**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Advance Directives (written documents that instruct health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) were formulated and maintained in the medical record for one Resident (#106), out of a total sample of 25 residents. Specifically, the facility failed to ensure Advanced Directives were reviewed, documented, valid, and maintained in the medical record. Findings include: Review of the facility's policy titled Advanced Directives, dated as last revised 1/2024, indicated but was not limited to the following: -Advanced directives will be respected in accordance with state law and facility policy. -Information about whether or not the resident has executed an advanced directed shall be displayed in the medical record. -The plan of care will be consistent with his or her documented treatment preferences and/or advanced directives. -Advanced Directive- a written instruction for health care, recognized by state law, relating to the provisions of health care. -Do Not Resuscitate- indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy (HCP), or representative has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used. -The staff will inform emergency medical personnel of a resident's advanced directive regarding treatment options and provide such personnel with a copy of such directive when transfer from the facility via ambulance or other means is made. Review of the Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) website (https://www.molst-ma.org) indicated but was not limited to the following: -All clinicians in any setting should talk about advanced care planning with patients and document patients' preferences as appropriate. Such discussions may result in filling out a MOLST form, if medically indicated and desired by the patient. -Filling out the MOLST form: Both Sections D and E (Patient and Clinician Signature) must be fully complete and legible for page 1 to be valid. -The MOLST form should be kept with the patient, easy to find, and taken with the patient outside of the home. -Copy the MOLST form for the patient's medical record. -MOLST requires a physician, nurse practitioner, or physician assistant signature to be valid. This signature confirms that the MOLST accurately reflects the signing clinician's discussion with the patient. --The MOLST form should be filled out and signed only after an in-depth conversation between the patient and the clinician signer. -If any section is not completed, there is no limitation on the treatment indicated in that section. -The form is effective immediately upon signature. Photocopy, fax, or electronic copies of a properly signed MOLST are valid. -Send this form with the patient at all times. -If no form is completed, no limitations on treatment are documented, full treatment may be provided. Resident #106 was admitted to the facility in February 2023 with diagnoses which included myocardial infarction, heart disease, and Parkinsons disease. Review of the Minimum Data Set (MDS) assessment for Resident #106 indicated he/she scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment indicating he/she was cognitively intact. Review of the electronic medical record for Resident #106 indicated he/she made his/her own medical decisions and his/her HCP was not invoked and he/she was a Do Not Resuscitate/Do Not Intubate (DNR/DNI). Review of the Physician's Orders indicated the following: -DNR/DNI ([DATE]) Further review of the electronic medical record failed to indicate a MOLST or DNR form had been scanned into the medical record. Review of the paper medical record failed to indicate a MOLST or DNR form had been completed and maintained as part of the medical record. Review of the Comprehensive Care Plan indicated but was not limited to the following: -ADVANCED DIRECTIVES: DNR/DNI, Self-Responsible, HCP on file ([DATE]) -Follow MOLST form as ordered. ([DATE]) Review of the Nursing, Social Service, and Physician progress notes from admission through [DATE] failed to indicate a discussion regarding a MOLST had occurred, a MOLST was signed, or that the resident wished to be a DNR/DNI. Further review of the progress notes indicated but were not limited to the following: -[DATE] Social Service Note: Advanced Directives: None. Full Code and is self-responsible at this time. -[DATE] Social Service Note: Met to discuss plan of care. In attendance were social worker, unit manager, program director, and rehab director. HCP was present via phone call and resident was present. He/she has a HCP but it is not activated at this time and is a full code status. -[DATE] Nurses Note: Resident was seen by physician today. Resident consented to medication change. -[DATE] Physician Progress Note: late entry for [DATE]: seen for falls. The progress notes failed to indicate a discussion had occurred regarding advanced directives or that advanced directives were formulated, implemented, and placed in the medical record. During an interview on [DATE] at 11:15 A.M., Unit Manager #3 said there was not a MOLST in Resident #106's chart and she did not know where it was. She said the form should be in the medical record. Additionally, she said he/she has been to the hospital a few times so perhaps it went with them. She said she was unsure why the form was not in the chart or where it was and deferred further questions to the Director of Social Services. During an interview on [DATE] at 11:15 A.M., the Director of Social Services said the MOLST form was not in the medical record, and it should be. She said she did not recall reviewing one with him/her and did not know where the MOLST was. During an interview on [DATE] at 11:56 A.M., the Director of Social Services said she did not have a copy of the MOLST in the Social Service office either. She said she put a call out to the physician to inquire about the MOLST. During an interview on [DATE] at 12:45 P.M., the Director of Nurses (DON) said she spoke to the physician, and he did not recall this particular case, but usually the provider would have the discussion, document, and write the orders. She said however, there are no notes regarding this in the medical record. On [DATE] at 11:00 A.M, the surveyor observed that there was a MOLST form flagged in the chart for physician review. The MOLST form was signed/initialed by Resident #106, dated [DATE], and indicated he/she wanted to have CPR attempted and did not want to be intubated. On [DATE] at 11:03 A.M., Resident #106 was in bed sleeping and unavailable for interview. During an interview on [DATE] at 11:07 A.M., Unit Manager #3 said there should be a current/valid MOLST in the medical record. She said a new one was completed yesterday after it was pointed out that he/she did not have one. She said the physician is coming in tomorrow to review and sign it. Review of the medical record indicated Resident #106 remained a DNR/DNI status at this time. During an interview on [DATE] at 9:58 A.M., Social Worker #3 said she did not know where the MOLST was, so she went over it to have Resident #106 sign a new one and he/she wants CPR. She said she flagged it for the physician to review. Additionally, she said the MOLST should be in the medical record as it needs to go everywhere with him/her. She said usually she would scan the original into the electronic medical record and put several copies in the paper medical record. She said that way, when they are sent to the hospital, copies are easily accessible to provide to the ambulance drivers (EMTs) because without the form indicating DNR, the EMT's would provide CPR if needed. During an interview on [DATE] at 10:38 A.M., the DON said there should be a copy of the MOLST in the medical record. She said the EMTs would do CPR without a valid MOLST if they were transporting the resident and he/she went into cardiac arrest. Additionally, she said there should be a physician's progress note indicating the discussion. She said the Social Worker re-did the MOLST on Tuesday and the physician is coming in today to review it and write the orders. Review of a progress note written on [DATE] by Social Worker #3 indicated when Resident #106 was admitted to the facility there was no MOLST, but the hospital discharge summary indicated DNR/DNI. The facility was unable to provide a copy of the MOLST indicating his/her wishes for DNR/DNI status, a progress note indicating the discussion had occurred, or confirmation the order entered into the medical record on [DATE] was a valid order based on a valid MOLST.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure for one Resident (#35) with a gastrostomy tube, of a total sample of 25 residents, that medications were administered in accordance with the physician's order and Professional Standards of Practice. Specifically, the facility failed to ensure Nurse #3 followed the physician's order when administering each of the Resident's medications via the gastrostomy tube (GT). Findings include: Review of the [NAME] Skill Checklist for Taylor's Clinical Nursing Skills. A Nursing Process Approach, 5th Edition, Skill 5-2 Administering Medications via a Gastric Tube, the following standard included but was not limited to the following: 10. Prepare medication. Pills: Using a pill crusher, crush each pill one at a time. Dissolve the powder with water or other recommended liquid in a liquid medication cup, keeping each medication separate from the others. Keep the package label with the medication cup, for future comparison of information. During an interview on 9/24/24 at 9:29 A.M., the surveyor observed Nurse #3 preparing and administering medications to Resident #35. Nurse #3 said that all of the Resident's GT medications were to be crushed and administered via the GT in warm water. On 9/24/24 at 9:30 A.M., the surveyor observed Nurse #3 pouring each of the Resident's morning medications, which included the following: - Lasix (diuretic) 20 milligrams (mg) VGT (via GT) in the AM - Aspirin 81 mg VGT in AM -Docusate sodium (stool softener) 100 mg give 2 caps by mouth (sic) in the AM -Fluoxetine Hcl (hydrochloride) (antidepressant) 60 mg VGT once daily -Metoprolol (antihypertensive) 25 mg 0.5 tab VGT two times a day -Multivitamin with minerals 1 VGT once daily -Vitamin D3 25 micrograms (mcg) VGT daily During the administration of the medications, the surveyor observed Nurse #3 place all the above medications in a small plastic crushing bag, crush the medications with a pill crusher, place all of the powdered medications in a plastic medication cup, and took them to the Resident's bedside. Nurse #3 then added 5 ml of warm water to the cup of multiple crushed medications, mixed the medications in the water, administered all the medications together via the GT, and flushed the tube with an additional 5 ml of water. Review of the Medication Administration Record (MAR) indicated the physician's order for administering the Resident's GT medications as follows: -Mix each medication with 5 milliliters (ml) of water and mix each medication separately During an interview on 9/24/24 at 9:35 A.M., Nurse #3 said she failed to follow the physician's order which indicated to mix and administer each medication separately in 5 ml of water. During an interview on 9/25/24 at 8:00 A.M., the Director of Nursing (DON) said that Nurse #3 should have followed the physician's order to prepare each GT medication separately in 5 ml of water, and not mix and administer them together via the GT.

Based on observations and interview, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with accepted professional standards of practice prior to administration for 1 of 4 medication carts reviewed. Specifically, the facility failed to: -For Residents #47, #82, and #117, ensure staff did not pre-pour medications and store them in the medication cart; and -Ensure Schedule II-V controlled substance medications were maintained in a separately locked, permanently affixed compartment. Findings include: Review of the facility's policy titled General Guidelines for Medication Administration, dated September 2018, indicated but was not limited to the following: -Medications are administered as prescribed in accordance with good nursing principles and practices, and only by persons legally authorized to administer. -Medications are administered at the time they are prepared. Medications are not prepared either in advance of medication pass or for more than one resident at a time. On 9/25/24 at 10:57 A.M., the surveyor and Nurse #1 observed the medication cart on Unit M2 and observed in the top drawer, three plastic pill cups which each contained multiple medications. Two of the pill cups were not labeled, the third cup had a piece of paper lying on top with Resident #117's first name only. During an interview on 9/25/24 at 10:59 A.M., Nurse #1 said he pre-poured the medications because the three residents come back from group at 11:00 A.M. and want their medications right away. He said Resident #82's pill cup contained oxycodone (schedule II drug). Nurse #1 said he should not have pre-poured the medication and the Oxycodone should be stored in the narcotic box (under double lock). Review of the narcotic book indicated Nurse #1 signed out the following Oxycodone but was not limited to the following: -Resident #47 had one Oxycodone 10 milligram (mg) signed out on 9/25/2024 at 11:00 A.M. by Nurse #1. -Resident #82 had one Oxycodone 15 mg signed out on 9/25/2024 at 11:00 A.M. During an interview on 9/25/24 12:11 P.M., the Director of Nurses (DON) said she expects the nurses not to pre-pour medication and all narcotics to be stored under double lock (narcotic box).

Based on observation and interview, the facility failed to ensure the residents' environment was clean, comfortable, and homelike. Specifically, the facility failed to ensure the resident common areas (activity rooms, pub/parlor/dining rooms) were maintained in good repair (without holes, painted) and homelike on units M2 and B2. Findings include: Review of the facility's policy titled Resident Right-Safe/Clean/Comfortable/Homelike Environment, dated as last revised September 2021, indicated but was not limited to the following: -It is the policy of the facility to provide a safe, clean, comfortable homelike environment in such a manner to acknowledge and respect resident rights -Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior During all days of survey (9/19-9/26/24), the surveyor observed the following: Unit B2: -the unit hallway had multiple areas where hand sanitizer pumps had been removed, revealing unpainted torn drywall -the dining room had a hole in the wall approximately three inches long by one and a half inches high, with crumbling dry wall. -the walls in the dining room were painted white and light blue with visible marks, nicks, food debris. -the door frame when exiting the dining room was observed with chipped paint and dark in color on the white paint with brown smudges on the right side of the door frame at eye level and at the top of the door frame. -the activity room was observed to have a medium blue paint with multiple areas of scraped off paint, revealing white wall throughout multiple levels of the room. -the wall air conditioner in the activity room had gray dust/debris on the front and top and the vent was pointed at the ceiling. The textured ceiling in front of the air conditioner had black particles of debris. -the activity room floor level baseboard heater had a gap between the tile floor and the heater, the gap had brown dirt and trash. During an interview on 9/25/24 at 3:05 P.M., Life Enrichment Specialist #1 was in the B2 unit dining room and said he was not sure how long the hole had been in the wall, but it had been there for some time. He said he was not sure if the common area rooms had been painted anytime recently. Unit M2: - the unit hallway had multiple areas of scraped off paint and areas of unpainted patches of plaster; the walls were visibly dirty and discolored with visible liquid streaks and corners with broken plaster. -the unit fire extinguisher had trash and torn up sugar packets wrappers between the extinguisher and the wall. The wall around the extinguisher was visibly dirty with dark streaks. - the pub/parlor had painting tape around the chair rail, outlets and baseboard, there was one coat (with visible bleed through) of blue paint on the lower section of the walls. The painting tape around the base board was scratched up with wear and tear. The blue paint had visible scuffs and scratches. During an interview on 9/25/24 at 3:24 P.M., Life Enrichment Specialist #2 said the staff had previously been utilizing another room for activities for residents and when they switched to using the pub/parlor the facility staff had started painting it but were unsure when it would be finished. During an interview on 9/25/24 at 4:05 P.M., the Housekeeping Manager said there was one housekeeping staff member assigned to each unit and they were responsible for dry and wet mopping resident rooms and cleaning resident bathrooms. She said there was one additional staff member who buffed the unit hallway floors. She said the unit housekeeper was responsible for wiping down the walls and high touch areas (handrails) on the units daily. She said the walls should not be visibly dirty. She said the housekeeping staff should have been cleaning under the baseboard heater in the B2 activity room and any trash that was observed between the wall and the fire extinguisher. She said the maintenance staff were responsible for cleaning the air conditioners and her staff had not noticed the debris on the B2 activity room ceiling. During an interview on 9/26/24 at 7:30 A.M., the Corporate Manager said he was responsible for plant operations and there were currently two staff in the maintenance department. He said the facility previously had a Director of Maintenance until June 2024. He said the current maintenance staff continued to work on crisis management for the facility (plumbing, electric, safety concerns) and there were not enough staff to address painting. He said the previous brand of hand sanitizer was changed which required new dispensers with a different method of installation which was why the dispensers were now in different spots, leaving unpainted exposed dry wall. He said he knew there was a hole in the B2 dining room as it was on his rounding list and that holes in walls, with the appropriate number of staff, should be fixed within a day. He said the previous Director of Maintenance, who left the facility in June (over three months prior to survey) had started painting the M2 pub/parlor and the room had not been finished.

4. Resident #79 was admitted to the facility in June 2022. Review of the paper and electronic medical record for Resident #79 indicated a drug regimen review was completed on 4/3/24 and then again on 9/18/24. There was no documentation to indicate the drug regimen review had been conducted by a licensed pharmacist in May, June, July, or August 2024.3. Resident #117 was admitted to the facility in November 2023. Review of the medical record for Resident #117 failed to indicate a medication regimen review was completed in May, June, July, and August 2024. During an interview on 9/24/24 at 10:17 A.M., Unit Manager #2 said the paper pharmacy reviews were in Resident #117's medical record. Unit Manager #2 reviewed the paper medical record and did not find any pharmacy reviews for May 2024, June 2024, July 2024 or August 2024. During an interview on 9/24/24 at 10:35 A.M., the DON said the facility came under new ownership in April 2024. The DON said she was not aware that the previous owner had hired a consultant pharmacist to complete pharmacy reviews, as the pharmacy did not have a pharmacist come into the facility. The DON said no pharmacy reviews were completed from May 2024 through August 2024. 2. Resident #13 was admitted to the facility in September 2022. Review of the paper and electronic medical records for Resident #13 indicated a drug regimen review was completed on 4/4/24 and then again on 9/23/24. There was no documentation to indicate the drug regimen review had been conducted by a licensed pharmacist in May, June, July or August 2024. Review of the medical record on 9/24/24 indicated the pharmacist consultant had completed the drug regimen review on 9/23/24 and had recommendations. During an interview on 9/24/24 at 11:05 A.M., Unit Manager #4 said he has not seen any pharmacy reviews for a while and he has not seen a pharmacist in the building. Based on interviews and record reviews, the facility failed to ensure a monthly medication regimen review was completed once per month for five out of five Residents (#3, #13, #117, #79, and #88) selected for unnecessary medication review and one out of one Resident (#94) reviewed for medication side effects. Specifically, the facility failed to have a licensed pharmacist conduct a drug regimen review for each resident in the months of May, June, July, and August 2024. Findings include: Review of the facility's pharmaceutical services contract indicated for Pharmacy Consulting Services- At the facility's written request, the Pharmacy shall arrange for a third party consultant pharmacist to provide pharmacy consulting services to the facility. The facility and such pharmacy consultant shall contract directly with each other and the Pharmacy shall have no other duties, responsibilities or liability with respect to such pharmacy consultant. During the entrance conference on 9/19/24 on 9:30 A.M., the Administrator said the facility had entered new ownership effective 4/1/24 and the Administrator and the Director of Nurses had started working at the facility in May 2024. 1. Resident #3 was admitted to the facility in January 2019. Review of the paper and electronic medical records for Resident #3 indicated a drug regimen review was completed on 4/4/24 and then again on 9/23/24. There was no documentation to indicate the drug regimen review had been conducted by a licensed pharmacist in May, June, July or August 2024. Review of the medical record on 9/24/24 indicated the pharmacist consultant had completed the drug regimen review on 9/23/24 and had recommendations. During an interview on 9/24/24 at 1:15 P.M., the Director of Nurses (DON) said the drug regimen review had just been completed and had not been reviewed by the physician at this time. 5. Resident #88 was admitted to the facility in August 2022. During an interview on 9/25/24 at 11:36 AM, Nurse #2 said that the pharmacist reviews each resident's drug regimen monthly, and the monthly pharmacy reviews are kept in the medical record. Record review indicated that the most recent MRR by the consultant pharmacist was on 9/18/24. Further record review indicated that there were no MRRs by the consultant pharmacist from May 2024 to August 2024. During an interview on 9/24/24 at 9:45 AM, the DON said that the facility had changed ownership in April 2024 and that the monthly MRRs had not been conducted by the consulting pharmacy from May 2024 to August 2024. 6. Resident #94 was admitted to the facility in May 2021. Record review indicated that the most recent MRR by the consultant pharmacist was on 9/18/24. Further record review indicated that there were no MRRs by the consultant pharmacist from May 2024 to August 2024. During an interview on 9/24/24 at 9:45 AM, the DON said that the facility had changed ownership in April 2024 and that the monthly MRRs had not been conducted by the consulting pharmacy from May 2024 to August 2024.

Based on interview and observation, the facility failed to ensure one Resident (#11) had running hot and cold water in their bathroom, out of a total sample of 29 residents. Findings include: Resident #11 was admitted to the facility in November 2011 with diagnoses which included seizure disorder, traumatic brain injury, and depression. During an interview on 6/29/23 at 12:08 P.M., Resident #11 said he/she has not had running water in his/her bathroom for months. Resident #11 said he/she has asked the nurses and the certified nursing assistants (CNA) if they could get his/her sink fixed for months. The Resident said it is driving him/her nuts; he/she can't wash his/her hands after going to the bathroom. On 6/29/23 at 12:09 P.M., the surveyor observed Resident #11's bathroom sink in his/her room, and found the sink had no handles on the hot or cold water stems. The surveyor attempted to turn on the hot and cold water by turning the stem controls and was unable to. The surveyor did not observe any hand sanitizer in the bathroom. During an interview on 6/29/23 at 12:12 P.M., Maintenance Worker #1 said he was not aware Resident #11's sink had no handles. He said if something is broken on the floors, the staff is supposed to put it in the TELS system (electronic system accessed by staff to report maintenance issues) and then it would be fixed. He has not been asked to fix Resident #11's sink. During an interview on 6/29/23 at 12:18 P.M., the Director of Maintenance said the staff never reported that Resident #11 had no handles on his/her sink. He remembers something about the previous resident in that room turning on the faucets and flooding the room, so the sink handles were removed from the bathroom sink. He was unable to recall which resident it was or if the resident still resides in the building. He said the staff is supposed to use the TELS system to report maintenance issues, but the staff will tell him verbally of problems and he instructs them put the issue in the TELS system but it doesn't always get there. During an interview on 6/29/23 at 12:22 P.M., CNA #4 said Resident #11 is on her assignment, and she was not aware the sink in the room was not working. She said she never goes in the bathroom, because Resident #11 is independent in toileting and he/she takes a shower every other day in the common shower. During an interview on 06/29/23 at 12:23 P.M., the Administrator said Resident #11 should have running water in his/her room.

Based on observation, record review, and interview, the facility failed for one Resident (#51), out of four residents with restraints, from a total sample of 29 residents, to ensure a pelvic restraint was used for the least amount of time as required. Findings include: Resident #51 was admitted to the facility in April 2021 with diagnoses including Huntington's disease (condition that leads to progressive degeneration of nerve cells in the brain that affects movement, cognitive functions, and emotions). Review of the 5/25/23 Minimum Data Set assessment indicated Resident #51 had impairment in both short and long-term memory, had severely impaired cognitive skills for daily decision making, was dependent on staff for all activities of daily living, and had bed rails that were identified as a restraint. Review of a Physical Restraint Initial Evaluation, signed as completed on 5/18/23, indicated the Resident's safety is impacted by his/her uncontrolled movements and needs the pelvic restraint or constant supervision or will end up on the floor. Rehab to evaluate and treat as indicated. Review of the Occupational Therapy (OT) Plan of Care assessment and treatment notes indicated Resident #51 was referred to OT by nursing on 5/24/23 after reports of increased frequency of the Resident sliding/falling out of his/her wheelchair due to no longer having a pelvic restraint (unknown when the pelvic restraint was discontinued). Review of OT daily treatment notes from 5/24/23 to 6/14/23 indicated staff were educated on proper restraint application techniques and a physician's order was obtained on 6/9/23 for the pelvic restraint. Review of a Nurse's note, dated 6/9/23, indicated the Resident completed trial of pelvic restraint, order updated for day and evening shift when in wheelchair and to release during meals if tolerated. Review of the June 2023 Physician's Orders indicated: -pelvic restraint to reduce risk of falls and support or neutral posture while in wheelchair; may release during (6/9/23) The physician's order was incomplete and did not include to release during meals if tolerated as indicated in the 6/9/23 nursing note. Review of the May through June 2023 Medication/Treatment Administration Records (MAR/TAR) failed to indicate the pelvic restraint was released at mealtimes as tolerated. On 6/27/23 at 12:50 P.M. in the B-2 Unit dining room, the surveyor observed Resident #51 seated at a table in a Broda chair (positioning chair) with a pelvic restraint in place around the Resident's waist and tied in a knot in the back of the Broda chair. At 12:57 P.M., Certified Nursing Assistant (CNA) #2 brought a lunch tray into the dining room, sat down next to the Resident and began to feed him/her their lunch meal. The Resident did not display any uncontrolled movements and the CNA did not release the pelvic restraint at any time during the meal observation from 12:57 P.M. to 1:10 P.M. On 6/29/23 at 1:43 P.M. in the B-2 Unit dining room, the surveyor observed Resident #51 seated at a table in a Broda chair with a pelvic restraint in place around the Resident's waist and tied in a knot in the back of the Broda chair. CNA #3 was standing alongside Resident #51 while feeding him/her their meal. The Resident did not display any uncontrolled movements and the CNA did not release the pelvic restraint at any time during the meal observation from 1:43 P.M. to 1:58 P.M. The surveyor asked CNA #3 if she was supposed to release the restraint during mealtimes. The CNA said she was agency staff, had never worked in the building before, and had no idea if she was supposed to release the restraint during meals. During an interview on 6/29/23 at 2:00 P.M., the surveyor reviewed the physician's order for the pelvic restraint. Nurse #5 said the order was not complete and did not include release during mealtimes. During an interview on 6/30/23 at 11:45 A.M., the surveyor reviewed Resident #51's medical record regarding the pelvic restraint with Nurse #5. She said she has tried to educate staff on releasing the restraint during meals, but it is challenging. She said following the conversation with the surveyor yesterday, she contacted the physician regarding the restraint and was given an order for a Rehab referral for staff education to release during mealtimes.

Based on policy review, record review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#58), of a total sample of 29 residents. Specifically, the facility failed to ensure an allegation of mistreatment by a Certified Nursing Assistant (CNA) was reported, thoroughly investigated, and action was taken to protect the Resident pending the outcome of the investigation. Findings include: Review of the facility's policies titled Abuse Identification and Reporting, dated 11/2017 and Abuse: Investigation, dated 12/2017, indicated but was not limited to: - Each resident has the right to be free from verbal, sexual, physical and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of their property. - Abuse: the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical hurt or pain or mental anguish to a resident. - All alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in process. -The nursing supervisor will take appropriate steps to protect the resident, if applicable, from further mistreatment, and to ensure that appropriate care is provided. These steps may include suspension of employee pending investigation. - Report to DPH and local law enforcement any reasonable suspicion of a crime committed against an individual who is a resident of, or receiving care from, the facility. If the events that cause reasonable suspicion result in serious bodily injury, the report must be made immediately (but not later than two hours) after forming the suspicion. Otherwise, the report must not be made later than 24 hours after forming the suspicion. - Any suspected allegation of abuse shall be immediately reported to the Executive Director or his/her designee. - Each facility shall immediately report to the DPH, suspected resident abuse, neglect, mistreatment or misappropriation of resident property. - The Executive Director or his/her designee will immediately take action to ensure resident safety. - An alleged violation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, will be reported immediately, but not later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury. Resident #58 was admitted to the facility in August 2022 with diagnoses including a seizure disorder. Review of the most recent Minimum Data Set (MDS) assessment indicated Resident #58 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15. Review of the grievance log and grievance investigations from January 2023 to July 2023 indicated the following grievance was logged onto the monthly log reports: A 2/17/23 grievance form indicated Resident #58's [family member] left a voicemail for the Administrator reporting improper treatment of the Resident by staff and it needs to stop. The investigation indicated Resident #58 was interviewed and reported that staff are meanies and Certified Nursing Assistant (CNA) #5 intentionally kicks him/her in the back of his/her wheelchair. The grievance documentation failed to indicate the facility identified the grievance as an allegation of abuse, failed to thoroughly investigate the allegation, failed to suspend the accused staff pending the outcome of the investigation, and failed to report it to local, state, and federal agencies according to facility policy. Review of the Health Care Facility Reporting System (HCFRS) on 6/29/23 at 8:00 A.M. failed to indicate Resident #58's allegation of abuse was reported as required. During an interview on 6/29/23 at 11:56 A.M., the Director of Social Services (DSS) said she completed the grievance form for Resident #58 and conducted the investigation. She said neither she nor the interdisciplinary team considered the Resident's grievance of a CNA intentionally kicking the Resident in the back of his/her wheelchair an allegation of abuse, did not thoroughly investigate it as an allegation of abuse, no action was taken to protect the Resident pending the outcome of the investigation, and it was not reported to DPH.

Based on interview and record review, the facility failed to ensure an allegation of abuse by one Resident (#58) was reported to the Department of Public Health's (DPH) Health Care Facility Reporting System (HCFRS) within the required two hour time frame, out of a total sample of 29 residents. Findings include: Resident #58 was admitted to the facility in August 2022 with diagnoses including a seizure disorder. Review of the most recent Minimum Data Set (MDS) assessment indicated Resident #58 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15. Review of the grievance log and grievance investigations from January 2023 to July 2023 indicated the following grievance was logged onto the monthly log reports: A 2/17/23 grievance form indicated Resident #58's [family member] left a voicemail for the Administrator reporting improper treatment of the Resident by staff and it needs to stop. The investigation indicated Resident #58 was interviewed and reported that staff are meanies and Certified Nursing Assistant (CNA) #5 intentionally kicks him/her in the back of his/her wheelchair. Further review of the grievance failed to indicate the facility identified the grievance as a potential violation of a resident right and failed to report it to DPH as required. Review of the Health Care Facility Reporting System (HCFRS) on 6/29/23 at 8:00 A.M. failed to indicate Resident #58's allegation of abuse was reported as required. During an interview on 6/29/23 at 11:56 A.M., the Director of Social Services (DSS) said she completed the grievance form for Resident #58 and conducted the investigation. She said neither she nor the interdisciplinary team considered the Resident's grievance of a CNA intentionally kicking the Resident in the back of his/her wheelchair an allegation of abuse and it was not reported to DPH within 2 hours as required.

Based on interviews, record review, and policy review, the facility failed to ensure that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for one Resident (#58), of a total sample of 29 residents. Specifically, the facility failed to ensure an allegation of abuse by a Certified Nursing Assistant (CNA) on 2/17/23, was thoroughly investigated and protected the Resident pending the outcome of the investigation. Findings include: Review of the facility's policy titled Abuse Identification and Reporting, dated 11/2017, indicated but was not limited to: - Each resident has the right to be free from verbal, sexual, physical and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of their property. - Abuse: the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical hurt or pain or mental anguish to a resident. - Any suspected allegation of abuse shall be immediately reported to the Executive Director or his/her designee. - All alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in process. - The nursing supervisor will complete the Abuse Prohibition Investigation Report, parts I, II, and III. These sections include: - Event identification details, notification of appropriate persons, and confirmation of resident examination. - Interview appropriate individuals. The nursing supervisor will coordinate the interview process during the shift in which the event was reported. Any individual(s) who may have knowledge of the events should be interviewed. This includes the alleged victim, employees working during the shift when the event was discovered/reported, as well as visitors and other residents who may have witnessed something. - The Executive Director or his/her designee will immediately take action to ensure resident safety. - If the suspected perpetrator is another resident, the Director of Nursing Services or his/her designee shall separate the residents so they do not have access to each other until the circumstance of the alleged incident can be determined. Resident #58 was admitted to the facility in August 2022 with diagnoses including a seizure disorder. Review of the most recent Minimum Data Set (MDS) assessment indicated Resident #58 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15. Review of the grievance log and grievance investigations from January 2023 to July 2023 indicated the following grievance was logged onto the monthly log reports: A 2/17/23 grievance form indicated Resident #58's [family member] left a voicemail for the Administrator reporting improper treatment of the Resident by staff and it needs to stop. The investigation indicated Resident #58 was interviewed and reported that staff are meanies and Certified Nursing Assistant (CNA) #5 intentionally kicks him/her in the back of his/her wheelchair. Further review of the grievance failed to indicate interviews were conducted with any individual(s) who may have witnessed or had knowledge of the events including the alleged perpetrator (CNA #5), employees working during the shift when the event was discovered/reported, as well as visitors and other residents who may have witnessed something. During an interview on 6/29/23 at 11:56 A.M., the Director of Social Services (DSS) said she completed the grievance form for Resident #58 and conducted the investigation. She said neither she nor the interdisciplinary team considered the Resident's grievance of a CNA intentionally kicking the Resident in the back of his/her wheelchair an allegation of abuse and it was not thoroughly investigated to include an interview with the alleged perpetrator and suspension of the alleged perpetrator pending the outcome of the investigation as required.

Based on record review, policy review, and interview, the facility failed to ensure that the Risk for Falls care plan was individualized with appropriate interventions after a fall for one Resident (#84), out of a total sample of 29 residents. Findings include: Resident #84 was admitted to the facility in December 2018 with diagnoses which included seizures, traumatic brain injury, and dementia. Review of the medical record indicated Resident #84 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of 15. The Resident had three falls from April 2023 to June 2023. Review of the facility's policy titled Assessing Falls and Their Causes, revised January 2018, included but was not limited to: -Review the resident's care plan to assess for any special needs of the resident -When a resident falls, the following information should be recorded in the resident's medical record: Appropriate interventions to prevent future falls Review of a Nursing Note, dated 6/18/23, indicated Resident #84 was lying on the floor at bedside. Review of the Fall Incident Report, dated 6/18/23, indicated Resident #84 was lying on the floor at bedside. The incident report was incomplete; no investigation or statements were attached or provided when requested. Review of the current Resident's Fall Care Plan included but was not limited to: -Moderate risk for Falls -Encourage Resident to use call light -Ensure call light within reach -Ensure resident is wearing appropriate footwear -Follow facility fall protocol -Provide new non-slip safety socks -Safety checks -Soft helmet on at all times -Diversional activities No new intervention was implemented after the fall on 6/18/23. During an interview on 6/30/23 at 3:15 P.M., the Director of Nurses (DON) said, when a resident falls the nurse is responsible to complete the incident report, get witness statements and to update the care plan with a new intervention. The DON said the incident report and full investigation should have been completed and the care plan should have been updated with an intervention to prevent another fall.

Based on observation, record review, and interviews, the facility failed for one Resident (#16) to provide an ongoing activity program to meet and support the individual preferences of the Resident, out of a total sample of 29 residents. Specifically, the facility failed to ensure the Resident's television (TV) was functioning so the Resident could watch their preferred show. Findings include: Resident #16 was admitted to the facility in October 2022 with diagnoses including schizophrenia and depression. Review of the Minimum Data Set (MDS) assessment, dated 11/01/22, indicated Resident #16 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The MDS indicated Resident #16 was able to independently turn the television to the program of his/her choice. Review of the Activities Care Plan indicated but was not limited to the following: Focus: Attend activities of interest/choice and engages in self-initiated leisure activities Goals: Will initiate leisure activities one to two times a day such as visiting with family/friends, talks to family and friend daily. Listening to jazz music in the afternoon. Interventions: Enjoys daily TV show, provide activity calendar in room; and Respect wishes to decline invitations when revisit/leisure activities are preferred. On 06/27/23 at 11:44 A.M., the surveyor observed the Resident sitting in his/her room, the room was dark, and the TV was not turned on. On 06/27/23 at 03:08 P.M., the surveyor observed the Resident sitting in his/her room, the room was dark, and the TV was not turned on. During an interview on 6/27/23 at 3:10 P.M., the Resident said he/she could not watch his/her favorite show because the TV was not working. The Resident said the facility was aware and did nothing about it. During an interview on 06/28/23 at 03:13 P.M., the surveyor informed the Unit Manager about the Resident's TV not working. The Unit Manager said she would notify the Activity Director. On 06/28/23 at 05:16 P.M., the surveyor observed the Resident sitting in the dark in his/her room, and the TV was not turned on. On 06/29/23 at 08:49 A.M., the surveyor observed the Resident sitting in the dark in his/her room, and the TV was not turned on. During an interview on 6/29/23 at 08:52 A.M., Resident #16 said, I would like to watch my favorite show; the TV has not been working. During an interview on 06/29/23 at 4:34 P.M., the Activity Director said the Unit Manager told her yesterday that the Resident's TV has not been working. The Activity Director said she was going to get him/her another TV. During an interview on 06/30/23 at 11:06 A.M., the Resident said he/she did not watch TV for over one week. He/she said the facility gave him/her a new television this morning so that he/she can watch his/her favorite show. Until the surveyor's intervention, the facility staff was unaware that the Resident's TV was not working. During an interview on 06/30/23 at 02:22 P.M., the Resident said that he/she watched all his/her favorite shows today and was happy. The Resident said that he/she likes this new television.

Based on observation, record review, and interview, the facility failed to ensure the care and treatment of residents with catheters was provided per standards of practice. Specifically, the facility failed to position catheter bags off the floor to prevent the risk for infection for one Resident (#29), out of 29 sampled residents. Findings include: Review of the Agency for Healthcare Research and Quality (AHRQ) website indicated drainage bags should be always kept below the level of the bladder and off the floor to avoid the risk of infection (March 2017). Resident #29 was readmitted to the facility in May 2023 with diagnoses including retention of urine, unspecified. Review of the Minimum Data Set (MDS) assessment, dated 2/1/23, indicated that the Resident is cognitively competent and requires extensive assistance with personal hygiene. Review of Resident #29's Clinical Record indicated the use of an indwelling urinary catheter (a sterile tube inserted to the bladder to drain urine). Review of the Physician's Orders, dated June 2023, included an order to change CD [catheter drainage] bag monthly on the 15th of the month on 11-7 shift as needed for urinary retention. The surveyor observed the Resident's urinary catheter as follows: 06/27/23 at 01:18 P.M.- Urinary catheter bag on the floor without a privacy bag 06/27/23 at 01:24 P.M.- Urinary catheter bag on the floor, Certified Nursing Assistant (CNA #1) entered the room to assist the Resident in B bed, then left, the catheter remained on the floor. 06/28/23 at 02:01 P.M.- Urinary catheter bag on the floor 06/29/23 at 10:04 A.M.- Urinary catheter bag on the floor 06/30/23 at 11:02 A.M.- Resident #29 returned from Dialysis; urinary catheter bag on the floor During an interview and observation on 6/30/23 at 11:04 A.M., Nurse #3 entered the Resident's room and observed the catheter bag on the floor. Nurse #3 said the catheter bag should not have been on the floor. The surveyor observed Nurse #3 pick up the urinary catheter bag from the floor and hang it on the lower side of the bed frame. The surveyor did not observe Nurse #3 change the urinary catheter bag for potential contamination. During an interview on 6/30/23 at 11:30 A.M., the Unit Manager said the Resident's urinary catheter should not be touching the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure appropriate care and maintenance of oxygen administration equipment was provided for one Resident (#33), out of a total sample of 29 residents. Findings include: World Health Organization: Care, cleaning and disinfection of oxygen concentrators Checklist (2022) -Inspect and clean air intake filter (1-2 times per week) 1. Pull the filter gently out and replace with spare one. 2. Put the filter in cool, soapy water and swirl gently to remove debris. 3. Remove from soapy water and place it in [NAME] area until completely dry. 4. Store the spare filter until next cleaning is needed. Resident #33 was admitted to the facility in October 2012 with diagnoses including chronic obstructive pulmonary disease (lung disease which blocks airflow and makes it difficult to breathe). Review of the medical record indicated the following current Physician's Order: -Change oxygen tubing every week on Thursday 11:00 P.M. - 7:00 A.M. shift (8/4/21) -Clean oxygen concentrator weekly on Thursdays on 11:00 P.M. - 7:00 A.M. shift (8/3/22) -Oxygen at 2 liters/minute via nasal cannula (lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows), continuous (8/3/22) On 6/27/23 at 9:49 A.M. and 12:52 P.M., the surveyor observed Resident #33 seated in a Broda chair (positioning chair) in the B-2 unit dining room. Oxygen tubing was noted to be connected to the concentrator with a bottle of sterile water, with a nasal cannula in place in the Resident's nostrils. The concentrator was on and set to a flow rate of 2.0 liters/minute. The surveyor inspected the filter for the oxygen concentrator which was observed to be almost fully covered with light, gray-colored dust and debris. The Resident said he/she was not aware there was a filter on the oxygen concentrator that required staff cleaning. On 6/28/23 at 9:05 A.M., the surveyor observed Resident #33 seated in a Broda chair in his/her room. Oxygen tubing was noted to be connected to the concentrator with a bottle of sterile water, with a nasal cannula in place in the Resident's nostrils. The concentrator was on and set to a flow rate of 2.0 liters/minute. The surveyor inspected the filter for the oxygen concentrator which was observed to be almost fully covered with light, gray-colored dust and debris. On 6/29/23 at 1:26 P.M., the surveyor observed Resident #33 seated in a Broda chair in his/her room. Oxygen tubing was noted to be connected to the concentrator with a bottle of sterile water, with a nasal cannula in place in the Resident's nostrils. The concentrator was on and set to a flow rate of 2.0 liters/minute. The surveyor inspected the area of the concentrator where the filter should be, and there was no filter in place. On 6/29/23 at 2:10 P.M., the surveyor brought Nurse #5 to Resident #33's room to inspect the oxygen concentrator. Nurse #5 said she didn't know why the Resident's concentrator did not have a filter, but there should be one in place.

Based on record review, policy review, and interview, the facility failed to ensure one Resident's (#13) medication regime was free from unnecessary psychotropic medications, in a sample of 29 residents. Specifically, the facility failed to ensure an as needed (prn) medication order for Klonopin (anticonvulsant used as adjunct therapy for psychosis) was limited to 14 days, then evaluated by the physician as required. Findings include: Review of the facility's policy titled Antipsychotic Medication Use, last revised 11/2017, included but was not limited to: -Residents will not receive prn doses of psychotropic medications unless that medication is necessary to treat specific conditions that is documented in the clinical record -The need to continue prn orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the prn order will be indicated in the order. Resident #13 was admitted to the facility in September 2022 with diagnoses including delusional disorder. Review of the 6/10/23 Minimum Data Set assessment indicated Resident #13 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 3 out of 15 and received psychotropic medication daily. Review of the June 2023 Physician's Orders included but was not limited to: -Klonopin (Clonazepam) 1 milligram (mg) every 24 hrs prn for anxiety (2/13/23) indefinite The order did not indicate a stop date or a re-evaluation of the order. Review of the pharmacy recommendations for March, April, May, and June 2023 all indicated a recommendation for an end date of the Klonopin prn order. However, the physician did not address the recommendation or otherwise document a reason for the open-ended prn order. During an interview on 6/29/23 at 1:45 P.M., the surveyor and Nurse #5 reviewed Resident #13's medical record. She confirmed the prn order for Klonopin did not have an end date and said prn orders for psychotropic medications need to have an end date and be re-evaluated for their continued use.

Based on observation, policy review, and interview, the facility failed to ensure that medications were properly stored and labeled in accordance with current accepted professional standards in 1 of 4 medication carts reviewed. Findings include: Review of the facility's policy titled Storage of Medications, revised August 2020, indicated but was not limited to the following: Expiration Dating (Beyond-Use Date): -Certain medications or package types, such as Intravenous (IV) solutions, multiple dose injectable vials, ophthalmics, nitroglycerin tablets, and blood sugar testing solution strips require an expiration date once opened to ensure medication purity and potency. -When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. -The Nurse shall place a date opened sticker on the medication and record the date opened and the new date of expiration. -The expiration date of the vial or container will be 30 days from opening, unless the manufacturer recommends another date or regulations/guidelines require different dating. -If a vial or container is found without a stated opened date, the date opened will automatically default to the date dispensed and the expiration date will be calculated accordingly, unless otherwise indicated in a facility-specific policy. On 6/30/23 at 9:25 A.M., during medication cart (Unit B1-high side) review with Nurse #2, the Surveyor observed the following: -One bottle of Timolol Maleate 0.5% Ophthalmic Solution (treats glaucoma), labeled with a Resident's name, dispense date of 5/6/23, packaging bag and bottle opened, not labeled with the date opened or the triggered expiration date -One vial of Haloperidol Decanoate Injection 50 milligram (mg)/milliliter (ml) (antipsychotic/treats behaviors), labeled with a Resident's name, dispense date of 4/17/23, vial cap removed, not labeled with the date opened or the triggered expiration date -One Albuterol Sulfate Inhalation Aerosol 90 microgram (mcg)/actuation (ACT) (treats shortness of breath/wheezing), labeled with a Resident's name, dispense date of 2/21/22, not labeled with the date opened or the triggered expiration date once opened During an interview on 6/30/23 at 9:25 A.M., Nurse #2 said the eye drops, injection vial, and the inhaler should have been labeled with the date opened and expiration date and were not. During an interview on 6/30/23 at 3:15 P.M., the Director of Nurses (DON) said all eye drops, injectable vials, and inhalers should be labeled once opened with the open date and expiration date. The date should be written on the sticker or the medication bottle/vial. The staff did not follow the facility policy for storage of medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to include and identify the Home Health Aide (HHA) role of care between the facility and the hospice provider, in the person-centered hospice care plan for one Resident (#22), out of a total sample of 29 residents. Findings include: Review of the contract agreement between the facility and the consultant Hospice provider, signed as effective 3/3/23, indicated but was not limited to: Responsibilities of the Nursing Facility: -In accordance with applicable laws and regulations, including without limitation, Hospice and Facility shall comply with the General Terms and Conditions as part of this Agreement. Nursing Facility shall consult with Hospice regarding the development and/or modification of a Plan of Care for each eligible resident. -The Plan of Care must identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the Plan of Care. - Provide Home health aide services that do not duplicate Room and Board Services provided by facility. Resident #22 was admitted to the facility in July 2016 with diagnoses including cerebral vascular disease, thyrotoxicosis (excessive amounts of thyroid hormone in the blood), major depressive disorder, Parkinsonism (nervous system disorder), and nephrotic syndrome (too much protein in the urine due to a kidney disorder). Review of the Physician's Orders, dated June 2023, indicated Resident #22 was admitted to Hospice on 3/5/23. Review of the clinical record indicated Resident #22 was evaluated for Hospice services and admitted on [DATE] for services. The surveyor did not observe HHA visit to the Resident on the following dates and times: 06/27/23 at 9:51 A.M.- Resident in bed alone, no HHA present. 06/27/23 at 10:52 A.M.- Resident in bed with his/her hat on, no HHA present. 06/28/23 at 11:11 A.M.- Resident up in wheelchair asleep, no HHA present 06/29/23 at 2:34 P.M.- Resident lying in bed asleep, no HHA present in the room. 06/30/23 at 2:40 P.M.- Resident in wheelchair asleep, no HHA present. 07/03/23 at 8:00 A.M.- Resident in bed awake, no HHA present. 07/03/23 at 2:48 P.M.- Resident in wheelchair with head tilted forward, no HHA present in the room. Further review of the clinical record indicated the facility failed to identify in the care plan the care and services to be provided by the HHA as agreed upon in the Hospice agreement for the HHA to visit the Resident two times a week. The Hospice provider was not available for an interview. During an interview on 06/30/23 at 02:50 P.M., Certified Nursing Assistant # 1 said Resident #22 did not receive visits from the HHA, as per her observation on the Unit. During an interview on 7/3/23 Unit Manager #1 said the facility did not include in the Hospice care plan the care and services that outline services provided by the HHA.

Based on observation and interview, the facility failed to ensure that dignity was provided during the dining experience for seven Residents (#9, #33, #27, #37, #51, #76 and #77), out of a total sample of 29 residents. Specifically, the facility failed to ensure that: 1. For Residents #9, #33, #37, #51, #76 and #77, staff did not provide a towel as a clothing protector while eating; 2. For Residents #9, #27, #33, #46, #51, #77, staff delivered meals to all residents seated at the table simultaneously, resulting in residents waiting an extended period of time to receive their meal while watching their tablemates eat; and 3. For Resident #51, did not stand over the Resident while feeding him/her in the dining room. Findings include: 1. On 6/27/23 at 11:50 A.M. and 6/28/23 at 11:44 A.M., the surveyor observed six Residents (#9, #33, #37, #51, #76 and #77) of seven Residents in the B-2 Unit dining room with white towels draped around their necks as clothing protectors. 2. On 6/28/23 at 11:44 A.M., the surveyor observed seven residents in the B-2 Unit dining room: two Residents (#76 and #33) were seated at one table, five Residents (#27, #37, #46, #51 and #77) were seated at another table, and one Resident (#9) was seated alone with an overbed table in front of him/her. -On 6/28/23 at 12:12 P.M., the surveyor observed Certified Nursing Assistant (CNA) #2 deliver a lunch tray to Resident #37 who was seated at a table with four other Residents (#77, #46, #27 and #51). The residents at the table sat idly and watched Resident #37 eat his/her meal. -On 6/28/23 at 12:15 P.M., Resident #46 received his/her lunch tray and began to eat. Three other residents at the table sat idly and watched Resident #37 eat his/her meal. -On 6/28/23 at 12:16 P.M., Resident #76 received his/her lunch tray and began to eat. One other resident at the table (Resident #33) sat idly and watched Resident #76 eat his/her meal. -On 6/28/23 at 12:22 P.M., Resident #77 received his/her lunch tray. Two other residents seated at the table sat idly and watched Resident #77 eat his/her meal. -On 6/28/23 at 2:25 P.M., Resident #9 received his/her lunch tray. Three other residents in the dining room sat idly while Resident #77 ate his/her meal. -On 6/28/23 at 12:29 P.M., Resident #33 received his/her lunch tray, 13 minutes after his/her tablemate (Resident #76) received his/her lunch tray. -On 6/28/23 at 12:33 P.M., Resident #27 received his/her lunch tray, 21 minutes after the first lunch tray was delivered to Resident #37. Resident #51 sat idly while watching Resident #27 eat his/her meal. -On 6/28/23 at 12:42 P.M., Resident #51 received his/her lunch tray, 30 minutes after Resident #37 received his/her lunch tray. 3. On 6/29/23 at 1:43 P.M. in the B-2 Unit dining room, the surveyor observed CNA #3 standing over Resident #51 while feeding him/her their meal. The CNA remained standing alongside the Resident feeding him/her for the duration of the meal. During an interview on 6/29/23 at 1:45 P.M., CNA #3 said she was an agency nurse and had never worked on the unit before. The surveyor asked her if she routinely stood over Residents while feeding them or did she sit alongside them. CNA #3 did not respond to they surveyor and remained standing. During an interview on 6/30/23 at 11:45 A.M., Nurse #5 said residents should be provided their meals timely, appropriate clothing protectors should be used and not bathing towels, and staff should not stand up while feeding residents their meals.

Based on record review, review of the rehab consultant's contract and policy, review of the American Physical Therapy Association (APTA) guidelines, review of Massachusetts law, and interviews, the facility failed to provide skilled physical therapy services in accordance with professional standards when the physical therapist is supervising the physical therapist assistant from an offsite setting and when providing telehealth physical therapy. In addition, based on observations, record review, interview, and policy review, the facility failed to implement their falls policy after Resident #107 fell. Specifically, the facility failed to: 1. Provide regularly scheduled, documented collaboration between the physical therapist and the physical therapy assistant regarding patient care; 2. For Residents #91, #17, and #117, ensure the the physical therapist performed at least a monthly onsite re-examination of the Residents and failed to include the required information and consent for telehealth visit for the discharge assessment; and 3. For Resident #107, follow their policy and document a fall occurred, investigate the fall, complete an incident report with the required information, document, and monitor the injury to the right foot. Findings include: 1. Review of the facility's contract for rehabilitative services titled, Amended and Restated Therapy Services Agreement, signed 10/25/19, indicated but was not limited to the following: -Shall provide, in accordance with the patient's applicable plans of care, federal and state laws and regulations, and the terms and conditions of this agreement, the following services: -Physical therapy, occupational therapy, speech and language therapy and the management thereof, such management including, but not limited to, periodic written therapy related educational offers offerings to providers and to inpatient and outpatients, provided in accordance with the patient's applicable plans of care and the requirements of federal and/or state laws and regulations, and the terms of exhibit B attached hereto and incorporated herein. -Make therapy personnel available at the facility 7 days per week on an as needed basis. Shall assign individual therapy personnel to provide therapy services and schedule the times at which therapy services will be provided. Review of Massachusetts Board of Health Professionals, general law 259 CMR 5.00: Physical Therapist, dated 8/7/20, indicated but was not limited to the following: 5.02: Patient Care Management 1c. All components of clinical care, and their supporting documentation, are the sole responsibility of the physical therapist. 6. Perform reexaminations and document the findings when they change in the plan of care is needed, prior to any planned discharge, in response to changes in the patient's medical status. -Summarize patient status and document reason for discharge. Ensure safe and quality care at all times, and in those situations in which a physical therapy assistant provides patient care, serve as the supervising physical therapist. -Serve as the only supervisor of physical therapy assistants. -Determine the frequency and the amount of supervision of the physical therapy assistant by regularly consulting with the physical therapist assistant to discuss the needs of the patient and the needs of the physical therapy assistant and by utilizing the following factors: 10. Provide supervision to the physical therapy assistant including at a minimum: -On site reexamination of the patient. -On site review of the plan of care with appropriate revisions or termination. 5.03: assessment and documentation of physical therapy treatment program This documentation shall be contained in the patient's ongoing treatment notes or in a formal review of the plan of care (or reevaluation). If by formal review of the plan of care or re-evaluation), it must be completed in a particular work setting by a physical therapist of record within the following timeframes: -Outpatient, rehabilitation, home health, skilled nursing facility: At least every 30 days. 5:05: Code of Ethics, Guide for Professional Conduct and Standards of Practice for Physical Therapy (1) The following documents in their most recently approved form are adopted as the ethical standards of practice. -(a) Code of Ethics for physical therapists. The APTA code of ethics delineates the ethical obligations of all physical therapists. -(C) Guide for professional conduct. The APTA guide for professional conduct provides a framework by which physical therapists may determine the propriety of their conduct and is intended to guide the professional development of physical therapy students. (e) Standards of practice for physical therapy and criteria for standards of practice for physical therapy. The APTA standards for practice and criteria for standards of practice provide foundation for assessment of physical therapy practice. Review of the American Physical Therapy Association (APTA) guideline titled, Direction and Supervision of the Physical Therapy Assistant, dated 10/26/22, indicated but was not limited to the following: A. When supervising the physical therapist assistant in any off-site setting, the following requirements must be observed: 1. There must be regularly scheduled and documented collaboration with the physical therapy assistant regarding patients and clients, the frequency of which is determined by the needs of the patient or client and the needs of the physical therapy assistant. 2. In situations which a physical therapist assistant is involved in the care of a patient or client, a supervisory visit by the physical therapist: a. Shall be made upon the physical therapist assistants request for a reexamination, when a change in the management plan or plan a care is needed, prior to any plan conclusion of the episode of care, and in response to changes to the patient or client's medical status. b. Shall be made at least once a month, or a higher frequency when established by the physical therapist, in accordance with the needs of the patient client c. Shall include: i. Onsite reexamination of the patient or client. ii. Onsite review of the plan of care with appropriate revision and termination. Review of the facility's contracted rehab services policy titled Guidelines for Using Telehealth for Assessment and Documentation, undated, indicated but was not limited to the following: -Telehealth is a delivery model that uses an interactive telecommunications system for the purpose of providing health related services at a distance. It means audio and video equipment that permits a 2-way, real time communication between a licensed therapist and a patient assisted by a therapy assistant or nurse who is located at a distant site which is not in proximity of the therapist. -In the therapy documentation, it is required to document the following: a. patient consented to telehealth visit. b. start and end times of the session delivered via telehealth. c. who was present in the session (i.e., therapist, patient, and who else may have helped facilitate the session). d. that this session was completed via telehealth. e. the originating site (where the patient and assistant are) and the distant site (where the therapist is). During an interview on 6/29/23 at 5:40 P.M., the Rehabilitation Director said they have not had a physical therapist in the building since December 2022. She said if she needs a physical therapy evaluation, she has a pool of physical therapists she can call, they do the evaluations, re-evaluations, and discharges. She said it is not ideal, but she is making it work until they hire a physical therapist for the building. During an interview on 6/30/23 at 2:40 P.M., Rehab Staff #1 said he was a physical therapist assistant (PTA) who works full-time in the facility. He said they have not had a physical therapist in the building since December 2022. He said most of the evaluations, progress notes, and discharges are done by telehealth or by the physical therapist completing assessments off-site by reviewing his notes and talking to him or the rehab manager. The surveyor asked for clarification for when the physical therapist does an evaluation, updated plan of care (recertification signed by the physician for continued physical therapy services), or discharge summary (discontinuation of physical therapy services), the resident is seen in person or by telehealth at the time of evaluation? Rehab Staff #1 said no, they don't always see the resident when completing documentation, they review my daily notes and talk to me. He said the Rehab Director calls in a physical therapist to complete the assessments, he talks to the therapist doing the notes to give them information, but he doesn't meet with them regularly or have any documentation of regularly scheduled meetings to discuss the residents. He said he pretty much works alone in the building as the only physical therapy staff member since December. During an interview on 6/30/23 at 3:31 P.M., the Rehab Director said Rehab Staff #1 is correct, sometimes the off-site physical therapist does recertification and discharge notes without doing the telehealth visit. She said they will get updated information from Rehab Staff #1 or her, and they have access to Rehab Staff #1's daily notes. She said by reading the current notes, she can't tell what documentation was completed via telehealth or in person and can't tell if the resident consented to a telehealth visit because they have not been documenting that information in the notes. She said she can't identify which documentation was completed by the therapist reviewing the physical therapy assistants notes and/or talking to him without seeing the resident. The surveyor requested a random sample of physical evaluation, Plan of Care and discharge summaries for review. During a telephonic interview on 7/5/23 at 11:56 A.M., Rehab Staff #2 (physical therapist) said she has been helping the facility for the past two months to provide physical therapy services. The Rehab Director will call her if she needs an evaluation done, updated plan of care, or discharge assessments. She said she has never been on-site at the facility, all physical therapy assessments have been done via telehealth, and/or by chart review and/or speaking with Rehab Director or Rehab Staff #1. She said she does not always see the residents when completing the assessments, but that the goal is to see them via telehealth. She said she does not include in her documentation how the resident assessment was performed (such as by telehealth, in person or by documentation review), and she did not document the resident consented to the telehealth visit. The surveyor reviewed her daily interaction forms (time sheets) dated, 6/7/23, 6/10/23, 6/11/23, 6/13/23, and 6/16/23, which indicated a total of 450 minutes of documentation time with no resident billing for assessments. Rehab Staff #2 said she was billing the facility for documentation, but she does not have a breakdown of what documentation was performed on those dates or if any specific residents were seen via telehealth. She feels she has adequate communication with Rehab Staff #1 but does not have any documentation of collaboration discussing specific residents or direct observations of him providing patient care. She said she feels Rehab Staff #1 has adequate skill set based on how long he has been a licensed physical therapy assistant and what she can see of him during a telehealth visit. During an interview on 07/03/23 at 8:16 A.M., the Administrator said he has requested a physical therapist to be in the building but has been told by the facility's contracted Rehab Company they do not have one and it is currently difficult to employ them. He said he is aware that the physical therapy assistant requires some level of supervision, he is not sure if the current supervision is adequate without having a physical therapist in the building on a regular basis. He said he will have to increase his oversight of the rehab department. In addition, he said the facility does not have a telehealth policy, they rely on the contracted rehab company's telehealth policy, which he is aware they are documenting the resident's consent to telehealth visits or the other requirements for telehealth. During a telephonic interview on 7/5/23 at 1:50 P.M., Massachusetts Board of Health Staff Member #1 said, there are no current waivers in place and Physical therapists must follow the outlined requirements listed in rules titled 259 CMR section 5.00 to provide onsite visits and oversight of physical therapy assistant. 2A. Review of Resident #91's Physical Therapy notes indicated the evaluation was completed by a physical therapist on 1/4/23, a physical therapy assistant progress note completed by Rehab Staff #1 on 3/24/23, and discharge summary completed by Rehab Staff #2, a physical therapist (PT) on 6/16/23. There were no PT progress/updated plan of care notes completed from 1/4/23 to 6/16/23 when the discharge summary was completed via telehealth. During an interview on 7/03/23 at 8:56 A.M., the Rehab Director reviewed Resident #91's physical therapy notes and said it appears the Resident did see a physical therapist since the start of care 1/4/23. She said the discharge summary was done by Rehab Staff #2 via telehealth but she can't confirm the resident was actually seen by telehealth or that the therapist just did the discharge summary looking at the PTA's notes; there is no documentation. Review of the Daily Interaction Form (timesheet), dated 6/16/23, indicated Rehab Staff #2 billed the facility for 120 minutes for documentation, and there was no resident billing for evaluation or resident time. During an interview on 7/5/23 at 11:56 A.M., Rehab Staff #2 said she can't recall if she did a telehealth heath visit with Resident #91 on 6/16/23 or she just did it by notes and talking to Rehab Staff #1. B. Review of Resident #17's physical therapy notes indicated the physical therapy evaluation was completed on 5/3/23, an updated plan of care was dated 5/31/23, but completed 7/3/23 by Rehab Staff #2. A second updated Plan of Care was dated 6/28/23, and it was also signed by Rehab Staff #2 on 7/3/23. During a telephonic interview on 7/5/23 at 11:56 A.M., Rehab Staff #2 said she completed Resident #17's two Updated Plan of Care assessments by reviewing Rehab Staff #21's notes and did not see the Resident #17 onsite or via telehealth. C. Review of Resident #117's physical therapy notes indicated the physical therapy evaluation was completed on 12/20/22, updated care plan was dated 1/17/23, additional plans of care updates were dated 2/14/23, 3/14/23, 4/11/23, and 5/9/23, all of which were completed by Rehab Staff #2 and all dated completed on 7/3/23. During an interview on 7/5/23 at 4:00 P.M., Rehab Staff #2 said she completed documentation for a few updated plans of care on 7/3/23 but she couldn't remember the resident's name. She said they were completed via chart review and she did not see the resident. During a telephonic interview on 7/5/23 at 4:14 P.M., the [NAME] President for the Contracted Rehab company said, after reviewing Resident #91, #17 and #117's physical therapy notes, the residents were not seen onsite for updated physical therapy assessments over their course of physical therapy. In addition, she said she can't confirm Resident #91's discharge summary was completed via telehealth because it wasn't documented, and Resident #17 and #117's plan of care assessments should have been completed monthly and not have all been completed on 7/3/23. She said she had no explanation for how those completed plan of care assessments could have all been completed on 7/3/23, especially if they were supposed to be done via telehealth. 3. Review of the facility's policies titled Accidents and Incidents-Investigating and Reporting, last revised 11/2017, and Assessing Falls and Their Causes, last revised 11/2018, included but was not limited to: -All accidents and incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator -The following data, as applicable, shall be included on the Report of Incident/Accident form: a. The date and time the accident or incident took place; b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.); c. The circumstances surrounding the accident or incident; d. Where the accident or incident took place; e. The name(s) of witnesses and their accounts of the accident or incident; f. The injured person's account of the accident or incident; g. The time the injured person's Attending Physician was notified, as well as the time the physician responded and his or her instructions; h. The date/time the injured person's family was notified and by whom; i. The condition of the injured person, including his/her vital signs; j. The disposition of the injured (i.e., transferred to the hospital, put to bed, sent home, returned to work, etc.); k. Any corrective action taken; l. Follow-up information; m. Other pertinent data as necessary or required; and n. The signature and title of the person completing the report. After a fall: - If a resident has just fallen, or is found on the floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injuries to the head, neck, spine, and extremities. - Nursing staff will notify the resident's Attending Physician and family in an appropriate time frame. When a fall results in a significant injury or condition change, nursing staff will notify the practitioner immediately by phone. When a fall does not result in significant injury or a condition change, nursing staff will notify the practitioner routinely (i.e., by fax or by phone the next office day). -After an observed or probable fall, the staff will clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred. -Within 24 hours of a fall, the nursing staff will begin to try to identify possible or likely causes of the incident. They will refer to resident-specific evidence including medical history, known functional impairments, etc. Resident #107 was admitted to the facility in March 2021 with diagnoses which included Huntington's disease (progressive neurological disease). Review of the MDS assessment, dated 6/10/23, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating the Resident was cognitively intact. On 6/29/23 at 2:25 P.M., the surveyor observed Resident #107 sitting in the day room on M2 Unit in his/her wheelchair, with no socks on and the right great toe was swollen and red with an open abrasion. During an interview on 06/29/23 at 02:30 P.M., Counselor #1 said Resident #107 had a fall the other day and did not tell anyone right away. She said the toe does not look good. During an interview on 6/29/23 at 5:30 P.M., Nurse #7 said Resident #107 self-reported the fall to the nurses yesterday. Nurse #7 said reviewing Resident's medical record, there is no nursing documentation about the fall, no incident report, no pain assessment, or skin assessment. Nurse #7 said Nurses #10 and #11 did write in the nurse's note that Resident #107 reported the right great toe was painful, red and swollen, but nothing about the fall. Nurse #7 said if a resident has a fall, the falls policy is you notify the doctor, start an incident report, do skin and pain assessments, perform neuro checks if they hit their head or it is unwitnessed, and you write nurse's notes to monitor the resident. During an interview on 6/29/23 at 5:45 P.M., the Rehabilitation Manager said she was aware of Resident #107's fall and she wrote a witness statement after the Resident informed her of the fall and the injury yesterday. She recommended the Resident use the wheelchair, so he/she does not walk on the right foot until the doctor looked at it. Review of a witness statement, dated 6/28/23 with time recorded of 2:35 P.M., and signed by the Rehab Director, indicated the following: - I received a call from Social Worker #2 asking for a wheelchair for Resident #107. -Resident #107 informed the Rehab Director he/she had hurt his/her foot. The right foot was bruised in multiple places, primarily on the big toe and the second toe. There was also a bruise in the top middle of the foot and the foot appeared swollen and discolored. -Resident #107 stated he/she had fallen the prior day around 10:30 A.M., in the activity room and did not tell anyone. -Rehab Director informed Nurse #11 and sent a message to the Director of Nursing to see Resident #107 immediately. During an interview with Resident #107 (with the Rehab Director present) on 6/29/23 at 6:00 P.M., Resident #107 said he/she fell really hard in the day room on Tuesday (6/26/23), and he/she didn't tell anyone until his/her toe started to swell. Resident #107 said he/she told Nurses #10 and #11, and they cleaned and bandaged his/her right big toe. Resident #107 said the toe really hurts bad now and he/she can't sleep at night. Resident #107 said he/she thinks it is broken; it hurts really bad. Review of the Nurses' Notes, dated 6/22/23 through 6/28/23, indicated the following: -On 6/28/23 at 4:15 P.M, Resident reported that his/her right foot was red and swollen and the big toe had a scrape and some serious drainage. The physician was notified and new orders to apply to the red swollen right foot/ toe abrasion normal saline wash, bacitracin and protective dressing, change daily. The physician will be in to see the resident tomorrow. -On 6/28/23 at 10:35 P.M., Resident complained of pain in the right great toe. Area inflamed and reddened Cleanse with normal saline, bacitracin ointment applied followed by a protective dressing. Tylenol was given for pain with some relief. The Resident was encouraged to stay off the foot and keep it elevated as much as possible. The Resident used a wheelchair to mobilize. Will continue to monitor. Further review of Resident #107's medical record indicated there was no further documentation of the fall, skin or pain assessments, incident report, or neurological checks. During an interview on 6/29/23 at 6:10 P.M., the Director of Nurses (DON) said she was aware Resident #107's fall, and she was concerned the toe was red and inflamed. The surveyor informed the DON there was no documentation about the fall in the medical record. The DON said she had started an investigation into the fall. The surveyor requested a copy of the investigation. During an interview on 6/29/23 at 6:25 P.M., the DON said there was no incident report completed, which would have triggered the falls investigation. She said the only documentation she could find was the Rehab Director's statement about the fall. She said the nurses were supposed to put statements in her box and they did not.

Based on interview and record review, the facility failed to ensure residents received proper treatment and assistive devices to maintain vision for one Resident (#62), out of a total sample of 29 residents. Specifically, the facility failed to ensure Resident #61's eye examination recommendations, to be seen and evaluated by a glaucoma specialist, were implemented. Findings include: Resident #62 was admitted to the facility in November 2016 with diagnoses which included diabetes and stroke with right-sided paralysis. Review of the Minimum Data Set (MDS) assessment, dated 4/15/23, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating the Resident was cognitively intact. In addition, section B1200 indicated the Resident wears corrective lenses. During an interview on 6/29/23 at 5:15 P.M., Resident #62 said he/she has been seen by the eye doctor and is supposed to see an eye specialist for the right eye evaluation of his/her cataract and glaucoma and they have never made an appointment. The Resident said the same thing happened last year, the eye doctor recommended he/she see an eye specialist and the appointment was never made. Review of the consultant Eye Care Group evaluation, dated 6/15/22, indicated but was not limited to the following: -Diabetes type 2, without complications -Glaucoma suspect, open angle with borderline findings, high risk; Both eyes -His/Her optic nerves look very suspicious of glaucoma; cupping has increased significantly from visit last year; I recommend seeing a glaucoma specialist for further evaluation and management -Cataract, nuclear; Both eyes Plan: -Consult with glaucoma specialist -Ophthalmology consult Review of the consultant Eye Care Group evaluation, dated 12/1/22, indicated but was not limited to the following: -Glaucoma suspect, open angle with borderline findings, high risk; Both eyes Plan: -Recommend consult with glaucoma specialist -Please schedule an appointment with a glaucoma specialist -Continue with same glasses Review of the consultant Eye Care Group evaluation, dated 6/9/23, indicated but was not limited to the following: -Glaucoma suspect, open angle with borderline findings, high risk; Both eyes -Diabetes type 2, without complications; No retinopathy -Cataract, nuclear; Stable; Both eyes Plan: -Recommend consult with glaucoma specialist; Follow up in 4 to 5 months -Continue with same glasses Review of Resident #62's medical record from 6/15/22 to 6/29/23 did not include any physician orders or documentation in the social and/or nursing notes that Resident #62 was referred to or seen by a glaucoma specialist or had an ophthalmology consult. During an interview on 6/29/23 at 5:45 P.M., Nurse #7 reviewed Resident #62's Eye Care Group evaluations and said she reviewed the scheduled appointments and the nurses' notes and can't find any documentation the Resident was seen for further evaluation of the glaucoma or cataracts. Nurses #7 said if the eye doctor makes an outside referral to a specialist, the social worker would schedule the appointment with the outside specialist. Nurse #7 called Social Worker #2 and Social Worker #2 said over the phone, there was no record Resident #62 was referred to an outside specialist. During an interview on 6/30/23 at 10:33 A.M., the Director of Social Services said she does not know why Resident #62 was never scheduled to see an eye specialist for glaucoma and cataract follow-up. During an interview on 6/30/23 at 12:46 P.M., Social Worker #1 said she was made aware last night Resident #62 had multiple recommendations to see an eye doctor for further evaluation of glaucoma and cataracts. She said she was unable to find any further documentation the referral was made.

Based on observations, record review, interviews, and policy review, the facility failed for one Resident (#51), out of a total sample of 29 residents, to ensure effective interventions were implemented to prevent three unwitnessed falls. Findings include: Review of the facility's policies titled Accidents and Incidents-Investigating and Reporting, last revised 11/2017, and Assessing Falls and Their Causes, last revised 11/2018, included but was not limited to: -The following data, as applicable, shall be included on the Report of Incident/Accident form: k. Any corrective action taken; l. Follow-up information; m. Other pertinent data as necessary or required; After a fall: -Within 24 hours of a fall, the nursing staff will begin to try to identify possible or likely causes of the incident. They will refer to resident-specific evidence including medical history, known functional impairments, etc. Resident #51 was admitted to the facility in April 2021 with diagnoses including Huntington's disease (progressive neurological disease). Review of the Minimum Data Set (MDS) assessment, dated 5/25/23, indicated Resident #51 had impairment in both short and long-term memory, had severely impaired cognitive skills for daily decision making, and dependent on staff for all activities of daily living. Review of the medical record and fall incident reports indicated Resident #51 had three unwitnessed falls as follows: -12/5/22: Resident found lying on his/her right side on the floor in the dining room at 10:15 A.M. No witnesses found; no injuries were noted. Immediate intervention identified was refer to rehab to evaluate and treat as indicated. Further review of the medical record indicated a referral/screen to rehab services form. The Occupational Therapist (OT) documented Resident #51 was at base line for activities of daily living and functional mobility. The Resident's wheelchair is in good condition. Resident gradually slid out of the wheelchair and due to lack of staff to reposition him/her, the Resident experienced a fall. Review of the interdisciplinary care plan for high risk of falls indicated a referral to rehab for wheelchair evaluation on 12/5/22. However, no interventions were developed to prevent further falls out of the wheelchair. -12/29/22: Resident found on the floor on his/her left side in activity/dining area at 10:04 A.M.; slid out of wheelchair; no witnesses found; no injuries observed post incident. Refer to rehab for wedge in the wheelchair or seat belt for preventative/positioning measures. The Director of Nurses and the Physician were notified. Review of the interdisciplinary care plan for high risk of falls failed to indicate a referral was made to rehab or any other intervention was developed to prevent further falls. Further review of the medical record failed to indicate a rehab referral was made for a wedge in the wheelchair or seat belt for preventative/positioning measures. -2/17/23: At 10:00 A.M., staff reported Resident #51 was found on his/her belly on the floor of the activity room next to his/her wheelchair. No witnesses found; no injuries observed at the time of the incident. Administrator, Physician and Responsible party were notified. Intervention: new order to re-evaluate resident for a wheelchair clip belt. Review of the interdisciplinary care plan for high risk of falls failed to indicate a referral was made to rehab or any other intervention was developed to prevent further falls. Further review of the medical record failed to indicate a rehab referral was made for a re-evaluation for a wheelchair clip belt. During an interview with the Occupational Therapist and Rehab Director on 7/3/23 at 3:00 P.M., the Rehab Director said for several months, and up until recently, staff would either not make referrals or would say it verbally to rehab staff in passing and a referral for an evaluation would never happen. The OT said they were not made aware of any referrals for rehab for Resident #51's falls out of the wheelchair on 12/29/22 and 2/17/23. She said nursing did not make a referral until 5/24/23 due to the Resident sliding/falling out of his/her wheelchair. The OT said a pelvic restraint was trialed in May 2023 and a physician's order was put into place on 6/9/23. The OT and Rehab Director said they did not know when the previous pelvic restraint was discontinued, but had they received referrals earlier, they could have initiated interventions to prevent Resident #51's falls out of his/her wheelchair.

Based on record review, policy review, and interviews, the facility failed to ensure the consultant pharmacist identified and reported irregularities (use of a medication that is inconsistent with accepted standards of practice) and/or recommendations were addressed by the physician or physician extender for three Residents (#13, #37, and #70), out of a total sample of 29 residents. Specifically, the facility failed to: 1. For Resident #13, ensure the consultant pharmacist's recommendations were addressed to ensure there was a stop date for an as needed (prn) Klonopin (anticonvulsant used as adjunct therapy for psychosis) as required, and an appropriate indication for antipsychotic therapy was identified on the physician's order; 2. For Resident #37, ensure the consultant pharmacist identified and reported an irregularity regarding inappropriate diagnoses to justify the use of antipsychotic medication; and 3. For Resident #70, ensure the consultant pharmacist's recommendations to change an order for analgesic medication to avoid exceeding the maximum recommended daily dose were reviewed and addressed by the Resident's physician/physician extender. Findings include: Review of the facility's policy titled Pharmscript-Medication Regimen Review, dated 8/2020, included but was not limited to: Policy: -The consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. The medication regimen review (MRR) includes evaluation of the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy. Procedures: -If a consultation is needed when the pharmacist is off-site, the consultant pharmacist works with facility personnel and electronic records to gather pertinent information related to the resident's status and/or request for consultation. -In performing medication regimen reviews, the consultant pharmacist incorporates federally mandated standards of care in addition to other applicable professional standards, such as the American Society of Consultant Pharmacist (ASCP) Practice Standards, and clinical standards such as the Agency for Healthcare Research and Quality (AHRQ) Clinical Practice Guidelines and American Medical Directors Association (AMDA) Clinical Practice Guidelines. -The consultant pharmacist identifies irregularities through a variety of sources including the resident's clinical record, pharmacy records, and other applicable documents. -Resident-specific irregularities and/or clinically significant risks resulting from or associated with medication are documented in the resident's active record and reported to the Director of Nursing (DON), Medical Director, and/or prescriber as appropriate. -Recommendations are acted upon and documented by the facility staff and/or prescriber. 1. Resident #13 was admitted to the facility in September 2022 with diagnoses including delusional disorder. Review of the medical record indicated the consultant pharmacist made recommendations regarding Resident #13's medication regime every month from February 2023 through June 2023. Further review of the medical record failed to indicate the recommendations were in the record. On 6/30/23 at 1:00 P.M., the Director of Nursing (DON) said the consultant pharmacist sends recommendations to her email and they are not in the medical record. She printed out pharmacy recommendations and provided them to the survey team for review. Review of the Consultant Pharmacist's recommendations for Resident #13 indicated recommendations to prescriber as follows: -2/26/23: Resident's Seroquel dose was recently increased. When this was increased, the indication for the order was changed to for anxiety. Anxiety is not an appropriate indication for antipsychotic therapy. Please update and clarify correct indication for use. -3/15/23: Resident is currently ordered Clonazepam 1 milligram (mg) every 24 hours as needed for anxiety. Prn orders for psychotropic medications are limited to 14 days. If the prescribing practitioner believes it is appropriate for the prn order to be extended beyond 14 days, they must document their rationale in the resident's medical record and indicate the duration of the prn order and give order a specific stop date. Please review this prn order and consider discontinuing if appropriate or document continued need for therapy and specify stop date. -4/11/23: Resident is currently ordered Clonazepam 1 mg every 24 hours as needed for anxiety. prn orders for psychotropic medications are limited to 14 days. Please review this prn order and consider discontinuing if appropriate or document continued need for therapy and specify stop date. Reissued recommendation-order is still open ended. -5/12/23: Resident is currently ordered Clonazepam 1 mg every 24 hours as needed for anxiety. prn orders for psychotropic medications are limited to 14 days. Please review this prn order and consider discontinuing if appropriate or document continued need for therapy and specify stop date. Reissued recommendation-order is still open ended. -6/23/23: Resident is currently ordered Clonazepam 1 mg every 24 hours as needed for anxiety. prn orders for psychotropic medications are limited to 14 days. Please review this prn order and consider discontinuing if appropriate or document continued need for therapy and specify stop date. Reissued recommendation-order is still open ended. Review of June 2023 Physician's Orders included but was not limited to: -Seroquel 200 mg, give half a tablet two times a day related to personal history of traumatic brain injury (4/28/23) -Seroquel 400 mg at bedtime for anxiety (1/23/23) -Klonopin (Clonazepam) 1 milligram (mg) every 24 hrs prn for anxiety (2/13/23) indefinite Further review of the medical record failed to indicate the physician/physician extender addressed the consultant pharmacist's recommendations. 2. Resident #37 was admitted to the facility in November 2022 with diagnoses including anxiety, major depressive disorder, and dementia with behavioral disturbance. Review of June 2023 Physician's Orders included but was not limited to: -Seroquel 25 mg in the afternoon for mood (11/1/22) -Seroquel 50 mg at bedtime for anxiety (11/28/22) Review of monthly consultant pharmacy medication reviews from February 2023 through June 2023 failed to indicate the consultant pharmacist identified the irregularity regarding inappropriate diagnoses to justify the use of antipsychotic medication. 3. Resident #70 was admitted to the facility in November 2022 with diagnoses including anxiety, depression, and psychotic disorder. Review of June 2023 Physician's Orders included, but was not limited to: -Acetaminophen 325 mg, give 2 tablets three times a day for pain (1/13/23) -Acetaminophen 650 mg every 6 hours as needed for elevated temperature, not to exceed 3 grams (gm) in 24 hours (11/28/22) -Acetaminophen 650 mg every 6 hours as needed for pain, not to exceed 3 mg in 24 hours (11/28/22) Review of consultant pharmacist recommendations for Resident #70 indicated recommendations to prescriber as follows: -Resident is receiving a total of 1950 mg scheduled Acetaminophen with prn ordered as well-650 mg every 6 hours prn pain or elevated temperature. Please consider the following adjustment in prn order to avoid exceeding the maximum recommended daily dose of 3000 mg/24 hours: 1. Discontinue Acetaminophen 650 mg every 6 hours prn pain or elevated temperature 2. Acetaminophen 650 mg one daily prn pain or elevated temperature. May give within 4 hours of routine dose. If no change is indicated please note medical necessity of current orders in progress note and potential risk versus therapeutic benefit in progress note. Further review of the medical record failed to indicate the physician/physician extender addressed the consultant pharmacist's recommendations. During an interview on 6/29/23 at 1:45 P.M., the surveyor and Nurse #5 reviewed the pharmacy recommendations. She said pharmacy recommendations for Residents #13, #37 and #70 should have been addressed by the physician, and she would have expected the pharmacist to identify appropriate diagnoses to justify the use of the antipsychotic medication. The nurse said the pharmacy sends their recommendations directly to the Director of Nursing and are supposed to be provided to the unit manager at morning meeting, but there has not been a unit manager in several months and the recommendations never made it to the unit or the medical record for physician review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility: 1. Failed to ensure 1 of 4 kitchenettes was maintained in a sanitary manner to prevent potential illness or contamination of food; and 2. Failed to ensure the snack cart on the M2 Unit was maintained in a sanitary manner to prevent potential illness or contamination of food while serving snacks to residents. Findings include: Review of the 2013 Food Code, a model for safeguarding public health and ensuring food is safe for consumption, for Massachusetts indicated: 6-501.111 Controlling Pests: Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. 4-903.11 Storing Equipment, Utensils, Linens, and Single-Service and Single-Use Articles: Clean equipment and multiuse utensils which have been cleaned and sanitized, laundered linens, and single-service and single-use articles can become contaminated before their intended use in a variety of ways such as through water leakage, pest infestation, or other insanitary condition. 1. On 1/28/23 at 10:40 A.M., the surveyor observed the resident kitchenette on the M2 Unit and made the following observations: -The upper corner cabinet (with the Lazy [NAME]) when opened had live cockroaches, the upper tray of the Lazy [NAME] was stained with a dark liquid, the entire surface area was dirty, had food particles, and trash. The lower tray, the entire surface area was dirty, had food particles, trash and two open sleeves of lids were stored on the dirty shelf. The cabinet shelf under the Lazy [NAME] was dirty, had food particles, trash, and in the back corner had small packets of graham crackers, peanut butter crackers, and an open packet of sugar. - The upper cabinet top shelf was dirty and when the box of tea bags was removed, there was a live cockroach stuck to the bottom of the box. The middle cabinet shelf was stained with dried liquid stains, food particles, trash including plastic cups, tea bags, dirty packets of sugar and straws stuck to the surface. There was a white cardboard box of snacks for the residents containing peanut butter cookies, Ritz bits, and graham crackers. While in the kitchen an unidentified Certified Nursing Assistant (CNA) came in with a plastic bin of additional crackers and cookies and placed the bin on the middle dirty shelf. The bottom shelf had crumbs of food throughout the cabinet and in the back of the cabinet there were two dead cockroaches. The plastic container of T-stick thermometers was visibly dirty. -The drawers and the cabinet were dirty with food particles and sticky to touch in various places. The bottom drawer had an open sleeve of plastic cup tops loosely stored on the bottom shelf. Under the bottom drawer were numerous dead cockroaches, trash, and food particles. -Under the sink cabinet, the back half of the cabinet floor was covered with a black substance. Stored on top of the black substance was a coffee machine and a toaster. During an interview on 6/28/23 at 2:56 P.M., the Regional Food Service Manager (RFSM) said the kitchenette cabinets were not clean. She said she does not know what the black stuff is under the sink but she will have it taken care of. There should not be anything stored under the sink. 2. On 6/27/23 at 2:49 P.M., the surveyor observed CNA #4 with a gray cart which had a plastic bin of cookies, one bottle of ginger ale, and one yogurt. The surveyor observed the top of the cart to be dirty with dried liquid stains, the second shelf had mice droppings, and the third shelf had mice droppings, including on top and inside the white box of disposable gloves. During an interview on 6/27/23 at 2:50 P.M., Certified Nursing Assistant (CNA) #4 said she got the cart out of the Pub Room and was serving snacks to the residents in their rooms. She said she did not clean the cart before using it and she did not notice the mouse droppings on the second and third shelves or in the box of gloves. During an interview on 6/28/23 at 2:56 P.M., the RFSM reviewed the picture of the gray cart CNA #4 was using to serve snacks and said she should not have served snacks off the cart; the cart was not clean and it was not a cart from the kitchen which the kitchen would have cleaned before using.

Based on record review and interview, the facility failed to ensure the arbitration agreement presented to residents in the admission packet included the required information for two Residents (#31 and #96), out of a sample of three records reviewed. Findings include: Review of the facility's admission packet, Attachment M Arbitration Agreement, dated 9/2017, did not contain the following required information: 1. The agreement must explicitly grant the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it. 2. The agreement must explicitly state that neither the resident nor his or her representative is required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility. Review of the facility's admission folder for three sampled residents indicated the arbitration agreement they signed did not have the required information (listed above) as follows: -Resident #31 signed the arbitration agreement on 11/4/20. -Resident #60 signed the arbitration agreement on 4/3/23. -For Resident #96, the facility could not find his/her admission folder. During an interview on 6/29/23 at 9:40 A.M., the Administrator reviewed the admission packet Arbitration agreement with the surveyor and said it does not contain all the required information.

Based on observation and interview, the facility failed to establish and maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections in the facility. Specifically, the facility failed to ensure that laundry room personnel performed hand hygiene after handling soiled linens and wore appropriate personal protective equipment when handling soiled linens. Findings include: According to the Centers for Disease Control and Prevention (CDC), Appendix D, Best Practices for Personal Protective Equipment (PPE) for Laundry Staff: -Practice hand hygiene before application and after removal of PPE. -Wear tear-resistant reusable rubber gloves when handling and laundering soiled linens. On 6/30/23 at 11:00 A.M., the surveyor observed Employee #2 in the laundry room wearing thick, black, reusable gloves, a reusable gown, and a face mask, loading linen soiled with feces into the middle washing machine. After loading the soiled linen into the machine, Employee #2 was observed pushing the soiled laundry bin toward the soiled laundry holding room but stopped at an area where the soiled laundry gets sorted. Employee #2 then removed the thick, black, reusable gloves, exposing a pair of disposable gloves underneath. Employee #2 placed the soiled black gloves on top of another laundry bin that was covered with a sheet. Employee #2 then walked back to the sink, removed the disposable gloves, and washed her hands. Employee #2 walked back to the washing machine and noticed a piece of laundry sticking out of the washing machine. With ungloved hands, she tucked the piece of soiled laundry into the washing machine, shut the door, and started the machine. Employee #2 went back to the dirty laundry cart, and with ungloved hands, grasped the rim of the dirty laundry bin with both hands and pushed it into the soiled laundry holding area. Employee #2 came out of the room, walked over to clean laundry, and without cleansing her hands, started to fold the clean laundry. During an interview on 6/30/23 at 11:05 A.M., the laundry supervisor, who was present at the time, said that Employee #2 contaminated her hands and the clean laundry by failing to properly sanitize her hands, and by not using gloves when touching soiled items (soiled laundry bin). During an interview on 7/3/23 at 6:30 P.M., the Director of Nurses (DON) said that Employee #2 failed to follow accepted infection control practices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain an effective pest control program on one (M2 Unit) of four units reviewed. Findings include: During an interview on 6/27/23 at 11:19 A.M., Resident #31 said there is still a pest control problem with cockroaches in the kitchenette and mice running around at night. He/she said you can even hear them in the ceilings at night. The surveyor observed mice droppings behind the dressers, along the walls and in the closet behind the piles of plastic bags. In the bathroom, the surveyor observed a hole at the base of the door jamb stuffed with paper towels. Resident #31 said his/her roommate stuffs the mouse holes with paper towels to try to stop the mice from coming into their room. Review of the Pest Control provider's logbook for the M2 Unit indicated continued pest sightings including cockroaches and mice on the following dates: -undated sheet of paper indicated night shift Monday-Wednesday-Friday, M 2 kitchen and nurses' station, mice sightings in rooms [ROOM NUMBER]. -3/28/23, mice sightings in room [ROOM NUMBER] and at the nursing station. -3/29/23, mice sightings, four to five mice running from bedroom to nursing station. -4/4/23, mice sighting at the nursing station and room [ROOM NUMBER]. -4/8/23, mice sightings at the nurses' station, dead mouse found in the medication room. -4/9/23, mouse sighted in room [ROOM NUMBER]. -4/9/23, three mice found at the nurses' station. -4/9/23, roaches found in the nutrition room/snack room. -4/13/23, roaches found crawling in room [ROOM NUMBER]. -4/13/23, roaches in room [ROOM NUMBER]. -4/14/23, roaches in the kitchenette. -4/14/23, mouse in room [ROOM NUMBER] by the A bed. -4/22/23, mice in room [ROOM NUMBER] and the kitchenette. -4/23/23, roaches found in room [ROOM NUMBER] and mice in rooms 236, 239, and at the nurses' station. -4/27/23, mice in room [ROOM NUMBER] closet. -4/29/23, mouse in the kitchenette. -5/7/23, mouse in room [ROOM NUMBER] and roaches in the kitchenette -5/20/23, mice in room [ROOM NUMBER] and roaches in the kitchen -5/2423, mice all over the night shift and the Med room, including rooms 236, 239, 237, 234, 233, 232, 231, 230. -5/26/23, a lot of mice where they eat dinner, room [ROOM NUMBER] mice and cockroaches, and mice in rooms 226, 227, 229, 231, and parlor pub room mice. 6/4/23, mice in rooms 223, 235, 237 6/6/23, mice and cockroaches in room [ROOM NUMBER], 224 and the kitchenette. There were no entries in the logbook after 6/6/23. On 6/27/23 at 11:15 A.M., the Surveyor toured M2 Unit and made the following observations: room [ROOM NUMBER]- The adjoining bathroom door jamb bottom had rusted out leaving a 2-inch gap, which was stuffed with insulation to partially block the hole that was created. There was evidence of mice droppings along the wall and behind the dressers. room [ROOM NUMBER]- There was evidence of mice droppings in the closet and the back of the dresser, and underneath the first bed, both at the head of the bed and the foot of the bed. room [ROOM NUMBER]- When the surveyor opened the door to the room, a large cockroach fell from the door jamb landing on the surveyor. room [ROOM NUMBER]- Behind the door there was a visible mouse hole. Room labeled dining room (but used for activities), the floor was visibly dirty with food particles and there was evidence of mice droppings in two of the four corners of the room. On 6/27/23 at 2:46 P.M., the surveyor observed the The Pub (room which is also used by Activities). The back left corner of the room had a large hole, partially filled with foam that the mice chewed through. In the room there was a large number of mice droppings along the walls and in the activity room supply closet. On 6/27/23 at 2:49 P.M., the surveyor observed Certified Nursing Assistant (CNA) #4 with a gray cart which had a plastic bin of cookies, one bottle of ginger ale, and one yogurt. The surveyor observed the top of the cart to be dirty and have dried liquid stains, the second shelf had mice droppings and the third shelf had mice droppings, including on top and inside the white box of disposable gloves. During an interview on 6/27/23 at 2:50 P.M., CNA #4 said she got the cart out of the pub room and was serving snacks to the residents in their rooms. She said she did not clean the cart before using it and she did not notice the mouse droppings on the second and third shelves or in the box of gloves. On 6/27/23 at 2:53 P.M., in the room next to the Pub Room (contained electronics and a staff desk), the surveyor observed, under the desk and around the filing cabinets, evidence of large amounts of mice droppings, dirt, and debris. There was a mouse hole behind the door. On 6/27/23 at 3:00 P.M., in the tub room by the nursing station, the surveyor observed that the green tub had mice droppings inside the tub. On 6/28/23 at 9:40 A.M., the surveyor observed room [ROOM NUMBER] which had mice droppings behind the toilet, a live cockroach in the bathroom, and a large number of mice droppings behind the trash can and behind the dresser, some mice droppings along the wall, and under the radiator. During an observation and interview on 6/28/23 at 2:56 P.M., the surveyor, with the Regional Food Service Manager (RFSM) present, observed live cockroaches when opening the kitchenette cabinet with the Lazy [NAME] and a live cockroach stuck to the bottom of a box of tea bags. The RFSM said the kitchenette cabinets were not clean. The RFSM said she was aware of the rodent infestation in the building, and it is a lot better than it was, but she was under the impression it was doing better than this. During an interview on 6/28/23 at 4:40 P.M., the Director of Housekeeping said she does daily audits, and most days she does not see any mice droppings, occasionally she sees a small cluster, but mostly none. She said she deep cleans all the kitchenettes twice a day, which includes the floors, counters, and outside of the cabinets. She said she is not responsible for cleaning inside the cabinets, the kitchen staff is. On 6/28/23 at 4:42 P.M., the surveyor, the [NAME] President (VP) of Engineering and VP of Operations went to tour the M2 Unit and viewed rooms #223 and #227, the Pub Room, the room next to the Pub Room (computers and staff desk), and the Dining room (activity room) and observed mice droppings and mouse holes in the walls. In addition, pictures (taken by the surveyor) were reviewed of the unsanitary kitchenette with evidence of cockroaches, additional mouse droppings and mouse holes in resident rooms on the M2 Unit. While in the Pub Room, they observed the gray cart which had new mice droppings on the bottom shelf. The surveyor made the VPs aware that she had observed CNA #4 clean the cart on 6/27/23. During an interview on 6/28/23 at 4:45 P.M., both the VP of Engineering and VP of Operations said they have pest control three times a week and are working hard to control the pests, but they can see there are still problems with sanitation, mice droppings, and mice holes. During an interview on 6/29/23 at 12:29 P.M., the Maintenance Director said the M2 Unit just opened in October 2022, all brand new after the flood. He said he has plugged some holes on the unit, since it opened, but he was not aware of any additional mice holes until he was told yesterday. During the survey, the surveyor's attempts to meet with/interview the pest control provider were unsuccessful.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure nursing staff provided care and services that met professional standards of practice, when upon readmission to the facility, Resident #1's medications were not reconciled according to the Facility Policy and three medications were administered at doses that were not consistent with his/her Physician's Orders. Findings include: Review of the Facility Policy titled Reconciliation of Medications on Admission, dated as last revised 4/2018, indicated the purpose is to ensure medication safety by accurately accounting for the resident's medication, routes and dosages upon admission and readmission. Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of medications that includes the drug name, dosage, frequency, route, and indication for use. Medication reconciliation reduces medication errors and enhance resident safety. The Policy indicated to gather information needed to reconcile the medications list; -approved medication reconciliation form; -discharge summary form from the referring facility; -admission/readmission order sheet; -all prescription and supplement information from the resident/family during the medication history; and -most recent medication administration record (MAR), if this is a readmission. Resident #1 was admitted to the Facility in November 2021, diagnoses included left sided hemiparesis (weakness or paralysis to one side of the body) secondary to an old cerebral vascular accident (stroke), chronic obstructive pulmonary disease, vascular dementia, bulimia nervosa (eating disorder) and anxiety. Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated the dosage of three of his/her medications were to be changed upon readmission; -Clonazepam (antianxiety used to treat panic disorders and seizures) 0.5 milligrams (mg) tablet, take one half tablet (0.25 mg) three times a day by mouth; -Divalproex (anti-seizure medication used to treat seizures and bipolar disorder) 125 mg Enteric Coated (EC) tablet, give two tablets (250 mg) by mouth two times a day; and -Olanzapine (antipsychotic medication used to treat schizophrenia and bipolar disorder) 5 mg, take 0.5 tablet (2.5 mg) by mouth two times a day. Review of Resident #1's Physician's Progress Note, dated 2/04/23, indicated his/her Divalproex dose was increased and his/her Clonazepam and Olanzapine doses were decreased due to over sedation. Review of Resident #1's Nursing Progress Note (written by Nurse #2), dated 2/04/23, indicated that Resident #1 was seen by his/her Physician with no new orders, continue current medications. However, review of Resident #1's Physicians Orders, dated for the month of February 2023, indicated he/she was being administered; -Clonazepam Tablet 0.5 mg, give one tablet by mouth three times a day for agitation and anxiety, dated as started 12/31/22; -Divalproex Tablet Delayed Release 125 mg, give by mouth two times a day for anxiety, dated as started 8/25/22; and -Olanzapine Tablet 5 mg, give one tablet by mouth two times a day for depressive episodes, dated as started 8/25/22. Review of Resident #1's Medical Record, indicated there was no documentation to support a Medication Reconciliation was completed upon his/her readmission to the Facility. During an interview on 2/28/23 at 11:30 A.M., Nurse #2 said she was Resident #1's nurse upon readmission from the Hospital, where he/she had been from 1/21/23 to 2/04/23. Nurse #2 said she did not complete a Medication Reconciliation Form. Nurse #2 said she handed the Physician Resident #1's Hospital Discharge Summary and said the Physician told her everything was all set and that there were no changes to his/her medications. During an interview on 2/16/23 at 4:15 P.M., the Assistant Director of Nurses (ADON) said she has nothing to do with the admission or readmission process. The ADON said medication reconciliation should be done with all admissions and/or readmissions. The ADON said the readmission process should be, that the nurses are looking at the resident's medication list from the hospital, any medications they were on at home, and if they were taking any medications before they left the building. The ADON said those medications are then reviewed with the Physician for verification. During an interview on 2/15/23 at 4:30 P.M., the Director of Nurses (DON) said there is currently no process in place to double check admission or readmission orders and said she was uncertain if nurses were using a medication reconciliation form. The DON said it is the Facility's expectation to have all medications and treatments verified by a Physician upon admission and/or readmission, and documented by the Nurse who completed it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed, interviews and observations for two of three sampled nursing units (M2 and B2) and one of three sampled residents (Resident #1), the Facility failed to ensure they provided all residents a safe, clean, comfortable, and homelike environment. When during the survey, there was signs of physical disrepair, rodent droppings, and bugs in resident rooms and common areas. Findings include: During a tour of the Facility conducted on 2/15/23 at approximately 11:00 A.M., the surveyor made the following observation in Resident #1's room which was located on the M2 unit: -mouse droppings in the draws (all 3 draws) tall dresser; -light switch in room was not working; -one of the two over the bed lights was not working; -used/soiled paper towels left on the floor in bathroom; and -multiple holes in walls throughout the room. Resident #1 was on a medical leave of absence at the time of the survey and was unable to be interviewed by the surveyor regarding any concerns he/she had related to the condition of his/her room. M2 Dietary Kitchen, observation at 11:07 A.M., included the following: -hair comb observed laying on the countertop; -there was a dead cockroach in the microwave; -another live cockroach was observed crawling on the counter. room [ROOM NUMBER], observation at 11:09 A.M., included the following; -there were no working lights; -window blinds were broken; -tiny fruit flies were seen in the room, on the walls, and on the bed sheets; -dark stained (urine like) sheets on bed that was closest to the window; -basin with resident belongings left on floor; and -clear trash bag with clothing sitting on floor. Observations made on Unit B2; room [ROOM NUMBER], bathroom, observations made at 11:27 A.M., included the following; -laminate flooring that had been installed over an old tile floor, had approximately one-half inch lifting up from old tile, creating safety hazard. B2 Shower Room observations made at 11:34 A.M., included the following; -wet dirty towel disposed of on the floor. During an interview on 2/15/23 at 3:21 P.M., the Social Worker (SW) said that the cleanliness of the building was not up to par and said she felt that Unit M2 was the worst of the units. The SW said that mice and bugs love sugar and that a number of residents hoard food in their rooms. During an interview on 2/15/23 at 2:50 P.M., Certified Nurse Aide #5 said the M2 unit has a number of behavioral residents and they often will hoard food, hide their dirty clothes, and that is when the bugs and mice come out. During an interview on 3/01/23 at 1:52 P.M., Nurse #3 said the cleanliness of the building was still not great. Nurse #3 said bugs and mice are a bad situation for the residents. During an interview on 2/28/23 ay 11:30 A.M., Nurse #2 said that she recently stepped on a mouse to kill it and says she tries not to step on cockroaches because their eggs may be carried everywhere. During an interview on 2/16/23 at 11:49 A.M., the Director of Housekeeping said if staff report any concerns to her department she will address them. The Director said that typically Housekeeping Department staff do not go into residents dresser draws to check them for bugs or rodent droppings. The Director said personal laundry should not be placed on the floor of a residents room. The Director said it is the responsibility of Housekeeping Staff to clean the kitchettes on each of the floors. During an interview on 2/15/23, the Administrator said they are working on both the pest and rodent issue and said he has contracted more time with the pest control companies. The Administrator said he realizes that there is still an issues with both. During an interview on 2/15/23 at 12:50 P.M., the Regional Director of Clinical Services said the bathroom floor in room [ROOM NUMBER] required immediate attention related to being a high safety risk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. For Resident #4, the facility failed to ensure that the appropriate legal documentation (a Roger's treatment plan) was obtained prior to administering an antipsychotic. In Massachusetts, if a person, who has been determined to be incapacitated by the court, is prescribed antipsychotic medications, the incapacitated person will need a guardian who has been granted [NAME] authority by the court. Resident #4 was admitted to the facility in September 2013 with a traumatic brain injury and had a guardian. A review of the medical record for Resident #4 indicated that the resident returned from the hospital in February, 2020. Review of the discharge summary indicated that the hospital initiated Seroquel (an antipsychotic) 25 milligrams (mg) at bedtime for psychosis. A review of the medication administration record indicated that Seroquel 25 mg was given from 2/3/20 through 2/12/20. For Resident #4, a review of the decree and order of appointment of guardian for an incapacitated person , dated 8/23/17, did not include authorization for treatment with an antipsychotic medication. During an interview on 2/18/20 at 9:00 A.M. the Director of Social Services said Resident #4 did have a court appointed guardian and had been receiving an antipsychotic since he/she was re-admitted from the hospital. She said Resident #4 had never previously been on an antipsychotic and she was not sure why he was on it. She said the facility had not obtained consent for the antipsychotic from the guardian and the guardianship had not been expanded to include treatment with an antipsychotic. 2. For Resident #78, the facility failed to ensure that the appropriate legal documentation (a Roger's treatment plan) was obtained prior to administering an antipsychotic. In Massachusetts, if a person, who has been determined to be incapacitated by the court, is prescribed antipsychotic medications, the incapacitated person will need a guardian who has been granted [NAME] authority by the court. Resident #78 was admitted to the facility in August 2019 with a diagnosis of an anoxic brain damage. A review of the medical record for Resident #78 indicated the Resident was under conservatorship of a person from the state of Connecticut. The court documentation, dated 2/13/19, indicated the conservator must obtain prior approval from the court to place the Resident in an institution for long term care. The medical record did not contain any additional legal documentation upon review on 2/13/20. During an interview on 2/14/20 at 10:46 A.M., the Director of Social Services said the expansion of guardianship to include authority to admit Resident #78 to the facility was not obtained prior to admission, as indicated in the court document. She said a hearing was held on 2/5/20 and at that time the Connecticut court had authorized the Resident to be admitted to the facility, over five months after the admission date. A review of the physician orders indicated an order for Seroquel (an antipsychotic) 50 milligrams (mg) three times per day. Further review indicated that on 9/11/19, Resident #78 was administered a one time dose of Haldol (an antipsychotic) 5 mg intramuscularly (IM). Additionally, on 11/15/19, Resident #78 was administered a one time dose of Zyprexa (an antipsychotic) 10 mg by mouth and Haldol 5 mg IM. During an interview on 2/14/20 at 10:46 A.M., the Director of Social Services said Resident #78 was admitted to the facility on an antipsychotic and because the guardianship/conservatorship person was from out of state, the facility did not have the Massachusetts required authority for treatment with an antipsychotic. She said the facility submitted paperwork to their attorney on 9/4/2019 and a hearing had not been scheduled as of this time. She said the facility had not submitted for the expansion to be reviewed on an emergency basis with the court and that Resident #78 had been receiving an antipsychotic since admission, over 5 months prior, without the court authorization. Based on record review and staff interview, the facility failed to ensure a Roger's Treatment Plan was obtained for two residents (#4, and #78) who were prescribed and administered an antipsychotic medication, from a total sample of 26 residents. Findings include:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure the resident representative, for one sampled Resident (#23), who was determined to lack the capacity to make health care decisions, had consented to treatments and care. The total sample was 26 residents. Findings include: For Resident #23, the physician had determined that the Resident lacked the capacity to make healthcare decisions. The facility had given the Resident informed consent forms to sign for the following medications antipsychotic, hypnotic, anticonvulsant. The Resident also signed for the pneumococcal vaccination. Resident #23 was admitted [DATE] with multiple diagnoses that included dementia and cerebrovascular accident. A review of the MDS (Minimum Data Set) annual assessment dated [DATE], indicated the Resident was assessed to have a Brief Interview of Mental Status (BIMS) score of 3. The score of 3 out of 15 indicates severe cognitive impairment. The medical record had an invoked Healthcare Proxy signed by the physician on 1/3/18. The physician determined Resident #23 did not have the capacity to make healthcare decisions and determined the duration of the incapacity to be permanent. Resident #23 signed informed consents for administration of an antipsychotic medication, Seroquel, on 9/6/19, for an anticonvulsant, Depakote, on 10/22/19, and for a hypnotic, Doxepin, on 10/22/19. Additionally, Resident #23 signed for the Pneumococcal vaccination on 10/22/19. The Resident had signed all these consents when the Resident had been determined unable to make healthcare decisions since 1/3/18. During interview on 2/11/20 at 1:05 P.M., the Director of Social Service said, What are we suppose to do, the Court system does not work that fast, so the Resident signs until the Guardianship is completed. The medical record noted that the a Guardianship had been started over a year ago. The new Guardianship was just approved 2/6/20 and handed to the surveyor for review. Social Worker #2 had no other information and both said that they do not know what to do when the Courts take so long to approve a Guardianship.

Based on Resident Council Minutes review and interview, the facility failed to ensure that each resident's right to privacy related to their behavioral health status was respected, and not documented in Resident Council Minutes, which are available for review by all residents and distributed to department heads throughout the facility. Findings include: Review of the August 2019 through January 2020 Resident Council Minutes indicated an attendance list of residents with a corresponding letter or number. Review of the September 2019 Resident Council Minutes indicated that residents referred to in the minutes were assigned a number on the last page of the minutes. Sampled Resident #10 had asked to be put on the shopping list. The response to the request was written as follows: Resident #A had significant behaviors while out in the community (the last time he/she went to Walmart). Will educate resident #A regarding expected behaviors in the community. Sampled Resident #10 was identified by name in the minutes. Review of the October 2019 Resident Council Minutes indicated that sampled Resident #130 asked if he/she could go to Bingo on the M 1 unit. The response to the request was written as follows: Resident #20 may attend Bingo if behaviorally stable. Resident #130 was identified by name in the minutes. During interview on 2/19/20 at 12:46 P.M. the Activity Director said that she coordinates the monthly Resident Council Meetings, and takes minutes to reflect what is discussed at the meetings. The minutes are then distributed to department heads and are available for all residents to read.

Based on policy review, employee record review, grievance form review, and staff interview, the facility failed to: 1. implement written policies and procedures for screening staff prior to orientation, and 2. failed to implement written policies and procedures for misappropriation of resident property for two residents (#128 and #130) of eight grievances reviewed. Findings include: Review of facility policies for Abuse: Screening (last revised 12/2017), Abuse: Prohibition (last revised 12/2017), Abuse: Identification and Reporting (last revised 12/2017), Abuse: Investigation and Reporting (last revised 6/2018), included the following: -The Facility Executive Director will be the Abuse Prevention Coordinator -The Nurse Aide Registry is checked prior to employment for all facility employees. -The person responsible for hiring will ensure that the request for the required criminal background check (CORI) has been submitted no later than the date of initial orientation. -Documentation on all above information will be maintained as part of the employment record. -Thorough investigation into the allegation of misappropriation of resident property by facility management and local law enforcement no later than 24 hours -Immediately report the alleged misappropriation to the Department of Public Health 1. Review of five employee files indicated that five of five employees did not have criminal background checks no later than the date of initial orientation as required. One of five employee files reviewed failed to indicate that the Nurse Aide Registry check was conducted prior to employment, as required. During interviews with the Staff Development Coordinator on 2/20/20 at 11:45 A.M. and 1:30 P.M., he said that the CORI and Nurse Aide Registry check information is kept in the employee file. He said he would look in the computer to see if he could find any documentation, and bring it to the survey team. As of the time of exit at 3:30 P.M., no further documentation was provided to the survey team. 2. Resident #128 was admitted to the facility in 11/2016 with diagnoses including history of a stroke with hemiparesis (slight weakness one on side of the body) and heart failure. Review of the most recent annual Minimum Data Set, with a reference date of 8/10/19, indicated that Resident #128 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15, and required extensive assistance from staff for all activities of daily living. Review of a 5/2/19 grievance form indicated that Resident #128 reported that a CNA (certified nursing assistant) took $7.00 that was kept in his/her undergarment when he/she was changing clothes. Further review of the grievance form failed to indicate that the allegation was reported to DPH, failed to indicate that the allegation was thoroughly investigated, that it was reported to the resident's responsible person, and that a written report of the findings were provided to the administrator and to other officials in accordance with state law within five working days of the occurrence. 3. Resident #130 was admitted to the facility in 9/2018 with diagnoses including paraplegia (paralysis of the legs and lower body), and traumatic brain injury. Review of the annual Minimum Data Set, with a reference date of 9/7/19, indicated that Resident #130 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15, and required supervision from staff for all activities of daily living. Review of a 4/30/19 grievance form indicated that Resident #130 reported that his/her Amazon gift card in the value of $30.00 was missing. Further review of the grievance form failed to indicate that the allegation was reported to DPH, failed to indicate that the allegation was thoroughly investigated, and that a written report of the findings were provided to the administrator and to other officials in accordance with state law within five working days of the occurrence. During interview with the Administrator on 2/19/20 at 10:01 A.M., she said that the allegations of misappropriation of Resident #128's money, and Resident #130's gift card were not thoroughly investigated, and not reported to the police and Department of Public Health as required.

Based on record review and staff interview, the facility failed to complete a comprehensive assessment, AIMS test, ( Abnormal Involuntary Movement Scale) for one sampled Resident (#280) in a total sample of 26 Residents. Findings include: For Resident #280, the facility failed to complete an initial comprehensive assessment to identify potentially irreversible movement disorders related to the administration of Zyprexa (an antipsychotic medication). Resident #280 was admitted to the facility in February, 2020, with diagnoses that include traumatic brain injury. Record review of the Resident's physician's orders dated 2/10/20 indicated that Resident #280 was receiving Zyprexa 10 mg daily. During interview on 2/13/20 at 2:15 P.M., the Assistant Director of Nursing (ADON) stated that the AIMS tests are completed on admission and then every 3 months. Further record review indicated that the facility failed to complete an initial AIMS ( Abnormal Involuntary Movement Scale ) test. The facility policy for the AIMS testing did not indicate a frequency of how often the AIMS are to be completed, however the Administrator also said that the frequency should be on admission and every 6 months there after. Although the frequency conveyed to the surveyor by the ADON and the Administrator was not the same (every 3 or every 6 months), they both said that it should have been completed on admission to establish the baseline. During interview on 2/13/20 at 2:15 P.M., LPN #3 said that the facility failed to completed the AIMS test on admission.

Based on record review and interview, the facility failed to develop a comprehensive, person centered base line care plan that at the minimum included healthcare information necessary to properly care for one Resident (#280) in a total sample of 26 residents. Findings include: For Resident #280 the facility failed to complete a baseline care plan that addressed the Resident's immediate care needs relating to a seizure disorder and antipsychotic/psychotropic drug use. Resident #280 was admitted to the facility in February 2020, with diagnoses that include traumatic brain injury, seizure disorder, and cerebral vascular accident with right hemiparesis (weakness or the inability to move on one side of the body). The admission MDS assessment had not yet been completed, however the admission Nursing Evaluation (V-10) was completed on 2/11/20. This form is an admission assessment which once completed will generate the base line care plan depending on the areas of concern. As a result of the areas checked, the 48 hour base line care plan was generated for the following care areas: -Trauma informed care -Falls -Staff dependency for meeting emotional, intellectual, physical and social needs R/T cognitive deficits -Cognition -Side rails -Communication -ADLS -Nutrition -Dental needs The Nursing Evaluation form addressed psychotropic and antipsychotic use, however the sections addressing these medications had not been filled out resulting in the 48 hour care plan not addressing psychotropic drug use. Also the Resident had a TBI with a diagnosis of seizure disorder which was also not addressed in the evaluation.

3. For Resident #62, the facility failed to develop an individualized comprehensive care plan to ensure the Resident received vision and hearing care needs. Review of the clinical record indicated Resident #62 was admitted to the facility in October 2018. Resident #62 medical diagnoses included anoxic brain damage, contracture of muscles, multiple sites and abnormal posture. Review of Resident #62's admission packet included a non-dated signed consent for vision and hearing care needs. Review of Resident #62's physician's orders dated 12/23/19, included instructions for vision and hearing care needs On 2/18/20 at 3:29 P.M., during an interview with unit manager #3, she said that Resident #62 did not receive vision and hearing evaluation since his/her admission to the facility. Unit Manager #3 said she did not know if the Resident had issues with his/her vision and hearing. She said a comprehensive care plan was not developed. Unit manager #3 said she would review with the director of nurses (DON) to ensure that a comprehensive individualized care plan is developed for the Resident. 4. For Resident #61, the facility failed to develop an individualized comprehensive care plan to ensure the Resident received vision and hearing care needs. Resident #61 was admitted to the facility in December 2016. The Resident medical diagnoses included gastrostomy status, dysphagia, oropharyngeal phase, pneumonia and traumatic brain injury. On 02/11/20 at 08:15 A.M., during the initial tour, Resident observed in bed, flat position appeared uncomfortable and unable to communicate. Resident's mouth was observed to have dry white foamy thick secretions. This observation was consistent until 2/12/20 at 9:20 A.M., Resident was asleep at the time. Review of the quarterly Minimum Data Set (MDS), assessment with a referenced date of 12/14/19, indicated that the Resident had a Brief Interview for Mental Status (BIMS) score of 0 of 15, indicating that the Resident had severe cognitive impairment. The MDS indicated that Resident required extensive care from staff for personal hygiene. Review of the clinical record indicated Resident had a dental evaluation on 1/25/20. The recommendation was to continue with daily oral care. Resident was to receive nothing by mouth (NPO) on continuous feeding mouth care was not provided or maintained as recommended. On 02/13/20 at 08:15 A.M., during an interview with Unit manager #3 she said she would ensure that a comprehensive individualized care plan is developed for the Resident to receive oral care. Based on observation, record review and interview, the facility failed to develop an individualized comprehensive care plan for two residents (#56, #67} out of a total sample of 26 residents. For Resident's #56 and #67, the facility failed to list specific interventions for the care and safety of the Residents utilizing the restraint of the Posey Bed. Findings include: 1. For Resident 56, the facility used the restraint of a Posey Bed (an enclosed bed) for this Resident with Traumatic Brain Injury. The plan of care for this restraint had no specific interventions for the maintenance of the restraint according to manufacturer's guidelines, such as checking the zippers, clips, bed frame and canopy, maintenance checks specific for what they need to do, staff education on the use of the restraint, and monitoring of the Resident when in the enclosed bed. A review of the Posey Bed manufacturer's guidelines indicated that the bed is a passive alternative to direct restraints such as belts, vests but is still a restraint. When using this restraint the staff must have training on the restraint device, have an approved care plan, monitoring of the Resident when in the enclosed bed and the staff must check the canopy, and zippers before leaving the resident unattended to help reduce the risk of a fall or unassisted bed exit. The guidelines indicate to follow the physician's orders and plan of care for monitoring the resident in the bed. The guidelines included to never leave a patient unattended without proper monitoring and failure to monitor could result in serious injury or death. The guidelines indicated the need to check the bed frame, zippers, clips and canopy of the restraint device for patient safety. Resident #56 has multiple diagnoses that include Traumatic Brain Injury and seizure disorder. A review of the Minimum Data Set (MDS) quarterly assessment, dated 9/14/19, indicated the Resident was assessed as severely cognitively impaired, exhibits behaviors of physical and verbal behavioral symptoms and wanders. The MDS indicated that the Resident uses bed rails and trunk restraint daily. The plan of care initiated 6/8/15, for risk of falls had multiple interventions that included the use of a enclosure bed pelvic restraint as indicated. Another plan of care for the restraints of pelvic restraint and the enclosure bed dated 6/7/18, included the interventions of getting consent and doing quarterly restraint assessments that determine the need for the devices. This plan noted the enclosure bed is used during bedtime and rest periods. Both plans of care had no documentation of interventions for monitoring the Resident's safety, no documentation staff training using this restraint, no intervention of checking restraint equipment (zipper, clips or netting and canopy care) and no intervention when the maintenance department is to oversee the checking of the Posey Bed. The Resident's plan of care for this type of restraint only noted to use as indicated with no other interventions included in the plan of care. 2. For Resident #67, the facility used the restraint of a Posey Bed (an enclosed bed) for this Resident with Traumatic Brain Injury. The plan of care for this restraint had no specific interventions for the maintenance of the restraint according to manufacturer's guidelines, such as checking the zippers, clips, bed frame and canopy, maintenance checks, staff education on the use of the restraint, and monitoring of the Resident when in the enclosed bed. Resident #67's diagnoses include Traumatic Brain Disorder. The plan of care for the Posey Bed restraint initiated 11/25/14, indicated that the Resident had the restraint for safety and multiple falls. The interventions indicated that the restraint bed is used during bedtime and rest periods and evaluations are to be done quarterly. The plan of care had no information for the safety checks needed and maintenance of the devices. When the surveyor had reviewed the electronic medical record for the Resident's plan of care on 2/13/20 there were no intervention to check the bed restraint equipment. When the plan of care was copied on 2/18/20 the staff had added a new intervention on 2/14/20 to ensure the zipper and clip are secure and functioning properly. functioning properly. Prior to this, the interventions had no information regarding the checking of equipment for safety and function.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure that one Resident (#4) in a total sample of 26 Residents, who was unable to carry out activities of daily living was able to get out of bed in the morning and was provided nail care. Findings include: Resident #4 was admitted to the facility in February 2013 with a history of traumatic brain injury and had a recent decline related to cancer. A review of the most recent quarterly minimum data set (MDS) dated [DATE] indicated Resident #4 was cognitively intact with a score of 15 out of 15 on the Brief Interview for Mental Status. The MDS indicated Resident #4 required extensive assistance of two staff with bed mobility, transferring between surfaces and toilet use and the Resident needed extensive assistance of one staff with dressing and personal hygiene. During an interview on 2/11/20 at 11:03 A.M., Resident #4 said he/she would like to get his/her pants on and get up into his/her wheelchair. The surveyor spoke with Certified Nursing Assistant (CNA) #7 who said that there were two CNAs on the unit at this time and the two were splitting the assignment that Resident #4 was on and that was why he/she was not out of bed yet. During an interview on 2/11/20 at 12:10 P.M. Resident #4 said he/she preferred to get out of bed earlier in the day, but had to wait for staff to get him/her out of bed. At this time, the surveyor observed the resident to have long, jagged fingernails. On 2/13/20 at 10:13 A.M. Resident #4 was observed to be in bed. The Resident said he/she had been cleaned up by CNA #7 and that he/she would like to get out of bed. During an interview on 2/13/20 at 10:18 A.M., CNA #7 said that in order to get Resident #4 out of bed it required the assistance of herself, CNA #8 and Nurse #9. She said when she had provided care to Resident #4 he/she had said they wanted to get up later and that unfortunately when the Resident gets out of bed he/she does not want to stay up for long and will want to go back to bed and there are not enough staff to help him/her go back and forth to bed as is their preference. During an interview on 2/18/20 at 9:50 A.M. Resident #4 said his/her nails were too long and he/she would like to have them cut. The Resident's nails were observed to be long, jagged and untrimmed. During an interview on 2/18/20 at 11:39 A.M., CNA #7 said that the CNA staff were supposed to be providing nail care to all residents, but there were only two CNAs on the unit during one shift for 30 residents and they did not always have time to provide nail care.

Based on observations, interviews and record review the facility staff failed to provide necessary treatment to promote healing of a pressure injury. Specifically, the staff failed to ensure an air mattress was at the appropriate setting to promote healing of a pressure injury for one Resident (#4) in a total sample of 26 Residents. Findings include: Resident #4 was admitted to the facility in February 2013 with a history of traumatic brain injury and had a recent decline related to cancer. A review of the medical record indicated Resident #4 returned from a hospitalization in February 2020 with a stage 2 pressure injury. A review of the physician orders indicated an order for a low air loss mattress. There were no setting specifications included in the order. A review of the medical record indicated Resident #4 weighed 163 pounds as of 1/9/20. On 2/11/20 at 8:45 A.M. Resident #4 was observed in bed to be lying on a air mattress. The air mattress was observed to be set at a setting of 9 which indicated a weight of 350 pounds. On 2/12/20 at 9:33 A.M. Resident #4 was observed in bed with the air mattress set at 9/ 350 pounds. On 2/13/20 at 11:00 A.M. Resident #4 was observed to be in bed, with the air mattress set at 9/ 350 pounds. During an interview on 2/13/20 at 4:42 P.M., the Assistant Director of Nurses said Resident #4 was re-admitted from a hospitalization in February 2020 with a stage 2 pressure injury to the coccyx. During an interview on 2/13/20 at 1:44 P.M. the Director of Nurses said the air mattress for Resident #4 should have been set based on weight and the setting number should have been 4, not 9.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure two Residents (#4 and #89) with limited mobility received the appropriate equipment and assistance to maintain or improve mobility. The total sample was 26 Residents. Findings include: 1. For Resident #4 the facility failed to follow a physician's order for a Prevalon boot to the left lower extremity. Resident #4 was admitted to the facility in February 2013 with a history of traumatic brain injury. A review of the most recent minimum data set (MDS) dated [DATE] indicated Resident #4 had impairment on both sides of the left lower extremity. On 2/11/20 at 11:03 A.M. Resident #4 was observed in bed. On the wall behind the Resident's headboard the surveyor observed a photo of a foot wearing a boot. The boot on the foot was labeled wear in bed, left foot, lever out (which would keep the foot from rolling to the side). On 02/12/20 at 9:33 A.M., the surveyor observed Resident #4 in bed and the left foot did not have a boot on. On 2/13/20 at 11:00 A.M. the surveyor observed Resident #4 in bed not wearing a boot to the left lower extremity. The Resident said the boot had not been put on for a while. The surveyor observed a black boot (as in the photo on the wall) in the closet of Resident #4. A review of the medical record for Resident #4 indicated a physician order for a Prevalon boot to the left foot at all times when in bed. A review of the February Treatment Administration Record (TAR) indicated that this order was not on the TAR for the nurses to ensure it was administered as ordered. During an interview on 2/14/20 at 1:23 P.M. Physical Therapist #1 said Resident #4 was on rehabilitation services in September 2019 and had been given a Multipodus boot because the left lower extremity was rotating to the outer ankle and the Resident was having contractures. She said the staff were educated at that time for Resident #4 to wear the boot on the left lower extremity when in bed. A review of the physical therapy Discharge summary dated [DATE] indicated Resident #4 presented with dorsi- flexion minus 2 degrees and would benefit from 30 seconds of dorsi- flexion stretch, 3 times, prior to donning Multipodus boot to optimize effectiveness. The discharge summary indicated staff were educated and the goal of treatment was met. During an interview on 2/14/20 at 1:42 P.M. the Director of Nurses said she had spoken with the nurse on the unit and was told the boot was to prevent pressure injuries. The surveyor informed the Director of Nurses about the interview with physical therapy and she said she would have to review this further. No further information was provided by the end of the survey as to why Resident #4 had not been wearing the Multipodus boot to maintain range of motion and decrease contractures. 2. For Resident #89 the facility staff failed to follow a physician's order for bilateral extremity Multipodus boots, at all times for contracture management. Resident #89 was admitted to the facility in June of 2012 with diagnoses of cerebral palsy, seizures and cerebral vascular disease. Review of the most recent quarterly MDS, dated [DATE], indicated Resident #89 had limited and impaired range of motion in both sides of his/her upper and lower extremities. Review of the physician orders, Treatment Administration Record and plan of care indicated the Resident was to wear bilateral Multipodus boots at all times for contracture management. On 2/11/20 at 10:00 A.M., the surveyor observed Resident #89 in bed, and 2 blue Multipodus boots were observed on the window sill of the Resident's room. On 2/12/20 at 12:49 P.M., the surveyor observed Resident #89 in a Broda chair in their room and the Resident was not wearing the Multipodus boots. The boots were observed on the window sill. On 2/13/20 at 11:11 A.M., the surveyor observed Resident #89 in bed and the Resident did not have the mulitpodus boots on. On 2/18/20 at 1:11 P.M., Resident #89 was in bed and the surveyor observed the boots on the widow sill. CNA # 4 was interviewed about Resident care and devices, she said that she was the consistent caregiver. CNA #4 was asked about any devices or equipment the Resident required and she said that the Resident did not have any.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure staff provided an environment free of accident hazards for one Residents (#56) out of a total sample of 26 residents. For Resident #56, the facility was using a Posey Bed (an enclosed bed) and failed to ensure his/her safety, as evident of a fall out of the enclosed bed and the Resident sustaining a laceration; and for Resident #56, the facility staff failed to fully investigate the cause of the accident from the restraint bed, and subsequently the facility staff failed to have preventative interventions in place as outlined in the manufacturer's guidelines for the use the Posey Bed restraint. The facility has six enclosed beds being used in the facility. Findings include: For Resident 56, the facility used a Posey Bed (an enclosed bed used as a restraint) for this Resident with a traumatic brain injury and when he/she had sustained a fall from the restraint bed, had not fully investigated the cause for the restraint either being defective or not used according to manufacturer's guidelines. The investigative documentation indicated when the Resident was placed in the enclosed bed and the nurse noted it was secured, the Resident was found later by staff crawling on the floor by the doorway, bleeding from his/her forehead. The Resident's fall was not witnessed by any staff and the investigation narrative indicated that when put in the Posey Bed, the Resident was agitated and pulled the net of the bed apart. The Resident's unwitnessed fall from the restraint bed investigative report noted that it was highly likely that the fall was due to a undiagnosed UTI (Urinary Tract Infection). The report for the corrective measures was the enclosure bed clip will be replaced upon readmission. The bed clip was never mentioned as a potential problem either in the fall report or the investigation narrative. The Resident had been sent to the hospital after being found and admitted to the hospital with a diagnosis of sepsis due to a urinary tract infection and the laceration to the eyebrows. A review of the Posey Bed manufacturer's guidelines indicated that the bed is a passive alternative to direct restraints such as belts and vests but is still a restraint. When using this restraint that staff must have training on the restraint device, have an approved care plan, monitoring of the Resident when in the enclosed bed and the staff must check the canopy, and zippers before leaving the resident unattended to help reduce the risk of a fall or unassisted bed exit. The guidelines indicate to follow the physician's orders and plan of care for the monitoring. The guidance also indicated to never leave a patient unattended without proper monitoring and failure to monitor could result in serious injury or death. A review of the physician's orders and the plan of care had no documentation of any of the guidelines specific for Resident # 56's needs. A review of the Minimum Data Set (MDS) quarterly assessment dated [DATE], indicated that the Resident was assessed as severely impaired for cognition, exhibits behaviors of physical and verbal behavioral symptoms and wanders. The MDS noted the Resident used bed rails and a trunk restraint daily. The Falls Care Plan, initiated 6/8/15, included multiple interventions that indicated the use of a Enclosure bed /pelvic restraint as needed. Another plan of care for use of a pelvic restraint and the enclosure bed, dated 6/8/18, listed the interventions of getting consent and doing quarterly restraint assessment that determine the need for the device. Neither plan of care had any intervention for monitoring the Resident's safety, no intervention for staff training using this restraint, no intervention for checking restraint equipment (zipper, clips or netting and canopy care) and no intervention of how and when the maintenance staff is to oversee the checking of the Posey Bed. The medical record indicated the Resident had a fall from the bed on 11/3/19 and was found crawling on all fours on the floor by the doorway of his/her room bleeding from a forehead laceration. The Resident's bed is positioned by the window and the Resident had to crawl across the room to reach the doorway. The facility report of the unwitnessed fall, dated 11/3/19, included no predisposing situation factors (wandering, exhibiting behaviors), no environmental factors (equipment, bed position,etc,), nor predisposing situation factors such as restraints and bed rails. The facility's investigation narrative indicated that two nurses had put the Resident to bed for a nap due to his/her being very restless and agitated and noted that the bed was secured. It had no information of how the nurse had secured the bed. The report indicated that after 10 minutes the Resident was found in the doorway of his/her room. The facility's corrective measures was to send the the Resident to the hospital and Resident $56 was admitted to the hospital with sepsis due to an urinary tract infection. The staff noted that the enclosure bed clip will be replaced upon readmission. There was no documentation in the fall report or witness statements of the enclosed bed clip needing replacement. During interview on 2/12/2020 at 12:30 P.M., the Director of Nurses said that she could not explain the need to replace the bed clip. She said the Administrator oversaw the investigation. After meeting with the Director, the surveyor asked the Administrator about the Resident's fall from the restraint bed. The Administrator was asked about the investigation and the nurse reporting the bed was secured and on the corrective measures it is documented that the enclosure bed clip will be replaced upon the Resident' s readmission. The Administrator said,well it may have been needed to be replaced. The Resident sustained a fall with facial laceration from the restraint bed with no clear documented reports of having considered the Posey Bed restraint to be possibly malfunctioned or staff had not used the equipment properly.

Based on record review and interview, the facility failed to have the attending physician review the identified pharmacological irregularities so that action could be taken to address concerns for one resident (#21) in a total sample of 26 Residents. Findings include: The facility policy for Drug Regimen Review, dated as effective 11/28/16 and revised 10/1/18, indicated the following: -the consultant's monthly report will be provided to the facility within 5 business days of completion of monthly consulting rounds. If provided electronically, the Director of Nursing or designee shall print out the report to facilitate follow up and required notification of the attending physician and medical director. 1. Resident #21 was admitted to the facility in November 2013 with a diagnosis of traumatic brain injury. A review of the medical record for Resident #21 indicated a monthly medication regimen review was completed by a pharmacist on 12/31/19. The assessment indicated a consultant report was generated. A review of the paper record did not include the consultant pharmacist recommendation to the physician. During an interview on 2/19/20 at 2:09 P.M., the Assistant Director of Nurses said she had obtained the pharmacy consultant recommendation from the Director of Nurses for Resident #21. The recommendation indicated that Resident #21 was taking Valproic Acid routinely and recommended laboratory work include a Valproic acid level, ammonia level and Liver Function Test (LFT) due to a black box warning. The Assistant Director of Nurses said this recommendation had not been reviewed by the physician prior to the surveyor inquiry, six weeks after the recommendation.

Based on record review and interview, the facility failed to ensure that PRN (as needed) orders for psychotropic medications were limited to 14 days and failed to ensure the attending physician or prescribing practitioner evaluated the resident for the appropriateness of extending the medication, for one Resident (#89) in a total sampled of 26 residents. Findings include: Resident #89 was admitted to the facility in June of 2012, with diagnoses of cerebral palsy and seizure disorder. Following a readmission from an acute hospitalization for infection and seizures, the nurse's note, dated December 2019, indicated she reviewed medication orders with the physician. The nurse documented that the physician ordered the benzodiazepine medication Lorazepam solution, two MG/ML, inject two mg intramuscularly as needed for seizures, may administer one time and then call MD. There was no stop date included in the physician's order. A review of the Medication Administration Records (MAR) for December 2019, January 2020 and February 2020, as well as the monthly physician orders, physician notes and pharmacy reviews, failed to identify and/or provide a documented rationale for the continued need for the PRN Lorazepam without a stop date. During interview on 2/19/20 at 2:00 P.M., Unit Nurse Manager #4 said that she was working the day Resident #89 had the seizure and the seizure had lasted 40 minutes. The nurse documented that the physician ordered the benzodiazepine medication Lorazepam solution two MG/ML, inject two mg intramuscularly as needed for seizures, may administer one time and then call MD. There was no stop date included in the physician's order. The Unit Nurse Manager #4 had no documentation from the physician of why the as needed medication did not have a stop date and/or the clinical rationale for the continued use of the medication.

Based on record review and interview, the facility failed to provide routine dental services for one Resident (#62) in a total sample of 26 Residents. Findings include: On 2/18/20 the surveyor observed while speaking to Resident #62 that there were thick, foamy secretions in the Resident's mouth and that Resident #62's teeth were yellow stained and appeared to need cleaning. Resident #62 was admitted to the facility in October 2018. Resident #62's medical diagnoses included anoxic brain damage, contracture of muscles, multiple sites and abnormal posture. Review of Resident #62's physician's orders dated 12/23/19, included orders for a dental consult. Further record review indicated that there was no documentation that Resident #62 had received dental care services since his/her admission in October 2018 and there was a non-dated signed consent for dental care. During an interview on 2/18/20 at 3:29 P.M.,Unit Manager #3 said that Resident #62 did not receive dental care services at the facility. Unit Manager #3 immediately contacted the facility social services. During an interview on 02/18/20 04:12 P.M., social worker #1 said that the Resident's family had refused services on admission. The social worker said this information was documented on admission. Review of both the electronic and paper record did not include documentation that the family declined services. the facility staff did not provide documentation that the family refused dental services.

Based on record review and staff interview, the facility failed to develop an integrated, person centered hospice care plan identifying coordination of care between the facility and the hospice provider for one Resident (#51), in a total sample of 26 Residents. Findings include: Resident #51 was admitted to the facility in May 2015 with diagnoses that included dementia and Huntington's disease. Review of the physician's interim orders included a verbal order dated 9/13/19 : I certify that the Resident's prognosis is 6 months or less if the disease runs its normal course Review of the clinical record indicated Resident #51 was admitted on to hospice services on 9/13/19, with diagnoses of Huntington's Chorea disease and Dementia in other disease classified elsewhere with behavioral disturbances Review of the Hospice Nursing Facility Services Agreement included the following: * (1.14 p. 2 of 22) The Plan of Care must reflect Resident and family goals and interventions based on problems identified in initial, comprehensive, and updated comprehensive assessments, and includes all services and information necessary for the palliation and management of the terminal illness. * (2.3 p. 3 of 22) Nursing Facility plan of care must identify the care and services that are needed. The plan of care must identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the plan of care. * (2.11, p. 5 of 15) Nursing Facility will assure that patient care is directed by a Registered Nurse during each nursing shift. Review of the hospice care plan initiated 9/16/19 did not include the responsibilities of the hospice disciplines as agreed upon. Review of the significant change Minimum Data Set (MDS), assessment referenced date 9/19/19 indicated Resident # 51 was unable to complete a Brief Interview for Mental Status and was severely cognitively impaired. The MDS indicated the Resident required extensive assistance for all activities of daily living. The MDS indicated the Resident was receiving hospice care services. The hospice home health schedule was not available on the unit for review. During an interview on 02/19/20 at 11:00 A.M., Unit Manager #3 said she did not have a hospice schedule available for review. She said they usually give it to her to her but she did not have one for this week. Unit Manager #3 confirmed that the Resident's hospice care plan did not include which provider was responsible for performing the care that have been agreed upon and included in the Plan of Care.

Based on policy review, grievance review and interview, the facility failed to ensure that eight grievances voiced by residents/representatives were addressed and prompt efforts were made to resolve the grievances, and failed to ensure that two of the eight grievances reviewed were reported to the Department of Public Health (DPH) as required. Findings include: Review of the facility Grievance Policy (last revised 11/2017), included the following: -the facility will support each resident's right to voice grievances and to ensure that after a grievance has been received, the Grievance Official, identified as the administrator, will collaboratively work with team members to resolve the issue, provide oversight, review and track grievances, lead investigations, ensure that they are either confirmed or not confirmed, and provide written grievance decisions to the resident and/or resident's family. -the written grievance decisions will include: a summary statement of the resident's grievance, steps taken to investigate the grievance, summary of the pertinent findings or conclusions, statement of whether the grievance was confirmed or not confirmed, any corrective action taken by the Facility as a result of the grievance, and the date the written decision was issued. -immediate reporting of alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property by anyone furnishing services on behalf of the provider, to the administrator of the provider, and as required by state law. -upon receipt of a written grievance and/or complaint, the Administrator will refer it to the appropriate department head for investigation. The department head will submit a written report of such findings to the Administrator within 3 working days of receiving the grievance and/or complaint. 1. A grievance form dated 4/30/19 indicated that Resident #130 reported that his/her Amazon gift card in the value of $30.00 was missing. Further review of the grievance form failed to: -indicate that a referral was made to an appropriate department head for investigation, -that an investigation was conducted, -failed to indicate pertinent findings or conclusions, and -failed to indicate a statement as to whether the grievance was confirmed or not. The Administrator indicated on the grievance form that Resident #130 was informed that he/she had to submit a receipt for the gift card before being reimbursed. However no receipt was received by the facility. The Administrator signed the grievance as resolved on 5/3/19. The grievance of misappropriation of resident property was not reported to DPH as required. 2. A grievance form dated 5/2/19 indicated that Resident #128 reported that a CNA (certified nursing assistant) took $7.00 that was kept in his/her undergarment when he/she was changing clothes. Further review of the grievance form failed to: -indicate that a referral was made to an appropriate department head for investigation, -that an investigation was conducted, -failed to indicate pertinent findings or conclusions, and -failed to indicate a statement as to whether the grievance was confirmed or not. The Administrator indicated on the grievance form that Resident #128's money had been found, and signed that the grievance was resolved on 5/3/19. The grievance of misappropriation of resident property was not reported to DPH as required. 3. A grievance form dated 6/3/19 indicated that Resident #107's family reported that when they arrived for a visit on 6/2/19, the resident was lying in bed with shoes on, food on his/her face, and after removing the shoes from the resident's feet, the family member observed a sore on his/her foot. The form indicated that nursing staff performed a skin assessment on 6/3/19 and found no open areas, and that the resident is independent in ambulation, and put self to bed with shoes on. The grievance form failed to indicate that the family's grievance related to the resident having food on his/her face when they came to visit was investigated. The Administrator signed the grievance as resolved on 6/5/19. 4. A grievance form dated 6/12/19 indicated that Resident #50 reported to social services that he/she was missing four black shirts, and two green Celtics shirts. The housekeeping/maintenance department was assigned to investigate the grievance. The summary of the issue indicated that the resident did not get his/her clothing items labeled. The resolution indicated that the Resident was educated on reimbursement process for missing items: repurchase items and submit receipts. The form indicated that the issue was not resolved because the Resident did not repurchase the items and submit receipts. The grievance was signed as resolved on 6/14/19. 5. A grievance form dated 6/19/19 indicated that Resident #107's family reported to social services that concerns with the resident's feet, showers, hygiene. The family also requested that the Resident be transferred to New York, and had concerns about his/her medications. Nursing staff was assigned to investigate the grievance. The summary of the investigation indicated that the nurse met with the Resident's family and addressed their concern about his/her feet, showers, and oral hygiene. The grievance did not address the family's desire to have the Resident transferred to New York, and their concern about the Resident's medications and was therefore not resolved. The grievance was signed as resolved on 6/21/19. 6. A grievance form dated 7/17/19 indicated that Resident # 13 was missing five shirts. The laundry department was assigned to investigate the missing items. Three shirts were found, but two shirts remained missing. Laundry staff indicated that they looked everywhere for the items, but were unable to find them. The form indicated that the grievance was not resolved because they were unable to reach the Resident's daughter by telephone. The facility did not replace the Resident's missing shirts. The grievance form was not signed as resolved. 7. A grievance form dated 11/19/19 indicated that Resident #66's family reported that he/she was missing two running shoes. Further review of the grievance form failed to indicate that a referral was made to an appropriate department head for investigation, that an investigation was conducted, failed to indicate pertinent findings or conclusions, failed to indicate a statement as to whether the grievance was confirmed or not. The plan to correct the issue was to reimburse the Resident once a new pair of shoes was purchased by the family. The grievance form was not signed as resolved. 8. A grievance form dated 2/11/20 indicated that Resident #49 reported that he/she was missing a black pocketbook which contained a wallet, dentures, hearing aids, and his/her social security card. Staff searched the Resident's room and were unable to find the missing items. The investigation indicated that the items were not found and the facility would make a referral to dental, audiology, and would assist in replacing the social security card. The facility did not replace the black pocketbook or wallet. The grievance form indicated that the grievance was not resolved. The Administrator signed the form on 2/13/20. During interview with the Administrator on 2/19/20 at 10:01 A.M., we reviewed grievances for Residents #130, #128, #107, #50, #13, #66, #49 as noted above. She said that five of the eight grievances were not thoroughly investigated, eight of eight grievances were not resolved, and two of the eight grievances should have been reported to DPH as required. The Administrator said that if a resident/representative does not provide a receipt for a missing item, or does not re-purchase the item and provide a receipt to the facility, they will not replace or reimburse the resident for the missing item. The facility's grievance policy did not indicate that residents would not be reimbursed for items unless they provided a receipt.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure that professional standards were followed for seven Residents (#4, #78, #54, #21, #105, #15 and #51) out of a total sample of 26 Residents and one Resident (#99) out of 2 closed records reviewed. Findings include: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and Practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered nurse and practical nurse incorporate into the plan of care, and implement prescribed medical regimens. The rules and regulations 9.03 define standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. 1. For Resident #4 the facility failed to ensure that a physician's order was obtained prior to a skin treatment and that the treatment was documented on the administration record per professional standards. Professional standard reference, Massachusetts Board of Nursing: It is the responsibility of the licensed nurse to ensure that there is a proper patient care order from a duly authorized prescriber prior to the administration of any prescription or non-prescription medication or activity that requires such order in accordance with accepted standards of practice and in compliance with the Board's regulations. Resident #4 was admitted to the facility in February 2013 with a history of traumatic brain injury. On 2/11/20 at 10:44 A.M. the surveyor observed a square bandage on the right upper arm of Resident #4. The bandage was dated 2/4/20, one week prior. On 2/13/20 at 11:23 A.M. the surveyor observed the square bandage still on the right upper arm of Resident #4, dated 2/4/20. Resident #4 said he/she did not know why the bandage was on his/her arm. A review of the medical record did not include any physician order or treatment for a dressing to the right arm. A review of a nursing progress note dated 2/4/20, written by Nurse #9, indicated there was a scab on the right upper arm of Resident #4 and that the area was washed and a dry sterile dressing was applied. During an interview on 2/13/20 at 4:04 P.M., Nurse #9 was asked why there was a bandage on the arm of Resident #4. Nurse #9 replied is that bandage still there? The nurse then said that she had put the bandage on the arm of Resident #4 on 2/4/20 and that she guessed no one, including herself, had looked at it since. Nurse #9 said she was not sure if she got an order from the physician or if the dressing had been indicated on the treatment administration record. 2. For Resident #21 the facility failed to ensure that a physician's order for TED (thromboembolism-deterrent) stockings (compression) was followed and documented appropriately on the treatment record. Review of the medical record for Resident #21 indicated the resident had bilateral lower extremity edema (swelling caused by excess fluid). A review of the physician orders indicated an order for ted stockings to the lower extremities to be put on the morning and removed every night for bilateral edema. A review of the care plan for Resident #21 indicated the resident was to wear ted stockings for edema in the lower extremities. The surveyor observed Resident #21 on 2/11/20 in the unit day room in a wheelchair with leg rests. The Resident was observed to be wearing brown moccasins, with no socks or ted stockings. The bilateral lower extremities were observed to be red and dry. The surveyor observed Resident #21 on 2/18/19 at 12:05 P.M. in the unit day room, sitting in a wheelchair with his/her feet on leg rests. The Resident was observed to be wearing brown moccasins, no socks or ted stockings in place. A review of the Treatment Administration Record (TAR) for February 2020 indicated Resident #21 had worn ted stockings every day, as indicated by the nurse's initial indicating they were applied as ordered. During an interview on 2/19/20 at 11:46 A.M., Nurse #12 said she was the assigned nurse for Resident #21 on 2/18 and 2/19/20. She said the central supply staff had just brought up the ted stockings for the Resident and that was why they were not on the Resident the day prior (2/18/20). She said she was not sure why she had signed off Resident #21 had been wearing ted stockings as ordered. 3. For Resident #54 the facility failed to ensure a physician's order for a helmet, related to a seizure disorder, was followed and documented appropriately. Resident #54 was admitted to the facility in March 2019 with diagnoses of traumatic brain injury and a history of seizures. A review of the most recent Minimum Data Set, dated [DATE], indicated Resident #54's level for cognitive skills for daily decision making was moderately impaired (poor decisions, cues or supervision required). The Resident required extensive assist of two staff for dressing. A review of the care plans indicated Resident #54 was at risk for falls related to gait and balance problems with an intervention of wearing a helmet at all times (removed for activity of daily living care). A review of the physician orders for Resident #54 indicated an order written on 3/21/19 for a helmet to be applied at all times, check placement of helmet every shift for safety and to monitor seizure activity every shift. A review of the February 2020 Treatment Administration Record indicated the Resident wore the helmet every shift from 2/1 through 2/13/20. , Resident #54 was observed on all days of survey from 2/11 through 2/19/20, to be out of bed, in a wheelchair and not wearing a helmet. Specifically, Resident #54 was observed: on 2/11/20 at 10:15 A.M. not wearing a helmet, 2/12/20 at 8:45 A.M. not wearing a helmet, and 2/13/20 at 9:24 A.M. not wearing a helmet. On 2/13/20 at 9:40 A.M. the surveyor observed the room of Resident #54 and was unable to locate a helmet in the room. During an interview on 2/14/20 at 8:31 A.M. CNAs (Certified Nursing Assistant) #7 and #8 were interviewed. They said they share the care for Resident #54. They said Resident #54 had a helmet when he/she was admitted , but he/she kept taking it off and would not wear it. They could not recall the last time the Resident wore the helmet. On 2/18/20 at 10:00 A.M. the surveyor observed Resident #54 with his/her private nursing aide ambulating with a rolling walker (followed by the wheelchair) down the hallway. Resident #54 was not wearing a helmet at that time. During an interview on 2/18/20 at 3:30 P.M. Nurse #10 said that the helmet for Resident #54 was in his/her locked closet. She said the helmet was provided to the Resident based on a diagnosis of seizure disorder. She said Resident #54 does not like to wear the helmet and will whip it off. Nurse #10 and the surveyor went to the room of Resident #54. Nurse #10 obtained the key for the locked closet (family preference) from the medication cart. The nurse opened the closet and pulled out a light brown soft helmet. The helmet was observed to have dust, with a dust bunny on the inside. Nurse #10 said she was unsure why it was documented on the Treatment Administration Record was wearing the helmet daily, as he/she had not been. The nurse was unsure if the physician was aware. 4. For Resident #78 the facility failed to ensure that professional standards of nursing were followed by dating a telephone order and adding the orders to the medication administration record. Professional standard reference: The minimum elements required for inclusion in a complete medication order include: a valid medication order date. The nurse is accountable for ensuring that any orders he or she implements are reasonable based on the nurse's knowledge of that particular patient's care needs at that time and must also ensure that the orders (whether written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) originate from an authorized prescriber, pursuant to established protocols of the organization. Resident #78 was admitted to the facility in August 2019 with diagnoses including anoxic brain damage, mood disorder and major depressive disorder. A review of the medical record indicated a telephone order written by Nurse #9 which was not dated, but was between orders written on 8/29/19 and 12/5/19. The undated order indicated: give Zyprexa 10 milligrams (mg) by mouth, in addition to morning dose; give Haldol 5 mg IM (intramuscular) now, give Benadryl 50 mg IM now and if no change in 2 hours, transfer out. A review of the nursing progress notes included a note on 11/15/19 written by Nurse #9 which indicated Resident #78 was administered an additional Zyprexa 10 mg by mouth and then IM Haldol 5 mg and IM Benadryl 50 mg related to behaviors. During an interview on 2/13/20 at 3:25 P.M. Nurse #9 said she could recall the events from 11/15/19. She said she had contacted the physician, obtained a telephone order for Zyprexa as she thought this was the antipsychotic medication Resident #78 was taking. When the Resident did not de-escalate after the Zyprexa, the physician was called again for the order for IM Haldol and Benadryl. She said she remembered giving Resident #78 the injection and she was not sure why it was not on the November MAR or why the telephone order was not completely properly. 5. For Resident #99 the facility failed to ensure a physician's order was transcribed onto the medication administration record to ensure it was ordered from the pharmacy and provided to the Resident. A review of the medical record for Resident #99 indicated that the resident was re-admitted from the hospital in December 2019. The nursing progress note on 12/3/19 indicated a recommendation for sodium zirconium cyclosillicate (to treat hyperkalemia-high potassium level in the blood) from the hospital, which the physician declined until laboratory work could be reviewed. A review of the physician visit dated 12/5/19 indicated Resident #99 was previously on Kayexalate (60 ml by mouth on Monday and Fridays), which was discontinued at the hospital. A review of the physician interim order form indicated the physician wrote an order on 12/5/19 to stop the Kayexalate and start sodium zirconium cyclosillicate. A nursing progress note dated 12/17/19 indicated the nurse found the written interim order that was written on 12/5/19 for sodium zirconium cyclosillicate which was never put onto the medication administration record. The physician was called by the nurse for clarification of dose and frequency. The physician ordered sodium zirconium cyclosillicate 10 grams (gm) 3 times per week (Monday, Wednesday, Friday). A review of the December 2019 Medication Administration Record (MAR) indicated the Kayexalate for Resident #99 was discontinued on 12/5/19. The order for sodium zirconium cyclosillicate 10 gm was not administered until 12/20/19. Resident #99 missed doses on 12/6, 12/13, 12/16, and 12/18/19 (the Resident was at the hospital from 12/8 through 12/12/19). During interview on 2/18/20 at 2:20 P.M. the Director of Nurses said that she had not been the Director at the time of the transcription error, was unable to locate any medication error report and was not sure who had been aware of it at the time. 6. For Resident #105, the facility staff inaccurately documented the status of the Resident's wearing bilateral knee pads and bilateral Geri-sleeves. Review of the current physician orders included orders for Geri-sleeves to be applied every shift to both arms to prevent skin injuries (initiated on 6/5/19); and for the staff to apply knee pads to both knees for protection, every shift (initiated on 12/9/19). Review of the Treatment / Medication Administration Records for December 2019 and January 2020, indicated that staff documented each shift from 12/9/19 through 2/18/20 that the knee pads and Geri-sleeves were applied to all extremities each shift. The surveyor observed Resident # 105 on 2/11/20, 2/12/20, 2/13/20, 2/18/20, and 2/19/20 not wearing the Geri-sleeves to either one of his/her arms. The Geri-sleeves were not observed in the chair or on the floor. Multiple observations were made throughout all days. However, during observations compression stockings were observed on the Resident's legs and observation included a variation of one stocking on and one stocking off, no stocking on either leg and not in the area. Record review failed to include a current physician's order for the compression stockings and indicated that they had been discontinued on 2/21/19. In addition, the surveyor observations of Resident # 105 on 2/11/20, 2/12/20, 2/13/20, 2/18/20 and 2/19/20 revealed that the knee pads were not on the Resident's knees, on the floor, wedged in different places in his/her chair or not properly positioned on the Resident's knees. The observations included no knee pads on either knee on 2/11/20, - on 2/12/20, the left and right knee pads were on the floor, - on 2/13/20, one knee pad was on, the other was not in view and the knee pad on had slipped below the knee, - on 2/18/20, no knee pads on. During interview on 2/19/20 at 1:30 P.M., Unit Manger #4, said the Resident had orders for bilateral compression stockings, bilateral Geri-sleeves and bilateral knee pads. She said that the nursing staff documented on the administration records of their application, but that the Resident frequently removed them. The surveyor asked how do staff document how often the Resident removed theses ordered treatment devices and the Unit Manager #4 said the nurses document the non-adherence in the nurses notes. Review of the nurses notes from 12/9/19 through 2/18/20 indicated that the staff documented on three occasions that the Resident had removed the knees pads and twice on 2/11/20 that Resident # 105 had removed the Geri-sleeves. The Unit Manager was unaware there was no current order for the compressions stocking, which staff documented several times in the nurses' notes that they were applied.

Based on observation and interview, the facility failed to ensure that food was stored, prepared, and served in accordance with professional standards of food service safety. Findings included: On 2/13/20 at 9:00 A.M., the surveyor observed, with the food Service Supervisor (FSS) the following: A large stainless-steel food preparation table was towards the center of the kitchen. The table had one sink on each side of the table with inoperable hot and cold-water faucets. In addition, the sinks were observed to have drains that were open to the facility drainage system, posing a potential for harmful gases, bacteria, and/or pest infestation. The FSS said that the sinks had been inoperable for over a year and that the maintenance staff were aware of it. The FSS agreed that the drains, open to the facility drainage system, were a sanitation concern and created a potential reservoir for bacterial growth and pest infestation. The floor under the stainless-steel table where the hot and cold-water pipes and drains entered the floor, was observed to have a significant amount of black substance and debris on it. In the dry food storage room, several metal storage racks were observed to be rusted and in need of replacement or painting. The floor in the dry storage room was observed to have scattered debris on it and required sweeping/mopping. A large stand up fan was observed to be in the dish room with a moderate accumulation of dust on the fan grill cover. A wall mounted exhaust fan to the right of the stove was observed to have a large accumulation of dark, black colored debris. The FSS said that the fan required cleaning. On 2/13/20 at 3:39 P.M., the Corporate Maintenance Director said that he did not know why the repair to the inoperable sink and drain had not been conducted sooner. .

Based on observations, staff interviews, and record review, the facility failed to: -Ensure a water management plan was developed and implemented as part of their ongoing risk management for Legionella infection and other water borne pathogens Findings include: The facility failed to ensure that a water management plan was developed and implemented as part of their ongoing risk management for Legionella infection or other waterborne bacteria with a system of surveillance that included a facility risk assessment, testing protocols, ongoing monitoring of control measure locations, and annual water testing. During interview on 2/19/20 at 4:00 P.M., the Administrator stated that they (the Maintenance Director and the Infection Control Nurse) had a meeting to discuss the Legionella water management plan but said that the facility had not developed a water management plan for ongoing risk management for Legionella infection or other waterborne bacteria. The Maintenance Director said that the facility had not conducted a facility risk assessment and there was no water management team.

Based on a resident group meeting, individual interviews with residents and staff, review of Resident Council Minutes, and policy review, the facility failed to ensure that grievances and recommendations of the Resident Council were acted upon, resolved, and written grievance decisions provided to the Resident Council. Findings include: Review of the facility Grievance Policy (last revised 11/2017), included the following: -The facility will support each resident's right to voice grievances and to ensure that after a grievance has been received, the Grievance Official will collaboratively work with team members to resolve the issue and provide written grievance decisions to the resident and /or resident's family. -If a grievance is submitted orally, the facility employee taking the grievance must write it up on the grievance report form. -The Resident Council is an additional forum within the facility for voicing complaints/grievances. Complaints/grievances received from this Council will be acted upon in accordance with this procedure. Review of the August 2019 through January 2020 Resident Council Minutes indicated the following headings: -Old Business -New Business -Activities -Social Work -Nursing -Laundry -Maintenance -Dietary -Rehabilitation -Administrator -Neuro program Issues identified in the minutes included the announcement of upcoming activities, individual dietary requests such as sub sandwiches, salads, etc., missing lock box keys, laundry processes. The September 2019 minutes indicated under new business that a new television programming package was underway. A group meeting was held with nine Residents on 2/12/20 at 2:00 P.M. The residents were asked about their monthly resident council meeting. The residents said, on a monthly basis, the Activity Director assisted in coordinating and taking minutes for the meetings. The August 2019 through January 2020 Resident Council meeting minutes were reviewed with the group. The residents said that they felt their monthly meetings were not effective, because issues that are brought forward were not being documented and fixed. During the group meeting the residents voiced the following concerns: -8 out of 9 residents in attendance said that they see mice and cockroaches in their rooms on a daily basis. -9 out of 9 residents said that staff speak their own language while providing care, the residents have observed staff sleeping in chairs at the nursing desk, and there are long waits for call bells to be answered. -Residents said that half of the building was without cable television for 3 months and 2 weeks when the cable company discovered that the facility was stealing cable for 9 years, and the cable company disconnected service. The residents were told by Administrative staff that that cable service was coming, but offered no other alternatives for television. The residents said that issues regarding mice and cockroaches in the facility, long call bell response times, staff speaking their own language, staff sleeping at the nursing desk, and interruption in television service for more than 3 months have been brought up in Resident Council dozens of times. The residents said that they not only have brought these issues up in Resident Council, but have told the administrator about the issues as well. They concluded the group meeting by adding they felt as though they no longer wanted to bring up concerns at resident council or to staff because their concerns were not addressed by the facility. They said that they were just given excuses, and their grievances were not acted upon. The Activity Director was interviewed on 2/19/20 at 12:50 P.M. She said that she coordinates the monthly Resident Council Meetings, takes minutes, and when complete, distributes them to department heads. We reviewed feedback from the resident group. She said that she was told by residents in Resident Council many times, and was well aware that staff often spoke in their own language in the presence of residents, there were long response times for call bells, there was an infestation of mice and cockroaches in the building, and television service was out for about 3 months. The surveyor shared that the Resident Council Minutes did not reflect the Activity Director's knowledge of the residents' concerns. The Activity Director said she would investigate and follow up with the surveyor. Several hours later, she returned and said that she reviewed past Resident Council minutes, and was unable to provide evidence that she documented ongoing Resident Council concerns since May 2018. When asked why she did not document the residents' concerns, she said that that if she hasn't observed the concerns herself firsthand, she doesn't document it or complete a grievance form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff and resident interviews, the facility failed to ensure that the residents had a safe, clean, comfortable and home-like environment on four of four units. Findings include: On 2/11/20 at 9:11 A.M., on the resident unit M 1, the surveyor noted a strong foul odor. There was a stale urine odor along with an underlying smell of body odor that emanated from the unit when entering the unit through the double doors. The unit did not smell clean, the odor was hard to discern, as it had multiple elements that were adding to it. The surveyor observed rooms #137 and #120 to be dirty with numerous items strewn throughout the room and discarded and old looking food items were observed in the rooms as well. The M 1 shower room had dirty tiles, some of which were stained and broken. The shower vent was heavily caked with dust. On 2/12/20 at 10:44 A.M., upon entering the M 1 unit, the surveyor noted a very strong, overwhelming odor of urine. On 2/13/20 at 8:54 A.M., upon entering the M 1 unit, the surveyor noted a very pungent urine odor and this demonstrated that regardless of the time of day, the urine odor was prevalent on this unit. Rooms #120 and 137 were dirty and the residents had personal items, that were mixed with food and hygiene products piled on the window sill and and piled on the floor. There were multiple holes in the walls in room [ROOM NUMBER]. Under both of the beds in rooms #120 and #137, dust, dirt, paper, and other items had fallen and rolled under the beds. The bathroom of room [ROOM NUMBER] had what appeared to be dried feces on the floor and toilet seat. Subsequent observations of the bathroom revealed the feces-like material remained in the bathroom throughout the survey. The surveyor further observed on the M1 unit: -many of the ceiling tiles in the day room were stained and bulging downwards -room [ROOM NUMBER] had a strong smell of urine. -the smell of urine remained on M 1 throughout the survey. On 2/13/20 at 9:30 A.M. the surveyor, the Administrator, and the Director of Maintenance conducted environmental observations of M 1: - Upon entering M 1 unit, through the double doors, there was a strong urine odor. - The shower room was dirty, it had tiles missing and some broken tiles on the floor and walls. The grout throughout the shower room had rust stains, black stains, and what appeared to be soap scum on them. The vent in the shower room was caked with dust. - room [ROOM NUMBER] - The room had numerous items piled up and placed in a disorganized manner throughout the room. The items (pink wash basins, clothing, boxes, paper work cleaning supplies, personal care items) were piled on the bed, piled up in the bathroom sink and tub, piled on the over bed table, piled on the floor and piled on the window sill. The room had numerous holes in the walls and had multiple areas of patched holes that had not been painted. There was old uneaten food, containers of milk, juice, applesauce mixed within the other items. The floor of the room had numerous items stored directly on it. - room [ROOM NUMBER]- There were bags of items that were piled on the window sill and piled so high you could not look out the window. All of the Resident's items were stored in the bags on the window sill so that it was impossible for a room mate or visitors to look out the window. The Administrator stated that they were aware of the condition of these Residents' rooms and the other concerns identified, but the residents who reside in those rooms, refused to have any interventions. She did not state why the other concerns had not been addressed. On 2/19/20 at 2:00 P.M., the surveyor spoke with a Resident (who does not want to be identified), he/she said the residents had concerns about other residents who did not have their rooms cleaned and felt this contributed to the mice and cockroach infestation. The Resident said that not only did residents stored food in their rooms, the staff failed to clean up after them and often left meal trays in the hallway and unit kitchen for hours. During the environmental observations of the M 1 unit, the condition of the residents' bedroom furniture, tray tables were observed with broken drawers, chipped wood and scratches. The Administrator said she had was aware of the condition of the resident furniture and had ordered replacements. The purchase order was requested and was not provided. The individual resident room lighting was poor and some lighting fixtures did not have strings that would allow the residents to turn the light on and off unless they got out of the bed. All the handrails throughout the unit were in poor condition with most of the handrails with scratches and bare wood exposed and gouged. The rails were in need of sanding and refinishing, as the condition of the handrails present a possible infection control issue because of the bare wood being exposed, the handrails could not be cleansed/sanitized properly. (Any time the original finish is worn off a piece of equipment that is used by a resident/staff/visitors it cannot be cleansed properly due to the integrity of the equipment being compromised.) B 2 Unit Review of the Ombudsman facility monitoring and pre-survey report indicated that odors can be a problem, especially on the B 2 unit Some areas could definitely use paint and repair damage from wheelchairs. Lighting could be better in common areas-most in need is the dining area next to the sunroom on B 2 On 02/11/20 through the morning hours, on Unit B 2, the surveyor observed that all the residents' bedrooms had no overhead lighting and the over the bed lights can only be turned on if the resident was able to stand and push the button on and off. The over bed lights had no pull cords or strings available for residents to use. The Dining room across from the nurses' station was an old three bed room that is now the dining area. This area had no overhead lighting and only had three wall mounted over the bed lights. This area is used for meals and some activities and with no ceiling lights the room was dark. The Activity area was observed to have some ceiling lights but not above the far left area of the room. Resident #19 was observed sitting in that corner, with no ceiling lights or lamps, attempting to read his/her book and kept moving his/her head and the book to get some reflected light from the window. Resident #19 was observed sitting in his/her room later that day and said he/she could not read in his/her room or the day room. During an interview on 2/11/20 at 12:30 P.M., the Administrator was asked about the lighting situation on the Unit B 2 and she said she was not aware of an issue. When asked about environmental rounds, she said she does them every week with maintenance and enters the results on the TELs (electronic building management system)system. She could offer no information of why the residents on B 2 could not put their over bed lights on and off. The surveyor observed environmental issues of window blinds being broken and some windows were discolored (2 in the day room). The window blinds were broke in rooms # 206, 211 and 216 and the closets had no doors but they used curtains. Rooms #203, 215 and 216 had no covers for the closets. Resident #38, on 2/12/20 mid morning, while sitting in an activity, was using markers on a piece of paper and said to the surveyor, do you like my drawing and before the surveyor could answer, the Resident said I can't see it. The room was dark with no overhead lighting. The Resident was not able to see the coloring she/he had done on his/her paper. On 2/18/20 at 9:28 A.M., the surveyor walked into Resident #23's room. The Resident was lying on the bed and the room had no lights on. The Resident asked the surveyor to please pick out his/her pink pants in the closet. The surveyor informed him/her that I would get a staff person. The Resident asked me to turn on the light over his/her bed and when asked if they could put the light on Resident #23 said no. He/she also said, I had a stroke and my right arm is not working. I have to ask staff to put the light on. B 1 Unit On 2/11/20 at 8:40 A.M. the surveyor observed the cover of the wall heating unit in room [ROOM NUMBER] falling off. On 2/11/20 at 8:42 A.M. and throughout the survey, the surveyor observed the small dining room blinds on the B 1 unit to be bent and no longer attached to the string. B 2 Unit 02/14/20 12:18 PM the surveyor observed that one large window in the activity room had a large milky white spot covering most of the window, making it difficult to see through. The other two windows had large whitish, milky areas in the center of the windows, not as large as the other window, but still made it difficult to see through. There were 11 windows along outside wall of dining/activity room. All of the 11 windows had areas of smeared substances (unable to discern what the substance was) present on the lower portion of the windows (at sight level if seated at tables), which made it difficult to see through the windows. M 2 Unit On 2/11/20 at 8:00 A.M., the surveyor observed M 2 Unit Residents' rooms. There were multiple rooms observed with missing head of bed light pull strings broken. A few rooms were observed to have broken blinds or no blinds at all, and no closet cover. On 2/12/20 at 10:00 A.M., this observation was shared with the Administrator. Later that morning the Administrator conducted an environment tour. The Administrator provided to the surveyor a list of 15 rooms that had no head of bed light pull string, broken blinds, no blinds at all, and no closet cover.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to: - ensure residents were free from physical restraints imposed for the purpose of convenience and /or that the restraints were required to treat the resident's medical symptoms, - ensure that the facility staff implemented the least restrictive alternative for the least amount of time and, - the facility failed to ensure staff documented ongoing re-evaluation for the need for restraints for five residents (#78, #56, #67, #21, #105) out of a total sample of 26 residents. Findings include: 1. For Resident #78, the facility failed to thoroughly document the use of a manual restraint (to hold or limit a resident's movement by using body contact as a method of physical restraint) on 9/11/19 and 11/15/19. Resident #78's medical record failed to include documentation of the behaviors indicating the need for a manual restraint, the amount of time the Resident was held in a manual restraint, a nursing evaluation following a manual restraint (including vital signs and skin checks), and a physician's order following an emergency manual restraint. Resident #78 was admitted to the facility in August 2019 with diagnoses including anoxic brain injury (harm to the brain due to a lack of oxygen). During an interview on 2/12/20 at 12:20 P.M. the Program Director and the Assistant Program Director provided the surveyor with a copy of the behavioral safety training manual and reviewed the Safety-Care program with the surveyor. The Program Director and the Assistant Program Director said that the facility followed Safety Care as their policy and procedure for behavioral interventions, including manual restraints. The Program Director said that all staff members (Activity Techs, nurses, Certified Nursing Assistants) were trained in Safety Care and the techniques, including different types of manual restraints. She said all staff complete a course including a test and physical demonstration in order to be certified. The Program Director and the Assistant Program Director were trained to provide the certification training. They said the Activity Techs request medication or nursing intervention when the safety care techniques are no longer effective. They said use of the manual hold as a restraint intervention would not be implemented for more than 20 minutes. a. A review of the nursing progress notes for Resident #78 indicated that on 9/11/19 at 8:55 A.M. Resident #78 became extremely anxious and requested the key to leave. The Resident ran towards the exit door and was unable to be redirected. The progress note indicated that Resident #78 was manually restrained by two Activity Tech staff members. During an interview on 2/12/20 at 10:45 A.M., the Administrator said there was no incident report or investigation for Resident #78 related to the events on 9/11/19. She said the neurobehavioral Program Director would have a behavioral event form for any manual restraint events. A review of the behavioral event form for Resident #78, dated 9/11/19, indicated the form was completed by Activity Tech #6. The time of the event was noted to be 8:55 A.M. The form indicated Resident #78 presented with physical aggression because he/she wanted to leave the unit and a two person hold (manual restraint) was done to maintain Resident #78's safety. There was no additional documentation on the behavioral event form to describe the behaviors of Resident #78. The section for interventions only indicated safety care techniques. The other interventions listed on form such as verbal de-escalation, verbal directive and education were not indicated as having been attempted by staff. The back of the form, labeled Nursing Evaluation, was left blank. A review of the nursing progress note from 9/11/19, indicated the psychiatrist was contacted and ordered Haldol (antipsychotic) 5 milligrams (mg) and Benadryl (antihistamine, can be used for anxiety) 50 mg intramuscularly (IM) and the physician was in agreement. The medications were administered to the Resident at 10:30 A.M. by Unit Manager #2 (1 hour and 35 minutes after the event started). During an interview on 2/13/20 at 12:10 P.M., the Neurobehavioral Program Director said that the safety technique referenced on the behavior event form for Resident #78 from 9/11/19 was a two person manual hold. She said that the hold was a standing hold in which the Resident was held by his/her arms and walked back to his/her room. The Program Director said she did not have any documented statements from staff to indicate this is the process that was followed. The Program Director said she could not say for sure how long Resident #78 was held in a manual hold, as it was not indicated on the form, but said she did not believe it was more than 20 minutes. The Program Director said she could not speak to why the event started at 8:55 A.M. and the Resident was administered IM medication at 10:30 A.M. ( an hour and a half after the event started). She said the process was the for Activity Tech staff to initiate the behavioral event form, give the form to the charge nurse to complete and then the form would be collected by the Assistant Program Director. She said she was not sure why the back section of the form for the nursing evaluation was not completed. She said there was no additional documentation regarding the manual restraint of Resident #78 on 9/11/19. During an interview on 2/13/20 at 12:18 P.M. the Assistant Program Director said that on 9/11/19 the Activity Techs had telephoned her because Resident #78 was trying to leave the unit, was yanking on the door, and was screaming. She said the doors on the unit are secure and if pressed by a resident would not open, but the alarm would sound. She said she instructed the staff to do a standing manual restraint and escort the Resident back to his/her room. The Assistant Program Director said that when she arrived onto the unit the Resident continued to be combative and screaming, and was unable to be redirected. She said they attempted to release the manual restraint, but the Resident became combative again. She said she requested medical intervention from the nurse at that time. She said she was not sure how long the manual hold was implemented as it was not documented on the form. During an interview on 2/19/20 at 10:00 A.M., Nurse #11 said she was Resident #78's primary nurse on 9/11/19. She said she remembered the Resident's behaviors escalated about wanting to leave and was attempting to get out the door. She said she was not sure how long the Resident was in a manual hold for, but she did remember that Resident #78 was still being manually held, due to moving around and combativeness, when the IM Haldol and Benadryl were administered (at 10:30 A.M.) according to her nursing note. She said she did not recall getting an order for the manual restraint and did not know an order for the restraint was needed. b. A review of the nursing progress notes for Resident #78 indicated that on 11/15/19, after breakfast, the Resident and his/her roommate were circling each other. Resident #78 was brought to the unit dining room to be separated from the roommate and he/she began to escalate and yell. The physician was contacted, was informed the Resident had already received his/her morning medication and the physician ordered an additional dose of Zyprexa (antipsychotic) 10 mg by mouth. The nursing progress note indicated Resident #78 was being held by four people and after an hour, the Resident continued to want to go after his/her roommate. The physician was notified again and ordered Haldol 5 mg IM and Benadryl 50 mg IM. The note indicated that Resident #78 calmed down around 1:00 P.M. and could be released. The behavioral event form for Resident #78, dated 11/15/19, indicated that the form was completed by the Assistant Program Director. The time of the event was noted to be 9:15 A.M. The form indicated Resident #78 was following his/her roommate around and saying he/she wanted to be with the roommate. The event form indicated staff attempted to redirect Resident #78 away from the roommate, but Resident #78 refused and a manual restraint hold was implemented for his/her safety. The interventions listed on the form included verbal directive, verbal de-escalation, response interruption, relocation, education, chair hold and a two person hold. The back of the event form labeled Nursing Evaluation was left blank. Review of the nurse progress note documentation for the 11/15/19 incident involving Resident #78 indicated the Resident required a four person manual hold, this conflicted with the information on the behavioral event form for the 11/15/19 event which indicated the Resident was held with a two person manual hold. The behavioral event form for 11/15/19 included two staff member statements. The statement from the Assistant Program Director indicated Resident #78 was following his/her roommate around and when the roommate asked for personal space Resident #78 refused. The statement indicated staff attempted to redirect Resident #78 and when the Resident refused, Resident #78 was kept in the main activity room and all other residents were removed. The statement indicated staff put Resident #78 in a two person manual standing hold (held by the arms) and then the Resident became combative and was moved to a two person manual seated hold and was still not calm. The statement indicated the Resident later became calm, however no time frame was indicated. The statement from the Program Director for 11/15/19 indicated she arrived when Resident #78 was in a two person standing hold and then the Resident was moved to a two person seated hold. The statement indicated the total time of the event was 20 minutes with two to four minute manual holds done three times. During an interview on 02/13/20 at 12:18 P.M., the Assistant Program Director said that on 11/15/19 Resident #78 was placed in a seated manual hold and was pushing the chair back that he/she was seated in. She said the Resident was then lowered to the floor and held until a medication intervention was implemented. She said attempts to release the hold were unsuccessful. The Assistant Program Director said she was not sure how long the Resident was held for. During an interview on 2/13/20 at 3:30 P.M., Activity Tech #5 said that a Code [NAME] (dangerous person) was called on 11/15/19 in relation to Resident #78. She said that Resident #78 was screaming and was in the main dining room on the unit. She said the Resident was placed using a three person manual hold into a chair and when Resident #78 started to push the chair backwards staff moved him/her, using a three person manual hold on the resident, they put him/her on the ground (floor), and said the Occupational Therapist was holding Resident #78's head (4 persons total). Activity tech #5 said that the Resident was held in a manual hold by staff for approximately 30 minutes. During an interview on 2/13/20 at 3:39 P.M. Nurse #9 said that she was the primary nurse for Resident #78 on 11/15/19. She said that when she entered the main dining room she saw that Resident #78 was on the ground (floor) and was digging his/her nails into Activity Tech #5. She said she contacted the physician and obtained the order for Zyprexa as she thought this was the medication Resident #78 was taking on a regular basis and then later obtained an additional order for IM Haldol and Benadryl. She said she did not get an order for the manual restraint of Resident #78. She said she had not completed an incident report or any other documentation regarding the event. During an interview on 2/19/20 at 9:43 A.M., the Occupational Therapist (OT) said she was one of the first staff members to arrive on 11/15/19 to assist with Resident #78. The OT said when she arrived at the main dining room on the unit, Resident #78 was being manually held in a chair, but kept pushing on the chair. The OT said staff decided to remove the chair the Resident was sitting in and staff lowered the Resident to the floor. The OT said she took the chair away and stood behind the Resident to help lower to the ground (floor) and said she held Resident #78's head to help prevent him/her from sustaining an injury. The OT said, while she was holding Resident #78's head, she was making a shush type sound to try to calm him/her down, but said the shush sound only upset Resident #78, who made a shush sound back at her, and that the Resident spit in her face. The OT said staff put a face mask on Resident #78 at that time. A review of the Safety-Care Behavioral Safety Training Trainee Manual indicated the following: physical management interventions should always be applied in the least restrictive manner that is safe, with the minimum physical force necessary for safety and stability. Once a stable hold has been established, de-escalation should continue, using the prompt or wait strategies. It is generally counterproductive to sooth or tell the person to calm down. A review of the Safety-Care manual indicated the following: following any use of physical management procedures, the individual's physical status should be evaluated and include at a minimum: alertness, orientation and responsiveness, assess for bruises, cuts, scrapes, sprains or other injury, monitor for complaints of pain. Furthermore, the Safety-Care manual indicated that the use of physical management (manual restraint) should be considered an emergency (never routine) procedure and documented as such. Any physical management procedure, of any duration, should be thoroughly documented using appropriate incident reporting forms or electronic data entry systems. 2. For Resident #56, who was diagnosed with a Traumatic Brain Injury, the facility used a Posey Bed (an enclosed bed) as a restraint and there was no documentation to review regarding the facility's staff maintenance of the Posy Bed restraint according to manufacturer's guidelines. The maintenance documentation should include the checking of the zippers and clips, the bed frame, staff education on the use of the restraint, and monitoring of the Resident when in the enclosed bed. A review of the Posey Bed manufacturer's guidelines indicated that the bed is a passive alternative to direct restraints such as belts, vests but is still a restraint. When using this restraint the staff must have training on the restraint device, have an approved care plan, monitoring of the Resident when in the enclosed bed and the staff must check the canopy and zippers before leaving the resident unattended, to help reduce the risk of a fall or unassisted bed exit. The guidelines noted to follow the physician's orders and plan of care for the monitoring. The guidelines indicated to never leave a patient unattended without proper monitoring and failure to monitor could result in serious injury or death. A review of the maintenance documentation titled the Canopy Enclosure Inspection, conducted weekly, included the room numbers of the six restraint beds in the facility and had a check mark for each room. The documentation had no information of what is specifically inspected on the restraint device. The manufacturer's guidelines noted that an inspection of the Posey Bed should be done at least monthly to ensure the canopy and frame are intact and safe for use. The inspection needed to include all moving bed parts to check for loose hardware. Resident #56 is a long term resident admitted [DATE] and has multiple diagnoses that included Traumatic Brain Injury and seizure disorder. A review of the Minimum Data Set (MDS) quarterly assessment dated [DATE], indicated the Resident was assessed as severely impaired for cognition, exhibits behaviors of physical and verbal behavioral symptoms and wanders. The MDS indicated the Resident uses bed rails and trunk restraint daily. The physical restraint assessments for the Posey Bed Enclosure Bed were reviewed through 12/5/19 and they all include the same documentation for the use of the restraint due to impulse disorder and falls. The restraint evaluations for the Enclosure Bed, dated 1/5/19, 3/27/19, 11/14/19, and 12/5/19 noted the prior alternatives attempted to reduce the risk of harm had been three alternatives: - 1:1 activities - regular toileting - alarm devices (bed/chair/door) For the use of the enclosure bed only the above three alternatives had been attempted and the listed reason for the restraint was the impulse disorder resulting in multiple falls. The restraint evaluation dated 1/5/19 indicated the interdisciplinary team made the decision to use the enclosed bed for an abnormal gait, resulting in multiple falls. None of the restraint evaluations included dates of restraint reduction or consideration of reducing use of the Posey Bed. A review of Resident #56's physician's orders indicated the use of the enclosure bed for naps and sleep, with no orders for checking the Resident's safety in the restraint bed. The consent form for restraint indicated that the use of the restraint was for Traumatic Brain Disorder and impulse disorder. A review of Resident #56's medical record indicated he/she experienced a fall from the restraint bed on 11/3/19 and sustained an injury of a facial laceration. There was no documentation of having considered the Posey Bed restraint to have possibly malfunctioned or of staff not using the equipment properly. 3. For Resident #67, the Resident has had the Posey Bed restraint since 2014 with no documentation of having attempted other restraints or a reduction in use of the bed restraint. The restraint plan of care had no documentation of assessing the function and safety of the device and indicated the bed was being utilized for the medical symptom of an unsteady gait. Resident #67 is a long term care resident admitted [DATE] with a diagnosis of Traumatic Brain Disorder. A review of the medical record indicated that a physical restraint consent was signed and dated 10/3/13 for the enclosure bed and the medical symptom was documented as an unsteady gait. The Minimum Data Set (MDS) annual assessment dated [DATE], indicated that the Resident had short and long term memory deficits, exhibited verbal behavioral symptoms and did not wander or reject care. The assessment indicated the Resident needed extensive assistance of two staff for bed mobility and was totally dependent on staff for activities of daily living. Additionally, the assessment indicated the Resident had range of motion limitation on both lower extremities. The care plan for the Posey Bed restraint initiated 11/25/14, indicated the Resident had the restraint for safety and multiple falls. Multiple revisions of the care plan interventions indicated that the restraint bed was used during bedtime and rest periods and evaluations should be conducted quarterly. The plan had no documentation related to restraint reduction or the need to attempt alternative devices. There was no documentation for the safety checks needed or maintenance of the enclosed bed. During survey on 2/14/20 the following was added to the care plan: ensure zipper and clip are secure and functioning each time the Resident is put in bed. Prior to this, the plan had no documentation of the safety check. During interview on 2/13/20 at 10:25 A.M., Unit Manager # 2 could not offer an explanation of why there was no documentation of a restraint reduction. When the surveyor had reviewed the electronic medical record for the Resident's plan of care, on 2/13/20, there were no interventions to check the bed restraint equipment. When the plan of care was copied on 2/18/20, the staff had added a new intervention on 2/14/20 to ensure the zipper and clip are secure and functioning properly.4. For Resident # 21, the Posey Bed restraint has been implemented since 2019 with no documentation of staff having attempted other interventions. The restraint plan of care had no documentation of how staff checked the function and safety of the device. Resident #21 was admitted to the facility in November of 2013 with diagnoses that included dementia and a traumatic brain disorder. Review of Resident # 21's medical record indicated that on 8/12/19, the physician reordered the Posey enclosure bed to be used while in bed, due to the Resident's poor balance, unsafe behavior, dementia and his/her numerous attempts to get out of bed without assistance. The documentation was unclear when the previous order for the Posey bed was discontinued. However, the restraint evaluation, dated 5/21/19 indicated that the Resident had frequent falls and that the enclosure bed was initiated to prevent Resident #21 from getting out bed and falling. The 5/21/19 evaluation indicated that the Resident had been in the enclosure bed since 9/14/18. Review of the quarterly MDS assessment, dated 11/16/19, indicated Resident #21 had short and long term memory deficits and was totally dependent with bed mobility and transfers, requiring two staff, and was not ambulated during the assessment period. The MDS indicated side rails were used while in bed. On 8/13/19, Resident #21 was re-evaluated for a physical restraint because he/she was displaying poor balance with unsafe behaviors, including unassisted transfers. The enclosure bed was reinstated. Review of the plan of care for falls, initiated on 7/29/14 and dated as last revised on 10/30/19, indicated that as of 7/23/19, the facility reinstated the enclosure bed, but had to wait for the enclosure bed,as there was no beds available (dated 7/31/19). The care plan for the restraint dated 8/13/19 indicated that the reason for implementation of the bed was for poor balance and unsafe behaviors and the interventions included quarterly assessments, consult rehab services, and monitor for psychosocial impact. The plan of care did not include evidence to check the bed restraint equipment for safety and function. On 11/25/19, the most recent restraint assessment indicated the bed enclosure was used for unsafe bed mobility. The MDS assessment dated [DATE] indicated that Resident #21 was totally dependent for bed mobility. During interview on 2/13/20 at 8:23 A.M., Certified Nurse Aide (CNA) #7 said that Resident #21 had an enclosure bed because he tries to get out of bed often. CNA #7 said that they had tried floor mats and a low bed, but he/she would still try to get out of bed and had falls. 5. For Resident #105, the facility failed to ensure the Resident was free from restraints and was not confined for the convenience of the staff. Resident #105 was admitted in January of 2019 with diagnoses that included Alzheimer's dementia with behavioral disturbances and a history of falls. The Annual MDS assessment, dated 1/11/20, indicated Resident # 105 was severely cognitively impaired, required extensive assistance of two staff for bed mobility and transfers and required one person physical assistance with wheelchair mobility. The MDS indicated a trunk restraint was used daily while Resident #105 was in a wheelchair. Review of Resident # 105's physician orders from 4/8/19, indicated that he/she had an order for a pelvic restraint when in wheelchair, release and reposition every 2 hours and as needed under direct supervision. Review of the interdisciplinary care plan for falls, initiated on 1/25/19 and dated as revised on 1/15/20, indicated Resident # 105 was at risk for falls due to impaired gait, poor safety awareness, and limitations associated with dementia. The goal was for the Resident to not sustain any serious injury and the interventions included an enclosure bed when available, safety checks, low bed, anticipate needs, ghost alarms (wireless alarm system that is activated by movement) on both sides of bed, pelvic restraint as ordered in wheelchair, provide supervision in a safe environment, and review information associated with falls. On 3/6/19, a care plan for restraints was implemented and revised on 4/8/19. The goal of the restraint was to prevent injury as the Resident is a high risk for falls related to impaired mobility, cognitive loss, poor posture, and frequent attempts to self transfer. The goals included for the Resident to have no adverse effects from the pelvic restraint and to maintain an upright position. The interventions included quarterly evaluations, to release and reposition the restraint every 2 hours, monitor skin for signs of pressure injuries, try alternative methods before using the restraint, and to discuss necessity of the restraint with the guardian. Review of the restraint assessment for Resident # 105 indicated that on 3/6/19, an initial assessment for a self release clip belt was initiated due to unsteady gait, agitation, sliding out of the wheelchair, unbuckles seatbelt, attempts to self-transfer and climbs out of bed. The assessment indicated that the Resident's frequent attempts to self transfer and slide out of the wheelchair were the reasons for the restraint. The assessment indicated alternate methods such as supervision of ambulation, positioning devices, regular toileting, anticipating needs and rest periods did not alter the Resident's attempts to self transfer. On 4/25/19, a restraint assessment was completed and was indicated as an initial restraint evaluation. The assessment failed to identify the type of restraint or changes in the plan or type of restraint. However, record review and physician orders indicated that the self release seat belt was discontinued and the pelvic restraint was initiated on 4/6/19. Additional restraint assessments were completed on 7/11/19, 10/16/19, 12/30/19 and 12/31/19. The 7/11/19 and 10/16/19 restraint assessments indicated that no restraint reduction had been trialed and indicated the need for the restraint was unsafe mobility, posture and frequent attempts to self transfer. The 7/11/19 assessment failed to identify the type of restraint used. The 12/30/19 and 12/31/19 restraint assessments indicated a trial reduction of the pelvic restraint was initiated on 12/30/19. The length of time the trial reduction was 10 minutes, because Resident # 105 was moving forward and attempted to scratch the writer of the assessment. On 2/11/20 at 10:20 A.M. the surveyor observed Resident #105, with additional observations conducted throughout lunch and at 1:00 P.M Resident #105 was seated in a specialized chair, that was comparable to the Broda style chair. The chair had a high back and extending legs rests. The chair could be placed in different angles of recline. The Resident remained in the chair from 10:20 A.M. through 1:00 P.M. in the day / dining room on the unit. The Resident had a pelvic restraint on and the restraint was stained with food and dirty in appearance. The restraint was not removed during any of the observations and during the observations, a staff member remained in the room. Resident #105 was asleep during the observations on 2/11/20. On 2/13/20 at 11:10 A.M., the surveyor observed Resident # 105 seated in the day / dining room. The Resident was in the specialized chair and the pelvic restraint was in place. A staff member was in the room reading from a book. The Resident was placed in the corner of the room and was asleep. Additional observations included the noon meal during which time staff members were assisting with the meal and the pelvic restraint on Resident #105 remained in place. On 2/18/20 at 12:44 P.M., the surveyor observed Resident # 105 in the dining room, asleep in the specialized chair with a pelvic restraint on. On 2/18/20 at 1:46 P.M., the surveyor observed Resident # 105 in the dining room and he/she was in the specialized chair with a pelvic belt on which was dirty with food stains and discolored. The Resident was attempting to adjust him/herself in the chair but did not attempt to get out of chair. During interview on 2/18/20 at 11:30 A.M., CNA #4 said the pelvic belt was on the resident because he/she tried to get up out of the chair. During interview on 2/19/20 at 9:50 A.M., the Rehabilitation Director said that her department was currently providing rehabilitation services for positioning for Resident #105 and as part of the treatment they had provided a new specialized chair. The Rehabilitation Director said prior to implementing the specialized chair, the resident had specialized seating equipment and had been in a different style chair. She said that she and her staff were not involved in restraints assessments and would never recommend a restraint. During interview on 2/19/20 at 1:30 P.M., Unit Manger #4 said the pelvic restraint was used to prevent the Resident from getting out of the chair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews with staff, residents, and the facility failed to ensure the there was sufficient staff to meet the needs of residents, specifically 3 Residents (#67, #4, #17) in assisting a resident out of bed when the resident wished to get up, assisting a resident to get out of bed in time for their shower, and providing nail care to a resident who could not care for themselves regarding nail care,in a total sample of 26 Residents. Findings include: 1. During a group meeting with nine residents on 02/12/20 from 1:00 P.M. to 2:00 P.M., the residents said there was not enough staff on the units as there were only two Certified Nursing Assistants (CNAs) during the day (7:00 A.M. to 3:00 P.M.) The residents said they often have to wait for call lights to be answered and this is really difficult overnight (11:00 P.M. to 7:00 A.M.) due to having only one CNA. 2. During an interview on 2/11/20 at 2:30 P.M. the Ombudsman said the residents had voiced concerns about there not being enough staff to help. A review of the Ombudsman report indicated that corporate mandated reductions in staffing related to decreased census. 3. During an interview on 02/11/20 at 10:07 A.M. CNA #7 said there were 30 Residents on the B 1 unit and only 2 CNAs during the day (7:00 A.M. to 3:00 P.M.) She said there were not enough CNAs to get the care done for these residents, it was too difficult. She said the CNAs did not get the morning care done until 11:00 A.M. She said there were three or four residents on B 1 who were independent with care and three residents who needed the assistance of a Hoyer device to transfer between surfaces, which required two staff. She said there were multiple residents who required two or more staff members for care due to behaviors. 4. During an interview on 2/11/20 at 4:15 P.M., Nurse #9 said there were not enough staff on the unit. She said that at times she was required to help staff with care or transferring a resident utilizing a mechanical lift (which requires two staff) making it difficult to get her nursing work done timely. 5. During an interview on 2/11/20 at 9:11 A.M., Unit Manager #4 said she frequently worked as a nurse on the medication cart on the unit and that staffing was based on the census in the facility, not on the individual unit. She said that a scheduled CNA for the unit M 1 would often be pulled to go work on another unit which left four CNAs on the unit, which was not enough. 6. Resident #67 was admitted in October 2013 with a diagnosis of Traumatic Brain Disorder. The Minimum Data Set (MDS) annual assessment dated [DATE] indicated that Resident 67 needed extensive assistance by two staff for bed mobility and totally dependent on staff for activities of daily living. A nursing progress note from 12/21/19 at 2:31 P.M. indicated Resident #67 had spent most of the beginning of the morning in bed due to a shortage of staff. During an interview on 2/13/20 at 10:25 A.M. the Director of Nurses said the nurse should not have written that in the progress note. She said she did not know why there were not enough staff available to assist Resident #67 in getting out of bed. 7. Resident #4 was admitted to the facility in February 2013 with a history of traumatic brain injury. A review of the most recent quarterly minimum data set (MDS) dated [DATE] indicated Resident #4 was cognitively intact with a score of 15 out of 15 on the Brief Interview for Mental Status. The MDS indicated Resident #4 required extensive assistance of two staff with bed mobility, transferring between surfaces, toilet use, and the resident needed extensive assistance of one staff with dressing and personal hygiene. During an interview on 2/11/20 at 11:03 A.M.,. Resident #4 said he/she would like to get his/her pants on and get up into his/her wheelchair. The surveyor spoke with Certified Nursing Assistant (CNAs) #7 who said that there were two CNAs on the unit at this time and the two were splitting the assignment that Resident #4 was on and that was why he/she was not out of bed yet. During an interview on 2/11/20 at 12:10 P.M. Resident #4 said he/she preferred to get out of bed earlier in the day, but had to wait for staff to get him/her out of bed. At this time, the surveyor observed the resident to have long jagged fingernails. On 2/13/20 at 10:13 A.M. the surveyor observed Resident #4 in bed. The Resident said he/she had been cleaned up by CNA #7 and that he/she would like to get out of bed. During an interview on 2/13/20 at 10:18 A.M. CNA #7 said that in order to get Resident #4 out of bed it required the assistance of herself, CNA #8 and Nurse #9. She said when she had provided care to Resident #4 he/she had said they wanted to get up later and that unfortunately when the Resident gets out of bed he/she does not want to stay up for long and will want to go back to bed and there are not enough staff to help him/her go back and forth to bed as they want. During an interview on 2/18/20 at 9:50 A.M., Resident #4 said his/her nails were too long and he/she would like to have them cut. The Resident's nails were observed to be long, jagged and untrimmed. During an interview on 2/18/20 at 11:39 A.M., CNA #7 said that the CNA staff were supposed to be providing nail care to all residents, but there were only two CNAs on the unit during one shift for 30 residents and they did not always have time to provide nail care. During an interview on 2/19/20 at 8:52 A.M., CNA #7 said that there was not enough staff to do additional activity of daily living (ADL) care, such as nail care. She said that if she had to choose between changing an incontinent resident or cutting a residents nails, she would choose changing the incontinent resident. 8. During an interview on 2/12/20 at 9:44 A.M., Resident #17 said there were not enough staff on the unit. The Resident said that after 3:00 P.M. it took a long time for call lights to be answered. The Resident said he/she was transferred out of bed with a mechanical lift and often missed his/her shower because there were not enough staff to get him/her out of bed. A review of the most recent quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #17 was cognitively intact with a score of 15 out of 15 on the Brief Interview for Mental Status. 9. A review of the daily census provided on 2/11/20 indicated the following number of residents on each unit: M 1- long term care unit 38 active residents M 2 - neurobehavioral unit 32 active residents B 2 - neurobehavioral unit 31 active residents B 2 - neurobehavioral unit 31 active residents A review of the schedule for nursing staff indicated the following for each unit for 2/11/20: 7:00 A.M. to 3:00 P.M. shift M 1- 4 CNAs (9-10 residents per CNA) M 2- 3 CNAs (10-11 residents per CNA) B 1 - 2 CNAs (15-16 residents per CNA) B 2 - 2 CNAs (15-16 residents per CNA) 3:00 P.M. to 11:00 P.M. shift M 1 - 3 CNAs (12-13 residents per CNA) M 2 - 3 CNAs (10-11 residents per CNA) B 1 - 2 CNAs (15-16 residents per CNA) B 2 - 2 CNAs (15-16 residents per CNA) 11:00 P.M. to 7:00 A.M. shift M 1 - 2 CNAs (19 residents per CNA) M 2 - 1 CNA (32 residents per CNA) B 1 - 2 CNAs (15-16 residents per CNA) B 2 - 1 CNA (31 residents per CNA) During an interview on 2/18/20 at 12:35 P.M. the Administrator said that the staffing levels were based on census of the entire facility and PPD (patient per day calculation). The Administrator said she was aware that many of the residents on the three neurobehavioral unit required two to three staff members for care based on behaviors and that staffing levels have continued to be at two CNAs per shift for two of the three neurobehavioral units. She said only the CNAs and the nurses could provide hands on care. She said she has been aware that staffing has been an issue and that having one CNA on the 11:00 P.M. to 7:00 A.M. shift with one nurse on the neurobehavioral units was an issue.

Based on employee records and staff interviews, the facility failed to complete the performance review for the Certified Nurse Assistants (CNA) annually and provide regular in-service training based on the outcome of these reviews. Specifically the facility failed to ensure that staff completed a performance review of every aide and provide regular in-service training based on the outcomes of these reviews. There was no process in place to ensure the CNA staff received at least 12 hours of annual education as required. Findings include: A review of the facility policy and procedure for inservice training, last reviewed 4/2018, indicated that the facility will complete a performance review of nurse aides annually and the annual in-services must: - Ensure the continuing competence of the nurse aides - Be no less than 12 hours per year - Address the special needs of the residents as determined by the facility - Include training that addresses the care of the residents with cognitive impairment - Include training in dementia management and abuse prevention. During an interview on 2/19/20 9:10 A.M., the Staff Development Coordinator (SDC) had been asked earlier at 8:25 A.M. to gather employee records with dementia training, annual competencies and safety training education for the employees and was given a list of employees (seven) in all. The SDC explained the facility's company has the Relias system that provides and tracks the education of the CNA staff. He had not implemented the system here due to not having had the training on it. He could offer no documentation of having completed performance reviews on the CNA staff and had no process to determine if the CNA staff achieved the 12 hours annually as required. The Clinical Director of Operations later produced a CNA skills competency checklist for the CNA staff that was three pages long and could not identify documentation of the CNA staff having this completed annually. She said the SDC should have been using the Relias education system which is an electronic education system that provides education and tracking the amount of education that each employee has received for training.

Based on observations, interviews and review of facility policy and procedures, the facility Administration failed to utilize resources effectively, failed to ensure resident care was maintained at the highest practicable physical, mental and psychosocial well-being of each resident. Findings include: During the extended annual recertification survey conducted from 2/11/20 through 2/20/20, the Department of Public Health determined the facility provided substandard care and identified numerous care area concerns. The survey team determined the facility had failed to adequately address concerns brought to their attention from the Resident Council, failed to ensure residents were free from restraints or restraints were the least restrictive and the use of a restraint was not for the convenience of staff; the facility failed to ensure the environment was clean, homelike, pest free and maintained in a manner that met resident needs and preferences; and the facility failed to ensure staffing was adequate and supported resident care needs through employee education, training and evaluating performance reviews. In addition, multiple care areas were identified including resident care not provided as ordered, infection control breeches, standard of practice concerns, pest infestation control not effective and failed to follow recommendations, by not acting upon additional interventions to prevent further infestation, and staffs' ability to care for residents with behavorial disturbances and dementia. During interview on 2/19/20 at 3:00 P.M., the Administrator said that the facility's QAPI committee had identified many of the concerns identified by the survey team. However, she could not provided evidence that the facility had developed programs to address the identified problems.

Based on review of the Facility Assessment Tool and interview, the facility failed to identify a designated governing body who is legally responsible for the management of the facility. Findings include: Review of the Facility Assessment (date completed 8/22/19) with the last Quality Improvement Performance Improvement (QAPI) review of 8/16/19, indicated the following people were involved in completing the assessment: the Administrator, Director of Nursing, Medical Director and the Governing Body Representative was left blank. The Governing body is responsible and accountable for the QAPI program, per regulation. Under Policies and Procedures for Provision of Care of the Facility Assessment, it indicated: Policies and procedures are reviewed annually by the QAPI team and signed off by the Administrator, Director of Nursing and the Medical Director. On 2/20/20 at 12:10 P.M., the survey team interviewed the Administrator. The survey team had identified several systemic concerns throughout the survey and asked the Administrator who the governing body members were. The Administrator said: I don't know who the governing body is.

Based on documentation review and staff interview, the Facility Assessment tool failed to include the following information: a. identification of the Facility's governing body b. an accurate number of licensed beds c. documentation of the initiation of the Antibiotic Stewardship program. d. resources necessary to assess the risk and management of building water to reduce the risk of growth and spread of Legionella and other water borne pathogens in the water. Findings include: The facility failed to accurately conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The Facility Assessment tool dated 8/2019, failed to identify the Governing Body Representative and failed to accurately identify the facility's licensed beds. The Assessment Tool for education requirements/in-services was noted to include various orientation topics, but had no specific information for ongoing training such as the certified nurse assistant training of 12 hours of education required annually. The Assessment had no documentation of their facility based and community based risk assessment and the Assessment failed to identify the resources necessary for implementation of the Infection Control program or the new Antibiotic Stewardship program. The Assessment failed to include a management plan to reduce the risk of growth and spread of Legionella and other water borne pathogens in the facility's water system. During interview ton 2/19/20 at 2:00 P.M., the Administrator said that the Facility Assessment Tool did not accurately reflect the bed capacity, specific information for the required 12 hour/year education of CNA (Nurse Aide) staff, and included no information regarding the ongoing monitoring for the Antibiotic Stewardship program.

Based on interview and document review, the facility failed to have an effective Quality Assurance Performance Improvement (QAPI) program that followed up on identified areas of concerns. The QAPI program was said to be ineffective by the Adminitrator who was identified as the person responsible and accountable for developing, leading, and closely monitoring the QAPI program. Findings include: The facility had a recertification extended survey conducted 2/11/20 - 2/20/20 and the survey team had numerous concerns found with resident restraints, grievances, Resident Counci grievances, environmental issues, employee training, and employee education. During an interview on 2/19/20 at 3:00 P.M., the Administrator was asked to explain the QAPI program. She explained the facility follows the QAPI policy and procedure, last revised 6/2019, and said every department head had a project and reported on the matter to the QAPI committee. The Administrator said they meet monthly and quarterly. The quarterly meetings were attended by the Medical Director, department managers, vendors, the Staff Development Coordinator (SDC) and the pharmacist. She explained that the facility has a QAPI calendar and they can pick subjects from that calendar to develop into a performance project. A review of the QAPI calendar for 2019 included multiple areas and the following were areas that the Administrator said they have been projects: grievances, Resident Council, Relias Mandatory in-services, employee competencies, staffing levels, environmental audits, infection control. The one project identified by the Administrator as being in process was regarding customer service and that they had family complaints on the weekends and said they resolved the problem by hiring a weekend supervisor. The surveyors asked the Administrator how she knew the project was working, and she said, well I asked the supervisor and she said it was fine. The Administrator had not developed any plan of action such as audit tools or surveys to ask families regarding their weekend staffing concerns. The survey team had numerous concerns found with resident restraints, grievances, Resident Council, environmental issues, and employee training and education. The QAPI calendar identified issues that the Administrator said they had worked on but she could offer no information of any specific projects either ongoing or that had been completed of the resident problems found during this survey. When the Administrator was asked if the QAPI was an effective program for resolving points of concern, she said no, it is not. A review of the QAPI policy and procedure noted that the Administrator is responsible and accountable for developing, leading, and closely monitoring a QAPI program.

Based on observation, interviews, and review of the facility's pest control service reports and pest sighting logs, the facility failed to maintain an effective pest control program so that the facility was free of rodents and cockroaches. Findings include: During an observation of the first floor resident care units, conducted on 2/12/20 at 10:30 A.M., several residents reported that they saw and heard mice and saw cockroaches in their rooms, bathrooms, the dining/recreation areas and in the designated outside resident areas. Mouse traps were observed in resident rooms, resident dining rooms, and kitchenettes. During the Resident Group interview, held on 2/12/20 at 1:00 P.M., eight out of the nine participating residents said that they saw mice and cockroaches on a daily and/or regular bases. The participating residents, represented at least one resident from each of the four units. The residents said that they saw mice and or cockroaches as recently as 2/11/20. The residents said that they discussed the pest problems in their Resident Council meetings and had reported the pest sightings directly to staff, but that it went on deaf ears. The residents said that the maintenance staff did replace mouse traps, and would look at the dead cockroaches in resident bathrooms and were well aware of the problem. The residents said at the beginning of the year 2020, the dumpster was over flowing with trash bags because the trash collection service had not picked up the trash. The residents said the pest control service placed extra mice traps to help control the rodent problem. The Director of Maintenance was interviewed on 2/13/20 at 8:45 A.M. The Director of Maintenance said that the facility had a policy for pest control and that the facility maintained an on-going pest control program to ensure that the building was kept free of pests. The Director of Maintenance was asked about current pest issues and he said that there issues with bugs. The Director of Maintenance said that he was aware that cockroaches had been observed in a bathroom as recently as 2/11/20 and 2/12/120 and that there had been recent and current sightings of mice. The Director of Maintenance said the pest control company provided services twice a month. During interview with the Director of Maintenance, on 2/13/20, he said that rodents and cockroaches were and are a current problem. He said the pest control service provided him with extra traps, and that he replaces the traps as needed. The Director said that he and his staff are notified of pest issues from staff and residents. He said the facility has an electronic system that staff use to notify him of pest control issues but only staff can enter into this system. The Director of Maintenance could not state when, who, what locations or how often traps were replaced by his department. He said that the pest sighting logs are filled in by either himself or his staff. The Director denied any issues with trash removal. The Director of Maintenance said that between his staff and the pest control service that pests were controlled in the facility, even though there had been recent ongoing sightings of mice and cockroaches. Review of the electronic maintenance work orders from 1/1/2019 through 2/1/2020, indicated five reports of cockroaches and five reports of mice. Review of the written pest sighting logs were from 12/3/18 through 1/28/20, indicated the logs were completed by the maintenance staff, and included the date of the sighting, the person reporting (maintenance staff), the type of pest and date of pest control service. The logs identified cockroaches and mice, the locations identified infestation on four of the four resident units, and included resident rooms, dining/day rooms and kitchens. There was no documentation of pest sighting from 1/28/20 through 2/13/20. Review of the contracted pest control service reports, from 8/21/19 through 1/31/20, indicated the facility had cockroaches and mice located throughout the building and in resident rooms, resident common areas, and the kitchen areas. The service reports indicated that they placed traps and reviewed the pest sighting log book. The service reports indicated the pest control service were aware that the facility maintenance staff were replacing mice traps, but did not know how frequently and/or the location. On 12/31/19, the pest control service report had identified the concern that had also been brought to the attention of the survey team during the resident group meeting, that trash was piled up and around the dumpster. The reports indicated that there was ongoing cockroach activity and mice activity in every service report. They recommended the facility keep all areas clean of food residue and debris, to close up gaps in walls and under doors to limit pest traffic from the outside. These and other recommendations had previously been made on 10/4/19 and 10/18/19. There was no evidence that the areas were addressed by the facility. During interview on 2/13/20 at 10:30 A.M., the Medical Director said that he was aware the facility had a pest infestation, as he said he saw a mouse last week. During interview on 2/19/20 at 12:45 P.M., the Activity Director was asked if the residents had discussed pest infestation in the Resident Council Meeting. The Activity Director said she was aware that it had been brought up and was surprised that she had not included the information in any of the past six months of Resident Council Minutes. She said that residents also would tell her about pests during the day, and that a resident had showed her a picture of a mouse on a trap. The Activity Director said the picture was blurry and therefore did not notify the maintenance department. The Activity Director said unless she sees the mice or cockroach herself, she does not report, or file any type of sighting report or grievance. On 2/19/20 at 1:30 P.M., the picture of the mouse on a trap was reviewed by the survey team. The picture observed was confirmed as the same picture the Activity Director had observed. The picture was of a mouse entrapped in a mouse trap. On 2/19/20 at 3:00 P.M., the Director of Maintenance was asked for recent pest control service reports and/or additional evidence of pest control. He said that he was just notified that the pest control representative was no longer employed with the pest control service and that the service had not been in since 1/31/20. He said he had no additional information supporting pest control prevention and the pest control service had no one for the survey team to interview. The Maintenance Director had stated that both cockroaches and mice had been seen since 1/31/20, and he had no evidence that the sightings were addressed. There was no documentation and/or documentation presented to the survey team that indicated the facility followed the pest control recommendations to ease the ongoing pest control infestation.