**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure residents were provided care in accordance with professional standards of practice for two Residents (#13 and #86), out of a total sample of 27 residents. Specifically, the facility failed:1. For Resident #13, to ensure physician's orders were complete for the management of a continuous glucose monitoring sensor and included orders to remove and change the device every 14 days; and2. For Resident #86, to complete weekly skin check documentation per physician's orders.Findings include:1. Review of the facility's policy titled Freestyle Libre 2 Flash Glucose Monitoring System, June 2023, indicated but was not limited to: -Always obtain physician’s orders for the use of fingerstick blood glucose testing via a facility approved blood glucose meter to guide treatment decisions. -Review the resident’s orders to evaluate special needs of the resident. -Review and follow manufacturer's guidelines for use. Review of [NAME] Freestyle Libre Continuous Glucose Monitoring (CGM- https://www.freestyle.[NAME]/us-en/home.html) guidelines, included but was not limited to: -the Libre CGM is a small sensor-based system that provides real-time glucose readings day and night, without fingerstick; -The sensor lasts up to 14 days, and it is recommended to rotate application site of the sensor between arms. Resident #13 was admitted to the facility in July 2025 with diagnoses including diabetes mellitus, type 2. Review of the Minimum Data Set (MDS) assessment, dated 7/29/25, indicated Resident #13 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 14 out 15 and was receiving insulin. During an interview with observation on 8/25/25 at 10:42 A.M., the surveyor observed a glucometer (device used to measure blood glucose levels) on Resident #13’s nightstand. Resident #13 said the glucometer was used to check his/her blood sugar utilizing their Libre 2 monitor. He/she said their monitor was changed every 14 days and the nurses use it to check his/her blood sugar. Review of Resident #13's Physician's Orders indicated but was not limited to: -Insulin Lispro per sliding scale: if 1 - 149 = 0 units; 150 - 199 = 1 unit; 200 - 249 = 2 units; 250 - 299 = 3 units; 300 - 349 = 4 units; 350 - 399 = 6 units; 400 - 449 = 8 units; 450 - 499 = 10 units; 500 - 1000 = 12, subcutaneously before meals and at bedtime, 7/25/2025 Further review of Resident #13’s Physician's Orders failed to indicate orders for the use of the Libre continuous glucose monitoring device to implement the sliding scale, and orders to remove and reinsert the sensor device every 14 days. During an interview on 8/27/25 at 2:51 P.M., Nurse #1 said Resident #13 had a Libre Blood Glucose Monitor to monitor his/her blood glucose. She said she would check Resident #13's blood glucose either using his/her Libre monitor or via a fingerstick. Nurse #1 said when a resident had a Libre monitor they would need an order to change and apply a new monitor every 14 days, and an order for use of the device to obtain blood glucose levels to implement the insulin sliding scale. Nurse #1 reviewed Resident #13's medical record and said he/she did not have a physician's order to change the device every 14 days or to use the device to check his/her blood glucose. During an interview on 8/28/25 at 9:46 A.M., the Nurse Practitioner (NP) said Resident #13 had a Libre monitor and should have an order to change the monitor every 14 days and to use it to monitor their blood glucose. The NP reviewed Resident #13’s medical record and said he/she did not have an order to change the monitor or to utilize it to monitor their blood glucose levels but should have. During an interview on 8/28/25 at 12:56 P.M., the Director of Nursing (DON) reviewed Resident #13’s orders and said he/she did not have a physician's order to change the device every 14 days and to utilize the Libre to monitor their blood glucose levels but should have. 2. Resident #86 was admitted to the facility in April 2019 with diagnoses which included chronic peripheral venous insufficiency (a condition of impaired blood flow that can cause swelling, pain, and skin changes). Review of Physician’s Orders indicated, but was not limited to, the following: -Dermatological Consult related to bilateral lower extremity (BLE) skin inflammation (7/19/25); -Weekly skin check on Tuesday 7-3 shift (1/16/24). Review of the Resident's current care plan indicated, but was not limited to, the following: -I have impaired skin integrity related to bilateral lower extremity skin condition. I am at risk for skin impairment related to limited mobility, incontinence of bowel/bladder, diabetes. -Administer treatments as ordered and monitor effectiveness. Report abnormal findings to practitioner. Document findings and interventions. -Monitor for new or worsening signs and/or symptoms of complications and infection: necrosis, erythema, warmth, edema, exudate, foul odor, maceration, pain/tenderness, fever/chills, etc. Review of Resident #86’s medical record indicated his/her last weekly skin check was performed six weeks prior on 7/15/25 and indicated no skin issues. Review of the Resident's progress notes indicated an entry on 7/19/25 that stated the NP assessed the Resident for BLE skin buildup and discharge; new orders for labs and aerobic culture of the right lower extremity (RLE); NP prescribed Prednisone 40mg daily for 5 days, Clobetasol topically twice per day for 7 days, and a dermatology consult. During an interview on 8/28/25 at 2:05 P.M., the Director of Nursing (DON) reviewed the Resident’s medical record and said there was missing documentation of weekly skin checks. The DON said although the Resident’s legs were open to air and observed by staff during routine care, weekly skin checks should be documented in the electronic health record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure one Resident (#46), out of 27 sampled residents, and one Resident (#159), out of three closed records, received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices to achieve their highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed:1. For Resident #46, to ensure the Wound Physician's recommendations were addressed and implemented timely for a skin tear; and2. For Resident #159, to: a. Accurately transcribe the physician's order to send Resident #159 to the emergency room for evaluation, resulting in a minimum of a nine-hour delay (6/30/25 5:00 P.M. to 7/1/25 2:00 A.M.) in transferring the Resident to the hospital, and b. Report abnormal urinalysis results to the Physician in a timely manner. Findings include:1. Review of the facility's policy titled Consultant Physician Services, dated as adopted 2/2023, indicated but was not limited to the following: -Consultant physician services are available to the residents as ordered by their attending physician or physician designee. -After completion of the consult, the consultant physician will provide the facility with a consultation report which shall include any orders, recommendations, or follow up actions. -The resident’s attending physician should be informed of the recommendations, treatments, diagnostics, and medications ordered by the consultant. -Orders from the consultant physician will be entered in the resident’s medical record. Review of the facility's contract with the Wound Physician, dated 3/12/25 effective 4/1/25, indicated but was not limited to the following: -Facility Responsibilities: The facility agrees to support delivery of wound care services and commits to inform the resident’s primary care provider of the provider’s recommendations within 24 hours. Resident #46 was admitted to the facility in May 2025 with diagnoses which included a displaced left femur fracture, diabetes mellitus, history of falls, and abnormal gait/mobility. Review of the Minimum Data Set (MDS) Assessment, dated 8/27/25, indicated Resident #46 scored 11 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she had moderate cognitive impairment. Additionally, he/she had a skin tear. Review of the medical record including nursing progress notes indicated he/she sustained the skin tear on 6/9/25 and a dressing was applied. Review of the Initial Wound Evaluation and Management Summary, dated 6/19/25, indicated but was not limited to the following: -Site 1: Skin Tear of the Right Skin (full thickness), measuring 5 x 5 centimeters (cm), depth unmeasurable due to tissue overgrowth. Recommended treatment Silver sulfadiazine (topical antibiotic cream) followed by a bordered gauze dressing twice daily. Review of the Physician's Orders indicated but were not limited to the following: -Cleanse skin tear to right shin with normal saline (NS), pat dry, apply xeroform (mesh gauze occlusive dressing), followed by an ABD pad and kerlix (gauze roll) every three days for wound care (6/17/25) Review of the physician's orders failed to indicate the wound care recommendation from 6/19/25 was implemented. Review of the Wound Evaluation and Management Summary, dated 6/26/25, indicated but was not limited to the following: -Site 1: Skin Tear of the Right Skin (full thickness), measuring 5 x 4 cm, depth unmeasurable due to non-viable tissue and necrosis (dead cells or tissue). Recommended treatment Silver sulfadiazine, skin prep (breathable protective film like barrier) followed by a bordered gauze dressing twice daily. Review of the Physician's Orders indicated but were not limited to the following: -Cleanse skin tear to right shin with normal saline (NS), pat dry, apply xeroform, followed by an ABD pad and kerlix every three days for wound care (started 6/17/25 and discontinued 6/27/25) -Skin tear wound of the right shin, cleanse with NS, pat dry, apply silver sulfadiazine, skin prep border, followed by gauze island with border dressing twice daily (6/30/25) The facility failed to implement the recommendation made on 6/19/25 which was repeated on 6/26/25 until 6/30/25 (11 days later). Additionally, the treatment that was in place was discontinued on 6/27/25 and there was no treatment in place from 6/27/25 through 6/30/25. Review of the Wound Evaluation and Management Summary, dated 7/3/25, indicated but was not limited to the following: -Site 1: Skin Tear of the Right Skin (full thickness), measuring 5 x 5 cm, depth unmeasurable due to dry fibrinous exudate (scab). Wound progress: not at goal. Recommended treatment skin prep daily followed by a bordered gauze dressing twice daily. Review of the Physician's Orders indicated but were not limited to the following: -Skin tear wound of the right shin, cleanse with NS, pat dry, apply silver sulfadiazine, skin prep border, followed by gauze island with border dressing twice daily (started 6/30/25 and discontinued 7/8/25). -Skin tear wound of the right shin, cleanse with NS, pat dry, apply skin prep and cover gauze island with border dressing daily (7/9/25) The facility failed to implement the recommendation made on 7/3/25 until 7/9/25 (6 days later). Review of the nursing and physician progress notes failed to indicate the provider was notified the next day of the consultant recommendations and did not want the orders changed at that time. During an interview on 8/28/25 at 11:35 A.M., Nurse #3 said the Unit Manager (UM) handles writing all the orders and she has nothing to do with wound rounds; the new orders just appear in the computer. During an interview on 8/28/25 at 1:03 P.M., UM #1 said Resident #46 was on a different unit in June and July, so she could not speak specifically to why those recommendations were not done, however she reviewed the medical record including wound notes, orders, and progress notes and confirmed the orders were not written timely and there were no notes indicating the physician declined the recommendations. During an interview on 8/28/25 at 2:09 P.M., the Director of Nurses (DON) said wound rounds are done on Thursdays and if the recommendations are uploaded early enough, they should be reviewed that day, if not the next day. She said if the UM is off, the expectation is the floor nurses would ensure the orders were written, but there was not a specific person assigned to ensure they were complete. When asked how a floor nurse would know if orders needed to be obtained and written she said, they might have to work on that process. 2. Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following:-The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, 9324, dated as last revised April 11, 2018, indicated but was not limited to the following:-Licensed nurses accept, verify, transcribe, and implement orders.-Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. -In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber. Resident #159 was admitted to the facility in May 2025 with diagnoses which included: Severe sepsis with septic shock, acute kidney failure, hyponatremia, retention of urine, and generalized edema. Review of the MDS assessment, dated 6/10/25, indicated Resident #159 scored 15 out of 15 on the BIMS, indicating Resident #159 was cognitively intact. Further review of section HO100A indicated he/she had an indwelling catheter. Review of the form titled Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST), dated 5/28/25 and signed by Resident #159 indicated he/she wished to be a full code with further directions to transfer to hospital. a. Review of a Social Service note, dated 7/2/25 at 10:09 A.M., indicated Discharge Note-Resident #159 was sent to the Hospital yesterday and admitted with sepsis. Review of Resident #159’s Nursing Progress notes indicated the following:-6/30/25 at 9:29 P.M., Nurse #2 wrote, labs reviewed with Physician #1 order to repeat in the AM. -7/1/25 at 2:40 A.M., Nurse #7 wrote, Lab from 6/30 found with an order from Physician #1 to send to the emergency room for evaluation, discuss with patient that he/she could wait till the morning and discuss with another provider or we could send him/her now as physician recommended this morning, he/she wanted to go. Patient was transferred via ambulance to an outside hospital. Review of the medical record failed to include the 6/30/25 lab slip. During an interview on 8/27/25 at 2:45 P.M., Medical Records Staff #1 said the nurses transcribe the physician order written on the lab slips. She said the nurses can put the lab slips in the shredder bin or put them in the scan folder, and she scans them into the medical record. Medical Record Staff #1 reviewed the electronic medical record and the Blood lab results from 6/29/25 with any physician notation was not in the medical record. During a telephonic interview on 8/27/25 at 4:50 P.M., Physician #1 said he reviewed the labs for Resident #159 and faxed back to the facility to send Resident #159 to the ER for evaluation. He said his instruction was clear. The surveyor requested a copy of the lab results with his written instructions and Physician #1 agreed to send a copy. On 8/27/25 at 4:56 P.M., the surveyor received the lab results with instructions for Resident #159 from Physician #1 on the Cookside Unit fax. Review of the lab results, dated 6/30/25, indicated the following: -Specimen was collected on 6/30/25 at 5:17 A.M. and reported on 6/30/25. -Results indicated multiple abnormal values. -The written instructions from Physician #1 at the bottom of the page indicated: Two arrows pointing at the words ER evaluation. -There were no instructions noted to repeat labs in the morning. -The original fax time stamp printed indicated it was faxed from the Cookside Unit to the physician’s office on 6/30/25 at 1:06 P.M. -Time stamp on the fax from the physician to the surveyor on 8/27/25 matched the actual time surveyor received the fax, 8/27/25 at 4:56 P.M. Review of facility form titled Skilled Nursing Facility to Hospital Transfer Form, dated 7/1/2025, indicated Resident #159 was transferred to the hospital on 7/1/25 at 2:11 A.M., a minimum of 9 hours after the facility would have received the fax from Physician #1’s office. During an interview on 8/27/25 at 4:10 P.M., Nurse #1 said the process is to print the lab results in the morning and for Physician #1, he wants the lab slips faxed over to his office, and he faxes back written instructions on the lab slip. Nurse #1 said once you receive the fax back, you transcribe the order and write a note and then you can shred the written communication, or you can put it in the scan folder. During an interview on 8/27/25 at 4:17 P.M., Nurse #2 said he found Resident #159’s lab slip on the desk and thought the physician’s written instructions said to repeat labs in the A.M. Nurse #2 said he wrote a note to repeat labs in the A.M., and left the lab slip on a pile of other papers. Nurse #2 said the next day, Nurse #7 told him, she sent Resident #159 to the hospital. Nurse #2 said, Nurse #7 told him she saw the lab slip on the desk and knew Physician’s #1’s writing and read the order on the lab slip to send Resident #159 to the hospital. Nurse #2 said the lab slip was sent over during the day shift. Nurse #2 said he interpreted the physician instructions differently than Nurse #7. During an interview on 8/27/25 at 4:58 P.M., Nurse #2 viewed the faxed lab results and said it looks like the physician wrote re-evaluation. He said he can now see the “ER evaluation”. During an interview on 8/28/25 at 7:35 A.M., the DON said the first nurse misread the physician instructions, and the 11-7 nurse who knew the physician better read it as send the Resident to the ER. During an interview on 8/28/25 at 8:30 A.M., with both Physician #1 and the DON present, Physician #1 said if the lab slip was sent to my office at 1:00 P.M, he would have acted upon and returned it to the facility within 1-2 hours. Physician #1 said the lab results were not faxed over to the facility after 5:00 P.M. Physician #1 said he was sending out Resident #159 for low sodium and would not have expected it to be a 911 call but would expect the Resident to go to the hospital within a couple hours. Physician #1 confirmed the written instructions on the lab slip said to send to ER, not repeat labs in the A.M. b. Review of Resident #159’s urinalysis, collected on 6/27/25 and reported to the facility on 6/29/25 at 9:52 A.M., indicated abnormal results with greater than 100,000 CFU/ML of klebsiella pneumonia, ESBL. Review of Nursing Progress notes, dated 6/27/25 at 4:43 A.M., Nurse #7 wrote, Urine obtained. Results pending. Review of Social service note, dated 6/27/25 at 3:34 P.M., this morning, interdisciplinary team discussed Resident #159. Foley was taken out this morning, Lab work ordered to determine fluid restriction and sodium tablets. Review of Nursing progress note, dated 6/30/25 at 3:51 P.M., written by the DON, Resident noted with overall decline, failed voiding trial x 2, noted with increased pain and edema in lower extremities, Doppler completed and noted without Deep vein thrombosis (DVT). Resident does continue to voice he/she would like to go home but does not feel he/she is ready. Nursing continues to work on pain management and Foley training has been complicated by poor dexterity. Labs today are significant for elevated white blood cell (WBC) and urine culture with bacteria. Call to physician (MD) to report labs a (sic) decline. Surveyor requested DON obtain a copy from Physician #1’s office of the urinalysis. Review of Nursing Notes, dated 6/29/25, did not indicate abnormal urinalysis lab results were communicated with physician and/or his designee. During an interview on 8/28/25 at 4:28 P.M., the DON said she called Physician #1’s office, and they do not have a copy of the lab results or fax which would have been sent back to the facility. The DON said she checked the electronic communication system used to communicate with physicians and said there was no notification to the physician or his designee with the results of the urinalysis on 6/29/25. Further review of the electronic medical record indicated there were no physician or Nurse Practitioner documentation of the abnormal urinalysis results reported to the facility on 6/29/25.

Based on record review and interview, the facility failed to ensure one Resident (#46), out of a total sample of 27 residents, received the necessary care and treatment to prevent and promote healing of pressure injuries. Specifically, the facility failed to ensure Wound Physician recommendations were addressed and implemented timely. Findings include: Review of the facility's policy titled Pressure Ulcer /Skin Breakdown - Clinical Protocol, dated as last revised 3/2014, indicated but was not limited to the following:-The physician will authorize pertinent orders related to wound treatments.-The physician will help identify medical interventions related to wound management. Review of the facility's policy titled Consultant Physician Services, dated as adopted 2/2023, indicated but was not limited to the following:-Consultant physician services are available to the residents as ordered by their attending physician or physician designee.-After completion of the consult, the consultant physician will provide the facility with a consultation report which shall include any orders, recommendations, or follow up actions.-The resident's attending physician should be informed of the recommendations, treatments, diagnostics, and medications ordered by the consultant.-Orders from the consultant physician will be entered in the resident's medical record. Review of the facility's contract with the Wound Physician, dated 3/12/25, effective 4/1/25, indicated but was not limited to the following:-Facility Responsibilities: The facility agrees to support delivery of wound care services and commits to inform the resident's primary care provider of the Provider's recommendations within 24 hours. Resident #46 was admitted to the facility in May 2025 with diagnoses which included a displaced left femur fracture, diabetes mellitus, history of falls, and abnormal gait/mobility. Review of the Minimum Data Set (MDS) assessment, dated 8/27/25, indicated Resident #46 scored 11 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she had moderate cognitive impairment. Additionally, he/she was a risk for pressure ulcers, and had one unhealed unstageable pressure injury (pressure injury where the depth of tissue damage cannot be determined due to the presence of slough (yellow/green/grey dead tissue) or eschar (thick, leathery layer of dead tissue) covering the wound bed). Review of the medical record, including nursing progress notes, indicated the pressure ulcer was observed on 6/8/25, the Nurse Practitioner (NP) was notified and a treatment ordered. Review of the Initial Wound Evaluation and Management Summary, dated 6/19/25, indicated but was not limited to the following:-Site 2: Unstageable Deep Tissue Injury (DTI- purple/maroon discoloration due to prolonged pressure) of the left medial heel, measuring 4 x 5.5 centimeters (cm), intact blood-filled purple/maroon discoloration. Recommended treatment was skin prep (breathable protective film like barrier) once daily. Review of the Physician's Orders indicated but were not limited to the following:-Apply skin prep to left heel every day shift for wound care. (6/17/25) Review of the Wound Evaluation and Management Summary, dated 8/7/25, indicated but was not limited to the following:-Site 2: Unstageable (due to necrosis-dead cells or tissues) of the left medial heel, measuring 2.5 x 2.1 cm x depth not measurable due to presence of non-viable tissue and necrosis. Thick adherent devitalized necrotic tissue 100%, Wound progress not at goal. Recommended treatment skin prep peri wound, Apply collagen sheet (gel sheet to maintain a moist wound environment), calcium alginate (highly absorbent/promotes moist healing environment), and Santyl (wound gel to debride necrotic tissue) followed by gauze island dressing once daily. Review of the physician's orders indicated the wound care order was not implemented until 8/12/25 (five days after he/she was seen by the wound care physician). Review of the Wound Evaluation and Management Summary, dated 8/21/25, indicated but was not limited to the following:-Site 2: Unstageable (due to necrosis) of the left medial heel, measuring 2 x 2 cm x depth not measurable due to tissue overgrowth. Recommended treatment skin prep peri wound, Apply collagen sheet and calcium alginate followed by gauze island dressing once daily. Review of the physician's orders indicated the wound care order was not implemented until 8/26/25 (five days after he/she was seen by the wound care physician. Review of the nursing and physician progress notes failed to indicate the provider was notified the next day of the consultant's recommendations and did not want the order changed at that time. Further review of the physician's progress note, dated 8/21/25, indicated Resident #46 was followed by the wound physician for the decubitus ulcer on the left heel and they agree with all recs. During an interview on 8/28/25 at 11:35 A.M., Nurse #3 said Unit Manager (UM) #1 already did wound rounds with the wound physician earlier this morning. She said UM #1 usually is not here on Thursdays, so UM #2 or a desk nurse will do rounds. She said they handle writing all the orders and she has nothing to do with wound rounds; the new orders just appear in the computer. During an interview on 8/28/25 at 1:03 P.M., UM #1 said she did rounds today, but normally she is off on Thursdays. She said the wound notes typically import to the electronic medical record late afternoon and the orders should be put into the computer by the next day. She said rounds used to be on Friday, but by the time the notes were imported, the orders were not getting entered until Monday, so we switched wound rounds to Thursdays, so we could get the ordered entered the next day. She said normally UM #2 does rounds with the doctor on Thursday and then Friday she would write all the orders, complete the assessments, evals, and progress notes. She said when she is off, as far as she knows there is not someone assigned to ensure the orders are written. She said that is why there was a delay with the 8/7/25 and 8/21/25 recommendations getting entered. She said typically no one covers if she takes a few days off, so her work sits there until she returns. During an interview on 8/28/25 at 2:09 P.M., the Director of Nurses (DON) said wound rounds are done on Thursdays and if the recommendations are uploaded early enough, they should be reviewed that day, if not the next day. She said if the UM is off, the expectation is the floor nurses would ensure the orders were written, but there was not a specific person assigned to ensure they were complete. When asked how a floor nurse would know if orders needed to be obtained and written she said, they might have to work on that process.

Based on interviews and record review, the facility failed to ensure monthly Medication Regimen Review (MRR) recommendations made by the pharmacy consultant were addressed timely and maintained as part of the permanent medical record for two Residents (#16 and #5), out of a total sample of 27 residents.Specifically, the facility failed:1. For Resident #16, to ensure the April 2025 and May 2025 consultant pharmacist recommendations were maintained as part of the permanent medical record and acted upon timely to assess the need for Meclizine (an anticholinergic medication used to treat nausea, vomiting and dizziness) and to obtain an A1c (blood test that measures an average blood sugar level over a period of two to three months); and2. For Resident #5, to ensure the April 2025, May 2025, and July 2025 consultant pharmacist recommendations were maintained as part of the permanent medical records and acted upon timely to sequence multiple as needed pain medications and to obtain labs related to specific medication use.Findings include:Review of the facility's policy titled Pharmacy Services-Role of the Consultant Pharmacist, revised April 2019, indicated but was not limited to the following: -The consultant pharmacist will provide specific activities related to medication regimen including: -a documented review of the medication regime of each resident at least monthly, or more frequently under certain conditions, based on applicable federal and state guidelines; -appropriate communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of medications and pharmacy services, including medication irregularities, and pertinent resident-specific documentation in the medical record, as indicated; -providing the facility with written or electronic reports and recommendations related to all aspects of medication and pharmaceutical services review 1. Resident #16 was admitted to the facility in April 2021 with diagnoses including type 2 diabetes mellitus, hypertension, and major depression disorder. Review of the medical record indicated the consultant pharmacist made recommendations for Resident #16 in April 2025 and May 2025 and generated a report to be acted upon and reported to the physician, however, the surveyor was unable to locate either the 4/28/25 or the 5/30/25 MRR report in the Resident's medical record. During an interview on 8/27/25 at 10:59 A.M., Nurse #3 and the surveyor reviewed Resident #16’s medical record and could not locate the MRR reports for April 2025 or May 2025. Nurse #3 said she was not sure how the pharmacy recommendations were addressed. Nurse #3 said she believed the Unit Managers (UM) took care of them. On 8/27/25 at 11:30 A.M., the Director of Nursing (DON) provided the surveyor with a printed copy of the April and May reports. Review of the 3/15/25 Consultant Pharmacist Recommendations to Prescriber report for Resident #16 indicated the following recommendation: -Pt is currently receiving Meclizine which is a highly anticholinergic medication. Please consider discontinuing or re-evaluating for necessity. Meclizine is also on the Beer’s list. Review of the current Physician’s Orders included the following medication: -Meclizine HCL oral tablet 12.5 milligrams (MG) give 12.5 MG by mouth every 12 hours as needed for dizziness, dated 2/26/24. Further review of the medical record failed to indicate the physician addressed the consultant pharmacist's recommendation by discontinuing or documenting the necessity for the use of Meclizine. Review of the 5/30/25 Consultant Pharmacist Recommendations to Prescriber report for Resident #16 indicated the following recommendation: -The following are labs recommended to upload for monitoring the patient’s medication treatment as well as the recommended minimum collection frequency: -Antidiabetic meds: A1C q3m -If unavailable, please consider ordering the labs. Review of current Physician's Orders included the following medications: -Insulin Glargine Subcutaneous Solution 100 Unit/milliliter (ML) (insulin Glargine) Inject 65 units subcutaneously in the morning related to type 2 diabetes mellitus with hyperglycemia, dated 5/24/2025 -Insulin Glargine Subcutaneous Solution 100 Unit/ML (insulin Glargine) Inject 10 units subcutaneously at bedtime related to type 2 diabetes mellitus with hyperglycemia, dated 5/24/2025 -Novolog Solution 100 Unit/ML (Insulin Aspart) inject as per sliding scale: -if 150-199 give 4 units subcutaneously -200-249 give 6 units subcutaneously -250-299 give 8 units subcutaneously -300-349 give 10 units subcutaneously -350-399 give 12 units subcutaneously -400-499 give 14 units subcutaneously before meals for diabetes. Notify MD if blood sugar less than 70 or greater than 450 dated 8/26/25 -Metformin Tablet 500 milligrams (mg) give one tablet orally two times a day for diabetes Review of the laboratory reports noted an A1c was last collected on 2/21/25. The A1c results flagged high at 7.9 out of a reference range of 4.1-6.0. Further review of the medical record failed to indicate the physician addressed the consultant pharmacist's recommendation by ordering an A1c every 3 months. During an interview on 8/28/25 at 9:49 A.M., UM #1 reviewed the April and May pharmacy recommendations. The UM said the reports were usually e-mailed to her and she would print out and give them to the physician to address the recommendations. The UM said she would then in return review the recommendations and make any needed changes in the resident’s medical record. The recommendations were then scanned into the resident’s medical record. The UM said the pharmacy recommendations from April and May were not addressed. The UM said that the facility had switched to a new pharmacy around May 2025. The UM said she had not received any recommendations by e-mail during the transition. The UM said she had informed the DON, and she had started to receive the pharmacy recommendations in June. During an interview on 8/28/25 at 1:00 P.M., the DON said she did not keep copies of the pharmacy recommendations. The DON said the Unit Managers were responsible for making sure pharmacy recommendations were reviewed and completed by the physicians. The DON said the recommendations should have been addressed but were missed with the changeover in pharmacies. 2. Resident #5 was admitted to the facility in February 2025 with diagnoses which included artificial knee joint, morbid obesity, anxiety, and depression. Review of the Minimum Data Set (MDS) assessment, dated 8/1/25, indicated Resident #5 was administered an antipsychotic medication. Review of the medical record indicated the consultant pharmacist made recommendations for Resident #5 in April 2025 and May 2025 and generated a report to be acted upon and reported to the physician, however, the surveyor was unable to locate either the 4/29/25 or the 5/30/25 MRR report in the Resident's medical record. On 8/28/25 at approximately 10:30 A.M., the DON provided the surveyor with a printed copy of the April and May reports. Both reports were unsigned by the provider. Review of the MRR, dated 4/29/25, indicated Resident #5 was taking multiple as needed (PRN) pain medications requiring sequencing, which is typically done by assigning intensity of pain to each agent. Please consider providing pain scales or severities within the order to provide direction for administration. Acetaminophen (APAP) and Hydrocodone-APAP. Review of the MRR, dated 5/30/25, indicated labs were recommended to upload for monitoring of the patient's medication treatment as well as the recommended minimum collection frequency. Antipsychotics: Lipids every 12 months and Allopurinol/Uloric: uric acid level annually. If unavailable, please consider ordering the labs. Review of the medical record failed to indicate the pain medications were sequenced, failed to indicate the requested labs were ordered, and failed to indicate the recommendations were reviewed and declined by the provider. During an interview on 8/28/25 at 11:35 A.M., Nurse #3 said the Unit Managers handle the pharmacy recommendations. During an interview on 8/28/25 at 1:03 P.M., UM #1 said the pharmacy recommendations go to all the UMs, and we get them to the providers. She said there was an issue in the spring and for some reason she was not getting them, so they were not done. During an interview on 8/28/25 at 2:09 P.M., the DON said all the pharmacy recommendations should be addressed within the month. She said they did not keep the forms once the orders were written all the time, but she should. She said she was unaware the recommendations from April and May were never addressed.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure the main kitchen walk-in refrigerator was maintained in a sanitary and safe condition. Findings include:1. Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: 3-305.11 (A) Except as specified in paragraphs (B) and (C) of this section, food shall be protected from contamination by storing the food (1) in a clean, dry location. 4-602.11 (D) Equipment is used for storage of packaged or unpackaged food such as a reach-in refrigerator and the equipment is cleaned at a frequency necessary to preclude accumulation of soil residues. 4-602.13 Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Review of the facility's policy titled Sanitization, revised November 2022, indicated but was not limited to the following:-The food service area is maintained in a clean and sanitary manner.Policy Interpretation and Implementation:-All kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. -All utensils, counters, shelves, and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning. On 8/25/25 at 8:00 A.M. and on 8/28/25 at 11:14 A.M., the surveyor observed in the walk-in refrigerator:-shelving with several areas of rust;-shelving with extensive patchy areas of raised yellow, powdery substance;-black powdery buildup on the walk-in refrigerator wall inches away from raw onions stored in a mesh bag;-debris and spillage underneath shelving including brown and black colored spillage underneath an area of shelving that contained raw meat and/or poultry;-debris and black buildup along the perimeter and in the corners of the floor. During an interview on 8/28/25 at 2:27 P.M., the Food Service Director (FSD) and surveyor observed the shelving and floor in the walk-in refrigerator. The FSD said the walk-in refrigerator should be kept in a clean and sanitary condition.

Based on observation, record review, and interview, the facility failed to ensure that for one Resident (#43), out of a total sample of 26 residents, the nurse provided the Resident privacy while administering medication, specifically an insulin injection. Findings include: Review of the facility's policy titled Specific Medication Administration Procedures, undated, included but was not limited to the following: Policy To administer medications in a safe and effective manner. B. Privacy: 1) Provide privacy for resident during administration of medications. Review of Resident #43's current Physician's Orders indicated: -Tresiba (antihypoglycemic medication; insulin), 100 units/milliliter, inject 15 units subcutaneously once daily. On 7/16/24 at 4:10 P.M., the surveyor observed Nurse #8 at the medication cart in the hallway drawing up the ordered dose of Tresiba in an insulin syringe. The surveyor heard Nurse #8 call Resident #43, who was standing in the hallway waiting for the medication to be administered, and then ask the Resident where he/she wanted the medication injected. With multiple residents and staff in the area, the surveyor observed Resident #43 lift his/her shirt, exposing his/her abdomen, and Nurse #8 administered the medication in the Resident's left lower abdomen. During an interview on 7/16/24 at 4:15 P.M., Nurse #8 said she didn't understand that she had not respected the Resident's privacy by administering the Resident's insulin in the middle of the corridor where other residents and staff were present. During an interview on 7/17/24 at 1:04 P.M., Unit Manager (UM) #1 said that Nurse #8 had discussed the situation with her and said that she made a mistake by administering the insulin in the hallway. UM #1 also said that insulin should always be administered to a resident in the resident's room to afford them privacy and that the nurse should have known that.

Based on observations, interviews, and record review, the facility failed to ensure activity of daily living (ADL) care was provided to maintain good personal grooming for one Resident (#115), in a total sample of 26 residents. Specifically, the facility failed to ensure nail care was performed for Resident #115. Findings include: Review of the facility's policy titled ADL - Nail Care, undated, indicated the following: -the purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections -nail care includes daily cleaning and regular trimming -trimmed and smooth nails prevent the resident from accidentally scratching and injuring his/her skin Resident #115 was admitted to the facility in August 2023. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/23/24, indicated the Resident was dependent on one staff person for personal hygiene and that Resident #115 scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident was cognitively intact. Review of the Care Plans indicated Resident #115 was at risk for skin impairments related to frail skin with an intervention to avoid scratching. On 7/11/24 at 8:20 A.M., the surveyor observed Resident #115 to have long fingernails varying in length which had a brown tint. During an interview on 7/12/24 at 12:40 P.M., the surveyor observed Resident #115 using a small wooden tool to pick underneath his/her nails and the Resident said he/she did not like their nails this long. Resident #115 said he/she had asked for a manicure but no one would do it. The Resident said he/she had been trying to fix their own nails by breaking them. The Resident pointed to their middle finger and said he/she did not know what happened to that one, the middle fingernail was observed jagged with broken parts over the nail bed. The Resident said the longer nails were hard. During an interview on 7/12/24 at 12:50 P.M., Certified Nursing Assistant #1 said she was caring for Resident #115 on this day, was working until 7:00 P.M. and would cut the Resident's nails. She said the CNAs can cut resident's nails and they were usually done during shower days. During an interview on 7/16/24 at 8:15 A.M., Resident #115 said no one had cut their nails this weekend and he/she had broken another one. The surveyor observed the Resident to have a long thumb nail on the left hand and long thumb, middle and pinky nail on the right hand. The Resident said he/she just wants someone to cut them, nothing fancy. During an interview on 7/16/24 at 8:20 A.M., Unit Manager #1 said the Resident's nails should have been cut during shower day, even if the Resident does not get out of bed to get showered, the nails should still be cut on that day. She said the Resident's nails should have been trimmed.

Based on observation, interview and record review, the facility failed to arrange for an audiology appointment for one Resident (#115), out of 26 sampled residents, to address the Resident's hearing loss. Findings include: Resident #115 was admitted to the facility in August 2023. Review of the Minimum Data Set (MDS) assessment, dated 5/23/24, indicated Resident #115 scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident was cognitively intact. During an interview on 7/11/24 at 8:20 A.M., Resident #115 said he/she was unable to hear the surveyor and asked the surveyor to speak louder. The Resident said he/she did not have hearing aids but hoped to be getting them soon. On 7/17/24 at 7:47 A.M., the surveyor observed Certified Nursing Assistant (CNA) #2 assisting Resident #115 to get set up for breakfast. The surveyor observed Resident #115 tell CNA #2 that he/she could not hear the CNA. Review of the Social Work progress notes, dated 3/13/24, indicated Resident #115 requested an appointment for a hearing evaluation and reported more difficulty hearing. The progress note indicated the unit secretary was made aware. Review of the medical record failed to indicate Resident #115 had been seen by an audiologist for difficulty with hearing in the four months since the request was made. During an interview on 7/17/24 at 7:53 A.M., Unit Manager #1 said Resident #115 had some difficulty hearing and could hear when spoken to with a raised voice. She said the Resident had been seen by the primary care physician and was treated for wax removal from the ears in January 2024. She said she was not sure if the Resident had been referred to an audiologist and would follow up. During an interview on 7/17/24 at 8:50 A.M., Unit Manager #1 said the Resident had not seen an audiologist and no follow up had been made to the Resident's request for a hearing evaluation four months prior.

Based on record review and interviews, the facility failed to ensure the Physician documented a clinical rationale for disagreeing with the consultant pharmacist's identified and reported irregularity (order for an antipsychotic medication without supporting diagnosis for usage) for one Resident (#40), out of a total sample of 26 residents. Findings include: Review of the facility's policy titled Pharmacy Consultant Med Review, last reviewed January 2023, included but was not limited to: The Pharmacy Consultant provides: -Consultation of all aspects of the provisions of pharmacy services in the facility -Reviews each medication regime of all residents in the facility once per month to examine: -Supporting Diagnosis -Gradual dose reductions attempted Resident #40 was admitted to the facility in June 2024 with diagnoses including adult failure to thrive and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Minimum Data Set (MDS) assessment, dated 7/2/24, indicated Resident #40 had moderate cognitive impairment as evidenced by a score of 10 out of 15 on the Brief Interview for Mental Status (BIMS). Resident #40 had received an antipsychotic medication. Review of the medical record indicated a Physician's Order for Quetiapine Fumarate (antipsychotic) oral tablet 25 milligrams (mg) one tablet at bedtime for behaviors (6/25/24). Further review of the medical record indicated a pharmacy consultant recommendation, dated 6/26/24, indicated: -This patient is currently receiving an antipsychotic medication and documentation of a diagnosed specific condition is unclear. Please provide an appropriate specific indication for use. Diagnosis of dementia without behaviors is listed. -If the medication is no longer indicated, please consider a dose reduction of 25-50% with the goal of discontinuation. The Physician placed a checkmark next to disagree and signed on the signature line. There was no rationale for disagreeing with the consultant pharmacist's recommendation documented on the form or in the medical record. During an interview on 7/17/24 at 11:02 A.M., Nurse #6 said the Physician should have documented a rationale for disagreeing with the consultant pharmacist's recommendation to provide an appropriate diagnosis for the usage of the antipsychotic medication. During an interview on 7/17/24 at 1:20 P.M., the Assistant Director of Nursing (ADON) said Resident #40 currently had no behaviors and was receiving the antipsychotic medication prior to admission to the facility. The ADON said Resident #40's diagnoses did not support the use of Quetiapine Fumarate. The ADON said the Physician should have written a rationale for disagreeing with the pharmacist's recommendation and provided an appropriate diagnosis for the usage of the antipsychotic medication.

Based on record review and interview, the facility failed to ensure one Resident (#40), out of a total sample of 26 residents, was free from unnecessary psychotropic medication. Specifically, for Resident #40, the facility failed to ensure an antipsychotic was given to treat a specific condition. Findings include: Review of the facility's policy titled Antipsychotic Medication Use, last revised October 2022, included but was not limited to: -Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. -Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident. Review of the facility's policy titled Pharmacy Consultant Med Review, last reviewed January 2023, included but was not limited to: The Pharmacy Consultant provides: -Consultation of all aspects of the provisions of pharmacy services in the facility -Reviews each medication regime of all residents in the facility once per month to examine: -Supporting Diagnosis -Gradual dose reductions attempted Resident #40 was admitted to the facility in June 2024 with diagnoses including adult failure to thrive and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Minimum Data Set (MDS) assessment, dated 7/2/24, indicated Resident #40 had moderate cognitive impairment as evidenced by a score of 10 out of 15 on the Brief Interview for Mental Status (BIMS). Resident #40 had received an antipsychotic medication. Review of the medical record indicated a Physician's Order for Quetiapine Fumarate (an antipsychotic, used to treat symptoms of psychosis such as delusions, hallucinations, paranoia, or confused thoughts) oral tablet 25 milligrams (mg) one tablet at bedtime for behaviors (6/25/24). Further review of the medical record indicated a pharmacy consultant recommendation, dated 6/26/24, indicated: -This patient is currently receiving an antipsychotic medication and documentation of a diagnosed specific condition is unclear. Please provide an appropriate specific indication for use. Diagnosis of dementia without behaviors is listed. -If the medication is no longer indicated, please consider a dose reduction of 25-50% with the goal of discontinuation. The Physician placed a checkmark next to disagree and signed on the signature line. There was no rationale for disagreeing with the consultant pharmacist's recommendation documented on the form or in the medical record. Review of the Nurse Practitioner's (NP) progress notes indicated the following: -6/26/24: advancing dementia, stable mood, otherwise no behavior problem continue to monitor -7/1/24: psych: stable, alert, oriented, cooperative, Alzheimer's disease with late onset, continue with supportive measures, monitor mood and behavior, follow up in house psych as needed, continue with Seroquel -7/15/24: psych: stable, alert, oriented, cooperative, Alzheimer's disease with late onset, continue with supportive measures, monitor mood and behavior, follow up in house psych as needed, continue with Seroquel Review of the medical record failed to indicate the medical rational for the use of an antipsychotic medication. During an interview on 7/17/24 at 11:02 A.M., Nurse #6 reviewed the medical record and said Resident #40 was not being seen by psychiatric services as he/she had no behaviors. Nurse #6 said the Physician did not provide an appropriate diagnosis for the usage of the antipsychotic medication. During an interview on 7/17/24 at 1:20 P.M., the Assistant Director of Nursing (ADON) said Resident #40 currently had no behaviors and was receiving an antipsychotic medication prior to admission to the facility. The ADON said the physician would not have a Resident seen by psychiatric services when they are not displaying signs of behaviors. The ADON said the physician would not adjust or discontinue any antipsychotic medications if a Resident was admitted to Short Term Rehab (STR). The ADON said Resident #40 had been admitted to STR and would be going back to his/her prior living situation. The ADON said Resident #40's diagnoses did not support the use of Quetiapine Fumarate. The ADON said the Physician should have provided an appropriate diagnosis for the usage of the antipsychotic medication.

Based on record review and interviews, the facility failed to maintain accurate medical records in accordance with accepted professional standards for two Residents (#99 and #115), in a sample of 26 residents. Specifically, the facility failed to ensure the electronic medical record orders accurately reflected the advanced directives indicated on the Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) for Resident #99 and Resident #115. Findings include: 1. Resident #99 was admitted to the facility in September 2022. Review of the medical record indicated the designated Health Care Proxy for Resident #99 signed a new MOLST changing the code status from a Full Code (attempt resuscitation) to a Do Not Resuscitate, Do Not Intubate on 10/29/23. Review of the electronic medical record on 7/12/24, including physician orders and a section designated Code Status indicated Resident #99 was a full code (resuscitation would be attempted). The electronic medical record did not reflect the accurate code status of Do Not Resuscitate from the MOLST signed on 10/29/23. During an interview on 7/16/24 at 11:02 A.M., Unit Manager #1 said the electronic medical record code status section and orders should reflect the changes made to the MOLST in October 2023 and the medical record was not accurate. 2. Resident #115 was admitted to the facility in August 2023. Review of the medical record indicated on 3/13/24 Resident #115 signed a new MOLST indicating the Resident would continue with a code status of Do Not Resuscitate and added the directive of no longer wanting to be sent to the hospital, did not want to have artificial nutrition, and did not want to have artificial hydration. Review of the electronic medical record on 7/12/24, including physician orders and a section designated Code Status indicated Resident #115 had orders to be transferred to the hospital, was undecided on artificial nutrition and was undecided on artificial hydration. The electronic medical record did not reflect the accurate directives of do not hospitalize, no artificial nutrition and no artificial hydration from the MOLST signed on 3/13/24. During an interview on 7/16/24 at 11:02 A.M., Unit Manager #1 said the electronic medical record code status section and orders should reflect the changes made to the MOLST in March 2024 and the medical record was not accurate.

Based on a resident group meeting, staff interviews, and document review, the facility failed to ensure grievances and concerns from Resident Council were acted upon and promptly resolved from 12/6/23 through 7/8/24 as required. Findings include: Review of the facility's policy titled Resident Council, dated as last revised 1/2023, indicated but was not limited to the following: -Concerns that are raised at the meeting must be recorded in minutes and followed with a concern/response form filled out by the designated staff representative and addressed to the corresponding Department Head to provide a resolution. All supporting documentation (i.e., in-services, staff education, clinical notes) must be attached. Concern/response forms must be completed within 7 days of being issued. Review of the facility's policy titled Grievances, dated as last revised 10/2023, indicated but was not limited to the following: -The Grievance Officer coordinates adequate and timely handling of grievances/complaints and ensures the grievances/complaints and resolutions are maintained and reviewed with administration routinely. Review of the Grievance/Concern & Comment Form, dated 1/9/24, indicated Resident Council had voiced concerns which included requesting more soups to be offered, late dinner trucks, missing items on trays, and the menu not being followed. -The facility indicated tray time audits would be done and food concerns were being addressed during the newly established Food Committee (Established in December 2023 due to repeated food concerns in the fall). Review of the Food Committee Meeting Minutes, dated 12/6/23, indicated the resident's voiced concerns regarding daily soup no longer being offered, missing items on trays, individual likes/dislikes were not correct, too much pork especially at breakfast, and not getting snacks offered twice daily. Review of the Food Committee Meeting minutes, dated 1/16/24, indicated the same food concerns voiced from the 12/6/23 Food Committee Meeting and the 1/9/24 Resident Council Meeting. The facility failed to indicate a plan and/or resolution had been developed and implemented for these concerns. Review of the Food Committee Meeting minutes, dated 2/22/24, indicated the same food concerns voiced from the 12/6/23 Food Committee Meeting, the 1/9/24 Resident Council Meeting, and the 1/16/24 Food Committee Meeting. -The facility indicated the Food Service Director and Dietitian were reviewing the menu and would address the pork and starch concerns with dietitian approved changes. Additionally, they were working on starting soup of the day in the main dining room (MDR) and the frequency was to be determined. The facility indicated a plan had been developed to address resident concerns regarding the pork, starches, and soups (three months after the Food Committee was developed due to ongoing food complaints), however, as of July 2024, failed to implement such plan. Review of the Grievance/Concern & Comment Form, dated 2/29/24, indicated repeated food concerns without resolution and additional concerns with call light wait times. Review of the Grievance/Concern & Comment Form, dated 5/7/24, indicated Resident Council had continued concerns regarding evening snacks not always being passed, trays being delivered late, the menu was not always followed, and long call light wait times. The facility failed to indicate a plan and/or resolution had been developed and implemented for these concerns. Review of the Resident Council Meeting minutes, dated June 2024, indicated the facility was working on the menu to incorporate local food preferences such as soup. Additionally, the Council indicated they were not in agreement with the Dietary Department that food trucks were no longer late as meals were consistently late, and call light wait times were an ongoing issue. The facility failed to indicate a plan and/or resolution had been developed and implemented for these concerns. Review of the Grievance/Concern & Comment Form, dated 6/11/24, indicated Resident Council concerns included call lights continue to be extremely long, over an hour some days, and the evening snack pass was not being done. The facility failed to indicate a plan and/or resolution had been developed and implemented for these concerns. Review of the Resident Council Meeting minutes, dated 7/9/24, indicated the facility was working on the menu to incorporate local food preferences such as soup. (Repeated from last month.) Additionally, the Resident Council continued to express concerns regarding long call light wait times and late meal delivery, food preferences not being followed, and snacks not being passed. The facility failed to indicate a plan and/or resolution had been developed and implemented for these concerns. On 7/12/24 at 10:30 A.M., the surveyor held a Resident Council Meeting with 18 residents that regularly attend meetings. The following concerns were voiced by the Council as repeated concerns that they felt had not resolved: daily soup not being offered, not getting the correct items on trays, evening snack not being passed out, meal delivery very late, and call light wait times were excessively long. Additionally, they said they requested to be part of the call light audits that are supposedly being done and have never seen them or been part of them. Several residents said call lights wait times are 30-45 minutes regularly, sometimes over an hour. Four residents said when no one answers the call light they have called the facility from their personal cell phone to get assistance. The Council said the results of the grievances are so-so, and minor individual things get resolved, but overall, they do not feel the issues/concerns they have repeatedly brought up have been addressed and a resolution has not been brought back to the council. The facility developed a Food Committee to address ongoing resident complaints. The Food Committee failed to address repeated resident concerns. After three months (late February 2024), the facility developed a plan to incorporate more soup on the menu, specifically in the MDR. In July 2024, this plan had yet to be implemented and the residents continued to voice the same repeated concerns. The facility failed to provide documentation related to the resolution of the grievances Resident Council had repeatedly brought forward. During an interview on 7/12/24 at 2:00 P.M., the Administrator said the Food Committee was developed in December 2023 because of repeated food complaints. She said the Committee was to meet monthly to discuss food complaints in addition to the monthly Resident Council Meetings. She said the complaints were the same as what was being brought forth in Resident Council. The Administrator said they did not meet monthly as planned and did not think the meetings had been very effective to address the Residents' food concerns. During an interview on 7/17/24 at 1:40 P.M., the Administrator said the Food Committee consists of herself and the Food Service Manager (FSM). She said some of the smaller concerns have been resolved but the larger issues have not. She said regarding the late meal trucks, they did audits and concluded it was the passing out of the trays that was the issue, but it still has not been resolved. Additionally, she said the facility used to have a daily soup and when they switched providers in October 2023 that went away. She said the residents have been asking for more soup since at least December (7-8 months). The addition of soup was supposed to start in the MDR, but it has not, as the dietitian has not reviewed the menu and approved the changes, and the grievance remains unresolved. Despite tray accuracy audits by the dietitian, the residents continue to complain that they are getting the wrong items on their trays. Despite using a cart with a bell to alert the residents of evening snack time, the residents are still complaining that an evening snack is not being offered, and the concern has not been resolved. Regarding the call lights, the Administrator said the Director of Nurses was doing the call light audits, but she was not available to speak with at the time of the survey and the audits were not provided. The Administrator said the residents continue to request to be part of the audit process as they continue to have concerns with call light wait times. The Administrator said the system needs improvement as these grievances are being repeated monthly and change has not been implemented or is ineffective therefore, they are not being resolved as they should be. During an interview on 7/17/24 at 2:28 P.M., the FSM said they started the Food Committee in December 2023, but it is not effective. She said regarding the daily soups, she said she had to meet with the Dietitian to make changes to the menu and add soup, but she had not done that yet. Regarding the tray accuracy audits, she said the issues continue because the meal tickets no longer print what should be put on the tray; the ticket only lists the residents' dislikes, and the staff (the cook and two dietary aides) must make substitutions while preparing the trays, leaving room for error. The FSM said they were working on the areas of concern: not having soup available, late meals, and getting items they do not like, but there has not really been a resolution to their complaints.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to follow professional standards of practice for two Residents (#343 and #104), out of a total sample of 26 residents. Specifically, the facility failed: 1. For Resident #343, to monitor the Resident's left upper extremity midline catheter insertion site for signs/symptoms of infection and/or infiltration every shift in accordance with the physician's order; and 2. For Resident #104, to ensure the physician conducted an accurate assessment of the Resident upon admission, per accepted standards of clinical practice, resulting in an inaccurate diagnosis of schizophrenia to be added to the Resident's list of active diagnoses. Findings include: 1. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, Advisory Ruling Number 9324, dated as revised July 10, 2002, indicated: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. -Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Review of the facility's policy titled Midline Dressing Change, date revised January 2023, indicated but was not limited to the following: -Assessment of peripheral catheter sites are performed at the following times: -A. During dressing changes -B. Every 2 hours during continuous therapy -C. Before and after administration of intermittent intravenous medications (or at least once every 8 hours between intermittent doses) -D. At least every 24 hours when maintained for access only -Assessment is to include the absence or presence of erythema (redness of the skin), drainage, swelling, induration (hardening or firmness); skin temperature at site, or complaint of tenderness at the site or along the vein tract Resident #343 was admitted to the facility in June 2024 with diagnoses including acute cholecystitis (gallbladder inflammation), liver disease, and abscess of the liver. Review of the Minimum Data Set (MDS) assessment, dated 7/3/24, indicated Resident #343 had moderate cognitive impairment as evidenced by a score of 11 out of 15 on the Brief Interview for Mental Status (BIMS). Review of the Physician's Orders indicated but were not limited to the following: -IV-Midline (valved) monitor site every shift for signs/symptoms of infection and/or infiltration, dated 6/30/24, order type: monitoring order-MAR (Medication Administration Record), no routine schedule -IV-Midline (non-valved) monitor site every shift for signs/symptoms of infection and/or infiltration, dated 7/10/24, order type: NSG Order-MAR, schedule routine every shift, everyday Review of the MAR for July 2024 indicated there was no documentation from 7/1/24 through 7/9/24 that the IV-Midline (valved) site was being monitored every shift for sign/symptoms of infection and/or infiltration. Further review of the nursing progress notes indicated the following: -7/1/24 at 8:18 P.M., Continues IV antibiotics as ordered for cholecystitis via left arm midline without adverse effect. No complaints voiced. -7/6/24 at 11:19 P.M., Left arm midline clean, dry, flush with normal saline without resistance. No signs of infection noted. Review of the nursing progress notes, 7/1/24 through 7/9/24, failed to indicate Resident #343's midline had been monitored every shift. During an interview on 7/17/24 at 11:00 A.M., Nurse #5 reviewed the July 2024 MAR for the physician's order to monitor the midline insertion site for signs/symptoms of infection and/or infiltration every shift and said there was no documentation from 7/1/24 through 7/9/24. Nurse #5 said the order was not entered until 7/10/24. Nurse #5 said she did not know why there was no order for monitoring the insertion site until 7/10/24. During an interview on 7/17/24 at 11:24 A.M., Nurse #6 reviewed the July 2024 MAR for the physician's order to monitor the midline insertion site for signs/symptoms of infection and/or infiltration every shift and said there was no documentation from 7/1/24 through 7/9/24. Nurse #6 said she noticed there was no order attached to the MAR for the nurses to document. Nurse #6 said the original order was transposed as a standard order and did not populate to the MAR. Nurse #6 said she had correctly re-entered the order on 7/10/24. During an interview on 7/17/24 at 1:45 P.M., the Assistant Director of Nursing (ADON) reviewed the July 2024 MAR for the physician's order to monitor the midline insertion site for signs/symptoms of infection and/or infiltration every shift and said there was no documentation from 7/1/24 through 7/9/24. The ADON said the order had been entered incorrectly. The ADON said her expectation would be that nursing would have entered the order correctly and document on the MAR they were monitoring the midline insertion site for signs/symptoms of infection and/or infiltration every shift. 2. Review of the facility's policy titled Antipsychotic Medication Use, dated last revised October 2022, indicated a diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident. According to the American Psychiatric Association (APA) symptoms of schizophrenia usually first appear in early adulthood and must persist for at least six months for a diagnosis to be made. Before a diagnosis can be made, however, a psychiatrist should conduct a thorough medical examination to rule out substance misuse or other neurological or medical illnesses whose symptoms may mimic schizophrenia. A diagnosis has clinical, personal and social significance. In the clinical context, a diagnosis reveals the nature of an illness. A correct diagnosis provides a basis for effective treatment. An incorrect diagnosis may delay or impede effective treatment or even exacerbate a situation by inviting inappropriate treatment. A diagnosis has personal significance insofar as it can become central to how a person experiences him- or herself. While a correct diagnosis of a severe disorder can be enormously difficult to integrate into one's sense of self, an incorrect diagnosis can be crippling. A diagnosis is also a label to which others respond and thus has profound social implications. Social judgments are made in response to a diagnosis of mental illness, and diagnoses can play an important role in awarding entitlements and determining placements. A diagnosis asserts itself on multiple levels of experience. Rendering a diagnosis can be a complex process. Consider, for example, that psychotic experiences are part of multiple diagnoses. The treatment for an affective disorder with psychotic features, a schizophrenic disorder, a post-traumatic stress reaction, a severe personality disorder and a substance abuse disorder can vary dramatically; yet, psychotic processes may be present in each. Making the correct diagnosis will depend on the psychologist engaging in a thoughtful and competent process and often requires having sufficient time and opportunity to interact with an individual in order to differentiate among various possibilities. ([NAME], S. APA Ethics Director (2005). Diagnosis, record reviews and the new Ethics Code. Monitor of Psychology, Volume 36 (No. 1), page 80. https://www.apa.org/monitor/jan05/ethics Resident #104 was admitted to the facility in March 2023 with a diagnosis of dementia with behavioral disturbance. Review of the psychiatric hospital discharge summary from March 2023 indicated Resident #104 had a diagnosis of dementia with behavioral disturbance. The discharge summary indicated this was the first inpatient psychiatric admission for Resident #104; the Resident had not had any symptoms of paranoia or hallucinations prior to January 2022 and there had been no history of mental health concerns. Review of the physician admission Progress Note, from the Nurse Practitioner, dated 3/27/23, indicated Resident #104 had a diagnosis of dementia with other behavioral disturbance, unspecified dementia severity, unspecified dementia type. The progress note listed six active diagnoses: dementia, hypertension, diabetes, seizure disorder, gastroesophageal reflux disorder, and low back pain. Review of the physician History and Physical Progress Note from the primary physician, dated 3/28/23, indicated Resident #104 had completed a psychiatric stay related to paranoid schizophrenia. The progress note listed seven active diagnoses including the six active diagnoses from the Nurse Practitioner and a new diagnosis of paranoid schizophrenia with a plan to continue the use of antipsychotic medication. Review of the medical record failed to indicate Resident #104 had a diagnosis of schizophrenia prior to the admission to the facility. Review of the Pre-admission Resident Review Abbreviated Level II Evaluation, dated 3/8/23, indicated Resident #104 had a diagnosis of dementia and had presented with delusions and hallucinations. The evaluation did not indicate any history of schizophrenia. During an interview on 7/16/24 at 8:40 A.M., Physician #1 said he had completed the History and Physical for Resident #104. He said he would not have diagnosed the Resident with schizophrenia on his own and that he must have obtained the information from a record review of hospital discharge paperwork. He said he would review the information and follow up with the surveyor. During an interview on 7/16/24 at 10:00 A.M., the family member and guardian of Resident #104 said the Resident had no history of mental illness (including delusions or hallucinations) prior to 2022 and the Resident had a diagnosis of dementia. During an interview on 7/16/24 at 12:35 P.M., Physician #1 said he had only been able to locate information regarding a diagnosis of schizophrenia from after the March 2023 admission to the facility. He said he does not diagnose residents with schizophrenia and would only indicate the diagnosis if it had been given by a psychiatrist. The Physician requested to review the Resident history with the community providers. Review of the medical record included a hospital discharge summary from November 2023, following the diagnosis of schizophrenia from Physician #1 which indicated Resident #104 was admitted for a diagnosis of dementia with behavioral disturbance. The discharge summary indicated the history of present illness included a diagnosis of schizophrenia. Review of the electronic medical record indicated a diagnosis of schizophrenia was added to the active diagnoses as of 12/1/23. Review of the behavioral health group Progress Notes from August 2023 through December 2023 indicated Resident #104 had a chief complaint of dementia with behavioral disturbance with a primary diagnosis of psychotic disorder with delusions and a secondary diagnosis of unspecified dementia. Review of the behavioral health group Progress Notes from 4/10/24 and 5/29/24 indicated a chief complaint of paranoid schizophrenia with a primary diagnosis of paranoid schizophrenia. During an interview on 7/17/24 at 10:01 A.M., the Minimum Data Set (MDS) nurse said the diagnosis of schizophrenia was referenced in the medical record from Physician #1, the diagnosis was then sent with the Resident's medical information to the hospital in November 2023 and was added to the list of active diagnoses in the electronic medical record when the Resident returned from the hospital admission on [DATE]. During an interview on 7/17/24 at 10:11 A.M., Physician #1 said he had reviewed the medical history of Resident #104 and the Resident did not have a diagnosis of schizophrenia. He said the diagnosis of schizophrenia should not have been included on the list of diagnosis on his Progress Notes. He said the correct diagnosis for the Resident was dementia with paranoia.

Based on observation, interview, and record review, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed to: 1. Ensure the treatment cart on Cookside Unit was locked when not in direct supervision of the licensed nurse; and 2. Ensure safe storage of medications and biologicals according to current standards of practice in 2 of 3 observed medication carts. Findings include: Review of the facility's policy titled Specific Medication Administration Procedures, dated as last revised December 2019, indicated but was not limited to the following: -Security: All medication storage areas (carts, medication rooms, central supply) are locked at all times unless in use and under the direct supervision of the medication nurse/aide. -Check expiration date on package/container before administering any medication. When opening a multi-dose container, place the date on the container. Review of the facility's policy titled Medication Storage, dated as last revised October 2022, indicated but was not limited to the following: -The center will have medications stored in a manner that maintains the integrity of the product, ensures the safety of the residents, and is in accordance with the Department of health guidelines. -All medications will be stored in a locked cabinet, cart, or medication room that is accessible only to authorized personnel, as defined by facility policy. -Medication will be stored in an orderly, organized manner in a clean area. -Medication will be stored in the original, labeled containers received from the pharmacy. -Medication will be stored at the appropriate temperature in accordance with the pharmacy and/or manufacturer labeling. -Medications requiring refrigeration will be stored in a refrigerator that is maintained between 2 to 8 degrees Celsius (36-46 degrees Fahrenheit). 1. On 7/17/24 the surveyor made the following observations: -8:10 A.M., Treatment cart in the hallway across from small day room near entry to Cookside Unit. The cart was unlocked and not in view of staff. -8:59 A.M., Treatment cart in the hallway across from small day room near entry to Cookside Unit. The cart was unlocked and not in view of staff. A cell phone and binder were on top of it. -9:02 A.M., Staff member retrieved cell phone and binder from the top of the cart and left the unit. The cart remained unlocked in the hallway, not in view of staff. -9:22 A.M., Treatment cart in the hallway across from small day room near entry to Cookside Unit. The cart was unlocked and not in view of staff. -9:52 A.M., Surveyor brought Unit Manager (UM) #3 to the hallway where the treatment cart remained unlocked and not in view of staff. During an interview on 7/17/24 at 9:52 A.M., UM #3 said the treatment cart should be locked when not in use, and it should not be in the hallway unlocked. She said the cart should be stored in the clean utility room. During an interview on 7/17/24 at 11:28 A.M., the Assistant Director of Nurses (ADON) said the treatment cart should be kept in the clean utility room, unless in use, and it should be locked when not in use. She said the cart should not be in the hallway unlocked. 2. On 7/17/24 at 9:30 A.M., the surveyor inspected the Birchside Medication Cart with Nurse #9, and observed the following: -One of two insulin pens in the cart had no pharmacy (patient demographics) label attached, the pen had the number 218M written in black marker, and the words 0700 open. No other patient identifier was on the insulin pen. During an interview on 7/17/24 at 9:30 A.M., Nurse #9 said she knows that insulin pen belongs to the Resident in 218M, because they get it every day, but it should have the pharmacy label on it and the date opened/date expires label with dates written on it and the pen does not have either. She said the pen would need to be disposed of and re-ordered from the pharmacy. During an interview on 7/17/24 at 9:45 A.M., UM #2 said all insulins should have the pharmacy label and the opened/expires label on them and they should be dated when opened with the opened/expires date. She said that insulin pen needs to be thrown out and re-ordered. During an interview on 7/17/24 at 9:52 A.M., UM #3 said all insulin pens need to be labeled with the resident's name and the date opened/date expires written on the label. She said that pen needs to be replaced. On 7/17/24 at 11:18 A.M., the surveyor inspected the Arborside Medication Cart with Nurse #4, and observed the following: -Five insulin pens were stored in one Styrofoam cup together, not in individual plastic bags. One of the four pens had no cap on the pen leaving the rubber seal exposed. -Five boxes with insulin vials inside; 2 of the 5 vials were not labeled with date opened or date expires. -Two unopened insulins in their boxes and plastic bag from the pharmacy were in the med cart. Further review of the five insulin pens in the cup indicated the pens belonged to three different residents. -One had no pharmacy label, a resident's name was written in black marker, the open/expires dates were on the label. -Two had pharmacy labels with resident's names, but the open/expiries label had no dates written on it. -One had a pharmacy label with resident's name on it, however it was so faded, the name was almost completely removed from the white label, the open/expires dates were not written on it. Further review of the two opened insulin vials indicated they both had the pharmacy label on them, however neither had the opened/expires dates written on them. Further review of the two unopened insulin vials indicated they were both labeled from the pharmacy and inside the plastic bag from the pharmacy. One had a bright green label on the bag that said, Keep Refrigerated Until Opened and the other had a bright yellow label on the bag that said, Keep Refrigerated. Both insulin packages indicated the prescription was filled/dispensed from the pharmacy on 7/16/24. During an interview on 7/17/24 at 11:18 A.M., Nurse #4 said he does not know why the insulins were not labeled, stored in the cup, or not in the fridge. During an interview on 7/17/24 at 11:20 A.M., UM #1 said all insulins should be labeled with the pharmacy printed Resident label and the date opened/expires should be filled in when it is opened. During an interview on 7/17/24 at 11:28 A.M., the ADON said all insulins should be labeled with the printed pharmacy label and when the pen or vial is opened the date opened and date of expiration should be written on the label. She said the vials should be stored in their box and the pens should be in the individual plastic bags from the pharmacy. She said they should not be stored in a cup together.

Based on observations, interviews, and menu review, the facility failed to ensure that menus posted were followed. Findings include: Review of the breakfast menu for 7/11/24 indicated that residents should have received French toast casserole, sausage, choice of hot or cold cereal. On 7/11/24 at 7:30 A.M., the surveyor observed Dietary Staff #2 preparing breakfast trays with French toast instead of a French toast casserole. During an interview on 7/11/24 at 7 A.M., Dietary Staff #2 said this is what is for breakfast and was unaware of a French toast casserole being on the menu. During an interview on 7/11/24 at 11:13 A.M., Resident #94 said they are unaware if the food served differs from the menu until a meal is served. He/She said the kitchen beats to its own drum, and he/she can't depend on the menu for accuracy. He/She said they had cookies for dinner last night because he/she didn't like the meal and a request for a tuna sandwich took over an hour. Review of the lunch menu for 7/15/24 indicated that residents should have received beef and broccoli stir fry, steamed rice, vegetable blend, blushing pears, and an egg roll. On 7/15/24 at 12:20 P.M., the surveyor observed lunch trays being passed on the Birchside Unit with no egg rolls present. Review of the breakfast menu for 7/17/24 indicated that residents should have received sausage, egg of choice, and cinnamon toast. On 7/17/24 at 8:04 A.M., the surveyor observed the cook preparing breakfast trays with plain toast and scrambled eggs. The breakfast sausage was not available. During an interview on 7/17/24 at 08:34 A.M., Dietary staff # 3 said that the breakfast was scrambled eggs and toast, she said they did not have cinnamon and they had sausage yesterday. She said she was unsure why it was on the menu today but it was not available. During an interview on 7/17/24 at 12:14 P.M., the Food Service Director (FSD) said that sometimes items are not available to order from the vendor. She said she was unable to order eggrolls, cinnamon toast, and the sausage for today. She said that she does not communicate with the residents if an item is not available. She said she lets the activities staff know if there are omissions or substitutions. During an interview on 7/17/24 at 12:35 P.M., Activities Assistant #1 said the kitchen does not inform activities if they do not have an item to serve. She said there is no communication regarding menu changes. During an interview on 7/17/24 at 12:23 P.M., the Registered Dietitian said she was unaware of any menu changes and the FSD should inform her if there are any changes in the menu. She said the kitchen also needs to communicate with the residents if something is served other than what is on the menu. During an interview on 7/17/24 at 12:40 P.M., the Administrator said the kitchen should communicate any menu changes with the residents and the dietitian to ensure the meal still meets the nutritional needs of the residents. During an interview on 7/17/24 at 12:46 P.M., the Activity Director said the kitchen doesn't tell us if a menu item is unavailable or if there are changes to the menu we post. She said that she knows this frustrates the residents and it is often brought up at the monthly Resident Council Meeting.

Based on observation, test tray results, and interview, the facility failed to ensure staff served food that is palatable and at an appetizing temperature for 2 out of 2 test trays conducted. Findings include: During initial resident screening on 7/11/24, the residents expressed the following concerns about the food served at the facility: -Food temperatures are cold for foods that are supposed to be hot. -The milk is warm. -The food served lacks palatability. -The bread is soggy. -There are missing items from tray and the meal tray is not reflective of meal ticket. On 7/15/24 at 10:30 A.M., the residents at the Resident Group Meeting expressed concern regarding the palatability of the food served at the facility. During an interview on 7/11/24 at 11:13 A.M., Resident #94 said the food is either tasteless or too salty. During an interview on 7/11/24 at 3:35 P.M., Resident Representative #1 said the food is awful, the meat is dry, and the vegetables have no flavor. Test Tray #1: On 7/12/24 at 12:00 P.M., the surveyor requested a lunch tray be sent to the Arborside Unit second meal truck which was to arrive to the unit at 12:15 P.M. The truck left the kitchen at 12:20 P.M and arrived at the unit at 12:21 P.M. The test tray was removed and conducted with the Food Service Director (FSD) obtaining temperatures in degrees Fahrenheit (F) with the facility thermometer at 12:37 P.M. with the following results: Baked fish-133.8 F, warm (not hot), flavorful Rice-118.5 F, tepid (lukewarm) and bland to taste. Spinach-118.7 F tepid and bland to taste. Coffee-151.7 F hot to taste. Milk-63.5 F warm to taste. Brownie (not temped) tasty with dry consistency. Test Tray #2: On 7/15/24 at 8:00 A.M., the surveyor requested a breakfast test tray to the Arborside Unit which was to arrive to the unit at 7:40 A.M. The food truck left the kitchen at 8:15, and arrived on the unit at 8:17 A.M the test tray and 2 other meals were not in the food truck but were brought to the unit in a cart that was not enclosed. The test tray was conducted with the FSD obtaining temperatures at 8:43 A.M., with the following results: Milk: 59.7 F, warm to taste. Black coffee: 139.2 F, warm to taste. Toast 97.8 F, cold, soggy, and bland to taste. Scrambled eggs 120.2 F mushy, little flavor, and tepid to taste. Results of the test trays validated the residents' concerns of cold food, warm milk, food lacking palatability. During an interview on 7/15/24 at 8:54 A.M., the FSD said she did not want to try the foods on the test tray. She said the food trucks were late today which can account for the hot foods not being hot and the cold foods being warm. She said that the Registered Dietitian had told her that meal trays are supposed to be inside of the meal cart to retain temperature. She said she was aware that there were a few trays that were not in a meal cart. During an interview on 7/15/24 at 10:38 A.M., the Registered Dietitian (RD) said the temperature for the milk was too high and the food was not within a range she would expect it to be served. She said she expects all food trays to arrive to the floor inside of a meal truck to preserve the temperature and she had communicated this concern with the FSD through the Test Tray Evaluation Forms. Review of Test Tray Evaluation Forms completed by the RD indicated the following: -On 5/20/24 the starch was a poor temperature at 109.9 F and the kitchen took longer to serve the food. -On 4/23/24 the temperatures were low at the start of tray pass and the vegetables temperature was 96.8 F pasta was 114 F. -On 4/16/24 the temperatures for pork and peas temperature were recorded as poor. -On 4/16/24 the temperatures for all hot items were marked as poor and comments include the tray was not in food truck and the temperature was not adequate. During an interview on 7/15/24 at 1:04 P.M., the Administrator said the trays should not be transported or left on top of the meal trucks and that she recently purchased another meal truck to ensure all meal trays would fit inside so foods would retain temperatures. She said she is aware of continued resident concerns related to food palatability as they are raised through the residents' Food Council Committee.

Based on observations, interviews and policy review, the facility failed to store, distribute, and serve food under sanitary conditions to promote safe food handling. Specifically, the facility failed to: 1. Ensure hair was restrained when preparing food; and 2. Ensure staff practiced proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another). In addition, to ensure the use of gloves was limited to a single use task; and 3. Ensure staff monitored cooked food temperatures being held for service to residents. Findings include: 1. Review of facility's policy titled Hair Restraints, dated 2020, indicated but was not limited to the following: -Hair Restraints, hats, and/or beard guards shall be used to prevent hair from contacting exposed food. Any facial hair that is longer than the eyebrow shall require coverage with a beard guard in the production and dishwashing areas. During an initial tour of the main kitchen on 7/11/24 at 7:16 A.M., the surveyor observed: -Dietary staff #2 did not have hair restrained while preparing breakfast. -Dietary staff #4 did not have beard hair restrained while assembling breakfast trays. During an interview on 7/11/24 at 7:59 A.M., Dietary Staff #2 said she had forgot to restrain her hair prior to serving breakfast. During an interview on 7/11/24 at 8:34 A.M., the Food Service Director (FSD) said part of the dietary staff uniform is a hair net or hat to restrain hair. On 7/12/24 at 12:20 P.M., the surveyor observed Dietary staff #4 with no covering or restraint for his beard hair and his long hair was not fully retrained in a hair net as he prepared trays for resident's lunch. During an interview on 7/12/24 at 12:50 P.M., the FSD said Dietary Staff #4 did not have his hair fully secured in the hairnet and had no beard hair net covering his beard. During an interview on 7/15/24 at 1:04 P.M., the Administrator said all kitchen staff should wear hairnets or beard guards to prevent hair from encountering food. 2. Review of the Food and Drug Administration Food Code, dated 2022, indicated but was not limited to the following: -Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. - If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. -Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: -Inside the food establishment if the receptacles and units: Contain food residue and are not in continuous use; or after they are filled. During an initial tour of the main kitchen on 7/11/24 at 7:16 A.M., the surveyor observed: -Dietary Staff #2 failed to change gloves or perform hand hygiene in between touching pieces of French toast, syrup, hardboiled eggs, pancakes, and plates. She also failed to use serving utensils for French toast, hardboiled eggs, and pancakes. -Two large trash bins were uncovered, and one bin had trash overflowing on to the floor. During an interview on 7/15/24 at 1:04 P.M., the Administrator said the trash in the kitchen should be always covered. She said that the cooks should not be touching food even with gloved hands due to cross contamination. 3. Review of the Food and Drug Administration Food Code, dated 2022, indicated but was not limited to the following: -Employees are properly maintaining the temperatures of time/temperature control for safety foods during hot and cold holding through daily oversight of the employees' routine monitoring of food temperatures Review of refrigerator temperature logs failed to indicate ongoing monitoring to ensure safe operation of refrigeration equipment to ensure cold foods were held at 41 degrees Fahrenheit (F) or below as follows: -Nourishment kitchen refrigerators were last taken on 7/1/24, 10 days prior. -Main kitchen refrigerators were blank on the dates of 6/12/24, 6/14/24 through 6/16/24, and 6/24/24 through 6/30/24. -Main kitchen refrigerators were not taken in July 2024. Review of the steam table temperature logs failed to indicate ongoing monitoring to ensure food items were being held above 135 degrees F as follows: -Steam table temperatures were blank on the date of 6/12/24, 6/14/24 through 6/16/24, and 6/24/24 through 6/30/24. -Steam table temperatures were not taken in July 2024. During an interview on 7/11/24 at 7:59 A.M., Dietary Staff #2 said she had not recorded the temperature of the food from the steam table prior to serving breakfast. During an interview on 7/11/24 at 8:34 A.M., the Food Service Director (FSD) said the steam table temperatures are required to be taken prior to the meal being served and recorded and it was concerning that there was a lack of temperatures recorded. She said the temperatures are recorded on the sheets on the clipboard and was unable to provide any additional information regarding the lack of logs. She said that it was her expectation that the temperatures for the refrigerators and freezers are recorded daily. She said she expects the cook to take and record the temperature of the food items on the steam table prior to serving the meal to ensure safe serving temperatures.

Based records reviewed and interviews, for one of four sampled staff members personnel files (Nurse #1), the Facility failed to ensure they consistently implemented measures related to abuse prevention and hiring practices, when training on the Facility Abuse Policy was not conducted on hire at orientation for Nurse #1, in accordance with the Facility Policy. Findings include: Review of the Facility Policy titled Abuse, dated as most recently revised 10/23/22, indicated that Facility personnel will be trained on hire at orientation on definitions of abuse, identification of abuse, prevention of abuse and obligation to report abuse. Review of Nurse #1's Personnel File, maintained by a staffing agency and provided to the Surveyor by the Facility Director of Nursing, indicated there was no documentation to support that the Facility or the staffing agency trained Nurse #1 on definitions of abuse, identification of abuse, prevention of abuse and obligation to report abuse on hire at orientation. During an interview on 9/11/23 at 1:00 P.M., the Director of Nursing said that there was no documentation to support that the Facility or the staffing agency trained Nurse #1 on definitions of abuse, identification of abuse, prevention of abuse and obligation to report abuse on hire at orientation. During an interview on 9/22/23 at 9:40 A.M., the [NAME] President of the Staffing Agency (that employed Nurse #1) said she did not have documentation of the agency having trained Nurse #1 on the Facility's Abuse Policy or on definitions of abuse, identification of abuse, prevention of abuse and obligation to report abuse on hire at orientation. Although the [NAME] President provided copies of training materials from the staffing agency orientation, which included information on abuse, there was no documentation in the materials provided that supported that Nurse #1 had attended an orientation or received the training materials. The [NAME] President said that she thought that each individual facility where an agency nurse was assigned and worked, reviewed orientation documents with the nurse, including their Abuse Policy, when the agency nurse reported to work at their Facility.

Based on records reviewed and interviews, for one of three sampled personnel records (Nurse #1) and for the last four nurses hired by the Facility (Nurses #2, #3, #4 and #5) the Facility failed to ensure they consistently implemented measures related to abuse prevention measures through hiring practices, when Massachusetts Nurse Aide Registry (NAR) checks were not conducted upon hire, in accordance with the Facility Policy. Findings include: Review of the Facility's Abuse Policy, dated as revised 10/23/22, indicated that the Facility abuse prevention protocol included screening potential employees. The Policy indicated that the Facility screening process consisted of inquiries into State NARs. Review of Nurse #1's Personnel File, who started working at the Facility on 8/31/22, indicated there was no documentation to support the Facility conducted a Massachusetts Nurse Aide Registry check, upon hire. During an interview on 7/05/23 at 12:15 P.M., the Business Office Manager said that her job included conducting screenings of potential employees, which included conducting inquiries into the Massachusetts NAR. The Business Office Manager said that she only inquired into the status of Certified Nurse Aides (CNAs) on Massachusetts NAR and said that she could not provide documentation that the Facility checked Nurse #1's status on the Massachusetts NAR at the time of her hire. Review of the Facility's New Hires Report, dated 7/05/23, indicated the Facility hired four nurses (Nurses #2, #3, #4 and #5) since April 2023. The Business Office Manager said that she had not inquired into the statuses of Nurses #2, #3, #4 and #5 on the Massachusetts NAR. During an interview on 7/05/23 at 12:20 P.M., the Director of Nursing said that since April 2023 she had been aware that the Facility was not conducting inquiries into the Massachusetts NAR for newly hired nurses.

Based on observation, interview, and record review, the facility failed to provide an appropriate seating device to support the Resident's right lower leg with a long leg brace for comfort and proper support for one Resident #308, out of a total sample size of 21 residents. Findings include: Resident #308 was admitted to the facility in February 2023 with a diagnosis of right total knee replacement, complicated by an injury to the patella tendon (kneecap tendon), requiring the Resident to wear a full leg hinged brace, locked in zero degrees of extension (prevents the knee from bending). During an interview on 2/26/23 at 9:10 A.M., Resident #308 said he/she was admitted Friday night and has not been seen by rehab and had to ask nursing for a walker to use the bathroom and a wheelchair to sit up out of bed. The surveyor observed the Resident sitting in a wheelchair, with the right leg unsupported, hanging off the wheelchair seat with the foot supported on the metal bar of the overbed tray table (the wheelchair did not have leg rests). Resident #308 said he/she needs a recliner or something to support the right leg, because it is uncomfortable with the brace and the brace is sliding down. During an interview on 2/26/23 at 9:25 A.M., Nurse #6 said they do have rehab staff that come in and evaluates new admissions over the weekend, but Resident #308 had not been seen yet. During an interview on 2/27/23 at 10:30 A.M., Rehab Staff #2 said the first thing she did was get Resident #308 leg rests, because the right leg with the brace needed to be supported. Rehab Staff #2 said Resident #308 was seen over the weekend by per diem rehab staff and she does not know why the Resident was not given leg rests. During an interview on 3/2/23 at 12:30 P.M., Rehab Staff #3 said they have per diem staff that come in over the weekend and evaluate the new residents. She said they do have access to equipment like wheelchairs and leg rests. Rehab Staff #3 said if a resident is not seen by rehab, the nurses have extra equipment in the shower room on the Cookside Unit to give to residents until rehab is able to see them. During an interview on 3/2/23 at 3:30 P.M., Unit Manager #3 said they don't always have equipment available in the shower room for residents over the weekend. The surveyor and the Unit Manager #3 viewed the Cookside Unit shower room and there was no equipment in the shower room. Specifically, there was no assistive walking devices, wheelchairs, cushions, or leg rests in the shower room. Unit Manager #3 said she does not know who is responsible for making sure equipment is available for residents, especially over the weekends and after hours. During a telephonic interview on 3/3/23 at 12:15 P.M., the Rehab Director said Resident #308 came in late on Friday and was not seen by the regular rehab staff but was seen on Sunday by their per diem staff. She said Resident #308 was evaluated bedside Sunday afternoon and was not evaluated up in the wheelchair, therefore they did not assess wheelchair positioning. The Rehab Director said they should have extra equipment like wheelchairs and legs rests in the shower room on the unit for late admissions. The surveyor informed the Rehab Director there was no extra equipment, including leg rests in the shower room on the Cookside Unit. She said, she is not responsible for making sure there is extra equipment on hand in the shower room for weekend admissions. The Rehab Director said the nurses can have the maintenance person open the rehab room on the weekends for access to wheelchairs and leg rests if needed. She said the nurses should make sure they have extra equipment on the units.

2. Resident #86 was admitted to the facility in January 2023 with diagnoses which included a recent left below knee amputation, diabetes, bacterial infection, history of diabetic foot ulcer, and acquired absence of fingers and toes. Review of the Minimum Data Set (MDS) assessment, dated 1/20/23, indicated Resident #86 scored a 13 out of 15 on the Brief Interview for Mental Status, indicating he/she was cognitively intact. In addition, the MDS indicated Resident had a major orthopedic surgery and required surgical wound care. a. Review of a Nursing Progress Note, dated 1/13/23, indicated Resident #86 was admitted with a left below the knee amputation with an ace wrap and brace in place and that the Resident had declined a full body skin check due to increased fatigue. Review of the physician consult Referral Form, dated 1/26/23, indicated but was not limited to the following: -Left below knee amputation, staples removed, will need to set up prosthesis company for shrinker and prosthesis. -Call with concerns of infection in incision. Review of the Care Plan for Pressure Ulcer indicated but was not limited to the following: Resident is at risk for skin breakdown related to immobility and has skin breakdown related to recent surgical below the left knee amputation, and history of chronic diabetic ulcers. -Wound infection will not increase in size through the next review. -Monitor condition of skin daily and report any changes promptly to the physician. -Skin check weekly by licensed nurse. -Treatment to wound as ordered. Review of the current Physician's Orders included but was not limited to: -Weekly skin check on Wednesdays 7:00 A.M. to 3:00 P.M. shift, initiated 1/13/23. -Bilateral lower extremity monitor and apply abdominal dressing (ABD, gauze pad) followed by ace wrap daily, initiated 1/20/23. Review of the Treatment Administration Record (TAR) indicated but was not limited to the following: Weekly skin check on Wednesdays, indicated it was completed on 2/1/23 coded as CDI (Clean Dry Intact), 2/8/23 coded as CDI, 2/15/23 coded as no new areas and 2/22/23 coded as no new areas. Review of Wound Management documentation in the electronic medical record, including all skin assessments indicated, there was no assessment performed 1/28/23 through 2/27/23. Review of a Nursing Note, dated 1/16/23, indicated skin warm and dry, color good. Review of a Nursing Note, dated 1/20/23, indicated skin warm and dry, color good. Review of a Nursing Note, dated 1/21/23, indicated left below knee amputation site dressing intact. Review of a Nursing Note, dated 1/24/23, indicated skin warm and dry, color good. Review of a Nursing Note, dated 1/26/23, indicated Resident returned from surgical follow up, staples removed, incision healing well and will return for follow up, okay to proceed with shrinker and prosthesis. Review of a Nursing Note, dated 1/26/23, indicated left below knee site open to air had steri-strips in place. No signs or symptoms of infection. Review of a Nursing Note, dated 1/30/23, indicated skin warm and dry, color good. Review of a Nursing Note, dated 2/14/23, indicated skin warm and dry, color good, left below knee amputation site unremarkable. Review of a Nursing Note, dated 2/21/23, indicated Resident out of building upon start of shift, return from leave of absence at 7:45 PM. Skin warm and dry color good. Small abrasion noted to stump steri-strips reinforced. Patient states this injury occurred while out. Dressing change to right lower extremity no drainage noted dry flaking skin. Review of a Nursing Note, dated 2/23/23, indicated Resident returned back from appointment with infectious disease doctor. Per infectious disease doctor, patient has early stump infection over the left below knee amputation site. Physician recommended Augmentin 875/125 milligram one tab by mouth twice a day for 14 days. Review of the infectious disease Physician's Progress Note, dated 2/23/23, indicated but was not limited to the following: -Resident seen today for follow up consultation for diabetic foot infection. -Resident problems have been found to be methicillin-resistant staphylococcus aureus (MRSA) septicemia and enterococcal bacteremia (infections). -Resident had undergone a left below knee amputation and has been treated with intravenous (IV) antibiotics and has been discharged to nursing home. -Resident still has an open wound noted over the left amputation stump with minimal drainage. -Resident has early stump infection over the left below knee amputation site. Physician is going to start resident on oral Augmentin (antibiotic) for 2 weeks. During an interview on 3/1/23 at 10:31 A.M., Unit Manger #3 said there is no skin assessment, they just check it off on the TAR and then the nurses should write a skin assessment in the nursing note. She said there is no other place to document a skin assessment. The surveyor and the Unit Manager #3 looked in the medical record and there was no documentation found for the left below knee surgical incision since admission, including the staples upon admission, post staple removal, post infectious disease consultation that identified drainage and early signs of infection. b. During an interview on 02/26/23 at 10:30 A.M., Resident #86 said they don't always change the dressing on my right foot. Resident instructed the surveyor to look at the dressing on his/her right foot and said it has not been changed since last Thursday. The surveyor observed the dressing on the right foot to be dated 2/23/23. Review of the Physician's Orders included but was not limited to: -Bilateral lower extremity monitor and apply abdominal dressing (ABD, gauze pad) followed by ace wrap daily, initiated 1/20/23. Review of the February 2023 TAR indicated but was not limited to the following: -Bilateral lower extremity: monitor and ABD, followed by an ace wrap daily. -The TAR was signed off as being completed on both 2/24/23 and 2/25/23. During an interview on 02/27/23 at 04:30 P.M., Unit Manager #3 said it looks like the nurses did not do the dressing change since 2/23/23 and signed off on it on 2/24 and 2/25. She said the orders are for the dressing to be changed daily and they should not be signing off on it, if they did not do the dressing change. c. During an interview on 02/26/23 at 10:30 A.M., Resident #86 said he/she has to wash the stump shrinker out and hang it in the bathroom to dry. Resident said it gets dirty and he/she now has an infection in the stump and is taking antibiotics. The surveyor observed the stump shrinker on Resident #86's left lower extremity to be soiled with staining. During an interview on 02/27/23 at 04:20 P.M., Resident #86 said Rehab Staff #3 washed the stump shrinker today because it was dirty. Resident said the Rehab staff hung the stump shrinker on the showerhead in the bathroom. The surveyor observed the stump shrinker hanging over the showerhead. During an interview on 03/1/23 at 10:31 A.M., Rehab Staff #3 said she worked with Resident #68 on Monday and washed the stump shrinker out and hung it on the showerhead because it looked soiled. Rehab Staff #3 said the prosthesis company did not give instructions on how to keep it clean and said she has washed it out a couple of times. Based on interviews and record reviews, the facility failed to ensure wound management was conducted for two Residents (#38 and #86), in a total sample of 21 residents. Specifically, the facility failed: 1. For Resident #38, to ensure wound recommendations, approved by the physician, were implemented; and 2. For Resident #86: a. to ensure skin evaluations were performed weekly per physician's orders, and staff documented and monitored the below knee surgical incision site for early signs of infection, b. to perform dressing changes to the right foot, per physician's orders, and c. to maintain the cleanliness of the stump shrinker (sock worn to reduce, prevent and control edema) being worn over the left below knee amputation that was currently being treated for an infection. Findings include: 1. Resident #38 was admitted to the facility in January 2016 and had a history of having a feeding tube. Review of the medical record indicated the feeding tube had previously been removed and the wound from the feeding tube site had re-opened. Review of the Physician's Orders on 3/1/23 included an order written on 12/3/22 for the old feeding tube site: cleanse with normal saline, apply Mupirocin ointment, followed by Calcium Alginate, cover with a foam dressing. Review of the Treatment Administration Records for January and February 2023 indicated the treatment had continued without any changes. Review of the Wound Evaluation and Management Summary, from the wound consultant, dated 1/20/23, indicated the following treatment to the site: add Calcium Alginate with Silver, add Optilock dressing, add Triad cream to periwound (tissue surrounding a wound). Review of the Wound Evaluation and Management Summary, from the wound consultant, dated 2/10/23, indicated the following changes to the treatment: add Mupirocin ointment, add Calcium Alginate, discontinue Calcium Alginate with Silver, continue Optilock dressing, continue Triad cream to the periwound. Review of the Wound Evaluation and Management Summary, from the wound consultant, dated 2/24/23, indicated the following changes to the treatment: continue Calcium Alginate, discontinue Mupirocin Ointment, continue Optilock dressing, continue Triad cream to the periwound. During an interview on 3/1/23 at 12:11 P.M., the Assistant Director of Nurses said she did not conduct rounds with the wound consultant and was not sure if the nurses were present when the wound consultant was seeing residents. She said she was not sure why the orders did not match the recommended changes made by the wound consultant. She said she was not sure how the nurses would obtain the Wound Evaluation and Management Summary and did not know how the floor nurses would know there were changes to the recommendations. She said she tracks the status of the wounds in the facility on a spreadsheet but did not reconcile the wound treatments ordered in the medical record versus the recommendations made by the wound consultant to ensure accuracy. During an interview on 3/1/23 at 12:38 P.M., Unit Manager #2 said she had not accompanied the wound consultant during rounds for Resident #38. She said she was unsure of the process for when the wound consultant made recommended changes on how those changes were implemented. During an interview on 3/1/23 at 3:33 P.M., Nurse #7 said she was not aware of the changes to the treatment but had been applying Calcium Alginate and the Optilock dressing on the wound. During an interview on 3/2/23 at 8:53 A.M., the primary Physician said he was aware of all recommendations made by the wound consultant, had read all of the recommendations, and approved the treatments, which should have been conducted as recommended by the wound consultant.

Based on record review, policy review, and interview, the facility failed to provide the necessary respiratory care and services in accordance with professional standards of practice for one Resident (#2A), out of a total sample of 17 residents. Findings include: Review of the facility's policy titled Oxygen Therapy (revised October 2022) indicated but was not limited to the following: The administration of supplemental oxygen is an essential element of appropriate management for a wide range of clinical conditions. However, oxygen should be regarded as a drug and therefore requires prescribing in all but emergency situations. Failure to administer oxygen appropriately can result in serious harm to the patient. The safe implementation of oxygen therapy with appropriate monitoring is an integral component of the Healthcare Professional's role. Oxygen is administered according to physician order. Oxygen orders should include: -Liter flow -Delivery mode -Frequency Residents who use oxygen will be monitored throughout their shift by the unit nurse to determine effectiveness of the treatment. Oxygen use will be documented on the Electronic Medication Administration Record (EMAR) or Electronic Treatment Administration Record (ETAR). Resident #2A was admitted to the facility in April 2023 with diagnoses including End Stage Renal Disease-requiring hemodialysis, dysphagia-requiring the placement of a Gastrostomy Tube (G-Tube), and a fall resulting in a subdural hematoma. Review of the medical record indicated that on 4/18/23 at 1:02 A.M., the Resident's oxygen levels (saturations) were abnormal (low) at 81% on room air. The Resident was placed on Oxygen at 2 liters per minute (LPM) and the saturation was up to 96%. The physician ordered a chest x-ray. The x-ray completed on 4/18/23 had no indication of pneumonia, but the Resident remained on Oxygen because of the low saturations. Another chest x-ray was ordered on 4/24/23 which indicated the Resident had pneumonia. The medical record indicated that on the following dates the Resident was receiving oxygen: 4/18-2 LPM via nasal canula (nc) 4/20-3 LPM via nc 4/21-3 LPM via nc 4/22-2 LPM via nc 4/23-3 LPM via nc 4/25-2.5 LPM via nc 4/26-1.5 LPM via nc 4/27-2 LPM via nc 4/28-3 LPM via nc 4/29-2 LPM via nc 5/1-2 LPM via nc 5/4-3 LPM via nc 5/5-3 LPM via nc Further review of the April and May 2023 Physician's Orders, EMAR, and ETAR indicated that an order to administer Oxygen had not been obtained. During an interview with the Director of Nursing, Assistant Director of Nursing, Infection Control Preventionist and Corporate Nurse on 5/9/23 at 2:25 P.M., they confirmed that the Resident had been receiving Oxygen without a physician's order as required.

Based on record review and interview, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, through ongoing communication and collaboration with the dialysis facility for one of one Resident (#10), receiving dialysis. Specifically, the facility failed to ensure the hemodialysis communication book was completed by facility staff pre-treatment and dialysis staff post-treatment. Findings include: Review of the facility's policy titled Dialysis, revised 1/28/22, indicated but was not limited to the following: -A communication process must be established between the nursing home and the dialysis facility to be used 24-hours a day. -The care of the resident receiving dialysis services must be reflected by ongoing communication, coordination and collaboration between the nursing home and the dialysis staff. -The facility uses a dialysis communication book which contains a document titled- Dialysis Communication Record- for ongoing communication with the Dialysis center. This is a form of written communication that occurs between the nursing facility and the Dialysis facility that includes, but is not limited to, recommendations made by the Dialysis center staff for the nursing facility to implement, and the Resident's condition before, during, and after receiving hemodialysis. Resident #10 was admitted to the facility in November 2021 with diagnoses that included end stage renal disease, receiving hemodialysis, diabetes, and generalized edema. Record review indicated that the Resident receives hemodialysis at a Dialysis facility three times a week on Monday, Wednesday, and Friday. Review of the Dialysis Communication Records, from 10/1/22 through 3/1/23, indicated that neither the facility staff nor the staff at the Dialysis facility completed the Dialysis Communication Record in its entirety (missing pre-/post-weights, vital signs, signatures, etc.). During an interview on 3/2/23 at 1:15 P.M., Unit Manager #1 reviewed the Dialysis Communication Book with the surveyor and said that neither this staff nor the staff at the Dialysis facility had completed the Dialysis Communication Record as required.

Based on record review, document review, and interview, the facility failed to ensure that services were coordinated with the Hospice provider to implement the resident's plan of care as required in the provider contract agreement for one Resident (#98), from of a total sample of 21 residents. Specifically, the facility failed to ensure: a. a physician's order for the provision of Hospice care was obtained, and b. an integrated care plan was developed to accurately reflect services provided by both the Hospice provider and facility staff. Findings include: Review of the Hospice Care Services Agreement, signed 5/25/17, included but was not limited to: -The Hospice provider shall collaborate with the Facility and jointly develop written coordinated Plans of Care for each person admitted to Hospice, and the care provided to the Hospice Patient shall be in accordance with the plan; -Hospice and Facility will delineate the responsibility of respective functions agreed upon in the Hospice Plan of Care; -The Facility shall perform and document services described in this Agreement in accordance with the Facility's protocols, policies, and procedures to the extent they are consistent with Hospice protocols, policies, and procedures, and Hospice's Plan of Care for each Hospice Patient. Review of the facility's policies titled Hospice Services, last revised January 2023, and Hospice Services, last revised 3/4/22, included but were not limited to: -Once a resident and/or resident representative has agreed to Hospice services, the Licensed Nurse will obtain the order from the medical provider; -The Facility and Hospice will identify the specific services that will be provided by each entity and this information will be communicated in the plan of care. Resident #98 was admitted to the facility in November 2022 with diagnoses including cancer. Review of the Minimum Data Set (MDS) assessment, dated 11/17/22, indicated Resident #98 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of 15 and received Hospice services. Review of the medical record indicated Hospice documentation identifying the provision of the following services: -Skilled Nursing once weekly for eight weeks and as needed visits for symptom management -Home Health Aide five days a week for eight weeks Further review of the medical record failed to indicate a physician's order was obtained for Hospice services to be provided to Resident #98 and failed to indicate a comprehensive care plan had been developed that identify the care and services that are needed, and specifically identify which provider is responsible for performing the respective functions that have been agreed upon to maintain the resident's highest practicable physical, mental, and psychosocial well-being. During an interview on 3/1/23 at 9:27 A.M., the surveyor reviewed Resident #98's medical record with Unit Manager #1. The Unit Manager confirmed there was no physician's order in place for Hospice services and said the facility did not develop an integrated care plan that delineates services provided by Hospice staff and facility staff.

Based on resident and staff interviews, policy review, and document review, the facility failed to ensure grievances and concerns from the Resident Council were acted upon timely and resolved to the residents' satisfaction. Findings include: Review of the facility's policies titled Resident/Family Council, last reviewed 2/18/22, and Grievance Policy, last revised 1/28/22, included but was not limited to: -Residents may voice grievances to the Resident Services Coordinator, Performance Improvement Coordinator, Social Service designee, or Charge Nurses. The management team shall investigate any grievance; -Staff shall be informed regarding decisions reached in the Resident and/or Family Visitor Council; -It is the policy of this facility to follow all regulatory guidance and support that each resident has the right to voice grievances and complaints and that resolution will be actively pursued in a reasonable amount of time; -When a resident, representative, or other person linked to a resident has a grievance or complaint a staff member should encourage that person to file a written grievance using the facility Grievance/Complaint Report form; -If a person does not wish to complete the report, the staff member receiving the grievance should ensure the form is filled out and passed along in accordance with the policy; -If the grievance or complaint rises to the level of potential abuse, neglect, or misappropriation the Administrator should be notified immediately. Otherwise, the information should be given to the Administrator within 24 hours; -Upon receipt of the written grievance and/or complaint, the Administrator will refer it to the appropriate department head for investigation. The department head will submit a written report of the findings to the Administrator within 72 hours of receiving the grievance and/or complaint; -The Administrator will review the findings with the person that completed the investigation to determine corrective actions and formulate a resolution of the issue; -Receipt of the grievance and/or complaint will be logged by the Administrator in the facility grievance log. This log will be utilized for tracking and trending as part of the facility QAPI program; -The person filing the grievance and/or complaint will be informed of the findings and actions taken. This report will be completed by the Administrator or designee within 3-5 working days; -Copies of all reports must be signed and will be made available to the person who filed the complaint. The original reports will be filed in a book labeled Grievance/Complaints. -The Administrator is responsible for overall compliance of the grievance and/or complaint process. Review of the Resident Council Minutes, dated 12/6/22, indicated residents had concerns about the select menu not being followed, soggy grilled cheese sandwiches, cleanliness/smell of shower room and personal bathrooms on the Arborside Unit, spilled hot beverages on napkins on food trays, not getting showers on their scheduled day, Aides walking in on them in the bathroom (will knock, but not wait for permission to enter), and cellphone use by staff during care. Review of the Resident Council Minutes, dated 1/17/23, indicated residents continued to have concerns about the select menu not being followed, soggy grilled cheese sandwiches, napkins are wet on food trays, cold food, showers not given on their scheduled days, nursing staff do not knock on doors, and cellphone use by staff is ongoing. Review of the Resident Council Minutes, dated 2/7/23, indicated residents continued to have concerns about the select menu not being followed, soggy grilled cheese sandwiches, staff use of cellphones ongoing, beds not being made daily or stripped on shower days, and aides leave Hoyer lifts in room after patient care. During an interview on 3/1/22 at 1:11 P.M., the Activity Director said there are recurrent issues with food including temperatures, following selective menu, soggy grilled cheese sandwiches, and wet napkins on food trays. In addition, there were issues with cell phone use by staff during care, Hoyer lifts left in residents' rooms and cleanliness of rooms. She said following a resident council meeting she completes a Resident Council Concern Form and gives it to the appropriate department head for follow up and resolution. During an interview on 3/2/23 at 10:20 A.M., the Administrator said grievances brought forward during the Resident Council Meetings are not documented on a Grievance Form. He said each department head is notified of the grievance by the Activity Director and is responsible for addressing and resolving the issue. He said the grievances were not completed, followed up, and resolved as required and he needed to come up with a system to ensure that grievances brought forward through the Council are addressed, department heads provide him a written report of their findings within 72 hours, and there is timely resolution and follow-up with the residents.

2. Resident #6 was admitted to the facility in October 2015. During an interview on 3/2/23 at 9:10 A.M., Resident #6 said several months prior a Certified Nursing Assistant had dropped the Resident's tablet and the screen had smashed. The Resident showed the surveyor the tablet, which was in bubble wrap on their bureau, which had a screen with multiple cracks spidering from the corner of the screen through the screen. Resident #6 said the Social Worker had helped him/her fill out a grievance form and had been told the screen would be replaced, but had not heard anything back. Review of the grievance form, dated 9/12/22, indicated Resident #6 had a broken/cracked tablet screen because the tablet had been dropped. The follow-up section of the grievance indicated Resident #6 had been told the screen would be replaced and noted it would be purchased by the Activity Department. The form was signed by the Administrator and indicated a follow up would be conducted after the screen was purchased. During an interview on 3/2/23 at 10:07 A.M., the Activity Director said she did not know anything about purchasing a new screen for Resident #6 and had never been asked. During an interview on 3/2/23 at 10:20 A.M., the Administrator said Resident #6 had inquired about the cracked screen again, a couple of weeks ago. He said a new grievance was not initiated when the Resident followed up a couple of weeks ago and there had been no purchases made to replace the screen, as indicated on the grievance. He said he did not know why this had not been followed up on. 3. Resident #85 was admitted to the facility in July 2021. Review of a grievance, dated 9/4/22, indicated the family member of Resident #85 had completed a grievance indicating Resident #85 had been placed on a bedpan around 3:00 P.M. and had been left there for 2 hours. The grievance form indicated there was an investigation in progress and the Resident had been placed on a bedpan around 3:00 P.M. by a CNA and by 4:00 P.M., when the CNA had left for the day, the Resident had not rung their call light for assistance to get off the bedpan. The follow-up section indicated Resident #85 had requested to be put on the bedpan, said they would be a while and was taken off the bedpan around 4:30 P.M. (approximately an hour and a half after being put on the bedpan) and a voicemail had been left for the family letting them know this information. There was no additional information. During an interview on 3/2/23 at 10:20 A.M., the Administrator said there was no additional information regarding the investigation into the grievance or how future incidents could be prevented. During an interview on 3/2/23 at 11:10 A.M., Resident #85 said he/she had not heard any follow-up to being left on the bedpan months prior. Based on policy review, interview, document review, and record review, the facility failed to implement the facility's grievance policy for 9 of 9 grievances reviewed and for two Residents (#6 and #85), from a sample of 21 residents. Specifically, the facility failed to: 1. For 5 of 9 grievances reviewed, notify the Administrator as required if a grievance/complaint involves a potential violation of a resident right or allegation of neglect or abuse and for 9 of 9 grievances reviewed, investigate and resolve grievances according to facility policy; 2. For Resident #6, follow up on a grievance of a broken item for over five months; and 3. For Resident #85, to research and follow up on a grievance of being left on a bed pan for over an hour. Findings include: Review of the facility's policy titled Grievances, revised September 2020, indicated the following: -It is the policy of this facility to follow all regulatory guidance and support that each resident has the right to voice grievances and complaints and that resolution will be actively pursued in a reasonable amount of time; -If the grievance or complaint rises to the level of potential abuse, neglect, or misappropriation the Administrator should be notified immediately. Otherwise, the information should be given to the Administrator within 24 hours; -Upon receipt of the written grievance and/or complaint, the Administrator will refer it to the appropriate department head for investigation. The department head will submit a written report of the findings to the Administrator within 72 hours of receiving the grievance and/or complaint; -The Administrator will review the findings with the person that completed the investigation to determine corrective actions and formulate a resolution of the issue; -The person filing the grievance and/or complaint will be informed of the findings and actions taken. This report will be completed by the Administrator or designee within 3-5 working days; -Copies of all reports must be signed and will be made available to the person who filed the complaint. The original reports will be filed in a book labeled Grievance/Complaints. -The Administrator is responsible for overall compliance of the grievance and/or complaint process. Review of the Grievance Log and Grievances for August 2022, September 2022, October 2022, November 2022, December 2022, and January 2023 - the following grievances were logged onto the monthly log reports: 1. a. On 8/1/22, Resident #53 reported an incident that occurred on 7/28/22. The Resident reported that he/she was given the wrong medication by an agency staff, was given more medication shortly after taking the medication, and subsequently became unresponsive and was transported to the emergency room. Further review of the grievance form indicated it was blank with no information to indicate it was investigated and resolved. b. On 8/19/22, the staff documented a resident's family reported missing bottom dentures. The grievance form indicated the bottom denture was not located and payment for replacement was authorized by the Administrator. Further review of the grievance failed to indicate the bottom denture was replaced and the grievance resolved. c. On 8/27/22, the staff documented the resident's sister reported: -the resident is never out of bed or dressed -the resident's hair looks as if it's dirty. Had issues in the past with scaling scalp due to no hair care -nails are very long-no clippers available -rings on right ring finger are too tight- need to be removed and given to family (2 rings) -feel as if some of these concerns describe neglect -bathing and getting up and dressed each day are basic and healthy rights for every human being Further review of the grievance form indicated the Administrator was not notified of the allegation immediately according to facility policy. d. On 9/1/22, the staff documented the resident reported an incident that occurred on 8/24/22 in which he/she was put on a bedpan by a Certified Nursing Assistant (CNA) and was left on it for a while. The resident reported he/she was in pain from being on the bedpan for so long and having had a recent fracture. The resident reported another CNA finally came in to assist him/her and was told the CNA that put him/her on the bedpan left the building. Further review of the grievance form indicated the Administrator was not notified of the allegation immediately according to facility policy and failed to indicate the grievance was investigated and resolved. e. On 9/11/22, the staff documented the resident reported not receiving a shower in three weeks. Review of the grievance form indicated on 9/12/22, the Director of Nursing reviewed the grievance and documented that the resident was COVID positive on 8/25/22, his/her roommate was COVID positive prior to that date and the resident was informed and agreed. Further review of the grievance form indicated the Administrator was not notified of the allegation immediately according to facility policy. f. On 1/13/23, the staff documented the resident reported that a CNA was rude and abrupt. Further review of the grievance form failed to indicate the grievance was investigated and resolved. g. On 1/15/23, the staff documented the resident's family reported difficulty getting staff to provide incontinent care after having a bout of diarrhea. The resident pressed the call light and rang a hand bell from 4:00 P.M. to 5:30 P.M. before a CNA came to deliver the resident's dinner tray. The resident was told he/she would have to wait to be changed until after eating his/her dinner. The Administrator signed the grievance on 1/18/23. Further review of the grievance form indicated the Administrator was not notified of the allegation immediately according to facility policy and failed to indicate the grievance was investigated and resolved. h. On 1/20/23, the staff documented the resident's family reported: -staff person cellphone use -resident yelling for help on 1/19/23 and a CNA ignoring him/her Further review of the grievance form indicated it was blank with no information to indicate it was investigated and resolved. i. On 1/24/23, the staff documented the resident's family reported during a care plan meeting that a CNA was rude to the resident telling him/her to get up and get it yourself regarding a shirt to get dressed. The family also reported that the resident has to wait long periods of time to use the bathroom or be changed. Further review of the grievance form indicated the Administrator was not notified of the allegation immediately according to facility policy and failed to indicate the grievance was investigated and resolved. During an interview on 3/2/23 at 10:20 A.M., the Administrator said he is solely responsible for the grievance process. The surveyor and Administrator reviewed the Grievance book. The Administrator said the grievances were incomplete and should have been investigated and resolved. He said he should have been notified immediately of a potential violation of a resident right or allegation of neglect or abuse.

7. Resident #81 was admitted to the facility in April 2019 with diagnoses of venous insufficiency (chronic) and obesity. Review of the Wound Evaluation and Management Summary, from the wound consultant, dated 1/20/23 indicated Resident #81 had a trauma/injury to the left calf measuring 7 centimeters (cm) in length by 3 cm in width by in immeasurable depth. During an interview on 2/27/23 at 1:08 P.M., the Assistant Director of Nurses (ADON) said Resident #81 had told the wound consultant that he/she had scratched themselves. The ADON said she had never inquired how the Resident had scratched themselves or what would have caused a large scratch. During an interview on 2/27/23 at 1:35 P.M., Nurse #7 said Resident #81 often used a back scratcher to scratch his/her legs as they were unable to reach that low with their hands. She said the staff had provided education to the Resident multiple times with no effect. Review of the care plans for Resident #81 failed to include the current injury to the left calf and failed to indicate the interventions in place to prevent future injuries from occurring. During an interview on 2/27/23 at 2:26 P.M., the ADON said she was not sure why the injury was not on the care plans with interventions. Based on record review and interview, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for seven Residents (#45, #53, #91, #43, #90, #63, and #81), out of a total sample of 21 residents. Specifically, the facility failed to ensure that: 1. Resident #45 had a care plan developed for a diabetic wound of the right great toe; 2. Resident #53 had a care plan developed for: a. the use of antipsychotic medication that identified target behaviors, non-pharmacological interventions and measurable goals of treatment, and b. the Resident's diagnosis of Parkinson's disease; 3. Resident #91 had a care plan developed for: a. a Foley catheter, b. anticoagulant therapy, and c. a seizure disorder; 4. Resident #43 had a care plan developed for diabetes (insulin dependent); 5. Resident #90 had a care plan developed for diabetes (insulin dependent); 6. Resident #63 had a care plan individualized to include hand rolls and an air boot; and 7. Resident #81 had a care plan developed for self-inflicted open areas to the skin. Findings include: Review of the facility's policy titled Care Plan-Comprehensive, last revised 10/22/22, included but was not limited to: -The comprehensive, person-centered care plan will: -Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being -Assessments of residents are ongoing and care plans are revised as information about the residents' conditions change 1. Resident #45 was admitted to the facility in November 2017 with diagnoses including type 2 diabetes mellitus. Review of the medical record indicated on 2/2/23, Nurse #1 documented in a progress note that the Resident had an open area on his/her great toe. The Physician was notified, and a referral was made to the Consultant Wound Physician. Review of the 2/3/23 Wound Evaluation and Management Summary indicated Resident #45 had a diabetic wound of the right medial first toe. Review of comprehensive care plans failed to indicate a care plan had been developed to address the newly identified diabetic wound of the Resident's right great toe. 2. Resident #53 was admitted to the facility in September 2021 with diagnoses including severe major depressive disorder with psychotic features and Parkinson's disease (disorder of the central nervous system that affects movement). Review of the February 2023 Physician's Orders included but was not limited to: -Quetiapine (Seroquel-antipsychotic) 100 milligrams (mg) at bedtime (1/9/23) Review of comprehensive care plans failed to indicate a care plan had been developed for: a. the use of Seroquel that identified targeted signs and symptoms for its use, any Resident specific non-pharmacological approaches, and measurable goals to meet the Resident's needs; and b. the Resident's diagnosis of Parkinson's disease. 3. Resident #91 was admitted to the facility in September 2022 with diagnoses including Parkinson's disease, acute kidney failure, and seizures. Review of the February 2023 Physician's Order included but was not limited to: -Foley Catheter #16 French, 10 milliliters (ml) balloon to closed drainage, every shift (11/24/22) -Foley Catheter 16 French, 10 ml Foley catheter as specified by Physician and as needed (prn) (11/24/22) -Foley Catheter, irrigate Foley catheter with 60 ml normal saline prn for blockage (11/24/22) -Foley Catheter Care, check CD [catheter drainage] bag to ensure that it is not compromised, every shift (11/24/22) -Foley Catheter Changing CD bag prn only if visibly damaged or compromised, prn (11/24/22) -Eliquis (anticoagulant) 5 mg twice daily (9/13/22) -Levetiracetam (anticonvulsant) 250 mg twice daily (9/13/22) -Primidone (anticonvulsant) 50 mg twice daily (9/13/22) Review of comprehensive care plans failed to indicate a care plan had been developed for: a. a Foley catheter; b. anticoagulant therapy; and c. seizure disorder. During an interview with Unit Manager #1 on 3/1/23 at 9:27 A.M., the surveyor reviewed Resident #45, #53 and #91's medical records. She said Resident #45 should have had a care plan developed for the diabetic wound; Resident #53 should have had a care plan developed for the use of Seroquel and diagnosis of Parkinson's disease, and Resident #91 should have had a care plan developed of for his/her Foley catheter, anticoagulant use, and seizures. 4. Resident #43 was admitted to the facility in February 2022 with diagnoses including insulin dependent diabetes mellitus. Review of the February 2023 Physician's Orders indicated the following: -Insulin Lispro (short acting)- Sliding scale: If Blood Sugar is: 150-199 = (1 Unit); 200-249 = (2 Units); 250-299 = (3 units); 300-349 = (4 units); 350-399 = (6 units); 400--449= (8 Units); >450 (10 Units) and call physician Before meals and at Bedtime (6:30 A.M., 11:30 A.M., 4:30 P.M., and 8:00 P.M.). -Insulin Glargine (long acting insulin) solution 100 unit/milliliter (ml) amt.-16 units, subcutaneous, once a day at 6:00 A.M. Record review indicated that the Resident was being administered a dose of insulin every day at 6:00 A.M. and could potentially be receiving doses in addition to the daily insulin depending on the blood sugar results. Review of the comprehensive care plans failed to indicate that a care plan had been developed related to the Resident's diagnosis of diabetes/insulin use that addressed potential problems, goals, and interventions. 5. Resident #90 was admitted to the facility in July 2021 with diagnoses that included diabetes mellitus (DM). Review of the February 2023 Physician's Orders indicated the following: --Insulin Lispro (short acting)- Sliding scale: If Blood Sugar is: 150-199 = (1 Unit); 200-249 = (2 Units); 250-299 = (3 units); 300-349 =(4 units); 350-399 = (6 units); 400--449= (8 Units); >450 (10 Units) and call physician; Before meals and at Bedtime (6:30 A.M., 11:30 A.M., 4:30 P.M., and 8:00 P.M.). Lantus U 100 (insulin Glargine-long acting) solution amt.-30 units, subcutaneous, once a day at 6:00 A.M. Record review indicated that the Resident was being administered a dose of insulin every day at 6:00 A.M. and could potentially be receiving doses in addition to the daily insulin depending on the blood sugar results. Review of the comprehensive care plans failed to indicate that a care plan had been developed related to the Resident's diagnosis of diabetes/insulin use that addressed potential problems, goals, and interventions. During an interview on 3/2/23 at 12:55 P.M., Unit Manager #1 said that Resident #43 and Resident #90 should have had care plans developed for diabetes but did not. 6. Resident #63 was admitted to the facility August 2022 with diagnoses including rheumatoid arthritis and osteoarthritis. Review of the January 2023 Physician's Orders indicated: -Hand roll placed, on in the morning (8:00 A.M.) and taken off at 3:00 P.M., initiated 1/14/23 -Apply air boot to feet while resting in bed. May remove boot for Activities of Daily Living (ADL), wound care and skin assessment. Reapply boot after completing task, every Shift, Days, Evenings, Nights, initiated 1/27/23. Review of the comprehensive care plan indicated but was not limited to the following: Problem: Potential for alteration in skin integrity related to limited mobility. Resident also has apressure wounds to the right heel and left heel (Deep Tissue Injury (DTI)). Goal: Skin will remain intact daily through next review Approach: -Low air loss mattress set to 150, check setting and functioning every shift -Apply Barrier ointment after each cleaning/Activities of Daily Living (ADL) care -Consult with Physical Therapy/Occupational Therapy to improve mobility -Heel floats using pillows while resting in bed as tolerated -Avoid scrubbing/rubbing on skin during ADLs, Only dab skin using a towel to dry -Use PH balanced skin soap for cleansing -Monitor condition of skin daily and report changes promptly to physician. Further review of the care plan failed to indicate that the care plan had been individualized to include the hand rolls and the air boot, per the physician's order. During an interview on 3/2/23 at 1:30 P.M., Unit Manager #1 said the care plan should have been updated to include the interventions but was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Resident #45 was admitted to the facility in November 2017 with diagnoses including type 2 diabetes mellitus. Review of a 2/2/23 Nursing Progress Note indicated Resident #45's left great toe was open/slit. The covering Physician was notified and ordered a referral to the consultant wound Physician. Review of the Wound Evaluation and Management Summary from the consultant Wound Physician, dated 2/3/23, indicated Resident #45 had a diabetic wound of the right, medial, first toe. The wound consultant made a recommendation to apply Bacitracin (topical antibiotic) to the wound twice daily for eight days and off-load the wound to prevent any trauma. Review of February 2023 Physician's orders included, but was not limited to: -Left great toe: Apply a layer of Bacitracin twice a day to left great toe slit. ***May d/c (discontinue) treatment when area is healed (2/4/23) -Monitor for signs/symptoms of infection to left great toe (2/2/23) a. The order was transcribed incorrectly and indicated the treatment was for the left great toe and not the right great toe. b. Review of the Treatment Administration Record (TAR) for February 2023 indicated Bacitracin was applied to the left great toe (not the right toe) twice daily and signs and symptoms of infection to the left great toe (not the right toe) were monitored by nursing as evidenced by nursing initials in the corresponding boxes. During an interview on 3/1/23 at 10:21 A.M., the surveyor reviewed Resident #45's medical record with Unit Manager #1. She said she did not realize the order was entered incorrectly and staff signed off that treatments were done to the incorrect toe. Unit Manager #1 and the surveyor entered Resident #45's room she asked the Resident to look at the toe that gets the dressing. The Resident removed his/her right sock to reveal an open area on his/her right great toe. 7. Resident #91 was originally admitted to the facility in September 2022 with diagnoses including seizures. The Resident was re-admitted to the facility with a new urinary catheter after a brief hospitalization in November 2022. Review of the medical record indicated 11/4/22 hospital documentation including, but not limited to: -During the hospitalization the patient was found to be retaining urine, Foley was inserted by urology -Plan is to discharge patient back to the nursing home with instructions to follow-up with urology within 2 weeks for Foley removal. Review of a 11/25/2022 Nursing Progress Note indicated Resident #91 had a Foley catheter in place until he/she is seen by the urologist. Review of the medical record failed to indicate Resident #91 ever saw a urologist for a follow up visit. During an interview on 2/26/23 at 9:30 A.M., Resident #91 said that he/she had a Foley catheter placed in the hospital in November 2022. The Resident said he/she had not seen a urologist or had a urinary voiding trial conducted to see if the Foley catheter could be discontinued. During an interview on 3/1/23 at 9:27 A.M., the surveyor and Unit Manager #1 reviewed Resident #91's medical record. Unit Manager #1 was unable to find any documentation to indicate the Resident had a follow-up appointment with the urologist. Nurse #5 said that she did not recall the Resident having an appointment with a urologist either in person or via telehealth or having a voiding trial to see if the Foley catheter could be removed. During an interview on 3/1/23 at 11:40 A.M., the surveyor reviewed Resident #91's medical record with the Assistant Director of Nursing (ADON). She said she remembers the Resident came back from the hospital with a new catheter but doesn't know if the Resident has seen a urologist yet. She said some appointments being canceled a few times but believes that was for a neurologist and not a urologist. She said if a resident is going to have a voiding trial to see if a catheter can be removed, a physician must write an order for it to be done and the Resident has not had a voiding trial. During an interview on 3/2/23 at 9:41 A.M., the surveyor reviewed Resident #91's medical record with Physician #1. He said he did not know that Resident #91 returned from the hospital in November 2022 with a new Foley catheter. He said he thought he/she had it in place ever since admission in September. Physician #1 said did not review the hospital discharge information and did not know about the instructions for the Resident to see a urologist for Foley removal within two weeks of readmission to the facility. He said he did not know if Resident #91 has seen a urologist since returning to the facility. Based on observation, record review, policy review, and interview, the facility failed to ensure that staff provided care and services according to accepted standards of clinical practice for seven Residents (#101, #10, #43, #90, #63, #45, and #91), out of a total sample of 21 residents. Specifically, the facility failed: 1. For Resident #101, to ensure laboratory work was completed, as ordered by the physician; 2. For Resident #10, to: a. obtain a physician's order with instructions/ranges for physician notification of a low or a high capillary blood glucose (CBG), and b. apply TED stockings (elastic stockings) as ordered and accurately document as administered; 3. For Resident #43, to: a. have a physician's order to perform CBG's/Finger Stick Blood Sugars (FSBS) to correlate with the administration of the sliding scale insulin, b. obtain a physician's order with instructions/ranges for physician notification of a low or a high CBG, along with protocols/interventions in place for hypoglycemia or hyperglycemia, and c. Ensure the hospital discharge summary was reviewed for changes, and/or recommendations resulting in Urology and Nephrology consults not being scheduled/obtained as recommended; 4. For Resident #90, to have a physician's order to perform CBG's/FSBS to correlate with the administration of the sliding scale insulin; 5. For Resident #63, to accurately document treatments (apply air boots, float heels, and apply hand roll) administered in the medical record; 6. For Resident #45, to ensure: a. a Physician's order was transcribed according to professional standards of clinical practice, and b. staff accurately documented treatments administered in the medical record; and 7. For Resident #91, the facility failed to ensure hospital discharge instructions for a follow up appointment with a urologist to remove a Foley catheter was scheduled. Findings include: 1. Resident #101 was admitted to the facility in November 2022 with diagnoses that included acute kidney failure and dehydration. Record review indicated that the Resident had laboratory work completed on 1/4/23. Review of the laboratory results indicated that the Blood Urea Nitrogen (BUN) and the Creatinine were higher than the reference range (normal value range). Review of the laboratory results document indicated the physician reviewed the values on 1/9/23 (initialed by the physician indicating that he was aware of the results) and then noted/transcribed onto the results document- Repeat BMP (Basic Metabolic Profile). Review of the Physician's Progress Notes dated 1/10/23, 1/24/23, and 2/23/23, did not address repeating the BMP or awaiting any results of the BMP. Further record review indicated that a repeat BMP had never been ordered as indicated by the physician. During an interview on 3/2/23 at 1:00 P.M., Unit Manager #1 said that there had not been a repeat BMP ordered by the facility. 2. Resident #10 was admitted to the facility in November 2021 with diagnoses that included end stage renal disease, receiving hemodialysis, diabetes, and generalized edema. Review of the February 2023 Physician's Orders indicated the following: -TEDs on in A.M. (8:00 A.M.) off in P.M. (8:00 P.M.); The order start date was 4/4/22 and was open ended (still an active order). -Check Capillary Blood Glucose (CBG) twice a day on Monday, Wednesday, and Friday (6:00 A.M. and 4:30 P.M.); The order start date was 11/22/21 and was open ended. a. Further review of the Physician's Order indicated that there were no instructions/ranges for when the physician was to be notified of either a low or a high CBG. During an interview on 3/2/23 at 12:00 P.M., Unit Manager #1 said that there should be instructions/ranges as to when the physician should be notified with the CBG results (low blood sugar/high blood sugar). b. During an interview on 3/2/23 at 2:10 P.M., the surveyor observed that Resident #10 was not wearing TED stockings. Resident #10 said the TED stockings were in the bureau. The Resident said he/she was not able to put them on independently. The Resident said the staff had not asked about the stockings or put them on him/her for at least a couple of days. Review of the TAR for 2/26/23, 2/27/23, and 3/1/23, indicated that the nursing staff had been applying and removing the TED stockings but were not. During an interview on 3/2/23 at 2:30 P.M., the surveyor made Unit Manager #1 aware that staff had been documenting that they were applying and removing the TED stockings (2/26, 2/27, and 3/1/23). Unit Manager #1 said that they should not be documenting if it was not done. 3. Resident #43 was admitted to the facility in February 2022 with diagnoses including insulin dependent diabetes mellitus. a. Review of the February 2023 Physician's Orders indicated the following: Insulin Lispro solution 100 unit/ml, Amt, per sliding scale- subcutaneous. Special instructions: Sliding scale: If Blood Sugar is: *150-199 = (1 unit) *200-249 = (2 units) *250-299 = (3 units) *300-349 = (4 units) *350-399 = (6 units) *400--449= (8 units) *>450 (10 Units) and call physician; Before meals and at Bedtime (6:30 A.M., 11:30 A.M., 4:30 P.M., and 8:00 P.M.). Further record review did not indicate a physician's order to perform Capillary Blood Glucose (CBG)/Finger Stick Blood Sugar (FSBS) check at 6:30 A.M., 11:30 A.M., 4:30 P.M., and 8:00 P.M.) that correlated with the administration of the sliding scale insulin. b. Review of the February 2023 Physician's Orders indicated the following: Check Capillary Blood Glucose (CBG) once a day on Monday, Wednesday, and Friday (6:00 A.M.). The order start date was 11/28/22 and was open ended. The physician's order did not indicate instructions/ranges for physician notification of either a low CBG or a high CBG or protocols/interventions for either. During an interview on 3/2/23 at 1:30 P.M., Unit Manager #1 said there should be an order for obtaining/performing the CBG to correlate with the sliding scale, the CBG should have specific ranges for physician notification and that there should be protocols for low/high blood sugar interventions. c. Resident #43 was hospitalized in January 2023 and returned to the facility in February 2023. Review of the Hospital Discharge summary, dated [DATE], indicated but was not limited to the following: Discharge Diagnosis: Acute Kidney Injury (AKI) Bilateral hydronephrosis (A condition characterized by excess fluid in a kidney due to a backup of urine and is caused by a blockage in a tube that connects the kidney to the bladder.) -resolving Urinary Tract Infection (UTI) Proteinuria-Protein in the urine -Follow-up with Urology (branch of medicine that focuses on the urinary-tract system) -Proteinuria-Consider outpatient nephrology (branch of medicine that specializes in diseases that affect the kidneys and their ability to function) Further record review indicated that neither a Urology nor Nephrology consult/follow-up was completed as per the recommendations from the hospital. During an interview on 3/2/23 at 1:33 P.M., Unit Manager #1 said that no consults had been obtained/booked and that the physician never addressed the recommendations from the hospital. 4. Resident #90 was admitted to the facility in July 2021 with diagnoses that included diabetes mellitus (DM). Review of the February 2023 Physician's Orders indicated the following: Insulin Lispro solution 100 unit/ml, Amt, per sliding scale- subcutaneous. Special instructions: Sliding scale: If Blood Sugar is: *150-199 = (1 unit) *200-249 = (2 units) *250-299 = (3 units) *300-349 = (4 units) *350-399 = (6 units) *400--449= (8 units) *>450 (10 units) and call physician; Before meals and at Bedtime (6:30 A.M., 11:30 A.M., 4:30 P.M., and 8:00 P.M.). Further record review did not indicate a physician's order to perform CBG/Finger Stick Blood Sugar (FSBS) checks at 6:30 A.M., 11:30 A.M., 4:30 P.M. and 8:00 P.M. that correlated with the administration of the sliding scale insulin. During an interview on 3/2/23 at 1:30 P.M., Unit Manager #1 said that there should be an order for obtaining/performing the CBG to correlate with the sliding scale and there was not. 5. Resident #63 was admitted to the facility in August 2022 with diagnoses including rheumatoid arthritis and osteoarthritis. Review of the February 2023 Physician's Orders indicated the following: a. Apply air boot to feet while resting in bed. May remove boot for Activities of Daily Living (ADL), wound care and skin assessment. Reapply boot after completing task, every Shift. Days, Evenings, Nights (start date 1/27/23-open ended) b. Elevate legs/float heels while in bed as tolerated, every Shift. Days, Evenings, Nights (start date 9/20/22-open ended) c. Resident to have hand roll placed, on in the morning (8:00 A.M.) and taken off at 3:00 P.M. (start date 1/14/23-open ended) The surveyor observed the following: -On 2/26/23 at 9:51 A.M. and 2:00 P.M., Resident #63's hand rolls were not in place, in either hand, the heels were not floated, and the air boots had not been applied. -On 2/27/23 at 9:00 A. M., Resident #63's hand rolls were not in place, in either hand, the heels were not floated, and the air boots had not been applied. -On 3/1/23 at 11:00 A.M., Resident #63's hand rolls were not in place, in either hand, the heels were not floated, and the air boots had not been applied. Review of the Treatment Administration Record (TAR) documentation for 2/26/23, 2/27/23, and 3/1/23 indicated that the air boots were applied to the feet, legs/heels were floated, and the hand rolls were applied/in place as ordered by the physician. On 3/2/23 at 2:35 P.M., the surveyor, accompanied by Unit Manager #1, observed that the wedge used to float Resident #63's heels and the air boots were located on the Resident's bureau. The air boots had not been applied and the Resident's legs and their heels were not elevated/floated as ordered. The Resident's hand rolls were not in place. The Resident's fingernails of the 4th and 5th fingers appeared to be long and pressing against the skin of the Resident's palm which appeared to be reddened and excoriated. During an interview on 3/2/23 at 2:40 P.M., Unit Manager #1 said that the staff should not be documenting on treatments that they had not performed and that the air boots and hand roll had not been applied according to the physician's order and that the Resident's heels were not floated/legs elevated.

Based on record review and interview, the facility failed to ensure the Physician evaluated the residents' conditions and total program of care for four Residents (#45, #53, #91 and #63), out of a total sample of 21 residents. Specifically, the physician failed to review the following total programs of care: 1. For Resident #45, for the development of a diabetic wound; 2. For Resident #53, for the re-admission status of Resident #53 after emergency room evaluation following an adverse medication event; 3. For Resident #91, for the re-admission status of Resident #91with dehydration and an indwelling Foley catheter (flexible tube inserted through the urethra and into the bladder to drain urine); and 4. For Resident #63, for the wound of the left heel. Findings include: 1. Resident #45 was admitted to the facility in November 2017 with diagnoses including type 2 diabetes mellitus. Review of the medical record indicated a diabetic ulcer to the right great toe developed in February 2023. Review of a Nursing Progress Note, dated 2/2/23, indicated a covering Physician was notified of the wound and gave an order for the Resident to be seen by the consultant Wound Physician. Review of the Wound Evaluation and Management Summary from the consultant Wound Physician, dated 2/3/23, indicated Resident #45 had a diabetic wound of the right, medial, first toe, measuring 1.2 centimeters (cm) length by 0.4 cm width by 0.1 cm depth with dried fibrinous exudate (scab). The Wound Consultant made a recommendation to apply Bacitracin (topical antibiotic) to the wound twice daily for eight days and off-load (distribute the load to other areas which are not susceptible to pressure) the wound to prevent any trauma. Review of the Wound Evaluation and Management Summary from the consultant Wound Physician, dated 2/10/23, indicated the wound had deteriorated, measuring 1.2 cm length by 0.8 cm width by 0.1 cm depth with 5% granulation tissue (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process) and 95% dermis (the inner layer of the two main layers of the skin). The Wound Consultant made a recommendation to change the wound treatment to apply Bacitracin once daily for seven days and add a sterile gauze sponge and paper tape daily for 30 days. Review of the Wound Evaluation and Management Summary from the consultant Wound Physician, dated 2/17/23, indicated the wound had improved, measuring 1.2 cm length by 0.8 cm width by not measurable depth with 5% granulation tissue and 95% dermis. The Wound Consultant made a recommendation to discontinue the current treatment of Bacitracin once daily and to start Mupirocin ointment (used to treat secondarily infected traumatic skin lesions due to specific bacteria) once daily for nine days and continue sterile gauze sponge and paper tape daily for 28 days. Review of the Wound Evaluation and Management Summary from the consultant Wound Physician, dated 2/24/23, indicated the wound had improved, measuring 1.0 cm length by 0.6 cm width by not measurable depth with 10% granulation tissue and 90% dermis. The Wound Consultant made a recommendation to continue Mupirocin ointment once daily for eight days and continue sterile gauze sponge and paper tape daily for 21 days. Review of the medical record failed to indicate Resident #45 was seen by either the Physician or Nurse Practitioner during the month of February 2023 for evaluation of the Resident's change in condition and total program of care. 2. Resident #53 was admitted to the facility in September 2022 with diagnoses including Parkinson's disease (disorder of the central nervous system that affects movement) and chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe). Review of the medical record indicated Emergency Department documentation, dated 7/28/22, included but not limited to: -Patient presents to the emergency department from nursing home with reported change in mental status. Patient says he/she was given too many medications. Per Emergency Medical Services, the patient received 8 milligrams (mg) of Narcan (opioid reversal agent) which helped arouse him/her. Review of a Nursing Progress Note, dated 7/28/22, indicated: -At approximately 5:25 P.M., Resident was minimally responsive and confused. Resident was unable to keep his/her eyes opened, skin pale and slurring speech. Unable to get blood pressure. Administered Narcan with no change. 911 called and picked up Resident at approximately 6:10 P.M., Physician notified. Review of Physician/Nurse Practitioner Progress Notes failed to indicate Resident #53 was sent out to the hospital via 911 after being found unresponsive by staff, failed to review hospital documentation, and reassess the resident upon his/her return from the hospital. The Physician's progress note did not reflect a comprehensive review of the resident's medical care. During an interview on 3/1/23 at 9:27 A.M., the surveyor and Unit Manager #1 reviewed Resident #53's medical record. Unit Manager #1 was unable to find any documentation in the Physician's or Nurse Practitioner's Progress Notes that indicated the Resident was sent out to the hospital, the discharge documentation was reviewed, and the resident was reassessed after returning to the facility. During an interview on 3/2/23 at 9:41 A.M., the surveyor reviewed Resident #53's medical record with Physician #1. He said he does not recall the Resident being sent out to the hospital in July 2022. The Physician said if a resident goes out to the hospital, either he or the Nurse Practitioner would review the hospital documentation, reassess the resident and include that information in their notes. He said neither he nor the Nurse Practitioner documented anything in their records about Resident #52's ER visit via 911 in July 2022 3. Resident #91 was re-admitted to the facility with a new urinary catheter after a hospitalization for dehydration in November 2022. Review of the medical record indicated hospital documentation, dated 11/4/22, included but not limited to: -During the hospitalization the patient was found to be dehydrated, retaining urine, Foley was inserted by Urology -Plan is to discharge patient back to the nursing home with instructions to follow-up with Urology within 2 weeks for Foley removal. Review of a Nursing Progress Note, dated 11/25/22, indicated Resident #91 had a Foley catheter in place until he/she is seen by the urologist. Review of 19 Physician/Nurse Practitioner Progress Notes failed to indicate Resident #91 had a Foley catheter and had instructions from the hospital for a follow-up appointment with a Urologist for Foley catheter removal as follows: 11/8/22, 11/10/22, 11/15/22, 11/17/22, 11/29/22, 12/1/22, 12/15/22, 12/22/22, 12/27/22, 12/29/22, 1/3/23, 1/10/23, 1/24/22, 1/26/23, 1/30/23, 2/7/23, 2/9/23, 2/21/23, and 2/23/23. During an interview on 2/26/23 at 9:30 A.M., Resident #91 said that he/she had a Foley catheter placed in the hospital in November 2022. The surveyor observed a catheter tube hung on the bed frame and connected to a covered bag attached to the side of the bed. The Resident said he/she had not seen a Urologist or had a urinary voiding trial conducted to see if the Foley catheter could be discontinued. During an interview on 3/1/23 at 9:27 A.M., the surveyor and Unit Manager #1 reviewed Resident #91's medical record. Unit Manager #1 was unable to find any documentation in the Physician's or Nurse Practitioner's Progress Notes that indicated the hospital discharge documentation was reviewed, a follow-up appointment with the Urologist was ordered, and a clinical rationale for the continued use of the Foley catheter including a voiding trial was documented. During an interview on 3/2/23 at 9:41 A.M., the surveyor reviewed Resident #91's medical record with Physician #1. He said he does not recall reviewing hospital documentation from Resident #91's hospitalization in November 2022 and did not know the Resident was supposed to have a follow-up appointment with a urologist for Foley removal. The Physician said if he or the Nurse Practitioner had reviewed the Resident's hospital documentation and realized he/she had a new catheter, they would have documented it in their progress notes. 4. Resident #63 was admitted to the facility in August 2022 with diagnoses including rheumatoid arthritis and osteoarthritis. Record review indicated that on 9/9/22, staff identified that the Resident had developed deep tissue injuries (DTI- pressure-related injury to subcutaneous tissues under intact skin) of the right and left heels. Review of the medical record indicated Resident #63 was seen by the wound consultant physician on 9/9/22, 9/16/22, 9/23/22, and 9/30/22. Review of the Wound Consultant's Note, dated 10/7/22, indicated but was not limited to the following: NOTE: Signing off on patient who remains in the facility. Patient to be referred to Primary Care Physician (PCP) Left heel dressing twice a day (BID). Review of the Physician's Progress Notes, and the Nurse Practitioner's (NP) Notes indicated but were not limited to the following: -Physician's Progress Notes, dated 9/20/22 and 9/27/22, did not indicate/address that the Resident had developed DTIs of the right and left heels on 9/9/22. -Physician's Progress Note, dated 9/29/22, indicated that the Resident has an ulcer of the left foot, unspecified ulcer stage-wound specialist consult. Did not address the DTI of the Resident's right heel. -Physician's Progress Note, dated 10/4/22, indicated that the Resident has an ulcer of the left foot, unspecified ulcer stage-continue with dressing change. Did not address the DTI that was still present on the Resident's right heel. -NP's Progress Notes, dated 9/12, 9/19, 9/26, and 10/3/22, did not indicate/address that the Resident had developed DTIs of the right and left heels on 9/9/22. Review of the Wound Management Detail Report indicated that the DTI of Resident #63's right heel resolved on 10/10/22. Further review of the Physician's Progress notes, and the NP's Progress Notes indicated but were not limited to the following: -Physician's Progress Note, dated 10/13/22, indicated ulcer of left foot, unspecified ulcer stage. Culture of discharge, sensitive to Amoxicillin (an antibiotic) 500 milligrams three times a day until 10/28/22. -Physician's Progress Notes, dated 10/18/22 and 10/20/22, indicated ulcer of left foot, unspecified ulcer stage, continue with wound care. -Physician's Progress Note, dated 11/15/22, indicated ulcer foot/wound MD (The wound physician had discontinued services on 10/7/23). Physician's Progress Note, dated 12/20/22, indicated ulcer of left foot, unspecified ulcer stage. -NP's Progress Note, dated 10/17/22, indicated ulcer of left foot, unspecified ulcer stage. Wound MD to see the ulcer, culture the discharge (The wound physician had discontinued services on 10/7/22 and the culture had been obtained and the Resident was receiving an antibiotic until 10/28/22). -NP's Progress Note, dated 1/30/23, did not indicate that the Resident had a DTI of the left heel (not addressed in the progress note). The Physician's and NP's Progress Notes did not comprehensively address the condition of the DTI on the Resident's left heel in their progress notes. During an interview on 3/2/23 at 10:39 A.M., the Physician said that he was not aware that the wound physician had discharged the Resident back to his care on 10/7/22 regarding the Resident's wounds. He said that the facility's Assistant Director of Nursing was certified in wound care and felt that she would be telling him what the wound looked like and if there was a need for a change in the treatment. The physician reviewed his and the NP's progress notes and agreed they were not a comprehensive review of the total plan of care for Resident #63's wounds.

Based on observation, interview, and schedule review, the facility failed to ensure there was sufficient staff available to provide nursing services and care required to meet the residents' needs resulting in long wait times for call light response. Findings include: Review of the Facility Assessment, dated as last updated 11/1/22, indicated: All staffing is primarily based on the daily census on each unit. Each Resident's preference for schedule, waking times, naps, bathing, bedtime, etc., is reflected in their individual plan of care. Our current staffing patterns allow for these needs to be met on an individual basis. Staffing patterns are increased based on acuity and behavior, example being if a Resident needs 1:1 attention for a period of time, or need for 2 staff members to handle a transfer, such as with a Resident that requires a Hoyer lift (a device utilized to physically lift someone out of bed requiring 2 people). Review of the facility's policy titled Call Bell Policy, revised on 1/28/22, indicated it was the expectation that call lights would be answered promptly. Upon entrance to the facility on 2/26/23 at 7:30 A.M., the facility had a census of 99 residents in house (46 on Arborside, 39 on Birchside, and 14 on Cookside). During an interview on 2/26/23 at 9:45 A.M., Family Member #1 said there were not enough certified nursing assistants (CNA) at the facility and the ones who are working do not have enough time to provide care. He/she said it was scary to leave their loved one at the facility when there was not enough staff. Family Member #1 said on Saturday 2/25/23 there was one CNA on the Birchside unit from 12:00 P.M. to 3:00 P.M. and lunch was unable to be delivered on time. Review of the nursing staffing schedule for Saturday 2/25/23 indicated the following for the 7:00 A.M. to 3:00 P.M. shift: Arborside 46 residents: 3 CNAs from 12:00 P.M. until 3:00 P.M. Birchside 39 residents: 1 CNA from 12:00 P.M. to 3:00 P.M. Cookside 14 residents: 1 CNA from 7:00 A.M. to 3:00 P.M. During an interview on 3/1/23 at 4:50 P.M., Unit Manager #3 said she had come to the facility on 2/25/23 to help provide care to the residents on the Birchside unit. She said she arrived at the facility around 1:00 P.M. and assisted on the unit until 3:00 P.M. She said there was one CNA and herself working as a CNA as well as two nurses on the unit and they did the best they could. Review of the Birchside unit schedule indicated on 2/26/23 at 9:15 A.M. there were 3 CNAs for 39 residents. During an interview on 2/26/23 at 9:30 A.M., CNA #3 said she was leaving for the day and the Birchside unit would have 2 CNAs for 39 residents until another CNA arrived around 1:00 P.M. On 2/26/23 at 9:15 A.M., the surveyor observed the call light system on the Birchside unit to indicate a resident call light had been activated 19 minutes prior. The call light was observed to be answered at 9:17 A.M., after 21 minutes. On 2/26/23 at 10:48 A.M., the surveyor observed the call light system on the Birchside unit to indicate the call light for Resident #81 had been on for 15 minutes. During an interview on 2/26/23 at 12:00 P.M., Resident #81 said he/she waits 15 to 20 minutes for their call light to be responded to. He/she said they have limited mobility and are unable to do a lot of things for themselves. Review of the Birchside nursing staffing schedule indicated on 3/1/23 from 3:00 P.M. to 4:30 P.M. there were 2 CNAs for 39 residents. On 3/1/23 from 3:25 P.M. through 3:50 P.M., the surveyor observed the call lights on the Birchside unit. As of 3:28 P.M. one call light had been activated for 20 minutes. As of 3:45 P.M. that same call light had been activated for 37 minutes, an additional call light for 30 minutes and an additional call light for 19 minutes. The initial call light was answered at 3:50 P.M., after 42 minutes since activation. During an interview on 3/2/23 at 8:25 A.M., CNA #5 said there are times when there were only 2 CNAs working on the Birchside unit for 40 residents, making it difficult to respond to call lights timely. She said at this time there were 3 CNAs on the unit for 40 residents. On 3/2/23 from 8:33 A.M. through 8:45 A.M., the surveyor observed the call lights on the Birchside unit. At 8:33 A.M., the call light for Resident #23 had been activated for 32 minutes, an additional call light for 15 minutes and another for 13 minutes. During an interview on 3/2/23 at 8:39 A.M., (after waiting 38 minutes) Resident #23 said they wanted their room light shut off so they could go back to sleep. The Resident said he/she often waits a long time for the call light to be answered. At 8:44 A.M., the surveyor observed the call light for Resident #16 had been activated for 20 minutes. During an interview on 3/2/23 at 8:45 A.M., Resident #16 said he/she had been waiting for their urinal and thought the staff had forgotten about him/her. He/she said the normal wait time for a call light is 30 minutes. During an interview on 3/1/23 at 3:23 P.M., the Director of Nurses said the management staff had been personally filling in as many open positions for nurses or as CNAs as they could. She said the facility was having difficulty obtaining staff from the contracted staffing agencies. During an interview on 3/1/23 at 3:28 P.M., Scheduler #1 said she usually contacted three different nursing staffing agencies to attempt to get staff and had only had success with one of the agencies who had been able to provide three CNAs. She said she previously was able to work with two staffing agencies who were able to send nursing staff to the facility, but those two agencies would no longer send staff. During an interview on 3/2/23 at 12:53 P.M., the Administrator said the approach to call lights was for all staff, not just the CNAs, to answer call lights so that no Resident has to wait that long for a call light to be answered. Refer to F835

Based on record review, policy review, and interview, the facility failed to have the attending physician review and sign the identified pharmacological recommendations so that action could be taken to address them for one Resident (#38), in a sample of five residents reviewed for unnecessary medications. Findings include: Review of the facility's policy titled Pharmacy Consultant Med Review, dated as revised in January 2023, indicated: -the pharmacy consultant will document his/her findings and recommendations on the monthly drug/regimen review report -the unit manager/designee will make sure all recommendations are acted upon, all recommendations are reported to the physicians, there is documentation in the chart that notification and follow-up occurred, notify the resident's physician of recommendations and document in the resident's chart that this was done, and remind the physician to sign the resident's consultant report. Resident #38 was admitted to the facility in January 2016 with diagnoses of depression and anxiety. Review of the medical record for Resident #38 indicated the pharmacy consultant had recommendations on the following dates: -4/27/22 -9/1/22 -9/27/22 -10/25/22 -12/23/22 Review of the Pharmacy Consultant's Note to the Attending Physician/Prescriber indicated the following: 4/27/22: please review the following medications (Trazodone, Ativan, Remeron) as potential contributing factors and determine if the dose reduction/discontinuation might be appropriate. The form did not indicate the physician/prescriber had responded and the form was not signed by the physician. 9/1/22: please consider reducing the dose of Levaquin. The form indicated the physician agreed and the dose was decreased. The form was not signed by the physician. 9/27/22: please re-evaluate this order (Trazodone as needed), stating a rationale to continue and a measurable duration. The form indicated the physician agreed and indicated re-eval continue with treatment. and was not signed by the physician. The record review did not include any evaluation completed by the physician for the as needed Trazodone. 10/25/22: please re-evaluate this order (Trazodone as needed) stating the rationale to continue and a measurable duration per the regulation. The form indicated the physician disagreed with writing a rationale to continue and a measurable duration. The form was signed by the Director of Nurses, not the physician. During an interview on 3/1/23 at 2:10 P.M., the Director of Nurses said they were unable to locate the Note to Attending Physician/Prescriber reviewed or signed by a physician on 4/27/22. She said she the other forms were not signed by the physician as she did not know the physician had to sign them. She said the process was for the nurse to call the physician and receive a telephone order with any recommendations. She said the recommendations from 9/27/22 and 10/25/22 for evaluation of the as needed Trazodone had not been completed by the physician.

Based in record review, policy review and interview, the facility failed to ensure that the resident's drug regimen was free from unnecessary drugs without adequate monitoring in place for six Residents (#45, #91 #10, #34, #43 and #90) from a total sample of 21 residents. Specifically, the facility failed to ensure that: 1. Residents #45, #91, #10, and #34 had been monitored for signs/symptoms of adverse consequences (i.e., side effects) and the effectiveness of an anti-coagulant; and 2. Residents #43 and #90 had been monitored for signs/symptoms of adverse consequences (i.e., side effects) and the effectiveness of an anti-diabetic agent. Findings include: 1. Review of the facility's policy titled Anticoagulant Therapy, last revised 1/2022, included but was not limited to: -The staff and physician will identify and address potential complications in individuals receiving anticoagulation; for example, someone with a fall risk, a history of gastrointestinal bleeding, or poorly controlled hypertension; -The staff and physician will monitor for possible complications in individuals who are being anticoagulated, and will manage related problems A. Resident #45 was admitted to the facility in November 2017 with diagnoses including chronic atrial fibrillation. Review of the February 2023 Physician's Order included but was not limited to: -Eliquis (anticoagulant) 5 milligrams (mg) twice daily (4/9/21) The physician's order failed to include monitoring of potential complications/adverse consequences for the use of Eliquis. Review of August 2022 through March 2023 Medication Administration Records (MAR) indicated that Eliquis was administered as ordered by the physician. Review of interdisciplinary care plans included but was not limited to: -Focus: Resident receives an anticoagulation medication, which may increase his/her risk for bleeding (8/31/22) -Approach: Inform Physician/Nurse Practitioner with any symptoms of bleeding for further orders (8/31/22); Monitor for any signs/symptoms of bleeding: bleeding gums, excessive or easily bruising, petechiae (pinpoint, round spots that appear on the skin as a result of bleeding), nosebleeds, melena (black colored stool), tarry stools, hematuria (blood in the urine), hematemesis (vomiting blood) and change in mental status (8/31/22) -Goal: Bleeding signs and symptoms will be observed promptly and appropriate measures will be taken immediately (target date-11/28/22) Further review of the medical record failed to indicate that staff monitored the Resident for signs of bleeding as required. B. Resident #91 was admitted to the facility in September 2022 with diagnoses including atrial fibrillation. Review of the February 2023 Physician's Orders included but was not limited to: -Eliquis 5 mg twice daily (9/13/22) The physician's order failed to include monitoring of potential complications/adverse consequences for the use of Eliquis. Review of September 2022 through March 2023 MAR/Treatment Administration Records (TAR) indicated that Eliquis was administered as ordered by the Physician. During an interview on 3/1/23 at 9:27 A.M., the surveyor and Unit Manager #1 reviewed Resident #45 and #91's medical records. The Unit Manager said staff is not monitoring any residents on anticoagulant therapy for potential adverse consequences or complications but should be. C. Resident #10 was admitted to the facility in November 2021 with diagnoses that included chronic atrial fibrillation. Review of the MAR indicated that the Resident was receiving Warfarin (also known as Coumadin, anticoagulant) 4 mg daily at 8:00 P.M. from 2/24/23 through 3/1/23, with an International Ratio (INR) to be drawn on 3/2/23. The value of the INR determines the dose of the Warfarin to be administered. Review of interdisciplinary care plans indicated but was not limited to the following: -Focus: Resident receives an anticoagulation medication, which may increase his/her risk for bleeding (8/22/22) -Long Term Goal: Bleeding signs and symptoms will be observed promptly, and appropriate measures will be taken immediately (target date11/19/22) -Approach: -Monitor for any signs/symptoms of bleeding: bleeding gums, excessive or easily bruising, petechiae, nosebleeds, melena, tarry stools, hematuria, hematemesis, and change in mental status (11/19/22) -Provide anticoagulation medication as ordered (11/19/22) -Obtain INR as ordered, report to Physician/Nurse Practitioner (8/22/22) Further record review failed to indicate a physician's order for the staff to monitor for signs and symptoms of bleeding or that staff had monitored the Resident for signs of bleeding as required. D. Resident #34 was admitted to the facility in March 2021 with diagnoses that included history of venous thrombosis and emboli and long term use of anticoagulants. Review of the February 2023 Physician's Orders indicated Resident #34 was receiving Xarelto (an anticoagulant) 15 mg one tablet- once a day at 7:00 P.M. Review of the interdisciplinary care plans indicated but was not limited to the following: -Focus: Resident receives an anticoagulation medication, which may increase his/her risk for bleeding (8/23/22) -Long Term Goal: Bleeding signs and symptoms will be observed promptly and appropriate measures will be taken immediately (target date-11/20/22) -Approach: -Inform Physician/Nurse Practitioner with any symptoms of bleeding for further orders (11/20/22) -Monitor for any signs/symptoms of bleeding: bleeding gums, excessive or easily bruising, petechiae, nosebleeds, melena, tarry stools, hematuria, hematemesis, and change in mental status (11/20/22) -Provide anticoagulation medication as ordered (11/20/22) Further record review failed to indicate a physician's order for the staff to monitor for signs and symptoms of bleeding or that staff had monitored the Resident for signs of bleeding as required. During an interview on 3/2/23 at 12:55 P.M., Unit Manager #1 said that an order was obtained on 3/1/23 for staff to monitor Resident #10 and Resident #34, but prior to that date, the staff was not monitoring for potential adverse consequences or complications (signs and symptoms of bleeding related to anti-coagulant use) but should have been. 2. Review of the facility's policy titled Diabetic Management, dated 1/2023, indicated but was not limited to the following: It is the policy of the facility to: -Quickly restore normal cerebral function and prevent hyperglycemia or hypoglycemia -Recognize, treat, or prevent complications commonly associated with diabetes Documentation Guidelines: Symptoms of hyperglycemia (diabetic acidosis-high blood sugar), care provided and residents response to care Symptoms of hypoglycemia (insulin reaction-low blood sugar), care provided and residents response to care Notification of the physician of change in condition. A. Resident #43 was admitted to the facility in February 2022 with diagnoses including insulin dependent diabetes mellitus. Review of the February 2023 Physician's Orders indicated the following: -Insulin Lispro (short-acting insulin) solution 100 unit/ml, Amt, per sliding scale- subcutaneous. Special instructions: Sliding scale: If Blood Sugar is: 150-199 = (1 Unit); 200-249 = (2 Units); 250-299 = (3 units); 300-349 = (4 units); 350-399 = (6 units); 400--449= (8 Units); >450 (10 Units) and call physician; Before meals and at Bedtime (6:30 A.M., 11:30 A.M., 4:30 P.M., and 8:00 P.M.). -Insulin Glargine (long-acting insulin) solution 100 unit/ml amt.-16 units, subcutaneous, once a day at 6:00 A.M. Further record review failed to indicate a physician's order for the staff to monitor for signs and symptoms of hypo/hyperglycemia or that staff had monitored the Resident for signs of hypo/hyperglycemia as required. B. Resident #90 was admitted to the facility in July 2021 with diagnoses that included diabetes mellitus (DM). Review of the February 2023 Physician's Orders indicated the following: -Humalog U 100 insulin (Insulin Lispro) solution 100 unit/ml, Amt, per sliding scale- subcutaneous. Special instructions: Sliding scale: If Blood Sugar is: 150-199 = (1 Unit); 200-249 = (2 Units); 250-299 = (3 units); 300-349 = (4 units); 350-399 = (6 units); 400--449= (8 Units); >450 (10 Units) and call physician; Before meals and at Bedtime (6:30 A.M., 11:30 A.M., 4:30 P.M., and 8:00 P.M.). Lantus U 100 (insulin Glargine) solution amt.-30 units, subcutaneous, once a day at 6:00 A.M. Further record review failed to indicate a physician's order for the staff to monitor for signs and symptoms of hypo/hyperglycemia or that staff had monitored the Resident for signs of hypo/hyperglycemia as required. During an interview on 3/2/23 at 12:55 P.M., Unit Manager #1 said that Resident #43 and Resident #90 should have had physician's orders in place for staff monitoring for potential adverse consequences or complications (signs and symptoms of hypoglycemia or hyperglycemia) related to insulin use but did not.

4. Resident #86 was admitted to the facility in January 2023 with diagnoses which included a recent left below knee amputation, major depressive order disorder, and generalized anxiety. Review of the Physician's Orders indicated there were two orders for as needed -Alprazolam (psychotropic medication) 1 mg tablet, twice a day as needed for anxiety: a. Start date 1/16/23, end date 2/7/23 (Beyond 14 days) b. Continuation order dated 2/7/23 which had no stop date. Review of the MAR indicated but was not limited to the following: -1/19/23 through 2/27/23, Resident #86 was administered Alprazolam 1mg on 13 occasions. Review of physician, nurse practitioner, and psych notes, dated 1/30/23 and 2/13/23, did not indicate a written rationale for continuing the as needed Alprazolam past 14 days. Review of the Nursing Progress Notes, dated 1/30/23 and 2/13/23, did not indicate the physician was contacted to extend the as needed Alprazolam medication. During an interview on 3/01/23 at 11:45 A.M., Unit Manager #3 said the process for as needed psychotropic medication is for the order to be written for 14 days and then to contact the physician to see if he wants to continue or discontinue the medication. She said if the doctor wants the medication to continue, the nurse writes new orders for 14 days and should write a nursing note indicating the doctor wants to continue the medication. Unit Manager #3 said the communication is usually done verbally with the physician and she is not aware if the doctor writes a note for the rationale to continue the medication. 3. Resident #38 was admitted to the facility in January 2016 with diagnoses of depression and anxiety. Review of the medical record indicated Resident #38 had an order for Trazodone as needed (PRN) on the following dates: 8/2/22 through 10/27/22 10/27/22 through 1/31/23 1/31/23 with no end date Review of the Physician's Orders included an order written on 10/27/22 through present to re-eval the PRN Trazodone and to write a note whether to continue or d/c (discontinue). The order was signed off as completed by a nurse on the 14th and 28th of each month. Review of the Note to Attending Physician/Prescriber forms indicated the pharmacy consultant recommended the following: 9/27/22: please re-evaluate this order (Trazodone as needed), stating a rationale to continue and a measurable duration. The form indicated the physician agreed and indicated re-eval continue with treatment. and was not signed by the physician. 10/25/22: please re-evaluate this order (Trazodone as needed) stating the rationale to continue and a measurable duration per the regulation. The form indicated the physician disagreed with writing a rationale to continue and a measurable duration. The form was signed by the Director of Nurses, not the physician. Review of the Nursing Progress Notes indicated the nurses had documented the following: 11/14/22: order to continue the PRN Trazodone as ordered 11/28/22: continue with PRN Trazodone at this time due to frequent use 1/14/23: continue PRN Trazodone at this time due to resident use Review of all Physician Progress Notes (8/30/22, 9/19/22, 10/3/22, 10/25/22, 11/21/22, 12/22/22, 1/3/23, 2/27/23) failed to indicate the physician had participated in the re-evaluation of the PRN Trazodone. During an interview on 3/2/23 at 8:51 A.M., the Physician said the PRN Trazodone for Resident #38 should have an end date and the re-evaluation of the medication should have been reflected in his progress notes. During an interview on 3/2/23 at 9:20 A.M., the Director of Nurses said she had reviewed the medical record of Resident #38 and was unable to locate the physician re-evaluation of the PRN Trazodone. She said the current PRN order for Trazodone does not have an end date to reflect the duration of use. Based on interview, policy review, and record review, the facility failed to ensure four Residents (#53, #91, #38, and #86) were free from unnecessary psychotropic medications, in a total sample of 21 residents. Specifically, the facility failed to ensure: 1. For Resident #53, resident specific, targeted behaviors were identified and monitored for the use of the psychotropic medications Sertraline (antidepressant) and Quetiapine (antipsychotic); 2. For Resident #91: a. resident specific, targeted behaviors were identified and monitored for the use of the psychotropic medications Cymbalta (antidepressant) and Zyprexa (antipsychotic), and b. an as needed (PRN) psychotropic medication included a duration for use and was reviewed by the physician with a documented rationale for continued use; 3. For Resident #38, a psychotropic medication ordered PRN included a duration for use and was reviewed by the physician with a documented rationale for continued use; and 4. For Resident #86, the initial order for psychotropic medication was limited to 14 days, a written rationale to extend as needed (PRN) psychotropic medications past 14 days was provided, and a stop date for the second order written extending the use of the psychotropic medication was included. Findings include: Review of the facility's policy titled Psychotropic Medications, last revised February 2022, included but was not limited to: -The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in the long-term care facility to include regular review for continued need, appropriate dosage, side effects, risks and/or benefits; -Attending Physicians must document that a psychotropic medication is necessary to treat a specific condition/behavior; -Other medications not classified as a psychotropic that can also act like a psychotropic should not be used as a substitute for a psychotropic without proper clinical documentation for its use; -Residents should not receive as needed (prn) doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record; -The need to continue prn orders for psychotropic medication beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the prn order will be indicated in the order. 1. Resident #53 was admitted to the facility in September 2021 with diagnoses including major depressive disorder. Review of the Minimum Data Set (MDS) assessment, dated 9/23/21, indicated Resident #53 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and received psychotropic medication daily. Review of the February 2023 Physician's Orders included but was not limited to the following: -Sertraline (antidepressant) 75 milligrams (mg) at bedtime (1/22/22) -Quetiapine (antipsychotic) 100 mg at bedtime (1/9/23) The physician's order failed to include monitoring of targeted behaviors, signs/symptoms for the use of Sertraline and Quetiapine as required. Review of the February 2023 Medication Administration Records (MAR) indicated Resident #53 received Sertraline and Quetiapine as ordered by the physician. Further review of the medical record failed to indicate Resident specific, targeted behaviors were monitored for the use of Sertraline and Quetiapine as required. 2. Resident #91 was admitted to the facility in September 2022 with diagnoses including Parkinson's disease (disorder of the central nervous system that affects movement) and anxiety. Review of the MDS assessment, dated 12/15/22, indicted Resident #91 was cognitively intact as evidenced by a BIMS score of 15 out of 15 and received psychotropic medication daily. Review of the February 2023 Physician's Orders included but was not limited to the following: -Cymbalta 20 mg once a day (10/27/22) -Zyprexa 5 mg once a day (11/19/22) -Valium 1 mg every 12 hours PRN (11/8/22-open ended) -Re-evaluate continued use of Valium, document rationale for continued use on the 14th, 28th of the month (11/8/22) a. The physician's order failed to include monitoring of targeted behaviors, signs/symptoms for the use of Cymbalta, Zyprexa and Valium as required. b. Review of the medical record failed to indicate the Physician re-evaluated and documented a clinical rationale for Resident #91's continued use of PRN Valium as required. During an interview on 3/1/23 at 9:27 A.M., the surveyor and Unit Manager #1 reviewed Resident #91's medical record. The Unit Manager said the Physician did not re-evaluate the Resident's use of PRN Valium and did not document a clinical rationale for its continued use. She said no Resident specific targeted behaviors have been identified or monitored for the use of psychotropic medications. During an interview on 3/2/23 at 9:41 A.M., Physician #1 said that neither he nor his Nurse Practitioner had re-evaluated Resident #91's use of PRN Valium and had not documented a clinical rationale for its continued use.

Based on observation, test tray results, and interview, the facility failed to ensure that staff served food that is palatable and at an appetizing temperature on 2 out of 3 units, for 2 out of 2 test trays conducted. Findings include: Test Tray #1: On 2/27/23 at 12:04 P.M., Food Truck #2 left the main kitchen, and arrived on the Birchside Unit at 12:06 P.M. The surveyor observed that meal service began at 12:08 P.M. and the food truck door remained open while staff removed trays from the truck and distributed them to residents in the dining room and in their rooms. At 12:21 P.M., the surveyor, Staff #2, and Staff #4, conducted a test tray with the last tray that was removed from the food truck, and the results in degrees Fahrenheit (F) were as follows: -milk 50 F and slightly cool to taste -spaghetti and meat sauce: 130 F tepid (lukewarm) to taste -tapioca pudding: 60 F warm to taste -green beans: 100 F cool and bland to taste -garlic toast: 90 F tepid to taste The food was not served at a palatable and appetizing temperature. During an interview on 2/27/23 at 12:10 P.M., Staff #2 and Staff #4 said residents often complain that the food is too cold. Test tray #2: On 3/1/23 at 11:41 A.M., the surveyor requested a test tray be prepared for the Arborside Unit. On 3/1/23 at 12:40 P.M., the surveyor observed the residents' food trays be prepared and loaded into the food truck for the Arborside Unit. At 12:51 P.M., the food truck left the kitchen, and arrived on the Arborside Unit at 12:55 P.M. At 1:10 P.M., the surveyor and the Corporate Food Service Director (FSD) conducted a test tray with the last tray that was removed from the food truck, and the results were as follows: Rice-130 F (lukewarm) Pork Chop-120 F (lukewarm) Vegetable-120 F (lukewarm) Chocolate Milk-68 F (warm to taste) Coffee-140 F The food was not served at a palatable and appetizing temperature. During an interview on 3/1/23 at 1:20 P.M., the Corporate FSD agreed that the food was not served at a palatable temperature, especially the milk.

Based on observations and interviews, the facility failed to store, distribute, and serve food under sanitary conditions to promote safe food handling. Findings include: During an initial tour of the main kitchen on 2/26/23 at 8:15 A.M., the surveyor observed: --microwave oven under the food preparation counter had multiple brown, yellow, and orange splatters on all surfaces -industrial mixer had white, pink, and brown dried substances stuck onto the attachment hub During an interview on 2/26/23 at 8:20 A.M., [NAME] #1 said that dietary service department has had low staffing for a while and cleaning has not been done regularly. She said there is no master cleaning list or daily cleaning assignments. On 2/27/23 at 8:08 A.M., the surveyor reviewed the Arborside Unit nourishment kitchen and observed the following: -microwave oven had multiple dried food splatters (yellow, orange, and red) on all surfaces -freezer with thick ice stained with a brown substance built up along the sides and bottom of the freezer On 2/27/23 at 8:21 A.M., the surveyor reviewed the Cookside Unit nourishment kitchen and observed the following: -microwave oven had multiple dried food splatters and crumbs (brown, yellow, and orange) on all surfaces -refrigerator thermometer reading was 15 degrees Fahrenheit -freezer with thick ice buildup along the sides and bottom of the freezer On 2/27/23 at 8:25 A.M., the surveyor reviewed the Birchside Unit nourishment kitchen and observed the following: -microwave oven had multiple dried food splatters and crumbs (yellow, white, and orange) on all surfaces -refrigerator thermometer reading was 51 degrees Fahrenheit -all shelves of the refrigerator had multiple sticky pink, clear, and brown splatters During an interview with observation on 2/27/23 at 8:35 A.M., the surveyor and Food Service Manager (FSM) reviewed the Arborside Unit, Cookside Unit, and Birchside Unit nourishment kitchens together. The FSM said the thermometers must not be functioning properly and need to be replaced, and the refrigerator/freezers need to be cleaned and defrosted. 2. On 3/1/23 from 11:40 A.M. through 12:40 P.M., the surveyor observed the following in the dish room and main kitchen: -Numerous black flying insects were present in the kitchen, especially in the dish room. -The hand sink in the dish room area had numerous black flies present and the sink was visibly dirty with food debris present. -A metal cart located just outside the dish room had black flying insects present. -The walls in the dish room were visibly dirty with dried food/debris. -Two beige carts in the dish room were gouged and scratched and did not have a smooth surface for effective cleaning. -The food preparation area had small black flying insects present. -The floors in the dry storage room had numerous non-food items and food items present under the shelving. Review of the Pest Control Service Summary, dated 1/27/23, indicated but was not limited to the following: Notes: Met with the Director of Maintenance. She told exterminator that the fruit fly activity has been heavier . Performed a treatment for fly activity throughout the kitchen. Kitchen is overly wet, lots of standing water, which is one of the reasons why the fly activity is heavier than usual. Review of the Pest Control Service Summary, dated 2/27/23, indicated but was not limited to the following: Notes: Met with the Director of Maintenance. She told the exterminator that the fruit fly activity in the kitchen is still heavy and there was a mouse sighting recently. When I inspected the kitchen, I found sanitation needing improvement. The kitchen was very puddly and there is too much old standing water in sinks and trash barrels are too full with old food, all conducive conditions for pest activity. Please address sanitation issue to kitchen staff. During an interview on 3/1/23 at 3:30 P.M., the surveyors met with the FSD and reviewed the sanitation concerns. The FSD confirmed that the kitchen was unclean and unsanitary.

Based on observations and interviews, the facility failed to ensure it was administered in a manner that enabled it to use resources effectively to attain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the corporate operations for contracts failed to re-evaluate the use of the preferred vendors of staffing agencies. Findings include: During the recertification survey conducted from 2/26/23 through 3/2/23 the surveyor interviewed families and residents who had concerns with insufficient staffing. In addition, the surveyors observed long call light wait times. During an interview on 3/1/23 at 3:23 P.M., the Director of Nurses said the management staff had been personally filling in as many open positions for nurses or Certified Nursing Assistants (CNA) as they could. She said the facility was having difficulty obtaining staff from the contracted staffing agencies. She said there was an issue with payment to the staffing agencies and did not have any additional information. During an interview on 3/1/23 at 3:28 P.M., Scheduler #1 said she usually contacted three different nursing staffing agencies to attempt to get staff and had only had success with one of the agencies who had been able to provide three CNAs. She said she previously was able to work with two staffing agencies who were able to send nursing staff to the facility, but those two agencies would no longer send staff due to non-payment for services. During an interview on 3/2/23 at 12:53 P.M., the Administrator said they have contracts with six staffing agencies, but the staffing agencies do not have the nursing staff to send to the facility. He said only two out of the six staffing agencies have sent a total of five CNAs and no nurses. He said there were previously two additional staffing agencies that had been sending nursing staff to the facility, Agency #1 had stopped sending staff four or five months prior and Agency #2 had stopped sending staff two months prior. He said both of these staffing agencies had stopped sending staff due to a lack of payment which was not handled on a facility level. During an interview on 3/2/23 at 1:09 P.M., the Corporate Regional Administrator said she was aware the facility was unable to utilize Agency #1 and Agency #2, which had previously been able to supply the facility with nursing staff. She said she was under the impression the Corporation had set up a payment plan with both agencies. The surveyor requested documentation or communication from the Corporation to demonstrate a plan for working with the agencies who were able to supply staff. During an interview on 3/2/23 at 2:10 P.M., a Corporate Liaison for contracts said the Corporation had preferred vendors and was choosing to no longer utilize Agency #1 and Agency #2. She said the Corporation was not re-evaluating the nursing staffing agencies the facility used, despite the lack of nursing staff being sent by the current agencies. She said these decisions are made at a company level and not at a facility level.

Based on interview and document review, the Medical Director failed to attend the last two quarterly Quality Assessment and Performance Improvement (QAPI) meetings as required. Findings include: During an interview on 3/02/23 at 9:56 A.M. , the Medical Director said that he has not attended a QAPI meeting for approximately six months and has not received any notification as to when the meetings were scheduled. Review of the Sign-In Sheets for the quarterly QAPI meetings in October 2022 and January 2023 indicated the Medical Director had not been present at the meeting as evidenced by his missing signature. During an interview on 3/02/23 at 3:03 P.M., the Administrator said he had not notified the Medical Director of the schedule for the QAPI meetings.

Based on observation, interview, policy review, and review of staff and resident testing logs, and resident records, the facility failed to ensure outbreak testing for COVID-19 was implemented for staff and residents following as per facility policy. Specifically, the facility failed to: 1. Ensure staff COVID-19 weekly testing was accurately documented and completed for all staff until the facility went 14 days without a new case, and 2. Ensure 4 out of 6 residents reviewed were tested per the recommendations of Department of Public Health (DPH) Rapid response team and documented in medical record during outbreak testing. Findings include: Review of the infection control line listing for staff and residents indicated a staff personnel tested positive for COVID-19 on 12/18/22, and the facility remains in outbreak with the last positive staff case on 2/22/23. Review of the facility's policy titled Outbreak Testing Infection Control, dated 10/17/22, indicated but was not limited to the following: -It is the policy of this facility to follow all updated regulatory guidance from Centers for Disease Control and Prevention (CDC), CMS, and DPH regarding resident care during the COVID-19 pandemic. Testing: -Once a new case is identified the facility should initiate outbreak testing. Outbreak testing should include: -Testing all staff and residents on the affected units must take place as soon as possible. -Staff and residents who are recovered from COVID-19 in the last 30 days can be excluded from this testing. -After an initial round of testing: -Facilities should test exposed residents and staff at least every 48 hours on the affected unit until the facility goes 7 days without a new case, and then; -Once per week until the facility goes 14 days without a new case unless DPH epidemiologist directs otherwise. - If no additional cases are identified in the first 7 days of outbreak testing, it is not necessary to continue weekly testing until day 14. Review of the Centers for Medicare and Medicaid Services (CMS) guidance titled Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements, dated September 2022, indicated but was not limited to the following: - Documentation of Testing: a. Facilities must demonstrate compliance with the testing requirements. b. Facilities may document the conducting of tests in a variety of ways, such as a community transmission levels, schedules of completed testing, and/or staff and resident records. 1. During an interview on 3/1/23 at 4:05 P.M., the Infection Control (IC) Nurse said they have not made it out of outbreak mode, because they have not cleared their 14 days with no new staff or resident testing positive. She said the staff should be testing every Friday, they fill out a form with the lot number and the test results and then are supposed to log the results onto the log sheet for the month. The surveyor and IC Nurse reviewed the log sheet, which included the completed weekly test results for the week of 2/5 through 2/11/23, week of 2/12 through 2/18/23 and week of 2/19 through 2/25/23. Review of the completed logs for three weeks of testing indicated that a large majority of staff had not documented their test results on the log. The IC Nurse said there has been a problem with staff completing their testing. She said looking at these logs, she has no way of knowing if all the staff completed their weekly testing. Review of the outbreak testing, dated 2/5/23 through 2/11/23, indicated out of the 124 staff listed on the log, 76 staff members did not test. Review of the outbreak testing, dated 2/12/23 through 2/18/23, indicated out of the 124 staff listed on the log, 88 staff members did not test. Review of the outbreak testing, dated 2/19/23 through 2/25/23, indicated out of the 124 staff listed on the log, 92 staff members did not test. During an interview on 3/02/23 at 09:20 A.M., the Administrator said he was not aware there were any issues with the ongoing COVID-19 testing for staff. He said he believes the DON and the IC Nurse are in contact with the DPH epidemiologist and they guide the facility. The Administrator said, if a staff member has not tested as scheduled, they should not be working. During an interview on 03/02/23 at 09:30 A.M., the DON said the staff logs that were given to the surveyor were incomplete, the IC Nurse has a pile of completed COVID-19 tests that have just not been added to the log. The DON said, she sees people on the log that have not been tested and are out working on the floors now. She said it has been difficult to keep up with tracking and logging in the COVID-19 tests when we are all on the carts. The DON said we are working on going through the pile of tests right now, but the incomplete log is the only tracking I have now. The DON said she can't confirm right now that everyone working in the building has completed their weekly testing. 2. Review of e-mail correspondence between the Director of Nurses (DON) and the epidemiologist from DPH, dated 12/19/22, indicated but was not limited to the following: We have positives over the weekend, both on the Birchside unit. Unit is on quarantine and staff and resident testing every other day. The positive resident recently went out to the emergency room. Review of teleconference communication with Rapid Response Staff (emergency staffing provided by the Department of Public Health) for outbreak testing indicated but was not limited to the following: Start of COVID-19 outbreak on 12/18/22: -2/3/23 Contact with Rapid Response via teleconference. Cookside and Birchside Unit staff and residents tested testing daily. Arborside Unit tests weekly and if any symptomatic residents. -2/4/23 Contact with Rapid Response via teleconference. Continue with Cookside and Birchside Unit staff and resident testing daily and if any symptomatic residents. Arborside Unit tests weekly and if symptomatic. -2/6/23 Contact with Rapid Response via teleconference. Continue with Cookside and Birchside Unit staff and resident testing daily and if any symptomatic residents. Arborside Unit test weekly and if symptomatic. -2/7/23 Contact with Rapid Response via teleconference. Staff and residents on Cookside Unit testing change to every other day, Arborside Unit every other day, Birchside Unit test daily. -2/8/23 Contact with Rapid Response via teleconference. Residents on Cookside Unit test on day 7 (2/9) and day 14 (2/16). Staff and residents on Birchside Unit every other day, staff and residents on Arborside Unit test every other day then residents on day 7 and day 14 and staff weekly. -2/9/23 Contact with Rapid Response via teleconference. Residents on Cookside and Arborside Units, test on day 7 (2/9) and day 14 (2/16). Birchside Unit test every other day. Staff on Arborside and Cookside Unit test weekly, Birchside Unit every other day. -2/10/23 Contact with Rapid Response via teleconference. Residents on Cookside and Arborside Unit test on day 14 (2/16). Birchside Unit every other day. Staff on Arborside and Cookside Unit test weekly, Birchside Unit staff every other day. -2/17/23 Contact with Rapid Response via teleconference. Residents and staff on Arborside and Birchside Unit test daily. Cookside Unit staff weekly. -2/18/23 Contact with Rapid Response via teleconference. Last daily testing (2/18). Continue testing Arborside and Birchside Units on day 7 (2/25) and day 14 (3/4). Staff weekly. -2/19/23 Contact with Rapid Response via teleconference. Arborside and Birchside test on day 7 (2/25) and day 14 (3/4). Staff weekly. Continue with weekly testing for staff and symptomatic residents next testing date for residents is March 4th. Review of testing results and documentation for six Residents, two from each unit (Arborside, Birchside and Cookside) indicated the following missing tests: Random sample of six residents, two from each unit were reviewed for COVID-19 testing compliance from 2/3 through 2/25 as recommended by Rapid Response. The IC Nurse provided the available documentation for the COVID-19 tests and results for the following residents: Cookside Residents: -Resident #54- Missing COVID-19 tests, 2/3, 2/4, 2/5, 2/9, 2/16. -Resident #19- Missing COVID-19 tests, 2/4, 2/5, 2/9, 2/16 (performed admission testing on day 2/3 and 2/6). Birchside Residents: -Resident #48- Missing COVID-19 tests 2/3, 2/4, 2/5, and 2/9 (Resident tested positive for COVID-19 on 2/12/23). -Resident #38- No documentation of COVID-19 testing provided from 2/3 to 2/25/23. Arborside Residents: -Resident #53- Completed all required testing -Resident #45- Completed all required testing During an interview on 3/2/23 at 3:05 P.M., the IC Nurse said COVID-19 tests that were supposed to be performed per the recommendations of the DPH epidemiologist and Rapid Response team were not all documented in the medical record. She said she has no tracking log to determine if all testing for the residents was completed per the recommendations of the outbreak testing. During an interview on 3/2/23 at 3:30 P.M., Unit Manager #3 said when she was told everyone on the Unit had to be tested, she would test them and then call the DON or IC Nurse and verbally tell them the results. Unit Manager #3 said, she did not document the COVID-19 test was administered or the results in the medical record.