Every finding on record at Southshore Health Care Center

Based on interviews and records reviewed, for three of four sampled residents (Residents #1, #3 and #4), who had court appointed legal representatives or health care agents, the Facility failed to ensure it honored requests for copies of medical record information within two working days, when their representatives requested copies of documentation from their medical records verbally and/or through email correspondence, but were not provided with copies in accordance with federal regulations.Findings include: Review of the Facility Medical Record Policy and Procedure, dated January 2020, indicated it was the policy of the Facility to honor a resident's right of access to inspect and obtain a copy of their protected health information.Resident #1's clinical record indicated he/she was admitted to the Facility during July 2023 and his/her diagnoses included schizoaffective disorder.Resident #1's clinical record contained documentation which indicated the court appointed him/her a legal Guardian in April 2023.Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) Assessment, dated 1/16/26, indicated Resident #1 cognitive patterns were intact.During a telephone interview on 4/13/26 at 10:09 A.M., Resident #1's Guardian said that it was difficult to obtain copies of documents from Resident #1's clinical records from the Facility. The Guardian said that the Facility response to requests for clinical records took longer than it should and caused unnecessary delays.Review of email correspondence, dated 3/03/26, from Resident #1's Guardian to the Facility Social Worker indicated that the Guardian requested copies of Resident #1's medications and treatments sheets.Review of the Facility's Internal Investigation, dated 3/10/26, indicated the medication and treatment sheets were emailed to Resident #1's Guardian on 3/10/26, 7 days after they were initially requested.During an interview on 4/13/26 at 4:00 P.M., the Administrator said that there had been issues with the Facility's timely response to the Guardian's request for documents from Resident #1's clinical record.Resident #3's clinical record indicated he/she was admitted to the Facility during June 2025 and his/her diagnoses included bipolar disorder.Review of Resident #3's most recent Quarterly MDS Assessment, dated 1/09/26, indicated Resident #3 cognitive patterns were intact.During a telephone interview on 04/13/26 at 9:10 A.M., Family Member #1 said she was Resident #3's Health Care Agent. Family Member #1 said Resident #3 was completing a disability application which required documentation from the his/her clinical records and that she and his/her Attorney requested medical records from the Facility during 2025 which the Facility did not provide.During a telephone interview on 04/15/26 at 2:40 P.M., the Attorney said that on 12/01/25 he made a written request, which he provided to the Facility via fax, for documents from Resident #3's clinical record. The Attorney said that on 12/12/25, the Facility notified him that he needed to complete a specific form to make the request and he provided the completed form as required, via fax. The Attorney said that the Facility did not respond to his request or provide the requested documents.During an interview on 4/13/26 at 3:42 P.M., the Director of Nursing said that she was not aware that there had been requests for copies from Resident #3's medical record and, when she checked with medical records, they were unable to locate documentation for a response to the Attorney's request.Resident #4 was admitted to the Facility in November 2021, diagnoses include Parkinson's Disease, bipolar disorder, Hepatitis C, and repeated falls.Review of Resident #4's Quarterly MDS dated [DATE], indicated that his/her Brief Interview for Mental Status (BIMS) score was a three (3), indicating severe cognitive impairment (13-15 indicates cognitively intact, 8-12 indicates moderately impaired cognition, and 0-7 indicates severe cognitive impairment).Review of Resident #4's Physician's Orders, dated 3/2026, indicated that on 12/12/24 his/her Health Care Proxy (HCP) was invoked.During a telephone interview on 04/15/26 at 8:58 A.M., Resident #4's Health Care Agent (HCA) said that she requested copies of his/her medical records in September 2025. The HCA said that she was given and had completed the necessary paperwork to obtain the records.The HCA said that she has requested the copies of records numerous times and the Facility continues to say that they will look into it. The HCA said that she has yet to receive any copies of Resident #4's medical records.

Based on interviews and records reviewed, for two of four sampled residents (Residents #1 and #3) whose diagnoses included psychiatric disorders, the Facility failed to ensure they received and were provided appropriate Behavioral Health services that addressed and met their mental health needs.Findings include: The Facility Behavioral Management Guidelines Policy, dated April 2015, indicated it was the policy of the Facility to develop behavior plans and medication regimes, when appropriate, to optimize the functional abilities of residents.The Facility Assessment, dated as most recently updated 3/23/26, indicated the resident population served by the Facility included residents with psychiatric/mood disorders. The Assessment indicated the services provided by the Facility to address resident needs included consultant psychiatric services.The Behavioral Health Services Agreement between the Facility and the Psychiatric Service Agency, dated 9/21/23, indicated the Agency provided psychotherapeutic services to residents of the Facility.Resident #1's clinical record indicated he/she was admitted to the Facility during July 2023 and his/her diagnoses included schizoaffective disorder. Resident #1's clinical record contained documentation which indicated the court had appointed him/her a legal Guardian in April 2023.Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) Assessment, dated 1/16/26, indicated Resident #1 cognitive patterns were intact.Review of Resident #1's Care Plan for Behavior-related to a diagnosis of schizoaffective disorder, initiated 1/23/24, indicated interventions including investigate/monitor the need for psychological/psychiatric support and provide services as ordered by the physician.Review of the Physician Orders indicated he/she had an order, dated 9/23/24, for psychiatric consult and treatment as indicated.Review of the Psychological Service Note, dated 11/20/25, indicated that Resident #1 was terminated from ongoing counseling with the therapist as the therapist was leaving the Agency.During an interview on 4/13/26 at 1:15 P.M., Resident #1 said that he/she had been asking Facility staff for a mental health therapist since his/her prior therapist left and the Facility had not provided one. Resident #1 said that he/she thought Facility staff did not understand why he/she wanted a therapist.During a telephone interview on 4/13/26 at 10:09 A.M., Resident #1's Guardian said that the therapist who had provided Resident #1 with therapy/counseling, left the Facility without notice during 2025 and since that time the Facility had not obtained a replacement therapist to provide counseling services to Resident #1.During a telephone interview on 4/13/26 at 11:17 A.M., the Psychiatric Nurse Practitioner said he worked for the Psychiatric Service Agency and saw Resident #1 monthly for psychotropic medication monitoring. The Psychiatric Nurse Practitioner said that the therapist left the Agency in November 2025, and the Agency had not replaced them. The Psychiatric Nurse Practitioner said that Resident #1 would benefit from on-going, weekly counseling.Resident #3's clinical record indicated he/she was admitted to the Facility during June 2025 and his/her diagnoses included bipolar disorder.Review of Resident #3's most recent Quarterly MDS Assessment, dated 1/09/26, indicated Resident #3 cognitive patterns were intact.Review of Resident #3's Care Plan for Alteration in Mood related to a diagnosis of bipolar disorder, dated as initiated 6/30/25, indicated interventions included one to one therapy per recommendations.Review of the Psychological Service Note, dated 11/20/25, indicated that Resident #3 was terminated from ongoing counseling with the therapist as the therapist was leaving the Agency.During an interview on 4/13/26 at 1:00 P.M., Resident #3 said that he/she had been seeing a mental health therapist at the Facility and he/she did not know the reason therapy stopped, however, he/she would resume counseling if it were available.During a telephone interview on 04/15/26 at 12:20 P.M., the Case Manager said that she was Resident #3's case manager. The Case Manager said that Resident #3 would absolutely benefit from counseling and the lack of counseling had been a point of contention with the Facility. The Case Manager said that she did not know the reason that the Facility stopped providing counseling services to Resident #3.During an interview on 4/13/26 at 4:22 P.M., the Administrator said that the Psychiatric Service Agency had not been able to provide a therapist for the Facility residents, including Residents #1 and #3, since November 2025.

Based on interviews and records reviewed, for two of three sampled residents (Residents #1 and #3) the facility failed to ensure it protected and facilitated the resident's right to communicate with individuals and entities external to the facility, when staff failed to answer the Facility telephone on multiple days, leaving the telephone to ring and ring unanswered. Findings include: Resident #1's clinical record indicated he/she was admitted to the Facility during July 2023 and his/her diagnoses included schizoaffective disorder. Resident #1's clinical record contained documentation which indicated the court had appointed him/her a legal Guardian in April 2023.Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) Assessment, dated 1/16/26, indicated Resident #1's cognitive patterns were intact.During a telephone interview on 4/13/26 at 10:09 A.M., Resident #1's Guardian said that on multiple dates, when she called the Facility, the phone often rang and rang and went unanswered. The Guardian said that although Resident #1 had a telephone in his/her room, if he/she did not answer the phone, she called the Facility to assist her in getting in touch with Resident #1, however, the Facility phone was often not answered. The Guardian said that during these times, she would call the Facility repeatedly and allow the phone to ring and ring, however, her call would go unanswered.Resident #3's clinical record indicated he/she was admitted to the Facility during June 2025 and his/her diagnoses included bipolar disorder.Review of Resident #3's most recent Quarterly MDS Assessment, dated 1/09/26, indicated Resident #3 cognitive patterns were intact.During a telephone interview on 04/13/26 at 9:10 A.M., Family Member #1 said she was Resident #3's Health Care Agent (HCA). Family Member #1 said that when she called the Facility to speak to Resident #3, it was difficult getting someone in the Facility to answer the telephone. Family Member #1 said that on multiple occasions when she called the Facility repeatedly and the phone rang and rang and was not answered.During a telephone interview on 04/15/26 at 12:20 P.M., the Case Manager said that she was Resident #3's case manager. The Case Manager said that on occasion when she called the Facility to speak to Resident #3 or to speak to staff about Resident #3, the phone was not answered.During an interview on 4/13/26 at 4:22 P.M., the Administrator said on 2/24/26, she had received complaints about the facility's telephones not being answered, from Resident #1's Guardian, as well as other family members, and initiated an investigation. On 4/13/26, the Facility was found to be in Past Noncompliance and presented the Surveyor with a plan of correction, with an effective date of 3/10/26, which addressed the area(s) of concern as evidenced by:A) On 2/26/26, training of all Facility nurses was initiated by the Staff Development Coordinator/designee on phone protocols.B) On 2/26/26, the hours worked by the Receptionist (who managed the Facility telephone) were expanded to include coverage of the phones until 8:00 P.M.C) On 3/09/26, the Administrator offered Resident #1's Guardian a schedule of weekly telephone calls in order to enhance simplicity of contacting Resident #1 or Facility staff. D) By 3/09/26, portable telephone handsets had been provided to all Facility units to enable nurses to monitor the phones when away from the nursing station.E) By 3/09/26, wall mounted phones were installed and/or repaired on the Facility units to increase the ability of staff to hear the telephone ringing when away from the nursing station.F) During the March 2026 Resident Council Meeting, Residents were asked about telephone access and no issues were reported.G) Starting 2/26/26, the Administrator and/or the Director of Nursing monitored any grievances and complaints related to telephone access by residents, response to incoming calls by facility staff, as reported by residents/responsible persons and there have been no issues reported.H) The Administrator, Director of Nursing and/or their designee(s) are responsible for overall compliance.

Based on records reviewed and interviews for one of four sampled residents (Resident #4), the Facility failed to ensure they reported an injury of unknown origin to the State Survey agency. On 03/11/26, Resident #4 was observed with an injury of unknown origin and was transferred to the Hospital Emergency Department (ED) for evaluation, however the injury was not reported to their State Agency as required.Findings include:Review of the Facility Policy titled Abuse, Neglect, and Exploitation, dated 2023, indicated the Facility will develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property and establish policies and procedures to investigate any such allegations.The Policy indicated reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within a specific time frame:-Immediately, but no later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or-Not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in bodily injury.Resident #4 was admitted to the Facility in November 2021, diagnoses include Parkinson's Disease, bipolar disorder, Hepatitis C, and repeated falls.Review of Resident #4's Quarterly Minimum Data Set (MDS) dated [DATE], indicated that his/her Brief Interview for Mental Status (BIMS) score was a three (3), indicating severe cognitive impairment (13-15 indicates cognitively intact, 8-12 indicates moderately impaired cognition, and 0-7 indicates severe cognitive impairment).Review of Resident #4's Physician's Orders, dated 3/2026, indicated that his/her Health Care Proxy (HCP) was invoked on 12/12/24.Review of Resident #4's Nurse Progress Note (written by Unit Manager #1), dated 03/12/26, indicated he observed a red bump on his/her forehead with a split in the skin. The Note indicated there was no witnessed fall and he/she was transferred to the Hospital Emergency Department (ED) for evaluation. Review of Resident #4's ED Discharge summary, dated [DATE], indicated he/she presented from the Facility with a small hematoma and laceration on his/her forehead, increased somnolence and confusion.Review of Resident #4's Medical Record, indicated there was no documentation to support the injury of unknown origin was reported to the State Survey Agency as required.During a telephone interview on 04/15/26 at 8:58 A.M., Resident #4's Health Care Agent (HCA) said that a staff nurse called her on 03/12/26 to inform her Resident #4 had a bump on his/her forehead. The HCA said the nurse told her they were unaware of how he/she sustained the bump, but that he/she was going to be transferred to the ED for evaluation.During an interview on 04/13/26 at 12:58 P.M., Certified Nurse Aide (CNA) #4 said that she was the CNA assigned to Resident #4 on 03/12/26 and said the bump was not there while providing him/her with morning care.CNA #4 said she noticed the bump on his/her head around lunch time and reported it to the Nurse.During a telephone interview on 04/21/26 at 11:03 A.M., Nurse # 9 said on 03/12/26, Resident #4 had been at an activity and when he/she returned the staff member informed her that a bump was noted on Resident #4's head.Nurse # 9 said that there was a small bump on his/her head and we sent him/her out for evaluation because we did not know what it was. During an interview on 04/13/26 at 1:38 P.M., Unit Manager #1 said on 03/18/26, a bump was noted on Resident #4's forehead and he/she was sent out to the ED for evaluation.During an interview on 04/13/26 at 3:41 P.M., the Director of Nurses (DON) said that she was not made aware of the bump found on Resident #4's until days after the injury had been discovered.The DON said that when she had found out about the incident, she said it should have been reported as an injury of unknown origin to the State.The DON said that it is the Facility's expectation that if an injury of unknown origin is discovered by the staff, it must be immediately reported to the DON and Administrator and if the circumstances warrant, the incident will be reported to the DPH and any other agency as required.

Based on records reviewed and interviews for one of four sampled residents (Resident #4), who on 03/12/26 was found with an injury of unknown origin (bump on Resident #4's forehead), the Facility failed to ensure they conducted and maintained evidence of an investigation into the injury.Findings include:Review of the Facility Policy titled Accidents/Incidents, dated 04/2015, indicated that it is the responsibility of the staff to report all accidents and incidents which occur at the Facility.The Policy indicated that all accidents and incidents must be reported to the supervisor and appropriate documentation must be completed and every attempt will be made to ascertain the cause of the occurrence.Review of the Facility Policy titled Abuse, Neglect, and Exploitation, dated 2023, indicated that an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. The Policy indicated that an alleged violation is a situation or occurrence that is observed or reported by staff, but has not yet been investigated, and if verified, could be an indication of non-compliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown origin. Resident #4 was admitted to the Facility in November 2021, diagnoses include Parkinson's Disease, bipolar disorder, Hepatitis C, and repeated falls.Review of Resident #4's Quarterly Minimum Data Set (MDS) dated [DATE], indicated that his/her Brief Interview for Mental Status (BIMS) score was a three (3), indicating severe cognitive impairment (13-15 indicates cognitively intact, 8-12 indicates moderately impaired cognition, and 0-7 indicates severe cognitive impairment).Review of Resident #4's Physician's Orders, dated 3/2026, indicated that his/her Health Care Proxy (HCP) was invoked on 12/12/24.Review of Resident #4's Hospital Emergency Department (ED) Discharge summary, dated [DATE], indicated he/she presented from the Facility with a small hematoma and laceration on his/her forehead, with increased somnolence and confusion.Review of Resident #4's Medical Record indicated and the facility was unable to provide any documentation to support the injury of unknown origin was investigated as required.Review of Resident #4's Nurse Progress Note (written by Unit Manager #1), dated 03/12/26, indicated he had observed a red bump on his/her forehead with a split in the skin. The Note indicated there was no witnessed fall and he/she was transferred to the ED for evaluation. During a telephone interview on 04/15/26 at 8:58 A.M., Resident #4's Health Care Agent (HCA) said that a staff nurse called her on 03/12/26 to inform her that Resident #4 had a bump on his/her forehead. The HCA said the nurse told her they were unaware of how he/she sustained the bump, but that he/she was going to be transferred to the ED for evaluation.During an interview on 04/13/26 at 12:58 P.M., Certified Nurse Aide (CNA) #4 said that she was the CNA assigned to Resident #4 on 03/12/26 and said the bump was not there while providing him/her with morning care.CNA #4 said she noticed the bump on his/her head around lunch time and reported it to the Nurse.During a telephone interview on 04/21/26 at 11:03 A.M., Nurse #9 said on 03/12/26, Resident #4 had been in an activity and when he/she returned the staff member informed her that a bump was noted on Resident #4's head.Nurse #9 said that Unit Manager #1 was made aware of the injury. Nurse #9 said she did not fill out an incident report and did not think an investigation of how the injury occurred was completed. During an interview on 04/13/26 at 1:38 P.M., Unit Manager #1 said on 03/18/26, a bump was noted on Resident #4's forehead and he/she was sent out to the ED for evaluation.Unit Manager #1 said that he did not initiate an investigation and he did not fill out an incident report related the discovery of an injury of unknown origin. During an interview on 04/13/26 at 3:41 P.M., the Director of Nurses (DON) said that she was not made aware of the bump found on Resident #4's until days after the injury had been discovered.The DON said that it is the Facility's expectation that if an injury of unknown origin is discovered by the staff, it must be immediately reported to the DON and Administrator and so an investigation could have been conducted timely.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose physicians orders included the administration of a controlled substance medication, the facility failed to ensure that medication was properly secured and under direct supervision of nursing staff, when on 01/06/26 after administering him/her the medication, Nurse #1 left the blister pack card containing oxycodone (narcotic medication) unattended in Resident #1's room.Findings include:Review of the Facility's Policy titled Medication Storage in the Facility-ID1: Storage of Medications, undated, indicated that medications and biologicals are stored safely, securely, and properly.Review of the Facility's Policy titled Medication Storage in the Facility-ID2: Controlled Substance Storage, undated, indicated the following:-medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping 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.Review of the Facility's Investigation Report, dated 01/09/26, indicated that on 01/06/26 a staff nurse (Identified as Nurse #1) brought Resident #1's blister pack card of medication (packaging system for multiple doses of a medication that consists of individual pockets or blisters that hold tablets or capsules sealed with a strong paper-backed or aluminum foil which is easily pushed through to dispense) to his/her room and administered the medication to him/her at approximately 7:30 P.M. The Report indicated that when exiting Resident #1's room the nurse forgot to pick up his/her medication blister pack from the bedside table.The blister pack card contained oxycodone 5 milligrams (mg) tablets, which had 34 tablets in total remaining on the card.The Report indicated that Nurse #1 then remembered she had forgotten the medication blister pack card on Resident #1's bedside table, she went back to Resident #1's room to retrieve it and noted that the medication blister pack card was no longer on Resident #1's bedside table.The Report further indicated that the Director of Nursing (DON) was made aware of the incident, staff conducted a search of Resident #1's room and the medication blister pack card was not found.Resident #1 was admitted to the Facility in December 2025, diagnoses included quadriplegia C1-C4 complete (loss of sensation and motor function in all four limbs caused by cervical spinal cord injury), muscle weakness, neuropathic bladder (nerve damage from spinal cord injuries causing urinary incontinence), seizures, and atrial fibrillation.Review of Resident #1's Physician Order, dated January 2026, indicated he/she had an order for Oxycodone 5 milligrams (mg) tablet, give (2 tablets) total of 10 mg by mouth every four hours as needed (PRN) for severe pain.Review of Resident #1's Nurse Progress Note (written by Nurse #1), dated 01/06/26, indicated that Resident #1 requested oxycodone for pain and his/her medication was administered. The Note indicated that Nurse #1 went to check on Resident #1 when she realized she had left the blister pack card in his/her room, asked Resident #1 if he/she saw the oxycodone and he/she denied seeing the blister pack. The Note further indicated that the DON was notified.During an interview on 01/28/26 at 2:54 P.M. (which included review of her written statement), Nurse #1 said she worked the 3:00 P.M. to 11:00 P.M. shift on 01/06/26 and was assigned to care for Resident #1. Nurse #1 said Resident #1 complained of overall body pain, requested oxycodone and that Resident #1 told her that he/she wanted to make sure she was going to give him/her the oxycodone.Nurse #1 said she checked Resident #1's physician orders, unlocked the narcotic drawer, took the whole medication blister card of oxycodone and a medication cup into Resident #1's room. Nurse #1 said she showed Resident #1 the medication blister card so he/she could see that he/she was going to receive two oxycodone tablets. Nurse #1 said after she dispensed two tablets into the medication cup, there were 34 tablets of oxycodone left on the card. Nurse #1 said she placed the medication card on the bedside table, administered the medication to Resident #1 and left his/her room.Nurse #1 said about thirty minutes later she went to administer a narcotic medication to another resident and saw that Resident #1's medication card of oxycodone was not in the narcotic draw. Nurse #1 said she told Nurse #3 that she had misplaced Resident #1's oxycodone, and they both searched the medication cart, but could not find it.Nurse #1 said she realized she had left the medication card in Resident #1's room, so she immediately went to his/her room to look for it but said that the medication card was not on the bedside table. Nurse #1 said she called the DON and reported to her that she had left Resident #1's medication in his/her room and that she could not find it.Nurse #1 said she should not have brought the whole medication card into Resident #1's room but said she did it to prove to Resident #1 that he/she was getting the right medication and dose.During an interview on 01/28/25 at 2:28 P.M. (which included review of her written statement), Nurse #3 said on 01/06/26 Nurse #1 informed her that she (Nurse #1) could not find Resident #1's medication blister card of oxycodone. Nurse #3 said she and Nurse #1 looked through the locked medication narcotic draw, then the whole medication cart and said they did not find Resident #1's oxycodone.Nurse #3 said she asked Nurse #1 when the last time was that she had seen the medication card. Nurse #3 said Nurse #1 told her that she (Nurse #1) brought the medication card into Resident #1's room, gave him/her the oxycodone and that she (Nurse #1) could not remember what she did with the medication card after that.Review of the Narcotic Book page number 114 for Resident #1, indicated that on 01/06/26 at 19:20 P.M. (7:20 P.M.) the oxycodone amount on hand was 36, amount used was two, amount left was 34 and signed by Nurse #1. During an in-person interview 01/28/26 at 4:42P.M. and a follow-up telephone interview on 02/03/26 at 3:09 P.M., the Director of Nurses (DON) said on 01/06/26 Nurse #1 notified her that she (Nurse #1) could not find Resident #1's blister card of oxycodone and that she and Nurse #3 had looked everywhere. The DON said she started her investigation and the following morning (01/07/26) she reviewed video footage from the previous night with the Maintenance Director. The DON said the video footage showed that Nurse #1 entered Resident #1's room carrying a medication card, cup of water and medication cup and said when Nurse #1 exited Resident #1's room the medication card was not seen in her hand.The DON said Nurse #1 told her that she brought the whole card of oxycodone into Resident #1's room because he/she was accusatory towards her related to not receiving his/her pain correct medication. The DON said Nurse #1 told her that she dispensed two oxycodone pills from the card, she put the medication card on the bedside table, administered the medication to Resident #1 and she (Nurse #1) left Resident #1's room without the medication card. The DON said it was not typical or best practice for nurses to bring a whole medication card into a resident's room and said nurses should not be doing so. The DON said nurses should only be bringing in the exact amount of medication to be administered to a resident.The DON said it is her expectation that nurses prepare all medications at the medication cart, secure the medication card per facility policy, and said that any type of medication should not be left unattended at a resident's bedside.

Based on document review and interviews, the facility failed to ensure that it maintained an effective pest control program that provided an environment that was free of pests and rodents for the 79 residents residing at the facility. Findings include: During a tour of the kitchen on 8/21/2025 at 7:56 A.M., the surveyor observed the main kitchen dry food storage area and made the following observations: -On the left side of the room there were multiple shelves of canned goods with a large amount of mouse droppings on top of the cans. During an interview on 8/21/25 at 8:20 A.M., the Food Service Director (FSD) inspected the dry storage area with the surveyor and said the cans of food with rust along the ends and mouse droppings were the emergency food supply. He said they have had a mouse problem for a while. During an interview with observation on 8/21/25 at 9:00 A.M., Resident #88 said there were mice in their room. The surveyor observed a grocery store paper bag with a loaf of bread, an open box of snacks and an unopen box of snacks, none of the items were in plastic containers and were all accessible to mice. On the windowsill in the room were seven packages of shortbread cookies. During an interview on 8/21/25 at 1:00 P.M., Resident #10 said there were mice and rats in the facility, and he/she can see them and hear them run across the room. During an interview on 8/21/25 at 1:10 P.M., Resident #51 said there are mice in the resident rooms, and the residents complain about it at the Resident Council meeting. During the Resident Council meeting on 6/19/25, five residents on the [NAME] Wing said that they have seen mice all over their rooms including on the top of their beds. The resolution was listed as: pest control vendor as (sic) been notified. During the Resident Council meeting on 7/17/25, multiple residents on both the East and [NAME] units complained that they are still seeing mice in and out of their rooms. The resolution to the issue was blank. A second resolution indicated that mouse traps were purchased and spread throughout the facility. The facility indicated they will continue to monitor the traps. During the Resident Council meeting on 8/15/25, East Wing: one resident reports he/she has seen ants and mice throughout his/her room (resolution: we have put down additional traps. I will inform the pest vendor when they come in next week). During the Resident Council meeting with the surveyor on 8/25/25 at 1:30 P.M., Resident #17 provided a written note with a concern regarding a mouse traveling from the outside into the heating duct and it then travels from room to room keeping the Resident awake half of the night. The Resident indicated that the mouse is starting to climb on things in the rooms and reported patching a hole in the tiles of the bathroom. In addition to the mouse, the Resident reported seeing ants everywhere and a cockroach or two. During a review of the Pest Control Service logs on 8/27/25, the documents indicated that the previous pest control service had not provided pest control services to the facility since 4/12/25. Further review of the Pest Control Service logs indicated that from 4/12/25 through 8/11/25 the facility was without professional pest control services. On 8/12/25, a new Pest Control Service began servicing the facility. Extensive services were documented at that time including, but not limited to:-glue boards in the drop ceiling as activity was reported by staff. The new Pest Control services' plan was to return in 2 weeks for the start of the Biweekly Pest Program. During an interview on 08/27/25 at 1:15 P.M., the Maintenance Director said that the facility did not have a professional Pest Control Service from 4/12/25 until 8/12/25, when the new Pest Control Service took over at the facility. The Maintenance Director was not aware of the reason for the previous Pest Control Service ending its relationship with the facility or the delay in obtaining a new Pest Control vendor. During an interview on 08/27/25 at 1:30 P.M., the Administrator said that he has been the administrator at the facility since 7/2/25. He said he was aware of the pest problem as reported by staff and residents and said he brought in the current Pest Control Service on 8/12/25. He could not say why the previous administration at the facility terminated their relationship with the previous Pest Control Service, or the reason for the facility failure to ensure pest control services were provided from 4/12/25 to 8/11/25. The Administrator said that he understood that the facility is required to maintain an environment for residents that is free from pests and rodents.

Based on the results of 2 of 2 test trays (one breakfast and one lunch meal) and staff and resident interviews, the facility failed to provide residents with meals and drinks that were palatable, attractive, and at a safe and appetizing temperature. Findings include: During the Resident Council Meeting, held with the surveyor on 8/25/25 at 1:30 P.M. with 12 residents in attendance, the residents complained about the food as follows:-8 of 12 residents said the food is not good, it's repetitive, and desserts are served frozen. During interviews on 8/21/25 at 9:05 A.M., four residents (#30, #81, #27, and #13) on the [NAME] Unit complained that they disliked the meals they are served. Review of Food Committee Minutes, dated 5/21/25, indicated residents complained that the temperature of the food was so-so. The Food Service Director (FSD) indicated that dining services does at least two test trays a month and will do one every week as a follow-up.Review of Test Tray Evaluations provided by the FSD, indicated test trays were conducted with inadequate food temperatures as follows:-6/3/25 [NAME] Unit: -noodles 128 degrees -milk 46 degrees-6/25/25 East Unit: -meatloaf 128 degrees -asparagus 119 degrees -roasted potatoes 123 degrees -pudding 48 degrees-8/14/25 East Unit: -waffle 129 degrees On 8/27/25, the surveyor conducted two test trays one at the breakfast meal and one at the lunch meal. On 8/27/25 at 7:25 A.M., the surveyor observed the breakfast test tray to be assembled and loaded onto the meal truck with 19 resident meal trays. The truck left the kitchen at 7:33 A.M. and arrived to the East Unit at 7:34 A.M. The test tray was the last tray served and removed from the truck at 7:55 A.M. The surveyor conducted the test tray with the Food Service Director (FSD) present with the following results: Test Tray #1 Breakfast Meal-East Unit-French Toast-80 degrees-cool, dry, bland, and unappealing to taste.-Cream of Wheat hot cereal-120 degrees, bland and warm to taste-Orange juice-48 degrees-cool to taste -Whole milk-45 degrees-cool to taste -Hot coffee-114 degrees-lukewarm, unappealing to taste During an interview at this time, the FSD said the French toast, cream of wheat, and hot coffee temperatures were not at appropriate temperatures. The FSD tasted the French toast and said that it wasn't palatable. The FSD said that it took a significant amount of time, longer than usual, to deliver the trays. On 8/27/25 at 11:30 A.M., the surveyor observed the lunch test tray to be assembled and loaded onto the meal truck. The truck left the kitchen at 11:32 A.M. and arrived to the East Unit at 11:33 A.M. The test tray was the last tray served and removed from the truck at 11:47 A.M. Test Tray #2 Lunch Meal, East Unit-Baked chicken: 130 degrees, warm, dry, bland and unappealing to taste. -Rice: 140 degrees, warm, bland, and unappealing to taste. -Mixed vegetables: 112 degrees, lukewarm, bland, and unappealing in flavor and taste.-melon: 55 degrees, cool to taste-Milk: 42 degrees, cold to taste-Coffee: 135 degrees, hot to taste During an interview on 8/27/25 at 11:55 A.M., following completion of the lunch test tray, the FSD said that temperatures and food palatability were not acceptable for both the breakfast and lunch test trays. The FSD said the rice could use some salt.

Based on document review and interview, the facility failed to ensure the attending physician and/or responsible party was notified of changes in a resident's condition for two Residents (#83, #8), out of a total sample of 20 residents. Specifically, the facility failed:1. For Resident #83, that the physician was notified of a change in mental status, verbalizations of wanting to leave the facility and exit seeking behavior; and2. For Resident #8, to inform the attending physician of a significant weight loss. Findings include:Review of the facility's policy titled Condition: Significant Change; dated 4/2015; indicated, but was not limited to, the following: -The physician, resident/patient, and/or responsible party will be notified by the nurse in the event of a change in condition -This notification shall be documented in the clinical record 1. Resident #83 was admitted to the facility in August 2025 and had diagnoses including alcohol dependence with withdrawal and major depressive disorder. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 8/15/25, indicated Resident #83 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 out of 15, exhibited no hallucinations, delusions or behaviors, received no psychotropic medication and had an activated health care proxy (an individual designated to make medical decisions on your behalf when a doctor determines you lack the capacity to make or communicate your own decisions). Review of a Nursing Progress Note, dated 8/17/25, indicated Resident #83 called 911 (a phone number used to contact emergency services) around 7:00 A.M. and a police officer came to the facility to speak with the Resident. The note indicated Resident #83 told the officer that somebody was playing in his/her back and that he/she doesn't belong here and needs to leave. Review of a Nursing Progress Note, dated 8/18/25, indicated Resident #83 called 911 and stated there was something behind his/her window. Staff checked the window and showed the Resident that there was nothing behind the window. Review of a Nursing Progress Note, dated 8/23/25, indicated around 6:00 A.M., the lead Certified Nursing Assistant (CNA) informed the nurse that Resident #83 was outside walking in the parking lot. The nurse indicated the Resident was last seen about 10 minutes before seated in the TV room on the unit. After three attempts, the Resident agreed to return to the building. Further review of the medical record failed to indicate Resident #83's physician or HCP was notified of the Resident's change in cognitive status as evidenced by statement that somebody was playing in his/her back and something was behind his/her window, verbalization that he/she doesn't belong at the facility and needs to leave and walking in the parking lot unaccompanied the morning of 8/23/25. During interviews on 8/25/25 at 1:31 P.M. and 2:32 P.M., the Director of Nursing (DON) said the physician and HCP should have been notified of the change in the Resident's cognitive status as well as leaving the building and walking in the parking lot unaccompanied the morning of 8/23/25. 2. Review of the facility's policy titled Weights, dated 4/2015, indicated, but was not limited to, the following: -If a significant weight loss/gain is identified (> 5% in 30 days or > 10% in 6 months), the IDT [interdisciplinary team], Dietitian, Physician and Family are notified. Resident #8 was admitted to the facility in July 2025 with diagnoses including multiple sclerosis, diabetes, and hypothyroidism. Review of the MDS assessment, dated 7/29/25, indicated Resident #8 was moderately cognitively impaired as evidenced by a BIMS score of 9 out of 15. Review of Resident #8's medical record indicated the Resident's weights were documented as follows: -7/29/25: 162.4 pounds (lbs.) -8/7/25: 159 lbs. -8/18/25: 144 lbs. -8/20/25: 145 lbs. From 7/29/25 to 8/20/25, Resident #8 had lost 17.4 lbs. (or 10.71% of his/her body weight). Review of Resident #8's Progress Notes indicated that on 8/19/25, the facility dietitian identified the Resident had an 18.4-pound weight loss in two weeks. The Dietitian met with the Resident and added yogurt and ice cream to the Resident's meals twice daily to arrest in further weight loss. Further review of Resident #8's Progress Notes failed to indicate the Resident's attending physician was notified of the Resident's significant weight loss until after Unit Manager #1's interview with the surveyor on 8/26/25. The medical record failed to include a Physician's Progress Note, indicating the Resident had been seen by the attending physician, from date of admission until 8/26/25. During an interview on 8/25/25 at 3:06 P.M., Nurse #3 said if the nurse notices a Resident has had weight loss when a weight is obtained, the nurse should inform the attending physician and dietitian. Nurse #3 said she entered the Resident's weight into the medical record on 8/18/25 and notified the dietitian that the Resident had lost weight. Nurse #3 said she should have notified the Resident's attending physician but did not. During an interview on 8/26/25 at 4:06 P.M., Unit Manager #1 said there was no indication in the Resident's record that the attending physician was notified of Resident #8's weight loss. Unit Manager #1 said the attending physician should have been notified. During an interview on 8/27/2025 at 12:08 P.M., the DON said Resident #8's attending physician should have been notified of the Resident's weight loss immediately upon discovery. The surveyor attempted to contact Resident #8's attending physician on 8/27/25 and 8/28/25 but the physician was unable to be reached.

Based on observation, record review, and interviews, the facility failed to provide two Residents (#15, #83), out of a total sample of 20 residents, with adequate supervision and effective interventions to prevent avoidable accidents. Specifically, the facility failed:1. For Resident #15, to develop and consistently implement effective interventions to prevent recurrent falls; and2. For Resident #83, to provide adequate level of staff supervision to maintain his/her safety in an effort to prevent an elopement from the facility.Findings include:Review of the facility's policy titled Accidents/Incidents, dated 4/2015, indicated, but was not limited to, the following: -It is the responsibility of staff to report all accidents and incidents which occur at the facility. -Occurrences of a serious nature requires notification to the Administrator and Director of Nurses. Review of the facility's policy titled Comprehensive Care Plans, revised 11/2017, indicated, but was not limited to, the follow: -The facility is committed to providing residents with all necessary care and services to enable them to achieve the highest quality of life. -Care plans are oriented toward preventing avoidable decline in clinical and functional levels, maintaining a specific functioning and reflect resident preferences and right to refuse certain services or treatment. -The Interdisciplinary Team (IDT) develops a comprehensive Care Plan for each resident that includes measurable objectives and timelines to accommodate preferences, special medical, nursing, and psychosocial needs identified in the RAI (Resident Assessment Instrument) and IDT. -The Care Plan is evaluated and revised as needed, but at least quarterly. 1. Review of the facility's policy titled Falls Management, revised 4/2024, indicated, but was not limited to, the following: -A fall is defined as any incident in which a resident/patient unintentionally has a change in elevation/plane. -A fall risk evaluation will be conducted on each resident/patient upon admission, with the quarterly MDS (Minimum Data Set) cycle, and when a significant change in status occurs (including a fall). -The interdisciplinary team will develop, initiate, and implement an appropriate individualized care plan based on the Fall Risk Evaluation score. A score of 0-9 indicated no to low risk, while a score of 10+ indicates moderate to high fall risk. -A fall risk evaluation will be conducted by the nurse on duty/supervisor on any resident/patient sustaining a fall with or without injury. -The interdisciplinary team will meet at the next morning meeting to review any falls and evaluate additional needs for changes in the plan of care. Resident #4 was admitted to the facility in November 2021 with diagnoses including dementia, psychotic disturbance, repeated falls, and Wernicke's encephalopathy (a neurological condition caused by vitamin B1 [thiamine] deficiency, characterized by symptoms of confusion, ataxia [poor muscle control], and opthalmoplegia [weakness of the eye muscles]). Review of the MDS assessment, dated 6/6/25, indicated a Brief Interview for Mental Status (BIMS) assessment was unable to be completed as Resident #4 was rarely/never understood. Further review of the MDS assessment indicated the Resident had one fall with injury since the previous MDS assessment completed 3/7/25. Review of Resident #4's Care Plans indicated but was not limited to: Focus:[Resident #4] is at risk for fall related injury Disease process/condition Dementia, Muscle weakness [sic] Fall History: Fall in the last month Fall in the last 2-6 months Fracture r/t (related to) fall in last 6 mos (dated initiated 10/11/22) Interventions: -Assess resident for pain, offer repositioning, toileting, snacks or beverage (date initiated 4/21/25) -Floor mats while in bed (date initiated 12/16/24) -Frequent checks when resident is in bed. While awake offer toileting and snacks (date initiated 7/8/24) -Frequent checks while resident is wandering and redirect as needed for safety (date initiated 6/9/23, date resolved 8/26/25) -Invite, encourage, remind, escort to activity programs consistent with resident?s [sic] interests to enhance physical strengthening needs (date initiated 10/11/22) -md review of pain management, new orders for ibuprofen (date initiated 11/7/24) -Med review (date initiated 9/27/24) -Monitor resident after visits to redirect intrusive wandering into other residents rooms (date initiated 4/22/24, date resolved 8/26/25) -Monitor Silca Splint to right hand thumb for increase [sic] edema or skin breakdown OT/PT eval as needed (date initiated 10/23/24) -Monitor stop signs across door entrances are in proper position across door entrance not hanging on floor (date initiated 10/23/24, date resolved 8/26/25) -Notify family member ask if new clothes tapered leg pants can be bought to resident r/t (related to) recent fall 12/6/22 (date initiated 12/7/22, date resolved 8/26/25) -Offer 2nd snack prior to bedtime (date initiated 7/20/23) -Offer seat close to nurse's station when resident allows (as tolerated) and offer an activity: Sensory bin, 1:1 conversation, etc. (date initiated 10/11/22, date resolved 8/26/25) -Offer toileting/provide incontinent care prior to change of shifts (date initiated 10/27/24, date resolved 8/26/25) -Overlay to mattress to define parameters while in bed (date initiated 3/7/23) -Provide environmental adaptations; Low/platform bed Call light within reach Adequate glare free lighting Area free of clutter (date initiated 10/11/22, date resolved 8/26/25) -Referral for screen & treatment as needed PT Mental Health OT (date initiated 10/11/22) -Report falls to physician and responsible party (date initiated 4/19/25) -Toilet resident prior to meals (date initiated 4/7/23, date resolved 8/26/25) Review of Resident #4's Fall Risk Evaluations completed on 7/5/24, 7/15/24, 9/9/24, 9/27/24, 10/6/24, 10/12/24, 10/18/24, 10/26/24, 12/6/24, 12/13/24, 1/13/25, 2/23/25, 4/18/25, 6/2/25 indicated the Resident was at risk for falls. Review of Resident #4's Physician Progress Notes consistently identify that the Resident had falls, but failed to address the Resident's fall risk or identify any fall prevention interventions. Review of Resident #4's medical record indicated Resident #4 had 11 falls since 7/1/24. Review of Resident #4's falls indicated: -9/9/24 at 3:15 P.M., Resident #4 was found in the hallway lying in the fetal position on his/her left side. The Resident was unable to describe what happened. No injury was noted. Predisposing factors included confusion, impaired memory, and wandering. The incident report provided to the surveyor did not include any additional staff statements. No new intervention was added to the Resident's fall prevention care plan. -10/6/24 at 3:33 P.M., Resident #4 had an unwitnessed fall in another Resident's room. No injury was noted. Predisposing factors included confusion, impaired memory, active exit seeker, and wandering. Two staff statements were included with the incident report and indicated neither staff member was aware of the Resident's fall until they were informed after the incident. No new intervention was added to the Resident's fall prevention care plan. -11/16/24 at 6:15 P.M., the nurse was notified by another resident that Resident #4 was lying on the floor. The nurse observed the Resident lying on the floor, crying, with a small pool of blood under the Resident's head. The Resident was sent to the hospital for further evaluation. No predisposing factors were identified. Staff statements included with the incident report were reviewed but no staff members witnessed the fall or indicated in their statements when the Resident was last seen or what he/she was doing when last seen. No new intervention was added to the Resident's fall prevention care plan. Review of the hospital After Visit Summary, dated 11/20/24, indicated the Resident was diagnosed with a closed intertrochanteric fracture of the left femur (a fracture of the left femur at the hip joint) and underwent surgical trochanteric nail insertion on 11/16/24. The Discharge summary, dated [DATE], indicated the Resident had a history of recurrent falls and was transferred to the hospital after an unwitnessed fall. Imaging showed a left hip fracture and left olecranon (elbow) fracture. The Resident's hip fracture was repaired surgically and the elbow fracture was treated nonoperatively with a splint. The Resident was also noted to have severe compression deformities of T12 (the twelfth thoracic vertebra, or bone in the spine), L1-L2 (the first two lumbar vertebrae), and L4 (the fourth lumbar vertebra) of indeterminate age, which were managed conservatively. -12/6/24 6:42 P.M., Resident #4 was found on the floor beside his/her bed. The nurse indicated the Resident was sitting on a wedge pillow that was used in his/her bed. No injury was noted. Predisposing factors included confusion, gait imbalance, impaired memory, and recent illness. The incident report provided to the surveyor did not include any additional staff statements. No new intervention was added to the Resident's fall prevention care plan. -12/13/24 6:16 P.M., Resident #4 was found sitting on the floor next to his/her bed. No injury was noted. No predisposing factors were identified. The incident report provided to the surveyor did not include any additional staff statements. No nursing progress note was entered in the Resident's medical record on 12/13/24. The Resident's fall prevention care plan was updated to include floor mats while in bed. -2/23/25 at 11:00 A.M., Resident #4 was observed sitting in his/her wheelchair in front of the nurse's station and tried to get up and lost his/her balance and fell. A skin tear was noted on the Resident's left upper arm. No predisposing factors were identified. A staff statement included with the incident report indicated the staff member was not aware of how the Resident had fallen as she was busy assisting another resident at the time of the fall. No new intervention was added to the Resident's fall prevention care plan. Review of Resident #4's Resident Care Card indicated the Resident was at high risk for falls but failed to include the use of floor mats as indicated in the Resident's fall prevention care plan. On 8/25/25 at 9:27 A.M. and on 8/27/25 at 7:20 A.M. and 8:35 A.M., the surveyor observed Resident #4 lying in bed with no floor mats in place. During an interview on 8/26/25 at 4:06 P.M., Unit Manager #1 said when a resident has a fall, a risk report is completed in the electronic medical record, and the nurse gathers statements from staff members and notifies the physician and responsible party. Unit Manager #1 said a new fall prevention intervention should be put into place at the time of the fall, but it can be difficult to develop a new intervention for a resident who falls repeatedly. During an interview on 8/27/25 at 7:25 A.M., Certified Nursing Assistant (CNA) #10 said she was familiar with Resident #4. CNA #10 said the Resident does not use floor mats next to his/her bed but has a mattress with a raised edge because he/she still does try to climb out of bed sometimes. During an interview on 8/27/25 at 8:42 A.M., CNA #5 said CNAs do not have access to the residents' care plan interventions or care card/Kardex in the electronic health record but have a paper Resident Care Card they can refer to in a binder at the nurses' station to obtain information about residents' care needs. During an interview on 8/27/25 at 11:26 A.M., Unit Manager #1 reviewed Resident #4's fall prevention care plan with the surveyor and said the Resident no longer used floor mats and he was not aware it was in the Resident's care plan. During an interview on 8/27/25 at 12:08 P.M., the Director of Nursing (DON) said that floor mats were implemented for Resident #4 after a fall and he/she should still have them in place when in bed as this intervention was not discontinued. The DON said fall prevention interventions should be updated immediately after a fall to prevent further falls and/or injury and that if needed, the interdisciplinary team could revise the interventions after the circumstances of a fall were reviewed. The surveyor attempted to contact Resident #4's attending physician on 8/27/25 and 8/28/25, but the physician was unable to be reached. 2. Review of the facility's policy titled Elopement, dated July 2015, indicated but was not limited to: -Elopement is defined as the ability of a resident who is not capable of protecting himself or herself from harm to successfully leave the facility unsupervised and unnoticed and who may enter into harm's way. -The Licensed Nurse will conduct an Elopement Risk Screen on admission, re-admission, annually, quarterly, and upon change of condition. -A care plan will be developed and implemented for any resident at risk for elopement. Resident #83 was admitted to the facility in August 2025 following a hospitalization and had diagnoses including alcohol dependence with withdrawal and major depressive disorder. Review of the comprehensive MDS assessment, dated 8/15/25, indicated Resident #83 had moderate cognitive impairment as evidenced by a BIMS score of 9 out of 15, exhibited no hallucinations, delusions or behaviors, received no psychotropic medication and had an activated health care proxy. During an interview on 8/25/25 at 2:03 P.M., Nurse #3 said she initiated the admission process for Resident #83 late in the evening on 8/12/25 using hospital discharge paperwork the Resident brought from the hospital. She said there was no other hospital documentation available at the time of the admission. Nurse #3 said although Resident #83 was admitted with an activated HCP, she did not wait until she could reach the HCP to complete the elopement assessment and obtained information from the Resident. Review of an initial elopement assessment, dated 8/12/25, indicated Resident #83 was not at risk for wandering and not at risk for elopement. Review of the medical record indicated but was not limited to the following nursing progress notes: -8/17/25: Around 7:00 A.M., Resident #83 called 911 and a police officer came to the facility. The Resident stated that somebody is playing in his/her back and he/she doesn't belong there and needs to leave. -8/18/25: Resident #83 called 911 and stated there was something behind his/her window. Further review of the medical record failed to indicate the Resident was reassessed or safety interventions developed and put into place after expressing delusional thoughts/hallucinations and verbalizing feeling the need to leave the facility. Review of the medical record indicated hospital documentation (for the hospitalization immediately preceding admission) was uploaded and accessible in the electronic medical record on 8/13/25. Review of hospital documents indicated but was not limited to the Resident's past medical history, hospital course of treatment and a psychiatric evaluation. The Resident had a psychiatric assessment and was found to have poor insight, poor judgment and to not have capacity to make decisions and his/her HCP was activated. The physicians' notes indicated that Resident #83's HCP reported that the Resident had a history of elopement from his/her previous facility and eloped from the hospital while there for a medical procedure in July 2025. The case manager's discharge planning notes indicated the facility offered and the HCP accepted a bed for Resident #83 on their general long-term care unit and noted that, should any elopement risk arise, they would work with his/her HCP to transfer the Resident to a facility with a secure unit. Review of a Nursing Note, dated 8/23/25, indicated around 6:00 A.M., Certified Nursing Assistant (CNA) #4 alerted Nurse #4 that Resident #83 was found outside unaccompanied in the parking lot. Nurse #4 indicated the Resident refused to come back inside the facility but agreed to come inside the facility after the third attempt. During an interview on 8/25/25 at 1:54 P.M., CNA # 4 said she came into the facility on 8/23/25 at 6:15 A.M. and as she was walking on the unit, she heard the front door alarm going off. CNA #4 said she went out to the parking lot and saw Resident #83 walking in the parking lot toward the road. She said she was able to convince him/her to sit in a chair in the front of the building, but he/she refused to come back inside. She said she left the Resident alone seated in a chair in the front of the building while she went inside to get Nurse #4. The Surveyor attempted to reach Resident #83's HCP and Nurse #4 by telephone on 8/26/25 without success. Review of the medical record failed to indicate that a reassessment of the Resident's elopement risk was conducted, and no safety interventions were put into place to prevent further elopement/attempts from the facility. Review of the report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 8/25/25, indicated that on 8/23/25, Resident #83 was last seen at approximately 3:00 P.M. At 5:30 P.M., facility staff were notified by the local police department that Resident #83 was found down the street at a liquor store by police who notified emergency medical services (EMS) related to his/her confused state. Review of the elopement investigation (in progress) included written statements, dated 8/23/25 and 8/24/25, taken by the DON and the Assistant Director of Nurses indicated but was not limited to the following: -CNA #4 said on 8/23/25 around 6:15 A.M. she heard the front door alarm go off and she went to the lobby and saw Resident #83 walking around the parking lot. She indicated she asked the Resident to come inside, and he/she refused. She said she managed to get the Resident to sit in a chair in front of the building while she went to the unit to get Nurse #4. -CNA #3 said the last time she saw Resident #83 was at 3:00 P.M. on 8/23/25 lying in bed under the covers. -Nurse #3 said the last time she saw Resident #83 on 8/23/25 was around lunchtime. She indicated around supper time, the local Fire Department (sic) called to inform them that they found the Resident on the street and transferred him/her to the hospital. During an interview on 8/26/25 at 1:45 P.M., the Director of Maintenance (DOM) said they believe Resident #83 exited through the East Unit door at the end of the hallway on 8/23/25. The DOM said the door at the end of the hallway is never used, however, when residents were testing positive for COVID a few weeks ago, they started using that door to take the COVID positive residents out to smoke. He said he came into the building on 8/24/25 to troubleshoot what happened with the door to find out how the Resident could have gotten out. He said the staff that take residents out that door to smoke must enter a code into the keypad to unlock it and prop the door open because there is no keypad outside and otherwise, they would not be able to get back in. He said once the door closes, staff need to re-enter the code into the keypad to re-engage the alarm. The DOM demonstrated entering the code into the keypad, opening the door and propping it open with a pen. The door alarm sounded, then shut off after approximately 20 seconds. He removed the pen and the door closed. He said when the click sound stops, that means the door is disarmed and cannot be activated again until someone enters the code into the keypad. He opened the door again and no alarm sounded. During an interview on 8/26/25 at 11:08 A.M., Police Officer #1 provided the survey team with a police log report, dated 8/23/25. He said Resident #83 was found by police in the community at a liquor store (one mile from the facility) at 5:02 P.M. and was transported to the hospital by the local fire department's EMS. Review of the EMS run report, dated 8/23/25 at 5:17 P.M., indicated upon EMS arrival, Resident #83 was standing outside a liquor store. The Resident told emergency personnel that he/she was lost and not sure how he/she got there. EMS transported Resident #83 to the hospital. During interviews on 8/25/25 at 1:31 P.M. and 8/26/25 at 10:50 A.M. and 12:40 P.M., the DON said she believes the Resident exited the facility through the East Unit door that did not have the alarm activated. She said an investigation revealed that staff prop open the alarmed East Unit door while they take residents out to smoke and after a short amount of time, the alarm disengages. She said when they came back inside, they should have ensured the door was secured shut and entered the code into the keypad to reactivate the alarm, but that did not happen. She said the physician and HCP should have been notified of the Resident's elopement attempt the morning of 8/23/25, a reassessment of the Resident's elopement risk should have been conducted, and safety interventions should have been put into place prevent the elopement that occurred later that day and that was not done.

Based on review of Resident Council Minutes, a resident group meeting, interviews, and record reviews, the facility failed to ensure grievances brought forward from the Resident Council were addressed and promptly resolved to ensure the residents felt their concerns were acted upon. Findings include: Review of the Resident Council Minutes, dated 4/8/25, indicated but was not limited to:-Two residents on the west unit indicated they were missing clothes Further review of the Resident Council Minutes and corresponding documents, dated 4/8/25, failed to indicate the concern had been addressed and responded to by the facility. On 8/25/25 at 4:26 P.M., the Activities Director reviewed the Resident Council Minutes and corresponding documentation. The Activities Director said there should be a response from the Laundry/Housekeeping Department head but there was not. Review of the Resident Council and Food Committee Minutes, dated 5/21/25, indicated but was not limited to:-Multiple residents from both units stated that the Assistant Director of Nurses (ADON) spoke to the residents disrespectfully and they felt intimidated by her-Residents reported the food temperature was so-so Further review of the Resident Council Minutes and corresponding documents, dated 5/21/25, failed to indicate the concern regarding the ADON had been addressed and responded to by the facility. The Dining services responded that they would increase the frequency of test trays from twice monthly to once weekly. Review of the subsequent documented test trays failed to indicate weekly test trays had been conducted. On 8/25/25 at 4:26 P.M., the Activities Director reviewed the May 2025 Resident Council Minutes, and corresponding documentation. The Activities Director said the Nursing Department response should have included education to the ADON but did not. During an interview on 8/26/25 at 5:08 P.M., the Director of Nurses (DON) said she could not provide documented evidence of re-education to the ADON regarding the May 2025 Resident Council concerns. Review of the Resident Council Minutes, dated 6/19/25, indicated but was not limited to:-Five residents on the [NAME] wing stated they saw mice all over their rooms including on top of their beds Further review of the Resident Council Minutes and corresponding documents, dated 6/19/25, indicated but was not limited to:-the pest vendor was notified Review of the Resident Council Minutes, dated 7/17/25, indicated but was not limited to:-Residents on both East and [NAME] wings stated they were still seeing mice in and out of their rooms-Several residents from both wings claimed they were missing clothes Further review of the Resident Council Minutes and corresponding documents, dated 7/17/25, indicated but was not limited to:- Mouse traps were purchased and spread throughout the facility-The Laundry/Housekeeping department head would speak to residents to find out what was missing and resolve the grievance On 8/25/25 at 4:26 P.M., the Activities Director reviewed the July 2025 Resident Council Minutes and corresponding documentation. The Activities Director said the concern regarding missing clothing came up every month and the head of laundry always addressed it with residents. Review of the Resident Council Minutes, dated 8/15/25, indicated but was not limited to:-Resident on the East wing reported he/she saw ants and mice throughout his/her room Further review of the Resident Council Minutes and corresponding documents, dated 8/15/25, indicated but was not limited to:-Facility put down additional traps and would inform the pest vendor with next visit During a meeting on 8/25/25 at 1:30 P.M., the surveyor met with 12 residents during a Resident Council Meeting. The following concerns were voiced:-Resident #45 said he/she stopped attending meetings a few months ago because there was not point. Resident #45 said nothing got done and nothing changed.-Resident #58 said the same issues were brought up over and over again on repeat.-Eight out of 12 residents agreed that concerns were brought up and not addressed or corrected, one resident said the meetings were a waste of his/her time.-Seven out of 12 residents agreed laundry was frequently missing.-Seven out of 12 residents agreed mice were seen regularly. Resident #17 provided a written note with a concern regarding a mouse traveling from the outside into the heating duct and traveling from room to room, and it kept him/her awake half of the night. The Resident indicated that the mouse is starting to climb on things in the rooms and reported patching a hole in the tiles of the bathroom. In addition to the mouse, the Resident reported seeing ants everywhere and a cockroach or two.- Seven out of 12 residents agreed the ADON was degrading. Resident #45 said she spoke to the residents like she wanted to fight them and had a bad attitude. Resident #45 said it had been reported during Resident Council in the past but did not improve. During an interview on 8/25/25 at 4:26 P.M., the Activities Director said the Food Service Director completed the Food Committee Minutes at the start of each Resident Council Meeting and took their own notes. The Activities Director said to ensure every concern was addressed she provided the department heads with a form regarding any concerns that arose during the Resident Council Meeting, and they should respond with a resolution within three days. The Activities Director said some concerns do come up repeatedly including pests and missing laundry. Refer to F804 and F925

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to:1. Ensure the main kitchen dry food storage was maintained in a sanitary condition; 2. Follow proper sanitation and food handling practices while thawing chicken to prevent the outbreak of foodborne illness; and3. Ensure the tile flooring in the main kitchen was maintained in a sanitary and safe condition.Findings include:1. Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated, but was not limited to: -6-501.111 Controlling Pests. Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments.-6-501.111 Controlling Pests. The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by:-(B) Routinely inspecting the PREMISES for evidence of pests-(D) Eliminating harborage conditions.On 8/21/2025 7:56 A.M., the surveyor observed the main kitchen dry food storage area and made the following observations:-On the left side of the room there were multiple shelves of canned goods encrusted with rust along the can ends and a large amount of mouse droppings on top of the cans.During an interview on 8/21/25 at 8:20 A.M., the Food Service Director (FSD) inspected the dry storage area with the surveyor. He said the cans of food with rust along the ends and mouse droppings were the emergency food supply. He said they have had a mouse problem for a while, and they used to sanitize the tops of the cans because of the mouse droppings, and he thinks that is why they became rusted. The FSD said he was not aware of the rust and mouse droppings on the cans, and he needs to replace them. 2. Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: -3-501.13 Thawing. TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed: (A) Under refrigeration that maintains the FOOD temperature at 5oC (41oF) or less Pf (priority foundation); or (B) Completely submerged under running water: (1) At a water temperature of 21oC (70oF) or below Pf, (2) With sufficient water velocity to agitate and float off loose particles in an overflow Pf, and (3) For a period of time that does not allow thawed portions of READY-TO-EAT FOOD to rise above 5oC (41oF) Pf, or (4) For a period of time that does not allow thawed portions of a raw animal FOOD requiring cooking as specified under 3-401.11(A) or (B) to be above 5oC (41oF), for more than 4 hours including: (a) The time the FOOD is exposed to the running water and the time needed for preparation for cooking Pf, or (b) The time it takes under refrigeration to lower the FOOD temperature to 5oC (41oF) Pf On 8/21/25 at 7:56 A.M., the surveyor observed in the main kitchen a large stainless steel mixing bowl placed on a sink worktable containing approximately 10 raw chicken breasts submerged in stagnant water. The outside of the mixing bowl was ambient temperature to touch. During an interview on 8/21/25 at 8:20 A.M., the FSM said the chicken in the mixing bowl was going to be served as an alternate meal today. He touched the mixing bowl with the back of his hand and said the dietary staff should have taken the frozen chicken out and placed it in the refrigerator to thaw and not left it in standing water. 3. Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: 1-2 Definitions 1-201 Applicability and Terms Defined 1-201.10 Statement of Application and Listing of Terms. Easily Cleanable. (1) Easily cleanable means a characteristic of a surface that: (a) Allows effective removal of soil by normal cleaning methods; (b) Is dependent on the material, design, construction, and installation of the surface; and (c) Varies with the likelihood of the surface's role in introducing pathogenic or toxigenic agents or other contaminants into food based on the surface's approved placement, purpose, and use. Smooth means: (3) A floor, wall, or ceiling having an even or level surface with no roughness or projections that render it difficult to clean. 6-201.12 Floors, Walls, and Ceilings, Utility Lines. Floors that are of smooth, durable construction and that are nonabsorbent are more easily cleaned. Requirements and restrictions regarding floor coverings, utility lines, and floor/wall junctures are intended to ensure that regular and effective cleaning is possible and that insect and rodent harborage is minimized. On 8/21/2025 at 7:56 A.M., the surveyor observed, in the main kitchen, several areas of compromised flooring with several sections of tiling missing revealing deeply recessed areas of the floor exposing the subfloor underneath and pooling water. During an interview on 8/27/25 at 11:26 A.M., the FSD said the flooring is in need of repair and the maintenance department is aware but haven't fixed it yet.

Based on observations, interview, and records reviewed, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to:1. Ensure Transmission Based Precautions (TBP), specifically Isolation Precautions, were implemented as indicated for residents positive for COVID-19;2. Maintain and implement a Water Management Program to mitigate the risks of Legionella;3. Ensure the infection surveillance line lists were complete and accurate;4. Ensure medications were handled in a sanitary manner during administration for one out of two nurses observed; and5. Ensure personal protective equipment (PPE) was used properly by staff while caring for Resident #1 who was on Enhanced Barrier Precautions (EBP) to prevent the potential spread of infection. Findings include:1. Review of the facility's policy titled COVID-19 New Facility Outbreak for Massachusetts (MA), dated 6/24/23, indicated but was not limited to the following: -Residents with COVID-19 should be placed in a private room or in a room with another confirmed COVID-19 positive individual. (Use MA Department of Public Health (DPH) Isolation Sign for positive residents). -Place Pink Isolation sign on the door. Review of the facility's policy titled Section 1: Isolation, dated as last revised 3/2025, indicated but was not limited to the following: -TBP are for patients who are known or suspected to be infected or colonized with infectious agents, including certain epidemiologically important pathogens, which require additional control measures to effectively prevent transmission. Review of the MA DPH Isolation sign posted at the doorway of Residents #28, #77, #52, and #39's rooms indicated but was not limited to the following: -In Addition to Standard Precautions Staff and Providers MUST Clean Hands when entering and exiting, Gown (change between each resident), N95 Respirator, Eye Protection, and Gloves. Review of the medical records for Residents #28, #77, #52, and #39 indicated they had tested positive for COVID-19 and were on Isolation Precautions. The surveyor made the following observations on 8/21/25: -At 8:57 A.M., a staff member was at the doorway of Resident #28 and #77's room, she donned (put on) a gown, gloves, and face shield. She was wearing a surgical mask and did not don an N95 Respirator. Resident #39 exited his/her room, and the Certified Nursing Assistant (CNA) redirected him/her back into their room. Upon re-entry to the hallway, she donned a new gown, gloves, and face shield. She was wearing a surgical mask and did not don an N95 Respirator and proceeded to enter the room to answer the call light. -At 9:01 A.M., a Laundry Worker was pushing a large linen cart down the hallway delivering personal laundry. She parked the cart outside of Resident #28 and #77's room. She donned a gown, gloves, and N95 Respirator. She did not put on a face shield. She then proceeded to bring the laundry into their room. Upon exiting the room, she donned a clean surgical mask and moved her cart to Resident #52 and #39's room. She donned a gown and gloves. She did not don an N95 Respirator or face shield and entered the room to deliver the laundry. -At 9:18 A.M., CNA #5 donned a gown and gloves and entered Resident #28 and #77's room. She was wearing a surgical mask and did not have an N95 or a face shield on. -At 9:21 A.M., Nurse #7 donned a gown, face shield and gloves and entered Resident #28 and #77's room. She was wearing a surgical mask and did not have an N95 on. -At 9:26 A.M., an X-Ray Technician entered the room of Resident #28 and #77 with no PPE on. Nurse #7 came to the doorway of the room, and they entered the room together. -At 9:50 A.M., CNA #5 donned a gown, gloves, and face shield and entered Resident #28 and #77's room. She was wearing a surgical mask and did not have an N95 on. -At 9:54 A.M., Nurse #7 was at the med cart in front of Resident #39 and #52's room pouring medications. She donned a gown, put an N95 over her surgical mask, donned gloves, and a face shield. She entered the room with the medications. -At 9:56 A.M, CNA #5 donned a gown, gloves, and face shield and entered Resident #28 and #77's room. She was wearing a surgical mask and did not have an N95 on. -At 2:15 P.M., a staff member was outside with Residents #28 and #77. The residents were smoking. The staff member was wearing a gown, gloves, and face shield. She was wearing a surgical mask and did not have an N95 on. -At 4:08 P.M., a staff member was outside with Residents #28 and #77. The residents were smoking. The staff member was wearing a gown, gloves, and face shield. She was wearing a surgical mask and did not have an N95 on. During an interview on 8/21/25 at 10:32 A.M., Nurse #1 said Residents positive for COVID-19 have an isolation sign and all staff should have a gown, N95, face shield, and gloves on when they enter the room. During an interview on 8/21/25 at 10:46 A.M., CNA #5 said staff should have a gown, N95, face shield, and gloves on when they enter the COVID-19 rooms. She said she was unsure if they always had to wear the N95, but said she usually wears one. During an interview on 8/21/25 at 10:53 A.M., Nurse #7 said for the COVID positive rooms you are supposed to wear a gown, gloves, N95, and a face shield. She said sometimes she puts the N95 over her surgical mask, like she did today, but not always. She said the X-Ray Technician should have put PPE on, but he refused. During an interview on 8/22/25 at 1:05 P.M., the Staff Development Coordinator (SDC)/Infection Preventionist (IP) and the Director of Nurses (DON) said all staff should have full PPE on to enter the COVID positive rooms. She said that it includes a gown, N95, face shield, and gloves. Additionally, she said the PPE expectations is the same when the staff take the Residents out to smoke and the N95 should not be placed over a surgical mask. 2. Review of the facility's policy titled Section L: Legionella Policy, dated as last reviewed 1/2025, indicated but was not limited to the following: -It is the policy of this facility to have a water management program to reduce legionella bacteria growth and spread in the facility, and to educate staff on hire and annually on legionella symptoms. (Refer to the separate Water Management Program Policy). -Common Sources of infection: Outbreaks of Legionnaires' disease are often associated with large or complex water systems. The most likely sources of infection include water used for showering (potable water), cooling towers, decorative fountains, and hot tubs. -Legionella is usually spread through water droplets in the air. Review of the facility's policy titled Water Management Plan, undated, indicated but was not limited to the following: -All Healthcare facilities shall comply with the federal requirements for the purpose of reducing the risk of growth and spread of Legionella and other opportunistic pathogens in the water system. -Facilities shall adopt and implement a water management plan for their water system. The plans should include at minimum an overview of the facility characteristics, description of water supply, areas of concern, and sample sites to be tested. -Environmental assessments shall be updated annually and under the following conditions: positive case of legionellosis, completion of construction, modification, or repair activities that may affect the water system, and any other conditions specified by the department. The facility shall retain copies of completed environmental assessment forms. -Facility shall maintain the environmental assessment, sampling and management plan and any associated sampling results, on the facility premises for at least three years. Such records should be made available to the local and state department upon request. Review of the Water Management Plan Binder indicated but was not limited to the following: -Environmental Assessment and Procedures, dated 2/27/18, indicated the assessment is to discover any vulnerabilities that would allow for amplification of Legionella and to structure a response in advance. Showers, tubs, faucet taps should be periodically flushed to help mitigate the potential for stagnation. Daily testing of the water temperature delivered at the taps and recorded should be conducted. Environmental sampling for Legionella will be performed annually. Once Assessment is completed, it should be reviewed and updated at least one time per year. Water Management Committee members should include at minimum: Infection Control, Facilities Management, Nursing, and Administration. -Annual Water Management Plan Revision and Updates, dated 2/11/19 and 3/10/20, were in the binder. No additional annual updates were provided. Review of the Weekly Water Temperature logs indicated but were not limited to the following: -Record from 3/2/24 through 11/30/24 indicated three rooms on East Unit, three rooms on [NAME] Unit, the Kitchen, and Laundry rooms were all temperature tested weekly. -Record from 12/7/24 through 8/15/25 indicated four rooms on East Unit and four rooms on [NAME] Unit were temperature tested weekly. The log failed to indicate water temperature testing was conducted in the kitchen or laundry rooms. During an interview on 8/22/25 at 1:05 P.M., the IP and DON said they were not part of a Water Management/Legionella Committee or team. They said water committee includes the Administrator and Maintenance Supervisor and they were not routinely part of it and did not know when the Water Management Plan was discussed. During an interview on 8/22/25 at 1:55 P.M., the Maintenance Supervisor said the weekly water temperature testing logs should have sinks/showers/faucets from varying rooms on each unit, the shower/tub room, laundry, kitchen and kitchenettes. He said when they run the water they check the temperature. He said when the form was full at the end of November it appears the other sites dropped off. He said only the rooms on the units have been checked since November 2024 and there was no log of any temps in any kitchen/laundry areas. He said it seems when the copies with site written on them ran out, they just started doing four rooms on each unit and he did not know why. The Maintenance Director said he did not have a Water Management Committee or meetings. He said the Water Management Plan says it should be updated annually and did not know why it had not been done since 2020. Additionally, he said he has never met with the firm that does that Water Management Plan. He said the binder is on the shelf and they put the documents in it once they are done, same with the lab that does the Legionella testing. During an interview on 8/22/25 at 2:30 P.M., the Administrator said he had only been at the facility for a couple months and was under the impression the water temps, pressure, flushing was all up to date. He said the Maintenance Department handles it and he has not seen the plan or been part of any committee meetings as he had only been at the facility for less than two months. He said they only had informal conversations to ensure the logs were complete, but he had not seen the actual logs. He said the logs should include resident rooms on each unit, the laundry, kitchen, kitchenettes, administration wing etc. He said the exact location should vary every week. He said it was concerning it had not been done correctly since November and no one noticed. 3. Review of the facility's policy titled Infection Prevention Program, dated as last reviewed 1/2025, indicated but was not limited to the following: -Elements of the Infection Prevention Program include but are not limited to monitoring and documenting infections, tracking and analyzing outbreaks of infections. -Analyze trends and clusters of infections, and any increase in the rate of infection or resistant organisms, in a timely manner. -Maintain the monthly infection reports by unit to record each resident infection. -Monitor community acquired (CA) infections in residents admitted to the facility and attempt to obtain results and diagnosis of infection. -If an infection is counted for the month and continues in to the next month it is only counted once. Review of the Monthly Infection Reports from January through July 2025 indicated but were not limited to the following: JANUARY -A Resident was coded with an ongoing infection with an antibiotic listed. No additional information related to the infection was documented. Site, date of onset, symptoms, culture date/results, and comments were all left blank. -A Resident was coded with pneumonia on three occurrences and treated with the same antibiotic. The first was listed as not meeting criteria to be counted due to only having one symptom, the second had four symptoms listed and was coded as ongoing, and the third was coded as asymptomatic with a positive chest X-Ray. -A Resident was coded with a urinary tract infection (UTI), one symptom was listed, no culture or results were documented. -A Resident was coded on two lines with skin listed as the category, both lines had different antibiotics, comment was cellulitis. No symptoms were documented on either line. -On 24 of 24 line items, the box Infection Cleared Y/N was left blank. FEBRUARY -A Resident was coded with a UTI and on an antibiotic. The date of onset was listed as ongoing. This UTI was not on the January line list and no other information related to the infection was documented. -A Resident was coded with a blood stream infection with an antibiotic listed, symptoms were listed as ongoing. The date of onset was listed as 2/20/25. No other information related to the infection was documented. -A Resident was coded with a UTI and on antibiotics, the culture date and results was left blank. -On 19 of 19 line items, the box Infection Cleared Y/N was left blank. MARCH -A Resident was coded with a Gastrointestinal (GI) infection and on antibiotics. No other information related to the type of infection was documented. -A Resident was coded with an other infection, symptom was chest pain, and on an antibiotic. Comment was leukocytosis (high white blood cells), no blood work results were documented. -On 17 of 17 line items the box Infection Cleared Y/N was left blank. APRIL -A Resident was coded with a skin infection, listed as onset date 4/1/25, on antibiotics, and coded as ongoing. -For eight Infections, the box indicating to count or not count was left blank. -On 19 of 19 line items, the box Infection Cleared Y/N was left blank. MAY -A Resident was coded with an other infection, comments indicate C. Diff infection, no symptoms, culture date/results were documented. -On 16 of 16 line items, the box Infection Cleared Y/N was left blank. JUNE -A Resident was listed with a date of onset 6/16/25, no category was listed, an antibiotic was listed, no culture date/results were documented. -On 16 of 16 line items, the box Infection Cleared Y/N was left blank. JULY -A Resident was coded with a GI infection and on antibiotics, date of culture was left blank -On 8 of 8 line items, the box Infection Cleared Y/N was left blank. The sample of the line lists reviewed failed to consistently indicate infection symptoms, culture dates/results, and if the infection had cleared. Additionally, infections were listed as ongoing when they were not all on the month prior. During an interview on 8/22/25 at 1:05 P.M., the IP said when things are coded as ongoing, they were carried over from the month prior. She said they should have been on the line list the month prior; however, some were missing. The IP said they all should have every applicable box filled out on the worksheet, including if the infection cleared or not. She said the culture dates and results should be there for tracking purposes as well. She said the follow-up notes when not meeting criteria could be better and she was working on that. During an interview on 8/22/25 at 1:05 P.M., the DON said the line list should be complete for tracking purposes. She said usually when information is missing the lab will call and we probably tell them over the phone without updating the paper copy. She said the ones listed as ongoing should have been carried over from the month prior. Additionally, the DON said without the culture results listed a pattern cannot be identified with the data as it is listed. She said the IP was still learning the role. 4. Review of the facility's policy titled Medication Administration, Oral, dated June 2015, indicated but was not limited to the following: -Do not touch the medication when opening a bottle or unit dose packing Resident #24 was admitted to the facility in September 2024. Review of the current Physician's Orders for Resident #24 indicated, but were not limited to the following: - Diltiazem HCL ER 120 milligrams (mg) 1 cap daily (9/28/24) - Duloxetine HCL 60mg 1 cap in the morning (1/3/25) - Metoprolol Tartrate 50mg 1 tab two times a day (9/28/24) - Gabapentin 300mg capsule two times a day (9/28/24) On 8/21/25 at 9:11 A.M., the surveyor observed Nurse #2 preparing medications for Resident #24. While verifying the medications and removing them from their individual unit dose packages, the nurse was observed to pop the following medications from their individual dose packages directly into his hands: - Diltiazem HCL ER 120mg 1 cap - Duloxetine HCL 60mg 1 cap - Metoprolol tartrate 50mg 1 tab - Gabapentin 100mg - 3 individual tabs to equal the 300mg dose During an interview on 8/21/25 at 9:43 A.M., Nurse #2 said he did not realize he had popped those pills directly into his hand prior to placing them into the medication cup and he shouldn't have done that. He said nurses should not touch the pills before administering them to the residents, as that would be a concern for germs. During an interview on 8/21/25 at 11:11 A.M., the IP said the expectation is for the licensed nurses to complete medication administration with good infection control practices, like hand hygiene. The IP said the licensed nurses should not be touching any of the medications or popping them directly into their hands during medication pass or at any time. She said this would be a breech in the infection control practices and should not be occurring. 5. Review of the facility's policy Enhanced Barrier Precautions Policy, dated July 2022, indicated but was not limited to the following: - It is the policy of this facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multi-drug resistant organisms (MDROs). Novel or targeted MDROs are organisms that are resistant to all or most antibiotics tested, are uncommon in a geographic area, or have special genes that allow them to spread their resistance to other germs. - Enhanced barrier precautions require the use of a gown and gloves for certain residents during specific high-contact resident care activities in which there is an increased risk for transmission of multidrug-resistant organisms. - High-contact resident care activities include bathing/showering, providing hygiene, dressing, transferring, linen changes, toileting, device care and wound care. - Enhanced barrier precautions will also be implemented for residents with wounds, or indwelling medical devices (central lines, catheter, feeding tube, etc.) regardless of their MDRO colonization status that reside on a unit or wing where a resident known to be infected or colonized with a novel or targeted MDRO resides. - Signage will be posted on the door or wall outside of the resident room indicated the need for enhanced barrier precautions, the required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves. - Carts with appropriate PPE will be placed outside the resident's room. Resident #1 was admitted to the facility in July 2025 with diagnoses including but not limited to Parkinson's disease and muscle weakness. Review of Resident #1's Minimum Data Set (MDS) assessment, dated 8/1/25, indicated he/she was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15. Furthermore, the MDS assessment indicated Resident #1 had a feeding tube and required assistance from staff for activities of daily living (ADL) and functional mobility. Review of Resident #1's comprehensive care plans indicated he/she had an increased susceptibility for infection related to a G-Tube (gastrostomy tube – surgically placed to give access to the stomach for supplemental feeding, hydration or medicine). Interventions for the comprehensive care plan were implemented on 5/13/24 and included but were not limited to EBP as ordered. On 8/22/25 at 2:23 P.M., the surveyor made the following observations: - Resident #1 had an EBP sign posted on the doorway entrance to his/her room and a PPE cart outside of the doorway that included gowns, gloves, masks and face shields. - At 2:23 P.M., the surveyor observed CNA #1 transferring Resident #1 from a wheelchair at beside to his/her bed. CNA #1 was not wearing a gown or gloves. - At 2:27 P.M., CNA #1 re-entered Resident #1's room without donning any PPE. - At 2:45 P.M., CNA #1 exited Resident #1's room with a pair of pants and no PPE. During an interview on 8/22/25 at 2:45 P.M., CNA #1 said she assisted Resident #1 with transferring from his/her chair to their bed. CNA #1 said she also helped assist Resident #1 with changing his/her clothing. CNA #1 said she did not wear a gown because she was not performing ADL care with the resident. CNA #1 and the surveyor reviewed the signage outside of Resident #1's room which indicated a gown was required when transferring and/or dressing. CNA #1 said she did not wear a gown when assisting Resident #1 and did not need to because she did not perform ADL care. During an interview on 8/22/25 at 2:51 P.M., the Assistant Director of Nursing (ADON) said gowns and gloves should be worn when transferring or undressing a resident. During an interview on 8/22/25 at 2:52 P.M., the IP said CNA #1 should have worn a gown and gloves when transferring or undressing Resident #1.

Based on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards for five Residents (#72, #57, #31, #1, #5), out of a total sample of 20 residents. Specifically, the facility failed:1. For Resident #72, to implement physician's orders to apply palm rip/palm roll to the Resident's left hand; 2. For Resident #57, to implement physician's orders to apply his/her glasses and left upper extremity splint;3. For Resident #31, to implement physician's order for laboratory blood work;4. For Resident #1,a. to reconcile and implement physician's order for enteral tube feeding, andb. to reconcile and implement physician's order for oxygen use; and5. For Resident #5,a. to implement the physician's order for oxygen use, and b. to implement the physician's orders for wound treatments. Findings include: Review of [NAME], Manual of Nursing Practice 11ed, dated 2019, indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. -In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber. 1. Resident #72 was admitted to the facility in February 2022 with diagnoses including dementia, cerebrovascular accident (CVA/ stroke – a disruption of blood flow to the brain, which can lead to brain damage), and muscle weakness. Review of Resident #72's Minimum Data Set (MDS) assessment, dated 7/4/25, indicated Resident #72 was severely cognitively impaired, as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of 15. Review of Resident #72's Occupational Therapy Discharge summary, dated [DATE], indicated the Resident received skilled occupational therapy due to increased bilateral hand contractures impacting feeding as well as positioning in bed. At discharge, the Resident was able to tolerate bilateral hand palm roll orthoses for the entirety of the day shift. The Discharge Summary indicated patient and caregiver training was completed on orthosis management and it was recommended that the Resident wear bilateral palm roll orthoses for day shift at least five times per week. Review of Resident #72's Physician's Orders indicated, but was not limited to, the following: - SPLINT: Apply palm rip/palm roll to Left Hand at AM care and off PM care as tolerated. Remove splint for skin hygiene. Check skin integrity Q shift (order date 1/28/25) - SPLINT: Apply Palm roll to right hand at AM Care and off PM care as tolerated. Remove splint for skin hygiene. Check skin integrity Q shift (order date 8/20/25) Review of Resident #72's August 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) indicated the Resident's palm rip/palm roll was applied and removed as ordered. Review of Resident #72's Care Plan indicated, but was not limited to, the following: Focus: Orthosis mgmt. [management] – maintain and promote skin integrity d/t [due to] past CVA affecting LUE [left upper extremity] and contracture R [right] hand (revised 8/20/25) Interventions: Splint: B [bilateral] palm grip orthosis/palm roll on AM care off PM care as tolerated after hand hygiene; check skin q [every] shift (revised 8/20/25) Focus: Resident has an ADL [activities of daily living] deficit related to: disease process/condition, mood/behavior problem, pain, weakness (initiated 6/22/22) Interventions: Splint: L [left] palm grip orthosis/palm roll 4-6 hours per day M-F [Monday-Friday] as tolerated after hand hygiene; check skin q shift (revised 7/18/23) Review of Resident #72's Resident Care Card indicated, but was not limited to, the following: -Splints/Braces/Immobilizers: Type: hand Where: hand When: at all x's [times] -Skin protection: Hand roll Review of Resident #72's Progress Notes failed to indicate the Resident declined to wear his/her left palm roll. During an interview on 8/21/25 8:50 A.M., the surveyor observed that Resident #72 was wearing a right-hand palm roll. Resident #72 said he/she had had a stroke. Resident #72 showed the surveyor his/her left hand and said he/she was unable to extend his/her left middle finger fully. A palm roll was observed on the Resident's bedside table. The Resident said he/she was supposed to be wearing it. On 8/21/25 at 11:30 A.M., the surveyor observed that Resident #72 was not wearing his/her left palm roll. On 8/26/25 at 9:29 A.M., the surveyor observed Resident #72 wearing a right-hand palm roll only. During an observation with interview on 8/26/25 at 10:16 A.M., the surveyor observed Resident #72 wearing a right-hand palm roll only. The Resident showed the surveyor his/her left hand and was unable to fully extend his/her middle (3rd) and ring (4th) finger. The Resident said he/she should be wearing a palm roll in each hand. During an interview on 8/27/25 at 9:52 A.M., Certified Nursing Assistant (CNA) #6 said she is familiar with Resident #72, and the Resident has a device he/she wears on the right hand, but nothing on the left. CNA #6 said there is no Resident Care Card to refer to for instructions on how to care for the Resident, but there is information on the CNA assignment sheet to refer to. During an interview on 8/27/25 at 11:39 A.M., Unit Manager #2 said Resident #72 wears a splint on his/her right hand and does not wear any device on the left. During an interview on 8/27/25 at 12:08 P.M., the Director of Nursing (DON) said the therapy department should educate unit staff when implementing a new device or new exercises for a Resident. The DON said that if a Resident has an order for a device, it should be implemented as it is her expectation that the physician's orders are followed. During an interview on 8/27/25 at 1:35 P.M., Occupational Therapist (OT) #1 said Resident #72 was recently discharged from occupational therapy with bilateral palm rolls. OT #1 said that Resident #72 does like to wear the palm rolls and should be wearing them in both hands. 2. Review of the facility's policy titled Splints/Orthotics/Prosthetics, dated April 2015, indicated but was not limited to: -Nursing staff will apply/remove the designated splint/orthotic/prosthetic device during scheduled wearing times, -If the resident refuses to wear the device, notify the rehab department, physician, and responsible party Resident #57 was admitted to the facility in October 2021 with diagnoses that included cerebral infarction (stroke) with hemiplegia (weakness or paralysis of one side of the body) affecting his/her left side. Review of Resident #57's MDS assessment, dated 6/13/25, indicated he/she had impaired range of motion on one side. Review of Resident #57's Occupational Therapy Discharge summary, dated [DATE], indicated he/she received Occupational Therapy from 6/3/25 through 7/30/25 due to decreased compliance with his/her splinting device. The Discharge Summary indicated patient and caregiver training was completed on orthosis management and staff had demonstrated the ability to don/doff the splint properly. The Discharge Summary indicated Resident #57 should continue to wear the splint daily for contracture management. Review of Resident #57's Physician's Orders indicated but were not limited to: -Apply glasses in morning, keep glasses in medication cart, dated 11/23/24 -Splint: Apply Left Palm Roll and wrist as tolerated. Apply Left elbow orthosis on with morning care and off with evening care, dated 1/28/25 Review of Resident #57's August 2025 MAR and TAR indicted his/her glasses, left palm roll, and left elbow orthosis had been signed off as administered. Review of Resident #57's Resident Care Card, dated 7/1/25, indicated but was not limited to: -Splints/braces/immobilizers: Type: hand Where: left When: at all times On the following dates and times during survey, the surveyor observed Resident #57 not wearing his/her glasses or his/her left upper extremity splint: -8/21/25 at 9:22 A.M. -8/25/25 at 9:18 A.M. and 2:55 P.M. -8/26/25 at 9:30 A.M. and 12:55 P.M. -8/27/25 at 7:41 A.M. and 11:09 A.M. Review of Resident #57's August 2025 progress notes failed to indicate he/she had refused to wear his/her left upper extremity splint or glasses. During an interview on 8/27/25 at 11:14 A.M., CNA #7 said he/she was caring for Resident #57. CNA #7 said Resident #57 never wears glasses and that he/she was not instructed to apply a splint to his/her left upper extremity. CNA #7 said sometimes the rehab department comes around and applies splints but has not applied his/hers today. During an interview on 8/27/25 at 11:19 A.M., Nurse #5 said Resident #57 should be wearing his/her left upper extremity splint. Nurse #5 said Resident #57 should be wearing his/her glasses, but she had not been able to find them. Nurse #5 said physician's orders should be followed. During an interview on 8/27/25 at 1:18 P.M., Unit Manager #2 said Resident #57 should be wearing his/her glasses and left upper extremity splint during the day. Unit Manager #2 said sometimes rehab applied the splints. During an interview on 8/27/25 at 12:27 P.M., the DON said physician's orders should be followed. 3. Resident #31 was admitted to the facility in November 2024 with diagnoses which included End Stage Renal Disease, dependence on renal dialysis, and Type 2 diabetes mellitus. Review of Resident #31's medical record indicated that he/she received dialysis treatment at a local dialysis center every Tuesday, Thursday and Saturday, and any medical issues, either at the facility or the dialysis center, were to be documented/communicated via the Resident's dialysis communication book. Review of the Nursing Policy and Procedure Manual for Hemodialysis, dated 2015, indicated but was not limited to the following: -Communication: - The communication book/sheet will be reviewed upon return from dialysis. Review of the Hemodialysis Communication Sheet from the dialysis center, dated 8/9/25, indicated to Please check stool with stool card b/c (because) hemoglobin 7 per provider. (normal hemoglobin ranges between 14.0 grams per deciliter (gm/dL) and 17.5 gm/dL per dL). During an interview on 8/20/25 at 12:20 P.M., Nurse #2 said that he had received a telephone order from the physician on 8/9/25 to obtain a Complete Blood Count (CBC) with differential blood test (a blood test that measures the number and types of various blood cells, including red blood cells, white blood cells and platelets), on the next lab day. He said that the lab test was ordered due to communication by the dialysis center of a critically low hemoglobin of 7, following the Resident's dialysis treatment on Saturday 8/9/25. Nurse #2 said the next laboratory day would have been on Monday 8/11/25. Nurse #2 said he could not find that the CBC with differential had been done on Monday 8/11/25 as ordered. During an interview on 08/22/25 at 12:55 P.M., the DON said that Nurse #2, who received the verbal order from the physician on 8/9/25, failed to put in the request order for the blood work to be drawn on 8/11/25, the next laboratory day. The DON said she understood the Resident's hemoglobin was reported as 7, critically low, and a concern of the dialysis center when communicated via the hemodialysis communication sheet on 8/7/25. 4. Review of the facility's policy untitled, dated August 2022, indicated but was not limited to the following: - This facility reconciles medication frequently throughout a resident's stay to ensure that the resident is free of any significant medication errors, and that the facility's medication error rate is less than 5 percent. - admission Processes: b. compare orders to hospital records, etc. Obtain clarification as needed; c. transcribe orders in accordance with procedures for admission orders. Resident #1 was admitted to the facility in July 2025 with diagnoses including Parkinson's disease, chronic obstructive pulmonary disease (COPD), and muscle weakness. Review of Resident #1's MDS assessment, dated 8/1/25, indicated he/she was cognitively intact as evidenced by a BIMS score of 15 out of 15. Furthermore, the MDS assessment indicated he/she had a feeding tube and used oxygen. Review of Resident #1's medical record indicated he/she was discharged to the hospital for a change in medical status on 8/17/25 and returned to the facility on 8/19/25. a. Review of the facility's policy titled Enteral Feeding, dated April 2015, indicated but was not limited to the following: - Enteral feeding provides an alternative method of nutritional support via gastrostomy (G-Tube) or jejunostomy (J-Tube) and is used to enhance and maintain nutritional status when there is an inability to take adequate nutrients orally. - Check physician order for formula, rate and water flushes. Review of Resident #1's Physician Orders indicated but were not limited to the following: - 9/24/24 through 8/19/25: Administer Glucerna 1.2 continuous; 12 hours nocturnal via feed pump at 140 mL (milliliters)/hr (hour) (6 P.M. to 6 A.M.); flush 150 mL every 3 hours during feed time. - 1/9/24 through 8/19/25: Change tube feeding system every 24 hours (bag, tubing, and syringe); be sure to date and initial; every night shift. - 6/4/25 through 8/19/25: Enteral Feed Order in the afternoon for Bolus TF (tube feed) of 240 mL at 3 P.M. - 8/21/25: Glucerna 1.2 CAL (calories); rate 240 mL bolus feed in afternoon at 12:30 P.M. - 8/21/25: Glucerna 1.2 CAL; rate 240 mL bolus feed in afternoon at 4:00 P.M. Further review of Resident #1's Physician's orders failed to indicate a continuous TF order was in place upon return from the hospital on 8/19/25. Furthermore, the physician's orders indicated the bolus TF orders were put in place two days after the Resident returned from the hospital. Review of the MAR for August 2025 failed to indicate a continuous TF was administered to the resident from 8/19/25 to 8/26/25. Furthermore, the MAR indicated bolus TF orders were not administered on 8/19/25 and 8/20/25. Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated but was not limited to the following: - Tube feed as per dietician recommendations. During an interview on 8/22/25 at 8:26 A.M., Resident #1 said he/she has been receiving their continuous TF overnight and their two bolus feedings during the afternoon. During an interview on 8/22/25 at 12:56 P.M., Nurse #3 said Resident #1 receives a continuous TF overnight and has two bolus feedings during the afternoon. During an interview on 8/26/25 at 10:39 A.M., Nurse #3 said she worked 3:00 P.M. to 11:00 P.M. on 8/25/25 and hung Resident #1's overnight continuous tubing feeding. Nurse #3 and the surveyor reviewed Resident #1's medical record including MAR and physician's orders. Nurse #3 said there was no order for Resident #1's continuous overnight TF and there should be. Nurse #3 said there was no indication on the MAR the continuous overnight TF was completed. Nurse #3 said the continuous overnight TF should have only been put up if there were orders present. During an interview on 8/26/25 at 11:00 A.M., the Regional Dietitian said she would expect orders for tube feedings to be re-implemented when a resident returns from a hospitalization unless there is a change indicated in the discharge paperwork. The Regional Dietitian said Resident #1 should have had orders in place upon return from the hospital. The Regional Dietitian reviewed Resident #1's medical record and said it appears the continuous feeding was not implemented upon readmission to the facility, and the bolus feedings were not implemented until 8/21/25, two days after he/she returned. During an interview on 8/26/25 at 11:27 A.M., the DON said she would expect there to be orders for any tube feeding after return from a hospitalization. The DON said Resident #1's orders should have been reviewed. The DON said nursing should have clarified and inputted tube feeding orders and should not have hung a tube feeding without orders present. b. Review of Resident #1's Physician's Orders indicated but were not limited to the following: - 10/28/24 through 8/19/25: Oxygen (O2) continuously via NC (nasal cannula) at 2 liters/minute (LPM) every shift; check pulse oximetry and LPM. - 11/3/24 through 8/19/25: Change O2 tubing every Sunday on 11 P.M. to 7 A.M. - 11/3/24 through 8/19/25: Monitor O2 saturation on room air weekly; every evening shift every Sunday. - 8/22/25: O2 continuously via NC at 2-4 LPM every shift; check pulse oximetry and LPM. Further review of Resident #1's physician's orders failed to indicate an oxygen order was in place upon return from the hospital on 8/19/25. Furthermore, the physician's orders indicated the continuous oxygen orders were put in place three days after the Resident returned from the hospital. Review of the MAR for August 2025 failed to indicate continuous oxygen was administered to the Resident from 8/19/25 to 8/22/25. Review of Resident #1's comprehensive care plan for COPD indicated the following intervention was in place: - 6/4/25: Administer oxygen as ordered and monitor its effectiveness by checking oxygen saturation, as indicated. During an interview on 8/21/25 at 10:00 A.M., Resident #1 said he/she had been on oxygen for a while, and he/she has been using the oxygen since they returned from the hospital a couple days ago. During an interview on 8/22/25 at 12:57 P.M., Nurse #3 said Resident #1 had been utilizing oxygen for quite a while. Nurse #3 reviewed Resident #1's medical record and said there were not currently orders in place for Resident #1's oxygen and there should be. Nurse #3 said the orders should have been re-instated when Resident #1 returned from the hospital and oxygen requires an order for its use. During an interview on 8/26/25 at 11:27 A.M., the DON said she would expect any resident utilizing oxygen to have orders in place. The DON said Resident #1's oxygen orders should have been put in place upon re-admission to the facility on 8/19/25. 5. Resident #5 was admitted to the facility in July 2025 with diagnoses including: heart failure, type I diabetes, muscle weakness and hypertension. Review of Resident #5's MDS assessment, dated 8/5/25, indicated he/she was cognitively intact as evidenced by a BIMS score of 13 out of 15. Furthermore, the MDS assessment indicated he/she did not have shortness of breath or trouble breathing when at rest or lying flat. a. Review of the medical record indicated Physician's Orders for: - Oxygen (O2) continuously via nasal canula at 2 Liters/minute, every shift, check pulse oximetry and Liters per Minute (LPM), effective 7/31/25 - Change O2 tubing every Sunday (Sun) on the 11:00 P.M.-7:00 A.M. shift, every night shift, every Sun. The surveyor observed Resident #5 in bed with O2 being administered via nasal canula supplied by an O2 concentrator with the following liters per minute (L) flow rate set: - On 8/21/25 at 8:53 A.M. and 1:50 P.M.: O2 concentrator was observed at 3L. - On 8/22/25 at 10:38 A.M.: O2 concentrator was observed at 3L. - On 8/26/25 at 10:18 A.M., 12:51 P.M., and 4:20 P.M.: O2 concentrator was observed set at 2.5L. Review of Resident #5's nursing progress notes failed to indicate clinical or medical rationale for changes in O2 settings from the physician's orders. Furthermore, review of the medical record indicated nursing progress note documentation of the following: - On 8/1/25: Resident #5 continuous oxygen at 3L via nasal canula. - On 8/2/25: Resident #5 continues on oxygen 3-4 L via nasal canula with no shortness of breath or distress noted. - On 8/3/25: Resident #5 is on 3-4L of oxygen via nasal canula. - On 8/4/25: Resident #5 continues on oxygen 3-4L via nasal canula with an oxygen saturation rate of 91%, and no shortness of breath or respiratory distress noted. - On 8/5/25: 3L of oxygen via nasal canula with no shortness of breath or respiratory distress noted for Resident #5. During an interview on 8/26/25 at 10:50 A.M., Nurse #1 said Resident #5 was at baseline today with oxygen saturation rate at 94% and he/she is on 2 L of O2. Nurse #1 said she evaluates residents' respiratory assessment by monitoring their baseline and checking the residents' levels. During an interview on 8/26/25 at 4:40 P.M., Nurse #1 said she verified the physician's oxygen orders to be 2L/min. Nurse #1 and the surveyor observed the O2 concentrator for Resident #5. Nurse #1 said the settings were high and she lowered the oxygen flow settings down to 2L/min. During an interview on 8/27/25 at 10:52 A.M., the DON said a resident who uses oxygen should have an MD order and staff should be checking every shift for function of the oxygen, as well as liters per minute to ensure it matches the MD order. The DON and surveyor reviewed the findings made throughout the survey process. The DON said Resident #5 should have had their oxygen set to the orders as provided by the physician and checked every shift. The DON said Resident #5 should have had documentation in his/her medical record indicating the clinical/medical rationale for the changes. b. Review of the facility's policy titled Clean Dressing Technique, undated, indicated but not limited to the following: - Check physician order for current, correct treatment. - Cleanse wound with solution ordered. During an interview on 8/21/25 at 3:03 P.M., Resident #5 said he/she has wound areas from surgery and other areas as well that are being treated in the facility. Review of Resident #5's admission skin assessment, completed 7/21/25, indicated he/she had the following wound areas: -Left Heel -Right Heel -Left Outer Ankle -Left Inner Ankle -Right Inner Ankle Review of Resident #5's Physician's orders indicated the following: -Left Heel: wound wash, skin prep to peri-wound, apply dime thick amount of hydrogel, calcium alginate to inside wound bed, dry protective dressing, kling wrap. -Right Heel: wound wash, skin prep to peri-wound, apply dime thick amount of hydrogel, calcium alginate to inside wound bed, dry protective dressing, kling wrap. -Left ankle/lateral foot: wound wash, skin prep to peri-wound, apply dime thick amount of hydrogel, calcium alginate to inside wound bed, dry protective dressing, kling wrap. -Left Inner Calf: wound wash, skin prep, maxisorb, foam dressing. -Right Calf: cleanse with wound wash, apply betadine. On 8/26/25 at 1:06 P.M., the surveyor observed Nurse #1 and Unit Manager (UM) #2 perform wound care for Resident #5 and made the following observations: -Nurse #1 removed old dressing to right heel, washed heel with sterile water, applied skin prep, hydrogel, calcium alginate, 2x2 non-sterile dressing followed by kling wrap. UM #2 supported Resident #5's leg while treatment was completed. -Nurse #1 removed old dressing to left heel, washed heel with sterile water, applied skin prep, hydrogel, calcium alginate, 4x4 non-sterile dressing followed by kling wrap. UM #2 supported Resident #5's leg while treatment was completed. -Nurse #1 applied betadine to Resident #5's left inner calf, followed by 4x4 gauze and kling roll. UM #2 supported Resident #5's leg while treatment was completed. -Nurse #1 cleaned the treatment field and both Nurse #1 and UM #2 left the room. -No wound care treatment observed by surveyor for the right calf or left ankle/lateral foot areas. Review of Resident #5's TAR indicated all wound treatments were completed as ordered on 8/26/25. Furthermore, the TAR indicated all wound areas should be cleansed with wound wash. Review of Resident #5's comprehensive care plan indicated but not limited to the following interventions: - Follow MD orders for skin care and treatments (Utilize Best Practice Guidelines). During an interview on 8/26/25 at 4:23 P.M., Nurse #1 was unable to answer questions regarding the dressing changes observed and could not answer what the current dressing orders were. Nurse #1 said orders are completed and signed as completed until the wound specialist discontinues the orders. Nurse #1 said he/she completed a dressing to the left calf, left heel, and right heel but could not verify his/her current wound care orders and referred to the Unit Manager. During an interview on 8/26/25 at 4:32 P.M., the UM #2 said he/she was present for the dressing changes on the left heel, right heel, and left calf. UM #2 said wound wash should be normal saline and not sterile water. UM #2 reviewed Resident #5's orders and said there were five active wound treatment orders. During an interview on 8/27/25 at 12:15 P.M., the DON said wound treatments should be done by following the physician's orders. The DON said if the wound dressing orders are scheduled for the 7:00 A.M. – 3:00 P.M. shift, the expectation is the dressings will be completed on that shift. The DON and surveyor reviewed the findings of only three wound dressing changes out of five completed and the left inner calf was completed with the incorrect dressing. The DON said Resident #5 should have had all wound dressing orders followed as ordered and all the dressing orders should have been completed.

Based on observation, record review, and interviews, the facility failed to ensure one Resident (#5), out of a total sample of 20 residents, had their call light accessible and within reach in order to utilize to call for assistance. Findings include: Review of the facility's policy titled Call Light, Use of, dated April 2015, indicated but was not limited to the following:- All [Corporate Name] Health Care Systems resident/patients will have a call light or alternative communication device within his/her reach when unattended.- When providing care to the residents/patients be sure to position the call light conveniently, telling/showing the resident/patient where the call light is located. Resident #5 was admitted to the facility in July 2025 with diagnoses including muscle weakness, abnormalities of gait and mobility and heart failure. Review of Resident #5's Minimum Data Set (MDS) assessment, dated 8/5/25, indicated he/she was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. On 8/22/25 at 10:41 A.M., the surveyor observed Resident #5 in bed with his/her call light device tucked into the second drawer of their bedside dresser. The call light was not within reach.On 8/22/25 at 12:01 P.M., the surveyor observed Resident #5 in bed with his/her call light tucked into the second drawer of their bedside dresser. The call light was not within reach.On 8/26/25 at 4:20 P.M., the surveyor observed Resident #5 in bed with his/her call light device tucked into the drawer of their bedside dresser. The call light was not within reach. Review of Resident #5's comprehensive care plan for falls indicated but was not limited to the following interventions:- Provide environmental adaptations: call light within reach During an interview on 8/22/25 at 10:41 A.M., Resident #5 said the staff move the call light a lot and he/she cannot get to it. Resident #5 said he/she likes to have the call light next to them so he/she can reach it. During an interview on 8/22/25 at 11:00 A.M., Certified Nursing Assistant (CNA) #5 said all residents on the [NAME] Unit use a traditional call bell plugged into the wall. CNA #5 said all residents should have their call bell in reach at all times. CNA #5 said she usually ties the call bell to a resident's side rail but if they do not use side rails, they can use the clip to leave them with a resident. During an interview on 8/22/25 at 11:01 A.M., CNA #9 said all residents should have a call bell in reach to communicate their needs to the staff. CNA #9 said staff make sure call bells are within reach at all times. CNA #9 said call bells should have a clip but when they do not, they are tied to the side rails. During an interview on 8/27/25 at 1:00 P.M., Nurse # 5 said call bells should always be left in reach of the resident. Nurse #5 said Resident #5 is able to use their call bell to ask for assistance from staff. During an interview on 8/27/25 at 1:02 P.M., the Director of Nursing (DON) said call bells should always be left within the resident's reach. The DON said a call bell should never be left in a resident's drawer and out of their reach.

Based on record review and interview, the facility failed to implement their abuse policy when one Resident (#51), was involved in a resident-to-resident altercation, in a total sample of 20 residents. Specifically, the facility failed to ensure facility staff who were aware of the incident reported the altercation to leadership to allow for reporting, investigating, and implementing measures to prevent potential future altercations. Findings include: Review of the facility's policy titled Abuse, Neglect and Exploitation, dated as reviewed 2/2023, indicated but was not limited to:1.Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.2. The facility will develop and implement written policies and procedures that establish policies and procedures to investigate any such allegations.3. The facility will provide ongoing oversight and supervision of staff to assure that its policies are implemented.4. The facility will have written procedures to assist staff in identifying the different types of abuse, this includes certain resident-to-resident altercations.5. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.6.Written procedures for investigation include: -Identifying staff responsible for the investigation-Identifying and interviewing all involved persons including the alleged victim, alleged perpetrator, witness, and others who might have knowledge of the allegation-Focusing the investigation on determining if abuse, neglect, exploitation, and/ or mistreatment has occurred-Providing complete and thorough documentation of the investigation7. The facility will have written procedures that include reporting of all alleged violations to the administrator, state agency, adult Protective Services and to all other required agencies within specified timeframes (Immediately, but not later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury). Resident #51 was admitted to the facility in July 2023 with diagnoses which included metabolic encephalopathy (a condition where the brain's function is impaired due to an underlying metabolic disturbance). Review of Resident #51's Minimum Data Set (MDS) Assessment, dated 7/18/25, indicated he/she was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Review of Resident #51's progress note, dated 7/22/24, indicated but was not limited to:-Resident #51 told staff that Resident #14 made fun of him/her in the hallway-Nurse spoke to Resident #14 who denied making fun of Resident #51 Review of the facility grievance binder and the Health Care Facility Reporting System (HCFRS, a web-based system that health care facilities must use to report incidents and allegations of abuse, neglect, and misappropriation) failed to indicate the resident-to-resident altercation had been documented and/or reported. During an interview on 8/27/25 at 11:14 A.M., Certified Nursing Assistant (CNA) #7 said when there is an incident between residents the staff should ensure residents are safe and report it to a nurse or a facility manager. During an interview on 8/26/25 at 5:01 P.M., Nurse #6 said any time a resident-to-resident altercation occurs the facility staff must make sure the resident is safe and notify the facility management team so they can investigate it. Nurse #6 said a resident-to-resident altercation included physical touch, verbalizations, and/or gestures. Nurse #6 said even if the accused is joking it is about how the resident on the receiving end feels about it. During an interview on 8/27/25 at 11:19 A.M., Nurse #5 said when a resident-to-resident altercation occurs the staff must ensure everyone is safe and then notify the manager. Nurse #5 said if a resident reported being made fun of, she would follow the abuse policy. During an interview on 8/27/25 at 11:50 P.M., Social Worker #1 said when a resident-to resident altercation occurs it needs to be reported and investigated. During an interview on 8/27/25 at 12:27 P.M., the Director of Nurses (DON) said when a resident-to-resident altercation occurs staff should ensure that all residents are safe. The DON said that abuse, allegations of abuse, or suspicion of abuse should be reported in the HCFRS and investigated. The DON said the facility should also ensure interventions to prevent any potential future abuse are implemented. During an interview on 8/27/25 at 2:55 P.M., the DON said she was still looking to see if there was an investigation for the 7/22/24 resident-to-resident altercation. During an interview on 8/27/25 at 3:18 P.M., the DON said the nurse did not report the altercation to management and it was not reported or investigated. The DON said the policy should have been followed.

Based on record review and interviews, for one Resident (#51), of 20 sampled residents, the facility failed to ensure an allegation of abuse was reported timely to the state agency as required. Findings include:Review of the facility's policy titled Abuse, Neglect and Exploitation, dated as reviewed 2/2023, indicated but was not limited to:-Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability- The facility will have written procedures that include reporting of all alleged violations to the administrator, state agency, adult Protective Services and to all other required agencies within specified timeframes (Immediately, but not later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury)-Appendix A; Massachusetts: Abuse, neglect, and/or exploitation allegations should be reported via the electronic reporting platform to the Massachusetts Department of Public Health within the appropriate timeframe. Resident #51 was admitted to the facility in July 2023 with diagnoses which included metabolic encephalopathy (a condition where the brain's function is impaired due to an underlying metabolic disturbance) Review of Resident #51's Minimum Data Set (MDS) Assessment, dated 7/18/25, indicated he/she was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Review of Resident #51's progress note, dated 7/22/24, indicated but was not limited to:-Resident #51 told staff that Resident #14 made fun of him/her in the hallway-Nurse spoke to Resident #14 who denied making fun of Resident #51 Review of the facility grievance binder and the Health Care Facility Reporting System (HCFRS, a web-based system that health care facilities must use to report incidents and allegations of abuse, neglect, and misappropriation) failed to indicate the alleged resident-to-resident altercation was documented and/or reported. During an interview on 8/26/25 at 5:01 P.M., Nurse #6 said any time a resident to resident altercation occurs the facility staff should ensue the resident is safe and notify the facility management team. Nurse #6 said a resident-to-resident altercation included physical touch, verbalizations and/or gestures. Nurse #6 said even if the accused is joking it is about how the resident on the receiving side of the joke feels. During an interview on 8/27/25 at 11:19 A.M., Nurse #5 said when a resident-to-resident altercation occurs the staff must ensure everyone is safe and then notify a manager. Nurse # 5 said if a resident reported being made fun of she would follow the abuse policy. During an interview on 8/27/25 at 11:50 P.M., Social Worker # 1 said when a resident-to resident altercation occurs it needs to be reported. During an interview on 8/27/25 at 12:27 P.M., the Director of Nurses (DON) said abuse/allegations of abuse, suspicion of abuse should be reported to HCFRS. During an interview on 8/27/25 at 3:18 P.M., the DON said the nurse did not report the 7/22/24 altercation to management and it was not reported. The DON said the policy should have been followed.

Based on record review and interviews, for one Resident (#51), of 20 sampled residents, the facility failed to ensure allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated. Specifically, for Resident #51, the facility failed to ensure a resident-to-resident verbal altercation was investigated. Findings include:Review of the facility's policy titled Abuse, Neglect and Exploitation, dated as reviewed 2/2023, indicated but was not limited to:1. Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.2. The facility will develop and implement written policies and procedures that establish policies and procedures to investigate any such allegations.3. The facility will provide ongoing oversight and supervision of staff to assure that its policies are implemented.4. The facility will have written procedures to assist staff in identifying the different types of abuse, this includes certain resident-to-resident altercations.5. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.6.Written procedures for investigation include: -Identifying staff responsible for the investigation-Identifying and interviewing all involved persons including the alleged victim, alleged perpetrator, witness, and others who might have knowledge of the allegation-Focusing the investigation on determining if abuse, neglect, exploitation, and/ or mistreatment has occurred-Providing complete and thorough documentation of the investigation7. The facility will have written procedures that include reporting of all alleged violations to the administrator, state agency, adult Protective Services and to all other required agencies within specified timeframes (Immediately, but not later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury). Resident #51 was admitted to the facility in July 2023 with diagnoses which included metabolic encephalopathy (a condition where the brain's function is impaired due to an underlying metabolic disturbance). Review of Resident #51's Minimum Data Set (MDS) Assessment, dated 7/18/25, indicated he/she was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Review of Resident #51's progress note, dated 7/22/24, indicated but was not limited to:-Resident #51 told staff that Resident #14 had made fun of him/her in the hallway-Nurse spoke to Resident #14 who denied making fun of Resident #51 Review of the facility grievance binder and the Health Care Facility Reporting System (HCFRS, a web-based system that health care facilities must use to report incidents and allegations of abuse, neglect, and misappropriation) failed to indicate the alleged abuse had been investigated. During an interview on 8/26/25 at 5:01 P.M., Nurse #6 said any time a resident-to-resident altercation occurs the facility staff should ensure the resident is safe and notify the facility management team so they can investigate it. During an interview on 8/27/25 at 11:19 A.M., Nurse #5 said when a resident-to-resident altercation occurs the staff must ensure everyone is safe and then notify a manager. Nurse # 5 said if a resident reported being made fun of, she would follow the abuse policy. During an interview on 8/27/25 at 11:50 P.M., Social Worker #1 said when a resident-to resident altercation occurs it needs to be investigated. During an interview on 8/27/25 at 12:27 P.M., the Director of Nurses (DON) said when a resident-to-resident altercation occurs staff should ensure that all residents are safe. The DON said that abuse/allegations of abuse, suspicion of abuse should be investigated. During an interview on 8/27/25 at 2:55 P.M., the DON said she was still looking to see if there was documentation, including an investigation, regarding the 7/22/24 resident-to-resident altercation. During an interview on 8/27/25 at 3:18 P.M., the DON said the nurse did not report the altercation to management and it was not investigated. The DON said the policy should have been followed.

Based on observation, interview, and record review, the facility failed to develop, implement and individualize comprehensive care plans for three Residents (#83, #51, and #5), out of a total sample of 20 residents. Specifically, the facility failed:1. For Resident #83, to develop and implement comprehensive care plans for a change in mental status including delusions and hallucinations and elopement risk;2. For Resident #51, to ensure a comprehensive care plan was developed to address his/her history of thoughts to self-harm; and3. For Resident #5, to ensure a comprehensive care plan was developed to address his/her oxygen therapy usage. Findings include:Review of the facility's policy titled Comprehensive Care Plans, last revised November 2017, indicated but was not limited to: -This facility is committed to providing residents with all necessary care and services to enable them to achieve the highest quality of life. Recognizing each resident as an individual, we identify and meet those needs in a resident-centered environment. Care plans are oriented toward preventing avoidable decline in clinical and functional levels, maintaining a specific level of functioning and reflect resident preferences and right to refuse certain services or treatment. -Care plans are a combination of: -Data concerning the resident that is obtained from the physician -Clinical records such as the hospital discharge summary -Evaluations done professional and other disciplines -The resident and/or family goals for treatment -Acute/chronic events, behaviors and/or illness -Based on the above, the Interdisciplinary Team develops a comprehensive Care Plan for each resident that includes measurable objectives and timelines to accommodate preferences, special medical, nursing and psychosocial needs identified in the RAI and IDT -The Care Plan is evaluated and revised as needed, but at least quarterly 1. Resident #83 was admitted to the facility in August 2025 and had diagnoses including major depressive disorder. Review of the Minimum Data Set (MDS) assessment, dated 8/15/25, indicated Resident #83 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 out of 15, exhibited no hallucinations, delusions or behaviors, received no psychotropic medication and had an activated health care proxy (an individual designated to make medical decisions on your behalf when a doctor determines you lack the capacity to make or communicate your own decisions). Review of a Nursing Progress Note, dated 8/17/25, indicated Resident #83 called 911 (a phone number used to contact emergency services) around 7:00 A.M. and a police officer came to the facility to speak with the Resident. The note indicated Resident #83 told the officer that somebody was playing in his/her back and that he/she doesn't belong here and needs to leave. Review of a Nursing Progress Note, dated 8/18/25, indicated Resident #83 called 911 and stated there was something behind his/her window. Staff checked the window and showed the Resident that there was nothing behind the window. Review of a Nursing Progress Note, dated 8/23/25, indicated around 6:00 A.M., the lead Certified Nursing Assistant (CNA) informed the nurse that Resident #83 was outside walking in the parking lot. The nurse indicated the Resident was last seen about 10 minutes before seated in the TV room on the unit. After three attempts, the Resident agreed to return to the building. Review of comprehensive care plans failed to indicate a care plan had been developed to address the Resident's change in mental status, verbalizations of needing to leave the facility, and elopement attempt on 8/23/25. During an interview on 8/25/25 at 1:31 P.M., the Director of Nursing (DON) said care plans should have been developed and interventions put into place to address the change in the Resident's mental status and elopement risk but were not. 2. Resident #51 was admitted to the facility in July 2023 with diagnoses which included schizoaffective disorder (a mental health condition characterized by symptoms such as hallucinations, delusions, and mood disorders) and auditory hallucinations (the perception of the presence of hearing something that is not actually there). Review of Resident #51's MDS assessment, dated 7/18/25, indicated Resident #51 reported feeling down, depressed or hopeless and experienced social isolation at times during the assessment look back period. Review of Resident #51's progress notes indicated but was not limited to: -3/19/25: Resident #51 vocalized auditory hallucinations of self-harm, he/she was placed on one-to-one supervision, the provider was notified and a new order to transfer him/her to the hospital was obtained. -3/19/25: Facility staff received a call from the hospital stating Resident #51 was cleared for any mental health concerns and will return to the facility. -3/20/25: Resident #51 returned from the hospital and had psychiatrically cleared. Review of Resident #51's care plan failed to indicate it had been individualized to include his/her history of thoughts to self-harm. During an interview on 8/27/25 at 11:19 A.M., Nurse #5 reviewed Resident #51's care plans and said there was no care plan for his/her history of thoughts of self-harm. During an interview on 8/27/25 at 11:50 A.M., Social Worker #1 said Resident #51's care plans had not been personalized to include his/her history of thoughts of self-harm. During an interview on 8/27/25 at 12:27 P.M., the DON said care plans should be personalized and specific to each resident. 3. Resident #5 was admitted to the facility in July 2025 with diagnoses including heart failure and hypertension. Review of Resident #5's MDS assessment, dated 8/5/25, indicated he/she did not have shortness of breath or trouble breathing when at rest or lying flat. The MDS did not indicate the Resident was using oxygen (O2) therapy in the facility. The surveyor observed the Resident in bed receiving O2 via a nasal canula supplied by an O2 concentrator as follows: - On 8/21/25 at 8:53 A.M. and 1:50 P.M. - On 8/22/25 at 10:38 A.M. - On 08/26/25 at 10:18 A.M., 12:51 P.M., and 4:20 P.M. Review of the medical record indicated Physician's Orders for: - O2 continuously via nasal canula at 2 Liters/minute, every shift, check pulse oximetry and Liters per Minute (LPM), effective 7/31/25 - Change O2 tubing every Sunday on the 11:00 P.M.-7:00 A.M. shift, every night shift, every Sun. Review of Resident #5's comprehensive care plans failed to indicate a care plan related to oxygen use was developed or implemented. During an interview on 8/27/25 at 10:46 A.M., Nurse #5 said the unit manager is responsible for updating the care plans and would oversee the care plan status. Nurse #5 said when a resident is admitted on O2, they should have a care plan related to O2. Nurse #5 said any nurse can update the information as needed in a care plan if anything changes or needs to be updated. The nurse reviewed Resident #5's care plans and said she did not see a care plan related to O2 but would expect there to be one. During an interview on 8/27/25 at 10:52 A.M., the DON said a resident who uses O2 should have a respiratory care plan with interventions that indicate their need for O2 use. The DON said Resident #5 should have a respiratory care plan related to their O2 use.

Based on observation, record review, and interview, the facility failed to provide indwelling catheter (a flexible tube inserted into the bladder to drain urine outside of the body) care and management consistent with professional standards for one Resident (#5), out of a total sample of 20 residents. Specifically, the facility failed to ensure the Foley catheter was assessed for removal as soon as possible or determine a clinical condition related to the Foley catheter placement on admission to the facility. Findings include:Resident #5 was admitted to the facility in July 2025 with diagnoses including heart failure, muscle weakness, and diabetes. Review of the Minimum Data Set (MDS) assessment, dated 8/4/25, indicated he/she was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Furthermore, the MDS assessment indicated he/she had an indwelling catheter and no genitourinary diagnoses. During an observation with an interview on 8/21/25 at 2:08 P.M., the surveyor observed Resident #5 in bed with a Foley catheter hanging from the side of the bed. Resident #5 indicated he/she was unsure of the reason for the catheter and did not know how long he/she had had it. Review of Resident #5's Physician's Orders indicated but were not limited to the following:- 7/31/25: Foley catheter care every shift- 7/31/25: Replace Foley catheter as needed if still not draining after irrigation- 7/31/25: Insert Foley catheter 16 Fr (French - catheter size) with 10 mL (milliliter) balloon- 7/31/25: Call physician if Foley catheter does not drain after replacement Review of the Hospital Discharge Summary documentation indicated Resident #5 had a Foley catheter. The documentation further indicated a voiding trial should be initiated and the Resident may need a consult with Urology if he/she failed the trial. Review of Resident #5's medical record failed to indicate a voiding trial had been attempted upon admission to the facility. Further review of the medical record failed to indicate any clinical rationale for continued use of the Foley catheter and/or supporting diagnoses for its use. Review of the Physician (MD) progress notes failed to indicate a clinical or medical reasoning for the current placement of the Foley catheter, voiding trial and/or follow up with Urology regarding Foley catheter placement. During an interview on 8/26/25 at 10:50 A.M., Nurse #1 said when a resident admits to the facility with a Foley catheter, orders are put in place for care and management, including size of the catheter and to change the catheter once a month. Nurse #1 said residents with Foley catheters will have voiding trials completed if there is an order in the medical record. Nurse #1 said a diagnosis of urinary retention would be expected for a resident with a Foley catheter. During an interview on 8/27/25 at 12:15 P.M., the Director of Nursing (DON) said a resident who admits to the facility with a Foley catheter is expected to have a diagnosis related to the need for the catheter use, such as urinary retention or neurogenic bladder. The DON said unless otherwise indicated, all residents with a Foley catheter would have a voiding trial to attempt to remove the Foley catheter. The DON and the surveyor reviewed the findings of Resident #5. The DON said a voiding trial should have been completed for Resident #5 and he/she should have documentation in their record of an appropriate diagnosis for the use of the Foley catheter. The DON said if there was any contraindication for the voiding trial it should be documented in the medical record by the attending Physician and/or consulting Physicians such as a Urologist.

Based on records reviewed and interviews for two of three sampled residents (Resident #3 and Resident #1) who were assessed by nursing to be at risk for skin breakdown and were assessed to have pressure injuries, the Facility failed to ensure nursing staff adequately assessed, obtained physician's orders for and provided wound care treatments in accordance with professional standards of practice in an effort to promote wound healing, as result there was a delay in treatment for both residents, and Resident #3's pressure injury which was facility acquired, was noted to have worsened. Findings include: Review of the Facility Policy titled, Prevention and Management of Pressure Injuries, dated 07/2017, indicated residents with pressure injuries and those at risk for skin breakdown are identified, assessed, and provided appropriate treatment to encourage healing and/or maintenance of skin integrity. The Policy further indicated the following; -A head to toe skin assessment is to be performed upon admission and readmission; -The resident is assessed for pressure injury risk factors; -The resident's skin is observed daily with care; and -Pressure injuries are assessed and documented at least weekly and with a significant change is the wound until it is resolved. 1) Resident #3 was admitted to the Facility in January 2024, diagnoses include a right humerus (upper arm) fracture, anemia, diabetes mellitus, and bipolar disorder. Review of Resident #3's Norton Plus Assessment (used to identify residents who are at risk for skin breakdown), dated 01/19/24, indicated he/she had a score of 13, a score of 11-15 indicated he/she was at moderate risk for skin breakdown. Review of Resident #3's Weekly Skin Audits, dated 01/19/24 through 02/23/24, indicated that there were no skin impairments noted since the last review. Review of Resident #3's Nurse Progress Note, dated 02/07/24, indicated he/she had a small (open) area to his/her left side between buttocks just below his/her sacral region, area cleaned, dressed, measured and physician was made aware. Review of Resident #3's Pressure Injury Evaluation, dated 02/07/24, indicated he/she had a Facility Acquired Stage II (stage two, is a partial thickness skin loss involving the epidermis and/or dermis) to his/her left buttocks measuring 1.0 centimeters (cm) length x 0.5 cm width, with no measurable depth noted, and with 100 percent (%) healthy tissue. Review of Resident #3's Medical Record indicated there was no weekly Pressure Injury Evaluation completed on 02/14/24. Further review of Resident #3's Medical Record, which included nurse progress notes and his/her Treatment Administration Record (TAR) indicated that there was no documentation to support nursing staff observed, assessed, or completed treatments to his/her pressure injury from 02/08/24 through 02/20/24. Review of Resident #3's Pressure Injury Evaluation, dated 02/21/24, indicated the original area was now a Stage III (stage three is full thickness tissue loss) pressure injury measuring 2.0 cm length x 0.8 cm width, and nursing noted they were unable to measure depth related to 75 % unhealthy tissue. Review of Resident #3's Physician's Order, dated 02/21/24, indicated to wash the sacral wound with normal saline, pat dry, apply boarder foam dressing daily and as needed. During an interview on 03/29/24 at 9:00 A.M., Nurse #1 said on 02/07/24, she had identified Resident #3's pressure area injury and had informed the physician at that time. Nurse #1 said she could not recall if she had obtained any treatment orders from the physician at that time. During an interview on 03/19/24 at 3:56 P.M., the Assistant Director of Nurses (ADON) said she had thought the pressure injury was present upon admission and that the nurse had obtained orders for Resident #3's wound treatment. The ADON said she identified and documented Resident #3's pressure area on 02/21/24 and noted that a Pressure Evaluation Form had not been completed on 02/14/24. During an interview on 03/19/24 at 4:42 P.M., the Director of Nurses (DON) said that she had not realized Resident #3 had developed a Stage II pressure injury until 02/21/24 when the ADON identified the area (which at that time had deteriorated to a Stage III pressure injury) and obtained orders from his/her physician. The DON said it is the expectation of the Facility that all residents are to have head-to-toe skin assessment performed weekly by nurses and said the nurse is responsible for documenting the findings on the appropriate forms. The DON said if a pressure area is identified upon assessment, the identifying nurse should initiate and complete a Pressure Injury Evaluation Form and communication with the physician for any treatment required. 2) Resident #1 was admitted to the Facility in November 2023, diagnoses included dementia, anemia, septicemia (an infection in the blood), metabolic encephalopathy (problem in the brain that is caused by a chemical imbalance in the blood), and seizure disorder. Review of Resident #1's Hospital Discharge Summary, dated 12/14/23, indicated he/she had a Stage II pressure injury to his/her buttocks and he/she had foam dressings to his/her left/right buttocks in place. Review of Resident #1's Nurse Progress Note (written by Graduate Nurse (GN) #1), dated 12/14/23, indicated he/she was readmitted with a pressure injury to his/her left buttocks, after an acute hospital admission. Review of Resident #1's re-admission Norton Plus Assessment, dated 12/15/23, indicated the score was 6 which indicated high risk for skin breakdown (score of ten or below is high risk). Review of Resident #1's Skin Assessment (upon re-admission), dated 12/15/23, indicated he/she had a Stage II pressure injury to his/her left/right buttocks. However further review of the assessment indicated no measurements were documented. Review of Resident #1's Medical Record, which included nurse progress notes and his/her TAR indicated there was no documentation to support nursing staff observed, assessed, or completed treatments to his/her left/right buttock pressure injury from 12/14/23 through 12/19/23. Further review of the Medical Record indicated there was no documentation to support that a physician's order had been obtained for treatment of the pressure injury until 12/19/23. Review of Resident #1's Pressure Injury Evaluation, dated 12/19/23, indicated he/she had a Stage II pressure injury, measuring 8.0 cm x 8.0 cm, with no depth noted, with 25 % necrotic tissue and 25 % slough. Review of Resident #1's Physician's Order, dated 12/20/23, indicated nursing to clean the pressure area with normal saline, apply Alginate (antimicrobial ointment) to buttocks and cover with bordered foam dressing daily and as needed. During an interview on 03/19/24 at 1:28 P.M., Graduate Nurse (GN) #1 said she documented that Resident #1 had a pressure injury to his/her left buttocks but had not completed a skin assessment upon re-admission. GN #1 said she did not get a physician's order for any type of treatment for the pressure injury that she had identified and said she was unable to locate a physician's order for a treatment in his/her re-admission orders. During an interview on 03/19/23 at 2:27 P.M., Nurse #1 said she had identified Resident #1's pressure on 12/19/23, after reading his/her Discharge Summary, and said she obtained a Physician's Order to provide a treatment to the area. During an interview on 03/19/24 at 3:56 P.M., the Assistant Director of Nurses (ADON), said she was not aware that Resident #1 had returned from the Hospital with a pressure injury and said as she was reviewing Resident #1's re-admission paperwork a few days later, she noted that a pressure injury evaluation was not completed upon re-admission when the pressure injury was identified The ADON said Graduate Nurse #1 had documented a pressure injury to Resident #1's left buttocks in his/her re-admission note. The ADON said that GN #1 had not done a skin assessment and had not obtained orders from his/her physician to treat the newly identified area. During an interview on 03/19/24 at 4:42 P.M., the Director of Nurses (DON) said that she was unaware that Resident #1 was readmitted with a Stage II pressure injury until 12/19/23 when Nurse #1 identified the area and obtained orders from his/her Physician. The DON said it the Facility's expectation that a thorough skin assessment is performed on any resident upon admission or re-admission and said if skin issues are identified, the nurse must complete a wound evaluation form that would include the type of wound, location, measurement, and other necessary factors. The DON also said that the nurse identifying the skin issue was also responsible for calling the Physician and obtain the required treatment orders for the resident.

Based on observations, records reviewed and interviews, for one of three sampled residents (Resident #3), the Facility failed to ensure safety devices functioned properly, and failed to provide adequate supervision, when on 7/17/17, Resident #3, a severely cognitively impaired resident, at risk for elopement, eloped from the building, and was found outside lying on the ground by a visitor. Resident #3 was transferred to the hospital where he/she was noted to have a laceration above his/her right eye and was diagnosed with [REDACTED]. Findings include: The Policy titled, Elopement, dated 7/2015, indicated the Facility strives to promote resident safety by maintaining a process to screen all residents for risk of elopement and implement preventative strategies for those identified at risk. The Policy further indicated the licensed nurse will have visual contact with each resident at the beginning of any shift and/or know the location of each resident. The Policy indicated that elopement is defined as the ability of a resident who is not capable of protecting himself/herself from harm to successfully leave the facility unsupervised and unnoticed and who may enter into harm's way. The Policy titled, Wandering Management System, dated 4/2015, indicated a wander management system is used for residents at risk for elopement as assessed and determined by the interdisciplinary team. The Policy further indicated the wander management system (wanderguard) bracelet will be applied to the resident's wrist or ankle and not removed until replacement is needed, checked and documented every shift for placement, check function daily and wander management system doors checked and documented weekly by maintenance. Resident #3's [DIAGNOSES REDACTED]. The Elopement and Wandering Screen, dated 7/13/17, indicated Resident #3 exhibited behaviors of trying to leave the Facility, wandered aimlessly and was at risk for wandering and elopement. The screen indicated an individualized plan of care was to be developed based on Resident #3's assessed needs and risk factors. The Significant Change Minimum Data Set (MDS), dated [DATE], indicated Resident #3 required extensive assist with ambulation, experienced hallucinations, delusions and that his/her behaviors included wandering daily. The Resident Daily Flow Sheet, dated 7/2017, indicated Resident #3 required assist with ambulation and had wandering behavior. The Care Plan, dated as initiated, 6/1/15, indicated Resident #3 was at risk of leaving the Facility related to delusions that he/she needs to leave and go to work, wandered without regard to safety or purpose, required assistance with ambulation and wore a wanderguard bracelet. The Nurses Note, dated 7/17/17, indicated at approximately 6:00 P.M. Resident #3 eloped from the unit, fell outside and was found outside on his/her right side with an abrasion on the right side of his/her head. The note indicated blood was noted on the concrete and Resident #3 was transferred to the hospital for evaluation. The Accident/Incident Report and Investigation, dated 7/17/17, indicated at 6:00 P.M. Resident #3 eloped and was walking outside on rough surfaces and was noted to have an abrasion to the right side of his/her head. The Investigation of Accident and Incident Report, dated 7/17/17, indicated at approximately 6:00 P.M. a woman entered the Facility and told Certified Nurse Aide (CNA) #3 that there was a resident walking outside. The investigation indicated CNA #3 and Nurse #1 went outside and found Resident #3 lying on the ground outside in a neighbor's driveway. The Investigation further indicated the wanderguard system did not sound and possibly malfunctioned. The Department of Public Health Incident Report, dated 7/17/17, indicated at 6:00 P.M. Resident #3 was found outside lying on the ground with an abrasion to his/her right forehead, was transferred to the hospital where he/she had a CT Scan that revealed a subdural hematoma. The report further indicated the Code Alert Company adjusted the sensitivity of the wander management system to cover a broader field of operation at the front lobby door. The Communication Systems Job Work Order, dated 7/18/17, indicated at 8:30 A.M. the Roam (Code) Alert System's main front door sensitivity was adjusted to a broader field of operation. The Surveyor interviewed CNA #3 at 4:25 P.M. on 12/4/17. CNA #3 said a woman came into the Facility and informed her that there was a resident outside. CNA #3 said she ran, got Nurse #1 and they both went outside. CNA #3 said she did not hear the Code Alert sounding and did not know how Resident #3 got out of the Facility. The Surveyor interviewed Nurse #1 at 3:52 P.M. on 12/4/17. Nurse #1 said he was notified that Resident #3 was outside, he found Resident #3 outside lying on his/her right side bleeding from his/her head and called EMS. Nurse #1 said Resident #3 was a wanderer, an elopement risk and he did not know how Resident #3 eloped without the Code Alert sounding. The Surveyor interviewed the Director of Maintenance at 1:45 P.M. on 12/6/17. The Director of Maintenance said the Code Alert System is checked weekly, was functioning properly and he did not know how Resident #3 got out of the Facility without the Code Alert System alarm sounding. The Surveyor interviewed the Administrator at 2:10 P.M. on 12/6/17. The Administrator said Resident #3 wore a wanderguard bracelet and he did not know how Resident #3 got out of the Facility. The Administrator said no one saw Resident #3 leave the Facility or heard the Code Alert System sound and that Resident #3 was transferred to another Facility with a secured locked unit for his/her safety. The Surveyor interviewed the Director of Nurses at 3:10 P.M. on 12/6/17. The DON said Resident #3 wandered around the Facility, was an elopement risk, wore a wanderguard and the Facility staff did not know how Resident #3 got out of the Facility. The DON said Resident #3 was transferred to another Facility with a secured locked unit for his/her safety. On 12/6/17, the Facility was found to be in past non-compliance. In response to the incident, the Facility took the following corrective action: The Surveyor observed the Code Alert Systems located at the main front door and the north unit exit door. Both Code Alert System doors were functioning, operating properly and the alarm sounded appropriately when activated for multiple random observations times during the survey. A) Both Code Alert System doors were immediately tested on [DATE] to ensure that the sensors were functional and operational. B) The Communication Systems Vendor tested both Code Alert System doors on 7/18/17 and adjusted the main front door wander management system sensitivity to cover a broader field of operation. C) A Facility wide audit was completed on 7/18/17 on all Resident's who wore a wanderguard bracelet to ensure that the bracelet was on each resident and that the bracelets were functioning properly and activated the Code Alert System appropriately. D) Educational Inservice's on Responding and Monitoring Wanderguard System/Code Alert System were completed on 7/18/17, 7/22/17, 7/23/17, 7/31/17, 8/1/17, 8/2/17, 8/3/17, 8/4/17, 8/5/17, 8/7/17, 8/8/17 and 8/9/17 with all Facility staff. E) Resident Wanderguard bracelets are checked every shift for placement and weekly for functioning by the Nursing Department. F) Operation of door monitors and function of Code Alert System's are tested weekly by the Director of Maintenance. G) The Director of Maintenance will be responsible for ensuring on-going weekly Code Alert System testing and will present the findings to the Monthly Safety Committee Meeting and Quarterly Performance Improvement Committee for three Quarters. H) The Director of Nurses will be responsible for ensuring on-going audits and will present the findings to the Quarterly Performance Improvement Committee for three Quarters. I) A Quarterly Performance Improvement Committee Meeting was held on 10/18/17 with the Medical Director present and the results of the audits were reported to the Committee. J) The Quarterly Performance Improvement Committee will continue to review findings with additional measures to be implemented as needed.