Every finding on record at Sixteen Acres Health and Rehabilitation Center LLC

Based on observations, interviews, and records review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections in the facility main laundry area, and on one unit (Unit #2) out of three resident units.Specifically, the facility failed to:1. Ensure that laundry personnel in the main facility laundry room wore the indicated Personal Protective Equipment (PPE-items such as gowns and gloves worn by staff to decrease the spread of infections) when sorting dirty laundry and linens soiled with feces.2. Ensure that facility staff followed appropriate hand hygiene standards on Unit #2 when: -Certified Nurse Aide (CNA) #1 failed to perform handwashing procedure while entering and exiting individual resident rooms with Enhanced Barrier Precautions (EBP) signage posted and clearly visible at the doorway of the resident rooms. -CNA #1 failed to perform handwashing procedure after the removal of gloves and after providing high contact resident care. Findings include: 1. Review of the facility policy titled Personal Protective Equipment Guidelines, revised 12/12/12, included but was not limited to: >Personal Protective Equipment (PPE: items such as gowns and gloves worn to prevent the spread of infection) was provided to our employees at no cost to them. Training is provided in the use of the appropriate PPE for the tasks or procedures that employees will perform. The facility is responsible to clean, maintain, and/or dispose of PPE. Home laundering is not permitted. -Employees of other companies working in the facility must wear PPE when occupational exposure may occur. -Wear appropriate face and eye protection when splashes, sprays, spatters, or droplets of blood or other potentially infectious materials (OPIM) pose a hazard to the eye, nose or mouth. -Remove immediately or as soon as feasible any garment contaminated by blood or OPIM, in such a way as to avoid contact with outer surface. Review of the facility policy titled Laundry Handling Practices, revised 12/12/12, included but not limited to: >Proper handling of linen and laundry will reduce the likelihood of recontamination. -Use Standard Precautions (basic infection practices used in healthcare for all patient's, at all times, to prevent the spread of infections from both known and unknown sources) in the handling of all soiled laundry. Wear protective gloves and other appropriate PPE when having contact with contaminated laundry. -Handle contaminated laundry as little as possible, with minimal agitation. Review of the facility policy titled Standard Precautions, dated 3/8/20, included but was not limited to: -Standard precaution includes a group of infection prevention practices that apply to all residents regardless of the suspected or the confirmation infection status. These practices include the use of gloves, gowns, masks, eyewear, or face shields. The choice of PPE is dependent upon the anticipated exposure. It also includes equipment or personnel items that have been handled by a resident and thus require PPE to avoid potential transmission of pathogens. <All resident blood, body fluids, excretions and secretions other than sweat will be considered potentially infectious. <Standard precautions will be used on all residents. -Appropriate PPE (personal protective equipment) will be utilized using the guidelines below. Hand hygiene should take place before and after donning any PPE. <Mask and eyewear (or face shields) - should be worn during procedures that are likely to generate droplets/splashing or blood or body fluids. <Gown/Aprons (fluid resistant) - should be worn when there is potential for soiling clothing with blood/body fluids. <Hand washing/hand hygiene - should take place after glove removal and must take place according to policy and procedure regardless of the employee's perception of how his or her hands are. On 12/4/25 at 1:02 P.M., the surveyor observed the following with Laundry Personnel #1 and #2 in the facility main laundry room: -No evidence of PPE supplies present in the dirty linen sorting room. During an interview at the time, Laundry Personnel #1 said laundry staff kept PPE that were not stored in the dirty linen sorting room. Laundry Personnel #1 said he did not know where PPE should be stored. -The surveyor observed a non-operational sink in the dirty linen sorting room. There was a blue cloth, a plastic wrapper inside the sink, a small red and white box labelled drywall screws and a paint brush on the countertop and brown dust in and around the edges of the sink. -No evidence of a paper towel dispenser or trash container was located near the hand washing sink in the dirty linen sorting room. -An empty box labeled hand gloves was observed on a large table in the dirty linen sorting room with individually bagged linens and clothing in a clear plastic bag. During an interview at the time, Laundry Personnel #2 said that PPE was not available in the dirty linen sorting room but was located down the hallway in the clean linen room. Laundry Personnel #2 further said that laundry personnel typically use the sink located in the washing room to perform hand hygiene prior to sorting dirty linens. On 12/4/25 at 3:00 P.M., the surveyor observed Laundry Personnel #2 in the dirty linen sorting room and a large grey bin next to Laundry Personnel #2 with linens that included towels soiled with feces. Laundry Personnel #2 was not observed to be wearing a gown or face shield at the time. The surveyor failed to observe evidence of available PPE supplies in the dirty linen sorting room. During an interview at the time Laundry Personnel #2 said that she should have worn PPE such as a gown and eye protection when sorting the dirty linens to prevent transferring germs and pathogens into her clothing and/or splashes from the towels soiled with fecal matter. During an interview on 12/4/25 at 3:13 P.M., the Director of Nursing (DON) said that laundry personnel should don PPE when sorting soiled linens in the dirty linen sorting room to prevent the transfer of pathogens on staff clothing and transmission of pathogens to staff. The DON also said that the dirty room in the main laundry department should have appropriate supplies of PPE and a functional sink with paper towel and trash container for staff use. 2. Review of the facility policy titled Hand Hygiene, dated 3/8/20, included but was not limited to: >It is the policy of this facility that staff will perform hand hygiene as a means of cleaning hands by using either soap and water, (hand washing) or antiseptic hand rub (Alcohol-based hand Rub - ABHR). -To decrease the risk of transmission of infection. <Alcohol based hand sanitizers are the most effective product for reducing the number of germs on the hands and is the preferred method of cleaning the hands in most clinical situations. <Soap and water are appropriate for use whenever hands are visibly dirty, before eating, and after using the restroom. -Guidelines for decision of use ABHR or Soap and water during routine patient care: <Immediately before touching a patient. <After touching a patient or the patient's immediate environment. <After contact with blood, body fluids or contaminated surfaces. -Immediately after glove removal. On 12/4/25 at 11:30 A.M., the surveyor observed the following: -CNA #1 entered and exited individual resident rooms with Enhanced Barrier Precautions (EBP- measures using protective barrier gowns and gloves as an infection control intervention designed to reduce transmission of multi-drug-resistant organisms [MDRO] during high contact resident care) signage posted outside the rooms without performing hand hygiene prior to or upon exit from the residents' rooms. -CNA #1 entered a resident room with EBP signage posted, without performing hand hygiene, assisted the resident with incontinent care and exited the room. -CNA #1 was observed to assist another resident with EBP signage posted, along with a second staff member to transfer into a wheelchair using a mechanical lift, then exited the room after the resident was transferred without performing hand hygiene. During an interview on 12/4/25 at 11:55 A.M., CNA #1 said that she did not complete hand hygiene because she was just entering and exiting the rooms and was not providing any ADL care for the residents. CNA #1 said she thought she used the ABHR, but she might not have. CNA #1 said she should have used the ABHR to clean her hands when entering and exiting resident rooms to prevent the spread of infection. During an interview on 12/4/25 at 1:33 P.M., Unit Manager (UM) #2 said that staff should use ABHR when entering and exiting a resident's room. UM #2 said that staff might unintentionally touch a doorknob and/or the bathroom stall while in the residents' room and might not be aware. UM #2 further said that the use of ABHR when staff enter and exit a resident room prevents the spread of germs and infections.

Based on observations, interviews and record review the facility failed to follow professional standards of practice for food safety to prevent the potential spread of foodborne illness in the main facility kitchen and on three (Unit #2, #3 and #4) of three unit kitchenettes.Specifically, the facility failed to:1.Implement control measures for monthly cleaning of the facility's ice machine located in the main kitchen, and proper storage of the ice scoop, increasing the risks for residents to develop foodborne illnesses and infections.2. ensure that food items were properly stored in the kitchenettes on Unit #2, #3 and #4 and that Unit #2 and Unit #3 kitchenettes were maintained in safe, clean, and sanitary conditions. Findings include: 1. Review of the facility's policy titled Ice, revised October 2022, indicated the following:-Ice will be prepared and distributed in a safe and sanitary manner.-The exterior of the ice machine will be cleaned weekly.-Ice bins will be cleaned monthly and as needed.-Ice scoops will be cleaned and stored in a separate container that limits exposure to dust and moisture retention. Review of the Indigo NXT Ice Machine Installation, Operation and Maintenance Manual, dated May 2022, indicated the following:-You are responsible for maintaining the ice machine in accordance with the instructions in this manual.-Clean the area around the ice machine as often as necessary to maintain cleanliness and efficient operation.-Wipe surfaces with a damp cloth rinsed in water to remove dust and dirt from the outside of the ice machine.-De-scale and sanitize the ice machine every six months for efficient operation.-The remedial de-scaling procedure de-scales all components in the water flow path and is used between bi-yearly detailed de-scaling and sanitizing procedure.-Ice machine de-scaler is used to remove lime scale and mineral deposits.-Ice machine sanitizer disinfects and removes algae and slime. On 12/3/25 at 7:25 A.M., the surveyor observed the following in the facility's main kitchen:-The ice machine with the lid closed.-The ice scoop was stored on the top of the ice machine (not in a separate container).-The Ice Machine Cleaning Log was posted on the outside of the ice machine.-The Ice Machine Cleaning Log indicated boxes for each month of the year.-The Cleaning Log indicated the last time the ice machine was cleaned was on 9/7/25.-The boxes on the Cleaning Log for the months of October 2025, November 2025, and December 2025 were blank.The surveyor placed their hand on the top of the ice machine (where the ice scoop was stored) and slid their fingertips approximately six inches along the top of the machine. When the surveyor removed their hand dry, brown, dusty debris was observed on their fingertips. During an interview on 12/3/25 at 8:20 A.M., the Food Service Director (FSD) said that the ice machine observed by the surveyor in the main kitchen was new and that the facility had received it a few months ago. The FSD said the ice scoop was stored on top of the ice machine because when the ice machine was delivered, it did not come with a separate bin for storing the ice scoop. The FSD also said that the ice machine's ice bin was supposed to be cleaned monthly and that the outside of the ice machine was supposed to be cleaned as needed to ensure that it was free of dust and dirt. During an interview on 12/5/25 at 10:15 A.M., the District FSD said that the ice machine was supposed to be cleaned monthly. The District FSD said that monthly cleaning included emptying the ice bin, cleaning the flap (door that covers the ice bin), gasket, and the ice bin. The District FSD said monthly cleaning targeted the ice bin, flap and gasket because those areas were breeding grounds for bacterial growth and could cause illness. The District FSD said the ice machine in the facility's main kitchen was the only ice machine in the facility and that keeping the ice machine clean was important to reduce the risk of illness for the residents. During an interview on 12/9/25 at 8:59 A.M., the FSD said the ice from the ice machine in the main kitchen was used to keep medication carts and beverage carts drinks cold and was also used for resident consumption. 2. Review of the facility policy titled Food Receiving and Storage, revised 2014, included but was not limited to the following: -Foods shall be .stored in a manner that complies with safe food handling practices. -Food Services, or other designated staff, will maintain clean food storage areas at all times. -Uncooked and raw animal products will be stored in drip proof containers. -Food items and snacks kept on the nursing units must be maintained as below: >All food items to be kept below 41 degrees Fahrenheit (F) must be placed in the refrigerator located in the nourishment kitchens (kitchenette) labeled with use-by date within 3 days. >All foods belonging to residents must be labeled with the resident's name, the item and the use by date. >Beverages must be dated when open and discarded after twenty-four (24) hours. >Other opened containers must be dated and sealed or covered during storage. Review of the facility's policy titled Environment, revised 9/2017, included but was not limited to the following: -All food preparation areas, food service areas .will be maintained in a clean and sanitary condition. >All food contact surfaces will be cleaned and sanitized after each use. On 12/9/25 at 8:23 A.M. through 8:33 A.M., the surveyor observed the following in facility kitchenettes:Unit #2 kitchenette: In the refrigerator: >McDonald's plastic cup containing a straw and clear liquid that was unlabeled and undated. >Two raw hamburger patties dated 9/6/25, unlabeled in the refrigerator (not in a leak proof container). In the microwave oven: >Flaking rusted areas on the inside of the oven door and on the inner cabinet casing. Unit #3 kitchenette: In the upper left sided kitchenette cabinet: >Uncle Ben's Street Food microwaveable meal, with use a by date of 10/10/25. >One uncovered container of unwrapped peppermint herbal tea bags, with a use by date of 7/2/21. >One open and undated gallon of spring water, approximately 1/4 full. In the refrigerator freezer: >A thick layer ice covering the floor of the freezer casing that contained blue, brown and yellow particles. Unit #4 kitchenette: On the left side of the food service area, below the microwave oven: >An area of splattered, dried, brown substance on the countertop, inside the top drawer and down the length of the cabinet surfaces. Inside the microwave oven: >Red/brown substance containing rice pieces that was crusted along the floor of the microwave casing. Inside the refrigerator: >One covered bowl containing a pale yellow, soft product with a resident name, dated 12/5/25. >One covered bowl of red liquid, unlabeled and dated 12/5/25. >One clear produce bag containing green grapes with a resident's name, undated. During an interview on 12/9/25 at 8:59 A.M., the Food Service Director (FSD) said the Dietary Aides clean, restock and discard outdated food/liquids for all facility kitchenettes twice a day at 6:30 A.M., and 4:30 P.M. The FSD said cleaning and restocking should include the refrigerator, freezer, microwave, cabinets and surfaces and cleaning involved the use of a sanitizer product and clean rags twice a day. The FSD further said all facility staff were responsible to clean up food and liquid spills when they occur and there was no scheduled defrosting or preventative maintenance for the unit refrigerators/freezers at this time. The FSD said all food brought in from outside sources should be labeled with the date received and the resident's name and prepared food and liquids that are three days after being placed in the refrigerator should be discarded during the 6:30 A.M. rounds by Dietary staff. On 12/9/25 at 9:48 A.M. through 9:58 A.M., the surveyor and the District Manager of Dining Services observed all the Unit kitchenettes. During an interview at the time, the District Manager of Dining Services said all the findings observed by the surveyor were a concern but fixable. The District Manager of Dining Services said all facility staff are responsible to ensure that food items and beverages were labeled with a resident's name, dated, and discarded on time and all stored food items should be covered. The District Manager of Dining Services said prepared foods and open liquids should be discarded on day three of morning rounds by the Dietary department and she had a concern with foods that were kept after the best by date. The District Manager of Dining Services said microwave rust could chip off and flake into resident's food and then be consumed. The District Manager of Dining Services further said frozen blue, brown and yellow particles in the freezer could be food or plastic pieces and raw meat should be stored in a leak proof container and not be in the unit kitchenettes. The District Manager of Dining Services also said all staff should be cleaning up spills and food debris between Dietary Aide visits on the units and expired foods could cause illness for the facility's vulnerable population. During an interview on 12/9/25 at 1:54 P.M., the Administrator said the rusty microwave had been reported during morning rounds a few weeks ago but was unable to recall the exact date. The Administrator said the microwave should have been taken out of use when the concern had been identified. During an interview on 12/9/25 at 2:00 P.M., the Infection Preventionist (IP) said that all food items should be covered, labeled and dated and surfaces kept clean in all of the unit kitchenettes. The IP said that outdated foods and dirty surfaces could cause illness like Salmonella (bacteria that can cause foodborne illness) to the residents in the facility.

Based on record review, and interviews, the facility failed to ensure that a Physician ordered pain medication was available to be administered for one Resident (#4) out of a total sample of 21 residents.Specifically, for Resident #4, the facility failed to ensure that Morphine Sulfate (pain medication) was available to be administered to the Resident every four hours as ordered by the Physician, over six consecutive opportunities, for two consecutive days. Findings include:Review of the facility pharmacy policy titled Provider Pharmacy Requirements, effective June 2020, indicated:-The provider pharmacy is responsible for rendering the required services in accordance with local, state and federal laws and regulations; facility policies and procedures; community standards of practice; and professional standards of practice. Review of the facility policy titled Medication and Treatment Orders, reviewed June 2022 indicated:-Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in the state. Resident #4 was admitted to the facility in November 2025 with diagnoses including pressure ulcer of the sacrum, and aphasia. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #4 was unable to complete a Brief Interview for Mental Status (BIMS) as evidenced by a score of 99 entered on the MDS assessment. Review of the active Physician orders dated 12/8/25, indicated:-Morphine Sulfate Oral Solution 10 mg (milligrams) per 5 ml (milliliters), Give 10 mg/5 ml via G-tube (gastrostomy tube: a flexible tube placed through the abdomen directly into the stomach used for long term nutrition, fluids and medications) every four hours for [pressure ulcers] pain management. Review of the December 2025 Medication Administration Record (MAR) indicated:-Morphine Sulfate Oral Solution was scheduled to be administered at 1:00 A.M., 5:00 A.M., 9:00 A.M., 1:00 P.M., 5:00 P.M., and 9:00 P.M.Further review of the December 2025 MAR failed to indicate the scheduled Morphine Sulfate Oral Solution was administered as ordered on:>12/7/25 at 1:00 P.M., 5:00 P.M., and 9:00 P.M.>12/8/25 at 1:00 A.M., 5:00 A.M., and 9:00 A.M. Review of the eMAR (electronic) Medication Administration Record notes documented after the medication was due to be administered indicated the following: -12/7/25 at 2:48 P.M., Morphine Sulfate Oral Solution 10 mg/5 ml medication on order. -12/7/25 at 9:30 P.M., Morphine Sulfate Oral Solution 10 mg/5 ml medication not given, medication not available, waiting for delivery from pharmacy.-12/8/25 at 12:30 A.M., Morphine Sulfate Oral Solution 10 mg/5 ml medication not given, medication not available, waiting for delivery from pharmacy.-12/8/25 at 5:30 A.M., Morphine Sulfate Oral Solution 10 mg/5 ml medication not given, medication not available.-12/8/25 at 9:06 A.M., Morphine Sulfate Oral Solution 10 mg/5 ml, hold pending arrival, may give when available. On 12/4/25 at 8:52 A.M., Resident #4 was observed lying in bed and awake, with the head of bed elevated. Resident #4 was observed to be non-responsive to the surveyor's prompts at conversation. On 12/4/25 at 1:17 P.M., Resident #4 was observed lying in bed and asleep, with visitors present at his/her bedside.On 12/8/25 at 8:07 A.M., Resident #4 was observed lying in bed, eyes closed, with the head of bed elevated. During an interview on 12/8/25 at 10:10 A.M., the surveyor, Unit Manager (UM) #3, and Nurse #2, reviewed Resident #4's December 2025 MAR. UM #3 said that the MAR indicated that Resident #4 had not received Morphine Sulfate Oral Solution as ordered for the past six scheduled doses. Nurse #2 said that the medication had not been administered because it was not available from the pharmacy. Nurse #2 further said when the pharmacy was notified that the Morphine Sulfate medication was needed, the pharmacy staff indicated that the medication would be delivered with the next pharmacy delivery. Nurse #2 also said that pharmacy medication delivery issues are ongoing for Resident #4's Morphine Sulfate Oral Solution. Both UM #3 and Nurse #2 were unsure if the pharmacy medication issues had been reported to the Administrator.

Based on observation, interview, and record review, the facility failed to ensure one Resident (#14) out of a total sample of 21 residents was provided assistance with personal hygiene care and services. Specifically, the facility failed to ensure that Resident #14 was offered and/or provided grooming assistance timely for nail care when the Resident required total dependence of staff for hygiene, bathing, and dressing. Findings include: Review of the facility policy for Activities of Daily Living (ADLs - basic self-care tasks that individuals perform daily to maintain their health and well-being), last reviewed 12/2022, indicated:-A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene. -The facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. -the facility will provide care and services for the following activities of daily living:a. Hygiene- bathing, dressing, grooming, and oral care b. Mobility- transfer and ambulation, including walkingc. Elimination- toileting and incontinent care 1. Resident #14 was admitted to the facility in June 2024 with diagnoses including Parkinson's Disease, Dementia, left hand contracture and lack of coordination. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #14:-was unable to complete the Brief Interview of Mental Status (BIMS) examination and had severely impaired cognitive skills for daily decision making. -had no behaviors. -required substantial/maximal assistance with personal hygiene including grooming needs. Review of Resident #14's ADL care plan, last revised 9/25/25, indicated:-the Resident will receive assistance with ADLs due to impaired mobility.-goal: Resident will remain clean and free of body odor, well-groomed and well-nourished with assistance. -grooming: Resident required assisted care of one staff for all grooming. Review of Resident #14's November 2025 and December 2025 Nursing Progress Notes failed to indicate that the Resident had refused care relative to grooming and/or personal hygiene. Review of Resident #14's December 2025 Medication Administration Record (MAR) failed to indicate that the Resident exhibited any documented behaviors from 12/1/25 to 12/8/25. Review of Resident #14's Visual/Bedside Kardex Report dated 12/8/25, indicated that the Resident requires assisted care of one staff for all grooming. Review of Resident #14's Task List Report dated 12/8/25 and initiated 6/12/24, indicated that the Resident receives personal hygiene/grooming from a Certified Nurse's Aide (CNA) every day and every shift. On 12/3/25 at 9:03 A.M., the surveyor observed Resident #14 sitting up in bed. The surveyor observed that the Resident's fingernails were approximately 1/8 inch long and had a dark brown substance and food debris underneath the fingernails on both hands. During an interview on 12/3/25 at 2:33 P.M., Resident #14's Healthcare Proxy (HCP) said that he/she visits the Resident once a week in the facility and was concerned that the Resident's fingernails were long and dirty and would like his/her fingernails to be cleaned and trimmed because it is unhygienic. On 12/4/25 at 1:09 P.M., the surveyor observed Resident #14 sitting up in bed watching television while eating lunch with his/her hands. The surveyor observed that the Resident's fingernails remained untrimmed and had a dark brown substance and food debris underneath the nails of both his/her hands. On 12/8/25 at 8:41 A.M., the surveyor and Nurse #4 observed Resident #14 sitting up in bed eating breakfast with his/her hands. The surveyor and Nurse #4 further observed that the Resident's fingernails had a dark brown substance and food debris underneath the fingernails. During an interview at the time, Nurse #4 said that the Resident's fingernails were dirty, had not been cleaned and should have been cleaned daily because it could potentially become an infection control concern for the Resident. On 12/8/25 at 8:52 A.M., the surveyor and CNA #2 observed Resident #14 sitting up in bed eating breakfast in his/her room. During an interview at the time, CNA #2 said that the Resident's fingernails were dirty, did not appear to have been cleaned and should have been. CNA #2 also said that Resident's fingernails should be groomed daily or when they are observed to be soiled.

Based on record review, and interview, the facility to ensure that medical records were complete and accurate for one Resident (#4) out of a total sample of 21 residents. Specifically, for Resident #4, the facility staff failed to provide documentation that the Provider was notified when the Resident's Morphine Sulfate Oral Solution was not available to be administered as ordered placing the Resident at risk of not having pain appropriately managed. Findings include: Review of the facility policy titled Medication and Treatment Orders, reviewed June 2022 indicated the following:-Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in the state. Review of the facility policy titled Change in Resident's Condition or Status and Notification, reviewed June 2022 indicated the following:-The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician, Physician Assistant (PA) or on-call Physician when there has been a significant change in the resident's medical/mental conditions or status including but not limited to a need to alter the resident's medical treatment significantly. Resident #4 was admitted to the facility in November 2025 with diagnoses including pressure ulcer of the sacrum, and aphasia. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #4 was unable to complete a Brief Interview for Mental Status (BIMS) assessment as evidenced by a score of 99 entered on the MDS assessment. Review of the active Physician orders dated 12/8/25, indicated:-Morphine Sulfate Oral Solution 10 mg (milligrams) per 5 ml (milliliters). Give 10 mg/5 ml via G-tube (gastrostomy tube: a flexible tube placed through the abdomen directly into the stomach used for long term nutrition, fluids and medications) every four hours for pain management [of sacral pressure ulcer]. Review of the December 2025 Medication Administration Record (MAR) indicated that the prescribed Morphine Sulfate Oral Solution was scheduled to be administered at the following times daily: 1:00 A.M., 5:00 A.M., 9:00 A.M., 1:00 P.M., 5:00 P.M., and 9:00 P.M.Further review of the December 2025 MAR failed to indicate that Resident #4's scheduled Morphine Sulfate Oral Solution was administered as ordered on:-12/7/25 at 1:00 P.M., 5:00 P.M., and 9:00 P.M. (3 doses)-12/8/25 at 1:00 A.M., 5:00 A.M., and 9:00 A.M. (3 doses) Review of the eMAR medication administration record indicated the following notes documented after the missed medication times:-12/7/25 at 2:48 P.M., Morphine Sulfate Oral Solution 10 mg/ 5 ml on order, PA [said] ok [okay] to give on arrival.-12/7/25 at 9:30 P.M., Morphine Sulfate Oral Solution 10 mg/ 5 ml not given, medication not available, waiting for delivery from pharmacy (no documentation that Provider was contacted)-12/8/25 at 12:30 A.M., Morphine Sulfate Oral Solution 10 mg/ 5 ml not given, medication not available, waiting for delivery from pharmacy (no documentation that Provider was contacted)-12/8/25 at 5:30 A.M., Morphine Sulfate Oral Solution 10 mg/ 5 ml not given, medication not available (no documentation that Provider was contacted)-12/8/25 at 9:06 A.M., Morphine Sulfate Oral Solution 10 mg/ 5 ml, hold pending arrival, may give when available, PA aware.Further review of the eMAR Medication Administration documentation and Nursing Progress Notes failed to indicate that the Physician/PA had been notified that Resident #4 had not been administered Morphine Sulfate Oral Solution as ordered on 12/7/25 at 5:00 P.M., and 9:30 P.M., and 12/8/25 at 12:30 A.M., and 5:30 A.M. During an interview on 12/8/25 at 10:10 A.M., the surveyor, Unit Manager (UM) #3, and Nurse #2 reviewed Resident #4's December 2025 MAR and UM #3 said that the MAR indicated that Resident #4 had not received Morphine Sulfate Oral Solution as ordered for the past six scheduled doses. Nurse #2 said that the medication had not been administered because it was not available from the pharmacy. UM #3 and Nurse #2 were unsure if the pharmacy medication issues had been reported to the Administrator. UM #3 further said that she was unsure if the Physician/PA had been notified of the missed medication doses and that there should have been a progress note written or documentation on the MAR that indicated the Physician/PA had been notified of the missed medication doses.

Based on observation, and interview, the facility failed to ensure that medications were stored according to professional standards of practice for one unit (4th floor) out of three total units. Specifically, for the 4th floor unit, the facility failed to: -ensure that a controlled substance medication was stored in a safe and secure compartment for controlled substances and/or other drugs subject to abuse inside the medication cart, when an Oxycodone tablet was found in a medication cup during a medication cart observation. -ensure that a controlled substance medication that was refused by a resident was appropriately destroyed and not left unlabeled and accessible in the medication cart with the potential of being diverted or accidentally administered to a resident. Findings include: Review of the facility policy titled Storage of Medications, dated 10/1/19, included but was not limited to:>Medications and biologicals are stored safely, securely, and properly, following manufacturers' recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. -The provider pharmacy dispenses medications in containers that meet regulatory requirements, including standards set forth by the United States Pharmacopeia (USP). Medications are kept in these containers. Nurses may not transfer medications from one container to another or return partially used medication to the original container. -All medications dispensed by the pharmacy are stored in the container with the pharmacy label.-Disposal of any medications prior to the expiration date will be required if contamination or decomposition is apparent. Review of the facility policy titled Controlled Substance Storage, dated 10/1/19, included but was not limited to:>Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. -Schedule II - V medications and other medications subject to abuse or diversion are stored in a permanently affixed, double locked compartment separate from all other medications or per state regulation. -The access system to controlled medications is not the same as the system giving access to other medications (the key that opens the compartment is different from the key that opens the medication cart). -If a key system is used, the medication nurse on duty maintains possession of the key to controlled substance storage area. Back-up keys to all medication storage areas, including those for controlled substances, are kept by the director of nursing (DON) or designee. Review of the facility policy titled Controlled Substance Disposal, dated 10/1/19, included but was not limited to:>Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. -When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It is destroyed in the presence of two licensed nurses, and the disposal is documented on the accountability record/book on the line representing that dose. -The administrator, nurses and or pharmacists witnessing the destruction ensures that the following information is entered on the individual controlled substance accountability record/book:<Date of destruction<Resident's name <Name and strength of medication<Prescription number<Amount of medication destroyed<Signatures of witnesses -Accountability records for controlled substances that are disposed of/or destroyed are maintained with the unused supply until it is destroyed or disposed of and then stored for 5 years or per applicable law or regulation. On 12/5/25 at 9:53 A.M., during a medication cart observation with Nurse #3 on the 4th floor unit, the surveyor observed the following: -Nurse #3 opened the medication cart and stepped to the side of the medication cart.-The surveyor opened the top drawer of the medication cart to observe the contents of the medication cart. -Nurse #3 then picked up an unknown item from the top drawer of the medication cart and held the item behind her back. -When the surveyor asked to see the removed item, Nurse #3 presented a plastic medication cup with a small round white tablet inside the cup. During an interview at the time, Nurse #3 said the round white tablet inside the plastic medication cup was an Oxycodone (opioid analgesic, classified as Schedule II-controlled substance) tablet, that a resident had refused earlier in the day. Nurse #3 said that the Oxycodone tablet should have been destroyed with another Nurse immediately when the resident had refused the Oxycodone tablet, but it was not destroyed. Nurse #3 said ensuring the controlled substance medication was destroyed immediately and appropriately prevents medication errors and accuracy of the controlled substance count. During an interview on 12/5/25 at 12:30 P.M., Unit Manager (UM) #1 said the Oxycodone tablet should have been placed in the sharps container that is sealed for safety to prevent residents and other staff members from gaining access to the medication. UM #1 said when a resident refused to take a controlled substance medication, the expectation for nursing staff was that the Nurse should seek another Nurse and immediately dispose of the medication in the sharps container to ensure other staff members do not have access to the medication for safety. UM #1 said that the risk of the Nurse leaving the controlled substance medication inside the medication cart that was not double locked was that the Nurse might forget the medication and/or administer the medication to another resident. UM #1 said failing to properly destroy the medication can affect the controlled substance medication count. During an interview on 12/5/25 at 2:35 P.M., the Director of Nursing (DON) said when controlled substance medications were refused by residents, the controlled substance medication should be immediately destroyed and disposed of into the sharps container for safety to prevent other residents in the facility and staff members access to the medication.

Based on observation, interviews, and record reviews, the facility failed to provide necessary care and services in a timely manner, consistent with Residents' needs and choices, to improve the Resident's ability to carry out activities of daily living (ADLs) relative to mobility for one Resident (#10) out of a total sample of 21 residents. Specifically, the facility failed to respond to Resident #10's request to be assessed for the use of a walker and the ability to walk when: -The Resident used a wheelchair for mobility. -The Resident reported improved abilities to move his/her legs. -The Resident requested therapy services to address his/her ability to stand and use a walker. Findings include: Review of the facility policy titled Functional Impairment - Clinical Protocol, dated 2001 and revised September 2012, indicated the following: - . periodically during a resident's stay, .staff will assess the resident's physical condition and functional status. - Staff will monitor . the resident's functional progress, both while receiving therapy and in general while on the unit. Review of the facility's ADL Policy, dated 12/22/21 and reviewed December 2022, indicated the following: -The facility will ensure a resident is given the appropriate treatment and services to . improve his or her ability to carry out the ADLs. -Care and services for ADLs included mobility. Resident #10 was admitted to the facility in May 2020 with diagnoses including Chronic Pain Syndrome, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, Lymphedema, Muscle Wasting and Atrophy, and Abnormality of Gait and Mobility. Review of the Minimum Data Set (MDS) Assessment, dated 8/23/24, indicated Resident #10: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 total possible points. -required partial/moderate assistance to complete sitting to standing. -required partial/moderate assistance to complete transfers to and from the bed/chair/toilet. Review of Resident #10's clinical record indicated the Resident's most recent Physical Therapy intervention had been provided from 9/25/24 through 11/22/24 and was discontinued 11/26/24. Review of the Physical Therapy Discharge summary, dated [DATE], indicated Resident #10: -required partial/moderate assistance for transfers to and from the bed and chair. -goal for marching in place was discontinued due to the Resident's inability to clear his/her foot in standing. -status for walking was not applicable. Review of Resident #10's Care Plan Conference Record, dated 9/4/25, indicated the Resident inquired about Rehabilitation Services, standing, and use of a walker. Review of Resident #10's Social Service Progress Note, dated 9/4/25, indicated the following:-A care plan meeting was held with the Resident on 9/4/25.-The Resident expressed interest in restarting Physical Therapy. Review of Resident #10's ADL Care Plan, revised 9/4/25, indicated: . initiate Rehab (Rehabilitation) Screen PRN (as needed). Review of the MDS Assessment, dated 11/24/25, indicated Resident #10: -was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15 total possible points. -had no upper extremity and lower extremity range of motion impairments. -used a motorized wheelchair independently. -performed transfers to and from the bed/chair/toilet with supervision or touching assistance. -did not receive any Rehabilitation Therapies during the observation period for the MDS Assessment. Review of Resident #10's clinical record failed to indicate any evidence the Resident had been assessed by Rehabilitation Services since the Resident's inquiry on 9/4/25. On 12/3/25 at 10:58 A.M., the surveyor observed Resident #10 mobilizing through the hallway in a motorized wheelchair without any assistance from staff. During an interview on 12/3/25 at 11:05 A.M., Resident #10 said he/she had problems with his/her legs due to weakness and Lymphedema which had caused him/her difficulty moving his/her legs on his/her own. Resident #10 said that he/she felt he/she had made improvements with his/her legs and could now lift them up into bed on his/her own. Resident #10 said that he/she was feeling stronger than he/she had in the past and that he/she wanted to try standing with a walker and eventually see if he/she could walk. Resident #10 said that he/she was not currently able to walk and required the use of his/her motorized wheelchair for independence with mobility. Resident #10 further said, I don't want to keep sitting in this chair. Resident #10 also said that he/she had inquired about having therapy several months prior and did not know why it was taking so long to be seen by someone from the Rehabilitation Department. During an interview on 12/4/25 at 12:20 P.M., the Rehabilitation Director said Resident #10 had not used a walker or walked for a very long time. The Rehabilitation Director said that although residents' statuses could change over time, use of a walker was not appropriate and safe for Resident #10. The Rehabilitation Director said if a resident required an assessment that involved gait training, the assessment would be completed by the Physical Therapist. The Rehabilitation Director said that Resident #10 had not been assessed by the Physical Therapist since the Resident's request on 9/4/25. During an interview on 12/4/25 at 1:50 P.M., the Rehabilitation Director said she had spoken with the Resident following the surveyor's inquiry and that the Resident felt he/she was stronger now and would be able to stand with a walker. The Rehabilitation Director said that the Resident expressed the desire to work on standing and progress to walking. The Rehabilitation Director said that a Physical Therapy Evaluation was now scheduled for the following date (12/5/25). During an interview on 12/5/25 at 2:40 P.M., the Physical Therapist (PT) said that he had not been alerted to the Resident's request to be assessed for the use of a walker and potential for walking until 12/4/25 (following the surveyor's inquiry). The PT said he was going to assess the Resident that same day to determine whether the Resident would benefit from Physical Therapy services. Review of the Physical Therapy Evaluation, dated 12/5/25, indicated Resident #10: -was being evaluated after being referred for gait training. -referral was prompted because the Resident verbalized interest in pursuing goals to be able to ambulate on the unit. -stated, I want to be able to move around with a walker. -was able to ambulate two feet with moderate assistance. -A treatment plan was developed for the Resident to receive Physical Therapy services. -Goals were developed and included but were not limited to gait training. -rehabilitation potential was good. During an interview on 12/9/25 at 8:45 A.M., the Social Worker (SW) said if a resident expressed a desire for rehabilitation services during a care plan meeting, the SW would verbally notify the Rehabilitation Director. The SW said that there was no formal communication in place to alert the Rehabilitation Director when a resident requested rehabilitation services. During an interview on 12/9/25 at 9:30 A.M., the Rehabilitation Director said when a staff member referred a resident for rehabilitation services, the staff member was supposed to complete a written Rehabilitation Referral Form, and that the referral forms were kept on all units. The Rehabilitation Director said she had never received a written rehabilitation referral relative to Resident #10's 9/4/25 request. The Rehabilitation Director said that Resident #10 was evaluated by the PT on 12/5/25 (three months after the Resident's request for rehabilitation services) and would now be receiving Physical Therapy services.

Based on interviews, and records review, the facility failed to refer one Resident (#3) out of a total sample of 21 residents to the PASRR office when the Resident experienced a significant change in status assessment.Specifically, the facility failed to refer Resident #3 to the PASRR office when the Resident:-had a previous negative PASRR screening for serious mental illness (SMI).-expressed a wish to commit suicide.-required modification to his/her care plan relative to his/her suicidal statement.-required antipsychotic medication that was previously discontinued to be re-ordered and administered following his/her suicidal statement. Findings include: Review of the facility policy titled PASRR, dated 11/1/21 and last reviewed 2023, indicated the following: -When an individual who resides in a nursing facility has experienced a significant change or the individual is newly identified as having a condition that may impact the individual's PASRR disability status, the appropriateness of the individual's nursing facility placement, or the individual's need for specialized services, the facility must submit an updated PASRR Level I Screening Form to the appropriate PASRR office. -In all instances, the nursing facility must request a resident review from the PASRR office no later than the next business day following the date in which the facility detects that the member: -experienced a significant change; or -is newly identified as having a condition that may impact the individual's PASRR disability status, the appropriateness of the individual's nursing facility placement, or the individual's need for specialized services. Resident #3 was admitted to the facility in March 2023 with diagnoses including Intracranial Injury with loss of consciousness, Depression, and Anxiety. Review of the Level I PASRR Screening, completed 3/9/23, indicated Resident #3: -had a mood disorder. -had severe anxiety/panic. -had not required any of the listed treatments or interventions within the previous two years due to mental illness or disorder (MI/D). -had not experienced limitations in major life activities in at least one of three areas listed (interpersonal functioning, concentration, adaptation to change) due to MI/D either currently or within the previous six months. -had a negative screen for serious mental illness (SMI). -was not indicated for a Level II PASRR evaluation due to no diagnosis or suspicion of SMI. Review of the Minimum Data Set (MDS) Assessment, dated 7/24/25, indicated Resident #3: -was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15 total possible points. -received antipsychotic medication. -had no upper extremity (shoulder, wrist and hand) range of motion impairments. -required set up and clean up assistance for eating. Review of Resident #3's August 2025 Physician orders indicated the following: -Risperidone Oral Tablet 0.25 milligrams (mg), give one tablet by mouth two times a day for Psychosis, dated 8/3/25. -An order dated 8/14/25 and discontinued 8/21/25, for Risperidone Oral Tablet 0.25 mg, give one tablet by mouth in the evening for Psychosis until 8/21/25. Review of the Behavioral Health Provider Note, dated 9/11/25, indicated Resident #3: -chief complaint was insomnia. -target symptoms included insomnia, inappropriate sexual behaviors, agitation, and aggression. -was being seen for routine follow-up. -had experienced a recent loss of a sibling. -history of suicidal ideation (SI) was unknown. -Risperdal had been recently discontinued. -mood was stable. Review of Resident #3's Clinical Nurses Note, dated 9/16/25, indicated the Resident stated intention to commit suicide with use of a butter knife or by any means necessary. Further review of the Clinical Nurses Note indicated the following: -No sharp objects near Resident. -One to one (1:1) supervision provided. -The Resident was evaluated by a Crisis Clinician. -The on-call Provider ordered 15-minutes checks to be completed for the Resident and to transfer the Resident to the emergency department if suicidal ideations continued. Review of Resident #3's Physician order, dated 9/17/25, indicated:-Risperidone Oral Tablet 0.25 mg, give 0.25 mg by mouth every evening shift related to irritability and anger, and violent behavior. Review of Resident #3's Clinical Nurse Note, dated 9/18/25, indicated: -The Physician recommended for the Resident to transfer to a psychiatric facility to address medications and the Resident's Depression. -The Resident's Legal Guardian declined the hospital transfer. -The Resident was to continue to have psychiatric services provided at the facility. Review of Resident #3's clinical record failed to indicate any evidence that Resident #3 had been referred to the PASRR office for a change in condition after the Resident expressed a wish to commit suicide, and antipsychotic medication was re-ordered for administration to manage the Resident's symptoms. During an interview on 12/9/25 at 10:56 A.M., the Social Worker (SW) said that Resident #3 would often make comments about killing him/herself when he/she was mad. The SW said the Resident's statements relative to killing him/herself were never specific until 9/16/25 when the Resident stated he/she would use a butter knife to stab him/herself in the neck. The SW said that the facility had never referred Resident #3 to the PASRR office for review relative to a significant change for SI.

Based on observation and interview, the facility staff failed to maintain a clean, orderly, homelike environment on one unit (Unit Four) out of three units. Specifically, the facility failed to ensure that the air conditioning (AC) vent located on the ceiling, and the ceiling tiles surrounding the vent in the hallway outside of the resident rooms were maintained in good repair and a clean, homelike environment. Findings include: On 8/20/24 at 9:58 A.M., the surveyor observed the following on Unit Four: -A blue and white disposable incontinence pad (used to absorb urine on the resident's beds) was placed on the floor in the middle of the resident's hallway, topped with a yellow caution sign, indicating a water/slip hazard. -Directly above the disposable incontinence pad and hazard sign was a leaking AC vent with water droplets dripping from the left side of the vent. -The ceiling tiles around the AC vent were dark water-stained, with larger water-stained markings on the right side of the vent, some darker in color and spanning three tiles around the vent. During an interview immediately following the observation, Maintenance Staff #1 and #2 said that the AC vent had looked like this for a while, and they were unsure if anyone had been in to fix the leaking AC vent. The surveyor observed that the disposable incontinence pad, yellow sign and stained ceiling tiles remained in the same condition for the duration of the survey from the initial observation on 8/20/24 through 8/22/24. During an interview on 8/22/24 at 11:23 A.M., the Director of Maintenance (DOM) said that the ceiling vent for the air-conditioner on the fourth floor does leak due to condensation when the weather is warmer and that it is an ongoing issue. The DOM said that because of this, the ceiling tiles do become stained and require him to frequently change them out, sometimes monthly. The DOM said that the pipes are wrapped to try and reduce the condensation, but it does not stop them from leaking on hot days. The DOM said that it is not homelike having the disposable pad and yellow hazard sign in the hallway as well as the stained tiles and leaking AC vent.

Based on record and policy review, and interview, the facility failed to ensure that the required transfer documentation was completed and the transfer documentation communicated the appropriate information to the receiving health care institution for one Resident (#13), out of a total sample of 22 residents. Specifically, the facility failed to ensure Resident #13 was transferred to the emergency room with a form that included important information relative to the Resident's medical history and the reason for transfer, putting the Resident at risk for complications and adverse events upon transfer to the hospital. Findings include: Review of the facility policy titled Transfer/Discharge Notifications, revised on September 2022, indicated the following: -Documentation by the physician must be in the medical record and include the following information: A. The basis for the transfer B. The specific resident need(s) that cannot be met, facility attempts to meet the residents needs, and the service available at the receiving facility to meet the need(s) -Information provided to the receiving provider must include a minimum of the following: A. Contact information of the Practitioner responsible for the care of the resident. B. Resident Representative information including contact information. C. Advanced Directive Information. D. All special instructions or precautions for ongoing care, as appropriate. E. Comprehensive care plan goals. F. All other necessary information, including a copy of the resident's discharge summary, consistent with state and federal regulations as applicable, to ensure a safe and effective transition of care. Resident #13 was admitted to the facility in December 2021, with diagnoses including Schizoaffective Disorder (mental health condition marked by a mix of schizophrenia symptoms like hallucinations [seeing things or hearing voices] and delusions [believing things that are not real or not true], and mood disorder symptoms such as depression, mania and hypomania), Conversion Disorder (also known as functional neurological symptom disorder {FND} is a condition where mental health issues disrupt how your brain works) with seizures or convulsions, Major Depressive Disorder (symptoms lasting greater than two weeks of a persistently low or depressed mood and a loss of interest in activities that a person used to enjoy), Post-Traumatic Stress Disorder (PTSD: a mental and behavioral disorder that develops from having experienced a traumatic event, causing flashbacks, nightmares and severe anxiety), Anxiety (feeling of unease, such as worry or fear, that can be mild or severe/ intense, excessive, and persistent worry and fear about everyday situations) and Borderline Personality Disorder (mental illness that can cause a person to have long-term difficulty managing their emotions). Review of the Resident Census indicted the Resident was sent to the hospital on 7/12/24 and 7/30/24. Review of the Resident's medical record indicated no documented evidence of any discharge paperwork that included the Resident's Advanced Directives (legal documents that provide instructions for medical care and only go into effect if you are unable to communicate your own wishes), any specific instructions or precautions for ongoing care, and/or Provider (Physician/ Medical Doctor) information for the hospital transfers on 7/12/24 and 7/30/24. During an interview on 8/22/24 at 11:56 A.M., the Director of Nursing (DON) said when Resident #13 was sent to the hospital on 7/12/24 and 7/30/24, at minimum the E-interact transfer form (a form used by the facility when a resident is transferred out of the facility) and/or a Nurse's note should have been completed. The DON said that the facility has a transfer packet that is usually sent out with the Resident that would include Physician's orders, the Advanced Directives, pertinent labs, and the most recent progress note from the Provider. The DON said at the time of this interview there was no documented evidence that the receiving facility/hospital received the appropriate documentation when the Resident was transferred to the hospital on 7/12/24 and 7/30/24 and there should have been as required.

Based on interview, record and policy review, the facility failed to ensure the risks and benefits of bed rails was reviewed with the Resident and/or Resident Representative and informed written consent was obtained prior to the use of bed rails for one Resident (#15) out of a total sample of 22 residents. Specifically, for Resident #15, the facility failed to ensure the risks and benefits of bed rails was reviewed with Resident #15's Guardian (a court appointed person who makes important personal and healthcare decisions for an adult who lacks the capacity to make their own decisions) and written consent was obtained from the Guardian prior to the installation and use of bed rails. Findings include: Review of the facility policy titled Use of Side Rails, undated, indicated the following: -Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks. Resident #15 was admitted to the facility in February 2024, with a diagnosis of Paranoid Schizophrenia (type of Schizophrenia characterized by paranoia [distrust, suspicious, and fearful without any good reason], delusions and hallucinations). Review of the Resident's Permanent Decree of Guardianship, signed by the Justice of Probate and Family Court Department on 3/8/00, indicated Resident #15 was appointed a Permanent Guardian on 3/8/00. Review of the side rail care plan indicated the use of side rails for Resident #15 was initiated on 2/23/24 and resolved on 7/5/24. Review of the Physician's orders dated 4/10/24, indicated Resident #15 had quarter (1/4) side rails (rail/bar approximately one-quarter of the length of the bed, that attaches to the side of the bed and can be used to help patients get in and out of bed) to both sides of his/her bed. Review of the Nursing Progress Note dated 7/5/24, indicated Resident #15 had his/her side rails removed from his/her bed. Review of the Informed Consent for the Use of Side Rails Form, indicated Resident #15 had consented to his/her use of side rails. Further review of the medical record did not indicate that Resident #15's Guardian had been provided with the risk and benefits of side rail use or that the Guardian had provided consent for the facility to use side rails on Resident #15's bed. During an interview on 8/22/24 at 12:05 P.M., the Director of Nursing (DON) said she was unable to locate any documentation that staff at the facility had attempted to reach out to Resident #15's Guardian to acquire consent for the use of side rails. The DON said that staff should have reached out to the Guardian to obtain consent and documented in the Resident's medical record that attempts were made to obtain a signed consent for the use of side rails, but this was not done.

Based on record review and interview, the facility failed to maintain complete and accurate medical records for one Resident (#15) out of a total sample of 22 residents. Specifically, for Resident #15, the facility failed to contact the Resident's Guardian (a court appointed person who makes important personal and healthcare decisions for an adult who lacks the capacity to make their own decisions) and ensure that the Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST- form that indicates what types of medical treatment a resident wishes to have concerning life-sustaining treatment) form was signed by the Guardian and not by the Resident. Findings include: Review of the facility's policy titled Massachusetts Advanced Directives, last revised 8/3/22, indicated the following: -Guardian: A person who is appointed by the court to make decisions for an incapacitated person. A Guardian's authority varies based on the type of guardianship and grants specifically permitted by a Judge. -The Nursing Home Administrator is responsible for appointing staff who will initiate conversation to identify residents' responsible parties. Elected staff will confirm that information is appropriately documented in the medical record. Resident #15 was admitted to the facility in February 2024 with a diagnosis of Paranoid Schizophrenia (type of Schizophrenia characterized by paranoia [distrust, suspicious, and fearful without any good reason], delusions and hallucinations). Review of the Resident's Permanent Decree of Guardianship, signed by the Justice of Probate and Family Court Department on 3/8/00, indicated Resident #15 was appointed a Permanent Guardian on 3/8/00. Further review of the Resident's Guardianship paperwork indicated no documentation where the court indicated the Resident retained the ability to sign a MOLST Form. Review of Resident #15's MOLST Form on file indicated that the MOLST was completed and signed by the Resident on 2/24/24 after his/her admission to the facility and signed by the Physician/Nurse Practitioner/Physician Assistant on 2/26/24. Further review of the Resident's medical record indicated no documentation that the facility staff had contacted Resident #15's Guardian regarding completing a MOLST Form. During an interview on 8/22/24 at 9:46 A.M., the Director of Nursing (DON) said Resident #15 should not have completed his/her own MOLST Form and the facility staff should have consulted with the Resident's Guardian on what capacity the Guardian had to make advanced directive decisions, and this was not done.

Based on record review and interview, the facility failed to ensure that a Minimum Data Set (MDS) Assessment was accurately coded for one Resident (#39) out of a total sample of 22 residents. Specifically, for Resident #39, the facility staff failed to accurately code that the Resident had falls on the most recent Quarterly MDS Assessment. Findings include: Resident #39 was admitted to the facility in August 2020, with diagnoses including Central Cord Syndrome (a cervical spinal cord injury that can cause loss of power and sensation in the arm and hands) and Unspecified Dementia (a mental disorder that occurs when someone has Dementia but does not have a specific diagnosis). Review of the Quarterly MDS assessment dated [DATE], indicated the Resident had no falls during the look back period (the time frame during which a resident's condition is captured by the MDS Assessment). Review of the Resident's Nursing Progress Notes indicated the Resident had documented falls on 3/30/24, 4/5/24 and 4/23/24, during the look back period for the most recent Quarterly MDS Assessment. During an interview on 8/22/24 at 10:47 A.M., the MDS Nurse said Resident #39 did have falls during the look back period and the 4/23/24 MDS assessment was coded inaccurately and needed to be modified.

Based on observations and interviews, the facility failed to ensure its staff provided meals that were palatable, and of appropriate temperatures on three (Second Floor, Third Floor, and Fourth Floor) out of three Units observed. Findings include: During the initial pool process conducted by the survey team on 5/1/23, the following food concerns were identified by Residents/Resident Representatives: -Numerous concerns that hot meals were served cold -Food did not taste good -Sausage was too spicy -Requests for staff to reheat food regularly -Non preferred food items routinely delivered on food trays, despite written documentation/requests not to receive specific items On 5/2/23 at 11:16 A.M., the surveyor requested test trays and calibrated thermometers to be sent to all three units and the following was observed: The following temperatures were obtained in the kitchen prior to food being delivered to the units: Roasted Pork: 180 degrees Fahrenheit (F) Roasted Pork minced: 180 degrees F Roast Pork pureed: 163 degrees F Rice pilaf: 175 degrees F Gravy: 179 degrees F Broccoli: 172 degrees F Broccoli pureed: 164 degrees F Mashed potatoes: 167 degrees F Quiche: 162 degrees F Milk 40: degrees F Hot beverage: 172 degrees F At 11:55 A.M., The surveyor observed the kitchen staff to begin to plate the food. 1. On 5/2/23 at 12:33 P.M., the second meal cart was delivered to Second Floor. At 12:40 P.M., the last meal tray was delivered, and the following temperatures were obtained with Certified Nurses Aide (CNA) #5. Roasted Pork: 104 degrees F, lukewarm to taste Roasted Pork ground: 98 degrees F, lukewarm to taste Rice: 118 degrees F, lukewarm to taste Potatoes: 90 degrees F, lukewarm to taste Pineapple: 70 degrees F, cool to taste 2. On 5/02/23 at 12:57 the second cart was delivered to Third Floor. At 1:13 P.M., after the last tray was delivered the following food temperatures were obtained with Unit Manager (UM) #1: Mashed potatoes: 100 degrees F, lukewarm to taste Rice pilaf: 92 degrees F, room temperature to taste Roasted pork minced: 79 degrees F, room temperature to taste. UM #1 said that the temperature was below what it should be. Roasted pork: 78 degrees F, room temperature to taste. UM #1 said that she would not eat that because it was too cold. Broccoli: 78 degrees F, room temperature to taste. UM #1 said that the broccoli was also below temperature Pineapple: 65 degrees F 3. On 5/2/23 at 12:44 P.M., the second meal cart was delivered to Fourth Floor At 12:54 P.M., the last meal tray was delivered, and the following temperatures were obtained with Nurse #1: Pureed Green Beans: 72 degrees F, cool to taste. Pureed Pork: 80 degrees F, lukewarm to taste. Ground Pork: 80 degrees F, lukewarm to taste. Broccoli: 76 degrees F, warm to taste. Pork: 73 degrees F, cool to taste. Ice Cream: 36 degrees F, already melting, center was still frozen, but the majority of ice cream was liquid. Following the temperatures being taken Nurse #1 said she was unaware of what temperature the food should be served to the Residents. During an interview on 5/02/23 at 1:58 P.M., with the Food Service Director (FSD) and the Administrator, the food temperatures were reviewed. Both the FSD and the Administrator said that the food should have been served to the Residents warmer than what they were receiving. The administrator said that the facility had been reviewing this issue for some time and was aware of the concerns of cold food. During a follow up interview on 5/02/23 at 2:51 P.M., the FSD said that the meals were delivered late for breakfast yesterday (5/1/23), this morning and for lunch today. He said that it is due to being short staffed/call outs.

Based on interview and record review the facility failed to ensure its staff completed a Comprehensive Minimum Data Set (MDS) Assessment within the required time frames for eleven Residents (#141, #142, #145. #190, #191, #14, #18, #24, #30, #36, and #59) out of 38 sampled residents. Specifically, 1. for Residents #141, #142, #145, #190, and #191 the facility failed to ensure its staff completed Admission MDS Assessments within the required 14 days of admission to the facility and 2. For Residents #14, #18, #30 #36, and #59 the facility failed to ensure its staff completed an Annual MDS Assessment at least every 12 months. 1. For Residents #141, #142, #145, #190, and #191 the facility failed to complete an Admission MDS Assessment within 14 days of Admission a. Resident #141 was admitted to the facility 3/22/23. Review of the Resident's MDS Assessments indicated the Resident should have had an Admission MDS completed with an Assessment Review Date (ARD) of 3/29/23. Review of the MDS dated [DATE] indicated it had not been completed. b. Resident #142 was admitted to the facility 4/3/23. Review of the Resident's MDS Assessments indicated the Resident should have had an Admission MDS completed with an ARD of 4/10/23. Review of the MDS dated [DATE] indicated it had not been completed. c. Resident #145 was admitted to the facility 4/1/23. Review of the Resident's MDS Assessments indicated the Resident should have had an Admission MDS completed with an ARD of 4/8/23. Review of the MDS dated [DATE] indicated it had not been completed. d. Resident #190 was admitted to the facility 4/5/23. Review of the Resident's MDS Assessments indicated the Resident should have had an Admission MDS completed with an ARD of 4/12/23. Review of the MDS dated [DATE] indicated it had not been completed. e. Resident #191 was admitted to the facility 2/28/23. Review of the Resident's MDS Assessments indicated the Resident should have had an Admission MDS completed with an ARD of 3/7/23. Review of the MDS dated [DATE] indicated it had not been completed. 2. For Residents #14, #18, #24 #30 #36, and #59 the facility failed to ensure its staff completed an Annual MDS Assessment at least every 12 months. a. Resident #14 was admitted to the facility in March 2019. Review of the Resident's MDS Assessments indicated the Resident should have had an Annual MDS completed with an ARD of 3/8/23. Review of the MDS dated [DATE] indicated it had not been completed until 4/30/23. b. Resident #18 was admitted to the facility in February 2021 Review of the Resident's MDS Assessments indicated the Resident should have had an Annual MDS completed with an ARD of 2/24/23. Review of the MDS dated [DATE] indicated it had not been completed until 4/26/23. c. Resident #24 was admitted to the facility in October 2013. Review of the Resident's MDS Assessments indicated the Resident should have had an Annual MDS completed with an ARD of 4/21/23. Review of the MDS dated [DATE] indicated it had not been completed. d. Resident #30 was admitted to the facility in August 2018. Review of the Resident's MDS Assessments indicated the Resident should have had an Annual MDS completed with an ARD of 2/24/23. Review of the MDS dated [DATE] indicated it had not been completed until 4/26/23. e. Resident #36 was admitted to the facility in March 2015. Review of the Resident's MDS Assessments indicated the Resident should have had an Annual MDS completed with an ARD of 3/8/23. Review of the MDS dated [DATE] indicated it had not been completed until 4/26/23. f. Resident #59 was admitted to the facility in March 2020. Review of the Resident's MDS Assessments indicated the Resident should have had an Annual MDS completed with an ARD of 2/22/23. Review of the MDS dated [DATE] indicated it had not been completed until 4/26/23. On 5/4/23 at 9:55 A.M., the MDS Nurse said there had been some turnover in staffing in the MDS department and she was aware there were significant problems with the MDS Assessments. She further said Admission MDS Assessment for Resident's #141, #142, #145, #190, and #191 were incomplete and should have been completed within 14 days of the Residents' admissions to the facility and the Annual MDS Assessments for Residents #14, #18, #30 #36, and #59 had not been completed at least every 12 months as, required.

Based on record review and interview the facility failed to ensure its staff completed quarterly review Minimum Data Set (MDS) Assessments for 22 Residents (#3, #4, #6, #10, #16, #20, #25, #34, #37, #39, #42, #53, #55, #57, #60, #68, #71, #79, #81, #82, #83, and #84) out of a total of 38 sampled residents. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual indicated the Quarterly MDS Assessment must be completed no later than 14 calendar days after the Assessment Reference Date (ARD-refers to the last day of the observation period that the assessment covers for the resident). 1. Resident #3 was admitted to the facility in July 2016. Review of the Quarterly MDS Assessment with an Assessment Reference Date (ARD) of 3/22/23 indicated it had not been completed within 14 days of the ARD. 2. Resident #4 was admitted to the facility in December 2016. Review of the Quarterly MDS Assessment with an ARD of 2/10/23 indicated it had not been completed within 14 days of the ARD. 3. Resident #6 was admitted to the facility in September 2004. Review of the Quarterly MDS Assessment with an ARD of 2/9/23 indicated it had not been completed within 14 days of the ARD. 4. Resident #10 was admitted to the facility in November 2021. Review of the Quarterly MDS Assessment with an ARD of 3/14/23 indicated it had not been completed within 14 days of the ARD. 5. Resident #16 was admitted to the facility in March 2017. Review of the Quarterly MDS Assessment with an ARD of 3/22/23 indicated it had not been completed within 14 days of the ARD. 6. Resident #20 was admitted to the facility in September 2018. Review of the Quarterly MDS Assessment with an ARD of 3/1/23 indicated it had not been completed within 14 days of the ARD. 7. Resident #25 was admitted to the facility in June 2019. Review of the Quarterly MDS Assessment with an ARD of 3/15/23 indicated it had not been completed within 14 days of the ARD. 8. Resident #34 was admitted to the facility in May 2021. Review of the Quarterly MDS Assessment with an ARD of 3/22/23 indicated it had not been completed within 14 days of the ARD. 9. Resident #37 was admitted to the facility in October 2020. Review of the Quarterly MDS Assessment with an ARD of 3/21/23 indicated it had not been completed within 14 days of the ARD. 10. Resident #39 was admitted to the facility in November 2019. Review of the Quarterly MDS Assessment with an ARD of 3/24/23 indicated it had not been completed within 14 days of the ARD. 11. Resident #42 was admitted to the facility in December 2019. Review of the Quarterly MDS Assessment with an ARD of 3/8/23 indicated it had not been completed within 14 days of the ARD. 12. Resident #53 was admitted to the facility in December 2021. Review of the Quarterly MDS Assessment with an ARD of 3/15/23 indicated it had not been completed within 14 days of the ARD. 13. Resident #55 was admitted to the facility in December 2022. Review of the Quarterly MDS Assessment with an ARD of 3/12/23 indicated it had not been completed within 14 days of the ARD. 14. Resident #57 was admitted to the facility in January 2020. Review of the Quarterly MDS Assessment with an ARD of 3/1/23 indicated it had not been completed within 14 days of the ARD. 15. Resident #60 was admitted to the facility in September 2022. Review of the Quarterly MDS Assessment with an ARD of 4/15/23 indicated it had not been completed within 14 days of the ARD. 16. Resident #68 was admitted to the facility in March 2021. Review of the Quarterly MDS Assessment with an ARD of 3/14/23 indicated it had not been completed within 14 days of the ARD. 17. Resident #71 was admitted to the facility in May 2021. Review of the Quarterly MDS Assessment with an ARD of 3/1/23 indicated it had not been completed within 14 days of the ARD. 18. Resident #79 was admitted to the facility in August 2021. Review of the Quarterly MDS Assessment with an ARD of 2/22/23 indicated it had not been completed within 14 days of the ARD. 19. Resident #81 was admitted to the facility in May 2022. Review of the Quarterly MDS Assessment with an ARD of 2/17/23 indicated it had not been completed within 14 days of the ARD. 20. Resident #82 was admitted to the facility in July 2022. Review of the Quarterly MDS Assessment with an ARD of 4/8/23 indicated it had not been completed within 14 days of the ARD. 21. Resident #83 was admitted to the facility in January 2023. Review of the Quarterly MDS Assessment with an ARD of 4/16/23 indicated it had not been completed within 14 days of the ARD. 22. Resident #84 was admitted to the facility in August 2012. Review of the Quarterly MDS Assessment with an ARD of 2/16/23 indicated it had not been completed within 14 days of the ARD. On 5/4/23 at 9:55 A.M., the MDS Nurse said there had been some turnover in staffing in the MDS department and she was aware there were significant problems with the MDS Assessments. She further said the Quarterly Assessments for the Resident's in question were not completed within the required timeframes.

Based on record review and interview, the facility failed to ensure its staff: 1. provided a written Notice of Transfer and Discharge to the resident and/or residents representative at the time of discharge and 2. failed to notify a representative in the Office of the State Long Term Care Ombudsman when a resident was transferred from the facility for six Residents (#241, #13, #29, #85, #61, and #70) out of a total of 22 residents sampled. Findings include: Review of the facility policy titled Transfer/Discharge Notification, revised September 2022, indicated the following: -In accordance with 42 CFR 483.15, all Bear Mountain Healthcare Centers will issue residents with appropriate transfer discharge notification . -Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand -Send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman in accordance with state and federal regulation 1. For Resident #241 the facility failed to ensure staff provided the Resident and/or Resident's Representative with a copy of the notice of transfer and discharge and failed to notify the State Long Term Care Ombudsman of the transfer. Resident #241 was admitted to the facility in February 2023. Review of the Nursing Progress Note dated 3/30/23 indicated the Resident was transferred to the hospital and remained there until they returned to the facility on [DATE]. Further review of the Resident's medical record indicated no documentation that the Resident and/or the Resident's Representative was provided with a copy of the notice of transfer and discharge nor was the State Long Term Care Ombudsman notified of the transfer. On 5/3/23 at 2:45 P.M., the Director Of Social Services (DSS) said the Social Work Department sends the notice of transfer and discharge and updates the State Long Term Care Ombudsman of transfers. She further said for Resident #241 she had no documentation to show that the Resident and/or the Resident's Representative was provided with a written copy of the notice of transfer or discharge nor was there any documentation that the State Long Term Care Ombudsman had been notified of the Resident's transfer, as required. 44129 2. For Resident #13, the facility failed to ensure its staff provided the required notification to the Office of the State Long Term Care Ombudsman when the Resident was transferred to the hospital. Resident #13 was admitted to the facility in May 2021. Review of the medical record indicated the Resident was transferred to the hospital on 2/26/23. Further review of the medical record indicated no evidence the facility notified the Office of the State Long Term Care Ombudsman of the transfer to the hospital. 3. For Resident #29, the facility failed to ensure its staff provided the required notification to the Office of the State Long Term Care Ombudsman when the Resident was transferred to the hospital. Resident #29 was admitted to the facility in January 2023. Review of the medical record indicated the Resident was transferred to the hospital on 3/25/23. Further review of the medical record indicated no evidence the facility notified the Office of the State Long Term Care Ombudsman of the transfer to the hospital. During an interview on 5/3/23 at 2:53 P.M., the DSS said there was no evidence the facility notified the Office of the State Long Term Care Ombudsman that Residents #13 and #29 were transferred to the hospital, as required. 45435 4. For Resident #61, the facility failed to ensure its staff provided the required notification to the Office of the State Long Term Care Ombudsman when the Resident was transferred to the hospital. Resident #61 was admitted to the facility in July 2022. Review of the Nursing progress notes indicated the Resident was transferred and admitted to the on hospital on 2/26/23 and 3/15/23. Review of the Resident's medical record showed no documented evidence that the Office of the State Long-Term Care Ombudsman was notified of the Resident's transfer to the hospital, as required. 5. For Resident #70, the facility failed to ensure its staff provided the required notification to the Office of the State Long Term Care Ombudsman when the Resident was transferred to the hospital. Resident # 70 was admitted to the facility in April 2021. Review of the Nursing progress notes indicated the Resident was transferred and admitted to the hospital on 4/4/23. Review of the Resident's medical record showed no documented evidence that the Office of the State Long-Term Care Ombudsman was notified of the Resident's transfer to the hospital, as required. 42712 6. Resident #85 was admitted to the facility in August of 2022. Review of a nursing progress note entered on 3/28/23 at 11:35 A.M., indicated that Resident #85 was sent to the emergency room for evaluation. Review of the clinical record indicated no documented evidence that the Resident or Resident Representative had received a copy of the transfer/discharge notice at the time of transfer. During an interview on 5/03/23 at 2:45 P.M., the DSS said there was no evidence that the transfer/discharge notice was done for the Resident's 3/28/23 hospitalization as required.

Based on record review and interview, the facility failed to ensure its staff provided written notification of the Bed-Hold policy to the Resident and/or the Resident's Representative for four Residents (#61, #70, #241 and #85) who were transferred to the hospital, out of a total sample of 22 residents. Findings include: Review of the facility policy titled Bed-Hold Policy, dated 12/6/21, indicated the following: -Upon admission and when a resident is transferred for hospitalization or for therapeutic leave, a representative of the business office or designee will provide information concerning our bed-hold policy. -When emergency transfers are necessary, the facility will provide the resident or representative (sponsor) with information concerning our bed-hold policy within 24 hours of such transfer. -A copy of the resident's bed-hold or release record will be filed in the resident's medical record. 1.Resident #61 was admitted to the facility in July 2022. Review of the Nursing progress notes indicated the Resident was transferred and admitted to the hospital on 2/26/23 and 3/15/23. Review of the Resident's medical record showed no evidence that a written copy of the Bed Hold Policy was provided to the Resident and/or the Resident Representative. 2.Resident # 70 was admitted to the facility in April 2021. Review of the Nursing progress notes indicated the Resident was transferred and admitted to the hospital on 4/4/23. Review of the Resident's medical record showed no evidence that a written copy of the Bed Hold Policy was provided to the Resident and/or Resident Representative. During an interview on 5/2/23, at 3:27 P.M., the Director of Social Services (DSS) said that she had worked at the facility since April 10, 2023. She said that when residents were transferred, the families were usually called by the nurses and the social work department sent out written notifications including the Bed-Hold notification. She said that she had a binder in her office where she kept a copy of the written notifications. She said she had no evidence that the Bed-Hold policy was provided to Resident #61 and/or Resident Representative for transfers on 2/26/23 and 3/15/23, or for Resident #70 and/or Resident Representative for transfer on 4/4/23, as required. 42741 3.Resident #241 was admitted to the facility in February 2023. Review of the Nursing Progress Note dated 3/30/23 indicated the Resident was transferred to the hospital and remained there until he/she returned to the facility on [DATE]. Further review of the Resident's medical record indicated no documentation the Resident and/or the Resident's Representative was provided with a copy of the facility's Bed Hold Policy. 42712 4. Resident #85 was admitted to the facility in August of 2022. Review of a nursing progress note entered on 3/28/23 at 11:35 A.M., indicated that Resident #85 was sent to the emergency room for evaluation. Review of the clinical record indicated no documented evidence that the Resident or Resident Representative had received a copy of the Bed Hold Policy at the time of transfer. On 5/3/23 at 2:45 P.M., the DSS said the Social Work Department sends the Bed Hold Policy to the Resident and/or Resident's Representative when a resident was transferred from the facility. She further said for Resident #241 and #85 she had no documentation to indicate the Resident and/or the Resident's Representative was provided with a written copy of the Bed Hold Policy, as required.

Based on interview and record review, the facility failed to ensure its staff developed and/or implemented a comprehensive care plan in consultation with the Resident/Resident representative for four Residents (#2, #60, #145, and #29) out of a total sample of 22 residents. Findings include: 42741 1. For Resident #2 the facility failed to ensure its staff completed skin assessments as ordered by the Physician. Resident #2 was admitted to the facility in July 2022. Review of the facility policy titled Skin Body Audit, revised 5/9/22, indicated the following: -Licensed nurses will perform skin body audits on a weekly basis . Review of the Resident's May 2023 Order Summary Report indicated the following: -Weekly skin checks Mondays 3 to 11 shift. Please complete skin assessment underneath Assessments in Point Click Care (PCC-the electronic medical record the facility utilized) .with a start date of 1/3/23 Further review of the Resident's medical record indicated the last skin assessment that was completed for the Resident was on 1/4/23. On 5/2/23 at 10:49 A.M., Nurse #2 said skin assessments should be done weekly by a Nurse. Documentation should be completed and the Nurse should sign off that the skin assessment was done on either the MAR or Treatment Administration Record (TAR). Nurse #2 reviewed Resident #2's chart and said the Resident should have had his/her skin assessed on Mondays during the 3 to 11 shift per the Physician's Orders but she was unable to find any documentation that the Resident had had any recent skin assessments completed. On 5/2/23 at 2:44 P.M., the Director of Nursing (DON) said she had reviewed the Resident's medical record and she was unable to find any skin check assessments for the Resident from 1/4/23 until present and she was unable to tell if skin assessments had been completed, as required, because there was no documentation. 42690 2. For Resident #60 the facility failed to ensure its staff developed a comprehensive, individualized, person-centered care plan relative to the Resident's psychosocial well-being. Resident #60 was admitted to the facility in September 2022 with diagnoses including anxiety and adjustment disorder with depressed mood. Review of the medical record indicated no documented evidence that a psychosocial assessment was completed upon admission or anytime thereafter. PCC indicated that a Psychosocial History and Assessment was 211 days overdue. Additionally, the medical record indicated no documented evidence that an individualized, person-centered care plan had been developed relative to psychosocial well-being, that included mood or Adjustment Disorder. During an interview on 5/01/23 at 11:03 A.M., Resident #60 became visibly upset during the conversation as evidenced by tears in his/her eyes and a increase in volume of speech. He/she said that all he/she wanted to do was to leave but everyone kept saying that he/she cannot go home. The Resident said that he/she had been at the facility for almost eight months and felt like a prisoner. The Resident said that his/her spouse visits daily but can leave to go home, while he/she cannot and that was upsetting. The Resident said that no one would help him/her and began to cry. During an interview on 5/03/23 at 12:42 P.M., the Director of Social Services (DSS) said that she did not see that a personalized care with interventions relative to adjustment disorder, mood, depression or anxiety had been developed. She continued to review the Resident's medical record and said that he/she did have a psychosocial assessment dated [DATE], however it was incomplete. She additionally said that the interdisciplinary team (IDT) will meet with the resident within 48 hours of their admission. She said that shortly thereafter the social workers completed a mood and psychosocial assessment as well as completed those same assessments quarterly. She continued to say that the assessment was never completed for Resident #60 and the appropriate care plans had never been developed as required. 3. For Resident #145 the facility failed to ensure its staff developed a comprehensive, individualized, person-centered care plan relative to activities. Resident #145 was admitted to the facility in April 2023. Review of the medical record indicated no documented evidence that an individualized, person-centered care plan had been developed relative to activities. Further review of the medical record indicated an Activity Interview for Daily and Activity Preferences had been completed on 4/19/23 and indicated the following: -Yes - the interview should be conducted with the Resident >>The Resident indicated it was very important to him/her to participate in the following areas: -To listen to music -To be around animals such as pets -To keep up with the news -To go outside and get fresh air whenever possible -To participate in religious services or practices >>The Resident indicated it was somewhat important to him/her to participate in the following areas: -To have books, newspapers, and magazines to read -To do things with groups of people -To do favorite activities On 5/01/23 at 1:39 P.M., the surveyor observed Resident #145 to be seated in a geriatric chair (a specialized chair that also reclines), with an overbed table placed in front of him/her, in the hallway near the nurse's station. The surveyor noted the Resident had been seated in the same location since first observed during breakfast that morning. The surveyor did not note any activities provided to him/her throughout this observation period. On 5/01/23 at 3:23 P.M., the surveyor observed the Resident to be in the same location, sleeping, with nothing on the overbed table in front of him/her. On 5/03/23 at 10:45 A.M., the surveyor observed the Resident sleeping in the geriatric chair located in the corridor near the nurse's station. During an interview on 5/03/23 at 12:49 P.M., the Activities Director (AD) said that the Resident was placed in the hallway for safety purposes. She additionally said that he/she was social with staff but we do not have a care plan for him/her identifying interventions and/or activity preferences. The AD said that a comprehensive care plan was usually completed within three to five days of a resident's admission. She said that a comprehensive care plan related to activities had not been developed for Resident #145 and should have been as required. 44129 4. For Resident #29, the facility failed to ensure its staff developed a comprehensive, person-centered, and culturally competent care plan. Resident #29 was admitted to the facility in January 2023 with a diagnosis of unspecified dementia. Review of the MDS assessment dated [DATE] indicated the Resident had severely impaired cognition as evidenced by a BIMS score of zero out of 15. Review of the Resident's Psychotropic Medication (medication that affects mood and behavior) Care Plan indicated the Resident utilized psychotropic medication relative to behaviors due to his/her dementia, however there was no evidence of an individualized behavioral care plan. Review of the Resident's Dementia Care Plan, dated 1/29/23, indicated the following: -Administer medications as ordered. -Engage Resident in simple, structured activities that avoid overly demanding tasks. -Resident needs assistance with all decision making. -Resident requires approach that maximizes involvement in daily decision making and activity (did not specify approaches individualized to the Resident's cognitive status) Review of the Resident's Activity Care Plan, dated 2/20/23, indicated the following: -Activities staff will deliver a monthly calendar and encourage participation as tolerated. -Activities staff will offer independent activities to Resident as desired and tolerated. -Activities staff will visit one on one with Resident. Further review of the Resident's care plan did not include the Resident's preference and potential for future discharge, or if he/she were to remain in the facility, did not include a care plan for adjustment to long-term care. During an interview on 5/2/23 at 3:35 P.M., the Resident's Representative said the Resident's religion and dietary restrictions related to his/her religion were very important to him/her, could be combative and difficult to care for, and was to remain in the facility for long-term care. She further said she did not recall being included in a care plan conference; however, she did remember telling staff of the Resident's dietary restrictions when he/she was admitted . During an interview on 5/2/23 at 4:28 P.M., the Food Service Director (FSD) said he was not aware the Resident had dietary restrictions related to his/her religion. During an interview on 5/3/23 at 10:06 A.M., the Activity Director said the Resident's Activity care plan was not created timely, was neither personalized nor comprehensive, was too vague, and not up to her standards. During an interview on 5/3/23 at 1:47 P.M., DON said a Mood/Behavior care plan should have been initiated upon admission and there were no personalized interventions related to managing the Resident's specific behaviors. In addition, she said the Resident's Dementia care plan was not personalized and should have included specific items such as what the Resident's limitations and abilities were along with personalized interventions.

Based on record review and interview, the facility failed to ensure its staff completed and/or transmitted discharge information for five Residents (#13, #29, #60, and #241) out of 38 sampled residents. Findings include: Review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, dated October 2019, indicated a discharge assessment must be submitted no later than fourteen days after the date of discharge. 1. Resident #13 was admitted to the facility in May 2021. Review of the medical record indicated the Resident was transferred to the hospital on 2/26/23. Further review of the medical record indicated no evidence a discharge assessment was transmitted, as required. 2. Resident #29 was admitted to the facility in January 2023. Review of the medical record indicated the Resident was transferred to the hospital on 3/25/23. Further review of the medical record indicated no evidence a discharge assessment was completed, as required. 3. Resident #60 was admitted to the facility in September 2022. Review of the medical record indicated the Resident was transferred to the hospital on 3/23/23. Further review of the medical record indicated no evidence a discharge assessment was completed, as required. 4. Resident #67 was admitted to the facility in September 2022. Review of the medical record indicated the Resident was transferred to the hospital on 4/12/23. Further review of the medical record indicated no evidence a discharge assessment was completed, as required. 5. Resident #241 was admitted to the facility in February 2023. Review of the medical record indicated the Resident was transferred to the hospital on 3/30/23. Further review of the medical record indicated no evidence a discharge assessment was completed, as required. During an interview on 5/4/23 at 9:55 A.M., the MDS nurse said the discharge assessments were not transmitted and/or completed for Residents #13, #29, #60, #67 and #241, as required.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required extensive assistance of two staff members and the use of a mechanical lift for all transfers, the Facility failed to ensure staff implemented and followed interventions from his/her plan of care related to his/her individual care needs with transfers. On 07/28/22 during the evening shift, Resident #1 was transferred into bed by two staff members without the use of a mechanical lift, he/she sustained a laceration to his/her left leg, was later transferred to the Hospital Emergency Department where he/she received twelve sutures to close his/her left leg wound, he/she was also diagnosed with a left ankle fracture and admitted to the Hospital for further treatment. Findings Include: Review of the Facility Policy titled Comprehensive Care Plan, undated, indicated that an individualized comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The Policy indicated that each resident's comprehensive care plan was designed to reflect currently recognized standards of practice for problem areas and conditions. Resident #1 was admitted to the Facility in March 2015, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she required extensive assistance of two staff members for transfers. Review of Resident #1's Certified Nurse Aide (CNA) Care Card, updated 06/03/22, indicated he/she required the assistance of two staff members for transfers with the use of a mechanical lift. Review of Resident #1's Alteration in Ability to Complete Activities of Daily Living Care Plan, dated as revised on 06/13/22, indicated he/she required assistance of two staff members and the use of a mechanical lift for transfers. Review of Resident #1's Nurse Progress Note, dated 07/28/22, indicated that at 6:45 P.M., Certified Nurse Aide (CNA) #2 reported that Resident #1's left leg was bleeding a lot. The Note indicated that CNA #2 told the nurse that she saw blood under Resident #1's wheelchair after putting him/her into bed. The Note indicated that when this nurse went to Resident #1's room, she observed an open wound on his/her left calf that measured 4.0 centimeters (cm) in length, 0.75 cm wide, and 1.0 cm deep. The Note indicated there was a copious amount of fresh red blood and that there was a puddle of blood on the floor beside Resident #1's bed. During an interview on 09/07/22 at 11:42 A.M., Nurse #1 said that on 07/28/22 she worked the 7:00 A.M. to 7:00 P.M. shift and at approximately 6:25 P.M., CNA #2 told her that Resident #1 was bleeding. Nurse #1 said she went an assessed Resident #1, and observed him/her laying on the bed slightly diagonal across the bed with his/her head not quite up to the pillow. Nurse #1 said Resident #1's left leg was hanging over the side of the bed, he/she was bleeding from his/her shin, and that there was a puddle of blood on the floor. Nurse #1 said she did not see a mechanical lift inside or nearby the room. During an interview on 09/19/22 at 10:46 A.M., Certified Nurse Aide (CNA) #2 said that at approximately 6:30 P.M. on 07/28/22, she and CNA #1 transferred Resident #1 into bed without the use of a mechanical lift. CNA #2 said she had not provided care for Resident #1 in the past, did not know that Resident #1 required the use of a mechanical lift and said she did not look at his/her CNA Care Card before providing care to him/her. During an interview on 09/07/22 at 12:15 P.M., Certified Nurse Aide (CNA ) #1 said she did not assist CNA #2 with transferring Resident #1 back to bed on 7/28/22. However, review of the Facility's Internal Investigation Report, indicated the Facility was able to determine that CNA #1 and CNA #2 manually transferred Resident #1 back to bed on 7/28/22, and did not use a mechanical lift as required. Review of Resident #1's Nurse Progress Note, dated 07/28/22 (written by the 11:00 P.M. to 7:00 A.M. nurse) indicated that it was reported to this on-coming nurse during change of shift report, that Resident #1 had sustained a laceration to his/her left leg. The Note indicated that while doing rounds, Resident #1's left leg dressing was observed to have blood seeping through and upon unwrapping the dressing his/her laceration was bleeding profusely. The Note indicated that Resident #1's Physician was notified, 911 was called, and he/she was transferred to the Hospital Emergency Department. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 08/03/22, indicated that on 07/28/22 at approximately 6:45 P.M., Resident #1 sustained a laceration during a transfer. The Report indicated that the Facility internal investigation findings were that Resident #1's laceration was noted immediately after a transfer and he/she was later transferred to the Hospital Emergency Department for further evaluation due to significant bleeding. The Report indicated that Resident #1's wound was treated and he/she was also diagnosed with a left ankle fracture. The Report indicated that the Facility determined that the Certified Nurse Aides (CNAs) who performed Resident #1's transfer said they transferred him/her back into bed by a two-person physical transfer. The Report indicated that Resident #1 was non-weight bearing and that his/her Care Plan and CNA Care Card indicated that CNAs should transfer him/her with the use of a mechanical lift. The Report indicated that the Facility investigation concluded that Resident #1 most likely sustained the fracture at the same time he/she suffered the laceration and indicated that dried blood was found on the left footrest prong of his/her wheelchair. Review of the Hospital Emergency Department Documentation Summary Report, dated 07/29/22, indicated Resident #1 was evaluated and noted to have lacerations above his/her ankle joint, his/her wounds were irrigated, and closed with twelve sutures. The Report indicated that x-rays revealed that Resident #1 had a left ankle fracture, he/she was administered intravenous antibiotics, and was admitted to the Hospital. During an interview on 09/07/22 at 12: 51 P.M., the Director of Nursing (DON) said that during her investigation into Resident #1's injuries, she interviewed both CNA #1 and CNA #2 about what occurred during Resident #1's transfer on 07/28/22, and that eventually they both told her that they had transferred Resident #1 into bed without the use of a mechanical lift. The DON said Resident #1 was a hard and complicated transfer because he/she had contractures, could not weight bear, and therefore required the use of a mechanical lift with all transfers. The DON said both CNA #1 and CNA #2 did not follow Resident #1's plan of care.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required extensive assistance of two staff members and the use of a mechanical lift for all transfers, the Facility failed to ensure he/she was provided with the appropriate level of assistance, which included the use of an assistive device, required to maintain his/her safety, in an effort to prevent incident/accidents resulting in injury. On 07/28/22, Resident #1 was transferred into bed by two staff members without the use of a mechanical lift, he/she sustained a laceration to his/her left leg, was transferred to the Hospital Emergency Department where he/she received twelve sutures to close the wound, was also diagnosed with a left ankle fracture, and was admitted to the Hospital for further treatment. Findings Include: The Facility Policy titled Mechanical Lifts, dated 01/10/17, indicated that a mechanical lift would be used to transfer patients/residents for whom manual transfer is not recommended. Resident #1 was admitted to the Facility in March 2015, diagnoses included dementia, anxiety, depression, muscle wasting, and age related [CONDITION(S)]. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 required extensive assistance of two staff members for transfers. Review of Resident #1's Certified Nurse Aide (CNA) Care Card, updated 06/03/22, indicated he/she required the assistance of two staff members for transfers with the use of a mechanical lift. Review of Resident #1's Alteration in Ability to Complete Activities of Daily Living Care Plan, dated as revised on 06/13/22, indicated he/she required the assistance of two staff members and the use of a mechanical lift for transfers. Review of Resident #1's Nurse Progress Note, dated 07/28/22, indicated that at 6:45 P.M., Certified Nurse Aide (CNA) #2 reported that Resident #1's left leg was bleeding a lot. The Note indicated that CNA #2 told this nurse that she saw the blood under Resident #1's wheelchair after he/she was transferred into bed. The Noted indicated that when this nurse went to Resident #1's room, she observed an open wound on his/her left calf that measured 4.0 centimeters (cm) in length, 0.75 cm wide, and 1.0 cm deep. The Note indicated there was a copious amount of fresh red blood from the wound and that there was a puddle of blood on the floor beside Resident #1's bed. Review of the Event/Incident Report, dated 07/28/22, indicated that Resident #1 was observed with a laceration to his/her left lower leg. The Report indicated that the laceration occurred in Resident #1's room during a transfer. The Report indicated that CNA #2 reported to Nurse #1 that Resident #1 was bleeding after he/she was transferred from his/her wheelchair into his/her bed. Review of Resident #1's Wound Documentation Form, dated 07/28/22, indicated that when he/she was transferred from his/her wheelchair into bed, he/she sustained a laceration that was 4.0 centimeters (cm) in length, 0.75 cm wide, and 1.0 cm deep with a copious amount of fresh bleeding. Review of Resident #1's Nurse Progress Note, dated 07/28/22, (from the 11:00 P.M. to 7:00 A.M., shift) indicated that it was reported to this on-coming nurse during the change of shift report, that Resident #1 had sustained a laceration to his/her left leg. The Note indicated that while doing rounds, Resident #1's left leg dressing was observed to have blood seeping through and upon unwrapping the dressing his/her laceration was bleeding profusely. The Note indicated that Resident #1's Physician was notified, 911 was called, and he/she was transferred to the Hospital Emergency Department. Review of the Hospital Emergency Department (ED) Documentation Summary Report, dated 07/29/22, indicated Resident #1 was evaluated and noted to have lacerations above his/her ankle joint, his/her wounds were irrigated, and closed with twelve sutures. The ED Summary Report also indicated that x-rays revealed that Resident #1 had a left ankle fracture, he/she was administered intravenous antibiotics, and was admitted to the Hospital. Review of the Nurse #1's written Statement, dated 07/29/22 indicated that she had last observed Resident #1 seated in his/her wheelchair in his/her room when she administered medications to him/her at 5:00 P.M. The Statement indicated that at 6:25 P.M., CNA #2 told her that Resident #1 was bleeding a lot and when she (Nurse #1) entered his/her room, observed Resident #1 laying across his/her bed with his/her left leg dangling over the edge. The Statement indicated Resident #1 had a large laceration on his/her shin with cutaneous tissue visible. During an interview on 09/07/22 at 11:42 A.M., Nurse #1 said that on 07/28/22 she worked 7:00 A.M. to 7:00 P.M. shift and at approximately 6:25 P.M., CNA #2 told her that Resident #1 was bleeding. Nurse #1 said she went to assess Resident #1 and observed him/her laying on the bed slightly diagonal across the bed with his/her head not quite up to the pillow. Nurse #1 said Resident #1's left leg was hanging over the side of the bed, he/she was bleeding from his/her shin and that there was a puddle of blood on the floor. Nurse #1 said she did not see the mechanical lift inside or nearby the room. During an interview on 09/19/22 at 10:46 A.M., CNA #2 said that at approximately 6:30 P.M. on 07/28/22, she and CNA #1 transferred Resident #1 into bed without the use of a mechanical lift. CNA #2 said she had not provided care for Resident #1 in the past, did not know that Resident #1 required the use of a mechanical lift with transfers and said she did not look at his/her CNA Care Card prior to caring for him/her. During an interview on 09/07/22 at 12:15 P.M., Certified Nurse Aide (CNA ) #1 said she did not assist CNA #2 with transferring Resident #1 back to bed on 7/28/22. However, review of the Facility's Internal Investigation Report, indicated the Facility was able to determine that CNA #1 and CNA #2 manually transferred Resident #1 back to bed on 7/28/22, and did not use a mechanical lift as required. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 08/03/22, indicated that on 07/28/22 at approximately 6:45 P.M., Resident #1 sustained a laceration during a transfer. The Report indicated that the Facility internal investigation findings were that Resident #1's laceration was noted immediately after a transfer and he/she was later transferred to the Hospital Emergency Department for further evaluation due to significant bleeding. The Report indicated that Resident #1's wound was treated and he/she was diagnosed with a left ankle fracture. The Report indicated that the Facility determined that the two Certified Nurse Aides (CNA #1 and CNA #2) that performed Resident #1's transfer said they transferred him/her into bed by a two-person manual transfer. The Report indicated that Resident #1 was non-weight bearing and that his/her Care Plan and CNA Care Card indicated that CNAs should transfer him/her with the use of a mechanical lift. The Report indicated that the Facility investigation concluded that Resident #1 most likely sustained the fracture at the same time he/she suffered the laceration and indicated that dried blood was found on the left footrest prong of his/her wheelchair. During an interview on 09/07/22 at 12: 51 P.M., the Director of Nursing (DON) said that during her investigation into Resident #1's injuries, she interviewed both CNA #1 and CNA #2 about what occurred during Resident #1's transfer on 07/28/22. The DON said after speaking with both CNAs individually, they both told her they transferred Resident #1 into bed without the use of a mechanical lift. The DON said Resident #1 was a hard and complicated transfer because he/she had contractures, could not bear weight, and therefore required the use of a mechanical lift.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose physicians' orders included nursing to administer 2.5 milligrams (mg) of [MEDICATION(S)] (narcotic) oral liquid solution for pain management, the Facility failed to ensure Resident #1 was free from a significant medication error. On 6/20/22, Resident #1 was administered 50 milligrams (mg) of [MEDICATION(S)], 20 times the prescribed dosage. As a result Resident #1 became extremely lethargic, was found slumped over in bed and could not be aroused by nursing, and required treatment with [MEDICATION(S)] (medication to treat a narcotic overdose in an emergency situation). Findings include: The Facility's Standard of Practice, Perry and Potter 7th edition, 2010, indicated that: - Drug errors occur as a result of failure of nurses to make clinical judgements when administering medications. -To promote a rigorous problem-solving approach and to not simply give drugs automatically. - Adhere to steps in preventing medication errors which include to be sure to read labels at least three times before removing the container from the supply drawer, when placing the medication in an administration syringe or cup, and just before administering the medication to the resident, to double check all calculations and verify with another nurse and to question unusually large or small doses. Lexicomp, an e-pharmacology reference, dated 2020, indicated there is a risk of medication errors with the administration of [MEDICATION(S)]. Dosing errors occur due to confusion between milligrams (mg) and milliliters (ml), which can result in accidental overdose and death. Adverse effects may cause respiratory depression, serious life threatening or fatal respiratory depression. Resident #1 was admitted to the Facility in 10/2013, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Medication Error Incident Report, indicated on 6/20/22 at 10:40 A.M., indicated Resident #1 was administered the wrong dose of [MEDICATION(S)] liquid solution. The Report indicated that Resident #1 was administered 50 milligrams (mg) (20 times the prescribed dose of [MEDICATION(S)]) instead of the physician ordered 2.5 milligram (mg) dose. The Report indicated the possible contributing factors were, Nurse #2 did not perform medication administration steps correctly, she missed steps and did not read the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the manufacturer label on the [MEDICATION(S)] bottle indicated the following: - [MEDICATION(S)] concentration 20 milligrams (mg) per 1 milliliter (ml) a liquid concentration, each milliliter (ml) contained 20 milligrams (mg) of [MEDICATION(S)]. Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #1 on 6/20/22 at 10:40 A.M. Review of the Controlled Substance, Book Number 10/ 1, Page Number 58, indicated on 6/20/22 at 10:40 A.M., for Resident #1's [MEDICATION(S)] administration, Nurse #2 signed for and removed; - 2.5 mls of [MEDICATION(S)] solution from the [MEDICATION(S)] bottle (that was labeled it contained a concentration of 20 milligrams (mg) per 1 ml), - The documentation indicated Nurse #2 obtained, prepared, and administered 50 mg of [MEDICATION(S)] to Resident #1, (not 2.5 mg (0.0125 ml), as ordered). Review of Resident #1's Physician Order, dated 6/20/22, indicated to administer [MEDICATION(S)] 0.4 mg, in the nostrils one time for an overdose. Review of Resident #1's Nursing Progress Note, dated 6/20/22 at 4:37 P.M., written by Nurse #2 indicated (on 6/20/22) Resident #1 was administered the wrong dose of [MEDICATION(S)], [MEDICATION(S)] was given and he/she was monitored. During an interview on 7/19/22 at 2:06 P.M., Nurse #2 said on 6/20/22, at approximately 10:40 A.M., Resident #1 was complaining of pain, Nurse #2 said she obtained a new lower weird order, from hospice, for [MEDICATION(S)] sulfate 0.125 milliliters. Nurse #2 said she mixed up the concept of milligrams with milliliters, so instead of administering 2.5 mg as ordered, she administered 2.5 milliliters, using a 1 milliliter syringe three times and administered a total dose of [MEDICATION(S)] solution 50 milligrams to Resident #1. Nurse #2 said on 6/20/22 around 2:00 P.M., she realized that Resident #1 was very lethargic, this was a change in Resident #1's baseline condition, and said she went to another unit to consult with Nurse #4. During an interview on 7/19/22 at 2:00 P.M., Nurse #4 said Nurse #2 came to her unit, and they both looked at Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #4 said Nurse #2 was upset, and said she (Nurse #2) had made a medication error and she needed to obtain [MEDICATION(S)] for Resident #1. Nurse #4 said she went to evaluate Resident #1, noted he/she was lethargic, was slumped over in bed, and not arousable with a sternal rub. Nurse #4 said she administered nasal [MEDICATION(S)] and Resident #1 was then arousable, and she (Nurse #4) notified the physician of Resident #1's overdose. The Nurse Progress Note, dated 6/20/22, written by Nurse #4 indicated (on 6/20/22) Resident #1 was lethargic and unresponsive to verbal stimuli, this writer (Nurse #4) was informed by Nurse #2 that Resident #1 was in distress and needed [MEDICATION(S)]. The Note indicated Nurse #4 administered [MEDICATION(S)] to Resident #1 at his/her bedside with positive effect, he/she opened his/her eyes and began talking shortly afterwards. The Physician's Progress Note, dated 6/21/22, indicated Resident #1 was evaluated due to receiving the incorrect dose of [MEDICATION(S)], unfortunately he/she received 2.5 ml of [MEDICATION(S)], instead of 2.5 mg. Resident #1 was status post [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 7/19/22 at 2:00 P.M., the Director of Nurses said this medication error was so unfortunate, when Nurse #2 read the [MEDICATION(S)] medication order in the computer, she read it as [MEDICATION(S)] 2.5 mls, she did not read the milligrams. The DON said Nurse #2 drew up 2.5 milliliters of [MEDICATION(S)] using a 1 ml syringe, The DON said Nurse #2 used three 1 ml syringes in total, two of which contained 1 ml and the third contained 0.5 mls, and then administered the excessively high dose of [MEDICATION(S)].

Based on interviews and records reviewed, for two of three sampled residents (Residents #1 and #2), the Facility failed to ensure Resident #2 was free from abuse when, on 1/27/22 around 10:30 A.M., Certified Nurse Aide (CNA) #1 found Resident #1, a confused resident with a known history of sexually inappropriate behaviors, completely naked laying on top of Resident #2, a confused, non-verbal resident who was unable to move away from Resident #1 or call for help. CNA #1, Nurse #1, Nurse #2 and Unit Manager #1 did not immediately intervene or separate the residents, instead they left Resident #1 laying (naked) on top of Resident # 2, stood outside of Resident #2's room and observed the residents for around five minutes, waiting for the Director of Nursing (who staff called twice) to come to the unit to observe Resident #1's inappropriate behavior for herself. Findings include: The Facility Abuse Prohibition Policy, revised 10/16/20, indicated that the Facility prohibits the mistreatment, neglect and abuse of residents by anyone. Review of Resident #1's clinical record indicated that the most recent Admission Minimum Data Set (MDS) Assessment, dated 10/30/21, indicated that his/her cognitive patterns were severely impaired. Review of Resident #1's Nursing Progress Notes indicated the following; -10/28/21, staff members reported that Resident #1 tended to get grabby with female staff members. -11/22/21, Resident #1 tried to touch staff members inappropriately while care was being given and Resident #1's behavior did not change when staff members asked him/her to keep his/her hands to him/herself. -01/20/22, Resident #1 was very inappropriate toward staff members, including making sexual innuendos and remained inappropriate despite being asked by staff members to stop. During staff interviews with Nurse #4 on 2/09/22 at 12:39 P.M., with Nurse #5 on 2/10/22 at 12:45 P.M., with Nurse #6 on 2/10/22 at 4:45 P.M., with Nurse #7 on 2/10/22 at 4:24 P.M., with Nurse #8 on 2/10/22 at 10:30 A.M., with CNA #5 on 2/10/22 at 11:00 A.M., with CNA #9 on 2/10/22 at 11:30 A.M., with CNA #6 on 2/10/22 at 11:49 A.M. and with CNA #7 on 2/10/22 at 12:30 P.M., indicated the following; Nurses #4, #5, #6, #7, #8 and CNAs #5, #6, #7, #9, all said that between October 2021 and January 2022, Resident #1 exhibited sexually inappropriate behavior during care. CNAs #5, #6, #7 and #9 said that Resident #1 touched staff member's waist, buttocks, crotch or breasts during care and made sexual gestures. CNA #7 said that on occasion, Resident #1 had an erection during care and he/she gestured toward the erection and stated words to the effect of, [OBSCENITY] or suck. CNA #9 said that on the one occasion when she cared for Resident #1, he/she got out of bed, pushed her backwards toward a wall and Resident #1 put his/her hand under her (CNA #9) shirt on her breast. CNA #9 said that Resident #1 attempted to put his/her hand into the waist of her pants and said she was able to move away from him/her. Nurses #4, #5, #6, #7 and #8 said that CNAs reported that Resident #1 exhibited sexually inappropriate behaviors during care and grabbed staff member's breasts, buttocks or crotch. Nurse #8 said that during care, Resident #1 would grab CNAs hands and try to move their hands to his/her genitals and would try to put his/her hands between staff member's legs or on their buttocks. Nurse #7 said that CNAs reported that Resident #1 also made sexual comments and gestures. Review of a Nurse Progress Note, dated 1/27/22, indicated that at around 10:30 A.M., Resident #1 was found in Resident #2's room laying naked on top of Resident #2. Review of Resident #2's clinical record indicated that the most recent Quarterly MDS Assessment, dated 11/10/21, indicated that his/her cognitive patterns were severely impaired, he/she did not speak, he/she rarely understood others, he/she did not ambulate and he/she required the extensive assistance from staff members with bed mobility and transfers. During an interview on 2/07/22 at 3:20 P.M., CNA #1 said that she was assigned to care for Resident #1 during the 7:00 A.M. to 3:00 P.M. shift on 1/27/22. CNA #1 said that around 10:00 A.M., she noticed that Resident #1 was not in his/her room and when she exited Resident #1's room to look for him/her, she saw Resident #1 on Resident #2's bed. CNA #1 said that Resident #1 was completely naked, and was on top of Resident #2 in Resident #2's bed. CNA #1 said that Resident #2 was lying on his/her back and Resident #1 appeared to be climbing into Resident #2's bed from the foot of the bed. CNA #1 said that when she first saw Resident #1, Resident #1 was moving up toward the head of Resident #2's bed. CNA #1 said that she did not separate Resident #1 and Resident #2 or remove Resident #1 from Resident #2's room, but said she shouted for Nurse #1 to come to Resident #2's room and assist her. During an interview on 2/09/22 at 12:10 P.M., Nurse #1 said that she was Resident #1's nurse during the 7:00 A.M. to 3:00 P.M. shift on 1/27/22. Nurse #1 said that when CNA #1 called for her to come to the doorway of Resident #2's room, she observed that Resident #1 was completely naked in Resident #2's bed. Nurse #1 said although Resident #1 was facing toward Resident #2, he/she was lower in the bed so that Resident #1's head was near Resident #2's abdomen. Nurse #1 said that Resident #1 and Resident #2 were awake and were not moving. Nurse #1 said she did not separate Resident #1 and Resident #2 or remove Resident #1 from Resident #2's room. Nurse #1 said Nurse #2 joined her and CNA #1 standing in the doorway of Resident #2's room. During an interview on 2/07/22 at 12:40 P.M., Nurse #2 said that on 1/27/22 CNA #1 called for Nurse #1 to come to Resident #2's room. Nurse #2 said that she followed Nurse #1 to Resident #2's room and saw Resident #1 and Resident #2 lying in Resident #2's bed. Nurse #2 said that Resident #1 was completely naked and was lying on top of Resident #2. Nurse #2 said she did not immediately separate Resident #1 and Resident #2 or remove Resident #1 from Resident #2's bed. Nurse #2 said she asked Nurse #1 whether they should remove Resident #1 from Resident #2's bed and Nurse #1 told her they should call for help. Nurse #1 said that she called the Director of Nursing (DON) from a cell phone she had in her pocket and asked the DON to come to Resident #2's unit. Nurse #1 said that she waited for the DON in the doorway of Resident #2's room, along with Nurse #2 and CNA #1 . During an interview on 2/07/22 at 11:45 A.M., Unit Manager #1 said that during a meeting on 1/27/22, the Director of Nursing (DON) received a telephone call and, when the DON ended the call, the DON asked her (Unit Manager #1) to respond to an incident on Resident #2's unit. Unit Manager #1 said that when she arrived on Resident #2's unit, Nurse #2 directed her toward Resident #2's room and, when she arrived in Resident #2's room, she saw Resident #1, who was completely naked, lying on top of Resident #2 in Resident #2's bed. Unit Manager #1 said that she did not separate Resident #1 and Resident #2 or remove Resident #1 from Resident #2's bed. Unit Manager #1 said she called the DON and asked her to come to Resident #2's unit. Nurse #1 said that she stood outside of Resident #2's room with CNA #1, Nurse #2 and Unit Manager #1 for around five minutes from her first call to the DON, and said both the DON, and Assistant Director of Nursing arrived to Resident #2's room and at that point they removed Resident #1 from Resident #2's bed. Although Resident #2 was unable to be interviewed about the alleged incident due to his/her communication and cognition deficits, an unimpaired individual would experience mental anguish when a completely naked stranger crawled on top of them in bed, was unable to move away on his/her own, as well as when staff did not immedialty intervene on Resident #2's behalf, and separate them or remove Resident #1 from on top of Resident #2, but instead, stood in the doorway and observed.

Based on interviews and records reviewed, for two of three sampled residents (Residents #1 and #2) the Facility failed to provide adequate supervision for Resident #1 and Resident #2 to prevent an avoidable incident/accident, when, on 1/27/22 around 10:30 A.M., Resident #1, a confused resident with a known history of sexually inappropriate behaviors, who was completely naked, got into Resident #2's bed, and was found laying on top of Resident #2, a confused, non-verbal resident who was unable to move away or call for help. Although staff were aware that Resident #1's behaviors were escalating, that he/she was able to remove and disengage personal alarms, no additional interventions were put into place in an attempt to prevent further incidents from occurring. Findings include: Review of the Facility Event/Incident Report Policy, revised July 2015, indicated it is the Facility policy to provide an environment that is free from hazards over which the Facility has control. The Policy indicated the Facility identified each resident at risk for accidents and adequately planned care and implemented procedures to prevent accidents. The Policy indicated accidents/incidents included resident to resident altercations. Review of the Facility Care Plan Policy, revised 10/16/09 indicated that it was the policy of the Facility to develop comprehensive care plans which contained identified problem areas, measurable goals and the interventions to be utilized to reach goals. Review of Resident #1's clinical record indicated that the most recent Admission Minimum Data Set Assessment (MDS), completed 10/30/21 indicated that his/her cognitive patterns were severely impaired. Review of Resident #2's clinical record indicated that most recent Quarterly MDS Assessment, completed 11/10/21, indicated that his/her cognitive patterns were severely impaired, he/she did not speak, he/she rarely understood others, he/she did not walk and he/she required the extensive assistance from staff with bed mobility and transfers between surfaces. During interviews with Nurse #4 on 2/09/22 at 12:39 P.M., with Nurse #5 on 2/10/22 at 12:45 P.M., with Nurse #6 on 2/10/22 at 4:45 P.M., with Nurse #7 on 2/10/22 at 4:24 P.M., with Nurse #8 on 2/10/22 at 10:30 A.M., with CNA #5 on 2/10/22 at 11:00 A.M., with CNA #9 on 2/10/22 at 11:30 A.M., with CNA #6 on 2/10/22 at 11:49 A.M. and with CNA #7 on 2/10/22 at 12:30 P.M., staff said the following; Nurses #4, #5, #6, #7, #8 and CNAs #5, #6 and #7 said that between October 2021 and January 2022, Resident #1 regularly exhibited sexually inappropriate behaviors during care. CNAs #5, #6 and #7 said that Resident #1 touched staff member's waist, buttocks, crotch or breasts during care and made sexual gestures. Nurses #4, #5, #6, #7 and #8 said that CNAs regularly reported to nursing that Resident #1 exhibited sexually inappropriate behavior during care such as grabbing staff member's breasts, buttocks or crotch, making sexual comments, gestures and trying to move staff members hands to his/her genital area. Review of Resident #1's clinical record, dated October 2021 through to 1/27/22, indicated there was no documentation to support a Care Plan was developed to address Resident #1's sexually inappropriate behaviors, including interventions for staff to redirect or monitor for behaviors. During interviews with the Director of Nursing on 2/07/22 at 8:30 A.M. and the MDS Coordinator on 2/07/22 at 12:21 P.M., the Director of Nursing and the MDS Coordinator said that the Facility did not develop a comprehensive Care Plan until after the incident 1/27/22, for Resident #1's sexually inappropriate behaviors which contained identified problem areas, measurable goals and interventions to be utilized by staff. During an interview on 2/09/22, CNA #4 said that around 6:00 A.M. on 1/27/22, while she changed Resident #1's incontinence brief and clothes in bed, Resident #1 placed his/her hand on his/her genitals and stated words to the effect of, do you see the boy. CNA #4 said that she told Resident #1 that his/her behavior was not appropriate. CNA #4 said that between 6:00 A.M. and 7:00 A.M. on 1/27/22, she saw Resident #1 in his/her wheelchair peeking out of the doorway of his/her room. CNA #4 said that she thought Resident #1 was watching for an opportunity to sneak out of his/her room. CNA #4 said that, at one point, she heard Resident #1's wheelchair alarm sounding and she found that Resident #1 had removed the alarm from his/her wheelchair and placed it under the pillow on his/her bed. CNA #4 said that while she was replacing the wheelchair alarm, Resident #1 placed his/her hands between her (CNA #4) legs and grabbed her crotch. CNA #4 said that she reported Resident #1's sexually inappropriate behavior to the nurse. During an interview on 2/09/22 at 12:10 P.M., Nurse #1 said that on 1/27/22 during the 7:00 A.M. to 3:00 P.M. shift, she worked with Resident #1 for the first time and, said when she arrived that morning, staff members from the 11:00 P.M. to 7:00 A.M. shift reported to her that Resident #1 exhibited sexually inappropriate behaviors during the night. Nurse #1 said that when she went into Resident #1's room between 7:00 A.M. and 8:00 A.M. on 1/27/22 to speak with Resident #1's roommate, Resident #1 waved and gestured for her to come closer to him/her. Nurse #1 said that when she moved closer to Resident #1, Resident #1 pointed at and gestured towards his/her genital area. Nurse #1 said that a short time later, Resident #1 was in the hallway after having gotten out of bed without sounding the bed alarm. Nurse #1 said that she checked Resident 1's bed alarm and found that it had been deactivated. Nurse #1 said that that shortly before 9:00 A.M. on 1/27/22, she spoke to the Director of Nursing, the Assistant Director of Nursing, the MDS Coordinator and the Social Worker and told them that Resident #1 exhibited sexually inappropriate behaviors and could move around the unit without staff members being aware because he/she was able to deactivate his/her personal and wheelchair alarms. During interviews with the MDS Coordinator on 2/07/22 at 12:21 P.M., and the Social Worker on 2/07/22 at 11:05 A.M., they said that on 1/27/22 shortly before 9:00 A.M., Nurse #1 told them that Resident #1 exhibited sexually inappropriate behavior. The Director of Nursing, Assistant Director of Nursing, and the MDS Coordinator also said that on 1/27/22 shortly before 9:00 A.M., Nurse #1 told them that Resident #1 exhibited sexually inappropriate behavior. During an interview on 2/07/22 at 3:20 P.M., CNA #1 said that she was assigned to care for Resident #1 on 1/27/22 during the 7:00 A.M. to 3:00 P.M. shift, and said this was the first time she had care for him/her. CNA #1 said that staff members on the previous shift (11:00 P.M. to 7:00 A.M.) told her that Resident #1 was touchy feely with staff members during the night shift. CNA #1 said that Nurse #1 told her that Resident #1 knew how to deactivate his/her bed and wheelchair alarms and that Nurse #1 said that between 7:00 A.M. and 8:00 A.M., she had found Resident #1 out of his/her bed without his/her bed alarm sounding. CNA #1 said that around 10:00 A.M., she noticed that Resident #1 was not in his/her room and she noticed that his/her wheelchair and bed alarms in his/her room were not sounding. CNA #1 said she exited Resident #1's room to look for him/her and she saw Resident #1, who was completely naked, on Resident #2's bed. CNA #1 said that Resident #2 was lying on his/her back in bed and Resident #1 was climbing into Resident #2's bed from the foot of the bed. CNA #1 said Resident #1 was moving up toward the head of Resident #2's bed. CNA #1 said that she shouted for Nurse #1 to assist her. Nurse #1 said that when she joined CNA #1 in the doorway of Resident #2's room, she saw that Resident #1 was completely naked and was on top of Resident #2. Nurse #1 said that although Resident #1 was facing Resident #2, who was lying on his/her back in bed, Resident #1 was lower in Resident #2's bed so that Resident #1's head was near Resident #2's abdomen. Nurse #1 said that Resident #1 and Resident #2 were awake but were not moving. Nurse #1 said that she called the Director of Nursing (DON) from a cell phone she had in her pocket and asked the DON to come to Resident #2's unit. Nurse #1 said that she and CNA #1 waited for the DON in the doorway to Resident #2's room and were joined by Nurse #2 and Unit Manager #1. Nurse #1 said that around five minutes later, the DON and the Assistant Director of Nursing arrived on the unit, came to Resident #2's room and that the Assistant Director of Nursing removed Resident #1 from Resident #2's bed. Review of Resident #1's clinical record indicated that there was no documentation to support that, although staff were aware that Resident #1 exhibited sexually inappropriate behaviors, that behaviors were escalating and that he/she had been able to disengage and remove his/her personal alarms, that additional preventative measure were put into place, including increased staff supervision or frequent monitoring, in an effort to prevent further incidents. Although Resident #2 was not interviewed about the alleged incident due to his/her communication and cognition deficits, an unimpaired individual would experience mental anguish when a completely naked stranger crawled on top of them in bed and they were unable to move away from the person or call for help.

Based on observations, record reviews and interviews, the facility failed to provide adequate supervision and/or assistance to prevent accident hazards for 4 sampled Residents (# 31, # 47, # 69 and # 70) , out of a total sample of 23 residents and failed to secure a medication cart. Findings include: 1. For Resident #47, the facility staff failed to immediately assess the resident after a fall. The Resident sustained a fracture of the left hip. Review of the Fall Reduction Policy, dated 1/10/17 indicated that in the event a resident falls, conduct a physical assessment to determine if there are any injuries. Notify the nursing supervisor immediately. Resident #47 was admitted to the facility in October 2020, with diagnoses including ataxia. Review of the Minimum Data Set (MDS) Assessment, dated 7/8/21, indicated that the resident was cognitively intact, as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status Assessment (BIMS), required extensive assistance with ambulation and transfers and had no falls since the last MDS Assessment. Review of the Nurse's Note, dated 9/29/21 at 1:54 P.M., indicated that the Resident was found on the floor in his/her room. The note further indicated that the staff assisted the Resident to the wheelchair and to the toilet, prior to an assessment by the nurse. The nurse assessed the Resident while the Resident was seated on the toilet. The Resident complained of left hip pain but was able to transfer to the wheelchair. Review of the nurse's note, dated 9/29/21 at 6:11 P.M., indicated that the nurse administered Tylenol for left side pain. Review of the Nurse's Note, dated 9/29/21 at 8:07 P.M. indicated that the Resident was still exhibiting pain and the Nurse Practitioner ordered a STAT (immediate) x-ray of the left hip and pelvis. Review of the nurse's note, dated 9/29/21 11:38 P.M., indicated that x-ray results showed the resident had a fracture to the left femoral neck. The Resident was transferred to the hospital. During an interview with Certified Nurse Aide (CNA) # 8 on 1/18/22 at 2:37 P.M. she said that prior to the fall, he/she was able to do a stand/pivot transfer. On 1/18/22 at 2:47 P.M. the surveyor observed the Resident lying in bed sleeping on his/her back. The bed was raised to a 30 degree angle. 2 half side rails were raised. During an interview with Nurse #3 on 1/18/22 at 2:52 P.M. she said that the protocol was to assess a resident after a fall for pain, bleeding and evidence of a possible fracture, prior to transferring the resident. During an interview with the Assistant Director of Nursing (ADON) on 1/18/22 at 3:57 P.M. she said that the CNAs should not have transferred the Resident prior to the nurse assessing him/her. 2. The facility failed to ensure medications were secured at an unattended medication cart. Review of the facility Medication Administration-General Guidelines Policy, dated 10/01/19, indicated, but is not limited to: During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. In addition, privacy is maintained always for all resident information, example: Medication Administration Record (MAR) (by closing the MAR book/covering the MAR sheet or computer screen) when not in use. On 1/18/22 at 7:55 A.M., the surveyor observed on the Fourth Floor, the South Hall Medication cart parked outside a resident's room. The cart was unattended, unlocked and a medication cup containing three pills, was on top of the cart. Staff were observed passing by the medication cart. During an interview on 1/18/22 at 7:58 A.M., Nurse #3 said she should not have left the medication cart unlocked and a medication cup containing medications, on the top of the cart, when she left the cart unattended. 3. For Resident #69, the facility failed to ensure fall prevention interventions were implemented. Resident #69 was admitted to the facility in December 2021 with diagnoses including dementia and muscle weakness. Review of the Fall Risk Assessment, dated 12/18/21, indicated the Resident was a high risk for falls with a score of 17 (score above 10 represents a high risk for falls). Review of the Event/Incident Report, dated 12/22/21, indicated the Resident had an unwitnessed fall in the hallway. The Resident fell out of the wheelchair and onto his/her face. The Resident sustained a hematoma (an injury that causes blood to collect and pool under the skin) on the forehead and a lump on his/her nose. Review of two Certified Nursing Assistant statements indicated a thump was heard when Resident #69 fell . The statements did not indicate a chair alarm was activated. Further review of the report indicated the Resident's alarm was on the chair and did not function when the fall occurred. Resident #69 was transferred to the emergency room for further evaluation and returned to the facility. Review of the 12/24/21 MDS Assessment indicated the Resident had severe cognitive impairment as evidenced by a score of one out of 15 on the Brief Interview for Mental Status (BIMS) Assessment. On 1/11/22 at 1:27 P.M., the surveyor observed the Resident ambulating in his/her room. The resident's wheelchair was positioned inside the resident's doorway, facing the hallway. There was a chair alarm hanging on the backrest of the wheelchair and was not sounding. During an interview on 1/11/22 at 1:30 P.M., Nurse #4 said the chair alarm did not activate when the Resident got out of the wheelchair. 4. For Resident #70, the facility failed to ensure medications were kept secured when not administered. Resident #70 was admitted to the facility in July 2018. Review of the MDS Assessment, dated 12/9/21, indicated Resident #70 was cognitively intact as evidenced by a BIMS Assessment score of 15 out of 15. On 1/14/22 at 8:16 A.M., the surveyor observed Resident #70 seated in a recliner in his/her room. A medication cup containing two pills was observed on the over bed table which was positioned next to the Resident. When the surveyor asked the Resident what was present in the medication cup, he/she said don't ask me and proceed to take the medication in the surveyors presence. There was no nursing staff present during this observation. Review of the 1/2022 Medication Administration Record (MAR), indicated the following medications were to be administered at 6:00 A.M.: - [MEDICATION(S)] (medication to treat fluid retention and high blood pressure), 2.0 milligrams (mg) - Pepcid (medication to reduce stomach acid), 20 mg Further review of the MAR indicated these medications were signed off by the nurse as administered at 6:00 A.M. on 1/14/22. During an interview on 1/19/22 at 10:45 A.M., Nurse #12 said she usually worked the 11:00 P.M. to 7:00 A.M. shift., and if a resident was sleeping when she went to administer his/her medications, she would not leave the medications unattended at the resident's bedside. She said she would dispose of the medications and re-administer them when the resident was awake. Nurse #12 said that when medications are administered to residents, the nurse needs to verify that the resident took the medications. She further said that if the medications were left at the bedside, they could be dropped or thrown away and not taken by the resident. She also said that if would be possible that someone else could take the medications if the nurse was not present to verify that they were taken, as prescribed. During an interview on 1/19/22 at 11:37 A.M., the Director of Nurses (DON) said that there were no residents in the facility that were able to self administer medications. She said that when nurses administer medications, they were required to stay with the resident to ensure that the resident had taken them, even if the resident was alert and oriented. The DON said it was the standard for the facility to not leave medications at the resident's bedside for them to self administer. 5. For Resident #31, the facility failed to ensure the environment remained free of accident hazards and provide adequate supervision. Resident #31 was admitted to the facility in October 2021 with diagnosis including dementia, [CONDITION(S)] and [CONDITION(S)] following a [CONDITION(S)] disease (one sided weakness following a stroke), unsteadiness on feet, aphasic (a disorder that affect one's speech) and lack of coordination. Review of the clinical record indicated Resident #31 was at risk for wandering as evidenced by the following documentation: - An Exit Seeking/Elopement Evaluation/Wandering note, dated 11/14/2021, which was completed due to the Resident attempting to exit through the stairwell door. The assessment indicated the following: *Resident is self - mobile via wheelchair *Risk factor includes his/her desire to return home *Exit seeking behavior *Resident attempted to elope through the stairwell. *Behavior has occurred for 1-3 days *Wandering behavior places the Resident at significant risk of getting to a potentially dangerous place *Behavior has gotten worse since last assessment *Resident understands verbal content *Summary and plan indicated the Resident was considered to NOT be at risk at the time of this assessment. - A Nurse's Note, dated 11/30/21, indicated the Resident continued to wander out of bed and without assistance. - A Nurse's Note, dated 1/3/22, indicated the Resident is alert but confused at baseline, is at risk for elopement and alarms are in place. On 1/18/22 at 8:12 A.M., the surveyor observed Resident #31 attempting to exit the unit through the stairwell located near the nurse's station. He/she was observed with his/her left hand outreached pressing the red, door release button. The Resident's right hand had pushed the door to the stairwell slightly open, before the surveyor intervened. At this time, the Resident was unsupervised. The surveyor did not observe any signage or magnetic stop sign across the door. During an interview on 1/18/22 at 8:30 A.M., the Director of Nurses (DON) said that Resident #81 had previously attempted to exit through the stairwell (at the end of the hallway), back in November 2021. She said the staff placed a magnetic stop sign across the doorway to deter him/her from trying to exit but did not place the magnetic stop signs on the other stairwell doors, including the door in which Resident #81 attempted to exit from at the time of the surveyor's observation.

Based on observations, interviews and record review, the facility failed to ensure treatment and services were provided to prevent an identified pressure ulcer (injury to the skin and underlying tissue resulting from prolonged pressure to the area) from worsening for one sampled Resident (#70), out of a total sample of 23 residents. Findings include: Review of the facility policy titled Wound Care Protocols, dated 3/11/13, indicated the intent was to promote the prevention of pressure ulcer development as well as the healing of existing pressure ulcers. The policy included but was not limited to: - residents/patients will be evaluated by the nurse for risk of skin break down - a weekly body audit will be completed on all patients/residents - wounds will have weekly assessments and documentation on each area until healed - wound dressings will be verified each shift for placement - the facility will designate an interdisciplinary team to review all wounds and make recommendations on a routine basis Review of the facility policy titled Wound Documentation, dated 3/11/13, indicated the goal was to ensure appropriate wound documentation is recorded in the patient/resident medical record. The policy also included the following but was not limited to: - at the onset of a new wound or the deterioration of an existing wound, the nurse will notify the physician, patient/resident and/or responsible party and document the notification in the medical record - at the onset of a new wound, the nurse will initiate a weekly wound flow sheet (pressure or non-pressure) for each wound. Weekly wound assessments will be performed and documented until healed. - the criteria for weekly wound care documentation will include the following: - type of wound - staging or classification of the wound - correct anatomical position - measurements in centimeters (cm) including depth, wound base tissue - drainage - odor - tunneling/undermining - wound edges and area around the wound (periwound) - pain assessment - treatment and response to treatment Review of the facility policy titled Wound Measurement, dated 3/11/13, indicated the facility will obtain measurements at the onset of a new wound and track and measure the progression of healing from week to week. Resident #70 was admitted to the facility in July 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Alteration in Skin Integrity Care Plan, initiated 2/12/20, indicated to complete the pressure ulcer risk assessment as scheduled, monitor the skin and notify the nurse of abnormal findings/changes, and conduct weekly skin checks. Review of the Physicians Order, initiated 8/31/20, indicated to conduct weekly skin checks on the 11:00 P.M. to 7:00 A.M. shift. Review of the Norton Scale for Predicting Risk of Pressure Ulcers, dated 6/10/21, indicated Resident #70 was at a moderate risk for pressure ulcers. Review of the Weekly Skin Check form, dated 8/12/21, indicated Resident #70 did not have any areas present on his/her skin. Further review of the form indicated a small area on the Resident's coccyx (tailbone) was identified and Triad cream (type of wound cream) was applied. There was no documented evidence that a clinical assessment of the of the area was obtained relative to the measurement or the presence of drainage or odor. Review of a Nurses's Note, dated 8/13/21, indicated Resident #70 complained of buttock pain, and the Nurse documented the Resident had shearing (skin injury which is generated when skin is moved against a fixed surface) on his/her bilateral gluteal folds (area on the back of the upper thigh that meets the lower area of the buttock), and Triad cream was applied. The Nurse indicated in the note that the Resident was encouraged to get out of bed to relieve pressure off of his/her buttocks and that a Rehabilitation Services request was submitted. There was no documented evidence that a clinical assessment of the area was obtained relative to measurement, drainage and odor. Review of a Nurse's Note, dated 8/18/21, indicated narcotic pain medication was administered for the Resident's complaints of hip/buttock pain. A subsequent Nurse's Note indicated a circular area was observed on the Resident's upper buttock. The Nurse indicated in the progress note that the wound bed was red in color and had purplish tissue surrounding the wound, had small amounts of drainage, yellow colored eschar (dead tissue), and that an order was obtained to apply Santyl (ointment that removes dead tissue from wounds so that they can start to heal), and that a request was submitted for rehabilitation therapy to evaluate Resident #70. There was no documented evidence that a clinical assessment of the of the area was obtained relative to the measurement of the wound, nor evidence that Rehabilitation Services evaluated him/her. Review of a Nurse's Notes, dated 8/21/21 indicated the treatment was administered to the Resident's buttock wound. The area was documented as circular in shape, had eschar present which was purplish, black in color, and had moderate amounts of purulent (foul smelling) drainage on the old dressing. The Resident was administered narcotic pain medication for complaints of buttock pain. There was no documented evidence that a clinical assessment of the of the area was obtained relative to the measurement of the wound, nor any indication that the Physician was notified of the clinical changes relative to the status of the wound. Review of a Nurse's Note, dated 8/24/21, indicated the Resident was medicated for buttock pain, the treatment was changed to his/her upper buttocks and the area was observed to have moderate amounts of eschar and slough (yellow white dead skin tissue in a wound bed), moderate amounts of purulent drainage and that the facility requested the Wound Physician to evaluate the wound. Review of the Wound Physician Note, dated 8/24/21, indicated Resident #70 was evaluated for a left buttock wound. The Wound Physician indicated the Resident presented with an unstageable full thickness skin and tissue pressure ulceration to his/her left iliac crest. The area had slough, had a foul odor and measured 3.0 centimeters (cm) by 9 cm (length) by 4.5 cm (width) by 0.01 cm (depth). The Wound Physician recommended that Rehabilitation Services evaluate Resident #70 for a specialized cushion, an out of bed schedule to be initiated and an X-ray of the area to rule out an infection. Review of the Minimum Data Set Assessment, dated 9/9/21, indicated Resident #70 was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) Assessment score of 14 out of 15, was at risk for pressure ulcers and had one Unstageable Pressure Ulcer due to coverage of the wound bed by slough and/or eschar. On 1/18/22 at 10:12 A.M., the surveyor observed Resident #70 positioned in the recliner in his/her room. During an interview at this time, the Resident said that the Wound Physician evaluated his/her wounds weekly. During an interview on 1/19/22 at 11:18 A.M., the Director of Nurses (DON) said that when an area on a resident's skin was identified, the Physician would be notified and a description of the area would be completed either on an assessment form or in the progress notes which would include the location of the area, the size, odor if any, description of any drainage if applicable, and an assessment of the area surrounding the wound. The DON further said an assessment would be completed relative to nutrition, turning and repositioning, wound/skin interventions (i.e air mattress, specialized cushions), and the wound consultant would be notified so that the area could be assessed. The DON said that there should be a clinical assessment and documentation on Resident #70's pressure ulcer when it was first identified. During a follow up interview on 1/19/22 at 3:45 P.M., the DON said that she was unable to locate evidence that a wound assessment was conducted for Resident #70 when the area on first identified on 8/13/21. She further said that the wound should have been measured when identified and then weekly. The DON said that the pressure ulcer should be assessed daily when treatment (dressing) changes were completed, and if there were changes to the area, the Physician should be alerted. She further said that she could not find documented evidence that this occurred for Resident #70.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who had a history of blood clots and required treatment with an anticoagulant medication, the Facility failed to ensure nursing staff implemented and followed their Medication Orders Policy regarding Resident #1's orders related to the administration of [MEDICATION(S)] (anticoagulant). The Hospital Discharge Summary indicated Resident #1's dose of [MEDICATION(S)] should be tapered down after 30 days, then continued daily at a lower dose for an additional 30 days, before being discontinued. However nursing staff changed the orders without clarifying them with the Physician and the administration of Resident #1's [MEDICATION(S)] was stopped after 30 days. Resident #1 was transferred to the Hospital Emergency Department due to complaints of back pain with shortness of breath, was diagnosed with a new right middle lobe pulmonary embolism and was admitted . Findings include: Review of the Facility's Policy titled Medication Orders, dated 10/01/2019, indicated any dose or order that appears inappropriate considering the resident's age, condition, allergies, or diagnosis is verified by nursing with the attending physician. The Policy also indicated that the Prescriber is contacted by nursing to verify or clarify an order when the directions are confusing. Review of the Facility's Medication Error Incident Report, dated 06/22/21, indicated Resident #1's anticoagulant medication was stopped earlier than ordered because nursing transcribed the medication with a stop date. Review of the Facility's Internal Investigation Report, dated 06/22/21, indicated that Resident #1's anticoagulant medication was not on his/her active medication profile. The Report indicated that there was no evidence to support the Physician was contacted for clarification related to his/her anticoagulant medication. Review of Resident #1's Hospital Discharge Summary, dated 04/20/21, indicated that [MEDICATION(S)] ([MEDICATION(S)]) was ordered upon discharge from Hospital. The Report indicated that Resident #1's [MEDICATION(S)] to be administered as follows: - [MEDICATION(S)] 5 milligram (mg) tablet, 2 tablets (10 mg total) every 12 hours for 30 days (until 5/19/21), - [MEDICATION(S)] 10 mg two times daily for seven days (until 5/26/21) - then continue [MEDICATION(S)] 5 mg, two times daily (no end date) Review of Resident #1's Physician Order Summary, dated 04/20/21 through 06/30/21, indicated his/her orders for [MEDICATION(S)] were as follows; - administer [MEDICATION(S)], 5 milligram (mg) tablet, give 2 tablets (total of 10 mg) by mouth two times a day related to acute embolism and [CONDITION(S)] of deep veins of upper extremity, until 04/24/21, then administer [MEDICATION(S)],10 mg two times daily for three days (until 4/28/21), and then taper down dose to [MEDICATION(S)] 5 mg, give one tablet by mouth two times a day. Review of Resident #1's Initial Admission Assessment, dated 04/23/21 and completed by the Physician Assistant, indicated that Resident #1 was being treated with [MEDICATION(S)] 10 mg two times daily for seven days, then followed by 5 mg two times daily on a continuous basis. However on 4/24/21, Nurse #2 revised Resident #1's [MEDICATION(S)] orders as follows: - [MEDICATION(S)] 5 mg, give 2 tablets (10 mg total) by mouth two times a day until 05/22/21 (with no further instructions). Resident #1's [MEDICATION(S)] was stopped on 05/22/21, however this order was not consistent with the Physician Assistant Progress Note that indicated Resident #1 was to be on [MEDICATION(S)] continuously or the Hospital Discharge Summary that indicated Resident #1 was to be on [MEDICATION(S)] with the dose being tapered. During an interview on 07/21/21 at 1:15 P.M., Nurse #2 said she reviewed Resident #1's medication orders on admission after Nurse #1 had done the initial review. Nurse #2 said she changed Resident #1's orders to reflect a stop date for the [MEDICATION(S)] because the Hospital Discharge Summary had a stop date for this medication. Nurse #2 said the order for [MEDICATION(S)] was confusing. Nurse #2 said she did not call the Physician to clarify the order for [MEDICATION(S)]. During an interview on 07/21/21 at 12:10 P.M., the Medical Director said the Hospital sometimes add stop dates on medications that are long term use medications. The Medical Director said his team of providers at the Facility always go back and review medications for new admits. The Medical Director said sometimes Nurses don't read the entire order to the Physician when they call the on-call system for medication verification. The Medical Director said it is was a systems issue and that they (the Facility) have been working on it. The Medical Director said he was not contacted by anyone from nursing to clarify Resident #1's anticoagulant medication orders. Review of Hospital Discharge Summary Record, dated 06/21/21, indicated Resident #1 was treated for a new right sided pulmonary embolism (blood clot). On 07/21/21, the Facility provided the Surveyor with a plan of correction which addressed the concerns as evidenced by: A) Resident #1 was transferred to the Hospital on 06/21/21 and admitted , and returned two days later with new orders for the [MEDICATION(S)]. B) On 06/24/21, the Director of Nurses completed a Facility wide audit to ensure all residents on anticoagulant medications had appropriate and correct orders in place, there were no issues found. C) The Director of Nurses immediately completed weekly audits on orders reviewed and transcribed by Nurse #2 on 06/24/21, and will continue to conduct audits for three months. D) The Director of Nurses completed audits on all orders for anticoagulant medications in the Facility that were transcribed by nurses, there were no issues found . E) The Director of Nurses and Unit Managers implemented a new process on 06/24/21 to review all orders for residents newly admitted during morning daily morning meetings; no issues have been found so far. This process will continue as part of quality assurance. F) The Director of Nurses completed an in-service education on 06/22/21 for all licensed staff regarding anticoagulants and stop dates, questioning orders by calling the physician for clarifications, and documenting medication orders and changes to medications. G) Results of the audits will be discussed in the quality Assurance Performance Improvement (QAPI) meeting which is also attended by the Medical Director. H) The Director of Nurses (DON) and/or designee will be responsible for overall compliance.

Based on records reviewed and interviews for 1 of 5 sampled residents (Resident #1), the Facility failed to assess Resident #1 to determine if he/she was in need of Basic Life Support (BLS); Cardiopulmonary Resuscitation (CPR- an emergency procedure in which the heart and lungs are made to work by compressing the chest overlying the heart and forcing air into the lungs) and an Automatic External Defibrillator (AED - a device that can identify an abnormal heart rhythm that needs a shock, which increases the chance of survival), first to a resident requiring this emergency care prior to the arrival of emergency medical personnel. Resident #1. The Facility failed to ensure licensed staff could provide Basic Life Support (BLS). Both the physician order [REDACTED].#1 chose life supporting resuscitation in the event of a cardiac or respiratory arrest. Resident #1 had a witnessed [MEDICAL CONDITION]. Resident #1 had agonal breathing (ineffective breathing requiring cardio-pulmonary resuscitation) for 20 minutes prior to the Emergency Medical System being activated and CPR being performed. The Licensed staff did not apply the Automated External Defibrillator (AED) - a device that can identify an abnormal heart rhythm that needs a shock, which increases the chance of survival when it was brought to Resident #1's room. Resident #1 was transported to the Hospital in [MEDICAL CONDITION] and was treated with Advanced Cardiac Life support and pronounced dead at 3:50 A.M. at [DATE]. Findings include: The Facility Policy titled, Emergency Medical Response, dated [DATE], indicated, prior to the arrival of Emergency Medical Services (EMS), nursing staff will provide basic life support, and CPR will be initiated for any resident who experiences [MEDICAL CONDITION] (cessation of respirations and/or pulse) if the resident has a physician's orders [REDACTED]. Resident #1's [DIAGNOSES REDACTED]. The Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form, dated [DATE], indicated that Resident #1's guardian wanted CPR, ventilation, and transfer to the hospital. A physician's orders [REDACTED].#1 had full code status (all resuscitative measures were to be implemented in the event of a cardiac respiratory arrest if the heart stops beating, or if breathing stops, including CPR with basic and advance life support). Nurse's note, timed at 3:28 A.M. and dated [DATE], indicated: -At 2:00 A.M. 2:25 A.M. (2 different times were documented as the time Resident #1 became unresponsive) the Resident was found trying to get out of bed and became unresponsive. Resident #1's oxygen saturation and heart rate decreased (the decreasing oxygen saturation levels and heart rate were not documented), oxygen was applied. Emergency response was called, cardiopulmonary resuscitation was administered. Emergency Medical Services was called at 2:45 A.M. - At 2:50 A.M. Emergency Medical Services (EMS) took over resident care. - At 3:28 A.M. Resident #1 was transported to the Hospital. The Dispatch Report, dated [DATE] at 2:45 A.M., indicated there was an unresponsive resident with shallow breathing. The first Ambulance Run Report, dated [DATE], indicated EMS was dispatched for an unresponsive resident with shallow breathing and according to the caller, 'this is not a [MEDICAL CONDITION].' Upon arrival of EMS, the resident was found laying on the floor while one Nurse was performing compressions, one component of CPR. EMS took over CPR, applied the AED, the Resident was in asystole (a [MEDICAL CONDITION] rhythm in which there is no discernable electrical activity on the electrocardiogram monitor also called flat line) with no shock advised. Resident #1 was transported to the Hospital. The second Ambulance Run Report, dated [DATE], indicated the Emergency Medical Technician stated, We got here and they had just started CPR. They said he/she was unresponsive with agonal respirations (ineffective breathing requiring CPR) for 20 minutes before they started CPR. The Nurse said they were doing CPR for 10 minutes. The Surveyor interviewed Nurse #1, who was the Nurse assigned to Resident #1 during the 11:00 P.M. to 7:00 A.M. shift on [DATE], on [DATE] at 11:00 A.M. and on [DATE] at 9:10 A.M. Nurse #1 said at 2:00 A.M. or 2:25 A.M. (Nurse #1 could not recall if it was 2:00 A.M. or 2:25 A.M.), Resident #1 became unresponsive. Resident #1's breathing was irregular and he/she was gasping (agonal breathing - ineffective breathing). She applied oxygen via a nasal cannula at 2 liters, and he/she had erratic heart rates, low as 40 beats per minute and oxygen saturation levels low as 70%. Nurse #1 said she applied oxygen via nasal cannula. Nurse #1 said that when Resident #1 was unresponsive with irregular breathing. Nurse #1 failed to identify and assess the agonal breathing (a indicator of CPR) which delayed CPR and activation of the EMS, she did not apply the AED when it arrived on the Unit, and she did not ventilate Resident #1 with 2 breaths via the bag valve mask. Instead, she performed only chest compressions, bystander CPR. The Surveyor interviewed the Director of Nurses (DON) at 10:08 A.M. on [DATE]. The DON said that Resident #1 was a full code, and that he/she wanted life sustaining measures implemented in the event of a cardiopulmonary arrest. The DON said she was not aware that the AED was not applied to Resident #1 during his/her cardiopulmonary arrest, nor that there was a delay in CPR due to the staff not recognizing agonal breathing (ineffective breathing) with in an unresponsive Resident. The DON said the AED should have been used with his/her cardiopulmonary arrest. The Hospital report, dated [DATE], indicated Resident #1 was transported to the Hospital in [MEDICAL CONDITION] and was treated with Advanced Cardiac Life support and pronounced dead at 3:50 A.M. at [DATE].

Based on record review and interviews, for 1 of 5 sampled residents (Resident #1), the Facility failed to notify the Physician of Resident #1's new onset of shortness of breath, and of Resident #1 feeling sick with a low oxygen saturation level of 90 % (percentage of oxygen in the blood, 90% or greater is normal, 90% or lower warrants immediate medical attention). Subsequently on [DATE], Resident #1 had a witnessed arrest and became unresponsive with agonal breathing (ineffective breathing) and sustained a [MEDICAL CONDITION] (sudden unexpected loss of heart function, breathing and consciousness). Finding include: The Facility policy titled, Physician, Nurse Practitioner, Physician Assistant Notification Guidelines, dated ,[DATE], indicated it is the responsibility of the licensed professional nurse to observe for changes in the resident condition, to make assessments of the change, and to notify the Physician. Information required prior to contacting the Physician included: Vital signs (oxygen saturation), subjective symptoms (what does the resident state), physical assessment of lungs. The Clinical Nursing Skills and Techniques, 7th edition, 2010, indicated the pulse oximetery is the noninvasive measurement of arterial blood oxygen saturation, the percent to which hemoglobin is filled with oxygen. The more hemoglobin saturated by oxygen the higher the oxygen saturation. Normal oxygen saturation is greater than 90%. Resident #1's [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#1 had full code status (all resuscitative measures were to be implemented in the event of a cardiac respiratory arrest if the heart stops beating or if breathing stops, including CPR with basic and advance life support). The Nurses Progress note, dated [DATE] at 5:15 P.M., documented by Nurse #4, indicated Resident #1 had returned from a renal appointment with no recommendations (no documentation of shortness of breath or dyspnea). The Surveyor interviewed Family Member #1 at 2:05 P.M. on [DATE] and at 2:38 P.M. on [DATE]. Family Member #1 said that on [DATE] at approximately 8:30 P.M. he/she called Resident #1's unit and spoke to the covering Nurse, who asked Family Member #1, words to the effect of, if she should believe Resident #1 when Resident #1 complains of shortness of breath or needing oxygen. Family Member #1 said of course I believe (Resident #1). The Surveyor interviewed Nurse #4 at 3:49 P.M. on [DATE] and at 2:50 P.M. on [DATE]. Nurse #4 was assigned to Resident #1 on [DATE] during the 3:00 P.M. to 11:00 P.M. shift. Nurse #4 said that Resident #1 complained of shortness of breath a couple of times around 8:30 P.M Nurse #4 said Resident #1 had no signs of respiratory or cardiac distress other than dyspena (difficulty breathing) but has psychosomatic complaints before. Nurse #4 said there was no care plan in place for Resident #1 having psychosomatic complaints. Approximately 5.5 to 6 hours after Resident #1 complained of shortness of breath he/she was found unresponsive, at approximately 2:00 A.M. or 2:25 A.M. Nurse #4 said that she did not notify the Physician of Resident #1's new onset of shortness of breath, nor did she document in the Nurse's Notes Resident #1's shortness of breath. Nurse #4 said she obtained a heart rate and blood pressure which were not elevated, but did not document nor remember the heart rate and blood pressure values. When Nurse #4 was asked what was Resident #1's respiratory rate, Nurse #1 said it was normal Nurse #1 said she did not obtain an oxygen saturation level nor listen to Resident #1's lungs. A Nurse's Note, dated [DATE] and timed at 3:28 A.M., indicated Resident #1 complained of abdominal pain around 1:45 A.M., stating I feel sick. Resident vital signs were; (clinical measurements that indicate the state of a resident's essential body function) blood pressure ,[DATE] (normal ,[DATE]), oxygen saturation level (percentage of oxygen in the blood, greater that 90% is normal, 90% or lower warrants immediate medical attention) was 90% on room air.At 2:00 A.M. 2:25 A.M. (Nurse #1 documented 2 different times as to when Resident #1 became unresponsive), Resident #1 was found trying to get out of bed, became unresponsive, oxygen saturation and heart rate decreased, oxygen was applied, Emergency Response was called, cardiopulmonary resuscitation was administered, and the Emergency Medial Services took over the care at 2:50 A.M. The Surveyor interviewed Nurse #1, who was the Nurse assigned to Resident #1 during the 11:00 P.M. to 7:00 A.M. shift on [DATE], on [DATE] at 11:00 A.M. and on [DATE] at 9:10 A.M. Nurse #1 said she did not know that 90% oxygen saturation was abnormal, and she did not notify the physician at 1:45 A.M., that Resident #1 felt sick and had a low oxygen saturation level of 90%. Nurse #1 said at 2:00 A.M. or 2:25 A.M., Resident #1 became unresponsive. Resident #1's breathing was irregular and he/she was gasping (agonal breathing - ineffective breathing). Nurse #1 applied oxygen via a nasal cannula at 2 liters, and he/she had erratic went up and down heart rates as low as 40 beats per minute and oxygen saturation levels as low as 70%. The Ambulance Run Report, dated [DATE], indicated EMS was dispatched for an unresponsive resident with shallow breathing and according to the caller, 'this is not a [MEDICAL CONDITION].' Upon arrival of EMS, the resident was found laying on the floor while one Nurse was performing chest compression, one element of CPR. EMS took over CPR, applied the AED, the Resident was in asystole with no shock advised. Resident #1 was transported to the Hospital. The Hospital report, dated [DATE], indicated Resident #1 was transported to the Hospital in [MEDICAL CONDITION], was treated with Advanced Cardiac Life support, and was pronounced dead at 3:50 A.M. at [DATE].

Based on records reviewed and interviews, for 1 of 5 sampled residents (Resident #1), who on [DATE], had a witnessed [MEDICAL CONDITION], Resident #1 became unresponsive, sustained a [MEDICAL CONDITION] (sudden unexpected loss of heart function, breathing, and consciousness). The Facility failed to ensure that acceptable standards of practice were followed: - Staff did not administer respiratory ventilations and cardiac compressions when Resident #1 had agonal breathing (ineffective breathing), which requires Cardiopulmonary Resuscitation (CPR), because they were unable to assess and identify agonal breathing. There was a lack of competence with recognizing and assessing an unresponsive resident with agonal breathing. - Staff did not immediately activate the Emergency Medical Services (911) when Resident #1 was found unresponsive as there was a 20 minute delay. - Failed to perform ongoing assessment of Resident #1 after the oxygen saturation was 70% (the percentage of oxygen in the blood stream normal is greater than 90%) and oxygen was applied. Staff did not know an oxygen saturation of 90 % was not an acceptable level. - Failed to thoroughly assess Resident #1's Respiratory status which, included, respiratory rate, lung sounds, heart sounds, level of consciousness. -Failed to identify when Resident #1 went from respiratory distress to [MEDICAL CONDITION]. Unable to identify and assess agonal breathing and its impact. - Staff did not apply the Automated External Defibrillator (AED) - a device that can identify an abnormal heart rhythm that needs a shock, which increases the chance of survival when it was brought to Resident #1's room . The Emergency Department physician's report, dated [DATE] indicated Resident #1 presented in [MEDICAL CONDITION] (without a heart beat or respirations). Resident #1 was found to have agonal respirations for approximately 20 minutes before nursing staff at the Facility called the Emergency Medical System (911). Advanced Cardiac Life Support was attempted without success. Resident #1 died in the Emergency Department. Findings include: - The Massachusetts Board of Registration in Nursing (Board) is created and authorized by Massachusetts General Laws (M.G.L.) c. 13, §§ 13, 14, 14A, 15 and 15D, and G.L. c. 112, §§ 74 through 81C to protect the health, safety, and welfare of the citizens of the Commonwealth through the regulation of nursing practice and education. The Board's regulation at 244 CMR 9.03(6) requires all nurses to comply with Nursing Competency Related to Advisory Ruling (AR). According to the Advisory Ruling, Nurses are responsible and accountable for their nursing judgments, actions and competency with regard to performing CPR in accordance with accepted standards of practice. The Basic Life Support, Provider Manual from the American Heart Association, dated 2016, indicated [MEDICAL CONDITION] victims sometimes present with agonal gasp (a sign the body is not receiving the oxygen it needs, which can be indicative of [MEDICAL CONDITION]).[MEDICAL CONDITION] dispatchers should inquire about victims absence of responsiveness and quality of breathing (normal versus not normal). If the victim is unresponsive with absence or abnormal breathing, then the rescuer and dispatcher should assure that the victim is in [MEDICAL CONDITION]. Implementing Automated External Defibrillator Program, American Heart Association (AHA), dated 2016 indicated that a strong chain of interventions can improve chances of survival and recovery for victims of [MEDICAL CONDITION] and other emergencies. Four of five links in the AHA adult chain of interventions include: - Recognition and activation of the emergency response system - Immediate high-quality Cardiopulmonary Resuscitation - Rapid defibrillation - Basic and advanced emergency services Defibrillation is a process in which an electronic device gives an electric shock to the heart. Defibrillator stops ventricular fibrillation by using an electrical shock and allows the return of a normal heart rhythm. A victims chance of survival decreases by 7 to 10 percent for every minute that passes without defibrillation. The Facility's policy titled, Emergency Medical Response, dated ,[DATE], indicated the Facility follows American Heart Association Guidelines for CPR and Emergency Cardiovascular Care. If a critical emergency occurs, 911 will be called. Prior to the arrival of Emergency Medical Services (EMS), nursing staff will provide basic life support. CPR will be initiated for any resident who experiences [MEDICAL CONDITION] (cessation of respirations and/or pulse) if the resident has a physician order [REDACTED]. The Facility's policy titled, Automatic External Defibrillator (AED), [DATE] indicated AEDs are provided to treat any [MEDICAL CONDITION]. Emergency response drills will be conducted on a quarterly basis. Before the AED is used, the nurse obtains the victims's chart and reviews the Advance Directives. If CPR is indicated, the staff who discovered the Resident, calls an Emergency call. A member of the Emergency Response team obtains the nearest AED. Another member calls 911. The AED is positioned next to the victim but is not applied unless the victim is not responding, has no pulse and is not breathing (agonal, grasping breath, is not effective breathing). Resident #1's [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#1 had full code status (all resuscitative measures were to be implemented in the event of a cardiac respiratory arrest including CPR, if the heart stops beating or if breathing stops with basic and advance life support). Nurse's note, timed at 3:28 A.M. and dated [DATE], indicated: -At 2:00 A.M. 2:25 A.M. (Nurse #1 documented 2 different times as to when Resident #1 became unresponsive), the Resident was found trying to get out of bed and became unresponsive. Resident #1's oxygen saturation and heart rate decreased, oxygen was applied. Emergency response was called, cardiopulmonary resuscitation was administered. - At 2:50 A.M. Emergency Medical Services (EMS) took over resident care. - At 3:28 A.M. Resident #1 was transported to the Hospital The Dispatch Report, dated [DATE] at 2:45 A.M., indicated there was an unresponsive resident with shallow breathing. The first Ambulance Run Report, dated [DATE], indicated EMS was dispatched for an unresponsive resident with shallow breathing and according to the caller, this is not a [MEDICAL CONDITION]. Upon arrival of EMS, the resident was found laying on the floor while one Nurse was performing compression, one component of CPR. EMS took over CPR, applied the AED, the Resident was in asystole (a [MEDICAL CONDITION] rhythm in which there is no discernable electrical activity on the electrocardiogram monitor also called flat line) with no shock advised. Resident #1 was transported to the Hospital. The second Ambulance Run Report, dated [DATE], indicated the Emergency Medical Technician stated, We got here and they had just started CPR. They said he/she was unresponsive with agonal respirations (ineffective breathing requiring CPR) for 20 minutes before they started CPR. The Nurse said they were doing CPR for 10 minutes. The Hospital report, dated [DATE], indicated Resident #1 was transported to the Hospital in [MEDICAL CONDITION], was treated with Advanced Cardiac Life support, and pronounced dead at 3:50 A.M. at [DATE]. The Surveyor interviewed Nurse #1 at 11:00 A.M. on [DATE] and at 9:10 A.M. on [DATE]. Nurse #1 said at 2:00 A.M. or 2:45 A.M., Resident #1 became unresponsive. Resident #1's breathing was irregular and he/she was gasping (agonal breathing - ineffective breathing). She applied oxygen via a nasal cannula at 2 liters, and he/she had erratic (went up and down) heart rates (as low as 40 beats per minute) and oxygen saturation levels (as low as 70%). Nurse #1 said that when Resident #1 was unresponsive with irregular breathing that she did not recognize the agonal breathing which delayed CPR and activation of the EMS, she did not apply the AED when it arrived on the Unit, and she did not ventilate Resident #1 with 2 breaths via the bag valve mask. Instead she performed only chest compressions, bystander CPR. Review of the education records indicated Nurse #1 and Nurse #2 had not been trained with the mock code drills at the Facility. The Surveyor interviewed the Director of Nurses (DON) at 10:08 A.M. on [DATE]. The DON said she was not aware that the AED was not applied to Resident #1 during his/her cardiopulmonary arrest, nor that there was a delay in CPR due to the staff not recognizing agonal breathing in an unresponsive Resident. The DON said the AED should have been used with his/her cardiopulmonary arrest.

Based on records reviewed and interviews for 1 of 5 Residents (Resident #1), the Facility failed to: - Notify the Physician and provide the necessary care and treatment for [REDACTED].M. to 11:00 P.M. shift. - Failed to thoroughly assess Resident #1's Respiratory status which, included, respiratory rate, lung sounds, heart sounds, level of consciousness. - Failed to perform ongoing assessment of Resident #1 after the oxygen saturation was 70% (the percentage of oxygen in the blood stream normal is greater than 90%) and oxygen was applied. -Failed to identify when Resident #1 went from respiratory distress to [MEDICAL CONDITION]. - Failed to recognize and treat an abnormal oxygen saturation (percent of oxygen in the blood stream) level of 90% (percentage of oxygen in the blood 90% or greater is normal, 90% or lower warrants immediate medical attention) on the 11:00 P.M. to 7:00 A.M. shift. - Failed to recognize Resident #1's agonal breathing (ineffective breathing requiring cardio-pulmonary resuscitation) for 20 minutes prior to the Emergency Medical System being activated and CPR being performed. - Staff did not apply the Automated External Defibrillator (AED) - a device that can identify an abnormal heart rhythm that needs a shock, which increases the chance of survival when it was brought to Resident #1's room . Findings include: The Facility policy titled, Physician, Nurse Practitioner, Physician Assistant Notification Guidelines, dated ,[DATE], indicated it is the responsibility of the licensed professional nurse to observe for changes in the resident condition, to make assessments of the change and to notify the Physician. Information required prior to contacting the Physician included; Vital signs (oxygen saturation), subjective symptoms (what does the resident state), physical assessment of lungs. The Clinical Nursing Skills and Techniques, 7th edition, 2010, indicated the pulse oximetery is the noninvasive measurement of arterial blood oxygen saturation, the percent to which hemoglobin is filled with oxygen. The more hemoglobin saturated by oxygen the higher the oxygen saturation. Normal oxygen saturation is greater than 90%. Resident #1's [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#1 had full code status (all resuscitative measures were to be implemented in the event of a cardiac respiratory arrest including CPR, if the heart stops beating or if breathing stops with basic and advance life support). The Nurses Progress note, dated [DATE] at 5:15 P.M., documented by Nurse #4, indicated Resident #1 had returned from a renal appointment with no recommendations (no documentation of shortness of breath or dyspnea). The Surveyor interviewed Family Member #1 at 2:05 P.M. on [DATE] and at 2:38 P.M. on [DATE]. Family Member #1 said that on [DATE] at approximately 8:30 P.M. he/she called Resident #1's unit and spoke the covering Nurse, who asked Family Member #1 words to the effect that if she should believe Resident #1 when Resident #1 complains of shortness of breath or needing oxygen. Family Member #1 said of course I believe him/her. The Surveyor interviewed Nurse #4 at 3:49 P.M. on [DATE] and at 2:50 P.M. on [DATE]. Nurse #4 was assigned to Resident #1 on [DATE] during the 3:00 P.M. to 11:00 P.M. shift. Nurse #4 said that Resident #1 complained of shortness of breath a couple of times around 8:30 P.M. Nurse #4 said Resident #1 had no signs of respiratory or cardiac distress other than dyspena (difficulty breathing) but has psychosomatic complaints before. Nurse #4 said there was no care plan in place for Resident #1 having psychosomatic complaints. Approximately 5.5 to 6 hours after Resident #1 complained of shortness of breath he/she was found unresponsive, at approximately 2:00 A.M. or 2:25 A.M. Nurse #4 said that she did not notify the Physician of Resident #1's new onset of shortness of breath, nor did she document in the Nurse's Notes Resident #1's shortness of breath. Nurse #4 said she obtained a heart rate and blood pressure which were not elevated. Nurse #4 but did not document nor remember the heart rate and blood pressure values. When she was Nurse #4 was asked what was Resident #1's respiratory rate, Nurse #1 said it was normal Nurse #1 said she did not obtain an oxygen saturation level nor listen to Resident #1's lungs. Nurse #4 said she did not know if she communicated in the 11:00 P.M. to 7:00 A.M. shift report, Resident #1's change in respiratory status. A Nurse's Note, dated [DATE] and timed at 3:28 A.M., indicated Resident #1 complained of abdominal pain around 1:45 A.M., stating I feel sick. Resident vital signs were; (clinical measurements that indicate the state of a resident's essential body function) blood pressure ,[DATE] (normal ,[DATE]), oxygen saturation level (percentage of oxygen in the blood, greater that 90% is normal, 90% or lower warrants immediate medical attention) was 90% on room air.At 2:00 A.M. 2:25 A.M. (Nurse #1 documented 2 different times as to when Resident #1 became unresponsive), Resident #1 was found trying to get out of bed, became unresponsive, oxygen saturation and heart rate decreased, oxygen was applied, Emergency Response was called, cardiopulmonary resuscitation was administered, and the Emergency Medial Services took over the care at 2:50 A.M. The Surveyor interviewed Certified Nursing Assistant (CNA #1) at 8:42 A.M. CNA #1 witnessed Resident #1 become unresponsive in bed. Resident #1 was trying to get out of bed and the CNA assisted him/her back into bed, Resident #1's head went down, he/she did not respond to his/her name, his/her head flexed forward, and it would not pop back up. The Dispatch Report, dated [DATE] at 2:45 A.M., indicated there was an unresponsive resident was shallow breathing. The first Ambulance Run Report, dated [DATE], indicated the Emergency Medical Services (EMS) was dispatched for an unresponsive resident with shallow breathing and according to the caller 'this is not a [MEDICAL CONDITION].' Upon arrival of EMS, the resident was found laying on the floor while one Nurse was performing compressions, one component of CPR. EMS took over CPR, applied the Automatic External Defibrillator (AED), the Resident was in asystole (a [MEDICAL CONDITION] rhythm in which there is no discernable electrical activity on the electrocardiogram monitor also called flat line) with no shock advised. Resident #1 was transported to the Hospital. The second Ambulance Run Report, dated [DATE], indicated Emergency Medical Technician stated, We got here and they had just started CPR. They said he/she was unresponsive with agonal respirations (ineffective breathing requiring CPR) for 20 minutes before they started CPR. The Nurse said they were doing CPR for 10 minutes. The Surveyor interviewed Nurse #1, who was the Nurse assigned to Resident #1 during the 11:00 P.M. to 7:00 A.M. shift on [DATE], on [DATE] at 11:00 A.M. and on [DATE] at 9:10 A.M. Nurse #1 said that at the change of shift report at 11:00 P.M. on [DATE], Resident #1's dyspnea (having difficulty breathing) was not communicated to her. Nurse #1 said she did not know that 90% oxygen saturation was abnormal, and she did not notify the physician at 1:45 P.M., that Resident #1 felt sick and had a low oxygen saturation level of 90%. Nurse #1 said at 2:00 A.M. or 2:45 A.M., Resident #1 became unresponsive. Resident #1's breathing was irregular and he/she was gasping (agonal breathing - ineffective breathing) she applied oxygen via a nasal cannula at 2 liters, and he/she had erratic (went up and down) heart rates (as low as 40 beats per minute) and oxygen saturation levels (as low as 70%). Nurse #1 said that when Resident #1 was unresponsive with irregular breathing, she did not recognize the agonal breathing which delayed CPR and activation of the EMS, she did not apply the AED when it arrived on the Unit, and she did not ventilate Resident #1 with 2 breaths via the bag valve mask. Instead, she performed only chest compressions, bystander CPR. The Hospital report, dated [DATE], indicated Resident #1 was transported to the Hospital in [MEDICAL CONDITION] and was treated with Advanced Cardiac Life support and pronounced dead at 3:50 A.M. at [DATE]. The Surveyor interviewed the Director of Nurses (DON) at 10:08 A.M. on [DATE]. The DON said she was not aware that the Automatic External Defibrillator (AED) was not applied to Resident #1 during his/her cardiopulmonary arrest, nor that there was a delay in CPR due to the staff not recognizing agonal breathing (ineffective breathing) with in an unresponsive Resident. The DON said the AED should have been used with his/her cardiopulmonary arrest.

Based on records reviewed and interviews for 1 of 3 sampled residents (Resident #1), the facility failed to ensure that Resident #1 remained free from accidental hazards. The Facility failed to implement effective interventions with adequate supervision to prevent injuries. Resident #1 sustained 3 falls, which resulted in right and left hip fractures (both required orthopedic surgeries) and a left wrist fracture during a 5 week length of stay. Findings include: Resident #1 was admitted to the facility in 8/2015, for rehabilitation following a fall and a urinary tract infection. Resident #1's [DIAGNOSES REDACTED]. The fall risk assessment, dated 8/29/15, indicated Resident #1 was at high risk for falls with a score of 14 (a total score of 10 or above represents high risk). The nurse's admission note, dated 8/29/15 at 4:00 P.M., indicated Resident #1 was at high risk for falls and had multiple mechanical falls (prior to admission) resulting in fractures. The interim falls care plan, dated 8/29/15, indicated Resident #1 would have a call bell in reach, required assistance with transfers, and a bed alarm (a pad senor alarm under a resident's buttocks). The Surveyor interviewed the Director of Physical Therapy at 11:30 A.M. on 2/18/16. The Director of Physical Therapy said that Resident #1 was supposed to be an assist of one for transfers and ambulation with a wheeled walker. The Director of Physical Therapy said this Resident was impulsive, and someone should be with Resident #1 when he/she is getting out of bed. The nurse's note of 8/30/15 at 6:00 A.M., indicated Resident #1 was confused and urinated seven times during the 11:00 P.M. to 7:00 A.M. shift. Resident #1 was non-compliant with using the call bell and was re-educated with no effect. A tab alarm (a tab alarm clipped to the Resident) was added. The nurse's note and investigation of 9/5/15, indicated on 9/5/15 at 6:30 A.M., Resident #1 was found in Resident #1's room lying on the right side complaining of upper thigh pain and guarding his/her right hip. Resident #1 had two alarms (a senor pad and tab alarm), which did sound to alert staff. Resident #1 stated, he/she was trying to go to the bathroom. CNA #1's witness statement, dated 9/5/15, indicated Resident #1 was toileted at 4:55 A.M. on 9/5/15. The cause of the fall was documented as Resident weakness, unsteady gait and non-complaint with safety procedures. Resident #1 was sent to the Community Hospital for evaluation. The investigation file included no information to indicate the facility attempted to determine why both alarms failed to sound to alert staff to Resident #1's attempt to self transfer. There were no new interventions added to address the alarm not sounding. The Community Hospital's Physician admission note of 9/5/15, indicated that Resident #1 had a fall and sustained a right femoral hip fracture and required a surgical repair with an open reduction and internal fixation (ORIF). The Surveyor interviewed Nurse #1 at 5:43 A.M. on 2/19/16. Nurse #1 said that Resident #1 had an unwitnessed fall on 9/5/15 at 6:30 A.M., in which both the alarms did not sound. Nurse #1 said that the sensor alarm had not been under the Resident's buttocks, it had been under the lower back and because of his/her (low) weight the sensor pad does not stay under Resident #1. Nurse #1 said that the tabs alarm had been disconnected. Nurse #1 said that Resident #1 had a tendency to disconnect the tab alarm, the staff had clipped the tab alarm on Resident #1's clothing on his/her back where it can't be reached by Resident #1. Resident #1 was re-admitted to the facility on [DATE]. The interim falls care plan, dated 9/15/15 indicated Resident #1's pertinent interventions: call bell in reach, a clutter free environment, a toileting program, a floor mat and a bed alarm. The nurse's note and fall investigation of 9/20/15, indicated Resident #1 fell on [DATE] at 9:30 A.M., Nurse #3 witnessed Resident #1 attempting to get into his/her bed. Resident #1 had turned off the sensor alarm and disconnected the tab alarm. The witness statement of the assigned CNA #2 indicated Resident #1 was toileted at 9:30 A.M. and Resident #1 was then asked to stay in his/her room. The falls care plan was updated on 9/22/15 to include while Resident #1 is out of bed, Resident #1 is to be in a supervised area. The initial Minimum Data Set of 9/22/15 indicated Resident #1 as moderately cognitively impaired, had required a 2 person physical assist with bed mobility and transfers The nurse's note and fall investigation of 10/6/15, indicated Resident #1 sustained an unwitnessed fall on 10/6/15 at 5:30 A.M. Resident #1 was found on the floor in his/her room, crying out in pain holding his/her left wrist. The sensor alarm was sounding but the tab alarm was not attached to Resident #1. The witness statement of CNA #3 indicated Resident #1 was assisted to use the toilet at 5:15 A.M. was sleeping at 5:20 A.M. and she did not hear the alarm because CNA #3 was in another Resident's room and the TV in that room was loud. Resident #1 was transferred to the Community Hospital for evaluation. The Community Hospital Discharge Summary dated 10/10/15 indicated Resident #1 was admitted on [DATE]. Resident #1 had a traumatic fall and fractured the left hip and left wrist. The left hip was surgically repaired. The Surveyor interviewed Nurse #1 at 5:43 A.M., on 2/19/16. Nurse #1 said that for the fall of 10/6/15, it was an unwitnessed fall in which only the sensor alarm was sounding but the tab alarm was off the Resident. Nurse #1 did not know why the tab alarm was not on Resident #1. The Surveyor interviewed CNA #3 at 12:32 P.M. on 2/18/16. CNA #3 said that for Resident #1's fall on 10/6/15 at 5:30 A.M., CNA #3 was in another resident's room and the television was so loud, that she did not hear Resident #1's alarm sounding. CNA #3 said that Resident #1 does not use the call bell to ask for assistance, she said when she has to go she just gets up right away. Resident #1 sustained three fractures from two falls during a 5 week length of stay for Rehabilitation. Surveyor interviews with Nurse #1 and Nurse #3 on 2/19/16 at 5:43 A.M. and on 2/18/16 at 1:45 P.M., indicated that the alarms were not effective and did not sound for the fall of 9/5/15 nor was Resident #1 capable of using the call bell.

Based on record review and interview, the Facility failed for one of three sampled residents (Resident #1), to ensure staff implemented the plan of care. Resident #1 required two staff for transfers, and on 12/11/14, certified nurse aide (CNA) #1 transferred Resident #1 to the wheelchair, without assistance of another staff person; and Resident #1 sustained a laceration to the left lower leg requiring 9 sutures to close. Findings include: The Quarterly Minimum Data Set (MDS) assessment, dated 11/24/14, indicated Resident #1's Brief Interview for Mental Status (BIMS) assessment denoted Resident #1 was severely cognitively impaired. The MDS indicated Resident #1 required extensive assistance of two persons for bed mobility and transfers. Resident #1's Care Plan for Fall Risk, initiated 1/18/13, indicated Resident #1 was at risk for falls related to decreased mobility and non ambulatory status. Interventions included transfer of two staff members. The CNA Care Card, utilized by the CNAs' providing care, indicated Resident #1 needed assist of two people to transfer to the chair or into the bed. The Nurses's Note, dated 12/11/14, indicated, at approximately 10:30 A.M., Nurse #3 was called into Resident #1's room by Certified Nurse Aide (CNA) #1 and upon arrival, observed a laceration, which was actively bleeding, on Resident #1's left lower leg. The note indicated Resident #1's injury was assessed by the Physician Assistant, and Resident #1 was transferred to the emergency room for treatment of [REDACTED]. The Surveyor interviewed Nurse #3 at 1:01 P.M., on 1/12/15. Nurse #3 said CNA #1 told her that no one helped him with Resident #1's transfer. The Surveyor interviewed CNA #1 at 12:02 P.M., on 1/12/15. CNA #1 said he was familiar with Resident #1's care needs and previously had transferred Resident #1 with two staff members. CNA #1 said although he assumed Resident #1 required two staff members to transfer, he transferred Resident #1 from the bed into the wheelchair alone after he was unable to locate any staff members to assist. CNA #1 said although it was his responsibility to check resident care cards prior to providing care, he did not check Resident #1 care card for interventions or appropriate plan of care prior to providing care. The Surveyor interviewed the Director of Nurses at 8:30 A.M., and throughout the day on 1/12/15. The Director of Nurses said it was the expectation that all care providers review care cards and plans of care for appropriate interventions prior to providing care, and that all care be provided per resident 's plan of care.

Based on record review and interview, the Facility failed for one of three sampled residents (Resident #1), to ensure that Resident #1 was transferred with an assist of 2 staff persons per Plan of Care which resulted in an avoidable injury. On 12/11/14, Certified Nurse Aide (CNA) #1 transferred Resident #1 without assistance of another staff person. During the transfer, Resident #1 received a laceration to left leg area which required nine sutures to close. Findings include: The Quarterly Minimum Data Set (MDS) assessment, dated 11/24/14, indicated Resident #1's Brief Interview for Mental Status (BIMS) assessment denoted Resident #1 was severely cognitively impaired. The MDS indicated Resident #1 required extensive assistance of two persons for bed mobility and transfers. Resident #1's Care Plan for Fall Risk, initiated 1/18/13, indicated Resident #1 was at risk for falls related to decreased mobility and non ambulatory status. Interventions included transfer of two staff members. The CNA Care Card, utilized by the CNAs' providing care, indicated Resident #1 needed assist of two people to transfer to the chair or into the bed. The Nurses's Note, dated 12/11/14, indicated, at approximately 10:30 A.M., Nurse #3 was called into Resident #1's room by Certified Nurse Aide (CNA) #1 and upon arrival, observed a laceration, which was actively bleeding. The note indicated that Resident #1's injury was assessed by the Physician Assistant, and Resident #1 was transferred to the emergency room for treatment. The Surveyor interviewed Nurse #3 at 1:01 P.M., on 1/12/15. Nurse #3 said she asked CNA #1 what happened, and questioned who was helped CNA #1 with Resident #1's transfer. Nurse #3 said CNA #1 told her that no one helped him with Resident #1's transfer. The Surveyor interviewed CNA #1 at 12:02 P.M., on 1/12/15. CNA #1 said he was familiar with Resident #1 and previously had transferred Resident #1 with two staff members. CNA #1 said although he assumed Resident #1 required two staff members to transfer, he transferred Resident #1 from the bed into the wheelchair alone after he was unable to locate any staff members to assist. CNA #1 said he was unaware how Resident #1 was injured. CNA #1 said although it was his responsibility to check resident care cards prior to providing care, he did not check Resident #1 care card for interventions or appropriate plan of care prior to providing care. The Emergency Department Summary Report, dated 12/11/14, indicated that Resident #1 was assessed to have a left lower leg laceration which measured 6 centimeters (cm) and had a large area at the end of the wound where the skin was completely avulsed (torn way). The report indicated Resident #1's laceration was sutured with 9 sutures and the skin tear/avulsion was treated with a dressing. The Surveyor interviewed the Director of Nurses at 8:30 A.M., and throughout the day on 1/12/15. The Director of Nurses said it was the expectation that all care providers review care cards and plans of care for appropriate interventions prior to providing care, and ensure that all care be provided in accordance with each resident's plan of care.