Every finding on record at The Benjamin Healthcare Center

Based on observations and interviews, the facility failed to maintain a homelike environment on two out of three resident units. Findings include:During a tour of the 2 East Unit on 4/16/26 at 9:04 A.M., the surveyor made the following observations:-2 East Corridor: There was chipped paint throughout all handrails, stained/damaged walls/ceilings throughout the corridor, and words written in pencil on the walls. At the end of the corridor, near the storage room, there was a hole in the wall that is covered by peeling silver tape and peeling wallpaper on two windowpanes, exposing yellow insulation behind the windowpane.-room [ROOM NUMBER]: There was unpainted wall behind all four wall lights. There was a sticky brown substance on two light switches. There were multiple words written on the wall in the room and the bathroom in crayons and black marker. The call light wall plate was covered in rust-like substance in the bathroom. There was a hole in the sink with a rust-like substance surrounding it. -room [ROOM NUMBER]: The baseboard heater was not fully attached to the wall and covered in a rust-like substance. There was a privacy curtain missing. In the bathroom, the handrail was loose with broken hardware and a broken tile. There was a brown stained caulking/tile in the corner next to the toilet.-room [ROOM NUMBER]: There was peeling/chipped paint on two walls, unpainted plaster on the ceiling and walls, and unpainted wall behind all four wall lights.-room [ROOM NUMBER]: The baseboard heater was covered in a rust-like substance. There was chipped paint and multiple gouges on all four walls. There were multiple words written on the wall in crayons and pencil.-room [ROOM NUMBER]: There was a significant gouge under the baseboard heater, unpainted wall behind all four wall lights, and chipped paint on two walls. -room [ROOM NUMBER]: There was chipped paint and multiple gouges on all four walls, unpainted wall behind two wall lights, and significant gouges around the baseboard heater. -room [ROOM NUMBER]: There was unpainted wall behind the wall light, exposed drywall on one wall, a significant gouge above the baseboard heater which was not fully attached to the wall, and a broken thermostat cover. In the bathroom, the ceiling had large area of damaged, discolored drywall, a call light wall plate was covered in a rust-like substance, there were holes in the wall tile, and a brown substance covered the door frame.-room [ROOM NUMBER]: There was chipped paint on three walls and unpainted walls behind two wall lights. In the bathroom, the call light wall plate was covered in a rust-like substance.-room [ROOM NUMBER]: The baseboard heater was covered in a rust-like substance. There were multiple gouges on two walls. The closet was missing handles. In the bathroom, there were broken wall tiles, and the sprinkler had an open area around it which had an exposed, mulch-like, brown substance visible.-room [ROOM NUMBER]: There was chipped paint on three walls, significant gouges around the baseboard heater, and unpainted wall behind two wall lights. -room [ROOM NUMBER]: There were multiple gouges on one wall.-room [ROOM NUMBER]: There were multiple gouges on two walls and unpainted/unsanded plaster on the ceiling.-room [ROOM NUMBER]: There was peeling/chipped paint and multiple gouges on two walls. -room [ROOM NUMBER]: There was a missing privacy curtain. During a tour of the 2 East Unit on 4/16/26 at 9:04 A.M., the surveyor made the following observations:-room [ROOM NUMBER]: The bathroom door had significant chips in the door and the wall next to the bathroom door was missing paint. The back of the bedroom door had significant scuff marks and the walls throughout the room were dirty with stains. -room [ROOM NUMBER]: The bottom of the bedroom door had a large chip in the wood. The vent outside the bathroom door was loose and coming apart from the wall. -room [ROOM NUMBER]: There were four small holes in the wall opposite the beds and a stain on the ceiling above the clock. The radiator in the room was loose and coming apart from the wall. -room [ROOM NUMBER]: The plaster on the ceiling was peeling and there was visible rust around the bottom of the bathroom door. -room [ROOM NUMBER]: The radiator was broken. There were gouges in the wall opposite the B bed with plaster exposed. There were three small holes in the wall under the clock. The dresser drawers next to the A bed were broken. -room [ROOM NUMBER]: [NAME] was peeling off the bottom of the bathroom door. There were two holes in the wall where the privacy curtain hangs. -room [ROOM NUMBER]: The entire ceiling was stained. Plaster was exposed surrounding the vent in the bathroom. The radiator was broken and coming apart from the wall. -room [ROOM NUMBER]: There was a rust-like substance around the bottom of the bathroom door. Drywall was exposed under the bedroom light and plaster was peeling on the right side of the top of the window.-room [ROOM NUMBER]: The radiator had significant visible rust. Paint was peeling away from the wall underneath the window and plaster was exposed. The ceiling above the window had stains and plaster exposed. -room [ROOM NUMBER]: The radiator was bent and broken.-room [ROOM NUMBER]: The radiator had significant visible rust. There were gouges in the wall with plaster exposed behind the A bed. -room [ROOM NUMBER]: There was a crack in the wall above the radiator. -The Activity Room/Dining Room: There were four tiles with stains and cracks by the outside patio door, the radiator by the back window was loose and coming apart from the wall, and the wall to the left of the television had peeling paint and plaster exposed. During an interview on 4/16/26 at 8:47 A.M., the Administrator and Director of Information Technology said that the building has not had any plans to fix room concerns as noted above and had just been working on bigger building projects until the building is bought by the new owner. Both said that all other maintenance had been on hold.

Based on observations, interviews, and record review, the facility failed to provide treatment and care in accordance with professional standards for one Resident (#15) out of a total sample of 20 residents. Specifically, the facility failed to identify and accurately document a bruise. Findings include:Review of the facility policy titled 'Skin Integrity Management', undated, indicated the following:-Perform skin inspection on admission, weekly, and readmission. Document weekly on Treatment Administration Record (TAR) and on weekly body check sheet.-Perform wound assessment and complete Skin Integrity Report upon initial identification of altered skin integrity and weekly thereafter.-Document care daily in Nurse's Notes/TAR and weekly on Skin Integrity Report. Resident #15 was admitted to the facility in July 2022 with diagnoses including dementia and heart failure. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/16/26, indicated that Resident #15 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15, and required assistance with activities of daily living (ADLs). On 4/14/26 at 8:51 A.M., the surveyor observed Resident #15 lying in bed with a quarter-sized bruise on his/her left upper arm that was purple and green in color. The Resident was unable to answer questions regarding the bruise or its etiology. Review of Resident #15's active physician orders for April 2026 indicated the following:-Apixaban (a blood thinner medication), 5-milligram tablet- give 5 milligrams by mouth two times a day related to heart failure, start date 10/14/25.-Monitor for discolored urine, black tarry stools, sudden severe headache, nausea/vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, shortness of breath, nose bleeds, every shift, start date 12/12/24. Review of Resident #15's skin assessment, dated 4/13/26, indicated skin is dry and intact. Review of Resident 15's medical record failed to indicate that the facility identified and accurately documented a bruise. During an interview on 4/16/26 at 9:18 A.M., Certified Nursing Assistant (CNA) #4 said CNAs are responsible for checking the residents' skin daily and reporting any changes to the nurse. CNA #4 said he noticed Resident #15 had a bruise on his/her left upper arm this morning and it is in a visible area that would be easily seen during ADL care. During an interview on 4/15/26 at 2:05 P.M., Nurse #5 said CNAs check residents' skin daily during ADL care and are supposed to report changes in skin to the nurse who is responsible for documenting it in a skin assessment form. Nurse #5 said the skin assessment form is updated weekly and whenever there is a change in the resident's skin, including new bruises. On 4/15/26 at 2:07 P.M., the surveyor and Nurse #5 observed Resident #15's bruise to his/her left upper arm. Nurse #5 said she was unaware of the bruise. Nurse #5 assessed the bruise and said it looked like an older bruise, and that the Resident is on Eliquis/Apixaban so he/she is at risk for bruising. Nurse #5 said the bruise was likely present when the skin assessment was completed on 4/13/26 and should have been documented but it was not and was likely overlooked. During an interview on 4/16/26 at 10:41 A.M., the Director of Nursing (DON) said CNAs are responsible for monitoring the residents' skin daily and reporting any changes, including bruises, to the nurse who will document it in a skin assessment. The DON said Resident #15's bruise to his/her left upper arm is in a visible area and should have been captured in the skin assessment on 4/13/25 but it was not, especially because there is a physician's order to monitor the Resident's skin for bruising every shift.

Based on record review and interview, the facility failed to develop a plan of care for the use of an antipsychotic medication for one Resident (#27) out of a total sample of 20 residents. Findings include: Resident #27 was admitted in February 2022 with diagnoses including vascular dementia with behavioral disturbances.Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #27 was receiving an antipsychotic medication. Review of the care plan in place for Resident #27 indicated the following: Focus: Resident #27 is receiving Psychotropic medications sertraline (an antidepressant) due to Dx (diagnosis) of depression. Review of the active physician's orders indicated Resident #27 was not prescribed sertraline, but was prescribed Risperidone (an antipsychotic medication used to treat schizophrenia or bipolar disorder) at 0.25 milligrams (mg) one time per day for behaviors. Review of the care plan failed to indicate Resident #27 had a care plan for the use of antipsychotic medications. During an interview on 4/16/26 at 10:41 A.M., the Director of Nursing said that if a resident is on an antipsychotic, then a care plan should be put in place to monitor any side effects of the medication.

Based on observations, interviews, and record review, the facility failed to ensure assistance with Activities of Daily Living (ADLs) was provided for one Resident (#35) out of a total sample of 20 residents. Specifically, for Resident #35, the facility failed to ensure supervision with meals and the use of utensils. Findings include:Review of the facility policy titled 'Activity of Daily Living', undated, indicated the following:-ADL assistance will be provided according to the needs of the residents. Assistance can be provided intermittently or continually.-Supervision can be provided intermittently or continually; supervision can mean cueing, encouragement, reminding or other. Resident #35 was admitted to the facility in March 2025 with diagnoses including dementia and need for assistance with personal care. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/13/26, indicated that Resident #35 was unable to participate in the Brief Interview for Mental Status exam and was assessed by staff to have severely impaired cognition. The MDS further indicated that Resident #35 required substantial/maximal assistance for eating. Review of Resident #35's current Activities of Daily Living care plan, last revised 9/16/25, included the following intervention:-Eating: at times he/she able to self-feed. Provide supervision/assistance give finger foods when the resident has difficulty using utensils. Review of Resident #35's Risk for Aspiration care plan created on 3/12/25, including the following interventions:-Alternate liquids and solids.-Give small bites and sips.-Keep head of bed elevated 90 degrees during meal and thirty minutes afterwards. On 4/14/26 at 8:47 A.M., Resident #35 was observed in a recliner chair at the nurse's station, the Resident was reclined at 30 degrees, the breakfast tray was in front of him/her the bedside table was set a little high for the Resident. The Resident grabbed a cinnamon bun off the tray by hand, then without eating it, put it back. At 9:04 A.M., the Resident picked up his/her fork and attempted to eat the oatmeal, which was very thin; the fork was not holding up any food and the Resident put the fork down. Nurse #1 came by and gave the Resident a spoonful of oatmeal then left. At 9:07 A.M., the Resident put the cinnamon bun in the oatmeal bowl, he/she then attempted to pick up the cinnamon bun which fell on his/her chest. At 9:17 A.M., the Resident was still attempting to eat his/her oatmeal with a fork no staff came to provide assistance.On 4/15/26 at 8:43 A.M., Resident #35 received his/her breakfast tray, on the tray was a jelly packet. The Resident picked up the packet and started licking it. At 8:45 A.M., the Resident continued to lick on the unopened jelly packet.At 8:49 A.M., the Resident picked up the cup of coffee from the tray and took a sip.At 8:53 A.M., the Resident picked up the knife and attempted to scoop the eggs. He/she was unable to bring any food to his/her mouth.At 9:00 A.M., The Resident continued to attempt to eat the eggs with the knife while licking the jelly packet.At 9:02 A.M., 19 minutes from when the Resident had received his/her breakfast tray, no staff provided assistance. During an interview on 4/15/26 at 9:29 A.M., Certified Nursing Assistant (CNA) #1 said the Resident requires supervision sometimes and at times he/she can eat independently. She further said staff should watch the Resident to ensure he/she is using the utensils properly and should be positioned properly in the chair. During an interview on 4/15/26 at 9:33 A.M., Nurse #1 said the Resident requires on and off supervision, she said the use of wrong utensils this was an issue when the Resident had been admitted to the facility but now he/she is doing much better. She further said the care plan should reflect the level of assistance that Resident requires. During an interview on 4/15/26 at 11:03 A.M., the Director of Nursing said Resident #35 requires supervision with meals and assisting to use the correct utensils and have correct positioning.

Based on observations, interviews, and record review, the facility failed to provide necessary treatment, services, interventions to promote healing and prevent new pressure ulcers from developing for one Resident (#12) out of 20 total sampled residents. Specifically, the facility failed to ensure the Resident's air mattress was set at the correct setting according to the physician's order. Findings include:Review of the facility policy titled 'Support Surface Guidelines', dated 1/2026, indicated but not limited to the following:-Any individual at risk for developing pressure ulcers should be placed on a redistribution support surface, such as foam, static, alternating air, gel, or air loss device when lying in bed.Review of the facility policy titled 'Pressure injury prevention and management', dated 11/2025, indicated the following but not limited to:-Provide appropriate, pressure-redistributing, support surface. Resident #12 was admitted to the facility in January 2024 with diagnoses including dementia and muscle weakness. Review of Resident #12's Minimum Data Set (MDS) assessment, dated 2/27/26 indicated Resident #12 had severe cognitive deficits as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. This MDS further indicated Resident #12 had a stage 3 pressure ulcer of the sacrum, was at risk of pressure ulcers, and was dependent on staff for activities of daily living (ADLs). Review of Resident #12's active physician orders indicated:-May have alternate pressure reliever mattress while in bed, monitor for functioning and setting Q (every) shift. Setting at 100 every shift. On 4/15/26 at 6:53 A.M., the surveyor observed Resident #12 in bed, the air mattress pump dial was set to 120 pounds. On 4/16/26 at 6:50 A.M., the surveyor observed Resident #12 in bed, the air mattress pump dial was set to 120 pounds. On 4/16/26 at 9:51 A.M., the surveyor observed Resident #12's sacrum with a large pink area with intact skin and no drainage noted. Review of Resident #12's plan of care related to skin, initiated 5/22/25, indicated the Resident has potential/impairment to skin integrity of the buttocks related to fragile skin. Review of Treatment Administration Record (TAR) for 4/15/26 and 4/16/26 indicated nursing documented the physician's orders for air mattress set to 100 pounds was implemented every shift. Review of Resident #12's most recent weight on 3/19/26, indicated the Resident weighed 102.6 pounds. During an interview on 4/16/26 at 6:52 A.M., Certified Nursing Assistant (CNA) #2 said he does not change the air mattress settings, but he can tell if it is inflated correctly when the Resident is in bed. He further said if there was any issue he would notify the nurse. During an interview on 4/16/26 at 6:55 A.M., Nurse #4 and the surveyor observed Resident #12's air mattress with the Resident lying on it. The air mattress was set to 120 pounds. Nurse #4 said it is set by the Resident's weight but was not sure how much the Resident weighed. During an interview on 4/16/26 at 6:58 A.M., Nurse #1 said Resident #12's air mattress should be set to 100 pounds per the orders. She further said the Resident's pressure ulcer was healed but still had a fragile area and is still at risk for skin breakdown. During an interview on 4/16/26 the Director of Nursing said the air mattress should have been set according to the Resident's weight.

Based on observations, interviews, and record reviews, the facility failed to implement fall interventions for three Residents (#48, #27, and #28) out of a total sample of 20 residents.1. For Resident #48, the facility failed to ensure his/her bed and chair alarms were in place and functioning.2. For Residents #27 and #28, the facility failed to ensure fall mats were in place. Findings include:Review of the facility policy titled 'Fall Prevention Program', undated, indicated the following:-Objective: To ensure that each resident who is at high risk for falls and/or experiences a fall at the facility is reviewed by their unit's interdisciplinary team for causes, risk factors, and preventative measures/interventions.-If the resident is at risk or has fallen both out of bed and/or wheelchair both bed and chair alarms will be placed. 1. Resident #48 was admitted to the facility in August 2025 with diagnoses including Parkinson's disease, difficulty walking, unsteadiness on feet, muscle weakness, and repeated falls. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/27/26, indicated that Resident #48 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of a possible 15, and required assistance with activities of daily living. Review of Resident #48's medical record indicated he/she had nine falls since admission from 9/13/25 to 3/6/26, with one fall on 12/27/25 resulting in a right rib fracture and subsequent hospitalization. Review of Resident #48's physician orders indicated the following:-Apply bed alarm while in bed, monitor for functioning every shift for safety, start date 1/4/26. Review of Resident #48's fall care plan, revised 3/6/26, indicated the following interventions:-Bed/chair alarm to alert staff when resident gets up unassisted, initiated 1/2/26. On 4/14/26 at 9:52 A.M., the surveyor observed Resident #48 in bed; there was a bed alarm unplugged on his/her bedside table. There were no other alarms attached to the Resident's bed. At the time of this observation, the Resident said he/she fell on the floor four weeks ago. On 4/15/26 at 6:18 A.M. and 7:57 A.M., the surveyor observed Resident #48 asleep in bed; there was a bed alarm unplugged on his/her bedside table. There were no other alarms attached to the Resident's bed. On 4/15/26 at 8:47 A.M., the surveyor observed a staff member delivering Resident #48's breakfast tray. At 8:49 A.M., the surveyor went into the Resident's room and observed Resident #48 sitting up in his/her wheelchair; there was a chair alarm in place but nonfunctional as evidenced by the light being off and the alarm did not sound when unplugged. The Resident said she is supposed to have alarms. On 4/15/26 at 11:31 A.M., the surveyor observed Resident #48 sitting up in his/her wheelchair in the recreation room; there was a chair alarm in place but nonfunctional as evidenced by the light being off and the alarm did not sound when unplugged. During an interview on 4/16/26 at 11:18 A.M., Certified Nursing Assistant (CNA) #3 said Resident #48 has bed and chair alarms in place for her safety due to risk of falls, and the nurse is responsible for ensuring the alarms are in place and functioning. During an interview on 4/16/26 at 9:38 A.M., Nurse #5 said Resident #48 is a fall risk and sustained a fracture from a recent fall, so bed and chair alarms were implemented as a safety intervention. Nurse #5 said nursing is responsible for checking alarms for placement and functionality every shift, and she knows the alarms are functional when the light is on. Nurse #5 said she was unaware Resident #48's bed alarm was not in place, and chair alarm was nonfunctional at the time of the surveyor's observations, which can put the resident at potential risk for falls. During an interview on 4/16/26 at 10:47 A.M., the Director of Nursing (DON) said Resident #48 has a history of falls since admission and has interventions in place including a bed and chair alarm for safety. The DON said alarms should be on and functioning all the time and all staff, including nursing staff, are responsible for checking alarms are in place and functioning. The DON said she was unaware Resident #48's bed alarm was not in place, and chair alarm was nonfunctional at the time of the surveyor's observations putting the Resident at potential risk for falls. 2 a) Resident #27 was admitted to the facility in February 2022 with diagnoses including vascular dementia, history of falling, and osteoporosis. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/13/26, indicated that Resident #27 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15, and required assistance with activities of daily living, including mobility. Review of Resident #27's medical record indicated he/she was at high risk for falls with four falls from 12/17/25 through 1/12/26. Review of Resident #27's physician orders indicated the following:-Place floor mat to both sides of the resident's bed, every shift for safety, start date 3/14/22. Review of Resident #27's fall care plan, revised 3/7/26, indicated the following interventions:-May have floor mat on both sides of the bed, while in bed, initiated 1/30/24. On 4/14/26 at 8:59 A.M., the surveyor observed Resident #27 sitting up in bed eating breakfast. The Resident said he/she had a history of falling, and the surveyor observed a fall mat folded up in the corner of his/her room with no fall mats on the floor. On 4/15/26 at 6:59 A.M., 7:57 A.M., and 9:01 A.M., the surveyor observed Resident #27 in bed with a fall mat only on the right side of the bed. During an interview on 4/16/26 at 11:18 A.M., Certified Nursing Assistant (CNA) #3 said Resident #27 is a fall risk and should have two fall mats in place on both sides of the bed to prevent potential injury. CNA #3 said the CNAs are usually responsible for putting the fall mats into place. During an interview on 4/16/26 at 10:57 A.M., Nurse #6 said Resident #27 has a recent history of falls and should have floor mats on both sides of the bed for safety due to risk of injury. Nurse #6 said the Resident has a physician's order for bilateral floor mats and the care plan indicated to use bilateral floor mats and these should have been followed but they were not. During an interview on 4/16/26 at 10:47 A.M., the Director of Nursing (DON) said physician orders and care plan interventions should be followed and that Resident #27 should have had bilateral floor mats in place due to potential risk for falls. 2b) Resident #28 was admitted to the facility in February 2019 with diagnoses including left-sided hemiplegia/hemiparesis (paralysis) following cerebral infarction (stroke), bilateral above-knee amputations, muscle weakness, and fall. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/20/26, indicated that Resident #28 was unable to complete the Brief Interview for Mental Status (BIMS), and staff assessed him/her to have severely impaired cognition. The MDS further indicated that Resident #28 was dependent on staff for activities of daily living. Review of Resident #28's fall care plan, revised 9/10/25, indicated the Resident was at high risk for falls and included following interventions:-Floor mat will be on while Resident is in bed, initiated 3/25/21. On 4/14/26 at 9:19 A.M., the surveyor observed Resident #28 in bed with no fall mats on the floor. The Resident was unable to answer any questions related to falls or the use of fall mats. On 4/15/26 at 6:39 A.M. and 9:01 A.M., the surveyor observed Resident #28 in bed with no fall mats on the floor. On 4/16/26 at 7:13 A.M., the surveyor observed Resident #28 in bed with no fall mats on the floor. During an interview on 4/16/26 at 11:04 A.M., Certified Nursing Assistant (CNA) #4 said Resident #28 is a fall risk and should have fall mats in place to prevent potential injury. During an interview on 4/16/26 at 10:57 A.M., Nurse #6 said Resident #28 is a fall risk. Nurse #6 said Resident #28 is supposed to have fall mats in place per her care plan and this should have been followed but it was not. During an interview on 4/16/26 at 10:47 A.M., the Director of Nursing (DON) said care plan interventions should be followed and that Resident #28 should have had fall mats in place due to potential risk of injury.

Based on record review and interview, the facility failed to address a significant weight loss and complete a comprehensive assessment after a significant weight loss was identified for one Resident (#20) out of a total sample of 20 residents. Findings include: Review of the facility policy titled 'Weight Monitoring Policy', undated, indicated the following:-Compare the new weight to the residents' previous weight. Note the difference between the weights and whether, this is a weight loss (-), or a weight gain (+). If the residents' new weight differs by 3 or more pounds, the resident needs to be reweighed on the same day at the same time. Any weight loss/gain of 3 pounds or greater requires the resident to be reviewed at the weekly weight focus review and placed back on weekly weights until stabilized. -Determine whether this weight change is significant. An unexpected loss or gain of 5% or more within one month, and/or 10% in six months is significant. -Notify physician and dietician of a significant weight change. Resident #20 was admitted in April 2025 with diagnoses including dementia, dysphagia (difficulty swallowing), Parkinson's disease, and unspecified protein-calorie malnutrition. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #20 could not participate in the Brief Interview for Mental Status (BIMS) due to severe cognitive impairment. Review of the MDS indicated Resident #20 requires substantial to maximal assistance with eating meals. Review of the care plan for Resident #20 indicated the following: -Focus: Alteration in nutritional status r/t (related to) altered chewing/swallowing ability r/t dysphagia . At risk for weight loss r/t altered texture diet aeb (as evidenced by) hx (history) of abnormal weight loss and varying PO (by mouth) intake. Risk of self-feeding difficulties r/t Parkinson's disease, tremors in hands (initiated 5/24/25).-Goal: Resident will have no significant weight changes x 90 days (initiated 5/24/25).-Monitor/record/report to MD (medical doctor) PRN (as needed) s/sx (signs/symptoms) of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3 pounds in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months (initiated 5/24/25).-Weigh as ordered, review and alert RDN (Registered Dietitian Nutritionist) for significant weight changes of 3 pounds in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months (initiated 5/24/25). Review of Resident #20's weight record indicated the following: -1/8/26: 135.8 pounds (lbs)-1/22/26: 131.4 lbs -2/12/26: 129 lbs -2/19/26: 126.9 lbs -2/26/26: 125 lbs -3/5/26: 124.8 lbs-4/2/26: 123.8 lbs -4/9/26: 122.4 lbs Review of the weight summary indicated Resident #20 lost 8.9 pounds from 1/8/26 to 2/19/26, which is a 6.5% significant weight loss in one month. Review of the medical record failed to indicate the weight loss was identified or assessed. Review of the weight summary indicated Resident #20 lost a total of 12 pounds from 1/8/26 to 4/2/26, which is an 8.8% significant weight loss in 3 months. Review of the last quarterly nutrition assessment, dated 10/24/25, indicated Resident #20 was on Mirtazapine (a medication used to stimulate appetite) and an oral nutrition supplement. Review of the physician's orders indicate the following: -Mirtazapine (initiated 8/12/25).-Magic cup (an oral nutrition ice cream) (initiated 8/6/25).-Boost supplement 3 times per day in between meals (initiated 1/6/26). Review of the medical record failed to indicate that any additional interventions were implemented after the significant weight loss, or a comprehensive assessment had been completed since the last quarterly assessment for Resident #20. During an interview on 4/14/26 at 3:25 P.M., the Dietitian said that she had recently started in the facility after a gap in dietitian coverage and that she was catching up, focusing more on monthly significant weight losses and six-month weight losses. The Dietitian said that nurses enter the weights into the electronic medical record and she reviews them weekly when she comes into the facility. The Dietitian said that when she is aware of a significant weight loss, she will meet with the resident and determine if there can be any changes in food preferences, as well as implement supplements. The Dietitian confirmed that greater than a 7.5% weight loss in 3 months is considered a significant weight loss and was unaware of Resident #20's weight loss. The Dietitian said she would evaluate Resident #20 and implement interventions. Review of the nutrition progress note, dated 4/14/26, indicated Resident #20 had a significant weight loss with a new intervention to increase the Boost nutritional supplement to a very high calorie Boost supplement.

Based on record review and interview, the facility failed to maintain accurate medical records for two Residents (#27 and #35) out of a total sample of 20 residents. Specifically;For Resident #27, the facility failed to maintain a complete and accurate medical record with accessible physician's notes. For Resident #35, the facility failed to complete daily documentation for activities of daily living care. Findings include: 1. Resident #27 was admitted in February 2022 with diagnoses including vascular dementia with behavioral disturbances. Review of the medical record for Resident #27 failed to indicate that there were any physician progress notes in the electronic medical record or the physical paper record since admission in February 2022. During an interview on 4/15/26 at 12:45 P.M., the Assistant Director of Nursing said that Resident #27's physician does not put his notes in the medical record, neither electronic or paper record, and the facility has to request his notes via email or fax. 2. Resident #35 was admitted to the facility in March 2025 with diagnoses including dementia and need for assistance with personal care. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/13/26, indicated that Resident #35 was unable to participate in the Brief Interview for Mental Status exam and was assessed by staff to have severely impaired cognition. The MDS further indicated that Resident #35 was dependent on staff for care. Review of the ADL (activities of daily living) documentation for the month of April 2026 indicated the following missing documentation: -12 out of 46 grooming/shower opportunities for documentation were missing. -12 out of 46 dressing/undressing opportunities for documentation were missing. -12 out of 46 bladder care opportunities for documentation were missing. -12 out of 46 feeding opportunities for documentation were missing. -12 out of 46 for toileting, sit-lying opportunities for documentation were missing. -12 out of 46 sit-to-stand opportunities for documentation were missing. -12 out of 46 chair-to-bed transfer opportunities for documentation were missing. -12 out of 46 toilet transfer opportunities for documentation were missing. During an interview on 4/15/26 at 9:29 A.M., Certified Nursing Assistant (CNA) #1 said all care provided should be documented. During an interview on 4/15/26 at 9:33 A.M., Nurse #1 said all staff should have complete documentation whenever they provide care. During an interview on 4/16/26 at 10:55 A.M., the Director of Nursing said documentation of ADLs is a point of care and staff should document after giving care. She further said there was a glitch in the software for documentation. Review of the ADL documentation report failed to indicate a pattern from glitched software.

Based on observations, records reviewed and interviews, for three of three shower rooms utilized by the residents, the Facility failed to ensure it provided a safe, functional, and sanitary environment, when door locks to the shower rooms did not function properly, shower rooms were not clean, smelled musty, were observed with visible areas of mold, and the overhead ventilation system was nonfunctional.Findings include:The Facility Policy, Infection Prevention and Control Program, dated revised August 2016, indicated the infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program.The Policy indicated important facets of infection prevention includes the following, identifying possible infections or potential complications of existing infections, instituting measures to avoid complications or dissemination, educating staff and ensuring that they adhere to proper techniques and procedures and enhancing screening for possible significant pathogens.During a tour on 09/10/25 at 10:39 A.M., of the Shower Room on 2 [NAME] (Second Floor), the Surveyor observed the following; -The shower room door had a key entry doorknob and above the key entry doorknob was a push coded entry lock that staff were trying to utilize to enter the shower room. Two staff members were observed trying to unlock and open the shower room door but had difficulty with the push button coded entry locked shower door. -The shower room appeared dry, however there was an obvious musty odor to the room. -Three rolling shower chairs were stored in the shower. -A white folded adult brief (a type of disposable undergarment for urinary or bowel incontinence) was leaning against the back of one of the shower chairs. -The shower had a built-in bathroom bench and it contained the following items. -a moist damp towel. -an unopened 2XL package of socks were placed on top of the moist damp towel. -a sponge, an opened half empty bottle of Derma Vera skin and hair cleanser. -an opened half empty capped bottle of body oil. -one opened capped Derma Daily product was located next to the moist damp towel. -Several areas on the shower ceiling, bathroom tile molding, and the curtain rod, were observed covered with black spots.-The shower curtain had several areas of black colored spots adhered to curtain. -The shower room ventilation grill (regulates air flow from an HVAC Unit) located in the ceiling, had a large amount of dust build up which was adhered to the grill. At the time of the observation there did not appear to be any airflow in or out of the ceiling vent. The Surveyor held a single sheet of toilet paper up against the vent and it was not pulled into or blown away from the vent.During a tour on 09/10/25 at 10:46 A.M., of the Shower Room on 2 East (Second Floor), the Surveyor observed the following. -The shower door key entry doorknob was unlocked (so anyone, including residents,could enter or exit the shower. Located above the key entry doorknob there was an outline of a silver plate mounted with an empty hole without a push button coded entry lock, and a surgical glove was tucked in the hole. -The shower room felt humid, appeared wet, damp, moist and smelled musty. -Water droplets were observed on two of the shower walls. -Several areas of black spots were observed on the white grout around the shower titles. -A Rolling shower chair was located in the shower. -The Shower Pull Cord cover plate and screw securing the Emergency Pull Station were rusted and the white pull cord string was frayed. -There was one opened bottle of Derma Vera Skin and Hair Cleaner located on the shower grab bar leaning against the wall. -A white face cloth (observed to have areas of black and brown discoloration) was wrapped around the showers grab bar. -A bottle of hand sanitizer was sitting on the floor. -The shower liner and curtain had several areas of black spots adhered to the liner and curtain. -The shower had a built-in bathroom bench and it contained the following items; -several damp towels were folded on top of one another. -two Anti-perspirant deodorant spray bottles, one was uncapped. -Under the built-in bathroom bench, on the floor next to the floor vent, there were two white towels (observed to have areas of black discoloration on them). -one bottle of Derma Vera skin and hair Cleaner was lying on the floor. -The shower room ventilation grill located in the ceiling, had a large amount of dust build up, which was adhered to the grill. At the time of the observation there did not appear to be any airflow in or out of the ceiling vent. The Surveyor held a single sheet of toilet paper up against the vent and it was not pulled into or blown away from the vent.During a tour, on 09/10/25 at 11:01 A.M., of the Shower Room on 1 [NAME] (First Floor), the Surveyor observed the following;-The shower room ventilation grill located in the ceiling, had a large amount build up dust, which was adhered to the grill. At the time of the observation there did not appear to be any airflow in or out of the ceiling vent. The Surveyor held a single sheet of toilet paper up against the vent and it was not pulled into or blown away from the vent. -The shower curtain had several areas of black spots adhered to the curtain. -The shower had a built-in bathroom bench, and it contained the following items; -a folded wet white (observed to have wet areas stained with black, light brown and a light red discolorations) scattered over the towel. -one opened torn Vitamin A & D Ointment package. -two cans aerosol cans of fresh scent air spray. -fourteen different bottles of bathing products. -white towel and Residents clothing. -A pink water picture, without a top, located on top of a towel, was filled with the following items; -five packaged toothbrushes, -a couple of Vitamin A&D Ointment packages and a bottle of lotion. -Several pieces of clear plastic were observed on the floor including, one plastic razor blade cover. -Under the built-in bathroom bench, there was one bottle of body oil on the floor.During a tour on 09/10/25 at 1:26 P.M., the Maintenance Director, accompanied by the Surveyor, said the Facility's ventilation (HVAC) system does not work in all three Unit Showers or throughout the building.During a follow-up interview at 3:11 P.M., the Maintenance Director said around two to three weeks ago himself and management (including the Facility's new management) assessed the main HVAC system (located on the Facility's roof), and they discussed that the system was not working. The Maintenance Director said he was not informed by management to obtain quotes to fix the HVAC system at the Facility.The Maintenance Director said at this time staff have been instructed to keep the shower room door open for at least 30 minutes to one hour after giving a resident a shower to help with ventilation in the shower rooms.The Maintenance Director said also, about two to three weeks ago, it had been brought to his attention that the Residents Showers rooms had mold. The Maintenance Director said he was able to treat and cleaned the 2 East Unit Shower for the mold but said he had not treated and clean up the mold in 2 [NAME] or 1 [NAME] Showers at this time. The Maintenance Director said the Facility did not hire a professional mold remediation company and that he was the only one treating and cleaning up the mold in the Residents' Showers.During interview on 09/10/25 at 1:45 P.M., the Director Nurses (DON) said her expectations of staff after a resident shower was that their personal belongings and hygiene supplies be removed from the shower room after use. The DON said showers are shared by all residents. The DON said housekeeping cleans the showers, but that she was unaware how often they were cleaned. The DON said to the best of her knowledge, the shower room doors are not locked and at times the doors are left open.The DON said she was unaware that the Facility's ventilation system was not working. The DON said last week she observed Maintenance working on completing treatments in the showers and said it was her understanding that all the shower rooms were completed at this time.During a tour on 09/10/25 at 1:54 P.M., the DON, Assistant Director of Nurses (ADON), accompanied by the Surveyor, toured all three Resident Shower Rooms. -At 1:54 P.M. of the Shower Room on 2 East (Second Floor) condition of the residents' shower was unchanged in appearance from the earlier Surveyor tour in the morning at 10:46 A.M.Despite the shower being unkept, Review of the CNA Documentation titled, 2 East 7-3/3-11 Assignment, dated 09-10-25, indicated four residents were scheduled to be showered.During interview on 09/10/25 at 1:58 P.M., CNA #3 said one of his assigned residents showered by him/herself.During interview on 09/10/25 at 1:58 P.M., the ADON said staff are to clean up after a Residents shower and are not to leave the shower door opened or the door unlocked for safety reasons. -At 2:07 P.M. of the Shower Room on 2 [NAME] (Second Floor) condition of the residents' shower was unchanged in appearance from the earlier Surveyor tour in the morning at 10:39 A.M.Despite the shower being unkept, Nursing said three residents who were scheduled for a shower today did receive a shower. Review of the Documentation titled, CNA Assignment Sheet Unit 2 West, dated 09-10-25, indicated three residents were scheduled to be showered. -At 2:15 P.M. of the Shower Room on 1 [NAME] (First Floor) condition of the residents' shower was unchanged in appearance from the earlier Surveyor tour in the morning at 11:01 A.M.During interview on 09/10/25 at 2:15 P.M., CNA #1 said one of her residents did shower today by him/herself.Despite the shower being unkept, the Documentation titled, 1 [NAME] 7-3/3-11Assignement, dated 09-10-25, indicated five residents were scheduled to be showered, four residents' refused, and one resident showered.During a tour on 09/10/25 at 3:16 P.M., the Maintenance Director, accompanied by the Surveyor, observed the water temperature in 2 East's Residents' Shower was not within acceptable temperature range for a resident to shower, and after 6 minutes the temperature of the water remained cold, and the temperature gauge was not moving despite readjusting and moving the handle. The Maintenance Director said the self-gauge and pressure switch needed to be replaced.The Maintenance Director said currently the water gauge read 80-degree Fahrenheit (27 degree Celsius), that the handle indicated it is turned up to 110-degree Fahrenheit, but the water continued to be cold, and the unit was therefore not working correctly.The Maintenance Director said the residents and staff can visually see the water temperature gauge when moving the handle. The Maintenance Director said depending on the individual's preference, the handle is self-set between 100-degree Fahrenheit to 110-degree Fahrenheit (38 degree Celsius to 43 degrees Celsius) range and the water temperature can be increased to the 110-degree Fahrenheit to 120-degree Fahrenheit (43 degree Celsius to 49 degrees Celsius) range.The Maintenance Director said the residents' showers have not been part of his daily water temperature audit checks since the Facility restored the hot water in the Facility last week.During an interview at the Exit Conference, on 09/10/25 at 5:40 P.M. the DON said she was aware 2 East Residents' Shower needed a new temperature gauge and pressure value and that the temperature of the water was cold. The DON said she was unaware of the Facility's HVAC ventilation system not working, was unaware if there was a HCVA plan for repair or replacement, and that Maintenance would be aware of the plan.

Based on observations, records reviewed, and interviews, for one of three resident units (2-West Unit), which had a resident census of 27, nine of whom were identified to be at risk for elopement, the Facility failed to ensure they maintained a safe and functional environment for residents, staff, and visitors, when the alarm on the stairwell fire door malfunctioned, the alarm was removed, and then a staff member zip tied the fire door closed, preventing the door from opening in case of an emergency for seven days from 06/18/2025 through 06/24/2025. The Facility also failed to ensure that multiple fire doors throughout the facility had functioning alarms, that a fire door self-closed once opened, and that staff monitored malfunctioning alarmed doors for resident safety. Findings include: The Facility's Protocol, titled, Fire Safety Plan, undated, indicated the Facility would establish a clear and effective response plan for fire emergencies that ensured the safety of all residents, staff, and visitors, and staff would ensure all egress paths were unobstructed. The Facility's Policy, titled Incidents, dated as revised in 2011, indicated the Facility would provide a safe and comfortable environment for their residents. The Facility's Policy, titled Safety and Supervision of Residents, dated July 2017, indicated the Facility would maintain an environment as free from accident hazards as possible, employees would identify and report accident hazards, and the Facility would remove the hazards to the extent possible. Review of the Health Care Facility Reporting System (CFR) report, dated 06/24/25, indicated that during a Department of Public Health (PH) licensure monitoring visit of the Facility, it was observed that the 2-West Unit Fire Door was secured closed by zip ties. On 06/25/25 at 08:32 A.M., the Surveyor and the Maintenance Director observed the 2-West Unit Fire Door. The door was observed to be a double door that opened into a stairwell, and there was a crash bar on the left side door and a locking doorknob on the right side. The Surveyor was able to open the door without an alarm sounding. Review of the posted signs on the 2-West Unit Fire Door indicated, This is a Fire Door Do Not Block, Fire Door Keep Closed, and EXIT. A lit EXIT sign was secured to the ceiling directly above the 2-West Unit Fire Door. During an interview on 06/25/25 at 03:09 P.M., Nurse #1 said that on 06/18/25 she reported to work at 03:00 P.M., and said that Nurse #2 told her that the alarm on the 2-West Unit Fire Door was malfunctioning. Nurse #1 said she notified Security and the Maintenance Director and said that the Maintenance Director removed the alarm from the door and left the unit. Nurse #1 said that Security Guard #1 later returned and secured the door using zip ties. Nurse #1 said she did not notify the Director of Nurses or Administrator about the zip ties. During an interview on 06/25/25 at 11:21 A.M., the Maintenance Director said that on 06/18/25 at 03:30 P.M., the door alarm on the 2-West Unit Fire Door was malfunctioning, said he could not fix it, so he removed it. The Maintenance Director said he was unsure when the zip ties were placed on the door, and said they were removed when the locksmith installed the new locking knob on 06/24/25. However, the alarm on the door remained broken. During a telephone interview on 06/25/25 at 12:29 P.M., Security Guard #1 said that on 06/18/25 at 02:00 P.M., nursing asked him to help stop the alarm from sounding at the 2-West Unit Fire Door. Security Guard #1 said while he was trying to turn off the alarm, after a resident attempted to go through the door, the key broke, said he contacted the Maintenance Director, who removed the alarm from the door. Security Guard #1 said on 06/18/2025, between 4:00 P.M. and 05:00 P.M., the Maintenance Director handed him zip ties and instructed him to secure the door with them, said he looped some of the zip ties together and slid them under the bar on the left door and around the doorknob on the right door, and then left the unit. Security Guard #1 said he told nursing staff that he was concerned that the door was not safe. During an interview on 06/25/25 at 01:20 P.M., Certified Nurse Aide (CNA) #2 said that on 06/18/25 the door alarm on the 2-West Unit Fire Door was malfunctioning and said the Maintenance Director was called to fix it. CNA #2 said that when she returned to work on 06/19/25 she saw that the alarm was missing from the door and the doors were held closed with zip ties, said she thought it was unsafe. CNA #2 said she did not report it to the Director of Nurses or the Administrator. During an interview on 06/25/25 at 10:11 A.M., the Human Resources (HR) Manager said that on 06/24/25 at 11:30 A.M., she was told by the Director of Nurses (DON) that the 2-West Unit Fire Door was secured closed with zip ties. The HR Manager said the zip ties were removed some time after she left at 05:30 P.M. on 06/24/25. The HR Manager showed the Surveyor an electronic photograph on her personal mobile device and said that she took the photograph on 06/24/25 before the zip ties were removed. Review of the electronic photograph viewed on the Human Resources (HR) Manager's personal mobile device indicated the 2-West Unit Fire Door was held together with four black zip ties that were chained together and looped through the crash bar on the left door and around the doorknob on the right door. During an interview on 06/25/25 at 12:38 P.M., the Facility's appointed Receiver said that he was not aware that the 2-West Unit Fire Door was secured with zip ties until the morning of 06/25/25, when the Administrator called him. The Receiver said it was a safety issue and an emergency situation that the door was secured with zip ties, and said that never should have happened. The Receiver said the Facility did not have a system in place to track communication between the Maintenance department and other departments regarding repair requests and completion of repairs. During an interview on 06/25/25 at 10:51 A.M., the Director of Nurses (DON) said that on 06/18/25 she was aware that the Maintenance Director was asked by nursing to fix the alarm on the 2-West Unit Fire Door, and said the Maintenance Director later said the door was all set. The DON said she was in the Facility on 06/20/25 and 06/23/25 and was not notified by anyone that the 2-West Unit Fire Door was held shut with zip ties until sometime in the evening 06/24/25, when the locksmith conducted repairs on the door. The DON said the fire egress doors should never be impeded, as it is unsafe. During an interview on 06/25/25 at 08:47 A.M., The Administrator said she was not aware that the 2-West Unit Fire Door was secured closed with zip ties until 06/24/25 at 02:30 P.M., when the Director of the Division of Health Care Facilities Licensure and Certification at the Department of Public Health emailed her. The Administrator said it was unsafe for the door to be secured closed with zip ties. On 07/01/2025 at 09:09 A.M., the Surveyors observed the following: - The 1-West Fire Door, that the alarm was not on and functioning and that the door, once opened, was not able to self-close. - The [NAME] Ground Floor Fire Door at the bottom of the interior stairwell, 1-East Fire Door, and the Central Staircase Fire Door on the 2nd Floor, that the alarms were not on and functioning. On 07/01/2025, the Surveyors also observed on 5 separate occasions, at 09:42 A.M., 11:50 A.M., 12:45 P.M., 12:51 P.M., and 02:53 P.M. through 03:00 P.M., that the surveillance security cameras were not being continuously monitored by a staff member. During an interview on 07/01/2025 at 09:44 A.M., the Administrator said that the 1-West Fire Door, [NAME] Ground Floor Fire Door, 1-East Fire Door, and the Central Staircase Fire Door, that the alarms should be on and functioning, and that the 1-West Fire Door should be functional and close properly. The Administrator also said that it was her expectation that the surveillance security cameras would be monitored by a staff member 24 hrs/7 days a week continuously.

Based on observation, record reviews and interviews, the facility failed to ensure food is stored, prepared and distributed in accordance with professional standards in food safety and sanitation to prevent the spread of pathogens, which could result in foodborne illness for the residents. Specifically: 1. The facility failed to ensure frozen foods were maintained frozen. 2. The facility failed to ensure available food was not expired, and that food was dated and securely stored. 3. The facility failed to ensure the dietary staff practiced proper hand hygiene and handled food in a way to minimize possible cross-contamination. 4. The facility failed to ensure the dish machine met proper sanitation requirements when staff used expired test strips and the wrong test strips. 5. The facility failed to ensure staff tested the sanitation buckets used to clean and sanitize the kitchen and surfaces. Findings include: Review of the facility's policy titled (4) Freezers, Policy: It is the policy of the facility that the freezer be maintained in a clean and sanitary condition. Review of the facility's policy titled: Chapter 3 Food, not dated, indicated the following: (E) A food that is labeled frozen and shipped by a food processing plant shall be received frozen. Gloves, Use limitation. (A) If used, SINGLE-USE gloves shall be used for only one task such as working with READY-TO-EAT FOOD or with raw animal food, use for no other purpose, and discarded when damaged or soiled, or when interruptions occur in operation. Review of the facility's policy titled Personal Hygiene, dated 2010, indicated, Hands are the major source of food contaminants. Frequent hand washing with special attention under fingernails can greatly reduce instances of foodborne illness. Clean Hands: Before handling or service food After returning to kitchen from another work area After handling soiled equipment, dishes, or utensils. Use a dedicated hand-washing sink supplied with soap dispenser and disposable paper towels. 8.Leave the water running while drying hands. Dry hands with a clean, disposable towel being careful to avoid touching the faucet handles or towel holder with clean hands. Discard the towel. 1. On 4/28/25 at 7:25 A.M., the following was observed in the main kitchen: The walk-in freezer outside built-in thermometer read 30 degrees Fahrenheit. Upon walking into the freezer, the surveyor immediately felt the temperature was not consistent with freezing. After stepping out and confirming with [NAME] #1 that it was the walk-in freezer the surveyor returned to the freezer. There was no internal thermometer in the freezer and the following was observed: -Multiple boxes of food were labeled keep frozen, -A bag of shrimp was soft, not solid to touch and was not frozen. -A plastic bag of French fries, not labeled or dated was soft and not solid to touch. -Ice fell from the corner of the unit as if it was melting. -A bag of imitation crabmeat was soft and not frozen solid to touch. -A plastic bag containing whipped cream was soft and not solid frozen to touch. -A sealed bag of beef and port meatballs was soft and not frozen solid to touch. -An open cardboard box with the internal plastic bag open and not secure had pasta with filling and was not frozen to touch. All the food observed and touched was consistent with being defrosted and not frozen. Review of the document labeled Dietary Temperature Sheet dated 4/26/25 indicated the freezer was documented as -2 (-2 degrees Fahrenheit) at breakfast, -3 (-3 degrees Fahrenheit) at lunch and -2 (-2 degrees Fahrenheit) at dinner. Review of the document labeled Dietary Temperature Sheet dated 4/27/25 indicated the freezer was documented as (0 degrees Fahrenheit), at breakfast, lunch and dinner. The Dietary Temperature Sheet indicated at the bottom and underlined: If any of the temperatures are out of range, please notify the Food Service Director Immediately. On 4/28/25 at 7:52 A.M., the Maintenance Director entered the kitchen and entered the freezer with the surveyor and used a thermometer and obtained the temperature of 40 degrees Fahrenheit. The Maintenance Director said he began working at the facility about 4 weeks ago and has been checking the freezer almost daily because of some mechanical issues which affected the temperature. The Maintenance Director was asked for work orders for work done on the freezer and he said he did he fixing with parts he had and did not have any invoices. During a return visit to the kitchen on 4/28/25 at 10:40 A.M., the walk-in freezer thermometer outside of the freezer was at 30 degrees Fahrenheit. The inside of the freezer did not feel consistent with freezing. The food inside the freezer was soft and not frozen to touch. [NAME] #1 said food remains in the freezer, that he did not know the plan for the food stored in the freezer that was no longer frozen. [NAME] #1 said he thought the Food Service Director was called about the freezer. Further, [NAME] #1, with [NAME] #2 present, said food in the freezer has been soft, this has been going on and that the temperatures in the Dietary Temperature Sheet do match-up with the temperatures he has seen. On 4/28/25 at 11:07 A.M., the Administrator and Food Service Director were not available for interview. The Surveyor asked the Director of Nursing (DON), who was identified as being the leadership for the facility, if she was aware that the walk-in freezer which was storing food was not keeping the food frozen. The DON said she was not aware. The DON and Assistant Director of Nursing (ADON) went to the kitchen and entered the walk-in freezer and said the food they touched was soft, defrosted and not frozen. The DON said a plan would need to be put in place. During an interview on 4/28/25 at 12:07 P.M., the Food Service Director (FSD) said he was not notified by staff that the walk-in freezer was not maintaining the frozen food frozen. The FSD said he was just told now when he got to the facility. The FSD said they are currently tossing out the food saying, 'when in doubt toss it (food) out'. The FSD said there have been issues with the freezer and he believed they were resolved. The FSD said the Maintenance Director has been monitoring the freezer daily. The FSD said no one had directly told him that the food was soft and not solid, and staff should have made him aware of any concerns. The FSD said he would expect frozen food to be solid to touch. During an observation and interview on 4/28/25 at 12:35 P.M., the FSD and surveyor observed the walk-in freezer, including a large entrée pan which was soft to touch. The FSD said large food items like the entrée would not be that soft in a short time and it would take one or two days of above freezing to defrost. 2. Review of a poster in the kitchen, next to the walk-in refrigerator indicated the following: Proper Food Labeling. Food that has been removed from the original container or has been prepared must be labeled for easy identification. Clearly marked labels allow for easy use-by date identification. On 4/28/25 at 7:25 A.M., the following was observed in the main kitchen: The Dry Storage room: -A large plastic bag of split peas, not dated when opened and tied in a knot. -A box of taco shells, with the bag inside revealing taco shells open to air, not secured and not dated as to when the taco shells were opened. -A large open bag of jasmine rice not dated when opened and secured with a knotted bag. -A open bag of shell pasta with the plastic bag knotted and not dated. -A plastic wrapped opened bag labeled cheese sauce mix, with a best by date of 'SEP 2024' (September) -A bottle of [NAME] Food coloring, covered with dust with a faded lable date of 3/15/17. -An unidentified food product in an open bag with no label or date. During an observation and interview on 4/29/25 at 9:13 A.M., the Registered Dietician (RD) and surveyor observed the Dry Storage room: -Two boxes of corn meal, one opened the other not opened with a best by date of SEP (September) 24. -Two bags of pasta, not in box with delivery date, that were open, tied in a knot and did not have an open date. During an interview at the time of this observation, the RD said all food items should be labeled with the date it was opened, that food should be stored securely, and food should not be expired. 3. During an observation of the meal distribution line on 4/29/25 at 11:41 A.M., the surveyor observed the following: Cook #1 wearing gloves on both hands was touching ready to eat bread directly, then touched his clothing with his gloved hands. [NAME] #1 removed the gloves, did not wash his hands, went and picked up a spatula, then placed gloves on both hands and touched the knob of the oven and touched the oven's surface. [NAME] #1 used his potentially contaminated gloves and touched grilled cheese sandwiches directly and placed them in wax bags. [NAME] #1 then touched the fry pan handle where the grilled cheese was being cooked and then touched three more grilled cheese sandwiches. [NAME] #1 reached into a box of wax bags, removed a few bags and touched the grilled cheese sandwiches directly and placed them in the bag. [NAME] #1 then touched the door to the food steamer appliance, walked the length of the serving table then picked up several serving utensils. At 11:50 A.M., two Diet Aids took turns to wash their hands in the hand washing sink. Both were observed to use their washed hands to turn off the water and in doing so potentially contaminating their hands, before pulling paper towels to dry their hands. During an interview on 4/29/25 at 3:22 P.M., the FSD said he saw [NAME] #1 handling food and did not know he did not wash his hands prior to placing the gloves on. The FSD said hand washing is required prior to putting on and taking off gloves. The FSD said if gloves are used to touch food directly, they should not be in contact with other surfaces, other items and should be changed between tasks. The FSD said he expects the staff to provide proper hand washing. 4. During an observation and interview on 4/29/25 at 2:27 P.M., of the dish machine (a dish machine is designed to handle a high volume of dishes. A low temperature dish machine model uses chemicals to sanitize and to kill bacteria or harmful microorganisms). The FSD ran the dish machine with a rack. Diet Aid #1 said they test the dish machine three times a day. Diet Aide showed the surveyor the test strips he used, and both bottles of test strips were expired. One expired February 2024 and the other February 2025. Diet Aid #1 said these test strip bottles are what he has been using every day. Review of the document not dated of the manufacturer's Installation Instructions provided by the FSD for the dish machine indicated: -The black or gray cam controls sanitizer. The sanitizer cam is adjustable. Set sanitizer concentrations to 50 parts per million (notice do not exceed 100 PPM'S (parts per million)). Monitor chlorine levels by using chlorine test strips. On 4/29/25 at 2:42 P.M., the FSD said staff monitor the dish machine by using test strips to ensure the sanitizer is at 50 PPM. The FSD he was not aware the staff was using expired test strips and that because the test strips are expired, they may not have the same effect to measure the sanitation process. 5. During an observation on 4/29/25 at 11:41 A.M., a Diet Aid was observed to remove a rag from a red bucket of liquid and use it to wipe down a cart used for transporting kitchen items and then returned the rag to the red bucket. During an observation and interview on 4/29/25 at 2:47 P.M., the FSD said they clean and sanitize the kitchen with a solution which is a calibrated mix, which is at the three-bay sink. The FSD said they do not fill the sink and use the premix solution to fill the red buckets. The FSD said the staff are not monitoring the solution in the red buckets. The FSD said there is no control or nothing to demonstrate the sanitizer is at the correct level to ensure it is properly sanitizing the kitchen. During the survey the Administrator was not available for interview and the Director of Nursing was identified as being in charge. During an interview on 4/29/25 at 3:47 P.M. the Director of Nursing said proper hand washing and food handling should be followed by staff.

2. Resident #28 was admitted to the facility in August 2022 and has diagnoses that include but are not limited to Alzheimer's Disease, and urinary tract infection. Review of the Minimum Data Set (MDS) dated [DATE], indicated Resident #28 scored a 0 out 15 on the Brief Interview for Mental Status indicating he/she as having severe cognitive impairment. The MDS also indicated Resident #28 was dependent on staff for most aspects of daily care. On 4/28/25 at 8:38 A.M., Resident #28 was observed near the nursing desk in a recliner chair, Resident #28 was observed to be frail and did not respond to the surveyor's greeting. Review of Resident #28's medical record indicated that Resident #28 had a legal guardian. Review of Resident #28's paper medical record under both the care plan tab and social service tab failed to indicate documentation related to interdisciplinary care plan meetings. Review of Resident #28's electronic medical record indicated a Social Worker note, dated 5/25/24, which indiated the following: -IDT (Interdisciplinary Team) review of care plan underway. Guard (sic) not available today for care plan review. Will schedule review at guardian's convenience (if desired). Further review of the record failed to indicate any further Social Work progress notes, or documentations that care planning meetings occurred. During an interview on 4/30/25 at 10:58 A.M., the Director of Nursing said care plan meetings are scheduled by the social worker and the residents, their representatives and the interdisciplinary team are invited to attend. She said she believes they should be done quarterly but is unsure of the scheduling and/or requirements of the meeting. The Director of Nursing said if a care plan meeting occurred, there would be documentation of the meeting in the resident's medical record. During the survey the facility did not have a Social Worker, therefore there was no interview with a Social Worker. Based on record reviews and interviews, the facility failed to ensure four Residents (#16, #28, #5, and #45) were allowed to participate in the development and implementation of his/her person centered care plan by failing to conduct an interdisciplinary care plan meeting quarterly, out of a total sample of 24 residents. Findings include: Review of the facility's policy titled, Resident Participation-Assessment/Care Plans, not dated, included but was not limited to the following: -The resident and his or her representative are encouraged to participate in the resident's assessment and in the development and implementation of the care plan. The resident/representative's right to participate in the development and implementation of his/her plan of care includes the right to: a. participate in the planning process, 7. A seven (7) day advance notice of the care planning conference is provided to the resident and his or her representative. The Social Service Director or designee is responsible for notifying the resident/representative and for maintaining records of such notices. Review of the facility policy titled, Care Planning-Interdisciplinary team, not dated, indicated the following: -Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized care plan for each resident. 2. The care plan is based on the resident's comprehensive and is developed by a Care Planning/Intradisciplinary Team which includes, but is not necessarily limited to the following personnel: a. The resident's attending physian, b. The Registered Nurse who has responsibility for the resident; c. The dietary Manager/dietician; d. The Social Services Worker responsible for the resident; e. The Activity Director/Coordinator; f. Therapists (speech, occupational, recreational, etc.) as applicable; g. Consultants (as appropriate); h. The Director of Nursing (as applicable); 1. The Charge Nurse responsible for the care; j. Nursing Assistants responsible for the resident's care; and k. Others as appropriate or necessary to meet the needs of the resident. 4. Every effort will be made to schedule care plan meetings at the best time of day for the resident and family. 1. Resident #16 was admitted to the facility in September 2007 with diagnoses including hemiplegia and need for personal assistance. Review of Resident #16's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15, which indicated he/she is cognitively intact. The MDS also indicated Resident #16 requires substantial/maximal assistance for all functional tasks. During an interview on 4/28/25 at 8:32 A.M., Resident #16 was unable to say if he/she had participated in a care plan meeting recently. Review of Resident #16's medical record failed to indicate any evidence of a care plan meeting taking place within the past year. During an interview on 4/30/25 at 10:58 A.M., the Director of Nursing said care plan meetings are scheduled by the social worker and the residents, their representatives and the interdisciplinary team are invited to attend. She said she believes they should be done quarterly but is unsure of the scheduling and/or requirements of the meeting. The Director of Nursing said if a care plan meeting occurred, there would be documentation of the meeting in the resident's medical record. The Director of Nursing said she was unaware of the last time Resident #16 had a care plan meeting. The facility is currently without a social worker to interview. 3. Resident #5 was admitted to the facility in August 2010 with diagnoses that included hypertension, diverticulosis of the large intestine, anemia, unspecified convulsions, and major depressive disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/15/25, indicated the Resident was assessed by staff to have severely impaired cognition. The MDS further indicated Resident #95 is dependent for all self-care activities and requires supervision/touching assistance for self-feeding. Review of Resident #5's medical record on 4/30/25 at 1:57 P.M., indicated the last care plan meeting for the Resident took place on 6/22/24. During an interview on 4/30/25 at 10:58 A.M., the Director of Nursing said care plan meetings are scheduled by the social worker and the residents, their representatives and the interdisciplinary team are invited to attend. She said she believes they should be done quarterly but is unsure of the scheduling and/or requirements of the meeting. The Director of Nursing said if a care plan meeting occurred, there would be documentation of the meeting in the resident's medical record. The facility is currently without a social worker to interview. 4. Resident #45 was admitted to the facility in October 2023 with diagnoses that include hemiplegia and hemiparesis, anoxic brain injury and dysphagia Review of Resident #45's most recent Minimum Data Set (MDS) Assessment, dated 2/1/25 indicated that the Resident could not participate in the Brief Interview for Mental Status Exam and was assessed by staff as having severe cognitive impairment. Review of Resident #45's medical record failed to indicate any evidence of a care plan meeting taking place within the past year. During an interview on 4/30/25 at 10:58 A.M., the Director of Nursing said care plan meetings are scheduled by the social worker and the residents, their representatives and the interdisciplinary team are invited to attend. She said she believes they should be done quarterly but is unsure of the scheduling and/or requirements of the meeting. The Director of Nursing said if a care plan meeting occurred, there would be documentation of the meeting in the resident's medical record. The facility is currently without a social worker to interview.

Based on observations, record reviews and interviews, the facility failed to adequately maintain the nutrition and hydration status of three Residents (#71, #45 and #13) out of a total sample of 24 residents 1. For Resident #71, the facility failed to ensure significant weight loss was assessed and continually monitored. 2. For Resident #45, the facility failed to implement physician's orders for weekly weights, dietary recommendations for fortified foods and the dietitian failed to evaluate significant weight loss following hospitalization. 3. For Resident #15 the facility failed to ensure quarterly nutrition assessments were completed on a resident with a feeding tube. 4. For Resident #13, the facility failed to obtain weights as ordered. Findings include: Review of the facility policy titled, Resident Nutrition Services, dated 2001, indicated the following: -The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits. 1. Resident #71 was admitted to the facility in November 2024 with diagnoses including Alzheimer's Disease. Review of Resident #71's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status (BIMS) of 6 out of a possible15, which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #71 requires supervision for all functional daily tasks. Resident #71 was unable to be interviewed about is/her nutritional status secondary to cognitive impairment. Review of Resident #71's weights and physician orders indicated the following: -On admission, Resident #71 weighed 122 lbs. (pounds) and his/her diet orders was for house diet, regular texture, regular consistency, initiated on 11/13/24. -On 1/23/25, Resident #71 weighed 112 lbs., an 8.2% weight loss. On 1/29/25, a physician order was initiated for Ensure Plus, three times a day, give between meals. (This would be a daily supplement equaling 1,050 calories.) -On 3/6/25, Resident #71 weighed 108.9 lbs. On 3/19/25, Resident #71's physician order for Ensure Plus was discontinued and the Resident was prescribed Boost VHC. one time a day for weight monitoring. (This would be a daily supplement equaling 530 calories a day, 520 less calories than Ensure Plus.) -On 4/26/25, Resident #71 weighed 103.2 lbs., a continued 5.23% weight loss. Review of the dietary notes indicated the following: -1/28/25: Weight Watch. Resident with suboptimal PO (by mouth) intake at meals c/w (consistent with) a significant weight loss x1 month. Weight: 1/23/25 112 12/19/24 119 11/2/24 120. WT (weight) is down 7#(pounds)/5.9% x1 month and is down 8#/6.1% x3 months. Resident is consuming 26-50% at most meals intermittently 51-75%. 237ml (milliliters) Ensure + added 3x/day to help stabilize weight. Will follow. -3/18/25: Resident with a 3.1% WT loss x1mo and down 7.2% x3mos and down 10.7% x10mos. Trialed Boost VHC, resident consumed 100%. Boost + and Boost breeze d/c'd and boost VHC 237ml added 1x/day. Will trial thrive ice cream. Review of Resident #71's medical record indicated the Dietitian had not completed a quarterly assessment due in February 2025. During an interview on 4/29/25 at 9:52 A.M., Nurse #1 said Resident #71 has had continual weight loss since admission to the facility. Nurse #1 said when a weight loss occurs, the Registered Dietitian, physician and health care proxy are notified. Nurse #1 said Resident #71 was a poor eater, however, has improved his/her intake over the last couple of months. Nurse #1 said Resident #71 used to be on a nutritional supplement three times a day and was changed to one time a day and she did not know why because the Resident would drink the supplement. During an interview on 4/29/25 at 1:47 P.M., the Registered Dietitian (RD) said she works at the facility twice a week. The RD said she was out of the facility in September for a medical issue and since coming back to work she has had a difficult time catching up and completing the resident assessments that need to be completed. The RD said significant weight loss is 5% in one month, 7.5% in three months and 10% in six months and that Resident #71 has had consistent and significant weight loss since admission to the facility. The RD said she started Resident #71's quarterly nutritional assessment in February 2025 but did not complete it, only entering the Resident's weight. The RD said she recommended a change to Resident #71's supplement after continued weight loss, however, could not answer why a change was recommended that would result in a total of less calories. The RD said she did not document her reasoning, and it could possibly be because the Resident refused to drink the supplement. The RD said she was unaware of Resident #71's weight on 4/26/25 and the newest significant weight loss. The RD said that the Resident is difficult to work with because of his/her cognition status and is a bane of my existence. Review of the Medication Administration Reports (MAR) for January 2025 to March 2025 failed to indicate the Resident refused the Ensure Plus supplement. During an interview on 4/30/25 at 10:58 A.M., the Director of Nursing said she expects the Dietitian to complete assessments quarterly and was unaware Resident #71's supplement was decreased from three to one time a day and has had continued weight loss. 2. Review of facility policy titled Assisting the Resident with In-Room meals, dated as revised December 2013, indicated the following: -1. Review the residents' care plan and provide for any special needs of the resident. -3. Check the tray before serving it to the resident to be sure that it is the correct diet ordered, and that the food consistency is appropriate to the resident's ability to chew and swallow. Resident #15 was admitted to the facility in March 2013 with diagnoses that included type 2 diabetes and need for assistance with personal care. Review of Resident #15's most recent Minimum Data Set (MDS) Assessment, dated 3/25/25, indicated a Brief Interview for Mental Status score of 6 out of a possible 15, indicating that the Resident has severe cognitive impairment. -On 4/28/25 at 8:54 A.M. Resident #15 was observed eating breakfast. Resident #15's meal ticket indicated double portions and fortified cereal, but his/her meal did not appear to be double portions. -On 4/29/25 at 8:45 A.M., the surveyor observed Resident #15 eating breakfast in the hallway. Resident #15's meal did not appear to be double portions. The surveyor observed two other residents on a puree diet who did not require double portions, and the portions were the same as Resident #15. The Resident also had oatmeal (which was not pureed) on his/her tray, the surveyor was unable to determine if it was fortified cereal. During an interview on 4/29/25 at 10:05 A.M., Dietary staff #1 said that he was the cook this morning and said that the oatmeal was fortified. He said he added some milk and honey to it to fortify it. -On 4/29/25 at 1:00 P.M., the surveyor observed Resident #15 eating lunch in the hallway. Resident #15's meal ticket called for double portions and fortified mashed potatoes, neither of which was observed on the Resident's tray. The Resident was also indicated to receive a fortified ice cream which was also not present. -On 4/29/25 at 1:08 P.M., the surveyor observed the lunch tray of another Resident (#28) who received a puree diet, and is not indicated to receive double portions, and the portion was the same as Resident #15. Review of Resident #15's most recent Mini Nutritional Assessment, dated 2/17/25, indicated a risk score of 8, which indicates at risk for Malnutrition. Review of Resident #15's active nutrition care plan indicated the following: -1/15/25, downward weight trend, add fortified mash potatoes at lunch and dinner meals and double portions at all meals, last revised 1/14/25. -FF (fortified) mashed potatoes added at lunch and dinner and double portions added to all meals, created 2/16/25. - Monitor weight as ordered, created 2/12/21. -RD (Registered dietitian) to evaluate and make diet changes or recommendations PRN (as needed) RD available for diet education upon request, created 2/12/21. Review of progress notes indicated a note written on 1/14/25 by the Dietitian which indicated: -Resident with a downward weight trend without a significant weight loss noted at this time, weight is down 11.8 pounds or 7.9% over 6 months. -Interventions will provide double portions at all meals and fortified mashed potatoes at lunch and dinner meals. Review of Resident #15's meal tickets as of 4/29/25 indicated the following: -Breakfast: Diet Order: Puree, LCS (low calorie sweeteners), NAS (No added salt) , Regular liquids. Notes: Double portions, apple juice, fortified cereal -Lunch: Notes: Double portions, apple juice, send magic cup with meal, fortified mashed potatoes. Dislikes: potatoes -Dinner: Notes: Double portions, send magic cup with meal, fortified mashed potatoes. Dislikes: potatoes. Review of Resident #15's active physician orders indicated the following: -Weekly weight on THURSDAY 7-3, revised 4/1/25. -Nutrition consult for weight loss, dated 1/13/25. -NAS (No added salt) diet, Puree texture, Regular consistency. Double portions at all meals, dated 2/13/25. -Glucerna 1.5 four times a day for significant wt (weight) loss noted, dated 1/8/24. -Nutritional Consult, dated 4/1/25. -Thrive ice cream twice daily, two times a day, dated 4/7/25. Review of Resident #15's weights for April 2025 indicated the following: 4/3/25: 123.8 lbs. (pounds) 4/25/25: 134.8 lbs. Review of the medical record failed to indicate that weights were obtained on 4/10/25 and 4/17/25 as indicated in physician's orders for weekly weights. Review of the medical record indicated that the Resident was hospitalized from [DATE] through 3/18/25. Review of Resident #15's weights indicated that prior to hospitalization the Resident weighed 146 lbs. on 2/27/25, and the next documented weight on 3/28/25 (10 days after returning from the hospital) indicated a weight of 122.6 lbs. Review of the Nurse Practitioner progress note, dated 3/25/25 indicated, This patient is well developed and in no acute distress, PT (patient) is frail post hospital stay with visible weight loss. Review of a nursing progress note, dated 4/1/25, indicated, The resident is noted with weight loss. [He/She] returned from the hospital weighing 127.6 lbs. This past week [his/her] weight was 122.8 and was double checked. The NP (Nurse Practitioner) was notified and she gave new orders for weekly weight, to obtain a nutritional consult. The dietician was made aware. [His/Her] HCP (health care proxy) was called with no answer, no voicemail. [sic] The medical record indicated that following return from the hospital, Resident #15 continued to lose weight, specifically, 5 lbs. between readmission from the hospital on 3/18/25 and reweight on 3/28/25. Review of the medical record on 4/30/25 failed to indicate that the Dietitian had evaluated Resident #15 following readmission from the hospital or since the order was obtained for a nutritional consult on 4/1/25. During an interview on 4/29/25 at 9:01 A.M., Nurse #5 said that fortified cereal can be cream of wheat or oatmeal and the cook adds butter, cream, sugar and other ingredients to add more calories for residents who are losing weight. During an interview on 4/29/25 at 1:38 P.M., the Food Service Director (FSD) said that if a resident on puree diet had double portions, there would be two scoops of everything on the plate, or very large scoops of everything that was served. He said that no fortified mashed potatoes have been made in the facility, he was not sure if any residents required this intervention. He said that fortified cereals for pureed diet orders are made with cream of wheat. He said that they add cream or half- and- half, sugar, cinnamon and nutmeg to the cereal. He said that this is what he expects his staff to use. He said adding milk and honey, as indicated by dietary staff #1 in the morning, would not be considered fortified cereal. During an interview on 4/29/25 at 2:24 P.M., the Dietitian said when residents experience weight loss, she may add fortified cereal to their menu, she further said that adding milk and honey to cereal would not be considered fortified cereal. When asked if fortified potatoes are an option as well, she said it's an option, but she generally does not recommend it. She did not recall recommending it for Resident #15. She said she was not sure if it was being implemented. She further said that if other residents receiving a puree diet without double portions recommended looked like they had the same amount of food on their plate, then the double portions were probably not being implemented. The Dietitian said she was aware of Resident #15's weight loss upon readmission from the hospital but was not aware of the physician's order for a nutritional consult. When the surveyor asked if one had been done if it would be documented in the medical record, she said it should be. The Dietitian said she was not sure if there was an exact recipe for fortified cereal or potatoes but that she would look into it. The Dietitian further said that the order for thrive ice cream that was started on 4/7/25 was a change from a magic cup supplement because the facility switched products but was not necessarily a new intervention. The Dietitian also said that if a resident has an order for weekly weights, she expects them to be completed. During an interview on 4/30/25 at 9:00 A.M., the Director of Nurses said that fortified cereal, fortified mashed potatoes and double portions of meals should be provided as recommended for residents. She said nurses should also be obtaining weights as ordered. The Director of Nurses said she would have expected the dietitian to evaluate the resident following readmission, especially since there was a weight loss noted on admission and would have expected the nutritional consult to have been completed after it was ordered by the physician on 4/1/25. -On 4/29/25 the Dietitian left a copy of the expected recipe for fortified cereal for the surveyor which included: -1 packet instant oatmeal (plain) -1/4 cup half- and- half -1/2 cup evaporated milk -1/2 cup water -1 tablespoon margarine -1 tablespoon brown sugar 3. Resident #45 was admitted to the facility in October 2023 with diagnoses that include hemiplegia and hemiparesis, anoxic brain injury and dysphagia. Review of Resident #45's most recent Minimum Data Set (MDS) Assessment, dated 2/1/25, indicated that the Resident could not participate in the Brief Interview for Mental Status Exam and was assessed by staff as having severe cognitive impairment. The MDS further indicates the use of a feeding tube. Review of Resident #45's physician orders indicated the following: -Jevity (a high-calorie, fiber-fortified therapeutic nutritional supplement often used for tube feedings) 1.2 @ 80 ml/hr [milliliters per hour] up at 7:30 pm and down at 6:30 am-up at 7:30 pm down 6:30a for supplement Jevity 1.2 @ 80 ml/hr up at 7:30 pm and down at 6:30 am, dated 8/14/24. [sic] Review of the medical record indicated that the most recent progress note written by the dietitian was completed on 7/16/24, nine and a half months ago. Review of the medical record indicated that the most recent Quarterly Nutrition Assessment was completed 8/14/24, eight and a half months ago and indicated the following: -A Mini Nutritional Assessment score of 10 indicating the resident is at risk for malnutrition. -Trial of reducing tube feeding to 11 hours per day and providing three meals per day. Will follow. Review of the medical record failed to indicate any further assessments or follow ups regarding Resident #45's nutrition During an interview on 4/29/25 at 1:47 P.M., the Dietitian said that she is the only dietitian for the facility. She said she works usually two days per week. The Dietitian said she assesses everyone on admission and that quarterly assessments should be completed after that, but the quarterly assessments have not always been done. She said that if a resident is at high risk, such as experiencing weight loss, or utilizing a feeding tube she will make sure they are completed. She said Resident #45 does not have an up-to-date quarterly assessment completed. During an interview on 4/30/25 at 9:34 A.M., the Director of Nurses said that she would expect Nutrition Assessments to be completed quarterly and would expect that the Dietitian will complete them. She said the facility only has one dietitian. 4. Resident #13 was admitted to the facility in February 2020 with diagnoses including parkinsonism, dementia, schizophrenia, and depression. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/8/25, indicated that Resident #13 had a severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 2 out of 15. Review of Resident #13's physician's order, dated 1/29/24, indicated weigh every 3 weeks in the afternoon on Thursday. Review of Resident #13's Weight and Vitals Summary indicated the following weights: -4/29/2025, 164.4 pounds (Lbs.) (35 days since last weight 3/25). -3/25/2025, 161.6 Lbs. (74 days since last weight 1/10). -1/10/2025, 163.6 Lbs. 38 days since last weight on 12/4). -12/3/2024,162.0 Lbs. (82 days since last weight on 9/12 - 6lbs). -9/12/2024, 168.2 Lbs (31 days since last weight on 8/12). -8/12/2024, 169.8 Lbs. -8/10/2024, 169.8 Lbs. (45 days since last weight on 6/27). -6/27/2024, 170.0 Lbs. (54 days since last weight on 5/4 -3lbs.). -5/4/2024, 173.8 Lbs. (25 days since last weight 4/9). Review of Resident #13's Medication Administration Record (MAR) indicated that weights were signed off as complete on 10/10/24, 10/31/24, 11/21/24,12/12/24, 1/2/25,1/22/25, 2/13/25, 3/6/25, 3/27/25, 4/17/25, but review of entire medical record failed to find any documentation of weights recorded on these dates. During an interview on 4/30/25 at 11:27 A.M., Nurse #4 said she does not know why Resident has an order for weights every 3 weeks, but monthly weights are done during the first week of every month. She was not aware of Resident refusing to be weighed. During an interview on 4/30/25 at 10:58 A.M., the Director of Nursing said that physician's order for weights should be followed and physician should be notified if weight not obtained according to order.

Based on observation, record review and interview, the facility failed to ensure meals were provided in accordance with standards of nutritional standards to ensure the nutritional needs of residents were met. Specifically, the facility failed to ensure the menu, including the therapeutic breakdown for specialized diets, was provided to the staff serving the daily meals. Findings include: Review of the 268 CMR: BOARD OF REGISTRATION OF DIETITIANS/NUTRITIONISTS 268 CMR 5.00: PROFESSIONAL STANDARDS AND ETHICAL CODES, included but was not limited to the following: (4) Foodservice Systems: In the areas of menu planning, foodservice purchasing, production, distribution and service, safety and sanitation, facility layout, and management, examples of appropriate activities include, but are not limited to, the following: (a) Planning, developing, controlling and evaluating food service systems; (b) Establishing and maintaining standards of food production, service, sanitation, safety, and security; (c) Developing menu patterns and evaluating such for nutritional adequacy; (d) Planning layout designs and determining equipment requirements for food service facilities; (e) Developing specifications for the procurement of food and food service equipment and supplies. Review of a document provided to the surveyor on 4/30/25 by the Food Service Director, titled, Resident Summary Report indicated the following breakdown of residents with Special Diets: Multiple residents are listed as having one or more of the following Special Diets: -Fifty residents require NAS (No Added Salt, which is a regular diet with no additional salt with meals) -Thirty-nine residents require LCS (Low Concentrated Sugar, a diet which means avoiding foods with a lot of sugar or high calorie sweeteners and is prescribed to manage blood sugar levels). -Twenty-one residents require Low Fat (A diet plan that limits the amount of dietary fat consumed). -Twelve residents require Low K (Low Potassium, a diet which limits food with high potassium levels, like potato, and stewed tomatoes). -One Resident has a Low Lactose Diet (A diet which involves avoiding or limiting the consumption of lactose-containing foods and beverages, like milk, cheese, yogurt and ice cream). During an observation of the main kitchen and interview on 4/28/25 at 7:25 A.M., [NAME] #1 said the we have problems here, When asked what [NAME] #1 meant by problems, he said we do not have enough food. [NAME] #1 said we do not follow the menus, and we cook what we have available. [NAME] #1 said today for breakfast they are having scrambled eggs and toast. [NAME] #1 pointed to a binder with menus and said these are the menus and he was not sure which week they were using. A review of the menu did not indicate a breakdown for the specialized diets, also known as therapeutic diets. (A therapeutic diet is a specialized eating plan designed to meet the nutritional needs of individuals based on their specific health conditions or illnesses. It may involve modifying nutrient levels, such as carbohydrates or fats, and can be ordered by healthcare professionals as part of treatment for various diseases or clinical conditions). During an interview on 4/28/25 at 12:07 P.M., the Food Service Director (FSD) said they are following the menu for week 4 today because they did not receive items for the week 2 menu which was what week they were on. Review of the menu week 4 for Monday lunch, used for today 4/28/25 indicated Spaghetti, meat sauce, garlic bread, with a lunch alternate of grilled cheese, roast potato and steamed vegetables. The menu indicated cookie for dessert. The menu did not indicate what the 50 residents who have a NAS diet could or could not have or how much they could have. The menu did not indicate what the thirty-nine residents requiring LCS could have or not have or how much of something they could have to meet the LCS diet. The menu did not indicate what the twenty-one residents on a low-fat diet could have or could not have or how much of something they could have to meet the low-fat diet. The menus did not indicate what the twelve residents on a low-potassium diet could or could not consume or how much of something they could have to meet the low-potassium diet. The menu did not indicate what the one resident on a lactose free diet could consume or not consume or how much of something they could eat to meet the low-lactose diet. Review of the four-week cycle of menus did not indicate the specialized diets and how the specialized diets were met. During an interview on 4/28/25 at 4:54 P.M., [NAME] #2 said the freezer was broken but the meal for tonight was planned and was cooked ham (a meat higher in sodium), rice and vegetables. This meal was not on the week 2 menu and did not have a breakdown for the specialized diets. During an interview on 4/29/25 at 11:56 A.M. [NAME] #2 said he follows the menu provided and that the Resident's diet ticket has the diet order and any special needs like special cups or plates. [NAME] #2 said he is provided with a menu and does not have any therapeutic breakdown to indicate what should be served or not served and how much to serve for the diets including NAS, LCS, Low-fat, and Low- Potassium diets. During an interview on 4/29/25 at 8:34 A.M., The Registered Dietician (RD) said the kitchen is working off the week 2 menu. The RD said the facility takes care of residents with diagnoses that include hypertension, congestive heart failure and diabetes that require specialized nutritional needs to maintain their health. The RD said they have specific therapeutic diets such as NAS, low cholesterol, LCS. The RD said residents do well with liberalized diets, but diet orders are to be provided and followed. The RD said the menus provided to the cooks do not have the breakdown for the therapeutic diets and should be detailed with the breakdown for the individual needs for the therapeutic diets. During an interview on 4/29/25 at 10:05 A.M., the FSD said Residents require many types of diets including different diet textures like puree, ground and different diet portions and therapeutic diets. The FSD said since he began working at the facility last August or September 2024, therapeutic diets were non-existent and this was a concern. The FSD said the cooks use the resident's tray ticket which has the diet order, and aside from the order, the cooks do not know the therapeutic breakdown or know which foods are restricted due to a specialized diet. The FSD said the breakdown needs to be worked on with the RD.

2. Resident #65 was admitted to the facility in January 2025 with diagnoses that include type 2 diabetes mellitus, dementia and failure to thrive. Review of the Minimum Data Set (MDS) dated [DATE], indicated Resident #65 was unable to complete the Brief Interview for Mental Status (BIMS) and the staff assessed his/her to have severe cognitive impairment. The MDS also indicated Resident #65 is dependent on staff for daily care activities including bathing, dressing and eating. Further review of the MDS indicated Resident #65 as being 66 inches in height and weighing 114 pounds and has the nutritional approach of a feeding tube with the percentage of intake by artificial route as 51% or more. During an interview on 4/29/25 at 9:39 A.M., Certified Nursing Assistant (CNA) #3 said Resident #65 used to receive meal trays but he/she no longer eats or takes anything by mouth. During an interview on 4/29/25 at 4:24 P.M., Nurse #7 said when Resident #65 was admitted he/she had an order for puree food and enteral feeding. Nurse #7 said Resident #65 began to refuse to eat and did not eat much of anything, so the Nurse Practitioner gave an order for Resident #65 to be NPO (nothing by mouth). Review of Resident #65's medical record indicated a physician's order, dated 3/13/25, NPO every shift. Review of the Medication Administration Record (MAR) dated March 3/13/25 through 3/31/25 indicated nursing staff documented by a check mark that the Diabetic Snack at Bedtime was administered. Review of the MAR dated 4/1/25 through 4/28/25 indicated nursing staff documented by a check mark that the Diabetic Snack at Bedtime was administered. During an interview on 4/29/25 at 4:28 P.M., Nurse #7 said Resident #65 is NPO and said the order for the diabetic snack at bedtime should have been discontinued when the Resident became NPO. Nurse #7 reviewed the MAR and said the nursing staff checked that the diabetic snack was provided. During an interview on 4/30/25 at 10:31 A.M., the Director of Nursing (DON) said the nurses should be aware of the orders they are signing off as administered and should not have signed that the diabetic snack was administered to Resident #65 who is NPO. Based on observations, record review and interviews, the facility failed to ensure medical records were maintained accurately for Residents (#184, #65, #5, #59 and #79) out of a total sample of 24 residents. Specifically, 1. For Resident #134, the facility failed to accurately document the completion of physician orders; 2. For Resident #65, who had a physician's order dated 3/13/25 to be NPO (nothing by mouth) the facility documented that Resident #65 was adminstered a diabetic snack at bedtime. 3. For Resident #5, the facility documented the Resident received a dietary supplement with all meals when they did not. 4. For Resident #59, the facility failed to follow physician's order for correct oxygen setting and for documenting use of oxgyen. 5. For Resident #79, the facility failed to follow physician's order for correct oxgen setting and for documenting use of oxygen. Findings include: 1. Resident #184 was admitted to the facility in April 2025 with diagnoses including diabetes with polyneuropathy, edema and weakness. Review of Resident #184's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status score of 2 out of a possible 15, which indicated he/she had severe cognitive impairment. The MDS also indicated the Resident is dependent on staff for mobility tasks. On 4/29/25 at 1:07 P.M., Resident #184 was observed out of bed sitting in his/her wheelchair. The Resident was not wearing bilateral compression stockings. On 4/29/25 at 5:15 P.M., Resident #184 was observed lying in bed and was not wearing compression stockings. Review of Resident #184's physician orders indicated the following order: -Apply compression stockings knee length (to) bilateral legs in the morning (for) edema, initiated on 4/9/25. Review of Resident #184's Treatment Administration Record for April 2025 indicated nursing innacurately marked this order as complete on 4/29/25. During an interview on 4/30/25 at 10:58 A.M., the Director of Nursing said she expects all orders to be followed as written by the physician and nurses should not be marking orders as complete if not actually completed. 3. Resident #5 admitted to the facility in August 2010 with diagnoses that included hypertension, diverticulosis of the large intestine, anemia, unspecified convulsions, and major depressive disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/15/25, indicated the Resident was assessed by staff to have severely impaired cognition. The MDS further indicated Resident #95 is dependent for all self-care activities and requires supervision/touching assistance for self-feeding. On 4/29/25 at 8:47 A.M., 8:53 A.M., 9:02 A.M. and 12:27 P.M., and 4/30/25 at 8:46 A.M., 8:52 A.M., and 9:04 A.M., Resident #5 was observed eating his/her meal. There were no nutritional supplements observed on his/her meal tray. Review of physician's order dated 12/12/24 indicated the following: -Ensure Plus, three times a day 237mlb/wmeals [sic]. Review of Resident #5's Medication Administration Record (MAR) indicated that nursing on 4/29/25 for breakfast and lunch and on 4/30/25 at breakfast, the Resident received his/her Ensure Plus with their meal, contrary to direct observation. Review of Resident #5's medical record failed to indicate he/she refused Ensure Plus supplements with his/her meals. During an interview on 4/30/25 at 9:15 A.M., Nurse #2 said supplements do not come up from the kitchen on the Resident's meal tray, it is provided by the nurse. Nurse #2 and the surveyor reviewed the physician's order and Nurse #2 confirmed Resident #5 should be receiving an Ensure Plus supplement with all his/her meals per the physician's order. During an interview on 4/30/25 at 10:58 A.M., the Director of Nursing said she expects all orders to be followed as written by the physician and nurses should not be marking orders as complete if not actually completed. 4. Resident #59 was admitted to the facility in July 2023 with diagnoses including rheumatoid arthritis and dependence on oxygen. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/8/25, indicated that Resident #59 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 2 out of 15. The MDS also indicated that Resident used oxygen. On 4/28/25 at 8:01 A.M., 4/29/25 at 8:02 A.M., and 4/30/25 at 8:23 A.M., the surveyor observed Resident #59 wearing oxygen set at 4 liters. Review of Resident #59's physician order, dated 4/8/25, indicated oxygen at 2 litres as needed via nasal cannula for dyspnea to keep O2 saturation (sats) above 92% every 8 hours as needed for shortness of breath related to dependence on supplemental oxygen. Review of Resident #59's physician progress note, dated 4/8/25, indicated Resident was oxygen dependent. Review of Resident #59's nursing progress notes, dated 4/1/25- 4/29/25, indicated that Resident is on oxygen 2 liters via nasal cannula. Review of Resident #59's Medication Administration Record (MAR) for April 2025, failed to indicate that Resident #59 used oxygen. During an interview on 4/30/25 at 11:27 A.M., Nurse #4 said that oxygen should be set according to the physician's orders and should be documented when used. During an interview on 4/30/25 at 10:58 A.M., the Director of Nursing (DON) said that oxygen should be provided accorded to physician's orders and should be documented on MAR and nurses notes when used. 5. Resident #79 was admitted to the facility in December 2024 with diagnoses that including acute respiratory failure with hypoxia and chronic diastolic heart failure. Review of Resident #79's most recent Minimum Data Set (MDS) Assessment, dated 3/8/25, indicated a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15, indicating that the Resident had moderate cognitive impairment. The MDS further indicated that the Resident used oxygen. On 4/28/25 at 8:29 A.M., 4/29/25 at 8:06 A.M., and 4/30/25 at 8:18 A.M., the surveyor observed Resident #79 wearing oxygen set at 3 liters. Review of Resident #79's physician order, dated 12/7/24, indicated oxygen at 2 liters via nasal cannula as needed for O2 less than 90% on room air as needed every 6 hours as needed for shortness of breath. Review of Resident #79's physician progress note, dated 4/25/25, indicated Resident remains oxygen dependent. Review of Resident #79's nurses progress notes, dated from 4/1/25-4/29/25, indicated Resident continued on 2 liters of oxgyen. Review of Resident #79's MAR for April 2025 failed to indicate that Resident used oxygen. During an interview on 4/30/25 at 11:27 A.M., Nurse #4 said that oxygen should be set according to the physician's orders and should be documented when used. During an interview on 4/30/25 at 10:58 A.M., the Director of Nursing (DON) said that oxygen should be provided accorded to physician's orders and should be documented on MAR and nursing notes when used.

2. Resident #184 was admitted to the facility in April 2025 with diagnoses including diabetes with polyneuropathy, edema and weakness. Review of Resident #184's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status score of 2 out of a possible 15, which indicated he/she had severe cognitive impairment. The MDS also indicated the Resident is dependent on staff for mobility tasks. Review of Resident #184's physician orders indicated the following order: -Apply compression stockings knee length (to) bilateral legs in the morning (for) edema, initiated on 4/9/25. On 4/28/25 at 12:19 P.M., and at 2:00 P.M., Resident #184 was observed out of bed sitting in his/her wheelchair. The Resident was not wearing bilateral compression stockings. On 4/28/25 at 4:38 P.M., Resident #184 was observed lying in bed and was not wearing compression stockings. On 4/29/25 at 1:07 P.M., Resident #184 was observed out of bed sitting in his/her wheelchair. The Resident was not wearing bilateral compression stockings. On 4/29/25 at 5:15 P.M., Resident #184 was observed lying in bed and was not wearing compression stockings. During an interview on 4/30/25 at 10:58 A.M., the Director of Nursing said she expects all orders to be followed as written by the physician. The Director of Nursing said she was unaware Resident #184 had an order to wear compression stocking or that he/she had not been wearing them. Based on record review and interview, the facility failed to ensure that physician's orders were followed for two Residents (#45 and #184) out of a total sample of 24 residents. Specifically, 1. For Resident #45 the facility failed to complete weekly skin checks as indicated in the physician's orders. 2. For Resident #184, the facility failed to implement physician's orders to apply compression stockings. Findings include: 1. Resident #45 was admitted to the facility in October 2023 with diagnoses that include hemiplegia and hemiparesis and anoxic brain injury. Review of Resident #45's most recent Minimum Data Set (MDS) Assessment, dated 2/1/25, indicated that the Resident could not participate in the Brief Interview for Mental Status Exam and was assessed by staff as having severe cognitive impairment. Review of Resident #45's physician's orders indicated the following: -Weekly skin assessment on Mondays, dated 5/6/24. Review of Resident #45's most recent Norton Assessment (an assessment to determine risk for skin breakdown), dated 1/27/25, indicated a risk score of 7 which indicates a high risk for skin breakdown. Review of Resident #45's active skin care plan, updated 1/16/25, indicated: Potential for Further Skin Breakdown to Decreased Mobility & Incontinence. pressure ulcer coccyx area point size 6/13/24 resolved new open area coccyx area 1/13/2025 [sic] Review of the Assessments tab in the Electronic Medical Record indicated that in the past three months, weekly skin checks were completed on 2/3/25, 3/3/25, 3/10/25, 3/31/25 and 4/28/25. Review of the medical record indicated that from 2/1/25 to 4/30/25 nine weekly skin checks were omitted. Review of the two most recent weekly skin checks completed on 3/31/25 and 4/28/35 indicated an intact dressing to the coccyx but failed to indicate any description of the wound. Review of the April Treatment Administration Record indicated that skin checks had been completed as ordered by the physician. During an interview on 4/29/25 at 11:26 A.M. Nurse #1 said that the facility does skin checks weekly, and they should be documented in the medical record. During an interview on 4/30/25 at 7:36 A.M., Nurse #2 said that Resident #45 has a pressure wound that is being treated. During an interview on 4/30/25 at 9:31 A.M., the Director of Nurses said that skin checks are completed weekly. She said the process is to open a skin check assessment in the documents tab and document the completed skin check. She said that she would expect that skin is fully assessed, including removing dressings and documenting the wound underneath. The Director of Nurses said that even if a resident is followed by the consulting wound physician weekly, the nursing staff should still be completing skin checks as ordered.

Based on observations, record review and interviews, the facility failed to provide a call light for one Resident (#11) out of a total sample of 24 residents. Findings include: Resident #11 was admitted to the facility in April 2020 with diagnoses including prostate cancer. Review of Resident #11's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 6 out of a possible 15, which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #11 is dependent on staff for functional daily tasks. During an interview on 4/28/25 at 8:39 A.M., Resident #11 was observed lying in bed without a call light in place. Further observation indicated the Resident did not have a call light at all as the string was missing from the wall. Resident #11 said the call light string often breaks and he/she has not had a call light for some time. Resident #11 said he/she would like to have a call light as this is how he/she can call for help if needed. Throughout all days of survey, Resident #11 was observed without a call light available to him/her. Review of Resident #11's fall care plan last revised 3/19/25, indicated the following intervention: -Call light within resident's reach, answer call light promptly During an interview on 4/30/25 at 7:35 A.M., Nurse #1 said all residents should have a call light available in order to call for assistance if needed. Nurse #1 said the call light strings often break and she was unaware Resident #11's call light was broken. During an interview on 4/30/25 at 10:58 A.M., the Director of Nursing said all residents should have a call light available for use.

Based on record review and interview, the facility failed to ensure Advance Directives (written documents that instruct health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) were accurately documented for one Resident (#45) out of a total sample of 24 residents. Specifically, for Resident #45, the facility failed to ensure that Advanced Directives indicated on the MOLST form (Massachusetts Medical Order for Life-Sustaining Treatment form) were consistently documented in the medical record. Findings include: Review of Resident #45's most recent Minimum Data Set (MDS) Assessment, dated 2/1/25, indicated that the Resident could not participate in the Brief Interview for Mental Status Exam and was assessed by staff as having severe cognitive impairment. Further review of the MDS indicated the Resident's code status was a DNR (Do not resuscitate), DNI (Do not Intubate). Review of the medical record indicated a MOLST form signed and dated 9/21/22 that indicated Do Not Resuscitate (DNR), Intubate and Ventilate, use noninvasive ventilation, transfer to hospital, use dialysis, use artificial nutrition and use artificial hydration. Review of Resident #45's active physician orders indicated the following -Do Not Resuscitate (DNR) (DNI), dated 4/30/24. Review of Resident #45's active advanced directives care plan, dated 5/6/24, indicated, Legal Guardian in place. Follow MOLST---- Resident/family will express changes in code status wishes to appropriate persons, i.e. MD [doctor], social worker, nurse. [sic] During an interview on 4/30/25 at 7:37 A.M., Nurse #2 said that a MOLST form should be signed by the resident or health care proxy. She said the orders should match what is on the MOLST form and be consistently documented in the medical record. During an interview on 4/30/25 at 9:30 A.M., the Director of Nurses said that the physician's order should match the MOLST form and that all aspects of the medical record should have a resident's advanced directives consistently documented.

2. Resident #72 was admitted to the facility in October 2024 and has diagnoses that include but are not limited to unspecified dementia with mood disturbance, Review of Resident #72's comprehensive MDS with an assessment reference date of 10/14/24, indicated Resident #72 scored a 5 out of 15 on the Brief Interview for Mental Status exam indicating he/she as having severe cognitive impairment. The MDS also indicated Resident #72 was dependent on staff for daily care including eating, bathing and dressing. During an observation on 4/28/25 at 9:03 A.M., Resident #72 was observed with a wander guard on his/her right ankle. Resident #72 was pacing in and out of a different resident's room. Resident #72 made eye contact with the surveyor but did not respond to the surveyor's greeting. On 4/28/25 at 12:43 P.M., Resident #72 was observed walking/wandering and going in and out of a resident's room. During an interview on 4/29/25 at 9:39 A.M., Certified Nursing Assistant (CNA) #3 said Resident #72 is dependent on staff for care. CNA #3 said Resident #72 paces and walks in and out of other rooms and he/she has been like that since he/she was admitted . CNA #3 said Resident #72 does not wander as far as he/she used to but will go in and out of rooms near his/her room. During an interview on 4/30/25 at 10:18 A.M., Nurse #5 said Resident #72 is confused and paces back and forth on the unit. Nurse #5 said Resident #72 has paced and wandered since he/she was admitted and now does not wander as far. Review of Resident #72 medical record indicated the following: -A physician's order dated 10/9/24, May have wander guard, check placement every shift (right ankle) every shift. -A physician's order dated 10/8/24, Monitor behavior: pacing wandering, intrusive, every shift for behaviors. -A care plan focus, Resident has inappropriate behaviors: (pacing, wandering intrusive, and roaming) resident tears his/her clothes, dated 10/8/25. -Care plan focus, High Risk for injury r/t (related to) falls due to constantly pacing/wandering. Review of the Treatment Administration Record, dated October 2024 indicated Resident #72 was documented as having pacing, wandering, and intrusive behaviors 7 out of 7 days shifts, 6 out of 7 evening shifts and 4 out of 7-night shifts, preceding the seven days before the MDS Assessment reference date of 10/14/24. Review of the MDS assessment dated [DATE] failed to indicate the behaviors of intrusive wandering or pacing were coded as Resident #72's pattern of behavior. During an interview on 4/30/25 at 11:32 A.M., The Director of Nursing (DON) said the MDS nurse was not available for interview. The DON said she was familiar with Resident #72 and said his/her behaviors of pacing and intrusive wandering improved. The DON said the wandering/pacing should be coded on the MDS if it is occurring and documented during the look back period. 3. Resident #82 was admitted to the facility in August 2021 and had diagnoses that included but not limited to cerebral infarction, dysarthria (difficulty articulating words), and major depressive disorder. Review of the Minimum Data Set assessment, dated 2/4/25, indicated Resident #82 was assessed by staff to have severely impaired cognition and requires supervision/touching to partial/moderate assistance for daily activities. Review of the Minimum Data Set assessment, dated 2/4/25, indicated Discharge-Return Not Anticipated was coded. Further review indicated the MDS was coded as a planned discharge and checked as a discharged to short term general hospital (acute hospital, IPPS). Review of Resident #82's medical record indicated in a Discharge Summary with an effective date 2/4/25 that Resident #82 was discharged home. During an interview on 4/30/25 at 11:29 A.M., the Director of Nursing said she would expect the discharge MDS to be coded correctly and confirmed Resident #82 was discharged home. The MDS Coordinator was not available to interview. Based on observation, record review and interview, the facility failed accurately complete the Minimum Data Set Assessments (MDS) for three Residents (#45, #82 and #72) out of a total of 24 sampled residents. Specifically, 1. For Resident #45 the facility failed to accurately code the presence of a Stage 4 pressure ulcer. 2. For Resident #72 the facility failed to accurately assess his/her behaviors patterns on the comprehensive MDS. 3. For Resident #82 the facility failed to ensure an accurate discharge MDS assessment was completed. Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument User's Manual (RAI Manual) 3.0, Version 1.19.1, dated October 2024 indicated the following: -Clinical standards do not support reverse staging or back staging as a way to document healing, as it does not accurately characterize what is occurring physiologically as the ulcer heals. For example, over time, even though a Stage 4 pressure ulcer has been healing and contracting such that it is less deep, wide, and long, the tissues that were lost (muscle, fat, dermis) will never be replaced with the same type of tissue. Previous standards using reverse staging or back-staging would have permitted identification of such a pressure ulcer as a Stage 3, then a Stage 2, and so on, when it reached a depth consistent with these stages. Clinical standards now would require that this ulcer continue to be documented as a Stage 4 pressure ulcer until it has completely healed unless it becomes unstageable. Nursing homes can document the healing of pressure ulcers using descriptive characteristics of the wound (i.e., depth, width, presence or absence of granulation tissue, etc.) or by using a validated pressure ulcer healing tool. 1. Resident #45 was admitted to the facility in October 2023 with diagnoses that include hemiplegia and hemiparesis, anoxic brain injury and dysphagia. Review of Resident #45's most recent Minimum Data Set (MDS) Assessment, dated 2/1/25, indicated that the Resident could not participate in the Brief Interview for Mental Status Exam and was assessed by staff as having severe cognitive impairment. The MDS further indicated that the Resident had a stage 2 pressure injury. Review of the most recent wound consultant note, dated 4/23/25, indicated that Resident #45 has a stage 4 pressure wound (a wound that extends below the subcutaneous fat into your deep tissues, including muscle, tendons, and ligaments. In more severe cases, they can extend as far down as the cartilage or bone) to the sacrum, full thickness and that the duration of that wound is > (greater than) 1569 days. Review of the medical record failed to indicate that Resident #45 has a stage 2 pressure ulcer (a wound that has opened into the first and some of the second layer of skin). Further Review of the MDS Assessment failed to indicate the presence of a stage 4 pressure ulcer. During an interview on 4/29/25 at 11:26 A.M. Nurse #1 said Resident #45 still has a small open area to his/her sacrum. During an interview on 4/30/25 at 7:36 A.M., Nurse #2 said the area to Resident #45's sacrum is smaller now but still present and getting treatment. Nurse #2 said it started as a stage 4 pressure ulcer. During an interview on 4/30/25 at 9:33 A.M., The Director of Nurses said that Resident #45's wound has improved and is no longer a stage 4 pressure ulcer, and it is now a stage 2 pressure ulcer and that is why it is coded that way on the MDS Assessment. The MDS coordinator was not available to interview.

2. Resident # 16 was admitted to the facility in September 2007 with diagnoses including lack of coordination, hemiplegia, and need for personal assistance. Review of Resident #16's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 13 out of a possible 15, which indicated he/she was cognitively intact. The MDS also indicated Resident #16 required substantial/max assistance with bed mobility tasks. On 4/28/25 at 8:32 A.M.,10:00 A.M., and 12:11 P.M., Resident #16 was observed lying in bed with both heels lying directly on the mattress. Two protective heel booties observed on the Resident's wheelchair next to the bed. On 4/28/25 at 4:39 P.M., Resident #16 was observed lying in bed with both heels lying directly on the mattress. Resident #16 pointed to the protective booties on the wheelchair and said he/she typically wears the booties but no one helped to put them on today. On 4/29/25 at 6:50 A.M., Resident #16 was observed lying in bed with both heels lying directly on the mattress. Two protective heel booties observed on the Resident's wheelchair next to the bed. Review of Resident #16's risk for pressure injury care plan, last revised 4/28/25, indicated the following intervention: -Apply booties while in bed Review of Resident #16's physician orders indicated the following order as of 3/3/25: -May apply booties while resident is in bed. Review of Resident #16's last Norton_assessment dated [DATE], indicated the Resident had a score of 7, indicating the Resident is at very high risk for pressure ulcer development. During an interview on 4/30/25 at 9:30 A.M., Nurse #2 said care plans and orders should be followed as written. During an interview on 4/30/25 at 10:58 A.M., the Director of Nursing said she expects all care plans to be followed as written. The Director of Nursing said Resident #16 is a high risk for pressure ulcer development and should have his/her protective booties on at all times when in bed. Based on observations, record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for two Residents (#31 and #16) out of a total sample of 24 Residents. Specifically, 1. For Resident #1 the facility failed to develop an Activities of Daily Living (ADLs) care plan. 2. For Resident #16, the facility failed to implement a care plan for risk of pressure injury. Findings include: Review of facility policy titled, Care Plans, Comprehensive Person-Centered, not dated, indicated the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. -1. 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. 1. Resident #31 was admitted to the facility in September 2024 with diagnoses that include diabetes, adult failure to thrive, pain and acute embolism and thrombosis of the deep veins in the left lower extremity. Review of Resident #31's most recent Minimum Data Set (MDS) Assessment, dated 3/22/25, indicated a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15, indicating that the Resident is cognitively intact. The MDS further indicates that the Resident ranges from substantial/ maximal assist to dependent for various aspects of Activities of Daily Living (ADLs) and transfers. Review of Resident #31's care plan failed to indicate a plan of care around ADL care needs. Review of Resident #31's physician's orders failed to indicate any orders with instruction on how to transfer the resident or the level of assist required to assist the Resident with ADL care. During an interview on 4/30/25 at 7:32 A.M., Nurse #1 said that the Certified Nurse's Aides (CNAs) do not currently use a paper Kardex (a form explaining to staff the needs of each resident) or care card but they are able to pull it over from the Electronic Medical Record that triggers based on the resident's care plan. During a follow up interview on 4/30/25 at 8:12 A.M. Nurse #1 said that they used to use paper care cards, but they are out of date. She said the Kardex from the Electronic Medical Record (EMR) is the most up to date. She further said there should be an ADL care plan for all residents, so staff know the level of care that the resident requires. Review of Resident #31's current Kardex in the EMR failed to indicate the level of assistance needed for ADLS, transfers and eating. During an interview on 4/30/25 at 8:42 A.M., the Director of Nurses said that the CNA Kardex triggers from the care plan. She said it would primarily be the ADL care plan that would trigger onto the Kardex. The Director of Nurses reviewed Resident #31's care plan and said there is no plan of care in place for ADLs. She said she would expect that all residents will have a plan of care in place for ADL care to indicate the level of assistance that staff need to provide.

Based on interview and record review the facility 1) failed to prevent an accident resulting in a burn for 1 Resident (#29) and 2) failed to follow a fall care plan resulting in injury for 1 Resident (#2) out of a total sample of 19 residents. Findings include: 1. For Resident #29 the facility failed to provide supervision and setup assistance with a meal in accordance with the plan of care, resulting in a burn. Resident #29 was admitted to the facility in July 2018 with diagnoses including ataxia and muscle weakness. Review of Resident #29's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was cognitively intact and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), had no behaviors, did not reject care and requires supervision with setup help for meals. During an interview on 11/15/22 at 1:48 P.M., Resident #29 said he/she was burned by hot tea a few months ago. Resident #29 said he/she has some weakness on his/her left side and when his/her breakfast tray was brought in by staff, the cup containing hot tea was located at the far end of his/her tray. Resident #29 said when he/she reached for the hot tea, his/her hand and arm felt weak and he/she spilled the tea on his/her chest. The Resident said his/her chest was burned because of this. Resident #29 showed the surveyor a discolored area to his/her left chest. Resident #29 said he/she saw the doctor and was given a topical treatment for the burn. During a follow up interview on 11/17/22 at 8:41 A.M., Resident #29 was observed in his/her room eating breakfast unsupervised. Resident #29 said he/she has never gotten assistance with meals and staff have never set up his/her tray. The Resident said staff leave the meal trays in his/her room and he/she needs to prepare the tray him/herself to eat. Resident #29 said after being burned, the staff continue to not set up his/her meal trays and the cup with hot liquids are always at the far end of the tray. Resident #29 said the staff are never present as he/she eats to provide supervision or assistance as needed. Review of Resident #29 ' s medical record indicated he/she has had two incidents of being burned by hot beverages. Review of a nurse's note dated 2/3/22 indicated the following: -At 7:45 P.M., it was reported to the nurse that when giving Resident #29 a cup of coffee it fell on him/her by accident. The nurse assessed the Resident and indicated a slightly red area on Resident #29 ' s right upper thigh. The note indicated the Resident told the nurse the coffee fell on his/her leg as he/she was trying to grab it. -A skin observation tool dated this same day on 2/3/22 indicated a right thigh (front) burn. Review of an Incident Report Form dated 9/27/22 indicated the following: -Resident #29 was eating breakfast in his/her room without staff present. The Resident went to grab a cup of tea and the tea spilled on his/her chest. -A Certified Nursing Assistant (CNA) entered Resident #29 ' s room at 8:45 A.M. as the Resident was screaming from dropping the tea on him/herself. -A nurse went to the room to assess the Resident. Resident #29 reported that he/she spilled tea on his/her chest. Upon assessment the left breast was noted with some redness, no blister noted. Review of Resident #29 ' s medical record indicated the following: *An incident note dated 9/27/22 at 4:41 P.M. which indicated the following: -Resident spilled his/her cup of tea on his/her chest area. -Resident presents alert and oriented x 3. Left chest area slightly red no blister he/she denies any pain or discomfort. -Doctor was in house, she assessed the resident. Treatment/ new orders received: Silvadene cream (a topical antimicrobial cream indicated for use in burns) to chest area until resolved. *A nurse's note dated 9/27/22 10:27 P.M, which indicated Resident #29 ' s left upper chest site was open and pink. No drainage and no blisters noted. *A physician note dated 9/27/22 which indicated Resident #29 had a hot water burn on the anterior chest wall on above his/her breast. The area was red and raised with a broken blister 1 x 2 cm (centimeters) in size. *A physician's order dated 9/27/22 for Silvadene external cream 1% (Silver Sulfadiazine): apply to chest area topically three times a day for burn chest area. *The September and October Medication Administration Record (MAR) indicated Silvadene External Cream 1% (Silver Sulfadiazine) was administered. Review of the August 2022 Licensed Nursing Summary, dated a month before the incident, indicated Resident #29 required continual supervision, ratio of 1:8 for eating. Review of Resident #29 ' s Activity of Daily living care plan indicated the following interventions: *Provide equipment within easy reach, initiated on 11/20/14 *Supervise/ assist with eating 1:8, initiated 12/16/20 Review of Resident #29 ' s care card (a form indicating the level of assistance a resident requires) updated 9/2020 indicated the Resident required supervision with setup, help for eating. During an interview on 11/17/22 at 8:54 A.M., CNA #1 said she is very familiar with Resident #29. She said the Resident does not need any supervision or setup assistance with meals and said the staff will just leave the tray and the Resident will set it up and feed him/herself independently During an interview on 11/17/22 at 10:35 A.M., Nurse #3 said if a Resident is care planned for setup and supervision with meals the staff should set up the meal tray and should be checking on the resident throughout the meal. During an interview on 11/17/22 at 10:42 A.M., the Director of Nursing said the Resident has had two occurrences of accidents with hot liquids. The Director of Nursing said the incident in February occurred when the Resident asked an activities staff person for coffee, and the Resident spilled the hot coffee while reaching for it. The Director of Nursing said that the facility was unsure if the coffee was the correct temperature during this incident and the intervention after this was staff education and was unable to say if any other interventions or care plan updates were initiated. The Director of Nursing said that her understanding of the September burn was that the Resident went to grab the cup of tea and his/her hand was shaking and it spilled on his/her chest. The Director of Nursing said she assessed the Resident's skin that day and the skin was red on his/her chest and the physician came in and put an order in for Silvadene cream. The Director of Nursing reviewed the physician and nursing progress notes which indicated there was an open area and said she was never aware that the burn was documented as being open by the physician or nurse. The Director of Nursing said that if a resident's care plan and care card indicates supervision and setup assistance with meals it should be provided. On 11/16/22 at 12:10 P.M., the surveyor observed lunch on the 2 West resident care unit. The dietary staff brought up a cart with coffee and hot water dispensers in addition to the meal trucks. The staff did not obtain temperatures of the hot beverages prior to serving the meal and beverages to residents. On 11/17/22 at 11:15 A.M., the surveyor asked Cook #1 for the temperature logs of the hot beverages for 9/27/22. Cook #1 said the kitchen does not temp hot beverages before sending them to the units and he thought the nurses took to the temperatures of the hot liquids before serving. During an interview on 11/17/22 at 11:19 A.M., Registered Dietitian #1 said there is no policy for temping hot water or coffee before sending them to the units and said nurses do not obtain temperatures of the hot liquids on the unit prior to serving them. 36876 2. For Resident #2, the facility failed to follow his/her fall care plan, resulting in multiple falls one with significant injury. Review of the Falls and Fall Risk managing policy, undated, indicated: Policy Statement: To identify residents at risk for falls and related factors, thus preventing residents from falling while minimizing complications of injury *The licensed nurse with the input of the interdisciplinary team will identify appropriate interventions to reduce the risk of falls. Resident #2 was admitted to the facility in April 2014 with diagnosis including schizophrenia and hypertension. Review of Resident #2's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated he/she is moderately cognitively impaired and requires assistance with bathing, dressing and toileting. On 11/16/22 at 11:53 A.M. the surveyor observed Resident #2 walking to the dining room with his/her rolling walker and accompanied by a Certified Nurses Aide (CNA). There was a sign taped to his/her rolling walker indicating, always walk with rolling walker. Review of Resident #2's care plans indicated he/she had 2 active fall care plans: -Resident #2 is at high risk for falls due to psychoactive drug use, unsteady gait, anxiety, and impulsiveness. Revised 10/24/22. Goal: Resident will have no injury due to fall through the next review day. Revised 7/10/22. Interventions: Assist with toileting every 2 hours to ensure safety. Check on resident from time to time to make sure he/she has his/her non-skid socks on at all times. 1/5/2021. Provide hand bell and encourage him/her to use it to call for assistance. 7/16/21. To use call light/or ask staff for assistance with transferring when in bed. Reinforce that the resident uses call light for assistance. 3/6/22 -Resident #2 is at risk for falls due to confusion, impulsiveness, behavioral issues, Revised 3/29/2019: Goal: Resident will be free of falls through the review date: Revised 4/22/22. Interventions: be sure the resident's call light is within reach and encourage resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. 4/3/2018. Encourage resident to use walker for ambulation. 3/29/19. Ensure that the resident is wearing appropriate footwear when ambulating. Have maintenance to strip the floor to prevent slippage when getting out of bed. 3/29/19. Staff to frequently check resident. 3/29/19. Review of Resident #2's falls reports indicated he/she sustained the following falls: *On 1/10/22 at 5:00 P.M., Resident #2 was found sitting on floor of the bathroom. Resident #2 told staff that he/she was reaching for his/her walker and fell . *On 3/6/22 at 7:35 A.M., Resident #2 was found on floor in room of his/her room and said he/she fell while trying to hang up jacket. *On 4/16/22 at 2:30 P.M., Resident #2 was heard calling for help and found on floor of his/her bathroom. Resident #2 said he/she lost his/her balance and fell . *On 4/18/22 at 7:00 P.M., Resident #2 was witnessed falling in his/her room while walking with a cane. *On 7/10/22 at 11:30 A.M., Resident #2 was found on the floor of his/her room with pants down. Resident #2 was unable to report what happened. *On 10/22/22 at approximately 1:09 A.M., Resident #2 fell while getting out of bed. The fall report indicated that Resident #2 sustained a laceration to the back of his/her head and was sent to the hospital for further evaluation. Review of the hospital paperwork indicated that Resident #2 had a CT scan which indicated he/she had sustained a small subarachnoid hemorrhage (bleeding around the brain) and mild traumatic brain injury. The hospital recommended Resident #2 follow up with a concussion clinic. During observations of Resident #2's room on 11/16/22 at 10:50 A.M. there were no non-skid strips on either side of Resident #2's bed as indicated in his/her fall care plan. Review of Resident #2's clinical record indicated that he/she had been residing in his/her current room since December 2020. During an interview with Nurse #5 on 11/16/22 at 10:56 A.M., she said that she did not think there currently are, or have ever been non-skid strips in Resident #2's room. During an interviews with Maintenance Worker #1 on 11/16/22 at 10:59 A.M., and 1:37 P.M., he said that maintenance staff is asked by nursing to put down non-skid strips in Resident rooms but he could not recall ever being asked to do so in Resident #2's room. He said that he was able to connect with the Maintenance Director who was currently out of the building and verified that maintenance staff has never put down non-skid strips in Resident #2's room.

Based on records reviews and interviews, for three of three nursing units (1 West, 2 East and 2 West), the Facility failed to ensure they maintained sufficient nursing staff levels to provide for and meet resident care needs in accordance with their individualized plans of care when residents, who were continent at baseline, complained of unusually long wait time for staff to respond to call lights that resulted in episodes of incontinence which was upsetting to them and staff reported that due to short staffing they were unable to provide care to all residents on their unit on more than once occasion. Findings include: Review of Facility's monthly Resident Council Minutes, dated from January 2020 through July 2020, indicated that at at all seven of the monthly meetings conducted during the referenced time range, residents shared with facility staff their concerns of low staffing levels, that there were not enough Certified Nurse Aides (CNAs) to assist them with care needs and staff response times to call lights was too long. During an interview on 08/07/20 at 11:15 A.M., the Ombudsman said that had residents had complained to her in the past few weeks of low staffing levels in the facility. The Ombudsman said that there have been times when residents who normally use a bedside commode to maintain continence, but needed staff assistance with transfers, had complained they experienced incontinence episodes because staff were not available to assist them in a timely manner. During an interview on 8/06/20 at 3:25 P.M., Resident #4 (who is alert, oriented, able to make his her needs known, is wheelchair dependent and continent of bowel and bladder), said that on 07/26/20 he/she called for assistance with toileting and that it took staff more than an hour to respond. Resident #4 said he/she suffered an episode of incontinence that day because he/she waited too long for assistance with his/her toileting needs. Resident #4 said he/she was emotionally upset and embarrassed because of this. Resident #4 said there was only one CNA assigned to provide care for the entire unit that day. Resident #4 said he/she complained the DON about the staffing. During an interview on 08/06/20 at 2:35 P.M., CNA #3 said that on 7/26/20 for the 7:00 A.M. to 3:00 P.M. shift, she was the only CNA assigned to work with two Nurses on Unit 2 West, to care for a total of 30 residents. CNA #3 said she tried to provide care to all of the residents, but said it was rushed. CNA #3 said although the nurse helped with meal trays, said she did not get any assistance from another staff member with toileting, transfers and repositioning of residents, even if the resident required staff assist of two. CNA # 3 said she was concerned because she was unable to provide any care to three residents on the unit that day and said she told the DON about her concerns. During an interview on 08/06/20 at 2:40 P.M., CNA #4 said that on 07/26/20 for the 7:00 A.M. to 3:00 P.M. shift, he was the only CNA assigned to work with two Nurses on Unit 2 East to care for a total of 36 residents. CNA #4 said he did not get any assistance from any other staff members. CNA #4 said he unable to get some residents out of bed that day, as required by their plan of care, because he could not do it alone. During an interview on 08/06/20 at 1:30 P.M., CNA #2 said twice in the past six weeks for the 7:00 A.M. to 3:00 P.M. shift he as the only CNA assigned to work with two Nurses on Unit 1 West, to care for a total of 38 residents. CNA #2 said the nurses were only able to provide minimal support passing meal trays. CNA #2 said low staffing levels has negatively impacted the quality of care he provides to residents, because he can not provide assistance to residents with toileting and repositioning needs in a timely manner, especially for those residents that require two staff members assistance during care. During an interview on 08/05/20 at 1:10 P.M., the Director of Nurses (DON) said that the Facility's staffing was low for the 3:00 P.M. to 11:00 P.M. shift, that day. The DON said that the Facility was usually able to fill staffing shortages. Although the DON said the Facility got the shifts with low staffing levels filled, review of the Facility staffing schedules 'as worked' and resident/staff interviews indicated that there continued to be insufficient staffing levels to provide care and adequately meet resident care needs in accordance with residents' individualized plan of care on 16 out of 36 days from 07/01/20 through 08/05/20. Review of the Facility's Unit Staffing Schedules indicated the number of Nurses and Certified Nurse Aides (CNA) needed on each unit daily to meet the needs of the residents was as follows: 7:00 A.M. to 3:00 P.M. shift, staffing schedule indicated 2 Nurses and 4 CNAs, for each unit. 3:00 P.M. to 11:00 P.M. shift, staffing schedule indicated 1 Nurse and 3 CNAs, for each unit. 11:00 P.M. to 7:00 A.M. shift, staffing schedule indicated 1 Nurse and 2 CNAs, for each unit. Review of the Facility resident roster sheets for Unit 1 West indicated there was a total census of 38 residents, of which twelve residents were totally dependent and required the assistance of two ( or more) staff members for care. Review of the Facility resident roster for 2 East indicated there was a total census of 36 residents, of which twelve residents were totally dependent and required the assistance of two (or more) staff members for care. Review of Facility resident roster for 2 West indicated there was a total census of 31 residents, of which seven residents were totally dependent and required the assistance of two (or more) staff members for care. Review of Facility schedules 'as worked' from 07/01/20 through 08/06/20 indicated the following: - 07/01/20 on Unit 2 East for the 11:00 P.M. to 7:00 A.M. shift, there was only one Certified Nurse Aide (CNA) and one Nurse assigned to care for a total of 31 residents. - 07/04/20 on Unit 2 East for the 11:00 P.M. to 7:00 A.M. shift, there was only one CNA and one Nurse assigned to care for a total of 36 residents. - 07/12/20 on Unit 1 West for the 7:00 A.M. to 3:00 P.M. shift, there were only two CNAs and two Nurses assigned to care total of 38 residents; - 07/12/20 on Unit 2 West for the 7:00 A.M. to 3:00 P.M. shift, there were only two CNAs and two Nurses assigned to care for a total of 31 residents. - 07/18/20 on Unit 2 East for the 7:00 A.M. to 3:00 P.M. shift, there were only two CNAs and two Nurses assigned to care for a total of 36 residents. - 07/19/20 on Unit 1 West for the 7:00 A.M. to 3:00 P.M. shift, there were only two CNAs and two Nurses assigned to care for a total of 31 Residents. - 07/24/20 on Unit 2 West for the 7:00 A.M. to 3:00 P.M. shift, there were only three CNAs and one Nurse assigned to care 31 residents. - 07/24/20 on Unit 1 West for the 11:00 P.M. to 7:00 A.M. shift, there was only one CNA and one Nurse assigned to care for a total of 38 residents. - 07/25/20 on Unit 1 West for the 7:00 A.M. to 3:00 P.M. shift, there were only two CNAs and two Nurses assigned to care for 38 residents. - 07/25/20 on Unit 2 East for the 7:00 A.M. to 3:00 P.M. shift, there were only two CNAs and two Nurses assigned to care for a total of 36 residents. - 07/26/20 on Unit 1 West for the 7:00 A.M. to 3:00 P.M. shift, there were only two CNAs and two Nurses assigned to care for 38 residents. - 07/26/20 On Unit 2 East for the 7:00 A.M. to 3:00 P.M. shift, there was only one CNA and two Nurses assigned to care a total of 36 residents. - 07/26/20 On Unit 2 West for the 7:00 A.M. to 3:00 P.M. shift, there was only one CNA and two Nurses assigned to care for a total of 31 residents. - 07/27/20 on Unit 2 West for the 11:00 P.M. to 7:00 A.M. shift, there was only one CNA and one Nurse assigned to care for a total of 31 residents. - 08/01/20 on Unit 1 West for the 7:00 A.M. to 3:00 P.M. shift, there were only two CNAs and two Nurses assigned to care for a total of 38 residents. - 08/02/20 on Unit 1 West for the 7:00 A.M. to 3:00 P.M. shift, there were only two CNAs and two Nurses assigned to care for a total 38 residents. - 08/02/20 on Unit 2 East for the 7:00 A.M. to 3:00 P.M. shift, there were only two CNAs and two Nurses assigned to care for a total of 36 residents. - 08/02/20 on Unit 2 West for the 7:00 A.M. to 3:00 P.M. shift, there were only two CNAs and two Nurses assigned to care for a total of 31 residents. - 08/03/20 on Unit 1 West for the 11:00 P.M. to 7:00 A.M. shift, there was only one CNA and one Nurse assigned to care for 38 residents. - 08/03/20 on Unit 2 East for the 3:00 P.M. to 11:00 P.M. shift, there were only two CNAs and two Nurses assigned to care a total of 36 residents. - 08/03/20 on Unit 2 West for the 3:00 P.M. to 11:00 P.M. shift, there were only two CNAs and two Nurses assigned to care for 31 residents. - 08/03/20 on Unit 2 West for the 11:00 P.M. to 7:00 A.M. shift, there was only one CNA and one Nurse assigned to care for a total of 31 residents. - 08/04/20 on Unit 1 West on the 11:00 P.M. to 7:00 A.M. shift, there was only one CNA and one Nurse assigned to care for a total of 38 residents.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who was cognitively impaired and dependent on staff for all care, the Facility failed to ensure he/she was free from injury, when on 2/10/19 Resident #1 was left seated in a recliner chair beside a radiator for approximately four hours between 10:30 A.M. and 2:30 P.M, and as a result Resident #1 sustained a second-degree burn (a partial thickness burn causing pain, redness, swelling, and blistering) on his/her left arm. Findings include: Resident #1 was admitted to the Facility in (MONTH) 2014, and his/her [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) Assessment, dated 12/19/18, indicated Resident #1 was severely cognitively impaired and require extensive physical assistance from two people for repositioning and transfers. The Plan of Care, dated as reviewed on 1/4/19, indicated Resident #1 required a mechanical lift transfer with assist of two, and required extensive assistance from staff with all activities of daily living (ADL). Nurse Progress Notes, dated 2/10/19, indicated a Family Member approached staff and reported that Resident #1, who was non-verbal, had intact blisters on his/her left elbow. A Nurse Practitioner Progress Note, dated 2/11/19, indicated Resident #1 had a second degree burn on his/her left arm described as a mix of intact fluid filled blisters, flat blisters, blisters with pink base and scant amounts of serous drainage. The Surveyor interviewed the Nurse Practitioner at 1:40 P.M. on 3/12/19. The Nurse Practitioner said although she did not document the size of Resident #1's burn, it extended from his/her mid-lower part of his/her lateral (side) arm to the mid-upper part of his/her lateral arm, approximately six inches in length and with multiple blisters at varying stages. A hand-written statement, signed by Charge Nurse #1, included as part of the Facility's Internal Investigation File, indicated at approximately 2:30 P.M. on 2/10/19, Resident #1's Granddaughter reported Resident #1's left elbow was irritated with intact blisters of unknown origin. The Statement indicated that on investigation it was determined Resident #1 may have been sitting too close to a baseboard radiator where he/she obtained the injury. The written statement indicated that following Resident #1's injury a locked box was placed over the thermostat control in his/her room so that staff could control the room temperature. The Surveyor interviewed the Director of Maintenance at 12:35 P.M. on 3/12/19. The Director said the baseboard radiator in Resident #1's room was installed in 1970 and was covered with a light piece of sheet metal which tended to over-heat if the thermostat control was raised over 72 degrees F, therefore allowing heat to travel up the wall. The Director said on the day of the incident, 2/10/19, the thermostat control was not covered and it was believed that someone, either another resident, staff member or family member, had adjusted the thermostat control to 80 degrees F. Review of the Staffing Schedule, dated 2/10/19 for the 7:00 A.M. to 3:00 P.M. shift indicated Certified Nurse Aides (CNAs)#1, #2 and #3 were scheduled to work on the Unit where Resident #1 resided. The Surveyor interviewed CNA #1 at 11:30 A.M. on 3/12/19. CNA #1 said she was assigned to care for Resident #1 on 2/10/19. CNA #1 said she transferred Resident #1 out of bed and into a recliner chair, with the help of CNA #2 at approximately 10:30 A.M. CNA #1 said she placed Resident #1 next to the wall with the baseboard radiator, to the left of his/her bed. CNA #1 said that while she did go back and check on Resident #1 a few times throughout the day and fed him/her lunch, said she did not change or reposition Resident #1 and did not move his/her recliner chair away from the wall with the base board radiator. The Surveyor interviewed CNA #2 at 12:15 on 3/12/19. CNA 2 said he did not recall helping with Resident #1's care on 2/10/19 and to the best of his recollection he last saw Resident #1 in his/her room around lunch time sitting in a recliner chair beside the wall next to his/her bed. The Surveyor interviewed CNA #3 at 10:45 A.M. on 3/13/19. CNA #3 said she did not help to provide care to Resident #1 on 2/10/19. CNA #1 said at approximately 2:30 P.M. she saw a visitor come out of Resident #1's room and approach the Nurses Station where she said something about blisters on Resident #1's arm. CNA #3 said she and other staff responded and said when she entered Resident #1's she saw Resident #1 sitting in a recliner chair, with his/her arms resting on the rails of the chair, and said the recliner chair was placed right up against the wall. CNA #3 said Resident #1 had what she described as big water bumps on his/her left arm or words to that effect. CNA #1 said she also responded to Resident #1's Family Member's concerns and said when she entered the room, at approximately 2:30 P.M, Resident #1 was still sitting in the same position in his/her recliner chair against the wall where she had placed him/her earlier that morning at approximately 10:30 A.M. CNA #1 said Resident #1 had blisters on his/her left arm. The Surveyor interviewed the Administrator at 10:15 A.M. on 3/12/19. The Administrator said it was determined during the course of the Facility's Investigation that Resident #1 was burnt due to sitting for an extended period of time next to the wall were the electric baseboard radiator was located. The Administrator said the heating system was old and the radiators were covered with a thin metal cover which tended to over heat allowing the wall temperature to increase. On the afternoon of 3/12/19, the Surveyor along with the evening Maintenance Assistant, tested the baseboard radiator temperature and wall temperature in Resident #1's room. - At 4:38 P.M. the Maintenance Assistant set the thermostat control in Resident #1's room to 80 degrees F and temperatures recorded at that time indicated the baseboard radiator metal cover was 74 degrees F and the wall temperature approximately 4 inches above the heater, at the level of Resident #1's arm rest on his/her recliner chair, was 74 degress F. - At 4:47 P.M., the radiator cover temperature was 155.6 degrees F and the wall temperature was 111 degrees F. - At 4:50 P.M.,. the radiator cover temperature was 165.4 degrees F and the wall temperature was 117.1 degress F On the morning of 3/13/19, the Surveyor and the Director of Maintenance tested the baseboard radiator temperature and wall temperature in random resident rooms through out the facility ant it was determined that radiator covers and wall temperatures ranged from 75.5 degrees F to 142.2 degrees F. - At 9:20 A.M., the wall temperature in Resident #1's room was 84 degrees F when the thermostat control was set at 72 degrees F. - At 10:10 A.M. the wall temperature in Resident #1's room was 138.2 degrees F, an increase of 54.2. degrees F, after the thermostat control was set at 80 degrees F.

Based on records reviewed and interviews, for one of five sampled residents (Resident #1), the Facility failed to ensure he/she was free from neglect when on 10/15/18, following a fall, Certified Nurse Aide (CNA) #3 and CNA #4, picked Resident #1 up off the floor and placed him/her back in bed. CNA #3 and CNA #4 did not inform the Nurse on duty of Resident #1's fall. The following day (on 10/16/18), Resident #1 complained of leg pain and his/her right knee was swollen and red, and Resident #1 declined to get out of bed. On 10/17/18, when examined by the Nurse Practitioner for continued complaints of leg pain, Resident #1 was found to have shortening of the right leg, with external rotation of his/her right foot and bulging at his/her right hip (abnormal findings indicating of a possible fracture). Resident #1 was transferred to the Hospital where he/she was diagnosed with [REDACTED]. Findings include: The Facility's Policy titled Abuse Prohibition, dated 5/1/17, indicated Neglect is defined as failure to provide goods and services necessary to avoid physical harm mental anguish or mental illness. The Policy indicated that all incidents of possible abuse or neglect and injuries of unknown etiology must be reported to the Nursing Supervisor who will immediately initiate an investigation. Resident #1 was admitted to the Facility in (MONTH) (YEAR), and his/her [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) Assessment, dated 9/1/18, indicated Resident #1 had mild cognitive impairment, and he/she was non-ambulatory. A Fall Risk Assessment, dated 9/15/18, indicated Resident #1 was identified at high risk for falls. An electronic report, dated 10/23/18, forwarded by the Facility to the Department of Public Health via the Health Care Facility Reporting System (HCFRS), indicated Resident #1 was found on the floor by staff, an X-ray was ordered and Resident #1 was transferred to the emergency room for treatment of [REDACTED]. A Facility Care Centered Follow up Investigation Report, provided to the Surveyor by the Facility during an on-site survey, dated as conducted on 10/17/18, indicated the following: - It was determined that on 10/15/18 Resident #1 was found on the floor and was put back to bed by CNA #3 and CNA #4. CNA #3 and CNA #4 failed to follow the Facility's Protocol for reporting incidents. - A Nurse progress note, dated 10/16/18, indicated Resident #1 complained of right knee pain, his/her knee appeared slightly swollen and warm, the Nurse Practitioner was informed and a portable X-ray was performed with no new significant changes noted. - On 10/17/18 Resident #1 was evaluated by the Nurse Practitioner for continued complaints of leg pain, and was transferred to the Hospital for further evaluation. A Hospital Discharge Summary, dated 10/21/18, indicated Resident #1 underwent surgical repair of a fractured right hip. Hand written statements documented and signed by CNA #3 and CNA #4, dated 10/17/18, indicated that on 10/15/18, when they went to put Resident #1 to bed, they found him/her on the floor laying on his/her right side, and they put him/her back to bed without informing a Nurse. The Surveyor interviewed CNA #3 at 10:15 A.M. on 1/18/19. CNA #3 said that on 1/15/18, she and CNA #4 entered Resident #1's room at approximately 7 :00 P.M. to help him/her get ready for bed. CNA #4 said when they entered the room Resident #1 was laying on the floor. CNA #3 said she stayed with Resident #1 while CNA #4 went to find the Nurse. The Surveyor interviewed CNA #4 at 10:35 A.M. on 1/18/19. CNA #4 said she heard a noise in Resident #1's room and when she and CNA #3 entered the room, they saw Resident #1 laying on the floor beside his/her bed. CNA #4 said she went to find a Nurse, but was unable to do so. CNA #4 said when she went back to the room, Resident #4 was trying to raise him/herself up off the floor by pulling on the bed, and said she and CNA #3 lifted him/her and put him/her back into bed. Both CNA #3 and CNA #4 said they continued to carry on with their assignments and did not tell anyone that Resident #1 had fallen until questioned by management during the Facility's Internal investigation, two days later, on 10/17/18. The Surveyor interviewed Nurse #3 at 4:17 P.M. on 1/17/19 and the Nursing Supervisor at 4:35 P.M. on 1/17/19. Nurse #3 and the Nursing Supervisor said they were on the unit throughout the evening of 10/15/18, and were unaware that Resident #1 had fallen and was put back to bed by CNA #3 and CNA #4. Nurse #3 and the Nursing Supervisor said they did not perform a physical assessment on Resident #1 or notify the Physician because they were not informed of the incident. The Surveyor interviewed Resident #1's roommates, Resident # 2 and Resident #3, together at 2:00 P.M. on 1/11/19. Resident's #2 was admitted to the Facility in (MONTH) 2014, and his/her [DIAGNOSES REDACTED]. A Quarterly MDS Assessment, dated 11/10/18, indicated Resident #2 had moderate cognitive impairment, but did have good recall. Resident #3 was admitted to the Facility in (MONTH) 2012, and his/her [DIAGNOSES REDACTED]. A Quarterly MDS Assessment, dated 11/3/18, indicated he/she was alert and oriented. Both Resident #2 and Resident #3 said they heard a thud and when they turned around they saw Resident #1 laying on the floor. Resident #2 and Resident #3 said Resident #1 can not speak for him/herself and said when staff lifted him/her up off the floor, he/she was crying. Resident #3 said Resident #1 stayed in bed for a couple of days, said he/she groaned and moaned, and any time staff touched him/her, he/she heard Resident #1 cry. The Surveyor interviewed CNA #1 at 9:55 A.M. on 1/17/19. CNA #1 said Resident #1 has difficulty speaking and makes gestures and mumbling sounds. CNA #1 said that on the morning of 10/16/18, he went in to get Resident #1 washed and dressed and out of bed before breakfast, which was Resident #1's normal routine. CNA #1 said as he was washing Resident #1, he/she grimaced as though in pain, and his/her face turned red. CNA #1 said he asked Resident #1 if he/she was in pain and Resident #1 shook his head, yes, and pointed at his/her right leg. CNA #1 said he asked Resident #1 if he/she wanted to get out of bed and Resident #1 shook his/her head, indicating no. CNA #1 said Resident #1 remained in bed throughout the day and evening, and said whenever he/she was turned and repositioned, he/she moaned in pain which was very unusual for him/her. The Surveyor interviewed CNA #2 at 11:00 A.M. on 1/11/19. CNA #2 said he worked the 11:00 P.M. shift on 10/15/18 and on 10/16/18. CNA #2 said Resident #1 moaned and groaned whenever he/she was turned or repositioned and said no-one had reported to him that Resident #1 had fallen. The Surveyor interviewed the Nurse Practitioner at 9:05 A.M. on 1/17/19. The Nurse Practitioner said she got a call from staff on 10/16/18 who reported Resident #1 had fallen and complained of right knee pain. The Nurse Practitioner said she asked staff to get a mobile X-ray. The Nurse Practitioner said the X-ray showed [MEDICAL CONDITION] changes and no fractures were identified of the knee. The Nurse Practitioner said that on the morning of 10/17/18, she went to evaluate Resident #1, at which time he/she was in bed and looked to be in pain. The Nurse Practitioner said when she pulled back the bedclothes, Resident #1 was guarding his/her right leg and shook his/her fist at her not to touch his/her leg. The Nurse Practitioner said Resident #1 had bulging of his/right hip, with shorten and external rotation of his/her right leg, which were obvious signs of a [MEDICAL CONDITION]. The Nurse Practitioner said she asked staff to transfer Resident #1 to the Hospital for further evaluation and treatment. A Hospital Discharge Summary, dated 10/21/18, indicated Resident #1 underwent surgical repair of a fractured right hip.

Based on records reviewed and interviews, for one of five sampled residents (Resident #1), the Facility failed to ensure that staff assessed Resident #1's complaints of right leg pain and failed to implement pain management interventions in response to Resident #1's new/acute complaints of leg pain, following a fall on the evening of 10/15/18. On the morning of 10/17/18, the Nurse Practitioner evaluated Resident #1 at which time he/she was found to have shortening of the right leg, with external rotation of his/her right foot and bulging at his/her right hip. Resident #1 was transferred to the Hospital where he/she underwent surgical repair for a fractured right hip. Findings include: The Facility's Policy titled Pain Management, not dated, indicated nursing staff will assess each individual for pain whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. The Policy also indicated that staff will evaluate how pain is affecting the individual's quality of life including complications following a fall. Resident #1 was admitted to the Facility in (MONTH) (YEAR), and his/her [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) Assessment, dated 9/1/18, indicated Resident #1 had mild cognitive impairment and had no complaints of pain. Resident's #2 was admitted to the Facility in (MONTH) 2014, and his/her [DIAGNOSES REDACTED]. A Quarterly MDS Assessment, dated 11/10/18, indicated Resident #2 had moderate cognitive impairment but did have good recall. Resident #3 was admitted to the Facility in (MONTH) 2012, and his/her [DIAGNOSES REDACTED]. A Quarterly MDS Assessment, dated 11/3/18, indicated he/she was alert and oriented. The Surveyor interviewed Resident #1's roommates, Resident # 2 and Resident #3, together at 2:00 P.M. on 1/11/19. Both Resident #2 and Resident #3 said that on the evening of 10/15/18 they heard a thud and when they turned around they saw Resident #1 laying on the floor. Resident #2 and Resident #3 said Resident #1 can not speak for him/her self and said when staff lifted him/her up off the floor, he/she was crying. Resident #3 said Resident #1 stayed in bed for a couple of days, said he/she groaned and moaned, and said any time staff touched Resident #1, he/she cried. The Surveyor interviewed CNA #1 at 9:55 A.M. on 1/17/19. CNA #1 said Resident #1 has difficulty speaking and makes gestures and mumbling sounds. CNA #1 said that on the morning of 10/16/18, he went in to get Resident #1 washed and dressed and out of bed, before breakfast which was Resident 1's normal routine. CNA #1 said as he was washing Resident #1, he/she grimaced as though in pain, and his/her face turned red. CNA #1 said he asked Resident #1 if he/she was in pain and Resident #1 shook his head, yes, and pointed at his/her right leg. CNA #1 said he asked Resident #1 if he wanted to get out of bed and Resident #1 shook his/her head, indicating no. CNA #1 said he then asked Resident #1 if he/she had fallen and Resident #1 shook his head, yes. CNA #1 said he left Resident #1 in bed and went to find Nurse #2 and reported to her Resident #1 was in pain and had reported he/she had fallen. The Surveyor interviewed Nurse #2 at 12:35 P.M. on 1/11/19. Nurse #2 said CNA #1 told her Resident #1 reported he/she had fallen, did not want to get out of bed and had right leg pain. Nurse #2 said she went into Resident #1's room and he/she was mumbling the word pain and didn't want to get out of bed. Nurse #2 said Resident #1's right knee looked slightly swollen and red. Nurse #2 said she did not examine Resident #1 for any other signs of injury and said she did not give Resident #1 Tylenol for his/her knee pain. Nurse #2 said she called the Nurse Practitioner and got an order for [REDACTED].#2 said she left at 3:30 PM. on 10/16/18, at which time the X-ray had not been performed, and said she asked Nurse #1 who was working a double shift, from 7:00 A.M. to 11:00 P.M., words to the effect, to keep an eye on Resident #1. The Surveyor interviewed Nurse #1 at 11:00 A.M. on 1/11/19. Nurse #1 said Resident #1 remained in bed all day and when she asked him/her were it hurt, Resident #1 pointed at his/her right knee and said, words to the effect, pop, pop pop. CNA #1 said Resident #1 remained in bed throughout the day and evening, and said whenever he/she was turned and repositioned, he/she moaned in pain which was very unusual for him/her. The Surveyor interviewed CNA #2 at 11:00 A.M. on 1/11/19. CNA #2 said he worked the 11:00 P.M. shift on 10/15/18 and on 10/16/18. CNA #2 said Resident #1 moaned and groaned whenever he/she was turned or repositioned and said no-one had reported to him that Resident #1 had fallen. A Nurse Progress Note, dated 10/16/18, documented by Nurse #1, indicated Resident #1 was alert and oriented, he/she denied pain, was afebrile and remained in bed. The next sentence indicated Resident #1 received Tylenol for right knee pain. This is not consistent with statements made by CNA #1, CNA#2, Resident #2 and Resident #3. A Nurse Progress Note, dated 10/17/18, documented by Nurse #1, indicated at approximately 9:00 A.M. Resident #1 was reclined in bed guarding his/her knee, when asked if it hurt he/she shook his/her head and was given Tylenol. The Progress Note indicated Resident #1 was later seen by the Nurse Practitioner and was transferred to the emergency room for further evaluation. There was no documentation to indicate a pre and post pain assessment was completed of Resident #1's complaint of right leg pain. Resident #1's medications orders, renewed on 10/1/18, indicated he/she was prescribed Tylenol (an [MEDICATION NAME] medication) 2 tablets every 6 hours PRN (as needed) for moderate pain. Resident #1's Medication Administration Record [REDACTED]. Nurse #1 said she did not recall assessing Resident #1's pain level and did not recall giving him/her Tylenol. Nurse #1 said it is her practice to always document in the electronic MAR indicated [REDACTED]. Nurse #1 said words to the effect, it would be safe to say that if I did not document in the electronic MAR, then I did not give Resident #1 Tylenol on 10/16/18 or 10/17/18. The Surveyor interviewed the Nurse Practitioner at 9:05 A.M. on 1/17/19. The Nurse Practitioner said she got a call from staff on 10/16/18 who reported Resident #1 had fallen and complained of right knee pain. The Nurse Practitioner said she asked staff to get a mobile X-ray of his/her right knee which she would review during a schedule visit on 10/17/18. The Nurse Practitioner said the X-ray showed [MEDICAL CONDITION] changes and no fractures were identified. The Nurse Practitioner said when she went to evaluate Resident #1, he/she was in bed and looked to be in pain. The Nurse Practitioner said when she pulled back the bedclothes, Resident #1 was guarding his/her right leg and shook his/her fist at her not to touch his/her leg. The Nurse Practitioner said Resident #1 had bulging of his/right hip, with shorten and external rotation of his/her right leg, which were obvious signs of a [MEDICAL CONDITION]. An Ambulance Run Report, dated 10/17/18 and timed at 11:31 A.M., indicated Resident #1's primary [DIAGNOSES REDACTED]. A Hospital Discharge Summary, dated 10/21/18, indicated Resident #1 underwent surgical repair of a fractured right hip.

Based on observation, interview and policy review, the Facility staff failed to 1. provide professional standards of care for infection control and 2. monitor and secure a Foley catheter (a Foley catheter is a thin, sterile tube inserted into the bladder to drain urine from the bladder) to prevent risk of trauma and to prevent urinary tract infections for 2 Residents (#69 and #196-A), out of a total sample of 34 Residents. Findings include: 1. Resident #69 was recently transferred and admitted to the hospital for [MEDICAL CONDITION] with acute kidney injury. Resident #69 was readmitted to the Facility in 10/2018 with a Foley catheter. Review of the undated Facility policy, titled, Foley Catheter Insertion, Male Resident indicated .Tape catheter to top of thigh or lower abdomen. Secure drainage tubing to bottom bed sheet with clip from drainage set. On 10/9/18 at 9:16 A.M. and 12:06 P.M., the Surveyor observed Resident #69 sitting in a chair in his/her room. The Foley catheter bag was lying on the floor behind the chair, uncovered, with a scant (tiny, insufficient, not measurable) amount of hematuria (red blood in the urine). The catheter and tubing were not secured. On 10/10/18 at 9:45 A.M., the Surveyor observed Resident #69 lying in his/her bed with the Foley catheter bag lying uncovered and unsecured on the floor, there was no output observed in the bag. On 10/10/18 at 2:28 P.M., the Surveyor observed Resident #69 sitting in a chair in his/her room. The Foley catheter bag was lying on the floor next to the chair, uncovered and unsecured. There was no output noted in the bag. Review of the nurses notes indicated the following: 10/10/18 at 7:23 A.M. - there was no urine output recorded. 10/10/18 at 12:43 A.M. - Resident #69 holding the Foley catheter, nurse told the resident to let the Foley catheter alone to allow the urine to flow out. Resident #69 told the nurse to leave me alone. 10/9/18 at 10:21 P.M. - Resident #69 complained of discomfort due to the catheter in place trying to remove it. Resident said he/she emptied the Foley catheter bag. Nurse reeducated resident who told her to leave me alone. 10/9/18 at 2:48 P.M. - Resident #69 complained of pain due to the catheter, draining 300 ml of bloody urine, bloody urine reported to the doctor with no new orders. 10/8/18 at 10:20 P.M. Resident #69 complained of discomfort due to the catheter in place, trying to remove it. Resident said he/she emptied the bag. Nurse educated Resident #69 who said I am a doctor myself. (Resident #69 is not a doctor). Review of the Medication Administration Record [REDACTED]. Output was documented as follows: 10/8/18 7-3 = 400 ml 10/8/18 3-11 = Resident emptied 10/8/18 11-7 = no documentation 10/9/18 7-3 = 300 ml 10/9/18 3-11 = Resident emptied 10/9/18 11-7 = no output recorded 10/10/18 7-3 = 100 ml Review of the plan of care for Resident #69 failed to include a plan of care for the Foley catheter and failed to include a plan of care for Resident #69 trying to remove the Foley catheter or that Resident #69 was emptying the output from the bag. During an interview with Certified Nursing Assistant (CNA) #1, on 10/10/18 at 2:28 P.M., she said that she had emptied Resident #69's Foley catheter at approximately 7:30 A.M. and she reported to the nurse that there was only about 100 ml of urine. The nurse told her to check again at the end of the shift. On 10/10/18 at 2:30 P.M., the Surveyor observed Resident #69 with Nurse #1. Nurse #1 picked up the Foley catheter bag off the floor, said there is no output and put it back onto the floor next to the chair. Nurse #2 entered the room and Nurse #1 showed her that the catheter bag had no output and put it back onto the floor next to the chair, Nurse #1 picked the catheter bag up again and placed it back on the floor this time behind the chair. Nurse #2 put her hand on Resident #69's lower abdomen and said, that is hard, you need to call the doctor. During an interview with Nurse #1 on 10/10/18 at 2:30 P.M., she said she was with CNA #1 at 7:30 A.M., and was aware that there was only 100 ml of urine at that time. She said she asked CNA #1 to let her know what the output was at the end of the shift. She was not aware that there was no output on the previous shift. During an interview with the Director of Nurses on 10/11/18 at 4:11 P.M., she said she was unable to locate a Facility policy, but the standard of practice is to notify the doctor if output is less than 30 ml per hour. She said if there was no output on 11-7 or even 100 ml of output, the doctor should have been notified. She also said the catheter bag should be in a privacy bag and should not be on the floor. Review of the emergency room notes indicated that Resident #69 was seen in the emergency roiagnom on [DATE] for a distended (increased in size) bladder. 1500 ml of urine was drained (the normal capacity of a bladder is between 400 - 600 ml). He/She was admitted to the hospital for recurrent acute [MEDICAL CONDITION] due to [MEDICAL CONDITION] and a urine culture consistent with a urinary tract infection. See F726 2. Resident #196-A was admitted to the facility in 9/2018 with [DIAGNOSES REDACTED]. On 10/9/18, at 9:04 A.M., 10/10/18, at 12:32 P.M., and 4:05 P.M., and 10/11/18, at 8:32 A.M., the Surveyor observed Resident (#196-A) lying in bed. The Foley catheter tubing was hanging off the left side of the bed and the catheter tubing was unsecured. The Foley catheter bag was hanging off the bed touching the floor. Review of the Facility policy on 10/11/18, at 11:00 A.M., titled, Foley Catheter Insertion, Male Resident not dated (page 40, step 25) indicated .Tape catheter to top of thigh or lower abdomen. Secure drainage tubing to bottom bed sheet with clip from drainage set. During an interview on 10/10/18, at 12:41 P.M., Nurse #3 said the Foley catheter should be secured to the Resident's leg and the Foley catheter bag should be off of the floor and in a privacy bag. During an interview on 10/11/18, at 8:37 A.M., Nurse #4 said the Foley catheter should be secured to the leg and in a privacy bag.

Based on records reviewed and interviews for one of seven sampled residents (Resident #1), who was severely cognitively impaired and assessed at risk for falls, the Facility failed to ensure adequate supervision was provided when on 1/10/18, Activity Aide #2 left residents unsupervised in the dining room during a scheduled activity program. Resident #1 fell and sustained a fractured left hip which required surgical repair. Findings include: Resident #1's [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment, dated 12/2/17, indicated Resident #1 was severely cognitively impaired and required supervision with transfers and ambulation. A Fall Risk Assessment, dated 12/4/17, indicated Resident #1 was assessed at high risk for falls. A Nurse Progress Note, dated 1/10/17, indicated that at approximately 4:00 P.M. a resident called out to staff alerting them that someone was on the floor in the dining room, and when staff responded they discovered Resident #1 lying on the floor. The Progress Note indicated that on initial assessment Resident #1 was able to move all his/her extremities but when staff tried to assist Resident #1 to a standing position, Resident #1 started to grimace and pointed to his/her left hip. The Progress Note indicated the Nurse Practitioner and Resident #1's Family Member were notified, and Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation. The Progress Note indicated that Resident #1's Family Member called the Facility later that evening and informed staff that Resident #1 had a fractured left hip, that he/she required surgical repair, was being admitted to the Hospital, and scheduled to have surgery the next day. Surveyor #1 interviewed the Director of Nurses (DON) #2 at 2:09 P.M. on 3/12/18. DON #2 said that at the time of Resident #1's fall he/she was in the dining room at a scheduled supervised activity program. DON #2 said it was the Facility's practice that residents are supervised during all activities and that if the assigned Activity Aide needs to the leave the room for any reason, he/she is to telephone another staff member for relief and is not to leave until that person arrives. DON #2 said that at the time of Resident #1's unwitnessed fall on 1/10/18, the assigned Activity Aide (Activity Aide #2) did not call for someone to relieve her, and left residents unsupervised in the dining room. Surveyor #1 interviewed Nurse #8 at 3:31 P.M. on 3/12/18. Nurse #8 said she was in the lobby opposite the min dining room when she heard a resident call out for help saying that someone was on the floor in the dining room. Nurse #8 said when she ran into the dining room, she saw Resident #1 lying on the floor, other residents were in the dining room and said there were no staff present at that time. Surveyor #2 interviewed Activity Aide #2 at 4:00 P.M. on 3/12/18. Activity Aide #2 said that on the afternoon of 1/18/18, she had a total of six residents, including Resident #1, in the dining room watching a movie of television. Activity Aide #2 said she really needed to go to the bathroom and said while she knew she should not have left the residents unsupervised, she did not call for someone to relieve her. Activity Aide #2 said when she returned to the dining room, Resident #1 was lying on the floor and nursing staff were assessing him/her.

Based on record review and staff interview the facility failed to notify the physician and legal guardian at the time of a fall for 1 Resident (#3) in a total sample of 25 Residents. Finding include; Resident #3 was admitted to the facility in 5/1999. [DIAGNOSES REDACTED]. Review of an incident report submitted to the Department of Public Health's Health Care Facility Reporting System on 1/11/17 indicated that Resident #3 had a fall on 1/9/17 at approximately 3:00 P.M. The report indicated that the 7:00 A.M. to 3:00 P.M. nurse (nurse #1) was aware of the fall at the time, but did not report the incident to staff nurses and did not document the fall in the Resident's medical record. The incident report form indicated that Resident #3 had an x-ray on 1/10/17 with a result of a left femur fracture. The facility's Incident/Accident report dated 1/10/17 indicated that the Unit Manager (U.M.) #1 was made aware on 1/10/17 at around 10:00 A.M. of the fall that occurred on 1/9/17 by Certified Nursing Assistants (CNA #1) and CNA #2 (over 19 hours after the fall occurred). On 6/28/17 at 3:37 P.M., during interview with Nurse #1 she stated she was made aware around 3:00 P.M. on 1/9/17 by CNA #1 that Resident #3 was on the floor. Nurse #1 reported that she asked the Resident what happened and he/she said that he/she had rolled out of bed to the floor. The Nurse said that she did assess the Resident's vital signs including blood pressure, temperature, pulse, and that the Resident could move his/her extremities as usual and denied pain. She said she did not document this information. Nurse #1 said she should have initiated an incident report which would have included notifying the physician, completing a falls assessment, pain assessment, updating the care plan and doing 10-15 minute checks, as the fall was unwitnessed. She said that after she left the facility she traveled that night out of the country for the next three and a half weeks, and it was not until she returned that she learned that Resident #3 had fractured his/her left femur. On 6/28/17 at 4:20 P.M., during interview with UM #1, she said she was approached by CNA #1 and was asked if she was aware that Resident #3 fell the day before. UM #1 said that she was not aware and went to Resident #3 to do an assessment and Resident #3 reported to her I fell yesterday, you know and I have pain in my leg. UM#1 said at that time that she notified the physician, who gave orders for a portable x-ray. Review of the facility's incident/accident report dated 1/10/17 indicated that the physician was notified at 10:00 A.M. on 1/10/17, 19 hours after Resident #3 had fallen. In addition, the incident/accident report indicated that the legal guardian's office was notified of the fall at 10:15 A.M., 19 hours after the fall.

Based on record review and interview the facility failed to ensure for 1 sampled Resident (#3), nursing services met standards of quality of care by failing to report and investigate a fall with fracture for 19 hours, resulting in delay in treatment. Findings include: Resident #3 was admitted to the facility in 5/1999. [DIAGNOSES REDACTED]. Review of the significant Minimum Data Set (MDS) with a completion date of 12/31/16, indicated that Resident #3 had a Brief interview of Mental Status score of 13 out of 15 which indicated Resident #3 was cognitively intact. The MDS indicated that Resident #3 required extensive assistance of 2 people for bed mobility, extensive assistance of one person for transfers and dressing, and was totally dependent on staff for bathing. The MDS indicated that Resident #3 required a wheelchair for mobility. Additionally the MDS indicated that Resident #3 received schedule pain medication regimen and was pain free in the previous five days from 12/31/17. Review of the fall risk assessment dated [DATE] indicated a fall score of 16. The falls risk assessment indicated that a total score of 10 or above represents High risk. Review of the facility's policy on Accidents and Incidents indicated that all accidents or incidents involving resident, employees, visitors, vendors etc., occurring on the facility premises shall be investigated and reported to the Administrator. The policy further indicated that the Nurse Supervisor/Charge Nurse and /or the department director or supervisor shall promptly initiate and document the investigation of the accident or incident. The policy indicated that the following data , as applicable, shall be included on the Report of Incident/Accident form: a. The date and time the accident or incident took place b. The nature of the injury/illness ( e.g , bruise, fall, nausea, etc., ); c. The circumstances surrounding the accident or incident; d. Where the accident or incident took place; e. The name(s) of witnesses and their accounts of the accident or incident; f. The injured person's account of the accident or incident; g. The time the injured person's attending physician was notified, as well as the time the physician responded and his or her instructions; h. The date/time the injured person's family was notified and by whom; J The disposition of the injured ( i.e., transferred to the hospital, put to bed, sent home, returned to work, etc.,); k. Any corrective action taken; l. Follow up information m. Other pertinent date as necessary or required; and n. The signature and title of the person completing the report Review of an incident report submitted to the Department of Public Health's Health Care Facility Reporting System on 1/11/17 indicated that Resident #3 had a fall on 1/9/17. The Incident report form indicated that Resident #3 had a fall on 1/9/17 at approximately 3:00 P.M. The report indicated that the 7:00 A.M. to 3:00 P.M. nurse (Nurse #1) was aware of the fall at the time, but did not report the incident to other staff nurses and did not document the fall in the Resident's medical record. The incident report form indicated that Resident #3 had an x-ray on 1/10/17 with a result of a left femur fracture. The facility's Incident/Accident report dated 1/10/17 indicated that the Unit Manager (U.M.) #1 was made aware on 1/10/17 at around 10:00 A.M. of the fall that occurred on 1/9/17 by Certified Nursing Assistants (CNA #1) and CNA #2 (over 19 hours after the fall occurred). Review of the hospital discharge summary dated 1/13/17 indicated that Resident #3 had a non displaced femoral neck fracture and that on 1/11/17 underwent a successful closed reduction percutaneous pinning. Resident #3 was discharged back to the facility on [DATE]. On 6/28/17 at 3:37 P.M., during interview with Nurse #1 she stated she was made aware around 3:00 P.M. on 1/9/17 by CNA #1 that Resident #3 was on the floor. Nurse #1 reported that she asked the Resident what happened and he/she said that he/she had rolled out of bed to the floor. Nurse #1 said that she did assess the Resident's vital signs including blood pressure, temperature, pulse, and that the Resident could move his/her extremities as usual and denied pain. She said she did not document this information. She said the Resident insisted on getting to up off the floor. Nurse #1 said CNA #1 and CNA #2 assisted her to get Resident #3 into bed. Nurse #1 said she should have initiated an incident report which would have included notifying the physician, completing a falls assessment, pain assessment, updating the care plan and doing 10-15 minute checks, as the fall was unwitnessed. She said that after she left the facility she traveled that night out of the country for the next three and a half weeks, and it was not until she returned that she learned that Resident #3 had fractured his/her left femur. During interview with CNA #1 on 6/29/17 at 9:36 A.M., she said she answered a call light in Resident #3's room and found him/her on the floor. She said she could not recall if the bed alarm was sounding or if he/she had a bed alarm in use. CNA #1 said Nurse #1 and CNA #2 came in the room and that Resident #3 was saying get me up, get me up. CNA #1 said that she and Nurse #1 and CNA #2 got Resident #3 back into bed. CNA #1 said she did not report the fall to anyone as as she figured Nurse #1 would have done an incident report. CNA #1 said that the next morning CNA #2 was caring for Resident #3 and got a report the Resident had pain. CNA #1 said that she and CNA #2 then told the Unit Manager that Resident #3 had a fall the previous day around shift change (3:00 P.M.) During interview with CNA #2 on 6/29/17 at 10:14 A.M., she said she was in the dining room when a co-worker told her that Resident #3 was on the floor in his/her room. She said she went to the room and Nurse #1 checked him/her out and then she along with CNA #1 and Nurse #1 assisted the Resident off the floor. She said at this point it was time to leave and Nurse #1 stayed behind with Resident #3. CNA #2 said the following morning (1/10/17) she did not receive any report that Resident #3 had a fall. CNA #2 said when she went to Resident #3 and he/she complained of left hip pain and she became worried. CNA #2 said she went to CNA #1 and together they went to the Unit Manager to report that Resident #3 had a fall the previous day. On 7/5/17 at 4:39 P.M., during interview via phone with Nurse #2 he said he was the 3:00 P.M. through 11:00 P.M. nurse that cared for Resident #3 on 1/9/17. He said he did not get any report from the previous shift nurse that Resident #3 had a fall. He said that he gave Resident #3 his/her evening medications and did not notice or have any suspicion that Resident #3 had any condition change. Review of a the nurses progress note, dated 1/10/17 with a time of 0628 (6:30 A.M.), indicated that Resident #3 slept on and off throughout the night, he/she complained of pain on his/her left leg 4 out of 10 on the pain scale, scheduled [MEDICATION NAME] 5 milligrams given with good effect, fluid encouraged as needed. vital signs; blood pressure 141/78, pulse 93, oxygen saturation 98 percent, temperature 98.8. Safety precautions maintained, no fall. During interview on 6/29/17 at 9:07 A.M., via telephone, with Nurse #3, who had written the above nurses progress note, said she worked on the 11:00 P.M. -7:00 A.M., shift on 1/9/17-1/10/17. She said that she did not receive any report from the previous shift nurse that Resident #3 had a fall. She said she did take Resident #3's vital signs in the morning and gave him/her scheduled pain medication. She said he/she indicated a pain score of 4 out of 10 which she said was unusual for him/her. She said that Resident #3 said his/her leg hurt but he/she did not say anything about a fall. During interview via telephone with CNA #3 on 6/29/17 at 9:28 P.M., he said that he worked a double shift from 3:00 P.M. through 7:00 A.M., and that he was assigned to care for Resident #3. CNA #3 said he was not given any report from nursing staff that Resident #3 had a fall. CNA #3 said that when he went to assist Resident #3 to get up for supper, Resident #3 complained of pain. CNA said he reported the complaint of pain to Nurse #2 and Nurse #2 said that he was aware and that Resident #3 could stay in bed for supper. CNA #3 said it was unusual for Resident #3 to stay in bed for supper, that he/she typically is up in his/her wheelchair. CNA #3 said he assisted Resident #3 in washing up in bed and Resident #3 remained on his/her back. At 11:30 P.M., CNA #3 said Resident #3 complained of pain. CNA #3 said he reported the pain to the nurse but he was not sure what was done about the pain. CNA #3 said that Resident #3 did not get up out of bed since he came on shift at 3:00 P.M. On 6/28/17 at 4:20 P.M., during interview with UM #1, she said she was approached by CNA #1 and was asked if she was aware that Resident #3 fell the day before. UM #1 said that she was not aware and went to Resident #3 to do an assessment and Resident #3 reported to her I fell yesterday, you know and I have pain in my leg. UM#1 said at that time that she notified the physician, who gave orders for a portable x-ray. During interview with Resident #3 on 6/29/17 at 8:40 A.M., he/she was asked about what he/she recalled about the fall on 1/9/17. He/she said that he/she stepped on the floor and then landed on the floor. He/she said the nurses came and picked me up and put me into bed. The Resident was asked if he/she had any pain and he/she said he/she had hip pain but the nurses knew about it and I went to the hospital (on 1/10/17). Resident #3 said prior to the fall he/she would stay up in his/her wheelchair and watch television. When asked if he/she got up again the night of the fall he/she responded no. Review of the nurses note dated 1/10/17 at 22:34 (10:34 P.M.), indicated the following; Numerous calls received (times 5) from Boston Medical center between a nurse and doctor, inquiring how the resident fell . Writer not able to answer questions. Resident admitted ( to the hospital). (The facility did not have a report or investigation initiated at the time of the fall to give to Boston Medical Center the information they needed on the investigation of Resident's # 3's fall.) During interview with the Director Of Nurses on 6/28/17 at 3:53 P.M. she said the facility did not fail the policy of incident reporting and investigation but that an individual staff person (Nurse #1) did not follow the policy. She said she attempted both by phone and email to reach nurse #1 about Resident #3's fall but was unable to reach her as she was out of the country. For a period of 19 hours Resident #3 did not have any Licensed Nursing Staff or Certified Nursing Aid staff aware that he/she had a fall with a resulting injury. As per facility policy a prompt Incident/Accident report and investigation was not initiated at the time of the occurrence resulting in a delay in Resident #3 in getting necessary care and treatment of [REDACTED].

Based on records reviewed and interviews, for one of five sampled residents (Resident #1), the Facility failed to provide sufficient preparation and orientation for Resident #1's Facility-initiated discharge. On 8/26/16, Resident #1, who resided at the Facility for [AGE] years, was sent to the hospital via a Section 12 (authorization for a temporary, involuntary transfer and possible admission to the hospital), and was medically and psychiatrically cleared to return to the Facility and on 8/26/16, the Facility failed to readmit Resident #1. As of 9/1/16, the Hospital was still trying to make arrangements for Resident #1's long-term care placement. Findings include: Resident #1's Face Sheet indicated he/she was admitted to the Facility in May 1997. The Quarterly Minimum Data Set (MDS) Assessment, completed 7/29/16, indicated Resident #1 was cognitively intact and his/her Health Care Proxy was not invoked. The Facility's Bed Hold Policy, Attachment B: Transfer and Discharge Notice: Resident Rights and Appeals, undated, indicated that the Resident had the right to meet with the Facility Administrator regarding this decision to have the Resident discharged . The policy indicated that the Director of Social Services, or designee, was specifically responsible for the supervision of the Resident's discharge process, and the Resident had the right to appeal the nursing Facility's plan to discharge him/her. The Social Work Progress Note, dated 8/25/16, indicated that Resident #1 was involved in another altercation with another resident (identified as Resident #2) in the dining room on 8/24/16, around dinner time. The Progress Note indicated Resident #1 told Social Worker #1 and a certified nurse aide that Resident #1 called the man (Resident #2) a punk, the man (Resident #2) slapped Resident #1 and Resident #1 threw soda on the man (Resident #2). The Progress Note indicated Resident #1 told Family Member #1 that he/she was being hit and Family Member #1 told another unknown family member who showed up and assaulted two residents and one staff member. The Progress Note indicated Resident #1 pointed out Resident #2 to the unknown family member, and the unknown family member pushed Resident #1 (in a wheelchair) to Resident #2's room, where the fight occurred. Staff attempted to intervene and got hurt in the process. The Progress Note indicated the Social Worker #1 consulted with the Psychiatric Consultant who sent over a Section 12 for Resident #1, and both Resident #1 and Resident #2 were sent to the hospital. The Psychiatric Consultant Note, dated 8/25/16 , indicated Resident #1 arranged for a family member to physically assault another resident that Resident #1 identified to the family member. The note indicated after consulting with Social Worker #1, the Psychiatric Nurse, and the Administrator, the recommendation was for an immediate Section 12, due to the safety of others within the Facility. The note indicated Resident #1 was transferred to a hospital to be medically and psychiatrically assessed. The Hospital Record, dated 8/26/16, indicated Resident #1's behaviors were evaluated by psychiatric staff and there was no indication Resident #1 had behaviors which placed himself/herself or others at risk. There was no indication in Resident #1's clinical record that Resident #1's Behavioral Care Plan, or any Care Plan, was updated to include interventions related to his/her discharge to the hospital on [DATE]. The Surveyor interviewed Family Member #1 at 2:55 P.m. on 8/31/16. Family Member #1 said that, on 8/26/16, the staff told her that Resident #1 was being sent to the hospital, but would not give a reason why. The Surveyor interviewed the Psychiatric Consultant at 4:50 P.M. on 9/1/16. The Psychiatric Consultant said on 8/25/16, Social Worker #1 told her about the incident that occurred on 8/24/16 between Resident #1 and Resident #2. The Psychiatric Consultant said because Resident #1 had the means, plan and follow through, there was a concern that Resident #1 would do this (incident that occurred) again. The Psychiatric consultant said it was an issue of safety for staff and Resident #1 and other residents, and that a Section 12 (authorization for a temporary, involuntary admission to the hospital) was recommended. The Psychiatric Consultant said on 8/26/16, when Social Worker #1 told her that Resident #1 returned to the facility on [DATE] with no psychiatric assessment completed, another Section 12 was ordered and on 8/26/16, Resident #1 was transferred to another hospital to have a psychiatric assessment. The Surveyor interviewed Social Worker #1 at 4:00 P.M. on 9/1/16. Social Worker #1 said the Facility would normally issue a Notice of Intent to Discharge Resident with Less than 30 Days' Notice (Expedited Appeal) form to any resident that was being discharged , which also explained the appeal rights, the reason for discharge, and the location of discharge. Social Worker #1 said, on 8/29/16, the Administrator told her that Resident #1 was not coming back to the Facility. Social Worker #1 said she had not talked to Resident #1 or to Family Member #1 since 8/26/16, when Resident #1 was transferred to the Hospital for a psychiatric evaluation. Social Worker #1 said she had not sent any discharge paperwork to Resident #1 since his/her discharge on 8/26/16. Social Worker #1 said, at the time that Resident #1 went to the hospital on [DATE] for a psychiatric evaluation, it was not the intent to discharge Resident #1 to the hospital. The Surveyor interviewed the Administrator at 6:55 P.M. on 9/1/16. Although the Administrator said the team, which was comprised of the Medical Director and the Psychiatric Consultant and himself, decided not to readmit Resident #1 on 8/26/16 because of his/her behaviors exhibited prior to his/her hospitalization and for the safety of the other residents and staff at the Facility, this was not consistent with the hospital's evaluation. The Surveyor interviewed Resident #1 at 11:25 A.M. on 9/2/16. Resident #1 said that, on 8/26/16, staff told him/her nothing and just that the Facility was sending me to the hospital, or words to that effect. When the Surveyor asked Resident #1 if anyone at the Facility called him/her after 8/26/16, Resident #1 said, No, no one called me, or words to that effect. The Surveyor interviewed Case Manager #1 at 1:55 P.M. on 9/6/16. Case Manager #1 said on 8/29/16, she spoke with the Social Worker #1 who said the Facility would not readmit Resident #1, even though Resident #1 was medically cleared to return to the Facility and did not meet the criteria for a psychiatric in-patient admission. Case Manager #1 said Social Worker #1 gave her some names of Facilities to try and refer Resident #1 to but at this point, she had yet to find another Facility for Resident #1 to transfer to, after calling over 20 places. Review of Resident #1's clinical record indicated the Facility failed to provide sufficient preparation and orientation to Resident #1 in order to ensure a safe and orderly discharge from the Facility on 8/26/16. A reasonable person would experience psychosocial harm and emotional distress as a result of being displaced from his/her home of [AGE] years.

Based on records reviewed and interviews, for one of five sampled residents (Resident #1), the Facility failed to permit Resident #1 to return to the Facility after a hospitalization for an evaluation. The Hospital's Emergency Department Physician's Documentation, dated 8/26/16, indicated Resident #1 did not require inpatient stabilization. Case Manager #1 said Resident #1 was medically and psychiatrically cleared and was ready to return to the Facility. Although Resident #1 was assessed at the hospital where the Facility transferred Resident #1 for a psychiatric evaluation, and on 8/26/16, Resident #1 was medically and psychiatrically cleared to return to the Facility, the Facility decided to discharge Resident #1 to the hospital on [DATE]. Findings include: Resident #1 was admitted to the Facility in May 1997. Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 was cognitively intact and his/her Health Care Proxy was not invoked. Resident #1's Care Plan for Mood and Behavior, dated 6/25/14, indicated Resident #1 exhibited agitation and combativeness. The Social Work Progress Note, dated 8/25/16, indicated that Resident #1 was involved in another altercation with another resident (identified as Resident #2) in the dining room on 8/24/16, around dinner time. The Progress Note indicated Resident #1 told Social Worker #1 and a certified nurse aide that Resident #1 called the man (Resident #2) a punk, the man (Resident #2) slapped Resident #1 and Resident #1 threw soda on the man (Resident #2). The Progress Note indicated Resident #1 told Family Member #1 that he/she was being hit and Family Member #1 told another unknown family member who showed up and assaulted two residents and one staff member. The Progress Note indicated Resident #1 pointed out Resident #2 to the unknown family member, and the unknown family member pushed Resident #1 (in a wheelchair) to Resident #2's room, where the fight occurred. Staff attempted to intervene and got hurt in the process. The Progress Note indicated the Social Worker #1 consulted with the Psychiatric Consultant who sent over a Section 12 for Resident #1, and both Resident #1 and Resident #2 were sent to the hospital. The Hospital's Emergency Department Physician's Documentation, dated 8/26/16, indicated Resident #1 was seen and evaluated by psychiatry, who felt there were no active psychiatric issues requiring inpatient stabilization, and the referring Facility stated they refused to take Resident #1 back. Resident #1's clinical record indicated the Facility never sent Resident #1 the Notice of Intent to Discharge Resident with less than 30 Days' Notice (Expedited Appeal) form, which would have indicated that the Facility did not intend to readmit Resident #1 following his/her transfer to the hospital on [DATE]. There was no documentation in Resident #1's clinical record to support that Resident #1's needs were not met in the Facility,or that Resident #1's Care Plan was updated. The Surveyor interviewed Social Worker #1 at 4:00 P.M. on 9/1/16. Social Worker #1 said if a resident did not want to be discharged , then they (Facility) would issue the resident a Notice of Intent to Discharge with less than 30 Days' Notice Expedited Appeal form (which included the location and reason for discharge) and we (Facility) would explain the appeal process to the resident. Social Worker #1 said she had not talked to, and did not send any discharge paperwork to, Resident #1 or to Family Member #1 since Resident #1 was discharged to the hospital on [DATE]. Social Worker #1 said, at the time that Resident #1 went to the hospital on [DATE] for a psychiatric evaluation, it was not the intent to discharge Resident #1 to the hospital. The Surveyor interviewed the Administrator at 6:55 P.M. on 9/1/16. Although the Administrator said the team, which was comprised of the Medical Director and the Psychiatric Consultant and himself, decided not to readmit Resident #1 because of his/her behaviors exhibited prior to his/her hospitalization and for the safety of the other residents and staff at the Facility, this was not consistent with the hospital's evaluation. The Administrator said Resident #1 was considered discharged from the Facility on 8/26/16. The Surveyor interviewed Case Manager #1 at 1:55 P.M. on 9/6/16. Case Manager #1 said on 8/29/16, she spoke with Social Worker #1 who said the Facility would not take Resident #1 even though Case Manager #1 said she made it clear to Social Worker #1 that Resident #1 was medically and psychiatrically cleared to return to the Facility and did not meet the criteria for a psychiatric in-patient admission. Case Manager #1 said, although Social Worker #1 said Resident #1 exhibited behavioral issues at the Facility, Resident #1 had not exhibited any behavioral issues while at the Hospital from 8/26/16 through 9/6/16, which would indicate he/she was a risk to himself/herself or others. A reasonable person would experience psychosocial harm and emotional distress as a result of being displaced from his/her home of [AGE] years.

Based on records reviewed and interviews, for one of five sampled residents (Resident #1), the Facility failed to promote Resident #1's quality of life in a manner and in an environment that maintained or enhanced each residents dignity and respect when, on 8/26/16, the Facility failed to readmit Resident #1. On 8/26/16, Resident #1 was transferred to the hospital for a psychiatric evaluation, and was medically cleared to return to the Facility, where Resident #1 resided for over [AGE] years. However, the Facility said Resident #1 was discharged to the hospital on [DATE]. Findings include: Resident #1's Face Sheet indicated he/she was admitted to the Facility in May 1997. The Quarterly Minimum Data Set (MDS) Assessment, completed 7/29/16, indicated Resident #1 was cognitively intact. The MDS assessment indicated Resident #1 had a history of [REDACTED]. Resident #1's Behavioral Care Plan, dated 4/22/16, indicated Resident #1 had a psychiatric evaluation requested on 8/24/16, he/she was sent to one hospital on [DATE], under a Section 12 (authorization for a temporary, involuntary hospitalization ), and Resident #1 was sent to another hospital on [DATE], under a Section 12. Resident #1 was discharged to the hospital on [DATE], on the day of the second transfer. However, there was no indication that further interventions were initiated for Resident #1's behavioral care plan prior to his/her discharge from the Facility on 8/26/16. The Facility's Resident-to-Resident Altercation Policy, undated, indicated that the staff would make any necessary changes in the care plan approaches to any or all of the involved individuals and to document in the resident's clinical record all interventions and their effectiveness. The Nurse Progress Note, dated 8/24/16, indicated Resident #1's unknown family member came to the Facility, wheeled Resident #1 to another unit, and the unknown family member beat up Resident #2. Resident #1 said Resident #2 hit him/her and Resident #1 decided to report the incident to Resident #1's unknown family member. The Progress note indicated the Police were called and came to the Facility and interviewed Resident #1, who was difficult to understand. The Social Work Progress Note, dated 8/25/16, indicated that Resident #1 was involved in another altercation with another resident (identified as Resident #2) in the dining room on 8/24/16, around dinner time. The Progress Note indicated Resident #1 told Social Worker #1 and a certified nurse aide that Resident #1 called the man (Resident #2) a punk, the man (Resident #2) slapped Resident #1 and Resident #1 threw soda on the man (Resident #2). The Progress Note indicated Resident #1 told Family Member #1 that he/she was being hit and Family Member #1 told another unknown family member who showed up and assaulted two residents and one staff member. The Progress Note indicated Resident #1 pointed out Resident #2 to the unknown family member, and the unknown family member pushed Resident #1 (in a wheelchair) to Resident #2's room, where the fight occurred. Staff attempted to intervene and got hurt in the process. The Progress Note indicated the Social Worker #1 consulted with the Psychiatric Consultant who sent over a Section 12 for Resident #1, and both Resident #1 and Resident #2 were sent to the hospital. The Nurse Progress Note, dated 8/25/16, indicated Resident #1 continued to threaten to call family to beat up resident, yelled and screamed and stated he/she did not care. The Nurse Progress Note dated 8/26/16, indicated Resident #1 continued to pose a danger to other residents by calling family in to beat up other residents. The Nurse Progress Note indicated proper protocol was not followed by either by Resident #1 or the unknown family member. The Progress note indicated Resident #1 was transferred to another hospital via a section 12 (temporary involuntary admission to a hospital). The Application for an Authorization of Temporary Involuntary hospitalization (Section 12) form, dated 8/25/16, indicated Resident #1 threatened to hurt another resident, and called and organized his/her family member to go the Facility and punch another resident, and a nurse was injured. The Form indicated that Resident #1 had plans, intent and the means to hurt other residents. The Psychiatric Consultant Note, dated 8/25/16 , indicated Resident #1 arranged for a family member to physically assault another resident that Resident #1 identified to the unknown family member. The note indicated after consulting with Social Worker #1, the Psychiatric Nurse, and the Administrator, the recommendation was for an immediate Section 12, due to the safety of others within the Facility. The note indicated Resident #1 was transferred to a hospital to be medically and psychiatrically assessed. The note indicated Resident #1 endangered the safety of staff and residents and, due to Resident #1 behavioral history and recent incident, it was believed that Resident #1's needs could not be met at this Facility. The Social Work Progress Note, dated 8/26/16, indicated that it was at the recommendation from the Psychiatric Consultant that Resident #1 return to the hospital for a psychiatric evaluation, and another Section 12 was provided for Resident #1 to go to a different hospital. Social Worker #1 said at the time of Resident #1's transfer on 8/26/16, the plan was not to discharge Resident #1 as he/she was transferred to another hospital for a psychiatric evaluation. The Application for an Authorization of Temporary Involuntary hospitalization (Section 12) form, dated 8/26/16, indicated Resident #1 had verbal and physical aggressions, threat to harm other resident with plans, intent, means and follow through. The Facility's Plan of Action, dated 8/26/16, indicated the Facility had implemented the following safety precautions that included that the Facility was actively seeking to find alternative placement for this resident (Resident #1) for the safety of other residents. The Hospital's Psychiatry Consultation Note, dated 8/26/16, indicated there was no evidence of acute psychiatric illness or change in Resident #1's mental status at this time, and therefore an inpatient admission is not warranted. The Consultation Note indicated the Administrator stated that the patient and his/her family were a danger, and that he (the Administrator) could not allow Resident #1 to return to the Facility. The Consultation Note indicated that given the time of day, that the Administrator could not offer an alternative placement or respite bed, nor would he agree to take Resident #1 back with PRN (as needed) medication or with family supervision. There was no indication in Resident #1's clinical record that Resident #1's Behavioral Care Plan, or any Care Plan, was updated to include interventions related to his/her discharge to the hospital on [DATE]. There was no indication that Resident #1 was placed on one-to-one supervision or to have supervised visitations. The clinical record indicated Resident #1's family member was barred from entering the Facility. Nurse #1 indicated that after the incident on 8/24/16, Resident #1 went back to bed with no issues and watched television. The staff did not transfer Resident #1 to the hospital until the day after this altercation. The Surveyor interviewed Family Member #1 at 2:55 P.m. on 8/31/16. Family Member #1 said Resident #1 had been at the Facility for [AGE] years and was upset that the Facility was now saying that other's safety were endangered and refused to readmit Resident #1. Family Member #1 said Resident #1 had no place to go. Family Member #1 said the Facility took Resident #1's wheelchair that he/she needed in the hospital and he/she had not been out of bed since 8/26/16. Family Member #1 said this was very upsetting, or words to that effect, to both her and Resident #1. Family Member #1 said Resident #1 was considered homeless and Resident #1 was getting frustrated, or words to that effect. Family Member #1 said she contacted 6 entities so far in order to get assistance with this issue, but at this time she had not found any place for Resident #1 to go. The Surveyor interviewed Nurse #1 at 5:35 P.M. on 9/1/16. Nurse #1 said, on 8/24/16, he observed Resident #1's unknown family member wheel Resident #1 to the other unit where Resident #2 resided. Nurse #1 said after Resident #1's family member left the building on 8/24/16, the police were called and came to the Facility, staff put Resident #1 back to bed, and he/she watched the television for the rest of the shift. The Surveyor interviewed Unit Manager #1 at P.M. on 9/1/16. Unit Manager #1 said Resident #1 had increased agitation on 8/25/16 and 8/26/16 and had verbal outbursts and was unable to be redirected or reasoned with, and Resident #1 did not want to talk to staff and yelled and swore at staff to get out of his/her room, and Resident #1 said I don't care, and I would do it again, or words to that effect. Unit Manager #1 said Psychiatric Consultant recommended Resident #1 go to the hospital for a psychiatric evaluation and, on 8/26/16, Resident #1 was transferred to another hospital via a Section 12 order. The Surveyor interviewed the Psychiatric Consultant at 4:50 P.M. on 9/1/16. The Psychiatric Consultant said on 8/25/16, Social Worker #1 told her about the incident that occurred on 8/24/16 between Resident #1 and Resident #2. The Psychiatric Consultant said because Resident #1 had the means, plan and follow through, there was a concern that Resident #1 would do this again (as to this incident that occurred). The Psychiatric Consultant said another Resident in the room, Resident #3, tried to break up the fight and almost got punched in the face but did not make contact. The Psychiatric consultant said it was an issue of safety for staff and Resident #1 and other residents, and that a Section 12 was recommended. The Psychiatric Consultant said, on 8/26/16, when Social Worker #1 told her that Resident #1 returned to the facility on [DATE] with no psychiatric assessment completed, and because there was a concern that Resident #1 could do it again, that he/she needed a psychiatric evaluation so another Section 12 was ordered and, on 8/26/16, Resident #1 was transferred to another hospital. The Surveyor interviewed Social Worker #1 at 4:00 P.M. on 9/1/16. Social Worker #1 said on 8/25/16, Resident #1 was unable to be redirected and had angry outbursts when she tried to reason with him/her. Social Worker #1 said Resident #1 had the plan, had executed the plan and it was the concern of the larger community and to have Resident #1 be assessed around the safety of Resident #1 and of others. Social Worker #1 said she consulted with the Psychiatric Consultant regarding this incident and Resident #1 was transferred to a hospital on [DATE], for a psychiatric evaluation, and Resident #2 was also sent to the hospital for an evaluation. The Social Worker #1 said, and the hospital discharge summary dated 8/25/16, indicated that Resident #1 returned to the Facility with no new orders. Social Worker #1 said on 8/26/16, she told the Psychiatric Consultant that Resident #1 continued to have angry outbursts, Resident #1 was not able to be redirected, and to see if another hospital could give the staff some direction. Social Worker #1 said it was a safety concern for staff and other residents. The Surveyor interviewed the Administrator at 6:55 P.M. on 9/1/16. Although the Administrator said the team, which was comprised of the Medical Director and the Psychiatric Consultant and himself, decided to not readmit Resident #1 on 8/26/16, because of his/her behaviors exhibited prior to his/her hospitalization and for the safety of the other residents and staff at the Facility, this was not consistent with the hospital's evaluation. The recommendation of two different psychiatric evaluations indicated Resident #1 was stable and cleared to return to the Facility. The Administrator said Resident #1 was considered discharged from the Facility on 8/26/16. The Surveyor interviewed Resident #1 at 11:25 A.M. on 9/2/16. Resident #1 said the Facility just said they were sending me to the hospital, or words to that effect. Resident #1 asked the Surveyor several times about his/her wheelchair and said the Nursing Facility had his/her wheelchair. Resident #1 said his/her my whole check from Social Security was still at the Facility, or words to that effect. Resident #1 said the Hospital cleared me, or words to that effect. Resident #1 said he/she was a Resident at the Facility for seventeen years and that it was his/her home, or words to that effect. The Surveyor interviewed Case Manager #1 at 1:55 P.M. on 9/6/16. Case Manager #1 said that, on 8/29/16, she spoke with Social Worker #1 who said the Facility would not readmit Resident #1 back to the Facility, even though Resident #1 was medically cleared to return and he/she did not meet the criteria for a psychiatric in-patient admission. Case Manager #1 said she called the Facility a few times and made it clear that Resident #1 was medically cleared to return to the Facility and had no medical needs to be at the hospital. Case Manager #1 said she contacted at least 20 Facilities, and had yet to find another Facility for Resident #1 to transfer to. Resident #1's transfer to the hospital, on 8/26/16, for a psychiatric evaluation, was not justification for the Facility, where he/she resided for [AGE] years, to discharge Resident #1 without proper discharge notice, thus rendering Resident #1 homeless. Resident #1 had no assistance with discharge planning from the Facility; Resident #1's wheelchair, clothes, television, and money were at the Facility; Resident #1 did not require the level of assistance of an acute hospital setting, and Resident #1's freedom had been taken away. A reasonable person would experience psychosocial harm and emotional distress as a result of being displaced from his/her home of [AGE] years.

Based on record review, interviews and observation, for 1 of 3 sampled residents (Resident #1), the Facility failed to ensure that Resident #1 was assessed for signs and symptoms of a change in condition, by a licensed nurse, when on [DATE] it was reported that Resident #1 "did not look well", and appeared to have difficulty breathing. Staff did not take vital signs or intervene until Resident #1 was in full respiratory distress. Resident #1 was transferred to the Hospital and died that night from septic shock and end organ damage. Findings include: Review of Resident #1's nurse's note, dated [DATE] (7:00 A.M. to 3:00 P.M.), indicated that Resident #1 was sent to the Hospital due to shortness of breath. Resident #1's nurse's note indicated that his/her temperature was 101.7 Fahrenheit, respirations were 32 per minute, oxygen saturation was 87% on room air and pulse was 125 beats per minute. Review of Resident #1's Hospital discharge report, dated [DATE] to [DATE], indicated that he/she presented to the emergency department unresponsive, tachypneic, [MEDICAL CONDITION], hypotensive, hypoxic, with a fever, altered mental status, not moving extremities spontaneously and not following commands. The note indicated that, at the Facility, staff observed that Resident #1 developed a temperature of 101.7 Fahrenheit, an oxygen saturation of 87% on room air, did not eat well and became less responsive. The note indicated that emergency service personnel arrived to the Facility and determined that Resident #1's systolic blood pressure was 60. The note indicated that Resident #1's white blood count was elevated (19,000), indicating an infectious process. The note indicated that Resident #1 was diagnosed with [REDACTED]. Review of Resident #1's Hospital note, dated [DATE], indicated that Resident #1 passed away at approximately 11:30 P.M. on [DATE]. CNA #1 was interviewed on [DATE] at 8:50 A.M. CNA #1 said that on [DATE], during the morning, she observed that Resident #1 "did not look well", or words to that effect. CNA #1 said that Resident #1 usually responded to comments and questions but that, on this morning, Resident #1 was awake but laid motionless in bed and did not respond to any of her comments. CNA #1 said that she told Resident #1's assigned nurse (Nurse #1) that Resident #1 "did not look good", or words to that effect and at approximately 9:30 A.M. Nurse #1 arrived to the bedroom. CNA #1 said that Resident #1's poor appearance had not changed. CNA #1 said that at approximately 2:25 P.M. she told CNA #2 that Resident #1 did not look well. CNA #1 said that CNA #2 immediately told Nurse #2 that Resident #1 did not look well and Nurse #2 assessed Resident #1. CNA #2 was interviewed on [DATE] at 1:08 P.M. CNA #2 said that she had provided care to Resident #1 for approximately [AGE] years and was familiar with his/her normal appearance and functioning. CNA #2 said that Resident #1 was usually very vocal but that on [DATE] she noticed that Resident #1 was quiet. CNA #2 said that, at approximately 9:35 A.M., Resident #1 was awake but that his/her mouth was wide open, eyes were closed and he/she appeared to have difficulty breathing. CNA #2 said that she called out Resident #1's name, but he/she did not respond. CNA #2 said that this was not Resident #1's normal appearance. CNA #2 said that she told Nurse #1 that Resident #1 did not look well. CNA #2 said that Nurse #1 told her "Don't say that", or words to that effect. CNA #2 said that Nurse #1 expressed that she did not want to hear any bad news. CNA #2 said that Nurse #1 later went into Resident #1's bedroom to change Resident #1's wound dressing and then returned to the nursing desk and told CNA #2 that she (Nurse #1) could watch Resident #1's breathing from the desk. CNA #2 said that, from where Nurse #1 sat at the desk, Nurse #1 was unable to clearly see Resident #1 breathing. The Surveyor observed Resident #1's bedroom and bed and the unit's nursing desk on [DATE] at 9:40 A.M. The Surveyor measured the linear distance from the nursing desk to Resident #1's bed. The distance measured approximately 30 feet. The Surveyor was able to see Resident #1's bed when standing at the nursing desk. CNA #2 said that, sometime after lunch, she entered Resident #1's bedroom and called loudly to Resident #1, but there was no response. CNA #2 said that Resident #1's mouth was wide open, eyes closed, skin pale and breathing was faint. CNA #2 said that she told Nurse #1 that Resident #1 looked like he/she was dying. CNA #2 said that Nurse #1 told CNA #2, again, that she could see Resident #1 breathing from the desk. CNA #2 said that Nurse #1 then told her that Resident #1 "better not die on my shift", or words to that effect. CNA #2 said that, sometime between 2:00 to 2:30 P.M., she asked Nurse #2, who was sitting next to Nurse #1, to see Resident #1. CNA #2 said that Nurse #2 obtained Resident #1's vital signs, determined that Resident #1 had a fever and Nurse #2 administered oxygen to Resident #1. CNA #3 was interviewed on [DATE] at 12:50 P.M. CNA #3 said that she was assigned to feed Resident #1 his/her lunch, but that Resident #1 was unable to eat the meal. CNA #3 said that she told CNA #1 that Resident #1 did not look good and was unable to eat because of her condition. CNA #3 said that she told CNA #1 that when she called Resident #1's name he/she did not respond. CNA #3 said that CNA #1 told her that she had already told Nurse #1 that Resident #1 was not doing well. CNA #3 said that she told Nurse #1 that Resident #1 did not eat lunch. Nurse #2 was interviewed on [DATE] at 8:40 A.M. Nurse #2 said that she overheard Nurse #1 say (while seated at the nursing desk) that she was aware that Resident #1 was not doing well but that things were fine "as long as she doesn't die on me", or words to that effect. Nurse #2 said that, at approximately 2:15 P.M., CNA #2 told her that Resident #1 did not look well and CNA #2 wanted Nurse #2 to see Resident #1. Nurse #2 said that she assessed Resident #1 and determined that his/her lips were blue (cyanotic) and he/she had labored breathing. Nurse #2 said that she did not observe, and was not aware of, Nurse #1 obtaining Resident #1's vital signs during the shift. The Nursing Supervisor was interviewed on [DATE] at 11:20 A.M. Nursing Supervisor said that at approximately 2:00 P.M. CNA #2 told her that Resident #1 was not feeling well. The Nursing Supervisor said that she arrived to the unit and entered Resident #1's bedroom and observed Nurse #1 and Nurse #2 obtaining Resident #1's vital signs and administering oxygen. The Nursing Supervisor said that Resident #1 was in respiratory distress and used abdominal muscles to breathe. The Nursing Supervisor said that Nurse #1 told her that she was able to monitor Resident #1's breathing from the desk. The Nursing Supervisor said that, from the desk, Nurse #1 was not able to accurately monitor Resident #1's breathing and that Nurse #1 should have performed a bedside assessment which should have included temperature, pulse, oxygen saturation, blood pressure and listening to lung sounds. The Nursing Supervisor said that it was impossible for Nurse #1 to obtain this data from the nurses desk. Nurse #1 was interviewed on [DATE] at 10:35 A.M. Nurse #1 said that on [DATE] Resident #1 appeared lethargic but did not exhibit any signs of distress and that, despite the observations made by other staff, Resident #1 did not exhibit subjective signs of respiratory distress at the Facility. Nurse #1 said that she did not recall if she recorded any of Resident #1's vital signs she took during the shift. Nurse #1 said that it was not expected to record normal vital signs in Resident #1's record. The Director of Nurses (DON) was interviewed on [DATE] at 2:30 P.M. The DON said that she expected that after CNA #1 and CNA #2 told Nurse #1 that Resident #1 did not appear well that Nurse #1 would have assessed Resident #1's condition, obtained a full set of vitals, determined if there was a significant change in status and documented the condition and vital signs in Resident #1's chart. The DON said that there was no evidence that Nurse #1 performed any of these responsibilities. The DON said that Nurse #1 could not accurately assess Resident #1's condition in bed from a seat at the nurses desk.