Every finding on record at Watertown Rehabilitation and Nursing Center

Based on record review and interview the facility failed to implement an Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics.Findings include:Review of the facility policy titled Antibiotic Stewardship, dated as revised December 2016, indicated but was not limited to: Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program.The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents. During the survey period the surveyor requested infection control and antibiotic stewardship information. The facility did not implement a program for antibiotic stewardship and did not implement a system to monitor antibiotic use. Based on records reviewed, one resident was treated with antibiotics for pneumonia without an appropriate indication for use. One resident was treated with antibiotics for UTI (urinary tract infection) without an appropriate indication for use, and one resident was treated with antibiotics for eye redness without an appropriate indication for use.The facility failed to have any documented information related to tracking, follow up or review with the physician or nurse practitioner following the initiation of the antibiotics for any active physician antibiotic orders prescribed. During an interview on 4/28/26 at 7:49 A.M., Nurse #8 said we do not have line listings on the unit for infections or antibiotics and said the staff tell the Director of Nurses if someone has an infection. Nurse #8 said he is not familiar with the antibiotic stewardship program and does not track or review start and stop dates of antibiotics. During an interview on 4/28/26 at 7:53 A.M., the Nursing Supervisor said she does not review the antibiotic usage or communicate with the providers regarding start and stop dates and said the Director of Nurses (DON) tracks infections and would manage the antibiotic stewardship program. During an interview on 4/28/26 at 12:13 P.M., the Director of Nurses (DON) said the facility is not implementing the antibiotic stewardship program and said we need to do better at monitoring the use of antibiotics, reviewing start and stop dates and indication of use for the antibiotics prescribed. The DON said she does not have any information regarding the program as it has not been implemented.During an interview on 4/28/26 at 12:15 P.M., the Regional Nurse said she expects the facility to have an effective ongoing antibiotic stewardship program in place.

Based on observation and interview, the facility failed to properly follow food storage practices in the kitchen to prevent the risk of foodborne illness in accordance with professional standards for food service safety. Specifically, the facility failed to properly store, date and label food product to prevent the risk of foodborne illness.Findings include:During the initial kitchen walk-through on 4/26/26 at 7:15 A.M., the surveyor made the following observations:In the walk-in refrigerator:- A container of what appeared to be coleslaw was unlabeled and undated.- A container labeled Beets had a prepared date of 4/15 and a use-by date of 4/17.- A second container labeled Beets had a prepared date of 4/21 and a use-by date of 4/23.- A container of cooked rice had a prepared date of 4/22 and a use-by date of 4/24.- A container of what appeared to be grilled hamburgers had a prepared date of 4/23 and use-by date of 4/25.- A container with a peanut butter sandwich had a single date of 4/23.- A container of raw chicken breast in a container with a prepared date of 4/20/26 that was sitting in about half an inch of juice and blood.- A container of what appeared to be creamed peas with no label or date.- An opened bag of grated cheese that had no label or date.- A plastic bag of croissants that had no label or date.- A container of ginger ale that was stored directly on the floor below the rack of food products.In the walk-in freezer:- A pitcher of broccoli florets that was not covered and was open to air.- Boxes of product were stored directly on the floor.In the dry storage room:- Multiple bags of opened hamburger rolls were not covered or labeled and were open to air. The hamburger rolls were hard to the touch.During an interview on 4/28/26 at 7:19 A.M., the Foodservice Director (FSD) said ready-to-eat food including peanut butter sandwiches should be discarded after one day and all other food should be discarded after three days. The FSD then said all prepared food should be dated and labeled as to what it is.During a follow-up interview on 4/28/26 at 11:08 A.M., the surveyor shared the observations from 4/26/26, the FSD said the food should have been properly labeled, dated and discarded if past the written date. The FSD then said the raw chicken should have been discarded because it was sitting in juice and blood.

Based on observation, record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically,1. For Resident #15, the facility a. failed to ensure staff implemented contact precautions for Resident #15, with active C-diff Infection (Clostridium difficile, a spore forming toxin that can develop in the intestines after antibiotic use and causes watery diarrhea), and b. failed to follow proper infection control practices for shared medical equipment, and c. failed to ensure staff performed hand hygiene after providing care. 2. The facility failed to implement Enhanced Barrier Precautions (EBP) for two Residents (#130 and #2) out of a total of 32 Residents who required the use of EBP.Findings Include: Review of the facility policy titled Infection Control Policy and Procedure, dated 2026, indicated but was not limited to: To help prevent the development and transmission of communicable diseases and infections in the Facility and to ensure that the Facility: I. Develops and implements an ongoing infection prevention and control program (IPCP) to prevent, recognize and control the onset and spread of infection to the extent possible and B. Written standards, policies, and procedures for the IPCP, which shall include, but are not limited to:a. A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the Facility;b. When and to whom possible incidents of communicable disease or infections should be reported. c. Standard and transmission -based precautions to be followed to prevent spread of infections;d. When and how isolation should be used for a resident; including but not limited to; i. The type and duration of the isolation, depending upon the infectious agent or organism involved, and f. The hand hygiene procedures to be followed by staff involved in direct resident contact. VII. Prevention and Control of Transmission of InfectionI. Enhanced Barrier Precautions ( EBP)a. Enhanced barrier precaution means an infection control intervention designed to reduce transmission of multidrug resistant organisms that employs targeted gown and glove use during high contact resident care activities.ii. For residents who enhanced verification options are indicated enhanced barrier precautions shall be employed when performing the following high contact resident care activities: 1. Dressing2. Bathing /showering3. Transferring 4. Providing hygiene 5. Changing linens 6. Changing briefs or assisting with toileting.IX. Transmission Based PrecautionsE. When a resident is placed on transmission-based precautions the staff should implement the following:a. Clearly identify the type of precautions and the appropriate PPE to be used;c. Make PPE readily available near the entrance to the residence room; d. DON appropriate PPE upon entry into the environment (e.g., room or cubicle) of resident on transmission-based precautions (e.g., contact precautions);e. Use disposable or dedicated non-critical resident-care equipment (e.g., blood pressure cuff, bedside commode) if non critical equipment is shared between residents, it will be clean and disinfected following manufacturer's instructions with an EPA registered disinfectant after use;F. Contact Precautions are intended to prevent transmission of infections that are spread by direct (e.g., person-to-person)or indirect contact with the resident or environment and require the use of appropriate PPE including a gown and gloves upon entering (i.e., before making contact with the resident or residence environment) the room or cubicle. Prior to leaving the residence room or cubicle, the PPE is removed and hand hygiene is performed.1a. Resident #15 was admitted to the facility in October 2024 with the following diagnoses: pneumonia, primary hypertension, and osteoarthritis. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/28/26, indicated that Resident #15 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15, and required Substantial/maximal assistance with Activities of Daily Living tasks. Review of the medical record for Resident #15 indicated the Resident was discharged from the hospital in April, 2026. Discharge paperwork indicated Resident #15 tested positive for C.diff and was started on oral antibiotics. Review of the active physician orders indicated the following: Contact Precautions r/t (related to) severe C. Diff every shift. Start Date: 4/25/26.Review of Resident #15 Care Plan indicated: Resident has C. Difficile. Date Initiated: 4/25/26. Interventions include: -CONTACT Precautions: Wear gown and gloves when entering room and when in room. Place soiled linens in plastic bags. After removing gown and gloves, wash hands with soap and water. Resident stays in room.- Encourage/ assist with hand washing after being toileted and before and after meals.On 4/27/26 at 6:49 A.M., the surveyor observed a precaution bin hanging outside Resident #15's room. The precaution bin was filled with personal protection equipment (PPE) masks, gowns, and gloves. There was a contact precaution sign on the wall outside of the entrance to the room. The door to the room was open and Nurse #10 was observed taking vital signs inside the room. Nurse #10 was not wearing PPE. Nurse #10 then exited Resident #15's room, closed the door with her bare contaminated hand, and without washing her hands she proceeded to push the vital signs machine down the hall. Nurse #15 did not disinfect the vital signs machine. On 4/27/26 at 6:52 A.M., Nurse #10 was observed pushing the same contaminated vital signs machine into another resident room and began to take vital signs on another resident. Nurse #10 then exited the room and without washing her hands she proceeded to push the vital signs machine down the hall. Nurse #15 did not disinfect the vital signs machine and did not perform hand hygiene.On 4/27/26 at 6:55 A.M., the Director of Nurses (DON) was overheard telling Nurse #10 to wipe down the vital signs machine and to use hand sanitizer after she exited a resident's room.During an interview on 4/27/26 at 6:57 A.M., Nurse #10 said Resident #15 is on contact precautions for C.diff and said she should have worn PPE when entering the room because C. diff is contagious and said the vital signs machine should have been wiped down in between after each use. Nurse #10 said she should have performed hand hygiene. 1b. On 4/27/26 at 6:58 A.M., the surveyor observed Certified Nursing Assistant (CNA) #2 enter Resident #15's room without wearing any PPE. CNA #2 was observed providing care to Resident #15. CNA #2 was then observed exiting the Resident's room, and with her bare contaminated hand she closed the door and did not perform hand hygiene. During an interview on 4/27/26 at 7:02 A.M., CNA #2 said she does not know why the Resident is on precautions and said she didn't notice the sign outside of the door and said she thinks it is for the other Resident in the room but was not sure. CNA #2 said no one mentioned to her that either Resident had to be on precautions. During an interview on 4/27/26 at 7:03 A.M., Nurse #7 said Resident #15 has active C.diff and is on contact precautions and said staff must wear PPE when entering the room and must wash their hands with soap and water. During an interview on 4/27/26 at 7:05 A.M., the DON said there is a contact precaution sign and precaution bin outside Resident #15's room but she does not know why, and the DON said she would have to look into it to see why the Resident is on contact precautions. The DON said staff must follow the infection control guidelines and wear PPE whenever entering the room and must perform hand hygiene.During an interview on 4/28/26 at 7:47 A.M., the Nursing Supervisor said staff must follow contact precautions and clean equipment in-between use to prevent the spread of infections and said staff must wash their hands with soap and water especially for Resident #15 who has C.diff. On 4/27/28 at 7:50 A.M., the surveyor observed the Director of Nursing hanging up a sign next to the contact precaution sign located outside of Resident #15's room. The sign written in black marker indicated: Wash hands with soap & water before you leave the room. Must wear gown & glove before you enter room. Change gown and gloves to take care of 2nd resident.During an interview on 4/28/26 at 12:05 P.M., the Regional Nurse said staff must follow the infection control guidelines for Contact Precautions and should not enter the room without the appropriate PPE and said staff must disinfect equipment in-between use and must wash their hands with soap and water to prevent the spread of C.diff. 2a. During an observation on the Fourth Floor Unit on 4/27/26 at 7:08 A.M., the surveyor observed CNA #4 entering a resident's room and providing personal care for Resident #130. There was a sign on the Resident's doorway to indicate the need for Enhanced Barrier Precautions (EBP) for both A & B beds. CNA #4 utilized gloves only and did not use gowns when providing personal care to the Resident.During an interview on 4/28/26 at 8:00 A.M., CNA #4 said he should have used the appropriate Personal Protective Equipment (PPE) when providing personal care to Resident #130 and said he was giving Resident #130 a bed bath and should have on gown and gloves for protection. 2b. During an observation on the Fourth Floor Unit on 4/27/26 at 12:44 P.M., the surveyor observed CNA #4 enter a resident's room and was providing personal care for Resident #2. There was a sign on the Resident's doorway to indicate the need for Enhanced Barrier Precautions (EBP). CNA #4 utilized gloves only and did not use gowns when providing personal care to the Resident.During an interview on 4/28/26 at 8:01 A.M., CNA #4 said he should have used the appropriate Personal Protective Equipment (PPE) when providing personal care to Resident #2 and said he was washing the resident up and should have put on gown and gloves when giving him/her a bed bath. During an interview on 4/28/26 at 7:49 A.M., the Nursing Supervisor said staff must follow the guidelines for EBP and said staff should not be performing personal care without the use of appropriate PPE and said any close contact care requires the appropriate EBP protection. During an interview on 4/28/26 at 12:05 P.M., the Director of Nurses (DON) said staff must follow the infection control guidelines for EBP and wear PPE whenever providing personal care to Residents who have a sign indicating the need for EBP.

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 injector pen was stored properly and failed to ensure access to the medication storage room was limited to authorized personnel on one of three units. Findings include:Review of the facility policy titled Medication Labeling and Storage dated 2001 indicated that the facility stores all medications and biologicals in locked compartments . only authorized personnel have access to keys. Further review indicated that the medication label includes the expiration date when applicable. 1. On 4/28/26 at 12:20 P.M. the surveyor observed a Lantus insulin injector pen on the second-floor nursing station desk. The surveyor also observed several residents and staff in the area. During an interview on 4/28/26 at 12:20 P.M., Nurse #5 said that she had put it there because the pharmacy had delivered the wrong medication. Nurse #5 then said that she should have locked the insulin up and not left it on the nurse's desk. 2. On 4/26/26 at 7:06 A.M., the surveyor and Nurse #2 observed the fourth-floor low side medication cart: -Humalog insulin unopened and not refrigerated. Manufacture's direction is to keep unopened insulin refrigerated until ready to use. On 4/26/26 at 7:11 A.M., the surveyor and Nurse #2 observed the fourth-floor high side medication cart: -Spiriva inhaler opened and undated. -Latanoprost 0.005% eye drop opened and undated. -Spiriva Respimat 2.5 micrograms (mcg) opened and undated. During an interview on 4/26/26 at 7:22 A.M., Nurse #2 said nurses are responsible for dating medications when they are opened and refrigerate insulin until they are ready to use. During an interview on 4/28/26 at 9:40 A.M., the Director of Nursing said medications with short expiration dates should be dated when opened, and insulin should be refrigerated until ready to use. 3. On 4/26/26 at 7:15 A.M., the surveyor observed the medication storage room located on the 3rd floor unit was unlocked. The surveyor was able to gain access to the medication storage room. No staff were present at the nurse's station and residents were visible at the nurse's station and in the hall. During an interview on 4/26/26 at 7:26 A.M., Nurse #6 said he is not sure why the medication room is unlocked and said it must be locked at all times. During an interview on 4/28/26 at 12:51 P.M., the Director of Nursing said the medication storage room should not be unlocked and said nurses must lock the medication storage room when not in use. 4. On 4/26/26 at 7:22 A.M., the Surveyor and Nurse #6 observed the medication cart on the 3rd floor high side had the following medications that were open and undated and one medication due to expire today. On 4/26/26 at 7:22 A.M., the surveyor and Nurse #6 observed the following medication in the 3rd floor medication cart: -One Lantus (insulin glargine) Vial opened and undated. During an interview on 4/26/26 at 7:27 A.M., Nurse #6 said the opened bottle of Lantus is used and undated and said the Lantus should have been dated when opened. During an interview on 4/28/26 at 12:50 P.M., the Director of Nursing said the bottle of Lantus must be dated when opened and should not be in the medication cart without an opened date.

Based on observation, record review and interview, the facility failed to ensure their process for self-administration of medications was followed for two Residents (#82 and #30) out of a total sample of 32 residents. Specifically:For Resident #82, the facility failed to ensure the Resident took his/her medications timely after leaving the medications at the bedside and failed to have a physician's order to self-administer any other medications other than the inhaler.For Resident #30, the facility failed to ensure the Resident was assessed for the capacity to self-administer medications and failed to ensure the Resident took his/her medications after leaving the medications at the bedside.Findings include:Review of the facility policy titled Self Administration of Medications dated 2001 Indicated that residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Further review indicated that nursing staff reviews the self-administered medication record for each nursing shift and transfers pertinent information to the Medication administration record kept at the nursing station appropriately noting the doses that were self-administered.1. Resident #82 was admitted to the facility in July 2021 with diagnoses including history of suicidal ideations, psychoactive substance abuse disorder and depression.Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #82 is cognitively intact, scoring a 15 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #82 requires supervision with activities of daily living.On 4/26/26 at 8:13 A.M., the surveyor observed a medication cup, with 6 medications in it, at the bedside. During an interview on 4/26/26 at 8:13 A.M., Resident #82 said that the medications were his/her nighttime medications. Resident #82 then said that the evening nurse leaves his/her medications with him/her to take when he/she is ready to go to sleep. Resident #82 then said that he/she didn't fall asleep until around 3 A.M., and he/she forgot to take the medications last night. Resident #82 then took the nighttime medications in front of the surveyor at 8:13 A.M. Review of the physician's orders indicated an order for Resident may self-administer Inhaler and keep locked at bedside. Further review failed to indicate that Resident #82 could self-administer any other medications. Further review indicated that the medications given at 9:00 P.M. and 10:00 P.M. consisted of the following:Docusate Sodium Capsule 100 MG (milligrams) give 200 mg by mouth at bedtime for constipation.Melatonin Tablet 5 MG give 5 mg by mouth at bedtime for Insomnia.Remeron Oral Tablet 15 MG (Mirtazapine) give 1 tablet by mouth at bedtime.Zoloft Tablet 25 MG (Sertraline HCl) give 1 tablet by mouth at bedtime for depression.Gabapentin Capsule 100 MG give 2 capsules by mouth three times a day for neuronal pain. Review of the care plan indicated a focus for the following: Resident has requested to administer his/her own inhaler medication Date Initiated: 4/15/26. Further review failed to indicate a care plan for the self-administration of any other medications or for leaving the medications at bedside. Review of the facility document titled Medication Self-Administration Screen dated 4/15/26 indicated Resident #82 is fully able to self-administer medications as ordered. However Resident #82 did not self-administer medications as ordered on 4/26/26 at 8:13 A.M., as observed by the surveyor.During an interview on 4/27/26 at 10:55 A.M., the Director of Nursing (DON) said that the Resident should be assessed for each medication for self-administration. The DON then said that medications should never be left at the bedside for the Resident to take whenever he/she chooses, and that the nurse is supposed to stay with all residents to ensure the medications have been taken. During an interview on 4/27/26 at 12:53 P.M., Nurse #1 said that medications that have been removed from their containers and placed in a medication cup, are never to be left with a resident even if they are allowed to self-administer. Nurse #1 then said that the nurse is supposed to stay with the residents to ensure the medications have been taken.2. Resident #30 was admitted to the facility in December 2021 with diagnoses including alcohol abuse, depression and type 2 diabetes.Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #30 is cognitively intact, scoring a 15 out of 15 on the Brief interview for mental status exam. Further review indicated that Resident #30 requires supervision for activities of daily living. On 4/26/26 at 7:40 A.M., the surveyor observed pills in cup at bedside. The surveyor also observed two tubes of medication at bedside, one tube of hydrocortisone cream and one tube of Ketonzole cream and one of an anti-fungal cream. During an interview on 4/26/26 at 7:40 A.M., Resident #30 said that the nurse sometimes leaves the medication for him/her to take later. Review of the medical record failed to indicate that Resident #30 had been assessed for the safe self-administration of medications. Review of the physician orders dated April 2026 failed to indicate a physician's order for the self-administration of medications. Review of the care plan failed to indicate Resident #30 can self-administer medications. During an interview on 4/27/26 at 10:55 A.M., the Director of Nursing (DON) said that the Resident should be assessed for each medication for self-administration. The DON then said that medications should never be left at the bedside and that the nurse is supposed to stay with the residents to ensure the medications have been taken. During an interview on 4/27/26 at 12:53 P.M., Nurse #1 said that medications are never to be left with a resident. Nurse #1 then said that the nurse is supposed to stay with the residents to ensure the medications have been taken.

Based on observation, record review and interview the facility failed to provide reasonable accommodation of needs and preferences for one Resident (#52) out of a total sample of 32 residents. Specifically, for Resident #52, the facility failed to provide an appropriate wheelchair and therapy to manage the wheelchair, to increase desired independence.Findings include:Resident #52 was admitted to the facility in January 2026 with diagnoses including bipolar disorder, depression and anxiety.Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #52 is moderately cognitively impaired, scoring a 9 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #52 is dependent on staff for activities of daily living.Review of the care plan indicated that Resident #52 is dependent on staff for activities of daily living.On 4/26/26 at 8:42 A.M. the surveyor observed Resident #52 in a reclining chair (Geri-chair) next to his/her bed.During an interview on 4/26/26 at 8:42 A.M., Resident #52 said that he/she wants a wheelchair so that he/she can be more independent. Resident #52 said that he/she was given a wheelchair in the past but the leg rests did not fit and the wheelchair has disappeared.Review of the Physical Therapy (PT) evaluation dated 1/10/26 indicated the plan of treatment included wheelchair management training with a short-term goal of patient will increase ability to safely propel self in wheelchair 25 feet with Min A (minimum assist) on level surfaces in order to decrease level of assistance from caregivers, facilitate participation with functional daily activities and increase performance skills with functional tasks. Further review indicated a long-term goal of 150 feet with modified independence. Review of the PT treatment encounter notes dated 1/10/26 through 2/8/26 indicated the following:1/10/26-pending wheelchair for out of bed. 1/23/26-patient issued a standard wheelchair for when patient is out of bed.1/27/26-wheelchair management: training in safe maneuvering through doorways, analysis of patient's body alignment and functional skills in new or existing wheelchair, assessment of current seating system for appropriate modifications and safe and efficient wheelchair mobility over various surfaces. Further review failed to indicate assessments or outcomes of above listed wheelchair training and failed to indicate if the wheelchair was assessed as appropriate for Resident #52. Review of the PT Discharge summary dated [DATE] indicated that Resident #52 is dependent on others for wheelchair propulsion. Review of the Occupational Therapy (OT) evaluation dated 1/12/26 failed to indicate goals for the use of a wheelchair. Review of the OT treatment encounter notes dated 1/12/26 through 3/16/26 indicated the following:2/10/26-patient was provided with new wheelchair.Further review failed to indicate wheelchair training was provided and failed to indicate if the newly issued wheelchair was assessed as appropriate for Resident #52. Review of the OT Discharge summary dated [DATE] failed to indicate wheelchair training was provided and failed to indicate if the newly issued wheelchair was assessed as appropriate for Resident #52. During an interview on 4/27/26 at 12:58 P.M., the Director of Rehabilitation (DOR) said that we should have provided a wheelchair that was appropriate for Resident #52 to use. The DOR then said that Resident #52 should have been assessed for what type of wheelchair was appropriate and then provided therapy to assist the Resident obtain his/her maximum functional ability. The DOR said that we dropped the ball on this one and Resident #52 was not provided the therapy needed to maximize functional mobility with a wheelchair.

Based on observations, record reviews and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs) for dependent Residents for one Resident (#73) out of a total sample of 32 Residents. Specifically, the facility failed to ensure incontinence care was provided timely and in accordance with the standards of care and the Resident care plan.Findings include:Review of the facility policy, titled, Activities of Daily Living (ADL), Supporting, dated as revised April 2025, indicated but was not limited to the following:Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.5. Appropriate care and services are provided for Residents who are unable to carry out ADL's independently, with the consent of the Resident, and in accordance with the plan of care, including appropriate support and assistance with:a. hygiene (bathing, dressing, grooming and oral care);c. elimination (toileting)1. Resident #73 was admitted to the facility in April 2026 with the following diagnoses: vascular dementia with other behavioral disturbance, type two diabetes mellitus, acute kidney failure, and primary hypertension.Review of the most recent Minimum Data Set (MDS) assessment, dated 4/15/26, indicated that Resident #73 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15, and is dependent on staff with activities of daily living. Further review of the MDS indicated Resident #73 is incontinent of bowel and bladder.Review of Resident #73's incontinence care plan dated 4/8/26 and last revised 4/23/26, indicated the following: Resident is incontinent of urine.Interventions:-Assist to toilet as needed.-Provide incontinence care as needed-Provide preventative skin care with incontinence careReview of Resident #73's incontinence care plan dated 4/8/26 and last revised 4/23/26, indicated the following: Resident is incontinent of bowel.Interventions:-Assist to toilet as needed.-Preventative skin care with each incontinent episode.-Provide peri-care after each incontinent episode.Review of Resident #73's ADL Care Plan dated 4/8/26 and last revised 4/23/26, indicated the following: Resident has an ADL Self Care Performance Deficit r/t (related to) Bipolar, Dementia, Cerebral infarction.Interventions:-TOILET USE: The Resident is totally dependent on staff for toilet use.- PERSONAL HYGIENE/ORAL CARE: The Resident requires total staff participation with personal hygiene and oral care.On 4/28/26 the surveyor made the following observations on the fourth-floor nursing unit:At 7:50 A.M., Resident #73 was observed sitting in a chair in the hall across from the nurse's station. The Resident was wearing a nursing gown and had socks on. Staff and other Residents walked past the Resident on the nursing unit.At 7:54 A.M., the surveyor observed a large puddle located under Resident #73's chair that went from under the chair to halfway across the floor in the hallway. The Resident did not have any beverages and there were no observed spills within the area of the observations. One staff member was observed walking past Resident #73 and one staff member was observed standing at the nurses station directly across from Resident #73.At 8:07 A.M., the Nursing Supervisor noticed Resident #73 was wet and a puddle was on the floor coming from the Residents chair. The Nursing Supervisor told another staff member to contact housekeeping to clean up urine and said another staff member would come over to change Resident #73 who had an incontinent episode in the hall. The Nursing supervisor and Nurse #9 placed a blanket on the floor to cover the urine puddle.At 8:17 A.M., Nurse #9 walked over to Resident #73 and told the surveyor that Resident #73 is incontinent of urine and that he/she needed to be changed as she walked Resident #73 back to his room that was located right next to where the Resident was sitting. Nurse #9 was observed walking Resident #73 into his/her room and assisting him/her to sit on the edge of the bed. Nurse #9 said I will be right back with your breakfast, as she exited the room and began checking the meal truck in the hall. Nurse #9 did not provide incontinence care.At 8:22 A.M., a staff member walked into Resident #73's room and delivered a breakfast tray and placed it on the overbed table and walked out of the room. Resident #73 was visible from the hall.At 8:37 A.M., the surveyor observed Resident #73 walking out of his/her room and into the hall. The Resident was reaching down between his/her legs and appeared to be lifting the incontinence brief up in the front over his/her gown.At 8:40 A.M., the Surveyor observed a staff member approach Resident #73 and said, come on let's go back to your room, CNA #3 then walked Resident #73 into his/her room and sat the Resident on his/her bed and partially shut the bedroom door. The Resident was visible from the hallway. CNA #3 did not provide incontinence care.At 8:47 A.M., CNA #3 walked into Resident #73's room, stood Resident #73 up and then sat the Resident in a chair located near the window and exited the room. CNA #3 said I am going to go back and change Resident #73 and wash him/her. CNA #3 did not provide incontinence care. At 8:50 A.M., the surveyor observed Resident #73 walk out of his/her room and into the hall. The Resident lifted his/her gown up and was wearing an incontinent brief that appeared to be full of dark colored urine and was sagging down. Resident #73 was struggling to pull up the brief with one hand. The Residents incontinence brief appeared to be leaking. One staff member walked past Resident #73 as he/she was exposing the leaking incontinent brief. Another Resident was sitting in the hall and said What are you doing? You need a new one on.At 8:52 A.M., the Nursing Supervisor was observed walking over to Resident #73 and said, What are you doing?, as she walked Resident #73 back into his/her room and said CNA #3 will be coming in and will help you get ready for the day. The Resident was observed sitting on the edge of his/her bed. The Nursing Supervisor then exited the room.At 8:54 A.M., CNA #3 was observed entering the Residents room to provide ADL care.During an interview on 4/28/26 at 11:50 A.M., CNA #3 said she was late coming into work and did not provide incontinent care when she first arrived this morning and said the first time, she changed Resident #73 was after breakfast. CNA #3 said the Resident needed to be changed because the incontinence brief was full of urine and he/she was wet. CNA #3 said she was not aware of the Resident having an incontinent episode in the hall before breakfast and said he/she should have been changed before and after breakfast to keep his/her skin clean because he/she is incontinent and needs help During an interview on 4/28/26 at 11:51 A.M., Nurse #8 said he observed Resident #73 sitting in the chair in the hall and saw staff cleaning up the urine that was on the chair and on the floor while he was in the middle of a medication pass down the hall. Nurse #8 said he would expect staff who found the Resident to provide incontinent care because he/she was wet with urine and needed to be changed.During an interview on 4/28/26 at 11:57 A.M., the Nursing Supervisor said Resident #73 should have been changed this morning when the Nurse walked him/her back into the room because Resident #73 was visibly wet and his/her incontinent brief was full of urine. The Nursing Supervisor said it was concerning that he/she was not changed and said the nurse should have changed him/her and not placed the Resident back in bed sitting in a wet incontinence pad.During an interview on 4/28/26 at 12:40 P.M., the Director of Nursing said Resident #73 should have been provided incontinence care when the staff first observed him/her sitting in the hall in a puddle of urine and said Resident #73 is dependent on staff and should not have had to sit in a wet incontinence brief for an hour during the breakfast meal.During an interview on 4/28/26 at 12:44 P.M., the Regional Nurse said it is her expectation that staff provide incontinence care timely and said the staff should have washed Resident #73 and provided a new brief when they first observed him/her in the hall leaking urine.

Based on observations, record review and interviews, the facility failed to ensure a safe smoking environment for the residents of the facility. Specifically, 1.The facility failed to provide adequate supervision for Resident #69 during smoking, resulting in a burn. 2.The facility failed to provide adequate supervision for other residents, while smoking. Findings include: Review of the facility policy titled 'Smoking Policy-Residents', dated October 2023, indicated the following but not limited to: -This facility has established and maintains safe resident smoking practice. Review of the Resident Smoking Agreement, dated 11/19/25 indicated the following: -Residents may not provide other residents with cigarettes or other smoking paraphernalia and may not light a cigarette for another resident. 1. Resident #69 was admitted to the facility in November 2025 with diagnoses including muscle wasting and atrophy, multiple sclerosis and anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #69: -Was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of a total possible score of 15. -Uses Tobacco. During an interview on 4/27/26 at 8:16 A.M., Resident #69 said that he/she has a wound on his/her right ankle from a cigarette burn that had happened a while back. The Resident said he/she got burned when he/she went to light his/her cigarette using another resident's cigarette and the other resident's cigarette ash fell off and fell into Resident #69's boot. The Resident said there was a staff member outside with them, but he/she did not alert the staff to what had happened. The Resident said he/she removed his/her boot and took out the ashes. Resident #69 said she/he never made anyone from the facility aware until a week after when the area had formed a blister. Review of a progress note dated 4/5/26 indicated the following: -At approximately 3:50 PM, the resident requested a bandage for an open blister on his/her right ankle. The nurse on duty responded promptly and performed an assessment, asking the resident about the cause. The resident reported that the injury occurred approximately one week ago while smoking outside, when a cigarette butt fell into his/her shoe, resulting in a blister that has since opened. -The nurse and supervisor assessed the area and observed an open wound on the right ankle measuring approximately 0.5 cm (centimeters) in circumference and 0.3 cm in depth, with serous drainage noted. No redness or signs of infection were observed in the surrounding tissue. First aid was initiated, and the wound was cleansed and covered with bordered gauze. The Resident's footwear was assessed and noticed that was wide open no lace in place, and a smoking safety reassessment was completed. --Education was provided to both nursing staff and activity staff responsible for supervising smoking to reinforce safety measures and prevent recurrence. Resident were educated on wearing different shoes that are not wide open. Different shoes were offered. Resident HCP (name redacted) made a call and waiting for call back. NP (Nurse Practitioner) on call (name redacted) updated and order obtained foe TX (treatment). [sic] Review of Resident #69's Plan of Care for smoking dated 11/19/25, indicated the following: - The resident is at risk of injury related to smoking-Supervised smoking.Review of the smoking agreement and assessment indicated the following: -Smoking evaluation done 11/19/25 indicated Resident required supervision with smoking. -Resident smoking agreement done 11/19/25 - smoker requiring supervision. During an interview on 4/27/26 at 9:29 A.M., the Director of Nursing (DON) said supervision of residents during smoking includes not letting the residents light cigarettes using each other cigarettes. She said the staff supervising the smoking group should be lighting the residents' cigarettes as this could cause accidents like burns. During an interview on 4/27/26 at 11:22 A.M., the DON said she does not know if hot ashes from a cigarette could cause a burn since she has never smoked and would have to google that. During an interview on 4/27/26 at 11:26 A.M., Activity Staff #2 said they should always have two staff supervising smoking but don't always. She said on 4/5/26 she was the only person providing supervision and so the residents were not always provided with continuous supervision and so this could have caused an unsafe situation for Resident #69 and other residents too. Activity Staff (#2) said she was not aware that Resident #69 got burned while smoking.2. During an observation of the smoking group on 4/27/26 at 9:18 A.M., the surveyor observed multiple residents outside the building at the designated smoking area. The area was littered with cigarette butts on the ground. Only one staff member was outside responsible for the supervision of smoking activities. The surveyor observed multiple residents lighting their cigarettes from each other's cigarettes. The Director of Nursing (DON) came outside to the designated smoking area and together with the surveyor observed the residents lighting each other's cigarettes with their own cigarettes. At 9:29 A.M., the surveyor and the DON observed the staff supervising the residents borrowing another resident's cigarette and lit another resident's cigarette. During an interview on 4/27/26 at 9:30 A.M., the Activities Director said the staff supervising the smoking group should be lighting the residents' cigarettes and they should be supervising safety during the smoking session. During an interview on 4/27/26 at 9:32 A.M., the Administrator said the staff that is outside supervising the residents should have a lighter and light the residents' cigarettes. The staff should be supervising for safe smoking. He further said the ground should be free of cigarette litter. During an interview on 4/27/26 at 9:37 A.M., Activity Staff #1 said residents should not be lighting each other's cigarettes to prevent accidents like burning. She said the staff supervising the residents should be lighting their cigarettes.

Based on interviews and record review, the facility failed to develop a care plan for one Resident #46 out of a sample of 32 residents. Specifically, the facility failed to develop a person centered Post Traumatic Stress Disorder (PTSD) care plan with the Resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the Resident.Findings include: A review of the facility policy titled 'Trauma-Informed Care and Culturally Competent Care' revised August 2022 indicated the following:-To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice.-To address the needs of trauma survivors by minimizing triggers and/or re-traumatization.-Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being.-Trauma informed care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization.-Trigger is a psychological stimulus that prompts recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening.-Triggers are highly individualized.-Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate.Resident #46 was admitted to the facility in March 2026 with diagnoses including PTSD.A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 indicating intact cognition. Further review of the MDS indicated Resident #46 has a diagnosis of PTSD.A review of the trauma questionnaire dated 3/13/26 indicated Resident #46 answered Yes to the following questions:-Have you ever been in a serious car accident, or a serious accident at work or somewhere else?-Have you ever been in a major natural or technological disaster, such as fire, tornado, hurricane, flood, earthquake, or chemical spill?-Have you ever witnessed a situation in which someone was seriously injured or killed, or have you ever witnessed a situation in which you feared someone would be seriously injured or killed?Review of Resident #46's care plan failed to indicate a PTSD care plan.During an interview and record review on 4/27/26 at 8:10 A.M., Social Worker #2 reviewed the medical record and said that the Resident has a diagnosis of PTSD and a person-centered PTSD care plan with triggers was not in place and should be in place. Social Worker #2 said the process for ensuring a person-centered PTSD care plan is in place is to identify the trauma at intake by completing a trauma assessment then creating a person-centered care plan from that information.During an interview on 4/27/26 at 10:48 A.M., the Director of Nurses said residents with a PTSD diagnosis should have a person-centered PTSD care plan with personalized triggers to minimize retraumatization.

Based on observation, record review and interview, the facility failed to provide or obtain from an outside resource, routine and emergency dental services to meet the needs of one Resident (#52) out of a total sample of 32 residents. Specifically for Resident #52, the facility failed to obtain a dental consult for broken carious teeth and mouth pain resulting in the development of an abscess in the left jaw.Findings include: Review of the facility policy titled dental services policy and procedure dated 2026 indicated that the facility will assist residents in obtaining routine and 24-hour emergency dental care to meet the needs of each resident.Resident #52 was admitted to the facility in January 2026 with diagnoses including bipolar disorder, depression and anxiety.Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #52 is moderately cognitively impaired, scoring a 9 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #52 is dependent on staff for activities of daily living.Review of Resident #52's care plan indicated a focus of the Resident having oral/dental health problems, Date Initiated: 01/10/2026. Further review indicated the following:Goal-The resident will be free of infection, pain or bleeding in the oral cavity by/through reviewdate. Date Initiated: 01/10/2026. Interventions-* Coordinate arrangements for dental care, transportation as needed/as ordered.Date Initiated: 01/10/2026. Provide mouth care as per ADL personal hygiene.Further review of the care plan indicated that Resident #52 is dependent on staff for activities of daily living.Review of the facility document titled Activation of Health Care Proxy/Durable Power of Attorney for Health Care indicated that on 1/13/26 Resident #52's Health Care Proxy (HCP) was activated.During an interview on 4/26/26 at 8:42 A.M., Resident #52 said that he/she has had mouth pain that had been going on for a long time. Resident #52 said that he/she had just started an antibiotic for a mouth abscess and was taking medicine for the pain.On 4/26/26 at 8:42 A.M., the surveyor observed Resident #52's left side of the face to be swollen. The surveyor then observed Resident #52's bottom teeth to be broken, jagged and black. The surveyor then observed the gums to be red and swollen along the bottom jaw line.Review of the facility document titled Nursing Evaluation with [NAME] (Admit, Readmit, Quarterly, COC) - V 5, SECTION 7. Oral Evaluation/Nutritional Screening, dated 1/9/26, indicated that on admission to the facility Resident #52 had broken/carious teeth and mouth pain.Review of the medical record indicated a dental consult activation form was blank. Further review failed to indicate that Resident #52 had been evaluated by a dentist since admission to the facility.Review of the physician orders dated April 2026 indicated an order dated 1/10/26, for dental consultation as needed. Further review indicated an order dated 2/11/26 for oxycodone HCl Oral Tablet 5 MG (milligrams) give 1 tablet by mouth every 4 hours as needed for pain. Further review indicated an order dated 4/25/26 for Clindamycin HCL 300 mg give 1 capsule by mouth every 8 hours for tooth abscess for 7 Days.Review of the Medication Administration Record (MAR) dated April 2026 indicated that Resident #52 received seven doses of oxycodone for pain on April 1st, 4th, 5th, 9th, 10th, 18th and 23rd.Review of the progress note dated 4/10/26 indicated that Resident #52 received oxycodone for mouth pain. Further review failed to indicate a Nurse Practitioner (NP) note for 4/25/26. During an interview on 4/28/26 at 11:50 A.M., Unit Secretary #1 said that she had not been informed to obtain a dental consultation until 4/26/26, and as of this time she had not been able to obtain a dental consultation. Unit Secretary #1 said that Resident #52 was not signed up for the facility's regular dental service that see the residents in the facility. Unit Secretary #1 said that she could not obtain a dental consultation outside of the facility as Resident #52 was not able to transfer independently from a wheelchair to the dental chair.Review of the medical record failed to indicate that the Healthcare Proxy (HCP) was presented with the opportunity to sign up for the dental services that can be provided within the facility.During an interview on 4/28/26 at 12:38 P.M., HCP #1 said that she was aware that Resident #52's teeth were in bad repair and had been for years. HCP #1 said that she was not presented with the opportunity to sign up for dental services upon admission and had she known that dental services were available at the facility she would have done so. During an interview on 4/28/26 at 11:51 A.M., Nurse #1 said that if the Resident had complained of mouth pain on admission he/she should have been seen by a dentist.During an interview on 4/28/26 at 12:11 P.M. Nurse Practitioner (NP) #1 said that she was not made aware of the condition of Resident #52's teeth or of him/her experiencing mouth pain until 4/25/26. NP #1 said that she would want to know immediately if a resident was taking oxycodone for mouth pain and if she had known she would have done an oral assessment immediately. NP #1 said that on 4/25/26 she completed an oral assessment of Resident #52's mouth and observed the teeth to be black and broken on the lower jaw. NP #1 also said that the gums were red and inflamed. NP #1 also said that Resident #52's face was significantly swollen, and the Resident was complaining of mouth pain. NP #1 said that Resident #52 had developed an abscess in the lower left jaw. NP #1 said that mouth pain is an indicator of an underlying infection and if left untreated could develop into an abscess as it did.During an interview on 4/28/26 at 12:50 P.M., the Director of Nursing (DON) said that a dental consultation should be obtained for any resident admitted to the facility with broken carious teeth and/or mouth pain. The DON then said that HCP #1 should have been given the option to sign up for the dental services that could be provided in the facility but that the dental consult activation form in the medical record indicated that it was not presented as the form was blank. During an interview on 4/28/26 at 1:45 P.M. Nurse Practitioner #2 said that she was in the facility on 4/10/26, but was not informed that the Resident was experiencing mouth pain or taking oxycodone for mouth pain. NP #2 said that if she had been informed, she would have immediately assessed the Resident's oral status. NP #2 said that oxycodone is a very strong medication and if the Resident is needing oxycodone for mouth pain that would indicate a potentially serious problem like infection.

Based on observations, record review and interview the facility failed to accurately document in the medical record for two Residents (#82 and #30) out of a total sample of 32 residents. Specifically: For Residents #82 and #30 the facility failed to accurately document the time the Residents took their medications on the Medication Administration Record.Findings include: Review of the facility policy titled Self Administration of Medications dated 2001 Indicated that residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Further review indicated that nursing staff reviews the self-administered medication record for each nursing shift and transfers pertinent information to the Medication administration record kept at the nursing station appropriately noting the doses that were self-administered.1. Resident #82 was admitted to the facility in July 2021 with diagnoses including history of suicidal ideations, psychoactive substance abuse disorder and depression.Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #82 is cognitively intact, scoring a 15 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #82 requires supervision with activities of daily living.On 4/26/26 at 8:13 A.M., the surveyor observed a medication cup, with 6 medications in it, at the bedside. During an interview on 4/26/26 at 8:13 A.M., Resident #82 said that the medications were his/her nighttime medications. Resident #82 then said that the evening nurse leaves his/her medications with him/her to take when he/she is ready to go to sleep. Resident #82 then said that he/she didn't fall asleep until around 3 A.M., and he/she forgot to take the medications last night. Resident #82 then took the nighttime medications in front of the surveyor at 8:13 A.M. Review of the physician's orders indicated an order for Resident may self-administer Inhaler and keep locked at bedside. Further review failed to indicate that Resident #82 could self-administer any other medications. Further review indicated that the medications given at 9:00 P.M. and 10:00 P.M. consisted of the following:Docusate Sodium Capsule 100 MG (milligrams) give 200 mg by mouth at bedtime for constipation.Melatonin Tablet 5 MG give 5 mg by mouth at bedtime for Insomnia.Remeron Oral Tablet 15 MG (Mirtazapine) give 1 tablet by mouth at bedtime.Zoloft Tablet 25 MG (Sertraline HCl) give 1 tablet by mouth at bedtime for depression.Gabapentin Capsule 100 MG give 2 capsules by mouth three times a day for neuronal pain.Review of the Medication Administration Record (MAR) dated 4/25/26 at 9:00 P.M. and 10:00 P.M. indicated, in error, that Resident #82 took his/her medications at the prescribed time.During an interview on 4/27/26 at 10:55 A.M., the Director of Nursing (DON) said that the nurse should document accurately in the MAR what time the Resident took his/her medications. The DON then said that medications should never be left at the bedside for the Resident to take whenever he/she chooses. During an interview on 4/27/26 at 12:53 P.M., Nurse #1 said that medications that have been removed from their containers and placed in a medication cup, are never to be left with a resident even if they are allowed to self-administer. Nurse #1 then said that the nurse is supposed to stay with the residents to ensure the medications have been taken and document accurately in the MAR what time those medications were taken.2. Resident #30 was admitted to the facility in December 2021 with diagnoses including alcohol abuse, depression and type 2 diabetes.Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #30 is cognitively intact, scoring a 15 out of 15 on the Brief interview for mental status exam. Further review indicated that Resident #30 requires supervision for activities of daily living. On 4/26/26 at 7:40 A.M., the surveyor observed pills in cup at bedside. The surveyor also observed two tubes of medication at bedside, one tube of hydrocortisone cream and one tube of Ketonzole cream and one of an anti-fungal cream. During an interview on 4/26/26 at 7:40 A.M., Resident #30 said that the nurse sometimes leaves the pills and creams for him/her to take later.Review of the physician orders dated April 2026 failed to indicate pills scheduled to be administered within the two-hour window before and after 7:40 A.M. Review of the Medication Administration Record dated 4/26/26 indicated, in error, that Resident #30 took his/her medications at the scheduled time of 9:00 A.M. During an interview on 4/27/26 at 10:55 A.M., the Director of Nursing (DON) said that medications should never be left at the bedside. The DON also said that the nurses is supposed to administer and document the administration of medications accurately in the medical record. During an interview on 4/27/26 at 12:53 P.M., Nurse #1 said that medications are never to be left with a resident. Nurse #1 then said that the nurse is supposed to stay with the residents to ensure the medications have been taken and document accurately in the MAR what time those medications were taken.

Based on observation and interviews, the facility failed to maintain a functioning call system for one Resident (#61) out of a total sample of 32 residents. Findings include:Review of the facility policy titled 'Answering the Call Light' date revised September 2022, indicated the following but not limited to:-Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.-Report all defective call lights to the nurse supervisor promptly.-Be sure that the call light is plugged in and functioning at all times. Resident #52 was admitted to the facility in April 2026 with diagnoses including paranoid schizophrenia and schizoaffective disorder. Review of Resident #61's Minimum Data Set (MDS) assessment dated , 4/14/26, indicated the Resident scored a 14 out of 15 on the Brief Interview for Mental Status exam, indicating intact cognition. The MDS further indicated that the Resident required set-up assistance for activities of daily living. On 4/26/26 at 8:14 A.M., the surveyor observed the Resident in his/her bed, the Resident did not have access to a call light as there was no call light cord to pull. When asked how the Resident would call for help he/she said he/she would yell out for help. On 4/26/26 at 2:16 P.M., the surveyor observed the Resident lying in his/her bed with no access to a call light. On 4/27/26 at 6:45 A.M., the surveyor observed the Resident lying in his/her bed, the Resident did not have access to a call light. During an interview on 4/27/26 at 6:54 A.M., the surveyor and Certified Nursing Assistant (CNA) #1 observed Resident #61 lying in his/her bed. The Resident did not have access to a call light. CNA #1 said she did not realize that the Resident did not have a call light, she said all residents should have a call light. During an interview on 4/27/26 at 6:58 A.M., Nurse #2 said all residents should have access to a call light. During an interview on 4/27/26 at 8:56 A.M., the Maintenance Director said staff would write on the clip board at the nurse's station if anything needed to be fixed or put into TELS (a system of notifying maintenance needs). He said he was not aware that Resident #61 did not have a call light and that all residents should have access to a call light. During an interview on 4/28/26 at 11:50 A.M., the Administrator said he expects all residents to have access to a call light.

Based on record review and interviews, for one of three sampled residents (Resident #1) who was alert, oriented and able to make his/her needs known, the Facility failed to ensure that Resident #1 was treated in a dignified and respectful manner, when during a treatment session with rehabilitation department, the Physical Therapist Assistant (PTA) approached Resident #1, leaned forward close to Resident #1's face, and loudly stated, Get off the drugs, before exiting the area. Resident #1 said that the PTA's statement was disrespectful and that he/she did not like it.Findings include:Review of the Facility's Resident Rights Policy, not dated, indicated to ensure the preservation of every resident's right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.Resident #1 was admitted to the Facility in February 2023, with diagnoses that included multiple sclerosis, schizoaffective disorder bipolar type, other stimulant use, and mild cognitive impairment of uncertain. Review of Resident #1's Annual Minimum Data Set (MDS) assessment, dated 10/02/25, he/she was alert, oriented, able to make self understood and understood others. The MDS indicated that he/she required assistance with Activity Daily Living (ADL) care, and for mobility he/she used a wheelchair. The Facility's Internal Investigation, dated 09/29/25, indicated that the Director of Rehabilitation reported a resident/staff member incident involving Resident #1. The Investigation indicated that, according to the Occupational Therapist (OT), about one month prior (to 9/29/25), she discussed Resident #1's therapy progress and fatigue levels with Resident #1 in the Therapy Gym while the Physical Therapist Assistant (PTA) was present. The OT said during the discussion, the PTA interrupted the conversation and asked Resident #1 if he/she wanted advice, and after the resident responded affirmatively, the PTA approached Resident #1, leaned forward close to his/her face and loudly stated, Get off the drugs, before leaving the area.During an interview on 12/03/25 at 11:58 A.M., the Director of Rehabilitation (DOR) said that on 09/29/25, during a meeting, the Occupational Therapist (OT) reported a resident/staff member incident that had occurred around three weeks earlier during a therapy session. The DOR said that the OT reported that Resident #1 was discussing his/her therapy progress and feelings of fatigue when the Physical Therapist Assistant (PTA), who was seated next to the desk area completing documentation, interrupted the conversation, approached Resident #1, leaned forward and stated, Get off the drugs. The DOR said that the OT did not immediately report the incident to her or any other member of the management team. During an interview on 12/03/25 at 2:09 P.M., Resident #1 said that he/she recalled an incident in which the Physical Therapy Assistant (PTA) approached him/her and said, Get off the drugs. Resident #1 said that he/she did not report the incident to anyone because he/she did not want the PTA to get in trouble. Resident #1 said that the PTA was generally kind and had always treated him/her well. Resident #1 said that the PTA could have offered advice differently, rather than in a disrespectful manner, and that he/she did not like how and what the PTA had said to him/er.During a telephone interview on 12/08/25 at 11:57 A.M., the Physical Therapist Assistant (PTA) said that he did say to Resident #1, Get off the drugs, but said that he was giving Resident #1 advice. The PTA said he had a good rapport with Resident #1 and knew Resident #1 well. The PTA said that he did not believe his advice would upset Resident #1.During a telephone interview on 12/08/25 at 1:15 P.M., the Occupational Therapist (OT) said that the incident between Resident #1 and the PTA had occurred around three weeks earlier (exact date unknown) during a therapy session with Resident #1, who was asking how he/she could improve not feeling fatigued. The OT said the Physical Therapist Assistant (PTA) was not part of the conversation; however, the PTA approached and interrupted them. The OT said that the PTA leaned forward, close to Resident #1's face and loudly made the statement, Get off the drugs! The OT said the PTA left after saying that.The OT said that she did not report the incident because she thought that the PTA's behavior was unprofessional not abusive. The OT said that during a meeting on 09/29/25, she mentioned the incident to the Director of Rehabilitation (DOR). The OT said that she was a travel therapist, but aware of the Facility's abuse policy related to reporting.During an interview on 12/03/25 at 3:12 P.M., the Administrator said he was notified on 9/29/25 by the Director of Rehabilitation (DOR) of an alleged resident/staff member incident in which the Physical Therapist Assistant (PTA) made a remark to Resident #1, that was overheard by the Occupational Therapist (OT). The Administrator said the OT could not recall the exact date of the incident but reported that she felt the remark made by the PTA to Resident #1 to Get off the drugs was unprofessional.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who was alert, oriented and able to make his/her needs known, the Facility failed to ensure that staff implemented and followed their abuse policy, when during a rehabilitation session Occupational Therapist (OT) witnessed Physical Therapist Assistant (PTA) interact with Resident #1 in potentially abusive manner, but did not immediately report the incident as required, but instead waited several weeks to do so, which was when Administration first became aware of the incident. Findings include:Review of the Facility Policy titled Resident Right to Freedom from Abuse, Neglect, and Exploitation, not dated, indicated the Facility will develop written policies and procedures that define how staff will communicate and coordinate situations of abuse, neglect, misappropriation of resident property, and exploitation.Resident #1 was admitted to the Facility in February 2023, with diagnoses that included multiple sclerosis, schizoaffective disorder bipolar type, other stimulant use, and mild cognitive impairment of uncertain. Review of Resident #1's Annual Minimum Data Set (MDS) assessment, dated 10/02/25, he/she was alert, oriented, able to make self understood and understood others. The MDS indicated that he/she required assistance with Activity Daily Living (ADL) care, and for mobility he/she used a wheelchair. The Facility's Internal Investigation, dated 09/29/25, indicated that the Director of Rehabilitation reported a resident/staff incident involving Resident #1. The Investigation indicated that according to the Occupational Therapist (OT), approximately one month prior, she had discussed Resident #1's progress in therapy and complaint of fatigue levels with Resident #1 in the Therapy Gym while the Physical Therapist Assistant (PTA) was present. The Investigation indicated that during the discussion, the PTA interrupted the conversation and asked Resident #1 if he/she wanted advice and after the resident responded affirmatively, the PTA approached Resident #1, leaned forward, and loudly stated, Get off the drugs, before leaving the area.During an interview on 12/03/25 at 11:58 A.M., the Director of Rehabilitation (DOR) said that on 09/29/25, during a meeting, the Occupational Therapist (OT) reported an incident that had occurred approximately three weeks earlier and stated that the incident made her uncomfortable. The DOR said that the OT described the Physical Therapist Assistant's (PTA) interaction with Resident #1 and indicated that the PTA's behavior was unprofessional. The DOR said that the OT reported that the PTA leaned forward toward Resident #1 and stated, Get off the drugs.The DOR said that she informed the OT that the incident should have been reported to the Administrator or the Director of Nursing (DON) at the time it occurred. The DOR said that Resident #1 was not receiving physical therapy at the time of the incident and was only receiving occupational therapy, which was nearing completion. During a telephone interview on 12/08/25 at 1:15 P.M., the Occupational Therapist (OT) said on 9/29/25, when she told the DOR about the incident that had occurred between Resident #1 and the PTA, that the incident had occurred around three weeks earlier during a therapy session with Resident #1. The OT said that the PTA leaned forward toward Resident #1's face and stated loudly to him/her, Get off the drugs.The OT said that she did not immediately report the incident to the Facility administration. The OT said that she believed the PTA's behavior was unprofessional not abuse and was why she had not reported it at that time. The OT said that she was aware of the Facility's abuse policy related to reporting and acknowledged her failure to report the incident, as required.During an interview on 12/03/25 at 3:12 P.M., the Administrator said that the Occupational Therapist (OT) failed to immediately report the incident involving alleged verbal abuse by the Physical Therapist Assistant (PTA), as required by Facility policy. The Administrator said that the OT did not follow the Facility's Abuse Prevention and Reporting Policy.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had an activated Health Care Proxy (HCP), the facility failed to ensure that on 08/11/25, his/her Health Care Agent (HCA) was notified of his/her transfer to another Skilled Nursing Facility (SNF).Findings include:Review of the Facility Policy titled, Change in a Resident's Condition or Status, dated as last revised 02/2021, indicated that the Facility will promptly notify the resident, his/her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status.The Policy further indicated that the Nurse will notify the residents representative when a decision has been made to discharge the resident from the Facility.Resident #1 was admitted to the Facility in November 2023 diagnoses include progressive dementia, diabetes mellitus, and chronic renal insufficiency.Review of Resident #1's Physician's Orders, dated as of 08/11/25, indicated that his/her HCP had been invoked since 11/15/23.Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 08/08/25, indicated he/she had significantly impaired cognition, only sometimes understood what was being said, only sometimes could make his/herself understood, and indicated that his/her primary language spoken/understood was Hattian Creole.Review of Resident #1's Social Service Progress Note, dated 08/01/25, indicated that the social worker sent a referral to the SNF at his/her HCA request. Review of Resident #1's Nurse Progress Note, dated 08/11/25, indicated that he/she had been transferred to another SNF. During a telephone interview on 08/11/25 at 11:44 A.M., Resident #1's Health Care Agent (HCA) said although she had requested that Resident #1 be transferred to another SNF, the Facility did not communicate an actual transfer date or time at which Resident #1 was to be transferred to another SNF.The HCA said on 08/11/25 she received a phone call from the accepting SNF informing her that Resident #1 had arrived, that they said they were unaware that Resident #1 was being transferred that day (08/11/25) to their facility and they did not have the appropriate information required.During a telephone interview on 08/14/25 at 3:50 P.M., the Director of Social Services said that on 08/01/25, Resident #1's transfer had been initiated via e-mail, at the request of his/her HCA.The Director said that all e-mails regarding his/her discharge had been Carbon Copied (cc'd) to the HCA. The Director said that Resident #1's HCA never responded to any of the e-mails. The Director said that she called and left a voice mail for the HCA, but the HCA never responded. The Director said because she never spoke to the HCA, that she could only assume that the HCA knew about the date and time of transfer. During a telephone interview on 08/20/25 at 2:03 P.M., the Director of Admissions from the accepting SNF said that Resident #1's transfer had been tentatively planned for 08/11/25, however she also said that the facility never confirmed the transfer date, provided a transfer time or completed a nurse-to-nurse clinical report. During an interview on 08/12/25 at 2:09 P.M., the Nurse Supervisor said that on 08/01/25, she was informed that Resident #1 was to be transferred to another SNF soon and she had been asked to fax the requested information to the appropriate parties.The Supervisor said she never contacted Resident #1`'s HCA about the transfer because it was the HCA who initiated the transfer, and that the Social Service staff were responsible for the discharge/transfer process.During an interview on 08/12/25 at 3:39 P.M., the Director of Nurses (DON) said that she was not aware that Resident #1's HCA was not aware of the details of his/her transfer to the other facility. The DON said that she thought the Director of Social Services communicated with the HCA prior to the transfer.The DON said that it is the Facility's expectation to fully inform residents and their responsible party of all details of a discharge/transfer from the Facility and the discharging nurse is to call the accepting Facility and provide the accepting nurse with a report of the incoming resident.

Based on observations, record review and interviews, the facility failed to ensure respiratory care was provided consistent with professional standards of care for one Resident (#42) out of a sample of 32 residents. Specifically for Resident #42, the facility failed to ensure oxygen was administered in accordance with the physician's orders and the oxygen equipment was kept clean. Findings include: Review of the facility policy titled Oxygen Administration, dated 2001, indicated the following: -Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. -Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated. Resident #42 was admitted to the facility in April 2024 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and shortness of breath. Review of Resident #42's most recent Minimum Data Set (MDS) assessment, dated 4/24/25, indicated the Resident has a Brief Interview for Mental Status exam score of 15 out of a possible 15, indicating he/she is cognitively intact. The MDS also indicated Resident #42 is dependent on staff for self-care and mobility tasks. On 5/4/25 at 8:21 A.M. and 1:42 P.M., Resident #42 was observed lying in bed wearing an oxygen nasal canula. The oxygen concentrator was set to 4 liters per minute. The concentrator filter was filled with dust. On 5/5/25 at 5:38 A.M., 8:29 A.M. and 11:08 A.M., Resident #42 was observed lying in bed wearing an oxygen nasal canula. The oxygen concentrator was set to 4 liters per minute. The concentrator filter was filled with dust. On 5/6/25 at 6:33 A.M., Resident #42 was observed lying in bed wearing an oxygen nasal canula. The oxygen concentrator was set to 4 liters per minute. The concentrator filter was filled with dust. Review of Resident #42's physician orders indicated the following order: Oxygen at 0-2 Liters/Minute via Nasal Cannula as needed, every shift for shortness of breath, low sats (saturation). Review of Resident #42's COPD care plan, last revised 7/27/24, indicated the following intervention: Provide Oxygen therapy as needed to maintain SpO2 (oxygen saturation levels) within parameters. During an interview on 5/6/25 at 6:41 A.M., Nurse #4 said nursing should be checking oxygen levels every two hours to ensure the oxygen is on and at the right level. Nurse #4 said Resident #42 has a diagnosis of COPD, wears oxygen and is ordered to use two liters as needed. Nurse #4 said a resident with a diagnosis of COPD should not have oxygen levels more than ordered secondary to a risk of carbon dioxide retention. Nurse #4 said she did not check Resident #42's oxygen level during the overnight shift. Nurse #4 said she does not believe the Resident would change the oxygen level on his/her own. Nurse #4 said it is the responsibility of the nursing staff to ensure oxygen filters are clean and was unaware of Resident #42's dirty filter. During an interview on 5/6/25 at 11:00 A.M., the Director of Nursing said oxygen orders should be followed as prescribed by the physician and a resident should not receive more oxygen than ordered. The Director of Nursing said the oxygen concentrators are expected to be clean and the nursing or housekeeping staff are responsible for this.

Based on observations, record review and interviews, the facility failed to provide assistance with meals for five Residents (#33, #44, #67, #2 and #48) out of a total sample of 32 residents. Findings include: Review of the facility policy titled, Activities of Daily Living (ADL), Supporting, indicated the following: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). -Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their condition(s) demonstrate that diminishing ADLs are unavoidable. -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of treatment and in accordance with the plan of care, including appropriate support and assistance with: -d. dining (meals and snacks). 1. Resident #33 was admitted to the facility in October 2017 with diagnoses including dysphagia (difficulty swallowing), muscle weakness and lack of coordination. Review of Resident #33's most recent Minimum Data Set (MDS) assessment, dated 4/14/25, indicated the Resident had a Brief Interview for Mental Status exam score of 9 out of a possible 15, indicating he/she had moderate cognitive impairment. The MDS also indicated Resident #33 required set-up assistance for self-feeding tasks. On 5/4/25 at 1:34 P.M., Resident #33 was observed eating lunch in his/her room with no staff present to supervise and was not visible from the hallway. Resident #33 was eating with his/her hands and had a significant amount of food that had fallen onto his/her chest. On 5/5/25 at 8:42 A.M., Resident #33 was given his/her breakfast while lying in bed. Once set-up, the staff member left the room. At 8:51 A.M., Resident #33 was observed eating alone without supervision, and had a significant amount of food that had fallen onto his/her chest. On 5/6/25 at 8:57 A.M., Resident #33 was given his/her breakfast while lying in bed. Once set-up, the staff member left the room. At 9:04 A.M., Resident #33 remained alone, without supervision from staff and was observed with a significant amount of eggs that had fallen onto his/her chest. The Resident had only eaten the eggs, and had not had anything to drink and did not eat the other food on his/her tray. Review of Resident #33's Activity of Daily Living care plan, last revised 11/4/24, indicated the following intervention: -Eating: Continual Supervision/Assist, prefers to eat with hands, utensils encouraged. Review of Resident #33's nutritional care plan, last revised 11/4/24, indicated the following: -Provide prescribed diet and supervise meals/safe swallow strategies a/o (as ordered) -Provide house, regular diet with cut meats a/o; monitor intakes and weights; honor food preferences; assist at meals as needed and provide close supervision; SLP screen as needed. Review of Resident #33's Kardex (a form indicating the level of assistance needed for resident care) indicated the following: Eating: Continual Supervision / Assist prefers to eat with hands, utensils encouraged. During an interview on 5/6/25 at 10:51 A.M., Certified Nursing Assistant (CNA) #2 said she relies on nursing to report a resident's level of care needed and can also look up the Kardex on the computer. CNA #2 said Resident #33 requires supervision and cueing throughout his/her meals. During an interview on 5/6/25 at 10:56 A.M., Nurse #5 said she expects staff to follow the Kardex and care plans of the residents in order to provide the level of care needed. Nurse #5 said Resident #33 is independent with meals after set-up. During an interview on 5/6/25 at 11:00 A.M., the Director of Nursing said she expects residents to receive ADL care at the level of care required and care planned. 2. Resident #44 was admitted to the facility in January 2023 with diagnoses including dysphagia (difficulty swallowing), feeding difficulties, muscle weakness and lack of coordination. Review of Resident #44's most recent Minimum Data Set (MDS) assessment, dated 1/24/25, indicated the Resident did not have a Brief Interview for Mental Status exam completed. The MDS further indicated Resident #44 requires set-up assistance for self-feeding tasks. On 5/5/25 at 8:34 A.M., Resident #44 was observed eating breakfast in the day room with no staff present to supervise and was not visible from the hallway. Resident #44 was eating with his/her hands and had a significant amount of food that had fallen onto his/her chest. Resident #44 was observed holding an empty coffee cup and could be heard saying Hey over here! as he/she held up the empty coffee cup. On 5/6/25 at 8:28 A.M., Resident #44 observed eating breakfast in the day room with no staff present to supervise and was not visible from the hallway. Resident #44 was observed eating alone without supervision and had a significant amount of food that had fallen onto his/her chest. Review of Resident #44's Activity of Daily Living care plan last revised 11/15/24, indicated the following intervention: Resident requires supervision from staff for all meals. Uses lip plate for meals Review of Resident #44's nutritional care plan last revised 8/3/24, indicated the following: -Provide, serve diet as ordered. Monitor intake and record q (every) meal. -OT (occupational therapy) to screen and provide adaptive equipment for feeding as needed. Review of Resident #44's Kardex (a form indicating the level of assistance needed for resident care) indicated the following: Eating/Nutrition: Resident requires supervision from staff for all meals. Uses lip plate for meals. During an interview on 5/6/25 at 8:52 A.M., Certified Nursing Assistant (CNA) #5 said Resident #44 needs supervision during meals and will sometimes need help. During an interview on 5/6/25 at 9:02 A.M., Nurse #8 said Resident #44 needs supervision and said the Resident likes to do most of it but needs help sometimes. Nurse #8 said staff follow the Kardex and care plans in order to provide the level of care needed. During an interview on 5/6/25 at 10:49 A.M., the Director of Nursing said she expects staff to not leave residents that require supervision with meals unsupervised and expects residents to receive ADL care at the level of care required and care planned. 3. Resident #67 was admitted to the facility in January 2023 with diagnoses including dementia, diabetes mellitus, and anxiety. Review of Resident #67's most recent Minimum Data Set (MDS) assessment, dated 2/25/25, indicated the Resident was unable to complete a Brief Interview for Mental Status exam. The MDS further indicated Resident #67 requires set-up assistance for self-feeding tasks and requires a mechanically altered diet (change in texture of food or liquids). On 5/4/25 at 8:54 A.M., Resident #67 was given his/her breakfast while lying in bed. Once set-up, the staff member left the room. At 8:56 A.M., Resident #67 was observed eating alone without supervision, and had a significant amount of food that had fallen onto his/her chest. A cup of orange juice was observed spilled on to the breakfast tray and on the Residents shirt. On 5/5/25 at 8:39 A.M., Resident #67 was given his/her breakfast while sitting in the day room. Once set-up, the staff member left the day room. A container of milk was left unopened on the table. The surveyor observed Resident #67 picking up the closed container of milk, bringing it to his/her lips and attempting to drink from the closed milk container. The Resident began shaking the milk container and again attempted to drink from the milk container. Resident #67 was observed eating alone without assistance or supervision and had a significant amount of food that had fallen onto his/her chest. On 5/6/25 at 8:36 A.M., Resident #67 was given his/her breakfast while lying in bed. Once set-up, the staff member left the room. At 8:44 A.M., Resident #67 remained alone, without supervision from staff and was observed with a significant amount of food that had fallen onto his/her chest. Review of Resident #67's Activity of Daily Living care plan last revised 3/25/24, indicated the following intervention: Eating: The resident requires (1) staff participation to eat. Review of Resident #67's nutritional care plan last revised 8/31/24, indicated the following: Provide Diet as ordered. Review of Resident #67's Kardex (a form indicating the level of assistance needed for resident care) indicated the following: Eating/Nutrition: The resident requires (1) staff participation to eat. During an interview on 5/6/25 at 8:45 A.M., Certified Nursing Assistant (CNA) #3 said Resident #67 does not need supervision or assistance and can eat alone in his/her room. During an interview on 5/6/25 at 9:04 A.M., Nurse #8 said Resident #67 needs assistance because he/she has dementia and needs help with eating. Nurse #8 said staff must follow the Kardex and care plan in order to provide the level of care needed. During an interview on 5/6/25 at 10:50 A.M., the Director of Nursing said she expects staff to provide ADL care at the level of care required and that which they are care planned for and said Resident #67 should not be eating alone and without assistance. 4.) Resident #2 was admitted to the facility in April 2023 with diagnoses including dysphagia (difficulty swallowing), failure to thrive, and malnutrition. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/4/25, indicated Resident #2 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS also indicated Resident #2 required supervision or touching assistance with eating. Review of Resident #2's active physician's order, initiated 2/18/25, indicated: - Regular diet, mechanical soft texture, thin consistency, for sitting up at a 90 degree angle, small sips and bites, 1:1 f (feed). Review of Resident #2's active plan of care related to activities of daily living deficit, revised 4/20/25, indicated: - EATING: Resident #2 is supervised after set-up. Review of Resident #2's kardex (a form indicating the level of assistance needed for resident care), dated 5/6/25, indicated the following: - EATING: Resident #2 is supervised after set-up. Review of Resident #2's dietary progress note, dated 3/11/25, indicated - Spoke with Resident who reports that ongoing cough is interfering with intake as he/she often feels like he/she is going to choke during meals. Advised Resident to eat slowly and chew food thoroughly. On 5/4/25 at 9:28 A.M., the surveyor observed Resident #2 eating breakfast alone in his/her room. Resident #2 says that his/her food is chopped up because he/she is at risk for choking. Resident #2 coughed twice during this observation. Resident #2 said he/she has had this cough for months, but it recently had been getting worse and would like to see the doctor again about it. During an observation on 5/4/25 from 1:36 P.M. to 1:43 P.M., Resident #2 was eating alone in his/her room. There were no staff in the adjacent hallway or within view of the Resident. During an observation on 5/5/25 at 8:51 A.M. to 9:01 A.M., Resident #2 was eating alone in his/her room. There were no staff in the adjacent hallway or within view of the Resident. Resident #2 coughed four times during this observation. At 8:53 A.M., the Resident said sometimes he/she feels like he/she might choke when eating because of the cough. Resident #2 said staff never supervises him/her with meals. During an interview on 5/5/25 at 9:15 A.M., Certified Nurse Assistant (CNA) #8 said Resident #2 does not require supervision with meals and is never supervised with meals. CNA #8 said Resident #2 has had a cough for a long time. CNA #8 said it is expected that staff provide the level of assistance or supervision that is indicated on the Resident's care plan and kardex. CNA #8 said supervision with meals means staff must be in the room with the Resident for the entire meal, not in the hallway. During an interview on 5/5/25 at 9:25 A.M., Nurse #10 said Resident #2 does not require supervision with meals. Nurse #10 said Resident #2 has had a cough for a long time. Nurse #10 said it is expected that staff provide the level of assistance or supervision that is indicated on the Resident's care plan and kardex. During an interview on 5/6/25 at 10:54 A.M., the Director of Nursing (DON) said it is expected that staff provide the level of assistance or supervision that is indicated on the Resident's care plan and kardex. The DON said supervision with meals means staff must be sitting in the room with the Resident for the entire meal, not in the hallway. The DON visualized Resident #2's active care plan, kardex, and physician's order with the surveyor and said staff should have provided supervision with meals for Resident #2. 5. Resident #48 was admitted to the facility in June 2018 with diagnoses that included muscle wasting and atrophy, dysphagia following cerebral infarct and epilepsy. Review of Resident #48's most recent Minimum Data Set (MDS) Assessment, dated 4/28/25, indicated a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating that the Resident had severe cognitive impairment. The MDS further indicated that the Resident was dependent on staff for eating. On 5/5/25 at 8:24 A.M., the surveyor observed the Certified Nurses Aide (CNA) bring the breakfast tray into the Resident's room, set up the breakfast, and leave the room. The Resident was observed behind a closed curtain and not visible from the hallway. The surveyor entered the Resident's room and observed the Resident sitting up in bed with breakfast set up in front of the Resident on the bedside table. The Resident was not initiating eating and was observed looking at the tray. On 5/5/25 at 8:40 A.M., Resident #48 remained alone in room behind a curtain not visible from the hallway. The surveyor entered the room to observe the Resident. The Resident had not initiated eating any of his/her breakfast. On 5/5/25 at 8:51 A.M., 27 minutes after the Resident received his/her tray, a CNA went in to check on the resident and was encouraging him/her to eat. On 5/5/25 at 12:32 P.M., Resident #48 was observed in bed with a curtain pulled around the bed. There were no staff present and Resident #48 was observed eating mashed potatoes with his/her hands. On 5/6/25 at 8:45 A.M., the surveyor observed the CNA bring in Resident #48's breakfast tray and set up the tray. The CNA left the room. The surveyor observed the Resident sitting up in bed with the breakfast tray in front of him/her. The Resident had eggs in his/her mouth but was not chewing. The curtain was pulled around the bed, and the Resident was not visible from the hallway. During an observation on 5/6/25 from 8:51 A.M. to 9:06 A.M., Resident #48 remained alone in his/her room eating, not visible to staff. At 9:06 A.M., a CNA went to remove the Resident's tray, 21 minutes after initially setting up the tray for the Resident. Review of Resident #48's active Activities of Daily Living care plan, updated 12/11/23 indicated, the Resident has ADL Self-Care Deficit as evidenced by: Needs assistance with ADLs complicated by CVA (cerebrovascular accident) with left hemiparesis, Degenerative joint disease, with interventions that include, Eating: extensive assist of one. [sic] Review of Resident #48's Kardex (a form that lets staff know how much assistance a resident requires) in the Electronic Medical Record indicated: Eating: extensive assist of one. During an interview 5/6/25 at 9:06 A.M., CNA #1 said that staff utilize the Kardex from the computer that is accessible through the CNA charting. CNA #1 said that Resident #48 does not require assistance with meals and can feed him/herself. CNA #1 said that when he went into the Resident's room to take the tray out from breakfast he tried to help him/her eat, but said that he/she was coughing on the food and couldn't eat it. During an interview on 5/6/25 at 12:25 P.M., the Director of Nurses said that Resident #48 requires assistance with meals and she would expect that staff are assisting residents per the care plan and Kardex instructions.

Based on observations, interviews, and record reviews for three Residents (#95, #20, and #53) out of four residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5%. Three out of three nurses observed made 4 errors out of 32 opportunities resulting in a medication error rate of 12.5%. Specifically, 1.) For Resident #95, the nurse administered the incorrect dose of vitamin B6 and failed to administer scheduled xarelto (a blood thinner). 2.) For Resident #20, the nurse failed to ensure the correct dose of metoprolol (a blood pressure lowering medication) was administered when she did not ensure blood pressure and pulse were within acceptable parameters as indicated in the physician's order. 3.) For Resident #53, the nurse administered the incorrect dose of polyethylene glycol (a laxative medication). Findings include: Review of the facility policy titled 'Administering Medications', revised April 2019, indicated: - Medications are administered in accordance with prescriber orders, including any required time frame. - The following information is checked/verified for each resident prior to administering medications: vital signs, if necessary. 1. Resident #95 was admitted to the facility in July 2022 with diagnoses including a history of stroke with residual hemiparesis (weakness on one side of the body). Review of the most recent Minimum Data Set (MDS) assessment, dated 3/24/25, indicated Resident #95 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Review of Resident #95's active physician's orders indicated: - Vitamin B6 tablet 100 milligram (mg), give one tablet one time a day, initiated 1/31/24, scheduled at 9:00 A.M. - Xarelto tablet 10 mg, give one tablet one time a day, initiated 8/24/22, scheduled at 9:00 A.M. On 5/6/25 at 8:36 A.M., the surveyor observed Nurse #9 prepare and administer the following medication to Resident #95. Nurse #9 said all Resident #95's medications due to be administered that morning had been administered. - One vitamin B6 50 mg tablet, instead of 100 mg as ordered by the physician. - Nurse #9 failed to prepare and administer Xarelto 10 mg tablet as ordered by the physician. During an interview on 5/6/25 at 12:06 P.M., the Director of Nursing (DON) said all medications should be given as ordered. During a follow-up interview on 5/6/25 at 12:27 P.M., Nurse #9 said she was unaware she had not administered the xarelto 10 mg tablet to Resident #95. Nurse #9 said Resident #95 had not declined or received the xarelto 10 mg tablet after the surveyor observed the medication administration this morning. Nurse #9 said the xarelto should have been administered. Nurse #9 further said she should have administered two tablets of vitamin B6, instead of one tablet, because the tablets in the medication cart are only 50 mg. 2.) Resident #20 was admitted to the facility in April 2008 with diagnoses including hypertension (high blood pressure). Review of the most recent Minimum Data Set (MDS) assessment, dated 3/4/25, indicated Resident #20 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 7 out of 15. Review of Resident #20's physician's order, initiated 6/16/18, indicated: - Metoprolol succ (succinate) ER (extended release) 25 milligram (mg) tab (tablet), give one tablet in morning, hold if SBP (systolic blood pressure) is less than 100 or pulse less than 60, scheduled at 8:00 A.M. On 5/6/25 at 8:59 A.M., the surveyor observed Nurse #7 prepare and administer the following medication to Resident #20: - One Metoprolol succinate ER 25 mg tablet. During a follow up interview on 5/6/25 at 9:05 A.M., Nurse #7 said she did not know what Resident #95's blood pressure or pulse was because she did not obtain vital signs prior to administering the metoprolol. Nurse #7 said she should have obtained vital signs because there were parameters to hold if blood pressure or pulse were below certain levels. During an interview on 5/6/25 at 12:06 P.M., the Director of Nursing (DON) said if there was a physician's order that included parameters to hold the medication if blood pressure or pulse is below a certain level, then the nurse should have obtained vital signs before administering the medication to ensure the correct dose was given. 3.) Resident #53 was admitted to the facility in January 2016 with diagnoses including an intestinal obstruction and failure to thrive. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/25/25, indicated Resident #53 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 8 out of 15. On 5/6/25 at 10:15 A.M., the surveyor observed the Assistant Director of Nursing (ADON) prepare and administer the following medication to Resident #53: - Polyethylene glycol 3350 powder, filled approximately halfway to 17 gram (gm) indicator line in the bottle cap (which is used to measure the dose). Instructions on the polyethylene glycol bottle indicate instructions that 17g (cap filled to line). Review of Resident #53's physician order, initiated 4/25/24, indicated: - Miralax powder (Polyethylene glycol 3350), give 17 gram one time a day, scheduled for 9:00 A.M. During a follow up interview on 5/6/25 at 10:20 A.M., the ADON said he was unaware that the 17 gram line on the polyethylene glycol bottle cap was where it was. The ADON showed the surveyor he filled in an area in the cap below the 17 gm indicator line, which appeared to be a cap thread used to close the bottle. The ADON inspected the bottle closely and said he now sees the 17 gm indicator line is higher than what he administered. The ADON said he only gave an insufficient dose of polyethylene glycol. During an interview on 5/6/25 at 12:06 P.M., the Director of Nursing (DON) said all medications should be given as ordered. The DON said the nurse should have filled the polyethylene glycol to the 17 gm indicator line in order to administer the correct dose. Refer to F760.

2. Resident #92 was admitted to the facility in February 2022 with diagnoses including dysphagia and hemipelgia. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #92 is cognitively intact as evidenced by a score of 14 out of a possible 15 on the Brief Interview for Mental Status Exam (MDS). On [DATE] at 7:09 A.M., the surveyor observed an open container of Nicotine lozenges on the over bed table. There were two new lozenges and two half dissolved lozenges on top of the table. Resident #92 said that staff give him/her a hard time about his/her nicotine lozenges. Review of Resident #92 clinical record indicated the following: -A self administration of medication evaluation, dated [DATE], indicating Resident #92 is unable to self-administer his/her medications. -A physician's order indicating: Nicotine Mini Mouth/Throat Lozenge, 4 MG. One Lozenge in the cheek every four hours as needed for smoking AND one lozenge in the cheek every hour for quit (sic) smoking. Hold if Resident is asleep. During an interview on [DATE] at 8:51 A.M., Nurse #2 said that Resident #92 cannot self administer medications. Nurse #2 said that Resident #92's nicotine lozenges are kept in the medication cart and nursing staff deliver them to him/her per the physicians order. During an interview on [DATE] at 9:07 A.M., Regional Nurse #1 said medications should not be left at bedside. Based on observation and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically: 1.) The facility failed to ensure medications and biologicals were labeled and stored according to manufacturer's guidelines in four of four medication carts observed. 2.) The facility failed to ensure nicotine lozenges were not left unsecured at the residents bedside, for one Resident (#92) out of a total sample of 32 residents. Findings include: Review of the facility policy titled 'Medication Labeling and Storage', revised February 2023, indicated: - Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. - The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. - If the facility has discontinued, outdated, or deteriorated medication or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. 1. On [DATE] at 8:35 A.M., the surveyor and Nurse #9 observed the following in the 2nd floor low side medication cart: - One open and undated bottle of proheal liquid protein. This bottle was three quarters full and had sticky, hardened residue around the opening. The proheal bottle label indicated to discard 60 days after opening date. During a follow up interview on [DATE] at 8:37 A.M., Nurse #9 said proheal has a shortened expiry date once opened and should have been dated when it was opened. On [DATE] at 9:27 A.M., the surveyor and Nurse #7 observed the following in the 4th floor low side medication cart: - 32 loose pills in drawers of medication cart. - One open and undated bottle of prostat liquid protein. The prostat bottle label indicated to discard 3 months after opening. During a follow up interview on [DATE] at 9:29 A.M., Nurse #7 said there should not be loose pills in the medication cart. Nurse #7 also said prostat has a shortened expiry date once opened and should have been dated when it was opened. On [DATE] at 9:36 A.M., the surveyor and Nurse #5 observed the following in the 3rd floor high side medication cart: - 48 loose pills in the drawers of medication cart. During a follow up interview on [DATE] at 9:38 A.M., Nurse #5 said there should not be loose pills in the medication cart. On [DATE] at 10:20 A.M., the surveyor and the Assistant Director of Nursing (ADON) observed the following in the 3rd floor low side medication cart: - 15 loose pills in drawers of medication cart. - One open and undated bottle of prostat liquid protein. The prostat bottle label indicated to discard 3 months after opening. - One insulin glargine-yfgn insulin pen, dated as opened [DATE] and date as expired [DATE]. - One unlabeled and undated injection syringe filled with clear liquid stored loosely in a drawer of medication cart. During a follow up interview on [DATE] at 10:22 A.M., the ADON said there should not be loose pills in the medication cart. The ADON said prostat has a shortened expiry date once opened and should have been dated when it was opened. The ADON said insulin should be discarded when expired and not be available in the medication cart. The ADON said the syringe was filled with insulin he had drawn up for a resident earlier in the shift but had not given it to him/her yet. The ADON said it should not have been stored in the medication cart that way. During an interview on [DATE] at 12:06 P.M., the Director of Nursing (DON) said prostat and proheal should have been dated when they were opened because they have shortened expiry date once opened. The DON said there should not be loose pills in the medication cart. The DON said insulin should be discarded 28 days after opening, or when dated as expired. The DON said insulin should not be prefilled and stored loosely in the medication cart unlabeled and undated.

Based on observations, interviews and records reviewed, the facility failed to ensure staff treated residents in a dignified manner during the dining experience for two Residents, (#44, and #71), out of a total sample of 32 Residents. Specifically: 1. For Resident #44, the facility failed to acknowledge a resident's request for assistance in the day room. 2. For Resident #71, facility failed to provide a dignified dining experience evidenced by staff not communicating with him/her for the duration of the meal. Findings include: Review of the facility policy titled Quality of Life-Dignity, dated as revised February 2020, indicated -Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. -Residents are treated with dignity and respect at all times. 1. Resident #44 was admitted to the facility in January 2023 with diagnoses including dysphagia (difficulty swallowing), feeding difficulties, muscle weakness and lack of coordination. Review of Resident #44's most recent Minimum Data Set (MDS) assessment, dated 1/24/25, indicated the Resident did not have a Brief Interview for Mental Status exam completed. The MDS also indicated Resident #44 requires set-up assistance for self-feeding tasks. On 5/5/25 from approximately 8:57 A.M. to 9:11 A.M., Resident #44 was observed sitting in the day room after the breakfast meal. A breakfast tray was observed on the table in front of Resident #44. Resident #44 attempted to take a sip from an empty coffee cup and could be heard repeatedly saying Hey over here! as he/she held up the empty coffee cup waving it in the air, attempting to signal staff members who were walking in and out of the day room. A staff member walked over to the table where Resident #44 was sitting and picked up an empty juice cup from the breakfast tray and walked out of the day room. A staff member was observed walking into the day room, past Resident #44 and turned on the television. Resident #44 could be heard repeatedly saying More, no-good, no-good empty, hey, hey! as the staff member continued to remove breakfast trays from the day room. Staff that were in the day room removing trays and did not acknowledge Resident #44. Review of Resident #44's communication care plan last revised 2/3/25, indicated the following: - Encourage resident to continue to make needs known and to call for assistance to ensure safety. - Staff will anticipate and meet needs. During an interview on 5/6/25 at 9:11 A.M., CNA #6 said Resident #44 is behavioral and said he/she does this all the time. During an interview on 5/6/25 at 10:49 A.M., the Director of Nursing said she expects staff provide supervision and communicate with residents during the meals and provide care as needed for each Resident. 2. Resident #71 was admitted to the facility in November 2023 with diagnoses including dysphagia (difficulty swallowing), dementia, diabetes mellitus, and mild cognitive impairment. Review of Resident #71's most recent Minimum Data Set (MDS) assessment, dated 2/6/25, indicated Resident #16 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 1 out of 15. Further review of the MDS indicated Resident #71 speaks Haitian/Creole and is dependent on staff for feeding tasks. On 5/5/25 at 8:34 A.M., Resident #71 was observed sitting in the day room facing a window, with his/her back facing the entry door. The Resident was alone at the table with his/her breakfast tray within reach not set up for consumption. No staff were present in the room to assist the Resident with their meal. At 8:47 A.M., the surveyor observed Certified Nursing Assistant (CNA) #5 enter the dining room and sat down next to Resident #71. CNA #5 began to feed Resident #71 the breakfast meal. CNA #5 did not attempt to communicate with the Resident. At 9:01 A.M., CNA #5 said Done? Try your milk as he brought a cup containing coffee and not milk, up to the Residents lips. The Resident did not respond and did not drink the coffee. At 9:03 A.M., the surveyor observed CNA #5 open a carton of milk and pour it into a dirty juice cup. CNA #5 held up the cup of milk and said you want to Resident #71. The Resident did not respond and did not drink the milk. CNA #5 proceeded to pick up the breakfast tray and exited the day room. CNA #5 only spoke to Resident #71 in English and made no attempt to communicate with him/her throughout the meal in his/her own language. On 5/6/25 at 8:33 A.M., Resident #71 was observed sitting in the day room facing a window, with his/her back facing the entry door. The Resident was alone at the table with his/her breakfast tray within reach not set up for consumption. No staff were present in the room to assist the Resident with their meal. At 8:40 A.M., Nurse #8 was observed walking into the day room and sat down next to Resident #71 and began to feed him/her the breakfast meal. Nurse #8 did not attempt to communicate with the Resident. At 9:03 A.M., Nurse #8 said you don't like egg? as she attempted to feed eggs to Resident #71. Resident #71 did not respond. Nurse #8 only spoke to Resident #71 in English and made no attempt to communicate with him/her throughout the meal in his/her own language. Review of Resident #71's socialization care plan last revised 11/27/24, indicated the following intervention: Exhibit patience when directing conversation or questions to Resident- Resident is French Creole speaking. Review of Resident #71's dementia care plan last revised 11/7/24, indicated the following interventions: - Allow adequeate [SIC] time for response. - Ask simple questions which require yes and no answers when possible. Review of Resident #71's Kardex (a form indicating the level of assistance needed for resident care) indicated the following: -Eating/Nutrition: requires supervision with meals. Communication: Ask simple questions which require yes and no answers when possible. -Face to face communication, repeat if necessary. - Ask simple questions which require yes and no answers when possible. During an interview on 5/6/25 at 8:51 A.M., Certified Nursing Assistant (CNA) #5 said Resident #71 needs help with feeding because he/she can't do it alone because he/she has dementia. CNA #5 said the Resident speaks Haitian/Creole and said a lot of the staff working speak that language. CNA #5 said he speaks Haitian/Creole but did not speak to him/her because he knows what the Resident likes. During an interview on 5/6/25 at 9:13 A.M., CNA #6 said the Resident speaks Creole but does not communicate with staff. CNA #6 said he/she does not have cue cards or use a language line and does not know if the facility has those things. During an interview on 5/6/25 at 10:47 A.M., the Director of Nursing said she expects staff to communicate with residents in his/her preferred language.

Based on records reviewed and interviews for one of seven sampled residents (Resident #3), who upon admission was assessed as being at high risk for skin breakdown and was documented by nursing to have intact skin, the Facility failed to ensure Resident #3 received adequate care and services related to the prevention of the development and/or worsening of a pressure injury. On 8/02/24, Resident #3's weekly skin assessment indicated he/she had an area of impaired skin integrity on his/her buttocks that was un-measurable, however physician's orders for treatment were not obtained until 8/14/24, almost two weeks later. Upon his/her discharge from the facility, Resident #3's pressure injury was documented as having worsened into an unstageable pressure injury due to necrosis. Finding include: Review of the Facility Policy titled, Pressure Ulcer/Skin Breakdown-Clinical Protocol, dated as last revised 12/2023, indicated the nursing staff will assess and document an individual's significant risk factors for developing pressure ulcers. The Policy also indicated that the nurse shall describe and document the following, a full assessment of the pressure injury, including location, stage, length, width, and depth, presence of exudates or necrotic tissue and current treatments. During an interview on 08/28/24 at 3:57 P.M., the Director of Nurses (DON) said the Facility's expectation is that when a pressure injury is identified by a nurse, that the nurse begin an investigation, notify the physician, obtain physician orders for treatments and make recommendations to be seen by Wound Physician (MD), who does weekly rounds in the facility. The DON said that the Day Supervisor accompanies the Wound MD on weekly rounds, that the Day Supervisor follows-up on and communicates any recommendations given by the Wound MD to the residents physician, but said that the Day Supervisor was on vacation when Resident #3's pressure areas were observed, and was not aware he/she needed to be seen by the Wound MD. Resident #3 was admitted to the Facility in July 2024, diagnoses included, metabolic encephalopathy (problem in the brain caused by a chemical imbalance), urinary tract infection, dementia with agitation, peripheral vascular disease, and hypertension. Review of Resident #3's physician's orders, dated 07/31/24, indicated his/her Health Care Agent (HCA) was responsible for his/her medical care needs. During a telephone interview on 08/26/24 at 10:36 A.M., Family Member #2 said that her biggest concern regarding Resident #3 was his/her risk for skin breakdown. Review of Resident #3's Admission Skin Assessment, dated 07/26/24, indicated that the nurse documented that his/her sacrum was pink and blanchable. Review of Resident #3's Admission Nursing Evaluation, dated 07/26/24, indicated he/she had an immediate care need related to risk for an alteration in skin integrity. Review of Resident #'3's Medical Record indicated there was no documentation to support that a Baseline Care Plan and/or a Comprehensive Care Plan had been developed and implemented related to skin breakdown. Review of Resident #3's Norton Scale for Predicting Risk of Pressure Injury, dated 08/02/24, indicated he/she had a score of 9, placing him/her at high risk for developing pressure injuries (Low risk 16-20, Moderate Risk 11-15, and High Risk 0-10). Review of Resident #3's Weekly Skin Assessment, dated 08/02/24, completed by Nurse #4, indicated the nurse identified an area of altered skin integrity, that Resident #3 had an un-measurable area of skin breakdown on his/her buttock area. Review of Resident #3's physicians orders and Treatment Administration Records (TAR), dated 8/02/24, indicated there was no documentation to support physician's orders were obtained for treatment. Review of Resident #3's Weekly Skin Assessment, dated 08/09/24, completed by Nurse #4, indicated Resident #3 had altered skin integrity, and the nurse identified an impaired un-measurable open area (pressure injury) on his/her buttock area. Review of Resident #3's Initial Wound Evaluation and Management Progress Note, dated 08/09/24 (written by the Wound Physician), indicated he/she had a full thickness wound to his/her sacrum measuring 1.3 centimeters (cm) by 1.4 cm by 0.05 cm. and recommended treatment with a Hydrogel dressing covered with a gauze sponge, to be completed once daily for 30 days. Review of Resident #3's Physicians Orders and Treatment Administration Records (TAR), dated 8/09/24, indicated there was no documentation to support physician's orders were obtained by nursing for treatment. Review of Resident #3's Wound Evaluation and Management Progress Note, dated 08/12/24 (written by the Wound Physician), indicated he/she had an unstageable full thickness wound, due to necrosis, to his/her sacrum measuring 2.0 cm x 2.1 cm by 0.1 cm. and recommended the continuation of treatment with a Hydrogel dressing covered with a gauze sponge, to be completed once daily for 27 days. Review of Resident #3's Physician and/or Nurse Practitioner progress notes, indicated there was no documentation to support they were made aware of his/her skin breakdown, until physician's orders for treatment were obtained on 8/14/24, almost two weeks after his/her skin breakdown was first documented by nursing. Review of Resident #3's Medical Record, Nurse Progress Notes, Physician's Orders, Medication Administration Records (MAR) and his/her Treatment Administration Record (TAR), indicated there was no documentation to support nursing staff notified the physician and obtained orders for treatments for his/her facility acquired pressure injury until 08/14/24, which was also the day Resident #3 was discharged home from the facility. During a telephone interview on 08/29/24 at 12:38 P.M., Nurse #4 said when he had completed Resident #3's weekly skin assessments, on 08/02/24 and 08/09/24, that he had identified stage two (partial loss of dermis) pressure injuries and said he thought Resident #3 had already been referred to the Wound Physician (who visits weekly). Nurse #4 said he could not recall if he contacted Resident #3's physician for treatment orders, and said he does not know why physician's order had not been obtained for treatments or dressing changes for his/her buttocks. During an interview on 08/28/24 at 11:55 A.M., Nurse #1 said that if a nurse observes an alteration in skin integrity while performing a resident skin assessment, that nurse should call the physician and obtain an order for treatment to the area, notify the resident's responsible party, refer the resident to the Wound Physician, write a progress note, and add the resident to skin risk rounds. During an interview on 08/28/24 at 3:57 P.M., the Director of Nurses (DON) said that she had been unaware of Resident #3's pressure injury. The DON said that it is the Facility's expectation that when a pressure injury is identified by a nurse, that the nurse begin an investigation, notify the physician and HCA as applicable, obtain physician orders for treatments, make recommendation for evaluation by Wound Physician and document accordingly.

Based on observation, record review and interview, the facility 1. failed to maintain acceptable parameters of nutrition for 3 of 6 sampled Residents (#57, #98 and #161) receiving tube feedings (TF), and 2. failed to identify a significant weight loss for 1 Resident not receiving tube feeding (#52) out of a total of 30 sampled Residents. Findings include: Review of the facility's Weighing and Measuring the Resident policy, dated March 2011 indicated: *The purpose of this procedure is to determine the resident's weight to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident. *Report significant weight loss/gain to the nurse supervisor. *The threshold for significant unplanned and undesired weight loss/gain will be based on the following criteria: 1 month- 5% weight loss is significant; greater than 5% is severe. 3 months- 7.5% weight loss is significant; greater than 7.5% is severe. 6 months- 10% weight loss is significant; greater than 10% is severe. *Notify the Nurse Supervisor if the resident refuses the procedure. *Report other information in accordance with professional standards of practice. 1. Resident #57 was admitted to the facility in October 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #57's most recent Minimum Data Set assessment dated [DATE] indicated he/she is severely cognitively impaired and requires physical assistance with eating. On 5/24/22 the surveyor observed Resident #57 resting in bed. Resident #57 was thin/frail. During an interview with Nurse #1 on 5/24/22 at 8:20 A.M., he said that Resident #57 eats meals and also receives nutrition through tube feed (TF). Review of Resident #57's Nutrition Care plan, revised 4/4/22 indicated: Resident has increased protein needs .requires nectar (thickened) liquids and TF; initiated 10/13/21. *Monitor/record/report to physician as needed signs/symptoms of malnutrition; emaciation, muscle wasting, significant weight loss. *Provide TF regimen: [MEDICATION(S)] 1.5; on at 12 A.M., off at 8 A.M., and water flushes as ordered. *Dietitian to evaluate and make diet change recommendations. Review of Resident #57's Activities of Daily Living Care plan, dated 10/12/21, indicated he/she is dependent on 1 staff to provide and feed all meals and snacks. Review of Resident #57's Kardex indicated: Monitor/documentation/report as needed any signs/symptoms of dysphagia; pocketing choking, coughing, drooling, holding food in mouth. Several attempts at swallowing. Refusing to eat. Appears concerned during meals. Review of Resident #57's weights indicated: 10/1/21 152.6 lbs (pounds) 10/4/21 153.9 lbs No weights were documented for November 2021 and December 2021. 1/1/22: 128.8 lbs (a severe loss of of 15.5 % of his/her total body weight) 2/2/22: 129.9 lbs 4/4/22: 118 lbs 5/2/22: 116.5 lbs Review of Dietitian #1's assessment dated [DATE] indicated her assessment of Resident #57 was based on an October weight and did not address or identify his/her significant weight loss. Review of Dietitian #2's assessment dated [DATE] indicated: Significant weight loss. Identified cause of weight change; inadequate intake. Nutrition Plan (Recommendations): Continue TF as ordered as tolerated. Increase TF to full strength if intakes are under 50% of meals for over 5 days. If intakes are over 75% for 5 days discontinue TF. Continue regular diet nectar liquids as tolerated. Review of Resident #57's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #57's TF. On 5/24/22 at 12:17 P.M., the surveyor observed Resident #57 resting in bed. Resident #57's lunch tray was mostly untouched as he/she had only drank his/her milk and his/her breadstick was gone, leaving all of his/her pasta, salad and desert still on the tray. The surveyor then spoke with Certified Nursing Assistant (CNA) #2 and CNA #3. CNA #2 said that Resident #57 does not require any assistance with meals and CNA #3 said that Resident #57 does need help with his/her meals. On 5/25/22 at 8:15 A.M., the surveyor observed CNA #1 deliver Resident #57's breakfast tray to him/her. CNA #1 told the surveyor that Resident #57 does not require assistance with meals and only needs supervision. CNA #1 was observed walking up and down the hallways passing meals and did not sit with Resident #57 to provide supervision, cuing or assistance during breakfast. At 8:29 A.M., the surveyor observed Resident #57's tray was placed back on the truck and he/she had taken only a few bites of hot cereal, drank his/her beverages and had left the rest of his/her meal untouched. On 5/25/22 at 12:31 P.M., the surveyor observed Resident #57 laying flat in bed, watching TV. Resident #57's lunch meal was uncovered on the overbed table in front of him/her. No staff were providing assistance or supervision. Review of Resident #57's Activities of Daily Living logs dated 4/25/22 through 5/25/22 indicated Resident #57 received assistance with 21 out of 80 documented meals. During an interview with Dietitian #1 on 5/26/22 at 8:01 A.M., she said that she had assessed Resident #57 in January for significant weight loss based on an October weight as that was what was available to her. Dietitian #1 said at that time, it was difficult to obtain weights. Dietitian #1 said that residents who have experienced significant weight losses should be weighed weekly. Dietitian #1 could not say why interventions were not implemented to address Resident #57's weight loss until 5/19/22. During an interview with the Nurse Practitioner on 5/26/22 at 12:16 P.M., she said that she was aware that Resident #57 had some weight loss, but was not aware that he/she had experienced a 25.1 lb weight loss in January 2022. 2. Resident #161 was initially admitted to the facility in October 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of his/her most recent Minimum Data Set assessment dated [DATE] indicated he/she is severely cognitively impaired, is totally dependent on staff for activities of daily living, and receives nutrition through tube feeding (TF). Review of Resident #161's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] @ 40 ml/hr continuously with H20 (water) flush 200 ml every 6 hours, 3/7/2022. On 5/24/22 the surveyor observed Resident #161 resting in bed. Resident #161 appeared thin and frail with his/her TF running at bed side. Review of Resident #161's weights indicated: Weights: 10/11/21: 178.3 lbs (pounds) 11/01/21: 179.1 lbs 11/14/21: 179.1 lbs No weights were recorded from December 2021 through February 2022. 3/22/22: 115.2 lbs (a severe loss of of 35% of his/her total body weight since 10/11/21). 4/02/22: 116.5 lbs 5/02/22: 115.1 lbs Review of Dietitian #2's assessment dated [DATE] (12 days after Resident #161's weight loss was documented) indicated: no significant change - previous weights inaccurate. Review of Resident #161's transfer orders from his/her previous facility indicated his/her weight on 8/29/21 at the previous facility was 178.1 lbs. During an interview with Dietitian #2 on 5/26/22 at 11:20 A.M., she said that that she over-sees the facility and assists with assessments. Dietitian #2 said that she was not aware that Resident #161 had a documented weight of 178.1 lbs from his/her transferring facility which would confirm his/her documented weights in October 2021 and November 2021. During an interview with Dietitian #2 on 5/27/22 at 11:50 A.M., she said that she started working at the facility in February 2022 and she initially thought that Resident #57's documented weights of 178 lbs were errors because of the large differences in the weights. Dietitian #2 said that she recently determined that Resident #57 had an actual significant weight loss. During an interview with the Nurse Practitioner on 5/26/22 at 12:18 P.M., she said that she was not aware of Resident #161's significant weight loss. 3. Resident #98 was admitted to the facility in July 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #98's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident had short and long term memory problems, no behaviors or rejection of care, was dependent on staff for care activities and had a feeding tube. On 5/24/22 at 9:01 A.M., Resident #98 was observed lying in bed. He/she appeared thin and frail and had a tube feed running. Review of Resident #98's medical record indicated the following: -physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -An admission nutritional assessment dated [DATE] which indicated the Resident's current weight was 150.6 pounds (lbs), received 100 percent of total calories via tube feeding and was at risk for nutrition risk due to dependence on tube feeding for nutrition support. -A quarterly nutrition assessment dated [DATE] which indicated the Resident's current weight was 151 lbs. and new interventions to order weekly weights and monitor weights and tube feed for tolerance. -A quarterly nutrition assessment dated [DATE] which indicated the Resident's current weight was 151 lbs., continue tube feeding as ordered, order weekly weights, monitor weights and tube feed for tolerance and a new weight was needed. -A nutrition assessment dated [DATE] which indicated the Resident's current weight was 100.3 lbs, no significant change, the Resident was totally dependent on tube feeding for 100% of caloric needs. -A care plan initiated 5/18/22 for total dependence on enteral nutrition with interventions to monitor/record/report to MD as needed any signs/symptoms of malnutrition: emaciation, muscle wasting, significant weight loss- 3 lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Review of Resident #98's weights indicated the following: 7/14/21: 150.6 lbs (pounds) 8/12/21: 151 lbs. No weights were recorded September 2021 through February 2022, despite orders for weekly weights. 3/22/22: 102 lbs. (a 32.45% weight loss in 7 months, there no weights taken within 6 months) 3/30/22: 103.3 lbs 4/05/22: 103.3 lbs 4/19/22: 100.3 lbs 5/03/22: 101.3 lbs 5/24/22: 101.4 lbs Further review of Resident #98's medical record failed to indicate the dietitian had assessed the Resident after the significant weight loss, failed to indicate any new interventions had been added after the Resident had a significant weight loss, failed to indicate During an interview on 5/25/22 at 3:30 P.M., Certified Nursing Assistant (CNA) #8 CNA said the CNAs work with nurses to get weights and will tell nurses the weights. During an interview on 5/25/22 at 3:35 P.M., Nurse #6 said if there is a weight gain or loss, the nurse will notify the dietitian and if there is a significant weight change, the nursing staff will perform a reweigh to validate the weight. Nurse #6 said a weight change of 2 pounds (loss or gain) would trigger a reweigh and if a reweigh validates the weight then the dietitian and physician are notified to determine interventions. Nurse #6 said weights are recorded in the Electronic Health Record (EHR) only and there is not a weight book on the unit. During an interview on 5/26/22 at 8:22 A.M., Dietitian #1 said she does not see residents in the facility but helps oversee the dietitians. Dietitian #1 said weights are documented in the EHR and should always be documented there. Dietitian #1 said the dietitian would have used the most recent recorded weight in her nutrition assessments and it may not have been accurate. Dietitian #1 said she would consider Resident #98's weight loss to be concerning and said since the weight change occurred over 7 months and not 6 months it would not have triggered in the system. Dietitian #1 acknowledged the Resident had a 32.45% weight loss between 8/12/21 and 3/22/22 and there were no other weights obtained during that time frame, so it wouldn't trigger as expected for a weight loss of more than 10% in 6 months. Dietitian #1 said the staff should be following the facility policy regarding weight changes and reweighs and said the dietitian should be monitoring for weight trends. Dietitian #1 said it was concerning that a resident on a continuous tube feed had a large weight loss and said the expectation would be that the dietitian would be notified of the weight loss. During an interview on 5/27/22 at 12:05 P.M., Dietitian #2 said Resident #98 is on her risk sheet and should be getting weekly weights. Dietitian #2 said she documented a weight of 151 lbs on the Feb quarterly assessment and that was based on his/her August 2021 weight and was unsure if it was accurate. Dietitian #2 said the next assessment did not trigger for a significant weight change and said residents getting a tube feed should not have a weight loss if their calorie needs are being met. Dietitian #2 said she will document if she requests a reweigh and said she did not see that she requested a reweigh. Dietitian #2 was unable to say if any interventions had been added after the Resident's significant weight loss and that the physician or Nurse Practitioner should have been notified of the weight loss. During an interview on 5/27/22 at 1:05 P.M., Nurse Practitioner #1 said Resident #98 has been getting a tube feed continuously since admission and she was not notified of any weight loss for the Resident. 4. Resident #52 was admitted to the facility in August 2019, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the most recent Minimum Data Set (MDS) MDS assessment dated [DATE], revealed that on the Brief Interview for Mental Status (BIMS) exam, Resident #52 scored a 1 out of a possible 15 indicating severely impaired cognition. The MDS further indicated Resident #52 had no behaviors and required supervision and one person physical assistance for eating. During an observation on 5/24/22 at 9:02 A.M., Resident #52 was observed in his/her room in bed. Resident #52 appeared thin and frail and was attempting to feed him/herself, however he/she was dropping the food on his/her chest. During a record review on 5/24/22 at 12:51 P.M., the following was indicated: * Resident #52's weight report indicated that on 5/3/22, Resident #52 weighed 159.6 pounds (lbs) and on 5/6/22, Resident #52 weighed 149 lbs, which is a 6.64 % loss. The record failed to indicate Resident #52 was re-weighed to check for accuracy of the weight, however weekly weights continued to be taken in the weeks following the loss, and Resident #52's recorded weight remained 149 lbs. * Review of the clinical progress notes failed to indicate the physician or dietitian were aware of the weight loss. Further, the clinical progress notes failed to indicate Resident #52's care plan was reviewed or revised, following the weight loss. During an interview with Resident #52's Certified Nursing Assistant (CNA) #7 on 5/27/22 10:37 A.M., she said that the CNA's were responsible to weigh Resident #52 and report the weight to the nurse. The nurse will tell them if they need to obtain a reweigh. She was not aware that Resident #52 had a weight loss. During an interview with the Resident's Nurse (#6) on 5/27/22 at 10:48 A.M., he said that CNAs weigh the residents and the nurse enters the weights in the computer. Nurse #6 said that if there was a significant weight loss, the nurse will re-weigh the resident with the CNAs to confirm if the weight was accurate. Nurse #6 said that both weights would be documented in the clinical record. Further, if there was an actual weight loss, the nurse will notify the physician and write a progress note in the record. Nurse #6 said that he did not notify the dietitian of significant weight losses because the dietitian had access to the system and could check resident weights herself. During an interview with the Dietitian #2 on 5/27/22 at 11:56 A.M., she said that she had never been notified of Resident #52's weight loss and therefore she had not seen the Resident or made any recommendations to address the weight loss.

Based on observation, record review and interview, the facility failed to implement a treatment in a timely manner for an existing pressure ulcer for 1 Resident (#161) out of a total of 36 sampled Residents. Findings include: Resident #161 was initially admitted to the facility in October 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of his/her most recent Minimum Data Set assessment dated [DATE] indicated Resident #161 is severely cognitively impaired, is totally dependent on staff for activities of daily living, and receives nutrition through a feeding tube. Review of Resident #161's Norton Plus Scale for Predicting Pressure Ulcers, dated 3/2/22 indicated he/she was at high risk for developing pressure ulcers. On 5/24/22 the surveyor observed Resident #161 resting in bed on an air mattress. Review of Resident #161's Skin Assessment's dated 4/4/22, 4/12/22, 4/19/22 and 4/26/22 indicated that Resident #161's skin was dry and intact. Review of Resident #161's Wound assessment dated [DATE] indicated he/she developed an unstageable pressure ulcer on his/her coccyx: Wound assessment 4/28/22: Unstageable 2.5 CM (centimeters) X 2.3 CM. 10% granulation (new tissue), 70% necrotic (dead tissue) Treatment: Wash with NS (normal saline) dry, apply Santyl (a topical treatment) to wound, cover with gauze sponge then gauze island with border. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The treatment order indicated: Santyl Ointment 250 Unit apply to coccyx topically every day shift for wound care, initiated 5/5/22. During an interview with the Corporate Nurse on 5/27/22 at 11:28 A.M., she said that on 5/5/22 the facility became aware that there was no treatment in place for Resident #161's pressure ulcer and the same day completed an internal incident report and implemented orders.

Based on interviews and records reviewed, for two of three sampled residents (Resident #2 and Resident #3), the Facility failed to ensure they were provided the appropriate level of assistance and/or supervision to maintain resident safety to prevent incidents or accidents, that resulted in or could potentially result in injury. 1) On 12/18/21 Resident #2, who required physical assistance of two staff members for mobility and transfers, had an unwitnessed fall out of bed, and was not provided the necessary level of staff assistance when transferred back into bed. Resident #2 was transferred to the Hospital Emergency Department on 12/19/21 for evaluation related to complaints of leg pain and was diagnosed with a fractured right hip. 2) On 12/31/21 Resident #3, who had a legal guardianship in place, who had approved of his/her right to maintain the ability to go outside with staff supervision, the Facility failed to prevent an incident of elopement, when Resident #3 went outside unsupervised and eloped without staff knowledge, and his/her whereabouts was unknown until 1/04/22 when the Facility was informed that Resident #3 was found at a local homeless shelter. Findings Include: The Facility's Policy, Change in a Resident's Condition or Status, dated 2017, indicated the Nurse Supervisor/Charge Nurse will notify the resident's attending Physician or On-Call Physician when there has been: an accident or incident involving a resident and a significant change in the resident's physical/emotional/mental condition. 1) Resident #2 was admitted to the Facility in January of 2004, diagnoses included [CONDITION(S)], failure to thrive, [CONDITION(S)], legal [CONDITION(S)] and depression with anxiety. Resident #2's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she was intact cognitively, was able to make his/her needs known, and required extensive assist of two persons with activities of daily living including bed mobility and transfers. Review of Resident #2's Fall Plan of Care, dated 12/14/21, indicated Resident #2 was a risk for falls characterized by history of falls/injury, and had multiple risk factors related to visual deficits, legally blind. During an interview on 1/12/22 at 5:05 P.M., Nurse #5 said Resident #2 was bed bound with limited mobility, Nurse #5 said on 12/18/21 at around 2:00 A.M., upon entering Resident #2's room, he found Resident #2 on the floor with his/her head and trunk on the floor, and his/her legs were in an upright position leaning on his/her bed. Nurse #5 said Resident #2's head was on the floor towards the end of the bed. Nurse #5 said he was shocked to find Resident #2 on the floor, in this position, since Resident #2 had limited mobility. Nurse #5 said Resident #2 was really confused and was unable to say what happened upon assessment. Nurse #5 said he transferred Resident #2 back to bed via Hoyer lift (mechanical device to assist with lifting/transfers from one place to another) with Certified Nurse Aide (CNA) #1 and CNA #2. Reviewed of the Facility Staffing Schedule, dated 12/17/21 into 12/18/21, indicated CNA #1 and CNA #2 were assigned to work on the Unit with Nurse #5. During an interview on 1/13/22 at 6:00 P.M., CNA #1 said he worked the overnight shift that started on 12/17/21 at 11:00 P.M. and ended on 12/18/21 at 7:00 A.M., and said he was unaware Resident #2 fell out of bed that night. CNA #1 said he did not assist Nurse #5 with a Hoyer lift transfer to help transfer Resident #2 back to bed anytime during the shift. During an interview on 1/19/22 at 11:15 A.M., CNA #2 said she worked the overnight shift that started on 12/17/21 at 11:00 P.M. and ended on 12/18/21 at 7:00 A.M., and said she was unaware Resident #2 fell out of bed that night. CNA #2 said she did not assist Nurse #5 with a Hoyer lift transfer to help transfer Resident #2 back to bed anytime during the shift. Although, Nurse #5 said he transfer Resident #2 from the floor to the bed using a mechanical lift and with the assistance of CNA #1 and CNA #2, both of them denied being aware Resident #2 fell out of bed and both CNA's were adamant they did not assist Nurse #5 with the Hoyer lift transfer that night to transfer Resident #2 back to bed. Review of Resident #2's Fall Report, dated 12/18/21 at 2:15 A.M., indicated Resident #2 was found halfway off his/her bed and Resident #2 was very confused at the time of the incident. The Report indicated when the Nurse (later identified as Nurse #5) asked Resident #2 what happened, Resident #2 said to the Nurse I was going to the bathroom. The Report indicated Resident #2, who had reduced mobility, was too confused to offer any rational explanation as to what had happened to him/her. Further review of Resident #2's medical record, including Nurse Progress Notes written by Nurse #5 indicated there was no documentation to support Nurse #5 assessed or monitored Resident #2's condition after the unwitnessed fall and that he/she had required a mechanical lift transfer back to bed. Review of Resident #2's Hospital Department Emergency Note, dated 12/19/21, indicated Resident #2 was evaluated and diagnosed with a right intertrochanteric hip fracture. The Note indicated Resident #2 said he/she fell and his/her right hip/leg was quite painful. The Note indicated Resident #2 was wheelchair-bound at baseline and his/her right upper extremity was contracted and held in flexed position. During an interview on 1/19/22 at 11:23 A.M., CNA #3 said she worked the following overnight shift that started on 12/18/21 at 11:00 P.M. and ended on 12/19/21 at 7:00 A.M., and said Resident #2 was in a lot of pain, confused and said she was unable to touch him/her. CNA #3 said she told Resident #2's nurse he/she was confused and in a lot of pain. Reviewed of the Facility Staffing Schedule, dated 12/18/21 into 12/19/21, indicated Resident #2's nurse was Nurse #5. Review of Nurse #5's progress note for 12/18/21 and 12/19/21, indicated there was no documentation to support Nurse #5 assessed Resident #2 for his/her complaints of pain or for reports of his/her increased confusion. During an interview on 1/13/21 at 9:16 A.M., Nurse #1 said on 12/19/21 upon arrival at 7:00 A.M. Resident #2 was in excruciating pain, confused and was not at his/her baseline. Nurse #1 said she was informed by Nurse #5 that Resident #2 had a fall on the 11:00 P.M. to 7:00 A.M. shift (documentation indicated Resident #2's fall was on 12/18/21 at 2:15 A.M.). Nurse #1 said she assessed Resident #2 and he/she had tenderness to touch in the right upper leg. Nurse #2 said she called the Nurse Practitioner (NP) and a hip x-ray was ordered. Nurse #1 said Resident #2 would moan in pain, was uncomfortable despite the medications given to him/her and said she called the Emergency Medical Services (EMS) for Hospital transfer. Nurse #1 said the x-ray mobile company came prior to sending Resident #2 to the Hospital and their report indicated Resident #2 sustained a right hip fracture. During an interview on 1/13/22 at 6:25 P.M., the Director of Nursing (DON) said she was unable to find any documentation indicating Resident #2 was being monitored after his/her unwitnessed fall on 12/18/21. The DON said it is best practice to monitor a residents neurological signs status post an unwitnessed fall, to monitor frequently and to assess any changes that may occur, document and notify the Physician immediately. During an interview on 1/28/22 at 10:40 A.M., the Physician said Resident #2's right intertrochanteric hip fracture could of been caused by [CONDITION(S)] and/or it could of been caused by the unwitnessed fall on 12/18/21. The Physician said Resident #2 was frail and he/she did not weigh much. 2) Resident #3 was admitted to the Facility in April 2021, diagnoses included major neurocognitive disorder with traumatic brain injury, [CONDITION(S)], Korsakoff's (primary affects the memory system in the brain) and [CONDITION(S)] disorder. The Facility's Final Investigation Report, undated, indicated Resident #3 had a court appointed temporary guardianship in place. The Investigation indicated that staff reported on 12/31/21 they were informed by another resident in the Facility that Resident #3 went to the store and he/she had not come back to the Facility. The Investigation indicated Resident #3 used smoking times to go outside. The Investigation indicated Resident #3's Guardian called the Facility on 1/04/22 to inform the Facility that Resident #3 was found at the shelter (approximately 3.5 miles from the Facility) and would not be returning to the Facility. Review of Resident #3's Elopement Care Plan, dated 6/20/21, indicated Resident #3 was at risk for elopement due to his/her decreased cognition, poor safety awareness, new admission wanting to leave complicated by disease process of dementia and [CONDITION(S)]. Interventions included when on a social leave of absence to ensure a responsible party (staff member to supervise) was present and they have signed him/her out, an elopement assessment to be completed quarterly and as needed if his/her cognition declines, monitor his/her whereabouts, frequently redirect away from doors, and the systems in the Facility will prevent him/her from being successful in leaving. Review of Resident #3's Smoking Care Plan, dated 6/20/21, indicated Resident #3 was at risk to go outside to smoke with no supervision and during non-smoking times. Interventions included to provide him/her support, consolation and to redirect him/her to comply with facility smoking regulations. Review of Resident #3's Minimum Data Set (MDS) assessment, dated 10/13/21, indicated he/she was moderately cognitively impaired. Review of the Facility's Entrance/Exit Log Book, dated 12/31/21, indicated Resident #3 and or a staff member did not sign the Entrance/Exit Log Book on behalf of Resident #3 leaving the Facility that day. During an interview on 1/20/21 at 2:14 P.M., Resident #3's Legal Guardian said he received a call on 12/31/21 and was informed that Resident #3 was missing. The Guardian said he learned that day after speaking with Nursing, that this was not the first time Resident #3 has been off the Facility grounds without staff supervision. The Guardian said he was not informed this had happened in the past and said Resident #3 continued to make poor choices which had extended his/her need for Legal Guardianship twice. The Guardian said Resident #3 has had a recent history of disappearing, which has led to hospitalization s. The Guardian said Resident #3 needed staff supervision to ensure his/her safety. During an interview on 1/12/22 at 6:25 P.M., Nurse #2 said on 12/31/21, around dinner time, Resident #3 said, he/she was going downstairs to smoke and get fresh air. Nurse #2 said it was not until around 6:00 P.M. when it was brought to her attention by another resident, that Resident #3 had not return to the unit and staff informed her Resident #3's dinner tray was in his/her room and untouched. Nurse #2 said Resident #3 would go to the convenience store (0.5 miles from the Facility) to purchase items and would come back to the Facility. Nurse #2 said Resident #3 would let the nurse know he/she was going to the store. Nurse #2 said there were no restrictions for residents to go off Facility grounds and said residents did not need to sign out off the unit or at the front desk. Nurse #2 said she was unaware if Resident #3 had gone to the store, but said he/she had in the past without staff supervision. Nurse #2 said on 12/31/21 she did not write a Nurse Progress Note in regards to Resident #3's elopement and at 7:00 P.M. she informed the on-coming Nurse Resident #3 was missing. During the interview on 1/19/21 at 12:16 P.M., the Receptionist said on 12/31/21 she was at the front desk and said she had not seen any of the residents leave the Facility around dinner time. The Receptionist said she did not know what Resident #3 looked like. The Receptionist said residents do not sign the Exit and Entrance Facility Log. The Receptionist said she was unaware of the Facility's Elopement Policy/Procedure, did not know the residents who are at high risk for elopement in the Facility and said she was unaware of a Facility's elopement book. During an interview on 1/12/22 at 3:36 P.M., the Nurse Practitioner (NP) said Resident #3 had poor safety awareness associated with his/her traumatic brain injury, decline in his/her overall function and history of substance abuse. The NP said she would not feel comfortable if Resident #3 went off the Facility grounds without staff supervision. The Facility's Policy, titled Smoking Policy, dated October 2018, indicated the Facility has established designed smoking times and monitored by staff during these times in designated smoking area for residents. During an interview on 1/13/22 at 6:30 P.M., the Director of Nursing (DON) said Resident #3's elopement evaluation was not done. The DON said Resident #3 went outside with other residents and staff to smoke. The DON said the smoking area requires supervision and residents are supervised by staff at all times when they are outside. During an interview on 1/28/22 at 11:00 A.M., Resident #3's Physician said he was unaware of Resident #3's elopement on 12/31/21.

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who had limited mobility and required two staff persons to assist with mobility and transfers, the Facility failed to ensure he/she was provided with care that met professional standards of practice, after he/she experienced an unwitnessed fall. On 12/18/21, at around 2:00 A.M., Resident #2 was found by nursing with his/her head and trunk on the floor, legs upright resting on the bed, however there was no documentation by nursing to support he/she was assessed or monitored for physical injury, and although Nurse #5 said he assisted Resident #2 back to bed with a mechanical lift and help from two staff members, staff working on the Unit that night denied knowing Resident #2 had fallen out of bed and denied ever assisting Nurse #5 in putting Resident #2 back to bed. Resident #2 was transferred to the Hospital Emergency Department on 12/19/21 for evaluation related to complaints of leg pain and was diagnosed with a fractured right hip. Findings Include: The Facility's Policy, Neurological Assessment, dated as revised on 2010, indicated Neurological Assessments are indicated following an unwitnessed fall, always include frequent vital signs and change in vital signs or a neurological status in a previously stable resident should be reported to the Physician immediately. The Policy indicated the following information should be recorded in the resident's medical record; the date and time the procedure was done, all assessment data obtained during the procedure, how the resident tolerated the procedure, if the resident refused the procedure, the reason why and the intervention taken, the name and title of the individual(s) who performed the procedure and recording the data. Resident #2 was admitted to the Facility in January of 2004, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2's Quarterly Minimum Data Set (MDS) Assessment, dated 12/15/21, indicated that he/she was intact cognitively, was able to make his/her needs known, and required extensive assist of two persons with activities of daily living including bed mobility and transfers. Review of Resident #2's Fall Report, dated 12/18/21 at 2:15 A.M., indicated Resident #2 was found halfway off his/her bed and was very confused at the time of the incident. The Report indicated when the Nurse (later identified as Nurse #5) asked Resident #2 what happened, Resident #2 said to the Nurse I was going to the bathroom. The Report indicated Resident #2, who had reduced mobility, was too confused to offer any rational explanation as to what had happened to him/her. Review of Resident #2's Hospital Department Emergency Note, dated 12/19/21, indicated Resident #2 was evaluated and diagnosed with a right intertrochanteric hip fracture. The Note indicated Resident #2 said he/she fell and his/her right hip/leg was quite painful. The Note indicated Resident #2 was wheelchair-bound at baseline and his/her right upper extremity was contracted and held in flexed position. During an interview on 1/12/22 at 5:05 P.M., Nurse #5 said on 12/18/21, upon entering Resident #2's room, he found Resident #2 on the floor with his/her head and trunk on the floor, and his/her legs were in an upright position leaning on his/her bed. Nurse #5 said Resident #2's head was on the floor towards the end of the bed. Nurse #5 said he was shocked to find Resident #2 on the floor in this position, since Resident #2 had very limited bed mobility. Nurse #5 said he assessed Resident #2, and he/she had no pain or injury. Nurse #5 said he reported the fall to the On-Call Service, spoke with the Physician, and the Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 1/27/21 at 4:00 P.M., the On-Call Physician's Director of Operations said on 12/18/21, the On-Call Physician's Service did not receive a call from the Facility in regards to concerns of Resident #2's medical status. The Director of Operations said the On-Call Service received three calls from the Facility on 12/19/21, the first call on 12/19/21 was at 8:45 A.M. reporting Resident #2 had a tender right leg, the second call was at 5:26 P.M. reporting Resident #2 needed to be sent out to the Hospital, and the third call was 20 minutes later at 5:46 P.M., again reporting that Resident #2 needed to be sent out to the Hospital Emergency Department. Nurse #5 said he followed the Facility's protocol and obtained Resident #2's vital signs after his/her unwitnessed fall. Nurse #5 said repeatedly Resident #2 was really confused, was not at his/her baseline medically and needed to be followed closely. Nurse #5 said he did not continue to monitor vital signs after Resident #2's unwitnessed fall. However, review of Resident #2's medical record, which included review of Nurse #5's progress notes, indicated there was no documentation to support Resident #2 was assessed immediately after the unwitnessed fall on 12/18/21, or to support that Nurse #5 monitored or re-assessed Resident #2 during the overnight shift. During an interview on 1/28/22 at 10:40 A.M., Resident #2's Physician said when a resident falls, it is expected Nursing to perform an assessment on the resident, call the Nurse Practitioner (NP)and/or Physician or the On-Call Physicians Service to notify them of the fall, the circumstances around the fall so the NP/Physician can give further orders based on the information received. The Physician said with an unwitnessed fall it is important to monitor the residents neurological status closely to be aware of any changes of condition in the resident. The Physician said it is also important if it is an unwitnessed fall, and it is unknown if the head or another body part was struck, because further testing may need to be ordered. The Physician said if the head was struck and the resident is on any blood thinners for medications, it may increase the risk of bleeding to occur. Review of Resident #2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #5 acknowledged during his interview that on 12/18/21 he had not notified Resident #2's Physician of the fall, and said the Physician was not notified until 12/19/21 during the day shift (7:00 A.M. to 3:00 P.M.). During an interview on 1/12/22 at 5:05 P.M., Nurse #5 said after finding Resident #2 on the floor, he transferred Resident #2 back to bed via Hoyer lift (mechanical device to assist with lifting/transfers from one place to another) with the help of Certified Nurse Aide (CNA) #1 and CNA #2. Reviewed of the Facility Staffing Schedule, dated 12/17/21 into 12/18/21, indicated CNA #1 and CNA #2 were assigned to work on the Unit with Nurse #5. During an interview on 1/13/22 at 6:00 P.M., CNA #1 said he worked the overnight shift that started on 12/17/21 at 11:00 P.M. and ended on 12/18/21 at 7:00 A.M., and said he was unaware Resident #2 fell out of bed that night. CNA #1 said he did not assist Nurse #5 with a Hoyer lift transfer to help transfer Resident #2 back to bed anytime during the shift. During an interview on 1/19/22 at 11:15 A.M., CNA #2 said she worked the overnight shift that started on 12/17/21 at 11:00 P.M. and ended on 12/18/21 at 7:00 A.M., and said she was unaware Resident #2 fell out of bed that night. CNA #2 said she did not assist Nurse #5 with a Hoyer lift transfer to help transfer Resident #2 back to bed anytime during the shift. During an interview on 1/13/22 at 6:25 P.M., the Director of Nursing (DON) said there was no Neurological Assessments completed by Nursing after Resident #2's unwitnessed fall on 12/18/21 and no documentation to support Resident #2 was being monitored by nursing prior to his/her transfer to Hospital Emergency Department on 12/19/21. The DON said it is best practice to monitor a resident neurological signs after an unwitnessed fall, that nursing should continue to assess vital signs, monitor the resident frequently, and assess for any changes that may occur. The DON said nursing should document the incident, any assessments, and notify the Physician immediately.

Based on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #2), who were assessed as being at increased risk for weight loss, the Facility failed to ensure weights were obtained as ordered by the Physician and weights remained stable, as a result both residents experienced undesired significant weight losses. Findings include: The Facility's Policy, titled Weight Assessment and Intervention, dated as revised on 12/2021, indicated: - Residents would be weighted upon admission, the next day, and weekly for two weeks or as recommended or order thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. - Weights will be recorded in each unit's Weight Record chart or notebook and in the resident's medical record. - Any three pound weight change has been confirmed; nursing will immediately notify the Physician and Dietitian of the weight change and they are expected to respond within 24 hours. Documentation of this notification shall be entered in the resident's medical record. - The Dietitian will review all resident weights routinely but at least monthly; monitoring residents for unplanned, undesired weight changes. - Significant weight change was defined as: 5% in one month, 7.5 % in three months or 10% in six months. 1) Resident #1 was admitted to the Facility in October of 2021, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Physician order, dated 10/08/21, indicated nursing to obtain weekly weights, for four weeks. Review of the Resident #1's Electronic Medical Record (EMR) indicated that on 10/08/21 he/she had a documented weight of 179 pounds ( lbs). Further review of Resident #1's EMR indicated there was no documentation to support his/her weight was obtained or documented again until 11/29/21. Review of Resident #1's Care Plan related to nutritional risk, dated as initiated 10/11/21, indicated risk factors that included gastroesophageal reflux disease, [CONDITION(S)] and hypertension. Goals included for the resident to maintain adequate nutritional status as evidenced by maintaining weight within 5% of 180 lbs, no signs and symptoms of malnutrition, and consuming at least 50% of at least 3 meals daily. Interventions included monitor, record and report to the physician signs and symptoms of malnutrition, emaciation, muscle wasting or significant weight loss. Review of the Admission Nutritional Assessment, dated 10/20/21, indicated Resident #1 had a meal intake of over 50% daily. Current height was 69 inches, weight was 179 lbs with an ideal body weight of 160 lbs. Continue diet as ordered, monitor weights, skin integrity and laboratory values as ordered. Review of the Nurse Practitioner (NP) Progress Note, dated 10/21/21, indicated nursing reported Resident #1 had declined. Resident #1 was resting in bed and said he/she felt okay. The Note indicated that Resident #1 had not been eating or drinking well. Resident #1 was assessed for malaise and fatigue. Treatment was to monitor closely and laboratory tests were ordered. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was transferred to the hospital emergency room for evaluation. Review of the Hospital Discharge Summary, dated 11/08/21, indicated Resident #1 weighed 169 lbs on admission 10/22/21. The summary indicated this was significant weight loss of 10 lbs in 14 days. During an interview on 1/12/22 at 1:44 P.M., the Nurse Practitioner (NP) said Resident #1 appeared frail and not motivated on assessment 10/21/21. The NP said Resident #1's appetite was not great, but said she was not aware of any weight loss. The NP said resident weights are usually recorded in the EMR. During an interview on 1/13/21 at 2:05 P.M., the Dietician said Resident #1 was assessed by another dietician on admission. The Dietician said that residents are weighed within 24 hours of admission then weekly, times four weeks, and weights are recorded in the EMR. The Dietician said weights have not been obtained and recorded consistently. During an interview on, 1/20/22 at 1:05 P.M., the NP said she was not aware that Resident #1 had not had weights completed as ordered. The NP said she did not know the hospital had recorded Resident #1's weight at 169 lbs, which was a significant weight loss (5.88%) from his/her admission weight to the facility. The NP said that weights are not done and recorded timely. 2) Resident #2 was admitted to the Facility in January of 2004, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Nutrition Care Plan, dated 12/14/21, indicated Resident #2 was at nutritional risk related to history of underweight Body Mass Index, a significant weight loss continued over 6 months with need for nutritional repletion, potential for a self-feeding deficit due to his/her visual deficits and inability to use right hand for self-feeding. Interventions included monitor weights per facility policy as ordered. Review of the NP's Progress Note, dated 9/07/21, indicated Resident #2's weight was about 80.0 pounds and nursing was monitoring Resident #2's weights. Review of the NP's Progress Note, dated 10/25/21, indicated Resident #2 had a chronic health condition, adult failure to thrive, and had a very poor outcome to motivate Resident #2 to eat. The Note indicated Resident #2 did not have a documented recent weight in his/her EMR. Review of Resident #2's Physician's Progress Note, dated 10/27/21, indicated Resident #1 had no recent weights to compare with. Review of Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 was therefore due to be weighted by Nursing on 10/27/21, 11/1/21, 11/8/21, 11/15/21, 11/22/21, 11/29/21, 12/6/21 and 12/13/21. Review of Resident #2's EMR indicated there was no documentation to support weights were obtained weekly starting on 10/21/21, as ordered by the Physician. Review of the Weight Status Report for Resident #2's Unit, dated 12/06/21, indicated Resident #2's weight was documented as 56.9 pounds. Based on Resident #2's weight on 9/07/21 at 80.0 pounds (Nurse Practitioner's Progress Note) and 56.9 pounds on 12/06/21 (Weight Status Report), this reflects a severe significant weight loss of 31.4% in three months. During an interview on 1/13/22 at 2:11 P.M., the Dietician said Resident #2 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Dietician said she was unaware and had not been informed by staff Resident #2 had a recent significant weight loss. The Dietician said staff should have weighted and recorded Resident #2's weight as ordered by the Physician in his/her EMR. The Dietician said it was important to monitor Resident #2's weights to prevent further weight loss and it was a helpful indication of Resident #2's health status. Although, the Dietician said she was able to complete Resident #2's Quarterly Nutritional Assessment on 12/15/21, prior to him/her being transferred to the hospital on 12/19/21, the Dietician said she was unaware of Resident #2's most recent weight of 56.9 pounds on 12/06/21. The Dietician said on 12/15/21 she referred to Resident #2's last weight documented in his/her EMR on 6/01/21 as 65.2 pounds to complete his/her Quarterly Nutritional Assessment. The Dietician said there were no other weights documented in Resident #2's EMR. During an interview on 1/13/22 at 6:25 P.M., the Director of Nursing (DON) said Nursing did not document Resident #2's weekly weights in his/her EMR per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON said the only weight documentation on Resident #2's floor was his/her Weight Status Report, dated 12/06/21, indicating Resident #2's weight was 56.9 pounds and it was not documented in his/her EMR. The DON said Resident #2's weights should have been measured and recorded in his/her EMR as ordered by the Physician on a weekly basis. During an interview on 1/20/22 at 1:27 P.M., the Nurse Practitioner (NP) said she was unaware that Resident #2's weights were not being done weekly and had not been documented by Nursing in the EMR. The NP said it was important to know Resident #2's weight since he/she was being monitored closely and had a diagnosed of failure to thrive. The NP said that she would expect nursing to notify her of Resident #2's current weight loss so she could reassess, look at further testing/labs, speak with the nutritionist and assess Resident #2's intake closely. During an interview on 1/28/22 at 10:40 A.M., Resident #2's Physician said on 10/27/21 he wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician said he was concerned Resident #2 was losing weight and had been diagnosed of failure to thrive. The Physician said on 10/27/21 he needed to adjust Resident #2's medications. The Physician said he was not aware of and had not been informed Resident #2's weights were not being done weekly. The Physician said it was important to obtain Resident #2's weights to be able to monitor his/her weight trends and treat accordingly.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] #1 was readmitted on ,d+[DATE] after requiring hospital admission, that nursing reconciled medications from his/her Hospital Discharge Summary, notified the physician of new medications, and then transcribed them into Resident #1's Medication Administration Record. As a result, Resident #1 was not administered an anticoagulant medication, the correct dose of a cardiac medication or a medication ordered for muscle weakness for 18 days. Resident #1 became symptomatic, was transferred to the hospital and admitted with high blood pressure, rapid heart rate, weakness and anxiety. Findings include: The Facility Policy titled Medication Therapy, dated 2017, indicated that the Resident's clinical record must contain a written order for all prescriptions and over-the-counter medications taken by the resident. All decisions related to medications shall include appropriate elements of the care process. Upon or shortly after admission, and periodically thereafter, the staff and practitioner (assisted by the Consultant Pharmacist) will review an individual's current medication regime. Periodically, and when circumstances are present that represent a greater risk for medication related complications, the staff and practitioner will review the medication regime for continued indications, proper dosage and duration and possible adverse consequences. The physician will identify situations where medications should be tapered, discontinued or changed to another medication. The Consultant Pharmacist shall review each resident's medication regimen monthly, as requested by the staff or practitioner, or when a clinically significant adverse consequence is confirmed or suspected. Resident #1 was readmitted to the Facility in 11/2021 after an acute hospital stay for [CONDITION(S)] [CONDITION(S)] (rapid heartbeat). Review of the Hospital Discharge Summary, dated 11/11/21, indicated the following new medications were added to his/her medication regime. -[MEDICATION(S)] (a blood thinner to treat [CONDITION(S)]) 5 milligrams (mg) by mouth two times daily. -[MEDICATION(S)] XL (a beta blocker to treat high blood pressure) 50 mg by mouth every morning. -[MEDICATION(S)] (to treat muscle weakness) 90 mg by mouth every six hours scheduled. Review of Resident #1's Nursing Progress Notes dated 11/11/21, indicated there was no documentation by nursing related to his/her re-admission or medication reconciliation with the physician. Review of the Nurse Practitioner (NP) Note, dated 11/11/21, indicated she assessed Resident #1 on the day of re-admission and the addition of [MEDICATION(S)] and [MEDICATION(S)], however the increased dose of [MEDICATION(S)] was not referenced. Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Physician Orders indicated there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 had not received the additional medications as ordered by the hospital for 18 days. The increased dose of [MEDICATION(S)] was omitted for 18 days (total of 18 missed doses). [MEDICATION(S)] was omitted for 18 days (total of 36 missed doses) and [MEDICATION(S)] was omitted for 18 days (total of 72 missed doses). During an interview on, 1/12/22 at 1:44 P.M., the NP said Resident #1 was sent to the hospital on 11/29/21 for evaluation, after he/she presented with a change in condition. The NP said Resident #1 was lethargic, was not able to participate in therapy and was diaphoretic (sweating heavily). During an interview on 1/13/22 at 2:43 P.M., the Occupational Therapist (OT) said she reported to nursing that Resident #1 had declined late November in performance from a moderate/minimal assist climbing stairs to moderate/maximum assist with all physical and occupational therapies. The OT said Resident #1's cognition was declining as well, and said these changes were also reported to nursing. Review of Resident #1's medical record indicated there were no Nursing Progress Notes regarding the OT reporting Resident #1 had a decline in physical and occupational therapies. During an interview on 1/19/22 at 10:42 A.M., Pharmacist #2 said that the pharmacy had not received physician orders and did not dispense [MEDICATION(S)], [MEDICATION(S)] XL 50 mg or [MEDICATION(S)] for Resident #1. During an interview on 1/19/22 at 2:31 P.M., the Pharmacy Consultant said her role at the facility is to complete new admission and re-admission drug reviews and monthly drug reviews of all residents. The Pharmacy Consultant said that medication reconciliation is not part of the drug regimen review and is not within her scope of practice. During a follow-up interview on 1/20/22 at 1:05 P.M, the Nurse Practitioner said she was not aware Resident #1 had medication changes on re-admission from the hospital on 11/11/21. The NP said she was not aware Resident #1 was started on [MEDICATION(S)] secondary to [CONDITION(S)], that his/her [MEDICATION(S)] XL was increased to 50 mg once daily or that [MEDICATION(S)] was started for weakness and tremors. The NP said nursing would usually notify her of any medication changes when a resident is readmitted , but said there has been a lack of staff and supervision which creates a problem with consistency.

Based on record review and interview, the facility failed to ensure 1.) One Resident (#510) out of 6 applicable residents, with an identified pressure ulcer was provided treatment to promote wound healing. Subsequently, Resident #510's wound worsened and 2.) the facility failed to document weekly skin checks for a resident at risk for pressure ulcers, for 1 Residents and (#59) from a total sample of 34 residents. Findings include: Review of the facility's policy titled Pressure Ulcers/Skin Breakdown, dated 2017 indicated the following: 1. Nursing staff and attending physician will assess and document an individual's significant risk factors for developing pressure sores: for example immobility, recent weight loss, and a history of pressure ulcers. 2. In addition the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudate or necrotic tissue b. Pain assessment c. Resident's mobility status d. Current treatments, including support surfaces and e. All active diagnoses. Further review of the policy indicated the following under Treatment/management. The physician will authorize pertinent orders related to wound treatments, including wound cleaning, debridement approaches, dressing (occlusive, absorptive, etc.) and application of topical agents if indicated for type of skin alteration. Review of the facility's policy dated as revised 2018 indicated the following definitions: Stage 3 Pressure injury, Full thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the injury and granulations tissue and epibole (rolled edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location. Stage 4 Pressure Injury: Full thickness skin and tissue loss; Full thickness and tissue loss with exposed or directly palpable facia, muscle, tendon, ligament, cartilage, or bone in the injury. Slough and eschar may be visible. Epibole (rolled edges) undermining and or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an unstageable pressure injury. 1. Resident #510 was admitted to the facility in December of 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set Assessment (MDS) with an assessment reference date of 1/13/21 indicated Resident #510 scored 15 out of 15 on the Brief Interview of Mental Status (BIMS), which indicated intact cognition. Further review of the MDS indicated Resident #510 required extensive assistance from staff for bed mobility, hygiene, bathing, was at risk for developing pressure ulcers and had stage 2 pressure ulcer upon admission/reentry. Review of a care plan dated 1/8/2021 indicated the following: Focus: I will have no further skin break down before my discharge. I will respond to treatment as evidenced by improved wound healing and less pain and drainage. Interventions included, air mattress ordered, consult with wound consultant physician per medical doctor orders, please observe my wound and surrounding skin for redness, swelling, severe pain, warmth, increased drainage, and report accordingly. See my treatment record for my dressing change orders. Review of the medical record indicated that Resident #510 was readmitted from a hospital back to the facility in January 2021. The record failed to have a Nursing Admission/Readmission Assessment. Review of a weekly skin check dated 1/6/20 indicated that Resident 510's skin was not clean and intact and indicated the following: cite coccyx, type: pressure. The areas on the skin check for length, width, depth, and stage were blank. The area next to the description of the open area (include site, wound bed, wound exudate, surrounding tissue, wound edges, signs and symptoms of infection) did not include a description and indicated, Resident #510 returned from the hospital with an open area on the coccyx area. The Resident was referred to the wound doctor. The note did not include the required description of the open area. Review of the hospital inpatient discharge summary dated 1/6/21 indicated under hospital course problem list the following: -Decubitus ulcer on coccyx, likely stage III. The patient will get [MEDICATION(S)] dressing every three days. Wound care will continue at rehab (facility). Review of a late entry nursing progress note dated 1/7/21 indicated the following: Resident returned from the (hospital) after 15 days. Resident returned with a decubitus ulcer on his/her coccyx. Resident had a [MEDICATION(S)] dressing done every three days. NP #1 was notified, and the wound doctor was notified. The same dressing will be continued until the Resident is out of quarantine. Nursing will continue to monitor and implement the plan of care. Review of Nurse Practitioner #1's progress note dated 1/6/21 indicated, under history of present illness, decubitus ulcer stage III seen by wound MD (doctor), on [MEDICATION(S)] dressing daily. Review of the physician's active and discontinued orders and treatment administration record (TAR) dated, 1/2021 failed to indicate an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the interim physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional review of the Nursing Progress notes indicated the following: - Two progress notes dated 1/9/21 one at 9:31 A.M., and 10:55 P.M., skin dry and intact. - Two progress notes dated 1/11/21, one at 12:12 A.M., and 8:51 P.M., skin dry and intact. - A progress note dated 1/12/21 at 3:24 P.M., skin dry and intact. - A progress note dated 1/14/21 at 8:43 P.M., skin dry and intact. - A progress note dated 1/15/20 at 12:55 A.M., skin dry and intact. The Nursing Progress notes failed to identify the coccyx pressure ulcer, or any treatments implemented to Resident #510's coccyx pressure ulcer. Review of Nurse Practitioner #1's progress note dated 1/11/21 did not indicated any information about the coccyx pressure ulcer. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound documentation: every day and evening shift, dated 1/15/21. Review of the medical record failed to indicate the wound doctor examined and made recommendations for the coccyx pressure ulcer as per the Nurse Practitioner (NP) progress note. Review of the medical record failed to indicate weekly skin checks were completed for 1/8/21 and 1/15/21 as per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record indicated that Resident #510 was transferred and admitted to the hospital on 1/16/21. During an interview on 7/02/21 11:56 A.M., Nurse #11 said he did the skin check dated 1/6/21 on Resident #510. Nurse #11 said Resident #510 had a coccyx pressure ulcer before going to the hospital. Nurse #11 said Resident #510 was readmitted to the facility with a protective dressing with foam on his/her coccyx from the hospital. Nurse #11 said the wound was open, red and he was unable to determine the depth. Nurse #11 said NP #1 would evaluate the wound the next day. Nurse #11 said any pressure ulcer treatments are on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 7/6/21 at 11:02 A.M., the DON said on admission or readmission the nurse who does the skin check is to measure and describe any pressure ulcers, inform the nurse practitioner, and obtain treatment orders. The surveyor reviewed the medical record with the DON and the DON acknowledged that there was no order for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 7/6/21 at 2:14 P.M. NP #1 said Resident #510 returned from the hospital with a stage III coccyx pressure ulcer. NP #1 said she thought a [MEDICATION(S)] dressing was being done daily and that the wound doctor was keeping tabs on Resident #510's wound. NP #1 said an order would need to be written for the nurses to administer a treatment to the pressure ulcer. NP #1 said she did not get reports from nursing staff on the condition of the pressure ulcer. NP #1 said she could not say what was being done for the pressure ulcer wound the ten days prior to writing the order on 1/15/21. Review of the Hospital Emergency Department document dated 1/16/21 indicated the physicians assessment/plan as the following: -Stage 4 decubitus ulcer, packed with gauze and dressed, surgical consult and antibiotics as above. 2. Resident #59 was admitted to the facility in 4/2021 after an acute hospital stay for [CONDITION(S)] (blood infection) from pneumonia and a urinary tract infection with additional chronic breathing and heart failure. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #59 was alert with a Brief Interview for Mental Status (BIMS) cognitive score of 15 out of 15. He/she required extensive assistance of two staff for moving around in bed, transferring in and out of bed and toileting. Extensive assistance of one staff was needed for personal hygiene and bathing. He/she was continent of urine and bowel but was not able to walk. The MDS also indicated that Resident #59 was at risk for pressure ulcers and had a Stage 2 (shallow open ulcer with a red or pink wound bed) skin injury to the sacrum (base of the spine area). Review of the current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident's current care plan dated 4/22/2021, indicated that Resident #59 had a stage 2 right buttock pressure ulcer. The goal of the plan of care was for the Resident to respond to the provided treatment evidenced by improved wound healing with less pain and drainage. The target date for this improvement was 7/14/2021. The following interventions were initiated 4/22/2021 for improved wound healing: - medicate the resident prior to dressing changes as needed. - observe the wound and surrounding skin for redness, swelling, severe pain, warmth, increased drainage and report accordingly. - record the amount, type and odor of drainage from the wound. - see the treatment record for dressing change orders. Review of the treatment sheets in the Resident's electronic medical record, indicated the weekly skin assessments were completed and signed off as such by the nurse on duty that shift. Review of the corresponding weekly skin checks in the resident's electronic medical record were not completed. There was no documentation on the weekly skin sheet for the following weeks: - 4/30/2021 - 5/7/2021 - 5/17/2021 - 5/29/2021 - 6/5/2021 - 6/12/2021 - 6/19/2021 - 6/26/2021 - 7/3/2021 During an interview 6/30/2021 at 11:27 A.M., Nurse #1 said she completes the weekly skin checks for Resident #59 on his/her shower days. She said she did not document the findings on the weekly skin check form in the Resident's electronic medical record. If the Resident had an injury, I report the finding to the DON. During an interview 7/1/2021 at 4:20 P.M., the DON said all weekly skin assessments are to be documented on the weekly skin check form in the resident's electronic medical record.

Based on record review, policy review and staff interview, the facility failed to 1.) Notify the physician or nurse practitioner in a timely manner of critically high laboratory results for 1 Resident (#56) who was subsequently hospitalized for 6 days for an acute kidney injury and [CONDITION(S)] and 2.) the facility failed to ensure an Admission/Readmission nursing assessment was completed and that treatment orders were obtained for a coccyx pressure ulcer for 1 Resident (#510) from a total sample of 34 residents. Findings include: 1. Resident #56 was admitted to the facility in September 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #56's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #56 had severe cognitive impairment and required extensive assistance with daily care. Review of Resident #56's medical record indicated that Resident #56 had routine laboratory work completed on 6/9/21. Review of the 6/9/21 laboratory results indicated the following: -Blood Urea [MEDICATION(S)] Level (BUN) (a blood test that reveals important information on how the kidneys and liver are working) of 83. Normal BUN values fall in the range of 7 to 20 mg/dl. -White Blood Cells (WBC) (a blood test that may indicate infection or inflammation) of 15.9, Normal WBC values fall in range of 4.8 to 10.8 Review of Resident #56's medical record indicated that on 6/9/21, the Nurse Practitioner (NP) evaluated Resident #56 for follow up of the abnormal laboratory results. The NP ordered to repeat the laboratory tests the next day 6/10/21. Review of Resident #56's 6/10/21 laboratory results indicated the following: -BUN remains critically high at 81 -WBC of 12.1 Review of Resident #56's NP note dated 6/10/21 indicated Resident #56 was evaluated and his/her critically high BUN and leukocyte (white blood cell) results were reviewed. Nursing was encouraged to push fluids. Resident #56 also received a tube feeding with flushes of 125 millimeters(ml) of water every 6 hours. Plan was to check the Basic Metabolic Panel (BMP) test, Complete Blood Count (CBC) with Differential, Urinalysis (UA)& Culture and Sensitivity (CS) in the morning and encouraged oral fluids of 1.5 liters per day. Review of Resident #56's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Basic Metabolic Panel (BMP) (a test that gives practitioner's information about fluid balance, levels of electrolytes, and how well the kidneys are working). -Complete Blood Count with Diff (CBC) (a test that indicates the counts of white blood cells, red blood cells, platelets, concentration of hemoglobin and hematocrit). -UA/C&S (Urinalysis and urine culture and sensitivity) Review of the laboratory results on 6/11/21 (reported to the facility at 8:28 P.M.) indicated the following: -BUN remains critically high at 81 -WBC remains high at 12.3 Urinalysis indicated the following: -Leukocytes Esterase (a screening test that detect at substance that suggests there are WBC in the urine), result indicates 1+. Normal values would be negative. -Bacteria, result indicate 1+. Normal values would be negative. -[MEDICATION(S)], result indicates occasional. Normal values would be negative. -[MEDICATION(S)], result indicates trace. Normal values would be negative. Review of Resident #56's nursing progress notes dated from 6/11/21 to 6/13/21 failed to indicate the Physician or NP was notified at all regarding Resident #56's critically high BUN results from 6/11/21 nor that Resident #56 would only take sips of fluids and was not meeting the 1.5 liters a day as ordered. Review of Resident #56's NP progress notes dated 6/14/21 indicated Resident #56's lab results from 6/11/21 were reviewed and the NP ordered to insert a peripheral intravenous (a small, short plastic catheter that is placed through the skin, into a vein to give fluids and medication to the body) and run 1 liter of normal saline at 70ml/hr. The IV team was unsuccessful in inserting the peripheral IV, unable to obtain a vein. Question of starting a mid-line (an 8-12 cm catheter inserted in upper arm with the tip located just below the armpit, it is used for medication or fluids that do not irritate veins). Plan is to continue to gain IV access. Resident #56 was transferred to hospital on 6/15/21 for further evaluation. Review of Resident #56's hospital report indicated the Resident was hospitalized from June 15, 2021 to June 21, 2021 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #56 was treated with intravenous (IV) hydration for acute kidney injury, IV [MEDICATION(S)] (an antibiotic medication used to treat infections), and administered blood products for low blood counts. During an interview on 7/2/21 at 12:30 P.M., via telephone, Nurse #3 told the surveyor that he worked on June 11, 2021 evening 3:00 P.M.-11:00 P.M. shift and June 12, 2021 night 11:00 P.M.-7:00 A.M. shift and was the nurse providing care for Resident #56. Nurse #3 told the surveyor that he was not aware of the critically high BUN results for Resident #56. He told the surveyor that Resident #56 was tolerating sips of fluids only during his shifts. During an interview on 7/2/21 at 12:55 P.M., via telephone, Nurse #4, told the surveyor that she worked the weekend of 6/12/21 and 6/13/21. She told the surveyor that she did not get any report from previous shifts or from the nursing supervisor about the critically high BUN results for Resident #56. She told the surveyor that the facility fax machine had been broken and that she had told someone about it. She said that she was not sure if that was the reason why they did not receive the result. During an interview with the Director of Nursing on 7/2/21 at 2:30 P.M., she told the surveyor that if the facility received any critical lab results, the expectation was for the nursing staff to notify the physician or nurse practitioner immediately. During an interview with the Nurse Practitioner (NP) on 7/6/21 at 10:30 A.M. via telephone, she told the surveyor that she was not notified by the nurses regarding Resident #56's critical lab results that came in on 6/11/21. 2. Review of the facility's policy titled Admission Assessment and Follow Up: Role of the nurse dated 2017, indicated the purpose is to gather information about the resident's physical, emotional, cognitive and psychosocial condition upon admission for the purposes of managing the resident, initiating the plan of care, and completing the required assessment instruments, including the MDS. Further review of the policy indicated to conduct a physical assessment and supplemental assessments including activity level, pain assessment, fall risk assessment, neurological assessment and skin assessment, functional assessment and behavioral assessment. Documentation; indicated the following information should be recorded in the resident's medical record: the date and time of the assessment, the name of the individual who performed the assessment, all relevant assessment data obtained, orders obtained from the physician, how the resident tolerated the assessment and the signature and title of the person recording the assessment. Review of the facility's policy titled Pressure Ulcers/Skin Breakdown, dated 2017, indicated the following: 1. Nursing staff and the attending physician will assess and document an individual's significant risk factors for developing pressure sores: for example, immobility, recent weight loss, and a history of pressure ulcers. 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudate or necrotic tissue b. Pain assessment c. Resident's mobility status d. Current treatments, including support surfaces and e. All active diagnoses. Resident #510 was admitted to the facility in December of 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #510 was no longer residing in the facility. Review of the comprehensive Minimum Data Set Assessment (MDS) with an assessment reference date of 1/13/21, indicated Resident #510 scored 15 out of 15 on the Brief Interview of Mental Status (BIMS), which indicated intact cognition. Further review of the MDS indicated Resident #510 required extensive assistance from staff for bed mobility, hygiene, bathing, was at risk for developing pressure ulcers and had a stage 2 pressure ulcer upon admission/reentry. Review of the medical record indicated that Resident #510 was readmitted to the facility in January, 2021. The medical record failed to have an Admission/Readmission Assessment including the required areas as indicated in the facility's policy. Review of a weekly skin check dated 1/6/20, indicated that Resident #510's skin was not clean and intact and indicated the following: cite: coccyx, type: pressure. The areas on the skin check for length, width, depth, and stage were blank. The area next to the description of the open area (include site, wound bed, wound exudate, surrounding tissue, wound edges, signs, and symptoms of infection) indicated, resident returned from the hospital with an open area on the coccyx area. Resident was referred to the wound doctor. The note did not include the required description of the open area. There was no evidence in the Resident's medical record to indicate any further Nursing Assessments were completed. Review of the physician's active and discontinued orders and Treatment Administration Record (TAR) dated, 1/2021 failed to indicate an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 7/2/21 11:56 A.M., Nurse #11 said he recalled Resident #510 returning from the hospital. He said he did not complete the Nursing Admission/Readmission assessment and that the Assistant Director of Nursing would assist with the nursing assessment, verify the orders from the hospital and obtain orders. Nurse #11 said he recalled Resident #510 having a protective dressing with foam from the hospital on his/her coccyx. He said it was open, red and was unable to determine the depth. He said the nurse practitioner would evaluate the wound the next day. Nurse #11 said any treatments for the care of a pressure ulcer are on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #510's medical record failed to indicate physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 7/6/21 at 11:02 A.M., the DON said on admission or readmission the nurse who does the skin check is to measure, describe any pressure ulcers, inform the nurse practitioner, and obtain treatment orders. The surveyor reviewed the medical record with the DON and the DON acknowledged that there was no order for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON also acknowledged that an Admission/Readmission nursing assessment was not conducted and part of the medical record. During an interview on 7/06/21 at 3:10 P.M., the Regional Clinical Nurse said an Admission/Readmission Nursing assessment was required to be conducted when Resident #510 was readmitted to the facility. Ref. to F686

Based on records reviewed and interviews for one of seven sampled residents (Resident #3), who was a Full Code (attempt resuscitation), the Facility failed to ensure staff immediately activated their emergency code protocol (code blue), when he/she was found unresponsive. On [DATE], Nurse #1 found Resident #3 unresponsive, failed to call a code blue, initiate cardiopulmonary resuscitation (CPR), and activate 911, because when he checked the medical record to determine his/her code status, there was a photocopy of a Medical Order for Life Sustaining Treatment (MOLST) form that indicated a Do Not Resuscitate (DNR) status, however, that form belonged to another resident (Resident #6) with the same first and last name as Resident #3, that had been placed in Resident #3's medical record in error. The error resulted in Resident #3 not receiving CPR immediately after he/she was found unresponsive. Resident #3 was pronounced dead at the Facility. Findings Include: Review of the Facility's Emergency Procedure-Cardiopulmonary Resuscitation Policy, dated 2017, indicated that Sudden [MEDICAL CONDITION] (SCA) is a loss of heart function due to abnormal heart rhythms (arrhythmias); [MEDICAL CONDITION] occurs soon after symptoms appear; the chances of surviving SCA may increase if CPR is initiated immediately upon collapse and early delivery of a shock with a defibrillator plus CPR within ,[DATE] minutes of collapse can further increase chances of survival. The Policy indicated that if a resident is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR shall initiate CPR unless it is known that a DNR order that specifically prohibits CPR exists or if there are obvious signs of irreversible death (e.g., rigor mortis-post mortem stiffening of the limbs). Review of the Massachusetts Board of Registration of Nursing Advisory Ruling on Nursing Practice, titled Nursing Practice and Cardiopulmonary Resuscitation, revised ,[DATE], indicated to guide the decision making of the nurse when a patient has been found unresponsive, in the context of practice in all settings where healthcare is delivered require initiating cardiopulmonary resuscitation when a patient has been found unresponsive and has not yet been declared dead by a provider authorized pursuant to M.G.L c. 46 9 except when the patient has a current valid DNR order/status. Review of the Police Report, dated [DATE] at 11:20 A.M., indicated that Police, Fire Department, and Emergency Medical Services (EMS) responded to a call about a patient who had low oxygen levels and difficulty breathing. The Report indicated that upon the arrival of EMS, they immediately began CPR and airway management, but stopped because Resident #3's jaw was locked and he/she had signs of irreversible signs of death that EMS felt indicated Resident #3 had been dead for several hours. The Report indicated that Resident #3 was cold to touch with gloved hands and paramedics deemed Resident #3 not viable at 11:31 A.M. Resident #3's [DIAGNOSES REDACTED]. toxins from the blood). Review of Resident #3's Hospital Discharge Summary, dated [DATE], indicated that his/her code status at discharge was a Full Code. Review of Resident #3's Physician Orders, dated ,[DATE], indicated that Resident #3's code status was a Full Code. Review of Resident #3's Medication Administration Record, [REDACTED]. Review of Resident #3's Advance Directives Care Plan, dated [DATE], indicated that Resident #3 was educated and understood what occurred when the heart stopped, wished to be resuscitated, and wanted to be a Full Code. Review of Resident #3's medical record indicated there was an original pink MOLST form that was blank. Review of Resident #3's Nurse Progress Note, dated [DATE], indicated that at 6:30 A.M. during rounds, Resident #3 was assessed to have no pulse, no breath sounds, and no blood pressure. The Note indicated that Nurse #1 notified the covering Physician, and an order was obtained for a Registered Nurse (RN) to complete a death pronouncement. Further review of Resident #3's Nurse Progress Note, dated [DATE], indicated that, at 8:15 A.M., Nurse #1 reported to the Nursing Supervisor that Resident #3 had passed away and that Resident #3's code status was Do Not Resuscitate (DNR). The Note also indicated that a MOLST form that belonged to Resident #6, (who had the same first and last name as Resident #3), was in Resident #3's medical record. The Note indicated that the Nursing Supervisor then called the Assistant Director of Nursing (ADON) at 10:30 A.M. to inform him that Resident #3's code status was supposed to be a Full Code. During an interview on [DATE] at 3:16 P.M., Nurse #1 said that on [DATE] at 6:30 A.M., when he went into Resident #3's room, he observed him/her laying on his/her back in bed, not breathing, had no pulses, his/her skin was pale, cold to the touch, and his/her arms and legs moved easily. Nurse #1 said he went directly to Resident #3's medical record and saw a white photocopy of a MOLST form that was completed and signed with Resident #3's name on it, and that the form indicated that his/her code status was DNR. Nurse #1 said that he confirmed that he could use a photocopy of the MOLST form with another nurse. Nurse #1 said he did not compare Resident #3's code status on the MOLST form to the physician's orders [REDACTED].#3's MOLST form. Nurse #1 said he did not check Resident #3's physician's orders [REDACTED]. Nurse #1 said had he known Resident #3 was a Full Code when he found him/her unresponsive at 6:30 A.M., he would have called an emergency code (code blue) and performed cardiopulmonary resuscitation (CPR) on Resident #3. Nurse #1 said he never imagined that the wrong MOLST form would have been in Resident #3's medical record. During an interview on [DATE] at 1:52 P.M., the Nursing Supervisor said that, at 8:15 A.M. on [DATE], Nurse #1 told her that Resident #3 had died , and that his/her code status was DNR. The Nursing Supervisor said that at 9:15 A.M. as she was preparing to complete the RN death pronouncement for Resident #3, she went through both Resident #3's and Resident #6's medical record because they had the same name. The Nursing Supervisor said that was when she discovered that the date of birth on the white photocopy MOLST form in Resident #3's medical record that indicated he/she was a DNR was not Resident #3's date of birth and said she determined that the form belonged to Resident #6 and that Resident #3 should have been a Full Code. The Nursing Supervisor said that after she discovered what happened, more than three and a half hours after Resident #3 was observed unresponsive, she called the Assistant Director of Nursing (ADON) and told him that they had messed up, that the wrong MOLST form was in Resident #3's medical record and that Resident #3 was a Full Code. The Nursing Supervisor said after speaking with the ADON they called 911 and began to attempt CPR on Resident #3. During an interview on [DATE] at 12:29 P.M., the Director of Nursing (DON) said she did not know how a photocopy of Resident #6's MOLST form got into Resident #3's medical record.

Based on records reviewed and interviews for one of seven sampled residents (Resident #3), who was a Full Code (attempt resuscitation), the Facility failed to ensure policies and procedures were developed, implemented, and staff were trained to ensure a complete and accurate medical record was maintained with residents that have the same or similar names to ensure their advanced directives were followed in accordance with their physician's orders [REDACTED].>On [DATE], Nurse #1 found Resident #3 unresponsive, went to Resident #3's medical record, noted a white photocopy of a Medical Order for Life Sustaining Treatment (MOLST) form that indicated he/she was a Do Not Resuscitate (DNR), however, that form was Resident #6's MOLST form, who had the same first and last name as Resident #3. Cardiopulmonary resuscitation (CPR) was not immediately initiated for Resident #3, who was a Full Code, and he/she was pronounced dead at the Facility. Findings Include: Resident #3 was admitted to the Facility in December of 2020 to the fifth floor and two weeks later was transferred to the fourth floor. Review of Resident #3's Physician Orders, dated ,[DATE], indicated that Resident #3's code status was a Full Code. Review of Resident #3's medical record indicated there was an original pink MOLST form that was blank. Resident #6 was admitted to the Facility in [DATE] to the fifth floor and remained on the fifth floor. Review of Resident #6's Physician Orders, dated ,[DATE], indicated that Resident #6's code status was DNR. Review of Resident #6's medical record indicated there was a completed and signed white photocopy of a MOLST form that indicated he/she was a DNR. Review of Resident #3's Nurse Progress Note, dated [DATE], indicated that a MOLST form that belonged to Resident #6, (who had the same first and last name as Resident #3), was in Resident #3's medical record. The Note indicated that the Nursing Supervisor then called the Assistant Director of Nursing (ADON) at 10:30 A.M. to inform him that Resident #3's code status was supposed to be a Full Code. During an interview on [DATE] at 3:16 P.M., Nurse #1 said that on [DATE] at 6:30 A.M., when he went into Resident #3's room, he observed him/her laying on his/her back in bed, not breathing, had no pulses, his/her skin was pale, cold to the touch, and his/her arms and legs moved easily. Nurse #1 said he went directly to Resident #3's medical record and saw a white photocopy of a MOLST form that was completed and signed with Resident #3's name on it, and that the form indicated that his/her code status was DNR. Nurse #1 said the form was not the usual pink color and said he was not sure if the white photocopy of the MOLST form was acceptable. Nurse #1 said he went to the fifth floor to ask another nurse about the form and said that they agreed that Resident #3 was a DNR. Nurse #1 said he went back a second time to the fifth floor and spoke to another nurse, Nurse #3, after doing a general search of Resident #3's name in the Electronic Health Record (EHR) because a different picture of a resident came up, not Resident #3. Nurse #1 said he wanted to be sure he had the correct medical record. Nurse #1 said both he and Nurse #3 determined that he had the correct medical record. Nurse #1 said he did not compare Resident #3's code status on the MOLST form to the physician's orders [REDACTED].#3's MOLST form. Nurse #1 said before he left the Facility, after his shift on [DATE], the Nursing Supervisor told him that the date of birth on the MOLST form did not match the date of birth on the face sheet that was in Resident #3's medical record. Nurse #1 said he was not aware that the wrong MOLST form was in Resident #3's medical record. Nurse #1 said had he known Resident #3 was a Full Code when he found him/her unresponsive at 6:30 A.M., he would have called an emergency code (code blue) and performed cardiopulmonary resuscitation (CPR) on Resident #3. Nurse #1 said he never imagined that the wrong MOLST form would have been in Resident #3's medical record. Nurse #1 said he was not aware of any Facility Policy related to alerting staff of residents with the same or similar names. During an interview on [DATE] at 12:41 P.M., Nurse #3 said that on [DATE], Nurse #1 came up to the fifth floor where he was working to verify if he had Resident #3's correct medical record. Nurse #3 said they determined that Nurse #1 had the correct medical record. Nurse #3 said there were no name alerts on either Resident #3 or Resident #6's medical record. During an interview on [DATE] at 1:52 P.M., the Nursing Supervisor said that, at 8:15 A.M. on [DATE], Nurse #1 told her that Resident #3 had died , and that his/her code status was DNR. The Nursing Supervisor said Nurse #1 told her that he had gone upstairs to the fifth floor regarding something to do with a wrong medical record but said that he did have the right medical record, and she said that she did not understand what he meant by that. The Nursing Supervisor said she then went to the fifth floor to verify with Nurse #3 to ensure that Nurse #1 did have the correct medical record for Resident #3 and said that was when she became aware that there was another resident (Resident #6) with the same first and last name as Resident #3. The Nursing Supervisor said that at 9:15 A.M. as she was preparing to complete the RN death pronouncement for Resident #3, she went through both Resident #3's and Resident #6's medical record because they had the same name. The Nursing Supervisor said that was when she discovered that the date of birth on the white photocopy MOLST form in Resident #3's medical record that indicated he/she was a DNR was not Resident #3's date of birth and said she determined that the form belonged to Resident #6 and that Resident #3 should have been a Full Code. The Nursing Supervisor said as she went through Resident #3 and Resident #6's medical record and said that in addition to the incorrect photocopy of the MOLST form she also found Resident #6's Hospital Discharge Summary in Resident #3's medical record. The Nursing Supervisor said that after she discovered what happened, which was more than three and a half hours after Resident #3 was observed unresponsive, she called the Assistant Director of Nursing (ADON) and told him that they had messed up, that the wrong MOLST form was in Resident #3's medical record and that Resident #3 was a Full Code. During interviews on [DATE] at 10:27 A.M., on [DATE] at 9:51 A.M., on [DATE] at 11:15 A.M., and on [DATE] at 1:43 P.M., Nurse #4, Nurse #5, Nurse #6, and Nurse #7 all said they were not aware of any Facility Policy related to name alerts for residents with the same or similar names. During an interview on [DATE] at 12:29 P.M., the Director of Nursing (DON) said she did not know how a photocopy of Resident #6's MOLST form got into Resident #3's medical record. The DON said there were no name alert stickers on Resident #3 and Resident #6's medical records. Review of Resident #4 and Resident #5's medical record, who had the same last name, indicated there was no documentation to support that a name alert was placed on or in their medical records. During an interview on [DATE] at 1:37 P.M. and on [DATE] at 8:35 A.M., the DON said she was unsure why Resident #4 and Resident #5 did not have name alerts on their medical records and said that there was no Facility policy to alert staff for residents with same or similar names.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), the Facility failed to prevent Resident #1 from being abused on 4/30/17, when Nurse #1 pushed Resident #1 down into his/her chair forcefully, dug her fingernails into Resident #1's neck, scratched his/her face, and spat approximately 2 times into Resident #1's face. The Police Report, and the Surveillance videotape from the Facility, indicated that Nurse #1 forcibly pushed Resident #1 down into his/her chair, Nurse #1 spat in Resident #1's face, and Resident #1 was observed to have a long red mark on his/her face as a result. Although Resident #1 was unable to recall the incident to the Surveyor due to his/her cognitive impairment, the Reasonable Person Concept presumes that an unimpaired individual would experience pain and mental anguish from being pushed down into a chair, scratched on the face, and spat in the face. Findings include: The Facility's Abuse Prohibition Policy, dated 1/2/16, indicated that each resident had the right to be free from verbal, sexual, physical and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of their property. Further, every resident at the Facility would be treated with respect and dignity at all times. Resident #1's Minimum Data Set Assessment Form, completed 4/5/17, indicated that he/she had severe cognitive impairment and had a [DIAGNOSES REDACTED]. The Internal Investigation, dated 4/30/17, indicated that Resident #1 had a 6 centimeter laceration on his/her face, starting at the right lower lip and ending mid cheek above the laceration, with a circular reddened area of approximately 1 centimeter in diameter. The Surveyor interviewed the Administrator and the Director of Nurses (DON) at 9:40 A.M. on 6/9/17 and throughout the day. The Administrator and the DON identified Nurse #1 as the Nurse interacting with Resident #1 in the footage captured on the videotape by the Facility's surveillance camera. The Administrator and the DON said in the videotape footage they observed Nurse #1 push Resident #1 back into his/her chair and observed Nurse #1 lunge her body towards Resident #1. The Administrator and DON identified Certified Nurse Aide (CNA ) #1 and CNA #2 as the CNA's seen in the same videotape footage. On 6/9/17, the Surveyor reviewed the videotape recorded from a surveillance camera provided by the Administrator. The Administrator said although there was a time stamp difference, and the security system was not accurately displaying the current time, the date of 4/30/17 was accurate. The Time Stamp on the video at 9:12:00 on 4/30/17, indicated Nurse #1 forcibly pushed Resident #1 down into a chair in the hallway. The Time Stamp on the video at 9:12:13 on 4/30/17, indicated that Nurse #1 then quickly lunged her body directly at Resident #1 while he/she was sitting in the chair. The Police Report, dated 5/3/17, indicated that at 9:12:00 on 4/30/17, Nurse #1 forcibly pushed Resident #1 down into his/her chair, and at 9:12:13, Nurse #1 spat in Resident #1's face. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 11:40 A.M. on 6/9/17. CNA #1 said on the morning of 4/30/17 around 8:00 A.M., she observed Nurse #1 shove Resident #1 into his/her chair in the hallway, dig her long fingernails into Resident #1's neck, scratch Resident #1's face and and spit approximately 2 times into Resident #1's face. CNA #1 said Nurse #1 said, I can't believe it, Resident #1 spit in my mouth and on my face! or words to that effect. CNA #1 said when she observed Nurse #1 lunge towards Resident #1, that was when Nurse #1 spit approximately 2 times into Resident #1's face. CNA #1 said Nurse #1 told her (CNA #1) to tell everyone that she (Nurse #1) was shaving Resident #1 and that was how Resident #1 got a cut on his/her face. CNA #1 said Resident #1 looked at her with eyes that made her fell like Resident #1 wanted help. The Surveyor interviewed CNA #2 at 12:30 P.M. on 6/13/17. CNA #2 said she observed Nurse #1 grab Resident #1 by the shoulder and push Resident #1 forcibly into his/her chair in the hallway. CNA #1 and CNA #2 said that when they saw Resident #1 in the morning of 4/30/17 prior to the incident with Nurse #1, Resident #1 did not have any scratch marks on the right side of his/her face. The Surveyor interviewed the Nurse Supervisor at 3:19 P.M. on 6/13/17, and Police Officer #1 at 2:25 P.M. on 6/15/17. The DON, the Nurse Supervisor, Police Officer #1, CNA #1, and CNA #2 said they observed a scratch mark on the right side of Resident #1's face after the incident with Nurse #1. The DON, Nurse Supervisor, CNA #1, and CNA #2 said Nurse #1 told them that Resident #1 sustained the skin laceration on the right side of his/her face when she (Nurse #1) was shaving him/her. However, the DON, the Nurse Supervisor, Police Officer #1, CNA #1, and CNA #2 said they observed that Resident #1 had hair stubble on his/her face and he/she did not look shaved. Police Officer #1 said that Nurse #1 told her that she (Nurse #1) did not know how Resident #1 sustained the laceration on the right side of his/her face. Police Officer #1 said Nurse #1 told her that Resident #1 spat in her (Nurse #1's) face, she went to wash her face in the staff bathroom, and said when she returned, she (Nurse #1) observed a red mark on Resident #1's face. Police Officer #1 said, and the Police Report dated 4/30/17, indicated that Nurse #1 was being charged with Assault (a threat or attempt to inflict offensive physical contact or bodily harm on a person) and Battery (the crime or tort (wrongful act) of intentionally or recklessly causing offensive physical contact or bodily harm that was not consented to by the victim (Resident #1) on a person over 60 (years of age) with Injury. Nurse #1 declined to be interviewed and referred the Surveyor to speak to her lawyer. The Facility provided the Surveyor with a copy of Nurse #1's written statement which indicated that Resident #1 was very agitated and combative by spitting, scratching, punching nursing staff during care and was redirected with no effect and Resident #1 had red marks on the right side of his/her face. Although Nurse #1's written statement did not indicate that she pushed Resident #1 down into his/her chair forcefully, dug her fingernails into Resident #1's neck, scratched Resident #1's face, and spit approximately 2 times into Resident #1's face, the surveillance video, the Police Report, statements from CNA #1 and CNA #2 and interviews with Police Officer #1, CNA #1 and CNA #2 indicated that Nurse #1 did do these things to Resident #1. Although Resident #1 was unable to recall the incident to the Surveyor due to his/her cognitive impairment, the Reasonable Person Concept presumes that an unimpaired individual would experience pain and mental anguish from being pushed down into a chair, scratched on the face, and spat in the face.