Every finding on record at The Center at Advocate

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had a Legal Guardian in place who informed the Facility that she was to be contacted for everything, the Facility failed to ensure that staff promptly notified his/her Guardian when he/she requested a social leave of absence from the Facility with a visitor.Findings include:Review of the Facility Policy titled, Guardianship, undated, indicated the Facility will recognize and honor the authority of court-appointed guardians while protecting each resident's rights.The Policy indicated that the Facility would obtain and maintain guardianship documentation, verify the guardian's authority, involve the guardian in decision making as appropriate, and document any restrictions affecting the resident's care, visitation, or the ability to leave the Facility.During a telephone interview on 07/29/26 at 5:32 P.M., Resident #1's Legal Guardian said that on 06/20/26 at 9:54 P.M., she received a phone call from a nurse (later identified as the Nurse Supervisor) at the Facility saying Resident #1 had been seen talking to and planned to go out with a friend that afternoon and had not returned.The Guardian said the Facility was aware that he/she had a Legal Guardianship in place and said the Facility never called her to inform her of Resident #1's plans to out or to obtain permission for Resident #1 to go out with any visitors.Resident #1 was admitted to the Facility in May 2026, diagnoses include encephalopathy, alcohol dependance, altered mental status, major depression, and seizure disorder.Review of Resident #1's Decree and Order of Appointment of Guardian for an Incapacitated Person, dated 04/21/26, indicated he/she had a Legal Guardian in place.Review of Resident #1's admission Minimum Data Set (MDS) dated [DATE], indicated that his/her Brief Interview for Mental Status (BIMS) score was a nine (9), indicating his/her cognition was moderately impaired (13-15 indicates cognitively intact, 8-12 indicates moderately impaired cognition, and 0-7 indicates severe cognitive impairment).Review of Resident #1's Medical Record indicated there was no documentation to support that on 6/20/26, Facility staff contacted and notified his/her Legal Guardian prior to Resident #1 leaving the Facility with his/her friend.During a telephone interview on 07/30/26 at 5:03 P.M., Nurse #1 said on 06/20/26, she arrived for her evening (3:00 P.M.-11:00 P.M.) shift and said as she was walking by the nurse's station, she observed Resident #1 talking to the day shift (7:00 A.M.-3:00 P.M.) nurse and said it looked like he/she was leaving with a visitor.Nurse #1 said she thought Resident #1 had signed out for a Social Leave of Absence (SLOA) with a friend and said she thought the day shift staff were aware, so she did not question it. Nurse #1 said she was not aware that Resident #1 required restricted visitations.During an interview on 07/30/26 at 3:09 P.M., the Nurse Supervisor said on 6/20/26, she was unaware Resident #1 had left the building earlier in the day or that Resident #1 had a Legal Guardian in place.The Supervisor said the day shift nurse should have called his/her Guardian for permission before allowing Resident #1 to leave the building with the visitor.During an interview on 07/30/26 at 4:27 P.M., the Director of Nurses (DON) said she was unaware on 6/20/26 that Resident #1 had left the Facility with a visitor.The DON said for any resident that has legal representation in place, the Nurse must call and obtain permission from their legal representative in order for them to leave the Facility and it must be documented in their resident's medical record.

Based on record reviews and interviews for one of three sampled residents (Resident #1), who was to be admitted with visitation restrictions, the Facility failed to ensure he/she was provided care and services that met professional standards of practice regarding his/her admission Process, when nursing staff were unaware of his/her specific need for restricted visitation because the information was not adequately communicated during the admission process, which included nursing not thoroughly reviewing the discharge documentation provided by Hospital.Findings include:Review of the Facility Policy titled admission of a Resident, undated, indicated the admission process in intended to obtain all possible information regarding the resident for the development of the comprehensive plan of care, and to assist the residents in becoming comfortable in the Facility.The Policy indicated the following pre-admission information should be gathered (but not limited to);-History and Physical;-Discharge Summary;-Physician's Orders;-Consultation Notes;-Mental Health Evaluations;-Physician's Progress Notes; and-Nursing Notes.During a telephone interview on 07/29/26 at 5:32 P.M., Resident #1's Legal Guardian said that on 06/20/26 at 9:54 P.M., she received a phone call from a nurse (later identified as the Nurse Supervisor) from the Facility saying the staff could not locate Resident #1 and he/she had been seen talking to and planned to go out with a friend.The Guardian said the Facility was aware that he/she had Legal Guardian in place and said that included in the Hospital Discharge paperwork, the Hospital had made the Facility aware he/she should have been restricted to visitations. Resident #1 was admitted to the Facility in May 2026, diagnoses include encephalopathy, alcohol dependance, altered mental status, major depression, and seizure disorder.Review of Resident #1's Decree and Order of Appointment of Guardian for an Incapacitated Person, dated 04/21/26, indicated he/she had a Legal Guardian in place.Review of Resident #1's admission Minimum Data Set (MDS) dated [DATE], indicated that his/her Brief Interview for Mental Status (BIMS) score was a 09, indicating his/her cognition was moderately impaired (13-15 indicates cognitively intact, 8-12 indicates moderately impaired cognition, and 0-7 indicates severe cognitive impairment).Review of Resident #1's Hospital Discharge Paperwork, dated 05/20/26, indicated he/she had cognitive impairment, lacked the capacity to make decisions, and had a Guardian in place.The Paperwork indicated the assessment and plan for Resident #1's concern for visitations with a certain individual and that he/she was advised that he/she cannot leave Against Medical Advice (AMA).During a telephone interview on 07/30/26 at 11:29 A.M., the admission Nurse Liaison said that she was the one who screened Resident #1 for admission to the facility, was aware of Resident #1's history, the need for him/her to transfer to a Massachusetts Facility, and of his/her newly appointed legal guardian.The Liaison said she believes there was a conversation had between her and the Facility prior to admission regarding Resident #1's circumstances.During an interview on 07/30/26 at 1:03 P.M, the Director of Social Services said she was aware that there was an issue with someone trying to get access to Resident #1, but she does not recall talking about any specific issues or concerns with the Interdisciplinary team (IDT).During a telephone interview on 07/30/26 at 5:03 P.M., Nurse #1 said on 06/20/26, she arrived for her evening shift (3:00 P.M.-11:00 P.M.) and said as she was walking by the nurse's station, she observed Resident #1 talking to the day shift (7:00 A.M. - 3:00 P.M) nurse and said it looked like he/she was leaving with a friend.Nurse #1 said she thought Resident #1 had signed out for a Social Leave of Absence (SLOA) with his/her friend, that staff day shift was aware he/she was going out, and that he/she signed out at the nurse's station. Nurse #1 said she was unaware that Resident #1 was supposed to have restricted visitations.During an interview on 07/28/26 at 11:54 P.M. the Unit Manager said she does not recall ever reading any information regarding Resident #1's visitation restrictions or safety concerns from the Hospital discharge paperwork.During an interview on 07/30/26 at 3:09 P.M., the Nurse Supervisor said she was unaware Resident #1 had left the building on 6/20/26 earlier in the day without signing out, was unaware he/she had a Guardianship in place or that he/she required restricted visitations.During an interview on 07/30/26 at 4:27 P.M., the Director of Nurses (DON) said she did not know Resident #1's had not signed out prior to leaving the building.The DON said it is the Facility's expectation that all sources of information be thoroughly reviewed by all team members to ensure all areas of care are identified and the residents' needs are appropriately met.

Based on records reviewed and interviews for one of three sampled residents (Resident # 1), who upon admission required restricted visitations, the Facility failed to ensure they developed and implemented a comprehensive person-centered care plan with interventions, treatment goals, and outcomes that addressed his/her person-centered safety needs.Findings include:Review of the Facility Policy titled Comprehensive Care Plans, dated a last revised 09/2024, indicated the Facility would develop and implement measurable objectives and timeframes to meet the residents' medical, nursing, mental and psychological needs and all services that are identified in the resident's comprehensive assessment and meet professional standard of quality.The Policy further indicated that the comprehensive care plan will describe at minimum the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Resident #1 was admitted to the Facility in May 2026, diagnoses include encephalopathy, alcohol dependance, altered mental status, major depression, and seizure disorder.Review of Resident #1's Decree and Order of Appointment of Guardian for an Incapacitated Person, dated 04/21/26, indicated he/she had a Legal Guardian in place.Review of Resident #1's admission Minimum Data Set (MDS) dated [DATE], indicated that his/her Brief Interview for Mental Status (BIMS) score was a 09, indicating his/her cognition was moderately impaired (13-15 indicates cognitively intact, 8-12 indicates moderately impaired cognition, and 0-7 indicates severe cognitive impairment).Review of Resident #1's Hospital Referral and Discharge Paperwork, dated 12/17/25-05/20/26, indicated he/she had cognitive impairment, lacked the capacity to make decisions, and has a Guardian in place.The Referral indicated the assessment and plan for Resident #1's concern included visitor restrictions and advising the resident that he/she cannot leave Against Medical Advice (AMA).Review of Resident #1's Medical Record from 05/20/26 through 06/20/26, indicated there was no documentation to support a Care Plan identifying visitor restrictions had been developed and implemented that was person-centered to meet his/her safety needs.During an interview on 07/30/26 at 1:03 P.M, the Director of Social Services said she was aware that upon admission that Resident #1, (whose primary residence was in another state) required restricted visitations.The Director said she does not recall talking about the issues with the Interdisciplinary Team (IDT) and said they had not put any measures in place (including a care plan) to make staff aware of his/her potential safety risks.During an interview on 07/30/26 at 4:27 P.M., the Director of Nurses (DON) said she was unaware of the visitor restrictions needed for Resident #1.The DON said it is the Facility's expectation that any resident that has specific needs, that the IDT will develop and implement a comprehensive care plan addressing each resident's specific care needs.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose primary residence was in a different state, and while in the facility required restricted visitations, the Facility failed to ensure he/she was provided an adequate level of staff supervision, when on 6/20/26 Resident # 1 was seen by a staff member standing at the nursing station, with nursing staff in the same area, talking to a visitor, a short time later Resident #1 left the Facility with the visitor for a social leave, without signing out in accordance with to the Facility Policy and he/she chose not to return to the Facility.Findings include: Review of the Facility Policy titled, Resident Sign Out/ Sign in Procedure, undated, indicated residents leaving the facility independently or with family/friends must notify the nurse before departing.The Policy indicated the Licensed Nurse will do the following;-Verify that the resident is medically stable to leave;-Determine if the resident is leaving independently or with a responsible person;-Review any physician's orders or care needs that may affect the resident while off site;-Ensure the Resident completes the sign out/in sheets provided with resident name, date, time out, expected return time, and signature; and-The Nurse will document the resident's departure in the medical record.Resident #1 was admitted to the Facility in May 2026, diagnoses include encephalopathy, alcohol dependance, altered mental status, major depression, and seizure disorder.Review of Resident #1's Decree and Order of Appointment of Guardian for an Incapacitated Person, dated 04/21/26, indicated he/she had a legal guardian in place.Review of Resident #1's admission Minimum Data Set (MDS) dated [DATE], indicated that his/her Brief Interview for Mental Status (BIMS) score was a 09, indicating his/her cognition was moderately impaired (13-15 indicates cognitively intact, 8-12 indicates moderately impaired cognition, and 0-7 indicates severe cognitive impairment).Review of Resident #1's Hospital Discharge Paperwork, dated 05/20/26, indicated he/she had cognitive impairment, lacked the capacity to make decisions, and had a Legal Guardian in place.The Paperwork indicated the assessment and plan for Resident #1's concern included restricted visitations and that he/she was advised he/she cannot leave Against Medical Advice (AMA).During a telephone interview on 08/05/26 at 11:24 A.M., the Hospital SW said that day Resident #1 was discharged to the Facility, she and her co-worker had a conversation with a staff member (exact name unknown), and the staff member asked to have his/her hospital paperwork sent again because what had been received by the facility, had been redacted (sensitive, confidential context within the document was intentionally blocked out).The Hospital SW said the Facility had access to all of Resident #1's paperwork through an electronic medical record portal and said the facility staff members continued to ask for multiple pages of information they could have accessed themselves through the portal.During an interview on 07/30/26 at 1:03 P.M, the Director of Social Services said she was aware that there was an issue with one of Resident #1 potential visitors.The Director said she does not recall reading the Hospital Social Service notes provided to the Facility during the referral process and did not recall the Management team discussing that there were any concerns noted in the Hospital Discharge Paperwork.During a telephone interview on 07/30/26 at 5:03 P.M., Nurse #1 said on 06/20/26, she arrived for her evening shift (3:00 P.M.-11:00 P.M.) and said as she was walking by the nurse's station, she observed Resident #1 talking to the day shift (7:00 A.M. - 3:00 P.M) nurse and said it looked like he/she was leaving with a friend.Nurse #1 said she thought Resident #1 had signed out for a Social Leave of Absence (SLOA) with his/her friend, that staff day shift was aware he/she was going out, and that he/she signed out at the nurse's station, so she did not think anything about it.Nurse #1 said she was unaware that Resident #1 was supposed to have restricted visitations. Nurse #1 said at 8:30 P.M., she went to administer Resident #1's medications and that's when she discovered that he/she had not returned to the Facility. During an interview on 07/28/26 at 11:54 P.M. the Unit Manager said she does not recall ever reading any information regarding Resident #1's visitation restrictions or safety concerns from the Hospital discharge paperwork.During an interview on 07/30/26 at 4:27 P.M., the Director of Nurses (DON) said she does not recall reading Resident #1's discharge paperwork until after being made aware that he/she had let staff know he/she was going out for a Social Leave of Absence (SLOA) on 6/20/26 and had not returned.The DON said the Facility's expectation is to know where all residents are at all times and if a resident intends to go outside of the building at any time, the staff and resident must follow the Facility sign out/in procedures to ensure resident safety.

Based on records reviewed, interviews, and observations for one of three sampled residents (Resident #3) who required Enhanced Barrier Precautions (EBP-an infection control intervention designed to reduce transmission of Multi-Drug-Resistant Organisms (MDRO) in nursing homes) related to wound care needs, the Facility failed to ensure nursing staff were aware of when to use and implement the necessary infection control practices during the provision of care. Findings include:Review of the Facility's Policy titled Enhanced Barrier Precautions (EBP) dated as last revised 09/2024, indicated that EBP's are utilized for the prevention of transmission of multi-drug-resistant organisms (MDRO's) to residents.The Policy further indicated that a physician's order for EBP's will be obtained for residents with any of the following:-Wounds (chronic wounds such as pressure injuries, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers); and/or-Indwelling medical devices (central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO.-PPE for EBP's is only necessary when performing high-contact care activities (dressing, bathing, transferring, providing hygiene, changing linens, briefs, toileting, device care and wound care)Resident #3 was admitted to the Facility in 09/2025, diagnoses include dementia with behaviors, repeated falls, and depression.Review of Resident #3's, admission assessment dated [DATE], indicated that he/she was admitted with two (2) Stage 2 (partial thickness skin loss where the outer layer and part of the underlying dermis is damaged) pressure injuries, one to each of his/her heels.Review of Resident #3's admission Minimum Data Set (MDS) Assessment, dated 09/30/25, indicated he/she had two Stage 2 pressure injuries present on admission.During an interview on 12/31/25 at 1:32 P.M., the Infection Preventionist (IP) said that she was not aware that Resident #3 had two pressure injuries upon admission.The IP said that if a resident is admitted with or develops a pressure injury nursing staff must notify her and initiate EBP's (put a sign at their room door and provide PPE outside of the room) to help minimize the spread of any infection.Review of Resident #3's Physician's Orders, dated 12/19/25, indicated that there was no documentation to support that a Physician's Order had been obtained to maintain EBP's (until after being identified by the Surveyor during the survey).During an observation on 12/19/25 at 9:36 A.M., the Surveyor observed that there was no signage on Resident #3's room outside the doorway to indicate that he/she was on any kind of precautions and there was no Personal Protective Equipment (PPE- gowns, gloves, masks, eye protection) designated to his/her room. During the same observation the Surveyor observed two Certified Nurse Aides (CNA) in Resident #3's room providing direct care for him/her without wearing the appropriate PPE.During an interview on 12/19/25 at 10:05 A.M., CNA #2 said that Resident #3 was not on any precautions that she was aware of, that she had provided Resident #3 personal care in the morning and had not worn PPE other than gloves. During an interview on 12/19/25 at 10:16 A.M., Nurse #4 said that Resident #3 has a pressure injury to his/her left heel that was open and bleeding. Nurse #4 said that he/she should be on EBP's. Nurse #4 said she was not sure why there was no sign for EBP's outside of his/her room.During an interview of 12/19/25 at 1:24 P.M., the Director of Nurses (DON), said she did not know Resident #3 was not placed on EBP's and said he/she should have been secondary to his/her pressure injury, wound care needs.The DON said that it was the Facility's expectation that any resident with a history of an MDRO, indwelling device, and wounds, that they must be placed on EBP's immediately, and also be reported to her and the IP to ensure proper infection control procedures are being followed.

Based on records reviewed and interviews for two of three sampled residents (Resident #1 and #3) who received wound care services by either an Out-Patient Clinic or Facility Contracted Provider, the Facility failed to ensure nursing staff provided care and services that met professional standards of quality related to A) notifying the attending physician of recommendations made by their wound care clinicians and B) adequate monitoring and assessment of the residents wounds by nursing to determine if areas were improving or deteriorating. Findings include:Review of the Facility Policy titled Consulting Physician/Practitioners Orders, dated as last revised 09/2024, indicated that the attending physician shall authenticate orders for the care and treatment of assigned residents.The Policy further indicated that consulting physician/practitioner orders are those orders provided to the facility by a physician/practitioner other than the residents' attending physician who is acting on behalf of the attending physician, including a Wound Clinic Physician or Nurse Practitioner, clinical nurse specialist, or physician's assistant to the Wound Physician. Review of the Facility Policy titled Pressure Injury Prevention Guidelines, dated as last revised 09/2024, indicated the goal is to prevent formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present. The Policy indicated that the compliance with interventions will be documented in the medical record;-For at-risk residents: treatment or medication administration records.-For residents who have a pressure injury present: treatment or medication administration records; weekly wound summary and charting.The Policy further indicated that the effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound. Considerations for needed modifications include:-Development of a new pressure injury; and-Lack of progression towards healing or changes in wound characteristics.1) Resident #1 was admitted to the Facility in February 2024, diagnoses include schizophrenia, bipolar disorder, diabetes mellitus with neuropathy, and a non-healing left hip surgical wound that developed into a Stage IV (full thickness tissue loss where skin damage extends down to exposed muscle, tendon, or bone) pressure injury.A) During a telephone interview on 12/15/25 at 3:30 P.M., Family Member #1 said that he escorts Resident #1 to his/her outpatient clinic wound appointments monthly. Family Member #1 said that the Facility does not follow the recommendations made by Resident #1's Wound Care Provider and said that he was concerned that by not following the recommendations, that it may be hindering his/her recovery.Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated he/she Stage IV (pressure injury to his/her left hip.Review of Resident #1's Out-Patient Clinic's Wound Care Summary, dated 08/06/25, indicated he/she had a Stage IV pressure injury to his/her left hip and a new wound to his/her left buttocks.The Clinic's Summary further indicated a treatment order for his/her left buttocks wound; -Clean Wound with saline, pat dry 2 times a day and each diaper change; and-Apply Moisture Barrier cream to the wound.Review of Resident #1's Medical Record indicated that there was no documentation to support a treatment order had been obtained from his/her physician for his/her left buttocks wound. Review of Resident #1's Out-Patient Clinic's Wound Care Summary, dated 11/06/25, indicated he/she had a Stage IV pressure injury to his/her left hip (increased in size) and a new Stage IV sacral pressure injury, debrided of a large amount of necrotic (dead) tissue.The Clinic's Summary further indicated that the Wound Physician's treatment recommendations were as follows;-Initiate an external catheter for management of incontinence (if successful, stop using adult briefs);-Place Resident #1 on a full air mattress (not an overlay);-Resident #1 is to be bedbound except for physical therapy (must be returned to bed when physical therapy is done);-Turn to a 30-degree lateral side lying position, use wedge pillows to keep in positions, and do not place wedge or pillow under the wound; and -May sit up in bed on his back for 30 minutes for meals then must be returned to side lying position.Review of Resident #1's Medical Record indicated that there was no documentation to support that nursing staff reviewed the recommendations that had been suggested by the Outpatient Clinic or that they were brought to the attention of Resident #1's Attending Physician for approval or rejection.During an interview on 12/19/25 at 12:51 P.M., the Assistant Director of Nurses said that if a Nurse receives any recommendations from a provider, including an outpatient wound clinic, the recommendations must be reviewed with the resident's physician for either approval or denial immediately.B) Review of Resident #1's readmission Skin Assessment, dated 08/01/25, indicated he/she had an unspecified area to his/her left thigh.However, there was no description of the area, including length, width, depth or stage documented by nursing.Review of Resident #1's Weekly Skin Assessments, dated 09/02/25, 10/07/25, 10/14/25, 10/21/25, 10/28/25, 11/04/25, 11/11/25,11/25/25, 12/02/25,12/10/25, and 12/16/25 indicated that there was no documentation to support nursing staff had measured or monitored the progress toward healing of his/her left hip Stage IV pressure injury and the effectiveness of the treatment.Review of Resident #1's Weekly Skin Assessments, dated 11/04/25, 11/25/25, 12/02/25, 12/10/25, and 12/16/25, indicated that there was no documentation to support nursing staff measured or monitored the progress toward healing of his/her Stage IV pressure injury to his/her sacrum and the effectiveness of the treatment.Review of Resident #1's Nurse Progress Notes and Treatment Administration Records (TAR), dated September 2025 through December of 2025, indicated there was no documentation to support nursing staff were measuring or monitoring the affected areas.During an interview on 12/19/25 at 11:09 A.M., Nurse #1 said that Resident #1 goes out to a wound clinic monthly and said she was not aware if the nursing staff in the Facility were measuring his/her wounds weekly.During a telephone interview on 12/31/25 at 1:32 P.M., the Staff Development Coordinator said that although Resident #1 was being seen by an outpatient wound clinic, the facility nurse who was completing the weekly skin assessment should be measuring Resident #1's pressure injuries on a weekly basis.During a telephone interview on 12/31/25 at 12:18 P.M., the Outpatient Clinic's Wound Nurse said that when Resident #1 comes to his/her monthly appointments, his/her son reports to her that the Facility was not always following the recommendations provided. The Clinic's Wound Nurse said that a clinician at the wound clinic measures Resident #1's wounds each month.2) Resident #3 was admitted to the Facility in 09/2025, diagnoses include dementia with behaviors, repeated falls, and depression.A) Review of Resident #3's In-House Wound Care Specialist Progress Note, dated 12/08/25, indicated that he/she had bilateral unstageable (severe wound where there true depth is hidden by a covering of dead, necrotic tissue making it impossible to see if muscle or bone is exposed until that covering is removed through debridement) pressure injuries to his/her heels.The Wound Note indicated the clinician recommended the implementation of an air mattress to his/her bed to improve pressure redistribution.Review of Resident #3's Medical Record indicated that there was no documentation to support nursing staff informed his/her attending physician of the recommendations made on 12/08/25 by the wound care clinician.During an observation on 12/19/25 at 9:37 A.M., the Surveyor noted that Resident #3 did not have an air mattress on his/her bed.B) Review of Resident #3's admission Assessment, dated 09/23/25, indicated he/she was admitted with two pressure injuries (one to each heel). Both areas had been measured and staged by the admitting nurse.Review of Resident #3's Nurse Progress Note, dated 09/23/25, indicated he/she had a fluid filled blister to his/her right heel and his/her left heel was discolored and scabbed. Review of Resident #3's Nurse Progress Noted, dated 09/24/25, indicated he/she had a left heel deep tissue injury (DTI) with eschar (dead tissue and unstageable).Review of Resident #3's Podiatry Note, dated 10/27/25, indicated he/she had eschars to bilateral heels.Review of Resident #3's Weekly Skin Assessments, dated 09/30/25, 10/07/25, 10/14/25, 10/21/25, 10/28/25, 11/05/25, 11/11/25, and 11/18/25, indicated that there was no documentation to support nursing staff had observed any skin impairments to his/her heels.Review of Resident #3's Weekly Skin Assessments, dated 11/25/25, 12/02/25, 12/10/25, and 12/16/25, indicated that there was no documentation to support nursing measured or monitored the progress and/or deterioration of his/her bilateral heel pressure injuries.Review of Resident #3's Nurse Progress Notes and Treatment Administration Records (TAR), dated September 2025 through December of 2025, indicated there was no documentation to support nursing staff were measuring or monitoring the affected areas.During a telephone interview on 12/31/25 at 1:32 P.M., the Staff Development Coordinator said that any resident that has pressure injury must have measurements completed weekly on the resident's skin assessment form. During an interview on 12/19/25 at 12:51 P.M., the Assistant Director of Nurses said that if a Nurse receives any recommendations from a provider, including an outpatient wound clinic, the recommendations must be reviewed with the resident's physician for either approval or denial immediately.During an interview on 12/19/25 at 1:24 P.M., the Director of Nurses (DON) said she was unaware that Resident's #1 and #3's wounds were not being measured weekly or that their wound care recommendations had not been reviewed by their attending physician's.The DON said that it is the Facility's expectation that all recommendations received by a third-party provider must be reviewed with the resident's attending physician. If the recommendations are approved, nursing will obtain a physician's order timely.

Based on records reviewed and interviews for one of three sampled residents (Resident #2), whose Advanced Directives indicated he/she chose to be a Do Not Resuscitate (DNR, instructs healthcare providers not to do cardiopulmonary resuscitation (CPR) if patients breathing stops or their heart stops beating) the Facility failed to ensure nursing staff honored his/her right to self-determination, when after he/she became unresponsive, was not breathing, was found to be without a pulse, and nursing staff initiated CPR.Findings include:Review of the Facility Policy titled Resident's Rights Regarding Treatment and Advanced Directives, dated as last revised 09/2024, indicated that the Facility will support and facilitate a resident's right to request, refuse, and/or discontinue medical or surgical treatments and to formulate advanced directives.The Policy further indicated that upon admission, should the residents have an advanced directive, copies will be made and placed in the chart and communicated to staff, during the care plan process the Facility will identify, clarify, and review with the resident or legal representative whether they desire to make any changes related to advanced directives.Resident #2 was admitted to the Facility in June 2025 diagnoses include schizoaffective disorder, diabetes mellitus, a history of dysphagia (difficulty swallowing), and Gastrointestinal Reflux Disease (GERD).Review of Resident #2's Hospital Discharge Summaries, dated 06/18/25 and 07/02/25, indicated that his/her code status at time of discharge was Do Not Resuscitate (DNR), Do Not Intubate (DNI-No CPR/No Intubation).Review of Resident #2's Massachusetts Order for Life Sustaining Treatment (MOLST) Form, dated and signed 07/01/25, indicated he/she had chosen to be a DNR/DNI, Do Not Ventilate and Do Not use Non-Invasive Ventilation. Review of Resident #2's History and Physical, dated 07/05/25, indicated he/she was a DNR/DNI and that the physician had discussed the advanced directives with the Health Care Agent (HCA) and Resident.Review of Resident #2's Physician's Orders, dated 07/14/25, indicated his/her Health Care Proxy had been invoked.Review of the report submitted by the Facility via Health Care Facility Reporting System (HCFRS), dated 11/24/25, indicated that Resident #2 had a choking event, received the Heimlich Maneuver successfully, walked back to his/her room with the assistance of two nurses, quickly became unresponsive and CPR was initiated until the MOLST Form had been located and CPR ceased (by EMS) due to being a DNR.During an interview on 12/19/25 at 11:09 A.M., Nurse #1 said that on 11/24/25, Resident #2's had been on her assignment since 7:00 A.M. Nurse #1 said that around shift change (3:15 P.M.) Resident #2 came walking out towards the nurse's station and said she noticed he/she was grabbing at his/her neck and attempting to speak. Nurse #1 said it appeared that he/she was choking and she immediately initiated the Heimlich Maneuver, providing two thrusts, resulting in Resident #2 expelling a good amount of what looked to be chewed food from his/her mouth.Nurse #1 said that Resident #2 was able to and insisted on walking back to his/her room with the help of Nurse #2, Certified Nurse Aide (CNA) #1 and herself. Nurse #1 said that his/her color was grey, he/she began to lay back, and became unresponsive.Nurse #1 said that she left Nurse #2 and CNA #1 in Resident #2's room while she ran to check his/her code status. Nurse #1 said that she looked in Point Click Care (PCC, the Facility's Electronic Medical Record) at his/her face sheet and determined that he/she was a full code. Nurse #1 said she called a Code Blue, returned to Resident #2's room and initiated CPR with Nurse #2 until EMS arrived and took over lifesaving needs.Nurse #1 said that it was not until after the EMS took over that she noticed the Former Director of Nurses (DON) with a pink MOLST Form in her hands informing EMS that Resident #1 was not a Full Code, but a DNR/DNI.During a telephone interview on 12/30/25 at 12:29 A.M., Nurse #2 said that she was the Nurse helping Nurse #1 with administering CPR to Resident #2.Nurse #2 said that when EMS arrived, she had gone to Resident #2's chart and located his/her MOLST Form indicating he/she was a DNR/DNI. Nurse #2 said she immediately handed it to the former DON and that was when EMS announced to stop CPR, that Resident #2 was a DNR/DNI.During an interview on 12/18/25 at 2:02 P.M., Certified Nurse Aide (CNA) #1 said that at 3:15 P.M., Resident #2 walked to the nurse's station from his/her room, and she noted that he/she was unsteady on his/her feet (which had been unusual). CNA #1 said that she, Nurse #1 and Nurse #2 walked Resident #2 back to his/her room and said they were trying to prevent him/her from laying down, but he/she laid down flat and almost instantly became unresponsive.CNA #1 said that one of the nurses said to call a code blue, everyone began arriving with the crash cart, Automatic Electronic Defibrillator, and she said she called Emergency Medical Services (EMS/911).During an interview on 12/19/25 at 8:40 A.M., the Director of Social Services said that she had missed Resident #2's advanced directives and MOLST from upon admission and that Resident #2 had elected to be a DNR/DNI as his/her advanced directive.During an interview on 12/19/25 at 1:24 P.M., the Director of Nurses (DON) said that it is the Facility's expectation that upon the identification of an unresponsive resident in need of emergency services such as CPR, the nurse and/or designee must physically see the resident's MOLST to determine their advanced directives.0n 12/19/25, the Facility presented the Surveyor with a plan of correction with an effective date of 11/21/25 that addressed the area of concern identified in this survey, as follows: A) Resident #2 had been pronounced dead at the Facility on 11/18/25.B) On 11/18/25, the incident was reviewed by the Director of Nurses, Assistant Director of Nurses, Nursing Supervisor, Administrator, and Medical Director via an Ad-[NAME] Quality Assurance and Performance improvement meeting.C) On 11/19/25, licensed staff directly involved with the incident were educated on Emergency access to MOLST Forms and verification of code status during emergencies.D) On 11/19/25, the Administrator, Nurse Managers, and Social Services completed a Facility wide audit of all current residents with a MOLST or Advanced Directives in place, ensuring accuracy of code status, physician's orders, Point Click Care (PCC) Electronic Medical Record (EMR), and prompt scanning of forms into the EMR.E) On 11/19/25, the Staff Development Coordinator (SDC) and DON initiated mandatory education for facility staff (NSG, SS, Physician's) regarding Code Status Verification and Emergency Response by staff. F) Effective 11/19/25, Social Services and Nursing Managers will audit 10 random resident records weekly to review for compliance, they will do this for 4 months, and then for two more months or until 100 percent compliance is met.G) On 11/25/25, the Facility reviewed the POC at their scheduled QAPI meeting.H). The Administrator, the (new) Director of Nurses and/or their designees are responsible for overall compliance.

2. On 6/4/25 at 9:47 A.M., during the medication pass in the 3 [NAME] unit corridor, Nurse #9 left the medication cart to find medications in the medication room. Nurse #9 left the laptop computer screen open. While Nurse #9 was away, several staff and two residents passed the open screen, and they were able to see a resident's name and their Medication Administration Record. Nurse #9 then returned to the medication cart. During an interview on 6/4/25 at 9:51 A.M. Nurse #9 said she had forgotten to close the laptop screen before leaving for the medication room. Nurse #9 said the screen showing resident medical information should be closed when the laptop is unattended. Based on observation and interview the facility failed to maintain confidential resident information (medication administration information) on 2 of 5 resident units (2 [NAME] and 3 West). Findings include: 1. On 6/4/25 at 9:02 A.M., on the 2 [NAME] unit, the surveyor observed an unattended medication cart. The laptop computer on top of the cart was a open and displaying a resident's name and their Medication Administration Record. The laptop screen was visible to residents and staff in the corridor. During an interview on 6/4/25 at 9:04 A.M., Nurse #1 returned to the medication cart. She shut the laptop computer screen, said that it should not be open and should be in a private setting when the cart is unattended. During an interview on 6/5/25 at 10:46 A.M., with the Director of Nursing she said that it is the expectation that the laptop computer screen by covered or in a private setting when it is open to a resident's medical record.

Based on record review and interviews, the facility failed to ensure a comprehensive resident centered care plan was developed for one Resident (#118) out of a total sample of 30 Residents. Specifically, the facility failed to develop an individualized comprehensive resident centered care plan related to the monitoring and care of a pacemaker. Findings include: Review of the facility policy title Use of Pacemaker, undated, indicated the following: -All residents with a pacemaker will be monitored according to standard protocol and plan of care. -All documentation about the pacemaker will be placed in the residents' chart and part of their permanent record. Resident #118 was admitted to the facility in February 2025 with diagnoses including bradycardia and presence of a pacemaker. Review of Resident #118's most recent Minimum Data Set (MDS) assessment, dated 5/15/25, indicated the Resident scored a 5 out of a possible 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment Review of the care plan, dated as initiated 2/26/25, indicated the following: Resident has a pacemaker related to cardiac dysrhythmia and is at risk for activity intolerance, pacemaker failure and altered cardiac output. Intervention: Monitor vital signs as ordered or per facility protocol and record. Notify physician of significant abnormalities from baseline values. Review of Resident #118's current physician orders failed to indicate a pacemaker setting rate, serial number and cardiologist information. During an interview on 6/5/25 at 9:00 A.M., Nurse #4 said the pacemaker setting should be in the physician orders and that the nurses check the Resident's heart rate and would report any abnormal rate. During an interview on 6/5/25 at 9:18 A.M., Nurse #3 said the pacemaker setting should be in the physician orders. The setting would guide the nurses to know how low or high the pacemaker is set to. During an interview on 6/5/25 at 10:47 A.M., the Director of Nursing said the physician orders should have the pacemaker setting and all the details in regards to the pacemaker.

Based on interview and record review the facility failed to ensure grievances were filed and resolved in a timely manner for one Resident (#48) out of a total sample of 30 residents. Findings include: Review of the facility policy titled Resident and Family Grievances, dated as revised 2/2023, indicated the following: -Policy: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. -Definitions: Prompt efforts to resolve include facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance. Resident #48 was admitted to the facility in March 2024 and has diagnoses that include major depressive disorder and mild neurocognitive disorder without behavioral disturbance. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/26/25, indicated that on the Brief Interview for Mental Status exam Resident #48 scored a 7 out of a possible 15, indicating severely impaired cognition. During an interview on 6/3/25 at 9:00 A.M., Resident #48 stated that his/her roommate constantly blares the television at night when he/she is trying to sleep and that even though he/she complains about it to staff, no one does anything. Review of Resident #48's clinical progress notes indicates the following notes written by Nurse #2: -5/7/25: Resident expressing to writer that roommate TV is too loud not able to sleep especially at night, and that would like intervention, its just annoying. Writer requested roommate to try accommodate his/her peer however stated that that doesn't concern him/her whatsoever. (sic) -5/10/25: c/o (complain of) not wanting to be in the same room with roommate because roommate has his/her TV on all night and that makes him/her can't sleep, patient wants to be in a different room and will speak to the Unit Manager. (sic) Review of the facility's grievance log book failed to indicate that a grievance was filed regarding Resident #48's complaint on 5/7/25 or 5/10/25. During an interview on 6/4/25 at 12:22 P.M., with Nurse #2 he said that when Resident #48 complained about the roommates TV blaring at night he took the following action: -he spoke to the roommate; and -he did not file a grievance but rather reported the complaint to the Unit Manager and she took it from there. Nurse #2 said that he thinks that the situation has improved and was not aware that the Resident continued to have concerns regarding the roommates television. The Unit Manager was not available during the survey. During an interview on 6/4/25 at 1:13 P.M., with the Nursing Home Administrator (NHA) she said that anyone can file a grievance and that when they do the facility will try to fix the problem immediately. The NHA said that they will write up both the complaint and the resolution to the grievance on the grievance form. The NHA could not say why a grievance, that included a resolution to Resident #48's ongoing concern, was not completed. The NHA said that if the Resident were offered a room change it would be documented in Resident's medical record.

Based on observation and interview, the facility failed to ensure staff stored all drugs and biologicals in accordance with accepted professional standards of practice. Specifically, the facility failed to properly secure a medication cart on 1 of 5 units (2 West). Findings include: On 6/4/25 at 9:02 A.M., on the 2 [NAME] unit the surveyor observed an unlocked and unattended medication cart. The surveyor was able to open and access the cart. During an interview on 6/4/25 at 9:04 A.M., Nurse #1 returned to her cart. She closed and locked the medication cart and said that the cart should be locked when unattended. During an interview on 6/5/25 at 10:46 A.M., with the Director of Nursing she said that it is the expectation that the medication cart be locked when not attended.

Based on record review, policy review and interview the facility failed to ensure a comprehensive plan of care was developed for Trauma Informed Care for one Resident (#78) out of a total sample of 30 residents. Specifically, for Resident #78, who had a history of trauma, the facility failed to develop a comprehensive trauma care plan, with individualized triggers. Findings Include: Review of the facility policy titled, Trauma Informed Care, undated, indicated the following: Policy Statement -It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Policy Explanation and Compliance Guidelines: -The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized care plans and interventions. -The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the resident's care plan. -The facility will evaluate whether the interventions have been able to mitigate (or reduce) the impact of the identified triggers on the resident that may cause re-traumatization. The resident and/or his or her family or representative will be included in this evaluation to ensure clear and open discussion and better understand if interventions must be modified. -In situations where trauma survivors are reluctant to share their history, the facility will still try and identify triggers which may re-traumatize the resident and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident. Resident #78 admitted to the facility in November 2023 with diagnoses that included Post-Traumatic Stress Disorder (PTSD), vascular dementia, and anxiety. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/25/25, indicated the Resident was assessed by staff to have moderate cognitive impairment. The MDS further indicated Resident #78 has an active diagnosis of PTSD. Review of Resident #78's medical record failed to indicate a plan of care for PTSD with identified triggers. During an interview on 6/5/25 at 8:10 A.M., Nurse #6 said she believed the social workers complete the trauma assessments and develop the PTSD care plans, and she would expect triggers to be identified to better care for the residents. During an interview on 6/5/25 at 8:28 A.M., Unit Manager #1 said the entire team works together to develop the PTSD care plan and she would expect triggers to be identified so we know how to best care for the residents. During an interview on 6/5/25 at 9:35 A.M., the Administrator said the social worker would initiate the trauma informed assessment and psych services would be consulted. The Administrator said it was a team effort, and she would expect a PTSD care plan to be developed with identified triggers. The Social Worker was not availabe for interview.

Based on observations, record reviews and interviews, the facility failed to ensure residents at risk for developing pressure ulcers received necessary treatment and services, consistent with professional standards of practice for two Residents (#2 and #61) out of a total sample of 30 residents. Specifically, the facility failed to follow physician orders for air mattress settings. Findings include: Review of the facility policy titled Use of Support Surfaces, undated, indicated the following: 7. For powered devices, or those requiring air, the licensed nurse will check each shift and prn (as needed) for proper functioning, and/or inflation. 1. Resident #2 was admitted to the facility in December 2000 with diagnoses including multiple sclerosis and diabetes. Review of Resident #2's most recent Minimum Data Set Assessment (MDS) assessment, dated 5/27/25, indicated the Resident scored a 15 out of possible 15 on the Brief Interview for Mental Status exam, indicating intact cognition. The MDS further indicated that Resident #2 required a pressure reducing device and was at risk of developing pressure ulcers/injuries. On 6/4/25 at 1:08 P.M., the surveyor observed Resident #2 lying in his/her bed with an air mattress setting at 125 lbs (pounds). On 6/5/25 at 7:08 A.M., the surveyor observed Resident #2 lying in his/her bed with an air mattress setting at 125 lbs. Review of the medical record indicated the following physician orders, dated 8/22/24: -Air mattress to bed setting at 150 (resident request) check setting and function q shift for wound prevention. -Right hip: clean with normal saline, cover with foam dressing change every three days for protection every day shift. Review of Resident #2's weekly skin evaluation, dated 6/1/25 indicated the following : -Blanchable area with no visible drainage noted to the right hip. Review of Resident #2's skin care plan, dated as revised on 5/27/25, indicated the following focus: -At risk for a pressure injury related to poor mobility, decreased range of motion, diagnosis of diabetes, bowel incontinence, left below the knee amputation, history of pressure areas, noncompliant with repositioning side to side and psoriasis. -Intervention: Air mattress to bed setting at 150 per resident request, check function and setting every shift. During an interview on 6/5/25 at 9:48 A.M., Certified Nursing Assistant (CNA) #3 said she adjusts Resident #2's air mattress setting to firm when she is performing activities of daily. During an interview on 6/5/25 at 10:00 A.M., Nurse #4 said nurses are responsible for checking air mattress settings. Nurse #4 further said air mattresses are checked every shift and settings are listed in the physician order. During an interview on 6/5/25 at 10:02 A.M., Nurse #3 said air mattresses are set by weight, nurses are responsible for checking air mattresses every shift, and that Resident #2's air mattress should be set to 150 pounds. During an interview on 6/5/25 at 10:50 A.M., the Director of Nursing said nurses should have checked the air mattress for the correct setting every shift and the expectation is to follow the physician order. 2. Resident #61 was admitted to the facility in August 2023 with diagnoses including multiple sclerosis and pressure ulcer of sacral region stage 3. Review of Resident 61's most recent Minimum Data Set Assessment (MDS) assessment, dated 4/18/25, indicated the Resident scored a 14 out of possible 15 on the Brief Interview for Mental Status exam, indicating intact cognition. The MDS further indicated that Resident #61 required a pressure-reducing device, had a pressure ulcer/injury and a non removable dressing/device. On 6/4/25 at 7:54 A.M., the surveyor observed Resident #61 lying in his/her bed, the air mattress was set at 340 Lbs (pounds). The resident also had a wound vacuum (a medical procedure that uses negative pressure to promote wound healing). On 6/4/25 at 1:11 P.M., the surveyor observed Resident #61 lying in his/her bed, the air mattress was set at 340 Lbs (pounds). On 6/5/25 at 7:11 A.M., the surveyor observed Resident #61 lying in his/her bed, the air mattress set at 340 Lbs (pounds). Review of the medical record indicated the following physician orders: -Air mattress to bed. Setting on 160. Check functioning of mattress every shift. Check for proper setting every shift, dated 8/21/24. -Continuous Negative Pressure wound Vacuum to sacrum, dated 6/3/25. Review of Resident #61's skin care plan revised on 4/30/25 indicated the following interventions: -Sacral wound pressure stage three. -Air mattress to bed. Setting on 160. Check functioning of mattress every shift. Check for proper setting every shift. -Evaluate need for alternating pressure mattress and adhere to manufacturer guidelines to ensure settings are correct, check function every shift of mattress when in place. During an interview on 6/5/25 at 9:48 A.M., Certified Nursing Assistant (CNA) #3 said she adjust the air mattress setting to firm when she is performing activities of daily. During an interview on 6/5/25 at 10:00 A.M., Nurse #4 said nurses are responsible for checking air mattress settings. Nurse #4 further said air mattresses are checked every shift and settings are listed in the physician order. During an interview on 6/5/25 at 10:02 A.M., Nurse #3 said air mattresses are set by weight, nurses are responsible for checking air mattresses every shift, and that Resident #61's air mattress should be set to 160 pounds. During an interview on 6/5/25 at 10:50 A.M., the Director of Nursing said nurses should have checked the air mattress for the correct setting and the expectation is to follow the physician order.

Based on observation, record review and interview the facility failed to ensure nursing staff provided assistance with Activities of Daily Living (ADLs) for one dependent Resident (#111) out of a total sample of 30 residents. Specifically, for Resident #111 the facility failed to provide assistance with the removal of facial hair. Findings Include: Review of the facility policy titled Activities of Daily Living (ADL's), undated, indicated the following: Policy -The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable. -Care and services will be provided for the following activities of daily living: bathing, dressing, grooming, and oral hygiene. Policy Explanation and Compliance Guidelines: -A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Resident #111 was admitted to the facility in March 2024 with diagnoses including displaced fracture of the greater trochanter of the right femur, fracture of T7-T8 vertebrae, malignant neoplasm of the upper lobe of the right lung, and contracture of right hand. Review of Resident #111's most recent Minimum Data Set (MDS) assessment, dated 5/13/25, indicated the Resident had a Brief Interview for Mental Status exam score of 13 out of a possible 15, indicating intact cognition. The MDS further indicated Resident #111 required substantial/maximal assistance for self-care activities. During an interview on 6/3/25 at 8:45 A.M., Resident #111 said he/she normally does not have facial hair and would like it removed but needs assistance. On 6/3/25 at 8:45 A.M., and 3:31 P.M., 6/4/25 at 7:41 A.M., 12:29 P.M., and 4:12 P.M., and 6/5/25 at 7:39 A.M., Resident #111 was observed with upper lip, chin, and neck hair. Review of Resident #111 personal hygiene care card (documentation indicating level of care provided for combing hair, shaving, applying make-up, and washing/drying face and hands), indicated Resident #111 required substantial/maximal assistance to complete personal hygiene. Review of Resident #111's nursing progress notes failed to indicate he/she refused ADL care. During an interview on 6/5/25 at 8:10 A.M., Nurse #6 said the Certified Nursing Assistants (CNA's) normally shave residents during morning care with their permission. Nurse #6 said Resident #111 required assistance of one to two people for self-care, would only refuse care if he/she was in pain and it should be documented in the medical record if a resident refused care. During an interview on 6/5/25 at 8:35 A.M., CNA #2 said we shave residents with their permission, and if they refuse, we will try again later and if they continue to refuse, we notify the nurse. CNA #6 said she does not have Resident #111 today but does assist him/her with shaving when he/she is assigned to her. During an interview on 6/5/25 at 9:40 A.M., the Administrator said she would expect facial hair to be removed with the resident's permission during routine care and any refusals should be documented in the medical record.

Based on observations, interviews, and record review, the facility to ensure that services provided met professional standards for one Resident (#10), out of a total sample of 30 residents. Specifically, the facility failed to complete a physician order for weekly skin check and failed to identify bruises for three days. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: - Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize errors. Review of the facility policy titled Skin Assessment, undated, indicated the following: -A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. -Documentation of skin assessment-document if resident refused assessment and why. Resident #10 was admitted to the facility in April 2025 with diagnoses including dementia and chronic long-term use of anticoagulants (medications used for thinning blood). Review of Resident #10's most recent Minimum Data Set (MDS) assessment, dated 5/14/25, indicated the Resident scored 3 out of a possible 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment. The MDS further indicated that Resident #10 is dependent for all activities of daily living (ADLs). On 6/3/25 at 9:03 A.M., the surveyor observed Resident #10 lying in his/her bed. Resident #10's right arm was on top of the covers with a deep purplish yellowish fading bruise on the back and forearm. On 6/4/25 at 7:24 A.M., the surveyor observed Resident #10 lying in his/her bed. Resident #10's right arm had purplish/yellowish bruising to the back and forearm. On 6/5/25 at 7:31 A.M., the surveyor observed Resident #10 lying in his/her bed. Resident #10's right arm had purplish/yellowish bruising to the back and forearm. Review of Resident #10's current physician orders indicated the following: -Skin check weekly on Wednesday 3-11 shift I=intact, O=open, and complete skin assessment on Universal Design for Assessment (UDA) every shift every Wednesday for skin check. Review of Resident #10's anticoagulant care plan, dated as initiated 5/1/25, indicated: -Resident is currently taking an anticoagulant related to Atrial Fibrillation. Interventions: -Daily skin inspection report abnormalities to the nurse. -Monitor/document /report to medical doctor (MD) as needed, signs and symptoms of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Review of Resident #10's weekly skin evaluations dated 5/7/25, 5/14/25, 5/21/25, and 5/28/25 failed to indicate bruising to the right arm. Review of Resident #10's medical record failed to indicate a weekly skin evaluation was completed on 6/4/25 as ordered. Review of Resident #10's nursing progress notes failed to indicate bruising to right hand/forearm had been identified. During an interview on 6/5/25 at 7:33 A.M., Certified Nursing Assistant (CNA) #1 said she saw the bruise on the Resident's right arm on Tuesday (6/3/25) but did not tell the nurse about it. She said when giving care, if a bruise is identified, the CNAs are supposed to report it to the nurse immediately. During an interview on 6/5/25 at 7:38 A.M., Nurse #5 said skin checks are completed weekly and should identify any bruises, skin tears and pressure injuries. She said the CNAs are responsible for reporting to the nurses immediately if they observe any skin alterations. Nurse #5 further said any bruises on a resident should be documented in the progress notes. During an interview on 6/5/25 at 9:20 A.M., Nurse #3 said skin checks should be completed weekly, and any skin alterations are documented in the progress notes and the weekly skin evaluation. Nurse #3 further said a skin check should have been completed yesterday as per the orders. During an interview on 6/5/25 at 10:47 A.M., the Director of Nursing said skin checks should be completed weekly per the physician orders, daily with care and any bruises should be documented in the medical record.

Based on records reviewed and interviews for one of five sampled residents (Resident #1), who was totally dependent on staff for bed mobility, which included turning, repositioning and incontinence care, the Facility failed to ensure his/her was provided with the necessary level of staff supervision and/or assistance, when on 03/02/25, Resident #1 was positioned onto his/her side during care, the staff member left the room to get supplies, leaving him/her unattended and when staff member returned he/she was found on the floor after falling out of bed. Resident #1 was transferred to the Hospital Emergency Department (ED) where he/she was diagnosed with multiple bone fractures and was admitted for care. Findings include: Review of the Facility Policy titled Incidents and Accidents, dated as last revised 11/01/24, indicated that an accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. The Policy further indicated that the purpose of incident reporting can include the following; -Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent reoccurrences and improve the management of the resident's care; -Conducting root cause analysis to ascertain causative/contributing factors as part of the Quality Assurance Performance Improvement (QAPI) to avoid further occurrences; and -Alert risk management and/or administration of occurrences that could result in claims of further reporting requirements. Review of the report submitted by the Facility via Health Care Facility Reporting System (HCFRS), dated 03/10/25, indicated that Resident #1 was found on the floor and sent to the Hospital Emergency Department for evaluation. The Report further indicated that at approximately 12:25 A.M., Resident #1 put his/her call light on, Nurse #1 responded and that Resident #1 asked to be changed. Nurse #1 said that she informed Certified Nurse Aide (CNA) #1, who went to Resident #1's room to provide care. The Report indicated that CNA #1 went into Resident #1's room, asked him/her what was needed and stepped out of the room to get supplies to change Resident #1. The Report indicated that when CNA #1 returned to Resident #1's room, he/she was found on the floor. Review of Resident #1's Hospital ED report, dated 03/02/25, indicated he/she suffered a left scalp abrasion, left superior and inferior pubic ramus (part of the pelvic bone) fracture, left scapular (shoulder blade) fracture and a left clavicle (collar bone) fracture. The Report indicated Resident #1 was admitted and remained in the Hospital for six days. Resident #1 was admitted to the Facility in February 2025, diagnoses included but was not limited to Peripheral Artery Disease (PAD) with bilateral foot gangrene, diabetic neuropathy, Acute Lymphoblastic Leukemia (ALL) in remission, chronic pain and chronic urinary retention with an indwelling catheter in place. Review of Resident #1's Physical Therapy Evaluation, dated 02/17/25, indicated he/she was totally dependent for bed mobility and does not attempt to initiate. Review of Resident #1's Care Plan, titled ADL-Self-Care deficit, dated 02/18/25, indicated he/she was totally dependent on staff for all ADL's, including all transfers (mechanical lift required), repositioning, and toileting/incontinent care. Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 02/21/25, indicated that Resident #1 required total physical assistance from staff members for toileting needs, bed mobility and repositioning. Review of Resident #1's Occupational Therapy (OT) Note, dated 02/26/25, indicated that OT was working on bed mobility exercises to increase functional skills. The Note indicated Resident #1 required maximum assistance to position self towards the center of the bed due to severe right lateral lean when in bed. During a telephone interview on 04/23/25 at 2:52 P.M., Resident #1 said that on 03/02/25 at approximately 12:30 A.M., he/she put his/her call light on and told Nurse #1 that he/she needed to be changed. Resident #1 said two male CNA's (exact names unknown) came into the room to change him/her, turned and rolled him/her onto his/her side toward the window, left him/her on the bed like that and then they both walked away to go get some supplies for incontinent care. Resident #1 said he/she then rolled right off the bed and landed on concrete ledge on the floor that was below his/her window. Resident #1 said there was no bed rail on his/her bed to grab onto to help him/herself hold on. During a telephone interview on 04/24/25 at 9:27 A.M., Nurse #1 said she answered Resident #1's call light early in the morning on 03/02/25, toward the beginning of the night shift and he/she asked to be changed. Nurse #1 said she told CNA #1 that Resident #1 needed to be changed. Nurse #1 said she did not see how many CNA's entered Resident #1's room to provide him/her care. Nurse #1 said she went to go do something and CNA #1 came back to her and said Resident #1 was on the floor. Nurse #1 said that when she entered the room, Resident #1 was lying up against the concrete ledge that extended out from the floor under the window and they had to move the bed away from the window in order for her to assess Resident #1 for potential injuries. Nurse #1 said that Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation once she saw his/her face begin to bruise. During an interview on 04/28/25 at 12:06 P.M., CNA #1 said that around 12:15 A.M., Nurse #1 informed him that Resident #1 was wet and needed to be assisted with incontinent care. CNA #1 said he went to Resident #1's room, asked him/her what he/she needed and said Resident #1 told him that he/she needed to be changed. CNA #1 said he did not touch (reposition) Resident #1 to start care, but left the room to go get supplies first, that were needed to assist with care. CNA #1 said when he returned to the room approximately 2-3 minutes later, Resident #1 was on the floor. CNA #1 said there was no other CNA in the room helping him that night. During an interview on 04/22/25 at 1:07 P.M., the Certified Occupational Therapist Assistant (COTA) said that Resident #1 was bed bound and could use his/her hands to some extent, for example grasping his/her drink and he/she was working on self-feeding. During an interview on 04/22/25 at 1:39 P.M., the Director of Rehabilitation (DOR) said that she did not remember talking about Resident #1 being able to utilize side rails for mobility and said he/she was not assessed by the rehabilitation department for the use of side rails. The DOR said that Resident #1 was totally dependant for bed mobility, positioning, and incontinent care and said she was not certain who decides how many staff, one versus two should be providing a resident's care. During an interview on 04/22/25 at 4:16 P.M., CNA #5 said Resident #1 was difficult to reposition if the staff were unaware of his/her abilities. CNA #5 said Resident #1's body would slip (tilt) to one side and if he/she was not positioned correctly, he/she could have an accident. During an interview on 04/23/25 at 12:34 P.M., the Director of Nurse (DON) said that she does not know how Resident #1 ended up being found on the floor. The DON said that the Facility's expectation is to provide a safe environment for all residents and provide the necessary service and care needs that each resident requires. During an interview on 04/23/25 at 11:51 A.M., the Administrator said in the morning of 03/02/25 is when she learned of Resident #1 being found on the floor after requesting to be cleaned and changed earlier in the shift. The Administrator said she only knew the circumstances as they were reported to her.

Based on record review and interviews, for one of five sampled residents (Resident #1) who had requested bed rails be placed on his/her bed for repositioning and safety reasons, the Facility failed to ensure his/her request was adequately addressed when bed rails were not provided and was told he/she did not need them. Findings include: Review of the Facility Policy titled Resident Rights, dated 11/01/24, indicated that each resident has the right to a dignified existence, self-determination, and communication with the access to people and services inside and outside the facility. The Policy further indicated that the resident has the right to be informed of, participate in his or her treatment. Resident #1 was admitted to the Facility in February 2025, diagnoses included but not limited to Peripheral Artery Disease (PAD) with bilateral foot gangrene, diabetic neuropathy, Acute Lymphoblastic Leukemia (ALL) in remission, chronic pain and chronic urinary retention with an indwelling catheter in place. Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 02/21/25, indicated he/she was alert, oriented, was his/her own decision maker, and had scored a 15/15 on his/her Brief Interview for Mental Status (BIMS) Assessment (0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired cognition, and 12-15 suggests a resident is cognitively intact). Review of Resident #1's Physician's Order, for February 2025, indicated he/she had a new Physician's Order dated 2/14/25, to place two (2) quarter (1/4) bed rails on his/her bed. Review of Resident #1's Admission Bed Rail Assessment, dated 02/14/25, indicated that he/she had not been consulted regarding the use of the bed rails. During a telephone interview on 04/22/25 at 12:02 P.M., Family Member #1 said that on 02/21/25, he told Nurse #7 that he was worried about Resident #1's safety because he/she did not have bed rails on his/her bed. Family Member #1 said that Resident #1 had bed rails on his/her hospital bed both at home and while in the Hospital and said he/she (Resident #1) felt more comfortable and safer with the bed rails on the bed. During a telephone interview on 04/23/25 at 2:52 P.M., Resident #1 said that no one at the facility ever asked if he/she wanted bed rails on his/her bed. Resident #1 said that he/she had requested them, but was only told that he/she did not need them. Resident #1 said bed rails were not put on his/her bed during his/her stay at the facility. During a telephone interview on 04/23/25 at 3:24 P.M., Nurse #2 said that she does not remember doing Resident #1's bed rail assessment upon admission. Nurse #2 said that residents sign a bed rail consent form upon admission and then nursing informs maintenance department staff when they need to place bed rails on the residents' bed. During an interview on 04/22/25 at 12:50 P.M., the Nurse Manager said that she was not aware that the staff had not consulted with Resident #1 regarding the use of bed rails. During an interview on 04/22/25 at 1:39 P/M., the Director of Rehabilitation (DOR) said that she did not remember talking about Resident #1 being able to utilize bed rails for mobility and said he/she was not assessed by the rehabilitation department for the use of bed rails. During an interview on 04/22/25 at 12:34 P.M., the Director of Nurses (DON) said that she was not aware that Resident #1 was not consulted on the use of bed rails. The DON said that the Facility's expectation to assess each resident for bed rails upon admission, obtain consent, and then have maintenance install the side rails to the bed if the Resident requests them for safety and security.

Based on records reviewed and interviews, for one of five sampled residents (Resident #2) whose Physician's Orders included the administration of a narcotic medication for pain, the Facility failed to ensure the resident was free from a significant medication error due to omission, when Resident #2 missed two consecutive doses of scheduled pain medication because nursing staff could not gain access to the facility's Emergency Medication Dispensing System (EMDS, electronic kiosk system that requires a security code to be entered by nursing staff in order to access and dispense stored medications). Finding include: Review of the Facility Policy titled Medication Errors, dated as last revised 11/01/24, indicated that the Facility is to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. The Policy further indicated that all medications shall be administered as follows; -According to a Physician's Order, including medication omissions; -Per Manufacturer's specifications regarding the preparation, and administration of the drug or biological; and -In accordance with the accepted standards and principles which apply to professionals providing services. Resident #2 was admitted to the Facility in November 2024, diagnoses included status post multiple back surgery, diabetes mellitus, bipolar disorder, and acute on chronic pain. Review of Resident #2's Physician's Orders, dated 01/23/25, indicated to administer Hydromorphone (Dilaudid, narcotic/pain medication) 2 milligrams (mg), give 2 tablets every four hours for pain, hold for sedation. Review of Resident #2's Medication Administration Record (MAR), dated 03/28/25, indicated he/she was not administered his/her scheduled doses of Dilaudid at 6:00 P.M. and 10:00 P.M. During an interview on 04/22/25 at 3:27 P.M., Resident #2 said that he/she was unable to get two doses of his/her pain medication because the medications were not ordered in a timely manner to be delivered from the pharmacy and was told by nursing that only the Director of Nurses (DON) could override the Emergency Medication Dispensing System (EMDS) to retrieve the pain medication from their emergency supply. During an interview on 04/22/25 at 2:20 P.M., Nurse #3 said that Nurse #4 (who was assigned to Resident #2 on 03/28/25) was an agency nurse and did not have security code access to the EMDS, so she was tried to help obtain Resident #2's medication from the EMDS for her. Nurse #3 said when she went to obtain the 6:00 P.M. dose for Nurse #4 to administer to Resident #2, the EMDS displayed a error code, stating that there was not enough medication to fill the request and the EMDS would not unlock for them. Nurse #3 said that the only person who could unlock the EMDS was the DON and she (DON) was not able to come into the Facility to unlock the EMDS and release the medication. During a telephone interview on 05/01/25 at 1:43 P.M., Nurse #4 said that she was Resident #2's nurse on the evening (3:00 P.M.-11:00 P.M.) shift on 03/28/25 when the medication error of omission occurred. Nurse #4 said that she did not have access to the Facility's EMDS and Nurse #3 tried to help her obtain the medication for Resident #2, however, the EMDS had an error code and would not dispense the medication. Nurse #4 said that she was told only the Director of Nurses (DON) could override the error code in the EMDS and was unable to get to the Facility to do so. Nurse #4 said that the omission of the two doses of pain medication was considered a medication error. During a telephone interview on 05/01/25 at 1:22 P.M., the Pharmacy Representative for the Facility said that both the DON and Assistant Director of Nurses (ADON) have administrative access and were able to override error message issues in the EMDS. The Pharmacy Representative said that there was a miss count earlier in the day with the EMDS, so when the nurse tried to re-access the medication it locked her out from obtaining that specific medication, and also said there had been alternative medications available. The Pharmacy Representative said that either the DON or ADON could have accessed the medication if needed and if there had not been enough doses, the original order should have been placed STAT, and a representative from the pharmacy could have delivered the doses needed. During an interview on 04/22/25 at 12:34 P.M., the DON said she was not aware if the nursing staff had called the pharmacy on 03/28/25 for help, but said if the staff had called the pharmacy to help override the error, that the pharmacy could have helped with the lock out issue. The DON said that it is the Facility's expectation is that all prescribed medications should be ordered timely. The DON said that if a medication is needed from the EMDS and an error occurs, the nurse must call the pharmacy for additional guidance to gain access to the appropriate medication to prevent a medication error. On 04/23/25, the Facility was found to be in Past Noncompliance and presented the Surveyor with a plan of correction (with an effective date of 03/29/25) that addressed the area(s) of concern as evidenced by: A) Resident #1 was administered all other pain medication as ordered, and was monitored for effectiveness. B) On 03/29/25, the DON investigated the incident with the pharmacy to resolve the override issues and lockouts. C) On 03/29/25, the Director of Nurses (DON) educated the licensed nurses on ordering medications form the pharmacy, obtaining medications form the EMDS, and what actions to take if a medication is unavailable. D) On 03/29/25, the DON began an audit of controlled substance medications and ensured medications needed were on hand or ordered from the pharmacy. E) On 03/29/25, The DON educated all licensed nurses on obtaining a physician's order to hold a missed medication and possibly provide an asked for alternative medication until issues resolved. F) Results of all audits and observations will be brought to and reviewed at Quality Assurance and Performance Improvement (QAPI) meetings for the next three months or until compliance is achieved. G) The DON and or Designee are responsible for overall compliance.

Based on records reviewed, interviews, and observation for three of five sampled residents (Resident #3, #4 and #5), who had all been assessed as being their own person, the Facility failed to ensure that 1) Resident #3 was assessed for the use of bed rails and that his/her physicians order was for bed rails, and 2) after Resident #4 and #5 underwent a room change, that the bed rails were provided on their new beds, per their physicians orders. Findings include: Review of the Facility Policy titled Proper Use of Bed Rails, dated as last revised 11/01/24, indicated that the facility is to utilize a person-centered approach when determining the use of bed rails. The Policy further indicated that a proper assessment, informed consent, and a physician's order must be obtained prior to utilizing bed rails. 1) Resident #3 was admitted to the Facility in April 2025, diagnoses include status post left total knee replacement, bipolar disorder, Chronic Obstructive Pulmonary Disease (COPD) and obesity. Review of Resident #3's Informed Consent for Use of Bed Rails, dated 04/18/25, indicated he/she had consented to the use of bilateral quarter bed rails. Review of Resident #3's Physician's Order, dated 04/18/25, indicated to provide two grab bars (not bed rails) for bed mobility and positioning. Review of Resident #3's Admission Bed Rail Assessment, dated 04/18/25, indicated the form was blank, and that a bed rail assessment had not been completed upon admission or by the date of survey. During an observation on 04/22/25 at 2:00 P.M., the Surveyor observed bilateral quarter bed rails attached to his/her bed. 2) Resident #4 was admitted to the Facility in March 2024, diagnoses included atrial fibrillation, neurocognitive disorder, peripheral vascular disease, and depression. Review of Resident #4's Informed Consent for Use of Bed Rails, dated 03/02/24, indicated that he/she consented to the use of bed rails. Review of Resident #4's Quarterly Bed Rail Assessment, dated 02/28/25, indicated the use of two quarter bed rails may be used on his/her bed. During an observation on 04/22/25 at 4:44 P.M., the Surveyor observed Resident #4's bed, however there were no bed rails installed on it. During an interview on 04/22/25 at 4:44 P.M., Resident #4 said that he/she did not know why there were no bed rails on his/her bed and said that he/she used to have them on his/her bed before he/she changed rooms. Resident #4 said that he/she used the bed rails to help move him/herself in bed. Review of the Facility Room Change Summary Report, dated 04/23/25, indicated that on 03/04/25, Resident #4 had undergone a room change. 3) Resident #5 was admitted to the Facility in March 2025, diagnoses included anemia, cirrhosis, diabetes mellitus, and a history of falling. Review of Resident #5's Informed Consent for Use of Bed Rails, dated 03/24/25, indicated that he/she consented to the use of Bed Rails. Review of Resident #5's Admission Bed Rail Assessment, dated 03/24/25, indicated the use of bed rails had been assessed to be used on his/her bed. Review of Resident #5's Physician's Order, dated 03/24/25, indicated to provide two quarter grab bars for bed mobility and positioning. During an observation on 04/23/25 at 10:00 A.M., the Surveyor observed Resident #5's bed, however there were no bed rails installed on it. Review of the Facility Room Change Summary Report, dated 04/23/25, indicated that on 03/27/25, Resident #5 had undergone a room change. During an interview on 04/23/25 at 10:44 A.M., the Director of Maintenance said that he was not aware that two residents (#4 and #5, who had orders for and previously had bed rails in place on the beds), had their rooms changed, and therefore was not aware that bed rails needed to be installed on their new beds. The Director said nursing staff will inform the maintenance department when bed rails are to be installed or removed from a bed and if a resident moves to a different room nursing must inform them if the bed rails need to be removed from the residents original bed and installed on the resident's bed in the new room. The Director said each time before bed rails are installed to a bed, the maintenance worker will complete an entrapment assessment to ensure proper placement. During an interview on 04/23/25 at 11:05 A.M., the Assistant Director of Nurses (ADON) said that when a resident is admitted , the nurse doing the admission needs to complete the Admission Bed Rail Assessment, obtain informed consent from the Resident, obtain a physician's order, and inform maintenance that they need to install bed rails to the bed. During an interview on 04/23/25 at 12:34 P.M., the Director of Nurses (DON) said that it is the Facility's expectation that upon admission nursing completes a bed rail assessment, obtain informed consent from the resident and/or representative if being used, obtain a physician's order, and inform maintenance to install or remove bed rails after the appropriate steps have been taken for the use of bed rails.

Based on records reviewed and interviews, for three of five sampled resident (Resident #2, #4, and #5), the Facility failed to ensure that the resident and/or his/her family member or legal representative participated in the development and implementation of their person-center care plans, when the residents and/or their legal representatives were not invited to attend an interdisciplinary care plan meeting following the completion of their Comprehensive Minimum Data Set (MDS) Assessment. Findings include: Review of the Facility Policy titled, Comprehensive Care Plans, dated as last revised 11/01/24, indicated that comprehensive care plan will be reviewed and revised by the IDT after each comprehensive and quarterly Minimum Date Set (MDS) Assessment. The Policy further indicated that the IDT includes, however, not limited to; -The Attending Physician; -A Registered Nurse; -A Certified Nurse Aide; -A member of the food and nutrition services staff; -The Resident and the resident's representative, to the extent practicable; and -And other appropriate staff or professionals in disciplines as determined by the resident's needs. 1) Resident #2 was admitted to the Facility in November 2024, diagnoses include status post multiple back surgery, diabetes mellitus, bipolar disorder, and acute on chronic pain. Review of Resident #2's Quarterly Minimum Data Set (MDS) dated , 02/17/25, indicated that he/she was alert, oriented and had a Brief Interview of Mental Status (BIMS) score of 15 (score of 13-15 indicated cognitively intact). During an interview on 04/22/25 at 3:27 P.M., Resident #2 said he/she has never attended a comprehensive care plan meeting. Resident #2 and said that the staff has not invited him/her to attend a care plan meeting with the team to talk about his/her goals and interventions since he/she has been admitted . Review of Resident #2's Medical Record indicated that there was no documentation to support that the facility scheduled and conducted a comprehensive care plan meeting after the completion of his/her admission and/or quarterly MDS. 2) Resident #4 was admitted to the Facility in March 2024, diagnoses included atrial fibrillation, neurocognitive disorder, peripheral vascular disease and depression. Review of Resident #4's Annual MDS, dated [DATE], indicated that he/she was alert and had a BIMS score of 7/15 (score or 8-12 indicates moderate cognitive impairment). Review of Resident #4's Medical Record indicated that there was no documentation to support he/she had been invited or attended a comprehensive care plan meeting after completion of his/her latest annual MDS. 3) Resident #5 was admitted to the Facility in March 2025, diagnoses included anemia, cirrhosis, diabetes mellitus, and a history of falls. Review of Resident #5's Admission MDS, dated [DATE] indicated that he/she was alert and had a BIMS score of 11/15 (score of 8-12 indicates moderate cognitive impairment). Review of Resident # 5's Medical Record indicated that there was no documentation to support that the facility scheduled, conducted and invited him/her to the care plan meeting. During an interview on 04/22/25 at 1:17 P.M., the Director of Social Services said that the MDS Nurse generates the Care Plan Meeting Schedules, and that the Receptionist is responsible for sending out invitations to the resident and/or their responsible party. The Director of Social Services said she had not invited Resident #2 to the latest care plan review and said that she did not see a care plan note for his/her latest comprehensive care plan meeting. During an interview on 04/23/25 at 10:00 A.M., the MDS Nurse said that the receptionist was responsible for inviting the Resident and/or the Resident Representative to attend the comprehensive Care Plan Meetings. The MDS Nurse said that each resident has the right to attend their own care plan meetings. During a telephone interview on 04/28/25 at 12:06 P.M., the Support MDS Nurse said that she reviews the new admissions every morning and puts the resident on a MDS and care plan schedule for the building. The MDS Nurse said that she does not know how Resident # 5 was missed and said that it is expected that all residents and their representatives are invited to attend all comprehensive care plan meetings. During an interview on 04/23/25 at 12:24 P.M., the Director of Nurses said that it is the Facility's expectation that all residents and families are to be invited to the care plan meetings, that the care plan meetings are completed in a timely manner and in accordance with the completion of a residents' MDS.

Based on record review and interview, the facility failed to provide the appropriate treatment and services for one Resident (#192), with a known history of mental disorders, suicidal ideation, and adjustment difficulty. Specifically, the facility failed to develop, implement, and update the plan of care, resulting in an attempted suicide after the vocalization of suicidal ideation. Findings include: Review of the facility policy titled Suicide Prevention, dated 8/1/23, indicated the following: - Suicidal Ideation is defined as self-reported thoughts about engaging in suicide-related behaviors. - All staff members will immediately report any suicidal ideation to the resident's charge nurse and facility social worker. - Immediately notify the resident's physician if the resident presents with suicidal ideation, even if he or she isn't specific about a plan or intent. - Objectively and thoroughly document the resident's mood and behaviors, as well as actions taken, in the medical record. - All staff will be trained annually on risk factors and warning signs of suicide, as well as how to respond to a resident with suicidal ideation. Review of the facility policy titled Suicide Assessment, revised February 2023, indicated the following: - Residents will be assessed for suicide risk upon admission and as indicated. The facility social worker or designee will conduct and medical record review and then interview the resident regarding any risk factors that have been identified. Protective factors will be explored with the resident as well. - Risk factors include, but are not limited to: * History of prior suicide attempts or self-injurious behavior * Current or past psychiatric disorders and/or recent change in psychiatric treatment * Symptoms such as hopelessness, helplessness, anxiety/panic, and impulsivity * Triggering events that lead to despair such as the loss of a relationship, health decline, chronic pain, death of a loved one, family turmoil/chaos .etc. - If the assessment indicates the resident is having suicidal thoughts, specific discussions about thoughts, plans, behaviors, and intent will occur. Review of the facility policy titled Behavioral Health Services, revised February 2023, indicated the following: - It is the policy of this facility to ensure all residents receive the necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning. - Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders, psychosocial difficulty, and trauma or post-traumatic stress disorders. - The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. - The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care . Staff will: * Complete PASARR screening * Obtain history from medical records, the resident, and as appropriate the resident's family and friends * Monitor the resident closely for expressions or indications of distress * Assess and develop a person-centered care plan for concerns identified in the resident's assessment. - Facility staff will implement person-centered care approaches designed to meet the individual goals and needs of each resident, which includes non-pharmalogical interventions. - The Social Services Director shall serve as the facility's contact person for questions regarding behavioral health services provided by the facility and outside sources such as physician, psychiatrist, or neurologist. Review of the facility assessment, revised 3/19/24, indicated the facility is able to manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities. On average, the facility manages about 50 residents with behavioral health needs. Resident #192 was admitted in December 2023 with diagnoses including bipolar disorder, depression, schizoaffective disorder, and generalized anxiety. Review of the admission Minimum Data Set (MDS), dated [DATE], indicated Resident #192 scored a 10 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Review of the Resident's hospital discharge paperwork given to the facility upon admission and dated 12/1/23, indicated the following note from the psych team: - Pt now endorsing SI. Told Case Mgmt that he/she wants to end his/her life. I spoke with patient and he/she states that he/she has thought about suicide for a while and wishes he/she could end his/her life, but states 'he/she is not allowed'. Denies prior suicide attempts or access to firearms, but states if I did have access to firearms, I would kill myself and states I have nothing to live for. Endorses multiple prior psychiatric hospitalization s. Will place on Section 12, consult APS (Acute Psychiatric Service). Per review of prior records, did note this during his/her prior hospital admission as well. At time of admission, a psychosocial well-being care plan was developed for Resident #192 and indicated the following: Focus: This resident is at risk for altered psychosocial well-being related to Adjustment to new environment/rehab setting, decline in functional/medical status, dx Schizoaffective d/o Bipolar 1, anxiety/panic d/o, depression, FTT (failure to thrive) in adult (initiated 12/2/23) Interventions: - Activities to meet with this resident to develop and activity plan (initiated 12/2/23) - Behavioral health services as ordered and needed (initiated 12/2/23) - Encourage family members/residents representatives to be involved as allowed by resident to also participate in this plan to be able to provide direct support (initiated 12/2/23) - Encourage the resident to make their own decisions when able (initiated 12/2/23) - Encourage the resident to see a positive view of themselves (initiated 12/2/23) - Following up with responses to concerns brought up (initiated 12/2/23) - Medications as ordered to help manage their mood and behaviors (initiated 12/2/23) - Monitor and document mood and behaviors (12/2/23) - Provide 1:1 to allow this resident to verbal feeling/concerns (12/2/23) - Provide the resident praise for all their efforts made (initiated 12/2/23) - Remind this resident of their goals and reassure them on progress made (12/2/23) Review of Resident #192's other comprehensive care plans failed to indicate a care plan was developed for the Resident's history of suicidal ideation (SI) or any interventions related to the safety of Resident #192. Review of the progress note, dated 1/8/24, indicated the following: Resident stated that he/she wanted to die. Social Worker (SW) went to talk to Resident #192. Resident #192 stated he/she was afraid of a woman and that she will kill him/her. SW asked to describe the woman. Resident stated she worked here and gave the description of the CNA that is working with him/her. SW informed unit manager and DON. Review of the psych progress note, dated 1/8/24, indicated Resident #192 denied SI, but reported low mood. The progress note indicated that Resident #192 was on an established medication regimen with moderately severe depression. Review of the clinical record failed to indicate any changes had been made to Resident #192's plan of care, care plan, or that notification to the physician had occurred after the Resident had expressed suicide ideation. Review of the clinical record indicated on 1/24/24, Resident #192 was sent to the hospital for a planned procedure. Resident #192 returned to the facility on [DATE]. Review of the hospital discharge paperwork, dated 1/31/24, indicated Resident #192 reported suicidal ideation in the hospital and was provided a one on one sitter and was placed on a section 12 (an involuntary hospitalization if assessed to be a danger to self or others). During an interview on 6/10/24 at 8:52 A.M., the Director of Nursing said that the hospital discharge paperwork is reviewed by the clinical liaison team and the admitting nurse will review any discharge paperwork from the hospital. The Director of Nursing said that the next day, when she is in the facility, the whole interdisciplinary team, including her, reviews the discharge paperwork. During an interview on 6/10/24 at 9:24 A.M., the Director of Nursing said she wasn't notified of the section 12 that took place in the hospital. The Director of Nursing said that hospital discharge paperwork is reviewed by a clinical liaison team and the admitting nurse and then the full discharge summary is reviewed the next morning by the clinical team. Review of the clinical record failed to indicate that, upon readmission to the facility, Resident #192's plan of care was reviewed or updated, despite Resident #192's vocalization of suicidal ideation in the hospital and a section 12. Review of the progress note, dated 2/16/24, indicated the following: - Resident section 12'd 2:20 pm after acting oddly this morning refusing to talk and refusing therapy which continued after lunch. Resident was covering his/her face with his/her hands and refusing to speak but did eat lunch. Call placed to nurse practitioner to report and was given order to send to ED. When this nurse went back in to resident room he/she was found with a clear plastic bag tied around his/her head full of condensation. Bag [sic] removed and resident was attempting to take plastic bag from nurse. Awake, alert but still refusing to speak. Resident taken to nurses station for 1:1 monitoring and psych in the building section 12'd him/her. EMS notified and resident transferred to hospital [sic] for psych eval. Review of the psych note, dated 2/15/24, indicated the following: - Resident is AOx3 (alert and oriented), he/she was found by nursing staff with a plastic bag over his/her head. Resident has an extensive hx of SI but with no past activity. Resident section12A to hospital d/t safety concern, further evaluation. Review of the hospital paperwork, dated 2/19/24, indicated the following: - Presents from his/her SNF(Skilled Nursing Facility) after staff there reportedly found him/her with a plastic bag over head in an attempt to self-harm. At that time he/she stated he/she felt like he/she 'wasn't being listened to' there and has made passive SI statement since then without much other detail . During an interview on 6/6/24 at 11:15 A.M., the Director of Nursing said when a resident is admitted with a history of suicidal ideation, a care plan should be developed with interventions to keep the Resident safe and supportive services would be put in place, including psych and social services. During an interview on 6/6/24 at 10:38 A.M., the Psych Nurse Practitioner said she would consider someone with a history of SI who has recently expressed SI to be put on 15 minute checks or moved closer to the nursing station. The Psych NP said she was not notified of Resident #192's return from the hospital with a verbalization of SI. The psych NP said that Resident #192 had some issues with being at the nursing facility and with his/her brother placing him/her here. During an interview on 6/6/24 at 9:36 A.M., the Social Services Assistant (SSA) #1 said that he is not a social worker, but at the time Resident #192 was admitted , an outside contract service provided social worker support as needed. SSA #1 said he would expect a care plan to be developed for suicidal ideation and if a Resident expressed suicidal ideation then the Resident should be seen immediately. During an interview on 6/10/24 at 8:30 A.M., SSA #1 said that if a resident expressed SI then that Resident should be checked in on daily from social services to make sure they are safe. SSA #1 said that Resident #192 was having a difficult time adjusting to the facility and his/her brothers decision to keep him/her at the facility. Review of the clinical record did not indicate that any interventions were put in place or updated after return from the hospital, between 1/31/24 - 2/16/24, for Resident #192 with a known history of suicidal ideation and adjustment difficulty.

Based on record review and interview, the facility failed to provide behavioral health services for four Resident's (#192, #91 #64, and #73) with a history of suicidal ideation (SI) and/or depression, out of a total universe of 67 residents. Specifically, 1. Resident #192 expressed suicidal ideation and the facility failed to provide the appropriate services, which resulted in staff finding Resident #192 with a tightly tied plastic bag around his/her head during an attempted suicide, 2. the facility failed to provide behavioral health services timely for Resident #91, 3. failed to provide behavioral health services after an increase in depression scores for Resident #64 and #73. Findings include: Review of the facility policy titled Suicide Prevention, dated 8/1/23, indicated the following: - Suicidal Ideation is defined as self-reported thoughts about engaging in suicide-related behaviors. - All staff members will immediately report any suicidal ideation to the resident's charge nurse and facility social worker. - Immediately notify the resident's physician if the resident presents with suicidal ideation, even if he or she isn't specific about a plan or intent. - Objectively and thoroughly document the resident's mood and behaviors, as well as actions taken, in the medical record. - All staff will be trained annually on risk factors and warning signs of suicide, as well as how to respond to a resident with suicidal ideation. Review of the facility policy titled Suicide Assessment, revised February 2023, indicated the following: - Residents will be assessed for suicide risk upon admission and as indicated. The facility social worker or designee will conduct and medical record review and then interview the resident regarding any risk factors that have been identified. Protective factors will be explored with the resident as well. - Risk factors include, but are not limited to: * History of prior suicide attempts or self-injurious behavior * Current or past psychiatric disorders and/or recent change in psychiatric treatment * Symptoms such as hopelessness, helplessness, anxiety/panic, and impulsivity * Triggering events that lead to despair such as the loss of a relationship, health decline, chronic pain, death of a loved one, family turmoil/chaos .etc. - If the assessment indicates the resident is having suicidal thoughts, specific discussions about thoughts, plans, behaviors, and intent will occur. Review of the facility policy titled Behavioral Health Services, revised February 2023, indicated the following: - It is the policy of this facility to ensure all residents receive the necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning. - Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders, psychosocial difficulty, and trauma or post-traumatic stress disorders. - The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. - The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care . Staff will: * Complete PASARR (pre-admission screening and resident review) * Obtain history from medical records, the resident, and as appropriate the resident's family and friends * Monitor the resident closely for expressions or indications of distress * Assess and develop a person-centered care plan for concerns identified in the resident's assessment. - Facility staff will implement person-centered care approaches designed to meet the individual goals and needs of each resident, which includes non-pharmacological interventions. - The Social Services Director shall serve as the facility's contact person for questions regarding behavioral health services provided by the facility and outside sources such as physician, psychiatrist, or neurologist. Review of the facility assessment, revised 3/19/24, indicated the facility is able to manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities. On average, the facility manages about 50 residents with behavioral health needs at a time. Resident #192 was admitted in December 2023 with diagnoses including bipolar disorder, depression, schizoaffective disorder, and generalized anxiety. Review of the admission Minimum Data Set (MDS), dated [DATE], indicated Resident #192 scored a 10 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Review of the Resident's hospital discharge paperwork given to the facility upon admission and dated 12/1/23, indicated the following note from the psych team: - Pt now endorsing SI. Told Case Mgmt that he/she wants to end his/her life. I spoke with patient and he/she states that he/she has thought about suicide for a while and wishes he/she could end his/her life, but states 'he/she is not allowed'. Denies prior suicide attempts or access to firearms, but states if I did have access to firearms, I would kill myself and states I have nothing to live for. Endorses multiple prior psychiatric hospitalization s. Will place on Section 12, consult APS (Acute Psychiatric Stay). Per review of prior records, did note this during his/her prior hospital admission as well. Review of the PASARR Unit for Department of Mental Health, dated 11/29/23, indicated that Resident #192 had a PASARR Level II completed and was appropriate for a provisional emergency admission to a nursing facility that cannot exceed 7-calendar days. The PASARR (Pre-admission screening and resident review) evaluation indicated the following: - Upon admission to a nursing facility, it is the responsibility of the nursing facility to contact the PASARR authority in the event of a significant change in resident status, including: * Improvement or decline in condition, or * If the nursing facility newly identifies a condition that may impact the individual's PASARR disability status, appropriateness of nursing facility placement and/or specialized services, to determine whether a new PASARR evaluation is needed. At time of admission, a psychosocial well-being care plan was developed for Resident #192 and indicated the following: Focus: This resident is at risk for altered psychosocial well-being related to Adjustment to new environment/rehab setting, decline in functional/medical status, dx Schizoaffective d/o Bipolar 1, anxiety/panic d/o, depression, FTT (failure to thrive) in adult (initiated 12/2/23) Interventions: - Activities to meet with this resident to develop and activity plan (initiated 12/2/23) - Behavioral health services as ordered and needed (initiated 12/2/23) - Encourage family members/residents representatives to be involved as allowed by resident to also participate in this plan to be able to provide direct support (initiated 12/2/23) - Encourage the resident to make their own decisions when able (initiated 12/2/23) - Encourage the resident to see a positive view of themselves (initiated 12/2/23) - Following up with responses to concerns brought up (initiated 12/2/23) - Medications as ordered to help manage their mood and behaviors (initiated 12/2/23) - Monitor and document mood and behaviors (12/2/23) - Provide 1:1 to allow this resident to verbal feeling/concerns (12/2/23) - Provide the resident praise for all their efforts made (initiated 12/2/23) - Remind this resident of their goals and reassure them on progress made (12/2/23) Review of Resident #192's other comprehensive care plans failed to indicate a care plan was developed for the Resident's history of suicidal ideation (SI). Review of the Psychiatric Evaluation and Consultation note, dated 12/4/23, indicated Resident #192 has felt depressed since childhood and has had multiple hospitalization s related to SI. The note also indicated: Resident was admitted to unit with SI, aware of resident's verbalizing SI. The note indicated that Resident #192 was on an established medication regimen to manage his/her mood, depression, and anxiety. The psychiatric consultation note recommendations indicated the following: Monitor resident for safety, provide medications as prescribed, encourage resident to participate in unit activities. Continue to monitor acute changes in behaviors, nutrition status, and sleep patterns. Redirect when possible, maintain adequate safety precautions, appropriately use diversionary activities on the unit, and provide positive encouragement. Patient would benefit from continued treatment to promote mental wellness and emotional stability. Review of the Patient Health Questionnaire-9 (PHQ-9) (an assessment of depression), dated 12/4/23, indicated Resident #192 scored a 23 out of a possible 27 points, indicating severe depression. During an interview on 6/7/24 at 9:26 A.M., Certified Nursing Assistant CNA #4 said that if a resident had changes in their mood or behaviors, staff would document the changes on the behavior sheets. CNA #4 remembered Resident #192. CNA #4 said that Resident #192 could be mean to staff, but did not say that he/she refused care. Review of the progress notes, behavior monitoring sheets, and medication administration record (MAR) failed to indicate that the facility was monitoring for any change in Resident #192's daily mood and depression. Review of the progress note, dated 1/8/24, indicated the following: Resident stated that he/she wanted to die. Social Worker (SW) went to talk to Resident #192. Resident #192 stated he/she was afraid of a woman and that she will kill him/her. SW asked to describe the woman. Resident stated she worked here and gave the description of the CNA that is working with him/her. SW informed unit manager and DON (Director of Nursing). Review of the psych progress note, dated 1/8/24, indicated Resident #192 denied SI, but reported low mood. The progress note indicated that Resident #192 was on an established medication regimen with moderately severe depression. Review of the clinical record failed to indicate any changes had been made to Resident #192's plan of care, care plan, or that notification to the physician had occurred after the Resident had expressed suicide ideation. Review of the physician note, dated 1/9/24, did not indicate that the physician addressed Resident #192's suicidal ideation. During an interview on 6/7/24 at 9:29 A.M., Nurse #4 said that if a resident had changes in their mood or behavior, nursing staff would document the changes in the clinical record and leave a note for the Nurse Practitioner. Review of the clinical record indicated on 1/24/24, Resident #192 was sent to the hospital for a planned procedure. Resident #192 returned to the facility on [DATE]. Review of the hospital discharge paperwork, dated 1/31/24, indicated Resident #192 reported suicidal ideation in the hospital and was provided a one on one sitter and was placed on a section 12 (an involuntary hospitalization if assessed to be a danger to self or others). During an interview on 6/10/24 at 8:52 A.M., the Director of Nursing said that the hospital discharge paperwork is reviewed by the clinical liaison team and the admitting nurse will review any discharge paperwork. The Director of Nursing said that the next day the whole team reviews discharge paperwork. During an interview on 6/10/24 at 9:24 A.M., the Director of Nursing said she wasn't notified of the section 12 that took place in the hospital. The Director of Nursing said that hospital discharge paperwork is reviewed by a clinical liaison team and the admitting nurse and then the full discharge summary is reviewed the next morning by the clinical team, which she is a part of. Review of the clinical record failed to indicate that, upon readmission to the facility, Resident #192's plan of care was reviewed or updated, despite Resident #192's vocalization of suicidal ideation in the hospital and a section 12. Review of the PHQ-9, dated 2/2/24, indicated Resident #192 scored a 19 out of 27, indicating moderately severe depression. There was no indication that Resident #192 was evaluated or seen by psych services, social services, or any behavioral health interventions were updated between 2/2/24 - 2/16/24. Review of the progress notes, behavior monitoring sheets, and medication administration record (MAR) failed to indicate that the facility was monitoring for any change in Resident #192's daily mood and depression. Review of the communication log from January 2024 through February 2024 for the 2nd floor unit failed to indicate any information related to Resident #192 or changes in his/her mood or behavior were communicated to psych services. Review of the progress note, dated 2/16/24, indicated the following: - Resident section 12'd 2:20 pm after acting oddly this morning refusing to talk and refusing therapy which continued after lunch. Resident was covering his/her face with his/her hands and refusing to speak but did eat lunch. Call placed to nurse practitioner to report and was given order to send to ED. When this nurse went back in to resident room he/she was found with a clear plastic bag tied around his/her head full of condensation. Bag [sic] removed and resident was attempting to take plastic bag from nurse. Awake, alert but still refusing to speak. Resident taken to nurses station for 1:1 monitoring and psych in the building section 12'd him/her. EMS notified and resident transferred to hospital [sic] for psych eval. Review of the psych note, dated 2/15/24, indicated the following: - Resident is AOx3 (alert and oriented), he/she was found by nursing staff with a plastic bag over his/her head. Resident has an extensive hx of SI but with no past activity. Resident section 12A to hospital d/t safety concern, further evaluation. Review of the hospital paperwork, dated 2/19/24, indicated the following: - Presents from his/her SNF(Skilled Nursing Facility) after staff there reportedly found him/her with a plastic bag over head in an attempt to self-harm. At that time he/she stated he/she felt like he/she 'wasn't being listened to' there and has made passive SI statement since then without much other detail . During an interview on 6/7/24 at 9:31 A.M., Nurse #5 said that Resident #192 was quiet and did not complain. She said that Resident #192 did not have a lot of issues and that he/she did not want to be here at the facility. During an interview on 6/7/24 at 8:38 A.M., the Activities Director said that Resident #192 was quiet and kept to himself/herself. The Activities Director said that Resident #192 was encouraged to leave his/her room but he/she declined and would not participate in activities. The Activities Director said that Resident #192 was upset because he/she did not want to be in the facility and felt that his/her family had left him/her here. During an interview on 6/6/24 at 9:36 A.M., the Social Services Assistant said that he is not a social worker or licensed for social work or counseling services. He said that the facility had a contract company that has since closed. He said that if a Resident expressed SI then he would contact the LICSW (Licensed Social Worker) from the company to do an evaluation via telehealth. During an interview on 6/10/24 at 8:31 A.M., Social Services Assistant #1 said that Resident #192 had some cognitive issues, but engaged the best that he/she could. Social Services Assistant #1 said that there was an adjustment period that he/she struggled with slightly due to his/her family and brother. Social Services Assistant #1 said that if a Resident verbalizes a recent SI, then that Resident should be followed on a regular basis and seen daily or once a shift to make sure they are feeling safe. Social Services Assistant #1 said that the care plan should be updated and supportive care in place During an interview on 6/6/24 at 10:38 A.M., the Psychiatric Nurse Practitioner (Psych NP) said she reviews all of the referrals for behavioral health given by the nurses. She said the referrals are either given verbally or kept in a folder on the floors. The Psych NP said she provides medication management and will briefly talk to the residents if necessary, but said she does not provide talk therapy. The Psych NP said that when a Resident expresses suicidal ideation, she would section 12 the Resident if they were actively suicidal. The psych NP said that she would consider SI was active if there was a plan behind the statement. The psych NP said that Resident #192 has an extensive and complex history and that he/she was supposed to be in the facility on respite. She said she didn't want to change the Resident's medications because he/she was supposed to be in the facility short-term. The psych NP said that even if Resident #192 made a passive statement of SI, she would expect something to be put in place like 15-minute checks or moving his/her room closer to the nurses station for monitoring. The psych NP said that Resident #192 was alert and oriented and knew everything that was going on and felt like his/her brother was keeping him/her in the facility. The psych NP said that Resident #192 would have benefited from ongoing supportive talk therapy services because of his/her history, but that those services are provided by another provider. During an interview on 6/6/24 at 11:15 A.M., the Director of Nursing (DON) said that anyone with a history of SI should have a care plan developed and implemented and that the interventions are related to the safety of the Resident. The DON said the Psych NP does medication management and the facility has social services and emotional therapy support would be provided by a psychiatric provider. She said there is a psychologist that comes into the building and said if there was a recent expression of SI from a resident, she would expect all available options of behavioral health services to be involved. The DON said that Residents with depression should have behavioral monitoring that would pick up a change in status like not engaging, or not attending activities, more isolation, etc. The DON said that she would want those residents to have therapy beyond medications. During an interview on 6/7/24 at 7:36 A.M., Physician #1 said that he believes that Residents would benefit from counseling services and non-pharmalogical interventions, but that he feels the facility needs more support to provide those services. During an interview on 6/10/24 at 11:47 A.M., the psych NP said that she was not made aware of Resident #192's suicidal ideation during his/her hospital stay and would have seen him/her upon return to the facility. During an interview on 6/10/24 at 11:47 A.M., the Director of Nursing said that the facility was never made aware of the Resident's suicidal ideation expressed during the most recent hospital stay on 1/31/24 and, if she had known, the facility wouldn't have taken Resident #192 back to the facility. 2. Resident #91 was admitted in December 2023 with diagnoses including major depressive disorder, schizoaffective disorder, and dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #91 scored a 4 out of a possible 15, indicating severe cognitive impairment. Review of the progress note, dated 12/28/2023, indicated the following: Note Text: This nurse was notified by speech, that pt voiced to her that he/she was depressed and mentioned SI. This nurse went to speak with pt voiced he/she hated his/her sister for putting him/her here, that there is no need for him/her to be here. Pt went on to say more about living with his/her sister, getting a job but his/her sister dropped him/her off here Resident said he/she was going to take care of the situation by killing him/her self, asked pt if he/she had a plan, he/she stated yes he/she did. Asked him/her what it was, he/she said he/she was just going to do it and isn't telling me how. Asked pt if he/she felt suicidal now, he/she stated yes because he/she is so upset and hates his/her sister. DON notified. Safety maintained. Review of the clinical record failed to indicate that Resident #91's suicidal ideation was addressed by psych or social services. Review of the care plan for Resident #91 indicated the following: Focus: The resident exhibits behaviors putting themselves, by making suicidal statements and/or others at risk for potential injury R/T choosing to not participate or allow care to be completed. History of physical abuse toward others, History of withdrawal from usual daily activities (group or independent), refusal of care (initiated 12/28/23). Interventions: - Administer medication as ordered (initiated 12/28/23) - Behavioral health services as ordered and treat as indicated (initiated 12/28/23) - Encourage attendance to activities (initiated 12/28/23) - Identify and implement nonpharmacological interventions (identify what these are for this resident): _________ (initiated 12/28/23) - Keep resident representative informed of changes or continued behaviors impacting the residents care (initiated 12/28/23) - Monitor and document behaviors for further review (initiated 12/28/23) - Social worker to provide routine visits and provide support as needed (initiated 12/28/23) Review of the care plan failed to indicate that a suicidal ideation care plan was developed with appropriate interventions for the Resident's safety. Review of the care plan failed to indicate that any interventions were carried out after Resident #91 verbalized suicidal ideation. Review of the psych Nurse Practitioner note, dated 1/8/24, 11 days after the initial suicidal ideation, indicated Resident #91 presented with low mood and was upset about his/her sister not visiting while at the facility. The progress note did not mention Resident #91's suicidal ideation. During an interview on 6/10/24 at 11:47 A.M., the psych NP said that she is aware of Resident #91's suicidal ideation expressions and that his/her story changes because of memory issues. The psych NP said that Zoloft (a medication used to treat depression) was started on 12/29/23, but it takes 2 weeks for that medication to take effect. The psych NP could not say if she assessed Resident #91. 41456 3a. Resident #64 was admitted to the facility in February 2024 with diagnoses including major depression. Review of Resident #64's most recent Minimum Data Set (MDS) dated [DATE], indicated Resident #64 had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, which indicated he/she was cognitively intact. The MDS also indicated Resident #64 was independent with daily functional tasks. Review of Resident #64's record indicated he/she completed the PHQ-9 (an assessment of depression) upon admission and scored a 0, which indicated he/she was displaying no symptoms of depression. Review of the Psychiatric Nurse Practitioner note on 4/4/24 indicated the following: - Resident is very withdrawn, limited interaction with peers, upon assessment resident with limited communication ability, (he/she) uses one word response, unable to express (him/herself). Present with flat affect. Review of Resident #64's record indicated he/she completed the PHQ-9 (an assessment of depression) again on 5/10/24 and scored a 12, which indicated he/she was displaying symptoms of moderate depression. Review of the Psychiatric Nurse Practitioner note on 5/10/24 indicated the following: - Resident reports; Little interest in doing things for several days. Feeling depressed for more than half the days. Having trouble falling and staying asleep for more than half the days. Having little energy for more than half the days. Denies having poor appetite/overeating. Feeling bad about (him/herself) for several days. Trouble with concentration for several days. Moving slowly nearly every day. Denies any thoughts/plans of hurting (him/herself)/or others. PHQ-9 score 12-moderate depression. Review of Resident #64's mood care plan last revised 5/9/24, indicated the following intervention: -Behavioral Health Services as ordered and treat as indicated. Review of Resident #64's medical record failed to indicate the Resident received any additional behavioral health services after the PHQ-9 indicated an increasing level of depression. During an interview on 6/6/24 at 9:36 A.M., the Social Services Assistant said that he is not a social worker or licensed for social work or counseling services. He said that the facility had a contract company that has since closed. He said that if a Resident expressed an increase in depression the facility would make a referral to support services and the social worker would check in with these residents. During an interview on 6/6/24 at 10:38 A.M., the Psychiatric Nurse Practitioner (Psych NP) said she reviews all of the referrals for behavioral health given by the nurses. She said the referrals are either given verbally or kept in a folder on the floors. The Psych NP said she provides medication management and will briefly talk to the residents, if necessary, but said she does not provide talk therapy. During an interview on 6/6/24 at 11:15 A.M., the Director of Nursing (DON) said the Psych NP does medication management and the facility has social services and emotional therapy support would be provided by a psychiatric provider. She said there is a psychologist that comes into the building, and she would expect all available options of behavioral health services to be involved with anyone expressing increased levels of depression. The DON said that Resident's with depression should have behavioral monitoring that would pick up a change in status like not engaging, or not attending activities, more isolation, etc. The DON said that she would want those residents to have therapy beyond medications. During an interview on 6/7/24 at 7:36 A.M., Physician #1 said that he believes that Residents would benefit from counseling services and non-pharmacological interventions, but that he feels the facility needs more support to provide those services. 3b. Resident #73 was admitted to the facility in February 2024 with diagnoses including depression. Review of Resident #73's most recent Minimum Data Set (MDS) dated [DATE], indicated Resident #73 had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, which indicated he/she was cognitively intact. The MDS also indicated Resident #73 required substantial assistance with daily functional tasks. Review of Resident #73's record indicated he/she completed the PHQ-9 (an assessment of depression) on 2/16/24 and scored a 14, which indicated he/she was displaying symptoms of moderate depression. Review of the Psychiatric Nurse Practitioner note on 4/4/24 indicated the following: - Resident is very withdrawn, limited interaction with peers, upon assessment resident with limited communication ability, (he/she) uses one word response, unable to express (him/herself). Present with flat affect. Review of Resident #73's record indicated he/she completed the PHQ-9 (an assessment of depression) again on 5/13/24 and scored a 15, which indicated he/she was displaying symptoms of moderately severe depression, an increase from the previous PHQ-9. Review of the Psychiatric Nurse Practitioner note dated 4/8/24 indicated Resident #73 was at risk for worsening mood and behavior. Review of the Psychiatric Nurse Practitioner note dated 5/10/24 indicated the following: - Resident reports; little interest in doing things for more than half the days. Feeling depressed nearly every day. Having trouble falling and staying asleep for more than half the days. Having little energy for more than half the days. Poor appetite for more than half the days. Feeling bad about (him/herself) for several days. Denies having trouble with concentration. Moving slowly nearly every day. Denies any thoughts plans of hurting (him/herself)/others. PHQ-9 score 15 - moderately severe depression. Review of the Psychiatric Nurse Practitioner note dated 5/13/24 indicated the following: - Resident reports having poor sleep in the past weeks. (He/she) reports (he/she) can't sleep more than 2 hours straight, (he/she) has poor sleep and depressed mood. -Resident #73's anti-depressant was increased at this time. Review of Resident #73's psychotropic medication care plan last revised 5/28/24, indicated the following intervention: -Behavioral Health Services PRN (as needed). Review of Resident #73's medical record failed to indicate the Resident received any additional behavioral health services after the PHQ-9 indicated an increasing level of depression. During an interview on 6/6/24 at 9:36 A.M., the Social Services Assistant said that he is not a social worker or licensed for social work or counseling services. He said that the facility had a contract company that has since closed. He said that if a Resident expressed an increase in depression the facility would make a referral to support services and the social worker would check in with these residents. During an interview on 6/6/24 at 10:38 A.M., the Psychiatric Nurse Practitioner (Psych NP) said she reviews all of the referrals for behavioral health given by the nurses. She said the referrals are either given verbally or kept in a folder on the floors. The Psych NP said she provides medication management and will briefly talk to the residents, if necessary, but said she does not provide talk therapy. During an interview on 6/6/24 at 11:15 A.M., the Director of Nursing (DON) said the Psych NP does medication management and the facility has social services and emotional therapy support would be provided by a psychiatric provider. She said there is a psychologist that comes into the building, and she would expect all available options of behavioral health services to be involved with anyone expressing increased levels of depression. The DON said that Resident's with depression should have behavioral monitoring that would pick up a change in status like not engaging, or not attending activities, more isolation, etc. The DON said that she would want those residents to have therapy beyond medications. During an interview on 6/7/24 at 7:36 A.M., Physician #1 said that he believes that Residents would benefit from counseling services and non-pharmacological interventions, but that he feels the facility needs more support to provide those services.

Based on observations and interviews the facility failed to ensure it was administered in a manner that enabled the facility to use its resources effectively to attain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility administration failed to ensure the appropriate behavioral health services were in place for one Resident (#192) who attempted suicide after verbalizing suicidal ideation. Findings Include: During the survey process it was identified that the Administration's failure to ensure adequate behavioral health services were provided for residents with mental health disorders. Out of a total universe of 67 residents identified with depression disorder, 7 residents were not provided the behavioral health services after an identification of decreased mood through the PHQ-9 (personal health questionnaire-9) (a tool used to measure depression). Review of the facility assessment, revised 3/19/24, indicated the facility is able to manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD (post traumatic stress disorder), other psychiatric diagnoses, intellectual or developmental disabilities. On average, the facility manages about 50 residents with behavioral health needs. Review of the Behavioral Health Service Agreement, dated December 2022, indicated the following services were provided to the facility: - Provide psychiatric evaluations at the request of the attending physician for the purpose of assessing the specific needs of residents of the facility with psychiatric symptomology and recommending therapeutic interventions. - Perform psychopharmacological consults and monitoring; and psychotherapeutic services. - Act as a liaison for emergency situations in the event of a psychiatric crisis - Maintain certain that all residents that have a referral for behavioral health management services receive an evaluation within 10 days. Resident #192 was admitted in December 2023 with diagnoses including bipolar disorder, depression, schizoaffective disorder, and generalized anxiety. Review of the admission Minimum Data Set (MDS), dated [DATE], indicated Resident #192 scored a 10 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Review of the Resident's hospital discharge paperwork given to the facility upon admission and dated 12/1/23, indicated Resident #192 verbalized that he/she would kill him/herself if he/she had a gun in the hospital. The Resident was placed on a section 12 (an emergent mental health measure to prevent a patient from harming themselves) and cleared prior to admission. Review of the clinical record did not indicate that any SI (suicide ideation) care plan had been developed or any interventions for safety were put into place following admission. Review of the progress note, dated 1/8/24, indicated Resident #192 verbalized SI and was subsequently evaluated by the behavioral health services (Psychiatric Nurse Practitioner) for immediate safety. No changes were made to the Resident's plan of care. Review of the clinical record failed to indicate any changes had been made to Resident #192's plan of care, care plan, or that notification to the physician had occurred after the Resident had expressed suicide ideation. Review of the clinical record indicated on 1/24/24, Resident #192 was sent to the hospital for a planned procedure. Resident #192 returned to the facility on [DATE]. Review of the hospital discharge paperwork, dated 1/31/24, indicated Resident #192 reported suicidal ideation in the hospital and was provided a one on one sitter and was placed on a section 12 hospitalization . Review of the clinical record failed to indicate that, upon readmission to the facility, Resident #192's plan of care was reviewed or updated, despite Resident #192's vocalization of suicidal ideation in the hospital and a section 12. There was no indication that Resident #192 was evaluated or seen by behavioral health services, social services, or any additional behavioral health interventions were updated between 2/2/24 - 2/16/24. Review of the record indicated, on 2/16/24, Resident #192 attempted suicide by placing a bag tightly over his/her head. Resident #192 was subsequently sent to the hospital and never returned to the facility. During an interview on 6/6/24 at 10:38 A.M., the psych NP said that she does not provide talk therapy to residents and that the other provider within her contract company should be utilized. The psych NP said she primarily focuses on medication management and checking in with residents. The psych NP said that Resident #192 would have benefited from talk therapy given everything that was going on with him/her. The psych NP also said that if a Resident is expressing suicidal ideation then certain safety measures should be put in place and a care plan should be developed to keep the Resident safe. During an interview on 6/7/24 at 9:21 A.M., the Administrator said that he brought supportive care services on board when the facility opened a behavioral health unit (around September 2023) to provide oversight and the Psychiatric NP is in a couple of times per week. The Administrator said that the psych NP is a consultant and sometimes meets with the residents to provide support and make recommendations to the doctor. He said he is unsure what she does when she sees them, but would assume she goes in to meet and talk with the residents. The Administrator said that social workers would be providing talk therapy to the residents, but that he doesn't differentiate the difference between talk therapy and when the psych NP goes to meet with residents. The Administrator said that if a Resident expresses suicidal ideation then the interdisciplinary team should be involved (department heads), as well as, psych services. The Administrator was not aware that the psych NP was not providing talk therapy services and just providing medication management. During an interview on 6/6/24 at 11:15 A.M., the Director of Nursing said emotional therapy and support would be provided by a contract provider that comes in (a psychologist), but could not say why Resident #192 had not been provided those services. During an interview on 6/10/24 at 11:54 A.M., the Director of Nursing said that she came on board last year and the social services department needs some work. She said she was never made aware of Resident #192's SI in the hospital and would not have taken him/her back if she knew. During an interview on 6/7/24 at 7:36 A.M., Physician #1 said that he believes that Residents would benefit from counseling services and non-pharmalogical interventions, but that he feels the facility needs more support to provide those services. The Administrator or Director of Nursing were unable to provide evidence throughout survey that the behavioral contract services were meeting the facilities expectations for behavioral health services provided to residents.

Based on observations, record review, policy review and interviews, the facility failed to 1) prevent a worsening of range of motion with new contracture development for one Resident (#125) and 2) failed to implement interventions for contracture management for one Resident (#16) out of a total sample of 38 residents. Findings include: Review of the facility policy titled, Prevention of Decline in Range of Motion, dated 2/2024 indicated the following: -Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable. -The facility in collaboration with the medical director, director of nurses and as appropriate, physical/occupational consultant shall establish and utilize a systemic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventative care. -Licensed nurses will assess resident's range of motion (such as current extent of movement of his/her joints and identification of limitations) on admission/readmission, quarterly, and upon a significant change. -Residents who exhibit limitations and range of motion, initially and thereafter, will be referred to the therapy department for a focused assessment of range of motion. -Staff will be educated on the risk factors for a decline in range of motion. These include but are not limited to: limbs or digits immobilized because of injury or surgical procedures, immobilization (e.g. Bed rest), deformities arising out of neurological deficits, pain, spasms, and immobility associated with arthritis, late stage Alzheimer's disease or other conditions. 1. Resident #125 was admitted to the facility in December 2023 with diagnoses including dementia and diabetes. Review of Resident #125's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident was unable to complete the Brief Interview for Mental Status exam and staff had assessed him/her to have severe cognitive impairment. The MDS also indicated Resident #125 was dependent on staff for all functional tasks. Section GG of the MDS indicated the Resident did not have any impairments in range of motion. On 6/4/24 at 8:31 A.M., Resident #125 was observed lying in bed with both hands in a fisted position. When asked, the Resident was unable to open his/her hands. On 6/7/24 at 11:30 A.M., Resident #125 was observed lying in bed with both hands in a fisted position. When asked, the Resident was unable to open his/her hands. Review of Resident #125's full list of medical diagnoses failed to indicate a neurological diagnosis that would lead to a contracture. Review of the discharge summary from the hospital prior to admission indicated Resident #125 had bilateral lower extremity contractures but failed to indicate contractures of the Resident's upper extremities were present upon admission. The hospital paperwork also recommended staff complete ROM (range of motion) exercises with the resident. Review of Resident #125's admission nursing assessment dated [DATE], failed to indicate the Resident had an impairment of range of motion to his/her upper extremities. Review of the Occupational Therapy evaluation dated 12/27/23 indicated Resident #125's muscle tone was normal and failed to indicate the Resident had an upper extremity contracture. Review of the Nursing assessment dated [DATE] indicated Resident #125 had an impairment in range of motion to both upper extremities, a change from the assessment 3 months prior. Review of Resident #125's medical record failed to indicate a referral was made to rehabilitation at this time as a change in range of motion is first noted. During an interview on 6/7/24 at 11:35 A.M., Certified Nursing Assistant (CNA) #3 said she was unaware if Resident #125 had a decline in range of motion of his/her hands. CNA #3 entered Resident #125's room and attempted to open the Resident's hands. On both hands, CNA #3 was only able to straighten the Resident's first two fingers but the third, fourth and fifth fingers were bent in a fisted position and CNA #3 could not straighten these fingers. As CNA #3 was attempting to straighten Resident #125's fingers, the Resident pulled his/her arms away wincing in pain. During an interview on 6/7/24 at 11:37 A.M., Nurse #3 said she was never told about a decline in Resident #125's range of motion. During an interview on 6/7/24 at 11:46 A.M., Unit Manager #2 said he was unaware of a decline in range of motion to Resident #125's hands. Unit Manager #2 then entered the Resident's room and attempted to straighten the fingers on both of Resident #125's hands. Unit Manager #2 could straighten the first two fingers on both hands but was unable to straighten the third, fourth and fifth fingers of each hand. As Unit Manager #2 was attempting to straighten the Resident's fingers, the Resident winced in pain and pulled his/her arm back. Unit Manager #2 said Resident #125 definitely had contractures of both hands. Unit Manager #2 said staff should be doing basic range of motion exercises during basic care and report any changes in range of motion to him so he could make a referral to the therapy department. During an interview on 6/7/24 at 12:03 P.M., the Director of Nursing (DON) said staff should be able to identify changes in range of motion and would be expected to report any changes to the nurse. The DON said the nurse would need to communicate any changes in range of motion to the therapy department so an evaluation could be completed. The DON said she was unaware Resident #125 had bilateral hand contractures. During an interview on 6/10/24 at 8:14 A.M., the Director of Rehabilitation (DOR) said all residents in the facility are screened quarterly to see if there have been any changes to the Resident's functional status. The DOR said a potential decline in range of motion is also looked at during the screening process. The DOR said she would also expect a referral from the nursing department if the nursing staff noticed a decline in range of motion for any of the residents in the facility. The DOR and surveyor looked through the screening logbook and the nursing referral book together. Both books failed to indicate a quarterly screen had been completed for Resident #125 since admission or that a referral was made to the therapy department in March 2024 when the decline in range of motion was indicated in the nursing assessment. The DOR said she was unaware Resident #125 had two new hand contractures and that the positioning of Resident #125's hands were a change and it would be appropriate for the Resident to have an occupational therapy evaluation. 48990 2.) For Resident #16, the facility failed to implement a physician's order for a left hand resting splint. Review of the facility policy titled 'Prevention of Decline in Range of Motion', revised 2/2024, indicated: -The facility will provide treatment and care in accordance with professional standards of practice. This includes, but is not limited to: ii. Appropriate equipment (braces or splints). Resident #16 was admitted to the facility in March 2014 with diagnoses including with a left hand contracture and a history of traumatic brain injury. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/24/2024, indicated that Resident #16 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. This MDS also indicated Resident #16 was dependent on staff for dressing, transfers, and mobility. Review of the physician's order, dated 10/30/23, indicated: - Patient to wear resting hand splint on left hand in am and removed at bed, every day and evening shift *-*** kept in bedside drawer****** Review of the plan of care related to need for assistance with ADLS, dated 5/16/24, indicated - (L) resting hand sprint on in AM, off in PM. On 6/4/24 at 8:33 A.M., the surveyor observed Resident #16 in bed eating breakfast. Resident #16 did not have a resting hand splint on his/her left hand. On 6/4/24 at 12:10 P.M., the surveyor observed Resident #16 in bed eating lunch. Resident #16 did not have a resting hand splint on his/her left hand. Resident said staff need to help put it on his/her left hand, but when he/she asks staff says they can't do it. The surveyor also made the following observations of Resident #16 without his/her left resting hand splint: - On 6/4/24 at 2:38 P.M., Resident #16 said staff had not offered the resting hand splint today. - On 6/5/24 at 8:12 A.M. - On 6/6/24 at 10:01 A.M., Resident #16 said staff had not offered the resting hand splint today and asked surveyor to put it on. On 6/6/24 at 10:07 A.M., Certified Nurse Assistant (CNA) #10 said Resident #16 is supposed to have a carrot (a device used for hand contractures) in his/her left hand but that sometimes staff can't find it, but that he/she does not refuse it. CNA #10 took a carrot out of Resident #16's drawer and applied it to Resident #16's left hand. During an interview on 6/7/24 at 11:30 A.M., Unit Manager #2 said Resident #16 should be wearing a left resting hand splint. Unit Manager #2 said Resident #16 should not be wearing a carrot because it is not a replacement for a left resting hand splint. Unit Manager #2 entered Resident #16's room and located a left resting hand splint and asked Resident #16 if he/she would like it on, and the Resident said yes. During an interview on 6/7/24 at 12:09 P.M., the Director of Nursing (DON) said Resident #16 should be wearing a left resting hand splint and that a carrot is not a replacement for this device. The DON said if Resident #16 had refused to wear the left resting hand splint that it should be documented in the Treatment Administration Record (TAR) or progress notes. Review of TAR and progress notes failed to indicate Resident #16 had refused to wear the left resting hand splint.

Based on record review and interview, the facility failed to assure sufficient social services were provided to meet the needs of one Resident (#192), out of a total sample of 38 residents. Specifically, Resident #192 did not receive social support after verbalizing suicidal ideation (SI), resulting in an attempted suicide. Findings include: Review of the facility policy titled Social Services, revised February 2023, indicated the following: - The facility, regardless of size, will provide medically-related social services to each resident, to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. - Any need for medically-related social services will be documented in the medical record. - Services to meet the resident's needs may include: * Assisting residents in voicing and obtaining resolution to grievances about treatment, living conditions, visitation rights and accommodation of needs. * Making referrals and obtaining needed services from outside entities * Providing or arranging for needed mental and psychosocial counseling services * Identifying and seeking ways to support residents' individual needs through the assessment and care planning process. * Identifying and promoting individualized, non-pharmacological approaches to care that meet the mental and psychosocial needs of each resident. * Meeting the needs of residents who are grieving from losses and coping with stressful events. - The facility should provide social services or obtain services from outside entities during situations that include: * Expressions or indications of distress that affect the resident's mental and psychosocial well-being, resulting from depression * Difficulty coping with change or loss * Need for emotional support - The resident's plan of care will reflect any ongoing medically-related social service needs, and how those needs are being addressed. - The Social Worker, or social services designee, will monitor the resident's progress in improving physical, mental, and psychosocial functioning. Review of the facility assessment tool, dated 3/19/24, indicates the facility provides pscyho/social/spiritual support including supporting emotional and mental well-being and helpful coping mechanisms. Resident #192 was admitted in December 2023 with diagnoses including bipolar disorder, depression, schizoaffective disorder, and generalized anxiety. Review of the admission Minimum Data Set (MDS), dated [DATE], indicated Resident #192 scored a 10 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Review of the Resident's hospital discharge paperwork given to the facility upon admission and dated 12/1/23, indicated the following note from the psych team: - Pt now endorsing SI. Told Case Mgmt that he/she wants to end his/her life. I spoke with patient and he/she states that he/she has thought about suicide for a while and wishes he/she could end his/her life, but states 'he/she is not allowed'. Denies prior suicide attempts or access to firearms, but states if I did have access to firearms, I would kill myself and states I have nothing to live for. Endorses multiple prior psychiatric hospitalization s. Will place on Section 12, consult APS. Per review of prior records, did note this during his/her prior hospital admission as well. At time of admission, a psychosocial well-being care plan was developed for Resident #192 and indicated the following: Focus: This resident is at risk for altered psychosocial well-being related to Adjustment to new environment/rehab setting, decline in functional/medical status, dx Schizoaffective d/o Bipolar 1, anxiety/panic d/o, depression, FTT (failure to thrive) in adult (initiated 12/2/23) Interventions: - Activities to meet with this resident to develop and activity plan (initiated 12/2/23) - Behavioral health services as ordered and needed (initiated 12/2/23) - Encourage family members/residents representatives to be involved as allowed by resident to also participate in this plan to be able to provide direct support (initiated 12/2/23) - Encourage the resident to make their own decisions when able (initiated 12/2/23) - Encourage the resident to see a positive view of themselves (initiated 12/2/23) - Following up with responses to concerns brought up (initiated 12/2/23) - Medications as ordered to help manage their mood and behaviors (initiated 12/2/23) - Monitor and document mood and behaviors (12/2/23) - Provide 1:1 to allow this resident to verbal feeling/concerns (12/2/23) - Provide the resident praise for all their efforts made (initiated 12/2/23) - Remind this resident of their goals and reassure them on progress made (12/2/23) Review of Resident #192's other comprehensive care plans failed to indicate a care plan was developed for the Resident's history of suicidal ideation (SI). Review of the Patient Health Questionnaire-9 (PHQ-9) (an assessment of depression), dated 12/4/23, indicated Resident #192 scored a 23 out of a possible 27 points, indicating severe depression. Review of the Psychiatric Evaluation and Consultation note, dated 12/4/23, indicated Resident #192 has felt depressed since childhood and has had multiple hospitalization s related to SI. The note also indicated: Resident was admitted to unit with SI, aware of resident's verbalizing SI. The note indicated that Resident #192 was on an established medication regimen to manage his/her mood, depression, and anxiety. The psychiatric consultation note recommendations indicated the following: Monitor resident for safety, provide medications as prescribed, encourage resident to participate in unit activities. Continue to monitor acute changes in behaviors, nutrition status, and sleep patterns. Redirect when possible, maintain adequate safety precautions, appropriately use diversionary activities on the unit, and provide positive encouragement. Patient would benefit from continued treatment to promote mental wellness and emotional stability. Review of the clinical record did not indicate that social services were provided for Resident #192 between his/her admitted and 1/8/24. Review of the Social Worker progress note, dated 1/8/24, indicated the following: Resident stated that he/she wanted to die. Social Worker (SW) went to talk to Resident #192. Resident #192 stated he/she was afraid of a woman and that she will kill him/her. SW asked to describe the woman. Resident stated she worked here and gave the description of the CNA that is working with him/her. SW informed unit manager and DON. Review of the clinical record indicated on 1/24/24, Resident #192 was sent to the hospital for a planned procedure. Resident #192 returned to the facility on [DATE]. Review of the hospital discharge paperwork, dated 1/31/24, indicated Resident #192 reported suicidal ideation in the hospital and was provided a one on one sitter and was placed on a section 12 (an involuntary hospitalization if assessed to be a danger to self or others). Review of the clinical record did not indicate that social services were provided for Resident #192 between 1/31/24 and 2/16/24. Review of the clinical progress note, dated 2/16/24, indicated Resident #192 was found with a plastic bag tied around his/her neck in an attempted suicide and was sent to the hospital for evaluation. Review of the hospital paperwork, dated 2/19/24, indicated the following: Presents from his/her SNF(Skilled Nursing Facility) after staff there reportedly found him/her with a plastic bag over head in an attempt to self-harm. At that time he/she stated he/she felt like he/she 'wasn't being listened to' there and has made passive SI statement since then without much other detail . During an interview on 6/10/24 at 8:31 A.M., Social Services Assistant (SSA) #1 said that Resident #192 had some cognitive issues, but engaged the best that he/she could. Social Services Assistant #1 said that there was an adjustment period that he/she struggled with slightly due to his/her family and brother. Social Services Assistant #1 said that if a Resident verbalizes a recent SI, then that Resident should be followed on a regular basis and seen daily or once a shift to make sure they are feeling safe. Social Services Assistant #1 said that the care plan should be updated and supportive care in place During an interview on 6/6/24 at 9:36 A.M., the Social Services Assistant #1 said that he is not a social worker, but at the time Resident #192 was admitted , an outside contract service provided social worker support as needed. Social Services Assistant #1 said he would expect a care plan to be developed for suicidal ideation and if a Resident expressed suicidal ideation then the Resident should be seen immediately. During an interview on 6/10/24 at 8:30 A.M., Social Services Assistant #1 said that if a resident expressed SI then that Resident should be checked in on daily from social services to make sure they are safe. Social Services Assistance #1 said that Resident #192 was having a difficult time adjusting to the facility and his/her brothers decision to keep him/her at the facility.

Based on observations, record reviews and interviews, the facility failed to 1.) implement fall care plan interventions to prevent a fall resulting in an injury for 1 Resident (#7) 2.) failed to prevent an elopement from the facility for 1 Resident (#45) and 3.) failed to complete fall assessments and fall investigations for 1 Resident (#100) out of 28 sampled Residents. Findings include: 1. For Resident #7, the facility failed to implement fall care plan interventions (non-skid strips and a fall mat), resulting in a fall with soft tissue laceration over his/her right frontal scalp, requiring sutures (a stitch made to close a wound). Resident #7 was admitted to the facility in August 2022, with diagnoses including dementia without behavioral disturbances, anxiety, and type 2 diabetes mellitus. Review of the most recent Minimum Data Assessment Set (MDS) dated [DATE], indicated a Brief Interview of Mental Status (BIMS) score of 9 out of possible 15, indicating moderately impaired cognition. Review of Resident #7's care plan for falls dated 9/8/22, indicated the following interventions: - non-skid strips (a device used to improve traction and reduce slips) at bedside to resident floor in his/her new room, dated 11/2/22 - fall mat (a device used to reduce risk of injury from impact) on the floor, dated 11/21/22 - every 15 minute observational check, dated 11/21/22 - bed in lowest position to the floor, dated 11/21/22. - bed cradle to prevent bed sheet entanglement, dated 11/21/22. Review of resident #7's fall assessment dated [DATE] indicated a score of 11 and he/she is at high risk for falls. On 4/26/23 at 7:50 A.M., the surveyor entered Resident #7's bedroom and observed there were no non-skid strips on Resident #7's floor, as indicated in the care plan to prevent falls. Review of the facility incident report dated 3/21/23, indicated that Resident #7 was found on the floor next to his/her bed. The report also indicated Resident #7 sustained a laceration to his/her right frontal head. Resident #7 was transferred to a Hospital Emergency Department for further evaluation. Review of the Hospital report indicated Resident #7 sustained a soft tissue laceration on his/her right frontal scalp from a fall, and required suturing. During an interview with Nurse (#2) on 4/26/23 at 8:45 A.M., she said she was the nurse on duty on 3/21/23, when Resident #7 fell in his/her room and sustained the head laceration. Nurse #2 said she found Resident #7 on the floor next to his/her bed. She said that Resident #7 told her that he/she got out of bed and fell . The surveyor asked Nurse #2 if there were non-skid strips on the floor and a fall mat next to Resident #7's bed at the time of his/her fall, and she answered no. During an interview with Unit Manager (UM) #3, he acknowledged that currently there were no non-skid strips on the floor at Resident #7's bed side. 41456 2. For Resident #45, the facility failed to prevent an elopement from the facility. Resident #45 was admitted to the facility in December 2018 with diagnoses including dementia. Review of Resident #45's most recent Minimum Data Set (MDS), dated [DATE], indicates the Resident was unable to complete the Brief Interview for Mental Status (BIMS) and staff had assessed him/her to have moderately impaired cognition. The MDS also indicates the Resident requires limited assistance from staff for activities of daily living. Review of the incident report dated 6/4/22 indicated the following: *On Saturday 6/4/22, at approximately 1:30 P.M., (the Resident) received visitors (spouse) and (daughter). (The Resident) had been out to the nurses' station requesting afternoon medication. (The Resident) was noted to be dressed and had his/her purse. (The Resident) returned to his/her room after receiving medication and then was witness a few minutes later at [NAME] elevator with visitors. Nurse approached (the Resident) and visitors, siting that he/she could not go out without authorization. (The Resident) stated he/she was not going anywhere, wanted some sun, and that (the Resident) and his/her family would return in ten minutes. Nurse walked outside with them and stayed with them. She then asked the receptionist to contact the supervisor to come down for assistance, as she needed to return to the unit. Supervisor was notified and the nurse returned to the floor. After approximately 10 minutes, nurse was returning to[the] visit when [the] receptionist notified her that there was no one outside. At which time, facility grounds [were] searched, police, guardian and management team notified. Review of an admission social work note dated 12/13/18, indicated the following: *This writer spoke to (the Resident's) guardian who clarified some of the dynamics with her role, the family, and previous issues. She stated that she is supportive of family visits but not allowing (the Resident) to leave the unit with family. She said that she plans to be in to visit next week and will speak to the team then further in depth. Review of a social services not on 12/14/18, indicated the following: *(The Resident) had previously been in another facility, where he/she was removed by his/her husband, and their adopted daughter. (The Resident) was brought home and the police were involved after the guardian had contacted them. During an interview on 4/24/23 at 12:43 P.M., Unit Manager #2 said the staff were aware of Resident #45's family dynamics when admitted and he/she was never to have unsupervised visits with family. During an interview on 4/24/23 at 11:06 A.M., the Assistant Director of Nursing (ADON) said the staff were aware upon Resident #45's admission that there was a difficult family situation, and that the Resident was not to be unsupervised during visits with the family and was not allowed out of the facility with the family. The ADON said nursing should not have taken the Resident off the unit with the family and should not have left him/her alone outside with the family. 3. For Resident #100, the facility failed to complete fall assessments after 3 falls. Review of the facility policy titled, Falls Management, dated April 2015, indicated the following: *A fall risk evaluation will be conducted on each resident/patient upon admission, with the quarterly MDS (Minimum Data Set) cycle, when a significant change in status occurs, annually and following a fall. *A fall risk evaluation will be conducted by the nurse on duty/supervisor on any resident/patient sustaining a fall with or without injury. Resident #100 was admitted to the facility in September 2022 with diagnoses of diabetes. Review of Resident #100's most recent Minimum Data Set (MDS), dated [DATE], indicates the Resident has a Brief Interview for Mental Status (BIMS) score of 0 out of a possible 15 indicating the Resident has severe cognitive impairment. The MDS also indicates Resident #100 requires extensive assistance from staff for all daily functional tasks. Review of Resident #100's medical record indicated the following: *A nursing note dated 9/20/22 indicating the Resident was found kneeling next to bed. The record failed to indicate a fall assessment was completed after this fall. *A nursing note dated 10/2/22 indicating the Resident fell at 4:00 A.M. resulting in a hematoma to the right eye. The facility was unable to provide an incident report with an investigation into the cause of the fall and the medical record failed to indicate a fall assessment was completed after the fall. *A nursing note dated 11/11/22 indicating the Resident fell at 11:30 A.M. in the day room. The facility was unable to provide an incident report with an investigation into the cause of the fall and the medical record failed to indicate a fall assessment was completed after the fall. During an interview on 4/25/23 at 12:13 P.M., the Assistant Director of Nursing said after a resident falls the physician or nurse practitioner needs to be notified, a falls assessment needs to be completed and an incident report investigating the cause of the fall needs to be completed. The Assistant Director of Nursing said she was unable to find incident reports for the falls on 10/2/22 and 11/11/22 as well as fall assessments for all 3 falls. Further review of Resident #100's medical record failed to indicate the physician or nurse practitioner were notified of the Resident's falls on 10/2/22 and 11/11/22.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure he/she was free from abuse, when two staff members witnessed Certified Nurse Aide (CNA) #1 direct profanities at Resident #1, while also refusing to assist him/her in going back to bed. Finding include: Review of the Facility's Policy titled Abuse, Mistreatment, and Neglect Process, revised during April 2018, indicated all residents be free from any type of abuse. Review of the Facility's Incident Report Form, dated 11/04/21, indicated it was alleged Resident #1 was verbally abused when he/she asked CNA #1 put him/her to bed, that CNA #1 was rushing Resident #1 and was also witnessed by staff saying to Resident #1 words to the effect of you can put yourself to [OBSCENITY] ing bed. Resident #1's medical history included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Minimum Data Set assessment, dated 11/02/21, indicated he/she displayed verbal behavioral symptoms directed toward others, and required a one person extensive physical assist with transfers to bed. During an interview on 12/09/21 at 12:30 P.M., Activity Aide #1 said that on 11/03/21 sometime between 7:30 P.M. and 8:30 P.M., she witnessed a brief interaction between Resident #1 and CNA #1. Activity Aide #1 said she heard CNA #1 acknowledge that Resident #1 wanted to go to bed, and prompted Resident #1 to follow her. Activity Aide #1 said Resident #1 usually self-propelled his/her own wheelchair, and said she saw Resident #1 following five feet behind CNA #1, headed toward his/her room. Activity Aide #1 said she heard CNA #1 verbally trying to rush Resident #1, and said she heard CNA #1 twice say to Resident #1, words to the effect of come on, lets go, are you coming or not. Activity Aide #1 said Resident #1 got upset and, responding back to CNA #1 and said words to the effect of don't you see me [OBSCENITY] ing trying to CNA #1. Activity Aide #1 said CNA #1 replied back in an aggressive tone to Resident #1 and said words to the effect of I'm not your [OBSCENITY] ing maid, don't [OBSCENITY] with me, put yourself to bed. Activity Aide #1 said Resident #1 then told CNA #1 it was her job and got paid to assist him/her to bed. Activity Aide #1 said CNA #1 stated again to Resident #1 I'm not your [OBSCENITY] ing maid, don't [OBSCENITY] with me, put yourself to bed. and that CNA #1 walked away. Activity Aide #1 said Resident #1 appeared angry and sad. Activity Aide #1 said she did not know what happened afterward. During an interview on 12/09/21 at 1:50 P.M., CNA #2 said on 11/03/21 sometime between 7:00 P.M. and 8:30 P.M., she witnessed an interaction between Resident #1 and CNA #1. CNA #2 said she saw Resident #1 self-propelling his/her wheelchair at a decent pace approximately five paces behind CNA #1 along the hallway toward the nursing station. CNA #2 said she heard Resident #1 say to CNA #1 that he/she felt like she (CNA #1) was ignoring his/her request to be assisted to bed. CNA #2 said Resident #1 said words to the effect of why are you ignoring me? What the [OBSCENITY] is your problem? to CNA #1. CNA #2 said CNA #1 replied to Resident #1 in a loud agitated tone of voice, and said words to the effect of you are my [OBSCENITY] ing problem and find someone else to put you to bed because I'm not putting you to bed. CNA #2 said Resident #1 was shaking and appeared upset. CNA #2 said she saw Nurse #1 approach CNA #1 and Resident #1 to intervene and said Resident #1 was assisted by another CNA to bed. During an interview on 12/14/21 at 3:35 P.M., Nurse #1 said she did not witness the incident. Nurse #1 said Resident #1 was assisted to bed by another CNA as he/she requested. During an interview on 12/15/21 at 2:20 P.M., Social Worker #1 said on 11/04/21 she interviewed Resident #1 as a part of the facility's investigation. Social Worker #1 said Resident #1 told her that last night (11/03/21) when she asked CNA #1 to be assisted to bed, CNA #1 said to him/her words to the effect of I'm not your [OBSCENITY] ing slave, you can put yourself to [OBSCENITY] ing bed. Social Worker #1 said Resident #1 was angry, upset, and felt CNA #1 should not have spoken to him/her or treated him/her that way. Social Worker #1 said Resident #1 told her he/she was assisted to bed by another CNA as requested. Social Worker #1 said although Resident #1 provided a clear account of the incident experienced the preceding day, he/she would most likely be unable to recall events reliably after a period of time elapses. During an interview on 12/02/21 at 1:45 P.M., Resident #1 was unable to provide a consistent account of the alleged incident that occurred on 11/03/21. Although Resident #1 was unable to provide a consistent account of alleged verbal abuse by CNA #1, a reasonable person of intact cognitive functioning would have experienced mental anguish.

Based on observation, record review and interview, the facility failed for 1 sampled resident (#2) of 4 applicable residents with pressure sores, out of a total sample of 21 residents, to ensure that necessary treatment and services were provided to promote healing. Findings include: For Resident #2, the facility failed to ensure that the resident received effective, preventive interventions that would relieve pressure to the resident's coccyx, in order to prevent worsening of a pressure sore. Resident #2 was admitted to the facility in February 2014, with [DIAGNOSES REDACTED]. The resident was admitted with two stage II pressure ulcers on her/his buttocks. Review of the resident's most recent quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated that the resident was totally dependent for bed mobility, transfer, and bathing. The resident was also receiving treatment for [REDACTED]. The resident was incontinent of bowel and bladder. On 9/29/15 at 9:15 A.M., during treatment observation with Nurse #2 revealed a pressure ulcer to the resident's coccyx. The wound measured approximately 3.2 cm long x 2 cm wide and was greater than 1 cm deep. The wound had a slight odor, the surrounding tissue with brownish discoloration. There was no drainage (the previous dressing had been removed during morning care). During the treatment Nurse #2 filled the wound with a 4 inch by 4 inch gauze dressing. Review of the Resident Care Plan, dated 2/19/15, updated 9/12/15, included the following: Problem: Actual Pressure Ulcer Stage 4, lower sacrum (coccyx). Approach: * Incontinence management per plan of care (check and toilet resident every 2 hours and as necessary, provide incontinent care following each incontinence episode, provide excellent skin cleansing and creams following each change and may use briefs when out of bed to maintain dignity). * Pressure relieving device for bed and chair. * Turn and reposition frequently with care. * Weight shift in chair. Review of the clinical record indicated that the resident received various modes of treatment from 5/29/15 through 9/24/15 which included change in dressing materials and physical therapy modalities (diathermy and closed pulse pressure irrigation). Review of the clinical record indicated a Nurse Practitioner order, dated 6/5/15, for a ROHO (air-cell based cushion which mimics the pressure relieving properties of water, used to prevent and treat pressure ulcers) cushion and tilt chair for chronic non healing wound on coccyx. Review of the treatment Administration Record, dated June 2015, indicated the following: ROHO cushion and tilt chair for chronic wound on coccyx while out of bed. There were the letters FYI written in the hour column. There was not a start date or any nurses initials to signify that the ROHO cushion was in place and at the correct inflation. Review of a Physical Therapy Treatment Encounter Note, dated 6/30/15, indicated the following: Patient found sitting in wheelchair without a cushion. This PT (Physical Therapist) retrieved ROHO cushion for patient to be transferred onto by nursing staff. Nursing staff educated on proper positioning of patient on ROHO cushion at all times when in wheelchair in order to provide proper pressure relief off coccyx wound. Review of a Physical Therapy Treatment Encounter Note, dated 7/22/15, indicated the following: Patient requiring max assist to reposition sheet under patient versus cloth pad or blanket in order to decrease pressure off coccyx. Staff educated and signed training form in order to facilitate wound healing. Review of a Rehab In-Service Training Form, dated 7/22/15, indicated the following: * Please keep 1 sheet may be folded 1 time), under Resident in order to preserve skin integrity. * Please do not use cloth pad or blanket under patient while in bed or chair. This form was signed by 4 staff members. During interview on 10/1/15 at 9:05 A.M., Physical Therapist (PT) #1 said that she found the resident up in his/her chair on 6/30/15 without the ROHO cushion. She said she searched for the ROHO cushion but could not find one. She said she had to issue Resident #2 another ROHO. Surveyor #2 asked PT #1 if the ROHO cushions were normally issued from the therapy department, she said yes. Surveyor #2 asked PT #1 is she could provide documentation that a ROHO cushion had been issued on or about 6/5/15 (the date of the Nurse practitioner order for a ROHO cushion). She said the only documentation she had in regard to the ROHO cushion being issued is when she issued the ROHO cushion on 6/30/15. She continued to say that maybe the resident had a different cushion, but she didn't see any other cushion. Surveyor #2 asked PT #1 about the education the staff received in regard to placing cloth incontinent pads and blankets under the resident. PT #1 said that she found the resident on several occasions in bed and in the chair with a cloth incontinent pad located under the resident's buttocks. She said she felt she needed to do formal inservicing on 7/22/15. Surveyor #2 said that only 4 staff members signed the inservice sheet. PT #1 said she could not get everyone and it was her understanding that the Unit Managers would continue the education. During observation on 9/28/15, from 11:00 A.M. through 5:00 P.M. (6 hours), Surveyor #2 observed Resident #2 sitting up in her/his wheelchair, the hoyer lift pad was under the resident and on top of the ROHO, as the day progressed the hoyer pad became wrinkled under her/his buttocks. Surveyor #2 did not observe the resident returned to bed for incontinent care every two hours per the plan of care. During observation on 9/29/15, from 11:00 A.M. through 3:00 P.M. (4 hours), Surveyor #2 observed Resident #2 sitting up in her/his wheelchair, the hoyer lift pad was under the resident and on top of the ROHO, and as the day progressed the hoyer pad became wrinkled under her/his buttocks. Surveyor #2 did not observe the resident returned to bed for incontinent care every two hours per the plan of care. During observation on 9/30/15, from 11:00 A.M. through 5:30 P.M. (6.5 hours), Surveyor #2 observed Resident #2 sitting up in her/his wheelchair, the hoyer lift pad was under the resident and on top of the ROHO, as the day progressed the hoyer pad became wrinkled under her/his buttocks. Surveyor #2 did not observe the resident returned to bed for incontinent care every two hours per the plan of care. On 09/30/15 at 4:00 P.M., during interview Unit Manager #1 (UM #1) said that she spoke with rehab who said that the hoyer pad was not too thick, but needs to be free of wrinkles. UM #1 said unfortunately we have the old style hoyer lift so we can't take the hoyer pad off like the newer machines. UM #1 said that the resident is up no more than 4 hours during the day to aid in healing, and does not return to bed for incontinent care every two hours (per the plan of care). Surveyor #2 asked why the resident was up for at least 6 hrs which the surveyor observed on 9/28/15. UM #1 said she wasn't sure, maybe there was bingo, but then the staff should have gotten the resident up out of bed later. On 9/30/15, at 5:30 P.M., during interview, Surveyor #2 observed Resident #2 being fed supper by Certified Nursing Assistant #2. Surveyor #2 asked CNA #2 what time would Resident #2 return to bed. CNA #2 said Resident #2 would go back to bed after supper, around 7:00 P.M. that is her/his usual time. Despite the resident had been in the wheelchair since 11:00 A.M. A Physical Therapy Treatment Encounter Note, dated 6/22/15, indicated the coccyx ulcer 0.2 x 0.5 centimeters (cm), during the following months the coccyx wound deteriorated as indicated by the Wound Care Specialist Evaluation, dated 10/1/15, wound size 3.2 x 2.2 x 1.2 cm. On 9/24/15 a Wound Care Specialist Evaluation indicated that the wound size was 2.8 x 2.7 x 1.1 cm and had deteriorated, significant drainage from wound and maceration of surrounding tissues, would recommend dressing be changed back to calcium alginate/foam- recommendations discussed with nursing team and nurse practitioner. Despite this recommendation, the facility did not obtain a physician order [REDACTED]. The facility failed to prevent the worsening of Resident #2's coccyx pressure sore which started as 2 stage two pressure ulcers and progressed to one stage 4 pressure ulcer. The facility failed to consistently ensure that a pressure relieving device (ROHO cushion) was properly in place, the facility failed to ensure the resident received timely position changes (chair to bed within 4 hrs), the facility failed to ensure that timely incontinent care was provided every two hours and failed to follow the recommendation of the wound care specialist on 9/24/15, until 9/29/15, for change in the treatment regime.

Based on record review and interviews for 1 of 3 sampled residents (Resident #1) the Facility failed to ensure that Resident #1 was free from medication errors and received medications as prescribed by the Physician. At 9:00 P.M. on 12/18/13, Nurse #1 administered medications to Resident #1 that were prepoured for Resident #2. Nurse #1 said when he realized his mistake he did not inform the Physician and a short time later Resident #1 experienced [MEDICAL CONDITION] activity, became unresponsive and was transferred to the Hospital for evaluation. Resident #1 received [MEDICATION NAME] (an opioid antagonist) and intravenous fluids in the emergency room (ER) and returned to baseline level of consciousness and mental status, and was admitted to the Hospital for further observations. Findings include: Resident #1 was admitted to the Facility in November, 2013, and his/her [DIAGNOSES REDACTED]. The Surveyor interviewed Nurse #1 at 11:50 A.M. and throughout the day, on 3/12/14. Nurse #1 said that at approximately 6:00 P.M. on 12/18/13, he prepoured Resident #1's and Resident #2's evening medications and placed them in medication cups, on which he had written their names, and then placed these cups in the top drawer of the medication cart. Resident #1's monthly medication orders, dated 12/1/13, indicated Resident #1's prescribed medications, due each night at 8:00 P.M. included: [MEDICATION NAME] (an [MEDICAL CONDITION] medication) 500 mg 1 tablet, [MEDICATION NAME]-Acetamin (a narcotic [MEDICATION NAME]) 7.5-500 1 tablet, [MEDICATION NAME] (an antipsychotic medication) 300 mg 1 tablet, [MEDICATION NAME] (cholesterol lowering medication) 40 mg 1 tablet and [MEDICATION NAME] (an antidepressant medication) 100 mg 1 tablet. There was no order in place for [MEDICATION NAME] or [MEDICATION NAME]. Resident #2's monthly medication orders, dated 12/1/13, indicated Resident #2's prescribed medications, due each night at 9:00 P.M. included: [MEDICATION NAME] HCL (an antidiabetic medication) 1000 mg 1 tablet, [MEDICATION NAME] (used for the treatment of [REDACTED]. Nurse #1 said at approximately 9:00 P.M. on 12/18/13, he removed one of the medication cups, containing the prepoured medications, from the top drawer of the medication chart, and without checking the name written on the cup, administered these medications to Resident #1. Nurse #1 said that close to 10:00 P.M. he removed the second cup of prepoured medications from the medication cart, and when he went to administer these medications to Resident #2, he realized that it was Resident #1's medication cup he was holding and that he had mistakenly administered Resident #2's medications to Resident #1. Nurse #1 said he did not call the Physician and did not notify the Charge Nurse that he had administered Resident #1 the wrong medications in error. Nurse #1 said he went back to Resident #1 and administered him/her the medications he had prepoured earlier that evening. The Nurse's Progress Note, dated 12/18/13, indicated at approximately 10:00 P.M. Resident #1 was found unresponsive, his/her heart rate was 128 beats per minute, his/her blood pressure was 94/65 and his/her respirations were 20 breathes per minute. The Progress Note indicated the Physician was notified and Resident #1 was transferred to the Hospital for evaluation. Nurse #1 said as he was administering Resident #2 his/her prepoured medications, a Certified Nurse Aide (CNA) called for help with Resident #1. Nurse #1 said Resident #1 was drooling from his/her mouth and was unresponsive. Nurse #1 said he thought Resident #1 was having a [MEDICAL CONDITION] and he called the Charge Nurse for help. The Surveyor interviewed the Charge Nurse at 1:45 P.M. on 3/12/14. The Charge Nurse said Resident #1's eyes were closed, and he/she did not respond to verbal or tactile stimuli (touch). The Charge Nurse said Resident #1 was breathing, he/she did have a pulse and his/her blood pressure was audible. The Charge Nurse said he called for an ambulance and called the Physician and Resident #1 was transferred to the Hospital for further evaluation. The Hospital Discharge Summary, dated 12/22/13, indicated that in the ER Resident #1 was given [MEDICATION NAME] 0.5 milligrams (mg), and 2 liters of intravenous normal saline after which his/her blood pressure and heart rate started to improve, and he/she was admitted to the Hospital for further observation. The Discharge Summary indicated Resident #1's change in condition was most likely secondary to a medication error in which he/she inadvertently received [MEDICATION NAME] and [MEDICATION NAME] intended for another resident. Nurse #1 said when Resident #1 became unresponsive he did not tell the Charge Nurse of the earlier medication error which he had made, he did not tell the Paramedics when they arrived to transfer Resident #1 to the Hospital, and he did not place a telephone call to the ER to alert them of the medication error. The Surveyor interviewed the Director of Nurses (DON) at 9:00 A.M. on 3/12/14. The DON said Nurse #1 did not report the medication error involving Resident #1 during the course of the Facility's Investigation.

Based on observation, record review and interview, the facility failed to ensure that necessary treatment and services were provided to promote healing of a pressure ulcer for 1 of 5 applicable residents (#2) with pressure ulcers, from a total sample of 18 residents. Findings include: For Resident #2, the facility failed to ensure that the facility acquired pressure ulcer, which had worsened, was treated according to the facility's pressure sore protocols. Resident #2 was admitted to the facility in 10/09 with [DIAGNOSES REDACTED]. Presently the resident also has an unstageable right heel ulcer and a stage two pressure ulcer to the coccyx. On 5/9/12 review of the most recent quarterly Minimum Data Set (MDS), dated [DATE], indicated that the resident required extensive assist for bathing, dressing and transfers. Resident #2 is totally dependent for eating. There was no indication of a pressure ulcer at the time of this MDS. Review of the facility's house policy-pressure ulcer protocol indicated the following: *Stage one-House barrier cream (antimicrobial ointment used to protect skin, treat diaper rash and dry skin) *Stage two- If less than 0.1 centimeter(cm) deep; use house barrier cream, If greater than 0.1 cm deep; use hydrogel *Stage three-If no necrotic base; use hydrogel, if necrotic base; use Santyl ( a [MEDICATION NAME] agent used to treat pressure ulcers) *Stage four- With necrosis, use Santyl or follow orders from surgical clinic Review of the Decubitus/Pressure Ulcer Report on 5/10/12 included the following: *3/19/12 Stage two to coccyx- dimensions: 2 cm by 1 cm with depth of 0.1 cm treatment ordered barrier cream every shift (as opposed to hydrogel as the pressure ulcer protocol indicated) *3/26/12 Stage two to coccyx-dimensions: 2 cm by 1 cm, no depth charted, open pink, clean with scant serous drainage-barrier cream applied *4/3/12 no reference to the stage two pressure ulcer on coccyx *4/11/12 Stage two to coccyx- dimensions: 2 cm by 0.5 cm, depth of 0.2 cm, open area dark red with scant bleeding when cleansed ( wound worsening in depth, no change to a hydrogel product which is indicated within the facility pressure ulcer protocol) *4/19/12 Stage two to coccyx- dimensions: 1.5 cm in diameter (no indication if this is measuring the length or width) depth of wound not charted- (no change in treatment plan) *4/25/12 Stage two to coccyx-dimensions: 2 cm by 1 cm with 0.1 cm depth- (no change to treatment plan) *5/3/12 Stage two to coccyx- now two open areas- dimensions: 1.5 cm in diameter with 0.1 cm depth, and second pressure ulcer 1 cm diameter with 0.1 cm depth, base pink clean (wound worsening, no change to treatment plan) *5/9/12 Stage two to coccyx-dimensions: 2.5 cm by 2.5 cm with 0.2 cm depth, base red, scant bleeding when cleansing-barrier cream applied (wound worsening, no change to a hydrogel product which is indicated within the facility pressure ulcer protocol) The two previously noted pressure ulcers merged to create one larger pressure ulcer. On 5/10/12 at 10:00 A.M., during the treatment observation of the coccyx pressure ulcer, the surveyor observed slough(a thick, sticky, yellow or white tissue that adheres to the ulcer bed which impedes wound healing). Nurse #1 was proceeding with application of the barrier cream. The surveyor stopped the treatment and asked Nurse #1 if she could identify the material in the wound bed. She acknowledged it was slough tissue and at that time she stopped the treatment and requested that Nursing Supervisor #1 (who is also the facility wound nurse) come and assess the wound for a possible change in treatment. Nursing Supervisor #1 came into the resident's room and agreed it was slough tissue and that the physician would be notified to obtain a new treatment order. On 5/9/12 at 2:00 P.M., during interview, Nurse #1 said that the resident's pressure sore to the right heel was getting better, but the stage two to the resident's coccyx looked worse. On 5/10/12 at 10:30 A.M., during interview with Nursing Supervisor #1, the surveyor asked her why the facility did not follow their pressure ulcer protocols, as the resident's pressure ulcer had clearly worsened. Nursing Supervisor #1 said because sometimes when a resident really "wets" a lot (referring to urinary incontinence), the barrier cream works. She said that there was no provision for not following the pressure ulcer protocol, but that sometimes the staff call the doctor to work outside of the pressure ulcer protocols. She said that there was no documentation in the medical record to support that any conversation with a physician had occurred to keep using the barrier cream.

Based on observation, record review and staff interview, the facility failed to provide adequate supervision and effective interventions to prevent falls for 1 of 4 residents (#1) with falls, in a total sample of 20. This resident fell 4 times culminating in a fracture. Findings include: Resident #1 has resided in the facility since 2006. [DIAGNOSES REDACTED]. The Falls care plan initiated on 1/19/09 and in place until the resident's return from hospital after the 1/28/11 fracture, included: Problem: At risk for falls; unsteady gait, syncope, incontinent of bowel and bladder and previous history of falls. Goal: Resident will remain free from injury. Interventions: * Room well lit. * Call light within reach. * Out of bed daily with assistance. * Bed in low position with brakes on. * Provide rest periods, PRN (as needed). * Keep path clear and free of obstacles. * Proper footwear for ambulation. * Document findings. * Assist with ambulation with walker. * PT (physical therapy) Screen. * Try self-releasing seat belt. (discontinued) The ADLs care plan of the same period, includes: * The resident required extensive assist for any /all ADLs. * Assist to bathroom while out of bed. * Keep call light or bell within reach of the resident and respond appropriately to needs. Nurses' notes and nursing summaries document the resident as having moderately impaired cognition and decision-making, dizziness and transient confusion relative to metabolic [DIAGNOSES REDACTED]. Review of the clinical record and incident reports revealed the following: On 3/30/10 at 4:14PM, "Resident was observed on the floor in room close to the window.... stated, 'I was watching TV, fell asleep in the wheelchair and ended up on the floor.' ...." "Forgot or did not call for assistance." Corrective Action: "... offer to be toileted; instruct resident to seek assistance if transferring." This resident already required extensive assistance for ADLs and had been instructed to call for assistance. This intervention, however, was not appropriate for this incident as the resident fell asleep and slipped from the chair. On 4/21/10 at 3:55PM, "Resident found on floor next to night stand with door open. The resident stated 'looking for something, lost balance and fell to floor.' Sustained 2 skin tears, on left arm and right leg. Forgot or did not call for assistance." Corrective Action: "May benefit from geri-sleeves and legs... Remind resident to request assistance for ambulation, reaching up/down for articles in the room, etc." The resident had already been requested to call for assistance. This intervention continued to be ineffective and the resident fell again. On 12/9/10 at 8:50PM, "Resident heard screaming, 'Help, Help.' Found resident lying on left side on the floor next to the closet and wheelchair. Resident stated, 'I was trying to get something from my closet and slipped.' Left knee was bruised and the resident stated 'I hit my head.' Resident transferring without assistance. Change in mental status." Corrective Action: "Will be encourage to call for help whenever needed." The resident had already been requested to call for assistance. However, this intervention continued to be ineffective and the resident fell again. On 1/28/11 at 8:20PM, "Certified Nursing Assistant (CNA) toileted resident and waited outside the door upon resident request. The CNA heard resident shouting for help and when the CNA walked into the bathroom, found the resident on the right knee in front of the toilet. The CNA assisted the resident back to the toilet while calling for the nurse. The resident stated, 'I wanted to get up and I slipped.' Right knee was red and swollen, couldn't move right knee due to severe pain...10 on a scale of 1-10. Resident transferring without assistance. Change in mental status." Corrective Action: "Bathroom call light within reach. Encourage resident to call for help." The resident had already been requested to call for assistance after the previous falls. Again, this intervention continued to be ineffective and the resident had an additional fall resulting in a fracture of the upper end of the right tibia. Throughout the survey (3/7/11 to 3/9/11) each afternoon, the resident was observed in bed asleep or lying in bed awake, calling out to anyone who might pass by. The resident was frail and thin and stated to surveyor, "I hate my situation.... I use to be so independent." In summary, the facility failed to provide adequate supervision and revise the care plan. Three of the 4 falls occurred when the resident attempted to transfer without calling for assistance. The facility was aware that the resident could not be relied on to remember or be willing to call for assistance, and failed to develop interventions that addressed the resident's failure to call for help. The care plan was not revised to reflect new interventions when the old ones were found to be ineffective. The above was confirmed by Nurse #2 when interviewed on 3/8/11at 2PM.