**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure professional standards of care were met for one Resident (#57), out of five residents observed during medication administration and one Resident (#21), out of a total sample of 18 residents. Specifically, the facility failed: 1. For Resident #57, to ensure the Resident had taken all of his/her medications before leaving the Resident's room; and 2. For Resident #21, to ensure nursing performed pain assessments to determine, per physician's orders, which dosage of oxycodone (pain medication used to treat moderate to severe pain; opioid) to administer to the Resident. Findings include: Review of [NAME], Manual of Nursing Practice 11ed, 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: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. 1. Review of the facility's policy titled Oral Medication Administration - Specific Procedures, revised 6/3/13, indicated but was not limited to the following: -Administer medication and remain with resident while medication is swallowed. Resident #57 was admitted to the facility in January 2023 with diagnoses including Parkinson's disease, hypertension, and fluid overload. Review of the active Physician's Orders for Resident #57 indicated but were not limited to the following: -Vitamin D3 50 micrograms (mcg) Give one tablet by mouth daily in AM at 8:00 A.M. (1/26/23) (Vitamin D supplement) -Tamsulosin 0.4 milligrams (mg) Give 0.4 mg by mouth daily at 8:00 A.M. (1/26/23) (medication used to relax prostate and bladder muscles in men) -Potassium Chloride Extended Release 20 milliequivalents (meq) once a day at 8:00 A.M. (2/22/23) (potassium supplement) -Metoprolol Succinate Extended Release 25 mg once a day at 8:00 A.M. (4/13/23) (medication used to treat high blood pressure) -Omeprazole Delayed Release 20 mg once a day at 8:00 A.M. (4/19/23) (medication used to reduce excess stomach acid) -Carbidopa-Levodopa 25-100 mg Give one tablet by mouth three times a day at 8:00 A.M., 1:00 P.M., and 7:00 P.M. (5/24/24) (medication used to manage symptoms of Parkinson's disease, such as tremors) -Eliquis 5mg Give 5 mg by mouth twice a day at 8:00 A.M. and 7:00 P.M. (5/24/24) (medication used to prevent blood clotting) -Furosemide 40 mg twice a day at 8:00 A.M. and 1:00 P.M. (5/24/24) (diuretic) -Multiple Vitamins Give one tablet by mouth daily at 8:00 A.M. (5/24/24) -Seroquel 25 mg Give half a tablet (12.5mg) orally every AM at 8:00 A.M. (5/24/24) (antipsychotic medication) On 10/23/24 at 10:52 A.M., the surveyor observed Nurse #6 prepare and administer Vitamin D3, Tamsulosin, Potassium Chloride, Metoprolol Succinate, Omeprazole, Carbidopa-Levodopa, Eliquis, Furosemide, Multiple Vitamins, and Seroquel to Resident #57. On 10/23/24 at 11:09 A.M., the surveyor observed Nurse #6 leave Resident #57's room before the Resident had finished taking all of the medication. Review of Resident #57's medical record failed to indicate that the Resident was able to self-administer medications. During an interview on 10/23/24 at 11:14 A.M., Nurse #6 said she usually administers Resident #57's medications and leaves the room before making sure he/she has taken all of the medications because he/she is cognitively intact. During an interview on 10/23/24 at 4:32 P.M., the Director of Nursing (DON) said that Resident #57 is not able to self-administer medications and that it is her expectation that the nurse stays with the Resident until he/she finishes taking all of their medications. 2. Resident #21 was admitted to the facility in October 2023 with diagnoses which included unspecified pain, generalized abdominal pain, and polyneuropathy (a nerve disease with symptoms that include pain). Review of Resident #21's Minimum Data Set (MDS) assessment, dated 7/16/24, indicated Resident #21 had frequent pain and was receiving pain medication on an as needed basis. Review of Resident #21's active Physician's Orders indicated but was not limited to the following: -Pain monitoring each shift, notify physician/nurse practitioner if pain is not controlled, every shift 07:00-15:00, 15:00-23:00, 23:00-07:00, active 10/10/23. -oxycodone- schedule II, 5 mg tablet, take 2 tablets (10 mg) by mouth every 4 hours as needed for severe pain, active 10/10/23; -oxycodone- schedule II, 5 mg tablet, take 1 tablet by mouth every 4 hours for moderate pain, as needed, active 10/10/23; -acetaminophen tablet, 325 mg, 2 tablets (650 mg) by mouth as needed every 6 hours for pain. Review of Resident #21's 2024 Medication Administration Record (MAR) for the months of August, September, and October indicated the Resident received oxycodone on an as needed basis. Further review of Resident #21's August 2024 MAR indicated but was not limited to the following: -650 mg acetaminophen was administered two times; -5 mg oxycodone was administered two times; -10 mg oxycodone was administered 35 times. -Documentation of pain severity (such as moderate, severe, or utilizing a pain scale) related to administering 10 mg of oxycodone for severe pain included the following: -8/3/24: Pain Comment: 9/10 (pain scale based on a scale of 0-10 with 10 being the worst pain). Further review of the August 2024 MAR indicated but was not limited to the following documentation of reasons for administering 10 mg of oxycodone for severe pain: -8/5/24: per Resident's request; -8/6/24: generalized pain; -8/11/24: abdomen; -8/13/24: per Resident's request; -8/27/24: per Resident's request; -8/29/24: complaints of left side pain; -8/30/24: left upper quadrant pain. Review of Resident #21's medical record indicated there were no nursing progress notes in August 2024 that indicated a pain assessment was performed with the administration of 5 mg or 10 mg of oxycodone. Additionally, there were no nursing progress notes that stated the severity of the Resident's pain when any oxycodone was administered. Further review of Resident #21's September 2024 MAR indicated but was not limited to the following: -650 mg acetaminophen was administered five times; -5 mg oxycodone was administered five times; -10 mg oxycodone was administered 18 times. -Documentation of pain severity (such as moderate, severe, or utilizing a pain scale) related to administering 10 mg of oxycodone for severe pain included the following: -9/1/24: Pain Comment: 8/10 -9/17/24: Pain scale 3. Further review of the September 2024 MAR indicated but was not limited to the following documentation of reasons for administering 10 mg oxycodone for severe pain: -9/2/24: complaints of general discomfort; -9/2/24: complaints of left flank pain; -9/10/24: per Resident's request; -9/14/24: per Resident's request; -9/23/24: complaints of generalized discomfort. Review of Resident #21's medical record indicated there were no nursing progress notes in September 2024 that indicated a pain assessment was performed with the administration of 5 mg or 10 mg of oxycodone. Additionally, there were no nursing progress notes that stated the severity of the Resident's pain when any oxycodone was administered. Further review of Resident #21's October 2024 MAR (10/1/24-10/28/24) indicated but was not limited to the following: -650 mg acetaminophen was administered one time; -5 mg oxycodone was administered 12 times; -10 mg oxycodone was administered 20 times. Documentation of pain severity (such as moderate, severe, or utilizing a pain scale) related to administering 10 mg of oxycodone (ordered for severe pain) included the following: -10/24/24: complaints of pain to left side/flank area #8; -10/26/24: abdominal 8/10. Further review of the October 2024 MAR indicated, but was not limited to the following documentation of reasons for administering 10 mg oxycodone for severe pain: -10/1/24: generalized pain; -10/11/24: abdominal; -10/18/24: pain comment: flank; -10/21/24: increase pain left hip/side; -10/24/24: per Resident request; -10/27/24: abdominal pain; -10/27/24: per Resident request. During an interview on 10/28/24 at 2:00 P.M., the surveyor and Unit Manager (UM) #2 reviewed Resident #21's oxycodone orders and MAR. UM #2 said she expects nursing to use an appropriate scale to assess Resident #21's pain. UM #2 said she expects nursing to administer the appropriate oxycodone dosage based on the severity of the Resident's pain and the physician's order. UM #2 said reasons for administering oxycodone, such as generalized pain and per Resident request, are not acceptable. During an interview on 10/29/24 at 12:26 P.M., the Director of Nursing (DON) said the facility's policy is to use a numerical pain scale. The DON acknowledged the Resident's oxycodone orders indicate the terms moderate and severe for pain and do not indicate a numerical pain scale. The DON said nursing should be using a numerical pain scale to assess Resident #21's pain level to determine, per physician's orders, which pain medication or which dose of oxycodone is appropriate for the Resident.

Based on observation, record review, and staff interview, the facility failed to ensure side rails were not implemented per the declination of consent from the Health Care Proxy (HCP) for one Resident (#121), of a total sample of 18 residents. Findings include: Resident #121 was admitted in October 2024 for a respite stay with a diagnosis of dementia. Review of the medical record indicated that upon admission, the Resident's HCP signed that he/she declined the use of side rails for the Resident. On 10/22/24 at 9:10 A.M., the surveyor observed Resident #121's bed to have side rails at the upper left and right sides. Resident #121 was not in the bed. On 10/25/24 at 10:18 A.M., the surveyor observed Resident #121's bed to have side rails at the upper left and right sides. Resident #121 was not in the bed. During an interview on 10/25/24 at 10:25 A.M., Unit Manager #1 said that the side rails that were on the Resident's bed were from the previous resident that occupied the bed. Unit Manager #1 also said that no side rail assessment for use of the side rails had been conducted, and the side rails should have been removed from the bed when Resident #121 was admitted . Unit Manager #1 confirmed that the HCP had signed that he/she declined consent for the use of side rails.

Based on records reviewed, policy review, and interview for two Residents (#4 and #26), of 18 sampled residents, the facility failed to ensure that each Resident's drug regimen was free from unnecessary psychotropic medications. Specifically, for Residents #4 and #26, the facility failed to ensure an Abnormal Involuntary Movement Scale (AIMS, a clinical outcome checklist completed by a healthcare provider to assess the presence and severity of adverse outcomes, such as abnormal movements of the face, limbs, and body in patients) assessment was completed timely. Findings include: Review of the facility's policy titled Psychotropic Medication Consent, dated as reviewed 2/24, indicated but was not limited to: -In order to meet Section 72BB's requirements for documenting informed consent, prior to the administration of any drug included on Attachment A, long term care facilities must complete the Department's prescribed for (Attachment B), and prior to or upon administration, include the completed form in the resident's medical record. -Written informed consent must be obtained each time a new or renewed prescription falls outside the dosage to which the resident or the resident's legal representative previously consented, or once a year, whichever is shorter. Resident #4 was admitted to the facility in March 2018 with diagnoses which included dementia, paranoid personality disorder, bipolar disorder, personality disorder, and generalized anxiety disorder. Review of Resident #4's Minimum Data Set (MDS) assessments, dated 5/31/24 and 8/3/24, both indicated the Resident was receiving antipsychotic medication on a routine basis. Review of Resident #4's active physician's orders indicated, but was not limited to, the following: -aripiprazole tablet, 5 milligram (mg), One tablet (5mg) by mouth daily, active 10/10/20; -risperidone tablet, 0.5mg, One tablet (0.5mg) by mouth daily at bedtime four times a week, omit Sunday/Wednesday and Thursday, active 6/25/24; -risperidone tablet, 0.25mg, take one tablet by mouth weekly on Sundays/Wednesdays/Thursdays, active 6/25/24. Review of Resident #4's 2024 Medication Administration Record for June through October indicated the Resident was administered their scheduled aripiprazole and risperidone per physician's orders. Review of care plans for Resident #4 indicated but was not limited to the following: -AIMS every six months while I am taking antipsychotic medication. Further review of Resident #4's medical record indicated AIMS assessments were completed on 12/18/23 and 8/5/24. Resident #26 was admitted to the facility in June 2021 with diagnoses which included dementia and bipolar disorder. Review of Resident #26's MDS assessments, dated 6/18/24 and 9/18/24, both indicated the Resident was receiving antipsychotic medication on a routine basis. Review of Resident #26's active physician's orders indicated, but was not limited to, the following: -risperidone tablet, 0.5mg, one half tablet (0.25mg) by mouth daily in the morning, active 7/17/23; -risperidone tablet, 0.5mg, once a day on Sunday, active 8/14/24; -risperidone tablet, 0.5mg, twice a day on Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, active 8/14/24. Review of Resident #26's 2024 Medication Administration Record for June through October indicated the Resident was administered their scheduled risperidone per physician's orders. Review of care plans for Resident #26 indicated but was not limited to the following: -AIMS every six months while I am taking antipsychotic medication. Further review of Resident #26's medical record indicated AIMS assessments were completed on 12/18/23 and 8/5/24. During an interview on 10/29/24 at 12:34 P.M., the DON said for residents receiving anti-psychotic medication, an AIMS assessment should be performed every six months. The DON said, for Residents #4 and #26, the 8/5/24 AIMS assessments should have been completed in June 2024, not in August 2024.

Based on record review and interview, the facility failed to maintain medical records that are complete, accurate, and systemically organized within accepted professional standards of practice for one Resident (#15) of 18 sampled residents. Specifically, the facility failed to document two administered doses of glucagon (an anti-hypoglycemic (low blood sugar) agent that increases blood glucose) on the Medication Administration Record (MAR). Findings include: Review of the facility's policy titled Administration of Medications - General Guidelines, Specific Procedures, dated as revised 1/15/15, indicated but was not limited to: -Medication administration is documented on the resident's Medication Administration Record at the time the medication is given by the person who administered the medication. -When as needed medications are administered, the following documentation is provided (date, time, dose, and route of administration). -The person administering medication reviews the Medication Administration Records to ascertain that all necessary doses were documented. Resident #15 was admitted to the facility in October 2023 with diagnoses which included diabetes mellitus and peripheral vascular disease (PVD). Review of the Minimum Data Set (MDS) assessment, dated 7/22/24, indicated Resident #15 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Review of Resident #15's Physician's Orders indicated but was not limited to: -glucagon solution 1 milligram (mg)/milliliter (mL); inject 1 mg intramuscularly (into muscle) as needed for severe hypoglycemia and if resident is unresponsive or unable to swallow anything by mouth, may repeat dose after 15 minutes if no response, dated 10/2/23 Review of Resident #15's nursing progress note, dated 10/26/24, indicated Resident #15 was diaphoretic and unresponsive with blood glucose reading indicating an abnormally low blood sugar. Further review of the nursing progress note indicated facility staff administered two doses of glucagon to Resident #15. Review of Resident #15's October 2024 MAR failed to indicate the glucagon had been administered. During a telephonic interview on 10/29/24 at 8:56 A.M., Nurse # 2 said on 10/26/24 Resident #15 had received two doses of glucagon and she wrote a progress not indicating that but did not ensure the medication administration had been documented on the MAR. During an interview on 10/28/24 at 2:53 P.M., Nurse #5 said anytime a medication is administered it should be documented on the MAR with the date and time of administration. During an interview on 10/29/24 at 11:29 A.M., Nurse #9 said the administration of any medication, including as needed medications, should be documented in the Resident's MAR. During an interview on 10/29/24 at 10:04 A.M., Unit Manager #3 said Resident #15 was hypoglycemic on 10/26/24 and was administered two doses of glucagon. Unit Manager #3 reviewed Resident #15's October 2024 MAR and said the glucagon administration had not been recorded but it should have been signed off. During an interview on 10/29/24 at 11:54 A.M., the Director of Nurses said the administration of any medication should be documented in the Resident's MAR.

Based on observation, interview, and policy review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to ensure: 1. For Resident #20, who has an indwelling urinary catheter, that staff implemented Enhanced Barrier Precautions (EBP-an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities); and 2. For Resident #32, who has an open wound, that staff implemented EBP. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) guidance titled Enhanced Barrier Precautions in Nursing Homes, dated 3/20/24, indicated but was not limited to: - Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities. - EBP are used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning (putting on) of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing - EBP are indicated for residents with any of the following: a. Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or b. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO - EBP should be used for any residents who meet the above criteria, wherever they reside in the Facility Review of the Centers for Disease Control and Prevention (CDC) Enhanced Barrier Precautions sign, undated, indicated but was not limited to: -Everyone must: clean their hands, including before entering and when leaving the room. -Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy), and wound care. Review of the facility's policy titled Enhanced Barrier Precautions, dated 3/2024, indicated but was not limited to: -EBP are to be initiated for residents who have an infection or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply. -Residents with wounds/ or [sic] indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. -Wounds include chronic wounds, such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. -Indwelling medical device examples include central lines, urinary catheters, feeding tubes, tracheostomies. Procedure -The use of gown and gloves for high-contact resident care activities is indicated with EBP. -High-contact care includes: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, wound care. 1. Resident #20 was admitted to the facility in December 2020 with diagnoses including benign prostatic hyperplasia, bladder cancer, and urinary retention. Review of the Minimum Data Set (MDS) assessment, dated 8/28/24, indicated Resident #20 had an indwelling urinary catheter. On 10/28/24 at 9:32 A.M., the surveyor observed Resident #20 in his wheelchair with the urinary catheter drainage bag with privacy shield hanging from the wheelchair frame. CNA #2 was assisting Resident #20 to the bathroom for morning hygiene and dressing. The surveyor observed an EBP sign posted at the door of Resident #20's room indicating the Resident was on EBP. During an interview on 10/29/24 at 9:44 A.M., CNA #2 said that she assisted the Resident with morning activities of daily living (ADLs) in the bathroom and that Resident #20 does not require precautions when performing care. CNA #2 said that the EBP sign is posted on the door because he/she has a catheter but that she does not have to take any special precautions when going into the room or performing care. During an interview on 10/29/24 at 11:57 A.M., the Director of Nursing (DON) said that it is her expectation that staff follow EBP when indicated while providing care to residents. 2. Resident #32 was admitted to the facility in September 2024 with a diagnosis of lung cancer with metastasis to the bone. Review of the MDS assessment, dated 9/24/24, indicated that the Resident had an unhealed pressure ulcer requiring pressure ulcer care. During an observation of Resident #32's wound care on 10/28/24 at 1:27 P.M., Unit Manager #2 performed hand hygiene and donned (put on) gloves, but failed to don a gown. The surveyor observed Unit Manager #2 reposition the Resident and perform wound care as ordered with no gown on. The surveyor observed an EBP sign posted outside of the Resident's room and gowns available in a hanging organizer mounted to the Resident's room door. During an interview on 10/28/24 at 1:37 P.M., Unit Manager #2 said that the Resident requires EBP due to his/her open wound and that she should have worn a gown while performing wound care. During an interview on 10/29/24 at 11:57 A.M., the DON said that it is her expectation that staff follow EBP when indicated while performing wound care.

Based on observation, interview, and record review, the facility failed to ensure it was free from a medication error rate of greater than five percent when one of two nurses made four errors out of 30 opportunities, totaling a medication error rate of 13.33%. These errors impacted two Residents (#38, #57), out of five residents observed. Specifically, 1. For Resident #38, Repaglinide (an oral antihyperglycemic medication used to help control high blood sugar), and Metformin (an oral antihyperglycemic medication used to help control high blood sugar) were not administered as ordered by the physician during the medication pass; and 2. For Resident #57, Carbidopa-Levodopa (a medication used to treat symptoms of Parkinson's disease) and Furosemide (a diuretic medication used to aid the body in removing excess fluid) were not administered as ordered by the physician during the medication pass. Findings include: Review of Lippincott Nursing Procedures, Ninth Edition, Safe Medication Administration Practices, General, indicated that nurses must adhere to the five rights of medication administration: identify the right patient by using at least two patient-specific identifiers; select the right medication; administer the right dose; administer the medication at the right time; and administer the medication by the right route. Review of the facility's policy titled Administration of Medications - General Guidelines - Specific Procedures, revised 1/15/15, indicated but was not limited to the following: -Medications are administered in accordance with written orders of the physician or other authorized prescriber. -Medications ordered to be given before meals must be administered at least one hour before meals. 1. Review of the active Physician's Orders for Resident #38 indicated but were not limited to the following: -Repaglinide 2 milligrams (mg) One tablet by mouth daily at 11:30 A.M. (6/1/21) -Metformin 500 mg Take two 500 mg tablets (1000 mg) by mouth daily before breakfast and dinner at 8:30 A.M., 5:30 P.M. (5/31/24) On 10/23/24 at 10:18 A.M., the surveyor observed Nurse #6 prepare and administer Repaglinide and Metformin to Resident #38. Nurse #6 failed to administer the Repaglinide within one hour before or after the scheduled administration time indicated in the physician's order. Nurse #6 failed to administer the Metformin before breakfast as ordered. During an interview on 10/23/24 at 10:14 A.M., Nurse #6 said that Resident #38 likes to take her medications together. During an interview on 10/23/24 at 4:32 P.M., the Director of Nursing (DON) said that it is her expectation that medications are administered within a one hour window before or after the medication's scheduled time. 2. Review of the active Physician's Orders for Resident #57 indicated but were not limited to the following: -Carbidopa-Levodopa 25-100 mg Give one tablet by mouth three times a day at 8:00 A.M., 1:00 P.M., and 7:00 P.M. (5/24/24) -Furosemide 40 mg twice a day at 8:00 A.M. and 1:00 P.M. (5/24/24) On 10/23/24 at 10:52 A.M., the surveyor observed Nurse #6 prepare and administer medications, including Carbidopa-Levodopa and Furosemide, to Resident #57. Nurse #6 failed to administer the Carbidopa-Levodopa and Furosemide within one hour before or after the scheduled administration times as ordered by the physician. Review of Resident #57's electronic Medication Administration Record indicated that on 10/23/24, the scheduled 8:00 A.M. doses of Carbidopa-Levodopa and Furosemide were charted late. Nurse #6 entered in the comments for the late administration on time. During an interview on 10/23/24 at 4:32 P.M., the DON said that it was her expectation that medications are administered within a one-hour window before or after the medication's scheduled time.

Based on interview, observation, and record review, the facility failed to ensure a dignified and homelike dining experience was provided for one Resident (#49), out of a total sample of 18 residents. Findings include: Resident #49 was admitted to the facility in May 2019 with diagnoses which included dementia. Review of the most recent Minimum Data Set assessment, dated 8/16/23, indicated Resident #49 was severely cognitively impaired, sometimes able to make self understood, sometimes able to understand others and was dependent for eating. During dining observations made on 11/9/23 and 11/14/23, the surveyor observed the following: On 11/9/23 at 12:05 P.M., Resident #49 was seated in a Broda chair (type of recliner) lined up against the wall with three other residents seated in recliner chairs. Certified Nurse Assistant (CNA) #3 moved an overbed table in front of Resident #49, placed Resident's lunch on the table and fed the Resident his/her lunch standing next to Resident #49. CNA #3 fed Resident #49 the entire meal, which included drinks and dessert, while she stood next to the Resident. On 11/14/23 at 11:40 A.M., Resident #49 was seated in a Broda chair lined up against the wall with five other residents seated in recliner chairs. A staff member placed the lunch tray on the overbed table in front of Resident #49 and fed the Resident his/her lunch standing next to Resident #49. The staff member fed the Resident the entire meal, which included drinks and dessert, while she stood next to the Resident. During an interview on 11/15/23 at 8:59 A.M., Unit Manager #1 was made aware of the surveyor's observations. Unit Manager #1 said it was the expectation that staff would not stand while feeding residents and all residents would have a homelike dining experience. During an interview on 11/15/23 at 9:10 A.M., the Administrator was made aware of the surveyor's observations. The Administrator said it was the expectation that all residents have a comfortable and homelike dining experience.

Based on observation and interview, the facility failed to ensure residents in one of three dining rooms had a comfortable and homelike dining experience. Specifically, residents seated at the same table were not fed at the same time, resulting in them having to sit and watch others eating or being fed while waiting their turn to be fed by staff. Findings include: During dining observations throughout the survey, the surveyors observed the following in the first-floor dining area: On 11/9/23 at 11:48 A.M., the surveyor observed several residents sitting in recliner chairs along the wall of the room watching other residents being fed, while waiting for their meal to be served or to be moved to a table when space was available to be fed. The dining service started at 11:48 A.M. and the last tray was passed at 12:25 P.M. Additional observations on 11/9/23 included: -Table 1: 11:48 A.M., six residents were seated at the table; three residents had meals and were eating independently, while three residents watched and waited for their meals. 11:55 A.M., seven minutes later meals were served to two more residents, while one resident sat without a meal. 12:00 P.M., 12 minutes after the first meal was served at the table, the last resident received their meal. -Table 2: 11:48 A.M., two residents were seated at the table; one resident had a meal and was eating independently, while the other resident watched and waited. 12:00 P.M., 12 minutes later, the second resident received their meal. -Table 3: Three residents were seated in recliner chairs at the table. 11:55 A.M., a meal was placed and set up for one resident who required total assist with eating. The meal was left in front of this resident. At 12:05 P.M., a staff member brought a chair over to the table and started to feed the resident. The other two residents waited and watched while the resident was fed. 12:07 P.M., 12 minutes later, a meal was placed and set up for the second resident and a staff member assisted the resident to eat, while the third resident waited and watched the resident being fed. 12:13 P.M., 18 minutes after the first meal was served at the table, the third resident received their meal and was assisted by a staff member. -Table 4: Two residents were seated across from each other in recliner chairs at the table. 12:00 P.M., meal was delivered, and a staff member started to feed the first resident, while the second resident watched and waited. 12:21 P.M., 21 minutes later, the second resident received their meal as was assisted by a staff member. On 11/10/23 at 11:40 A.M., the surveyor observed several residents sitting in recliner chairs along the wall of the room watching other residents being fed, while waiting for their meal to be served or to be moved to a table when space was available to be fed. The dining service started at 11:40 A.M. and the last tray was served at 12:15 P.M. Additional observations on 11/10/23 included: -Table 2: Two residents were seated across from each other in recliner chairs at the table. 11:45 A.M., one meal was served, and a staff member started to feed the first resident, while the second resident watched and waited. 12:03 P.M., 18 minutes later, the second resident received their meal and was fed by staff member. -Table 3: Three residents were seated in recliner chairs. One resident was being assisted by a staff member to eat as the two other residents watched and waited for their meals. 11:48 A.M., a staff member was observed to move another resident in a recliner chair to the table and was served a meal and assisted by staff to eat as the two other residents watched and waited for their meals. 11:50 A.M., one resident still waiting for a meal was observed to reach over to another resident's tray three times and grab at food from the plate of a resident being fed by staff. 11:55 A.M., the resident observed to grab at food was provided with a meal and assisted by staff to eat. 12:05 P.M., 17 minutes after the first meal was served at the table, the last resident was served a meal and fed by staff. The surveyor did not observe staff wash any residents' hands or wipe down the tables prior to meal delivery. Additional observations on 11/13/23 included: On 11/13/23 at 11:38 A.M., the surveyor observed several residents sitting in recliner chairs along the wall of the room watching other residents being fed, while waiting for their meal to be served or to be moved to a table when space was available to be fed. Dining service started at 11:38 A.M. when the first truck was delivered to the unit and the last tray was served at 12:22 P.M. -Table 1: Four residents were seated at the table. 11:46 A.M., one resident was provided a meal and fed by staff as three other residents watched and waited for their meals. -Table 2: Three residents were seated at the table. 11:48 A.M., two residents were provided with meals and as staff set up these two residents, the third resident was observed to grab at another resident's meal until his/her meal was provided. -Table 3: Five residents were seated at or next to the table in recliner chairs. 11:51 A.M., meals were served for two residents who required assistance to eat, while the three remaining residents watched and waited. 11:55 A.M., meal was served, and a staff member started to feed the third resident, while the two remained residents watched and waited. 12:05 P.M., meal was served, and a staff member started to feed the fourth resident, while one remaining resident watched and waited. 12:15 P.M., 24 minutes after the first meal was served, the fifth resident received their meal and was fed by a staff member. The surveyor did not observe staff wash any residents' hands or wipe down the tables prior to meal delivery. On 11/14/23 at 11:30 A.M., the surveyor observed 10 residents sitting in the dining room. Dining service started at 11:37 A.M. when the first truck was delivered to the unit and second truck was delivered at 12:04 P.M. Additional observations on 11/14/23 included: -11:40 A.M., one resident was observed to be fed by a staff member, while six residents watched and waited for their meals. -11:45 A.M., two residents remained without meals and five meal trays remained on the first meal truck. -11:54 A.M., one resident remained without a meal as the other residents were eating or being assisted by staff to eat. -11:54 A.M., an additional resident was brought into the dining area and assisted by a staff member to eat. -12:04 P.M., the second meal truck arrived on the unit and the last resident was provided with a meal, 27 minutes after the first tray on the first truck was provided. The surveyor did not observe staff wash any residents' hands or wipe down the tables prior to meal delivery. During an interview on 11/15/23 at 8:58 A.M., Unit Manager #1 was made aware of the observations of the dining experience provided to the residents. Unit Manager #1 said the facility had been working on the dining issues and is aware they need to adjust dining arrangements and seating, and it was her expectation that all residents should be provided with a homelike and comfortable dining experience. During an interview on 11/15/23 at 9:12 A.M., the Administrator was made aware of the observations of the dining experience provided to the residents. The Administrator said all residents should be provided with a homelike, comfortable, and dignified dining experience.

Based on observations, interviews, and record review, the facility failed to ensure an individualized plan of care was followed for Resident #5, in a total sample of 18 residents. Specifically, the facility failed to ensure a hand splint was applied for Resident #5 with decreased range of motion. Findings include: Resident #5 was admitted to the facility in March 2018 with diagnoses which included left-sided hemiplegia following a stroke. Review of the care plans for Resident #5 indicated a problem of having contractures and decreased range of motion to the left hand and left upper extremity (arm) and was at risk for contracture. The goal included to be free from further decrease in range of motion to the left upper extremity. The interventions included to apply an orthotic left-hand roll splint tube daily from 8:00 A.M. through 2:00 P.M. Review of the Physician's Orders included an order to utilize a left-hand roll splint tube, to be worn daily from 8:00 A.M. to 2:00 P.M. and to apply a sling to the left upper extremity when out of bed, except when wearing left upper extremity splint. On 11/9/23 at 9:05 A.M., the surveyor observed a sign in the room of Resident #5 which indicated Resident #5 was to wear a left hand splint every day for six hours. On 11/9/23 at 9:05 A.M., 10:05 A.M. and 10:52 A.M., the surveyor observed Resident #5 to be lying in bed with no orthotic equipment on their left hand and the surveyor did not observe any hand splints in the Resident's room. On 11/9/23 at 12:00 P.M. and 1:40 P.M., the surveyor observed Resident #5 up in a wheelchair wearing a sling on the left arm. During an interview on 11/9/23 at 2:25 P.M., Resident #5 said there was nothing else in the sling, just their hand. On 11/10/23 at 8:42 A.M., 11:52 A.M., and 1:37 P.M., the surveyor observed Resident #5 lying in bed not wearing any orthotic equipment to the left hand. On 11/14/23 at 8:50 A.M., the surveyor observed Resident #5 lying in bed, not wearing any orthotic equipment to the left hand. During an interview on 11/14/23 at 8:51 A.M., Certified Nursing Assistant (CNA) #1 said Resident #5 wears a sling when out of bed. She said the Resident previously had a left-hand splint, but the Resident does not wear the splint and the sling at the same time. She said Resident #5 does not wear a splint on the 7:00 A.M. to 3:00 P.M. shift but might wear it on the 3:00 P.M. to 11:00 P.M. shift. During an interview on 11/14/23 at 8:57 A.M., the Director of Rehabilitation (Rehab) said Resident #5 had a sling to ensure comfort and she would have to review if the Resident's current plan included the continued use of a left-hand splint. During an interview on 11/14/23 at 9:46 A.M., the Director of Rehab said Resident #5 should have been wearing the left-hand splint as ordered. She said the sling should have been worn during transfers and when Resident #5 was not wearing the hand splint (outside of the hours of 8:00 A.M. and 2:00 P.M.) She said she checked the Resident's room and was unable to locate the hand splint and the staff were unsure of what happened to the hand splint or why it was not being worn.

Based on observation, interview, policy review, and record review, the facility failed to provide necessary respiratory care and services for one Resident (#276), out of a total sample of 18 residents. Specifically, the facility failed to ensure oxygen tubing was changed weekly. Findings include: Review of the facility's policy tilted Use of Oxygen Concentrators, revised October 2023, indicated but was not limited to: -To assure there is an established procedure for the safe and effective use of oxygen concentrators; -Oxygen Cannula or mask will be changed weekly and prn; and -Oxygen tubing will be dated and labeled. Resident #276 was admitted to the facility in November 2023 with diagnoses including chronic obstructive pulmonary disease (COPD- lung disease that blocks airflow and makes it difficult to breathe), malignant neoplasm of right lung, and respiratory failure. Review of Resident #276's Minimum Data Set (MDS) assessment, dated 7/21/2023, indicated the Resident's Brief Interview for Mental Status (BIMS) score was 14 out of 15, indicating he/she was cognitively intact. Review of Resident #276's current Physician's Orders indicated but were not limited to: -Oxygen (O2): 1-4 liters per minute via nasal cannula continuously to maintain an O2 saturation greater than 89%, start date: 11/1/23; and -Tubing: CNA to change and date new oxygen tubing weekly on the 11-7 shift every Saturday, start date: 11/1/23. On 11/9/23 at 1:30 P.M., the surveyor observed Resident #276 in his/her room utilizing three liters of Oxygen via nasal cannula attached to a concentrator. Resident #276's oxygen tubing was undated. On 11/10/23 at 10:17 A.M., the surveyor observed Resident #276 in his/her room utilizing three liters of Oxygen via nasal cannula attached to a concentrator. Resident #276's oxygen tubing was dated 11/8/23. On 11/13/23 at 10:00 A.M., the surveyor observed Resident #276 in his/her room utilizing three liters of Oxygen via nasal cannula attached to a concentrator. Resident #276's oxygen tubing was dated 11/8/23. On 11/14/23 at 9:15 A.M., the surveyor observed Resident #276 in his/her room utilizing three liters of Oxygen via nasal cannula attached to a concentrator. Resident #276's oxygen tubing was dated 11/8/23. Review of Resident #276's Medical Administration Record (MAR) for November 2023 did not indicate his/her oxygen tubing had been changed on 11/4/23 or 11/11/23. During an interview on 11/14/23 at 9:14 A.M., Resident #276 said he/she thought staff replaced the oxygen tubing since he/she arrived at the facility. Resident #276 said he/she was not certain if it was changed. During an interview on 11/14/23 at 2:00 P.M., Nurse #2 said oxygen tubing is changed by nursing staff on the overnight shift weekly. Nurse #2 said there is a physician's order for each resident who is on Oxygen when the tubing is due to be changed. Nurse #2 said the order would populate on the MAR for the nurse on the day the tubing was due to be changed. During an interview on 11/14/23 at 3:10 P.M., Unit Manager (UM) #2 said residents on Oxygen are monitored by nursing staff as well as the in house respiratory therapist. UM #2 said oxygen tubing was due to be changed weekly on the date indicated in the physician's order. UM #2 was made aware of the surveyor's observations of Resident #276's oxygen tubing. The surveyor and UM #2 reviewed the physician's orders for Resident #276. UM #2 said the oxygen tubing should have been changed and dated on the Saturday overnight shift on 11/11/23 based on the physician's orders. During an interview on 11/15/23 at 9:50 A.M., the Director of Nurses (DON) said the expectation was for oxygen tubing to be changed weekly per the physician's order.

Based on observation, record review, policy review, and interview, the facility failed to ensure that all drug records were in order and that an account of all controlled drugs was maintained. Specifically, the facility failed to ensure for one Resident (#11), information was entered on the narcotic accountability record immediately after a schedule IV-controlled substance (low potential for abuse and low risk for dependence) was removed from the medication cart. Findings include: Review of the facility's policy titled Preparation and General Guidelines: Medication Administration-General Guidelines, dated as revised January 2018, indicated but was not limited to the following: -Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. -Preparation: Five Rights: Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. -Administration: The person who prepared the dose for administration is the person who administers the dose. -Documentation: The individual who administers the medication dose records the administration on the Medication Administration Record directly after the medication is given. Review of the facility's policy titled Medication Storage in the Facility: Controlled Substance Storage, dated as revised January 2018, indicated but was not limited to the following: -Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility in accordance with federal, state, and other applicable laws and regulations. -A controlled substance accountability record is prepared by the pharmacy/facility for all Schedule II, III, IV, and V medications. -The following information is completed on the accountability form upon dispensing or receipt of a controlled substance: a. Name of resident, b. Prescription number, c. Name, strength, and dosage form of medication, d. Date received, e. Quantity received, and f. Name of person receiving medication supply. Review of the facility's policy titled Medication Orders: Controlled Substance Prescription, dated as revised January 2018, indicated but was not limited to the following: -Documentation of the Controlled Substance Prescription: Each controlled substance prescription is documented in the resident's medical record with the date, time and signature of the person receiving the prescription and recorded on the Medication Administration Record. Review of the facility's policy titled Narcotic Count, dated as revised April 2023, indicated but was not limited to the following: Nurses will inspect the narcotic book to ensure correctness and accuracy. Resident #11 was admitted to the facility in May 2021, with the following diagnoses: Spondylolisthesis (spinal disorder in which a bone slips forward onto the bone below it causing pain), Spondylosis cervical region (age related wear affecting discs in neck sometimes called arthritis of the neck), and chronic pain. Review of Resident #11's current Physician's orders, included but was not limited to the following: -Tramadol 50mg (Schedule IV) by mouth every day at 8:30 A.M. for chronic pain. During inspection of the Medication Cart on Unit 2 A/B at 10:55 A.M. with Nurse #2, the surveyor observed the following: -The Narcotic Medication Card in the Medication Cart for Resident #11's Tramadol 50 milligram (mg) tablets (schedule IV Narcotic pain medication), contained 40 tablets. -The Narcotic Book documentation log for Resident #11's Tramadol 50 mg tablets had 41 tablets on the register. Review of Resident #11's Medication Administration Record (MAR), indicated Tramadol 50mg was administered as ordered by Nurse #2. During an interview on 11/14/23 at 10:55 A.M., Nurse #2 said the medication was administered earlier during morning medication pass and should have been signed out of the Narcotic Book at the time of administration, but it was not. During an interview on 11/14/23 at 12:57 P.M., Unit Manager #2 said when a narcotic is administered it should be documented on the MAR and in the Narcotic Book at the time of administration, and never later in the day. During an interview on 11/14/23 at 1:49 P.M., the Director of Nurses said all narcotics should be documented in the Narcotic Book when they are removed from the medication cart and administered; the documentation should not be done later in the day.

Based on observations, interviews, and document review, the facility failed to offer a nourishing evening snack when there was greater than 14 hours between dinner and breakfast service. Findings include: Review of the facility's schedule for Meal Times, dated as revised 03/24/23, indicated there was 14.5 hours between dinner and breakfast service on all units. The Meal Times schedule indicated: Unit 1 Truck 1: Breakfast 7:30 A.M. Dinner 5:00 P.M. Unit 2 Truck 1: Breakfast 7:40 A.M. Dinner 5:10 P.M. A&B Breakfast 7:50 A.M. Dinner 5:20 P.M. Unit 2 Truck 2: Breakfast 7:55 A.M. Dinner 5:25 P.M. Unit 1 Truck 2: Breakfast 8:00 A.M. Dinner 5:30 P.M. During a Resident Group Meeting held on 11/10/23 at 1:26 P.M., seven of seven residents said they sometimes were provided with an evening snack when they asked for it. Residents said the snacks might include ice cream or cake. During an interview on 11/14/23 at 2:15 P.M., the Food Service Director said the kitchen did not provide substantial snacks after dinner to residents. She said if a resident asked for an evening snack, staff would provide whatever food and drink was stocked in the kitchenette. The Food Service Director said snacks included pudding, apple sauce, yogurt, cookies, and ice cream. The Food Service Director said the kitchenettes were stocked by evening kitchen staff based on the nursing unit's request. The Food Service Director said the current meal truck schedule was greater than 14 hours without any substantial snacks offered to residents. During an interview on 11/14/23 at 2:57 P.M., Certified Nursing Assistant (CNA) #2 said snacks, such as ice cream, cookies, and toast, were offered between 7:00 P.M.-8:00 P.M. CNA #2 said sometimes leftover sandwiches from lunch were stored in the kitchenette and staff would offer those sandwiches in the evening, but typically there weren't any leftover sandwiches from lunch. During an interview on 11/15/23 at 9:12 A.M., the Administrator was made aware of the 14.5-hour gap between dinner and breakfast. The Administrator acknowledged the extended timeframe between dinner and breakfast.

Based on observation, interview, and policy review, the facility failed to ensure food stored in three of three nourishment kitchens, including food brought into the facility from family/visitors (including but not limited to leftovers) was stored in a safe and sanitary manner. Findings include: Review of the facility's policy titled Food Brought to Resident/Patients by Family and Other Visitors, dated 1/2023, indicated but was not limited to: -Food brought to residents/patients by family or visitors will be handled and stored in a safe and sanitary manner. -Food items that require refrigeration must be labeled with patient's/resident's name and date the food was brought in and stored in a closed container to prevent contamination. -Food will be held in the refrigerator for three days following date on the label and will be discarded by staff upon notification to patient/resident (or sooner if considered unsafe for consumption or expires). Review of the facility's policy titled Prepared Meal Leftover Policy, dated 4/2023, indicated but was not limited to: -All prepared meal foods will be kept as leftovers for no longer than 72 hours. -These leftovers will be wrapped and dated at the initial time of storage. -At the end of 72 hours, all leftovers will be discarded. Review of the facility's protocol for Communal Bottled Beverages in the Kitchenettes, undated, indicated but was not limited to: ATTENTION NURSING STAFF: -You will begin seeing the labels found below on all communal bottled beverages in the kitchenettes. -Dietary will document the date the bottle was stocked -When you open it, the date you opened it needs to be documented on the label as well as the date of three days from the day you opened it -If you find any beverages that are past the date to be used by, please discard. 1. On 11/14/23 at 10:25 A.M., the surveyor observed the following in the First Floor Nourishment kitchenette: -Eight single serving cups of orange juice with manufacturer expiration/best buy date 11/12/23, no date stocked was observed. -One carton of opened Lactaid milk, with manufacturer's expiration date of 11/19/23 and use within 14 days, no date stocked, no date opened and no discard date was observed on carton. -One opened bottle of Thick It Juice, date stocked 11/11/23, manufacturer's label indicated product must be used within 10 days of opening and no date opened and no use by date was observed on bottle. -One opened carton of Thick It Milk, manufacturer's label indicated use within four days of opening, no date stocked, no date opened and use by date was observed on carton. -One 5.3 ounce (oz) container of yogurt with manufacturer's expiration date of 8/29/23 -Two 4 oz containers of yogurt, one with manufacturer's expiration date of 10/4/23 and one with an expiration date of 10/25/23. -One opened carton of thickened orange juice, dated as opened 11/4/23, manufacturer's label indicated use within seven days of opening, no use by date/discard date was observed. -One opened case of beer containing five cans, no label of any type was observed. During an interview on 11/14/23 at 11:07 A.M., Nurse #1 said kitchen staff were responsible for stocking the nourishment refrigerator and floor staff were responsible for general cleanliness of the kitchenettes. Nurse #1 observed the Thick It Juice carton without any labels and said staff members were responsible for completing the date opened and date of discard at the time a product was opened. Nurse #1 said staff tried to follow the protocol. 2. On 11/14/23 at 11:45 A.M., the surveyor observed the following in the 2 MED Nourishment kitchenette: -Undated food (soup, yogurt parfait, pasta salad and an unidentified homemade item) with resident names on them. -A clear covered plastic container with a cake inside, labeled with a resident name and dated 11/8/23, six days prior. -A bottle of ranch dressing with an expiration date of 9/14/21. During an interview on 11/14/23 at 11:56 A.M., Certified Nursing Assistant (CNA) #1 said the refrigerator in the kitchenette was a resident refrigerator and family members brought food in, placed it in the refrigerator and took food out as desired. She said staff would date and label the food the day the family brought it in. 3. On 11/14/23 at 1:30 P.M., the surveyor observed the following in the 2A+B Nourishment kitchenette: -One bottle of opened ginger ale, date stocked 11/13/23, no date opened or use by date was observed. -One bottle of opened diet ginger ale, date stocked 11/9/23, no date opened or use by date was observed. -One bottle of opened cranberry juice, date stocked 11/13/23, no opened date or use by date was observed. -One carton of opened thickened cranberry juice, date stocked 11/12/23, no opened date or use by date was observed. -Two bottles of unopened diet soda, no dates at all were observed on the bottles. -One bottle of unopened apple juice, no dates at all were observed on the bottle. During an interview on 11/14/23 at 2:15 P.M., the Food Service Director (FSD) and surveyors observed the First Floor nourishment kitchenette refrigerator. The FSD said the facility recently implemented a food/labeling system which included date stocked, date opened and date of discard. The FSD said, per the facility policy, food should be discarded three days after date opened. The FSD said kitchen staff should be monitoring for expired foods when refrigerators are stocked. Observations of all three nourishment kitchenettes were reviewed with the FSD. The FSD said either family or staff should label food brought in by family and should be discarded per facility policy.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Health Care Proxy had been activated, and who had Physician's orders for a treatment to wounds on his/her right foot, the Facility failed to ensure that nursing staff notified Resident #1's Physician and Health Care Agent (HCA) in a timely manner, when nursing found maggots between Resident #1's toes on his/her right foot. Findings include: The Facility Policy, titled Change in Resident Condition, undated, indicated the following: -it is the policy of the facility that the resident's attending physician and the resident's responsibility party/next of kin are notified of a change of condition -the licensed nurse in charge of the resident unit is responsible for timely notification of the attending physician or the physician on call and for the notification of the responsible party/next of kin Resident #1 was admitted to the Facility in April 2019, diagnoses included Dementia, Diabetes Mellitus, Peripheral Vascular Disease, Hypertension, and Peripheral autonomic neuropathy (damage to nerves that manage body functions). Review of Resident #1's Health Care Proxy Activation Form, dated 02/28/2023, indicated Resident #1's Health Care Proxy (HCP) was activated. Review of Resident #1's Significant Change in Status Minimum Data Set (MDS) Assessment, dated 05/02/23, indicated that Resident #1 had moderate impaired decision making. During an interview on 8/08/23 at 3:20 P.M., Nurse #2 said she worked the 3:00 P.M.-11:00 P.M. shift on 7/22/23 and Resident #1 had complained of right foot pain while holding his/her right leg up in the air and the dressing to his/her right foot was falling off. Nurse #2 said she went to change Resident #1's dressing and saw the open area between his/her great toe and second toe was bloody, she cleaned the area and noticed a couple small maggots fall onto the absorbent pad that she placed under his/her right foot. Nurse #2 said she was not sure if the maggots she saw was a change in status to Resident #1's right foot wound and she informed Nursing Supervisor #1. Nurse #2 said she had not notified Resident #1's Physician and did not know if Resident #1 had a Health Care Agent and said she had not looked in Resident #1's medical record to see if he/she had a HCA in place. During an interview on 8/09/23 at 2:09 P.M., Nursing Supervisor #1 said that on 7/22/23 Nurse #2 informed her that she saw a maggot on Resident #1's toes on his/her right foot and thought Nurse #2 had notified Resident #1's Physician and HCA because it was her (Nurse #2) responsibility to do so. During an interview on 8/09/23 at 3:57 P.M., Nurse #3 said she worked the 11:00 P.M.-7:00 A.M. shift on 7/22/23 and was not aware maggots were found on Resident #1's wound to his/her right foot because Nurse #2 had not told her during change of shift report. Review of Resident #1's Nursing Progress Note, dated 7/23/23, indicated during dressing change to Resident #1's right foot numerous maggots were found between his/her right great toe and second toe and between fourth and fifth toes and in house supervisor was made aware. During an interview on 8/08/23 at 2:29 P.M., Nurse #1 she worked the 7:00 A.M.-3:00 P.M. shift on 7/23/23 and when she went to do the treatment to Resident #1's right foot, upon removing the old dressing she saw numerous maggots between his/her great toe and second toe and between the fourth and fifth toes. Nurse #1 said she told Nursing Supervisor #2 about finding the maggots on Resident #1's right foot and she called Nursing Supervisor #3 at home who told her to notify the Nurse Practitioner (NP) and the ADON. Nurse #1 said although she was told to notify the NP, said she had not done so because Nursing Supervisor #2 said that she had notified the NP and the ADON. Nurse #1 said she had not received a call back from the NP during her shift. Nurse #1 said she knew Resident #1's HCP was activated, and she had not notified his/her HCA because she was told by Nursing Supervisor #2 that the ADON would notify Resident #1's HCA on 7/24/23. The Surveyor was unable to interview Nursing Supervisor #2, as she did not respond to the voice messages left on her telephone or the Department of Public Health request for an interview sent via letter to her last known address. However, review of Resident #1's Medical Record, indicated there was no documentation to support his/her Physician and Health Care Agent was notified on 7/23/23, that maggots were found in his/her wounds. During an interview on 8/07/23 at 3:54 P.M., Resident #1's Health Care Agent (HCA, Family Member #1) said Resident #1's had wounds to his/her right foot. The HCA said she had not received a phone call until 7/24/23 from the Assistant Director of Nurses (ADON) who told her they found maggots on Resident #1's right foot that were coming out between his/her great toe. During an interview on 8/08/23 at 3:49 P.M., the Assistant Director of Nurses (ADON) said on 7/23/23 she received a phone call from Nursing Supervisor #2 who told her that maggots were seen on Resident #1's right foot wound between his/her toes. The ADON said she told Nursing Supervisor #2 to notify the NP and Nursing Supervisor #2 told her that she had already notified the NP. The ADON said she was not aware that Resident #1's HCA had not been notified that day. The ADON said on 7/24/23 she helped another nurse do the treatment to Resident #1's right foot and that maggots were still present in between his/her great toe and second toe, and she notified the NP and Resident #1's HCA. During an interview on 8/08/23 at 4:35 P.M. and telephone interview on 8/09/23 at 1:34 P.M., the Director of Nurses (DON) said the ADON notified her on 7/22/23 that a bug was found between Resident #1's toes on his/her right foot and Resident #1's Physician and HCA were not notified on 7/22/23. The DON said on 7/23/23 Nurse #1 noticed that Resident #1 had maggots between his/her great toe and second toe on his/her right foot and that Nursing Supervisor #2 notified the NP, but she had not documented the notification in Resident #1's medical record. The DON said Resident #1's Health Care Proxy was activated, and his/her HCA was not notified until 7/24/23 and said the nurses had not followed the Facility's policy and they should have notified Resident's #1's Physician and HCA and documented in his/her medical record.

Based on policy review, observations, and interviews, the facility failed to serve meals in a dignified manner during 2 out of 2 lunch observations. Specifically, the facility failed to serve all residents in the same location at the same time, and failed to remove serving trays and plate warmers prior to serving the meals to the residents. Findings include: Review of the facility's policy titled Tray Pass Guidelines, undated, indicated, but is not limited to: -ALL residents in one room/location should receive their trays at the same time. On 7/16/21 from 11:14 A.M. to 12:10 P.M. on Unit 2 A & B, the surveyor observed eight residents seated in the dining room. The food truck arrived on the unit at 11:44 A.M., and the first tray was given to a resident at 11:45 A.M. The resident's meal tray was placed on the table in front of him/her, and the plate was left on the plate warmer. The resident's tablemate was provided his/her meal at 12:04 P.M., 19 minutes later. The meal tray was placed on the table in front of the resident, and the plate was left on the plate warmer. On 7/16/21 at 11:56 A.M., another resident in the dining room was given his/her meal. The meal tray was placed on the table in front of the resident, and the plate was left on the plate warmer. At 12:05 P.M., his/her two tablemates were provided their meals, nine minutes after the first tray was provided. The meal trays were placed on the table in front of the residents, and the plates were left on the plate warmers. On 7/16/21 at 12:08 P.M., 24 minutes after the first meal tray was delivered, the remaining three residents in the dining room were provided their meals. The trays were placed on the table in front of the residents, and the plates were left in the plate warmers. On 7/20/21 from 11:15 to 12:25 P.M. on Unit 2 A & B, the surveyor observed eight residents seated in the dining room. The food truck arrived on the unit at 11:35 A.M., and meal trays were given to six residents by 11:50 A.M. All of the food trays were placed directly on the table in front of the residents, and the plates were left in the plate warmers. The remaining two residents in the dining room were provided their meals at 12:05 P.M., and 12:20 P.M. respectively, more than 30 minutes after the first meal trays were distributed. The food trays were placed directly on the table in front of the residents and the plates were left on the plate warmers. During an interview on 7/16/21 at 3:00 P.M., the Administrator said that low staffing has been an issue in the facility for a while, and is affecting timeliness of meal distribution, and not creating a homelike dining experience.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, observations, and interviews, the facility failed to provide two Residents (#62 and #68) the right to participate in his/her formulation of their advance directives, out of 22 sampled residents. Findings include: Review of the facility's policy titled Do Not Resuscitate [DNR] Policy, reviewed [DATE], indicated that upon admission, the responsibility of the Director of Admissions/Social Service are to review and inform the resident and/or family the policy on DNR status. They are to discuss choices available and their results with the resident/responsible party. Nurses are then informed of the resident's decision and provide nurses the Cardiopulmonary Resuscitation form to obtain the health care provider's progress note and order. Nurses are to place original Cardiopulmonary Resuscitation form in chart after provider writes progress note and order. The health care provider must verify with resident/family that a DNR/CPR order is his/her wish and document this in the initial progress notes. The health care provider must write an order in the resident's chart reflecting his/her decision. Resident #62 was admitted in [DATE] with diagnoses of multiple falls, diabetes (non-insulin dependent), and hypertension. Review of Resident #62's medical record indicated the Resident is alert and oriented. The Health Care Proxy (HCP) was not invoked. Review of the Social Worker's note, dated [DATE], indicated that Resident #62 deferred to the health care agent to sign, specifically, the admission forms, as he/she was tired and there were a lot of forms to sign. Review of the medical chart indicated that the HCP was not activated and the health care agent signed a Comfort Care/ DNR form on [DATE] for Resident #62. Review of the Comfort Care form, dated [DATE], indicated that it was not signed by a licensed clinician until [DATE]. There was no documentation to indicate the physician conferred with Resident #62 on this DNR. Review of the Physician's order, dated [DATE], indicated Resident #62 is a DNR. There were no interim orders from the physician to indicate the Resident's HCP was invoked or that the Resident's code status was reviewed with the Resident by the prescriber. During an interview on [DATE] at 11:02 A.M., Nurse #1 said Resident #62 is a full code. Nurse #1 said the label on the spine of Resident #62's medical record is red and indicates that he/she is a full code. [NAME] colored spine indicates a DNR. She said Resident #62 is alert and wants to be a full code. On [DATE] at 11:02 A.M., the surveyor reviewed the medical record with Nurse #1 as the documentation indicated that Resident #62 was still his/her own person and the physician has not invoked the HCP, but the health care agent signed a Comfort Care/DNR form for the resident. During an interview on [DATE] at 11:07 A.M., the Minimum Data Set (MDS) Nurse said that she documents the code status of the resident at the top of a care plan, but does not write a care plan for advance directives. The surveyor reviewed Resident #62's medical record and validated that the Resident does not have a care plan for advance directives, only the letters DNR are typed at the top of any care plan. There was no documentation in the Resident's chart that a licensed clinician addressed the code status with the Resident and/or invoked his/her health care proxy. The MDS nurse said that she thinks Resident #62 transferred from another facility and it was activated there, but was not sure. The MDS Nurse and surveyor could not find the documentation to support the health care agent's right to sign in place of the Resident. During an interview on [DATE] at 1:40 P.M., the Social Worker said that she thought the HCP was invoked at the hospital and is aware the facility Physician/NP is required to review the code status with the Resident and/or family/health care agent. The Social Worker did not review code status with Resident #62 upon admission. 2. Resident #68 was admitted to the facility in [DATE] with diagnoses of urinary tract infection, falls and a traumatic hematoma (blood collection under tissues) on the left buttocks. Review of Resident #68's medical record indicated their health care agent signed the MOLST (Medical Orders for Life Sustaining Treatment), which was for a DNR on [DATE]. Review of Resident #68's medical record indicated their health care agent signed a Comfort Care Do not Resuscitate (DNR) form on [DATE]. Review of Resident #68's medical record failed to indicate their health care proxy was invoked at the time the health care agent signed the MOLST and Comfort Care forms, indicating Resident #68 is a DNR. Review of the Social Worker's Social History and Assessment form, dated [DATE], indicated the Health Care Proxy is unavailable. Review of Resident #68's medical record failed to indicate that a licensed clinician addressed the code status with the Resident and/or invoked his/her HCP on the dates the health care agent signed the advance directives.

Based on observation and staff interview, the facility failed to ensure, for one Resident (#68), out of a total sample of 22 residents, the right to personal privacy of his/her own physical body during medical treatment was maintained. Findings include: On 7/20/21 at 11:49 A.M., the surveyor observed Nurse #6 transport Resident #68 in his/her wheelchair from the dining room into his/her room. A lab technician was observed entering the Resident's room with a rolling cart, and began to prepare supplies to draw blood. The surveyor observed the technician drawing blood from the Resident's arm. The Resident was in full view of the passersby in the hallway, including three surveyors, three Certified Nursing Assistants, one nurse, and one unit manager. During an interview on 7/20/21 at 1:20 P.M., Nurse #6 said that the laboratory technician should have closed the door prior to drawing blood to protect Resident #68's privacy.

Based on policy review, grievance book review, and interview, the facility failed to ensure that: a) staff addressed and/or promptly resolved 2 out of 9 resident grievances reviewed, and b) staff reported 4 out of 9 grievances reviewed to the Department of Public Health (DPH), as allegations of misappropriation, and abuse/neglect, as required. Findings include: Review of the facility's Grievance policy, last reviewed April 2020, indicated that: -A Resident/Staff/Family Member grievance will be responded to within 72 hours and resolved. -Notify department head of residents' complaint when presented. -Any resident/staff/family member or designated representative who has a complaint or suggestion, shall report to the charge nurse or social worker on the unit involved, or complete a grievance form. -The charge nurse or social worker will respond appropriately, after assessing the nature of the complaint, and will complete the grievance form if one has not already been completed by the resident/staff/family member or designated representative. -The charge nurse or social worker will consult with other individuals/disciplines (e.g. Director of Nurses, Nursing Supervisor, etc ) for advice and assessment of the complaint as necessary. -The grievance form itself will be submitted to the Administrator/Department Head as soon as possible. If grievance is of an emergency nature it must be reported to the Administrator immediately. -Grievances, actions taken and results are to be documented on the grievance report and kept on file in the administrator's office. Review of the Grievance Book/Missing Items Book indicated the following: 1. A grievance brought forward by a resident's daughter, dated 11/9/19, indicated that the resident felt that a Certified Nursing Assistant (CNA) was rude to him/her, failed to ensure the resident was adequately dressed prior to being moved to the dayroom during the night (1:30 A.M.) wearing only a nightgown, and was cold and uncomfortable. The grievance indicated that a CNA on the next shift (7:00 A.M.-3:00 P.M.) gave the resident a blanket. Further review of the grievance form failed to include pertinent findings or conclusions, and a statement as to whether the grievance was confirmed or not. Additionally, the grievance was not reported to the DPH as required. 2. A grievance (documented on a Resident Incident Report form) brought forward by facility staff, dated 11/28/20, indicated that a resident was missing a gold chain and cross. Further review of the grievance indicated that staff was interviewed, the resident's room and laundry were searched, but the chain and cross were not found. The documentation failed to indicate that the grievance was resolved, and that the missing chain and cross were replaced or the resident was reimbursed. Additionally, the grievance was not reported to the DPH as required. 3. A grievance brought forward by a resident's daughter, dated 9/2/19, indicated that the resident was missing $7.00. Further review of the form failed to indicate that an investigation was conducted, failed to include pertinent findings or conclusions, and a statement as to whether the grievance was confirmed or not. The form indicated that the resident was reimbursed $7.00 on 9/16/19. Additionally, the form was not signed or dated by the person completing the investigation, and it was not reported to DPH as required. 4. A grievance brought forward by a resident's family, dated 12/10/19, indicated that a CNA refused to assist the resident to find a missing hearing aid, and was very fresh and impatient with him/her, and the resident was upset. Further review of the grievance indicated that the CNA was counseled, and the grievance was resolved on 12/16/19, 6 days following the filing of the grievance, and not 72 hours according to facility policy. The facility failed to ensure that the grievance was reported to DPH as required. During interviews on 7/16/21 at 3:30 P.M. and 7/21/21 at 10:30 A.M., the Administrator/ Grievance Officer said that he started at the facility in November 2020, and that three of the reportable grievances occurred before his time. He said that he needs to pay closer attention to the grievances to ensure they are completed according to policy, and if necessary, reported to DPH as required.

Based on policy review, review of the Grievance Book and Lost Items Reports, and staff interview, the facility failed to report allegations of misappropriation of resident property, neglect, and mental abuse as required for 4 out of 9 grievances reviewed. Findings include: Review of the facility's policy titled Resident Abuse, Mistreatment, and Neglect, last reviewed January 2021, indicated, but is not limited to: -The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. -Mental abuse is defined as, but not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. -Neglect is defined as failure of a facility or individual to provide treatment or services necessary to maintain health or safety of a resident. -Resident property misappropriation is the deliberate misplacement, exploitation or wrongful temporary or permanent use of a resident's belongings or money without such resident's consent. -Employees are obligated to report immediately to their supervisors or their administrator, any observed or suspected incidents of abuse. This reporting is necessary in order that the nursing home can inform the alleged violations to DPH prior to preliminary investigation as required. -Upon reporting of any alleged abuse, the administrator must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made. If the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to other officials in accordance with State law. 1. A grievance brought forward by a resident's daughter, dated 9/2/19, indicated that the resident was missing $7.00. The form indicated that the resident was reimbursed $7.00 by the facility on 9/16/19. The allegation of misappropriation of resident property was not reported to DPH as required. 2. A grievance brought forward by a resident's daughter, dated 11/9/19, indicated that the resident felt that a Certified Nursing Assistant (CNA) was rude to him/her, failed to ensure the resident was adequately dressed when placed the resident in the dayroom during the night (1:30 A.M.) wearing only a nightgown, and was cold and uncomfortable. The grievance indicated that a CNA on the next shift (7:00 A.M.-3:00 P.M.) gave the resident a blanket. The allegation of neglect was not reported to the DPH as required. 3. A grievance (documented on a Resident Incident Report form) brought forward by facility staff, dated 11/28/20, indicated that a resident was missing a gold chain and cross. Further review of the grievance indicated that staff was interviewed, the resident's room and laundry were searched, but the chain and cross were not found. The allegation of misappropriation of resident property was not reported to the DPH as required. 4. A grievance brought forward by a resident's family, dated 12/10/19, indicated that a CNA refused to assist the resident to find a missing hearing aid, and was very fresh and impatient, and spoke to him/her in an unkind manner that upset him/her. The CNA told the resident that she did not have time to look for the hearing aid, and proceeded to take the resident back to the unit. The grievance indicated that upon arrival back to the unit, the nurse noticed how upset the resident was. The allegation of verbal/mental abuse was not reported to DPH as required. During interviews on 7/16/21 at 3:30 P.M. and 7/21/21 at 10:30 A.M., the Administrator/ Grievance Officer said that he started at the facility in November 2020, and that three of the reportable grievances occurred before his time. He said that he needs to pay closer attention to the grievances, and report to DPH as required.

Based on record review and interview, the facility failed to ensure a baseline care plan was established within 48 hours of admission for one Resident (#52), out of a total sample of 22 residents and two closed records. Findings include: Resident #52 was admitted to the facility in March 2021, with medical diagnoses including type 2 diabetes mellitus, unspecified dementia with and without behavioral disturbance, major depressive disorder, primary insomnia, essential hypertension, chronic obstructive pulmonary disease, gastro-esophageal reflux disease without esophagitis, dorsalgia (back ache), and muscle weakness. Review of the facility's policy for Centered Focus: 48 Hours Baseline and Comprehensive Care Plan, revised November 2020, indicated, but is not limited to: - Initial goals based on admission orders - All physician orders, which includes medications and administration schedule - Dietary services - Social services - PASARR recommendation (s) was completed and - Therapy services - A discharge plan based on residents identified discharge needs should also be present. - The baseline care plan must be revised as needed until the comprehensive care plan has been developed. Once the comprehensive care plan has been developed, updates to the baseline care plan are no longer required. Review of Resident #52's medical record indicated that an interdisciplinary care plan evaluation was not completed within 48 hours with the social worker, rehabilitation representative, and nursing representative. Further review of the medical record indicated there was no documentation of a 48 hour care plan in the record. Review of the Minimum Data Set (MDS) assessment, dated 6/22/21, indicated Resident #52 had severe cognitive impairment, as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of 15. The MDS indicated the Resident requires limited assistance for transfer, supervision to walk in room and in corridor and eating. The MDS indicated Resident requires total dependence for dressing, toilet use, and personal hygiene. During an interview on 07/20/21 at 04:00 P.M., Unit Manager #1 said she inquired with Unit Manager #2 and looked everywhere in Resident #52's medical record and could not find the 48-hour care plan. During an interview on 07/20/21 at 04:10 P.M., the MDS coordinator said, she reviewed the medical record for Resident #52 and could not retrieve the baseline care plan. The MDS coordinator said it was not in the care plan book and was not in the Resident's medical record; she said it was not done.

Based on interviews, record review, and observations, the facility failed to revise and update care plans to accurately reflect the status and/or preferences of 1 Resident (#9), out of a total sample of 22 residents. Review of the facility's policy titled Comprehensive Care Plan, undated, indicated that the comprehensive care plan must be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review. During an interview on 7/20/21 at 12:45 P.M., the Staff Development Coordinator/ Infection Preventionist (SDC/IP) said that they do not have a policy specific for care plan revision. Resident #9 was admitted in April 2019 with diagnoses including seizure disorder. Review of Resident #9's Minimum Data Set (MDS) assessment, dated 4/20/21, indicated that the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15. Review of Resident #9's care plans indicated that the facility implemented padded side rails as a safety intervention to minimize injury if Resident were to have a seizure (revised 4/27/21). During an interview on 7/14/21 at 4:00 P.M., Resident #9 said that he/she has never had padded side rails. On 7/14/21 at 4:00 P.M., 7/15/21 at 2:00 P.M., 7/19/21 at 4:30 P.M., and on 7/20/21 at 3:00 P.M., the surveyor observed Resident #9 in bed with no padding on side rails During an interview on 7/19/21 at 4:30 P.M., Resident #9 said that he/she had informed the facility staff that he/she does not want padding a long time ago. Resident #9's care plan was not revised to reflect the Resident's refusal of treatment.

Based on record review, observation, and staff interviews, the facility failed to ensure that care and services were provided according to accepted standards of clinical practice for three Residents (#4, #26, and #319), out of a total sample of 22 residents. Specifically, 1. For Resident #4, the facility failed to ensure that a left hand splint device was applied as ordered by the physician, and accurately documented in the medical record; 2. For Resident #319, the facility failed to obtain a physician's order for admission to the facility for respite care; and 3. For Resident #26, the facility failed to use safe handling practices when disposing of syringes after use. Findings include: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and Practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered nurse and practical nurse incorporate into the plan of care, and implement prescribed medical regimens. The rules and regulations 9.03 define standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. It is the responsibility of the licensed nurse to ensure that there is a proper patient care order from a duly authorized prescriber prior to the administration of any prescription or non-prescription medication or activity that requires such order in accordance with accepted standards of practice and in compliance with the Board's regulations. 1. Resident #4 was admitted to the facility with diagnoses including Parkinson's disease, abnormal posture, and muscle weakness. Review of the quarterly Minimum Data Set assessment, dated 4/12/21, indicated that Resident #4 had severely impaired cognitive skills for daily decision making and is dependent on two or more staff for activities of daily living. Review of Occupational Therapy (OT) notes indicated that Resident #4 received OT services from 10/28/19 to 2/14/20 for therapy to address issues including extensive adduction of the metacarpophalangeal (MP) joint (the large knuckle joint located where the fingers and thumb meet the hand) of the right and left first digits. Treatment included passive range of motion to bilateral upper extremities to decrease tightness and excessive adduction of the bilateral first fingers, and the use of a left hand orthotic device for improved positioning of the left hand joints. Resident #4 met his/her goal of tolerating the left hand orthotic device for up to four to six hours on 2/14/20. Review of the July 2021 physician's orders indicated: -Apply left hand splint device daily from 10:00 A.M. to 2:00 P.M., passive range of motion and hand hygiene prior to splint application. Monitor daily and notify rehab of any changes (11/5/20). On 7/15/21 at 10:25 A.M., the surveyor observed Resident #4 seated in a Broda chair (positioning chair) in the Unit 2 dining room. The Resident did not have a left hand splint device applied to his/her left hand. On 7/15/21 at 12:25 P.M., the surveyor observed Resident #4 in his/her room lying upright in bed. The Resident did not have a left hand splint device applied to his/her left hand. On 7/16/21 at 10:15 A.M., the surveyor observed Resident #4 seated in a Broda chair in the Unit 2 dining room. The Resident did not have a left hand splint device applied to his/her left hand. On 7/16/21 at 11:14 A.M., the surveyor observed Resident #4 seated in a Broda chair in the hallway outside of the dining room. The Resident did not have a left hand splint device applied to his/her left hand. On 7/16/21 at 12:07 P.M., the surveyor observed Resident #4 seated in a Broda chair in the unit dining room, being fed by staff. The Resident did not have a left hand splint device applied to his/her left hand. On 7/19/21 at 10:14 A.M., 10:31 A.M., 10:44 A.M., 11:03 A.M., 11:46 A.M., and 12:00 P.M., the surveyor observed Resident #4 lying in bed asleep. Both of the Resident's arms and hands were resting on top of the blanket and were clearly visible. The Resident did not have a left hand splint device applied to his/her left hand. Review of Resident #4's July 2021 Medication Administration Record/ Treatment Administration Record (MAR/TAR) indicated that the Resident's left hand splint device was signed off as applied at the time of the surveyor's observations of it not being applied. During an interview on 7/19/21 at 12:35 P.M., Nurse #1 said that she documented on the MAR that the splint was in place when it wasn't. She said that CNA staff needs to make sure to apply the left hand splint device to Resident #4's left hand, and nursing should not sign off that it is in place when it is not. On 7/21/21 at 11:17 A.M., the surveyor observed Resident #4 lying in bed awake. Both of the Resident's arms and hands were resting on top of the blanket and were clearly visible. The Resident did not have a left hand splint device applied to his/her left hand. Review of the July 2021 MAR/TAR indicated that nursing signed off that the left hand splint device was applied at the time of the surveyor's observation when it was not in place. On 7/21/21 at 11:20 A.M., the surveyor brought Nurse #6 to Resident #4's room. Nurse #6 said that the Resident should have the brace applied to his/her left hand, and was not sure why it wasn't on. The brace was observed placed on a small bureau at the foot of the Resident's bed. The nurse could not explain why the device was signed off as applied on the MAR/TAR when it was not in place. 2. Review of the facility's policy titled Respite Care Program Policy & Procedure, last reviewed November 2020, indicated, but is not limited to: -The following items shall be considered as part of the overall Respite Care Policy and Procedure: Written order for Respite Care- An individual shall be admitted to respite care only upon the written order of a facility credentialed physician who designates placement as medically necessary and socially appropriate; a client cannot be admitted without a facility credentialed doctor's order and physical. If the client has been seen by his or her physician within 90 days of admission, and that same physician will follow the client during their admission, then a copy of that physical is acceptable. If the client has not had a physical during the previous 90 days, then a physical is required within 48 hours of admission. Resident #319 was admitted to the facility in July 2021 for Respite (short-term relief for primary caregivers) with diagnoses including Parkinson's disease. Review of Resident #319's medical record failed to indicate a physician's order for admission to the facility for respite care, or any other type of admission. Further review of the medical record failed to indicate any documentation from the Resident's physician in the community. There was no evidence in the medical record that the Resident had a physical within 90 days of admission, and that same physician would follow the Resident during their admission. During an interview on 7/16/21 at 1:35 P.M., Unit Manager #2 said that there was no physician's order for Resident #319's admission to the facility for respite. She said the physician should have written an order for his/her respite admission to the facility. 3. On 7/14/21 at 9:51 A.M., the surveyor observed Nurse #3 bring a bottle of insulin and two capped syringes to Resident #26 in his/her room. The Resident removed the caps from the syringes, and drew up insulin into the syringes, and injected it into his/her abdomen. The Resident then gave the two used syringes to the nurse, and the nurse recapped the two dirty syringes, and left the room. Review of the facility's policy titled Safe Practice Tips for Handling Sharps, undated, indicated, but is not limited to: -Never recap needles (our needles are retractable). -Use single-use, safety engineered needles. During an interview on 7/14/21 at 9:53 A.M., the surveyor asked Nurse #3 if she usually recaps used needles and she stated, No, but his/her needles are not retractable. During an interview on 7/19/21 at 9:20 A.M., the Staff Development Coordinator (SDC) said that it is not the facility's practice to recap used syringes. When the surveyor asked for syringe training for Nurse #3, she was unable to provide any proof of training for syringe safety.

Based on record review, observation, and interviews, the facility failed to ensure that one Resident (#4), with a limited range of motion, received appropriate care and services to maintain or improve their mobility, out of a total sample of 22 residents. Findings include: Resident #4 was admitted to the facility with diagnoses including Parkinson's disease, abnormal posture, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment, dated 4/12/21, indicated that Resident #4 had severely impaired cognitive skills for daily decision making, and is dependent on two or more staff for activities of daily living. Review of Occupational Therapy (OT) notes indicated that Resident #4 received OT services from 10/28/19 to 2/14/20 for therapy to address issues including extensive adduction of the metacarpophalangeal (MP) joint (the large knuckle joint located where the fingers and thumb meet the hand) of the right and left first digits. Treatment included passive range of motion to bilateral upper extremities to decrease tightness and excessive adduction of the bilateral first fingers, and the use of a left hand orthotic device for improved positioning of the left hand joints. Resident #4 met his/her goal of tolerating the left hand orthotic device for up to four to six hours on 2/14/20. Review of the July 2021 physician's orders indicated: -Apply left hand splint device daily from 10:00 A.M. to 2:00 P.M., passive range of motion and hand hygiene prior to splint application. Monitor daily and notify rehab of any changes (11/5/20) Review of Resident #4's care plan for activities of daily living, mobility, skin, and incontinence indicated, but is not limited to: -Needs: I have personal care, mobility and incontinence issues which are not new for me. I am receiving skilled OT to help prevent a left hand contracture -Interventions: Apply left hand splint daily from 10:00 A.M. to 2:00 P.M., passive range of motion and hand hygiene prior to splint application. Monitor daily and notify rehab of any changes. -Goal: Left hand free from contracture for 90 days On 7/15/21 at 10:25 A.M., the surveyor observed Resident #4 seated in a Broda chair (positioning chair) in the Unit 2 dining room. The Resident did not have a left hand splint device applied to his/her left hand. On 7/15/21 at 12:25 P.M., the surveyor observed Resident #4 in his/her room, lying upright in bed. Certified Nursing Assistant (CNA) #8 was at the Resident's bedside preparing to feed the Resident. Resident #4 did not have a left hand splint device applied to his/her left hand. A photograph with instructions for application of the left hand splint device was noted to be taped to the top of a small bureau near the foot of the Resident's bed. On 7/16/21 at 10:15 A.M., the surveyor observed Resident #4 seated in a Broda chair in the Unit 2 dining room. The Resident did not have a left hand splint device applied to his/her left hand. On 7/16/21 at 11:14 A.M., the surveyor observed Resident #4 seated in Broda chair in hallway outside of the dining room. The Resident did not have a left hand splint device applied to his/her left hand. On 7/16/21 at 12:07 P.M., the surveyor observed Resident #4 seated in a Broda chair in the unit dining room, being fed by staff. The Resident did not have a left hand splint device applied to his/her left hand. On 7/19/21 at 10:14 A.M., 10:31 A.M., 10:44 A.M., 11:03 A.M., 11:46 A.M., and 12:00 P.M., the surveyor observed Resident #4 lying in bed asleep. Both of the Resident's arms and hands were resting on top of the blanket and were clearly visible. The Resident did not have a left hand splint device applied to his/her left hand. During an Interview on 7/19/21 at 12:35 P.M., Nurse #1 said that CNA staff needs to make sure to apply the left hand splint device to Resident #4's left hand. On 7/21/21 at 11:17 A.M., the surveyor observed Resident # 4 lying in bed awake. Both of the Resident's arms and hands were resting on top of the blanket and were clearly visible. The Resident did not have a left hand splint device applied to his/her left hand. On 7/21/21 at 11:20 A.M., Nurse #6 said that the Resident should have the brace applied to his/her left hand, and was not sure why it wasn't on. The brace was observed placed on a small bureau at the foot of the Resident's bed.

Based on record review and staff interview, the facility failed to ensure that psychotropic medications were not administered without clinical indication for their use based on an assessment of the residents' condition and therapeutic goals as documented in the medical record for two Residents (#17 and #53), out of a sample of 22 residents. Findings include: 1. Resident #17 was admitted to the facility in April 2021 with diagnoses including artificial opening of gastrointestinal tract, hypertension, and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment, dated 4/27/21, indicated that Resident #17 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15, required assistance with activities of daily living, and did not receive any psychotropic medications. Review of the medical record and a progress note from the consultant psychiatric provider, dated 7/12/21, indicated a recommendation that Resident #17 start the medication Celexa 10 milligrams (mg) daily for depression. The consultant's notes failed to identify targeted behaviors, and signs/symptoms of depression for the use of the antidepressant medication. Further review of the medical record indicated a 7/13/21 physician's telephone order for Celexa 10 mg daily. The order failed to identify a diagnosis for the use of Celexa, failed to identify targeted behaviors/signs/symptoms, and failed to indicate that potential side effects of the medication were to be monitored. Review of the comprehensive care plan for psychotropic medication use, developed on 7/13/21, indicated, but is not limited to: -Needs: I have complaints of feeling depressed-I was seen by psych on 7/12/21 and he recommended I start Celexa. -Interventions: Follow orders for my psychotropic med as ordered/as needed and monitor effect; monitor me for any mood, anxiety, or sleep issues and for any adverse effects to the use of the meds-notify my physician as needed -Goal: I want to be free from mood issues X 90 days; I want to be free from adverse side effects of antidepressant medication X 90 days During an interview on 7/19/21 at 10:35 A.M., Nurse #1 and the surveyor reviewed Resident #17's medical record. She said that there was no documentation in the medical record to indicate that the Resident exhibited any signs or symptoms of depression, and the Resident did not verbalize that he/she was experiencing any signs or symptoms of depression. She said that there were no resident specific behaviors and/or symptoms identified for the use of the medication, so they can monitor the medication's effectiveness. Nurse #1 said that they also were not monitoring for side effects of the medication. 2. Resident #53 was admitted to the facility in June 2021 with diagnoses including non-Alzheimer's dementia and Parkinson's disease. Review of the Minimum Data Set assessment, dated 6/15/21, indicated that Resident #53 has severe cognitive impairment as evidenced by a BIMS score of 3 out of 15, required extensive assistance to dependence on staff for activities of daily living, and received antipsychotic medication daily. Review of the July 2021 physician's orders indicated an order for Risperidone 0.5 milligram (mg) twice daily (6/9/21). Review of the comprehensive care plan for psychotropic medication use, developed on 6/22/21, indicated, but is not limited to: -Needs: I have a diagnosis of dementia and depression. I take routine Lexapro and Risperidone. I have a history of behaviors and a geri-psych stay (before admission). I have no mood issues or behaviors since admission here. -Interventions: Follow orders for psychotropic medications and monitor side effect; monitor me for any mood issues or behaviors, also for any signs or adverse side effects to the use of the meds; ways to attempt to alleviate any behaviors are: redirection, distraction, 1:1 attention. -Goal: I want to be free from mood issues or behaviors X 90 days; I want to be free from adverse side effects of psychotropic medication X 90 days Review of the April 2021 through July 2021 Medication Administration Record/ Treatment Administration Record (MAR/TAR) failed to indicate that behaviors/symptoms and potential side effects of the antipsychotic medication were being monitored. During an interview on 7/19/21 at 10:35 A.M., Nurse #1 and the surveyor reviewed Resident #53's medical record. She said that targeted behaviors, signs or symptoms as a rationale for the use of the medication have not been identified or documented in the medical record. She said that she does not know why Resident #53 is on Risperidone, and that he/she was admitted with it.

Based on observation and interview, the facility: 1) Failed to ensure that insulin stored in 1 out of 2 medication carts was appropriately labeled and dated per accepted professional standards; and 2) Failed to store medication securely in one Resident's (#6) room. Findings include: Review of the facility's policy titled Storage of Medications, revised January 2018, indicated, but is not limited to: - Medication and biological are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. - The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 1. On 07/15/21 at 3:38 P.M., the surveyor and Nurse #5 inspected the medication cart on the first floor and observed the following: For Resident #7: -One bottle of Novolog insulin (used to lower blood sugar) undated and in use. For Resident #52: -One bottle Humalog insulin (used to lower blood sugar) not appropriately labeled and in use. During an interview on 07/15/21 at 03:45 P.M., Nurse #5 said upon opening insulin vials the opening and discard date must be written on the bottle. Nurse #5 said that the bottles of insulin were not labeled appropriately upon opening to prevent the use of expired medications. 2. On 7/21/21 at 11:17 A.M., the surveyor observed a tube of Secura Protective Ointment on a small bureau at the foot of Resident #4's bed. During an interview on 7/21/21 at 11:20 A.M., Nurse #6 said that the Certified Nursing Assistants (CNA) use the protective cream on Resident #4's skin when they change the Resident's brief, and did not put it away. Nurse #6 said that the ointment should have been put away and not left out unsecured.

Based on interview, policy review, Resident Council Minutes review, and Food Committee Minutes review, the facility failed to ensure that grievances brought forward through Resident Council regarding missing items, cold food, accuracy of food trays, and lack of staffing, were acted upon promptly (addressed and resolved), per the facility policy. Findings include: During a resident group meeting on 7/15/21 from 2:00 P.M. to 3:00 P.M., 10 out of 10 residents in attendance said: -The food is often cold when they get it. -It takes a long time for staff to deliver meal trays. -There are often missing items on their food trays. -No snacks are offered in the evening. -It takes a long time for staff to answer call bells. 7 out of 10 residents in attendance said: -They have had missing clothing items, and these items have never been found; -They have reported the missing items to staff, but haven't heard back from anyone; and -None of their missing items have been replaced. The residents said that they have brought these issues to the attention of facility staff on several occasions, but they are unresolved, and continue to occur every day. During an interview on 7/16/21 at 3:00 P.M., the Administrator said he is not aware of any written grievances since he started working in the facility in November 2020. He said that that any issues identified during Resident Council are to be addressed according to the grievance policy. Review of the facility's Grievance policy, last reviewed 4/2020, indicated that: -A Resident/Staff/Family Member grievance will be responded to within 72 hours and resolved. -Notify department head of residents' complaint when presented. -Any resident/staff/family member or designated representative who has a complaint or suggestion, shall report to the charge nurse or social worker on the unit involved, or complete a grievance form. -The charge nurse or social worker will respond appropriately, after assessing the nature of the complaint, and will complete the grievance form if one has not already been completed by the resident/staff/family member or designated representative. -The charge nurse or social worker will consult with other individuals/disciplines (e.g. Director of Nurses, Nursing Supervisor, etc ) for advice and assessment of the complaint as necessary. -The grievance form itself will be submitted to the Administrator/Department Head as soon as possible. If grievance is of an emergency nature it must be reported to the Administrator immediately. -Grievances, actions taken and results are to be documented on the grievance report and kept on file in the administrator's office. Review of Resident Council Minutes and Food Committee Minutes from 2/25/21 through 6/22/21, indicated grievances of low staffing, missing clothing items, ongoing issues related to the quality of food, and missing items from their food trays. The grievances were as follows: The Food Committee minutes, dated 2/25/21, indicated that residents are often missing items on meal trays, and the Certified Nursing Assistants (CNA) or nurses must call the kitchen often for replacements. The residents also indicated that the roast beef was tough, and they were unable to cut or chew it. The minutes failed to indicate which residents attended the meeting, and which residents brought forward the grievance. There was no evidence that the facility staff followed-up on the grievance. During the Resident Council Meeting, 10 out of 10 residents said that these problems persist. The Resident Council Minutes, dated 4/22/21, indicated that, Several residents have stated again that they think there should be more help on the floors (CNAs). There was no evidence that the facility staff followed-up on the grievance. During the Resident Council Meeting, 10 out of 10 residents said that these problems persist. The Resident Council Minutes, dated 5/20/21, indicated that, One resident looking for two sweaters, not sure if they are being labeled. Will check with department head and get back to her, and Residents are still having issues with some of the food. There was no evidence that the facility staff followed-up on the grievance. The Resident Council Minutes, dated 6/17/21, indicated that, One resident looking for a pair of shoes that she cannot find since changing units. Will check with department head as well as previous unit and get back to her. There was no evidence that the facility staff followed-up on the grievance. During interviews on 7/16/21 at 3:30 P.M. and 7/21/21 at 10:30 A.M., the Administrator/ Grievance Officer said that he is aware of the issue of lack of staffing brought forward by the Resident Council, but that he was not aware of the persistent food complaints. He said that some of the residents in the Resident Council make the same complaints regarding missing items every month. He said he doesn't always believe they are missing; instead the items may have been taken home by family. He said that he needs to pay closer attention to the Resident Council and Food Committee meeting minutes.

8. For Resident #50, the facility failed to implement the care plan and provide the Resident padded side rails. Resident #50 was admitted to the facility in March 2018 with diagnoses including seizures. On 7/16/21 at 9:21 A.M., the surveyor observed Resident #50 in bed with both half bed rails in the up position; the rails were not padded. On 7/16/21 at 9:21 A.M., the surveyor observed Resident #50 in bed with both half bed rails in the up position; the rails were not padded. Review of Resident #50's care plan for seizure disorder, dated 3/17/21, indicated the following: -the Resident had a seizure disorder; -the Resident had two padded side rails on his/her bed. Review of the July 2021 physician orders, indicated Resident #50 may use two half side rails in bed-padded. During an interview on 7/16/21 at 9:25 A.M., CNA #8 said Resident #50 never had pads on his/her bed rails. During an interview on 7/16/21 at 10:16 A.M., Nurse #3 said she did not know the residents because she is an agency nurse. The surveyor reviewed the Resident's care plan and orders with Nurse #3, and she said both indicated Resident #50 should have had pads on his/her bed rails when he/she was in bed, but the Resident did not. 6. For Resident #9, the facility failed to develop and implement a care plan that addressed a) Resident #9's diagnosis of suicidal ideations; b) monitoring of side effects of Resident #9's psychotropic medications; and c) Resident #9's refusal to allow the prescriber to adjust the Resident's medications. Resident #9 was admitted to the facility with diagnoses including: anxiety, depression, schizoaffective disorder, bipolar disorder with psychotic features, borderline personality disorder, and suicidal ideations. Review of Resident #9's July 2021 medications are as follows: Olanzapine (antipsychotic) 2.5 mg for bipolar once daily, Trazodone (antidepressant) 200 mg at bedtime for generalized anxiety and primary insomnia, Zolpidem (sleeping aid-short term use primarily) 5 mg at bedtime for insomnia, and Sertraline (antidepressant) 200 mg daily for bipolar disorder. Review of Resident #9's care plan for Psychotropic Med Use, revised 4/27/21, failed to indicate that the facility addressed a) Resident #9's diagnosis of suicidal ideations; b) monitoring of side effects of Resident #9's psychotropic medications; and c) Resident #9's refusal to allow prescriber to adjust his/her medications. Interventions for Resident #9's Psychotropic Med Use care plan, revised 4/27/21, indicated, but is not limited to: -follow orders for my psychotropic meds and monitor effect; -My MD reviews my meds for possible dose reduction as needed. Review of the mental health visits notes, dated 2/15/21, 4/5/21, and 5/31/21, indicated the patient adamantly refuses any psych med change. Review of July 2021 nurses' documentation indicated Resident #9 had no behavioral issues. This is inconsistent with the mental health visits documentation. 7. For Resident #68, the facility failed to develop and implement a care plan to address the Resident's advance directives. Resident #68 was admitted in June 2021 with diagnoses including traumatic hematoma left buttock area, urinary tract infection and elevated white blood count. Review of the medical record indicated the health care agent signed a Do Not Resuscitate (DNR) on 6/28/21 and a MOLST (Medical Orders for Life Sustaining Treatment) on 6/25/21. Further review of the medical record failed to indicate that the health care proxy was invoked when the health care agent signed the DNR and MOLST. Review of Resident #68's care plans failed to indicate that care plans were developed to address the Resident's code status and that the health care proxy was invoked on 7/1/21. Review of the Social Worker's (SW) note, dated 6/29/21, indicated that Resident #68 was pleasant and able to provide some information, but SW wanted to confirm accuracy with daughter. Review of June and July 2021 physician's notes failed to indicate a discussion was attempted and/or conducted with Resident #68 regarding his/her wishes for a code status. During an interview on 7/19/21 at 11:07 A.M., the MDS nurse said that she is responsible for the care plans and did not develop an advance directive care plan for Resident #68.Based on policy review, observation, interview, and record review, the facility failed to ensure that comprehensive care plans were developed and consistently implemented for eight Residents (#4, #17, #53, #11, #52, #9, #68, and #50), out of a total sample of 22 residents. Findings include: Review of the facility's policy titled Comprehensive Care Plan, undated, indicated, but is not limited to: -All homes will develop and implement a comprehensive, person-centered care plan for each resident, that includes measurable objectives and timeframe's to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. -The comprehensive care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required; any specialized services or specialized rehabilitative services the nursing facility will provide. -A comprehensive care plan must be developed within seven days after completion of the comprehensive assessment; reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessment. -The services provided or arranged by the facility, as outlined by the comprehensive care plan must meet professional standards of quality; be provided by qualified persons in accordance with each resident's written plan of care; be culturally competent and trauma-informed. Review of the facility's policy titled Person-Centered Focus: 48 Hours Baseline and Comprehensive Care Plan, undated, to be reviewed July 2022, indicated that all homes will develop a care plan within 48 hours that includes at a minimum all physician orders, which includes medications and administration schedule. 1. For Resident #4, the facility failed to ensure the comprehensive care plan was developed for the use of a left hand splint device and was consistently implemented. Resident #4 was admitted to the facility with diagnoses including Parkinson's disease (disorder of the central nervous system that affects movement), abnormal posture, and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated 4/12/21, indicated that Resident #4 had severely impaired cognitive skills for daily decision making, and is dependent on two or more staff for activities of daily living. Review of the July 2021 physician's orders indicated: -Apply left hand splint device daily from 10:00 A.M. to 2:00 P.M., passive range of motion and hand hygiene prior to splint application. Monitor daily and notify rehab of any changes (11/5/20). Review of the care plan for activities of daily living, mobility, skin, incontinence includes, but is not limited to: -Needs: I have personal care, mobility and incontinence issues which are not new for me. I am receiving skilled Occupational Therapy (OT) to help prevent a left hand contracture [shortening and hardening of tissues leading to the rigidity of joints]. -Interventions: Apply left hand splint daily from 10:00 A.M. to 2:00 P.M., passive range of motion and hand hygiene prior to splint application. Monitor daily and notify rehab of any changes. -Goal: Left hand free from contracture for 90 days On 7/15/21 at 10:25 A.M., the surveyor observed Resident #4 seated in a Broda chair (positioning chair) in the Unit 2 dining room. The Resident did not have a left hand splint device applied to his/her left hand. On 7/15/21 at 12:25 P.M., the surveyor observed Resident #4 in his/her room, sitting upright in bed. Certified Nursing Assistant (CNA) #8 was at the Resident's bedside preparing to feed the Resident. Resident #4 did not have a left hand splint device applied to his/her left hand. On 7/16/21 at 10:15 A.M., the surveyor observed Resident #4 seated in a Broda chair in the Unit 2 dining room. The Resident did not have a left hand splint device applied to his/her left hand. On 7/16/21 at 11:14 A.M., the surveyor observed Resident #4 seated in Broda chair in the hallway outside of the dining room. The Resident did not have a left hand splint device applied to his/her left hand. On 7/16/21 at 12:07 P.M., the surveyor observed Resident #4 seated in a Broda chair in the unit dining room, being fed by staff. The Resident did not have a left hand splint device applied to his/her left hand. On 7/19/21 at 10:14 A.M., 10:31 A.M., 10:44 A.M., 11:03 A.M., 11:46 A.M., and 12:00 P.M. the surveyor observed Resident #4 lying in bed asleep. Both of the Resident's arms and hands were resting on top of the blanket and were clearly visible. The Resident did not have a left hand splint device applied to his/her left hand. During an interview on 7/19/21 at 12:35 P.M., Nurse #1 said that the Certified Nursing Assistants (CNA) need to make sure to apply the left hand splint device to Resident #4's left hand according to the care plan and physician's orders. She said that nursing should ensure that it is in place. 2. For Resident #17, the facility failed to ensure that a comprehensive care plan that identified Resident-centered behaviors/sign/symptoms of depression was developed for the use of the medication Celexa (antidepressant). Resident #17 was admitted to the facility in April 2021 with diagnoses including artificial opening of gastrointestinal tract, hypertension and dysphagia. Review of the MDS assessment, dated 4/27/21, indicated that Resident #17 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 13 out of 15, required assistance with activities of daily living, and did not receive any psychotropic medications. Review of a progress note from the consultant psychiatric provider, dated 7/12/21, indicated a recommendation that Resident #17 start the medication Celexa 10 milligrams (mg) daily for depression. The consultant's notes failed to identify targeted behaviors and/or signs/symptoms of depression for the use of the antidepressant medication. Further review of the medical record indicated a 7/13/21 physician's telephone order for Celexa 10 mg daily. The order failed to identify targeted behaviors, signs/symptoms of depression for the use of the antidepressant medication. Review of the comprehensive care plan for psychotropic medication use, developed on 7/13/21, failed to identify Resident- specific targeted behaviors, signs/symptoms of depression. The care plan indicated, but is not limited to: -Needs: I have complaints of feeling depressed-I was seen by psych on 7/12/21 and he recommended I start Celexa. -Interventions: Follow orders for my psychotropic med as ordered/as needed and monitor effect; monitor me for any mood, anxiety, or sleep issues and for any adverse effects to the use of the meds-notify my physician as needed. -Goal: I want to be free from mood issues X 90 days; I want to be free from adverse side effects of antidepressant medication X 90 days. During an interview on 7/19/21 at 10:35 A.M., Nurse #1 and the surveyor reviewed Resident #17's care plan for psychotropic medication use. Nurse #1 said that the care plan should include Resident specific behaviors and/or symptoms, so they can monitor the medications effectiveness in treating his/her symptoms. She also said that potential side effects were not being monitored as indicated on the care plan. 3. For Resident #53, the facility failed to ensure that a comprehensive care plan was developed that identified Resident-centered behaviors and signs/symptoms for use of the antipsychotic medication Risperidone. Resident #53 was admitted to the facility in June 2021 with diagnoses including non-Alzheimer's dementia and Parkinson's disease. Review of the MDS assessment, dated 6/15/21, indicated that Resident #53 has severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 3 out of 15, required extensive assistance to dependence on staff for activities of daily living, and received antipsychotic medication daily. Review of the Social History and Assessment, dated 6/14/21, indicated that Resident #53 had a geriatric psychiatric hospital stay in the fall of 2020. There was no specific information documented in the assessment related to the hospital admission, or that indicated that the Resident received Risperidone. Review of the July 2021 physician's orders indicated an order for Risperidone 0.5 mg twice daily (6/9/21). Review of the comprehensive care plan for psychotropic medication use, developed on 6/22/21 did not include Resident-specific behaviors, signs/symptoms as a rationale for the use of Risperidone. The care plan indicated, but is not limited to: -Needs: I have a diagnosis of dementia and depression. I take routine Lexapro (antidepressant) and Risperidone. I have a history of behaviors and a geri-psychiatric hospital admission (before admission to the facility). I have no mood issues or behaviors since admission here. -Interventions: Follow orders for psychotropic medications and monitor side effects; monitor me for any mood issues or behaviors, also for any signs or adverse side effects to the use of the meds; ways to attempt to alleviate any behaviors are: redirection, distraction, 1:1 attention. -Goal: I want to be free from mood issues or behaviors X 90 days; I want to be free from adverse side effects of psychotropic medication X 90 days During an interview on 7/19/21 at 10:35 A.M., Nurse #1 and the surveyor reviewed Resident #53's medical record. Nurse #1 said that targeted behaviors have not been identified on the care plan or monitored, but should be. She said that she does not know why Resident #53 is on Risperidone, and that he/she was admitted with it. After further review of the medical record, Nurse #1 said that there was no hospital documentation from the geri-psychiatric hospital admission prior to admission to the facility. 4. For Resident #11, the facility failed to develop a care plan to address the Resident's activity needs to prevent feelings of isolation, and enhance his/her quality of life. Resident #11 was admitted to the facility in July 2018 with diagnoses including senile degeneration of brain and unspecified dementia with behavioral disturbance. Review of the most recent MDS assessment, dated 04/29/21, indicated that Resident #11 had severely impaired cognitive skills for daily decision making. Further review of the medical record revealed that no care plan had been developed for Resident #11's activity needs. During an interview on 07/20/21 at 09:23 A.M., the Activity Assistant said she does provide 1:1 activity services to the Resident. The Activity Assistant could not provide the time of the day that she provided individual activity services to the Resident. She said there was a care plan in the care plan book. Review of the care plan book indicated there was no activity care plan for the Resident. The medical record included therapeutic activities progress notes that were repeatedly the same. During an interview on 07/21/21 at 09:50 A.M., the Unit Manager said, there was no activity care plan in the medical record. During an interview on 07/21/21 at 09:57 A.M., the Activity Director (AD) said she did not have an initial assessment on the Resident. The AD said the residents are assessed quarterly for activity of interest to them. The AD said Resident #11 did not have an activity care plan in the care plan book or in the medical record. The Activity Director said the facility provided one-to-one activities with the Resident at least 2-3 times a week. Further review of Resident #11's medical record review failed to indicate documentation that the Resident was receiving One-to-One Activities. 5. For Resident #52, the facility failed to develop an individualized care plan to address the Resident's Advance Directives. Resident #52 was admitted to the facility in March 2021 with diagnoses including unspecified dementia with and without behavioral disturbance. Review of Resident #52's care plans failed to indicate that an Advanced Directives care plan was developed to address Resident/Representative health care wishes, in the event the Resident became incapacitated. Advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. See §489.100 Review of the physician's orders dated July 2021, indicated Resident #52 is a Full Code. During an interview on 7/21/21 at 11:20 A.M., Unit Manager #1 said she was not aware that the facility had to develop an Advance Directives care plan for the Resident. Unit Manager #1 said the facility failed to develop an advance directive care plan to address the Resident/ Representative health care wishes, in the event the Resident became incapacitated. During an interview on 7/21/21 at 10:20 A.M., the MDS coordinator said she did not develop an advance directives care plan. She added that she only writes the code status of the Resident on the top of the care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure 1 Resident (#13), out of a total sample of 22 residents, was provided with an environment free from accidents and hazards. Specifically, the facility failed to ensure Resident #13 was provided adequate supervision/assistance to prevent 12 falls, and failed to implement effective fall prevention interventions to prevent further falls. Findings include: 1. Resident #13 was admitted to the facility in April 2019 with the following diagnoses: gait disorder, dementia, and chronic pain. On 7/20/21 at 12:00 P.M., the surveyor observed Resident #13 eating lunch in the dining room. He/she sat in a tilt-in-space wheelchair (allows the resident to be tilted backward without extending the hips), while he/she eats. The wheelchair was in the upright position. During an observation and interview on 7/20/21 at 1:14 P.M., Resident #13 was seated in a tilt-in-space wheelchair and was yelling. He/she was restless and put his/her legs over the side of the wheelchair. Certified Nurse Aide (CNA) #13 put the Resident's legs back in the wheelchair and tilted the wheelchair back. The surveyor asked CNA #13 why she tilted Resident #13 back, and she said we tilt him/her back to keep the him/her from getting up. Review of the clinical record indicated Resident #13 sustained 12 falls between August 2020 and June 2021. Nine of the falls were unwitnessed, and three were witnessed. The Resident was transferred to the Emergency Department (ED) for further evaluation for six of the 12 falls. After the last transfer to the ED on 6/16/21, the Resident returned to the facility and had another fall. Review of Resident #13's care plan for activities of daily living (ADL), dated 4/20/20 with a goal date of 7/22/20, indicated the following: Needs- -Dependent for bathing, self-care, and dressing, -Assisted with other mobility -Uses a walker -updated 7/21/20 assisted-supervised walking -updated 1/19/21 supervised-independent walking in room Interventions- Stand-by assist (staff directly next to resident) for transfers and ambulation Modification to interventions, dated 5/4/20, indicated Resident #13 requires stand-by assist (SBA-caregiver standing next to resident), and a rolling walker for all transfers and ambulation. Review of the care plan for activities of daily living (ADL) dated 4/20/21, with a goal date of 7/20/21, indicated the following: Needs: -Independent walking in room, and supervised for other mobility needs -Resident continues to ambulate when fatigue, encourage rests. Behavior Section: Resident wanders but can usually be easily redirected. Review of the CNA care card, dated October 2019, indicated the following: -Transfers: Assist of 1 -Ambulation: supervised with walker -5/7/20 Rehabilitation Discharge Status: SBA with rolling walker for all transfers and ambulation. -5/11/21 Rehabilitation/Nursing Communication: SBA for bed mobility, transfers, and ambulation with RW. Review of the incident report, dated 8/20/20 at 8:30 P.M., indicated Resident #13 had an unwitnessed fall and was found sitting on the floor next to his/her bed. Resident was last seen walking around his/her room. The report indicated no new or modified fall prevention interventions were implemented and the Fall Risk Assessment to be 21 (high risk for falls). Review of the incident report, dated 10/26/20 at 7:30 A.M., indicated Resident #13 had an unwitnessed fall and was found lying on the left side of his/her face in his/her room. The Resident complained of pain on his/her left side, and in the arm and shoulder. Resident #13 was sent to the ED for evaluation. The report indicated no new or modified fall prevention interventions implemented and the Fall Risk Assessment to be 21 (high risk for falls). Review of the incident report, dated 11/13/20 at 4:30 P.M., indicated Resident #13 had an unwitnessed fall and was found on his/her knees next to his/her bed. The Resident had a small bruise on his/her left knee. The report indicated no new or modified fall prevention interventions were implemented and the Fall Risk to be 16 (high risk). Review of the incident report, dated 1/12/21 at 1:35 P.M., indicated Resident #13 had an unwitnessed fall in the hallway and was found lying on his/her back. Resident #13 complained of left hip and tailbone discomfort. The Resident was last seen ambulating on the unit. Resident #13 was sent to the ED for evaluation. The report indicated no new or modified fall prevention interventions were implemented. and the Fall Risk to be 19 (high risk). Review of the incident report, dated 1/25/21 at 11:50 A.M., indicated Resident #13 had an unwitnessed fall and was found on his/her left side on the floor in resident's room. The Resident was last seen ambulating in the hallway. Resident #13 had two skin tears and required six Steri-strips (wound closure strips). The report indicated no new or modified fall prevention interventions were implemented, and the Fall Risk to be 19 (high risk). Review of the incident report, dated 4/7/21 at 2:55 P.M., indicated Resident #13 had a witnessed fall. The Resident picked up his/her walker and fell sideways in the hallway. The report did not indicate if the Resident had been provided the recommended level of assistance when he/she ambulated in the hallway. The report indicated no new or modified fall prevention interventions were implemented and the Fall Risk to be 20 (high risk). Review of the incident report, dated 4/10/21 at 6:45 P.M., indicated Resident #13 had an unwitnessed fall and was found next to his/her bed yelling out in pain. The report indicated that it was unclear if the Resident hit his/her head and was transferred to the ED for evaluation. The report indicated no new or modified fall prevention interventions were implemented, and the Fall Risk to be 20 (high risk). Review of the incident report, dated 4/23/21 at 8:00 A.M., indicated Resident #13 had an unwitnessed fall and was found on the floor near room [ROOM NUMBER] with a hematoma on the back of his/her head, and a skin tear on his/her right elbow. Resident #13 was last seen walking on the unit. He/she was sent to the ED for evaluation and admitted , then returned to the facility. The report indicated no new or modified fall prevention interventions were implemented, and the Fall Risk to be 22 (high risk). Review of the incident report, dated 5/11/21 at 6:15 P.M., indicated Resident #13 was found on the floor in his/her room with a laceration under his/her chin, and holding his/her right hip. Resident #13 was last seen walking in his/her room. The Resident was sent to the ED for evaluation. The report indicated no new or modified fall prevention interventions were implemented, and the Fall Risk to be 22 (high risk). Review of the incident report, dated 6/5/21 at 7:30 P.M., indicated Resident #13 had a witnessed fall in the hallway. The report did not indicate if he/she had been provided the recommended level of assistance when he/she ambulated in the hallway. The report indicated no new or modified fall prevention interventions were implemented, and the Fall Risk to be 22 (high risk). Review of the incident report, dated 6/16/21 at 8:15 A.M., indicated Resident #13 had an unwitnessed fall and was found lying on his/her back in the doorway of another resident's room with an empty wheelchair on top of his/her legs. He/she complained of pain in his/her ribs, hips and legs. The Resident was last observed walking in the hallway. Resident #13 was sent to the ED for evaluation. The report indicated no new or modified fall prevention interventions were implemented and the Fall Risk to be 22 (high risk). Review of the incident report dated 6/16/21 at 5:00 P.M., indicated Resident #13 had a witnessed fall in the hallway when he/she lost his/her balance walking in the hallway. The report did not indicate if he/she had been provided the recommended level of assistance when he/she ambulated in the hallway. The Resident had small skin tears on his/her left elbow and lower leg. The report indicated no new or modified fall prevention interventions were implemented and Fall Risk to be 22 (high risk). During an interview on 7/19/21 at 2:50 P.M., the surveyor reviewed Resident #13's care plan and the Fall Incident Reports with Unit Manager (UM) #1. UM #1 said when a resident falls the process is: -staff complete an incident report, -determine the root cause of the fall, and -make modifications to or add to the fall prevention interventions, if indicated. UM #1 further said, if no changes were indicated, the rationale was to be documented. UM #1 said the root cause of each of Resident #13's falls had not been determined, and the only fall prevention intervention that was modified on and off were the 15-minute checks, which were ineffective. She said she could not find documentation for the rationale as to why new fall prevention interventions were not added or current ones modified. She said fall prevention interventions should be addressed after each fall, since the interventions in place were ineffective, but there was no documentation to indicate any new interventions in the medical record. During an interview 7/20/21 at 2:36 P.M., the Minimum Data Set (MDS) Nurse said Resident #13 did not like when staff tried to assist him/her, so it was difficult for staff to provide the recommended level of assistance the Resident required to prevent falls. During an interview on 7/21/21 at 9:57 A.M., the Director of Nurses (DON) said most of Resident #13's falls seem to be due to a decline in condition, and staff had done everything possible for him/her. The DON further said the Resident is a wanderer that should not be wandering because he/she is not safe. She also said, if there was a fall prevention interventions that were not effective for Resident #13, we should have modified the interventions in attempts to prevent further falls, but we did not.

Based on policy review, observation, record review, and interview, the facility failed to ensure that 6 Residents (#39, #62, #68, #59, #53, and #319), out of a sample of 22 residents, were assessed for risk of entrapment as evidenced by incomplete side rail assessments. Findings include: Review of the facility's policy for bed rails (undated) indicated, but was not limited to: -If alternatives are not adequate, the resident will be assessed for use of bed rails-including a review of risks which includes entrapment. -Informed consent is obtained. Review of the side rail rationale screen, dated 8/29/2018, indicated, but is not limited to: -yes or no check off for accident hazards/entrapment- does resident attempt to climb over, around, between or through rails or over the foot board; resident or part of body could get caught between rails, openings, or between rails and mattress. 1. Resident #39 was admitted to the facility in May 2021 with diagnoses of diabetes, hypertension, and lower back pain. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/28/21, indicated that he/she was cognitively intact and required extensive assist with bed mobility, transfers, and walking. Review of the Side Rail Rationale Assessment form, dated 5/21/21, indicated that the Resident used the side rails for positioning/ support and that the rails served as an enabler to promote independence. The assessment did not address accident hazards/ entrapment for use of the rails prior to installation. During an interview on 7/20/21 at 9:35 A.M., the surveyor and SDC reviewed the side rail assessment for Resident #39 and the missing information to address entrapment. She stated, I just forgot to check that off. 2. Resident #62 was admitted to the facility in June 2018 with diagnoses of multiple falls, diabetes, and hypertension. Review of the medical record indicated Resident #68 was alert, with intermittent confusion. Review of Resident #62's medical record indicated that the Side Rail Rationale Assessment, dated 6/18/21, was incomplete. Questions 9, 10, 11, and 12 (includes the resident's diagnoses, height/weight, acute medical condition and underling medical conditions) were left blank. In addition, the assessment was not signed by staff. 3. Resident #68 was admitted to the facility in June 2021 with diagnoses of falls and a hematoma (localized bleeding outside of blood vessels) related to trauma. Review of the medical record indicated Resident #68 was alert, with intermittent confusion. Review of Resident #68's Side Rail Rationale Assessment, dated 6/27/21, indicated it was incomplete and missing the Resident's height. In addition, the form was not signed by a Therapy representative, as required. 4. Resident #59 was admitted to the facility in December 2019 with diagnoses including Alzheimer's disease. Review of the most recent MDS assessment, dated 6/22/21, indicated Resident #59 is severely cognitively impaired. Review of Resident #59's medical record indicated the Informed Consent form for side rails was blank, except for the date of 3/12/18. During an interview on 7/15/21 at 12:54 P.M., Unit Manager #2 reviewed the blank side rail assessment with the surveyor and said that the side rail assessment was inaccurate because Resident #59 does not use the side rails. During an interview on 7/15/21 at 1:05 P.M., the alternate health care proxy, who was visiting Resident #59, said that the side rails are used by the Resident. 5. Resident #53 was admitted to the facility in June 2021 with diagnoses including non-Alzheimer's dementia and Parkinson's disease. Review of the Minimum Data Set assessment, dated 6/15/21, indicated that Resident #53 has severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 3 out of 15, and required extensive assistance to dependence on staff for activities of daily living. Review of the July 2021 physician's orders indicated an order for 2 half side rails as enabler while in bed (6/30/21). Further review of the medical record failed to indicate that a Side Rail Rationale Assessment was conducted to assess the Resident's risk of entrapment. During an interview on 7/19/21 at 10:35 A.M., Nurse #1 and the surveyor reviewed Resident #53's medical record. She said that the side rail assessment should be under the assessment tab in the medical record, but it was not there. The surveyor asked if there was any other place that the assessment could be located, and she replied, No. No further documentation was provided to the survey team prior to exit on 7/21/21. 6. Resident #319 was admitted to the facility in July 2021 for Respite (short-term relief for primary caregivers) with diagnoses including Parkinson's disease. Review of the medical record indicated a physician's order for 2 half side rails as enabler while in bed (7/9/21). Further review the medical record indicated a Side Rail Rationale Assessment document. The assessment included 18 questions to assess the Resident's risk for entrapment prior to the installation of side rails. Of the 18 questions, 5 were blank as follows: 9. Review of medical diagnosis, conditions, symptoms and /or behavioral symptoms if present: yes/no 10. Weight 11. Acute medical or surgical conditions: yes/no 14. Communication issues: yes/no 18. Accident hazards/entrapment-does the resident attempt to climb over, around, between or through rails or over the foot board; resident or part of body could get caught between rails, openings, or between rails and mattress.

On 7/19/21 at 9:00 A.M., the surveyor observed CNA #9 walking in the hallway on the 1st floor unit with gloves on. She touched two different residents, walked to the linen closet and took out clean linens, and then finished feeding a resident. She got up, with the same gloves on, and rolled a chair behind the nurse's station. She closed the Nurse's station door behind her, then took clean straws and cups and put them in the nourishment kitchen. She did not change her gloves and perform hand hygiene in between touching residents or in between touching contaminated items and clean items, as required. During an interview on 7/19/21 at 9:27 A.M., CNA #9 said she should not have touched two residents with the same gloves on, but she did. She said she should not have put clean cups and straws back into the kitchen using the contaminated gloves. CNA#9 also said she should have changed her gloves, and performed hand hygiene each time, but she did not. Based on policy review, observations, record review, and interviews, the facility failed to adhere to Infection Control Practices to prevent the development and potential transmission of communicable diseases and infections, including COVID-19, and perform hand hygiene as required on 2 out of 3 units. Findings include: Review of the facility's policy titled Hand Hygiene, reviewed July 2020, indicated that all employees shall perform hand hygiene in accordance with the recommendations of the Center for Disease Control and Prevention (CDC) Guidelines for Hand Hygiene in Health Care Settings, and CMS [Centers for Medicare & Medicaid Services] guidance. The policy lists some situations that require hand hygiene including, but is not limited to: after removing gloves, aprons and gowns, before and after eating or handling food, before and after assisting a resident with meals, before and after assisting a resident with personal care. The policy specifically lists that alcohol based hand rubs (ABHR) cannot be used in place of proper hand washing techniques in a food service setting. Hand hygiene procedures are to be followed by staff involved in direct resident contact. Review of CDC Hand Hygiene Recommendations: Guidance for Healthcare Providers about Hand Hygiene and COVID-19, updated May 17, 2020, indicated, but is not limited to: -Hand hygiene is an important part of the U.S. response to the international emergence of COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in healthcare settings. CDC recommendations reflect this important role. -The exact contribution of hand hygiene to the reduction of direct and indirect spread of coronaviruses between people is currently unknown. However, hand washing mechanically removes pathogens, and laboratory data demonstrate that ABHR formulations in the range of alcohol concentrations recommended by CDC, inactivate SARS-CoV-2. [1,2] -ABHR effectively reduces the number of pathogens that may be present on the hands of healthcare providers after brief interactions with patients or the care environment. -CDC recommends using ABHR with 60-95% alcohol in healthcare settings. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and are effective in the absence of a sink. [3] -Hands should be washed with soap and water for at least 20 seconds . before eating. On 7/14/21 at 11:45 A.M., the surveyor observed Certified Nursing Assistant (CNA) #5 assist a resident with his/her protective covering while the resident was eating, and then continue distributing trays. CNA #5 did not perform hand hygiene in between residents. On 7/15/21 at 9:30 A.M., the surveyor observed CNA #4 enter a resident's room to tell the resident that she will be getting him/her out of bed shortly. CNA #4 touched the resident's shoulder and tucked the sheet onto the resident's shoulders. CNA #4 left the room and failed to perform hand hygiene. On 07/19/21 at 11:41 A.M., the surveyor observed nine residents in the Medical 2-unit dining room for 30 minutes. The surveyor did not observe the residents receive hand hygiene prior to eating lunch. On 07/19/21 at 11:55 A.M., the surveyor observed CNA #3 with gloves donned (on). After she set up the resident's tray, she exited the room leaving the gloves on her hands and applied hand sanitizer gel to gloves. During an interview on 7/19/21 at 12:05 P.M., CNA #3, she said that she remembers being educated that she can use hand sanitizer gel over the gloves. During an interview on 7/19/21 at 1:30 P.M., the Staff Development Coordinator/ Infection Control Preventionist (SDC/ICP) said that was unacceptable practice to apply ABHR over gloves since personal protective equipment (PPE) was in sufficient supply and available for staff. During an interview with Resident #12 in his/her room on 7/16/21 at 11:45 A.M., Nurse #5 delivered a lunch tray for the Resident and placed it on the overbed table. She removed the cover from the plate, poured the drinks into the cups, and left the room. Nurse #5 did not perform hand hygiene for herself and did not provide hand hygiene to the Resident or encourage the Resident to perform hand hygiene independently. The surveyor asked the Resident if any staff had provided hand hygiene or encouraged him/her to wash his/her hands prior to eating meals, and the Resident said, No. The Resident began to eat his/her lunch. On 7/16/21 from 11:14 A.M. to 12:10 P.M. on Unit 2 A & B, the surveyor observed eight residents seated in the dining room. The food truck arrived on the unit and two Certified Nursing Assistants (CNA), and one nurse began to distribute the lunch trays to the residents. The staff failed to provide hand hygiene or encourage the residents to wash their hands prior to serving the meal. The surveyor observed all eight residents in the dining room eat their meals without being offering hand hygiene and/or assistance to perform their own hand hygiene. On 7/20/21 from 11:15 A.M. to 12:25 P.M. on Unit 2 A & B, the surveyor observed eight residents seated in the dining room. The food truck arrived on the unit and three Certified Nursing Assistants (CNA), and two nurses began to distribute the lunch trays to the residents. The staff failed to provide hand hygiene or encourage the residents to wash their hands prior to serving the meal. The surveyor observed all eight residents in the dining room eat their meals without hand hygiene being performed.

Based on policy review, record review, and interviews, the facility failed to annually conduct inspections of resident's bed frames, bed rails, and mattresses to assess these safety devices for the potential hazard of entrapment. Findings include: Review of the facility's policy titled Policy and Procedure for Bed Assessment Regulatory Compliance (undated) indicated, but is not limited to: -Using the Bed Assessment Tool and documentation form, the Maintenance Department will perform/document a bed assessment every time bed rails or new mattresses are installed. -At a minimum, every bed in the Facility must have a bed assessment done at least once per year. On 7/15/21 at 2:35 P.M., Maintenance Staff #1 provided the surveyor with a bed rail assessment binder that included bed system measurement device test results for all beds in the facility. Review of the documentation failed to indicate that all beds with bed rails were inspected as required: -2019, only 7 beds were inspected. -2020, only 57 beds were inspected. -2021, only 2 beds have been inspected thus far. During an interview on 7/16/21 at 2:30 P.M., Maintenance Staff #1 said that he has not kept up with bed rails inspections and that the maintenance department has not checked the beds of new admissions. During an interview on 7/20/21 at 10:28 A.M., the Maintenance Director said that there was no system in place to track inspections of beds every time bed rails are applied, and/or a new mattress is installed. He said that the bed rail assessment binder was complete, and any inspection documents that were not in the book, were not done. Resident #12 was admitted to the facility in August 2019 with diagnoses including chronic pain syndrome. Review of the Minimum Data Set assessment, dated 4/22/21, indicated that Resident #12 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 14 out of 15, needed limited assistance with bed mobility, and was dependent for all activities of daily living. The surveyor observed Resident #12 lying in bed with bilateral side rails up on the following dates: -7/14/21 at 8:35 A.M. -7/15/21 at 7:30 A.M. -7/16/21 at 8:51 A.M. Resident #53 was admitted to the facility in June 2021 with diagnoses including non-Alzheimer's dementia and Parkinson's disease. Review of the Minimum Data Set assessment, dated 6/15/21, indicated that Resident #53 has severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15, required extensive assistance for bed mobility, and extensive assistance to dependence on staff for activities of daily living. The surveyor observed Resident #53 lying in bed with bilateral quarter side rails up on the following dates: -7/15/21 at 12:25 P.M. -7/19/21 at 10:14 A.M. -7/21/21 at 11:17 A.M. During an interview on 7/19/21 at 11:37 A.M., the surveyor and Maintenance Assistant #1 reviewed the bed rail assessment documentation. He said that Residents #12 and #53's beds had not been assessed since 4/15/19 and 5/20/19 respectively.

Based on observations and interviews, the facility failed to implement safe food handling practices in the kitchen. Specifically, the facility failed to ensure: 1. one dietary staff member used proper hand hygiene during food preparation; and 2. one dietary staff member properly restrained her hair during meal preparation. 1. On 7/20/21 at 1:40 P.M., the surveyor observed Dietary Staff #2 in the kitchen chopping celery. He touched his mask and adjusted it several times while he prepared the food. He did not perform hand hygiene each time after touching his mask, but instead wiped his hands on a rag and then continued to chop the celery. During an interview on 7/20/21 at 1:42 P.M., Dietary Staff #2 said he should not have touched his mask and then touched the food. He said he should have sanitized or washed his hands instead of wiping them on a rag. During an interview on 7/20/21 at 1:43 P.M., the Food Service Director (FSD) said staff must sanitize or wash their hands after they touch their mask. 2. On 7/14/21 at 8:35 A.M., the surveyor, accompanied by the Food Service Manager, observed the following food sanitation concerns in the kitchen: -Hairnets were not readily available prior to entering the kitchen. The Food Service Supervisor invited the surveyor to enter the kitchen without offering a hairnet. -The Cook's hair was not fully restrained by her hairnet during meal preparation. During an interview on 07/14/21 at 09:05 A.M., the Food Service Supervisor said that he did not think about offering a hairnet to the Surveyor. The Food Service Supervisor said he was new to the facility and did not think about placing the hairnets at the kitchen entrance door to make them easily accessible for visitors. -On 07/14/21 from 11:30 A.M. to 11:50 A.M., the surveyor entered the kitchen and observed the meal service. The surveyor observed that the cook did not have her hair fully restrained by a hairnet. During an interview on 07/16/21 at 09:16 A.M., Dietary Staff Member #1 said all hair should be covered with the hairnet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and observations, the facility failed to update the facility assessment to accurately reflect the staffing of licensed nurses and certified nursing assistants (CNA) on duty. Findings include: Review of the Facility Assessment Tool, updated 4/7/21 and reviewed at the Quality Assurance Performance Improvement (QAPI) committee on 4/21/21 indicated the facility had 117 licensed beds and the average daily census is 65-70 residents. The average age is [AGE] years old of the residents. Review of the current census during the survey was 72 with one resident on medical leave. Review of the Facility Assessment Tool indicated the staff required for Activities of Daily Living (ADL) as follows: -Residents requiring an assist of 1-2 staff: dressing for 41 residents, bathing for 27 residents, transfer for 28 residents, for feeding 9 residents, and for toileting 23 residents. -Residents who are completely dependent on staff: dressing for 25 residents, bathing for 41 residents, transfer for 17 residents, feeding for 12 residents and toileting for 36 residents. -The total number of staff listed as needed on average per 24 hours is as follows: -Licensed nurses providing direct care 20; and -Certified nursing assistants (CNA) 39 Review of the staffing sheets indicated a significant difference from the facility assessment of required staff as follows: -Nine to 10 nurses were scheduled to provide resident care (one nurse per unit for each of the three shifts and a supervisor); and -17-21 CNAs were staffed per 24-hour period covering three units. During an interview on 7/21/21 at 10:30 A.M., the Administrator said that he had heard that the residents had complained about low staffing but that he did not have anything in writing. He said that low staffing has been an issue for a while and that he did not address low staffing levels during the QAPI committee meeting.

Based on record review, policy review, and interviews, the facility failed to implement an Antibiotic Stewardship program that included antibiotic use protocols and a system to monitor antibiotic use in the facility as indicated by the facility's policies. The facility failed to adhere to their antibiotic use policies for one Resident (#68), out of 22 sampled residents. Findings include: Review of the facility's policy titled Antibiotic Stewardship Program 2016 Policy, revised November 2020, indicated the policy is aligned with the Centers for Disease Control and Prevention (CDC) Core Elements of Antibiotic Stewardship for Nursing Homes (2015), and the facility is to implement an Antibiotic Stewardship Program (ASP). Nursing Home ASP activities should, at a minimum, include these basic elements: leadership, accountability, drug expertise, action to implement recommended policies or practices, tracking measures reporting data, education for clinicians, nursing staff, residents and families about antibiotic resistance and opportunities for improvement. Review of the facility's policy titled Antibiotic Stewardship- Order for antibiotics, revised November 2020, indicated that antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotics Stewardship Program. The policy indicated on item #3 that all new antibiotic orders will be reviewed by the clinical team at the next morning meeting. Item #4 details the process of a culture and sensitivity (C&S) that is negative. Results will be treated as a high priority. The facility is to communicate to the clinician/prescriber and the SDC/ICP [Staff Development Coordinator/ Infection Control Preventionist] will review labs and antibiotics that are ordered based on C&S. Review of the facility's policy titled Antibiotic Stewardship - Staff and Clinician Training Roles, undated, indicated that direct care staff and clinicians will be provided initial training and ongoing information about the facility Antibiotic Stewardship Program (ASP) including appropriate prescribing, monitoring, and surveillance of antibiotics use and outcome. The policy identifies the certified nursing assistants and licensed staff's responsibilities. The SDC/ICP will monitor individual resident antibiotic regimens including review of clinical documentation supporting antibiotic orders including start and stop dates. The SDC/ICP and the Director of Nurses will participate in meetings on a regular basis and will facilitate the team completion of the facility infection control assessment, yearly and as needed. Resident #68 was admitted to the facility in June 2021 with diagnoses of a urinary tract infection (UTI), and an elevated white blood count. Review of the June 2021 physician's order indicated an order for a urinalysis with a culture and sensitivity to rule out a UTI. A chest x-ray was also ordered. Review of the test results indicated both were negative for infection. The Resident remained on the antibiotic without a diagnosis. During an interview on 7/15/21 at 11:35 A.M., Nurse #1 said that they do not have protocols that provide non-medical interventions prior to clinicians ordering antibiotics. If a clinician orders an antibiotic, we cannot tell them not to prescribe. The surveyor inquired as to their antibiotic stewardship program (ASP), but the nurse said she was not aware of protocols concerning antibiotics. During an interview on 7/19/21 at 10:07 A.M., the SDC/ICP said that the management team meets on Thursdays to review antibiotics. Review of the meeting document, dated 7/15/21, indicated it contained the signatures of facility staff who attended and a printout of the residents who are on antibiotics. There was no additional documentation to indicate what the meeting entailed and what interventions the facility would implement based on the review. The SDC/ ICP further said that there are no protocols regarding ASP and she was not aware of the components required to develop an effective ASP, and/or the facility's responsibility to involve the clinicians who are prescribing the antibiotic and the facility's licensed staff. During an interview on 7/19/21 at 10:30 A.M., the SDC/ICP reviewed Resident #68's medical record which indicated that he/she was on an antibiotic for prophylactic treatment of unknown infection and the SDC/ICP said that the clinician wanted the antibiotic administered to Resident #68. This is inconsistent with the facility's ASP policies. The SDC/ICP said that she was not aware that it was the responsibility of the facility to educate physicians, nurse practitioners, physician assistants and nursing staff regarding antibiotic stewardship. Review of training documentation failed to indicate clinicians and nursing staff were educated on the ASP, including interventions before antibiotics prescribed, non-medical interventions and protocols as documented in the facility's policy.