Every finding on record at Vantage at Lowell LLC

Based on observation and interviews, the facility failed to store and handle food in accordance with professional standards for food service safety, potentially putting the residents at risk for foodborne illness. Specifically, the facility failed to: Ensure that perishable food items and produce were stored, labeled/dated, and discarded appropriately, and did not show signs of decomposition. Ensure staff did not handle ready-to-eat food with potentially contaminated gloves. Findings include: Review of the facility's policy titled Preventing Foodborne Illness - Food Handling, dated October 2025, indicated, but was not limited to, the following:-Policy Statement: Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. -This facility recognizes that the critical factors implicated in foodborne illness are:>Poor personal hygiene of food service employees;>Inadequate cooking and improper holding temperatures;>Contaminated equipment; and>Unsafe food sources. -All employees who handle, prepared or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents. Review of the facility's policy titled Food: Safe Handling for Foods from Visitors, revised February 2023, indicated, but was not limited to, the following:-Refrigerator/freezers for storage of foods brought in by visitors will be properly maintained and:>Daily monitoring for refrigerated storage duration and discard of any food items that have been stored for greater than/equal to 7 days (storage of frozen foods and shelf stable items may be retained for 30 days). 1. On 6/1/26 at 7:08 A.M., the surveyor made the following observations during the initial walk-through of the main kitchen:-An opened container of cottage cheese labeled with an opened date of 5/21/26 in the reach-in refrigerator.-Two crates of half-pint fat-free milk cartons dated 5/31/26 in the walk-in refrigerator; additionally, there were four half-pint fat-free milk cartons dated 5/31/26 that were mixed with whole milk cartons in a large, black container in the walk-in refrigerator.-One opened 46-ounce carton of orange juice, labeled with an opened date of 5/24/26. -Tomatoes stored in a large, clear container in the walk-in refrigerator with significant signs of decomposition, including textural and color changes; multiple tomatoes had a fuzzy black, white, and/or green growth resembling mold scattered throughout with a milky, liquid substance underneath them.-Green peppers stored in large, clear container in the walk-in refrigerator with significant signs of decomposition, including textural changes, with a dark green, liquid substance underneath them. On 6/1/26 at 7:47 A.M., the surveyor made the following observation during the tray line service at breakfast:-Three half-pint fat-free milk cartons dated 5/31/26 mixed with whole milk cartons in a large, black container with ice next to the tray line. The surveyor observed the Food Service Director grabbing milk cartons from the large, black container and placing them on resident trays for service. On 6/1/26 at 1:43 P.M., the surveyor made the following observations in the left-wing nourishment kitchen:-One 46-ounce bottle of nectar-thick orange juice, opened and approximately 3/4 full, with no opened date and manufacturer's instructions to discard if not used within 10 days of opening. -One 46-ounce bottle of nectar-thick lemon-flavored water, opened and approximately halfway full, with no opened date and manufacturer's instructions to discard after seven days of opening. -One 32-ounce carton of a nectar-thick dairy drink, opened and approximately 1/3 full, with no opened date manufacturer's instructions to discard after seven days of opening.-One 46-ounce bottle of cranberry juice cocktail, opened and approximately halfway full, with no opened date. On 6/1/26 at 1:54 P.M., the surveyor made the following observations in the right-wing nourishment kitchen:-One 46-ounce bottle of nectar-thick orange juice, opened and approximately 3/4 full, with no opened date and manufacturer's instructions to discard if not used within 10 days of opening. On 6/2/26 at 1:50 P.M., the surveyor made the following observations during a follow-up visit to the main kitchen:-An opened container of cottage cheese labeled with an opened date of 5/21/26 in the reach-in refrigerator.-One full crate of half-pint fat-free milk cartons dated 5/31/26 in the walk-in refrigerator. -Tomatoes stored in a large, clear container in the walk-in refrigerator with significant signs of decomposition, including textural and color changes; multiple tomatoes had a fuzzy black, white, and/or green growth resembling mold scattered throughout with a milky, liquid substance underneath them.-Green peppers stored in a large, clear container in the walk-in refrigerator with significant signs of decomposition, including textural changes, with a dark green, liquid substance underneath them. During an interview on 6/4/26 at 9:03 A.M., the Food Service Director (FSD) said she checks the main kitchen one to three times daily for dating/labeling and food quality, including signs of decomposition/mold on produce, due to risk of foodborne illness. The FSD said the opened container of cottage cheese in the reach-in refrigerator should have been discarded one week after opening, or on 5/28/26, and it was not. The FSD said the tomatoes in the walk-in refrigerator were moldy and should have been discarded; she said the peppers showed signs of decomposition and should have been discarded. The FSD said the half-pint milk cartons dated 5/31/26 should have been discarded the morning of 6/1/26 and should not have been served during the breakfast tray line service. The FSD said the opened container of orange juice in the walk-in refrigerator should have been discarded within one week, or by 5/31/26, and it was not. The FSD said nursing is responsible for dating beverages in the nourishment kitchens once opened; dietary is responsible for checking the nourishment kitchens one to three times daily and ensuring foods/beverages in the refrigerators are discarded appropriately and should not be utilized past manufacturer's instructions. During an interview on 6/4/26 at 9:03 A.M., the Corporate District Manager said the opened container of cottage cheese in the reach-in refrigerator should have been discarded one week after opening, or on 5/28/26, and it was not. The Corporate District Manager said the tomatoes and peppers in the walk-in refrigerator should have been discarded. The Corporate District Manager said the half-pint milk cartons dated 5/31/26 should have been discarded the morning of 6/1/26, however would find it acceptable if staff had tasted the milk on or after 6/1/26 and if it tasted okay, could be served to the residents. The Corporate District Manager said all staff are responsible for dating beverages in the nourishment kitchens once opened; dietary is responsible for checking the nourishment kitchens one to three times daily and ensuring foods/beverages in the refrigerators are discarded appropriately and should not be utilized past manufacturer's instructions. During an interview on 6/4/26 at 9:45 A.M., the Director of Nursing (DON) said all staff are responsible for dating beverages in the nourishment kitchens once opened, and the juices in the nourishment kitchens should have been labeled with an opened date or discarded due to risk of foodborne illness. 2. On 6/1/26 at 7:26 A.M., the surveyor made the following observations during the tray line service at breakfast:-At 7:33 A.M., the [NAME] paused assembling hot breakfast plates to make a fruit plate. With gloved hands, the [NAME] touched the left handle of the reach-in refrigerator with her left hand to open it, potentially contaminating her left glove, retrieved a container of fruit cocktail, unwrapped the container, and proceeded to assemble the fruit plate. Without changing gloves, the [NAME] re-wrapped the container of fruit cocktail, touched the left handle of the reach-in refrigerator with her right hand to open it, potentially contaminating her right glove, returned the container of fruit cocktail to the refrigerator, and used her left hand to close the refrigerator door. Without changing gloves, the [NAME] returned to the steamtable to continue assembling hot plates and proceeded to handle ready-to-eat French toast directly with both potentially contaminated gloved hands for multiple resident plates for service. During an interview on 6/2/26 at 6:35 A.M., the [NAME] said it is acceptable to touch food directly with gloved hands as long as she changes her gloves in between tasks. The [NAME] said she should have changed her gloves after potentially contaminating them when touching the refrigerator door and door handle and before directly handling ready-to-eat French toast, but did not. The [NAME] said not changing gloves when potentially contaminated puts the residents at risk of foodborne illness. During an interview on 6/4/26 at 9:03 A.M., the Food Service Director (FSD) said dietary staff should not touch food directly and should utilize utensils for serving. The FSD said staff should change gloves after potential contamination, including touching refrigerator doors and door handles due to risk of foodborne illness. The FSD said the [NAME] should have changed her gloves and performed hand hygiene after touching the refrigerator door and door handle and should have used utensils to serve the French toast. During an interview on 6/4/26 at 9:03 A.M., the Corporate District Manager said dietary staff should not touch food directly and should utilize utensils for serving due to risk of foodborne illness.

Based on observation and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically, the facility failed to ensure medications were dated once opened according to manufacturer's guidelines, failed to ensure an unopened insulin was stored properly in two of two medication carts observed, and the treatment cart was locked when unattended on one of two units. Findings include:Review of the facility policy titled 'Medication Labeling and Storage', undated, indicated:-Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices.-Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly.-Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.-Multi-dose vials that have been opened or accessed (example, needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. 1.On 6/2/26 at 1:57 P.M., the surveyor and Nurse #3 observed the left-wing B-side medication cart:-Budesonide formoterol 160/4.5 micrograms (mcg) opened and undated.-Bevespi glycopyrrolate and formoterol 9mcg/4.8mcg opened and undated.-Anoro ellipta 62.5mcg/25mcg opened and undated.-Qvar redihaler 40mcg opened and undated.-Symbicort 160/4.5mcg opened and undated.-Fluticasone propionate nasal spray 50 mcg opened and undated.-Humalog kwik pen insulin unopened and not refrigerated. Manufacturer's directions to keep unopened insulin refrigerated until ready to use.-Novolog insulin unopened and not refrigerated. Manufacturer's directions to keep unopened insulin refrigerated until ready to use. During an interview on 6/2/26 at 2:07 P.M., Nurse #3 said inhalers and nasal sprays should be dated once opened and insulins should be refrigerated until ready to use. During an interview on 6/2/26 at 2:17 P.M., Unit Manager #1 said medications with short expiration dates should be dated when opened and insulins should be refrigerated until ready to use. 2. On 6/2/26 at 1:57 P.M., the surveyor and Nurse #2 observed the right-wing A-side medication cart:-Lantus insulin vial opened and undated.-Lantus insulin pen unopened and not refrigerated. Manufacturer's directions to keep unopened insulin refrigerated until ready to use.-Trilegy ellipta inhaler opened and undated.-Budesonide and formoterol inhaler opened and undated. 3. On 6/2/26 at 2:41 P.M., the surveyor observed the right-wing treatment cart unlocked and unattended. During an interview on 6/2/26 at 2:37 P.M., Nurse #2 said inhalers and insulins should be dated when opened. Unopened insulin should be refrigerated, and treatment carts should be locked. During an interview on 6/4/26 at 9:31 A.M., the Director of Nursing said medications with short expiration dates including inhalers and insulin should be dated once opened and unopened insulin should be refrigerated.

Based on observation, interviews, and record review, the facility failed to ensure services provided met professional standards for three Residents (#6, #17, and #78) out of a total sample of 21 residents. Specifically: 1.For Resident #6, who has a wound on his/her right foot, the facility failed to ensure the physician order to offload the right foot from pressure was implemented,2. For Resident #17, who has a wound on his/her right foot, the facility failed to ensure the physician order to offload the right foot from pressure was implemented,3. For Resident #78, who was assessed as being at risk of and had a recent history of pressure ulcers/injuries, the facility failed to ensure his/her air mattress was at the correct setting as indicated in the physician's order. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019 indicated the following: - The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. 1. Resident #6 was admitted to the facility in June 2021 with diagnoses including paraplegia, diabetes and chronic non-pressure ulcer of the right foot. Review of Resident #6's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she had intact cognition. On 6/1/26 at 8:05 A.M., Resident #6 was observed lying in bed with his/her right foot directly on the bed and not offloaded from pressure. During an interview at this time, Resident #6 said he/she had a wound on his/her right foot but had never had any type of equipment to offload pressure on the foot from the bed. On 6/2/26 at 6:45 A.M,. Resident #6 was observed lying in bed with his/her right foot directly on the bed and not offloaded from pressure. On 6/4/26 at 6:53 A.M., Resident #6 was observed lying in bed with his/her right foot directly on the bed and not offloaded from pressure. Review of Resident #6's physician's orders indicated the following order initiated on 9/18/25: -Right lateral Foot. Keep pressure off wounds, Apply off loading air boot when in bed Review of Resident #6's wound care plan initiated on 10/8/24 indicated the following intervention: -Elevate and offload heels while in bed Date Initiated: 10/08/2024 During an interview on 6/4/26 at 8:29 A.M., Nurse #5 said Resident #6 has a wound on his/her right foot. Nurse #5 then reviewed Resident #6's physician orders with the surveyor and said the Resident has an order to offload pressure to the right foot when in bed and that his/her foot should never be directly on the bed. Nurse #5 said this order has not been implemented by the staff. During an interview on 6/4/26 at 9:30 A.M., the Director of Nursing (DON) said all orders should be implemented as ordered by the physician. The DON said this order for Resident #6 needs to be implemented daily so that the would on his/her foot does not worsen from additional pressure from the mattress. 2. Resident #17 was admitted to the facility in May 2023 with diagnoses including polyneuropathy and chronic kidney disease. Review of Resident #17's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, which indicated he/she was cognitively intact. On 6/1/26 at 8:08 A.M., Resident #17 was observed lying in bed with his/her right heel directly on the bed. The Resident refused an interview at this time. On 6/2/26 6:44 A.M., Resident #17 was observed lying in bed with his/her right heel directly on the bed. The Resident refused an interview at this time. On 6/4/26 at 6:53 A.M., Resident #17 was observed lying in bed with his/her right heel directly on the bed. Review of Resident #17's physician orders indicated the following order initiated on 5/28/26: -Cleanse right heel wound with non-cytotoxic wound cleanser (dakin's solution), Apply betadine to peri-wound, gently pack with silver alginate rope. Cover with foam bordered gauze and apply offloading shoe/boot. During an interview on 6/4/26 at 8:29 A.M., Nurse #5 said Resident #17 has a wound on his/her right foot. Nurse #5 then reviewed Resident #17's physician orders with the surveyor and said the Resident has an order to offload pressure to the right foot when in bed and that his/her foot should never be directly on the bed. Nurse #5 said this order has not been implemented by the staff. During an interview on 6/4/26 at 9:30 A.M., the Director of Nursing (DON) said all orders should be implemented as ordered by the physician. The DON said this order for Resident #17 needs to be implemented daily so that the would on his/her foot does not worsen from additional pressure from the mattress. 3. Resident #78 was admitted to the facility in June 2021 with diagnoses including multiple sclerosis, chronic pain syndrome, and type 2 diabetes with polyneuropathy (a complication of diabetes characterized by progressive, widespread damage to the peripheral nerves). Review of the most recent Minimum Data Set (MDS) assessment, dated 4/9/26, indicated that Resident #78 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15, and required assistance from staff with activities of daily living. The MDS further indicated that Resident #78 was at risk of developing pressure ulcers/injuries. On 6/1/26 at 9:06 A.M., 12:02 P.M., 12:41 P.M., and 1:37 P.M., the surveyor observed Resident #78 lying in bed on an air mattress set to 250 pounds. Resident #78 said he/she is on an air mattress due to a history of pressure injuries on her buttocks that have been chronically reopening and closing over the last five years. The Resident said his/her air mattress setting is supposed to be at 200 pounds. On 6/2/26 at 6:52 A.M. and 1:59 P.M., the surveyor observed Resident #78 lying in bed on an air mattress set to 250 pounds. On 6/4/26 at 6:48 A.M., the surveyor observed Resident #78 lying in bed on an air mattress set to 250 pounds. Review of Resident #78's active physician orders indicated the following: -Alternating pressure air mattress to bed to promote healing of wounds, setting should be at 200, every shift for skin, initiated 3/28/22. Review of Resident #78's altered skin care plan indicated the following: -Focus: Resident #78 has actual skin breakdown to bilateral buttocks, MASD (moisture-associated skin damage- erosion or inflammation of the skin caused by long-term exposure to moisture), recent DTI (deep tissue injury- a type of pressure ulcer/injury where damage occurs to underlying soft tissues beneath intact skin), initiated 9/30/21. -Goal: Wounds will show signs of improvement by decrease in size and no symptoms of infection through next review, initiated 9/9/21. -Intervention: Air mattress to bed set per order, initiated 10/17/22. During an interview on 6/4/26 at 7:01 A.M., Certified Nursing Assistant #7 said Resident #78 has an air mattress due to open areas on his/her buttocks, and the risk of an overinflated air mattress is potential worsening of skin issues. CNA #7 said she is unsure of Resident #78's air mattress settings, and the nurse is responsible for monitoring/adjusting the air mattress. During an interview on 6/4/26 at 6:52 A.M., Nurse #7 said Resident #78's air mattress should be set to 200 pounds per the physician's order and checked for the correct setting every shift by nursing. During a telephone interview on 6/4/26 at 11:21 A.M., Nurse Practitioner #2 said physician orders should be followed as written, including air mattress orders, and the risk of an overinflated air mattress is potential worsening of skin issues. During an interview on 6/4/26 at 12:08 P.M., the Director of Nursing (DON) said physician orders should be followed as written. The DON said Resident #78's air mattress should have been set to 200 pounds as indicated in the physician's order, not 250 pounds, and the risk of an overinflated mattress is potential development or worsening of skin issues.

Based on observation, interviews, and record review, the facility failed to ensure staff maintained complete and accurate medical records for 3 Residents (#6, #17 and #45) out of a total sample of 21 residents. Specifically, the facility failed: For Residents #6 and #17, the facility failed to accurately document the implementation of physician orders, and 2. For Resident #45, to ensure behavior monitoring documentation was completed every shift on the Documentation Survey Report (a report showing Certified Nursing Assistant documentation for activities of daily living). 1a. Resident #6 was admitted to the facility in June 2021 with diagnoses including paraplegia, diabetes and chronic non-pressure ulcer of the right foot. Review of Resident 36's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she had intact cognition. On 6/1/26 at 8:05 A.M., Resident #6 was observed lying in bed with his/her right foot directly on the bed and not offloaded from pressure. During an interview at this time, Resident #6 said he/she had a wound on his/her right foot but had never had any type of equipment to offload pressure on the foot from the bed. On 6/2/26 at 6:45 A.M,. Resident #6 was observed lying in bed with his/her right foot directly on the bed and not offloaded from pressure. On 6/4/26 at 6:53 A.M., Resident #6 was observed lying in bed with his/her right foot directly on the bed and not offloaded from pressure. Review of Resident #6's physician's orders indicated the following order initiates on 9/18/25: -Right lateral Foot. Keep pressure off wounds, Apply off loading air boot when in bed Review of the Treatment Administration Report for the days of observations indicated that nursing had documented the above order as complete. During an interview on 6/4/26 at 8:29 A.M., Nurse #5 said Resident #17 has a wound on his/her right foot. Nurse #5 then reviewed Resident #6's physician orders with the surveyor and said that this order should not have been marked as completed if the Resident's foot was not offloaded. During an interview on 6/4/26 at 9:30 A.M., the Director of Nursing (DON) said orders should only be marked as completed if actually done. The DON said doing otherwise would be an inaccurate medical record. 1b. Resident #17 was admitted to the facility in May 2023 with diagnoses including polyneuropathy and chronic kidney disease. Review of Resident #17's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, which indicated he/she was cognitively intact. On 6/1/26 at 8:08 A.M., Resident #17 was observed lying in bed with his/her right heel directly on the bed. The Resident refused an interview at this time. On 6/2/26 6:44 A.M., Resident #17 was observed lying in bed with his/her right heel directly on the bed. The Resident refused an interview at this time. On 6/4/26 at 6:53 A.M., Resident #17 was observed lying in bed with his/her right heel directly on the bed. Review of Resident #17's physician orders indicated the following order initiated on 5/28/26: -Cleanse right heel wound with non-cytotoxic wound cleanser (dakin's solution), Apply betadine to peri-wound, gently pack with silver alginate rope. Cover with foam bordered gauze and apply offloading shoe/boot. Review of the Treatment Administration Report for the days of observations indicated that nursing had documented the above order as complete. During an interview on 6/4/26 at 8:29 A.M., Nurse #5 said Resident #17 has a wound on his/her right foot. Nurse #5 then reviewed Resident #17's physician orders with the surveyor and said that this order should not have been marked as completed if the Resident's foot was not offloaded. During an interview on 6/4/26 at 9:30 A.M., the Director of Nursing (DON) said orders should only be marked as completed if actually done. The DON said doing otherwise would be an inaccurate medical record. 2. Resident #45 was admitted to the facility in January 2025 with diagnoses including delirium, anxiety, and depression. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/28/26, indicated that Resident #45 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of a possible 15. Review of Resident #45's medical record indicated the Resident exhibited behaviors per nursing progress note on 1/30/26 (manic episode with Resident kicking things/punching staff) and was hospitalized from [DATE] to 5/28/26 for altered mental status/delirium with worsening hallucinations over the previous month. Review of the Documentation Survey Report for the month of May 2026 indicated that behavior monitoring was only documented on 57 out of 93 shifts. Review of the Documentation Survey Report for the month of June 2026 indicated that behavior monitoring was only documented on 6 out of 10 shifts. During an interview on 6/2/26 at 8:21 A.M., Certified Nursing Assistant (CNA) #2 said that CNA's are responsible for documenting daily care, including behaviors in the electronic medical record. During an interview on 6/4/26 at 12:08 P.M., the Director of Nursing (DON) said all medical record documentation should be accurate and complete, including behavior monitoring by CNAs.

Based on interview and record review, the facility failed to ensure that one Resident (#58), out of a total sample of 21 residents, was free from significant medication errors.Specifically, the facility failed to ensure nursing held midodrine (medication used to raise blood pressure) in accordance with the physician's orders. Findings include:Review of the facility policy titled 'Administering Oral Medications', dated October 2010, indicated but not limited to the following:-Verify that there is a physician's medication order for this procedure.-Review the resident's care plan to assess any special needs of the resident. Resident #58 was admitted to the facility in March 2026 with diagnoses including orthostatic hypotension. Review of the most Minimum Data Set (MDS) assessment, dated 4/17/26, indicated that Resident #58 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 15 out of 15. Review of Resident #58's physician's order, dated 4/21/26, indicated:-Midodrine HCL tablet 2.5 milligram (mg), give one tablet by mouth two times a day for hypotension. Hold for systolic blood pressure (SBP) is greater than 130 take with meal. Review of Resident #58's Medication Administration Record (MAR), dated April 2026 through May 2026, indicated nursing administered Resident #58's midodrine on the following dates and times despite the physician's order to hold for a systolic blood pressure greater than 130: -4/15/26 at 6:00 P.M., blood pressure 138/70.-4/18/26 at 6:00 P.M., blood pressure 154/88.-4/19/26 at 6:00 P.M., blood pressure 132/74.-4/30/26 at 6:00 P.M., blood pressure 132/78.-5/2/26 at 6:00 P.M., blood pressure 132/70.-5/3/26 at 6:00 P.M., blood pressure 132/74.-5/18/26 at 8:00 A.M., blood pressure 132/72.-5/19/26 at 8:00 A.M., blood pressure 136/77.-5/19/26 at 6:00 P.M., blood pressure 138/76.-5/24/26 at 8:00 A.M., blood pressure 132/75-5/30/26 at 6:00 P.M., blood pressure 134/66 During an interview on 6/2/26 at 9:07 A.M., Unit Manager (UM) #1 said that Resident #58 receives midodrine. UM #1 said that midodrine is used to help raise his/her blood pressure. UM #1 said that Resident #58's order has parameters that nursing should be following and hold the midodrine if systolic blood pressure is greater than 130. During an interview on 6/2/26 at 12:53 P.M., the Director of Nursing said nurses should be following physician's orders for blood pressure parameters and medication should not be administered outside the parameters.

Based on record review, observation, and interview, the facility failed to ensure pharmaceutical services met the needs of each resident. Specifically, the facility failed to ensure an insulin emergency kit was replaced by the pharmacy after being opened on one out of two units. Findings include: Review of the facility policy titled 'Emergency Pharmacy Service And Emergency Kits', dated January 2024, indicated:-The nurse records the medication used from the emergency kit on the medication order/use form and calls the pharmacy for replacement of the kit/dose and/or flags the kit with a color-coded lock to indicate need for replacement of kit/dose as soon as possible after the medication has been administered. On 6/2/26 at 2:09 P.M., during the inspection of the medication room on the left-wing, the surveyor observed an insulin kit in the refrigerator; the kit was opened and some of the contents had been removed from the kit. There was no documentation indicating what had been removed, when it was removed and who had removed the items. There was no way of knowing if the kit had been reordered from the pharmacy for a replacement kit. During an interview on 6/2/26 at 2:13 P.M., Nurse #3 said it seemed like the only item missing was a Lantus insulin, she said the nurse who opened the kit should have documented the paperwork located in the kit and faxed it to the pharmacy for a replacement kit. During an interview on 6/2/26 at 2:16 P.M., Unit Manager #1 said when the emergency kits are opened the nurse should document what was taken out of the kit and faxed to the pharmacy for a replacement. During an interview on 6/4/26 at 11:33 A.M., the Director of Nursing said the nurse opening the kit should fill out the form in the kit and fax it to the pharmacy for a replacement kit.

Based on record review and interview, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) plan. Specifically, the facility failed to monitor the effectiveness and of a QAPI plan put in place for 1a. falls assessments being completed and 1b. the temperature of the food served to the residents. Findings include: Review of the facility policy titled Quality Assurance Equality Assurance and Performance Improvement, undated, indicated the following:A system must be in place in order to monitor policies using the data gathered, including input from staff, residents, families and others as appropriate. Performance indicators should be used to monitor the continuum of care and outcomes. Findings should be reviewed in the context of established benchmarks and/or targets established by the facility for performance. The Administrator and leaders will evaluate the QAPI program on an ongoing basis to determine if conclusions based on findings are accurate and interventions for improvements have been implemented. 1a. During an interview on 6/4/26 at 11:49 A.M., the Administrator said that through the month of April 2026, he had initiated a QAPI plan for the completion of falls assessments throughout the facility. The Administrator said that QAPI projects are monitored with audits and discussed monthly at each QAPI meeting. Review of the QAPI Action Plan for April 2026 indicated a concern of fall assessments not being completed monthly and every quarter. The QAPI estimated completion date indicated that the project was ongoing. During the interview on 6/4/26 at 11:49 A.M., the Administrator was asked if the QAPI project was reviewed during the May 2026 QAPI meeting and the Administrator could not say if the falls assessment QAPI was followed up on or reviewed during the May monthly QAPI meeting. The Administrator also could not provide any follow up audits or meeting minute notes regarding the falls assessments. During an interview on 6/4/26 at 11:54 A.M., Corporate Nurse #1, who was the former Director of Nursing, said that falls assessments were not reviewed during the monthly meetings in May 2026 and the facility could not provide any measures of performance for the falls assessment QAPI plan. 1b. During the Resident Group meeting on 6/2/26 at 10:11 A.M., all residents who were able to cognitively participate, about 9 Residents in total, complained that the food is consistently cold and cold every morning during the breakfast meal. Review of the Resident Council Minutes, dated April 2026 indicated the following:Residents said the food on the trays and coffee is often served cold. A staff member explained that the team will observe a meal pass and might buy a pellet warmer.Review of QAPI plan, dated 4/15/26, indicated the following: Problem statement: Food temperatures have been temping below temp range. Goal: All temps will be within range. Review of the QAPI audits for April and May indicate that the Administrator had completed tray temperatures weekly until 5/15/26. Review of the QAPI plan for food temperatures indicated that during the Resident council May meeting minutes the Residents stated food was much improved and temps were [sic]. Review of the Resident Council Minutes, dated 5/26/26, indicated the following: Is food being served at proper temperature? Residents say no but understand it is a work in progress, residents say it is inconsistent. During an interview on 6/4/36 at 10:30 A.M., the Corporate Food Service staff member said that the facility has tried to maintain the appropriate temperatures on their end and has implemented sign off sheets and has checked the steam tables to ensure proper holding temperatures. The Corporate Food Service staff member said that the food service department has done everything they can on their end and that a QAPI had been started with nursing. She could not speak to the QAPI plan and deferred to the Administrator and nursing. During an interview on 6/4/26 at 11:49 A.M., the Administrator said that food has been an issue since they got the current food service company in place and said he doesn't feel as though the QAPI has been resolved, despite the documentation on the May QAPI minutes. The Administrator said that he thinks a pellet warmer will be a game changer but could not speak to the status of the pellet warmer. The Administrator said that he was in charge of doing the random audits for obtaining the temperatures of the food, but he said that he would only get the temperature of one item on the tray, usually the meat.

Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Specifically,1.) For Resident #78, the facility failed to implement enhanced barrier precautions. 2.) For Resident #7, the facility failed to implement enhanced barrier precautions. Findings include: Review of the facility policy titled 'Enhanced Barrier Precautions, undated, indicated, but was not limited to the following:-Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents.-Gloves and gown are applied prior to performing the high contact resident care activity. -Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: bathing/showering, providing hygiene, and wound care.1.) Resident #78 was admitted to the facility in June 2021 with diagnoses including osteoarthritis and diabetes.Review of the most recent Minimum Data Set (MDS) assessment, dated 4/9/26, indicated Resident #78 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS also indicated Resident #78 was dependent on staff for bed mobility, transfers, and mobility.Review of Resident #78's plan of care related to skin breakdown of bilateral buttocks, revised 4/16/26, indicated: Follow protocol for Enhanced Barrier precautions.Review of Resident #78's Kardex (a quick-reference tool used to communicate patient care information to nurses and certified nurse assistants), dated 6/2/26, indicated: Wear gown when providing wound care.On 6/1/26 at 12:38 P.M., the surveyor observed Nurse #1 roll Resident #78 onto his/her side in bed and remove his/her brief, cleanse wounds of his/her bilateral buttocks, and apply a topical cream to these bilateral buttock wounds. Nurse #1 was only wearing gloves and was not wearing a precaution gown during this observation. Nurse #1 said this bilateral buttock wounds are chronic wounds. There was a sign indicating the need for enhanced barrier precautions posted on Resident #78's door.During an interview on 6/2/26 at 11:30 A.M., Resident #78 said staff is supposed to wear a precaution gown when performing wound care, but more than half the time they do not. During an interview on 6/2/26 at 11:31 A.M., Certified Nurse Assistant (CNA) #1 said Resident #78 is on enhanced barrier precautions because of his/her wounds. CNA #1 said staff should wear a gown and gloves during any high contact resident care, such as wound care. During an interview on 6/2/26 at 9:43 A.M., the Infection Control Nurse said Resident #78 was on enhanced barrier precautions because of his/her chronic bilateral buttocks wounds. The Infection Control Nurse said nurses should always wear a precaution gown and gloves during wound care.During an interview on 6/2/26 at 12:01 P.M., the Director of Nursing (DON) said residents with chronic wounds require enhanced barrier precautions. If a Resident is on enhanced barrier precautions, the staff should wear a precaution gown and gloves for all high contact resident activities, including wound care or hygiene/bathing. The DON said Resident #78 is on enhanced barrier precautions and the nurse should have worn a gown in addition to gloves during wound care.2.) Resident #7 was admitted to the facility in February 2026 with diagnoses including diabetes and chronic kidney disease.Review of the most recent Minimum Data Set (MDS) assessment, dated 4/3/26, indicated Resident #7 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS also indicated Resident #7 had an indwelling urinary catheter. Review of Resident #7's plan of care, revised 3/15/26, indicated: Special Instructions: Enhanced barrier precautions d/t (due to) foley (indwelling urinary) catheter.Review of Resident #7's Kardex, dated 6/2/26, indicated: Wear gowns with dressing, transferring, bathing/showering, providing hygiene, toileting, changing linens, toileting/incontinent care.On 6/1/26 at 10:15 A.M., the surveyor observed Certified Nurse Assistant (CNA) #4 providing a bed bath to Resident #7. CNA #4 was wearing gloves but was not wearing a precaution gown. There was no sign outside of Resident #7's door indicating the resident was on Enhanced Barrier Precautions and there was no cart containing PPE outside of the door. During an interview on 6/2/26 at 11:16 A.M., Resident #7 was observed in his/her wheelchair with urinary catheter bag visible attached to bottom of wheelchair. Resident #7 said she has an indwelling urinary catheter. Resident #7 says staff are supposed to wear a precaution gown, but they often do not. During an interview on 6/2/26 at 11:23 A.M., CNA #3 said she was unaware if Resident #7 was on any special precautions. CNA #3 said she was unaware if enhanced barrier precautions were required for residents with indwelling urinary catheters. During an interview on 6/2/26 at 11:24 A.M., Nurse #3 said she had never heard of enhanced barrier precautions. Nurse #3 said Resident #7 was on universal precautions, not enhanced barrier precautions, because he/she had an indwelling urinary catheter. Nurse #3 said because Resident #7 had an indwelling urinary catheter that staff should always wear a precaution gown and gloves while performing hygiene or providing a bed bath.During an interview on 6/2/26 at 12:01 P.M., the Director of Nursing (DON) said residents with indwelling urinary catheters require enhanced barrier precautions. If a Resident is on enhanced barrier precautions, the staff should wear a precaution gown and gloves for all high contact resident activities, including hygiene/bathing. The DON said staff should have been wearing a precaution gown, in addition to gloves, while performing hygiene or providing a bed bath to Resident #7.

Based on interviews and record review, the facility failed to provide behavioral health services, resulting in subsequent psychiatric hospitalization, for one Resident (#45) out of a total sample of 21 residents. Findings include:Review of the facility policy titled Behavioral Health Services, undated, indicated the following:-Policy Statement: The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. -Behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care. -Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care. -Residents who do not display symptoms of, or have not been diagnosed with, mental, psychiatric, psychosocial adjustment, substance abuse or post-traumatic stress disorder(s) will not develop behavioral disturbances that cannot be attributed to a specific clinical condition that makes the pattern unavoidable. -Staff training regarding behavioral health services includes, but is not limited to:a. Recognizing changes in behavior that indicate psychological distress;b. Implementing care plan interventions that are relevant to the resident's diagnosis and appropriate to his or her needs;c. Monitoring care plan interventions and reporting changes in condition; andd. Protocols and guidelines related to the treatment of mental disorders, psychosocial adjustment difficulties, history of trauma and post-traumatic stress disorder.-Behavioral health services are provided by staff who are qualified and competent in behavioral health and trauma-informed care. -Staff are scheduled in sufficient numbers to manage resident needs throughout the day, evening and night. Resident #45 was admitted to the facility in January 2025 with diagnoses including delirium, anxiety, and depression. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/28/26, indicated that Resident #45 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of a possible 15. During an interview on 6/2/26 at 1:00 P.M., Resident #45 said he/she has anxiety, depression, and new hallucinations which resulted in a hospitalization last month. Resident #45 said he/she has not experienced any further hallucinations since returning from the hospital. Resident #45 said he/she was seen by behavioral health services once in July 2025 but did not receive any additional follow-up and would have liked to continue receiving behavioral health services for his/her mental health. During an interview on 6/2/26 at 1:05 P.M., Family Member #1 said Resident #45 started experienced new hallucinations over the last few months that had been worsening, including a child living underneath his/her roommate's bed and a man pulling women into his room and raping them. Family Member #1 also said Resident #45 had increased behaviors, including attempting to hit nursing staff a couple weeks prior to his/her hospitalization. Family Member #1 said she told Resident #45's Health Care Proxy about the hallucinations, who had discussed it with nursing staff. During a telephone interview on 6/2/26 at 3:12 P.M., Resident #45's Health Care Proxy (HCP #1) said Resident #45 started developing new hallucinations that had been worsening over the last month which resulted in hospitalization. HCP #1 said the Resident would speak nonsensically, hear things that weren't there, and would see a man come into his/her room. HCP #1 said she notified facility staff of the new hallucinations one month ago. HCP #1 said she cannot recall Resident #45 being seen by behavioral health services and would have wanted the Resident to receive these services for his/her mental health. Review of Resident #45's behavioral health services note, dated 7/24/25, indicated:-Chief Complaint: Increased anxiety and depression- restlessness. -Problem: Nursing staff requested writer to assess patient as patient has increased anxiety and depression, but fair appetite. Patient stating he/she is doing well, but restless, anxious and stating he/she feels tired and depressed. -Clinical Assessment: Increase Sertraline (a prescription antidepressant medication) to 75 mg (milligrams) PO (by mouth) once a day for depression/anxiety, and also start Buspirone (a prescription medication typically used for anxiety) 2.5 mg (milligrams) by mouth twice a day for depression and patient continues to benefit from psychiatric medications. Monitor mood, document behaviors and contact (behavioral health services) if needed. -Follow-Up: 1-4 weeks -Plan/Recommendations: >Discontinue Trazodone (a prescription antidepressant medication) 25 mg (milligrams) by mouth every 8 hours as needed for anxiety for 14 days. >Sertraline Hydrocholoride, give 25 mg (milligrams) by mouth for depression/anxiety (together with scheduled 50 milligrams TTO/total 75 milligrams). >Buspirone Hydrochloride, give 2.5 mg (milligrams) by mouth twice a day PRN (as needed) for anxiety. Review of the medical record failed to indicate that Resident #45 received behavioral health services follow-up after the initial visit on 7/24/25, or that the recommendations for trazodone or buspirone were implemented.Review of Resident Council Minutes for October 2025 indicated Resident #45 said there was a child staying in the room next to her, and the Resident was told to notify nursing staff if she sees others in his/her bathroom besides residents. Review of the medical record failed to indicate a referral to psych/behavioral health services was made during this time. Review of Resident #45's nursing progress note, dated 1/30/26, indicated the following: Resident was noted to (be) acting weird, like a manic episode, she was flaring her legs kicking things, punching staff, unable to redirect. Review of the medical record failed to indicate the physician was notified of this new behavior or that behavioral health services were contacted. Review of Resident #45's psychotropic medication care plan, initiated 5/7/26, indicated the following interventions:-Psych services as indicated, initiated 5/7/26. Review of Resident #45's care plan meeting progress note, dated 5/20/26, indicated the following: HCP #1 states Resident #45 has a history of VH (visual hallucinations) and seeing people in the bathroom. Resident #45 states the hallucinations are not distressing or frightening. No command content. Discussed Resident following up with psych which HCP #1 was in agreement to and consent for behavioral health in chart. Review of the medical record failed to indicate a referral was made to behavioral health services after this meeting and prior to the Resident's hospitalization. Review of the medical record indicated that Resident #45 was hospitalized from [DATE]-[DATE] for hallucinations requiring psychotropic medication adjustment. During an interview on 6/4/26 at 12:57 P.M., Certified Nursing Assistant #6 said Resident #45 hallucinates sometimes, such as grabbing things that aren't there. During an interview on 6/2/26 at 2:11 P.M., Nurse #6 said she is unsure about Resident #45's mood or behaviors. Nurse #6 said the unit manager, nursing, and secretary are responsible for ensuring behavioral health follow-up visits are scheduled and completed, and that Resident #45 should have been seen within 1-4 weeks as recommended after his/her initial visit on 7/24/25. During an interview on 6/4/26 at 1:00 P.M., Nurse #5 said Resident #45 was having hallucinations a couple weeks ago resulting in hospitalization. During an interview on 6/2/26 at 2:31 P.M., the Infection Control Nurse said she also works as a unit manager on Resident #45's floor. The Infection Control Nurse said Resident #45 was initially seen by behavioral health services for increased anxiety and depression in July 2025; however, the recommended follow-up appointment never happened due to inconsistent staffing for behavioral health services for multiple consecutive months, and residents in the building, including Resident #45, could not receive the psych services they needed. The Infection Control Nurse said Resident #45 started having hallucinations one month prior to his/her hospitalization, and she was told of the hallucinations by activities during a meeting and notified the Nurse Practitioner. The Infection Control Nurse said the Nurse Practitioner ordered labs but did not make a referral to behavioral health services at this time. Infection Control Nurse said other nursing staff were not as aware of the hallucinations due to poor communication and documentation in the medical record. The Infection Control Nurse said Resident #45 would benefit from regular behavioral health services, which may have prevented Resident #45's recent hospitalization through medication adjustment/monitoring.During an interview on 6/4/26 at 1:01 P.M., the Activities Director said Resident #45 has been experiencing intermittent visual and auditory hallucinations since October 2025 that have been getting worse, including seeing a boy in the bathroom at nighttime. The Activities Director said she notified nursing, the Director of Nursing, and the administrator regarding Resident #45's hallucinations in October. During an interview on 6/4/26 at 10:38 A.M., Nurse Practitioner (NP) #1 said there was a lapse in behavioral health coverage for a few months during which providers were not consistently coming to the facility. NP #1 said the medication recommendations made by behavioral health services in July 2025 should have been implemented but weren't. NP #1 said she was unaware Resident #45 was having hallucinations until approximately two days prior to his/her hospitalization and was unaware the Resident was having hallucinations for one month prior, but would have wanted to be notified. NP #1 said it would have been beneficial for Resident #45 to have been followed by behavioral health services. NP #1 said behavioral health services can assist with medication management and could have identified the need for psychotropic medication adjustment that could have prevented the Resident's hospitalization. The surveyor was unable to communicate with anyone at behavioral health services due to no staff assigned to Resident #45 in the established timeframe. During an interview on 6/4/26 at 12:08 P.M., the Director of Nursing (DON) said there has been a lapse in behavioral health services since she has been there and in-house providers do not address psych medication changes. The DON said nursing should be documenting all behaviors and should have notified the physician as soon as Resident #45 started developing hallucinations. The DON said it would have been beneficial for Resident #45 to be followed by behavioral health services especially for psychotropic medication management, which could have prevented the Resident's hospitalization.During a telephone interview on 6/4/26 at 1:06 P.M., the Medical Director said behavioral health services are an important support service for all residents. The Medical Director said Resident #45 should have received behavioral health follow-up and psychotropic medication monitoring, which could have prevented the Resident's hospitalization.

Based on observations, interviews, and record review, the facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC) consistent with professional standards of practice for one Resident (#84), out of a total sample of 21 residents. Specifically, for Resident #84, the facility failed to implement a physician's order for weekly routine PICC dressing changes, as required. Findings include:Review of the facility policy titled 'Central Venous Catheter Dressing Changes', dated March 2018, indicated:-Central venous catheter dressings will be changed at specific intervals, or when needed, to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings.-Change transparent semi-permeable membrane (TSM) dressings at least every 7 days and PRN (when wet, soiled, or not intact). Resident #84 was admitted to the facility in March 2026 with diagnoses including acute osteomyelitis (a serious inflammatory bone infection) of the right ankle and foot. Review of the Minimum Data Set (MDS) assessment, dated 5/8/26, indicated Resident #84 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The MDS further indicated Resident #84 received intravenous medications. On 6/1/26 at 9:47 A.M., the surveyor observed Resident #84 in bed with a PICC dressing on his/her left arm. The dressing was undated, the Resident said he/she was receiving antibiotics three times a day for foot infection. Resident #84 said the dressing had been changed a few days ago. Review of Resident #84's physician's order, initiated 5/6/26, indicated:-Change PICC on left arm weekly and as needed as needed for dressing change.-Change PICC on left arm weekly and as needed every day shift every Thursday for dressing change.-Measure arm circumference and external catheter with each PICC dressing change on left arm as needed. Record each measurement. Discontinued 5/7/26. Review of Resident #84's Treatment Administration Record (TAR), dated 5/8/26 to 5/28/26, failed to indicate the PICC line dressing had been changed, or arm circumference and external catheter measured. During an interview on 6/2/26 at 1:54 P.M., Nurse #3 said the PICC line dressing should be changed 24 hours after admission, every seven days and as needed. The dressing should be dated when changed and arm circumference and external catheter measured. During an interview on 6/2/26 at 2:20 P.M., Unit Manager #1 said the PICC line dressing should have been changed weekly with arm circumference, external catheter measured, and the dressing should be dated. She further said Resident #84's orders should have indicated a schedule to change the dressing. During an interview on 6/4/26 at 7:44 A.M., the Director of Nursing said PICC dressing changes should be done 24 hours after admission and every seven days. She further said Resident #84 had been sent out to the hospital and upon return the PICC dressing change orders fell off.

Based on record review and interview, the facility failed to identify and address a significant weight gain for one Resident (#1), with diagnosed congestive heart failure, out of a total sample of 21 residents. Findings include: Review of the facility policy titled Weight Assessment and Intervention, revised March 2022, indicated the following: Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. The evaluation includes:The relationship between current medical condition or clinical situation and recent fluctuations in weight Resident #1 was admitted in July 2025 with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, and hypertension. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #1 scored a 14 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the care plan for Resident #1 indicated the following:Focus: Resident #1 has congestive heart failure (CHF) and is at risk for respiratory distress (initiated 7/11/25) Interventions: Monitor/document/report any signs and symptoms of congestive heart failure: weight gain unrelated to intake (initiated 7/11/25) Focus: Resident #1 is at nutrition related risk d/t (due to) PMH (past medical history) including afib (atrial fibrillation), HTN (hypertension) & HD (heart disease) w/ CHF (congestive heart failure) (initiated 7/16/25)Goal: Maintain a weight free from significant changes (initiated 5/2/22) Review of the weight summary report for Resident #1 indicated the following weights: 8/1/25: 192 lbs (pounds) 10/31/25: 187.7 lbs12/9/25: 189.3 lbs2/13/26: 215.6 lbs3/5/26: 219.4 lbs Review of the weights indicated that between 12/9/25 to 2/13/26, Resident #1 gained 26.3 pounds in 3 months, which is a 12% significant weight gain. Review of the medical record failed to indicate that the dietitian was notified or the physician was notified of the weight gain. Review of the nursing progress notes failed to indicate that the significant weight gain was identified. Review of the physician's progress note, dated 2/16/26, failed to address the significant weight gain. Review of the physician's progress note, dated 3/9/26, indicated Resident #1 had CHF exacerbation with pleural effusion (fluid in between the lungs and chest wall). Review of the progress note indicated Resident #1's diuretic medication was increased from 20 milligrams to 40 milligrams. Review of the nutrition progress notes indicated that Resident #1 was evaluated for his/her significant weight gain on 3/16/26, one month after the significant weight gain was identified. During an interview on 6/2/26 at 12:38 P.M., the Dietitian said that if a Resident has a weight loss or gain over 5% in the last month then it would be considered significant. The Dietitian said that resident's should be seen within 3-5 days if there is a change in status. The Dietitian said that if a Resident had congestive heart failure, then she would have expected the Resident to be evaluated by the Dietitian sooner than one month. The Dietitian said that Resident's on diuretics and who are diagnosed with CHF could have potential health impacts due to weight changes. During an interview on 6/4/26 at 8:30 A.M., the Director of Nursing said that she would have expected Resident #1 to be seen at least within the week of a significant weight change, especially with a CHF diagnosis.

Based on observations, record reviews and interviews, the facility failed to provide assistance with oral care, specifically assistance with dentures, for one Resident (#36) out of a total sample of 21 residents. Findings include: Review of the facility policy titled, Dentures, Cleaning and Storing, undated, indicated the following:-Provide denture care before breakfast and at bedtime. Encourage and assist the resident as needed to rinse his or her mouth after each meal. -Encourage the resident to keep dentures in his or her mouth as much as possible. When dentures are left out of the mouth for several days, the bone structure to the mouth changes and the gums will shrink causing the dentures to fit improperly. Resident #36 was admitted to the facility in June 2021 with diagnoses including dementia. Review of Resident #36's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 5 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #36 had no natural teeth and required supervision for oral care. On 6/1/26 at 7:55 A.M., Resident #36 was observed lying in bed with no observable teeth. During an interview at this time, Resident #36 said he/she has dentures but has not worn them in a long time. Resident #36 said staff do not assist him/her with any oral care. Resident #36 said he/she would like to wear his/her dentures. On 6/2/26 at 8:19 A.M., Resident #36 was observed lying in bed eating breakfast. He/she had no dentures in and said staff had not asked to assist him/her to put his/her dentures in prior to eating. Resident #36 said he/she would have worn the dentures to eat had they been offered. Review of Resident #36's last dental visit on 3/12/26 indicated the Resident has dentures and needs assistance with placing the dentures in his/her mouth and with daily oral care. Review of Resident #36's activities of daily living care plan initiated on 7/9/21, indicated the following intervention:-Requires cues/assistance by staff with personal hygiene and oral care. Review of Resident #36's denture care plan initiated on 4/10/23 indicated the following intervention:-Provide mouth care as per ADL personal hygiene Review of Resident #36's Kardex (a form indicating the level of assistance required) indicated the following:-Requires cues/assistance by staff with personal hygiene and oral care. Review of Resident #36's medical record failed to indicate the Resident refuses the use of dentures. During an interview on 6/2/26 at 8:21 A.M., Certified Nursing Assistant (CNA) #2 said she has worked at the facility for a year and knows Resident #36 well. CNA #2 said she has never seen Resident #36 wear dentures while she has worked at the facility. CNA #2 said providing a resident with assistance with dentures is part of daily care. During an interview on 6/2/26 at 10:44 A.M., the Director of Nursing (DON) said she would have expected the staff to place Resident #36's dentures in his/her mouth prior to meals as it is part of oral care. The DON said if the Resident refused the use of dentures she would have expected to see a note of refusal in the medical record. On 6/4/26 at approximately 8:00 A.M., Resident #36 was observed lying bed after eating breakfast. The Resident did not have his/her dentures in and said no one offered to assist him/her to place the dentures in his/her mouth. Resident #36 said he/she had no difficulty eating breakfast but would have worn his/her dentures if offered. During an interview on 6/4/26 at approximately 8:10 A.M., CNA #6 said she was responsible for Resident #36's care today. CNA #6 said she did not offer to place Resident #36's dentures in his/her mouth prior to breakfast.

Based on observation and interview, the facility failed to protect resident privacy on one of two units. Specifically:1. The facility failed to ensure nursing staff were not on personal cellphone calls during the medications pass on the Right Unit.2. The facility failed to ensure nursing staff covered computer screens, displaying personal resident information while unattended on the Right Unit. Findings include:Review of the facility's policies titled Release of Information, undated, and Electronic Medical Records, undated, did not include information related to procedures or guidelines related to staff taking personal calls during medication pass or expectations for securing and locking computer screens while unattended. 1. On 6/4/26 at 1:00 P.M., the surveyor approached Nurse #5 at her medication cart on the Right Unit. Nurse #5 was preparing medications, and her phone was standing vertically on the medication cart in front of a cup of medications. A resident nearby was speaking to Nurse #5 and Nurse #5 said oh that's just my old guy/girl. When the surveyor approached Nurse #5 and said she had questions about a resident and asked if Nurse #5 was on her phone, Nurse #5 responded that's okay. The surveyor informed her that the surveyor would be asking questions about a resident which would include personal and identifying information. Nurse #5 then said I'll call you back, and hung up the phone. During an interview on 6/4/26 at 1:25 P.M., The Director of Nursing said that nurses should not be on the phone while performing medication pass and should not speak about residents while on a personal call. 2. On 6/1/26 at 8:32 A.M., Nurse #1 left her nursing cart to deliver medications to a resident room. The computer screen was left open with resident health care information displayed to anyone walking by. On 6/1/26 at 12:20 P.M., and from 12:39 P.M. to 12:55 P.M., Nurse #1 left her nursing cart to deliver medications to a resident room. The computer screen was left open with resident health care information displayed to anyone walking by.During an interview on 6/4/26 at 1:25 P.M., the Director of Nursing said computer screens at the nursing carts should be closed when nursing is not present to ensure patient confidentiality.

Based on records reviewed, interviews and observations, for one of three sampled residents (Resident #1) whose bed was equipped with an air mattress, had limited mobility in his/her lower extremities and was dependent on staff for bed mobility, the facility failed to ensure he/she was provided with the necessary level of staff assistance during care to maintain his/her safety. On 04/08/26, Certified Nurse Aide #1, while providing care to Resident #1 by herself, turned and repositioned Resident #1 onto his/her side, away from herself (CNA #1), Resident #1 rolled off the bed and fell to the floor. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation and treatment and was diagnosed with bilateral distal femur fractures (both legs above the knee joint area).Findings include:Review of the facility's policy, titled Falls and Fall Risk, Managing, undated, indicated that staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.Resident #1 was admitted to the facility in July 2025, diagnoses included Chronic Obstructive Pulmonary Disease (COPD-a progressive lung disease that makes it difficult to breathe), Congestive Heart Failure (CHF- a long-term condition that affects the heart's ability to beat well), and Cerebral Vascular Accident (CVA/stroke).Review of the Report submitted by the facility via the Health Care Facility Reporting System (HCFRS), dated 04/09/26, indicated that on 04/08/26, Resident #1 was being cleaned in bed by a Certified Nurse Aide (CNA-later identified as CNA #1), when Resident #1 was rolled onto his/her left side, with his/her right leg on top, [away from CNA #1] slipped out of CNA #1's hands and onto the floor. Resident #1 was transferred to the Hospital ED for evaluation and treatment.Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated he/she was diagnosed with bilateral distal femur fractures with displacement (fracture fragments are not in line with normal anatomy) and lipohemarthrosis (marrow fat leaks into the joint space; a hallmark finding in distal femur fractures that extend into the knee joint).Review of the Facility's Post Fall Investigation, dated 04/08/26, indicated that the Root Cause of the Fall was changing resident that required two [staff] assist by one [staff] assist and air mattress.The Investigation included the intervention initiated immediately after the fall, to prevent a reoccurrence, was to educate [the CNA] to ask for help for residents who [per care plan were dependent] required assistance of two staff members.Review of Resident #1's Minimum Data Set (MDS) assessment, with a reference date of 01/15/26, indicated Resident #1 was dependent on staff for dressing, hygiene, toileting (the ability to maintain perineal hygiene), required maximum staff assistance for bed mobility, was non-ambulatory and always incontinent of bowel and bladder.The Assessment also indicated that Resident #1 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS- score of 13-15 suggests no cognitive impairment, 8-12 suggests moderate cognitive impairment, and 0-7 suggests severe cognitive impairment).Review of Resident #1's admission/readmission screen, dated 4/03/26, indicated he/she expressed a desire to have side rails while in bed, that bilateral quarter side rails were recommended, consent had been obtained, physician's order was in place and he/she had a plan of care in place for the use of side rails.Review of Resident #1's Activities of Daily Living (ADL) Care Plan, reviewed and renewed with his/her January 2026 MDS, that had a goal date of 04/15/26, indicated the following interventions were in place on 04/08/26:-He/she was totally dependent on staff for positioning and turning in bed/chair.-He/she required assist/dependent for toileting and personal hygiene.Review of Resident #1's Skin Care Plan, with a goal date of 04/15/26, indicated he/she was at risk for [impaired] skin integrity due to decreased mobility and incontinence. The Care Plan included an intervention to ensure he/she had an air mattress as ordered.During an observation and interview on 04/21/26 at 10:50 A.M., the surveyor observed Resident #1 lying in bed on an air mattress, with bilateral 1/4 side rails in the up position at the head of the bed. The side rails were short in length and nearer the top of the bed and would be difficult for Resident #1 to access and hold on while receiving care.Resident #1 said that he/she fell out of bed recently when he/she was being changed. Resident #1 said his/her side rail was not used (up) that day. Resident #1 said his/her legs were very heavy and when he/she was put on his/her side by CNA #1, he/she felt his/her legs begin to slip and he/she fell off the bed, landing on the floor. Resident #1 said CNA #1 rolled him/her away from, and not towards, herself (CNA #1). Resident #1 said he/she was not a surgical candidate and now he/she has to wear braces to both legs. Resident #1 said when he/she tries to move his/her legs the pain is 10 out of 10.During an interview (which included a review of her written witness statement) on 04/21/26 at 3:46 P.M., Certified Nurse Aide (CNA) #1 said that Resident #1 was well known to her and she had provided care for him/her several times. CNA #1 said Resident #1 was on her assignment on 04/08/26 and she thought she could provide his/her care by herself. CNA #1 said in the past, she had changed Resident #1's bed linens by herself and Resident #1 was able to hold onto the side rail while she did it.CNA #1 said on 04/08/26 she went into Resident #1's room, noticed his/her brief was soiled and offered to change it. CNA #1 said she pulled Resident #1 towards her in bed using his/her incontinent pad and then rolled Resident #1 onto his/her left side [away from herself] so he/she could hold onto the side rail while she provided incontinent care, and that in the blink of an eye Resident #1 rolled off the bed onto the floor.CNA #1 said any resident who uses an air mattress needs two staff assist and if Resident #1's care plan said that he/she was dependent for bed mobility it meant he/she needed assistance of two staff members.CNA #1 said she had sometimes provided Resident #1's care with another CNA, but on that day, she felt she could provide his/her care by herself. CNA #1 said she should have had someone else with her to provide Resident #1's care.During an interview (which included a review of her written witness statement) on 04/21/26 at 3:16 P.M., Nurse #1 said she was on duty on 04/08/26 when she was alerted by CNA #1 that Resident #1 had fallen out of bed. Nurse #1 said she immediately went to Resident #1's room and found him/her on the floor next to his/her bed. Nurse #1 said Resident #1 was in a lot of pain and said his/her right knee hurt.Nurse #1 said Resident #1 was well known to her and that he/she required assistance of two staff members for bed mobility and care due to his/her size, immobility, and need of a mechanical lift for transfers out of bed. Nurse #1 said CNA #1 required more education because the other CNAs used two assists to care for Resident #1 but CNA #1 closed Resident #1's door and began providing care without asking for help from other staff.Nurse #1 said that staff should always roll residents towards themselves when in bed and not away from themselves.During an interview (which included a review of his written witness statement) on 04/21/26 at 3:33 P.M., Nursing Supervisor #1 said he was on duty on 04/08/26 when he was alerted that Resident #1 had sustained a fall out of bed. Nursing Supervisor #1 said when he arrived at Resident #1's room he/she was on the floor next to his/her bed and he/she complained of right knee and right hip pain.Nursing Supervisor #1 said Resident #1 required assistance of two staff members for care and that CNA #1 should have had someone else with her while she provided care for Resident #1.During a telephone interview on 04/22/26 at 2:31 P.M., Physical Therapist #1 said she completed Resident #1's PT evaluation on 04/06/26. PT #1 said Resident #1 required partial/moderate assistance with bed mobility from a therapy standpoint and was dependent for bed mobility from a nursing standpoint. PT #1 said the level of assistance often differs between therapy and nursing.During an interview on 04/21/26 at 4:27 P.M., the Director of Nurses (DON) reviewed Resident #1's ADL Care Plan with the surveyor and the DON said that Resident #1 was dependent for bed mobility which meant he/she needed assistance of two staff members. The DON said that the facility determined that CNA #1 should not have rolled Resident #1 away from her and that Resident #1's air mattress played a role in his/her fall as they can be unstable.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) the facility failed to ensure they maintained a complete and accurate medical record related to his/her Activities of Daily Living (ADLs), when daily documentation by Certified Nurse Aides was incomplete, with some ADL's left blank. Findings include:Review of the facility's policy titled Charting and Documentation, undated, indicated the following:-All services provided to the resident shall be documented in the resident's medical record.-Documentation in the medical record will be complete and accurate.Resident #1 was admitted to the facility in July 2025, diagnoses included Chronic Obstructive Pulmonary Disease (COPD-a progressive lung disease that makes it difficult to breathe), Congestive Heart Failure (CHF- a long-term condition that affects the heart's ability to beat well), and Cerebral Vascular Accident (CVA/stroke).Review of Resident #1's Certified Nurse Aide (CNA) Activities of Daily Living (ADL) flow sheet for the month of April 2026 indicated the following:*Bathing, dressing, bladder/bowel continence, personal hygiene, and preventative skin care was left blank, and not coded as being provided on 15 out of 21 applicable shifts:-04/01/26- day shift (7:00 A.M through 3:00 P.M.) evening shift (3:00 P.M. through 11:00 P.M.) night shift (11:00 P.M. through 7:00 A.M.)-04/02/26- day, evening, and night-04/03/26- day and night-04/04/26- evening and night-04/05/26- evening and night-04/06/26- day and night-04/07/26- night*Turned and repositioned every two hours was left blank, and not coded as being provided on 13 of 21 applicable shifts:-04/01/26- day and evening-04/02/26- day, evening, and night-04/03/26- day and night-04/04/26- evening and night-04/05/26- evening and night-04/06/26- night-04/07/26- night*Eating and amount eaten was left blank, and not coded as being provided on 11 out of 21 applicable meals:-04/01/26- breakfast, lunch, dinner-04/02/26- breakfast, lunch, dinner-04/03/26-breakfast and lunch-04/04/26- dinner-04/05/26- dinner-04/06/26- lunchDuring an interview on 04/21/26 at 1:20 P.M., Certified Nurse Aide (CNA) #2 said CNAs are supposed to chart on all resident care provided. CNA #2 said the information is documented either immediately after the care is provided or by the end of their shift.During an interview on 04/21/26 at 5:00 P.M. the Director of Nurse (DON) said that the CNAs are expected to document all the resident care they provide by the end of their shifts and there should not be blanks on Resident #1's CNA flow sheet.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who had limited mobility, required the use of an air mattress, and was dependent on staff to meet his/her care needs, the facility failed to ensure his/her Activities of Daily Living (ADL) Care Plan was individualized, with interventions that clearly identified the appropriate number of staff assistance required to safely meet his/her needs.Findings include:Review of the facility's policy, titled Comprehensive Person-Centered Care Plans, revision date of 03/2022, included the following:-A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. -Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Review of the facility's policy, titled Activities of Daily Living (ADL), Supporting, undated, included the following:-Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with:*hygiene (bathing, dressing, grooming, and oral care)*mobility (transfer and ambulation)*elimination (toileting)*dining (meals and snacks)Resident #1 was admitted to the facility in July 2025, diagnoses included Chronic Obstructive Pulmonary Disease (COPD-a progressive lung disease that makes it difficult to breathe), Congestive Heart Failure (CHF- a long-term condition that affects the heart's ability to beat well), and Cerebral Vascular Accident (CVA/stroke).Review of Resident #1's ADL Care Plan, with a goal date of 04/15/26, included the following:-Focus: I have and ADL self-care performance deficit related to activity intolerance, limited mobility, CHF, Osteoarthritis, and CVA. -Goal: I will improve current level of function with ADLs through the next review date. -Interventions:*Mobility: requires assist/dependent with wheelchair*Bathing/Showering: requires assist/dependent*Bed/Chair Mobility: Totally dependent on staff for positioning and turning in bed *Dressing: Requires assist/dependent staff to dress*Personal Hygiene: Requires two assist (updated on 04/09/26- previously stated assist)*Toileting: Requires assist/dependent*Transfer: Requires assist/dependentFurther review of the plan of care indicated that although interventions were implemented to show Resident #1 was dependent on staff when he/she needed to be turned and repositioned during the provision of ADL care, the care plan did not identify the number of staff assistance required to safely meet his/her care needs.During an interview on 04/21/26 at 3:46 P.M., Certified Nurse Aide (CNA) #1 said that Resident #1 was well known to her and that she had provided care for him/her several times. CNA #1 said Resident #1 was on her assignment on 04/08/26 and she thought she could provide his/her care by herself. CNA #1 said in the past, she had changed Resident #1's bed linens by herself.During an interview on 04/21/26 at 4:27 P.M., the Director of Nurses (DON) said if Resident #1's care plan said that he/she was totally dependent for bed mobility that it meant he/she needed assistance of two staff members during that task. The DON said the CNAs should not determine the resident's level of staff assistance. The DON said Resident #1's care plan should specifically state the level of staff assistance and the required staff members for each intervention listed.

Based on observations, record review and interviews, the facility failed to ensure residents at risk for developing pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to prevent new ulcers from developing for two Resident (#24 and #53) out of a total of 22 Residents. Specifically, the facility failed to ensure the Resident's air mattress were set at the correct setting according to the physician's order. Findings include: Review of the facility policy titled Prevention of Pressure Injuries, dated and revised April 2020, indicated the following: - Support Surfaces and Pressure Redistribution: Select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice. Resident #24 was admitted to the facility in November 2024 with diagnoses including Parkinsonism, stage 4 pressure ulcer of sacral region, and unspecified protein calorie malnutrition. Review of Resident #24's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status score of 6 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated that the Resident has one stage 4 pressure ulcer and is at risk of developing pressure ulcers and is dependent on staff for all activities of daily living. The surveyor made the following observations: - On 5/13/25 at 9:40 A.M.,12:05 P.M. and 4:25 P.M., Resident #24 was lying on his/her bed. An air mattress was present and operating and was set to the first bar which indicated the softest setting. Next to the setting dial was a diagram indicating what each setting's corresponding weight setting should be. The setting at which Resident #24's air mattress pump was set to was for 50 pounds. - On 5/14/25 at 6:52 A.M., and 8:31 A.M., Resident #24 was sleeping in his/her bed. An air mattress was present and operating and was set to the first bar which indicated the softest setting. Next to the setting dial was a diagram indicating what each setting's corresponding weight setting should be. The setting at which Resident #24's air mattress pump was set to was for 50 pounds. Review of Resident #24's Physician's order dated 11/22/24 indicated the following: - Alternating pressure air mattress set to 150, check setting q (every) shift. Review of Resident #24's most recent weight dated 5/8/25 indicated that the Resident last weighed 91.5 lbs. (pounds). Review of Resident #24's skin integrity risk and sacral pressure ulcer care plan dated 11/21/24, indicated the following intervention: Air mattress as ordered. Review of Resident #24's Norton's Scale for Predicting Pressure Ulcers (an assessment that indicates the risk of developing pressure ulcers) dated 4/10/24 indicated that the Resident scored a 6 which indicates the Resident is at a high risk of developing pressure ulcers. During an interview on 5/14/25 at 8:55 A.M., Nurse #1 said air mattress settings are set to each resident's weight and by physician's order. During an interview on 5/14/25 at 10:05 A.M., Unit Manager #1 said air mattress settings are set by a resident's weight. Unit Manager #1 reviewed Resident #24's weight and the surveyor's photo of the air mattress pump and she said the settings are too low and they need to be adjusted. Unit Manager #1 said if the air mattress settings are too low it could affect Resident #24's skin and increase pressure ulcer risk. During an interview on 5/14/25 at 10:22 A.M., the Director of Nursing (DON) said air mattress settings should be set by a resident's weight and by the physician's order. The DON reviewed the surveyor's photo of Resident #24's air mattress settings, and she said it was set too low. 2.Resident #53 was admitted to the facility in March 2024 with diagnoses including adult failure to thrive. Review of Resident #53, the most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 2 out of a total possible 15 on the Brief Interview for Mental Status indicating he/she was severely cognitively impaired. The MDS further indicated the Resident was dependent for positioning and was at risk for developing pressure ulcers. On 5/13/25 at 8:07 A.M., the Surveyor observed Resident #53 lying in his/her bed. The air mattress was set at 380 lbs. (pounds). On 5/13/25 at 12:16 P.M., the Surveyor observed Resident #53 lying in his/her bed. The air mattress was set at 380 lbs. (pounds). On 5/13/25 at 4:28 P.M., the Surveyor observed Resident #53 lying in his/her bed. The air mattress was set at 380 lbs. (pounds). Staff entered the Resident's room and repositioned him/her. On 5/14/25 at 7:49 A.M., the surveyor and Nurse #1 observed the Resident lying in his/her bed the air mattress was set at 380 lbs. Nurse #1 said the air mattress should not be set that high as the Resident weighed less than 100 lbs. Review of the physician's order dated 8/26/24 indicated the following: -Air mattress with bolsters on bed set at 150 check setting every shift. Review of care plan Resident has potential for skin/tissue integrity risk related to decreased mobility, dated 4/3/25 indicated the following intervention: -Air mattress with bolsters on bed check each shift for proper inflation. During an interview on 5/14/25 at 7:49 A.M., Nurse #1 said she had not done her rounds yet to ensure air mattress was in the correct setting, she said nurses are responsible for ensuring correct setting every shift. During an interview on 5/14/25 at 8:35 A.M., Unit Manager #1 said air mattresses are set to resident's weights and that Resident #53's air mattress should be set to less than 100lbs and not 380 lbs. During an interview on 5/14/25 at 10:31 A.M., the Director of Nursing said physician orders should be followed for proper air mattress setting.

Based on observation, record review and interview, the facility failed to ensure practices to support nutritional needs for one Resident (#48), out of a total sample of 22 residents were implemented in accordance with professional standards of care. Specifically, Resident #48, who was assessed for nutritional risk, experienced a severe weight loss, which was not evaluated by the registered dietitian. Findings include: Review of the facility's policy titled, Weight Assessment and Intervention, revision date March 2022 indicated the following: Residents weights are monitored for undesirable and unintended weight loss or gain. Weight Assessment 1. Residents are weighed upon admission and at intervals established by the interdisciplinary team., 2. Weights are recorded in each unit's weight record or chart and in the individual's medical record. 3. Any wight change of 5% or more since the last weight assessment is retaken the next day for confirmation. a. if the weight is verified, nursing will immediately notify the dietician in writing. 4. Unless notified of significant weight change, the dietician will review the unit weight record monthly to follow individual weight trends over time. 5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria (where percentage of body weight loss=(usual weight-actual weight)/(usual weight) x 100): a. 1 month-5% wight loss is significant; greater than 5% is severe. b. 3 months-7.5 % weight loss is significant; greater than 7.5 % is severe. c. 6 months-10% wight loss is significant; greater than 10 % is severe. Resident #48 was admitted to the facility in July 2024 and has diagnoses that include but are not limited to Parkinson's disease without dyskinesia, unspecified dementia, and depression. Review of the most recent comprehensive Minimum Data Set assessment dated [DATE], indicated Resident #48 scored an 8 out of 15 on the Brief Interview for Mental Status exam, indicating Resident #48 has moderately impaired cognition. Further, the MDS indicated Resident #48 requires supervision or touching assistance to eat, is 71 (5 foot nine inches) in height and weighs 130 pounds and is on a mechanically altered diet. On 5/13/25 at 7:44 A.M., and 8:31 A.M., Resident #48 was observed on his/her back in bed. Resident #48 did not respond to the surveyors greeting. Resident #48 was administered oxygen through a nasal cannula and looked to be frail and dependent. An open carton of Ensure (a dietary supplement) was on his/her bedside table. On 5/13/25 at 12:26 P.M., Resident #48 was sitting up in bed with a Certified Nursing Assistant (CNA) assisting him/her with eating his/her lunch. CNA # 3 said Resident #48 eats a little at a time and needs assistance. On 5/14/25 at 8:30 A.M., Resident #48 was observed sitting up in a wheelchair eating his/her breakfast. Resident #48 was feeding him/herself. His/her tray consisted of a pureed entree, whole milk, mighty shake (a dietary supplement), and hot cereal. The food was partially consumed by Resident #48. Review of Resident #48's care plan with the focus: Resident is at nutrition related risk d/t (due to) altered skin integrity and pmh (past medical history) including dementia, DVT (deep vein thrombosis) PNA (pneumonia) Parkinson's, TIA (transient ischemic attack), and depression. Date initiated 7/24/24 Goal: 1. Maintain a weight free from significant changes. 2. PO (by mouth) intake to meet daily nutrition and hydration needs. 3. Tolerates diet/textures a/o (as ordered), 4. Nutritional related labs wnl (within normal limits) and 5. Improved skin integrity, date initiated 7/24/2024 revision on 4/4/2025. Interventions included but not limited to Monitor/Record/report to MD (medical doctor) s/sx (signs /symptoms of malnutrition: Emaciation (cachexia) muscle wasting, significant weight loss: 3 lbs. (pounds) in 1 week, greater than 5% in 1 month, greater than 7.5% in 3 months, and greater than 10% in 6 months. RD (registered dietitian) to evaluate and make diet change recommendations PRN (as needed). Review of Resident #48's medical record indicated in part, the following on the weights and vitals summary. -10/4/2024 170.1 (sitting) -10/9/2024 167.6 (sitting -10/16/2024 165.6 (sitting) -10/24/2024 167.4 (sitting) -11/2/2024 167.4 (sitting -11/8/2024 168.6 (sitting) -11/13/2024 168 lbs. (sitting) -11/20/2024 166.8 lbs. (sitting) -12/4/2024 167.2 lbs. (sitting) -1/5/2025 166 lbs. (sitting) -1/23/2025 144 lbs. (sitting) a 13.25 % loss of total body weight since 1/5/25, 19 days, which meets the criteria of severe weight loss. -1/30/2025 140.8 lbs. (mechanical lift) -3/21/2025 130 lbs. (bed scale) -4/7/2025 131 lbs. (mechanical lift) -5/14/2025 132.1 lbs. (mechanical lift) Review of Resident 48's medical record did not indicate Resident #48 was in the hospital from 10/4//24 through 1/23/25 when Resident #48 sustained a severe weight loss. Review of Resident #48's active physician's orders indicated the following: Diet-order summary, -regular diet pureed texture. Thin liquids consistency, order date 1/22/2025 Dietary Supplements order summary -Ensure three times a day or nutritional equivalent order date 5/14/2025 -Mighty shake three times a day or nutritional equivalent order date 1/16/2025 -ProSource/liquid Protein (30 ml) two times per day, order date 5/142025. Review of active and discontinued dietary orders failed to indicate any new dietary orders were entered after the severe weight loss experienced by Resident #48 on 1/23/25 until 5/14/25. Review of Resident #48's medical record indicated the following: -A [NAME]-Nutrition Assessment Comprehensive with an effective date 7/24/2024 indicated a BMI (body mass index) of 20.9, most recent weight 149.9. oral supplement 237 ml Ensure TID (three times a day). -A [NAME]-Nutritional Assessment with an effective date 10/15/2024 with a most recent weight of 167.6 and BMI of 23.4. Oral supplement 237 ml Ensure TID (three times a day). -A [NAME]-Nutritional Assessment Comprehensive with an effective date 1/15/2025 with the most recent date weight of 166.0 and a BMI of 23.1, with Oral supplement to include: liquid protein and BID (twice a day) mighty shake TID (three times a day) Resident now receiving regular/pureed diet with thin liquids. Will cont. (continue) to monitor. Review of Resident #48's medical record failed to indicate a nutritional assessment was conducted when Resident #48's weight went from 166 pounds on 1/5/25 to 144 pounds on 1/23/25 a 13.25 % severe weight loss, occurring a week after the [NAME]-Nutritional Assessment Comprehensive dated 1/15/25. Review of the medical record indicated a progress note dated 1/16/25 and entered by the Registered Dietitian indicated: RT (resident) with poor intake and altered skin integrity. Diet orders remain appropriate with textures per the SLP (speech language pathologist) Rec [recommend] add 30 ml liquid protein BID (twice a day) and mighty shake TID (three times a day) to better meet nutrition needs. Will continue to monitor. Review of the medical record indicated a [NAME]-Nutrition Assessment Comprehensive dated 3/26/2025, 63 days since Resident #48 sustained a severe total weight loss of 13.25 % in one week and continued to have weight loss as indicated by the weight entered on 1/30/25 at 140.8 lbs. equaling a 15.18 % of total body weight. indicated the most recent weight of 130.0 lbs. and a BMI of 18.1. During an interview on 5/14/25 at 9:57 A.M., Unit Manager #1 said Resident #48 was monitored closely for weight loss. She said Resident #48 was at baseline and began to stop eating and drinking around January. Unit Manager #1 said Resident #48 was downgraded to puree diet texture change which he/she did not like and may have contributed to the weight loss. Unit Manager #1 said the Dietitian is involved in risk meetings where Residents are reviewed for weight loss. Unit Manager #1 said Resident #48 did have supplements ordered. Unit Manager #1 said the family was aware and a decision was made to put Resident #48 on hospice services. During an interview on 5/14/25 at 10:11 A.M., the Registered Dietitian (RD) said she is in the facility two times a week. The RD said on admission all residents are assessed, and a nutritional care plan is implemented as most residents are at some nutritional risk. The RD said residents are followed for the length of their stay. RD said she runs weight reports each week which tells her if there are any weight changes for residents including gains or losses. The RD said if there is a 3 lb. weight change a re-weigh is obtained to determine if it is significant or not and she will assess the resident to see if new interventions are required. The RD reviewed Resident #48's weights entered into the medical record. The RD said Resident #48 was on hospice. The RD said Resident #48 was followed in risk meetings. The RD said Resident #48 had desired weight gain after admission, and she assessed him/her in January before the significant weigh loss occurred. The RD reviewed the record and said she did not enter a note that she was aware of the significant/severe weight loss or that she re-evaluated Resident #48's nutritional status after the significant weight loss. The RD said she should have conducted an assessment or a thorough review of Resident #48's weight loss, even if he/she was signing on to hospice. During an interview on 5/14/25 at 12:47 P.M., the Director of Nursing (DON) said weights are entered in the electronic medical record and reviewed for gains or loss. The DON said Resident #48 was followed in risk meetings and the RD is present at the meetings. The DON said the RD drives the care plan for nutritional care planning and interventions and should have provided an assessment/evaluation after Resident #48 sustained a significant (severe) weight loss.

Based on observations, record review and interview, the facility failed to provide continued therapy services and recommended by the Occupational Therapist for one Resident #24 out of a total sample of 22 Residents. Specifically, the facility failed to ensure that Resident #24 continued to receive Occupational Therapy services as recommended for the use of a hand orthotic while under hospice services. Findings include: Review of the facility policy titled Scheduling Therapy Services, dated and revised July 2013, indicated the following: - Therapy services shall be scheduled in accordance with the resident's treatment plan. - The therapist shall interview the resident and consult with the attending physician as to the type of treatment to be administered. - Therapy is scheduled in coordination with nursing service and is documented in the resident's medical record. - Nursing service shall be responsible for preparing and escorting the resident to the therapy area unless such treatment is scheduled in the resident's room. Resident #24 was admitted to the facility in November 2024 with diagnoses including Parkinsonism, pressure ulcer of sacral region, stage 4 and unspecified protein calorie malnutrition. Review of Resident #24's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated a Brief Interview for Mental Status score of 6 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated that the Resident has upper extremity impairment on one side and is dependent on staff for all Activities of Daily Living. During an observation on 5/13/25 at 9:40 A.M., Resident #24 was lying in his/her bed, his/her left hand was clenched in a fist position. The surveyor asked and motioned if the Resident was able to open his/her left hand, the Resident attempted to but was unable to. The surveyor did not observe any handroll or splinting device in the Resident's room. During observations throughout the survey period from 5/13/25 through 5/14/25, the surveyor did not observe any hand splint device or any orthotics in use or in Resident #24's bedroom. Review of Resident #24's visits from the Nurse Practitioner (NP) indicated the following: - Dated 3/20/25: Left hand in fist while in resting position. Able to open with some stiffness noted. PLAN: spoke with DOR (Director of Rehab) regarding stiffness to left hand. Therapy to evaluate as member may benefit from handroll. - Dated 3/25/25: Left hand in fist with flexed wrist while in resting position. Able to open with some stiffness noted. Seen by OT (Occupational Therapist) with plans for splint. SW (social worker) met with HCP (health care proxy) earlier today, agreeable to hospice at home. Hospice referral placed while at SNF (senior nursing facility). - Dated 4/3/25: Left hand in fist with flexed wrist while in resting position. Able to open with some stiffness noted. Seen by OT with plans for splint. Review of Resident #24's Occupational Therapy Evaluation and Plan of Treatment dated 3/24/25 indicated the following: - Reason for Referral/Current Illness: Pt is a 79 y/o male/female who been a LTC (long term care) resident of this facility who was referred to OT services to assess L (left) hand for hand roll due to limited ROM (range of motion)/increased tightness in flexed position. - Assessment Summary: Pt noted to have pain with L wrist and hand movement. Pt would benefit from OT services to address deficits with limited L wrist and hand ROM and splinting for proper positioning of L UE (upper extremity). Review of Resident #24's Occupational Therapy Discharge summary dated [DATE] indicated the following: - Discharge Recommendations and Status: Pt seen for OT evaluation only due to pt transitioning to Hospice Care. Recommend splinting care under Hospice services. Review of Resident #24's physician's order dated 3/25/25 indicated the following: Hospice evaluation and admit if appropriate. Review of Resident #24's care plans failed to indicate a care plan for the use of Occupational Therapy or the use of any hand orthotic/device. During an interview on 5/14/25 at 8:03 A.M., Certified Nursing Assistant (CNA) #1 said Resident #24's hand has always been flexed in a fist position and she does not remember ever seeing a hand towel or splint in use. During an interview on 5/14/25 at 8:55 A.M., Nurse #1 said Resident #24 was admitted with his/her hand flexed and tightened. Nurse #1 said when therapy services make recommendations, they will tell nursing who will ensure an order gets implemented. During an interview on 5/14/25 at 9:27 A.M., the Director of Rehab (DOR) said residents are seen by therapy upon admission to the facility, quarterly and if nursing makes a request for the resident to be seen by therapy services. The DOR said if therapy recommendations are made, we would evaluate the resident, make a care plan and have a physician's order implemented for any recommendations made by therapy. The DOR then said Resident #24 was referred to OT by the Nurse Practitioner due to his/her left hand positioning. The DOR said after the NP made the recommendations for OT, Resident #24 was admitted to hospice services on 3/25/25 so the Resident did not see OT. The DOR reviewed the NP recommendation on 4/3/25, eight days after Resident #24 was admitted to hospice services, the DOR said she did not know the NP still planned for a hand splint. The DOR then reviewed the OT Discharge summary dated [DATE] and she was not aware that the OT recommended splinting care under hospice services. The DOR said the facility should have coordinated with hospice services to ensure that Resident #24 was being evaluated by OT to see if a splint would be recommended. During an interview on 5/14/25 at 10:22 A.M., the Director of Nursing (DON) said Therapy should have followed up with hospice services to see if therapy would be recommended and to see if a hand device would be appropriate for Resident #24. During a follow up interview on 5/14/25 at 10:58 A.M., the DOR said she spoke with hospice services, and they approved Resident #24 to be seen by OT. The DOR said she evaluated Resident #24 and she is trialing the use of a hand roll for Resident #24 now.

Based on observations, record review and interviews, the facility failed to ensure staff treated residents in a dignified manner during the dining experience for one Resident (#24) out of a total sample of 22 Residents. Specifically, the facility failed to ensure that staff were not operating a cell phone while assisting Resident #24 with eating breakfast. Findings include: Review of the facility policy titled Quality of Life - Dignity, undated, indicated the following: - Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times. Resident #24 was admitted to the facility in November 2024 with diagnoses including Parkinsonism, stage 4 pressure ulcer of sacral region, and unspecified protein calorie malnutrition. Review of Resident #24's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status score of 6 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated that the Resident is dependent on staff for all Activities of Daily Living including eating. During a telephone interview on 3/9/25 at approximately 3:30 P.M., the facility's Ombudsman reported to the surveyor that about two weeks prior, he observed a Certified Nursing Assistant (CNA) using her cell phone while feeding a resident and the resident was staring at the CNA with the food being untouched. On 5/13/25 during breakfast service at 8:44 A.M., the surveyor made the following observations: Resident #24 was observed to be assisted by a staff member while eating breakfast. Resident #24's bedroom door was slightly open, the surveyor observed a staff member sitting in a chair next to Resident #24 who was lying in his/her bed. The staff member was observed to be using both of her hands while texting on her cell phone over Resident #24's breakfast tray. At 8:47 A.M., the surveyor observed the staff member to continuing to text on her phone instead of feeding Resident #24. At 8:54 A.M., 10 minutes after the initial observation, the staff member was observed to continue texting on her phone instead of assisting Resident #24 with eating his/her breakfast. Review of the facility's Resident Council Minutes indicated the following: - February 27, 2025: Nursing - Being on phones has gotten better. - April 24, 2025: Staff using phones and headphones while working is an ongoing issue they (the residents) would like to see resolved, even though it has improved from the past. During an interview on 5/14/25 at 10:05 A.M., Unit Manager #1 said staff members should never be on their cell phones while assisting residents with feeding and every resident should have a dignified dining experience. During a follow up interview on 5/14/25 at 10:18 A.M., Unit Manager #1 said the staff member on her cell phone was Resident #24's hospice CNA (Certified Nurse Aide) from the outside hospice agency. Unit Manager #1 then said she would still expect the hospice CNA to follow the facility's policies and procedures and provide a dignified dining experience for Resident #24. During an interview on 5/14/25 at 10:22 A.M., the Director of Nursing (DON) said it was a hospice CNA who was texting while assisting Resident #24 with feeding. The DON said no staff member should be using their cell phone while assisting a Resident with feeding and Resident #24 should have a dignified dining experience.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had limited mobility, and decreased sensation from diabetic neuropathy (nerve damage in the hands and feet) in his/her extremities, the Facility failed to ensure he/she was provided with adequate preventative measures to maintain his/her safety in an effort to prevent incidents/accidents, resulting in serious injury, when on 7/28/23 maintenance staff members moved Resident #1, who was in bed, to a new room and during the move they placed Resident #1's portable oxygen (O2) container (containing liquid oxygen) on the bed with him/her, the container tipped over and resulted in liquid O2 leaking out of the container onto Resident #1's bedding and he/she sustained a full thickness (full thickness injury, involves all layers of the dermis and which can often injure the underlying subcutaneous tissue) non-thermal burn to his/her left heel, which required treatment. Findings include: Review of the Facility's policy titled Oxygen Administration and Policy and Procedure, dated 12/06/22, indicated the oxygen equipment would be checked daily for the correct set up of equipment. Review of the Education form on Oxygen tanks, dated June 28, 2023, indicated portable oxygen tanks must always be kept upright and to never place on a resident's bed. According to Universal Industrial Gases, Inc, (uigi.com) and the MSDS (Material Safety Data Sheet) for Liquid Oxygen - O2, indicated the following, Oxygen gas is colorless, odorless, non-toxic cryogenic liquid or colorless, odorless, oxidizing gas. Contact with oxygen liquid, its cold vapors or cold piping can cause frostbite and cryogenic burns to exposed tissue. Resident #1 was admitted to the Facility in July 2023, diagnoses included a right ankle fracture, chronic obstructive pulmonary disease (constriction of the airways and difficulty breathing), paraplegia (paralysis of the legs and lower body), type 2 diabetes, and neuropathy (nerve damage in the hands and feet). Review of the Report submitted by the Facility in the Health Care Facility Reporting System (HCFRS), dated 07/28/23, indicated Resident #1 was being moved to another room while remaining in the bed, his/her portable oxygen container was placed on the bed by a staff member. The Report indicated the portable oxygen containers contents (liquid oxygen) spilled onto Resident #1's bedding and (the left side) Resident #1's lower back of leg and left heel came in contact with the wet bedding, they became cold and slightly painful. Review of Nurse #1's written Witness Statement (included in the Investigation Report), dated 07/28/23, indicated that maintenance staff notified her that they placed the portable oxygen container on Resident #1's bed (during his/her room change) causing his/her left heel and lower leg to be cold. The Statement indicated Resident #1 was assessed by Nurse #1 and his/her left heel and left lower leg were very pale and cold. During an interview on 11/29/23 at 11:48 A.M., Nurse #1 said she was called into Resident#1's room by maintenance staff who said they were in the process of moving his/her bed while he/she was in the bed, had placed the oxygen tank on the bed, it fell on its side and oxygen vapor was coming out. Nurse #1 said when she entered Resident#1's room the portable oxygen tank was already off the bed and his/her left heel was extremely pale and cold. Nurse #1 said she called for more help and the Nursing Supervisor, and the Director of Nursing took over care and began warming Resident#1's left heel and left lower extremity. Nurse #1 said later in her shift she assessed Resident #1's left heel and noted a small red area and notified the Nurse Practitioner and received orders to apply skin prep to the site. Review of the Occupational Therapist Assistants (COTA's) Treatment Encounter Note (included in the Investigation Report), dated 07/28/23, indicated she entered Resident#1's room and he/she reported discomfort in the left lower extremity and she uncovered his/her feet and saw his/her left heel was white and waxy. The Note further indicated that the bed underneath Resident#1's feet was ice cold and the portable oxygen tank was on the floor by the foot of the bed and emitting vapor out of the bottom of the container. During an interview on 11/29/23 at 12:20 P.M., the Occupational Therapy Assistant (COTA) said when she went in Resident#1's room, he/she complained of left heel pain. The COTA said she assessed his/her foot, and the left heel was cold and blanchable (skin that remains white or pale for longer than normal when pressed). During an interview on 11/29/23 at 11:35 A.M., the Nursing Supervisor said that maintenance staff had put the portable oxygen container on Resident #1's bed while he/she was in the bed during a move to another room. The Nursing Supervisor said Resident#1's left lower leg and left heel looked frostbitten, and that his/her skin was very cold. The Nursing Supervisor said she assisted the Director of Nursing with re-warming the left lower extremity and left heel and his/her skin color improved and the waxy appearance resolved. The Nursing Supervisor said it was several hours later that a red area developed on Resident #1's left heel and treatment was initiated. Review of the Director of Nurses (DON) written Witness Statement (included in the Investigation Report), dated 07/28/23, indicated she entered Resident#1's room and saw the oxygen container on the floor beside the bed and his/her left lower extremity and left heel were cold to touch, being colder at the left heel. Review of Resident #1's Nurse Progress Note, dated 07/28/23, indicated a small intact red area measuring 1.2 centimeters (cm) x 1.4 cm was noted on Resident#1's left heel and new orders were received to apply skin prep to site every shift. Review of Resident #1's Weekly Skin Wound Observation Tool, dated 07/28/23, indicated that his/her left heel had an acquired trauma/injury measuring 1.2 cm x 1.4 cm. Review of the Physician's orders, for Resident #1, dated 07/28/23, indicated skin prep to be applied to left heel once per shift by nursing for trauma injury. Further review of the Nurse Progress Notes, dated 07/29/23 and 07/30/23, indicated a blister had formed on Resident#1's left heel and then broken open and further treatment orders were obtained. Review of Resident#1's Physician's orders, dated 07/30/23, indicated he/she had new orders for a normal saline wash to left heel, apply ABD pad and Kling wrap twice daily. Review of the Nurse Practitioner Progress Note, dated 07/31/23, indicated Resident#1 sustained a burn blister from an oxygen container leaking cold fluid on to his/her left lower extremity. Review of Resident #1's Situation,Background, Assessment, and Recommendation (SBAR) Communication Form, dated 07/31/23, indicated he/she had a new blister to his/her left heel. Review of Resident #1's Hospital Discharge Summary, dated 08/08/23, indicated he/she was admitted to the hospital on 07/31/23 for altered mental status and while in-patient received treatment for a left heel wound from recent burn-infection and that follow up would be required on discharge from the hospital. Review of Resident #1's Wound Physician Evaluation, dated 08/10/23, (after his/her re-admission to the facility) indicated he/she had a left heel full thickness burn measuring 8.3 cm x 6.0 cm x 0.1 cm. The Wound Evaluation indicated that the primary dressing treatment as ordered by Physician was to apply Bacitracin ointment once daily for 15 days, and Xeroform gauze, apply once daily for 30 days to left heel burn wound and a secondary dressing to be applied to the left heel daily for 30 days. The Evaluation indicated Peri Wound Treatment of skin prep applied daily to left heel for 30 days. During an interview on 11/29/23 at 11:30 A.M., the Nurse Practitioner (NP) said Resident #1 had a red area on his/her left heel from an oxygen container that had leaked while it was placed on the bed and that his/her left lower extremity and left heel came in contact with the cold liquid. During an interview on 11/29/23 at 12:26 P.M., the Director of Nurses (DON) said the maintenance staff member had not followed facility protocol for oxygen storage when he placed the portable oxygen container on the bed. The DON said it is the Facility's expectations that non-clinical staff which included maintenance staff, as well as CNA's and Nurses followed facility oxygen storage protocol, which included keeping the portable oxygen containers in an upright position and never placing on a resident's bed. The Surveyor was unable to interview either of the maintenance staff members who were involved in the incident as they had both resigned and terminated their employment with the facility.

Based on record review and interviews the facility failed to ensure one Resident, (#31) received adequate supervision to prevent a fall with injury out of a total sample of 30 residents. Findings include: Review of facility policy titled 'Fall Reduction' revised 6/22/22 indicated the following: Goal: To identify residents at risk for falls and to decrease the incidence of resident falls. Procedure: *1. g. Instruct the resident to use the call light to call for assistance for transfer and mobility needs as indicated. Resident #31 was admitted to the facility in September 2021 with diagnoses including muscle weakness, frequent falls and abnormalities of gait. Review of Resident #31's most recent Minimum Data Set (MDS) Assessment, dated 3/1/23, indicated Resident #31 had intact cognition as evidenced by the Brief Interview for Mental Status (BIMS) score of 14 out of possible 15. Review of Resident #31's fall care plan date initiated 9/22/21 indicated an intervention dated 10/10/21- Remind resident to ask for assistance when ambulating with walker. Review of quarterly rehabilitation screen dated 6/9/22 indicated the following: Resident continues to require 1 assist for activities of daily living, ambulates and transfers with a rolling walker and supervision. Review of Massachusetts Monthly Licensed Nursing Summary indicated the following: Effective date 6/18/2022: Mobility - walks with physical assist of 1 due to poor safety awareness and unsteady gait. Effective date 7/26/22: Mobility - walks with physical assist of 1 due to poor safety awareness and unsteady gait. Effective date 8/20/22: Mobility- walks with physical assist of 1 due to poor safety awareness and unsteady gait. Review of clinical nurses note dated 8/29/22 indicated the following: Resident found on the floor in the hallway on the left side of body after colliding with another resident, put on back, assessed, able to move all four extremities, pupils equal and reactive to light and accommodation, does not remember what happened.Resident denied pain, skin tear on left hand and bruise on left side of head noticed, transfer by wheelchair to resident's room, skin tear cleaned and covered by dry dressing, continue monitoring. Nurse Practitioner notified, new order to transfer to hospital. Review of facility incident report dated 8/29/22 indicated the following: -Post fall investigation indicated Resident #31 was ambulating unassisted to the dining room with his/her rolling walker for activities. Root cause of the fall was the closed doors and intervention initiated immediately was to keep doors open and drop off resident to activities. Review of clinical nurses note date 8/30/22 indicated that Resident #31 was admitted at the hospital with left side rib fractures number 5,6,7. Review of hospital inpatient consult note dated 8/30/22 indicated work up in emergency room showed left side 5,6,7 three rib fractures. During an interview on 3/24/23 at 9:30 A.M., the Director of Rehabilitation said that Resident #31 was supposed to be supervised during ambulation at the time of the fall. During an interview on 3/24/23 at 10:13 A.M., Day Supervisor #1 said Resident #31 should have been within the vicinity of staff for supervision with ambulation.

Based on observations, record reviews and interviews, the facility failed to prevent a decline in range of motion causing the development of a contracture for 1 Resident (#59) out of a total sample of 30 residents. Findings include: Resident #59 was admitted to the facility in September 2021 with diagnoses including muscle weakness, failure to thrive, anxiety and depression. Review of Resident #59's most recent Minimum Data Set (MDS) dated , 2/2/21, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 indicating he/she is cognitively intact. The MDS also indicated Resident #59 requires extensive assistance from staff for bathing, grooming and toileting tasks. On 3/22/23 at 8:10 A.M., Resident #59 was observed lying in bed. His/her left hand was observed to be half closed into a fist. The third, fourth and fifth fingers were bent at the first and second knuckles and the Resident was unable to open his/her fingers when asked. Resident #59 said his/her hand started to bend like this about a month ago and he/she has been waiting to see a doctor about it. Review of an occupational therapy evaluation dated 7/19/22 indicated Resident #59 did not have any range of motion impairment of his/her left hand. Review of Resident #59's medical diagnoses failed to indicate a neurological condition that would cause a contracture. Review of the Nurse Practitioner note, dated 2/1/23, indicated Resident #59 had a contracture of his/her left hand affecting the 3rd. 4th and 5th fingers. The note failed to indicate the Nurse Practitioner referred the Resident to the therapy department or an orthopedic doctor to either provide treatment for the contracture or prevent further decline in range of motion. Review of the nurse practitioner note, dated 3/3/23, failed to indicate the Nurse Practitioner reassessed Resident #59's left hand contracture or had made a referral for treatment. Review of a nurses note written 3/17/23 indicated Resident #59's family member requested the Resident to be seen for a left-hand contracture. The note further indicated the Nurse Practitioner would be speaking with the Resident about seeing a hand contracture in the next week, almost 2 months after the Nurse Practitioner first observed a new contracture to Resident #59's left hand. During an interview on 3/23/23 at 10:31 A.M., Certified Nursing Assistant (CNA) #1 said she was unaware of a decrease in Resident #59's left hand. CNA #1 then entered Resident #59's room and with his/her permission attempted to open the Resident's hand. The CNA was unable to straighten the Resident's fingers. The Resident grimaced in pain as the CNA did this and said it was very painful to try to move/open his/her hand. During an interview on 3/23/23 at 10:36 A.M., Nurse #1 said she was made aware of the change to Resident #59's left hand range of motion a week ago. Nurse #1 said she believes the Nurse Practitioner is aware of it but she never made a referral to the therapy department. Nurse #1 said she is unsure what the Nurse Practitioner has done about Resident #59's hand, if anything. During an interview on 3/23/23 at 10:38 A.M., CNA #2 said she was notified of this change to Resident #59's hand a couple of weeks ago by the Resident's grandson. CNA #2 said she the nurse on duty looked at the Resident's hand but is unsure if the nurse reported it to the doctor or the therapy department. During an interview on 3/23/23 at 10:54 A.M., the Director of Rehabilitation (DOR) said she will receive both written and verbal referrals from the nursing staff regarding a change in a resident's status, including a change in range of motion. The DOR said she also does rounds in building and looking at a resident's range of motion would be part of those rounds. The DOR said she had not received a referral from nursing for the decline in range of motion of Resident #59's left hand and was not aware of it. She said Resident #59 was on occupational therapy services months ago and at that time, the Resident had full range of motion of his/her left hand. During a follow-up interview on 3/23/23 at 11:55 A.M., the DOR said she just examined Resident #59's left hand and said there is a new contracture of the left 3rd, 4th, and 5th fingers. The DOR reiterated she was never told of this new contracture by the nursing staff or nurse practitioner.

Based on observation, record review and interview, the facility failed to 1. assess a significant decline in Activities of Daily Living (ADLs) and, 2. failed to provide therapy services needed to assist the resident's ability to perform ADL's back to their baseline, for 1 Resident (#42) in a total of 22 sampled. Findings include: Resident #42 was admitted to the facility in November 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated [DATE], indicated that Resident #42 required limited assist for the following Activities of Daily Living (ADL's); bed mobility, bathing and walking in his/her room. Review of the medical record indicated that Resident #42 received physical and occupational therapy services from 11/21/21 through 2/11/22. Review of the physical therapy discharge summary dated 2/11/22, indicated that resident #42 required supervision/contact guard for all functional mobility. Review of the occupational therapy daily note dated 2/11/22, indicated that Resident #42 required contact guard to minimum assist and cues with all ADLs. Review of the occupational therapy discharge summary dated 2/11/22, indicated that Resident #42 required contact guard to limited assist for functional ambulation. Review of the facility document titled ADL Flow Sheet and dated February 2022 indicated that Resident #42 required limited assist for mobility, dressing, ambulation and grooming until approximately the 13th of the month, when a significant decline on all three shifts took place. Resident #42 now required extensive assistance to perform those activities and was not walking. Review of the MDS dated [DATE], indicated that Resident #42 required extensive assistance for bed mobility, was totally dependent for bathing and was no longer walking. Review of the medical record failed to indicate that the facility should anticipate a physical decline in Resident #42. Further review failed to indicate that Resident #42 was referred to the therapy department for assessment of the decline. During an interview on 4/12/22, at 3:23 P.M., Therapist #1 said that she was not aware of the significant decline in Resident #42's ADLs that took place after Resident #42 had been discharged from rehabilitation services or she would have evaluated Resident #42 for the possible need to reinstate therapy services. During an interview on 4/13/22, at 8:31 A.M., the Director of Nursing (DON) said that Resident #42 had had a significant decline in Activities of Daily Living (ADLs) and should have been assessed by the therapy department.

Based on record review, policy review and staff interview, the facility failed to maintain acceptable parameters of nutritional status by providing adequate interventions to maintain usual body weight and prevent significant weight loss for 1 Resident (#42) out of a total sample of 22 residents. Findings include: Resident #42 was admitted to the facility in November 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility policy titled Weight Monitoring and dated revised 12/22/21, indicated that the purpose of the policy is to ensure that residents maintain acceptable parameters of nutritional status. Further review indicated that the dietician will review weights monthly to follow individual weight trends over time. Negative trends will be evaluated for significant weight change. Review of facility document titled [NAME]-Nutrition Assessment Comprehensive and dated 11/26/21, indicated that Resident #42's admission weight was 202.2 pounds (lbs). Further review indicated that the in hospital weight prior to admission to the facility was 202.6 lbs and that Resident #42 reported that his/her usual body weight was approximately 200 lbs. Review of the medical record indicated a document titled [NAME] General Hospital physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility document titled Monthly Record of Weights indicated weights in lbs. as follows: 11/20/21; 202.2 lbs 12/2021; Week 1 = 199 Week 2 = not recorded Week 3 =189.7 a significant weight loss of 6.18% in 1 month. Week 4 = not recorded 1/2022; Week 1 = 186.6, a significant weight loss of 8.01% in 6 weeks. Week 2 = 183.9 Week 3 = 181.0 Week 4 = not recorded 2/2022; Week 1 = 169.0 a greater than 10% weight loss in less than 2 months. Week 2 = 169.0 Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #42 had sustained an unplanned significant weight loss. Review of the physicians orders dated 2/18/22, indicated a change in diet to add fortified foods at all meals, 9 weeks after the initial significant weight loss was identified. Review of the Review of facility document titled [NAME]-Nutrition Assessment Comprehensive and dated 2/18/22, indicated that as of 2/11/22, Resident #42's weight was 169 lbs. Further review indicated that the registered dietician did not believe that Resident #42's documented admission weight of 202.2 lbs was accurate and in spite of a greater than 10% weight loss in less than 2 months that Resident #42's intake was adequate. Review of the nurse's note dated 3/2/22, indicated that Resident #42 had sustained a significant weight loss. During an interview on 4/13/22, at 8:31 A.M., the Director of Nursing said that she didn't know why the dietician did not believe the admission weight as the pre-admission weight in the hospital was almost the same.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was identified as being at risk for falls, required the use of a gait belt and required one to two person staff assistance with transfers, the Facility failed to ensure he/she was provided with the appropriate level of staff assistance and the required assistive device to maintain his/her safety during a transfer. On 11/11/21 Certified Nurse Aide (CNA) #1 transferred Resident #1 without the use of a gait belt, and after assisting Resident #1 to stand, CNA #1 stepped away from Resident #1 leaving him/her unassisted and unsupported by a staff person. While standing alone, Resident #1 fell , immediately complained of pain in his/her right leg, was transferred to the Hospital Emergency Department, and diagnosed with a right [CONDITION(S)], which required surgical intervention to repair. Findings include: The Facility's Policy, titled, Fall Prevention, undated, indicated the Facility would identify residents at risk for falls, and would implement interventions to minimize or eliminate contributing factors for falls on residents at risk. The Facility's Policy, titled, Gait/Transfer Belt, dated 12/05/12, indicated Gait/Transfer belts would be used by direct care staff to assist in ambulating or transferring residents to ensure the safety of the resident and staff member and the use of proper body mechanics. Resident #1 was admitted to the Facility in June 2020, diagnoses included [CONDITION(S)], difficulty with walking, and generalized muscle weakness. Review of Resident #1's Quarterly Minimum Data Set assessment, dated 8/18/21, indicated Resident #1 required extensive physical assistance for mobility and required staff assistance for weight bearing during transfers and for toilet transfers. Review of Resident #1's Activities of Daily Living Care Plan, dated as revised 10/19/21, indicated he/she was at risk for falls, and required assistance from one to two staff persons for transfers. Review of Resident #1's Falls Care Plan, dated as revised 10/19/21, indicated Resident #1 required use of a gait belt for transfers The Facility's Internal Investigation, dated 11/11/21, indicated Resident #1 was transferred by CNA #1 without the use of a gait belt, fell to his/her right side, complained of pain, was transferred to the Hospital Emergency Department, and was diagnosed with a right [CONDITION(S)]. Review of the Hospital Discharge Summary, dated 11/15/21, indicated Resident #1 was transferred to the Hospital Emergency Department on 11/11/21 following a fall at the Facility, was diagnosed with a right [CONDITION(S)], and required surgical intervention to correct the fracture. During an interview on 11/22/21 at 1:22 P.M., CNA #1 said that on 11/11/21 she assisted Resident #1 to transfer off the commode by herself. CNA #1 said she had Resident #1 stand up using his/her walker, and then left Resident #1 standing alone, while she moved the commode away. CNA #1 said, while Resident #1 remained standing, she then went to move the wheelchair to put it behind him/her. CNA #1 said before she could get behind Resident #1 with the wheelchair, he/she fell , landing on his/her right side, and complained of pain in his/her right leg. CNA #1 said she knew Resident #1 required a gait belt for transfers, but said she did not use one. CNA #1 said in order to move the commode and get the wheelchair, she had to step away from Resident #1. During an interview on 11/22/21 at 2:29 P.M., The Director of Nurses (DON) said CNA #1 should have used a gait belt to transfer Resident #1, and said if two staff members had assisted with the transfer, with one person staying with Resident #1 and the other staff person to move the commode and get the wheelchair, the fall could have been prevented.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was identified as being at risk for falls and required the use of a gait belt (designed to assist staff to safely hold a resident during transfer/ambulation), as well as one to two person physical assistance with transfers, the Facility failed to ensure staff implemented interventions from his/her comprehensive plan of care to prevent falls, when Certified Nurse Aide (CNA) #1 transferred Resident #1 without a gait belt, after assisting him/her to stand up, CNA #1 stepped away from the resident leaving him/her unassisted and unsupported by a staff member. Resident #1 fell and was transferred to the Hospital Emergency Department, where he/she was diagnosed with a right [CONDITION(S)], which required surgical intervention to repair. Findings include: The Facility's Policy, titled, Comprehensive Care Plans, undated, indicated the Facility would develop and maintain a comprehensive care plan for each resident the identified the highest level of functioning the resident may be expected to attain. The Facility's Policy, titled, Fall Prevention, undated, indicated the Facility would identify residents at risk for falls, and would implement interventions to minimize or eliminate contributing factors for falls on residents at risk. The Facility's Policy, titled, Gait/Transfer Belt, dated 12/05/12, indicated Gait/Transfer belts would be used by direct care staff to assist in ambulating or transferring residents to ensure the safety of the resident and staff member and the use of proper body mechanics. Resident #1 was admitted to the Facility in June 2020, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly Minimum Data Set assessment, dated 8/18/21, indicated Resident #1 required extensive assistance with mobility and required staff assistance for weight bearing during transfers and for toilet transfers. Review of Resident #1's Activities of Daily Living Care Plan, dated as revised 10/19/21, indicated he/she was at risk for falls, and required physical assistance from one to two staff members for transfers. Review of Resident #1's Falls Care Plan, dated as revised 10/19/21, indicated Resident #1 required the use of a gait belt for transfers The Facility's Internal Investigation, dated 11/11/21, indicated Resident #1 was transferred by CNA #1 without the use of a gait belt, fell , landing on his/her right side, complained of pain, was transferred to the Hospital Emergency Department, and diagnosed with a right [CONDITION(S)]. Review of the Hospital Discharge Summary, dated 11/15/21, indicated Resident #1 was transferred to the Hospital Emergency Department on 11/11/21 following a fall at the Facility, was diagnosed with a right [CONDITION(S)], and required surgical intervention to repair the fracture. During an interview on 11/22/21 at 1:22 P.M., CNA #1 said that on 11/11/21 she assisted Resident #1 to transfer off the commode by herself. CNA #1 said she had Resident #1 stand up using his/her walker, and then left Resident #1 standing alone, while she moved the commode away. CNA #1 said, while Resident #1 remained standing, she then went to move the wheelchair to put it behind him/her. CNA #1 said before she could get behind Resident #1 with the wheelchair, he/she fell , landing on his/her right side, and complained of pain in his/her right leg. CNA #1 said she knew Resident #1 required a gait belt for transfers, but said she did not use one. CNA #1 said in order to move the commode and get the wheelchair, she had to step away from Resident #1. During an interview on 11/22/21 at 2:29 P.M., The Director of Nurses (DON) said CNA #1 should have used a gait belt to transfer Resident #1, and said if two staff members had assisted with the transfer, with one person staying with Resident #1 and the other staff person to move the commode and get the wheelchair, the fall could have been prevented.

Based on record record review and interviews for three of three samples Residents (Resident #1, #2 and #3), the facility failed to prevent emotional harm and intimidation when on 7/29/15 CNA's #1 & #2 made video recordings while providing care and posted the videos to Snapchat, without permission, and forwarded the videos to individuals who are not employees. Findings include: A Quarterly Minimum Data Set ((MDS) dated [DATE], indicated that Resident #1 was cognitively impaired and unable to make health care decisions and informed consent. A Quarterly MDS dated [DATE] indicated that Resident #2 was cognitively impaired and unable to make health care decisions and informed consent. An Quarterly MDS dated [DATE], indicated that Resident #3 was cognitively impaired and unable to make health care decisions and informed consent. An electronic incident report forwarded by the Facility to the Department of Public Health on 7/30/15 indicated that on 7/29/15, an unknown person contacted the facility to report that there was a video posted of two residents on Snapchat, which were very upsetting to her. Unit Manager #1 requested that she bring in the video so that she may review it. After Unit Manager #1 reviewed the video, she contacted the Director of Nurses (DON). The Surveyor interviewed Unit Manager #1 at 12:20 P.M. on 8/14/15. Unit Manager #1 said she saw two video recordings of Resident #1, and one recording of Resident #2. Unit Manager #1 said Resident #1 was seated on a raised toilet seat, while being asked personal questions related to ganga (marijuana) and sex. There was laughter heard in response when Resident #1 made nonsensical responses. Unit Manager #1 said she recognized CNA #1, as one of the voices asking Resident #1 the questions. Unit Manager #1 said the second recording showed CNA #2 approach Resident #1 (asleep in bed), she placed her hands on either side of Resident #1's upper torso, and she quickly screamed Resident #1's first and last name at him/her before stepping away. Unit Manager #1 said Resident #1's hands moved in a startled response to the sides of his/her face, his/her eyes opened wide appearing scared and then laughter was heard. Unit Manager #1 said the third recording showed Resident #2 being told repeatedly to make the sound yayaya and when he/she did as requested in a smiling manner, laughter was heard. Resident #2's smile showed he/she had some teeth missing. Unit Manager #1 said a caption was added the bottom of the recording that referenced a horror movie. Unit Manager #1 said Resident #1 and Resident #2 were vulnerable and dependent on the intimate care CNAs provided them. Unit Manager said CNA #1 and CNA #2's actions were cruel and if a reasonable person experienced the incidents as viewed in the recordings of Resident #1 and Resident #2, he/she would have felt angry, taunted, intimidated and bullied. The Surveyor interviewed the DON at 10:05 A.M. on 8/14/15. The DON said that during the Facility's internal Investigation she interviewed CNA #1 and CNA #2. The DON said CNA #1 admitted to recording and posting Resident #1 and Resident #2's videos on Snapchat (a video messaging application), and sending them to CNA #2 and approximately 6 other individuals not employed by the Facility. The Director of Nurses (DON) said CNA #2 told her that ganga referenced a cigar, not an illegal drug in the recording. The DON said that she reported this incident to the Police Department. The Surveyor interviewed the Police Detective at 2:00 P.M. on 9/8/15. The Police Detective said CNA #1 admitted to having Resident #2 make sounds, to laugh, and to adding the caption referencing the horror movie on the recording. The Police Detective said a forth video recording showed CNA #2 laying down alongside Resident #3 in his/her bed, she placed an arm across his/her body and told Resident #3 that she loved him/her. The Police Detective said Resident #3 reacted by angrily telling CNA #2 to get off him/her approximately three times. The Police Detective said a caption was added to the video recording that said words to the effect of I feel the love, it's in the air, LMAO (Internet slang meaning: Laughing My Ass Off). The Police Detective said CNA #2 admitted to lying in bed with Resident #3, and CNA #1 admitted to making the recording, and adding the caption. The facility was found to be in past non-compliance. Both CNA #1 and CNA #2 were initially suspended on 7/30/15 pending investigation then terminated. The Facility provided staff education regarding Abuse, Cell phone policy and HIPPA violations from 7/30/15 to 8/10/15. The facility appropriately reported the incidents to the Department of Public Health in accordance with state and federal regulations.