**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records reviewed, for one Resident (#1), of seven sampled residents, the facility failed to ensure care was provided to residents in accordance with professional standards of practice. Specifically, for Resident #1, the facility failed to ensure insulin was administered per physician's orders. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Review of the facility's policy titled Diabetes- Clinical Protocols, undated, indicated but was not limited to: - The Physician will follow up on any acute episodes associated with a significant sustained change in blood sugars or significant deterioration of previous glucose control and document resident status at subsequent visits until the acute situation is resolved. -The staff will identify and report issues that may affect, or be affected by, a patient's diabetes and diabetes management such as foot infections, skin ulcerations, increase thirst, or hypoglycemia. Review of the facility's policy titled Administering Medications, undated, indicated but was not limited to: - Medications are administered in a safe and timely manner, as prescribed. - Medications are administered in accordance with prescribed orders. Resident #1 was admitted to the facility in January 2023 with diagnoses including type 2 diabetes mellitus with hyperglycemia (high blood sugar) and long-term use of insulin. Review of the Minimum Data Set (MDS) assessment, dated 3/25/25, indicated Resident #1 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Further review of Resident #1's MDS indicated he/she had a diagnosis of diabetes mellitus and received insulin daily. Review of Resident #1's current Physician's Orders indicated but were not limited to: - If blood sugar (BS) remains below 70 after the second Glucose Gel administration, notify the doctor and follow directions as needed for hypoglycemia below 70, dated 1/6/23 - If Resident is awake and able to swallow give four ounces of rapid acting carbohydrate (regular juice or Glucose Gel tub). As needed for hypoglycemia, also if Resident has signs and symptoms of hypoglycemia with blood sugar near 70, dated 1/9/23 - If blood sugar is less than 70 after the first dose of Glucose Gel and symptomatic, notify the doctor to review diabetic medications for possible adjustment as needed for hypoglycemia below 70, dated 1/9/23 - Glucagon Emergency Kit 1 milliliter (ml) Inject 1 ml intramuscularly as needed for hypoglycemia blood sugar below 70 or resident is unresponsive with inability to swallow and call the doctor, recheck blood sugar in 15 minutes, dated 11/27/23 - Novolog (a fast-acting insulin analog used to manage blood sugar) Inject 6 units subcutaneously before meals, dated 10/11/24 Review of Resident #1's April 2025 MAR indicated but was not limited to: - Novolog Inject 6 units subcutaneously before meals, dated 10/11/24 - 4/18/25 at 4:00 P.M., Signed of as a 5 - 4/19/25 at 6:30 A.M., Signed of as a 5 - 4/19/25 at 4:00 P.M., Signed of as a 5 - 4/21/25 at 6:30 A.M., Signed of as a 5 - 4/22/25 at 6:30 A.M., Signed of as a 5 - 4/24/25 at 11:00 A.M., Signed of as a 9 - 4/29/25 at 4:00 P.M., Signed of as a 5 Further review of Resident #1's April MAR indicated his/her Novolog was not given per physician's orders 7 times out of 60 opportunities. Review of Resident #1's May 2025 Medication Administration Record (MAR) indicated but was not limited to: - Novolog Inject 6 units subcutaneously before meals, dated 10/11/24 - 5/2/25 at 4:00 P.M., Signed off as 10 (no sliding scale insulin required per order) - 5/3/25 at 4:00 P.M., Signed off as a 9 (other see progress note) - 5/4/25 at 6:00 A.M., Signed off as a 9 - 5/4/25 at 11:00 A.M., Signed off as a 5 (hold see nurse notes) - 5/4/25 at 4:00 P.M., Signed off as a 5 - 5/5/25 at 11:00 A.M., Signed off as a 5 - 5/8/25 at 6:30 A.M., Signed off as a 10 - 5/12/25 at 6:30 A.M., Signed off as a 10 Further of Resident #1's May MAR indicated his/her Novolog was not given per physician's orders 8 times out of 38 opportunities. Review of Resident #1's Nursing Notes indicated but was not limited to: - 4/18/25 at 4:00 P.M., failed to indicate a note was written - 4/19/25 at 6:34 A.M., low blood sugar - 4/19/25 at 5:46 P.M., blood sugar 74 - 4/21/25 at 7:04 A.M., blood sugar 74 - 4/22/25 at 6:45 A.M., blood sugar 79, snack given - 4/24/25 at 11:38 A.M., blood sugar 129 - 4/29/25 at 5:06 P.M., blood sugar 75 - 5/2/25 at 4:00 P.M., failed to indicate a note was written - 5/3/25 at 6:00 P.M., blood sugar 87 - 5/4/25 at 5:38 A.M., low blood sugar - 5/4/25 at 12:43 P.M., blood sugar 72 - 5/4/25 at 5:05 P.M., blood sugar 90 - 5/5/25 at 11:00 A.M., failed to indicate a note was written - 5/8/25 at 6:30 A.M., failed to indicate a note was written - 5/12/25 at 6:30 A.M., failed to indicate a note was written During an interview on 5/13/25 at 2:28 P.M., Nurse #1 said insulin should be given as ordered by the Physician and if it needed to be held then the Physician should have been called and a note would need to be written. During an interview on 5/13/25 at 2:48 P.M., Nurse Practitioner (NP) #1 said Resident #1 did not have an order or parameter to hold his/her Novolog insulin. NP #1 said if the insulin needed to be held then he or the Physician should have been notified, and documentation should have been available in the Resident's record. NP #1 said the facility calls often and he was unable to recall if they had called about these incidents. That's why it should have been documented in a nursing note. During an interview on 5/13/25 at 3:24 P.M., the Director of Nurses (DON) reviewed Resident #1's medical record and said Resident #1 did not have any parameters to hold his/her Novolog insulin. The DON said the insulin should have been given as ordered and if it needed to be held then the nurse should have notified the Physician or NP and documented it in a note. The DON said the expectation was for nurses to follow physician's orders.

Based on observation, interview, and record review, the facility failed to provide care and maintenance of a Peripherally Inserted Midline Catheter (PICC) (type of catheter inserted into a peripheral vein, typically in the arm, near the armpit, used to deliver medications intravenously (IV)), consistent with professional standards of practice for one Resident (#65), out of a total sample of seven residents. Specifically, the facility failed to complete a PICC dressing change by discarding or replacing the antimicrobial disc with a new one during dressing changes dated 5/4/25 and 5/11/25. Findings include: Review of the facility's policy titled Central Venous Catheter Care and Dressing Changes, undated, indicated but was not limited to the following: -The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter related infections that are associated with contaminated, loosened, soiled, or wet dressings. -Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g., damp, loosened or visibly soiled). -Maintain Sterile dressing (transparent semi-permeable membrane (TSM) dressing or sterile gauze) for all central vascular access devices. The type of dressing is based on the condition of the resident and his or her preference. -Change the dressing if it becomes damp, loosened or visibly soiled and: a. At least every 7 days for transparent semi-permeable membrane (TSM) dressing; b. at least every 2 days for sterile gauze dressing (including gauze under the TSM unless the site is not obscured). -Adhere to aseptic non touch technique (ANTT) when performing this procedure. Adhere to standard or surgical ANTT based on the ability to prevent touching key parts or key sites. -Assess the integrity of securement devices with each dressing change. -Removal of old dressing is an aseptic, non-sterile procedure. -While stabilizing the catheter, remove the dressing in the direction of the catheter insertion site (from the hub of the catheter toward the head) to avoid dislodging the catheter. Discard dressing, remove gloves and wash hands. -Visually inspect and/or palpate the insertion site as described above. -Use sterile gloves if there is a need to touch the insertion site. -Documentation: -Date and time dressing was changed -Location and objective description of insertion site -Any complications, interventions that were done -Signature and title of person recording the data. Resident #65 was admitted to the facility in July 2024 with diagnoses which included: left hip fracture, failed left total hip replacement, septicemia requiring intravenous antibiotics through PICC line. Resident #65 had a readmission in April 2025 with added diagnoses which included: Left hip conversion of prior hip surgery to total hip arthroplasty (hip replacement), left revision total hip arthroplasty with closed treatment for left greater trochanter fracture, and PICC placement. Review of the Minimum Data Set (MDS) assessment, dated 5/4/25, indicated Resident #65 scored 13 out of 15 on the Brief Interview for Mental Status (BIMS), indicating Resident #65 was cognitively intact. Review of the Hospital documentation of Resident #65's PICC insertion record, dated 4/14/25, indicated the Resident had a Bard power injectable PICC single lumen PICC line inserted on 4/14/25, with an external catheter length of 0 centimeters (cm), and a post right arm circumference of 26 cm. During an interview on 5/13/25 at 8:26 A.M., Resident #65 said he/she had a hip surgery which was complicated and now receives intravenous (IV) antibiotics and has this line in his/her arm (pointing to his/her PICC in the right upper arm). The surveyor observed the right PICC line in Resident #65's arm to have a round disc around the insertion site and a white square item blocking the visualization of the PICC insertion site. Review of the Physician's Orders indicated but was not limited to the following: -Change PICC line dressing weekly and as needed (PRN), initiated 5/4/2025 and discontinued 5/4/2025. -Change PICC line weekly and as needed, initiated 5/5/2025 and discontinued 5/13/2025. Review of the May 2025 Medication Administration Record (MAR) indicated but was not limited to the following: -Resident #65's PICC line dressing was changed by Nurse #2 on 5/4/25 and 5/11/25. Review of all nursing progress notes, dated 5/4/25 and 5/11/25, and provided to the surveyor during the survey, failed to include any documentation of the PICC line dressing change. During an interview on 5/13/25 at 12:25 P.M., Nurse #2, with Nurse #3 present, said she changed Resident #65's PICC line dressing twice on 5/4/25 and 5/11/25. Nurse #2 said she saw the white disc around the insertion site of the PICC line and was not sure what to do with the white disc, so she cleaned the surfaces with an alcohol prep pad and left the white disc in place and covered the area with a clear dressing. Nurse #2 said she was the last one to change the PICC line dressing on 5/11/25 and the white disc has remained over the PICC insertion site since admission. She said she signed the last dressing and dated it 5/11/25. On 5/13/25 at 12:33 P.M., the surveyor requested from Nurse #2, with Nurse #3 present, all of the facility's PICC line items required for a dressing change. Nurse #2 provided the surveyor with a package titled Dressing Change Kit with Chloraprep swabs and the contents included the following: 1 3M Tegaderm dressing 1 gauze 4 inches () by 4 1 gauze 2 by 2 1 Slit, non-woven gauze, 2 x 2 2 Alcohol prep pads 1 tape measure 1 chloraprep swab stick, 3 pack 1 roll of tape 1 towel 2 pairs of gloves 1 mask There was no antimicrobial disc included in the PICC dressing kit or shown to the surveyor. During an interview on 5/13/25 at 3:22 P.M., Nurse Practitioner (NP) #1 said if the Resident had an anti-microbial disc from the hospital, it should have been removed with the first dressing change and discarded. NP #1 said if the nurse had a new anti-microbial disc, it could have been applied to the PICC insertion site, but the old one should not be left on the PICC line insertion site. During an interview on 5/13/25 at 4:12 P.M., Nurse #2 said both times she changed the PICC line dressing, she cleaned the white antimicrobial disc and left it in place. Nurse #2 said she knows the external length of the PICC was zero. Nurse #2 confirmed she signed and dated the last dressing on Resident #65 on 5/11/25. During an interview on 5/13/25 at 5:05 P.M., the Director of Nurses (DON) said the antimicrobial disc should have been removed and discarded when the PICC line was changed and the clear Tegaderm dressing applied. The DON said she had no further documentation of the PICC dressing change on 5/4/25 or 5/11/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the proper size mattress was on the bed for one Resident (#323), out of a sample of 18 residents. Specifically, the facility failed to ensure the Mattress Bolster/Extender (an object used to fill gaps between the mattress and footboard of a bed) was put on the bariatric (obesity) bed, leaving a gap of approximately 10 inches between the end of the mattress and the footboard with the metal bed frame exposed, leaving the Resident at risk for entrapment and/or injury. Findings include: Review of the facility's policy titled Bed Safety, undated, indicated but was not limited to the following: -The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. -To try and prevent death/injuries from beds and related equipment. -Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems, including potential entrapment risks. -Review that gaps within the bed system are within the dimensions established by the Food and Drug Administration (FDA). Review shall consider situations that could be caused by the resident's weight, movement, or bed position. -Ensure that when bed system components are worn and need to be replaced, components meet the manufacturer specifications. Review of the Guidance for Industry and FDA Staff Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment Document, dated March 10, 2006, indicated but was not limited to the following: -Exclusions: The dimensional criteria described on pages 15-21 are recommended for a number of products, but not all types of hospital beds. We are listing those products below for which some, or all, of the dimensional criteria are not recommended. Please note that the products listed below are not free from risk of entrapment. We continue to suggest that users identify and address areas of potential entrapment for each patient or resident through a comprehensive bed safety program. Total exclusion from the scope of this guidance: Bariatric beds, pediatric beds and infant cribs are excluded because we did not use anthropometric (a person's size, form, and functional capacities) data for these groups in determining the recommended dimensional limits of the entrapment zones in this guidance. -Vulnerable patients are defined in A Guide to Bed Safety, developed by the Hospital Bed Safety Workgroup (described on pages 3-4), as: Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement or who get out of bed and walk unsafely without assistance. -Zone 7 - Between the Head or Foot Board and the End of the Mattress Zone 7 is the space between the inside surface of the head board or foot board and the end of the mattress. This space may present a risk of head entrapment when taking into account the mattress compressibility, any shift of the mattress, and degree of play from loosened head or foot boards. FDA recognizes this area as a potential for entrapment and encourages facilities and manufacturers to report entrapment events at this zone. Review of the Manufacturer Instructions for the Drive P750 Long Term Care Bariatric Bed indicated but were not limited to the following: -Mattresses must fit bed frame and assist rail snugly to prevent patient entrapment. Please follow the manufacturer instructions and monitor patient frequently. -Incompatible mattresses can create hazards. -Do not let any body parts protrude over the side or between parts, especially when the bed is being operated. -Entrapment issues can still arise when components and accessories are not properly installed. -Make sure the mattress is the correct size for bed frame to decrease the risk of entrapment. -It is recommended that a 39, 42 or 48 wide mattress that is made to fit an 80, 84 or 88 length bed frame is used. -Standard Features: 80, 84, 88 adjustable sleep surface. -Adjustable Mattress retainers. -Possible injury or death may occur of the bed is not adjusted to the proper length for the mattress being used. -Assembly: There are mounting positions for 3 different mattress lengths, 80, 84, and 88. Choose the appropriate one for your mattress. -Mattress retainer stops are designed to keep the mattress in place on the sleep surface. -Make sure the mattress fills the length and width between mattress retainer stops. Review of the Relief Max mattress manufacturer guidelines, undated, indicated but were not limited to the following: -Standard Dimensions: 36 x 80; Also Available 36 x 84 and Bariatric 42 and 48 width. Resident #323 was admitted to the facility in March 2025 with diagnoses which included metabolic encephalopathy (impaired brain function due to an underlying condition affecting cognition), dementia, anxiety, and morbid obesity. Review of the Nursing admission Evaluation indicated he/she was 76.8 inches tall and weighed 343 pounds, was dependent on staff or personal care, transfers, and ambulation. Review of the Nursing Side Rail Evaluation indicated he/she had problems with balance, poor trunk control, and was deconditioned. Review of the Comprehensive Care Plan indicated but was not limited to the following: -He/She had an Actual Fall on 3/29/25 and 4/2/25. Review of the Nursing progress notes indicated but were not limited to the following: -3/29/25: He/She was found on the floor lying face down near the roommate's bed at 7:05 A.M. -4/2/25: He/She was found on the floor lying in a supine (face up) position at 4:30 A.M. Surveyor Observations include: -On 4/1/25 at 9:45 A.M., Resident #323 was lying in bed with his/her feet dangling off the bed; metal bed frame exposed, gap approximately 10 from end of mattress to the footboard. One pillow (standard bed pillow for head) was bunched up partially under heels. No mattress bolster/extender was installed on the bed. -On 4/1/25 at 11:02 A.M., Resident #323 was lying in bed with his/her feet hanging off the end of the mattress. There was one pillow stuffed in part of the gap between the mattress and the footboard. No mattress bolster/extender was installed on the bed. -On 4/2/25 at 8:29 A.M., Resident #323 was sitting in bed, his/her feet were hanging off the end of the mattress touching the footboard. Multiple pillows were stuffed in part of the gap between the mattress and the footboard, no mattress bolster/extender was installed on the bed. Health Care Proxy (HCP) at bedside. During an interview on 4/1/25 at 9:45 A.M., Resident #323's HCP said the bed has had a large gap since he/she was admitted . She said she was told the bed was delivered without the extender, so she had been stuffing pillows in there so his/her feet didn't get stuck in the big gap. During an interview on 4/1/25 at 11:36 A.M., Resident #323's HCP said she asked if she could stuff more pillows in the gap and was told that it was okay because they didn't have anything else to put there. She proceeded to stuff 4-5 pillows in the opening. During an interview on 4/2/25 at 10:28 A.M., Nurse #4 said the regular bed was too small, which is why he/she is in the big bed, but the mattress is too small. There is no extender for it, so that is why his/her HCP stuffed the pillows in there. During an interview on 4/2/25 at 10:39 A.M., the Housekeeping Supervisor said the facility owned one bariatric bed and deferred any questions relating to the bed to the Maintenance Supervisor. During an interview on 4/2/25 at 3:15 P.M., the Director of Maintenance said the facility had two bariatric beds in the facility. He said one is extended, so it's longer than the other one. He said they had a couple different mattresses for the beds, and they were not the same length. He was unable to provide the surveyor with an inspection of the bed and mattress in question. He said the gap on the bed should not be that big. Additionally, he said he thought the bed used to have a longer mattress on it, but the residents did not like it, so there was different mattress on it. He said he had not looked at the bed/mattress closely, they just moved it into that room last week for this Resident. During a telephone interview on 4/2/25 at 3:15 P.M., Maintenance Staff #1 said the beds have annual inspections but the bariatric beds did not have any entrapment assessments because they did not have to be tested. He said the gap on the bed should not be that big and advised the Director of Maintenance to see if they had a [NAME] Wedge (bed extender/bolster) and to look at the bed. The surveyor and the Director of Maintenance went upstairs to look at Resident #323's bed. During inspection of the bed and interview on 4/2/25 at 3:40 P.M., the Director of Maintenance said the gap in the bed from end of the mattress to the footboard should not be that big. He installed the extender/bolster on the bed, closing the gap from approximately 10 to 4-5. During an interview on 4/2/25 at 3:45 P.M., Resident #323 and his/her HCP said that was much better than the big, huge gap that had been there for the last five days. During an interview on 4/4/25 at 9:55 A.M., the Director of Maintenance said they did not have an inspection log for the bed/mattress. At 10:49 A.M., he provided a mechanical inspection of the bed dated 10/29/24, however this was for the bed mechanics and not the mattress fitting the bed. He said they did not have any log indicating the mattress was the correct size for the bed frame. During an interview on 4/4/25 at 10:54 A.M., Nurse #2 said she did not know why the extender was not on the bed for five days. She said she thought they had the extenders in the facility and said it should have been put on last week and the gap should not have been filled with pillows. She said the extender is on there now, but it was not there on 4/1/25. During an interview on 4/4/25 at 1:33 P.M., the Director of Nurses said the mattress should fit the bed properly and the gap should not be that large. She said usually there is an extender/bolster in place if the bed is extended and did not know why it was not in place since Resident #323 was put into that bed.

Based on interview and record review, the facility failed to ensure the medication Metformin (diabetic medication) was discontinued per the Resident's request which had been documented in the Nurse Practitioner Progress Notes multiple times for one Resident (#65), out of a sample size of 18 residents, resulting in Resident #65 receiving 100 extra doses of Metformin. Findings include: Resident #65 was admitted to the facility in July 2024 with diagnoses which included: Type ll diabetes and diabetic neuropathy. Review of the Minimum Data Set (MDS) assessment, dated 2/18/25, indicated Resident #65 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating Resident #65 was cognitively intact. During an interview on 4/4/25 at 12:45 P.M., Resident #65 said he/she met with Nurse Practitioner (NP) #1, and requested he/she stop taking Metformin and NP #1 agreed. Resident #65 said it took two to three months for the nurses to take it off his/her daily medication list. Review of the Physician's Orders indicated Metformin HCI oral tablet 500 milligrams (mg), give one tablet by mouth two times a day for diabetes mellitus, initiated on 7/3/24 and discontinued on 1/10/25. Review of Physician and NP's telephone orders in the medical record and maintained in overflow, indicated only one telephone order, dated 1/10/25, discontinuing Metformin 500 mg daily. Review of Resident #65's Medication Administration Record (MAR) from 11/19/24 through 1/10/25 indicated Resident #65 was administered 100 doses of Metformin during this timeframe. Review of NP #1's Progress Note, dated 10/28/24, indicated: -Assessment and plan: 4. Type 2 diabetes mellitus (DM), A1C (blood test that measures your sugar level over the past 2-3 months) 5.2% (normal A1C is below 5.6%), continue oral agents. Review of NP #1's Progress Note, dated 11/19/24, indicated: - Patient has requested that his/her Metformin be placed on hold. Despite several attempts to educate patient, we are in agreement to hold oral agent. -Assessment and Plan: 4. Type 2 DM, A1C 5.2%, oral agents placed on hold per patient's request. Continue to trend blood glucose levels. Review of NP #1's Progress Note, dated 12/5/24, indicated: -Assessment and Plan: 4. Type 2 DM, A1C 5.2%, oral agents placed on hold per patients request. Continue to trend blood glucose levels. Review of NP #1's Progress Note, dated 12/10/24, indicated: -Assessment and Plan: 4. Type 2 DM, A1C 5.2%, oral agents placed on hold per patients request. Continue to trend blood glucose levels. Review of NP #1's Progress Note, dated 12/27/24, indicated: -Assessment and Plan: 7. Type 2 diabetes managed by diet monitor A1C. Review of NP #1's progress note, dated 1/3/25, indicated: -Assessment and Plan: 3. Type 2 DM, A1C 5.2%, Oral agents placed on hold per patient's request. Continue to trend glucose levels. Review of NP #1's Progress Note, dated 1/10/25, indicated: -Extensive discussion with medications discontinued including Metformin due to gastrointestinal upset. -Assessment and Plan: 7. Type 2 DM. Metformin discontinued secondary to gastrointestinal (GI) issues. Continue glimepiride. Monitor A1C. Recent A1C 5.2%. During an interview on 4/4/25 at 2:20 P.M., the Director of Nurses (DON) said the NP needs to write an order for the nurses to stop the medication. The DON said the nurses are not going to read all of the notes. During a telephonic interview on 4/10/25 at 9:52 A.M., NP #1 said she had a conversation with Resident #65 and to the best of her recollection she gave a verbal order to a nurse, but she can't remember which nurse. NP #1 said Resident #65 wants to be in control of his/her medications. NP #1 said at some point he/she complained of loose stools which was one of the reasons for stopping the medication.

Based on observation, interview, and test tray results, the facility failed to provide food to residents that was palatable and served at appetizing temperatures for both food and drinks for one of three test trays. Findings include: On 4/3/25 at 7:50 A.M., the surveyor requested a test tray, which left the kitchen at 7:47 A.M. The last tray was served off the meal cart at 8:16 A.M. The surveyor tested the tray with Medical Records Staff #1 with the following results: -Scrambled eggs were 111 degrees Fahrenheit (F). The eggs had a rubbery texture, were dry and cold. -Oatmeal was 119 degrees F, tepid (lukewarm) and pasty to taste. -Plastic cup of apple juice, which was served from the kitchen was 48.6 degrees F. It was not cold. -Milk carton 36.3 F. It was palatable and cold. -Cup of coffee served on the unit was 152.9 F. It was palatable and hot. During interviews with Residents after the completion of the breakfast meal pass on 4/3/25, the Residents made the following comments: -Resident #38 said he/she didn't like breakfast and sent it back, and he/she was given a couple of yogurts from the certified nursing assistant. -Resident #30 said he/she didn't like the eggs. -Resident #1A said the eggs were so-so. -Resident #53 said he/she didn't like the eggs, he/she said, look at my plate I didn't eat any of them. -Resident #7 said the eggs are terrible, he/she just had the toast and orange juice. -Resident #52 said he/she is not a fan of the eggs, they are liquid. Resident #52 said he/she doesn't understand why they can't just put onion and/or garlic powder in the eggs to try to make them taste better. He/she said they are over scrambled and leathery. The results of the test tray validated the Residents' complaints of unpalatable, unappetizing, and cold food.

Based on observation, meal ticket review, and interview, the facility failed to ensure residents were receiving the correct therapeutic diets. Specifically, the facility failed to: 1. Ensure during tray service in main kitchen that the dietary aides calling out the diets off the meal tickets were including the resident specific therapeutic diets, including heart healthy, no salt added, and low concentrated sugar diets for three meals observed; and 2. Ensure the residents were being offered and choosing the correct therapeutic diet off the menu and the alternative menu. Findings include: 1a. Review of the therapeutic diets for 4/2/25 dinner meal included the following: -Heart Healthy: Pork loin, no garlic mushroom gravy, no salt added white rice, and no salt added zucchini and onions. -Low concentrated sweet: sugar substitute On 4/2/25 at 4:50 P.M. the surveyor observed the main kitchen dinner tray line service and made the following observations: -Dietary staff was only calling out resident's diets as regular, ground, or mechanical soft diets and not calling out the resident specific therapeutic diets such as heart healthy, LCS, and NAS diets. -Residents with heart healthy diets served pork loin with the garlic mushroom gravy. -Residents with NAS diets with packets of salt on their trays. -Only one pan of white rice and one pan of zucchini and onion. b. Review of the therapeutics diets for 4/3/25 breakfast meal included the following: -Heart Healthy: Egg substitution, no added salt. -Low concentrated sweet (LCS)/No salt added (NAS): Biscuit instead of white toast, sugar substitute. On 4/3/25 at 7:50 A.M., the surveyor observed the main kitchen breakfast tray line service and made the following observations: -Dietary staff was only calling out resident's diets as regular, ground, or mechanical soft diets and not calling out the resident specific therapeutic diets such as heart healthy, LCS, and NAS diets. -Residents with heart healthy diets served regular scrambled eggs, not egg substitute. -Residents with NAS diets with packets of salt on their trays. -Only one pan of regular scrambled eggs, no egg substitute. -No biscuits on tray line. c. Review of the therapeutics diets for 4/3/25 lunch meal included the following: -Heart Healthy: Cube steak, no onion gravy, no salt added peas, sugar and pepper one package each. On 4/3/25 at 11:50 A.M., the surveyor observed the main kitchen lunch tray line service and made the following observations: -Dietary staff was only calling out resident's diets as regular, ground, or mechanical soft diets and not calling out the resident specific therapeutic diets such as heart healthy, LCS, and NAS diets. -Residents with heart healthy diets served cube steak with onion gravy. -Residents with NAS diets with packets of salt on their trays. -Green beans, carrots and cauliflower, there were no peas on the tray line. On 4/4/25 at 11:35 A.M., the surveyor observed the Corporate Food Service Manager on the lunch tray service line calling the correct therapeutic diets including heart healthy, NAS, and LCS, the correct texture, and removing salt packets from trays in which the resident was on a NAS diet. During an interview on 4/4/25 at 11:35 A.M., the Corporate Food Service Manager said he was working on the tray line today to ensure the trays were accurate. He said when asked by the surveyor he did notice the dietary staff was calling out regular diets and not including specific therapeutic diets such as heart healthy and NAS to the cooks. He said the cooks would not know to make a substitution unless they were told the therapeutic diet. 2. Review of the therapeutics diets for 4/4/25 lunch meal included the following: -Heart Healthy: Oven fried fish instead of the main meal BBQ rib patty and one slice of bread instead of cornbread. On 4/4/25 at 9:10 A.M., the surveyor reviewed diet slips filled out by Activity Staff #1 and made the following observations: -Resident #3A's diet slip indicated Heart Healthy, LCS regular. Resident #3A selected Cheeseburger with tomato for lunch and dinner. -Resident #4A's diet slip indicated Heart Healthy regular, NAS. Resident #4A selected Cheeseburger for lunch and dinner. -The following Resident's diet slips all indicated heart healthy diets: Resident #19, #324, #323, #65's, and Resident #1A's. Their diet slips indicated they were to be served for lunch BBQ Rib patty for lunch. During an interview on 4/4/25 at 9:10 A.M., Activity Staff #1 said he goes around to the resident rooms and tells them what is on the menu for lunch and dinner and encourages the residents to pick their meals. He said if they don't like the main meal, they could pick from the alternate menu. He said he is not aware of the difference when the meal ticket says heart healthy, NAS, or low concentrated sweets. Activity Staff #1 said he offered all the residents today BBQ rib patty for lunch. He said he was not aware the healthy heart substitution today was oven fried fish. He said if a resident doesn't like the main meal, he lets them pick anything off the alternate menu. Review of the menu Activity Staff #1 was offering residents on 4/4/25 for lunch included: BBQ rib patty, creamy coleslaw, spiced pear bar, cornbread, margarine, coffee/tea, and condiments. There were no choices for heart healthy or NAS/LCS. Review of the alternate menu taped on the clipboard Activity Staff #1 was offering to residents for lunch on 4/4/25 included: Grilled cheese/tomato, peanut butter and Jelly, cheeseburger, hamburger, chef salad, tuna salad, chicken salad, egg salad, ham salad, deli sandwich, and cottage cheese fruit plate. Activity Staff #1 said he was not aware if any of the choices were heart healthy, NAS, or LCS. He said they can pick anything off the alternate menu. During an interview on 4/4/25 at 11:35 A.M., the Corporate Food Service Manager said the cooks would not know to make the correct therapeutic substitutions unless they were told during the line if a resident was on a heart healthy or low concentrated sweets diet or if the menu was filled out to include the correct therapeutic diet. When asked by the surveyor, the Corporate Food Service Manager said residents on a heart healthy diet should have been offered the pan fried fish today. He said a cheeseburger instead of the BBQ ribs would not be an appropriate substitution for a heart healthy diet.

Based on record review and interviews, the facility failed to ensure staff maintained accurate documentation for two Residents (#1 and #65), out of a total sample of 18 residents. Specifically, the facility failed: 1. For Resident #1, to ensure Medication Administration Records (MAR) and Treatment Administration Records (TAR) were accurate and reflected the administration of medications and treatments per physician's orders; and 2. For Resident #65, to accurately record the resident's weight in the medical record. Findings include: Review of the facility's policy titled Charting and Documentation, undated, indicated but was not limited to the following: -Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. -Entries may only be recorded in the resident's clinical record by licensed personnel (e.g. registered nurse, licensed practical nurse, physicians, therapist, etc.) in accordance with state law and facility policy. Certified nursing assistants may only make entries in the resident's medical chart as permitted by facility policy. -Documentation in the medical record may be electronic, manual or a combination. -The following information is to be documented in the resident medical record as warranted: -Objective observations. -Medications administered. -Treatments or services performed 1. Resident #1 was admitted to the facility in January 2023 with diagnoses including Type 2 diabetes mellitus with hyperglycemia and use of insulin. Review of the Physician's Orders included but was not limited to: - Free style Libre 2 Reader Device (Continuous Glucose System Receiver) Apply 1 device transdermally one time a day for diabetes management. - Lantus (to treat elevated blood sugar) Solostar Subcutaneous Solution Pen-injector 100 Unit/ML (Insulin Glargine) Inject 30 Unit subcutaneously one time a day related to Type 2 diabetes Mellitus with Hyperglycemia alternate sites. - Anticoagulant medication (monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea joint pain, lethargy bruising and sudden change in mental status), every shift. - Novolog Flex Pen Subcutaneous Solution Pen Injector 100 Unit/ML (Insulin Aspart) Inject six units before meals related to type 2 diabetes mellitus with hyperglycemia. - Novolog Flex Pen Subcutaneous Solution Pen Injector 100 Unit/ML (Insulin Aspart) Inject as per sliding before meals daily. Review of Resident #1's January 2025 through March 2025 MARs indicated the following medications were not signed off as administered on 66 occasions as evidenced by several blank, unsigned boxes as follows: Free style Libre 2 Reader Device: (Day) 1/27/25, 2/9/25 Lantus Insulin: (day shift) 1/2/25, 1/3/25, 1/17/25, 1/22/25, 1/25/25, 1/29/25, 1/30/25, 1/31/25; 2/2/25, 2/3/25, 2/5/25, 2/16/25, 2/17/25, 2/19/25, 2/20/25, 2/25/25; 3/7/25. Anticoagulant medication: (Night) 1/16/25, 1/21/25, 1/24/25, 1/28/25, 1/29/25, 1/30/25; 2/1/25, 2/2/25, 2/4/25, 2/16/25, 2/19/25, 2/24/25, 3/4/25. Novolog Flex Pen: (every shift) 1/2/25, 1/3/25, 1/8/25, 1/10/25, 1/15/25, 1/17/25, 1/19/25, 1/22/25, 1/23/25, 1/25/25, 1/29/25, 1/30/25, 1/31/25 Novolog Flex: (morning) 1/2/25, 1/3/25, 1/8/25, 1/10/25, 1/15/25, 1/17/25, 1/19/25, 1/22/25, 1/23/25, 1/25/25, 1/29/25, 1/30/25, 1/31/25; 2/2/25, 2/3/25, 2/16/25, 2/17/25, 2/19/25, 2/20/25, 2/25/25, and 3/4/25 Review of Resident #1's January through March 2025 Physician's Treatment Orders included but was not limited to: -Coccyx pressure wound cleanser: Cleanse with wound cleanser, pat dry, apply Silver Sulfadiazine house barrier cream every day shift for wound healing -Diabetic foot care for prevention every evening shift for prevention, write a progress note if abnormal findings Review of the Resident #1's January 2025 through March 2025 TARs indicated the following medications were not signed off as administered on 12 occasions as evidenced by several blank, unsigned boxes as follows: -Coccyx pressure wound cleanser: (day shift) 1/2/25, 1/3/25, 2/9/25. -Diabetic foot care: (evening shift) 1/14/25, 1/18/25, 1/19/25, 1/29/25, 1/30/25; 2/1/25, 2/2/25, 2/5/25; 3/4/25. During an interview on 4/02/25 at 11:30 A.M., Nurse #5 said anytime a medication or treatment is administered it should be documented to prove it was done. During an interview on 4/03/25 at 10:25 A.M., Nurse #1 said the nurses are to document anytime a medication or treatment is administered. During an interview on 4/03/25 at 2:45 P.M., Nurse #3 said the nurses are to document anytime a treatment or medication is administered. During an interview on 4/04/25 at 2:30 P.M., the Assistant Director of Nurses (ADON) said she was not aware there was an issue with the documentation of MARs and TARs. She said the nurses might have administered the medications and provided the treatment but forgot to document. 2. Resident #65 was admitted to the facility in July 2024 with diagnoses which included: displaced fracture of the neck of left femur and surgical after care of left hip. Review of the Minimum Data Set (MDS) assessment, dated 2/18/25, indicated Resident #65 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating Resident #65 was cognitively intact. During an interview on 4/4/25 at 12:45 P.M., Resident #65 said at his/her last physical before being hospitalized in June, he/she weighed 180 pounds (lbs.). Resident #65 said while in the hospital he/she lost about 60 lbs., and they even put him/her on a medication to stimulate his/her appetite. Resident #65 said he/she has never weighed over 200 lbs. Review of Resident #65's weights indicated the following weights since admission: -7/3/24 weight: 208.7 lbs. sitting -7/3/24 weight: 208.7 lbs. mechanical lift -7/24/24 weight: 210.2 lbs. standing -8/12/24 weight: 211.6 lbs. wheelchair -8/20/24 weight: 211.1 lbs. wheelchair -9/11/24 weight: 211.8 lbs. mechanical lift -9/17/24 weight 211.1 lbs. mechanical lift -9/24/24 weight 212.3 lbs. wheelchair -10/1/24 weight 212.9 lbs. wheelchair -11/1/1/24 weight: 213 lbs. wheelchair -11/2/24 weight: 213 lbs. wheelchair -11/3/24 weight: 213 lbs.-last weight obtained-refusal -12/1/24 weight: 213 lbs.- last weight obtained-refusal -12/4/24 weight: 213 lbs. wheelchair -12/7/24 weight:157 lbs. wheelchair Review of the nutritional evaluation comprehensive, dated 7/5/24, indicated but was not limited to the following: -Resident #65's admission weight was 208.7 lbs. -Usual body weight 200# per resident. -Current body weight 208.7 lbs., body mass index (BMI) 30.8 (Overweight). -Resident believes he/she lost weight but unsure of amount, admit weight consistent with hospital weight and he/she is overweight per BMI. Review of nutritional evaluation comprehensive, dated 8/28/24, indicated but was not limited to the following: -Resident weight 211.1 lbs. (8/20/24) -Resident readmitted following a medical leave of absence. -Current body weight represents mild gain of 2.4 lbs. 1% increase since admission. Review of a Nutrition Dietary Note, dated 9/27/24, indicated current body weight 212.3 lbs. (9/24/24). Resident has had a mild weight gain of plus 3.6 lbs. since admission and per chart has excellent meal take. Review of a Nutrition Dietary Note, dated 10/25/24, indicated current body weight 212.9 lbs. (10/1/14). Weight is stable over last 30 days and current body weight represents a mild gain plus 4.2 lbs. since admission. Review of a Nutrition Dietary Note, dated 12/28/24, indicated current body weight 155 lbs. (12/19/24). Resident flagging for significant weight change and continues with wounds. Regarding weight, Resident noted with a sudden large drop from 213 lbs. to 157 lbs. in early December. Resident #65 was re-weighed and found that previous weights in 200's were including wheelchair weight (approximately 60 lbs.), which were falsely elevating true body weight. During an interview on 4/04/25 at 12:20 P.M., the Dietitian said Resident #65 did not have a significant weight loss, they found in December that Resident #65's recorded weight included the weight of the wheelchair. The Dietitian said when Resident #65's weight went from 213 lbs. to 157 lbs. in three days, the only conclusion was the weights in the 200's was wrong, and the CNAs were not subtracting the weight of his/her wheelchair.

Based on interviews, record review, and policy review, the facility failed to notify the physician and the Resident's responsible party about a change in condition, specifically a significant weight loss of 10.95% in one month, and to re-evaluate the potential need to alter the treatment plan for one Resident (#71), out of a total sample of 21 residents. Findings include: Review of the facility's policy titled Weight Measurement, dated as revised February 2022, included but was not limited to: - Residents with a weight variance of 5% more or less than the previous month will be re-weighed. - The charge nurse will notify the physician, responsible party and dietician when a 5% more or less variance is noted. Review of the facility's policy titled Change in a Resident's Condition or Status, undated, indicated but was not limited to the following: - Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition - The nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental conditioning - Significant change of condition is a major decline or improvement in the resident's status that: will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions and requires interdisciplinary review and/or revision to the care plan Resident #71 was admitted to the facility in June 2023 with diagnoses including: dysphagia (difficulty swallowing), hemiparesis (weakness of one side of the body), hypertension (high blood pressure), and diabetes type II. Review of the Minimum Data Set (MDS) assessment, dated 12/19/23, included but was not limited to the following: -Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the Resident was cognitively intact. -Section K of the MDS, which indicated swallowing/nutritional status, and triggered for weight loss of 5% or more in the last month or 10% or more in the last 6 months. -Section K also indicated that Resident #71 was not on a prescribed weight loss regimen. Resident #71's health care proxy (HCP) was invoked on 8/16/23 due to an acute change in condition experiencing hallucinations and remained invoked at the time of survey. Review of the medical record indicated the following weights for Resident #71: - 11/07/23: 210 pounds (lbs.) - 12/05/23: 187 lbs. - 12/06/23: 187 lbs. - 12/07/23: 187 lbs. (loss of 10.95% in one month) - 12/08/23: 188.2 lbs. - 01/07/24: 184.8 lbs. Review of Resident #71's weights from 11/07/23 to 12/07/23 indicated a significant weight loss of 10.95%. Review of Resident #71's Progress Notes, dated 12/1/23 through 2/2/24, failed to indicate any documentation of notification of the significant weight loss to the Physician, Nurse Practitioner, Dietitian, or HCP. During an interview on 2/2/24 at 11:11 A.M., Nurse #9 said if there are any changes in a resident's weight of three pounds they will obtain daily weights for three days. If the three weights demonstrate the loss or gain is accurate, it is reported to the MD or Nurse Practitioner and the Director of Nursing (DON). Nurse #9 reviewed the record and was unable to locate any documentation the weight loss had been reported to the MD, Nurse Practitioner, HCP, or Director of Nurses. During an interview on 2/6/24 at 3:36 P.M., the HCP for Resident #71 said she was unaware of any weight loss, as no one from the facility had notified her. She said she visits often, and it had never been brought to her attention, prior to the surveyor contacting her. During an interview on 2/6/24 at 3:41 P.M., the Dietitian said he was aware of the significant weight loss. The Dietitian said he had not made recommendations or notified the provider of Resident #71's significant weight loss. During an interview on 2/6/24 at 4:27 P.M., the DON said she was not aware of Resident #71's significant weight loss and the Resident was not followed at the weekly risk meeting. She said her expectation was for the physician, HCP, and dietitian to be notified of any significant weight loss, per facility policy, and it was not followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, the facility failed to ensure an abdominal binder (an elastic compression belt-like device that encircles the abdomen) was assessed as a potential restraint for one Resident (#48), out of a total sample of 13 residents. Findings include: Review of the facility's policy titled Use of Restraints, undated, indicated but was not limited to the following: - Restraints shall be used for the safety and well-being of the resident and only after other alternatives have been tried unsuccessfully - When the use of a restraint is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation of the need for the restraint will be documented - Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached to or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body - Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention and a restraint is required to: treat a medical symptom, protect the resident's safety, and help the resident attain the highest level of his/her physical or psychosocial well-being - Prior to placing a resident in restraints, there shall be a pre-restraint assessment and review to determine the need for restraint. The assessment shall be used to determine underlying cause of the problematic medical symptom and to determine if there are less restrictive interventions that may improve the symptoms - Restraints should only be used upon the written order of a physician and after obtaining consent from the resident or their representative Resident #48 was admitted to the facility in December 2023 and had the following diagnoses: dysphagia (difficulty swallowing) and metabolic encephalopathy (an alteration in brain chemistry). Review of the Brief Interview for Mental Status (BIMS), dated 3/4/24, indicated Resident #48 was cognitively intact with a score of 14 out of 15. The Resident's healthcare proxy (HCP) was activated in December 2023 and remained active for medical decisions at the time of survey (3/7/24). Review of the current Physician's Orders for Resident #48, dated 3/7/24, indicated but were not limited to the following: - Abdominal binder at all times, remove for care and skin checks. Check placement three times a day. (2/20/24) Review of the medical record for Resident #48 failed to indicate: -the abdominal binder had been assessed as a potential restraint or any alternative had been trialed or considered prior to the use of the abdominal binder; and -a written or verbal consent had been received by Resident's HCP prior to the use of the restraint. During an interview on 3/7/24 at 10:48 A.M., Family Member #1 said Resident #48 had an abdominal binder in place while on medical leave from the facility from 2/23/24 through 2/28/24. She said Resident #48 frequently plays with and attempts to self-remove his/her G-tube. She said she has inquired about the use of the abdominal binder since the Resident returned to the facility on 2/28/24. Review of the current care plans for Resident #48 indicated, but were not limited to the following: Problem: Initiated: 2/5/24 Resident has a behavior problem attempting to pull out feeding tube (G-tube); at times pulls on the G-tube (revised: 2/29/24) Goal: Initiated: 2/5/24 Resident #48 will have fewer episodes of attempting to pull out feeding tube (revised: 2/6/24) Interventions: Initiated: 2/5/24 Administer medications as ordered; explain procedures to the resident and provide time to adjust; if reasonable discuss the resident's behavior and explain why it is inappropriate; intervene as necessary - approach in a calm manner and divert attention Problem: Initiated: 12/31/23 Resident #48 has dysphagia (revised: 1/5/24) Goal: Initiated: 12/31/23 Resident will be free from signs or symptoms of aspiration (the drawing of fluid into the lungs) (revised: 1/15/24) Interventions: G-tube care Q-shift (1/25/24) Abdominal (ABD) Binder at all times to avoid resident from pulling at the g-tube. May remove for care, monitor skin for breakdown with care (2/20/22) Review of the February 2024 Treatment administration record (TAR) for Resident #48 indicated, but was not limited to the following: - Abdominal binder at all times, remove for care and skin checks, check placement three times a day (2/20/24) was signed off as being in place by the licensed nurses on the following days: 2/20/24, 2/21/24, 2/23/24 (9:00 A.M. only), 2/28/24 (5:00 P.M. only), and 2/29/24 - On 2/23/24 from 1:00 P.M., through 2/28/24 at 1:00 P.M. the Resident was documented as being unavailable related to their hospitalization The TAR failed to indicate the Resident was monitored for or exhibited any behaviors of attempting to self-remove or pulling at the G-tube throughout the month of February 2024 Review of the March 2024 TAR for Resident #48 indicated, but was not limited to the following: - Abdominal binder at all times, remove for care and skin checks, check placement three times a day (2/20/24) was signed off as being in place by the licensed nurses on the following days: 3/1/24 at 1:00 P.M. and 5:00 P.M. only, 3/2/24 all three scheduled times, 3/3/24 all three scheduled times, 3/4/24 at 9:00 A.M. and 5:00 P.M., 3/5/24 all three scheduled times, 3/6/24 at 5:00 P.M. The TAR failed to indicate the Resident was monitored for or exhibited any behaviors of attempting to self-remove or pulling at the G-tube from March 1st through March 7, 2024 During an interview on 3/7/24 at 2:33 P.M., Physician #1 said he provided the facility with an order to use an abdominal binder on the Resident since the Resident has behaviors and pulls at their G-tube to help preserve the tube and maintain the Resident's safety. He said the Resident was successful in removing their G-tube on 2/23/24 and was hospitalized and upon the Resident's return he continued to order for the abdominal binder to be used at all times to prevent the Resident from harming themselves and removing their G-tube. He said he is unaware of the facility process to determine if an alternative device or intervention could be tried or has been assessed. He said it is the facility's responsibility to ensure the behaviors are monitored and they evaluate the use of the device and the Resident's tolerance to the device and would expect that they followed their policies. He said to the best of his knowledge Resident #48 wears the abdominal binder and he has not been contacted to say the Resident cannot tolerate the device. He said he felt at this time to protect the Resident if the HCP is agreeable the abdominal binder would likely be the best option to ensure the integrity of the G-tube if the Resident is attempting to self-remove it. He said his expectation is that the facility communicates if there is a problem. Review of the daily skilled notes and progress notes for Resident #48 from 2/12/24 to current (3/7/24) indicated but were not limited to the following: - 2/12/24 at 6:32 A.M., Resident tugging at G-tube while feeding is running, redirection not successful - 2/21/24 at 2:18 A.M., Resident received new order for abdominal binder at all times. Remove for care and skin checks. Check placement three times a day - 2/21/24 at 3:47 P.M., Resident continues to pull at G-tube causing leakage, abdominal binder ordered and tolerated - 2/22/24 at 2:43 P.M., Abdominal binder in place - 2/23/24 at 8:35 A.M. To emergency room (ER) for G-tube replacement - 2/24/24 at 1:49 P.M., Resident sent to ER on [DATE] to have G-tube replaced after he/she pulled it out - 3/1/24 at 11:14 A.M. (Administration note) Abdominal binder at all times - will not keep in place The daily skilled notes and progress notes from 2/12/24 to 3/7/24 failed to indicate alternatives were attempted prior to the use of the abdominal binder or that the Resident exhibited any behaviors involving pulling at the G-tube or trying to remove the G-tube with the exception of the above notations. During an interview on 3/7/24 at 3:45 P.M., Nurse #4 said she didn't realize the abdominal binder could be considered a restraint until after she reviewed the facility policy definition of a restraint, but it could be a restraint and the facility should have completed a physical restraint assessment and documented the Resident's tolerance to the device. She said she didn't realize the order for the binder was still in place and written to be at all times. During an interview on 3/7/24 at 3:47 P.M., Nurse #1 said on review of the facility policy the abdominal binder does meet the definition of a potential restraint and the facility should have completed a physical restraint assessment for the Resident at the time the order was received and upon re-admission to the facility following the Resident's hospitalization. He said the device should be monitored to determine if the Resident can tolerate the device and self-remove the device and although he believes the Resident could likely remove the device on review of the medical record, he did not see that information documented anywhere. During an interview on 3/7/24 at 3:58 P.M., the Director of Nurses (DON) said Resident #48 had an order for an abdominal binder to be in place at all times due to the Resident having behaviors of pulling on the G-tube. She said the order was received prior to the Resident being hospitalized for self-removing their G-tube and remains active at this time. She reviewed the facility policy for restraint use and said the abdominal binder should have been assessed to determine whether it was a restraint for the Resident, as the binder does meet the definition of a potential physical restraint. She said the binder would likely be a restraint for the Resident but since she doesn't have an assessment done it's hard to tell. She said the policy for restraint use was not followed as it should have been and her expectation is that facility policies are followed. She said she would look to see if she had any other information on the Resident's use of the abdominal binder and whether it was considered a restraint for the Resident and get back to the survey team. During a follow up interview on 3/7/24 at 5:02 P.M., the DON said there was no documentation on an assessment of the device for Resident #48 to determine whether it was a restraint.

Based on observation, policy review and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#33), out of a total sample of 21 residents. Specifically, the facility failed to implement their policy for reporting and investigating an allegation of neglect for Resident #33 who was in pain and not administered pain medications for over an hour. Findings include: Review of the facility's policy titled Abuse, dated March 2023, indicated but was not limited to the following: -Any complaint of, observation of, or suspicion of resident abuse, mistreatment or neglect is to be thoroughly investigated and reported. -Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. -Reporting timeline requirements for all allegations 2-hour requirement to report to the Department of Public Health and Local Law Enforcement. -Facility investigation will be completed within 72 hours of the incident, documentation of investigation to be: completing an Incident and Accident report, obtaining statements from identified potential witnesses, completing necessary evaluations (pain, skin, body checks), and maintaining a timeline of events. Resident #33 was admitted to the facility in April 2022 with diagnoses which included but was not limited to osteomyelitis (infection of the bone), Stage 4 pressure ulcer (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone) of sacral region. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/17/24, indicated Resident #33 had intact cognitive function as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. On 1/31/24 at 7:10 A.M., the surveyor observed Resident #33 request pain medication from Nurse #4. The surveyor observed Nurse #4 tell Resident #33 that he/she would have to wait because the breakfast meal was on the way up from the kitchen. The surveyor observed the Resident shifting his/her weight in the wheelchair, had a furrowed brow, and was grimacing. The surveyor observed the Resident tell Nurse #4 that he/she was in a lot of pain. On 1/31/24 at 7:18 A.M., the surveyor observed Unit Manager #2 tell Nurse #4 to give Resident #33 his/her pain medication. Nurse #4 responded the breakfast trays were going to be on the unit shortly. On 1/31/24 from 7:18 A.M. through 8:09 A.M. the surveyor observed Nurse #4 to be on the unit and not administering pain medication to Resident #33. During an interview on 1/31/24 at 8:09 A.M., Nurse #4 said Resident #33 did request pain medications before breakfast and she was going to give the requested medication with his/her morning medication. On 1/31/24 at 8:17 A.M., the surveyor heard Resident #33 yell out from his/her room What is taking so long? I'm in so much pain and so sore, I asked for pain medication a while ago. At 8:23 A.M., the surveyor heard Resident #33 yelling out Please, I'm in pain! At 8:25 A.M., the surveyor observed Nurse #4 give Resident #33 the requested pain medication. The surveyor observed that Resident #33 waited at least 75 minutes for their requested pain medication. During an interview on 1/31/24 at 8:26 A.M., the Resident said he/she asked for pain medications before breakfast and has been in pain since he/she got out of bed at 5:30 A.M. Resident #33 said his/her pain was a 9 out of 10 (on a pain scale of 1-10 with 10 being the worst pain) and if it was any higher he/she would have to go to the hospital. During an interview on 2/1/24 at 7:15 A.M., Resident #33 said that he/she asked for pain medications from the night nurse an hour prior and had not received them. On 2/1/24 at 7:25 A.M. the surveyor observed Nurse #5 tell the Assistant Director of Nurses (ADON) that she was waiting for the next nurse to come relieve her and only one additional resident needed medication and indicated the Resident (which was not Resident #33). On 2/1/24 at 7:39 A.M., the surveyor observed Nurse #5 give Resident #33 the requested pain medication, at least 24 minutes after he/she asked for it. During an interview on 2/1/24 at 4:36 P.M., the Director of Nurses (DON) said she had met with Resident #33 who told her he/she had a lengthy delay (over an hour) for pain medication administered on 1/31/24 and 2/1/24 and on 1/31/24 the Resident said he/she was told to wait for the medication until after breakfast. The DON said the Resident should not have to wait for pain medication. The DON said she had not initiated an investigation into Resident #33 not receiving pain medication when requested. The DON said that the incident did meet the definition of neglect. During an interview on 2/1/24 at 4:48 P.M., the ADON said these two incidents with Resident #33 met the definition for neglect. During an interview on 2/2/24 at 3:08 P.M., the Social Worker said that she was informed of the two events with Resident #33 not receiving medication when asked. She said that she would leave it up to the DON to investigate and follow the facility abuse policy since she was already aware. During an interview on 2/6/24 at 3:25 P.M., the Administrator said neither incident of Resident #33 waiting for pain medications were neglect because there was no willful intent. He was unable to provide any investigative information for how the facility came to this conclusion. During an interview on 2/6/24 at 3:25 P.M., the DON said the first incident on 1/31/24 was not neglect because the nurse did not administer the medication because she misunderstood about giving medications during mealtimes and the second incident on 2/1/24 was being reviewed. She said there were no investigations available for either incident and neither incident had been reported to the Department of Public Health. At the time of the survey team exit, neither the DON nor the Administrator were able to provide statements, investigative materials, or resident statements regarding the two incidents that the DON acknowledged met the definition of neglect. Refer to F609, F610, F697

Based on observation, policy review, and interview, the facility failed to ensure an allegation of neglect was reported for one Resident (#33), out of a total sample of 21 residents. Specifically, the facility failed to report an allegation of neglect to the State Survey Agency (Department of Public Health) for Resident #33, who was experiencing pain of a 9 (on a scale of 1-10 with 10 being the worst pain), and who was not administered pain medications for over an hour. Findings include: Review of the facility's policy titled Abuse, dated March 2023, indicated but was not limited to the following: -Any complaint of, observation of, or suspicion of resident abuse, mistreatment or neglect is to be thoroughly investigated and reported. -Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. -Reporting timeline requirements for all allegations 2-hour requirement to report to the Department of Public Health and Local Law Enforcement. Resident #33 was admitted to the facility in April 2022 with diagnoses which included but is not limited to osteomyelitis (infection of the bone) and Stage 4 pressure ulcer (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone) of sacral region. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/17/24, indicated Resident #33 had intact cognitive function as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. On 1/31/24 at 7:10 A.M., the surveyor observed Resident #33 request pain medication from Nurse #4. The surveyor observed Nurse #4 tell Resident #33 that he/she would have to wait because the breakfast meal was on the way up from the kitchen. The surveyor observed the Resident shifting his/her weight in the wheelchair, had a furrowed brow, and was grimacing. The surveyor observed the Resident tell Nurse #4 that he/she was in a lot of pain. On 1/31/24 from 7:18 A.M. through 8:09 A.M., the surveyor observed Nurse #4 to be on the unit and not administering pain medication to Resident #33. During an interview on 1/31/24 at 8:09 A.M., Nurse #4 said Resident #33 had requested pain medications before breakfast, and she was going to give the requested medication to the Resident with his/her morning medication. On 1/31/24 at 8:17 A.M., the surveyor heard Resident #33 yell out from his/her room What is taking so long? I'm in so much pain and so sore, I asked for pain medication a while ago. At 8:23 A.M., the surveyor heard Resident #33 yelling out Please, I'm in pain! On 1/31/24 at 8:25 A.M., the surveyor observed Nurse # 4 give Resident #33 the requested pain medication. The surveyor observed that Resident #33 waited at least 75 minutes for his/her requested pain medication. During an interview on 1/31/24 at 3:27 P.M., the Director of Nurses (DON) said that her expectation was that the Resident would have received his/her medication when they asked and not have to wait until after breakfast to receive his/her requested pain medication since Resident #33 was in pain. During an interview on 2/1/24 at 7:15 A.M., Resident #33 said that he/she asked for pain medications from the night nurse an hour prior and had not received them. On 2/1/24 at 7:25 A.M., the surveyor observed Nurse #5 tell the Assistant Director of Nurses (ADON) that she was waiting for the next nurse to come relieve her and only one additional resident needed medication and indicated the Resident (which was not Resident #33). On 2/1/24 at 7:39 A.M., the surveyor observed Nurse #5 give Resident #33 the requested pain medication, at least 24 minutes after he/she asked for it. During an interview on 2/1/24 at 4:36 P.M., the Director of Nurses (DON) said she had met with Resident #33 who told her he/she had a lengthy delay (over an hour) for pain medication administered on 1/31/24 and 2/1/24 and on 1/31/24 the Resident said he/she was told to wait for the medication until after breakfast. The DON said the Resident should not have to wait for pain medication. The DON said that the incident did meet the definition of neglect. She said she had not reported the neglect to the Department of Public Health. During an interview on 2/1/24 at 4:58 P.M., the ADON said she trains staff on abuse and neglect in orientation and that these two incidents meet the definition of neglect. During an interview on 2/2/24 at 3:08 P.M., the Social Worker said that she was informed of the two events with Resident #33 not receiving medication when requested. She said that she would leave it up to the DON to follow the facility abuse policy since she was already aware. During an interview on 2/6/24 at 3:25 P.M., the Director of Nurses said the first incident on 1/31/24 was not neglect because the nurse did not administer medication because she misunderstood about providing medications during mealtimes and the second incident on 2/1/24 was being reviewed. She said neither incident had been reported to the Department of Public Health. During an interview on 2/6/24 at 3:25 P.M, the Administrator said the incidents for Resident #33 were not reported because they were not neglect. He said the acts had to be deliberate and he did not believe the two incidents were. Refer to F610, F697

Based on observation, policy review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#33), out of a total sample of 21 residents. Specifically, the facility failed to follow their policy for investigating an allegation of neglect for Resident #33 who was experiencing pain of a 9 (on a pain scale of 1-10 with 10 being the worst pain), and who waited over an hour for pain medication. Findings include: Review of the facility's policy titled Abuse indicated but was not limited to the following: -Any complaint of, observation of, or suspicion of resident abuse, mistreatment or neglect is to be thoroughly investigated and reported. -Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. -Reporting timeline requirements for all allegations 2-hour requirement to report to the Department of Public Health and Local Law Enforcement) -Facility investigation will be completed within 72 hours of the incident, documentation of investigation to be: completing an Incident and Accident report, obtaining statements from identified potential witnesses, completing necessary evaluations (pain, skin, body checks), and maintaining a timeline of events. Resident #33 was admitted to the facility in April 2022 with diagnoses which included but is not limited to osteomyelitis (infection of the bone) and Stage 4 pressure ulcer (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone) of sacral region. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/17/24, indicated Resident #33 had intact cognitive function as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. On 1/31/24 at 7:10 A.M., the surveyor observed Resident #33 request pain medication from Nurse #4. The surveyor observed Nurse #4 tell Resident #33 that he/she would have to wait because the breakfast meal was on the way up from the kitchen. The surveyor observed the Resident shifting his/her weight in the wheelchair, had a furrowed brow, and was grimacing. The surveyor observed the Resident tell Nurse #4 that he/she was in a lot of pain. On 1/31/24 from 7:18 A.M. through 8:09 A.M., the surveyor observed Nurse #4 to be on the unit and not administering pain medication to Resident #33. During an interview on 1/31/24 at 8:09 A.M., Nurse #4 said Resident #33 had requested pain medications before breakfast, and she was going to give the requested medication to the Resident with his/her morning medication. On 1/31/24 at 8:17 A.M., the surveyor heard Resident #33 yell out from his/her room What is taking so long? I'm in so much pain and so sore, I asked for pain medication a while ago. At 8:23 A.M., the surveyor heard Resident #33 yelling out Please, I'm in pain! On 1/31/24 at 8:25 A.M., the surveyor observed Nurse #4 give Resident #33 the requested pain medication. The surveyor observed that Resident #33 waited at least 75 minutes for his/her requested pain medication. During an interview on 1/31/24 at 3:27 P.M., the Director of Nurses (DON) said that her expectation was that the Resident would have received his/her medication when they asked and not have to wait until after breakfast to receive his/her requested pain medication since Resident #33 was in pain. During an interview on 2/1/24 at 7:15 A.M., Resident #33 said that he/she asked for pain medications from the night nurse an hour prior and had not received them. On 2/1/24 at 7:25 A.M., the surveyor observed Nurse #5 tell the Assistant Director of Nurses (ADON) that she was waiting for the next nurse to come relieve her and only one additional resident needed medication and indicated the Resident (which was not Resident #33). On 2/1/24 at 7:39 A.M., the surveyor observed Nurse #5 give Resident #33 the requested pain medication, at least 24 minutes after he/she asked for it. During an interview on 2/1/24 at 4:36 P.M., the DON said she had met with Resident #33 who told her he/she had a lengthy delay (over an hour) for pain medication administration on 1/31/24 and 2/1/24 and on 1/31/24 the Resident said he/she was told to wait for the medication until after breakfast. The DON said the Resident should not have to wait for pain medication. The DON said that the incident did meet the definition of neglect. She said she had not initiated an investigation. During an interview on 2/1/24 at 4:58 P.M., the Assistant Director of Nurses (ADON) said she trains staff on abuse and neglect in orientation and that these two incidents meet the definition of neglect. During an interview on 2/2/24 at 3:08 P.M., the Social Worker said she was informed of the two events with Resident #33 not receiving medication when requested. She said she would leave it up to the DON to investigate and follow the facility abuse policy since she was already aware. During an interview on 2/6/24 at 3:25 P.M., the Director of Nurses said the first incident on 1/31/24 was not neglect because the nurse did not administer medication because she misunderstood about not giving medications when residents were eating meals and the second incident on 2/1/24 was being reviewed. She said there were no investigative materials including staff or resident statements for the two incidents. During an interview on 2/6/24 at 3:25 P.M, the Administrator said the incidents for Resident #33 were not neglect because the acts had to be deliberate and he did not believe the two incidents were. He was unable to provide any investigative information for how the facility came to this conclusion. Refer to F697

Based on record review, policy review, and interview, the facility failed to provide the resident and their representative with a summary of the baseline care plan for two Residents (#65 and #74), out of a total sample of 21 residents. Findings include: Review of the facility's policy titled Care plans - Baseline, dated as revised July 2023, indicated but was not limited to the following: - a baseline care plan will be developed and implemented to assure a resident's immediate care needs are met and maintained - a baseline care plan will be developed within 48 hours of the resident's admission The facility policy does not indicate that a summary of the baseline care plan is provided to the resident or their representative as required. 1. Resident #65 was admitted to the facility in December 2023 with diagnoses including: neurocognitive disorder with Lewy bodies, metabolic encephalopathy, anxiety disorder, unspecified psychosis, and type 2 diabetes mellitus. Review of the medical record included the most recent Brief Interview for Mental Status (BIMS) which indicated a score of 2 out of 15, indicating the Resident was severely cognitively impaired, and his/her healthcare proxy (HCP) was activated. During an interview on 1/31/24 at 2:43 P.M., Family Member #1 said she does not feel the facility always communicates with her well in regard to Resident #65. She said she has not ever had a care plan meeting and is not aware of what the Resident's base line care plan information contains and was never provided with a copy of these documents and feels she has input that would be beneficial to the Resident's care. Review of the medical record for Resident #65 failed to indicate the family or resident were offered or provided a copy of the baseline care plans. 2. Resident #74 was admitted to the facility in January 2024 with diagnoses including: chronic respiratory failure, status post tracheostomy, and dysphagia (difficulty swallowing). Review of the most recent BIMS indicated a score of 15 out of 15, indicating the Resident was cognitively intact. During an interview on 2/6/24 at 9:22 A.M., the Resident said he/she had never had anyone review the goals of their care or been offered a copy of his/her baseline care plan information. During an interview on 2/2/24 at 1:38 P.M., the Social Worker said the first care plan meeting is held with residents or their families at or around day 21 of their stay. She said she does hold a 48-hour initial meeting to discuss discharge or long-term care plans, but care plans are not reviewed at that time and she does not offer the residents or their families a copy of their base line care plans. During an interview on 2/6/24 at 9:38 A.M., the Director of Nurses said she does not have any knowledge of baseline care plan meetings and all care plan meetings are scheduled and managed by the Social Worker. She said the Social Worker holds a 48-hour initial meeting with residents and/or their families, but she was not aware that baseline care plans were not discussed at that time or that a copy of the baseline care plans were not offered to the resident or their families.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and interview, the facility failed to provide an activities program designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, for two Residents (#56 and #65), out of a total sample of 21 residents. Specifically, the facility failed: 1. For Resident #56, to provide an activities program that would meet his/her individual interests to enhance his/her quality of life; and 2. For Resident #65, to plan for or provide an activities program that would meet his/her individual interests to enhance his/her quality of life. Findings include: Review of the facility's policy titled Activity Program, undated, indicated but was not limited to the following: -Activity programs designed to meet the needs of each resident are available on a daily basis. -Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. -Our activity programs consist of individual and small and large group activities that are designed to meet the needs and interests of each resident. -Adequate space and equipment are provided to ensure that needed services identified in the resident's plan of care are met. 1. Resident #56 was admitted to the facility in September 2021 with diagnoses which included Alzheimer's disease, dementia, depression, and malnutrition. Review of the Minimum Data Set (MDS) assessment, dated 12/13/23, indicated Resident #56 was rarely or never understood, did not speak and was unable to participate in interviews. He/she was dependent on staff for activities of daily living (ADLs) and was wheelchair bound. The surveyor made the following observations: -1/30/24 at 9:30 A.M., Resident #56 sitting in small day room on the unit in high back wheelchair, humming and chewing on a towel. -1/30/24 at 3:33 P.M., Resident sitting in small day room on the unit, chewing on a towel, news channel on the television (Resident not watching the television). -1/31/24 at 8:20 A.M., Resident sitting in small day room on the unit, chewing on his/her shirt, towel on his/her lap. Resident was facing the doorway/wall, television had Local news channel on (Resident not watching the television). -1/31/24 at 9:03 A.M., Resident sitting in small day room on the unit, hands in mouth, gnawing on fingers, with towel on his/her lap. Resident was moaning at times. -1/31/24 at 10:30 A.M., Resident sitting in small day room on the unit, hands in mouth, shirt pulled up with stomach exposed. Resident has been in same position and hasn't left the day room since 8:00 A.M. -1/31/23 at 10:45 A.M., Resident sitting in the small day room on the unit with no staff engagement, hands/fingers are in his/her mouth. -1/31/24 at 12:10 P.M., Resident sitting in the small day room on the unit, chewing on his/her shirt, TMZ (celebrity gossip news) on the television (Resident not watching the television), no staff engagement observed. Resident was moaning at times. -1/31/23 at 12:30 P.M., Certified Nursing Assistant (CNA) #2 entered the small day room and put a towel in Resident #56's hands. -1/31/24 at 12:40 P.M., Resident sitting in small day room on the unit alone with fingers in his/her mouth and towel in other hand. -1/31/23 at 12:43 P.M., the Assistant Director of Nurses (ADON) entered the small day room, removed the towel from the Resident's hands and left the room. The Resident was left sitting alone in the small day room with TMZ on the television (Resident was not watching the television). -1/31/24 at 1:07 P.M., Resident sitting in small day room alone, asleep in wheelchair, TMZ Divorce Court on the television (Resident not watching the television). -1/31/24 at 2:02 P.M., CNA #2 brought Resident from the small day room to his/her room and put him/her back to bed. Resident was left in the room with no music, no television, and no light on with curtain partially drawn. -2/1/24 at 12:36 P.M., Resident in his/her bed awake with no television or music on. -2/5/24 at 11:41 A.M., Resident in bed awake with no television or music on. Resident chewing on sheet/blanket. -2/5/24 at 5:00 P.M., Resident in bed awake with no television or music on, the room was dark. Resident chewing on a towel. -2/6/24 at 9:35 A.M., Resident in bed with no television or music on. -2/6/24 at 2:04 P.M., Resident lying in bed awake with no music or television on. Resident playing with shirt and blanket. Review of the most recent Activities Assessment, dated 12/9/23, indicated but was not limited to the following: -Resident is unable to initiate independent activities. Recreation provides weekly 1:1 (one to one) visits. -Resident enjoys watching tv, listening to music, and does best with tactile stimulation/sensory visits. -Resident needs prompting to successfully engage in activities. Review of the Activities Care Plan indicated but was not limited to the following: Focus: Resident is dependent on staff for meeting emotional, intellectual, physical, and social needs related to Alzheimer's Disease Goal: Resident will maintain involvement in cognitive stimulation, social activities, as desired through review date. Interventions: -Invite and assist Resident to scheduled activities. -Resident prefers activities which do not involve overly demanding cognitive tasks. Engage in simple, structured activities such as listening to music, sensory/tactile stimulation, and hand massages. During an interview on 1/30/24 at 9:30 A.M., Resident's roommate said he/she chews on his/her fingers or shirt, so they give him/her a towel to chew on. During an interview on 1/31/24 at 12:25 P.M., CNA #2 said Resident #56 always just sits in the small day room and chews on his/her fingers and shirt, so we give him/her a towel to chew on. During an interview on 1/31/24 at 3:00 P.M., Nurse #4 and Nurse #7 said there are not usually any small activities or 1:1 activities on this unit so residents that do not go to the large group just sit in the small day room on the unit. During an interview on 1/31/24 at 3:00 P.M., Nurse #4 said Resident #56 mostly just sits in the small day room. During an interview on 2/5/24 at 1:05 P.M., Nurse #4 said she does not see Resident #56 go to any activities or do any individual activities. The Resident usually sits in the small day room on the unit or in bed. Additionally, she said the Resident is always chewing on something, either his/her hand/fingers, a shirt, towel, or blanket. During an interview on 2/5/24 at 3:45 P.M., the Activity Director said the Room Visit Monitoring Form is the daily log of room visits, 1:1, and individual activities like hand massage. She said everything gets logged there and then put into the computer. They don't log it anywhere else, so all those type of visits/activities would be on that worksheet. She said she doesn't save them once the sheet is full, they get a new one. The surveyor requested to review the activity report, but the Activity Director said she does not know how to run a report of the last three months of activities for the Resident. The Activity Director said Resident #56 likes music and sensory blankets and the Room Visit Monitoring Form would have those activities on it. Review of the current Room Visit Monitoring Form for Resident #56 with the Activity Director indicated the Resident had a visit consisting of menu and/or menu/Chronicle (Chronicle is the daily one page news for Seniors noting historical events from that date), meaning he/she was given a Chronicle page and/or a menu. His/Her response to the activity was coded as S 17 times and once was coded as A. Per the document key, S means Sleeping and the A means Active (participation). There was one family visit documented and one visit documented as 1:1 check in and the response to that visit was coded as S or sleeping. No other activities were documented. When asked by the surveyor if providing a menu and or Chronicle to a resident that is unable to discuss the documents and was asleep would be an appropriate activity, the Activity Director said, well no, his/her family would have to do the menu and he/she should have other activities logged on the form but she does not. During an interview on 2/6/24 at 9:20 A.M., the Activity Director said she did not have the reports as requested on 2/5/24 and would check on them because she asked for them to be printed yesterday. The surveyor printed a 31 day look back for each activity task in the computer. These reports were generated and printed on 2/6/24 between 9:53 A.M. and 9:57 A.M. Review of the reports indicated there was one room visit documented on 1/31/24 at 10:19 A.M. The reports failed to indicate any other activities for Resident #56. The other activities included church, listening to music, morning greeting, music entertainment, parties, receive sacraments, manicure/nails painted, sensory programs, visit family/friends, watching TV/Movies, being around pets, and resident council all had zero visits logged into the computer, and each report read No Data Found. During an interview on 2/6/24 at 2:30 P.M., Unit Manager #2 said the Resident sometimes gets up but not always, and if he/she does get up they usually sit in the small day room. Additionally, she said Resident #56 never goes to activities and they do not do small group activities on that unit, so he/she just sits there and if they stay in bed, he/she just lies there. Unit Manager #2 said TMZ, Divorce Court and [NAME] News are not appropriate shows to engage the Resident. Additionally, she said the Resident always chews on something (fingers, shirt, towel, or blanket). She said she thinks it's a behavior of some sort or a coping mechanism. She said she had been asking why since she started but was told he/she always does it. She said sometimes he/she has a teddy bear but no other sensory objects, teethers, or blankets to utilize. She said the Resident should be brought to small group activities or have 1:1 with activities, as they don't do much with the Resident. 2. Resident #65 was admitted to the facility in December 2023 with diagnosis including: neurocognitive disorder with Lewy bodies, metabolic encephalopathy, anxiety disorder, unspecified psychosis, and type 2 diabetes mellitus. Review of the medical record included the most recent Brief Interview for Mental Status (BIMS) which indicated a score of 2 out of 15, indicating the Resident was severely cognitively impaired, and his/her healthcare proxy (HCP) was activated. During an interview on 1/31/24 at 2:43 P.M., Family Member #1 said she does not feel the facility always communicates with her well in regard to Resident #65. She said she comes in daily for about five hours a day in the late afternoon and feels Resident #65 is bored and has nothing to do and is often in bed when she arrives at the facility. She said the Resident was very active prior to being admitted and would fold laundry for long periods of time or check the mail frequently and open envelopes or play cards and doesn't feel that he/she is engaged in anything while they have been at the facility and it may be contributing to his/her restlessness. She said, There is a big lack of activities or things to do and doesn't feel the staff try to engage him/her in things. She said she usually has to bring the Resident to activities herself and she has never seen the staff offer to bring the Resident to any type of activity. She said she brings cloth napkins for the Resident to fold sometimes when she visits and that keeps them busy. She said her biggest worry is the Resident being bored which she fears would result in behaviors related to the Resident's disease process. Throughout the survey, the surveyor made the following observations of Resident #65: - 1/30/24 at 9:01 A.M., Resident lying in bed with eyes closed - 1/30/24 at 9:46 A.M., Resident dressed lying in bed looking out the window, smiling when engaged by surveyor, the television was not on and there was no music playing in the room. - 1/31/24 at 11:56 A.M., Resident lying in bed, not engaged, or participating in any activity, no music or television on in the room. - 2/1/24 at 7:35 A.M., Resident in bed with eyes closed - 2/1/24 at 1:11 P.M., Resident out of bed in his/her wheelchair self-propelling without a destination, the Resident was unable to answer questions - 2/2/24 at 9:38 A.M., Resident observed in bed, waving at surveyor on approach, there was no music or television on in the room - 2/2/24 at 10:44 A.M., Resident was transported to the unit dayroom for activities by CNA #4 - 2/2/24 at 11:37 A.M., Resident was observed sitting in his/her wheelchair in the unit dayroom, sitting beside the activity assistant shuffling papers - 2/6/24 at 11:09 A.M., Resident self-propelling and wandering in his/her wheelchair in the hallways - 2/6/24 at 11:23 A.M., Resident self-propelling and wandering in his/her wheelchair in the hallways During an interview on 2/1/24 at 1:14 P.M., Nurse #9 said Resident #65 typically stays in his/her room in the mornings and the staff get him/her up for lunchtime. She said the Resident's family comes in every day and she will take the Resident off the unit to big activities like music, or bring the Resident to the activity room and if she is present then the Resident will stay. She said the staff try to encourage the Resident to attend activities, but the Resident usually leaves the activities on their own. She said she is not aware of anything the Resident enjoys doing for activities and the Resident is still relatively new to the facility. During an interview on 2/2/24 at 9:59 A.M., CNA #4 said she provides care to the Resident every day she works. She said Resident #65 sleeps later into the morning and she usually gets them into their wheelchair between 10:30 A.M. and 11:30 A.M. daily. She said when she brings the Resident to activities, he/she doesn't seem to engage too much and sometimes will self-propel in their wheelchair out of the activity area. She said she is not aware of what kind of activities the Resident might enjoy. She said the Resident seems to do better with activities when his/her family member is present and the family has brought the Resident to things off the unit like music. Review of the Activity Interview for daily and activity preferences for Resident #65, dated as signed 1/3/24, indicated but was not limited to the following: Section B Interview for activity preferences: - The following items were marked as very important: listen to music, be around animals, do your favorite activities, go outside in good weather - The following items were marked as not very important: do things with groups of people Section C Primary respondent for daily and activity preferences - Resident Review of the current care plans for Resident #65 indicated but were not limited to the following for activities: FOCUS: - Resident has impaired cognition/dementia or impaired thought process related to dementia, impaired decision making, long-term and short-term memory loss (initiated: 1/3/24) INTERVENTIONS: - Provide a program of activities that accommodates Resident #65's abilities (SPECIFY) (initiated: 1/3/24) FOCUS: - Resident is dependent on staff for meeting emotional, intellectual, physical and social needs related to cognitive deficits, immobility (initiated: 1/4/24) GOAL: - Resident will maintain involvement in cognitive stimulation, social activities as desired throughout review date (revised: 1/4/24) INTERVENTIONS: - Ensure that activities the Resident is attending are: compatible with physical and mental capabilities; compatible with known interests and preferences, adapted as needed, compatible with individual needs and abilities and age appropriate. (revised: 1/4/24) - Invite Resident to scheduled activities (revised: 1/4/24) - Introduce Resident to residents with similar background, interests, and encourage/facilitate interactions (revised: 1/4/24) - Resident needs 1:1 bedside in room visits and activities if unable to attend out of room events (revised: 1/4/24) - Resident needs assistance to be escorted to activities (revised: 1/4/24) Resident #65's care plans failed to indicate their preference for music, animals, and going outside. During an interview on 2/2/24 at 12:32 P.M., the Activity Director said activities performs a preference interview and an activity review and assessment upon admission and quarterly. She reviewed the Resident's record and said the activity preference assessment review could not be located and she would have to look further into it. During an interview on 2/2/24 at 1:08 P.M., the Activity Director said the activity review assessment was started on 12/29/23 but was not locked as completed until today and could not be viewed in the system. She said the Resident does attend some activities and she would provide activity participation logs to the surveyors. She reviewed the Resident's care plans and said the activity care plans were not individualized to the Resident for activities that would provide life enhancement and more details were required. She said the staff could better engage the Resident if the care plans were more personalized for the Resident to indicate what activities were most beneficial for him/her. During an interview on 2/2/24 at 1:14 P.M., Activity Assistant #1 said she knows Resident #65 well and he/she does not typically stay or engage in activities easily when he/she attends. She said she finds the best method is to keep the Resident close to her, when his/her family is not present. She said today the Resident attended activities, and although could not participate in the trivia seemed happy to shuffle papers and sit beside her. She said she completed a puzzle during a 1:1 with the Resident the other day and that seemed to go well. She said she is unaware of what the Resident's activity preferences are or what they enjoy. She said the Resident does best and seems most engaged in activities when their family member is present with them. Review of the Activities Initial Review assessment for Resident #65, dated as signed 2/2/24, indicated but was not limited to the following: Section A: Past Activity Interests: - Resident enjoys independent activities of interest, as well as, some group activities. - Resident enjoys music, movies and active activities. - Resident is known to wander so hands on stimulation activities are the best. Section C: Current activity participation: - There was an answer of yes to the following questions: Resident wishes to participate in activities, group activities, 1:1 with staff and independent activities Section D: Limitations/Special needs: - There was an answer of yes to the following questions: activities should be modified to accommodate cognitive deficits, communication deficits, assistance should be provided to get Resident to an activity COMMENT: Resident does best when sitting near recreation staff during activities for any required assistance. Review of Resident #65's activity involvement logs, both on paper and computerized, indicated the following from 12/29/23 through 2/6/24: - Out of 40 days of activity participation opportunities the Resident participated in activities on 11 days. During an interview on 2/6/24 at 9:38 A.M., the Director of Nurses was made aware of the activity concerns for Resident #65 and she reviewed the current care plan for the Resident. She said there was no way to know what the Resident enjoys or would prefer to participate in by viewing the care plan. She said she knows the Resident and he/she does not engage easily and typically would leave an activity. She said she does not know why activity staff would not or have not left a radio for music in the Resident's room since the assessment indicated music was important, they probably should.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services to manage a contracture and prevent further potential complications in one Resident (#9) with muscular sclerosis, out of a total resident sample of 21 residents. Findings include: Resident #9 was admitted to the facility in July 2019 with diagnoses which included: multiple sclerosis (MS), dementia, and cognitive communication deficit. On 1/30/24 at 9:02 A.M., the surveyor observed Resident #9 sitting in a Broda chair (positioning chair) in his/her room with a closed left hand. The surveyor did not observe any brace or assistive device in the room or on the Resident. During an interview with observation on 1/31/24 at 8:09 A.M., the surveyor observed Nurse #9 assisting the Resident with his/her breakfast meal. The Resident's left hand was observed to be tightly closed with the arm lying across his/her upper abdomen. Nurse #9 said the Resident's left hand is contracted closed and is not usable. She said the Resident used to wear a splint on that hand but she is unsure of where it went or why the Resident no longer has one. On 1/31/24 at 11:54 A.M., the surveyor observed the Resident sitting in a Broda chair in his/her room watching television. The left arm was resting over the upper portion of the Resident's abdomen and the left hand was closed with no hand roll, cloth, splint, or device in place or observed in the room. Review of the medical record for Resident #9 indicated but was not limited to the following: - Two licensed monthly summaries completed on 1/8/23 and 3/3/23 respectively that indicated functional limitation related to contractures and limited range of motion (ROM). - Two healthcare Nurse Practitioner (NP) notes, dated 2/6/23 and 4/3/23, indicated Resident had muscle rigidity, extremity stiffness, and contractures. - An Occupational Therapy (OT) evaluation on 4/4/23 failed to indicate the Resident had any upper extremity contractures and indicated the ROM and strength in the Resident's upper extremities was not tested during this evaluation. - Review of the Certified Nurse Assistant (CNA) care card [NAME] on 1/31/24 failed to indicate the Resident had a contracture or any interventions were in place or necessary for the care and management of the Resident related to the left-hand contracture. - Review of the facility's NP and Attending Physician's Progress Notes from 1/30/23 through 1/31/24 failed to indicate the Resident was being monitored for continued progression of her MS, had contractures or had any treatment or management in place to prevent complications of the left-hand contracture. - Review of the Nurse Progress Notes from 1/1/2023 through 1/31/24 failed to indicate the Resident had a left-hand contracture or any treatment or management in place to prevent potential complications from a left-hand contracture. - Review of Resident #9's diagnosis list failed to indicate a contracture was present. - Current physician's orders from 2/1/24 failed to indicate the Resident had any orders for a device to prevent further complications of the left-hand contracture. Review of Resident #9's Minimum Data Set (MDS) assessments on file indicated but were not limited to the following: - Assessment reference date (ARD) 1/10/24; Section G, functional status question G0400, limitation in ROM: upper extremity (shoulder, elbow, wrist, hand) = no impairment The four prior MDS assessments with ARD's 10/11/23, 7/12/23, 4/1/23, and 2/22/23 also failed to indicate under Section G that the Resident had limited upper extremity ROM. During an observation with interview on 1/31/24 at 12:48 P.M., the surveyor observed Hospice Staff #3 sitting in the Resident's room and the Resident was sitting in his/her Broda chair and the television was on. The surveyor observed the Resident to have a closed left hand with his/her arm resting over his/her lap. Hospice Staff #3 said the Resident has been on and off hospice over the last few years and she knows the Resident well. She said the left hand cannot be opened and has been contracted for as long as she can remember. She said she does not recall the Resident ever having any type of brace or device placed in his/her hand since he/she has been on hospice. She attempted to open the Resident's left hand and said it was very tight and did not want to force the hand open and cause the Resident any pain or discomfort. Review of the Resident's current care plans, as of 1/31/24, failed to indicate the Resident had a left-hand contracture or any interventions in place to prevent potential complications related to the left-hand contracture. During an observation with interview on 2/1/24 at 7:32 A.M., Nurse #10 observed the Resident in bed with a closed left hand and no device in place with the surveyor present. She said the Resident's left hand had been contracted closed for a long time and the Resident does not use any type of splint or device to prevent complication of the contracture, although she believed the Resident did at one time prior to being on hospice services. She attempted to open the Resident's left hand for a skin inspection, the hand was tightly closed with the fingers lying straight down across the lower part of the palm and the thumb over the fingers. She said she could not manipulate the hand further than approximately a one finger width open without causing the Resident discomfort. She said pressure, moisture, and pain would be a potential concern for this Resident and management of the contracture to prevent these complications. She said the Resident is on hospice and could not be seen by skilled rehab until hospice was contacted for approval. During an interview on 2/1/24 at 1:18 P.M., CNA #6 said she knows the Resident and the Resident had a known left-hand contracture. She said the Resident does not have any type of brace or hand roll or towel placed in her left hand and she does not recall seeing anyone do that. She said the Resident doesn't use the left hand and it is closed all the time and the Resident has almost always been dependent on the staff for care. During an interview on 2/1/24 at 1:27 P.M., Nurse #9 said the Resident's left hand is contracted and cannot even be opened fully for skin checks but they can open it slightly to look inside. She said the Resident had a pillow like hand roll splint that he/she used to use, but she has not seen that device since the Resident has been on hospice this last time. She said she is not sure why the Resident doesn't have it or where it went but it has been a long time since the Resident has had it. She said typically if the staff identified an issue like this, they would write a note, inform management and notify skilled rehab to look at the patient for something, but rehab typically does not see people on hospice without prior approval, she said she would notify management of this concern for further guidance on what she should do. During an interview on 2/1/24 at 4:07 P.M., the Director of Rehab said he was contacted by nursing to perform a rehab screen on Resident #9 for the left-hand contracture and there is a scheduled OT evaluation for the Resident on 2/2/24. He said the hand contracture does not appear new but he would need to wait for a full OT evaluation. He reviewed the April 2023 OT evaluation and said that evaluation was not completed to the standard since the upper extremities were not evaluated and the evaluation scheduled would be more complete. During an interview on 2/1/24 at 4:34 P.M., the Director of Nurses (DON) said Resident #9 had been known to have the left-hand contracture since at least October of 2023 when she started working at the facility. On review of the medical record, she said she does not know why there is no mention of the contracture or why there was no care plan in place to manage the contracture and prevent complications. On 2/2/24 at 9:39 A.M., the surveyor observed the Resident out of bed sitting in a Broda chair in his/her room with an unrolled flat face cloth placed in between the palm and fingers of the left-hand contracture. The Resident appeared comfortable and smiled at the surveyor but was unable to answer any questions. During an interview on 2/2/24 at 9:54 A.M., CNA #4 said she provides care to the Resident every day she is at the facility and knows Resident #9 very well. She said the left hand of Resident #9 has been contracted for a very long time. She said when you open the hand it is very minimally and only to clean it. She said the Resident used to have a roll that was pillow like and held in place with an elastic on the back that was worn in the Resident's left hand and that the Resident would sometimes remove the roll but she does not know what happened to it and doesn't believe she has seen it since maybe around last spring, when the Resident went back on hospice services. Review of the most recent Hospice certification and plan of care dated: 12/18/23 for certification period: 12/29/23 - 2/26/24, failed to indicate Resident #9 had a left-hand contracture or any treatments or management in place to prevent potential complications of the contracture.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and policy review, the facility failed to identify a significant weight loss of over 10% in one month and provide treatment and interventions to prevent further unprescribed, unplanned weight loss for one Resident (#71), out of a total sample of 21 residents. Findings include: Review of the facility's policy titled Weight Measurement, dated as revised February 2022, included but was not limited to: - All residents will be weighed at a minimum monthly - Residents with a weight variance of 5% or more or less than the previous month will be re-weighed. - The charge nurse will notify the physician, responsible party and dietician when a 5% more or less variance is noted. - The dietician will review the resident weight and make recommendations accordingly. - When a significant weight fluctuation of 5% more or less is noted, the resident will be weighed based on determination of the Interdisciplinary Team (IDT). - The resident plan of care will be updated accordingly. Resident #71 was admitted to the facility in June 2023 with diagnoses including: dysphagia (difficulty swallowing), hemiparesis, hypertension, and diabetes type II. Review of the Minimum Data Set (MDS) assessment, dated 12/19/23, included but was not limited to the following: - Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident is cognitively intact. - Section K of the MDS, which indicated swallowing/nutritional status, and triggered for weight loss of 5% or more in the last month or 10% or more in the last 6 months. - Section K also indicated that Resident #71 was not on a prescribed weight loss regimen. Review of Resident #71's current Physician's Orders indicated the Resident was on a 2 gm (gram) Na+(sodium) diet with regular consistency texture and thin liquids, and small portions. Review of Resident #71's Nutritional Quarterly Assessment, dated 11/29/23, indicated but was not limited to the following: - Nutritional plan: discontinue super cereal and super pudding (high calorie, high nutrient food) due to good intake and to encourage gradual weight loss On 1/31/24 at 8:06 A.M., the surveyor observed Resident #71, sitting upright in bed, consuming 100% of his/her breakfast, feeding himself/herself, with a Certified Nursing Assistant (CNA) present in the room. On 2/1/24 at 7:33 A.M., the surveyor observed Resident #71, sitting upright in bed, consuming 100% of his/her breakfast, feeding himself/herself. Review of Resident #71's weights in the medical record indicated the following: - 11/07/23: 210 pounds (lbs.) - 12/05/23: 187 lbs. - 12/06/23: 187 lbs. - 12/07/23: 187 lbs. (loss of 10.95% in one month) - 12/08/23: 188.2 lbs. - 01/07/24: 184.8 lbs. Review of Resident #71's weights from 11/07/23 to 12/07/23 indicated a significant weight loss of 10.95%. Review of Resident #71's Progress Notes by nursing, Primary Physician, Nurse Practitioner or the Registered Dietitian, dated 12/1/23 through 2/2/24, failed to indicate any documentation of the significant weight loss. During an interview on 2/2/24 at 11:16 A.M., CNA#3 said she reports any changes in a resident's weight to the nurse and was not aware of Resident #71's weight loss. During an interview on 2/2/24 at 11:11 A.M., Nurse #9 said if there are any changes in a resident's weight of three pounds they will obtain daily weights for three days. If the three weights demonstrate the loss or gain is accurate, it is reported to the MD or Nurse Practitioner and the Director of Nursing (DON). Nurse #9 reviewed the record and was unable to locate any documentation the weight loss had been reported to the MD, Nurse Practitioner, HCP or DON. Nurse #9 said she doesn't know why Resident #71's super cereal and super pudding had been discontinued. During an interview on 2/6/24 at 3:41 P.M., the Registered Dietitian said he was aware of the significant weight loss, but said he was not sure how or why the weight loss occurred. He said when the Resident was admitted he/she weighed around 210 pounds, and now the Resident weighed around 180 pounds. He said the super cereal and super pudding were discontinued because the Resident was starting to eat better. The Dietitian said the process for when a significant weight loss was identified was for the Dietitian to speak with the nursing staff and the resident regarding food preferences for extra calories, make recommendations and notify the provider. The Dietitian said he had not made recommendations (to address the weight loss) or notified the provider of Resident #71's significant weight loss. During an interview on 2/6/24 at 4:02 P.M., the MDS nurse said the quarterly MDS, dated [DATE], indicated a weight loss of greater than 5% without a prescribed weight loss regimen and was completed by the dietitian. She said the dietitian sends a report to the DON and the resident is followed by the IDT at the weekly risk meeting. She said the dietitian is responsible for creating the nutritional care plan. The MDS nurse reviewed the record and said there was no nutritional care plan for Resident #71. During an interview on 2/6/24 at 4:27 P.M., the DON said her expectation for residents with weight loss is to obtain three re-weights, notify the MD or Nurse Practitioner, HCP and dietitian, and update the care plan accordingly. Residents with significant weight loss are followed by the IDT weekly in the Risk meeting. She said she was not aware of Resident #71's significant weight loss and the resident is not followed at the weekly risk meeting. She said the dietitian creates the initial nutritional care plan, and her expectation is for the resident to have one in the medical record, but there was not one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure enteral nutrition and fluids provided via a percutaneous endoscopic gastrostomy tube (PEG, an opening into the stomach for delivery of nutrition and hydration) or gastrostomy tube (G-tube, a tube inserted into the stomach through which nutrition is provided) were provided in accordance with professional standards of practice and facility policy for two Residents (#74 and #48), out of a total sample of 21 residents. Specifically, the facility failed: 1. For Resident #74, to ensure enteral feedings were provided via PEG tube in accordance with physician orders; and 2. For Resident #48, to ensure enteral formula containers and water flush bags were labeled with the Resident's name, date and time hung, and initialed by staff members. Findings include: Review of the facility's policy titled Enteral Tube Feeding via Continuous Pump, undated, included but was not limited to: - The purpose of this procedure is to provide a guideline for the use of a pump for enteral feedings. - Preparation: Verify that there is a physician's order for this procedure. - General Guidelines: Check the enteral nutrition label against the order before administration. Check the following information: Resident name, ID, and room number; type of formula; date and time formula was prepared; route of delivery; access site; method (pump, gravity, syringe); and rate of administration (milliliters (mL)/hour). - Initiate Feeding: On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order. 1. Resident #74 was admitted to the facility in January 2024 with diagnoses including quadriplegia, tracheostomy (a small surgical opening made through the neck to assist with breathing), dysphagia (difficulty swallowing liquid or food), and paralysis of the vocal cords. Review of the Minimum Data Set (MDS) assessment, dated 1/11/24, indicated Resident #74 had a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating he/she was cognitively intact. Review of Section K: Swallowing/Nutritional Status of the MDS assessment indicated Resident #74 was receiving nutritional support through a feeding tube and he/she received 51% or more of total calories through the feeding tube. The assessment also indicated the Resident was averaging 501 cubic centimeters (cc) per day or more of fluid intake. On 1/31/24 at 1:23 P.M., the surveyor observed Resident #74 was resting in bed without a tube feeding running. Prior to the observation, Resident #74's Medical Administration Record (MAR) was reviewed and indicated the tube feeding was hung on this date. On 1/31/24 at 2:23 P.M., the surveyor observed Resident #74 was resting in bed without a tube feeding running. During an interview at this time, Resident #74 said he/she was at therapy but no one had put up feeding since he/she returned. On 1/31/24 at 2:45 P.M., the surveyor observed Unit Manager #1 (who was working a shift as nurse on the unit) went into Resident #74's room with a feeding bottle and water bag. Unit Manager #1 hung the tube feed with a rate of 100 mL(milliliters)/hour and a flush rate of 250 mL/hour at every four hours. The Unit Manager dated the tube feeding as 1/31/24 at 2:35 P.M. and started the tube feeding prior to exiting the Resident's room. Review of Resident #74's current Physician's Orders indicated but were not limited to: - Start Date 1/5/24: NPO (nothing by mouth) - tube feeding only diet: NPO texture, NPO consistency - Start Date 1/5/24: Elevate head of bed (HOB) 30-45 degrees during feeding and at least one hour post feeding every shift - Start Date 1/27/24: Enteral Feed Order in the evening Glucerna 1.2 at 80 mL/hour x 20 hours = up at 1 P.M. and down at 9 A.M. - Start Date 1/6/24: Glucerna 1.2 at 100 mL/hour x 16 hours 4 P.M. - 8 A.M., H2O (water) flush at 250 mL/hour every four hours Review of Resident #74's January MAR indicated the following: - Glucerna 1.2 at 100 mL/hour x 16 hours (4 P.M. - 8 A.M.) order was administered daily from 1/6/24 through 1/31/24. - Glucerna 1.2 at 80 mL/hour x 20 hours (1 P.M. - 9 A.M.) order was administered daily from 1/27/24 through 1/31/24. Review of Resident #74's Dietitian documentation, dated 1/26/24, indicated the Resident was receiving tube feeding through PEG placement. The Dietitian documentation indicated recommendations were made to adjust the tube feeding to 80 mL/hour x 20 hours due to a desirable weight gain of six pounds (lbs.) since admission. During an interview on 1/31/24 at 2:24 P.M., Unit Manager #1 said the tube feeding for Resident #74 is administered daily. Unit Manager #1 said the feeding should be hung at 1:00 P.M. each day. She said she indicated on the MAR the tube feeding was administered prior to hanging the feeding. Unit Manager #1 said she intended to the hang the feed after marking it off as administered on the MAR but got distracted. Unit Manager #1 said she should mark off the tube feeding as administered after it was hung up in the Resident's room. She said the feeding was overdue to be administered. During an interview on 1/31/24 at 2:54 P.M., Unit Manager #1 reviewed the MAR for Resident #74. Unit Manager #1 said there were two tube feeding orders present on the MAR. She said there was an original order from admission on [DATE] and an order was updated on 1/27/24. Unit Manager #1 said she was not sure of the correct order for the tube feedings since there were two orders in the system. Unit Manager #1 said she knew the feeding was to be hung at 1:00 P.M. but was not certain of the correct tube feeding rate and water flushes per hour. During an interview on 1/31/24 at 2:57 P.M., Nurse #1 said she was in the process of clarifying Resident #74's feeding orders. Nurse #1 said there was a duplication of orders for Resident #74's tube feedings. Nurse #1 said the Resident was seen by the Dietitian on 1/26/24 and the recommendation for a rate change was completed. Nurse #1 said the recommendations were confirmed with the Resident's physician and the order was updated. Nurse #1 said the old order for tube feeding was never discontinued. Nurse #1 said the current feeding running in Resident #74's room was incorrect. Nurse #1 said orders for tube feedings should have a water flush rate. Nurse #1 said the orders were clarified and the feeding should be running at a rate of 80 mL/hour and water flushes at a rate of 100 mL/hour every four hours as recommended by the Dietitian and accepted by the Physician. Nurse #1 said she was going to reset the feeding to indicate the proper orders. During an interview on 1/31/24 at 3:24 P.M., the Director of Nurses (DON) said when the Dietitian sees a resident they will make recommendations for changes to tube feedings. The DON said these recommendations need to be accepted or declined by the resident's physician. The DON said once the physician accepts the recommendation, they are updated in the computer. The DON said the expectation is that old orders are discontinued. The DON and the surveyor reviewed the observations for Resident #74's feeding. The DON said she would expect nurses to clarify duplicate orders with the physician prior to hanging tube feedings and not check off that both orders were administered on the TAR. The DON said tube feedings should be hung according to the order. 2. Resident #48 was admitted to the facility in December 2023 with diagnoses including dysphagia, cerebrovascular disease, and pneumonia. Resident #48 had an activated Health Care Proxy (HCP) established on 12/18/23. Review of the MDS assessment, dated 1/16/24, indicated Resident #48 had a BIMS score of 6 of 15, indicating he/she had severe cognitive impairment. Review of Section K: Swallowing/Nutritional Status of the MDS assessment indicated Resident #48 was receiving nutritional support through a feeding tube and he/she received 51% or more of total calories through the feeding tube. The assessment also indicated the Resident was averaging 501 cc per day or more of fluid intake. On 1/31/24 at 11:31 A.M., the surveyor observed the Resident resting in bed with enteral feed running. The surveyor observed the feed bag to be undated, no rate of feed listed, no initials of the nurse who hung the feeding, and no time indicating when the feed was started. The water bag hung adjacent to the enteral feeding for water flushes was also undated and without a time indicating when the water bag was started. On 1/31/24 at 1:20 P.M., the surveyor observed the Resident resting in bed with enteral feed running. The surveyor observed the feed bag to be undated, no rate of feed listed, no initials of the nurse who hung the feeding, and no time indicating when the feed was started. The water bag hung adjacent to the enteral feeding for water flushes was also undated and without a time indicating when the water bag was started. On 2/1/24 at 7:37 A.M., the surveyor observed the Resident resting in bed with enteral feed running. The surveyor observed the feed bag to be undated, no rate of feed listed, no initials of the nurse who hung the feeding, and no time indicating when the feed was started. The water bag hung adjacent to the enteral feeding for water flushes was also undated and without a time indicating when the water bag was started. On 2/1/24 at 12:16 P.M., the surveyor observed the Resident resting in bed with enteral feed running. The surveyor observed the feed bag to be undated, no rate of feed listed, no initials of the nurse who hung the feeding, and no time indicating when the feed was started. The water bag hung adjacent to the enteral feeding for water flushes was also undated and without a time indicating when the water bag was started. Review of Resident #48's current Physician's Orders indicated but were not limited to: - Start Date 12/18/23: NPO-tube feeding only diet; NPO texture, NPO consistency. - Start Date 1/25/24: IsoSource 1.5 at 80 mL/hour x 22 hours (up at 10 A.M. and down at 8 A.M.) with 100 mL G-tube pre/post tube feed every shift. - Start Date 1/25/24: Flush G-tube with 160 mL water every four hours and continue additional hydration flush PRN (as needed). Review of Resident #48's December and January MARs indicated treatments were administered per physician's orders. During an interview on 2/5/24 at 1:05 P.M., Unit Manager #1 said enteral feeding bottles or bags are hung daily per physician's orders. She said she was uncertain of the facility policy, but expected enteral feeding bottles or bags to be dated and timed when they were hung by the nurse administering them. Unit Manager #1 said bottles and bags were only good for 24 hours. She said if a bottle was found undated and not timed, the expectation would be for the feeding to be stopped and a new bag or bottle to be hung because you would be unable to determine when the bag was hung up. Unit Manager #1 and the surveyor reviewed the observations made regarding undated, untimed enteral feedings hung in Resident #48's room. Unit Manager #1 said she believed one of those days she had hung the enteral feeding for Resident #48. She said the enteral feeding bag should have been dated, initialed and time stamped prior to administering. During an interview on 2/6/24 at 8:08 A.M., the DON said her expectation was for nurses to check orders prior to administering enteral feedings. The DON said enteral feeding bags or bottles should be labeled with the nurse's initials, date, and time. The DON said the enteral tube feeding bottles can only be up for 24 hours. The DON said she expects unlabeled or undated enteral feeding to be taken down and rehung because you could not be certain when it was hung. The DON and the surveyor reviewed the observations of Resident #48's enteral feedings. The DON said the enteral feeding bottles and bag should have been dated, timed and initialed by the nurse administering them.

Based on observation, record review, policy review, and interview, the facility failed to ensure staff provided respiratory care in accordance with professional standards for one Resident (#16), out of a total sample of 21 residents. Specifically, the facility failed to ensure nebulizer equipment was changed weekly and stored in a sanitary manner. Findings include: Review of the facility's policy titled Administering Medications through a small volume (Handheld) Nebulizer, undated, indicated but was not limited to the following: -The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. -When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. -Change equipment and tubing every seven days. Resident #16 was admitted to the facility in August 2022 with diagnoses which included chronic respiratory failure with hypoxia, pleural effusion, and chronic obstructive pulmonary disease (COPD). Review of the most recent Minimum Data Set (MDS) assessment, dated 11/8/23, indicated Resident #16 was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS) and needed maximum assistance and/or was dependent with activities of daily living (ADLs). The surveyor made the following observations: -1/30/24 at 11:36 A.M., Resident #16 was in bed, nebulizer machine was on the bedside table, facemask and tubing (undated) were opened, attached to the machine on the bedside table uncovered, next to and touching personal items on the table, and a clear plastic storage bag was under the machine (undated). -1/31/24 at 9:53 A.M., Resident #16 was in bed, nebulizer machine was on the bedside table, facemask and tubing (undated) were opened, attached to the machine on the bedside table uncovered, next to and touching personal items on the table, and a clear plastic storage bag was under the machine (undated). -1/31/24 at 12:46 P.M., Resident #16 was in bed, facemask and tubing (undated) were in a clear plastic storage bag (undated), hanging from the machine. -2/1/24 at 12:36 P.M., Resident #16 was in bed, facemask and tubing (undated) were in a clear plastic storage bag (undated), hanging from the machine. -2/5/24 at 12:00 P.M., Resident #16 was in bed, nebulizer machine was on the bedside table, facemask and tubing (undated) were opened attached to the machine on the bedside table uncovered, next to and touching personal items on the table, and a clear plastic storage bag was hanging from the machine (undated). -2/5/24 at 1:25 P.M., Resident #16 was in bed, nebulizer machine was on the bedside table, facemask and tubing (undated) were opened attached to the machine on the bedside table uncovered, next to and touching personal items on the table, and a clear plastic storage bag was hanging from the machine (undated). -2/6/24 at 9:20 A.M., Resident #16 was in bed, nebulizer machine was on the bedside table, facemask and tubing (undated) were opened, attached to the machine on the bedside table uncovered, next to and touching personal items on the table, and a clear plastic storage bag was hanging from the machine (undated). Review of Resident #16's current Physician's Orders indicated but was not limited to the following: -Albuterol Sulfate Nebulizer Solution (2.5 milligram (mg) / 3 milliliter (ml)) 0.083% one-unit inhale orally via nebulizer every six hours as needed for shortness of breath. (8/21/2023) Further review of the Physician's Orders failed to indicate an order to change equipment and tubing every seven days. Review of the Care Plan failed to indicate the equipment needed to be changed every seven days. During an interview on 1/30/24 at 11:36 A.M., Resident #16 said he/she does not use the nebulizer all the time. During an interview on 2/5/24 at 1:05 P.M., Nurse #4 said nebulizer equipment and tubing is changed as needed, there is no schedule or order to change it. Additionally, she said it is nursing judgment, if it is dirty etc. then we change it, but it should be dated when it is changed. During an interview on 2/5/24 at 12:30 P.M., the Assistant Director of Nurses (ADON) said she was not sure of the policy and would check with the Director of Nurses (DON) regarding the policy. During an interview on 2/5/24 at 4:30 P.M., the ADON said the DON was still looking for the policy and she could not speak to the process. During an interview on 2/5/24 at 4:53 P.M., the DON said nebulizer equipment should be cleaned and tubing replaced and dated weekly on the night shift. She said it was not an order in the computer, there was a book/binder on each unit to alert the night nurse who had a nebulizer and needed equipment and tubing changed. The DON was unable to locate the book on the Sachem unit. During an interview on 2/5/24 at 5:10 P.M., Nurse #2, who was on the Passport unit, was unable to locate the binder when the surveyor asked. Additionally, he was unable to speak to the process or if there was a book, however he said the tubing should be dated. During an interview on 2/5/24 at 5:15 P.M., the DON said the Respiratory Therapist had the books to update them and that was why she couldn't find them. During an interview on 2/5/24 at 5:20 P.M., the Respiratory Therapist said she keeps a worksheet to update who is on nebulizer treatments, inhalers, and other respiratory treatments. She said the list is all inclusive and uses it as her worksheet when she does rounds. Additionally, she said the nurses don't sign off anywhere when they change the equipment, but it should be dated when they change it. The Respiratory Therapist provided copies of the worksheets and the nebulizer change calendars from the binders. The surveyor requested historical logs, worksheets, and/or change calendar for the last 3 months. Review of the documents provided indicated five residents were on the calendars for nebulizer equipment changes and only three of the five were on the worksheet for having nebulizer orders. The worksheet had five additional residents with nebulizer treatment orders listed and Resident #16 was not on either of the documents. During an interview on 2/6/24 at 11:15 A.M., Unit Manager (UM) #1 said the nebulizer change order should populate on the treatment record in the computer for the night nurse and everyone knows it needs to be changed weekly and dated. UM #1 approached the surveyor at 11:30 A.M., and said the DON told her there was a nebulizer change binder. UM #1 said she was unaware of the binder. During an interview on 2/6/24 at 2:30 P.M., UM #2 said the tubing is changed nightly on the night shift and they don't date it stating, I don't know why, maybe for privacy or something. Additionally, she said she thinks the order populates in the computer but was unsure. UM #2 had worked the night shift the week prior and when asked about the nebulizer equipment changes UM #2 said she did not do them as she was not on the medication cart that night, so she did not do the treatments. During an interview on 2/6/24 at 11:00 A.M., the Respiratory Therapist said she was unable to provide the surveyor with historical worksheets as it was a shared document that she updates in the computer and does not save them. She said she uses them for her own tracking, and it is more of a worksheet. Additionally, she said she does not update the nebulizer change binder, the nurses on the floor do, and she has nothing to do with it, but if the book isn't accurate and the staff don't know the process then the process needs to be changed, because all the equipment isn't getting changed as it should if the list is not accurate.

Based on review of Resident Council Minutes, resident and staff interviews, and policy review, the facility failed to ensure staff documented, addressed, and promptly resolved concerns brought forward during Resident Council Meetings held from 8/7/23 through 1/12/24. Findings include: Review of the facility's policy titled Resident Council, undated, indicated but was not limited to the following: - the purpose of Resident Council is to provide a forum for: discussions of concerns and suggestions for improvement, consensus building and communication between the residents and facility - a Resident Council response form will be utilized to track issues and their resolutions, the facility department related to any issues will be responsible for addressing items of concern Review of the Resident Council Meeting Minutes, dated 8/7/23, indicated but were not limited to the following: Nursing: - Nursing staff are often talking on their phones in their native language during care with residents. - Certified Nurse Assistants (CNAs) chatting very loudly in the halls with each other throughout the night, residents are requesting consideration. Review of the Resident Council Meeting Minutes, dated September, indicated but were not limited to the following: Dietary: - No diet cola or diet ginger ale on the units Nursing: - Nursing improvement on call light response times and wearing name tags There was no evidence this was a voiced concern by the Resident council the prior month. There was no indication that the concerns of nursing staff speaking on the phone in their native language were addressed or responded to, nor was a response documented regarding the staff chatting loudly in the halls throughout the night. Review of the Resident Council Meeting Minutes, dated 10/27/23, indicated but were not limited to the following: Dietary: - Wrong salad dressings coming up on trays, receiving Italian when the preference is Ranch. There was no response or follow up documented regarding the lack of diet cola or ginger ale on the units. Nursing: - Starting to answer call lights in a timely manner - Nursing improvement on getting residents up in time for morning activities. There was no evidence this was a voiced concern by the Resident Council the prior two months. Housekeeping: - Housekeeping moving furniture to clean the floors. Residents are requesting Housekeeping ask permission before rearranging their furniture. Review of the Resident Council Meeting Minutes, dated 11/12/23, indicated but were not limited to the following: Dietary: There was no indication the residents' concerns of not receiving the correct salad dressings were addressed. Nursing: - Nursing improvement in call light response times, wearing name tags, and getting residents up on time for activities. There was no evidence that these were voiced concerns, only documentation speaks to improvement, in the prior two months. Housekeeping: There was no response to the prior month's concern or any documentation under the Housekeeping section of the meeting minute notes. Review of the Resident Council Meeting Minutes, dated 12/28/23, indicated but were not limited to the following: Nursing: - Starting to answer call lights in a timely manner and residents are being washed up in time for activities. There was no documentation of these concerns that were previously voiced in Resident Council in the prior three months. - Improvement with talking on the phone in other languages while providing direct care with residents. This is a follow up to a concern voiced by the Resident council in August 2023, four months prior to a documented resolution. Housekeeping: - Housekeeping has been asking prior to moving residents' furniture when cleaning the floors. This was follow up to a concern voiced by the Resident council in October 2023, two months prior to a documented resolution. Overall: Residents appreciate the nighttime staff making improvements to make it quieter at later hours of the night. This was a follow up to a concern voiced by the Resident Council in August 2023, four months prior to a documented resolution. Review of the Resident Council Meeting Minutes, dated 1/12/24, indicated but were not limited to the following: Dietary: - More diet cola has been ordered for the units This was a follow up to concern voiced by the Resident Council in September 2023, four months prior to a documented resolution. On 1/31/24 at 10:00 A.M., the surveyor held a Resident Group meeting with 11 residents in attendance. The residents said they felt their concerns were not addressed timely and they were not ever aware of any follow up occurring on the facility side. They said they bring things up in the meeting repeatedly for numerous meetings and when there was no resolution, they become frustrated and stop mentioning things they feel need improvement. They said if something is improved upon the improvement was not sustained and it did not seem to them as though the facility was paying attention to their concerns. The Resident Council said they were unaware of what the meeting minutes indicated and the Resident Council President said he/she had not ever had the opportunity to read and review the meeting minutes and felt it would be helpful. During an interview on 2/1/24 at 8:27 A.M., the Activity Director (AD) said the process for Resident Council is she takes attendance and then goes over the previous month's concerns. Upon reviewing the Resident Council Meeting Minutes from 8/7/23 through 1/12/24, she said she was unsure when any concerns were brought forward as the timeline for the initiation of a concern was unclear and not always documented in the meeting minutes, but the minutes indicated improvements and ongoing work. She said she discusses the meeting minutes with the administrator and interdisciplinary team the next day at morning meeting and they were notified of the concerns verbally and if they requested, they could receive a copy of the meeting minutes. She said she did not provide the departments with any documentation of a concern or receive any documentation back for the resolution of a concern, but if something was at the level of a grievance she would complete a grievance form and forward it to the appropriate department head. During an interview on 2/1/24 at 9:22 A.M., the Activities Director reviewed the Resident Council policy and said she did not use the Resident Council response forms and that may be a factor in why there is no documentation to show when concerns are brought forward, disseminated to the respective department heads or resolved. She said the policy for Resident Council was not being followed in that regard and the process could be improved.

Based on document review, policy review, and interviews, the facility failed to maintain a grievance process that supported the resident's right to formulate grievances anonymously and consistently document a resolution with acknowledgement. The total sample was 21 residents. Specifically, the facility failed to: 1. Have information on how to file a grievance in resident care and public areas and have forms accessible, so residents and/or visitors were able to anonymously notify the facility of their concerns; and 2. Document evidence of a concern of missing items being resolved with an acknowledged by the complainant for Resident #14. Findings include: Review of the facility's policy titled Administration, Grievance Policy, undated, indicated but was not limited to the following: - The facility will support the resident/responsible party to voice grievances/concerns regarding treatment, care, management of funds, lost articles and any violation of resident rights. - The resident/responsible party can bring forward their concerns verbally or by the written grievance process - Grievance forms are available on the nursing units and in the front lobby where applicable. - Upon receipt of the completed form the social worker will follow up with the person who filed the grievance and discuss the resolution and have the complainant sign or verbally acknowledge that they are in agreement with the issue being resolved. 1. During an initial tour of the facility on 1/30/24, the surveyors did not observe the availability of grievance/concern forms on any of the three nursing units or in any resident common areas throughout the facility. During an interview on 1/31/24 at 9:30 A.M., the Social Worker said she was the grievance officer and responsible for maintaining the grievance and missing items forms and ensuring they were complete. On 1/31/24 at 9:54 A.M., the surveyor observed a sign posted on the main bulletin board beside the large resident dining room on the first floor main hallway that said: Attention all residents and family members grievance forms are located at the nurses' stations. On 1/31/24 at 10:00 A.M., the surveyor held a Resident Group Meeting. The residents said they could not locate grievance forms on their units and grievance forms or missing item forms can only be completed if the Social Worker was available. They said no one else helped them with the process. On 2/1/24 at 9:26 A.M., the surveyor again observed the posted sign in the first floor main hallway indicating grievance forms were located at the nurses' stations. However, throughout the tour of the Passport, Joppa, and Sachem unit there were no forms or holders for grievance forms available at the nurses' stations for residents or their families to access anonymously without having to notify staff. During an interview on 2/2/24 at 1:50 P.M., the Social Worker said the grievance process allows residents or their responsible parties to communicate grievances verbally or in writing and the resident and/or their family could request a form from staff or request staff assist them with a written form as necessary. She said the forms are available behind the nurses' stations and on her office door in the basement (a non-resident area). The residents would have to request a form from staff to complete. She said grievance forms are not left available in the lobby as the policy indicates. She said the residents should be able to complete a grievance form anonymously or without notifying staff, but since they don't have access to the forms at this time they cannot and the process needed to change. 2. On 1/31/24 at 10:00 A.M., the surveyor held a Resident Group Meeting with 11 residents in attendance. The residents said missing items are a rampant problem at the facility. Resident #14 said he/she had experienced many missing items concerns and the concerns don't seem to be taken seriously or investigated thoroughly and go without resolution. During an interview on 1/31/24 at 11:07 A.M., the Social Worker said the missing items process follows the grievance process and she adjusted the form for ease of use and maintains a separate book for these concerns for organizational purposes. She said she investigates all missing items and brings a resolution forward to the residents and does the best she can to resolve the issue. Review of the Missing Items Documentation Form, undated, included the following: - Date of report - Person filling out report - Description of missing items - When was item last seen and by whom - Summary of investigation - Resolution - Administrator review The form does not have an area indicating the resolution was communicated, to whom, when, and/or if the Resident agrees that the concern is resolved. Review of the missing items book provided by the Social Worker indicated Resident #14 had a missing items form completed on 4/11/23, that indicated but was not limited to the following: - Description of missing items: black metal rosary beads, rose ankle socks, two lipsticks in a black tube with flowers on it: one shade pink, one shade poppy - When was item last seen and by whom: a few days ago by the resident - Summary of investigation: activities and social worker looked on 4/11/23 - Resolution: items not inventoried, lipsticks could be used, interventions in place for the resident The form failed to indicate that Resident #14 was made aware of the investigation outcome, or a resolution to the missing items. During an interview on 2/2/24 at 1:50 P.M., the Social Worker reviewed the missing items documentation form for Resident #14. She said the items were not found or located on the inventory sheet for the Resident. She said she believed the Resident was encouraged to use his/her lock box, but that the lock boxes were small, maybe six inches long by four inches wide, and could not hold much. She said this Resident had many issues with missing items and there were some conversations about getting the Resident a larger lock box, but there was no documentation to demonstrate that occurred or that the Resident was made aware of the resolution to the grievance. She said the process and forms need to change to capture all the required information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the facility's policy titled Weight Measurement, dated as revised February 2022, included but was not limited to: - All residents will be weighed at a minimum monthly - Residents with a weight variance of 5% or more or less than the previous month will be re-weighed. - The charge nurse will notify the physician, responsible party and dietician when a 5% more or less variance is noted. - The dietician will review the resident weight and make recommendations accordingly. - When a significant weight fluctuation of 5% more or less is noted, the resident will be weighed based on determination of the Interdisciplinary Team (IDT). - The resident plan of care will be updated accordingly. Resident #71 was admitted to the facility in June 2023 with diagnoses including: dysphagia (difficulty swallowing), hemiparesis, hypertension, and diabetes type II. Review of the MDS assessment, dated 12/19/2023, included but was not limited to the following: - BIMS score of 15 out of 15, which indicated the resident is cognitively intact. - Section K of the MDS, which indicated swallowing/nutritional status, and triggered for weight loss of 5% or more in the last month or 10% or more in the last 6 months. - Section K also indicated that Resident #71 was not on a prescribed weight loss regimen. Review of Resident #71's current Physician's Orders indicated the Resident was on a 2 Gm (gram) NA+(sodium) diet with regular consistency texture and thin liquids, and small portions. Review of Resident #71's Nutritional Quarterly Assessment, dated 11/29/23, indicated but was not limited to the following: - Nutritional plan: discontinue super cereal and super pudding (high calorie, high nutrient food) due to good intake and to encourage gradual weight loss Review of Resident #71's weights from 11/07/2023 to 12/07/2024 indicated a significant weight loss of 10.95%. Review of Resident #71's comprehensive care plan failed to indicate a nutritional care plan had been developed. During an interview on 02/06/24 at 3:41 P.M., the Registered Dietitian said he was aware of the significant weight loss. He said when the resident was admitted he/she was around 210 pounds, and now he/she was in the 180 range. During an interview on 02/06/24 at 4:02 P.M., the MDS nurse said the quarterly MDS, dated [DATE], indicated a weight loss of greater than 5% without a prescribed weight loss regimen and was completed by the dietitian. She said the dietitian is responsible for creating the nutritional care plan. The MDS nurse reviewed the record and said there was no nutritional care plan for Resident #71. During an interview on 02/06/24 at 4:27 P.M., the Director of Nurses said her expectation for residents with weight loss is to obtain three re-weights, notify the MD or Nurse Practitioner, HCP and dietitian, and update the care plan accordingly. She said the dietitian creates the initial nutritional care plan, and her expectation is for the Resident to have one in the medical record but there was not one. Based on observation, record review, policy review, and interview, the facility failed to ensure person-centered comprehensive care plans were developed and/or implemented for five Residents (#16, #56, #9, #65, and #71), out of a total sample of 24 residents. Specifically, the facility failed: 1. For Resident #16, to develop and implement resident centered individualized care plan with behavioral interventions for the use of antipsychotic medications; 2. For Resident #56, to implement interventions on the activities care plan; 3. For Resident #9, to develop and implement a comprehensive plan of care for the care and management of a known left-hand contracture; 4. For Resident #65, to develop and implement resident centered individualized care plans for the use of psychotropic medications and resident centered needs related to their cognitive deficits; and 5. For Resident #71, to develop and implement a comprehensive plan of care for nutritional monitoring and evaluation. Findings include: Review of the facility's policy titled Care Plans-Comprehensive, dated as last revised July 2023, indicated but was not limited to the following: -An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, emotional, and psychological needs is developed for each resident. -Each resident's comprehensive care plan is designed to: a. incorporate identified problem areas; b. incorporate risk factors associated with identified problems; c. identify professional services that are responsible for each element of care; d. reflect currently recognized standards of practice for problem areas and conditions. -Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident. -The care planning/interdisciplinary team is responsible for the review and updating of the care plans: a. when there is a significant change in the resident's condition; b. when the desired outcome is not met; c. when a resident is readmitted to the facility; and d. at least quarterly. 1. Resident #16 was admitted to the facility in August 2022 with diagnoses which included major depressive disorder, anxiety disorder, insomnia, and visual hallucinations. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/8/23, indicated Resident #16 was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS), needed maximum assistance and/or was dependent with activities of daily living (ADLs), and took psychotropic medications, including antipsychotics. Review of the current Physician's Orders indicated but were not limited to the following: -Olanzapine Tablet 2.5 milligrams (mg) give one tablet by mouth two times a day for psychotic disorder (9/29/23) (antipsychotic medication). Review of the Medication order history for Olanzapine indicated Resident #16 had started this medication 6/29/23 and the dose was increased on 9/29/23. Review of the current Comprehensive Care Plan failed to indicate a care plan had been developed for the use of psychotropic medications, specifically for the use of antipsychotic medications. During an interview on 1/31/24 at 3:00 P.M., Nurse #7 said there should be a specific antipsychotic medication use care plan just like there is an antianxiety and antidepressant medication use care plan. During an interview on 2/5/24 at 12:30 P.M., the Assistant Director of Nurses (ADON) said she was unsure what care plans should be in place as the Director of Nurses (DON) does most of the care plans. During an interview on 2/5/24 at 4:18 P.M., the ADON said she thinks the psychotropic medication use care plan is all they use, but the Resident does not have that one or a specific antipsychotic use care plan and he/she should. During an interview on 2/5/24 at 5:00 P.M., the DON said there should be a psychotropic medication use care plan and there was not. During an interview on 2/6/24 at 2:30 P.M., Unit Manager #2 said there should be a psychotropic medication use care plan but the Minimum Data Set (MDS) Nurse handles most of that. During an interview on 2/6/24 at 4:01 P.M., MDS Nurse #1 said she does not do all of the care plans, but there should be a general psychotropic medication use care plan and a specific antipsychotic care plan and there was not one for Resident #16 until yesterday. She said the social worker put the antipsychotic medication use care plan in, but it should have been there since the medication was started in June 2023. 2. Resident #56 was admitted to the facility in September 2021 with diagnoses which included Alzheimer's disease, dementia, depression, and malnutrition. Review of the most recent MDS assessment, dated 12/13/23, indicated Resident #56 was rarely or never understood, did not speak and was unable to participate in interviews. He/she was dependent on staff for ADLs and wheelchair bound. Review of the Activities Care Plan indicated but was not limited to the following: Focus: Resident is dependent on staff for meeting emotional, intellectual, physical, and social needs related to Alzheimer's Disease. Goal: Resident will maintain involvement in cognitive stimulation, social activities, as desired through review date. Interventions: -Invite and assist Resident to scheduled activities. -Resident prefers activities which do not involve overly demanding cognitive tasks. Engage in simple, structured activities such as listening to music, sensory/tactile stimulation, and hand massages. The surveyor made the following observations: -1/30/24 at 9:30 A.M., Resident sitting in small day room on the unit in high back wheelchair, humming and chewing on a towel. -1/30/24 at 3:33 P.M., Resident sitting in small day room on the unit, chewing on a towel, news channel on the television (Resident not watching the television). -1/31/24 at 8:20 A.M., Resident sitting in small day room on the unit, chewing on his/her shirt, towel on his/her lap. Resident was facing the doorway/wall, television had Local News channel on (Resident not watching the television). -1/31/24 at 9:03 A.M., Resident sitting in small day room on the unit, hands in mouth, gnawing on fingers, with towel on his/her lap. Resident was moaning at times. -1/31/24 at 10:30 A.M., Resident sitting in small day room on the unit, hands in mouth, shirt pulled up with stomach exposed. Resident has been in same position and hasn't left the day room since 8:00 A.M. -1/31/23 at 10:45 A.M., Resident still sitting in the small day room on the unit with no staff engagement, hands/fingers are in his/her mouth. -1/31/24 at 12:10 P.M., Resident sitting in the small day room on the unit, chewing on his/her shirt, TMZ (celebrity gossip news) on the television (Resident not watching the television), no staff engagement observed. Resident was moaning at times. -1/31/23 at 12:30 P.M., Certified Nursing Assistant (CNA) #2 entered the small day room and put a towel in Resident #56's hands. -1/31/24 at 12:40 P.M., Resident sitting in small day room on the unit alone with fingers in his/her mouth and towel in other hand. -1/31/23 at 12:43 P.M., the Assistant Director of Nurses (ADON) entered the small day room, removed the towel from the Resident's hands and left the room. The Resident was left sitting alone in the small day room with TMZ on the television (Resident was not watching the television). -1/31/24 at 1:07 P.M., Resident sitting in small day room alone, asleep in wheelchair, TMZ Divorce Court on the television (Resident not watching the television). -1/31/24 at 2:02 P.M., CNA #2 brought Resident from the small day room to his/her room and put him/her back to bed. Resident was left in the room with no music, no television, and no light on with curtain partially drawn. -2/1/24 at 12:36 P.M., Resident in his/her bed awake with no television or music on. -2/5/24 at 11:41 A.M., Resident in bed awake with no television or music on. Resident chewing on sheet/blanket. -2/5/24 at 5:00 P.M., Resident in bed awake with no television or music on, the room was dark. Resident chewing on a towel. -2/6/24 at 9:35 A.M., Resident in bed with no television or music on. -2/6/24 at 2:04 P.M., Resident lying in bed awake with no music or television on. Resident playing with shirt and blanket. Resident #56 was not observed to be involved in simple, structured activities such as listening to music, sensory/tactile stimulation, and hand massages at any time during the survey process, as indicated on the care plan. During an interview on 1/31/24 at 12:25 P.M., CNA #2 said Resident #56 always just sits in the small day room and chews on his/her fingers and shirt, so they give him/her a towel to chew on. During an interview on 1/31/24 at 3:00 P.M., Nurse #4 and Nurse #7 said there were not usually any small activities or 1:1 activities on this unit so residents that do not go to the large group just sit in the small day room on the unit. During an interview on 1/31/24 at 3:00 P.M., Nurse #4 said Resident #56 mostly just sits in the small day room. During an interview on 2/5/24 at 1:05 P.M., Nurse #4 said she does not see Resident #56 go to any activities or do any individual activities. The Resident usually sits in the small day room on the unit or in bed. Additionally, she said the Resident is always chewing on something, either his/her hand/fingers, a shirt, towel, or blanket. During an interview on 2/5/24 at 3:45 P.M., the Activity Director said Resident #56 likes music and sensory blankets and the Room Visit Monitoring Form would have those activities on it and it did not. Review of the current Room Visit Monitoring Form for Resident #56 with the Activities Director indicated the Resident had a visit consisting of menu and/or menu/Chronicle (Chronicle is the daily one page news for Seniors noting historical events from that date), meaning he/she was given a Chronicle page and/or a menu and his/her response to the activity was coded as S 17 times and once was coded as A. Per the document key, S means Sleeping and the A means Active (participation). There was one family visit documented and one visit documented as 1:1 (one to one) check in and the response to that visit was coded as S or sleeping. Review of the Room Visit Monitoring Form failed to indicate Resident #56 had been engaged in simple, structured activities such as listening to music, sensory/tactile stimulation, and hand massages, per the care plan. During an interview on 2/6/24 at 2:30 P.M., Unit Manager #2 said Resident #56 never goes to activities and they do not do small group activities on that unit, so he/she just sits there and if they stay in bed, he/she just lies there. She said sometimes he/she has a teddy bear but no other sensory objects, teethers, or blankets to utilize. She said the Resident should be brought to small group activities or have 1:1 with activities as they don't do much with the Resident.3. Resident #9 was admitted to the facility in July 2019 with diagnoses including: multiple sclerosis (MS), dementia, and cognitive communication deficit. On 1/30/24 at 9:02 A.M., the surveyor observed Resident #9 sitting in a Broda chair (positioning chair) in his/her room with a closed left hand. The surveyor did not observe a brace or assistive device in the room or on the Resident. During an interview on 1/31/24 at 8:09 A.M., Nurse #9 said the Resident's left hand is contracted closed and is not usable. Review of the medical record for Resident #9 indicated but was not limited to the following: - Two licensed monthly summaries, completed on 1/8/23 and 3/3/23 respectively, indicated functional limitation related to contractures and limited range of motion (ROM) - Two Nurse Practitioner's (NP) notes, dated 2/6/23 and 4/3/23, respectively, indicated Resident had muscle rigidity, extremity stiffness, and contractures Review of the Resident's current care plans as of 1/31/24 failed to indicate the Resident had a left-hand contracture or any interventions in place to prevent potential complications related to the left-hand contracture. During an interview on 2/1/24 at 4:34 P.M., the Director of Nurses (DON) said Resident #9 had been known to have the left-hand contracture since at least October of 2023 when she started. On review of the medical record, she said she does not know why there is no real mention of the contracture or why there was no care plan in place to manage the contracture and prevent complications. Refer to F658 and F688 4. Resident #65 was admitted to the facility in December 2023 with diagnoses including: neurocognitive disorder with Lewy bodies, metabolic encephalopathy, anxiety disorder, unspecified psychosis, and type 2 diabetes mellitus. Review of the medical record included the most recent BIMS which indicated a score of 2 out of 15, indicating the Resident was severely cognitively impaired and his/her healthcare proxy (HCP) was activated. During an interview on 1/31/24 at 2:43 P.M., Family Member #1 said the facility does not always communicate well with her. She said she has never had a care plan meeting to discuss Resident #65's care or things she would like for the Resident. Review of the current care plans for Resident #65 indicated but were not limited to the following: FOCUS: - Resident has impaired cognition/dementia or impaired thought process related to (r/t) dementia, impaired decision making, long-term and short-term memory loss (initiated: 1/3/24) INTERVENTIONS: - Provide a program of activities that accommodates Resident #65's abilities (SPECIFY) (initiated: 1/3/24) FOCUS: - Resident has been prescribed psychotropic medications: Specify target behaviors: antianxiety, antipsychotic (revised: 1/3/24) GOAL: - Maximize Resident's functional potential and well-being while minimizing hazards associated with drug related side effects (revised: 1/3/24) During an interview on 2/2/24 at 12:32 P.M., the Activity Director (AD) said she has not attended a care plan meeting for the Resident and is not aware of whether or not one has occurred yet. During an interview on 2/2/24 at 1:08 P.M., the AD reviewed Resident #65's care plans and said they are not specific or individualized to the Resident's needs or preferences as they relate to activities to provide life enhancement and should be more detailed to better reflect the Resident and for the staff to know how to engage him/her with activities. During an interview on 2/2/24 at 1:38 P.M., the Social Worker said residents usually have their first care plan meeting around day 21 of their stay. She said Resident #65 had not yet had a care plan meeting and she needed to call his/her family to schedule one. Resident #65 was past the 21-day mark for a first comprehensive care plan meeting with the interdisciplinary team and his/her family. During an interview on 2/6/24 at 8:51 A.M., Nurse #9 said she could not speak to the development or initiation of care plans or the meetings because they were managed exclusively by the management team and the unit nurses are not involved. She said she would not know one way or another if Resident #65 had a care plan meeting and the managers take care of those pieces. She said the nursing admission assessment does not trigger any care plans automatically for residents upon admission that she knows of. During an interview on 2/6/24 at 9:38 A.M., the DON reviewed Resident #65's care plans and said they are not individualized or specific to the Resident and sections that prompt the staff to specify are incomplete. She said the care plans should be more individualized and resident centered with preferences. She said care plan meetings are scheduled and managed by social services. She said the care plan development process is supposed to be the nurses on the units create the care plans and then management will beef them up, but the process needs to be improved.

Review of the facility's policy titled Administering Medications, undated, included but was not limited to the following: - Medications are administered in accordance with prescriber orders, including any required time frame. - Medication errors are documented, reported, and reviewed by the Quality Assurance and Performance Improvement (QAPI) committee to inform process changes and or the need for additional staff training. - If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. Resident #60 was admitted to the facility in January 2023 with a diagnosis of cerebral vascular accident (stroke). Review of the Minimum Data Set (MDS) assessment for Resident #60, dated 10/25/23, included a Brief Interview for Mental Status (BIMS) score of 0 out of 15 indicating severe cognitive impairment. Review of the Physician's Orders, active as of 1/31/24, indicated but was not limited to the following: - Acetaminophen (pain medication) 325 milligrams (mg) give 2 tablets to equal 650 mg by mouth three times a day for pain. (scheduled medication) On 1/31/24 at 10:10 A.M., the surveyor observed Nurse #4 preparing medication for administration as follows: -Acetaminophen 325 mg two tablets to equal 650 mg, placed into plastic medication cup. Nurse #4 then entered Resident #60's room with the medication cup and asked the Resident if they had pain. Resident #60 answered No, and Nurse #4 then took the medication cup out of the room and disposed of the tablets in the sharp's container located on her medication cart. During an interview on 1/31/24 at 2:22 P.M., Nurse #4 said she did not administer the medication as ordered because the Resident said he/she did not have any pain at the moment. She said she should not have held the medication without an order, but she has been busy. Based on observations, interviews, and record review, the facility failed to ensure one Resident (#60), out of a total sample of 21 residents, received care and treatment in accordance with professional standards. Specifically, the facility failed, for Resident #60, to administer scheduled pain medication as ordered. Findings include:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #73 was admitted to the facility in December 2023 with diagnoses including Stage 3 pressure injury of the left buttock, weakness, and rhabdomyolysis (breakdown of skeletal muscle due to direct or indirect muscle injury). Review of the MDS assessment, dated 12/23/23, indicated Resident #73 had a BIMS score of 14 of 15, indicating he/she was cognitively intact. Review of Section M: Skin Conditions of the MDS assessment indicated the Resident had two stage 3 pressure ulcers/injuries on admission. The assessment also indicated Resident #73 was receiving pressure ulcer/injury care including the application of non-surgical dressings and ointments. Review of Resident #73's December 2023 Physician's Orders indicated the following: - Start Date 12/18/23: Left Buttock - Normal Saline Wash (NSW) + Calcium Alginate + Cover with Border Gauze Dressing every day shift and as needed (PRN). Review of the consultant Wound Physician's documentation, dated 12/26/23, indicated the following: - Stage 3 pressure ulcer of the left buttock measuring 4.0 x 0.5 x 0.1 cm. - Stage 3 pressure ulcer of the right buttock measuring 2.5 x 1.0 x 0.1 cm. - Treatment recommendations for both pressure wounds included Calcium Alginate, Santyl, and a super absorbent gelling fiber with silicone border and faced dressing once a day x 30 days. - Further recommendations included: off-load area and reposition per facility protocol. Review of the Nursing Skin Assessment, dated 12/27/23, indicated the following: - Resident #73 was seen on 12/26/23 during wound rounds. - The assessment indicated the right upper sacrum area had been resolved. - The assessment indicated the left buttock pressure area had a size of 4.0 x 0.5 x 0.1 cm and was to be treated with Calcium Alginate followed by superabsorbent gelling fiber with silicone border and faced dressing. Further review of the Nursing Skin Assessment, dated 12/27/23, failed to indicate the consultant Wound Physician's recommendation for Santyl to the left buttock. The assessment also failed to indicate the Stage III pressure wound to the right buttock as indicated by the consultant Wound Physician. Review of Resident #73's December 2023 TAR indicated an order for the left buttock to have a treatment of NSW, Calcium Alginate, cover with border gauze dressing. The TAR indicated this was the only dressing treatment completed from 12/18/23 through 12/28/23 daily. The TAR failed to indicate orders for Calcium Alginate, Santyl, and super absorbent gelling fiber with silicone border and faced apply once daily for 30 days which was recommended by the consultant Wound Physician on 12/26/23. Review of Resident #73's medical record indicated a change in medical status resulting in rehospitalization on 12/28/23. The medical record indicated Resident #73 returned to the facility on 1/15/24. Review of Resident #73's current Physician's Orders indicated the following: - Start Date 12/18/23: Left Buttock - Normal Saline Wash (NSW) + Calcium Alginate + Cover with Border Gauze Dressing every day shift and as needed (PRN). - Start Date 1/21/24: Calcium Alginate apply once daily for 30 days on left buttock; superabsorbent gelling fiber with silicone border faced apply once daily for 30 days. - Start Date 1/21/24: Santyl apply once daily for 30 days on left buttock. Review of Resident #73's consultant Wound Physician's documentation, dated 1/19/24, indicated the following: - Resident was being evaluated for wound on his/her left and right buttock. - The stage 3 pressure ulcer of the right buttock had resolved on 1/19/24. - The stage 3 pressure ulcer of the left buttock measuring 1.2 x 0.9 x 0.1 cm. - The area was noted to be improving as evidenced by decreased surface area. - Treatment recommendation: Calcium Alginate, Santyl, and super absorbent gelling fiber with silicone border and faced dressing once daily for 30 days. - Further recommendations indicated: off-load the area and reposition per facility protocol. Review of Resident #73's Nursing Skin Assessment, dated 1/21/24, indicated the following: - Resident #73 was seen on 1/19/24 during wound rounds. - The left buttock pressure ulcer had a size of 1.2 x 0.9 x 0.1 cm and was improving. - The assessment indicated the area was to be treated with Calcium Alginate, Santyl and super absorbent gelling fiber with silicone border and faced dressing once daily for 30 days. - The assessment indicated recommendations for the area to be off-loaded and for the Resident to reposition per facility protocol. Review of Resident #73's consultant Wound Physician documentation, dated 1/26/24, indicated the following: - Resident was being evaluated for wound on his/her left and right buttock. - The stage 3 pressure ulcer of the left buttock measuring 1.0 x 0.8 x 0.1 cm. - The area was noted to be improving as evidenced by decreased surface area. - Treatment recommendation: Calcium Alginate, Santyl and super absorbent gelling fiber with silicone border and faced dressing once daily for 30 days. - Further recommendations indicated: off-load the area and reposition per facility protocol. Review of Resident #73's Nursing Skin Assessment, dated 1/26/24, indicated the following: - Resident #73 was seen on 1/26/24 during wound rounds. - The left buttock pressure ulcer had a size of 1.0 x 0.8 x 0.1 cm and was improving. - The assessment indicated the area was to be treated with Calcium Alginate, Santyl, and super absorbent gelling fiber with silicone border and faced dressing once daily for 30 days. - The assessment indicated recommendations for the area to be off-loaded and for the Resident to reposition per facility protocol. Review of Resident #73's January 2024 TAR indicated an order for NSW, Calcium Alginate, cover with border guard dressing was the only dressing treatment completed from 1/16/24 through 1/31/24 daily. The TAR failed to indicate orders for Calcium Alginate, Santyl and super absorbent gelling fiber with silicone border and faced apply once daily for 30 days which was recommended by the consultant Wound Physician on 1/19/24 and 1/26/24. Review of Resident #73's February 2024 TAR indicated an order for NSW, Calcium Alginate, cover with border guard dressing was the only dressing treatment completed from 2/1/24 through 2/6/24 daily. The TAR failed to indicate orders for Calcium Alginate, Santyl, and super absorbent gelling fiber with silicone border and faced apply once daily for 30 days which was recommended by the consultant Wound Physician on 1/19/24 and 1/26/24. On 2/6/24 at 11:40 A.M., the surveyor observed the following: - Nurse #8 gathered wound supplies from the treatment cart (including barrier paper, non-sterile 4x4 gauze pads, 4x4 drain sponge, bordered gauze and 2x2 calcium alginate) at the door of the Resident's room and set up on the overbed table after wiping it down with bleach. - Nurse #8 had the Resident roll to their side and undressed the left buttock wound. - Nurse #8 sprayed cleanser on the wound and patted it dry with gauze. - Nurse #8 ripped calcium alginate square in half to the approximate size of 2.0 x 1.0 cm. - Nurse #8 then stretched the calcium alginate dressing to be slightly larger than 2.0 x 1.0 cm. - Nurse #8 placed the calcium alginate over the wound and extended it onto healthy skin. - Nurse #8 covered the area with border gauze, then removed her gloves. During an interview on 2/6/24 at 12:00 P.M., Nurse #8 said the dressing she applied was NSW followed by calcium alginate and a border gauze dressing. Nurse #8 said calcium alginate does not have size directions, so she approximated the size of the wound when applying. Nurse #8 said there was a tiny spot in the corner or crease of the left buttock, and she therefore covered the entire area. Nurse #8 said the calcium alginate covered the open area plus the good skin surrounding to cover the tiny spot in the crease or corner of the left buttock. Nurse #8 said this was the only treatment order that populated on the TAR for the pressure injury. During an interview on 2/6/24 at 12:51 P.M., the ADON said the consultant Wound Physician comes in weekly on Tuesday or Friday to perform wound rounds for the facility. The ADON said she attends wound rounds with the consultant Wound Physician and documents in the weekly skin assessment in each resident's record. The ADON said the consultant Wound Physician documents treatments, assessments, and recommendations in their notes. The ADON says the consultant Wound Physician notes are then sent to the building. The ADON said once she receives recommendations from the consultant Wound Physician, she reviews them with the resident's physician or nurse practitioner. The ADON said the physician or nurse practitioner then accepts or declines the recommendations. The ADON said if recommendations are accepted, she puts the new orders into the system. The ADON and the surveyor reviewed the TAR for Resident #73. The ADON confirmed the current order in the TAR was for NSW, calcium alginate, cover with border gauze dressing every day shift. The ADON and surveyor reviewed the consultant Wound Physician recommendations made on 12/26/23, 1/19/24, and 1/26/24. The ADON said the recommendations were reviewed with the physician or nurse practitioner and accepted. The ADON said the orders were then put in Resident #73's medical record. The ADON and the surveyor reviewed the current physician's orders which include the updated recommendations for treatment made by the consultant Wound Physician. The ADON said she was not aware the orders were not populated onto the TAR. The ADON said the current treatment for Resident #73 should be alginate calcium apply once daily for 30 days, Santyl apply once daily for 30 days and superabsorbent gelling fiber with silicone border and faced apply once daily for 30 days. The ADON and the surveyor reviewed the surveyor's observations made during Resident #73's dressing change on 2/6/24. The ADON said Calcium Alginate should be fit to the size of the wound bed and should not cover intact skin. The ADON said the treatment applied to Resident #73 was incorrect and did not reflect the current recommendations. During an interview on 2/6/24 at 1:40 P.M., the DON said recommendations are made by the consultant Wound Physician after wound rounds weekly. The DON said those recommendations are reviewed with the resident's physician and either accepted or declined. The DON said if the recommendations are accepted, they are entered in as orders into the medical record. The DON and the surveyor reviewed the observations made during Resident #73's dressing change. The DON said she would expect the nurse to follow the TAR for the order that populates. The DON said Calcium Alginate should be cut to fit the size of the wound bed and never applied over intact skin. The DON said the order does not match the current recommendations from the consultant Wound Physician and physician. 2. Resident #33 was admitted to the facility in April 2022 with diagnoses which included pressure ulcer of the sacral region stage 4 and osteomyelitis. Review of the MDS assessment, dated 1/17/24, indicated Resident #33 was cognitively intact as evidenced by a score of 15 out of 15 on the BIMS, required maximum assistance/was dependent for Activities of Daily Living (ADLs) and had an unhealed stage 4 pressure ulcer, which was present on admission. Review of the current Physician's Orders indicated but was not limited to the following: -Skin Integrity check reminder-complete weekly skin check evaluation every evening shift on Friday. (9/12/23) -ROHO Cushion to wheelchair when in use, check placement and inflation every day and every evening shift. (1/23/24) -Treatment (pressure ulcer sacral region) cleanse with normal saline, pat dry, apply Calcium Alginate, Santyl ointment, and cover with a superabsorbent silicone dressing daily and as needed. (7/12/23) -Lidocaine 4% External Cream (for pain) apply to sacral wound topically every dayshift and as needed for pain management. (10/3/23) Review of the current Care Plans indicated but were not limited to the following: Focus: Resident #33 has a pressure ulcer to the left sacral region. Goal: Pressure Ulcer will show signs of healing and remain free from infection. Interventions: -Administer treatments as ordered and monitor for effectiveness. -Assess/record/monitor wound healing. Measure length, width, depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements and declines to the doctor. -Weekly treatment documentation to include measurements of each area of skin breakdown's width, length, depth, type of tissue and exudate. Review of the weekly Skin Assessments from June 2023 through February 2024 failed to indicate a weekly skin assessment had been completed between 7/17/23 and 9/15/23. During an interview on 2/6/24 at 2:30 P.M., Unit Manager #2 said all residents should have a skin check/assessment done weekly. During an interview on 2/5/24 at 12:30 P.M., the ADON said all residents should have weekly skin checks/assessments completed on the computer. During an interview on 2/06/24 at 1:40 P.M., the DON said all residents should have weekly skin assessments completed and was unsure why these ones were not done. Review of the Skin Assessment, dated 11/1/23, indicated Resident #33 had been seen by the wound physician on 10/31/23 and had a new order for his/her sacrum for Collagen rope with Silver (antimicrobial dressing used to restores balance and help jump start stalled wounds), followed by superabsorbent silicone dressing daily. Additionally, the skin check indicated the Physician would be notified of new recommendation for antibiotic. Review of the Skin Assessment, dated 11/7/23 indicated to continue the treatment of Collagen rope with Silver, followed by superabsorbent silicone dressing daily to his/her sacrum and per the Wound Physician to start a six-week course of antibiotic to treat osteomyelitis and to re-assess in six weeks. Review of the Skin Assessment, dated 11/28/23, indicated treatment was Collagen rope with Silver, followed by superabsorbent silicone dressing daily to his/her sacrum. Review of the Skin Assessment, dated 12/5/23, indicated treatment was Collagen rope with Silver, followed by superabsorbent silicone dressing daily to his/her sacrum. During an interview on 2/5/24 at 12:30 P.M., the ADON said she does weekly rounds with the Wound Physician, reviews the recommendations, writes the new orders, documents on the Skin Assessment the weekly measurement and new orders. During review of Resident #33's medical record including Physician Orders, TAR, Skin Assessments, Wound Care Summaries with the ADON she said the Calcium Alginate and Santyl treatment is not the same as Collagen rope with Silver and the order was never entered into the electronic medical record when it should have been in October 2023, so Resident #33 had been getting the wrong treatment since October 2023. Review of the Wound Physician's Wound Evaluation and Management Summaries from June 2023 through February 2024 indicated but were not limited to the following: -7/11/23, Stage 4 Pressure Wound was deteriorated due to infection. Wound treatment plan was to change the treatment to Calcium Alginate and Santyl ointment followed by superabsorbent silicone dressing and recommended to start intravenous antibiotics for six weeks for clinical osteomyelitis (Resident had documented historical/chronic osteomyelitis to the sacral area prior to admission). -9/26/23, Stage 4 Pressure Wound treatment plan was to add Lidocaine 4% cream to current treatment of Calcium Alginate and Santyl followed by superabsorbent silicone dressing. -10/24/23, Stage 4 Pressure Wound treatment plan included a recommendation to consider a six-week course of antibiotics for exposed bone. -10/31/23, Stage 4 Pressure Wound was not at goal and treatment plan was to change the treatment to Lidocaine 4% cream, followed by Collagen rope with Silver and to cover with superabsorbent silicone dressing and to consider a six-week course of antibiotics for exposed sacrum. -11/7/23, Stage 4 Pressure Wound was not at goal and treatment plan was to continue the treatment of Lidocaine 4% cream, followed by Collagen rope with Silver and to cover with superabsorbent silicone dressing and to consider a six-week course of antibiotics for exposed sacrum. -11/14/23 and 11/21/23, had the same treatment and antibiotic notes in treatment plan for the Sacral Stage 4 Pressure Wound as the 11/7/24 summary. -The Wound Evaluation & Management Summaries from 11/28/23 through 1/23/24 continued to list the treatment plan as Lidocaine 4% Cream, followed by Collagen rope with Silver and to cover with superabsorbent silicone dressing. Review of the Physician's Orders indicated an order for Lidocaine 4% Cream was obtained on 10/3/23 (seven days after the Wound Physician recommended it). Review of the Physician's Orders failed to indicate an order was obtained for antibiotics due to exposed bone from 10/24/23 through 11/21/23, as recommended by the Wound Physician. Further review of the Physician's Orders failed to indicate an order was obtained for the Collagen rope with Silver covered with superabsorbent silicone dressing from 10/31/23 through 2/6/24, as recommended by the Wound Physician. Review of the progress notes (including nurse, physician, and nurse practitioner notes) failed to indicate the recommendation to change the sacral wound treatment and to consider a six-week course of antibiotics had been reviewed with the Physician from 10/24/23 through 2/6/24. During an interview on 2/5/24 at 4:05 P.M., the ADON said Resident #33 had been getting the wrong treatment since October 2023 the Physician and Wound Physician do not want to change it now because he/she is doing well. During an interview on 2/1/24 at 2:39 P.M., Nurse Practitioner #1 said she typically goes with whatever the Wound Physician recommends, unless she adamantly disagrees but that is rare. She said the staff typically text her when the Wound Physician makes recommendations to obtain new orders and she was not aware recommendations were made in October to change the treatment or for the six-week course of antibiotics. The surveyor made observations of wound care on 2/1/24 at 9:06 A.M., which included but was not limited to the following: -Nurse #1 had supplies on the overbed table (skin cleanser, Calcium Alginate, Santyl, Lidocaine, Opti foam dressing). -Nurse #1 removed soiled dressing. -Nurse #1 sprayed the Skintegrity wound cleanser on the wound and patted the wound with gauze to dry. -Nurse #1 applied the Lidocaine 4% to the periwound (skin surrounding edge of wound) with a cotton swab. -Nurse #1 applied the Santyl ointment to the wound bed, sides of wound and the periwound. -The wound perimeter was noted to be macerated (softening and breakdown of skin from prolonged exposure to moisture). -Nurse #1 layered two 2x2 inch DermaGinate (Calcium Alginate) pads on top of each other in opposite directions (there was now eight points instead of four on a square the way the two pads were layered). -Nurse #1 then put the Calcium Alginate in the wound bed, pushing the center of the two layered pads into the wound. The pads were notably larger than the wound bed and hung over the wound covering the entire periwound and healthy tissue surrounding the wound. -Nurse #1 applied the Opti foam dressing over the Calcium Alginate. Review of the Santyl ointment website (https://santyl.com) indicated but was not limited to the following: -Apply Santyl ointment out to the edges of the wound. -New epithelial and granulation tissue grows from the wound edges. -Take care not to extend beyond the wound surface. Review of the Calcium Alginate website (https://dermarite.com) indicated but was not limited to the following: -Conforms readily to any wound bed. -Absorbent gel forming debriding agent. -Alginate should be folded cut to the shape of the wound and applied directly. During an interview on 2/1/24 at 9:38 A.M., Nurse #1 said during wound care she put the Lidocaine to the periwound, then Santyl to wound base and periwound, and put the Calcium Alginate into the wound extending over the wound edges to help with drainage. During an interview on 2/6/24 at 12:51 P.M., ADON said Calcium Alginate should just cover the wound itself; should not cover intact skin. During an interview on 2/06/24 at 1:40 P.M., the DON said the Calcium Alginate should be cut to fit and only be placed in wound bed; should avoid intact skin. During an interview on 2/6/24 at 2:30 P.M., Unit Manager #2 the Santyl should only have been put in the wound bed and not on the edges or the periwound and the Calcium Alginate should have been cut to fit in the wound and not extend over the wound or on the outside of the wound on healthy skin as it can damage healthy skin. Further Review of the Progress Notes indicated but were not limited to the following: -12/22/23, a wheelchair cushion was ordered and pending delivery. -12/29/23, wheelchair cushion was still pending delivery. -1/5/24, the ROHO cushion was in place. -1/10/24, Resident inquired about new cushion and did not get out of bed because he/she wants the new cushion. The cushion was in the building, but therapy had to do a full evaluation for safety. -1/12/24, new cushion in place. -1/20/24, ROHO cushion in place and staff educated on inflation. Review of the Physical Therapy Evaluation and Plan of Treatment, dated 1/11/24, indicated Resident Goals were to receive ROHO management education. Additionally, Rehab Staff #3 noted the ROHO needed to be checked daily. Review of the Physical Therapy Progress note, dated 1/18/24, indicated staff education was complete and Resident was being discharged from therapy. Review of the Physical Therapy Discharge summary, dated [DATE], indicated goals were met and staff education was completed on 1/18/24. Review of the Staff Education titled ROHO Training, undated, provided to the Surveyor by Rehab Staff #3 indicated the Director of Nurses (DON) and two Certified Nursing Assistants (CNAs) (CNA #1 and CNA #2). None of the nurses caring for Resident #33 were educated on the inflation of the ROHO, placement of the cushion, and how to fill the cushion. During an interview on 2/6/24 at 9:10 A.M., Rehab staff #3 said the floor nurses were responsible for maintaining the cushion and they were not part of this education, and they should have been. During an interview on 2/5/24 at 12:30 P.M., the ADON said Resident #33 has a ROHO cushion and it took a while to get it, but she has nothing to do with ordering and does not know who has been educated on how to use the cushion. During an interview on 2/5/24 at 1:05 P.M., Nurse #4 said Resident #33 has a ROHO cushion and she just makes sure it is intact, sanitizes it if it gets soiled, and it does not have any settings, it is inflated and does its own thing. Additionally, she said she doesn't have to do anything special, just visualize it, and she thinks the aides can put more air in it if needed but she has never seen it done. During an interview on 2/6/24 at 10:30 A.M., CNA #2 said Resident #33 has a cushion in his/her chair that has an air pump, but she doesn't know anything about it. During an interview on 2/6/24 at 10:46 A.M., CNA #1 said he checks the cushion for air, then after we get him/her in the chair if he/she says they are good we don't do anything, but if it needs air, there is a pump. CNA #1 said he doesn't check anything; he just goes by what the Resident says. During an interview on 2/6/24 at 2:25 P.M., Nurse #3 said she didn't know anything about the chair cushion. Then she said he/she has an air cushion, so we just check to make sure it has air in it, but that is all, nothing special. Based on observations, interviews, and record review, the facility failed to ensure three Residents (#69, #33, and #73), out of a total sample of 21 residents, received care and treatment to promote healing of pressure injuries. Specifically, the facility failed: 1. For Resident #69, to implement treatments as ordered for a stage 4 pressure injury (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) on the coccyx and a deep tissue injury (DTI) (intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation reveals a dark wound bed) on the left buttock; 2. For Resident #33, to complete weekly skin checks per physician's orders, obtain wound care orders per wound physician recommendations for a stage 4 pressure ulcer, transcribe orders into the electronic medical record, provide wound care per physician orders in line with current professional standards, and ensure staff were properly trained on the maintenance and inflation of ROHO cushion (specialty air inflated wheelchair cushion to promote wound healing); and 3. For Resident #73, to implement treatments as ordered to a stage 3 pressure injury (full-thickness loss of skin in which fat is visible in the ulcer and granulation tissue and rolled wound edges are often present) on the left buttock. Findings include: Review of the facility's policy titled Pressure Ulcers/Skin Breakdown- Clinical Protocol, undated, indicated but was not limited to the following: -the physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressing and application of topical agents. -the physician will help identify medical interventions related to wound management; for example removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound or to wound treatment. Review of the facility's policy titled Dressings, Dry/Clean, undated, indicated but was not limited to the following: -Purpose: to provide guidelines for the application of dry, clean dressings -Preparation: verify that there is a physician's order for the procedure; review the resident's care plan, current orders, and diagnosis to determine if there are special resident needs; check the treatment record -Documentation: the following should be recorded in the resident's medical record, treatment sheet or designated wound form: -date and time dressing was changed -wound appearance, including wound bed, edges, presence of drainage -name and title (or initials) of the individual changing the dressing -type of dressing used and wound care given -all assessment data (wound bed color, size, drainage) -how the resident tolerated the procedure -any problems or complaints made by the resident -the signature and title (or initials) of the person recording the data 1. Resident #69 was admitted to the facility in January 2024 with diagnoses of rectal cancer, Stage 4 pressure injury to the coccyx, and a Deep Tissue Injury (DTI) to the left buttock. Review of the Minimum Data Set (MDS) assessment, dated 1/18/24, indicated Resident #69 scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident was cognitively intact. Review of Section M: Skin Conditions of the MDS assessment indicated the Resident had a Stage 4 pressure ulcer/injury and an unstageable pressure ulcer/injury. The assessment also indicated Resident #69 was receiving pressure ulcer/injury care including the application of non-surgical dressings and ointments. Review of the care plans for Resident #69 indicated the Resident had a Stage 4 pressure injury to the coccyx and a DTI on the left buttock with interventions to measure the area weekly and to complete treatments as ordered. A. Review of the January 2024 Medication and Treatment Administration Records (MAR and TAR) indicated the following treatment order for the coccyx was initiated on 1/6/24: normal saline wash (NSW) followed by DCD (sic) every day shift for wound observations. Review of the medical record indicated Resident #69 was seen by the Wound Physician Consultant on 1/9/24. Review of the Initial Wound Evaluation Management Summary indicated Resident #69 had a Stage 4 pressure injury to the coccyx measuring 3.8 centimeters (cm) in length by 1.5 cm in width by 2.2 cm in depth. The treatment recommendation was to add Santyl (debriding ointment used to rid wound bed of dead tissue), and add Alginate Calcium (absorbent gel forming debriding agent to rid wound bed of dead tissue) once daily for 30 days followed by a gauze island with border dressing. Review of the Nursing Progress Note, dated 1/9/24, indicated Resident #69 was seen by the Wound Physician with new orders. Review of the Skin Assessment, dated 1/10/24, indicated there was a new order for the pressure injury to the coccyx to apply Alginate Calcium, apply Santyl, followed by a gauze island with border dressing. Review of the January 2024 MAR and TAR indicated a treatment order was initiated on 1/17/24 for the coccyx area to change the border gauze dressing and not use Santyl, every evening and night shift, and the order for NSW followed by DCD every day continued through the month. Review of the 1/19/24 Wound Evaluation and Management Summary from the Wound Physician indicated to continue the Alginate Calcium, discontinue the Santyl, add an ABD pad and discontinue the gauze island border. Review of the Skin Assessment, dated 1/21/24, indicated Resident #69 was seen by the Wound Physician on 1/19/24, the coccyx wound had excess drainage and there was a new order for Alginate Calcium once daily followed by ABD pad once daily. Review of the 1/23/24 Wound Evaluation and Management Summary from the Wound Physician indicated to continue the Alginate Calcium, add Benzocaine spray followed by an ABD pad. Review of the Skin Assessment, dated 1/26/24, indicated the coccyx treatment was for Alginate Calcium, Santyl followed by an ABD pad, and a Benzocaine spray. Review of the January 2024 MAR and TAR failed to indicate the treatment of Alginate Calcium and Santyl followed by a gauze island with border dressing was implemented between 1/9/24 and 1/18/24 and failed to indicate the treatment of Alginate Calcium followed by an ABD pad was implemented from 1/19/24 through 1/31/24. Review of the January and February 2024 MARs and TARs failed to indicate the Alginate Calcium was implemented, the gauze island border was discontinued, the ABD pad was ordered or the Benzocaine spray was added to the treatment. B. Review of the January 2024 TAR indicated the following treatment order for the left buttock was initiated on 1/6/24: NSW followed by DCD (sic) every day shift for wound observations. Review of the Initial Wound Evaluation Management Summary, dated 1/9/24, indicated Resident #69 had an unstageable DTI of the left buttock measuring 4 cm in length by 1.5 cm in width with 0.1 cm depth. The treatment recommendation was to add Santyl and Alginate Calcium once daily for 30 days followed by a gauze island with border dressing. Review of the Nursing Progress Note, dated 1/9/24, indicated Resident #69 was seen by the Wound Physician with new orders. Review of the Skin assessment dated [DATE] indicated there was a new order for the unstageable DTI of the left buttock to Alginate Calcium, apply Santyl followed by gauze island with border dressing. Review of the January MAR and TAR indicated the treatment for NSW followed by DCD (sic) was ordered from 1/6/24 through 1/17/24. On 1/17/24 the treatment order changed from once per day to three times per day (every shift) and continued as NSW followed by DCD (sic). Review of the 1/19/24 Wound Evaluation and Management Summary from the Wound Physician indicated to continue the treatment to the left buttock of Alginate Calcium, Santyl, and a gauze isl[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility failed to ensure medications with a shortened expiration date upon opening were properly labeled once opened to prevent potential use of an expired medication in one medication cart out of five medication carts in use by the facility. Findings include: Review of the facility's policy titled Administering Medications, undated, indicated but was not limited to the following: - The expiration/beyond use date on the medication label is checked prior to administering. - When opening a multi-dose container, the date opened is recorded on the container. On [DATE] at 11:45 A.M., the surveyor inspected the medication cart side A on the Joppa unit and made the following observations: -Four tubes of Erythromycin (antibiotic) eye ointment opened, and in use, for different residents with no opened date. During an interview on [DATE] at 11:47 A.M., Nurse #9 said the eye drops are only good for 30 days once opened and has no way of knowing if the medication has expired without an open date on the tube. During an interview on [DATE] at 4:32 P.M., the Director of Nursing (DON) was made aware of the surveyor's observations and said her expectation is that medications such as eye drops and eye ointments are dated upon opening and discarded after 30 days from the open date. She said medications are to be removed from the cart if they do not have an open date, so they cannot be used beyond the expiration date.

2. Review of the facility's policy titled Administering Medications, undated, indicated but was not limited to the following: -The Director of Nursing (DON) supervises and directs all personnel who administer medications and/or have related functions. -Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) Resident #66 was admitted to the facility in June 2023 with a diagnosis of Parkinson's disease. Review of the Physician's Orders, active as of 1/31/24, for Resident #66, indicated but were not limited to the following: -Carbidopa/Levodopa 25/100 milligrams (mg) (treats Parkinson's disease) one tablet by mouth (PO) four times a day -Multivitamin with minerals (supplement) one tablet PO daily -Amlodipine (treats high blood pressure) 5 mg one tablet PO daily -Sertraline 50 mg tablet with 25 mg tablet to equal 75 mg (treats depression) PO daily. On 1/31/24 at 10:00 A.M., the surveyor observed Nurse #4 remove the medications from a pouch and place them into a medication cup. The Sertraline 25 mg tablet missed the cup and landed on top of the medication cart. Nurse #4 put on gloves, picked up the Sertraline 25 mg tablet and placed it into the medication cup with the other medications. She then removed her gloves and performed hand hygiene. Nurse #4 then transferred the medication tablets into a pill crusher pouch and crushed them. She then took a scoop of applesauce and placed it into the medication cup and sprinkled the crushed medications on top of the applesauce. She then administered the medications to Resident #66. Resident #75 was admitted to the facility in November 2023 with diagnoses of urinary tract infection, anxiety, and anemia. Review of the Physician's Orders, active as of 1/31/24, for Resident #75, indicated but were not limited to the following: -Baclofen 10 mg one tablet (treats muscle spasms) PO twice a day -Multivitamin with minerals one tablet PO daily -Buspirone 7.5 mg one tablet (treats anxiety) PO every 12 hours On 1/31/24 at 10:06 A.M., the surveyor observed Nurse #4 remove the medications from a pouch and place them into a cup. The Buspirone 7.5 mg missed the cup and landed on top of the medication cart. Nurse #4 put on gloves, picked up the Buspirone 7.5 mg tablet and placed it in the medication cup with the other medications. Nurse #4 then removed gloves and performed hand hygiene. She then took the medication cup and administered the medications to Resident #75. During an interview on 1/31/24 at 2:22P.M., Nurse #4 said she had cleaned her medication cart in the morning, however she should not have administered the medication that fell on top of the cart to Resident #66 and Resident #75. She said she should have discarded that medication and administered a new one. During an interview on 1/31/24 at 3:50 P.M., the Director of Nurses said the top of the medication cart is considered dirty and medications that come in contact with the top of the mediation cart should not be administered because they could potentially be contaminated with germs, and it is an infection control breech. She said the expectation is that the nurse would and should have destroyed the medication and provided a new clean pill. 3. Review of the facility's policy titled Dressings, Dry/Clean, undated, indicated but was not limited to the following: -Verify that there is a physician's order for this procedure. -Assemble the equipment and supplies as needed. -The following equipment and supplies will be necessary when performing this procedure: Personal protective equipment (e.g. gowns, gloves, mask etc., as needed. -Steps in the procedure include: a. Wash and dry your hands thoroughly. b. Put on clean gloves. Loosen tape and remove soiled dressing. c. Pull glove over dressing and discard into plastic or biohazard bag. d. Wash and dry your hands thoroughly. e. Open dry, clean dressing(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface. f. Label tape or dressing with date, time, and initials. Place in clean field. g. Wash and dry your hands thoroughly. h. Put on clean gloves. i. Assess the wound and surrounding skin for edema, redness, drainage, tissue healing progress and wound stage. j. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually, from the center outward). k. Use dry gauze to pat the wound dry. l. Apply the ordered dressing and secure with tape or bordered dressing per note. Label with date and initial top of dressing. m. Discard disposable gloves and designated container. Wash and dry your hands thoroughly. Resident #73 was admitted to the facility in December 2023 with diagnoses including Stage III pressure ulcer of the left buttock, weakness, and rhabdomyolysis (breakdown of skeletal muscle due to direct or indirect muscle injury). Review of the Minimum Data Set (MDS) assessment, dated 1/21/24, indicated Resident #73 had a Brief Interview for Mental Status (BIMS) score of 14 of 15, indicating he/she was cognitively intact. Further review of Section M: Skin Conditions of the MDS assessment indicated the Resident had one Stage III pressure ulcers/injuries on admission and was receiving care and treatment for the areas. Review of Resident #73's current Physician's Orders indicated the following: - Start Date 12/18/23: Left Buttock - Normal Saline Wash (NSW) + Calcium Alginate + Cover with Border Gauze Dressing every day shift and as needed (PRN). - Start Date 1/21/24: Calcium Alginate apply once daily for 30 days on left buttock; superabsorbent gelling fiber with silicone border faced apply once daily for 30 days. - Start Date 1/21/24: Santyl apply once daily for 30 days on left buttock On 2/6/24 at 11:40 A.M., the surveyor observed the following: - Nurse #8 entered the room to dress the wound. Nurse #8 completed hand hygiene prior to entering the Resident's room. Nurse #8 donned (put on) PPE including gown, gloves, and a mask prior to entering the Resident's room. - Nurse #8 gathered wound supplies from the treatment cart (including barrier paper, non-sterile 4x4 gauze pads, 4x4 drain sponge, bordered gauze and 2x2 calcium alginate) at the door of the Resident's room and set up on the overbed table after wiping it down with bleach. - Nurse #8 had the Resident roll to their side, removed the Resident's brief and undressed the left buttock wound. She then removed her gloves, returned to the treatment cart outside of the room to retrieve saline wash. - Nurse #8 returned to the Resident's bedside. Nurse #8 indicated she did not have enough gloves and started to untie her gown. The Resident indicated a box of gloves on his/her nightstand. - Nurse #8 retrieved the box of gloves from the nightstand and retied the bottom of her gown, leaving the top untied. - Nurse #8 put on a new pair of gloves and opened all the supplies on the bedside table. - Nurse #8 sprayed cleanser on the wound and patted it dry with gauze. - Nurse #8 ripped calcium alginate square in half to the approximate size of 2.0 x 1.0 cm. - Nurse #8 then stretched the calcium alginate dressing to be slightly larger than 2.0 x 1.0 cm. - Nurse #8 placed the calcium alginate over the wound and extended it onto healthy skin. - Nurse #8 covered the area with border gauze, then removed her gloves. - Nurse #8 without gloves donned re-attached the brief and repositioned the Resident, covering him/her with bed sheets. - Nurse #8 opened a biohazard bag and placed the trash bag containing used supplies inside. She then gathered up remaining supplies and threw them away. - Nurse #8 removed her gown, without gloves donned, placed it in the trash before removing her mask and completing hand hygiene. During an interview on 2/6/24 at 12:00 P.M., Nurse #8 said she performed hand hygiene at the start and end of the dressing change. Nurse #8 said she did not perform hand hygiene between glove changes. Nurse #8 said she did believe she needed to perform hand hygiene between glove changes because she was putting on a clean pair of gloves. During an interview on 2/6/24 at 12:51 P.M., the surveyor reviewed the observations made during Resident #73's dressing change with the Assistant Director of Nurses (ADON). The ADON said hand hygiene should be performed prior to starting the dressing change, as well as in between each glove change and at the end of the treatment. During an interview on 2/6/24 at 1:40 P.M., the surveyor reviewed the observations made during Resident #73's dressing change with the Director of Nurses (DON). The DON said hand hygiene should be completed at the start and end of dressing changes, as well as between any changes of gloves. 4. Review of the facility's policy titled Clinical Services: Subject: Precautions to Prevent Infections, dated as last revised January 2020, indicated but was not limited to the following: -Transmission Based Precautions (TBP) are for patients who are known or suspected to be infected or colonized with an infectious agent, which require additional control measures to effectively prevent transmission. -Enhanced Barrier Precautions (EBP), which falls between standard and contact, require gown and glove use for certain residents during specific high-contact resident care activities. -High Risk Activities are identified as: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care or use of a device, and wound care. -Contact Precautions are intended to prevent transmission of infectious agents. -Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. -Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens. -Contact Precautions: gloves and gown (don before room entry, doff (take off) before room exit. Resident #33 was admitted to the facility in April 2022 with diagnoses which included pressure ulcer of the sacral region stage 4 and osteomyelitis. Review of the current Physician's Orders indicated but was not limited to the following: -EBP when providing high contact care. -Maintain Extended-Spectrum beta-lactamase (ESBL) precautions in urine every shift (ESBL is an antibiotic resistant bacteria). Review of the Care Plan for Resident #33 indicated but was not limited to the following: -Resident is on EBP; follow facility protocol on EBP -Resident has an actual Infection ESBL Urinary Tract Infection (UTI); TBP Required; Contact ESBL Urine. On 2/1/24 at 9:06 A.M., the surveyor observed wound care for Resident #33 and made the following observations: -Nurse #1 and Certified Nurses Assistant (CNA) #1 were in Resident #33's room when the surveyor entered the room. -Nurse #1 had a gown on, the gown was tied at the waist, the top/neck tie was not tied; gloves and facemask were on. -CNA #1 had a gown with both ties tied, gloved and facemask on. -Wound care was provided by Nurse #1 and CNA #1 assisted as needed with care, including turning. -CNA #1 exited the room with the gown, gloves, and facemask that were used during care still on and walked down the hallway. -CNA #1 re-entered the room pushing the Hoyer Lift (mechanical lift to transfer resident) with his dirty gloves and gown on. -CNA #1 left the Hoyer Lift in the doorway of the room and approached the Resident in bed. -CNA #1 put Resident #33's pants on, without changing gloves or performing hand hygiene, while Nurse #1 put wound care supplies away. -CNA #1 looked in the room for the Hoyer lift pad and was unable to locate one. -CNA #1 exited the room and walked down the hallway to retrieve a Hoyer pad, still with the same dirty gown, gloves and facemask on. -CNA #1 re-entered the room with a Hoyer pad and proceeded to put the pad under the Resident, without changing gloves or performing hand hygiene. -Nurse #1's gown was noted to be falling over her shoulders while providing care. -Nurse #1 adjusted the top of her gown several times, however, did not tie the top/neck tie. During an interview on 2/1/24 at 9:38 A.M., Nurse #1 said the gown should have been tied at the top and bottom. Additionally, she said CNA #1 should have removed his PPE (gown, gloves and facemask) when he exited the room and put on clean PPE when he re-entered the room both times. During an interview on 2/1/24 at 12:50 P.M., CNA #1 said he should not have worn the gown and gloves in the hallway. During an interview on 2/5/24 at 12:30 P.M., the ADON said Resident #33 was on EBP because of the wound and catheter and TBP because of the ESBL in his/her urine. She said PPE should be removed in the room and disposed of and the CNA should not have gone into the hallway with the gown and gloves on. During an interview on 2/6/24 at 2:30 P.M., Unit Manager #2 said staff should not have PPE on in the hallway and it should have been removed in the resident's room. Based on observations, interviews, policy review, and record review, the facility failed to ensure staff implemented infection prevention and control practices and policies. Specifically, the facility failed to: 1. Implement COVID-19 testing every 48 hours for all staff during a COVID-19 outbreak for 1 out of 5 sampled staff members; 2. Follow infection control standards during a medication pass, for Resident #66 and Resident #75; 3. Follow infection control practices during a wound dressing change for Resident #73; and 4. Appropriately utilize personal protective equipment (PPE) for residents on enhanced barrier precautions and transmission-based precautions for Resident #33. Findings include: 1. Review of the facility's policy titled Coronavirus Prevention and Control, dated as revised in January 2023, indicated if the facility identifies that the resident or staff member's first exposure occurred less than 2 days ago, then they should wait to test until 24 hours after any exposure and then test residents and staff at least every 48 hours on the affected unit until the facility goes seven days without a new case. Review of the facility's LTC (Long Term Care) Respiratory Surveillance Line List indicated a resident tested positive for COVID-19 on 12/25/23. During an interview on 2/2/24 at 2:00 P.M., the Infection Control Preventionist said the facility was in a COVID-19 outbreak from 12/25/23 through 1/31/24, affecting all three units. She said during this time the facility had initiated broad-based testing and was testing all staff and residents every 48 hours. She said she had not been physically present in the facility when the outbreak initiated and had instructed the Director of Nurses to conduct broad-based testing of all staff every 48 hours until the facility had gone 10 days without a new case. During an interview on 2/2/24 at 2:50 P.M., the Director of Nurses said she had documented the nursing floor staff testing on the handwritten nursing schedule and testing was conducted every other day. Review of the testing log indicated staff testing was initiated on 12/26/23 and then conducted every other day following that date. Review of time sheets indicated Nurse #4 worked on 12/27/23, 12/28/23, and 12/29/23. Review of the COVID-19 testing logs did not indicate Nurse #4 was tested during that time. During an interview on 2/6/24 at 12:23 P.M., Human Resources said Nurse #4 did not work between 1/3/24 and 1/9/24 as she was out sick. Review of the LTC Respiratory Surveillance Line List for staff did not indicate Nurse #4 had COVID-19. During an interview on 2/6/24 at 1:00 P.M., the Director of Nurses and the Infection Control Preventionist said Nurse #4 did not have COVID-19 when she was out sick. Review of time sheets indicated Nurse #4 returned to work on 1/10/24. Review of the COVID-19 testing logs indicated testing was conducted on 1/9/24 and 1/11/24 and did not include Nurse #4. Review of time sheets indicated Nurse #4 worked on 1/15/24 and 1/17/24 (scheduled COVID-19 testing day) and tested negative for COVID-19. Review of time sheets indicated Nurse #4 worked on 1/20/24. Review of the COVID-19 testing log indicated Nurse #4 had not been tested since 1/17/24, 3 days prior. During an interview on 2/6/24 at 1:00 P.M., the Director of Nurses said she tracked staff by having them test every other day and utilizing the nursing schedule. She said she was not sure why Nurse #4 had not tested for COVID-19 on 12/28/23 as the Nurse had been working at the facility but was not listed on the handwritten schedule as tested. The Director of Nurses said she was not sure why Nurse #4 had not been tested when she returned to the facility on 1/10/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review and interview, the facility failed to maintain an effective training program, as indicated in their facility assessment. Findings include: Review of the Facility Assessment, dated as updated in May 2023, indicated but was not limited to the following: -Throughout the year all employees receive training and education on topics related to patient care and services. -Some training provided during general orientation is repeated at least annually. -Other topics are provided during the year based on Quality Assurance Performance Improvement (QAPI) initiatives, ensuring regulatory compliance, best practices, clinical competencies, program development, etc. Review of annual mandatory training content titled: Round [NAME] Annual Education, dated 9/21/23, indicated the following trainings were provided during the 9/21/23 mandatory in-service: -Abuse and Neglect; Resident Rights; Advance directives; Health Insurance Portability and Accountability Act (HIPAA) -ADL Training; Assisting with care; Medication errors; Controlled substance count; Pain assessment; Peri-Care -Antibiotic Stewardship; Blood Borne Pathogens; Infection Control; Covid symptoms -Dementia: Overview of Mild Cognitive Impairment; Understanding the early stage of Dementia; Management of common medical conditions during middle and late stages of Dementia; Medical treatments of Dementia; and Palliative end of life care of persons with Dementia -Change in condition; How to deal with difficult behaviors; Documentation -Safety training; Elopement; Falls Prevention; Fire Safety; Hazard Communication; Preventing Workplace Violence -Person-Centered Care Plan; Skin tears and Pressure Ulcers; Trauma Informed Care; Wound Assessment -Communication; Corporate compliance; cultural competency; Lesbian, Gay, Bisexual, Transgender, Queer, and more (LGBTQ+) -Quality Assurance Performance Improvement (QAPI); and Survey Prep Review of the in-service education attendance record titled Mandatory In-services, dated 9/21/23, indicated 17 out of 93 employees on the pre-printed attendance list attended and completed the trainings. During an interview with the Assistant Director of Nurses (ADON) and Regional Nurse on 2/6/24 at 11:35 A.M., the ADON said she is responsible for staff training and has only been in the facility since October 2023. The Regional Nurse said she would provide a list of what specific content was covered in the mandatory in-services and they use a Round [NAME] annual education guide for mandatory education. The Regional Nurse reviewed the educational sign-in sheets and said, based on the number of people who appeared to have attended, the trainings were ineffective because not enough staff participated. The ADON said she would double check to see if any other in-services were provided prior to her start at the facility. During a follow up interview on 2/6/24 at 4:33 P.M., the ADON said there were no other in-service sign-in sheets or trainings available for the surveyors to review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on documentation review and interview, the facility failed to provide their staff training in effective communication, as indicated by the Facility Assessment. Findings include: Review of the Facility Assessment, dated May 2023, indicated but was not limited to the following: Staff training/education and competencies: -Throughout the year employees receive training and education on topics related to patient care and services. -Some trainings provided during general orientation is repeated at least annually. -Other topics are provided during the year based on Quality assurance performance improvement initiatives, ensuring regulatory compliance, best practices, clinical competencies and program development. List of staff training, and competencies needed by staff type: Nurses and Certified Nurse Assistants (CNAs) and other: Communication - effective communications for direct care staff Review of annual mandatory training content titled: Round [NAME] Annual Education, dated 9/21/23, indicated but was not limited to the following mandatory trainings were provided during the 9/21/23 in-service: -Communication Review of the In-service Education Attendance Record for the Round [NAME] training, dated 9/21/23, indicated 17 of 93 employees attended the required trainings. Review of the 2023 and 2024 staff education and in-service sign-in sheets provided by the facility failed to indicate further trainings had been completed on effective communication. During an interview with the Assistant Director of Nurses (ADON) and Regional Nurse on 2/6/24 at 11:35 A.M., the ADON said she is responsible for staff training and has only been in the facility since October 2023. The Regional Nurse said she would provide a list of what specific content was covered in the mandatory in-services and they use a Round [NAME] annual education guide for mandatory education. The Regional Nurse reviewed the educational sign-in sheets and said, based on the number of people who appeared to have attended, the trainings were ineffective because not enough staff participated. The ADON said she would double check to see if any other in-services were provided prior to her start at the facility. During an interview on 2/6/24 at 4:33 P.M., the ADON said there were no other in-service sign-in sheets or trainings available for the surveyors to review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review and interview, the facility failed to ensure staff attended and received education on the facility Quality Assurance and Performance Improvement (QAPI) program, as indicated in the Facility Assessment. Findings include: Review of the Facility Assessment, dated as updated in May 2023, indicated but was not limited to the following: -Throughout the year all employees receive training and education on related topics to patient care and services. -Some training provided during general orientation is repeated at least annually. -Other topics are provided during the year based on Quality Assurance Performance Improvement (QAPI) initiatives, ensuring regulatory compliance, best practices, clinical competencies, program development, etc. -List of staff training and competencies needed by staff type: -Nurses and Certified Nurse Assistants (CNAs), and Others: Quality Assurance Performance Improvement (QAPI). Staff educator or designee will educate facility staff on QAPI on hire Review of annual mandatory training content titled: Round [NAME] Annual Education, dated 9/21/23, indicated the following mandatory trainings were provided during the 9/21/23 in-service: -Quality Assurance Performance Improvement (QAPI) Review of the Inservice Education Attendance Record for the Round [NAME] training, dated 9/21/23, indicated 17 of 93 employees attended the required trainings. Review of the 2023 and 2024 staff education and in-service sign-in sheets provided by the facility failed to indicate further trainings had been completed. During an interview with the Assistant Director of Nurses (ADON) and Regional Nurse on 2/6/24 at 11:35 A.M., the ADON said she is responsible for staff training and has only been in the facility since October 2023. The Regional Nurse said she would provide a list of what specific content was covered in the mandatory in-services and they use a Round [NAME] annual education guide for mandatory education. The Regional Nurse reviewed the educational sign-in sheets and said, based on the number of people who appeared to have attended, the trainings were ineffective because not enough staff participated. The ADON said she would double check to see if any other in-services were provided prior to her start at the facility. During a follow up interview on 2/6/24 at 4:33 P.M., the ADON said there were no other in-service sign-in sheets or trainings available for the surveyors to review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on documentation review and interview, the facility failed to ensure their staff were educated on infection control and prevention which included, training on standards, policies, and procedures for the facility's infection prevention and control program. Findings include: Review of the Facility Assessment, dated May 2023, indicated but was not limited to the following: Staff training/education and competencies: - Throughout the year employees receive training and education on topics related to patient care and services. - Some trainings provided during general orientation is repeated at least annually. - Other topics are provided during the year based on Quality assurance performance improvement initiatives, ensuring regulatory compliance, best practices, clinical competencies and program development. List of staff training, and competencies needed by staff type: Nurses and Certified Nurse Assistants (CNAs), and other: -Infection control - a facility must include as part of its infection prevention and control program mandatory training that includes the written standards, policies and procedures for the program. -Orientation, in-service use of personal protective equipment (PPE), Infection control and hand washing, environmental rounds, Covid signs and symptoms, Outbreak and surveillance policy/procedures, Vaccine (influenza, Covid, Pneumonia, Hepatitis B) policy and Methicillin drug resistant organism policy and procedures. Review of annual mandatory training content titled Round [NAME] Annual Education, dated 9/21/23, indicated the following trainings were mandatory for staff and provided during the 9/21/23 mandatory in-service: -Antibiotic Stewardship; Blood Borne Pathogens; Infection Control; Covid symptoms Review of the In-service Education Attendance Record for the Round [NAME] training, dated 9/21/23, indicated 17 of 93 employees attended the required infection control and prevention trainings. Review of the 2023 and 2024 staff education and in-service sign-in sheets provided by the facility failed to indicate further trainings had been completed on all the facility required pieces of infection control and prevention as indicated in the Annual Round [NAME] education guidelines. During an interview with the Assistant Director of Nurses (ADON) and Regional Nurse on 2/6/24 at 11:35 A.M., the ADON said she is responsible for staff training and has only been in the facility since October 2023. The Regional Nurse said she would provide a list of what specific content was covered in the mandatory in-services and they use a Round [NAME] annual education guide for mandatory education. The Regional Nurse reviewed the educational sign-in sheets and said, based on the number of people who appeared to have attended, the trainings were ineffective because not enough staff participated. The ADON said she would double check to see if any other in-services were provided prior to her start at the facility. During a follow up interview on 2/6/24 at 4:33 P.M., the ADON said there were no other in-service sign-in sheets or trainings available for the surveyors to review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review and interview the facility failed to provide behavioral health trainings as required in accordance with their facility assessment. Findings include: Review of the Facility Assessment, dated May 2023, indicated but was not limited to the following: Staff training/education and competencies: - Throughout the year employees receive training and education on topics related to patient care and services. - Some trainings provided during general orientation is repeated at least annually. - Other topics are provided during the year based on Quality assurance performance improvement initiatives, ensuring regulatory compliance, best practices, clinical competencies and program development. List of staff training and competencies needed by staff type: Nurses and Certified Nurse Assistants (CNAs): Behavioral Health, including: Aggressive behaviors, Intrusive wandering, Self-destructive/self-injurious behaviors, coping mechanisms for unhealthy behaviors Nurses, CNAs, Activities and Social services: How to deal with difficult behaviors/mental health, Substance abuse (SUD) trainings Review of the in-service education attendance record titled Behavioral Health / SUD, dated 4/17/23, indicated but was not limited to the following: 45 of 107 employees on the pre-printed employee sign-in roster completed the training Review of the in-service education attendance record titled: Behavioral Residents, dated 4/26/23, indicated but was not limited to the following: 52 of 70 employees on the pre-printed employee sign-in roster completed the training Review of annual mandatory training content titled Round [NAME] Annual Education, dated 9/21/23, indicated but was not limited to the following trainings provided during the 9/21/23 mandatory in-service: -Dementia: Overview of Mild Cognitive Impairment; Understanding the early stage of Dementia; Management of common medical conditions during middle and late stages of Dementia; Medical treatments of Dementia; and Palliative end of life care of persons with Dementia -Change in condition; How to deal with difficult behaviors; Lesbian, Gay, Bisexual, Transgender, Queer, and more (LGBTQ+) Review of the in-service education attendance record titled Mandatory In-services (Round [NAME] Annual Education), dated 9/21/23, indicated but was not limited to the following: An additional four staff members completed Behavioral health/SUD training for a completion rate of 45.79% An additional seven staff members completed Behavioral Residents training for a completion rate of 84.28% During an interview with the Assistant Director of Nurses (ADON) and Regional Nurse on 2/6/24 at 11:35 A.M., the ADON said she is responsible for staff training and has only been in the facility since October 2023. The Regional Nurse said she would provide a list of what specific content was covered in the mandatory in-services and they use a Round [NAME] annual education guide for mandatory education. The Regional Nurse reviewed the educational sign-in sheets and said, based on the number of people who appeared to have attended, the trainings were ineffective because not enough staff participated. The ADON said she would double check to see if any other in-services were provided prior to her start at the facility. During an interview on 2/6/24 at 4:33 P.M., the ADON said there were no other in-service sign-in sheets or trainings available for the surveyors to review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review and interview, the facility failed to provide their staff training on facility ethic standards, policies, and procedures. Findings include: Review of the Facility Assessment, dated May 2023, indicated but was not limited to the following: Staff training/education and competencies: - Throughout the year employees receive training and education on topics related to patient care and services. - Some trainings provided during general orientation is repeated at least annually. - Other topics are provided during the year based on Quality assurance performance improvement initiatives, ensuring regulatory compliance, best practices, clinical competencies and program development. The Facility Assessment failed to indicate ethics and compliance training were required in accordance with the regulations. Review of annual mandatory training content titled Round [NAME] Annual Education, dated 9/21/23, indicated the following trainings were mandatory for staff, included but were not limited to the following and were provided during the 9/21/23 in-service: -Corporate compliance Review of the In-service Education Attendance Record for the Round [NAME] training, dated 9/21/23, failed to indicate ethics as a topic of education. Review of the 2023 and 2024 staff education and in-service sign-in sheets provided by the facility failed to indicate any trainings had been completed on the topic of ethics. During an interview on 2/6/24 at 4:33 P.M., the Assistant Director of Nurses said there were no other in-service sign-in sheets or trainings available for the surveyors to review.

Based on observation, medical record review, staff interview, and policy review, the facility 1.) Failed to release a physical restraint per the physician's orders and facility policy, and 2.) Failed to document the release and monitoring of a physical restraint in the medical record for one Resident (#30), out of a total sample of 19 residents. Review of the facility's policy titled Restraint Management System Guidelines, revised 9/2017, indicated the following but was not limited to: - Restraints must be released every two hours for a minimum of ten minutes. The Resident must be repositioned, exercised, or provided range of motion during this period. Findings include: Resident #30 was admitted to the facility in September 2021 with diagnoses that included muscle weakness, unsteady on feet, Alzheimer's dementia, and falls at home. Review of the Minimum Data Set (MDS) assessment, dated 2/7/22, indicated the Resident had severe cognitive impairment based on a Brief Interview for Mental Status (BIMS) score of 99. Further review of the MDS indicated the Resident's short- and long-term memory were impaired and the Resident's ability to make every day decisions about tasks and activities of daily living (ADLs) were severely impaired. Review of the medical record indicated that on 2/4/22 a physician's order was obtained for a self-releasing alarming Velcro seatbelt to be on while up in chair, and to release it during meals and ADLs. Review of the Restraint Decision Documentation Form, dated 2/4/22, indicated the initiation of a self-releasing alarming seatbelt to be utilized while up in the chair and to be released for ADLs and meals. Review of NSG: RESTRAINT- Physical (initial evaluation) Form V 2.0, dated 2/4/22, indicated but was not limited to the following: - Behavior prompting continued restraint use: unsteady gait, agitated behavior, aggressive behavior, frequent falls, attempts to self-transfer, delirium/acute confusion - Decision to restrain: impulsive, poor safety awareness On 4/14/22 at 12:00 P.M., the surveyor observed Resident #30 sitting up in his/her BRODA (supportive positional wheelchair) chair in his/her room being assisted by Certified Nursing Assistant (CNA) #3 with their lunch meal. The Resident was observed with the Velcro seatbelt still on. It had not been removed per the physician's order. On 4/19/22 at 12:12 P.M., the surveyor observed Resident #30 sitting up in his/her BRODA chair in the small dining room having their lunch. The Resident was observed with the Velcro seatbelt still on. It had not been removed per the physician's order. Further review of the medical record did not indicate there was any documented evidence that the Velcro seatbelt was being released and monitored while the Resident was sitting up in his/her BRODA chair. During an interview on 4/14/22 at 12:00 P.M., CNA #3 said she did not know what the restraint process was and did not know she was supposed to remove the Velcro seatbelt while she was feeding the Resident. During an interview on 4/14/22 at 12:57 P.M., Unit Manager #1 said the restraint should be removed during meals. She said staff will sometimes remove the restraint when the Resident is in view of staff. Unit Manager #1 said that due to lack of staffing it is difficult to keep a schedule on the removal of the restraint. She said they do not document on the Medication Administration Record/ Treatment Administration Record the release and monitoring of the restraint.

Based on observations, record review, and interviews, the facility failed to document the skin condition and effectiveness of treatment and follow the wound consultant's treatment plan for one Resident (#36), out of 19 sampled residents. Specifically, the facility failed to: 1. Document the Resident's extensive skin condition of both lower extremities during weekly nursing skin assessment or in nursing notes to monitor current skin condition and treatments. 2. Discontinue the application of Lac-Hydrin cream (prescription ointment to treat dry, scaly, or itchy skin conditions) to the left inside ankle venous wound after the wound was found to have deteriorated by the Wound Consultant on 3/8/22. 3. Restart the application of Lac-Hydrin cream to both lower extremities to treat a chronic skin condition after the most recent Wound Physician Consultant's evaluation on 4/5/22. Findings include: Resident #36 was admitted to the facility in February 2022 with diagnoses of dermatitis (skin inflammation), peripheral vascular disease (reduced blood flow to limbs), and failure to thrive. Review of the Minimum Data Set (MDS) assessment, dated 2/21/22, indicated Resident #36 scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she was cognitively intact. During an interview on 04/12/22 at 01:22 P.M., Resident #36 was lying in his/her bed with both legs exposed and the surveyor observed both lower legs (from knee to the toes) to have severely dry, flaky skin with multiple small, cracked areas and large areas of thick, brown scaly tissue with areas of red patchy skin. The Resident said his/her grandmother would be embarrassed with these legs. 1). Review of the Nursing admission note, dated 2/2022, indicated Resident #36 was admitted with yellow and brown scaling on bilateral lower extremities. There was no other nursing documentation of Resident #36's right and left lower leg skin condition. Review of Resident #36's current Physician's Orders indicated the following: -Skin integrity check every Monday. Review of Resident #36's Weekly Skin Check performed 2/22/22, 3/1/22, 3/8/22, 3/15/22, 3/22/22, 3/29/22, 4/12/22, and 4/19/22 indicated the following: -No skin observations were documented. -No new notable skin issues observed. During an interview on 04/19/22 at 10:30 A.M., the Wound Physician Consultant, with the Assistant Director of Nurses (ADON) present, said Resident #36 has a chronic skin condition and has severe plaques tissue growth on both lower legs. Plaques are defined as raised, inflamed and scaly patches of skin that may also be itchy and painful. During an interview on 04/19/22 at 04:49 P.M., the Director of Nurses reviewed Resident #36's skin assessments and nursing notes and agreed only the initial nursing admission note, dated 2/2022 had documentation of Resident #36's skin condition on both lower legs. 2). Review of the Wound Physician's note, dated 2/22/22, indicated the following: -Request of Resident #36's primary care physician a thorough wound care assessment and evaluation was performed on left inside ankle venous wound of less than 14 days. -wound size: 3 Centimeter (cm) length (L) x 2 cm Width (W) x Depth (D) Not measurable -Surface area: 6.00 centimeters squared (cm 2) -Primary dressing, apply moisturizer once daily for 30 days: Lac-Hydrin or Amlactin Review of the Wound Physician's note, dated 3/1/22, indicated the following: -Request of Resident #36's primary care physician a thorough wound care assessment and evaluation was performed on left inside ankle venous wound of less than 21 days. -wound size: 3 cm L x 2 cm W x D Not measurable -Surface area: 4.50 cm 2 -Primary dressing, apply moisturizer once daily for 23 days: Lac-Hydrin or Amlactin -Wound improved Review of Wound Physician's note, dated 3/8/22, indicated the following: -Request of Resident #36's primary care physician a thorough wound care assessment and evaluation was performed on left inside ankle venous wound of less than 28 days. -wound size: 4 cm L x 3 cm W x D Not measurable -Surface area: 12.00 cm 2 -Primary dressing, Xeroform sterile gauze apply once daily for 30 days, gauze roll 4.5 inches apply once daily for 30 days. -Discontinue Moisturizer -Wound deteriorated due to shear Review of past Physician's Orders indicated the following: -2/23/22 through 3/22/2022 Wound observation- Wound #1 Venous wound left medial ankle: Apply Lac-Hydrin moisturizer daily every day. Review of the Treatment Administration Record (TAR) indicated Resident #36 continued to receive Lac-Hydrin cream to the Venous wound left medial ankle from 3/8/22 through 3/22/22. Review of Resident #36's Wound-Weekly Observation Tool, dated 3/8/22, indicated the following: -Venous Wound left medial ankle -Treatment changes to treatment plan in last week, Xeroform followed by Kerlix (gauze wrap) -Current treatment plan was Lac-Hydrin or Amlactin once daily During an interview on 04/19/22 at 04:10 P.M., the ADON and the surveyor reviewed Resident #36's Wound Consultant's notes and the TAR. The ADON said she does not know why Resident #36 continued to have Lac-Hydrin cream applied to the left venous wound after the Wound Consultant's evaluation 3/8/22 indicated the wound had deteriorated and to discontinue the moisturizer Lac-Hydrin cream. She said when the Wound Consultant changes the orders for treatment, she just enters them into the computer and does not write any notes and can't remember the circumstances of the changes or discussions she had with the Wound Consultant Physician. During an interview on 04/19/22 at 04:49 P.M., the Director of Nurses reviewed Resident #36's current physician's orders, Wound Physician Consultant's notes, and TAR's, and said she would agree the treatment plan is hard to follow and confusing and they don't match up. 3. Review of the Wound Physician Consultant's note, dated 4/5/22, indicated the following: -(3) Left distal shin for at least 8 days: resolved -(4) Added diagnosis of xerosis (Dry skin) -Lac-Hydrin to legs Review of Resident #36's current Physician's orders did not indicate the Resident was receiving Lac-Hydrin cream to both legs. During an interview on 04/19/22 at 10:30 A.M., the Wound Physician Consultant, with the ADON present, said Resident #36 has a chronic skin condition and has severe plaques tissue growth on both lower legs. He said because the skin condition is chronic, the Resident was restarted on Lac-Hydrin cream after his last wound consultation visit on 4/5/22 to prevent the plaques build up from getting worse. The Wound Consultant reviewed his last note and confirmed Resident #36 should be receiving the Lac-Hydrin cream 1-2 days per week and was not aware he/she was not. During an interview on 04/19/22 at 04:10 P.M., the ADON said she heard the Wound Physician Consultant today say Resident #36 should still be receiving Lac-Hydrin cream to both legs 1-2 times a week and is not sure why he/she is not. She said initially we were putting the Lac-Hydrin cream on the entire right and left lower legs but stopped after 30 days because it can become an irritant. The ADON and the surveyor then reviewed Resident #36's current orders, Wound Physician Consultant notes, and the TAR. The ADON said she was not aware why the Resident had not started back on the Lac-Hydrin cream.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and in-service documentation review, the facility failed to ensure the nursing staff received the appropriate competencies and skill sets necessary for the care and treatment of residents. Specifically, the facility failed to ensure 1) annual competencies were completed and documented for 1 out of 1 nurse; and 2) agency staff were provided education on facility specific emergency procedures. Findings include: According to the Board of Registration in Nursing, 244 CMR 9.00: Standards of Conduct, a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. 1) Review of the facility's policy titled Mandatory Clinical Competency Skills: Nurses, revised 10/2019, indicated the following: -It is the policy of NHCA that all licensed nurses employed by the facility will demonstrate competency, during their orientation period and annually, performing the following skills: - Medication administration, blood glucose, CPR/AED, clean dressing technique, wound vac (if appropriate), G-tube placement/re-insertion check (if appropriate), supra pubic catheter re-insertion (if appropriate), tracheostomy care (if appropriate), indwelling catheter insertion (male and female), PICC line dressing change/weekly measurements, IV's, PT/INR testing, oxygen regulator change, Hoyer. Review of Nurse #1's education record indicated she began working at the facility on [DATE]. Further review of the education record indicated two competency fair packets dated 2020 and 2021. The packets had a series of individual competency forms with check marks but failed to indicate any additional information including the signature of the supervisor observing the competency, the date the competency was completed, or the signature of the employee who was being observed. During an interview on [DATE] at 01:43 P.M., Nurse #1 said when she was hired she worked closely with another staff nurse on the unit but could not recall a competency fair being completed and did not recognize the education packets being shown to her. During an interview on [DATE] at 02:10 P.M., Corporate Consultant #2 said the expectation is that the instructors educating staff should check and sign off the competencies when they are being completed. 2) During an interview on [DATE] at 08:52 A.M., the Director of Nurses said the facility is still utilizing agency staff to fill open positions for licensed nurses and nursing assistants. Review of the nursing schedules during the duration of the survey [DATE] through [DATE] indicated agency staff was used daily on various shifts. During an interview on [DATE] at 10:40 A.M., the surveyor requested three agency staff personnel's education/orientation records specific to the facility to include the emergency procedures. The Director of Nurses returned approximately thirty minutes later and said she was unable to provide the surveyor with the education records requested. During an interview on [DATE] at 1:55 P.M., Agency CNA #3 said she had been working in the facility for about two months. She said she had no formal orientation to the facility and just reported to the unit she was assigned. She said that she was shown her assignment and given a report on how to care for her residents but was not educated on emergency protocols. Agency CNA #3 was unable to speak to any particular policy or safety protocol such as what to do in a medical emergency or how to overhead page to alert staff to an emergency. During an interview on [DATE] at 02:10 P.M., Corporate Consultant #2 said all the education for agency staff is sent directly to the agency for employee review. She said the facility does not conduct training for agency staff in the building and does not keep a record of the education provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one out of one treatment cart on the Joppa Unit. Findings include: Review of the facility's policy titled Medication Storage in the Facility, dated 2017, indicated but was not limited to: - the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications - medication rooms, cart, and medication supplies are locked when not attended by persons with authorized access On 4/19/22 at 11:35 A.M., the surveyor entered the Joppa unit. The treatment cart was observed to be unsupervised and unlocked at the end of the hallway outside of room [ROOM NUMBER]. There was no nurse present in the hallway at the time the observation was made. The surveyor was able to open the treatment cart and observed several prescription and over the counter creams and ointments labeled with resident's names. During the time the surveyor was at the treatment cart, Nurse Consultant #1 walked down the hallway and said to the surveyor, This is not good. She said the nurse responsible for the treatment cart was new in her role and she was nervous and new to the survey process. Nurse Consultant #1 said she would stay with the treatment cart until the nurse was able to come out of the resident's room with the keys to lock the treatment cart.

Based on record review, policy review, and staff interview, the facility failed to ensure the antibiotic stewardship program was implemented per facility policy for one Resident (#15), out of a total sample of 19 residents. Findings include: Review of the facility's policy titled Antibiotic Stewardship Policy, revised 11/2017, indicated but was not limited to the following: - It is the policy of this facility to maintain an Antibiotic Stewardship Program (ASP) with the mission of promoting the appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use. - Provide a clearly defined, empiric therapy for the treatment of suspected infections when appropriate. - Promote safe and effective use of antibiotics that will adequately treat the patient for susceptible bacterial infections. - Minimize the emergence of bacterial resistance in the facility and community by monitoring and changing broad-spectrum antibiotics to appropriate narrowed therapy. Review of the Facility Assessment, dated 5/26/21, indicated but was not limited to the following: - As part of the antibiotic stewardship program the Center is not using broad spectrum antibiotics. We wait for the results of the culture then contact the physician and follow up orders. We discuss what the resident's symptoms are, follow the McGeer guidelines (criteria used in the surveillance and guidance for counting and identifying true infections), and do not use a change of mental status as the reason for ordering an antibiotic. Resident #15 was admitted to the facility in October 2021 with diagnoses that included atrial fibrillation, heart failure, stroke, dementia, and anxiety. Review of the Minimum Data Set (MDS) assessment, dated 1/19/22, indicated the Resident was frequently incontinent of urine and required extensive assist with toileting. Review of the medical record indicated Resident #15 had a urinalysis, with culture and sensitivity (UA C&S) obtained on 4/11/22. A urine culture test is performed to grow and identify organisms, while a sensitivity test helps to select an appropriate antibiotic that is effective against specific types of bacteria causing infection. Review of the UA C&S, for Resident #15, dated 4/13/22, indicated he/she did not have an infection as evidenced by a culture with less than 10,000 colonies of bacteria. Further review of the medical record indicated the urine results were faxed to the Nurse Practitioner (NP) on 4/15/22, two days after lab results were obtained. The NP initiated an order for Cipro (antibiotic used to treat infections) 500 mg twice a day for 10 days for a urinary tract infection. During an interview on 4/19/22 at 10:38 A.M., Unit Manager #1`said she reported the results to the NP and the NP initiated treatment because the Resident was presenting with behaviors and the Resident has a history of UTI's. She said the NP wanted to treat with antibiotics prophylactically at this point. Review of the nurses' notes indicated a McGeer's infection note was completed 4/15/22, the same day the antibiotic was initiated, indicating the Resident was suspected of having a urinary tract infection based on symptoms of cloudy urine and change in behaviors such as yelling and screaming. Further review of the nurses' notes, dated 4/1/22-4/18/22, did not indicate any documented evidence the Resident had an increase in his/her behaviors such as increased anxiety or agitation. The nurses' notes indicated the Resident presented with baseline confusion. During an interview on 4/19/22 at 4:40 P.M., the Director of Nurses (DON) said she spoke with the NP in regard to the initiation of the antibiotic and the NP said the Resident has a history of UTI's with sepsis (a serious medical condition that includes fever, difficulty breathing, low blood pressure, fast heart rate, and mental confusion). The DON said the NP wanted to treat the urine before the infection got worse. The DON said the Resident was presenting with increased agitation and anxiety. She also said the facility uses the McGeer criteria to identify true infections. Review of the MD/PA/NP notes, dated 10/28/21-4/8/22, did not indicate any documented evidence the Resident had a history of UTI with sepsis. The NP note on 4/8/22 indicated the Resident has increased agitation and anxiety and a UA C&S was to be obtained. No other MD/PA/NP notes indicated documentation the Resident had an increase in anxiety or agitation. Review of the Resident's History and Physical, dated 10/19/21, did not indicate any documented evidence the Resident has a history of UTI with sepsis. Review of the Discharge Summary from the hospital, dated 9/28/21, did not indicate any documented evidence that the Resident has a history of UTI with sepsis. The medical record failed to indicate any evidence of documentation for the appropriate usage of an antibiotic for a negative lab result. On 4/20/22 the Resident was seen and evaluated by the physician. The physician indicated in his progress note the urine culture has less than 10,000 colonies. The patient was afebrile (without fever). The physician note indicated to discontinue the use of the antibiotic and to monitor the patient's clinical symptoms.

Based on observations, interviews, and policy review, the facility failed to ensure food stored in nourishment kitchenettes was labeled and dated and the cleanliness was maintained to ensure a sanitary environment in order to prevent potential foodborne illness for 3 out of 3 nourishment kitchenettes. Findings include: Review of the facility's policy Use and Storage of Food Brought to Facility by Visitors for Residents dated March 2018, indicated but was not limited to the following: -Food and beverages brought in for residents by visitors will be monitored by staff for spoilage, contamination, and safety. -Facility is responsible for storing food brought in by family or visitors in a way which separate or easily distinguishes from facility food. -Resources made available to families or visitors to ensure that food brought in is labeled with resident's name, room number, and date upon arrival prior to storage in designated refrigerator. On 4/13/22 at 05:15 P.M., the Food Service Manager and the surveyor observed the three facility kitchenettes, and the following observations were made: Joppa Unit: -Box of ReadyCare Instant Food Thickener packets that contained seven individual packets that had an expiration date of 3/5/22. -Individual size container of Nilla Wafers with an expiration date of 10/3/21, not labeled. -Paper bag which contained a water bottle, open box of macaroon cookies, bottle of Ensure (nutritional supplement), not labeled, or dated. - Individually wrapped cookie packages scattered on two cabinet shelves, back corners and behind other food items. -Plastic container of various small candy bars and hard candy, not labeled, or dated. -Four open food products in the cabinet labeled with a resident's name but not dated. -One container of personal food in the refrigerator, not labeled, or dated. Sachem Unit: -Bag in the refrigerator which contained lasagna and a lemon lime jello, not labeled, or dated and was identified to be a staff member's dinner. -In the microwave was a plastic container of rice and meat dinner that was warm, not labeled or dated. -Bottom cabinet shelf had wood chipping off leaving wood particles, and cookies and clean plastic cups were stored. Passport Unit: -two staff members' meals stored in plastic containers labeled with staff name but not dated. During an interview on 04/13/22 at 5:15 P.M., the Food Service Director said the expired packets of Instant ReadyCare and Nilla Wafers should not have been in the cabinet and the individual packages of facility provided cookies are supposed to be contained in a plastic container. In addition, he said all resident's food brought in from home should be labeled with their name and dated. He continued, the staff should not be storing their personal meals in the refrigerators or using the microwave to heat up their food, they should be using the staff breakroom.

Based on Facility Assessment review and staff interview, the facility failed to identify resources based on the resident population to determine the necessary care, support services, and educational resources (in-servicing) needed to care for residents. Specifically, the facility failed to address the use of agency staff and the education and resources needed for the continued use of agency staff needed to fill licensed nurses and Certified Nursing Assistant (CNA) staff positions. Findings include: Review of the Facility Assessment, last updated 5/26/21, indicated the facility has 111 licensed beds with three units and has an average daily census of 82 residents. The Facility Assessment Tool had no information of the resources needed for the continued usage of agency nursing staff. The Facility Assessment failed to indicate the use of an orientation process when the agency staff worked at the facility. An orientation would include facility specific emergency procedures, abuse protocols, fire safety, knowing where emergency equipment is (e.g., automated external defibrillator) emergency codes, using the telephone system, knowing where supplies are located, and internal door codes. During an interview on 04/12/22 at 08:52 A.M., the Director of Nurses said the facility is still utilizing agency staff to fill open positions for licensed nurses and nursing assistants. During an interview on 4/20/22 at 1:55 P.M., Agency CNA #3 said she had been working in the facility for about two months. She said she had no formal orientation to the facility and just reported to the unit she was assigned. She said that she was shown her assignment and given a report on how to care for her residents but was not educated on emergency protocols. Agency CNA #3 was unable to speak to any particular policy or safety protocol such as what to do in a medical emergency or how to overhead page to alert staff to an emergency. During an interview on 4/20/22 at 3:12 P.M., the Facility Assessment was reviewed with the Administrator. The Administrator said if agency staff is being used, it should be identified in the Facility Assessment.