Every finding on record at Westborough Healthcare

Based on observations, and interviews, the facility failed to maintain proper sanitation and food handling practices to prevent the outbreak of foodborne illness in the main facility kitchen.Specifically, the facility failed to ensure that the minimum wash temperature necessary was maintained per manufacturer's guidelines for the dish machine utilized for cleaning and sanitizing dishware for resident use in the main facility kitchen, when the low temperature dish machine was operating at registered temperatures below acceptable ranges of 120 degrees Fahrenheit (F) for the wash cycle. Findings include:Review of The Food Safe Pal, Dishwashing Temperature Guidelines, dated 10/29/2024, retrieved from https://foodsafepal.com/dishwashing-temperature-guidelines/ indicated the following:-Ensuring that the wash and rinse water of your dishwasher reach a certain minimum temperature is just as important as cooking food to the proper minimum internal temperature.-Just as bacteria and other pathogens can survive on food that's not cooked to its minimum internal temperature, they can also survive on dishes and utensils that aren't washed and rinsed at the proper temperatures.-The minimum wash and rinse temperature depends on the type and whether it uses heat or chemicals to sanitize.-Those that rely on heat are called high-temperature dishwashers, while those that rely on chemicals are called low-temperature dishwashers.-For dishwashers that use chemicals to sanitize, the wash and rinse cycles should reach at least 120 Fahrenheit [F} (49 Celsius [C]).-Dishwashers that rely on chemicals to sanitize should reach a minimum of 120 F (49 C). Review of the temperature log provided by the Food Service Director (FSD) for February 2026, indicated for Low Temperature Dish Machine Temperature Log:-Wash Temperature: 120 degrees F-Rinse Temperature: 120 degrees F-If levels are out of acceptable range, do not wash dishes and notify supervisor. On 2/19/26 from 11:30 A.M. through 12:15 P.M., the surveyor and the FSD observed the following during a walkthrough of the kitchen: -Dish machine was in operation and running.-Dietary Aide #1 was pre-rinsing and loading dirty dishware and meal trays into the dish racks to be washed.-Dish machine wash temperature fluctuated and did not reach above 120 degrees F.-Dish machine wash temperature was observed at 80 degrees FDuring an interview at the time, Dietary Aide #1 was unable to verbalize the temperature reading on the dishwashing machine. The FSD said that washing and rinsing dishes at 80 degrees F was an acceptable temperature because the dishwashing machine had chemical sanitizer in the water. -The FSD provided a chemical testing strip, (test strips for sanitizing solutions - used to measure the concentration of active sanitizing agents, ensuring effective sanitation in various settings), tested the water using the test strip, and demonstrated to the surveyor the test strip matched corresponding testing parameter, and informed the surveyor that the sanitizer was at an acceptable level. -The FSD said there was no concern with the dishwashing temperature remaining at 80 degrees F. -Dietary Aide #1 continued to wash dishes while the machine temperature remained at 80 degrees F. On 2/19/26 at 1:00 P.M., the FSD and the Administrator reported to the surveyor that a Pilot (something that controlled the temperature of the dishwasher) had shut down, and that the pilot light had been corrected, and therefore the temperature of the dishwashing machine was working. During an interview on 2/19/26 at 1:43 P.M., the Administrator said the dishwashing machine was operating at an acceptable temperature (80 degrees F) because there was an acceptable level of sanitizer in the dishwashing machine. During a follow-up observation and interview on 2/19/26 at 4:15 P.M., the surveyor and the FSD observed the following: -Dish machine was in operation and running.-Dietary Aide #1 was pre-rinsing and loading dirty dishware and meal trays into the dish racks to be washed.-Dish machine wash temperature was observed at 100 degrees F.During an interview at the time, the FSD said the facility will continue to monitor the Pilot to ensure proper functioning of the dish washing machine. Dietary Aide #1 continued to wash dishes while the machine temperature was at 100 degrees F. At time of survey exit, no further evidence was provided to the survey team that the low temperature dishwashing machine met the minimum required temperature of 120 degrees F.

Based on observations, record reviews, and interviews, the facility failed to adhere to infection control standards of practice to prevent contamination and the spread of infections for two Residents (#9 and #38) out of a total sample of 21 residents, and also failed to clean and sanitize hands before and after removing resident meal trays on one unit (2nd Floor) out of three units observed.Specifically, 1.For Resident #9 and Resident #38, the facility failed to ensure that appropriate Personal Protective Equipment (PPE: items such as gowns and gloves worn to prevent the spread of infection) was worn as required for the Resident on Enhanced Barrier Precautions (EBP), and that hand hygiene was performed before donning (putting on) PPE and during provision of activities of daily living (ADL - washing, bathing and grooming) care, placing both Residents at increased risk of contamination and the spread of infections.2. For the 2nd Floor unit, the facility failed to ensure staff performed appropriate hand hygiene between handling meal trays being passed in multiple resident rooms. Findings include: Review of the facility policy titled Infection Control Guidelines for Nursing Procedures, revised in July 2024 indicated:-Standard precautions are the minimum infection prevention practices that apply to all resident care, regardless of suspected or confirmed infection status of the resident, in any setting where health care is delivered. These practices are designed to both protect (Direct Health Care Personnel) DHCP and prevent DHCP from spreading infections among residents. Standard precautions include:-Hand hygiene-Use of PPE-Transmission-Based Precautions (TBP) will be used whenever measures more stringent than Standard Precautions are needed to prevent the spread of infection. Transmission Based Precautions will be initiated when there is reason to believe that a resident has a communicable infectious disease. Transmission Based Precautions may include Enhanced Barrier Precautions.-Enhanced Barrier Precautions (EBP) are infection control intervention designed to reduce transmission of multi-drug-resistant organisms (MDROs).-Use of gowns and gloves during high-contact resident care activities that may provide opportunities for transmission of MDROs via staff hands and clothing. Example of high contact resident activities are dressing, bathing, showering, transferring, changing linen, personal hygiene, toileting/brief change. Review of CDC Guideline for Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, revised 6/28/24, retrieved from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html indicated: -Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. -Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). -Enhanced Barrier Precautions expand the use of gowns and gloves beyond anticipated blood and body fluid exposures. They focus on use of gowns and gloves during high-contact resident care activities that have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. -Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). -Standard Precautions still apply while using Enhanced Barrier Precautions. For example, if splashes and sprays are anticipated during the high-contact care activity, face protection should be used in addition to the gown and gloves. 1a. Resident #9 was admitted to the facility in May 2023 with diagnoses including Unspecified Dementia. Review of Resident #9's February 2026 Physician's orders indicated:-Maintain Enhanced Barrier Precautions due to wounds every shift, start 5/5/25.-Enhanced Barrier Precaution every shift, start 8/8/25. On 2/19/26 at 7:45 A.M., the surveyor observed the following:-Signage posted at Resident #9's door indicated that the Resident was on EBP.-EBP signage indicated that anyone entering the room should clean their hands when entering or exiting the room and staff must wear gloves and a gown for high contact care activities. -CNA #3 entered Resident #9's room and pulled the curtain.-CNA #3 was not observed to wear a gown.-CNA #3 washed and dressed Resident #9.-CNA #3 exited Resident #9's room, without washing or sanitizing her hands.-CNA #3 returned to Resident #9's room with CNA #4.-CNA #3 and CNA #4 were observed transferring Resident #9 with a hydraulic lift from the Resident's bed to his/her chair.-CNA #5 entered Resident #9's room, removed the hydraulic lift and brought the lift to another resident's room. CNA #5 was not observed disinfecting the hydraulic lift before removing the equipment from Resident #9's room. 1b. Resident #38 was admitted to the facility in April 2025 with diagnoses including Moderate Protein-calorie Malnutrition and Gastrostomy Status. Review of Resident #38's February 2026 Physician's orders indicated:-Enhanced Barrier Precautions related to G-Tube and wounds, start 12/30/25. On 2/19/26 at 9:34 A.M., the surveyor observed the following:-Signage posted at Resident #38's door indicated the Resident was on EBP.-EBP signage indicated that anyone entering the room should clean their hands when entering or exiting the room and staff must wear gloves and a gown for high contact care activities.-CNA #6 entered Resident #38's room and pulled the curtain.-CNA #6 was not observed to wear a gown.-CNA #6 washed and dressed Resident #38.-CNA #6 exited Resident #38's room, without washing or sanitizing her hands. During an interview on 2/19/26 at 9:38 A.M., CNA #6 said she forgot to wear a gown. During an interview on 2/19/26 at 9:42 A.M., CNA #3 said she was not aware that Resident #9 was on precautions. CNA #3 said she did not observe the precautions sign at the Resident's door. CNA #3 said she should have worn a gown before providing ADL care to Resident #9, but she did not. During an interview on 2/19/26 at 9:59 A.M., CNA #4 said she was not aware Resident #9 was on precautions. CNA #4 said she did not observe the precautions sign at the Resident's door. CNA #4 said she should have worn a gown before assisting CNA #3 to transfer Resident #9 with the hydraulic lift, but she did not. During an interview on 2/19/26 at 10:03 A.M., CNA #5 said she was not aware Resident #9 was on precautions. CNA #5 said she did not observe the precautions sign at the door and should have disinfected the hydraulic lift before removing the lift out of Resident #9's room but she did not. During an interview on 2/25/26 at 2:00 P.M., the Director of Nursing (DON) said it was her expectation for staff to adhere to the infection prevention protocols when EBP signage is displayed at a Resident's door. 2. Review of the facility policy titled Handwashing/Hand Hygiene dated 4/2018 and last revised 7/2024 indicated: -All staff shall be trained and regularly in-serviced on the importance of hand hygiene in prevention of the transmission of healthcare-associated infections -Use an alcohol-based hand rub at least 62% alcohol; or alternatively soap and water for the following situations: -Before and after entering isolation precaution settings -Before and after assisting a resident with meals On 2/19/26 at 7:49 A.M. through 8:30 A.M., the surveyor observed the following on the 2nd Floor unit: -CNA #7 entered a resident room with a meal tray and set it up for the resident and then exited the room. CNA #7 was then observed going directly to the meal tray cart and taking another tray from the cart without performing hand hygiene. -CNA #7 entered a second resident room with a meal tray, set up the resident's meal tray and exited the room. CNA #7 went directly to the tray cart and took another tray from the cart without performing hand hygiene. -CNA #7 entered a third resident room, set up the meal tray for the resident and then exited the room. CNA #7 went directly to the meal cart and took another meal tray from the cart and entered a fourth resident room. CNA #7 set up the resident's meal tray and exited the room without performing hand hygiene. -CNA #7 moved the meal tray cart to another section of the unit, took a meal tray from the cart and delivered the tray to a resident room. CNA #7 exited the room and did not perform hand hygiene. CNA #7 went directly to the meal cart, took another tray from the cart and entered a resident room with contact precautions signs outside the room. CNA #7 set up the tray for the resident and did not perform hand hygiene when exiting the room before going to take another meal tray from the cart. During an interview on 2/19/26 at 8:15 A.M., with Nurse #3 translating for CNA #7, CNA #7 said she should be performing hand hygiene between every meal tray passed, but she was not. During an interview on 2/19/26 at 8:54 A.M., the Assistant Director of Nurses (ADON) who was also serving as the Infection Preventionist (IP) for the facility said the staff should be performing hand hygiene between every resident meal tray passed to decrease the risk for the spread of infection.

Based on observation, and interviews, the facility failed to ensure that drugs and biologicals were stored in accordance with State and Federal laws in one (2nd Floor) of two medication storage rooms reviewed. Specifically, the facility failed to ensure multi-dose vial medications were dated once opened according to manufacturer's guidelines in the 2nd Floor medication storage room. Findings include:Review of the facility policy titled Storage of Medications, established 4/2018, revised 1/2024, included but was not limited to:-the facility shall store drugs and biologicals in a safe, secure, and orderly manner.-the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs will be destroyed. On 2/19/26 at 9:56 A.M., the surveyor and Nurse #1 observed the 2nd Floor medication storage room. The surveyor observed two multi-dose vials of medication opened with no open or expiration date indicated. The medications observed were:-Tuberculin, Purified Protein Derivative Diluted/Aplisol 5TU (Tuberculin Units) for intradermal test, 1 ML (milliliter) (10 tests), Once entered, vial should be discarded after 30 days.Review of the Tuberculin, Purified Protein Derivative Diluted/Aplisol package insert indicated that the multi-dose vial should be dated when opened and discarded after 30 days.-Insulin Lispro 10 ML multi-dose vial, 100 units per ML.Review of the Insulin Lispro package insert indicated that the multi-dose vial once opened should be discarded after 28 days. During an interview on 2/19/26 at 10:00 A.M., Nurse #1 said she did not know when the two vials of medication had been opened. Nurse #1 said that the multi-dose vials of Tuberculin serum and Insulin Lispro should have been labeled when they were opened but the two vials had not been labeled. Nurse #1 said that once opened the vials would be good for 30 days but since she couldn't tell when these two vials had been opened, she would have to discard them. During an interview on 2/19/26 at 11:15 A.M., the Director of Nursing (DON) said all multi-dose medication vials should be labeled with an open date indicating when they were first opened.

Based on record review and interview, the facility failed to inform one Resident (#5) out of a total sample size of 21 residents in advance of the risks and benefits of treatments prior to implementation of treatment.Specifically for Resident #5 the facility failed to obtain signed informed consent for the use of two psychotropic medications prior to administration of the medications to the Resident. Findings include:Review of the Facility policy titled Psychotropic Medication, dated 4/2018 last revised 7/2023, indicated:-a written informed consent from the resident (or legally authorized individual in the case of resident incompetence) is required for administration of psychotropic medication. Resident #5 was admitted to the facility in July 2025 with diagnoses including Anxiety Disorder, Alcoholic Liver Disease, Chronic Kidney Disease Stage 4. Review of Resident #5's Minimum Data Sets (MDS) assessment dated [DATE] indicated:-taking anti-anxiety and antidepressant medications.-was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) exam score of 15 out of a possible 15. Review of Resident #5's Psychotropic Medication Care Plan initiated 7/29/25 and revised 8/20/25 indicated:-Resident is taking psychotropic medications-Interventions included: discuss with MD, family re (regarding) ongoing need for use of medication.-Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy, initiated 7/29/25. Review of Resident #5's February 2025 Physician's orders indicated the Resident had orders for the following medications:-Sertraline HCL (hydrochloride) oral tablet (Antidepressant medication) 100 mg (milligrams) (Sertraline HCL), give 2 tablets by mouth one time a day for depression, 2 TABS = 200 mg, start date 11/23/25.-Trazodone HCL oral tablet (Antidepressant medication) 50 mg (Trazadone HCL), give 2 tablets by mouth at bedtime for anxiety and insomnia, start date 11/22/25. Review of Resident #5's Medication Administration Records (MAR) for November 2025, December 2025, January 2026 and February 2026 indicated the Sertraline HCL and Trazodone were administered as ordered by the Provider. Review of Resident #5's medical record failed to indicate evidence that the Resident or Resident's Representative had signed a written informed consent for the Trazodone or the Sertraline medications. The facility was unable to provide any evidence a signed informed consent was completed for Resident #5 prior to administration of Sertraline and Trazodone. During an interview on 2/25/26 at 7:44 A.M., Nurse #4 said when a resident gets an order for a new psychotropic medication, a signed written consent was obtained from the resident or the resident's health care proxy, prior to administering the medication. Nurse #4 said consent should always be obtained prior to administering any new psychotropic medications. Nurse #4 was unable to find evidence a written signed consent for Resident #5's Sertraline and Trazodone had been completed but she said one should have been obtained prior to administering the medications. During an interview on 2/25/26 at 8:00 A.M., the Director of Nursing (DON) said written signed consent for psychotropic medications should be obtained prior to administering any new psychotropic medications. The DON said Resident #5 should have signed informed written consents prior to administering the Trazodone and Sertraline, but she had no evidence consent was obtained prior to administration of the medications.

Based on record review, observations, and interviews, the facility failed to provide appropriate access to the call light for one Resident (#16) out of a total sample of 21 residents.Specifically, for Resident #16, the facility staff failed to place the Resident's call light within his/her reach placing the Resident at risk for unmet needs. Findings include:Review of the facility policy titled Answering call lights, established 4/2018 revised 1/2024, included but was not limited to:-The purpose of this procedure is to respond to the resident's requests and needs-When the resident is in bed provide the call light within easy reach of the resident.-Answer the resident's call as soon as possible Resident #16 was admitted to the facility in January 2023 with diagnoses including Bell's Palsy, insomnia unspecified, anxiety disorder, Major Depressive Disorder, and Unspecified Dementia. Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #16:-was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 possible points. -has adequate hearing and vision-has clear speech-could understand others and could make himself/herself understood. On 2/18/26 at 8:14 A.M., the surveyor observed Resident #16 lying in bed and the Resident's call bell hanging on the wall on the far side of the bedside chair. During an interview at the time, the Resident said that he/she didn't have a call bell to call for staff. When the surveyor asked how he/she would get assistance from staff, the Resident said he/she would just get out of bed and go into the hallway and ask for help. On 2/18/26 at 3:45 P.M., the surveyor observed Resident #16 lying in bed. There was a bedside chair observed on the left side of the Resident's bed and on the far side of the chair the Resident's call bell was attached to the wall beyond his/her reach. When the surveyor asked, the Resident said that he/she was not aware of any call bell, and if he/she needed someone he/she would just go into the hallway and call for help. On 2/19/26 at 9:39 A.M., the surveyor observed Resident #16 lying in bed and the call bell was clipped to the wall, on the other side of a chair that was placed beside the Resident's bed. The call bell was observed beyond the Resident's reach. During an interview at the time, Resident #16 said that he/she never had a call bell. On 2/19/26 at 9:41 A.M., the surveyor and Nurse #2 observed Resident #16 lying in bed and the call bell hanging on the wall on the far side of the Resident's bedside chair. During an interview at the time, Nurse #2 said the call bell should always be accessible to the Resident and not hooked on the wall beyond the Resident's reach. Nurse #2 unhooked the call bell from the wall and made the call bell accessible to Resident #16. During an interview on 2/19/26 at 11:15 A.M., the Director of Nursing (DON) said that call bells should always be accessible to the Residents.

Based on observation, interview, and record review, the facility failed to provide independent activities of choice to meet the mental and psychosocial needs of one Resident (#13), out of a total sample of 21 residents.Specifically, for Resident #13, the facility failed to ensure the Resident was provided with preferred television access in his/her bedroom, after the Resident requested assistance to access television programming, resulting in negative psychosocial outcome of increased anxiety and depressed mood of the Resident. Findings include:Review of the Facility Assessment, last revised 2/5/26, indicated:- The facility adjusts its activities to accommodate all residents, ensuring everyone has access to meaningful and enjoyable programs.- The facility inquires about each resident's hobbies, interest, and the activities they enjoyed at home and tailors programs to their preferences. Review of the facility's policy titled Residents Rights, revised January 2024, indicated that the residents have a right to:-a dignified existence.-be supported by the facility in exercising his or her rights.-communication with and access to people and services, both inside and outside the facility.-equal access to quality care, regardless of source of payment. Resident #13 was admitted to the facility in September 2016 with diagnoses including Tracheostomy, Gastrostomy, Anxiety, Insomnia, Depression, and Post Traumatic Stress Disorder (PTSD). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #13:-was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15-reported stable mood with no symptoms of depression. Review of the Activity Assessment, dated 12/10/25, indicated the following for Resident #13:-Preference for self-directed activities.-preferred 1:1 room activity-Types of entertainment in the Resident's room - TV, Phone, Radio, and other reading materials. Review of Resident #13's Activity Care Plan, last revised 12/11/25, indicated:-Goal was for the Resident to express satisfaction with type of activities and level of activity per preferred daily routine.-Resident preferred to spend his/her leisure time in his/her room and does not attend activities regularly.-Resident was mostly reserved and did not participate in groups. Review of Resident #13's Psychosocial Well-Being Care Plan, last revised on 6/30/35, indicated:-has potential for alteration in psychosocial well-being/coping mechanisms related to diagnoses of depression, anxiety, PTSD, failure to thrive, initiated 3/15/20.-interventions include direct problems to those who can address them and honor Resident preferences and choices. During an interview on 2/20/26 at 7:03 A.M., Resident #13 said that television was his/her only source of entertainment and activity and that he/she preferred to watch cable news programing and movies in his/her room. The Resident further said there were no movies, news, or other TV channels available. Resident #13 said he/she reported the issue several times to staff members, including maintenance, for the past twenty-five days that he/she was unable to watch channels on the television, but no one had assisted him/her. Resident #13 said the lack of response had been giving [him/her] a lot of anxiety and it was destroying [his/her] mental health. Resident #13 also said he/she had been told that the facility was in the process of obtaining satellite services but that had not yet occurred. The Resident demonstrated to the surveyor on the television set in his/her room that the channels available were TURBO and Golf Channel, and all other channels were nonfunctional and showed static. During an interview on 2/20/26 at 8:15 A.M., the Administrator said he was aware of Resident #13's inability to obtain TV channels. The Administrator said the Ombudsman had reported Resident #13's concern to him about two weeks ago. The Administrator said he did not follow up with the Resident because the facility was in the process of acquiring satellite television. During an interview on 2/20/26 at 9:27 A.M., the Ombudsman said Resident #13 made her aware of his/her inability to watch TV and/or watch movies when she visited the Resident on 1/29/26, which was interfering with his/her mental health. The Ombudsman said she presented Resident #13's concerns to the Administrator on 1/29/26. During an interview on 2/20/26 at 10:44 A.M., the Administrator said he did not follow up with Resident #13 after the Ombudsman informed him of the Resident's concern. The Administrator said he should have followed up with Resident #13 and offered a resolution, but he did not.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure they maintained a complete and accurate medical record related to his/her Advanced Directives, when after Resident #1 was found unresponsive, without a pulse, nursing was unable to readily locate and identify his/her code status. Findings include: Review of the Facility's Policy, titled Advance Directives, dated 01/2024, indicated: - information about whether the resident has executed an advance directive shall be displayed in the medical record. Resident #1 was admitted to the Facility in August 2024, diagnoses included Cerebrovascular Accident (stroke) with Hemiplegia (paralysis on one side of the body), Chronic Atrial Fibrillation, Diabetes Mellitus and Dysphagia (difficulty swallowing). Review of Resident #1's Physician's Orders, dated March 2025, indicated his/her Advanced Directives/Code status, was not identified or documented. Review of the Nurse Practitioner Progress Note, dated 03/26/25, indicated Resident #1 was a Full Code. During a telephone interview on 04/10/25 at 10:56 A.M., Nurse #1 said after Resident #1 was found on 03/31/25, unresponsive and not breathing, she went to check his/her medical record for his/her code status. Nurse #1 said Resident #1 did not have a completed Medical Orders for Life-Sustaining Treatment (MOLST) form and when she checked his/her Physician's Orders and Medical Record, she could not find his/her code status and because he/she had been very sick, thought he/she was a Do Not Resuscitate (DNR). Nurse #1 said she obtains the information she needs to care for the residents assigned to her from their Physician's Orders. During an interview on 04/10/25 at 10:12 A.M., the Director of Social Services said Resident #1 entered their facility from the hospital without a MOLST and until one was completed, that he/she was considered a Full Code. The Director of Social Services said the facility was working on Resident #1's MOLST form and were waiting for his/her Health Care Agent's signature. . During an interview on 04/10/25 at 12:51 P.M., the Assistant Director of Nursing (ADON) said Resident #1 entered the facility without a MOLST and that residents are considered a Full code until their MOLST form is completed. The ADON said the Physician's Orders should have identified Resident #1's code status and in this case it did not. During an interview on 04/10/25 at 1:14 P.M., the Director of Nursing (DON) said the facility discovered during their investigation into the events on 03/31/25, and determined that the Resident's Code status was not prominently displayed in Resident #1's Medical Record and were also not identified in the Physician's Orders. On 04/10/25, the Facility presented the Surveyor with a Plan of Correction that addressed the areas of concern identified in this survey; the Plan of Correction provided is as follows: A. Resident #1 no longer resides at the facility. B. On 3/31/25, a Facility wide audit was initiated by the Nursing Administration on all residents' Electronic Medical Records (EMR) to ensure a code status order was present and any records found without a code status order were corrected immediately. C. Audits, related to Code Status/Advanced Directives, will be conducted by the DON or designee weekly for four weeks, to ensure compliance with code status and physician orders. D. On 03/31/25, a Facility-wide audit was initiated by the Nursing Administration to ensure that residents with a MOLST and Code status orders in the EMR matched Social Service Records and any discrepancies discovered were corrected immediately. E. The Director of Nursing or designee will review all new admission orders the next day to ensure a Physician's Order for Code status has been entered in the EMR, and reviews will be conducted for four weeks. F. On 3/31/25, education of licensed Nursing and Certified Nurse Aides (CNA) staff was initiated by the ADON on the Code Blue Policy, which included location of MOLST form and/or Code Status in EMR. G. Code Blue drills were conducted by the ADON daily on various shifts for reinforcement of the education provided for seven days and were continued at unannounced intervals on all shifts for four weeks and results will be reported at the next QAPI meeting. H. On 04/01/25, a Quality Assurance Performance Improvement (QAPI) meeting was conducted, concern areas discussed included immediate response and ongoing monitoring plan to sustain compliance with MOLST and MD orders for Advanced Directives, and results of the Audits. I. On 04/04/25, the Facility completed the Education of all licensed nursing staff on the correct process for Advanced Directive Order Entry in Point Click Care (PCC) to ensure data entry/code status shows on Resident's header in PCC. J. The Director of Nursing and/or Designee are responsible for overall compliance.

Based on observation, and interview, the facility failed to adhere to safe food practices to prevent contamination of food and beverage items intended for resident consumption in the facility's main kitchen. Specifically, the facility failed to implement safe food practices in the main kitchen relative to: -discarding food that was spoiled. -labeling/dating, storage guidelines. -maintaining the facility kitchen in a clean, sanitary, and free of dust and debris manner. Findings include: Review of the facility policy titled Food and Supply Storage Department: Dietary and Hospitality, last revised 6/2018, included the following: -Refrigerated TCS Foods (Time/Temperature Control for Safety- are perishable items that require specific time and temperature controls to limit bacterial growth and reduce risk of foodborne illness, i.e. meat, eggs, dairy products, cut fruits and vegetables) -ready to eat foods prepared on site that is held longer than 24 hours should be properly labeled and dated with the common name, the preparation date (day 1) and use by date (maximum of 7 days .) -food products that are opened and not completely used: transferred from its original package to another storage container; or prepared at the facility and stored should be labeled as to its contents and used by dates. -Discard food that exceeds their use-by date or expiration date, is damaged, is spoiled, has the time and the temperature danger zone requirements, or incorrectly stored such that it is unsafe, or its safety is uncertain. Review of the Food and Drug Administration (FDA) Food Code, dated January 2023, included the following: -Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. During an initial walk-through of the facility kitchen on 11/12/24 at 7:18 A.M., the surveyor and Dietary Staff #1 observed the following: >the walk-in Refrigerator: -a large box of cucumbers and lemons that were covered in mold -an unlabeled and undated metal container of a brown sauce covered in mold -an unlabeled and undated metal container with white cooked meat -an unlabeled tray of individual containers of a white creamy substance >the reach-in Refrigerators: -six trays of unlabeled and undated individual containers of pudding in refrigerator #1 -two unlabeled and undated large containers of juice -four trays of unlabeled and undated individual containers of pudding in refrigerator #2 -two trays of unlabeled and undated individual containers of fruit >dry storage area: -an opened and resealed devil's food cake mix, undated -an opened and resealed brownie mix, undated -an opened and resealed 10-pound bag of macaroni, undated -an opened and resealed 10-pound bag of penne, undated -an opened and resealed bag of breadcrumbs, undated -a delivery truck/cart with cleans cups covered in food debris and a splattered white substance that had brown flecks in it. -a container of six black bananas During an interview on 11/12/24 at 7:36 A.M., Dietary Staff #1 said that the spoiled food, and unlabeled and undated items should have been thrown away in the trash. Dietary Staff #1 also said that the items should have been labeled or dated and they had not been. During an interview on 11/12/24 at 11:40 A.M., the Food Service Director (FSD) said that the spoiled items should have been thrown away and they had not been. The FSD also said that all the unlabeled items and undated items should have been labeled and dated and they were not and should have been discarded. The FSD said that the delivery truck/cart should have been cleaned and it was not cleaned.

Based on record review, and interview, the facility failed to ensure that the required transfer documentation was completed and the required transfer documentation communicated the appropriate information to the receiving health care institution for five Residents (#64, #18, #39, #11 and #29), out of a total sample of 19 residents. Specifically, the facility failed to ensure that Residents #64, #18, #39, #11, and #29, were transferred to the hospital with important information relative to the Residents' medical histories and the reasons for transfer, putting the Residents at risk for complications and adverse events upon transfer to the hospital. Findings include: 1. Resident #64 was admitted to the facility in October 2023, with diagnoses of Benign Prostatic Hypertrophy (prostate gland enlargement that can cause urination difficulty), Retention of urine (a condition that makes it difficult to empty the bladder), and mild cognitive impairment (slight decline in mental abilities). Review of the Resident's clinical record included the following: -a nursing progress note that indicated on 9/25/24 the Resident was transferred to the hospital for evaluation of difficulty swallowing. -MDS (Minimum Data Set) discharge tracking record dated 9/25/24, indicated that the Resident was discharged from the facility, return anticipated. -MDS entry tracking record dated 10/9/24, indicating that the Resident had returned to the facility. -a nursing progress note dated 11/6/24, indicated a Brief Interview for Mental Status (BIMS) Evaluation was completed with a of 15 out of 15, indicating that the Resident was cognitively intact. Further review of the Resident's clinical record did not include any evidence that any discharge paperwork that included the Resident's Advanced Directives (legal documents that provide instructions for medical care and only go into effect if you are unable to communicate your own wishes), any specific instructions or precautions for ongoing care, required clinical documentation, and/or Provider (Physician/Medical Doctor) information was completed and communicated to the hospital for the transfer on 9/25/24. During an interview on 11/14/24 at 2:00 P.M., Social Worker (SW) #2 said that she was unable to provide any evidence that the facility had provided the required necessary information to the hospital on 9/25/24 when the Resident was transferred to the hospital. 51571 2. Resident #18 was admitted to the facility in September 2024, with diagnoses including Metabolic Encephalopathy (a change in how the brain works due to a chemical imbalance in the blood), Emphysema unspecified (a chronic lung condition where air is abnormally present in the lungs causing shortness of breath), Chronic Obstructive Pulmonary Disease with (acute) exacerbation (COPD: a chronic lung disease that causes obstructed airflow from the lungs and leads to respiratory problems including difficulty breathing, shortness of breath and wheezing, with an acute worsening of symptoms that lasts for several days), and dependence on supplemental oxygen. Review of Resident #18's Minimum Data Set (MDS) assessment dated [DATE] indicated that the Resident was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. Review of a Nursing Progress Note dated 9/21/24, indicated: -the Resident fell when attempting to utilize the commode next to the bed and hit their head. Resident was noted with increased confusion and was sent out to the emergency room (ER). Review of a MDS (Minimum Data Set) discharge tracking record dated 9/21/24, indicated that the Resident was discharged from the facility, return anticipated. Review of a MDS entry tracking record dated 9/27/24, indicated that Resident#18 had returned to the facility. Review of the Resident's clinical record did not provide any evidence of necessary medical transfer information being provided to the hospital when the Resident was transferred to the hospital on 9/21/24. During an interview on 11/18/24 at 11:33 A.M., SW #2 said that she was unable to provide any evidence that the required medical information was sent on 9/21/24, when the Resident was transferred to the hospital. 47901 3. Resident #39 was admitted to the facility in October 2023, with diagnoses including Chronic Respiratory Failure with Hypoxia (a condition that occurs when the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide from the body, identified with symptoms of trouble breathing and fatigue and need for supplemental oxygen), Chronic Kidney Disease (when the kidneys are damaged and cannot filter blood the way that it should) and Psychotic Disorder with Delusions (a mental disorder characterized by a fixed, or false conviction in something that is not real or shared by other people). Review of Resident #39's clinical record indicated the following: -a nursing progress note that indicated on 9/6/24, the Resident was transferred to the hospital after the Resident had expressed not feeling comfortable in the facility. -MDS discharge tracking record dated 9/6/24, indicated that the Resident was discharged from the facility with anticipated return. -a nursing progress noted that indicated on 9/7/24, that the Resident had been admitted with diagnoses of Shortness of Breath (uncomfortable feeling of not being able to breathe deeply or normally) and Congestive Heart Failure (CHF - caused when the heart is unable to pump blood effectively resulting in fluid build-up in the lungs, arms, feet and other organs). -MDS entry tracking record dated 9/10/24, indicating that the Resident had returned to the facility. -a nursing progress note dated 9/10/24, indicating that the Resident had returned to the facility from the hospital. Further review of Resident #39's clinical record did not include any evidence that any discharge paperwork with specific instructions for the care of the Resident was sent to the hospital on 9/6/24 by the facility. During an interview on 11/14/24 at 11:08 A.M., Corporate Nurse #1 said she was unable to provide evidence that the facility had provided the required necessary information to the hospital on 9/6/24 when Resident #39 was transferred to the hospital. 45429 4. Resident #11 was admitted to the facility in May 2019, with diagnoses including personal history of traumatic brain injury (a head injury causing damage to the brain by external force or mechanism) and muscle weakness. Review of Resident #11's Nursing Progress Note dated 10/20/24, indicated that the Resident had been transferred to the hospital after shaking in his/her wheelchair and falling to the ground. Further review of Resident #11's clinical record did not include any evidence that the following information was provided to the receiving hospital when the Resident was transferred: -Contact information of the Practitioner responsible for the care of the Resident. -Resident Representative information including contact information. -Advanced Directive information. -All special instructions or precautions for ongoing care, as appropriate. -All other necessary information, . as applicable, to ensure a safe and effective transition of care. During an interview on 11/13/24 at 12:47 P.M., SW #1 said she could not find any evidence that the transfer paperwork had been completed for Resident #11's hospital transfer or that the required paperwork had been sent to the receiving facility. SW #1 also said that the required paperwork should have been completed but it had not been. During an interview on 11/14/24 at 3:01 P.M., SW #2 said that she was unable to locate a transfer summary for Resident #11's hospital transfer after searching through the Resident's clinical record. 5. Resident #29 was admitted to the facility in September 2024, with diagnoses including chronic heart failure (when the heart is unable to pump blood as it should resulting in fluid buildup in the feet, arms, lungs and other organs) and atrial fibrillation (A-fib: irregular, rapid heartbeat that can lead to blood clots and other heart related complications). Review of the Resident #29's Nursing Progress Note dated 11/7/24 indicated that the Resident was transferred to the hospital for chest pain and difficulty breathing. Further review of Resident #29's clinical record did not include any evidence that the following information was provided to the receiving hospital when the Resident was transferred: -Contact information of the practitioner responsible for the care of the Resident. -Resident Representative information including contact information. -Advanced Directive information. -All special instructions or precautions for ongoing care, as appropriate. -All other necessary information, . as applicable, to ensure a safe and effective transition of care. During an interview on 11/18/24 at 9:09 A.M., the Director of Clinical Operations #2 said that the transfer paperwork for Resident #29 had not been completed by the nursing staff for the hospital transfer, that it should have been completed but it was not.

Based on record review, and interview, the facility failed to provide a Notice of Bed-Hold Policy at the time of transfer to a hospital or shortly thereafter for five Residents (#64, #18, #39, #11, and #29) and/or their Representatives, out of a total sample of 19 residents. Specifically, the facility staff failed to provide Resident's #64, #18, #39, #11, and #29) and/or their Representatives with written notification relative to Bed-Holds when the Residents were transferred from the facility to the hospital and were expected to return to the facility. Findings include: Review of the facility policy titled Bed Holds/Returns, dated 11/2017 and revised 11/2024, included that prior to transfers out of the facility, residents or resident representatives will be informed in writing of the bed-hold and return policy. 1. Resident #64 was admitted to the facility in October 2023. Review of the Resident's clinical record included the following: -MDS (Minimum Data Set) discharge tracking record dated 8/20/24, indicated that the Resident was discharged from the facility, return anticipated. -MDS entry tracking record dated 8/27/24, indicating that the Resident had returned to the facility. Further review of the Resident's clinical record did not include any evidence that the Resident or their Representative was provided with a written Bed-Hold notice, upon the Resident's transfer to the hospital on 8/20/24. During an interview on 11/14/24 at 2:00 P.M., Social Worker (SW) #2 said that she was unable to provide any evidence that the facility provided the required Bed-Hold information to the Resident and/or their Representative when the Resident was transferred and admitted to the hospital on 8/20/24. 51571 2. Resident #18 was admitted to the facility in September 2024. Review of the Resident's clinical record included the following: -review of the Resident's MDS Assessment, dated 9/21/24, indicated that the Resident was transferred to the hospital from the facility, return anticipated. -Resident #18 returned to the facility on [DATE]. Review of the Resident's clinical record indicated no documented evidence that Bed-Hold information was provided to the Resident and/or their Representative when he/she was transferred to the hospital on 9/21/24. During an interview on 11/18/24 at 11:33 A.M., SW #2 said she was unable to provide any evidence that the Resident and/or their Representative was provided with information relative to Bed-Hold notices when the Resident was transferred to the hospital on 9/21/24. 47901 3. Resident #39 was admitted to the facility in October 2023. Review of Resident #39's clinical record indicated the following: -MDS discharge tracking record dated 9/6/24, indicated that the Resident was discharged from the facility with anticipated return. -MDS entry tracking record dated 9/10/24, indicating that the Resident had returned to the facility. Further review of Resident #39 clinical record did not include any evidence that the Resident and/or their Representative was provided with a written Bed-Hold notice, upon the Resident's transfer to the hospital on 9/6/24. During an interview on 11/14/24 at 11:08 A.M., Corporate Nurse #1 said she was unable to provide evidence that the facility had provided the required Bed-Hold information to the Resident and/or their Representative when the Resident was transferred and admitted to the hospital on 9/6/24. 45429 4. Resident #11 was admitted to the facility in May 2019. Review of Resident #11's Nursing Progress Note dated 10/20/24, indicated that the Resident had been transferred to the hospital. Further review of the Medical Record indicated no evidence the Resident and/or Resident Representative received a Notice of Bed-Hold Policy when he/she was hospitalized on [DATE]. During an interview on 11/13/24 at 12:47 P.M., SW #1 said that she could not find any evidence that the Bed-Hold paperwork had been completed for Resident #11's hospital transfer. SW #1 also said that the Bed-Hold paperwork should have been completed but it had not been. During an interview on 11/14/24 at 3:01 P.M., SW #2 said that she was unable to locate the Bed- Hold policy for Resident #11's hospital transfer after searching through the Resident's clinical record. 5. Resident #29 was admitted to the facility in September 2024. Review of the Resident #29's Nursing Progress Note dated 11/7/24, indicated that the Resident was transferred to the hospital. Further review of the medical record indicated no evidence the Resident and/or their Resident Representative received a Notice of Bed-Hold Policy when he/she was hospitalized on [DATE]. During an interview of 11/18/24 at 9:09 A.M., the Director of Clinical Operations #2 said that the Bed-Hold paperwork for Resident #29 had not been completed by the nursing staff for the hospital transfer, that it should have been completed but it was not.

Based on observation, interview, and record review, the facility failed to provide respiratory care and services consistent with professional standards of practice for three Residents (#18, #10 and #13), out of a total sample of 19 Residents. Specifically, the facility failed to: 1. For Resident #18, obtain Physician's orders for oxygen administration or the maintenance of oxygen and respiratory equipment. 2. For Resident #10, and Resident #13, maintain the Resident's oxygen concentrators (medical device that uses air in the atmosphere, filters it, and delivers concentrated oxygen) and filters in a clean, safe, functioning manner. Findings include: Review of facility policy titled Oxygen Administration, dated 11/2012, and reviewed 1/2024, indicated the following: The purpose of this procedure is to provide guidelines for safe oxygen administration: -Verify that there is a physician's order in place. -Review the Physician's order or facility protocol for oxygen administration. -Assemble the equipment and supplies as needed. -Vital signs if applicable -Lung sounds if applicable -Oxygen saturation, if applicable -Store the tubing in a plastic bag as able, marked with date -After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record as warranted: >The date and time of administration. >The name and title of the individual who administered. >The rate of oxygen flow, route. Review of the AARC (American Association for Respiratory Care) Clinical Practice Guideline, updated 2014: https://www.aarc.org/wp-content/uploads/2014/08/08.07.1063.pdf indicated the following: -All oxygen must be prescribed and dispensed in accordance with federal, state, and local laws and regulations. -Oxygen is a medical gas and should only be dispensed in accordance with all federal, state, and local laws and regulations. -Undesirable results or events may result from noncompliance with Physicians' orders or inadequate instruction for oxygen therapy. -Initial and ongoing patient clinical assessment of oxygen patients should be performed by licensed and/or credentialed respiratory therapists. -There is a potential in some spontaneously breathing hypoxemic patients with hypercapnia and chronic obstructive pulmonary disease that oxygen administration may lead to an increase in partial pressure of carbon dioxide (PaCO2). -Care plans should be developed at the initiation of oxygen therapy based on the needs of the individual patient and updated as necessary. Equipment maintenance and supervision indicated the following: -All oxygen delivery equipment should be checked at least once daily -Facets to be assessed include proper function of the equipment, prescribed flowrates, remaining liquid or compressed gas content, and backup supply. 1. Resident #18 was admitted to the facility in September 2024, with diagnoses including Emphysema unspecified (a chronic lung condition where air is abnormally present in the lungs causing shortness of breath), Chronic Obstructive Pulmonary Disease with (acute) exacerbation (COPD: a chronic lung disease that causes obstructed airflow from the lungs and leads to respiratory problems including difficulty breathing, shortness of breath and wheezing, with an acute worsening of symptoms that lasts for several days), and dependence on supplemental oxygen. Review of Minimum Data Set (MDS) Assessment, dated 9/12/24, indicated Resident #18: -was moderately cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. -had been receiving oxygen therapy during the reference period. Review of Resident #18's October 2024, and November 2024, Physician orders did not indicate any orders for oxygen administration or the care and services of oxygen and respiratory equipment. Further review of Resident #18's hospital discharge summary dated 9/27/24, indicated the Resident had a diagnosis of COPD and was receiving on 3- 4 LPM (liters per minute: the flow rate) home O2 (oxygen). Review of Resident #18's Nursing Progress Notes indicated the following: -9/6/24: 4 LPM of O2 via NC (nasal cannula: thin flexible tube that provides supplemental oxygen through the nose via nasal prongs) in use. -9/12/24: SpO2 (oxygen saturation: measure of oxygen in the blood as a percentage of the maximum oxygen the blood could carry) - 96% on 2 LPM of O2 -9/18/24: SpO2 - 96% on 2 LPM of O2. -11/3/24 at 7:13 A.M.: O2 was utilized during the shift -11/5/24: the Resident was complaining of discomfort to his/her nose with the O2 -11/10/24: 2 LPM of O2 at bedtime (HS) The surveyor observed Resident #18 lying in bed with oxygen being administered by nasal cannula set at 2 LPM via a stationary oxygen concentrator on the following dates: -On 11/12/24 at 9:06 A.M. -On 11/13/24 at 7:46 A.M. The surveyor observed that the oxygen tubing in use by the Resident was not labeled with a date. The surveyor further observed a portable oxygen concentrator laying on the floor with the oxygen tubing and nasal cannula attached to the portable concentrator also laying on the floor and not labeled or dated. During an interview and observation on 11/13/24 at 3:09 P.M., Nurse #3 said she was assigned to provide care for Resident #18. The surveyor observed Nurse #3 pick up the oxygen tubing attached to the stationary concentrator and administering oxygen to the Resident, from the Resident's bed and the tubing was dated 11/12/24, on two different sections of the oxygen tubing. The surveyor and Nurse #3 observed the portable oxygen concentrator and the attached oxygen tubing and nasal cannula laying on the floor of the Resident's room and was not dated or labeled. Nurse #3 said that the oxygen tubing should not laying on the floor. During an interview on 11/13/24 at 3:15 P.M., the Resident said that he/she used his/her portable oxygen concentrator and tubing that morning to go to the Day Room. The Resident said that the tubing for the portable concentrator was his/hers from home and had not been changed since his/her admission to the facility. The Resident said that the oxygen tubing on the stationary concentrator was changed last night. During an interview on 11/13/24 at 3:18 P.M., the Unit Manager (UM) #1 said that she believed that the Resident had their oxygen ordered on an as needed basis (PRN - pro re nata) and that the Resident usually used oxygen at night. UM #1 also said that there was usually an order set put in place upon admission for all residents who utilize oxygen. UM #1 also said she was not in the facility when Resident #18 was readmitted but remembered seeing Resident #18 being readmitted with oxygen and saw the Resident utilizing oxygen when he/she was readmitted . Further review of the medical record did not indicate an order set for oxygen ordered for Resident #18. During an interview on 11/14/24 at 11:18 A.M., the Director of Nursing (DON) said when the Resident was admitted to the facility the first time, the Resident was using oxygen and then left the facility. The DON said that the Resident has been in and out of the facility many times, and did not have oxygen orders when he/she was readmitted but should have orders for oxygen administration put in place. 50320 2a. Resident #10 was admitted to the facility in December 2023, with diagnoses including Morbid Obesity (when the person's weight is found to be more than 80 - 100 pounds above the individual's ideal body weight), Congestive Heart Failure (CHF- caused when the heart is unable to pump blood effectively resulting in fluid build-up in the lungs, arms, feet and other organs), and Chronic Obstructive Pulmonary Disease ( COPD: chronic lung disease that causes obstructed airflow from the lungs and leads to respiratory problems including difficulty breathing, shortness of breath and wheezing). Review of the Minimum Data Set (MDS) Assessment, completed 9/12/24, indicated Resident #10: -was receiving Oxygen therapy -had no instances of rejection of care. -had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 2 out of a possible 15 points. Review of Resident #10's care plan initiated 12/11/23 and last revised 11/3/24, indicated the Resident had altered respiratory status/difficulty breathing related to obesity and diagnoses of COPD. Care plan goals included: -maintain the Resident's Pulse Oximetry (SpO2) above 90% -the Resident will maintain a normal breathing pattern as evidenced by normal respirations, normal skin color and regular respiratory pattern. -Interventions included to administer medications as ordered and monitor for signs and symptoms of respiratory distress. Review of the Resident's November 2024 Physician's orders indicated: -Wipe down (oxygen) concentrator and clean filter weekly, every night shift every Sunday, initiated 2/15/24. -Oxygen at 0-3 liters per minute via nasal cannula, continuous, to maintain SpO2 88 - 92%, initiated 3/5/24. Review of Resident #10's November 2024 Treatment Administration Record (TAR) indicated the oxygen concentrator, and filter had been signed off as being cleaned on 11/3/24 and 11/10/24. On 11/12/24 8:51 A.M., the surveyor observed the filters on either side of the oxygen concentrator to be coated in dust. The surveyor also observed that the oxygen concentrator had a layer of dust at the base and the wheels. During an interview on 11/14/24 3:45 P.M., the Resident said he/she could not recall the staff ever cleaning his/her oxygen concentrator. During an interview on 11/14/24 3:46 P.M., Nurse #6 said she was responsible for cleaning Resident #10's oxygen concentrator the last two Sundays and that she signed the TAR that cleaning was completed on 11/3/24 and 11/10/24. Nurse #6 said she takes the filter out and cleans the filter and changes and dates the oxygen tubing during the cleaning process. When the surveyor asked Nurse #6 her process for cleaning the concentrator filter, Nurse #6 was initially unable to locate the filters on the oxygen concentrator. When the surveyor pointed out the filters that were observed, Nurse #6 demonstrated how she cleaned the filters by removing them from the concentrator and brushing and picking the dust off the filters and into the trash barrel. When the surveyor asked if Nurse #6 felt the filter was clean enough after completing the cleaning she demonstrated, she said no, the filters should be cleaned more thoroughly. 2b. Resident #13 was admitted to the facility in January 2019, with diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure (a condition that occurs when the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide from the body, identified with symptoms of trouble breathing and fatigue) and Dyspnea (difficult labored breathing or shortness of breath). Review of the Resident's MDS Assessment, completed 10/14/24, indicated: -Resident #13 was cognitively intact as evidenced by a BIMS score of 15 out of a possible 15. -Resident #13 was receiving oxygen therapy. -Resident #13 had no instances of rejection of care. Review of Resident #13's care plan initiated on 1/8/19 and revised 11/1/24, indicated: -the Resident had a focus area of respiratory alteration in gas exchange related to COPD, Dyspnea, and Respiratory Failure with hypoxia, and obstructive sleep apnea (a condition where sleep is interrupted by abnormal breathing). -interventions including administering oxygen per Physician's order. Review of Resident #13's November 2024 Physician's orders indicated: -Wipe down (oxygen) concentrator and clean filter weekly every night shift, every Sunday for infection control, initiated 2/14/24. -Oxygen from 1-3 liters to maintain oxygen saturations at 90% or above via nasal cannula. Titrate oxygen from 5-15 liters via non-rebreather or simple mask to maintain oxygen saturation at 90% if cannot maintain (oxygen saturation)send to emergency department for further evaluation, initiated 5/9/24. Review of Resident #13's November 2024 TAR indicated the oxygen concentrator, and filter had been cleaned on 11/3/24 and 11/10/24 by Nurse #6. On 11/12/24 at 9:01 A.M., the surveyor observed that Resident #13's oxygen concentrator had copious amounts of dust and dark gray smudges on the front and back panels of the device as well as the bottom and around the wheels. On 11/13/24 at 8:14 A.M., the surveyor observed the Resident's oxygen concentrator to have dust and a sticky film with stuck dirt and debris on the bottom and back, and dark gray stains, splatter, and smudges on the front and back of the device. On 11/13/24 at 12:32 P.M., the surveyor and Unit Manager (UM) #1 observed Resident #10 and Resident #13's oxygen concentrators. UM #1 said the oxygen concentrators and filters needed to be cleaned and it was embarrassing that they were not cleaned. UM #1 said the oxygen concentrators should be cleaned for infection control to keep bacteria from growing on the machine and the Resident breathing in the bacteria and causing an infection. UM #1 said the Nurse on duty was responsible for cleaning the machines per the schedule established by the Physician's order or as needed (PRN). UM #1 said if the Nurses were unable to clean the oxygen concentrators and filters, the Director of Nursing (DON) should be notified. During an interview on 11/14/24 at 3:57 P.M., the DON said the procedure for cleaning the oxygen concentrators and filters was to wipe the concentrators down with disinfecting wipes on the day the Physician's order specifies. The DON said the Nurses should be removing the filters and washing with water and allowing them to dry and then be put back on the concentrator. The DON said if the cleaning was not done, it should be passed on to the next Nurse to complete. The DON said there should be no dust or debris on the filters or on the Resident's concentrators.

Based on record review, and interview, the facility failed to post the required nurse staffing information daily. Specifically, the facility failed to: -post the total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurses (RN), Licensed Practical Nurses (LPN) or Licensed Vocational Nurses (LVN), and Certified Nurses Aides (CNA). -maintain a copy of the staffing records for 18 months as required. Findings include: During the facility survey, the surveyor observed the nurse staffing information was posted in the front lobby at the elevator on the following days: -11/12/24 -11/13/24 -11/14/24 -11/15/24 -11/18/24 The surveyor observed that the nurse staffing postings did not include the total number of hours and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: RNs, LPNs, LVNs, and CNAs. During an interview on 11/18/24 at 8:03 A.M., the Director of Clinical Operations (DCO) #2 said there was no facility policy for posting staffing. During an interview on 11/18/24 at 8:10 A.M., the facility Scheduler said she posts the schedule for the day in the lobby and the schedule was not posted anywhere else in the facility. The Scheduler said she did not know she was supposed to post the actual and total number of hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. During an interview on 11/18/24 at 8:48 A.M., the Administrator said he was unaware that the actual and total number of hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift needed to be on the staff posting. The Administrator also said he was unaware the staff posting needed to be kept on file for 18 months. The Administrator said he only had postings for 11/15/24, 11/16/24, and 11/17/24, available for review. The Administrator said the staff postings were thrown away after a few days have gone by.

Based on observation, record review, and interview, the facility failed to provide care and services according to professional standards of practice pertaining to an indwelling urinary catheter (a flexible tube inserted into the urethra to the bladder to drain urine outside of the body) for one Resident (#64) of two applicable residents, out of a total sample of 19 residents. Specifically, the facility failed to obtain Physician's orders, develop a plan of care, maintain and/or monitor Resident #64's indwelling urinary catheter. Findings include: Resident #64 was admitted to the facility in October 2023, with diagnoses including benign prostatic hypertrophy (prostate gland enlargement that can cause urination difficulty), retention of urine (condition that occurs when a person is unable to empty their bladder completely or partially of urine), and mild cognitive impairment (slight decline in mental abilities). Review of the Resident's clinical record included a Nursing Evaluation of the bladder completed on 10/10/24 which indicated that the Resident had a urinary catheter in place. Review of Resident #64's Minimum Data Set (MDS) assessment dated [DATE], indicated that the Resident had an indwelling urinary catheter and was diagnosed with obstructive uropathy (a structural or functional hindrance of normal urine flow). Review of the Resident's clinical record included a Nursing Progress Note dated 11/6/24, which indicated a Brief Interview for Mental Status (BIMS) Evaluation was completed. The BIMS score was 15 out of 15 indicating that the Resident was cognitively intact. Review of the Resident's Care Plan last revised 11/10/24, did not include any goals or interventions for the care and maintenance of an indwelling urinary catheter. During an interview on 11/12/24 at 10:56 A.M., the Resident said that they had a urinary catheter in place, and there was a urine drainage bag strapped to their left leg to collect the urine. Resident #64 said that no one can see the drainage bag because it was beneath the leg of their pants. The Resident said he/she empty the urinary drainage bag his/herself into the toilet. Resident #64 said he/she did not remember the staff ever caring for his/her urinary catheter. Review of the Resident #64's Physician's orders as of 11/13/24, did not provide evidence of any orders for the care and maintenance of an indwelling urinary catheter. During an interview on 11/18/24 at 10:30 A.M., the Director of Clinical Relations #2 said that she was unable to provide any evidence that the facility staff had put any care and services in place for the care of Resident #64's indwelling urinary catheter. The Director of Clinical Relations #2 further said that the indwelling urinary catheter was identified on the MDS assessment dated [DATE], and the Nursing Evaluation dated 10/10/24, but no Physician's orders were obtained and no plan of care was put in place, but should have been.

Based on observation, and interview, the facility failed to provide privacy and confidentiality for one Resident (#26), out of a total sample of 19 residents. Specifically, for Resident #26, the facility staff failed to ensure that personal privacy of the Resident's own body was maintained while providing personal care when he/she was observed to be naked. Findings include: Review of the facility policy titled Resident's Rights; last revised January 2024 indicated: -a dignified existence (a life where on is treated with respect, has the autonomy to make choices about their life, valued for their worth, regardless of their circumstances, allowing them to fulfil their potential and live with a sense of self-respect and self-worth). -privacy and confidentiality. Resident #26 was admitted to the facility in June 2024, with diagnoses including Schizoaffective Disorder (a combination of Schizophrenia and mood disorders), Bipolar Disorder (a mental health condition that causes extreme mood swings that include emotional highs [mania or hypomania] and lows [depression]), Unspecified Psychosis (a group of symptoms that indicate a person has lost touch with reality: hallucinations, delusions, disordered thinking or speaking, unusual beliefs or thoughts), Major Depressive Disorder (symptoms lasting greater than two weeks of a persistently low or depressed mood and a loss of interest in activities that a person used to enjoy), and Cognitive Communication Deficit (difficulty with communication that is caused by an underlying impairment in cognition or how someone thinks). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #26: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) exam of score of 15 out of 15. -was dependent on staff for activities of daily living (ADLs) care (bathing, dressing, grooming). On 11/12/24 at 9:37 A.M., the surveyor was standing in Resident #26's doorway with an open room door and observed the Resident was lying in his/her bed naked and being washed by Certified Nurses Aide (CNA) #3. The surveyor observed that there were two other residents lying in their beds in the room. The surveyor further observed the two other residents were awake and could visualize Resident #26 being washed in his/her bed and naked because Resident #26's privacy curtain was not closed. On 11/12/24 at 9:42 A.M., the surveyor observed another resident walk in and out of Resident #26's room while the door remained opened. During an interview on 11/12/24 at 9:54 A.M., CNA #3 said he was not aware the door was open while he provided personal care to Resident #26. CNA #3 said he should have pulled the privacy curtain closed, but he did not. During an interview on 11/13/24 at 10:02 A.M., the Director of Nursing (DON) said staff were expected to provide privacy to the Resident during ADL care.

Based on observation, record review, and interview, the facility failed to ensure a clean, homelike environment on one unit (Spruce Unit) out of three resident care units. Specifically, the facility failed to maintain the environment in a clean and homelike manner when the source of lingering odors of stale urine and unclean body odors in the Spruce Unit hallway were not adequately addressed and resolved. Findings include: The surveyors observed the following on the Spruce Unit: -On 11/12/24 at 9:15 A.M., the hallway outside of the Day Room had a strong odor of stale urine and unclean body odor. -On 11/13/24 at 7:58 A.M., the hallway outside of the resident rooms had a strong odor of stale urine and unclean body odor. -On 11/14/24 at 9:22 A.M., the hallway outside of the Day room had a strong odor of stale urine and unclean body odor. During an interview and observation with the Maintenance Director on 11/14/24 at 10:02 A.M., the Maintenance Director said that the Spruce Unit had a noticeable smell of body odor and urine while standing in the hallway outside of the Day room. The Maintenance Director also said that staff may have become accustomed to the smell and that it is more noticeable when you enter the unit from another floor. During an interview on 11/14/24 at 10:14 A.M., the Housekeeping Department Manager (HDM) said that the smell of body odor and urine is noticeable on the Spruce Unit. The HDM also said that she believed the odor becomes amplified when the heat gets turned on during the colder months and that the Spruce Unit has more incontinent (having no or insufficient voluntary control over urination or defecation) residents which is also a contributing factor. The HDM said that she had three housekeepers a day assigned for a complete room of the day cleaning schedule for each unit and the HDM provided the surveyor with the cleaning schedule. The HDM said that the strong odors have not improved since this cleaning schedule had been implemented on the Spruce Unit however. On 11/14/24 at 1:45 P.M., the surveyor observed the hallway outside of the residents rooms remained with a strong odor of stale urine and unclean body odor on the Spruce Unit. On 11/18/24 at 8:56 A.M., the surveyor observed the hallway outside of the Day Room remained with a strong odor of unclean body odor and stale urine on the Spruce Unit.

Based on record review, and interview, the facility failed to coordinate an assessment with the Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) program for one Resident (#44) out of a total sample of 19 residents. Specifically, the facility failed to complete a new Level I PASARR Assessment when Resident #44 had a significat change in status with a new diagnosis of Delusional Disorders (a belief in something that is untrue) following a psychiatric hospitalization and was started on treatment with an antipsychotic medication (medication used to treat symptoms of mental illness, including delusions - false convictions about something that is not real or shared by other people). Findings include: Resident #44 was admitted to the facility in June 2021 with a diagnosis of Major Depressive Disorder (a mental disorder characterized by low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities) and dependence on renal dialysis (a treatment that removes excess water, toxins, and solutes from the blood when the kidneys are no longer able to function properly). Review of the Resident's clinical record included a Preadmission Screening and Resident Review Level I assessment completed the day before admission to the facility. The Level I screening was positive and identified a diagnosis of Mood which included Major Depression as the only documented diagnosis of serious mental illness. Review of the Minimum Data Set (MDS) assessment dated [DATE]: -did not indicate that the Resident had a serious mental illness -included Depression as the only mental health diagnosis Review of the Resident's clinical record progress notes included a nursing note dated 9/10/21 that indicated: -original leave [sic] reason being altered mental status. -returned from hospital stay with course of tx (treatment) of psyche with new medications .Zyprexa (an antipsychotic medication used to treat symptoms of mental illness) . Review of the Resident's Behavioral Health Group clinical report dated 9/22/21 indicated: -the Resident had been recently transferred and admitted to the hospital directly from the renal dialysis appointment for mental status changes. -while at the hospital the Resident was started on Zyprexa. -the Resident was hospitalized for mental status changes, delusions, anxiety, and agitation. -the Resident returned to the facility with an order for Zyprexa 0.25 mg (mg - milligrams a unit of measure in the metric system equal to one-thousandth of a gram) by mouth daily. Review of the Resident's clinical record diagnosis list included a diagnosis of Delusional Disorders added on 9/22/21. Further review of the Resident's clinical record did not indicate that a new Level I Screening had been completed for the Resident, or referral for a Level II PASRR (an in depth evaluation to determine need, appropriate setting, and a set of recommendations for services to inform the individual's plan of care) evaluation as required. During an interview on 11/13/24 at 10:40 A.M., Social Worker (SW) #1 said that she was unable to provide evidence that a new Level I PASRR screen was submitted, or that a referral for a Level II evaluation was requested from the PASRR office, when the Resident returned from a psychiatric hospitalization on [DATE] with a new diagnosis of Delusional Disorder and an order for antipsychotic medication. SW #1 said that a new Level I evaluation and referral for a Level II evaluation should have been completed but it had not been.

Based on interview, and record review, the facility failed to ensure that a Preadmission and Resident Review Level (initial PASRR - initial pre-screening completed prior to admission to a Nursing Facility that assess for Serious Mental Illness [SMI] or Developmental Disabilities [DD]) screen was completed prior to admission to the facility for two Residents (#20 and #30) out of a total sample of 19 residents. Specifically, 1. For Resident #20, the facility failed to ensure the PASRR was completed accurately to reflect a psychiatric hospitalization . 2. For Resident #30, the facility failed to ensure that a Level I screen was completed prior to admission to the facility when the Resident had active diagnoses of mental disorders. Findings include: Review of the Preadmission Screening and Resident Review (PASRR) process retrieved from: https://www.mass.gov/preadmission-screening-and-resident-review-pasrr indicates the federal- and state-required process is designed to, among other things, identify evidence of serious mental illness (SMI) and/or intellectual or developmental disabilities (ID/DD) in all individuals (regardless of source of payment) seeking admission to Medicaid- or Medicare-certified nursing facilities. The PASRR process begins with a Level I Preadmission Screen, which is designed to identify all individuals seeking admission to a nursing facility that have, or may have, SMI and/or ID/DD. If the Level I screener suspects that the screened individual has SMI and/or ID/DD, he/she refers that individual to the appropriate PASRR authority for a Level II evaluation. The Level II evaluator confirms whether the individual has SMI and/or ID/DD and, if so, whether the individual requires a nursing facility level of care and specialized services. 1. Resident #20 was admitted to the facility in June 2019, with diagnoses including Alcohol Abuse, Depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Anxiety (feeling of unease, such as worry or fear, that can be mild or severe/ intense, excessive, and persistent worry and fear about everyday situations), Psychotic disorder with delusions (a fixed, or false conviction in something that is not real or shared by other people), Manic episode (extreme change in mood, that can lead to extreme agitation or irritability), and Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment). Review of Resident #20's PASRR Level I screen dated 4/2/19, indicated the Resident did not have one or more inpatient psychiatric hospitalization s. During an interview on 11/13/24 at 2:15 P.M., Social Worker (SW) #1 said the Level I PASRR was filled out incorrectly as Resident #20 had an in-patient psychiatric stay and was admitted to the facility from an in-patient psychiatric hospital. 2. Resident #30 was admitted to the facility in February 2016, with diagnoses including Delusional Disorder (a mental health disorder with one or more firmly held false beliefs that persist for at least one month), Unspecified Psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality) and Dementia. Review of Resident #30's medical record failed to indicate that a Level I PASRR had been completed prior to admission to the facility. During an interview on 11/18/24 at 10:02 A.M., SW #2 said Resident #30's Level I PASRR had not been completed, and should have been completed prior to the Resident's admission to the facility.

Based on observation, interview, and record review, the facility failed to maintain an environment that is free of accidents and hazards for one Resident (#18) out of a total sample of 19 residents. Specifically, for Resident #18, the facility failed to: -ensure that potentially hazardous smoking materials were stored in a secure area, and not inappropriately and insecurely stored in Resident #18's bedroom when both a stationary oxygen concentrator and portable oxygen concentrator were also stored and utilized in his/her bedroom putting the Resident and other residents at risk for accidental injury when there was easy access to the smoking materials. Findings include: Review of the facility's Policy titled Smoking Policy- Residents, established 11/2017 and last reviewed 3/2024 indicate the following: This facility shall establish and maintain safe resident smoking practices. -Oxygen use is prohibited in smoking areas. -Any smoking-related concerns will be noted in the resident care plan. -Residents are not allowed to keep lighters with them. Resident #18 was admitted to the facility in September 2024, with diagnoses including Metabolic Encephalopathy (a change in how the brain works caused by a chemical imbalance in the blood), Emphysema unspecified (a chronic lung condition where air is abnormally present in the lungs causing shortness of breath), Chronic Obstructive Pulmonary Disease with (acute) exacerbation (COPD: a chronic lung disease that causes obstructed airflow from the lungs and leads to respiratory problems including difficulty breathing, shortness of breath and wheezing, with an acute worsening of symptoms that lasts for several days), and dependence on supplemental oxygen. Review of Resident #18's Minimum Data Set (MDS) Assessment, dated 9/12/24, indicated that the Resident was moderately cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. Review of Resident #18's Smoking Evaluation, dated 10/12/24, indicated the following: -smokes. -can demonstrate smoking technique: holding cigarette, safe ability to get a cigarette, cigar, etc. lit safely by another (smoking supervisor), extinguishing and safe disposal of cigarette, etc. -was able to communicate that they understand smoking materials are for their own personal use. -was able to communicate that they understand smoking materials are for the use in designated smoking areas & must be stored in the facility's designated storage area (smoking box). -understands and agrees to use identified protective equipment while smoking, if indicated. -was currently evaluated to be a safe smoker under current facility policy. The Resident/Responsible party understands that they may not be permitted to smoke on the premises if future evaluations reveal that it is not safe. -was an independent smoker. -was independent with lighting cigarette. During an interview and observation on 11/13/24 at 3:15 P.M., Resident #18 said he/she had been independently going outside to smoke with no staff members and/or supervision. The Resident also said that he/she was never told that staff were supposed to supervise him/her when he/she go outside to smoke. The surveyor observed that the Resident had cigarettes and lighter in his/her room and the Resident said that he/she kept the lighter and cigarettes in their possession. Resident #18 further said that he/she store the lighter and cigarettes in a brown paper bag in the drawer of the nightstand in their room. Resident #18 said that nobody had told him/her to store the lighter and cigarette in any other place. During an interview and observation on 11/13/24 at 3:18 P.M., the Unit Manager (UM) said that the staff did a smoking evaluation on Resident #18 and assessed the Resident's ability to light his/her own cigarettes, hold the cigarette his/herself and that he/she did not require staff to light his/her cigarettes for him/her. The UM also said that the Resident does not need to be supervised by staff, but when he/she returned to the floor, his/her cigarettes and lighter were to be stored inside the medication cart and locked by nursing staff for safety. The surveyor observed the UM enter Resident #18's room at this time and ask the Resident about the storage of his/her cigarettes and lighter. The Resident said he/she kept the cigarettes and lighter in his/her possession in a brown bag inside their nightstand drawer. During an interview on 11/13/24 at 3:35 P.M., the UM said when the Resident was admitted to the facility, the Resident was not smoking. The UM said the Resident went to the hospital and when he/she returned from the hospital in October 2024, he/she was smoking. On 11/14/24 at 7:39 A.M., the surveyor observed the Resident lying in bed with eyes closed. The surveyor observed that a portable oxygen concentrator was located on the nightstand table next to a pack of cigarettes and a lighter. The surveyor observed the UM and a Nurse enter and then exit the Resident's room. The surveyor observed that the pack of cigarettes and lighter and portable oxygen concentrator remained on the Resident's nightstand table. On 11/14/24 at 7:43 A.M., the surveyor observed the Administrator enter the Resident's room and discussed the facility policy on storage of smoking materials with Resident #18. The Administrator was observed informing the Resident that cigarettes and lighters were to be locked up in the medication cart for safety and storage. The Administrator also said to the Resident that the staff will label the smoking materials with Resident's name for safe keeping and will replace if the materials were missing. The Administrator educated the Resident that it is the facility policy that his/her cigarettes and lighter are to be kept in a secure and locked area for safe keeping. The surveyor observed the Administrator remove the cigarettes and lighter materials from Resident #18's room including the brown paper bag that contained the additional cigarette materials. During an interview at the time, the Administrator said that the Resident should not have the cigarettes and smoking materials on their possession or in his/her room especially since Resident #18 is using oxygen.

Based on record review, and interview, the facility failed to meet professional standards of practice pertaining to Polysomnography (sleep study) for one Resident (#10), out of a total sample of 19 Residents. Specifically, for Resident #10, the facility failed to implement a Physician's order to obtain a sleep study to diagnose Obstructive Sleep Apnea (pauses in breathing during sleep, associated with partial or complete collapse of the throat and airway) resulting in delayed interventions and treatments for the Resident based on the sleep study results. Findings include: Review of the Board of Registration in Nursing Advisory, Ruling on Nursing Practice, titled: Accepting, Verifying, Transcribing and implementing Prescriber orders. Issued 9/22/93, revised 4/11/18, indicated: -Nurse's Responsibility and Accountability: >Licensed Nurses accept, verify, transcribe, and implement orders from duly authorized Prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. >Licensed Nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. >The paramount importance of patient safety must be reflected in practices that are specific to the setting and circumstance. >Determination of individual client/resident/patient allergy must be included in each situation. Resident #10 was admitted to the facility in December 2023, with diagnoses including Morbid Obesity (when the person's weight is found to be more than 80 - 100 pounds above the individual's ideal body weight), Congestive Heart Failure (CHF- caused when the heart is unable to pump blood effectively resulting in fluid build-up in the lungs, arms, feet and other organs), and Chronic Obstructive Pulmonary Disease ( COPD: chronic lung disease that causes obstructed airflow from the lungs and leads to respiratory problems including difficulty breathing, shortness of breath and wheezing). Review of the Resident's MDS Assessment, completed 9/12/24, indicated Resident #10: -was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 2 out of a possible 15. -received Oxygen therapy. -was dependent for bathing, dressing, and bed mobility, and required a Hoyer lift (a device that helps caregivers move a person from one place to another when the person cannot move themselves) for transfers. Review of the Resident's clinical record indicated the Resident's Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself) was not invoked (put into effect). Review of Resident #10's care plan initiated 12/11/23 and revised 11/3/24 indicated the Resident: -had altered respiratory status/difficulty breathing related to obesity and diagnoses of COPD. -Care plan goals included to maintain the Resident's Pulse Oximetry above 90%. -will maintain a normal breathing pattern as evidenced by normal respirations, normal skin color and regular respiratory pattern. -interventions included Administer medications as ordered and monitor for signs and symptoms of respiratory distress. Review of Resident #10's clinical record indicated an active Physician's order was written on 3/12/24, for a sleep study for Obstructive Sleep Apnea. Further review of the clinical record showed no evidence that the Resident had a sleep study completed. During an interview on 11/14/24 at 1:51 P.M., the Director of Nursing (DON) said she was unable to find any evidence that anyone had scheduled an appointment for a sleep study for Resident #10 or that the Resident had participated in a sleep study. During an interview on 11/14/24 at 2:13 P.M., with the DON and the Director of Clinical Operations (DOC) #1, DOC #1 said there was no policy for implementing or following Physician's orders. The DON said if a Physician had written an order for a consult (Consultation), the Nurse transcribing the Physician's order was responsible for making sure the order was implemented. The DON said in the case of Resident #10, the Nurse who transcribed the order should have made an appointment for the sleep study prescribed by the Physician. The DON said the Physician's order for Resident #10 to have a sleep study should have been followed through with and an appointment for the sleep study should have been made for the Resident. During an interview on 11/18/24 at 7:48 A.M., Resident #13 said they did not remember anyone recommending a sleep study. Resident #13 said he/she knew what a sleep study was, and he/she have never had one since being in the facility. The Resident further said he/she would participate in a sleep study if the doctor ordered one.

Based on observation, interview, and record review, the facility failed to ensure two Residents (#69 and #82) out of a total sample of 19 residents were provided assistance with personal hygiene care and services. Specifically, the facility failed to ensure that: 1. Resident #69 was offered and/or provided with grooming assistance for nail care when the Resident required partial/moderate (staff does less than half the effort) assistance of staff. 2. Resident #82 was offered and/or provided grooming assistance timely for hair care, facial hair care, and personal care when the Resident required total dependence (full staff performance of an activity with no participation by resident) of staff for hygiene, bathing, and dressing. Findings include: Review of the facility policy for Activities of Daily Living (ADLs - important tasks you do on a regular basis to take care of your body and overall well-being), Supporting last revised 11/2024, indicated: -appropriate care and services will be provided for residents who are unable to carry out ADLS independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with . hygiene (bathing, dressing, grooming and oral care) -Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice 1. Resident #69 was admitted to the facility in January 2023, with diagnoses including Age Related Cognitive Decline and Adult Failure to Thrive (a syndrome of global decline in older adults as a worsening of physical frailty that is frequently compounded by cognitive impairment, weight loss, decreased appetite or poor nutrition and inactivity). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #69: -was severely cognitively impaired as evidenced by a Brief Interview of Mental Status (BIMS) score of 3 out of 15 -had no behaviors. -required partial/moderate assistance with personal hygiene including grooming needs. Review of Resident #69's ADL care plan, last revised 11/2/24, indicated: -the Resident will receive assistance needed in ADL activities -grooming: total dependence with staff assist of 1 -report changes in ADL self-performance to Nurse Review of Resident #69's November 2024 Physician's orders indicated: -a weekly shower, skin evaluation, nail care, vital signs, Nurse note - every evening shift, every Tuesday, start date 1/23/24. Review of Resident #69's Treatment Administration Record (TAR) for November 2024 indicated that the Resident received showers and nail care on 11/5/24 and 11/12/24. Review of Resident #69's Behavior Tracking Log for November 2024 did not indicate any documented behaviors from 11/1/24 through 11/14/24. Review of Resident #69's clinical record indicated no documented evidence that the Resident refused care relative to grooming or personal hygiene. On 11/12/24 at 8:36 A.M., the surveyor observed Resident #69 sleeping in his/her wheelchair in the Day room on the Spruce Unit. The surveyor observed that the Resident's fingernails were approximately 1/4 inch long and had a black substance underneath the fingernails on both of his/her hands. On 11/13/24 at 8:02 A.M., the surveyor and the Director of Nursing (DON) observed Resident #69 sleeping in his/her bed in a hospital gown. The surveyor and the DON observed that the Resident's fingernails had a black substance underneath the untrimmed nails on both of his/her hands. During an interview at the time, the DON said that Resident #69's fingernails should have been cleaned and trimmed and the fingernails had not been cleaned or trimmed. During an interview on 11/13/24 at 8:14 A.M., Nurse #7 said that the Resident should be receiving nail care on his/her shower days. On 11/13/24 at 1:59 P.M., the surveyor observed Resident #69 lying in bed, sleeping in a hospital gown. The surveyor observed that the Resident's fingernails remained untrimmed and with a black substance underneath the nails of both his/her hands. On 11/14/24 at 9:01 A.M., the surveyor observed Resident #69 sitting in bed in a hospital gown and eating breakfast with his/her bare hands. The surveyor observed that the fingernails on both of the Resident's hands remained untrimmed, and a black substance was still present underneath the fingernails nails on both of his/her hands. 50320 2. Resident #82 was admitted to the facility in November 2023 with diagnoses including Right Above the Knee Amputation (AKA: a surgical procedure to remove the leg above the knee joint) and Non-Traumatic Subdural Hemorrhage (a type of brain bleed that happens without any prior trauma or pathology). Review of the Minimum Data Set (MDS) Assessment, dated 8/21/24, indicated Resident #82: -was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 points out of 15. -has no instances of rejections of care. Review of Resident #82's ADL care plan indicated the Resident required extensive to total dependent assist for hygiene, bathing, dressing. Review of the Resident's care Kardex (an overview of a resident's care needs) indicated the Resident was an extensive assist of one person to total dependence with hygiene, bathing and dressing. During an interview and observation on 11/12/24 at 9:38 A.M., the surveyor observed Resident #82 was dressed in a shirt and shorts, and the Resident's hair was sticking up on the right side of his/her head and he/she had facial hair growth on the cheeks, chin, and neck. During an interview at the time, the Resident said the Certified Nurses Aides (CNAs) only removed his/her facial hair when they felt like it and if he/she asked the CNAs to remove the facial hair, the CNAs would not always assist with his/her facial hair removal. On 11/13/24 at 8:28 A.M., the surveyor observed the Resident lying in bed and his/her hair was disheveled and sticking up in multiple directions, and facial hair growth remained on his/her cheeks, chin, and neck. The surveyor observed that the Resident was wearing a gray shirt from the previous day which had one large dark stain on the front of the shirt. During an interview at the time, the Resident said he/she was going to ask the Nurses to have his/her facial hair removed that morning. Resident #82 said his/her clothes had not been changed from the previous day and that he/she was still waiting to be washed up for the day. On 11/13/24 at 11:32 A.M., the surveyor observed Resident #82 was lying in bed, and was still wearing the gray shirt with a dark stain on the front. The surveyor observed the Resident's hair remained disheveled, was sticking out in all directions, and the facial hair growth on his/her cheeks, chin, and neck was still present. During an interview at the time, the Resident said he/she was still waiting to be washed up and have his/her clothes changed. On 11/13/24 at 4:12 P.M., the surveyor observed the Resident was still wearing the gray shirt with a dark stain on the front, his/her hair was disheveled and sticking up in all directions and he/she remained with facial hair on his/her cheeks, chin and neck. During an interview at the time, the Resident said he/she had not been washed up as yet today. Resident #82 said he/she asked to have the facial hair removed but no one came as yet to help him/her. During an interview on 11/14/24 at 9:06 A.M., CNA #4 said Resident #82 needed help with all of his/her Activities of Daily Living (ADLs). CNA #4 said she lets the Resident do as much as he/she can, and then CNA #4 will finish what care the Resident cannot complete. CNA #4 said that the Resident needed help with all parts of their ADL care except for feeding which the Resident completes independently. CNA #4 said the Resident never refused ADL care. During an interview on 11/14/24 at 9:10 A.M., Nurse #5 said Resident #82 needed help with all care including bathing, dressing and personal hygiene/grooming. Nurse #5 said the CNA's have a kardex to tell them how much assistance Resident #82 needed with ADLs. Nurse #5 said if anything changes with the Resident's care needs, the Nurses will tell the CNA's during morning report. Nurse #5 said the Resident did not refuse ADL care. Nurse #5 said the Resident should have assistance every day with ADLs. Nurse #5 said the Resident should have been provided assistance with facial hair removal when the Resident requested, and should have his/her clothes changed daily. Nurse #5 said he would speak to the CNA who was providing care for Resident #82 to make sure the Resident's facial hair was removed and he/she had clean clothes.

Based on record review and interview, the facility failed to implement advance directives and follow policies pertaining to advance directives for two Residents (#48 and #91) out of a total sample of 24 residents. Specifically, the facility staff failed to: 1. For Resident #48, follow the advance directive for a Do Not Resuscitate (DNR - a medical order issued by a physician or other authorized non-physician practitioner that directs healthcare providers not to administer CPR [cardiopulmonary resuscitation] in the event of cardiac or respiratory arrest), and provided CPR, with resulting hospitalization , rib fractures, and uncontrolled pain. 2. For Resident #91, allow the Resident to formulate his/her own advance directive when the Resident's healthcare proxy (HCP- a document with which a person appoints an agent to legally make health care decisions on their behalf) completed a MOLST (Medical Order for Life Sustaining Treatment) form for the Resident when the HCP was not invoked (made active). Findings include: Review of the facility policy, titled Advance Directives, dated [DATE], included the following: -Information about whether or not a resident has executed an advance directive shall be displayed prominently in the medical record. -An advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized by State law, relating to the provisions of health care when the individual is incapacitated. -DNR indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no CPR or other life-sustaining treatments or methods are to be used. -Advance directives will be respected in accordance with state law and facility policy. -If a resident is incapacitated and unable to receive information about his or her right to formulate and advance directive, the information may be provided to the resident's legal representative. 1. Resident #48 was admitted to the facility in [DATE] with diagnoses including Dementia and failure to thrive (FTT-downward change in growth and weight). Review of Resident #48's Advance Directive Care Plan, initiated [DATE], included: -Follow MOLST form as ordered, dated [DATE]. -Implement and honor Guardianship, dated [DATE]. Review of the Commonwealth of Massachusetts Order Appointing Temporary Guardian for an Incapacitated Person, in the interest of Resident #48, dated [DATE] indicated the Resident's Guardian had been authorized to consent to advance directives, including DNR, for the Resident. Review of the Commonwealth of Massachusetts Decree and Order of Appointment of Guardian for an Incapacitated Person, dated [DATE], included: - The Court authorized treatment of Resident #48, with treatment or action of authority, for the Guardian to consent to advance directives including DNR . - The appointed Guardian was permanent. Review of a Social Service Note, dated [DATE], included: -Guardianship became permanent this quarter and remains in place . -Court provided EOL (end of life) orders to allow Resident #48's advance directives to be changed and he/she is now DNR . Review of Resident #48's [DATE] Physician's orders included an order, revised [DATE] and discontinued [DATE], for: -Guardianship -DNR . Review of a Nursing Note, dated [DATE], indicated the following: -Nursing was unable to arouse Resident #48 and the Resident was verified pulseless. -Team was unable to locate MOLST and two-person CPR was initiated successfully from 17:00 (5:00 P.M.) through 17:09 (5:09 P.M.). -Paramedics arrived on-scene and transported the Resident to [Hospital] for further evaluation . Review of Resident #48's Hospital Discharge Summary dated [DATE], included the following: -A CT (computed tomography- computerized x-ray imaging procedure) of the Resident's chest was performed and indicated the upper abdomen had normal bones and chest wall, no osseous lesions. -A CT of the Resident's abdomen revealed: Acute bilateral lower rib fractures, likely sequela of recent CPR. Review of Resident #48's clinical record indicated the Resident returned to the facility on [DATE]. Review of a Physician's Order, dated [DATE] at 11:00 P.M., indicated: -administer 975 milligrams (mg) of Acetaminophen (over the counter medication for relief of pain) to the Resident every eight hours. -Scheduled times for administration were 7:00 A.M., 3:00 P.M., and 11:00 P.M. Review of Resident #48's [DATE] Medication Administration Record indicated facility staff administered Acetaminophen as ordered on [DATE]. Review of a Nurse Practitioner (NP) Progress Note, dated [DATE], included: - Resident #48 was admitted to the hospital on [DATE] for acute syncopal (loss of consciousness/passing out) episode and unresponsiveness. - CPR was performed and the Resident sustained bilateral lower rib fractures. - The Resident was experiencing rib pain. - The Resident's rib pain was poorly controlled despite 975 mg of APAP (Acetaminophen). - Will order Lidocaine (numbing medication) patch and PRN (pro re nata: as the situation demands/as needed) Tramadol (prescription medication used to treat moderate to severe pain) 25 mg every eight hours as needed. On [DATE], between the hours of 9:30 A.M. and 11:55 A.M., the surveyor observed Resident #48 lying in bed, dressed in a hospital gown. During an interview on [DATE] at 12:30 P.M., the Staff Development Coordinator (SDC) said that the facility's process to identify a resident's advance directive was for staff to refer to the directive indicated on each resident's MOLST form, and that MOLST forms were filed in the residents' paper records on the units. The SDC then said she observed a Nurse in the dining room with Resident #48 on [DATE], when the Resident was identified as unresponsive. The SDC also said the Resident was without pulse or respiration at that time. The SDC said she proceeded to Resident #48's paper record to locate the MOLST form, but when she opened the record, the MOLST form, labeled with the Resident's name, was blank. The SDC said she then attempted to access the Resident's electronic health record (EHR) to locate either a scanned copy of a completed MOLST form or a Physician order relative to resuscitation status, but the system was down, so she could not access the Resident's EHR. The SDC said that because the MOLST was blank and the computer was not accessible, an executed advance directive for DNR could not be verified, so CPR was initiated. The SDC said CPR was successful and Resident #48 had been resuscitated, was awake with pulse and respiration, but that the Resident's condition was uncertain, and the SDC was unsure of the condition of the Resident's ribs, so the Resident was transferred to the hospital for evaluation. During an interview on [DATE] at 1:01 P.M., the Director of Nursing (DON) said staff at the facility had a misunderstanding that residents with appointed Guardians could not have a MOLST completed. The DON said that residents who had court appointed Guardians granted authority to execute advance directives for the residents should all have completed MOLST forms in their records and accessible to staff. The DON said Resident #48's Guardian had been granted authority to execute an advance directive for the Resident, and the advance directive was for DNR. The DON said a MOLST form should have been completed with the instruction for staff to have access to on [DATE], but it was not. During an interview on [DATE] at 1:15 P.M., the Physician said at the time the Court ordered Guardianship was granted to include authorization for treatment of Resident #48, to consent to advance directives, the Guardian elected DNR for the Resident. During an interview on [DATE] at 2:08 P.M., the Social Worker (SW) said Resident #48's Court appointed Guardian was authorized to enter into an advance directive for DNR on a temporary basis on [DATE], then as a permanent Guardian on [DATE], and that the Guardian expressed the choice to elect DNR. The SW further said Resident #48's advance directive was DNR when the Resident was found unresponsive, without pulse, and resuscitated by staff on [DATE]. During an interview on [DATE] at 11:56 A.M., Certified Nurse Aide (CNA) #1 said prior to the Resident's episode on [DATE], when CPR was provided, he/she would often be up in his/her wheelchair during the day, and in the dining room singing. CNA #1 said Resident #48 did not get out of bed as yet on [DATE] because he/she was not doing well and had too much pain. CNA #1 further said Resident #48's pain seemed to be in his/her ribs as he/she would facially grimace, and guard (muscles tighten up around an injured area) and point to his/her ribs when being repositioned or provided with care. During an interview on [DATE] at 1:35 P.M., the NP said at the time Resident #48's Guardian was authorized to enter an advance directive for the Resident, the Guardian elected for DNR. The NP said that prior to the Resident having received CPR at the facility, she treated the Resident for knee pain, and she did not recall the Resident ever having rib pain. The NP said since the Resident's return to the facility, he/she presented with palpable (touch or feel that is intense) pain to the outer chest wall. The NP said the initial order for 975 mg of Acetaminophen every eight hours did not control Resident #48's rib pain, so she ordered Tramadol and a Lidocaine patch in addition to the scheduled Acetaminophen, in an attempt to control the Resident's pain. 44222 2. Resident #91 was admitted to the facility in [DATE] with diagnoses including Alzheimer's Disease and Dementia. Review of the Resident's HCP (HCP- a document with which a person appoints an agent to legally make health care decisions on their behalf) indicated that the document was signed by the Resident on [DATE]. Review of the clinical record included a MOLST form signed by the Resident's HCP dated [DATE]. There was no evidence in the medical record that the HCP was ever invoked (made active). During an interview on [DATE] at 10:10 A.M., Nurse #1 said that she was unable to find any evidence in the Resident's clinical record to indicate that the HCP was ever invoked. During an interview on [DATE] at 11:10 A.M., the Director of Nurses (DON) told the surveyor that the HCP should not have signed the MOLST form, and that the HCP was never invoked.

Based on records reviewed, review of surveillance camera video footage, and interviews, for one of three sampled residents (Resident #1) who had severe cognitive impairment and was dependent on staff for care, the Facility failed to ensure he/she was free from physical abuse, when on 03/05/23,Certified Nurse Aide (CNA) #2 physically abused Resident #1, as evidenced by review of the Facility's surveillance camera video footage from 03/05/23 during the day shift which showed Resident #1 coming out of his/her room, CNA #2 then approaches Resident #1 to redirect him/her back into the room, when Resident #1 does not comply, CNA #2 reaches out with his left hand pushes Resident #1's right shoulder and then with an open right hand, CNA #2 slaps Resident #1 on the left side of his/her face/head. Findings include: Review of the Facility's Policy titled, Abuse Prohibition, dated as revised December 2017, indicated that each resident has the right to be free from verbal, sexual, physical, and mental abuse. The Policy indicated that physical abuse includes, but is not limited to, hitting, slapping, pinching, kicking, and so on. The Policy also indicated that every resident will be treated with dignity and respect at all times. Review of the Facility's Investigation Report, undated, indicated that on 3/06/23 at approximately 6:00 P.M., CNA #1 reported to the Staff Development Coordinator (SDC) that he had concerns regarding an incident that occurred on 3/05/23 involving Resident #1 and CNA #2. The Report indicated that CNA #1 said the cameras near Resident #1's room should be checked for possible abuse on 3/05/23 between 8:00 and 8:30 A.M. The Report indicated that surveillance camera video footage revealed that CNA #2 pushed and slapped Resident #1, and that the Facility validated an isolated occurrence of abuse. Review of a Police Report, dated 3/06/23, indicated that while watching the video, it is apparent that a male (later identified as CNA #2) was signaling at Resident #1 in attempts to get him/her back into his/her room. The Report indicated that at this point, CNA #2 pushed Resident #1's right shoulder, and then slapped him/her across the face with an open hand. The Report indicated that an Elder Abuse Report was filed, and that CNA #2 would be charged with assault and battery. Resident #1 was admitted to the Facility in December 2022, diagnoses included vascular dementia and difficulty walking. Review of a Fall Risk Evaluation, dated 12/09/22, indicated Resident #1 was at high risk for falls. Review of Resident #1's Admission Minimum Set Data (MDS) Assessment, dated 12/14/22, indicated he/she had severe cognitive impairment and required assistance of one person to walk in his/her room and hallway. Review of Resident #1's Communication Care Plan, dated 12/22/22, indicated he/she had a communication problem related to dementia, and included the following interventions: -anticipate and meet needs, -ensure/provide a safe environment, and -monitor for physical/nonverbal indicators of discomfort or distress and follow up as needed. Review of Resident #1's Psychosocial Care Plan, dated as reviewed and renewed with the 12/14/22 MDS, indicated staff should: -help resident cope by suggesting possible solutions to conflict, and -honor resident preferences and choices whenever possible. During an interview on 03/21/23 at 2:14 P.M., the Administrator said the surveillance camera video footage system was very old, and the time stamp was inaccurate, and that the time stamp was ahead by at least 80 minutes or more. The Surveyor reviewed Facility surveillance camera video footage with the Administrator who identified the resident and staff seen on the video. The footage dated and time stamped 03/05/23 from 10:30:33 to 10:31:05, illustrated the following: 10:30:33 Resident #1 begins to walk out of his/her room, CNA #2 walks out of another room and approaches him/her. 10:30:43 CNA #2 motions with his right arm/hand and points toward Resident #1's room as if directing him/her to go back into his/her room. 10:30:47 CNA #2 is standing in front of Resident #1 in his/her doorway and he pushes the room door open with his right hand. Resident #1 continues to walk toward CNA #2 attempting to leave his/her room. 10:30:48 CNA #2 puts his left hand on Resident #1's right shoulder. 10:30:49 CNA #2 steps back with his left foot, which widened his stance, and then pushes Resident #1's left shoulder with his right hand. Resident #1 body responds with a whiplash-type movement, but he/she remained in a standing position. CNA #2 draws his entire right arm back, then swings the arm in a forward motion, and strikes Resident #1 with his right open hand across the left side of Resident #1's face/head. 10:31:05 CNA #1 steps out into the hallway from another room and looks down the hallway toward CNA #2 and Resident #1, who at the time are both standing in the hallway in front of Resident #1's room, and are no longer visibly engaged in an altercation. During an interview on 03/29/23 at 1:04 P.M. and review of CNA #1's written Witness Statement, dated 03/07/23, CNA #1 said that on 03/05/23 sometime between 8:00 A.M. and 8:30 A.M., he was in the room next to Resident #1's room caring for another resident when he heard an argument between Resident #1 and CNA #2. CNA #1 said he also heard a noise that sounded like a slap, and said he heard Nurse #1 ask CNA #2 what was happening. CNA #1 said he then stepped out into the hallway to see what was going on and said he saw CNA #2 and Resident #1 standing near each other in the hallway, and that was all. CNA #1 said he did not see CNA #2 push or slap Resident #1, but said he heard them arguing and then heard a noise that sounded like a slap. CNA #1 said he asked CNA #2 if he slapped Resident #1 and CNA #2 said yes, he had. CNA #1 said he did not report his suspicion of abuse to anyone until later that night (unsure of the time), when he said he told Nurse #1 that CNA #2 was rough with Resident #1. CNA #1 said Nurse #1 did not respond to his concern. CNA #1 said he assumed Nurse #1 witnessed the altercation between Resident #1 and CNA #2, since he heard her ask CNA #2 what was happening during the altercation, so he thought she would report it. CNA #1 said he was not sure that Nurse #1 reported the altercation to administration, and said he called the supervisor (later identified as the SDC) the next day at approximately 6:00 P.M. to report his suspicions of abuse and to tell her to check the surveillance camera video footage. Review of a written Interview conducted by the Director of Nurses (DON) with CNA #1, dated 03/09/23, indicated CNA #1 said that on 03/05/23 at approximately 8:00 A.M. to 8:30 A.M., he heard shouting in the hallway and a noise that sounded like a slap, and said he then stepped out into the hallway to see what was happening. The Interview indicated that CNA #1 said he asked CNA #2 what was happening and he said CNA #2 told him that Resident #1 threw water at him. The Interview indicated that CNA #1 did not visually witness any part of the incident, but said Nurse #1 was in the hallway and that CNA #1 said he heard Nurse #1 ask CNA #2 what was going on. Further review of the Interview indicated that CNA #1 said he brought his suspicions of abuse involving Resident #1 to Nurse #1 at approximately 2:30 P.M. that same day (03/05/23), and said Nurse #1 did not have a response. The Interview indicated that CNA #1 said on 03/06/23 at approximately 6:00 P.M., he called and notified the SDC of his suspicions of abuse. During an interview on 03/21/23 at 11:45 A.M. and review of the Staff Development Coordinator (SDC's) written Witness Statement, the SDC said CNA #1 called her on 03/06/23 at 5:59 P.M. and reported that on 03/05/23 there was an incident that occurred between CNA #2 and Resident #1 where he heard a noise that sounded like a slap and an argument, but did not see it. The SDC said CNA #1 suggested she look at the surveillance camera video footage from between 8:00 A.M. and 8:30 A.M. on 03/05/23, to see what happened. Review of Nurse #1's written Witness Statement, dated 03/07/23 indicated she worked on 03/05/23, and no one reported an incident of abuse to her. Review of Nurse #1's written Witness Statement, dated 03/09/23, indicated that on 03/05/23 at 10:00 P.M., CNA #1 told her that a staff member was rough with a resident. During an interview on 03/21/23 at 1:30 P.M., Nurse #1 said she was working on 03/05/23 during the day shift on Resident #1's unit and that she did not see or hear an argument take place between Resident #1 and CNA #2, and did not hear a noise that sounded like a slap. Nurse #1 said CNA #1 told her that CNA #2 was rough with Resident #1, but he did not say when, and that she did not ask when, and did not ask for details. Nurse #1 said she did not follow up with CNA #1, but should have. Nurse #1 said she did not do a skin check on Resident #1, and did not report the allegation of potential abuse to administration, but said she should have. Although the Administrator was not able to speak with CNA #2 in person or on the phone, he provided the Surveyor with a written transcript of voicemail messages that CNA #2 left in response to his attempted phone calls, dated 03/09/23, which indicated the following: - 9:51 A.M. I am sorry for what happened. - 10:13 A.M. I am really sorry for what happened. I was with Resident #1 and he/she was trying to do something. I don't remember exactly what, but he/she was trying to come out of his/her room. I was trying to redirect him/her but he/she would not listen. Resident #1 then threw water at me, and I was trying to stop him/her, but I went too fast and swung back. I was shocked because I had no intention of doing anything bad. During an interview on 03/21/23 at 12:31 P.M., Certified Nurse Aide (CNA) #2 said that on 03/05/23 sometime in the morning, around breakfast, Resident #1 was walking around without his/her walker, so he was trying to convince him/her to go back into his/her room so he/she would not fall. CNA #2 said he reacted so quickly because Resident #1 tried to throw something at him. CNA #2 said he hit Resident #1 on the arm, not in the face. CNA #2 said he is a master at his job, and he had no intention of harming Resident #1. During an interview on 03/21/23 at 1:51 P.M., the Director of Nurses (DON) said he watched the video footage and it showed that CNA #2 pushed Resident #1 backward with his left hand and then CNA #2 drew his right arm back and slapped Resident #1 across the face with his right hand. The DON said physical abuse was substantiated since it was all captured on the video camera. During an interview on 03/21/23 at 2:25 P.M., the Administrator said the SDC notified him of the potential abuse allegation on 03/06/23 at 6:00 P.M. The Administrator said he returned to the Facility and suspended CNA #2 immediately, watched the surveillance camera video footage, and then called the Police. The Administrator said that upon watching the video footage, he substantiated an allegation of physical abuse, he alerted CNA #2's staffing agency of the incident, and would not allow CNA #2 to return to the Facility.

Based on records reviewed and interviews for 1 of 4 sampled residents (Resident #1), the facility failed to provide Resident #1, who had a guardian and vocalized a desire to leave the facility, an escort to an appointment which resulted in Resident #1 leaving the appointment unaccompanied and was not found until 6 days later. Findings include: Resident #1 was admitted to the facility in December 2015 with [DIAGNOSES REDACTED]. Review of the clinical record for Resident #1 indicated he/she had a temporary guardian until July 2016. Quarterly Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview of Mental Status (BIMS) score of 10 which indicated cognitive impairment and that Resident #1 had a guardian. The Wander/Elopement Risk Evaluation, dated January 2016, indicated Resident #1 had a wanderguard placed on his/her crutch for a safety intervention for wandering and elopement. The Wander/Elopement Risk Evaluation, dated March 2016, indicated Resident #1 was not an elopement or wander risk. Nurses' notes, dated January 2016 and April 2016, indicated Resident #1 was sent to the hospital on two separate occasions, section 12 (an authorization for involuntary hospitalization due to mental health issues), for evaluation, after he/she expressed desire to leave the facility and became agitated because he/she was not able to leave. Psychiatric notes, dated February 2016 to May 2016, indicate Resident #1 had expressed the desire to leave the facility and in April 2016 recommended 15 minute checks to be initiated. Resident Monitoring Tool, dated April 2016 to June 2016, indicated staff performed 15 minute safety checks on Resident #1. Case Manager/Guardian #1 was interviewed on 6/14/16 at 12:13 P.M. and said that Resident #1 had two previous admissions at the facility and left both times against medical advice (AMA). Nurse #1 was interviewed on 6/10/16 at 5:00 P.M. and said that she received a call from the ambulance service that Resident #1 was not at the appointment for pick up and did not return to the facility after his/her appointment. Director of Nurses (DNS) was interviewed on 6/10/16 at 6:50 P.M. and said that Resident #1 went to the June 2016 appointment without an escort; however, he/she should have had one. The DNS said Resident #1 has not been located at this time. Unit Manager #1 was interviewed on 6/13/16 at 10:52 A.M. and said Resident #1 left the facility for an appointment in June 2016 with the ambulance service without an escort. Unit Manager #1 said that Resident #1 should have had an escort accompany him/her to the appointment. Administrator was interviewed on 6/15/16 at 9:01 A.M. and said that Resident #1 was located on 6/15/16, 6 days after the elopement, and was brought back to the facility by the Police and is now currently being evaluated at Hospital. The DNS and Administrator said, effective 6/10/16, no residents were to leave the facility without an escort until assessed for risk. The facility took the following corrective action in response to the incident: · All staff were educated on elopement, missing person policy and clinical rounds checklist · Audit of all resident progress notes for the past 30 days for any indications of wanting to leave the facility · All residents were assessed for wander/elopement risk and care plans were updated accordingly · Audit of all residents with wanderguards was conducted · Audit of all residents that have an invoked Health Care Proxy or Guardian was conducted; orders were obtained to provide an escort to appointments and care plans were updated · Audit of all BIMS (Brief Interview of Mental Status) scores were conducted; score 0-7 indicated need for escort to appointment, score 8-12 further review by interdisciplinary team to determine need for escort and Physicians notified, score 13-15 and own responsible person will be allowed to go to appointment alone; orders were obtained to provide an escort to appointments and care plans were updated · Elopement Books on all 3 units, the kitchen, and business office were updated

Based on records reviewed and interviews for 1 of 4 sampled residents (Resident #1), the facility failed to implement the Missing Resident Policy in a timely manner when they were first notified that Resident #1 was missing. Findings include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care, and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. On 6/9/16, the facility was notified at approximately 4:30 P.M. to 5:00 P.M. that Resident #1 was not at his/her appointment for pick up. Nurse #1 did not alert anyone that Resident #1 was missing until 7:00 P.M. Nursing Supervisor #1 said she was not notified at 7:00 P.M. that Resident #1 was missing. The Assistant Director of Nurses and Director of Nurses said they were notified at approximately 9:30 P.M. that Resident #1 was missing. The physician or guardian were not immediately notified. Nurse #1 did not notify the in house supervisor about Resident #1 missing until approximately 7:00 P.M. on 6/9/16 (after she received the second phone call from the ambulance service) and then again at approximately 9:00 P.M. to 9:15 P.M. Nurse #1 was interviewed on 6/10/16 at 5:00 P.M. and said Resident #1 had left the facility prior to the start of her shift with the ambulance service on 6/9/16 at 3:00 P.M. for a 4:00 P.M. dental appointment. Nurse #1 said she received a call from the ambulance service at around 4:30 P.M. to 5:00 P.M. that Resident #1 was not at the dental appointment for pick up. Nurse #1 said she did not call Resident #1's friend, the dental office, or notify her immediate supervisor that Resident #1 was missing and did not immediately notify the physician, police, or the guardian and went back to her medication pass. Nurse #1 said she received a second call from the ambulance service at around 7:00 P.M. inquiring about Resident #1's well-being and she told them that Resident #1 had not returned to the facility. Nurse #1 said between 9:00 P.M. to 9:30 P.M. she then called 911 the Police, the Physician, and Guardian. Missing Resident Search Steps Policy, dated 4/28/10, indicated staff members are to report the missing resident to the charge nurse or shift supervisor immediately. Supervisor #1 was interviewed on 6/10/16 at 5:40 P.M. and said she was not informed about Resident #1 missing from his/her appointment until around 10:00 P.M. at which time she said she immediately called the ADNS and the Physician. Assistant Director of Nurses (ADNS) was interviewed on 6/10/16 at 6:10 P.M. and said she received a phone call from Supervisor #1 about Resident #1 being missing until around 9:30 P.M. at which point she immediately notified the Director of Nurses (DNS) and the Administrator. Director of Nurses was interviewed on 6/10/16 at 6:50 P.M. and said she received a phone call from the ADNS about Resident #1 being missing at around 9:30 P.M. The DNS said that Nurse #1 should have notified her immediate supervisor at 4:30 P.M. when she received the first phone call from the ambulance service. Resident Event Report Worksheet, dated 6/9/16, indicated the DNS was notified at 9:47 P.M., the Administrator at 9:50 P.M., the Physician at 10:00 P.M., and the Family/POA (Power of Attorney) at 10:05 P.M. Administrator was interviewed on 6/15/16 at 9:01 A.M. and said that Resident #1 was located this morning, 6 days after the elopement, and was brought back to the facility by the Police and is now currently being evaluated at Hospital. The DNS and Administrator said, effective 6/10/16, no residents were to leave the facility without an escort until assessed for risk. The facility took the following corrective action in response to the incident: · All staff were educated on elopement, missing person policy and clinical rounds checklist · Audit of all resident progress notes for the past 30 days for any indications of wanting to leave the facility · All residents were assessed for wander/elopement risk and care plans were updated accordingly · Audit of all residents with wanderguards was conducted · Audit of all residents that have an invoked Health Care Proxy or Guardian was conducted; orders were obtained to provide an escort to appointments and care plans were updated · Audit of all BIMS (Brief Interview of Mental Status) scores were conducted; score 0-7 indicated need for escort to appointment, score 8-12 further review by interdisciplinary team to determine need for escort and Physicians notified, score 13-15 and own responsible person will be allowed to go to appointment alone; orders were obtained to provide an escort to appointments and care plans were updated · Elopement Books on all 3 units, the kitchen, and business office were updated

Based on records reviewed and interviews for 1 of 4 sampled residents (Resident #1), the facility failed to develop an elopement care plan for Resident #1 who was an elopement risk. Resident #1 was admitted to the facility in December 2015 with [DIAGNOSES REDACTED]. Findings include: Review of the clinical record for Resident #1 indicated he/she had a temporary guardian until July 2016. Quarterly Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview of Mental Status (BIMS) score of 10, which indicated cognitive impairment, and that Resident #1 had a guardian. The Wander/Elopement Risk Evaluation, dated January 2016, indicated Resident #1 had a wanderguard placed on his/her crutch for a safety intervention for wandering and elopement. The Wander/Elopement Risk Evaluation, dated March 2016, indicated Resident #1 was not an elopement or wander risk. Nurses' notes, dated January 2016 and April 2016, indicated Resident #1 was sent to the hospital on two separate occasions, section 12 (an authorization for involuntary hospitalization due to mental health issues), for evaluation after he/she expressed desire to leave the facility and became agitated because he/she was not able to leave. Psychiatric notes, dated February 2016 to May 2016, indicated Resident #1 had expressed the desire to leave the facility and in April 2016 recommended staff to perform 15 minute checks to be initiated. Resident Monitoring Tool, dated April 2016 to June 2016, indicated staff performed 15 minutes safety checks on Resident #1. Physician orders, dated January 2016 to June 2016, did not indicate an order for [REDACTED]. Care Plans, dated January 2016 to June 2016, did not indicate an elopement care plan, safety interventions for a wanderguard, or 15 minute checks were included in the plan of care. Resident Profile (used by the Certified Nursing Assistant (CNA) for care), dated 5/12/16, did not indicate Resident #1 was a wander/elopement risk, had a wanderguard, or was on 15 minute checks. Wandering Patient Bracelet Testing Policy, dated 4/28/11, indicated that once a wanderguard was placed on a resident it should be documented in the residents medical record and the care plan updated. There was no documentation to indicate the facility implemented this policy. Case Manager/Guardian #1 was interviewed on 6/14/16 at 12:13 P.M. and said that Resident #1 had two previous admissions at the facility and left both times against medical advice (AMA). Director of Nurses (DNS) was interviewed on 6/10/16 at 6:50 P.M. and on 6/13/16 at 2:43 P.M. and 3:45 P.M. and said that Resident #1 should have had an order written [REDACTED]. The DNS said Resident #1 had a care plan for difficulty accepting placement but that it was poorly written. The DNS and Administrator said, effective 6/10/16, no residents were to leave the facility without an escort until assessed for risk. The facility took the following corrective action in response to the incident: · All staff were educated on elopement, missing person policy and clinical rounds checklist · Audit of all resident progress notes for the past 30 days for any indications of wanting to leave the facility · All residents were assessed for wander/elopement risk and care plans were updated accordingly · Audit of all residents with wanderguards was conducted · Audit of all residents that have an invoked Health Care Proxy or Guardian was conducted; orders were obtained to provide an escort to appointments and care plans were updated · Audit of all BIMS (Brief Interview of Mental Status) scores were conducted; score 0-7 indicated need for escort to appointment, score 8-12 further review by interdisciplinary team to determine need for escort and Physicians notified, score 13-15 and own responsible person will be allowed to go to appointment alone; orders were obtained to provide an escort to appointments and care plans were updated · Elopement Books on all 3 units, the kitchen, and business office were updated

Based on records reviewed and interviews for 1 of 4 sampled residents (Resident #1) the facility failed to immediately notify the physician and guardian for Resident #1 who eloped while out at a dental appointment. Findings include: Review of the clinical record for Resident #1 indicated he/she had a temporary guardian until July 2016. Quarterly Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview of Mental Status (BIMS) score of 10 which indicated cognitive impairment and that Resident #1 had a guardian. Ease Care Trip Details Sheet, dated 6/9/16, indicated the ambulance service arrived at the dental appointment at 4:40 P.M. on 6/9/16 to pick up Resident #1 and was informed Resident #1 had walked out 5 to 10 minutes prior to their arrival. Area was searched and Resident #1 was not located. Ambulance service notified facility and it was confirmed that no one else was scheduled to pick up Resident #1. Ambulance service was aware that Resident #1's Social Worker has picked him/her up in the past. Dentist office closed at 5:30 P.M. and there was still no sign of Resident #1. Ambulance service stayed in the area for 10 more minutes and then left. Nurse #1 was interviewed on 6/10/16 at 5:00 P.M. and said Resident #1 had left the facility prior to the start of her shift with the ambulance service on 6/9/16 at 3:00 P.M. for a 4:00 P.M. dental appointment. Nurse #1 said she received a call from the ambulance service at around 4:30 P.M. to 5:00 P.M. that Resident #1 was not at the dental appointment for pick up. Nurse #1 said she did not call Resident #1's friend, the dental office, or notify her immediate supervisor that Resident #1 was missing and did not immediately notify the physician or the guardian and went back to her medication pass. Nurse #1 said she received a second call from the ambulance service at around 7:00 P.M. inquiring about Resident #1's well-being and she told them that Resident #1 had not returned to the facility. Nurse #1 said between 9:00 P.M. to 9:30 P.M. she then called 911 the Police, the Physician, and Guardian. Supervisor #1 was interviewed on 6/10/16 at 5:40 P.M. and said she was not informed about Resident #1 missing from his dental appointment until around 10:00 P.M. at which time she said she immediately called the ADNS and the Physician. Resident Event Report Worksheet, dated 6/9/16, indicated the DNS was notified at 9:47 P.M., the Administrator at 9:50 P.M., the Physician at 10:00 P.M., and the Family/POA (Power of Attorney) at 10:05 P.M. The DNS and Administrator said, effective 6/10/16, no residents were to leave the facility without an escort until assessed for risk. The facility took the following corrective action in response to the incident: · All staff were educated on elopement, missing person policy and clinical rounds checklist · Audit of all resident progress notes for the past 30 days for any indications of wanting to leave the facility · All residents were assessed for wander/elopement risk and care plans were updated accordingly · Audit of all residents with wanderguards was conducted · Audit of all residents that have an invoked Health Care Proxy or Guardian was conducted; orders were obtained to provide an escort to appointments and care plans were updated · Audit of all BIMS (Brief Interview of Mental Status) scores were conducted; score 0-7 indicated need for escort to appointment, score 8-12 further review by interdisciplinary team to determine need for escort and Physicians notified, score 13-15 and own responsible person will be allowed to go to appointment alone; orders were obtained to provide an escort to appointments and care plans were updated · Elopement Books on all 3 units, the kitchen, and business office were updated

Based on record review, observation and staff interview, the facility failed to ensure that 1 sampled resident (#12), in a total sample of 23 residents, received the necessary care and services to attain the highest level of functioning and well-being possible regarding bowel issues and bowel medications. Findings include: For Resident #12, the facility failed to administer bowel medications as ordered when the resident experienced more than 48 hours without a bowel movement. The resident became constipated, experienced pain, abdominal distention and developed a fecal impaction. Resident #12 was admitted to the facility in April 2009 with [DIAGNOSES REDACTED]. The resident also had a history of [REDACTED]. According to the Resident's most recent Minimum Data Set (MDS) Assessment, an Annual assessment dated [DATE], the resident was independent in decision making and his/her cognitive skills were intact. The resident had a Foley catheter in place for a [MEDICAL CONDITION] bladder and was coded "3" for bowel indicating that he/she was always incontinent. The resident was totally dependent for transfer and did not ambulate. In addition, the resident required extensive assistance for activities of daily living including dressing, hygiene, and bathing. Review of the physician's orders [REDACTED]. - MOM (Milk of Magnesia) 30 cc (cubic centimeters) if no BM in 48 hours may give Milk of Magnesia liquid PO at the hour of sleep as needed for constipation. -[MEDICATION NAME] , if no results from MOM may give [MEDICATION NAME] suppository one per rectum for constipation. -Fleet's enema, if no results from [MEDICATION NAME] suppository may give fleets type enema per rectum daily for constipation. Review of the facility bowel record book for April indicated the resident did not have a bowel movement (recorded as "0" in the bowel book) for 7 shifts or 56 hours on the dates of 4/27/12, 4/28/12 and 4/29/12. Review of the Resident's MAR for 4/29/12 indicated that Milk of Magnesia was not given to the resident as ordered when he/she had gone more that 48 hours without a bowel movement. The resident also did not receive a [MEDICATION NAME] suppository or a fleets enema. Nurses notes from the night shift on 4/30/12 include documentation that the resident was "awake at 3:00 A.M. complaining of left sided abdominal pain." "states been bothering (him/her) all day". "Abdomen firm". "Tenderness left side". "Bowel sounds + (positive)". "Stool noted rectum after digital." Nurses notes documented on 4/30/12 at 7:00 P.M. indicated that the resident complained of "abdominal distention." Following the resident's complaint of pain, the facility obtained an order to have a KUB (kidneys, ureters, and bladder) X-ray. The radiology report on 4/30/12 concluded that "there is a large amount of rectal stool present." The facility contacted the PA (Physician's Assistant) on 4/30/12. The PA ordered a second KUB X-ray to r/o bladder distention. The PA also ordered Intravenous fluids: [MEDICATION NAME] 5% with Normal Saline to infuse at 75 ml. per hour. The PA also ordered a fleet enema for the resident and ordered that the resident be NPO (nothing by mouth.) The PA did not see the resident on 4/30/12. Following administration of the fleet enema, the facility bowel book included documentation that the resident had a large bowel movement. On the following day, 5/1/12, the resident had another KUB X-ray which concluded that "there is a large amount of rectal stool present. The findings are worse than 4/30/12." The PA did not see the resident on 5/1/12 but issued a telephone order to: "Repeat KUB in the morning, NPO tonight and tomorrow till KUB result and administer IV fluids of D5NS at 75 cc per hour for 2 liters." No additional bowel medications were ordered. On 5/2/12, the PA visited the resident and wrote a progress note that indicated "abdominal distention, KUB showed severe constipation." The repeat KUB on 5/2/12 reported "a large amount of fecal material is present throughout the colon" with "considerable constipation." The PA again ordered a KUB X-ray to be done on 5/3/12. Radiology report of 5/3/12 concluded that the resident had "severe constipation" and "probable fecal impaction." The report concluded that on 5/3/12 "The appearance is clearly worse than on the recent exams and similar to the earlier study of 4/30/12." Nurses notes on 5/3/12 indicate that "shortly after the KUB the resident had a large bowel movement." Documentation later in the day reports that "resident moving her bowels all day soft and loose stool noted." The radiology report of a KUB done on 5/5/12 concludes that "the findings are improved from 5/3/12." During interview on 5/10/12 at 3:15 P.M. the DON (Director of Nurses) acknowledged that there was no evidence the resident received bowel medication as ordered to prevent constipation and fecal impaction. For Resident #12, the facility failed to administer bowel medications as ordered to prevent constipation and fecal impaction. In addition, the facility failed to provide effective nursing and medical interventions to resolve the resident's constipation, fecal impaction and pain during a 5 day period including: 4/29/12, 4/30/12, 5/1/12, 5/2/12 and 5/3/12.

5. For Resident #5 the facility failed to ensure the plan of care was followed for preventing falls. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the clinical record on 5/9/12 included the admission MDS of 1/6/12 that revealed the Resident had problems with long and short term memory, required extensive assistance with transfer and ambulation and was frequently incontinent. Review of the plan of care for falls at the time of admission on 1/3/12 indicated the resident was at risk for fall related injury as evidenced by a history of falls with a fall in the previous month. The approaches noted to prevent further falls included keep the area free of clutter and adequate glare free lighting, provide use of adaptive devices such as a walker or cane or wheelchair when needed, and tab alarm in bed and chair. Review of the incident report narrative and nurses notes of 2/6/12 at 11P.M. indicated a CNA heard a yell went to the room and observed the Resident standing at the foot of the bed and leaning forward as if she/he was about to fall and ran into the room to keep the resident from falling forward. The CNA slid his/her hands under the arms to stabilize the Resident. At this time the CNA noticed blood coming from left wrist. The nurse came into the bedroom and noted a skin tear on the left wrist which was swollen and painful. The physician was notified and an x-ray of the wrist was ordered. The x-ray results came back the next day with a radially displaced, comminuted distal radius fracture. The Resident was sent to the emergency room for examination. The Resident returned with a half cast and ace wrap having had a closed reduction in the emergency department. A statement that was signed by the nursing supervisor, but not dated, indicated the tab alarm was not on when the resident was found standing up at the bottom edge of the bed. Please refer to F 323 Based on record review and staff interviews, the facility failed to follow the care plan for 4 sampled residents ( #5, #9, #12, and #17) in a total sample of 23 residents. Findings include: 1. For Resident #9 the facility failed to follow the written plan of care to ensure that the resident was in a supervised area to prevent falls. Resident #9 was admitted to the facility 7/1/08 and readmitted [DATE]. This Resident's [DIAGNOSES REDACTED]. Resident #9 sustained a fall with serious injury on 4/15/12 at this facility that resulted in a [MEDICAL CONDITION] which required surgical repair. The Resident has had a decline in condition and was admitted to Hospice Service on 4/27/12. Review of the falls care plan dated 7/19/11 updated 10/11, updated 1/20/12, and updated 4/10/12 indicated that this Resident was at risk for injury related to falls. The contributing factors were dementia with [MEDICAL CONDITION], decreased safety awareness, and previous falls. This care plan had the following pertinent interventions: - Low bed with floor mats - Chair pad alarm -Tab alarm -written instructions that stated "Staff to assist (resident) in reaching (his/her) destination with cues and supervision" Additional interventions were to keep resident in a supervised area and provide closer supervision when he/she becomes agitated. Review of the nurse's note and facility investigation of 4/15/12 indicated that the resident had an unwitnessed fall in the dining room at about 3:15 P.M. Review of the incident report and witness statements obtained by the charge nurse after the fall on 4/15/12 indicated that the Resident was in the dining hall, no staff member witnessed the fall and that the resident was unsupervised at the time of the fall. The Resident was found "on the floor on back with chair alarm going off. Resident unable to explain what happened but screamed when you touch thigh or hip and femur". Under the section labeled "Probable Cause" on the investigation form, the written statement is "unassisted ambulation". Review of the nurse's note and facility investigation of 4/15/12 indicated that the Resident was grimacing in pain after the fall. The facility obtained x-rays which indicated a [MEDICAL CONDITION]. The resident was sent out to the hospital and under went surgical repair of the fracture. During interview with the unit manager on 5/15/12 at 10:30 A.M., he/she acknowledged that although this Resident was care planned to be in a supervised area, according to the statements provided by the staff assigned to work on 4/15/12, this Resident was not supervised at the time of the Resident's fall in the dining room. According to the written statements, the Certified Nursing Assistants were attending to other residents and the two nurses on duty were engaged in activities with other residents, and the Resident was not visible to them. Please refer to F323. 2. For Resident #9 the facility failed to ensure that facility policy and protocol for interventions for lack of bowel movements were followed from 4/20/12-4/25/12 after the Resident's readmission on 4/20/12 from the hospital for a surgical repair of a [MEDICAL CONDITION]. Record review on 5/15/12 indicated that Resident #9 was readmitted [DATE] from the hospital. The resident had a fall at the facility on 4/15/12 that resulted in a right [MEDICAL CONDITION] which required surgical repair. The Resident's [DIAGNOSES REDACTED]. Review of the hospital discharge summary indicated that the resident was NPO (nothing by mouth) for three days in the hospital. Pain medication, administered to manage post operative surgical pain and included in the hospital discharge orders, included sub lingual [MEDICATION NAME], UItram, and Tylenol. Review of the readmission orders [REDACTED]. Review of the physician readmission orders [REDACTED] The side effects of [MEDICATION NAME] and [MEDICATION NAME] include constipation. The Resident received [MEDICATION NAME] for pain management between 4/20/12-4/25/12 on 4/21/12, 4/22/212, and 4/23/12, and [MEDICATION NAME] on 4/24/12. The facility has a policy for monitoring a resident's bowels that included assessing the resident's bowel movements and charting them each sift. The policy specifies actions to be taken in the event of no bowel movement after 48 hours. Review of the "bowel book" dated 4/20/12-4/25/12 indicated that the resident did not have any bowel movements recorded from the 3-11 shift on 4/20/12 to the 3-11 shift on 4/25/12, a total of 16 shifts. The facility policy is included in the standing physician orders [REDACTED]. constipation". There was no nursing note addressing the Resident's bowel status during the 4/20/12-4/25/12 time frame. Review of the Nurse Practitioner note dated 4/23/12 indicated "Bowels have not moved since his/her readmission". During interview on 5/14/12 at 1:00 p.m. the Director of Nursing (DON) stated that on admission and readmission, the facility implements the standing orders for the bowel protocol. The DON further stated that the expectation after a resident returns to the facility after a surgical procedure and on pain medications that could contribute to constipation, is that staff would be monitoring the bowel movements and implementing the facility protocol. The DON confirmed that the standing orders were not in place for the resident and that the facility protocol had not been implemented. The Resident was noted to have bowel movements starting on 4/26/12. 3. For Resident #12, the facility failed to administer bowel medications as ordered in accordance with the medical plan of care. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. The resident had physician orders [REDACTED]. (cubic centimeters) liquid PO at hour of sleep as needed for constipation." According to the facility bowel book, the resident was coded as "0" (indicating no bowel movement) for 12 shifts or 96 hours on the dates of 1/21/12, 1/22/12, 1/23/12 and 1/24/12. Review of the Resident's MAR for January 2012 indicated that the resident did not receive Milk of Magnesia on either 1/22/12 or 1/24/12, when the medication should have been administered in accordance with the physician's orders [REDACTED]. According to the facility bowel book, the resident was again coded as "0" (indicating no bowel movement) for 7 shifts or 56 hours on the dates of 4/27/12, 4/28/12, and 4/29/12. Review of the Resident's MAR for April 2012 indicated that the resident did not receive Milk of Magnesia on 4/29/12 when he/she had gone more than 48 hours without a bowel movement. Nurses notes on 4/30/12 from the night shift include documentation that the resident was "awake at 3:00 A.M. complaining of Left sided abdominal pain states been bothering him/her all day. Abdomen firm tenderness Left side. BS + (positive). Stool noted rectum after digital." On 4/30/12 day shift, the resident complained of "abdomen distention." The facility obtained an order for [REDACTED]. Results of the X-ray were obtained later that day and concluded "there is a large amount of rectal stool present." Further radiology studies on 5/1/12 concluded that "There is a large amount of rectal stool present. The findings are worse than 4/30/2012." Additional radiology studies on 5/2/12 indicated "considerable constipation." On 5/3/12, the Radiology report impression was documented as "Severe constipation and Probable Fecal Impaction." Resident #12 experienced pain, severe constipation and fecal impaction as a result of the facility's failure to administer bowel medications in accordance with physician's orders [REDACTED]. Please refer to F309. 4. For Resident #17, the facility failed to implement the resident's nursing care plan for monitoring the [MEDICAL TREATMENT] access as ordered. For Resident #17, the facility failed to ensure that assessments of the resident's A-V (arterio-venous) fistula were completed and documented daily as required in the resident's nursing care plan. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident received [MEDICAL TREATMENT] three days a week and and had a A-V fistula implanted in his/her right arm as an access site for his/her [MEDICAL TREATMENT]. According to the resident's nursing care plan dated 4/17/12, [MEDICAL TREATMENT] care for the resident included an order to "monitor shunt site by palpating for thrill and bruit daily. Notify MD of absence of bruit or thrill." Review of the resident's Treatment Administration Record (TAR) for April, 2012 indicated that the palpating for thrill and bruit had not been signed off as being completed for any of the 14 days that the resident was in the facility, 4/17/12 through 4/30/12. Further review of the resident's clinical record indicated in nurse's notes that checks for presence of bruit and thrill had been completed on 4/17, 4/18, 4/19, 4/20, 4/21, 4/22, 4/23, 4/24, 4/25, 4/26, 4/28 and 4/30/12. There was no evidence that the checks for bruit and thrill had been completed for 2 of 14 days in April (4/27 and 4/29) as ordered.

Not corrected. Based on record review and staff interviews, the facility failed to follow the plan of care as ordered for 4 sampled residents (#5, #6, #15 and #16) in a total sample of 14 residents. Findings include: 1. For Resident #6, the facility failed to administer bowel medications as ordered in accordance with the medical plan of care Resident # 6 was admitted to the facility in 2/2011 with [DIAGNOSES REDACTED]. The Resident had physician orders [REDACTED]. The facility policy states: "3-11 begins this process". If no BM in 3 days follow this protocol beginning on day 3." a. 3-11 LN (licensed nurse) you must review your assignments BM book QD (every day)...if a resident has not had a BM now for the third day then administer/offer (and document) MOM A/O (as ordered) PRN. If the resident refuses you need to document this in a NN (nurses note) and also include what else you may have done or offered. b. 3-11 LN - will then write the resident's name on (this) form and then document also the time and medicine they gave. c. 11-7 LN will get this form QHS at report and you will monitor for results throughout your shift and if no BM by 6:00 A.M. then you will administer/offer (and document) [MEDICATION NAME] suppository. If the resident refuses then you need to document this in a NN and include what you have done or offered. d. 11-7 LN will document the results of the MOM or they will document that they gave the [MEDICATION NAME] suppository if no results. e. 7-3 LN will then get this form from report QAM (every morning) and will monitor for results and if no BM by 1:00 P.M. you will administer/offer a fleet enema if no results. f. 7-3 LN - if no results from the fleet enema then you need to call the MD by 3:00 P.M. for further orders for this day. Then intervention and documentation beyond this must continue as needed. Review of the bowel documentation for Resident #6 from 7/4/12 through 7/08/12 indicated that the Resident did not have a BM on any shift for 5 days. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to the facility policy, the Resident should have received MOM on 7/6/12. Interview with the DON (Director of Nurses) at 4:00 P.M. verified that the policy and MD orders had not been followed. For Resident # 6, the facility failed to follow the facility policy and MD orders for the administration of medications for the treatment of [REDACTED]. 2. For Resident #12, the facility failed to administer bowel medications as ordered in accordance with the medical plan of care. Resident # 12 was admitted to the facility in 2009 with [DIAGNOSES REDACTED]. The Resident had physician orders [REDACTED]." Review of the facility bowel record for Resident # 12 for 7/2/12 through 7/5/12 indicated that the Resident did not have a BM on any shift for 4 days. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview with the DON on 7/10/12 at 10:00 A.M. verified that the Resident did not receive bowel medications as ordered in accordance with physician orders [REDACTED]. A progress note written by the PA (physician assistant) dated 6/29/12 included documentation that Resident # 12 used to have a bowel movement every 4 days and this is not advisable in his/her medical condition. 3. For Resident # 15, the facility failed to administer bowel medications in accordance with the medical plan of care. Resident # 15 was admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. The Resident had physician orders [REDACTED]." Review of the facility bowel record for Resident # 15 for 7/2/12 through 7/5/12 indicated that the Resident did not have a BM on any shift for 4 days. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 4. For Resident # 16, the facility failed to administer bowel medications in accordance with the medical plan of care. The facility also failed to ensure that the Resident received nutritional supplements as ordered by the MD Resident # 16 was admitted to the facility in 2012 with [DIAGNOSES REDACTED]. The Resident had physician orders [REDACTED]." Review of the Resident's individual bowel record from 7/2/12 through 7/5/12 indicated that the resident did not have a BM on any shift for 4 days. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MOM should have been administered on 7/4/12. The Resident also received a [MEDICATION NAME] suppository on 7/6/12 after day 6 of no BM. According to facility policy, the Resident should have received the suppository on day 4 of no BM. Interview with Unit Manager # 1 on 7/10/12 at approximately 11:30 A.M. verified that the facility policy and MD orders had not been followed. The facility failed to follow the policy and MD orders for administration of medications for the treatment of [REDACTED]. In addition for Resident # 16, the facility failed to ensure that nutritional supplements were provided as ordered by the MD. Review of the MD orders dated 6/10/12 indicated the Resident was to receive: Ensure 8 ounces with all meals and Super Pudding with lunch and dinner. The surveyor observed the Resident's lunch tray on 7/10/12 at approximately 12:15 P.M. The tray did not contain either the Ensure or the super pudding. Review of the Resident's meal card from the kitchen did not indicate that the Resident was supposed to receive the Ensure or the super pudding. Interview with Unit Manager #3 on 7/10/12 verified the tray did not contain either the Ensure of the super pudding. Interview with the facility evening chef at 3:30 P.M. on 7/10/12 verified that in order for the Resident to receive Ensure and super pudding, the meal card and dietary slip had to contain the information. The facility failed to provide nutritional supplements as ordered for Resident # 16.

2. For Resident #5 the facility failed to ensure that a bed tab alarm was functioning and sounded when Resident #5 was found out of bed. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS of 1/6/12 on 5/9/12 revealed the Resident had problems with long and short term memory, required extensive assistance with transfer and ambulation and was frequently incontinent. Review of the plan of care for falls at the time of admission on 1/3/12 indicated the resident was at risk for fall related injury as evidenced by a history of falls with a fall in the previous month. The approaches noted to prevent further falls included keep the area free of clutter and adquate glare free lighting, provide use of adaptive devices such as a walker or cane or wheelchair when needed, and tab alarm in bed and chair. Review of the incident report and nurses notes of 2/6/12 at 11P.M. indicated a CNA heard a yell went to the room and observed the Resident standing at the foot of the bed and leaning forward as if she/he was about to fall and ran into the room to keep him/her from falling forward. The CNA slid his/her hands under the arms to stabilize the Resident. At this time the CNA noticed blood coming from the Resident's wrist. The nurse came into the bedroom and noted a skin tear on the left wrist which was swollen and painful. The physician was notified and an x-ray of the wrist was ordered. The x-ray results came back the next day with a radially displaced, comminuted distal radius fracture. The Resident was sent to the emergency room for examination. The Resident returned with a half cast and ace wrap having had a closed reduction in the emergency department. A statement that was signed by the nursing supervisor but not dated indicated the tab alarm was not on when the resident was found standing up at the bottom edge of the bed. Based on record review and staff interviews, the facility failed to provide adequate supervision to prevent accidents with serious injury for 2 residents (#9 and #5), out of a total sample of 23 residents. Findings include: Resident #9 was admitted to the facility 7/1/08 and readmitted [DATE]. This Resident's [DIAGNOSES REDACTED]. Resident #9 sustained a fall on 4/15/12 at this facility that resulted in a fractured hip which required surgical repair on 4/15/12. The Resident had a decline in condition and was admitted to Hospice Service on 4/27/12. Review of the falls care plan dated 7/19/11, updated 10/11, 1/20/12, and 4/10/12 indicated that this Resident was at risk for injury related to falls. The contributing factors were dementia with delusions, decreased safety awareness, and previous falls. This care plan had the following pertinent interventions: - Low bed with floor mats - Chair pad alarm -Tab alarm -"Staff to assist (resident) in reaching his/her destination with cues and supervision" Additional interventions were to keep resident in a supervised area and provide closer supervision when he/she becomes agitated. Review of the nurse's note and facility investigation of 4/15/12 indicated that the resident had an unwitnessed fall in the dining room at about 3:15 P.M. Review of the incident report and witness statements obtained by the charge nurse after the fall on 4/15/12 indicated that the Resident was in the dining hall, no staff member witnessed the fall and that the resident was unsupervised at the time of the fall. The Resident was found "on the floor on back with chair alarm going off. Resident unable to explain what happened but screamed when you touch thigh or hip and femur". Under the section labeled "Probable Cause" on the investigation form, the written statement is "unassisted ambulation". Review of the nurse's note and facility investigation of 2/20/11 indicated that the Resident was grimacing in pain after the fall. The facility obtained x-rays which indicated a hip fracture. The resident was sent out to the hospital and underwent surgical repair of the fracture. During interview with the unit manager on 5/15/12 at 10:30 A.M., he/she acknowledged that although this Resident was care planed to be in a supervised area, according to the statements provided by the staff assigned to work on 4/15/12, this Resident was not supervised at the time of the fall in the dining room. According to the written statements, the Certified Nursing Assistants were attending to other residents and the two nurses on duty were engaged in activities with other residents, and the Resident was not visible to them.

Based on record review and interviews, the Facility failed to thoroughly investigate and report to the Department of Public Health (DPH) allegations of suspected abuse for 3 sampled residents (Resident # 1, Resident # 9, and Resident #11) in a sample of 11 residents, per the Facility Abuse Policy. Findings include: The Facility's Policy on Conducting an Investigation regarding allegations of Abuse indicated that allegations of abuse were thoroughly investigated. The Policy indicated that the Facility must take action to prevent further potential abuse while the investigation is in progress. The Policy indicated that the type of allegation that was being reported and the details of the allegation were to be documented. The Policy indicated that the resident was to be evaluated for emotional distress. The Policy indicated that other residents identified with physical signs of abuse were to be documented, a list was to be developed for known and possible witnesses to the alleged incident. The Policy indicated that staff members, visitors, and /or residents who may have knowledge of the alleged incident being investigated were to be interviewed. The Policy indicated that the alleged perpetrator's version of the incident was to be obtained; the perpetrator's past performance or other incidents were to be reviewed, and coworkers and/or residents were to be interviewed to gain knowledge regarding their experiences with the accused person. The Policy indicated that actions taken by the Facility to protect the residents and to prevent a possible reoccurrence during the investigation was to be documented. The Policy indicated that upon the conclusion of the investigation, a summary report of the findings and conclusions was to be submitted to the State Survey Agency within 5 working days of the initial incident. The Nurse Consultant was interviewed on 10/19/11 at 11:30 A.M. The Nurse Consultant said that on 9/30/11, the Director of Nurses received a report that Certified Nurse Aide (CNA) #1 was abusive to residents. The Nurse Consultant said that staff interviews began on 10/3/11. The Nurse Consultant said that on 10/6/11, complaints were still vague, but staff, including CNA #2 and CNA #6 began coming forward with additional information. The Consultant said that grievances were reviewed and a list of potentially uninvestigated and unreported complaints was compiled and sent to the Department of Public Health. The following allegations were among the reports to DPH during October 2011. 1. The Record of Admission indicated that Resident #11 was admitted to the Facility in August 2004. The quarterly Minimum Data Set (MDS) assessment, dated 9/6/11, indicated that Resident #11 had problems with temporal orientation (orientation to year, month and day) and recall. The MDS indicated that Resident #11 required extensive assistance with feeding. The plan of care related to Resident #11's inadequate oral food/beverage intake, dated 3/8/11, indicated that Resident #11 had difficulty with chewing and difficulty swallowing. Resident #11's plan of care for nutrition, which was rewritten on 6/14/11, indicated that Resident #11 was at risk for nutritional decline related to dementia and depression. Interventions included providing feeding/dining assistance as needed. Resident #11 was observed by the Surveyors on 10/20/11 at 9:20 A.M, but Resident #11 kept his/her eyes closed and did not respond to questions or comments. Certified Nurse Aide (CNA) #2 was interviewed on 10/19/11 at 12:20 P.M, and CNA #2's written statement, dated 10/11/11, regarding the allegation was reviewed. CNA #2's written statement indicated that CNA #2 heard CNA #1 say that CNA #1 was taking Resident #11's tray away before Resident #11 finished the meal. CNA #2 said CNA #1 said words to the effect that Resident #11 took too [***] ing long to finish a meal. CNA #2 said CNA #1 said this in the dining room, where others could hear. CNA #2's statement indicated that CNA #1only gave Resident #11 half the food, because CNA #1 said it took too long to [***] ing feed Resident #11. CNA #2 said that Resident #11's facial expression showed signs of fear, when Resident #11 saw CNA #1. CNA #2 said Resident #11 told CNA #1 to stop and slow down during personal care, because CNA #1 was too rough. CNA #2 said CNA #2 reported these concerns to the former Director of Nursing (DON #2) and received no response. CNA #5 was interviewed on 10/19/11 at 4:15 P.M. and CNA #5's written statement regarding the allegation, dated 10/13/11 was reviewed. Interview with CNA #5 and CNA #5's statement indicated that CNA #5 observed CNA #1 feeding Resident #11 in the dining room (date unknown). CNA #5 said CNA #1 jammed food into Resident #11's mouth. CNA #5's statement indicated that Resident #11 kept telling CNA #1 to stop and asked CNA #1 how CNA #1 could be a nurse. CNA #5 said Resident #11 was a slow eater and CNA #1 was impatient with Resident #11. CNA #5 said although Resident #11 told CNA #1 to stop, CNA #1 continued to feed Resident #11. CNA #5 said CNA #1 made a mess of Resident #11's face and clothing protector. CNA #5's statement and interview with CNA #5 indicated that CNA #1 pushed the spoon into Resident #11's mouth, when Resident #11's mouth was closed. CNA #5 said the food went everywhere, because Resident #11 was not ready for more food. CNA #6 was interviewed on 10/19/11 at 4:45 P.M. and CNA #6's written statement regarding the allegation, dated 10/12/11 was reviewed. CNA #6 said CNA #1 did not allow Resident #11 adequate time to eat and was constantly forcing Resident #11 to eat. CNA #6 said CNA #1 did not feed Resident #11 all of the meal. CNA #6 said CNA #1 was rough while washing and moving Resident #11. CNA #6's written statement indicated that CNA #1 was disrespectful and rude to residents. CNA #6's written statement indicated that CNA #1 was rough during the provision of personal care to Resident #11. CNA #6 indicated that residents were afraid of CNA #1. CNA #6's written statement indicated that CNA #1 constantly "bad mouths" residents, told residents to shut up, and if CNA #1 did not like a resident, CNA #1 openly said mean things regarding that resident in public. CNA #2 reported concerns about CNA #1's treatment of [REDACTED]. 2. The Record of Admission indicated that Resident #1 was admitted to the Facility in May 2010. The quarterly Minimum Data Set (MDS) assessment, dated 9/22/11, indicated that Resident #1 had no problem with temporal orientation (orientation to year, month and day) and recall. The MDS indicated that Resident #1 was totally dependent for dressing and personal hygiene. Resident #1's plan of care related to self care deficit, dated 4/28/11, indicated that Resident #1 was dependent for dressing and required the assistance of one for dressing. The Grievance/Complaint Report, dated 3/21/11, indicated that Resident #1 asked CNA #1 why CNA #1 talked loud; CNA #1 threw a johnny on Resident #1's chest, and left the room to find someone else to care for Resident #1. The Grievance/Complaint Report indicated that CNA #1 was reassigned due to personality conflicts. Resident #1 was interviewed on 10/20/11 at 7:50 A.M. Resident #1 said that one morning, CNA #1 removed Resident #1's clothing to get Resident #1 dressed for the day. Resident #1 said during personal care, CNA #1 got mad at Resident #1. Resident #1 said Resident #1 did not know why CNA #1 was angry. Resident #1 said CNA #1 left the room without dressing Resident #1. Resident #1 said Resident #1 was left naked on the bed and was afraid. Resident #1 said Resident #1 yelled for assistance and a staff member assisted Resident #1 with clothing. Although the alleged incident took place in March 2011, documentation indicated that an investigation regarding the allegation was not initiated until October 2011. Unit Manager #1 was interviewed on 10/20/11 at 2:50 P.M. and Unit Manager #1's statements, dated 3/21/11 and 10/4/11 were reviewed. The statement, dated 3/21/11, indicated the following. On 3/20/11 during the 7:00 A.M to 3:00 P.M shift, CNA #1 was getting Resident #1 ready to get out of bed. Resident #1 asked CNA #1 why CNA #1 was talking so loud. Resident #1 told CNA #1 that if CNA #1 spoke in a normal tone of voice, Resident #1 could hear. The statement indicated that Resident #1 asked again why CNA #1 was talking so loud. The statement indicated that CNA #1 threw a johnny on Resident #1's chest and left the room. The statement indicated that CNA #1 told Resident #1 that CNA #1 was going to get someone else to take care of Resident #1. Nurse #6 was interviewed on 10/19/11 at 2:05 P.M. and Nurse #6's written statement regarding the allegation that was not dated, was reviewed. Nurse #6 said Resident #1 said CNA #1 rushed Resident #1 during personal care and Resident #1 did not like being rushed. Nurse #6's written statement indicated that after Resident #1 accused CNA #1 of talking loudly, CNA #1 tossed Resident #1's johnny, and told Resident #1 that CNA #1 was going to get someone else to provide personal care to Resident #1. The statement indicated that another CNA came in to finish Resident #1's care. Although the alleged incident took place on 3/11/11 (per Facility Report to Department of Public Health) or 3/20/11 (per statement of Unit Manager #1), an investigation was not initiated until October 2011. Residents/staff could not recall who replaced CNA #1 to finish Resident #1's personal care. 3. The Record of Admission indicated that Resident #9 was admitted in September 2002. Resident #9's care plan for cognitive loss, dated 10/15/10, indicated that Resident #9 had problems with decision-making and short-term memory. Interventions included promote dignity and converse with Resident #9. Resident #9's care plan for behavior, dated 3/18/11, indicated that Resident #9 exhibited socially inappropriate behavior, including calling out and repetitive actions, which included screaming. Interventions included anticipate care needs and meet care needs before Resident #9 became overly stressed. The Director of Maintenance (Director) was interviewed on 10/20/11 at 9:00 A.M and on 10/25/11 at 10:35 A.M. The Director said that on 3/11/11 at about 3:00 P.M, Resident # 9 was screaming, "help, help". The Director said this behavior was not unusual for Resident #9. The Director said Resident #9 was sitting in a geri-chair near the window of Resident #9's three-bed room. The Director said Resident #9 was alone in the room. The Director said CNA #10 approached the room and stood just outside the door. The Director said CNA #10 began dancing, laughing and mocking Resident #9 from the doorway. The Director said CNA #10 did not enter the room to offer assistance or to comfort Resident #9. The Director said that CNA #10 stopped, when CNA #10 noticed that the Director was watching. The Director said CNA #10 left the doorway and went to the nurses' station to get own belongings. The Director said CNA #10 left the unit. The Director said there were no other residents in the area, and the Director thought CNA #10's actions were directed at Resident #9. The Director thought CNA #1 was mocking Resident #9. The Director provided a copy of an e-mail, which was sent to the former Director of Nursing (DON #2), reporting the incident. The Director reported the observation to the former Assistant Director of Nursing immediately. The Director returned to the facility on [DATE] and noticed that CNA #10 was still working. The Director questioned why CNA #10 was not suspended and why an investigation was not initiated. The Director reported being told that the situation was taken care of. Although the alleged incident took place on 3/11/11, a complaint was not filed with Department of Public Health until 10/13/11.

Based on record review and interview, for 1 of 2 sampled residents (Resident #1), the Facility failed to ensure that Resident #1 was free of significant medication errors when Nurse #1 transcribed a physician order [REDACTED].#1 and Resident #1 received 12 incorrect doses of [MEDICATION NAME] [MEDICATION]) resulting in hospitalization for treatment of [REDACTED]. The findings included: A medication error report, dated 3/7/11, indicated that due to a failure to check medications with the MAR and failure to follow Facility policy by Nurse #1 and the Physician Assistant, there was an error in the prescribing, documenting and administering of [MEDICATION NAME] to Resident #1 when Resident #1 received 300 milligrams (mg) of [MEDICATION NAME] three times a day instead of 200 mg of [MEDICATION NAME] twice a day, for 4 days and was hospitalized for [REDACTED]. Resident #2's face sheet indicated that Resident #2 was admitted to the facility on [DATE] and Resident #2's [DIAGNOSES REDACTED]. Resident #1's face sheet indicated that Resident #1 was admitted to the facility on [DATE]. The face sheet indicated that Resident #1 had the same last name and a similar first name as Resident #2. Observation on the day of survey, indicated that Resident #1 and Resident #2 resided on different units/floors of the Facility. The [DIAGNOSES REDACTED]. A physician order, dated 1/31/11, indicated Resident #1's [MEDICATION NAME] dose was 200 mg twice a day for a total dose of 400 mg per day. A laboratory blood test result sheet, dated 2/28/11, for Resident #2, indicated that the physician assistant reviewed the results and wrote an order on the blood test result sheet to continue the current dose of [MEDICATION NAME] at 300 mg three times a day. A physician's telephone order, dated 2/28/11 and written by Nurse #1, indicated the physician assistant ordered that Resident #1's [MEDICATION NAME] dose should continue at the same dose of 300 mg, three times a day (total dose was 900 mg per day). The order was noted and posted by Nurse #1. The medication administration record for Resident #1, dated 3/1/11 to 3/31/11, indicated that on 3/1/11, 3/2/11, 3/3/11, and 3/4/11, Resident #1 received [MEDICATION NAME] 300 mg three times a day on each of the days for a total dose of 900 mg per day. A nurse's note, dated 3/4/11, indicated that Resident #1's confusion had increased from Resident #1's baseline confusion, and Resident #1 was exhibiting decreased strength and weakness in right hand. The note indicated the physician assistant was notified and Resident #1 was transferred to the Hospital for evaluation. The Physician Assistant (PA) was interviewed on 3/30/11 at 11:30 AM. The PA said that the PA reviewed the laboratory test result sheets in a back room on the second floor. The PA said that the PA reviewed the results for Resident #2 and since the [MEDICATION NAME] level was all right, the PA wrote to continue the current dose of 300 mg three times a day. The PA said that the sheet was placed in Resident #2's record and put on the desk at the nurses' station. The PA said that the PA should have written the order on a physician order [REDACTED]. Nurse #1 was interviewed on 3/30/11 at 1:00 PM. Nurse #1 said that on 2/28/11, Nurse #1 noted a pile of laboratory test result sheets on the nurses' station desk and reviewed them for orders. Nurse #1 said that Nurse #1 saw Resident #1's name on a sheet and there was a physician order [REDACTED].#1 obtained the MAR for Resident #1, discontinued the current dose on the MAR and wrote the new dose on the MAR. Nurse #1 said Nurse #1 pulled the yellow carbon copy and placed it in the bin for new orders that were to be checked at end of month editing. Nurse #1 said that Nurse #1 only looked at the last name of the resident listed on the laboratory result sheet and did not read the full name before posting the new order on Resident #1's MAR. Nurse #1 said that Nurse #1 did not know how the laboratory sheet for Resident #2 who resides on the second floor got to the 3rd floor where Resident #1 resides. The Assistant Director of Nursing (ADON) was interviewed in 3/30/11 at 2:10 PM. The ADON said that when Resident #1 began to exhibit weakness, Resident #1 was transferred to the Hospital. The ADON said that when the medication error was discovered the ADON spoke with Nurse #1 who said that the physician order [REDACTED]. The ADON said that Nurse #1 was counseled relative to this practice. The Director of Nursing (DON) was interviewed on 3/30/11 at 7:30 AM. The DON said that when the Physician Assistant (PA) was reviewing laboratory results, the PA wrote the new order for Resident #2 on the bottom of the laboratory result sheet instead of on a physician order [REDACTED]. The DON said that the sheet somehow was taken to the third floor and Nurse #1 did not read the resident's whole name before posting the order on Resident #1's MAR. The DON said that the medication error was not discovered until Resident #1 returned from the Hospital with the [DIAGNOSES REDACTED]. The DON said that Nurse #1 was terminated from the Facility. The discharge summary, dated 3/7/11, indicated that Resident #1 was hosptalized on [DATE], and Resident #1 had a [MEDICAL CONDITION] disorder that was being treated with [MEDICATION NAME] [MEDICATION]). The summary indicated Resident #1's [MEDICATION NAME] blood level drawn at the Hospital was elevated at 32 (normal range is 10.0-20.0) and Resident #1 had [MEDICATION NAME] toxicity. The summary indicated that Resident #1's [MEDICATION NAME] was held during the hospitalization and Resident #1's admission symptoms (weakness, change in mental status, slurred speech and difficulty speaking) had improved. The summary indicated that Resident #1 was discharged back to the facility on a [MEDICATION NAME] dose of 150 mg in the morning and 200 mg at bedtime.

Based on record review and interview, for 1 of 2 sampled residents (Resident #1), the Facility failed to ensure that services provided met the professional standards of practice when: - the Physician Assistant wrote the physician order [REDACTED]. - when Nurse #1 transcribed the physician order [REDACTED].#1 and Resident #1 received 12 incorrect doses of [MEDICATION NAME] (anti [MEDICAL CONDITION] medication) resulting in hospitalization for treatment of [REDACTED]. The findings included: The Facility policy relative to Verbal or Telephone Orders indicated that the verbal/telephone order should be repeated back to the practitioner, documentation should be made in the resident's progress notes about the physician visit including any new orders, and the order should be transcribed to the appropriate medication administration record. The Facility policy relative to Physician order [REDACTED]. The policy indicated that orders and dosages which appear inappropriate should be verified. Resident #2's face sheet indicated that Resident #2 was admitted to the facility on [DATE] and Resident #2's [DIAGNOSES REDACTED]. Resident #1's face sheet indicated that Resident #1 was admitted to the facility on [DATE]. The face sheet indicated that Resident #1 had the same last name and a similar first name as Resident #2. Observation on the day of survey, indicated that Resident #1 and Resident #2 resided on different units/floors of the Facility. The [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 1/14/11, indicated Resident #1 exhibited clear speech, and scored a 10 out of a possible 15 on a cognitive status test. The MDS indicated that Resident #1's [DIAGNOSES REDACTED]. A physician order, dated 1/31/11, indicated Resident #1 was to be administered [MEDICATION NAME] 200 milligrams (mg) twice a day for a total dose of 400 mg per day. A laboratory blood test result sheet, dated 2/28/11, for Resident #2, indicated that the physician assistant reviewed the results and wrote an order on the blood test result sheet to continue the current dose of [MEDICATION NAME] at 300 mg three times a day. A physician's telephone order, dated 2/28/11 and written by Nurse #1, indicated the physician assistant ordered that Resident #1's [MEDICATION NAME] dose should continue at the same dose of 300 mg, three times a day (total dose was 900 mg per day). The order was noted and posted by Nurse #1. The medication administration record for Resident #1, dated 3/1/11 to 3/31/11, indicated that on 3/1/11, 3/2/11, 3/3/11, and 3/4/11, Resident #1 received [MEDICATION NAME] 300 mg three times a day on each of the days for a total dose of 900 mg per day. The Physician Assistant (PA) was interviewed on 3/30/11 at 11:30 AM. The PA said that the PA reviewed the laboratory test result sheets in a back room on the second floor. The PA said that the PA reviewed the results for Resident #2 and since the [MEDICATION NAME] level was all right, the PA wrote to continue the current dose of 300 mg three times a day. The PA said that the sheet was placed in Resident #2's record and put on the desk at the nurses' station. The PA said that the PA should have written the order on a physician order [REDACTED]. Nurse #1 was interviewed on 3/30/11 at 1:00 PM. Nurse #1 said that on 2/28/11, Nurse #1 noted a pile of laboratory test result sheets on the nurses' station desk and reviewed them for orders. Nurse #1 said that Nurse #1 saw Resident #1's name on a sheet and there was a physician order [REDACTED]. Nurse #1 said that Nurse #1 obtained the MAR for Resident #1, discontinued the current dose on the MAR and wrote the new dose on the MAR. Nurse #1 said Nurse #1 pulled the yellow carbon copy and placed it in the bin for new orders that were to be checked at end of month editing. Nurse #1 said that Nurse #1 only looked at the last name of the resident listed on the laboratory result sheet and did not read the full name before posting the new order on Resident #1's MAR. Nurse #1 said that Nurse #1 did not know how the laboratory sheet for Resident #2, who resides on the second floor, got to the 3rd floor where Resident #1 resides. The Assistant Director of Nursing (ADON) was interviewed in 3/30/11 at 2:10 PM. The ADON said that when Resident #1 began to exhibit weakness, Resident #1 was transferred to the Hospital. The ADON said that when the medication error was discovered, the ADON spoke with Nurse #1 who said that the physician order [REDACTED]. The ADON said that Nurse #1 was counseled relative to this practice. The Director of Nursing (DON) was interviewed on 3/30/11 at 7:30 AM. The DON said that when the Physician Assistant (PA) was reviewing laboratory results, the PA wrote the new order for Resident #2 on the bottom of the laboratory result sheet instead of on a physician order [REDACTED]. The DON said that the sheet somehow was taken to the third floor and Nurse #1 did not read the resident's whole name before posting the order on Resident #1's MAR. The DON said that the medication error was not discovered until Resident #1 returned from the Hospital with the [DIAGNOSES REDACTED]. The DON said that Nurse #1 was terminated from the Facility. A medication error report, dated 3/7/11, indicated that due to a failure to check medications with the MAR and failure to follow Facility policy by Nurse #1 and the Physician Assistant, there was an error in the prescribing, documenting and administering of [MEDICATION NAME] to Resident #1 when Resident #1 received 300 mg of [MEDICATION NAME] three times a day, instead of 200 mg of [MEDICATION NAME] twice a day, for 4 days and was hospitalized for [REDACTED]. Refer to F333