Every finding on record at The Commons Skilled Nursing & Rehabilitation

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was dependent on staff to meet his/her care needs, the Facility failed to ensure he/she was provide quality care and treatment that met professional standards of practice, when on 01/23/26, after telling Certified Nurse Aide (CNA) #1 that he/she could not stand up any longer, CNA #1 helped lowered Resident #1 to the floor in his/her bathroom, however CNA #1 did not immediately inform nursing of the incident so he/she could be assessed for potential injury prior moving him/her, but instead waited to notify nursing after he picked Resident #1 up off the floor and transferred him/her back to bed. Findings include:Review of the facility's policy, titled Assessing Falls and Their Causes, dated 2001, indicated the following:-If a resident has just fallen or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities, and -If an assessment rules out significant injury, help the resident to a comfortable sitting, lying, or standing position, and then document the relevant details.Resident #1 was admitted to the facility in November 2025, diagnoses included non-[NAME] Lymphoma (type of blood cancer), left femur fracture, and a pelvic fracture.Review of Resident #1's Minimum Set Data Assessment, dated 11/12/25 indicated Resident #1 was dependent on staff to meet his/her care needs, and had intact cognition, evidenced by a Brief Interview for Mental Status (BIMS) score of 15/15.Review of an Incident Report, dated 01/23/26, indicated that CNA #1 lowered Resident #1 to the floor in his/her bathroom and Resident #1 sustained a right knee skin tear and a left calf hematoma.During an interview on 03/25/26 at 12:30 P.M., Resident #1 said that CNA #1 was helping him/her in the bathroom and that he/she stood up and faced the grab bar to hold on while CNA #1 provided care. Resident #1 said he/she told CNA #1 he/she needed to sit down because his/her knee was giving out and said he/she could not stand any longer. Resident #1 said CNA #1 told him/her to hold on for a minute, and because he/she could not stand any longer, CNA #1 had to lower him/her to the floor. Resident #1 said that he/she was crying because his/her right knee hurt. Resident #1 said he/she could not remember if CNA #1 got help or picked him/her up by himself. Resident #1 said once he/she was in bed, that the Nursing Supervisor and the Director of Nurses came in and asked him/her what happened.During a telephone interview on 03/25/26 at 11:06 A.M., CNA #1 said he was providing care for Resident #1 in the bathroom, he/she was standing facing the grab bar holding on, and that he had to lower him/her to the floor because he/she could not stand any longer. CNA #1 said he then got Resident #1 up by himself, put him/her in the wheelchair, and then transferred Resident #1 back to bed. CNA #1 said he did not notify a nurse until Resident #1 was back in bed, and he/she told him (CNA #1) that his/her right knee hurt. CNA #1 said he then told a nurse (exact name unknown) that he had lowered Resident #1 to the floor in the bathroom. CNA #1 said that if a resident has a fall, then a nurse should assess him/her before the resident is moved from the floor. CNA #1 said he had not considered this a fall because he had lowered Resident #1 to the floor.During a telephone interview on 03/26/26 at 208 P.M., Nurse #1 said she had not been notified by CNA #1 that he had lowered Resident #1 to the floor.During a telephone interview on 03/31/26 at 2:08 P.M., Nurse #2 said CNA #1 told her that Resident #1 got a skin tear on his/her knee during a transfer, so she went to Resident #1's room. Nurse #2 said she immediately told the Nursing Supervisor about the skin tear. Nurse #2 said that no one, including CNA #1, had informed her that Resident #1 had been lowered to the floor. During a telephone interview on 03/25/26 at 2:28 P.M., Nurse #3 said that CNA #1 had not told him that he lowered Resident #1 to the floor until after he picked him/her up, got him/her back to bed. Nurse #3 said a family member went to get the Nursing Supervisor. Nurse #3 said CNA #1 should have told him that he had lowered Resident #1 to the floor before he picked him/her up, so he/she could have been assessed, but he had not.During a telephone interview on 03/31/26 at 2:27 P.M., the (3:00 P.M. to 11:00 P.M.) Nursing Supervisor said she was called to Resident #1's unit by a family member who told her that Resident #1 had a fall. The Nursing Supervisor said CNA #1 told her that he was in the bathroom with Resident #1 and he tried to prevent him/her from falling by lowering him/her to the floor. The Nursing Supervisor said CNA #1 told her that he got Resident #1 up from the floor and transferred him/her back to bed. The Nursing Supervisor said that even though CNA #1 lowered Resident #1 to the floor, that this was considered a fall and Resident #1 should have been assessed for potential injury by a nurse before he/she (Resident #1) was moved up off of the floor. The Nursing Supervisor said CNA #1 should have pulled the emergency call light in the bathroom for help instead of getting Resident #1 up from the floor.During an in-person interview on 03/25/26 at 3:28 P.M. and a follow-up telephone interview on 03/31/26 at 3:49 P.M., the Director of Nurses (DON) said that based on her investigation, CNA #1 lowered Resident #1 to the floor in his/her bathroom, picked him/her up from the floor, and then put him/her back to bed without notifying a nurse until later. The DON said if a resident is lowered to the floor, it is still considered a fall, and a nurse must assess the resident for potential injury before he/she is moved. The DON said CNA #1 should have notified a nurse before he moved Resident #1 up off the floor.

Based on records reviewed and interviews, for three of three sampled residents (Resident #1, Resident #2, and Resident #3), the facility failed to ensure they maintained complete and accurate medical records, when their Certified Nurse Aide (CNA) flow sheets were left blank and the provision of care (e.g. bathing, dressing, grooming etc.) each resident required, was not documented as provided.Findings include: Review of the facility's policy titled, Charting and Documentation, with a revision date of 07/2017, indicated the following:-All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.1. Resident #1 was admitted to the facility in November 2025, diagnoses included Type 2 Diabetes Mellitus, Hypertension and Urinary Tract Infection.Review of Resident #1's Certified Nurse Aide (CNA) flow sheets for the month of December 2025, indicated the following dates (day, evening, and night shifts) were left blank:-12/02/25-12/04/25 through 12/08/25-12/11/25-12/13/25 and 12/14/252. Resident #2 was admitted to the facility in December 2025, diagnoses included status post fall and right lower leg infection.Review of Resident #2's CNA flow sheets for the month of January 2026, indicated the following dates (day, evening, and night shifts) were left blank:-01/02/26 through 01/04/26-01/07/26 and 01/08/26-01/12/26 and 01/13/263. Resident #3 was admitted to the facility in December 2023, diagnoses included dementia and anxiety.Review of Resident #3's CNA flow sheets for the months of December 2025 and January 2026, indicated the following dates (day, evening, and night shifts) were left blank:-12/02/25 through 12/04/25-12/06/25 through 12/15/25-12/17/25 and 12/18/25-12/20/25 through 12/22/25-12/24/25 through 12/28/25-12/30/25 and 12/31/25-01/01/26-01/03/26-01/06/26 through 01/14/26During an interview on 01/14/26 at 3:43 P.M., Certified Nurse Aide (CNA) #1 said they are supposed to document the care provided for each resident on the electronic CNA flow sheet once the care has been completed. CNA #1 said there was no [electronic] alert given to the CNA if the documentation was not completed.During a telephone interview on 01/16/26 at 11:53 A.M, the Director of Nurses (DON) said the Certified Nurse Aides (CNAs) were supposed to complete their flow sheets at the end of every shift. The DON said she was disappointed to see there were several missing days of CNA documentation for Resident #1, Resident #2 and Resident #3.

Based on observations, interviews and record review, the facility failed to use appropriate infection control practices. Specifically,1. The facility failed to use appropriate hand hygiene and use PPE (Personal Protective Equipment) in a room with Enhanced Barrier Precautions (EBPs) for one Resident (#8) out of a sample of 17 Residents.2. The facility failed to maintain infection control practices consistent with professional standards during the medication pass. Findings include:A review of the facility policy titled 'Enhanced Barrier Precautions with a revision date of March 2024 indicated the following: -Enhanced barrier precautions (EBPs) are utilized to reduce the transmission of multi-drug-resistant organisms (MDROs) to residents. -EBPs employ targeted gown and glove use in addition to standard precautions during high contact care activity (as opposed to before entering the room). -Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include device care or use (feeding tube). CDC (Center for Disease Control) guidelines for donning and doffing gloves indicate the following: To safely don (put on) gloves, you first wash your hands and then put on the first glove, followed by the second, ensuring a snug fit. To doff (take off) gloves, the CDC recommends first removing the first glove by grasping it at the wrist and peeling it off, turning it inside out, while holding it in your other gloved hand. Next, slide your bare fingers under the wrist of the second glove and peel it off, pulling it over the first glove to create a bag with both gloves inside. Immediately perform hand hygiene after removing the gloves. Resident # 8 was admitted to the facility in January 2025 with diagnoses including dysphagia. A review of the most recent Minimum Data Set (MDS) dated [DATE] did not indicate a Brief Interview Mental Status (BIMS) score because the Resident is rarely/never understood. Further review of the MDS indicated that Resident #8 is currently on a feeding tube. On 11/25/25 at 8:25 A.M., the Surveyor observed Resident #8's G-tube (Gastrostomy tube) alarm go off. Nurse #2 came into the Resident's room without a gown on, and a donned a pair of gloves. Nurse #2 straightened out the kink in the feeding tube. Nurse #2 removed his gloves, balled them in a fist, then returned to straighten out the feeding tube one more time without performing hand hygiene and donning a new pair of gloves. Nurse #2 threw the balled gloves in a trash can, left the room, performed hand hygiene outside the room. During an interview on 11/25/25 at 1:47 P.M., Nurse #2 said Resident #8's tube feed alarm goes off often because he/she sleeps on it causing it to bend and form kinks. Nurse #2 said Resident #8's room has Enhanced Barrier Precautions. Nurse #2 said he should have worn a gown prior to entering Resident #8's room. Nurse #2 said he should have performed hand hygiene and donned a new pair of gloves after he took off his gloves and returned to straighten out the feeding tube. During an interview on 11/26/25 at 9:05 A.M., the Infection Preventionist said she expects Nurses to wear gowns while providing high contact care in rooms with Enhanced Barrier Precautions. The IP said she expects Nurses to perform hand hygiene after doffing gloves, and before donning gloves to provide high contact care. During an interview on 11/26/25 at 9:06 A.M., the Director of Nurses said she expects Nurses to wear a gown prior to entering a room with Enhanced Barrier Precautions if they are going to provide high contact care. The DON said she expects Nurses to perform hand hygiene after doffing gloves and prior to donning a new pair of gloves while providing high contact care. 2. During an observation on 11/26/25 at 9:12 A.M. the surveyor observed Nurse #2 prepare medications for administration for Resident #8. Nurse #2 opened two capsules of Drizalma (an antidepressant medication) with his bare hands and poured the contents into a medication cup for administration to the Resident. During an observation on 11/26/25 at 9:33 A.M., the surveyor observed Nurse #2 prepare medications for administration for Resident #46. Nurse #2 popped two Bumex (a diuretic medication) tablets from the medication card into his bare hands and then placed them in the medication cup for administration to the Resident. During an observation on 11/26/25 at 9:47 A.M., the surveyor observed Nurse #2 prepare medications for administration for Resident #7. Nurse #2 dropped a fish oil capsule onto the medication cart, picked it up with his bare hands and placed it into the medication cup for administration to the Resident. During an interview on 11/26/25 at 9:54 A.M., Nurse #2 said that he should not have touched medications with his bare hands before administering them to the residents. During an interview on 11/26/25 at 10:39 A.M. the Director of Nurses said that nurses should not be touching medications with bare hands when preparing the medications for administration.

Based on record review and interview the facility failed to ensure the arbitration agreement provides for the selection of a venue that is convenient to both parties. The binding arbitration agreement must allow for the selection of a venue that is suitable in meeting the needs of both the resident or his or her representative, and the facility. Findings include:Resident #24 was admitted to the facility in October 2025 with diagnoses including metabolic encephalopathy, heart failure and cancer. Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #24 was moderately cognitively impaired, scoring a 12 out of 15 on the Brief Interview for Mental Status exam. Review of the facility document titled Massachusetts Health care Proxy dated 10/1/25 indicated that Resident #24's family member was the designated health care proxy. Review of the facility document titled Activation of Health Care Proxy/Durable Power of Attorney for Health Care, indicated that the health care proxy was activated on 10/15/25. Review of the facility document titled Exhibit C Arbitration Agreement dated April 2025 and signed by Resident #24's health care proxy on 10/23/25 failed to indicate the resident or his/her representative would be provided an opportunity to select a convenient venue. During an interview on 11/26/25 at 8:05 A.M., the Administrator said she was not aware of the requirement the arbitration agreement must state that the resident or his/her representative would be provided an opportunity to select a convenient venue.

Based on observation, record review and interview the facility failed to report an injury of unknown origin immediately, but not later than 2 hours after the injury was discovered, to the state agency, for one Resident (#51) out of a total sample of 17 residents. Findings include:Review of the facility policy titled Abuse, Neglect and Exploitation Prohibition and Prevention Program, dated August 2023 indicated that an injury of origin is an injury that is not observed by anyone, and cannot be explained by the resident. This type of injury is reported and investigated as potential abuse. Further review indicated that the facility must report injuries of unknown origin to the state agency within two hours. Resident #51 was admitted to the facility in November 2025 with diagnoses including dementia, and fracture of the left leg. Review of the medical record failed to indicate a completed Minimum Data set assessment.On 11/25/2025 at 8:15 A.M., the surveyor observed Resident #51's left hand to be swollen and bruised covering an area of approximately three inches in diameter. During an interview on 11/25/2025 at 8:15 A.M., Resident #51 said that the area hurts and that he/she did not know how it happened. Resident #51 also said that the area was not there yesterday. During an interview on 11/25/2025 at 8:17 A.M., Nurse #1 said that she noticed the area earlier this morning and gave the Resident Tylenol for pain. Nurse #1 said that she didn't work yesterday but did work on Sunday and the hand was not bruised or swollen on Sunday. During an interview on 11/25/25 at 1:16 P.M., the Director of Nursing said that she had found out about the bruise at 12:30 P.M., and had not started an investigation as to how the injury occurred and had not reported to the state agency. The Director of Nursing said that she didn't have to report the injury to the state agency right away and had 24 hours to do so because she didn't think that the injury was a result of abuse but was not able to determine the etiology of the injury. During an interview on 11/25/25 at 1:16 P.M., Physician #1 said that she was unable to determine how the injury occurred. The physician said that Resident #51 could have banged the area against something but was unable to determine the etiology.

Based on observation, record review and interview the facility failed to immediately investigate an injury of unknown origin for one Resident (#51) out of a total sample of 17 residents. Findings include: Review of the facility policy titled Abuse, Neglect and Exploitation Prohibition and Prevention Program, dated August 2023 indicated that an injury of origin is an injury that is not observed by anyone, and cannot be explained by the resident. This type of injury is reported and investigated as potential abuse. Further review indicated that the facility must start an investigation into the etiology of the injury immediately. Resident #51 was admitted to the facility in November 2025 with diagnoses including dementia, and fracture of the left leg. Review of the medical record failed to indicate a completed Minimum Data set assessment.On 11/25/2025 at 8:15 A.M., the surveyor observed Resident #51's left hand to be swollen and bruised covering an area of approximately three inches in diameter. During an interview on 11/25/2025 at 8:15 A.M., Resident #51 said that the area hurts and that he/she did not know how it happened. Resident #51 also said that the area was not there yesterday. Review of the progress notes failed to mention the injury on Resident #51's left hand. During an interview on 11/25/2025 at 8:17 A.M., Nurse #1 said that she noticed the area earlier this morning. Nurse #1 said that she didn't work yesterday but did work on Sunday and said the hand was not bruised or swollen on Sunday. During an interview on 11/25/25 at 1:16 P.M., the Director of Nursing said that she didn't find out about the bruise until 12:30 P.M., and had not started an investigation as to how the injury occurred. During an interview on 11/25/25 at 1:16 P.M., Physician #1 said that she was unable to determine how the injury occurred. The physician said that Resident #51 could have banged the area against something but was unable to determine the etiology.

Based on interview and record review, the facility to ensure that services provided met professional standards for one Resident (#39), out of 17 total sampled residents. Specifically, for Resident #39, the facility failed to complete a baseline AIMS (Abnormal Involuntary Movement Scale) assessment upon admission when prescribed an antipsychotic medication. Findings include: Resident #39 was admitted to the facility in November 2025 with diagnoses that included depression and anxiety disorder. Review of the most recent Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status score of 13 out of 15, indicating that the Resident is cognitively intact. Further review of the MDS indicated that the Resident takes antipsychotic medications. Review of physician's orders indicated the following:Aripiprazole (an antipsychotic medication) 10 mg (milligrams) once daily for major depressive disorder, single episode, severe without psychotic features, updated 11/21/25. Review of the November 2025 Medication Administration Record (MAR) indicated that the Resident received Aripiprazole daily beginning on 11/14/25. Review of the medical record failed to indicate that an AIMS assessment was completed. During an interview on 11/25/25 at 2:40 P.M., the Director of Nurses said that no AIMS assessment was ever completed on Resident #39. She said that the expectation is that AIMS assessments are completed on admission when a resident is taking an antipsychotic or at the initiation of an antipsychotic medication to monitor for side effects of the medication. During a follow up interview 11/26/2025 8:53 A.M., the Director of Nurses said that there was no specific facility policy for the completion of AIMS assessments.

Based on record review and interviews, the facility failed to maintain medical records in accordance with Nursing professional standards. Specifically, the facility failed to accurately transcribe physician's orders for one Resident (#8) out of a sample of 17 Residents.Findings include:A review of the facility's policy titled 'Charting and Documentation' with a revision date of July 2017 indicated the following:-All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.-Documentation in the medical record will be objective (not opinionated or speculative), and accurate.Resident #8 was admitted to the facility in January 2025 with diagnoses including dysphagia.Review of the most recent Minimum Data Set (MDS) dated [DATE] did not indicate a Brief Interview Mental Status (BIMS) score because the Resident is rarely/never understood.Further review of the MDS indicated Resident #8 was currently on a feeding tube.Review of a Nutritional Risk assessment dated [DATE] indicated the following:-Diet order/Consistency/Supplement-NPO (Nothing by mouth).Review of a Speech Therapy Evaluation and Plan of Care dated 4/9/25-5/8/25 indicated the following clinical impressions:-Patient is NPO at baseline. [sic]Review of Resident #8's November 2025 physician's orders indicated the following:-Propranolol (a medication used to treat a variety of heart, and circulatory conditions) 10 milligrams (1 tablet) oral three times daily starting 11/13/25, discontinued 11/25/25.Further review of the physician's orders indicated staff administered Propranolol as ordered from 11/13/25 at 2:00 P.M., to 11/25/25 at 2:00 P.M.During an interview on 11/26/25 at 9:12 A.M., Nurse #2 said all of Resident #8's medications should by administered via G-tube (Gastrostomy tube). Nurse #2 said Resident #8 is strictly NPO.During an interview on 11/26/25 at 9:11 A.M., the Dietitian said Resident #8 has been NPO since admission. The Dietitian said he/she should not be receiving medication by mouth.During an interview and medical record review on 11/26/25 at 10:28 A.M., the Director of Nurses and the Surveyor reviewed Resident #8's physician's orders. The DON said Resident #8 is NPO and should not be getting medication by mouth. The DON said the physician's orders were transcribed incorrectly. The DON said she expects physician's orders to be accurately transcribed.

Based on record review and interview the facility failed to ensure the arbitration agreement explicitly stated that neither the resident nor his or her representative is required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility. Findings include: Resident #24 was admitted to the facility in October 2025 with diagnoses including metabolic encephalopathy, heart failure and cancer. Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #24 was moderately cognitively impaired, scoring a 12 out of 15 on the Brief Interview for Mental Status exam. Review of the facility document titled Massachusetts Health care Proxy dated 10/1/25 indicated that Resident #24's family member was the designated health care proxy. Review of the facility document titled Activation of Health Care Proxy/Durable Power of Attorney for Health Care, indicated that the health care proxy was activated on 10/15/25. Review of the facility document titled Exhibit C Arbitration Agreement dated April 2025 and signed by Resident #24's health care proxy on 10/23/25, failed to indicate a statement that neither the resident or his/her representative is required to sign the binding arbitration agreement as a condition of admission to, or as a requirement to continue to, receive care at the facility. During an interview on 11/26/25 at 8:05 A.M., the Administrator said she was not aware of the requirement the arbitration agreement must state that neither the resident or his/her representative is required to sign the binding arbitration agreement as a condition of admission to, or as a requirement to continue to, receive care at the facility.

Based on record review, policy review, and interview, the facility failed to complete a Level I Preadmission Screening and Resident Review (PASARR- screen to determine if a resident had an intellectual or developmental disability and/or serious mental illness and needed further evaluation) for two Residents (#3 and #16), out of a total sample of 15 residents. Findings include: 1.For Resident #3 the facility failed to complete a level 1 preadmission screening and Resident Review. Resident #3 was admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder (PTSD). Review of Resident #3 most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of possible 15 indicating he/she was cognitively intact. Further review of the MDS indicated the Resident did not have any behaviors no hallucinations or delusions and had an active diagnosis of post-traumatic stress disorder. Review of Resident #3's medical record failed to indicate a Level 1 Preadmission Screening and Resident Review (PASARR) had been completed prior to admission to the facility. During an interview on 9/15/23 at 9:09 A.M ., the Director of Nursing said the facility does not complete PASARR prior to admission as all the residents admitted to the facility are either on Medicare or private pay. 43882 2. For Resident #16 the facility failed to complete a level 1 preadmission screening and Resident Review. Resident #16 was admitted to the facility in February 2023 with diagnoses including Parkinson's disease, bipolar disorder, major depressive disorder and anxiety. Review of Resident #16's Minimum Data Set (MDS) assessment dated [DATE] indicated Brief Interview for Mental Status (BIMS) score of 4 out of a possible 15 indicating severe cognitive impairment. Further review of the MDS indicated Resident #16 had taken an antidepressant and antipsychotic medication within the last 7 days. Review of Resident #16's medical record failed to indicate a Level 1 Preadmission Screening and Resident Review (PASARR) had been completed prior to admission to the facility. During an interview on 9/15/23 at 9:09 A.M ., the Director of Nursing said the facility does not complete PASARR prior to admission as all the residents admitted to the facility are either on Medicare or private pay.

Based on observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs), specifically providing assistance with grooming, for one Resident (#17) out of a total sample of 15 residents. Review of the facility policy titled Activities of Daily Living (ADL), last revised 3/2018, indicated the following: Policy Statement: *Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Policy Interpretation and Implementation: *2. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming and oral care) Resident #17 was admitted to the facility in August 2023 with diagnoses including unspecified fracture of upper end of right humerus, bicondylar fracture of tibia, and muscle weakness. Review of Resident #17's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated that he/she had a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15 which indicated that he/she has moderate cognitive impairment. The MDS also indicated Resident #17 requires extensive assistance of one person for daily self-care. On 9/13/23 9:39 A.M., Resident #17 was observed sitting in his/her room washed and dressed and had long facial hair on his/her chin. Resident #17 was asked about his/her facial hair and said he/she prefers no chin hair. Resident #17 was asked if he/she would like it removed, he/she said yes. On 9/14/23 at 8:34 A.M., and 9/15/23 at 8:26 A.M., Resident #17 was observed sitting in his/her wheelchair washed and dressed and had long facial hair on his/her chin. Resident #17 was asked if he/she was asked if he/she would like their facial hair removed during morning care, he/she said no. Review of Resident #17's Activity of Daily Living care plan, initiated 8/16/23, indicated the following intervention: *Hygiene: assist of 1 staff. Record review on 9/15/23 at 9:36 A.M., failed to indicate Resident #17 had any refusals or behaviors impeding morning care. During an interview on 9/15/23 at 8:55 A.M., Certified Nursing Assistant (CNA) #1 said facial hair removal is part of a resident's care and they should be asked if they would like it removed. CNA #1 was asked if she offered to remove Resident #17's facial hair during morning care. CNA #1 said not this morning. During an interview on 9/15/23 at 9:10 A.M., The Director of Nursing said removing unwanted facial hair is part of the daily care provided to residents and should be removed with the Resident's permission.

Based on observation, interview, and record review the facility failed to implement the care plan for an air mattress setting causing one Resident (#21) increased pain/discomfort out of a total sample of 15 residents. Resident #21 was admitted to the facility in October 2022 with diagnoses including Chronic Obstructive Pulmonary Disease, hypertension, and muscle weakness. Review of the Most Recent Minimum Data Set assessment dated [DATE], indicated a Brief Interview for Mental Status score of 15 out of possible 15 indicating intact cognition. On 9/13/23 at 8:48 A.M., the surveyor observed Resident #21 sitting up in bed eating breakfast with an air mattress set to 400 lbs. Additional observations of the air mattress set to 400 pounds (lbs.). were made on 9/13/23 at 11:18 A.M. and 3:10 P.M., 9/14/23 at 12:27 P.M. On 9/15/23 at 7:40 A.M., the surveyor observed Resident #21 lying in bed with an air mattress set to 400 lbs. Resident #21 said he/she was not comfortable in the bed. Review of Resident #21's medical record indicated the following: -Physician Order dated, 12/12/22 for a low air loss therapy mattress at all times set between 210-250 check placement and function each shift. -A Care Plan identified pressure ulcers as a problem with an intervention including low air loss therapy mattress set between 210-250 lbs. -A Care Plan identified alteration in comfort/pain with interventions including, monitor for indicators of pain, interview for pain symptoms, causes and relief patterns, and document. Assess the location and duration of pain and any contributing factors. -A nursing note dated 9/6/23 indicated Air Mattress not functioning delivery of new one expected tomorrow. -A Physician note dated 9/14/23 indicated Resident #21 was evaluated because of newly reported left anterior chest wall pain wrapping to axilla Resident #21 indicated symptoms started about the time he/she received a new mattress. Exam pain worsened with palpation and with range of motion on left shoulder, appears to most consistent with a mechanical injury and not cardiac etiology. During an observation and interview on 9/15/23 at 8:10 A.M., the surveyor observed the Director of Nursing (DON) enter Resident #21's room, check the air mattress setting and change it. The DON said the air mattress was set to the wrong setting. The DON asked Resident #21 if he/she had been uncomfortable and Resident #21 indicated he/she had. During an interview on 9/15/23 at 8:12 A.M., Resident #21 said he/he received a new air mattress maybe a week or two ago and it has been rigid. Resident #21 said the mattress now was a little softer. Resident #21 said he/she has been uncomfortable in the bed and when asked if he/she had told anyone about it said, two to three nights ago I was wild with pain. (Pain Assessment from 9/13/23 indicated Resident had pain two nights ago.) Resident #21 said he/she asked for voltaren pain gel yesterday for pain and once he/she got out of bed and sat up he/she felt better. Review of Resident #21's nursing pain record indicated the following: -9/6/23 on the 3-11 P.M. shift Resident #21 had a pain score of 4/10 and required pain medication. -9/13/23 on the 3-11 P.M. shift Resident #21 had a pain score of 5/10 and required pain medication. During an interview on 9/15/23 at 8:24 A.M., Nurse #1 said Resident #21's mattress had been replaced due to it not functioning but was unsure when it got changed out. Nurse #1 said the expectation for physicians' orders is to follow them as ordered. Nurse #1 looked at the Medication Administration Record (MAR) with the surveyor and said he omitted the order to check the air mattress function and setting. Nurse #1 said he failed to look at the air mattress for correct setting on 9/14/23. Nurse #1 said Resident #21 had expressed discomfort on 9/14/23 and he contacted the physician to assess the Resident. Nurse #1 said once Resident #21 got out of bed and was sitting in his/her wheelchair on 9/14/23 the discomfort cleared. During an interview on 9/15/23 at 9:04 A.M., the DON said the expectation is for nursing staff to follow physician's orders. The DON was unsure why the air mattress was set to 400 lbs. for the duration of the survey.

Based on observation, interview, and policy review, the facility failed to ensure medications 1. were stored properly and labeled 2. once opened, were dated as required for 2 out of 2 observed medication carts. Findings include: Review of the facility policy titled, Medication Labeling and storage revision date February 2023 included the following: -The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. -Multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. On 9/14/23 at 10:05 A.M., the surveyor observed the following while observing a medication pass on the A Unit: -An incruse inhaler, opened and undated. On 9/15/23 at 12:51 P.M., the surveyor observed the following on the B side medication cart: -Advair discus, open and undated. -Glargine insulin, with an open date of 8/15/23. During an interview on 9/15/23 at 12:51 P.M., Nurse #2 said insulin is good for 28 days once opened and the insulin should be discarded, and inhalers should be dated when opened. During an interview on 9/15/23 at 1:38 P.M., Unit Manager #1 said insulin is good for 28 days once opened and inhalers should be dated when opened.

Based on record review and interview the facility failed to ensure a plan of care was developed for Trauma-Informed Care for one Resident (#3), who was admitted with the diagnosis of Post-Traumatic Stress Disorder (PTSD), out of a total 15 sampled residents. Findings include: Review of the facility policy titled 'Trauma Informed and Culturally Competent Care' revised August 2022, indicated the following but not limited to: *To guide staff in providing care that is culturally competent and trauma- informed in accordance with professional standards of practice. *To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. *Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. Resident #3 was admitted to the facility on [DATE] with diagnoses including post traumatic stress disorder (PTSD). Review of Resident #3 most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of possible 15 indicating he/she was cognitively intact. Further review of the MDS indicated the Resident did not have any behaviors, no hallucinations or delusions, and had an active diagnosis of post traumatic stress disorder. Review of Resident #3's medical record failed to indicate a trauma informed care plan. During an interview on 9/15/23 at 9:09 A.M ., the Director of Nursing said that social services will see the residents if they have a diagnosis of PTSD and a care plan is developed. She further said Resident #3 should have a trauma informed care plan.

Based on record review, policy review and interview, the facility failed to implement an Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics and failed to complete Antibiotic usage audit tools (Line Listings), which are used to guide decisions for evaluating antibiotic prescribing patterns in accordance with the Antibiotic Stewardship Program for one resident (#16) out of a total sample of 15 residents. Findings include: Review of facility policy titled, Infection Control and Antibiotic Stewardship Program undated included the following: -Infection preventionist have been assigned responsibility for promoting an overseeing the antibiotic stewardship program, -Tracking as part of current surveillance the number of doses of each specific antibiotic and the site will be recorded. -Monthly surveillance reports are presented at the Infection Control and antibiotic stewardship committee and QAPI. Resident #16 was admitted to the facility in February 2023 with diagnoses including Parkinson's disease and atrial fibrillation. Review of Resident #16's Minimum Data Set (MDS) assessment dated [DATE] indicated Brief Interview for Mental Status score of 4 out of a possible 15 indicating severe cognitive impairment. Further review of the MDS indicated Resident #16 was always incontinent. During an interview on 9/13/23 at 11:42 A.M., Resident #16's family member said he/she has had 4-5 Urinary Tract Infections (UTI) since admission in February 2023. Resident #16's family member said he/she was unsure why Resident #16 continued getting UTI's. Review of Resident #16's Physician Progress Notes dated 9/11/23 indicated the following: -3/22/23 urinalysis, culture pending, will start vantin as awaiting culture and sensitivity results. -4/7/23, since last seen has completed a course of vantin. Back at baseline. -4/21/23, recent confusion x2 days. Check urinalysis, culture and sensitivity will start vantin course and monitor. -6/13/23, Urinalysis suggestive of UTI will begin course of vantin. -6/28/23, Has had 3 UTI's since admission. -9/6/23, Asked to evaluate as has had blood in urine, mildly confused from baseline. Will obtain Urinalysis Culture and Sensitivity, likely UTI. -9/8/23, urine sent to evaluate hematuria for UTI. -9/11/23, Started on vantin, urine culture pending. Review of the Infection Preventionist (IP) line listing of infections indicated Resident #16 had a UTI with antibiotic use in March 2023 and June 2023. Line Listings failed to indicate infection in month of April 2023 and September 2023 with antibiotic use. During an interview on 9/15/23 at 12:09 P.M., the Infection Preventionist (IP) said she obtained information on who has been started on an antibiotic primarily from other staff. The IP said she has her line listing is a combination of on the computer and on paper. The IP said she has not done any specific education with physician or staff on antibiotic stewardship besides handing them a blank McGeer's form (A form that helps identify if antibiotics should be used for symptoms). The IP was unable to say if she had questioned Resident #16 being placed directly on an antibiotic multiple times prior to culture results coming back. The IP said she missed that Resident #16 was on antibiotics for a UTI in the month of April. Review of Resident #16's medical record indicated the following: -Physician order dated 9/8/23 cefpodoxime 100 milligram (mg) tablet by mouth twice a day for UTI, last dose 9/13/23. -Lab Results preliminary 9/11/23 resulted Klebsiella Pneumoniae ssp pneumoniae, did not indicate treatment of cefpodoxime as susceptible. -Lab Results dated 9/12/23 preliminary resulted Klebsiella Pneumoniae ESBL. Lab results noted that Resident is being treated with Vantin 100 mg BID until 9/14/23. Susceptible antibiotics failed to indicate Vantin (Cefpodoxime) as appropriate medication.

Based on record review and interview, the facility failed to transmit discharge Minimum Data Sets (MDS's) within 14 days after completion for 22 Residents (#9, #6, #23, #4, #3, #25, #18, #22, #26, #21, #19, #7, #20, #13, #11, #14, #5, #15, #12, #8, #16, and #10) out of a total sample of 34 residents. Findings include: Review of the Minimum Data Sets for the following residents indicated that a discharge MDS had been started, and not transmitted within 14 days, on the following dates: - Resident #9 had a discharge MDS initiated on 3/8/22. - Resident #6 had a discharge MDS initiated on 3/28/22. - Resident #23 had a discharge MDS initiated on 4/3/22. - Resident #4 had a discharge MDS initiated on 3/5/22. - Resident #3 had a discharge MDS initiated on 2/18/22. - Resident #25 had a discharge MDS initiated on 8/6/22. - Resident #18 had a discharge MDS initiated on 3/16/22. - Resident #22 had a discharge MDS initiated on 5/6/22. - Resident #26 had a discharge MDS initiated on 4/13/22. - Resident #21 had a discharge MDS initiated on 3/18/22. - Resident #19 had a discharge MDS initiated on 3/30/22. - Resident #7 had a discharge MDS initiated on 3/24/22. - Resident #20 had a discharge MDS initiated on 5/6/22. - Resident #13 had a discharge MDS initiated on 3/4/22. - Resident #11 had a discharge MDS initiated on 3/3/22. - Resident #14 had a discharge MDS initiated on 3/21/22. - Resident #5 had a discharge MDS initiated on 3/7/22. - Resident #15 had a discharge MDS initiated on 3/12/22. - Resident #12 had a discharge MDS initiated on 3/31/22. - Resident #8 had a discharge MDS initiated on 4/20/22. - Resident #16 had a discharge MDS initiated on 4/20/22. - Resident #10 had a discharge MDS initiated on 3/30/22. During an interview on 8/10/22 at 10:04 AM the MDS coordinator said that the discharge MDS should have been submitted and wasn't. She said that the staff has been busy with everything after COVID and it probably slipped through the cracks.

Based on observations, interviews and facility policy review, the facility failed to implement infection control procedures to reduce the possible transmission of communicable diseases including COVID-19 by failing to perform hand hygiene when indicated on 1 of 1 resident units. Findings include: Review of the Centers for Disease Control (CDC) guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated Dec. 14, 2020, indicated the following: *Hand Hygiene-HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. *Put on clean, non-sterile gloves upon entry into the patient room or care area. *Change gloves if they become torn or heavily contaminated. *Remove and discard gloves before leaving the patient room or care area, and immediately perform hand hygiene. The facility policy titled Handwashing/Hand Hygiene, undated, indicated: * The facility considers hand hygiene the primary means to prevent the spread of infections. * All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. * Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situation: (f) Before donning sterile gloves. (l) After contact with objects (e.g., medical equipment in the immediate vicinity of the resident. On 1/8/21 at 9:00 A.M., the surveyor observed the facility's one unit (6 COVID-19 recovered residents and 3 COVID-19 negative residents). The following observations were made: * At 9:09 A.M., a Certified Nursing Assistant (CNA) #1 walked onto the unit, pushing a cart of beverages and glasses. CNA #1 stopped at a room, and without performing hand hygiene, after having touched the potentially contaminated cart, put on a pair of gloves, contaminating the gloves. CNA #1 then entered the resident room briefly and exited carrying the resident's breakfast tray. She performed hand hygiene, and then returned to the cart. * At 9:12 A.M., CNA #1 pushed the cart and stopped at another resident room. The resident in this room was negative for COVID-19. Without performing hand hygiene, after having touched the potentially contaminated cart, CNA #1 put on a pair of gloves, contaminating the gloves. CNA #1 then entered the resident room briefly and exited carrying the resident's breakfast tray. She performed hand hygiene, and then returned to the cart. * At 9:14 A.M., CNA #1 pushed the cart and stopped at another resident room. The resident in this room was negative for COVID-19. Without performing hand hygiene, after having touched the potentially contaminated cart, CNA #1 put on a pair of gloves, contaminating the gloves. CNA #1 then entered the resident room briefly and exited carrying the resident's breakfast tray. She performed hand hygiene, and then returned to the cart. * At 9:17 A.M., CNA #1 pushed the cart and stopped at another resident room. Without performing hand hygiene, after having touched the potentially contaminated cart, CNA #1 put on a pair of gloves, contaminating the gloves. CNA #1 then entered the resident room briefly and exited carrying the resident's breakfast tray. She performed hand hygiene, and then returned to the cart. * At 9:21 A.M., CNA #1 pushed the cart and stopped at another resident room. Without performing hand hygiene, after having touched the potentially contaminated cart, CNA#1 put on a pair of gloves, contaminating the gloves. CNA #1 then picked up a pitcher of water in one gloved hand, contaminating the pitcher, and a glass in the other with the gloved hand inside of the glass, contaminating the surface of the glass, and entered the room to leave the items with the resident. *At 9:23 A.M., CNA #1 pushed the cart and stopped at another resident room. Without performing hand hygiene, after having touched the potentially contaminated cart, CNA #1 put on a pair of gloves, contaminating the gloves. CNA #1 then picked up a pitcher of water in one gloved hand, contaminating the pitcher, and a glass in the other gloved hand, contaminating the surface of the glass, and entered the room to leave the items with the resident. * At 9:25 A.M., CNA #1 pushed the cart and stopped at a table where a resident was seated in the common area of the unit. Without performing hand hygiene, after having touched the potentially contaminated cart, CNA #1 put on a pair of gloves, contaminating the gloves. CNA #1 then picked up a pitcher of water in one gloved hand, contaminating the pitcher, and a glass in the other gloved hand, contaminating the surface of the glass, and provided both to the resident (resident is COVID-19 negative). * At 9:27 A.M., CNA #1 pushed the cart and stopped at the unit's kitchenette area. CNA #1 picked up a used pitcher of water in one hand and a used glass in the other hand and placed them on her cart. Then, without performing hand hygiene, she pushed the cart off of the unit. * At 9:34 A.M., CNA #1 returned to the unit and stopped at a resident room. CNA #1 opened a drawer outside the room and removed a gown. She put on the gown, then without performing hand hygiene after having touched the potentially contaminated drawer, CNA#1 put on a pair of gloves and entered the room to assist the resident. * At 9:36 A.M., CNA #2 opened a drawer outside a resident room and removed a gown. He put on the gown, then without performing hand hygiene after having touched the potentially contaminated drawer, CNA#2 put on a pair of gloves. As he was walking toward the resident room, where a resident had called him for assistance, he stopped and with his gloved hand picked up a piece of trash on the floor and placed it in a receptacle. Then, without removing the gloves or performing hand hygiene, CNA#2 knocked on the door of the resident's room with a gloved hand, contaminating the door's surface, and entered the room to assist the resident. * At 9:42 A.M., a Nurse (#1), without performing hand hygiene, put on a pair of gloves outside a resident room. He then opened a drawer with the gloved hands, potentially contaminating the drawer and gloves, and removed a gown. Nurse #1 put on the gown, potentially contaminating the gown's surface and entered the room to assist the resident. On 1/8/21 at 11:02 A.M., during an interview with the facility's Assistant Director of Nursing (ADON) she said that it was the expectation, and facility policy, that staff disinfect or wash their hands before putting on gloves and after contact with the resident' environment, due to the risk of spreading pathogens. CMS (Centers for Medicare and Medicaid Services) considers CMS and CDC COVID-19 guidance to be a national standard. The facility failed to abide by the standard and transmission-based precautions identified in its own policies and procedures, thus increasing the potential for transmission of COVID-19 in the facility.

Based on observation, record review and interview the facility staff failed to notify the physician of a change in condition for 1 Resident (#138) out of a total 12 sampled residents. Findings include: The facility policy for Change in a Resident's Condition or Status, revised (MONTH) (YEAR), indicated the following: * The nurse will notify the resident's attending Physician or Physician-on-call when there has been a significant change in the resident's physical condition. * A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. Resident #138 was admitted to the facility in 9/2019, with [DIAGNOSES REDACTED]. Review of Resident #138's note dated 9/5/19, indicated that Resident #138 was alert and oriented and able to make needs known. Review of Resident #138's pain assessment, completed on 9/5/19, indicated that Resident #138 reported a pain level of 4 out of 10, and indicated the location of the pain was generalized. During the pain assessment Resident #138 responded that it was very important that his/her pain be completely eliminated. During an interview on 9/8/19, at 8:24 [NAME]M., Resident #138 said that he/she had arrived to the facility a few days earlier and prior to this he/she had lived alone and was independent with his/her care and walked without a device. He/she explained that presently he/she was having a major setback and said I have severe, excruciating pain in my right foot and I have no explanation to what caused it and the nurses and therapists know about it, but nothing has been done. Further, he/she said I am very frustrated because I can't progress with this pain. I can't stand on my foot without having pain and it is sheer torture. Throughout the entire conversation the surveyor observed that the Resident grimaced and multiple times he/she also paused, putting his/her head backward with a pained look on his/her face. Resident #138's clinical record was reviewed on 9/09/19, at 1:35 P.M., and indicated the following: 1.) A nursing note dated 9/5/19, the resident denied any pain or discomfort. 2.) A pain care plan was created on 9/5/19 with the the following interventions: *Complete the pain assessment upon admission, quarterly and as needed when intensity/location of the pain changes. * If pain is unrelieved by current interventions, contact the physician 3.) A physician's orders [REDACTED]. 4.) A nursing progress note dated 9/8/19, at 1:45 P.M., that indicated that Resident #138 complained of right foot pain and that the pain was only noted when the foot was rotated internally. The note further indicated that the physician would evaluate the resident in the morning, that therapy was aware of the pain, and that the resident had not gotten out of bed on that day. Additionally, the note indicated that Resident #138 had required Tylenol twice that day. The clinical record failed to indicate that the physician had been notified that the pain was not relieved by the current interventions as per the facility policy and in accordance with Resident #138's care plan. 5.) A nursing progress note dated 9/8/19, at 10:46 P.M., indicated that the resident continued to complain of right foot pain. The clinical record again failed to indicate that the resident's physician or an on call physician was notified of the foot pain. Review of the clinical record on 9/10/19, at 9:00 [NAME]M., failed to indicate that the physician had been notified of the change in Resident #138's condition. On 9/10/19, at 9:00 [NAME]M., the Medication Administration Record [REDACTED]. There was no evidence to indicate Resident #138's pain had been assessed by nursing on 9/7/19 or 9/8/19. On 9/8/19 Resident #138 was administered Tylenol at 8:28 [NAME]M., and 3:09 P.M. On 9/9/19 Resident #138 was administered Tylenol at 8:19 [NAME]M. There was no documentation indicating what pain level Resident #138 had reported each time he/she received the Tylenol or that it was effective in treating the resident's pain. On 9/10/19, at 9:15 [NAME]M., the surveyor met Resident #138 who was in bed. Resident #138 said that he/she had not seen a physician since the first day at the facility and that the right foot pain had gotten progressively worse, causing him/her to spend most each day in bed. Resident #138 again said that the pain was sheer torture and at this point the pain was so prohibitive that he/she now needed to use a wheelchair, and could barely participate in the therapy that he/she had come to the facility for. The physical therapy and occupational therapy progress notes were reviewed on 9/10/19, at 9:40 [NAME]M., and indicated the following: 1.) During the physical therapy screening on 9/5/19, Resident #138 reported that he/she had sharp pain in the right foot when weight bearing and that the pain was an 8 out of possible 10. Further, the resident reported that the pain was exacerbated by standing. This was new from the admission pain assessment completed by nursing. The assessment indicated the resident was independent ambulating without a device prior to the recent hospitalization . 2.) On 9/6/19 Resident #138 had a physical therapy session and Resident #138 experienced fluctuating pain that he/she reported at 10 out of possible 10 that was exacerbated by standing. The clinical record failed to indicate that the physician was notified that in the 9/6/19 therapy session Resident #138 was reporting a significant change in his/her pain level. 3.) On 9/7/19 Resident #138 had an occupational therapy session and the therapist documented that the resident reported 7 out of possible 10 pain that was limiting his/her functional abilities. Further, the therapist documented that Resident #138 stated the pain in the right foot impacted his/her ability to transfer or take steps. The clinical record failed to indicate that the physician was notified that in the 9/7/19 occupational therapy session Resident #138 was reporting a significant change in his/her pain level. 4.) On 9/8/19 Resident #138 had a physical therapy session and the therapist documented that Resident #138 refused to ambulate and informed the therapist the right foot pain he/she was experiencing was torture. Additionally, the therapist noted that Resident #138 had received Tylenol prior to the therapy session with no relief of symptoms. The clinical record failed to indicate that the physician was notified that in the 9/8/19 physical therapy session Resident #138 reported pain that was not responding to the current pain control intervention. During an interview with Nurse #1 on 9/10/19, at 9:40 [NAME]M., he said that he was aware that Resident #138 had complained of foot pain but that he was not sure if the resident had been seen by the physician for the pain. He checked the communication book used by the nurses to communicate with physicians and said that there was no mention of Resident #138 in the book. As well, he reviewed the clinical progress notes and said that there was no indication that the physician was contacted regarding the worsening pain and there was no evidence of new orders for Resident #138 related to his/her worsening pain. During an interview with Resident #138's Physical Therapist (PT) on 9/10/19, at 9:45 [NAME]M., she said that she had performed the evaluation of Resident #138 on 9/5/19 and that he/she had complained of off the charts pain the minute his/her right foot hit the floor. She said that Resident #138 said that he/she couldn't stand without being in 10 out of possible 10 pain. She explained that after 10 minutes she was able to get him/her to stand and that she had made a decision to monitor the pain further before addressing it with the doctor. On 9/10/19, at 9:58 [NAME]M., the Director Of Nursing (DON) said that she had spoken with Resident #138's physician and the physician confirmed it was the first time that he was being informed of the Resident #138's worsening pain and change in condition. The DON said that the physician should have been notified of the pain so that a plan for treatment could be determined. On 9/10/19, at 10:17 [NAME]M., the surveyor accompanied the DON to meet with Resident #138. The DON assessed Resident #138's right foot, and when the DON touched his/her foot the resident grimaced. Resident #138 told the DON that it was frustrating to not be able to participate in rehabilitation due to the worsening pain. On 9/10/19, at 10:30 [NAME]M., the DON said to the surveyor that she knew nothing of the worsening pain that Resident #138 had been experiencing, or of the impact that it was having on his/her ability to participate in rehabilitation. She further said that it was the facility policy, as as well as her expectation, that the physician be notified so that treatment decisions and/or orders could be obtained. On 9/10/19, at 10:43 [NAME]M., During a follow-up with the DON she stated that the physician had not been notified that Resident #138 had not been responding to current interventions in place to treat pain and was experiencing worsening pain. She also said that the physician was aware now. The physician had ordered tests and said that he would come in later that day to assess the resident. Review of the physician's orders [REDACTED].M. indicated new orders for Stat X-Ray for right foot and right ankle, 3 views each. Obtain Uric Acid Level now. [MEDICATION NAME] 100 mg. capsule - 2 capsules by mouth every day for tight foot pain. [MEDICATION NAME] 20 mg. tablet - 1 tablet by mouth every day for right foot pain x 5 days. Review of the physician progress notes [REDACTED]. M. indicated Resident #138 stated that he/she had an episode of very similar pain in (MONTH) and was diagnosed with [REDACTED]. The progress note also indicated the pain continued to escalate in the hospital and had now worsened here. Staff and patient report that he/she was previously ambulatory, able to walk at least 30 feet, but now bearing weight is difficult due to pain. We have started Tylenol, renally dosed [MEDICATION NAME] (for Diabetes Mellitus neuropathic component), checking plain films (X-rays), and started a [MEDICATION NAME] burst for possible recurrent gout. Since receiving medications, patient's pain is reported to have dropped to a 2 out of 10 and this is corroborated during this provider's visit with the patient today. The facility failed to notify the physician of Resident #138's complaints of new and worsening foot pain for 5 days, during which the resident's pain was initially reported by the resident as a 4 out of 10 and progressed to (7 to 10) out of 10 pain level, which prevented Resident #138 from standing, walking and fully participating in his/her rehabilitation program.

Based on observation, record review and interview the facility staff failed to provide adequate pain management to 1 Resident (#138) out of a total 12 sampled residents. Findings include: The facility policy for Pain, undated, indicated the following: * The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. * The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated; for example ambulation or repositioning. * The physician will perform or order appropriate tests as needed to help clarify the sources of pain. For example, an x-ray. * The staff will reassess the individual's pain and related consequences at regular intervals; at least each shift for acute pain. * The staff will discuss significant changes in level of pain comfort with the Attending Physician who will consider adjusting interventions accordingly. Resident #138 was admitted to the facility in 9/2019, with [DIAGNOSES REDACTED]. Review of a nursing note for Resident #138's dated 9/5/19, indicated that Resident #138 was alert and oriented. Review of Resident #138's pain assessment dated [DATE], indicated that Resident #138 reported a pain level of 4 out of 10 and indicated the location of the pain was generalized. During the pain assessment Resident #138 responded that it was very important that his/her pain be completely eliminated. During an interview on 9/8/19, at 8:24 [NAME]M., Resident #138 said that he/she had arrived to the facility a few days earlier and prior to this he/she had lived alone and was independent with his/her care and walked without a device. He/she explained that presently he/she was having a major setback and said I have severe, excruciating pain in my right foot and I have no explanation to what caused it and the nurses and therapists know about it but nothing has been done. Further, he/she said I am very frustrated because I can't progress with this pain. I can't stand on my foot without having pain and it is sheer torture. Throughout the entire conversation the surveyor observed that the Resident grimaced and multiple times he/she also paused, putting his/her head backward with a pained look on his/her face. Resident #138's clinical record was reviewed on 9/09/19, at 1:35 P.M., and indicated: 1.) A nursing note dated 9/5/19, that documented that the Resident denied any pain or discomfort. 2.) Resident #138 had reported a pain level of 4 out of 10 on a 9/5/19 pain assessment and a pain care plan was created on 9/5/19 with the the following interventions: *Complete the pain assessment upon admission, quarterly and as needed when intensity/location of the pain changes. *If pain is unrelieved by current interventions, contact the physician. 3.) A physician's orders [REDACTED]. 4.) A nursing progress note dated 9/8/19 at 1:45 P.M., indicated that Resident #138 complained of right foot pain and that the pain was only noted when the foot rotated internally. The note further indicated that the physician would evaluate the resident in the morning, that therapy was aware of the pain and that the resident had not gotten out of bed on that day. Additionally, the note indicated that Resident #138 had required Tylenol twice that day. The clinical record failed to indicate that a pain assessment had been completed per the facility policy and in accordance with Resident #138's care plan. Although the nurse documented the Resident would see the physician in the morning there was no documentation to indicate that the physician was informed of the pain or saw the resident on 9/9/19. 5.) A nursing progress note dated 9/8/19, at 10:46 P.M., indicated that the resident continued to complain of right foot pain. The clinical record failed to indicate that a pain assessment had been completed per the facility policy and in accordance with Resident #138's care plan. Further, the record failed to indicate if the tylenol was effective in treating the pain. Further review of the clinical record on 9/10/19, at 9:00 [NAME]M., failed to indicate that Resident #138 had been reevaluated by the physician for the new/worsening pain as indicated in the progress note of 9/8/19. On 9/10/19, at 9:00 [NAME]M., the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. On 9/8/19 the Resident was administered Tylenol at 8:28 [NAME]M., and 3:09 P.M. On 9/9/19 the Resident was administered Tylenol at 8:19 [NAME]M. There was no documentation of the pain level Resident #138 had reported each time he/she received the Tylenol or evaluation of effectiveness after he/she received the tylenol. As of 9/10/19, at 9:15 [NAME]M., no further assessments of pain had been completed. On 9/10/19, at 9:15 [NAME]M., the surveyor met with the resident who was in bed. Resident #138 said that he/she had not seen a physician since the first day at the facility and that the pain in his/her foot had gotten progressively worse causing him/her to spend most of each day in bed. The Resident again said that the pain was sheer torture and that at this point the pain was so prohibitive that he/she now needed to use a wheelchair and could barely participate in the therapy that he/she had come to the facility for. The physician progress notes [REDACTED]. The physical therapy and occupational therapy progress notes were reviewed on 9/10/19, at 9:40 [NAME]M., and indicated the following: 1.) During the physical therapy screening on 9/5/19, Resident #138 reported that he/she had sharp pain in the right foot when weight bearing and that the pain was an 8 out of possible 10. Further, the resident reported that the pain was exacerbated by standing. This was new from the admission pain assessment completed by nursing. The assessment indicated the Resident was independent ambulating without a device prior to hospitalization . 2.) On 9/6/19 the Resident had a physical therapy session and the Resident experienced fluctuating pain that he/she reported at 10 out of possible 10 that was exacerbated by standing. The clinical record failed to indicate that a pain assessment had been completed per the facility policy and in accordance with Resident #138's care plan. 3.) On 9/7/19 the Resident had an occupational therapy session and the therapist documented that the Resident reported 7 out of possible 10 pain that was limiting his/her functional abilities. Further, the therapist documented that the Resident stated the pain in the right foot impacted his/her ability to transfer or take steps. The clinical record failed to indicate that a pain assessment was completed. 4.) On 9/8/19 the Resident had a physical therapy session and the therapist documented that the Resident refused to ambulate and informed the therapist the right foot pain he/she was experiencing was torture. Additionally, the therapist noted that the resident had received Tylenol prior to the therapy session with no relief of symptoms. The clinical record failed to indicate that a pain assessment was completed. During an interview with Nurse #1 on 9/10/19, at 9:40 [NAME]M., he said that he was aware that Resident #138 had complained of foot pain but that he was not sure if the Resident had been seen by the physician for the pain. He checked the communication book that the nurses used to communicate with physicians and said that there was no mention of Resident #138 in the book. As well, he reviewed the clinical progress notes and said that there was no mention that the physician was notified regarding the worsening foot pain and no new orders related to the pain. During an interview with Resident #138's Physical Therapist (PT) on 9/10/19, at 9:45 [NAME]M., she said that she had performed the initial evaluation of Resident #138 on 9/5/19 and that he/she had complained of off the charts pain the minute his/her right foot hit the floor. She said that Resident #138 said that he/she couldn't stand without being in 10 out of possible 10 pain. She explained that after 10 minutes she was able to get him/her to stand, and that she had made a decision to monitor the pain further before addressing it with the doctor. On 9/10/19, at 9:58 [NAME]M., the Director Of Nursing (DON) said that she was not aware that Resident #138 was experiencing worsening pain. She said that she had spoken with the physician and the physician confirmed that it was the first time that he was being informed of the Resident #138's worsening foot pain and change in condition. The DON said that the physician should have been notified of the pain so that a plan for treatment could be determined. On 9/10/19 at 10:17 [NAME]M., the Surveyor accompanied the DON to meet with Resident #138. The DON assessed Resident #138's right foot, and when the DON touched his/her foot the Resident grimaced. Resident #138 told the DON that it was frustrating to not be able to participate in rehabilitation due to the worsening pain. On 9/10/19, at 10:30 [NAME]M., the DON said to the surveyor that she knew nothing of the worsening pain that Resident #138 had been experiencing, or of the impact that it was having on his ability to participate in rehabilitation. She further said that it was the facility policy, as as well as her expectation, that the physician be notified so that treatment decisions and/or orders could be obtained. On 9/10/19, at 10:43 [NAME]M., During a follow-up with the DON she stated that the physician had not seen the Resident since 9/5/19 nor had he known of the change in his/her pain status, but now that he was aware of what was going on, a plan was being formulated. The DON said that in addition to ordering labs and an x-ray of the right foot and right ankle with 3 views each that he had decided to treat the pain as a gout flare up and ordered 20 mg of [MEDICATION NAME] (a medication to treat [MEDICAL CONDITION] conditions) for 5 days and 200 mg of [MEDICATION NAME] (a pain medication). Review of the physician's orders [REDACTED].M. indicated new orders for Stat X-Ray for right foot and right ankle, 3 views each. Obtain Uric Acid Level now. [MEDICATION NAME] 100 mg. capsule - 2 capsules by mouth every day for tight foot pain. [MEDICATION NAME] 20 mg. tablet - 1 tablet by mouth every day for right foot pain x 5 days. Review of the physician progress notes [REDACTED]. M., indicated Resident #138 stated that he/she had an episode of very similar pain in (MONTH) and was diagnosed with [REDACTED]. The progress note also indicated the pain continued to escalate in the hospital and had now worsened. Staff and patient report that he/she was previously ambulatory, able to walk at least 30 feet, but now bearing weight is difficult due to pain. We have started Tylenol, renally dosed [MEDICATION NAME] (for Diabetes Mellitus neuropathic component), checking plain films (X-rays), and started a [MEDICATION NAME] burst for possible recurrent gout. Since receiving his/her first dose of the [MEDICATION NAME], patient's pain is reported to have dropped to a 2 out of 10 and this is corroborated during this provider's visit with the patient today. The facility failed to respond to Resident #138's identified and increasing pain level for 5 days, which resulted in Resident #138's ineffective pain management, inability to stand or ambulate without significant pain and inability to fully participate in the rehabilitation program.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure that alleged incident of verbal abuse was reported to the Department of Public Health (DPH) within two hours as required. Findings include: The Facility Policy titled, Abuse Investigation and Reporting, revised 07/2017, indicated all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Resident #1 was admitted to the Facility in (MONTH) 2019. The Facility Investigation, dated 04/19/19, indicated that on 04/18/19 at approximately 11:30 P.M., Nurse #1 heard Resident #1 say They are going to kill me or words to that effect, and Certified Nurse Aide (CNA) #1 responded If you don't sit down, I'm going to kill you or words to that effect. The Investigation indicated the Director of Nurses (DON) was notified at 1:20 A.M. on 04/19/19 by Nurse Supervisor #1. Review of the Health Care Facility Reporting System (HCFRS) indicated the alleged verbal abuse that occurred on 04/18/19, involving Resident #1, was not reported to Department of Public Health (DPH) until 04/19/19 at 12:15 P.M., greater than 12 hours after the alleged incident. The Surveyor interviewed Director of Nurses (DON) at 11:15 A.M. on 05/07/19. The DON said allegations of verbal abuse should be reported to the DPH within two hours of the allegation.