Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the use of bilateral nephrostomy tubes (a catheter inserted directly into the kidney that drains urine into a collecting bag outside the body), the facility failed to ensure nursing developed and implemented a baseline care plan related to his/her immediate care and treatment needs related to his/her nephrostomy tubes. Findings include:Review of the Facility Policy titled, Care Planning, revised 02/15/25, included but was not limited to the following:The Facility will develop and implement a Baseline admission Care Plan for each resident that includes the instructions needed to provide effective person-centered care of the resident that meet professional standards of quality care. The baseline care plan will be developed within 48 hours of a resident's admission and will remain in place until the initial Interdisciplinary Team (IDT) Care Plan Meeting. All Physician orders inclusive of medications, diagnoses, dietary, and therapy services are considered part of the plan of care. Resident #1 was admitted to the Facility in January 2025, diagnoses included Urothelial Carcinoma (a type of cancer that develops in the urothelial cells lining the urinary tract which are found in the bladder, renal pelvis, ureters, and urethra), status post Cystectomy (removal of the bladder), status post hydronephrosis (a condition where one or both kidneys swell due to a buildup of urine over time, often caused by a blockage or obstruction in the urinary tract), and had both an ileal conduit/urostomy (a surgical opening where a portion of the small intestine is used to create a pathway for urine to exit the body after the bladder has been removed) and bilateral nephrostomy tubes. Review of Resident #1's admission Baseline Care Plan, dated 01/08/25, indicated there was no documentation to support that nursing developed a baseline care plan related to his/her nephrostomy tubes, which included goals and interventions, related care, treatment, and maintenance of the nephrostomy tubes. During an interview on 07/16/25 at 12:15 P.M., Unit Manager #1 said their policy is to develop a baseline care plan within 48 hours of admission. After reviewing Resident #1's Baseline Care Plan with the surveyor, Unit Manager #1 said there was no documentation to support that nursing developed a baseline care plan for his/her nephrostomy tubes, and there should have been one completed. During an interview on 07/16/25 at 2:30 P.M., the Director of Nursing (DON) said she reviewed Resident #1's Medical Record and said there was no documentation to support that nursing developed a Baseline Care Plan relative to his/her nephrostomy tubes within 48 hours of his/her admission, as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the use of bilateral nephrostomy tubes (a catheter inserted directly into the kidney that drains urine into a collecting bag outside the body) the facility failed to ensure he/she received adequate nursing care in accordance with professional standards of practice when there were no Physician's orders related to the care and treatment for his/her nephrostomy tubes. Findings include:Review of [NAME] R. [NAME] H (2019) Nursing care and management of patients with a nephrostomy, Nursing Times [online]; 115:11, 40-43) indicated (but was not limited to) the following:- Nurses need to understand how to care for and manage patients with a nephrostomy. - Nurses need to understand issues around fluid management, infection control and management of the tube and bags. - Patients with nephrostomy tubes are at risk of pyelonephritis (inflammation of the kidney, usually due to infection). They should be monitored for signs and symptoms of infection.- Fluid management: If the kidney has become obstructed after initial insertion of the tube insertion, the patient may enter a phase of diuresis, characterized by high-volume outputs from the tube (polyuria). This requires close monitoring of the patient's fluid balances and vital signs. Each drainage route should be monitored separately and an overall total fluid output calculated (usually left/right/urethral and total). The patient's intake (intravenous or oral) should closely match the output. A closely monitored and adjusted fluid balance will prevent patient deterioration associated with rapid fluid loss. - Check drainage tubing is patent (open) and not kinked or twisted. - Ensure nephrostomy is secured at all times with drain fixation dressing (and secondary film dressing if required). - Dressings need to support the nephrostomy tube to prevent accidental tugging and secure it to the patient's skin. - Apply and change body-worn belt as required.- Good wound site care is essential to avoid exit-site infection and should include keeping the drain site clean and dry. - Check insertion site daily for bleeding, infection signs (pain, redness, swelling, leakage). - Drainage bags should be changed every 5-7 days.- Nephrostomy tubes should be changed every three months as recommended by the manufacturer.- The nephrostomy bag should be kept below the level of the kidney to ensure dependent drainage and emptied when it becomes three-quarters full.Resident #1 was admitted to the Facility in January 2025, diagnoses included Urothelial Carcinoma (a type of cancer that develops in the urothelial cells lining the urinary tract which are found in the bladder, renal pelvis, ureters, and urethra), status post Cystectomy (removal of the bladder), status post hydronephrosis (a condition where one or both kidneys swell due to a buildup of urine over time, often caused by a blockage or obstruction in the urinary tract), and had both an ileal conduit/urostomy (a surgical opening where a portion of the small intestine is used to create a pathway for urine to exit the body after the bladder has been removed) and bilateral nephrostomy tubes. Review of Resident #1's Hospital Patient Care Referral Form, dated 01/07/25, under the section, Active Lines, Drains, Airways and Wounds, indicated he/she was being discharged to the Facility with bilateral nephrostomy tubes and a urostomy/ileal conduit. Review of Resident #1's Nursing admission Assessment, dated 01/07/25, completed by Nurse #4, indicated it did not include information about his/her nephrostomy tubes.Review of Resident #1's Nursing admission Summary Progress Note, dated 01/07/25, indicated Resident #1 was admitted with a diagnosis of Colovaginal Fistula, had a right-lower abdominal quadrant urostomy with minimal output, bilateral pcns (percutaneous nephrostomy tubes), pressure sores to bilateral lower extremities, and the Attending Physician approved/confirmed all medications. However review of Resident #1's January 2025 Physician's Orders indicated there were no treatment orders obtained by nursing for the care of his/her nephrostomy tubes. Review of Resident #1's Medical Record which included the Medication Administration Record (MAR), the Treatment Administration Record (TAR), and the Nursing Progress notes indicated there was no documentation to support Nursing staff attempted to obtain Physician's orders for the care and treatment of his/her nephrostomy tubes. There were no Physician's orders related to dressing changes, type and frequency, monitoring of intake and output from each nephrostomy tube, what to do if the nephrostomy tubes were to become obstructed, nephrostomy bag collection change frequency, and flushing instructions, as appropriate. Further review of Resident #1's Medical Record indicated there was no documentation to support Nursing staff routinely assessed and maintained his/her nephrostomy tubes, and no documentation to support Nursing staff were monitoring his/her fluid intake and output from each of his/her nephrostomy tubes or his/her ileal conduit/urostomy.Review of Resident #1's Nursing Progress Notes indicated the following:01/08/25 - Bilateral nephrostomy tubes patent and draining clear yellow urine, dressing to nephrostomy sites changed.01/12/25 - Nephrostomy patent, dressing done with moderate amount of redness around site. Washed, dried and dressing applied.However neither of these Nursing Progress Notes indicated Resident #1's fluid intake and output amounts. During an interview on 07/16/25 at 8:40 A.M., Nurse #4 said Resident #1 had a urostomy and bilateral nephrostomy tubes. After reviewing the Nursing admission Assessment in the electronic health record (EHR) with the surveyor, Nurse #4 said there was no box to check off to reflect if a resident had either a urostomy or nephrostomy on the Assessment. Upon further review of the Assessment Form in the EHR, Nurse #4 said she could have clicked on the field that indicated other which allows the user to type a short note and said she could have entered the information there. Nurse #4 also said that the location of the urostomy and nephrostomy tubes should have been documented on the Skin Assessment portion of the Assessment, and neither were.Nurse #4 said that nephrostomy care and treatment orders should have been obtained from the physician upon admission and that she did not know why they were missed. During an interview on 07/16/25 at 12:15 P.M., Unit Manager #1 said when a resident is admitted from the hospital, it was the responsibility of the admitting nurse to review the Hospital Discharge Summary to determine the resident's needs. Unit Manager #1 said after reviewing Hospital Discharge Summary, the admitting nurse would then review that information with the Attending Physician or their designee, confirm the orders, and then enter them into the EHR. Unit Manager #1 said there should have been Physician's orders in place for the care and treatment of Resident #1's nephrostomy tubes. Unit Manager #1 reviewed Resident #1's Nursing admission Assessment, Physician's Orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR) and said there were no Physician's Orders for the care and treatment of his/her nephrostomy tubes, and that Nurse #4 failed to document Resident #1 had nephrostomy tubes on the admission Assessment.Unit Manager #1 reviewed Resident #1's Nursing Progress Notes, dated 01/08/25 and 01/12/25, and said the nurses should not have been providing nephrostomy care without physician's orders, should have realized there were no orders, and nurses should have contacted the Physician to obtain them. Unit Manager #1 said that residents with nephrostomy tubes (and urostomy) should have their fluid intake monitored and documented as well as the fluid output from each source documented, and said there was no documentation to support nursing monitored Resident #1's fluid intake and output, as required. During an interview on 07/16/25 at 2:30 P.M., the Director of Nursing (DON) said prior to or upon admission, the admitting nurse should review the hospital discharge paperwork, then review and obtain necessary orders from the Attending Physician or the on-call provider. The DON said an example of the orders required for the care and treatment for nephrostomy tubes should include orders for how frequently to change the nephrostomy bag, flushing the nephrostomy tubes if appropriate, dressing changes, and fluid monitoring. The DON said she reviewed Resident #1's Medical Record and said there were no orders for nephrostomy care and no documentation to support that nursing staff were monitoring Resident #1s fluid intake or output from each nephrostomy tube or urostomy.After reviewing the Nursing Progress Notes during the interview with the surveyor, the DON said the nursing staff should not have been providing nephrostomy care without physician's orders because the orders are what dictate the specific care a resident should be receiving.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #3), the Facility failed to ensure they maintained complete and accurate medical records when the Certified Nurse Aide (CNA) Assignment Sheets (document that includes the residents' names, room numbers and a brief synopsis of resident care needs that CNAs use daily as a reference tool) and [NAME] (a readily accessible computerized document used by CNAs to quickly reference key information about a patient's care plan, allowing them to efficiently provide appropriate care during their shift), were updated to accurately reflect his/her change in ability to transfer in and out of bed. Findings include: Resident #3 was admitted to the Facility in August 2024, diagnoses included Hemiplegia (paralysis on one side of the body), Osteomyelitis (infection in the bone) of the left ankle and foot, and reduced mobility. Review of Resident #3's Significant Change Minimum Data Set (MDS) Assessment, dated 01/22/25 indicated Resident #3 was moderately cognitively impaired with a score of 9 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). The Assessment also indicated Resident #3 was dependent on staff for bed to chair to bed transfers. Review of Resident #3's CNA [NAME] indicated he/she required partial to moderate assistance from staff for transfers. Review of the CNA Assignment Sheet master copies (for Resident #3's unit located at the Nurses' Station) indicated that Resident #3 was able to transfer with the assistance of one staff member, and some assignment sheets indicated a different resident's name with the same room number assignment as Resident #3, which also indicated that the resident required the assistance of one staff member. During an interview on 02/05/25 at 12:05 P.M., the Director of Rehabilitation said Resident #3 had experienced a decline in condition and the MDS Assessment on 01/22/25 that indicated he/she was dependent for transfers meant that he/she required the use of a Hoyer lift (a mechanical device that helps move people with limited mobility from one place to another) for safety with transfers which require two staff members. During an interview on 02/04/25 at 10:40 A.M., CNA #1 said she uses the information on the CNA Assignment Sheet and [NAME] for information as to what kind of assistance her assigned residents required. CNA #1 said she keeps the Assignment Sheet in her pocket and uses it as a reference throughout her shift. During an interview on 02/04/25 at 12:54 P.M., CNA #2 said she uses the CNA Report [Assignment] sheets to obtain the information she needs in order to take care of the residents assigned to her. During an interview on 02/04/25 at 2:02 P.M., CNA #3 said ideally CNAs should verbally report off to each other at the change of every shift to discuss each resident and what their care needs were, but said that does not always happen. CNA #3 said she thinks there are two or three different master copies of the Unit's (Resident #3's unit) CNA Assignment Sheets, because CNA staffing numbers vary each shift, so the resident caseload needs to be split up differently depending on the number of CNAs working. CNA #3 said that the Assignment Sheets were rarely updated timely and that CNAs should not rely on them for current information as to how to care for their residents. In addition, CNA #3 said that the [NAME] information in the computer was also not kept up to date, and that she relied on herself to know what needed to be done for her residents. CNA #3 said she left a note for the Unit Manager two to three weeks ago (exact date unknown) requesting updated CNA Assignment Sheets, but said she was not sure if the Unit Manager ever updated them. During an interview on 02/04/25 at 2:40 P.M., CNA #4 said she gets the information she needs to care for the residents assigned to her from other CNAs, the CNA [NAME] and the CNA Assignment Sheet. During an interview on 02/04/25 at 2:50 P.M., CNA #5 said that she gets information about the residents in her care from the CNA that reports off to her at the change of shift, the CNA [NAME], and the CNA Assignment Sheets. During an interview on 02/04/25 at 4:10 P.M., CNA #6 said CNAs should find updated resident care information by looking at the [NAME] and the CNA Assignment Sheets. CNA #6 said that Resident #3 used to be able to transfer in and out of bed with one staff member assisting him/her but now he/she required a Hoyer lift with two staff members for transfers, but said he could not recall when this change occurred. During the interview, CNA #6 reviewed the CNA Assignment Sheet that indicated Resident #3 was able to transfer with the assistance of one staff member, with the surveyor. CNA #6 said that the information was incorrect and if a staff member did not know Resident #3 and used the CNA Assignment Sheet for guidance indicating Resident #3 only needed one person for assistance, that would be dangerous for Resident #3. During an interview on 02/05/25 at 2:35 P.M., the Unit Manager said the CNA Assignment Sheets, the [NAME] and as well as the Care Plan, should reflect whatever the residents' current care needs were and that she expected the CNAs to utilize the CNA Assignment Sheets as their primary source for resident care information. The Unit Manager said she was responsible for ensuring the CNA Assignment Sheets and the care [NAME] were up to date and said she was aware they were not. The Unit Manager said that she would try to hand-write any resident care changes on the CNA Assignment sheets as they occurred because she did not have access to the computerized template, and that until recently she did not know how to update the [NAME] in the computer system. During an interview on 02/04/25 at 4:45 P.M., the Director of Nursing (DON) said the CNA Assignment Sheets should not be the only resource for staff to obtain information as to what a resident's care needs were and that CNAs should be reviewing the [NAME] prior to caring for any resident. The DON said if a resident had a change in condition, the [NAME] should be updated within one week. After reviewing Resident #3's [NAME] and CNA Assignment Sheets with the surveyor, the DON said if Resident #3 required a Hoyer lift, the CNA Assignment Sheets and [NAME] should have been updated to reflect this change, and had not.

Based on observation, interview, and policy review the facility failed to maintain a clean and homelike environment for one Resident (#11) on one Unit (#1) out of three units observed. Specifically, for Resident #11 who resided on Unit #1 the facility failed to ensure that the Resident's window covering was maintained in a clean manner. Findings include: Review of the facility policy titled Environmental Services Guidelines, dated September 2011, indicated the following: -Cleaning of walls, curtains, blinds, etc. will be completed when dust/soil is visible. On 5/9/24 at 10:20 A.M., the surveyor observed multiple areas of dried dark brown material and a large stain on Resident #11's window covering. During an interview at the time, Resident #11 said his/her window covering was dirty and he/she would like to have it cleaned or replaced. Resident #11 further said that he/she had not seen anyone clean the window covering recently and he/she was unsure what the spots and large stain were from. On 5/13/24 at 8:31 A.M., the surveyor observed that Resident 11's window covering remained with multiple areas of dried dark brown material and a large stain. During an observation and interview on 5/14/24 at 3:36 P.M., the surveyor and the Housekeeping Director observed Resident #11's window covering that remained with multiple spots of dried dark brown material and a large stain. The Housekeeping Director said the Resident's window covering should be wiped down regularly and if it could not be cleaned, housekeeping should have asked to have the window covering removed and replaced. The Housekeeping Director further said no one had informed him of the large stain on the window covering and he had window coverings readily available in the facility, that once staff noticed the window covering was visibly dirty a new window covering should have been requested.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) Assessments for two Residents (#60 and #21), out of a total sample of 25 residents. Specifically, the facility failed to ensure the MDS Assessment was accurately coded relative to: 1. For Resident #60, the use of hypoglycemic medications (medications that reduce blood sugar [glucose]), antianxiety medication (used to treat feelings of fear, dread, uneasiness that may occur as a reaction to stress) and that the Resident was on dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). 2. For Resident #21, the administration of antipsychotic (used to treat symptoms of psychosis which include hallucinations, delusions and Dementia), antibiotic (used to treat bacterial infections), antianxiety and hypoglycemic medications. Findings include: 1. Resident #60 was admitted to the facility in October 2022, with diagnoses including End Stage Renal Disease (ESRD: medical condition in which the kidneys cease to function on a permanent basis), Psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality), Anxiety (reaction to stress that can cause fear, dread, and uneasiness), Type 2 Diabetes (inability for the body to regulate blood glucose levels in the blood) and dependence of renal dialysis. a. Review of the December 2023 Physician's orders indicated: -Insulin Lispro Kwikpen 100 Units(U)/1 milliliter (ml), 5 units with meals and 5 units at 6:00 A.M., and 5 units with lunch and dinner, initiated 2/13/23 -Insulin Glargine Pen 100 IU/1 ml solution, 16 units at 6:00 A.M., 16 units at 8:00 A.M. and 16 units at 8:00 P.M. -Clonazepam (antianxiety medication) 0.5 milligrams (mg) daily, initiated 12/28/23 -Dialysis on Mondays, Wednesdays, and Fridays, initiated 11/14/22 -Monitor the Dialysis shunt (surgically created connection between an artery and vein that provides access to the bloodstream for dialysis) every shift, bruit and thrill (sounds that can be heard or felt near a dialysis site and indicates that the site is working), initiated 11/14/22 Review of the December 2023 Medication Administration Record (MAR) indicated the Clonazepam, and the Insulin was administered as ordered and that the dialysis site and bruit and thrill were monitored as ordered. Review of the MDS assessment dated [DATE], indicated Resident #60 received Insulin (type of hypoglycemic medication) for 7 days. Further review of the MDS Assessment did not indicate that the Resident was on hypoglycemic and antianxiety medications or received dialysis during the assessment period. b. Review of the March 2024 Physician's orders indicated: -Dialysis on Mondays, Wednesdays, and Fridays, initiated 11/14/22 -Monitor the Dialysis shunt every shift, bruit and thrill, initiated 11/14/22 Review of the March 2024 MAR indicated the dialysis site, and the bruit and thrill were monitored as ordered. Review of the MDS assessment dated [DATE], indicated Resident #60 was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15 and was not receiving dialysis during the assessment period. On 5/9/24 at 9:00 A.M., the surveyor observed the Resident seated at the edge of the bed eating breakfast. During an interview, Resident #60 said that he/she had been receiving dialysis three times weekly on Mondays, Wednesdays and Fridays, had been on dialysis for a long time and has had no issues with the treatments. During an interview on 5/14/24 at 2:32 P.M., MDS Nurse #1 said that Resident #60's MDS Assessments dated 12/30/23 and 3/31/24 were reviewed and were inaccurate. Nurse #1 said the identified miscoded areas relative to the use of hypoglycemic medications, antianxiety medication, and that the Resident was not receiving dialysis were an oversight and modifications were made to the assessments. 2. Resident #21 was admitted to the facility in April 2021 with diagnoses including Adjustment Disorder with mixed Anxiety and Depressed Mood, Psychotic Disorder with delusions, Type 1 Diabetes (condition in which the body is unable to regulate blood sugar levels) and Schizophrenia (a serious mental disorder that interferes with a person's ability to think clearly, manage emotions, make decisions and relate to others). a. Review of the December 2023 Physician's orders indicated: -Augmentin (antibiotic) 500 mg-125 mg orally twice daily for a urinary tract infection (UTI), initiated 12/8/23 and discontinued 12/22/23 -Aripiprazole (antipsychotic) 15 mg daily, initiated 7/20/21 -Novolog Insulin 100 U/1 ml solution, per sliding scale (varies the dose of Insulin based on blood glucose [sugar] levels) before meals , initiated 7/12/23 -Novolog Insulin 100 U/1 ml solution, 6 units before meals, initiated 7/12/23 -Levemir Insulin 100 U/1 ml solution, 24 units at 8:00 P.M., initiated 6/1/22 Review of the December 2023 MAR indicated the Augmentin, Aripiprazole, and scheduled Insulin medications were administered as ordered. Further review of the December 2023 MAR indicated no documented evidence that an antianxiety medication was administered. Review of the MDS assessment dated [DATE], indicated Resident #21 received 7 days of Insulin and an antianxiety medication, and did not indicate that he/she received an antipsychotic, antibiotic or was on a hypoglycemic medication during the assessment period. b. Review of the March 2024 Physician's orders indicated Valium (antianxiety medication) 2 mg every 8 hours was initiated on 3/15/24. Review of the MDS assessment dated [DATE], indicated Resident #21 received antianxiety medication during the assessment period. Review of the March 2024 MAR indicated the Valium was not administered (was held) until 3/16/24. During an interview on 5/14/24 at 5:21 P.M., MDS Nurse #1 said he reviewed Resident #21's MDS Assessments dated 12/14/23 and 3/15/24, and the MDS Assessments were miscoded relative to the administration of an antipsychotic, antibiotic, antianxiety and hypoglycemic medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #82 was admitted to the facility in October 2023, with diagnoses including Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment), Polymyalgia Rheumatica (an inflammatory disorder causing muscle pain and stiffness), Atherosclerotic Heart Disease (damage or disease in the hearts major blood vessels), and Peripheral Vascular Disease (a circulatory condition where the blood vessels narrow and reduce blood flow to the limbs). Review of the Minimum Data Set (MDS) Assessment indicated the Resident had quarterly or comprehensive MDS Assessments completed with Assessment Reference Dates (ARD - date used as a specific end point of a look back period in the MDS Assessment process) of 11/2/23 and 2/2/24. Review of the Resident's medical record indicated no documentation that a Care Plan conference was held or the Resident and/or Resident Representative was involved in the care planning process after the completion of the 11/2/23 and 2/2/24 MDS Assessments. During an interview on 5/13/24 at 8:27 A.M., Nurse #4 said Care Plan conferences are held after the MDS Assessment is completed. The surveyor and Nurse #4 reviewed Resident #82's medical record and Nurse #4 said she was unable to locate any documentation a Care Plan conference had been held following the completion of the 11/2/23 and 2/2/24 MDS Assessments. Nurse #4 further said the Care Plan Meeting documentation should include who was invited to the meeting, who attended the meeting, and what changes were made to a resident's care plan. During an interview on 5/14/24 at 10:13 A.M., the Corporate Quality Assurance Nurse said Care Plan conferences should be held following the completion of the MDS Assessments. The Corporate Quality Assurance Nurse further said she was unable to locate any documentation to show Care Plan conferences were held for Resident #82 following the completion of the 11/2/23 and 2/2/24 MDS Assessments. She said documentation should be placed in the chart indicating who attended the conference and what was discussed at the care plan conference, but it did not appear this was done. Based on record review and interview, the facility failed to ensure that two Residents (#109 and #82) and/or their Representative, out of a total sample of 25 residents, were included in the comprehensive care planning process. Specifically, the facility failed to: 1. For Resident #109, schedule Care Plan meetings as required, and facilitate participation by the Resident and/or Representative in the care planning process. 2. For Resident #82, ensure that a Care Plan conference was held, and the Resident and/or Resident Representative was involved in the care planning process after the completion of two MDS Assessments. Findings include: Review of the facility policy titled Care Planning, revised on 10/28/22, indicated the following: -A letter will be sent to each resident or resident representative inviting them to the meeting. -Attendance: CP (Care Plan) Coordinator (Social Worker) oversees the meeting, Unit Manager, Activities Staff, Dietary, CNA (Certified Nurse ' s Aide) Rehabilitation Staff as indicated. -During the care plan meeting, IDT (interdisciplinary team) member will summarize their care plan goals and interventions with the IDT and resident/resident representative. -The resident/resident representative's input and changes to any part of the plan of care will be updated by the appropriate IDT member 1. Resident #109 was admitted to the facility in September 2023, with diagnoses including malnutrition, COPD (a chronic lung disease that causes obstructed airflow and breathing problems) and Respiratory Failure (a serious condition that makes it difficult to breathe on your own. Develops when the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide from the body). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was cognitively intact as evidenced by a BIMS (Brief Interview for Mental Status) score of 13 out of 15. During an interview on 5/9/24 at 10:39 A.M., Resident #109 said that he/she had meetings with outside community support for discharge planning that included the facility Social Worker (SW). Resident #109 said he/she could not recall participating in Care Plan meetings that included the IDT. Review of the medical record and UDA's (User Defined Assessments) indicated no documented evidence of care plan meetings since the Resident's admission in September 2023. During an interview on 5/14/24 at 1:44 P.M., Social Worker (SW) #1 said that Care Plan meetings are held typically every 92 days, unless there is a significant change. SW #1 said that meetings are held with the resident and/or their representative and the IDT (which can include social services, rehabilitation services, nursing, dietary and activities) to review the Resident's care plan and to talk about progress, discharge planning or any concerns the Resident might have. SW #1 said the Care Plan meeting is documented under the UDA titled Care Plan Meeting. SW #1 further said that if the assessments are not documented in the computer under the UDA then the meeting did not occur. SW #1 said that the Care Plan meetings most likely did not occur and that it may have been an oversight by the facility staff. During a follow-up interview on 5/14/24 at 2:09 P.M., SW #1 said that after talking with the MDS Nurse it appeared that the Resident should have had three Care Plan meetings and did not as required. SW #1 additionally said that the Resident was not on any Care Plan meetings schedules and should have been.

Based on observation, interview, record and policy review, the facility failed to provide care in accordance with professional standards of practice for one Resident (#18), out of a total sample of 25 residents, with a Peripherally Inserted Central Catheter (PICC: a thin, soft tube that is inserted into a vein in the arm, for long-term antibiotics, nutrition, medications, and blood draws. The PICC is a type of CVAD [Central Vascular Access Device] catheter) placing Resident #18 at risk for undiagnosed infiltration (when fluid or medication given by an intravenous device exits the vein and enters the soft tissues) and/or deep vein thrombosis (DVT: a blood clot in a deep vein). Specifically, the facility staff failed to: -appropriately monitor the PICC device and discontinue use when external catheter length measurements varied from the admission insertion measurements. -complete external catheter length and arm circumference measurements as ordered. -notify the Provider timely when changes in external catheter length and arm circumference measurements were identified. Findings include: Resident #18 was admitted to the facility in January 2024, with the following diagnoses: Osteomyelitis of the right femur (inflammation of the thigh bone or bone marrow due to infection), paraplegia (chronic condition that involves the partial or complete loss of muscle function and feeling in the lower half of the body, including both legs) and Stage 4 pressure ulcers of the right and left buttock (full thickness tissue loss with exposed bone, tendon or muscle. Slough [is non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture] or eschar [dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color] may be present on some parts of the wound bed). Review of the facility policy titled Central Vascular Access Device (CVAD): Dressing Changes, dated 7/1/18, included but was not limited to: -measurement of external catheter length upon admission/insertion of the PICC and with every dressing change. -measurement of upper arm circumference, 3 inches above insertion site or other location determined by insertion or admission Nurse, upon admission/insertion of the PICC and with every dressing change. -If the measurements are different, notify the Practitioner (Physician/Nurse Practitioner [NP]/ Physician Assistant [PA]) Nurse to discuss clinical plan. According to Lippincott Nursing Procedures - 9th Edition (2023), to ensure the PICC line has not migrated (moved out of the appropriate location for safe use): -the Nurse should measure the external length of the catheter during dressing changes. -Additionally, the Nurse should measure the arm circumference above the PICC insertion site when clinically indicated to monitor for the presence of edema (swelling) and DVT. Review of Resident #18's Physician orders from March 2024 to May 2024 indicated, but was not limited to, the following: -Intravenous (IV: medication administered through a catheter, such as the PICC, for stronger/quicker effect) antibiotic (medication given to treat infection), Cefepime 2 grams (gm) every 12 hours for treatment of Osteomyelitis and Stage 4 pressure ulcer of the right buttock, initated 3/5/24 and discontinued on 4/16/24. -Intravenous antibiotic Cefepime 2 gm every 12 hours for treatment of Osteomyelitis and Stage 4 pressure ulcer of the right buttock, initiated 4/16/24 and discontinued on 5/14/24. -PICC dressing change every 7 days, measure external catheter length and arm circumference at 3 inches above insertion site with each dressing change. admission external catheter length of 0 cm (centimeters) and arm circumference of 32 cm, initiated 3/7/24 and discontinued 5/2/24. -PICC dressing change every Thursday, measure external catheter length and arm circumference at 3 inches above insertion site with each dressing change. admission external catheter length of 0 cm and arm circumference of 32 cm, initiated 5/2/24. Review of PICC Insertion Report titled Record for IV Nurse dated 3/6/24, indicated the measurement of Resident #18 PICC's external catheter was 0 cm at time of insertion and the arm circumference that was measured 10 cm (3.9 inches) above the insertion site was 32 cm at time of insertion. Review of Resident #18's PICC care plan dated 1/31/24 and revised on 3/8/24, included the following interventions: -1/31/24: monitor for signs/symptoms of catheter and infusion related complications. -1/31/24: change dressing per policy, specific catheter type. -1/31/24: measure external catheter length, and upper arm circumference per policy and notify Prescriber (Physician/NP/PA) if change noted from previous measurements. Review of the March 2024 Treatment Administration Record (TAR) indicated scheduled PICC dressing changes were due on 3/12/24, 3/19/24 and 3/26/24. Further review of the March 2024 TAR indicated no Pro Re Nata (PRN: as needed) documentation for unscheduled dressing changes. Review of the PICC dressing change documentation on the scheduled TAR change dates indicated: -3/12/24: M was documented with no attached note in the TAR Documentation Report indicating what M meant. No measurements were documented. -3/19/24: held (not done), with attached note in TAR Documentation Report that indicated the dressing change was held due to the dressing being changed on 3/14/24 and change was not due until 3/21/24. No measurements were documented. -3/26/24: held, with attached note in TAR Documentation Report that indicated held due to dressing change was performed by the Wound Nurse. No measurements were documented. Review of the April 2024 TAR indicated weekly PICC dressing changes were due on 4/2/24, 4/9/24, 4/16/24, 4/23/24 and 4/30/24. Further review of the April 2024 TAR PRN PICC dressing documentation review indicated no documentation of unscheduled dressing changes. Review of the PICC dressing change documentation on the scheduled TAR change dates indicated: -4/2/24: M with no attached note in TAR Documentation Report that indicated what M meant. No measurements were documented. -4/9/24: M with no attached note in TAR Documentation Report that indicated what M meant. No measurements were documented. -4/16/24: held, with attached note in TAR Documentation Report that indicated the dressing was completed by the Wound Nurse. No measurements were documented. -4/23/24: held, with attached note in TAR Documentation Report that indicated completed by a different Nurse. No measurements were documented. -4/30/24: held, with attached note in TAR Documentation Report that indicated the Charge Nurse was to complete the dressing change. No measurements were documented. Review of May 2024 TAR indicated weekly PICC dressing changes were due on 5/2/24 and 5/9/24. Further review of May 2024 TAR PRN PICC dressing documentation indicated no unscheduled dressing change documentation. Review of the PICC dressing change documentation on the scheduled TAR change dates indicated: -5/2/24: dressing completed. Measurements included 13 cm external catheter length (+13 cm change from the time of insertion) and 38 cm arm circumference (+6 cm change from the time of insertion). Note attached in the TAR Documentation Report indicated dressing changed with no issues. -5/9/24: dressing completed. Measurements included 11 cm external catheter length (+11 cm change from the time of insertion) and 44 cm arm circumference (+20 cm change from the time of insertion). No attached note in the TAR Documentation Report. Review of the Nursing Progress Notes from March 2024 to May 2024 addressing PICC dressing changes, external catheter length and arm circumference measurements and/or notification to Provider of changes to measurements indicated the following: -3/14/24 at 9:59 P.M.: PICC dressing changed. External catheter length 0 cm and arm circumference 42 cm (+10 cm change from the time of insertion). -4/5/24 at 2:36 P.M.: PICC dressing changed by Unit Manager (UM) this shift. No measurements documented. -5/9/24 at 3:22 P.M.: PICC line dressing changed with no issues. External catheter length of 12.5 cm (+12.5 cm change from the time of insertion) and 38 cm circumference measured at 2 inches above the insertion site (+6 cm change from the time of insertion). During an interview on 5/14/24 at 9:45 A.M., Nurse #2 said if there was a change identified when performing a PICC dressing change, the Nurse would notify the Provider for orders. During an interview on 5/14/24 at 1:32 P.M., UM #2 said during a dressing change measurement would be obtained for the external catheter length and arm circumference and if there was variation in the measurements from the admission insertion measurements, that the Provider would be notified right away. UM #2 said that the expectation would be the PICC would not be used until orders from the Provider were obtained as the changed measurements place Resident #18 at risk for having infiltration and/or the catheter no longer being in the correct place for use. When the surveyor asked about the documentation process, UM #2 said if the Charge Nurse completed the dressing change, the expectation would be for the Nurse on the medication cart to document the dressing change as held, and note who completed the treatment. UM #2 said the Charge Nurse would then document the dressing change in a nursing progress note. The surveyor and UM #2 reviewed the 5/2/24 and 5/9/24 dressing change documentation on the Resident's TAR, and UM #2 said the measurements were different than the measurements obtained on the PICC insertion date. UM #2 said if those were the measurements obtained, the Nurse should not use the PICC without contacting the Provider for additional instructions. On 5/14/24 at 2:15 P.M., the surveyor observed UM #2 measure the external catheter length of Resident #18's PICC and the external catheter measurement obtained was 1.5 cm (+1.5 cm change from the time of insertion). UM #2 said that she would go speak with the Nurse Practitioner (NP) to obtain orders due to the measurement of 1.5 cm external catheter length being longer than the insertion length of 0 cm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide proper treatment and care for good foot health for one Resident (#226) out of a total sample of 25 residents. Specifically, for Resident #226, the facility staff failed to assess, and assist with completing and submitting the necessary podiatry consent form to facilitate timely podiatry services to address the Resident's long toenails. Findings include: Review of the facility policy titled Consulting Services, Podiatry/Dental/Optometry/Audiology approved on 12/22/16, indicated that residents/resident representative are provided information about consulting services upon admission and at any time when need arises. Resident #226 was admitted to the facility in April 2024 with diagnoses including localized edema (a disorder that causes swelling in a specific area of the body due to a buildup of fluid) and peripheral edema (swelling in the arms, legs, ankles, feet and hands caused by fluid retention in the tissues). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was mildly cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 7 out of 15. Review of the Resident's medical record indicated the Resident's Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself) had been invoked (put into effect by a Physician) on 4/29/24. On 5/9/24 at 11:15 A.M., the surveyor observed that the Resident was wearing flip flop sandals and his/her toenails were long, thick and slightly yellow. Resident #226 said that his/her toenails were uncomfortable and depending on what shoes he/she had on they sometimes hurt. Resident #226 said that he/she was unsure of who to contact to help get his/her toenails cut. Review of the Request for Services for the company contracted to provide podiatry services, indicated that the form was incomplete. Further review of the Request for Services form indicated no disciplines was selected, including podiatry services, and the signature area was blank. During an interview on 5/15/24 at 9:55 A.M., Nurse #5 said that she often completed paperwork when a new admission came into the facility and that the contracted service consent form was reviewed upon admission with the resident and/or their representative/HCP. Nurse #5 pulled up the contracted service consent form on the computer and found that the Resident's name and date of birth were completed, but no services were selected and the form was not signed. Nurse #5 said it appeared that the services provided by the contracted company had not been reviewed with the Resident or his/her Representative but should have been. During an interview on 5/15/24 at 10:22 A.M., Social Worker (SW) #1 said that the contracted company consent form was completed upon admission and faxed to the contracted company so that the consents were on file when a resident requested or required any of the services offered. SW #1 said that the Unit Manager (UM), SW and Director of Nurses (DON) are provided a list of residents that are to be seen by the contracted company through email. SW #1 said that the UM, SW and DON can also make a referral. SW #1 said she was not aware of Resident #226 receiving any services through the contracted company. During an interview and observation on 5/15/24 at 10:54 A.M., Nurse #3 said that she looks at feet and toenails when completing weekly skin checks. Nurse #3 said that Resident #226's toenails were long, and that she noticed it when he/she was admitted but the long toenails had not been addressed at this point. The surveyor and Nurse #3 observed Resident #226's toenails and Nurse #3 said his/her toenails were long, but thought she might be able to cut the toenails herself, except for one nail that was too thick. Nurse #3 said that she could also follow-up to ensure the Resident will be seen by a Podiatrist through the contracted company.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that one Resident (#35) out of a total sample of 25 residents, was provided with an environment that was free from accidental hazards. Specifically, for Resident #35, the facility failed to implement the appropriate size bed side rails and maintain the bed in the lowest position after the Resident sustained a fall and injury, as preventative measures for further falls and injuries. Findings include: Review of the facility policy titled Care Planning, revised on 10/28/22, indicated the following: -All MD (Medical Doctor) orders .are considered a part of the care plan. Resident #35 was admitted to the facility in March 2024, with a new diagnosis of above the knee amputation (AKA -surgically cutting off the limb) of the right leg. Review of the Fall Care Plan initiated on 3/26/24, indicated the Resident was at risk for falls due to a change in mobility/gait status post right AKA and deconditioning (physiological change following a period of inactivity, bedrest or sedentary lifestyle). Review of a Nurses Progress note dated 4/4/24 (late entry for 4/3/24), indicated the following: -CNA (Certified Nurses Aide) came out of another resident's room when they heard someone yelling help me and Resident #35 was seen hanging off the side of the bed. -Resident #35 was kneeling on the floor and had his/her hands on the bed rail. -Resident #35 said he/she was lying on their side when the air mattress shifted his/her weight, and he/she slipped out of the bed and caught him/herself on the bedrail and landed on his/her left leg. -Amputation site had been hit; two stitches popped open resulting in light bleeding. -Skin tear on the left lower abdomen. Review of the incident report completed on 4/3/24 due to an unwitnessed fall/near fall out of bed indicated the following: -Resident was lying on their side after patient care, waiting for wound care to be completed. -Environmental factors included: air mattress, no side rail. Review of the Active Orders Report indicated a Physician order for quarter (1/4) side rail on bilateral (both) side(s) of bed with a start date of 3/25/24. Review of the UDA (User Defined Assessment) section titled Side Rail assessment dated [DATE], indicated 1/4 bed side rails right upper and [right] lower. During a telephone interview on 5/14/24 at 9:25 A.M., CNA #1 said that the Resident was on an air mattress with the hand bar side rails in the locked position. CNA #1 said immediately after the (fall) incident, the new intervention was to install the longer bed side rails, also known as 1/4 bed side rails. During an interview on 5/14/24 at 10:33 A.M., the surveyor and Unit Manager (UM) #1 reviewed the Physician orders, the admission side rail assessment, and the comprehensive care plan for Resident #35. UM #1 said that the nursing staff had completed a side rail assessment upon the Resident's admission that indicated right upper and [right] lower 1/4 bed side rails were appropriate at this time. UM #1 said that was a documentation error and that it should have indicated right and left upper 1/4 bed side rails were appropriate at this time. UM #1 said that per the Physician orders and the side rail assessment, 1/4 bed side rails should have been in place upon admission and at the time of the Resident's fall on 4/3/24. UM #1 said that based on the information she had, the small hand positioning bars were in place rather than the required 1/4 bed side rails. The surveyor and UM #1 reviewed the updated care plan which indicated a new intervention on 4/5/24 to add 1/4 bed side rails to the bed, indicating that the 1/4 bed side rails had previously not been installed on the Resident's bed at the time of the fall that occurred on 4/3/24, as required per the Resident's care plan. Review of the Falls Care Plan initiated on 3/26/24 and updated on 4/5/24, after Resident #35 experienced a fall out of bed on 4/3/24, indicated to keep the bed in the lowest position at all times. On 5/13/24 at 10:40 A.M., the surveyor observed Resident #35 to be seated in bed with the head of the bed elevated, watching television. The surveyor further observed that the bed was not set to the lowest position. On 5/15/24 at 10:03 A.M., the surveyor observed Resident #35 lying in bed with the bed not set in the lowest position. During an interview immediately following the observation on 5/15/24 at 10:03 A.M., the surveyor and CNA #2 reviewed the [NAME] (a documentation system that enables Nurses to write, organize, and easily reference key patient information that shapes their nursing care plan and is utilized by the CNA's when providing care) and CNA #2 said that per the [NAME] the Resident's bed should be in the lowest position as an intervention for fall safety. The surveyor and CNA #2 walked to the Resident's room and observed that the bed was not in the lowest position as indicated in the Resident's care plan. CNA #2 said that the bed was not in the lowest position and that it should be much lower than the position it was found, per the Resident's plan of care.

Based on observation, interview, record and policy review, the facility failed to provide nutritional care and services for two Residents (#63 and #84), out of a total sample of 25 residents. Specifically, the facility staff failed to: 1. For Resident #63, provide a nutritional supplement when the Resident was identified as being at nutritional risk due to a resolving hip fracture. 2. For Resident #84, provide an increase in a nutritional supplement as indicated for added calories, protein and hydration support from once to twice daily. Findings include: Review of the facility's policy titled Nutrition Management, dated 6/6/22, indicated the following: -Review dietitian's recommendations. Obtain orders per recommendation. -Review dietitian's progress notes to identify ongoing progress and recommendations. 1. Resident #63 was admitted to the facility in June 2022, with diagnoses including Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment), and a fracture of the neck of the right femur (hip fracture) sustained in April 2024. Review of the Minimum Data Set (MDS) Assessment, dated 4/24/24 indicated the following: -Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of zero out of 15 total possible points. -Resident was dependent on staff for eating. -Resident had a fracture related to a fall in the past six months. -Resident had recent surgery requiring active skilled nursing facility (SNF) care. -Resident had repair of fracture of pelvis, hip, leg, knee or ankle. Review of the Readmission, Initial Nutritional History Assessment, dated 4/30/24 indicated the following: -Resident did not take supplements. -Resident had a resolving fractured right hip. -Resident was at nutritional risk due to experiencing or having the potential for unplanned weight loss, skin breakdown, and delayed wound healing. -The Dietitian made a recommendation for House supplement 237 milliliters (ml) twice a day. Review of the Physician's orders, dated 4/30/24 through 5/15/24 indicated the following: -Diet-House regular, regular texture, thin liquids. -HS (hour of sleep) substantial snack. Further review of the Physician's orders indicated no evidence of a Physician's order for the House supplement as recommended by the Dietitian on 4/30/24. Review of the Medication Administration Record (MAR) dated 4/30/24 through 5/14/24, indicated no evidence that a House supplement had been administered to Resident #63 as recommended by the Dietitian. During an interview on 5/14/24 at 1:53 P.M., Unit Manager (UM) #3 said when the Dietitian has a recommendation for a resident, it is communicated through an e-mail to the UM, the Director of Nurses (DON), and the Nurse Practitioner (NP). UM #3 said it was her responsibility to review the recommendation with the NP and obtain an order for the recommendation. UM #3 said she checks her e-mail every day and did not recall receiving an e-mail regarding Resident #63. UM #3 checked her e-mails and provided the surveyor with a recommendation for Resident #63, from the Dietitian, that was dated 4/30/24, and requesting to implement House supplement 237 ml twice a day. UM #3 said that she had been having computer problems and must have missed the recommendation. 2. Resident #84 was admitted to the facility in August 2023, with the diagnosis of Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy resulting in too much sugar in the blood). Review of the MDS Assessment, dated 2/1/24, indicated the following: -Resident had intact cognitive functioning as evidenced by a score of 15 out of a possible 15 points on the BIMS. -Resident required set-up and clean up assistance for eating. -Resident had malnutrition (a lack of proper nutrition caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat). -Resident had weight loss of 5% or more in the last month or 10% or more in the last six months (defined as significant weight loss), and was not on a Physician prescribed weight loss program. Review of the Dietitian Progress Note dated 2/13/24, indicated the following: -Resident #84 continued to present at nutritional risk. -Weight 162.9 pounds indicated a questionable significant weight loss x 180 days. -Weight loss was attributed to the use of different scales and resolving edema. -The Dietitian made a recommendation for the Boost Glucose Control ( nutritional supplement) to be increased to twice a day for added calorie/protein and hydration support. Review of the May 2024 Physician's orders indicated the following: -Diet - HCC (Diabetic diet), regular texture, thin liquids -Boost Glucose Control Chocolate, eight ounces daily at 10:00 A.M. Review of the Resident's MAR dated 2/13/24 through 5/9/24 indicated Resident #84 had been administered Boost Glucose Control Chocolate, eight ounces, daily at 10:00 A.M. During an interview on 5/10/24 at 10:53 A.M., the Registered Dietitian (RD) said that her process when she has a recommendation for a Resident is that she sends the recommendation via e-mail to the UM, the DON, and the NP. The RD said the recommendation to increase the Boost Glucose supplement from once a day to twice a day for Resident #84 was not sent to the UM, DON and the NP and the recommendation was never implemented. Review of the Dietitian Progress Note dated 5/10/24 at 11:27 A.M., indicated the following: -Resident was supplemented with Boost Glucose at 237 ml every day and was consuming 100%. -When the RD asked the Resident about the supplement and if he/she would like a second one, the Resident said he/she would like to have the supplement increased.

Based on interview and record review, the facility failed to maintain complete and accurate medical records for three Residents (#8, #21 and #60) out of a total sample of 25 residents. Specifically, the facility staff failed to: 1. For Resident #8, ensure accurate documentation relative to the units of Insulin (medication used to manage blood sugar levels) administered per the sliding scale for each of the readings requiring sliding scale coverage. 2. For Resident #21, accurately administer and document the base and sliding scale units of Insulin as ordered by the Physician. 3. For Resident #60, accurately document the bruit and thrill (sounds that can be heard or felt near a dialysis site and indicate that the site is working) assessment of the dialysis access site. Findings include: Review of the facility's policy titled, Diabetic Management Protocol, dated, April 2018, indicated the following: -Document all scheduled insulin/oral hypoglycemic medication on Medication Administration Record (MAR). -Document all sliding scale insulin medication on Diabetic Monitoring Flow Sheet. 1. Resident #8 was admitted to the facility in March 2013, with a diagnosis of Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy resulting in too much sugar in the blood). Review of the May 2024 Physician's orders indicated the following: -Insulin Glargine (long-acting insulin used to treat high blood sugar) 18 units subcutaneously (under the skin) at 8:00 P.M. -Insulin Lispro- (fast acting insulin used to control high blood sugar) 5 units base and sliding scale before meals, scheduled for 7:30 A.M., 11:30 A.M., and 4:30 P.M. -Check blood glucose before meals, scheduled for 7:30 A.M., 11:30 A.M., and 4:30 P.M. Insulin Lispro sliding scale: Below 80 mg/dl (milligrams per deciliter) mealtimes base= - (minus)2 units 80-149 mealtime base = 0 units 150-199 mealtime base = +1 unit 200-249 mealtimes base = +2 units 250-299 mealtime base = +3 units 300-349 mealtime base = +4 units 350 mealtime base = +5 units -Give mealtime Insulin after meal has been eaten. Review of the Medication MAR, dated 5/1/25 through 5/14/24, indicated the following: -the Resident received Insulin Glargine 18 units daily at 8:00 P.M. -the Resident received Insulin Lispro 5 units daily at 7:30 A.M., 11:30 A.M., and 4:30 P.M. Further review of the MAR showed no indication of what dose, if any Lispro Insulin was given as ordered per the sliding scale requirements for the following blood sugar readings: -At 7:30 A.M., the Resident's blood glucose readings were the following: -5/5/24 - 298 -5/6/24 -183 -5/7/24 - 241 -5/8/24 - 287 -5/10/24 - 263 -5/13/24 - 80 -5/14/24 - 245 -At 11:30 A.M., the Resident's blood glucose readings were the following: -5/1/24 - 261 -5/2/24 - 410 -5/3/24 - 249 -5/5/24 - 355 -5/9/24 - 285 -5/10/24 - 263 -5/11/24 - 241 -5/12/24 - 305 -5/13/24 - 265 -5/14/24 - 215 -At 4:30 P.M., the Resident's blood glucose readings were the following: -5/1/24 - 346 -5/2/24 - 272 -5/3/24 -154 -5/4/24 -189 -5/6/23 - 232 -5/6/23 -179 -5/8/24 - 206 -5/9/24 - 350 -5/10/24 - 311 -5/11/24 -159 -5/12/24 - 254 -5/14/24 - 256 Review of the Nurses Progress Notes, dated 5/1/24 through 5/14/24, showed no documented evidence of the number of units of Insulin that were administered per the sliding scale for each of the readings requiring sliding scale coverage. A Diabetic Monitoring Flow Sheet was not provided for Resident #8. During an interview on 5/15/24 at 9:31 A.M., the Corporate Quality Assurance Nurse said she was unable to provide documented evidence of the number of units of Lispro Insulin that was administered as ordered per the sliding scale for Resident #8. During an interview on 5/15/24 at 11:30 A.M., Nurse #7 said that the Insulin orders were confusing because some of the orders indicated to administer the Insulin before meals, after the blood glucose was tested, and another order indicated to administer the Insulin after the meal was eaten. When the surveyor asked Nurse #7 if she was able to see what dose of sliding scale Insulin the Resident had received on the past several days in the electronic MAR, Nurse #7 scrolled through the order history and said there was no documentation of what dose was administered. Nurse #7 said that the only documentation indicated base dose plus sliding scale, but that there was no indication of the number of units of Insulin given. Nurse #7 further said that the Insulin orders for the Resident were confusing to her and that she was a travel Nurse and did not want to say too much. 2. Resident #21 was admitted to the facility in April 2021 with a diagnosis including Type 1 Diabetes (condition in which the body is unable to regulate blood sugar [glucose] levels within the blood). Review of the May 2024 Physician's orders included the following: -Novolog Insulin 100 U/1 milliliter (ml) solution .6 units before meals, initiated 7/12/23 -Novolog Insulin 100 U/1 ml solution . per sliding scale before meals . 0-149 (blood sugar reading) = 0 units 150-199 = 1 unit 200-249 = 2 units 250-299 = 4 units 300-349 = 6 units 350-399 = 8 units 400-449 = 10 units 450 or over = 12 units -contact the Physician greater than 500, initiated 7/12/23 Review of the May 2024 Medication Administration Record (MAR) indicated the following: -Novolog Insulin, 6 units before meals was documented as administered daily -Novolog Insulin, per sliding scale, was documented as administered: -5/3/24 at 4:30 P.M., Blood Sugar = 326; the documentation indicated that 12 units of Insulin were administered, and 6 units were indicated per the sliding scale order -5/4/24 at 7:30 A.M., Blood Sugar = 207; the documentation indicated that 8 units of Insulin were administered, and 2 units were indicated per the sliding scale order -5/4/24 at 11:30 A.M., Blood Sugar =320; the documentation indicated that 13 units of Insulin were administered, and 6 units were indicated per the sliding scale order -5/5/24 at 7:30 A.M., Blood Sugar =89; the documentation indicated that 6 units of Insulin were administered, and 0 units were indicated per the sliding scale -5/5/24 at 11:30 A.M., Blood Sugar =223; the documentation indicated that 8 units of Insulin were administered, and 2 units were indicated per the sliding scale -5/7/24 at 11:30 A.M., Blood Sugar =223; the documentation indicated NA and 2 units were indicated per the sliding scale -5/9/24 at 7:30 A.M., Blood Sugar = 220; the documentation indicated that 7 units of Insulin were administered, and 2 units should have been administered per the sliding scale -5/9/24 at 11:30 A.M., Blood Sugar = 247; the documentation indicated that 9 units of Insulin were administered, and 2 units should have been administered per the sliding scale During an interview on 5/15/24 at 10:46 A.M., Nurse #6 said the 6 units of scheduled Insulin that Resident #21 receives are signed off as administered under that specific Insulin order and the amount of Insulin given per the sliding scale should be documented under the sliding scale order. The surveyor and Nurse #6 reviewed the May 2024 MAR and Nurse #6 said that she does not understand why the amounts of sliding scale Insulin on certain days did not match the sliding scale orders to be administered. Nurse #6 further said that the scheduled doses and the amount per the sliding scale should not be added together and documented under the sliding scale order as they are separate orders. During an interview on 5/15/24 at 10:53 A.M., Unit Manager (UM) #2 said that the dosage of Insulin administered per the sliding scale should be the amount documented under that specific Insulin order for Resident #21 and should not include the scheduled doses of Insulin. UM #2 said the schedule doses are documented under those specific Insulin orders. 3. Resident #60 was admitted to the facility in October 2022 with diagnoses including End Stage Renal Disease (ESRD: medical condition in which the kidneys cease to function on a permanent basis), dependence of renal dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) and presence of arteriovenous fistula (AV fistula: connection between an artery and vein to provide access for dialysis). Review of the May 2024 Physician's orders included the following: -Dialysis right arm shunt (AV fistula) monitoring bruit and thrill every shift, initiated 4/11/24 Review of the May 2024 Medication Administration Record (MAR) indicated an order to monitor the dialysis right arm shunt for bruit and thrill every shift and indicated an N (no presence of) on the following dates/times: -Shift 1 (7:00 A.M. to 3:00 P.M.) on 5/3, 5/8, 5/9 and 5/12/24 -Shift 2 (3:00 P.M. to 11:00 P.M.) on 5/4, 5/7, 5/8, and 5/10/24 -Shift 3 (11:00 P.M. to 7:00 A.M.) on 5/4, 5/5, 5/11, and 5/12/24 On 5/14/24 at 2:06 P.M., the surveyor and Nurse #2 reviewed Resident #60's May 2024 MAR relative to the documentation of the bruit and thrill. Nurse #2, who regularly works at the facility and with Resident #60, said the Resident's bruit and thrill are monitored every shift to ensure that the dialysis site was functioning. Nurse #2 said if the bruit and the thrill were not present, then the Nurse should call the Physician and the Resident's dialysis clinic for instructions. Nurse #2 reviewed the documentation and said that there have been no issues with the Resident's right arm shunt, that the Resident has been going to dialysis three times weekly as scheduled and there have been no complications. During an interview on 5/14/24 at 2:25 P.M., UM #2 said she has cared for Resident #60 frequently and there had never been any issues with his/her right arm dialysis shunt site. UM #2 reviewed the documentation relative to the bruit and thrill for May 2024 and said that the documentation was inaccurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record and policy review, the facility failed to maintain an infection prevention and control program designed to help prevent the potential transmission of communicable diseases and infections within the facility for one Resident (#112) out of a total sample of 25 residents. Specifically, the facility staff failed to clean and disinfect multi-use equipment after use on a resident prior to using the same equipment on Resident #112 who was at high risk for infection. Findings include: Review of the facility policy titled Procedure for Isolation: Initiation of Isolation Precautions dated 4/11/22 indicated but was not limited to: -If supplies go into the room, it must not be used for any other resident until it is cleaned and disinfected. -The blood pressure cuff may be cleaned with the healthcare system approved disinfectant product per the manufacturer's instructions. Review of the facility policy titled Enhanced Barrier Precautions (EBP: a type of precautions initiated to help prevent a resident who is at high risk for infection from contracting facility acquired infections), dated 1/10/23, indicated but was not limited to the following: -Enhanced Barrier Precautions expand the use of Personal Protective Equipment (PPE) and refer to the use of gown and gloves during high-contact care that provide opportunities to transfer Multi-Drug Resistant Organisms (MDROs: infection causing bacteria that have become resistant to antibiotics and are easily transmitted to others) -Nursing home residents with wounds and indwelling medical devices (device that enters the body providing an entry point for MDROs and other organisms) Resident #112 was admitted in December 2023 with the following diagnoses: Sepsis (the body's widespread and life threatening response to an infection), End Stage Renal Disease dependent on renal dialysis (ESRD: a permanent condition where the kidneys stop functioning and requires filtering of the blood regularly[dialysis] to remove the toxins the kidneys no longer cannot remove) and Obstructive Uropathy (the back up of urine into one or both kidneys due to a structural or functional obstruction in the urinary tract). Review of Resident #112's May 2023 Physician's orders indicated the following: -Enhanced Barrier Precautions due to an Indwelling Urinary Catheter (a tube inserted into the bladder to assist with draining of urine), initiated 4/19/24. On 5/15/24 at 8:30 A.M., during a medication administration the surveyor observed the following: -Nurse #1 taking the blood pressure of a resident in room [ROOM NUMBER] and then without cleaning or disinfecting the blood pressure cuff (device used to obtain the blood pressure) place the cuff into her scrubs (uniform) pocket. -Nurse #1 completed the medication administration for the resident in room [ROOM NUMBER] and exited the room and returned to the medication cart located in the hallway with the blood pressure cuff still in her pocket. -Nurse #1 was then observed to proceed down the hall to Resident #112's room which had an EBP sign attached to the door frame. -Nurse #1 was observed preparing medications for administration, performed hand hygiene appropriately, donned (put on) a gown (over the top of her scrubs where the soiled blood pressure cuff remained in her pocket) and gloves and entered Resident #112's room. -Nurse #1 was observed to assess the Resident, which included obtaining a blood pressure, for which she reached under her gown and removed the blood pressure cuff from her pocket, and then applied it to Resident #112's arm without cleaning/disinfecting the blood pressure cuff before use. During an interview immediately following the medication administration observation on 5/15/24, Nurse #1 said that she should not have used the blood pressure cuff that was used on another resident and stored in her uniform pocket on Resident #112, without first cleaning and disinfecting the blood pressure cuff. During an interview on 5/15/24 at 9:42 A.M. the Infection Control Nurse (IC Nurse) said the expectation would be to sanitize the blood pressure cuff after use before using it on another resident. The IC Nurse said Nurse #1 also should have notified the IC Nurse that there was no dedicated blood pressure cuff for Resident #112 since he/she was on EBP. The IC Nurse said relative to cleaning and disinfecting equipment, she would refer staff to the portions of the Procedure for Isolation: Initiation of Isolation Precautions policy that discuss cleaning and disinfecting equipment for cleaning and disinfecting policy and procedures.

Based on observation, interview and policy review, the facility failed to ensure that medications were labeled in accordance with professional standards to include an expiration date on two (#2 and #4) out of three observed medication carts, and on two units (Unit 1 and Unit 2) out of three observed units. Specifically, the facility failed to ensure that an ophthalmic (relating to the eye and its diseases) medication was appropriately labeled to indicate the bottle open date and/or discard date according to manufacturer's guidelines and prevent the administration of outdated medications that could result in contamination and infections for facility residents. Findings include: According to the National Library of Medicine (2022): https://www.ncbi.nlm.nih.gov/books/NBK540978/#:~:text=Latanoprost%20is%20a%20colorless%2C%20isotonic,46%20%C2%B0F)%20for%20storage, once Xalatan Ophthalmic Drops (generic name Latanoprost: eye drops used to treat high pressure in the eye) is opened, it may be stored at room temperature for 6 weeks. Review of the facility policy titled Medication Storage Information, undated, indicated: -opened Xalatan Ophthalmic Drops should be stored at room temperature and have an expiration date of 6 weeks after opening. On 5/14/24 at 11:54 A.M., the surveyor observed and Nurse #8 observed medication cart #2 on Unit 1. The surveyor and Nurse #8 observed one bottle of Xalatan Ophthalmic Drops in the medication cart drawer that was undated and did not indicate when the medication bottle was opened or when to discard the medication. During an interview at the time, Nurse #8 said the bottle of Xalatan Ophthalmic Drops should be dated when opened. Nurse #8 further said that he would discard the medication bottle when the bottle was empty, or when the Physician's order for the administration of the medication was completed. On 5/15/24 at 1:01 P.M., the surveyor and Nurse #9 observed medication cart #4 on Unit 2. The surveyor and Nurse #9 observed one bottle of Xalatan Ophthalmic Drops in the medication cart drawer without a date that indicated when the bottle was opened or when to discard the medication. During an interview at the time, Nurse #9 said that she was unsure how to know when to discard the medication bottle and would find out. Nurse #9 left and returned and said that the DON said eye drops did not have to be dated when opened. During an interview on 5/15/24 at 1:38 P.M., the surveyor and Director of Nurses (DON) reviewed the undated facility policy titled Medication Storage Information. The DON said the policy indicates that Xalatan Ophthalmic Drops should be discarded 6 weeks after opened. The DON said she could not provide an answer as to how Nurses would know when to discard the two undated bottles of Xalatan Ophthalmic Drops. The DON said the bottles of Xalatan Ophthalmic Drops should labeled when opened to indicate either the date opened or the discard date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record and policy review, and review of the facility assessment, the facility failed to ensure that annual performance appraisals were completed every 12 months and regular in-service education was provided based on the outcome of the performance appraisals for four Certified Nurses Aides (CNAs) out of a sample of five CNAs. Specifically, the facility failed to ensure that expectations, individual performance, and training requirements were communicated to CNA #3, CNA #4, CNA #5 and CNA #6 through the annual performance appraisal process as required. Findings include: Review of the Facility assessment dated [DATE] indicated: -The facility uses competency-based job descriptions, -a competency-based assessment process for the nursing department and annual performance appraisals to identify the training the staff needs to receive and accompanying plan. Review of the facility policy titled Performance Review indicated: -The facility will attempt to maintain a performance appraisal system that is administered at the completion of one's introductory period and at least once a year to every employee. -The performance appraisal will be used as a tool to assess one's performance and for such things as determining changes that may be appropriate to one's job, setting goals/expectations for the coming year, providing for an opportunity to receive feedback from employees about their job, and determining one's fitness for continued employment. Review of the facility personnel files for CNA #3, #4, #5, and #6 indicated the following: -CNA #3: date of hire 9/3/10, last performance appraisal was completed on 10/18/19. -CNA #4: date of hire 5/13/20, indicated no evidence that an annual performance appraisal had ever been completed. -CNA #5: date of hire 5/28/18, indicated no evidence that an annual performance appraisal had ever been completed. -CNA #6: date of hire 10/7/21, indicated no evidence that an annual performance appraisal had ever been completed. During an interview on 5/14/24 at 8:33 A.M., the Staff Development Coordinator (SDC) said she was not responsible for the staff's annual performance reviews and said she thought the Unit Managers (UMs) completed the annual performance reviews. During an interview on 5/14/24 at 9:05 A.M., the Director of Nurses (DON) said annual performance appraisals/ reviews were not completed consistently. The DON further said the process was for the Human Resource (HR) department to notify the UMs which employees were due for their annual performance appraisal, and it was the UMs responsibility to complete the performance appraisal and review with the employee annually. During an interview on 5/14/24 at 4:37 P.M., CNA #7 said she started working at the facility in 2018 and could not remember if she had ever received an annual performance appraisal. During an interview on 5/14/24 at 5:05 P.M., CNA #8 said she has worked at the facility for more than nine years, and used to have yearly performance appraisals with the UM, however it has been more than two years since she last had a performance appraisal. During an interview on 5/14/24 at 5:16 P.M., CNA #9 said the UMs used to do performance appraisals with the staff, but he could not recall the last time he had a performance appraisal. During an interview on 5/15/24 at 8:30 A.M., CNA #4 said she did not recall ever having had an annual performance appraisal. During an interview on 5/15/24 at 8:37 A.M., CNA #6 said she did not recall the last time she had received an annual performance appraisal. During an interview on 5/15/24 at 8:48 A.M., Nurse #4, who had previously worked as a UM at the facility said UMs, or the employee's direct supervisor were supposed to be notified by HR as to which employees were due to have performance appraisals completed. Nurse #4 said this should be done annually on the employee's anniversary date and the performance appraisals were to be reviewed by the manager with the employee. During an interview on 5/15/24 at 9:10 A.M., UM #2 said the annual performance appraisal process begins with HR providing a list of staff members that were due to be completed to the UMs. UM #2 said the UMs then complete the performance appraisal forms and review the data with the employee at which point the UM and the employee discuss the results, questions, and concerns. UM #2 said this process should be completed annually and the performance appraisals were to be retained in the employee's permanent personnel file. UM #2 further said the last performance appraisal she completed was for a Nurse over a year ago, she had never completed a performance evaluation for a CNA, and had not been notified by HR of any employees due for their annual performance appraisals in over a year. During an interview on 5/15/24 at 11:21 A.M., the DON said the facility did not have a consistent HR person in the building, therefore the annual performance appraisals had not been completed annually as required. During a follow-up interview on 5/15/24 at 1:56 A.M., the SDC said that while she ensured CNAs completed their required annual 12 hours of education, the education provided was not directly related to the results of the annual performance appraisals as she did not have access to that information.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was non-verbal, cognitively intact, understood others and was able to make his/her needs known by typing out messages on his/her cell phone screen, the Facility failed to ensure he/she was free from verbal abuse by a staff member, when on 11/26/23, at approximately 9:00 A.M., Certified Nurse Aide (CNA) #1 sent a text message to Resident #1 using language that included profanity, contained statements that were disparaging, insulting, humiliating, and accusatory toward Resident #1. Findings Include: Review of the Facility's Policy titled Resident Abuse Prevention, Investigation and Reporting, dated as revised 02/17/17 indicated the following: -It is the policy of the Facility and the responsibility of all staff to ensure an environment free of abuse, neglect, mistreatment, misappropriation of resident property, and exploitation. -Verbal Abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or degree of disability. Verbal abuse includes, but is not limited to, threats of harm and/or making statements to frighten a resident. -Mental Abuse: Includes humiliation, harassment, threats of punishment or deprivation. Resident #1 was admitted to the Facility in May 2023, diagnoses included an unspecified degenerative disease of the nervous system. Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 11/11/23, indicated Resident #1 was cognitively intact with a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS) and was dependent on staff for mobility and activities of daily living. Review of Resident #1's Communication Care Plan, reviewed and renewed with Quarterly MDS completed 11/11/23, indicated he/she was non-verbal and communicated by nodding yes or no or by using a pen stylus to text. The Care Plan indicated Resident #1's preferred method of communication was texting. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 11/30/23, indicated that an incident involving a verbally abusive text occurred on 11/26/23 involving CNA #1 and Resident #1. The Report indicated that a copy of the text, sent by CNA #1 to Resident #1 on 11/26/23, was sent to CNA #3 who shared it with the Director of Nurses (DON). The Report indicated that the Facility's internal investigation concluded that the allegation of verbal abuse was substantiated, and CNA #1 was terminated. Review of CNA #1's text, sent to Resident #1's phone, time stamped 8:46 (did not delineate A.M. or P.M. or date sent), indicated the content of the text sent to Resident #1 was exactly as follows: -I wasn't supposed to work this weekend and honestly IF I don't feel good, I'll be calling out every time I need to. -Have you considered why NO one wants to take care of you? -It's because you're a picky, control freak, and freaking cry and holler whenever something is not done the way YOU want it. You do that to me, when I've been taking care of you for the last 6 months. -OF COURSE someone new is going to get things wrong. -You're not like the other residents, easy going and very nice to the new aides. -Have you ever wondered why [CNA] NEVER wants to take care of you whenever I am there? Because of the same shit. -Everyone is tired of you and your attitude. -Every time I go into your room to take care of you, I'm fucking anxious and SO scared I'm going to get things wrong, because the first thing you do is cry like it is the end of the world, and complain to management, getting people in trouble. -I can do 99 things right, but you say nothing about it. Oh! But how dare I get one fucking thing wrong, you make a big deal about it. -I love you don't get me wrong, but someone has to tell you this shit. -The only two people that know how to do you, can't work every day and I'm sure [CNA] was there this weekend. -Have you fucking asked her why she wasn't taking care of you!!!!!!!?????? During a phone interview on 12/19/23 at 3:25 P.M., Certified Nurse Aide (CNA) #1 said she was assigned as Resident #1's primary caregiver on the day shift for approximately six months. CNA #1 said that she gave her personal phone number to Resident #1, because he/she took too long to type his/her communication on his/her phone screen. CNA #1 said she asked Resident #1 to text his/her menu requests the evening before her shift so she would not have to wait for Resident #1 to type them in the morning. CNA #1 said she may have gotten too attached to Resident #1 and said she spoke to him/her like she would a friend. CNA #1 said she was approved in advance for a day off on Sunday, 11/26/23, and said she was upset when Resident #1 texted her personal phone that morning to complain that he/she had a horrible day because she (CNA #1) was not at work. CNA #1 said that Resident #1 told her she shouldn't call out the next day because he/she couldn't bear to have another disastrous day. CNA #1 said she was frustrated by the text from Resident #1 and said she responded to Resident #1's out of frustration. CNA #1 said her text to Resident #1 on the morning of 11/26/23, was a spur of the moment reaction to Resident #1's text that expressed he/she was upset and inconvenienced by her (CNA #1's) day off. CNA #1 said that Facility Administration had a copy of the response that she texted to Resident #1. During an interview on 12/19/23 at 10:55 A.M., Resident #1 said that the text she received on 11/26/23 from CNA #1 was not the first inappropriate text he/she had received from her and said he/she overlooked the texts because he/she considered CNA #1 to be his/her friend. Although Resident #1 said he/she was not upset or bothered by the text from CNA #1, it would be reasonable to anticipate that for a resident who was totally dependent on staff to meet his/her care needs and who relies on the use of non-verbal communication (texting) with staff to make his/her care needs known, that they would be upset by the receiving and reading the disparaging, insulting, humiliating, and accusatory statements sent via a text from a caregiver and directed at him/her. During an interview on 12/19/23 at 12:30 A.M., CNA #3 said that CNA #1 texted her on the morning of 11/26/23 and complained that Resident #1 had texted her personal cell phone earlier that day, to complain about her(CNA #1) not being at work. CNA #3 said that CNA #1 told her that Resident #1 texted that she (CNA #1) had better not call out the following day because he/she (Resident #1) did not want to have another disastrous day by being assigned to an unfamiliar CNA. CNA #3 said that CNA #1 told her that she responded to Resident #1's text and that CNA #1 had sent her a copy of the text response she (CNA #1) had sent back to Resident #1. CNA #3 said the tone and content of CNA #1's text to Resident #1 bothered her, so she reported the incident to the Director of Nurses on the morning of 11/30/23, and shared a copy of the text with her. CNA #3 said she should have reported the incident to the DON immediately on 11/26/23 when she initially received a copy of the text from CNA #1. During an interview on 12/19/23 at 12:51 P.M., the Director of Nurses (DON) said it was not appropriate for staff to use their personal devices to communicate with residents. The DON said the incident that occurred at approximately 9:00 A.M. on 11/26/23, involving CNA #1 and Resident #1, was substantiated as verbal abuse at the conclusion of the Facility's internal investigation, and CNA #1 was terminated. The DON said that based on interviews and a behavioral health assessment of Resident #1, he/she did not appear to suffer any harm from the verbal abuse. On 12/19/23, The Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, The Plan of Correction is as follows: A) Facility Administration suspended Certified Nurse Aide (CNA ) #1 on 11/30/23 during the investigation and terminated her on 12/06/23. B) On 11/30/23, Resident #1 was educated by the Director of Nurses (DON) on acceptable forms of communication and that company policy did not support texting a staff member's personal phone as a communication tool. C) On 12/1/23, Resident #1 was seen by Behavioral Health Services for support and was monitored for any signs or verbalizations of distress. D) On 11/30/23, staff, as well as alert and oriented residents were interviewed by the DON (and/or completed a questionnaire) to determine if texting was utilized to communicate between any staff members and residents. E) On 11/30/23, staff were educated by the DON on the Facility's abuse policy and acceptable forms of communication between staff and residents. A posting was placed at the time clock as a reminder to staff that texting is not an acceptable form of communication with residents. F) On 11/30/23, the Facility Administrator initiated getting a tablet for Resident #1 to use for communication with staff. G) Random weekly interviews of alert and oriented residents, by the unit managers, were initiated on 11/30/23 and will continue three times per week for four weeks and then monthly for two months, to ensure residents are not receiving texts or calls from staff members on their personal devices. H) On 12/11/23, Facility Administration conducted an ad hoc Quality Assessment and Performance Improvement (QAPI) meeting to monitor the effectiveness of the plan of correction. I) Results of the resident and staff interviews will be reviewed and analyzed by the DON or Administrator and presented to QAPI monthly for three months or until substantial compliance is achieved and maintained. J) The Director of Nurses and/or Designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure that staff implemented and followed their Abuse Policy related to the need to immediately report allegations of abuse to the Supervisor, Administrator or Director of Nurses (DON), when on 11/26/23, after Certified Nurse Aide (CNA) #3 received a copy of a text message that CNA #1 had sent to Resident #1, that contained profanity, disparaging comments, insults, and ridiculed him/her (Resident #1), CNA #3 did not immediately report it to Facility administration as required, and waited until 11/30/23 (four days later) to report, therefore placing Resident #1 and other residents at risk for abuse. Findings include: Review of the Facility's Policy titled Resident Abuse Prevention, Investigation and Reporting, dated as revised 02/27/17, indicated that all staff who suspect abuse, neglect, mistreatment and or misappropriation must immediately make an oral report to his or her supervisor. The Policy indicated the following: -All employees are responsible for identifying and reporting immediately to their supervisor any witnessed abuse or allegation of abuse they are told about by residents, families, visitors, or other staff. -When an employee believes that he or she has reasonable cause to believe that a resident has been abused, neglected or mistreated, exploited or has had property misappropriated, (as those terms are defined in state regulations), he or she shall immediately report that suspicion to his or her supervisor. -Upon receiving an allegation of abuse, supervisors will take steps necessary to protect all residents and then immediately notify the administrator. Resident #1 was admitted to the Facility in May 2023, diagnoses included an unspecified degenerative disease of the nervous system. Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 11/11/23, indicated Resident #1 was cognitively intact with a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS) and he/she was dependent on staff for mobility and activities of daily living. Review of Resident #1's Communication Care Plan, reviewed and renewed with Quarterly MDS completed 11/11/23, indicated he/she was non-verbal and communicated by nodding yes or no or by using a pen stylus to text. The Care Plan indicated Resident #1's preferred method of communication was texting. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 11/30/23, indicated that an incident involving a verbally abusive (via text) occurred on 11/26/23 involving CNA #1 and Resident #1. The Report indicated the incident occurred on 11/26/23 but was not reported to the Director of Nurses until 11/30/23 (four days later). The Report indicated that the Facility investigation concluded that an allegation of verbal abuse was substantiated, and CNA #1 was terminated. During an interview on 12/19/23 at 12:30 A.M., Certified Nurse Aide (CNA) #3 said that CNA #1 texted her on the morning of 11/26/23 and said that Resident #1 had texted her personal phone earlier that day, to complain. CNA #3 said that CNA #1 told her that Resident #1 texted that she (CNA #1) had better not call out the following day because he/she (Resident #1) did not want to have another disastrous day by being assigned to an unfamiliar CNA. CNA #3 said that CNA #1 told her that she responded to Resident #1's text and that CNA #1 sent her a copy of that text response. CNA #3 said the tone and content of the text, that CNA #1 sent to Resident #1, bothered her and was very inappropriate, so she (CNA #3) reported the incident to the Director of Nurses on the morning of 11/30/23. CNA #3 said she should have reported the incident to the DON immediately on 11/26/23 when she received a copy of the text from CNA #1. Review of CNA #1's text, sent to Resident #1's cell phone, time stamped 8:46 (did not delineate A.M. or P.M. or date sent) included (but not limited to)the following statements as sent to Resident #1: -Have you considered why NO one wants to take care of you? -It's because you're a picky, control freak, and freaking cry and holler whenever something is not done the way YOU want it. -Everyone is tired of you and your attitude. -The first thing you do is cry like it is the end of the world, and complain to management, getting people in trouble. -Have you fucking asked her (CNA) why she wasn't taking care of you!!!!!!!?????? During an interview on 12/19/23 at 12:51 P.M., the Director of Nurses (DON) said she was not aware of the allegation of verbal abuse involving Resident #1 and CNA #1, that occurred via text on 11/26/23, until CNA #3 reported the allegation at approximately 9:00 A.M. on 11/30/23. The DON said that CNA #3 should have reported the incident to Facility Administration immediately, on 11/26/23. The DON said that CNA #1 was not immediately suspended, due to the delay in the reporting of the incident to Facility Administration, placing Resident #1 and the other residents at risk for abuse. The DON said that once she was aware of the incident, on the morning of 11/30/23, she immediately suspended CNA #1, pending the outcome of their investigation. The DON said the allegation of verbal abuse was substantiated and CNA #1 was terminated. On 12/19/23, The Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, The Plan of Correction is as follows: A) On 11/30/23, Certified Nurse Aide (CNA) #3 was re-educated by the Director of Nurses (DON) on Resident Rights and the Facility's Abuse Policies, with an emphasis on identification and timely reporting. B) On 11/30/23 all staff were educated by the DON on the Facility's abuse policy with emphasis on identifying abuse and timely reporting of abuse. C) On 12/11/23, Facility Administration conducted an ad hoc Quality Assessment and Performance Improvement (QAPI) meeting to monitor the effectiveness of the plan of correction. D) The QAPI subcommittee will continue to monitor any episodes in which staff and/or residents are reporting and the timeliness of such reporting. E) The Director of Nurses and/or Designee are responsible for overall compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure its staff provided the required discharge/transfer notices for two Residents (#56 and #97), and/or their Representatives and the Long-Term Care Ombudsman office, out of a sample of 24 residents. Findings include: Review of the facility policy titled, Admission/Discharge/Transfer Rights, facility reviewed on 10/24/22, indicated the following: - Normally all transfers and discharges require a 30 days' notice to the resident - Exception .immediate transfer or discharge is required by the resident's urgent medical needs and this is documented in the medical record . - If exception is met, less than 30 days notice is allowed and the following forms can be used: >Discharge Less Than 30 Days >Transfer Less Than 30 Days - The facility will send notice to a Representative of the Office of the State Long Term Care Ombudsman. -Notices should be sent daily to the local Ombudsman program either by postal mail or fax. 1. Resident #56 was admitted to the facility in March 2022. Review of the medical record indicated the Resident was transferred to the hospital on [DATE]. Further review of the medical record indicated no documented evidence that a written notice of transfer/discharge was provided to the Resident/Resident Representative upon transfer, and no documented evidence that the Ombudsman was notified of the transfer per the facility policy. 2. For Resident #97, facility staff failed to provide a written notice of transfer/discharge to the Resident and/or Resident Representative and also failed to notify the Ombudsman of the transfer. Resident #97 was admitted to the facility in September 2022. Review of a nursing progress note dated 11/19/22, indicated that Resident #97 developed respiratory distress at 6:30 P.M., and was transferred to the hospital for evaluation. Review of the medical record indicated no documented evidence that a written notice of transfer/discharge was provided to the Resident/Resident Representative upon transfer, and no documented evidence that the Ombudsman was notified of the transfer. During an interview on 1/11/23 at 12:51 P.M., Social Worker #3 said there was no evidence that a transfer discharge form and Ombudsman notification was done for Resident #97's transfer to the hospital in November, and Resident #56's transfer to the hospital in October as required.

Based on interview and record review, the facility failed to ensure that services were provided by a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. Findings include: Review of the facility policy titled Staffing in the Department of Nursing, dated 5/2/05, indicated the following: -The facility will ensure a RN is scheduled for at least eight consecutive hours a day, seven days a week. Review of the facility's weekly nursing schedule dated 12/16/22 through 12/17/22, indicated a RN was not scheduled for eight consecutive hours in a 24 hour period from 11 P.M. on 12/16/22 through 11 P.M on 12/17/22. During an interview on 1/10/23 at 2:34 P.M., the Director of Nursing (DON) said there should have been a RN scheduled for eight hours in that 24-hour period and there was not.

Based on interview and record review, the facility failed to ensure that its staff monitored the use of psychotropic medications (medications that affect brain activities associated with mental processes and behavior) to promote and maintain the highest practicable mental, physical, and psychosocial well-being of two Residents (#10 and #162), out of a sample of 24 residents. Findings include: Review of the facility policy titled Psychotropic Medications, facility reviewed 10/28/22, indicated that residents receiving psychotropic medication will be monitored for the effectiveness of the medication and for adverse reaction, with the results of such monitoring documented in the resident's record. 1. For Resident #10 the facility failed to ensure its staff monitored changes or side effects for the use of Risperidone (an antipsychotic used to treat a wide range of psychiatric and neurological disorders), Trazodone, (an antidepressant) and Depakote Sprinkles (an anti-seizure medication). Resident #10 was admitted to the facility in 2013 with diagnoses including Schizophrenia and Depression. Review of the January 2023 Physician's Orders indicated the following orders: -Trazodone 50 milligrams (mg: denotes strength) one tablet at bedtime for Depression, order date 6/11/21 -Risperidone 2 mg tablet daily at 8 A.M., order date 5/28/20 -Risperidone 4 mg tablet at bedtime, order date 10/2/19 -Depakote sprinkles 125mg capsules, give 5 capsules twice daily for Paranoid Schizophrenia, order date 8/4/21 Review of the October 2022, November 2022, December 2022, and the January 2023, Medication Administration Records (MARs) indicated no documented evidence that the Resident was monitored for psychotropic medication side effects. Review of the October 2022, November 2022, and December 2022, Treatment Administration Records (TARs) indicated no documented evidence that the Resident had been monitored for psychotropic medication side effects. Review of the medical record indicated no documented evidence that the resident had been monitored for psychotropic medication side effects. During an interview on 1/10/23 at 8:33 A.M., Nurse #1 said residents on psychotropic medications are monitored for side effects and the monitoring was documented in the electronic medical record on the MAR or TAR. During an interview on 1/10/23 at 9:07 A.M., Unit Manager (UM) #2 said she was unable to locate the psychotropic side effect monitoring in the Resident's record for October 2022, November 2022, and December 2022. During a subsequent interview on 1/10/23 at 9:28 A.M., UM #2 said that she was unable to locate the order for, and the documentation of psychotropic monitoring for Resident #10. She said she had looked through the discontinued orders to find it and it was not there. She said the psychotropic monitoring had not been done as required. 2. For Resident #162 the facility failed to ensure its staff monitored changes or side effects for the use of Abilify (an antipsychotic used to treat a wide range of psychiatric and neurological disorders), Trazodone, Citalopram, Bupropion HCL (antidepressants) and Alprazolam (an antianxiety medication). Resident #162 was admitted to the facility in December 2022 with diagnoses including Anxiety, Insomnia, and major Depressive Disorder. Review of the Active Orders Report, dated 1/10/2023 indicated the following: -Abilify 2 milligram (mg) tablet at 9 A.M. for major Depressive Disorder, order date 12/30/22 -Trazodone 100 mg, 2 tablets at 9 P.M. for Insomnia, order date 12/23/22 -Citalopram 40 mg tablet at 9 P.M. for Anxiety, order date 12/22/22 -Alprazolam 1 mg tablet twice daily as needed for Anxiety, order date 12/22/22 -Alprazolam 2 mg at bedtime for Anxiety, order date 12/22/22 -Bupropion HCL 300 mg at 9 A.M. for Anxiety, order date 12/22/22 Review of the Psychotropic use care plan initiated on 12/26/22, indicated the following: -Monitor for effectiveness of drug use -Monitor for side effects and report -Monitor for new onset of or change in mood/behaviors. Review of the medical record indicated no documented evidence that the Resident had been monitored for psychotropic medication side effects. During an interview on 1/10/23 at 1:24 P.M., with Nurse #10 and UM #1, Nurse #10 said that there should be monitoring in place for side effects when a resident is on psychotropic medications. She said that the monitoring would be in the Physician Orders and documented on the MARs either yes side effects observed and what they were, or no side effects observed. UM #1 said that if the order is not there, the monitoring is not being completed as the facility staff are educated to only document this information on the MARs. She additionally said that she did not see an order and could not provide additional evidence that the facility staff were monitoring for side effects of psychotropic drug use for Resident #162.

Based on interviews and record review, the facility failed to ensure that its staff coordinated and provided Hospice Care services in accordance with the plan of care for one Resident (#208), out of a sample of 24 residents. Specifically, facility staff failed to: 1) communicate with the contracted Hospice to assist with symptom management resulting in prescribed medications of the same drug class being used for the Resident, and 2) ensured that the contracted Hospice provided the facility with documentation of the care and services provided to the Resident by Hospice and ensure the documentation was readily available in the Resident's record. Findings include: Resident #208 was admitted to the facility in January 2023, with a diagnosis of Intracerebral Hemorrhage (bleeding into the tissues of the brain). 1. Review of the facility policy titled, Hospice Program, revised 3/28/22, indicated the following: - Purpose: to work collaboratively with the Hospice agency to provide end of life care. - When a resident participates in the Hospice program, a coordinated care plan between the facility, Hospice agency and resident/family will be developed and shall include directives for managing pain and other comfort measures. - The facility notifies the Hospice agency when the following occurs: significant change in the resident's physical, mental, social or emotional status, clinical complications that suggest a need to alter the plan of care . Review of the medical record indicated the Resident was admitted to Hospice services on 1/3/23. Review of the January 2023 Physician's Orders included the following: - May admit to Hospice, initiated 1/3/23. - Levsin (Hyoscyamine Sulfate), 0.125 milligram (mg) tablet administer 1 tablet sublingual (under the tongue) every six hours as needed for secretions (terminal secretions- which occur when mucous and saliva build up in the throat due to inability to clear one's throat or swallow), initiated 1/5/23 and discontinued 1/9/23. - Scopolamine 1 mg transdermal patch, apply every three days for secretions, initiated 1/9/23. Review of the January 2023 Medication Administration Record (MAR) indicated: - Levsin was administered the following dates and times: >1/6/23 at 12:53 A.M., 9:20 A.M., and 3:56 P.M., with documented positive effect >1/7//23 at 2:31 A.M., with minimal effect >1/9/23 at 12:07 P.M., with positive effect. Levsin not administered on 1/8/23 - Scopolamine was applied 1/9/23 during the morning shift Review of a nursing progress note dated 1/9/23 at 5:43 A.M., indicated: -the Resident has increased secretions. -Order obtained for 1 mg transdermal Scopolamine patch, change every three days. -Patch placed on back of left ear. During an interview on 1/9/23 at 3:04 P.M., the surveyor asked Nurse #6 if there was a plan to discontinue the Resident's Levsin since he/she had been prescribed Scopolamine, both of which treated the same symptoms. Nurse #6 said the only thing she knew was the information she received during shift-to-shift report that indicated the Resident began the Scopolamine patch per the night shift nurse, and to her knowledge there was not a plan to discontinue the Levsin. She further said she had been administering Levsin throughout the day today because the Resident continued with a large amount of secretions. During an interview on 1/9/23 at 3:51 P.M., Hospice Nurse #1 said the facility should call Hospice with any changes in condition and to her knowledge, the facility did not contact the Hospice agency last night to discuss the Resident's terminal secretions. She further said her visit today was to ensure the facility implemented medication recommendations made by the Hospice Nurse visit the prior day and to assess the Resident's response to the medication changes. In addition, she said she was not aware the facility obtained an order for a Scopolamine patch to alleviate the Resident's terminal secretions and that she would recommend discontinuing the Levsin because the Resident should not have had both medications. During an interview on 1/10/23 at 9:25 A.M., Nurse #5 said the Resident was on Hospice and exhibited terminal secretions during the early morning hours of 1/9/23, so she called the facility's on-call provider to report the condition and requested an order for a Scopolamine patch. She further said she did not call the Hospice on-call Nurse to report the Resident's condition, did not realize that the Resident already had a medication prescribed (Levsin) to alleviate his/her secretions, and she should have called Hospice first. 2. While reviewing the Resident's medical record, the surveyor was unable to locate the following: - information on the role the contracted Hospice provides in the facility as well as how to access the Hospice's 24-hour on-call system - the Physician certification of the terminal illness specific to the Resident. - the Hospice admission agreement, informed consent and benefit election form signed by the Resident and/or his/her Representative - the Hospice involvement of care form indicating which individuals were allowed to receive information about the Resident's care - Hospice initial visit assessment/notes (from 1/3/23) - the Hospice care plan specific to the Resident which included areas of concern and the associated interventions to be provided as well as the expected visit frequency of the Hospice Providers/Practitioners - the Hospice patient information sheet which includes the terminal diagnosis and the names of the primary Hospice Nurse, Social Worker and Spiritual Counselor assigned to the Resident - the list of medications and whether they were covered by the Hospice benefit. During an interview on 1/10/23 at 10:20 A.M., Unit Manager (UM) #3 said any Hospice recommendations, progress notes, care plans and admission paperwork should be in the Resident's chart, however she was unable to locate the information. During an interview on 1/10/23 at 10:40 A.M., Hospice Nurse #3 said UM #3 had been unable to locate prior Hospice recommendations and requested Hospice Nurse #3 re-write them for the record. During an interview on 1/10/23 at 10:54 A.M., Director of Nursing (DON) #4 said they were unable to locate the original Hospice recommendations from prior visits or the Hospice admission packet. DON #4 requested the Hospice agency fax the information to the facility for their records. During an interview on 1/10/23 at 1:50 P.M., with UM #3 and DON #4, the surveyor asked UM #3 where the staff would find pertinent Hospice information such as which Hospice services were in place (such as Home Health Aide, Social Work, Chaplain), how often their visit frequencies would be, as well as the Hospice plan of care, UM #3 said, that is a good question. DON #4 said they would have to call the Hospice agency if they could not locate the information in the Resident's chart. During an interview on 1/11/23 at 10:32 A.M., Hospice Nurse #2 said the Hospice paperwork had been found scattered all over the Residents' chart and she was surprised the Hospice admission paperwork was not yet sent over from the Hospice agency. She further said at the very least, the three-hole punched Hospice tab that included all the Hospice contact information should have been placed in the Resident's chart to differentiate the Hospice progress notes and recommendations from the facility's paperwork.

Based on interview and record review, the facility failed to ensure its staff followed their COVID-19 monitoring plan to prevent the spread of infection. Specifically, the facility's staff failed to screen for signs and symptoms of COVID-19 every shift (Q shift) on units experiencing a COVID-19 outbreak for two Residents (#65 and #158), out of a sample of three residents. Findings Include: Review of the facility policy titled COVID-19 Prevention and Outbreak Management, revised 5/12/22, indicated the following: - .It is the practice .of this facility to follow the guidance of government resources including Centers for Disease Control and Prevention (CDC), Centers for Medicare and Medicaid (CMS), Massachusetts Department of Public Health (DPH) . -If a resident is symptomatic for COVID-19 or positive for COVID-19 or exposed to COVID-19, symptom monitoring is enhanced to every shift. Review of the DPH memo titled Updated to Caring for Long-Term Care Resident's during the COVID-19 Response, including Visitation Conditions, Communal Dining, and Congregate Activities, dated October 13, 2022, indicated the following: -On unit(s) conducting outbreak testing, a long-term care facility should assess residents for symptoms of COVID-19 during each shift. During an interview on 1/10/23 at 1:54 A.M., the Infection Preventionist (IP) said Unit One and Unit Three started outbreak testing on 1/2/23. 1. Resident #65 was admitted to the facility in January 2023 and resided on Unit One. Review of the January 2023 Physician's Orders indicated no orders were in place for Q shift screening for signs and symptoms of COVID-19. Review of the January 2023 Medication Administration Record (MAR) indicated no documentation that the Resident was being screened Q shift for signs and symptoms of COVID-19. 2. Resident #158 was admitted to the facility in December 2022 and resided on Unit Three. Review of the January 2023 Physician's Orders indicated no orders were in place for Q shift screening for signs and symptoms of COVID-19. Review of the January 2023 MAR indicated no documentation that the Resident was being screened Q shift for signs and symptoms of COVID-19. During an interview on 1/11/23 at 9:39 A.M., Unit Manager (UM) #1 said Residents on Unit Three should have an order to be screened Q shift for signs and symptoms of COVID-19 and that the nurses should be documenting that information on the MAR. UM #1 reviewed the Resident's current Physician's Orders and MAR and said Resident #158 was not being monitored for signs and symptoms of COVID-19 Q shift, as required. She further said it was important to screen residents Q shift on units conducting outbreak testing as it would help the facility be proactive in identifying new cases of COVID-19. During an interview on 1/11/23 at 10:43 A.M., the IP said both Resident #65 and #158 should have been monitored Q shift for signs and symptoms of COVID-19. Both Residents should have had a Physician order in place and the Nurses should have been documenting the findings Q shift on the MAR, and this was not done, as required.

Based on observation, interview, and record review the facility failed to ensure there was sufficient nursing staff (including Certified Nurses Aides-CNAs) to provide services and nursing care that met the needs of residents on three Units (Unit One, Unit Two, and Unit Three), out of three units observed. Findings include: 1. Review of the Facility Assessment Tool revised 1/8/23, indicated the facility had identified the range of CNAs needed to care for the residents in the facility on an average day was between 24-32. Review of the Daily Nursing Schedules from 1/1/23, 1/7/23, and 1/8/23 indicated less than the Facility Assessment identified 24-32 number of CNAs needed per day, documented as follows: -On 1/1/23: A total of 22 CNAs worked and the following shifts were affected by short staffing of CNAs: >On the 7 A.M. to 3 P.M. shift: nine CNAs worked (Three CNAs on Unit One, Three CNAs on Unit Two, and Three CNAs on Unit Three) -On 1/7/23: A total of 21 CNAs worked and the following shifts were affected by short staffing of CNAs: >On the 7 A.M. to 3 P.M. shift: eight CNAs worked (Three CNAs on Unit One, Three CNAs on Unit Two, and Two CNAs on Unit Three) >On the 3 P.M. to 11 P.M. shift: seven CNAs worked (Two CNAs on Unit One, Three CNAs on Unit Two, and Two CNAs on Unit Three) -On 1/8/23: A total of 21.5 CNAs worked (.5 indicated a CNA who was on light duty related to a medical or physical need thus unable to provide all the necessary care a Resident may require).The facility did additionally call in two Nurses to function as CNAs which brought the total of CNAs to 23.5. The following shifts were affected by short staffing of CNAs: >On the 7 A.M. to 3 P.M. shift: 5.5 CNAs worked plus two Nurses (Two CNAs on Unit One, 2.5 CNAs on Unit Two, One CNA on Unit Three and two Nurses who floated (moved from Unit to Unit and provided assistance as needed) >On the 3 P.M. to 11 P.M. shift: eight CNAs worked (Three CNAs on Unit One, Two CNAs on Unit Two, and Three CNAs on Unit Three) During an interview on 1/10/23 at 12:07 A.M., the Director of Nursing (DON) said the following: -On the 7 A.M. to 3 P.M. shift there should be a minimum of four CNAs on two units and three CNAs on one unit. -On the 3 P.M. to 11 P.M. shift there should be a minimum of four CNAs on one unit and three CNAs on the other two units. She further said in total for an entire day there should have been a minimum of 24 CNAs that worked. DON did not specify out of the three units, which units required the minimum CNA staffing levels as outlined to the surveyor. During a follow-up interview on 1/10/23 at 2:34 P.M., the DON said on 1/1/23, 1/7/23, and 1/8/23 the minimum CNAs required to provide care to the residents was not provided. She further said she was unaware on 1/7/23 and 1/8/23 that there were not enough CNAs. 4. The following observations and interviews occurred with both residents and staff on Unit One, a long-term care unit: a) During an interview on 1/8/23 at 8:27 A.M., Nurse #3 said that staffing today on the unit included two nurses and two CNAs. She said that there were usually two nurses and three to four CNAs on the day shift for 40 residents. She further said that with COVID-19 on the unit, the residents required more care and the staff had to use full personal protective equipment (PPE) which made it very difficult to provide timely care. b) During an interview on 1/8/23 at 9:37 A.M., CNA #1, said there were only two CNAs on Unit One today and that it was difficult to provide the care the residents on the unit needed with just two CNAs. c) Resident #41 was admitted to the facility in May 2022. During an interview on 1/8/23 at 10:13 A.M., Resident #41 said the facility was short-handed. He/she said sometimes they only had two CNAs when they usually have three for 40 residents. He/she further said that the day shift had two meals to serve and pick up from, and there was no care before breakfast was over. Resident #41 said the other day he/she rang the call bell as he/she needed a brief changed, and the person who answered the call bell said she didn't know who was assigned to the Resident's care and would find out. The Resident said that a half hour went by, and no one came back, so he/she rang again and waited another half hour, with the bell ringing, before someone came in to provide care. He/She said that mostly happened at night. The Resident also said that one day it was 11 A.M. before he/she knew who was assigned to provide him/her care. The Resident reported there was only one CNA to provide care for 40 residents on Christmas Eve. d) Resident #17 was admitted to the facility in July 2022. During an interview on 1/8/23 at 1:38 P.M., Resident #17 said he/she was waiting for the nurse to give him/her cigarettes. He/she said that smoking was scheduled for 1:30 P.M., and it was after that time now. The Resident further said this was an ongoing issue and smoking breaks were not occurring at the scheduled time. e) Resident #84 was admitted to the facility in December 2020. During an observation and interview on 1/8/23 at 2:02 P.M., the surveyor observed a medication inhaler on Resident #84's overbed table. The Resident said sometimes it took too long for the staff to answer the call bell when he/she felt short of breath, and he/she did not want to wait for the medication. 2. The following interviews occurred with both residents and staff on Unit Two, the Rehabilitation Unit (short term care unit): a) Resident # 34 was admitted to the facility in December 2022. During an interview on 1/8/23 at 9:40 A.M., Resident #34 said that the 3:00 P.M. -11:00 P.M. shift seemed to have the least number of staff. He/she continued to say that recently (about 10 days ago) he/she waited so long for the call light to be answered that he/she soiled himself/herself. b) Resident #159 was admitted to the facility in December 2022. During an interview on 1/8/23 at 2:02 P.M., Resident #159 said that he/she has waited for at least 10-15 minutes at times on the call light, and that the facility did not have enough help. He/she continued to say that yesterday morning (1/7/23) after breakfast he/she asked to be helped to the bathroom. The staff told the Resident that they first needed to complete the meal tray pass but would come back. Resident #159 said he/she soiled himself/herself while waiting. The Resident again pushed the call light, but no one ever came. He/she said that about one hour later, he/she soiled his/her self again. Resident #159 said that even though they knew they were supposed to wait for staff to help, he/she did not want to wait anymore, and went to the bathroom independently. c) Resident #161 was admitted to the facility in January 2022. During an interview on 1/8/23 at 4:54 P.M., Resident # 161 said that staffing was a huge problem. The Resident said that he/she sat in his/her own feces for an hour and felt that the rash he/she developed was due to sitting in his/her own feces for too long. The Resident also said that he/she felt that the staff moods were affected due to being overworked and stressed. d) During an interview on 1/8/23 at 1:29 P.M., CNA #4 said that she was frustrated, worked Per Diem, did not typically work on the weekends, and was recently placed on light duty. She further said she was grateful that the nurse she was working with was a good nurse and was able to help because she would not be able to do her job otherwise. e) During an interview on 1/8/23 at 2:28 P.M., CNA #3 said that she was a regular weekend employee. She said she was the only full aide working on Unit Two with one other individual, who was working light duty and felt very overwhelmed. CNA #3 also said that it could be difficult when there were only two CNAs scheduled and the second CNA was a male because they only take care of the male residents, leaving her with all the female residents. 3. The facility failed to ensure sufficient staffing were scheduled to respond timely to resident call lights, provide assistance with meals for residents that required assistance, and provide supervision for residents at risk for falling on Unit Two. During the Recertification survey from 1/8/23 through 1/11/23, the information provided to the survey team indicated there were 44 residents residing on Unit Two. a) On 1/8/23 at 8:36 A.M., the surveyor observed two Nurses and two CNAs working on Unit Two. During an interview at this time, CNA #6 said the unit was supposed to have four to five CNAs scheduled but two CNAs had called out of work. She further said that both she and CNA #7 were regular staff and worked well together but if there was an agency CNA scheduled, the shift would be very difficult. b) Review of the list of residents on Unit Two who required supervision or were dependent for eating, provided by the facility dated 1/5/22, indicated the following: -there were eight Residents (#19, #30, #38, #40, #57, #68, #83 and #208) who were dependent for meals. -there were two Residents (#75 and #79) who required supervision with meals. -a notation that residents who were dependent or supervised may remain in their rooms with staff assistance if the Unit Dining Room was declined or the resident was not feeling well, but the nurse would need to be notified. c) On 1/8/23 from 9:10 A.M., through 9:33 A.M., the surveyor observed the following: - eight residents were seated in the Unit Two Dining Room, and breakfast trays were distributed by CNA's #6 and #7. - five of the eight residents seated in the dining room were observed to require assistance from CNA #6 and CNA #7. -At 9:16 A.M., all breakfast trays were provided for the seated residents, but two Residents (#68 and #83) were not being assisted with their breakfast meals. CNA#6 was observed to utilize a wheeled stool to move between two Residents (#38 and #40), while CNA #7 was providing assistance to Resident #30. -At 9:23 A.M., CNA #6 was observed to assist three Residents (#38, #40 and #83) by wheeling the stool from resident to resident to provide a bite/drink of food/fluid and then wheel over to the next resident. Resident #68 had a covered breakfast tray placed near him/her and was not yet assisted. -At 9:27 A.M., CNA #7 began to assist Resident #68 with the breakfast meal, leaving Resident #30 unassisted. When CNA #7 approached Resident #68 and asked if he/she was hungry, Resident #30 was heard to say he/she was big time hungry. No assistance was provided to Resident #30 at that time. During an interview on 1/8/23 at 9:32 A.M., CNA's #6 and #7 said that there were five residents in the Unit Dining Room who required assistance on this date, but sometimes there are six residents present who required assistance. CNA #7 said that they were better able to assist the residents when more staff were there but there were only two of them (CNAs) today. On 1/10/23 at 8:44 A.M. through 8:59 A.M., the surveyor observed the following in the Unit Two Dining Room: -At 8:44 A.M., all resident meal trays had been distributed and Unit Manager (UM) #3 and two CNAs were assisting some of the residents with the breakfast meal. Resident #68, Resident #40 and Resident #38 were observed to be present and had covered breakfast trays placed in front of them, and were not being assisted by facility staff. Resident #40 was observed with a bowl of hot cereal and was attempting to feed him/her self. -At 8:57 A.M., Resident #38 was observed to receive assistance from facility staff. -At 8:59 A.M., UM #3 was observed to assist Resident #68. On 1/10/23 at 1:21 P.M., the surveyor observed the following in the Unit Two Dining Room: - the lunch trays had been distributed to the nine resident who were seated in the Dining Room. - three CNAs were present and assisting residents with their meals. Resident #83, Resident #19 and Resident #57 had lunch trays positioned in front of them and were not being assisted. On 1/11/23 at 9:10 A.M., the surveyor observed the following in the Unit Two Dining Room: - eleven residents were seated in the Dining Room and the breakfast meal trays had been distributed. - four staff were present and assisting four residents with their breakfast meals. - four Residents ( #38, #83, #40 and #91) had a breakfast tray placed in front of them and were not eating nor was assistance being provided. During an interview on 1/11/23 at 10:40 A.M., UM #3 said that there were numerous residents on Unit Two that required staff assistance with their meals. She further said that Resident #91 was typically not in the Unit Two Dining Room during meals, but that it was observed that he/she was not eating well so she requested the Resident be in the Dining Room for more assistance. The surveyor relayed concerns about the previous observations with the number of staff and the number of residents who required meal assistance to UM #3 and DON # 4 (from a sister facility), who was also present. d) On 1/8/23 at 9:26 A.M., the Quality Improvement Manager approached the surveyor during the dining observation to indicate that she was present in the facility. On 1/8/23 at 9:40 A.M., the surveyor observed two resident call lights were ringing, one of which was blinking red. The surveyor observed both call lights answered by the Quality Improvement Manager. On 1/8/23 at 9:41 A.M., two call lights were observed to be on and blinking. Nurse #9 was observed to walk by one of these rooms and proceed down the hallway and enter another resident's room (one of which did not have a call light on). At 9:44 A.M., the Quality Improvement Manager answered one of the blinking call lights, while one remained blinking and had not been attended to. The surveyor observed no staff in the unit hallway at this time. At 9:47 A.M., the Director of Nurses (DON) #2 (from a sister facility) approached the surveyor to introduce herself and proceeded to answer the call light in the room which had remained blinking. On 1/8/23 at 10:09 A.M., the surveyor observed DON #3 (from a sister facility) on Unit Two. On 1/8/23 at 10:20 A.M., the surveyor observed the Administrator and DON #3 walking in the hallways of Unit Two. The surveyor observed a resident room with a red call light blinking. No staff were observed in the hallway to attend to the blinking red call light. At 10:23 A.M., the Administrator introduced himself to the surveyor and proceeded to answer the blinking red call light. On 1/8/23 at 11:14 A.M., a call light was observed to be on and blinking white in a resident room. The surveyor observed no staff were present in the hallway. At 11:20 A.M., (6 minutes later), CNA #6 was observed to respond to the blinking white call light. On 1/10/23 from 2:07 P.M. until 2:21 P.M., the surveyor observed numerous resident call lights blinking, one of which was ringing continuously without staff responding until 2:21 P.M. when UM #3 knocked and entered the room. The elapsed time from the initiation of the call light to when it was answered was 14 minutes. During an interview on 1/11/23 at 10:40 A.M., when the surveyor discussed the numerous observations pertaining to call light response time and lack of staff response to the call lights with UM #3, she said that resident call lights should be answered immediately because it is unknown what the resident need is. She further said that even if facility staff check in with the resident to ensure they are safe, turn off the call light and then go back to address what the resident needs/requests are, call lights should be answered immediately. e) During an observation on 1/8/23 at 10:03 A.M., Resident #23 was observed to ask DON #2 who she was and where she was from. DON #2 said that she was asked to come help in the facility today. Resident #23 said that they were always understaffed at the facility. He/she further said that residents were fed their dinner meals at 7:30 P.M., the previous night because they are understaffed and that he/she received the morning medications at 7:30 A.M. when they were scheduled to be administered between 5:00 A.M. and 6:00 A.M. f) During an interview on 1/8/23 at 10:57 A.M., Resident #207 said that he/she had a terrible day the previous day because of the lack of staffing in the facility. When the surveyor requested Resident #207 elaborate on the terrible day, the Resident declined but continued to state that it was terrible. g) During an interview on 1/8/23 at 3:54 P.M., Resident #18 said that there were staffing issues on Unit Two, especially on the weekends on the 7:00 A.M. to 3:00 P.M. shifts. Resident #18 said that the Unit routinely had two CNAs when there should be six, that two CNAs were not enough on the Unit, and that typically there was only one male CNA and one female CNA working which was problematic because the Unit had mostly female residents who would have to wait for the female CNA to provide personal care. Resident #18 said that he/she could tell when the Unit was short staffed because there was hardly anyone walking by his/her room. The Resident also said that he/she was not offered assistance to get out of bed until 10:30 A.M., when he/she likes to get up at 9:00/9:30 A.M. h) During an interview on 1/10/23 at 1:50 P.M., Nurse #6 said that she had not had a lunch break, had lots to do and was unable to take one. Nurse #6 said that she was never able to take breaks when working as the Nurse on Unit Two because there was too much to do and told the surveyor that she would eat when she was on her way home after her shift. i) During a family interview conducted on 1/8/23 at 1:42 P.M., he/she said that there had been a decline in the number of staff throughout the facility and he/she had concerns. The family member said that there was a lot of staff turnover and that the people working at the facility are doing the best they can with the number of staff they have, but overall the residents were receiving less care/services. j) During an interview on 1/8/23 at 2:31 P.M., one of the Residents (who requested to remain anonymous) said that he/she spoke with family about the staffing concerns at the facility and said that things at the facility cannot get any worse. The Resident said that medications that were supposed to be administered at 5:00 A.M. were not administered until 7:20 A.M., that he/she had talked to the nurse who apologized and said that they were late because the facility was so short staffed. The Resident said that items requested (like drinks) were not provided timely or not at all because of the staffing and something had to be done about it. k) During an observation on 1/10/23 at 7:34 A.M., the surveyor observed Resident #75 standing up from a recliner chair positioned across from the nursing station. An alarm box was observed on the floor next to the recliner and was not sounding. The surveyor went over to the Resident to ensure he/she was safe and requested staff assistance as there were no staff observed in the vicinity. Nurse #6 responded by running fast down the entire length of one hallway to assist the Resident and the surveyor. When the surveyor indicated to Nurse #6 that the alarm was not sounding and that there were no staff close by, the Nurse responded I see that. Nurse #6 later approached the surveyor and said that the battery on the alarm needed to be changed, which was completed. During an observation on 1/10/23 at 2:07 P.M., the surveyor observed Resident #75 sitting up from the recliner, which was positioned directly across from the nursing station, with both his/her feet on floor on one side of the recliner and his/her left hand on the leg rest, which was in the elevated position. The surveyor went over to the Resident during the observation as there were no staff visible down on the unit hallways and no staff present for an extended period of time at the nursing station. The surveyor requested assistance from another surveyor (located at the nursing station) and requested she notify staff who were in a closed office behind the Nursing Station, for assistance. The surveyor remained with Resident #75 who continued to actively try to unsafely get up out of the recliner. Nurse #6 (who was in the closed office and was notified by the other surveyor) ran over to the surveyor and Resident #75 to assist. When the surveyor asked Nurse #6 where the other staff was, she said that is a good question and now you see why I don't get breaks. During an interview on 1/11/23 at 10:40 A.M., with UM #3, the surveyor relayed the observations on lack of supervision for Resident #75, who was at risk for falling. UM #3 said that there should always be staff at or near the nursing station to assist with resident supervision.

Based on interview and record review, the facility failed to ensure that its staff conducted twice weekly COVID-19 testing for staff who are not fully up to date with COVID-19 vaccinations, for three staff members (Nurse #1, Laundry Staff #1 and Activities Assistant #1), out of a sample of three staff members. Findings Include: Review of the facility policy titled COVID-19 Testing, revised on 11/10/22, indicated the following: -In compliance with local, state, and federal regulation, has a testing plan for symptomatic, surveillance, and outbreak testing . -Staff who are not up to date with COVID-19 vaccines must conduct twice-weekly testings . -Up to date we will follow the Centers for Disease Control and Prevention (CDC) definition which means the individual has received the primary series with the monovalent vaccine and the bivalent booster two months after the most recent COVID-19 vaccine dose. Review of Massachusetts Department of Public Health Memo titled Updates to Long-Term Care Surveillance and Outbreak Testing, dated December 1, 2022 indicated the following: - .Staff who are not up to date with COVID-19 vaccines must conduct twice-weekly testing. -Staff who are not up to date with COVID-19 vaccines should be tested on two non-consecutive days during the testing week. -Staff surveillance testing is not required to be conducted onsite; however, a LTC facility must develop and maintain policies to document staff surveillance testing is being conducted in accordance with this guidance. 1. Review of Nurse #1 COVID-19 vaccination Certificate indicated he/she had not had the bivalent COVID-10 booster vaccine and was two months post his/her last COVID-19 vaccination. Review of Nurse #1's Schedule by Employee Report (days worked report) indicated that during the week of 12/5/22 through 12/11/22 the Nurse worked: 12/4/22, 12/6/22, 12/8/22, 12/9/22, and 12/10/22. Review of the facility's COVID-19 testing log for the week of 12/5/22 through 12/11/22 indicated: the Nurse only tested on ce on 12/6/22 that week. Review of Nurse #1's Schedule of Employee Report indicated that during the week of 12/12/22 through 12/18/22 the Nurse worked: 12/13/22 and 12/18/22. Review of the facility's COVID-19 testing log for the week of 12/12/22 through 12/18/22 indicated the Nurse did not test for COVID-19 on any of the days he/she worked in the facility that week. Review of Nurse #1's Schedule of Employee Report indicated that during the week of 12/19/22 through 12/25/22 the Nurse worked: 12/20/22, 12/21/22, 12/22/22, 12/23/22, and 12/24/22. Review of the facility's COVID-19 testing log for the week of 12/19/22 through 12/25/22 indicated the Nurse only tested on ce on 12/19/22 that week. 2. Review of the facility COVID-19 vaccination matrix (tracking log used to track COVID-19 vaccination status) indicated Housekeeper #1 had not received his/her bivalent COVID-19 booster vaccine and was two months post his/her last COVID-19 vaccination. Review of the Housekeeping and Laundry schedule for the week of 12/5/22 through 12/11/22 indicated Laundry Staff #1 worked: 12/6/22, 12/7/22, 12/8/22, and 12/9/22. Review of the facility's COVID-19 testing log for the week of 12/5/22 through 12/11/22 indicated Laundry Staff #1 only tested on ce on 12/6/22 that week. Review of the Housekeeping and Laundry schedule for the week of 12/12/22 through 12/18/22 indicated Laundry Staff #1 worked: 12/13/22, 12/14/22, 12/15/22, and 12/18/22. Review of the facility's COVID-19 testing log for the week of 12/12/22 through 12/18/22 indicated Laundry Staff #1 only tested on ce on 12/13/22 that week. Review of the Housekeeping and Laundry schedule for the week of 12/19/22 through 12/25/22 indicated Laundry Staff #1 worked: 12/20/22, 12/21/22, 12/22/22, and 12/23/22. Review of the facility's COVID-19 testing log for the week of 12/19/22 through 12/25/22 indicated Laundry Staff #1 did not test for COVID-19 on any of the days he/she worked in the facility that week. Review of the Housekeeping and Laundry schedule for the week of 12/26/22 through 1/1/23 indicated Laundry Staff #1 worked: 12/26/22, 12/27/22, 12/28/22, 12/29/22, 12/31/22, and 1/1/23. Review of the facility's COVID-19 testing log for the week of 12/26/22 through 1/1/23 indicated Laundry Staff #1 did not test for COVID-10 on any of the days he/she worked in the facility that week. 3. Review of the facility COVID-19 vaccination matrix indicated Activities Assistant #1 had not received his/her bivalent COVID-19 booster vaccine and was two months post his/her last COVID-19 vaccination. Review of the Activity Professional Schedule for the week of 12/19/22 through 12/25/22 indicated Activities Assistant #1 worked: 12/20/22 and 12/22/22. Review of the facility's COVID-19 testing log for the week of 12/19/22 through 12/25/22 indicated Activities Assistant #1 only tested on ce on 12/20/22 that week. Review of the Activity Professional Schedule for the week of 12/26/22 through 1/1/23 indicated Activities Assistant #1 worked: 12/26/22, 12/27/22, and 12/30/22. Review of the facility's COVID-19 testing log for the week of 12/26/22 through 1/1/23 indicated Activities Assistant #1 only tested on ce on 12/30/22 that week. During an interview on 1/10/23 at 3:23 P.M., the Infection Preventionist (IP) said Nurse #1, Laundry Staff #1, and Activities Assistant #1 were all considered not up to date on their COVID-19 vaccinations, so they needed to be tested twice weekly. She further said the facility's weekly testing schedule was from Monday through Sunday. The IP and the surveyor reviewed the facility COVID-19 testing log and the IP said: 1. Nurse #1 needed to be tested twice weekly and: -During the weeks of 12/5/22 through 12/11/22 the Nurse only tested on ce instead of twice. -During the week of 12/12/22- through 12/18/22 the Nurse had not tested at all and should have tested twice. -During the week of 12/19/22 through 12/25/22 the Nurse only tested on ce instead of twice. 2. Laundry Staff #1 needed to be tested twice weekly and: -During the weeks of 12/5/22 through 12/11/22 Laundry Staff #1 only tested on ce instead of twice. -During the week of 12/12/22- through 12/18/22 Laundry Staff #1 only tested on ce instead of twice. -During the week of 12/19/22 through 12/25/22 Laundry Staff #1 had not tested at all and should have tested twice. -During the week of 12/26/22 through 1/1/23 Laundry Staff #1 had not tested at all and should have tested twice. 3. Activities Assistant #1 needed to be tested twice weekly and: -During the weeks of 12/19/22 through 12/25/22 Activities Staff #1 only tested on ce and should have tested twice. -During the week of 12/26/22 through 1/1/23 Activities Staff #1 only tested on ce and should have tested twice.