Every finding on record at The Mansion at Brigham

Based on record review and interview, the facility failed to electronically submit direct care staffing data to the Centers for Medicare and Medicaid Services (CMS) for the entire reporting period, Fiscal Year (FY) Quarter 2, 2025 (January 1 - March 31), in accordance with the schedule specified by CMS. Findings include: Review of the Payroll Based Journal (PBJ) Staffing Report, CASPER Report 1705D, FY Quarter 2 2025 (January 1 - March 31), indicated the facility triggered for:-Failed to Submit Data for the Quarter (No Data Submitted for Quarter)-One Star Staffing Rating (Staffing Rating Equals 1) During an interview on 9/16/25 at 8:55 A.M., the Director of Nurses said that while she is not responsible for the reporting of the PBJ data, she would expect the facility to submit it as required. During an interview on 9/16/25 at 9:02 A.M., The Regional Nurse Consultant said that she is aware of the PBJ reporting concerns and said that the expectation is that the data is submitted as required. During an interview on 9/16/24 at 10:30 A.M., the Director of Operations said that the PBJ staffing had not been submitted for the quarter and has since been submitted as required. The expectation is that data is submitted as required.

Based on observations, record review, and interviews, the facility failed to ensure an intervention used to prevent and manage a pressure ulcer was effectively implemented for one Resident (#8), out of a total sample of 14 residents. Specifically, the facility failed to identify, intervene and ensure proper function when Resident #8's air mattress alert feature was illuminated and flashing, indicating a potential problem with the air mattress function. Findings include: Review of the document titled [NAME] Relief, Alternating Pressure with Low Air Loss System, Operation Manual, not dated, included but not limited to the following: Indications, this alternating pressure system with low air loss is designed to treat and prevent wounds by facilitating blood circulation and decreasing pressure of each tissue's contact area. Features: Designed to aid in the prevention and treatment of Stage 1-IV pressure ulcers. Visual/audible low-pressure alert (a diagram of a triangle with an exclamation point), 12.0 Troubleshooting 3. Problem: Alarm LED is lit during operation, Inspection Procedure: Check if there is leakage in the air tubes or air cells, Problem Solutions: Please contact (vendor) For assistance. Resident #8 was admitted to the facility in June 2020 and has diagnoses that include but are not limited to Alzheimer's disease, and pressure ulcer of the sacral (area at the base of the spine) region, stage 4. Review of the most recent Minimum Data Set (MDS), assessment dated [DATE], indicated Resident #8 scored zero out of 15 on the Brief Interview for Mental Status exam, indicating he/she as having severe cognitive impairment. Further the MDS indicated Resident #8 was dependent on staff for all aspects of daily care and had a stage 4 pressure ulcer. During an observation on 9/15/25 at 7:50 A.M., Resident #8 was in his/her bed. Resident #8 did not respond to the surveyor's greeting and was unable to participate in an interview. The control unit for the air mattress affixed to the footboard of Resident #8's bed was observed flashing an orange light - a triangle symbol with an exclamation point. Review of Resident #8's medical record indicated the following: Physician's' orders: -Left medial buttocks: cleanse with normal saline, pat dry, apply Santyl and then collagen powder then cover with superabsorbent silicone bordered gauze dressing, every day shift for wound care, date 9/10/25. -May have Alternating Pressure Air Mattress to-set for comfort range 150-200lbs (pounds)-check placement/setting/function every shift, date 7/16/25. -A Kardex (a document used by Certified Nursing Assistants (CNA) that indicates special instructions specific for a resident's care and needs), Skin, May have Alternating Pressure Air Mattress to-set for comfort range 150-200lbs (pounds)-check placement/setting/function every shift. -A care plan, date initiated 6/10/2020, My skin: I am at risk for pressure ulcer development/impaired skin integrity related to decreased mobility, bowel and bladder incontinence. Interventions/Tasks include but are not limited to, May have Alternating Pressure Air Mattress to-set for comfort range 150-200lbs (pounds)-check placement/setting/function every shift, dated 7/7/2024. On 9/15/25 and 9/16/25 the surveyors made the following observations: On 9/15/25 at 4:11 P.M., Resident #8 was lying in his/her bed. The air mattress alert indicator was illuminated orange and flashing. On 9/16/2025 at 7:47 A.M., Resident #8 was lying in his/her bed. The air mattress alert indicator was illuminated orange and was flashing. -At 7:50 A.M. the alert indicator continued to be flashing orange light. -At 8:14 A.M., Resident #8 was sitting up in his/her bed and the air mattress alert indicator light was off. -At 8:22 A.M., Resident #8 was sitting up in bed with the over bed tray table in front of him/her. The alert indicator on the air mattress control was lit and flashing orange. - At 8:40 A.M., Resident #8 was sitting up in bed. A rehabilitation staff member entered the room and provided Resident #8 his/her breakfast. The alert indicator, which could be viewed on the foot board, illuminated orange and was flashing. -At 8:49 A.M., Resident #9 was assisted to eat breakfast by the rehabilitation staff member. The air mattress alert indicator continued to be illuminated and flashing orange. -At 10:01 A.M., Nurse #2 entered Resident #8's room and administered his/her medication. The air mattress alert indicator was illuminated and flashing at this time. -10:54 A.M., Resident #8 was in bed. He/she had two drink cups in front of him/her on the over bed table. The alert indicator on the air mattress was illuminated and flashing orange. On 9/16/25 at 12:27 P.M., Resident #8 was up in a chair in the dining room for the lunch meal. During an interview on 9/16/25 at approximately 1:00 P.M., CNA #1 said Resident #8 stays up for only a short time because of the wound. CNA #1 said the Resident will be assisted back to bed before the end of the shift (3:00 P.M.) On 9/16/2025 at 3:22 P.M., Resident #8 was in bed. The alert indicator on the air mattress was illuminated orange and flashing. Review of the Treatment Administration Record (TAR) dated 9/1/25-9/30/25 indicated, May have Alternating Pressure Air Mattress to-set for comfort-range 150-200lbs-check placement, setting/function every shift as documented with a check mark and initials of the nurse on the day shift on 9/16/25. During an interview and observation on 9/16/25 at 3:41 P.M., Nurse #2 said the air mattress on Resident #8's bed is used because he/she has a pressure wound and that he/she has had the air mattress for a long time. Nurse #2 and the surveyor went to Resident #8's room and the alert indicator light was not flashing. Nurse #2 touched the air mattress control unit, and the alert indicator began flashing. Nurse #2 touched the mattress and said it was still inflated but the flashing light looked like a warning that the mattress was not working properly. The surveyor shared the observations made over the last 2 days, which included three different shifts and during the medication pass when Nurse #2 administered medication to Resident #8. Nurse #8 said he signed off on the TAR (Treatment Administration Record) today (9/16/25) that the air mattress was functioning. Nurse #2 said he did see it blinking during the medication pass. During an interview on 9/16/2025 at 4:01 P.M., and at 5:00 P.M., the Director of Nursing said if an air mattress is flashing it means there is a problem. The DON said it does not mean it is failing but that something needs to be addressed. The DON and surveyor went to Resident #8's room and the alert indicator was illuminated and flashing on Resident #8's air mattress. The DON said if she saw the light flashing, she would check to see if the parts are securely in the pump and she would expect the nursing staff to do the same thing. The DON pushed in the side tubes, and the flashing stopped. The DON said if that does not work, they would call the rental company that provides the air mattress. The DON said the nursing staff should have seen or been alerted by any staff who go into Resident #8's room, about the flashing light and to let her know. The DON said the nurses are to document on the TAR that the air mattress is functioning. During an interview on 9/17/25 at 9:43 A.M., Nurse #6 said Resident #8 has a pressure ulcer on his/her sacrum. Nurse #6 said interventions for treating the pressure ulcer are dressing changes, repositioning, providing incontinent care, and the use of the air mattress. Nurse #6 said the air mattress relieves pressure to the wound. Nurse #6 said the nursing staff make sure it is set correctly and functioning. Nurse #6 said if the alert signal is flashing it means the air mattress has something wrong with it and needs to be addressed. Nurse #6 said that any staff who provide care or enter the room should be alerting the nurse if the alert signal is flashing.

Based on observations, record review and interviews, the facility failed to ensure the environment remained free of accidents and hazards and was safe for all residents and, one Resident (#1), out of a total sample of 14 residents. Specifically, the facility failed to ensure:1. Safe practices in preparing food in the facility kitchen, which has the potential to affect all residents, when [NAME] #1 left a large double pot boiling over two gas burners, with the back burner spewing large flames shooting upwards and left unattended and,2. For Resident #1, the facility failed to implement interventions in the Resident's care plan to keep in supervised area, common areas for increased supervision when out of bed. Findings include: 1. Review of the facility's policy titled 'Safety', revised 9/2017 indicated, The kitchen and associated equipment will be properly maintained and that all Dining Services staff follow safe operating practices. On 9/15/25 at 6:48 A.M., in the facility kitchen, the surveyor observed a large rectangle hotel pan on the gas stove, covering the front and back gas burners, with a pot inside with vigorous boiling water, and large flames coming from the back gas burner. The flames varied in height and extended approximately 12 inches vertically and observed to be a concern. There were no staff in the kitchen at the time of the observation. There were no staff located nearby, in the adjacent hallway outside of the kitchen. -At 6:54 A.M., [NAME] #1 exited the elevator and entered the kitchen. [NAME] #1 immediately turned off the burner and said he put the burner on about 20 minutes ago. [NAME] #1 said the pot contained eggs. [NAME] #1 said he left the kitchen to go upstairs and should not have left the pan unattended on the burner. During an interview on 9/15/25 at 8:45 A.M., the Food Service Director said kitchen staff should never leave food cooking on the stove unattended. During an interview on 9/16/25 at 9:05 A.M., the Regional Food Service Director said the double boiler with the flames coming from the back should not have been unattended by kitchen staff. The Regional Food Service Director said ironically the staff had an in-service last week on fire safety. 2. Review of facility policy titled Fall Prevention Program, dated as reviewed and revised 3/4/24, indicated the following: -Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls Resident #1 was admitted to the facility in June 2025 with diagnoses that included dementia, pneumonia and hypertension. Review of the most recent Minimum Data Set (MDS) Assessment, dated 8/27/25 indicated a Brief Interview for Mental Status score (BIMS) of 1 out of a possible 15, indicating that the Resident has severe cognitive impairment. The MDS further indicated that the Resident had two or more falls since admission or the prior assessment, and no falls with injury. Review of Resident #1's active risk for falls care plan indicated that the Resident is high risk for falls related to advanced dementia, poor safety awareness and poor balance, created on 6/4/25. Interventions include the following: keep in supervised area, common area for increased supervision when out of bed, dated as initiated on 6/25/25. Review of Resident #1's Kardex (a document that provides information about the level of assistance a resident requires, as well as information about the resident's plan of care) indicated the following: -Safety: Keep in supervised area, common areas for increased supervision when out of bed. During an observation on 9/16/25 at 10:00 A.M., Resident #1 was observed up in his/her wheelchair in the dining room. There were no staff present in the dining room to supervise residents. Review of the CSC Fall risk evaluation, dated 6/3/25, indicated a fall risk score of 26, which according to the assessment places the Resident at risk for falls. Review of the CSC fall risk evaluation, dated 9/4/25, indicated a fall risk score of 15, which according to the assessment places the Resident at risk for falls. Review of Resident #1's fall incident reports and investigations indicated that the Resident sustained unwitnessed falls out of his/her wheelchair in the dining room on 7/13/25, 7/15/25 and 7/19/25. Review of the incident report/ investigation, dated 7/13/25 at 8:00 P.M., indicated the following: -The Resident was found on floor on his/her right side. -Nursing description: resident was found laying in the dining room floor, on [his/her] right side, no apparent injuries noted, able to move all extremities, neuros WNL (within normal limits), VSS (vital signs stable). (sic) -Was this incident witnessed?: No Review of the nursing progress note, dated 7/13/25, indicated the following in part: -Resident was found laying on the dining floor, on [his/her] right side. no apparent injuries note, Able to move his/her extremities, neuros WNL, VSS. Resident is alert and oriented x1 could not explain what caused the fall. Assessment was done. No apparent injuries observed. Assisted back to his/her chair with hoyer. NP (Nurse Practitioner) and HCP (Healthcare proxy) were notified. Neuro sign assessment were initiated. (sic) Review of the incident report/investigation, dated 7/15/25 at 2:09 P.M., indicated the following: -The Nurse was called because the Resident had slide out of [his/her] chair into the floor. As observed resident had his/her had (head) up against rim of the wall. sic) -Was this incident witnessed?: No -Other info: The resident was in the living room/ dining room watching TV with other residents. Review of witness statements as part of the investigation indicated that the Resident was last observed by staff at 1:00 P.M. by one staff member, 15 minutes prior to the incident by one staff member, and five minutes prior to the incident by another staff member. Review of the nursing progress note, dated 7/15/25, indicated the following: -This nurse was called because the resident had slid out of [his/her] chair onto the floor. As observed, the resident had [his/her] head against the wall's rim. The resident states that [he/she] slid out of the wheelchair onto the floor. Denies pain or any other discomfort. Moving all extremities, neurological assessment was within normal limits. Review of the incident report/ investigation, dated 7/19/25 at 7:15 P.M., indicated the following: -Aide came and reported to this nurse that the resident was in the dining room on the floor. -Was the incident witnessed?: No Review of the witness statements as part of the investigation indicated the Resident was last seen five minutes prior to the incident, but it was not witnessed. Review of the nursing progress note, dated 7/20/25, indicated the following in part: -Received in report that resident was found on floor yesterday without injuries. During an interview on 9/17/25 at 7:50 A.M., the Director of Nursing (DON) said that Certified Nurse's Aides (CNAs) utilize the electronic kardex that generates in the electronic medical record from the care plan in order to provide assistance necessary for residents. During an interview on 9/17/25 at 8:04 A.M., Nurse #4 said that she was assigned to Resident #1 on 7/15/25 when he/she fell. She said that staff walked into the dining room and found him/her on the floor, and she was called to assess the Resident. She said the fall was unwitnessed, and if a fall is unwitnessed, it means that the Resident was not being supervised as per the plan of care. She said that Resident #1 is a high fall risk and should be supervised when out of bed. She further said that there should always be a staff member in the dining room supervising the residents that are in there. She said that falls can happen quickly, even if stepping out of the dining room quickly. During an interview and observation on 9/17/24 from 8:33 A.M. to 8:39 A.M., the dining room was unsupervised with residents in there. At 8:39 A.M., CNA #2 entered the dining room to get linen from the linen closet that was located in the dining room. She then proceeded to leave the dining room. Nurse #4 stopped her and said that someone needed to stay in the dining room. The CNA told the surveyor that there is not usually continual supervision in the dining room and said, this is the first I've been told this. She said she was not aware of the need to supervise residents in the dining room and was not aware of any residents on the unit that specifically required supervision when out of bed. During an interview on 9/17/25 at 9:32 A.M., CNA #3 said that Resident #1 requires supervision because he/she is a high fall risk. He said staff should be supervising him/her whenever they are out of bed. During an interview on 9/17/25 at 9:23 A.M., the Director of Nurses said that she expects a resident's care plan to be followed to maintain safety. She said that she agrees with the surveyor's concern. She said that if Resident #1 was in the dining room specifically, then it should be supervised. She said that based on the investigation, indicating unwitnessed falls, Resident #1 was not being supervised when he/she was up in their wheelchair.

Based on resident interviews and test tray results, the facility failed to ensure food provided to the residents was prepared by methods that conserve palatability and are at appetizing temperatures on two of two units.Findings include:During the resident screening process on 9/15/25 beginning at 7:10 A.M., multiple residents on the first-floor unit expressed concerns regarding the meals to the surveyors, including not having enough food, running out of staples, the meals not being good and meals being cold. During the Resident Group attended by 17 residents, residents said the following: -A few participants said the facility runs out of inventory and staple foods like coffee, eggs butter, and bread. -One resident said they do not get their diet as ordered like heart healthy, and, -Many of the active participants had mixed reports about the food including no variety of food, the temperature of the hot food is not always hot, and a dislike of the food in general. As a result of the residents' reports about the meals on 9/16/25, the surveyors conducted test tray audits for the lunch meals for both units of the facility, the results were as follows: On 9/16/25 at 11:23 A.M., [NAME] #2 recorded the following temperatures of the food on the steam table: -pureed cream corn, 154.2 degrees Fahrenheit -marinated chicken thighs, 179.8 degrees Fahrenheit -roasted potatoes, 156.7 degrees Fahrenheit -dysphagia advanced potatoes (no skins on the potato) 163.9 degrees Fahrenheit - corn, 171.1 degrees Fahrenheit -gravy, 174.4 degrees Fahrenheit -ground chicken, 173 degrees Fahrenheit -mashed potatoes, 162.5 degrees Fahrenheit - puree chicken, 163 degrees Fahrenheit -puree corn 166.5 degrees Fahrenheit -milk in a cup, 42.6 degrees Fahrenheit -apple juice in a cup, 43.5 Fahrenheit. The regional Food Service Director said he will throw the milk and juice on ice because the holding temperature should be 41 degrees or below. On 9/16/25 at 11:53 A.M., the food truck left the kitchen and was delivered to the second floor. This truck contained a test tray and arrived at the second floor at 11:56 A.M., the surveyor received the test tray at 12:06 P.M. The following was recorded with facility staff present. -Marinated chicken thigh, 109 degrees Fahrenheit, had flavor, was warm not hot to taste. -Roasted Potatoes, 109 degrees Fahrenheit, warm not hot to taste. -Corn, 113 degrees Fahrenheit, tasted buttery, warm not hot to taste. -Apple Juice 53 degrees Fahrenheit, tasted warm not cold to taste. The staff present tasted the food with the surveyor and said the food was not hot enough. On 9/16/25 at 11:57 A.M., the food truck left the kitchen and was delivered to the first-floor unit. This truck contained a test tray and arrived at the second floor at 12:00 P.M., the surveyor received the test tray at 12:07 P.M. The following was recorded with the Regional Food Service Director present: -Marinated chicken thigh, 142 degrees Fahrenheit, had flavor, was hot to taste. -Roasted Potatoes, 113 degrees Fahrenheit, warm not hot to taste, and had a hard texture. -Corn, 116 degrees Fahrenheit, tasted warm not hot to taste. -Milk, 48.3 degrees Fahrenheit, was cool, not cold to taste. -Coffee, 167.2 degrees Fahrenheit, hot to taste. The Regional Food Service Director said he would like to see the corn and potatoes served at a hot palatable temperature. During an observation of the dining room on 9/16/25 at 12:10 P.M., four out of four residents sitting at one table had not consumed any of their potatoes and had large amounts of uneaten food on their plates. During an interview on 9/16/25 at 12:15 P.M. the test tray temperatures were reviewed with the Regional Food Service Director. He said ideally, they aim for cold beverages to be served under 50 degrees to be cold. The Regional Food Service Director said the hot foods should be served at a hot temperature.

Based on observations, record reviews, and interviews, the facility failed to ensure standards of quality of care were provided for one Resident (#8), out of a total sample of 14 residents. Specifically, the facility failed to ensure Resident #8 was provided care and treatment for a skin tear on the back of his/her right hand. Findings include: Resident #8 was admitted to the facility in June 2020 and has diagnoses that include but are not limited to Alzheimer's disease, and pressure ulcer of the sacral (area at the base of the spine) region, stage 4. Review of the most recent Minimum Data Set (MDS), assessment dated [DATE], indicated Resident #8 scored zero out of 15 on the Brief Interview for Mantal Status exam, indicating he/she as having severe cognitive impairment. Further the MDS indicated Resident #8 was dependent on staff for all aspects of daily care. During an observation on 9/15/2025 at 7:50 A.M., Resident #8 was in his/her bed. Resident #8 did not respond to the surveyor's greeting and was unable to participate in an interview. The back of Resident #8's right hand had several steri-strips (narrow adhesive bandages used to close small cuts or minor surgical incisions) covering dark discolored skin. On 9/16/25 the surveyor made the following observations: -At 7:30 A.M., Resident #8 was lying in his/her bed. The back of Resident #8's right hand was covered with several steri-strips, curled on the edges, with dark red skin under the steri-strips. -At 12:27 P.M. Resident #8 was up in his/her wheeled recliner chair. The back of Resident #8's right hand had several steri-strips, curled on the edges revealing dark discolored skin under the steri-strips. Review of Resident #8's clinical record indicated the following: -A Note text: date 8/26/25, At 10:40 P.M., CNAs (Certified Nursing Assistant) discovered a skin tear on Resident's right hand. The Nurse Practitioner was notified and viewed wound. She advised cleaning with NS (normal saline) and steri strips to approximate wound edges best as possible. Sterile gauze pad and bordered sterile bandage was applied. -A SNF (skilled nursing facility) Telehealth note dated 8/26/25 at 10:21 P.M., entered by the Nurse Practitioner. Chief complaint; skin tear R (right) hand. Diagnosis and Plan Ordered: Clean with NS, pat dry, approximate skin and apply steri-strips, cover with dressing and monitor daily. Review of Resident #8's Physician's orders, Medication Administration Record, and Treatment Administration Record, failed to indicate an order for the treatment or monitoring of Resident #8's right hand skin injury. Further review of Resident #8's medical record progress notes indicated the following: -8/31/25 18:54 (6:54 P.M.) Right hand outer bandage removed, gauze soaked off with NS, Steri-strips intact. No Sx (symptoms) infection. Cleaned with NS and dried. Border gauze dressing applied. -9/14/25 21:09 (9:09 P.M.) Complete weekly skin check, Hand wound dry with steri strips intact no s/sx of infection noted. The above notes were written and entered by the same nurse who documented the skin tear on 8/26/25. The progress notes from 8/26/25, with the exception of 8/31/25 and 9/14/25, to 9/16/25, failed to indicate Resident #8's right hand skin tear was monitored. Review of the physician's orders failed to indicate a treatment order or monitoring order of Resident #8's right hand skin tear. During an interview on 9/16/25 at 7:01 A.M., Nurse #5 said if a resident has a new skin tear or any new injury the doctor is called and orders obtained for care and treatment, family is notified, and an incident report is completed. During an interview on 9/16/25 at 1:22 P.M., and 3:39 P.M., Nurse #2 said if a resident has a skin tear the nurse would notify the MD (medical doctor), obtain orders for care and treatment, and an incident report would be completed. Nurse #2 said Resident #8 had a skin tear about two weeks ago. Nurse #2 said skin tears with steri-strips should be monitored at least daily to check that the skin tear is healing, dry and has no signs of infection. Nurse #2 said a physician's order is required to trigger the nurse to document and monitor the skin tear. Nurse #2 said there is no order to monitor Resident #8's right hand skin tear. During an interview on 9/16/25 at 3:20 P.M., the Director of Nursing (DON) said that there was no incident report for Resident #8's right hand skin tear. The DON said incident reports are to be completed by the nurse and entered into the electronic medical record. The DON said she reviews incident reports and without it entered in the medical record she would not be aware of the injury to follow up on it. The DON said Resident #8 is at risk for skin tears. The DON said there was no physician's order for the dressing that was applied and there was no physician's order for monitoring the skin tear each shift and there should have been an order in place.

Based on observation, record review and interview, the facility failed to ensure professional standards of practice for the care of a suprapubic urinary catheter (a tube placed through the suprapubic region into the bladder to drain urine) for one Resident (#35) out of a total sample of 14 residents. Specifically, the facility failed to ensure nursing changed Resident #35's catheter drainage bag (a collection pouch that connects to a urinary catheter to collect urine from the bladder) in accordance with physician's orders.Findings include: Resident #35 was admitted to the facility in March 2025 with diagnoses including neuromuscular dysfunction of the bladder. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/26/25, indicated the Resident scored a 13 out of possible 15 on the Brief Interview for Mental Status, indicating he/she was cognitively intact. The MDS indicated Resident #35 had an indwelling catheter. On 9/15/25 at 8:38 A.M., during the initial screening, Resident #35 was observed lying in bed with a catheter drainage bag hanging on the bedframe. The catheter drainage bag was observed unlabeled and undated. Review of Resident #35's active physician's order, dated 3/20/25, indicated:-Change catheter bag weekly, label with date. as needed. Review of Resident #35's Treatment Administration Record (TAR) failed to indicate that nursing had changed the Resident's suprapubic catheter drainage bag for the months of July 2025, August 2025 and September 2025. On 9/15/25 at 2:26 P.M., Resident #35 was observed sitting in his/her wheelchair with the catheter drainage bag hanging underneath his/her wheelchair seat, labeled and dated 9/10/25. During an interview on 9/15/25 at 2:26 P.M., Resident #35 said his/her catheter drainage bag is changed once a month when he/she returns to the facility from his/her urology appointments. Resident #35 said his/her drainage bag is not changed weekly, and the drainage bag was just recently changed shortly prior to the surveyor's interview with Resident. During an interview on 9/16/25 at 12:22 P.M., Nurse #3 said catheter care includes flushing the catheter's access port, changing the catheter drainage bag and cleaning the area daily. Nurse #3 said catheter drainage bags are changed weekly and as needed. Nurse #3 said tasks should be documented in the TAR in the electronic medical record and followed up with a progress note. Nurse #3 said the electronic medical record notifies the nurse when the drainage bag needs to be changed by displaying the order on the date it is due to be changed. Nurse #3 said that she changed Resident #35's drainage bag on 9/15/25 because she noticed the drainage bag needed to be changed but the bag was not scheduled to be changed. Review of the Medication Administration Record (MAR) with Nurse #3 indicated that the physician order was ordered as needed and not routinely scheduled. Review of the Treatment Administration Record (TAR) with Nurse #3 failed to indicate documentation that the drainage bag had been changed. Review of the medical record failed to indicate a progress note reflecting the drainage bag change. During an interview on 9/16/25 at 12:35 P.M., Nurse #3 said the physician's order should have been scheduled routinely instead of as needed. Nurse #3 said because the order was not scheduled routinely, the electronic medical record did not notify the nurse when the drainage bag needed to be changed and that the order was transcribed in error. During an interview on 9/17/25 at 8:34 A.M., the Director of Nursing said drainage bags are supposed to be changed weekly, and physician orders should be carried out.

Based on record review and interview, the facility failed to maintain acceptable parameters of nutritional status for one Resident (#33) out of a total sample of 14 residents. Specifically, the facility failed to obtain weekly weights to monitor the weight for Resident #33 as ordered by the physician resulting in the facility failing to identify a significant weight loss in a timely manner. Findings include: Review of the facility policy titled Weight Assessment and Intervention undated, indicated the following: -The nursing staff will measure resident's weights on admission, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. -Weights will be recorded in each unit's Weight Record chart or notebook and in the individual's medical record.-Any weight change 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing.-The Dietitian will respond within 24 hours of receipt of written notification.-The Dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether the criteria for significant weight change has been met. - The threshold for significant unplanned and desired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight -actual weight) / (usual weight) x 100:a. 1 month - 5% weight loss is significant; greater than 5% is severe.b. 3 month - 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months- 10% weight loss is significant; greater than 10% is severe. Resident #33 was admitted to the facility in May 2025 with diagnoses including chronic obstructive pulmonary disease (COPD), chronic atrial fibrillation and weakness. Review of the Minimum Data Set (MDS) assessment, dated 8/27/25, indicated Resident #33 had moderate cognitive impairment, as evidence by a Brief Interview for Mental Status (BIMS) score of 8 out of a possible score of 15. Further view of the MDS failed to indicate rejection of care.Review of the facility Matrix (a tool used by providers and government surveyors to assess resident needs and track compliance) indicated Resident #33 had an excessive weight loss/gain.Review of the facility Weight Record for Resident #33 indicated the following weight measurements:-5/30/25: 188 lbs. (pounds)-7/31/25: 154.0 lbs.-8/6/25: 153.5 lbs.-8/12/25:157.8 lbs.-8/19/25: 153.7 lbs. -9/13/25: 154.2 lbs. The medical record indicated that from 5/30/25 to 7/31/25, Resident #33 lost 34 pounds resulting in a -18.1% weight loss over two months since admission. Further view of the medical record failed to indicate that any weights were obtained between 5/30/25 and 7/31/25. Review of Resident #33s active physician orders indicated the following:-Diet: Regular diet, regular texture, thin liquids, dated 5/31/25.-Ensure: (a nutritional supplement) two times a day, dated 8/3/25.-Monthly weights: everyday shift, every month: reweigh if +/-3 lbs and notify NP/MD (Nurse Practitioner/ Doctor of Medicine), dated 8/21/25. Review of Resident #33's discontinued physician orders indicated the following: -Weigh weekly x4 weeks: active from 6/2/25 through 6/30/25, dated 5/30/25. -Weekly weights: active from 8/4/25 through 8/21/25, dated 7/31/25. Review of Resident #33's June 2025 Treatment Administration Record (TAR) failed to indicate any documented weights for the entire month. Review of Resident #33's medical record failed to indicate that weekly weights were not obtained between 6/2/25 and 6/30/25 in accordance with the physician's order that was implemented on 5/30/25. Further view of the medical record failed to indicate that Resident #33 had refused weights. Review of Resident #33's Nutritional admission Assessment, dated 6/6/25, completed by the Registered Dietitian (RD) indicated the following: -Resident relates stable weight 185-188-Eating/feeding: independent. -Inadequate energy intake aeb (as evidenced by) diarrhea, fair appetite related to diagnosis of GERD (Gastroesophageal Reflux Disease). -most recent weight 188 on 5/30/25. -goals: maintain weight. Review of a weight change note dated 8/3/25 at 6:47 A.M., written by the Registered Dietitian indicated the following: Resident is [AGE] year-old with PMH (past medical history): Esophagitis, COPD, CHF, diet; Regular. He/She eats meals in main dining room. He/She has had a significant weight loss 30# (pounds) over past 2 mo. Appetite is improving per observation and RN/CNA (Registered Nurse/Certified Nurse Aid) team, Resident HCP (healthcare proxy), NP (Nurse Practitioner) will be notified. Resident is not meeting his/her nutritional needs aeb (as evidenced by) weight loss plan; weekly weight serve diet as ordered add Ensure 237 cc (cubic centimeter, each equivalent to one milliliter) twice daily monitor appetite/wt (weight). (sic). Review of a weight change note written by the Registered Dietitian dated 8/7/25 at 2:26 P.M., indicated the following: Resident is 99 y/old with PMH: CHF, CAD. He/She is very HoH (hard of hearing) and has visual impairment. Diet; Regular, regular texture, thin liq (liquids). supplement Ensure 237 cc two times daily. He/She has a fair appetite - eats in main dining room. His/Her weight has trended down since admission. His/her HCP (health care proxy) has been notified of weight tread down. Plan: update food preferences serve diet as ordered monitor wt weekly. Review of Resident #33's Nutritional Quarterly/significant change assessment by the Registered Dietitian (RD) dated 8/26/25, indicated the following:-weight 153.7 dated 8/19/25-eating independently -Adequate energy intake aeb stable weight since admission.-Estimated calorie need: 1540-1550-1540 kcal/day Review of Resident #33's medical record indicated that the Resident was assessed by the Registered Dietitian (RD) on admission and after significant weight loss had been identified. During an interview on 9/16/15 at 1:34 P.M., Certified Nursing Assistant (CNA) #1 said CNAs are responsible obtaining weights and weights are done either weekly or monthly. CNA #1 said residents are weighed on admission or within 48 hours of admission date. CNA #1 said weights are documented on a sheet of paper and the assigned nurse documents the weights in the electronic medical record. During an interview on 9/16/25 at 2:31 P.M., Nurse #2 said residents are weighed on the same day they are admitted , then weekly. Nurse #2 said weights are documented in the electronic medical record under the weights tab. During an interview on 9/17/25 at 10:38 A.M., the Registered Dietitian (RD) said residents that are newly admitted are weighed on admission, then weekly for 4 weeks. The RD said CNAs are given a weekly weight list to obtain the scheduled weights and weights are entered into the electronic medical record by the nurse or director. The RD said she is informed of residents with significant weight changes by looking at weight reports in the electronic medical record, risk meetings and weekly clinical meetings. The RD said she would expect to be notified by staff if a resident has a significant weight loss and would assess the resident within that same week of the weight loss. The RD said she would recommend a reweigh for a 3-pound weight loss or gain. The RD said the risk of weights not being completed timely or as indicated in physician's orders, is further weight loss. She said Resident #33's weight loss would have been detected sooner if the weekly weights had been done. The RD said she would have assessed Resident #33 sooner if the weights were completed. During an interview on 9/17/25 at 10:58 A.M., the Director of Nursing said weights are completed on admission, then weekly for four weeks. The DON said if residents are stable after weekly weights are ordered, then the resident's weight order would be changed to monthly weights. The DON said it is her expectation that weekly weights are obtained as indicated in the physician's orders.

Based on interview and records reviewed, the facility failed to complete annual Certified Nurse Aide (CNA) performance reviews for two out of two eligible sampled CNAs.Findings include: During review of three CNA employee records, the surveyor was unable to locate annual performance reviews for two out of two eligible CNAs. During an interview on 9/16/25 at 7:59 A.M., the Regional Human Resources (HR) Director (who said she is covering for this facility in the absence of an HR director) reviewed the employee files with the surveyor and said that CNAs should receive an annual performance review. On 9/16/25 at 8:25 A.M., she followed up with the surveyor and said that she could not locate any performance reviews and at this time feels that they had not been completed. During an interview on 9/16/25 at 8:55 A.M., the Director of Nursing said that she has only been in the facility for three months but that performance reviews should be completed annually. During an interview on 9/16/25 10:01 A.M., The Director of Operations said that the expectation in the facility is that annual performance reviews are completed.

Based on observation and interview, the facility failed to ensure a gap in the bed was filled to prevent possible entrapment for one Resident (#42) out of a total sample of 14 residents. Findings include:Review of facility policy titled Bed Safety, undated, indicated the following:-2. To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following;b. Review that gaps within the bed system are within the dimensions established by the FDA. Resident #42 was admitted to the facility in July 2024 with diagnoses that included congestive heart failure and lower back pain. Review of Resident #42's most recent Minimum Data Set (MDS) Assessment, dated 9/3/25, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that the Resident's cognition is intact. The MDS further indicated that Resident #42's ability to roll from lying on back to left and right side and return to lying on back on the bed was dependent on staff. On 9/15/25 at 7:41 A.M. the surveyor observed Resident #42 sleeping in bed. There was a large gap between the mattress and the footboard without a gap filler in place. On 9/15/25 at 12:15 P.M., the surveyor observed Resident #42 eating lunch in bed. There was a large gap between the mattress and the footboard without a gap filler in place. On 9/16/25 at 6:59 A.M. and 1:45 P.M., the surveyor observed the Resident in bed. There was a large gap between the mattress and the footboard without a gap filler in place. On 9/17/25 at 7:01 A.M., the surveyor observed Resident #42 sleeping in bed. There was a large gap between the mattress and the footboard without a gap filler in place. The surveyor measured the gap to be approximately six inches. Review of the Bed/Side rail assessment, dated 5/30/25, indicated the following:-Are spacings between the bed rail, mattress and bed surround appropriate to prevent entrapment, in particular, between the end of the bed rail and the headboard; between the mattress and bed rail; and between the mattress and lowest rail of the bed rail when compressed by the bed occupant - the answer was left blank and not indicated in the assessment. During an interview and observation on 9/17/25 at 7:09 A.M., the Director of Nursing (DON) and the surveyor observed the gap at the foot of the bed between the mattress and the footboard. the DON said Resident #42 does not get out of bed per his/her choice and is dependent for bed mobility. She said that she has never seen a gap filler used at the foot of the bed before During a follow up interview on 9/17/25 at 7:33 A.M., the DON said she is asking maintenance to observe the bed and get a gap filler to put in place. During an interview on 9/17/2025 at 9:44 A.M., the Maintenance Director said he has been at the facility for a month and a half. He said that if there is a gap between the mattress and the footboard of the bed, then there should be a gap filler in place. During an interview on 9/17/25 at 9:47 A.M., the Administrator said that he observed Resident #42's bed and agreed that there should be a gap filler in place due to the gap between the mattress and the foot of the bed. 09/17/2025 10:23 AM During a follow up interview with the Maintenance Director he said that he checked all beds and observed that Resident #42's bed had a gap between the mattress and the footboard, he said he measured it to be between five and six inches.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who during the overnight shift (on 10/04/24 into 10/05/24) was found sitting on the floor by Nurse #1 and Certified Nurse Aide (CNA) #1 after an unwitnessed fall, the Facility failed to ensure he/she was provided with nursing care and treatment that met professional standards of quality care, when although Nurse #1 said she assessed Resident #1 prior to moving him/her off the floor, there was no documentation to support she adequately assessed Resident #1 after his/her fall for potential injury. The following day shift (7:00 A.M. to 3:00 P.M.) Resident #1 verbalized complaints of pain, reported he/she had fallen during the previous overnight shift, and was transferred to the Hospital Emergency Department (ED) for evaluation. Resident #1 was diagnosed with a T11 vertebral body acute fracture/edema (bottom part of the thoracic spine) and fractures of S3 and S4 fracture (a break in the sacrum, a triangular bone at the base of the spine, between the hips). Findings include: Standard Reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered and practical nurse incorporated into the plan of care and implement prescribed medical regimens. The rules and regulations 9.03 defined standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Review of the Facility Policy titled, Fall Prevention Program, dated 03/04/24, indicated when any resident experiences a fall the Facility will: -Assess the resident. -Complete a post-fall assessment. -Complete an incident report. -Notify Physician and family. -Review the Resident's care plan and update as indicated. -Document all assessments and actions. -Obtain witness statements in the case of injury. Review of the Facility Policy titled, Accidents and Incidents, dated 03/04/24, indicated for Facility Staff to utilize Point Click Care (PCC) risk management to report and investigate any accidents or incidents that occur on Facility property involving a Resident. The Policy indicated staff to initiate the following: -Falls require an incident/accident report. -The Supervisor or other designee will be notified of the incident/accident. -The Nurse will contact the resident's practitioner to inform them of the incident/accident, report any injuries or other findings, and obtain orders, if indicated, which may include transportation to the hospital dependent upon the nature of the injury. -In the event of an unwitnessed fall, the nurse will initiate neurological checks as per protocol, document on the neurological flow sheet and abnormal findings will be reported to the Practitioner. -The resident's Family or Representative will be notified of the incident/accident and any orders obtained or if the resident is to be transported to the hospital. -Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications, and orders obtained or follow-up interventions. Resident #1 was admitted to the Facility in September 2024, diagnoses included congestive heart failure, atrial fibrillation, hypertension, shortness of breath, and muscle weakness. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 10/15/24, indicated that on 10/05/24, Resident #1's daughters were visiting Resident #1, he/she complained of back pain, told them he/she had fallen overnight, and the family requested Resident #1 to be transferred to the hospital. The Report indicated Resident #1's fall was unwitnessed, and nursing assessment at the time of the fall did not reveal any acute injury. The Report indicated Resident #1 had been toileted, placed back into bed and had not complained of pain until later in the morning. The Report indicated Resident #1 was transferred to the Hospital Emergency Department where he/she was diagnosed with edema and fractures of S3-S4 and T11. During a telephone interview on 11/12/24 at 3:54 P.M., (which included a review of her Written Witness Statement, undated), CNA #1 said on 10/05/24, somewhere around 2:00 A.M. (exact time unknown) she heard a bang, went into Resident #1's room, and found him/her sitting on his/her buttocks on the floor. CNA #1 said Resident #1's walker was tipped over on the floor next to him/her and that Resident #1 said he/she was going to the bathroom. CNA #1 said Resident #1 said he/she was alright, so she and Nurse #1 assisted (lifted) Resident #1 up off the floor, assisted him/her to the bathroom, toileted him/her and then transferred Resident #1 back into bed. CNA #1 said prior to them moving Resident #1 off the floor she did not see Nurse #1 perform an assessment on Resident #1, other than hearing Nurse #1 ask Resident #1 if he/she was in pain. During a telephone interview on 11/12/24 at 2:32 P.M., (which included a review of her Written Witness Statement, dated 10/09/24), Nurse #1 said on 10/05/24, somewhere around 2:00 A.M. (exact time unknown) she heard a sound, like a walker falling on the floor, went into Resident #1's room, and found him/her sitting on his/her buttocks on the floor. Nurse #1 said Resident #1 was able to move his/her legs, arms, denied hitting his/her head and did not report having pain. Nurse #1 said she was satisfied with her initial assessment and waited to perform vital signs once Resident #1 was in bed, since Resident #1 said he/she had to go to the bathroom. Nurse #1 said she and CNA #1 helped Resident #1 ambulate to the bathroom with his/her walker but upon return from the bathroom they transferred Resident #1 via wheelchair since Resident #1 said he/she was tired. Nurse #1 said she did not document or complete any documentation related to Resident #1 fall and did not report Resident #1's fall on 10/05/24 to the next shift staff because Resident #1 said he/she was alright. Nurse #1 said she did not initiate neurological checks after Resident #1's unwitnessed fall since Resident #1 said he/she did not hit his/her head. However, although Nurse #1 said she assessed Resident #1 immediately after the fall, and that she had decided to wait and obtain a set of vitals after she and CNA #1 assisted Resident #1 back to bed, there was no documentation in Resident #1's medical record to support Nurse #1 had completed any type of assessment or that she had obtained Resident #1's vital signs on 10/05/24, after his/her unwitnessed fall. Nurse #1 said she was aware of the Facility's Policy related to Fall Prevention Program, Incidents/Accidents, Procedures, and what was required of nursing if a resident had an unwitnessed fall. Nurse #1 said on 10/09/24, (five days after the incident) she provided a written statement to the Facility and that was also when she documented Resident #1's unwitnessed fall in his/her medical record. During an interview on 11/05/24 at 4:02 P.M., (which included a review of her Written Witness Statement, dated 10/05/24), Nurse #2 said on 10/05/24 she worked the 7:00 A.M. to 3:00 P.M. shift and when she came on duty, she received change of shift report from Nurse #1 who had worked the overnight shift (from 10/04/24 into 10/05/24). Nurse #2 said during the change of shift report, Nurse #1 told her that Resident #1 had chronic pain, was on scheduled pain medications and had a wound that was not new to his/her coccyx area. Nurse #2 said Nurse #1 did not say anything in report to her about Resident #1 falling during the overnight shift. Nurse #2 said, on 10/05/24, she administered Resident #1's medications later in the morning (exact time unknown) which included scheduled pain medications, and shortly after that CNA #2 reported to her that Resident #1 said he/she was in pain due to a fall. Nurse #2 said since she had just administered pain medication to Resident #1, and she had not been informed of a fall in the change of shift report, she thought Resident #1 might have been talking about a fall he/she may have previously had at home. Nurse #2 said she was at the nursing station with the Director of Nursing (DON) when CNA #2 came to the desk a second time, reported that Resident #1 said he/she was still in pain and that Resident #1 had also said he/she had fallen during the previous overnight shift. Nurse #2 said shortly after she spoke with CNA #2, Resident #1's Family members came to the nursing station and questioned them saying he/she had a fall last night and you are not going to send him/her out to the hospital and that the family members continued to repeat that statement. Nurse #2 said she and the DON immediately went to assess Resident #1. Nurse #2 said upon entering Resident #1's room, Resident #1 was grimacing, as if he/she was in pain. Nurse #2 said Resident #1 was sent to the hospital via Emergency Medical Services (911). Review of Resident #1's Hospital Magnetic Resonance Imaging (MRI) Report, dated 10/06/24, indicated that Resident #1 had a fall, was in pain, and a Thoracic spine/Lumbar MRI was completed. The Report indicated Resident #1 had a T11 vertebral body acute fracture/edema (bottom part of the thoracic spine) and a fracture of his/her S3 and S4 fracture (a break in the sacrum, a triangular bone at the base of the spine, between the hips). During an interview on 11/05/24 at 2:39 P.M. the Director of Nurses (DON) said she was not informed of Resident #1's fall during the overnight shift (10/04/24 into 10/05/24) by Nurse #1. The DON said she assessed Resident #1 after Resident #1's family members notified them that Resident #1 told them he/she had a fall on the overnight shift and that they wanted him/her to be transferred to the hospital immediately. The DON said when she went to assess Resident #1, he/she said she/he had fallen sometime on the overnight shift, landed on his/her buttocks, and that staff had picked him/her up off the floor, placed him/her in the wheelchair, toileted him/her and then put him/her back into bed. The DON said she could not find any documentation in Resident #1's Medical Record regarding his/her unwitnessed fall on 10/05/24, including any type of nursing assessments or incident report. The DON said it was her expectation that Nurse #1 would have assessed Resident #1 for any potential injury, initiated obtaining neurological signs (since his/her fall was unwitnessed), completed pain and skin assessments, and notified the Physician and herself, The DON said Nurse #1 should have documented the fall in a Progress Note, and notified the oncoming shift nurse of the fall, but she had not. The DON said it was several days after the Resident #1's fall before she was able to speak to Nurse #1 regarding Resident #1's fall and determine what happened that night. The DON said Nurse #1 did not follow Facility's Procedures and Policy's.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who during the overnight shift on 10/04/24 into 10/05/24 was found sitting on the floor by Nurse #1 and CNA #1 after an unwitnessed fall, the Facility failed to ensure nursing reported the incident to the Physician, his/her Health Care Agent, Administrative staff and to the oncoming shift Nurse (Nurse #2) as required, and per Facility policy. Findings include: Review of the Facility's policy, titled Notification of Changes, dated 03/04/24, indicated the purpose of this Policy is to ensure the Facility promptly informs the resident's Physician; notifies, consistent with his or her authority, the resident's Representative when there is a change requiring notification. The Policy indicated circumstances requiring notification include accidents with potential to require Physician interventions. The Policy indicated additional considerations included that for competent individuals, the Facility must still contact the resident's Physician and notify resident's Representative. Review of the Facility's policy, titled Fall Prevention Program, dated 03/04/24, indicated when any resident experiences a fall, the Facility will notify residents Physician and Family. Review of Facility's policy, titled Incidents and Accidents, dated 03/04/2024, indicated staff to alert Risk Management and/or Administration of occurrences that could result in claims or further reporting requirements. The Policy indicated staff will notify the Supervisor or other Designee of the incident/accident. The Policy indicated the Nurse will contact the resident's Physician and Family to inform them of the incident/accident. Resident #1 was admitted to the Facility in September 2024, diagnoses included congestive heart failure, atrial fibrillation, hypertension, shortness of breath, and muscle weakness. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 10/15/24, indicated that on 10/05/24, Resident #1's daughters were visiting Resident #1, he/she complained of back pain, told them he/she had fallen overnight, and the family requested Resident #1 be transferred to the hospital. The Report further indicated that Resident #1's fall was unwitnessed, Nursing assessment at the time of the fall did not reveal any acute injury, that Resident #1 had been toileted, place back into bed and had not complained of pain until later in the morning. The Report indicated Resident #1 was transferred to the hospital (during the day shift on 10/05/24), was diagnosed with edema and fracture of S3-S4 (break in the sacrum) and T11 (on of the 12 vertebrae of the thoracic spine). Review of Resident #1's Medical Record indicated his/her Family was involved in his/her care. Resident #1 was his/her own person, that his/her Health Care Agent contact information and Family member contact information were clearly indicated in his/her record. Review of Resident #1's Medical Record indicated that for overnight shift (10/04/24 into 10/05/24), there was no Nurse Progress Note, no Incident Report and no documentation to support Resident #1's Health Care Agent, Physician, Director of Nurses (DON) or the oncoming day shift Nurse were notified of Resident #1's fall/incident. During a telephone interview on 11/12/24 at 2:32 P.M., (which included a review of her Written Witness Statement, dated 10/09/24), Nurse #1 said on 10/05/24, somewhere around 2:00 A.M. she heard a sound, like a walker falling on the floor, that she went into Resident #1's room, and found him/her sitting on his/her buttocks on the floor. Nurse #1 said Resident #1 was able to move his/her legs, arms and denied having any pain or hitting, his/her head. Nurse #1 said she was satisfied with her assessment and waited to perform vital signs once Resident #1 was in bed since he/she had to go to the bathroom. Nurse #1 said she and CNA #1 helped Resident #1 ambulate to the bathroom with his/her walker, but upon return from the bathroom they transferred Resident #1 via wheelchair since Resident #1 said he/she was tired. Nurse #1 said she did not report Resident #1's fall to the Physician, the DON or to Resident #1's Health Care Agent. Nurse #1 said she was aware of the Facility's Policy related to Fall Prevention Program, Incidents and Accidents and Documentation, which included reporting any incidents and accidents. Nurse #1 said on 10/09/24 she wrote and provided the Facility with a written statement, in which she documented Resident #1's fall. Nurse #1 said looking back she should of followed the Facility's Policy and reported Resident #1's fall to the Physician, to the oncoming shift Nurse, the DON, his/her Health Care Agent and documented the incident for Resident #1's safety and for other staff to be able to identify any changes that may occur with him/her. Review of Resident #1's Hospital Magnetic Resonance Imaging (MRI) Report, dated 10/06/24, indicated that Resident #1 had a fall, pain, and a Thoracic spine/Lumbar MRI was completed. The Report indicated Resident #1 had a T11 vertebral body acute fracture/edema (bottom part of the thoracic spine) and a fracture of his/her S3 and S4 fracture (a break in the sacrum, a triangular bone at the base of the spine, between the hips). During an interview on 11/05/24 at 2:39 A.M. the Director of Nurses (DON) said she was not informed of Resident #1's fall by the Nurse (identified as Nurse #1) that worked the overnight shift on 10/04/24 into 10/05/24. The DON said she and Nurse #2 assessed Resident #1 on 10/05/24, after Resident #1's family members notified them that Resident #1 had a fall on the overnight shift and wanted him/her to be transferred to the hospital immediately. The DON said she went to assess Resident #1, who reported that he/she had fallen sometime during the overnight shift, that he/she fell landing on his/her buttocks, staff picked him/her up off the floor, placed him/her in a wheelchair, toileted him/her and then placed him/her back into bed. The DON said she could not find any documentation in Resident #1's Medical Record regarding his/her fall on 10/05/24, including any assessments or an Incident Report. The DON said it was her expectation that Nurse #1 should have assessed Resident #1 for injury, initiated obtaining neurological signs (fall was unwitnessed), and completed pain and skin assessments. The DON said Nurse #1 should have also notified the Physician, facility administrative staff, documented the incident in a progress note, completed an Incident Report, notified the oncoming shift nursing staff, and obtained staff members written statements, but she had not. The DON said she began an investigation on 10/05/24 after being informed of Resident #1's fall. The DON said she had Nurse #1 complete all the Resident #1's fall documentation as a late entry, but that Nurse #1 did not do so until several days after the Resident #1's fall since Nurse #1 was not returning her phone calls or texts. The DON said Nurse #1 told her she did not report Resident #1's fall on 10/05/24, because she had forgotten to report and document the incident.

Based on record review and interview the facility failed to annually conduct, review, and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Findings include: Review of the facility policy titled, Facility Assessment, dated as 3/4/24, indicated this facility conducts and documents a facility-wide assessment to determine what resources are necessary to care for our residents competently during both day-to-day operations (including nights and weekends) and emergencies. The purpose of this policy is to establish responsibilities and procedures for the facility assessment process. 4. The Administrator is responsible for ensuring the completion of the facility assessment and maintaining all documents that pertain to the assessment. The Administrator serves as the leader of the facility assessment process, or may designate someone to lead the process. 10. The facility assessment will be reviewed and updated as necessary and at least annually, whenever there is, or the facility plans for, any change that would require a substantial modification to any part of the assessment. Additionally, the facility will consider specific staffing needs for each shift (e.g., day, evening, night, weekend shifts) and for each resident unit in the facility based on changes to resident population. Any changes to the assessment will be documented, along with a revision history. On 9/10/24 at 8:30 A.M., during the facility entrance conference the surveyor requested a copy of the facility assessment. On 9/11/24 at 9:00 A.M., the surveyor requested the facility assessment from Administrator #1. During an interview on 9/11/24 at 12:00 P.M., Administrator #1 said he was unable to locate the facility assessment. Administrator #1 provided the surveyor a copy of the facility assessment dated [DATE], and said he was unable to locate any other facility assessments. During an interview on 9/12/24 at 12:50 P.M., Administrator #2 said she was responsible to conduct the facility assessment review, but she did not. Administrator #2 said she was employed by the facility for about 10 weeks and that facility assessments are required annually. Administrator #2 said she did not have access to any previous facility assessments during her time as the Administrator. Administrator #2 said that the Director of Operations was aware she did not have any previous copies of facility assessments and that she was unable to complete the facility assessment. During an interview on 9/12/24 at 1:15 P.M., the Director of Operations said that Administrator #2 was supposed to complete the facility assessment update, but she did not. The Director of Operations said that facility assessments are required to be completed annually but one was not completed.

Based on record review and interview, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed to meet the facility-determined minimum for certified nurse assistant (CNA) staff on the weekends. Findings Include: During the Resident Group interview on 9/10/24 at 1:00 P.M., the Resident Group expressed concern about certified nurse assistant (CNA) staffing. The Resident Group said they do not feel there is enough CNAs, and they often must wait too long for their call lights to be answered. On 9/11/24 at 1:50 P.M., the Chief Nursing Officer (CNO) said there was no facility assessment for the facility. The CNO gave the surveyor a list of current staffing needs for direct care staff. The CNO said this does not include any supervisors. The CNO said the following staffing was determined to be necessary based on the facility needs since at least April 1, 2024: *Nurses - 7-3: 2 - 3-11: 2 - 11-7: 2 *CNAs - 7-3: 5 - 3-11: 4.5 - 11-7: 2 During offsite preparation, the CASPER Payroll-Based Journal (PBJ) Staffing Data Report submitted by the facility for fiscal year (FY) Quarter 3, 2024 (April 1 - June 30) was reviewed. The facility's report triggered that the facility reported excessively low weekend staffing. Review of the weekend staff schedule, dated April 1, 2024 to June 30, 2024, indicated that the facility was staffed below their determined minimum necessary CNAs for 20 weekend shifts. On these days there were no additional nurses scheduled who could assist with CNA duties. The weekend staff schedules indicated the following staffing during this quarter: - Sunday April 7th, 2024: only 4 CNAs on 7-3, but should be 5. - Sunday April 7th, 2024: only 1 CNA on 11-7, but should be 2. - Saturday April 13th, 2024: only 4 CNAs on 7-3, but should be 5. - Sunday April 14th, 2024: only 3 CNAs on 7-3, but should be 5. - Saturday April 20th, 2024: only 2 CNAs on 7-3, but should be 5. - Saturday April 20th, 2024: only 4 CNAs on 3-11, but should be 4.5. - Sunday April 21st, 2024: only 2 CNAs on 3-11, but should be 4.5. - Sunday May 5th, 2024: only 3 CNAs on 3-11, but should be 4.5. - Saturday May 11th, 2024: only 4 CNAs on 7-3, but should be 5. - Sunday May 12, 2024: only 4 CNAs on 3-11, but should be 4.5. - Sunday May 19, 2024: only 4 CNAs on 3-11, but should be 4.5. - Saturday June 1, 2024: only 4 CNAs on 3-11, but should be 4.5. - Sunday June 2, 2024: only 4 CNAs on 7-3, but should be 5. - Sunday June 2, 2024: only 4 CNAs on 3-11, but should be 4.5. - Saturday June 8, 2024: only 4 CNAs on 3-11, but should be 4.5. - Sunday June 9, 2024: only 4 CNAs on 7-3, but should be 5. - Saturday June 15, 2024: only 4 CNAs on 7-3, but should be 5. - Sunday June 16, 2024: only 4 CNAs on 7-3, but should be 5. - Sunday June 16, 2024: only 4 CNAs on 3-11, but should be 4.5. - Sunday June 23, 2024: only 4 CNAs on 7-3, but should be 5. Further review of the weekend staff schedules, dated July 1, 2024 to September 1, 2024, continued to indicate the facility was staffed below their determined minimum necessary CNAs on 16 weekend shifts. On these days there were no additional nurses scheduled who could assist with CNA duties. The weekend staff schedules indicated the following staffing: - Saturday July 6, 2024: only 4 CNAs on 7-3, but should be 5. - Sunday July 7, 2024: only 3 CNAs on 7-3, but should be 5. - Sunday July 7, 2024: only 3 CNAs on 3-11, but should be 4.5 - Saturday July 13, 2024: only 4 CNAs on 7-3, but should be 5. - Sunday July 14, 2024: only 4 CNAs on 7-3, but should be 5. - Sunday July 14, 2024: only 3 CNAs on 3-11, but should be 4.5. - Sunday July 14, 2024: only 1 CNA on 11-7, but should be 2. - Sunday July 21, 2024: only 4 CNAs on 7-3, but should be 5. - Sunday July 21, 2024: only 4 CNAs on 3-11, but should be 4.5 - Saturday July 27, 2024: only 4 CNAs on 3-11, but should be 4.5 - Saturday August 10, 2024: only 4 CNAs on 7-3, but should be 5. - Saturday August 10, 2024: only 4 CNAs on 3-11, but should be 4.5. - Saturday August 10, 2024: only 1 CNA on 11-7, but should be 2. - Sunday August 11, 2024: only 3 CNAs on 7-3, but should be 5. - Saturday August 31, 2024: only 4 CNAs on 3-11, but should be 4.5 - Sunday September 1, 2024: only 4 CNAs on 3-11, but should be 4.5. During an interview on 9/12/24 at 1:32 P.M., CNA #5 said the CNAs do the best they can, but they often can't get to everything when they are short staffed. CNA #5 said the facility's CNA staffing was the worst during April 2024 to June 2024 on the weekends. CNA #5 said it has gotten better since the facility started with a new agency, but they still struggle at times. CNA #5 said even with fully staffed ratios it's hard to get everything needed done. During an interview on 9/12/24 at 1:36 P.M., CNA #6 said CNA staffing was really bad on weekends during April 2024 to June 2024, but it's getting better. CNA #6 said it was often because the CNAs from an agency they used to have would call out, but it's been getting better since they changed staffing agencies. During an interview on 9/12/25 at 8:39 A.M., Nurse #5 said there is often not enough CNAs scheduled to support the nurses across all shifts. Nurse #5 said it's been better since the facility changed staffing agencies, but the nurses still can't get all required duties completed because there aren't enough CNAs. Nurse #5 said its specifically hard to get their documentation, paperwork, and care plans updated, even when the suggested staffing ratios are met and that she had often expressed this to management. During an interview on 9/12/24 at 7:31 A.M., the scheduler said the staffing ratios the CNO gave the surveyor were accurate and had been the needed staffing ratios since at least April 2024. The scheduler said sometimes staff complains there isn't enough staff, and the facility will attempt to get more staff when the acuity is higher, but the ratios given were the minimum needed. The scheduler said she was aware that the facility triggered for low weekend staffing and it sounds accurate that during that time there were at least 20 weekend shifts without enough CNA staff working because they couldn't replace the call outs or just didn't have enough CNAs. During an interview on 9/12/24 at 10:01 A.M., the Director of Nursing (DON) #1 said he was aware the facility triggered for low weekend staffing during the quarter of April 1, 2024 to June 30, 2024. DON #1 said during that quarter there was insufficient staffing on the weekends, and they hired more staff and changed staffing agencies. DON #1 said even with those changes it's still difficult to staff CNAs at times.

Based on interview and record review, the facility failed to develop a plan of care for dialysis and failed to ensure staff implemented dialysis care and services consistent with professional standards of practice for one Resident (#25), out of 17 sampled residents. Specifically, the facility failed to provide ongoing communication between the nursing facility and dialysis facility. Findings include: Resident #25 was admitted to the facility in August 2024 with diagnoses including end stage kidney disease, pneumonia, and fracture. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #25 scored an 11 out of 15 on the Brief Interview for Mental Status exam indicating moderately impaired cognition. Further review indicated Resident #25 required moderate assistance for most activities of daily living. Review of the physician's orders dated September 2024 failed to indicate a physician's order for hemodialysis. Review of the dialysis communication book indicated 3 undated Dialysis Communication Forms (DCF). Further review indicated DCF's dated 8/15/24, 9/7/24 and 9/10/24 (only three dated communication forms out of a possible 12). On 9/10/24, at 12:44 P.M., Nurse #4 said that Resident #25 went out to dialysis at 10:00 A.M. The surveyor and Nurse #4 observed Resident #25's dialysis communication book at nurse's station with the DCF dated 9/10/24 still in the communication book. Nurse #4 then said that Resident #25 should have the book with him/her as that is how the facility and the dialysis center communicate needs, changes, and concerns. Nurse #4 then said that Resident #25 goes to dialysis 3 times a week. Nurse #4 said that there should be a communication form completed each time the Resident goes to dialysis. Nurse #4 said she was not aware of which type of dialysis access Resident #25 had. During an interview on 9/10/24 at 1:45 P.M., Nurse #6 said that Resident # 25 has a CVC (Central Venous Catheter) for dialysis access, and she would expect that there would be a physician's order to monitor the CVC site for infection and drainage.

Based on interviews and record review, the facility failed to provide Substance Abuse Services for one Resident (#47) out of a sample of 17 Residents, and additionally failed to provide Substance Abuse Services for 6 additional Residents identified by the Social Worker. Findings include: A review of the facility policy titled 'Safety for Residents with Substance Abuse Disorder' with a revision date of 3/4/24 indicated the following: -It is the policy of this facility to create an environment that is free of accident hazards as possible, for residents with a history of substance use disorder. -Substance use disorder is defined as recurrent use of alcohol and/or drugs that causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home. 7. The facility will make an effort to prevent substance use which may include providing substance use treatment services, such as behavioral health services, medication-assisted treatment (MAT), alcoholic/narcotics anonymous meetings, working with the resident and the family, if appropriate, to address goals related to their stay in the nursing home, and increased monitoring and supervision. Resident #47 was admitted to the facility in August 2024 with diagnoses including bipolar disorder, post traumatic stress disorder and borderline personality disorder. A review of the Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 indicating intact cognition. Review of the medical record indicated Resident #47's most recent behavioral medication management progress note. The progress note dated 8/14/24 indicated the Resident has a history of using substances such as heroin and alcohol. During an interview on 9/12/24 at 11:19 A.M., Resident #47 said he/she has a history of ingesting heroin and alcohol. He/she said he/she last ingested heroin and alcohol eight months ago. The Resident said he/she participated in Alcoholic Anonymous (AA)/ Narcotics Anonymous (NA) meetings in the community, so he/she wanted to continue those services while in the facility. The Resident said no one in the facility has offered AA/NA services until today. During an interview on 9/12/24 at 9:21 A.M., the Social Worker said the facility does not offer any AA/NA services for residents with a history of substance use. She provided the surveyor a list of six additional Residents in the facility with a history of alcohol, narcotics and marijuana use. The Social worker said none of these residents have been offered AA/NA services.

Based on record review, policy review and interview, the facility failed to ensure recommendations from the Monthly Medication Reviews (MMRs) conducted by the consultant pharmacist were addressed and acknowledged by the physician in a timely manner for two Residents (#33 and #47) out of a total sample of 17 residents. Findings Include: Review of the facility policy titled Documentation and Communication of Consultant Pharmacist Recommendations dated 10/1/19, indicated that comments and recommendations concerning medication therapy are communicated in a timely fashion. Further review indicated that in the event that a problem requiring the immediate attention of the prescriber, the responsible prescriber is contacted by the consultant pharmacist or the facility, and the prescriber response is documented on the consultant pharmacist review record or elsewhere is the medical record. 1.) Resident #33 was admitted to the facility in April 2023 with diagnoses including but not limited to dementia and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #33 is severely cognitively impaired and is totally dependent for activities of daily living. Review of the Federal Drug Association (FDA) document Reference ID: 4029608, indicated that the initial Ativan dose for the elderly should not exceed 2 mg. Review of the doctor's order dated September 2024 indicated a new order for Ativan (an anti-anxiety, benzodiazepine medication) 5 mg. (milligrams) PRN (as needed) dated as initiated 7/26/24. Review of the MMR dated 8/18/24, indicated a request to the doctor for clarification of the Ativan dose. Review of the medical record failed to indicate the doctor was made aware of the MMR recommendation and failed to indicate a response to the MMR. 2.) Resident #47 was admitted to the facility in August 2024 with diagnoses including post-traumatic stress disorder (PTSD), hemiplegia and diabetes. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #47 scored a 15 out of 15 on the Brief Interview for Mental Status exam indicating intact cognition. Further review indicated Resident #47 required assistance with most activities of daily living. Review of the doctor's orders dated August 2024 indicated an order for Zetia (a cholesterol lowering medication) 10 mg. Give 10 mg by mouth one time a day for Diabetes. Review of the MMR dated 8/18/24, indicated a request to the doctor for clarification of the of the diagnosis for the use of the medication Zetia. During an interview on 9/10/24 at 4:38 P.M., Director of Nursing #1 (DON) said that the pharmacist reviewed all residents on 8/18/24. DON #1 then said that he was unable to locate any of the MMR's from 8/18/24, or any of the responses by the physician.

Based on observation, policy review and interview, the facility failed to ensure nursing staff stored all drugs and biologicals in accordance with accepted professional standards of practice. Specifically, the facility failed to properly secure the medication room on two of two units. Findings include: Review of the facility policy titled Medication Storage, dated 3/4/24, indicated that all drugs and biological's will be stored in locked compartments (i.e. medication rooms). Further review of the policy indicated that only authorized personnel will have access to the keys to the locked compartments. On 9/10/24 at 8:33 A.M., the surveyor observed the medication room on the first floor open. The surveyor also observed that no staff were present within eyesight of the open medication room. On 9/11/24, at 7:51 A.M., the surveyor observed the medication room on the second floor open. The surveyor also observed that no staff were present within eyesight of the open medication room. During an interview on 9/11/24 at 8:11 A.M. Nurse #1 said she left the medication room open after she went in to get masks. Nurse #1 said that it was a mistake to leave the door unlocked and open. Nurse #1 said the medication door should never be left open.

Based on record reviews and interviews the facility failed to ensure they provided laboratory services to meet the needs of its residents. Specifically, the facility failed to: 1.) Maintain a current Clinical Laboratory Improvement Amendment (CLIA) certificate appropriate for the level of testing performed within the facility, and 2.) For Resident #19 the facility failed to obtain an albumin level (a test that can help determine liver disease or kidney disease, or if the body is not absorbing enough protein). Findings include: 1.) On [DATE] at 8:30 A.M., during the entrance conference the surveyor requested the facility's CLIA certificate. Review of the facility policy titled, Laboratory Testing Waivers, dated [DATE], indicated the facility will ensure that laboratory services are provided to its residents in a manner that meets State and Federal regulations. 1. An application for a Clinical Laboratory Improvement Amendments (CLIA) will be made through the appropriate State agency for services that are categorized as waived under their requirements, i.e. bedside glucose testing 2. An agreement to provide laboratory services will be maintained with an off-site qualified laboratory to provide all other lab services. 3. The facility will assume responsibility to obtain services that meet professional standards and timeliness of the services. During an interview on [DATE] at 12:05 P.M., the Administrator #1 said that the facility did not have a current CLIA certificate but should. The Administrator #1 provided the surveyor with a CLIA certificate dated as expired [DATE] and the following document titled CLIA Laboratory User Fees dated [DATE], which indicated the payment was due by [DATE], for a CLIA renewal certificate period [DATE] to [DATE]. During an interview on [DATE] at 1:00 P.M. the Regional Nurse said there were 7 residents who required blood glucose monitoring. The Regional Nurse said the CLIA certificate should have been renewed but was not. 2.) Resident #19 was admitted to the facility in [DATE] with diagnoses including dementia, dysphagia, and osteoarthritis. Review of the facility policy titled, Laboratory Services and Reporting, dated [DATE], indicated the facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. 1. The facility must provide or obtain laboratory services to meet the needs of its residents. 2. The facility is responsible for the timeliness of the services. 6. All laboratory reports will be dated and contain the name and address of the testing laboratory and will be filed in the resident's clinical record. Review of Resident #19's physician's order, dated [DATE], indicated: - Check Albumin level next lab day [DATE]. On [DATE] at 12:30 P.M., the surveyor was unable to locate the results of the albumin level from [DATE] in the electronic health record or in the paper medical record. The surveyor requested the results from the facility. During an interview on [DATE] 10:01 A.M., Director of Nursing (DON) #1 said that Resident #19's albumin level was not obtained but should have been. During an interview on [DATE] at 12:04 P.M., the Regional Nurse said that they were unable to locate the results of the lab from [DATE]. The Regional Nurse said that nursing should have notified the laboratory service provider to perform the test but did not.

Based on observations, interviews, and record review, the facility failed to ensure staff developed and implemented a comprehensive person-centered care plan for four Residents (#4, #23, #25 and #47), out of a total sample of 17 residents. Specifically: 1.) For Resident #4, the facility failed to implement a fall care plan intervention to keep a urinal within reach and failed to develop a fall care plan intervention for fall mats. 2.) For Resident #23, the facility failed to develop personalized mood, behavior, and substance abuse care plans. 3.) For Resident #25, the facility failed to develop a comprehensive care plan for dialysis and antidepressant medication. 4.) For Resident #47, the facility failed to develop a comprehensive care plan for post-traumatic stress disorder (PTSD) and the use of psychotropic medication. Findings include: Review of the facility policy titled Comprehensive Care Plans, dated 3/4/24, indicated: - It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 1.) Review of the facility policy titled Fall Prevention Program, dated 3/4/24, indicated: 8. Each resident's risk factors and environmental hazards will be evaluated when developing the comprehensive care plan. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised if needed. Resident #4 was admitted to the facility in December 2021 with diagnoses including vascular dementia and adult failure to thrive. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/25/24, indicated Resident #4 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. This MDS also indicated Resident #4 had two falls since the previous MDS, dated [DATE]. On 9/10/24 at 8:18 A.M., the surveyor observed Resident #4 in bed with one fall mat under the bed, not fully in position. Only approximately one third of the fall mat was extended out from the left side of the Resident's bed. There was no urinal visible in his/her room. On 9/11/24 at 7:28 A.M., the surveyor observed Resident #4 in bed with one fall mat stored fully under his/her bed. No portion of the fall mat was extended to the area next to the Resident's bed. There was no urinal visible in his/her room. On 9/11/24 AT 8:20 A.M., the surveyor observed Resident #4 in bed eating breakfast. The fall mat had been moved and propped upright on the wall in the Resident's room. There was no urinal visible in his/her room. On 9/12/24 at 7:26 A.M., the surveyor observed Resident #4 in bed with one fall mat under the bed, not fully in position. Only approximately one third of the fall mat was extended out from the left side of the Resident's bed. There was no urinal visible in his/her room. During an interview on 9/12/24 at 7:29 A.M., Resident #4 said he/she used to have a urinal, but it's been gone for a long time. Resident said he/she would like to have the urinal again because then he/she wouldn't have to wait to go to the bathroom. Review of Resident #4's plan of care related to falls, revised 7/9/24, indicated: -Keep Urinal within reach. Review of Resident #4's plan of care related to falls, revised 7/9/24, failed to indicate use of fall mats. Review on Resident #4's physician's orders failed to indicate the use of fall mats. Review of Resident #4's medical record failed to indicate fall mats had been implemented or were in use. Further review of medical record failed to indicate any rationale for urinal not being within reach or any refusal of urinal. During an interview on 9/12/24 at 7:31 A.M., Certified Nurse Assistant (CNA) #3 said she cared for Resident #4 regularly on day shift. CNA #3 said Resident #4 had a history of falling out of bed. CNA #3 said Resident #4 should have two fall mats in place when in bed, not just one, but is not sure where the other one went. CNA #3 said a nurse a while back had told her in report that Resident #4 needed fall mats when in bed. CNA #3 said there is no urinal in the room. CNA #3 said this is because staff should never give Resident #4 a urinal because then he/she might use it. During an interview on 9/12/24 at 8:44 A.M., Nurse #5 said Resident #4 should have a fall mat on the left side of his/her bed whenever he/she is in bed. Nurse #5 said Resident #4 does not use a urinal. Nurse #5 said CNAs should be instructed on specific interventions necessary, such as fall mats and use of urinal, during shiftly report. Nurse #5 visualized Resident #4's care plan and said, based on the care plan, the Resident should have a urinal within reach to prevent falls. Nurse #5 said if this intervention was no effective or no longer necessary, the care plan should have been updated, but was not. Nurse #5 said there was not an intervention for fall mats, but there should have been one added because fall mats should not be used without either a physician's order or a care plan intervention. Nurse #5 said nurses are expected to check and update the care plan for interventions each shift, but it's not realistic because they don't have enough time with staffing levels in the facility. Nurse #5 said instead the nurses rely on shift report to communicate specific interventions, but that often doesn't happen either because of time constraints related to staffing levels. During an interview on 9/12/24 at 10:11 A.M., the Director of Nursing (DON) #1 said Resident #4's care plan should always be followed. DON #1 said fall mats should not have been used because they were determined to be a risk for Resident #4's roommate. DON #1 said the urinal should have been within Resident #4's reach because Resident #4's past falls were related to toileting needs. DON #1 said if interventions were not effective or no longer needed the care plan should have been updated but was not. DON #1 said Resident #4's care plan should always be followed but was not. 43807 2.) Resident #23 was admitted to the facility in July 2024 with diagnoses including borderline personality disorder, suicidal ideations, major depression disorder and opioid abuse. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 indicating intact cognition. A review of Resident #23's behavioral health medication management progress note dated 9/4/24 indicated the following: -Chief Complaint: follow up medication/mood management: Target Symptoms: Anxiety, Depression, Tearfulness, Suicidal and Homicidal ideation (history of present illness) HPI: Problem: Resident has a history of major depressive disorder, borderline personality d/o, suicidal ideation's, opioid abuse and autism is seen for a follow up visit. He/she is here s/p hospitalization for weakness and falls; did have a laminectomy 2 weeks prior to that. Troponin was elevated but stabilized then sent to rehab. He/she has chronic back and leg pain since 2012 when his/her SI thoughts started, previously admitted to psych for it and has hx ECT treatment as well. Since 2012, his/her SI thoughts have been gradually worsening. Recently he/she asked staff to give him/her more pills so he/she would overdose. Talked about a gun with staff another time. Sent to ER last visit for worsening depression and suicidal ideation, had plans to self-harm and also harm the doctor who he/she blames for not doing his/her surgery right. Said he/she would go to garden center, buy [NAME] glove seeds/digitalis, plans to grow them, then process/ferment them, then ingest. He/she additionally reported that he/she will be finding the license plate of the doctor who did his/her surgery and turn the Dr's car into a traveling bomb. [sic] -Substance Use / Addiction History: Opiates, Marijuana. -A review of Resident #23's progress note dated 9/4/24 indicated that a Certified Nurse's Assistant (CNA) reported the Resident was playing with his/her feces and had feces smeared on his/her hand and sheet. [sic] A review of Resident #23's care plan failed to indicate a history of homicidal ideation, opiate and marijuana abuse care plan with personalized interventions was developed. The care plan also failed to indicate the Resident's feces smearing behavior with personalized interventions. Further review of the mood care plan initiated on 8/6/24 indicated Resident #23 has a history of making suicidal statements, wanting to overdose on digitalis, but failed to indicate the Resident has a history of asking staff for more pills so he/she could overdose. During an interview on 9/12/24 at 9:21 A.M., the Social Worker said the Resident has a history of suicidal ideations, homicidal ideations, smearing feces, opioid abuse and marijuana abuse. The Social Worker there should be personalized care plans developed addressing Resident #23's mood and behavior. 36797 3.) Resident #25 was admitted to the facility in August 2024 with diagnoses including end stage kidney disease, pneumonia, and fracture. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #25 scored an 11 out of 15 on the Brief Interview for Mental Status exam indicating moderately impaired cognition. Further review indicated Resident #25 required moderate assistance for most activities of daily living. Review of the physician's orders dated August 2024 and September 2024 failed to indicate a physician's order for hemodialysis. Further review indicated an order for the antidepressants Mirtazapine 7.5 mg (milligrams) daily and Fluoxetine 60 mg daily. Review of the current care plan failed to indicate complete interventions for hemodialysis, including days, times and location of treatments. Further review failed to indicate how to care for the dialysis access site. Further review failed to indicate the use of antidepressant medications. During an interview on 9/10/24, at 12:45 P.M., Nurse#4 said that there should be a care plan that includes the days, times and place the Resident is scheduled to go to dialysis as well as how to care for the dialysis access site. During an interview on 9/10/24 at 1:45 P.M. Nurse #6 said that Resident # 25 has a Central Venous Catheter (CVC) for dialysis access, and she would expect that there would be a care plan to monitor the CVC site for infection and drainage. 4.) Resident #47 was admitted to the facility in August 2024 with diagnoses including post-traumatic stress disorder (PTSD), hemiplegia and diabetes. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #47 scored a 15 out of 15 on the Brief Interview for Mental Status exam indicating intact cognition. Further review indicated Resident #47 required assistance with most activities of daily living. Review of the physician's orders dated August 2024 and September 2024 indicated the following orders: 1. Zyprexa (an anti-psychotic) 5 mg (milligrams). 2. Trazodone (an anti-depressent) 50 mg. Review of the care plan dated 8/6/24, indicated a focus for alteration/risk for alteration in mood and/or behavioral status AEB (as evidenced by)/Related to: Depression, history of suicidal ideation's, PTSD. Further review failed to indicate a care plan for psychotropic medication use. During an interview on 9/10/24 at 4:38 P.M., Director of Nursing (DON) #1 said that he was unable to locate a psychotropic medication use care plan. During an interview on 9/12/24 at 8:50 A.M., DON #1 said that the care plan should include the specific psychotropic medications used with their corresponding potential side effects, and resident specific interventions. The DON then said that the care plan was not complete.

Based on observations and interviews, the facility failed to ensure residents on two of two units experienced a homelike dining experience. Findings include: Review of the facility policy titled, Promoting/Maintaining Resident Dignity During Mealtimes, dated 3/4/24, indicated that it is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights of each resident. On 9/10/24 between 8:00 A.M., to 9:00 A.M., the surveyors observed Residents on the first floor and second floor being served hot coffee in Styrofoam cups, hot cereal was served in in Styrofoam bowls, and plastic cutlery was utilized for residents. On 9/10/24 at 12:17 P.M., the surveyor observed on the first floor 6 of 6 residents being served their lunch meals on trays in the main dining room and 5 of 6 residents being served their lunch meals on trays with plastic cups and plastic cutlery in the secondary dining area on the first floor. On 9/11/24 at 8:16 A.M., the surveyor observed on the first floor 3 of 8 residents being served their breakfast meal on trays in the dining room, 8 of 8 residents had items being served in Styrofoam bowls and Styrofoam cups. On 9/11/24 at 8:36 A.M., the surveyor observed on the second floor 7 of 7 residents being served their breakfast meal on trays in the dining room, and 7 of 7 residents had items served items in Styrofoam bowls and cups. During Resident Group meeting on 9/11/24 at 10:36 A.M., 1 of 4 residents said they think there are not enough staff to wash the plates, so the kitchen uses paper and Styrofoam products, 4 of 4 residents said they wished to be served their meals off the trays with actual dishes. During an interview on 9/12/24 at 9:39 A.M., Certified Nurse Assistant #4 said that residents complain about the food being served in Styrofoam. During an interview on 9/12/24 at 11:02 A.M., Nurse #2 said Styrofoam use on the trays is an ongoing issue because of staffing issues in the kitchen. During an interview on 9/12/24 at 8:47 A.M., the Food Service Director said that the kitchen should not be using paper and Styrofoam products during meal times. The Food Service Director said that residents should not be served their meals on trays in the dining rooms. During an interview on 9/12/24 at 12:09 P.M., Administrator #1 said that paper products and Styrofoam should not be used on resident trays. Administrator #1 said that staff should serve residents on the linens provided on tables and not on their trays during mealtime.

Based on record review and interview, the facility failed to ensure licensed nursing staff had the appropriate competencies and skill set to identify, assess, and respond to a significant change in condition, for one Resident (#53), out of a total sample of 29 Residents. Specifically, the facility failed to alert EMS of a significant change in condition for greater than two hours when Resident #53 was identified as complaining of chest pain, could not sit up independently, had elevated blood pressure (,d+[DATE]), an elevated pulse (119) and the inability to open his/her left eye. When on [DATE] Resident #53 presented with a change in condition at approximately 6:40 P.M., with symptoms including chest pain, elevated blood pressure and pulse, weakness, and the inability to open his/her left eye. Nurse #1 failed to identify and respond timely to Resident #53 when informed of the change in condition by Certified Nursing Assistant (CNA) #7. Nurse #1 notified Nurse Practitioner #1 at approximately 8:47 P.M. about the change in condition and was then instructed to send Resident #53 out emergently. EMS was called at 9:11 P.M., Resident #53 was transferred and died at the hospital. Findings include: A competency can be described as according to the Board of Registration in Nursing, 244 CMR 9.00: Standards of Conduct, a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. Resident #53 was admitted to the facility in [DATE] with diagnosis including hypertension, fall with fracture, and atherosclerotic heart disease (narrowing of the arteries close to the heart). Review of Resident #53's Minimum Data Set assessment dated [DATE] indicated he/she scored 13 out of a possible 15 indicating he/she was cognitively intact and required assistance with bathing, dressing and toileting. Review of the Facility Assessment (a document with a competency-based approach produced by the facility assessing the capability of the facility and its population) updated date of [DATE] includes the following: -The facility accepts residents with combinations of conditions that require complex care and management. -Annual Training topics include identification of resident changes in condition, including how to identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention. -Staff Competencies include resident assessment and examination, admissions assessment, skin assessment pressure injury assessment, neurological check, lung sounds, nutritional check, observations of response to treatment, pain assessment. During an interview conducted on [DATE] beginning at 7:17 A.M., Nurse #1 said she thought she needed an order to send a Resident out by 911 when Resident #53 presented with a change in condition. Nurse #1 said she was very concerned with Resident #53's vital signs and said she knew something was off when she saw his/her pupil (left eye being closed). Nurse #1 said she has never had to send a Resident out by 911 before. Nurse #1 said she had not received emergency training by the facility but was CPR certified. On [DATE] at 9:01 A.M., the Administrator handed this surveyor the Change in Condition policy and said there was no policy for a medical emergency. Review of Nurse #1's education file included an initial nursing competency assessment packet dated ,d+[DATE]. The education packet indicates the packet to be completed during initial orientation, [DATE] days after hire and annually thereafter. Topics include recognizing changes in resident acuity, report pertinent information/significant changes in a timely manner to appropriate persons with evaluation completion date of ,d+[DATE]. There was no additional education that pertained to emergency medical management or initiating a call to 911. During interviews on [DATE] at 7:21 A.M. and 11:30 A.M. the Staff Development Coordinator (SDC) said competencies are completed yearly and the topics are included in the orientation packet. The SDC said there is currently a Change in Condition policy, and the facility needs more education on emergency procedures and handling a code situation/medical emergency. The SDC said the last time any type of emergency training was completed was possibly a year ago, she said when staff got the Automatic External Defibrillator (AED) and they went over how to use it. During an interview on [DATE] at 1:43 P.M., the DON said that Nurse #1 should have called 911 immediately after assessing Resident #53's condition.

Based on record review and interview, the facility failed to protect one Resident (#53) from neglect when the Resident was reported to have a significant change in condition out of a total sample of 29 residents. Specifically, on [DATE] Nurse #1 failed to assess the medical emergency timely and call 911 immediately when the Resident was found to have chest pain, was unable to sit up, had significantly elevated blood pressure (,d+[DATE]), a high pulse rate (119) and lost the ability to open his/her left eye. Furthermore, the Nurse failed to provide ongoing monitoring and assessment of the resident's condition. Resident #53 was transferred to the hospital and admitted to the intensive care unit over two hours after the change in condition was noted, where he/she died of septic shock and pneumonia. Findings include: Review of the facility policy titled Abuse Prohibition, dated 2022, indicated The facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc. The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, and staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. Staff will refrain from all actions that could be considered abuse, mistreatment, and/or neglect. Neglect, as defined at S483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The American Nurses Association (ANA), Scope of Nursing Practice, Third Edition, indicated Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations. Resident #53 was admitted to the facility in [DATE] with diagnosis including hypertension, fall with fracture, and atherosclerotic heart disease (narrowing of the arteries close to the heart). Review of Resident #53's Minimum Data Set assessment dated [DATE] indicated he/she scored 13 out of a possible 15 indicating he/she was cognitively intact and required assistance with bathing, dressing and toileting. Review of the clinical record indicated Resident #53 was a full code and his/her own decision maker. Review of Resident #53's nursing progress note dated [DATE] indicated the following: CNA (Certified Nursing Aide) came to this nurse at approximately 7:30 P.M., stated [Resident #53] was not looking right. Went to his/her room and he/she was lying in his bed. When sat up he/she fell [sic] back across the bed. Had two CNA's straighten him/her in bed HOB (head of bed) elevated. Resident stated he/she was having chest pain across his chest. When asked if his/her pain was only in his/her chest or was it radiating anywhere, he/she stated no only his/her chest. Attempted to get vital signs, but unable to get radial B/P or pulse. Tried with regular cuff still unable to obtain either. Checked chest with stethoscope very hard to hear a heart beat. Temp was 97.2. Finally in right wrist got B/P (blood pressure) of ,d+[DATE] and pulse of 119. (Resident #53's previously documented blood pressure on [DATE] at 12:09 P.M. was ,d+[DATE]). At this time his/her left eye was closed. Asked Resident #53 to open his/her eye and he/she stated it is open but it was not. 7:45 P.M. Call placed to NP (Nurse Practitioner) covering. No call back. 8:00 P.M. Repeat call to covering service. Call back about 10 minutes. Told her scenario and she stated send him/her to ER. 8:15 P.M. Call placed to [spouse] to inform he/she was having some trouble and we were sending over to the ER for evaluation. While on phone with [spouse], NP #1 called back again on other line and asked resident code status. Told her his/her status and she stated send him out right away 911 tell them with stroke sx (symptoms). 8:30 P.M. Call 911 told them patient with stroke sx. Stayed on phone until ambulance confirmed. Then got paperwork ready for them. 8:45 P.M. EMT's arrived. Upon exam they were unable to get B/P or pulse or sats (oxygen saturation). 9:00 P.M. Ambulance arrived and got signs. Low B/P and Pulse still no sats. Checked eye that was closed and noted pupil blown and right pupil sluggish. Review of Resident #53's medical record failed to indicate any other nursing assessments were performed after the intial assessment at 7:30 P.M. Review of Resident #53's active physician orders, dated [DATE], indicated Nitroglycerin Tablet Sublingual 0.4mg give one tablet sublingually every 5 minutes as needed for Chest Pain x (times) 3 doses, if no relief, Call MD. Review of Resident #53's [DATE] Medication Administration Record (MAR), indicated Nurse #1 did not administer the Nitrogylcerin Tablet Sublingual 0.4mg when Resident #53 complained of chest pain. Review of the hospital paperwork indicated Resident #53 was admitted to the intensive care unit (ICU) on [DATE] and died hours later on [DATE] at 1:51 A.M. from septic shock and pneumonia. During an interview on [DATE] at 9:10 A.M., CNA #7 said she punched in around 6:30 P.M. on [DATE] and went right up to her assigned floor. CNA #7 said Resident #53's call light was going off when she arrived on the floor. She said Resident #53 complained of head pain and said he/she could not open one of his/her eyes. CNA #7 said she told the incoming Nurse (#1) right away around 6:40 P.M. that Resident #53 was not looking good and that she could not sit him/her up. CNA #7 said that was totally different for Resident #53 as he/she was supposed to be going home the next day. CNA #7 said the one other nurse in the building did not come to the floor to assist Nurse #1. CNA #7's statements during the interview indicate that Resident #53's change of condition was brought to Nurse #1's attention at approximately 6:40 P.M., not 7:30 P.M. as documented in the clinical record. During an interview on [DATE] at approximately 7:45 A.M., Nurse #4 said that if a nurse assesses a Resident who is a full code having an acute change in condition, they should call 911 and then inform the physician. Nurse #4 said that it can take a while to get a call back if you call an answering service to speak to a covering physician. During an interview on [DATE] at 12:42 P.M., Nurse Practitioner (NP) #1 said that she told Nurse #1 to send Resident #53 out to the hospital as he/she was exhibiting symptoms of a stroke. NP #1 said she would expect staff to contact 911 urgently and if family needed to be notified, a second staff person should contact family while someone else contacts 911. During a follow up interview on [DATE] at 12:12 P.M., NP #1 said she received the page of Resident #53's change in condition at 8:47 P.M. on [DATE]; approximately 2 hours after Nurse #1 was alerted by CNA #7. NP #1 said the report said Resident #53 was experiencing shortness of breath, chest pain, facial droop, BP ,d+[DATE], full code. NP #1 said she called Nurse #1 at 9:05 P.M. and again at 9:07 P.M. and said her order was to send Resident #53 to the Emergency Department for evaluation. NP #1 said she would expect staff to contact 911 urgently for someone who was exhibiting symptoms of a stroke. During interviews on [DATE] at 12:53 P.M., and [DATE] at 3:11 P.M., Nurse #1 said that on [DATE], a CNA (#7) told her that Resident #53 doesn't look too good. Nurse #1 said that Resident #53 was unable to hold his/her body up, his/her left eye was closed and he/she was unable to open it. Nurse #1 said she thought Resident #53 was having a stroke. Nurse #1 said that a CNA stayed with Resident #53 while she contacted the on-call and left a message, and then called again when she didn't hear back timely. CNA #7 had said that staff did not stay with the Resident but checked in on him/her. Nurse #1 said that the covering NP called back and said to send Resident #53 to the hospital because he/she was exhibiting symptoms of a stroke. Nurse #1 said she then contacted Resident #53's spouse to alert them about his/her change in condition and while she was on the phone with the spouse the NP called back a second time and again said to call 911 and send Resident #53 to the ER. Nurse #1 said that she called Resident #53's spouse before calling 911 because she wanted to make sure his/her family was aware. Nurse #1 said that she was told by the Director of Nursing (DON) that she should have sent Resident #53 to the hospital sooner. During a follow up interview on [DATE] at 7:17 A.M., Nurse #1 said she was unsure why there was such a delay to call the NP or to call 911 emergently after she assessed Resident #53. She said she was making phone calls and obtaining vital signs after she was made aware by CNA #7 that Resident #53 was not feeling well. Nurse #1 said she was unsure what nurse was the supervisor that night and said she never called the one other nurse who was in the building for help. Nurse #1 said she should have called 911 when the change in condition was first noticed and said she should not have waited to page the NP. Nurse #1 said she did not administer the Nirtoglycerin as ordered for chest pain. Nurse #1 said she did not call the one other nurse in the building for assistance during the medical emergency. Review of Nurse #1's timecard dated [DATE], indicated she punched in at 6:34 P.M. Review of CNA #7's timecard dated [DATE], indicated she punched in at 6:35 P.M. Review of Resident #53's Emergency Medical Services run report indicated 911 was called at 9:11 P.M. after the change of condition was observed hours prior. During an interview on [DATE] at 1:43 P.M., the DON said that Nurse #1 should have called 911 immediately after assessing Resident #53's condition and then notified the NP. The DON said that Nurse #1 should have contacted Resident #53's family after placing a call to 911 and not before. The DON said if the on call NP does not call back right away in an emergent situation 911 should be called right away and said not to wait for a call back order. See F726 On [DATE] at 2:25 P.M. the Administrator was provided with the Immediate Jeopardy Template.

Based on records reviewed and interviews, for one of four sampled residents (Resident #1), who was assessed as being at increased risk for falls and had a history of [REDACTED].#1's safety was maintained, when he/she was found sitting on a set of stairs past a closed alarmed safety gate, was sent to the Hospital Emergency Department for an evaluation and was diagnosed with [REDACTED]. Findings include: Review of Resident #1's medical record indicated his/her medical history included toxic [MEDICAL CONDITION], dementia with behavioral disturbance, adjustment disorder with mixed disturbance of emotions and conduct, and a history of falls. Review of Resident #1's Mood Disorder Care Plan, dated 12/11/20, indicated his/her exit seeking wandering behavior and restlessness occurred especially in the evening hours. Interventions included medication management and monitoring for mood and behavioral changes. Review of Resident #1's Elopement Risk/Wanderer Care Plan, dated 12/17/20, indicated he/she has impaired safety awareness and verbalized the desire to leave. Interventions included staff to identify pattern of wandering and intervene as appropriate. Review of Resident #1's Admission Minimum Data Set (MDS) assessment, dated 12/21/20, indicated he/she was moderately cognitively impaired, displayed wandering behaviors, required extensive assistance of one person with ambulation, used a walker as an assistive device, was unsteady without staff assistance during transitions from a seated to standing position, and was unsteady when walking. Review of Resident #1's Limited Physical Mobility related to Weakness Care Plan, dated as revised 12/23/20, indicated he/she required extensive assistance of one staff person for locomotion using the rolling walker and required a wheelchair for longer distances. Review of Resident #1's Falls Care Plan, updated on 01/05/21, indicated he/she was moved to a room close to the nursing station with improved visibility by staff, for safety. Review of Resident #1's Progress Note, dated 01/12/21, written by Nurse #1, indicated at 1:20 P.M. Resident #1 was seated in the wheelchair just outside his/her room reading a book with the over the bedside table in front of him/her. The Note indicated at 1:30 P.M., Resident #1 was no longer seated in his/her wheelchair and was immediately found sitting on the third step down from the top of the staircase, beyond the safety gate, and that the alarm was not sounding. Review of Resident #1's Progress Note, dated 01/12/21, written by the Director of Nurses (DON), indicated she was around the corner when she heard Nurse #1 say don't move, and went over, saw Resident #1 sitting on the third step down from the top of the staircase, with his/her right arm holding the railing and his/her legs straight out in front of him/her. The Note indicated the alarm to the stairway gate had not sounded. The Note indicated the alarms to both gate staircases sounded when opened and checked for function by staff. The Note indicated both she (DON) and Nurse #1 obtained Resident #1's vital signs, assessed Resident #1 to find no obvious signs of injury and no complaints of pain were voiced. The Note indicated Resident #1 was guided to an upright position with a gait belt, positioned into a wheelchair and assisted back to his/her room by staff for further. Review of Resident #1's Progress Note, dated 01/12/21 at 2:45 P.M., indicated that upon assessment, Resident #1 said he/she had slipped down the stairs, that he/she could not specify accurately the location of his/her pain, and did not know if he/she struck his/her head. The Note indicated that after returning Resident #1 to his/her room, the resident complained of dizziness, a sharp pain in his/her head and was transferred to the Hospital Emergency Department for evaluation. Review of Resident #1's Hospital Emergency Department Note, dated 01/12/21, indicated he/she sustained a ruptured right eye globe, ocular laceration and multiple left rib fractures. The Note indicated Resident #1's right eye pupil was blown (pupil is fixed and dilated) and appeared acute at this time, that without emergent ophthalmic intervention, he/she will likely lose right-sided eyesight. The Note also indicated there were acute fractures of the left 4th and 5th ribs and probable nondisplaced fractures of the left anterior 6th and 7th ribs. During an interview on 02/10/21 at 10:00 A.M., Nurse #1 said Resident #1 was at high risk for falls. Nurse #1 said on the day of the incident, Resident #1 was on 15 minutes checks for safety. Nurse #1 said although Resident #1 should not, he/she was capable of rising unassisted from the wheelchair and would walk holding the hallway railing or a bedside table, in an attempt to ambulate unassisted. Nurse #1 said on 01/12/21 when she went to conduct Resident #1's 15 minute check, he/she was not sitting in his/her wheelchair across from the nursing station, where she had seen him/her a short time prior. Nurse #1 said she noticed the unit door was open that led to the hallway, the staircases with alarmed gates, and to other resident bedrooms. Nurse #1 said no alarms had sounded. Nurse #1 said she saw Resident #1 sitting on the second or third step down from the top of the staircase. Nurse #1 said the gate to the staircase was closed. Nurse #1 said when she opened the gate, to assess Resident #1, the alarm sounded. During an interview on 01/29/21 at 11:30 A.M., Nurse #2 said Resident #1 could stand, walk relatively far, was quick and usually held onto objects. Nurse #2 said prior to the incident on 01/12/21, he had redirected Resident #1 back up the stairs and away from the staircase after being alerted by the alarmed gate sounding. Nurse #2 said on another occasion prior to the 1/12/21 incident, before he could reach Resident #1, he/she had made it safely down the staircase to the lowest steps on the first floor. Nurse #2 said although Resident #1 was unharmed during those previous incidents, the Director of Nurses (DON) was informed of those occurrences. Nurse #2 said on 01/12/21, staff assisted Resident #1 back to his/her room and found no areas of bruising or swelling. Nurse #2 said Resident #1 told him he/she felt dizzy and kept complaining of a sharp headache. Nurse #2 said Resident #1 also complained of pain on other areas of his/her the body. Nurse #2 said Resident #1 was sent to the Hospital Emergency Department for evaluation since the fall on the staircase was unwitnessed and it was unknown by staff if Resident #1 went over or under the gate. On 1/29/21 at approximately 08:15 A. M, the Surveyor and the Director of Nurses (DON) observed the metal gates located on the second floor Unit in front of the two staircases. The DON demonstrated that while standing in front of the gates, the gates only opened when pulled towards her. The DON demonstrated that with slight pressure applied to the gates, as she pulled them towards her, the alarms sounded. The DON then silenced the alarms by entering a keypad code on the wall alarm panel. The DON said the two gates to the staircases did not lock at any time and could be pulled open easily. During the observation the Surveyor noted that all residents have access to the staircase from the ground level, that there were no barriers to prevent residents from going up the stairs to the first floor landing, at which point the staircase splits off into two sets of stairs, residents can then proceed on either side of the staircase and go up the stairs to the second floor where the alarmed gates are located. During an interview on 01/29/21 at 08:15 A.M. and 12:10 P.M., the Director of Nurses (DON) said Resident #1 was a quiet exit seeker. The DON said none of the residents from the first or second floor Units, including Resident #1, were permitted to use the staircase unless they were using them for rehabilitative purposes with the appropriate staff member. The DON said residents throughout the Facility were discouraged from using the staircases and those who had wandering behaviors on either Unit were monitored by staff The DON said she was aware that Resident #1, prior to the incident on 01/12/21, had triggered the alarm by applying pressure to open the gate to the staircase, but said she was unaware that Resident #1 had walked down the stairs at any time prior to 01/12/21. The DON said she thought Resident #1 had been intercepted every time the alarmed gate sounded. During an interview on 02/11/21 at 10:15 A.M., the Maintenance Director said the main staircase led from the first floor up to a landing that split into two staircases that led to the second floor Unit. The Maintenance Director said a gate was located at the top of each staircase on the second floor Unit. The Maintenance Director said both gates were alarmed and easily pulled open toward the Unit away from the staircase. The Maintenance Director said a four digit code needed to be entered on the keypad on the wall before or once the gate was opened on the Unit to silence the alarm. The Maintenance Director said the gates were made of metal and there was a structural opening measuring approximately 22 from the floor to the bottom metal rail of the gates. The Maintenance Director said if someone tried, they could slide under the gates to bypass the alarm. The Maintenance Director said he confirmed following the incident that there were no operational issues with the gates and alarm functions.

Based on observation, record review and interview, for 1 of 14 sampled residents (Resident #8) the Facility failed to ensure that the resident did not develop an avoidable pressure ulcer after admission to the Facility, and ensure that treatment for [REDACTED]. Findings include: Resident #8 was admitted to the Facility in 5/2014, and upon admission to the Facility, he/she had no identified pressure ulcers behind his/her ears. On the morning of 7/7/14, the surveyor received a verbal report about each resident on Unit 2 from Nurse #3 . Nurse #3 said that Resident #8 was on Oxygen (O2) Therapy and that he/she had pressure ulcers behind his/her ears. On the morning of 7/7/14, the surveyor observed Resident #8 grimace when Nurse #4 assisted Resident #8 to remove his/her O2 tubing from his/her ears. At that time, the surveyor observed a blackened area under the O2 tubing on the back of the right ear of Resident #8. Clinical record review on 7/7/14, 2:15 P.M. for Resident #8 had no indication of pressure ulcers behind the ears. A nursing note dated 6/16/14 indicated that Resident #8 complained of "behind ear discomfort from cannula - lambs wool applied with good effect" The physician was not contacted, no treatment was started and there were no further nursing notes written about Resident #8's ear areas. The Admission Minimum Data Set (MDS) assessment, dated 6/11/2014 indicated Resident #8 had a Brief Interview for Mental Status (BIMS) score of 14, no pressure ulcers and was at risk of developing pressure ulcers. The resident also triggered on the MDS for O2 therapy. The Patient Weekly Skin Check Sheet for July 2014, dated, 7/1, for Resident #8 indicated "bilateral ears scabbed". Further record review indicated that the resident was alert and oriented, no further assessments of Resident #8's ears were found in his/her clinical record, no notifications made to the physician and no treatments started for Resident #8's ear areas. The surveyor observed Resident #8 in his/her room on the afternoon of 7/7/2014, 3:10pm, and asked him/her if the surveyor could look at the back of his/her ears, Nurse #4 was in the room at that time. Resident #8 agreed and began to remove his/her O2 tubing from his/her ears, Nurse #4 exited the room. The surveyor observed Resident #8 grimace as he/she removed the tubing from his/her ears. The surveyor observed a black, unopened area, approximately 3/4 inches in length, on the back of Resident #8's right earlobe, some redness was also observed on the right side of the head on the skin alongside the earlobe of Resident #8. The back of the left ear of Resident #8 was slightly red, not open, with an indentation that appeared to be from the O2 tubing. The surveyor asked Resident #8 if his/her ears hurt, he/she verbally responded that it hurt him/her when removing or putting on the O2 tubing. Review of the 6/2014 and 7/2014 treatment sheets for Resident #8 found no indication of any treatment started or being done for resident #8's ear areas. Review of the physician progress notes [REDACTED].#8 found no reference or indication of any skin issue with the ears of Resident #8. The surveyor conducted an interview with Resident #8 in his/her room on 7/8/14, 3:45 P.M.. Resident #8 was again asked by the surveyor if his/her ears hurt, Resident #8 replied "oh they hurt" The surveyor met with the Director of Nurses, Administrator and members of the facility's nursing team on 7/8/14 at 4:45 P.M. and informed them of the findings of a black area behind the right ear of Resident #8. The resident reported to the surveyor that is was painful when applying or removing the O2 tubing. The surveyor also informed the team that there was no indication of any treatments or further assessments addressing the resident's ears found in the resident's clinical records.

Based on record review and interview, for one of three sampled residents (Resident #1), the Facility failed to ensure that staff consistently transferred Resident #1 to and from his/her bed and wheelchair with two staff per the plan of care. CNA #2 said he, CNA #1, and another CNA were strong and transferred Resident #1 to and from the bed and wheelchair using a gait belt by themselves. CNA #2 said some of the nurses were aware that he transferred Resident #1 in and out of bed and from the wheelchair by himself and never told him to use 2 staff. On 5/1/13, CNA #1 transferred Resident #1 by herself from his/her bed to the wheelchair; CNA #1 heard a crackle sound in Resident #1's left arm and Resident #1 sustained a right humerus fracture. Findings include: The Record of Admission indicated that the staff admitted Resident #1 to the Facility in January 2011. The January 2013, physician orders [REDACTED]. The physician orders [REDACTED]. The plan of care, dated 1/23/12, related to Resident #1's risk for falls and left sided weakness included: pad sensors on bed and chair; left side of bed against wall; call light within reach; 2 persons (staff) for transfer activities, and educate/remind resident to request assistance prior to transfer activity. The nurse's note, dated 1/23/13, indicated that at 11:30 P.M., Resident #1 yelled out staff names. The nurse's note indicated that the evening nurse reported that Resident #1 slept all day and was now awake and yelling. The nurse's note indicated that the evening nurse gave Resident #1 prn Ativan. The nurse's note indicated that at 11:55 P.M., the nurse went to Resident #1's room. The nurse's note indicated that Resident #1 was lying on the blue matt. The nurse's note indicated that Resident #1 had no injury. The plan of care, dated 2/13/13, related to Resident #1's impaired functional mobility, included: assist of 2 staff for bed mobility and transfer activity. The Surveyor interviewed the Director of Nurses (DON) on 6/24/13, at 9:50 A.M. The DON said Resident #1 had a history of [REDACTED]. The DON said Resident #1 required extensive assist of 2 staff for transfer activities The Quarterly Minimum Data Set (MDS) assessment, completed on 3/21/13, indicated that Resident #1 had cognitive impairment, understood others, and made himself/herself understood. The MDS assessment indicated that Resident #1 was dependent on 2 staff for bed mobility and transfer activities. The MDS assessment indicated that Resident #1 was non ambulatory and dependent on the staff for locomotion and toilet use. The MDS assessment indicated that Resident #1 was incontinent of bowel and bladder functions. The MDS assessment indicated that Resident #1 had a history of [REDACTED]. The nurses' notes, dated 1/24/13 to 4/29/13, indicated that Resident #1 received prn Ativan for yelling and screaming when indicated and had no falls. The Surveyor interviewed Nurse #1 on 6/24/13, at 11:30 A.M. The Surveyor interviewed Nurse #2 on 6/24/13, at 8:00 A.M. The Surveyor interviewed Nurse #3 on 6/24/13, at 9:20 A.M. The Surveyor interviewed Nurse #4 on 6/27/13, at 10:44 A.M. The Surveyor interviewed CNA #3 on 6/24/13, at 3:10 P.M. The Surveyor interviewed CNA #4 on 6/24/13, at 8:45 A.M. The Surveyor interviewed CNA #5 on 6/24/13, at 8:56 A.M. The Surveyor interviewed CNA #6 on 6/26/13, at 9:00 A.M. Nurse #1, Nurse #2, Nurse #3, Nurse #4, CNA #3, CNA #4, CNA #5, and CNA #6 said Resident #1 was not able to weight bear on his/her left leg and required 2 staff for transfer activities. CNA #3, CNA #4, CNA #5, and CNA #6 said they used a gait belt when transferring Resident #1. CNA #3, CNA #4, CNA #5, and CNA #6 said one CNA stood on either side of Resident #1; they assisted Resident #1 to stand; Resident #1 stood and bore weight on his/her right leg, and they pivoted Resident #1 to the wheelchair or bed. Nurse #2, Nurse #3, CNA #3, CNA #4, CNA #5, and CNA #6 said they never observed anyone transfer Resident #1 to or from the bed or wheelchair without assistance from staff. Nurse #4 said although she did not observe staff transfer Resident #1 by themselves, she believed that some CNAs transferred Resident #1 by themselves when staff were not available. Nurse #4 said Resident #1's call light or alarm could not be heard by staff on some areas of Resident #1's unit. CNA #3 and CNA #6 said if the staff did not immediately meet Resident #1's request to be transferred, Resident #1 yelled, and tried to put his/her legs on the floor. CNA #3, CNA #4, CNA #5, and CNA #6 said when Resident #1 wanted to be transferred back to bed or to the wheelchair, they activated Resident #1's call light, and waited with Resident #1 until a second staff member came to the room to assist them. CNA #3, CNA #4, CNA #5, and CNA #6 said although the staff tried to respond quickly to Resident #1's call light sometimes they were with other residents and did not respond to the call light for 15 minutes. Nurse #3 said Resident #1 was inpatient and wanted the staff to immediately transfer him/her to and from the bed or wheelchair as soon as he/she yelled. Nurse #3 said the staff told Resident #1 that he/she had to wait for another staff member before transferring him/her to or from the bed or the wheelchair and Resident #1 was usually agreeable. Nurse #3 said on a few occasions, she observed Resident #1 try to get up from the wheelchair without staff assistance. CNA #2 said prior to Resident #1's fracture of the arm, he believed the staff could transfer Resident #1 with one or two staff pending Resident #1's physical ability and mood at the time of the transfer activity. CNA #2 said he, CNA #1, and another CNA were strong and transferred Resident #1 to and from the bed and wheelchair using a gait belt by themselves. CNA #2 said some of the nurses were aware that he transferred Resident #1 in and out of bed and from the wheelchair by himself and never told him to use 2 staff. CNA #2 said Resident #1 frequently yelled and tried to get out of bed or into bed by himself/herself. CNA #2 said since Resident #1's fracture of the arm, the nurse told him to transfer Resident #1 with 2 staff via lift. CNA #1 said she usually transferred Resident #1 to and from the bed and wheelchair with 2 staff. CNA #1 said on a few occasions, Resident #1 yelled, became anxious, wanted to immediately be transferred in or out of bed, and tried to get in or out of bed by himself/herself, which was not safe for Resident #1. CNA #1 said although she told Resident #1 to wait for a staff member to assist him/her, Resident #1 continued to yell, and tried to get out of bed. CNA #1 said sometimes, one CNA was on break and the other CNA and the nurse were with other residents and were not available to assist her. CNA #1 said on at least 2 occasions, prior to 5/1/13, when Resident #1 would not wait for staff assistance, she transferred Resident #1 out of bed, with the gait belt, to the wheelchair by herself and had no issue. CNA #1 said on one occasion, a nurse came in while she independently transferred Resident #1 to the wheelchair. CNA #1 said she explained Resident #1's behaviors to the nurse and the nurse did not tell her not to transfer Resident #1 by herself. Nurse #1 said on one occasion, she heard Resident #1 scream. Nurse #1 said she went to Resident #1's room and observed CNA #1 transfer Resident #1 to the wheelchair by herself. Nurse #1 said CNA #1 told her that Resident #1 was agitated and tried to transfer himself/herself to the wheelchair and would not wait for a staff member. Nurse #1 said CNA #1 had no difficulty transferring Resident #1 out of bed by herself. Nurse #1 said she told CNA #1 not to transfer Resident #1 out of bed by herself. Nurse #1 said she did not provide CNA #1 with an alternate plan if Resident #1 would not wait for another staff member to assist him/her out of bed and did not report the incident to the DON. The Accidents and Supervision to Prevent Accidents Policy indicated that the Facility was to identify, evaluate, and analyze hazards and risks. The Accidents and Supervision to Prevent Accidents Policy indicated that the Facility was to monitor the effectiveness and modify approaches when necessary. The Patient Mobility-Safety Policy indicated that the nurses were to communicate employee non-compliance regarding patient mobility to appropriate supervisor for disciplinary purposes The DON said although she was aware that Resident #1 sometimes tried to swing his/her legs out of bed, she was not aware that CNA #1 on a few occasions, transferred Resident #1 out of bed to the wheelchair due to Resident #1 not wanting to wait for another staff member. Nurse #2, Nurse #3 Nurse #4, CNA #1, CNA #2, CNA #4, CNA #5, and CNA #6 said there were 2 residents, who asked to be toileted every hour and there were other residents, similar to Resident #1, who displayed unsafe behaviors when the staff did not immediately meet their needs. Nurse #4 and CNA #1 said on 5/1/13, Resident #1's unit was busy. CNA #1 said there were a lot of call lights after dinner. The nurse's note, dated 5/1/13, indicated that Resident #1 was scheduled for an evening shower. The nurse's note indicated that Resident #1 was in bed, loudly calling out names, and attempted to fling his/her legs off the bed. The nurse's note indicated that Resident #1 disconnected the alarm plug and set off the alarm. The nurse's note indicated that the CNA went to Resident #1's room to prepare him/her for the shower. CNA #1 said at 6:45 P.M., Resident #1 yelled and said he/she needed to use the toilet. CNA #1 said she told Resident #1 that the staff were busy with other residents and she and another staff member would assist her to the shower chair as soon as possible. CNA #1 said she told Resident #1 that she would then toilet him/her, give him/her a shower, and wash his/her hair. CNA #1 said Resident #1 yelled out staff names, became agitated and tried to swing his/her legs off the bed. CNA #1 said she asked Resident #1 if he/she would wait for another staff member to assist her. CNA #1 said Resident #1 continued to scream out resident names and continued to try to get out of bed. CNA #1 said based on her past experience with Resident #1, she knew if she transferred Resident #1 to the shower chair and commode, Resident #1 would calm down and be safe. CNA #1 said she was afraid to leave Resident #1 alone to ring the bathroom light or seek help. CNA #1 said in error, she did not yell for help or activate the call light in Resident #1's room. CNA #1 said Resident #1 wore nonskid socks. CNA #1 said she told Resident #1 she would assist him/her out of bed. CNA #1 said she assisted Resident #1 to sit at the edge of the bed. CNA #1 said she placed the gait belt around Resident #1's waist. CNA #1 said Resident #1 placed his/her right arm around her neck. CNA #1 said she stood in front of Resident #1 and held the gait belt on both sides of Resident #1. CNA #1 said she assisted Resident #1 to stand. CNA #1 said Resident #1 stood on his/her right leg and his/her left arm was bent against his/her body, which was the usual place of his/her right arm. CNA #1 said as she pivoted Resident #1 to the wheelchair, she heard a crackle noise, and Resident #1's left arm flopped from the bent position downward. CNA #1 said she sat Resident #1 on the chair and called for the nurse to come to Resident #1's room. The nurse's note, dated 5/1/13, indicated that at approximately 6:45 P.M., the CNA called her to Resident #1's room. The nurse's note indicated that the CNA told her that she transferred Resident #1 to the shower chair and Resident #1's left arm made a snapping noise, and his/her arm flopped. The nurse's note indicated that Resident #1 sat in the shower chair and had no acute distress. The nurse's note indicated that Resident #1 had left arm pain. The physician order, dated 5/1/13, included: transfer to the Emergency Department (ED). The nurse's note, dated 5/1/13, indicated that the ED Physician reported that Resident #1 had a left humeral head fracture. The nurse's note indicated that the ED Physician placed a sling on Resident #1's left arm. The DON said CNA #1 told her that she transferred Resident #1 out of bed by herself instead of with 2 staff per the plan of care. .

Based on observation, record review and interview, the facility failed to provide the necessary care and services in order to control the pain of 1 Resident (#9) in a sample of 15 residents. Findings include: For Resident #9, the facility failed to adequately manage the resident's pain by not developing effective interventions to try to prevent or address the pain or evaluate the status of the resident's pain after interventions. Resident #9 was admitted to the facility on [DATE] with a new [DIAGNOSES REDACTED]. An admission minimum data set (MDS) completed on 4/5/13, indicated the resident has short and long term memory problems, moderately impaired decision making skills and needs extensive assistance with activities of daily living(ADLS). In addition, the resident had experienced pain in the last seven days. The Care Area Assessment (CAA) for pain, dated 4/5/13, indicated the resident's [DIAGNOSES REDACTED]. The resident's non-verbal indicators of pain identified were vocal behaviors (sighing, moaning, groaning, crying, etc.). In addition, the pain had an effect on the resident's mood. The resident is monitored every shift for pain and receives Tylenol every four hours as needed. The decision was made to proceed with a care plan to promote an optimal level of comfort for the resident. Review of the resident's record indicated there was no care plan developed to address the resident's pain. Review of the physician's orders [REDACTED]. Review of the medication administration record (MAR) for 4/2013 and 5/2013 indicated the resident's pain level is to be recorded every shift. Review of the MAR for 4/1/13 through 4/30/13 indicated the resident's pain level was not consistently recorded. On 14 days out of the month the resident's pain level was recorded as a "0" which meant the resident was not in any pain. For 9 days out of the month the pain level was left blank. Review of nursing notes indicated the resident experienced back pain. For example: - 4/10/13 at 5:15 A.M. "Restless, yelling, up to void. Returned to bed." The pain level documented on the MAR for the 11:00 P.M - 7:00 A.M. shift was "0", and there was no indication the resident was assessed to determine if the cause of the yelling was due to pain. - 4/10/13 at 5:40 A.M. "Continues yelling, restless...medicated with [MEDICATION NAME] 12.5 mg." The pain level documented on the MAR for the 11:00 P.M - 7:00 A.M. shift was "0", and there was no indication the resident was assessed to determine if the cause of the yelling and restlessness was due to pain. - 4/12/13 at 2:30 P.M. "Continues with restlessness, complained of back pain, Tylenol given, awaiting effectiveness. MD (medical doctor) notified via fax as he/she has chronic pain." The administration of the Tylenol as well as the resident's pain level were not documented on the MAR. - 4/14/13 (7-3) - "This AM (morning) resident was found sleeping on stomach...patient says this position is comfortable for him/her". - 4/16/13 at 2:30 P.M. "Complained of lower back pain, hot pack and Tylenol with good effect. Prior to that he/she couldn't relax." On 4/18/13, the physician ordered [MEDICATION NAME] 25 mg every four hours PRN for pain. A Pain assessment dated [DATE] indicated the resident has chronic back pain and displays nonverbal expressions when in pain including: frowning, crying, thrashing, fidgeting and irritability. The resident's pain also affects the resident's sleep. The causes of pain identified were scoliosis, muscle weakness and T7-T12 fractures. The pain increases with movement. The resident does not receive any scheduled pain medications, but does receive [MEDICATION NAME] 25 milligrams (mg) every 4 hours as needed. Further review of nursing notes indicated the following: - 4/21/13 (3-11) "Resident up in gerichair for dinnertime in the dining room. After his/her meal, the resident started to complain of back pain and rectum pain. Resident given [MEDICATION NAME] at 5:30 P.M. Resident began exhibiting unsafe behaviors trying to undress and get out of chair". - 4/24/13 at 12:30 A.M. "Restless. Medicated with [MEDICATION NAME] 12.5 mg." The pain level was not documented on the MAR. There was no indication the resident was assessed for pain, although fidgeting was identified as an indicator of pain for the resident. - 4/24/13 at 5:30 A.M. 'Up and down all night. Re-medicated with [MEDICATION NAME] 12.5 mg." The pain level was not documented on the MAR, nor was there indication the resident was assessed for pain. - 4/29/13 AT 2:30 P.M. "Out of control, yelling at staff, attempting to get out of his/her chair without assist, very weak, impulsive, lacks safety awareness. Spoke with son, may use lap buddy." The resident was not assessed for pain although the resident's symptoms were identified as nonverbal indicators of pain. Review of the MAR from 5/1/13 - 5/30/13 indicated the resident's pain level was recorded as a "0" 20 times, which meant the resident was not in any pain. Nursing notes indicated the resident continued to experience pain. For example: - 5/1/13 at 3:00 P.M. "Resident restless and calling out intermittently throughout the shift. Complained of back pain. Tylenol 650 mg given x2 this shift." There was no effect documented on the MAR or nurses notes to determine the effectiveness of the Tylenol. - 5/7/13 at 7:00 A.M. 'Restless this shift. [MEDICATION NAME] given for back pain. [MEDICATION NAME] given for anxiety." - 5/10/13 (7-3) "Medicated with [MEDICATION NAME] for back pain." There was no indication on the MAR or nurse's notes if the [MEDICATION NAME] was effective. - 5/15/13 (7-3) "Complained of back pain at 1:30 P.M. Tylenol given with good effect." - 5/19/13 (7-3) "Complained of back pain at 10:00 A.M. medicated with Tylenol with positive effect. Complained of pain again at 2:15 P.M. medicated with Tylenol with positive effect." - 5/22/13 at 3:00 P.M. "Resident complained of pain during treatment." Review of the MAR indicated the resident was not administered pain medications. - 5/23/13 (7-3) "Resident complained of lower back pain. [MEDICATION NAME] 12.5 mg given." Review of the MAR indicated pain medications were not administered to the resident at that time. - 5/24/13 at 4:00 P.M. "Resident crying, anxious 'get me out of jail', unable to redirect, keeps jumping out of bed. New order for [MEDICATION NAME] 12.5 mg now for agitation and [MEDICATION NAME] 12.5 mg daily at HS (hour of sleep)." Review of the MAR and nurse's notes indicated the resident was not assessed for pain, although the resident's symptoms were identified as indicators of pain. - 5/25/13 (3-11) "Resident very anxious, calling out often help or hello. Crying for no apparent reason. Redirection incredibly difficult. Complained of the "worst back pain I ever felt in my life'. Tylenol at 3:30 P.M. and 8:00 P.M.. [MEDICATION NAME] at 4:30 P.M. and 9:00 P.M...spoke with son at length regarding resident's behavioral issues and severe anxiety. Son voiced possibility of obtaining an antianxiety medication." The resident's pain level was not recorded on the MAR for the 3:00 P.M.- 11 P.M. shift. - 5/26/13 93-11) "Resident complained of back pain. [MEDICATION NAME] and Tylenol administered with good effect." - 5/28/13 (7-3) "Resident anxious yelling 'hello' and banging on tables at 8:00 A.M. [MEDICATION NAME] given with good effect. Resident complained of terrible back pain. [MEDICATION NAME] given with positive effect." The physician's progress notes from 03/2013 to 05/2013 were reviewed and made no mention of the resident's back pain. On 5/30/13 at 3:35 P.M., the resident was observed lying in his/her bed. At that time, the surveyor asked the resident how he/she was feeling. The resident stated he/she had a bad night last night. The resident stated the back pain feels like "bones are shooting out of his/her back like electric shocks" and there is "pressure on his/her lower back." The resident stated "it was really acting up last night." Review of the MAR indicated the resident did not receive pain medications on 5/29/13 or 5/30/13. On 5/30/13 at 4:00 P.M., the surveyor interviewed the Assistant Director of Nurses (ADON) about the resident's back pain. When asked if the resident may benefit from a scheduled pain regime to help manage the resident's pain, the ADON stated "that's a good idea." On 5/30/13 at 5:00 P.M., during a discussion with the Director of Nurses, she stated she would have a discussion with the physician about the management of the resident's back pain.

Based on record review and staff interview, the facility failed to develop a comprehensive care plan for 1 Resident (#9) from a sample of 15 residents. Findings are: For Resident #9, the facility failed to develop a comprehensive care plan with effective interventions to keep the resident as pain free as possible. Resident #9 was admitted to the facility on [DATE] with a new [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) completed on 4/5/13, indicated the resident has short and long term memory problems, moderately impaired decision making skills and needs extensive assistance with activities of daily living(ADLS). In addition, the resident had experienced pain in the last seven days. The Care Area Assessment (CAA) for pain, dated 4/5/13, indicated the resident's [DIAGNOSES REDACTED]. The resident's non-verbal indicators of pain were identified as vocal behaviors, (sighing, moaning, groaning, crying, etc.) In addition, the pain had an effect on the resident's mood. The resident is monitored every shift for pain and receives Tylenol every four hours as needed. The decision was made to proceed with a care plan to promote an optimal level of comfort for the resident.. Review of the resident's record indicated there was no care plan to address the resident's pain, although the resident was identified as having pain and the CAA stated the facility would proceed to develop a care plan for pain. On 5/30/13 at 4:00 P.M., the surveyor interviewed the Assistant Director of Nurses (ADON). The ADON stated she was not aware that a care plan for pain had not been developed. On 5/30/13 at 5:00 P.M., during a discussion with the Director of Nurses (DON), she stated she was not aware a care plan was not developed in the area of pain for this resident, who was continuously experiencing back pain. (See F309).