Every finding on record at Windsor Nursing & Retirement Home

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to properly label and date thickened liquids, by not indicating open dates, in one of one nourishment kitchenettes and two of two resident unit refrigerators and failed to ensure one opened thickened liquid was refrigerated after opening in one of one nourishment kitchenettes.Findings include: Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following:3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.(B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety.(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request. On 3/18/26 at 9:22 A.M., the surveyor made the following observation of the shared nourishment kitchenette:-One thickened cranberry cocktail carton, opened with no opened date identified, stored in upper cabinet, not refrigerated. Manufacturer's instructions on label indicated after opening may be kept up to 7 days under refrigeration. On 3/18/26 at 9:35 A.M., the surveyor made the following observation of the A wing nourishment refrigerator:-One thickened dairy beverage opened but not dated. Manufacturer's instructions on label indicated to refrigerate after opening and discard within 3 days. On 3/18/26 at 9:45 A.M., the surveyor made the following observation of the B wing nourishment refrigerator:-Three thickened beverage cartons open and not dated. Manufacturer's instructions indicated after opening may be kept up to 7 days under refrigeration. During an interview on 3/18/26 at 10:10 A.M., Food Service Director (FSD) #1 said the kitchen staff are responsible for checking the kitchenette and nourishment refrigerators and that all items should be labeled with dates indicating when they are received at the facility and when the item is opened. FSD #1 said it is his expectation that the kitchen staff would have discarded undated and out-of-date items and that the opened thickened liquids in the kitchenettes should have been refrigerated after opening.

Based on interview and record review, the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws. Specifically, the facility failed to ensure a nurse assigned to direct resident care had an active license as a Registered Nurse. Findings include:According to the Massachusetts Board of Registration in Nursing a Registered Nurse is the designation given to an individual who is licensed to practice professional nursing, holds ultimate responsibility for direct and indirect nursing care, is a graduate of a Board approved school for professional nursing, and is currently licensed as a Registered Nurse pursuant to M.G.L. c. 112. Review of the employee file for Nurse #5 indicated the nurse was hired on [DATE] and their Registered Nurse (RN) License expired on [DATE]. The printed License Verification did not include a date the information was obtained. Review of the job description for Nurse #5 indicated the primary purpose of the position was to provide quality nursing care to residents, utilizing the nursing process of assessment, planning intervention, implementation, and evaluation while maintaining all standards of professional nursing. Qualifications included current Massachusetts nursing license as an RN. The surveyor attempted to contact Nurse #5 on [DATE] at 10:35 A.M., with no return call prior to the end of survey. During an interview on [DATE] at 10:36 A.M., the Administrator said Nurse #5 came forward this week to tell management that she did not have an active nursing license. He said the process was for Human Resources to check all licenses prior to hire. He said the Human Resource staff member had been out on leave since [DATE]. During an interview on [DATE] at 10:40 A.M., the Director of Nurses said Nurse #5 was a floor nurse assigned to a medication cart and had been doing direct resident care. Review of the employee time sheet indicated Nurse #5 worked as a floor nurse doing direct resident care on the following days:[DATE] for 8 hours[DATE] for 6 hours[DATE] for 8 hours[DATE] for 8.5 hours[DATE] for 7.75 hours[DATE] for 8.25 hours[DATE] for 9 hours[DATE] for 8 hours[DATE] for 8 hours[DATE] for 9 hours[DATE] for 7.75 hours[DATE] for 9 hours[DATE] for 7.75 hours[DATE] for 7.5 hours[DATE] for 7.75 hours[DATE] for 8.25 hours[DATE] for 8.75 hours[DATE] for 7.75 hours and[DATE] for 8 hours During an interview on [DATE] at 11:22 A.M., a representative from the Massachusetts Bureau of Health Professions Licensure said the RN license for Nurse #5 expired on [DATE] and this was not a retroactive decision, and the license had been expired since that date. During an interview on [DATE] at 11:30 A.M., the Assistant Director of Nurses said Nurse #5 completed her shift on [DATE] (the first day of survey), left the facility and then called her to notify the facility that Nurse #5 did not have an active license. During an interview on [DATE] at 12:16 P.M., the Administrator said the covering Human Resource staff should have checked the RN license for Nurse #5 as part of the hiring process and there is no indication this was done at that time.

Based on observations, interviews, and record review, the facility failed to implement safe smoking strategies for one Resident (#1), out of two sampled residents who smoked cigarettes. Specifically, the facility failed to ensure the safe smoking strategy of wearing a smoking apron (flame-resistant protective garment designed for individuals, often in wheelchairs, to shield themselves and their clothing from hot ashes) was implemented for Resident #1 while smoking.Findings include:Resident #1 was admitted to the facility in May 2019. Review of the Minimum Data Set assessment, dated 2/9/26, indicated Resident #1 scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had a moderate cognitive impairment. During an interview on 3/18/26 at 2:10 P.M., Resident #1 said he/she smoked one to two cigarettes per day. The Resident said he/she had not gotten up for the day yet and planned to go to the next smoking break. Review of the Nursing Annual Assessment, dated 3/8/26, indicated Resident #1 wished to smoke cigarettes and lacked adequate judgement toward their ability to smoke safely, with an intervention to wear a smoking apron. Review of a Care Plan for smoking indicated Resident #1 needed to wear an apron while smoking if indicated on the assessment. On 3/18/26 at 4:10 P.M., the surveyor observed Resident #1 outside smoking with supervision from the Housekeeping Supervisor. Resident #1 was not wearing a smoking apron. He/she was observed smoking with their left hand and the cigarette had a long ash, the Resident attempted to flick the ash, but nothing came off. The Resident brought the cigarette with the long ash to their mouth to continue smoking. The Resident moved their left hand with the cigarette to the left of them and the long ash fell off the cigarette to the left of the Resident. During an interview on 3/18/26 at 4:10 P.M., the Housekeeping Supervisor said none of the facility residents who smoke required any safety devices such as aprons. She said Resident #1 did not need a smoking apron. During an interview on 3/19/26 at 1:04 P.M., Resident #1 said he/she was currently waiting to go outside to smoke. The Resident said the staff put a smoking apron on him/her last night. The Resident said the staff would previously put an apron on him/her but had not in a long time until last night at the 6:00 P.M. smoking time. During an interview on 3/19/26 at 1:10 P.M., Unit Manager #1 said Resident #1 should be wearing an apron while smoking and staff should assist the Resident in putting it on. During an interview on 3/19/26 at 2:20 P.M., the Housekeeping Supervisor said after the surveyor inquiry on 3/18/26 she had inquired with the nursing staff if Resident #1 needed to wear an apron while smoking and they had said yes. She said she often supervisors the smoking times for residents and had not been told Resident #1 needed to wear a smoking apron. During an interview on 3/19/26 at 2:28 P.M., the Director of Nurses said changes to smoking safety interventions, such as an apron, are added to the care plans and care cards (used by Certified Nursing Assistants (CNA) to determine care needs). She said the staff who were not CNAs or nurses would need to be told of any changes and there currently was not a process for this.

Based on observation, interview, and record review, the facility failed to ensure one Resident (#10), out of a total of sample of 19 residents, was provided with a therapeutic diet based on his/her comprehensive assessment and as ordered by the physician. Specifically, the facility failed to ensure he/she was administered the correct enteral feeding (delivering nutrition directly into the gastrointestinal tract for individuals unable to consume enough food by mouth) formula based on their nutritional needs.Findings include:Review of the facility's policy titled Enteral Tube Medication Administration, effective date 6/1/10, indicated but was not limited to:-The facility assures the safe and effective administration of enteral formulas and medications via enteral tubes.-Selection of enteral formulas are based on nursing assessment of the resident's condition, in consultation with the physician, dietitian, and consultant pharmacist.Resident #10 was admitted to the facility in January 2026 with diagnoses including malignant neoplasm of supraglottis (cancerous growth in the upper part of the larynx) and severe protein malnutrition.Review of the Minimum Data Set assessment, dated 1/19/26, indicated Resident #10 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15 and had received 51% or more of nutrition through his/her gastrostomy tube (G-tube, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications).During an interview on 3/17/26 at 10:04 A.M., Resident #10 said he/she had a G-tube and had received his/her medications and bolus feeds (administration of a limited volume of enteral formula over brief periods of time) through it.Review of Resident #10's current Physician's Orders indicated but was not limited to:-Formula: Jevity Strength 1.5, Volume to administer: 240 milliliters (ml), five times daily, dated 1/19/26During an interview with observation on 3/18/26 at 12:04 P.M., the surveyor observed Nurse #3 prepare and administer Jevity 1.2 CAL (calorie dense) 240 ml to Resident #10. Nurse #3 showed the surveyor the container of Jevity 1.2 CAL and said Resident #10 was scheduled for Jevity 1.2 five times a day through his/her G-tube.On 3/19/26 at 8:40 A.M., the surveyor observed Nurse #3 prepare and administer Jevity 1.2 calorie 240 ml to Resident #10 via his/her G-tube.During an interview on 3/19/26 at 8:56 A.M., Nurse #3 reviewed Resident #10's physician's orders. She said Resident #10 was prescribed Jevity 1.5 CAL 240 ml five times daily via G-tube. She said she administered Jevity 1.2 CAL to Resident #10. She checked her medication cart and the medication room on the unit and said there was only Jevity 1.2 CAL on the unit. She said the Jevity 1.2 formula she administered to Resident #10, on 3/18/26 at 12:04 A.M. and 3/19/26 at 8:40 A.M., was the incorrect formula and Jevity 1.5 CAL was not administered to Resident #10.During an interview on 3/19/26 at 9:13 A.M., Unit Manager #2 said enteral feeding formula is ordered to meet the nutritional needs of residents. She said the Registered Dietitian needed to be notified to adjust Resident #10's enteral feeding because of the difference in the formula. She said there was Jevity 1.5 CAL in the facility, but there was only Jevity 1.2 CAL on the unit.During an interview on 3/19/26 at 10:26 A.M., the Registered Dietitian said when a resident is on enteral feeding, the type of formula administered is calculated to their caloric and protein needs. He said if residents receive the incorrect enteral feeding formula, they are at risk for weight loss and dehydration. He said Resident #10 was prescribed Jevity 1.5 CAL per his/her nutritional assessment and what he/she was on prior to admission. He said Jevity 1.2 CAL was not clinically appropriate for Resident #10 and could have been problematic if he/she continued to receive it. He said he was not sure why Jevity 1.2 CAL was even in the facility, but it should not have been.

Based on interview and personnel record review, the facility failed to ensure the new hire employee records maintained documentation to indicate staff were provided education and offered information on obtaining the 2025-2026 COVID-19 vaccination for two out of five newly hired employees. Findings include: Review of the facility's policy titled COVID-19 Vaccine Requirements Residents and Staff, reviewed in March 2024, indicated the following:-Employees are required to be up to date with COVID-19 vaccine per DPH (Department of Public Health)-{Facility} educates staff about the vaccines, offers, and administers the vaccines, and documents vaccination status according to state and federal guidelines-Personnel declining the vaccine must include a statement certifying he or she received information about the risks and benefits of COVID-19 vaccine Food Service Director #3 was hired on 1/5/26. Review of the employee file failed to indicate the new employee had been offered the most recent COVID-19 vaccination. Nurse #5 was hired on 2/6/26. Review of the employee file failed to indicate the new employee had been offered the most recent COVID-19 vaccination. During an interview on 3/19/26 at 11:40 A.M., the Consultant Staff Development Coordinator indicated there was no information in the employee files regarding Food Service Director #3 or Nurse #5 being educated or offered the COVID-19 vaccination. She said the Infection Control Preventionist was responsible for the staff vaccination process. During an interview on 3/19/26 at 12:26 P.M., the Infection Control Preventionist said the process was for vaccines to be reviewed with new employees during the orientation process. She said for tracking purposes she kept a spreadsheet of staff vaccination status to indicate if they were educated and if the received or declined the vaccine. She said Food Service Director #3 was listed on the spreadsheet, but there was no information regarding the status of vaccines being offered. She said Nurse #5 was not on the spreadsheet. She said she had no information on either employee and could not speak to why the vaccine information was not provided to the employees.

Based on interview and record review, the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN/ CMS-10055) was completed and signed to ensure the Resident/Resident Representative was fully informed of the services being discontinued and a determination was made to continue or discontinue services at a skilled level of care for two Residents (#10, #52), out of three sampled residents who received beneficiary notification, as required by Centers for Medicare & Medicaid Services (CMS). Findings include:The SNF ABN (CMS-10055) notice is administered to a Medicare recipient when the facility determines that the beneficiary no longer qualifies for Medicare Part A skilled services and the resident has not used all of the Medicare benefit days for that episode. The SNF ABN provides information to residents/beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility. 1. Resident #10 was admitted to the facility in January 2026, under a skilled level of care. A Notice of Medicare Non-Coverage was issued to Resident #6 indicating the last covered day of skilled Medicare Part A services was 1/19/26. Review of the medical record failed to indicate the SNF ABN (CMS-10055) was completed and signed by Resident #10 and/or his/her resident representative.During an interview on 3/19/26 at 3:33 P.M., Social Worker Consultant #1 and Minimum Data Set (MDS) Nurse #1 reviewed the documentation for Resident #10. Social Worker Consultant #1 said Resident #10 was not given the ABN notice but should have.2. Resident #52 was admitted to the facility in November 2025, under a skilled level of care. A Notice of Medicare Non-Coverage was issued to the Resident indicating the last covered day of skilled Medicare Part A services was 12/5/25. Review of the medical record failed to indicate the SNF ABN (CMS-10055) was completed and signed by Resident #52 and/or the resident representative.During an interview on 3/18/26 at 4:34 P.M., Social Worker Consultant #1 reviewed the documentation for Resident #52. She said Resident #52 was planning to stay for long-term care and was not given the ABN notice but should have.

Based on observation and interview, the facility failed to ensure residents in two of three dining rooms had a comfortable and homelike dining experience. Findings include: During dining observations throughout survey on 1/2/25, 1/3/25, 1/6/25, and 1/7/25, surveyors observed the following: On 1/2/25 at 9:14 A.M., the surveyor observed seven residents in the A Unit dining room. There were no tablecloths or placemats observed in the dining room. All residents were served their meal from the food truck to the table. All meal plates remained on the heating elements and residents were observed to eat breakfast off the serving trays. Meal covers were stacked on the table. On 1/2/25 at 12:15 P.M., the surveyor observed 13 residents in the Main Dining room. The tables were observed to have white tablecloths, cloth napkins, flower centerpieces, water glasses, porcelain coffee cups and silverware. Staff were observed to serve juices/water and coffee prior to meals being served from the adjacent kitchen. Residents were observed to eat lunch from plates which were removed from heating elements and placed on the table. On 1/2/25 at 12:23 P.M., the surveyor observed 11 residents in the B Unit dining room. There were no tablecloths or placemats observed in the dining room. The television was tuned into the noon time news. All residents were served their meal from the food truck to the table. All meal plates remained on the heating elements and residents were observed to eat lunch off the serving trays. Meal covers were stacked in the middle of the tables. One resident was observed seated alone on the side of the dining room with the meal placed on an overbed table. The meal plate remained on the heating element and the resident was observed to eat lunch off the serving tray with the meal cover left on the corner of the tray table. One staff member was observed to stand throughout the meal as he fed another resident lunch. On 1/2/25 at 12:36 P.M., the surveyor observed seven residents in the A Unit dining room. There were no tablecloths or placemats observed in the dining room. Water glasses and coffee cups were observed to be made of a plastic type of material. The television was tuned into a home show. All meal plates remained on the heating elements and residents were observed to eat lunch off the serving trays. Meal covers and trash (i.e., milk cartons/dirty paper napkins/cup covers) were stacked in the middle of the tables. One resident was seated alone at a table and observed to eat lunch off the serving tray. There was a large plastic container on the table filled with puzzles/activity books which overflowed onto the table. The meal cover was left on the table. On 1/3/25 at 8:45 A.M., the surveyor observed six residents seated in the A Unit dining room. There were no tablecloths or placemats observed in the dining room. All residents were served their meal from the food truck to the table. All meal plates remained on the heating elements and residents were observed to eat breakfast off the serving trays. Meal covers and trash (i.e., milk cartons/dirty paper napkins/cup covers) were stacked on the tables. On 1/3/25 at 12:20 P.M., the surveyor observed nine residents seated in the B Unit dining room. There were no tablecloths or placemats observed in the dining room. All residents were served their meal from the food truck to the table. All meal plates remained on the heating elements and residents were observed to eat lunch off the serving trays. Meal covers were stacked on the tables. On 1/3/25 at 12:26 P.M., the surveyor observed 16 residents seated in the Main Dining room. The tables were observed to have white tablecloths, cloth napkins, flower centerpieces, water glasses, porcelain coffee cups and silverware. Staff were observed to serve juices/water and coffee prior to meals being served from the adjacent kitchen. Residents were observed to eat lunch from plates which were removed from heating elements and placed on the table. On 1/3/25 at 12:31 P.M., the surveyor observed six residents seated in the A Unit dining room. There were no tablecloths or placemats observed in the dining room. All residents were served their meal from the food truck to the table. All meal plates remained on the heating elements and residents were observed to eat lunch off the serving trays. Meal covers were stacked on the tables. One resident was seated alone at a table and observed to eat breakfast off the serving tray. There was a large plastic container on the table filled with puzzles/activity books which overflowed onto the table. The meal cover was left on the table. On 1/6/25 at 8:45 A.M., the surveyor observed six residents seated in the A Unit dining room. There were no tablecloths or placemats observed in the dining room. All residents were served their meal from the food truck to the table. All meal plates remained on the heating elements and residents were observed to eat breakfast off the serving trays. Meal covers and trash (i.e., milk cartons/dirty paper napkins/cup covers) were stacked on the tables. On 1/7/25 at 12:15 P.M., the surveyor observed six residents seated in the A Unit dining room. There were no tablecloths or placemats observed in the dining room. All residents were served their meal from the food truck to the table. All meal plates remained on the heating elements and residents were observed to eat lunch off the serving trays. Meal covers and trash (i.e., milk cartons/dirty paper napkins/cup covers) were stacked on the tables. One resident was seated alone at a table and observed to eat breakfast off the serving tray. There was a large plastic container on the table filled with puzzles/activity books which overflowed onto the table. The meal cover was left on the table. On 1/7/25 at 12:22 P.M., the surveyor observed nine residents seated in the B Unit dining room. There were no tablecloths or placemats observed in the dining room. All residents were served their meal from the food truck to the table. All meal plates remained on the heating elements and residents were observed to eat lunch off the serving trays. Meal covers and trash (i.e., milk cartons/dirty paper napkins/cup covers) were stacked on the tables. During an interview on 1/9/25 at 1:44 P.M., the Administrator was made aware of the surveyor's observations. The Administrator said all residents in the facility should have the same homelike dining experience.

Based on observation, record review, and interview, the facility failed to ensure audiology services were offered to ensure the highest practicable level of care for one Resident (#76), out of a total sample of 19 residents. Specifically, for Resident #76, when their hearing aids went missing, the facility failed to offer/provide alternative treatment, and/or to assist in arranging audiology services to obtain new hearing aids, resulting in a 98-day delay in services. Findings include: Review of the facility's policy titled Resident/Patient Belongings Policy, dated 1/20/17, indicated but was not limited to the following: -Staff will respond in a timely manner to concerns about a missing item. -An investigation will be initiated to assist in locating missing belongings. -The results of the investigation will be reviewed with the resident and/or responsible party. Review of the facility's policy titled Consulting Services; Podiatry/Dental/Optometry/Audiology, dated 11/22/16, indicated but was not limited to the following: -Services are offered to all residents as a means of providing highest practicable level of functioning and care. -Resident/resident representatives are provided information about consulting services upon admission and at any time when the need arises. Resident #76 was admitted to the facility in April 2024 with diagnoses which included Alzheimer's dementia. Review of the Minimum Data Set (MDS) assessment, dated 10/11/24, indicated Resident #76 scored 3 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she had severe cognitive impairment. Additionally, he/she was hard of hearing and wore hearing aids. During an interview on 1/2/25 at 9:30 A.M., Resident #76 had difficulty hearing and understanding the surveyor. He/she expressed frustration with the inability to hear and converse with the surveyor. Observations throughout the survey indicated Resident #76 was alert and confused, able to make his/her needs known, and staff needed to speak loud and slow for him/her to understand them without requesting they repeat themselves multiple times. Review of the medical record, including physician's orders, indicated the following: -Bilateral Hearing Aids information only. Hearing aids charging in the med room or by the nursing station. Put on resident in the morning. Remove and place to charge in the evening. (4/14/24) Review of the Medication Administration Record (MAR) indicated the following: -September 2024: hearing aids were documented as put in the morning and removed/charging from 9/1/24-9/22/24. On 9/23/24 hearing aids were documented as put in the morning and documented as missing on 9/23/24 at 7:39 P.M., and five of the next seven days they were documented as missing/not available/not located. -October 2024: 25 of 31 days the hearing aids were documented as missing/misplaced/not available. -November 2024: 24 of 30 days the hearing aids were documented as missing/not available/not located. -December 2024: 15 of 31 days the hearing aids were documented as missing/not available/not located. Review of the progress notes failed to indicate the facility had searched for the hearing aids, notified management, notified the family, filed a grievance for a missing item, offered him/her alternative hearing devices, or attempted to arrange an appointment with an audiologist at the time they were documented as missing (9/23/24). Review of the medical record indicated on 12/30/24 the Director of Social Services filed a grievance after Resident #76's family reported the hearing aids missing. (98 days after they were documented as missing.) During an interview on 1/7/25 at 1:20 P.M., Nurse #1 said Resident #76's hearing aids have been missing for a few months. Additionally, she said usually if an item is missing, we would tell the supervisor, and they deal with it. During an interview on 1/7/25 at 1:35 P.M., Desk Nurse #1 said he was aware the hearing aids were missing, but did not know for how long. He said alternate services should have been offered to Resident #76 sooner. During an interview on 1/7/25 at 2:16 P.M., Certified Nursing Assistant #2 said they usually charge the hearing aids at the nurses' station, and she was not sure how long they have been missing this time, but it had been a while. During an interview on 1/9/25 at 10:35 A.M., Social Worker #1 said she was not made aware the hearing aids were missing until 12/30/24 when the Resident's family reported it to her. Additionally, she said when staff noted the hearing aids to be missing back in September an appointment for audiology should have been made. She said she was unsure why the process was not followed. During an interview on 1/9/25 at 12:05 P.M., the DON said she was not made aware the hearing aids had been missing since September 2024 and only found out last week when the family reported it to the Social Worker. During an interview on 1/9/25 at 1:01 P.M., the Administrator said he was not made aware of the missing hearing aids until last week when the Resident's family notified the Social Worker. He said when an item like hearing aids are missing the facility should offer something like an amplifier pending an audiology appointment for replacement hearing aids. He said at that time they offered Resident #76 an amplifier and he/she declined it; his/her family was going to take the Resident to see an audiologist for replacement hearing aids. He said staff need education on the process because they identified the hearing aids were missing, but the progress notes do not indicate anything was done about it, and we were not made aware they were missing until last week.

Based on observation, interview, and document review, the facility failed to ensure all medications used in the facility were stored and labeled in accordance with currently accepted professional standards in two of two medication carts reviewed. Findings include: Review of the facility's policy titled Storage of Medications, dated as revised 6/10/22, indicated but was not limited to the following: -Orally administered medications are kept separate from externally used medications, such as lotions -Outdated, contaminated or deteriorated medications and those in containers without secure closures are immediately removed from stock, and disposed -Medication storage areas are kept clean Review of the facility's policy titled Administration Procedures for all Medications, dated 9/20/13, indicated but was not limited to the following: -Check expiration date on package/container before administering any medication. When opening a multidose container, place the date on the container. -Once removed from the package or container, unused or partial doses should be disposed of. Review of the facility's policy titled Equipment and Supplies for Administering Medications, dated 6/1/10, indicated but was not limited to the following: -Charge nurse on duty ensure that equipment and supplies relating to medication administration are clean and orderly. On 1/3/25 at 2:29 P.M., the surveyor completed a review of the medication cart on Unit A, low side, with Nurse #1, and made the following observations: - In the top drawer on the right-hand side: two small clear plastic medication cups, uncovered and not labeled. One contained a thick creamy white substance with a spoon placed inside, and one contained approximately 15 milliliters (ml) of a clear liquid. -On the bottom of the top drawer on the right-hand side: yellowish crusted substance stuck to the bottom of the drawer, multiple loose pills, yellowish-white powdery substance on the bottom of the drawer. Nurse #1 said the cup with the white substance was Eucerin cream (moisturizer) that she needed to apply to a resident, and the other cup contained normal saline (a mixture of sodium chloride and water). She said she was going to do treatments, and got called away, so she placed the two cups in the top of the medication cart. -Two bottles of artificial tears, seal broken indicating it was in use, not labeled with an open or discard date. -Multiple single dose prescription medications, not labeled with a resident name, scattered under the over-the-counter medication bottles. -On the bottom of the second drawer on right-hand side, dried yellowish crusted substance, multiple loose pills and a powdery substance on the bottom of the drawer. -One bottle of Timolol eye drops (used to treat high pressure in the eye), seal broken indicating it was in use, not labeled with an open or discard date. -One bottle of Dorzolomide eye drops (used to treat high pressure in the eye), seal broken indicating it was in use, not labeled with an open or discard date. -One Advair diskus inhaler (used to treat symptoms of asthma), foil packaging removed, indicating it was in use, not labeled with an open or discard date. Nurse #1 said the eye drops and inhalers are in use but do not have a shortened expiration date upon opening. She said she goes by the expiration date on the outside of the container. Nurse #1 said the single dose prescription medications came from the omni cell (automated dispensing cabinet) and are supposed to remove only what you are going to administer at that time. She said the medications should not be stored in the cart without a resident name. Nurse #1 said she is not sure who is responsible for cleaning the cart. On 1/3/25 at 3:04 P.M., the surveyor completed a review of the medication cart on Unit B high side with Nurse #3, and made the following observations: -Two bottles of Prednisolone eye drops (used to treat inflammation in the eyes), seal broken indicating it was in use, not labeled with an open date. -Three bottles of artificial tears eye drops, seal broken indicating it was in use, not labeled with an open date. -Two bottles of Maxifloxin eye drops (used to treat infections of the eye), seal broken indicating it was in use, not labeled with an open date. Nurse #3 said eye drops should be labeled upon opening with an open date because they have a shortened expiration date once opened. She said if they do not have an open date they cannot be used. During an interview on 1/6/25 at 2:59 P.M., Desk Nurse #1 said the 11:00 P.M. - 7:00 A.M. shift nurse is responsible for cleaning and maintaining the medication carts. He said when a nurse notices loose medications in the cart, they should be removing and destroying the medication. During an interview on 1/9/25 at 8:17 A.M., the Director of Nursing (DON) said no medications should be stored in the cart once prepared for administration, uncovered and not labeled. She said the 11:00 P.M. - 7:00 A.M. staff is supposed to remove all expired medications, clean and stock the medication carts nightly, and housekeeping is responsible for thoroughly cleaning the carts monthly. The DON said she is unsure of expiration dates on specific eye drops; however, they are stored in a multi-use vial, and multi-use vials have shortened expiration dates, and must be labeled upon opening.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another). In addition, to ensure the use of gloves was limited to a single use task. Findings include: Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: - 3-301.11 Preventing Contamination from Hands. (A) FOOD EMPLOYEES shall wash their hands as specified under S 2-301.12. (B) Except when washing fruits and vegetables as specified under S3-302.15 or as specified in (D) and (E) of this section, FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT. - 3-304.15 Gloves, Use Limitation. (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. Review of the facility's policy titled Dietary: Sanitary Conditions, dated 10/27/22, indicated but was not limited to the following: -The facility will obtain food from sources approved or considered satisfactory by the federal, state or local authorities; and follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. -Safe food handling for prevention of foodborne illnesses begins when food is received from a vendor and continues throughout the facility food handling processes. -Cross contamination: refers to transfer of harmful substances or disease-causing microorganisms to food by hands, food contact surfaces, sponges, cloth towels or utensils which were not cleaned after touching raw food and then touch ready-to-eat foods. Hand Washing, Glove Use, and use of alcohol-based hand sanitizers: -Since the skin carries microorganisms, it's critical that staff involved in food preparation consistently utilize good hygienic practices and techniques for hand hygiene. -The appropriate use of utensils such as gloves, tongs, deli paper and spatulas are essential in preventing foodborne illness. Gloved hands are considered a food contact surface that can be contaminated or soiled. -Failure to change gloves between tasks can contribute to cross contamination. -Disposable gloves are a single use item and should be discarded after each use. NOTE: The use of disposable gloves is not a substitute for proper hand washing with soap and water. On 1/2/25 at 8:30 A.M., the surveyor observed the breakfast tray line service in the main kitchen and made the following observations: -Cook #1 was plating breakfast plates wearing a disposable glove handling the pancakes, toast, and bacon with her gloved hands. [NAME] #1 used the scoop to plate the scrambled eggs and then arranged them on the plates with her gloved hands. -Cook #1 was observed leaving the steam table to cook pancakes on the griddle, touching multiple surfaces with her gloved hands. [NAME] #1 returned to the steam table continuing to plate breakfast as described above wearing the same gloved hands as above. -Cook #1 left the steam table for a second time, cracked three eggs on the griddle and handled the spatula cooking the eggs. [NAME] #1 discarded one egg, cracked a fourth egg on the griddle and continued cooking. [NAME] #1 returned to the steam table continuing to plate breakfast as described above wearing the same pair of gloves. [NAME] #1 was not observed changing her gloves or performing hand hygiene at any time. During an interview on 1/2/25 at 8:35 A.M., the Food Service Manager (FSM) said [NAME] #1 should be serving food from the steam table using utensils and not her gloved hands. He said she should be removing her gloves and performing hand hygiene in-between tasks like cracking raw eggs before returning to the steam table to serve food. On 1/3/25 at 11:42 P.M., the surveyor observed lunch tray line service in the Main kitchen and made the following observations: -Cook #2 was observed wearing two pairs of gloves while plating lunch plates. -Cook #2 was observed leaving the tray line to obtain supplies and returning to the tray line, removing one pair of gloves and continuing to plate lunch service. -Cook #2 was observed leaving the tray line a second time, handling a kitchen towel/potholder to remove meatloaf from the oven to replace a pan on the steam table. [NAME] #2 was observed removing the second pair of gloves and his hands were visible dripping a water like substance. [NAME] #2 obtained a new pair of gloves, entered the walk-in freezer (touching the door handle) and held his hands up to the fan in a waving motion. [NAME] #2 put on the new pair of gloves and returned to the lunch tray service line to continue plating meals. During an interview on 1/03/25 at 11:51 A.M., the FSM said [NAME] #2 should not be wearing two pairs of gloves, he should not be drying his hands in the walk-in and [NAME] #2 should be performing hand hygiene every time he changes his gloves.

Based on record review and interview, the facility failed to ensure an accurate medical record for one Resident (#84), out of a total sample of 19 residents. Specifically, the facility failed to ensure the medical record indicated the dietary recommendation for Mirtazapine (antidepressant used for an appetite stimulant) had been reviewed by the provider timely. Findings include: Resident #84 was admitted to the facility in September 2024 with diagnoses including dementia, anxiety, depression, obsessive-compulsive disorder (OCD), and had a history of falls with traumatic subdural hematoma. Review of the Minimum Data Set (MDS) assessment, dated 9/23/24, indicated he/she scored 11 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she had moderate cognitive impairment. Review of the weights documented in the medical record indicated the following: 9/18/24: 155.8 pounds (lbs.) 9/28/24: 130.4 lbs. 10/12/24: 124.2 lbs. 10/28/24: 124.8 lbs. 12/16/24: 112.8 lbs. Review of the Dietitian's progress note, dated 10/17/24, indicated Resident #84 continues to present with variable and often inadequate intake of meals. Resident denies need for supplemental foods or oral supplements, which have been offered several times since admission. Weight change: unclear on accuracy of prior weights but would suggest severe weight loss. Resident presents with moderate signs of muscle wasting and moderate fat wasting and meets criteria for severe chronic disease related to malnutrition. Per discussion with team, plan will be to start on Mirtazapine (pending resident agreement) in effort to increase appetite as resident continues to refuse any oral supplements to halt weight loss. Review of the medical record failed to indicate the recommendation had been reviewed with the physician and he/she approved/declined it or that the Resident declined the recommendation. Further review of the progress notes indicated Resident #84 was accepting only ice cream as a supplemental food and he/she was being provided ice cream on trays and whenever he/she asked for it. Review of the medical record indicated he/she was taking multiple psychotropic medications to manage disease process and symptoms and was followed by the Psych Nurse Practitioner (NP) and had recent medication changes. Review of the Dietitian's progress note, dated 12/17/24, indicated he discussed with the NP trialing Mirtazapine to assist with appetite, which will be passed on to psych. Review of the Physician's progress note, dated 12/17/24, indicated he/she had severe malnutrition, to continue Magic Cup (nutrient enhanced ice cream), plan to discuss Mirtazapine as an appetite enhancer with Psych NP. Additionally, noting his/her mental health is likely playing a role. Further review of the medical record failed to indicate the recommendation for the Mirtazapine made in October had been addressed prior to December. During an interview on 1/7/25 at 1:20 P.M., Nurse #1 said she was not aware of the dietary recommendation or the process on how they get addressed. She said Resident #84 will only take ice cream and the Magic Cups as supplements. During an interview on 1/7/25 at 1:35 P.M., Desk Nurse #1 said when the dietitian has recommendations he reviews them with the NP. He said he was aware of the weight loss but not of a pending recommendation for Mirtazapine. Additionally, he said management does risk meetings and they discuss weight loss, but I only get report on the out of the ordinary stuff. He reviewed the medical record and was unsure if the recommendation had been addressed between 10/17/24 and 12/17/24 because there were not any notes indicating such. During an interview on 1/9/25 at 9:12 A.M., NP #1 said initially she did not want to add another medication given recent medication changes and his/her extensive psych history. She said she could not recall if she documented that initially but should have. She said she wanted to watch his/her weights and intakes, when he/she continued to lose weight, it was discussed again, and the decision was to defer the recommendation to the Psych NP. She said the Psych NP was going to review Resident #84's medical record and advise at her next visit, which was yesterday, and she was waiting on the written progress note to review the Psych NP's recommendations today. She said the staff have continued to give him/her ice cream and Magic Cups and monitor his/her weights when he/she will allow them to. The facility failed to ensure NP #1's review and decline of the recommendation was documented in the medical record for two months until the same recommendation was reconsidered in December 2024. During an interview on 1/9/25 at 12:05 P.M., the Director of Nurses (DON) said the recommendation for Mirtazapine was discussed in the weekly risk meeting on 10/17/24 and they should have ensured the follow up was documented in the medical record. She said they need to have a better system in place to ensure recommendations are reviewed and documented timely. Additionally, she said Resident #84 is a hard one because he/she will not take any supplements except ice cream and Magic Cups. She said they talk about him/her frequently, give him/her all the ice cream he/she wants and monitor weights when he/she will get weighed. She said they do as much as they can for him/her, but they need to improve the documentation in the medical record.

Based on observation, record review, and interview, the facility failed to initiate the grievance process on behalf of one Resident (#76), out of a total sample of 19 residents. Specifically, for Resident #76, the facility failed to initiate an investigation when his/her hearing aids were determined to be missing, file a grievance for the missing hearing aids, and follow the grievance process, resulting in a 98-day delay in offering and/or providing alternative audiology services. Findings include: Review of the facility's policy titled Resident/Patient Belongings Policy, dated 1/20/17, indicated but was not limited to the following: -Staff will respond in a timely manner to concerns about a missing item. -An investigation will be initiated to assist in locating missing belongings. -The results of the investigation will be reviewed with the resident and/or responsible party. Review of the facility's policy titled Grievance Policy, dated as last revised 9/20/19, indicated but was not limited to the following: -All residents and/or their representatives may voice grievances/complaints and recommendations for change. -Social service will serve as the resident advocate in the grievance/complaint process. -Our facility will assist residents or their representative in filing grievances or complaints. -Affiliate leadership will investigate, document, and follow up on all formal concerns and grievances registered by any resident or resident representative. Resident #76 was admitted to the facility in April 2024 with diagnoses which included Alzheimer's dementia. Review of the Minimum Data Set (MDS) assessment, dated 10/11/24, indicated Resident #76 scored 3 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she had severe cognitive impairment. Additionally, he/she was hard of hearing and wore hearing aids. During an interview on 1/2/25 at 9:30 A.M., Resident #76 had difficulty hearing and understanding the surveyor. He/she expressed frustration with the inability to hear and converse with the surveyor. Observations throughout the survey indicated Resident #76 was alert and confused, able to make his/her needs known, and staff needed to speak loud and slow for him/her to understand them without requesting they repeat themselves multiple times. Review of the medical record, including physician's orders, indicated the following: -Bilateral Hearing Aids information only. Hearing aids charging in the med room or by the nursing station. Put on resident in the morning. Remove and place to charge in the evening. (4/14/24) Review of the Medication Administration Record (MAR) indicated the following: -September 2024: hearing aids were documented as put in the morning and removed/charging from 9/1/24-9/22/24. On 9/23/24 hearing aids were documented as put in the morning and documented as missing on 9/23/24 at 7:39 P.M., and five of the next seven days they were documented as missing/not available/not located. -October 2024: 25 of 31 days the hearing aids were documented as missing/misplaced/not available. -November 2024: 24 of 30 days the hearing aids were documented as missing/not available/not located. -December 2024: 15 of 31 days the hearing aids were documented as missing/not available/not located. Review of the progress notes failed to indicate the facility had searched for the hearing aids, notified management, notified the family, or filed a grievance for the missing hearing aids at the time they were documented as missing (9/23/24). Further review of the medical record indicated on 12/30/24 the Director of Social Services filed a grievance after Resident #76's family reported the hearing aids missing. Review of the grievance book indicated a grievance for the missing hearing aids was not filed until his/her family reported the hearing aids missing on 12/30/24. During an interview on 1/7/25 at 1:20 P.M., Nurse #1 said Resident #76's hearing aids have been missing for a few months. Additionally, she said usually if an item is missing, we would tell the supervisor, and they deal with it. Additionally, she said she was not aware of any formal process for missing items or if they are logged on a grievance. During an interview on 1/7/25 at 1:35 P.M., Desk Nurse #1 said when items are discovered to be missing, first we would search the room, laundry, and dining room, then notify administration. There is not a form to fill out, it is usually verbal communication, then we should notify families if applicable, and it should be documented in the progress notes. He said Resident #76 has misplaced hearing aids before and we found them in the pocket of the walker, he said he was aware the hearing aids were missing, but did not know for how long, and said there is not a progress note indicating the process was followed between September and when the Social Worker documented the missing items on 12/30/24 and there should have been a note. During an interview on 1/9/25 at 10:35 A.M., Social Worker #1 said she was not made aware the hearing aids were missing until 12/30/24 when she filed the grievance. She said when staff noted the hearing aids to be missing back in September, the grievance should have been initiated then. She said she was unsure why the grievance process was not followed. During an interview on 1/9/25 at 12:05 P.M., the DON said she was not part of the investigation into the missing hearing aids and directed further questions to the Social Worker and Administrator. Additionally, she said when an item such as glasses, hearing aids, dentures are missing, staff should be searching the area immediately and notifying supervisor, the family, myself and the Administrator. A grievance would be filed if the item was not located for follow up. She said she was not made aware the hearing aids had been missing since September 2024 and only found out last week when the family reported it to the Social Worker. During an interview on 1/9/25 at 1:01 P.M., the Administrator said he was not made aware of the missing hearing aids until last week when the Social Worker filed the grievance. He said standard procedure would be when an item like hearing aids are missing, the areas are searched, departments are notified, management is notified, and the family if applicable. He said if the search is unsuccessful, a grievance would be filed. He said staff need education on the process because they identified the hearing aids were missing, but the progress notes do not indicate anything was done about it, and we were not made aware they were missing until last week. Refer to F685

Based on record review, interview, and observation, the facility failed to follow professional standards of practice for one Resident (#197), out of a total sample of 19 residents. Specifically, the facility failed to follow and provide care in accordance with the physician's order for management of the Resident's right upper extremity Peripherally Inserted Central Catheter (PICC-a thin flexible tube inserted into a vein in the upper arm and guided into a large vein above the right side of the heart called the superior vena cava) which included dressing changes, measurement of the external length of the catheter and upper arm, and monitoring of the insertion site for signs/symptoms of infection. Findings include: 1. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, Advisory Ruling Number 9324, dated as revised July 10, 2002, indicated: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's 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. Review of the facility's policy titled Vascular Access Device (VAD) Insertion Care and Removal, dated 7/1/2018, indicated but was not limited to the following: -Central vascular access device (CVAD): Dressing changes -CVADs require a sterile transparent semipermeable membrane dressing and shall be changed with a practitioner order: a. Upon admission or 24-hour post-insertion; b. Every seven days; c. As needed (PRN) if compromised. -PICC Lines require measurements which include: a. Total catheter length: i. Upon admission or insertion; ii. Obtained from insertion nurse or discharge facility. b. External catheter length-measured from insertion site to beginning of WING HUB OR other location as determined by insertion nurse or admission nurse; compared to previous measurement; i. Upon admission or insertion; ii. Every dressing change and PRN. c. Upper arm circumference- three inches above insertion site or other location as determined by the insertion nurse or admission nurse; compare to previous measurement: i. Upon admission or insertion; ii. Every dressing change and PRN. Resident #197 was admitted to the facility in December 2024 with diagnoses which included osteomyelitis (infection of the bone) of the right foot, right great toe amputation, and peripheral neuropathy. Review of the Physician's Orders indicated but were not limited to the following: -Change PICC line transparent dressing every evening shift, weekly on Wednesday. -Measure external length on admission and each dressing change. -Measure arm circumference on admission and with each dressing change. -Monitor intravenous (IV) site every shift, assess IV right PICC for signs and symptoms of infection, dressing clean dry and intact. On 01/2/25 at 10:01 A.M., the surveyor observed Resident #197 lying in bed and with the Resident's permission observed his/her right arm PICC line. The surveyor observed the transparent dressing to be dated 12/25/24, and observed a small amount of dried blood around the insertion site. Review of Resident #197's Treatment Administration Record (TAR) indicated but was not limited to the following: -12/18/24: PICC line dressing was changed, no documentation of external catheter length or arm circumference. -12/25/24: PICC line dressing was changed, no documentation of external catheter length or arm circumference. -1/1/25: Nurse #8 signed off PICC line dressing was changed; no documentation of external catheter length or arm circumference (On 1/2/25 and 1/3/25 the PICC line dressing was observed dated 12/25/24). Review of nursing notes on 12/18/24, 12/25/24, and 1/1/25 indicated there was no documentation the PICC line dressing was changed and no documentation of the external catheter length or arm circumference. During an interview on 1/3/25 at 4:50 P.M., Nurse #9 observed Resident #197's PICC line dressing and said it was dated 12/25/24. Nurse #9 returned to the medication cart and reviewed Resident #197's physician's orders and TAR and said the PICC line dressing was signed off that it was changed on 1/1/25 and it was not. Nurse #9 said when checking the PICC line everyday you inspect the dressing, look for drainage, and signs and symptoms of infection. During an interview on 1/3/25 at 5:01 P.M., the Director of Nurses (DON) said she would expect the nurses to change the dressing within 24 hours of admission and then weekly. She said the nurses should be inspecting the site daily for signs and symptoms of infection and drainage. The surveyor and DON viewed Resident #197's PICC dressing and it was dated 12/25/24. The DON said she will have to review Resident #197's orders. During an interview on 1/7/25 at 8:57 A.M., the DON said when the nurses do a PICC line dressing change they should be recording the catheter length and arm circumference on the TAR. She said that's the way the orders should be written and the nurses should be recording the information right on the TAR. The DON said she will look for additional documentation. During an interview on 1/9/25 at 11:25 A.M., the DON said she could not find nursing documentation of the external length or arm circumference in Resident #197's medical record. She said she spoke to Nurse #8 and Nurse #8 told her she did not get to change the PICC line on 1/1/25. The DON said Nurse #8 should not have marked the PICC line changed if she did not complete it.

Based on observations, record review, and interview, the facility failed to ensure post-fall interventions were developed and implemented to mitigate the risk of future falls resulting in two falls in three months, one of which resulted in a head strike causing bruising for one Resident (#78), out of a total sample of 19 residents. Findings include: Review of the facility's policy titled Fall Risk Reduction, dated as last revised 11/2/23, indicated but was not limited to the following: -All residents will be assessed for fall risk factors. Those determined to have risk factors will receive individualized interventions based on the risk factors to reduce risk for falls and minimize the actual occurrence of falls. -Complete a Resident Fall Risk Assessment on admission, readmission, change in condition. -Develop individualized plan of care. -Include fall interventions on Kardex and Care Plan. -Review and revise Care Plan/Kardex regular to ensure individualized. -Review resident new admit/new fall weekly for four weeks to determine effectiveness of interventions. Review of the facility's policy titled Accidents and Incidents-Investigating and Reporting, dated as last revised 12/29/11, indicated but was not limited to the following: -The nurse supervisor/charge nurse and/or the department director or supervisor must conduct an immediate investigation of the accident or incident. -If Incident/Accident Report is completed for a fall, corresponding post fall investigation shall also be completed. Review of the facility's policy titled Falls Management: Post Fall, dated as last revised 9/30/24, indicated but was not limited to the following: -All residents experiencing a fall will receive appropriate care and investigation of the cause. -Review resident's medical record and assessments to identify any causes that may have contributed to the fall. -Complete an Incident Report/Post Fall Investigation/5 Whys analysis after the fall. -Update the Care Plan/Kardex to reflect new interventions. -Conduct interdisciplinary falls team meeting at the subsequent clinical morning meeting, review the 5 Whys Analysis, Determine need for additional actions/interventions based on team evaluation of root cause, and communicate information to staff. -Review resident at interdisciplinary morning meeting to determine effectiveness of interventions. Revise care plan accordingly. -Remove any causes of fall and implement preventive measures to prevent recurrence. Resident #78 was admitted to the facility in October 2022 with diagnoses which included muscle weakness, unspecified abnormalities of gait and mobility, and dementia. Review of the Minimum DataSet (MDS) assessment, dated 10/18/24, indicated that Resident #78 scored 3 out of 15 on the Brief Interview for Mental Status (BIMS) indicating cognitive impairment. Additionally, he/she was dependent on staff with transfers and had a history of falls. Review of the Comprehensive Care Plan indicated the following: PROBLEMS/STRENGTHS: At risk for falls. The following risk factors have been identified. Change in mobility/gait, confused/forgetful, exhibits unsafe behavior. Recent witnessed fall. GOALS: Resident will be free from injury related to falls through review period. INTERVENTIONS: -Fall risk assessment upon admission, re-admission, significant change in condition (11/1/22) -Ask resident to sit back when noted to be sitting forward in wheelchair (11/2/23) -Offer to get out of bed before dinner if in bed for nap (11/2/23) -Check to see if wishes to get out of bed at change of shift (11/2/23) -Offer the option to get out of bed early am 11-7 shift if awake (11/2/23) -Likes safely sitting on the floor attempt to determine reason and attempt to mitigate risks preemptively, monitor for changes in frequency (11/2/23) -Monitor for proper positioning in wheelchair (11/2/23) -Rehab to review for alternate wheelchair seating (11/2/23) -Bed will be positioned low when she is in bed to prevent falls (3/12/24) -To be reclined in Broda (wheelchair that can tilt or recline) chair after meals (9/24/24) Review of the Fall Risk Evaluation from admission indicated the following: -10/22/22 Score 8 (Fall risk score was not defined on evaluation), History of falls in the past 2-6 months, moving from seated to standing position not steady, only able to stabilize with assist During an interview on 1/7/25 at 2:28 P.M., the Director of Nurses (DON) said the facility only completes fall risk assessments upon admission, re-admission, or with a significant change in condition. She said when a resident has a fall it is not considered a change of condition. Review of the medical record indicated Resident #78 had two falls since June 2024, both falls were related to slipping out of the wheelchair. Review of the facility Incident Reports, nursing progress notes for the falls indicated the following: FALL 6/1//24: -Observed sitting on the floor in front of Broda chair in dayroom. -Report indicated Resident #78 attempted to stand -Back of Broda chair was at a 90-degree angle may have contributed to the fall -No additional predisposing factors were identified. -No witness statements were provided. -No injury was noted. -New intervention identified to recline back of wheelchair short time after meals. Intervention had a line drawn through it and written below the crossed out intervention read would not necessarily have prevented fall -No intervention added to the care plan or Kardex to prevent future falls/mitigate the risk of future falls. FALL 9/20/24: -Observed on floor in dayroom, fell out of wheelchair -Predisposing factors indicated the wheelchair was not reclined -No additional predisposing factors were identified. -No witness statements were provided. -Sustained bruising to right side of forehead, ice pack applied, and neurological checks completed -New intervention identified to recline wheelchair after meals -Intervention, care plan and Kardex were updated as follows: Resident is to be reclined in his/her Broda chair after meals (9/24/24) The facility identified that Resident #78 fell on [DATE] from Broda/wheelchair. The facility failed to develop and implement additional interventions to prevent future falls/mitigate the risk of falls resulting in an additional fall from Broda/wheelchair sustaining a bruise to the right side of his/her forehead. The surveyor made the following observations: -1/6/25 at 11:28 A.M., Resident #78 sitting in Broda chair in activity room with back of chair in upright position, not reclined. -1/7/25 at 12:30 P.M., Resident #78 sitting in Broda chair in dayroom after lunch, back of chair in upright position, not reclined. During an interview on 1/6/25 at 2:48 P.M., Nurse #4 said she completes an incident report packet and updates the care plan with a new intervention to prevent the fall from occurring again. She said the incident report packet is then given to the DON for review. During an interview on 1/9/24 at 7:51 A.M., the DON said when a fall occurs, the nurse completes an incident report packet. She said the packet consists of a root cause analysis to help the nurses determine a new intervention to reduce the risk of the fall occurring again. She said the nurse updates the interventions, care plans and updates the Kardex with information for the Certified Nursing Assistants (CNA) after the fall. The DON reviewed the incident report packet dated 6/1/24 and said the incident report is incomplete; there was no intervention put into place and the care plan was not updated as it should have been. She said the nurse identified an intervention, but does not know why it was crossed out and not implemented. She said she is new to the facility, and was not present at the time of this fall. The DON said all falls are reviewed the next morning and weekly for four weeks by the Interdisciplinary Team (IDT), and is unsure why it was not identified by the IDT that this fall report was incomplete.

Based on record review, policy review, observation, and interview, the facility failed for one Resident (#88), out of a total sample of 19 residents, to provide care and implement pressure prevention interventions resulting in the development of facility acquired pressure ulcers (injuries to the skin and underlying tissue resulting from prolonged pressure exerted over areas of the body) on both the left and right buttocks and right heel of Resident #88. Findings include: Review of the facility's policy titled Skin Integrity Management, dated as revised on 3/16/22, indicated but was not limited to the following: - Based on assessment the facility will ensure that residents receive the necessary treatment and services consistent with professional standards of practice to prevent the occurrence of pressure ulcers - Refer to pressure ulcer prevention protocol Review of the facility's policy titled Pressure Ulcer Prevention Protocol, dated as revised December 2015, indicated but was not limited to the following: - Prevention interventions for residents at risk, as defined by risk assessment, [NAME] plus score of 15 or less - Turning and positioning program to include all residents in the facility will be turned in bed every two hours - Reposition residents in bed and chair every two hours - Use devices that float heels. For short term use with cooperative residents place pillows under the calves to raise the heels off the bed. Place heel suspension boot or use heels-up device for long term use. This should be done even if an alternating air mattress is in use. - Monitor and assist with hygiene - For incontinence individualized toileting or change schedule based on assessment - Encourage the use of toilets, commodes, bedpans and urinals to promote dry skin - Apply skin protectant after cleansing incontinence (the loss of bowel and bladder control) Resident #88 was readmitted to the facility in September 2023 following a brief hospital stay with diagnoses including COVID-19, urinary tract infection, and hypertension (high blood pressure). The Brief Interview for Mental Status (BIMS) score was 7 out of 15 on the re-admission nursing assessment indicating severe cognitive impairment. The Resident's healthcare proxy was not activated, indicating the Resident was competent to make his/her own decisions. During an interview on 10/10/23 at 9:55 A.M., the Nurse Practitioner (NP) said she has not activated the Resident's healthcare proxy and Resident #88 is making their own decisions at this time. Review of the Admission Nursing Assessment for Resident #88, following his/her brief hospitalization in September 2023, indicated but was not limited to the following: - Resident was incontinent of bowel and bladder and used disposable incontinence products - The skin was free of pressure ulcers and there were no identified open areas or areas of discoloration on the buttocks - The right heel had a red blanchable (indicates normal blood flow to the area) area that was 4 centimeters (cm) in length (L) by (x) 4cm in width (W) size and was not an area of pressure - The left heel had a red blanchable area that was 4cm L x 4cm W and was not an area of pressure - Resident #88 required assist for transfers, dressing, toileting and hygiene/bathing - Mobility limitations included the need for substantial/maximal assist to move from lying to sitting position in the bed and was dependent on others for transfers out of the bed or to stand - [NAME] plus score of 6 - with an indication to refer to pressure ulcer prevention protocol for care plan suggestions, and an indication that a score of 10 or less was high risk - Speech was clear and Resident readily answered questions and was oriented to person and place Review of the Minimum Data Set (MDS) assessment for Resident #88, dated 9/21/23, indicated but was not limited to the following: - Section GG (functional abilities): Roll left and right while lying on the back in bed and moving from a lying to sitting position in the bed: Moderate assistance required Sitting to lying, sitting to standing, chair to bed & bed to chair transfers: Maximal assistance required - Section H (bladder and bowel): No trial or toileting program to manage incontinence; always incontinent of bowel and bladder - Section M (skin conditions): Resident is at risk for developing pressure ulcers and does not have any pressure ulcers or injuries Skin treatments: pressure reducing surface for bed, turning and repositioning program, applications of ointments/medications other than to feet During an observation with interview on 10/5/23 at 11:03 A.M., Family Member #1 and Family Member #2 were at the bedside of Resident #88. The Resident was out of bed and sitting in a Broda chair (positioning wheelchair) with a gel cushion pad and mechanical lift sling underneath them. Both family members said they had concerns with the care of Resident #88 and said they did not feel he/she was being repositioned or gotten out of bed consistently, or being changed and cleansed following episodes of incontinence, and as a result developed new open areas on his/her skin. They said they had reported their concerns to the facility. Review of the medical record indicated Resident #88 developed two facility acquired Stage 2 pressure ulcers one on his/her left buttocks and another on the right buttocks first identified on 9/27/23 and a right heel deep tissue pressure injury first identified on 10/3/23. Review of the Certified Nurse Assistant (CNA) Care Kardex (summary of resident's care and preferences), undated, indicated but was not limited to the following: - Bowel and bladder incontinent - Toileting, hygiene and bathing - Dependent for care with one assist - Bed mobility - Dependent for care with two assist - Transfers - Dependent for care with two assist and Hoyer (mechanical lift device) - Quarter size bilateral side rails, air mattress to bed setting two - Skin interventions: house protocol; bed cradle when in bed; off-load heels when in bed and encourage to keep off-loaded; gel cushion to Broda chair Review of the CNA Activities of Daily Living (ADL) documentation and positioning for Resident #88 indicated but was not limited to the following: September 2023: Resident bed mobility, transfers, toileting, hygiene and bathing documentation was incomplete (blank) on the following days: - 9/19/23, 9/23/23, 9/29/23, and 9/30/23. Review of September 2023 CNA positioning sheet for Resident #88: From 9/10/23 - 9/30/23 indicated 23 of the 63 shifts for positioning opportunities were either blank or documented as the Resident positioning being not applicable. Review of October 2023 CNA ADL sheets (reviewed on 10/10/23) indicated: Resident bed mobility, transfers, toileting, hygiene and bathing: documentation was incomplete (blank) on the following days: - 10/1/23: night shift, 10/3/23, 10/4/23, 10/5/23, 10/6/23, 10/7/23, 10/8/23, 10/9/23. Review of October 2023 CNA functional ability documentation (reviewed on 10/10/23) titled Roll right / roll left (this indicates positioning per the Director of Nurses) from 10/1/23 - 10/9/223 indicated 7 of the 27 shifts for positioning opportunities were either blank or documented as the Resident positioning was not attempted/not applicable. Review of the CNA documentation indicated the facility failed to ensure a consistent repositioning and turning schedule was in place as well as consistent incontinence care was being provided or any off-loading of the Resident's heels. Review of the current care plans for Resident #88 indicated but was not limited to the following: (9/5/23) Breakdown: Resident is at risk for skin breakdown related to five or more medications, diagnosis of hypertension (HTN), mobility and physical condition. Goal: Resident will be free of skin breakdown x 90 days through next review date Interventions (all dated 9/5/23): encourage activity and mobility; weekly skin check by licensed nurses; encourage repositioning every one to two hours or reposition resident every two hours in bed and every one hour in the chair; ensure resident/family participation by providing education on prevention and treatment while a resident at the facility as well as after discharge (9/28/23) Stage 2: pressure ulcers on the left (Lt) and right (Rt) buttocks related to decreased mobility; (10/3/23 revised) right heel deep tissue injury (DTI) Goals: Stage 2 pressure areas will show signs and symptoms of healing as evidenced by decrease in size and depth (9/28/23); Stage 2 pressure areas will be free of infection (9/28/23) DTI on Rt heel will resolve with current treatment by next review (10/3/23) Interventions: Minimize or eliminate contributing factors by low air loss mattress (9/28/23); pressure redistribution cushion to chair when out of bed (9/28/23); refer to at risk skin care plan (9/28/23) treatment to areas per physician orders (9/28/23) follow skin and wound care protocols (9/28/23) weekly documentation of wound site, treatment response and progression (9/28/23) incontinence plan - refer to incontinence care plan (9/28/23) treatment to Rt heel as ordered (10/3/23) bed cradle applied to bed (10/3/23) off-load heels and encourage resident to keep off-loaded (10/3/23) Further review of the care plans failed to identify a care plan for incontinence care and management or refusal/resistance to care. Throughout the survey the surveyor made the following observations of Resident #88: - 10/5/23 at 9:18 A.M., Resident in bed lying on their back on an air mattress, his/her heels were flat against the mattress and not off-loaded with pillows or any special devices. - 10/10/23 at 9:44 A.M., Resident in bed lying on his/her back on an air mattress, his/her heels were not elevated off the mattress with any pillows or an off-loading device. - 10/10/23 at 10:11 A.M., Resident lying in bed on his/her back on an air mattress, bilateral heels are flat against the mattress and no pillows or off-loading devices are observed in the area of the foot of the bed. - 10/10/23 at 10:27 A.M., Resident lying in bed on his/her back on an air mattress, bilateral heels are flat against the mattress and no pillows or off-loading devices are observed by the foot of the bed or in the vicinity. - 10/10/23 at 11:31 A.M., Resident lying in bed on his/her back on an air mattress, his/her heels were not elevated off the mattress with pillows or any off-loading devices. - 10/10/23 at 12:08 P.M., Resident in bed on his/her back with head of bed elevated to approximately 90 degrees, eating lunch, his/her heels are not elevated off the mattress with pillows or any off-loading devices. - 10/11/23 at 8:48 A.M., Resident is out of bed in Broda chair on a gel cushion with socks and shoes in place. During an interview on 10/10/23 at 9:44 A.M., Resident #88 said he/she feels that there are times the staff do not come in to help him/her and he/she has to wait a long time to be changed when he/she is wet or dirty. The Resident said he/she does not usually have a pillow under their legs, feet or heels but once in a while one is put there when he/she complains their legs hurt. The Resident said they lie on their back most of the time and no one tries to position him/her on their side unless they are washing or changing them. The Resident was observed to be on their back, without any off-loading devices or pillows under their legs to elevate their heels off the bed, and their heels were directly touching the mattress. The Resident was agreeable to the surveyor observing his/her buttocks wounds but did not wish for the surveyor to view his/her heels as they did not wish to remove their socks. Review of the initial skin record for Resident #88's Lt buttock wound, dated 9/28/23, indicated but was not limited to the following: - Left buttock stage 2 (partial thickness skin loss wound with exposed underlying tissue) pressure ulcer, not present on admission, first identified on 9/27/23 - wound assessment: 2cm L x 1cm W x 0.1cm depth (D) with a scant (minimal) serous (thin clear to yellow fluid) drainage, and the surrounding skin normal in color Review of the weekly assessment for Resident #88 Lt buttock wound, dated 10/6/23, indicated but was not limited to the following: - Lt buttock wound had not resolved - wound assessment: 2.5cm L x 7cm W x 0.1cm D with no drainage and bright red surrounding skin - wound progress was documented as unchanged Review of the initial skin record for Resident #88's Rt buttock wound, dated 9/28/23, indicated but was not limited to the following: - Right buttock stage 2 pressure ulcer, not present on admission, first identified on 9/27/23 - wound assessment: 0.8cm L x 0.8cm W x 0.1cm D with a small amount of serous drainage, and the surrounding skin normal in color Review of the weekly assessment for Resident #88's Rt buttock wound, dated 10/6/23, indicated but was not limited to the following: - Rt buttock wound had not resolved - wound assessment: 0.7cm L x 0.7cm W x 0.7 with a small amount of serous drainage and pink surrounding skin - wound progress was documented as improved Review of the initial skin record for Resident #88's Rt heel, dated 10/6/23, indicated but was not limited to the following: - Rt heel DTI (a local area of purple or dark maroon intact skin or blood-filled blister due to damage of underlying soft tissue from pressure or sheering) pressure wound, not present on admission, first identified on 10/3/23 - wound assessment: 1.2 cm L x 1cm W - no depth and no drainage with pink surrounding skin During an interview on 10/10/23 at 10:23 A.M., Nurse #1 said she completed the 10/6/23 weekly assessment on Resident #88's Lt and Rt buttock wounds. She reviewed the information and said she should have documented the wound as deteriorated, as the Lt buttock pressure ulcer had grown in size from 1cm W to 7cm W and the Rt buttock pressure wound had an increased depth from 0.1cm to 0.7cm. She said prior to the development of both the Lt and Rt stage 2 pressure ulcers to the Resident's buttocks the intervention in place was turning and repositioning, but the areas had developed despite the CNAs repositioning the Resident. She said since the wounds were discovered the staff were applying Triad cream (a thick white cream used to coat and protect open areas of skin from incontinence) to the buttocks wounds as a treatment. She said for the Resident's heels the nurses were applying skin prep and the CNAs were supposed to be off-loading the Resident's heels with pillows, but the information on off-loading the heels does not get documented anywhere. She said the nurses are currently treating the heels with skin prep and that is documented on the treatment administration record (TAR). On 10/10/23 at 10:27 A.M., the surveyor entered the Resident's room with Nurse #1 and Nurse #2 to view the Resident's bilateral buttocks wounds. The Resident was rolled to his/her right side by the two staff members. The buttocks appeared to have dark red/purple discoloration on both the right and left upper buttocks, but the open areas could not be visualized well related to a thick layer of white cream over the area. The staff replaced the Resident's brief and straightened the draw sheet underneath the Resident and left the Resident lying on his/her back. The Resident was not observed to have any pillows under his/her legs, heels, or feet during this time and no off-loading device was in place for the heels. The two staff nurses were not observed to correct the situation or off-load the Resident's heels prior to leaving the room and did not ask the Resident if they declined having pillows placed under his/her legs to off-load the heels. Review of the TAR and treatment orders for Resident #88 from 9/15/23 through 10/10/23 indicated but was not limited to the following: - Air mattress every shift; Resident on low air loss mattress set at 2, check settings every shift (initiated: 9/28/23) - Site: bilateral heels, red and blanchable day and evening shift apply skin prep to heels (discontinued: 10/6/23) - Right heel DTI treatment day and evening apply skin prep to heels (initiated: 10/6/23) - Apply triad cream to coccyx with incontinence care every shift (initiated: 9/28/23) During an interview on 10/10/23 at 11:48 A.M., CNA #1 said she is familiar with Resident #88's care. She said the Resident is incontinent and requires full assistance with care. She said the Resident is now on an air mattress and has some skin issues and is to be repositioned every two hours. She said she does not know why the Resident's heels are not off-loaded on pillows today but she did not provide his/her care today. She said the Resident or his/her family will notify the staff if they need anything and the Resident does not have any behaviors but does prefer to stay in bed most days. During an interview on 10/10/23 at 12:17 P.M., CNA #2 said he is familiar with the Resident's care and provided care to the Resident today (10/10/23). He said the Resident can be uncomfortable at times and that is when he/she is repositioned. He said the Resident did not want to get out of bed today so he would reapproach the Resident after lunch. He said the Resident should have pillows under his/her feet for off-loading but he did not do that today. He said he has not repositioned the Resident yet today, but he will do that and use pillows to do so after the Resident has his/her lunch. He said the Resident is incontinent and wears a brief and he checks to see if incontinence care is necessary about two or three times a shift or if the Resident or family requests it. He said they are using a thick cream on the Resident's buttocks because there are some skin areas. During an interview on 10/10/23 at 2:56 P.M., Family Member #4 said she was visiting the Resident on 10/2/23 and was unhappy with the lack of care the Resident received on this day. She said the Resident was not approached by any staff during her visit that lasted over six hours and no repositioning, incontinence care or checks were completed on the Resident. She said she placed a complaint on that day because she was aware that the Resident had already developed skin issues at the facility and felt the lack of care she witnessed was likely a contributing factor. During an interview on 10/11/23 at 8:52 A.M., CNA #2 reviewed the CNA documentation for Resident #88 for September and October with the surveyor and said the Resident should have been repositioned every two hours. CNA #2 said that documentation would be made on paper for the month of September and could not explain the missing documentation on the positioning sheet or why it would be marked does not apply since the Resident requires assistance with bed mobility. During an interview on 10/11/23 at 8:58 A.M., CNA #1 said in September of 2023 they documented repositioning on paper every two hours but starting on 10/1/23 they started a new system that simply asks them if they provided repositioning. She said all residents should be repositioned and checked for incontinence about every two hours. She said the CNAs are supposed to document all care provided to their assigned residents every day to prove it was completed. She could not explain why Resident #88 had so many episodes of missing documentation. She said there is nowhere in the CNA documentation that the CNAs can document that they off-loaded the Resident's heels or that they applied any creams; that would likely be in the nurses' paperwork. During an interview on 10/11/23 at 9:14 A.M., Nurse #2 reviewed the medical record of Resident #88. He said when the Resident returned from the hospital the risk for skin breakdown care plan should have been updated since the skin risk Norton Score had changed and the Resident had moved from what he would consider moderate risk to high risk. He said upon reviewing the care plan that there were no interventions in place to prevent the breakdown of the Resident's buttocks or heels except for repositioning. He reviewed the Resident ADL documentation and repositioning sheets for both September and October of 2023 and said that if the documentation was not complete you would have to go by if it's not documented, it's not done. He said having the Residents' repositioning be coded as not applicable or does not apply does not make any sense since the Resident requires assistance with all ADLs and repositioning. He said it does not appear that there was any documentation available to support the premise that prevention for pressure ulcers was in place for this Resident prior to the areas developing on his/her left and right buttocks and right heel. He said the Resident did not have a care plan for incontinence to show any interventions on managing incontinence or any evidence of a care plan that indicated the Resident would be resistive to care. Review of the facility incident report and investigation packet for Resident #88's Lt and Rt buttocks stage 2 pressure ulcers, indicated but was not limited to the following: - Areas were identified on 9/27/23 - [NAME] plus skin risk assessment score = 12, indicating moderate risk (completed on 9/28/23) - Clinical risk factors: immobility; no lab values available for review or evidence Resident has refused preventative measures during the past month - Facility interventions: preventative skin care, consistent turning and repositioning, pressure reduction support surfaces, weekly skin checks, incontinence management program; preventative measures on care plan, preventative measures on CNA care plan - Summary: all preventative measures were not in place, but investigation reveals the area is unavoidable related to: Resident recovering from COVID-19 and very fatigued with limited mobility. Further review of the investigation packet indicated: Page two of the investigation and witness statements were blank and incomplete. During an interview on 10/11/23 at 10:05 A.M., the Director of Nurses (DON) said that the Resident's care plan for skin breakdown prevention should have been updated when he/she returned from their hospitalization and their [NAME] risk score had changed, making them high risk. She said repositioning should have been appropriate for the Resident but upon reviewing the repositioning sheets said the documentation was not completed as it should have been and it appeared the Resident was not repositioned as he/she should have been to prevent the development of pressure areas. On review of the provided incident report for the pressure areas on the Resident's left and right buttock, she could not explain why the investigation concluded all preventative measures were not in place but the areas were unavoidable. She said she did not complete the investigation and would check with the Nurse consultant. An incident report for the right heel DTI was requested by the survey team. During an interview on 10/11/23 at 10:14 A.M., the Nurse Consultant said she felt the facility was doing a good job and must have checked off that all prevention was not in place in error, as she believed all preventative measures were in place. She reviewed the repositioning documentation and lack of evidence that repositioning occurred for Resident #88 on numerous days prior to the development of the areas and following. She said she did not review the documentation when she completed the investigation and asked the staff if the Resident was being repositioned and they confirmed that he/she was. During an interview on 10/12/23 at 8:07 A.M., the NP said although Resident #88 is not in good health that with prevention in place the pressure areas on Resident #88's right and left buttocks and right heel should not have developed. She said although there are times the Resident declines to get out of bed, the Resident shouldn't have developed pressure areas if he/she was consistently repositioned or had consistent preventative measures in place. During an interview on 10/12/23 at 9:31 A.M., the DON said the incident report and investigation for the Rt heel DTI for Resident #88 had not yet been completed and was not available. She said there was minimal documentation she could find to show any prevention was in place for the Resident prior to the pressure areas developing on 9/27/23 to the buttocks and 10/3/23 to the right heel. She said there is no documentation that the Resident's heels were being off-loaded or that repositioning was occurring consistently. She said it appears the facility did not consistently implement pressure prevention measures consistently for Resident #88 and the protocols were not in place as they should have been resulting in the Resident developing pressure areas that he/she should not have developed.

Based on interviews, policy review, and review of Resident Council Minutes, the facility failed to ensure that grievances brought forward through Resident Council from 4/27/23 through 9/26/23 were addressed and promptly resolved as required. Findings include: Review of the facility's Grievance Policy, last revised 9/20/19, indicated but was not limited to: -The resident has the right to voice grievances to the facility such as grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents; and other concerns regarding their stay. -Affiliate leadership will investigate, document, and follow up on all formal concerns and grievances registered by any resident or resident representative. -The facility Administrator will serve as the Grievance Official who is responsible for overseeing the grievance process including receiving and tracking grievances through to their conclusion, leading any necessary investigations by the facility, issuing written grievance decisions to the resident. -Upon verbal receipt of the grievance/concern, the Grievance/Concern Form will be initiated by the staff member receiving the concern and documented on the Grievance/Concern Log. -The Grievance Official and/or department manager will contact the person filing the grievance within 72 hours to acknowledge receipt and provide an initial response, -Investigate and report on the grievance, take corrective actions as needed, and notify the person filing the grievance of the findings within seven working days of the grievance filing. -All written grievance decisions will include the date the grievance was received, a summary statement of the resident grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the residents' concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken by the facility and the date the written decision was issued. 1. Review of the 4/27/23 Resident Council Minutes, signed by the facility Administrator, indicated 14 residents participated in the meeting, and brought forward the following grievances: -Residents feel as if grievances are not being followed through. -Residents said that when they file grievances, they feel staff are blaming them with certain comments that are made. -Residents voiced that their laundry is taking extended amounts of time to be returned to their room (3-4 days). -Residents voiced that the nursing staff is still slow to turn off door alarms on B-Wing. Specifically, staff on the 3:00 P.M. to 11:00 P.M. shift are slowest to decode the alarm. -Certified Nursing Assistants (CNA) are still not introducing themselves and letting the residents know what their goals/tasks are for the day (ex., showers, appointments, etc.) -Residents state that since the day rooms have been closed, nursing staff are now hiding within their rooms and by the bathrooms located on the units. -Residents state they feel as if the nursing staff have a lack of concern for residents needing help and would rather sit at the desk and converse. -Residents are still upset by how long it takes nursing staff to answer call bells and then end up having an accident while nursing staff is conversing amongst each other. -Residents are upset at the lack of privacy the nursing staff gives them as they just barge into the residents' rooms without knocking and asking if it's okay to enter first. Review of the 5/4/23 Resident Council Minutes failed to indicate how many residents participated in the meeting. The minutes indicated the Administrator and Director of Nursing were in attendance, and the following grievances were brought forward: -Staff walk into rooms without knocking or announcing who they are and what they are there to do. -Staff are not kind/polite-residents are met with an attitude from staff members on the floor. -Residents feel as if they bother staff and/or are an inconvenience when asking for help. -Staff tell residents they are not my patient and not my assignment; staff state they will inform their aide, but there is infrequent follow through. -Alarms are not responded to timely during all shifts, frequently disrupting residents' sleep. -Staff are constantly on their phones and/or have ear buds in while on the floor. -Staff are conversing with other staff in languages other than English; residents voiced this concern and the possibility that staff are talking about them. -Food comes to the rooms cold, warm food on cold plates. -Residents feel staff do not listen when they say they don't feel well. Review of a 5/18/23 follow up document to the 5/11/23 Resident Council meeting indicated, but was not limited to: -Call light audits to be completed to track call light response. -Staff have been educated on phone utilization (in the moment education) when a staff member is identified as having their phone and/or headphone in. Review of the 6/21/23 Resident Council Minutes failed to indicate how many residents participated in the meeting. The minutes were signed by the Administrator and the following grievances were brought forward: -Call light-delay in response to call lights: call light audits to be completed 10 X per day for three months (effective 6/28/23) -Staff not announcing who they are when entering room. -Appointments not being communicated to residents and/or families. Review of the 7/25/23 Resident Council Minutes, signed by the facility Administrator, indicated 24 residents participated in the meeting, and brought forward the following grievances: -Residents stated that staff are still not knocking and announcing who they are before they enter the residents' rooms. -Staff are still not explaining to the residents the reason for being there (medication, care, 1:1 activities, housekeeping, etc.). -Staff are still not wearing their name tags. -Residents stated they would like staff to have a more respectful approach toward residents. -Resident stated they are still not being informed about their scheduled appointments outside of the facility. -Resident stated call light response is slightly improving, but still slow (specifically 3:00 P.M. to 11:00 P.M.). -Residents said when the CNAs tell a resident that they will address one of their concerns with the nurse on duty, the residents would like a quick follow-up conversation with the CNA to acknowledge the CNA brought their concern up to the nurse and didn't forget. Review of the 8/16/23 Resident Council Minutes, signed by the facility Administrator, failed to indicate how many residents were in attendance. The following grievances were brought forward: -Staff still not consistently wearing name tags. -Staff on units are using their cell phones. Review of the 8/28/23 Resident Council Minutes, signed by the facility Administrator, indicated 14 residents participated in the meeting, and brought forward the following grievances: -Residents stated staff are still not knocking and announcing themselves prior to entering resident rooms. -Staff are rude when coming into rooms to answer call bells. -Staff are entering resident rooms and turning lights on/off and TVs on/off, volume up and down without consent from residents. -Residents state they are still not being informed of their appointments until the day of the appointment. -Residents state CNAs and nurses are not informing residents who their assigned CNA/Nurses are and their goals for the day (showers, weights, appointments, etc.) -Call light response is still slow, especially on the 3:00 P.M. to 11:00 P.M. shift. Review of the 9/26/23 Resident Council minutes, signed by the facility Administrator, indicated 10 residents participated in the meeting, and brought forward the following grievances: -Nursing provided no response to August Resident Council Minutes -Staff are still not effectively communicating their scheduled appointements. -They would like clarification from the CNAs that they passed requests/concerns to the nurses. On 10/6/23 at 11:00 A.M., the surveyor held a resident group meeting with 18 residents in attendance. The surveyor reviewed grievances identified in the 4/27/23 through 9/26/23 Resident Council Minutes as listed above. The residents said they are frustrated and feel unheard. They said these issues have been raised repeatedly during monthly Resident Council meetings, are unresolved, and continue to be a problem. During an interview on 10/6/23 at 12:59 P.M., the Administrator reviewed the 4/27/23 through 9/26/23 Resident Council minutes with the surveyor. He said the grievances voiced by the residents during the Resident Council meetings have not been addressed through the grievance process and are unresolved. During an interview on 10/12/23 at 9:30 A.M., the Activity Director (AD) said that she sets up and facilitates monthly Resident Council meetings and records the meeting minutes. The AD said she does not complete a grievance form for any issues raised during the Resident Council meetings.

Based on policy review, review of Resident Council Minutes, grievance review, and resident and staff interviews, the facility failed to ensure that staff: 1. Addressed and promptly resolved several grievances brought forward during Resident Council Meetings held on 4/27/23 through 9/26/23; and 2. For Resident #88, the facility failed to ensure the grievance process was implemented and concerns resolved in a timely manner. Findings include: Review of the facility's Grievance Policy, last revised 9/20/19, indicated, but was not limited to: -The resident has the right to voice grievances to the facility such as grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents; and other concerns regarding their stay. -Affiliate leadership will investigate, document, and follow up on all formal concerns and grievances registered by any resident or resident representative. -The facility Administrator will serve as the Grievance Official who is responsible for overseeing the grievance process including receiving and tracking grievances through to their conclusion, leading any necessary investigations by the facility, issuing written grievance decisions to the resident. -Upon verbal receipt of the grievance/concern, the Grievance/Concern Form will be initiated by the staff member receiving the concern and documented on the Grievance/Concern Log. -The Grievance Official and/or department manager will contact the person filing the grievance within 72 hours to acknowledge receipt and provide an initial response, -Investigate and report on the grievance, take corrective actions as needed, and notify the person filing the grievance of the findings within seven working days of the grievance filing. -All written grievance decisions will include the date the grievance was received, a summary statement of the resident grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the residents' concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken by the facility and the date the written decision was issued. 1. Review of the 4/27/23 Resident Council Minutes, signed by the facility Administrator, indicated 14 residents participated in the meeting, and brought forward the following grievances: -Residents feel as if grievances are not being followed through. -Residents said that when they file grievances, they feel staff are blaming them with certain comments that are made. -Residents voiced that their laundry is taking extended amounts of time to be returned to their room (3-4 days). -Residents voiced that the nursing staff is still slow to turn off door alarms on B-Wing. Specifically, staff on the 3:00 P.M. to 11:00 P.M. shift are slowest to decode the alarm. -Certified Nursing Assistants (CNA) are still not introducing themselves and letting the residents know what their goals/tasks are for the day (ex., showers, appointments, etc.) -Residents state that since the day rooms have been closed, nursing staff are now hiding within their rooms and by the bathrooms located on the units. -Residents state they feel as if the nursing staff have a lack of concern for residents needing help and would rather sit at the desk and converse. -Residents are still upset by how long it takes nursing staff to answer call bells and then end up having an accident while nursing staff is conversing amongst each other. -Residents are upset at the lack of privacy the nursing staff gives them as they just barge into the residents' rooms without knocking and asking if it's okay to enter first. Review of the 5/4/23 Resident Council Minutes failed to indicate how many residents participated in the meeting. The minutes indicated the Administrator and Director of Nursing were in attendance, and the following grievances were brought forward: -Staff walk into rooms without knocking or announcing who they are and what they are there to do. -Staff are not kind/polite-residents are met with an attitude from staff members on the floor. -Residents feel as if they bother staff and/or are an inconvenience when asking for help. -Staff tell residents they are not my patient and not my assignment; staff state they will inform their aide, but there is infrequent follow through. -Alarms are not responded to timely during all shifts, frequently disrupting residents' sleep. -Staff are constantly on their phones and/or have ear buds in while on the floor. -Staff are conversing with other staff in languages other than English; residents voiced this concern and the possibility that staff are talking about them. -Food comes to the rooms cold, warm food on cold plates. -Residents feel staff do not listen when they say they don't feel well. Review of a 5/18/23 follow up document to the 5/11/23 Resident Council meeting indicated but was not limited to: -Call light audits to be completed to track call light response. -Staff have been educated on phone utilization (in the moment education) when a staff member is identified as having their phone and/or headphone in. Review of the 6/21/23 Resident Council Minutes failed to indicate how many residents participated in the meeting. The minutes were signed by the Administrator and the following grievances were brought forward: -Call light-delay in response to call lights: call light audits to be completed 10 X per day for three months (effective 6/28/23) -Staff not announcing who they are when entering room. -Appointments not being communicated to residents and/or families. Review of the 7/25/23 Resident Council Minutes, signed by the facility Administrator, indicated 24 residents participated in the meeting, and brought forward the following grievances: -Residents stated that staff are still not knocking and announcing who they are before they enter the residents' rooms. -Staff are still not explaining to the residents the reason for being there (medication, care, 1:1 activities, housekeeping, etc.). -Staff are still not wearing their name tags. -Residents stated they would like staff to have a more respectful approach toward residents. -Resident stated they are still not being informed about their scheduled appointments outside of the facility. -Resident stated call light response is slightly improving, but still slow (specifically 3:00 P.M. to 11:00 P.M.). -Residents said when the CNA tells a resident that they will address one of their concerns with the nurse on duty, the residents would like a quick follow-up conversation with the CNA to acknowledge the CNA brought their concern up to the nurse and didn't forget. Review of the 8/16/23 Resident Council Minutes, signed by the facility Administrator, failed to indicate how many residents were in attendance. The following grievances were brought forward: -Staff still not consistently wearing name tags. -Staff on units are using their cell phones. Review of the 8/28/23 Resident Council Minutes, signed by the facility Administrator, indicated 14 residents participated in the meeting, and brought forward the following grievances: -Residents stated staff are still not knocking and announcing themselves prior to entering resident rooms. -Staff are rude when coming into rooms to answer call bells. -Staff are entering resident rooms and turning lights on/off and TVs on/off, volume up and down without consent from residents. -Residents state they are still not being informed of their appointments until the day of the appointment. -Residents state CNAs and nurses are not informing residents who their assigned CNA/Nurses are and their goals for the day (showers, weights, appointments, etc.) -Call light response is still slow, especially on the 3:00 P.M. to 11:00 P.M. shift. Review of the 9/26/23 Resident Council Minutes, signed by the facility Administrator, indicated 10 residents participated in the meeting, and brought forward the following grievances: -Nursing provided no response to August Resident Council minutes -Staff are still not effectively communicating their scheduled appointments. -They would like clarification from the CNAs that they passed requests/concerns to the nurses. On 10/6/23 at 11:00 A.M., the surveyor held a resident group meeting with 18 residents in attendance. The surveyor reviewed grievances identified in the 4/27/23 through 9/26/23 Resident Council minutes as listed above. The residents said they are frustrated and feel unheard. They said these issues have been raised repeatedly during monthly Resident Council meetings, are unresolved, and continue to be a problem. Review of the Grievance Log failed to indicate any grievances brought forward during Resident Council Meetings from 4/27/23 to 9/26/23 were documented on the Grievance/Concern Log according to facility policy. During an interview on 10/6/23 at 12:59 P.M., the Administrator reviewed the 4/27/23 through 9/26/23 Resident Council minutes with the surveyor. He said the grievances voiced by the residents during the Resident Council meetings have not been addressed through the grievance process as required. He said the grievances are supposed to be documented and kept in the Grievance Log and resolved within seven working days and were not. The Administrator and surveyor reviewed call bell response audits conducted July 2023 through September 2023 in an attempt to assess residents' complaints of long call bell times. However, the audits were ineffective because the auditor was answering the call bells and not auditing staffs' response time to call bells. During an interview on 10/12/23 at 9:30 A.M., the Activity Director (AD) said she does not complete a grievance form for any issues raised during the Resident Council meetings. 43935 2. Resident #88 was admitted to the facility in September 2023 with diagnoses including: COVID-19, urinary tract infection, and hypertension (high blood pressure). During an interview on 10/5/23 at 11:03 A.M., Family Member #1 and Family Member #2 were in the Residents' room and said they had care concerns. They said they feel the Resident is not being changed following incontinent episodes or being repositioned and now has open areas on his/her skin. They informed the facility of their concerns on 10/2/23. During an interview on 10/10/23 at 11:31 A.M., Family Member #1 was in the Residents' room and said she is there daily and feels the staff are not encouraging the Resident to get out of bed, repositioning him/her in the bed, providing incontinence care, or keeping the pillows under his/her legs to off-load his/her heels. She said she has not heard back from the facility on a plan to correct the issues and feels the concerns are ongoing. During an interview on 10/10/23 at 1:53 P.M., the Ombudsman said Resident #88's family had care concerns and informed the facility but is still waiting for follow up from the facility on the issues. Review of the facility's Grievance Book and Log failed to indicate a grievance was initiated for Resident #88. During an interview on 10/10/23 at 2:38 P.M., the Director of Nurses (DON) said she was aware of the concerns on 10/2/23 and thought she addressed them on the spot and therefore did not complete a grievance form. She said she was unaware the concerns were unresolved. During an interview on 10/10/23 at 2:48 P.M., Family Member #1 said she comes to the facility daily to make sure the Resident is getting the care he/she needs because she feels unless she is there to tell them when the Resident needs something they do not come in and take care of him/her. She said she feels the situation should have been improved since the family put in a complaint but it has not yet been resolved. During an interview on 10/10/23 at 2:56 P.M., Family Member #4 said she was at the facility on 10/2/23 and felt the facility did not provide the Resident with any care for the six hours she was at the bedside. She said she lodged a complaint and the DON came up to speak with her and assured her things would improve, but she feels the issues have not been resolved at this time and she has not heard back from the facility regarding a plan to ensure the concerns do not continue moving forward. The facility failed to investigate and report back on the grievance or provide any follow up with the family of Resident #88 regarding their voiced concerns in the seven-day time frame as delineated by the facility grievance policy. During an interview on 10/11/23 at 10:47 A.M., the Social Worker said she was not aware Resident #88's family had voiced concerns and said a grievance should have been completed to ensure the process was followed and issues were resolved timely. During an interview on 10/11/23 at 12:05 P.M., the Administrator said the concerns brought forth on 10/2/23 by Resident #88's family should have been placed on a grievance form to ensure the facility followed the process and resolved the concerns in a timely manner but it wasn't and the process for grievance resolution was not followed.

Based on record review, observations, policy review, and interviews, the facility failed to assist one Resident (#43) and their family, out of a total sample of 19 residents, in sourcing a replacement hearing device after the loss of the Resident's hearing aids. Findings include: Review of the facility's policy titled Overcoming Communication barriers, dated as revised 10/27/22, indicated but was not limited to the following: - it is the facility policy to reduce communication barriers and provide methods to ensure adequate communication between residents and staff and enable residents to maintain social interaction to the extent possible - the interdisciplinary team will assess the resident for communication barriers upon admission, annually and whenever a potential communication problem becomes evident - adaptive tools for communication will be maintained in a location accessible to the resident and staff providing care - the resident's care plan will identify methods instituted to assist in communicating needs Resident #43 was admitted to the facility in August 2022 with diagnoses including dementia, anxiety, and mood disturbance. On 10/5/23 at 10:28 A.M., the surveyor observed Resident #43 in his/her room. When the surveyor attempted to speak with the Resident, the Resident said he/she could not hear anything and doesn't have hearing aids, but would like them, and requested the surveyor speak with their family. Review of the medical record for Resident #43 indicated the Resident was severely cognitively impaired with an activated healthcare proxy (HCP). Review of the current care plans for Resident #43 indicated but were not limited to the following: Communication device in use: hearing aids (3/14/23) Goal: communication will be at optimal level (3/14/23) Interventions: (all dated 3/14/23) - announce yourself when entering the Resident's space - Face Resident directly and speak clearly and distinctly - Ask yes or no questions and allow nodding or shaking of the head - Explain all activities and procedures clearly - Establish daily routines: keep call bell and personal items in reach During an interview on 10/5/23 at 3:52 P.M., Resident #43's HCP said the Resident lost their hearing aids at the facility about six months ago. He said he requested a larger hearing device or alternative device because he believes the Resident may have accidentally thrown the devices away in their confused state. He said the Resident still has not been given an alternative device or had their hearing aids replaced and is very hard of hearing (HOH). He said the facility has not followed up with him on a plan and that when he visits, he sometimes has to write down what he wants to say to the Resident because the Resident gets frustrated with the situation since they cannot hear well. Review of the progress notes for Resident #43 indicated the following: - 3/9/23 Nursing note: HCP informed the Resident's hearing aids are missing - 3/10/23 Nursing note: HCP is aware of missing hearing aids and is looking for information on where the hearing aids were made - 5/8/23 Nurse Practitioner note: Resident is hearing impaired and was seen by an ears, nose and throat specialist (ENT) on 2/10/23 with cerumen (ear wax) removal but hearing not improved - 5/23/23 Quarterly activity note: Resident is very HOH and becomes easily agitated when he/she cannot hear others speaking to him/her - 9/12/23 Social service note: Resident has been seen by audiology, will follow up as needed, no specific concerns Review of the notes indicated the Resident lost their hearing aids in March of 2023 and has been without an assistive hearing device since that time, seven months prior. During an interview on 10/10/23 at 10:35 A.M., the Social Worker said she is newer to the facility and was unaware the Resident lost his/her hearing aids at the facility. She said the Resident does get frustrated when he/she cannot hear but the Resident's requests for hearing aids are unreliable since the Resident is demented and she believed the Resident did not want any hearing devices. During an interview on 10/10/23 at 10:39 A.M., Nurse #2 said the Resident lost their hearing aids at the facility and he believes the investigation determined the Resident may have thrown them away in error. He said he is unaware of any alternative hearing devices being offered to the Resident or his/her HCP to assist the Resident with hearing. He said it was a previous social worker managing the issue and he has not heard any follow up on it since they left. He said the Resident does get frustrated at times and will repeatedly say I can't hear you and then will stop communicating. Review of the care plan meeting notes indicated but were not limited to the following: - 3/14/23: HCP was at meeting and the lost hearing aids were discussed; there is a notation that the unit manager was going to look into an amplifier for the Resident to use to hear better and the HCP was in agreement with the plan. - 6/13/23: HCP attended the meeting by telephone and voiced concerns that the Resident repeats the same things over and over and doesn't hear anything. Another notation of determining if an amplifier for hearing would be beneficial. On 10/10/23 at 3:43 P.M., the surveyor observed Resident #43 sitting in their room and waving to them. Resident #43 said, I wish we could have a nice conversation but I can't hear anything. The Resident said that they wished they had some hearing aids but doesn't know where they went and then said, I'm sorry I can't hear, I guess I don't have hearing aids. During an interview on 10/11/23 at 12:00 P.M., the Administrator said he first learned the Resident had lost their hearing aids sometime in June and that the HCP had requested an alternative device such as an amplifier to assist the Resident with hearing since it was larger than hearing aids and wouldn't be as easily lost. He said he believed the facility case manager was following up on the issue and he was unaware of any further follow up at this point and there was no grievance completed. During an interview on 10/11/23 at 1:04 P.M., the Case Manager said she believes she first heard about the missing hearing aids sometime in June and her plan was to help the Resident's HCP obtain some type of replacement device at that time. She said she has not followed up with the HCP at this time and she dropped the ball in ensuring a replacement device was given to the Resident so they could hear better and the Resident does not have a replacement device for hearing at this time. During an interview on 10/11/23 at 2:50 P.M., the Administrator said the expectation is that the facility would have replaced the hearing aids of Resident #43 or provided the Resident with an alternative device to assist the Resident in hearing to the best of their ability, but at this time that expectation had still not been met.

Based on record review and interview, the facility failed to ensure that individualized, resident-centered, comprehensive care plans were developed and consistently implemented for one Resident (#32), out of a total sample of 23 residents. Specifically, the facility failed to ensure a care plan was developed for the use of psychotropic medications that included individualized, resident-centered, targeted signs/symptoms or behaviors. Findings include: Review of the facility's policy titled Care Planning, last revised 10/28/22, included but was not limited to: -The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that include measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. -The purpose is to provide effective and person-centered care to the resident. -The Standardized Care Plans, MUST be individualized for the resident by adding Care Needs/Preferences, interventions, and resident specific strategies based on the assessment of a resident's needs, strengths, goals, life history, and preferences. Resident #32 was admitted to the facility in September 2023 with diagnoses including bipolar disorder, major depression, and anxiety. Review of the 9/20/23 Minimum Data Set assessment indicated Resident #32 is cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15 and received antipsychotic and antidepressant medication daily. Review of the October 2023 Physician's Orders included but was not limited to: -Benztropine (used to treat side effects of antipsychotic medication) 0.5 milligrams (mg) twice daily (9/14/23) -Topiramate (anticonvulsant used for bipolar disorder) 25 mg at 9:00 A.M. (9/20/23) -Bupropion HCL (antidepressant) 100 mg at 9:00 A.M. (9/14/23) -Celexa (antianxiety) 5 mg at 9:00 A.M. (9/15/23) -Zyprexa (antipsychotic) 5 mg at 9:00 P.M. (9/14/23) Review of September 2023 and October 2023 Medication Administration Records indicated Resident #32 was administered psychotropic medication as ordered by the Physician. Review of comprehensive care plans included but was not limited to: -Problem: Psychotropic Medication-Resident requires psychotropic medications secondary to bipolar, depression, anxiety (9/19/23) -Interventions: Administer medications as ordered; monitor for effectiveness of drug use; monitor for side effects and report; dose reductions as indicated; psych consult as needed; encourage involvement in appropriate activities (9/19/23) -Goal: Will have smallest, most effective dose without side effects X 90 days (9/19/23) Further review of the care plan failed to identify Resident specific targeted signs/symptoms or behaviors for the use of Benztropine, Topiramate, Bupropion, Celexa and Zyprexa and any specific non-pharmacological approaches and measurable goals to meet the Resident's needs. During an interview on 10/11/23 at 8:40 A.M., Nurse #1 reviewed Resident #32's medical record. She said the care plans don't include resident specific targeted signs/symptoms or behaviors, non-pharmacological interventions and measurable goals for the use of psychotropic medication but should. During an interview on 10/12/23 at 8:40 A.M., the Director of Social Services said she was not aware that care plans for the use of psychotropic medications should include resident specific targeted signs/symptoms or behaviors, non-pharmacological interventions and measurable goals.

Based on observation, interview, and policy review, the facility failed for two Residents (#82 and #302) to ensure respiratory equipment and tubing was managed and stored in a sanitary way to prevent the potential of contamination from environmental debris and germs. Findings include: Review of the facility's policy titled Oxygen and Respiratory Equipment, dated 2/27/13, indicated but was not limited to the following: - Respiratory equipment used on an as needed basis should be contained in a closable plastic bag when not in use to prevent contamination 1. Resident #82 was admitted to the facility in September 2021 with diagnoses including chronic obstructive pulmonary disease (COPD). The most recent Brief Interview for Mental Status (BIMS) was a score of 15 out of 15 which indicated the Resident was cognitively intact. During an observation with interview on 10/5/23 at 2:12 P.M., the surveyor observed a nebulizer machine (a machine used to turn liquid medications into a fine mist for inhalation) and tubing sitting on the window ledge with the mouthpiece touching the wall and not secured from potential contamination of germs. Resident #82 said he/she has a nebulizer machine he/she uses as needed for shortness of breath and he/she has never seen the tubing stored in a plastic bag; it is always left on the window ledge. The surveyor observed Resident #82's nebulizer equipment and tubing, not in use by the Resident, on the following days/times: - 10/5/23 at 3:30 P.M.: Tubing connected to machine, left open to air and environmental debris and possible contamination from germs on the window ledge, no plastic storage bag in the vicinity - 10/6/23 at 7:33 A.M.: Nebulizer set up and tubing sitting open to the air on the window ledge not secured in a plastic storage bag - 10/6/23 at 12:22 P.M.: Machine and tubing on the window ledge open to air with the mouthpiece touching the wall, there was no storage bag observed in the room During an interview on 10/6/23 at 12:25 P.M., Nurse #3 observed the nebulizer equipment for Resident #82 and said the equipment should be stored in a more sanitary manner to protect it from germs and the process for storing respiratory equipment was not being followed. 2. Resident #302 was admitted to the facility in September 2023 with diagnoses including COPD. Review of the Nursing admission assessment for Resident #302 indicated he/she was alert and oriented to person, place and time. During an observation with interview on 10/5/23 at 11:37 A.M., the surveyor observed Resident #302's bilevel positive airway pressure (BIPAP) (a non-invasive ventilator used to assist with breathing) mask touching the bedside table directly and nebulizer tubing and set up sitting on the bedside table, not secured in a storage bag or device to protect it from germs or environmental debris. Resident #302 said that is how his/her equipment is usually kept. The surveyor observed Resident #302's BIPAP mask and nebulizer equipment and tubing, not in use by the Resident, left open to air and environmental debris on the on the following days/times: - 10/5/23 at 3:30 P.M - 10/6/23 at 7:30 A.M. and 12:20 P.M. During an interview on 10/6/23 at 12:25 P.M., Nurse #3 observed the BIPAP and nebulizer equipment of Resident #302 and said the equipment should be stored in a more sanitary manner to protect it from germs and the process for storing respiratory equipment was not being followed. During an interview on 10/6/23 at 2:28 P.M., the Director of Nurses said respiratory equipment and tubing should be stored in a plastic storage bag when not in use by the residents. She said the policy for respiratory equipment was not met as it should have been.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who had a history of wandering with no sense of direction or purpose, exhibited exiting seeking behaviors, was assessed by nursing to be at an increased risk for elopement, and required the use of a wander guard bracelet for safety, the Facility failed to ensure Resident #1 was provided with adequate supervision to maintain his/her safety, to prevent an incident/accident (elopement) resulting in injury. On 9/15/22, unbeknownst to staff on his/her unit Resident #1 wandered off the unit, Resident #1 then made his/her way undetected by dietary staff through the kitchen area, and exited a back door of the Facility to the loading dock area. Resident #1 fell off the loading dock to the ground below, and was on the ground lying in front of a parked car for approximately 15 minutes before being found by staff. Resident #1 sustained a laceration to the back of his/her head, 911 were activated, and Resident #1 was transferred to the Hospital Emergency Department for further evaluation. Findings include: The Facility's Policy, titled Elopement Prevention and Response, dated as last revised September 28, 2022, indicated the Facility provides a secure environment for residents identified at risk for elopement, and to provide a secure environment through the implementation of individualized care plan interventions. The Policy indicated the following: -monitoring and managing residents at risk for elopement to minimize the risk of a resident leaving a safe area without authorization and/or appropriate supervision; -ensure the residents environment remains as free of accident hazards as possible; -each resident receives adequate supervision and assistance devices to prevent accidents; -elopement is when a resident leaves the premises or a safe area without knowledge; -wandering refers to random or repetitive locomotion. This movement may be goal-directed (the person appears to be searching for something such as an exit) or nay be non-goal-directed or aimless; -an elopement risk evaluation is completed by nursing staff on all residents upon admission, re-admission, quarterly, annually and significant change in condition; -residents determined to be at risk for elopement, a care plan goal and individualized approaches to ensure safety will be implemented by Interdisciplinary Team; -the risk evaluation tool addresses the resident's mobility and psychological, behavioral, physical and cognitive functions; -interventions will be based on assessment of risk factors for elopement including, but not limited to: medical diagnoses, pharmacological review, psychosocial triggers, cognitive status, behavior patterns, and lifestyle history. Resident #1 was admitted to the Facility in July 2022, diagnoses included Dementia, Gastro-[CONDITION(S)] Reflux Disease, Major Depressive Disorder, Hypertension, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], and Migraines. Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 8/06/22, indicated that Resident #1 had severe cognitive impairments. Review of Resident #1's Wandering/Elopement Risk Assessment, dated 8/26/22, indicated that Resident #1 had a history of wandering, and he/she was at high risk for elopement. The Assessment indicated that a facility alarm (known as a wander guard), was placed on his/her left ankle. Review of a Nurse Progress Note, dated 8/26/22, indicated that Resident #1 had a wander guard device placed to his/her left ankle to ensure his/her safety from potential elopement. The Note indicated that Resident #1 self-propelled throughout the first floor with no sense of direction, destination, or purpose related to Dementia. The Note indicated that Resident #1 could open unlocked doors. Review of an Incident/Accident Report, dated 9/15/22 at 8:00 P.M., indicated that Resident #1 had a fall on the ground near the kitchen loading dock. The Report indicated that Resident #1 sustained a laceration to the back of his/her head. Review of a Nurse Progress Note, dated 10/01/22 (late entry for 9/15/22), indicated that Resident #1 was found lying near the loading dock by the kitchen and he/she was found by kitchen staff. The Note indicated that Resident #1 had blood present to the back of his/her head and 911 was called. The Note indicated Emergency Medical Services (EMS) arrived and transported Resident #1 to the Hospital Emergency Department. Review of a Physician Progress Note, dated 9/16/22, indicated that Resident #1 had an unwitnessed fall and nursing to continue to monitor him/her closely as he/she had a strike to his/her head. Review of a Nurse Progress Note, dated 9/17/22, indicated that Resident #1 had an abrasion to his/her occipital region with scattered scabs, his/her left arm noted with scabbed area measuring 1 inch x 0.5 inch, and scattered bruising to his/her right buttock. Review of the Physician Orders and Treatment Record for Resident #1, indicated he/she had a new order dated 9/20/22, to monitor Resident #1's back and side of the head hematoma day and evening, and monitor him/her for signs/symptoms of worsening. Review of the Facility's Internal Investigation Report, undated, indicated that on 9/15/22 between 7:33 P.M. and 7:55 P.M., Resident #1 wandered in his/her wheelchair near the kitchen, stood up from his/her wheelchair and entered the bathroom. The Report indicated that Resident #1 exited the bathroom then opened the kitchen door and entered. The Report indicated that unbeknownst to dietary staff, Resident #1 exited out the back door and he/she walked off the loading dock. The Report indicated that at approximately 8:07 P.M., dietary staff walked out the back kitchen door, heard someone say help me, and then saw Resident #1 laying on the ground. The Report indicated that Resident #1 has dementia, a history of wandering, wore a wander guard bracelet, and was at risk for elopement. The Report indicated that Resident #1 fell and sustained a laceration to the back of his/her head, 911 was called and he/she was transported to the hospital. During an interview on 10/04/22 at 4:34 P.M., Certified Nurse Aide (CNA) #4 (who was assigned to work the 3:00 P.M. -11:00 P.M. shift on Resident #1's unit on 9/15/22) said Resident #1 wandered up and down the hallways, into other resident's rooms and to the other unit in the facility. CNA #4 said Resident #1 needed to be supervised by staff every day while he/she was in his/her wheelchair. CNA #4 said that the last time she saw Resident #1, he/she was in the middle of the long hallway on the unit and that she did not see he/she leave the unit. During an interview on 10/05/22 at 11:30 A.M., CNA #5 (who was assigned to work the 3:00 P.M. -11:00 P.M. shift on Resident #1's unit on 9/15/22) said that Resident #1 required supervision with his/her wheelchair mobility, that he/she would wander about the unit and all staff were responsible to supervise where he/she was. CNA #5 said that she was assigned to care for Resident #1 that evening and last she saw him/her was sometime between 7:00 P.M.-7:30 P.M. sitting in front of the nurse's station. During an interview on 10/05/22 at 12:07 P.M., Nurse #4 (who was assigned to work the 3:00 P.M. -11:00 P.M. shift on Resident #1's unit on 9/15/22) said that she saw Resident #1 in his/her wheelchair wandering up and down the hallway on the unit. Nurse #4 said she did not know that Resident #1 was supposed to be supervised while in his/her wheelchair, or how he/she got out of the Facility. During an interview on 10/06/22 at 12:23 P.M., the Assistant Director of Nurses (ADON) said that Resident #1 self-propelled in his/her wheelchair and would try to open the bathroom doors and storage closet near the main kitchen. The ADON said on 8/26/22 Resident #1 was assessed for wandering/elopement and a wander guard bracelet was place to his/her left ankle. The ADON said that Resident #1 was a risk for elopement and that staff should have been supervising him/her that night. During an interview on 10/04/22 at 1:55 P.M., Nurse #1 said Resident #1 would wander in his/her wheelchair from the A-wing unit to the B-wing unit and he/she needed to be redirected back to the A-wing unit where he/she resided. Nurse #1 said he was doing his med pass when Dietary Aide #2 approached him and said run, run there is a resident outside on the ground. Nurse #1 said he ran outside and saw Resident #1 lying on the ground in the back parking lot near the loading dock. Nurse #1 said Resident #1 was unable to move his/her extremities upon assessment and that another staff member noticed blood on the back of his/her head. Nurse #1 said he applied pressure to the back of Resident #1's head with a 4 x 4 gauze. Nurse #1 said Nurse #3 called 911 and Resident #1 remained lying on the ground until EMS arrived. The Surveyor viewed the Facility surveillance camera video footage provided by the Administrator. The footage from channel 12 (Elevator camera) is dated and time stamped from 19:30:39-20:56:58 on 9/15/22, and footage from channel 07 (back lot/loading dock camera) is dated and time stamped from 19:34:10 to 20:53:56 on 9/15/22, and depicted the following: Channel 12-Elevator: Surveillance camera footage showed the following sequence of events: -19:33:52 (7:33:52 P.M.) Resident #1 is seen self-propelling in his/her wheelchair towards main kitchen doors and stops in front of the bathroom on the right side of the hallway. -19:34:07 (7:34:07 P.M.) Resident #1 starts to open the bathroom door from seated position. -Video footage skips from 19:34:08 (7:34:08 P.M.) to 19:41:30 (7:41:30 P.M.) -19:41:30 (7:41:30 P.M.)-19:45:59 (7:45:59 P.M.) Resident #1's wheelchair remained unoccupied and facing towards the bathroom door. - Video footage skips from 19:46:00 (7:46:00 P.M.) to 19:56:57 (7:56:57 P.M.) -19:56:57 (7:56:57 P.M.) Resident #1's wheelchair still unoccupied near the bathroom and facing towards the main kitchen doors. Channel 07 Back lot/loading dock: Surveillance camera footage showed the following sequence of events: -19.52:14 (7:52:14 P.M.) The back kitchen door opens. -19.52:17 (7:52:17 P.M.) Resident #1 walks out from the kitchen and closes the door. -19.52:23 (7:52:23 P.M.) Resident #1 turns around and starts walking across the loading dock. -19:52:34 (7:52:34 P.M.) Resident #1 is seen stepping off the loading dock and then falling to the ground below landing in front of a parked car. -19:52:35 (7:52:35 P.M.)-19:56:40 (7:56:40 P.M.) Resident #1 remains lying on the ground below the loading dock in front of a parked car (later identified as the Housekeeping Supervisors car). -19:56:40 (7:56:40 P.M.)-19:57:22 (7:57:22 P.M.) A staff member (later identified as the Housekeeping Supervisor) approaches and gets into the car, starts it, backs up, and drives off (without noticing Resident #1 who was still lying on the ground). -19:57:22 (7:57:22 P.M.)-20:09:40 (8:09:39 P.M.) Resident #1 remains lying on the ground below the loading dock. -20:07:50 (8:07:50 P.M.) Dietary Aide #1 and #2 exit out the back kitchen door, down the ramp and walk out of camera view. -20:09:21 (8:09:21)-20:10:54 (8:10:54 P.M.) Dietary Aide #2 walks across the parking lot towards her car, stops at the back of the car turns and looks at Resident #1 lying on the ground at (8:09:39 P.M.), she then walks towards Dietary Aide #1's car as he is backing up. Dietary Aide #1 stops, gets of his car and walks over to where Resident #1 is lying on the ground. Dietary Aide #2 walks to her car, grabs something from inside it and runs into the building, Dietary Aide #1 remains with Resident #1. -20:11:03 (8:11:03 P.M.)-20:23:09 (8:23:09 P.M.) Several staff members are seen exiting and entering the back kitchen door attending to and remaining with Resident #1. -20:23:10 (8:23:10 P.M.) EMS arrives on scene. -20:24:11 (8:24:11 P.M.)-20:44:41 (8:44:41 P.M.) EMS assess Resident #1, and he/she is transferred to the Hospital Emergency Department for evaluation. During an interview on 10/04/22 at 3:38 P.M., Dietary Aide #1 (with interview assistance and translation provided by Interpreter #1) said the front and back kitchen doors were not locked or alarmed. Dietary Aide #1 said he was doing the dishes in the dish room and did not see or hear Resident #1 come into the kitchen and go out the back door. Dietary Aide #1 said (at the end of their shift), he and Dietary Aide #2 left out the kitchen back door, he went to his car and Dietary Aide #2 said someone is yelling for help. Dietary Aide #1 said they saw Resident #1 lying on the ground by the loading dock and he stayed with Resident #1 and Dietary Aide #2 went back into the building to get a nurse. During an interview on 10/04/22 at 4:08 P.M., Dietary Aide #2 (with interview assistance and translation provided by Interpreter #2) said the front kitchen doors had no locks or an alarm and the back door was not locked, and the door alarm was not on. Dietary Aide #2 said she was in the main dining room cleaning before going home and did not see or hear Resident #1 enter the kitchen or go out the back door. Dietary Aide #2 said she went out the kitchen back door to go home with Dietary Aide #1 and heard someone say help me. Dietary Aide #2 said she used her cell phone flashlight and saw Resident #1 lying on the ground near her car and the loading dock. Dietary Aide #2 said Dietary Aide #1 stayed with Resident #1 while she went inside to get a nurse. During an interview on 10/06/22 at 3:19 P.M., Dietary Aide #4 said she was the first to arrive on the morning of 9/15/22 and that the back kitchen door was unlocked that morning. Dietary Aide #4 said that she would enter the master code on the keypad to deactivate the Maglock (electronic locking device) alarm system for the day and the night staff were responsible to reactivate the alarm system when they left for the night. Dietary Aide #4 said the kitchen back door was left unlocked and the alarm deactivated every day. During an interview on 10/04/22 at 4:43 P.M., the Maintenance Director said it was the building's practice and he was aware that kitchen staff were deactivating the Maglock keypad alarm system on the kitchen back door. The Maintenance Director said the back door alarm was deactivated every day during kitchen hours for easier access to the trash dumpster and for receiving food deliveries. During an interview on 10/05/22 at 1:10 P.M., the Food Service Director said the back kitchen door Maglock system alarm was turned off by kitchen staff who first enters the kitchen in the morning. The Food Service Director said the staff typed in a master code on the door keypad that deactivated the alarm for the day and was reactivated when staff leaves for the night by re-entering the master code on the door keypad. The Food Service Director said all kitchen staff knew the master code that deactivated the door alarm and used it for receiving food deliveries, so staff would not have to keep putting in the code with the ten second delay on the keypad. During an interview on 10/04/22 at 4:57 P.M., the Administrator said the Maglock system on the kitchen back door was deactivated early in the morning by the first staff member to arrive and was done daily for taking out the trash and receiving food deliveries. The Administrator said the kitchen back door should not have been deactivated and no one should have a code to deactivate any door in the facility. During an interview on 10/05/22 at 12:27 P.M., the Administrator said that prior to the Facility's investigation into this incident, he was not aware that the kitchen staff was deactivating the Maglock system on the back door of the kitchen, or that they had the master code to deactivate the door. On 10/04/22, 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 being monitored for pain and his/her functional status will be evaluated by Rehabilitation Therapy. Resident #1 was placed on 1:1 when out of bed and he/she continues to wear wander guard bracelet. Care Plan has been updated and the Interdisciplinary Team (IDT) team will continue to follow until he/she is at baseline and his/her one-to-one status is lifted or determined a necessary intervention. B) On 9/23/22, All other residents had new elopement assessments completed. To ensure elopement policy is followed which includes, completion of elopement risk assessment and updating plan of care, roam alert bracelet placement is documented on the Medication Administration Record (MAR) and elopement book is updated. This was completed by the Nursing Management Team. C) On 9/22/22, 9/23/22, 9/26/22, 9/27/22, and 10/03/22, the Nursing Management Team conducted Educational In-services for all staff on the Facility's Elopement Prevention and Response Policy. D) Code Green Drills (elopement) will be conducted weekly for 30 days, monthly for 60 days, and then quarterly and thereafter by the Staff Developer. The results will be brought to QAPI committee monthly for 90 days. The Staff Developer/and or will be responsible for this compliance E) On 9/16/22, Food Service Director was educated by the Administrator and Regional Director of Operations on Safety and Security of the kitchen. F) On 9/16/22, the Food Service Director conducted Educational In-service for all Dietary staff on Safety and Security of the Kitchen. G) On 9/20/22, the Staff Developer conducted Dementia training In-service for all Dietary staff. H) On 9/23/22 and 9/28/22, the Maintenance Director conducted Educational In-services for all staff on Door Security and System Breach. I) On 9/16/22, the Roam Alert System and Maglock System was audited/evaluated by the Maintenance Department and by Berkshires Director of Facilities Management on 9/19/22. Both systems were deemed to be fully functional. J) The Facility will be replacing the kitchen doors and installing an additional locking mechanism. The new doors, Maglocks and keypads have been ordered by the Director of Facilities Management. K) All door security and alarm systems will be checked for functionality. The checks will be conducted 2 times per week for 30 days, then weekly by the Maintenance Department. The results will be brought to the QAPI committee monthly for 90 days. The Maintenance Director/and or designee will be responsible for this compliance. L) The Administrator/and or designee are responsible for overall compliance.

Based on record review and staff interview, the facility failed to ensure that for two Residents (#16, #45), from a total sample of 31 residents, that staff provided care and treatment in accordance with Professional Standards of Practice, resulting in: Residents #16 and #45 being transferred to the hospital for assessment and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: The Practice Principles, Wound Care Essentials, copyright 2020, indicates that: * wound assessment-an appraisal of a patient's condition based on clinical signs and symptoms, laboratory data, and medical history-is an integral part of wound management. *wound documentation essentials .documentation is an essential component of wound assessment. Every wound assessment should be documented thoroughly, accurately, and legibly, with an accompanying signature as well as the date and time of the assessment. Wounds should be documented on the patient's admission, weekly, with each dressing change, upon any significant change in the wound, and upon discharge. 1) For Residents #16 and #45, the facility staff failed to ensure that: -the Residents' skin was thoroughly assessed and monitored and the Residents' skin status was documented. -treatments were provided according to the physician's orders, resulting in the hospitalization of both Residents for infected wounds with maggots in them. A. Review of Resident #16's Minimum Data Set assessment, dated 1/6/21, indicated that Resident #16 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15, and required assistance of staff for all activities of daily living. During an interview on 4/6/21 at 10:00 A.M., Resident #16 said that at the end of last summer, he/she developed a wound area on his/her foot that was very painful. The Resident said that he/she saw that large maggots were on his/her foot, and told the former Unit Manager. Resident #16 said that when the Unit Manager came to look at his/her foot and saw the maggots, the Unit Manager tried to cover it up so no one else would see it. Resident #16 said that a few maggots fell on the floor. The Resident said that the pain was so bad they sent him/her out to the hospital, and he/she was diagnosed with [CONDITION(S)] ( a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock,and death). Resident #16 said that while in the emergency room , they soaked his/her feet in [MEDICATION(S)] (a topical antiseptic that provides infection protection against a variety of germs) to kill the maggots. Review of nursing progress notes indicated that on 6/2/20, the Resident complained of right lower extremity burning pain. The Resident was assessed by the nurse and was found to have +3 pitting [CONDITION(S)] (after pressing on a swollen area your body has an indentation or dimple that takes 30 seconds to go away), with a small amount of purulent (having a milky look and texture) discharge oozing off the skin. The physician was notified, and the Resident was started on the antibiotic [MEDICATION(S)] 100 milligrams (mg), twice a day for 10 days. Review of the interdisciplinary care plan for [CONDITION(S)] (serious bacterial infection of the skin), developed on 6/2/20, indicated that Resident #16 had a bacterial infection involving the dermis (inner layer of the two main layers of the skin) and subcutaneous tissue (layer of tissue that underlies the skin). Interventions included: -notify physician if the temperature was 100 degrees or greater regardless of other symptoms -administer antibiotics as ordered -monitor symptoms such as pain, tenderness, swelling, warmth, redness spreading to surrounding tissues -notify physician of new or worsening symptoms The care plan failed to identify the specific location of Resident #16's infection. Further review of the medical record failed to indicate that weekly skin assessments were being conducted and documented as per the facility's policy and standards of practice. Review of a nursing progress note, dated 7/5/20, indicated that Resident #16 was readmitted to the facility following a brief hospitalization for [CONDITION(S)] and [CONDITION(S)] on 7/4/20. The note indicated that the Resident's right leg was edematous (fluid filled), inflamed, and aggressively red with an open area on the right lower leg. The medical record failed to indicate that a wound assessment was conducted and documented weekly thereafter. Review of Resident #16's July 2020 nursing progress notes indicated: -7/6/20 [CONDITION(S)] on right leg continues to be aggressively red, edematous. -7/12/20 Right leg reddened, small opening with [MEDICATION(S)] in place (there was no physician's order in place for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . -7/14/20 Small amount of serous drainage noted on old dressing. There was no other information in the medical record that addressed Resident #16's skin integrity during July 2020. Review of wound management documentation and At Risk documentation, failed to indicate that Resident #16's open area on his/her right leg was identified, assessed, or was monitored. Review of a nursing progress note, dated 8/1/20, indicated that the nurse was asked to see Resident #16 for a complaint of leg pain. On assessment, both lower extremities were noted to be dark red, +3 swelling, right more so than left. The right leg was draining black and thick exudate (mass of cells and fluid that has seeped out of blood vessels, especially in inflammation). Toes with +4 swelling, weeping clear fluid. Left leg with copious amounts of clear fluid draining. The Nurse Practitioner was updated, and gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of hospital documentation indicated that Resident #16 presented to the hospital emergency roiagnom on [DATE] with bilateral leg swelling and [CONDITION(S)] (superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries). The Resident was found to have maggots between his/her toes (right second, third, and fourth toes, and between left fourth and fifth toes). The Resident was admitted and treated with intravenous antibiotics, [MEDICATION(S)] and [MEDICATION(S)], and was discharged back to the facility on [DATE]. During an interview on 4/12/21 at 10:00 A.M., Unit Manager #1 reviewed Resident #16's medical record and was unable to find orders for treatment to the Resident's legs in July 2020 (as documented in nursing progress notes), unable to find skin assessments or weekly documentation of skin issues prior to the Resident's return from the hospital on 8/5/20, and confirmed that the interdisciplinary care plan had not been updated to reflect the open area on the Resident's leg. B. Review of Resident #45's Minimum Data Set (MDS) assessment, dated 2/17/21, indicated that Resident #45 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15, required extensive assistance of two or more staff for activities of daily living, and had functional limitations in range of motion in both lower extremities. Review of nursing progress notes, dated 7/22/20, indicated that Resident #45 complained of right dorsal (area of the foot facing upward while standing) foot burning pain, with +2 [CONDITION(S)] (after pressing on an area which leaves a pit, it takes fewer than 15 seconds to go away) with a small amount of drainage. The physician was notified, and ordered the antibiotic [MEDICATION(S)] 500 milligrams (mg) 4 times daily for 10 days, and the diuretic [MEDICATION(S)] 20 mg daily for 3 days for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the interdisciplinary care plans failed to indicate that the care plan for skin risk had been updated to reflect the Resident's new skin infection, and treatment. Further review of the medical record failed to indicate that weekly skin assessments were being conducted and documented as per the facility's policy, and that the change to the Resident's skin integrity, that was identified on 7/22/20, had been thoroughly assessed and documented. A thorough assessment would include, but not limited to, location of the wound, exudate (drainage)-amount, color, odor- surrounding tissue, shape of wound, [CONDITION(S)], maceration (occurs when is in contact with moisture too long). Review of July 2020 physician's orders indicated that Resident #45 was to have a Unna-Z stretch [MEDICATION(S)] paste bandage applied to bilateral lower extremities at 6:00 A.M., every 3 days (initiated 12/2/19). Review of the July 2020 Treatment Administration Records (TAR) and accompanying treatment notes indicated that the treatment was provided on 2 out of 11 occasions as indicated by staff's initials in the box corresponding to the date and time of the treatment: -7/2/20: staff initials -7/5/20: H (treatment held due to sleeping) -7/8/20: staff initials -7/11/20: M (no notation) -7/14/20: M (no notation) -7/17/20: M (no notation) -7/20/20: M (held due to not documented on previous shift) -7/23/20: M (held due to legs left open to air) -7/26/20: M (held due to sleeping) -7/29/20: M (no notation) During an interview on 4/9/21 at 10:33 A.M., the Director of Nursing said that the letter H documented on the TAR indicated that the treatment was held, and that she did not know what the letter M indicated. During an interview on 4/13/21 at 10:55 A.M., Nurse #4 and Unit Manager #1 confirmed that the letter H documented on the TAR indicated that the treatment was held. They did not know what the letter M indicated, and said that it may indicate missed. Review of two nursing progress notes, dated 8/1/20, indicated that Resident #45 complained of left foot pain, and was assessed by the nurse. The nurse documented that the Resident's left foot was noted to have a grapefruit sized abscess (tender mass filled with pus) on the dorsal aspect of the foot that was draining thick, purulent exudate. The abscess was described as dark red and hot to the touch. The Nurse Practitioner was updated, and ordered the Resident to be sent to the hospital for evaluation. Review of hospital documentation indicated that Resident #45 was evaluated in the emergency roiagnom on [DATE]. emergency room triage notes indicated that the facility called the emergency department to report that Resident #45 had a large wound on the dorsal aspect of the left foot that they think is full of maggots. Upon evaluation, the Resident was found to have extensive infection to the left foot with + 4 [CONDITION(S)], evidence of wet gangrene (death of body tissue due to lack of blood flow), and maggots were in the wound. The wound was debrided (removal of damaged tissue and foreign objects) and the maggots were removed from the wound. Resident #45 was admitted to the hospital and treated with intravenous [MEDICATION(S)] (antibiotic). The Resident was discharged back to the facility on [DATE]. During an interview on 4/9/21 at 9:31 A.M., Nurse #5 said that on 8/1/20, that she went into Resident #45's room to remove the wrapping on the Resident's feet. She said she immediately noted that the wrappings on the Resident's feet, were saturated so much that the socks and shoes got wet as well. The Resident had an orange sized area on top of the foot that was grayish white in color, raisin like in texture, and had a [MEDICATION(S)] smell (yeast). Nurse #5 said that she did not know how long the wrappings had been on the Resident's foot. Nurse #5 said that she saw maggots in-between the Resident's toes and crawling all over his/her foot. Nurse #5 said that she did not document her observations of the maggots in the medical record. During interviews on 4/9/21 at 10:33 A.M. and 4/14/21 at 1:30 P.M., the Director of Nursing (DON) said that there was no process in place for documentation of skin assessments, weekly skin assessments were not being done and documented, skin rounds were not being done, care plans weren't being developed and updated, there was no follow up with physician's orders, and nursing staff were doing skin treatments without physician's orders. 2. For Resident #69, the facility failed to follow the physician's orders for a) medication administration of [MEDICATION(S)] (used to treat manic phase of [CONDITION(S)] disorder) and Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -the facility staff transcribed to start [MEDICATION(S)] 125 mg on 3/27/21 twice daily at 6:00 A.M. and 11:00 P.M. -The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. on 3/27/21 and 6:00 A.M. on 3/28/21 to Resident #69. -Resident #69 did not receive his/her first dose of [MEDICATION(S)] until 11:00 P.M. on 3/28/21, when it should have been a standard order effective 3/27/21. Review of the facility's policy titled Medication Ordering and Receiving from Pharmacy, dated 11/1/03, indicated: The dispensing pharmacy is called if an emergency arises requiring immediate pharmacist consultation concerning appropriateness of therapy, drug information, etc. If the required information is unavailable from the dispensing pharmacy, the pharmacy will determine the appropriate method for obtaining it, including speaking with the facility's consultant pharmacist. Medications are not borrowed from other residents. The ordered medication is obtained either from the emergency box or from the provider pharmacy. The emergency supply is maintained in the Pyxis machines or medication room at the nursing station along with a list of supply contents; expiration dates are noted on the packaging of each individual drug. During an interview on 4/13/21 at 11:17 A.M., Nurse #3 said that the Resident was to receive the first dose of [MEDICATION(S)] 125 mg at 11:00 P.M. Nurse #3 said, because the order was written after 09:00 A.M. and the [MEDICATION(S)] was not available, the nurse changed the time. There was no verbal order to verify that the physician was made aware. Nurse #3 said it was held because it was not available. Nurse #3 said if the medication was not available they would check the Pyxis, and if it not in there, they would call the physician to inform him. Nurse #3 said medication should not be held without communicating with the physician. During an interview on 4/13/21 at 12:30 P.M., the Director of Nursing Services (DNS) said she was not aware of the medication omission error.

Based on record review, observation, review of facility policy and interviews, the Facility failed to to ensure a Resident (#55), who reported on 6/29/18 that another Resident (#39) had aggressively acted in an explicit sexual manner, that included standing naked with penis exposed, masturbating and asking for oral sex, was provided protection and interventions that addressed the Resident's distress and prevented the reoccurrence of a second incident of sexual abuse involving Resident #39. The total sample included 23 residents and 3 closed records. Findings include: The Facility's Policy and Procedure, last revised on 2/17/17, on Resident Abuse Prevention, Investigation on Reporting and Sexual Abuse, indicated the Facility does not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends or other individuals. The Policy(s) included definitions of abuse to help staff with the recognition of incidents of abuse. The following definitions of abuse are provided for Resident-to-Resident abuse: aggressive or inappropriate behavior by one resident towards another constitutes resident to resident abuse. The policies indicated that upon receiving an allegation of abuse, all employees are responsible for identifying and reporting the allegation immediately. Upon receiving an allegation of abuse, the Facility will take the necessary steps to protect all residents and implement a system to prevent future resident-to-resident altercations. On 6/29/18 at 3:30 P.M., the Administrator said that he was reporting an allegation of sexual abuse to the Department of Public Health. The Administrator said Resident #55 reported, while sitting outside, Resident #39 had exhibited explicit sexual behavior that included exposing him/herself to Resident #55 while exposing his penis, masturbating and asked Resident #55 to perform oral sex. The Facility's Incident Report/Internal Investigation, dated 6/29/18, indicated on 6/29/18, Resident #55 reported that he/she was outside on the patio. Resident #55 said that Resident #39 was at the bedroom window, naked and masturbating. Resident #55 reported the incident to staff and staff interviewed Resident #55. The report said the Resident (#55) was not in emotional distress, did not want to talk to support services, that the police were notified and an investigation was on-going. The investigation was incomplete and failed to indicate the immediate action plan. Resident #55's medical record indicated he/she was admitted to the Facility in 10/2012. The most recent Quarterly Minimum Data Set, dated dated [DATE], indicated Resident #55 had intact cognition having scored a 15 out of 15 on the BIMS (Brief Interview of Mental Status) assessment. Resident #55's record included no documentation to indicate that the Unit staff had knowledge of the incident of sexual abuse reported on 6/29/18. There was no comprehensive assessment of the Resident and the medical record had not altered the Resident's plan of care was not updated to ensure Resident #55's safety and the prevention of the potential of future sexual abuse. Review of the interdisciplinary progress notes, physician orders/progress notes, psychiatric progress notes made no mention of the incident reported on 6/29/18 or of the Resident's psychosocial condition following the allegation. The last interdisciplinary progress note documented in the medical record at the time of the review was dated 6/27/18. Resident #39's medical record indicated he/she was admitted to the Facility in 11/2015 with [DIAGNOSES REDACTED]. The most recent Quarterly Minimum Data Set, dated dated [DATE], indicated Resident #39 had some cognition loss, having scored a 12 out of 15 on the BIMS assessment. The MDS indicated the Resident did not display any behaviors. The MDS indicated the Resident was independent in his/her activities of daily and ambulated independently. Further review of Resident #39's medical record indicated that Resident #39 had a history of [REDACTED]. The record indicated the Resident had been hospitalized from [DATE]-9/11/17, for behaviors that included public masturbation, nudity and a drastic increase of sexual behaviors with a hyper focus of wanting to have sex with an unidentified resident. Resident #39's medical record indicated that following the hospitalization the Resident continued to display sexually inappropriate behavior and was identified to remain at risk of repeating these behaviors that were identified in his/her care plan as deliberate masturbation. The record indicated the plan was to move the Resident into a private room near the nurse's station in 1/2018. The staff would redirect the Resident and pull curtains when displaying behaviors. Record review failed to indicate that the Facility staff (other than the Administrator, Director of Nurses and Social Services) had knowledge of the resident-to-resident sexual abuse incident reported on 6/29/18. The last interdisciplinary note was written on 4/22/18. There were no behavior monitoring sheets. The psychiatric progress note dated 6/29/18, indicated he met with the Resident at 4:30 P.M. (the incident had occurred at lunch time on 6/29/18) and that the Facility staff had reported no incidents of increased and/or inappropriate behaviors since move to room (1/2018). The progress note indicated the Resident was alert, grateful and discussed placement and past life history. There was no mention of the sexual abuse. The therapist indicated the Resident's room provided the Resident with privacy and relatively close supervision from the nurse's station. Resident #39's medical record failed to indicate that the Facility took the necessary steps to protect other Residents from further incidents of sexual abuse by Resident #39. There was no documentation to indicate changes were made to the plan of care or what efforts would be made to prevent further episodes of sexual abuse. The Surveyor interviewed Resident #55 on 7/2/18 at 9:00 A.M. Resident #55 said that on 6/29/18, while outside with the occupational therapist and waiting for the cook out to start, Resident #39 was standing in the window of his/her room naked. Resident #39 began to masturbate and asked Resident #55 for a blow job. Resident #55 said he/she notified the occupational therapist of the incident, but by the time the therapist responded to the Resident, Resident #39 was no longer visible in the window. Resident #55 said that the Administrator and the Social Worker (#1) had asked if he/she was okay (following the 6/29/18 incident ), but that he/she had not received any other information since. Resident #55 said the SW# 1 told him/her that the other Resident had mental disabilities and that he/she should position him/her self with his/her back to Resident #39's window when Resident #55 was on the patio. Resident #55 said he/she did not know if Resident #39 was still in the building and said he/she felt Resident #39 was given a pass, because of his/her mental disabilities. The Resident said he/she did not like conflict and thought he/she would be okay, but that the incident was frightening. Resident #55 said that a second incident had occurred after the 6/29/18 incident on 7/1/18. Resident #55 said during the second incident Resident #39 yelled out from the window of his/her room for oral sex (blow job). Resident #55 said he/she had not reported the second incident, but said to the Surveyor that he/she was feeling the effects of the abuse and was angry and reported he/she was frightened. Following the interview with Resident #55, the Surveyor on 7/2/18 at 9:30 A.M. , observed Resident #39's room from the nurse's station and the door to the room was closed, and staff would be unable to observe the Resident. The Surveyor met with Resident #39, who was asleep in bed. At the time of the visit, the Resident did not have on any clothing that could be identified. The Resident asked what did the Surveyor want and declined being interviewed. Subsequently, the door to his/her room remained shut. The Surveyor interviewed Unit Manager #2 on 7/2/18 at 9:30 A.M. and inquired about the incident between Resident #55 and Resident #39. UM #2 said she did not share any information because she had not gone to the Facility morning meeting. However, Unit Manager #2 said that the Facility had applied tinted sheets on the windows of Resident #39's windows, so that you could not see into the room from the outside. On 7/2/18 at 9:45 A.M., UM #2 said that Resident #39 liked to be naked and this was a long term behavior and had no other information to share with the Surveyor about the sexual abuse allegation. During interview on 7/2/18 at 12:58 P.M., with Occupational Therapist #1, he said the Resident was out on the patio on 6/29/18. He said he had finished treatment with the Resident and the cook out was being set up, when Resident #55 called him over. He said the Resident said Resident #39 was at his/her window, (located facing the patio area) was naked, masturbating and was asking Resident #55 for explicit sexual acts. The Therapist could not see Resident #39 and notified the Activity Director of the incident. The Surveyor shared with the Administrator, on 7/3/18 at 8:20 A.M., that the Resident (#55) had a second sexual assault by the Resident and had admitted he/she had not reported it. The Surveyor shared that Resident #55 said he/she had initially not wanted to cause problems, but was now angry, frightened, and felt that the Facility had given a pass to Resident #39. Resident #55 had stated the Administrator and the Social Worker had spoken with him/her but had no knowledge of a police report, whether Resident #39 was still in the building or any other supportive information. The Administrator said Resident #55 said he/she was fine when he had spoken with him/her 3 days ago. Following the interview, the Administrator provided the Surveyor with a LATE ENTRY progress note that was entered into the electronic record on 7/2/18 at 12:30 P.M. by Social Worker #1 (4 days after the incident). The progress note indicated that Social Worker #1 met briefly with Resident #55 on 6/29/18 at 1:00 P.M., as a follow-up to an incident that occurred earlier in the day. The note indicated that the Resident reported the incident to the Social Worker and the Social Worker asked if the Resident was all right. The note indicated the Resident said he/she was fine. The Social Worker indicated the Resident was having a hard time understanding why he/she had to change his/her routine (was asked to turn his/her back to the window). The Social Worker indicated she told Resident #55 that repositioning him/her self, as well as choosing a more suitable location while outside, would in essence would take the wind out of his/her sails and thereby extinguish the behavior by paying no attention to it. Social Worker #1 was interviewed on 7/3/18 at 10:00 A.M. and confirmed the late entry note as written and said that she had not seen or followed up with the Resident since 6/29/18. During interview on 7/3/18 at 3:00 P.M., Psychotherapist #1 said that he had been in the building all day on 6/29/18. He said he was not informed or aware that Resident #39 had sexually abused another Resident or of the behavior on 6/29/18. He said it was his expectation that staff would have shared the information about the incident with him. He said that Resident #55's Psychotherapist (#2) had been in the Facility on 7/2/18. He said he had contacted her and she said that she had not been informed of the sexual abuse incident and if had been made aware would have assessed Resident #55. Psychotherapist #2 was interviewed via telephone on 7/518 at 12:40 P.M. and stated that she had not been informed of the sexual abuse when in the facility on 7/2/18. confirmed this statement with the Surveyor via the telephone.). Psychotherapist #1 said he conferred with Psychotherapist #2 and would be assessing Resident #55. Review of the psychotherapist progress note dated 7/3/18 indicated Psychotherapist #1 met with Resident #55. The therapist explained he was aware of the report Resident #55 made on 6/29/18 and asked about Resident #55's emotional condition following the incident. The progress note indicated Resident #55 was assertive and angry about the experience and was consistent in his/her reporting of the two incidents. Resident #55 said Resident #39 was the aggressor, as he/she knocked on the window to get his/her attention. Resident #55 said that this is my home, I should not have to deal with this!

Based on observation, record review, and staff interview, for 1 Resident (#55) of a total sample of 23 sampled Residents, the Facility failed to prevent further sexual abuse from occurring while the investigation of an allegation of sexual abuse was in progress. Findings included: The Facility's Policy and Procedure on Protection and Prevention of allegations of abuse, indicated that all reports of Resident abuse shall be promptly and thoroughly investigated and that all staff were to ensure the safety, welfare, and privacy of all Residents involved in an altercation during and after the investigation process. The policy indicated a system to follow-up on all altercations with an emphasis to prevent future altercations will be in place such as: * Upon receipt of an allegation of abuse, staff will take the necessary steps to protect all residents. * Care plans will be updated to incorporate recommendations from the formal incident review process in addition to the immediate updates that may have occurred at the time of or proactively prior to the altercation. *Staff education needs will be identified with appropriate education provided. Resident #55 was admitted to the Facility in 10/2012. The most recent Quarterly Minimum Data Set, dated dated [DATE], indicated Resident #55 had intact cognition having scored a 15 out of 15 on the BIMS (Brief Interview of Mental Status) assessment. The Facility's Incident Report/Internal Investigation, dated 6/29/18, indicated on 6/29/18, Resident #55 reported that he/she was outside on the patio. Resident #55 said that Resident #39 was at the bedroom window, naked with penis exposed and masturbating. Resident #55 reported the incident to staff and staff interviewed Resident #55. The report said that Resident #55 was not in emotional distress, did not want to talk to support services, and that the police were notified. The report also said that an investigation was on-going. The Surveyor reviewed Resident #55's medical record on 7/2/18, including interdisciplinary progress notes, care plans, physician progress notes [REDACTED]. Review of the record failed to indicate that staff (other than the Administrator, Director of Nurses, occupational therapist and Social Services) were aware of the incident on 6/29/18 and were monitoring the Resident's emotional condition following the incident. The last interdisciplinary progress note was dated 6/27/18, 2 days before the incident. Resident #39's medical record indicated he/she was admitted to the Facility in 11/2015 with [DIAGNOSES REDACTED]. The most recent Quarterly Minimum Data Set, dated dated [DATE], indicated Resident #39 had some cognition loss, having scored a 12 out of 15 on the BIMS assessment. The MDS indicated the Resident did not display any behaviors. The MDS indicated the Resident was independent in his/her activities of daily and ambulated independently. Review of Resident #39's medical record indicated that Resident #39 had a history of [REDACTED]. Record review revealed that the last interdisciplinary note was written on 4/22/18. There were no behavior monitoring sheets. The psychiatric progress note dated 6/29/18 indicated he met with the Resident at 4:30 P.M. (the incident had occurred at lunch time on 6/29/18) and that the Facility staff had reported no incidents of increased and/or inappropriate behaviors since move to room (1/2018). The progress note indicated the Resident was alert, grateful and discussed placement and past life history. There was no mention of the sexual abuse alleged by Resident #55. The therapist indicated the Resident's room provided the Resident with privacy and relatively close supervision from the nurse's station. Resident #39's medical record failed to indicate that the Facility staff took steps to protect residents from further reoccurrence of sexual abuse exhibited by the Resident. There was no documentation to indicate changes were made to the plan of care or what eforts would be made to prevent further episodes of sexual abuse. The Surveyor interviewed Resident #55 on 7/2/18 at 9:00 A.M. Resident #55 said that on 6/29/18, while outside with the occupational therapist and waiting for the cook out to start, Resident #39 was standing in the window of his/her room naked with penis exposed. Resident #39 began to masturbate and was aggressive when asking for Resident #55 for a blow job. Resident #55 said he/she notified the occupational therapist of the incident, but that by the time the therapist responded to the Resident, Resident #55 said that the Administrator and the Social Worker (#1) had asked if he/she was okay (following the 6/29/18 incident, but that he/she had not received any other information since. Resident #55 said the staff (SW# 1) had told him/her the other resident had mental disabilities and that he/she should position self with back to Resident #39's window when Resident #55 was on the patio. Resident #55 said he/she did not know if Resident #39 was still in the building and said he/she felt Resident #39 was given a pass, because of mental disabilities. The Resident said he/she did not like conflict and thought he/she would be okay, but that it (the incident) was frightening. Resident #55 said that a second incident had occurred after the 6/29/18 incident on 7/1/18. Resident #55 said during the second incident the Resident #39 yelled out, from the window of his/her room for oral sex (blow job). Resident #55 said he/she had not reported the second incident, but said that he/she was feeling the effects of the abuse and was angry and repeated he/she was frightened. Following the interview with Resident #55, the Surveyor on 7/2/18 at 9:30 A.M., observed Resident #39's room from the nurse's station and the door to the room was closed, and staff would be unable to observe the Resident. The Surveyor interviewed Unit Manager #2 on 7/2/18 at 9:30 A.M. and inquired about the incident between Resident #55 and Resident #39. Unit Manager #2 said she did not share any information because she had not gone to the Facility morning meeting. However, Unit Manager #2 said that the Facility had applied tinted sheets on the windows of Resident #39, so that you could not see into the room from the outside. On 7/2/18 9:45 A.M., Unit Manager #2 said that Resident #39 liked to be naked and this was a long term behavior and had no other information to share with the Surveyor about the abuse allegation. During interview with the Administrator on 7/3/18 at 8:20 A.M., he said that Resident #55 was fine and he had met with the Resident on 6/29/18 and 6/30/18 and that Social Worker #1 had met with the Resident on 6/29/18. The Surveyor shared that during review of both Resident's medical records, there was no indication that staff were aware of the alleged sexual assault and there was no monitoring of either Resident. The Surveyor shared the psychotherapist's note dated 6/29/18, indicating that the Facility staff had reported no incidents of increased and/or inappropriate behaviors since move to room (1/2018). The Surveyor shared that the Resident (#55) had a second sexual assault by the Resident and had admitted he/she had not reported it. The Surveyor shared that Resident #55 said he/she had initially not wanted to cause problems, but was now angry, frightened, and felt that the Facility had given Resident #39 a pass. Resident #55 had stated the Administrator and the Social Worker had spoken with him/her but had no knowledge of a police report, whether Resident #39 was still in the building, or any other supportive information. The Administrator said Resident #55 said he/she was fine when he had spoken with him/her three days ago. Following the interview, the Administrator provided a LATE ENTRY progress note that was entered into the electronic record on 7/2/18, four days after the incident at 12:30 P.M., by Social Worker #1. The progress note indicated that Social Worker #1 met briefly with Resident #55 on 6/29/18 at 1:00 P.M., as a follow-up with an incident that had occurred earlier in day. The note indicated the Resident reported the incident to the Social Worker and the Social Worker asked if the Resident was all right. The note indicated the Resident said he/she was fine. The Social Worker indicated the Resident was having a hard time understanding why he/she had to change his/her routine (was asked to turn back to window). The Social Worker indicated she told Resident #55 that repositioning self, as well as choosing a more suitable location while outside would in essence would take the wind out of his/her sails and thereby extinguish the behavior by paying no attention to it. Social Worker #1 was interviewed on 7/3/18 at 10:00 A.M. and confirmed the late entry note as written and said that she had not seen or followed up with the Resident since 6/29/18. Review of the psychotherapist progress note dated 7/3/18, indicated Psychotherapist #1 met with Resident #55. The therapist explained he was aware of the report Resident #55 made on 6/29/18, and asked about Resident #55's emotional condition following the incident. The progress note indicated Resident #55 was assertive and angry about the experience and was consistent in his/her reporting of the two incidents. The Resident said Resident #39 was the aggressor, as he/she knocked on the window to get Resident #55's attention. The Resident said that this is my home, I should not have to deal with this!

Based on record review and interview, for 2 of 8 sampled residents (Resident #6 and Resident #7), the Facility failed to ensure nursing staff implemented interventions identified in the plan of care for related to monitoring a resident with a chronic condition and change in medical status. Findings include: -Staff failed to implement an adequate plan of care for Resident #6. On 5/16/16 Resident #6 was admitted to the Facility, he/she had a tracheotomy (surgical procedure to create an opening in through the neck into the trachea, windpipe) and laryngectomy (surgical removal of the voice box), required oxygen via a humidified [MEDICAL CONDITION] mask, and suctioning. Facility staff failed to implement or clarify Resident #6's orders related to oxygen administration, [MEDICAL CONDITION] care, laryngectomy tube care, and suctioning, until 10 days after admission. -Staff failed to implement interventions in Resident #7's plan of care related to monitoring for signs and symptoms of [DIAGNOSES REDACTED] (low blood glucose). On 5/26/16 after Nurse #7 administered insulin to Resident #7, Resident #7 was lethargic throughout the morning. Resident #7's blood glucose level was not rechecked, and Resident #7 was admitted to the hospital related to altered mental status secondary to [DIAGNOSES REDACTED]. Findings include: 1. Resident #6 was admitted to the Facility in May 2016, medical history included: [MEDICAL CONDITION] with a [MEDICAL CONDITION] and laryngectomy tube. A. The Hospital Patient Care Referral Form and Discharge Summary, dated 5/16/16, indicated, Resident #6 was to receive oxygen at 3 liters per minute via [MEDICAL CONDITION] mask. Review of Resident #6's Admission Physicians Orders, dated 5/16/16, indicated there were no Physician's orders for oxygen. Resident #6's Interim Physician's Orders 11 days after admission, dated 5/27/16, indicated humidified oxygen at 3-4 liters per minute continuous via laryngectomy tube to keep O2 saturation (amount oxygen saturation in blood) above 90%. Resident #6 Interim Physician's Orders, dated 6/3/16, indicated oxygen via mist to keep O2 saturation above 90% and discontinue humidified oxygen at 3-4 liters per minute via laryngectomy tube, but the delevery route was not specified. Resident #6 Interim Physician's Orders, dated 6/7/16, indicated discontinue previous oxygen orders, administer 1-3 liters of oxygen via [MEDICAL CONDITION] mask to keep O2 saturation greater than 90% as needed. B. The Hospital Patient Care Referral Form and Discharge Summary, dated 5/16/16, indicated, Resident #6's oxygen was to be administered via a [MEDICAL CONDITION] (HTM, mask covers [MEDICAL CONDITION] site) at 24% FIO2 (fraction of inspired oxygen). Review of Resident #6's Admission Physicians Orders, dated 5/16/16, indicated apply [MEDICATION NAME] topically to affected area twice daily, and that there were no Physicians Orders for; humidified [MEDICAL CONDITION] mask, FIO2 parameters, [MEDICAL CONDITION] care, and laryngectomy care. Resident #6 Interim Physician's Orders, dated 5/17/16, indicated apply [MEDICATION NAME] to trachesotomy stoma (artificial opening made into a hollow organ, on the surface of the body leading to the trachea or the gut) twice daily, [MEDICAL CONDITION] care every shift and keep laryngectomy tube 9 millimeter (mm) x 55 mm at bedside. Resident #6's Interim Physician's Orders, dated 5/25/16, indicated all [MEDICAL CONDITION] care was changed to laryngectomy care and included cleanse laryngectomy tube with hydrogen peroxide daily on the 7:00 A.M. to 3:00 P.M. shift. Resident #6 Interim Physician's Orders, dated 5/26/16, indicated discontinue keep laryngectomy tube 9 mm x 55? at bedside, and [MEDICAL CONDITION] care every shift. Resident #6's Interim Physician's Orders indicated, keep laryngectomy tube 9 mm x 55 mm at bedside, cleanse laryngectomy tube with hydrogen peroxide daily on 7:00 A.M. to 3:00 P.M. shift. Resident #6's Interim Physician's Orders, dated 5/27/16, indicated discontinue 3 liters humidified water via laryngectomy tube and [DIAGNOSES REDACTED].#6's Interim Physician's Orders indicated new orders included: laryngectomy tube care every shift and add [DIAGNOSES REDACTED]. Resident #6's Interim Physician's Orders, dated 6/7/16, indicated 28% humidification [MEDICAL CONDITION] on the 11:00 P.M. to 7:00 A.M., shift, and empty humidification bag every shift. C. The Hospital Patient Care Referral Form and Discharge Summary, dated 5/16/16, indicated, Resident #6 was to be suctioned as needed. Review of Resident #6's Admission Physicians Orders, dated 5/16/16, indicated there were no Physicians Orders for suctioning. Resident #6's Interim Physician's Orders, dated 5/17/16, indicated suction [MEDICAL CONDITION] site with [MEDICATION NAME] (oral suctioning tube) as needed for excretions. Resident #6's Interim Physician's Orders, dated 5/26/16, indicated discontinue suctioning to [MEDICAL CONDITION] site with [MEDICATION NAME] as needed. Resident #6's Interim Physician's Orders indicated, suction laryngectomy tube with [MEDICATION NAME] as needed for secretions. Surveyor #1 and Surveyor #2 interviewed Unit Manager #1 at 11:05 A.M., on 6/8/16. Unit Manager #1 said the Admission Physician's Orders for Resident #6 were obtained using the Hospital Discharge Summary and Referral Form. Unit Manager #1 said she transcribed Resident #6's treatment orders. Unit Manager #1 said all new admissions are double checked the next day at morning meeting. Unit Manager #1 said Resident #6's Admission Physicians Orders were incomplete and Resident #6 should have had Physicians Orders specific to oxygen, [MEDICAL CONDITION] and laryngectomy tube care needs, and suctioning. Surveyor #1 and Surveyor #2 interviewed Clinical Coordinator #2 at 3:55 P.M. on 6/09/16. Clinical Coordinator #2 said he verified Resident #6's admission orders [REDACTED]. Clinical Coordinator #2 said he did not know what Respiratory HTM 24% FIO2 meant, assumed Resident #6's admission order for 3L humidified water via laryngectomy tube was for oxygen, and wrote a Respiratory Skilled Observation sheet for use the use of oxygen at 2 L for Resident #6 because it was the normal thing to do. Clinical Coordinator #2 said the Hospital Discharge Summary was difficult to understand, that he questioned the entire Hospital Discharge Summary, felt it was very vague, said he attempted to call the Hospital to clarify Resident #6's discharge instructions, and was unable to speak with nursing staff at that time. Surveyor #1 and Surveyor #2 interviewed the Director of Nurses (DON) at 2:40 P.M. on 6/09/16. The DON said Resident #6's admission orders [REDACTED]. The DON said the Facility should have consulted the respiratory therapist prior to admitting Resident #6 to the Facility. 2. Resident #7's [DIAGNOSES REDACTED]. The Facility's Policy titled Diabetic Management Protocol, dated January 2009, indicated residents who have diabetes will receive care according to accepted standards of care focused on maintaining blood glucose control and preventing both acute and chronic complications. The Policy indicated identify usual symptoms the resident experiences when blood glucose is low or high, assess for and respond to any change in condition. Resident #7's Medication Administration Record [REDACTED]. Resident #7's Treatment Administration Record (TAR), dated 5/01/16 through 5/31/16, indicated monitor for signs and symptoms of low blood glucose (less than 70 mg/dl, milligrams per deciliter, early signs include: anxiety, shakiness, dizziness, paleness, and unusual hunger, later signs that are more serious and more obvious include: loss of coordination, lethargy, weakness, confusion, and loss of consciousness). Resident #7's plan of care for diabetes management, updated in March 2016 through June 2016 indicated, Resident #7 was an insulin dependent diabetic, his/her usual symptoms indicating low blood glucose was changes in mental status and high blood glucose was angry outbursts. The plan of care indicated nursing interventions included; monitor blood glucose levels, administer oral hypoglycemic medications or insulin as ordered, monitor for signs and symptoms of low blood glucose, and high blood glucose, and notify the physician if blood glucose level is 60 or below or 400 and above. The Situation, Background, Appearance, and Review (SBAR) Communication Form, dated 5/26/16 and completed at 10:00 A.M., by Nurse #7 indicated, Resident #7 experienced a change in condition, his/her symptoms had become worse, and Resident #7 was experiencing shortness of breath, confusion, and weakness (symptoms of possible low blood glucose level). The Fire Rescue Prehospital Care Report, dated 5/26/16, indicated nursing staff reported that Resident #7 had become increasingly lethargic since 7:00 A.M., blood glucose at 7:00 A.M., was 208 mg/dl, he/she received 4 units of insulin at 7:30 A.M., and nursing staff had not reassessed Resident #7's blood glucose level. The Prehospital Care Report indicated that at 10:40 A.M., Resident #7's blood glucose level was critically low at 34 mg/dl. The Hospital Discharge Summary, dated 5/31/16, indicated Resident #7 was admitted related to [MEDICAL CONDITIONS] and altered mental status secondary to low blood glucose. Surveyor #1 and Surveyor #2 interviewed Nurse #7 at 2:50 P.M., on 6/08/16. Nurse #7 said and documentation indicated, on 5/26/16 she checked Resident #7's blood glucose level at 7:30 A.M., blood glucose level was 208, and she administered 4 units of regular insulin per physician's orders. Nurse #7 said Resident #7 became more lethargic throughout the morning, but did not recheck Resident #7's blood glucose level, and had not thought to recheck Resident #7's blood glucose level until Emergency Medical Technicians arrived and asked if a blood glucose level had been obtained. Nurse #7 said she knew Resident #7 was a diabetic, should be monitored for signs and symptoms of [DIAGNOSES REDACTED] after receiving insulin, but thought Resident #7 was experiencing a change in respiratory status and forgot to recheck Resident #7's blood glucose level. Surveyor #1 and Surveyor interviewed the Director of Nurses (DON) at 2:40 P.M., on 6/09/16. The DON said Nurse #7 should have rechecked Resident #7's blood glucose level as part of the assessment for the SBAR Communication that is reported to the Physician. The DON said anytime a diabetic resident experiences a change in condition a blood glucose level should be obtained.

Based on record review and interviews, for one of three Residents (Resident #1), the Facility failed to follow the Behavior Care Plan. On 11/20/13 at 9:45 P.M. Resident #1 was seated in the dining room and when awoken, Resident #1 refused Certified Nurse Aide (CNA) #1's offer to go to his/her room to go to bed. After Resident #1 vehemently refused the care, CNA #1 did not ensure Resident #1's safety, stop the task and/or leave the room, per the care plan. CNA #1 was joined by Nurse #1, and they stood the angry, protesting and kicking Resident #1, and ambulated him/her to his/her room, and once in his/her room, he/she kicked at CNA #2 and caused a skin tear to his/her own left lower leg. Findings include: Resident #1's [DIAGNOSES REDACTED]. Resident #1 had a history of [REDACTED]. Resident #1's Behavior Care Plan, March 2013, indicated Resident #1's behaviors included angry outbursts, had a low tolerance, and was known to strike out. The care plan indicated that if Resident #1 became combative or resistive (of care) stop the task and/or leave the room after providing for (Resident's) safety. The Surveyor interviewed CNA #1 at 3:04 P.M. on 4/28/14. CNA #1 said that on 11/20/13 at 9:45 P.M., she, as Resident #1's assigned caregiver, approached Resident #1, who was seated in an arm chair pushed up to a dining table in the dayroom, asleep with his/her head resting on the table top. CNA #1 said she woke Resident #1 and asked him/her if he/she wanted to go to his/he room and go to bed. CNA #1 stated Resident #1 told CNA #1 words to the effect of, "No" and yelled, "Leave me alone"! CNA #1 said Resident #1 also attempted to strike at CNA #1. CNA #1 said Nurse #1 entered the dayroom to insist Resident #1 stand and go with CNA #1 and Nurse #1 toward his/her room to go to bed for the night. CNA #1 said Resident #1 stood and ambulated with staff while loudly protesting and trying to kick staff en route to his/her room. The Surveyor interviewed CNA #2 at 2:32 P.M. on 4/28/14. The Surveyor also reviewed CNA #2's 11/20/13 written statement with her during the interview. CNA #2 stated that Resident #1 was known to be loud, [MEDICAL CONDITION] unpredictable. CNA #2 also said that she believed she assisted Resident #1 into bed. CNA #2 said she remembered Resident #1 kicked out at CNA #2 and caused a skin tear to his/her own (Resident #1) left lower leg. CNA #2's 11/20/13 written statement indicated that she assisted Resident #1 to his/her room after Resident #1 had punched a nurse (Nurse #1). CNA #2 indicated Resident #1 attempted to kick CNA #2 all the way up the hall too. Although, when interviewed by the Surveyor at 12:27 P.M. on 5/6/14, Nurse #1 denied having any substantive contact with Resident #1 during the shift/time frame in question, including during the incident, she (Nurse #1) wrote a clinical note in Resident #1's medical record during the shift that indicated: Resident sleeping in day room. Attempt to assist CNA in getting resident to come to room results in this nurse being punched (by Resident #1) again. Resident #1 screamed, was accusatory and swearing, and kicked at a CNA resulting in resident tearing his/her own skin left lower leg. Resident #1 requested Police and FBI and Resident #1 punched a 2nd nurse in face. Resident #1 requested knife to kill (him/her) self. The note indicated the Facility's consulting psychiatric service was called. Resident #1's clinical nurses' notes for 11/20/13 indicated the EMS (Emergency Medical Services) arrived at 10:00 P.M. and transported Resident #1 to the hospital. The Physician's 11/21/13 interim order indicated, Resident #1 required steri-strips to close the skin tear on the left shin and staff were to monitor Resident #1 for signs and symptoms of infection and apply a dry protective dressing daily for 7 days.