**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide a dignified and respectful existence by 1.) failing to respect a resident's personal room environment for 1 Resident (#45) and 2.) speaking in a language other than English while in Resident areas and while providing care in 2 of 2 units out of a sample of 20 residents. Findings include: Review of the facility policy titled 'The Fundamentals of Resident Rights-Dignity and Respect' with no revision date indicated the following: *A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. *The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. *Each resident has the right to be treated with dignity and respect. All staff activities and interactions with residents must focus on assisting the resident in maintaining and enhancing his or her self esteem and self-worth and incorporating the resident's preferences and choices. Staff must respect each resident's individuality when providing care and services while honoring and valuing their input. 1. Resident #45 was admitted to the facility in November 2020 with diagnoses including multiple sclerosis, depression, schizophrenia and a history of suicidal ideation. A review of the Minimum Data Set Assessment (MDS) dated [DATE], indicated a Brief Interview for Mental Status Exam (BIMS) score of 13 out of a possible 15 indicating intact cognition. Further review of the medical record indicated Resident #45 makes his/her own decisions and his/her health care proxy (HCP) is not activated. During a review of Resident #45's medical record on 3/2/23, at 8:29 A.M., social work progress notes written on 2/21/23, and 2/22/23, indicated the following: *Social Worker (SW) met with Resident #45 for a psychosocial visit, the resident stated he/she was upset because someone had voiced discomfort with pictures hanging on his/her wall containing nudity. SW provided support and validation, the resident and SW discussed the content in the pictures and the importance of ensuring that residents and staff feel safe physically and emotionally where they live and work, SW explained the importance of being sensitive to others and the role trauma plays in situations like this. The resident initially voiced disagreement and frustration about this. SW validated the resident's frustration. The resident stated he/she would take down the pictures. The SW clarified that this was not the request. The resident gave the SW permission to speak to his/her HCP about this. SW recommended that the resident keep the pictures in an area of his/her room that is not immediately visible to those entering the room. SW will continue to monitor and support the resident. *SW met the resident for a psychosocial visit, the resident stated he/she felt better but still felt frustrated, the resident stated that he/she hoped more people will come to embrace diversity in all forms and he/she appreciates all efforts the facility has done to continue to give him/her support. During an interview on 3/2/23, at 9:19 A.M., Resident #45 told the surveyor that staff were suggesting he/she take his/her art down. Resident #45 who identifies as gay, described his/her art as eclectic. The surveyor observed the pictures which were non-pornographic pictures of models. There were no pictures hanging in Resident #45's room of fully naked people with visible genitalia or breasts exposed. The pictures staff described as nude were male models with their shirts off and in one of the pictures, were two men sitting with the upper portion of their buttocks exposed. The picture was small, framed and hung towards the bottom of the wall near the window and not visible to anyone walking past the room. Resident #45 said when the Social Worker met with him/her to discuss the picture, the possibility of taking them down and hiding them away from the staff and resident's view, he/she was frustrated. Resident #45 said that he/she felt horrible, angry, and felt as if his/her personhood was being questioned. Resident #45 then said it is 2023 and he/she could not believe this was happening. Resident #45 said other residents are not able to wander in his/her living area due to their diagnoses. Resident #45 then said that his/her privacy curtain is always drawn for his/her privacy and his/her roommate's privacy. Resident #45 said when he/she was admitted to the facility, he/she was assured that he/she could express himself/herself in a way that made him/her comfortable. During an interview on 3/2/23, at 10:10 A.M., Unit Manager (UM#2) said Nurse #1 approached her with concerns about naked pictures in Resident #45's room. UM #2 then said that when she went to Resident #45's room to look at the pictures, she decided to ask the Social Worker to address the concern. During an interview on 3/2/23, at 10:33 A.M., Nurse #1 said she was the one who brought up the concern with the pictures in Resident #45's room due to the nakedness they expressed. Nurse #1 said the nakedness made her uncomfortable, and she was also worried about Resident #45's roommate's privacy. The surveyor asked Nurse #1 about Resident #45's roommate's cognition. Nurse #1 said Resident #45 roommate has cognitive deficits. During an interview on 3/2/23, at 11:24 A.M., the Social Worker said she was concerned about staff and visitors being triggered by the naked pictures in Resident #45's room. The Social Worker said she felt it was her duty to protect the staff and the visitors. The Social Worker then said that other naked pictures, for example male and female bikini pictures, naked baby pictures would have had less of a negative reaction from staff. The surveyor and the Social Worker both walked by the Resident #45's room, the privacy curtain was pulled and neither Resident #45 or the pictures were visible from the hallway, Resident #45's roommate could not see into Resident #45's side of the room. The Social Worker acknowledged the observation. The Social Worker said that she expects staff from different cultural backgrounds to respect the residents wishes. During a telephone interview on 3/3/23, at 3:34 P.M., Resident #45's partner and HCP said Resident #45 reached out for support after the Social Worker met with him/her about the pictures in his/her room. The HCP said that Resident #45 was distraught, upset and frustrated about the situation. Resident #45's partner told him/her to not take the pictures down, the facility was aware that Resident #45 is openly gay and that the facility, at admission, told him/her that he/she could create a space in his/her room to his/her liking. During an interview on 3/2/23, at 1:35 P.M., with the Director of Nursing said that residents are the first priority in the facility, their rights should be respected at all times by staff, even though staff may not agree with the resident's beliefs and expressions, it is their responsibility to take care of the resident and not judge or impose their own beliefs and value system.2. The facility failed to provide a dignified experience for residents in 2 of 2 units evidenced by staff speaking in languages other than English in resident areas and while providing care. During initial interviews on 3/1/23, multiple residents reported to the surveyor that Certified Nursing Assistant staff speak in foreign languages in front of residents during care. resident's reported that this makes them feel uncomfortable or that staff could be speaking about them negatively without them knowing. On 3/2/23, at 12:15 P.M. the surveyor observed staff providing care to a resident in a room on the 1st floor and could be heard speaking in a language other than English. On 3/2/23, at approximately 12:25 P.M. the surveyor observed three staff in the hallway of the 2nd floor unit speaking in a language other than English. On 3/3/23, at 7:23 A.M., the surveyor observed staff on the 2nd floor nursing unit bringing a resident into the shower unit. The staff person and other staff in the shower room were speaking in a language other than English. The surveyor was informed on 3/3/23, that the facility has no written policy regarding language. During an interview on 3/3/23, at 9:24 A.M. the Director of Nursing said that the expectation is for staff to speak in a language that residents understand at all times.

Based on interview and record review the facility failed to ensure an allegation of abuse by one Resident (#50) was reported to the Department of Public Health's (DPH) Health Care Facility Reporting Systems (HCFRS) within the required two hour time frame, out of a total 20 sampled residents. Findings include: The facility policy titled Protecting Residents from abuse, neglect and misappropriation of property, updated 11/23/22, indicated the following: * Employees of the Boston Home (TBH) will treat residents and their personal property with respect and will provide care to the resident as defined in the Resident's Care Plan. * The Administration of the Boston Home will provide an environment that is conducive to quality patient care and which protects patients from abuse, neglect, mistreatment, misappropriation of patients property or exploitation by staff, visitors, family members or other residents. * The Administration will report to DPH within 2 hours using the HCFRS: -allegations of abuse or knowledge of serious bodily injury of unknown origin. * The Administration will report within 24 hours to DPH using the HCFRS: -neglect exploitation or mistreatment. Resident #50 was admitted to the facility in April 2017 and had diagnoses that included paraplegic with advanced Multiple Sclerosis. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/3/23, indicated Resident #50 scored a 14 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam, indicating intact cognition. The MDS further indicated Resident #50 had no behaviors and was totally dependent on staff for Activities of Daily Living (ADLs), including bathing. Review of a Social Worker (SW) progress note dated 12/19/22, indicated the following: On 12/19/2022, SW and Nurse Manager spoke with Resident #50 about a concern he/she had voiced. CEO was notified immediately and investigation began. The Resident stated he/she feels safe at TBH. SW notified the ombudsman. Nurse Manager notifying MD. Review of the facility's grievance binder on 3/02/23, at 8:40 A.M., failed to indicate any grievances had been filed by or on behalf of Resident #50's concern. During an interview on 3/02/23, at 10:35 A.M., with the Social Worker (SW) said she had met with Resident #50 on 12/19/22, and Resident #50 complained that a Certified Nursing Assistant (CNA #2) had sprayed water directly in his/her face because he/she complained that CNA #2 had dumped the contents of his/her urinary catheter bag on the shower floor and that it smelled. The SW provided the surveyor with a copy of the facility's investigation to review. Review of the investigation file indicated the following: * A statement from accused CNA #2 indicted that while showering Resident #50 on 12/16/22, Resident #50 repeatedly said you are burning my face. After the shower, according to CNA #2's statement, then he/she (Resident #50) got mad and told me in the presence of my partner (Another CNA) you did try to burn my face. * Review of the investigation file indicated that the incident was reported in HCFRS on 12/19/22, 3 days after Resident #50 made the allegation to CNA #2, in the presence of another CNA. * A statement from the SW indicated that she interviewed Resident #50 on 12/19/22, and Resident #50 told her that CNA #2 emptied his/her catheter bag onto the floor of the shower room, where there is a drain. Resident #50 complained about the smell of urine and that CNA #2 sprayed water in his/her face each time he/she complained. Resident #50 further stated that each time CNA #2 sprayed water in his/her face, she said oops. During an interview on 3/03/23, at 10:21 A.M., Resident #50 recounted to the surveyor what had occurred on 12/19/22. Resident #50 said that at the start of the shower CNA #2 dumped urine from his/her catheter bag on the floor of shower rather than in the little toilette that the other girls dump into. Resident #50 said CNA #2 did not like that he/she told her it smelled, so she sprayed him/her several time in the face. Resident #50 describes it was awful because each time she did it I felt like I was drowning and I didn't know when I should breathe because of the water going in my face. Resident #50 added I told everyone that day what happened, the nurse, the other staff because it was the worst shower I have ever had here and I have been here for 6 years. On 3/03/23, at 10:25 A.M., the surveyor called and left a voicemail for CNA #2. As of 3/6/23, CNA #2 failed to return the call. During an interview on 3/3/23, at 10:40 A.M., the Director of Nursing (DON) said that all staff are mandatory reporters, even on themselves, and when Resident #50 alleged CNA #2 was burning his/her face, CNA #2 should have reported the allegation immediately. The DON said the allegation should have been reported to HCFRS when Resident #50 made the allegation on 12/16/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 2 Resident's (#27 and #48) out of a total sample of 20 Residents. Findings include: 1. For Resident #27, the facility failed to accurately code a stage 4 (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure injury on the MDS assessment. Resident #27 was admitted to to the facility in May 2016 with diagnosis including multiple sclerosis and dysphagia. Review of Resident #27's annual MDS assessment, dated 12/9/22, indicated that he/she had one stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister) pressure ulcer. Further review of the MDS indicated that there was no documentation to support that nursing had coded that Resident #27 had a stage 4 pressure ulcer. Review of the Treatment Administration Record, dated December 2022, indicated an active physician's order dated 11/23/22, which required for nursing to complete a dressing for a stage 4 pressure ulcer. Review of the Wound Evaluation and Management Summary, dated 12/7/22, indicated Resident #27 had a stage 4 pressure ulcer of the sacrum for at least 230 days duration. During an interview on 3/3/23, at 7:51 A.M., the MDS nurse said that she coded the MDS incorrectly. 2. Resident #48 was admitted to the facility in May 2012 with diagnoses including Multiple Sclerosis and gastroesophageal reflux disease. Review of Resident #48's most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated that Resident #48 scored 15 out of a possible 15 on the Brief Interview for Mental Status Exam indicating that Resident #48 is cognitively intact. Further review indicated that Resident #48 requires assistance with bathing, dressing and transfers. Additional review of the MDS indicated that at the time of the MDS, (reference date 1/13/23), Resident #48 had 2 Stage III pressure ulcers. Review of Resident #48's wound physician note dated 1/11/23, indicated that Resident #48 had 2 Stage IV pressure ulcers. During an interview on 3/3/23, at 8:36 A.M., the MDS Coordinator said that at the time of the MDS submission, there was a consultant who was working on the MDS. The MDS Coordinator acknowledged the wound physician's documentation indicating that on 1/11/23, Resident #48 had documented Stage IV pressure ulcers and one had deteriorated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) Resident #60 was admitted to the facility in November 2021 with diagnosis including multiple sclerosis and chronic pain. Review of the Minimum Data Set assessment dated [DATE], indicated Resident #60 is at risk of developing pressure ulcers/injuries. Review of the physician's order, dated 12/22/21, indicated for nursing to check inflation of mattress setting to 200 pounds. Review of Resident #60's most recent weight record, dated 2/14/23, indicated he/she weighed 194.40 pounds Review of the Treatment Administration Record (TAR), dated March 2023, indicated that nursing had implemented the physician's order and set to 200 pounds. On 3/1/23 at 8:06 AM and on 3/2/23 6:53 A.M., the surveyor observed Resident #60 in his/her bed and the air mattress was set to 280 pounds. During an interview on 3/2/23 12:19 P.M., Nurse #1 said that the Unit Manager will check the mattress settings. During an interview on 3/2/23 at 12:39 P.M., Unit Manager #2 said that nurses are required to verify the correct settings for air mattresses. The Unit Manager said she corrected several Resident's air mattress settings this morning. 3. Resident #71 was admitted to the facility in February 2021 with diagnoses including Guillian-Barre syndrome and legally blind. Review of Resident #71's Minimum Data Set Assessment (MDS) dated [DATE] indicated he/she scored 15 out of a possible 15 on the Brief Interview for Mental Status Exam indicating he/she is cognitively intact and is totally dependent on staff for dressing, bathing and eating. During an interview with Resident #71 on 3/1/23 at 9:57 A.M., the surveyor observed his/her hands were contracted. Resident #71 said he/she does wear splints, but he/she forgot to ask staff to put them on. Review of Resident #71's physician's orders indicated the following: *Hand splints to be donned during the day when seated in wheelchair, stockinette donned under splints for purposes of tone management, every day at 7:00 A.M. - 3:00 P.M., initiated 4/22/21 On 3/1/23 at 1:45 P.M., and 3/2/23 at 9:24 A.M., Resident #71 was observed not wearing hand splints. Review of the clinical record failed to indicate that Resident #71 refused to wear his/her hand splints. Review of the Treatment Administration Record on 3/3/23 at 8:00 A.M., failed to indicated Resident #71 refused to wear his/her hand splints. Review of Resident #71's care plans failed to indicate any care plans of refusals of care, including the use of hand splints. On 3/3/23 at 9:55 A.M., the surveyor observed Resident #71 in his/her wheel chair not wearing hand splints. The surveyor then met with Unit Manager #1. Unit Manager #1 said that the expectation is not for Residents to ask for their hand splints and for staff to don them as ordered. The surveyor then informed Unit Manager #1 of the observations of Resident #71 not wearing his/her hand splints. Unit Manager #1 said that Resident #71 can be behavioral and refuse to wear his/her hand splints at times. Unit Manager #1 acknowledged that there was no documentation to indicate Resident #71 refused to wear his/her hand splints. Based on observation, record review and interview the facility failed to implement the plan of care for 3 Residents (#46, #60 and #71) out of a total sample of 20 residents. 1). For Resident #46 the facility failed to implement a custom wedge cushion between his/her legs, failed to elevate her/his heels above the mattress, failed to ensure blue booties were on his/her feet and failed to ensure the mattress setting was set at the prescribed setting. 2). For Resident #60 the facility failed to ensure that nursing implemented a physician's order for air mattress settings. 3). For Resident #71, the facility failed to apply hand splints per his/her plan of care. Findings include: 1. Resident #46 was admitted to the facility in March 2014 with diagnoses including multiple sclerosis and neurogenic bladder. Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #46 is totally dependant on staff for all activities of daily living. Further review indicated Resident #46 is cognitively impaired and is rarely/never understood. Review of the doctors orders dated March 2023 indicated to use customized wedge for bilateral lower extremities (BLE) when in bed/supine- to elevate BLE for reduce swelling, to off load heels and keep BLE joints in neutral alignment. Further review indicated an order for soft booties when in bed and wheelchair to off load bilateral heels and promote neutral alignment. Review of the current care plans indicated that Resident #46 had an intervention to use a customized wedge cushion for bilateral lower extremities (BLE) when in bed/supine- to elevate BLE for reduce swelling, to off load heels and keep BLE joints in neutral alignment. Further review indicated to have the air mattress setting at 120 pounds (lbs), rotation every 10 minutes. Further review failed to indicate Resident #46 refuses the above interventions. Review of the nurse's notes failed to indicate Resident #46 refuses care plan interventions. On 3/1/23, at 8:34 A.M., the surveyor observed Resident #46 lying in bed without a wedge cushion between her/his legs, Resident #46's heels were flat on the mattress, no blue booties were on Resident #46's feet and the mattress setting was at 120 lbs, rotating every 15 minutes. On 3/1/23, at 4:58 P.M., the surveyor observed Resident #46 lying in bed without a wedge cushion between her/his legs, Resident #46's heels were flat on the mattress, no blue booties were on Resident #46's feet and the mattress setting was at 120 lbs, rotating every 15 minutes. On 3/2/23, at 7:49 A.M. the surveyor observed Resident #46 lying in bed without a wedge cushion between her/his legs, Resident #46's heels were flat on the mattress, no blue booties were on Resident #46's feet and the mattress setting was at 120 lbs, rotating every 15 minutes. During an interview on 3/2/23, at 9:03 A.M., the Physical Therapist said that the custom wedge cushion that was supposed to be between Residents #46's legs and the booties that were supposed to be on Resident #46's feet, were in the rehab room because the rehab aide had put them in there and not returned them to the resident. During an interview on 3/2/23, at 10:52 A.M., Unit Manager #2 said that Resident #46 was supposed to have a wedge cushion between her/his legs, blue booties on and her/his heels elevated off of the mattress. Unit Manager also acknowledged the incorrect mattress setting. Unit Manager #2 said that the nurses were supposed to check the mattress settings to ensure the proper setting was in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) Resident #13 was admitted to the the facility in May 2022 with diagnoses including traumatic brain injury and hemiplegia affecting the right side. Review of Resident #13's Minimum Data Set (MDS) assessment, dated 2/17/23, indicated he/she is at risk of developing pressure ulcers/injuries. Review of Resident #13's plan of care related to activities of daily living, dated as 10/28/22, indicated he/she required and open toe shoe on his/her right foot. Review of Resident #13's physical therapy Discharge summary, dated [DATE], indicated he/she was able to tolerate closed toe shoe. On 3/1/23 at 8:35 A.M., 3/1/23 at 4:32 P.M., 3/2/23 at 8:27 A.M., 3/2/23 at 11:59 A.M. and 3/2/23 at 12:50 P.M., the surveyor observed Resident #13 wearing a closed toe shoe on his/her right foot. During an interview on 3/2/23 at 12:22 P.M., Nurse #1 said that Resident #13 wore a closed toe shoe on his right foot. During an interview on 3/2/23, at 12:50 P.M., the Unit Manager #2 said that it had been almost 4 months since Resident #13 required an opened toe shoe. Unit Manager #2 said that she should have updated Resident #13's plan of care on 12/7/22, when Resident #13 was able to wear a closed toe shoe on his/her right foot. 3.) Resident #27 was admitted to to the facility in May 2016 with diagnoses including multiple sclerosis and dysphagia. Review of Resident #27's plan of care related to activities of daily living, dated 8/26/20, indicated he/she required noodles on his/her mattress to increase safety. Review of Resident #27's plan of care related to activities of daily living, dated 9/18/20, indicated keep raised edge mattress in place for safety. Review of the physician's order, dated 4/1/22, indicated Resident #27 required an air mattress. On 3/1/23, at 8:11 A.M., 3/1/23, at 4:33 P.M., and on 3/2/23, at 6:52 A.M., the surveyor observed Resident #27 in bed sleeping there were no noodles on the mattress and there was no raised edge mattress. During an interview on 3/2/23, at 12:16 P.M., Certified Nurse Aide #1 said she was not aware that Resident #27 required noodles or a raised edge mattress. During an interview on 3/2/23, at 12:19 P.M., Nurse #1 said said she was not aware that Resident #27 required noodles or a raised edge mattress. During an interview on 3/2/23, at 12:41 P.M., Unit Manger #2 said she that said that Resident #27 no longer required noodles or a raised edge mattress. Unit Manager #2 said she should have updated Resident #27's plan of care in April 2022 when he/she received the new air mattress. Based on observation, record review and interview the facility failed to revise the plan of care for 3 Residents (#46, #13, and #27) out of a total sample of 20 residents. 1). For Resident #46 the facility failed to revise the plan of care for the use of a blue water bottle at bedside. 2). For Resident #13 the facility failed to revise a plan of care related to wearing an opened toe shoe after his/her dark callous on his/her right foot resolved on 12/7/22. 3). For Resident #27 the facility failed to revise a plan of care when nursing obtained a new mattress (4/1/22) for Resident #27 and he/she no longer required interventions including, noodles on the mattress to increase safety and a raised edge mattress. Findings include: 1. Resident #46 was admitted to the facility in March 2014 with diagnoses including multiple sclerosis and neurogenic bladder. Review of the Minimum Data Set assessment dated [DATE], Resident #46 is fed by a tube directly into the stomach. Further review indicated that Resident #46 is totally dependant on staff for all activities of daily living and does not take anything by mouth. Further review indicated Resident #46 was cognitively impaired and is rarely/never understood. Review of the current care plan indicated that Resident #46 had an intervention for the use of a blue water bottle at bedside at all times within reach of the Resident. On 3/1/23, at 8:34 A.M., the surveyor observed Resident #46 lying in bed without a blue water bottle in the room. On 3/01/23, at 4:58 P.M., the surveyor observed Resident #46 lying in bed without a blue water bottle in the room. On 3/02/23, at 7:49 A.M. the surveyor observed Resident #46 lying in bed without a blue water bottle in the room. During an interview on 3/2/23, at 10:52 A.M., Unit Manager #2 said that Resident #46 can't have anything by mouth and she should have removed the blue water bottle from the care plan.

Based on observation, record review and interview the facility failed to ensure professional standards of practice were maintained during enteral feeding administration for 1 Resident (#46) out of a total sample of 20 residents. Findings include: Review of the facility policy titled TBH (the Boston home) GT (gastric tube) policies dated as revised 10/1/20, failed to indicate when closed system enteral feeding bottles are to be changed or how long they are to continue to infuse the enteral feeding without changing the bottle. Review of the doctor's orders dated March 2023 indicated an order for Jevity 1.2 cal. (calorie) 30 ml (milliliters) per hour for 20 hours up at 4:00 P.M. down at 12 P.M., for a total of 600 ml. On 3/1/23, at 8:36 A.M., the surveyor observed an enteral feeding bottle of Jevity 1.2 cal. hung and infusing, with a date of 2/26/23, written on the bottle. On 3/2/23, at 7:42 A.M., the surveyor observed a bottle of Jevity 1.2 cal hanging with a date of 3/2/23, and a time of 7:00 A.M. During an interview on 3/2/23, at 9:10 A.M., Unit Manager #2 said that she changed the enteral feeding bottle this morning at 7:00 A.M. (39 hours after the 48 hour limit) because the bottle had run empty. Unit Manager #2 then said that enteral feeding bottles should be changed every 48 hours regardless if there are contents still in the bottle. She then said that she had not noticed the date of when the bottle had been hung when she took it down. During an interview on 3/2/23, at 9:01 A.M., the Director of Nursing said that standard of practice is that enteral feeding bottles are to be changed every 48 hours for a closed system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure staff maintained medical records that were accurate for one Resident (#46) out of a total sample of 20 residents. Specifically the facility documented that a wedge cushion was in place, soft booties were in place as ordered, heels were off loaded, mattress settings were accurate and that skin checks were completed as documented. Findings include: Resident #46 was admitted to the facility in March 2014 with diagnoses including multiple sclerosis and neurogenic bladder. Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #46 is totally dependant on staff for all activities of daily living. Further review indicated Resident #46 is cognitively impaired and is rarely/never understood. Review of the doctors orders dated February and March 2023 indicated to use customized wedge for bilateral lower extremities (BLE) when in bed/supine- to elevate BLE for reduce swelling, to off load heels and keep BLE joints in neutral alignment. Further review indicated an order for soft booties when in bed and wheelchair to off load bilateral heels and promote neutral alignment. Further review indicated to have the air mattress setting at 120 pounds (lbs), rotation every 10 minutes. Further review indicated to perform a skin check once a week. On 3/1/23, at 8:34 A.M., the surveyor observed Resident #46 lying in bed without a wedge cushion between her/his legs, Resident #46's heels were flat on the mattress, no blue booties were on Resident #46's feet and the mattress setting was at 120 lbs, rotating every 15 minutes. On 3/1/23, at 4:58 P.M., the surveyor observed Resident #46 lying in bed without a wedge cushion between her/his legs, Resident #46's heels were flat on the mattress, no blue booties were on Resident #46's feet and the mattress setting was at 120 lbs, rotating every 15 minutes. On 3/2/23, at 7:49 A.M. the surveyor observed Resident #46 lying in bed without a wedge cushion between her/his legs, Resident #46's heels were flat on the mattress, no blue booties were on Resident #46's feet and the mattress setting was at 120 lbs, rotating every 15 minutes. Review of the Treatment Administration Record (TAR) dated 3/1/23, indicated that the nurse signed the TAR on the 7 A.M.- 3 P.M. shift and the 3 P.M.- 11 P.M. shifts indicating that the wedge cushion, the soft booties, the mattress setting and the heels off loaded doctor's orders were all followed as ordered. Review of the TAR dated January 2023 indicated that a skin check was completed on 1/18/23. Review of the medical record failed to indicate that a skin check was completed on 1/18/23 Review of the TAR dated February 2023 indicated that a skin check was completed on 2/1/23, 2/8/23, 2/15/23 and 2/22/23. Review of the medical record failed to indicate that a skin check was completed on 2/1/23, 2/8/23, 2/15/23 and 2/22/23. Review of the TAR dated March 2023 indicated that on 3/1/23, the nurse signed on the 7 A.M.-3 P.M. shift that a skin check had been completed. Review of the medical record failed to indicate that a skin had been completed on 3/1/23. Review of the medical record failed to indicate that weekly skin checks were completed for 1 week in January 2023, for 4 weeks in February 2023 and 1 week in March 2023 as documented complete on the TARs. During an interview on 3/2/23, at 2:06 P.M. Unit Manager #2 said that the skin checks, if completed, would be found under the assessment tab in the electronic medical record. The Unit Manager also acknowledged that the skin checks had not been completed as documented on the TARs.

Based on observation, policy review and interview, the facility failed to ensure its staff implemented appropriate infection control measures to help prevent transmission of communicable diseases and infections for four Residents during the dining experience. Specifically, the facility failed to ensure two staff members (#A and #B) performed hand hygiene in between assisting 4 residents during their lunch meal. Findings include: Review of the facility policy titled, Hand Hygiene, dated as revised 1/2020, indicated healthcare personnel will decontaminate their hands prior to and after each patient contact using alcohol based hand rub. On the the second floor dining room on 3/2/23, two surveyors observed the following: -At 12:28 P.M., the surveyors observed staff #A picking up crackers and dipping the crackers into humus with her bare hands. Staff #A then placed the food directly into the Resident's mouth. Staff #A did not perform hand hygiene. Staff #A then turned to assist another Resident. Staff #A picked up the utensil using the same hand and she began to assist a totally dependent Resident with his/her meal. Staff #A then returned to assist the first Resident with crackers and humus without performing hand hygiene. On 3/2/23 at 12:38 P.M., Staff #A identified the food she was assisting the first Resident with as crackers and humus. -At 12:30 P.M., the surveyors observed at a different table, Staff #B picking up crackers and dipping the crackers into humus with her bare hands. Staff #B then placed the food directly into the Resident's mouth. Staff #B did not perform hand hygiene. Staff B then wiped her hand off on the Resident's clothing protector and then turned to assist another Resident. Staff #B then picked up the utensil using the same hand and began to assist a totally dependent Resident with his/her meal. Staff #B then returned to the other Resident without performing hand hygiene. Staff #B was observed going between feeding both Residents for approximately 7 minutes without performing hand hygiene. On 3/2/23, at 12:37 P.M., Staff #B identified the food she was assisting the Resident with as crackers and humus. The staff member then started to use a spoon for the crackers and humus, however Staff #B did not perform hand hygiene between the Residents. During an interview on 3/2/23, at 12:47 P.M., Unit Manager #2 said that staff #A and staff #B should perform hand hygiene between Residents. Unit Manager #2 said staff #A and staff #B should have not used their bare hands while assisting Residents with meals. During an interview on 3/2/23, at 1:43 P.M., the Infection Control (IC) nurse said she was made aware of the observations. The IC nurse said staff should perform hand hygiene between feeding residents and not touch food with their bare hands. During an interview on 3/3/23, at 7:05 A.M., the Director of Nursing said hand hygiene should have been preformed between Residents.