Based on record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR- Preadmission screening for residents with a mental disorder or intellectual disability) was accurately completed prior to the admission of one Resident (#4), in a total sample of 14 residents. Findings include: Review of the Nursing Facility Bulletin 169: Updates to Nursing Facility Regulations: PASRR for Intellectual Disability (ID), Developmental Disability (DD), and Serious Mental Illness (SMI), dated October 2021, indicated the following: A Level I Screening identifies whether an applicant for admission to a nursing facility has, or may have, ID, DD, and/or SMI (i.e. a positive Level I Screening). Effective October 29, 2021, a Level I Screening must be conducted using the revised Preadmission Screening and Resident Review (PASRR) Level I Screening Form, PASRR-L1 (10/21). If the individual has a positive Level I Screening, the screener must refer the individual to the appropriate PASRR authority for a Level II Evaluation or Abbreviated Level II Evaluation, as applicable, unless the individual satisfies all of the criteria for an Exempted Hospital Discharge. Resident #4 was admitted to the facility in December 2023 with a diagnosis of schizoaffective disorder following a seven-week hospitalization on a psychiatric unit. Review of the medical record included a PASRR, dated 12/1/23, with the following information: -current location: psychiatric hospital -Section B: -Question 4A: does the applicant have any of the following documented diagnoses of mental illness or disorder; answer: no (the box to indicate a diagnosis of schizoaffective disorder was not checked) -Question 5A: within the past two years has the applicant required one of the treatments listed below; answer: no (the box to indicate an inpatient psychiatric hospitalization was not checked) -SMI Screening Results: If you answered YES to questions 5A, 5B, or 6 check positive SMI screen; answer: negative SMI screen (Level II PASRR Evaluation not indicated). -Section E: -Question 14: Has the application screened positive for SMI only, and does the applicant possibly qualify for a categorical determination: No responses were checked in this section. During an interview on 6/17/25 at 11:50 A.M., the Administrator said there was no additional information in the PASRR electronic portal system or with the PASRR office regarding if they received the Level I screen for Resident #4 and there was no indication Resident #4 had a Level II PASRR evaluation. He said the facility Social Workers were responsible for the oversight of the PASRR process but there currently was not a Social Worker.

Based on document review and interview, the facility failed to ensure that monthly medication regimen reviews (MRR) were communicated to the physician and addressed in a timely manner for one Resident (#1), out of a total sample of 14 residents. Specifically, the facility failed to ensure recommendations from August and September 2024 by the pharmacy consultant to evaluate continued use of as needed Geri-tussin (cough syrup) and menthol lozenge was reviewed and responded to by the provider in a timely manner. Findings include: Review of the facility's policy titled Medication Reconciliation Policy, revised January 2025, indicated but was not limited to the following: -This facility reconciles medication to ensure that the resident is free of any significant medication errors -Monthly Processes: Provide pharmacy consultant access to all medication areas and records for completion of pharmacy services activities -Respond to any medication irregularities reported by pharmacy consultant within relevant time frames. Review of the facility's policy titled Consultant Pharmacist Services Provider Requirements, dated 8-2020, indicated but was not limited to the following: -The facility will ensure regular and reliable consultant pharmacist services are provided to residents. -Reviewing the medication regimen (medication regimen review) of each resident at least monthly. -Documenting the review and findings in the resident's medical record or a readily retrievable format. -A written or electronic report of findings and recommendations resulting from the activities described above is given to the Attending Physician, Director of Nursing at least monthly. -The facility has a process to ensure the findings are acted upon. Resident #1 was admitted to the facility in April 2019 with diagnoses which included hypotension and dysphagia (difficulty swallowing). Review of the Physician's Orders indicated Resident #1 was prescribed the following medications: -Geri-tussin syrup 100 milligrams (mg) / 5 milliliters (ml), give 10 ml as needed (PRN), discontinued 11/4/2024. -Menthol lozenge 1 lozenge PRN, discontinued 11/4/24. Review of the progress notes indicated the following: -Pharmacy Consultant made recommendations on 8/16/24 to review the unused PRN menthol lozenge and geri-tussin. -Pharmacy Consultant made recommendations on 9/11/24 to review the unused PRN menthol lozenge and geri-tussin. Review of the medical record failed to include the pharmacy consultant recommendation report made in August and September 2024. Further review failed to indicate the physician was made aware of the recommendations until 11/4/24, 80 days after the initial recommendation was made. During an interview on 6/17/25 at 1:20 P.M., the Director of Nursing (DON) said the pharmacy consultant reviews all resident medical records monthly. She said they submit a report to the physician to review and sign, and it is placed in the resident's medical record. The DON said all recommendations should be completed prior to the next monthly review. She said she is unable to locate Resident #1's August and September 2024 pharmacy recommendation report; the reports are not in Resident #1's medical record. The DON said the physician did not address the recommendations timely as they should have been.

Based on observations, document review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment for one Resident (#207), of 14 sampled residents. Specifically, the facility failed to ensure his/her indwelling Foley catheter (tube inserted into the bladder to drain urine into a collection bag outside the body) was maintained in a sanitary manner. Findings include: Review of Centers for Disease Control and Prevention (CDC) guidance titled Summary of Recommendations, Guideline for Prevention of Catheter-Associated Urinary Tract Infections, dated March 2024, indicated but was not limited to: -Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. Review of the facility's policy titled Urinary Catheter Care, undated, indicated but was not limited to: -Infection Control: be sure the catheter tubing and drainage bag are kept off the floor. Resident #207 was admitted to the facility in June 2025 with diagnoses which included retention of urine and neuromuscular dysfunction of bladder (a urinary dysfunction in which the bladder does not empty properly, depending on the type of neurological disorder causing the problem, the bladder may empty spontaneously or may not empty at all). Review of Resident #207's Minimum Data Set assessment, dated 6/11/25, indicated he/she had an indwelling urinary catheter. Review of Resident #207's Physician's Orders indicated but was not limited to: -Foley catheter to drainage bag for urinary retention, dated 6/5/25 -Provide catheter care every shift and as needed, dated 6/5/25 Review of Resident #207's care plans indicated but was not limited to: -Resident #207 has an indwelling Foley catheter for diagnosis of urine retention and neurogenic bladder, dated 6/5/2025 On the following dates of the survey, the surveyor observed Resident #207 lying in bed with his/her indwelling Foley catheter not attached to the bed and lying directly on the floor with no protective barrier: -6/12/25 at 9:15 A.M., and -6/16/25 at 7:36 A.M. During an interview on 6/16/25 at 12:44 P.M., Certified Nursing Assistant (CNA) #1 said urinary (Foley) catheter bags should be hanging from the bed and should not be touching the floor. During an interview on 6/17/25 at 1:47 P.M., CNA #6 said indwelling urinary (Foley) catheters should never be sitting directly on the floor and should be hanging from the bed. During an interview on 6/17/25 at 1:35 P.M., Nurse #2 said urinary (Foley) catheters should be hanging from the bed and should not be touching the ground to prevent contamination. During an interview on 6/17/25 at 3:25 P.M., the Director of Nurses said urinary (Foley) catheter bags should be hanging from the bed or wheelchair and should not be resting on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a [NAME] Treatment Plan (court approved treatment plan for the administration of antipsychotic medications) was active and current for administration of an antipsychotic medication for one Resident (#10), out of a total sample of 14 residents. Findings include: Review of the facility's policy titled Psychoactive Medication Policy, dated [DATE], indicated but was not limited to the following: -Residents who have guardians need to have a [NAME] in order for the facility to administer antipsychotic medication Resident #10 was admitted to the facility in [DATE] with diagnoses which included schizophrenia and dementia. Review of the medical record indicated Resident #10 was found to be incapable of taking care of himself/herself by reason of mental illness and Guardianship was appointed on [DATE] by the Commonwealth of Massachusetts Probate and Family Court. Subsequent review of the medical record indicated the court issued an expansion of the Guardianship on [DATE] and authorized administration of antipsychotic medication via a [NAME] Treatment Plan, which expired on [DATE] at 4:00 P.M. Review of the Physician's Orders, dated [DATE], indicated: -Clozapine (antipsychotic) 100 milligrams (mg) by mouth twice a day, start date, [DATE], discontinued [DATE]. -Clozapine 50 mg by mouth at bedtime, start date [DATE], discontinued [DATE]. -Clozapine 100 mg by mouth twice a day, start date, [DATE] Review of the Medication Administration Records (MAR), dated [DATE] through [DATE], indicated Resident #10 was administered Clozapine 100 mg by mouth twice a day as ordered by the physician without an active [NAME] Treatment Plan in place. During an interview on [DATE] at 10:22 A.M., the Administrator said the facility does not have a social worker at this time and he will need to go through documents left in the prior social worker's office to see if the active treatment plan can be located. During a subsequent interview on [DATE] at 11:13 A.M., the Administrator said Resident #10 has a permanent legal guardian in place and there is no updated court approved [NAME] Treatment plan. He said he contacted the facility's attorney used for guardianship and they do not have anything that is up to date. The Administrator said the most recent treatment plan is expired, and the facility will need to submit a new request to the court.

Based on record review and interview, the facility failed to electronically submit direct care staffing data to Centers for Medicare and Medicaid Services (CMS) for the entire reporting period, Fiscal Year (FY) Quarter 2 2025 (January 1 -March 31) in accordance with the schedule specified by CMS. Findings include: Review of the facility's policy titled Payroll Based Journal, dated as revised January 2025, indicated but was not limited to: -It is the policy of this facility to electronically submit timely to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS -The facility will submit direct care staffing information in the uniform format specified by CMS -The facility will submit direct care staffing information on the schedule specified by CMS, but no less frequently than quarterly Review of the PBJ Staffing Report, CASPER Report 1705D, FY Quarter 2 2025 (January 1 - March 31), indicated the facility triggered for: -Failed to Submit Data for the Quarter (No Data Submitted for Quarter) -One Star Staffing Rating (Staff Staffing Rating Equals 1) -Excessively Low Weekend Staffing (Submitted Weekend Staffing data is excessively low) -No RN (Registered Nurse) Hours (Four or More Days Within the Quarter with no RN Hours) -Failed to have LN (Licensed Nurse) coverage 24 hours per day (Four or More Days Within the Quarter with <24 hours/day Licenses Nursing Coverage) During an interview on 6/16/25 at 8:35 A.M., the Administrator said PBJ Data was reported and he would find evidence of submission for the surveyor. During an interview on 6/16/25 at 11:03 A.M., the Director of Operations said the facility does submit the PBJ staffing data but there was an issue in all their buildings, and he had a call out to CMS. During an interview on 6/16/25 at 2:55 P.M., the Regional Clinical Nurse said the Director of Operations was still working on it, but the person responsible for submitting PBJ data was let go about a month ago and the company was under the impression the PBJ data had been submitted, and they were working with CMS to submit it now. During an interview on 6/17/25 at 11:29 A.M., the Administrator said corporate was responsible for submitting the PBJ data, but he did not think it happened for FY Quarter 2 2025 and could not provide evidence of submission.

Based on the Beneficiary Protection Notification Review, interview, and policy review the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), Form CMS-10055 and the Notice of Medicare Non-Coverage (NOMNC), Form CMS 10123, were provided timely and explained to the resident/resident representative for two Residents (#19 and #49), out of three sampled residents. Specifically, the facility failed to issue the SNF ABN and failed to issue and explain the NOMNC timely ensuring the Resident/Resident representative understood the appeal process. Findings include: Review of the facility's policy titled Advance Beneficiary Notices, dated as last revised 3/4/24, indicated but was not limited to the following: -It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage. -The current Center for Medicare and Medicaid Services (CMS) approved version of the forms shall be used. a. For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), Form CMS-10055. b. For Part B items and services, the facility shall use the Advanced Beneficiary Notice of Non-Coverage (ABN), Form CMS-R131. c. A Notice of Medicare Non-Coverage (NOMNC), Form CMS 10123, shall be issued to the resident/resident representative when Medicare covered service(s) are ending, no matter if a resident is leaving the facility or remaining at the facility. This informs the resident on how to request an appeal to expedite determination from their Quality Improvement Organization (QIO). -Delivery requirements: a. The notice shall be written legibly in a language and/or format that the resident/representative understands. Verbal explanations detailing the reasons for the determination of possible non-coverage shall be provided. b. The notice shall be hand delivered, if possible, to obtain beneficiary or resident representative signature. c. The notice shall be prepared with an original and at least two copies. The facility shall retain the original and give a copy to the resident/representative. d. If the notice cannot be hand delivered, a telephone call shall be made, followed up immediately with a mailed, emailed, faxed, or hand delivered notice. Documentation shall comply with form instructions regarding telephone notices. e. Mail, secure fax machine and internet email may also be utilized for delivery of the notice if in-person issuance is not able to be performed. -The original notice shall be placed into the resident's financial file. The notice shall be retained at least five years. -A notice must be completed before delivery, and a copy must be provided to the resident/representative immediately after signing it. Review of the NOMNC, Form CMS 10123, indicated but was not limited to the following: -Request for an immediate appeal should be made as soon as possible, but no later than noon of the day before the effective date indicated. A. Resident #21 received Medicare Part A skilled services. Review of the medical record indicated Resident #21 was a long-term care (LTC) Resident and his/her Health Care Proxy (HCP) had been invoked. The facility failed to provide the surveyor with a copy of the SNF ABN, Form CMS-10055. The facility provided the surveyor with the ABN, Form CMS-R131. Review of the ABN failed to indicate a physical copy was provided to the HCP, a discussion took place with the HCP, the HCP signed any document or was aware of the services expected to not be covered or options available regarding services and billing options. The Resident was receiving Medicare Part A services and the SNF ABN (Form CMS-10055) should have been issued, not the ABN (Form CMS-R131). Review of the NOMNC indicated the notice was provided to Resident #21's HCP via a telephone call on 2/7/24 at 1:30 P.M., with a voicemail message left for effective date for last covered day (LCD) of 2/9/24. The NOMNC failed to indicate the document was mailed to the HCP. Further review of the NOMNC failed to indicate a physical copy was provided to the HCP, a discussion took place beyond a voicemail message or that the HCP signed any document or was aware of the appeal rights related to ending of the skilled benefit. Review of the progress notes from January and February 2024 failed to indicate a conversation took place or the documents were mailed. During an interview on 5/3/24 at 12:39 P.M., Resident #21's HCP said she was notified and told she needed to sign the form to show Resident #21 would not be getting therapy because he/she reached their max level, but she was not provided with any other information on her right to appeal the decision. She said she would have liked to appeal against the decision as the Resident was previously walking and eating a regular diet and feels he/she would benefit from more rehab services. She said she was not provided with the information on the appeal process and wished she was. During an interview on 5/3/24 at 1:53 P.M., Minimum Data Set (MDS) Nurse #1 said she found proof that Resident #21's HCP received the forms via certified mail on 2/23/24. Review of the secondary documents provided indicated the HCP signed for a certified mail letter delivery on 2/23/24 (16 days after the initial notice date and after the appeal window had closed). The documents were signed/dated 2/24/24. B. Resident #49 received Medicare Part A skilled services. Review of the medical record indicated Resident #49 was a LTC resident and his/her HCP had been invoked. The facility failed to provide the surveyor with a copy of the SNF ABN, Form CMS-10055. The facility provided the surveyor with the ABN, Form CMS-R131. Review of the ABN failed to indicate a physical copy was provided to the HCP, a discussion took place with the HCP, the HCP signed any document or was aware of the services expected to not be covered or options available regarding services and billing options. The resident was receiving Medicare Part A services and the SNF ABN (Form CMS-10055) should have been issued, not the ABN (Form CMS-R131). Review of the NOMNC indicated the notice was provided to Resident #49's HCP via a telephone call on 4/15/24 at 1:00 P.M., for effective date for last covered (LCD) of 4/17/24. The NOMNC failed to indicate the document was mailed to the HCP. During an interview on 5/3/24 at 12:27 P.M., Resident #49's HCP said she was not notified that the Resident was coming off skilled services or that she had any options to appeal. She said she had not received any paperwork in the mail that provided this information to her. She said the Resident may benefit from more therapy and asked if she could still appeal and was informed, she was outside of the window and would need to alert the facility of her desire and initiate a screening process, from there she said she will likely not bother. During an interview on 5/3/24 at 12:42 P.M., MDS Nurse #1 said the forms are sent via mail to the HCP and although they are not in the medical record, they are probably in the financial files. Additionally, she said the documents are not mailed in a way that can be tracked. During an interview on 5/3/24 at 12:53 P.M., MDS Nurse #1 said there was no further information available for Resident #49 and she did not have signed copies of the forms. She said there was no documentation in the medical record that the HCP was aware of the information or appeal rights. She said she didn't have the second page of Resident #49's NOMNC and thinks the original was mailed without a copy being made. Additionally, she said it appears from the documentation for both Residents #21 and #49 the process was not followed. During an interview on 5/3/24 at 1:53 P.M., MDS Nurse #1 said for Resident #49 she found evidence the second page was completed on the NOMNC but could not find evidence the documents were mailed or returned. She said they did not follow up and was unaware of the HCP's desire or awareness of the appeal rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, the facility failed to ensure staff developed and implemented a baseline care plan within 48 hours of the resident's admission, which included the instructions needed to provide effective and person-centered care to the resident and provide the resident and/or their representative with a summary of the baseline care plan for two Residents (#52 and #109), out of a total sample of 15 residents. Specifically, the facility failed: 1. For Resident #52, to provide him/her a written summary of the baseline care plan by completion of the comprehensive care plan and document receipt of the information within the Resident's clinical record; and 2. For Resident #109, to develop a baseline care plan for Post-Traumatic Stress Disorder (PTSD- mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations). Findings include: Review of the facility's policy titled The Baseline Care Plan, last reviewed December 2022, indicated but was not limited to the following: -The facility will develop and implement a Baseline Care Plan for each resident within 48 hours of admission. -The resident and representative, if applicable, will be informed of the initial plan for delivery of care and services by receiving a written summary of the Baseline Care Plan. 1. Resident #52 was admitted to the facility in January 2024 and had diagnoses including respiratory failure with dependence on supplemental Oxygen. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/17/24, indicated Resident #52 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. During an interview on 5/6/24 at 10:50 A.M., Resident #52 said he/she did not have a meeting within 48 hours of their admission and did not receive any written summary of the baseline care plan since admission. The Resident said he/she keeps all records the facility provides including meal tickets and he/she would have kept a copy of the baseline care plan so he/she would know what his/her care needs were. During an interview on 5/7/24 at 2:01 P.M., the Social Worker (SW) said the MDS Coordinator is responsible for coordination of the baseline care plan meetings and ensuring completion. During an interview on 5/8/24 at 8:25 A.M., the MDS Coordinator said she begins the baseline care plan and provides the copy to the rest of the interdisciplinary team to complete, and it is signed at the clinical morning meeting and uploaded into the resident's chart. She said she didn't know why this Resident's baseline care plan was not completed and she said that the interdisciplinary team should have signed the care plan. She said that she does not provide a copy to the resident or resident representative and was unaware she should be providing a copy of the baseline care plan. During an interview on 5/8/24 at 8:36 A.M., the Director of Nursing (DON) said the MDS Coordinator oversees the care plan process including the paper process for baseline care plans. She said the baseline care plan for Resident #52 was incomplete and failed to indicate clinical information, contributing staff signatures, and failed to indicate if the resident was offered or received a written summary of the baseline care plan. She said the expectation is that the resident or resident representative receive a copy of the baseline care plan since their care is collaborative and person-centered. 2. Review of the facility's policy titled Trauma Informed Care, dated as last revised 3/4/24, indicated but was not limited to the following: -It is the policy of this facility to provide care and services which address the needs of trauma survivors by minimizing triggers and/or re-traumatization. -DEFINITIONS: Trauma results from an event or series of events, or circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. -The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals to develop and implement individualized care plan interventions. -The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as ways to mitigate or decrease the effect of the trigger on the resident and will be added to the resident's care plan. Resident #109 was admitted to the facility in April 2024 with diagnoses including PTSD and depression. Review of the Nursing admission Assessment failed to indicate a diagnosis of PTSD. Review of the MDS assessment, dated 4/30/24, Section I6100 indicated Resident #109 had a diagnosis of PTSD. Review of the Social Services Assessment, dated 5/3/24, indicated the assessment was incomplete. Review of the medical record failed to indicate a PTSD Assessment had been completed. Review of the paper Baseline Care Plan in the Resident Record/Chart with Nurse #1 failed to indicate the care plan had been developed. The document was blank. During an interview on 5/3/24 at 1:35 P.M., Nurse #1 said the facility no longer uses paper forms and the Baseline Care Plan would be in the computer and initiated within 48 hours of admission. Additionally, he said Resident #109 did not have a current care plan for PTSD. Review of the Care Plan failed to indicate a care plan had been developed for PTSD. Review of the Care [NAME] (summary of resident's care and preferences) failed to indicate any trauma associated triggers to guide resident care. During an interview on 5/3/24 at 1:39 P.M., Resident #109 said he/she does have a diagnosis of PTSD, and no one had asked about it, how the trauma occurred, or what things may re-trigger the trauma. Resident #109 shared with the surveyor the physical and emotional trauma they had endured and said they have been incapable of being in a closed space with a male and could never think of having a male being nearby during care or providing personal care and speaking of it now is causing anxiety. Additionally, Resident #109 said no one at the facility had discussed this or said they could put barriers in place to ensure events like this would not come up. The surveyor encouraged Resident #109 to speak with the SW and share the triggers to ensure comfort and safety at the facility. During an interview on 5/3/24 at 11:12 A.M., SW #1 said she had not completed a PTSD Assessment on Resident #109 and had not seen one at this facility. Additionally, she said there was no Baseline Care Plan for PTSD and there should be one to identify the resident's triggers and therefore ensure the staff can do their best to avoid them or work around the process for the Resident as best as possible. SW #1 said she was unsure of the facility policy but said the regulatory guidelines in this instance were not followed.

Based on observation, interview, record review, and policy review, the facility failed to implement interventions on the Falls Care Plan for one Resident (#21), out of a total sample of 15 residents to meet the resident's physical, psychosocial and functional needs. Findings include: Review of the facility's policy titled Comprehensive Care Plans, dated as last revised 3/4/24, indicated but was not limited to the following: -It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. -The comprehensive care plan will describe, at minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. -Qualified staff responsible for carrying out interventions specified in the care plan. Review of the facility's policy titled Fall Reduction, dated as last revised 6/22/22, indicated but was not limited to the following: -The facility will implement interventions to minimize and/or eliminate contributing factors for falls for residents at risk based in the individual resident's needs. -Implement intervention(s) as appropriate to prevent reoccurrence. Resident #21 was admitted to the facility in January 2024 with diagnoses including dementia, muscle weakness, unsteadiness on feet, and history of right hip traumatic fracture. Review of the Minimum Data Set (MDS) assessment, dated 4/10/24, indicated Resident #21 had severe cognitive impairment as evidenced by a score of 6 out of 15 on the Brief Interview for Mental Status (BIMS), required assistance with activities of daily living (ADLs), and had a history of recent falls. Review of the Physician's Orders indicated but were not limited to the following: -Place Dycem on top of the cushion prior to seating patient in the wheelchair (4/23/24). Review of the Comprehensive Care Plans indicated but was not limited to the following: FOCUS: Risk for injury related to falls as evidenced by/related to history of falls, impaired mobility. GOAL: Free from fall related injury through next review. INTERVENTIONS: -Non-skid strips to side of bed and in front of the closet (1/25/24) -Place Dycem (non-slip pad) on top of cushion prior to seating patient in wheelchair (4/24/24) The surveyor made the following observations: -5/2/24 at 10:18 A.M., no non-skid strips on floor next to bed or in front of closet and no Dycem on wheelchair cushion. -5/3/24 at 8:30 A.M., no non-skid strips on floor next to bed or in front of closet; Resident was sitting in wheelchair with no Dycem on the wheelchair cushion. -5/3/24 at 9:56 A.M., no non-skid strips on floor next to bed or in front of closet and no Dycem on wheelchair cushion. (Dycem was under wheelchair cushion). -5/7/24 at 8:41 A.M., no non-skid strips on floor next to bed or in front of closet and no Dycem on wheelchair cushion. During an interview on 5/7/24 at 11:20 A.M., Nurse #3 said there were not any non-skid floor strips in Resident #21's room and the wheelchair cushion did not have a Dycem on top of it per the care plan. During an interview on 5/7/24 at 12:04 P.M., the Director of Nurses (DON) said there were no non-skid strips next to bed or closet and there was no Dycem on top of the cushion. She said she would expect the staff to be following the care plan and Resident #21 likely had a room change after the intervention was initially added for the floor strips, but she would expect the interventions to follow the Resident with a room change. During an interview on 5/7/24 at 12:04 P.M, Consulting Staff #1 said she did not realize the order/care plan said the Dycem should be on top of the cushion, and it was only beneath the cushion. Additionally, she said the floor strips were not there and they should have been placed in this room when he/she had a room change. She said she would expect the interventions to go with them when they move rooms.

Based on observations, interviews, record review, and policy review, the facility failed to ensure activity of daily living (ADL) care was provided to maintain good personal grooming for one Resident (#46), out of a total sample of 15 residents. Specifically, the facility failed to ensure nail care was performed for Resident #46. Findings include: Review of the facility's policy titled Nail Care, last revised 3/4/24, indicated but not limited to: - The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health. - Routine cleaning and inspection of nails will be provided during activities of daily living (ADL) care on an ongoing basis. - Routine nail care, to include trimming and filing, will be provided/offered on a regular schedule and as needed based on resident need and preference. - Principles of nail care: nails should be kept smooth to avoid skin injury; each resident will have his/her own nail care equipment (e.g., clippers, emery boards, files, etc.); equipment will not be shared between residents. - Procedure: document completion of task, any complications, or if resident refuses. Resident #46 was admitted to the facility in May 2021 with diagnoses including need for assistance with personal care and muscle weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/21/24, indicated the Resident was dependent on staff for ADLs and personal hygiene. The MDS assessment also indicated Resident #46 was cognitively intact as evidenced by a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS). During an observation with interview on 5/2/24 at 9:05 A.M., the surveyor observed Resident #46 to have long fingernails. Resident #46 said he/she had long fingernails because staff do not cut them routinely. Resident #46 said he/she had a shower three days prior and no one attempted to cut his/her nails. Resident #46 said he/she was embarrassed by how long and dirty their fingernails were and he/she would not typically like them to be long but could not manage them on his/her own. On 5/3/24 at 7:19 A.M., the surveyor observed the Resident in bed and noted his/her fingernails to be long, yellowed and have a brown substance underneath some of the nails. During an observation with interview on 5/6/24 at 8:43 A.M., the surveyor observed the Resident to be resting in bed and noted his/her fingernails to be long, yellowed and have a brown substance underneath four fingers on the right hand. Resident #46 said he/she had a shower three days prior but his/her nails were not cut or trimmed by staff. Resident #46 said he/she was embarrassed by their nails being so long and untrimmed. Review of the Certified Nurse Assistant (CNA) flow sheets indicated Resident #46 was dependent for grooming and personal care. Review of the documentation in the medical record failed to indicate the last time Resident #46 had their fingernails cut, filed, or cleaned. Furthermore, the documentation in the medical record failed to indicate Resident #46 had refused fingernail care. During an interview on 5/3/24 at 8:13 A.M., CNA #2 said Resident #46 usually gets showered once a week and nail care would typically be done at that time. CNA #2 said while nail care is typically completed after a shower, it can be done any day during any shift if the Resident needs or wants their nails trimmed. CNA #2 said residents are accommodated for nail care when they ask. During an interview on 5/3/24 at 9:03 A.M., CNA #3 said Resident #46 should have his/her nails trimmed and filed on shower days but it can be done at any time nail care is needed. CNA #3 said if a resident refuses or is reluctant to nail care they would notify the nurse to document attempts that were made and resident response. CNA #3 said at times Resident #46 can be resistive to nail care but if you talk to him/her and re-approach he/she is reasonable. CNA #3 said if Resident #46 continued to refuse care, staff could have the nurse or Director of Nursing (DON) talk with him/her about why nail care was necessary. CNA #3 said he thought Resident #46 last had nail care about two to three weeks ago, but the Resident was not currently on their assignment. During an interview on 5/7/24 at 9:58 A.M., Nurse #6 said CNA staff would be noting the length of nails when completing morning care daily. Nurse #6 said if fingernails were assessed to be long or dirty during morning care, CNAs would complete nail care. Nurse #6 said there was no specific day or time when nail care was performed, but rather to be completed when fingernails were noted to be long or dirty. Nurse #6 said CNAs would report to the nurse if a resident refused nail care. Nurse #6 said they would re-approach the resident and educate them on the importance of nail care. Nurse #6 said if a resident continued to refuse nail care it should be documented in a nursing note. During an interview on 5/7/24 at 11:53 A.M., the DON said staff are expected to assess fingernails for cleanliness and length during daily care. The DON said she would also expect staff to assess fingernail length on shower days. The DON said if a resident needed nail care, she would expect staff to be trimming, filing and cleaning fingernails. The DON said nursing documentation should reflect refusal of nail care. The DON and the surveyor reviewed the observations and interviews with Resident #46 related to nail care. The DON said Resident #46 often refuses care, but refusal of nail care should be documented in the record as well as any re-approach and education provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, the facility failed to provide indwelling catheter (a flexible tube inserted into the bladder to drain urine outside of the body) care and management consistent with professional standards for three Residents (#34, #160, and #16), out of a total sample of 15 residents. Specifically, the facility failed: 1. For Resident #34, to ensure the Foley catheter was assessed for removal as soon as possible or determine a clinical condition related to Foley catheter placement on admission to the facility; 2. For Resident #160, to ensure orders were in place for the Foley catheter and Foley catheter care, and to ensure the Foley catheter bag was hung at an appropriate level, below the bladder to discourage backflow of urine which helps prevent urinary tract infections (UTIs); and 3. For Resident #15, to ensure the catheter bag was hung at an appropriate level, below the bladder, to discourage backflow of urine which helps to prevent UTIs. Findings include: Review of the facility's policy titled Appropriate Use Indwelling Catheters, last revised 3/4/24, indicated but was not limited to the following: - It is the policy of this facility to ensure that a resident who is continent of bladder on admission receives services and assistance to maintain continence unless his/her clinical condition is or becomes such that continence is not possible to maintain. - An indwelling urinary catheter will be utilized only when a resident's clinical condition demonstrates that catheterization was necessary. - It is the policy of this facility to ensure each resident with urinary incontinence: b. Who is admitted with an indwelling urinary catheter, or each resident who subsequently receives an indwelling catheter, will be assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary. - Any decision regarding the use of an indwelling urinary catheter will be based on the resident's condition and goals for treatment. - The resident and/or representative will be included in discussions about the indications, use, potential benefits and risks of urinary catheters, and alternatives to help support the resident's rights to make an informed decision. - The use of an indwelling urinary catheter will be in accordance with physician orders, which will include the diagnosis or clinical condition making the use of catheter necessary, size of the catheter, frequency of change (if applicable). - Documentation to support decision making will be included in the medical record, including but not limited to: a. Clinical or medical conditions demonstrating the need for an indwelling urinary catheter. b. Assessment of incontinence, including the type, frequency, duration, and complicating factors associated with the incontinence. c. Assessment of psychosocial and functional factors affecting urinary continence status. d. Services provided to restore normal bladder function to the extent possible. e. Response to interventions prior to the decision to use an indwelling catheter. f. Resident's wishes and prognosis. - Indwelling urinary catheters will be used on a short-term basis, unless the resident's clinical condition warrants otherwise. - The interdisciplinary team, with the support and guidance form the physician, will assure the ongoing review, evaluation, and decision-making regarding the insertion, continuation, or removal of an indwelling catheter. - The plan of care will address the use of an indwelling catheter, including strategies to prevent complications. Review of the facility's policy titled Catheter Care, dated as last revised 3/4/24, indicated but was not limited to the following: -It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. -Catheter care will be performed every shift and as needed. -Privacy bags will be available and catheter drainage bags will be covered at all times while in use. -Ensure drainage bag is located below the level of the bladder to discourage backflow of urine. 1. Resident #34 was admitted to the facility in March 2024 with diagnoses including retention of urine, history of UTI, benign prostatic hyperplasia (BPH - a condition in which the flow of urine is blocked due to the enlargement of the prostate gland). Review of the Minimum Data Set (MDS) assessment, dated 3/8/24, indicated Resident #34 was cognitively intact with a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS) evaluation. The MDS assessment further indicated Resident #34 had an indwelling catheter placed and was dependent for activities of daily living (ADL), bed mobility and transfers. The MDS assessment indicated Resident #34 had a Genitourinary (reproductive/urinary system) diagnosis of BPH only. On 5/6/24 at 8:53 A.M., the surveyor observed Resident #34 resting in bed with his/her Foley catheter hanging from the side of the bed. Resident #34 said he/she does not need the Foley catheter. Resident #34 said it was put in during a hospitalization and has not been removed. Resident #34 said he/she has asked the nursing staff in the facility to remove the Foley catheter and has been given no explanation as to why he/she has it. On 5/7/24 at 12:24 P.M., the surveyor observed Resident #34 resting in bed with his/her Foley catheter hanging from the side of the bed. Resident #34 said he/she has never been given the opportunity of having the Foley catheter removed. Resident #34 said he/she would like to try to have the Foley catheter removed. Review of Resident #34's active Physician's Orders indicated but were not limited to: - 3/1/24: Provide Foley catheter care every shift and as needed - 3/2/24: Foley catheter order - Size 16 French (Fr) with 10 cubic centimeter (cc) balloon Review of Resident #34's Admission/re-admission Nursing Assessment, dated 3/1/24, indicated the following under Section 34 - Bladder: - Resident #34 had been incontinent or had a catheter for an unknown period. - Resident #34 was incontinent 1-2 times a week. - Resident #34 was taking diuretic (medication that help reduce fluid buildup in the body) medications. - Resident #34's catheter size and type were not indicated on the assessment. Further review of the electronic record indicated the Admission/re-admission Nursing Assessment, dated 3/1/24, was noted to be in progress and incomplete. Review of Resident #34's medical record failed to indicate a voiding trial had been attempted upon admission to the facility. Further review of the medical record failed to indicate the facility had contacted Resident #34's Urologist in the community to gather information related to the Foley catheter placement. Additionally, the medical record failed to indicate Resident #34 had been seen by a Urologist since admission to the facility. Review of the Hospital Summary documentation indicated Resident #34 had a chronic Foley catheter and diagnoses including BPH and history of UTIs. The documentation failed to indicate how long the Foley catheter had been inserted and if/when a voiding trial for removal had been attempted. Review of the Physician (MD) and Nurse Practitioner (NP) progress notes indicated Resident #34 had a chronic indwelling Foley catheter. MD/NP progress notes failed to indicate medical reasoning for current placement of Foley catheter, voiding trial and/or follow up with Urology regarding Foley catheter placement. During an interview on 5/7/24 at 2:18 P.M., Nurse #1 said when a resident with a Foley catheter is admitted to the facility, we check to make sure there is a reasoning or clinical diagnosis. Nurse #1 said staff would reach out to the MD to discuss the continued use or discontinuation of use related to the Foley catheter. Nurse #1 said if it was appropriate orders would be obtained from the MD to start a voiding trial. Nurse #1 said if a resident was seeing a Urologist in the community, they would contact them to gather more information regarding the Foley catheter placement. Nurse #1 said he was uncertain if Resident #34 had any voiding trials since admission or his diagnosis related to the Foley catheter placement. During an interview on 5/7/24 at 2:40 P.M., the Director of Nursing (DON) said she believed the hospital documentation indicated Resident #34 had a voiding trial during his/her stay which he/she failed. The DON said she would have to review the clinical hospital documentation to verify the information related to the voiding trial. During an interview on 5/8/24 at 11:41 A.M., Consulting Staff #1 said she would expect documentation in the record related to diagnoses and reasoning for Foley catheter placement. Consulting Staff #1 said she would expect documentation related to rationale for follow up with urology and/or voiding trials. On 5/7/24 at 2:40 P.M., the surveyor requested any additional information related to Resident #34 and a voiding trial or other clinical reasoning related to Foley catheter placement. No additional information was provided to the surveyor by the facility prior to exit. 2. Resident #160 was admitted to the facility in April 2024 with diagnoses including UTI, kidney transplant, and retention of urine. Review of the MDS assessment, dated 4/23/24, indicated Resident #160 had moderate cognitive impairment as evidenced by a score of 12 out of 15 on the BIMS and failed to indicate the Resident had an indwelling catheter. Review of the Admission/re-admission Nursing Assessment, dated 4/17/24, Section J indicated Resident #160 had a catheter. Review of the Physician's Orders failed to indicate orders for the catheter or catheter care. Review of the Comprehensive Care Plan indicated but was not limited to the following: FOCUS: Alteration/Risk for alteration in Bowel/Bladder continence as evidenced by/related to indwelling catheter and diagnosis of urinary retention. GOAL: Free from complications of catheter. INTERVENTIONS: -Dependent on staff for Foley care. -Foley catheter care every shift and as needed. -Ensure anchoring bag to promote adequate drainage/prevent backflow. -Change catheter and drainage bag per facility protocol/orders. -Ensure drainage bag is covered for dignity at all times. -Empty and record urine from foley every shift and as needed. Review of the Care Card/[NAME] indicated but was not limited to the following: -Foley catheter care every shift and as needed. -Ensure anchoring bag to promote adequate drainage/prevent backflow. -Change catheter and drainage bag per facility protocol/orders. -Ensure drainage bag is covered for dignity at all times. The surveyor made the following observations: -5/2/24 at 10:45 A.M., Resident sitting in wheelchair at nurses' station with Foley catheter drainage bag attached to armrest of wheelchair (above the bladder). -5/3/24 at 8:30 A.M., Resident sitting in wheelchair at nurses' station with Foley catheter drainage bag attached to armrest of wheelchair (above the bladder). -5/3/24 at 8:33 A.M., Resident sitting in wheelchair at nurses' station with Foley catheter drainage bag attached to armrest of wheelchair (above the bladder). Nurse #3 stopped and spoke to Resident and failed to move the drainage bag below the bladder. -5/3/24 at 8:45 A.M., Resident sitting in wheelchair at nurses' station with Foley catheter drainage bag attached to armrest of wheelchair (above the bladder). Nurse #3 stopped and gave Resident a drink, failed to move the drainage bag below the bladder and then assisted to put Resident back to bed. During an interview on 5/7/24 at 11:20 A.M., Nurse #3 said there should be orders for the catheter and catheter care and there were not any. During an interview on 5/7/24 at 12:04 P.M., the DON said Resident #160 should have a physician's order for the catheter and catheter care. She said there is a batch set of orders that should have been implemented and they were not. Additionally, she said the catheter drainage bag should not be hung on the armrest, it should be below the bladder on the wheelchair frame. 3. Resident #16 was admitted to the facility in December 2023 with diagnoses including urinary retention and history of urogenital implants. Review of the MDS assessment, dated 2/29/24, indicated Resident #16 was cognitively intact as evidenced by a score of 14 out of 15 on the BIMS and he/she had an indwelling catheter. Review of the Physician's Orders indicated but was not limited to the following: -Foley catheter care every shift and as needed (5/3/24). Review of the Comprehensive Care Plan indicated but was not limited to the following: FOCUS: Indwelling Foley catheter: neurogenic bladder/urine retention. GOAL: Will be/remain free from catheter-related trauma through review date INTERVENTIONS: -Has a chronic Foley. Position catheter bag and tubing below the level of the bladder. -Change catheter once a month per doctor orders. -Catheter privacy bag is covered every shift when out of bed. Review of the Care Card/[NAME] indicated but was not limited to the following: -Has a chronic Foley. Position catheter bag and tubing below the level of the bladder. -Monitor/Document for pain/discomfort due to catheter. The surveyor made the following observations: -5/2/24 at 10:45 A.M., Resident sitting in wheelchair at nurses' station with Foley catheter drainage bag attached to armrest of wheelchair (above the bladder). -5/2/24 at 1:15 P.M., Resident in hallway returned from appointment with Foley catheter drainage bag attached to armrest of wheelchair (above the bladder). -5/6/24 at 12:48 P.M., Resident in hallway with Foley catheter drainage bag attached to armrest of wheelchair (above the bladder). -5/6/24 at 4:23 P.M., Resident in hallway with Foley catheter drainage bag attached to armrest of wheelchair (above the bladder). -5/7/24 at 8:40 A.M., Resident sitting in wheelchair at nurses' station with Foley catheter drainage bag attached to armrest of wheelchair (above the bladder). Multiple staff members stopped and spoke to Resident between 8:40 A.M. and 9:00 A.M., none of the staff members moved the catheter drainage bag from the armrest of the wheelchair. -5/8/24 at 7:37 A.M., Resident self-propelling from dining room in wheelchair with Foley catheter drainage bag attached to armrest of wheelchair (above the bladder). -5/8/24 at 7:41 A.M., Resident sitting in front of nurses' station with the DON and Nurse #7. -5/8/24 at 8:19 A.M., Staff Development Coordinator/Infection Control Nurse (SDC/IP) was interacting with Resident (cleaning the white board), Foley catheter drainage bag was attached to armrest of wheelchair (above the bladder), SDC/IP did not adjust catheter bag. Resident self-propelled down hallway in wheelchair past the SDC/IP after the above interaction and again the SDC/IP did not adjust the Foley catheter bag. -5/8/24 at 8:28 A.M., Resident sitting in front of nurses' station, SDC/IP sitting at nurses' station, acknowledged Resident, however, did not adjust catheter bag. Nurse #3 observed walking by Resident and did not adjust catheter bag. -5/8/24 at 11:08 A.M., Resident sitting in front of nurses' station with Foley catheter drainage bag attached to armrest of wheelchair (above the bladder). SDC/IP and Nurse #3 sitting at desk, neither adjusted catheter bag. During an interview on 5/8/24 at 7:39 A.M., Certified Nursing Assistant #4 said Resident #16 transfers him/herself into wheelchair and puts the catheter bag there (pointing to armrest). During an interview on 5/8/24 at 7:42 A.M., Resident #16 shook his/her head and said they do not get up independently to get into the wheelchair and staff put the catheter bag on the armrest of the wheelchair. During an interview on 5/7/24 at 12:04 P.M., the DON said the catheter drainage bag should not be hung on the armrest, it should be below the bladder on the wheelchair frame. During an interview on 5/8/24 at 11:36 A.M., Consulting Staff #1 said she was just on the unit and saw Resident #16's catheter drainage bag hanging on the arm rest of the wheelchair. She said she tried to move it and the Resident declined. Additionally, she said if he/she likes it up there and wants it there it should have been care planned that way and it was not. She said the care plan would need to be updated for Resident preference if that was the case.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure one Resident (#109), out of a sample of 15 residents, received culturally competent, trauma-informed care accounting for resident experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. Specifically, the facility failed to assess Resident #109 and identify triggers of trauma to prevent potential re-traumatization. Findings include: Review of the facility's policy titled Trauma Informed Care, dated as last revised 3/4/24, indicated but was not limited to the following: -It is the policy of this facility to provide care and services which address the needs of trauma survivors by minimizing triggers and/or re-traumatization. -DEFINITIONS: Trauma results from an event or series of events, or circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. -The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals to develop and implement individualized care plan interventions. -The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as ways to mitigate or decrease the effect of the trigger on the resident and will be added to the resident's care plan. Review of the facility's policy titled Behavioral Health Services, dated as last revised 12/6/21, indicated but was not limited to the following: -The facility will ensure that a resident who displays or is diagnosed with a mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services. -The resident will receive, and the facility will provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Resident #109 was admitted to the facility in April 2024 with diagnoses including post-traumatic stress disorder (PTSD- mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations) and depression. Review of the Nursing admission Assessment failed to indicate a diagnosis of PTSD. Review of the Minimum Data Set (MDS) assessment, dated 4/30/24, Section I6100 indicated Resident #109 had a diagnosis of PTSD. Review of the Social Services Assessment, dated 5/3/24, indicated the assessment was incomplete. The medical record failed to indicate a PTSD Assessment had been completed. Review of the care plans failed to indicate a baseline or comprehensive care plan for PTSD had been developed to note any potential triggers to try and mitigate the effects and decrease the likelihood of re-traumatization. Review of the care [NAME] (summary of resident's care and preferences) failed to indicate any trauma associated triggers to guide resident care. During an interview on 5/3/24 at 1:39 P.M., Resident #109 said he/she does have a diagnosis of PTSD, and no one had asked about it, how the trauma occurred, or what things may re-trigger the trauma. Resident #109 shared with the surveyor the physical and emotional trauma they had endured and said they have been incapable of being in a closed space with a male and could never think of having a male being nearby or providing personal care and speaking of it now is causing anxiety. Additionally, Resident #109 said no one at the facility had discussed this or said they could put barriers in place to ensure events like this would not come up. The surveyor encouraged Resident #109 to speak with the SW and share the triggers to ensure comfort and safety at the facility. During an interview on 5/3/24 at 11:12 A.M., Social Worker (SW) #1 said she had not completed a PTSD assessment on Resident #109 and had not seen one at this facility. Additionally, she said there was no care plan for PTSD and there should be one to identify the Resident's triggers and therefore ensure the staff can do their best to avoid them or work around the process for the Resident as best as possible. SW #1 said she was unsure of the facility policy but said the regulatory guidelines in this instance were not followed. During an interview on 5/3/24 at 1:35 P.M., Nurse #1 said there was not a care plan for PTSD in the Resident's medical record.

Based on record review, policy review, and interview, the facility failed to ensure for one Resident (#15), out of a sample of 15 residents, that their as needed (PRN) psychotropic medication, Lorazepam (antianxiety), was re-evaluated 14 days after the medication was prescribed to ensure it was beneficial and necessary for the Resident in accordance with the standard of practice. Findings include: Review of the facility's policy titled Psychotropic Medication Treatment in Long Term Care (LTC), dated January 2021, indicated but was not limited to the following: -It is the policy to abide by state and federal regulations when requesting consent and administering medications. -Pharmacy Consultant will perform monthly medication regimen reviews. These reviews will identify existing irregularities regarding indications for use, dose, duration, and the potential for, or existence of adverse consequences or other irregularities. Any identified concerns must be reported to the attending physician and the Director of Nurses (DON). Resident #1 was admitted to the facility in June 2019 with diagnoses including dementia, mood disorder, anxiety, and epilepsy (seizure disorder). Review of the Minimum Data Set (MDS) assessment, dated 2/7/24, indicated Resident #1 had severe cognitive impairment as evidenced by a score of 2 out of 15 on the Brief Interview for Mental Status (BIMS) and had anxiety. Review of the Physician's Orders indicated but was not limited to the following: -Lorazepam Oral Concentrate milligrams/milliliter (ml) give 0.5 ml by mouth every four hours as needed for anxiety/agitation. (4/14/24) Further review of the Lorazepam order failed to indicate a stop date or re-evaluation date as required. Review of the Consultant Pharmacist's Note, dated 4/16/24, indicated to evaluate PRN Lorazepam. The facility failed to provide the surveyor with a copy of the full pharmacist recommendation. During an interview on 5/7/24 at 12:04 P.M., the DON said all psychotropic PRN medications, including Lorazepam, should be written for 14 days only and then re-evaluated. She said the order should not be written with no stop date and would have to be clarified as it had been over 14 days since the order was written. During an interview on 5/7/24 at 12:04 P.M., Consulting Staff #1 confirmed that all psychotropic PRN orders should be written for 14 days and then re-evaluated and extended if needed. She said they should not be left open ended unless being used for seizures and this is not the case as the order is written for anxiety/agitation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility failed to ensure the residents' environment was clean, comfortable, and homelike. Specifically, the facility failed to ensure the residents' rooms and environment were maintained in good repair and homelike on 2 of 2 resident care units. Findings include: Review of the facility's policy titled Safe and Homelike Environment, dated as last revised 10/10/24 (sic) indicated but was not limited to the following: -The facility will provide a safe, clean, comfortable, and homelike environment. -Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas, and activity areas. -Orderly is defined as an uncluttered physical environment that is neat and well-kept. -Sanitary includes, but is not limited to, preventing the spread of disease causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to, equipment used in the completion of the activities of daily living. -Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. -General Considerations: Report any furniture in disrepair to Maintenance promptly. -Report any unresolved environmental concerns to the Administrator. The facility failed to provide a preventative maintenance policy. Between 5/2/24-5/3/24, the surveyor observed the following: -room [ROOM NUMBER]: Baseboard heater broken/separated; window curtain dirty with rust color stains; nightstand door broken/hanging off; bathroom sink with rust around faucet and hot water knob; ceiling above/in the closet was stained a rust color which looked like water damage and the wallpaper border was falling off the wall. -room [ROOM NUMBER]: Window blinds broken, missing multiple slats leaving large gap of uncovered window. room [ROOM NUMBER]A wheelchair filthy with caked on food/debris. -room [ROOM NUMBER]: Window cracked/broken and taped with bright red tape; baseboard/wall with scuffed up paint. -room [ROOM NUMBER]: Entry wall scuffed up with paint chipped off the wall; window curtain filthy with rust-colored stains; Bathroom wall and ceiling in disrepair with what looked like water damage to plaster/sheet rock with staining and old patch work repairs. -room [ROOM NUMBER]: Window curtain filthy with rusty colored stains; multiple holes in the wall next to the window; Bathroom sink with rust stains around faucet into sink and around hot water handle. -room [ROOM NUMBER]: Window curtain with yellow/rust-colored stains. -Unit One Day Room: Multiple window blinds broken with missing and/or broken slats, some windows with no blinds at all; Baseboard heater panels broken/hanging off the wall. -Second Floor Kitchenette: Wall grate dented and in disrepair, not fully secured to the wall. -room [ROOM NUMBER]: Window in disrepair, frame appeared to be missing parts and was taped with silver tape. -room [ROOM NUMBER]: Window blinds broken with multiple missing slats and exposed window. room [ROOM NUMBER]A left side bed rail covered with dried dirt/debris on grab handle. -room [ROOM NUMBER]: Large crack down the corner of the wall. room [ROOM NUMBER]B wheelchair armrest torn with rough material to grasp and exposed foam. -room [ROOM NUMBER]: Window broken with multiple cracks taped together with duct tape. -room [ROOM NUMBER]: Window falling off the rail/track and no screen on the window. -Unit Two Day Room: Window blinds with broken slats, baseboard heater panels broken/hanging off the wall. During an interview on 5/7/24 at 11:50 A.M., the Administrator and Consulting Staff #1 said they did not believe there was a policy for routine facility maintenance. During an interview on 5/8/24 at 9:38 A.M., the Maintenance Director said they do rounds on the units, but he did not have a schedule for rounding the floors. He said each floor has a maintenance book and he checks that twice a day but was unaware of the damage to the rooms when shown by the surveyor. During a follow-up interview on 5/8/24 at 1:18 P.M., the Maintenance Director said before a new admission comes in, they check the beds, but he does not walk around the room or look up at the ceiling. He said these concerns would be his responsibility to repair but he was unaware of them. Additionally, he said it is not very homelike with broken blinds and baseboard heaters and the broken windows that are taped are a safety concern. He said several of the rooms were in disrepair and he would have to walk around the entire building to see what else needed to be repaired. During an interview on 5/8/24 at 1:32 P.M., the Administrator said his expectation is that rounds are completed to identify issues and expect that the residents have a homelike environment and these concerns with stains on curtains, holes in the walls, and broken windows etc. should have been identified and a solution in process but they were not. During a follow-up interview on 5/8/24 at 4:16 P.M., the Administrator said they have a rounding process in place, but it needs improvement. He said the Maintenance Director is not part of it and he should be. Additionally, he said each department head is assigned a room/area and they are supposed to complete a checklist to identify concerns, however he said there is no tracking process for the forms, and he only had one returned to him with no concerns identified. He said he was unaware of the concerns the surveyor showed him and those areas would need to be addressed. The Administrator said those rooms are not very homelike with the damage and the broken windows are dangerous and should not be duct taped together.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #19 was admitted to the facility in [DATE] with diagnoses including neuropathy (group of diseases resulting from damaged or malfunctioning of nerves that causes weakness, numbness and pain in hands and feet), repeated falls, and muscle weakness. Review of the most recent MDS assessment, dated [DATE], indicated Resident #19 was cognitively intact as evidenced by a BIMS score of 15 out of 15. Review of the medical record indicated Resident #19 had a total of two falls between [DATE] and [DATE]. Review of Resident #19's Incident Report, dated [DATE], indicated but was not limited to the following: - On [DATE] at 3:30 P.M., the nurse heard a loud noise coming from the dining room and noted Resident #19 lying on his/her back. Resident #19 said he/she was trying to pick up lucky coins, fell and hit his/her head. Review of the medical record and interdisciplinary care plan for falls failed to indicate any interventions were developed or implemented after the fall to prevent recurrence. Review of Resident #19's Incident Report, dated [DATE], indicated but was not limited to the following: - On [DATE] at 4:10 A.M., Certified Nursing Assistant (CNA) heard the resident calling out for help, entered the room and called for the nurse to come into the room. The nurse observed Resident #19 sitting up on the floor. Resident #19 said he/she was going to the bathroom, slipped and fell. - Resident #19 complained of soreness in their right side of his/her face and right knee. Review of the medical record indicated a Fall Risk Assessment was started but incomplete with errors after the fall on [DATE]. Further review of the medical record and review of the interdisciplinary care plan for falls failed to indicate any interventions were developed or implemented after the fall to prevent recurrence. During an interview on [DATE] at 12:44 P.M., Nurse #1 said when a resident has a fall, he completes an incident report in the computer and obtains witness statements. He said the fall is reviewed and the resident's care plan is updated with interventions to decrease the resident's risk of falling again. During an interview on [DATE] at 12:48 P.M, the DON said her expectation is for Resident #19's care plan to be updated with a new intervention that is relevant to how the fall occurred to reduce the risk of falling again. She said all falls are supposed to be reviewed with the risk management team to ensure new interventions, and care plans are put into place for the resident's safety. She said Resident #19's medical record and care plan has not been updated with any new interventions as it should have been after his/her falls, per facility policy. 3. Review of the facility's policy titled Elopements and Wandering Residents, dated [DATE], indicated but was not limited to: -Elopement is defined as when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. -The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. -Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. -Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. Resident #26 was admitted to the facility in [DATE] with diagnoses including unspecified intellectual disabilities, dementia with behavioral disturbances, and unspecified psychosis. Review of the MDS assessment, dated [DATE], indicated Resident #26 scored a 13 out of 15 on the BIMS assessment. Resident's Healthcare Proxy (HCP) was activated due to impaired judgement and intellectual disabilities. During an interview on [DATE] at 12:39 P.M., Resident #26 said they had walked to the grocery store about one year ago and when they came back, the staff put the wanderguard (device to sound an alarm to prevent elopement/wandering) on him/her and then he/she kept it in their pocket. Resident #26 said he/she did not have the wanderguard device anymore and did not know when he/she stopped needing it. Review of the medical record indicated the facility failed to complete an elopement risk screen upon Resident #26's return to the facility on [DATE]. Additionally, the nursing progress notes indicated staff applied a wanderguard to right wrist on [DATE]. The medical record indicated a physician's order was received for a wanderguard to be placed on [DATE]. Review of the Care plans for Resident #26 failed to indicate a comprehensive care plan with interventions to prevent or identify risks for elopement/wandering was developed or implemented. Review of the nursing progress notes indicated on [DATE] the hand/arm of Resident #26 was swollen, the wanderguard was removed and the Resident was told to always keep the wanderguard in his/her pocket. Review of the current and active task progress notes indicated the following: -Resident has a wanderguard and carries it in his/her pocket (with serial number and expiration of [DATE]) -Elopement risk identification sheet completed and placed in elopement book -Monitor resident when going towards the elevator, for tailgating of other residents or family members Review of the Physician's Orders indicated the order for the wanderguard was updated on [DATE] to include in the description: - Wanderguard in place, check function every shift; with serial number and an expiration date of [DATE] (the device expiration date had already occured when this ordered was updated.) Review of the Physician's Orders indicated the order for wanderguard was discontinued on [DATE]. Review of the assessments for Resident #26 indicated an Elopement Risk Screen was created on [DATE] and was not completed, no additional Elopement Risk Screens were completed for Resident #26. Review of the Quarterly Care Plan review, dated [DATE], indicated Resident #26 was an elopement risk and had a wanderguard. During an interview on [DATE] at 2:40 P.M., the MDS Coordinator said she opened an elopement focused care plan for Resident #26 but did not create any interventions. She also said the risk assessment should have been completed to determine if Resident #26 continued to be an elopement risk, but it was not completed. She said in the intervention section of the care plan is where the wanderguard information should be such as placement and expiration date. She said that the wanderguard device should have been replaced when the order was updated in January since the wanderguard device had expired. During an interview on [DATE] at 7:45 A.M., the DON said she would expect to find the location of the wanderguard placed on the body, the serial number of the device, and an expiration date that had not passed to be in the care plan and orders for Resident #26 after his/her elopement. She said that she would expect that an elopement assessment was completed. She said there was a nursing note that indicated the Resident kept the wander guard device in his/her pocket, but she said she feels this does not prevent elopement since the device was not secure on the Resident's body. She said she would expect that there were personalized interventions in place to identify and reduce risks of the Resident having another elopement, but there were not. She said Resident #26 should still have the wanderguard device in place unless an assessment was completed and the assessment determined the Resident was not a risk for elopement. She said there was no assessment indicating the Resident was no longer at risk for elopement. Based on observation, record review, policy review and interview, the facility failed to provide adequate supervision and an environment free from accidents and/or hazards for three Residents (#4, #19, and #26), out of a total sample of 15 residents. Specifically, the facility failed: 1. For Resident #4, to follow their fall Reduction policy for investigating falls and initiating fall prevention interventions; 2. For Resident #19, to follow their fall Reduction policy for investigating falls and initiating fall prevention interventions; and 3. For Resident #26, to follow their Elopements and wandering residents policy for assessing risk factors and implementing interventions to prevent further elopements. Findings Include: 1. Review of the facility's policy titled Fall Reduction, dated as last revised [DATE], indicated but was not limited to the following: - Goal: To identify residents at risk for falls and to decrease the incidence of resident falls. - The facility will identify residents at risk for falls through use of a Fall Assessment Tool. - The facility will implement interventions to minimize and/or eliminate contributing factors for falls for residents at risk based on the individual resident's needs. - The facility will provide education on fall prevention to caregivers, residents, and family. - In the event that a fall occurs, the facility will investigate the factors contributing to the fall and develop a plan of action to minimize further falls. - Upon admission, readmission, quarterly, annually and with change in condition and/or after a fall has occurred, residents will be evaluated for risk of potential falls by completing a Fall Risk Assessment. - Residents at risk, in addition to the Universal Safety Standards; will be reviewed for resident specific intervention(s) as deemed appropriate. - In the event a resident falls, the following measures will be instituted: e. Evaluate why the resident may have fallen, clarify the details of the fall. f. Implement intervention(s) as appropriate to prevent recurrence. g. Document in the medical record. h. Complete an Incident Report. - Resident falls will be reviewed in the Standard of Care Meeting and may include, but not be limited to, the following: identification of trends, evaluation of effectiveness of interventions and development of additional measures as indicated. Resident #4 was admitted to the facility in [DATE] with diagnoses including schizoaffective disorder, history of falling, and muscle weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident #4 had a moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. Further review of the MDS assessment indicated Resident #4 required assistance of one staff member for transfers, ambulation, toileting, and dressing activities. Review of the medical record indicated Resident #4 had a total four falls between [DATE] and [DATE]. Review of Resident #4's Incident Report, dated [DATE], indicated: - On [DATE] at 5:30 A.M., the nurse heard Resident #4 calling for help from their room and responded. The nurse found Resident #4 on the floor, unclothed, just beside his/her bed with his/her body facing the door. - Resident #4 stated they had slipped and fallen on the floor landing on his/her right hip. Resident #4 had complaints of right hip and neck pain. Review of the medical record failed to indicate a Fall Risk Assessment was completed for the incident on [DATE]. Review of the medical record failed to indicate any interventions were developed or implemented post fall. Review of Resident #4's interdisciplinary care plan for falls failed to indicate any interventions were developed or implemented post fall. Review of Resident #4's Incident Report, dated [DATE], indicated: - On [DATE] at 3:50 P.M., another resident reported to the nurse that Resident #4 was on the floor. The nurse and two other nurses went into Resident #4's room and observed him/her to be seated on the floor next to his/her bed with both feet slightly bent. Resident #4 was observed to have one foot slightly stuck underneath his/her buttock. - Resident #4 said he/she was trying to get out of bed. Review of the medical record failed to indicate a Fall Risk Assessment was completed for the incident on [DATE]. Review of the medical record failed to indicate any interventions were developed or implemented post fall. Review of Resident #4's interdisciplinary care plan for falls failed to indicate any interventions were developed or implemented post fall. Review of Resident #4's Incident Report, dated [DATE], indicated: - On [DATE] at 3:30 P.M., the nurse was called into Resident #4's room by the Certified Nursing Assistant (CNA). The nurse discovered Resident #4 on the ground lying on their back at the foot of the bed. No visible injury was noted. - Resident #4 said he/she went to the bathroom in the wheelchair and it moved from them causing him/her to fall. - The incident report indicated Resident #4 had a numerical pain scale rating of 3 out of 10 related to the head/neck and he/she was ambulatory with assistance. - The incident report indicated Resident #4 had removed gripper socks and donned their own socks prior to the incident occurring. The facility's Fall Risk Assessment completed on [DATE] indicated Resident #4's last known fall was during the current stay/within the last month, he/she had dizziness/generalized weakness related to mobility, he/she was oriented to person and place, he/she had no communication/sensory deficits, he/she was behavioral/non-compliant with instructions and takes medication for the cardiovascular or central nervous system. The Fall Risk Assessment failed to indicate a fall risk score for Resident #4. Review of Resident #4's interdisciplinary care plan for falls indicated an intervention of Physical Therapy (PT) referral for screen and treatment as needed. Review of the PT therapy documentation indicates Resident #4 had been receiving skilled services since [DATE] after returning to the facility from a hospitalization for a previous fall. Review of Resident #4's Incident Report, dated [DATE], indicated: - On [DATE] at 10:30 A.M., the nurse was told by a Certified Nursing Assistant (CNA) that the Resident was on the floor in the dining room. The nurse and another nurse on the unit responded to Resident #4 in the dining room. Resident #4 was observed to be lying on his/her back with his/her head between a chair and the piano in the dining room. - Resident #4 said he/she was trying to transfer from the wheelchair to a standard chair when they lost their balance and fell to the floor hitting their head on the chair. The facility's Fall Risk Assessment completed on [DATE] indicated Resident #4's last known fall was within the last three months, he/she requires assist of one person for mobility, he/she is oriented to person and place, he/she has no communication/sensory deficits, Resident #4 exhibits impulsive behavior, he/she takes medication for cardiovascular or central nervous system, and he/she has no problem with volume/electrolyte status. The Fall Risk Assessment failed to indicate a fall risk score for Resident #4 indicating level of fall risk. Review of the medical record failed to indicate any interventions were developed or implemented post fall. Review of Resident #4's interdisciplinary care plan for falls failed to indicate any interventions were developed or implemented post fall. During an interview on [DATE] at 2:32 P.M., Resident #4's Health Care Proxy (HCP) said he was concerned regarding Resident #4's falls which have increased over the last year. The HCP said he is notified by the facility after Resident #4 has a fall. The HCP said Resident #4 has had no major injuries from the falls. The HCP said he did not feel like the facility informed him of what they were doing to prevent further falls or incidents for Resident #4. The HCP said he was not informed if the facility determined the cause of the fall or any plans to prevent future falls. The HCP said he was unaware of any interventions put in place after a fall occurs. The HCP said there was no communication on how the facility plans to prevent futures issues and it would be a great improvement to ensure quality care is being provided. During an interview on [DATE] at 12:04 P.M., the Director of Nursing (DON) said when a fall occurs in the facility the nursing staff would complete an incident report. The DON said the interdisciplinary team would update the resident's care plan with interventions within a day or so. The DON said all falls are reviewed weekly on Friday at the facility's Risk Meeting. The DON said interdisciplinary care plan interventions should be followed. During an interview on [DATE] at 8:36 A.M., Nurse #5 said after a resident sustains a fall in the facility, the nurse would complete a fall risk assessment and fall incident report. Nurse #5 said any orders would be updated. Nurse #5 said the interdisciplinary care plan would be updated to reflect any fall interventions implemented. During an interview on [DATE] at 11:55 A.M., the Director of Rehabilitation (DOR) said they are notified of a resident's fall through a screen form. The DOR said the screen is either given to her directly or left in her office depending on when a resident falls. The DOR said the form is reviewed and additional information is gathered the following morning in the clinical meeting. The DOR said the rehabilitation department would complete a screen and/or an evaluation to determine the need for skilled therapy services after a fall occurs. During an interview on [DATE] at 1:35 P.M., the DON said the interdisciplinary care plan should be updated after each fall that occurs in the facility. The surveyor and the DON reviewed the medical record for Resident #4. The DON said interventions should be updated on the fall care plan after each incident and were not.

Based on observations, interviews, record review, and policy review, the facility failed for four Residents (#53, #54, #34, and #1), out of a sample of 15 residents, to ensure staff provided respiratory care and services consistent with professional standards of practice. Specifically, the facility failed: 1. For Resident #53, to ensure orders were in place for Oxygen and the equipment/tubing was changed per policy; 2. For Resident #54, to ensure a Respiratory care plan was developed and the nebulizer equipment/tubing/mask were stored and changed per policy; 3. For Resident #34, to ensure nebulizer equipment was clean and mask/tubing were stored per policy; and 4. For Resident #1, to ensure the oxygen equipment/tubing was changed per policy. Findings include: Review of the facility's policy titled Oxygen Administration Policy and Procedure, dated as last reviewed 12/6/22, indicated but was not limited to the following: -Oxygen is administered by Licensed Nurses with a physician's order. Orders should specify the oxygen equipment and flow rate, or concentration required as routine or as needed. -Oxygen equipment will be checked daily for correct flow and concentration, properly filled humidification system if in use, and correct set up of equipment. -Check the physician's order. If it is unclear, clarification must be obtained. -All tubing will be changed at least weekly, more often if soiling with secretions occurs. Review of the facility's policy titled Nebulizer Therapy, dated as last revised 3/4/24, indicated but was not limited to the following: -Verify practitioner's order. -Correctly assemble the tubing, nebulizer cup, and mouthpiece or mask per manufacturer's specifications and ensure connections are secured tightly. -Clean after each use. -Store nebulizer cup and the mouthpiece in a zip lock bag. -Change nebulizer tubing weekly or as needed. -Periodically disinfect unit per manufacturer recommendations. 1. Resident #53 was admitted to the facility in March 2024 with diagnoses including acute respiratory failure, acute on chronic heart failure, obesity, and cerebral infarction (stroke). Review of the Minimum Data Set (MDS) assessment, dated 4/2/24, indicated Resident #53 was cognitively intact as evidenced by a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS) and was not receiving oxygen therapy. Review of the Physician's Orders failed to indicate an order for oxygen therapy or equipment care/management. Review of the Comprehensive Care Plan indicated but was not limited to the following: FOCUS: At risk for and has impaired gas exchange and shortness of breath related to diagnosis of respiratory failure and use of oxygen. GOAL: Will have no complications related to shortness of breath; Will maintain normal breathing pattern. INTERVENTIONS: -Oxygen as needed per order. Review of the progress notes indicated Resident #53 was receiving oxygen therapy. The surveyor made the following observations: -5/2/24 at 11:06 A.M., Resident lying in bed with Oxygen via nasal cannula on at 2 liters per minute (LPM); tubing dated 4/21/24. -5/3/24 at 11:15 A.M., Resident lying in bed with Oxygen via nasal cannula on; tubing dated 4/21/24. -5/7/24 at 8:41 A.M., Resident lying in bed with Oxygen via nasal cannula off; tubing dated 5/2/24. The facility failed to ensure orders were in place for Oxygen and the equipment was changed per policy. During an interview on 5/2/24 at 11:06 A.M., Resident #53 said they had been on Oxygen since admission to the facility. During an interview on 5/3/24 at 11:20 A.M., Nurse #3 said there should be an order for Oxygen and there is not. During an interview on 5/3/24 at 11:31 A.M., Consulting Staff #2 said there should be an order for the Oxygen and there was not. During an interview on 5/7/24 at 12:04 P.M., the Director of Nurses (DON) said there should be a physician's order for the use of Oxygen. 2. Resident #54 was admitted to the facility in April 2024 with diagnoses including diseases of the circulatory system, encounter for surgical aftercare following surgery on the circulatory system, and dissection of ascending aorta (tear in the body's main artery). Review of the MDS assessment, dated 4/9/24, indicated Resident #54 was cognitively intact as evidenced by a score of 13 out of 15 on the BIMS. Review of the Physician's Orders indicated but were not limited to the following: -Albuterol Sulfate Inhalation Nebulizer Solution 0.083% one vial inhale orally via nebulizer every four hours as needed for wheezing (4/3/24). (medication to open airway) -Ipratropium Bromide Inhalation Solution 0.02% one vial inhale orally via nebulizer every four hours as needed for wheezing (4/3/24). (medication to open airway) The physician's orders failed to indicate an order for nebulizer equipment care/management. Review of the Medication Administration Record (MAR) indicated Resident #54 received the medication via nebulizer three times in April 2024. Review of the Comprehensive Care Plans for Resident #54 failed to indicate a Respiratory Care Plan had been developed. The surveyor made the following observations: -5/2/24 at 11:06 A.M., Resident sitting on edge of bed, nebulizer face mask hanging off the nightstand onto the floor, unbagged (to protect from germs/debris), tubing dated 4/4/24. -5/7/24 at 8:41 A.M., Resident sitting on edge of bed, nebulizer face mask in nightstand drawer attached to nebulizer, mask unbagged, (to protect from germs/debris), lying in drawer full of personal belongings including unfolded gray non-skid slipper socks, tubing dated 4/4/24. The facility failed to ensure a Respiratory care plan was developed and the nebulizer equipment was stored and changed per policy. During an interview on 5/7/24 at 8:41 A.M., Resident #54 said they use the breathing treatment frequently and it helps. Resident #54 demonstrated how the nurse fills the machine and placed the mask on his/her face to show the surveyor how it worked. Additionally, he/she said they were unsure how often the tubing was changed because they had only been here (at facility) for about a month and didn't think it had been changed since admission. 3. Resident #34 was admitted to the facility in March 2024 with diagnoses which included chronic obstructive pulmonary disease (COPD-lung disease that blocks airflow), respiratory failure, and dependence on supplemental Oxygen. Review of the MDS assessment, dated 3/8/24, indicated Resident #34 was cognitively intact as evidenced by a score of 14 out of 15 on the BIMS and received Oxygen therapy. Review of the Physician's Orders indicated but were not limited to the following: -Oxygen at 4 LPM via nasal cannula for diagnosis of respiratory failure and COPD every shift (3/2/24). -Clean oxygen filter weekly on Thursdays 11 P.M. - 7 A.M. shift (3/1/24). -Change oxygen tubing weekly on Thursday 11 P.M. - 7 A.M. shift (3/4/24). -Albuterol Sulfate Inhalation Nebulizer Solution inhale orally via nebulizer every four hours as needed for shortness of breath (3/1/24). -Change nebulizer tubing weekly on Thursday 11 P.M. - 7 A.M. shift (3/4/24). Review of the April and May 2024 MAR and Treatment Administration Records (TAR) indicated the Resident received Oxygen and Albuterol medication via nebulizer daily and the tubing was signed off as changed last on 5/2/24. Review of the Comprehensive Care Plan indicated but was not limited to the following: FOCUS: Diagnosis of COPD and obstructive sleep apnea and requires oxygen, inhaler, nebulizer treatments and BiPAP. GOAL: Will display optimal breathing pattern daily. INTERVENTIONS: -Oxygen therapy as ordered by the physician. -Give aerosol or bronchodilators as ordered (Albuterol Nebulizer) The surveyor made the following observations: -5/2/24 at 9:07 A.M., Resident wearing nebulizer mask actively receiving a breathing treatment, Nebulizer machine in use laden with dust, crumbs/debris of orange color, small pieces of hair, and three twist off caps to from unit dose packaging. -5/3/24 at 7:20 A.M., Resident in bed with Oxygen in place, nebulizer mask and tubing on top of nebulizer machine, unbagged (to protect from germs/debris), an empty bag under the machine. The facility failed to ensure nebulizer equipment was clean and mask/tubing were stored per policy. During an interview on 5/3/24 at 7:24 A.M., Nurse #1 said the nebulizer mask and tubing should be cleaned and stored in the storage bag after use and it was not currently stored the way it should be. 4. Resident #1 was admitted to the facility in June 2019 with diagnoses including dementia, cerebrovascular disease, and palliative care. Review of the MDS assessment, dated 2/7/24, indicated Resident #1 had severe cognitive impairment as evidenced by a score of 2 out of 15 on the BIMS. Review of the Physician's Orders indicated but were not limited to the following: -Continue Oxygen for comfort only every shift for comfort (4/8/24). -Oxygen at 2 LPM for oxygen saturation less than 90% for comfort (10/26/23) -Change oxygen tubing every seven days on night shift and as needed (10/27/23). Review of the May 2024 MAR and TAR indicated the Resident received Oxygen daily and the tubing was signed off as changed last on 5/1/24. Review of the Comprehensive Care Plan indicated but was not limited to the following: FOCUS: Potential for altered respiratory status/difficulty breathing and needs oxygen therapy. GOAL: Will have no signs and symptoms of poor oxygen absorption; Will maintain normal breathing pattern. INTERVENTIONS: -Provide oxygen as ordered. The surveyor made the following observations: -5/2/24 at 9:25 A.M., Resident sitting in dining room in wheelchair with Oxygen in place. Tubing appeared old, was yellow from area below the chin up around both ears and up to the prongs that enter the Resident's nose. The tubing was yellow and opaque (cloudy-not clear and see through) and dated 4/10/24, the humidifier bottle attached to the concentrator was unlabeled/undated and the bottle was empty, and the concentrator was set to 2 LPM. -5/2/24 at 9:27 A.M., Nurse #1 entered the dining room, he opened a new disposable humidifier bottle and re-attached the Oxygen tubing dated 4/10/24. -5/3/24 at 7:06 A.M., Resident sitting in the dining room with no Oxygen in place or available in the room, appeared comfortable and not in distress. 5/3/24 at 9:48 A.M., Resident in the dining room, Oxygen in place via nasal canula at 2 LPM, tubing and humidifier bottle dated 5/2/24. The facility failed to ensure the oxygen equipment was changed per policy. During an interview on 5/2/24 at 9:27 A.M., the surveyor asked Nurse #1 about the tubing, and he said it was old and dirty looking and was supposed to be changed weekly. Nurse #1 checked the label and said the tubing was from 4/10/24 and should not be in use, and it was an infection control risk for germs. Additionally, he said the tubing needed to be changed and the procedure for changing it weekly was not completed as it should have been. During an interview on 5/3/24 at 11:31 A.M., Consulting Staff #2 said there should be physician's orders in place for Oxygen and the tubing for all nebulizers and oxygen should be changed weekly on Sundays and should populate on the TAR. During an interview on 5/7/24 at 12:04 P.M., the DON said there should be orders in place for Oxygen which include rate and delivery method. She said the tubing should be changed weekly on Sundays and dated accordingly, and the nebulizer equipment/mask should be cleaned and stored in a bag when not in use. She said they don't have orders that populate. Her expectation is that it is nursing practice, and the nurse should get in report who is on nebulizers or oxygen and this facility changes the equipment on Sunday nights. Additionally, she said an individualized respiratory care plan should be in place. The DON said herself or the Staff Development Coordinator/Infection Control Nurse (SDC/IP) walk the units on Mondays to ensure tubing was changed. When asked how she knows who is on Oxygen, she said she uses her clinical squares (personal worksheet of clinical information specific for each resident which she creates/updates), but not all of these residents are on her squares so she will need to look at the process to ensure things are not missed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #9 was admitted to the facility in April 2024 with diagnoses which included personality disorder and chronic pain syndrome. Review of the medical record indicated Resident #9 was prescribed the following: -Olanzapine 5 milligrams (mg) give 2.5 mg by mouth in the evening for mood disorder Review of the progress notes indicated the Pharmacy Consultant made recommendations on 4/16/24 for an AIMS assessment to be completed. Review of the electronic and paper medical records failed to include the Consultant Pharmacist Recommendation from April 2024. At 8:45 A.M., the surveyor requested the Pharmacy Consultant Recommendation from the DON. During an interview on 5/8/24 at 10:01 A.M., the DON provided the surveyor with a Summary of Recommendations for DNS/Medical Director. The DON said she was unable to locate the Consultant Pharmacist Recommendation for April 2024. Review of the Summary of Recommendations for DNS/Medical Director dated for recommendations created between 4/1/24 and 4/16/24 indicated Resident #9 was taking an antipsychotic, and AIMS testing was to be performed now and every 6 months to monitor for tardive dyskinesia (involuntary movement disorder). Review of the electronic and paper medical record failed to indicate the Pharmacy Consultant recommendation was reviewed or addressed by the facility. During an interview on 5/8/24 at 10:53 A.M., Social Worker (SW) #1 said AIMS assessments are completed by their psychology consultant services. SW #1 reviewed Resident #9's medical record with the surveyor and said Resident #9 has not been seen by their psychology services yet, and an AIMS assessment had not been completed. 4. Resident #19 was admitted to the facility in December 2019 with diagnoses which included major depressive and bipolar disorders. Review of the medical record indicated Resident #19 was prescribed the following medications: -Escitalopram 30 mg by mouth every morning -Benadryl 25 mg by mouth as needed -Cepacol Sore throat lozenge one lozenge by mouth as needed -Mucinex extended release 400 mg by mouth as needed Review of the progress notes indicated the following: -Pharmacy Consultant made recommendations on 1/19/24 to review the Escitalopram dosage. -Pharmacy Consultant made recommendations on 2/14/24 to review the Escitalopram dosage. -Pharmacy Consultant made recommendations on 3/20/24 to review the Escitalopram dosage and unused as needed medications; Benadryl, Cepacol, and Mucinex. -Pharmacy Consultant made recommendations on 4/16/24 to review the Escitalopram dosage and unused as needed medication, Benadryl. During an interview on 5/8/24 at 8:45 A.M., the surveyor requested the pharmacy recommendations from the DON for Resident #19. She said she is only able to provide March 2024 Note to Attending Physician/Prescriber, and the Summary of Recommendations for DNS/Medical Director for the month of April 2024. She said she is unable to locate any pharmacy recommendations for the months of January and February 2024 for Resident #19. She said the pharmacy recommendations were not kept in the Resident's permanent medical record as they should have been. Review of the Note to Attending physician/Prescriber, dated 3/20/24, indicated Resident #19 was receiving Escitalopram 30 mg daily, and the recommended dose should not exceed 10 mg per day in residents over [AGE] years old. Physician/Prescriber response was blank and incomplete. Review of the Note to Attending Physician/Prescriber, dated 3/20/24, indicated Resident #19 was prescribed as needed Benadryl, Cepacol, and Mucinex that have not been used in over 90 days and can lead to medication errors and potentially using expired medications. Physician/Prescriber response was blank and incomplete. Review of the Summary of Recommendations for DNS/Medical Director, dated for recommendations created between 4/1/24 and 4/16/24, indicated Resident #19 was taking Escitalopram 30 mg daily, and the recommended dosage should not exceed 10 mg per day in residents over [AGE] years of age. Further review indicated Resident #19 was prescribed as needed Benadryl that has not been used in over 90 days and can lead to medication errors potentially using expired medication. Review of the electronic and paper medical record failed to indicate the Pharmacy Consultant recommendation was reviewed or addressed by the facility. Based on interviews, record review, and policy review, the facility failed to ensure monthly Medication Regimen Review (MRR) recommendations made by the pharmacy consultant were addressed timely and maintained as part of the permanent medical record for three Residents (#21, #9, and #19), out of 5 residents selected for an unnecessary medication review. Specifically, the facility failed: 1. To ensure facility wide recommendations were addressed timely and maintained as part of the medical record; 2. For Resident #21, to ensure the January, February, and March 2024 consultant pharmacist recommendations were acted upon timely and to ensure the January, February, March, and April 2024 consultant pharmacist recommendations were maintained as part of the permanent medical record; 3. For Resident #9, to ensure the April 2024 consultant pharmacist recommendations were maintained as part of the permanent medical record and acted upon timely for Abnormal Involuntary Movement Scale (AIMS) testing to be completed; and 4. For Resident #19, to ensure January 2024, February 2024, March 2024, and April 2024 consultant pharmacist recommendations were maintained as part of the permanent medical record and acted upon timely to decrease dosage of Escitaloram (an antidepressant) medication. To ensure March 2024 consultant pharmacist recommendations were maintained as part of the permanent medical record and acted upon timely to re-evaluate need for Benadryl (anti-itch), Cepacol (throat lozenge), and Mucinex (an expectorant) medications. Findings include: Review of the facility's policy titled Medication Regimen Review, dated as effective January 2024, indicated but was not limited to the following: -The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy. -The findings for the offsite MRR are phoned, faxed, or emailed timely to the Director Nursing (DON) or designee and are documented and stored with the other Consultant Pharmacist recommendations in the resident's active record. -The prescriber is notified of the consultant findings applicable to the prescriber by the facility in a timely manner to allow the prescriber sufficient time to respond prior to the next monthly consultant visit. -Recommendations are acted upon and documented by the facility staff and/or the prescriber. a. Prescriber accepts and acts upon suggestion or rejects and provides an explanation including medical rationale for disagreeing. 1. During an interview on 5/7/24 at 12:04 P.M., the Director of Nurses (DON) said she did not have copies of previous monthly MRRs (December 2023-March 2024). She said she did not know where they were and said they were not kept as part of the resident's medical record once addressed. Additionally, she said only the admission review is scanned into the record. The DON said she had to call the pharmacy to get copies of the previous MRR reviews to make a binder for 2024 even though many of them were not done. Review of the MRR binder provided indicated but was not limited to the following: -January and February 2024 review reports were all unsigned. -March 2024 reviews were signed 5/3/24. -April 2024 reviews were signed 5/3/24. Review of the Executive Summary of the Consultant Pharmacists Monthly Visits indicated but were not limited to the following: -12/21/23: Residents Reviewed 43; Recommendations forwarded to the Physician were 23 and Nursing 4; The three most prevalent areas of focus were Psychotropic Management, Deprescribing Initiative, and Unused as needed (PRN) medication. The care center's follow up of last visit's recommendations was determined to be 44.4%. -1/19/24: Residents Reviewed 48; Recommendations forwarded to the Physician were 33 and Nursing 4; The three most prevalent areas of focus were Psychotropic Management, Deprescribing Initiative, and Risk/benefit documentation. The care center's follow up of last visit's recommendations was determined to be 11.5%. -2/14/24: Residents Reviewed 52; Recommendations forwarded to the Physician were 24 and Nursing 3; The three most prevalent areas of focus were Psychotropic Management, Unused as needed (PRN) Medications, and Risk/benefit documentation. The care center's follow up of last visit's recommendations was determined to be 53.3%. -3/20/24: Residents Reviewed 50; Recommendations forwarded to the Physician were 34 and Nursing 2; The three most prevalent areas of focus were Psychotropic Management, Unused PRN Medications, and Deprescribing Initiative. The care center's follow up of last visit's recommendations was determined to be 12.5%. -4/16/24: Residents Reviewed 55; Recommendations forwarded to the Physician were 37 and Nursing 6; The three most prevalent areas of focus were Psychotropic Management, Deprescribing Initiative, and Unused PRN Medications. The care center's follow up of last visit's recommendations was determined to be 32.3%. In summary 11.5% - 53.3% of recommendations were addressed by the facility in the five monthly summaries reviewed. During an interview on 5/7/24 at 12:04 P.M., the DON said the MRR recommendations should be given to the provider and addressed timely, scanned into medical record after they have been completed, and a progress note should be written. She said her expectation for all recommendations to be addressed within a week or so but certainly before the next review. Additionally, she said right now there is no tracking method in place to ensure all the recommendations have been addressed. 2. Resident #21 was admitted to the facility in January 2024 with diagnoses including unspecified dementia with agitation, adjustment disorder with mixed anxiety and depressed mood, and insomnia. Review of the Minimum Data Set (MDS) assessment, dated 4/10/24, indicated Resident #21 had severe cognitive impairment as evidenced by a score of 6 out 15 on the Brief Interview for Mental Status (BIMS) and took antipsychotic and antidepressant medications. Review of the Pharmacist's progress notes indicated recommendations were made 1/19/24, 2/13/24, 3/20/24, and 4/16/24. Review of the medical record (paper chart and electronic medical record) failed to indicate any of the recommendations had been completed and failed to indicate copies of signed/completed recommendations were filed or scanned into the record. The surveyor requested copies of the MRR from the DON for 1/19/24, 2/13/24, 3/20/24, and 4/16/24 for Resident #21 on 5/7/24 at 3:53 P.M. During an interview on 5/7/24 at 3:53 P.M., the DON said she had the March and April recommendations as she just had those addressed. She said she did not have the ones previous and would call the pharmacy to have them sent over. The MRRs provided by the DON indicated but were not limited to the following: -1/19/24- This Resident is receiving an antipsychotic agent Seroquel. Please update the diagnosis for this medication in PCC (the electronic medical record). A list of appropriate diagnosis/conditions was part of the recommendation including Dementia with behavioral symptoms. The document was unsigned by the Physician. -2/13/24- This Resident is receiving an antipsychotic agent Seroquel. Please update the diagnosis for this medication in PCC. A list of appropriate diagnosis/conditions was part of the recommendation including Dementia with behavioral symptoms. The document was unsigned by the Physician. (SAME RECOMMENDATION FROM JANUARY 2024) -2/13/24- This Resident has an order for a psychoactive PRN Trazodone which has been in place without a stop date recorded. After 14 days, the use of this psychoactive PRN may be continued if it is determined that the benefit of treatment outweighs the potential/actual risk of the continued PRN therapy. Please consider discontinuing this medication or scheduling this medication if necessary. If this medication is continued as a PRN, a stop date or evaluation date must be added to the PRN order. The document was unsigned by the Physician. -3/20/24- This Resident is receiving an antipsychotic agent Seroquel. Please update the diagnosis for this medication in PCC. A list of appropriate diagnosis/conditions was part of the recommendation including Dementia with behavioral symptoms. (SAME RECOMMENDATION FROM JANUARY and FEBRUARY 2024). The document was signed by the Physician and dated 5/3/24 indicating a diagnosis of Dementia with Behavioral Symptoms. -3/20/24-This Resident has an order for a psychoactive PRN Trazodone which has been in place without a stop date recorded. After 14 days, the use of this psychoactive PRN may be continued if it is determined that the benefit of treatment outweighs the potential/actual risk of the continued PRN therapy. Please consider discontinuing this medication or scheduling this medication if necessary. If this medication is continued as a PRN, a stop date or evaluation date must be added to the PRN order. The document was signed by the Physician and dated 5/3/24 indicating the Resident was no longer on the PRN Trazodone. -4/16/24- Recommendation to discontinue an unused PRN and or lab work was addressed and signed by the Physician 4/17/24. In summary, the Consultant Pharmacist recommended adding an appropriate diagnosis for the use of an antipsychotic (Seroquel) in January, February, and March which was not addressed until 5/3/24 to add a diagnosis of Dementia with Behavioral Symptoms. During an interview on 5/7/24 at 12:04 P.M., the DON said the MRR recommendations should be given to the provider and addressed timely, scanned into medical record after they have been completed, and a progress note should be written. She said her expectation for all recommendations to be addressed within a week or so but certainly before the next review. Additionally, she said this diagnosis was not added to the Resident profile in PCC until 5/3/24 and it should have been addressed sooner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 5/6/24 at 10:20 A.M., the surveyor observed Nurse #4 place a package of SalonPas patches (medication used to treat pain) on top of Unit Two high side medication cart along with a clear plastic container, uncovered, unlabeled with two loose pills inside. Nurse #4 then locked her cart, and walked down the hallway, leaving the medication on top of the cart, out of view, unsecured and unattended. During an observation with interview on 5/6/24 at 10:21 A.M., Nurse #4 returned to the medication cart. Nurse #4 said the two loose pills were blood pressure medications for a resident that she could not administer because the resident's blood pressure was too low, and she needed to destroy them. She said the SalonPas patches were placed on top of the cart, because she needs to apply them to a resident. Nurse #4 said she is not supposed to leave medications unlocked and unattended and should have placed them inside the medication cart before she walked away. During an observation and interview on 5/6/24 at 3:14 P.M., the surveyor observed the medication cart on Unit two high side with Nurse #9 and made the following observations: -In the fourth drawer on the left-hand side: a small, clear plastic medication cup, uncovered and not labeled, which included: four loose pills. Nurse #9 said she does not know what medications are in the clear plastic cup, and medications are not supposed to be stored unlabeled and uncovered in the medication cart. During an interview on 5/6/24 at 3:19 P.M., Nurse #4 said she put the pills in the cup and stored them in the medication cart. She said the resident was not in their room when she attempted to administer them and forgot to destroy them prior to giving report to Nurse #9. During an observation and interview on 5/7/24 at 8:12 A.M., the surveyor observed the medication cart on Unit one high side with Nurse #3 and made the following observations: -In the top drawer: a small, clear plastic medication cup, uncovered, and not labeled which included: 5 loose pills. Nurse #3 said she does not know what the medication is, she just took count and report from the 11:00 P.M.-7:00 A.M. nurse and has not opened the top drawer yet. During an interview on 5/7/24 at 8:18 A.M., Nurse #8 said she had worked the 11:00 P.M.-7:00 A.M. shift and prepared a resident's medication, got called into another resident's room, and placed the container with the pills in the top drawer. She said she was going to administer the medications before she went home for the day. During an interview on 5/7/24 at 8:33 A.M., the DON said medications should be administered once prepared. She said her expectation is for the nurse to destroy the medications, document in the resident's record the medications were not given, notify the physician, and document the physician's response in a progress note. During an interview on 5/7/24 at 12:04 P.M., the DON said the medication and treatment carts should be locked when not in use, never left unattended, and medications should not be left on top of the medication cart. Based on observation, interview, and policy review, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed: 1. For Resident #50, to ensure the medications were administered under direct supervision and not left at the bedside; 2. To ensure medication and treatment carts on Unit One were locked when not in direct supervision of the licensed nurse; and 3. Ensure safe storage of medications and biologicals according to current standards of practice in 2 of 2 observed medication carts. Findings include: Review of the facility's policy titled Medication Administration-General Guidelines, dated as effective January 2024, indicated but was not limited to the following: -Medications are administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications. -Medications are administered in accordance with written/electronic orders of the prescriber. -When medications are administered by mobile cart taken to the resident's location, medications are administered at the time they are prepared. -Residents can self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. -The resident is always observed after administration to ensure that the dose was completely ingested. -Medications are not pre-poured either in advance of the med pass or for more than one resident at a time. -No medications are kept on top of the cart. Review of the facility's policy titled Storage of Medications, dated as effective January 2024, indicated but was not limited to the following: -Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. -Medication rooms, carts, and medication supplies are locked when not attended to by persons with authorized access. 1. Resident #50 was admitted to the facility in December 2023 with diagnoses including depression, alcohol dependence in remission, and alcoholic cirrhosis of the liver (severe liver disease causing the inability for the liver to function properly). Review of the Minimum Data Set (MDS) assessment for Resident #50 indicated he/she had moderate cognitive impairment as evidenced by a score of 12 out 15 on the Brief Interview for Mental Status (BIMS). The surveyor made the following observations: -5/2/24 at 11:44 A.M., Resident in his/her room, two plastic medication cups containing a slightly pale-yellow thick liquid. Each cup had approximately 30 milliliters (ml) in it. -5/2/24 at 1:58 P.M., Resident in his/her room, two plastic medication cups containing a slightly pale-yellow thick liquid. Each cup had approximately 30ml in it. -5/2/24 at 4:05 P.M., Resident in his/her room, two plastic medication cups containing a slightly pale-yellow thick liquid. Each cup had approximately 30ml in it. Review of the Physician's Orders for Resident #50 indicated but were not limited to the following: -Lactulose Oral Solution 10 grams/15 ml, give 60 ml by mouth three times a day related to Hepatic Failure, unspecified without coma (liver failure). Nursing to Monitor Resident taking medication. (1/22/24) Review of the Medication Administration Record (MAR) indicated but was not limited to the following: -Lactulose Oral Solution 10 grams/15 ml, give 60 ml by mouth three times a day related to Hepatic Failure, unspecified without coma (liver failure). -Nursing to Monitor Resident taking medication, had been signed off as administered 5/2/24 at 9:00 A.M. and 1:00 P.M. Review of the comprehensive care plan failed to indicate Resident #50 self-administered medications. Review of the medical record failed to indicate a Self-Administration Assessment Form had been completed. Further review of the physician's orders failed to indicate Resident #50 had an order to self-administer medications. Further review of the medical record indicated Resident #50 had recently (April 2024) been hospitalized for an elevated ammonia level resulting from hepatic encephalopathy (loss of brain function when a damaged liver does not remove the toxins from the blood). The lactulose helps to reduce ammonia levels in the body. The discharge summary indicated to ensure he/she is receiving the lactulose as prescribed. During an interview on 5/3/24 at 11:40 A.M., Nurse #3 said Resident #50 can self-administer and has an order. Additionally, she said she left the lactulose at the bedside yesterday. During an interview on 5/3/24 at 11:44 A.M., Nurse #2 said no residents on this unit self-administers medications. She said if they did, they would have an assessment and an order to self-administer. During an interview on 5/7/24 at 12:04 P.M., the Director of Nurses (DON) said Resident #50 should not have medication left at the bedside. Additionally, she said if a resident were to self-administer medications, they would need an assessment and an order to do so, and Resident #50 does not have those things. She said the nurses should be staying and observing him/her take the medication and if they refuse the medication the nurse should be documenting accordingly. 2. The surveyor made the following observations: -5/2/24 at 10:47 A.M., Unit One, Treatment Cart observed in the hallway, with drawers facing outward, unlocked, staff not in the vicinity of the cart, residents roaming the halls. -5/2/24 at 10:47 A.M., Unit One-High Side, Medication Cart observed in the hallway near room [ROOM NUMBER], with drawers facing outward, unlocked, staff not in the vicinity of the cart, residents roaming the halls. Additionally, Resident from room [ROOM NUMBER] was standing next to the medication cart, agitated, and pacing around the cart. -5/2/24 at 12:00 P.M., Unit One, Treatment Cart observed in the hallway, with drawers facing outward, unlocked, staff not in the vicinity of the cart, residents roaming the halls. -5/3/24 at 8:30 A.M., Unit One, Treatment Cart observed in the resident day room, with drawers facing outward, unlocked, staff not in the vicinity of the cart, residents roaming the halls with access to the day room. At 8:36 A.M. and 9:00 A.M., the treatment cart remained unlocked in the resident day room. -5/3/24 at 11:00 A.M., Unit One-Low Side, Medication Cart observed in the hallway near nurses' station, with drawers facing outward, unlocked, nurse was sitting behind the desk unable to see the drawers of the medication cart, residents were roaming the halls. The nurse got up several times and failed to lock the medication cart until it was moved down the hallway at 11:33 A.M. During an interview on 5/3/24 at 11:40 A.M., Nurse #3 said the medication and treatment carts should be locked when the nurse is not with the cart. During an interview on 5/7/24 at 12:04 P.M., the DON said the medication and treatment carts should be locked when not in use and never left unattended where residents have access to them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, the facility failed to provide education, assess for eligibility, and offer pneumococcal vaccinations per facility policy and the Centers for Disease Control and Prevention (CDC) recommendations for three Residents (#9, #13, and #34), out of a total sample of five residents reviewed for immunizations. Findings include: Review of the facility's policy titled Pneumococcal Vaccine, updated May 2023, indicated but was not limited to the following: -It is the policy of this facility to offer and administer pneumococcal Vaccine to eligible individuals who consent for vaccination. -Vaccination for adults ages 19 through [AGE] years old with certain chronic medical conditions or risk factors. The CDC [Centers for Disease Control and Prevention] recommends vaccination for those with any of these conditions and risk factors: -Chronic lung disease, including chronic obstructive pulmonary disease, emphysema, and asthma. -Residents will be screened for needing vaccine, and if deemed appropriate will be offered the vaccine. -Vaccine information sheets will be provided to those who accept or decline vaccination. -Resident/Responsible party must sign or give verbal consent for vaccine prior to administration. -MD order for vaccine administration will be obtained. Review of the CDC website titled Pneumococcal Vaccine Timing for Adults (cdc.gov), dated 3/15/23, indicated but was not limited to the following: -For adults 65 and over who have not had any prior pneumococcal vaccines, then the patient and provider may choose Pneumococcal conjugate vaccine (PCV) 20 or PCV15 followed by Pneumococcal polysaccharide vaccine (PPSV) 23 one year later. -For adults 65 and over who has had Pneumococcal Conjugate Vaccine 13 (PCV13) and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) and it has been 5 years or greater since the last Pneumococcal Vaccination, then the patient and the vaccine provider may choose to administer the 20-Valent Pneumococcal Conjugate Vaccine (PCV20). 1. Resident #9 was admitted to the facility in April 2024 and was [AGE] years old. Review of the immunization record failed to indicate Resident #9 had previously received any pneumococcal vaccinations. Review of the medical record indicated a consent form for the Pneumococcal Vaccine, that was blank and incomplete. Further review of the record failed to indicate documentation of screening, assessment for eligibility to receive the pneumococcal vaccine, the provision of education related to the vaccine, and administration of the vaccine in accordance with facility policy and CDC recommendations. 2. Resident #13 was admitted to the facility in August 2022 and was [AGE] years old. Review of the immunization record indicated Resident #13 received the Pneumococcal Vaccine 23 in May 2012, and was eligible to receive the Pneumococcal Conjugate Vaccine PCV20 per CDC recommendations. Review of the medical record indicated a consent form for the Pneumococcal Vaccine, that was blank and incomplete. Further review of the record failed to indicate any documentation of screening, assessment for eligibility to receive the pneumococcal vaccine, the provision of education related to the vaccine, and administration of the vaccine in accordance with facility policy and CDC recommendations. 3. Resident #34 was admitted to the facility in March 2024 and was [AGE] years old with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Review of the immunization record failed to indicate Resident #34 had previously received any pneumococcal vaccinations. Review of the medical record indicated a consent form for the Pneumococcal Vaccine, that was blank and incomplete. Further review of the record failed to indicate any documentation of screening, assessment for eligibility to receive the pneumococcal vaccine, the provision of education related to the vaccine, and administration of the vaccine in accordance with facility policy and CDC recommendations. During an interview on 5/7/24 at 2:50 P.M, the Infection Preventionist Nurse (IPN) said the admitting nurse has the residents sign the consent for vaccination upon admission, once signed they are placed in the medical record. She said she follows up with the residents within one to two days after admission, enters the order for the vaccine, and completes a progress note. The surveyor and IPN reviewed Residents #9, #13, and #34's medical records together. IPN said Residents #9, #13, and #34 consents for vaccination were blank and incomplete. She said all three residents were missing documentation of screening, assessment for eligibility, and education on the risks versus the benefits of receiving the vaccination. She said all three residents are not up to date with their Pneumococcal vaccine as they should be per facility policy.

Based on record review and interview, the facility failed to electronically submit direct care staffing data to Centers for Medicare and Medicaid Services (CMS) for the entire reporting period, Fiscal Year (FY) Quarter 1 2024 (October 1 - December 31) in accordance with the schedule specified by CMS. Findings include: Review of the CMS Payroll Based Journal (PBJ) Staffing Data Report, CASPER Report 1705D, indicated the facility failed to submit data for the quarter. During an interview on 5/8/24 at 7:44 A.M., the Nursing Staff Scheduler said she did not know who did the PBJ reporting. During an interview on 5/8/24 at 12:38 P.M., Consulting Staff #5 said in reviewing the data sent to him from the facility it appears the data from October 1-15 was missing. He said the first 15 days of data were missing from the previous owners and that is probably why it got kicked back. Additionally, he said he was going to look into it further. During an interview on 5/8/24 at 1:18 P.M, Consulting Staff #5 said the previous owners did not file the data for October 1-15 as they should have and therefore that data submission was incomplete. During an interview on 5/8/24 at 3:00 P.M., the Administrator said he was unaware of the reporting status prior to his employment start date and deferred questions to Consulting Staff #4. During an interview on 5/8/24 at 3:00 P.M., Consulting Staff #4 said the previous owners should have submitted the data and he was unsure why it was not done.

Based on observation, document review, policy review, and interviews, the facility failed to: 1. Maintain an infection prevention and control program with a complete system of surveillance to identify any trends of actual or potential infections within the facility; 2. For Resident #36, ensure staff wore personal protective equipment (PPE) as required for Enhanced Barrier Precautions (EBP); 3. For Resident #160, ensure EBP were implemented, and PPE was utilized when providing high contact resident care; and 4. Ensure policy and procedures for EBP were developed and implemented, effective 4/1/24 as required. Findings include: Review of the facility's policy titled Infection Prevention and Control Program, undated, indicated but was not limited to the following: - The facility maintains an organized, effective facility-wide program to systematically identify and reduce the risk of acquiring and transmitting infections among residents, visitors, volunteers and healthcare workers. The program is interdisciplinary in design and works in collaboration with other programs and services within the facility. - Ongoing surveillance is recognized as a fundamental component of a strong effective infection control and prevention program. The Infection Preventionist will perform ongoing surveillance to identify opportunities to prevent and/or reduce the rate of infections within residents, employees, and visitors. - The McGeer criteria will be used to standardize the definition and criteria for infection. - Standardized logs will be used for line listing infections throughout the month. These will be reviewed regularly by the facility Infection Control Preventionist for any trends that need to be addressed before the monthly infection control report. - Surveillance activities will be ongoing and documented for the purpose of tracking, trending and identifying needs. - Surveillance will include information collected by either concurrent or retrospective review of resident records, review of microbial reports, reports from resident care providers, families, and review of other documents as appropriate. - Surveillance activities will include employee, visitor, and resident practices as they relate to unprotected exposure to communicable diseases including but not limited to Influenza, gastrointestinal virus, and COVID-19. Review of the facility's policy titled Enhanced Barrier precautions, dated 5/3/24, indicated but was not limited to the following: - It is the policy of this facility to implement enhanced barrier precautions - Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs gown and gloves use during high contact resident care activities. - An order for EBP will be obtained for residents with any of the following: Wounds, and/or indwelling medical device, even if the resident is not known to be infected or colonized with a Multidrug-resistant organism - PPE for EBP is only necessary when performing high-contact care activities - Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. - High-contact resident care activities include: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, wound care (any skin opening requiring a dressing) - EBP should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. 1. Review of the facility's surveillance sheets titled Antibiotic Use Tracking Sheet for the months of February 2024, March 2024, and April 2024 indicated the following: -The February 2024 tracking sheet 3 out of 6 residents met McGeer criteria for infection and 6 out of 6 residents were started on antibiotics -The March 2024 tracking sheet 4 out of 5 residents met McGeer criteria for infection and 5 out of 5 residents were started on antibiotics -The April 2024 tracking sheet 6 out of 6 residents met McGeer criteria for infection and all were started on antibiotics The surveillance data sheets failed to indicate any tracking or trending of illness, not prescribed antibiotics, for surveillance of the potential spread of illnesses. During an interview on 5/7/24 at 12:17 P.M., the Infection Preventionist (IP) said she completes surveillance for COVID-19 and Influenza outbreaks but does not keep a line listing of illness on a day-to-day basis that do not require the use of antibiotics. During an interview on 5/7/24 at 3:10 P.M., the IP said she reviews the resident progress notes every day for signs or symptoms of an infection, but she does not document the information anywhere. She said there is no system of surveillance to identify any potential spread of illnesses. 2. Resident #36 was admitted to the facility in December 2021 with diagnoses including Type 2 diabetes and chronic osteomyelitis (infection of bone tissue). Review of the active Physician's Orders, dated 5/4/24, indicated: - Enhanced Barrier Precautions, please use enhanced barrier precautions (gloves, gown) during all close contact resident care every shift for infection control. On 5/6/24 at 8:02 A.M., the surveyor observed Certified Nursing Assistant (CNA) #1 don (put on) gloves and enter Resident #36's room; the CNA was not observed to don a gown. A sign posted outside of the door indicated but was not limited to the following: Stop; Enhanced Barrier Precautions; Providers and staff must wear a gown and gloves for high contact care activities. Outside of the door was a clear plastic bin containing PPE (gloves and gowns). On 5/6/24 at 8:17 A.M., the surveyor observed CNA #1, open Resident #36's room door, doff his gloves in the trash located inside the Residents' room at the doorway, and exit the room. The surveyor then observed the trash in Resident #36's room by the doorway, inside the trash only used gloves were observed. During an interview on 5/6/24 at 8:22 A.M., CNA #1 said he just gave Resident #36 a bed bath and set him/her up for breakfast. He said he did not wear a gown only gloves to provide care because he/she is not on precautions. CNA #1 and the surveyor then reviewed the sign posted outside of the room together that indicated Enhanced Barrier Precautions; Providers and staff must wear a gown and gloves for high contact care activities. CNA #1 said no one told him Resident #36 was on precautions, and he did not notice the sign upon entering the room. During an interview on 5/6/24 at 10:32 A.M., Nurse #4 said Resident #36 is on EBP precautions for open wounds on his/her abdomen and requires a gown and gloves for all high contact care activities. During an interview on 5/6/24 at 10:48 A.M., Consulting Staff #3 said when residents are on precautions it is communicated to the CNAs in shift to shift report and written on the CNA care cards. She said precautions signs and PPE bins are placed outside of the rooms to alert staff of the precautions needed for that specific resident. Review of the CNA care card failed to indicate Resident #36 was on precautions. During an interview on 5/7/24 at 2:03 P.M., the Director of Nursing (DON) said CNA #1 did not wear the required PPE while providing care for Resident #36. She said assisting a resident with bathing is considered a high contact care activity and requires the use of a gown with gloves when Enhanced Barrier Precautions are in place. She said they just began utilizing EBP a couple of days ago and the staff development coordinator has not completed the education with all of the staff yet. 3. Resident #160 was admitted to the facility in April 2024 with diagnoses including retention of urine and gastrostomy status. Review of the Minimum Data Set (MDS) assessment, dated 4/23/24, indicated Resident #160 had a gastrostomy tube (feeding tube), and failed to indicate the Resident had a urinary catheter. The surveyor made the following observations: - 5/3/24 at 9:20 A.M., a therapist and CNA transferred Resident #160 from his/her bed into the wheelchair. Neither staff member had a gown on during the transfer. There was no EBP sign, nor any PPE aside from gloves available in the direct proximity of the Resident's room. After the transfer, the therapist wheeled the Resident off the unit. Review of the Physician's Orders failed to indicate an order for EBP. Review of the comprehensive care plan failed to indicate Resident #160 was on EBP. During an interview on 5/3/24 at 8:45 A.M., Nurse #2 said no one on this unit (Unit 1) is on EBP. During an interview on 5/3/24 at 9:10 A.M., Nurse #3 said EBP has something to do with residents having a catheter or feeding tube but said we don't do anything differently for them. She said she did not really understand it and requested Consulting Staff #2 speak with the surveyor. During an interview on 5/3/24 at 9:12 A.M., Consulting Staff #2 said the facility had not implemented EBP yet. During an interview on 5/3/24 at 12:31 P.M., the DON said they have not rolled out EBP yet. 4. Review of the Centers for Medicare and Medicaid Services (CMS), Quality, Safety, and Oversight (QSO) Reference #QSO-24-08-NH memo dated 3/20/24, indicated but was not limited to the following: -SUBJECT: EBP in Nursing Homes to prevent spread of multi-drug resistant organisms (MDROs). -In July 2022, the Centers for Disease Control (CDC) released recommendations for implementation of PPE use in nursing homes to prevent spread of MDROs, and therefore CMS is updating its infection prevention and control guidance accordingly. The recommendations now include the use of EBP during high contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status. -EBP are indicated for residents with wounds and/or indwelling medical devices. -Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. -EBP should be used for any resident who meets the above criteria, wherever they reside in the facility. -EBP is employed when performing the following high contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care. -Effective Date: 4/1/2024 The surveyor made the following observations on Unit 1: -No EBP signs or PPE carts/set ups were on the unit, except for one set, for a resident on Contact Precautions for an active infection. -During initial screening on the unit on 5/2/24, several residents were observed to have wounds and/or indwelling medical devices (pressure ulcer, Foley catheters and feeding tubes specifically). During an interview on 5/3/24 at 8:45 A.M., Nurse #2 said no one on this unit is on EBP. During an interview on 5/3/24 at 9:12 A.M., Consulting Staff #2 said the facility had not implemented EBP yet. During an interview on 5/3/24 at 12:31 P.M., the DON said they have not rolled out EBP yet. She said they got the memo, and it was supposed to be effective April 1, 2024. She said they have ordered more supplies, are getting the signs ready, and then they will do education. She said she did not have a policy at this time and Consulting Staff #1 was working on it. The facility policy titled Enhanced Barrier Precautions, dated 5/3/24, was provided by Consulting Staff #1 at the end of the business day on 5/3/24.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a been diagnosed with a deep vein thrombosis (DVT), with new orders from the Nurse Practitioner for an anticoagulant medication to be started, the Facility failed to ensure nursing notified Resident #1's Physician, when his/her medication was unavailable to be administered in accordance with his/her Physician orders, as a result Resident #1 did not receive his/her first scheduled dose, he/she was transferred to the Hospital Emergency Department (ED) for evaluation and was admitted . Findings include: The Facility Policy, titled Change in Resident's Condition or Status and Notification, date reviewed June 2022, indicated the following: -to ensure that the resident and/or his/her representative, and his/her attending Physician/Physician extender are notified of changes in the resident's medical/mental condition and/or status -the RN Nurse Supervisor/Charge Nurse will notify the resident's attending Physician, Physician extender or on-call Physician when there has been a significant change in the resident's medical/mental conditions and/or status including but not limited to: A need to alter the resident's treatment significantly -the Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical condition or status Resident #1 was admitted to the Facility in February 2024, diagnoses included atrial fibrillation (irregular heartbeat), hypertension, history of transient ischemic attack (TIA, mini stroke), chronic pain syndrome, mild cognitive impairment, muscle weakness, and hyperlipidemia (high cholesterol). Review of Resident #1's Nurse Practitioner Progress Note, dated 3/08/24, indicated that Resident #1's ultrasound report was positive for a DVT of his/her left lower extremity (LLE), and that Eliquis (anticoagulant) will be initiated. Review of Resident #1's Physician orders, dated 3/08/24, indicated there was a new order as follows: -Eliquis 5 mg by mouth twice a day times one week, then Eliquis 2.5 mg by mouth twice a day times six months Review of Resident #1's Medication Administration Record (MAR), for March 2024, indicated that on 3/09/24 Resident #1's Eliquis 5 milligrams (mg) was not administered at 8:00 A.M. as ordered, and Nurse #1 documented code 9 which indicated see nurses notes. Review of Resident #1's Nurse Progress Notes, on the following dates indicated: -3/09/24 at 06:15 A.M., late entry (by Nurse #3) Pharm delivered medications, but Eliquis was not in delivery -3/09/24 at 13:43 (1:43 P.M.) (written by Nurse #1) (Medication Administration Note) Eliquis oral tablet 5 mg, give 5 mg by mouth two times a day for DVT not available (therefore, was not administered). During an interview on 4/24/24 at 3:40 P.M., Nurse #1 said she worked 7:00 A.M. to 7:00 P.M. on 3/08/24 and 3/09/24 and was assigned to care for Resident #1. Nurse #1 said Resident #1 had an ultrasound of his/her LLE on 3/08/24 which were positive for a DVT. Nurse #1 said the NP was in the Facility, received the results of the ultrasound and she (NP) wrote new orders for Resident #1 to start Eliquis. Nurse #1 said she entered Resident #1's new medication orders into their electronic medical record system (Point Click Care/PCC) and said once the orders are entered they are sent (electronically transmitted) directly to Pharmacy A that the Facility uses. Nurse #1 said on 3/09/24, Resident #1's Eliquis medication was unavailable to administer to him/her at 8:00 A.M. because it had not been delivered from the Pharmacy and said she called the Pharmacy (could not recall who she spoke to) and was told the Eliquis would be delivered on the next scheduled delivery. Nurse #1 said she checked the Facility E-Kit (emergency medication supply) and Eliquis was not one of the medications available. Nurse #1 said she had not notified Resident #1's Physician that his/her Eliquis was not available to administer to him/her at 8:00 A.M. because the Pharmacy said it would be delivered on the next scheduled delivery. Nurse #1 said on 3/09/24 Resident #1's Family Member told her Resident #1 was having a lot of pain in his/her LLE, and when she looked at his/her LLE it was swollen and discolored. Nurse #1 said she then asked the MDS Coordinator to assess Resident #1's LLE and after the MDS Coordinator assessed Resident #1 she told Nurse #1 that Resident #1 needed to be sent to the Hospital ED because the Facility did not have Eliquis to administer to him/her. During an interview on 4/24/24 at 1:21 P.M., the Nurse Practitioner (NP) said she was at the Facility on 3/08/24 when Resident #1's ultrasound was done, and the imaging technician informed her that Resident #1's ultrasound of his/her left lower extremity looked positive for a DVT. The NP said she wrote orders for Resident #1 to start Eliquis for the DVT. The NP said said she was not notified on 3/09/24 by nursing that Resident #1's had not received his/her Eliquis, because it had not been delivered from the Pharmacy. The NP said Resident #1 was transferred to the Hospital ED on 3/09/24 due to increased LLE pain. During an interview on 4/25/24 at 1:38 P.M., the Minimum Data Set (MDS) Coordinator said on 3/09/24, Nurse #1 told her that Resident #1 had not received his/her Eliquis medication because she was waiting for the Pharmacy to deliver the medication and that Nurse #1 asked her to look at Resident #1's left leg. The MDS Coordinator said she assessed both of Resident's #1's legs and his/her left foot and ankle were mottled bluish purple in color and cool to touch. Review of Resident #1's Hospital Emergency Department Physician's Note, dated 3/09/24, indicated that Resident #1 was sent to the ED for evaluation of concerns for left foot pain, cyanosis, cool and appearing ischemic. The Note indicated Resident #1 was diagnosed with left popliteal (space behind knee joint) and left calf vein DVT's, was to be started on Eliquis, however he/she was not. The Note indicated that vascular surgery evaluated Resident #1, a Computed tomography angiogram of the abdomen with runoff was performed and showed Resident #1 had an acute arterial thrombosis involving his/her left leg. The Note indicated Resident #1 was admitted and he/she was taken to the operating room for an embolectomy (surgical removal of a blood clot) and emergent fasciotomy (procedure to relieve pressure in the muscle compartment). During an interview on 4/24/24 at 4:51 P.M., the Director of Nurses (DON) said the Nursing Supervisor notified her on 3/09/24 that Resident #1 had not received his/her Eliquis medication because it had not been delivered from the Pharmacy, he/she developed increased pain in his/her LLE with skin color changes and was being transferred to the Hospital ED for evaluation. The DON said she did not know if Nurse #1 had notified Resident #1's Physician when the Eliquis was unavailable to administer to him/her that day. The DON said if a medication is unavailable and has not been delivered from the pharmacy, she expects all nurses to notify the residents Physician.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a been diagnosed with a deep vein thrombosis (blood clot, DVT), with new orders from the Nurse Practitioner for an anticoagulant (blood thinner) medication to be administered, the Facility failed to ensure nursing notified the correct Pharmacy in order to obtain Resident #1's medication in a timely manner, as a result Resident #1 did not receive his/her first scheduled dose as ordered and he/she was transferred to the Hospital for evaluation. Findings include: The Pharmacy Policy, titled Provider Pharmacy Requirements, effective date January 01, 2021, indicated the following: -that regular and reliable pharmaceutical service is available to provide residents with prescription and nonprescription medications, services, and related equipment and supplies. -providing routine and timely pharmacy services as contracted, and emergency pharmacy service 24 hours per day, seven days per week -emergency or stat (immediately) medications are available for administration no more than four (4) hour(s) after the order is received by the pharmacy The Pharmacy Policy, titled Medication Ordering and Receiving from Pharmacy: Emergency Pharmacy Service and Emergency Kits, effective date January 01, 2021, indicated the following: -emergency pharmacy service is available on a 24-hour basis, emergency needs for medication are met by using the facility's approved emergency medication supply or by special order from the provider pharmacy and the provider pharmacy supplies emergency medications including emergency drugs -telephone/fax numbers for emergency pharmacy service are posted at nursing stations -the dispensing pharmacy supplies emergency or stat medications according to the provider pharmacy agreement Resident #1 was admitted to the Facility in February 2024, diagnoses included atrial fibrillation (irregular heartbeat), hypertension, history of transient ischemic attack (TIA, mini stroke), chronic pain syndrome, mild cognitive impairment, muscle weakness, and hyperlipidemia (high cholesterol). Review of Resident #1's Ultrasound Report, dated 3/08/24, indicated that Resident #1 had a deep vein thrombosis involving his/her left popliteal (joint in back of the knee) and upper calf veins. Review of Resident #1's Nurse Practitioner Progress Note, dated 3/08/24, indicated that Resident #1's ultrasound report was positive for a DVT of his/her left lower extremity (LLE), and that Eliquis (anticoagulant) will be initiated. During an interview on 4/24/24 at 1:21 P.M., the Nurse Practitioner (NP) said Resident #1 was having LLE pain with mild swelling, was tender to touch and she ordered an ultrasound of his/her LLE. The NP said she was at the Facility on 3/08/24 when Resident #1's ultrasound was done, and the imaging technician informed her that Resident #1's ultrasound of his/her LLE looked positive for a DVT. The NP said she wrote orders for Resident #1 to start Eliquis for the DVT. Review of Resident #1's Physician orders, dated 3/08/24, indicated he/she had a new order as follows: -Eliquis 5 mg by mouth twice a day times one week, then Eliquis 2.5 mg by mouth twice a day times six months. During an interview on 4/24/24 at 3:40 P.M., Nurse #1 said she worked 7:00 A.M. to 7:00 P.M. on 3/08/24 and 3/09/24 and was assigned to care for Resident #1. Nurse #1 said the NP wrote new orders for Resident #1 to start Eliquis. Nurse #1 said she entered Resident #1's new medication orders into their electronic medical record system (Point Click Care/PCC) and said once the orders are entered, they are sent (electronically transmitted) directly to Pharmacy A that the Facility uses, but said she had also called the Pharmacy with Resident #1's new orders. Nurse #1 said when she entered Resident #1's medications orders into PCC on 3/08/24 there was no drop-down box to choose the Pharmacy (A or B) because the drop-down box does not show up when new orders are entered. Nurse #1 said she never saw Pharmacy B listed when she entered Resident #1's new medication orders. During an interview on 4/24/24 at 2:47 P.M., Nurse #2 said new medication orders for residents are entered into Point Click Care (PCC, the facility's electronic medical record system) under the order medications tab, and that once the medication(s) order is entered into the PCC system it is then sent (electronically transmitted) directly to the Pharmacy. Nurse #2 said there were two Pharmacies listed in the PCC system, Pharmacy A and Pharmacy B and the Facility only deals with Pharmacy A. Nurse #2 said nurses have to click the pharmacy drop- down box, choose Pharmacy A and said that if a nurse chooses Pharmacy B, then Pharmacy A would not receive the medication order. Review of Resident #1's Medication Administration Record (MAR), for March 2024, indicated that on 3/09/24 Resident #1's Eliquis 5 milligrams (mg) per his/her Physician orders was not administered at 8:00 A.M., Nurse #1 documented code 9 which indicated see nurses notes. Review of Resident #1's Progress Notes, on the following dates indicated: -3/09/24 at 06:15 A.M., late entry (written by Nurse #3) Pharm delivered medications but Eliquis was not in delivery -3/09/24 at 13:43 (1:43 P.M.) (written by Nurse #1) (Medication Administration Note) Eliquis oral tablet 5 mg, give 5 mg by mouth two times a day for DVT, not available (and therefore was not administered). Further review of Resident #1's medical record, indicated there was no documentation to support Nurse #1 called Pharmacy A on 3/09/24 to check on when Resident #1's Eliquis medication was due to be delivered. During an interview on 5/02/24 at 1:24 P.M., the Nursing Supervisor said she worked 11:00 A.M. to 11:00 P.M. on 3/09/24 and she notified the Director of Nursing (DON) that Resident #1 had not received his/her Eliquis because it had not been delivered from the Pharmacy and he/she had increased pain to his/her LLE with skin color changes. The Nursing Supervisor said she told the DON Resident #1 was being transferred to the Hospital Emergency Department for evaluation. Review of email correspondence between the Facility's Chief Nursing Officer and the Director of Clinical Pharmacy Services & Education (Pharmacy A) indicated the following: -On 4/01/24 at 11:11 A.M., Chief Nursing Officer sent an email to the Director of Clinical Pharmacy Services & Education stating that she was doing a chart review and asked if the Director could look into why there was a delay in receiving Resident #1's Eliquis medication. -On 4/01/24 at 11:27 A.M., the Director of Clinical Pharmacy Services & Education responded to the Chief Nursing Officer saying, that it looks as if we received two orders for Eliquis on 3/08/24. One for 2.5 mg twice a day (BID) profile only and one for 5 mg BID profile only. When our pharmacist went into Point Click Care (PCC) to view the orders, it appears whomever entered the orders selected Pharmacy B as the dispensing pharmacy, which automatically makes these orders profile only, so we do not see and/or fill them. During an interview on 4/24/24 at 4:35 P.M., the Chief Nursing Officer (CNO) said she was reviewing Resident #1's medical record because there was a delay in receiving his/her Eliquis medication from the Pharmacy. The CNO said she contacted the Pharmacy A Director via email and was told the orders for Resident #1's Eliquis were profile only, so the Pharmacy had not filled the order. Review of Resident #1's Scheduling/Source Order Details Report, indicated that Nurse #1 entered Resident #1's Eliquis medication orders on 3/08/24 and Pharmacy B was listed not Pharmacy A. During an interview on 4/24/24 at 4:51 P.M., the Director of Nurses (DON) said Resident #1 had an ultrasound of his/her lower left extremity (LLE) on 3/08/24 and the results were positive for a DVT, and the NP ordered Eliquis to be started. The DON said the Nursing Supervisor notified her on 3/09/24 that Resident #1 had not received his/her Eliquis medication because it had not been delivered from the Pharmacy. The DON said on 3/11/24, she reviewed Resident #1's Eliquis medication order in the PCC system and discovered there were two Pharmacies listed in the Pharmacy drop-down box and if Nurse #1 had not clicked the Pharmacy drop-down box to choose Pharmacy A, then the Pharmacy would not have received Resident #1's order for Eliquis. The DON said the Pharmacy that was listed on Resident #1's Eliquis order was Pharmacy B, and not Pharmacy A which was pharmacy the Facility used. The DON said spoke to Nurse #1 and that Nurse #1 told her she (Nurse #1) had not realized there were two Pharmacies listed when she entered Resident #1's order for the Eliquis into the PCC system. The DON said if a medication is unavailable and has not been delivered from the pharmacy, she expects all nurses to call the Pharmacy and notify the residents Physician.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was moderately cognitively impaired and required extensive physical assistance by staff to meet his/her care needs, the Facility failed to ensure that nursing staff notified his/her providers (Physician #1 and/or Nurse Practitioner (NP) #1) when on 06/10/23, Resident #1 was noted to have new areas of bruising, and around that same time that the bruises were found, Resident #1 reported an incident that had occurred during care provided by a staff member, which was concerning for the potential of physical abuse. Findings include: The Facility Policy, titled Abuse Prohibition dated as updated 02/20/23, indicated the following: - all allegations of abuse will be reported and thoroughly investigated, and -the physician will be notified immediately. Resident #1 was admitted to the Facility in February 2022, diagnoses included chronic respiratory failure with hypoxia, anxiety disorder, and muscle weakness. Review of Resident #1's Minimum Data Set (MDS) Quarterly Assessment, dated 04/07/23, indicated he/she had moderate cognitive impairment, and required extensive assist of one staff member for transfers. Review of the Report submitted by the Facility via Health Care Facility Reporting System (HCFRS), dated 06/22/2033, indicated that Resident #1 was found to have bilateral bruises on his/her upper thighs, and it was alleged that Certified Nurse Aide (CNA) #1 handled him/her roughly during a toilet transfer. The Report indicated that the Physician was notified. However, review of Resident #1's Medical Record indicated there was no documentation to support that Physician #1 or NP #1 had been notified of the allegation, and/or the bruises found on Resident #1 on 06/10/23 at 12:45 A.M. During an interview on 07/07/23 at 9:21 A.M., Nurse Practitioner (NP )#1 said she was not notified about bruises found on Resident #1's thigh and arm on 06/10/23, or of an allegation of potential physical abuse. NP #1 said she and Physician #1 are Resident #1's primary providers, and staff typically notify her first about issues, but in this case they had not. NP #1 said she and/or Physician #1 typically document and follow up with a resident after they have been notified of such issues. NP #1 said she had not seen any documentation that indicated Physician #1 had been notified either. NP #1 said the Facility should have notified them, but had not. During an interview on 07/07/23 at 2:37 P.M., Physician #1 said he was not notified about bruises found on Resident #1's thigh and arm or of an allegation of potential physical abuse on 06/10/23. During an interview on 07/17/23 at 10:30 A.M., Nursing Supervisor #1 said she had not notified Physician #1 or NP #1 after she became aware of the bruises on Resident #'s left inner thigh and left upper arm, or of Resident #1's allegation of physical abuse. Nursing Supervisor #1 said she should have notified either Physician #1 of NP #1, but had not. During an interview on 07/11/23 at 10;30 A.M., the Director of Nurses (DON) said she was on vacation at the time of the alleged incident, but gave Nursing Supervisor #1 a list of tasks, which included notifying the Physician/Nurse Practitioner. The DON said when she entered the information regarding the incident into HCFRS, she indicated that the Physician was notified, since she had given direction to Nursing Supervisor #1 to do so. The DON said she could not provide documentation to support the Physician #1 or NP #1 were notified of the bruises and/or allegation of potential physical abuse involving Resident #1. The DON also said that since the alleged incident occurred on a weekend, when called Physician #1 and NP #1's office, she was told that Physician #1's on-call service had not been notified either, but should have been.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was moderately cognitively impaired and required extensive physical assistance by staff to meet his/her care needs, the Facility failed to ensure that staff implemented and followed steps identified in the facility abuse policy related to abuse prevention, when on 06/10/23, Resident #1 was noted by nursing to have new areas of bruising, and when asked by staff how he/she got the bruises, Resident #1 alleged that a staff member threw him/her on the toilet because he/she was not moving his/her feet fast enough, however, the facility administration was not immediately notified of the potential abuse allegation, and the local police were also not notified. as required. Findings include: The Facility Policy, titled Abuse Prohibition dated as updated 02/20/23, indicated the following: - all allegations of abuse ill be reported and thoroughly investigated, - any employee who has reasonable cause to believe a resident has been abused, mistreated, or neglected shall immediately report alleged incidents to their supervisor, Director of Nurses (DON) or Administrator, -the physician will be notified immediately, -the Administrator is responsible for ensuring that there has been notification to local law enforcement within two hours after identification of the alleged/suspected incident, and -any employee who fails to report an incident of abuse immediately to the appropriate supervisor will receive disciplinary action, may result in termination as this is a Zero Tolerance policy; reporting is mandatory. Resident #1 was admitted to the Facility in February 2022, diagnoses included chronic respiratory failure with hypoxia, anxiety disorder, and muscle weakness. Review of Resident #1's Minimum Data Set (MDS) Quarterly Assessment, dated 04/07/23, indicated he/she had moderate cognitive impairment, and required extensive physical assistance of one staff member for transfers. Review of the Report submitted by the Facility via Health Care Facility Reporting System HCFRS), dated 06/22/23 indicated that Resident #1 was found to have bilateral bruises on his/her upper thighs, and it was alleged that Certified Nurse Aide (CNA) #1 handled him/her roughly during a toilet transfer. The Report indicated that the Police were not notified. During an interview on 07/17/23 at 10:30 A.M., and review of Nursing Supervisor #1's Written Witness Statement, undated, Nursing Supervisor #1 said that on 06/10/23 at the start of her shift (7:00 A.M. to 7:00 P.M.) the night nurse (later identified as Nurse #1), and CNA #2 told her that Resident #1 had two bruises and made statements that were concerning. Nursing Supervisor #1 said Resident #1 told her that, Sometimes I don't move fast enough, and they just swing me into the chair. Nursing Supervisor #1 said she observed two bruises on Resident #1, one oval shaped bruise on his/her left inner thigh, and one round bruise on his/her left inner biceps. Nursing Supervisor #1 said she notified the DON immediately, but did not call the Police, and did not call Physician #1 of NP #1, but should have. Nursing Supervisor #1 said she had not documented Resident #1's bruises or anything related to the allegation of physical abuse, in his/her medical record, but should have. During an interview on 07/06/23 at 2:00 P.M., and 07/11/23 at 10:30 A.M., the Director of Nurses (DON) said Nursing Supervisor # 1 notified her on 06/10/23 in the morning, that bruises were noticed on Resident #1 during the overnight shift, and that Resident #1 said he/she had been thrown on the toilet. The DON said she immediately reported the incident as a physical abuse allegation, and gave Nursing Supervisor #1 directions on how to proceed via phone. The DON said on 06/10/23, sometime around 7:00 A.M., Nursing Supervisor #1 reported that Nurse #1 and CNA #2 had just told her that Resident #1 had bruises and there was an allegation of physical abuse. The DON said however, that Nurse #1 should have called her immediately when she became aware of the bruises and the allegation on 06/10/23 at 12:45 A.M., but had not. The DON also said she was on vacation at the time of the alleged incident, but gave Nursing Supervisor #1 specific instructions regarding what to do about the the allegation, which included notifying the Police, but she had not. Review of Resident #1's Medical Record indicated there was no documentation to support that Nurse #1 notified the Director of Nurses (DON) or the Administrator (during the overnight shift on 6/09/23 into 6/10/23) after she became aware at approximately 12:45 A.M., of an allegation that he/she had potentially been physically abused by a staff member. Further review of the Record indicated there was no documentation to support the Facility notified the Police of the allegation of potential physical abuse prior to the day of the survey (07/06/23). During an interview on 07/06/23 at 12:24 P.M. and review of Certified Nurse Aide (CNA) #2's Written Witness Statement, dated 06/09/23, CNA #2 said she worked on Resident #1's unit during the night shift that started at 11:00 P.M on 06/09/23 and ended at 7:00 A.M. on 06/10/23. CNA #2 said she provided care for Resident #1 at approximately 12:45 A.M. (6/10/23) and said she noticed a bruise on his/her thigh. CNA #2 said Resident #1 told her that a CNA (later identified as CNA #1) transferred him/her to the toilet a morning or so prior (exact date unknown), and was rough. CNA #2 said she notified Nurse #1 immediately. Review of Nurse #1's Written Witness Statement, dated 06/10/23 at 12:45 A.M., indicated that CNA #2 notified her of bruising on Resident #1. The Statement indicated that Nurse #1 noted a bruise on Resident #1's inner thigh, measuring 4 centimeters (cm) by 10 cm, and a bruise on his/her left inner biceps (upper arm), measuring 1 cm by 1 cm. The Statement indicated that Resident #1 told Nurse #1 that he/she was in the bathroom with CNA #1 and he/she had not moved fast enough, so CNA #1 pushed him/her, and his/her leg hit the bar. However, review of Resident #1's Medical Record indicated there was no documentation to support Nurse #1 wrote a progress note regarding the bruises. The Surveyor was unable to interview Nurse #1 as she did not respond to the Department of Public Health telephone call or letter requests for an interview. During an interview on 07/06/23 at 3:31 P.M., Corporate Nurse #1 said the Police were not notified of the allegation of potential physical abuse involving Resident #1 until the day of survey and said they should have been notified immediately after the allegation was made. Corporate Nurse #1 said once Nurse #1 was made aware of the bruising on Resident #1 and the allegation of potential physical abuse, she should have notified the DON immediately, but she did not. Corporate Nurse #1 said Physician #1 and/or NP #1 should also have been notified of the bruises and allegation, but said she could not provide documenation to support this was done. During an interview on 07/11/23 at 11:15 A.M., the Staff Development Coordinator (SDC) said that staff have been instructed to notify the DON or Administrator immediately if they witness or suspect abuse. The SDC said no one called the Police regarding Resident #1's allegation, but they should have. During an interview on 07/06/23 at 11:13 A.M., the Administrator said he was not involved in the investigation, and said he thought the bruises were noticed by Nursing Supervisor #1 on 06/10/23. The Administrator said he did not see CNA #2's Written Witness Statement that indicated she noticed bruises on Resident #1's inner thigh and left upper arm on 06/10/23 at 12:45 A.M. The Administrator said he also did not see Nurse #1's Written Witness Statement that indicated CNA #2 reported the bruises to her on 6/10/23 at 12:45 A.M. and that Resident #1 told Nurse #1 that CNA #1 pushed him/her during a transfer and his/her leg hit the bar. The Administrator said Nurse #1 should have called the DON immediately when she saw the bruises and was made aware of the allegation of potential physical abuse, but she had not. The Administrator said he did not think the Police had been called, and said per facility policy, they should have been. During the course of the investigation, which included staff interviews, review of staff members written statements, and the facility HCFRS Report, the Surveyor noticed discrepancies regarding the location of the new areas of bruising noted on Resident #1, (bilateral thighs verses left upper thigh and left biceps). The DON and other staff members could not speak to the discrepancies, and the Facility could not provide any further documentation to clarify the exact location of the bruises.

Based on records reviewed and interviews, for one of three sampled residents (Resident #) who was moderately cognitively impaired and required extensive physical assistance by staff to meet his/her care needs, who on 06/10/23 was noted by nursing to have new areas of bruising and had made an allegation of potential physical abuse by a Certified Nurse Aide (CNA), the Facility failed to ensure they obtained and maintained evidence that their investigation was conducted in a manner consistent with Federal Regulations and Facility Policies, which included ensuring their investigation was thorough. Findings include: The Facility Policy, titled Abuse Prohibition dated as updated 02/20/23, indicated the following: -the Administrator and Director of Nursing are responsible for investigation and reporting, -all allegations of abuse will be reported and thoroughly investigated, -the investigation will begin immediately after reporting the actual or suspected incident, -the investigation should be thorough with witness statements from staff, residents, visitors, and family members who may be interviewable and have information regarding the allegation, Resident #1 was admitted to the Facility in February 2022, diagnoses included chronic respiratory failure with hypoxia, anxiety disorder, and muscle weakness. Review of Resident #1's Minimum Data Set (MDS) Quarterly Assessment, dated 04/07/23, indicated he/she had moderate cognitive impairment, and required extensive assist of one staff member for transfers Review of the Report submitted by the Facility via Health Care Facility Reporting System HCFRS), dated 06/22/23 indicated that Resident #1 was found to have bilateral bruises on his/her upper thighs, and it was alleged that Certified Nurse Aide (CNA) #1 handled him/her roughly during a toilet transfer. The Report indicated that the Police were not notified. The Facility was unable to provide statements or interviews from other residents, or from staff who worked shifts prior to when CNA #2 noticed new areas of bruising (on Resident #1's inner thigh and upper arm) despite being told by Resident #1 that the bruises were a result of a toilet transfer a morning or so prior (to 06/10/23 at 12:45 P.M.). Review of the Resident #1's Medical Record indicated there was no documentation to support that he/she was immediately assessed by nursing or monitored by nursing or any other discipline after the bruises were observed, and the allegation of potential physical abuse was made. Review of Resident #1's Skin Assessment, dated 06/04/23, indicated he/she did not have any open areas or marks on his/her skin. Review of Resident #1's Skin Assessment, dated 06/10/23, indicated he/she did not have any open areas or marks on his/her skin. Review of an the Facility Incident Report (not part of medical record), dated 06/10/23 at 10:11 A.M., indicated that Nursing Supervisor #1 documented that Resident #1 had a bruise on his/her left inner thigh and left upper arm. The Report also indicated that Resident #1 said, Sometimes my legs don't work and they have to swing me into the seat. However, review of Resident #1's Medical Record indicated neither Nurse #1 or Nursing Supervisor #1 had not documented the new bruises including the measurements of the areas in a progress note. During an interview on 07/06/23 at 3:31 P.M., Corporate Nurse #1 said she was unable to find any documentation in Resident #1's Medical Record related to bruising on his/her thigh or arm noted on 06/10/23. Corporate Nurse #1 said she was also unable to find any documentation to support that Nursing staff had assessed Resident #1 following the allegation of potential physical abuse on 06/10/23. Corporate Nurse #1 said Nurse #1 should have documented measurements and locations of the bruises in the medical record, but she had not. During an interview on 07/06/23 at 2:00 P.M., and 07/11/23 at 10:30 A.M., the Director of Nursing (DON) said Nursing Supervisor # 1 notified her on 06/10/23 in the morning, that bruising was noticed on Resident #1 during the overnight shift, and that Resident #1 said he/she had been thrown on the toilet. The DON said Resident #1 identified CNA #1 as the accused, and said she had no documentation to support this and/or who Resident #1 reported this information to. The DON said she could not find any documentation in Resident #1's Medical Record to support that Nursing had assessed the Resident or his/her skin after noting the new bruises, and after being notified of an allegation of potential physical abuse. The DON said Resident #1's skin should have been assessed and documented in the Medical Record, but was not. The DON said she was on vacation during the time of the alleged incident, and could not provide statements or interviews from staff on shifts prior to the alleged incident and could not provide statements or interviews from other residents that received care from CNA #1. During an interview on 07/06/23 at 11:13 A.M., the Administrator said he was not involved in the investigation, and could not provide any other documentation to support that a thorough investigation had been done. The Surveyor requested the investigation file several times during survey, and the Facility could not provide written witnesses statements or documentation of interviews from staff that worked on Resident #1's unit prior to 06/10/23 at 12:45 A.M., who may have witnessed the alleged potential physical abuse or who may have observed the bruises prior to CNA #2 finding and reporting them. The Facility was also unable to provide statements and/or interviews from other residents on Resident #1's unit that had been cared for by CNA #1. During the course of the investigation, which included staff interviews, review of staff members written statements, and the facility HCFRS Report, the Surveyor noticed discrepancies regarding the location of the new areas of bruising noted on Resident #1, (bilateral thighs verses left upper thigh and left biceps). The DON and other staff members could not speak to the discrepancies, and the Facility could not provide any further documentation to clarify the exact location of the bruises.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who on 6/10/23 was found to have new areas of bruising on his/her left thigh and left upper arm, and had reported an allegation of potential physical abuse by a Certified Nurse Aide (CNA) during care, the Facility failed to ensure they maintained a complete and accurate medical record when there was no nursing documentation in the Medical Record related to the bruises, and no documentation to support nursing assessed Resident #1 for any other potential injuries after he/she made an allegation to nursing of potential physical abuse by a staff member. Findings include: Review of the Facility's Policy, titled Charting and Documentation, undated indicated the following: -observations, medications administered, services performed, etc., will be documented in the resident's clinical record, and -all incidents, accidents, or changes in a resident's condition must be recorded. The Policy also indicated that documentation of procedures and treatments shall include care-specific details and shall include at a minimum: -the date and time the procedure/treatment was provided, -the name and title of the individual(s) who provided the care, -the assessment data and/or any unusual findings obtained during the procedure/treatment, -how the resident tolerated the procedure/treatment, -whether the resident refused the procedure/treatment, -notification of family, physician or other staff, if indicated, and -the signature and title of the individual documenting. Resident #1 was admitted to the Facility in February 2022, diagnoses included chronic respiratory failure with hypoxia, anxiety disorder, and muscle weakness. Review of Resident #1's Minimum Data Set (MDS) Quarterly Assessment, dated 04/07/23, indicated he/she had moderate cognitive impairment, and required extensive assist of one staff member for transfers. Review of the Report submitted by the Facility via Health Care Facility Reporting System (HCFRS), dated 06/22/2033, indicated that Resident #1 was found to have bilateral bruises on his/her upper thighs, and it was alleged that Certified Nurse Aide (CNA) #1 handled him/her roughly during a toilet transfer. The Report indicated that the Physician was notified. During an interview on 07/17/23 at 10:30 A.M., and review of Nursing Supervisor #1's Written Witness Statement, undated, Nursing Supervisor #1 said that on 06/10/23 at the start of her shift (7:00 A.M. to 7:00 P.M.) the night nurse (later identified as Nurse #1), and CNA #2 told her that Resident #1 had two bruises and made statements that were concerning. Nursing Supervisor #1 said Resident #1 told her that, Sometimes I don't move fast enough, and they just swing me into the chair. Nursing Supervisor #1 said she observed two bruises on Resident #1, one oval shaped bruise on his/her left inner thigh, and one round bruise on his/her left inner biceps. Nursing Supervisor #1 said she had not documented Resident #1's bruises or anything related to the allegation of physical abuse, in his/her medical record. During an interview on 07/06/23 at 12:24 P.M. and review of her Written Witness Statement, dated 06/09/23, Certified Nurse Aide (CNA) #2 said she worked on Resident #1's unit during the overnight shift that started at 11:00 P.M on 06/09/23 and ended at 7:00 A. M on 06/10/23. CNA #2 said she went in to provide care for Resident #1 at approximately 12:45 A.M. and said she noticed a bruise on his /her thigh. CNA #2 said she notified Nurse # 1 immediately. Review of Nurse #1's Written Witness Statement, dated 06/10/23, indicated that CNA #2 notified her about bruising on Resident #1. The Statement indicated that Nurse #1 noted a bruise on Resident #1's inner thigh, measuring 4 centimeters (cm) by 10 cm, and a bruise n his/her left inner biceps (upper arm), measuring 1 cm by 1 cm. The Statement indicated that Resident #1 told Nurse #1 that he/she was in the bathroom with CNA #1 and he/she had not moved fast enough, so CNA #1 pushed him/her, and his/her leg hit the bar. Review of Resident #1's Medical Record indicated that there was no documentation related to new areas of bruising found by nursing staff on his/her left thigh or left upper arm after he/she reported an incident during care that was concerning for the potential of physical abuse, despite Nurse #1, CNA #2, and Nursing Supervisor #1's statements which indicated they noted bruising on his/her left upper arm and left inner thigh. Resident #1's Skin Assessment, dated 06/10/23 at 10:24 P.M. (which was more than nine hours after the bruises were first noted) also indicated he/she did not have any marks on his/her skin. During an interview on 07/06/23 at 3:31 P.M., Corporate Nurse #1 said she was unable to find any documentation in Resident #1's Medical Record related to bruising on his/her thigh or arm on 06/09/23 (prior to being found by nursing on 06/10/23). Corporate Nurse #1 said she was also unable to find any documentation to support that nursing staff had assessed Resident #1 for any other possible injuries following the allegation of potential physical abuse on 06/10/23. Corporate Nurse #1 said Nursing staff should have documented a skin assessment and measurements of the bruises, but had not. During an interview on 07/06/23 at 2:00 P.M., and 07/11/23 at 10:30 A.M., the Director of Nurses (DON) said she could not find any documentation in Resident #1's Medical Record to support that Nursing had assessed him/her or his/her skin after noting new bruises, and after bring notified of an allegation of potential physical abuse. The DON said Nursing should have assessed Resident #1's skin and documented in the Medical Record, but had not. During the course of the investigation, which included staff interviews, review of staff members written statements, and the facility HCFRS Report, the Surveyor noticed discrepancies regarding the location of the new areas of bruising noted on Resident #1, (bilateral thighs verses left upper thigh and left biceps). The DON and other staff members could not speak to the discrepancies, and the Facility could not provide any further documentation to clarify the exact location of the bruises.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to document the recapitulation of the Resident's stay that included pre- and post-discharge medications for two Residents (#57 and #58) of two closed records reviewed. Findings include: Review of the facility's policy titled Discharge Summary and Plan, last revised September 2012, included but was not limited to: -When the facility anticipates a resident's discharge to a private residence, another nursing care facility a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment. -The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of a resident's status at the time of the discharge in accordance with established regulations. 1. Resident #57 was admitted to the facility in October 2022 for short term rehabilitation following a hospitalization for urinary tract infection and a fall. Review of the medical record indicated Resident #57 was discharged to a rest home with services on 11/4/22. Review of the medical record indicated a Discharge summary dated [DATE]. The Discharge Summary failed to include a summary of the Resident's pre- and post-discharge medication as required. 2. Resident #58 was admitted to the facility in October 2022 for short term rehabilitation following a hospitalization for pneumonia. Review of the medical record indicated a Discharge summary dated [DATE]. The Discharge Summary failed to include a summary of the Resident's pre- and post-discharge medication as required. During an interview on 1/13/23 at 12:20 P.M., the Director of Nurses (DON) said the Discharge Summaries for Residents #57 and #58 should have included the Residents' pre- and post-discharge medication.

Based on observation, interview, and record review, the facility failed to ensure that one Resident (#24) received the proper treatment to maintain hearing abilities, out of a total sample of 14 residents. Findings include: Resident #24 was admitted to the facility in September 2021 with medical diagnoses including difficulty hearing. Review of the Minimum Data Set (MDS) assessment, dated 12/2/22, indicated Resident #42 has severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 03 out of 15 and indicated Resident #24 had moderate hearing difficulty and did not have hearing aids. Review of the January 2023 Physician's Orders indicated bilateral hearing aids, supplies labeled in case in room. Resident can manage them independently. Document inserting them in the morning, and removing them in the afternoon, as needed for prevention. Review of the clinical record failed to indicate that the hearing aids were provided for self-applying to the Resident, as instructed. Further review of the clinical record failed to indicate that nursing staff were documenting the inserting time of the hearing aids in the morning and the removal time in the afternoon. During an interview on 1/10/23 at 8:35 A.M., Certified Nursing Assistant (CNA) #1 said the Resident was hard of hearing and the Resident asked her to get closer to him/her during care. CNA #1 said she did not say anything because she thought staff were already aware of it. During an interview on 1/10/23 at 8:45 A.M., the surveyor observed Resident #24 in his/her bedside chair staring while the surveyor was speaking to him. The Resident motioned for the surveyor to come closer using his/her right hand and asked the surveyor to come closer because he/she was having difficulty hearing. Resident #24 told the surveyor that his/her hearing aids were not with him/her. During an interview on 1/10/23 at 2:12 P.M., Nurse #5 said that the Resident has hearing aids, but he/she would not wear them. Nurse #5 said she did not know where the Resident's hearing aids were stored. During an interview on 1/12/23 at 3:14 P.M., Nurse #6 said the Resident #24 does not have a hearing aid. The nurse then reviewed the Resident's physician's orders and said the Resident has a hearing aid that he/she could manage independently.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility failed to safely store medications on two of two units. Specifically, the facility failed to: 1. Maintain a temperature log that reflected a minimum of daily temperature checks in the first-floor medication room; and 2. Ensure medication carts were secured when not in view of the licensed nurse. Findings include: Review of the facility's policy titled Medication Storage in the Facility, dated September 2013, indicated but was not limited to the following: - medications requiring refrigeration are kept in a refrigerator at temperatures between 36 and 46 degrees Fahrenheit (F) - the facility should maintain a temperature log in the storage area to record temperatures at least once a day - medication supply is only accessible to licensed nursing personnel or those with authorized access - medication carts are kept locked when not in attendance of persons with authorized access 1. On 1/12/23 at 10:37 A.M., the surveyor observed the first-floor medication room with Nurse #1. Review of the medication room refrigerator logs for November 2022, December 2022, and January 2023 indicated 17 days in November without documented temperatures, 14 days in December without documented temperatures, and 3 days in January (to date) without documented temperatures. During an interview on 1/12/23 at 10:40 A.M., Nurse #1 said the process is for the nurses to document temperatures twice a day and the holes in the documentation indicated the temperatures were not monitored as they should have been, and the policy was not being met. During an interview on 1/12/23 at 12:54 P.M., the Director of Nurses (DON) said the medication refrigerators should be monitored and documented at least daily and the expectation was not being met. 2. On 1/13/23 at 7:59 A.M., the surveyor observed the medication cart for the high side on the second floor parked outside of room [ROOM NUMBER]. The cart was unlocked, the medications within unsecured, and there was no nurse in the area. During an interview on 1/13/23 at 8:06 A.M., Nurse #7 approached the medication cart and the surveyor and said the cart was unlocked and the medications unsecured. He said he likely just forgot to lock the cart when he walked away. He said the standard of practice is to secure medication carts when they are not in direct view of the nurse who has the keys, and that standard was not being followed. During an interview on 1/13/22 at 9:50 A.M., the DON said medication carts are to be secured when not in direct view of the nurse and the policy for medication storage was not met.

Based on interviews, policy review, and record review, the facility failed to assist a Resident (#35) in obtaining recommended dental services, in a total sample of 14 residents. Findings include: Resident #35 was admitted to the facility in May 2022. Review of the Minimum Data Set (MDS) assessment, dated 10/26/22, indicated Resident #35 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the Resident was cognitively intact. Review of the medical record for Resident #35 indicated the Resident was responsible for his/her own healthcare decision making. During an interview on 1/10/23 at 1:40 P.M., the Resident said that he/she needed a full upper plate (dental). The Resident said he/she had been seen by the dentist but had not heard what the plan was for follow-up. Review of the medical record indicated the following: -The contracted dental provider's Dental Progress Note, dated 9/22/22, listed the chief complaint as: wants removable partial denture with a treatment plan of extractions and refer to oral surgeon. -The Dental Visit Referral Report Clearance Form, dated 10/17/22, recommended the Resident be seen by an oral surgeon for the extraction of the maxillary (upper) teeth; the form was signed by the facility Nurse Practitioner. -The Dental Visit Referral Report/Medical Clearance Form, dated 11/14/22, recommended the Resident be seen by an oral surgeon for the extraction of the remaining maxillary teeth; the form was signed by the Nurse Practitioner. -The Dental Visit Referral Report/Medical Clearance Form, dated 12/5/22, recommended the Resident be seen by the oral surgeon for the extraction of the remaining maxillary teeth; the form was signed by the Nurse Practitioner. -The Dental Progress Note, dated 12/17/22, indicated Resident #35 had not yet had the recommended work completed and needed to be seen by an oral surgeon. It referenced the original dental progress note dated 9/22/22. Review of the medical record also included the dental provider's Responsible Party Consent form for a removable partial denture was undated and unsigned in the medical record. During an interview on 1/12/23 at 8:37 A.M., the Nurse Supervisor said Resident #35 had no upcoming appointments with an oral surgeon. During an interview on 1/12/23 at 12:45 P.M., the Nursing Supervisor, while reviewing the electronic and paper medical record for Resident #35 said, the Dental Progress Note dated 9/22/22 and the Referral Report dated 10/17/22 indicated for the Resident to see an oral surgeon. She said she was unable to locate any information to indicate Resident #35 had been referred to an oral surgeon as requested by the dentist.

Based on observation and interview, the facility failed to provide a sanitary environment for one Resident (#9), out of a total sample of 14 residents. Specifically, the facility failed to ensure the wheelchair for Resident #9 was clean and sanitary. Findings include: During an interview with observation on 1/10/23 at 2:30 P.M., the surveyor observed Resident #9 sitting in his/her wheelchair with dried beige substance on the left wheel, backrest, crossbars, and left handle. Resident #9 said they did not think the wheelchair gets cleaned and said the staff do not wipe up spills when they occur. During an interview with observation on 1/11/23 at 8:09 A.M., the surveyor observed Resident #9 sitting in his/her wheelchair in their room. The wheelchair had a dried beige substance stuck to the backrest, left handle, splattered throughout the left wheel and on the lower crossbars. Resident #9 said it has been a long time since anyone has cleaned his/her wheelchair and it is embarrassing to have it in the condition it is in. During an interview on 1/11/23 at 10:18 A.M., Certified Nurse Assistant (CNA) #2 observed Resident #9's wheelchair and said it was very dirty and should be cleaned but she was unsure what the process was for getting it cleaned. She said it looked like the chair had been dirty for a long time and it shouldn't be like that. During an interview on 1/11/23 at 3:12 P.M., the Infection Preventionist said the resident's wheelchairs are supposed to be cleaned by housekeeping on a schedule and there used to be a process in place for environmental rounds to ensure the equipment and rooms were clean and sanitary. She said that process has not been completed by herself in a long time and the Maintenance department would know more about the process. She was made aware of the observations by the surveyor of Resident #9 wheelchair and said it was unsanitary and should not be like that. During an interview on 1/11/23 at 3:35 P.M., the Maintenance Director said housekeeping is responsible for maintaining the cleanliness of resident equipment. He said environmental rounds would catch an issue with equipment cleanliness but environmental rounds have not been completed since June 2022. During an interview on 1/12/23 at 9:20 A.M., the Housekeeping Supervisor said the resident's wheelchairs should be washed monthly by the housekeeping department. She said she does not have a schedule or any documentation that would indicate the last time Resident #9's wheelchair was cleaned. She observed Resident #9 wheelchair and said it was very dirty and needed to be cleaned and it was not what she would consider acceptable to have a resident sitting in a wheelchair that looked like that. During an interview on 1/13/23 at 2:00 P.M., the Administrator said the expectation is for resident wheelchairs to be cleaned at least monthly and when they appear dirty, she said the expectation was not met for Resident #9.

Based on interview and document review, the facility failed to resolve concerns brought forward during Resident Council meetings. Findings include: Review of the Resident Council Meeting Minutes and Concern Forms for January 2022 through December 2022 identified the following unresolved concerns: 1/20/22: transportation for bus trips was noted to be a resident concern and documents indicate residents can shop online (no additional information or resolution was provided). 2/17/22: bus trips continue to be on hold related to transportation issues and documents indicate families can bring in items or residents can online shop (no additional information or resolution was provided). 3/24/22: bus trips continue to be on hold related to transportation issues and documents indicate families can bring in items or residents can online shop (no additional information or resolution was provided). 4/26/22: bus trips continue to be on hold related to transportation issues and documents indicate families can bring in items or residents can online shop (no additional information or resolution was provided). 5/19/22: bus trips continue to be on hold related to transportation issues and documents indicate families can bring in items or residents can online shop (no additional information or resolution was provided). - Review of a Concern Form for second floor residents indicated prolonged call light answering times. The Department response was four new staff were hired recently and more information needed to be provided. The concern was checked off as unresolved (8 months later). 6/16/22: bus trips continue to be on hold related to transportation issues and documents indicate families can bring in items or residents can online shop (no concern form completed) - Review of a Concern Form for linen supply (especially washcloths) indicated it was still an issue, even with the addition of the recent supply on 6/8/22. The facility response was there is a new housekeeping manager in place and they are aware of the situation and will determine par levels. The concern was checked as unresolved. - Review of a Concern Form indicated prolonged call light times on the second floor. The response was education to the nursing staff on placement of certified nurse aides (CNAs) on the unit. The concern was checked as unresolved (and was previously brought up in May 2022). 7/28/22: bus trips continue to be on hold related to transportation issues and documents indicate families can bring in items or residents can online shop (no additional information or resolution was provided). - call lights continue to be answered slowly on the second floor (no additional information or resolution was provided). - second floor residents voiced that the staff do not knock on their doors or use privacy curtains consistently (no additional information or resolution was provided). - second floor residents voiced CNAs are sleeping while on their shift (no additional information or resolution was provided). - second floor residents voiced concerns of CNAs using their cell phones while providing care to the residents (no additional information or resolution was provided). 8/25/22: bus trips will be looked into, and activity director will get pricing for contracts (no additional information or resolution was provided). 9/22/22: bus trips are being looked into, and activity director is discussing possible options with administrator (no additional information or resolution was provided). 10/20/22: bus trips continue to be looked into, the activity director is discussing options with the administrator; the residents are reminded that families can bring in items and they can be assisted with online shopping (no additional information or resolution was provided). - low staffing and lack of showers - staff using cell phones - staff need reeducation on approach, etiquette, and conversation - privacy curtains not being used - staff sleeping All issues indicated the administrator would monitor them and no additional information or resolution was provided for any of the six concerns. 11/17/22: Indicating the resident said everything was good. No mention of previous issues either. There was no indication there was any inquiry or resolution to the group concerns from the previous month. 12/15/22: staff using cell phones. Review of a Concern Form indicated the response was for informal reeducation to staff. The Concern Form did not indicate if the concern was resolved but was signed as completed. -staff sleeping on the evening and night shift. Review of Concern Form indicated the accused staff denied the allegations. The Concern Form did not indicate it was resolved but was signed as completed. -waiting for beds to be made. Review of a Concern Form indicated the response was that clarification of who can make beds was provided at the Resident Council Meeting. The Concern Form did not indicate if the concern was resolved but was signed as completed. -privacy not provided during care. Review of a Concern Form indicated the response was for ongoing education. The Concern Form did not indicate if the concern was resolved but was signed as completed. - request for more chairs in the second-floor dining room. Review of a Concern Form indicated the chairs were checked for safety and comfort and no problems found. The concern was not addressed in the response and the form did not indicate whether the concern was resolved but was signed as completed. During an interview on 1/11/23 at 1:35 P.M., the Activity Director (AD) said when a concern is brought up at Resident Council, if she can address it immediately, she does not complete a concern form she just notes the concern in the minutes. She said if the concern is group wide, she will complete a concern form, then give it to the responsible department head for response to Resident Council within two weeks. She said if the concern is for only one resident and a grievance type issue, she would put it on a facility grievance form and hand it off to social services for processing. She said if a concern form is unresolved, she will either document the issue in the meeting minutes or complete another concern form; she said she is unsure when a concern form would become a grievance because there is no official policy for the concern forms that she is aware of. She said she stopped documenting the residents' group concern about bus trips because she couldn't come up with a resolution and didn't think it was necessary to keep putting it in the notes. She said at this time the concern is unresolved and the residents are still not going out on bus trips. During an interview on 1/11/23 at 2:27 P.M., Social Worker #1 said if a concern is voiced at Resident Council that cannot be resolved at that time, then the concern should be documented on the facility grievance/concern form. She said there should not be two processes for concerns, and any concern that is voiced and cannot be solved immediately should be documented on a facility grievance/concern form for resolution and to ensure the residents are made aware of the resolution. She reviewed some concern forms from Resident Council that are unresolved at this time for the 2022 year and said these concerns should have been documented and gone through the facility process for grievances and the process for resolving concerns brought forward in Resident Council was not followed. During an interview on 1/12/23 at 8:48 A.M., the Administrator said the concerns brought forth by Resident Council are grievances and should be treated as such. She said there are numerous concerns documented inaccurately or with inaccurate responses and the process is not working. She said the process for resolving resident concerns is not being followed as it should be.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, the facility failed to ensure that residents had a homelike environment. Findings include: On 1/13/23 at 11:45 A.M., the surveyors conducted an environmental tour of the first and second floor units and observed the following: -The first-floor resident hallway, lower half of the wall was dusty and contained dried liquid drip stains. -room [ROOM NUMBER], on the right side of the room, the wall wainscoting was scraped revealing wood beneath. There were multiple wires hanging loosely from the lower wall. The floor had a large yellow tint. The linoleum tile floor had a couple of gouges revealing the subfloor. -room [ROOM NUMBER], the linoleum tile floor had gouges and wear revealing the subfloor beneath. -The first floor back activity room contained a maroon upholstered armchair that was stained with dark spots, faded, distressed and sunken in at the arm rests. The legs of the chair were scraped showing a darker color beneath. -room [ROOM NUMBER], the baseboard heater cover was scraped and splattered with an orange substance. -room [ROOM NUMBER], the bathroom sink had a slow drain. The sink filled up quickly and was slow to empty. -room [ROOM NUMBER], the right wall had gouges and scrapes of missing plaster. Part of the heater baseboard cover was resting on the floor. -The second-floor dining room vertical blinds had approximately five missing slats. -In the shared bathroom of room [ROOM NUMBER]/207 there was a commode seat frame which had rust on the legs and on the metal that supports the seat. The water in the sink was slow to drain. -room [ROOM NUMBER], the lower third of the door frame and door was heavily scraped, chipped, and dented.

Based on observation, interview, and policy review, the facility failed for seven Residents (#7, #9, #13, #16, #19, #47, and #159) to address and resolve voiced grievances regarding the television reception at the facility. Findings include: Review of the facility's policy titled Grievances/Concerns, dated 12/6/21, indicated but was not limited to the following: - grievances/concerns may be submitted orally or in writing - the person receiving the grievance orally will submit a grievance form on the resident's behalf - the grievance/concern investigation will be initiated upon receipt and a written resolution will be made available to the administrator within five working days - the administrator will review the findings and the resident will be informed of the actions taken within 10 working days of the grievance being made During an interview on 1/10/23 at 11:23 A.M., the surveyor observed Resident #7 to have the television (TV) on and the picture was snowy and difficult to see. Resident #7 said the TV reception is poor and he/she has complained about it in the past and has been told that the reception cannot be fixed, and it is something he/she will have to learn to deal with. During an interview on 1/10/23 at 3:12 P.M., the surveyor observed Resident #9 to be watching TV. The picture on the television was full of white, snow-like images and was difficult to see. Resident #9 said the TV reception is a continuous issue and was told that it cannot be fixed. Resident #9 said they brought it up numerous times including in Resident Council without any resolution. During an interview on 1/10/23 at 11:12 A.M., the surveyor observed Resident #13 to have the TV on with the picture on the television jumping in and out of frame and a loud static noise. The picture on the television was illegible. Resident #13 said he/she has complained about the TV reception and was told numerous times it is the TV service which is not good and cannot be fixed. Resident #13 said it has been an issue for a long time. During an interview on 1/10/23 at 8:23 A.M., the surveyor observed Resident #16 lying in bed with the TV on and headphones in place. Resident #16 said the picture is always unclear and snowy and both he/she and his/her roommate have complained about it for a few months and was told it's as good as it gets and they just need to deal with it. Resident #16 said it is an issue that is not resolved and it is his/her main form of entertainment and not having it at a level which is easily viewable is not acceptable to him/her. During an interview on 1/10/23 at 8:42 A.M., the surveyor observed Resident #19 yelling about his/her dissatisfaction with the TV reception. Resident #19 said they have complained about it for at least three months and it is his/her main form of entertainment. He/she said they were informed by maintenance that the issue cannot be fixed and they need to do their best to watch channels that have better reception. The surveyor observed the TV on with a soft static noise heard in the background and a picture that jumped in and out of frame with multiple gray lines going across the picture. During an interview on 1/10/23 at 2:55 P.M., the surveyor observed Resident #47 watching TV which had an unclear picture with gray lines running through the picture at many levels. Resident #47 said he/she has complained about the TV reception many times and has been told many times that the TV service has poor reception and that is just the way it is. Resident #47 said the problem is unresolved. During an interview on 1/10/23 at 3:32 P.M., Resident #159 said he/she has put in complaints about the television reception at the facility for as long as they can remember. He/she said the reception was so bad and the facility had not resolved the issue, so residents felt they needed to purchase a streaming service for themselves to enjoy TV without having to worry about poor reception. He/she said the facility has been made aware of the concern of poor TV reception numerous times and still have not fixed the issue. Review of the facility supplied Grievance Book for January 2022 through January 2023 failed to indicate any grievances were completed for any residents regarding the television reception in the facility. During an interview on 1/11/23 at 3:35 P.M., the Maintenance Director said he is aware of the ongoing concern and issue of television reception. He said the concern is ongoing since he started in February 2022. He said the issue is most significant for residents who reside on the second floor and in rooms at the ends of the hallways and is related to room location versus the location of the dish network equipment in the facility. He said the television reception is affected by any storm or weather that may affect the dish and sometimes it is one or two channels that are affected and sometimes it is all channels. He said he has never seen a concern or grievance form completed for the issue and has never completed one himself as it was a problem prior to him starting at the facility and he thought it was well known. During an interview on 1/11/23 at 2:27 P.M., Social Worker #1 said residents, or their families, can convey grievances orally and staff would then complete the grievance form and forward the form to social services. The Social Worker said she was made aware of the numerous voiced concerns by residents regarding the television reception and she said a grievance form should have been completed so the process could be followed, and the residents could receive a resolution to their concerns. She said it appears the grievance process needs work and is not being followed in the facility. During an interview on 1/12/23 at 8:48 A.M., the Administrator said she was aware of the numerous voiced grievances regarding the television reception in the facility. She said it is an ongoing issue and has been for some time. She said she never thought to document the concern on a grievance form or to follow up with the individual affected residents. She said the concern should have been placed on a grievance form and the process for grievances should have been followed for these residents and it was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the facility's policy titled Pacemaker, Care of a Resident with a, undated, indicated the following: Monitoring: -The pacemaker battery will be monitored remotely through the telephone or an Internet connection. The resident's cardiologist will provide instructions on how and when to do this. -The resident will have an EKG annually, or as ordered, to monitor for changes in the heart's electrical activity. -Make sure the resident has a medical identification card that indicates he or she has a pacemaker. The medical record must contain this information as well. When the resident is transferred to another facility this information must be communicated to the receiving facility in the discharge summary. Documentation: -For each resident with a pacemaker, document the following in the medical record upon admission: -The address and telephone number of the cardiologist, type of pacemaker, date of implant, paced rate -When the resident's pacemaker is monitored by the physician, document the date and result of the pacemaker surveillance, including: -how the resident pacemaker was monitored (phone, office, internet), type of heart rhythm, functioning of the leads, frequency of utilization, battery life -Ensure the presence of a care plan related to the resident's cardiovascular condition, the placement of a pacemaker and ongoing care, support and monitoring thereof. Resident #29 was admitted to the facility in March 2022 with multiple diagnoses including sick sinus syndrome (a type of heart rhythm disorder) with pacemaker placement (a small device implanted in the chest to control heartbeat). Review of the Physician Order Summary Report, dated 4/1/22, indicated the Resident had diagnoses of presence of cardiac pacemaker and sick sinus syndrome. Review of the Nurse Practitioner's Progress Notes, dated 9/22/22, 11/18/22, 12/6/22, 12/8/22, 12/13/22, 12/20/22, and 1/5/23, indicated the Resident had a pacemaker in his/her right chest. Review of the care plan with a target date of 12/25/22 indicated in the diagnosis list the presence of a cardiac pacemaker. However, there was no focus area, goal or intervention in place addressing the care and monitoring of the pacemaker. Review of the paper and electronic medical record failed to indicate the cardiologist, the type of pacemaker, date of implant, paced rate, the frequency of checks, how it is monitored or battery life. During an interview on 1/13/23 at 8:45 A.M., the Nursing Supervisor said that she was unable to find the pacemaker information on the care plan (other than the diagnosis list) for Resident #29. She said she could not find a record of a cardiology appointment or information on the type of pacemaker in the medical record. The Nursing Supervisor said she was not aware the Resident had a pacemaker and did not have a schedule for checking it. The surveyor accompanied the Nursing Supervisor when she went to examine the Resident. The Nursing Supervisor confirmed the Resident had a pacemaker. The Nursing Supervisor said the pacemaker information is usually on the care plan but this one was not. During an interview on 1/13/23 at 11:00 A.M., the Nursing Supervisor said the facility was not able to find any information to indicate Resident #29 had been seen by a cardiologist or any information about the pacemaker. Based on observation, interviews, policy review, and record review, the facility failed to follow professional standards of practice for three Residents (#32, #4 and #29), in a total sample of 14 residents. Specifically, the facility failed: 1. For Resident #32, to follow physician's orders to change a dressing for a suprapubic catheter (tube inserted in the belly to drain the bladder); 2. For Resident #4, a. To implement the bowel protocol, b. To follow hospital recommendations for bowel medications following a fecal impaction, and c. To accurately follow physician's orders for bowel regimen medications; and 3. For Resident #29, to ensure a pacemaker was monitored per the professional standards of practice. Findings include: 1. Resident #32 was admitted to the facility in August 2022 with a diagnosis of urinary retention. Review of the medical record indicated Resident #32 had an indwelling Foley catheter until 12/30/22 when surgery was conducted to insert a suprapubic catheter. Review of the paper Physician's Interim Orders included an order written by the Nurse Practitioner on 12/30/22 to change the dressing over the suprapubic tube daily and as needed. Review of the active electronic Physician's Orders included an order to change the dressing over the suprapubic tube one time per day, starting 12/31/22. Review of the January 2023 Medication and Treatment Administration Records (MAR and TAR) failed to include the order to change the suprapubic tube daily, therefore it did not indicate the daily dressing was completed as ordered. On 1/12/23 at 9:31 A.M., the surveyor and Nursing Supervisor observed the suprapubic site of Resident #32. There was no dressing observed on the suprapubic tube, as ordered. During an interview on 1/12/23 at 9:37 A.M., the Nursing Supervisor said the order to change the dressing on the suprapubic tube was not entered in to the electronic medical record correctly and because of this was not completed daily as ordered. 2. Review of the facility's policy titled Bowel Protocol, dated as last revised on 7/26/21, indicated the purpose was to assure residents had periodic bowel movements to prevent constipation with the following protocol if a resident were to go 3 days without a bowel movement: -the charge nurse will compile a list of residents who need to start the bowel protocol - administer Milk of Magnesia (MOM), indicate time given, indicate results -if MOM is ineffective, administer a suppository, indicate time given, indicate results -if suppository was ineffective, administer a Fleet enema, indicate time given, indicate results -if Fleet enema is ineffective, contact the supervisor and the physician for further interventions Resident #4 was admitted to the facility in April 2019. Review of the Physician's Orders for Resident #4 included the following orders: -Milk of Magnesia, give 30 milliliters (ml) by mouth every 24 hours as needed, initiated 4/1/19 -Bisacodyl Suppository 10 mg, insert one rectally as needed for constipation if MOM is ineffective, initiated 4/1/19 -Enema (Sodium Phosphates) insert 1 dose rectally as needed if no results from suppository, initiated 4/1/19 Review of the Activities of Daily Living (ADL) Flow Sheets included a section for Bowel Elimination. Review of the October 2022 bowel elimination section indicated Resident #4 did not have a bowel movement on the following days: 10/2/22: 7:00 A.M. to 3:00 P.M. or the 3:00 P.M. to 11:00 P.M. shift 10/3/22: all shifts 10/4/22: all shifts and the next bowel movement was on 10/5/22 during the 11:00 P.M. to 7:00 A.M. shift; three days since the previous bowel movement. Review of the Nursing Progress Notes and bowel elimination section on the flow sheets failed to indicate the size or form of the bowel movement from 10/5/22 to determine if there were any concerns in which the Resident was assessed for constipation. Review of the Nursing Progress Notes indicated on 10/5/22 at approximately 9:00 A.M. Resident #4 was sent to the hospital for uncontrollable pain of the left side. Review of the hospital Patient Visit Information, dated 10/5/22, indicated Resident #4 was constipated and to use enemas as previously prescribed to help with constipation. Review of the hip/pelvis X-ray results, included within the Visit Information indicted Resident #4 had a fecal impaction of the rectosigmoid colon. Review of the section for Medications Administered in the Emergency Department (ED) included Acetaminophen, Sodium Chloride and Morphine Sulfate. There was no indication the hospital had initiated a bowel protocol. Review of the Nursing Progress Notes indicated Resident #4 was to be picked up from the hospital on [DATE] at 3:30 P.M. The Nursing Progress Notes, dated 10/5/22 at 10:30 A.M. and 9:38 P.M., failed to indicate the nurses were aware of the constipation noted on the front of the Patient Visit Information page or the fecal impaction noted on the results in the information provided. Review of the Medication Administration Record (MAR) for October 2022 failed to indicate any bowel protocol was initiated for Resident #4 on 10/5/22 when they returned from the hospital with a fecal impaction. Review of the Progress Note from the Nurse Practitioner, dated 10/6/22, indicated Resident #4 had a fecal impaction found at the Emergency Department and it was advised to continue with an enema. The progress note indicated the Nurse Practitioner advised nursing staff to administer the Milk of Magnesia (MOM) and suppository at the same time and to follow the bowel protocol of using the enema if ineffective. The NP noted a goal of Resident #4 having regular, formed bowel movements. Review of the MAR indicated the MOM and suppository were administered on 10/6/22 at 10:10 A.M., 18 hours after returning from the hospital. Review of the Physician's Interim Orders included the following orders written on 10/20/22: -use as needed bowel regimen every shift through 10/23/22 -starting 10/24/22 use Fleet enema once every other day for 10 days Review of the MAR for October 2022 indicated none of the as needed bowel regimen were utilized from 10/20/22 through 10/24/22. Review of the MAR indicated the Fleet enema order was entered to be administered every Monday, Wednesday, Friday, Sunday and not as every other day, as ordered. The MAR indicated the order for Fleet enema was initiated on 10/21/22 (instead of 10/24/22) and administered on 10/21/22, 10/23/22. The MAR indicated on 10/24/22 the medication was not given, and the electronic medication administration notes included a note from a nurse indicating the enema was not administered, no other information was available. Review of the MAR indicated the enema should have been administered on 10/26/22, this administration was left blank and there was no documentation in the medical record to indicate why it was not given. Review of the Activities of Daily Living (ADL) flow sheets section for Bowel Elimination for October 2022 indicated Resident #4 did not have a bowel movement on the following days: 10/25/22: 7:00 A.M. to 3:00 P.M. or the 3:00 P.M. to 11:00 P.M. shift 10/26/22: all shifts 10/27/22: all shifts 10/28/22: 11:00 P.M. to 7:00 A.M. shift and the next bowel movement was on 10/28/22 during the 7:00 A.M. to 3:00 P.M. shift; three days since the previous bowel movement. During an interview on 1/12/23 at 1:06 P.M., the Nursing Supervisor said the Certified Nursing Assistants (CNAs) completed the ADL flow sheets and only record if a bowel movement occurred. She said if a resident was being monitored for bowel movements, then there would be an order to monitor the form and size of the bowel movements. She said she was not sure if they were recording the bowel size and form for Resident #4. During an interview on 1/12/23 at 4:05 P.M., the Director of Nurses said the nurses had not administered the enema or initiated the bowel protocol when Resident #4 had returned from the hospital on [DATE]. He said the nurses did not initiate any protocol until the Nurse Practitioner ordered the use of the as needed medications on 10/6/22. During an interview on 1/12/23 at 6:50 A.M., the Director of Nurses said the expectation is that the nurses will be able to assess the Resident and utilize the as needed medications without the Nurse Practitioner giving orders to utilize the as needed medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the Department of Public Health 105 CMR 150.720 Standards for Long Term Care Facilities indicated that hot water supply temperatures should be between 110 and 120 degrees Fahrenheit (F) in resident areas. On 1/13/23, during an environmental tour of the facility, the surveyors found the following hot water temperatures in resident bathroom sinks: -room [ROOM NUMBER]: 126.0 degrees F at 11:55 A.M. -Rooms #111/109 (shared bathroom): 126.5 degrees F at 12:04 P.M. -room [ROOM NUMBER]: 126.0 degrees F at 12:07 P.M. -Rooms #213/215 (shared bathroom): 124.2 degrees F at 12:09 P.M. -Rooms #205/207 (shared bathroom): 124.3 degrees F at 12:11 P.M. Review of the facility Water Temperature Logbook indicated the last day water temperatures were recorded was on 12/2/22, over one month prior. During an interview on 1/13/23 at 12:25 P.M., the Maintenance Director said the facility has been falling behind on taking water temperatures. He said water temperatures should be taken daily. The surveyors and the Maintenance Director took a tour to check water temperatures with the facility thermometer. The following temperatures were taken by the Maintenance Director while touring with the surveyors: -room [ROOM NUMBER]: 129.0 degrees F at 12:25 P.M. -room [ROOM NUMBER]: 129.0 degrees F at 12:30 P.M. -room [ROOM NUMBER]: 129.6 degrees F at 12:34 P.M. -Rooms #205/207 (shared bathroom): 122.2 degrees F at 12:36 P.M. During an interview on 1/13/23 at 12:38 P.M., the Maintenance Director said that the water temperature fluctuates with the temperature outside and the time of day. He also said the water is hotter when no one is using it. He said that the water temperatures should be between 110 degrees F and 120 degrees F. During an interview on 1/13/23 at 1:09 P.M., the Administrator said she had been notified by a staff member on 1/10/23 that the water temperatures were running hot. She said she thought the water temperatures had been checked since then. During an interview on 1/13/23 at 1:17 P.M., with the Administrator present, the Maintenance Director said he was made aware of increased hot water temperatures 1/10/23 and had been checking the water temperatures since then but did not have any documentation to indicate the water temperatures remained in a safe temperature range. He said he had not checked every Resident sink, every day and had not increased water temperature checks based on the reported concern. Based on observations, interviews, medical record review, and maintenance record review, the facility failed to ensure the resident environment remained as free from accidents and hazards as possible. Specifically, the facility failed to: 1. Implement interventions to reduce the potential for a resident to resident altercation between Resident #26 and Resident #38; and 2. Ensure water temperatures were maintained at safe and comfortable levels in resident bathrooms. Findings include: 1. Resident #26 was admitted to the facility in September 2016 with a diagnosis of adjustment disorder. Review of the Minimum Data Set (MDS) assessment, dated 12/21/22, indicated Resident #26 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she was cognitively intact. Resident #38 was admitted to the facility in April 2021 with a diagnosis of dementia. Review of the MDS assessment, dated 12/14/22, indicated Resident #38 scored an 11 out of 15 on the BIMS, indicating he/she had moderately impaired cognition. During an interview on 1/10/23 at 12:45 P.M., Resident #26 said he/she shared a bathroom with Resident #38 who resided in the room next door. Resident #26 said Resident #38 will come into the room of Resident #26, touch their belongings, and stand next to his/her bed. Resident #26 said he/she did not want Resident #38 in his/her room or in his/her space and had told staff that he/she would use violence. Resident #26 went on to say that he/she would protect him/herself from Resident #38 entering his/her space. Resident #26 said he/she had completed a grievance about Resident #38 and had not heard back on a plan yet. The Resident said this was not the first time and staff had previously put a sign on the door in the bathroom to keep Resident #38 from exiting through the wrong door and a slide latch had been added to the outside of the bathroom door on the side of Resident #26. Resident #26 said the latch does not always work because the roommate of Resident #26 will forget to latch it sometimes at night. The surveyor reviewed the grievance provided by the Resident. The grievance/concern form, dated 1/7/23, indicated Resident #26 said Resident #38 had entered the room of Resident #26 through the bathroom and stood at the end of the bed of Resident #26 and pulled on the legs of Resident #26. At that time, Resident #26 strongly stated get out. The grievance continues by stating Resident #26 said this was not the first time this has happened, and no current interventions were working. The back of the form indicated a copy was given to the Social Worker and the Administrator. On 1/10/23 at 1:00 P.M., the surveyor observed the outside hallway around the room of Resident #38. There was a name plate below the room number, above a hand sanitizer, which had a very small print of the name of Resident #38. From the hallway, there were no other identifiers to indicate this was the room of Resident #38. Inside the room of Resident #38, on the bathroom door was a sign that indicated this was the bathroom and to knock before entering. In addition, there was a large print sign on the bathroom door indicating this was the room of Resident #38, the sign was not visible from the hall. Review of the medical record for Resident #26 included a Nursing Progress Note, dated 1/10/23, which indicated Resident #26 had concerns about Resident #38 entering his/her room and Resident #26 declined to switch rooms and Resident #26 was seen by psychiatric services. Review of the Behavioral Health Group progress note, dated 1/10/23, indicated Resident #26 had made a statement that he/she wanted to punch someone, that the statement was made in the context of frustration and the Resident does not appear to be a harm to self or others. The progress note does not include any information regarding Resident #38 entering the room of Resident #26 or strategies for Resident #26 to utilize to prevent violence. Review of the medical record for Resident #38 included a care plan which indicated the following: Focus: Behavior- wandering into other resident's rooms, history of striking out (revised 1/10/23) Goal: display no behavior through next review Interventions: redirect and establish limits for inappropriate behaviors associated with safety and ambulation; redirect as needed when wandering During an interview on 1/12/23 at 8:35 A.M., Resident #26 said he/she had not been offered any resolution to Resident #38 wandering in to his/her room. On 1/12/23 at 10:30 A.M., the surveyor requested from Administration any information regarding the grievance for Resident #26. During an interview on 1/12/23 at 1:00 P.M., the Director of Nurses and the Administrator said they had just come from meeting with Resident #26. The Administrator said she had not gotten the grievance regarding Resident #26, prior to the surveyor inquiry and they met with the Resident who was satisfied with the plan. During an interview on 1/13/23 at 8:40 A.M., Resident #26 said he/she had met with the Administrator and the Director of Nurses on 1/12/23 and he/she was happy that they were going to be checking in on a weekly basis. The Resident said he/she had exhausted all of his/her ideas and they would need to come up with their own ideas about how to keep Resident #38 out of his/her room. Resident #26 said that he/she had agreed to not be violent and then added, but I will tell you that if I feel threatened, I will protect myself. During an interview on 1/13/23 at 9:14 A.M., Nurse #4 said she was an agency nurse who had been working at the facility this week and had worked on 1/11/23, 1/12/23, and 1/13/23. She said she was aware that Resident #38 had a tendency to wander and had witnessed this over the three days. She said she was not aware of any issues between Resident #26 and Resident #38 and did not know she was supposed to be redirecting Resident #38 away from the room of Resident #26. During an interview on 1/13/23 at 9:17 A.M., the Nursing Supervisor said the interventions in place included a lock on the bathroom on the side of Resident #26, although the roommate of Resident #26 forgets to lock this. She said there is a sign inside the bathroom to direct Resident #38 back to his/her room and not to the room of Resident #26, but Resident #38 does not read the sign, so this does not work. The surveyor inquired how Resident #38 can find his room with the large print sign posted inside of the room, she said this was not effective. She said the interventions to prevent a resident to resident altercation were for staff to redirect Resident #38. She said she was not sure how the agency staff would know to redirect Resident #38 from Resident #26. During an interview with the Administrator and the Director of Nurses on 1/13/23 at 9:45 A.M., the Administrator said the plan was to meet with Resident #26 weekly to follow up on the interventions which were in place (lock on the bathroom, signs, staff redirection). The Administrator said no new interventions were being implemented at this time. She said she did not notice the large print sign for Resident #38 to find his/her room was located inside his/her room. The Director of Nurses said he was unaware the care plans for Resident #38 were not up to date to include interventions to help prevent wandering and he was not sure how the agency staff were supposed to offer redirection if they were unaware of the intrusive wandering of Resident #38 and the thoughts of self-protection from Resident #26.

c. Resident #35 was admitted to the facility in May 2022. Review of the paper and electronic medical record included visits from the Nurse Practitioner and failed to indicate Resident #35 was seen by the primary Physician since admission 7 months prior. During an interview on 1/12/23 at 12:50 P.M., the Nurse Supervisor and surveyor looked through the resident's electronic medical record and paper record. The Nursing Supervisor said she could not find any progress notes from the primary Physician. On 1/12/23 the surveyor requested the Physician's visits. On 1/13/23 at 8:07 A.M., the surveyor was provided with the primary Physician's Progress Notes that had not been included in the medical record. This included: the History and Physical dated 5/23/22, a Progress Note dated 6/15/22 and a Progress Note dated 10/19/22. All of the Progress Notes were electronically signed on 1/12/23 (date of surveyor request). d. Resident #29 was admitted to the facility in March 2022. Review of the paper and electronic medical record included visits from the Nurse Practitioner and failed to indicate that Resident #29 was seen by the primary Physician in the previous 9 months since admission. During an interview on 1/13/23 at 8:45 A.M., the Nursing Supervisor said that she was unable to find any Physician's Progress Notes. On 1/13/23, the surveyor requested the Physician's visits, which were later provided. The following Physician's Progress Notes were provided for Resident #29 which had not been included in the medical record: a Progress Note dated 4/20/22, a Progress Note dated 8/1/22, and a Progress Note dated 12/7/22. During an interview on 1/13/23 at 8:07 A.M., the DON said the Physician's Progress Notes had not been coming over to the facility and the facility was unaware until surveyor inquiry. 4. Resident #35 was admitted to the facility in May 2022. During an interview on 1/10/23 at 1:42 P.M., Resident #35 said that he/she is scheduled for a shower one day per week (Wednesdays 3:00 P.M. to 11:00 P.M. shift). He/she said when they do not get their weekly shower, it is not provided on another day. The Resident said that he/she missed the shower on Wednesday last week and it was not provided on another day. Review of the shower schedule on 1/11/23 at 4:15 P.M. indicated the Resident was scheduled for a shower on this day. During an interview on 1/12/23 at 8:27 A.M., the Resident said he/she was showered, as scheduled, yesterday (1/11/23). Review of the bathing activity of daily (ADL) flow sheet indicated there were no showers provided in January 2023. Further review of the bathing ADL flow sheet indicated the following (code: A-Tub, B-Shower, C-Bed Bath) for the months of October through December 2022: -October 2022: From 10/19/22 through 10/31/22 there were blanks on the 3:00 P.M. to 11:00 P.M. shifts. From 10/1/22 through 10/18/22 only bed baths were provided. No other showers were indicated as having been completed during any other shift in the month of October. -November 2022: There were blanks on the following 3:00 P.M. to 11:00 P.M. shifts: 11/1/22 through 11/4/22, 11/7/22, 11/8/22, 11/12/22, 11/16/22, 11/17/22, 11/20/22, 11/25/22-11/30/22. This form indicated only C for bed baths. It did not indicate any showers for the month of November. -December 2022: There were blanks on the following 3:00 P.M.-11:00 P.M. shifts: 12/8/22, 12/9/22, 12/19/22, 12/23/22, 12/26/22, and 12/28/22. Only the letter C was present for bed baths. No showers were indicated as having been completed on any shift in the month of December. During an interview on 01/12/23 at 5:25 P.M., Certified Nursing Assistant (CNA) #3 said a letter B should be entered when a resident receives a shower. CNA #3 said Resident #35 had gotten a shower yesterday and it had not been documented. Upon further review, she said the staff had not filled out the ADL flow sheets to accurately reflect when Resident #35 received showers.Based on interview and record review, the facility failed for seven Residents (#9, #25, #4, #48, #29, #35, and #57) to maintain a medical record that was accurate and complete, out of a total sample of 14 residents and three closed records. Specifically, the facility failed to: 1. Identify and correct a sudden documented change in wound classification for Resident #9; 2. Ensure consultant information was available in the medical record for Resident #25; 3. Ensure Physician Progress Notes were readily accessible for Residents #4, #48, #29, and #35; 4. Maintain complete and accurate activities of daily living (ADL) documentation for Resident #35; and 5. Reflect the accurate code status for Resident #57. Findings include: During an interview on 1/12/23 at 3:58 P.M., the Director of Nurses (DON) said the facility does not have a policy regarding medical records. 1. Resident #9 was admitted to the facility in July 2019 with diagnoses including Protein-calorie malnutrition, adult failure to thrive, and muscle weakness. Review of the medical record indicated Resident #9 developed a shear wound to his/her right heel in May 2022. Review of the most recent Minimum Data Set (MDS) assessment, dated November 2022, indicated under Section M- Skin, Resident had a Stage 3 pressure ulcer and no other ulcers, wounds, or skin problems on his/her feet. Review of the Care Area Assessment (CAA) Worksheet for the coinciding MDS indicated the stage 3 pressure ulcer was on the Resident's heel. Review of the Wound Physician's notes for Resident #9 indicated the right heel wound was classified as a full thickness shear wound, with an etiology of shear and recommendations to float heels in bed and off-load the wound from the development of the wound in May 2022 through September 2022 at which time the wound was reclassified as a non-pressure wound to the right heel, full thickness, with an etiology of trauma/injury. The wound recommendations in September 2022 continued to be to off-load the wound and float heels in bed. During an interview on 1/10/23 at 2:47 P.M., Resident #9 said he/she has had a wound on his/her right heel for a while and he/she sees a wound doctor at the facility every week. He/she said they believe the wound occurred related to the manner in which they self-propelled in the wheelchair but doesn't know any special medical terms for that. He/she said they do not remember any injury or trauma that may have occurred to the area since it started. During an interview on 1/12/23 at 1:36 P.M., the Infection Preventionist (IP) said she also is the wound nurse for the facility. She said the right heel wound on Resident #9 had an etiology of shear and the MDS was correct indicating the area as pressure. She said she is unaware of any injury or trauma that occurred to the area in September and could not explain why the area was reclassified, but states it is not accurate. During an interview on 1/12/23 at 3:41 P.M., the Director of Nurses (DON) said no trauma or injury occurred to Resident #9's right heel and the etiology of the wound was and is shearing, which is a form of pressure and the MDS was accurately coded. He could not explain the sudden change in classification of the wound in September 2022 and said the change in classification appeared to be an error in the medical record. During an interview on 1/13/23 at 10:17 A.M., the Wound Consultant Physician was asked about the sudden classification change in Resident #9's right heel wound. He said the change was made in relation to an update in his electronic medical record software that eliminated the option of shear wound as a classification. He said the Resident did not suffer a trauma or injury to the area and he has never changed his opinion that the etiology of the wound is shear. During a follow up interview on 1/13/23 at 10:48 A.M., the DON was made aware of the conversation with the wound physician and said the medical record had an discrepancy in the wounds classification and required correction. 2. Review of the facility' policy titled Charting and Documenting, undated, indicated but was not limited to the following: - Observations, medications administered, services performed, etc., will be documented in the resident's clinical record. Resident #25 was admitted to the facility in June 2019 with diagnoses including Alzheimer's disease and dementia. On 1/10/23 at 9:01 A.M., the surveyor observed Resident #25 sitting in his/her wheelchair with a rash covering his/her arms and neck. Resident #25 stated they were itchy. Review of the medical record indicated Resident #25 has suffered from a rash of unknown origin since at least July 2022 and indicated the Resident had been seen by outpatient dermatology in December 2022. The consult note and test results from the dermatology appointment could not be located in the paper or electronic medical record. During an interview on 1/12/23 at 4:29 P.M., the Infection Preventionist said Resident #25 had skin scrapings completed at the dermatologist's office and she believed the Resident's rash was ruled out for being related to scabies, although she couldn't locate any test results or documentation from the dermatologist's office to confirm that. During an interview on 1/12/23 at 5:21 P.M., Nurse #1 said she could not locate the test results or dermatology visit note in Resident #25's medical record and had contacted the dermatologist's office for a copy of the information. During an interview on 1/13/23 at 9:50 A.M., the DON said that the consultant information from Resident #25's visit to dermatology should have been in the medical record to ensure a clear accurate record and it was not. 3a. Resident #4 was admitted to the facility in April 2019. Review of the paper and electronic medical record only included visits from the Nurse Practitioner and failed to indicate Resident #4 had been seen by the primary Physician in the previous 12 months. On 1/12/23 the surveyor requested the Physician's visits. On 1/13/23 at 8:07 A.M. the surveyor was provided with the primary Physician's Progress Notes. The following Progress Notes had not been included in the medical record for Resident #4: 1/3/22, 3/16/22, 5/23/22, 7/13/22, and 10/17/22. b. Resident #48 was admitted to the facility in August 2022. Review of the paper and electronic medical record only included visits from the Nurse Practitioner and failed to indicate Resident #48 had been seen by the primary Physician since admission. On 1/12/23 the surveyor requested the Physician's visits. On 1/13/23 at 8:07 A.M., the surveyor was provided with the primary Physician's Progress Notes. The following Progress Notes had not been included in the medical record for Resident #48: 8/29/22 History and Physical, 9/20/22 visit, 1/4/23 visit. 5. Resident #57 was admitted to the facility in October 2022 for short term rehabilitation following a hospitalization for a urinary tract infection and a fall. Review of the medical record included a Massachusetts Medical Order for Life Sustaining Treatment (MOLST), signed by the Resident on 12/19/17, which indicated the Resident wished to not receive cardiopulmonary resuscitation (Do Not Resuscitate (DNR)), to not be intubated and to not use non-invasive ventilation. Review of a Health and Physical (H&P) assessment completed by the Resident's Physician, dated 10/31/22, indicated Resident #89 wished to be a Full Code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) and not a DNR as indicated on the MOLST. During an interview on 1/13/23 at 12:20 P.M., the surveyor and Director of Nursing (DON) reviewed Resident #57's medical record. The DON said the Physician's H&P documentation was inaccurate and should reflect Resident #57's advanced directive indicated on the signed MOLST in the medical record.

Based on record review, document review, and interview, the facility failed to implement an antibiotic stewardship program to determine if antibiotics were prescribed for the appropriate diagnosis by ensuring cultures were obtained prior to the start of an antibiotic. Findings include: Review of the Facility Assessment, dated 8/18/2017 with an Addendum for the Infection Control Program, included but was not limited to: -Infection Control Preventionist (ICP) chairs the antibiotic stewardship program. Line listings, trending and tracking of infections and precautions. Review of the facility binder titled Infection Control Line Listing indicated that infections and the corresponding antibiotics prescribed to treat the infections were listed for the months of January 2022 through January 2023. Review of the facility Line Listing, dated January/February 2022, indicated six residents received antibiotics and did not meet the McGeer's criteria (no culture was obtained) for that infection. The line listing culture date, culture site, culture result, and comments section were left blank for three out of six residents. Review of the facility Line Listing, dated March 2022, indicated six residents received antibiotics and did not meet the McGeer's criteria (no culture was obtained) for that infection. The line listing culture date, culture site, culture result, and comments section were left blank for five out of six residents. Review of the facility Line Listing, dated April through June 2022, indicated 12 residents received antibiotics and did not meet the McGeer's criteria (no culture was obtained) for that infection. The line listing culture date, culture site, culture result, and comments section were left blank for 10 out of 12 residents. Review of the facility Line Listing, dated July 2022, indicated five residents received antibiotics and did not meet the McGeer's criteria (no culture was obtained) for that infection. The line listing culture date, culture site, culture result, and comments section were blank for four out of five residents. Review of the facility Line Listing, dated August through September 2022, indicated five residents received antibiotics and did not meet the McGeer's criteria for that infection (no culture was obtained). The line listing culture date, culture site, culture result, and comments section were blank. The comments section was left blank for five out of five residents. Review of the facility Line Listing, dated October through November 2022, indicated eight residents received antibiotics and did not meet the McGeer's criteria for that infection (no culture was obtained). The line listing culture date, culture site, culture result, and comments section were blank. The comments section was left blank for seven out of eight residents. Review of the facility Line Listing, dated December 2022, indicated three residents received antibiotics and did not meet the McGeer's criteria for that infection (no culture was obtained). The line listing culture date, culture site, culture result, and comments section were blank. The comments section was left blank for three out of three residents. Review of the facility Line Listing, dated January 2023, indicated four residents received antibiotics and did not meet the McGeer's criteria for that infection (no culture was obtained). The line listing culture date, culture site, culture result, and comments section were blank. The comments section was left blank for four out of four residents. The facility failed to maintain a comprehensive infection control line listing or antibiotic line listing. The antibiotic line listing presented to the surveyor for facility infections and antibiotic use for the months of January 2022 through January 2023 was incomplete. During an interview on 1/12/23 at 11:05 A.M., the Infection Control Preventionist Nurse said that she was new to the position and had not been trained in Antibiotic Stewardship. She said that she was not aware about developing the Antibiotic Stewardship Program. She also said that she was not aware that a comprehensive analysis of the use of antibiotics was to be completed for each month so that tracking the use of antibiotics and determining if there were any trends, could be established. The Infection Control Preventionist Nurse said that she had not completed the line listings as per the instructions from the McGeer's criteria. During an interview on 01/12/23 at 12:43 P.M., the Director of Nurses (DON) reviewed the Antibiotic Stewardship for the whole year and agreed that the line listings were incomplete.

Based on observation, interview, policy review, and document review, the facility failed to ensure the dish machine temperatures were monitored to ensure the machine was reaching temperatures to clean and sanitize the dishes as required per the manufacturer. Findings include: Review of the facility's policy titled Dish Machine, dated May 2020, indicated but was not limited to the following: - all staff will receive training consistent with manufacturer recommendation for dish machine use - high temp machines must reach water temperatures in accordance with manufacturer specifications for wash and rinse - dietary staff will record dish machine temperatures on a log after each meal service Review of the facility provided CMA Dish Machine owner's manual, Revision 2.08.A, undated, indicated but was not limited to the following: - the CMA-180 is a hot water sanitizing single rack dish machine - the wash temperatures should cycle at a minimum of 155 degrees Fahrenheit (F) - the rinse/sanitation cycle should reach a minimum of 180 degrees F Review of the Dishwasher Temperature Monitoring Log on 1/10/23 at 12:50 P.M. indicated the temperatures for the dishwasher at both breakfast and lunch had not been logged for today. During an interview on 1/10/23 at 12:51 P.M., [NAME] #1 said the dishwasher is tested for temperatures three times a day after the completion of meal service. He observed the dishwasher temperature log with the surveyor and could not explain why the temperature for breakfast or lunch were not logged even though the breakfast dishes were already washed and the lunch dishes were just started. He said the wash cycle on the dish machine should go to 155 degrees F and the sanitize/rinse cycle should hit 180 degrees F, but the temperatures can only be taken while the machine is running. On 1/10/23 at 12:57 P.M., the surveyor photographed and made a photocopy of the dishwasher temperature log. During an observation with interviews on 1/10/23 at 1:02 P.M., the surveyor, with Dietary Aide #1 present, observed the dishwasher running with a load of lunch dishes in it. The wash temperature was observed to reach 135 degrees F and the rinse/sanitize cycle reached 168 degrees F. Dietary Aide #1 was asked if the temperatures had reached the required level to ensure the cleanliness and sanitation of the dishes inside and he stated he was unsure and would have to check with the cook. [NAME] #2 said the temperatures need to reach 155 degrees F for wash and 180 degrees F for sanitation. She said the machine didn't always run at those temperatures when it was first started and needed to be run a few times to reach the required temperatures. Dietary Aide #1 said he was unaware of the need to run the machine until the temperatures were met. During an interview on 1/11/23 at 7:02 A.M., the Food Service Director (FSD) said the temperatures should have been logged prior to using the machine to clean the dishes to ensure they were being cleaned and sanitized properly. He said his expectation of the staff to monitor and document the dishwasher temperatures was not met.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #4 was admitted to the facility in April 2019. Review of the medical record for Resident #4 included a Physician's Interim Order, dated 1/12/23 to collect a stool specimen to rule out c-difficile (c-diff) (a bacterial infection in the colon). The interim order was observed in the medical record on 1/12/23 at 4:00 P.M. Review of the Nursing Progress note, dated 1/12/23, indicated Resident #4 had a foul smelling bowel movement overnight and that morning. The note indicated the Nurse Practioner had been in earlier that afternoon and ordered for a stool collection sample to be sent out to rule out a c-diff infection and parasites. On 1/12/23 at 4:00 P.M., the surveyor observed the room of Resident #4 to not have any precaution signs or a precaution cart to provide supplies to care for the Resident with a possible infection. On 1/13/23 at 8:58 A.M., the surveyor observed the room of Resident #4 to not have any precaution signs or a precaution cart. During an interview on 1/13/23 at 9:00 A.M., the Nursing Supervisor said the Nurse Practitioner would like to rule out the c-diff infection for Resident #4 and that was why the stool sample had been ordered. She said until the stool sample was collected and tested the Resident should have been on precautions to prevent the spread of infection. During an interview on 1/13/23 at 9:50 A.M., the Director of Nurses said if residents have symptoms and are being tested to rule out any infectious process that would require precautions, the expectation would be that they are on those precautions until the infection was ruled out. Based on observations, interviews, record review, and policy review, the facility failed to establish and maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections in the facility. Specifically, the facility failed to: 1. Ensure that healthcare personnel performed hand hygiene, per the facility policy, while providing care to COVID-19 positive residents; 2. Ensure staff performed hand hygiene and appropriately wore personal protective equipment (PPE) prior to entering resident rooms as indicated by posted signs outside of resident rooms; 3. Follow infection control procedures while handling COVID-19 Binax tests; and 4. Follow infection control precautions for Resident #4 who was suspected of an infection. Findings include: Review of the facility assessment dated [DATE], indicated the Cedarwood Gardens believes that a strong successful infection prevention and control program is paramount. The Infection Control Preventionist oversees all infection control tasks including COVID-19 tests and results, maintains our internal tracking system for COVID, reports to regulatory agencies as required. Implementation and adherence to infection control and prevention practices are keys to preventing the transmission of healthcare associated infections, including respiratory diseases spread by droplet or airborne routes. The facility infection prevention and control practices include the following topics designed to prevent, identify, report, investigate, control infections and communicable diseases. -Hand hygiene -Standard precautions/transmission-based precautions (Contact, Droplet, Airborne) -Tracking and trending of facility acquired infections. -On-going staff education related to proper infection control and prevention -Handling, storing, processing, and transporting all linens and laundry in accordance with accepted national standards to produce hygienically clean laundry and prevent the spread of infection -Selection and use of Personal Protective Equipment 1. On 1/10/23 at 10:07 A.M., the surveyor observed Certified Nursing Assistant (CNA) #2, entering room [ROOM NUMBER]. The surveyor observed the COVID-19 isolation precautions sign at the door. CNA #2 was observed entering the room and did not perform hand hygiene prior to applying PPE. During an interview on 1/10/23 at 10:11 A.M., CNA #2 agreed that she did not perform hand hygiene prior to applying PPE and entering the room. On 1/10/23 at 10:12 A.M., the surveyor observed CNA #1 applying PPE prior to assisting CNA #2 in room [ROOM NUMBER]. CNA #1 did not perform hand hygiene. During an interview on 1/10/23 at 10:14 A.M., CNA #1 said she did not perform hand hygiene hygiene prior to applying PPE. 2a. On 1/10/23 at 10:15 A.M., the surveyor observed Housekeeper #1 cleaning the lower hall on the second floor. The surveyor observed the Housekeeper going from one COVID-19 positive room to another cleaning; she did not perform hand hygiene prior to applying PPE and was not wearing goggles or eye protection. As the Housekeeper was about to enter room [ROOM NUMBER] without performing hand hygiene or wearing eye protection, the surveyor intervened and asked the Housekeeper about not wearing eye protection and performing hand hygiene prior to entering a room with a COVID-19 isolation precautions sign at the door. During an interview on 1/10/23 at 10:18 A. M., Housekeeper #1 said she forgot to sanitize her hands and was never told by her supervisor that she needed to wear eye protection to enter COVID-19 positive rooms, she said she was new to healthcare. During an interview on 1/12/23 at 11:11 A.M., the Infection Control Preventionist Nurse said the expectation for droplet precautions is all staff perform hand hygiene, apply eye protection, in the form of goggles or a disposable face shield, prior to entering the room. b. On 1/11/23 at 11:25 A.M., the surveyor observed Rehabilitation Staff #1 performing an ultrasound treatment on a COVID-19 positive resident. The staff member did not have the isolation gown secured and the top of the gown was hanging down exposing the staff member's right shoulder, right upper arm, and top of her uniform. During an interview on 1/11/23 at 11:28 A.M., Nurse #1 observed Rehabilitation Staff #1 in the COVID-19 positive room and said the gown was not secured appropriately and could result in the staff unnecessarily exposing herself to COVID-19. She verbally directed the staff to correct the situation. During an interview on 1/11/23 at 11:31 A.M., Rehabilitation Staff #1 said she was aware she was treating a COVID-19 positive resident and was required to wear full PPE. She said the gown was not properly secured and began slipping off during the treatment. She said she should have secured the gown and ensured her clothing was covered and protected from the possible transmission of COVID-19 but she did not. During an interview on 1/12/23 at 11:07 A.M., the Director of Nurses said the expectation is for PPE to be used as required on the posted signs and the gowns should be secured to ensure the staff members' clothing is not exposed. He was made aware of the surveyors observations and said Rehabilitation Staff #1 did not wear her PPE correctly and the expectation was not met. 3. On 1/12/23 at 7:24 A.M., the surveyor observed the Receptionist performing the BinaxNOW COVID-19 Ag Card test. The surveyor observed that the Receptionist was not performing hand hygiene nor wearing gloves as she was opening the Binax Cards and handing them to the staff. The Receptionist's technique was not appropriate as she was continuously touching clean to dirty and dirty to clean. During an interview on 1/12/23 at 8:50 A.M., the Receptionist said when she was assigned to perform the facility Binax testing, they made her watch a Video about administering the test, but there was not much emphasis on infection control. The Receptionist agreed that she did not perform hand hygiene doing Binax testing. On 1/13/23 at 6:50 A.M., the surveyor observed the Receptionist seated at the front desk and a staff member waiting in the sitting area. There was a COVID-19 Binax test, with the nasal swab inserted, directly on top of a pile of blank individual staff testing logs (which would be taken and completed by the next staff member) on the Receptionist's desk. On 01/13/23 at 07:50 A.M., the surveyor observed the Receptionist, with ungloved hands, placing the test kit that was actively in use, with a nasal swab inserted, onto her mouse pad. During an interview on 01/13/23 at 07:51 A.M., the Receptionist said she did not know she needed to wear gloves while handling active COVID-19 tests or perform hand hygiene after handing them. On 1/13/23 at 7:58 A.M., the surveyor observed the Receptionist seated at the front desk and a staff member was waiting in the sitting area. There was a COVID-19 Binax test, with the nasal swab inserted directly on the mouse pad of the Receptionist's desk. During an interview on 1/13/23 at 7:59 A.M., the Receptionist said she was unaware that an active COVID-19 test could not be placed on common use surfaces (mouse pad, papers to be used). She said she was unaware that the surface was now contaminated and had talked with another surveyor about hand hygiene, but did not understand that the tests could contaminate surfaces as well as hands. During an interview on 1/12/23 at 11:11 A.M., the Infection Control Preventionist said the Receptionist should have performed hand hygiene while performing the Binax Now testing.