Based on interview, record and policy review, the facility failed to develop and implement a comprehensive person-centered care plan for one Resident (#29) out of a total sample size of 31 residents. Specifically, the facility staff failed to develop and implement timely a comprehensive person-centered care plan specific to required care and services for Resident #29 when the Resident was discharged from and then re-admitted to the facility. Findings include: Review of facility's policy titled Comprehensive Care Plans and Revisions dated 8/22/23, indicated the following: -It was the facility's policy to ensure the timeliness of each resident's person-centered, comprehensive care plan .and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his/her care. -Comprehensive care plans must be developed within 7 days after completion of the comprehensive assessment. Resident #29 was re-admitted to the facility in June 2024, with diagnoses including Diabetes (disease in which the body's ability to produce or respond to the hormone insulin is impaired resulting in elevated blood glucose [sugar] levels in the blood), Asthma (a condition where the airways become inflamed and narrow making it difficult to breathe) and Congestive Heart Failure (CHF- caused when the heart is unable to pump blood effectively resulting in fluid build-up in the lungs, arms, feet and other organs). Review of Resident #29's clinical record indicated the following: -The Resident had a previous admission to the facility in May 2024 to June 2024. -The most recent comprehensive assessment had been completed on 5/13/2024. -The Resident was re-admitted to the facility in June 2024 (within 24 hours). -No evidence the facility staff had developed and implemented a comprehensive person-centered care plan after Resident #29 was re-admitted to the facility. During an interview on 7/22/24 at 4:52 P.M., MDS Nurse #1 said Resident #29's care plan had been deleted from the medical record when the Resident was discharged from the facility on 6/13/24. MDS Nurse #1 said Resident #29 was only discharged overnight and returned to the facility the day after discharge, therefore Resident #29 was classified as an interrupted stay. MDS Nurse #1 said Resident #29's comprehensive person-centered care plan should have been created on the date the Resident was re-admitted to the facility. During an interview on 7/23/24 at 7:20 A.M., MDS Nurse #1 said Resident #29 did not have a comprehensive person-centered care plan in place from 6/14/24 through 7/21/24. MDS Nurse #1 said the comprehensive person-centered care plan should have been in place to ensure proper delivery of care and services to meet Resident #29's needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide care and services according to professional standards for one Resident (#143) out of a total sample of 31 Residents, who had an indwelling urinary catheter (Foley Catheter/Foley - a tube placed through the urethra into the bladder to drain urine) and had been identified as being at risk for developing a urinary tract infection (UTI- an infection of the urinary system caused by bacteria entering the body through the urethra). Specifically, 1) The facility staff failed to change the indwelling urinary catheter according to professional standards of practice thereby increasing the risk of urinary infections for the Resident. 2) The facility staff failed to administer an antibiotic (medication that fights infection) to Resident #143 prior to changing an indwelling urinary catheter as ordered. Findings Include: Review of the 2009 Centers for Disease Contol (CDC) Healthcare Infection Control Practice Committee Guidelines last updated 6/6/19, indicated the folowing: -Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. -Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. Review of the facility policy titled Indwelling Urinary Catheter (Foley) Maintenance Guidelines and Critical Notes last reviewed 8/24/23, indicated the following: -Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. -Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. -Inappropriate or unnecessary use of an indwelling urinary catheter can result in catheter associated urinary tract infection. Resident #143 was admitted to the facility in April 2023, with a diagnosis of Obstructive and Reflex Uropathy (condition when urine cannot drain through the urinary tract due to obstructed urinary flow which can cause back-up of urine into the kidneys). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #143 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of a total score of 15. On 7/18/24 at 9:36 A.M., the surveyor observed a urinary drainage bag hanging from Resident #143's bed. Review of the Physician's active orders dated 7/22/24 indicated the following: -Foley change monthly, every day shift starting on the 10th and ending on the 10th every month, -Levaquin (antibiotic) 750 mg (milligrams) prior to Foley change, initiated 5/27/24 -Levaquin oral tablet 750 mg, give 750 mg by mouth one time a day starting on the 28th of the month for Foley change, give Levaquin 750 mg prior to Foley change monthly, initiated 4/27/24 Review of the Treatment administration Record (TAR) dated 5/1/24 - 5/31/24 indicated that Resident #143's Foley catheter was changed on 5/27/24. Review of the Medication Administration Record (MAR) dated 5/1/24 -5/31/24 indicated Resident #143 had been administered Levaquin 750 mg by mouth at 9:00 A.M. on 5/28/24 (1 day after the Foley catheter was changed). Review of the Treatment administration Record (TAR) dated 6/1/24 - 6/30/24 indicated that Resident #143's Foley catheter was changed on 6/10/24 (14 days after the Foley catheter was previously changed). Review of the Medication Administration Record (MAR) dated 6/1/24 - 6/30/24 indicated Resident #143 had been administered Levaquin 750 mg by mouth at 9:00 A.M. on 6/28/24 (18 days after the Foley catheter was changed). Review of the Treatment administration Record (TAR) dated 7/1/24 - 7/31/24 indicated that Resident #143's Foley catheter was changed on 7/10/24 (one month after the Foley catheter was previously changed). Review of the Medication Administration Record (MAR) dated 7/1/24 - 7/31/24 indicated that Resident #143 was scheduled to be administered Levaquin 750 mg by mouth at 9:00 A.M. on 7/28/24. Further review of the May 2024, June 2024 and July 2024 TAR and MAR records did not indicate that Resident #143 had been administered Levaquin 750 mg prior to changing the Foley catheter as ordered on the following dates: -5/27/24 -6/10/24 -7/10/24 Review of Resident 143's Physician and Nursing Progress Notes in the clinical record provided no evidence that the routine Foley catheter changes that were performed on 5/27/24, 6/10/24, and 7/10/24, were based on clinical indications such as infection, obstruction or a compromised closed drainage system. During an interview on 7/23/24 at 9:32 A.M., Unit Manager (UM) #1 said there was a Physician's order in place to change Resident #143's Foley catheter routinely on the 10th of every month and an order for Levaquin 750 mg to be administered prior to changing the Foley catheter. UM #1 said that the Levaquin administration was documented on the MAR and the Foley catheter change was documented on the TAR. UM #1 said she was unsure why Resident #143 required monthly Foley catheter changes and said the Levaquin was ordered to be given a few hours prior to each Foley catheter change to help prevent infections because Resident #143 had frequent UTI's. During a review at the time of Resident 143's May 2024, June 2024 and July 2024 MARs and TARs, UM #1 said that Resident #143 had not been administered Levaquin 750 mg as ordered prior to Foley catheter changes on 5/27/24, 6/10/24 and 7/10/24. UM #1 said the Resident should have been administered the Levaquin to prevent him/her from developing a UTI.

Based on observation and interview, the facility failed to maintain safe and sanitary conditions for two nourishment kitchens (Fifth Floor and Third Floor [Garden Terrace]) out of four applicable nourishment kitchens to prevent contamination and the spread of food borne infections. Specifically, 1. The facility failed to maintain the toaster in the Fifth Floor nourishment kitchen in a safe and sanitary manner. 2. The facility failed to maintain clean and sanitary conditions for the ice machine in the Third Floor nourishment kitchen. Findings include: Review of the facility's policy titled Ice Machines, dated 7/16/21 and revised 6/3/24, indicated the following: -Ice machines should be maintained in a clean and sanitary state . -Countertop ice makers sit on top of a counter and may also dispense water via touch control. 1. On 7/23/24 at 8:38 A.M., the surveyor observed that the Fifth Floor nourishment kitchen toaster had a buildup of crumbs and a butter packet wrapper inside the toaster. On 7/23/24 at 2:06 P.M., the surveyor observed that the Fifth Floor nourishment kitchen toaster still remained with a buildup of crumbs and a butter packet wrapper inside the toaster. During an interview on 7/23/24 at 3:32 P.M., Corporate Nurse #1 said the staff did not have a policy specific to cleaning of the kitchenettes. During an interview on 7/23/24 at 4:13 P.M., the Housekeeping Supervisor said that housekeeping cleaned the unit nourishment kitchens daily. The Housekeeping Supervisor further said that housekeeping cleaning included cleaning the outside of the ice machines and removing crumbs and debris from the toasters. 2. On 7/23/24 at 1:25 P.M., the surveyor observed the following in the Garden Terrace Unit nourishment kitchen: -A countertop water and ice dispenser on top of the counter. -The grate over the water and ice dispenser's drain pan had areas that were coated with dried white debris and rust. -The bottom of the drain pan contained areas of brown, black and white debris. -The outer edges of the touchless dispenser indicator (area on the front of the water and ice dispenser used to improve sanitation when retrieving ice or water) were surrounded by dried white debris. -There were two areas of white debris that extended from under the spout (where ice and water are dispensed), down the front of the ice and water dispenser. -Crusty, dried white buildup of debris was observed where the spout was attached to the water and ice dispenser. During an interview on 7/23/24 at 1:28 P.M., Certified Nurses Aide (CNA) #1 said staff on the Unit used the countertop water and ice dispenser every day to provide residents on the unit with ice and water. During an interview on 7/23/24 at 1:30 P.M., Unit Manager (UM) #2 said Housekeeping staff were responsible for cleaning the Unit nourishment kitchen, including the outer surfaces of the ice machine. During an interview on 7/23/24 at 1:35 P.M., the Housekeeping Supervisor said Housekeeping staff were responsible for cleaning the Unit nourishment kitchens. The Housekeeping Supervisor said there was no written cleaning schedule, list of items to be cleaned, or cleaning logs maintained for the Unit Nourishment Kitchens and that the Housekeeping staff knew what was supposed to be cleaned. The Housekeeping Supervisor said the Housekeeping staff were required to clean the outside areas of the countertop water and ice dispenser daily. The surveyor and the Housekeeping Supervisor observed the countertop water and ice dispenser in the Garden Terrace Unit nourishment kitchen at the time. The Housekeeping Supervisor said the front outer surfaces of the countertop water and ice dispenser had areas of dried debris that should have been cleaned. The Housekeeping Supervisor also said these areas of debris looked like they had been there for a while and that the countertop water and ice dispenser had not been cleaned thoroughly. The Housekeeping Supervisor further said it was important to ensure the countertop water and ice dispenser was clean to prevent bacterial growth, so that residents could safely consume water and ice from the dispenser.

Based on interview, record and policy review, the facility failed to offer Pneumococcal Vaccinations for one Resident (#51), out of five applicable Residents, out of a total sample of 31 residents, putting the Resident at risk for developing facility acquired Pneumonia. Specifically, the facility failed to ensure that Pneumococcal Vaccination was provided to Resident #51 after obtaining consent from the Resident's Representative. Findings include: Review of the CDC (Centers for Disease Control) website: Pneumococcal Vaccine for Adults greater than or equal to 19 Years, https://www.cdc.gov/vaccines/schedules/hcp/imz/adult-schedule-notes.html#note-pneumo indicated: -Adults aged >65 (greater than 65) years who have received both Pneumococcal Conjugate Vaccine 13 (PCV13) and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) according to previous Pneumococcal Vaccine recommendations but have not yet received a final dose of PPSV23 at age >65 years are recommended to complete their Pneumococcal Vaccine series by receiving either a single dose of Pneumococcal Conjugate Vaccine 20 (PCV20) or PPSV23. >If PCV20 is selected, it can be administered at least 5 years after the last Pneumococcal Vaccine dose. >If PPSV23 is selected, it can be administered at an interval >1 year since the PCV13 dose and >5 years since the last PPSV23 dose. Review of the facility policy titled Influenza Vaccine and Pneumococcal Vaccine Policy for Residents dated 9/13/23, indicated but was not limited to: -Guidance to follow CDC recommendations for Pneumococcal Vaccination timing. -Education is provided to the resident and/or representative regarding benefits and side effects or risks and a consent form is signed. -If, based on the Nurse's assessment contraindications are not noted, the Pneumococcal Vaccine is administered per Physician standing orders. Resident #51 was admitted to the facility in August 2021, with diagnoses including Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment), Chronic Obstructive Pulmonary Disease (COPD- a chronic lung disease that causes restricted airflow from the lungs and difficulty breathing), Emphysema (a chronic lung condition where air is abnormally present in the lungs causing shortness of breath) and was over the age of 65. Review of Resident #51's Massachusetts Immunization Information System (MIIS) record indicated Unspecified Pneumococcal Vaccination on 10/1/10 and PCV13 vaccination on 4/26/19. Review of Resident #51's vaccination consents indicated Pneumococcal consent dated 8/19/21, requesting Pneumococcal Vaccination. Review of the Resident's July 2024 Physician's orders indicated an order dated 6/4/24, to give Pneumococcal Vaccine per CDC guidelines. Review of the Resident's clinical record did not indicate that the Resident had received any additional doses of Pneumococcal Vaccination. During an interview on 7/23/24 at 3:25 P.M., Corporate Nurse #1 said Resident #51 should have received the PCV20 vaccination. Corporate Nurse #1 further reviewed the clinical record and said she was unable to find evidence that the Resident had received the PCV20 vaccination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, policy and record review, the facility failed to provide services according to professional standards of practice relative to medication administration for two Residents (#51 and #13) out of a total sample of 31 residents. Specifically, the facility staff failed to: 1. Administer Pantoprazole Sodium (prescription medication used to treat heartburn [burning, stabbing, or squeezing sensation in the chest, nausea] and conditions caused by too much acid in the stomach) to Resident #51 when the Pantoprazole Sodium was ordered by the Physician, was available to be administered, and the Physician was not notified of the missed doses of Pantoprazole Sodium, which increased the Resident's risk for discomfort. 2. Administer Lidocaine (topical [application to body surfaces such as skin or mucous membranes] medication used to treat symptoms of pain) External Patches to Resident #13 when the Lidocaine External Patches were ordered by the Physician, and were available to be administered, which increased the Resident's risk for experiencing pain. Findings include: Review of the facility's policy titled Administration of Medications dated 4/24/19, and revised 8/24/23, indicated the following: -The facility will ensure medications are administered . per Physician order to address residents' diagnoses and signs and symptoms. Review of the facility's policy titled Medication Shortages/Unavailable Medications, dated 12/1/07 and revised 1/1/22, indicated the following: -If a medication shortage is identified at the time of medication administration, facility staff should immediately take action to notify the Pharmacy. -The facility Nurse should document the missed dose and the explanation for such missed dose on the Medication Administration Record (MAR) . and in the Nurse's notes . -Such documentation shall include: a description of the circumstances of the medication shortage, a description of the Pharmacy's response upon notification, and actions taken. 1. Resident #51 was admitted to the facility in August 2021, with a diagnosis of gastroesophageal reflux disease (GERD: condition in which stomach acid repeatedly flows back up into the tube [esophagus] connecting the mouth and stomach resulting in irritation of the esophagus and heartburn) and Dementia (loss of cognitive functioning to such an extent that it interferes with a person's daily life and activities). Review of Resident #51's clinical record indicated the following active Physician's order, initiated 4/11/24 with no stop date: -Pantoprazole Sodium Oral Suspension, give 10 milliliters (ml) by mouth two times a day for heartburn/GERD, 2 milligrams (mg)/1 ml dosing for total of 20 mg per dose. Further review of the Physician's order indicated the Pantoprazole Sodium Oral Suspension was stored in the refrigerator. Review of a Minimum Data Set (MDS) assessment dated [DATE], indicated the following: -The Resident's speech was unclear. -The Resident rarely/never made him/herself understood. -Staff assessment of the Resident's cognitive patterns indicated the Resident was severely cognitively impaired. Review of Resident #51's June 2024 MAR indicated the ordered dose of Pantoprazole Sodium Oral Suspension was not administered to the Resident for: -one of two ordered doses on 6/13/24. -two of two ordered doses on 6/16/24. -one of two ordered doses on 6/20/24. Further review of the Resident's June 2024 MAR indicated the doses were not administered due to other/see progress note. Review of Resident #51's June 2024 Progress Notes indicated on the Orders Administration Notes that the ordered Pantoprazole Sodium Oral Suspension was not administered on the following dates due to being unavailable: -once on 6/13/24 -twice on 6/16/24 -once on 6/20/24 Further review of the June 2024 Progress Notes indicated no evidence that the Pharmacy was contacted regarding the Resident's Pantoprazole Sodium Oral Suspension being unavailable and what action was taken. Review of Resident #51's Monthly Pharmacy Review dated 6/30/24, indicated a recommendation: -that education be provided to staff that the Resident's Pantoprazole Sodium Oral Suspension was stored in the refrigerator and had been documented as unavailable. -to make sure the Prescriber was aware of missed doses. Review of Resident #51's July 2024 MAR indicated the ordered dose of Pantoprazole Sodium Oral Suspension was not administered to the Resident for: -two of two ordered doses on 7/4/24. -one of two ordered doses on 7/16/24. -one of two ordered doses on 7/17/24. Further review of the Resident's July 2024 MAR indicated the doses were not administered due to other/see progress note. Review of Resident #51's July 2024 Progress Notes indicated on the Orders Administration Notes that the ordered Pantoprazole Sodium Oral Suspension was not administered on the following dates due to being unavailable: -twice on 7/4/24 -once on 7/16/24 -once on 7/17/24 Further review of the July 2024 Progress Notes indicated no evidence the Pharmacy was contacted regarding the Resident's Pantoprazole Sodium Oral Suspension being unavailable and what action was taken. 2. Resident #13 was admitted to the facility in March 2024, with diagnoses including Osteoarthritis (common form of degenerative arthritis found in the joints that can cause inflammation and result in pain, stiffness, and loss of mobility) and Dementia. Review of Resident #13's Pain Care Plan, initiated 3/23/24, and revised 4/2/24, indicated Pain meds (medications) as ordered. Review of Resident #13's active Physician's order, initiated 3/24/24, with no stop date, indicated the following: -Lidocaine External Patch 4% (Lidocaine), Apply to knee topically one time a day for pain. Review of Resident #13's March 2024 through June 2024 MARs indicated that the ordered dose of Lidocaine was not administered to the Resident on the following dates (a total of 10 days): -3/31/24. -4/4/24, 4/5/24, 4/10/24, 4/19/24, and 4/21/24. -5/13/24 and 5/20/24. -6/11/24 and 6/20/24. Review of Resident #13's Orders Administration Notes for March 2024 through June 2024, indicated the Resident's Lidocaine Patch was not administered on: -3/31/24, 4/4/24, and 4/10/24 - due to medication pending arrival. -4/5/24, 4/19/24 and 4/21/24 - with no description of why the medication was not administered. -5/13/24, 5/20/24, 6/11/24, and 6/20/24 - due to the medication being unavailable. Further review of the Resident's Orders Administration Notes indicated no information to what actions were taken relative to Lidocaine Patches being unavailable for administration to Resident #13. During an interview on 7/19/24 at 11:48 A.M., with Unit Manager (UM) #2 and the Physician, UM #2 said staff did not administer the doses of Pantoprazole Sodium Oral Suspension as ordered for Resident #51 on the dates indicated above. UM #2 said Pantoprazole Sodium had never been unavailable for Resident #51 since it had been ordered by the Physician, that the medication was stored in the refrigerator because it was in liquid form and required refrigeration. UM #2 said the Physician's order specified that the medication was stored in the refrigerator to alert Nurses at the facility that they needed to obtain the medication from the refrigerator to administer it to the Resident. UM #2 further said the Nurse should have obtained the Pantoprazole Sodium Oral Suspension from the refrigerator and administered it to the Resident as ordered. UM #2 also said Lidocaine Patches were ordered as house stock and were available on all Units and in the facility's Central Supply storage room, and if there were no Lidocaine Patches in the medication cart at the time of administration, the Nurse should have obtained the Lidocaine Patches either from the Medication Room or the Central Supply storage room. UM #2 said if medication was unavailable, the Nurse would be required to contact the Pharmacy, and if the medication was unable to be obtained from the Pharmacy, the Nurse would be required to notify the Physician of the missed dose(s) and obtain new orders. During an interview at the time, the Physician said he did not recall ever having been notified of any missed doses of Pantoprazole Sodium Oral Suspension for Resident #51. The Physician further said that he takes his own calls for residents whose care he supervised on the Unit, so staff at the facility were expected to contact him to make him aware of missed medications. The Physician further said he was not the Physician who supervised Resident #13's care. During an interview on 7/19/24 at 1:30 P.M., Nurse #1 said Resident #51's Pantoprazole Sodium Oral Suspension was stored in the refrigerator in the Medication Room on the Unit. Nurse #1 also said Lidocaine Patches were not ordered for specific residents but were ordered as house stock and were stored in the Medication Rooms on the Units and in the Central Supply storage room. At the time, the surveyor and Nurse #1 observed the Unit's Medication Room refrigerator and storage cabinet. The surveyor observed that the refrigerator contained Resident #51's bottle of Pantoprazole Sodium Oral Suspension which was approximately two thirds full, and the storage cabinet contained several boxes of unopened Lidocaine Patches. Nurse #1 said she had never been aware of a time when Resident #51's ordered Pantoprazole Sodium Oral Suspension was unavailable for administration. Nurse #1 further said she was not aware of any time Lidocaine Patches were not available to administer to Resident #13. Nurse #1 also said that the Nursing Supervisor always had access to the facility's Central Supply storage room, so if house stock medications were not available on the Units, the Nursing Supervisor could obtain the house stock medications from the Central Supply storage room. On 7/19/24 at 4:45 P.M., the surveyor and the Director of Nursing (DON) observed the facility's Central Supply storage room where the surveyor observed several unopened boxes of Lidocaine Patches on a shelf. During an interview at the time, the DON said Nurses administering medications were expected to adhere to the facility's policies relative to medication administration and missed medication doses.

Based on record review, policy review, and interview, the facility failed to ensure that its staff notified the Physician regarding a change in the treatment plan for one Resident (#70), out of a total sample of 28 residents. Specifically, the facility staff failed to notify Resident #70's Physician when dialysis treatment was not administered as ordered. Findings include: Resident #70 was admitted to the facility in June 2017 with diagnoses including End Stage Renal Disease (when the kidneys can no longer filter the blood of waste and extra fluid) and dependence on renal dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working properly). Review of the facility policy titled Dialysis, revised 8/18/2022, indicated: -This facility assures that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice . -the facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. -The resident receiving dialysis shall receive consistent care pre and post dialysis. The vascular access site shall be checked daily with physician notification for any known or suspected problem. -Document in the clinical nursing record: dialysis treatment completed, order changes, condition of the shunt site, complaints from resident (if applicable), and whether physician and responsible party notification. Review of the Resident's March 2023 Physician's orders indicated to send the Resident to dialysis on Monday/Wednesday/Friday for dialysis treatment (start date 1/13/2023). Review of the Resident's March 2023 Medication Administration Record (MAR) indicated documentation that the Resident received dialysis treatment on Wednesday 3/15/23. Review of the Resident's progress notes dated 3/15/23 did not show any evidence that the Resident did not receive dialysis treatment as ordered, or that the Resident's Physician was notified of any changes to the treatment plan. During an interview on 3/16/23 at 7:49 A.M., Unit Manager (UM) #2 told the surveyor that the Resident did not receive dialysis treatment on 3/15/23 as planned, and so the Resident was being prepared for transport to the dialysis center on Thursday 3/16/23. UM #2 said that the Resident was transferred to the dialysis center on 3/15/23 but was returned to the facility without receiving dialysis treatment due to incontinence. The UM said that she was unable to provide any evidence that the charge nurse or any other staff member had notified the Physician regarding the missed dialysis treatment, but that the Physician should have been notified.

Based on record review, policy review, and interview, the facility failed to ensure that its staff provided care and services consistent with professional standards for one Resident (#70), who required renal dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working properly) out of one applicable resident, in a total sample of 28 residents. Specifically, the facility staff failed to: 1) evaluate the resident pre and post dialysis treatment, 2) communicate and maintain ongoing documentation with the dialysis center, 3) ensure that the dialysis center received the most current information regarding Physician's orders for the Resident, and 4) maintain documentation regarding the Resident's weight per the plan of care. Findings include: Resident #70 was admitted to the facility in June 2017 with diagnoses including End Stage Renal Disease (ESRD-when the kidneys can no longer filter the blood of waste and extra fluid), dependence on renal dialysis, and Type 2 Diabetes Mellitus (DM II- a condition that affects the way the body processes blood sugar, and does not produce insulin or resists insulin). Review of the facility policy titled Dialysis, revised 8/18/22, indicated: -The facility assures that each resident receives care and services for the provision of hemodialysis and /or peritoneal dialysis consistent with professional standards of practice including: .ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. -Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. -The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. -Document in the clinical nursing record: dialysis treatment completed, order changes, condition of the shunt site, complaints from the resident (if applicable), and whether physician and responsible party notification. -Pre Dialysis - initiate the Pre/Post Dialysis Communication Form to be sent to the dialysis clinic with the resident. (Med Pass Form #LCCA-528) -Post-Dialysis - obtain vital signs of resident upon return from dialysis and complete the Pre/Post Dialysis Communication Form -Maintain dialysis transfer form in the resident's medical record - do not destroy. Review of the March 2023 Physician's orders indicated to send the Resident for dialysis treatment three times a week on Monday/Wednesday/Friday (start date 1/13/23). Review of the February and March 2023 Medication Administration Records (MARs) indicated the Resident attended dialysis treatments as ordered. 1) There was no evidence in the dialysis communication binder that the facility staff had completed evaluations pre and post dialysis treatments, or utilized the facility communication form (Med Pass Form #LCCA-528) as indicated in the facility policy for Dialysis. 2) There was no indication in the dialysis communication binder of regular communication and collaboration between the facility and the dialysis center. Review of the Resident's dialysis communication binder for 2023 included: -four notes from the facility staff to the dialysis center dated 2/22/23, 2/24/23, 2/27/23, and 3/15/23 -two notes from the dialysis center to the facility dated 3/1/23 and 3/6/23 3) The dialysis center did not have the most current Physician's orders related to Insulin. Review of the March 2023 Physician's orders indicated: -Insulin Glargine Solution (a long acting form of medical insulin to treat diabetes), Inject 8 unit(s) subcutaneously (medication administered under the skin by injection or infusion) at bedtime for Diabetes (start date 3/9/23). Review of the Resident's dialysis communication binder indicated the most recent Physician's orders were dated 2/22/2023 and included the following order for insulin: -Insulin Glargine Solution 100 Unit/Milliliters (U/ML), Inject 16 unit(s) subcutaneously at bedtime for Diabetes (twice the dose that was prescribed on 3/9/23). 4) There was no evidence of regular weight monitoring by the facility or from communication with the dialysis center. Review of the Resident's care plan revised 2/6/2023 indicated: -dry weights (weight without the excess fluid that builds up between dialysis treatments) obtained from dialysis center. Review of the facility form MED-PASS LCCA-528 indicated for the facility to weigh the Resident pre and post dialysis, and to obtain a pre and post dialysis weight from the dialysis center on dialysis days. Review of the the Resident's weight record for 2023 included the following weights: -1/12/2023 184 lbs (pounds) (Hoyer Lift) (a mechanical lift used for a person that is non-weight bearing) -1/19/2023 186 lbs (Dry Weight / Dialysis) -2/1/2023 186 lbs (Dry Weight / Dialysis) -3/3/2023 186.5 lbs (Dry Weight / Dialysis) During an interview on 3/16/23 at 8:23 A.M., Unit Manager (UM) #2 told the surveyor that the dialysis communication binder goes with the Resident each time to the dialysis center, and that the Resident had been attending his/her dialysis treatments regularly since January 2023. UM #2 and the surveyor reviewed the dialysis communication binder together and noted that there were only four notes written by facility staff for 2023. UM #2 said that facility staff were supposed to write something in the dialysis communication binder before the Resident leaves for treatment but that didn't always occur. UM #2 also said that there was no guidance for staff to write any specific information but rather to just indicate how the Resident was doing. UM #2 and the surveyor also reviewed the Physician's orders dated 2/22/23 located in the dialysis communication binder and noted that the updated Physician's order of 3/9/23 for a reduction in the Resident's Insulin Glargine was not reflected in the binder. UM #2 said that the Physician's orders in the dialysis communication binder should have been updated with any changes but they had not been. UM #2 told the surveyor that she was not aware of any guidance to monitor the Resident's weight relative to dialysis treatments.

Based on observation, policy review, record review and interview, the facility failed to ensure its staff assessed two Residents (#43 and #35) for the risk of entrapment related to bed rail use. Specifically, 1) for Resident #43 the facility failed to ensure its staff assessed the Resident for risk of entrapment related to bed rail use prior to the installation of bed rails and quarterly thereafter, and 2) for Resident #35 the facility failed to ensure its staff assessed the Resident for risk of entrapment related to bed rail use after a significant change in weight. Findings include: Review of the facility policy for Safe and Effective Use of Bed Rails, dated 11/16/21, indicated the following: -Policy: to prevent entrapment and other safety hazards associated with bed rail use. -Residents will be assessed upon admission, readmission, or upon initiation, utilizing the Evaluation for Use of Bed Rails Assessment. -If bed rails are determined to be appropriate for use with a resident, a reassessment of bed rail use will be assessed at a minimum quarterly and potentially with a change of condition. 1) Resident #43 was admitted to the facility in March 2016. Review of the current care plan for falls, with goal date of 3/19/23, indicated the Resident utilized 1/4 bed rails for assist with repositioning when he/she was in bed (initiated 12/9/19). During an observation on 3/16/23 at 3:59 P.M., the surveyor observed bilateral 1/4 bed rails on the Resident's bed. Review of the clinical record indicated no Resident assessment for the risk of entrapment related to bed rail use was completed prior to bed rail installation, or quarterly thereafter. During an interview on 3/16/23 at 10:55 A.M., Unit Manager (UM) #1 said that she thought the bed rail assessments were supposed to be done when bed rails were initiated and then annually (facility policy stated they were to be done quarterly). UM #1 reviewed Resident #43's clinical record and said she could not find a completed initial assessment or any other assessments for the risk of entrapment related to bed rail use. She said she thought there was an assessment for bed rail use in the Electronic Health Record (EHR) but when she reviewed the EHR she said there was not one and she would need to look into it. 2. Resident #35 was admitted to the facility in October 2015. Review of the clinical record indicated the Resident had a significant weight loss as evidenced by a weight of 140.2 pounds (lbs) on 8/10/22 and a weight of 125.8 lbs on 1/10/23, which resulted in a weight loss of 10.27% in five months. Review of the Minimum Data Set (MDS) assessments for Resident #35 indicated a Significant Change of Status assessment was initiated on 1/16/23. Further review indicated, under section K, that the Resident had a weight loss of 5% or more in the last month or 10% or more in the last six months and was not on a Physician prescribed weight loss regimen. Review of the current care plan for Activities of Daily Living (ADLs), with goal date of 4/24/23, indicated the Resident utilized 1/4 bed rails to aid with bed repositioning. During an observation on 3/16/23 at 10:50 A.M., the surveyor observed bilateral 1/4 bed rails on the Resident's bed. During an interview on 3/16/23 at 10:54 A.M., UM #1 reviewed the clinical record and said there were no bed rail assessments done since 2018 and there should have been

Based on observations, interviews, and policy review, the facility failed to ensure its staff adhered to safe food practices relative to labeling/dating, and storage guidelines in order to reduce the risk of cross contamination/spoilage of food items for resident consumption in the main facility kitchen. Findings include: Review of the facility policy titled Food Safety, reviewed 4/27/22, indicated that food was to be stored and maintained in a clean, safe and sanitary manner following federal, state and local guidelines to minimize contamination and bacterial growth. The policy also included the following: -pre-packaged food is placed in a leak-proof, pest proof, non-absorbent, sanitary container with a tight fitting lid. The container is labeled with the name of the contents and date (when the item is transferred to the new container). Use by Date is noted on the label or product when applicable. -associate (employee) food will not be stored with resident food. -Cold Food Storage: >leftovers are dated properly and discarded after 72 hours unless otherwise indicated >raw meat that is placed in the cooler is in a pan and dated when pulled, manufacturers' directions are followed in regard to how long the thawed meat can be kept under refrigeration. The date begins from the date the meat is thawed, which is approximately three days from the date pulled. -Dry Storage: >opened packages of food are resealed tightly to prevent contamination of the food item and 'use by date' will be used when applicable >opened food items will be removed from the original packaging that it was delivered in before being placed in an ingredient bin or storage container >scoops will be stored in a manner that does not have the potential to contaminate the food ingredients. For example, the scoops will be stored outside of the bin or placed in a holder on the side of the bin. During the initial kitchen tour on 3/15/23 at 7:32 A.M., the surveyor observed the following: Reach-in refrigerator: -open and undated package of sliced orange cheese Walk-in refrigerator: - covered container of pasta and red sauce with no label or date, - covered container of meat sauce with no label or date - covered bowl of cold salad with no date - covered container of macaroni and cheese with no label or date - covered plate of meat loaf slices with no label or date - covered pan of raw thawed meat with no label or date - covered clear container with three uncooked ground beef logs with no label or date - pitcher of shredded cabbage mixture with no label or date - clear covered container of red sauce dated 2/15 Dry Storage Room: - wrapped open package of dry pasta with no date - loosely opened undated box of parboiled rice with a cup inside of the product - covered bin of open bags of flour with no date - clear covered container with dried product with no label or date. The top of the container had dried product that was brown debris. A scoop was placed on top of the dirty cover and was open to air. During a follow-up kitchen tour on 3/17/23 at 1:42 P.M. through 2:27 P.M., with the Food Service Director (FSD), the surveyor observed the following: Reach-in Refrigerator: - small covered pan of cut up ham that was undated - wrapped open undated bag of parmesan cheese - styrofoam container of food Walk-in Refrigerator: - covered undated container of cabbage salad - covered undated pan of meat loaf - covered undated bowl of lettuce - covered undated container of cut up onions - clear covered container with three uncooked ground beef logs that were undated, one of the packages was opened. Dry Storage Room - covered bin containing multiple bags of open flour that were undated - covered container with dried product which the FSD identified as Panko, that was unlabeled and undated. A scoop was placed on top of the clear container which had with dried brown residue/debris. - loosely opened undated chocolate morsels with a cup within the product - loosely opened undated box of parboiled rice with a cup inside of the product - loosely opened undated box of pureed bread with a cup within the product During an interview on 3/17/23 at 2:27 P.M., the FSD said that all food items in the refrigerators should be labeled/dated and used or be discarded within 3 days (72 hours). The FSD discarded the styrofoam container in the reach in refrigerator and said that it should not have been kept in there as she thought it belonged to an employee. She further said that opened boxes of product in the dry store room should be in sealed containers that should be labeled and dated. The FSD said that cups or scoops should not be kept within the food product because there would be a concern for contamination.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had a history of falls and required extensive assistance from two staff members with all transfers for safety, the Facility failed to ensure staff consistently implemented and followed interventions identified in his/her Activities of Daily Living (ADL) plan of care and on his/her Resident Care Card, related to the need for two staff members to assist with all transfers. On 02/05/23, during the evening shift, Certified Nurse Aide (CNA) #1 transferred Resident #1 without a second staff member present to assist her, the following day Resident #1 reported that CNA #1 was rough and twisted his/her wrist during the transfer, causing him/her discomfort. In addition, documentation on Resident #1's ADL Flowsheet (completed by the CNA's) for February 2023, indicated that there were multiple days on the evening shift, where staff transferred him/her alone, and did not have a second staff member there to assist with the transfer, as required. Findings include: Review of the Facility's Policy, titled Person-Centered Care Planning, dated 08/16/22, indicated the facility will develop a person-centered care plan that addresses the goals, preferences, needs and strengths of the resident, including those identified in the comprehensive resident assessment, to assist the resident to attain or maintain his or her highest practicable well-being and prevent avoidable decline. The Policy indicated the care plan will be developed and implemented to ensure consistency with implementation across all shifts. Resident #1 was admitted to the facility in January 2020, medical diagnoses included dementia, history of falls, and muscle weakness. Review of Resident #1's most recent Minimum Data Set (MDS) Assessment, dated 02/01/23, indicated that his/her cognitive patterns were severely impaired, with a score of 2 out of 15 on the Brief Interview for Mental Status (BIMS, score of 0-7 indicates severe impairment, 8-12 indicates moderate impairment, 13-15 indicates intact cognition). The MDS indicated Resident #1 required extensive physical assistance from two staff members for transfers. Review of Resident #1's Activities of Daily Living (ADL) Care Plan, dated as reviewed 02/01/23, indicated he/she required assistance of two staff members for all transfers. Review of Resident #1's Care Card (reference guide used by CNA's, identifies residents specific care needs, including number of staff required to provide assistance during tasks), in effect on 02/05/23, indicated he/she required assistance from two staff members for all transfers. However, review of Resident #1's Activity of Daily Living (ADL) Flowsheets, dated February 2023, indicated that he/she was transferred with assistance from one staff member during the evening shift (as documented by the CNAs), on 18 out of 28 days. During an interview on 03/09/23 at 11:55 A.M., Resident #1 said that a Certified Nurse Aide (CNA, later identified as CNA #1) twisted his/her arm while transferring him/her back to bed. Resident #1 was not able to recall the exact date of the alleged incident. Review of the Facility's Incident Report, dated 02/06/23, indicated staff observed a bruise to Resident #1's right hand. The Report indicated Resident #1 told Nurse #1 that the female CNA who put him/her to bed on 02/05/23 (during the 3:00 P.M. to 11:00 P.M. shift) was rough. During an interview on 03/09/23 at 1:55 P.M., Nurse #1 said that while she was passing medications during the day shift, on 02/06/23, she noticed Resident #1 had a bruise on his/her right hand. Nurse #1 said that when she asked Resident #1 how he/she got the bruise, said he/she told her (Nurse #1) that CNA #1 was rough when transferring him/her to bed last night (2/05/23 on the evening shift). During an interview on 03/09/23 at 3:15 P.M., Certified Nurse Aide (CNA) #1 said that during the evening shift on 02/05/23, she transferred Resident #1 into bed without assistance from a second staff member. CNA #1 said she was often assigned to Resident #1 for care and routinely transferred him/her without assistance from a second staff member. CNA #1 said she did not realize Resident #1 required assistance of two staff members for transfers, and said she had not checked his/her (CNA) Resident Care Card or Care Plan. CNA #1 said when she is unfamiliar with a resident, she knows to look at the Care Card/Care Plan. During an interview on 03/09/23 at 2:05 P.M., Certified Nurse Aide #3 said Resident #1 required assistance from two staff members to safely transfer into and out of bed. During an interview on 03/09/23 at 2:15 P.M., Unit Manager #1 said that on the morning of 02/06/23, Resident #1 told her that CNA #1 transferred his/her back to bed on 2/05/23 (during the evening shift), and that CNA #1 twisted his/her arm when transferring him/her into bed. Unit Manager #1 said Resident #1 told her CNA #1 did not have another staff member there to help with the transfer. Unit Manager #1 said Resident #1 required assistance from two staff members for safety with all transfers, and that it was indicated on his/her Care Plan and on his/her Resident Care Card that the CNA's reference. During an interview on 03/09/23 at 4:38 P.M., the Director of Nurses (DON) said that based on Resident #1's assessments and the care planned interventions, Resident #1 was to be provided assistance of two staff members for all transfers. The DON said the outcome of his investigation into the incident on 02/05/23, was that CNA #1 should not have transferred Resident #1 without a second staff member. The DON further said he thought that Resident #1's allegation that CNA #1 was rough during the transfer may have been because she (CNA #1) transferred him/her without a second staff member. The DON said he was also concerned that based on review of Resident #1's February 2023 CNA Flowsheet, that the Care Plan intervention and Resident Care Card instructions for the need for two staff members to assist with all transfers, was not consistently being implemented by staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure staff maintained acceptable parameters of nutritional status for one Resident (#55) in a total sample of 27 residents. Findings include: Resident #55 was readmitted to the facility in May of 2021 with diagnoses including cerebral vascular accident (stroke). Review of the annual Minimum Data Set (MDS) assessment, dated 4/10/21, indicated the Resident had severely impaired cognition as evidenced by a score of 7 out of 15 on the Brief Interview for Mental Status and weighed 144 pounds (lbs.). Review of the electronic medical record indicated the following weights: -On 5/7/21: 147.6 lbs. -On 6/9/21: 130.1 lbs. -On 6/15/21: 130.2 lbs. (weight loss of 17.4 lbs. in one month; greater than 10% loss) Review of the Resident Assessment Instrument defines significant weight loss as 5% or more in one month or 10% or more in 6 months. Review of the care plan for nutrition, with goal date of 7/26/21, indicated the following: -Goal: Resident will maintain adequate nutritional status as evidenced by maintaining weight within 5% of 150 lbs Further review indicated no new interventions since 1/12/21. Review of the Certified Nurse Aide (CNA) [NAME] indicated the Resident needed verbal cueing to complete meals and to ensure the Resident was out of bed for meals. On 6/25/21 at 11:11 A.M., the surveyor observed Resident #55 in bed asleep with the covers pulled up. The breakfast meal was still in front of him/her with untouched scrambled eggs and whole waffle. The plastic ware was still in its bag, sealed. The milk was unopened, juice and coffee nearly full. On 6/25/21 at 12:37 P.M., the surveyor observed the Resident in bed asleep, covers pulled up. The lunch tray was in front of him/her, everything was closed and sealed. On 6/25/21 at 1:26 P.M., the surveyor observed the Resident in bed asleep, lunch tray was still in front of him/her, unable to observe if any of the meal had been eaten. Review of the clinical record indicated the last nutrition assessment was done on 4/9/21. During an interview on 6/25/21 at 3:45 P.M., the Registered Dietician (RD) said that she was aware the Resident had a recent significant weight loss and that she should have written a note but didn't. During an interview on 6/25/21 at 3:50 P.M., CNA #1 said he didn't always have the Resident on his assignment, but was familiar with him/her and that the Resident usually didn't get out of bed for meals. During an interview on 6/25/21 at 3:52 P.M., Nurse #1 said she was the nurse who took care of the Resident during the day shift that day and the Resident stayed in bed for both breakfast and lunch. During an interview on 6/25/21 at 4:02 P.M., Unit Manager #1 said that usually when there was a weight discrepancy they did a reweigh. The surveyor asked if anyone was notified after the 6/15/21 weight and she said no. She said if anyone (Physician or RD) was notified it would have been in a progress note. During an interview on 6/25/21 at 4:28 P.M., the RD said it normally didn't take her so long to do an assessment following a weight loss. She said that she wasn't notified of the weight loss, but found it from a report that she runs. She said that she understood the concern and that it was likely she would revise the care plan once she does the assessment because the interventions in place had not prevented the weight loss.