Every finding on record at The Guardian Center

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had an activated Health Care Proxy (HCP), the Facility failed to ensure that nursing staff promptly notified his/her Health Care Agent (HCA) when he/she experienced a significant change in status, related to the development of Moisture-Associated Skin Damage (MASD) to his/her buttocks.Findings include:Review of Facility Policy titled Change in a Resident's Condition or Status, dated as revised February 2021, indicated that the Facility promptly notifies the resident, his/her attending physician and the resident's representative of changes in the residents' medical/mental conditions and/or status.Resident #1 was admitted to the Facility in February 2025, diagnoses included Parkinson's disease, Dementia, and Type II Diabetes Mellitus.Review of Resident #1's Physician's Progress Note to Activate Health Care Proxy Form, dated 02/17/25, indicated his/her Health Care Proxy had been activated. Review of Resident #1's Annual Minimum Data Set (MDS) Assessment, dated 02/12/26, indicated he/she scored a 2 out of 15 on his/her Brief Interview for Mental Status (BIMS) (13-15 cognitively intact, 8-12 moderate cognitive impairment and 0-7 severe cognitive impairment), indicating he/she had severe cognitive impairment.During a telephone interview on 06/08/26 at 1:35 P.M., Family Member #1 (HCA) said that on 03/14/26 she went to visit Resident #1 and that when she entered his/her room there was a Certified Nurse Aide (CNA) providing incontinence care to him/her. Family Member #1 said that she had observed purple red discolored open areas to his/her buttocks and found out the areas were being treated with Triad cream, which was a new order.Family Member #1 said she was not notified when Resident #1 had initially developed the areas on his/her buttocks and that she did not know when the order for the Triad cream had started because she was never notified.Review of Resident #1's Interim Skin Assessment, dated 03/02/26, indicated he/she had MASD to his/her buttocks and the Wound Team was notified.Review of Resident #1's Physician's Orders, dated 03/02/26, indicated to apply Triad Hydrophilic cream (used for wound care to manage light to moderate moisture) to his/her buttocks every shift for MASD.During a telephone interview on 06/18/26 at 11:46 A.M., Nurse #6 said on 03/02/26 she notified the Nurse Practitioner (NP) that Resident #1 had developed reddened areas on his/her buttocks related to MASD and that she obtained a new treatment order for Triad cream from the NP. Nurse #6 said she believed she had informed Resident #1's HCA of his/her new skin areas and treatment order and said she would have documented it in his/her progress notes but could not remember. Nurse #6 said that nurses are supposed to notify a Resident's HCA of any change in their condition and that it is documented in a progress note.Review of Resident #1's medical record including his/her nurse progress notes, indicated there was no documentation to support that on 03/02/26 Nurse #6 had notified Resident #1's HCA that he/she had developed new skin areas on his/her buttocks and that a new treatment order was obtained.During an interview on 06/10/26 at 4:10 P.M., the Director of Nursing (DON) said she did not recall that Resident #1 had developed MASD on his/her buttocks in early March 2026. The DON said after reviewing Resident #1's medical record an interim skin assessment was completed on 03/02/26, the NP was notified and that a treatment order had been obtained. The DON said she also observed during the record review that there was no documentation in Resident #1's medical record that Nurse #6 had notified his/her HCA on 03/02/26 that he/she had new skin areas and a new order for triad cream.The DON said it is her expectation that nurses notify a resident's HCA of any significant change, any new order and that they document it in the resident's medical record.

Based on records reviewed and interviews for one of three sampled residents (Resident #2), the Facility failed to ensure they maintained complete and accurate medical/clinical records, including but not limited to the documentation of notification to a Health Care Agent (HCA) of newly observed pressure injuries.Findings include:Review of the Facility Policy titled Charting and Documentation, dated as last revised 07/2017, indicated that 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.The Policy further indicated that documentation of procedures and treatments will include care-specific details, including:-The notification of family, physician, or other staff, if indicated.Resident # 2 was admitted to the Facility in February 2020, diagnoses included vascular dementia, diabetes mellitus, depression and anxiety.Review of Resident #2's Nurse Progress Note, dated 10/31/25, indicated that bilateral heels had been observed with Deep Tissue (pressure) Injuries (DTI, damage of soft tissue beneath intact skin).The Progress Note further indicated that the HCA and Provider had been notified.Review of Resident Skin Incident Report, dated 10/31/25, indicated the provider and the HCA were notified of the discovery of Resident #2's new pressure injuries to his/her heels.During a telephone interview on 12/18/25 at 11:00 A.M., Nurse #2 said that she had documented that both the provider and family (HCA) were aware of the new skin developments, however, Nurse #2 said that she only notified the provider, and she had not notified the HCA. Nurse #2 said that she thought the Unit Manager had notified the HCA.During an in-person interview on 12/09/25 at 2:03 P.M., the Unit Manager said that she that according to the Nurses note and incident report, dated 10/31/25, Nurse #2 had indicated that she made the HCA aware of the new pressure injuries identified to Resident #2's heels.During a follow-up telephone interview on 12/22/25 at 1:49 P.M., the Unit Manager said she did not recall notifying Resident #2's HCA of the new pressure areas. The Unit Manager said Nurse #2 should not have documented that the HCA had been notified unless she (Nurse #2) had made the notification herself.During an in-person interview on 12/10/25 at 9:39 A.M., the Director of Nurses (DON) said that because the skin incident report and Nurse Progress note, that were dated 10/31/25, both indicated that Nurse #2 had notified Resident #2's HCA, said she assumed that the proper notification had been made.During a follow-up telephone interview on 12/22/25 at 2:47 P.M., the DON said it is Facility's expectation that nursing promptly notify a resident's HCA of any significant change and once the Nurse is certain that the appropriate notification has been made, then the nurse should document it on the appropriate forms.

Based on records reviewed and interviews for one of three sampled residents (Resident #2), who had an invoked Health Care Proxy (HCP), the Facility failed to ensure that nursing staff promptly notified his/her Health Care Agent (HCA) when he/she experienced a significant change in status with a decline in condition, related to the development of deep tissue injuries (DTI, damage of soft tissue beneath intact skin) to his/her heels.Findings include:Review of Facility Policy titled Change in a Resident's Condition or Status, dated as revised 02/2021, indicated that the Facility promptly notifies the resident, his/her attending physician and the resident's representative of changes in the residents' medical/mental conditions and/or status.Resident # 2 was admitted to the Facility in February 2020, diagnoses included vascular dementia, diabetes mellitus, depression and anxiety.Review of Resident # 2's Physician's Orders, dated 11/06/22, indicated his/her Health Care Proxy had been invoked. Review of Resident #2's Annual Minimum Data Set (MDS) Assessment, dated 09/09/25, indicated he/she scored a ten (10) out of 15 on his/her Brief Interview for Mental Status (BIMS) (13-15 cognitively intact, 8-12 moderate cognitive impairment and 0-7 severe cognitive impairment), indicating he/she had moderate cognitive impairment.Review of Resident #2's Nurse Progress Note, dated 10/31/25, indicated that bilateral heels had been observed with unstageable pressure injuries.The Progress Note further indicated that the Family and Provider had been notified.Review of Resident #2's Weekly Skin Assessment, dated 10/31/25, indicated he/she had a right heel DTI two (2) centimeters (cm) by (x) 2.6 cm and a left heel DTI 1.6 cm x 2.4 cm.During a telephone interview on 12/09/25 at 1:09 P.M., Family Member #2 said that on 11/04/25 she had been visiting with Resident #2 in the afternoon and that Resident 2 had complained about being cold.Family Member #2 said that she was adjusting his/her blankets and noticed that Resident #2 had purple booties on both of his/her feet, that she lifted his/her feet, removed the booties to put on socks and noticed an area of deep purple and black on Resident #2's heels.Family Member #2 said that she took pictures of Resident #2's heels, sent them via her phone to Resident #2's HCA and said that the HCA was not aware of the newly developed areas.During a telephone interview on 12/18/25 at 11:00 A.M., Nurse #2 said that she had documented that both the provider and family (HCA) were made aware of the new skin developments, however, Nurse #2 said she only notified the provider, and that she had not informed the HCA. Nurse #2 said that she thought the Unit Manager had notified the HCA.During an in-person interview on 12/09/25 at 2:03 P.M., the Unit Manager said that she that according to the Nurses note and incident report, dated 10/31/25, it looked as if Nurse #2 had made the HCA aware of the new pressure injuries identified to Resident #2's heels.During a telephone interview on 12/22/25 at 1:49 P.M., the Unit Manager said she did not recall notifying Resident #2's HCA of the new pressure areas. The Unit Manager said Nurse #2 should not have documented that the HCA had been notified unless she made the notification herself.During an in-person interview on 12/10/25 at 9:39 A.M., the Director of Nurses (DON) said that because the skin incident report and the Nurse Progress note, both dated 10/31/25, indicated that Nurse #2 had notified the HCA, that she assumed that the proper notification had been made.During a telephone interview on 12/22/25 at 2:47 P.M., the DON said it is the Facility's expectation that nursing promptly notify a resident's HCA of any significant change and once the Nurse is certain that the notification has been made, then the nurse should document it on the appropriate forms.

Based on staff interviews and review of the facility policy, the facility failed to track and analyze data, including the progress and outcome of projects identified in the facility's Quality Assurance Performance Improvement (QAPI) program. Findings include: Review of the facility's policy titled Quality Assurance Performance Improvement (QAPI), revised February 2020, indicated the following: Policy statement: This facility shall develop, implement, and maintain an ongoing, facility wide, data-driven QAPI program that is based on indicators of outcomes of care and quality of life for our residents. -The objective of the QAPI program is to: 1. Provide a means to measure current and potential indicators for outcomes of quality of care and quality of life. 2. Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. 3. Reinforce and build upon effective systems and processes related to the delivery of quality care and services. 4. Established systems through which to monitor and evaluate corrective actions. Implementation: -The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: a. Tracking and measuring performance; b. Establishing goals and thresholds for performance measurements: c. Identify and prioritize quality deficiencies: d. Systematically analyzing underlying causes of systemic quality deficiencies; e. Developing and implementing corrective action and performance improvement activities; and f. Monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. -The committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities and make adjustments to the plan. Coordination: -The QAPI coordinator assists other committees, individuals, departments, and/or services and developing quality indicators, monitoring tools, assessment methodologies and documentation, and in making adjustments to the plan. During an interview on 4/30/25 at 2:00 P.M., The Administrator said the QAPI committee meets monthly, and she goes over the QAPI plan. She said she takes notes on the programs they are working on but does not have any data for review. The Administrator said one of her current QAPI programs is staff appreciation, which they review monthly looking at what can be done for staff, and she gave examples which included providing lunches and different recognition ideas. The Administrator said there is no data or outlined goals for staff appreciation. The Administrator gave a second example of a current QAPI program, which was for the environment of the first-floor unit. She said they have been working on it for the last year. The Administrator things they have focused on was hanging new pictures, ongoing painting and fixing the edges of the furniture. The Administrator had no data or outlined goals for the improvements on the first-floor unit. The Director of Nurses (DON) joined the QAPI meeting and provided the surveyor with a completed QAPI project related to one Resident receiving a burn from a hot liquid. The DON was unable to provide any data driven out comes. The Administrator and the DON said they do not have any other QAPI projects ongoing at this time. The Administrator said she does not have any past QAPI projects that are data-driven with outcomes at this time. Review of the facilities QAPI program failed to provide evidence of an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality

Based on interview and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) Committee which included the required members at their meetings. Specifically, the facility's Infection Preventionist failed to attend two of the last three quarterly QAPI meetings. Findings include: Review of the facility's policy titled Quality Assessment and Performance (QAPI), revised February 2020, 11/19/24, indicated but was not limited to: - Policy: This facility shall develop, implement, and maintain an ongoing, facility wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life of our residents. -The Administrator is responsible for ensuring that this facility's QAPI program complies with federal, state, and local Regulatory agency requirements. Review of the QAPI Attendance Sheets, dated 7/25/24 and 10/30/24, failed to indicate the Infection Preventionist was in attendance. During an interview on 4/30/25 at 2:00 P.M., the Administrator and the surveyor reviewed the QAPI Attendance Sheets, dated 7/25/24 and 10/30/24. The Administrator could not identify the Infection Preventionist signature at either meeting.

Based on observation, interview and record review, the facility failed to ensure professional standards of practice were followed for seven Residents (#2, #25, #29, #263, #265, #82, and #27) out of total of 23 residents. Specifically, the facility failed to: 1. For 1a. Resident #2, 1b. Resident #25, 1c. Resident #29 , 1d. Resident # 262, and 1e. Resident #265, the facility failed to ensure physician prescribed medications were administered within an acceptable time frame; and 2. For Resident #82 and #27 to administer medication per the physician order. Findings include: Review of [NAME], Manual of Nursing Practice 11ed, dated 2019, indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. -In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber. Review of Nursing Rights of Medication Administration, (https://www.ncbi.nlm.nih.gov), indicated it is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration. The five traditional rights in the traditional sequence include: -'Right patient' - ascertaining that a patient being treated is, in fact, the correct recipient for whom medication was prescribed. -'Right drug' - ensuring that the medication to be administered is identical to the drug name that was prescribed. -'Right Route' - Medications can be given to patients in many different ways, all of which vary in the time it takes to absorb the chemical, time it takes for the drug to act, and potential side-effects based on the mode of administration. -'Right time' - administering medications at a time that was intended by the prescriber. Often, certain drugs have specific intervals or window periods during which another dose should be given to maintain a therapeutic effect or level. -'Right dose'-- Incorrect dosage, conversion of units, and incorrect substance concentration are prevalent modalities of medication administration error. 1a. Review of Resident #2 Medication Administration Record (MAR) indicated the following: a. Aspirin 81 milligrams (mg) by mouth one time a day at 9:00 A.M. b. Lamotrigine tablet 100 mg give 100 mg by mouth at 9:00 A.M. c. Metoprolol succinate extended-release tablet extended release 24 hours 50 mg at 9:00 A.M. d. Ocuvite-lutein capsule, give 1 capsule by mouth at 9:00 A.M. e. Polyethylene Glycol 3350 powder 17 GM/scoop, give one scoop at 9:00 A.M. f. Senna tablet 8.6 mg, give one tablet at 9:00 A.M. g. Spiriva handihaler capsule 18 MCG, one dose inhale orally one time a day at 9:00 A.M. h. Vitamin D3 tablet, give 1000 units by mouth one time a day at 9:00 A.M. I. Docusate Sodium give 100 mg by mouth two times a day at 8:00 A.M. and 8:00 P.M. J. Eliquis tablet give 5 mg by mouth every 12 hours for anticoagulant at 8:00 AM and 8:00 P.M. k. Furosemide tablet 20 mg give 3 tablets by mouth two times a day at 8:00 A.M. and 8:00 P.M. l. Potassium Chloride extended relief 20 MEQ give 2 tabs two times a day for hypokalemia at 9:00 A.M. and 8:00 P.M. Review of the MAR printed on 4/29/25 at 1:01 P.M indicated the above listed medications had not been administered as orderd. 1b. Review of Resident #25 Medication Administration Record (MAR) indicated the following: a. Aspirin 81 milligrams (mg) by mouth one time a day at 9:00 A.M. b. Furosemide tablet 20 mg give 1 tablet by mouth one time a day at 8:00 A.M. c. Lantus subcutaneous solution 100 unit/ML, inject 12 units subcutaneously one time a day at 8:00 A.M. d. Lisinopril tablet 5 mg for hypertension at 9:00 A.M. e. Metformin HCI oral solution 500 mg/5ML, give 10ML by mouth for diabetes at 9:00 A.M. f. Colace capsule 100 mg at 9:00 A.M. and 5:00 P.M. g. Glucerna three times a day for a supplement at 10;00 A.M., at 10 A.M., 4:00 P.M., and 8:00 P.M. Review of the MAR printed on 4/29/25 at 12:39 P.M indicated the above listed medications had not been administered as orderd. 1c. Review of Resident #29 Medication Administration Record (MAR) indicated the following: a. Amlodipine Besylate oral tablet 5 mg, give one tablet one time a day for hypertension at 9:00 A.M. b. Atorvastatin Calcium oral tablet 10 mg, give one tablet by mouth one time a day for high cholesterol at 9:00 A.M. c. Lisinopril oral tablet 40 mg, give one tablet by mouth on time a day for hypertension at 9:00 A.M. d. Metoprolol Succinate ER oral tablet extended release 24-hour 25 mg, give by mouth one time a day at 9:00 A.M. e. Oxybutynin Chloride ER oral tablet extended release 24-hour release 10 mg, give one time a day at 9:00 A.M. f. Glycolax powder give 17 grams by mouth two times a day at 8:00 A.M. and 5:00 P.M. g. Muscle rub cream 10 to 15% applied to back and neck two times a day at 9:00 A.M and 5:00 P.M. Review of the MAR printed on 4/29/25 at 12:57 P.M indicated the above listed medications had not been administered as ordered. 1d. Review of Resident #263 Medication Administration Record (MAR) indicated the following: a. Duloxetine HCL oral capsule delayed release particles 60 mg, give 1 capsule by mouth one time a day at 9:00 A.M. b. Ensure one time a day for 237 ml 1 x day at 10:00 A.M. c. Protein liquid one time a day for 30 ml at 10:00 A.M. d. Oxycodone HCL oral tablet 5 mg, give 5mg by mouth every 4 hours for pain 12:00 A.M., 4 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M. Review of Resident #263's medication administration with Nurse #2 indicated he/she had not received the prescribed morning medications, including the Oxycodone HCL oral tablet 5 mg. 1e. Review of Resident #265 Medication Administration Record (MAR) indicated the following: a. Aspirin 81 milligrams (mg) by mouth one time a day for heart attack at 9:00 A.M. b. Folic Acid oral tablet 1 mg, give tablet by mouth one time a day at 9:00 A.M. c. Glucerna one time a day for supplement at 10:00 A.M. d. Iron oral tablet 325 mg, give 1 tablet by mouth at 8:00 A.M. e. Protein liquid one time a day 30ml's at 10 A.M. f. Revefenacin inhalation solution 175 mcg/3ml, 3 ml inhale orally via nebulizer one time a day for chronic obstructive pulmonary disease (COPD) at 9:00 A.M. g. Risperidone oral tablet 0.25 mg, give 1 tablet by mouth one time a day at 9:00 A.M. h. Vitamin D325 MCGs for a supplement at 9:00 AM i. Budesonide inhalation suspension 0.5 mg/2ml, 2 ml inhale orally via nebulizer two times a day for COPD at 9:00 A.M. j. Lamotrigine oral tablet 150 mg, give 1 tabby mouth two times a day for mood disorder at 9:00 A.M. and 8:00 P.M. k. Miconazole Nitrate external cream 2 %, apply to Peri-stoma topically two times a day for abdominal skin irritation at 9:00 A.M. and 5:00 P.M. l. Olanzapine oral tablet 5 mg, give 0.5 tablet by mouth two times a day for psychotic disturbance at 9:00 A.M. and 10:00 P.M. Review of the MAR printed on 4/29/25 at 12:59 P.M indicated the above listed medications had not been administered as ordered. During an interview on 4/29/25 at 12:31 P.M., Nurse #2 said she is behind giving medications because she did not get access code until close to 8:00 A.M. and has had to ask for some medication from the Pyxis machine (automated medication dispensing system). Nurse #2 said she is now giving out her morning and afternoon medications together. Nurse #2 said she gave Resident # 263 his/her morning medications late, which included 5 mg of oxycodone scheduled for 8:00 A.M. Nurse #2 said she still has to give out morning medications for Resident #2, #25, #29, and #265. During an interview on 04/30/25 at 12:59 P.M., the Director of Nurses said medications should be administered following the physician orders. She said the nurse should have notified us she was having difficulty, and we would have provided help. 48084 2a. Resident #82 was admitted to the facility in May 2023 with diagnoses which include atrioventricular heart block and hypertensive heart disease. Surveyor observation during the medication administration pass included but were not limited to the following: 4/29/24 at 8:54 A.M., Nurse #1 poured an Enteric Coated (EC) Aspirin 81milligrams (mg) tablet into the medication cup with Resident #82's other morning medications and administered the medications to Resident #82. Review of the Physician Orders indicated but were not limited to the following: -Aspirin 81mg oral tablet Chewable Give one tablet by mouth one time a day for Myocardial Infarction (MI-heart attack) prophylaxis. (5/20/23) Review of the MAR indicated but was not limited to the following: -Aspirin 81mg oral tablet Chewable was signed off as administered. 2b. Resident #27 was admitted to the facility in April 2019 with diagnoses which include cerebrovascular disease. Surveyor observation during the medication administration pass included but were not limited to the following: 4/29/24 at 9:07 A.M., Nurse #1 poured an EC Aspirin 81mg tablet into the medication cup with Resident #27's other morning medications and administered the medications to Resident #27. Review of the Physician Orders indicated but were not limited to the following: -Aspirin Tablet Chewable 81mg Give one tablet by mouth one time a day related to cerebrovascular disease (12/15/20). Review of the MAR indicated but was not limited to the following: -Aspirin Tablet Chewable 81mg was signed off as administered. During an interview on 4/29/25 at 1:28 P.M., Nurse #1 said she administered EC Aspirin to both Resident #82 and #27 and their orders were both for Chewable Aspirin. She said there was Crushable Aspirin in the mediation cart and removed a bottle of Chewable Aspirin 81mg tablets. She said she only uses the Chewable Aspirin if a resident needs their medications crushed otherwise she administers regular Aspirin (EC Aspirin). She said they really are not the same thing, but that is what she always does. During an interview on 4/29/25 at 4:05 P.M., Unit Manager #1 said EC Aspirin and Chewable Aspirin are not the same and cannot be used interchangeably. She said the nurse should be administering the medication per the physician order. During an interview on 4/29/25 at 4:33 P.M., the Director of Nurses said EC Aspirin and Chewable Aspirin are not the interchangeable. She said the nurses should only be administering exactly what was ordered by the physician.

Based on interview and record review, the facility failed to provide equal access to physical and occupational services for two Residents (#56 and #262) out of a sample of 23 residents. Specifically, the facility: 1. Limited Resident #56's physical and occupational therapy based on having Medicaid insurance to two times a week for two weeks. 2. Limited Resident #262's physical and occupational therapy based on having Medicaid insurance to two times a week for two weeks. Findings include: 1. Resident #56 was admitted [DATE] with the following diagnosis: left lower extremity deep vein thrombosis (blood clot), Type 2 diabetes mellitus with diabetic neuropathy (nerve damage), muscle weakness, difficulty walking, and unsteadiness on feet. Review of the Minimum Data Set (MDS) assessment, dated 4/2/25, indicated Resident #56 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating Resident #56 was cognitively intact. Review of Resident's primary insurance indicated Resident was covered by Medicaid. Review of the Facility Grievance/Concern Report dated 3/31/25 indicated but was not limited to the following: -Individual initiating concern: Resident and Resident representative; relationship Family Member #1. -Print individual's name: Resident #56 -Concern reported to: Social worker, and Director of Nurses. -Describe concern using factual terms: Have not seen anyone from rehab, staff nervous about getting resident up and out of bed since not seen yet. -What other action was taken to resolve this concern? Rehab evaluation completed 3/31/25. Review of physician orders indicated but was not limited to the following: -Occupational (OT), Physical (PT), and/or Speech evaluation and treat as needed dated 3/28/2025. -Skilled OT effective 4/1/2025 2 x week, times 2 weeks to include: activity training, therapeutic exercises, therapeutic activities, group therapy, wheelchair management, neuromuscular re-education, end date 4/15/2025. - Effective 3/31/2025, skilled physical therapy evaluation and treat 2 x week, times 2 weeks for treatment to include gait training, therapeutic exercises, therapeutic activity, neuromuscular re-education, end date 4/14/2025. -Re-certification clarification order for skilled PT 2 x/week for 2 weeks to include therapeutic exercises, therapeutic activities, gait training, neuromuscular re-ed, group, and wheelchair management. During an interview on 4/23/25 at 2:05 P.M., with Resident #56 present, Family Member #2 said Resident #56 went to the hospital because he/she needed rehab to help him/her walk and manage the pain in the left leg. FM #2 said the left leg swells and is red in color. FM #2 said Resident #56 is not getting enough rehab, he/she only gets rehab on Monday and Tuesday and then no more rehab for the rest of the week, it's not enough. During a telephonic interview on 4/23/25 at 2:15 P.M., FM #1 said Nursing Consultant #1 told him/her it was a Medicaid insurance issue and Resident #56 can only have PT two times a week. FM #1 said we are hoping to get different insurance to get more services, so Resident #56 can return home. Review of the rehabilitation services indicated but was not limited to the following: Physical Therapy Services: 3/31/25 (Monday)- Evaluation/treatment 4/1/25 (Tuesday)- Treatment 4/7/25 (Monday) - Treatment 4/10/25(Thursday)-Treatment 4/14/25 (Monday)- Treatment 4/17/25 (Thursday)- Treatment 4/21/25 (Monday)- Treatment Since admission a total of 7 visits in 22 days. Occupational Therapy Services: 4/1/25 (Tuesday)-Evaluation 4/9/25 (Wednesday)- Treatment 4/11/25 (Friday)- Treatment 4/15/25(Tuesday)- Treatment 4/16/25 (Wednesday) Treatment 4/23/25 (Wednesday)- treatment Since admission a total of 6 visits in 24 days. 2. Resident #262 was admitted to the facility March 2025 with the following diagnosis: Left hip replacement and left hip osteoarthritis. Review of the Minimum Data Set (MDS) assessment, dated 4/16/25, indicated Resident #262 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating Resident #56 was cognitively intact. During an on 4/23/25 at 2:02 P.M., Resident #262 said my biggest problem is I only get physical therapy two times a week and I have been here for two weeks. Resident #262 said it is ridiculous, I came here for rehab, and I am going home tomorrow. Review of the rehabilitation services indicated but was not limited to the following: Physical Therapy Services: 4/13/25 (Sunday)- Evaluation/treatment 4/15/25 (Tuesday)- Treatment 4/20/25 (Sunday)-Treatment Since admission a total of 3 visits in 13 days. Occupational Therapy Services: 4/11/25 ()-Evaluation/treatment 414/25 (Wednesday)- Treatment 4/18/25 (Friday)- Treatment Since admission a total of 3 visits in 13 days. During an interview on 4/24/25 at 4:00 P.M., the Rehabilitation (Rehab) Director said residents get rehab depending on the insurance they have. The Rehab Director said if a resident has Medicare A insurance, they are put on rehab 5 x week, and if they are Medicaid insurance, they are approved for 2 x week for 2 weeks for both PT and OT. The Rehab Director said the Administrator has it set up this way. She said after two weeks Medicaid residents can be re-evaluated and get an additional 2 x week for two weeks. Rehab Director said she was aware Resident #262 thought he/she was not getting enough rehab. During an interview on 4/24/25 at 4:05 P.M., Rehab Staff #1 said he saw Resident #262 two times a week for occupational therapy and discharged Resident #262 today, reaching all his/her goals. Rehab Staff #1 said Resident #262 was discharged at a supervision level in the shower and set up for dressing, and the last time he/she was seen for OT services was 4/18/25 (6 days ago). Rehab Staff #1 said the Administrator controls the visits. During an interview on 4/24/25 at 4:20 P.M., the Administrator said they get whatever therapy they need and said it doesn't matter what insurance they have. The Administrator said initially, Medicaid patients are initially two times a week for two weeks, then they are re-assessed. During a telephonic interview on 4/24/25 at 4:32 P.M., Rehab Staff #2 said she completed the physical therapy evaluation on Resident #262 and wrote up his/her evaluation for two times a week for two weeks. Rehab Staff #2 said when she comes to this building, she can only care-plan evaluations for all Medicaid patients two times a week for two weeks, and then they are re-evaluated for an additional 2 x week for 2 weeks. Rehab Staff #2 said she also completed the physical therapy evaluation for Resident #56, who was more involved than Resident #262. Rehab Staff #2 said she also care planned Resident #56 for physical therapy two times a week for two weeks. Rehab Staff #2 said it is specific to this building, all Medicaid evaluations care plans can only be written two times a week for two weeks. Rehab Staff #2 said a Medicaid patient can't be put on therapy five times a week. During an interview on 4/30/25 at 9:14 A.M., Physician #1 said it is his expectation his residents admitted here for rehabilitation are seen daily. Physician #1 said he was not aware that only Medicaid patients were put on rehab 2 x a week for two weeks and then reevaluated. Physician #1 said he was not aware of any regulations that Medicaid patients are limited in their rehab compared to other insurances, he would have to investigate it.

Based on observation, record review, and interview the facility failed to ensure it was free from a medication error rate of greater than 5% when one of two nurses observed during the medication pass made two errors out of 26 opportunities, resulting in a medication error rate of 7.69%. Those errors impacted two Residents (#82 and #27). Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice dated as revised April 11, 2018, indicated but was not limited to the following: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers. Review of the facility policy titled Administering Oral Medications, dated as last revised October 2010 indicated but was not limited to the following: -The purpose of this procedure is to provide guidelines for the safe administration of oral medications. -Steps in the Procedure: Place Medication Administration Record (MAR) within easy viewing distance, Select the drug from the drawer, Check the label on the medication and confirm the medication name and dose with the MAR, Check the medication dose, and Re-check to confirm the proper dose. a. Resident #82 was admitted to the facility in May 2023 with diagnoses which include atrioventricular heart block and hypertensive heart disease. Surveyor observation during the medication administration pass included but were not limited to the following: 4/29/24 at 8:54 A.M., Nurse #1poured an Enteric Coated (EC) Aspirin 81milligram (mg) tablet into the medication cup with Resident #82's other morning medications and administered the medications to Resident #82. Review of the Physician Orders indicated but were not limited to the following: -Aspirin 81mg oral tablet Chewable Give one tablet by mouth one time a day for Myocardial Infarction (MI-heart attack) prophylaxis. (5/20/23) Review of the MAR indicated but was not limited to the following: -Aspirin 81mg oral tablet Chewable was signed off as administered. b. Resident #27 was admitted to the facility in April 2019 with diagnoses which include cerebrovascular disease. Surveyor observation during the medication administration pass included but were not limited to the following: 4/29/24 at 9:07 A.M., Nurse #1 poured an EC Aspirin 81mg tablet into the medication cup with Resident #27's other morning medications and administered the medications to Resident #27. Review of the Physician Orders indicated but were not limited to the following: -Aspirin Tablet Chewable 81mg Give one tablet by mouth one time a day related to cerebrovascular disease. (12/15/20) Review of the MAR indicated but was not limited to the following: -Aspirin Tablet Chewable 81mg was signed off as administered. During an interview on 4/29/25 at 1:28 P.M., Nurse #1 said she administered EC Aspirin to both Resident #82 and #27 and not Chewable Aspirin as ordered. During an interview on 4/29/25 at 4:05 P.M., Unit Manager #1 said EC Aspirin and Chewable Aspirin are not the same and cannot be used interchangeably. She said the nurse should be administering the medication per the physician order. During an interview on 4/29/25 at 4:33 P.M., the Director of Nurses said EC Aspirin and Chewable Aspirin are not interchangeable. She said the nurses should only be administering exactly what was ordered by the physician.

Based on observation, record review, and interview, the facility failed to ensure the physician ordered pain medication Oxycodone 5 milligrams(mg), were administered every four hours as prescribed for one Resident (#263) out of a total sample of 23 residents. Specifically, the facility failed to administer on 4/29/25 the 8:00 A.M. prescribed dose of Oxycodone 5 mg for effective pain control. Findings include: Review of the facility policy titled, Pain Assessment and Management, dated 2001, indicated but was not limited to the following: -The medication regime is implemented as ordered. -Results of the interventions are documented in communicated directly to the provider when appropriate. -Ongoing communication between the prescriber and the staff is necessary for optimal and judicious use of pain medications. Resident #263 was admitted to the facility in April 2025 with diagnoses which included: squamous cell carcinoma of the skin of the scalp and neck, non-pressure chronic ulcer of skin, complex regional pain syndrome. Review of the Minimum Data Set (MDS) assessment, dated 4/18/25, indicated Resident #263 scored 12 out of 15 on the Brief Interview for Mental Status (BIMS), indicating Resident #56 had moderate cognitive impairment. Review of Nursing Rights of Medication Administration, (https://www.ncbi.nlm.nih.gov), indicated it is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration. The five traditional rights in the traditional sequence include: -'Right patient' - ascertaining that a patient being treated is, in fact, the correct recipient for whom medication was prescribed. -'Right drug' - ensuring that the medication to be administered is identical to the drug name that was prescribed. -'Right Route' - Medications can be given to patients in many different ways, all of which vary in the time it takes to absorb the chemical, time it takes for the drug to act, and potential side-effects based on the mode of administration. -'Right time' - administering medications at a time that was intended by the prescriber. Often, certain drugs have specific intervals or window periods during which another dose should be given to maintain a therapeutic effect or level. -'Right dose'-- Incorrect dosage, conversion of units, and incorrect substance concentration are prevalent modalities of medication administration error. During an interview on 4/29/25 at 11:57 P.M., Resident #263 was observed lying in bed with his/her dressing off and said please, please, you must help me with pain. Resident #263 said the Oxycodone doesn't work; he/she needs help with his/her pain medication. Review of Skin and Wound Note, dated 4/16/2025, indicated but was not limited to the following: -New consult for patient with known squamous cell carcinoma to the right scalp/face. Now with a large open area that is quite tender with all parts of exam. -Wound assessment: - Location right scalp/face -Primary etiology: Carcinoma -Size 11 centimeters by 11 centimeters by .4 cm depth calculated area is 121 square centimeters -Wound pained at rest: 6. Review of physician orders indicated but was not limited to: -Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) Give 5 mg by mouth every 4 hours for Pain related to squamous cell carcinoma of the skin and scalp and neck, date initiated 4/24/25. -Scheduled administration is pain 12:00 A.M., 4 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M. Review of the facility narcotic book for Resident #263 Indicated but was not limited to the following: -4/29/25 indicated at 4:13 A.M., Oxycodone 5 mg was administered. -4/29/25 indicated at 8:00 A.M., Resident #263 was not administered Oxycodone 5 mg. -4/29/25 indicated at 12:00 P.M., Oxycodone 5 mg was administered. Review of Resident #263's Medication Administration Record (MAR) indicated but was not limited to the following: -Scheduled 8:00 A.M. dose of Oxycodone 5 mg was not administered. -Scheduled 12:00 P.M. dose of Oxycodone 5 mg was administered with a pain level recorded of 10 (severe pain). During an interview on 4/29/25 at 12:02 P.M., Consultant Nurse said Resident #263 just told her, he/she only wants Tylenol because the other medication makes him/her too sleepy. During an interview on 4/29/25 at 12:08 P.M., Nurse #2 said the last time Resident #263 received pain medication was at 4:13 A.M., when he/she received 5 mg of Oxycodone. Nurse #2 said Resident #263 did not receive his/her scheduled dose of Oxycodone at 8:00 A.M., because she was behind schedule. During an interview on 4/30/25 at 8:18 A.M., the Assistant Director of Nursing (ADON) said Resident #263's pain medication was not given in the morning as it should have been. ADON said the physician was made aware and Resident #263 was administered his/her 12:00 P.M. dose of Oxycodone 5 mg. During an interview on 04/30/25 at 12:59 A.M., the Director of Nurses said medications should be administered following the physician orders.

Based on record review and staff interview, the facility failed to ensure the court appointed legal guardian was fully informed in advance and given information necessary to make health care decisions to the extent required by the court, including the risk and benefits of psychotropic medication for one Resident (#7) from a total sample of 23 residents. Findings include: Review of the medical record indicated Resident #7 was admitted to the facility in January 2025 and had been declared an incapacitated person and had a legal guardian appointed by the court in September 2016. Guardianship protects the rights of the person who is unable to make or communicate decisions about everyday health, care, and safety. The guardian is responsible for and must be consulted for all healthcare decisions and required consents. The Guardian was granted court authorization on 1/24/2025 to admit Resident #7 to a nursing facility for short term services. Further review of the medical record indicated when Resident #7 was admitted to the facility, the court appointed guardian failed to sign all the necessary admission paperwork including consent for admission, treatment, and administration of psychotropic medication. All the paperwork was signed by the Resident, who had been deemed unable to make healthcare decisions. Review of Resident #7's current Physician's Orders indicated but were not limited to: -Fluoxetine (antidepressant) 30 milligrams (mg) daily, start date 1/25/25. Review of the Psychotropic Consent Form, dated 1/25/25, indicated Resident #7 signed the form which indicated he/she understood the listed risks and benefits for Fluoxetine 30 mg daily. Additional review of Resident #7's January 2025 through April 2025 Medication Administration Records (MAR) indicated the Resident was administered Fluoxetine as ordered. During an interview on 4/30/25 at 10:47 A.M., Unit Manager #1 said all admission paperwork including the Psychotropic Consent Form should have been signed by the Guardian on admission but was not; Resident #7 signed all the necessary admission forms. During an interview on 4/30/25 at 11:15 A.M., the Director of Nursing said all admission paperwork, including the Psychotropic Consent Form should have been signed by the legal guardian upon Resident #7's admission to the facility.

Based on observation, interview, document review, and policy review, the facility failed to ensure staff properly labeled all drugs and biologicals used in the facility in accordance with currently accepted principles. Specifically, the facility failed to: 1. Ensure staff properly labeled the packaging box and/or its multidose vial of Tubersol (tuberculin) (purified protein derivative, a combination of proteins that are used in the diagnosis of tuberculosis) stored inside two of three medication room storage refrigerators reviewed; and 2. Ensure staff properly labeled all medications stored in one of three medication carts reviewed once opened. Findings include: Review of the facility's policy titled Medication Storage in the Facility, revised February 2018, indicated but was not limited to the following: -Certain medications or package types, such as multiple dose injectable vials, certain ophthalmic (per manufacturer specifications), once opened, require an expiration date shorter than the manufacturer's expiration date to ensure medication purity and potency. -When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated, if applicable, for medications requiring a shortened expiration date. -The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration, if applicable. 1. Review of the facility's document titled Medications with Shortened Expiration Dates, revised September 2023, indicated but was not limited to the following: -Tubersol (tuberculin PPD Mantoux injection), discard vials in use after 30 days a. [NAME] Unit Medication Storage Room During an observation with interview with Nurse #6 on 4/18/24 at 11:18 A.M., the surveyor observed one opened packaging box of Tubersol with a multidose vial inside with the pop top removed indicating it had been used. Neither the packaging box nor the vial was labeled with the open date, or the new expiration date once opened. Nurse #6 said the vial should have been labeled when opened but wasn't, and that it was only good for 30 days once opened. b. Grove Unit Medication Storage Room During an observation with interview with Nurse #8 on 4/18/24 at 1:14 P.M., the surveyor observed one opened packaging box of Tubersol with a multidose vial inside with the pop top removed indicating it had been used. Neither the packaging box nor the vial was labeled with the open date, or the new expiration date once opened. Nurse #8 said the vial had been used and should have been labeled with the open date and expiration date but wasn't. She said the packaging box should have also been labeled. She said the vial was only good for 30 days once opened. During an interview on 4/18/24 at 1:29 P.M., Unit Manager #3 said the Tubersol boxes should have been labeled with the dates when opened and the expiration dates. She said she wasn't sure how long the vials would be good for once opened. 2. Review of manufacturer's instructions, dated February 2023, indicated but was not limited to the following: Indications for Use: -Rhopressa (netarsudil ophthalmic solution) 0.02% is indicated for the reduction of elevated intraocular pressure (IOP) in patients with open-angle glaucoma or ocular hypertension. How Supplied/Storage and Handling: -Store at 2 degrees Celsius (C) to 8 degrees C (36 degrees Fahrenheit (F) to 46 degrees F) until opened. After opening, the product may be kept at 2 degrees C to 25 degrees C (26 degrees F to 77 degrees F) for up to six weeks. On 4/18/24 at 12:46 P.M., the surveyor reviewed the Meadows Unit low side medication cart with Nurse #7 and observed the following: -one opened bottle of Rhopressa ophthalmic solution 0.02%, not stored inside its packaging box, seal broken, labeled with a resident's name, bottle not labeled with the date when opened or the new expiration date once opened. During an interview on 4/18/24 at 12:46 P.M., Nurse #7 said the bottle had been opened and did not know the facility's policy for labeling but said it should have been labeled when opened. He said the medication had a shortened expiration of 30 days after opening. During an interview on 4/23/24 at 12:59 P.M., the Director of Nursing (DON) said the Tubersol packaging boxes and multidose vials stored inside should have been labeled with the open dates and expiration dates. She said the Rhopressa eye drop bottle should have also been labeled with the open date and expiration date. She said both medications have a shortened expiration once opened but was not sure how many days. The DON said the shortened expiration is to preserve the efficacy of the medication.

Based on records reviewed, policy review, and interviews, for one Resident (#207), of 22 sampled residents, the facility failed to implement an individualized, person-centered care plan. Specifically, the facility failed, for Resident #207, who was status post partial left hip replacement, to implement the intervention for the use of an abductor wedge pillow to maintain anterior hip precautions. Findings include: Review of the facility's policy titled Comprehensive Person-Centered Care Plans, dated as revised March 2022, indicated but was not limited to: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident -The comprehensive, person-centered care plan: describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change Resident #207 was admitted to the facility in April 2024 and had diagnoses including unspecified fracture of left femur, closed fracture with routine healing, and aftercare following joint replacement surgery. Review of the Minimum Data Set (MDS) assessment, dated 4/17/24, indicated Resident #207 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of current Physician's Orders indicated the following: -Maintain anterior hip precautions (to keep the hip within safe positions while it heals); abductor wedge pillow (device to support limb alignment, helps to prevent your hip from turning in or away from your body) while in bed every shift for left hip fracture for six (6) weeks, 4/15/24 Review of the Surgical Incision to Left Hip care plan, initiated 4/17/24, indicated the following interventions: -Abductor wedge pillow in bed x 6 weeks, 4/17/24 -Anterior hip precautions, 4/17/24 During an observation with interview on 4/18/24 at 3:33 P.M., the surveyor observed Resident #207 lying in bed. His/her legs were not abducted away from the midline of his/her body. An abductor wedge pillow device was observed resting on top of the Resident's dresser and not positioned between the Resident's legs. Resident #207 said he/she was supposed to have the wedge pillow between his/her legs to help with positioning, but no one put it there and said, my knee goes this way pointing to the left knee then inward toward the right. During an observation with interview on 4/22/24 at 7:07 A.M., the surveyor observed Resident #207 lying in bed on his/her back. The Resident's legs were elevated on two pillows and not abducted away from the midline of his/her body. An abductor wedge pillow device was observed resting on top of the Resident's dresser. Resident #207 said he/she didn't have the wedge pillow but was supposed to be using it to keep his/her legs separated. During an interview on 4/22/24 at 3:15 P.M., Certified Nursing Assistant (CNA) #2 said she was assigned to the Resident that day and that Resident #207 was supposed to have the wedge pillow between his/her legs while in bed. During an interview on 4/23/24 at 10:04 A.M., Nurse #5 said Resident #207 had a left hip fracture after a fall at home and came to the facility on hip precautions. He said the Resident was supposed to have the abductor pillow between the legs while in bed. Nurse #5 said staff were expected to implement care planned interventions and apply the wedge pillow per physician's orders. During an interview on 4/23/24 at 1:11 P.M., the Director of Nursing (DON) said Resident #207 arrived at the facility following joint surgery for a left femur fracture and was on anterior hip precautions requiring an abductor wedge pillow while in bed x 6 weeks. She said the Resident needed the wedge pillow to keep his/her legs a certain distance apart to prevent leg crossing and avoid leg/hip rotation. She said interventions should have been implemented per physician's orders and the current care plan. During an interview on 4/23/24 at 2:52 P.M., the Rehab Director said Resident #207 had a fall at home and had hip surgery. She said the Resident was on hip precautions and always needed an abductor wedge pillow between the legs when in bed to keep the legs from getting too close together which could pop the hip back out. The Rehab Director said the Resident should not be bending forward greater than 90 degrees, twisting, or crossing his/her legs to keep the legs abducted (away from the midline of the body).

Based on observation, interview, and policy review, the facility failed to ensure a reasonable accommodation was made for one Resident (#207), out of a total sample of 22 residents. Specifically, the facility failed to ensure the Resident was provided with a call bell device that was within reach and able to be used if the Resident desired to call for assistance. Findings include: Review of the facility's policy titled Answering the Call Light, revised March 2021, indicated but was not limited to the following: -Upon admission and periodically as needed, explain, and demonstrate use of the call light to the resident. -Ask the resident to return the demonstration. -When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. -Some residents may not be able to use their call light. Be sure you check on these residents frequently. Resident #207 was admitted to the facility in April 2024 and had diagnoses including unspecified fracture of left femur, closed fracture with routine healing, aftercare following joint replacement surgery, hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (stroke) affecting the left non-dominant side, osteoarthritis, and transient cerebral ischemic attack. Review of the Minimum Data Set (MDS) assessment, dated 4/17/24, indicated Resident #207 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. During an observation with interview on 4/18/24 at 3:30 P.M., the surveyor observed Resident #207 lying in bed. His/her left arm and hand were contracted upward toward his/her chest. The Resident's call bell control device was observed on top of the bed linens on the Resident's left side. Resident #207 said he/she could somewhat reach the call bell with his/her right hand but was unable to, saying ow and it's terrible, while attempting to reach over to grab it. During an observation on 4/19/24 at 10:56 A.M., the surveyor observed Resident #207 seated in a wheelchair (with the bed to his/her left) playing a puzzle game on his/her tablet on an overbed table utilizing a stylus with the right hand. The Resident's left arm and hand were contracted upward toward the chest. A call bell control device was observed lying on the bed to the Resident's left side. During an observation with interview on 4/22/24 at 7:07 A.M., the surveyor observed Resident #207 lying in bed. His/her left arm and hand were contracted upward toward the chest. A call bell control device was observed lying on the bed to the Resident's left side. Resident #207 was unable to demonstrate for the surveyor his/her ability to reach it with the right hand and said he/she could not push the buttons. During an observation with interview on 4/22/24 at 9:01 A.M., the surveyor observed Resident #207 seated in a wheelchair (with the bed to his/her left) eating breakfast with his/her right hand. The Resident's left arm and hand were contracted upward toward the chest. The call bell control device was not within reach of the Resident and was observed positioned on the opposite side of the bed under a blanket. Resident #207 said he/she must yell down the hallway if he/she needs someone. During an interview on 4/22/24 at 3:15 P.M., Certified Nursing Assistant (CNA) #2 said Resident #207 had recent hip surgery and the call bell should be within reach but the Resident would call if he/she needed staff assistance. CNA #2 said the Resident had no deficits that she knew of and wasn't sure of the level of assistance needed. On 4/23/24 at 8:50 A.M., the surveyor observed Resident #207 seated in a wheelchair (with the bed to his/her left) eating breakfast with his/her right hand. The Resident's left arm and hand were contracted upward toward the chest. The call bell control device was not within reach of the Resident and was observed positioned on top of the mattress to the Resident's left side. During an observation with interview on 4/23/24 at 9:30 A.M., the surveyor observed Resident #207 seated in a wheelchair (with the bed to his/her left) in his/her room. The Resident's left arm and hand were contracted upward toward the chest. The call bell control device was not within reach of the Resident and was observed positioned on top of the mattress to the Resident's left side. Resident #207 said he/she could not reach it. The Resident said even if he/she could reach it, it's difficult to push the buttons to call for help because of arthritis and decreased strength in his/her fingers. The Resident said sometimes he/she can get the television on but then can't turn it off. CNA #3 entered the Resident's room and said the call bell should have been within reach of the Resident but it was not. During an interview on 4/23/24 at 10:04 A.M., Nurse #5 said the Resident had left sided weakness and a left-hand contracture and the call bell device should be placed to the Resident's right, not his/her left, and it was a long one so should be next to him/her as much as possible and within reach. Nurse #5 said the Resident should be able to use it and, if not, then staff should accommodate his/her needs. Nurse #4 said he was not sure if the Resident was assessed for his/her ability to use it. On 4/23/24 at 10:21 A.M., the surveyor and Nurse #5 entered the Resident's room. Resident #207 was seated in a wheelchair (with the bed to his/her left) in his/her room playing a game on his/her tablet on an overbed table utilizing a stylus with the right hand. The Resident's left arm and hand were contracted upward toward the chest. Resident #207's call bell control device was positioned closely to his/her left side on top of the bed. Resident #207 demonstrated using the end of his/her stylus to push the red nurse call bell button on the call bell control device. Resident #207 said he/she couldn't press the buttons with his/her fingers because of arthritis and decreased strength. The Resident said no other call bell device had been offered or provided to him/her. During an interview on 4/23/24 at 1:11 P.M., the Director of Nursing (DON) said on admission it's standard practice to make sure residents can use their call light. She said the call bell should be within the resident's reach including when out of bed. The DON said the facility had adaptive call lights they could provide if needed but staff did not identify the need for this Resident.

Based on records reviewed, policy review, and interview for three Residents (#9, #35, and #75), of 22 sampled residents, the facility failed to ensure that each resident's drug regimen was free from unnecessary psychotropic medications. Specifically, for Residents #9, #35, and #75, the facility failed to ensure an Abnormal Involuntary Movement Scale (AIMS, a clinical outcome checklist completed by a healthcare provider to assess the presence and severity of adverse outcomes, such as abnormal movements of the face, limbs, and body in patients) assessment was completed. Findings include: Review of the facility's policy titled Use of Psychotropic Medication, undated, indicated but was not limited to: -Residents who receive an antipsychotic medication will have an Abnormal Involuntary Movement Scale (AIMS) test performed on admission, every six months, with a significant change in condition, change in antipsychotic medication, as needed or as per facility policy. 1. Resident #9 was admitted in February 2023 with diagnoses that included unspecified dementia, mood disturbance, anxiety disorder, other specified depressive episodes, and bipolar disorder. Review of Resident #9's Minimum Data Set (MDS) assessment, dated 3/28/24, indicated the Resident scored 3 out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Further review indicated that the Resident was receiving antipsychotic medication on a regular basis. Review of Resident #9's active Physician's Orders indicated but was not limited to, the following: -Risperdone Oral Solution, 1 milligram (mg)/milliliter (ml). Give 0.5 ml by mouth three times a day for bipolar disorder. Review of Resident #9's Medication Administration Record (MAR) for the months of March and April 2024 indicated the Resident was routinely given their medication as ordered by the physician. Review of Resident #9's medical record, indicated an AIMS test was completed on the following dates: 3/9/23 7/7/23 9/9/23 During an interview on 4/23/24 at 3:40 P.M., the Director of Nursing (DON) said an AIMS test should have been performed in March 2024, per policy, for Resident #9. 2. Resident #35 was admitted in January 2016 with diagnoses that included unspecified major depressive disorder, dementia with psychotic disturbance, and anxiety. Review of Resident #35's MDS assessment, dated 11/9/23, indicated the Resident scored 0 out of 15 on the BIMS indicating severe cognitive impairment. Further review indicated that the Resident was receiving antipsychotic medication on a regular basis. Review of Resident #35's active physician's order indicated, but was not limited to, the following: -Olanzapine Tablet, 5 mg. Give one tablet by mouth one time a day related to unspecified psychosis. Review of Resident #35's medical record, indicated an AIMS test was completed on the following dates: 2/23/23 11/10/23 During an interview on 4/23/24 at 3:40 P.M., the DON said the AIMS test was completed 2/23/23 and 11/10/23 for Resident #35. The DON said, per policy, AIMS testing should be completed every six months and there was a greater than six-month gap in AIMS testing for Resident #35. The DON said an AIMS test should have been performed in August 2023, per policy, for Resident #35. 46562 3. Resident #75 was admitted to the facility in May 2021 with the following diagnoses: Alzheimer's disease, dementia, and anxiety. Review of the MDS assessment, dated 3/28/24, indicated Resident #75 was severely cognitively impaired as evidenced by a BIMS score of 0 out of 15, and received antipsychotic medication on a routine basis. Review of Resident #75's Physician's Orders indicated but was not limited to: -Olanzapine (anti-psychotic) 5 mg by mouth two times a day, 3/9/24 - 3/25/24 -Olanzapine 5 mg by mouth at bedtime, 3/25/24 - 3/27/24 -Olanzapine 2.5 mg by mouth once daily, 3/26/24 - 3/27/24 -Olanzapine 5 mg by mouth at bedtime, 3/27/24 - 4/12/24 -Olanzapine 2.5 mg by mouth once daily, 3/28/24- 4/12/24 -Olanzapine 2.5 mg by mouth once daily, 3/28/24 - 4/12/24 -Olanzapine 5 mg by mouth at bedtime, 4/12/24 -Olanzapine 1.25 mg by mouth once daily, 4/13/24 Review of Resident #75's MAR for March and April 2024 indicated he/she received Olanzapine per physician's orders. Review of Resident #75's Practitioner Notes/Psychiatric Follow-ups, dated 3/25/24 and 4/8/24, failed to indicate an AIMS assessment had been completed. Review of Resident #75's medical record indicated an AIMS assessment had been completed on 4/23/24 (45 days after the anti-psychotic medication was initiated). During an interview on 4/23/24 at 1:20 P.M., Unit Manager #2 and the surveyor reviewed the medical record and could not locate an AIMS assessment prior to the one completed on 4/23/24. Unit Manager #2 said she had just completed the AIMS assessment and it should have been completed when the medication was started. During an interview on 4/23/24 at 3:10 P.M., the DON said Resident #75 started Olanzapine upon return from the hospital in March 2024, the DON said an AIMS assessment should have been completed when the medication was initiated.

Based on observation, interview, and policy review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections within the facility. Specifically, the facility failed to adhere to infection control practices for hand hygiene while preparing medications. Findings include: Review of the facility's policy titled Administering Medications, revised 2022, indicated but was not limited to the following: -Staff follows established facility infection control procedures (e.g. handwashing) for the administration of medications, as applicable. Review of the facility's policy titled Handwashing/Hand Hygiene, revised March 2023, indicated but was not limited to the following: -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. -Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: after removing gloves. On 4/22/24 at 9:26 A.M., the surveyor observed Nurse #5 prepare a resident's 9:00 A.M. medications at his medication cart. Nurse #5 donned (put on) a pair of gloves to crush the resident's medications in a plastic medication pouch, poured the contents into applesauce, then doffed (took off) the gloves in the adjacent trash receptacle. Nurse #5 did not perform hand hygiene after removing the gloves or before donning a new pair of gloves to pour a bottle of Ensure (nutrition shake) into a plastic cup. Nurse #5 doffed the second set of gloves then administered the resident's medications without performing hand hygiene prior. During an interview on 4/22/24 at 9:28 A.M., Nurse #5 said he should have performed hand hygiene each time he removed his gloves and before he administered the medications to the resident. During an interview on 4/23/24 at 12:50 P.M., the Director of Nursing said staff should be performing hand hygiene any time before and after donning and doffing gloves in general and during med pass.

Based on observation, interview, and record review, the facility failed to follow professional standards of practice for one Resident (#206), out of a total sample of 22 residents. Specifically, the facility failed to administer medications per physician's orders and manufacturer's instructions for use. Findings include: Review of the facility's policy titled Administering Medications, revised April 2022, indicated but was not limited to the following: -Medications are administered in a timely manner, and as prescribed. -Medications are administered in accordance with prescriber orders, including any required time frame. -The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Resident #206 was admitted to the facility in April 2024 with diagnoses including benign prostatic hypertension (BPH) (enlarged prostate), acute embolism and thrombosis of unspecified deep veins of right lower extremity, Alzheimer's disease, and dementia. Review of current Physician's Orders indicated the following: -May change form of medication as needed (liquid), 4/12/24 -May crush meds, combine and mix with food according to crush guidelines or use liquid equivalent, 4/12/24 -Aspirin 81 milligrams (mg) oral tablet, delayed release, give one tablet by mouth one time a day, 4/12/24 -tamsulosin HCL (Flomax) oral capsule 0.4 mg, give 1 capsule by mouth one time a day for BPH, 4/12/24 On 4/18/24 at 9:52 A.M., the surveyor observed Nurse #4 prepare Resident #206's 9:00 A.M. medications and observed the following: 9:52 A.M. - Nurse #4 opened an over-the-counter bottle of chewable Aspirin 81 mg from the top drawer of her medication cart and added one whole tablet into a medication cup along with one whole tamsulosin HCL (Flomax) 0.4 mg capsule. Nine other whole tablets and two whole capsules were also added to the medication cup. 10:03 A.M. - Nurse #4 said she wasn't familiar with the Resident and wasn't sure how he/she took his/her pills and asked another staff member who said to just ask the Resident. 10:14 A.M. - Nurse #4 asked the Resident how he/she took his/her medications, but the Resident did not answer. He/she was observed playing with a straw inside a plastic cup. 10:17 A.M. - Nurse #4 asked Unit Manager (UM) #3 who said the Resident needed his/her medications crushed. Nurse #4 crushed all the medication tablets including the Aspirin and added the contents to approximately 1 tablespoon (tbs.) of applesauce. Nurse #4 opened the tamsulosin HCL capsule and sprinkled it onto the applesauce. She did not consult with the physician prior. Nurse #4 entered the room to administer the medications to the Resident. The surveyor asked Nurse #4 if all the medications were able to be either crushed or opened. Nurse #4 said yes. 10:32 A.M. - Nurse #4 attempted to administer the medications to Resident #206 approximately 3-4 times but the Resident refused shaking his/her head no. Review of the manufacturer's Patient Information document, revised November 2009, indicated the following: Flomax is a prescription alpha blocker medicine used to treat the signs and symptoms of benign prostatic hyperplasia (BPH), a condition your doctor may refer to as an enlarged prostate. How should I take Flomax? -Take Flomax as prescribed by your doctor -Do not crush, chew, or open Flomax capsules What are the possible side effects of Flomax capsules? -Decreased blood pressure when changing positions. Flomax may cause a sudden drop in blood pressure upon standing, especially after the first dose or when changing doses. -Fainting -Dizziness -Lightheadedness During an interview on 4/18/24 at 10:38 P.M., the surveyor reviewed the physician's orders with Nurse #4 who said she didn't use the right Aspirin bottle. She said she did not follow physician's orders for a delayed release tablet, instead dispensing a chewable tablet. Nurse #4 said there was an order to crush the medications but not an order to open the tamsulosin HCL delayed release capsule. During an interview on 4/22/24 at 11:53 A.M., Nurse #4 said there were no facility guidelines that she followed for opening medication capsules and no increased side effects she was aware of for opening the tamsulosin HCL delayed release capsule. Nurse #4 said she was not aware of the potential side effects of the medication or if the capsule should not be opened. She said she just did it. During an interview on 4/23/24 at 11:35 A.M., the Pharmacist said tamsulosin HCL is a time release capsule and opening it can cause a rapid drug release which could be an issue. She said the physician should be aware the capsules are being opened by staff and even though there are trials out there, the current recommendation is to not open, crush, or chew it. The Pharmacist said the physician could override this if other alternatives were tried and nothing else worked. During a telephone interview on 4/23/24 at 12:28 P.M., Physician #1 said he was not aware staff were opening any of the capsules. He said the Resident arrived from the hospital and his/her medications were just continued from there with no changes. Physician #1 said there had not been anything else tried in place of the tamsulosin HCL capsule, the medication was just continued. During an interview on 4/23/24 at 12:50 P.M., the Director of Nursing (DON) said the Aspirin and tamsulosin HCL should have been administered per physician's orders. She said anything like that with a discrepancy should have been clarified with the physician and an order obtained. She said this way if staff need to open a capsule, then they have the order. The DON said the nurse should have clarified with the physician that it was okay to open the capsule prior to opening and attempting to administer it. She said opening the capsule can change how the medication is absorbed, in theory it would be quicker. The DON said all medications should be administered to residents per the five rights.

Based on document review and interview, the facility failed to ensure their arbitration agreement specifically provides for the selection of a neutral arbitrator and venue that is convenient to both parties. Findings include: Review of the Arbitration Agreement in use by the facility (undated) failed to indicate the residents or their representatives had the right to a neutral arbitrator or venue agreed upon by both parties. During an interview on 4/23/24 at 12:50 P.M., the Administrator reviewed the Arbitration agreement in use by the facility and said she could not find any language in the agreement that reflects the selection of a neutral arbitrator or venue to be agreed upon by both parties. During an interview on 4/23/24 at 1:54 P.M., the Chief Operating Officer reviewed the Arbitration agreement in use by the facility and said he could not find any language in the agreement that reflects the selection of a neutral arbitrator or venue to be agreed upon by both parties.

Based on interviews and records reviewed for one of three sampled residents (Resident #1) who on 12/14/22 during the 7:00 A.M. to 3:00 P.M. shift accused Certified Nurse Aide (CNA) #1 of abusing him/her and reported the allegation to the Director of Nursing, the Facility failed to ensure that the allegation of physical abuse was reported to the Department of Public Health (DPH) within 2 hours in accordance with the Facility Policy and Federal regulations. Findings include: Review of the Facility Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating Policy, dated as revised April 2021, indicated that the Administrator or designee reported allegations of resident abuse to the State Agency within 2 hours. Review of Resident #1's medical record indicated he/she was admitted to the Facility during September 2022 and diagnoses included depression and traumatic subdural hemorrhage (brain bleed). Review of Resident's most recent Quarterly Minimum Data Set Assessment, dated 12/22/22, indicated that his/her long and short term memory skills were intact. Review of a Nursing Progress Note, dated 12/14/22, indicated that during a visit with Activity Aide #1, Resident #1 accused a staff member of abuse. During an interview on 1/25/23 at 4:30 P.M., Activity Aide #1 said that on 12/14/22 Resident #1 told her that he/she asked a staff member to close his/her privacy curtain and the staff member hit him/her on the head. Activity Aide #1 said that she reported Resident #1's allegation of abuse to the Activity Director. During an interview on 1/23/23 at 10:50 A.M., the Activity Director said that on 12/14/22, Activity Aide #1 told her that Resident #1 alleged he/she was abused by a staff member. The Activity Director said that she spoke to Resident #1 and said Resident #1 told her that he/she had been hit by a staff member on the face or head. The Activity Director said that she reported Resident #1's allegation of abuse to the Director of Nursing. During an interview on 1/23/23 at 12:30 P.M., the Director of Nursing said that on 12/14/22 the Activity Director reported that Resident #1 alleged abuse by a staff member. The Director of Nursing said that she spoke with Resident #1 and said Resident #1 identified CNA #1 as the implicated staff member. Review of the report submitted by the Facility via the Health Care Facility Reporting System (HCFRS) regarding Resident #1's allegation of physical abuse indicated that the Facility submitted the report on 12/21/22 at 10:19 A.M., seven days after Resident #1's allegation of abuse was initially reported to the Director of Nursing. The Director of Nursing said that the allegation that CNA #1 abused Resident #1 on 12/14/221 was not submitted by the Facility to the DPH within 2 hours per Facility Policy and Federal Regulation.

Based on observation, record review, and interview the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for four Residents (#89, #69, #22, and #29), out of a total sample of 27 residents. Specifically, the facility failed: 1. For Resident #89, to implement the Resident's interdisciplinary care plan for activities which resulted in a decline in the Resident's psychosocial well-being; 2. For Resident #69, to implement the Resident's interdisciplinary care plan for his/her dominant language and failed to support the Resident's cultural and activities preferences; 3. For Resident #22, to regard the Resident's need for communication in his/her dominant language of Portuguese and failed to implement their Translation and/or Interpretation of facility services policy; and 4. For Resident #29, to ensure staff provided person-centered care and services to determine and support the Resident's cultural preferences and communication needs. Findings include: 1. Resident #89 was admitted to the facility in September 2022 with diagnoses including legal blindness. Review of the Minimum Data Set (MDS) assessment, dated 9/27/22, indicated Resident #89 speaks Chinese and requires an interpreter to communicate with his/her Physician and health care staff. The Interview for Daily and Activity Preferences was conducted and keeping up with the news was very important, going outside to get fresh air was somewhat important and doing things with groups of people was not very important to Resident #89. Resident #89's Care Plan for Activities, initiated 9/28/22, indicated that the Resident prefers to stay in the comfort of his/her room and enjoys listening to Chinese news on his/her [NAME] (name of Amazon's personal digital assistant, which lets you use voice commands to control a compatible device for features like streaming, news reports or even to turn on your smart lights). However, there was no documentation to indicate how Resident #89 would be assisted by staff to utilize the [NAME] due to his/her blindness. Review of a 10/13/22 Care Plan Meeting Note indicated Resident #89's Representative was present at the meeting and expressed that his only wish is to have Resident #89 put back to bed after lunch time to rest. The note also indicated that the Resident has been offered out of room activities, however, he/she prefers to stay in his/her room and listen to Chinese news on an [NAME] device in his/her room. On 11/2/22 at 9:14 A.M., the surveyor observed Resident #89 lying in bed awake. An electronic device was noted on the bedside table, but it was unplugged from the electrical outlet and the screen was dark. On 11/3/22 at 2:37 P.M., the surveyor observed Resident #89 seated at a table in the unit dayroom sleeping. On 11/4/22 at 9:24 A.M. and 10:10 A.M. and 11:15 A.M., the surveyor observed Resident #89 sleeping while seated in a wheelchair in the unit dining room facing the wall. There was nothing on the table in front of the Resident. During an interview on 11/4/22 at 11:15 A.M., the Activity Director (AD) said that she doesn't know anything about the electronic device on the Resident's bedside table. On 11/9/22 at 9:30 A.M., the surveyor observed Resident #89 seated at a table in the unit dining room sleeping. A plastic children's construction toolset including a saw, tape measure, wrench, hammer and screwdriver was on the table in front of the Resident. During an interview on 11/9/22 at 9:59 A.M., Activity Assistant #1 said she was not aware of Resident #89's activity preferences and cannot communicate with him/her because she does not speak Chinese. She said the Resident should have specialized activity items because he/she is blind. The Activity Assistant said she was not aware that Resident #89 had an [NAME] device and that he/she enjoyed listening to Chinese news on his/her [NAME] device. On 11/9/22 at 2:17 P.M., the surveyor observed Resident #89 seated at a table in the unit dining room sleeping. The Resident was not in his/her room resting or listening to Chinese news as identified in the comprehensive assessment and Activities care plan. During a telephone interview on 11/11/22 at 4:30 P.M., Resident #89's Health Care Proxy (HCP) indicated he has seen a drastic decline in the Resident's quality of life since admission to the facility. He said Resident #89 used to enjoy listening to YouTube or the radio. The HCP indicated the Resident told him no one at the facility speaks Chinese; there is nothing to do and all he/she wants to do is sleep. 36542 2. Resident #69 was admitted to the facility in September 2022 with a history of cerebral vascular accident. Review of the medical record for Resident #69 indicated the following languages: Chinese, Cantonese, Vietnamese. Review of the Admission Nursing Assessment, dated 9/22/22, indicated Resident #69 spoke Chinese. Review of the care plans for Resident #69 indicated he/she spoke Cantonese and Vietnamese with interventions of having access to a communication board and utilizing the language line. Review of the Social Service note, dated 9/26/22, indicated Resident #69 would be monitored for adjustment to environment and encourage staff to utilize the language line and provide a communication board. Review of the Social Service assessment, dated 9/27/22, indicated Resident #69 spoke Vietnamese. On 11/2/22 at 8:30 A.M., the surveyor observed Resident #69 lying in bed. He/she said, How are you? and when the surveyor attempted to engage in conversation the Resident said he/she did not speak English. At this time, the surveyor observed a green sign in the Resident's room indicating to utilize the Cantonese language line for the Resident. There was no communication board available to utilize. The surveyor observed Resident #69 on the following days of survey to be lying in bed with no television or music programs in his/her language: 11/2/22 at 8:30 A.M., 11:08 A.M., and 11:44 A.M. 11/3/22 at 2:15 P.M. 11/4/22 at 11:40 A.M. 11/8/22 at 8:30 A.M. and 11:35 A.M. On 11/8/22 at 8:26 A.M., the surveyor observed a communication board located on the Resident's nightstand titled Basics and indicated it was in traditional Chinese. During an interview on 11/8/22 at 12:10 P.M., the Activity Director said Resident #69 spoke Vietnamese and Cantonese, although she had attempted to utilize the Vietnamese language line with Resident #69 and the translator was unable to understand him/her. She said she had added the communication board to the Resident's room this past weekend and had reviewed it with the Resident to ensure he/she understood. She said the cable at the facility did not have any channels in the Resident's language and only the activity staff had the equipment to allow the Resident to listen to music or watch programs in his/her primary language, so the Resident could only do this when activity staff were available. During an interview on 11/8/22 at 12:28 P.M., the Social Worker said prior to the admission of Resident #69, and five other residents from a facility with an Asian community, there had not been any residents at the facility who spoke any Asian dialects. She said prior to the surveyors' inquiries on language communication, the facility staff had only utilized the language line for residents and they were not utilizing any communication boards. During an interview on 11/10/22 at 9:05 A.M., Nurse #10 said she could not remember if Resident #69 spoke Cantonese or Mandarin and that there was a sign posted in the Resident's room indicating which language to use with the language translator line. She said she usually uses hand gestures or non-verbal gestures to determine what the Resident needed. She said there are times where the language line was not helpful because the translators could not understand the residents, or the staff could not understand the translator. 43935 3. Review of the facility's policy titled Translation and/or Interpretation of facility services, dated November 2020, indicated but was not limited to the following: - the facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. - interpreters and translators must be appropriately trained in medical terminology, confidentiality of protected health information (PHI), and ethical issues that may arise in communicating health-related issues - family members and friends shall not be relied upon to provide interpretation services for the resident, unless explicitly requested by the resident. If a family member or friend is used to interpret the resident must provide written consent for disclosure of PHI - it is understood that providing meaningful access to services provided by this facility requires also that the LEP resident's needs and questions are accurately communicated to staff. Oral interpretation services therefore include interpretation from the LEP resident's primary language back to English - in order to provide meaningful access to services provided by this facility, translation and/or interpretation must be provided in a way that is culturally relevant and appropriate to the LEP individual - quality assurance and performance improvement (QAPI) committee shall assess bi-annually the LEP population in the surrounding community and determine if the current language access program serves the needs of the eligible population and make adjustments as needed - staff shall be trained upon hire and at least annually on how to provide language access services to LEP residents Resident #22 was admitted to the facility in August 2022 with diagnoses including Parkinson's disease, encephalopathy of unclear etiology, reduced mobility, abnormalities of gait and mobility, and anxiety. Review of Resident #22's Comprehensive Nursing Assessment upon admission indicated: the Resident's family member was the activated healthcare proxy (HCP), the Resident's dominant language was foreign to the facility, and the Resident preferred to have his/her information provided verbally (the dominant language was Portuguese). During an interview on 11/3/22 at 8:40 A.M., Family member #2 was at the bedside of Resident #22 and said the Resident speaks Portuguese and can speak and understand very little English. During an interview on 11/3/22 at 9:17 A.M., Certified Nursing Assistant (CNA) #2 said the Resident is predominately Portuguese speaking. She said the facility has a language line for interpreter services, but the staff do not usually use it. Resident #22 joined the conversation and said the staff rarely use the language line to speak to him/her and he/she has no way of communicating to the staff unless his/her family is with him/her or one of two Portuguese speaking staff members he/she has met are available. He/she does not want to get out of bed for activities but would like people to stop in and chat or play cards with him/her. He/she said there is nothing particular they wish to chat about but wishes people would socialize with him/her more and that he/she enjoys it very much when they do. During an interview on 11/3/22 at 9:26 A.M., Family member #1, who is the Resident's activated healthcare proxy (HCP), said the Resident is not confused but gets very frustrated when he/she is not understood by the staff and has a hard time communicating with the staff. Family member #1 said the facility believes the Resident is confused simply because of the language barrier and their inability to communicate with him/her effectively. Family member #1 said Resident #22 would benefit immensely from someone he/she could speak with. Family member #1 said the Resident is frustrated by the language barrier and would like more social interaction. Family member #1 said she is not aware of anyone coming to play cards with the Resident or spending time with him/her just to socialize but having that social interaction with someone would be beneficial to help the Resident's mood and feel less isolated. During an interview on 11/03/22 at 3:38 P.M., the Surveyor observed Resident #22 in bed, an interpreter said the Resident said he/she doesn't get out of bed anymore because they don't get any therapy and their legs don't work anymore. Review of the OT Discharge Summary, dated 10/17/22, indicated Resident #22 received OT services from 10/4/22 through 10/17/22. Further review indicated but was not limited to the following: - Resident agreeable to the idea of rehab services but not compliant with actual physical participation - Limited progress made Review of OT Treatment notes, indicated but was not limited to the following: - Primarily Portuguese speaking indicated on all treatment notes - 10/6/22 Demonstrates increased confusion with following simple directions during attempts to transfer. Actively participates with skilled interventions and compliant with training techniques. - 10/13/22 Resident not responding to session with active participation and was resistive during process of transfers, although encouragement given. - 10/14/22 Resident required continual verbal cuing for sequencing of tasks and will acknowledge saying ok or yes. However, even with maximum verbal encouragement is not physically participating in activity. Education to Resident and family however secondary to language barrier therapist unable to determine level of comprehension. During an interview on 11/8/22 at 8:01 A.M., Physical therapy assistant (PTA) #1 said he worked with the Resident a few times and believes the decision was made to take the Resident off of rehab services because they were not making enough progress. He said he does not speak the dominant language of the Resident but would use one word instructions or hand gestures to communicate to the Resident what they needed to do and did not think it caused any difficulty. During an interview on 11/8/22 at 10:01 A.M., the Director of Rehab (DOR), who is an Occupational therapist said Resident #22 was removed from services for reaching his/her maximum potential. She said there was a language barrier, but rehab staff would play charades or use simple one word instruction for communication with the Resident. On 11/03/22 at 4:32 P.M., the surveyor observed the Resident in his/her room, in bed with their eyes open and the lights off. There was no television or music on in the Resident's dominant language and no communication cards were found at the bedside for the Resident to be able to communicate with non-Portuguese speaking staff as the care plan indicated. During an interview on 11/4/22 at 8:47 A.M., Family member #2 said he looked for the communication cards but there are none available for the staff to use. He said he knows they have a language line, but he does not think they use it and has never seen it used by a staff member who does not speak or understand Portuguese. He said the Resident struggles to communicate with anyone in the facility or to make his/her preferences, needs and desires known. During an interview on 11/4/22 at 8:51 A.M., CNA #1 said she is not Portuguese speaking and has provided care for the Resident. She said she knows the language line is available for interpreting, but she has never used it. She said usually she can work with the Resident to figure out what they want through hand gestures and simple one word responses. She said it is hard to communicate with Resident #22, but she does the best she can. During an interview on 11/4/22 at 9:15 A.M., Nurse #8 said she cares for the Resident routinely when she is on duty. She said the Resident is Portuguese speaking. She said she has contacted the Resident's family by phone for translation. She said the Resident is anxious at times and would benefit from someone speaking with him/her about his/her mood but she doesn't believe the facility psychotherapist can speak Portuguese so that wouldn't be possible, she said the Resident was recently started on a medication for the anxiety and that does seem to help. Review of Resident #22's current care Kardex (summary of resident's care and preferences), dated 11/8/22, lacked any information that the Resident was not English speaking or required interpreter services to make their needs known. During an interview on 11/4/22 at 10:45 A.M., Family Member #1 said she feels Resident #22 would benefit from having a person who could just go in and speak with them and spend some time with them because socializing is a main form of enjoyment for the Resident. She said any form of socialization or communication whether it be by psychotherapy, which he/she had at home, or any staff member would greatly benefit the Resident's mood and reduce his/her anxiety since they could interact with someone in their own language. On 11/04/22 at 12:27 P.M., the surveyor observed Resident #22 in bed without any form of entertainment within reach with their eyes open and the lights off. Review of the most recently completed Activity assessment for Resident #22 indicated the following: - Resident's primary language is Portuguese, and he/she will need an interpreter to make his/her needs known - Favorite activities include cards (no other activities are noted here) - Preferred activity setting is his/her own room - Resident would like staff to play cards in his/her room with them - Resident is oriented to self, place and time and cooperative - Resident will be encouraged to maintain their current level of activity interest such as playing card games Review of the Individual activity participation record for Resident #22, from August 2022 thru current (11/4/22) indicated the following: - card games were not offered or participated in throughout the 95 days of the look back period - 1:1 (one to one) visits/media cart was only offered twice in the 95 days look back Review of the activities/recreational notes for Resident #22 indicated the Resident has been seen five times in the last 95 days for a 1:1 visit and was offered some independent activities following a quick chat. During an interview on 11/4/22 at 1:46 P.M., the Activity Director (AD) said am visits last about 1 minute and is a hello greeting and offer of coffee, as the afternoon visits are similar and offer snacks. She couldn't explain why the Resident was not consistently offered someone to play cards with them or why he/she was only seen for 1:1 visits, that included a quick chat and dropping off independent materials, only five times since August 2022. She said the staff member who performed the five activity visits is the only staff member she has that speaks Portuguese and that may have played a part in the limited interactions. She said activities involvement with the Resident needed to be improved upon. 42742 4. Resident #29 was admitted to the facility with diagnoses including cognitive communication deficit, dementia, and Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors). Review of the Minimum Data Set (MDS) assessment, dated 10/3/22, indicated that Resident #29 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score not being performed due to the Resident being rarely understood. The MDS indicated Resident #29 was of Asian descent with Cantonese as his/her primary language and needed or wanted an interpreter to communicate with a doctor or health care staff. Review of the Admission Activity Assessment, dated 9/29/22, indicated Resident #29 was originally from China and speaks both Cantonese and Mandarin but his/her primary language was Cantonese and needed a translator to communicate verbally. Resident #29's favorite activities included Bingo and television but also liked music, games, coloring, walking, reading a book, and going outside. On 11/2/22 at 12:31 P.M., the surveyor did not observe any assistive communication devices in Resident #29's room. On 11/2/22 at 1:50 P.M., the surveyor observed Resident #29 sitting alone in his/her wheelchair in front of the nurses' station. Staff did not interact with the Resident and there were no materials of interest, food, or refreshments offered or provided. On 11/3/22 at 10:06 A.M., the surveyor observed Resident #29 sitting alone in his/her wheelchair in front of the nurses' station. An overbed tray table was located directly in front of the Resident but there was nothing on top of it. Staff was not observed interacting with or engaging the Resident with independent or 1:1 activities. On 11/7/22 at 8:30 A.M., the surveyor observed a picture board above the Resident's bedside table in his/her room. A staff member was assisting the Resident with breakfast but was not observed utilizing the picture board to aid in communication. The staff member was not interacting with the Resident. The Resident was observed staring straight ahead. On 11/9/22 at 10:30 A.M., the surveyor observed Resident #29 sitting alone in his/her wheelchair in front of the nurses' station. Staff was not observed interacting with the Resident or engaging him/her with materials of interest. The Resident then fell asleep. An overbed tray table was observed directly in front of the Resident with nothing on it. During an interview on 11/9/22 at 12:21 P.M., the Activities Director said Resident #29 participated in group activities, but when not in group activities enjoyed coloring, flower arranging, and watching television. The Activities Director said staff should have been engaging and offering materials of interest to the Resident. The surveyor observed the main dining room on the Meadows Unit to have five shelves of activity resources including music, games, and books. During an interview on 11/10/22 at 7:27 A.M., Certified Nursing Assistant (CNA) #7 said the Resident spoke Chinese but did not respond to staff. CNA #7 said she communicated with the Resident based on his/her facial expressions and his/her reactions and gestures but had to use the Resident's gaze to see what he/she really needed. CNA #7 said she relied on the Resident's family member to help when she was there but did not utilize other resources and did not receive culturally competent care training at the facility. She said there was nothing specific to culture. CNA #7 said staff should have been engaging the Resident and offering activities. During an interview on 11/10/22 at 7:37 A.M., Nurse #4 said she did not have cultural training at the facility and could not answer what the Resident's cultural preferences were. Review of the interdisciplinary care plans failed to indicate a care plan had been developed to reflect Resident #29's cultural and communication needs including risks, preferences, measurable goals, objectives, and timetables. During an interview on 11/10/22 at 7:42 A.M., Unit Manager (UM) #1 said she had not received any cultural training to better determine Resident #29's needs and preferences and went by what the daughter said. UM #1 said the Resident should have been care planned for culture/communication and staff should have engaged the Resident and provided activities based on the Resident's preferences. UM #1 said there was a communication binder on another unit where five other Asian residents resided. She said there was not a binder available on this unit, however, to assist with communication for Resident #29. During an interview on 11/10/22 at 8:36 A.M., the Director of Nursing (DON) said there should have been cultural training for staff but there was not and there were no cultural facility policies or procedures developed for staff to follow. The DON said staff should have been engaging the Resident and utilizing resources for independent activities and well as for communication. The DON said she was not sure why Resident #29 was separated from the other residents of the Asian community residing on another unit to encourage interaction and overall well-being.

Based on observations, interviews, and record review, the facility failed to ensure quality of care was provided, according to the plan of care, facility protocols, and professional standards of practice for three Residents (#32, #55, and #69), out of 27 total sampled residents. Specifically, the facility failed: 1. For Resident #32, to promote and manage the delivery of safe nursing care in accordance with accepted Standards of Nursing Practice by failing to conduct ongoing assessment of a change in condition, inform the Physician of the change, and provide necessary care and treatment for a Resident with a hematoma (collection (or pooling) of blood outside the blood vessel) and worsening pain and swelling; 2. Resident #55, to provide appropriate care and equipment to maintain their level of function (transfer and ambulation) resulting in a decline in functional status; and 3. Resident #69, to appropriately evaluate and provide equipment to get out of bed and participate in daily socialization with peers. Findings include: 1. Resident #32 was admitted to the facility in September 2022 with diagnoses including atrial fibrillation. Review of the Minimum Data Set (MDS) assessment, dated 9/27/22, indicated Resident #32 spoke Chinese and required an interpreter to communicate with his/her Physician and health care staff. Review of the medical record indicated Resident #32 was started on anticoagulation therapy (blood thinning) during an acute hospitalization in October 2022. Review of the November 2022 Physician's Orders indicated: -Heparin 5000 units/milliliters (mL) injected subcutaneously (under the skin) three times a day (10/11/22) -Acetaminophen 325 milligrams, two tablets every 6 hours as needed for pain/fever (9/23/22) Review of the medical record indicated 11/4/22 Hospital Emergency Department Documentation that included but was not limited to: -Resident presenting to the emergency department with a large hematoma on the dorsum of the right hand; -The hematoma is a fluid collection in the right hand measuring 4.1 X 2.1 X 4.3 centimeters dorsally; -Patient is complaining of worsening pain The Resident was discharged back to the facility on [DATE] with an educational information sheet for a Hand Bruise that recommended home care to include: -elevate the hand -apply ice -acetaminophen, ibuprofen, or naproxen to control pain Review of the medical record indicated no new physician's orders to monitor or otherwise assess the large hematoma to the Resident's right hand. On 11/7/22 at 8:45 A.M., the surveyor observed Resident #32 lying in bed supine moaning with his/her right hand elevated on a pillow with a towel covering it. The Resident opened his/her eyes, removed the towel pointed at his/her right hand and said, ice. The top of the Resident's hand had a large dark bluish/black blood-filled hematoma that extended from the Resident's wrist to the base of his/her fingers and encompassed the entire dorsal aspect of the Resident's right hand. The observation reflects an increase in size of the hematoma as documented in the hospital emergency room report. During an interview on 11/07/22 at 8:46 A.M., the surveyor alerted Nurse #14 that Resident #32 requested ice for his/her right hand. Nurse #14 said the Resident's hand looks bad. Although the hospital documentation indicated to apply ice, the Nurse reviewed the medical record and said Resident #32 does not have an order for ice and cannot provide it without an order. Review of the medical record failed to indicate any documentation of ongoing assessment of the appearance/condition of the hematoma on the Resident's hand. During an interview on 11/7/22 at 9:11 A.M., Unit Manager #2 said Resident #32 was sent to the hospital on 11/4/22 for evaluation of a bruise and swelling as a result of Heparin use. She said the hematoma on the Resident's right hand is larger today than it was when he/she went to the hospital on 11/4/22. She said although the Physician is on vacation, she spoke to him on Friday and he said to send the Resident to the hospital and spoke to him again this morning and obtained orders for care and monitoring of the hematoma (ice, elevation of the hand, monitor radial pulse, monitor right hand color, sensation and movement, monitor worsening signs/symptoms of right hand hematoma), three days after the hematoma was identified. During telephone interviews on 11/7/22 at 1:01 P.M. and 1:54 P.M., Physician #1's office staff indicated Resident #32's Physician is on vacation and has been since 11/3/22 and will return on 11/8/22. She said neither the covering Physician's office nor the Nurse Practitioner had been contacted by the facility regarding Resident #32 and don't know anything about the Resident. During a telephone interview on 11/8/22 at 10:45 A.M., Physician #1 said that he has been on vacation since 11/3/22 and returned today. He said he was not contacted by anyone from the facility while he was on vacation and was unaware Resident #32 had a hematoma and was sent to the hospital on 11/4/22. He said he learned about the hospitalization when he retrieved his messages this morning. Physician #1 said he did not give orders for Resident #32 to be sent to the hospital or for care and treatment of the Resident's hematoma. He said he would be in to see Resident #32 on 11/9/22. On 11/9/22 at 9:39 A.M., the surveyor observed Resident #32 lying in bed with his/her right hand elevated on a pillow (no ice was on the hand) and was moaning. The top of the Resident's hand had a large bluish/black blood-filled hematoma that extended from the Resident's wrist to the thumb. All five fingers on the Resident's hand were swollen. The Resident opened his/her eyes and repeatedly said, ice. The observation reflects an increase in size of the hematoma, and increased swelling from the observation on 11/8/22. On 11/9/22 at 9:41 A.M., the surveyor alerted Nurse #15 that the Resident requested ice. Nurse #15 asked Resident #32 to rate his/her pain on a scale from 0 to 10. The Resident did not respond. The surveyor told the Nurse that Resident #32 does not speak English. The Nurse said at other places she has worked, they had a book or binder with communication pictures, but there isn't one here. The Nurse touched the Resident's right hand and the Resident recoiled and said, Ow, Ow, Ow, Ow. Nurse #15 said this is her first time working with this Resident and was not told at report that the Resident has a large blister, could not speak/understand English and was in pain. She said she was just told the Resident is having ice applied to his/her hand. On 11/9/22 at 11:10 A.M., the surveyor accompanied Physician #1 at Resident #32's bedside. The Resident was lying in bed with his/her right hand elevated on a pillow and moaning. The Physician visually assessed the Resident's right hand and said the anticoagulant medication needs to be stopped immediately. The Resident recoiled and said Ow when the Physician picked up his/her hand to examine it. He said the hematoma and swelling was due to trauma. Physician #1 said that he recalls receiving a text from Unit Manager #2 while he was on vacation. He showed the surveyor the text message exchange between him and Unit Manager #2. The texts dated 11/4/22 include, but are not limited to a photograph of Resident #32's right hand that showed bruising and a fluid filled blister on the top of the hand; a copy of a venous Doppler study of the Resident's left hand, dated 10/17/22; Physician #1 directed the Unit Manager to stop Heparin and start Eliquis (anticoagulant) 2.5 mg twice daily and call his office as he was on vacation until 11/7/22. 36542 2. Resident #55 was admitted to the facility in July 2022 with a diagnosis of Parkinson's disease and a history of a stroke. Review of the care plans for Resident #55 indicated a decreased ability to perform activities of daily living (ADLs) with the following care needs as of 10/26/22: -dependent with locomotion on Broda chair -maximum assist of 2 staff with transfers between surfaces (bed to chair) -maximum assist with eating A care plan indicated Resident #55 demonstrated a potential risk for aspiration related to impaired swallowing with an intervention to have the Resident out of bed and at a 90-degree angle when swallowing food or drinks. Review of the medical record indicated the following timeline for the ADL status of Resident #55: 7/18/22: started Physical Therapy (PT) 7/20/22: started Occupational Therapy (OT) 8/5/22: using rolling walker and able to transfer to the toilet with contact guard (one or two hands on body, no assistance) from staff 8/22/22: ambulating 100 feet with a walker and contact guard from staff 9/6/22: sit to stand with minimum assist from Broda chair to rolling walker 9/8/22: tested positive for COVID-19 9/12/22: self-feeding with right upper extremity 9/16/22: ambulated 100 feet with contact guard 9/17/22: recertified to continue OT services, continued to make progress towards goals 9/23/22: PT focused on muscle strength and gait training; OT contact guard for use of the over toilet commode 9/24/22: sent to emergency room at 10:50 P.M. related to elevated blood pressure and temperature 9/24/22: PT discharged Resident due to being at the hospital; OT noted discharged prior to caregiver education and exercise program 9/25/22 at 12:00 P.M. Resident returned from the hospital, 14 hours after being sent out The surveyor made the following observations on 11/2/22 at: -9:00 A.M. Resident #55 was in a blue Broda chair (wheelchair which can recline and tilt). The Resident's sides and back were supported by pillows. The Resident's feet were dangling from the Broda, there was no footrest and the feet could not touch the ground. -12:30 P.M. Resident in Broda chair in the back dining room. Staff observed to place pillows behind the back of the Resident to sit his/her torso up vertically. The Resident's feet continue to dangle. -3:05 P.M. the Resident was in the Broda chair with his/her face towards the ceiling. There was a table with puzzles in front of him/her which they could not see due to the position. On 11/3/22 at 8:20 A.M., the surveyor observed Resident #55 in bed. The blue Broda chair was observed in the bathroom area of the room. The surveyors observed a blanket on the seat of the chair and one on the back rest of the chair. The chair was in a reclined position. The surveyors attempted to put the chair up to a seated position through the recline lever and the tilt lever and the chair would not stay in the upright position. On 11/4/22 at 8:35 A.M., the surveyor observed Resident #55 in the main dining room in the blue Broda chair, reclined with feet dangling. The Resident was attempting to self-feed breakfast; they were observed to be leaning back with pillows between the back and the back rest, but not supportive enough to be at a 90-degree angle. The Resident was observed to have dropped eggs on his/her lap. At 8:43 A.M. Resident #55 was observed to ask Nurse #7 for help, a staff member assisting another resident said Resident #55 did not need help with eating, Nurse #7 explained that the Resident requested it. During an observation with interview on 11/4/22 at 8:45 A.M., Nurse #7 said there are pillows behind the Resident's back and she was not sure why. The surveyor asked her if the chair was functioning and if it could be used in the upright position. The surveyor observed Nurse #7 try the recliner function and the tilt function and neither would keep the chair in the upright position. On 11/4/22 at 10:20 A.M., the surveyor observed Resident #55 seated in a straight back, stationary chair, sitting comfortably and able to look straight ahead with his/her feet on the ground. During an interview on 11/4/22 at 10:25 A.M., Unit Manager #2 said Resident #55 was previously in a regular wheelchair, but had started to lean to the side, so was switched to a Broda chair. She said she was not sure when this happened or if rehabilitation services had evaluated the positioning of Resident #55. During an interview on 11/8/22 at 8:53 A.M., the Director of Rehabilitation said Resident #55 was making progress while on rehabilitation services and was recertified for OT on 9/17/22 and PT on 9/18/22 (one week prior to the emergency room visit). She said according to the treatment notes and progress notes, Resident #55 should have been able to continue with ambulation up to 100 feet with the rolling walker, transfer between surfaces with minimum assistance, and utilize a wheelchair for longer distances. She said she was not sure why Resident #55 was discharged from rehabilitation services without a plan following a 14-hour emergency room visit. She said she was not sure where the blue Broda chair had come from and had recently discovered residents at the facility were not utilizing equipment designated for them. During an interview on 11/10/22 at 9:20 A.M., the Director of Rehabilitation said Resident #55 was evaluated by OT and had transferred from bed to chair with the assist of two staff and was only able to stand briefly. She said Resident #55 would be referred back to PT as this was not the prior level of function and he/she could no longer ambulate. 3. Resident #69 was admitted to the facility in September 2022 with a history of cerebral vascular accident and a contracture to the left leg. Review of the medical record for Resident #69 indicated the following languages: Chinese, Cantonese, Vietnamese. Review of the Recreation Comprehensive Assessment, dated 9/23/22, and completed with the Health Care Proxy of Resident #69 indicated adaptive equipment of a Broda chair. Review of the ADL (Activities of Daily Living) Record for September, October and November 2022 (until 11/8/22) all indicated transferring out of bed was N/A (Not Applicable.) On 11/2/22 at 8:30 A.M., the surveyor observed Resident #69 in bed, the light was on, his/her eyes were open. At 11:08 A.M. and at 11:44 A.M., Resident #69 was still in bed, with no changes. There was no wheelchair observed in the room or in the corridor. During an interview on 11/2/22 at 12:00 P.M., Certified Nursing Assistant (CNA) #4 said Resident #69 does not get out of bed and the staff had attempted to get him/her up, but the Resident had screamed. During an interview on 11/2/22 at 5:04 P.M., the family of Resident #69 said the Resident had transferred from another facility. She said the Resident was getting out of bed at the other facility and would eat meals in the main dining room and attend activities. She said the staff did tell her the Resident screamed when they had attempted to get him/her out of bed, but she was not sure why this happened. She said the Resident had a left leg contracture and would need a special wheelchair. She said at the previous facility Resident #69 had a wheelchair with a separate head rest, the chair tilted and was all black. On 11/03/22 at 2:15 P.M., the surveyor observed Resident #69 in bed, eyes open. There was no wheelchair observed in the room or in the corridor. On 11/4/22 at 11:40 A.M., the surveyor observed Resident #69 lying in bed with his/her eyes open and staring straight ahead. There was no wheelchair observed in the room or in the corridor. At 11/4/22 at 11:51 A.M., the surveyor asked Nurse #7 where the wheelchair was for Resident #69. During an interview on 11/4/22 at 12:30 P.M., Nurse #7 said the staff were unable to locate a wheelchair for Resident #69. She said she had spoken with the Certified Nursing Assistant who had attempted to get the Resident out of bed and the attempt had been made with a standard wheelchair, so she was not sure what kind of chair was appropriate for the Resident. On 11/8/22 at 8:36 A.M., Unit Manager #2 said the rehabilitation department had previously tried to get the Resident up to a standard wheelchair, but Resident #69 did not like to get into the wheelchair. She said she had never asked the family of Resident #69 about the status of the Resident at the previous facility. Review of the Physical Therapy documentation indicated Resident #69 was on PT from 9/24/22 through 10/22/22. The evaluation indicated the prior equipment was unknown and the Resident would benefit from PT to address wheelchair seating and positioning. Review of all the treatment encounter notes failed to indicate a therapist had attempted to put Resident #69 into an appropriate wheelchair. Review of the PT Discharge Summary, dated 10/25/22, indicated per staff pt (resident) does not tolerate being up in w/c (wheelchair), becomes behavioral necessitating back to bed for safety. During an interview on 11/8/22 at 9:15 A.M., the Director of Rehabilitation said the PT department did not document that they had attempted seating and positioning with Resident #69. She said there was no indication in the documentation that the staff had tried anything other than a standard wheelchair. She said with the contracture to the left leg, the screaming would have been an indicator to trial a different type of wheelchair. During an interview on 11/9/22 at 2:00 P.M., the Director of Rehabilitation said the rehabilitation department had evaluated Resident #69 and the Resident had been seated in a Broda chair today without any issues.

Based on observations, interviews, and record review the facility failed to ensure behavioral health services were provided to Resident #63 with major depressive disorder, who exhibited frequent crying. The total sample was 27 residents. Findings include: Review of the facility's policy titled Depression-Clinical Protocol, dated as revised November 2018, indicated the following: -the physician will identify the need for additional consultation (psychiatric, psychological, etc) to help define the nature, severity, causes and complications of any mood disorder Resident #63 was admitted to the facility in July 2022 with a diagnosis of dementia, major depressive disorder (recurrent severe without psychotic features) and anxiety. Review of the Preadmission Screening and Resident Review (PASARR) Level II, dated 7/21/22, indicated Resident #63 was psychiatrically hospitalized in June 2022 and had a recent history of voicing suicidal ideation. Review of a psychiatric hospital History and Physical, dated 6/11/22, indicated Resident #63 had been admitted for recurrence of major depressive disorder and vague suicidal statements. Patient states (his/her) only problem right now is severe depression. Review of the Care Plans for Resident #63 indicated Resident #63 had a primary language of Spanish and needed a translator to make needs known. The Care Plans also indicated the Resident had a sad mood and withdrawal related to placement, potential for adjustment difficulties, diagnoses of anxiety and depression, and to provide psychiatric services as needed. There was no information on the Care Plans regarding the history of suicidal ideation or the goal or interventions regarding suicidal ideation. Review of the Progress Notes from the Psychiatric Nurse Practitioner, indicated - On 8/19/22, the Resident displayed anxiety and weepy mood, unable to relieve. - On 9/16/22, the Resident was anxious and agitated, was Spanish speaking and required an interpreter. There was no indication an interpreter was utilized. Review of the Medication Administration Record (MAR) for Resident #63 indicated the Resident was anxious 30 days and was crying 26 days out of 31 days in October 2022. On 11/2/22 at 8:32 A.M., the surveyor observed Resident #63 walking on the unit, crying and saying in Spanish my house. On 11/3/22 at 9:19 A.M., the surveyor observed Resident #63 on the telephone, crying, asking in Spanish how long he/she had to stay here. At 9:30 A.M. the Resident was off the phone and walking the hall, crying. On 11/4/22 at 8:30 A.M., the surveyor observed Resident #63 standing at the nurses' station crying. At 8:35 A.M. a Certified Nursing Assistant helped the Resident call their family member and the Resident cried through the conversation. On 11/8/22 at 11:38 A.M., the surveyor observed the Resident in their room, on their bed, crying, eyes red. Resident says, mi casa (my house) On 11/09/22 at 10:32 A.M., the surveyor heard the Resident sobbing from their room, approximately 25 feet from the nurses' station. Unit Manager #2 and Certified Nursing Assistant (CNA) #4 were observed to leave the residents room and leave the unit. On 11/9/22 at 10:37 A.M., the surveyor observed Resident #63 alone in his/her room, loudly sobbing, and shaking the footboard of his/her bed. On 11/9/22 at 10:40 A.M., the surveyor observed Resident #63 leave his/her room with red eyes, tears coming down, look up and down the hall and start walking the halls of the unit. On 11/9/22 at 2:15 P.M., the surveyor observed Resident #63 seated in a chair at the nurses' station, visibly sobbing. At 2:22 P.M. Nurse #10 was observed to repeatedly hand the Resident a telephone. The Resident would take the phone, hear something and start crying hard again. During an interview on 11/9/22 at 2:30 P.M., Nurse #10 said they were attempting to call the [family member] of Resident #63, but it continued to go to voicemail. Nurse #10 said she was not able to communicate with the Resident in his/her primary language and only the Medical Records staff and one CNA working at this time were able to communicate in the primary language of the Resident. She said the CNA was busy and could not help the Resident. During an interview on 11/4/22 at 3:03 P.M., the Social Worker said Resident #63 was frequently crying. She said she was able to communicate with the Resident in his/her primary language. She said the family of Resident #63 had not been visiting and did not answer the telephone when the Resident called. The Social Worker said the Resident had voiced to the Social Worker that he/she wanted to be with their family and that the Social Worker did not know how to help with this. She said the Resident had not been seen by a psychotherapist for the mood disorder, anxiety or crying. She said she was unsure if the consultant psychotherapist for the facility spoke Spanish, but that they could have used the language line to work with the Resident. During an interview on 11/10/22 at 8:58 A.M., Nurse #10 said Resident #63 was so upset the previous day with repeatedly getting the voicemail of his/her [family member] that he/she would literally slump his/her body and become dead weight.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the assistance of two staff members for transfers, the Facility failed to provide the necessary level of assistance to maintain Resident #1's safety when on 08/26/20, Certified Nurse Aide (CNA) #1 used a slide board without the assistance of another staff member to transfer Resident #1 from his/her wheelchair to his/her bed, as a result Resident #1 fell and sustained a right arm fracture. Findings include: The Facility's Policy titled, Falls Management, dated 02/2020, indicated that patients will be assessed for falls as part of nursing assessment process, and those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. The Policy also indicated that the Facility will develop an individualized plan of care and will review and revise plans of care regularly. Resident #1 was admitted to the Facility in August 2020 with [DIAGNOSES REDACTED]. The RMS Event Summary Report, dated 08/26/20, indicated Resident #1 was being transferred by a staff member using a slide board when he/she slid off the board, landing on the floor on his/her right side. The Report indicated education was provided to staff regarding Resident #1 had not been cleared for slide board transfers. The Report indicated Resident #1 complained of right upper extremity pain, the Physician was notified that he/she sustained a fracture, and he/she was transferred to the Hospital Emergency Department for evaluation. Review of Resident #1's Nurse Progress Note, dated 08/26/20, indicated he/she had a fall, complained of severe right upper extremity pain, the Physician was notified and ordered an x-ray of the right shoulder, elbow, and wrist. Review of Resident #1's Radiology Report, dated 08/27/20, indicated Resident #1's right humerus bone (long bone that runs from the shoulder to the elbow) was fractured and displaced. Review of Resident #1's Nurse Progress Note, dated 08/27/20, indicated the Physician was notified of the x-ray results and ordered Resident #1 to be transferred to the Hospital Emergency Department for evaluation. Review of Resident #1's Plan of Care related to Activity of Daily Living (ADLs), submitted by the Facility in Health Care Facility Reporting System (HCFRS) on 09/01/20, revised on 08/18/20, indicated, he/she was an extensive assist of two staff members using a straight cane and pivot with partial weight bearing on heels only, during wheelchair transfers. Review of Resident #1's Activity of Daily Living (ADL) Record, dated August 2020, indicated that on 08/26/20 for the 3:00 P.M. to 11:00 P.M. shift, CNA #1 documented that Resident #1 was totally dependent with the assistance of two staff members during transfers. During an interview on 01/22/21 at 12:00 P.M., Certified Nurse Aide (CNA) #1 said that on 08/26/20 at 11:00 P.M. she transferred Resident #1 by herself using a slide board from his/her wheelchair to his/her bed and during the transfer Resident #1 slid off the board landing on the floor on his/her right side. CNA #1 said she did not review Resident #1's plan of care for transfers prior to transferring Resident #1. CNA #1 said she did not ask another staff member for assistance when transferring Resident #1 because they were all busy at the time. CNA #1 said the day prior to the fall (on 08/25/20) she said she had helped Occupational Therapist (OT) #1 to transfer Resident #1 with using the slide board and said she thought that she could now use the slide board to transfer Resident #1. During an interview on 01/22/21 at 3:45 P.M., Nurse #1 said she was at the Nurses Station when she heard that Resident #1 had fallen and that he/she was on the floor. Nurse #1 said when she arrived at Resident #1's bedroom, he/she was on the floor and said that the slide board was in his/her room. Nurse #1 said Resident #1 required the assistance of two staff members for transfers and said that CNA #1 used a slide board to transfer him/her and said that CNA #1 did not ask for help to transfer Resident #1. The Surveyor was unable to reach Nurse #2 for an interview, however Review of a Written Statement, written by Nurse #2, dated 08/27/20, indicated that when she arrived for her shift at 11:00 P.M. she was called to Resident #1's room by an unnamed CNA. The Statement indicated that Nurse #2 saw Resident #1 sitting upright on the floor with his/her back to the bed. The Statement indicated that Resident #1 had right sided [MEDICAL CONDITION] and that Resident #1 said he/she fell on his/her right side and that his/her right arm was hurting. The Statement indicated that Resident #1 was transferred to the Hospital Emergency Department for further evaluation. During an interview on 01/22/21 at 12:37 P.M., Occupational Therapist (OT) #1 said she had requested CNA #1's help on 08/25/20 to transfer Resident #1 using the slide board because she did not feel safe to assess his/her transfer abilities without a second staff person. OT #1 said she was still assessing safest strategies for transferring Resident #1. During an interview on 01/22/21 at 12:22 P.M., the Director of Rehabilitation said at the time of fall (on 08/26/20), nursing staff had not been trained by the rehabilitation staff to use the slide board to transfer Resident #1. During an interview on 01/22/21 at 1:30 P.M., the Director of Nurses (DON) said CNA #1 had used the slide board the day before the fall with OT #1 to transfer Resident #1 and thought CNA #1 had been trained to use the slide board but said that CNA #1 should have had a second staff member with her for the transfer and that CNA #1 did the transfer by herself. There was no documentation to support and the Facility was unable to provide documentation that staff were educated on using the slide board to transfer Resident #1 prior to the fall on 08/26/20.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the assistance of two staff members for transfers, the Facility failed to ensure staff implemented and followed his/her plan of care, when on 08/26/20, Certified Nurse Aide (CNA) #1 used a slide board without the assistance of another staff member to transfer Resident #1 from his/her wheelchair to his/her bed, as a result Resident #1 fell and sustained a right arm fracture. Findings Include: The Facility's Policy titled, Falls Management, dated 02/2020, indicated that patients will be assessed for falls as part of nursing assessment process, and those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. The Policy also indicated that the Facility will develop an individualized plan of care and will review and revise plans of care regularly. Resident #1 was admitted to the Facility in August 2020 with [DIAGNOSES REDACTED]. Review of Resident #1's Plan of Care related to Activity of Daily Living (ADLs), submitted by the Facility in Health Care Facility Reporting System (HCFRS) on 09/01/20, revised on 08/18/20, indicated, he/she was an extensive assist of two staff members using a straight cane and pivot with partial weight bearing on heels only, during wheelchair transfers. Review of Resident #1's Activity of Daily Living (ADL) Record, dated August 2020, indicated that on 08/26/20 for the 3:00 P.M. to 11:00 P.M. shift, CNA #1 documented that Resident #1 was totally dependent with the assistance of two staff members during transfers. Review of Resident #1's Nurse Progress Note, dated 08/26/20, indicated he/she had a fall, complained of severe right upper extremity pain, the Physician was notified and ordered an x-ray of the right shoulder, elbow, and wrist. Review of Resident #1's Radiology Report, dated 08/27/20, indicated Resident #1's right humerus bone (long bone that runs from the shoulder to the elbow) was fractured and displaced. Review of Resident #1's Nurse Progress Note, dated 08/27/20, indicated the Physician was notified of the x-ray results and ordered Resident #1 to be transferred to the Hospital Emergency Department for evaluation. The RMS Event Summary Report, dated 08/26/20, indicated Resident #1 was being transferred by a staff member using a slide board when he/she slid off the board, landing on the floor on his/her right side. The Report indicated education was provided to staff regarding Resident #1 had not been cleared for slide board transfers. The Report indicated Resident #1 complained of right upper extremity pain, the Physician was notified that he/she sustained a fracture, and he/she was transferred to the Hospital Emergency Department for evaluation. During an interview on 01/22/21 at 12:00 P.M., Certified Nurse Aide (CNA) #1 said that on 08/26/20 at 11:00 P.M. she transferred Resident #1 by herself using a slide board from his/her wheelchair to his/her bed and during the transfer Resident #1 slid off the board landing on the floor on his/her right side. CNA #1 said she did not review Resident #1's plan of care for transfers prior to transferring Resident #1. CNA #1 said she did not ask another staff member for assistance when transferring Resident #1 because they were all busy at the time. CNA #1 said the day prior to the fall (on 08/25/20) she said she had helped Occupational Therapist (OT) #1 to transfer Resident #1 with using the slide board and said she thought that she could now use the slide board to transfer Resident #1. During an interview on 01/22/21 at 12:37 P.M., Occupational Therapist (OT) #1 said she had requested CNA #1's help on 08/25/20 to transfer Resident #1 using the slide board because she did not feel safe to assess his/her transfer abilities without a second staff person. OT #1 said she was still assessing safest strategies for transferring Resident #1. During an interview on 01/22/21 at 12:22 P.M., the Director of Rehabilitation said at the time of fall (on 08/26/20), nursing staff had not been trained by the rehabilitation staff to use the slide board to transfer Resident #1. There was no documentation to support and the Facility was unable to provide documentation that staff were educated on using the slide board to transfer Resident #1 prior to the fall on 08/26/20. During an interview on 01/22/21 at 1:30 P.M., the Director of Nurses (DON) said CNA #1 had used the slide board the day before the fall with OT #1 to transfer Resident #1 and thought CNA #1 had been trained to use the slide board but said that CNA #1 should have had a second staff member with her for the transfer and that CNA #1 did the transfer by herself.

Based on record review, and review of the Facility's incident report and interviews, the facility failed to ensure that residents received timely treatment and care, by failing to complete an accurate comprehensive assessment for an unwitnessed fall, for 1 sampled resident (#6) out of a total sample of 23 residents. Findings include: For Resident #6, the facility failed to accurately document and assess the Resident's injuries post fall, subsequently the staff's documentation alternated the locations of the injuries from right to left and back to right, which resulted in inappropriate testing and a delay in care and treatment. Findings include: Resident #6 was admitted in 6/2001 and had [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) assessment, dated 1/12/17, indicated the Resident had moderate cognitive impairment and was at a supervised level for care (including ambulation). The MDS indicated that the Resident's Health Care Proxy was invoked and had advanced directives that included do not resuscitate, do not intubate, do not hospitalize and other directives. Review of the Quarterly MDS dated [DATE], indicated the Resident had cognitive impairment, and was independent on transfer, ambulation and toileting. Record review indicated the Resident had sustained several falls in the past and on 7/9/16 had an unwitnessed fall and sustained multiple injuries. The nurse's note dated 7/9/16 at 8:39 P.M. indicated that Resident #6's roommate notified the staff, on 7/9/16 at 7:20 P.M., that the Resident was on the floor. The note indicated the Resident was found in the hallway supine with a right temporal hematoma. The note indicated the Resident stated he/she was taking a walk and lost his/her balance. The Resident did not have his/her walker and the note indicated the Resident was able to move all extremities and was denying pain at the time of the fall. The nurse did not include current vital signs in the assessments, as the nurses note contained vital signs taken on 6/27/16 and the note indicated all vital signs were within normal limits. The nurse notified the Health Care Agent and the physician. The Resident was assisted back to bed and the nurse obtained orders for an ice pack to right temporal head area every shift for 48 hours. The next nurse's note written, after the fall and titled change in condition follow-up note. was on 7/10/16 at 4:39 A.M. The nurse indicated the Resident complained of right leg pain and his/her right temporal head area remained red and swollen. The nurse indicated ice was applied to the Resident's head and was given Tylenol ([MEDICATION NAME] - used to treat minor aches and pains) with effect. On 7/10/16 at 12:39 P.M. the nurse's note indicated there was no change in the Resident's condition, however indicated that the Resident complained of pain at a level of 8 out 10. The nurse identified the Resident's pain location in the left shoulder and left rib area. The nurse notified the physician and obtained orders for x-rays of the left shoulder and left ribs and [MEDICATION NAME] (Nonsteroidal anti-[MEDICAL CONDITION] drug used to treat mild pain) 600 mg, every 6 hours as needed. The note indicated the x-rays of the left shoulder and left ribs were negative. There was no additional assessment of the Resident's condition or evidence that the [MEDICATION NAME] was administered and/or effective. Review of the subsequent change in condition notes were as follows: - On 7/10/16 at 3:13 P.M., the nurse's note reiterated the prior note, but included that on assessment there was a decreased range of motion in the left upper extremity and complaints of pain by the Resident while moving left side near rib area. The note indicated the results of the x-ray (which were reviewed during record review and indicated that there were no left sided injuries) were reported to the physician and that the resident had poor oral intake. -On 7/10/16 at 10:42 P.M. and 11:00 P.M., the 2 nurses notes indicated the Resident had complaints of right leg pain and his/her right thigh remained swollen and red. The nurse indicated the Resident was given Tylenol, ([MEDICATION NAME] - used to treat minor aches and pains) with effect and ice packs were applied. There was no mention of pain associated with the left shoulder or left rib. -On 7/11/16 at 6:59 A.M., the nurse indicated the Resident had generalized pain and administer the medication [MEDICATION NAME]. The note does not indicate the effect of the medication, but indicated the right temporal head area and right thigh remained swollen. The subsequent notes indicated the Resident was transferred to the hospital on [DATE] at 11:13 A.M. The Facility's transfer notes, dated 7/11/16, indicated the Resident had fallen on 7/9/16 and complained of pain of the right hip, right elbow and right forehead. There was no mention of complaints of pain of the left shoulder, left ribs or the x-ray results. Review of the Hospital's history and physical, dated 7/11/16 and completed by the Resident's primary physician, indicated the Resident was transferred after a fall that had occurred 2 days prior to transfer. The physician documented that the Health Care Agent had informed the hospital staff that the Facility did not want to transfer the Resident to the emergency room after the fall, because of his/her advance directives. However, the physician documented that after . the Resident developed . a tremendous amount of swelling the Resident was transferred for care. The note indicated the Resident was sedated with an antipsychotic medication ([MEDICATION NAME]), due to distress and agitation, in order to obtain x-rays. The x-rays showed multiple fractures including right pelvis, back and right elbow. The Hospital's admission assessment indicated that the Resident had substantial bruising, swelling, pain and tenderness in the right elbow, right head and right hip. In addition, the hospital's comprehensive assessment determined a right scalp hematoma, spinal fractures that include L3 and L6, nondisplaced [MEDICAL CONDITION] inferior and superior rami pubic and nondisplaced [MEDICAL CONDITION] symphysis pubis and a fracture of right upper arm. Review of the Facility's incident report for the 7/9/16 fall, dated 7/18/16, indicated the that the Resident's roommate notified the staff of an unwitnessed fall. The report indicated a right temporal hematoma and that the Resident was found in a supine position. There was not a comprehensive assessment of the Resident's condition and the staff statements provide little information identifying the Resident's condition. The investigation does not address the discrepancy in documentation of pain for the left verses the right side and does not provide any information that was identified by the hospital summary (significant bruising and swelling). The summary indicated that Rehab will evaluate the Resident, staff will medicate for pain and that the right arm will be monitored for circulation, sensation and movement (CSM). During interview on 3/23/17 at 8:40 A.M., the Surveyor asked about the fall with Unit Manager #2. Unit Manager #2 made no response when asked about the x-ray taken of the left side when documentation indicated the injuries were sustained on the right. Subsequent to the interview with the Unit Manager, the Facility offered no explanation or provided any additional documentation that substantiated and supported the x-rays taken of the left side verses the right. During the survey exit on 3/23/17 at 4:00 P.M., the Director of Nurses made a general statement that the Resident complained of left side pain . there was no mistake for taking the x-rays. However, she did not offer any comprehensive assessment that indicated the facility had accurately completed that had ensured the Resident received timely and appropriate treatment and care for trauma sustained after a fall.

Based on interview and record review for one of three sampled residents (Resident #1), the Facility failed to ensure that Certified Nurse Aide (CNA) #1 immediately reported an allegation that Nurse #1 abused Resident #1 when Nurse #1 wrapped a tank top shirt around Resident #1's hand and fingers, as in a manner of a mitten, and tied the shirt around his/her wrist to prevent Resident #1 from pulling at his/her gastrostomy tube (a tube inserted into the stomach used to provide nutrition to people who are unable to obtain nutrition by mouth). Findings include: The Facility's Policy and Procedure on Abuse Prohibition, indicated that all incidents of suspected abuse, neglect, involuntary seclusions, injuries of unknown origin, or misappropriation must tell the abuser to stop immediately and orally report the incident to his/her supervisor immediately. Resident #1's quarterly Minimum Data Set (MDS) Assessment Form, dated 12/24/15, indicated Resident #1 had a [DIAGNOSES REDACTED]. The MDS indicated Resident #1 had limited range of motion on both sides, of the upper and lower extremities and was cognitively impaired. The Surveyor interviewed Resident #1 at 3:50 P.M., on 2/29/16. Resident #1 was unable to recall the incident. The Facility Internal Investigation, dated 1/21/16, indicated at approximately 8:15 A.M., Resident #1 was found in bed with his/her left hand and fingers wrapped in a tank top shirt, as in the manner of a mitten, and tied around his/her wrist. The investigation indicated CNA #1 told the Director of Nurses (DON) that on 1/21/16 at approximately 3:45 A.M., she observed Resident #1 with an undergarment type of shirt wrapped around his/her hand. CNA #1 said Nurse #1 told her that she had tied the shirt around Resident #1's hand and fingers to prevent Resident #1 from pulling at the gastrostomy tube. The investigation indicated CNA #1 completed her sheduled shift, left the Facility, and did not report the incident to anyone. The investigation indicated that Resident #1 was assessed with [REDACTED]. The Surveyor interviewed CNA #1 at 7:15 A.M., on 3/1/16. CNA #1 said that on 1/21/16 at approximately 4:00 A.M., as she provided care to Resident #1, she found a sock in the bed sheets. CNA #1 said she asked Nurse #1 about the sock, and Nurse #1 told her that she had placed a sock over Resident #1's hand to prevent Resident #1 from pulling at the gastrostomy tube. CNA #1 said she left Resident #1's room after completing care. CNA #1 said at approximately 5:00 A.M., she entered Resident #1's room as Nurse #1 was providing care to Resident #1. CNA #1 said she observed Resident #1 with an undergarment type of shirt wrapped around his/her hand that resembled a mitten. CNA #1 said the she asked Nurse #1 is that okay, or words to that affect. CNA #1 said Nurse #1 told her that Resident #1 had received medication to help him/her sleep, and she would removed the shirt from Resident #1's hand once Resident #1 fell asleep. CNA #1 said she did not report the allegation to any staff member as Nurse #1 told her it would be okay for a short time. CNA #1 said she did not question Nurse #1 because she knew best, or words to that affect. CNA #1 said she completed her scheduled shift and left the Facility. CNA #1 said she did not report the allegation to any staff member until contacted by the DON on 1/21/16. The Surveyor interviewed the Director of Nurses (DON) at 8:30 A.M., and throughout the day on 2/29/16. The DON said it was the Facility policy for staff to immediately report all allegations of abuse and accused staff to be immediately suspended, pending the internal investigation. The DON said that once the allegation became known to management, Nurse #1 was suspended effective 1/21/16.

Based on interview and record review for one of three sampled residents (Resident #1), the Facility failed to ensure that Resident #1 remained free from restraints imposed for convenience of staff. On 1/21/16 at approximately 5:00 A.M., Nurse #1 wrapped a tank top shirt around Resident #1's left hand and fingers, as in a manner of a mitten, and tied the shirt around his/her wrist to prevent Resident #1 from pulling at his/her gastrostomy tube (a tube inserted into the stomach used to provide nutrition to people who are unable to obtain nutrition by mouth), and then left the Facility at the end of her scheduled shift, leaving Resident #1 in bed, with his/her hand restrained by the shirt. Findings include: The Health Care Proxy Activation Form, signed and dated, 7/2/15, by the Physician, indicated Resident #1's Health Care Proxy was invoked due to multiple [MEDICAL CONDITION] and dementia. Resident #1's quarterly Minimum Data Set (MDS) Assessment Form, dated 12/24/15, indicated Resident #1 had a [DIAGNOSES REDACTED]. The MDS indicated Resident #1 had limited range of motion on both sides, of the upper and lower extremities. The Surveyor interviewed Resident #1 at 3:50 P.M., on 2/29/16. Resident #1 was unable to recall the incident. The Facility Internal Investigation, dated 1/21/16, indicated at approximately 8:15 A.M., Certified Occupational Therapy Aide #1 found Resident #1 in bed with his/her left hand and fingers wrapped in a tank top shirt, as in the manner of a mitten, and tied around his/her wrist. The investigation indicated that Resident #1 was assessed with [REDACTED]. The physician's orders [REDACTED].#1's left wrist as tolerated, apply ice every 15 minutes, every shift as needed for swelling. The Surveyor interviewed the Director of Nurses (DON) at 8:30 A.M., and throughout the day on 2/29/16. The DON said Resident #1 was assessed with [REDACTED]. The DON said Nurse #1 was identified as the staff member who wrapped and tied Resident #1's left hand in the tank top shirt. The Director of Nurses said Resident #1 had never been assessed for the need for restraint use during his/her admission at that Facility. The Surveyor interviewed Nurse #1 at 3:30 P.M., on 3/3/16. Nurse #1 reviewed her statement, dated 1/27/16. Nurse #1 said Resident #1 pulled out the gastrostomy tube twice during Nurse #1's scheduled shift and she was concerned Resident #1 would continue to pull at the gastrostomy tube. Although Nurse #1's statement indicated she put a sock on Resident #1's right hand, Nurse #1 said she was unable to recall if the incident involved Resident #1's right or left hand. Nurse #1 said the correct hand was the hand which was assessed with [REDACTED].#1 said she initially put a sock over Resident #1's hand to deter him/her from pulling at the gastrostomy tube, but when that failed, she wrapped the tank top shirt around Resident #1's right hand and fingers, as in a manner like a mitten, and tied the shirt around Resident #1's wrist, and put a sock over the shirt. Nurse #1 said Resident #1 was able to move his/her hand, but was unable to grab at the gastrostomy tube as the shirt acted like a mitten. Nurse #1 said she planned to remove the shirt from Resident #1's hand after she medicated Resident #1 and before staff arrived for the next scheduled shift. Nurse #1 said she completed her scheduled shift, and left the Facility after receiving an urgent phone call, forgetting to remove the tank top shirt from Resident #1's hand. Nurse #1 said her actions were not intentional to restrain Resident #1, but done to deter Resident #1 from pulling at the gastrostomy tube, as in a protective manner. Nurse #1 said she believed the only thing she did wrong was not removing the shirt from Resident #1's hand before she completed her shift. The physician's orders [REDACTED]. The Facility's Policy and Procedure for Use of Restraints indicated that emergency restraints could only be used for short periods to treat a medical symptom, or as a last resort to protect the safety of the resident and others is the resident's unanticipated, violent or aggressive behavior placed self or others in imminent danger.

Based on record review and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure Resident #1, who had a possible bowel obstruction on 9/13/13, received assessment and treatment of [REDACTED]. Approximately five hours after the results of the abdominal x-ray were received by Nurse #1, Resident #1 had increased abdominal pain, the Nurse Practitioner was informed, and was told to send him/her immediately to the Hospital. Physician #1 said the increased abdominal pain due to a possible bowel obstruction placed an added stress on his/her impaired cardiac status. Findings include: The admission history and physical examination [REDACTED]. The Surveyor interviewed Unit Manager #1 at 7:45 A.M. and 9:30 A.M. on 5/5/14. The Surveyor interviewed Nurse #2 at 8:00 A.M. on 5/5/14. Unit Manager #1, Nurse #1, Nurse #2, and Nurse #3 denied that Resident #1 had any abdominal pain or complaints of constipation on 9/10/13 or 9/11/13. Nurse #2 said Resident #1 had no complaints of pain but requested milk of magnesia at approximately 6:00 A.M. on 9/12/13 for constipation that was given with results pending when this nurse left duty. Nurse #3 said she was assigned to Resident #1's nursing care needs during the day shift on 9/12/13. Nurse #3 said Resident #1 had complained of constipation on 9/12/13 but then had a large formed bowel movement and continued to have a soft abdomen and bowel sounds were present in a all four quadrants. The evening shift nurse's note, dated 9/12/13, indicated Resident #1 had no complaints of discomfort. Nurse #2 said Resident #1 had requested the laxative milk of magnesia (MOM) at approximately 6:00 A.M. on 9/13/13 for constipation and abdominal discomfort after having an extra extra large bowel movement. Nurse #2 said the MOM was given as requested and Tylenol was refused because he/she seemed comfortable after having the extra extra large bowel movement. The day shift nurse's note, dated 9/13/13, indicated a KUB was ordered because Resident #1's abdomen remained firm and distended with sluggish bowel sounds after having a BM and stool was oozing following the BM. The evening shift nurse's note, dated 9/13/13, indicated Resident #1 complained of abdominal pain that rated a 7 out of 10 and was administered [MEDICATION NAME] (narcotic pain medication) two tablets given at 4:30 P.M. with relief voiced within one hour. Nurse #1 said she received the KUB result at approximately 5:30 P.M. on 9/13/13 and immediately faxed the report to Physician #1's office with no return fax or telephone call received. Nurse #1 said at approximately 8:00 P.M., Resident #1 had symptoms of respiratory distress and NP #1 was made aware of the KUB result at that time. The evening shift nurse's note with no time indicated that NP #1 was notified of the KUB result, that Resident #1 vomited a moderate amount of yellowed colored phlegm, had increased congestion, had low blood oxygen saturation levels of 86% to 90% on room air with new orders given for oxygen 2 liters via nasal cannula for blood oxygen saturation levels below 90%, duo-nebulizer (respiratory treatment) treatments every 6 hours as needed, a stat chest x-ray, and blood work in the morning. The evening shift nurse's note indicated that Resident #1's blood oxygen saturation levels improved to 95% following the duo-nebulizer treatment that was given at 8:15 P.M. . The Surveyor interviewed NP #1 at 11:45 A.M. on 5/7/14. NP #1 said Nurse #1 first notified her at 8:20 P.M. that Resident #1 had developed respiratory symptoms and she order a chest x-ray (to be done immediately) and blood work to be completed the following morning. NP #1 said she was not notified that Resident #1's KUB indicated Resident #1 had a possible bowel obstruction, but rather, was told that the KUB indicated no obstruction when updated about Resident #1's change in respiratory status. The nurse's note, dated 9/13/13, indicated NP #1 was notified at approximately 10:30 P.M. that Resident #1 was screaming in abdominal pain with new orders given to transfer him/her to the Hospital for evaluation. NP #1 said she told Nurse #1 to send Resident #1 to the Hospital immediately due to the increased abdominal pain. Nurse #1 said she called the contracted ambulance, rather than, 911 because she did not believe Resident #1's change in condition was an emergency. Physician #1 said he would have immediately transferred Resident #1 to the Hospital for an abdominal CT (computed tomography) scan if he been verbally notified of the KUB result when it was received at about 5:30 P.M. on 9/13/13. The Emergency Department Note, dated 9/14/13, indicated the Emergency Medical Service (EMS) Responders were initially called due to Resident #1's complaint of abdominal pain and increased abdominal distention. The Emergency Department Note indicated the EMS Responders found Resident #1 in asystole (cardiac standstill that required immediate cardio-pulmonary resuscitation). The Emergency Department Note indicated resuscitation attempts were unsuccessful, and on examination, Resident #1 had a very large tense distended abdomen, and the cause of death was [MEDICAL CONDITION]. The Surveyor interviewed Physician #1 at 2:00 P.M. and 2:15 P.M. on 5/6/14. Physician #1 said it was likely that the increased abdominal pain and abdominal distention due to a possible bowel obstruction and the added delay in transport to the Hospital for assessment and treatment, added additional stress to Resident #1's cardiac status as he/she had an extensive cardiac history. Physician #1 said he would have transported Resident #1 to the Hospital at 5:30 P.M. if told by Nurse #1 of the KUB results and the failure to transport Resident #1 to the Hospital for assessment and intervention may have contributed to his/her further decline in condition. Refer to F157

Based on record review and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure that Physician #1, Family Member #1, or Resident #1 were immediately notified when Resident #1's KUB (abdominal x-ray of abdomen to rule out a bowel obstruction) results indicated that he/she had a possible colonic obstruction. Nurse Practitioner (NP) #1 said Nurse #1 incorrectly reported to her at about 8:00 P.M. that Resident #1's KUB indicated he/she did not have a bowel obstruction; and at 10:20 P.M, Resident #1's screamed out in abdominal pain; NP #1 was notified and ordered for Resident #1 to be transferred to the Hospital for an evaluation; and when the ambulance arrived, found Resident #1 in [MEDICAL CONDITION]. Findings include: The day shift nurse's note, dated 9/13/13, indicated a KUB was ordered because Resident #1's abdomen remained firm and distended with sluggish bowel sounds after having a bowel movement (BM) and stool was oozing following the BM. The Surveyor interviewed Nurse #1 at 4:25 P.M. on 5/5/14. Nurse #1 said she was assigned to Resident #1's nursing care needs during the evening shift on 9/13/13. Nurse #1 said she received the KUB result at approximately 5:30 P.M. on 9/13/13 and immediately faxed the report to Physician #1's office with no return fax or telephone call received. Nurse #1 said she did not know the office was closed. Nurse #1 said she did not notify Family Member #1 or Resident #1 of the KUB result. Nurse #1 said at approximately 8:00 P.M. Resident #1 had symptoms of respiratory distress and NP #1 was made aware of the KUB result at that time. The Surveyor interviewed NP #1 at 11:45 A.M. on 5/7/14. NP #1 said Nurse #1 first notified her at 8:20 P.M. that Resident #1 had developed respiratory symptoms. NP #1 denied that she had been notified that Resident #1 had a possible bowel obstruction, but rather, was told that the KUB indicated no obstruction when updated about Resident #1's change in respiratory status. Nurse #1 said that she notified NP #1 of the KUB result that included a possible bowel obstruction. The nurse's note, dated 9/13/13, indicated NP #1 was notified at approximately 10:30 P.M. that Resident #1 was screaming in abdominal pain with new orders given to transfer him/her to the Hospital for evaluation. NP #1 said she told Nurse #1 to send Resident #1 to the Hospital immediately due to increased abdominal pain. Nurse #1 said she called the contracted ambulance, rather than 911 ambulance located nearby the Facility because she did not believe Resident #1's change in condition was an emergency. The Surveyor interviewed Physician #1 at 2:00 P.M. and 2:15 P.M. on 5/6/14. Physician #1 said he would have immediately transferred Resident #1 to the Hospital for an abdominal CT (computed tomography) Scan if he been verbally notified of the KUB result when it was received at about 5:30 P.M. on 9/13/13 (Friday). Physician #1 said his office routinely closed on Fridays at 5:00 P.M. and he was on call until 7:00 P.M. Please refer to F 309.

Based on record review and interview, for one of three sampled residents (Resident #1), the Facility failed to educate staff and place thermometers by the microwaves to ensure liquids were heated to a safe temperature per Facility guidelines. On 1/8/13 Resident #1 sustained second degree burns (burn in which damage extends through the outermost layer of the skin and into the next layer of skin) on the left abdominal area when Resident #1 spilled hot tea on his/her abdomen that had been heated in the microwave. Findings include. The Facility microwave re-heating chart guidelines indicated that when heating refrigerated liquids in the microwave not to exceed heating the liquid for more than 2 minutes and not to exceed 135 degrees Fahrenheit. The Admission Record Form indicated that Resident #1 was admitted to the Facility October, 2012 and had a [DIAGNOSES REDACTED]. The Surveyor interviewed the Rehabilitation Manager at 1:15 P.M. on 3/4/13. The Rehabilitation Manager said that Resident #1 was able to feed himself/herself independently that included drinking hot beverages. The Rehabilitation Manager said Resident #1 was observed eating and was able to eat and drink independently after set up. The Rehabilitation Manager said Resident #1 was observed after the incident and had no change in Resident #1's functional ability. The Surveyor interviewed Nurse #1 at 11:15 A.M. on 3/4/13. Nurse #1 said he/she was on orientation and was assigned to Resident #1's unit during the evening shift on 1/8/13. Nurse #1 said Resident #1 requested a cup of tea. Nurse #1 said after he/she heated Resident #1's tea for about one to two minutes in the microwave, he/she placed the cup of tea on Resident #1's bedside table positioned over Resident #1's bed, and walked out of the bedroom before he/she took a sip of the tea. Nurse #1 said he/she did not think the tea was hot enough to burn Resident #1 because he/she placed a few drops of the tea on her wrist. Nurse #1 said he/she left the room to assist another resident. Nurse #1 said approximately 10 minutes later he/she was summoned to Resident #1's bedside because he/she had spilled the tea on himself/herself. Nurse #1 said he/she immediately responded to assist Resident #1; he/she removed his/her johnny, observed a pink area on the left side of his/her abdomen where the tea had spilled, first aid was provided, cool compresses were applied, and he/she summoned Nurse #2 for further assistance because he/she was on orientation. The Surveyor interviewed Nurse #2 at 11:50 A.M. on 3/4/13. Nurse #2 said Physician #1 was notified that Resident #1 had a small blister on the left abdominal area. Nurse #2 said Physician #1 gave no new orders. Nurse #2 said the area was cleansed and covered with a protective dressing. Nurse #1 and Nurse #2 said Resident #1 denied any pain and was left resting comfortably in bed with no concerns voiced. The incident report, dated 1/8/13, indicated that Resident #1 spilled tea on his/her abdomen, sustained a burn described as a small blister on his/her abdomen, Physician #1 was notified, and no new orders were indicated. The day shift nurse's note, dated 1/9/13, indicated that Resident #1 had two small pink areas on the left abdominal area and denied any pain. The evening shift nurse's note, dated 1/10/13, indicated Physician #1 was notified that the pinkened blistered areas on the left side of Resident #1's abdomin had opened and Physician #1 gave new orders: to cleanse areas with normal saline followed by silvadene (treatment for [REDACTED]. Physician #1's progress notes, dated 1/10/13, indicated that Resident #1 had spilled tea on the left abdominal area, sustained second degree burns, and recommendations included silvadene ointment. The treatment record narrative, dated 2/11/13, indicated that the treatment to the left abdominal area was discontinued because the burn had fully healed. The Surveyor interviewed the Director of Nurses (DON) at 8:45 A.M. and 4:00 P.M. on 3/4/13. The DON said he/she interviewed Nurse #1 as part of his/her internal investigation. The DON said Nurse #1 heated Resident #1's tea for one to two minutes in the microwave, and Nurse #1 placed the cup of tea on Resident #1's bedside table. The DON said Resident #1 accidentally spilled the cup of tea while seated in bed, sustained a burn on Resident #1's left abdominal area, and the burn was initially described as a pinkened area that blistered. The DON said Nurse #1 immediately responded, first aid was given, Physician #1 was notified, no new orders were initially obtained, and monitoring continued. The DON said Resident #1 sustained a burn because the tea was heated in the microwave for one to two minutes, and unfortunately it was too hot. The DON said an internal investigation was started and the DON realized that prior to this incident the Facility had not educated staff on the Facility guidelines on heating foods and liquids in the microwave and had not placed thermometers by the microwaves to ensure liquids were heated to a safe temperature per Facility guidelines. The Surveyor interviewed the Staff Development Coordinator (SDC) at 8:30 A.M. on 3/4/13. The SDC said since this incident staff had been educated on following the Facility guidelines regarding heating food and liquids in the microwave and this education was added to the orientation education package for new employees. The DON said Resident #1 had no previous incidents of spilling hot or cold liquids. The DON said the Facility had no previous incidents of burns due to hot liquids or foods that had been heated in the microwave. The DON said thermometers were placed by the microwaves to ensure liquids were heated to a safe temperature per Facility guidelines. The Surveyor interviewed Resident #1 at 8:15 A.M. on 3/4/13. Resident #1 said he/she accidentally spilled a cup of hot tea while in bed and sustained a burn on the left abdominal area that had since fully healed.