Based on record review and interview, the facility failed to ensure the Resident Representative was notified of a fall for one Resident (#48), out of a total sample of 19 residents. Specifically, the facility failed to ensure the activated Health Care Proxy (health care agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions) was notified of one fall resulting in a large bruise. Findings include: Review of the facility's policies, Notification of Changes Policy/Incident Reporting Process and Fall Prevention and Management Program Policy, undated, indicated but was not limited to: -The MD (physician) and responsible party MUST be notified at the time of the occurrence. Document in both incident report and the nurse's note this was completed. -The Nurse and/or Physician will notify and involve the family or significant others. Resident #48 was admitted to the facility in 10/2023 and had diagnoses including Alzheimer's disease, vascular dementia, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 1/7/25, indicated Resident #48 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status score of 10 out of 15, and had two falls since the last assessment. The assessment indicated Resident #48 had an activated Health Care Proxy. Review of the medical record and fall incident/accident reports indicated but was not limited to the following: -1/19/25 at 6:40 A.M. the nurse was at the nurse's station when the Resident's alarm sounded, and the nurse found the Resident sitting on the floor at the end of the bed. The Resident had a large reddish/purple bruise on his/her midback. Further review of the documentation failed to indicate staff notified the Resident's Healthcare Proxy of the fall. During an interview on 2/5/25 at 11:36 A.M., Unit Manager #4 reviewed Resident #48's medical record and the 1/19/25 fall incident/accident report. Unit Manager #4 said the Resident's physician was notified of the fall, but she could not find evidence that the Resident's Health Care Proxy was notified. During an interview on 2/5/25 at 4:01 P.M., the Director of Nursing said Resident #48's Health Care Proxy should have been notified of the fall on 1/19/25 and the notification should have been documented in the medical record. He said if it wasn't documented, it wasn't done.

Based on interview and record review, the facility failed to report an allegation of physical abuse to the State Agency (SA) within the mandated timeframes as required for one Resident (#13), out of a total sample of 19 residents. Findings include: Review of the facility's policy titled Abuse Policy, undated, indicated but was not limited to the following: -It is the policy that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. -The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made. -The Administrator or designee will inform the resident or resident's representative of the report of an incident and that an investigation is being conducted. -Covered individuals are obligated to comply with reporting requirements. If uncertain whether or not to report an incident, call the State Agency for further direction. -Inquiries concerning the abuse reporting and investigation should be referred to the Administrator. Resident #13 was admitted to the facility in November 2024 and had diagnoses including open wound of the left lower leg, paroxysmal atrial fibrillation, obstructive sleep apnea (OSA-sleep disorder where the upper airway repeatedly becomes blocked during sleep, leading to interrupted breathing), major depressive disorder, venous insufficiency, falls, and bilateral hearing loss. Review of the Minimum Data Set (MDS) assessment, dated 11/7/24, indicated Resident #13 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. During an interview on 2/3/25 at 10:58 A.M., Resident #13 said he/she would like the surveyor to speak with Family Member #1 to help answer any questions and called Family Member #1 from his/her cellular device placing her on speaker in the Resident's room. Resident #13 said late at night staff are pushing and shoving him/her and are abusive but provided no further details. Family Member #1 said the facility was poorly staffed to the point where she saw three fingerprint marks on the Resident's left upper arm as if someone had grabbed him/her. Family Member #1 said the left upper arm had three lines, maybe a couple inches each, but may now be faded. She said she could not remember when this happened, maybe one or two weeks ago, but she didn't report it to anyone. Family Member #1 further said abuse seemed to occur, but did not elaborate. Resident #13 said he/she could not recall if staff caused the red marks. Family Member #1 said staff can be too forceful and get frustrated at times. On 2/3/25 at 11:33 A.M., upon completion of the Resident/Family Member #1's interview, the surveyor immediately reported the allegation of physical abuse to the Administrator. Review of the Health Care Facility Reporting System (HCFRS) failed to indicate the alleged violation involving abuse was reported immediately by staff, but no later than 2 hours after the allegation was made as required. During an interview on 2/4/25 at 3:52 P.M., the Administrator said she did not report the allegation because neither the Resident nor Family Member #1 would discuss it. She said it should have been reported within two hours but wasn't. She said the investigation was in progress as she'd like the spouse to provide more information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure staff provided the resident and/or their representative with a summary of the baseline care plan for one Resident (#291), out of a total sample of 19 residents. Specifically, the facility failed to provide the Resident with a written summary of the baseline care plan and document receipt of the information within the Resident's clinical record. Findings include: Review of the facility's policy titled Care Plans - Baseline indicated but was not limited to the following: -The baseline care plan includes instructions needed to provide effective, person-centered care of the residents that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the residents including, but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; b. Physician orders; c. Dietary orders; d. Therapy Services; e. Social Services; and f. PASARR recommendations, if applicable. -The baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan (no later than 21 days after admission). Resident #291 was admitted to the facility in January 2025 and had diagnoses including morbid obesity, type 2 diabetes mellitus, uncontrolled hypertension, coronary artery disease, and a history of falls. Review of the Minimum Data Set (MDS) assessment, dated 1/26/25, indicated Resident #291 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. During an interview with Resident #291 and their daughter on 2/3/25 at 2:06 P.M., Resident #291 said he/she had been at the facility for about 1.5 weeks after having three falls at home and had been receiving nursing and therapy services. The Resident said he/she never had a meeting within the first several days of being there and never received a copy of the baseline care plan. The Resident's daughter said there was no care plan meeting and they never received a copy of the care plan information. Resident #291 said Social Worker (SW) #1 had stopped in that morning and said she was working on a discharge plan, but there was no update on a timeframe or what services would be in place. The Resident said SW #1 said she would try to contact his/her other daughter in Pennsylvania but the last update from his/her daughter was that no one had contacted her yet. Review of Resident #291's Baseline Care Plan indicated the patient or representative's signature line on the document was blank and was not dated to indicate it had been reviewed with the Resident/Resident's representative. Further review of the medical record failed to indicate documentation that the Resident was provided with a written summary of his/her baseline care plan that included initial goals for the resident, current medications and dietary instructions, and services and treatments to be administered by the facility and personnel acting on behalf of the facility. During an interview on 2/5/25 at 9:38 A.M., Resident #291 said when he/she was admitted to the facility from the hospital no one had met with her to discuss her plan of care until SW #1 did a day or two ago. She said she had asked to speak with SW #1 over and over and over again but didn't see her. The surveyor reviewed the Baseline Care Plan document with the Resident who said she had never seen it, no one reviewed it with her, and she never received a copy of it, but would have liked for those things to have happened. She said she used to work in the medical field and is aware of the process that should be followed. During an interview on 2/5/25 at 9:47 A.M., Nurse #3 said when residents are admitted either the admitting nurse or a supervisor will complete the baseline care plan within 48 hours, but the social worker typically would review the plan of care with the residents. She said she didn't know though what time period this should be done. During an interview on 2/5/25 at 9:56 A.M., SW #1 said she met with the Resident upon admission on [DATE] for an assessment, but the assessment format is the same for all new admissions and does not review specifically a summary of the baseline care plan. She said every admission goes through the same process. She said the summary is on the actual Baseline Care Plan document, but unfortunately it was not dated. She said she does not review other disciplines such as rehabilitation therapy, but each discipline will go in and speak to the Resident separately. The surveyor reviewed the medical record with SW #1 who said she reviews her own care goals with the residents and does not document a summary of the baseline care plan. She said she is in email communication with the Resident's daughters. During an interview on 2/5/25 at 12:16 P.M., SW #1 said there wasn't an Interdisciplinary (IDT) meeting with the Resident because they find that to be too overwhelming to the residents so each discipline will meet with the resident separately. She said she had no documentation that a summary of the baseline care plan was provided to the resident and/or representative. During an interview on 2/5/25 at 12:45 P.M., the surveyor reviewed a copy of the Baseline Care Plan with the Director of Nurses (DON) who said if it was not signed or dated by the resident, then he could not say if it was reviewed or not with the Resident and provided to him/her. He said he would keep looking for documentation to provide to the surveyor. During an interview on 2/5/25 at 4:03 P.M., the DON said he couldn't locate any documentation that the Resident was provided with a written summary of his/her baseline care plan that included initial goals for the resident, current medications and dietary instructions, and services and treatments to be administered by the facility and personnel acting on behalf of the facility.

Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for one Resident (#50), out of a total sample of 19 residents. Specifically, the facility failed to ensure a physician's order was obtained for the administration of oxygen (O2). Findings include: Review of Lippincott Nursing Procedures, Eighth Edition [Philadelphia: Wolters Kluwer, (2019)] indicated but was not limited to the following: Oxygen Administration: -Verify the practitioner's order for the oxygen therapy, because oxygen is considered a medication or therapy and should be prescribed. Review of the facility's policy titled Oxygen Administration, revised October 2012, indicated but was not limited to the following: -Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. -The nasal cannula is a tube that is placed approximately one-half inch into the resident's nose. It is held in place by an elastic band placed around the resident's head. -Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate prescribed per MD order. Resident #50 was admitted to the facility in December 2024 and had diagnoses including pneumonitis due to inhalation of food and vomit, acute and chronic respiratory failure with hypoxia, centrilobular emphysema (lung condition that causes shortness of breath), chronic obstructive pulmonary disease (COPD- group of lung diseases that block airflow and make it difficult to breathe), chronic diastolic heart failure, and dependence on supplemental oxygen. Review of the Minimum Data Set (MDS) assessment, dated 12/26/24, indicated Resident #50 was cognitively intact and was receiving continuous oxygen therapy. During an observation with interview on 2/3/25 at 1:16 P.M. and 2/4/25 at 11:15 A.M., the surveyor observed Resident #50 in his/her room. Nasal cannula (NC - lightweight tube which one end splits into two prongs which are placed in the nostrils from which a mixture of oxygen and air flows) tubing was observed inserted into the Resident's nostrils with the end of the tubing attached to an oxygen concentrator (provides oxygen for breathing) which was delivering a flow of 2 liters per minute (LPM) of oxygen. Resident #50 said he/she used the oxygen to help with his/her breathing. Review of current Physician's Orders failed to indicate an order for oxygen administration. During an interview on 2/5/25 at 10:38 A.M., Nurse #5 said there was an order for oxygen on 1/27/25 but it was no longer being monitored because the Resident was now receiving hospice care for symptom management. During an interview on 2/5/25 at 11:10 A.M., Nurse #2 said the oxygen was for comfort only secondary to hospice so the order and monitoring typically falls off. During an interview on 2/5/25 at 4:01 P.M., the surveyor reviewed the medical record with the Director of Nurses (DON) who said Resident #50 was admitted to hospice on 1/27/25 but said there should still be an order for oxygen and there wasn't. He said the order was entered on 1/27/25, signed off by the physician, then discontinued the same day and didn't know why. The DON said oxygen is a medication and there should have been an order for it. During an interview on 2/6/25 at 7:36 A.M., the DON said Unit Manager #3 discontinued the order because it was a titrated (adjusted liter flow) order that would require monitoring and forgot to enter the order for O2 for comfort measures. He said there was no order, but there should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure two Residents (#33, #67), out of a total sample of five residents reviewed for immunization, were screened for eligibility to receive the recommended pneumococcal vaccination, were educated on the benefits and potential side effects of the vaccine and were offered and administered (if applicable) the vaccine in a timely manner. Specifically, the facility failed to ensure Residents #33 and #67 were offered the Pneumococcal Conjugate Vaccine (PCV-a vaccine that helps protect against diseases caused by pneumococcal bacteria) at the time of admission or shortly thereafter, putting the Residents at risk for developing facility acquired pneumonia. Findings include: Review of the facility's policy titled Pneumococcal Immunization Program: Pneumococcal Vaccination, undated, indicated but was not limited to the following: - Purpose: to reduce morbidity and mortality from pneumococcal disease by vaccinating all patients who meet the criteria established by the Centers for Disease Control and Prevention's (CDC) Advisory Committee on Immunization Practices (ACIP). - [Facility Name] follows the requirements of The Centers for Medicare and Medicaid Services (CMS) and recommendations of the CDC's ACIP and the Massachusetts Department of Public Health (MDPH) for the control of Pneumococcal disease in Long-Term Care Facilities (LTCF). - ACIP recommends that all persons living in a long term care facility are assessed for, and receive the pneumococcal immunization if eligible. - All patient/resident admissions to [Facility Name] will be assessed for indications and contraindications (e.g. anaphylaxis) for the pneumococcal vaccine. ACIP recommends vaccination for: a. age [AGE] or older with no or unknown history or prior vaccination; c. Person age [AGE] years of age or older who got their first dose when they were under [AGE] years of age should be revaccinated with a single dose after 5-years have passed since the first dose. - This information will be documented on the [Facility Name] Medication Reconciliation form: a. Pneumococcal Polysaccharide 23 Valent (PPV23) Vaccine is recommended for any person age [AGE] years of age or older; b. A 2nd vaccine, if the 1st vaccine was prior to age [AGE] and is recommended at least 5 years between the 1st and 2nd vaccine; c. If the patient/resident has already received the pneumococcal (PPV23) immunization then date of immunization needs to be recorded; i. If vaccination date unknown: notify Medical Staff for further recommendations; d. If the patient/resident meets the above criteria to be vaccinated, a Pneumococcal Vaccine Information Statement (VIS) will be provided, and the patient/resident or healthcare proxy (HCP) will be queried for vaccination consent. - The Infection Control Preventionist maintains a list of all resident/patients on each Unit with their vaccination status. a. Review of the medical record for Resident #33 indicated but was not limited to the following: - admitted to the facility in February 2024. - Failed to produce a signed Immunization Consent form indicating consent/declination of the Pneumococcal vaccine. - Medication Reconciliation form failed to indicate a history of a Pneumococcal vaccination and was not signed by the Physician or Nurse Practitioner (NP). - Failed to indicate education of the Pneumococcal vaccine was provided to the Resident. Review of Resident #33's Massachusetts Immunization Information System (MIIS) form indicated a Pneumococcal vaccine (PPSV23) was administered on 6/22/16. b. Review of the medical record for Resident #67 indicated but was not limited to the following: - admitted to the facility in June 2024. - Failed to produce a signed Immunization Consent form indicating consent/declination of the Pneumococcal vaccine. - Medication Reconciliation form failed to indicate a history of a Pneumococcal vaccination. - Failed to indicate education of the Pneumococcal vaccine was further provided to the Resident. Review of Resident #67's MIIS form indicated a Pneumococcal vaccine (PPSV23) was administered on 2/12/16. During an interview on 2/5/25 at 1:58 P.M., the Infection Preventionist (IP) said when a resident is initially admitted to the facility the nurse completes a Medication Reconciliation form and indicates any vaccination history. The form is then reviewed and signed by the Physician or Nurse Practitioner (NP) and any further recommendations are followed. She said she will run the MIIS for each resident to determine when their last vaccinations were administered. The IP said the facility has no process for following up with the Physician or NP about vaccination history and recommendations, and the facility does not follow up with the resident or their representatives regarding obtaining vaccination history and or education about Pneumococcal vaccinations after admission. The IP reviewed the medical records of Resident #33 and Resident #67 and said both Residents were due for an updated Pneumococcal vaccination but had not been followed up in order to determine if they would like the vaccinations. The IP said she had not had any conversations with Resident #33 or Resident #67's providers regarding recommendations for Pneumococcal vaccinations.

Based on observation, interview, and record review, the facility failed to develop and implement an individualized, person-centered care plan to meet the physical, psychosocial, and functional needs for four Residents (#40, #48, #84, and #33), out of a total sample of 19 residents. Specifically, the facility failed to ensure a comprehensive care plan was developed: 1. For Resident #40, to address the use of antidepressant medication (used to treat obsessive compulsive disorder) that identified target behaviors, individualized, measurable non-pharmacological interventions and measurable goals of treatment; 2. For Resident #48, to address the use of antianxiety, antidepressant, and antipsychotic medication that identified target behaviors and individualized, measurable non-pharmacological interventions and measurable goals of treatment; 3. For Resident #84, to address a wound to the Resident's right medial calf; and 4. For Resident #33, to address an antipsychotic medication that identified target behaviors and individualized, measurable non-pharmacological interventions and measurable goals of treatment. Findings include: Review of the facility's policy titled Care Plans, undated, indicated but was not limited to: -The Interdisciplinary Team shall develop a comprehensive, individualized plan of care for each resident and is reviewed and revised in accordance with State and Federal regulations and professional standards of nursing care. The Care Plan guides the care and treatment provided to each resident. -Resident specific plans of care (e.g. Hospice or Behavioral Health) will be integrated into the resident's comprehensive core care plan. -The total Plan of Care includes established routines of care, professional standards of practice, physician's orders and progress notes, consultant reports, MARs (Medication Administration Record), TARs (Treatment Administration Record), flow sheets, various medical records and resident/family preferences. 1. Resident #40 was admitted to the facility in August 2023 and had diagnoses including obsessive compulsive disorder (OCD) and depression. Review of the Minimum Data Set (MDS) assessment, dated 10/29/24, indicated Resident #40 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15, and received antidepressant medication daily. Review of Physician's Orders indicated but was not limited to: -Fluvoxamine (antidepressant) 100 milligrams (mg) twice daily for obsessive compulsive disorder (last renewed 1/29/25) Review of September 2024 through February 2025 MARs indicated Fluvoxamine was administered to Resident #40 as ordered by the physician. Review of comprehensive care plans indicated but was not limited to: -Focus: Psychotropic Drug Use-antidepressant (1/12/24) -Interventions: Monitor psychotropic medications for side effects, especially lethargy and fall risk; monitor mood/behaviors with response to effectiveness of psychotropic medication, provide instruction/redirection for episodes of behaviors; assess and monitor cause of behaviors and measures taken to de-escalate; attempt gradual dose reduction at direction of medical provider. -Goals: Resident's mood and behavior will be monitored for stability and managed medically as evidenced by participation in activities of daily living (ADLs) and ordered rehab services. The care plan for the use of Fluvoxamine failed to identify resident specific, targeted behaviors for the use of the medication and failed to include measurable goals to ascertain the effectiveness of the medication and non-pharmacological interventions. During an interview on 2/5/25 at 11:36 A.M., Unit Manager #4 reviewed Resident #40's medical record including comprehensive care plans. She said Resident #40 has been taking Fluvoxamine for obsessive compulsive disorder for over a year. She said the care plan for the use of Fluvoxamine did not identify resident specific, targeted behaviors for the use of the medication and failed to include measurable goals of treatment to determine the effectiveness of treatment. During an interview on 2/5/25 at 4:01 P.M., the Director of Nursing (DON) said Resident #40's comprehensive care plan must include resident specific, targeted behaviors for the use of Fluvoxamine and have measurable goals of treatment. 2. Resident #48 was admitted to the facility in October 2023 and had diagnoses including Alzheimer's disease, vascular dementia, and anxiety disorder. Review of the MDS assessment, dated 1/7/25, indicated Resident #48 had moderate cognitive impairment as evidenced by a BIMS score of 10 out of 15, exhibited physical behaviors toward others and received antipsychotic, antidepressant and antianxiety medication daily. Review of Physician's Orders indicated but was not limited to: -Ativan (antianxiety) 0.5 mg tablet, give 1 tablet three times daily (11/15/24) -Depakote (used as a mood stabilizer) 250 mg tablet, give 1 tablet once daily (1/11/25) -Escitalopram (antianxiety) 10 mg tablet, give 1 tablet once daily (6/17/24) -Remeron (antidepressant) 30 mg tablet, give 1 tablet once daily before bedtime (11/30/23) -Zyprexa (antipsychotic) 2.5 mg tablet, give one tablet at breakfast and one at dinner (11/14/24) -Strattera (used to treat attention deficit hyperactivity disorder) 80 mg capsule, give 1 capsule once daily (1/10/25) Review of the September 2024 through February 2025 MARs indicated the psychotropic medications were administered to Resident #48 as ordered by the physician. Review of comprehensive care plans indicated but was not limited to: -Focus: Psychotropic Drug Use- Antianxiety, Antidepressant (1/12/24) -Interventions: Monitor psychotropic medications for side effects, especially lethargy and fall risk; monitor mood/behaviors with response to effectiveness of psychotropic medication; provide instruction/redirection for episodes of behaviors; assess and monitor cause of behaviors and measures taken to de-escalate; attempt gradual dose reduction at direction of medical provider. -Goals: Resident's mood and behavior will be monitored for stability and managed medically as evidenced by participation in ADLs and ordered rehab services. The care plan for the use of psychotropic medications failed to identify Resident #48 was receiving Zyprexa, and failed to identify resident specific, targeted behaviors for the use antianxiety and antidepressant medications and failed to include measurable goals to ascertain the effectiveness of the medication and non-pharmacological interventions. During an interview on 2/5/25 at 2:19 P.M., Unit Manager #4 reviewed Resident #48's medical record and said Zyprexa should be included in the care plan and resident specific, targeted behaviors should be identified for the use of all psychotropic medications but were not. During an interview on 2/5/25 at 4:01 P.M., the DON said the Resident's Zyprexa should be included in the comprehensive care plan and resident specific, targeted behaviors should be identified for the use of all psychotropic medications. 3. Resident #84 was admitted to the facility in June 2024 with diagnoses including peripheral vascular disease. Review of Resident #84's MDS assessment, dated 12/3/24, indicated he/she had moderate cognitive impairment as evidenced by a BIMS score of 10 out of 15. Further review of the MDS assessment indicated Resident #84 was at risk for pressure ulcers/injuries and had an unhealed wound. Review of Resident #84's Physician's Orders indicated but were not limited to the following: - 1/27/24: Right (R) medial calf dressing to be changed every other day; skin barriers/periwound: moisturizing lotion, dampen a piece of gauze with VASHE and gently scrub the wound bed; dampen a second piece of gauze and cleanse an area extending at least six inches around the wound including the entire area covered by the dressing and gauze wrap; soak a third piece of gauze with solution until just starting to drip, place on the wound and let sit for 5-10 minutes; remove gauze and cover with layer of Xeroform dressing; secondary dressing: cover with abdominal (ABD) pad, roll gauze and secure with tape. - 8/24/24: Weekly skin check: comment on condition of skin; include normal and abnormal finding in the comment section. Further review of Resident #84's medical record indicated he/she has been seen by the Wound Clinic for the right medial calf wound since 11/25/24. Wound Clinic documentation for Resident #84 indicated he/she seen was seen every two weeks. Review of Resident #84's medical record indicated a comprehensive care plan related to alteration in skin integrity with focus related to immobility, skin tears of the left upper extremity (LUE), venous ulcers left lower extremity (LLE), and potential for alteration in skin integrity. Further review of Resident #84's medical record failed to indicate a comprehensive care plan related to the right medial calf injury including the Resident's need to be treated by the Wound Clinic. During an interview on 2/5/25 at 10:07 A.M., Nurse #4 said Resident #84 had an active wound to the right medial calf and the Resident is treated by the Wound Clinic every two weeks and they make any dressing recommendations. Nurse #4 said typically the Unit Manager (UM) updates the care plan related to any skin integrity issues. During an interview on 2/5/25 at 12:39 P.M., UM #2 reviewed Resident #84's medical record and said the comprehensive care plan related to alteration in skin integrity did not include documentation related to the Resident's active wound areas. UM #2 said the comprehensive care plan did not include specific information about the Resident being treated by the Wound Clinic, and could be more individualized. During an interview on 2/5/25 at 1:21 P.M., the DON said any nurse can update the care plans for a resident but historically at the facility the unit managers were responsible for making sure they are up to date. The DON said comprehensive care plans should be updated with any changes or interventions specific to the resident. The DON said the care plan was not individualized and should be more specific to the Resident to include their needs. 4. Resident #33 was admitted to the facility in February 2024 with diagnoses including anxiety and Parkinson's disease (a progressive neurodegenerative disorder that affects movement, balance, and coordination). Review of Resident's #33's MDS assessment, dated 11/5/24, indicated he/she had a moderate cognitive deficit as evidenced by a BIMS score of 10 out of 15. Review of Resident #33's current Physician's Orders indicated but was not limited to: - Seroquel (antipsychotic medication) give 12.5 mg daily, dated 1/4/25 - Trazodone (antidepressant medication) give 50 mg twice daily as needed for agitation or anxiety, dated 11/12/24 - Trazodone 50 mg daily at bedtime, dated 4/23/24 Review of Resident #33's January and February MARs indicated he/she received Seroquel and Trazodone as ordered. Review of Resident #33's comprehensive care plans included but was not limited to: - Focus: Psychotropic Drug Use: Antidepressant medication (effective date 3/1/24) - Goal: Resident's mood and behavior will be monitored for stability and managed medically as evidenced by participation in ADLs (activities of daily living) and ordered rehab services (effective date 3/1/24) - Interventions: Monitor psychotropic medications for side effects, especially lethargy and fall risk (effective date 3/1/24), Monitor mood/behaviors with response to effectiveness of psychotropic medication (effective date 3/1/24) - Notes: Resident is on scheduled and PRN (as needed) Trazodone to help with sundowning. (effective date 3/1/24) Further review of Resident #33's comprehensive care plans failed to indicate a comprehensive care plan was developed for the use of his/her antipsychotic medication, identifying specific targeted signs/symptoms, Resident specific interventions, including non-pharmacological approaches, and measurable goals for the use of antipsychotic medication to meet the Resident's needs. During an interview on 2/5/25 at 3:10 P.M., UM #4 said comprehensive care plans were developed and updated by her, the MDS Nurse, and Social Services. UM #4 said Resident #33 did not have an individualized comprehensive care plan developed for the use of antipsychotic medication. During an interview on 2/5/25 at 4:43 P.M., the Director of Nursing (DON) said their expectation was for all residents to have individualized comprehensive care plans.

4. On 2/4/25 at 10:02 A.M. and 2/5/25 at 7:15 A.M., the surveyor observed a wall mounted sharps container in Resident #73's room grossly overfilled with contaminated sharps material with items such as a razor and blood-filled tubing from a blood collection vacutainer protruding from the container's opening increasing the risk for potential staff needlestick injuries and exposure to bloodborne pathogens. During an observation with interview on 2/5/25 at 10:57 A.M., Nurse #2 entered the Resident's room with the surveyor and said she didn't realize the sharps container was full, but any nurse could swap it out when it gets full with an empty one. She said she didn't know if maintenance routinely checked them, but there is a company that comes in to take the full ones that are stored in the soiled utility room. Nurse #2 said there is the potential for cross-contamination of blood from the exposed sharps contents and said it was a hazard due to the items sticking out of the container. Nurse #2 said the contents should be below the fill line. Nurse #2 sealed and removed the sharps container but was unable to replace it as she could not locate empty containers on the unit. Nurse #2 asked another staff member to get one for the Resident's room. During an interview on 2/5/25 at 12:33 P.M., the Administrator said the designated individuals responsible for sealing and replacing the containers was a waste company the facility had a contract with, but the agreement did not include frequency of visits. She said if a sharps container is full then nursing staff should call maintenance who will come and replace it. She said there were two wings in the facility not being used so could not understand why the container would be full. She said the contracted company does go into the resident rooms to collect full containers but there were no set dates or times. She said that the potential was there for cross-contaminations of blood-borne pathogens and a hazard risk related to exposed sharps. During an interview on 2/5/25 at 1:05 P.M., Maintenance Staff #1 said the waste company comes twice a month to do rounds in the facility, but they won't go in rooms sometimes if residents are sick. He said maintenance is the backup and nursing staff will call him to replace it but he hadn't heard about the overfilled container in Resident #73's room. He said he couldn't understand how the container got so full without being replaced. Based on observation and interview, the facility failed to provide an environment that was free from accidents and hazards on three of three units. Specifically, the facility failed: 1. For the Naushon Unit, to ensure that medicated treatment supplies and an unlocked treatment cart in the Clean Utility Room were accessible only to licensed staff; 2. For the Nobska Unit, to ensure that: a. medicated treatment supplies and an unlocked treatment cart in the Clean Utility Room were accessible only to licensed staff, and b. the daily supply closet door was locked and not accessible to residents; 3. For Resident #33, (Nobska Unit) that sharps were properly placed in the sharps container to decrease the risk of needlestick injuries and exposure to bloodborne pathogens; and 4. For Resident #73 (Penzance Unit), to ensure sharps containers were replaced routinely and not overfilled to decrease the risk of needlestick injuries and exposure to bloodborne pathogens. Findings include: Review of the facility Matrix (used to identify pertinent care categories for residents) provided to surveyors by the Director of Nursing on 2/3/25 indicated but was not limited to the following: -The Naushon Unit had 23 out of 36 residents with a diagnosis of Alzheimer's Disease/Dementia. -The Nobska Unit had 15 out of 35 residents with a diagnosis of Alzheimer's Disease/Dementia. Review of the facility Storage of Medication Policy, dated January 2024, indicated but was not limited to: Policy: The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 1. On 2/3/25 at 10:00 A.M., and 5:18 P.M., and on 2/4/25 at 8:49 A.M., 2:19 P.M., and 2:25 P.M., the surveyor observed the Clean Utility Room door unlocked on the Naushon Unit. The surveyor was able to open the door easily and enter the room which contained medicated treatment supplies and an unlocked treatment cart. The supplies stored and accessible in the clean utility room included but were not limited to: - Hydrocortisone Cream (a steroidal cream) - Bacitracin (an antibiotic ointment used to treat minor skin infections, such as cuts, scrapes, and burns) - Skin Prep Wipes (prepare intact skin for attachment sites, tapes, films, and adhesive dressings) - Alcohol Wipes - Iodine solution (an antiseptic and disinfectant agent, used for the treatment and prevention of infections in wounds and cuts) - Benzocaine (local anesthetic that numbs pain by blocking nerve signals) - Disinfection bleach wipes - An unlocked treatment cart which contained medicated treatment supplies including but was not limited to: - Antifungal cream - Antifungal powder - Hemorrhoidal Ointment - Betamethasone Topical Cream (used to help relieve redness, itching, swelling, or other discomforts caused by certain skin conditions) - Acyclovir Ointment (a prescription medication that treats herpes simplex virus infections) - Triamcinolone Cream (used to reduce inflammation and itching of the skin) - Lidocaine 4% cram (topical anesthetic) During an interview on 2/5/25 at 10:48 A.M., Nurse #4 said the clean utility room did not have a door that could be locked. Nurse #4 said the treatment cart should be locked for Resident safety and treatment supplies should not be accessible to residents. During an interview on 2/5/25 at 10:54 A.M., Unit Manager (UM) #2 said the clean utility room contained treatment supplies and the treatment cart contained resident specific treatment supplies. UM #2 said the treatment cart should have been locked as it contained prescription and non-prescription medicated treatment supplies. UM #2 said the door to the clean utility room did not have a lock on it because it contained the eye wash station, but treatment supplies should have been kept in a locked cabinet for safety and not potentially accessible to residents. During an interview on 2/5/25 at 4:43 P.M., the Director of Nursing (DON) said treatment carts should be locked when there is not a nurse directly in front of them and the medicated treatment supplies in the clean utility room should be locked up and not accessible to residents. 2a. On 2/3/25 at 10:32 A.M. and 5:13 P.M., and on 2/4/25 at 8:37 A.M., 2:07 P.M., 2:40 P.M., and 4:47 P.M., the surveyor observed the Clean Utility Room door on the Nobska Unit unlocked. The Clean Utility Room contained medicated treatment supplies and an unlocked treatment cart. On 2/4/25 at 2:04 P.M., the surveyor observed the door to the Clean Utility Room unlocked and open with treatment supplies visible and accessible and an unlocked treatment cart. The supplies stored and accessible in the clean utility room included but were not limited to: - Hydrocortisone Cream - Bacitracin - Skin Prep Wipes - Alcohol Wipes - Disinfection bleach wipes - An unlocked treatment cart which contained medicated treatment supplies including but was not limited to: - Antifungal cream - Antifungal powder - Hemorrhoidal Ointment - Betamethasone Topical Cream - Triamcinolone Cream - Arthritis pain relieving cream - Desonide cream (a topical corticosteroid medication used to treat inflammatory skin conditions such as eczema and psoriasis) - Premarin Cream (estrogen hormonal cream used to treat adults with vaginal symptoms due to menopause) - Diclofenac Sodium Topical Gel (used to treat the symptoms of rheumatoid arthritis) - Mupirocin Ointment (used to treat some skin infections) - Tinactin powder (used to treat infections such as athlete's foot, jock itch, and ringworm) During an interview on 2/4/25 at 5:13 P.M., UM #4 said having the door to the clean utility room unlocked and treatment supplies out and accessible to residents is a safety concern. UN #4 said the treatment supplies and the treatment cart should be locked to ensure resident safety in case a resident walks in. During an interview on 2/5/25 at 4:43 P.M., the DON said treatment carts should be locked when there is not a nurse directly in front of it and the medicated treatment supplies in the clean utility room should be locked up and not accessible to residents. b. On 2/3/25 at 8:53 A.M., 10:36 A.M., and 5:08 P.M., and on 2/4/25 at 8:37 A.M., 1:10 P.M., 1:56 P.M., and 2:04 P.M., the surveyor observed the door to the Daily Supply Closet on the Nobska Unit closed and locked. The key to the door, however, was still inserted and accessible to any residents passing by. The Daily Supply Closet contained but was not limited to: - Razors - Saline Enemas - Mouthwash with alcohol - Denture Cleanser Tabs - Hand Sanitizer containing 70% Ethyl Alcohol - Germicidal Wipes During an interview on 2/4/25 at 2:34 P.M., Certified Nursing Assistant (CNA) #1 and the surveyor observed the key in the door of the daily supply room. CNA #1 said the clean utility room contained soap, mouth wash, sanitizer, urinals, patient bags, razors, and hand sanitizer just to name a few things in there. CNA #1 said the key to the daily supply room should not be in the lock so no one can get in there and this was not safe if a resident was to get into the room. During an interview on 2/4/25 at 4:45 P.M., the Director of Maintenance (DOM) said the key to the daily supply room should not be kept in the lock of the door but in a closable magnetic key box to limit access to anyone who shouldn't be in there. During an interview on 2/5/25 at 4:43 P.M., the DON said the daily supply room should be locked with the key in the magnetic key box at the top of the door to limit access to staff only. 3. Review of the facility's service agreement for regulated medical waste and reusable sharps program, dated 4/23/24, indicated but was not limited to the following: -Waste company will provide reusable sharps containers for all customer locations designated as Group A and Group B, in Exhibit A, -Waste company will provide the resources and labor to install Reusable Sharps containers throughout the healthcare network and all reusable Sharps containers will be serviced by our trained service technicians. Service Program Details: Waste Solutions Efficiency Program: -Waste company will provide continuous monitoring of the customers' total regulated medical waste and sharps volumes. Review of the facility's policy titled Sharps Disposal, undated, indicated but was not limited to the following: - Policy Statement: This facility shall discard contaminated sharps into designated containers. -Whoever uses contaminated sharps will discard them immediately or as soon as feasible into designated containers. -Containers sharps will be discarded into containers that are: a. closable; b. puncture resistant; c. leakproof on sides and bottom; and d. impermeable and capable of maintaining impermeability through final waste disposal. -During use, containers for contaminated sharps will be handled as follows: c. Designated individual will be responsible for sealing and replacing containers when they are 75% to 80% full to protect employees from punctures and/or needlesticks when attempting to push sharps into the container. Review of the Occupational Safety and Health Administration (OSHA) web-based fact sheet titled, Protecting Yourself When Handling Contaminated Sharps, indicated but was not limited to the following: - A needlestick or a cut from a contaminated sharp can result in a worker being infected with human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and other bloodborne pathogens. The standard specifies measures to reduce these types of injuries and the risk of infection. Careful handling of contaminated sharps can prevent injury and reduce the risk of infection. Employers must ensure that workers follow these work practices to decrease the workers' chances of contracting bloodborne diseases. Sharps Containers: - The containers must be replaced routinely and not be overfilled, which can increase the risk of needlesticks or cuts. Occupational Safety and Health Administration. (2011, January). Protecting Yourself When Handling Contaminated Sharps. https://www.osha.gov/sites/default/files/publications/bbfact02.pdf Resident #33 was admitted to the facility in February 2024 with diagnoses including dementia and Parkinson's disease (a progressive neurodegenerative disorder that affects movement, balance, and coordination). Review of Resident's #33's Minimum Data Set (MDS) assessment, dated 11/5/24, indicated he/she had a moderate cognitive deficit as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. The surveyor observed a wall mounted sharps container less than 25% full in Resident #33's room with a blood-filled tubing from a blood collection vacutainer tube (a sterile plastic test tube with a colored rubber stopper creating a vacuum seal inside of the tube, facilitating the drawing of a predetermined volume of liquid) sticking out of the top of the sharps container. The tubing was visible from the hallway and accessible to residents that walk by Resident #33's room on the following days and times: - 2/3/25 at 9:20 A.M., Resident not in room - 2/3/25 at 10:39 A.M., Resident not in room - 2/3/25 at 12:35 P.M., Resident not in room - 2/3/25 at 2:14 P.M., two staff members walked into Resident's room - 2/3/25 at 2:48 P.M., Resident alone and unsupervised in room - 2/3/25 at 5:09 P.M., Resident alone and unsupervised in room - 2/4/25 at 8:19 A.M., Resident not in room - 2/4/25 at 1:11 P.M., Resident alone and unsupervised in room - 2/4/25 at 2:02 P.M., Resident alone and unsupervised in room - 2/4/25 at 2:39 P.M., MDS Nurse #1 in room with Resident During an interview on 2/4/25 at 2:39 P.M., MDS Nurse #1 said the vacutainer blood collection tube should not be sticking out of the sharps container but fully inside the sharps container. MDS Nurse #1 said if someone were to take or grab the vacutainer blood collection tube that could become a potential for blood borne pathogen contamination. During an interview on 2/5/25 at 4:43 P.M., the DON said all sharps should be fully submerged in the sharps container below the full line to decrease the potential for blood borne pathogen contamination.

2. Resident #40 was admitted to the facility in August 2023 and had diagnoses including obsessive compulsive disorder (OCD), and depression. Review of the most recent MDS assessment, dated 10/29/24, indicated Resident #40 was cognitively intact as evidenced by a BIMS score of 13 out of 15, and received antidepressant medication daily. Review of physician's orders indicated, but was not limited to: -Fluvoxamine 100 milligrams (mg) twice daily for obsessive-compulsive disorder (new order with dose increase on 11/5/24) -Monitor side effects of fluvoxamine-drowsiness, insomnia, constipation, weight gain, sexual problems, tremors, and dry mouth (1/10/24). Review of November 2024 through February 2025 MAR indicated fluvoxamine was administered as ordered by the physician. Further review of the medical record indicated staff monitored Resident #40 for side effects of Fluvoxamine only during the evening shift (3:00 P.M. - 11:00 P.M.). Staff failed to monitor the Resident for side effects during the day shift (7:00 A.M. - 3:00 P.M.) and night shift 11:00 P.M. - 7:00 A.M.). During interviews on 2/5/25 at 4:01 P.M. and 2/6/25 at 9:44 A.M., the DON said staff are supposed to monitor all residents on psychotropic medications for potential side effects of their use during all shifts on all days. He said staff should have monitored Resident #40 for side effects of fluvoxamine on all shifts. 3. Resident #48 was admitted to the facility in October 2023 and had diagnoses including Alzheimer's disease, vascular dementia and anxiety disorder. Review of the most recent MDS assessment, dated 1/7/25, indicated Resident #48 had moderate cognitive impairment as evidenced by a BIMS score of 10 out of 15, exhibited physical behaviors toward others and received antipsychotic, antidepressant and antianxiety medication daily. Review of Physician's Orders indicated but was not limited to: -Ativan 0.5 mg tablet, give 1 tablet three times daily (11/15/24) -Monitor for side effects of Ativan-nausea, blurry vision, headaches, confusion, fatigue, nightmares. -Depakote 250 mg tablet, give 1 tablet once daily (1/11/25) -Monitor side effects of Depakote-stomach upset, drowsiness, weight gain, dizziness, tremors, blurry vision, and confusion. -Escitalopram 10 mg tablet, give 1 tablet once daily (6/17/24) -Remeron 30 mg tablet, give 1 tablet once daily before bedtime (11/30/23) -Monitor side effects of Remeron-drowsiness, insomnia, constipation, weight gain, sexual problems, tremors, and dry mouth -Zyprexa 2.5 mg tablet, give one tablet at breakfast and one at dinner (11/14/24) -Monitor side effects of Zyprexa-drowsiness, tardive dyskinesia, akathisia, twitching, hyperglycemia, increased appetite, and weight gain. -Strattera 80 mg capsule, give 1 capsule once daily (1/10/25) Further review of physician's orders failed to indicate monitoring for side effects for Escitalopram and Strattera. Review of November 2024 through February 2025 MAR indicated all psychotropic medications were administered as ordered by the physician. Further review of the medical record indicated staff monitored the Resident for side effects of Ativan, Depakote, Remeron and Zyprexa only during the day shift (7:00 A.M. - 3:00 P.M.) and not during the evening shift (3:00 P.M. - 11:00 P.M.) and night shift (11:00 P.M. - 7:00 A.M.). Staff did not monitor Resident #48 for side effects of Escitalopram and Strattera. During interviews on 2/5/25 at 4:01 P.M. and 2/6/25 at 9:44 A.M., the DON said staff are supposed to monitor all residents on psychotropic medications for potential side effects of their use during all shifts on all days. He said Resident #48 should have been monitored for side effects for the use of Escitalopram and Strattera and monitoring should have been done during all shifts on all days for the Resident's other psychotropic medication. Based on record review and interview, the facility failed to ensure three Residents' (#33, #40, and #48) drug regimen was free from unnecessary psychotropic medications, out of a total sample of 23 residents. Specifically, the facility failed: 1. For Resident #33, to adequately identify and monitor target behaviors related to his/her antipsychotic use; 2. For Resident #40, to adequately monitor for potential side effects of fluvoxamine (antidepressant used in the treatment of obsessive-compulsive disorder); and 3. For Resident #48, to adequately monitor for potential side effects for the use of Ativan (antianxiety), Depakote (anticonvulsant used as a mood stabilizer), Escitalopram (antianxiety), Remeron (antidepressant), Zyprexa (antipsychotic), and Strattera (norepinephrine reuptake inhibitor (SNRI) used to treat attention deficit hyperactivity disorder). Findings include: Review of the facility's policy titled Antipsychotic Medication Use, last revised July 2022, indicated but was not limited to: - Policy Statement: Antipsychotic medications can be considered for residents with dementia only after medical, physical, functional, psychosocial, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. 1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. 2. The attending physician and other staff will gather document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. 3. The attending physician will identify, evaluate, and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications. 7. Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident. 18. The staff will observe, document, and report to the physician information regarding the effectiveness of any interventions, including antipsychotic medications. 19. Nursing staff shall monitor for any and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician: a. General/anticholinergic: Constipation, blurred vision, dry mouth, urinary retention, sedation; b. Cardiovascular: orthostatic hypotension, arrhythmias; c. Metabolic: increase in total cholesterol/triglycerides, unstable or poorly controlled blood sugar, weight gain; d. Neurological: akathisia, dystonia, extrapyramidal effects, akinesia; or tardive dyskinesia, stroke or TIA. Review of the facility's policy titled Psychotic Medication Use, last revised July 2022, indicated but was not limited to: - Policy Statement: Residents will not receive medications that are not clinically indicated to treat specific conditions. 12. Residents receiving psychotropic medications are monitored for adverse consequences, including: a. Anticholinergic effects- flushing, blurred vision, dry mouth, altered mental status, difficulty urinating, falls, excessive sedation and constipation; b. Cardiovascular effects- Irregular heart rate or pulse, palpitations, lightheadedness, shortness of breath, diaphoresis, chest/arm pain, increased blood pressure, orthostatic hypotension; c. Metabolic effects- increased cholesterol and triglycerides, poorly controlled or unstable blood sugar, weight gain; d. Neurologic effects- agitation, distress, extrapyramidal symptoms, neuroleptic malignant syndrome, Parkinsonism, tardive dyskinesia, cerebrovascular events; and e. Psychosocial effects- inability to perform ADLs or interact with others, withdrawal or decline from usual social patterns, decreased engagement in activities, diminished ability to think or concentrate. 13. If psychotropic medications are identified as possibly causing or contributing to adverse consequences, the prescriber will determine whether the medication(s) should be continued and document the rationale for this decision. 1. Resident #33 was admitted to the facility in February 2024 with diagnoses including anxiety and Parkinson's disease (a progressive neurodegenerative disorder that affects movement, balance, and coordination). Review of Resident #33's Minimum Data Set (MDS) assessment, dated 11/5/24, indicated he/she had a moderate cognitive deficit as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. Review of Resident #33's current Physician's Orders indicated but was not limited to: - Seroquel (antipsychotic medication) give 12.5 milligrams (mg) daily, dated 1/4/25 The physician order failed to provide an indication for the use of the antipsychotic medication. Review of Resident #33's January and February 2025 Medication Administration Record (MAR) indicated he/she received the Seroquel as ordered. Review of Resident #33's January and February 2025 behavior sheets indicated he/she was being monitored for the following behaviors: - Difficulty falling asleep - Inappropriate behaviors Review of Resident #33's Physician Note, dated 1/3/25, indicated but was not limited to: - nursing staff concern that the agitated behavior seem to be escalating - Dementia with sundowning/agitation - Resident will call out and say he/she wants to go home now Review of Resident #33's Physician Note, dated 2/3/25, indicated but was not limited to: - Apparently these late afternoon sundowning episodes are interfering with communication between staff and patient - Resident was started on low dose Seroquel; in my discussion with staff and spouse a few weeks ago - unclear if it has been helpful or not - Parkinson's dementia with hallucinations and sundowning The Physician notes failed to indicate what the target behavior or specific symptoms the staff should be monitoring to determine if the Seroquel is effective. During an interview on 2/4/25 at 2:34 P.M., Certified Nursing Assistant (CNA) #1 said she had never seen Resident #33 exhibit any behaviors that were inappropriate or physical. CNA #1 said Resident #33 would get more confused as the day would go on and call out for his/her spouse. During an interview on 2/4/25 at 2:34 P.M., CNA #2 said Resident #33 would sometimes have verbal outbursts but mostly he/she would become more confused or call out for his/her spouse. During an interview on 2/4/25 at 1:48 P.M., Nurse #1 said antipsychotic medications were used for restlessness and agitation. Nurse #1 said she was not aware why Resident #33 was started on Seroquel. Nurse #1 said Resident #33 would exhibit behaviors, at times, of trying to get out of bed and would call out for their spouse. Nurse #1 said she did not know what inappropriate behaviors on the behavior sheets referred to. During an interview on 2/4/25 at 4:33 P.M., Nurse # 8 said Resident #33 would hallucinate sometimes or would call out for his/her spouse. Nurse #8 said behaviors that were exhibited would be documented in his/her nurse's notes or on the behavior sheets. Nurse #8 and the surveyor reviewed Resident #33's behavior sheets. Nurse #8 said she was not aware what the inappropriate behaviors section on the Residents behavior monitoring sheet would refer to for Resident #33, but maybe just any behaviors that are out of his/her normal behavior. Nurse #8 said Resident #33 behavior sheets did not list the targeted behaviors of hallucinations or calling out, which are the only behaviors she known Resident #33 to exhibit. During an interview on 2/5/25 at 7:19 A.M., Nurse #6 reviewed Resident #33's behavior sheets and said he had not seen Resident #33 exhibit any inappropriate behaviors or difficulty falling asleep. Nurse #6 said he believed inappropriate behaviors were considered anything out of the normal for Resident #33. Nurse #6 said he was told in report Resident #33 was rude to staff and resistive to care but had never experienced that. Nurse #6 said Resident #33's behaviors should have been more specific and should include resistance to care. During an interview on 2/5/25 at 9:52 A.M., Nurse #7 and the surveyor reviewed Resident #33's behavior sheets. Nurse #7 said inappropriate behaviors are considered talking to staff sexually inappropriately, being sexually inappropriate, inappropriate vocabulary, or being physically inappropriate. Nurse #7 said she had never seen never seen those types of behaviors from Resident #33. Nurse #7 said Resident #33 would generally not exhibit any behaviors during the day, but around 2:00 P.M. or 3:00 P.M., he/she would start calling out for their spouse or for help and would become paranoid about missing the train or something with the family. Nurse #7 said Resident #33's behavior sheets did not include any specific or target behaviors for his/her needs or Seroquel use. During an interview on 2/4/25 at 4:47 P.M., Unit Manager #4 (UM) said Resident #33 would exhibit behaviors that would include looking for the bus, becoming agitated, afraid family is in danger or missing some event with their family. UM #4 said the nurses would document target behaviors for residents on their behavior sheets or in their nurses' notes. UM #4 reviewed Resident #33's behavior sheets and nurses notes and said Resident #33's behavior sheets were not specific and should include behaviors including paranoia and yelling out. UM #4 said the behavior sheets are used to monitor resident behaviors to determine if interventions are effective. UM #4 said it would be difficult to quantify the frequency, type, and time of day Resident #33 exhibited behaviors of paranoia and/or yelling because the behavior sheets did not match those known behaviors. During an interview on 2/5/25 at 4:43 P.M., the Director of Nursing (DON) said residents who receive antipsychotic medications should have specific targeted behaviors that they were being monitored for on their behavior sheets in accordance with the reason they are receiving the medication. The DON said difficulty falling asleep and inappropriate behaviors were not specific behaviors targeted to Resident #33. The DON said Resident #33 should have been monitored for yelling out and paranoia so the Physician could evaluate the efficacy of his/her Seroquel use.

Based on interview, policy review, and record review, the facility failed to implement a person-centered care plan for the use of multiple psychotropic medications for one Resident (#54), out of a total sample of 17 residents. Findings include: Review of the facility's policy titled Unnecessary Drug Therapy, undated, indicated but was not limited to the following: -Based on a comprehensive assessment of each resident, the facility must ensure that antipsychotic drug therapy is used to treat a specific condition as diagnosed and documented in the clinical record. -Residents who use antipsychotic drugs receive gradual dose reductions and behavioral interventions in an effort to discontinue these drugs. -It is the policy of this facility to encourage multidisciplinary efforts to determine factors responsible for resident behavior changes and recommend consideration of alternate (non-drug) means of treating those factors. -Behavioral symptoms and the development of a plan of care designed to attempt to reduce or eliminate the cause of harmful behavior. Resident #54 was admitted to the facility in October 2023 with diagnoses which included: bi-polar disorder, anxiety, and alcohol abuse in remission. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/8/23, indicated Resident #54 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Further review of the MDS indicated Resident #54 took antipsychotic and antidepressant medications daily. Review of the Physician's Orders for Resident #54 indicated the following: -Bupropion HCL XL 150 milligram (mg) 24-hour tablet, extended release, give 150 mg by oral route once daily. (10/26/23) (antidepressant) -Divalproex ER 250 mg tablet, extended release 24-hour, give 250 mg by oral route once daily. (10/26/23) (seizure medication used to treat behaviors/bi-polar disease) -Trazodone 150 mg tablet, give 150 mg by oral route once daily at night. (10/26/23) (antidepressant) -Quetiapine 100 mg tablet, give 100 mg by oral route once daily at night. (10/26/23) (antipsychotic) Review of the December 2023 Medication Administration Record (MAR) for Resident #54 indicated the Resident received the Bupropion HCL, Divalproex ER, Trazodone, and Quetiapine as ordered. Review of the Care Plan for Resident #54 failed to indicate resident specific behavior interventions, or the side effects of the multiple medications staff should be monitoring for. During an interview on 12/13/23 at 9:51 A.M., Nurse #10 said for residents on psychotropic medications there is no monitoring for side effects in place. During an interview on 12/13/23 at 1:28 P.M., Unit Manager #1 said there is not specific side effect monitoring. Additionally, she said the residents should have a person-centered care plan initiated and the psychotropic drug use care plan for Resident #54 is not personalized/person-centered as it should be. During an interview on 12/13/23 at 4:07 P.M., the Director of Nurses (DON) said there are no specific behavior interventions on Resident #54's care plan and there should be. He said the process needs to be improved because the care plan should be specific for each resident and the medication they are taking and this one is not.

Based on observation, interview, and record review, the facility failed to consistently implement the nutritional care plan interventions for one Resident (#23), out of a total sample of 17 residents, resulting in a gradual progressive weight loss. Findings include: Review of the facility's policy titled Clinical Nutritional Services: Interdisciplinary Care Plans, dated as revised January 2023, indicated but was not limited to the following: - each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals - the comprehensive care plan includes but is not limited to: measurable goals, needs and nutritional problems; nutritional interventions and approaches as needed; the prevention of unintentional weight loss Review of the facility's policy titled Nutritional Interventions, dated as revised October 2022, indicated but was not limited to the following: - the dietitian identifies residents that are at risk or potential risk for nutritionally related problems and recommends interventions to improve the resident's nutritional status based on the resident's preferences and tolerances - appropriate interventions are based on identified causes and risk factors, which may include but are not limited to: appropriateness of modified diets; use of high calorie supplements; change in dining location; requested monitoring parameters; and communication of resident needs with interdisciplinary team (IDT) Resident #23 was admitted to the facility in January 2021 and has diagnoses including: unspecified dementia without behavioral disturbances and dysphagia (difficulty swallowing). The most recent Brief Interview for Mental Status (BIMS) indicated the Resident is severely cognitively impaired with a score of 4 out of 15. Review of the current Physician's Orders for December 2023 included but was not limited to: - House mechanical soft, Dysphagia 3 diet - Ensure dietary supplement twice daily - Due to weight loss document each meal percentage eaten - Weekly weights On 12/12/23 the surveyor observed the following: - 8:42 A.M., Resident #23 was in bed with the head of the bed elevated and a breakfast tray in front of him/her consisting of scrambled eggs and hashbrowns on a lip plate (a plate to assist people with limited muscle control to keep food from sliding off the plate), a bowl of cream of wheat, a two handled sip cup containing milk and a two handled sip cup containing coffee. The Resident appeared confused, placing one of their cups on top of their eggs and moving it around the plate. He/she was not consuming any of the meal and the meal appeared to be untouched by the Resident. - 9:01 A.M., Resident #23 was in bed and none of the breakfast meal appeared to have been consumed. Upon interview, the Resident was unable to communicate with the surveyor his/her needs to consume their meal. Nurse #8 saw the surveyor observing the Resident and entered the room and offered to assist the Resident with his/her breakfast. Review of the current Interdisciplinary care plans for Resident #23 indicated but was not limited to the following: - Focus: Potential/Actual alteration in nutritional status related to (r/t) mechanically altered diet (1/4/21) - Goals: Will tolerate diet order and consume at least 50% of all meals; Weight stable; Will chew food without removing it; Maintain hydration status (1/4/21) - Interventions: House dysphagia 3/mechanical soft diet with thin liquids (6/14/23); registered dietitian to monitor nutritional status (1/4/21); adaptive equipment: lip plate and two handled sip cup (4/9/21); out of bed for all meals (12/1/23); supplements: Ensure twice daily (9/22/23) On 12/13/23 the surveyor observed the following: - 8:18 A.M., Resident in bed with his/her breakfast tray covered sitting on the overbed table, not set-up, and not in reach of the Resident - 8:28 A.M., Resident in bed with his/her breakfast tray covered sitting on the overbed table, not set-up, and not in reach of the Resident - 8:44 A.M., Resident in bed with his/her breakfast tray set up in front of him/her with scrambled eggs and breakfast potatoes on a lip plate, a bowl of diced peaches, a cup of yogurt, a bowl of hot cereal, and a two handled cup containing milk. The Resident was pinching a fork in between his/her left thumb and index finger which was moving back in forth, not well controlled by the Resident and the Resident was struggling to get any food on the fork for consumption, manipulating only a pea sized amount of eggs on the end of the fork and dropping it into his/her lap prior to it reaching their mouth. - 8:52 A.M., Resident dropped the fork from their left hand and picked up the spoon on the tray with his/her right hand attempting to scoop eggs onto the spoon and dropping it onto his/her lap placing the empty spoon into their mouth on three separate attempts. Then the Resident attempted to scoop more eggs onto the spoon pushing the eggs off of the tray and into his/her lap while in bed. - 8:55 A.M., Resident used the spoon in his/her right hand placing diced peaches from the bowl onto the spoon and successfully bringing the spoon to his/her mouth for consumption. Upon interview, the Resident said breakfast was okay and appeared confused while attempting to manipulate the utensils and manage the food for consumption. - 9:01 A.M., Resident in bed continuing his/her attempts to self-feed, a significant amount of food was present on the Resident's chest and lap. Review of the Certified Nurse Assistant (CNA) care card for December 2023 indicated but was not limited to the following: - Eating: Self performance extensive assist; Support of one person physical assist; Notes: one to one (1:1) dependent extensive assist, updated on 11/8/23 Review of the CNA documentation from 11/8/23 through 12/12/23 indicated the Resident received an extensive assist of one person for eating. At no time during the 43-minute observation during breakfast on 12/13/23 did the surveyor observe any staff enter Resident #23's room and assist them in eating their breakfast. Review of Resident #23's CNA documentation and documented meal consumption for breakfast on 12/13/23 indicated the Resident received an extensive assist by one staff member and consumed 100% of his/her breakfast. During a lunch time observation on 12/13/23 the surveyor observed the following: - 11:55 A.M., a truck of lunch trays arrives to the unit - 12:07 P.M., Resident #23 was sitting up at approximately a 90-degree angle in a recliner type chair at a table with his/her lunch plate set up in front of them without any staff assisting the Resident with his/her meal and the Resident was not self-initiating eating their lunch - 12:12 P.M., CNA #3 performs hand hygiene and sits beside Resident #23 and begins physically assisting the Resident with lunch time meal consumption for two bites, then performs hand hygiene and begins physically assisting the resident sitting across from Resident #23 with lunch - 12:16 P.M., CNA #3 performs hand hygiene and continues to physically assist Resident #23 with meal consumption and hands the Resident their beverage in their two handled sip cup, the Resident easily manages the cup, the CNA removed the Resident's lunch plate and the lunch meal was completed for the Resident at approximately 12:18 P.M. During an interview on 12/13/23 at 12:18 P.M., CNA #3 said Resident #23 requires physical assist for all meals and can sometimes use their silverware and attempts to feed themselves but would not be able to do so consistently throughout an entire meal. She confirmed the Resident had breakfast in bed and staff checked in on the Residents' progress and said the Resident consumed 100% of his/her breakfast on this morning with the staff just intermittently checking on him/her. When she was informed of the surveyor's observations of the Resident throughout breakfast, she said she did not see the food on the Resident's lap or bed and saw the plate was empty and informed the nurse that the Resident had eaten 100% of their breakfast. She said the Resident consumed about 50% of today's lunch and she had just finished physically assisting him/her. She said the Resident doesn't always eat well and struggles at times and will push the staff's hands away when they do not wish to eat anymore. On review of the Resident's care plan and CNA care card, CNA #3 said she was unaware the Resident was supposed to be out of bed for all meals and was 1:1 dependent for meal consumption. During an interview on 12/13/23 at 12:20 P.M., Nurse #6 said Resident #23 required assist with his/her meals at times, but not always and the staff need to keep an eye on the Resident to ensure he/she is eating by themselves. She said she was unaware the Resident struggled to manipulate their breakfast that morning. She said it was reported to her that the Resident consumed 100% of his/her breakfast and that is what she documented. She was made aware of the surveyor's observations from the breakfast meal this am (12/13/23) and reviewed the care plan and CNA care card and said she was unaware the Resident was required to be out of bed for all meals or was 1:1 dependent for eating. She said the care plan may need to be revised since the staff are not consistently physically assisting the Resident 1:1 with meals and not getting the Resident out of bed for all meals. Review of the November and December 2023 documented meal intakes for Resident #23, as recorded by the licensed nurse staff, indicated the following: - November 2023: out of 90 documented opportunities the Resident consumed an average of 47% of all meals - December 2023: out of 39 documented opportunities the Resident consumed an average of 52% of all meals Review of the Dietitian's Progress Notes and Evaluations for Resident #23 indicated the following: - 5/3/23, Resident had an unintended significant weight loss of 5.11% in one month from March 2023 - April 2023 related to decreased intake; interventions were put in place for a Magic Cup supplement at bedtime and an Ensure drink during A.M. snack; weight stable goal of +/- 5 pounds of current weight of 130 pounds (lbs.) - 6/13/23, Quarterly assessment: Weight = 129.8 lbs., weight stable; Resident requires assist at all meals - 7/8/23, Meal intake 25-75%, needs extensive assist for meals; 5.4% weight loss over six months which is important to note, but not clinically significant; current weight 129 lbs. - 9/1/23, Quarterly assessment: Weight on 8/29/23 = 128.7 lbs., up 1.1lbs. from 7/25/23; weight has been clinically stable for 6 months; discontinue Magic Cup, offer snack twice a day, nutritional goal of weight stability as evidenced by +/- 5% of current weight; body mass index (BMI)= 24.3 (normal) - 9/22/23, Weight loss of 5% in one month which is clinically significant; weight on 9/19/23 = 121.1 lbs; eats with extensive assist; add Ensure supplement twice a day to increase caloric intake - 10/12/23, Weight on 10/10/23 =123 lbs.; Ensure supplement in between meals; should be in the dayroom for lunch; eats with extensive assist - 11/3/23, Weight stabilized; totally dependent on others for meal consumption; continue Ensure supplement between meals to provide additional 250 calories each - 11/16/23, Weight = 118 lbs.; order for nurse to document meal intake; eats in the day room with staff feeding him/her - 11/22/23, Annual nutritional assessment: Current weight = 118.1 lbs.; eats in the day room with staff feeding him/her; receiving Ensure supplement in between meals; if 100% of supplement consumed it provides an additional 500 calories a day; has lost 8% of body weight in last six months which is not clinically significant, but important to note; BMI = 22.3; nutritional goals: meal intake greater than 75% overall, weight stability (+/- 5% of current weight), diet acceptance - 12/5/23, Weight = 117 lbs. down 3.9% from one month ago, not clinically significant but important to note; staff to bring to day room for all meals; nurse to document intake at each meal; extensive assist with meal consumption; continue to monitor During an interview on 12/13/23 at 1:07 P.M., the Dietitian said Resident #23 has had a gradual, continual weight loss and care plan interventions have been put in place. She said the Resident has significant cognitive loss and was not able to consistently provide themselves with nourishment and required staff to physically assist them with meal consumption. She said the Resident is to be out of bed and in the day room for all meals, the licensed nurses are documenting the amount of intake at each meal, and the Resident is receiving Ensure twice a day in between meals. She said there is not a way for her to know how much of the nutritional Ensure supplement the Resident is consuming because the staff simply sign off when the supplement is handed out. She said the intent of the supplement was to provide an additional 500 calories a day, but the amount consumed is not monitored or documented. She was made aware of the surveyor's observations from the morning of 12/12/23 and 12/13/23 and said the Resident should be out of bed for all meals and the staff should be assisting the Resident; the Resident would not be able to consume their meal independently. She said the expectation is that the staff are implementing all the interventions in place on the care plan to prevent further weight loss. Review of Resident #23's Medication Administration Record (MAR) from November 2023 through December 13, 2023, indicated but was not limited to the following: - Ensure supplement signed off as received at 10:00 A.M. and 2:00 P.M. daily throughout the month of November - Ensure supplement signed off as received at 10:00 A.M. and 2:00 P.M. daily from 12/1/23 - 12/13/23 The MAR failed to indicate the amount of supplement consumed, therefore preventing the dietitian from being able to assess the effectiveness of the dietary supplement intervention. During a dinner time observation with interview on 12/13/23, the surveyor observed the following: - 5:03 P.M., Resident out of bed in the day room for dinner sitting at a table - 5:08 P.M., CNA #4 said the Resident is supposed to be out of bed for all meals, always eats in the day room on the evening shift and is a total assist for meal consumption by staff, she said the Resident can manage their two handled cup but not their utensils related to confusion. - 5:28 P.M., Nurse #9 was physically assisting the Resident with his/her dinner consumption. Nurse #9 said the Resident does not have the cognitive ability to sequence the task of independently eating his/her meals alone and is dependent on the staff to manage his/her utensils to eat their meal. She said, to the best of her knowledge, the Resident requires total assistance with meals and is supposed to be out of bed and in the day room for all meals. During a breakfast observation on 12/14/23, the surveyor observed the following: - 8:10 A.M., Resident #23 was out of bed and in the day room awaiting his/her breakfast - 8:15 A.M., CNA #3 placed Resident's breakfast in front of him/her and walked away from the Resident; the Resident did not reach for their breakfast or utensils or initiate any move to consume their breakfast - 8:25 A.M., CNA #6 entered the day room and addressed the Resident sitting beside him/her and prompting the Resident to hold his/her cup; the Resident held their cup and began drinking his/her orange juice; CNA #6 provided 1:1 dependent assist to the Resident throughout the breakfast meal - 8:50 A.M., Resident held up his/her hand and confirmed to CNA #6 he/she was done with their breakfast meal, Resident was observed to consume less than 100% of the meal During an interview on 12/14/23 at 11:04 A.M., the Director of Nurses was made aware of the surveyor's observations of Resident #23 throughout the survey and said the expectation is anyone providing care to the Resident be aware and implement the individualized care plan interventions as documented in the medical record to meet the Resident's needs. He said it was clear the interventions on Resident #23's nutritional care plan were not consistently implemented as they should have been. He said the nurses should be documenting and calculating the total amount of food consumed at each meal and the amount of supplement consumed by the Resident to better determine if the interventions are effective. He said the process of consistently implementing care plan interventions seemed to be full of holes and needed work for the Resident's needs to be consistently met in accordance with their plans of care. During an interview on 12/14/23 at 12:04 P.M., the Dietitian said there is no clinical reason the Resident should be continuing to gradually lose weight if all the care plan interventions were consistently implemented by the staff. She said the intention of the interventions for the licensed staff to document meal intake and provide supplements was for closer monitoring and the nurses should be calculating and documenting meal intake as well as the amount of the supplement consumed twice daily or she has no way of knowing if the Ensure supplement is effective. She said it is important for the care plan interventions for Resident #23 to be consistently implemented to prevent further weight loss and stabilize the Resident's weight as in the past.

Based on interview, policy review, and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary psychotropic drugs without adequate monitoring for one Resident (#54), out of a total sample of 17 residents. Specifically, the facility failed to monitor for side effects of multiple psychotropic medications and to implement behavioral interventions in an effort to discontinue these drugs. Findings include: Review of the facility's policy titled Unnecessary Drug Therapy, undated, indicated but was not limited to the following: -According to The Centers for Medicare and Medicaid Services (CMS), an unnecessary drug is one that is: in excessive dose; for excessive duration; without adequate monitoring; without adequate indication for use; in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combination of the reasons above. -Based on a comprehensive assessment of each resident, the facility must ensure that antipsychotic drug therapy is used to treat a specific condition as diagnosed and documented in the clinical record. -Residents who use antipsychotic drugs receive gradual dose reductions and behavioral interventions in an effort to discontinue these drugs. -Residents on antipsychotic drug therapy will be monitored for specific conditions, behaviors both quantitatively and objectively and if effects. (sic) -It is the policy of this facility to encourage multidisciplinary efforts to determine factors responsible for resident behavior changes and recommend consideration of alternate (non-drug) means of treating those factors. -Consistent monitoring should be done to assess the risk/benefit relationship of psychotropic drug therapy, including the appropriateness of drug selection and dosage. Clearly defined criteria should be developed for evaluation of adverse drug reactions. -Behavioral symptoms and the development of a plan of care designed to attempt to reduce or eliminate the cause of harmful behavior. Resident #54 was admitted to the facility in October 2023 with diagnoses which included: bi-polar disorder, anxiety, and alcohol abuse in remission. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/8/23, indicated Resident #54 was cognitively intact as evidenced by a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS). Further review of the MDS indicated Resident #54 takes antipsychotic and antidepressant medications daily. Review of the Physician's Orders for Resident #54 indicated the following: -Bupropion HCL XL 150 milligram (mg) 24-hour tablet, extended release, give 150 mg by oral route once daily. (10/26/23) (antidepressant) -Divalproex ER 250 mg tablet, extended release 24-hour, give 250 mg by oral route once daily. (10/26/23) (seizure medication used to treat behaviors/bi-polar disease) -Trazodone 150 mg tablet, give 150 mg by oral route once daily at night. (10/26/23) (antidepressant) -Quetiapine 100 mg tablet, give 100 mg by oral route once daily at night. (10/26/23) (antipsychotic) Further review of the physician's orders failed to indicate an order to monitor for side effects of the psychotropic medications. Review of the December 2023 Medication Administration Record (MAR) for Resident #54 indicated the Resident received the Bupropion HCL, Divalproex ER, Trazodone, and Quetiapine as ordered. Review of the Care Plan for Resident #54 failed to indicate resident specific behavior interventions, or the side effects of the multiple medications staff should be monitoring for. During an interview on 12/13/23 at 9:51 A.M., Nurse #10 said residents on psychotropic medications have behavior monitoring sheets, but there is no monitoring for side effects of the medications. During an interview on 12/13/23 at 1:28 P.M., Unit Manager #1 said all residents on psychotropic medications have behavior sheets initiated on admission or when the order is written, but there is not specific side effect monitoring. During an interview on 12/13/23 at 4:07 P.M., the Director of Nurses (DON) said there is no specific reference to the type of medications being used or what side effects staff should be monitoring for.

Based on observation, interview, and policy review, the facility failed to maintain and consistently implement an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections for one Resident (#208). Specifically, the facility failed to ensure Enhanced Barrier Precautions (EBP), including gown and glove use were consistently implemented during care. Findings include: Review of the facility's policy titled Policy for Enhanced Barrier Precautions, dated 1/1/23, indicated but was not limited the following: -Care Center will follow the recommendations of the Centers for Disease Control and Prevention (CDC) regarding the utilization of EBP for residents during these situations: Indwelling catheters. -Person Protective Equipment (PPE) will consist of gloves, gowns after hand sanitizing by staff for any of the following activities: Dressing, Bathing/Showering, Transferring, Hygiene Care, Linen Changing, Toileting assists or brief changes, Device care: indwelling devices, catheters. -Resident's rooms, for those on EBP, shall be posted with an EBP sign facing the resident's door and a STOP alert advising visitors to Please see Nurse facing towards the public. Resident #208 was admitted to the facility in November 2023 with diagnoses which included history of falls, femur fracture, artificial right hip joint, and dementia. Review of the Physician's Orders for Resident #208 indicated but was not limited to the following: -Foley Catheter #14 French with 10 milliliter (ml) balloon to Catheter Drainage (CD) Bag-check patency every shift. (12/9/23) -Foley catheter care every shift. (12/9/23) -Maintain Enhanced Barrier Precautions every shift due to Foley catheter. (12/9/23) Review of the December 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) indicated the Foley catheter care was done as ordered and EBP were maintained. Throughout the survey, the surveyor observed the required EBP signage posted at the door of Resident #208 room. On 12/13/23 at 10:17 A.M., the surveyor observed the following: - Resident #208 lying in bed with legs to the side and held up in the air, attempting to remove a brief around the Foley catheter tubing. -The surveyor alerted Nurse #10 the Resident needed assistance. -Nurse #10 put gloves on and entered the room to ensure immediate safety of Resident #208. -Nurse #10 told the Resident she needed assistance to give him/her a boost in bed. -A second Nurse was at the nurses' station and approached the doorway of Resident #208's room. She then looked at the sign and opened the PPE cart. -Nurse #10 approached the doorway of Resident #208's room and said he/she is only on precautions for the catheter. -Resident #208 was lying in bed safely at this time. -Nurse #10 and the second Nurse approached Resident #208 with gloves on (no gown) and proceeded to reposition and boost him/her in bed and then put a clean brief on. -Both nurses then exited the room. During an interview on 12/13/23 at 12:38 P.M., Nurse #10 said EBP are to be maintained for anyone with a Foley catheter. Additionally, she said PPE for EBP is written on the sign, everyone should be wearing gloves and gowns with any personal care, and she should have put a gown on before boosting and changing the brief as the Resident was safe at that time. During an interview on 12/13/23 at 1:28 P.M., Unit Manager #1 said her expectation is that all staff follow the EBP guidelines and wear the appropriate PPE when providing care. Additionally, she said the nurses should have had a gown on when repositioning, boosting, and changing the Resident. During an interview on 12/13/23 at 4:07 P.M., the Director of Nurses (DON) said every resident with a Foley catheter is on EBP, and his expectation is staff will wear gloves and gowns when providing direct care. Additionally, he said Nurse #10 should have done hand hygiene and put on a gown and gloves and the other nurse should have put on a gown and gloves before either of them repositioned, boosted, and changed Resident #208.

Based on interviews, policy review, and observations, the facility failed to have information on how to file a grievance in resident care and public areas and have forms accessible, so residents and/or visitors were able to anonymously notify the facility of their concerns. Findings include: Review of the facility's policy titled Grievance (undated) indicated but was not limited to: -The right to file grievances verbally or in writing; -The right to file grievances anonymously During the Resident Group interview on 12/13/23 at 10:00 A.M., which consisted of 11 residents from all three open units, the residents said they would speak to the Social Worker or the Ombudsman if they had a grievance/concern. The residents said they were unsure of how to file a grievance when the Social Worker and/or Ombudsman were unavailable. The residents were unaware of where information on filing a grievance or grievance forms were located. During a tour on 12/13/23 at 11:58 A.M., the surveyor was unable to locate information on how to file a grievance verbally or anonymously, or any grievance forms on three of the three open resident units. During an interview on 12/13/23 at 10:15 A.M., the Activity Director said that the grievance process is reviewed at Resident Council. She said she encourages the residents to report concerns or file a grievance with the Social Worker or Ombudsman. She said she was unaware that residents could file grievances with any staff member and residents have the right to file grievances anonymously. During an interview on 12/13/23 at 3:00 P.M, the Social Worker said that she is the grievance officer for the facility. She said there are grievance forms on each unit behind the nurses' station. She said the residents or their families would have to notify a staff member to retrieve a form for them if they wanted to complete a grievance form. She said the process in place needs to be adjusted to ensure residents and their visitors can voice grievances and concerns without having to involve the staff if they choose in accordance with their rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and policy review, the facility failed to ensure all drugs and biologicals were secured in locked compartments with only authorized personnel having access. Specifically, the facility failed: 1A. For Resident #212, to ensure prescription medicated treatment powder and cream were not left unattended in the Resident's room, and B. For Resident #51, to ensure a bottle of vitamin supplement and a prescription cream were not left unattended in the Resident's room; and 2. To ensure staff kept the Medication Cart locked when not in use or under direct supervision of the nurse. Findings include: Review of the facility's policy titled Medication Storage Policy, undated, with attachment titled Omnicare: Common Medication Storage Guidance and Terminology, dated March 2020, indicated but was not limited to the following: -All medications stocked and packaged and labeled in accordance with federal and state regulations. Review of the facility's policy titled Administering Medications, undated, indicated but was not limited to the following: -Medications shall be administered in a safe and timely manner, and as prescribed. -During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. -Topical medications used in treatments must be documented on the resident's medication record (MAR). -Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. 1A. Resident #212 was admitted to the facility in December 2023 with diagnoses including history of falls and multiple fractures of the pelvis. Review of the most recent Brief Interview for Mental Status (BIMS), undated, indicated Resident #212 was cognitively intact as evidenced by a score of 14 out of 15. Review of the Self-Administration of Medications form, signed and dated 12/4/23 by Resident #212, indicated he/she wanted to have medications Administered by Nursing Staff. The surveyor observed the following: -12/12/23 at 9:00 A.M., a clear plastic bag with prescription Nystatin (antifungal) powder and a box containing a tube of prescription Clotrimazole 1% (antifungal) cream on the dresser next to the bed. -12/12/23 at 10:18 A.M., a clear plastic bag with prescription Nystatin (antifungal) powder and a box containing a tube of prescription Clotrimazole 1% (antifungal) cream on the dresser next to the bed. -12/12/23 at 2:20 P.M., a clear plastic bag with prescription Nystatin (antifungal) powder and a box containing a tube of prescription Clotrimazole 1% (antifungal) cream on the dresser next to the bed. Review of Resident #212's Physician's Orders failed to indicate an order for Nystatin or Clotrimazole. Further review of the Physician's Orders indicated but was not limited to the following: -House antifungal powder-apply to groin rash two times per day until healed then discontinue. (12/4/23) Review of the Treatment Administration Record (TAR) indicated the House antifungal powder was administered as ordered. Review of the Nurse's Note, dated 12/9/23, indicated Resident #212 was frustrated because he/she had to get up him/herself to place antifungal cream on his/her toes and was reminded that the nursing staff would apply the cream. During an interview on 12/12/23 at 10:18 A.M., Resident #212 said the powder and cream stay on the dresser all the time and that he/she puts it on him/herself sometimes because the staff don't always do it before bed. During an interview on 12/13/23 at 12:38 P.M., Nurse #10 said medications, including creams and powders, should not be left at the bedside ever, unless the Resident is able to self-administer medications; Resident #212 should not have had those in his/her room. During an interview on 12/13/23 at 1:28 P.M., Unit Manager #1 said medicated creams and powders should not be left at the bedside unless the resident is able to self-administer medications. Additionally, she said if a resident was able to self-administer medications the assessment would be done, and an order written. She said there are no residents on the unit that self-administer medications/treatments. During an interview on 12/13/23 at 4:07 P.M., the Director of Nurses (DON) said medication, including creams and powders, should not be left at the bedside ever unless the resident is able to self-administer medications. Resident #212 should not have had those two medications at their bedside. 1B. Resident #51 was admitted to the facility in March 2023. Review of the Minimum Data Set (MDS) assessment, dated 11/27/23, indicated Resident #51 was cognitively intact as evidenced by a BIMS score of 15 out of 15. On 12/12/23 at 8:30 A.M., the surveyor observed the following in Resident #51's room on the bedside table: -One bottle labeled chewable Cal Mag Plus (vitamin supplement), -One tube labeled Betamethasone Dipropionate (topical cream to treat itching and other skin conditions) and, -A blood glucose lancet (small needle-like device to prick skin to obtain a few drops of blood), lying next to the medications. On 12/12/23 at 8:34 A.M., the surveyor observed Nurse #2 enter Resident #51's room, approach the bedside table, pick up the lancet and place it in her pocket, and exit the room, leaving the other medications on the bedside table. During an interview on 12/12/23 at 11:45 A.M., Resident #51 said he/she no longer takes the Cal Mag Plus. On 12/13/23 at 7:48 A.M. and 1:20 P.M., the surveyor observed Cal Mag Plus and Betamethasone Dipropionate cream on Resident #51's bedside table. During an interview on 12/13/23 at 1:22 P.M., Nurse #3 said she was not aware the Resident had medications at the bedside, and they should not be there. During an interview on 12/14/23 at 10:05 A.M., Unit Manager #2 said Resident #51 should not have medications at the bedside. He said his expectation would be for any residents with medications at the bedside to have them stored in a locked drawer. In addition, the Unit Manager added that the Betamethasone Dipropionate cream was prescribed for another resident across the hall and should not have been left in the room of Resident #51. 2. The surveyor made the following observations on [NAME] Point Unit: -12/13/23 at 9:03 A.M., the medication cart was left unlocked and unattended with drawers facing into the hallway in front of room [ROOM NUMBER]; Nurse #10 was in room [ROOM NUMBER] with her back to the medication cart. -12/13/23 at 9:13 A.M., the medication cart was left unlocked and unattended with drawers facing into the hallway in front of room [ROOM NUMBER]; Nurse #10 left the medication cart and walked around the corner and into the kitchenette. -12/13/23 at 9:47 A.M., the medication cart was left unlocked and unattended with drawers facing into the hallway between rooms [ROOM NUMBERS]; Nurse #10 left the medication cart and walked around the corner to get wound care supplies. -12/13/23 at 10:08 A.M., the medication cart was left unlocked and unattended with drawers facing into the hallway between rooms [ROOM NUMBERS]; Nurse #10 went into room [ROOM NUMBER] to administer medications. -12/13/23 at 12:28 P.M., the medication cart was left unlocked and unattended with drawers facing into the hallway between rooms [ROOM NUMBERS]; Nurse #10 was sitting at a computer at the nurses' station with her back to the medication cart. During an interview on 12/13/23 at 12:38 P.M., Nurse #10 said the medication cart should be locked if she is not at or near it, and it was left unlocked. During an interview on 12/13/23 at 1:28 P.M., Unit Manager #1 said the medication cart should be locked at all times if not in view of the nurse and it should never be left unattended in the hallway. During an interview on 12/13/23 at 4:07 P.M., the Director of Nurses (DON) said the medication cart should always be locked when not in view of the nurse and never left unattended in the hallway.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and policy review, the facility failed to store and serve food in accordance with professional standards for food safety in three out of three nourishment kitchens. Specifically, the facility failed to properly label and date opened beverages and maintain safe and clean equipment. Findings include: Review of the facility's policy titled Unit Pantry Stock, dated as revised 1/2023, indicated but was not limited to: - Service and stock pantries daily or as needed per community specifications. - Label, date and discard outdated items per food storage policy. - Ensure all items are covered, labeled, and dated. - Procedure and responsibilities for cleaning and care of pantry area must be assigned. The responsible department(s) will maintain equipment temperature and cleaning logs per record retention policy. Responsibilities may include, but are not limited to: (a) cleaning and sanitizing of refrigerator/pantry: Food Service. Review of the facility's policy titled Food and Supply Storage, dated as revised on 1/2023, indicated but was not limited to: - Cover, label, date unused portions and open packages. Complete all sections on a [NAME] orange label or use the Medvantage/Freshdate labeling system. Products are good through the closure of business on the date noted on the label. On 12/13/23 at 7:50 A.M., the surveyor observed the following on the [NAME] Pointe Unit Kitchenette: - The top inside of the microwave had food particle spatter and dark brown stains. - The refrigerator had three bottles of opened cranberry juices undated, one bottle of opened apple juice undated, two opened caffeine free cola bottles undated, and one opened ginger ale bottle undated. On 12/13/23 at 9:57 A.M., the surveyor observed the following on the Nobska Unit Kitchenette: - The refrigerator had three opened bottles of cranberry juice undated, one opened bottle of apple juice undated, one opened bottle of diet ginger ale undated, and one opened bottle of ginger ale undated. On 12/13/23 at 10:12 A.M., the surveyor observed the following on the Naushon Unit Kitchenette: - The top inside portion of the microwave had food residue and spatter. The microwave also had two areas of rusted or burnt metal bulging out of the top of the microwave. - The refrigerator had two opened bottles of cranberry juice undated, one opened bottle of orange juice undated, two opened bottles of diet cola undated, one opened bottle of ginger ale undated, and one opened bottle of diet ginger ale undated. On 12/13/23 at 12:46 P.M., the surveyor observed the following on the [NAME] Pointe Unit Kitchenette: - The top inside of the microwave had food particle spatter and dark brown stains. - The refrigerator had one opened bottle of cranberry juice undated, two opened caffeine free cola bottles undated, and one opened bottle of ginger ale undated. On 12/13/23 at 12:45 P.M. and 3:25 P.M., the surveyor observed the following on the Nobska Unit Kitchenette: - The refrigerator had one opened bottle of cranberry juice undated. On 12/13/23 at 12:48 P.M. and 3:22 P.M., the surveyor observed the following on the Naushon Unit Kitchenette: - The top inside portion of the microwave had food residue and spatter. The microwave also had two areas of rusted or burnt metal bulging out of the top of the microwave. - The refrigerator had one opened bottle of cranberry juice undated and one opened bottle of caffeine-free cola undated. - The blender located on the countertop in the kitchenette had a white residue on the inside and outside of the glass container. On 12/13/23 at 2:30 P.M., the surveyor observed the following on the [NAME] Pointe Unit Kitchenette: - The top inside of the microwave had food particle spatter and dark brown stains. - The refrigerator had one opened bottle of cranberry juice undated, one opened bottle of caffeine-free cola undated, and one opened bottle of ginger ale undated. On 12/14/23 at 7:33 A.M., the surveyor observed the following on the [NAME] Pointe Unit Kitchenette: - The top inside of the microwave on the unit had food particle spatter and dark brown stains. - The refrigerator had one opened bottle of apple juice undated, one opened bottle of ginger ale undated, two opened bottles of caffeine-free cola undated, and one opened bottle of diet ginger ale undated. On 12/14/23 at 7:39 A.M., the surveyor observed the following on the Nobska Unit Kitchenette: - The refrigerator had one opened bottle of apple juice undated, one opened bottle of ginger ale undated, and one opened bottle of diet ginger ale undated. On 12/14/23 at 7:42 A.M., the surveyor observed the following on the Naushon Unit Kitchenette: - The top inside portion of the microwave had food residue and spatter. The microwave also had two areas of rusted or burnt metal bulging out of the top of the microwave. - The refrigerator had one opened bottle of cranberry juice undated, one opened bottle of diet cola undated, one opened bottle of ginger ale undated, one opened bottle of apple juice undated and one opened bottle of caffeine-free cola undated. - The blender located on the countertop in the kitchenette had a white residue on the inside and outside of the glass container. During an interview on 12/13/23 at 2:32 P.M., Certified Nursing Assistant (CNA) #1 said staff were able to get drinks and snacks for residents out of the kitchenette area when needed. CNA #1 said she did not need to label bottled beverages when opened because the kitchen staff put a used by sticker on all items when they deliver them to the unit. During an interview on 12/13/23 at 3:28 P.M., CNA #2 said staff were able to get drinks and other refreshments from the kitchenettes on the unit for residents. CNA #2 said staff should put the date on bottled beverage when opened in the kitchenette. During an interview on 12/13/23 at 3:39 P.M., Nurse #1 said the kitchenettes on each unit were stocked by the kitchen staff. Nurse #1 said if a new bottled beverage or package is opened staff are supposed to date the item for the day it was opened. Nurse #1 said if an item was undated, she would throw it out and open a new item because she could not be sure how long it was opened. During an interview on 12/14/23 at 9:40 A.M., the Food Service Director was made aware of the surveyor's observations. The Food Service Director said staff were to date bottles or packages when they were opened. The Food Service Director said if bottles of beverages were undated, they needed to be disposed of because it would be impossible to know when they were originally opened. The Food Service Director said microwaves should be cleaned daily by dietary staff. The Food Service Director said the microwaves should not have food spatter or spill. The Food Service Director said the Naushon Unit microwave would need to be replaced because it should not have any burnt or potentially rusted areas. The Food Service Director said dietary and nursing staff needed to work together to make sure items were properly dated or disposed of and the microwaves were properly maintained.

Based on observation, interview, and document review, the facility failed to maintain an infection prevention and control program to help prevent the potential transmission of a communicable disease when the facility was experiencing an outbreak of COVID-19 infections. Specifically, the facility failed to: 1. Ensure proper COVID-19 outbreak testing procedures were implemented for two of two facility staff reviewed (Staff #1, Staff #2); and 2. Ensure staff followed infection control guidelines for doffing (taking off) personal protective equipment (PPE) when exiting a COVID-19 positive resident's room. Findings include: During an interview on 11/8/23 at 8:57 A.M., the Administrator and Director of Nursing (DON) said the facility was experiencing a COVID-19 outbreak that began on 10/21/23 affecting the Nobska and Naushon (10/31/23) Units. They said the expectation for PPE was for staff to wear an N95 facemask, gown, face shield/goggles, and gloves prior to entering a COVID-19 positive resident's room and that the facility followed Department of Public Health (DPH), Centers for Disease Control and Prevention (CDC), and Centers for Medicare and Medicaid Services (CMS) guidance. The Administrator and DON said the facility was currently performing outbreak testing of all staff on the affected units starting within 24 hours, then every 48 hours thereafter until the facility goes seven days without a new COVID-19 case. 1. Review of the DPH Memorandum titled Update to Infection Prevention and Control Considerations When Caring for Long-Term Care Residents, including Visitation Conditions, Communal Dining, and Congregate Activities, dated May 2023, indicated but was not limited to the following: -Long-term care facilities are required to perform outbreak testing of residents and staff as soon as possible when a case is identified. -Once a new case is identified in a facility, following outbreak testing, long-term care facilities should test exposed residents and staff at least every 48 hours on the affected unit until the facility goes seven days without a new case unless a DPH epidemiologist directs otherwise. Residents and staff who have recovered from COVID-19 in the last 30 days can be excluded from this testing. Review of posted signage provided by Infection Preventionist (IP) #1 to the surveyor on 11/8/23 indicated the following: -Naushon and Nobska staff must Binax test every other day until further notice unless COVID positive within the last month. a. Review of Staff #1's October 2023 and November 2023 timecard indicated that he/she had worked on the following days on the following COVID-19 affected units: October 31 - (Naushon) November 1 - (Naushon) November 2 - (Naushon) November 3 - (Nobska) November 5 - (Naushon) November 6 - (Naushon) November 7 - (Naushon) November 8 - (Naushon) On 11/8/23 at 3:13 P.M, the surveyor reviewed Staff #1's timecards and corresponding staff Testing Logs with IP #2 who said Staff #1 worked on the affected units and only performed COVID-19 outbreak testing on 10/31/23 (negative) and 11/5/23 (negative). She said she did not have any further documentation of testing for Staff #1 and that Staff #1 failed to meet the requirement for outbreak testing. IP #2 said Staff #1 was not excluded from COVID-19 testing. During an interview on 11/8/23 at 3:24 P.M., the surveyor reviewed the timecards with Staff #1 who confirmed the days worked. Staff #1 said she typically works on the Nobska and Naushon Units and is supposed to test every two days when she comes in. Staff #1 said she might have forgotten to document her testing and if it's not documented, then she can't prove that she did it. Staff #1 said she will sometimes test on the units. During an interview on 11/8/23 at 3:39 P.M., IP #2 said staff are not supposed to be testing on the units, only in the testing room off the main lobby, and said she could not find any further testing for Staff #1. b. Review of Staff #2's October 2023 and November 2023 timecard indicted that he/she had worked on the following days on the following unit: October 31 - (Naushon) November 1 - (Naushon) November 2 - (Naushon) November 4 - (Naushon) November 5 - (Naushon) November 7 - (Naushon) November 8 - (Naushon) On 11/8/23 at 3:54 P.M., the surveyor reviewed Staff #2's timecards and corresponding staff Testing Logs with IP #2 who said Staff #2 worked on an affected unit and only performed outbreak COVID-19 testing on 11/2/23 (negative). IP #2 said she did not have any further documentation of testing for Staff #2 and that Staff #2 failed to meet the requirement for outbreak testing. IP #2 said Staff #2 was not excluded from testing. During an interview on 11/8/23 at 4:10 P.M., the surveyor reviewed the timecards with Staff #2 who confirmed the days worked. Staff #2 said she was not exempt from testing and primarily worked on the Naushon Unit, which was a COVID-19 affected unit. Staff #2 said she tests when she comes in on Mondays, Wednesdays, and Fridays in the testing room, but some days she tests on the unit and does it often. Staff #2 said if she tests on the unit, then she only verbalizes the results to Unit Manager (UM) #1 or other supervisors and does not document them. She said if it's not documented then it's not done but was told it was okay. Staff #2 said the facility policy should be adhered to. During an interview on 11/8/23 at 4:35 P.M., UM #1 said she has never seen staff test on the unit and has never been approached by staff verbalizing their COVID-19 testing results. 2. Review of Centers for Disease Control and Prevention (CDC) guidance titled Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19, dated June 2020, indicated but was not limited to the following (www.cdc.gov/coronavirus): Doffing (taking off the gear) 1. Remove gloves 2. Remove gown 3. Healthcare personnel (HCP) may now exit patient room On 11/8/23 at 9:40 A.M., the surveyor observed Certified Nursing Assistant (CNA) #1 exit a COVID-19 positive resident's room and doff her gloves and gown in middle of the hallway, not prior to exiting the resident's room. A sign posted outside the resident's room indicated he/she was on isolation precautions. During an interview on 11/8/23 at 9:40 A.M., CNA #1 said she had provided direct care to a COVID-19 positive resident inside the room. She said there was a trash can inside the room, but it was too small to doff her PPE, so she doffed her gown and gloves outside the room in the hallway trash. During an interview on 11/8/23 at 3:34 P.M., Infection Preventionist (IP) #2 said staff were expected to doff their gown and gloves prior to exiting a COVID-19 positive resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to ensure that staff developed and implemented a comprehensive, person-centered care plan for the care and treatment of a left foot surgical wound for one Resident (#69), out of a total sample of 18 residents. Findings include: Resident #69 was admitted to the facility in August 2021 with a diagnosis of a left foot toe amputation. Review of the most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the Resident is cognitively intact. The MDS further indicated Resident #69 had a surgical wound and was receiving surgical wound care. Review of the medical record indicated Resident #69 had a Physician's Order, dated 9/19/21, for the care and treatment of a left foot wound. During an interview on 9/20/21 at 1:49 P.M., the Director of Nurses (DON) said that a skin care plan for the surgical wound would be located in the care plan section in the electronic medical record (EMR). Review of Resident #69's Interdisciplinary Care Plans indicated there was no documented evidence that the facility developed a care plan that addressed the care and treatment of a left foot surgical wound.

Based on observations, interviews, and record review, the facility failed to ensure that one Resident (#372), out of a total sample of 18 residents, was free from significant medication error. Findings include: Resident #372 was admitted to the facility in September 2021 with a diagnosis of a right hip fracture. Review of Resident #372's Physician's orders, dated 9/8/21, indicated the Resident was to receive Lovenox (an anticoagulant medication that helps in the prevention of blood clots) 40 milligrams (mg) subcutaneous nightly for 28 days. Review of the Medication Administration Record (MAR) indicated the Resident received Lovenox 9/8/21 through 9/14/21 at 9:00 P.M. The MAR further indicated that the Lovenox was stopped on 9/14/21. Review of the Nurse Practitioner's progress note, dated 9/14/21, indicated the Resident was to continue the Lovenox for 28 days. Review of the MAR indicated that the Resident did not receive the Lovenox on 9/15/21. During an interview on 9/16/21 at 1:30 P.M., Nurse #2 said she was unsure why the Lovenox order was discontinued. During an interview on 9/16/21 at 3:30 P.M., the Director of Nurses (DON) said she was unsure why the order was discontinued. During an interview on 9/20/21 at 12:45 P.M., the DON said that a new nurse that was orienting was being taught how to discontinue orders in the Electronic Medical Record (EMR) system and that the Lovenox order was discontinued in error.

Based on staff interview, record review, and review of the Hospice agreement contract, the facility failed to ensure one Resident (#44) received appropriate Hospice services, out of a total of 18 residents. Findings include: Resident #44 was admitted to the facility in June 2021 with diagnoses that included Gastrointestinal hemorrhage (bleed), Atrial Fibrillation (irregular heart rhythm), Hypertension (high blood pressure), and Diabetes. Review of the Minimum Data Set (MDS) assessment, dated 6/3/21, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating the Resident has severe cognitive impairment. Review of the medical record indicated that Resident #44 was admitted to Hospice services on 7/22/21. Review of the Hospice/ Nursing Facility Agreement, dated 7/22/21, indicated under the section called Coordination of Care, the following: - Facility shall coordinate with Hospice in developing a plan of care for each Hospice patient. During an interview on 9/15/21 at 3:40 P.M., Nurse #1 said that all care plans are documented in the care plan section of the Electronic Medical Record (EMR). Review of Resident #44's Care Plans on 9/15/21 indicated that there was no documented evidence of a collaborative Hospice care plan in the medical record.

Based on observation, record review, and staff interview, the facility failed to ensure that infection control measures were adhered to during a medical treatment, in accordance with the facility's Wound Care Policy, for 1 sampled Resident (#32), out of a total of 18 residents. Findings include: Resident #32 was admitted to the facility in July 2021 with diagnoses which included insulin dependent diabetes and a Stage IV pressure ulcer. Review of Resident #32's medical record indicated the Resident was being treated for a healing Stage IV pressure injury on the coccyx. The medical record indicated that the treatment to the pressure wound consisted of the following: -cleanse with normal saline solution -apply Hydrofera Blue, apply bordered Hydrofera or gauze over Hydrofera Blue, secure with tape. -change every other day. On 9/17/21 at 1:45 PM, the surveyor observed Nurse #2 perform the treatment to the Resident's pressure wound. Before the surveyor arrived Nurse #2 began securing the materials and setting up for the dressing change. The surveyor observed Clinical Nursing Assistant (CNA) #1 holding the patient over in the bed so that Nurse #2 could perform the treatment. The surveyor observed Nurse #2 to have two pairs of gloves on to perform the dressing change. Nurse #2 had a standard pair of vinyl examination gloves on the inside, covered by a pair of purple, vinyl gloves on the outside. Nurse #2 placed a blue, disposable pad under the Resident's exposed back and removed the soiled dressing. Next, she cleansed the wound with normal saline that she squeezed from unit dose bullets onto the gauze 4 x 4. She then patted the wound dry with an additional 4 x 4 gauze pad. Nurse #2 then removed the purple outer pair of gloves, and without removing the inner pair of gloves, and without cleansing her hands, was observed preparing to open the clean Hydrofera blue dressing to apply to Resident's wound. The surveyor questioned Nurse #2 about her technique of wearing two pairs of gloves, and her failure to remove both pair of gloves and cleanse/wash her hands after cleaning the wound, and before moving on to perform the clean portion of the dressing change. Nurse #2 immediately stopped the treatment following the surveyor's inquiry into her dressing change technique. She then removed the inner pair of gloves, cleansed her hands with alcohol-based hand rub, applied clean gloves, and completed the dressing change. Review of the facility's Wound Care Policy on 9/17/21 at 2:00 P.M., indicated: 3. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the linen and other body sites. 4. Put on exam glove. Loosen tape and remove dressing 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves. Gowns will only be necessary if soiling of your skin or clothing with blood, urine, feces, or other body fluids is likely. Masks and eyewear will only be necessary if splashing of blood or other body fluids into your eyes or mouth is likely. 7. Use no touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers. 8. Pour liquid solutions directly on gauze sponges on their papers. Wear exam gloves for holding gauze to catch irrigation solutions that are poured directly over the wound. 10. Wear gloves when physically touching the wound or holding a moist surface over the wound. 11. Wash tissue around the wound that is usually covered by the dressing, tape or gauze with normal saline. Pat skin dry. 12. Remove dry gauze. Apply treatments as indicate. 13. Dress wound. [NAME] tape with initials, time, and date and apply to dressing. On 9/17/21 at 2:00 P.M., the Director of Nurses (DON) said that Nurse #2 did not follow the facility's policy when performing the treatment to the Resident's healing, Stage IV pressure wound.

Based on record review and staff interviews, the facility failed to designate a person who met the minimum qualifications to serve as the Director of Food and Nutrition Services to ensure the nutritional needs of the residents were being met. Findings include: During an interview on 9/14/21 at 9:30 A.M., the Administrator identified to the surveyor by name who the Food Manager was and said that he had only been in the position for a few months. During an interview on 9/14/21 at 10:00 A.M., the Food Manager said he had been at the facility since April 2021 and was working for the management company assigned to the JML food service department. He said that he did not have any certifications to meet the qualifications, and the food management company was going to train him and assist him in obtaining the proper qualifications. The Food Manager also said that the dietitian worked for the management company and was at the facility 32 hours a week. During an interview on 9/16/21 at 2:00 P.M., the Administrator said the Food Manager currently did not hold the correct qualifications and the food management company was assisting him in obtaining the proper certifications. The Administrator said the First [NAME] works closely with the Food Manager and both worked 40 hours a week. The Administrator said the First [NAME] did have a culinary degree, but did not have the documentation to show the surveyor at the time of survey. The Administrator confirmed that the Food Manager's date of hire was 4/4/21. During an interview on 9/16/21 at 2:30 P.M., the Dietitian said she works 32 hours a week at the facility and is not in charge of the kitchen. On 9/24/21, four days after the exit, via e-mail, the Administrator indicated she still did not have the documentation to verify the First Cook's educational degree or that either the Food Manager or the First [NAME] had the qualifications to be designated as the Director of Food and Nutrition services for the facility.