Every finding on record at St Mary Health Care Center

Based on observations, interviews, and record review, the facility failed to provide appropriate assistance for one Resident (#3) out of a total sample of 23 residents, to maintain left-hand range of motion (ROM) when the Resident had a left-hand contracture.Specifically, the facility failed to adequately identify and treat Resident #3's left-hand contracture in a timely manner, when the severity of the Resident's left-hand contracture changed, increasing the Resident's risk for further decrease in ROM and skin breakdown. Findings include:Review of the facility policy titled Resident Mobility and ROM, last revised July 2017, indicated:-Residents with limited ROM will receive treatment and services to increase and/or prevent further decrease in ROM.-The care plan will be developed by the interdisciplinary team (IDT) based on the comprehensive assessment and will be revised as needed. Resident #3 was admitted to the facility in January 2022 with diagnoses including symptoms and signs involving cognitive functions and awareness and need for assistance with personal care. Review of Resident #3's clinical record indicated the Resident was diagnosed with a left-hand contracture on 9/18/25. Review of Resident #3's ADL Care Plan intervention, revised on 11/17/25, indicated: [name of rolled gauze] to be applied to left hand for contracture management.Further review of Resident #3's comprehensive care plan indicated the Resident was at risk for impaired skin integrity and had potential for pressure ulcer development. Review of Resident #3's Minimum Data Set (MDS) Assessment, dated 12/30/25, indicated:-was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) of one out of 15 total possible points.-was dependent on staff for activities of daily living (ADLs).-has impaired upper extremity ROM on one side.-has received occupational therapy services within the previous seven days. Review of the Occupational Therapy Evaluation, dated 12/10/25, indicated for Resident #3:-was referred to occupational therapy services for his/her left-hand contracture and the Resident's left upper extremity ROM was impaired.-left hand was extremely tight due to spasticity.-The Occupational Therapist (OT) was barely able to get the Resident's fingers off of the palm of his/her hand .-would yell with attempts to move his/her left hand open due to it was tightly fisted.-was at high risk for skin breakdown as his/her fingernails are making contact with his/her skin. Review of Resident #3's Physician Orders, dated 12/14/25, indicated:-Tx (treatment) for left hand: wash with warm soapy water, pat dry with a gauze and apply hand cone with Velcro strap to keep the finger off the palm of the hand.-Nursing, please place hand cone to left hand with Velcro strap daily and keep on at all times except for removal for skin care twice a day. Call OT for any issues. Review of Resident #3's Occupational Therapy Treatment Encounter Note (TEN), dated 1/28/26, indicated:-required max (maximum) effort from the OT to get the Resident's left hand open enough to place a clean gauze roll.-has not made any progress despite increased doses of Baclofen (prescription muscle relaxant used to treat severe, chronic muscle spasms, stiffness, and rigidity).-was . poorly conscious and would only scream when his/her hand was being opened.-plan was to discontinue occupational therapy services on 1/30/26.-Nursing staff were changing the Resident's rolled gauze daily. Review of Resident #3's Occupational Therapy Discharge summary, dated [DATE], indicated:-required the use of rolled gauze in his/her left hand.-Use of the rolled gauze was keeping the skin in the Resident's left hand dry and without pressure from his/her fingernails.-Nursing staff were to continue applying rolled gauze in the Resident's left hand daily, to keep the Resident's skin dry and intact. On 4/8/26 at 9:17 A.M., the surveyor observed Resident #3 positioned in bed with his/her hands on top of the covers. The Resident's left hand was observed in a fisted position without a hand cone in the Resident's left hand. On 4/9/26 at 10:30 A.M., the surveyor observed Resident #3 seated in the hallway at the nurses' station. The Resident's left hand was observed in a fisted position and laying on the Resident's lap without a hand cone in the Resident's left hand. Review of Resident #3's April 2026 Treatment Administration Record (TAR) indicated the following treatments were signed off as completed daily from 4/1/26 through 4/9/26:-Nursing, please place hand cone to left hand with Velcro strap daily and keep on all times except for removal for skin care twice a day. Call OT for any issues.-Tx for left hand: wash with warm soapy water, pat dry with a gauze and apply hand cone with Velcro strap to keep the finger off the palm of the hand. During an interview on 4/9/26 at 12:45 P.M., the OT said she provided occupational therapy services to Resident #3 in December 2025 and January 2026 to address the Resident's left-hand contracture. The OT said the Resident was discharged from occupational therapy services on 1/30/26 and that the discharge plan was for nursing staff to clean the Resident's hand and place rolled gauze into the Resident's hand daily. The OT said the rolled gauze kept the Resident's hand dry and kept his/her fingers away from his/her palm so that the Resident's skin did not break down. The OT said the treatment for cleaning the Resident's hand and placing the rolled gauze was challenging and that nursing staff had not alerted her that they were unable to perform the treatment. The OT said the Resident was unable to tolerate the use of a hand cone due to the severity of the Resident's left-hand contracture and pain and that the treatment that was supposed to be in place was for the Licensed Nurses to clean the Resident's hand and place the rolled gauze between the Resident's fingers and palm on his/her left hand. During an interview on 4/9/26 at 1:00 P.M., Nurse #1 said she was responsible for Resident #3's care that day and that she attempted to place the rolled gauze in the Resident's left hand a few minutes prior to speaking with the surveyor. Nurse #1 said the Resident's left hand was too contracted to place the rolled gauze between the Resident's fingers and palm and that the Resident had been like this since Nurse #1 began providing care to the Resident about one month prior. Nurse #1 said she was only able to place the rolled gauze between the Resident's thumb and index finger. Nurse #1 then lifted the Resident's left arm and rolled gauze was observed in the Resident's lap where his/her left hand was laying prior to Nurse #1 lifting it up. Nurse #1 picked up the rolled gauze and placed the rolled gauze between the Resident's left thumb and index finger. Nurse #1 then attempted to move the Resident's middle, ring, and pinky fingers away from the Resident's palm and the Resident winced and called out don't! Nurse #1 said she could not move the Resident's fingers away from his/her palm to put the rolled gauze in place. During an interview on 4/9/26 at 1:24 P.M., the OT said the Resident was able to tolerate placement of rolled gauze into his/her left palm, between his/her index, middle, ring, and pinky fingers and his/her palm when occupation therapy services were discontinued in January 2026. The OT said if nursing staff were not able to place the rolled gauze anymore due to the Resident's contracture, nursing staff should have completed a referral to occupational therapy so that OT could have reassessed the Resident. The OT said it was a problem for the Resident if the nursing staff could not keep the Resident's fingers off his/her palm. During an interview on 4/9/26 at 2:35 P.M., Nurse #1 said she signed off on the treatment ordered for the Resident to have a hand cone placed in the left hand daily even though Resident #3 did not have a hand cone. Nurse #1 said she provided rolled gauze instead of the hand cone because the Resident did not have a hand cone and the Resident's hand was too contracted for a hand cone. Nurse #1 said using the rolled gauze was better than using nothing. Nurse #1 assisted Resident #3 to his/her room and turned the Resident's left forearm so that the palm side of the Resident's left hand could be observed. The Resident's left index and pinky fingers were observed bent and pressed against the Resident's palm, and the Resident's index and pinky fingernails, which were long, brown, and thick, pressed into the Resident's palm, making an indentation. The Resident's left middle and ring fingers were also bent with their fingertips laying against the Resident's palm. Nurse #1 tried and was unable to move the Resident's fingers away from his/her palm. During an interview on 4/9/26 at 3:49 P.M., the Director of Nursing (DON) said Resident #3's order for the use of a hand cone in the left hand should have been discontinued when it was determined that the Resident could not tolerate the hand cone. The DON said an order should have been obtained for the rolled gauze to be placed in the Resident's hand when the Resident was discontinued from occupational therapy services and the rolled gauze was identified as the appropriate treatment for the Resident's left-hand contracture. The DON said nursing staff should have notified the OT when they were no longer able to place the rolled gauze effectively in the Resident's left hand so that the Resident could be reassessed. During an interview on 4/10/26 at 1:53 P.M., the OT said she reassessed Resident #3's left hand contracture on 4/9/26, following the surveyor's inquiries. The OT said she was able to cleanse inside the Resident's palm, under the Resident's fingers, using a tongue depressor and some gauze, and that the Resident's palm could be visualized. The OT said she cleaned dead skin from the Resident's left palm and that the Resident's joint at the base of his/her left pinky finger on the palm side was macerated (softening and breaking down of skin due to prolonged exposure to moisture, appearing white, wrinkled, or soggy), and the Resident's left palm had a strong odor. The OT said the Resident is at risk for skin breakdown and that she was glad that the Resident did not develop a wound in his/her palm due to his/her contracture and pressure.

Based on observation, interview, and record review, the facility failed to ensure that competency and skills necessary to provide the level and type of care needed for one Resident (#12) were demonstrated by one Licensed Nurse (Nurse #3). Specifically, the facility failed to ensure that Nurse #3 completed the necessary training and competencies relative to gastrointestinal feeding tube management prior to providing tube feeding care and services for Resident #12. Findings include:Review of the Facility Assessment Tool (self-completed assessment that indicated what types of care a facility provided as well as what their staffing and educational plans to meet the Resident's needs), dated 10/1/25, included but was not limited to:*Nursing facilities will conduct, document, and review a facility-wide assessment, which includes both their resident population and the resources the facility needs to care for their residents. The assessment will be reviewed annually and updated as needed. >The purpose of the assessment is to evaluate the resident population and determine what resources are necessary to care for the residents competently during day-to-day operations (including nights and weekends) and emergencies. Use this assessment to make decisions about your direct care staff needs (including those who provide services under contract and volunteers), as well as your capabilities to provide services to the residents in your facility, at least annually and as necessary, per the above requirement. Using evidence-based, date driven methods focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychological well-being. -Consider the following competencies (this is not an inclusive list).>Specialized care - tube feedings. Review of the facility policy titled, Competency Evaluation, undated, included but was not limited to: *It is the policy of this facility to evaluate each employee to assure they meet appropriate competencies and skills for performing their job.>Competency - is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual need to perform work roles or occupational functions successfully. -The knowledge and skills required among staff to meet resident's needs are determined through the facility assessment process.-Evaluating competency of staff is accomplished through the facility's training program.-Initial competency is evaluated during the orientation process. An employee remains on orientation until all competencies are verified.-Subsequent and/or annual competency is evaluated at a frequency determined by the facility assessment, evaluation of the training program, and/or job performance evaluations. -A variety of methods may be used to evaluate learning and/or skills competency. Examples include, but are not limited to:>Lecture or demonstration with return by the employee.>Direct observation of the employee's ability to demonstrate use of tools, devices, or equipment.>Direct observation of the employee's ability to perform specific tasks.>Review of the employee's documentation.>Peer review or interviews with other staff, residents, and/or families.>Review of adverse events or other data.-Checklists are used to document training and competency evaluations.-Only designated individuals may verify competency.>Staff Development Coordinator.>Orientation preceptor.>Department Head/Administrator.>Higher level employee/professional who has demonstrated competency.>Consultant expert.>Physician.-Employee competency forms are maintained in the Staff Development Coordinator's offices for current training year, then forwarded to the Human Resources Director for placing into employee's personnel file. Review of the completed Matrix for Providers (listing of all residents in the facility and their pertinent care categories) provided to the survey team on 4/8/26 indicated the following:-Census: 114 residents.-1 resident receiving tube feeding. Review of the facility assessment failed to indicate nursing competencies and skills set necessary to provide the level and type of care needed for facility residents with tube feeding. Review of Nurse #3's facility education records failed to indicate evidence that any competencies relative to tube feeding was completed by the Nurse. Resident #12 was admitted to the facility in September 2020 with diagnoses including Multiple Sclerosis, encounter for surgical aftercare following surgery on the digestive system, Gastrostomy Status, Dysphagia, oral phase feeding difficulties, and Obstructive Sleep Apnea (OSA). Review of the Minimum Data Set (MDS) Assessment, dated 1/6/26, indicated Resident #12:-has severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of seven out of a possible 15 points. -received nutrition and hydration via a feeding tube. -received over 51 percent (%) of their calories via tube feed. -received fluid intake via a feeding tube and received over 501 cc (cubic centimeters) of fluid for hydration per day. Review of Resident #12's April 2026 Physician's orders indicated:-Free water flush via G-Tube 350 milliliters (ml) every 4 hours for Hydration related to GASTROSTOMY STATUS, initiated 2/18/26.-Enteral Nutrition via pump: Jevity 1.5 at 120 cc/ml from 6:00 P.M.- 6:00 A.M., initiated 12/15/25. On 4/9/26 at 8:28 A.M., the surveyor observed Resident #12 lying in bed with the head of the bed elevated and Nurse #3 providing enteral tube feeding care for the Resident. Nurse #3 assessed the feeding tube for gastric residual volume and attached a 60 ml catheter tipped syringe to the open enteral tube, removed the syringe plunger and poured the entire amount of water (refilling the syringe barrel thirteen consecutive times without use of the syringe plunger) from a large styrofoam cup into the syringe barrel attached to the enteral tube, allowing water to flow through the tube and into the Resident's stomach. Resident #12 was observed saying to Nurse #3 that the Nurse was making him/her heavy with all that water. During an interview at the time, Nurse #3 said that the large styrofoam cup held 350 ml of water and that the Resident had a Physician order in place for a 350 ml water flush every 4 hours. During a follow-up interview on 4/9/26 at 9:18 A.M., when the surveyor asked about the measurement of the large styrofoam cup, Nurse #3 used a 207 ml clear plastic cup to fill the total amount of water that was administered to Resident #12 into the large styrofoam cup, and the actual total measured was 828 ml. Nurse #3 said that Resident #12 was ordered for 350 ml water flush and not the 828 ml water flush that was given. Nurse #3 said that she administered an extra 478 ml of fluids without a Physician order and that it was important for her to follow the Physician orders as indicated. During an interview on 4/9/26 at 9:48 A.M., the Staff Development Coordinator (SDC) said that there was no Licensed Nurse competency related to tube feeding care and services for Nurse #3. The SDC said that he will check Nurse #3's personnel educational file and get back to the surveyor. During an interview on 4/9/26 at 3:45 P.M., the SDC said that there was no nursing competency conducted in the facility relative to tube feeding care and services. During an interview on 4/10/26 at 11:02 A.M., Nurse #3 said she completed general orientation when she started working in the facility in August 2024. Nurse #3 said that the orientation process included medication administration, resident assessment and wound care and services. Nurse #3 said that there were no competencies and/or return demonstration related to tube feeding care and services during the orientation process. Nurse #3 said that there had not been any performance evaluation completed when she completed her orientation process and she did not have any annual training since August 2024. Nurse #3 also said that she was not competent in care and services related to enteral tube feeding or had any prior competency or training related to tube feeding care and services for residents in the facility, and her prior experience and training related to tube feeding was when she was in nursing school. Nurse #3 said that she has knowledge on the basic steps in administering medications through the feeding tube which she learned from nursing school but did not learn this in the facility. During an interview on 4/10/26 at 2:20 P.M., the Director of Nursing (DON) said that there was no personnel education on file for Nurse #3 relative to tube feeding competency prior to the Nurse working with Resident #12. The DON also said that there was no tube feeding competency completed for licensed nursing staff prior to the start of the new SDC and there has not been any education and or staff competencies relative to tube feeding. During an interview on 4/14/26 at 2:15 P.M., the Administrator said that the facility assessment included a list of staff competencies, but the list was not an exclusive list. The Administrator said that the facility assessment should not be exclusive because he does not need to update the assessment frequently unless something happens. The Administrator said that the facility assessment includes the tool but not the process for staff to evaluate staff competencies. The Administrator said that he will need time to review the facility assessment and get back to the surveyor. During an interview on 4/14/26 at 3:03 P.M., the Administrator said that there was no competency for licensed nursing staff on tube feeding and there should have been to address the needs of the residents in the facility.

Based on interviews and records reviewed, the facility failed to ensure that three Residents (#96, #1 and #5) out of a total sample of 23 residents were provided the right to participate in the care plan process.Specifically, the facility failed to: 1. For Resident #96, ensure that the Resident was provided with the required information for participation in the care planning process when he/she was not informed of where the care meetings were held and the facility did not provide rationale why the Resident's participation in the care planning process was not practicable when the Resident's Healthcare Proxy declined to attend.2. For Resident #1, the facility failed to ensure the Resident was invited to participate in and attended his/her care plan meetings and provide facility rationale as to why the participation of the Resident was determined to be not practicable for the development of his/her care plan.3. For Resident #5, the facility failed to ensure that the Resident was invited to participate in and attended his/her care plan meetings and rationale was provided as to why the Resident's participation was determined to be not practicable for the development of his/her care plan.Findings include: Review of the facility policy titled Care Plans, – Comprehensive Person-Centered, last revised March 2022 indicated: -the interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. -the resident is informed of his or her right to participate in his or her treatment and provided advance notice of care planning conferences. -if the participation of the resident and his/her resident representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were to taken to include the resident or representative in the process. -the resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies. 1. Resident #96 was admitted to the facility in August 2022, with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and Schizophrenia. Review of the MDS (Minimum Data Set) assessment dated [DATE], indicated Resident #96: -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15. -was English speaking. -makes himself/herself understood. -usually understands others. -did not refuse care in the look back period. During an interview on 4/8/26 at 9:46 A.M., Resident #96 said that he/she had been invited to her care plan meetings with an invitation, however he/she did not know where the care plan meetings were held in the facility so he/she could attend, which he/she would like to do. Review of Resident #96's clinical record failed to indicate any documented evidence that the Resident participated in the care planning process with the interdisciplinary team (IDT) during the Resident's care plan meeting reviews held on 2/27/25, 5/29/25, 8/28/25, 12/2/25, and 3/3/26. Further review of Resident #96's clinical record: -failed to indicate the rationale for why the Resident did not or could not participate in any care plan meetings, or refusals to participate in the meetings in 2025 and 2026. -indicated that the Resident's Healthcare Proxy (HCP- a legal document that designates a trusted person to make medical decisions on your behalf if you are unable to do so) had been invited to attend the Resident's care plan meeting and declined to attend on 2/27/25, 8/28/25, 12/2/25 and 3/9/26. -the care plan meeting invitations did not indicate the location of the care plan meeting and that the Resident's need to call the Social Worker by telephone to confirm their attendance. During an interview on 4/13/26 at 11:01 A.M., the Social Worker (SW) said that Resident #96's decision to not attend their care plan meeting should have been documented in the Resident's clinical record and it had not been. The SW said that Resident #96 had not expressed an interest in attending his/her care plan meetings. The SW also said that there was no documented evidence in the progress notes that Resident #96 declined to attend his/her care plan meetings and there should have been. During an interview on 4/13/26 at 11:44 A.M., the Director of Nursing (DON) said that it is important to invite Resident #96 to his/her care plan meetings because the meetings are about the Resident and he/she deserve a voice in their plan of care and to know that their voice matters. 2.Resident #1 was admitted to the facility in December 2025, with diagnoses including Alzheimer's disease. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #1: -was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of two out of 15. -required assistance with activities of daily living (ADLs). Review of the MDS Schedule for Resident #1 indicated that the Resident had care plan meetings scheduled for 12/14/25, and 3/17/26. Review of the attendance sheets for the care plan meetings on 12/14/25 and 3/17/26 did not indicate that Resident #1 attended the meetings. Review of Resident #1's clinical record failed to indicate documented evidence that the Resident was invited to participate in and attended the care plan meetings on 12/14/25 and 3/17/26. Further review of the clinical record failed to indicate any refusal by Resident #1 to participate in the meetings. The clinical record did not indicate documentation of why the Resident was not present for the care plan meetings or that the participation of Resident #1 in their care plan meetings was not practicable. 3. Resident #5 was admitted to the facility in December 2020 with diagnoses including Alzheimer's disease. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] Section C, indicated that Resident #5 was severely cognitively impaired. Review of the MDS Schedule for Resident #5 indicated that the Resident had care plan meetings scheduled for 10/14/25, 1/5/26, and 4/4/26. Further review of the attendance sheets for the care plan meetings on 10/14/25, 1/5/26, and 4/4/26 did not indicate that Resident #5 attended the meetings. Review of Resident #5's clinical record failed to indicate documented evidence that the Resident was invited to participate in the care plan meetings held on 10/14/25, 1/5/26, and 4/2/26. Further review of the clinical record failed to indicate any refusal by Resident #5 to participate in the care plan meetings and documented rationale to indicate that the participation of Resident #5 in their care plan meetings was not practicable. During an interview on 4/14/26 at 1:35 PM the SW said there was no evidence that Resident's #1 and #5 were invited to participate in their care plan meetings. During an interview on 4/14/26 at 2:10 P.M., the DON said that the facility could not provide any documentation of Resident #1 and Resident #5's invitation to participate in their care plan meetings or any documentation showing refusal by Resident #1 and Resident #5 to participate. The DON said that there was no documentation Resident #1 and Resident #5's participation in and attending their care plan meeting was determined to not be practicable.

Based on observation, interview, and record review, the facility failed to provide necessary care and services relative to enteral feeding (delivery of nutrients through a feeding tube into the stomach/intestines), for one Resident (#12) out of a total sample of 23 residents. Specifically, for Resident #12, the facility failed to ensure that the accurate amount of water flushes as ordered by the Physician, and the appropriate tube feed flush procedure was being administered via the Resident's enteral feeding tube, when more than the ordered amount of water flushes was administered, placing the Resident at risk for gastrointestinal complications. Findings include:Review of the facility's policy titled, flushing a Feeding Tube, undated, included but limited to:*It is the policy of this facility to ensure that staff providing care and services to the residents via a feeding tube are aware of, competent in, and utilize facility protocols regarding feeding nutrition and care. Feeding tube care and services will be provided in accordance with resident needs and professional standards of practice.-Verify physician orders for tube feeding flush amount.-After tube placement has been verified, flush the tube utilizing the 60 milliliters (ML) catheter tip syringe (legacy feeding tubes) or 60 ml ENFit (a specialized, standardized syringe [ISO] designed specifically for enteral feeding) syringe (feeding tube with ENFit connector) with the prescribed amount of water every four (4) hours, before and after feedings and medications or as directed by the physician.-Notify physician of any abnormalities noted. Review of the facility's policy titled, Care and Treatment of Feeding Tubes, undated, included but limited to:*It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible.-Feeding tubes will be utilized according to physician orders, which typically include: the kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush. -The facility will utilize the Registered Dietitian in estimating and calculating a resident's daily nutritional and hydration needs. *Directions for staff on how to provide the following care will be provided:-Frequency and volume used for flushing, including flushing for medication administration, and what to do when a prescriber's orders does not specify. Review of the facility's policy titled, Appropriate Use of Feeding Tubes, undated, included but limited to:*It is a policy of this facility to ensure that a resident maintains acceptable parameters of nutritional and hydration status. Feeding tubes will be used only as necessary to address malnutrition and dehydration, or when the resident's clinical deems this intervention medically necessary. -A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal pharyngeal ulcers. -Feeding tubes (naso-gastric, gastrostomy, jejunostomy) will be utilized in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Review of the facility's policy titled, Documentation in Medical Record, undated, included but limited to:*Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.-Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. -Documentation shall be completed at the time of services, but no later than the shift in which the assessment, observation, or care services occurred.-Principles of documentation include, but are not limited to:>Documentation shall be factual, objective, and resident centered.>False information shall not be documented.>Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. >Documentation shall be timely and in chronological order.>Avoid generalizations and vague phrases or expressions. -When documentation occurs after the fact, outside acceptable time limits, the entry shall be clearly indicated as late entry. Resident #12 was admitted to the facility in September 2020 with diagnoses including Multiple Sclerosis, encounter for surgical aftercare following surgery on the digestive system, Gastrostomy Status, Dysphagia, oral phase feeding difficulties, and Obstructive Sleep Apnea (OSA). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #12:-has severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of seven out of a possible 15 points. -has received nutrition and hydration via a feeding tube. -has received over 51 percent (%) of calories via tube feed. -has received fluid intake via a feeding tube and received over 501 cc (cubic centimeters) of fluid for hydration per day. Review of Resident #12's April 2026 Physician's orders indicated:-Free water flush via G-tube 350 milliliters (ml) every 4 hours for hydration related to GASTROSTOMY STATUS, initiated 2/18/26.-Enteral Nutrition via pump:Jevity 1.5 at 120 cc/ml from 6:00 P.M.- 6:00 A.M., initiated 12/15/25.Review of Resident #12's April 2026 Medication Administration Record (MAR) indicated 350 ml of free water flush via G-tube was administered on 4/9/26, with a check mark and Nurse #3's initials. On 4/9/26 at 8:28 A.M., the surveyor observed Resident #12 lying in bed with the head of the bed elevated and Nurse #3 accessed Resident #12's enteral feeding tube and assessed for gastric residual volume. Nurse #3 then attached a 60 ml catheter tipped syringe to the open enteral tube, removed the syringe plunger and poured the entire amount of water (refilling the syringe barrel thirteen consecutive times without use of the syringe plunger) from a large styrofoam cup into the syringe barrel attached to the enteral tube, allowing water to flow through the tube and into the Resident's stomach. Resident #12 was observed saying to Nurse #3, you are making me heavy with all that water. Nurse #3 said that the large styrofoam cup held 350 ml of water and that the Resident had a Physician order in place for a 350 ml water flush every 4 hours. On 4/9/26 at 9:18 A.M., when the surveyor asked about the measurement of the large styrofoam cup, Nurse #3 used a 207 ml clear plastic cup to fill the total amount of water in the large styrofoam cup that was administered to Resident #12, and the actual total was 828 ml. Nurse #3 said that Resident #12 was ordered for 350 ml water flush and not the 828 ml water flush given. Nurse #3 said that she administered an extra 478 ml of fluids without a Physician order and the risk of administering extra fluids to Resident #12 would be aspiration, fluid overload, and pneumonia. Nurse #3 also said that it was important for her to follow the Physician orders as indicated. During an interview on 4/9/26 at 3:45 P.M., the Staff Development Coordinator (SDC) said that there were no licensed nursing competencies relative to tube feeding care and services. The SDC also said that the risk to Resident #12 receiving an extra 478 ml of fluids not ordered by the Physician, was fluid overload due to Resident #12's prior history of congestive heart failure. The SDC also said Resident #12 was at an increased risk for discomfort leading to bloating, pressure and discomfort in his/her abdomen. During an interview on 4/10/26 at 11:02 A.M., Nurse #3 said she went through regular orientation when she began working in the facility. Nurse #3 said that the orientation process included medication administration, resident assessment, wound care and learning the electronic medical record (EMR). Nurse #3 said that she had basic steps in administering medication through the feeding tube during her nursing education training in school but has not had any training or education relative to care of an enteral feeding tube prior to working with Resident #12. Nurse #3 also said she should not have documented 350 ml water flushes on Resident #12's (MAR) as the water flush information entered was inaccurate. During an interview on 4/10/26 at 2:20 P.M., the Director of Nursing (DON) said that there were no trainings and/or staff competencies related to tube feedings for the Licensed Nurses prior to Nurse #3 working with Resident #12. The DON also said that no tube feeding education and staff competencies were completed by licensed nursing staff prior to the current SDC starting at the facility. Please Refer to F726

Based on interview, and record review, the facility failed to ensure that Pneumococcal Vaccination was offered as required to one Resident (#1), of five applicable residents reviewed for Pneumococcal immunization, out of a total sample of 23 residents. Specifically, for Resident #1, the facility failed to offer Pneumococcal Vaccination to the Resident when he/she was eligible for Pneumococcal Vaccination PCV20 or PCV21 (Pneumococcal Conjugate Vaccine: vaccine used to protect against 20 and 21 types of pneumococcal bacteria that commonly cause serious infections) at the time of admission to the facility. Findings include: Review of the CDC (Centers for Disease Control and Prevention) guidelines reviewed at www.cdc.gov indicated: >Based on shared clinical decision-making, adults 65 years or older have the option to get PCV20 or PCV21, or to not get additional pneumococcal vaccines. They can get PCV20 or PCV21 if they have received both: PCV13 (but not PCV15, PCV20, or PCV21) at any age PPSV23 at or after the age of [AGE] years old Review of the facility policy titled Resident Pneumococcal Immunization, dated 1/1/25, included but was not limited to: -Purpose - To minimize the risk of acquiring, transmitting, or experiencing complications from the pneumococcal virus and provide a safe environment for our residents. -Policy - All (company name) long term care facilities will offer the pneumococcal vaccine to each resident. -Procedure - Each resident is offered a pneumococcal immunization, unless medically contraindicated or the resident has already provided documentation of immunization. Resident #1 was admitted to the facility in December 2025 with diagnoses including Pneumonia, Asthma and Chronic Kidney Disease. Review of Resident #1's medical record indicated the following: >an invoked Health Care Proxy (HCP- person appointed to make healthcare decisions for someone when they are unable to do so themselves), effective 11/13/25. >had received PPSV23 (Pneumococcal Polysaccharide Vaccine 23- specific type of pneumococcal immunization) on 11/5/10. >had received PCV13 (a specific type of pneumococcal immunization) on 1/10/20. >No evidence that PCV 20 or PCV21 had been offered. During an interview on 4/9/26 at 10:30 A.M., the Infection Preventionist (IP) said the facility followed CDC guidance for Pneumococcal immunizations of residents living in the facility. The IP said he was responsible to ensure that Pneumococcal Consent Forms were completed correctly and reviewed for immunization eligibility. The IP said Resident #1 was at high risk for exposure to pneumonia due to the Resident's age and living in a nursing home. The IP said Resident #1 was eligible to receive PCV 20 or PCV 21 in November 2025. The IP said he should have approached the Resident's HCP to inform them that Resident #1's Pneumococcal immunization was not up to date at the time of admission and offer to immunize but did not.

Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals were stored in accordance with professional requirements on one unit's (Dementia Unit -Third Floor Side A) medication cart, out of a total of three units reviewed. Specifically, the facility failed to ensure that a medication cart on the Third floor Side A was locked, and prepared medications were secured when the medication cart were left unattended, to prevent unauthorized personnel and residents' access to medications on and in the medication cart. Findings include:Review of the facility policy titled, Medication Storage, Storage of Medications, dated 1/2025, included but was not limited to:*Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.-The provider pharmacy dispenses medications in containers that meet state and federal labeling requirements, including those established by the United States Pharmacopeia (USP). Medications are to remain in these containers and stored in a controlled environment. This may include such containers as medication carts, medications rooms, medication cabinets, or other suitable containers. -In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets, and medication supplies should remain locked when not in use or attended to by persons with authorized access. During an observation on 4/10/26 from 8:19 A.M. to 9:00 A.M., the surveyor observed Nurse #1 on the Third Floor (Dementia Unit) with the following:-Nurse #1 prepared the following medications:>Lisinopril 10 milligrams (mg) tablet>Azathioprine 50 mg tablet>Vitamin D 25 micrograms (mcg) tablet>Aspirin 81 mg tablet>Folic Acid 1 mg tablet>Furosemide 40 mg tablet>Mesalamine DR 40 mg capsule>Trazodone 25 mg tablets>Albuterol HFA (hydrofluoroalkane) 90 mcg inhaler>Cyclosporine ophthalmic emulsion 0.05 percentage (%)>Serevent Diskus Salmeterol 50 mcg>Artificial tears eye drop-Nurse #1 crushed the medications, placed them in a clear plastic cup and added apple sauce to the medications.-Nurse #1 walked away from the medication cart and entered the Unit dining room leaving the cup of crushed medications, eye drops, and inhalers on the cart, the medication cart unlocked and the computer screen with private resident information open and visible for anyone to read.-The surveyor observed staff members escorting residents into the dining room, and staff and residents were walking by the area where the unsecured medication cart was positioned in the hallway. -Nurse #1 returned to the medication cart positioned in the hallway and pushed the medication cart to the other side of the hallway. The surveyor observed that the eye drops and inhaler medications remained on top of the medication cart, the cart was left unattended again, with the medication cart unsecured and the computer screen unlocked. During an interview on 4/10/26 at 9:00 A.M., Nurse #1 said that medication carts should be locked and medications put away for safety when the medication cart was unattended. Nurse #1 said that the risk of leaving crushed medications, prescription inhalers and eye drops, on top of the medication cart was that other staff members and residents would have access to medications left on the top of the cart and inside the medication cart if the cart was unlocked. Nurse #1 also said that she should have secured the computer screen when she stepped away from the computer to ensure that resident's information was protected. During an interview on 4/10/26 at 2:20 P.M., the Director of Nursing (DON) said that his expectation for nursing staff during medication administration was that Nurses place medications inside the medication cart and secure the medication cart when they walked away from the cart to prevent unauthorized personnel access to the medications on the top and inside the medication cart especially if the medication cart was positioned in the hallway on the Dementia Unit where residents and other staff members would have easy access to the unlocked medication cart. The DON further said that the Dementia Unit had residents that wander on the unit who might have access to the medication cart if the medication cart was left unattended with medications on top of the cart. The DON said that nursing staff should secure the computer screen when the Nurse walked away to protect resident information from unauthorized persons as leaving the computer screen up and unsecured was a HIPAA violation.

Based on observations, interviews, and record review, the facility failed to ensure that food was stored in a safe and sanitary manner, in accordance with professional standards for food service safety to prevent the spread of foodborne illness. Specifically, the facility's dietary staff failed to: -ensure food items were properly labeled and dated in the main kitchen refrigerators placing residents at risk for food borne illness. -discard left over food within 72 hours that had been clearly labeled and dated, placing residents at risk for foodborne illness. -maintain a clean and sanitary food storage freezer, stove, and blender used for the storage or preparation of resident food placing residents at risk for food borne illness. -store chemicals away from the drink station, placing residents at risk for receiving contaminated beverages. Findings include: Review of the Food and Drug Administration (FDA) Food Code 2017 included the following: Nonfood Contact Surfaces: The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. Storage of Equipment, Utensils: The improper storage of clean and sanitized equipment, utensils.may allow contamination before their intended use. Contamination can be caused by moisture from absorption, flooding, drippage, or splash. It can also be caused by food debris, toxic materials, litter, dust, and other materials. Review of the facility policy titled Food Storage, undated, included but was not limited to: -Sufficient storage facilities will be provided to keep foods safe. Food will be stored in an area that is clean., and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. >All freezer units will be kept clean.at all times. >Leftover food will be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 72 hours or discarded. On 4/8/26 at 7:45 A.M., the surveyor and [NAME] #1 observed the following in the facility's main kitchen: -In the walk-in refrigerator: >a soft meat-like product wrapped in plastic wrap, unlabeled and undated. >a clear plastic container with a clear plastic lid which contained a soft white substance, unlabeled and undated. >one silver steam table pan containing an unlabeled white substance, partially covered with plastic wrap, dated 4/3/26. >one silver steam table pan containing an unlabeled yellow substance covered with plastic wrap, dated 4/1/26. During an interview at the time, [NAME] #1 said the soft meat-like product was shredded chicken breast and the soft white substance was cottage cheese. [NAME] #1 said that both items should have been labeled and dated before being put into the refrigerator. [NAME] #1 said the white substance was rice and should have been covered completely and discarded on 4/6/26 because prepared food was only kept for three days and the yellow substance was pasta and should have been discarded on 4/4/26 because prepared food should be discarded after three days. -In the reach-in refrigerator: >one clear plastic container with a green lid, labeled chunked pineapple, dated 3/26/26. >one clear plastic container with a red lid, labeled fruit cocktail, dated 4/3/26. > one clear plastic container with a clear lid labeled apple slices, dated 4/3/26. >one green bowl filled with a yellow substance, unlabeled and undated. >one box of muffins with ripped clear plastic wrap covering, undated. During an interview at the time, [NAME] #1 said the chunked pineapple should have been discarded on 3/29/26 and should not still be in the refrigerator. [NAME] #1 said the fruit cocktail should have been discarded on 4/6/26 and not still be in the refrigerator. [NAME] #1 said apples should have been discarded on 4/6/26 and not kept in the refrigerator. [NAME] #1 also said the yellow substance was apple sauce and should have been labeled and dated before putting it into the fridge and the muffins should have been covered completely and dated when opened, before being put back into the refrigerator. -In the silver reach-in freezer: >a large area of splattered white and brown substances to the outer doors, handles, inner walls and the floor of the inner compartment. >Green, red and brown debris was observed on the inner compartment walls and floor of the freezer.During an interview at the time, [NAME] #1 said she was unable to identify the splattered white and brown substance on the freezer. [NAME] #1 said the green, red and brown debris to the inner compartment was spilled food and should have been wiped up at the time of the spill. -On the Ninja blender: >dried, thick splatters of red, brown and white substances observed on the front control buttons, sides and rotation platform. The rotation platform was also observed to have dried solid, chunks of white matter. During an interview at the time, [NAME] #1 said the dried substances and chunks on the Ninja blender looked like old food and the blender should have been cleaned. -On the juice station: >two red buckets of cleaning solution with suds observed directly on top of the juice concentrate boxes used to prepare resident beverages.During an interview at the time, [NAME] #1 said that cleaning chemicals should not have been left on top of the juice concentrate boxes because the buckets could spill on the drinks. During an interview on 4/8/26 at 2:04 P.M., the Food Service Director (FSD) said the chemicals should not have been left on the juice station because the juice station could be contaminated. The FSD said the dirty kitchen equipment, undated food items, uncovered food items, and leftover foods, that were dated beyond 72 hours, presented a risk to the residents for foodborne illness.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure he/she was provided with quality of care that met professional standards of practice, when he/she did not receive routine laboratory testing to ensure his/her Type 2 Diabetes Mellitus was controlled, when on 09/12/25 he/she experienced a significant change in condition, was found to be hyperglycemic (elevated blood sugar level) with critically high blood sugar reading, he/she required transfer to the Hospital Emergency Department (ED) for evaluation and was admitted for treatment. Findings include:Review of the Facility's policy, titled Diabetes, undated, indicated the following:-For residents who meet the criteria for diabetes testing, the Physician will order pertinent screening; for example [Hg] A1c (Hemoglobin A1c is a test that measures the average glucose level over the previous two to three months).Review of the American Diabetes Association website indicated the following:- A1C testing should be performed routinely in all people with diabetes at initial assessment and as part of continuing care. Measurement approximately every 3 months determines whether glycemic goals have been reached and maintained. Adults with type 1 or type 2 diabetes who have achieved and are maintaining glucose levels within their target range may only need A1C testing or other glucose assessments twice a year. Resident #1 was admitted to the Facility in February 2023, diagnoses included Type 2 Diabetes Mellitus and vascular dementia.Review of Resident #1's medical record indicated his/her Health Care Agent (HCA) was invoked permanently due to severe dementia on 08/12/2020 (prior to admission to the facility).Review of Resident #1's Physician's Order Review Report indicated his/her Health Care Agent's invocation was continued upon admission to the facility.During a telephone interview on 10/28/25 at 9:38 A.M., Family Member #1 (HCA) said that on 09/12/25 she was notified that Resident #1 was unresponsive, his/her blood sugar level was 611 milligrams/deciliter (mg/dl) (critically high, normal range is 70 mg/dl to 120 mg/dl) and he/she was being transferred to the Hospital ED for an evaluation. Family Member #1 said she wondered if the facility staff knew which residents had Diabetes Mellitus.Review of the Hospital ED Report, dated 09/12/25, indicated Resident #1 was admitted to the hospital with diagnoses of hyperosmolar hyperglycemic state (HHS- a serious complication of diabetes that happens when blood sugar levels are very high for a long period of time. Symptoms of HHS can include extreme thirst, frequent urination and confusion. HHS is an emergency that requires immediate medical care.) and hypernatremia (elevated sodium levels).Review of Resident #1's Diabetes Mellitus (DM) Care Plan, reviewed and renewed with the last Minimum Data Set (MDS) Assessment, indicated the goal was for Resident #1 to be free from any sign or symptom of hyper/hypoglycemia (high/low blood sugar) and have no complications related to DM.Further review of the Care Plan indicated for nursing to document and report any signs or symptoms of hyperglycemia: increased thirst, frequent urination, weight loss, poor wound healing, stupor, coma.Review of Resident #1's Nursing Progress Note, dated 09/12/25 at 5:38 P.M., indicated Resident #1 was observed leaning forward in his/her wheelchair and continued to lean forward despite repositioning, had been sleeping on and off throughout the day, and refused breakfast and lunch. The Nurse Practitioner was notified and ordered a urinalysis with culture and sensitivity, complete blood count and basal metabolic panel (laboratory tests). Review of Resident #1's Nursing Progress Note, dated 09/12/25 at 10:01 P.M., indicated Resident #1's laboratory results were reported, his/her glucose level was 611 mg/dl [critically high] and his/her sodium level was 160 mmol/l (millimoles/liter) [critically high- normal range is 133-145 mmol/l].Further review of the Note indicated Resident #1 was being transferred to the Hospital Emergency Department for an evaluation.During an interview on 10/29/25 at 12:47 P.M., Nurse #1 said she was on duty 09/12/25 for the day (7:00 A.M. through 3:00 P.M.) shift and the evening (3:00 P.M. through 11:00 P.M.) shift, that Resident #1 was on her assignment and was well known to her. Nurse #1 said that beginning in the morning on 09/12/25, Resident #1 was lethargic and did not look like him/herself. Nurse #1 said Resident #1's lethargy continued throughout the day and the other nurse on duty (Nurse #2) called the Nurse Practitioner for new orders.Nurse #1 said that she did not know Resident #1 had Diabetes Mellitus and said if she had known, she would have checked his/her finger stick blood sugar (blood sample taken from the fingertip for immediate blood glucose result) as part of her assessment.Although Nurse #1 said she was unaware that Resident #1 had DM, Nurse #1 was signing off on Resident #1's Treatment Administration Record (TAR) that she had provided Diabetic Foot Care (DFC) to him/her multiple evening shifts in August and September 2025. Review of Resident #1's TAR for the months of August and September 2025 indicated Nurse #1 signed off as providing DFC to him/her on 08/12/25, 08/16/25, 08/19/25, 08/22/25, 08/30/25, 08/31/25, and 09/12/25. During an interview on 10/29/25 at 1:22 P.M., Nurse #4 said Resident #1 was well known to her. Nurse #4 said she did not know that Resident #1 had DM.Although Nurse #4 said she did not know Resident #1 had DM, review of Resident #1's Medication and Treatment Administration Records (MARs and TARs) for the months of August and September 2025 indicated Nurse #4 signed off as providing DFC for him/her on 08/01/25, 08/02/25, 08/04/25, 08/08/25, 09/01/25, 09/05/25, and 09/10/25.During a telephone interview on 10/30/25 at 8:02 A.M., Nurse #2 said she was on duty on 09/12/25 for the day shift and was helping Nurse #1. Nurse #2 said Resident #1 continued to become more lethargic as the day progressed and she notified the Nurse Practitioner. Nurse #2 said she took Resident #2's vital signs, did a full body assessment and Resident #1 was very lethargic.Nurse #2 said she was aware Resident #1 had DM and said the thought had crossed her mind that his/her symptoms could be related to DM. Nurse #2 said she could not remember if she checked Resident #1's finger stick blood sugar and if she had she would have documented the result in his/her medical record.Review of Resident #1's medical record indicated there was no documentation to support that Resident #1's finger stick blood sugar was checked on 09/12/25 by Nurse #1 or Nurse #2, as part of their assessment.Review of Resident #1's Physician Visit Notes, dated 05/05/25 and 09/02/25, indicated Resident #1's most recent HgA1c was done in 05/2024 (well over one year ago), and his/her Type 2 Diabetes Mellitus was diet controlled.Review of Resident #1's medical record indicated there was no documentation to support that his/her HgA1c had been checked since 05/2024Review of Resident #1's Treatment and Medication Administration Records (TARs and MARs) for the months of August and September 2025 indicated there was no documentation to support that nursing was monitoring for signs and symptoms of hypo/hyperglycemia. During a telephone interview on 10/30/25 at 2:15 P.M., the Nurse Practitioner (NP) said Resident #1 was well known to her. The NP said that when a resident's Diabetes Mellitus is diet controlled, their HgA1c is checked either every six months or annually, depending on the situation. The NP said Resident #1's HgA1c was supposed to be checked annually and was due to be checked in May 2025. The NP said she did not know why it had not been done.The NP said when nursing called her on 09/12/25 to report Resident #1's change in condition, they did not discuss Resident #1's diagnosis of Diabetes Mellitus. The NP said she expected nursing would have checked Resident #1's finger stick blood sugar before calling her and that she too, should have thought to ask nursing to check it, and she had not.During a telephone interview on 10/31/25 at 10:02 A.M., the Director of Nurses (DON) said that it was his expectation that residents with diet-controlled DM would have their HgA1c checked either every six months or annually. The DON said he did not know Resident #1's HgA1c had not been checked in over one year. The DON said he did not know if the nursing staff was aware to check Resident #1's finger stick blood sugar when he/she had a deterioration in mental status on 09/12/25, and he expected they would have as part of their assessment.

Based on records reviewed and interviews for one of three sampled residents, (Resident #1), who had an invoked Health Care Proxy, the facility failed to ensure his/her representative was notified when he/she developed an alteration of his/her skin integrity to his/her buttocks and a fluid filled blister on his/her left foot, requiring physician ordered treatments.Findings include:Review of the Facility's policy, titled Notification of Changes, dated 08/2024, indicated the following:-The purpose of the policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his/her authority, the resident's representative when there is a change requiring notification.-Circumstances requiring notification include: A new treatment.Resident #1 was admitted to the facility in February 2023, diagnoses included Type II Diabetes Mellitus and vascular dementia.Review of Resident #1's medical record indicated his/her Health Care Agent (HCA) was invoked permanently due to severe dementia on 08/12/2020 (prior to admission to the facility).Review of Resident #1's Physician's Order Review Report indicated his/her Health Care Agent was invoked upon admission to the facility.During a telephone interview on 10/28/25 at 9:38 A.M., Family Member #1 (HCA) said that she had not been notified of any changes in Resident #1's skin condition until Resident #1 was transferred from the facility to the Hospital Emergency Department on 09/12/25. Family Member #1 said she called the facility weekly and was not notified of the impaired skin condition to Resident #1's buttocks or feet.Review of Resident #1's Physician's Orders for the month of September 2025 indicated he/she had an order dated 09/02/25, to apply Calazinc (cream used to protect the skin from moisture) to his/her buttocks every shift.During a telephone interview on 10/30/25 at 8:02 A.M., Nurse #2 said she completed Resident #1's Skin Check Form on 09/01/25 and Resident #1's buttocks were very excoriated. Nurse #2 said if she had notified Resident #1's HCA of his/her change in skin condition, she would have documented it on the Skin Check Form.Review of Resident #1's Skin Check Form, dated 09/01/25, indicated Resident #1 had a new area of Moisture Associated Skin Damage (MASD) on his/her buttocks. The box on the form that nursing completed to indicate if the family/HCA had been notified was left blank.Review of Resident #1's Nursing Progress Note, dated 09/10/25, indicated Resident #1 had a newly acquired fluid filled blister on his/her left medial (inside aspect of) foot.Review of Resident #1's Treatment Administration Record (TAR) for the month of September 2025 indicated he/she had a new Physician's order, dated 09/11/25, to cleanse the left foot blister with normal saline, apply skin prep (forms a protective film on the skin) to the area and edges, and leave the area open to air twice per day.During an interview on 10/29/25 at 1:22 P.M., Nurse #4 said she discovered Resident #1's left foot blister on 09/10/25 and attempted to call Resident #1's HCA but the call would not go through, and she did not reattempt. During a telephone interview on 10/30/25 at 8:02 A.M., Nurse #2 said Resident #1 was on her assignment on the 7:00 A.M. through 3:00 P.M. (day) shift on 09/11/25. Nurse #2 said she assumed Resident #1's HCA had been notified of his/her newly acquired foot blister at the time it was discovered.Review of Resident #1's medical record indicated there was no documentation to support that Resident #1's HCA had been notified of Resident #1's changes in skin condition on 09/01/25 or 09/10/25.During a telephone interview on 10/30/25 at 10:02 A.M., the Director of Nurses (DON) said it was his expectation that Resident #1's Health Care Agent should have been notified of his/her change in skin condition on both 09/01/25 and 09/10/25. The DON said it was part of facility protocol to notify the family/HCA at the same time the provider is notified of a change in resident condition.

Based on records reviewed and interviews, for 5 of 5 sampled residents (Residents #1, #2, #3, #4 and #5), who were alert and able to made their needs known, the Facility failed to ensure they were treated in a dignified and respectful manner, when they all reported that Nurse #1 responded to their request for assistance with yelling, rudeness and disrespect. Findings include: Review of the Facility Resident Rights Policy, undated, indicated residents had the right to be treated with dignity and respect in full recognition of their individuality and to receive services with reasonable accommodations to individual needs and preferences. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 6/13/25, indicated that 5 residents (Residents #1, #2, #3, #4 and #5) reported that Nurse #1 withheld medications, used a curt or aggressive tone of voice, threw medications on the resident's table and/or yelled at them. Resident #1 was admitted to the Facility in June of 2023 and his/her diagnoses included Alzheimer's Disease, osteoarthritis and vertigo. Resident #1's Quarterly Minimum Data Set Assessment (MDS), dated [DATE] indicated his/her cognitive patterns were intact, with a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 (13-15 suggest intact cognition, 8-12 suggests moderate impairment, and 0-7 suggests severe impairment). Resident #2 was admitted to the Facility in February of 2023 and his/her diagnoses included dementia and generalized anxiety disorder. Resident #2's Quarterly MDS, dated [DATE] indicated his/her cognitive patterns were intact, with a BIMS score of 15 out of a possible 15. Resident #3 was admitted to the Facility in April of 2025 and his/her diagnoses included dementia, major depressive disorder and anxiety disorder. Resident #3's admission MDS, dated [DATE] indicated his/her cognitive patterns were moderately impaired, with a BIMS score of 10 out of a possible 15. Resident #4 was admitted to the Facility in August of 2022 and his/her diagnoses included hemiparesis and hemiplegia following subarachnoid hemorrhage and anxiety disorder. Resident #4's Quarterly MDS, dated [DATE] indicated his/her cognitive patterns were intact, with a BIMS score of 15 out of a possible 15. Resident #5 was admitted to the Facility in July of 2024 and his/her diagnoses included major depressive disorder and anxiety disorder. Resident #5's Quarterly MDS, dated [DATE] indicated his/her cognitive patterns were intact, with a BIMS score of 15 out of a possible 15. During in-person interviews on: - 6/23/25 at 11:20 A.M. with Resident #4, - 6/23/25 at 11:35 A. M with Resident #3, - 6/23/25 at 11:46 A. M with Resident #5, - 6/23/25 at 11:56 A. M with Resident #1, and - 6/23/25 at 1:55 P.M with Resident #2, they said the following: The residents' all said when they requested assistance from Nurse #1 during the 11:00 P.M. to 7:00 A.M., she yelled at them and was rude. Resident #1 said that when he/she asked Nurse #1 for things, Nurse #1's tone of voice in response was sharp, brusque and dismissive. Resident #2 said Nurse #1 was awful to deal with, yelled at him/her and always responded to requests for medication by stating it was not time. Resident #3 said he/she recalled an incident in which Nurse #1 screamed and yelled at him/her and was mean in response to his/her request for medications. Resident #4 said Nurse #1 hollered at him/her, spoke to him/her with disrespect and made him/her feel afraid to ask for things. Resident #4 said that Nurse #1 routinely yelled at another resident in the hallway for taking off their clothes, loud enough for him/her (Resident #4) to hear. Resident #3 and Resident #4 said that when Nurse #1 brought them their medications, she threw them or banged them on the bedside table, instead of placing them in their hand. Resident #5 said that he/she had an incident in which Nurse #1 interrupted two CNAs providing care to him/her following an episode of incontinence and that Nurse #1 lashed out at him/her, telling him/her that he/she needed to use the bed pan, and that Nurse #1 did so in an angry tone of voice. During an interview on 6/25/25 at 3:35 P.M. by telephone, Nurse #3 said that residents had spoke to him about Nurse #1 coming on too strong and raising her voice. Nurse #3 said although residents had not specifically told him that Nurse #1 was disrespectful or rude, he said she thought Nurse #1 was strong willed and didn't realize when she crossed the line in her interactions with residents. During an interview on 6/25/25 at 3:45 P.M. by telephone, Nurse #4 said that Residents #2 and #4 told her that Nurse #1 yelled and wasn't very approachable. During a telephone interview on 6/27/25 at 12:46 P.M., the Nurse Supervisor said that she only worked alongside Nurse #1 at 11:00 P.M., for the change of shift. The Nurse Supervisor said that routinely, Nurse #1 would arrive and would remove Resident #6 from the nurses' station where she (Nurse Supervisor) had positioned him/her for supervision and monitoring. The Nurse Supervisor said that as soon as Nurse #1 arrived, she would grab Resident #6's wheelchair and abruptly move it from the nurses station, stating you don't belong here, in a reprimanding, loud tone of voice. During an interview on 6/30/35 at 11:28 A.M. by telephone, Certified Nurse Aide (CNA) #5 said that she worked during the 11:00 P.M. to 7:00 A.M. shift with Nurse #1. CNA #5 said that Nurse #1 lacked compassion, was annoyed by any resident's request and spoke rudely and condescendingly to residents. During an interview on 7/02/25 at 12:00 P.M. Nurse #1 said that she did not yell at, speak rudely to or disrespect residents. Nurse #1 said she thought resident's complaints may have been influenced by her strict adherence to medication times. Nurse #1 said that she spoke in a loud tone of voice because her voice was low and resident's were hard of hearing. Although Nurse #1 said she was not disrespectful, her statement seems suspect given the consistent corroborating statements of residents and staff. On 6/23/25 the Facility was found to be in past non-compliance and provided the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A. The Facility terminated Nurse #1 on 6/18/25. B. On 6/15/25, the Director of Social Services met with Residents #1, #2, #3, #4 and #5 to offer support and reassurance, and continue to meet with them as needed. C. On 6/15/25, the Director of Social Services and Clinical Manager conducted interviews of residents capable of being interviewed who were cared for by Nurse #1 to assess for other impacted residents. D. On 6/20/25 and on-going, the Facility Staff Development Coordinator initiated training of all staff on Resident Rights and mechanisms for reporting concerns. E. The Facility recognizes that all residents have the potential to be effected by the Rights Rights concern area identified, they will continue to offer support to residents and additional staff education as needed. F. On 6/19/25, the Facility Leadership initiated a Quality Improvement Project to improve staff knowledge regarding reporting and resident rights, which was presented during the QAPI meeting and will continue to be discussed until substantial compliance is met. G. The Administrator and/or Designee are responsible for overall compliance.

Based on record review, and interview, the facility failed to provide mental health services for one Resident (#24) out of a total sample of 21 residents, with a documented history of mental health concerns. Specifically, the facility failed to assess Resident #24's mental health status in timely manner after he/she expressed a plan to self-harm. Findings include: Review of the facility policy for Suicide Threats, last reviewed 2/2024, indicated: -Resident suicide threats shall be taken seriously and addressed appropriately. -all nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. -as indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. -if the resident remains in the facility, staff will monitor the resident's mood and behavior and updated care plans accordingly, until a physician has determined the risk does not appear to be present. -staff shall document details of the situation objectively in the Resident's record. Review of the facility policy for Behavioral Health Services, last reviewed 2/2024, indicated: -the facility will provide, and residents will receive behavioral health services as needed to attain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. -staff must promote dignity, autonomy, privacy, socialization and safety as appropriate for each resident and are trained in ways to support residents in distress. Resident #24 was admitted to the facility in January 2023 with diagnoses including Anxiety, Major Depressive Disorder and Cognitive Communication deficit. Review of Resident #24's medical record indicated he/she had a Guardian in place since 9/28/20. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #24 had moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 10 out of 15. Review of Resident #24's care plans last reviewed 11/12/24, indicated the Resident: -has a court appointed Guardian. -is dependent on staff for physical needs due to cognitive deficits. -has an ADL self-care performance and mobility deficit. -requires skin inspection every week and during care. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. -on 2/12/24, the Resident verbalized making a weapon out of a fork, related to Depression and suicidal ideation. -the Resident has a history of making accusations towards staff, sexually harassing the opposite gender and making inappropriate comments towards others. -an intervention to monitor the Resident for change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal. -an intervention to monitor/document/report as needed any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. Review of Resident #24's clinical record with a Nurses Progress Note written by the Director of Nursing (DON) dated 2/12/24, that indicated: -the Resident has broken a fork with a plan to harm him/herself. -the Resident's room had been searched and all utensils, razors and clippers had been removed from the room. -the intervention was to provide plastic utensils for all meals and that the nurses were to provide him/her with razors or nail clippers. -the DON made a verbal contract with the Resident for safety (term used to describe an agreement between a patient and a clinician to reduce the risk of self-harm or suicide). -the DON notified the Physician and the Physician would meet with the Resident. -that Psychiatric services would meet with the Resident. Further review of Resident #24's clinical record indicated that the Resident was not seen/assessed by the Physician or Psychiatric services until 2/15/24, three days after the Resident indicated suicidal expression. During an interview on 12/16/24 at 2:07 P.M., the DON said that the Resident had been assessed for safety. The DON also said that she had been concerned that Resident #24 would harm another person as well as him/herself. The facility was unable to provide documentation that the Resident had been assessed for risk of self-harm by a Clinician prior to 2/15/24, and any evidence that the Resident had been continuously monitored for safety. During an interview on 12/17/24 at 11:32 A.M., Social Worker (SW) #1 said that when a Resident expresses wanting to self-harm that the expectation is to provide one-on-one supervision with the Resident until they can be seen by the Consulting Psychiatric team to be assessed for risk and safety. SW #1 also that that if the Resident cannot be seen onsite in the building, then the Resident should be sent out for a psychological evaluation at the hospital. During an interview on 12/18/24 at 11:38 A.M., Physician #1 said that she had not been present in the facility when Resident #24 had expressed suicidal ideation and that the DON had notified her of the Resident's state. Physician #1 also said that Resident #24 had a long history of mental health concerns, paranoid delusions, a history of suicidal ideation, and had been sent out to the hospital by Physician #1 in the past for suicidal statements.

Based on observation, and interview, the facility failed to ensure that pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) were available to meet the needs of each resident in the facility for two medication storage rooms (Fourth and Fifth Floor Units). Specifically, the facility failed to ensure that Insulin (medication used to treat Diabetes) emergency medication kits (E-Kits) were re-ordered and replaced timely by the Pharmacy after being opened. Findings Include: Review of the facility Pharmacy policy titled Emergency Kit Policy & Procedure dated 01/01/2024, indicated the following: -A portable emergency kit or kits shall be made available for immediate administration of a medication not otherwise obtainable in the time required. The emergency kits are not a source of supplemental supply but are for emergency use. -The nurse will complete a full record of the drug withdrawal from the emergency kit on the emergency kit usage log. The pharmacy copy of this log is placed inside the emergency kit and is returned to the pharmacy with the kit after use. -The pharmacy shall be notified (by fax back sheet, or E-Kit pickup call) of the use of the emergency kit prior to the next scheduled delivery. -The pharmacy must exchange open emergency kits during the next business day after the kit is opened. Kits are not exchanged on holidays or outside of regular Monday thru Friday business days. -The pharmacy will send a new emergency kit and pick up the used one within the next routine day of business. On 12/17/24 at 8:38 A.M., the surveyor and Nurse #2 observed the Fifth Floor Medication Storage Room. Nurse #2 identified the Emergency Insulin kit was opened and had medication receipts dated 7/22/24 and 12/15/24, indicating the Insulin E-Kit was opened on 7/22/24 and medications had been removed on 7/22/24 and 12/15/24. During an interview at the time, Nurse #2 said that the Insulin E-kit had been opened on 7/22/24. Nurse #2 inventoried the open kit and said that a Humalog Quick Pen (rapid acting insulin) had been removed on 7/22/24 and Lantus Insulin (long-acting insulin) had been removed on 12/15/24. Nurse #2 said whenever an E-Kit is opened, the Nurse fills out a medication receipt for what was removed and sends it to the Pharmacy for re-ordering on the same day. Nurse #2 further said that a new E-kit usually gets delivered within a day of re-ordering. Nurse #2 was unable to provide evidence that the Insulin E-kit had been re-ordered from the Pharmacy after being opened on 7/22/24 and said that is should have been ordered but was not. On 12/17/24 at 9:24 A.M., the surveyor and Nurse #3 observed the Fourth Floor Medication Storage Room. Nurse #3 identified the Insulin E-kit was opened and had a medication receipt dated 12/10/24, indicating that the E-kit was opened, and medication was removed on 12/10/24. During an interview at the time, Nurse #3 said that the Insulin E-kit was open and then inventoried the contents of the kit and said that Glargine Insulin (long-acting, synthetic version of insulin) was removed on 12/10/24. Nurse #3 was unable to provide evidence that the E-kit had been re-ordered from the Pharmacy, and that it should have been re-ordered when it was opened on 12/10/24. Nurse #3 said whenever an E-kit is opened, it should be re-ordered the same day and usually is delivered by the Pharmacy the next day. Nurse #3 also said that if the E-kit is not delivered the next day, it is the Nurses' responsibility to call the Pharmacy and further request the E-kit get delivered to have the medications on hand in case of an emergency.

Based on record review, and interview, the facility failed to coordinate an assessment with the Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) program for two Residents (#13 and #84) out of a total sample of 21 residents. Specifically, the facility failed to complete a new Level I PASRR Assessment for: 1. For Resident #13, when there was a significant change in status on two dates with behavioral changes identified, new diagnoses of Major Depressive Disorder on 11/30/23 and Delusional Disorders on 7/30/24, were added to the Resident's clinical record, and adjustments to the Resident's psychotropic medication and plan of care were made. 2. For Resident #84, when there was a significant change in status on 2/8/22 with behavioral changes identified, a new diagnosis of Psychotic Disorder with delusions due to known physiological condition was added to the Resident's clinical record, and adjustments to the Resident's antipsychotic medication and plan of care were made. Findings include: Review of the facility policy titled Admission Criteria, reviewed 2/2024, included: -The facility will notify the State mental health authority or State intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has mental health illness or intellectual disability for resident review. -Definition of Significant Change- A major decline or improvement in an individual's status that Requires interdisciplinary review or revision of the care plan May result in a positive Level I Screening for SMI (SMI-Serious Mental Illness) or may result in a change in previous PASRR determinations. 1. Resident #13 was admitted to the facility in July 2023 with diagnoses including Dementia and Diabetes. Review of the PASRR assessment completed for the Resident on the day of admission to the facility, indicated that the Resident did not have any documented SMI. Review of the Resident's clinical record included a list of diagnoses which indicated: -Major Depressive Disorder was added on 11/30/23 -Delusional Disorders was added on 7/30/24 Review of the Resident's Behavioral Health Consultant Progress Notes indicated: >11/30/23: -may benefit from antidepressant for management of Depression -Primary Diagnosis: Major Depressive Disorder -Recommend to start Zoloft (antidepressant medication) 25 milligrams (mg) by mouth daily for Depression. >12/28/23: -chief complaint Depression -managed with .Zoloft 25 mg, seen today following medication changes -plan to continue current medication regime, recommend to document mood . >8/29/24: -Diagnosis of Delusional Disorders -Target symptoms: agitation, behavioral disturbance -managed with Zyprexa (antipsychotic medication - a class of drugs used to treat symptoms of psychosis, including hallucinations, delusions, and Dementia) 2.5 mg QAM (each morning) + 5 mg HS (at hour of sleep). During an interview on 12/17/24 at 11:25 A.M., the Social Worker (SW) said that the Resident should have had a new Level I PASRR screening done when a new SMI was identified and added to the Resident's diagnosis profile. The SW said that a new PASRR Level I screen should have been submitted to the PASRR Portal on 11/30/23 when a diagnosis of Major Depressive Disorder was added to the Resident's diagnosis list, and on 7/30/24 when a diagnosis of Delusional Disorder was added to the Resident's diagnosis list, but the PASRR screen had not been submitted. 2. Resident #84 was admitted to the facility in December 2021 with diagnoses including Unspecified Dementia with behavioral disturbance and Failure to Thrive. Review of the PASRR assessment completed for the Resident on the day of admission to the facility, indicated that the Resident did not have any documented SMI. Review of a Physician's order dated 2/8/22, indicated to add a diagnosis of Psychotic Disorder with Delusions due to known physiological condition. Review of the Resident's clinical record included a list of diagnoses which indicated: -Psychotic Disorder with delusions due to known physiological condition was added on 2/9/22 Review of the Resident's clinical record included: -Nursing Progress Note dated 2/9/22, Olanzapine (antipsychotic medication) 5 milligrams (mg) by mouth every morning and at bedtime -Physician Progress Note dated 2/19/22 .much better adjusted now .patient is on Zyprexa (OLANZapine). During an interview on 12/17/24 at 11:44 A.M., the Social Worker (SW) said that the Resident should have had a new Level I PASRR screening done when a new SMI was identified and added to the Resident's diagnosis profile. The SW said the Resident should have had a new PASRR Level I screening submitted when the new diagnosis of Psychotic Disorder with delusions due to known physiological condition was added to the Resident's diagnoses profile on 2/9/22, but the screen had not been done.

Based on observation, record review, and interview, the facility failed to ensure the environment was free from accidents and hazards for one Resident (#24) out of a total sample of 21 residents. Specifically, the facility failed to ensure hazardous items (razor blades) were not stored on the Resident's bedside table and easily accessible to Resident #24, who had a history of suicidal ideation (thoughts or ideas centered around death or self-harm) and other cognitively impaired residents on the unit. Findings include: Review of the facility policy for Behavioral Health Services, last reviewed February 2024 , indicated: -the facility will provide, and residents will receive behavioral health services as needed to attain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. -staff must promote dignity, autonomy, privacy, socialization and safety as appropriate for each resident and are trained in ways to support residents in distress. Review of Resident #24's medical record indicated the Resident had a Guardian (a court appointed person who makes important personal and healthcare decisions for an adult who lacks the capacity to make their own decisions) in place since 9/28/20. Resident #24 was admitted to the facility in January 2023 with diagnoses including Anxiety, Major Depressive Disorder and Cognitive Communication deficit. Review of Resident #24's clinical record revealed a Nurses Progress Note written by the Director of Nursing (DON) dated 2/12/24 that indicated: -the Resident has broken a fork with a plan to harm him/herself. -the Resident's room had been searched and all utensils, razors and clippers had been removed from the room. -the intervention was to provide plastic utensils for all meals and that the Nurses were to provide the Resident with razors or nail clippers. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #24 had moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 10 out of 15. Review of the Resident #24's care plans last reviewed 11/12/24, indicated: -the Resident has a court appointed Guardian. -the Resident is dependent on staff for physical needs due to cognitive deficits. -the Resident has an ADL self-care performance and mobility deficit. -the Resident requires skin inspection every week and during care. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. -on 2/12/24, the Resident verbalized making weapon out of a fork, related to Depression and suicidal ideation. -the Resident has a history of making accusations towards staff, sexually harassing the opposite gender and making inappropriate comments towards others. -an intervention to monitor the Resident for change in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, withdrawal. -an intervention to monitor/document/report as needed any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing meds or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. Review of the Nurse-to-Nurse Report sheet provided to the surveyor on 12/12/24 indicated that Resident #24 had a history of suicidal ideation and should have plastic silverware at all meals. On 12/12/24 at 11:26 A.M., the surveyor observed three disposable razor blades laying on top of Resident #24's bedside dresser. During an interview at the time, Unit Manager (UM) #1 said that the razors should not have been at the Resident's bedside as he/she has made a shiv (a handcrafted weapon resembling a knife) in the past. UM #1 was observed removing the three disposable razor blades from the Resident's room. During an interview on 12/16/24 at 2:07 P.M., the DON said that the disposable razors should not have been on Resident #24's bedside table. Please Refer to F742

Based on record review, and interview, the facility failed to provide or obtain diagnostic services for one Resident (#4) out of a total sample of 21 residents. Specifically, the facility failed to provide electrocardiogram (EKG- a test which records the electrical activity of the heart through repeated cardiac cycles) testing every six months for Resident #4 as ordered by the Resident's Physician for monitoring of antipsychotic medication use. Findings include: Review of the facility policy Lab and Diagnostic Test Results - Clinical Protocol, Reviewed February 2024 indicated: -The physician will identify, and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. -The staff will process test requisition and arrange for tests. Resident #4 was admitted to the facility in January 2022 with diagnoses including Unspecified Systolic Congestive Heart Failure, Major Depressive Disorder, and Borderline Personality Disorder. Review of Resident #4's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident: -was significantly cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15 points. -had heart failure -was taking an antipsychotic medication. Review of Resident #4's clinical record indicated: -The Resident had an active order dated 7/10/22 for an EKG, repeat every six months: on psychotropic medications. -No evidence found in the clinical record that any EKGs had been completed During an interview on 12/17/24 at 8:40 A.M., the Unit Manager (UM) said the orders for Resident #4 to have an EKG every six months should have been being completed or clarified with the Physician whether they were still needed. The UM said the Resident had an EKG in 2023 but she was unable to confirm if any other EKGs had been performed since 2023. The UM said she spoke with the Resident's Physician and clarified the order for the EKGs and an EKG was going to be scheduled for the Resident. During an interview on 12/17/24 at 9:53 A.M., the Director of Nursing (DON) said the order for the Resident to receive an EKG every six months was an active order as of 12/16/24. The DON was unable to provide evidence that any EKGs were completed in the last year. The DON said the orders for the EKG had been clarified with the Physician. Review of the Active Physician's orders for Resident #4 dated 12/17/24, indicated the Resident should receive an EKG every three months: report results to the Physician.

Based on observation, interview, and record review, the facility failed to adhere to infection control standards to prevent the potential transmission of communicable diseases and infections for one Resident (#9) out of a total sample of 21 residents. Specifically, the facility failed to ensure that staff performed proper hand hygiene between glove changes while providing wound care to Resident #9 to prevent contamination and the spread of infections. Findings include: Review of the facility policy titled Hand Hygiene Policy, dated 1/1/24 - 12/31/24 indicated: -Hand Hygiene: cleaning your hands with either antiseptic hand rubs (i.e. alcohol-based hand sanitizer including foam or gel) or by handwashing (with soap and water). -The Centers of Disease Control (CDC) and Prevention Hand Hygiene Guidelines in Healthcare Settings will be followed: 1. Alcohol-based hand sanitizers are the preferred method for hand hygiene, as it reduces the number of microorganisms on hands. Hand Sanitizers must be 60-95% alcohol. >When to wash with alcohol-based sanitizer: -before and after glove use -before and after procedure or treatment administration 2. Using gloves does not replace the need for hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Resident #9 was admitted to the facility in October 2020, with diagnoses including Alzheimer's Disease, Atrial Fibrillation, and Congestive Heart Failure. Review of Resident #9's Comprehensive Care Plan indicated: -Resident has a MASD (Moisture Associated Skin Disorder)/Stage 4 (pressure injury that extends to muscle, tendon, or bone) Sacro-Coccyx from ulcer related to disease process, history of ulcers, immobility and diagnosis of protein-calorie malnutrition, effective 10/11/23 -Risk for infection related to sacro-coccyx wound with an intervention to maintain Enhanced Barrier Precautions (EBP: an infection control intervention designed to reduce transmission of multidrug resistance organisms that employs targeted gown and glove use during high contact resident care activities) every shift for close contact until wound is healed, effective 10/2/24 Review of Resident #9's December 2024 Physician orders indicated: -Maintain Enhanced Barrier Precautions (EBP) every shift: May discontinue precautions once wound is resolved. -Treatment for Sacro-coccyx wound: 1) Cleanse with wound cleanser spray 2) Pat dry with gauze 3) Lightly pack wound with Iodoform packing strip (an antimicrobial packing) 4) skin prep (fast drying liquid skin protectant) peri-wound (surrounding area of the wound) and wound edges 6) Cover with white border gauze BID (twice a day) and as needed (PRN) for soilage On 12/18/24 at 8:05 A.M., the surveyor observed Nurse #1 and CNA #2 provide the following wound care for Resident #9's sacro-coccyx wound: -Nurse #1 and CNA #2 performed proper hand hygiene prior to entering room and put on (donned) gown and gloves. -Nurse #1 and CNA #2 assisted the Resident into a right-side lying position. -Nurse #1 removed (doffed) her gloves and donned new gloves without performing hand hygiene. -Nurse #1 doffed Resident #9's brief, removed her gloves and put on new gloves without performing hand hygiene. -Nurse #1 doffed the soiled dressing and disposed of it. She then doffed her gloves and donned new gloves without performing hand hygiene. -Nurse #1 assessed the wound, by touching the wound and surrounding tissue. She then doffed her gloves and donned new gloves without performing hand hygiene. -Nurse #1 told the surveyor that she needed to measure the wound, removed the sterile Q-Tip's from the nearby table, removed one Q-Tip from the package, put the other Q-Tip's back onto the nearby table, and used the sterile wrapping to measure the wound. -Nurse #1 doffed her gloves and donned new gloves on without performing hand hygiene. -Nurse #1 picked up her supplies off the nearby table and cleansed the wound according to the Physician orders. -Nurse #1 went into the bathroom and performed hand hygiene with soap and water and donned new gloves. -Nurse #1 dried the wound, doffed her gloves and donned new gloves without performing hand hygiene. -Nurse #1 applied skin prep to the wound according to the Physician orders, then doffed her gloves and doffed new gloves without performing hand hygiene. -Nurse #1 used her scissors from the nearby table to cut the Iodoform packing to size and applied the dressing to the wound according to Physician orders. -Nurse #1 doffed her gloves and reapplied new gloves without performing hand hygiene. -Nurse #1 applied the white border foam dressing according to Physician orders and doffed her gloves and used hand sanitizer. During an interview on 12/18/24 at 8:25 A.M., Nurse #1 said that she should have either used hand sanitizer or soap and water in between taking off her gloves and applying new gloves. Nurse #1 said that she did not perform hand hygiene appropriately throughout the procedure which puts the Resident at risk for developing an infection. During an interview on 12/18/24 at 9:48 A.M., the Director of Nursing (DON) said that Nurse #1 should have performed hand hygiene throughout the procedure whenever gloves were removed and prior to putting on clean gloves, according to the recommended Hand Hygiene guidelines and facility policy.

Based on interview, and record review, the facility failed to identify and complete in the required time frame, a Minimum Data Set (MDS) for a Significant Change in Status Assessments (SCSA) for two Residents (#9 and #34) out of a total sample of 21 residents. Specifically, the facility failed to: 1. For Resident #9, complete a SCSA within 14 days after the Resident had a decline in bowel functioning, bladder functioning, and a new pressure injury. 2. For Resident #34, complete a SCSA within 14 days after the Resident was admitted to a Hospice program. Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.19.1 dated October 2024 indicates: -A significant change is a major decline or improvement in a resident's status that: >Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting. >Impacts more than one area of the resident's health status. >Requires interdisciplinary review and/or revision of the care plan. -The SCSA is appropriate when: >There is determination that a significant change (either improvement or decline) in a resident's condition from their baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent quarterly assessments. >A SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The Assessment Reference Date (ARD) must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). A SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. Review of the facility policy titled Admission Criteria, dated 2/2024, indicated: -Definition of a Significant Change - A major decline or improvement in an individual's status that: a. In the case of a decline, will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting. b. Impacts more than one area of the resident's health status. c. Requires interdisciplinary review or revision of the care plan . 1. Resident #9 was admitted to the facility in October 2020. Review of Resident #9's MDS assessment dated [DATE], indicated: -Resident #9 was frequently incontinent of bladder function -Resident #9 was frequently incontinent of bowel function -Resident #9 had no pressure injury Review of Resident #9's most recent MDS assessment dated [DATE], indicated the following: -Resident #9 was always incontinent of bladder function -Resident #9 was always incontinent of bowel function -Resident #9 had a Stage 3 pressure injury During an interview on 12/18/24 at 9:18 A.M., MDS Nurse #1 said that Resident #9 should have had a Significant Change MDS Assessment completed during the most recent assessment period with an Assessment Reference Date (ARD) of 1/2/24, when facility staff identified a decline in bowel function, a decline in bladder function, and a change in skin condition with the development of a Stage 3 pressure injury. 50320 2. Resident #34 was admitted to the facility in August 2021. Review of Resident #34's clinical record indicated the Resident had a Physician's order to admit to Hospice services effective 9/10/24. Review of the Resident's MDS Assessments indicated no SCSA was completed within 14 days of Resident #34 signing onto Hospice services. Further review of the Resident's clinical record the MDS Nurse Progress Notes dated 11/19/24, indicated: -The Resident had experienced a significant change related to signing on to Hospice services on 9/9/24. -A SCSA was not completed within the required time frame per guidelines. -A SCSA was initiated on 11/19/24 to capture the Resident's current status and ensure accurate planning. During an interview on 12/17/24 at 11:59 A.M., the MDS Nurse said the SCSA was late and was not done within the 14 days as required because she was unaware of the start of Hospice services. The MDS Nurse said the significant change MDS should have been completed within 14 days of the Resident's sign on to Hospice, but it was not completed.

Based on record review, and interview, the facility failed to provide laboratory services for one Resident, (#33), out of a total sample of 21 residents. Specifically, the facility failed to obtain blood tests every three months for Resident #33 as ordered by the Resident's Physician. Findings include: Review of the facility policy Lab and Diagnostic Test Results - Clinical Protocol, Reviewed February of 2024 indicated: -The physician will identify, and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. -The staff will process test requisition and arrange for tests. Resident #33 was admitted to the facility in November 2017 with diagnoses including Schizophrenia, Major Depressive Disorder and Benign Prostatic Hyperplasia. Review of Resident #33's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of nine out of 15 points. Review of Resident #33's clinical record indicated: -An active Physician's order dated 12/6/21, to check fingerstick blood sugar (FSBS), white blood cell count (WBC), absolute neutrophil count (ANC), Basic Metabolic panel (BMP) this month and every three months. -A WBC and BMP blood draw had been completed on 9/20/24. -The clinical record showed no evidence the ANC and FSBS had been completed since 12/6/21, or that the WBC and BMP had been completed on any date other than the 9/20/24 blood draw. During an interview on 12/17/24 at 8:38 A.M., the Unit Manager (UM) said an active order for labs such as the ones written for Resident #33 should have been completed or clarified with the Physician whether the labs were still needed. During an interview on 12/17/24 at 9:53 A.M., the Director of Nursing (DON) said the order for blood tests for Resident #33 was still active as of 12/16/24. The DON was unable to provide evidence that the ANC, FSBS, WBC and BMP labs were drawn as ordered for Resident #33.

Based on record review, and interview, the facility failed to post the required nurse staffing information daily. Specifically, the facility failed to: -post the total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: >Registered Nurses (RN), >Licensed Practical Nurses (LPN) or Licensed Vocational Nurses (LVN), >and Certified Nurses Aides (CNA). -maintain a copy of the staffing records for 18 months as required. Findings include: During the facility survey, the surveyor observed that the nurse staffing information was posted in the front lobby on the following days: -12/12/24 -12/16/24 -12/17/24 The surveyor observed that the nurse staffing postings did not include the total number of hours and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: RNs, LPNs, LVNs, and CNAs. On 12/17/24, the surveyor requested copies of the nurse staffing information for the month of December 2024 which was provided by the facility Administrator. Review of all the nurse staff postings provided by the facility for the month of December 2024 did not include the total number of hours and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: RNs, LPNs, LVNs, and CNAs. During an interview on 12/17/24 at 1:53 P.M., the Administrator said he was unaware that the actual and total number of hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift needed to be on the nursing staff posting. The Administrator also said the facility has not been maintaining the posted daily staffing for 18 months as required and they should have been.

Based on observations, interviews, and policy and records reviewed, the facility failed to adhere to infection control guidelines to prevent contamination and the potential spread of infection. Specifically, the facility failed to: 1. Ensure that staff doffed (removed) personal protective equipment (PPE) when exiting a COVID-19 positive resident's room; and 2a. Ensure PPE was doffed as required after exiting a COVID positive resident room (Resident #55), and b. that social distancing was maintained for one Resident (#21), who was identified as having COVID-19, and was seated in the Unit Dining Room with other residents who were COVID-19 negative putting the other residents at increased risk for transmission of the virus. Findings include: 44222 1. Review of the Commonwealth of Massachusetts Memorandum titled Update to Infection Prevention and Control Considerations When Caring for Long-Term Care Residents, including Visitation Conditions, Communal Dining, and Congregate Activities, dated May 10, 2023, included but was not limited to: -Use of PPE - Effective May 12, 2023, all health care personnel (HCP) should return to using PPE, including face masks as indicated, as part of transmission-based precautions, in accordance with DPH return to work guidance and as outlined in their health care facility infection prevention and control policies and procedures. Universal source control (masking) in the facility is no longer required, but all long-term care facility personnel should wear required PPE when caring for patients with suspected or confirmed COVID-19, consistent with the DPH Comprehensive PPE Guidance. Review of the Massachusetts Memorandum titled Comprehensive PPE Guidance, dated May 5, 2023, included but was not limited to: -PPE for patients with suspected or confirmed COVID-19 -DPH recommends that a fit-tested N95 filtering facepiece respirator or alternative and eye protection be used when caring for patients with suspected or confirmed COVID-19. -N95 respirators should always be discarded after doffing, such as when leaving a room. -Disposable eye protection should be discarded when it is removed for any reason, it should not be reused. Reusable eye protection should be cleaned and disinfected when visible soiled and after removal/doffing. -Nonsterile, disposable patient isolation gowns, which are used for routine patient care in healthcare settings, are appropriate for use by HCP when caring for patients with suspected or confirmed COVID-19 when there is any contact with potentially infectious material. -Gloves should be worn when there is any contact with potentially infectious material. HCP should perform hand hygiene prior to donning and after doffing gloves. Review of the Facility Bed Board document, dated 10/17/23, identified the COVID-19 positive resident rooms. Review of the Isolation sign posted at the doorway of the COVID-19 positive resident rooms included the following: -STOP In addition to Standard Precautions Staff and Providers Must -Clean hands when entering and exiting -Gown - Change between each resident -N95 Respirator -Eye protection (goggles or face shield) -Gloves - change between each resident On 10/17/23 at 8:15 A.M., the surveyor observed Certified Nursing Assistant (CNA) #1 enter a COVID positive room and set up a breakfast tray on the bedside table for a resident. CNA #1 was wearing an N95 mask, but was not wearing a gown, gloves, or eye protection. When CNA #1 exited the room, the surveyor did not observe him doff his mask or perform hand hygiene. The surveyor noted that there was an Isolation sign and cabinet with PPE supplies at the entrance to room. During an interview on 10/17/23 at 8:24 A.M., CNA #1 told the surveyor that he had not worn a gown, gloves or eye protection when entering the COVID positive room because he did not notice the sign or PPE supply bin outside the doorway of the room. CNA #1 said that he had performed hand hygiene out of the view of the surveyor but did not doff his mask. He said that he should have worn a gown, gloves, and eye protection in the COVID positive room but he hadn't. He also said that no one told him to doff his mask when exiting the COVID positive rooms. During an interview on 10/17/23 at 12:15 P.M., the IP said that the CNA that was assisting the COVID positive resident with their breakfast tray should have been wearing an N95 mask, gown, gloves, and eye protection while in the room. The IP said the facility was following the Commonwealth of Massachusetts Memorandum titled Update to Infection Prevention and Control Considerations When Caring for Long-Term Care Residents, including Visitation Conditions, Communal Dining, and Congregate Activities, dated May 10,2023. 37400 2. On 10/12/23, the survey team was notified that one of the three units (Unit 5) had six COVID-19 positive residents. On 10/13/23 at 7:38 A.M., the surveyor entered the Fourth Floor Unit and was notified by Unit Manager (UM) #1 that there was a resident who resided on the Unit who tested positive for COVID-19, and that they were currently in the process of testing all of the residents. UM #1 further said that additional residents had been identified as COVID-19 positive on the Fourth Floor Unit. During an interview on 10/13/23 at 2:15 P.M., the IP said that she was currently testing residents for COVID-19 infection on Unit Four. She said that the residents were encouraged to stay in their rooms regardless of COVID-19 status, and if they were out of their rooms, they were encouraged to wear face masks. The IP said group activities and communal dining had been stopped on the affected units to minimize transmission. The IP said that although residents who were identified as positive for COVID-19 were instructed to isolate in their rooms, they had a right to leave their rooms but need to be encouraged to wear a face mask and be socially distanced from others. The IP further said that signage had been posted in the lobby, the elevators and in the stairwells prior to entering the Unit to indicate the PPE requirement on the Unit (wearing of an N95 mask while on the Unit). a. On 10/13/23 at 9:28 A.M., the surveyor observed Resident #55 in his/her room seated at the edge of the bed. An Isolation/Droplet Precautions sign, a PPE bin containing gloves, gowns, N95 masks and face shields, and a trash bin were observed located outside of the Resident's room. On 10/13/23 at 11:34 A.M., UM #1, who had an N95 mask in place, was observed to don a gown, gloves and eye protection and enter the Resident's room. Shortly after, two CNAs donned full PPE and entered the room to assist UM #1. At 12:09 P.M., UM #1 and the two CNAs were observed to exit Resident #55's room and upon exiting removed their gown and gloves and dispose of them in the trash bin outside of Resident #55's room, conduct hand hygiene and walk down the hallway. Neither the UM nor the CNAs removed their N95 masks after exiting the room, as required. On 10/13/23 at 12:09 P.M., the surveyor observed another CNA within the Resident's room wearing an N95 mask, eye protection, gown, and gloves in place. At 12:55 P.M., the CNA was observed to remove her gown and gloves, dispose of them in the trash bin located outside of the room, but did not remove her N95 mask or conduct hand hygiene. During an interview on 10/17/23 at 10:32 A.M., UM #1 said that Resident #55 was the first resident on the Fourth Floor Unit identified as COVID-19 positive. She said that they conducted testing on all the residents on the Unit and identified an additional four residents as having COVID-19. UM #1 said the facility had no shortage of PPE supplies, including N95 masks and that an N95 mask, gown, gloves, and eye protection were to be worn prior to entering a COVID-19 positive resident room. She further said that upon leaving the COVID-19 positive room, staff were to remove their gloves and gown and disinfect their eye protection with bleach wipes. UM #1 said they had always been instructed not to doff their N95 masks upon exiting a COVID-19 positive room because that could expose them to the COVID-19 virus. When asked what would be done for a resident on Isolation/Droplet Precautions that was not identified as COVID-19, UM #1 said that all the PPE, including the N95 mask would be removed. The surveyor discussed observations from 10/13/23 with staff exiting Resident #55's room without doffing their N95 masks and UM #1 said that they have always been instructed not to. On 10/17/23 at 1:09 P.M., the surveyor observed a CNA #1 deliver Resident #55's lunch meal in his/her room. The CNA was observed to have an N95 mask in place, donned a gown, gloves and face shield and enter the Resident's room. At 1:12 P.M., the surveyor observed CNA #1 in the adjoining room. The resident in that room was identified as not having COVID-19 and he/she was observed in the room and was eating lunch. The CNA was still wearing the same gown, face shield and N95 mask as was worn in Resident #55's room. During an interview on 10/17/23 at 1:14 P.M., CNA #1 said that he provided the lunch meal to Resident #55 but needed to replace his gloves and there were none in the Resident's room. He said he went into the other resident's room through the adjoining bathroom to get the gloves that he needed and then returned back into Resident #55's room to assist with the lunch meal. During an interview on 10/17/23 at 1:22 P.M., UM #1 said that staff should not enter a COVID-19 negative room with the PPE worn in a COVID-19 positive room. During an interview on 10/17/23 at 1:36 P.M., CNA #1 said that he should not be in a COVID-19 positive room and then go into a COVID-19 negative room with the same PPE in place. CNA #1 said that when he left a COVID-19 positive room, he was supposed to remove his gloves and gown and then sanitize his eye protection with the sanitizer located in the resident's bathroom. He further said he did not remove the N95 mask upon exiting a COVID-19 positive resident room. b. On 10/17/23 at 12:32 P.M. through 1:42 P.M., the surveyor observed the lunch meal in the Fourth Floor Unit Dining Room. Eight residents were seated in the room, including Resident #21 who was seated in a stationary chair in the middle of the room. An overbed table was positioned in front of him/her. All the residents had been provided with their lunch meals, except Resident #21. None of the residents had face masks in place and there were no staff present in the room. At 12:46 P.M., Nurse #1 collected Resident #21's lunch meal which was located on the meal cart. She approached the surveyor and asked if she should don a gown, gloves and eye protection when delivering Resident #21's lunch tray because he/she was COVID-19 positive. She further said that if the Resident was in his/her room, she would don full PPE prior to entering, but was unsure what to do since he/she was seated in the communal dining area with other residents. The surveyor encouraged Nurse #1 to follow up with administration. At 12:52 P.M., Nurse #1, wore full PPE (gown, gloves, N95 mask and eye protection) and provided Resident #21 his/her lunch tray. After providing the meal, Nurse #1 removed her gown, gloves, but did not remove her N95 mask, and discarded them in a trash bin outside of resident's room down the hallway. She was observed to disinfect her eye protection with the bleach wipes, conduct hand hygiene and returned to the Unit Dining Room to assist another resident seated in the room with his/her meal. During the observation, a resident who was seated in a wheelchair and had Oxygen (O2) applied via a nasal cannula (pronged tube inserted into the nose to deliver Oxygen therapy), was observed within close proximity (within arms reach) of Resident #21. During an observation of the Fourth Floor Unit Dining Room on 10/17/23 at 1:22 P.M., UM #1 said Resident #21 was COVID-19 positive and the other residents located in the Dining Room were negative for COVID-19. She said Resident #21 was a safety concern so he/she was put in the Dining Room for increased supervision. UM #1 said that the negative residents should not be in close proximity of Resident #21 and that they should be socially distanced. She further said that the residents, including Resident #21, should be wearing face masks when not eating. On 10/17/23 at 1:35 P.M., the surveyor observed Resident #21 seated in the Unit Dining Room with five other residents. A surgical mask was observed below Resident #21's chin and the Resident was no longer eating. Five other residents were observed in the room and there was no staff present. At 1:40 P.M., two CNAs entered the Dining Room and assisted two residents with their lunch meal. At 1:42 P.M., Resident #21 was observed to actively cough, wipe his/her nose with his/her bare hand, and spit on the floor in the Unit Dining Room. The two CNAs did not encourage Resident #21 to wear his/her mask, offer tissues or encourage the Resident to conduct hand hygiene. During an interview on 10/17/23 at 4:34 P.M., the IP said that residents who were COVID-19 positive were encouraged to eat in their rooms. She said if there was a safety concern, they should be seated in the Dining Room for increased supervision, but they should be socially distanced from other residents, should be wearing masks when not eating and that frequent hand hygiene should be offered.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed as being at risk for falls, required an extensive assist of two staff with transfers and the use of alarms for safety, the Facility failed to ensure staff consistently implemented interventions from his/her comprehensive plan of care, when the position change alarms in his/her room and bathroom, that would have alerted staff that he/she was attempting to ambulate without staff assistance, were not turned on by staff. On 5/23/21, staff found Resident #1 on the floor in his/her room after he/she experienced an unwitnessed fall, he/she complained of lower leg pain, his/her right leg was assessed to be shortened and Resident #1 was transferred to the hospital emergency department via 911, where he/she was diagnosed with an acute moderately displaced right femoral neck fracture (hip fracture). Findings include: Review of the Facility's Internal Investigation, dated 05/23/21, indicated that Resident #1 had an unwitnessed fall at approximately 1:30 A.M. after walking to the bathroom without staff assistance. The Investigation indicated that staff found Resident #1 lying in front of the bathroom door, he/she complained of lower leg pain, his/her right leg was assessed to be shortened and he/she required emergent transfer to the hospital emergency department. The Investigation indicated that staff said they did not hear an alarm sounding when Resident #1 got out of bed and walked to the bathroom independently. The Investigation indicated that staff said they did not check Resident #1's alarms for functioning and placement during rounds that shift as they were unaware that Resident #1 required alarms as a safety measure. Review of the Hospital Record, dated 05/23/21, indicated Resident #1 had an acute moderately displaced right femoral neck fracture (hip fracture). The Facility's policy titled, Position Change Alarms, Guidelines for The Use of Alarms, undated, indicated that position change alarm is defined as an alerting device intended to monitor a resident's movements which included infrared beam motion detectors. The policy indicated: - Each resident will be evaluated for fall risk by the interdisciplinary team; - A position change alarm may be implemented as one approach to alert staff when a resident requiring contact guard or physical assistance is attempting to stand or transfer independently; - The resident-centered care plan and Certified Nurse Aide (CNA) Care Card would be updated to reflect this approach and the specific types of alarm to be utilized; and - Alarm position and functioning would be assessed each shift and documented. Resident #1 was admitted to the Facility in December 2019 and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Plan of Care (POC) related to fall prevention, indicated that on 02/04/21, a door sensor alarm was placed on the outside of the bathroom to sound when the door opens. The POC indicated that on 03/24/21, a Ghost Alarm (sensor alarm) was placed to aim towards his/her bed and staff were to ensure alarm functioning every shift. Review of Resident #1's Plan of Care (POC) related to Activities of Daily living, dated 03/18/21, indicated that he/she required extensive assistance from two staff members while transferring between two different surfaces. Review of Resident #1's Quarterly Minimum Data Set, dated dated [DATE], indicated that he/she had severe cognitive impairment, used a walker and/or wheelchair for mobility, had lower and upper extremity impairments, and he/she was not steady while moving from seated to standing position and/or walking. The MDS indicated Resident #1 required limited assistance from one staff member for Activities of Daily Living (ADL). Review of Resident #1's Fall Risk Assessment, dated 05/11/21, indicated that he/she was at high risk for falls. During an interview on 06/09/21 at 2:30 P.M. and throughout the day of survey, the Director of Nurses (DON) said that the Facility documents resident alarm orders in the Resident Treatment Administration Records (TAR), Care Plans, and Care Cards. The DON said that during the investigation, staff said they were unaware that Resident #1 required alarms for safety, and that staff said they did not check the alarms the evening of his/her fall on 5/23/21. The DON said that during the investigation, the Facility discovered that Resident #1 did not have any alarms listed on his/her TAR; therefore, the order for alarms was added on 05/24/21. Review of Resident #1's TAR, dated May 2021, indicated that on 05/24/21, staff were to check the motion sensor alarm (near his/her bed) and the bathroom door alarm for proper function during each shift. On 06/09/21, the Facility was found to be in Past Non-Compliance and presented the Surveyors with a plan of correction which addressed the area(s) of concern as evidenced by: A. Resident #1 was urgently transferred to the hospital for further evaluation and treatment after his/her fall on 05/23/21 and was discharged back to the Facility. B. All resident alarms were audited by staff on 05/24/21 to ensure proper placement and functioning. C. The Facility added resident alarms to the hourly rounds form to ensure staff are also checking for alarms during their safety rounds. D. Facility initiated Certified Nurse Aide 'task' documentation in the electronic health record for residents who require an alarm(s) for fall prevention. E. An audit of all resident care plans, Kardex, and treatment administration records was completed by the Director of Nurses on 05/24/21. This audit is ongoing and completed by the Unit Managers. F. All Staff were re-educated 5/24/21 by the Director of Nurses regarding the expectations around using resident alarms as a safety intervention. G. Concern area (implementation of comprehensive care plans) will be addressed during the next QAPI meeting and the conversation will be ongoing with the committee as needed for compliance and safety. H. The Director of Nurses/Administrator is responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed for the appropriate use of position change alarms as a fall prevention intervention, the Facility failed to ensure he/she received the necessary assistive devices to maintain his/her safety to prevent an incident/accident with injury. On 5/23/21, Resident #1 had an unwitnessed fall in his/her room, staff found him/her on the floor, he/she complained of lower leg pain, his/her right leg was assessed to be shortened and he/she required emergent transfer to the hospital emergency department, where he/she was diagnosed with an acute moderately displaced right femoral neck fracture (hip fracture). At the time of the incident/accident staff said Resident #1's position change alarms were not sounding. Findings include: The Facility's policy titled, Position Change Alarms, Guidelines for The Use of Alarms, undated, indicated that position change alarm is defined as an alerting device intended to monitor a resident's movements which included infrared beam motion detectors. The policy indicated: - Each resident will be evaluated for fall risk by the interdisciplinary team; - A position change alarm may be implemented as one approach to alert staff when a resident requiring contact guard or physical assistance is attempting to stand or transfer independently; - The resident-centered care plan and Certified Nurse Aide (CNA) Care Card would be updated to reflect this approach and the specific types of alarm to be utilized; and - Alarm position and functioning would be assessed each shift and documented. Resident #1 was admitted to the Facility in December 2019 and diagnosis included Dementia with Lewy Bodies, [CONDITION(S)], Delusional Disorder, [CONDITION(S)], Hypertension, [CONDITION(S)], Polyosteoarthritis, Difficulty walking, Tachycardia, and [CONDITION(S)]. Review of Resident #1's POC related to fall prevention, indicated that on 02/04/21, a door sensor alarm was placed on the outside of the bathroom to sound when the door opens. The POC indicated that on 03/24/21, a Ghost Alarm (sensor alarm) was placed to aim towards his/her bed and staff were to ensure alarm functioning every shift. Review of Resident #1's Plan of Care (POC) related to Activities of Daily living, dated 03/18/21, indicated that he/she required extensive assistance from two staff members while transferring between two different surfaces. Review of Resident #1's Quarterly Minimum Data Set, dated dated [DATE], indicated that he/she had severe cognitive impairment, used a walker and/or wheelchair for mobility, had lower and upper extremity impairments, and he/she was not steady while moving from seated to standing position and/or walking. The MDS indicated Resident #1 required limited assistance from one staff member for Activities of Daily Living (ADL). Review of Resident #1's Fall Risk Assessment, dated 05/11/21, indicated that he/she was at high risk for falls. Review of the Facility's Internal Investigation, dated 05/23/21, indicated that Resident #1 had an unwitnessed fall at approximately 1:30 A.M. after walking to the bathroom without staff assistance. The Investigation indicated that staff found Resident #1 lying in front of the bathroom door in his/her room, he/she complained of lower leg pain, his/her right leg was assessed to be shortened and he/she required emergent transfer to the hospital emergency department. The Investigation indicated that staff said they did not hear an alarm sounding when Resident #1 got out of bed and walked to the bathroom independently. The Investigation indicated that staff said they did not check Resident #1's alarms for functioning and placement during rounds that shift, as they were unaware that Resident #1 required alarms as a safety measure. Review of Resident #1's Post Fall Evaluation, dated 05/23/21, indicated that he/she independently walked to the bathroom, lost his/her balance, fell into the floor, and he/she complained of hip pain. Review of the Hospital Record, dated 05/23/21, indicated Resident #1 had an acute moderately displaced right femoral neck fracture (hip fracture). During an interview on 06/10/21 at 4:00 P.M., Nurse #1 said residents who require alarms for fall prevention will have the order listed in the Treatment Administration Records (TAR). Nurse #1 said the order in the TAR will prompt her to check resident alarms for functioning and placement. Nurse #1 said that she does not typically work on Resident #1's unit; therefore, she was unaware that Resident #1 had alarms because it was not listed on his/her TAR. Nurse #1 said that when staff found Resident #1 on the floor, an alarm was not sounding. During an interview on 06/09/21 at 2:30 P.M. and throughout the Survey, the Director of Nurses (DON) said that the Facility will document resident alarm orders in the Resident Treatment Administration Records (TAR), Care Plans, and Care Cards. The DON said that during the investigation, staff said they were unaware that Resident #1 required alarms for safety, and said they did not check the alarms the evening of his/her fall on 5/23/21. The DON said that during the investigation, the Facility discovered that Resident #1 did not have any alarms listed on his/her TAR; said therefore, the order for alarms was added after the incident. On 06/09/21, the Facility was found to be in Past Non-Compliance and presented the Surveyors with a plan of correction which addressed the area(s) of concern as evidenced by: A. Resident #1 was urgently transferred to the hospital for further evaluation and treatment after his/her fall on 05/23/21 and was discharged back to the Facility. B. All resident alarms were audited by staff on 05/24/21 to ensure proper placement and functioning. C. The Facility added resident alarms to the hourly rounds form to ensure staff are also checking for alarms during their safety rounds. D. Facility initiated Certified Nurse Aide 'task' documentation in the electronic health record for residents who require an alarm(s) for fall prevention. E. An audit of all resident care plans, Kardex, and treatment administration records was completed by the Director of Nurses on 05/24/21. This audit is ongoing and completed by the Unit Managers. F. All Staff were re-educated 5/24/21 by the Director of Nurses regarding the expectations around using resident alarms as a safety intervention. G. Concern area (implementation of comprehensive care plans) will be addressed during the next QAPI meeting and the conversation will be ongoing with the committee as needed for compliance and safety. H. The Director of Nurses/Administrator is responsible for overall compliance.

Based on record review and interview, for 1 of 3 sampled residents (Resident #2), the Facility failed to ensure Resident #2, a bed-bound resident, was protected after Resident #1 physically assaulted Resident #2 in their bedroom. On 9/04/14, Resident #1 choked and threatened to kill Resident #2, who was lying in bed and resting. Staff intervened, but within hours staff returned Resident #1 to the same bedroom to sleep for the night with Resident #2 present. Resident #2 reported feeling afraid Resident #1 might attempt to kill him/her again during the night, and as of 9/24/14, he/she continued to be in fear of people being in his/her bedroom Findings include: Resident #1's Behavior Care Plan, dated 4/13/14, indicated he/she had a history of [REDACTED]. However, there were no documented incidents of assault behavior. Resident #1's quarterly Minimum Data Set (MDS) assessment, dated 7/08/14, indicated he/she had impaired cognition, a [DIAGNOSES REDACTED]. Resident #2's quarterly MDS, dated [DATE], indicated he/she had highly impaired vision, required extensive assistance with bed mobility and transfers, and did not ambulate. The Surveyor interviewed the Director of Nurses (DON) at 11:40 A.M. on 9/24/14. The DON said Resident #2 was bed bound due to generalized weakness, due to a stroke, and [MEDICAL CONDITION], and he/she was legally blind. The Surveyor interviewed Resident #2 at 12:15 P.M. on 9/24/14. Resident #2 said he/she was lying in bed resting, when Resident #1 jumped on him/her and squeezed his/her hands around his/her throat. Resident #2 said he/she was unable to breath. Resident #2 said Resident #1 told him/her, "I'm going to kill you!", or words to that effect. Resident #1 said a staff person entered the bedroom and pulled Resident #1 off of him/her and they left the bedroom. Resident #2 said later that evening, Resident #1 returned to the bedroom and slept in the bed next to him/her for the night. Resident #2 said he/she was afraid that during the night Resident #1 might strangle him/her again, or attack him/her with a knife. Resident #2 said the incident was frightening and unexpected and that the strangling was painful. Resident #2 said a family member visited him/her the next day (9/05/14), and the Family Member told Resident #1 she observed a red mark on his/her throat, which Resident #1 attributed to the incident. Resident #2 said that since the incident (as of 9/24/14), when people enter his/her bedroom his/her body tensed, he/she was hypervigilante and fearful. Resident #2 said, "I guess I'm afraid someone might hurt me again," or words to that effect. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 3:50 P.M. on 9/24/14. CNA #1 said that on 9/04/14, at approximately 8:30 P.M., he heard yelling and entered Resident #1's and Resident #2's bedroom. CNA #1 said he saw Resident #1 standing over Resident #2's bed with his/her hands around Resident #2's throat strangling him/her and saying, "I'm going to kill you!", or words to that effect. CNA #1 said Resident #2 was lying in bed and trying to push Resident #1 away with one hand, unsuccessfully. CNA #1 said he forcefully pulled Resident #1 off Resident #2 and Resident #1 continued to try to assault Resident #2. CNA #1 said he pushed Resident #1 out of the bedroom and walked him/her to a dayroom and gave him/her ice cream. CNA #1 said Resident #1 quickly calmed down. CNA #1 said at approximately 10:00 P.M. he went to check on Resident #2's well-being and saw Resident #1 asleep in bed, in their bedroom. CNA #1 said Resident #2 told him that he/she (Resident #2) was "okay." Review of Resident #1's Safety Checks indicated staff documented visual checks on Resident #1 beginning at 8:30 P.M. on 9/04/14 and ending at 10:00 P.M. on 9/04/14. Resident #1's Safety Checks resumed at 8:45 A.M. 9/05/14 and ended at 10:45 P.M. on 9/05/14, and then resumed at 7:00 A.M. on 9/06/14 and ended at 2:00 P.M. on 9/08/14. Review of Resident #1's Nurses Assessment note, dated 9/04/14, indicated a skin assessment was performed at 10:57 P.M. and Resident #1's skin was described as "intact." The DON said nursing staff returned Resident #1 to the same bedroom where the incident occurred (with Resident #2) at approximately 10:00 P.M., where he/she slept for the night. The DON said staff performed 15 minute supervisory checks on Resident #1 to manage Resident #2's safety. The DON said Resident #1 was moved from his/her bedroom (shared with Resident #2) to another unit/bedroom on 9/05/14. The DON said nursing staff did not notify her of the incident that evening and that Resident #1 should have been separated from Resident #2 until another bedroom could be found for Resident #1. The DON said Resident #2's continued exposure in close proximity to Resident #1 was a potentially unsafe situation for Resident #2. The Surveyor interviewed Nurse #3 at 3:15 P.M. on 9/24/14. Nurse #3 said Resident #1 arrived to his/her new unit/bedroom at approximately 2:15 P.M. on 9/05/14. .

Based on Incident Report review and Staff interview, the facility failed to prevent a 6 hour delay in treatment and an 11 hour delay in hospital transfer for one Resident, (Resident Non-Sampled D), in a total sample of 22 sampled and 10 non-sampled residents. The resident sustained [REDACTED].M.-7 A.M. staff) and was not evaluated or treated for [REDACTED]. Non-Sampled Resident D was admitted to the facility 4/2006 and readmitted in 03/2010. On 02/06/14 the Surveyor reviewed the facility incident report for Non-Sampled Resident D, as part of the incident/accident survey task. The incident report indicated the following: The Resident experienced a delay in treatment of [REDACTED]. According to the investigation, the Resident had [DIAGNOSES REDACTED]. According to the monthly nursing summary dated 1/22/14, the Resident was totally dependent for all activities of daily living (ADLs) including transfers. According to the summary section: "Reason/Dysfunction: unable to sequence or process tasks". The Resident required cueing for feeding, was non ambulatory, a stand pivot with two assists for transfer for toileting, transfer out of bed and into bed and used a wheelchair pushed by staff for mobility. According to the Certified Nursing Assistant (CNA) flow sheet documentation, dated 01/17/14 at 9:27 P.M. "the Resident required 2 or more persons to provide weight bearing support during transfers, with little self-performance". Further review of the CNA flow sheet documentation on 01/17/14 at 9:28 P.M. indicated : "Toilet Use" "Resident required one person to provide all transferring and hygiene needs while toileting, with no self performance". According to the CNA flow sheet notes, the last time the Resident was transferred on 01/18/14 was 9:27 P.M. and the last time the Resident was transferred for toileting was 9:28 P.M. There was no report or note prior to 01/18/14 of any redness or swelling of the right lower leg in the Resident's record. The incident report indicated that on 01/18/14 at approximately 7:00 A.M. the Resident was found to have swelling and redness at the base of the great right toe. According to the investigation, the Resident was "guarding" (protecting-reflex movement) the right leg and complaining of pain when the leg was touched. According to the investigation and review of nursing notes written in the medical record, the injury was reported by the 11 P.M.-7 A.M. staff to the 7 A.M.-3 P.M. staff. The Surveyor interviewed the Unit Manager (UM) by telephone on 2/10/14. The UM said that the covering physician was called at 7:30 A.M., but did not call back until 10:30 A.M. Review of the physician's orders [REDACTED].M. According to nursing notes 01/18/14 at 2:20 P.M. in the narrative section the nurse wrote "Writer observed resident in bed with right leg swollen and retracted, resident guarding leg and screaming during assessment". During the telephone interview with the Unit Manager on 02/10/14, he confirmed that the 6:00 A.M. scheduled dose of [MEDICATION NAME] 325, (two tablets) was given to the Resident at 6:00 A.M. The Resident was also given a PRN (as needed), dose of [MEDICATION NAME] 325, two tablets at 7:30 A.M. The Resident was given the [MEDICATION NAME] 5/325, 1 tablet at 10:35 A.M.. The Resident was next medicated with the [MEDICATION NAME] 5/325 2 tablets at 4:00 P.M. Review of the Rehabilitation (Rehab) therapy notes indicated that an "Urgent Medical Consult" was sought at 2:33 P.M. According to the "Rehab Screen" dated 1/18/14 written at 2:33 P.M., "Request for Acute Medical Issue" "RLE (right lower extremity) swollen, retracted, resident with severe pain". The incident investigation further states that a call was placed to the covering physician, who ordered an x-ray of the right leg. The x-ray was electronically signed off as read at 3:44:49 P.M. EST (eastern standard time). Results from the x-ray taken at the facility at were "spiral fracture, non displaced of the distal fibula shaft". According to the physician orders, the verbal order to transfer to the hospital was not obtained until 5:20 P.M. Review of the investigation and review of the nursing notes indicated that the Resident was transferred to the hospital at 6:00 P.M. (11 hours after the 7-3 staff were informed of the situation).and admitted to the hospital on [DATE]. The facility failed to prevent resident from sustaining a spiral [MEDICAL CONDITION] lower leg. The Resident experienced a delay in treatment of [REDACTED].

Based on record review, observation and interviews, the Facility failed to provide the necessary care and services for 1 sampled Resident (#8) out of 8 sampled Residents with pain, in a total sample of 22 residents. Findings included: The Facility failed to effectively manage pain for Resident #8. Resident #8 was admitted to the facility in October 2012. Pertinent [DIAGNOSES REDACTED]. On 12/5/2012, review of Resident #8's Minimum Data Set Tool (MDS) for October and November indicates that the resident is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 upon admission. MDS review for Pain Assessment indicates that Resident #8 is experiencing pain on a frequent basis which interferes with and limits activities. Pain indicator score is frequently 10 (very severe/horrible). Review of the Weekly Pain Assessments for 10/22-11/20/12 indicate that Resident# 8's acceptable pain tolerance level is generally a 3. Resident #8's Weekly Pain Assessments for 11/20/12-12/6/12 were not yet available in the computer system and upon request by the Surveyor. Further review of Resident #8's Pain Assessments indicates that he/she is not on a scheduled pain medication regimen, but does receive pain medication on an as needed basis (prn). Review of the physician's orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. PO (by mouth) 2 to 4 times per day from October 15th through November 20th which then increased up to 4 times per day between November 20th (date of fall) to December 6th 2012. Review of the incident report on 12/5/2012 indicates that Resident #8 had a witnessed fall on 11/20/2012 from his/her chair to the floor during morning care. The Resident complained of lower back pain immediately after the fall. Resident #8 had a portable x-ray of his/her hip and pelvis which did not reveal any fractures. There was no x-ray done of his/her back. Review of the Orthopedic Surgeon's follow-up report dated 11/26/2012 indicates that x-rays of the left hip and lower back taken at his/her office showed "what may be a new compression of L1". An MRI (magnetic resonance imaging) of the spine was recommended. Review of the Lumbar Spine MRI report of 11/30/2012 (10 days after Resident # 8's fall) indicates acute to subacute superior endplate compression fracture deformity at levels L1 and T11. Review of the Physical Therapy (PT) notes (prior to and following the fall of 11/20/12) indicates the following: - 11/12/12: Resident #8 is making excellent progress toward goals, ambulating up to 200 feet with rolling walker. - 11/13/12: PT recommends to Nursing staff that pain medication should be offered more frequently as he/she is ambulating more this week. -11/21/12: Resident complaining of increased pain when in motion or at rest. -11/23/12: Resident requiring extra effort and extended time to complete treatment using rolling walker and now requires contact guard for functional mobility. -11/26/12: Verbal encouragement required due to increased complaints of lower back pain. Resident complaining of severe pain and had been pre-medicated prior to therapy. Physician will be in tomorrow to discuss increased complaints of pain and decreased functional mobility. Review of a Physical Therapy progress note which was written and placed in the medical record on the day of Resident #8's surgical follow-up appointment of 11/26/2012, indicated the following: "He/she had been doing quite well with his/her mobility skills and was ambulating as needed with a rolling walker. He/she had a fall last Monday and has been complaining of pain in various regions since then. He/she has been receiving pain meds, but reports he/she is miserable with pain and is presenting with decreased tolerance to functional mobility skills. Any suggestions would be greatly appreciated." -11/27/12: Fair endurance; complaining of pain in low-mid back. -11/28/12: Complaining of pain; vomited -11/30/12: Fluctuating tolerance to therapies this week due to low/mid back pain; MRI today. -12/3/12: Complaining of back pain/awaiting MRI results. Impairment limiting progress-start hot packs to back. Review of the Physician's progress note dated 11/27/2012 indicates that the Resident is having difficulty with back pain and pelvic pain and is unable to participate with physical therapy due to pain; tender lower back; continue [MEDICATION NAME] for pain. Review of the 12/4/2012 physician's note indicates that the Resident is complaining of hip and back pain and is unable to walk, but [MEDICATION NAME] has been effective for the pain and that he/she has been taking it 3-4 times a day with good effect. Plan is to continue prn [MEDICATION NAME] for pain control. During an interview with Resident #8's primary care physician and the facility's Medical Director on the afternoon of 12/5/2012, the doctor said that he/she thought that the Resident's pain was controlled and that he/she did not want to put the resident on a scheduled pain medication regimen because it might cause confusion and constipation. During interviews with Resident #8 on 12/4/2012 and 12/5/2012, the Resident said that he/she was in pain, but did not like to complain to the staff. He/she also said that the medication occasionally relieved his/her pain if he did not move too much. During an interview with the Pharmacist on 12/5/2012, he/she said that he/she would recommend a re-evaluation of the current pain management therapy with Resident #8's physician. Review of the Pharmacy Consultation Report of 12/5/2012 indicated that the Resident was not reaching or maintaining adequate pain control according to recent assessments and documentation and that the resident is frequently requiring prn [MEDICATION NAME] (3-4 times per day) with positive effect, but pain scale shows a level 7-10 most days. Review of physician's orders [REDACTED]. PO twice per day and 2.5 mg. PO every 6 hours prn; re-evaluate after 3 days for efficacy and side effects; senekot (to prevent constipation) 2 tabs every night. Review of Resident #8's revised Care Plan of 12/5/2012 indicates to assess pain level each shift to ensure that pain level is less than or equal to 5, which is resident's acceptable level of pain, hot packs for pain relief during treatment modalities and a consultation with Occupational Therapy.