Every finding on record at The Massachusetts Veterans Home at Chelsea

Based on observations, interviews, policy review and record review, the facility failed to maintain a safe environment for three Residents (#31, #52, and #45) out of 25 total sampled residents. Specifically,1.) for Resident #31, the facility failed to provide fall mats in accordance with the physician's order. 2a.) For Resident #52, the facility failed to ensure staff stored the Resident's smoking materials in a locked area.2b.) For Resident #45, the facility failed to re-evaluate Resident's ability to safely maintain his/her own smoking materials after staff noted half burned cigarettes stored directly on his/her desk and was issued two smoking violations. Findings include: 1.) Review of the facility policy titled, Falls Prevention, dated as last reviewed 5/27/25, indicated to ensure that the safety and health of the resident veteran is protected by establishing a consistent and thorough assessment of resident veteran risk for falls and associated injuries, monitoring and assessment post-fall, and implementing individualized interventions to prevent falls. Resident #31 was admitted to the facility in July 2025 with diagnosis including Huntington's disease (progressive genetic disorder that causes the degeneration of nerve cells in the brain, leading to movement disorders, cognitive decline, and emotional disturbances) and hypotension. Review of Resident #31's most recent Minimum Data Set (MDS) assessment, dated 8/5/25, indicated he/she had a severe cognitive impairment as evidenced by a BIMs assessment score of 3 out of 15. This MDS indicated Resident #31 was dependent on staff for transfers and bed mobility and he/she had one fall with injury within the past two to six months. On 9/16/25 at 10:08 A.M., the surveyor observed Resident #31 in bed. He/she was laying at the bottom of the bed, and his/her legs were dangling off the footboard of the bed. Resident #31 had two upper side rails and one lower side rail in the up position. There were no fall mats on either side of his/her bed. Review of Resident #31's physician's orders, dated 8/12/25, indicated: -Other Equipment Order- at Bedtime, bilateral fall mats beside bed. Review of Resident #31's plan of care related to falls, dated as 7/30/25, indicated Resident #31 had a history of falls. Review of Resident #31's nurse practitioner note, dated 7/29/25, indicated: 7. fall risk: per family at home, he/she would slither off of the bed and land on the floor / they had recently put side rails in place/ we will start with padded 1/2 rails as per staff (4 rails considered a restraint) put pads beside bed. Review of Resident #31's nurse practitioner note, dated 8/12/25, indicated: -continue with total care/ staff has suggested bedside mats which I will order. On 9/17/25 at 7:01 A.M., 9/18/25 at 6:58 A.M., and on 9/19/25 at 7:06 A.M., the surveyor observed Resident #31 in bed, there were no fall mats on either side of the bed. During an interview on 9/17/25 at 3:53 P.M., Certified Nurse Assistant (CNA) #3 said that Resident #31 does not use fall mats beside the bed. During an interview on 9/18/25 at 7:01 A.M., CNA #4 said she had just finished the overnight shift (11:00 P.M. to 7:00 A.M.) she said that Resident #31 does not use floor mats. During an interview on 9/18/25 at 9:45 A.M., CNA #1 said that Resident #31 does not use fall mats. Durning an interview on 9/19/25 at 7:14 A.M., Nurse #2 said that she just finished the overnight shift, and she said that Resident #31 doesn't use fall mats During an interview 9/19/25 at 8:40 A.M., the Veterans Care Coordinator (VCC) #1 said that Resident #31 doesn't have fall mats. On 9/19/25 at 9:13 A.M., the surveyor along with VCC #1 reviewed the electronic health record and she said that nursing is documenting the fall mats as implemented during the day shift, and she said she was unsure why the day shift would be documenting the fall mats. VCC #1 and the surveyor were unable to locate any fall mats in Resident #31's room. During an interview on 9/19/25 at 9:46 A.M., the Director of Nursing said that nursing should implement Resident's floor mats for fall prevention. 2. Review of the facility policy titled Resident Smoking – Smoke Free Facility, dated 8/23/24, indicated: -A facility-wide Smoke Free Facility Policy was initiated on October 1, 2023. This change did not affect facility residents who were smokers as of that date. 1. As of October 1, 2023, the facility is a smoke, tobacco, and marijuana products free property. 10. Residents who smoke will be further assessed, using the 'Resident Safe Smoking Assessment', to determine whether or not safety interventions, which may include supervision, is required for smoking, or if resident is safe to smoke at all. 12. All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers responsible for supervising residents while smoking. Supervision will be provided as indicated on each resident's care plan. 14. If a resident or family does not abide by the smoking policy or care plan, the plan of care may be revised to include additional safety measures up to and including discharge from the facility. 15. All smoking materials of residents requiring supervision with smoking will be maintained by nursing staff. 17. The interdisciplinary team will help to support the resident's right to make an informed decision regarding smoking by: d. developing a safe smoking plan. 2a. Resident #52 was admitted to the facility in May 2024 with diagnoses including nicotine dependency. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/4/25, indicated Resident #52 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS also indicated Resident #52 actively used tobacco. Review of Resident #52 most recent Safe Smoking Assessment, dated 7/29/25, indicated: -He/she may maintain own smoking materials (per facility policy): No -He/she must request smoking materials from staff: Yes -He/she must be supervised by staff, volunteer or family member at all times when smoking: Yes Review of Resident #52's plan of care regarding smoking privileges, dated 5/13/25, indicated: -Escort by staff for time off unit. Review of Resident #52's ADL Fact Sheet, dated 9/19/25, failed to indicate if Resident could maintain his/her own smoking materials. This ADL Fact Sheet indicated: -Escort patient outside to smoke every 4 hrs. on 7 to 3 and 3 to 11. On 9/16/25 at 10:03 A.M., the surveyor observed cigarettes in Resident #52's room on his/her rolling bedside table. On 9/17/25 at 9:23 A.M., the surveyor observed cigarettes and a lighter in front of Resident #52 on his/her rolling bedside table. Resident #52 said he/she needed supervision with smoking but was allowed to keep his/her cigarettes and lighter in his/her room. On 9/19/25 at 8:31 A.M., the surveyor observed cigarettes and two lighters in front of Resident #52 on his/her rolling bedside table. Resident #52 said he just came back from a supervised smoke break. During an interview on 9/17/25 at 12:34 P.M., Social Worker #3 said Resident #52 required supervision while smoking. During an interview on 9/19/25 at 7:50 A.M., Certified Nurse Assistant (CNA) #5 and CNA #6 said Resident #52 requires supervision with smoking but can maintain his/her own smoking materials in the room. During a follow-up interview on 9/19/25 at 7:58 A.M., CNA #5 said staff would find safety measures required for smoking, such as supervision, on each residents ADL Fact Sheet. The surveyor observed Resident #52's ADL Fact Sheet with CNA #5, who said it indicated staff needed to escort patient outside to smoke every 4 hrs. on 7 to 3 and 3 to 11. CNA #5 said the ADL fact sheets never indicate information regarding each resident's ability to maintain smoking materials in their room, but the nurses would tell the CNAs if any resident could not. CNA #5 said she was never told that Resident #52 could not keep smoking materials in his/her room. During an interview on 9/19/25 at 8:51 A.M., Nurse #3 said Resident #52 required the nurse to lock up his/her smoking materials and should not have smoking materials in his/her room. Nurse #3 said she was unaware of the facility smoking policy, the process for determining if a resident was safe to smoke, or where information would be located indicating any safety interventions, such as supervision required, or how these safety interventions were communicated to staff. During an interview on 9/19/25 at 9:34 A.M., the Director of Nursing (DON) said only independent smokers can maintain their own smoking materials. The DON said Resident #52 required the nurse to lock up his/her smoking materials and should not have smoking materials in his/her room. During an interview on 9/19/25 at 11:47 A.M., Veteran Care Coordinator (VCC) #2 said Resident #52 required the nurse to lock up his/her smoking materials and should not have smoking materials in his/her room. VCC #2 further said it is the facility policy that any resident who requires supervision with smoking must have his/her smoking materials locked up by nursing. 2b. Resident #45 was admitted to the facility in January 2024 with diagnoses including diabetes and a history of substance abuse. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/15/25, indicated Resident #45 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. On 9/16/25 at 9:51 A.M., the surveyor observed greater than 50 cigarettes that were half-burned stored directly on the desk surface with a significant amount of ash-like substance surrounding them. There were also two clear plastic bottles filled with half-burned cigarettes and two lighters on the Residents bedside table. During an interview on 9/18/25 at 12:30 P.M., Resident #45 said he/she had received multiple smoking citations from security, but nothing ever happens. Review of Resident #45's plan of care relating to smoking, dated 6/16/25, indicated: -He/she should give cigarettes and lighter to charge nurse when he/she returns to the unit. Review of Resident #45 most recent Safe Smoking Assessment, dated 7/12/25 (after care plan referenced above), indicated: -He/she may maintain own smoking materials (per facility policy): Yes -He/she must request smoking materials from staff: No -He/she must be supervised by staff, volunteer or family member at all times when smoking: No During an interview on 9/17/25 at 8:45 A.M., the surveyor and Certified Nurse Assistant (CNA) #5 observed greater than 50 cigarettes that were half-burned stored directly on the desk surface with a significant amount of ash-like substance surrounding them, two clear plastic bottles filled with half-burned cigarettes, and two lighters. CNA #5 said Resident #45 can manage all his/her own smoking material and it's usually stored like that. CNA #5 said she never notified anyone about how it's stored because he/she maintains his/her own smoking materials. During an interview on 9/17/25 at 8:47 A.M., the surveyor and CNA #7 observed greater than 50 cigarettes that were half-burned stored directly on the desk surface with a significant amount of ash-like substance surrounding them, two clear plastic bottles filled with half-burned cigarettes, and two lighters. CNA #7 said she sees that all the time in his/her room. CNA #7 said he maintains his own smoking materials and smokes by himself/herself outside. CNA #7 said staff isn't concerned that he/she smokes in his/her room but will bring half smoked cigarettes back inside. CNA #7 said she never notified anyone about how it's stored because he/she maintains his/her own smoking materials. During an interview on 9/17/25 at 9:14 A.M., the surveyor and Nurse #4 observed greater than 50 cigarettes that were half-burned stored directly on the desk surface with a significant amount of ash-like substance surrounding them, two clear plastic bottles filled with half-burned cigarettes, and two lighters. Nurse #4 said she never notified anyone about how it's stored because he/she maintains his/her own smoking materials. During an interview on 9/17/25 at 9:38 A.M., the surveyor and the Director of Nursing (DON) observed greater than 50 cigarettes that were half-burned stored directly on the desk surface with a significant amount of ash-like substance surrounding them, two clear plastic bottles filled with half-burned cigarettes, and two lighters. The DON said she was not aware the Resident was storing smoking materials this way, but it should not be stored this way. During an interview on 9/17/25 at 10:33 A.M., Security Specialist #1 they last issued a smoking citation to Resident #45 two months ago. Review of the facilities report titled Public Safety Smoking Citation Report, dated August 2025, indicated: -Two smoking citations were issued to Resident #45, one on 8/1/25 and another on 8/6/25. During an interview on 9/19/25 at 10:48 A.M., The Superintendent said there is no policy for the citations, but the expectation is that when a Resident is discovered violating the smoking policy then security should be notified to issue a citation. They said the citations should be sent to the clinical managers to review with the IDT to decide on what the next step is. They said in morning meetings the team goes over security incidents/citations and address the concern at that time. They said they are usually present for this meeting. They both said they do not remember ever being notified of Resident #45's smoking citations or smoking material concerns in the month of August but would check the morning minute meeting to confirm. The Superintendent and Deputy Superintendent said they were not notified of the smoking violations and storage concerns but should have been so it could have been addressed. Review of the document titled Morning Meeting Matrix', dated 8/1/25 to 8/8/26, failed to indicate Resident #45's smoking citations or concerns were discussed. On 9/19/25 at 12:58 P.M., the surveyor attempted to contact the clinical manager responsible for Resident #65 and left a voicemail. The clinical manager did not return the surveyor's telephone call. Review of Resident #45's medical record fails to indicate Resident's ability to smoke and manage smoking materials was addressed or re-evaluated after smoking citations were issued on 8/1/25 or 8/6/25 according to facility smoking policy.

Based on interviews and records reviewed, the facility failed to ensure staff developed and implemented a comprehensive person-centered care plan for one Resident (#29) out of 25 total sampled residents. Specifically, for Resident #29, nursing failed to consistently implement the Resident's left hand palm guard and buddy loop finger splint to his/her right 4th and 5th digits (fingers). Findings include: Review of the facility policy titled Care Planning, dated 12/18/23, indicated:-The facility will develop and implement a plan for each resident that includes the instructions needed to provide effective and person-centered care of each resident that meets professional standards of quality care. Resident #29 was admitted to the facility in October 2023 with diagnosis cerebral infarction, diabetes, and depression. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/10/25, indicated that Resident #29 had a moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. This MDS indicated Resident #29 was dependent on staff for upper body dressing and he/she had an upper body range of motion impairment on both sides. The MDS indicated that Resident #29 did not reject care. During an interview on 9/16/25 at 10:04 A.M., Resident #29 was in his/her bed. The surveyor observed a palm guard on Resident #29's bedside table. There were no devices on his/her right hand. Resident #29 said that staff don't always remember to apply it (the palm guard), and I need to remind them. Review of Resident #29's physician's orders, dated 10/1/24, indicated: -Splint twice daily, apply palmer guard to left hand, on at 9:00 P.M., and remove at 9:00 A.M. Remove splint daily to assess skin. Review of Resident #29's physician's orders, dated 12/3/24, indicated:-Splint every shift, apply buddy loop finger splint to Right 4th and 5th digits, keep on at all times, remove daily to assess skin. Change position of buddy loop daily. Review of Resident #29's plan of care related to flexor contracture to the digits, dated 4/5/25, indicated: -Left palmar guard can be worn overnight, applied by nursing.-Right buddy loop splint can be applied by nursing to right D4 (ring finger) and D5 (little finger) fingers and can be worn at all times, removed during ADL care. Review of Resident #29's occupational therapy note, dated 4/3/25, indicated, -Resident continues to use the buddy loop for right D4 and D5 finger. States he/she uses left palmar guard when he/she remembers and/or when staff assist him/her with applying hand splint. Review of Resident #29's occupational therapy note, dated 6/2/25, indicated:-Late entry: request from nursing received to discuss buddy loop splint use with resident. Resident had expressed consideration in not using finger splint further, but post education provided by therapist re: purpose and rationale for splint use, he/she agreed to continue with use. Update shared with nursing this date. Review of Resident #29's occupational therapy note, dated 7/8/25, indicated: -Resident continues to use the buddy loop for right D4 and D5 finger. States he/she uses left palmar guard when he/she remembers and/or when staff assist him/her with applying hand splint. On 9/17/25 at 7:09 A.M., the surveyor observed Resident #29 was not wearing his/her left palm guard and he/she was not wearing right finger loop buddy. On 9/17/25 at 4:40 P.M., the surveyor observed Resident #29 was not wearing his/her right-finger loop buddy. On 9/18/25 at 7:06 A.M., the surveyor observed Resident #29 was not wearing his/her left palm guard and he/she was not wearing right finger loop buddy. On 9/18/25 at 4:45 P.M., the surveyor observed Resident #29 was not wearing his/her right-finger loop buddy. On 9/19/25 at 7:07 A.M., the surveyor observed Resident #29 was not wearing his/her left palm guard and he/she was not wearing right finger loop buddy. During an interview on 9/19/25 at 8:49 A.M., Certified Nursing Assistant #1 said that Resident #29 has not used the right-hand loop buddy in a while. During an interview on 9/19/25 at 7:15 A.M., Nurse #2 said that Resident #29 wears something on his 4th and 5th fingers sometimes and he/she will take it off and staff need to encourage use. Nurse #2 said that Resident #29 does not wear any devices on his/her left hand. During an interview on 9/19/25 at 8:41 A.M., the Occupational Therapist said that nursing should be offering and applying Resident #29's left palm guard and right-hand loop buddy. During an interview on 9/19/25 at 8:46 A.M., Veterans Care Coordinator (VCC) #1 said that nursing should be applying Resident #29's left palm guard during the night and removing according to the physician's orders and care plan. VCC #1 said that that if Resident #29 refuses the left palm guard this should be documented as refused in the medical record and the right-hand loop buddy should be documented as refused. VCC #1 reviewed the documentation and said that nursing was documenting the right buddy loop as applied and she was unable to find documentation to support that Nursing was applying the left palm guard. VCC #1 and the surveyor searched for Resident #29's right finger buddy loop and were unable to locate the buddy loop. During an interview on 9/19/25 at 9:48 A.M., the Director of Nursing said that nursing should implement Resident #29's plan of care for contracture management and apply the left palm guard and right finger loop buddy.

Based on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments for one Resident (#65) out of a 25 total sampled residents. Specifically, the facility failed to ensure Resident #65's neuriva capsules (a brain health supplement) were not stored unlocked at bedside. Findings include:Review of the facility policy titled Bedside Medication Storage and Self Administration of Meds, dated 12/18/23, indicated:-Procedures: A written order for the bedside storage of medication is present in the resident's medical record. -Procedures: Bedside storage of medication is indicated on the resident medication administration record (MAR) and in the care plan for appropriate medications. Resident #65 was admitted to the facility in January 2024 with diagnoses including quadriplegia (a condition where all four limbs experience paralysis). Review of the most recent Minimum Data Set (MDS) assessment, dated 7/1/25, indicated Resident #65 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. On 9/16/25 at 9:25 A.M. and 9/19/25 at 7:36 A.M. and 9:16 A.M., the surveyor observed three bottles of neuriva capsules on Resident #65's bedside table. On 9/16/25 at 9:27 A.M., Resident #65 said the nurse administers the neuriva capsules to him/her and does not self-administer because he/she is quadriplegic. Review of Resident #65's physician's order, initiated 7/4/25, indicated: -Patient Own Medication: Give (1 each) by mouth, Daily Medication Name: NEURIVA ORIGINAL BRAIN PERFORMANCE CAPSULES MAY TAKE OWN SUPPLY NOT SUPPLIED BY PHARMACY. Review of Resident #65's physician's orders failed to indicate a written order for bedside storage of neuriva capsules. Review of Resident #65's resident medication administration record (MAR) and care plan failed to indicate any information regarding bedside storage of neuriva. During an interview on 9/19/25 at 9:01 A.M., Certified Nurse Assistant (CNA) #8 and CNA #9 said Resident #65 keeps the bottles of neuriva capsules on his/her bedside table, but the nurse administers them. During an interview on 9/19/25 at 9:08 A.M., Nurse #5 said Resident #65 is quadriplegic and cannot take the neuriva capsules himself/herself. Nurse #5 said Resident #65 always keeps the neuriva capsules on his/her bedside table. Nurse #5 said Resident #65 did not have a physician's order to store the neuriva capsules at bedside. Nurse #5 said she was not sure if it needed to be locked because it's always just been on his/her bedside table. During an interview on 9/19/25 at 9:32 A.M., the Director of Nursing (DON) said the physician's order that Resident #65 may take own supply not supplied by pharmacy meant the Resident may order his/her own medication but should be locked in the medication cart with labeled with his/her name. The DON said Resident #65's neuriva capsules should not have been stored unlocked at bedside.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who had a history of combativeness and resistance with care, the Facility failed to ensure staff consistently implemented interventions identified in his/her plan of care, which indicated when Resident #1 refused care that staff shouldn't force him/her, but instead should reapproach him/her when he/she is more accepting of care. On 06/17/25, although Resident #1 told staff to leave his/her feet alone, exhibited combative behavior during foot care, staff continued with care and did not implement interventions to return later.Findings include: Review of the Facility's Care Planning Policy, dated 12/15/23, indicated that the Facility will develop and implement a plan for each resident that includes the instructions needed to provide effective and person-centered care of the residents that meets professional standards of quality care. Resident #1 was admitted to the Facility in January 2024, diagnoses included cognitive social or emotional deficits, cardiovascular disease, type 2 diabetes mellitus, hypertension, hyperlipidemia, and dementia. Review of Resident #1's most recent Quarterly Minimum Data Set (MDS), from 04/2025, indicated he/she was significantly cognitively impaired and had an invoked Health Care Proxy (HCP). Further review of the MDS Assessment indicated that Resident #1 exhibited behavioral symptoms that included rejecting care, which occurred on one to three days during the seven-day assessment period. Review of Resident #1's Activities of Daily Living (ADL's) Care Plan, reviewed and renewed with his/her 04/15/25 MDS, indicated that Resident #1 had a self-care deficit related to history of left extremity weakness and required assistance with activities of daily living. The ADL's Care Plan interventions indicated Resident #1 should be provided with foot/nail care, nails needed to be filed, and nail edges needed to be smoothed, to refer to a Podiatrist as necessary. Additional Interventions also indicated that Resident #1 has the right to refuse, if he/she refuses care, maintain safety and reapproach. During an interview on 07/29/25 at 2:00 P.M., the Charge Nurse said that Resident #1 has a history of rejecting and being combative with care and that it always takes two, sometimes three, staff members to provide care to him/her. The Charge Nurse said one of Resident #1's care plan interventions included to reapproach him/her multiple times if he/she refused care and to notify the provider. The Charge Nurse said since Podiatry was in the facility, there was no time to reapproach that day and she made the decision to have the Podiatrist see him/her. Ther Charge Nurse said Resident #1's toenail/foot care was essential, because he/she was a diabetic, his/her toenails were jagged and imbedded and that made it difficult for Resident #1 to be able wear shoes, which he/she needed to wear since he/she liked to propel him/herself in a wheelchair. During an interview on 07/29/25 at 12:53 P.M., the Assistant Director of Nursing (ADON) said Resident #1's ADL Care Plan addressed goals and interventions related to him/her rejecting care. The ADON said the Charge Nurse knew that Resident #1 was refusing podiatry care, and she should not have forced him/her to accept the treatment but instead should have sought out assistance from leadership for alternative care. The ADON said the Charge Nurse was educated to seek out help from the providers and nursing leadership when residents demonstrate noncompliance in accepting care.

Based on records reviewed and interview, for one of three sampled residents, (Resident #1) who had a history of being resistant and combative during care, the facility failed to ensure he/she was free from the use of physical restraint, when on 6/17/25, while Resident #1 was receiving foot care from the podiatrist, the Charge Nurse laid across his/her lap/leg area to prevent him/her from moving during the procedure.Findings include:Review of the Facility Policy titled Restraints and Safety Devices, dated 11/03/23, indicated physical restraints are used only after assessment by the Interdisciplinary Team (IDT), when an alternative to restraints has been determined to be ineffective by the IDT members, and when absolutely necessary to ensure the safety of the Veteran or others. Resident #1 was admitted to the Facility in January 2024, diagnoses included cognitive social or emotional deficits, cardiovascular disease, type 2 diabetes mellitus, hypertension, hyperlipidemia, and dementia.Review of Resident #1's Quarterly Minimum Data Set (MDS) indicated he/she was significantly cognitively impaired and had an invoked Health Care Proxy (HCP). Review of the Facility's Internal Investigation Report, dated 06/18/25, indicated that the Certified Occupational Therapist Assistant (COTA) reported to his supervisor that he was asked to assist with securing Resident #1 while he/she was receiving footcare by the Podiatrist, because Resident #1 has a history of becoming combative during care. The Investigation Report indicated that the COTA reported that he felt uneasy with the method being used because it limited Resident #1's mobility during the process of receiving podiatry care. During an interview on 07/29/25 at 1:31 P.M., the Certified Occupational Therapy Assistant (COTA) said that on 06/17/25, he was asked by the Charge Nurse, who was assisting the Podiatrist in providing treatment for Resident # 1, to hold his/her right hand. The COTA said his understanding was that he was to hold Resident #1's hand gently and distract him/her with calming words. The COTA said he held Resident #1's right hand as the Charge Nurse gently laid over his/her lap/legs and held Resident #1's left hand.The COTA said during the care session (which took about 5 to 10 minutes) the Podiatrist cut multiple toenails, and that Resident #1 verbally requested numerous times for his/her feet to be left alone while the Charge Nurse was across his/her lap/legs. The COTA said he felt uncomfortable with the way we were limiting Resident #1's mobility during the process of podiatry care. The COTA said if the Charge Nurse had told him that Resident #1 had been refusing podiatry care and the only method to use to get it done was to restrain him/her, that he would not have assisted them. During an interview on 07/29/25 at 2:00 P.M., the Charge Nurse said that Resident #1 had a history of agitation with personal contact and had been refusing to see the Podiatrist for the past six months. The Charge Nurse said on 06/17/25, Resident #1 was not on the list for the Podiatrist for that day, but she asked the Podiatrist to see him/her. The Charge Nurse said she saw the COTA walking by, and she asked him for assistance. The Charge Nurse said Resident #1 needed podiatry care since he/she was diabetic and had ingrown toenails. The Charge Nurse said she made the decision for Resident 1 to have podiatry care that day. The Charge Nurse said that she laid over the knees of Resident #1, as he/she was refusing, kicking, and combative during care. The Charge Nurse acknowledged that her approach was wrong and said she should have discussed it with the physician to send Resident #1 out of the hospital to have podiatry care. During an interview on 07/29/25 at 2:30 P.M., Certified Nurse Aide (CNA) #1 said on 06/17/25, his job that day was to assist the Podiatrist in positioning residents' feet at a right angle and stay on same side of the foot with the Podiatrist. CNA #1 said the Charge Nurse was holding Resident #1's left hand and the COTA was holding his/her right hand, and immediately Resident #1 became agitated. CNA #1 said the Charge Nurse laid across Resident #1's knees gently. CNA #1 said Resident #1 verbally requested multiple times for his/her feet to be left alone. CNA #1 said that Resident #1 was yelling, Leave me alone, stop. CNA #1 said Resident #1 was forced to receive the care, it was not his/her choice. During an interview on 07/29/25 at 3:17 P.M., the Deputy Executive Director (DED) said the Charge Nurse admitted to laying across Resident #1 to keep him/her from moving. The DED said the Charge Nurse said that Resident #1 was yelling, refusing care, and that Charge Nurse had referred to the incident as a lapse in judgment

Based on observation, interviews, and record review, the facility failed to ensure prescribed medications were secured in locked compartments or under proper supervision for two Residents (#31 and #7) out of 26 total sampled residents. Specifically: 1.) For Resident #31, the nurse left two pills at bedside without proper supervision. 2.) For Resident #7, the nurse left topical prescription medication at bedside without proper supervision. Findings include: Review of the facility policy titled Medication Storage and Security, revised 9/26/22, indicated: - It is the policy of the facility that medications be kept secure. - Medications being administered must be under constant surveillance. - Medications removed from a medication storage area must always remain with the individual and are not to be left unattended. Review of the facility policy titled Bedside Medication Storage and Self Administration of Meds, revised 10/24/23, indicated: - Bedside storage of medications is indicated on the resident medication administration record (MAR) and in the care plan for the appropriate medications. 1.) Resident #31 was admitted to the facility in June 2024 with diagnoses including legal blindness and osteoarthritis. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/14/24, indicated Resident #31 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. Review of Resident #31's assessment titled Patient/Resident Assessment of Ability to Self-Medicate, dated 6/20/24, indicated Resident #31 was not safe to self-administer medications. Review of Resident #31's medical record, including MAR and care plan, failed to indicate Resident #31 could store any medications at bedside. On 10/7/24 at 10:20 A.M., the surveyor observed Resident #31 with two blue pills in a medication cup beside his/her breakfast tray. There was no nurse within view of the Resident. Resident #31 said he/she doesn't like to take them all at once, so the nurse sometimes leaves medication to take later. During an interview on 10/7/24 at 10:29 A.M., Nurse #2 said he left Resident #31's pills before he/she took all of them. Nurse #2 said he should not have left the pills because Resident #31 required constant supervision until all his/her pills were taken. During an interview on 10/8/24 at 1:20 P.M., Nurse #3 said no medications should be left at bedside unless the Resident was assessed to be safe for the ability to self-administer the specific medication and had a physician's order to store the specific medication at bedside. During an interview on 10/9/24 at 9:59 A.M., the Director of Nursing (DON) said Nurse #2 should not have left pills unattended at bedside if he was out of view of the Resident. 2.) Resident #7 was admitted to the facility in October 2023 with diagnoses including hypertension and back pain. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/30/24, indicated Resident #7 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Review of Resident #7's physician's order, initiated 10/18/23, indicated: - Lidocaine 5% patch (a topical prescription medication), 1 patch, apply to right shoulder. - Lidocaine 5% patch, 1 patch, apply patch to lumbar spine. Review of Resident #7's medical record, including MAR and care plan, failed to indicate the Resident could self-administer medications or have any medications stored bedside. On 10/7/24 at 9:08 A.M. and 9:33 A.M., the surveyor observed two Lidocaine patches, which were opened and dated 10/7/24, with the plastic protector intact on the back on Resident #7's bedside table. During an interview on 10/9/24 at 8:50 A.M., Nurse #2 said he left the Lidocaine patches at bedside, but he should not have. During an interview on 10/8/24 at 1:14 P.M., Nurse #4 said he cares for Resident #7 frequently and there is no reason Lidocaine patches should have been left at his/her bedside. During an interview on 10/8/24 at 1:20 P.M., Nurse #3 said no medications should be left at bedside unless the Resident was assessed for the ability to self-administer the specific medication and had a physician's order to store the specific medication at bedside. During an interview on 10/9/24 at 9:59 A.M., the Director of Nursing (DON) said Lidocaine patches should never had been left at bedside.

Based on record review and interview, the facility failed to provide appropriate behavioral health services for 1 Resident (#40) out of a total sample of 26 residents. Findings include: Review of the facility policy titled Behavioral Management, revised 9/23/23, indicates the following: - The Massachusetts Veterans Home will maintain an interdisciplinary Behavioral Management Committee (BMC) designed to identify, intervene, and monitor isolated and ongoing behavioral events occurring within the facility. - Committee members will intervene as described below when behavioral events occur and will document all assessments and changes in designated sections of resident's medical record. - If psychotherapy is indicated, LICSW (licensed social worker) assessing the resident to determine the type of therapy, frequency, and duration of services recommended. - Documenting intervention and outcome in psychosocial section of the medical record, care plan, and ensuring this is reflected in the Minimum Data Set (MDS). Resident #40 was admitted in February 2024 with diagnoses including psychiatric disorder and depression. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #40 scored an 8 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. Review of the current care plan for Resident #40, initiated 10/7/21, indicated the following: - Resident has a history of major depressive disorder and suicide ideation evidenced by self-report, discussion, chart review and reports from the interdisciplinary team. - When suicide ideation behavior witnessed, call clinician and/or social worker to evaluation for risk and subsequent interventions. - Keep close monitor for safety until cleared by clinician or nursing supervisor - Assess environment for safety - Complete event report - Refer to [contracted] Mental Health Services in plan of care - Behavior Committee to monitor for ongoing evaluation Review of Resident #40's hospital discharge paperwork, dated 3/19/24, indicated that Resident #40 was expressing suicidal ideation and wanted to end it all. Resident #40 was cleared the next day to come back to the facility. Review of the clinical record did not indicate that any behavioral health services were provided by the facility to manage the Resident's mood after re-admission. Review of the Nurse Practitioner note, dated 7/19/24, indicated Resident #40 was experiencing worsening depression with continued decline and a mental health visit and psych follow up was recommended. Review of the record did not indicate that psych services or a mental health visit took place after the Nurse Practitioner note. Review of the Nurse Practitioner note, dated 7/24/24, indicated that Resident #40 was sent out to the hospital for a psychiatric evaluation. Review of the medical record failed to indicate that any behavioral health services were implemented after the psychiatric admission in July 2024. Review of the Nurse Practitioner note, dated 9/26/24, indicated Resident #40 was having increased anxiety and behavioral disturbances with suicidal ideation. Resident #40 was sent to the emergency department for an evaluation. Review of the hospital discharge paperwork, dated 9/26/24, indicated the following: I spoke with PES (psychiatric emergency service), who states the patient has a bed assigned for voluntary inpatient admission at the VA (veteran's affairs). Pending transfer at time of shift change. Review of the emergency department note, dated 9/26/24, indicated the following: . refusing his/her meds for 4-5 days, plan to jump out the window (not possible at Soldiers Home) called in by Soldiers Home physician. Is a VA patient. They tried to transfer him/her there. EMS (emergency medical services) brought him/her here instead. Needs geri-psych admission. Resident #40 was admitted back to the facility. Review of the record failed to indicate that Resident #40 was provided with a geri-psych admission or reviewed/assessed by psych services. During an interview on 10/8/24 at 1:40 P.M., the Director of Nursing said that Resident #40 was supposed to be sent out to a different psych hospital to have a subsequent psychiatric inpatient stay, but the ambulance who picked the Resident up would not go to the location of the geri-psych hospital. The Director of Nursing said that by the time the Resident came back to the facility, his/her pending bed at the geri psychiatric hospital was no longer being held. Resident #40 had never gone for an inpatient psych stay. During an interview on 10/8/24 at 1:56 P.M., Social Worker #1 said Resident #40 has been a long term resident at the facility and was aware of his/her psych hospitalization in March 2024. Social Woker #1 said Resident #40 had a section 12 in July and two weeks ago had another one, but was sent back from the hospital after he/she was medically cleared. Social Worker #1 said that Resident #40 was sometimes receiving individual therapy at the VA, but said it wasn't consistent and there hasn't been an individual therapist since May or June. Social Worker #1 said the VA offers group therapy, but that is not the best for Resident #40. Social Worker #1 said the VA usually hires interns and he is unaware if they are licensed individuals. Social Worker #1 said that he does not have access to the therapy notes and hasn't called to receive them or communicate with the VA providing therapy. During an interview with the Administrator and the Deputy Superintendent on 10/8/24 at 4:10 P.M., The Administrator then said that she was not sure if the facility could obtain psychological therapy information from the Veterans Administration where the Resident goes outpatient for mental health therapy visits. The Deputy Superintendent said that it is the facilities responsibility to ensure that the residents in the facility are receiving the mental health they need and that based on the continued suicidal ideations with subsequent psychiatric hospitalization s the Resident was experiencing, it may be an issue that the facility should have looked into.

Based on record review and interview, the facility failed to develop a trauma informed plan of care for 2 Residents (#109 and 92) out of a total sample of 26 residents. Findings include: Review of the facility policy titled Trauma Informed Care, revised 9/22/23, indicates the following: - It is the policy of the Massachusetts Veterans Home at [NAME] to provide care and services to residents that meet professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. - The Veterans Home will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, and primary care clinician, and any other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized care plan interventions. 1. Resident #109 was admitted in 08/2024 with diagnoses including post traumatic stress disorder (PTSD). Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #109 scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of Resident #109's history and physical assessment for long term care, dated 8/13/24, indicated Resident #109 has PTSD from physical abuse from his/her father. Review of the current care plan did not indicate that a trauma-informed plan of care was developed for Resident #109 or a PTSD assessment was completed. During an interview on 10/9/24 at 1:56 P.M., Social Worker #1 said that if a Resident has a diagnosis, then they should have a PTSD care plan. Social Worker #1 said that the care plan should include PTSD triggers and how to manage those triggers. Social Worker #1 said that the social worker who is responsible for the Resident should develop the care plan based on the PTSD assessment. 36797 2. For Resident #92 the facility failed to develop a resident centered comprehensive care plan that included triggers for PTSD. Resident #92 was admitted to the facility in March 2024 with diagnoses including PTSD, bipolar depression and kidney disease. Review of the facility document titled Behavioral Assessment/PTSD, not dated, indicated that Resident #92's triggers for an episode of PTSD are over stimulation and not understanding expectations. Further review indicated that early warning signs of distress are cursing, name calling, saying he/she does not feel well or feels hot. Further review indicated that his/her coping mechanisms are a change of activity, medication, warm shower, calling friends or family, watching TV and going outside. Review of the care plan dated 3/20/24, indicated a problem for PTSD and that Resident #92 was 100% disabled as a result of PTSD. Further review failed to indicate resident specific triggers for PTSD. During an interview on 10/08/24 at 1:56 P.M. Social Worker (SW) #1 said that the assigned social worker is responsible for assessing the residents for PTSD and then developing the care plan based on the results. SW #1 then said that he is the assigned SW for Resident #92 and did not follow through with including the individualized triggers that were found during the assessment, onto the care plan and should have.

Based on observation, interview, and record review for two Residents (#30, #264) out of 26 sampled residents, the facility failed to implement the plan of care. Specifically: 1. For Resident #30, the facility failed to follow the physician's order to apply heel protector booties. 2. For Resident #264, the facility failed to develop a plan of care for a pacemaker. Findings include: 1. Resident #30 was admitted to the facility in February 2024, and had diagnoses which included diabetes mellitus, hemiplegia, and peripheral vascular disease. Review of Resident #30's Minimum Data Set (MDS) assessment, dated 8/19/24, indicated he/she had a Brief Interview for Mental Status score of 15, signifying intact cognition, and was at-risk for the development of pressure ulcers. Review of Resident #30's most recent care plan indicated he/she was at risk for skin breakdown and required a pressure-relieving mattress. Review of Resident #30's physician order dated 9/30/24 indicated: - Please use heel protector booties while in bed. Review of Resident #30's Treatment Administration Record (TAR) dated October 2024 indicated the physician's order, dated 9/30/24 for heel protectors, was not transcribed onto the TAR. There was no documentation to indicate staff offered heel protectors to Resident #30. On 10/7/24 at 10:13 A.M. and on 10/8/24 at 8:47 A.M., the surveyor observed Resident #30 lying awake, in bed. Resident #30 was not wearing heel protector booties. The surveyor observed that booties were not visible in the bedroom or bathroom. During an interview on 10/8/24 at 8:50 A.M., Resident #30 said his/her ankle was sore, but that the skin was intact. Resident #30 said staff had discussed with him the use of protective booties while in bed to provide comfort to the ankle, but staff had not applied them. During an interview on 10/8/24 at 8:58 A.M., Certified Nurse Aide (CNA) #1 said she was assigned to Resident #30 on a regular basis. CNA #1 said Resident #30's left ankle was sore, but she was unaware that Resident #30 should wear heel protector booties while in bed. During an interview on 10/8/24 at 9:23 A.M., Nurse #5 said she was unaware there was a physician's order for Resident #30 to wear heel protector booties while in bed. 36797 2. Review of the facility policy titled Care Planning, revised 12/12/23 indicated the following: - it is the policy of the Veterans Home to develop and implement a comprehensive, person-centered care plan for each resident consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing and mental and psychological needs that are identified in the resident's comprehensive assessment. Review of the facility policy titled Pacemaker (Care of Patient with Permanent Cardiac) dated last reviewed 10/08. indicated the objective was to initiate and maintain the heartbeat when the normal pacemaker fails to do so in such conditions as AV block and in [NAME] arrhythmia's (slow heart rate). Further review indicated the following: 1. Assess patient's knowledge of his/her condition. 2. Attach identification bracelet stating type of pacemaker include physician's name, pacemaker rate and date of insertion. 3. explain condition to patient to allay fears and anxiety. 6. Observe and record vital signs at frequent intervals to determine effect of pacemaker. 8. Change of more than five impulses, missed beats, or failure of pacemaker to sense when rate drops below pre-set rate should be reported to physician. Resident #264 was admitted to the facility in February 2024 with diagnoses including dementia, diabetes and weight loss. Review of the hospital discharge report dated 9/26/24, indicated that Resident #264 has a single chamber medtronic pacemaker implanted on 1/12/17. Further review indicated the make, model, serial number and rate at which the pacemaker was set (45 beats per minute). Review of the current care plan dated 2/6/24, failed to indicate a care plan for the care of a pacemaker. Review Nursing Progress notes dated September 2024 and October 2024 failed to indicate Resident #264 had a pacemaker. Review of the physician's orders date October 2024 failed to indicate orders for the care of a pacemaker. Review of the Medication Administration Record dated October 2024 failed to indicate physician orders for the care of the pacemaker. Review of the Treatment Administration Record dated October 2024 failed to indicate physician orders for the care of the pacemaker. During an interview on 10/08/24 at 9:59 A.M., Nurse #1 said she was not aware Resident #264 had a pacemaker. Nurse #1 then said that she was not aware of a follow-up appointment scheduled for Resident #264 to check the pacemaker. Nurse #1 then said she would have to check with the clinic to see when a follow-up appointment would be needed.

Based on record review and interview the facility failed to ensure they followed standards of practice for 1 Resident (#264) out of a total sample of 26 residents. Specifically the facility failed to obtain lab results for a lab obtained during a hospitalization which was still pending upon discharge of the Resident from the hospital. Findings include: Resident #264 was admitted to the facility in February 2024 with diagnoses including dementia, diabetes and weight loss. Review of the medical record failed to indicate the facility had acquired the lab results. Review of the hospital document titled Hospital Course, dated 9/27/24 indicated that there were pending labs for Legionella. Review of the nursing progress notes failed to indicate that the facility called the hospital for the results of the pending labs. Review of the physician progress notes failed to indicate the physician was notified of the pending lab results. During an interview on 10/08/24 at 10:40 A.M., Nurse #1 said she was not aware that there was a pending lab result from Resident #264's 9/27/24 hospital discharge. During an interview on 10/08/24, at 10:57 A.M., the Superintendent of Operations said that it is the expectation that the nurse would call the hospital for the results of a pending lab on discharge from the hospital.

Based on record review and interview, the facility failed to ensure one Resident (#40) was safe from accidents/hazards out of a total sample of 26 residents. Specifically, the facility failed to appropriately assess the Resident for safety and ensure a safety care plan was developed to prevent an elopement. Findings include: Review of the facility policy titled Soldier's Home Policy Guide: Code Yellow: Missing Veteran, revised 9/22/23, indicated the following: -Policy: Veterans who are cognitively impaired have the right to a safe environment. Veterans who wander, exit seek, and/or elope their assigned unit will be identified and returned to their unit utilizing an expedited procedure for searching the Soldier's Home premises and surrounding communities. Resident #40 was admitted to the facility in February 2024 with diagnoses including psychiatric disorder and depression. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #40 scored an 8 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. Review of the MDS indicated Resident #40 is independent with wheelchair mobility. Review of the clinical record indicated that Resident #40 has an activated healthcare proxy as of 1/15/22 (when a person is designated to make decisions on the Resident's behalf when they are no longer able to). Review of the facility document titled Wander Data Collection Tool, dated 3/18/24 and 5/19/24, indicated that Resident #40 was not at risk of elopement, but that on 8/9/24, Resident #40 became a wander risk. Review of the Nurse Practitioner progress note, dated 7/19/24, indicated Resident #40 had left the campus in his/her wheelchair and was unable to return. Resident #40 stated that he/she cannot go uphill with his/her wheelchair and a good Samaritan called 9-1-1 to help Resident #40. Resident #40 had left the facility using his/her key card access. Review of the clinical record indicated that Resident #40's key card access was revoked after his/her elopement off campus. Review of the incident reports for Resident #40 indicated that on 9/28/24, Resident #40 had eloped off his/her locked unit and was found outside alone. Review of the incident report indicated that the employee entrance door on the unit was broken and Resident #40 was able to get off of the unit. Review of the care plan for Resident #40 indicated that on 9/28/24, 2 months after the initial elopement, a care plan was developed for Resident #40's elopement risk. During an interview on 10/8/24 at 1:04 P.M., the Director of Nursing said the Resident agreed to only go out on the patio with his/her keycard access. The Director of Nursing said that physical therapy is the department who assesses resident's capability of being able to have access to the key cards. During an interview on 10/8/24 at 1:17 P.M., the Physical Therapist said he assesses a resident's physical capabilities and navigation abilities when determining key card access, but never assesses their cognitive ability to leave campus. The Physical Therapist said Resident #40's health care proxy was pushing for Resident #40 to have key card access since his/her freedom is tied to his/her mental health. The Physical Therapist said that Resident #40 was getting confused and lost during his/her assessment, but that the health care proxy was adamant. During an interview on 10/8/24 at 1:56 P.M., Social Worker #1 said that given Resident #40's mental health status, he would not have recommended giving the Resident a key card. Social Worker #1 said his involvement in the decision to grant key card access is minimal. During an interview with the Administrator and the Deputy Superintendent on 10/8/24 at 4:10 P.M., the Administrator said that she would expect that the Physical Therapist would document and communicate all concerns with the Resident's ability to safely navigate outside independently during the assessment. The Administrator said that the health care proxy cannot dictate care when it comes to safety and the Physical Therapist should not have considered the health care proxy's wishes when making the decision to sign off on the safety of the Resident's ability to safely navigate outside.

Based on record review and interview the facility failed to ensure the physician was notified of a recommendation from a consulting dentist for one Resident (#79) out of a total sample of 26 residents. Findings include: Resident #79 was admitted to the facility February 2024 with diagnoses including dementia, diabetes and cancer. Review of the dental consult dated 7/15/24 indicated a recommendation for Peridex mouth rinse twice daily, swab with a toothette using 1/4 ounce of Peridex after breakfast and at bedtime. Review of the physician's orders dated July 2024, August 2024, September 2024 and October 2024 failed to indicate an order for Peridex mouth rinse. Review of the nursing progress notes dated after 7/14/24, failed to indicate acknowledgement or notification of the physician regarding the recommendation for the Peridex mouth rinse made by the dentist on 7/15/24. Review of the physician's progress notes failed to indicate a note written after 7/12/24. During an interview on 10/08/24 03:21 PM the Deputy Superintendent said that she would expect that nursing would inform the physician of the dentist's recommendation for Peridex and document the physician's response in the medical record. The Deputy Superintendent then said that she was not able to locate a policy and procedure regarding the notification of a consulting physician's recommendations to the primary care physician.

Based on records reviewed and interviews, for one of four sampled residents (Resident #1) who was cognitively intact, the Facility failed to ensure staff treated him/her in a respectful manner, when on 06/21/24 during the evening shift, Nurse #1 and Certified Nurse Aide (CNA) #1 were arguing in the hallway outside of Resident #1's room, they then enter his/her room to provide care, and continued their argument in front of him/her, which made him/her feel uncomfortable. Findings include: The Facility Policy, titled Resident Rights, has no date. The Facility will treat you with dignity and respect in full recognition of your individual rights. Resident #1 was admitted to the Facility in February 2024, diagnoses included paraplegia, spinal abscess, lumbar spinal stenosis, lumbar osteomyelitis, and neurogenic bladder/bowel. Review of Resident #1's Minimum Data Set (MDS) Assessment, dated 05/09/24, indicated that he/she had intact cognition, could communicate his/her needs, and was his/her own decision-maker. The MDS also indicated that Resident #1 required assistance from two staff members to meet his/her care needs. The Facility's Internal Investigation Summary Report, dated 06/24/24, indicated that Resident #1, who had filed the grievance, was in his/her room waiting for staff assistance with the nighttime routine on 06/21/24. Resident #1 overheard a disagreement among staff regarding a scheduled break time in the hallway, which continued as they entered his/her room, causing him/her significant discomfort. During an interview on 07/17/24, at 10:15 A.M., Resident #1 expressed his/her discomfort and loss of trust in the staff. Resident #1 said it was unprofessional for Nurse #1 and CNA #1 to enter his/her room and argue loudly in front of him/her. Resident #1 said he/she found it disrespectful that staff members did not respect his/her room and personal space. Resident #1 said he/she requested that Nurse #1 not provide care for him/her in the future. During a telephone interview on 07/18/24, at 11:49 A.M., Nurse #1 denied speaking loudly but admitted that discussing the break schedule with CNA #1 in Resident #1's room was disrespectful. During a telephone interview on 07/22/24, at 12:58 P.M., CNA #1 said on 6/21/24, she was late returning from her break, and that it was already time to assist Resident #1 into bed and provide care. CNA #1 said Nurse #1 was upset about her (CNA #1) being a few minutes late because she (Nurse) #1 said she had to do Resident #1's wound care. CNA #1 said she was not trying to discuss the issue any further once she and Nurse #1 entered Resident #1's room, but said it was difficult because Nurse #1 continued discussing the break schedule. CNA #1 said she knew it was disrespectful to have that type of conversation in a residents room. During an interview on 07/17/24, at 9:30 A.M., the interim DON said that Resident #1 had reported that he/she had felt uncomfortable because staff members were yelling at each other in front of him/her and that he/she felt Nurse #1 was more unprofessional towards CNA #1. The DON said both Nurse #1 and CNA #1 were suspended pending an investigation into the incident.

Based on records reviewed, review of surveillance camera video footage, and interviews for one of four sampled residents (Resident #2), who had moderate cognitive impairment, a history of behaviors, and was dependent on staff for care, the Facility failed to ensure he/she was free from abuse from staff members, when 1) on 6/29/24. Certified Nurse Aide (CNA) #4 engaged in a verbal altercation with Resident #2 and responded by throwing an object at him/her and 2) on 7/01/24, CNA #3 also engaged in a verbal altercation with Resident #2, was intimidating and confrontational while engaging with him/her, which resulted in escalating his/her behaviors. Findings include: The Facility's Policy titled Patient, Complaints, Mistreatment, Abuse or Neglect, revised 09/2018, indicated that Abuse is an overt act or an omission of care that results in the physical or emotional trauma of a patient. Examples of alleged abuse would include: -The aggressive imposition of a caregiver on a patient in the manner of pushing, shoving or any other form of physical touching that would constitute an assault under best practices as well as Massachusetts General Law. -The use of verbal means to insult or abuse a patient by threatening, shouting, cursing or teasing, speaking in a demanding/degrading manner. Resident #2 was admitted to the Facility in January 2024; diagnoses included dementia with behavioral disturbances, left leg DVT (deep vein thrombosis, blood clot), pulmonary emboli (blood clot in the lungs), and sinus arrhythmia. Review of Resident #2's Quarterly Minimum Set Data (MDS) Assessment, dated 04/10/24, indicated he/she had moderate cognitive impairment, required physical assistance with ADL, and ambulates independently. Review of Resident #1's Behavior Care Plan, reviewed and renewed with his/her January 2024 MDS, indicated that he/she exhibited or had the potential to demonstrate verbal behaviors, and included the following interventions: -maintain a comfortable environment by reducing noise and using dim lights. -employ therapeutic and non-judgmental communication. -staff is to reapproach in an unhurried manner, often during a cooling off period. -allow time to express your feelings of getting daily care without interruption. 1) Review of the surveillance camera video footage clips (video only, no audio) provided by the Facility, dated 06/29/24 from 11:50:24 A.M. to 11:53:17 A.M., related to an incident involving Certified Nurse Aide (CNA) #4 and Resident #2, illustrated the following: - 11:50:24, Resident #2 can be seen seated at his/her table for lunch, - 11:50:58, Resident #2 gets up and walks toward the unit hallway, - 11:51:23, CNA #4 walks toward the same hallway as Resident #2, - 11:51:31, Resident #2 can be seen passing the units' nursing station, CNA #4 can be seen behind him/her, and she stops to grab an object. - 11:51:43, Resident #2 suddenly turns back around and looks at CNA #4. - 11:51:51, CNA #4 can then be seen walking through the dining area, Resident #2 walks back to the hallway and approaches CNA #4, who was in front of the nurses' office. - 11:53:09, Resident #2 and CNA #4 can be seen engaging in a verbal alteration, Resident #2 proceeds to punch CNA #4 in the face. CNA #4 responds by throwing an object (appears to be a lunch box) at Resident #2, which does not hit him/her, - 11:53:17, CNA #4 walks back to the nursing station, grabs what appears to be a large container of sanitary wipes and moves toward Resident #2, as he/she approaches her. Staff and family members can be seen intervening to separate CNA #4 and Resident #2. During an interview on 07/17/24 at 2:32 P.M., the Administrator said on 06/29/24, the Supervisor called her and said Resident #2 had punched a staff member (later identified as CNA #4) and that Resident #2 had been sent out to the hospital. The Administrator said the facility's security officer reviewed the surveillance camera video footage and reviewed the incident from 06/29/24 that had occurred between Resident #2 and CNA #4. The Administrator said CNA #4 should have tried to de-escalated the situation or should have walked away, but instead had thrown an object at Resident #2. Review of an email received by the Director of Nurses (DON) on 07/17/24 at 8:53 A.M. indicated it was sent from Certified Nurse Aide (CNA) #4, and included her statement regarding the incident on 06/29/24, with Resident #2. CNA #4's statement indicated that Resident #2 approached her and asked if he/she could take the plate from her, that she replied, No, I got it, and then Resident #2 punched her. CNA #4's statement indicated she was upset and mad and that she threw her lunch plate at him/her to prevent him/her from attacking me more. The Surveyor was unable to interview CNA #4 as she did not respond to the Department of Public Health's telephone or letter requests for an interview. During an interview on 07/16/24 at 1:20 P.M., Nurse #2 said she was familiar with Resident #2 and said he/she could become easily agitated. Nurse #2 said she was Resident #2's nurse on both days of the incidents (6/29/24 and 7/01/24). Nurse #2 said that on 06/29/24, Resident #2 was quiet that morning with no behaviors and had finished his/her lunch meal. Nurse #2 said Resident #2 usually goes to his/her room after the meal. Nurse #2 said she had not witnessed any confrontational interaction between Resident #2 and CNA #4, until the incident that day. Nurse #2 said after the incident, Resident #2 was sent to the hospital for further evaluation. 2) Review of the surveillance camera video footage clips (video only, no audio), dated 07/01/24 from 11:40:57 A.M. to 11:45:18 A.M., related to the incident involving Resident #2 and CNA #3, illustrated the following: -11:40:57, Resident #2 can be seen sitting at the dining room table with another resident who was being fed by a CNA, -11:41:25, CNA #3 can be seen, seated at another table and was providing 1:1 supervision for another resident. CNA #3 can been seen looking in the direction of Resident #2, and looks to be doing so for an extended period of time (several minutes), - 11:44:20, CNA #3 and Resident #2 can then be seen having some sort of verbal exchange, and Resident #2 appears to become agitated, - 11:44:22, Resident #2 and CNA #3 are seen simultaneously standing up, CNA #3 appears to be gesturing to Resident #2 to come to where she is standing, as if to provoke him/her, -11:44:23, Resident #2 approaches CNA #3, and CNA #3 then picks up the napkin holder from the table and motioned with it toward Resident #2, - 11:44:28, Staff members are then seen intervening and separate Resident #2 and CNA #3, Resident #2 returns to his/her table. - 11:44:38, CNA #3 can been seen looking (staring) in Resident #2's direction and Resident #2's demeanor changes and he/she looks more agitated, - 11:44:59, Resident #2 approaches CNA #3 for the second time. CNA #3 appears to try to intimidate Resident #2 by pointing her finger at him/her and waving the napkin holder in Resident #2's face, -11:45:18, Staff members again intervene, the Nurse Practitioner (NP) is able to redirect and calm Resident #2 down, he/she walks away from the dining room area and is redirected back to his/her room. Nurse #2 said that on 07/01/24, at lunchtime, Resident #2 was seated at a different table in the dining room across from where CNA #3 was sitting with another resident, who required 1:1 supervision. Nurse #2 said she was unsure what made Resident #2 get agitated and that she had not heard the verbal interaction between Resident #2 and CNA #3. Nurse #2 said Resident #2 stood up, then moved in the direction of CNA #3. Nurse #2 said she believed CNA #3 was afraid of Resident #2, that CNA #3 had grabbed the napkin holder, but she (CNA #3) did not touch him/her. Nurse #2 said staff members intervened and Resident #2 returned his/her seat. Nurse #2 said that while she called out for help with the situation, the Nurse Practitioner was able to redirect Resident #2 and take him/her to his/her room. Nurse #2 said Resident #2 was assessed, and no injuries were noted. During an interview on 07/16/24 at 2:32 P.M., the Nurse Practitioner (NP) said she was coming onto the unit and noticed that Resident #2 was standing, he/she was agitated, that the dining area was noisy at the time, but that Resident #2 was not close to CNA #3 at that time. The NP said she was able to calm him/her down and took Resident #2 back to his/her room. The NP said Resident #2 was assessed, and he/she had no injuries were noted. During a telephone interview on 07/18/24 at 12:00 P.M., Certified Nurse Aide (CNA) #3 said that she was afraid that Resident #2 would attack her since he/she attacked another staff member over the weekend. CNA #3 denied she was looking in Resident #2 direction, said she had not tried to intimidate him/her, and denied having a verbal altercation with Resident #2. CNA #3 said she grabbed the napkin holder to defend herself. The Administrator said on 07/01/24, during lunch time, she received a called from the nurse that Resident #2 was agitated, that he/she approached and tried to attack CNA #3. The Administrator said she reviewed the surveillance camera video footage and reviewed CNA #3 interaction with Resident #2. The Administrator said CNA #3 responded to Resident #2 in an intimidating manner, and engaged in a verbal and threatening confrontation with Resident #2, which escalated his/her behaviors.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was alleged to have been subjected to verbal abuse by Certified Nurse Aide #1, the Facility failed to ensure they submitted a report to the Department of Public Health within the required timeframe (two hours), after being made aware of the allegation, when their report regarding the allegation was not submitted until seven days after administrative staff became aware of the allegation. Findings include: Review of the Facility's Policy titled Prevention/Identification of Abuse, Neglect or Mistreatment, dated October 13, 202, indicated the Compliance Officer or designee is responsible for reporting the incident to the appropriate regulatory agency or accreditation organization. The Policy indicated to notify the State Agency through the Health Care Facility Reporting System (HCFRS) for alleged violations involving Abuse immediately, but no later than 2 hours after the allegation is made if the events that cause the allegation involve abuse. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS) indicated the Facility submitted the report regarding an allegation of verbal abuse (that had occurred on 4/15/24) at 4:12 P.M. on 04/22/24, seven days after Housekeeper #1 reported the alleged incident to the Housekeeping Supervisor, and Administrative staff were initially made aware. Review of Resident #1's medical record indicated his/her diagnoses included alcohol abuse and dementia with behavioral issues. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 04/23/24, indicated he/she had severely impaired cognition, and displayed behavioral symptoms not directed toward others. During a telephone interview on 05/20/24 at 11:15 A.M., the Housekeeping Supervisor said at approximately 4:45 P.M. on 04/15/24, Housekeeper #1 reported to him that a Certified Nurse Aide (CNA) was heard telling Resident #1 that he/she was such an idiot after he/she repeatedly asked to go outside to smoke. The Housekeeping Supervisor said he immediately notified the Nursing Supervisor. During a telephone interview on 05/20/24 at 10:08 A.M., the Nursing Supervisor said on 04/15/24, sometime between 5:00 P.M. and 5:30 P.M. (exact time unknown) the Housekeeping Supervisor notified her that a CNA was heard calling Resident #1 an idiot after requesting to go out to smoke several times. The Nursing Supervisor said based on descriptions provided, the CNA was identified as CNA #1, and her employment was immediately suspended and Administration was notified. During an interview on 05/14/23 at 11:00 A.M., the Quality Nurse Manager said at approximately 5:00 P.M. on 04/15/24, the Administrator notified her there was an allegation of verbal abuse, that CNA #1 called Resident #1 an idiot. The Quality Nurse Manager said since the Administrator was not a registered user for the HCFRS system for the Facility yet, she was asked to submit the initial report within two hours. The Quality Nurse Manager said she immediately began to enter the information into HCFRS, but accidentally did not submit the report. The Quality Nurse Manager said once her error was identified (date not recalled), the report was submitted into HCFRS days later. Review of an email received on 05/17/24 at 2:47 P.M., from the Administrator indicated, that although the Facility became aware of the alleged incident of abuse on 04/15/24, it was not discovered until the following Monday on 04/22/24 that the report was not submitted to the DPH.

Based on interview, document review, and policy review, the facility failed to develop, implement, and maintain a Quality Assurance and Performance Improvement (QAPI) program that addressed the full range of care and services, was comprehensive and data-driven, and focused on indicators of outcomes of quality of life, care, and services to residents in the facility. Findings include: Review of the facility's policy titled Agency Quality Assurance Performance Improvement Committee (QAPI) dated 9/2018 indicated that the committee will review/analyze departmental reports and other QAPI data and discuss the need for improvement or change, make recommendations as appropriate to Executive Committee and perform follow-up analysis when indicted. Review of the facility document titled QAPI Program Meeting and dated 12/7/22, and 3/22/23, indicated the purpose of the meeting was to continually improve the quality of patient care at the Soldiers Home. To systematically and objectively monitor the effectiveness of care at the Soldiers Home. To identify and implement monitoring processes the ensures standards of patient safety are established and improved. Further review failed to indicate that data collected was reviewed for trends, analyzed for areas of improvement, analyzed for root cause and/or analyzed for effectiveness of improvements put in place. The meeting minutes also failed to indicate any discussion of potential areas needing improvement. During an interview on 8/3/23, at 1:27 P.M., the Director of Quality Management said the facility was not doing a real QAPI. She said that the facility was tracking some data but had not put plans in place for improvement and were not tracking outcomes of any interventions. The Director of Quality Management then said that she had started her job in May 2023 and had just recognized that the QAPI program was not being implemented per the facility policy.

Based on record review and interview the facility failed to develop and implement policies addressing: (a) How they will use a systematic approach to determine underlying causes of problems impacting larger systems; (b) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and (c) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained. Findings include: Review of the facility policy titled Agency Quality Assurance Performance Improvement Committee (QAPI) and dated 9/2018 failed to indicate how the facility will (a) use a systematic approach to determine underlying causes of problems impacting larger systems; (b) how the facility will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and (c) how the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained. During an interview on 8/3/23, at 1:27 P.M., the Director of Quality Management said the facility was not doing a real QAPI. She said that the facility was tracking some data but had not put plans in place for improvement or were tracking outcomes of any interventions. The Director of Quality Management then said that she had started her job in May 2023 and had just recognized that the QAPI program was not being implemented per facility policy.

Based on record reviews and interviews, the facility 1) failed to develop a dementia care plan for one Resident (#40), 2) failed to follow physician orders for two Residents (#22 and #2) and 3) facility failed to follow a physician order to ensure air mattress was maintained at the proper setting for one Resident (#37) out of a total sample of 17 residents. Findings include: 1. Resident #40 was admitted to the facility in March 2022 with diagnoses including dementia with behavioral disturbance. Review of Resident #40's most recent Minimum Data Set (MDS) dated [DATE], indicated that the Resident has a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15, indicating he/she has moderate cognitive impairment. The MDS also indicated that Resident #40 requires supervision for functional daily tasks. Review of Resident #40's care plans failed to indicate a dementia care plan or a care plan to address cognitive impairment. During an interview on 8/2/23, at 1:01 P.M., Nurse #3 said she is responsible for developing resident care plans based on the individual care needs and diagnoses. Nurse #3 said a resident with a dementia diagnosis should have a cognitive/dementia care plan. Nurse #3 said the speech therapist has been completing the cognitive assessments so she should be making the care plans. Nurse #3 looked at Resident #40's care plans and confirmed he/she did not have a dementia care plan and again said one should have been developed. During an interview on 8/2/23, at 2:14 P.M., the Director of Nursing said a dementia care plan should be developed for any resident who has dementia as a diagnosis. 2 A. Resident #22 was admitted to the facility in September 2018 with diagnoses including chronic right knee pain, obesity, and hypertension Review of Resident 22's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15, indicating he/she has moderate cognitive impairment and requires extensive assistance for functional daily tasks. Review of Resident #22's physician orders indicated the following orders: *Elastic stockings- apply elastic stockings to BLE (Both Lower Extremities) every AM and remove after 12 hours later, dated a initiated 7/26/23. On 8/2/23, at 9:54 A.M.,11:36 A.M., and 1:54 P.M., the surveyor observed Resident #22 sitting in his/her wheelchair. The Resident was wearing sneakers and socks. The Resident was not wearing compression stockings. On 8/3/23, at 10:35 A.M., the surveyor observed Resident #22 lying in bed wearing socks on both feet. Resident #22 was not wearing compression stockings. On 8/3/23, at 11:44 A.M., the surveyor observed Resident #22 sitting in his/her wheelchair. The Resident was wearing sneakers and socks. The Resident was not wearing compression stockings. During an interview on 8/03/23 at 11:44 A.M., Nurse #4 said Resident #22 should be wearing compression stockings because there is an order. Nurse #4 said resident orders are to be followed, care plans need to be followed and, staff will check the care plans for care needs. Nurse #4 said residents who have orders for compression stockings will be documented on the treatment administration record (TAR) and it is expected that Resident #22 would have compression stockings on. Nurse #4 walked into Resident # 22's room and observed the Resident sitting in his/her wheelchair without compression stockings on. During an interview on 8/3/23, at 11:04 A.M., the Director of Quality Management said staff are expected to follow all orders and care plan interventions. 2 B. Resident #2 was admitted to the facility in December 2020 with diagnoses including depression, anxiety, cervical spinal stenosis, back pain, and diabetes. Review of Resident #2's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15, indicating he/she has intact cognitive function. Further review indicated that Resident #22 requires total dependence for functional daily tasks. Review of Resident #2's physician orders indicated the following orders: *Pillow under calves to lift offload right lateral ankle off bed surface, dated 7/26/2023. On 8/2/23 at 7:28 A.M., and 9:00 A.M., the surveyor observed Resident #2 lying in bed with bilateral feet and ankles on the bed with both feet positioned laterally facing outward. No pillow was observed under the Resident's leg to offload pressure from his/her ankles. On 8/03/23 at 7:29 A.M., 7:44 A.M., and 9:30 AM., the surveyor observed Resident #2 lying in bed with bilateral feet and ankles on bed with feet positioned laterally facing outward. No pillow was observed under the Resident's leg to offload pressure from his/her ankles During an interview on 8/3/23, at 7:44 A.M., Certified Nursing Assistant (CNA) #2 said Resident #2 is unable to move on his own and sometimes staff will place pillows underneath his/her legs but not always. CNA #2 said care plans will indicate what the Resident needs for daily tasks. During an interview on 8/3/23, at 11:47 A.M., Nurse #4 said Resident orders are to be followed, care plans need to be followed and staff will check the care plans for care needs. Nurse #4 said Residents who have orders for off-loading heels will be documented on the treatment administration record (TAR) and it is expected that the Resident would have a pillow placed under calves as ordered. During an interview on 8/3/23, at 11:04 A.M., the Director of Quality Management (DQM) said staff are expected to follow all orders and care plan interventions. 36797 3. Review of the facility policy titled Alternating Pressure Pad (Air Mattress) dated (reviewed 10/21), failed to indicate what the mattress settings should be based on. Review of the manufacturer's user manual titled Med-Aire 8 indicated that the air mattress should be set up using the patient's weight as a guideline but could be adjusted for comfort. Resident #37 was admitted to the facility in February 2021 with diagnoses including diabetes, depression and anxiety disorder. Review of the Minimum Data Set assessment dated [DATE], indicated that Resident #37 scored a 5 out of a possible 15 on the Brief Interview for Mental Status exam indicating that Resident #37 is severely cognitively impaired. Further review indicated that Resident #37 is totally dependent on staff for all activities of daily living. On 8/2/23, at 8:32 A.M. and 4:08 P.M. the surveyor observed Resident #37's air mattress to be set at 450 lbs. (pounds). On 8/3/23, at 7:08 A.M., the surveyor observed Resident #37's air mattress to be set at 450 lbs. Review of the doctor's orders dated August 2023 indicated an order for the air mattress according to patients weight, check every shift. Review of the medical record indicated Resident # 37's weight on 7/1/23, was 252.6 lbs. During an interview on 8/3/23, at 7:08 A.M., Certified Nurse's Aide #1 said that she did not know what the mattress setting was supposed to be. During an interview on 8/3/23, at 7:15 A.M., Nurses #1 said that the nurse is responsible for ensuring the correct mattress setting. Nurse #1 said that Resident #37 weighs 252.6 lbs and that is what the mattress setting should be set at. During an interview on 8/3/23, at 11:10 A.M., the Director of Quality Management said that the facility follows the manufacturer's directions for the air mattress.

Based on record review and interview the facility failed to complete an Minimum Data Set assessment for a resident discharge/return anticipated and failed to complete an MDS assessment for a resident re-entry to the facility for one Resident (#32) out of a total sample of 17 residents, resulting in inaccurate MDS data and the possible failure to care plan for Resident #32's post hospital needs. Findings include: Resident #32 was admitted to the facility in November 2019 with diagnoses that included congested heart failure, coronary heart disease and lung cancer. Review of Resident #32's medical record indicated the following: *A nurse practitioner progress note dated 5/31/23, which indicated Resident #32 was in the hospital 5/24/23, through 5/31/23. *A care plan that indicated Resident #32 had an acute (hospital) admission 5/24/23, through 5/31/23. Review of Resident #32's MDS binder failed to indicate an MDS discharge return anticipated assessment was completed or an MDS re-entry assessment was completed as required. During an interview on 8/2/23, at 4:13 P.M., Minimum Data Set Nurse #1 said he reviewed Resident #32's MDS records and said a the discharge return anticipated MDS and the re-entry MDS were not completed and should have been. MDS Nurse #1 then said he did not know why they were missed.

Based on observation, record review and interview the facility failed to identify and complete a Significant Change in Status assessment, Minimum Data Set assessment (MDS) for one Resident (#32), who elected to receive hospice care services, out of a total sample of 17 residents. Findings include: Resident #32 was admitted to the facility in November 2019 and has diagnoses that include congested heart failure, coronary artery disease, and a lung mass. Review of Resident #32's medical record indicated the following: *An election for hospice services document signed by Resident #32's health care proxy dated 2/1/23. *An end-of-life care plan related to terminal diagnosis of cancer dated 4/6/23, that Resident #32 admitted back on Hospice care dated 2/3/23. Review of the MDS assessments for Resident #32 failed to indicate a Significant Change in Status assessment, MDS was completed as required. During an interview on 8/2/23, at 4:13 P.M., Minimum Data Nurse #1 said he reviewed Resident #32's MDS records and said a significant change MDS was not completed and should have been after the Resident had an order to admit to hospice on 2/3/23.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed as being at high risk for falls and care planned to require staff to provide 1:1 supervision (per administration, expectation was staff member to remain within arms' lengths of resident) at all times as a fall prevention measure, the Facility failed to ensure staff implemented interventions from his/her comprehensive plan of care, when on 05/07/21, Certified Nurse Aide (CNA) #1 who was assigned to provided 1:1 supervision to Resident #1 for a one hour block of time, from 8:00 A.M. to 9:00 A.M., can been seen on surveillance camera video footage, not providing 1:1 supervision at all times, she did not remain within an arm's length of Resident #1 during that entire time, can be seen on video, sitting with her back to him/her more than once and at other times was least 15 to 20 feet away from him/her. Resident #1 fell backwards, hit his/her head on the floor, sustained a head laceration, which required nine staples to close, and at the time of Resident #1's fall, CNA #1 was seated down the hall in a chair, with her back to him/her. Findings include: Review of the Facility policy titled, Fall Prevention Assessment, dated 11/05/20, indicated that the purpose of the Fall Prevention Assessment was to identify residents at risk for falls and associated injuries and to an implement appropriate plan of care to prevent falls. Resident #1 was admitted to the Facility in November 2019, medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 03/17/21, indicated he/she had severe cognitive impairment and was unable to make his/her own health care decisions. The MDS indicated Resident #1 required staff supervision while walking on the unit due to unsteadiness when walking and/or turning around. Review of Resident #1's Fall Risk Evaluations, dated 03/19/21, indicated he/she was at high risk for falls. Review of Resident #1's Plan of Care related to fall prevention, dated 04/08/21, indicated he/she required staff to provide 1:1 supervision due to an unsteady gait, poor balance, and poor safety awareness. Review of Resident #1's CNA Care Plan Reference Sheet Form, undated, indicated Resident #1 ambulated independently with a rollator (walker) and required staff to provide 1:1 supervision at all times for safety. Review of the Facility's Investigation, dated 05/07/21, indicated that morning, around 8:50 A.M., Resident #1, who was at high risk for falls and had a fall prevention care plan that required staff to provide 1:1 supervision (per administration, staff member to remain within an arm's length) at all times, was walking in the hallway, about 10 to 15 feet away from CNA #1, when he/she fell backwards, hit his/her head on the floor, and required a transfer to the hospital where he/she received nine staples to close a head laceration. The Investigation indicated that according to the surveillance video footage, CNA #1 failed to provide proper 1:1 supervision at all times to Resident #1, several times for several minutes, leading up to his/her fall, resulting in his/her fall with injury on 05/07/21. Review of the Hospital Medical Record, dated 05/07/21, indicated Resident #1 was evaluated in the Emergency Department after fall with head injury. The Record indicated he/she required nine staples to close the head laceration. Review of Resident #1's Nurse Progress Note, dated 05/07/21, indicated he/she returned from the hospital a few hours later with nine staples to his/her head. Review of Event Report, dated 05/07/21, 8:50 A.M., indicated that Resident #1 was ambulating with a walker when he/she fell backwards hitting his/her head on the floor sustaining a laceration to the back of his/her head. Review of the Physician's Progress Note, dated 5/07/21 and Written Witness Statement, dated 05/07/21, indicated Resident #1 was walking with his/her walker unaccompanied by staff and suddenly toppled backwards, hit the back of his/her head on the floor and sustained a head laceration with bleeding. The Statement indicated that someone needed to accompany Resident #1 at a closer distance to maintain his/her safety. During an interview on 06/28/21 at 9:00 A.M., Resident #1 said he/she recalled falling at the Facility on 05/07/21. Resident #1 said that while walking with his/her walker, he/she became dizzy and fell . Resident #1 said, Someone was supposed to be with me, real close, but they weren't with me. During an interview on 07/15/21 at 2:10 P.M., Certified Nurse Aide (CNA) #1 said that on 05/07/21 from 8:00 A.M. to 9:00 A.M., she was assigned to provide 1:1 supervision to Resident #1 because he/she was at risk for falls and elopement. CNA #1 said that when providing 1:1 supervision for Resident #1, she was supposed to stay close to the resident, in bubble space and said other staff members call it arms' length distance. CNA #1 said that staff members are required to stay within an arm's length of distance Resident #1, and said that she had provided 1:1 supervision of Resident #1 several times in the past, and knew what was required. CNA #1 said on that day, that while Resident #1 was walking in the hallway, she would sometimes walk with him/her but also sit in a chair in the hallway, observing him/her at times. CNA #1 said she was sitting in a chair when she saw Resident #1 tip backwards a little before he/she fell on to the floor, but said by the time she got to Resident #1, it was too late to prevent him/her from falling. The Compliance Officer (CO) said he interviewed CNA #1 about Resident #1's fall, asked her to explain what 1:1 supervision at all times of Resident #1 meant, and said CNA #1 answered appropriately, that CNA #1 said she needed to keep Resident #1 in her bubble and that CNA #1 further stated within arms' distance. During an interview on 06/28/21, at 2:00 P.M., the Chief Nursing Officer (CNO) said that on 05/07/21, CNA #1 neglected to implement interventions from Resident #1's plan of care when she failed to provide 1:1 supervision at all times to Resident #1, who was at high risk for falls and was care planned for fall prevention measures. The CNO said CNA #1 failed to maintain a safe distance (within arms' length) from Resident #1 for several minutes leading up to his/her fall with injury. The CNO said at the time of the fall, CNA #1 was seated in a chair with her back to Resident #1, who was ambulating and he/she was approximately 19 feet away from where CNA #1 was sitting (per CNO there were 19 floor tiles distance between them, and each tile measured 12 x 12 inches) at the time of the fall. The CNO said that all staff members, including CNA #1, were aware of Resident #1's needs and facility expectations when assigned to provide 1:1 supervision, at all times, to him/her as a fall prevention measure. The CNO said staff members were rotated and were only assigned for one hours blocks of time to provide 1:1 supervision for Resident #1. Review of the video footage provided by the Facility, and date stamped 05/07/21, from 08:30:00 to 08:52:32, depicted the hallway of Resident #1's care unit. The view of the hallway showed the nursing station directly to the left near the camera, and Resident #1's bedroom was towards the end of the hallway. The video depicted CNA #1 failing to provide proper 1:1 supervision at all times for Resident #1 on several occasions and for several minutes as he/she independently walked in the hallway with a walker, prior to his/her fall with injury. The video footage of Resident #1's unit depicts the following: 08:32:03 - 08:32:25, CNA #1 walked into view of the camera, past the nursing station and down the hallway, and sat into a chair in the hallway outside of Resident #1's bedroom. Resident #1 walked into view of the security camera, past the nursing station, and can be seen walking about 22 steps before coming approximately within an arm's length away from CNA #1. - CNA #1 failed to remain within an arm's length distance from Resident #1 for approximately 28 seconds. 08:38:10 to 08:38:22, Resident #1 walked into view of the camera, past the nursing station and walked about 15 steps before coming within approximately within an arm's length of distance from CNA #1. - CNA #1 failed to remain within an arm's length distance from Resident #1 for approximately 12 seconds. 08:39:42 to 08:41:21, Resident #1 and CNA #1 can be seen walking down the hallway together, then CNA #1 sat in the chair in the hallway as Resident #1 continued to walk about 19 steps (further than an arm's length of distance) away from her, past the nursing station, and became out of view of the camera for several seconds. Resident #1 walked back into view of the camera, past the nursing station, and can be seen walking about 22 steps (further than an arm's length of distance) before coming within an arm's length of CNA #1. Resident #1 walked about 18 steps (further than an arm's length of distance) passed CNA #1 before turning around at the end of the hallway and walking past CNA #1 again. CNA #1 stood up from the chair and walked about 7 steps to catch up to Resident #1. CNA #1 can be seen sitting in the chair with her back to Resident #1 as he/she walked down the far end of the hallway. - CNA #1 failed to remain within an arm's length distance from Resident #1 for almost three minutes. 08:43:48 to 08:44:32, Resident #1 walked about 12 steps away from CNA #1 and stood at the nursing station for about 45 seconds before CNA #1 walked up to him/her and came within arm's length of distance of Resident #1. - CNA #1 failed to remain within an arm's length distance from Resident #1 for approximately one minute and 24 seconds. 08:45:29 to 08:46:06, Resident #1 walked about 31 steps (further than an arm's length of distance) away from CNA #1, who walked the opposite direction towards the nursing station where she stood talking with staff. Resident #1 turned around at the end of the hallway and walked about 30 steps before returning within an arm's length of distance from CNA #1, who was near the nursing station. - CNA #1 failed remain within an arm's length distance from Resident #1 for approximately one minute and 17 seconds. 08:46:47 to 08:48:04, CNA #1 stood near the nursing station and grabbed a handful of linen and walked out of view of the security camera at the time Resident #1 walked in the opposite direction, about 56 steps to the end of the hallway where he/she turned around and walked about 36 steps before returning within an arm's length of distance from CNA #1. - CNA #1 failed to remain within an arm's length distance from Resident #1 for approximately two minutes and 37 seconds. 08:52:04 to 08:52:32, Resident #1 walked out of his/her bedroom, past CNA #1 who was sitting in the chair outside of his/her bedroom and walked about 17 steps towards the end of the hallway, turned around and walked about 14 steps forward, then walked about 7 steps backwards, and fell backwards onto the floor and his/her walker fell on top of him/her. CNA #1 stood up from the chair and walked over to Resident #1 after he/she had fallen onto the floor and sustained a head injury. - CNA #1 failed to remain within an arm's length distance from Resident #1 for approximately 28 seconds. On 06/28/21, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidence by: A. Resident #1 was sent to the hospital emergency department for evaluation and treatment, and returned to the Facility the same day, and his/her safety has been maintained since the fall on 05/07/21. B. On 05/07/21, Nursing Management wrote up a memo detailing 1:1 supervision requirements (within an arm's length) for staff education and future reference. C. All resident's Plan of Care and Care Plan Reference Sheets were reviewed by Nursing Management, and completed by 05/09/21, for the potential to be adversely affected by the concern area, Resident falls with injury. D. All nursing staff were in-serviced by Nursing Management (from 05/20/21 to 06/23/21) on the Facility's requirements of 1:1 resident supervision, Fall Prevention Assessments, resident's care card, and the Fall Prevention Policy. E. Nursing Management completed 15-minute checks (from 05/07/21 to 05/16/21) to ensure CNAs were appropriately completing 1:1 supervision for residents who required it for safety. F. Nursing Management completed 30-minute checks (effective 05/17/21 and remains on-going) to ensure CNAs were appropriately completing 1:1 supervision for residents who required it for safety. G. The concern area (resident falls and appropriate care plan implementation) was discussed during the weekly fall meeting (week of 05/10/21) with the interdisciplinary team to discuss Resident #1's fall, the Facility's Internal Investigation, and correction actions. H. The concern area (resident falls and appropriate care plan implementation) will be addressed at the next QAPI meeting and will continue to be discussed with the committee as needed for compliance and safety. I. The Facility updated the 1:1 supervision documentation form to include what the resident was doing at the time of the safety check. J. The Facility has reviewed and revised the supervision policy which is pending with their legal team for finalization. K. The Chief Nursing Officer/Chief Compliance Officer/ Designee is responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required 1:1 supervision (per administration, expectation was staff member to remain within arms' lengths of resident) at all times, including during ambulation, as a fall prevention intervention, the Facility failed to ensure Resident #1 was provided with an appropriate level of supervision, when on 5/07/21, the staff member who was assigned to provide 1:1 supervision at all times for him/her from 8:00 A.M. to 9:00 A.M., (staff members were rotated hourly due to the residents history of becoming agitated when same staff member provided 1:1 supervision for the entire shift), neglected to stay within an arm's length length of the resident several times during her assigned time, and during one of those times Resident #1 fell and sustained an injury. On 5/07/21, during the 7:00 A.M. to 3:00 P.M. shift, Certified Nurse Aide (CNA) #1, who was very familiar with Resident #1, had provided care to him/her many times and was aware the residents' care needs and plan of care, was assigned to provide Resident #1 with 1:1 supervision from 8:00 A.M. to 9:00 A.M., to help maintain his/her safety. CNA #1 can be seen on facility surveillance camera video footage failing to provide adequate 1:1 supervision at all times to Resident #1. At numerous times while CNA #1 was assigned to provide 1:1 supervision at all times, she can be seen with her back to Resident #1, and for several minutes just prior to him/her falling backwards and hitting his/her head on the floor, CNA #1 had her back to and was not within arms' length of him/her. Resident #1 was immediately assessed by nursing, was noted to be bleeding from his/her head, required emergent transfer to the Hospital Emergency Department, where he/she received nine staples to close the head laceration, he/she sustained as a result of the fall. Findings include: The Facility Policy titled, Prevention/Identification of Abuse, Neglect or Mistreatment, dated 03/11/21, indicated that neglect was defined as the failure to provide goods and services that are necessary to avoid physical harm and/or pain. Review of the Facility Policy titled, Fall Prevention Assessment, dated 11/05/20, indicated that the purpose of the Fall Prevention Assessment was to identify residents at risk for falls and associated injuries and to an implement appropriate plan of care to prevent falls. Resident #1 was admitted to the Facility in November 2019, medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 03/17/21, indicated he/she had severe cognitive impairment and was unable to make his/her own health care decisions. The MDS indicated Resident #1 required staff supervision while walking on the unit due to unsteadiness when walking and/or turning around. Review of Resident #1's Fall Risk Evaluations, dated 03/19/21, indicated he/she was at high risk for falls. Review of Resident #1's Plan of Care (POC) related to fall prevention, dated 04/08/21, indicated he/she required staff to provide 1:1 supervision at all times, due to an unsteady gait, poor balance, and poor safety awareness. Review of Resident #1's CNA Care Plan Reference Sheet Form, undated, indicated Resident #1 ambulated independently with a walker (rollator) and required staff to provide 1:1 supervision for safety. Review of the Facility's Investigation, dated 05/07/21, indicated that morning, around 8:50 A.M., Resident #1, who was at high risk for falls and had a fall prevention care plan that required staff to provide 1:1 supervision (remain within an arm's length) at all times, was walking in the hallway, about 10 to 15 feet away from CNA #1 (who was seated in a chair), when he/she fell backwards, hit his/her head on the floor, and required a transfer to the hospital where he/she received nine staples to close the laceration he/she sustained to his/her head. The Investigation indicated that according to the surveillance camera video footage, CNA #1 failed to provide proper 1:1 supervision to Resident #1 several times, for several minutes, leading up to his/her fall, resulting in his/her fall with injury on 05/07/21. Review of Event Report dated 05/07/21, 8:50 A.M., indicated that Resident #1 was ambulating with a rolling walker when he/she fell backwards hitting his/her head on the floor sustaining a laceration to the back of his/her head. Review of the Physician's Progress Note, dated 5/07/21 and Written Witness Statement, dated 05/07/21, indicated Resident #1 was walking with his/her walker unaccompanied by staff and suddenly toppled backwards, without bending his/her knees, hit the back of his/her head on the floor, sustained a head laceration with bleeding, and required a transfer to the hospital for further evaluation. The Written Statement indicated that someone needed to accompany Resident #1 at a closer distance to maintain his/her safety. During an interview on 06/28/21 at 9:00 A.M., Resident #1 said he/she recalled falling at the Facility on 05/07/21. Resident #1 said that while walking with his/her walker, he/she became dizzy and fell . Resident #1 said, Someone was supposed to be with me, real close, but they weren't with me. During an interview on 07/15/21 at 2:10 P.M., Certified Nurse Aide (CNA) #1 said that on 05/07/21 from 8:00 A.M. to 9:00 A.M., she was assigned to provide 1:1 supervision to Resident #1 because he/she was at risk for falls and elopement. CNA #1 said that when providing 1:1 supervision for Resident #1, she was supposed to stay close to the resident, in bubble space and said other staff members called it an arms' length distance. CNA #1 said that staff members are required to stay within an arm's length of distance Resident #1, and said that she had provided 1:1 supervision of Resident #1 several times in the past, and knew what was required. CNA #1 said that while Resident #1 was walking in the hallway, she would sometimes walk with him/her but also sit in a chair in the hallway, observing him/her at times. CNA #1 said she was sitting in a chair when she saw Resident #1 tip backwards a little before he/she fell on to the floor, but said by the time she got to Resident #1, it was too late to prevent him/her from falling. During an interview on 06/28/21, at 12:30 P.M., the Compliance Officer (CO) said that as part of the Facility's investigation into Resident #1's fall on 05/07/21, the surveillance camera footage was reviewed. The Compliance Officer said that when Resident #1 fell in the hallway, CNA #1 was not providing proper 1:1 supervision to Resident #1, based on what was seen on the video footage. The Compliance Officer (CO) said he interviewed CNA #1 about Resident #1's fall, asked her to explain what 1:1 supervision at all times of Resident #1 meant, and said CNA #1 answered appropriately, that CNA #1 said she needed to keep Resident #1 in her bubble and that CNA #1 further stated within arms' distance. During an interview on 06/28/21, at 2:00 P.M., the Chief Nursing Officer (CNO) said that on 05/07/21, CNA #1 neglected to implement interventions from Resident #1's plan of care when she failed to provide 1:1 supervision at all times to Resident #1, who was at high risk for falls and was care planned for fall prevention measures. The CNO said CNA #1 failed to maintain a safe distance (within arms' length) from Resident #1 for several minutes leading up to his/her fall with injury. The CNO said at the time of the fall, CNA #1 was seated in a chair with her back to Resident #1, who was ambulating and he/she was approximately 19 feet away from where CNA #1 was sitting (per CNO there were 19 floor tiles distance between them, and each tile measured 12 x 12 inches ) at the time of the fall. The CNO said that all staff members, including CNA #1, were aware of Resident #1's needs and facility expectations when assigned to provide 1:1 supervision at all time, of him/her as a fall prevention measure. The CNO said staff members were rotated and assigned for one hours blocks of time to provide 1:1 supervision for Resident #1, because he/she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 6/28/21 at 9:10 A.M., Nurse #2 said Resident #1 required 1:1 supervision at all times and said staff where aware that they needed to remain within arms' distance of him/her for safety reasons. During an interview on 6/28/21, at 9:13 A.M., CNA #3 said Resident #1 required 1:1 supervision at all times and said the expectation was that when staff members were assigned to provide Resident #1 with 1:1 supervision, they must stay within an arms' length distance of Resident #1 at all times. CNA #3 said they are assigned an hour each shift that they are responsible for providing 1:1 supervision for Resident #1 and then another staff member does the next hour. During an interview on 6/28/21, at 9:15 A.M., CNA #2 said Resident #1 required 1:1 supervision at all times and said staff members rotate taking turns providing 1:1 supervision for him/her, and were assigned for an hour to do so. CNA #2 said the staff member must stay within an arms' length of Resident #1 because he/she is a high risk for falls. Review of the video camera surveillance footage provided by the Facility, and date stamped 05/07/21, from 08:30:00 to 08:52:32, depicted the hallway of Resident #1's care unit. The view of the hallway shows the nursing station directly to the left near the camera, and Resident #1's bedroom was towards the end of the hallway. The video depicted CNA #1 failing to provide proper 1:1 supervision of Resident #1 on several occasions and for several minutes as Resident #1 independently walked in the hallway with a walker, prior to his/her fall with injury. The video camera surveillance footage of Resident #1's unit depicts the following: 08:32:03 to 08:32:25, CNA #1 walks into view of the camera, past the nursing station and down the hallway, and sits in a chair in the hallway outside of Resident #1's bedroom. Resident #1, who was not in his/her room, is then seen walking into view of the camera, past the nursing station, and is seen walking about 22 steps before coming approximately within an arm's length away from CNA #1. - CNA #1 failed to remain within an arm's length distance from Resident #1 for approximately 28 seconds. 08:38:10 to 08:38:22, Resident #1 walks into view of the camera, past the nursing station and walks about 15 steps before coming within approximately within an arm's length of distance from CNA #1. - CNA #1 failed to remain within an arm's length distance from Resident #1 for approximately 12 seconds. 08:39:42 to 08:41:21, Resident #1 and CNA #1 are seen walking down the hallway together, then CNA #1 sits in the chair in the hallway as Resident #1 continued to walk about 19 steps (further than an arm's length of distance) away from CNA #1 (who remains seated), past the nursing station, and then Resident #1 goes out of view of the camera for several seconds. Resident #1 then walks back into view of the camera, past the nursing station, and can be seen walking about 22 steps before coming within an arm's length of CNA #1. Resident #1 then walks about 18 steps (further than an arm's length of distance) passed CNA #1, who remains seated, before turning around at the end of the hallway and walks back past CNA #1 again. CNA #1 is seen getting up from the chair and walking about 7 steps to catch up to Resident #1. CNA #1 is next seen again, sitting in the chair with her back turned to Resident #1. -CNA #1 failed to remain within an arm's length distance from Resident #1 for almost three minutes. 08:43:48 to 08:44:32, Resident #1 walks about 12 steps away from CNA #1 and stands at the nursing station for about 45 seconds before CNA #1 walks up to him/her and is then within arm's length of distance of Resident #1. - CNA #1 failed to remain within an arm's length distance from Resident #1 for approximately one minute and 24 seconds. 08:45:29 to 08:46:06, Resident #1 walks about 31 steps (further than an arm's length of distance) away from CNA #1, who is seen walking in the opposite direction, away from Resident #1 towards the nursing station where she stood talking with staff. Resident #1 turns around at the end of the hallway and walks about 30 steps before returning within an arm's length of distance from CNA #1, who was near the nursing station. - CNA #1 failed to remain within an arm's length distance from Resident #1 for approximately one minute and 17 seconds. 08:46:47 to 08:48:04, CNA #1 stands near the nursing station, grabs a handful of linens and walks out of view of the surveillance camera, and at that same time Resident #1 can be seen walking in the opposite direction, about 56 steps to the end of the hallway where he/she turned around and walked about 36 steps before returning within an arm's length of distance from CNA #1. - CNA #1 failed to remain within an arm's length distance from Resident #1 for approximately two minutes and 37 seconds. 08:52:04 to 08:52:32, Resident #1 walks out of his/her bedroom, past CNA #1 who was sitting in the chair outside of his/her bedroom and walks about 17 steps towards the end of the hallway, he/she turns around and walks about 14 steps forward, then takes about 7 steps backwards, falls backwards onto the floor and his/her walker falls landing on top of him/her. CNA #1 who had her back to Resident #1, gets up from the chair and walks over to Resident #1, after he/she had fallen onto the floor. - CNA #1 failed to remain within an arm's length distance from Resident #1 for approximately 28 seconds. Review of the Hospital Medical Record, dated 05/07/21, indicated Resident #1 was evaluated in the Emergency Department after fall with head injury. The Record indicated he/she required staples to close the head laceration. Review of Resident #1's Nurse Progress Note, dated 05/07/21, indicated he/she returned from the hospital a few hours later with nine staples to his/her head. On 06/28/21, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidence by: A. Resident #1 was sent to the hospital emergency department for evaluation and treatment, and returned to the Facility the same day, and his/her safety has been maintained since the fall on 05/07/21. B. On 05/07/21, Nursing Management wrote up a memo detailing 1:1 supervision requirements (within an arm's length) for staff education and future reference. C. All resident's Plan of Care and Care Plan Reference Sheets were reviewed by Nursing Management, and completed by 05/09/21, for the potential to be adversely affected by the concern area, Resident falls with injury. D. All nursing staff were in-serviced by Nursing Management (from 05/20/21 to 06/23/21) on the Facility's requirements of 1:1 resident supervision, Fall Prevention Assessments, resident's care card, and the Fall Prevention Policy. E. Nursing Management completed 15-minute checks (from 05/07/21 to 05/16/21) to ensure CNAs were appropriately completing 1:1 supervision for residents who required it for safety. F. Nursing Management completed 30-minute checks (effective 05/17/21 and remains on-going) to ensure CNAs were appropriately completing 1:1 supervision for residents who required it for safety. G. The concern area (resident falls and appropriate care plan implementation) was discussed during the weekly fall meeting (week of 05/10/21) with the interdisciplinary team to discuss Resident #1's fall, the Facility's Internal Investigation, and correction actions. H. The concern area (resident falls and appropriate care plan implementation) will be addressed at the next QAPI meeting and will continue to be discussed with the committee as needed for compliance and safety. I. The Facility updated the 1:1 supervision documentation form to include what the resident was doing at the time of the safety check. J. The Facility has reviewed and revised the supervision policy which is pending with their legal team for finalization. K. The Chief Nursing Officer/Chief Compliance Officer/ Designee is responsible for overall compliance.

Based on interviews and records reviewed, the Facility failed, for one of three sampled residents (Resident #1) to provide supervision necessary to prevent an elopement, when Resident #1, who was cognitively impaired, eloped from the Facility without staff knowledge, was found by the Local Police, and required transfer to the Hospital for nausea and vomiting as a result of alcohol consumption. Findings include: The policy titled Code Yellow: Missing Resident, dated 8/1/17, indicated Residents who wander, exit seek, and/or elope their assigned unit would be identified and returned to their assigned unit, and any staff member who discovers a resident to be missing will activate the Code Yellow: Missing Resident by calling 211 on the phone and notifying the operator immediately at time of noted elopement. The Policy titled Wanderguard, dated 12/2009, indicated staff would assess residents to determine risk for elopement, and apply a wanderguard device (a small transmitter that sounds an alarm when a person at risk for elopement goes through a doorway) to the resident's limb. Resident #1 was admitted to the Facility 3/2017, [DIAGNOSES REDACTED]. Resident #1 had an activated Health Care Proxy in place (a person was designated to make health care decisions on his/her behalf, due to cognitive decline), and ambulated using a cane. Review of Resident #1's record indicated the following chain of events: - The Nurse's Notes, dated 4/22/17, indicated Resident #1 was off the unit for about five hours, and returned with a bag full of snacks and cigarettes, staff suspected alcohol use, however Resident #1 denied alcohol use, refused to tell staff where he/she had gone, and said he/she did not want to be at the Facility. - The Nurse's Notes, dated 4/23/17, indicated staff were not able to located Resident #1 after lunch, returned to the unit at approximately 3:00 P.M. with symptoms of alcohol use, was transferred to the emergency room , and later returned to the Facility. - The Nurse's Note, dated 5/21/17, indicated Resident #1 signed him/herself out at 1:56 P.M. and got out of the unit behind a visitor. The Note indicated Resident #1 was found at 3:45 P.M. walking outside on the street carrying a bag with an alcoholic beverage. The Note indicated a wanderguard device was applied to Resident #1. The Patient Wandering Assessment Guide, dated 5/21/17, indicated Resident #1 was at risk for wandering, and was assigned as Code Yellow. The Care Plan, initiated 5/21/17, and most recently revised 1/17/18, indicated Resident #1 was at high risk for elopement, interventions included staff would ensure the wanderguard was on his/her wrist or ankle, ensure wanderguard was in working order every shift, monitor Resident #1 on the unit, and Resident #1 would have an escort at all times when leaving the unit. The Nurse's Note, dated 5/22/17, indicated Resident #1 removed the wanderguard device, and staff applied the device to his/her cane. This was not consistent with the Policy titled Wanderguard, and the Care Plan initiated 5/22/17. The Event Report, dated 1/12/18, indicated that at approximately 3:00 P.M. staff could not locate Resident #1 and a Code Yellow was initiated. The Campus Police Report, dated 1/12/18, indicated at approximately 3:47 P.M., Campus Police were notified there was a Code Yellow called and that Resident #1 had not been seen since approximately 2:00 P.M. The Report indicated Resident #1 was found by the local Police Department and the Code Yellow was called all clear at approximately 5:00 P.M. The Surveyor interviewed Housekeeper #1 and the Director of Support Services at 12:48 P.M. on 5/22/18. Housekeeper #1 said at approximately 2:30 P.M. on 1/12/18 she was washing a window and saw Resident #1 walking down the street away from the Facility with his/her cane. Housekeeper #1 said she knew Resident #1 was not supposed to leave the Facility alone. Housekeeper #1 said she had not heard any alarms and had not seen Resident #1 leave the unit. Housekeeper #1 said she alerted Nurse #1 who was at the Nurses' station by saying (a resident) is walking down the street, or words to that effect, and Nurse #1 said don't worry, he/she will come back, or words to that effect, and said Nurse #1 did not go to investigate. Housekeeper #1 said Nurse #2 was looking for Resident #1 at approximately 3:00 P.M., and she told Nurse #2 that she had seen Resident #1 walking down the street. Housekeeper #1 said she alerted the Director of Support Services after speaking with Nurse #2 that she had seen Resident #1 walking down the street. The Surveyor interviewed Nurse #1 at 12:27 P.M. on 5/22/18. Nurse #1 said Resident #1 had a history of [REDACTED].#1 said that on 1/12/18 at approximately 2:00 P.M. Housekeeper #1 approached him while he was working at the Nurses' station and said she saw (a resident) outside, or words to that effect. Nurse #1 said Housekeeper #1 spoke in an accent, and he said he ignored her, or words to that effect, and did not go to investigate. Nurse #1 said that at approximately 3:00 P.M. Nurse #2 said she could not find Resident #1, and a Code Yellow was announced. Nurse #1 said he did not know how Resident #1 left the unit, said he did not recall hearing the wanderguard alarm sound at the time Resident #1 eloped. Nurse #1 said Resident #1 did have his/her cane with wanderguard device attached with him/her, and the wanderguard device was functioning and sounded the alarm when he/she returned. The Surveyor interviewed Nurse #2 at 3:12 P.M. on 5/22/18. Nurse #2 said Resident #1 walked using a cane, always had the cane with him/her, required the use of a wanderguard device due to history of elopement, however refused to have the device applied to his/her wrist, so it was applied to his/her cane. Nurse #2 said she came to work at approximately 2:45 P.M. on 1/12/18 and staff from the 7:00 A.M. to 3:00 P.M. shift were looking for Resident #1 at that time, and a Code Yellow was called. Nurse #2 said Housekeeper #1 told her she thought she saw Resident #1 walk down the street earlier. Nurse #2 said Resident #1 was located and returned to the Facility at approximately 5:00 P.M., was assessed by the Nurse Practitioner who was at the Facility at that time, and was later transferred to the Hospital for evaluation due to vomiting. The emergency room Note, dated 1/12/18, indicated Resident #1 arrived at the emergency room at 9:02 P.M. with [DIAGNOSES REDACTED].#1 was transferred back to the Facility. The Surveyor interviewed the Compliance Officer (CO) at 10:01 A.M. on 5/22/18. The CO said he reviewed the security camera footage from the time of Resident #1's elopement, and said he was not able to see when or how Resident #1 eloped from the Facility. The CO said it was likely Resident #1 exited behind a visitor, as he/she could easily be mistaken for a visitor.

Based on interviews and records reviewed, the Facility failed, for one of three sampled Residents (Resident #1), to provide supervision to prevent elopement, when Resident #1, who had a history of [REDACTED]. Findings include: The policy titled Code Yellow: Missing Resident, dated 8/1/17, indicated Residents who wander, exit seek, and/or elope their assigned unit would be identified and returned to their assigned unit, and any staff member who discovers a resident to be missing will activate the Code Yellow: Missing Resident by calling 211 on the phone and notifying the operator immediately at time of noted elopement. The Policy titled Wanderguard, dated 12/2009, indicated staff would assess residents to determine risk for elopement, and apply a wanderguard device (a small transmitter that sounds an alarm when a person at risk for elopement goes through a doorway) to the resident's limb. Resident #1 was admitted to the Facility 3/2017, [DIAGNOSES REDACTED]. Resident #1 had an activated Health Care Proxy in place (a person was designated to make health care decisions on his/her behalf, due to cognitive decline), and ambulated using a cane. Review of Resident #1's record indicated the following chain of events: - The Nurse's Note, dated 4/22/17, indicated Resident #1 was off the unit for about five hours, and returned with a bag full of snacks and cigarettes, staff suspected alcohol use, however Resident #1 denied alcohol use, refused to tell staff where he/she had gone, and said he/she did not want to be at the Facility. - The Nurse's Note, dated 4/23/17, indicated staff were not able to locate Resident #1 after lunch, Resident #1 returned to the unit at approximately 3:00 P.M. with symptoms of alcohol use, was transferred to the emergency room , and later returned to the Facility. - The Nurse's Note, dated 5/21/17, indicated Resident #1 signed him/herself out at 1:56 P.M. and got out of the unit behind a visitor. The Note indicated Resident #1 was found at 3:45 P.M. walking outside on the street carrying a bag with an alcoholic beverage. The Note indicated a wanderguard device was applied to Resident #1's wrist. The Patient Wandering Assessment Guide, dated 5/21/17, indicated Resident #1 was at risk for wandering, and was assigned as Code Yellow. The Care Plan, initiated 5/21/17, and most recently revised 1/17/18, indicated Resident #1 was at high risk for elopement, interventions included staff would ensure the wanderguard was on his/her wrist or ankle, ensure wanderguard was in working order every shift, monitor Resident #1 on the unit, and Resident #1 would have an escort at all times when leaving the unit. The Nurse's Note, dated 5/22/17, indicated Resident #1 removed the wanderguard device from his/her wrist, and staff applied the device to his/her cane. This was not consistent with the Policy titled Wanderguard, and the Care Plan initiated 5/22/17, and the policy titled Wanderguard. The Event Report, dated 1/12/18, indicated that at approximately 3:00 P.M. staff could not locate Resident #1, and a Code Yellow was initiated. The Campus Police Report, dated 1/12/18, indicated at approximately 3:47 P.M., Campus Police were notified there was a Code Yellow called and that Resident #1 had not been seen since approximately 2:00 P.M. The Report indicated Resident #1 was found by the local Police Department and the Code Yellow was called all clear at approximately 5:00 P.M. The Surveyor interviewed Housekeeper #1 and the Director of Support Services at 12:48 P.M. on 5/22/18. Housekeeper #1 said at approximately 2:30 P.M. on 1/12/18 she was washing a window and saw Resident #1 walking down the street away from the Facility with his/her cane. Housekeeper #1 said she knew Resident #1 was not supposed to leave the Facility alone. Housekeeper #1 said she had not heard any alarms and had not seen Resident #1 leave the unit. Housekeeper #1 said she alerted Nurse #1 who was at the Nurses' station by saying (a resident) is walking down the street, or words to that effect, and Nurse #1 said don't worry, he/she will come back, or words to that effect, and said Nurse #1 did not go to investigate. Housekeeper #1 said Nurse #2 was looking for Resident #1 at approximately 3:00 P.M., and she told Nurse #2 that she had seen Resident #1 walking down the street. Housekeeper #1 said she alerted the Director of Support Services after speaking with Nurse #2 that she had seen Resident #1 walking down the street. The Surveyor interviewed Nurse #1 at 12:27 P.M. on 5/22/18. Nurse #1 said Resident #1 had a history of [REDACTED].#1 said that on 1/12/18 at approximately 2:00 P.M. Housekeeper #1 approached him while he was working at the Nurses' station and said she saw (a resident) outside, or words to that effect. Nurse #1 said Housekeeper #1 spoke in an accent, and he said he ignored her, or words to that effect, and did not go to investigate. Nurse #1 said that at approximately 3:00 P.M. Nurse #2 said she could not find Resident #1, a Code Yellow was announced. Nurse #1 said he did not know how Resident #1 left the unit, said he did not recall hearing the wanderguard alarm sound at the time Resident #1 eloped, and said Resident #1 did have his/her cane with wanderguard device attached with him/her, and the wanderguard device was functioning and sounded the alarm when he/she returned. The Surveyor interviewed Nurse #2 at 3:12 P.M. on 5/22/18. Nurse #2 said Resident #1 walked using a cane, always had the cane with him/her, required the use of a wanderguard device due to history of elopement, however refused to have the device applied to his/her wrist, so it was applied to his/her cane. Nurse #2 said she came to work at approximately 2:45 P.M. on 1/12/18 and staff from the 7:00 A.M. to 3:00 P.M. shift were looking for Resident #1 at that time, and a Code Yellow was called. Nurse #2 said Housekeeper #1 told her she thought she saw Resident #1 walk down the street earlier. Nurse #2 said Resident #1 was located and returned to the Facility at approximately 5:00 P.M., was assessed by the Nurse Practitioner who was at the Facility at that time, and was later transferred to the Hospital for evaluation due to vomiting. The emergency room Note, dated 1/12/18, indicated Resident #1 arrived at the emergency room at 9:02 P.M. with [DIAGNOSES REDACTED].#1 was transferred back to the Facility.