weight and alternating every shift, every shift for offload spine, initiated on 5/6/25. Review of Resident #32's vitals summary report indicated his/her most recent weight was 157.8 pounds on 1/1/26. Review of Resident #32's skin integrity care plan, revised 3/3/26, indicated the following interventions: -Air mattress, initiated on 4/21/25. Review of Resident #32's Kardex (a form indicating the level of care a resident requires) instructions indicated the following: -Air flow mattress, monitor functioning and setting every shift. Set according to my weight (close to 157 pounds) and alternating to off-load spine. During an interview on 4/8/26 at 1:22 P.M., Certified Nursing Assistant (CNA) #3 said Resident #32 has a wound on his/her buttock and uses an air mattress as an intervention. CNA #3 said the nurse is responsible for monitoring the air mattress; she said she is unaware of how to check for the proper air mattress setting and does not adjust the setting. CNA #3 said if wound-related interventions are not implemented properly, the wound could get worse. During an interview on 4/8/26 at 1:29 P.M., Unit Manager #1 said Resident #32 has a facility-acquired wound to his/her left bilateral buttock that has been worsening over the last few weeks. Unit Manager #1 said the Resident has an air mattress that is supposed to be set to his/her weight. Unit Manager #1 said if an air mattress is on too firm of a setting it could cause wounds to worsen because Resident #32 has a pressure ulcer and a mattress that is too firm adds more pressure to the wound. Unit Manager #1 said nursing is responsible for checking the air mattress is at the correct setting every shift. On 4/8/26 at 1:55 P.M., Unit Manager #1 and the surveyor went to check Resident #32's air mattress which was set to 350 or more pounds; she said it must have been an accident and changed the air mattress to the correct setting. During an interview on 4/8/26 at 2:06 P.M., the Director of Nursing (DON) said the nurses and unit managers are responsible for checking air mattress settings every shift per the physician's order and if an air mattress is on too firm of a setting it could cause wounds to worsen because a firmer mattress adds more pressure and the etiology of Resident #32's wound is pressure-related. During an interview on 4/9/26 at 8:21 A.M., Hospice Staff #1 said she would expect air mattress settings to be implemented per physician orders. The facility is responsible for ensuring the air mattress is on the correct setting; she said if an air mattress is on too firm of a setting it could cause wounds to worsen. During an interview on 4/9/26 at 10:09 A.M., Physician #1 said she would expect air mattress orders specified to the Resident #32's weight to be followed. During an interview on 4/9/26 at 10:39 A.M., the Wound Nurse Practitioner (NP) said Resident #32 has an air mattress that is supposed to be set to his/her weight. The Wound NP said if an air mattress is on too firm of a setting it could cause wounds to worsen because a firmer mattress adds more pressure and the etiology of Resident #32's wound is pressure-related. During an interview on 4/9/26 at 12:57 P.M., the Clinical Director of Operations said if an air mattress is on too firm of a setting it could cause wounds to worsen because a firmer mattress adds more pressure and the etiology of Resident #32's wound is pressure-related. 3.For Resident #4 the facility failed to (a) follow wound care orders to a pressure wound as ordered by the physician, failed to assess and measure wound weekly, and (b) ensure an air mattress was at the correct setting. a) Resident #4 was admitted to the facility in March 2026 with diagnoses including pressure ulcer of the sacrum. Review of the Minimum Data Set (MDS) assessment, dated 3/27/26, indicated the Resident scored 13 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. The MDS further indicated that the Resident had a stage 3 pressure ulcer to the sacrum. -On 4/8/26 at 11:00 A.M., the surveyor observed Nurse #5 perform a wound dressing change to Resident #4's sacrum. The Resident had a quarter size open area with some granulating tissue and slough in the wound bed. Nurse #5 cleansed the wound bed with normal saline solution, applied calcium alginate and covered with border gauze dressing. Nurse #5 said the wound Nurse Practitioner measures the wounds weekly on Thursdays. Review of the April physician's orders indicated the following: - Gluteal cleft/coccyx wound- Vashe soak/cleansing prior to triad dressing, saturate gauze with vashe wound solution and apply directly to the wound bed. Soak wound bed for with vashe saturated gauze for 3-5 minutes. Remove saturated gauze from wound bed and discard. Gently pat dry wound bed, apply calcium alginate and cover with border dressing every day shift. Review of the pressure ulcer care plan date initiated 3/23/26 indicated the following interventions: -Administer my treatments as ordered and monitor for effectiveness. Notify my MD/PA slash NP as needed for signs of infection, wound worsening, or other abnormality that may impede the healing process. -Access my wound healing weekly. Measure length, width and depth where possible. Assess and document status of wound parameter, wound bed and healing progress. Report abnormal or negative outcomes to my MD slash NP as needed. -I use a therapeutic mattress on my bed. Review of Resident #4's treatment administration record for April indicated the following physician's order: - Gluteal cleft/coccyx wound- Vashe soak/cleansing prior to triad dressing, saturate gauze with vashe wound solution and apply directly to the wound bed. Soak wound bed for with vashe saturated gauze for 3-5 minutes. Remove saturated gauze from wound bed and discard. Gently pat dry wound bed, apply calcium alginate and cover with border dressing every day shift. Review of the medical record failed to indicate the pressure ulcer had been measured weekly. During an interview on 4/8/26 at 11:24 A.M., Nurse #5 said the order should have been modified since last Thursday as the wound nurse practitioner gave him a verbal order to change the wound treatment orders. When asked why he did not implement those orders when he got the verbal order Nurse #5 said he should have. During an interview on 4/8/26 at 11:37 A.M., Nurse Practitioner (NP) #2 said she knows the wound NP comes into the facility every Thursday and follows all the wounds. She said wound orders should be followed as ordered and if any changes should be implemented immediately. During an interview on 4/8/26 at 11:41 A.M., Unit Manager #2 said she does wound rounds with the wound NP, she said the wound NP did not see Resident #4 the previous week. UM #2 said wound orders are to be followed as per the physician's orders and any changes should go into the electronic medical record as an order. UM #2 said wounds should be measured weekly. During an interview on 4/8/26 at 2:26 P.M., the Director of Nursing said wound orders should be followed as ordered and if any changes it should be reflected in the electronic medical record. She also said wounds are to be measured once a week. During an interview on 4/9/26 at 10:47 A.M., Wound Nurse Practitioner #3 said she never gave any verbal orders to Nurse #5 for Resident #4's coccyx/sacrum wound. She further said all her communications are either faxed or emailed to the facility. She said she saw Resident #4 on the 3/29/26 and only saw his/her toes and not the coccyx/sacrum. b) On 4/8/26 at 8:14 A.M., 10:53 A.M., 11:12 A.M., 1:46 P.M., and 1:56 P.M., the surveyor observed Resident #4's lying on an air mattress, the dial on the pump was set to above 175 pounds (lbs). Review of the Resident most current weight documented on 4/1/26 indicated the Resident weighed 143.4 lbs. Review of the current physician's order indicated the following: -Low air loss mattress: Ensure air mattress is functioning properly and settings are correct. Firmness setting must correlate with patient weight margin of manufacture intervals every shift for skin integrity. During an interview on 4/8/26 at 8:14 A.M., Resident #4 said the mattress was uncomfortable because it was too firm. The Resident further said he/she has a wound on his/her buttocks that hurts sometimes. During an interview on 4/8/26 at 1:53 P.M., Certified Nursing Assistant #1 said she never changes the settings on the air mattress that if the mattress malfunctioned, she would notify the nurse. During an interview on 4/8/26 at 1:56 P.M., Nurse #5 said the air mattress should be set according to the resident's weight, he said if the mattress is too firm it could impede the wound healing. During an interview on 4/8/26 at 2:12 P.M., Unit Manager #2 said residents' air mattresses are set to their weights. During an interview on 4/8/26 at 2:26 P.M., the Director of Nursing said air mattress should be set according to the resident's weight following the manufactures guidelines. 4.For Resident #5 the facility failed to ensure treatment was provided according to the physician's order. Resident #5 was admitted to the facility in February 2026 with diagnoses including non- pressure chronic ulcer right foot and a deep tissue pressure injury (DTI) to right heel. Review of Resident #5's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident scored 14 out of total 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. The MDS further indicated unhealed DTI and infection to the right foot. On 4/8/26 at 2:00 P.M., the surveyor and Nurse #5 observed a wound dressing on Resident #5's right heel and ankle dated 4/7/26 with initials. The Resident said the dressing had been done late morning the previous day. Review of the current physician's order indicated the following: -Right heel DTI: cleanse with vashe, apply 1/4 strength dakins (a dilute sodium hypochlorite solution used as an antiseptic to clean skin, treat infected wounds, and reduce bacteria preventing infection) moist gauze, apply abdominal pad and rolled gauze every day and evening shift for wound care. Review of the pressure ulcer care plan date initiated 2/2/26 indicated the following: -Administer my treatment was ordered and monitored for effectiveness. Notify my MD/PA /NP as needed for signs of infection, wound worsening, or other abnormality that may impede the heali

Based on observations, interviews, and record reviews, the facility failed to ensure that effective pain management that was consistent with professional standards of practice was provided for one Resident (#4) out of a total sample of 33 residents. Specifically, the facility failed to provide interventions for pain management during wound care treatment, resulting in the Resident experiencing pain during the wound care.Findings include: Review of the facility policy titled 'Pain-Clinical Protocol' dated March 2018, indicated the following but not limited to:-The physician and staff will identify individuals who have pain or who are at risk for having pain. This includes reviewing known diagnoses and conditions that commonly cause pain, for example degenerative joint disease, rheumatoid arthritis, osteoporosis (with or without vertebral compression fractures), diabetic neuropathy, oral or dental pathology, and post-stroke syndromes.-The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated, for example, wound care, ambulation, or repositioning.-The physician will help identify causes of pain, for example, by examining the resident directly, reviewing the resident's history, and via discussion with the resident and staff. Resident #4 was admitted to the facility in March 2026 with diagnoses including peripheral vascular disease, type 2 diabetes and gangrene. Review of the Minimum Data Set (MDS) assessment, dated 3/27/26, indicated the Resident scored 13 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. The MDS further indicated the Resident was receiving scheduled pain medication regimen, reported pain occasionally, at a level of 4 out of 10 and had diabetic foot ulcers. Review of the pain care plan, initiated 3/23/26, indicated Resident #4 had the following interventions:-Anticipate my need for pain relief and respond immediately to any complaint of pain.-Monitor and report to my nurse any signs of non-verbal pain: Changes in breathing, vocalizations grunting, grimacing. Review of Resident #4's Wound Care Specialist note dated 3/26/26, indicated the following but not limited to:-Left 4th toe appeared necrotic eschar covered. Left 2nd toe eschar covered and left great toe eschar covered. No drainage present. Patient reports pain to left foot. Would recommend pain management, painting eschar areas with betadine, monitor for pain, and follow up with vascular surgeon. Review of Resident #4's April Physician orders indicated:-Acetaminophen tablet 325 milligrams (mg), give 2 tablets via G-tube every 4 hours as needed for pain.-Hydromorphone oral tablet 2mg, give one tablet via G-tube every 4 hours as needed for moderate pain.-Left 1st, 2nd and 4th toes: apply betadine and leave open to air, every day shift.Review of the Medication Administration Record failed to indicate Resident #4 had been medicated prior to the wound care treatment.On 4/8/26 at 11 A.M., the surveyor observed Nurse #5 perform wound care treatment to Resident #4's left foot. Resident #4 retracted his/her foot and groaned, indicating discomfort. Nurse #5 asked the Resident if he/she was in pain, the Resident said yes, the nurse told the Resident that he was going to medicate him/her after he was done performing wound care treatment.-At 11:12 A.M., Nurse #5 completed performing wound care and asked the Resident to rate his/her pain on a scale of (1-10), the Resident rated his/her pain at a 7 indicating severe pain. Nurse #5 exited the room.During an interview on 4/8/26 at 11:14 A.M., Resident #4 said the nurses do not offer him/her pain medication prior to wound care treatment. Resident #4 said he/she always experiences pain with wound care treatment and would like to have pain medication prior to the procedures.During an interview on 4/8/26 at 11:30 A.M., Nurse #5 said Resident #4 is on acetaminophen for pain management, he further said prior to wound care he should have assessed the Resident for pain and premedicated him/her. He also said during the wound care treatment when the Resident verbalized being in pain he should have stopped the procedure, medicated the Resident then continued with wound care treatment. Nurse #5 said he did medicate the Resident with hydromorphone after the wound care.During an interview on 4/8/26 at 11:37 A.M., Nurse Practitioner #2 said Resident #4 has multiple wounds and he/she should be assessed and medicated prior to wound care if they report they have pain.During an interview on 4/8/26 at 2:26 P.M., the Director of Nursing said Residents with wounds should be assessed and be premedicated prior to wound care. She further said if a resident reports pain during wound care the nurse should stop the treatment, medicate the resident then continue with wound care.

Based on observations, interviews, record review, and policy review, the facility failed to ensure that services provided met professional standards for 3 Residents (#146, #42, and #134), out of 33 total sampled residents. Specifically,1.) For Resident #146, the facility failed to notify the provider and obtain and implement Bumex (a diuretic medication) for a weight gain as ordered by the physician.2.) For Resident #42, the facility failed to (2a.) implement a functioning air mattress physician's order, (2b.) complete a wound treatment and dressing documentation in the Treatment Administration Record (TAR).3.) For Resident #134, the facility failed to ensure daily weights were obtained according to the physician's orders. Findings include: 1.Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: - Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Resident #146 was admitted to the facility in June 2023 with diagnoses including congestive heart failure. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/19/26, indicated Resident #146 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15. On 4/8/26 at 10:42 A.M., the surveyor observed Resident #146 sitting up in his/her wheelchair wearing compression stockings (used for managing lower extremity swelling). Resident #146 was unable to answer questions about recent swelling or increased weight. Review of Resident #146's physician's order, initiated 1/23/26, indicated: - Obtain weight 3 times a week, weight goal is 142-147, if weight goes above 147 lbs. Give 2mg Bumex in PM (evening) and Notify NP/MD. Review of Resident #146's weight summary log, dated 4/6/26, indicated a weight of 148.4. Review of Resident #146's medication administration record (MAR), dated 4/6/26, indicated the physician order to Obtain Weight 3 times a week, weight goal is 142-147, if weight goes above 147 lbs. Give 2mg Bumex in PM and Notify NP/MD, scheduled for 7:30 A.M., was documented as a weight of 148.4 pounds by Unit Manager #1. The MAR failed to indicate any P.M. dose of Bumex was administered. Review of Resident #146's medical record, including nursing progress notes, dated 4/6/26, failed to indicate a provider was notified of an elevated weight above 147 or that the P.M. dose of Bumex was administered. During an interview on 4/8/26 at 10:50 A.M., Unit Manager #1 said she documented the weight of 148.4 for Resident #146. Unit Manager #1 said she did not realize the Resident had an increased weight and did not request a reweight. Unit Manager #1 reviewed all locations and paperwork where additional weights would be recorded and said there was no re-weight obtained and she believed the weight of 148.4 was accurate. Unit Manager #1 said she did not realize the weight required the physician to be notified and the Bumex 2mg to be implemented, so neither was done but should have been. Unit Manager #1 said when Resident #146 requires a P.M. dose of Bumex, they must call the provider to obtain an order and time for the Bumex to be given. During an interview on 4/8/26 at 10:53 A.M., Nurse Practitioner (NP) #1 said if Resident #146 has a weight above 147 pounds the nurse must notify them to obtain an order for Bumex 2mg, and she was not aware of the facility notifying them of the 148.4 weight on 4/6/26. NP #1 said the facility did not notify them of a weight of 148.4 pounds on 4/6/26 but should have. During an interview on 4/8/26 at 11:41 A.M., the Director of Nursing (DON) said if Resident #146 had a weight increase to 148.4 she would have expected the nurse to obtain a reweight to validate the weight increase. The DON said if the weight was documented as 148.4 pounds, based on the physician's order, the nurse should have notified the provider and obtained an order to implement Bumex 2mg in the P.M. but did not. 2. A review of the facility policy titled 'Pressure Ulcers/Skin Breakdown-Clinical Protocol' with a revision date of April 2018 indicated the following: -The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer (s). -The physician will assist the staff to identify the type (for example, arterial or stasis ulcer) and characteristics (presence of necrotic tissue, status of wound bed, etc.) of an ulcer. -The physician will order pertinent wound treatments, including pressure reducing surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. -The physician will help identify medical interventions related to wound management, for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound or to wound treatment, etc. Review of the facility policy titled 'Support Surface Guidelines' with a revision date September 2013 indicated the following: -The purpose for this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. -Redistributing support surfaces are to promote comfort for all bed-or chairbound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction. -Any individual at risk for developing pressure ulcers should be placed on a redistribution support surface, such as foam, static air, alternating air, gel or air loss device, when lying in bed. A review of the 'Supra Air Low Air Loss Alternating Pressure Mattress and Pump-User's Manual' indicated the following: The functions of the Supra Air Loss Alternating Pressure Mattress and Pump control unit are described below. Power Switch (1)-Turn on/off the power switch, the control unit will start/stop operation. Resident #42 was admitted to the facility in June 2024 with diagnoses including type 2 diabetes mellitus with peripheral angiopathy and venous insufficiency. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 indicating intact cognition. 2a. A review of Resident #42's April 2026 physician's orders indicated the following: -Low air loss mattress: ensure air mattress is functioning properly and settings are correct. Firmness setting must correlate with the patient's weight within margin of manufacturers intervals, every shift for skin integrity issues. Pressure settings do not vary significantly between intervals and should be set to the best ability of the user never exceeding the weight interval margins. Review policy if needed. Start Date:11/15/24. On 4/7/26 at 7:56 A.M., the Surveyor observed Resident #42 lying in bed on an air mattress. The air mattress was turned off. On 4/7/26 at 9:34 A.M., the Surveyor observed Nurse #1 leave the Resident's room with a medication cart. Nurse #1 told the Surveyor she had finished attending to both residents in the room and was moving on to the next room. On 4/7/26 at 9:35 A.M., the Surveyor observed the Resident in bed lying on an air mattress. The air mattress was turned off. During interviews and an observation on 4/7/26 at 9:53 A.M., Unit Manager #3 and the Surveyor observed the Resident in bed, lying on an air mattress. The air mattress was turned off and partially inflated. The Unit Manager said the air mattress was off because it was not plugged into the power outlet. The Unit Manager plugged the air mattress into the outlet. The Resident's air mattress visibly started to inflate. The Resident said he/she could feel the air mattress inflating. The Unit Manager said this particular air mattress starts to deflate in an hour if it is not turned on. The Unit Manager said the Resident currently has a venous ulcer on his/her left lower extremity and is a high risk for pressure ulcers, therefore the air mattress should always be on while he/she is in bed and set according to his/her weight. The Unit Manager said the Resident's physician's orders should be followed. During an interview on 4/8/26 at 8:36 A.M., the Assistant Director of Nurses said the Resident's air mattress should always be turned on, set according to the Resident's weight while he/she is in bed as per the physician's orders. During an interview on 4/8/26 at 1:02 P.M., the Director of Nurses said Resident #42 is a high risk for pressure ulcers and currently has a venous ulcer on the lower left extremity. The DON said his/her air mattress should always be turned on and set according to his/her weight while in bed. 2b. A review of the March 2026 Treatment Administration Record (TAR) indicated the following: Bilateral lower legs: clean with wound cleanse or normal saline, pat dry with gauze over open wound bed, cover with ABD (Abdominal/Army Battle Dressing). Change daily every day shift for wound care. Start Date: 2/20/26. Further review of the TAR indicated holes (gaps in the medical record) dated 3/2/26 and 3/16/26. Review of the Nurse's progress notes failed to indicate documentation for the gaps in the TAR. Further review of Resident #42's census failed to indicate that the Resident was on a medical leave of absence on 3/2/26 and 3/16/26. During an interview on 4/10/26 at 7:15 A.M., the Assistant Director of Nurses said the Resident had two lower extremity venous ulcers, on the right and left lower extremities, but the right lower extremity ulcer resolved on 3/20/26. During an interview and medical record review on 4/9/26 at 9:36 A.M., Nurse #8 and the Director of Nurses said gaps in the TAR indicated that the treatment and dressing were not done as ordered. The Director of Nurses said Nurses should code in the TAR or write a progress note to explain why there were gaps in the medical record. During an interview on 4/9/26 at 1:14 P.M., the Director of Clinical Operations said the Resident does have a history of refusing wound care. The Director of Clinical Operations said the Nurses should document in the medical record if the Resident refuses care or document the correct code in the TAR. The Director of Clinical Operations was requested by the Surveyor to provide any documentation that would indicate why there were gaps in the Resident's TAR, no documentation was provided during the survey. 3.For Resident #134, the facility failed to ensure daily weights were obtained according to the physician's orders. Resident #134 was admitted to the facility in March 2026 with diagnosis including diastolic congestive heart failure. Review of Resident #134's Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 14 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. The MDS further indicated the Resident required supervision to complete activities of daily living (ADLS). Review of Resident #134's current physician orders dated 3/28/26 indicated the following: -Daily body weight. Notify MD/NP if weight gain 2 pounds in one day or 5 pounds in one week in the morning [sic] Review of the Medication Administration Record (MAR) for March and April indicated the clinical nursing staff signed off as weights being obtained. Review of weights and vitals summary failed to indicate weights were obtained and documented on the following dates: -3/29/26, 3/30/26, 3/31/26, 4/1/26, 4/3/26 and 4/5/26. Review of Resident #134's care plan failed to indicate a care plan for congestive heart failure was developed. During an interview on 4/8/26 at 12:05 P.M., Nurse #5 said if there is an order for daily weights the certified nursing assistant (CNA) would obtain the weights and either document in the weight's binder and/or inform the nurse who would document in the electronic medical record. He further said the Resident does not refuse care and the daily weights are for monitoring fluid overload due to congestive heart failure. During an interview on 4/8/26 at 12:13 P.M., Unit Manager #2 said the CNA's will obtain the weights and document on paper then give to the nurses who then input in the electronic medical records. She said the Resident is being monitored for fluid overload. During an interview on 4/8/26 at 12:50 P.M., the Director of Nursing said physician orders should be completed as ordered.

Based on observations and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements in two out of four medication carts observed. Specifically,1.) The facility failed to ensure medications with shortened expiry dates were dated once opened, according to manufacturer's guidelines.2.) The facility failed to ensure medications were stored in the original, labeled containers. Findings include:Review of the facility policy titled 'Medication Storage', revised April 2019, indicated:- Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received.- The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.- Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.- Schedule II-V controlled medications are stored in a separately locked, permanently affixed compartments. 1a.) On 4/7/26 at 12:50 P.M., the surveyor and Nurse #2 observed the following in the fourth-floor team one medication cart:- one incruse ellipta inhaler, open and undated. The label indicated to discard six weeks after opening.- one fluticasone propionate and salmeterol inhaler, open undated. The label indicated to discard one month after opening.- one anoro ellipta inhaler, open and undated. The label indicated to discard six weeks after opening.- one budesonide fumarate inhaler, open and undated. The label indicated to discard three months after opening.- one advair inhaler, open and undated.- one bottle of latanoprost eye drops, open and undated.- one fluticasone propionate and salmeterol inhaler, open, undated, and not labeled with resident name. This stored not in a box, directly in drawer. During an interview on 4/7/26 at 12:52 P.M., Nurse #2 said the eye drops and inhalers observed and listed above in the fourth-floor team one medication cart were open and not dated. Nurse #2 said these are medications with shortened expiry date and should have been dated once opened but were not. Nurse #2 further said the fluticasone propionate and salmeterol inhaler (which was not labeled with any resident's name) should have been stored in its original box and labeled with the resident's name. 1b.) On 4/7/26 at 12:43 P.M., the surveyor and Nurse #1 observed the following in the third-floor team two medication cart:- One bottle of prosource (liquid protein), open and undated. The label indicated to discard three months after opening. During an interview on 4/7/26 at 12:45 P.M., Nurse #1 said the prosource should have been dated upon opening but was not. During an interview on 4/8/26 at 8:59 A.M., the Director of Nursing (DON) said she would expect eye drops, inhalers, and liquid protein should be dated once opened because they have shortened expiry dates. 2.) On 4/7/26 at 12:43 P.M., the surveyor observed Nurse #1 sitting behind the nurses' station using the computer, not actively administering medications. The surveyor requested to observe her medication cart. The surveyor and Nurse #1 observed the following in the third-floor team two medication cart:- one clear, unlabeled medication cup containing one round white pill.- another clear, unlabeled medication containing two oval white pills. During an interview on 4/7/26 at 12:45 P.M., Nurse #1 said the white round pill was oxycodone (a scheduled II controlled medication) that was scheduled for 9:00 A.M. Nurse #1 said she tried administering it earlier, but the Resident was asleep and was unable to. Nurse #1 said controlled substances should be locked in a separate controlled substance box, but it was not. Nurse #1 said she also pre-poured the two white oval pills, which were Tylenol, but had not administered them yet. Nurse #1 said she stored these medications in her medication cart, unlabeled, because she was going to go back and administer them later. During an interview on 4/8/26 at 8:59 A.M., the Director of Nursing (DON) said medications should be prepared when the resident is ready to take medication and should be discarded if unable to be administered within a reasonable amount of time. The DON said controlled medications, such as oxycodone, should be stored in a separately locked container. The DON said medications should always be labeled with the resident's name.

Based on observations, interviews, and record review the the facility failed to notify the physician of a significant change in the resident's physical status for two Residents (#152 and #146), out of 33 total sampled residents. Specifically,1. For Resident #152, the facility failed to notify the provider of an admission with a right ankle pressure injury resulting in delayed treatment and monitoring of the Resident, deterioration of the wound and management of worsening wound condition. 2. For Resident #146, the facility failed to notify the provider of need to implement Bumex (a diuretic medication) for weight gain, which could potentially indicate the clinical complication of fluid overload. Findings include: 1.) Review of the facility policy titled 'Change in a Resident's Condition or Status', revised May 2017, indicated: Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status. -The nurse will notify the resident's Attending Physician or physician on call when there has been: b. discovery of injuries of an unknown source. d. significant change in the resident's physical/emotional/mental condition. -The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Resident #152 was admitted to the facility in March 2026 with a diagnoses of Parkinson's disease, Dementia, Anemia, Diabetes, and Malnutrition. Review of Resident #152's most recent Minimum Data Set (MDS) assessment, dated 3/30/26, indicated severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 7 out of 15. The MDS further indicated Resident #152 was dependent for all activities of daily living, had impairment to functional limitation in range of motion to bilateral lower extremities and was assessed to be at risk for developing pressure injuries. On 4/8/26 at 9:30 A.M., and 4/9/26 at 9:15 A.M., the surveyor observed Resident #152 sitting in his/her recliner. Resident #152's right ankle was exposed and there was a wound dressing in place. Review of Resident #152's hospital discharge paperwork, dated 3/23/26, indicated that the Resident had a Stage 2 pressure injury on his/her right ankle with a treatment of Vaseline gauze covered with an abdominal pad and wrapped with bulky gauze. During an interview on 4/9/26 at 9:20 A.M., Unit Manager #2 said that she was Resident #152's assigned nurse and she had done his/her skin check on 3/27/26 and that he/she did have a wound on his/her right ankle with a dressing that she had lifted to look and then returned to cover the wound. Unit Manager #2 said she did not communicate Resident #152's wound to the supervisor or to the doctor and she did not get an order for treatment to the wound. During a telephone interview on 4/9/26 at 12:15 P.M., Nurse #7 (evening supervisor) said she reviewed the hospital paperwork and did not see any wound orders for Resident #152 and had not received any report about Resident #152 needing a wound treatment from Unit Manager #2. Review of Resident #152's medical record failed to indicate the physician was notified of the impairment in skin condition so a treatment could be ordered if indicated. Review of Resident #152's March 2026 Treatment Administration Record (TAR) failed to indicate any order to monitor or treat Resident #152's wounds. During an interview on 4/9/26 at 9:04 A.M., Physician #2 said that the first time she was made aware of Resident #152's right ankle wound was 4/3/26 when Nurse #5 was completing a skin check and asked her to assess. Physician #2 said it was a stage 4 pressure injury as it was down to the bone. It was on 4/3/26 that treatment was initiated for Resident's pressure injury. Physician #2 said that the wound would have worsened without having treatment in place. During an interview on 4/9/26 at 12:22 P.M., the Director of Nursing said that all new admissions have a skin assessment that includes a chart review, as well as observation. If a wound is found during the physical skin check, the appearance should be documented, and the admitting nurse should either get an order for treatment of the wound or carry over the treatment order from the hospital, if there is one, until the resident can be seen by the doctor. The Director of Nursing said the risk of not getting treatment put into place timely for Resident #152's wound was that it would get worse. 2.) Review of the facility policy titled 'Weight and Measuring the Resident', revised March 2011, indicated: -Report significant weight loss/weight gain to the nurse supervisor. -Report other information in accordance with facility policy and professional standards of practice. Resident #146 was admitted to the facility in June 2023 with diagnoses including congestive heart failure. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/19/26, indicated Resident #146 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15. On 4/8/26 at 10:42 A.M., the surveyor observed Resident #146 sitting up in his/her wheelchair wearing compression stockings (used for managing lower extremity swelling). Resident #146 was unable to answer questions about recent swelling or increased weight. Review of Resident #146's physician's order, initiated 1/23/26, indicated: - Obtain Weight 3 times a week, weight goal is 142-147, if weight goes above 147 lbs. Give 2mg Bumex in PM and Notify NP/MD. Review of Resident #146's weight summary log, dated 4/6/26, indicated a weight of 148.4. Review of Resident #146's medication administration record (MAR), dated 4/6/26, indicated the physician order to Obtain Weight 3 times a week, weight goal is 142-147, if weight goes above 147 lbs. Give 2mg Bumex in PM and Notify NP/MD, scheduled for 7:30 A.M., was documented as a weight of 148.4 pounds by Unit Manager #1. Review of Resident #146's medical record, including nursing progress notes, dated 4/6/26, failed to indicate a provider was notified of an elevated weight above 147. During an interview on 4/8/26 at 10:50 A.M., Unit Manager #1 said she documented the weight of 148.4 for Resident #146. Unit Manager #1 said she did not realize the Resident had an increased weight and did not request a reweight. Unit Manager #1 reviewed all locations and paperwork where additional weights would be recorded and said there was no re-weight obtained and she believed the weight of 148.4 was accurate. Unit Manager #1 said she did not realize the weight required the physician to be notified of the weight increase and need for bumex, so she did not notify the provider of either. During an interview on 4/8/26 at 10:53 A.M., Nurse Practitioner (NP) #1 said if Resident #146 has a weight above 147 pounds the nurse must notify them to obtain an order for bumex 2mg. NP #1 said the facility did not notify them of a weight of 148.4 pounds on 4/6/26 but should have. During an interview on 4/8/26 at 11:41 A.M., the Director of Nursing (DON) said if Resident #146 had a weight increase to 148.4 she would have expected the nurse to obtain a reweight to validate the weight increase. The DON said if the weight was documented as 148.4 pounds, based on the physician's order, the nurse should have notified the provider and obtained an order to implement bumex 2mg in the P.M. but did not.

Based on record review and interviews, the facility failed to ensure that, within 48 hours of admission, nursing developed and implemented baseline care plan with interventions, treatments, goals, and outcomes that addressed the residents' overall immediate care needs for one Resident (#152), out of a sample of 33 Residents. Specifically, the facility failed to initiate a baseline care plan to address a right ankle Stage 2 (partial-thickness skin loss- shallow open ulcer with a red-pink wound bed, or an intact/ruptured serum-filled blister) pressure injury resulting in the development of a right ankle Stage 4 (full-thickness tissue loss- exposed bone, tendon, or muscle, often with undermining and tunnelling) pressure injury. Findings include: Review of the facility's policy titled, Care Plans-Baseline, undated, indicated:-A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission.-The interdisciplinary team will review the healthcare practitioner's orders (dietary, medications, routine treatments) and implement baseline care plan to meet the resident's immediate care needs including but not limited to: -Initial goals based on admission orders. -Physician orders. -Dietary orders. -Therapy services. -Social services. -PASARR recommendation, if applicable.-The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. Resident #152 was admitted to the facility in March 2026 and had diagnoses including Parkinson's, Dementia, and Diabetes. Review of the Minimum Data Set (MDS) assessment, dated 3/30/26, indicated Resident #152 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 7 of a possible 15. This MDS also indicated that Resident #152 was dependent for all activities of daily living. Review of Resident #152's hospital discharge paperwork, dated 3/23/26, indicated that the Resident had a stage 2 pressure injury on his/her right ankle. Review of Resident #152's clinical admission assessment skin check, dated 3/27/26, indicated:-Right ankle wound, bruising to right forearm, red, fragile buttocks/sacrum. Review of the medical record failed to indicate a baseline or comprehensive care plan for the care of a pressure injury was developed within 48 hours of Resident #152's admission. During an interview on 4/9/26 at 9:20 A.M., Unit Manager #2 said she did the skin check and she was aware that Resident #152 had a wound on his/her right ankle. Unit Manager #2 said that it is the Unit Manager's responsibility to initiate the baseline care plan and that she has 72 hours to do that. Unit Manager #2 said that she should have initiated a wound care plan even if she did not know if it was a wound caused by pressure, but she did not. During an interview on 4/9/26 at 12:22 P.M., the Director of Nursing said the admitting nurse should initiate the baseline care plan and it should include anything that nursing would need to know how to care for the patient.

Based on record review and interviews, the facility failed to identify and implement interventions for a significant weight loss for one Resident (#141) out of a total sample of 33 residents. Findings include:Review of the policy titled, Weighing and Measuring the Resident, dated March 2011, indicated the following:-Report significant weight loss/gain to the nurse supervisor. -The threshold for significant unplanned and undesired weight loss/gain will be based on the following criteria: 1 month - 5% weight loss is significant; greater than 5% is severe. -Notify the Nurse Supervisor if the resident refuses the procedure. -Report the information in accordance with the facility policy and professional standards of practice. Resident #141 was admitted to the facility in January 2024 with diagnoses including Alzheimer's Disease, leukemia and dementia. Review of Resident #141's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) and staff had assessed him/her to have severe cognitive impairment. The MDS also indicated Resident #141 is dependent on staff for all self-care and mobility tasks. Review of Resident #141's weight log indicated that on 3/2/26, the Resident weighed 164.8 lbs. (pounds) and on 4/1/26, the Resident weighed 156.4 lbs, which is a 5.1% significant weight loss. Review of Resident #141's physician orders failed to indicate the Resident had any nutritional interventions implemented at the time of the weight loss. Review of Resident #141's nutritional care plan last revised on 2/4/26, indicated the following interventions:-Monitor and report to my dietitian/MD/PA (physician's assistant) / NP (Nurse Practitioner) and signs of malnutrition, emaciation(cachexia), muscle wasting, significant weight loss : 3 lb (pounds) in 1 week, over 5% in 1 month, over 7/5% in 3 months, over 10% in 6 months. -Dietitian to evaluate and make diet changes recommendations, provide carb (carbohydrate) controlled diet. Review of Resident #141's medical record failed to indicate that nursing, the Dietitian, or the Physician was aware of the significant weight loss. Resident #141 was unable to be interviewed about his/her weight secondary to cognitive status. During an interview on 4/8/26 at 9:22 A.M., Unit Manager #1 said weights are entered into the medical record by nurses or the Dietitian and that at the time of weight entry, the staff should identify if a significant weight loss has occurred. Unit Manager #1 said if a weight loss has occurred, the Dietitian, Physician and family should be notified and a nutritional intervention should be implemented immediately. Unit Manager #1 said she was unaware of Resident #141's significant weight loss but said the Dietitian was aware. During an interview on 4/8/26 at 9:32 A.M., the Dietitian said a significant weight loss would be a loss of 5% in a month, 7.5% in 3 months and 10% in 6 months. The Dietitian said if a resident were to have a significant weight loss, he would implement an intervention immediately, within 24 hours. The Dietitian then reviewed Resident #141's weights and said he entered the Resident's most recent weight into the medical record but that when he entered the weight, he failed to look at the previous weight and identify this significant weight loss. The Dietitian said if he had identified the weight loss, he would have started Resident #141 on a nutritional supplement to address the weight loss and prevent further loss. During an interview on 4/8/26 at 12:41 P.M., the Director of Nursing said resident weights are entered into the medical record by the nurses or Dietitian and when weights are entered the previous weight should be looked at to identify if a weight loss has occurred. The Director of Nursing said a significant weight loss would be a loss of 5% in a month, 7.5% in 3 months and 10% in 6 months. She said a nutritional intervention should be implemented as soon as possible if a weight loss is identified. The Director of Nursing said she was unaware Resident #141 had a significant weight loss and the Dietitian should have assessed the Resident and implemented an intervention immediately and did not.

Based on interviews and record review, the facility failed to accurately document in the medical record for one Resident (#32) out of a total sample of 33 residents. Specifically, for Resident #32, the nurses inaccurately documented checking air mattress settings according to the Resident's weight per the physician's order. Findings include:Review of the facility policy titled 'Charting and Documentation', dated July 2017, indicated the following:-Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Resident #32 was admitted to the facility in January 2023 with diagnoses including Alzheimer's disease, stroke, and functional quadriplegia. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/4/26, indicated that Resident #32 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of a possible 15, and required assistance with activities of daily living including bed mobility. The MDS further indicated that Resident #32 had a pressure-reducing device for bed. On 4/7/26 at 7:39 A.M. and 10:43 A.M. and 4/8/26 at 6:40 A.M., 9:11 A.M., and 1:20 P.M., the surveyor observed Resident #32 lying in bed on an air mattress that was set to 350 or more pounds. The Resident was non-interviewable and unable to answer any questions about the air mattress setting. Review of Resident #32's physician orders indicated the following:-Air flow mattress with bumper pads, monitor functioning and setting according to weight and alternating every shift, and every shift to offload spine, initiated on 5/6/25. Review of Resident #32's vitals summary report indicated his/her most recent weight was 157.8 pounds on 1/1/26. Review of Resident #32's Treatment Administration Record (TAR) for April 2026 indicated the following:-On 4/7/26, the nurses documented monitoring the air mattress function and setting according to the Resident's weight for day shift. -On 4/8/26, the nurses documented monitoring the air mattress function and setting according to the Resident's weight for day shift. On 4/8/26 at 1:55 P.M., Unit Manager #1 and the surveyor went to check Resident #32's air mattress which was set to 350 or more pounds; she said it must have been an accident and changed the air mattress to the correct setting. Unit Manager #1 said she inaccurately documented in the TAR that the air mattress was set to the Resident's weight when it was not. During an interview on 4/8/26 at 2:06 P.M., the Director of Nursing (DON) said the nurse or unit manager is responsible for checking air mattress settings every shift and it should be documented accurately in the medical record. The DON said nursing should not be checking off orders as completed if they are not completed.

Based on observations, record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one Residents (#4) out of a total sample of 33 Residents. Specifically,1.For Resident #4 the facility failed to implement hand hygiene during a wound dressing treatment.2.The facility failed to adhere to contact precautions for Resident #4.Findings include:Review of facility policy titled 'Handwashing/Hand Hygiene', dated August 2019, indicated the following:-All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.-The use of gloves does not replace hand washing /hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Review of facility policy titled 'Isolation- Categories of Transmission-Based Precautions', dated October 2018, indicated the following:-Contact precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the residents' environment.-Staff and visitors will wear gloves (clean, non-sterile) when entering the room.-Staff and visitors will wear disposable gowns entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. 1. Resident #4 was admitted to the facility in March 2026 with diagnoses including peripheral vascular disease, type 2 diabetes and gangrene. Review of the Minimum Data Set (MDS) assessment, dated 3/27/26, indicated the Resident scored 13 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. The MDS indicated the Resident had diabetic wounds and a pressure ulcer. Review of Resident #4's Physician's orders indicated the following:-Gluteal cleft/coccyx wound pressure ulcer.-Wounds to left foot toes 1,2 and 4.-A G-tube site wound.During a wound dressing observations on 4/8/26 at 11:00 A.M., Nurse #5 sanitized his hands donned a gown and gloves and entered Resident #4's room. Nurse #5 removed a dressing from Resident #4's G-tube site. Nurse #5 then removed his gloves and without performing hand hygiene donned a new pair of gloves. He then cleansed the site with normal saline then applied a clean dressing. Nurse #5 removed his gloves and again without performing hand hygiene, donned a new pair of gloves and cleansed Resident #4's left foot toes then applied betadine. Nurse #5 then removed his gloves and without performing hand hygiene he donned a new pair of gloves; he then removed the dressing from Resident #4's sacrum. He then removed his gloves and without performing hand hygiene he donned a new pair of gloves. Nurse #5 then applied new gloves and completed the treatment to the sacrum. He then removed his gloves and sanitized his hands. During an interview on 4/8/26 at 11:22 A.M., Nurse #5 said he should sanitize his hands every time he removed his gloves before applying a new pair of gloves.During an interview on 4/8/26 at 2:26 P.M., the Director of Nursing said her expectation is that hand hygiene should be performed in between glove changes. 2. During an observation on 4/8/26 at 8:30 A.M., Certified Nursing Assistant (CNA) #1 entered Resident #4's room who is on contact precautions only wearing gloves, she did not wear a gown.During an interview on 4/8/26 at 8:36 A.M., CNA #1 said she thought she only needed to wear a gown if she needed to empty a foley catheter. She further said that she only wore gloves because she was not giving direct care.During an observation on 4/8/26 at 8:33 A.M., CNA #2 entered Resident #4's room who is on contact precautions, only wearing a mask, she did not have gloves and a gown on. She came out with a tray cover.During an interview on 4/8/26 at 1:43 P.M., CNA #2 said she should have worn a gown and gloves before entering the contact precaution room. During an interview on 4/8/26 at 2:26 P.M., the Director of Nursing said staff should wear the right personal protective equipment before entering a precaution room.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), the facility failed to ensure that upon admission, nursing developed and implemented baseline care plans with interventions, treatments, goals and outcomes, that addressed his/her overall immediate care needs. Findings include: Review of the Facility's Policy titled Care Plans - Baseline, dated as last revised 12/2016, indicated a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight hours of admission. The Policy indicated that the Interdisciplinary Team (IDT) will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: -Initial goals based on admission orders; -Physician Orders; -Dietary Orders; -Therapy Services; -Social Services; and -Pre-admission Screening and Resident Review (PASRR) recommendations, if applicable. The Policy further indicated that the baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an IDT person-centered care plan. Resident #1 was admitted to the Facility in January 2025, diagnoses included fracture of right femur (thigh bone), history of falling, difficulty in walking, muscle weakness, pressure injury of right heel (stage 2, partial-thickness skin loss involving the epidermis and dermis), and atrial fibrillation (irregular heart rate). Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated his/her immediate care needs were identified as followed: -Care of closed fracture; neck of right femur; status post right hemiarthroplasty (partial hip replacement surgery) -Activity status -Wound care of pressure injuries -Nutritional needs Review of Resident #1's Medical Record indicated there was no documentation to support that a Baseline Care Plan was developed and implemented, or that Comprehensive Care Plans that addressed these areas of concern were in place within 48 hours of his/her admission. Further review of Resident #1's Medical Record indicated that Comprehensive Care Plans for the identified care areas were not in place until five days later (on 1/23/25). During an interview on 06/24/25 at 1:39 P.M., Nurse #1 said that the nurses on the floor do not create baseline care plans for new admissions and that the Unit Manager was responsible for completing the baseline care plans. During a telephone interview on 07/01/25 at 11:06 A.M., Nursing Supervisor #1 said that completing a resident's baseline care plan was not her responsibility and that the Unit Manager would create the baseline care plans within 48 hours. During an interview on 06/24/25 at 2:23 P.M., the Unit Manager said it was her responsibility to create residents' baseline care plans within 48 hours of admission. The Unit Manager said Resident #1's baseline care plans were not completed timely because she had missed doing it. During an interview on 06/24/25 at 4:15 P.M., the Director of Nursing (DON) said she was not aware that the baseline care plan for Resident #1 had not been completed in a timely manner within 48 hours after his/her admission. The DON said it is her expectation that residents' baseline care plans are completed within 48 hours per the facility's policy. On 06/24/25, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. Resident #1 no longer resides at the Facility. B. On 04/18/25, the Director of Nursing provided education to Unit Managers and Nursing Management on ensuring Baseline Care Plans are completed within 48 hours to meet residents' immediate needs. C. On 04/21/25, the Director of Nursing completed a full house audit on all new admissions/re-admissions for baseline care plans to ensure care needs were identified, that baseline care plans were developed and previous plans were reviewed and updated as needed. D. The Director of Nursing and/or designee will conduct audits to ensure Baseline Care Plans are completed within 48 hours and that the care plans meet the residents' immediate needs weekly for one month, then monthly for two months, the audits will continue until substantial compliance is achieved. E. The results of the audits were reviewed during the April QAPI meeting and will continue to be brought forward and reviewed at the monthly QAPI Committee meeting until substantial compliance is achieved. F. The Director of Nursing and/or designee are responsible for overall compliance.

Based on records reviewed and interviews, for three of three sampled residents, (Resident #1, #2, and #3), the facility failed to ensure that upon admission, that nursing developed and implemented baseline care plans with interventions, treatments, goals, and outcomes that addressed the residents' overall immediate care needs. Findings include: Review of the Facility Policy titled Baseline Care Plans, dated as last revised 12/2016, indicated a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight hours of admission. The Policy indicated that the Interdisciplinary Team (IDT) will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to; -Initial goals based on admission orders; -Physician Orders; -Dietary Orders; -Therapy Services; -Social Services; and -Pre-admission Screening and Resident Review (PASRR) recommendations, if applicable. The Policy further indicated that the baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an IDT person-centered care plan. 1) Resident #1 was admitted to the Facility in February 2025 diagnoses included Respiratory Syncytial Virus (RSV, a virus that infects the lungs and respiratory tract) with pneumonia, new onset of seizures, and a nasal gastrostomy tube (tube inserted through the nose to the stomach used for temporary medical purposes) placed for nutritional purposes. Review of Resident #1's Hospital Discharge Summary, dated 02/04/25, indicated his/her immediate care needs were identified as followed; -New onset of seizures with new antiseizure medications; -RSV with suspected aspiration pneumonia (caused by drawing in debris into the lung) with the use of oxygen via nasal cannula at three (3) liters (l); -Nasogastric- tube in place for caloric needs; and -Agitation with new administration of antipsychotic medication. Review of Resident #1's Medical Record indicated there was no documentation to support that Baseline Care Plans were developed and implemented, or that Comprehensive Care Plans that addressed these areas of concern were in place within 48 hours of his/her admission. 2) Resident #2 was admitted to the Facility in November 2024 diagnoses include diabetes mellitus, depression, chronic pain syndrome, End Stage Renal Disease (ESRD) requiring dialysis, anemia, and Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #2's Skilled Nursing Facility (SNF) Transfer paperwork, dated 11/27/24, indicated his/her immediate care needs were identified as followed; -Major Depression with psychotropic medication use; -Chronic Pain Syndrome with daily narcotic use and constipation; -Diabetes Mellitus; and -COPD with compromised respiratory status. Review of Resident #2's Medical Record indicated there was no documentation to support that Baseline Care Plans were developed and implemented, or that Comprehensive Care Plans that addressed these areas of concern were in place within 48 hours of his/her admission. 3) Resident #3 was admitted to the Facility in March 2025 diagnoses include Congestive Heart Failure (CHF), atrial fibrillation with flutter, and Myocardial Infarction (MI). Review of Resident #3's Hospital Discharge Summary , dated 03/15/25, indicated his/her immediate care needs were identified as followed; -CHF with the need for daily weights; -Risk for an alteration in nutrition, requiring a No Added Salt (NAS) diet; and -Risk for dehydration related to diuretic use. Review of Resident #3's Medical Record indicated there was no documentation to support that Baseline Care Plans were developed and implemented, or that Comprehensive Care Plans that addressed these areas of concern were in place within 48 hours of his/her admission. During a telephone interview on 04/14/25 at 10:06 A.M., Nurse #2 said that the nurses on the floor are not responsible for creating Baseline Care Plans for the residents upon admission and that the Unit Manager does them within 48 hours. During an interview on 04/07/25 at 5:06 P.M., Nursing Supervisor #1 said that completing a resident's baseline care plan was not her responsibility and that the Unit Manager will create the baseline care plans within 48 hours. During an interview on 04/07/25 at 3:49 P.M., the Unit Manager said that it was her responsibility to ensure Residents' Baseline Care Plans were in place within 48 hours of admission. The Unit Manager said for Resident #1, she only entered the basic care needs and missed some of his/her required immediate care needs. The Unit Manager said that Unit Managers and/or the Charge Nurses are responsible for ensuring baseline care plans are in place within 48 hours so that staff are aware of their major needs until the comprehensive care plan is completed. During an interview on 04/07/25 at 4:45 P.M., the Director of Nurse (DON) said that she was not aware that the baseline care plans for these residents had not been completed in a timely manner. The DON said that it is the Facility's expectation that all resident's have a complete baseline care plan in place within 48 hours after admission that allows the staff to provide care and services that each resident requires.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was alert, oriented and made his/her own health care decisions, the Facility failed to ensure that he/she was fully informed in advance and given information including the risk and benefits of psychotropic medications prior to their use, when Resident #1 was administered nine (9) doses of an antipsychotic medication by nursing, before obtaining his/her consent to administer the medication. Findings include: Review of the Facility Policy titled, Resident Rights, undated, indicated that residents have the right to a dignified existence and to communicate with individuals and representatives of choice and the Facility will protect and promote your rights. The Policy further indicated that all residents have the right to be fully informed of their total health status in an understandable manner. Resident #1 was admitted to the Facility in February 2025 diagnoses included Respiratory Syncytial Virus (RSV, a virus that infects the lungs and respiratory tract) with pneumonia, new onset of seizures, and a nasal gastrostomy tube (tube inserted through the nose to the stomach used for temporary medical purposes) placed for nutritional purposes. Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 02/11/25, indicated he/she was alert, oriented, was his/her own decision maker, and had scored a 14/15 on his/her Brief Interview for Mental Status (BIMS) Assessment (0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired cognition, and 12-15 suggests a resident is cognitively intact). Review of Resident #1's Physician's Order, for February 2025, indicated he/she had a new Physician's Order for nursing to administer; -Quetiapine (Seroquel, antipsychotic medication) 25 milligrams (mg), administer one tablet by mouth at bedtime for agitation; and -Quetiapine 25 mg, administer one half tablet (12.5 mg) by mouth every eight (8) hours as needed (PRN) for agitation. Review of Resident #1's Medication Administration Record (MAR), dated 02/04/25 through 02/11/25, indicated he/she received a total of 9 doses of Quetiapine, before the Facility obtained signed written consent from him/her on 2/12/25, to administer the psychotropic medication. Review of Resident #1's Informed Consent for Psychotropic Administration Form, dated 02/12/25, indicated he/she gave consent for the administration of Quetiapine eight days after admission. During an interview on 04/07/25 at 5:06 P.M., Nursing Supervisor #1 said that she was the nurse completed Resident #1's admission and does not know why his/her psychotropic medication consent form had not been signed. Nursing Supervisor #1 said that the nurse responsible for admitting the resident is responsible for obtaining all consents. During an interview on 04/07/25 at 3:49 P.M., the Unit Manager said that she was unaware that Resident #1's psychotropic medication consents were not obtained in a timely manner. The Unit Manager said that the nurse admitting the resident is responsible for obtaining consents, including residents with physicians' orders for psychotropic medications. The Unit Manager said a consent form, for administration of psychotropic medications needs to be signed by the resident, or if the residents' Health Care Proxy is invoked then the form would need to be signed by the Health Care Agent. During an interview on 04/07/25 at 4:45 P.M., the Director of Nurses (DON) said that written consent for the administration of Quetiapine was not obtained upon admission for Resident #1, or prior to it being administered to him/her. The DON said the Facility's expectation is that the nurses are to obtain written consent and have the form signed for psychotropic medication prior to administering any psychotropic medication.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who had been maintained on oxygen via nasal cannula while at the Hospital, the Facility failed to ensure nursing staff provided care and services that met professional standards of practice, when despite Resident #1's continued need for oxygen, there was no physician order obtained for administration. Findings include: Review of the Facility Policy titled Medication and Treatment Orders, dated as [NAME] revised 07/2016, indicated that all medication and treatment orders will be consistent with principles of safe effective order writing and shall only be administered upon the written order of a person duly licensed and authorized to prescribe such medications and treatments in this state. Review of the Facility Policy titled Oxygen Administration, dated as last revised 10/2010, indicated to first verify that there is a physician's order in place. Resident #1 was admitted to the Facility in February 2025, diagnoses included Respiratory Syncytial Virus (RSV, a virus that infects the lungs and respiratory tract) with pneumonia, new onset of seizures, and a nasal gastrostomy tube (tube inserted through the nose to the stomach used for temporary medical purposes) placed for nutritional purposes. Review of Resident #1's Hospital Discharge (DC) Summary, dated 02/04/25, indicated that he/she had been maintained on three (3) Liters (l) of oxygen via nasal cannula secondary to RSV and pneumonia. Further review of the DC summary indicated that Resident #1 had been stable on room air at the time of his/her discharge. Review of Resident #1's Admission Nursing Assessment, dated 02/04/25, indicated he/she had been on oxygen via nasal cannula (however, no specific liter flow was noted). Review of Resident #1's Medication Administration Record and Treatment Administration Record, for February 2025, indicated there was no physicians order for the administration of oxygen, and parameter for liter flow. Review of Resident #1's Nurse Progress Note, dated 02/12/25, indicated he/she was being administered oxygen via nasal cannula (NC, tube that is places in the nares (nose) to provide oxygen flow) at two (2) l. Review of Resident #1's Nurse Practitioner Progress Note, dated 02/12/25, indicated to titrate (continuously measure and adjust) his/her oxygen as appropriate. During an interview on 04/07/25 at 3:49 P.M., the Unit Manager said that the nurse responsible for reconciling medications and entering the physician's orders into Point Click Care (PCC, the electronic medical record), are responsible for obtaining all medication and treatment orders upon admission. During a telephone interview on 04/14/25 at 9:53 A.M., the Assistant Director of Nurses (ADON) said that Resident #1 required the use of oxygen upon admission, but said she was unaware that nursing had not obtained a physician's order. During an interview on 04/07/25 at 4:45 P.M., the Director of Nurses (DON) said that she knew Resident #1 required the use of oxygen, however not aware that Resident #1 did not have a physician's order to administer oxygen The DON said that it is the Facility's expectation that upon admission all medication and treatments require a physician's order to administer any medication and/or treatment before providing the medication and/or treatment.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who upon admission, had Orthopedic recommendations for nursing to monitor his/her left wrist and cast, the Facility failed to ensure they maintained a complete and accurate medical record, when the Orthopedic recommendations were not transcribed by nursing onto his/her Treatment Administration Record (TAR), and therefore was no nursing documentation on the TAR to support nursing monitored Resident #1's left wrist/cast. Findings Include: Review of the Facility's Policy tilted Charting and Documentation, dated as last revised April 2008, indicated the following: -all services provided to the resident to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record -all observations, medications administered, services performed, etc., must be documented in the resident's clinical records Resident #1 was admitted to the Facility in February 2025, diagnoses included dementia, history of falling, fracture of lower end of left radius (bone located on the thumb side of the forearm), fracture of other parts of neck, and hypertension. Review of Resident #1's Hospital Discharge Summary, dated 02/12/25, indicated that his/her principal diagnosis was a fall resulting in a C3 (cervical vertebra) spinous process fracture (a break in the bony projection on the back of the C3 vertebra) and a left distal radius fracture. The Summary further indicated that Resident #1's left wrist was casted and included Orthopedic discharge recommendations to monitor for the following: -cast to kept clean and dry -if he/she starts to feel pain, numbness or tingling, elevate and ice the affected extremity -if it persists, despite elevation and ice, return to the hospital or clinic, as the cast may be on too tight and may need to be changed Review of Resident #1's Physician Orders, dated February 2025, indicated there was no documentation to support that a Physician's order related to the Orthopedic recommendations to monitor the cast to his/her left wrist was obtained. Review of Resident #1's TARs, dated February 2025, indicated there was no documentation to support that his/her left wrist/cast were being monitored by nursing staff. During an interview on 03/14/25 at 8:06 A.M., the Unit Manager said if a resident has a cast, nurses always monitor the resident for circulation, sensation, and motor function (CSM), and for any pain or signs of infection every shift, which are documented on the resident's TARs. During an interview on 03/18/25 at 10:33 A.M., the Nursing Supervisor said when a resident is admitted with a cast to one of their extremities it is common nursing practice to monitor the resident's CSM, pain and signs or symptoms of infection every shift. The Nursing Supervisor said she reviewed Resident #1's Hospital Discharge Summary upon admission to the Facility, verified his/her orders with the Physician, and entered all of the orders into the Point Click Care (PCC, electronic medical record) computer system. The Nursing Supervisor said she could not recall if Resident #1 had a cast to his/her left wrist or recall if there were orthopedic recommendations on his/her discharge summary and said she must have missed it. During an in-person interview on 03/11/25 at 3:44 P.M. and a telephone interview on 3/14/25 at 10:50 A.M., the Director of Nursing (DON) said if a resident is admitted with a cast to an extremity due to a fracture, nursing should be monitoring the resident's CSM and for signs and symptoms of pain every shift. The DON said she could not recall if Resident #1 had a left radius fracture or a cast to his/her left wrist upon admission and said she was not aware that there were orthopedic recommendations on his/her Hospital Discharge Summary. The DON said it is her expectation that nurses are properly reviewing each resident's discharge summaries and that there should not be any orders or recommendation missed.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment and was dependent on staff to meet his/her care needs, the Facility failed to ensure that on 10/29/24, after being made aware of an allegation that he/she had been physically abused by a staff member, they obtained and maintained evidence that a thorough investigation into the allegation had been completed and that a summary of their investigation findings was submitted to the Department of Public Health within five days, as required. Findings include: Review of the Facility's Policy titled, Policies and Procedures Regarding Investigation and Reporting of Alleged Violations of Federal or State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source, and Misappropriation of Resident's Property, Exploitation, Adverse Event, or Retaliation, dated as revised 12/21/23, indicated the following: -The investigation shall include interview of associates, visitors, or residents who may have knowledge of the alleged incident. Factual information should be documented, not assumptions or speculations. Written statements from involved parties should be obtained. The documentation of the investigation shall be kept in the Executive Director's office in an administrative file, and - Federal law requires the Facility to have evidence of investigation of alleged violations. The Verification of Investigation form shall be completed after the investigation is complete and provided to survey agencies when requested or required by State or Federal law. Resident #1 was admitted to the Facility in October of 2019, diagnoses included Alzheimer's Disease, bipolar disorder, and dementia. Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 09/12/24 indicated he/she had severe cognitive impairment and was dependent on staff for care. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted 12/06/24, indicated that sometime in the morning on 10/29/24, Certified Nurse Aide (CNA) #1 found Resident with his/her left second and third fingers discolored and painful to touch. The Report indicated that Resident #1 had most likely gotten his/her hand stuck in the spoke(s) of the wheelchair. The Report indicated that later in the day on 10/29/24, Family Member #1 reported that Resident #1 said he/she had been punched in the head and stomach multiple times by a staff member. The Report indicated that when asked if he/she had been hit, Resident #1 said he/she had not been, and that staff felt Resident #1 had not been abused. Review of the Facility's Internal Investigation Report, dated 10/29/24, indicated that on the morning of 10/29/24, Resident #1 was found to have bruising on his/her left second and third fingers, and the Facility had determined that he/she (Resident #1) had injured his/her fingers in his/her wheelchair spokes. The Report indicated that on 10/29/24, an allegation that Resident #1 had been punched in the head and stomach by a staff member had been reported to Facility Administration to (by a family member) sometime in the afternoon that day. Although the Investigation included Written Witness Statements from facility staff, their statements only pertained to the bruising on Resident #1's fingers. There was no documentation in the Witness Statements from staff that indicated they were even questioned or asked if they had ever witnessed a staff member physically abuse Resident #1, or if Resident #1 had ever reported to any of them that he/she had been hit by a staff member. The Investigation Report indicated that an allegation of abuse had not been reported to the DPH or investigated because Family Member #1, who initially reported the allegation of physical abuse to the Chief Clinical Officer on 10/29/24, had recanted. During an interview on 01/23/25 at 11:05 A.M. (which included review of her Written Witness Statement, dated 10/29/24), the Unit Manager said that on 10/29/24 sometime in the morning, CNA #1 told her that Resident #1 had bruising on his her left second and third fingers. The Unit Manager said she was not aware that there was an allegation of physical abuse involving Resident #1 until the Chief Clinical Officer notified her and the Director Of Nurses on 10/29/24 sometime in the afternoon. The Unit Manager said that once she was made aware of the allegation, she asked Resident #1 if anyone had punched him/her and said Resident #1 did not answer her. The Unit Manager said her written witness statement focused the bruises on Resident #1's fingers, and not the allegation of physical abuse. During an interview on 01/23/25 at 2:54 P.M., The Director of Nurses (DON) said that on 10/29/24, sometime in the morning, the Unit Manager told her that Resident #1 had bruises on his/her left second and third fingers. The DON said she investigated the injuries and determined that the bruises on Resident #1's fingers were from his/her wheelchair. The DON said later that day 10/29/24, she was made aware that there was an allegation of physical abuse by a staff member, involving Resident #1. The DON said she had not fully investigated the abuse allegation because Family Member #1 who had reported it, had recanted. The DON said she could not provide any documentation to support that Family Member #1 recanted the allegation. The DON said she also could not provide documentation of interviews to support that she or any other staff member had conducted interviews with Resident #1, Family Member #1, or staff specific to the abuse allegation. The DON said she could not provide written witness statements from staff members pertaining to the allegation of physical abuse. During an interview on 01/25/25 at 10:35 A.M., the Chief Clinical Officer (COO) said that he believed he was the first person to receive the allegation of physical abuse involving Resident #1 on 10/29/24, and that he had immediately notified the DON and the Unit Manager. The COO said the Facility should have conducted an investigation into the allegation of physical abuse, and not just Resident #1's bruised fingers, but they had not. The COO said an investigation should include staff member statements and/or interviews specifically pertaining to the allegation of abuse. The COO said the person reporting the allegation should have been interviewed but said there was no documentation to support that had been done. The COO said an attempt to identify any accused staff members should have been made via the investigation but was not.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was severely cognitively impaired, and was dependent on staff to meet his/her care needs, the Facility failed to ensure that on 10/29/24, after Facility Administration was made aware of an allegation of physical abuse, that they reported the allegation to the Department of Public Health (DPH) within two hours as required, and was not reported to the DPH until 12/06/24 (more than a month after Administration was made aware of the allegation). Findings include: Review of the Facility Policy titled Abuse Prohibition, dated as revised 12/21/23, indicated that all alleged violations of Federal and State laws which involve mistreatment, neglect, abuse, injuries of unknown source, exploitation, and misappropriation of resident property are reported immediately to the Executive Director of the Facility. Further review of the Policy indicated that such violations will also be reported to State Agencies in accordance with existing State law. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted on 12/06/24, indicated that on 10/29/24 a Certified Nurse Aide (CNA) found Resident with his/her left second and third fingers discolored and painful to touch. The Report indicated that later in the day on 10/29/24, Family Member #1 reported that Resident #1 said he/she had been struck in the head and stomach multiple times by a staff member. The Report indicated that when asked (by facility staff) if he/she had been hit, Resident #1 said he/she had not been. The Report further indicated that Family Member #1 later retracted the allegation and therefore the Facility had not reported the allegation of physical abuse to the DPH. The Facility was unable to provide any documentation to support that Family Member #1 had recanted his reporting of the allegation of physical abuse. Review of the Facility's Internal Investigation Report, dated 10/29/24, indicated that Family Member #1 said that Resident #1 alleged he/she had been punched in the head and stomach by a staff member. The Report indicated that Resident #1 did not say to Facility staff that he/she had been punched or struck by a staff member. The Report indicated that because Family Member #1 retracted his reporting of Resident #1's allegation, the Facility had not reported the allegation of physical abuse to the DPH. During an interview on 01/23/25 at 11:05 A.M. (which included review of her Written Witness Statement, dated 10/29/24), the Unit Manager said on 10/29/24, the Chief Clincal Officer notified her the Family Member #1 had reported an allegation of physical abuse involving Resident #1. The Unit Manager said Family Member #1 never told her that he recanted the allegation. During an interview on 01/23/25 at 2:54 P.M., the Director of Nurses (DON) said that on 10/29/24 sometime in the afternoon, she was notified by the Chief Clinical Officer that there was an allegation of physical abuse, which included Resident #1 being punched in the head and stomach by a staff member. The DON said she interviewed Resident #1 and he/she told her (DON) that he/she had not been punched. The DON said that Family Member #1 then recanted their reporting of the allegation of physical abuse, so she did not report the allegation of abuse to the DPH on 10/29/24. The DON said DPH called her in December (could not remember the exact date), and told her that the DPH had received report of an allegation of abuse that occurred on 10/29/24 involving Resident #1, and requested that they submit a report and their investigation. During an interview on 01/23/25 at 10:35 A.M., the Chief Clinical Officer (CCO) said that on 10/29/24, he received an allegation of abuse involving Resident #1 that he/she had alleged being punched by a staff member. The CCO said he was not in the Facility at the time, but said he immediately notified the DON and Unit Manager about the allegation of abuse. The CCO said he assumed the allegation of physical abuse had been reported to DPH on 10/29/24, but later found out, that it had not been.

Based on observation and interview the facility failed to store and handle food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure that staff dated food, that staff did not store personal food with resident food and ingredients, that dented cans were not accepted into storage/circulation and that staff did not directly handle ready-to-eat food with contaminated gloves. Findings include: Review of the facility's undated policy titled Food Storage indicated, but was not limited to, the following: - Food is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination or cross contamination. - All stock must be rotated with each new order received. Rotating stock is essential to ensure the freshness and highest quality of the foods. o Old stock is always used first (first in - first out method). o Supervise the person designated to put stock away to make sure it is rotated properly. o Food must be dated as it is placed on the shelves o Date marking to indicate the date or day which a ready-to-eat, potentially hazardous food should be consumed, or discarded will be visible on all high-risk food. Review of the facility's undated policy titled General Food Preparation and Handling indicated, but was not limited to, the following: - Food items will be prepared to conserve maximum nutritive value, develop and enhance flavor and be free of injurious organisms and substances. - Foods are received, checked and stored properly as soon as they are delivered. - Food in broken packages or swollen cans, cans with a compromised seal, or food with an abnormal appearance or odor will not be served. - Food will be prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid manual contact of prepared foods. On 1/14/25 at 7:17 A.M. the surveyor made the following observations during the initial kitchen walkthrough: - Two bottles of cranberry juice, open and undated, with a small amount of juice remaining in the walk-in refrigerator - A bottle of orange juice open but undated in the walk-in refrigerator; there was a grayish blue wispy growth on and around the cap of the bottle. - Two containers of fresh garlic, open and undated in the walk-in refrigerator. - Sliced cheese opened and placed in an undated and unlabeled plastic sealable bag in the walk-in refrigerator. - Dairy free sliced cheddar cheese, open but undated in the walk-in refrigerator. - A container labeled strawberries in sugar open and dated 11/29 in the walk-in refrigerator. - Feta cheese opened and placed in an undated plastic sealable bag in the walk-in refrigerator. - A can of pineapples and a can of butterscotch pudding with significant dents on the can rack near the dessert preparation area. - A can of beef stew with a significant dent on a separate can rack in the main kitchen. - An individually portioned container of food, undated and unlabeled, stored in the walk-in refrigerator adjacent to resident food and ingredients. - An undated and unlabeled black plastic bag containing individually portioned food in the reach in refrigerator next to resident food. During an interview on 1/14/25 at 7:18 A.M., Dietary staff #2 said the individually portioned container of food in the walk-in refrigerator was his lunch. During an interview on 1/14/25 at 7:23 A.M., Dietary staff #3 said the black plastic bag containing individually portioned food was her lunch. On 1/14/25 at 7:55 A.M., the surveyor made the following observations in the first-floor kitchenette refrigerator: - Five bottles of cranberry juice open but undated. - One bottle of orange juice open but undated. - Three nutritionally fortified supplemental shakes open but undated. On 1/14/25 at 8:00 A.M. the surveyor made the following observations in the second-floor kitchenette refrigerator: - Two bottles of cranberry juice open but undated. - One bottle of orange juice open but undated. On 1/14/25 at 8:04 A.M. the surveyor made the following observations in the third-floor kitchenette refrigerator: - One bottle of cranberry juice open but undated. - One bottle of orange juice open but undated. - One bottle of apple juice open but undated. - One nutritionally fortified supplemental shake open but undated. On 1/14/25 at 8:08 A.M. the surveyor made the following observations in the fourth-floor kitchenette refrigerator: - Three bottles of cranberry juice, open but undated. - Two bottles of orange juice open but undated. - Three bottles of apple juice open but undated. - One nutritionally fortified supplemental shake open but undated. - A half gallon of milk open but undated, the milk had a sour smell. During a continuous observation of the breakfast tray line service on 1/16/24 from 8:00 A.M. until 8:18 A.M. the surveyor made the following observations: - The server contaminated his gloves by grabbing utensils, the bottom of plates, and the bottom of four pre-portioned puree mold containers. The server then, using the same contaminated gloves, grabbed four slices of ready-to-eat french toast; he cut them in half and using the same contaminated gloves placed them on resident plates to be served. - The server then further contaminated his gloves by opening the food warming container by grabbing the containers door handle, by grabbing tongs, and by grabbing a large plastic container of utensils in order to move it. The server then, using the same contaminated gloves grabbed four slices of ready-to-eat french toast; he cut them in half and using the same contaminated gloves placed them on resident plates to be served. - The server then further contaminated his gloves by opening the food warming container by grabbing the containers door handle and with the same contaminated gloves grabbed two slices of ready-to-eat french toast; he cut them in half and using the same contaminated gloves placed them on resident plates to be served. - The server failed to change his gloves or wash his hands throughout the continuous observation. During an interview on 1/14/25 at 7:46 A.M., the Executive Chef said that the staff member who received the cans and put them away should check for dents and that dented cans should be set aside, not placed into circulation with the other cans on the can rack. The executive chef said that the beef stew, pineapple, and pudding cans should have been set aside/discarded and not placed in the can racks to be used. The executive chef said the wispy growth on the outside of the orange juice cap was mold and that containers of juice should be dated when opened. During an interview on 1/16/25 at 7:42 A.M., the Food Service Director (FSD) said that food should be labeled and dated when opened or prepared and discarded after three days. The FSD said that nursing staff should be dating bottles of juice and supplements when they open them. The FSD said the employees have a designated refrigerator for their food and that they should not be storing their personal food with resident food or ingredients. The FSD said that the strawberries in sugar should have been discarded. The FSD said that cans should be inspected when received and cans with dents should be set aside to be returned to the supplier; the FSD said that the cans with dents should not have been placed into rotation with the other cans on the can rack. The FSD said that staff should not touch ready-to-eat food with contaminated gloves. During an interview on 1/16/25 at 9:35 A.M., the Director of Nursing said that nursing should date juices and nutritionally fortified supplemental shakes when they open them.

Based on observations and interviews, the facility failed to provide a dignified experience for the residents of the facility by 1) failing to provide a dignified dining experience for the residents on the first floor unit, 2) ensuring a staff member was not on the phone while providing care for one Resident (#129) and 3) ensuring staff members were not storing person items in the room of one Resident (#38), out of a total sample of 34 residents. Findings include: Review of the facility policy titled, Quality of Life - Dignity, dated 2001, indicated the following: -Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. -Residents should be treated with dignity and respect at all times. -Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis or needs. Review of the facility's Resident Rights policy dated, August 2017, indicated: The facility is responsible to care for you in a manner and environment that enhances or promotes your quality of life. The facility is responsible to treat you with dignity and full recognition of your individuality. 1. The following was observed on the first floor unit on 1/14/25: -At 8:35 A.M., a nurse was observed standing while assisting a resident with his/her meal. The nurse was not at eye level with the resident. -At 9:07 A.M. the surveyor observed a staff member passing out breakfast trays in the hallway for the first-floor unit. The staff member said he/she is not a feeder; he/she is right there. He/She is not going to eat it while pointing at a Resident who was sitting less than five feet away from the staff member. The following was observed on the first floor unit on 1/15/25: -At 8:23 A.M., staff were referring to residents as feeders in an area where residents could hear and a staff member was observed feeding a resident while standing and not at eye level of the resident. -At 8:47 A.M., two staff members reviewing meals at the meal truck referred to residents as feeders with residents nearby and able to hear. -At 12:35 P.M., a staff member was observed standing at the side of a resident's bed while assisting the resident with his/her meal. The staff was not at eye level with the resident and was standing over him/her. -At 5:10 P.M., a staff member was feeding a resident who was sitting in a standard wheelchair while sitting in an elevated chair, not at the level of the resident. The following was observed on the first floor unit on 1/16/25: -At 8:16 A.M., a staff member was heard referring to residents as feeders in the dining room with residents present. During an interview on 1/16/25 at 8:03 A.M., Unit Manager #1 said staff should be sitting at the resident's level when assisting with meals and should not refer to residents with labels such as feeders. During an interview on 1/16/25 at 10:17 A.M., the Director of Nursing said staff should be sitting at the resident's level when assisting with meals and should not refer to residents with labels such as feeders. 48990 2.) Resident #129 was admitted to the facility in September 2023 with diagnoses including progressive supranuclear palsy (a brain disorder that affects movement, vision, speech, and thinking ability) and dysphagia (difficulty swallowing). Review of the most recent Minimum Data Set (MDS) assessment, dated 11/23/24, indicated Resident #125 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of 15. This MDS also indicated Resident #129 required set-up/clean-up assistance with eating. During the Resident Group Interview on 1/15/25 at 1:30 P.M., all participants said that Certified Nursing Assistants (CNA's) frequently are on their personal phones on the unit. Review of Resident #129's plan of care related to activities of daily living, revised 1/14/25, indicated he/she required set-up assistance for meals. On 1/14/25 at 9:32 A.M., the surveyor entered Resident #129's room. There was a Certified Nurse Assistant (CNA) sitting in Resident #129's room who immediately put down her cellular phone. The cellular phone dropped to the ground at the surveyors' feet. The cellular phone screen clearly displayed a person's name and a length of call time of greater than 8 minutes. The CNA declined to answer any of the surveyor's questions. On 1/14/25 at 9:34 A.M., the surveyor attempted to ask Resident #129 questions about the staff member in his/her room, but Resident #129 stared blankly and did not respond to questions. During an interview on 1/15/25 at 12:09 P.M., Unit Manager #2 said staff members should never use their cell phones in any resident room. During an interview on 1/16/25 at 8:38 A.M., the Director of Nursing (DON) said the facility policy is that staff should never use their cell phones on the unit and should definitely not use their cell phones in a resident room. 36876 3. Resident #38 was admitted to the facility in August 2019 with diagnoses including dementia and mild cognitive impairment. Review of the Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #38 is severely cognitively impaired evidenced by a score of 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam. On 1/15/25 at 8:37 A.M., the surveyor observed Resident #38 laying in bed. A cell phone was plugged in and charging on the windowsill of his/her room. Resident #38 was unable to say if the phone belonged to him/her. On 1/15/25 at 10:16 A.M., the surveyor observed Resident #38 resting in bed. The cell phone was no longer on the windowsill and the charger was still plugged into the wall. During the Resident Group Interview on 1/15/25 at 1:30 P.M., all participants said that Certified Nursing Assistants (CNA's) frequently are on their personal phones on the unit and also charge their personal phones in resident rooms. One participant said that CNA's have asked him/her if they could borrow their outlet to charge their phones. On 1/16/25 at 7:30 A.M., the surveyor observed Resident #38 asleep in bed. There was no cell phone or charger in the room. During an interview on 1/16/25 at 7:44 A.M., Unit Coordinator #1 said that Resident #38 has a landline in his/her room to make calls to his/her family. Unit Coordinator #1 said that usually, the family will contact the facility to set up a Zoom call and then staff use a tablet to facilitate the call. During an interview on 1/16/25 at 7:57 A.M., the Director of Nursing (DON) said that staff should not be utilizing resident spaces to charge their phones.

Based on interviews and record review, the facility failed to ensure one Resident's (#150) personal care choices were honored, out of a total sample of 34 residents. Specifically, the facility failed to provide showers for Resident #150 per his/her request and preference. Findings include: Review of the facility policy titled 'Quality of Life - Self Determination and Participation', revised October 2009, indicated: - Our facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life. - Each resident shall be allowed to choose activities, schedules, and health care that are consistent with his or her interests, assessments, and plans of care, including: Personal care needs, such as bathing methods. Resident #150 was admitted to the facility in November 2023 with diagnoses including heart failure and bilateral lower extremity lymphedema (a chronic condition that causes swelling in the body's soft tissue). Review of the most recent Minimum Data Set (MDS) assessment, dated 11/10/24, indicated Resident #150 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS also indicated Resident #150 was unable to walk and was dependent on staff for transfers and showering/bathing. On 1/14/25 at 8:02 A.M., Resident #150 told the surveyor he/she was very upset because he/she had not had a shower in four months. Resident #150 said staff told him/her they could not use the shower chair because it was too small for him/her. Resident #150 said he/she expressed concern and preference for a shower multiple times to many staff members, including the Chief Clinical Officer and Unit Manager #2. Resident #150 said staff have provided bed baths instead of showers, but that he/she never feels as clean as taking a shower. Review of Resident #150's progress note, dated 11/8/24, indicated the Resident prefers showering. Review of Resident #150's physician's order, initiated 11/26/24, indicated: - Weekly Shower Tuesday 7-3 Shift. Review of Resident #150's plan of care, revised 11/12/24, failed to indicate he/she preferred showers. During an interview on 1/15/25 at 11:52 A.M., Certified Nurse Assistant (CNA) #2 said she was consistently scheduled to provide care for Resident #150. CNA #2 said Resident #150 prefers showers. During an interview on 1/15/25 at 11:55 A.M., Nurse #1 said Resident #150 has an order for weekly showers, but has not been able to have a shower. Nurse #1 said instead of a shower, Resident #150 had been receiving bed baths, even though the physician's order was for weekly showers. Nurse #1 declines to answer any questions regarding why a shower was unable to be provided and refers the surveyor to Unit Manager #2. During an interview on 1/16/25 at 8:12 A.M., Unit Manager #2 said Resident #150 had been unable to have his/her shower preference accommodated because there was not a shower chair that could be safely used. Unit Manager #2 said the shower chair available was too small for his/her body size. Unit Manager #2 said when staff would move the shower chair, while containing Resident #150, it would buckle unsafely because of the weight. Unit Manager #2 said this put the CNAs and Resident #150 at risk for injury, so staff informed Resident #150 he/she could not have a shower until a safe shower chair was obtained. Unit Manager #2 said the shower chair was also physically too small, making the Resident unable to move within the chair and had no cushion which would cause pain in his/her buttocks. Unit Manager said a new safe shower chair was obtained on 1/14/24 (which was the first day of the recertification survey) and Resident #150 was able to have his/her first shower since at least the beginning of December 2024, maybe longer. During an interview on 1/15/25 at 2:31 P.M., the Chief Clinical Officer (CCO) said he was notified on 12/4/24 of the request for a larger shower chair for Resident #150. The CCO said he authorized the larger shower chair to be ordered on 12/4/24. The CCO said he spoke with Resident #150 who agreed to have bed baths until the larger shower chair came in, even though he/she said they did not like bed baths and preferred a shower. The CCO said there was no inventory completed to determine if another, larger shower chair was available for Resident #150 to use on 12/4/24. The CCO said last week he heard Resident #150 was upset because he/she still did not have a large enough shower chair, and at that time they completed a house inventory and located another, larger shower chair on another unit within the facility that Resident #150 could use. The CCO was unaware this newly located shower chair had not been used until 1/14/25 (the first day of the recertification survey). During a follow-up interview on 1/16/25 at 9:48 A.M., the CCO said he was just made aware the order for the shower chair was rejected by the distributer upon the initial order on 12/4/24. The CCO said there was a series of miscommunications, and the oversight should have been identified earlier but was not. The CCO said the facility did not consider this a grievance because they felt it was more a resident preference than a safety/care need. During an interview on 1/16/25 at 8:43 A.M., the Director of Nursing (DON) said if there were not a safe or comfortable shower chair she would expect that the facility would secure one to accommodate Resident #150's preference to shower.

Based on observations, interviews and record review, the facility failed to ensure that one Resident (#144) did not self-administer medications out of a total sample of 34 residents. Specifically, Resident #144 was observed with a card of pills left at bedside for self-administration without being assessed for self- administration. Findings include: Review of the facility policy titled 'Self-Administration of Drugs' dated August 2006, indicated the following but not limited to: -Residents in our facility who wish to self-administer their medications may do so, if it is determined that they are capable of doing so. -As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering. -If the staff determine that a resident a resident cannot safely self-administer medications, the nursing staff will administer the resident's medication. Review of facility policy titled 'Storage of Medications' dated April 2007, indicated the following but not limited to: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Resident #144 was admitted to the facility in December 2024 with diagnoses including ulcerative chronic proctitis, peripheral vascular disease. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident score a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. On 1/14/25 at 9:04 A.M., the surveyor observed a card of medications on the Resident s bedside table, with five pills in them, the label on the card was as follows sulfasalazine 500mg give 2 tabs by mouth twice daily. On 1/15/25 at 8:05 A.M., the surveyor and Charge Nurse #3 observed the medication card on the Resident's bedside table. The Resident stated a nurse had given him/her the card a couple of days ago. The card had three pills left. Review of the medical record failed to indicate that the Resident had been assessed for self- administration. During an interview on 1/15/25 at 8:35 A.M., Charge Nurse #3 said the Resident had not been assessed for self-administration and should not have any medications left by bedside. During an interview on 1/15/25 at 12:24 P.M., the Director of Nursing said the Residents should not have medication by bedside if they have not been assessed for self-administration.

Based on records reviewed, interviews and observations for one of six sampled residents (Resident #1), who experienced an acute change in his/her mental status, was exhibiting behaviors which included hallucinations with paranoia, refusing care and medications, was combative with staff and exiting seeking, the Facility failed to provide adequate supervision to maintain his/her safety and failed to ensure that window openings (including those on the third floor where Resident #1 resided which opened out from the bottom) were properly secured to prevent accidents. - On [DATE], at approximately 7:00 P.M., Resident #1 was agitated, combative, striking out at staff and was difficult to redirect. At approximately 7:15 P.M., Resident #1 tried to pull the Fire Alarm, he/she continued to be combative, and it took several staff members, as well as family members to get Resident #1 back to his/her room. Resident #1 was last seen by staff at approximately 8:00 P.M., sitting in a wheelchair in the hallway. - At approximately 9:00 P.M., staff were unable to locate Resident #1 on the unit, and began to conduct a search for him/her. When staff searched Resident #1's room, they observed bed sheets tied together, tied to a wooden dowel that went horizontally across the lower one of two wooden dowels that had been affixed along the casement of the floor level window in Resident #1's room, and the window, which cranked open from the bottom, was opened and the bed sheets were hanging out the window. Resident #1 was found down on the ground, in front of the facility and was pronounced dead by the Medical Examiner who was called to the scene by Police. Findings include: Resident #1 was admitted to the Facility in (MONTH) (YEAR). A Hospice Contract, dated [DATE], indicated Resident #1 was placed on Hospice Services for care and comfort related to end stage [MEDICAL CONDITIONS]. A Significant Change Minimum Data Set (MDS) Assessment, dated [DATE], indicated Resident #1 remained alert and oriented and had no inappropriate behaviors (at that time). A Nurse Progress Note, dated [DATE], indicated Resident #1 became hostile with staff, grabbed at name tags on staff members clothing, attempted to jab staff members with a pen, and a conversation which was translated by a staff member, from Spanish (Resident #1's native language) into English, indicated Resident #1 said staff were trying to poison and harm him/her, and Resident #1 said he/she was going to kill staff. The Note indicated Resident #1 was evaluated by Hospice Staff and new orders were obtained to administer [MEDICATION NAME] (antipsychotic) 25 milligrams (mgs) for hallucinations and [MEDICATION NAME] (sedative) 2 mg every four hours for anxiety. Review of Resident #1's Nurse Progress Notes, dated [DATE] through [DATE], indicated the following: - [DATE], Resident #1 displayed behaviors which included refusal of care and medications, was combative, was seen wandering in and out of other residents rooms, threw his/her supper tray down the hallway, his/her roommate had to be removed from the room for fear of harm, Resident #1's Health Care Proxy (HCP) expressed concerns to staff that Resident #1 may harm him/herself or others. - [DATE], Resident #1 was seen packing his/her clothes and was difficult to redirect with periods of hallucinations and paranoia. Resident #1 refused medications, was heard by his/her Family Member, who translated to staff speaking in his/her native language saying, God healed me and was non-trusting of staff. - [DATE], Resident #1 was observed by staff to be talking to him/herself, he/she refused his/her medications and was evaluated by the Hospice Nurse with a recommendation to be evaluated by Psychiatric services. - [DATE], Resident #1 had periods of increased agitation, was uncooperative with care, refused medications and refused to allow staff to obtain a urine specimen to rule out urinary tract infection. Resident #1 later became suspicious of staff and became combative, he/she was evaluated by the Physician, with recommendations for medication changes, and his/her Family Member came into the Facility in an attempt to help calm Resident #1 down. Review of Resident #1's Plan of Care related to behaviors, dated [DATE], indicated he/she was physically and verbally aggressive, and staff were to analyze times of day, places, circumstances, triggers and what deescalates his/her behaviors, and document. The Plan of Care indicate staff were to intervene before agitation escalates, and guide Resident #1 away from the source of stress. A Nurse Progress Note, dated [DATE], indicated Resident #1 was observed self propelling him/herself in the wheelchair up and down the hallway on the unit, he/she was going into other resident rooms, and when staff tried to redirect Resident #1, he/she became combative. A Psychiatric Consult Report, dated [DATE] indicated Resident #1 was psychotic with [MEDICAL CONDITION] and recommendation for medication changes included an increase in [MEDICATION NAME] and [MEDICATION NAME] dosages and to add a [MEDICATION NAME] (narcotic) patch for pain control. A Nurse Progress Discharge Note, dated [DATE], indicated that on [DATE] the following incidents occurred: - At approximately 7:15 P.M., Resident #1 was agitated, combative, striking out at staff and was difficult to redirect. The Note indicated Resident #1 tried to pull the Fire Alarm, continued to be combative and that it took several staff members, as well as visitors, to get Resident #1 back to his/her room. -At approximately 8:00 P.M., (the last time staff recall seeing Resident #1 on the unit) Resident #1 was seen sitting in his/her wheelchair in the hallway. - At approximately 9:00 P.M., Nurse #2 entered Resident #1's room and saw bed sheets tied together around the bottom wooden dowel that was in place (horizontally) along the window (that was at floor level) casement, and the sheets were hanging out the open the window. Search for Resident #1 was initiated, an emergency code was called, and staff found Resident #1 lying outside on the ground with Paramedics performing Cardiopulmonary Resuscitation (CPR). The Surveyor interviewed Nurse #2 at 12:15 P.M. on [DATE]. Nurse #2 said at approximately 7:00 P.M. on [DATE] she heard a call for help and saw staff and visitors trying to redirect Resident #1 away from the unit exit door that went to the stairwell. Nurse #2 said as she approached Resident #1, he/she struck out at her, hit her on her chest and then Resident #1 knocked over a nourishment cart. Nurse #2 said with the help of other staff members and visitors, Resident #1 was brought back to his/her room where he/she then placed him/herself on the floor. Nurse #2 said after a few minutes Resident #1 eventually settled down and allowed staff to help him/her into bed. Nurse #2 said following this outburst, she did not notify the Physician or place Resident #1 on close supervision. The Surveyor interviewed Maintenance Worker #3 at 11:30 [NAME]M. on [DATE]. Maintenance Worker #3 said sometime around 8:00 P.M., on [DATE], staff asked him to speak with Resident #1 and to translate for them, because he/she was mad' or words to that effect. Maintenance Worker #3 said Resident #1 told him that he/she wanted to sit in the hallway. Nurse #2 said, to the best of her knowledge, the last time she saw Resident #1, on [DATE], was at approximately 8:00 P.M., and said Resident #1 was sitting in his/her wheelchair outside of his/her room. Nurse #2 said she had not seen Resident #1 go back into his/her room. Nurse #2 said at approximately 9:00 P.M., when she went into Resident #1's room to administer his/her scheduled medications, Resident #1 was not in the room. Nurse #2 said she saw oxygen tubing trailing from Resident #1's bed to the window (bottom casement, floor level) which was open. Nurse #2 said she also observed that there were bed sheets tied together, tied to the bottom wooden dowel that was in place across the window and said the end of the sheets were hanging out the window. Nurse #2 said she went to the window, pulled on the sheets, and said she called out Resident #1's name but got no response. Nurse #2 said when she looked out the window she could not see anything because it was too dark. Nurse #2 said a search for Resident #1 was initiated and Resident #1 was found lying on the ground outside the main entrance to the Facility. The Surveyor interviewed the Receptionist at 12:30 P.M. on [DATE]. The Receptionist said she was outside on the sidewalk taking a break when she heard a noise, turned around, and saw an ambulance pull into the driveway and saw someone (later identified as Resident #1) falling from the window and heard a loud crash as he/she hit the ground. Maintenance Worker #3 said he was covering for the Receptionists break, was seated at the reception desk in the main lobby when a Paramedic ran in and asked for his help. Maintenance Worker #3 said he ran outside and saw Resident #1 lying on the ground. Maintenance Worker #3 said he and the Paramedic moved Resident #1, that he saw a broken window screen on the ground where Resident #3 had fallen and said when he looked up he saw sheets tied together hanging out from a third floor window. The Surveyor toured the Facility, starting at approximately 8:30 [NAME]M. on [DATE] with the Assistant Director of Nurses (ADON). The Surveyor made observations and took pictures in resident rooms containing lower casement windows. The Surveyor interviewed the Director of Maintenance regarding the windows at 9:50 [NAME]M. on [DATE]. The Director of Maintenance said the Facility had 22 rooms on each unit with lower casement (floor level) windows that extended from mid-wall (approximately hip level) down to the floor. The Director Maintenance said (and Surveyor observations indicated) these windows could be cranked open from the bottom and opened out approximately 12 inches. The Director of Maintenance said (and Surveyor observations indicated) each window had two wooden dowels placed horizontally across each them, the dowels were inserted into slotted holes that were drilled into the sides of wooden frame that were secured around the window casement. The Director of Maintenance said (and Surveyor observations indicated) that there was a gap of 42 inches horizontally across the windows, and he said the wooden dowels could be removed. The Director of Maintenance said (and Surveyor observations indicated) there there was a vertical 12 ½ inch gap between the lower casement of the window and the first wooden dowel, a 9 ½ inch gap between the two wooden dowels themselves, and a 6 inch gap between the top wooden dowel and the upper window casement. The Surveyor interviewed the Director of Nurses (DON) at 10:40 [NAME]M. on [DATE]. The DON provided the Surveyor with a picture, taken by the Facility, of Resident #1's room after his/her fall on [DATE], showing the knotted sheets still tied to the bottom dowel of the floor level window. The Surveyor reviewed the Facility video camera security footage, date stamped [DATE], with the Director of Maintenance at 4:30 P.M. on [DATE]. The Video Footage showed Resident #1 falling out the window at approximately 9:07 P.M. and his/her body being discovered by Paramedics (who just happened to arrive at the facility around that time while transporting another resident back to the Facility from an outside appointment).

Based on record review and interview, the Facility failed to meet the professional standards of quality for one sampled resident (#15) out of 27 sampled residents, related to skin assessment and pressure ulcer prevention. Findings include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care, and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a "nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice." 1. For Resident #15 the facility failed to prevent the development of 5 newly acquired pressure ulcers while being treated non-surgically for multiple right foot fractures and a right ankle fracture, with an ace wrap and hard walking boot. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident was hospitalized for [REDACTED]. The Resident was treated non-surgically with an ace wrap and hard walking boot for RLE stabilization. Review of the facility's admitting nursing note of 5/8/13 at 1:50 P.M. indicated that the Resident had some bruising or discoloration with swelling of the RLE at flexor surface (top portion of foot), which is tender to touch, but skin was intact. No other areas of discoloration or concern were documented. Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date of 5/15/13, indicated that Resident #15 was at high risk for developing a pressure ulcer, but did not have a pressure ulcer upon admission. Review of the physician's admission orders [REDACTED] *RLE boot at all times-remove for personal hygiene, ace wrap to RLE at all times except personal care. *Check RLE for circulation, sensation and motion (CSM) every shift (QS). *Weekly skin assessments (see below for description) every 3-11 P.M. on Fridays. Review of the facility's Skin Care Management Policy indicates that the weekly skin assessment should include a head to toe skin assessment by a licensed staff member. Review of the Resident's Care Plan for "Resident at risk for impaired skin integrity" dated 5/9/13 indicated the following interventions: *assess the Resident for presence of risk factors, treat, reduce and eliminate risk factors to extremities. *assess the skin weekly and pay attention to the bony prominences *avoid shearing of the skin *apply moisturizing lotion to heels every shift *report signs of breakdown (sore, tender, red or broken skin) Review of the 5/17/13 Weekly Body Check (3 days prior to the identification of the 5 pressure ulcers) indicated: normal feet, normal heels, redness/bruising, RLE ace wrap and boot in place. The documentation does not indicate that the ace wrap was removed for closer inspection of the Residnet's skin integrity. Review of the Nursing Treatment Sheets for 5/2013 indicated the following interventions: * Weight bearing as tolerated in walking boot. *Boot to RLE at all times except personal hygiene. *Ace wrap to RLE on at all times (does not indicate except for personal care per physician's orders [REDACTED]. Review of the 5/20/13 nursing progress note (12 days following admission to the facility) indicated that the Resident was complaining of pain in the right lower extremity. At at 11:00 A.M., the nursing documentation indicated that the walking boot and ace wrap were taken down. The following 5 pressure ulcers were identified for the first time since admission (5/8/13) on the Resident's RLE: (A centimeter is a unit of measurement which equals approximately 1/2 inch in length.) #1.) Right heel- a 5 centimeter (cm) x 6 cm pink blister with 4.5 cm x 3 cm maroon, boggy center. #2.) Right Achilles- blister at 5 cm x 2.0 cm, pink in color with a 3 cm x 1 cm. maroon and boggy center. #3.) Top of the right foot- surface blister measuring 6.0 cm x 7.0 cm pink with center 3 cm x 5 cm boggy and maroon in color. #4.) Right shin area - blister 5.0 cm. x 1.0 cm, pink in color. #5.) Right second toe- 0.5 cm x 0.5 cm, maroon and discolored. The 5/20/13 Nursing Progress note indicated that the Nurse Practitioner (NP) was notified regarding the Resident's new pressure ulcers. On 5/22/13 at 12:40 P.M., the NP discontinued the walking boot and ace wrap to right foot, initiated skin prep to all 'blisters" and discolored areas. Review of the nursing progress notes from 5/8/13 (date of admission) through 5/22/13 (5 new pressure ulcers were identified on 5/20/13), repeatedly indicate that the Resident's ace wrap and boot are in place at all times with positive CSM and positive pedal pulse to RLE, but no written description of staff removing the ace wrap and inspecting the skin integrity for discoloration, temperature or tissue injury during personal care, in accordance with physician's orders [REDACTED]. Review of the Weekly Body Checks (the Weekly Body Check Form captures results of the weekly skin inspection) indicated the following: Week 1 dated 5/10/13: RLE with ace wrap and boot in place, right foot with bruising, red and swollen. Feet/heels/skin-all dry checked. Week 2 dated 5/17/13: RLE with ace wrap and boot in place, foot bruising red and swollen. Feet-normal/heels-normal/skin-redness checked. Week 3 dated 5/24/13: Right sided weakness, Feet-redness/discoloration checked, heel-blister, skin-other checked with no further description of blister or other open areas. Week 4 dated 5/31/13: Right sided weakness, feet-open areas/discoloration checked. Review of the Nurse Practitioner (NP) note of 5/23/13 indicated that nursing identified breakdown on the right foot from the ace wrap/walking boot and that the Resident was progressing slowly in Physical Therapy due to foot ulcers.An antibiotic was started for increased swelling. The Resident did receive a new boot following an orthopedic visit on 5/28/13 (one week after the identification of the pressure ulcers). Review of the NP note dated 6/13/13 indicated that ulcerations on RLE were due to first walking boot and describes skin as: pressure ulcer on top of right foot, heel and over Achilles covered with thin black eschar, anterior ulcer pink, dry, almost healed. On 6/26/13, Surveyor #1 observed the dressing change to the RLE. Surveyor #1 observed 4 open areas with blackened, necrotic tissue and 1 area over the Achilles with an exposed tendon. Three of the measurements were slightly improved and two had worsened in size since the first identification of 5/20/13.The 6/26/13 UM's wound review nursing note indicated the measurements and descriptions as: #1.) Right heel- 2.9 cm. x 2.8 cm. lifting and unstageable, starting to leak sreosanguinous drainage. #2.) Right Achilles- 3.5 cm. x 1.2 cm. lifting, unstageable, wound base discolored with eschar. The exposed tendon was not documented. #3.) Top of the right foot- 3.0 cm. x 4.4 cm. lifting/unstageable with discolored necrotic area. #4.) Right shin area - 1.4 cm. x 0.5cm, lifting, no drainage, darkened eschar. #5.) Right second toe- 0.9 cm x 0.9 cm, unstageable, no active drainage, darkened eschar. On 6/28/13 review of the Vascular Consultant's Report of 6/28/13 indicated that the Resident had non-healing pressure ulcers to the right foot with poor circulation. Recommendations included not to debride (to remove dead tissue) the wounds, change dressing daily with xeroform (a non-adherent dressing with antibacterial qualities) and [MEDICATION NAME] (guaze wrap for protection), watch for signs of infection and do not put pressure on wounds. On 6/28/13 at 5:00 P.M., Surveyor #1 reviewed the findings with the Administrator and DON.

Based on record review, observation, staff and Resident interview, the facility failed to ensure the necessary care and services were provided to prevent the development of pressure ulcers (a lesion caused by unrelieved pressure that results in damage to the underlying tissue) for one Resident #15, in a total sample of 27 residents. Findings include: For Resident #15, the facility failed to prevent the development of 4 new pressure ulcers and promote the healing of one pre-existing area of discoloration from developing into a pressure ulcer, through the systematic and regular monitoring of Resident #15's right lower extremity (RLE) skin integrity, according to the physician's orders [REDACTED]. The findings include: Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident was hospitalized for [REDACTED]. Review of the Admission Minimum Data Set (MDS) on 6/25/13, with an assessment reference date of 5/15/13, indicated that the Resident had a (Brief Interview for Mental Status) BIMS score of 12 out of 15 (a score of 8-12 indicates moderately impaired for cognition). The Resident was also assessed to be at high risk for developing a pressure ulcer, but did not have a pressure ulcer upon admission. The Resident is unable to bear weight on his/her lower extremity and unable to ambulate. On 6/24/13, at approximately 9:30 A.M., during the facility tour and report, the Surveyor observed Resident # 15 complaining of pain in the right lower extremity. Upon Surveyor inquiry, the Unit Manager (UM) told Surveyor #2 that Resident #15 had two blisters on his/her feet that were healing. Review of the facility's admitting nursing note of 5/8/13 at 1:50 P.M. indicated that the Resident had some bruising or discoloration with swelling of the RLE at flexor surface (top portion of foot), which is tender to touch, but skin was intact. No other areas of discoloration were indicated. Review of the physician's admission orders [REDACTED] *RLE boot at all times-remove for personal hygiene, ace wrap to RLE at all times except personal care. *Check RLE for circulation, sensation and motion (CSM) every shift (QS). *Weekly skin assessments every 3-11 P.M. on Fridays. Review of the Resident's Care Plan for "Resident at risk for impaired skin integrity" dated 5/9/13 indicated the following interventions: *assess the Resident for presence of risk factors, treat, reduce and eliminate risk factors to extremities. *assess the skin weekly and pay attention to the bony prominences *avoid shearing of the skin *apply moisturizing lotion to heels every shift *report signs of breakdown (sore, tender, red or broken skin) Review of the 5/17/13 Weekly Body Check (3 days prior to the identification of the 5 pressure ulcers) indicated: normal feet, normal heels, redness/bruising, RLE ace wrap and boot in place. Review of the Nursing Treatment Sheets for 5/2013 indicated the following interventions: * Weight bearing as tolerated in walking boot. *Boot to RLE at all times except personal hygiene. *Ace wrap to RLE on at all times (does not indicate except for personal care per physician's orders [REDACTED]. Review of the 5/20/13 nursing progress note (12 days following admission to the facility) indicated that the Resident was complaining of pain in the right lower extremity and at 11:00 A.M., the walking boot and ace wrap was taken down. The following 5 pressure ulcers were identified for the first time on the Resident's RLE: (A centimeter is a unit of measurement which equals approximately 1/2 inch in length.) #1.) Right heel- a 5 centimeter (cm) x 6 cm pink blister with 4.5 cm x 3 cm maroon, boggy center. #2.) Right Achilles- blister at 5 cm x 2.0 cm, pink in color with a 3 cm x 1 cm. maroon and boggy center. #3.) Top of the right foot- surface blister measuring 6.0 cm x 7.0 cm pink with center 3 cm x 5 cm boggy and maroon in color. #4.) Right shin area - blister 5.0 cm. x 1.0 cm, pink in color. #5.) Right second toe- 0.5 cm x 0.5 cm, maroon and discolored. A stage II pressure ulcer is characterized by partial loss of the dermis (skin). They are shallow with a red or pink ulcer bed. A stage II pressure ulcer can also present as an intact or open/ruptured serum-filled blister. Review of the nursing progress notes from 5/8/13 (date of admission) through 5/22/13 (5 new pressure ulcers were identified on 5/20/13), repeatedly indicate that the Resident's ace wrap and boot are in place at all times with positive CSM and positive pedal pulse to RLE, but no written description of staff removing the ace wrap and inspecting the skin integrity for discoloration, temperature or tissue injury during personal care, in accordance with physician's orders [REDACTED]. The 5/20/13 Nursing Progress note indicated that the Nurse Practitioner (NP) was notified regarding the Resident's new pressure ulcers. On 5/22/13 at 12:40 P.M., the NP discontinued the walking boot and ace wrap to right foot, initiated skin prep to all 'blisters" and discolored areas. Review of the Weekly Body Checks indicate the following: Week 1 dated 5/10/13: RLE with ace wrap and boot in place, right foot with bruising, red and swollen. Feet/heels/skin-all dry checked. Week 2 dated 5/17/13: RLE with ace wrap and boot in place, foot bruising red and swollen. Feet-normal/heels-normal/skin-redness checked. Week 3 dated 5/24/13: Right sided weakness, Feet-redness/discoloration checked, heel-blister, skin-other checked with no further description of blister or other open areas. Week 4 dated 5/31/13: Right sided weakness, feet-open areas/discoloration checked. Review of the Nurse Practitioner (NP) note of 5/23/13 indicated that nursing noted breakdown on right foot from ace wrap/walking boot. The Resident was progressing slowly in Physical Therapy due to foot ulcers and an antibiotic was started for increased swelling. The Resident did receive a new boot following an orthopedic visit on 5/28/13 (one week after the identification of 4 new and one worsening pressure ulcer). Review of the NP note dated 6/13/13 indicated that ulcerations on RLE were due to first walking boot and describes skin as: pressure ulcer on top of right foot, heel and over Achilles covered with thin black eschar, anterior ulcer pink, dry, almost healed. On 6/25/13 at 11:15 A.M. Surveyor #1 interviewed the Resident's physician. The physician said that she had just returned from vacation. The physician also said that he/she did not think that the Resident's pressure ulcers were related to the walking boot and that the Resident had many co-morbidities that would put the Resident at risk for skin issues. Physical and Occupational therapies, which had been discontinued on 6/13/13, were re-ordered on [DATE]. Review of the Physician's Visit note on 6/25/13 at 3:30 P.M. indicated that the Resident's ulcers on right foot were healing "per nursing" and that the Resident was unable to tolerate any boot with poor ability to straighten leg. The visit note also indicated 5 pressure ulcers with black eschar (dead tissue) with some coming up at edges and no drainage noted, good capillary refill and confirmed vascular appointment this week. On 6/26/13 during Resident interview, Surveyor #1 observed the Resident in bed with a black, heavy and non-flexible walking boot on the right foot with the end of boot resting directly on the newly acquired second toe pressure ulcer. The Surveyor asked if the boot was comfortable. The Resident said that the boot was hot and heavy and turned her leg outward which increased his/her leg spasms. Following Surveyor observation of the black, non-flexible walking boot application to the resident's RLE on 6/26/13, review of the 5/22/13 Nurse Practitioner's revised orders (following the identification of the pressure ulcers of 5/20/13), indicates that the Resident should wear a soft boot to right foot as tolerated, while in bed every shift. The soft boot is light blue in color and has a free floating heel to alleviate pressure on heel. Following Surveyor inquiry, the soft boot with free-floating heal was observed on the Resident's RLE and the black, non-flexible walking boot was no longer in the Resident's closet. On 6/28/13 Surveyor #1 interviewed 3 of the Resident's friends who visit regularly. (Resident # 15 does not have family members) They said that the Resident had been complaining about the heaviness and tightness of the boot for weeks. Surveyor #1 asked how the staff responded to the Resident's complaints. They said that the staff did not really listen to the Resident and were dismissive of complaints of RLE discomfort/pressure relating to the walking boot. Further interview with the Resident's friends indicated that they had accompanied the Resident to the physician's appointment that day. They said that they were informed by the physician that the Achilles pressure ulcer may never heal and might require plastic surgery, due to its severity and exposure of the tendon. On 6/26/13 Surveyor #1 interviewed the Director of Nursing (DON), the Unit Manager (UM) #1 and the Assistant Director of Nursing (ADON) at approximately 12:00 P.M.. The DON said that the Resident had been admitted with a discoloration over the metatarsal area of his/her right foot and was at high risk of developing a pressure ulcer due to many co-morbidities, including [MEDICAL CONDITION]. During the interview, the UM said that the Resident had dry blisters which were healing and did not elaborate on the current status of the Resident's skin with the 5 new pressure ulcers. Shortly after the interview on 6/26/13, Surveyor #1 observed the dressing change to the RLE for Resident #15. Surveyor #1 observed 4 open areas with blackened, necrotic tissue and 1 area over the Achilles with an exposed tendon. Three of the measurements were slightly improved and two had worsened in size since the first identification of 5/20/13.The 6/26/13 UM's wound review nursing note indicated the measurements and descriptions as: #1.) Right heel- 2.9 cm. x 2.8 cm. lifting and unstageable, starting to leak sreosanguinous drainage. #2.) Right Achilles- 3.5 cm. x 1.2 cm. lifting, unstageable, wound base discolored with eschar. The exposed tendon was not documented. #3.) Top of the right foot- 3.0 cm. x 4.4 cm. lifting/unstageable with discolored necrotic area. #4.) Right shin area - 1.4 cm. x 0.5cm, lifting, no drainage, darkened eschar. #5.) Right second toe- 0.9 cm x 0.9 cm, unstageable, no active drainage, darkened eschar. On 6/28/13 review of the Vascular Consultant's Report of 6/28/13 indicated that the Resident had non-healing pressure ulcers to the right foot with poor circulation. Recommendations included not to debride (to remove dead tissue) the wounds, change dressing daily with xeroform (a non-adherent dressing with antibacterial qualities) and [MEDICATION NAME] (guaze wrap for protection), watch for signs of infection and do not put pressure on wounds. On 6/28/13 at 5:00 P.M., Surveyor #1 reviewed the findings with the Administrator and DON.

Based on record review and interviews, the Facility failed to ensure for one of one sampled resident (Resident #1), who had a history of [REDACTED]. Findings included: Resident #1 was admitted to the Facility in May 211, and [DIAGNOSES REDACTED]. A Physician Admission Note, dated 5/4/11, indicated Resident #1 presented as obese, well appearing, and alert and oriented, breathing comfortably, and had a trace of bilateral lower leg [MEDICAL CONDITION]. The progress note indicated that Resident #1's weight on admission was 235.8 pounds (lbs). A Physician order, dated 5/26/11, indicated staff were to weigh Resident #1 on Monday, Wednesday and Friday at 6 AM. The Nurse Practitioner (NP) was interviewed at 10:45 AM on 8/31/11 and at 9:45 AM on 9/23/11. The NP said it was protocol that if Resident #1 gained more than 2 to 3 lbs in a 2 day period, staff were to notify the NP or the Physician so that adjustments to Resident #1's prescribed diuretic medicates could be made. Nurse #10 was interviewed at 9 AM on 8/26/11. Nurse #10 said Nurse # 10 consistently cared for Resident #1 on the 11 PM to 7 AM shift, and said that Resident #1 was to be weighed at 6 AM on Monday, Wednesday and Friday. Nurse #10 said Nurse #10 was aware that it was practice for any resident with a cardiac condition who was having weights recorded, that an increase of 2 to 3 lbs between weights, was to be reported to the NP/ Physician, as this was a sign of fluid overload. Review of recorded weights documented on Resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Nurse #10 said Nurse #10 did not report Resident #1's weight gain to the NP and/or the Physician, and did not pass this information on to staff on the oncoming 7 AM to 3 PM shift. Nurse # 10 said this was an oversight on Nurse #10's part as Nurse #10 was very tired secondary to working 2 full time jobs. Nurse #9 was interviewed at 12 Noon on 8/31/11 and at 9 AM on 9/1/11 and at 9 AM on 9/26/11. Nurse #9 said Nurse #9 consistently cared for Resident #1 on the 7 AM to 3 PM shift and had cared for Resident #1 on 7/13/11. Nurse #9 said Nurse #9 had no recollection of a problem with Resident #1's weight at that time and said that while Nurse #9 spoke with the NP almost every day, Nurse #9 had no recollection of discussing Resident #1's weight with the NP at that time. The NP said staff had not informed the NP of Resident #1's 8.5 weight gain on 7/13/11. Review of Resident #1's MAR indicated [REDACTED]#1 weighed 265.8 lbs. Review of Nurse Progress Notes, dated 7/13/11 through 7/19/11, indicated there was no documentation the NP was informed of Resident #1's weight gain or that any changes to Resident #1's medications were made. The NP said the NP got a call from nursing staff on the morning of 7/20/11 informing the NP that Resident #1 had an unwitnessed fall during the night. The NP and the Physician saw Resident #1 later that morning, sometime between 9 am and 10 AM. A physician progress notes [REDACTED]. The physician progress notes [REDACTED].#1 had 4 plus [MEDICAL CONDITION] from toes to thighs, and had ascites (abnormal accumulation of fluid in the abdomen). The Physician's Progress Note indicated Resident #1 needed hospital level of care with Intravenous (IV) diuresis. The Physician's Progress Note indicated to transfer Resident #1 to the Hospital immediately. The Physician was interviewed at 10 AM on 8/31/11. The Physician said the Physician was not informed of Resident #1's significant weight gain until 7/20/11. The Physician said when the Physician saw Resident #1 on the morning of 7/20/11, Resident #1 was in acute [MEDICAL CONDITION]. The Physician said if the Physician had been made aware of Resident #1's weight gain prior to 7/20/11, the Physician would certainly have increased the dosage of Resident #1's prescribed diuretics in order to help manage Resident #1's chronic [MEDICAL CONDITION]. Resident #1 was not transferred to the Hospital immediately, (between 9AM and 10 AM) per physician's orders [REDACTED].#1 ceased breathing at 2:45 PM, the Physician and NP were notified, and an RN Prouncement of Death was performed. Refer to F 309

Based on record review and interviews, the Facility failed to ensure that one of five sampled residents (Resident #1) was appropriately assessed for a change in medical condition. During a 10 day period, between [DATE] and [DATE], Resident #1, who had a history of [REDACTED]. On [DATE] the Physician was asked to see Resident #1. On assessment the Physician found Resident #1 to be acutely ill, in [MEDICAL CONDITION] and ordered immediate transfer to the Hospital. However, before staff arranged transfer, Resident #1 died . A Death Certificate, signed and dated by the Physician at 2:45 PM on [DATE], identified Resident #1's immediate cause of death as [MEDICAL CONDITION] with a secondary contributing [DIAGNOSES REDACTED]. Findings included: Resident #1 was admitted to the Facility in [DATE], and [DIAGNOSES REDACTED]. Review of Resident #1's Advance Directives indicated Resident #1 was a DNR (in the event of cardiac or respiratory arrest, do not resuscitate). A Physician Admission Note, dated [DATE], indicated Resident #1 presented as obese, well appearing, and alert and oriented, breathing comfortably, and had a trace of bilateral lower leg [MEDICAL CONDITION]. The progress note indicated that Resident #1's weight on admission was 235.8 pounds (lbs). The Nurse Practitioner (NP) was interviewed at 10:45 AM on [DATE] and at 9:45 AM on [DATE]. The NP said Resident #1 was originally admitted to the Facility in [DATE], for short term rehabilitation (rehab) following a recent hospitalization for an acute episode of [MEDICAL CONDITION]. The NP said Resident #1 had a complicated cardiac history, and was treated with diuretic medications for fluid overload. The NP said Resident #1's laboratory blood tests and weight were monitored closely, but Resident #1 did not make great gains with treatments. The NP said after approximately 6 to 8 weeks of rehab and changes to medications, it was determined that Resident #1 required long term care and Resident #1 was transferred off the rehab unit to the long term care fourth floor unit. Family Member #2 was interviewed at 2 PM on [DATE]. Family Member #2 said Resident #1 had been ill for quite some time and had gradually gained weight from fluid buildup. Family Member #2 said that while on the Rehabilitation Unit, staff weighed Resident #1 frequently and adjustments were made to Resident #1's fluid medications. Family Member #2 said when Resident #1 was transferred to the long term care unit, staff did not weigh Resident #1 frequently. Family Member #2 said Resident #1 started to gain weight, had fluid build up in both legs, started to have difficulty breathing and when the skin on Resident #1's legs started to split and weep fluid, Resident #1 started falling and could no longer walk. A Physician order, dated [DATE], indicated staff were to weigh Resident #1 on Monday, Wednesday and Friday at 6 AM. The NP said it was protocol that if Resident #1 gained more than 2 to 3 lbs in a 2 day period, staff were to notify the NP or the Physician so that adjustments to Resident #1's prescribed diuretic medications could be made. Nurse #10 was interviewed at 9 AM on [DATE]. Nurse #10 said Nurse # 10 consistently cared for Resident #1 on the 11 PM to 7 AM shift, and said that Resident #1 was to be weighed at 6 AM on Monday, Wednesday and Friday. Nurse #10 said Nurse #10 was aware that it was practice for any resident with a cardiac condition who was having weights recorded, that an increase of 2 to 3 lbs between weights, was to be reported to the NP/ Physician, as this was a sign of fluid overload. The NP said, and review of the NP's progress notes, dated [DATE], [DATE], [DATE] and [DATE], indicated Resident #1 was gradually gaining weight and both legs were [MEDICAL CONDITION]. The NP said and progress notes, along with documented Physician orders, indicated adjustments to Resident #1's prescribed [MEDICATION NAME] (an oral diuretic) were made and on [DATE], Resident #1 weighed 249 lbs and [MEDICATION NAME] (an oral diuretic medication) was added to Resident #1's medication regime to help [MEDICATION NAME] (excessive drainage of urine) Resident #1. An NP Progress Note, dated [DATE], indicated Resident #1 was alert and talkative and was not in respiratory distress. The Progress Note indicated Resident #1 had 3 plus [MEDICAL CONDITION] (commonly referred to as swelling; when rating the severity, refer to as plus 1, plus 2, plus 3 or plus 4; the greater the number, the greater the swelling) in both legs and the right leg had blisters and several scabbed areas on toes. The Progress Note indicated Resident #1's prescribed diuretics, [MEDICATION NAME] and [MEDICATION NAME], were increased. The NP said when the NP saw Resident #1 on [DATE], Resident #1 was alert, had increased [MEDICAL CONDITION] in both legs and venous ulcers on both legs. The NP said the NP made adjustments to Resident #1's diuretic medications and ordered a treatment for [REDACTED].#1 did not have difficulty with urination at that point in time. Review of recorded weights documented on Resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Nurse #10 said Nurse #10 did not report Resident #1's weight gain to the NP and/or the Physician, and did not pass this information on to staff on the oncoming 7 AM to 3 PM shift. Nurse # 10 said this was an oversight on Nurse #10's part. Nurse #9 was interviewed at 12 Noon on [DATE] and at 9 AM on [DATE] and at 9 AM on [DATE]. Nurse #9 said Nurse #9 consistently cared for Resident #1 on the 7 AM to 3 PM shift and had cared for Resident #1 on [DATE]. Nurse #9 said Nurse #9 had given medications to Resident #1 on the morning of [DATE] but had no recollection of checking the documented weight record on Resident #1's MAR. Nurse #9 said Nurse #9 had no recollection of a problem with Resident #1's weight at that time and said that while Nurse #9 spoke with the NP almost every day, Nurse #9 had no recollection of discussing Resident #1's weight with the NP at that time. Review of a Nurse Progress Note, dated [DATE], indicated there was no documentation which indicated the NP and/or the Physician were notified of Resident #1's 8.5 lb weight increase, or that any changes to Resident #1's medical plan of care were made at that time. The Physician was interviewed at 10 AM on [DATE]. The Physician said the Physician left the day to day routine of patient care to the NP and said it was not the Facility's practice that staff would contact the Physician, but rather they would contact the NP who would then notify the Physician if there were any problems which needed his attention. The Physician said the Physician was not aware of Resident #1's significant weight gain on [DATE]. The NP said staff had not informed the NP of Resident #1's 8.5 lb weight gain on [DATE]. The NP said Resident #1 was already receiving large dosages of diuretics and said treatment options were limited. The NP said if the NP had been made aware of the 8.5 lb weight gain on [DATE], the NP would have reviewed Resident #1's medical plan of care and may have made changes to the plan of care. The Physician said if the Physician had been made aware of Resident #1's weight gain on [DATE], the Physician would certainly have increased the dosage of Resident #1's prescribed diuretics in order to help manage Resident #1's chronic [MEDICAL CONDITION]. Review of Resident #1's MAR indicated [REDACTED]#1 weighed 265.8 lbs. Review of Nurse Progress Notes, dated [DATE] through [DATE], indicated there was no documentation the NP was informed of Resident #1's weight gain or that any changes to Resident #1's medications were made. A Nurse Progress Note, dated [DATE], indicated Resident #1 was discovered on the floor and reported to staff that Resident #1 had slipped off the chair. The Progress Note indicated Resident #1 had no injuries. A late entry Nurse Progress Note, dated [DATE], indicated that on [DATE], the Restorative Aide reported to nursing staff that Resident #1 had been refusing to walk in the hallway, the NP was notified and laboratory blood tests were ordered. The Restorative Aide was interviewed at 2 PM on [DATE]. The Restorative Aide said Resident #1 was having shortness of breath, complained that Resident #1 felt tired and complained that Resident #1's legs hurt. The Restorative Aide said the Restorative Aide reported this to nursing staff. Family Member #2 said Resident #1 was experiencing more and more distress, was having difficulty breathing and had trouble passing urine. Family Member #2 said Family Member #2 told Nurse #9 on numerous occasions that Resident #1 was getting sick and was gaining weight. Family Member #2 said Family Member #2 brought in a medication from home which Resident #1 had previously used for a prostate problem, and showed this medication to Nurse #9. Family Member #2 said Nurse #9 ignored Family Member #2's concerns, did not do anything about Resident #1's condition, and told Family Member #2 that Nurse #9 could only do what the Doctor prescribed. Nurse #9 said Nurse #9 had no recollection of a discussion with Family Member #2 about Resident #1's medications or increase in weight. The Unit Manager was interviewed at 2:10 PM on [DATE] and at 8 AM on [DATE]. The Unit Manager said on the morning of [DATE], Resident #1 was weighed and was found to have an increase in weight. The Unit Manager said Resident #1 had no energy, legs were swollen and weepy and Resident #1 could not walk. The Unit Manager said the NP was informed and laboratory blood tests were ordered and drawn. A Diagnostic Laboratory (Lab) Report, dated [DATE], indicated Resident #1's BUN (blood, urea and nitrogen level) was 57 (therapeutic level ,[DATE]) and blood CO2 (carbon [MEDICATION NAME]) was 36 (therapeutic level ,[DATE]). The Report indicated the NP was aware and no new orders were documented. The Unit Manager said the NP was informed of Resident #1's blood results and said the NP would be in the following day, [DATE], to see Resident #1. The NP said the NP had no recollection of a call from nursing staff on [DATE] reporting Resident #1's laboratory blood test results. Family Member #2 said after getting nowhere with Nurse #9, Family Member #2 then talked to the Unit Manager about Family Member #2's concerns and brought up the subject of the prostate medication. The Unit Manager said that on the morning of [DATE], the Unit Manager did have a discussion with Family Member #2 concerning Resident #1's lack of energy and difficulty passing urine and said Family Member #2 did address a medication which Resident #1 had taken at home to help pass urine. The Unit Manager said the Unit Manager told Family Member #2 that the Unit Manager would pass this information on to the NP. The Unit Manager said the Unit Manager called the NP on the telephone and relayed Family Member #2's concerns, and the NP said the NP would be in later that day to assess Resident #1. The NP said the NP had no recollection of a call from the Unit Manager on [DATE]. The NP said the NP did not see Resident #1 on [DATE]. A Nurse's Progress Note, dated [DATE], indicated Resident #1 was alert with periods of forgetfulness, color was pale, and Resident #1 attended an outpatient cardiac appointment. The Progress Note indicated the NP was notified of Resident #1's lab results and the NP and Physician would be in to see Resident #1 the following day. Family Member #2 said that on [DATE], Resident #1 attended a previously arranged appointment with the Vascular Surgeon Nurse #9 said Nurse #9 called the NP on [DATE] and reported Resident #1's abnormal laboratory blood test results to the NP. Nurse #9 said the NP did not give any new orders at that time. Nurse #9 said the NP told Nurse #9 that the NP would round with the Physician the following day, on [DATE], and would see Resident #1 at that time. The NP said the NP was aware that Resident #1 would be attending an outpatient Vascular appointment on [DATE]. The NP said the NP had no recollection of a call from Nurse #9 on the afternoon of [DATE]. The NP said the first call the NP got from staff regarding Resident #1 was on the morning of [DATE] informing the NP that Resident #1 had an unwitnessed fall during the night. A Nurse's Progress Note, dated [DATE], indicated Resident #1 was found on the floor in a sitting position and indicated Resident #1 told staff Resident #1 felt more comfortable on the floor. Nurse #10 said at approximately 4 AM on [DATE], Nurse #10 heard Resident #1's bed alarm sound and when Nurse #10 entered Resident #1's room, Resident #1 was sitting on the floor with legs outstretched. Nurse #10 said Resident #1 denied that Resident #1 had hit Resident #1's head, and Nurse #10 said Resident #1 was helped back to bed and monitored closely throughout the remainder of the night. Review of a Neurological Assessment Record, dated [DATE], indicated that starting at 4 AM, Resident #1's vital signs and neurological signs were monitored every 15 minutes for the first hour, then every 30 minutes for the second hour, and then every 2 hours The Neurological Assessment Record indicated that between 4 AM and 5:45 AM, Resident #1's blood pressure ranged between ,[DATE] to ,[DATE], and heart rate between 84 and 90 beats per minute. The Unit Manager said on the morning of [DATE], Resident #1's weight had increased, staff reported Resident #1 had fallen during the night and the Unit Manager was concerned about Resident #1's condition. The Unit Manager said the Unit Manager called the NP who informed the Unit Manager that the NP and Physician would see Resident #1 during rounds later in the AM. The Unit Manager said as the Unit Manager was leaving the unit at approximately 9 AM on [DATE], to attend an educational program, the Unit Manager ran into the Physician and asked the Physician to look in on Resident #1. The Certified Nurse Aide (CNA) #7 was interviewed at 12 Noon on [DATE]. CNA #7 said CNA #7 consistently cared for Resident #1 on the 7 AM to 3 PM shift. CNA #7 said on the morning of [DATE], Resident #1 was having a hard time breathing. CNA #7 said CNA #7 reported this to Nurse #9. CNA #7 said that during the previous few days, Resident #1 had been getting increasingly weaker, had trouble breathing, couldn't walk, and was very tired. CNA #7 said CNA #7 repeatedly reported this to Nurse #9. Nurse #9 said Nurse #9 did not recall CNA #7 report any problems related to Resident #1. Nurse #9 said on the morning of [DATE] Resident #1 was alert and comfortable, had no difficulty breathing and sat out of bed as was Resident #1's usual routine. Nurse #9 said Nurse #9 was aware that the NP was to look in on Resident #1 sometime during the morning as a follow up visit secondary to Resident #1's earlier fall. The NP said the NP looked in on Resident #1 shortly after 8 AM on [DATE]. The NP said the NP was concerned about Resident #1's increased [MEDICAL CONDITION]. The NP said the NP left and found the Physician and asked the Physician to come back later during rounds to assess Resident #1. The Neurological Assessment Record indicated that between 7:45 AM and 1:45 PM, Resident #1's blood pressure ranged between ,[DATE] to ,[DATE], and heart rate between 71 to 78 beats per minute, and indicated Resident #1 was alert and comfortable. A physician progress notes [REDACTED]. The Physician's Progress Note indicated Resident #1 had increased confusion and somnolence over baseline, and appeared acutely ill. The Physician's Progress Note indicated Resident #1's blood pressure was ,[DATE] and heart rate was 60 and irregular, lungs sounds were dull with rales (crackling noises) in lower base, had 4 plus [MEDICAL CONDITION] from toes to thighs, and had ascites (abnormal accumulation of fluid in the abdomen) and abdominal wall [MEDICAL CONDITION]. The Physician's Progress Note indicated Resident #1 needed hospital level of care with Intravenous (IV) diuresis, and indicated to transfer Resident #1 to the Hospital immediately. The Physician said the Physician saw Resident #1 sometime between 9 AM and 10 AM on [DATE]. The Physican said Resident #1 was clearly having difficulty breathing with fluid overload and was acutely ill. The Physician said Resident #1 was a DNR ( in the event of cardiac or respiratory arrest, no attempts of artificial resuscitation was to be initiated) and the Physician said the Physician went downstairs to the Physician's office in the company of the NP, and with Resident #1's medical record, to discuss a plan of care and placed a call to Family Member #2 to discuss. Family Member #2 said the Physician called around 9:30 AM and Family Member #2 agreed with the plan to send Resident #1 to the Hospital for further treatment. Family Member #2 said that sometime after 2 PM, Family Member #2 received a call from the Facility informing Family Member #2 that Resident #1 had not been sent to the Hospital and that Resident #1 was dead. The NP said after the Physician spoke with Family Member #2, the Physician documented the Physician's Progress Note in Resident #1's medical record and the NP wrote an order to transfer Resident #1 to the Hospital. The NP said the NP flagged the order in Resident #1's medical record and brought the medical record back to the Unit. The NP said the NP could not pinpoint an exact time the NP brought the medical record back to the Unit but to the best of the NP's recollection it was sometime around 10 AM. The NP said Nurse #9 was at the nurses' station and the NP told Nurse #9 that Resident #1 was to be sent out to the Hospital. A documented order signed by the NP, and dated and timed by Nurse #9 at 2 PM on [DATE], indicated to send Resident #1 to the Hospital for evaluation of [MEDICAL CONDITION], and to send laboratory blood test results to the Hospital with Resident #1. The NP said the NP did not order 911 transfer as the NP assumed Nurse #9 would follow through with the transfer order. Nurse #9 said Resident #1 took morning medications without any problems and said Nurse #9 changed the bandages on Resident #1's legs that AM. Nurse #9 said Resident #1's legs were a little swollen, Resident #1's lungs were clear, there was no shortness of breath and Resident #1 was not in any distress. Nurse #9 said Nurse #9 did not see the NP or the Physician on the floor that morning and said when Nurse #9 left to go for lunch at 1:30 PM, Nurse #9 did not know if the NP or Physician had seen Resident #1 at any time throughout the AM. Nurse #9 said that although the vital signs documented on the Neurological Assessment Record at 1:45 PM were written by Nurse #9, Nurse #9 was off the unit at that time, and did not perform a Neurological Assessment on Resident #1 at 1:45 PM on [DATE]. Nurse #9 could not offer an explanation for this but said that maybe Nurse #9 had performed a Neurological Assessment on Resident #1 earlier before lunch, and made a mistake on the Neurological Assessment record on the timing of the assessment. The Unit Manager said that sometime mid-morning, the Unit Manager placed a call to the Unit to remind Nurse #9 to have the Physician see Resident #1. Nurse #9 said Nurse #9 had no recollection of this call. Nurse #9 said Nurse #9 checked all Physician orders [REDACTED].#1's medical record at that time. Nurse #9 said when Nurse #9 returned from lunch at 2 PM the Unit Manager was on the Unit and the Unit Manager said that Resident #1 was going out to the Hospital. The unit Manager said this statement was incorrect. The Unit Manager said Nurse #9 was completing transfer paperwork on Resident #1 when the Unit Manager returned to the Unit at approximately 2:15 PM. Nurse #9 said shortly after 2 PM Nurse #9 saw the order for transfer flagged in Resident #1's medical record and placed a call to the NP to confirm the order. Nurse #9 could not give an explanation as to why if there was a signed order by the NP to transfer Resident #1 to the Hospital, Nurse #9 would then place a call to confirm the order. The Unit Manager said the Unit Manager was standing at the nurses' station with Nurse #9 when a CNA approached and said Resident #1 was on the floor. CNA #8 was interviewed at 2:15 PM on [DATE]. CNA #8 said CNA #8 was walking past Resident #1's room at approximately 2:30 PM and CNA #8 saw Resident #1 standing up trying to use a urinal. CNA #8 said CNA #8 went into the room and asked Resident #1 if Resident #1 needed any help. CNA #8 said as CNA #8 took the urinal from Resident #1, Resident #1 started to sway and when CNA #8 suggested to Resident #1 to sit down, Resident #1 started to sway, toppled on to the right side and landed on the floor. CNA #8 said CNA #8 called out for help and another CNA who was passing, ran and got help from the nurses. Nurse #9 said as Nurse #9 entered the room, it appeared as though Resident #1 took a last breath and died . A Nurse's Progress Note, dated [DATE], and documented by Nurse #9, indicated at 11:45 AM, Resident #1 was seen by the Physician and the NP and an order was given to send Resident #1 to the Hospital for evaluation, and at 2:15 PM the Physician updated Family Member #2. The Progress Note indicated Resident #1 was in Resident #1's room "and wheelchair" when a CNA heard an alarm, and upon responding, Resident #1 was found on the floor. The Progress Note indicated Resident #1 ceased breathing at 2:45 PM, the Physician and NP were notified, and an RN Prouncement of Death was performed. A Death Certificate, signed and dated by the Physician at 2:45 PM on [DATE], identified Resident #1's immediate cause of death as [MEDICAL CONDITION] with a secondary contributing [DIAGNOSES REDACTED]. The Physician said the Physician was not on the Unit at the time of Resident #1's death. The Physician said the Physician was informed of Resident #1's death several hours after having seen Resident #1 and after having ordered Resident #'s transfer to the Hospital on the morning of [DATE]. The Physician said the Physician had spoken with Family Member #2 sometime between 9:30 AM and 10 AM and not at 2:15 PM. The Physician said Resident #1 had been sick for a long time and was very medically compromised. The Physician said the Physician could not say if Resident #1's outcome would have been any different if Resident #1 had been transferred to the Hospital earlier.