**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to follow the plan of care for one Resident (#100) by not following a doctor's order to offload heels, out of a total sample of 24 residents. Findings include: Resident #100 was admitted to the facility in August 2023 with diagnoses including dementia and pain in both feet. Review of Resident #100's most recent Minimum Data Set (MDS) assessment, dated 5/2/24, indicated the Resident had a Brief Interview for Mental Status exam score of 3 out of a possible 15, which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #100 is dependent on staff for all bed mobility tasks. On 5/06/24 at 8:37 A.M., Resident #100 was observed lying in bed with both heels directly on the bed. There was no pillow present in the bed or in the room to offload pressure from Resident #100's heels. On 05/07/24 at 7:36 A.M., 8:37 A.M., and 1:47 P.M., Resident #100 was observed lying in bed with both heels directly on the bed. There was no pillow present in the bed or in the room to offload pressure from Resident #100's heels. On 5/08/24 at 7:38 A.M., Resident #100 was observed lying in bed with both heels directly on the bed. There was no pillow present in the bed or in the room to offload pressure from Resident #100's heels. Review of the nursing note dated 5/02/24 indicated the following: Bruising noted on R (right) lateral foot. yellowish/blue in color. NP (nurse practitioner) made aware and assessed. NP informed that this resident is on 2 different blood thinners. NP looking into these medications as it may be the cause of resident easily bruising. HCP (health care proxy) updated. Review of the skin assessment dated [DATE] indicated Resident #100 had redness on his/her left heel and bruising to his/her right foot. Review of Resident #100's physician orders indicated the following order: Offload heels every shift when in bed, initiated on 4/24/24. During an interview on 5/08/24 at 7:39 A.M., Nurse (#2) said Resident #100's heels should be offloaded. During an interview on 5/08/24 at 10:02 A.M., the Director of Nursing said she expects all orders to be followed as ordered.

Based on observation, record review, and interview, the facility staff failed to provide supervision with meals for one Resident (#37) out of a total sample of 24 residents. Findings include: Resident #37 was admitted to the facility in October 2021 with diagnoses including dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/25/24, indicated that Resident #37 could not participate in the Brief Interview for Mental Status exam and was assessed by staff to have severely impaired cognition. The MDS further indicated that Resident #37 requires supervision with eating. Review of Resident #37's current activities of daily living care plan indicated that Resident #37 requires supervision after setup with eating. Review of the most recent Functional Abilities and Goals Assessment, dated 4/26/24, indicated that Resident #37 requires supervision or touching assistance with meals. Review of the task performance documentation for the last 30 days indicated that Resident #37 required varying assistance levels between independence and dependence with meals. During an observation on 5/06/24 at 9:29 A.M., Resident #37 was observed in his/her room, in bed eating breakfast. There were no staff present to provide supervision. Resident #37 was struggling to eat toast with a spoon. During an observation on 5/07/24 at 8:03 A.M., Resident #37 was observed in his/her room, in bed eating breakfast. There were no staff present to provide supervision. During an observation on 5/08/24 at 8:28 A.M., Resident #37 was observed in his/her room, in bed eating breakfast. There were no staff present to provide supervision. During an interview on 5/08/24 at 8:51, Nurse (#2) said that Resident #37 requires supervision with meals and sometimes assistance. During an interview on 5/08/24 at 8:39 A.M., the Director of Nursing said that residents that require supervision should be in the hallway or dining room when eating to be supervised and if a resident does not want to leave their room, then a staff member should be sitting in the resident's room while the Resident eats.

Based on observation, interview, record review, and policy review, the facility failed to ensure that one Resident (#57), out of 24 total sampled residents, received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to obtain weekly wound measurements and failed to obtain recommendations for wound treatments from a follow-up physician appointment for Resident #57. Findings include: The facility policy titled Skin Tears - Abrasions and Minor Breaks, Care of, revised September 2013, indicated, but was not limited to: -Obtain a physician's order as needed. Document physician notification in medical record. -Review the resident's care plan, current orders, and diagnoses to determine resident's needs. -Generate a Non-Pressure form and complete. Resident #57 was admitted to the facility in October 2022 with diagnoses including peripheral vascular disease and diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/07/24, indicated that Resident #57 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 15 out of 15. During an interview on 5/06/24 at 8:40 A.M., Resident #57 said he/she has a wound that never healed on his/her right amputation incision. The surveyor observed a dressing on his/her right amputated residual limb. Review of the active physician's order indicated the following order: -Residual limb wound care: Cleanse wound w/NS (normal saline), pat dry. Pack wound with one sterile 4x4 gauze (DRY DRESSING). May secure with another 4x4 gauze and tape. When changing dressing, DO NOT dampen dressing. Review of the plan of care related to the wound on the suture line of the right below the knee amputation, dated 1/04/24, indicated: -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations, initiated 10/20/22. Review of Resident #57's medical record failed to indicate any weekly wound assessments were completed for his/her non-healing surgical wound. Review of Resident #57's medical record on 5/07/24 indicated the last time the non-healing surgical wound had measurements documented was on 2/22/24, over 10 weeks prior. During an interview on 5/07/24 at 8:39 A.M., Nurse (#4) said Resident #57 should have weekly measurements done in the facility for his/her non-healing surgical wound. Nurse #4 said Resident #57 is followed by a vascular physician in the community for his/her non-healing surgical wound but is unable to locate documentation from recent visits or any weekly wound assessments or measurements completed since he/she was seen by the in-house wound provider in on 1/02/24. During an interview on 5/07/24 at 8:52 A.M., the Assistant Director of Nursing (ADON) said she had told the Unit Manager multiple times that weekly wound measurements and assessments were needed for Resident #57, as they were not being done. As well, the ADON said she told the unit manager multiple times that documentation from the vascular physician needed to be obtained because the facility didn't have it. The ADON said Resident #57's non-healing surgical wound should have been assessed with measurements weekly but was not. During a follow-up interview on 5/07/24 at 9:39 A.M., Nurse #4 provided the surveyor with paperwork from Resident #57's two most recent vascular physician progress notes dated 3/06/24 and 4/03/24. Nurse #4 said this documentation was obtained on that day. Nurse #4 said she would expect notes from a doctor's appointment to be sent back with the Resident and be reviewed for any order changes needed and that if the documentation did not return with the resident, that a nurse should have reached out to the doctors office and attempted to get it it faxed over the same day. Review of the vascular physician progress note, dated 4/03/24, indicated: -We placed bacitracin in the wound and put a dressing back on. -He/she should continue with bacitracin dressings and [sic] a daily basis. I will see her back in 4 weeks for a wound check. During an interview on 5/07/24 at 1:21 P.M., Nurse #4 said paperwork should be reviewed as soon as possible after a resident returns from an appointment for any recommendations. Nurse #4 said the facility's Nurse Practitioner (NP) defers to the vascular physician for treatment orders for Resident #57 because the in-house wound team no longer follows him/her, but that since the paperwork from the 4/03/24 appointment was never obtained the recommendation was missed. Nurse #4 said the Nurse Practitioner would like to observe the wound change today before approving the order, since it had been over a month since it was recommended. Nurse #4 said the follow-up appointment was not scheduled in time because they didn't have the paperwork. Review of nursing progress note, dated 5/07/24, indicated: -Spoke with NP (nurse practitioner) regarding delay in care for her wound, ordered from vascular surgery. Resident has been followed by Vascular surgery outpatient. Resident's wound will be evaluated by the NP at the time of the dressing change that will be scheduled for this afternoon, to assess and decide if the treatment which has been suggested by vascular is appropriate and will then be added to the plan of care if so. Resident will have a follow up on 5/15/24 at 12 PM. On 5/7/24 at 2:20 P.M., the surveyor observed the wound dressing change with Nurse #3 and the Nurse Practitioner. The Nurse Practitioner said she would have approved the wound recommendation from the vascular physician and will change the order at this time. During an interview on 5/07/24 at 1:50 P.M., the Director of Nursing (DON) said Resident #57 should have had weekly wound assessments including measurements completed. The DON said the nurses on the floor are responsible for obtaining paperwork after an appointment and ensuring all recommendations are reviewed with the physician. The DON said if paperwork is not sent back from the appointment, then the nurse, or a delegate, should call that day to attempt to obtain the paperwork.

Based on observations, record reviews and interviews, the facility failed to provide respiratory care services in accordance with professional standards of practice. Specifically, the facility failed to ensure oxygen administration was in accordance with the medical plan of care for one Resident (#5) out of a total sample of 24 residents. Findings include: The facility policy titled Oxygen Administration, undated, indicated the following but not limited to: -The purpose of this procedure is to provide guidelines for safe oxygen administration. -Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Resident #5 was admitted to the facility in June 2023 with diagnoses including chronic obstructive pulmonary disorder, neoplasm of bronchus or lung, chronic respiratory failure and dependent on supplemental oxygen. Review of Resident #5's most recent Minimum Data Set (MDS) assessment, dated 4/18/24, indicated Resident #5 scored a 10 out of 15 on the Brief Interview for Mental Status exam indicating that he/she had moderately impaired cognition. The MDS further indicated Resident #5 is dependent on oxygen. On 5/06/24 at 8:43 A.M., Resident #5 was observed lying in bed wearing oxygen via a nasal cannula at 3.5 liters/ minute. The oxygen concentrator filters were covered with a thick layer of dust. On 5/07/24 at 9:00 A.M., Resident #5 was observed lying in bed wearing oxygen via nasal cannula at 3.5 liters/ minute. The oxygen concentrator filters were covered with a thick layer of dust. On 5/07/24 at 10:46 A.M., Resident #5 was observed lying in bed wearing oxygen via nasal cannula at 3.5 liters/ minute. The oxygen concentrator filters were covered with a thick layer of dust. Review of the current physicians' orders indicated the following orders: -Oxygen continuous at 4 liters/minute via nasal cannula every shift for shortness of breath care and comfort. -Change tubing and clean air filter weekly every night shift every Sunday. -Change oxygen/nebulizer tubing and clean filter every evening shift every Monday. Review of the Treatment Administration Record for May 2024 indicated that the oxygen tube and filter was changed on Sunday 5/05/24 and that nursing staff was monitoring for oxygen administration at 4 liters/minute via nasal cannula every shift. Review of Resident #5's emphysema/COPD, chronic respiratory failure with dependent oxygen continuous use care plan, last revised 8/30/23, indicated the following intervention: -Oxygen settings per physician orders. During an interview on 5/07/24 at 10:53 A.M., Nurse #1 said the oxygen should be set at 4 liters/minute and that the filters should not have a thick coat of dust if they were changed two days ago. Nurse #1 further said physicians orders should be followed as ordered. During an interview on 5/08/24 at 8:35 A.M., the Director of Nursing said the expectation is for nurses to follow physician's order for oxygen setting and changing tubing and filters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) Resident #57 was admitted to the facility in October 2022 with diagnoses including end-stage renal disease, peripheral vascular disease and diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/07/24, indicated that Resident #57 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 15 out of 15. The MDS further indicated Resident #57 received dialysis. Review of the active physician's order, dated 7/28/23, indicated Resident #57 had dialysis every Monday, Wednesday, and Friday. Review of the active physician's order, dated 3/4/23, indicated: -Left IJ (internal jugular vein) tunneled HD (hemodialysis) catheter. For care, please F/U (follow up) with directed Tx (treatment) orders from the primary surgeon. Review of the plan of care related to dialysis, dated 10/02/2023, indicated: - Monitor/document/report PRN for s/sx of the following: Bleeding, Hemorrhage, Bacteremia, septic shock. During observation and interview on 5/06/24 at 8:40 AM, Resident #57 said he/she receives dialysis through tunneled hemodialysis catheter in his/her left chest. Resident #57 said there is not a dialysis emergency kit in his/her room with clamps and pressure dressings. The surveyor did not observe an emergency kit in Resident #57's room. During an interview on 5/07/24 at 8:26 A.M., Nurse (#3) said he doesn't know where dialysis emergency kits are located or where he would obtain emergency supplies if Resident #57 had unexpected bleeding from his/her tunneled hemodialysis catheter During an interview on 5/07/24 at 8:39 A.M., Nurse (#4) observed Resident #57's room with the surveyor and said there should be a dialysis emergency kit with a clamp available in Resident #57's room for use if unexpected bleeding occurred from the tunneled hemodialysis catheter, but that there was not. During an interview on 5/0/24 at 1:50 P.M., the Director of Nursing said there should be a dialysis emergency kit located in the room of every resident who receives dialysis which contains clamps and pressure dressings in case of an emergency. Based on record reviews, policy reviews and interviews, the facility failed to provide care and services consistent with professional standards for two Residents (#103 and #57) who required renal dialysis (a life sustaining treatment that helps the body remove extra fluid and waste products from the blood when the kidneys are not able to) out of a total sample of 24 residents. Specifically, the facility failed to ensure that clamps and pressure dressings were kept with the Resident's #103 and #57 in case of an emergency related to a tunneled hemodialysis catheter (a plastic tube used for exchanging blood between a patient and a hemodialysis machine). Findings include: The facility policy titled End-Stage Renal Disease, Care of a Resident with (sic), dated as revised September 2023, indicated the following but not limited to: -Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. -Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. -How to recognize and intervene in medical emergencies such as hemorrhages and septic infections. 1.) Resident #103 was admitted to the facility in September 2023 with diagnoses including end stage renal disease, dependent on renal dialysis. Review of Resident #103's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively impaired. The MDS further indicated the Resident was dependent on dialysis. Review of Resident #103's medical record indicated the following orders: -Check dialysis right upper chest tunneled catheter dressing every shift for bleeding or signs/symptoms of infection, notify practitioner if present every shift for monitoring. -If dialysis tunneled catheter of right upper chest dressing becomes dislodged, apply dry clear dressing and call practitioner as needed for maintenance check every shift. On 5/07/24 at 7:56 A.M., Resident #103 was observed lying in his/bed. The surveyor did not locate emergency clamps or pressure dressing with the Resident or in the Resident's room. During an interview on 5/07/24 at 10:55 A.M., Nurse #1 said the emergency clamp and pressure dressing should be taped to the wall in the Resident's room at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed, interviews and review of surveillance camera video footage, for one of three sampled residents (Resident #1), who had a diagnosis of Alzheimer's disease and was cognitively impaired, the Facility failed to ensure he/she was treated in a respectful and dignified manner which included being free from the use of restraints, when on 11/20/23, Certified Nurse Aide (CNA) #1 used a plastic bag to secure one of the wheels of Resident #1's wheelchair to restrict his/her movement and limit his/her ability to self propel the wheelchair on his/her own. Findings include: Review of the Facility Policy titled Use of Restraints, no date, indicated that examples of devices that are/might be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vests, wheelchair safety bars, Geri-chairs, lap cushions and lap trays that the resident cannot remove. Resident #1 was admitted to the Facility in April 2022, diagnosis included chronic kidney disease, Meniere's disease, spinal stenosis, and Alzheimer's disease. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she was cognitively impaired and had an invoked Health Care Proxy (HCP). Review of the Facility's Internal Investigation, dated 11/20/23, indicated that Resident #1's son came in to visit and was unable to move the resident in his/her wheelchair. The Investigation indicated they found that a plastic bag had been tied to Resident #1's wheelchair, effectively immobilizing him/her. The Investigation indicated that upon review the facility's video surveillance camera footage, it was confirmed that Certified Nurse Aide (CNA) #1 was the one who tied the plastic bag to the wheel of the wheelchair. The Investigation indicated that CNA #1 acknowledged she placed the plastic bag around Resident #1's wheelchair. Review of the surveillance camera video footage clips provided by the Facility, from the day shift (7:00 A.M. to 3:00 P.M.) dated 11/20/23 from 12:56:14 to 12:57:17, illustrated the following: -12:56:20, a staff is seen bringing Resident #1 in to the dining room. -12:56:31, Resident #1 can be seen self propelling in his/her wheelchair around the unit towards the dining room door, and CNA #1, who is standing by the door, can be seen interacting with Resident #1. -12:56:34, Resident #1 remains at the door to the dining room, and CNA #1 walks toward the cabinet area. -12:56:40, CNA #1 opens a cabinet door, pulls out a plastic bag, and walks toward Resident #1, who is still self propelling around in the area of the dining room. -12:56:56, CNA #1 is seen attaching the plastic bag in the back to the wheelchair and appears to be securing it. During an interview on 12/18/23 at 11:15 A.M., Certified Nurse Aide (CNA) #1 said she was concerned about Resident #1 wandering around, that he/she might have an altercation with another resident on the unit who also wanders. CNA #1 said she was only trying to avoid an altercation between the two residents and was not thinking of it as being restrained at the time, but said now she understands and that it was a mistake. During an interview on 12/19/23 at 11:00 A.M., Activities Assistant (AA) #2 said that Resident #1's son came to visit, wanted to move to a quiet room to visit with Resident #1, noticed the wheelchair was stuck and unable to move. AA #2 said she came over to check Resident #1's wheelchair and brakes, and noticed that there was a plastic bag secured tightly between the wheel and the seat frame. AA #2 said that this restricted the movement of Resident #1's wheelchair. AA #2 said immediately reported to Resident #1's nurse. During an interview on 12/05/23 at 2:21 P.M., the Director of Nurses (DON) said that she was notified by staff that Resident #1's son came to visit, was unable to move the resident in his/her wheelchair, and that it appeared that someone had tied the plastic bag to a wheel. The DON said she interviewed CNA #1, and that after they told her that they had reviewed the surveillance camera video footage from the unit, CNA #1 admitted securing the plastic bag to the wheelchair. The DON said CNA #1 told her she was only trying to avoid an altercation between Resident #1 and another resident that was also wandering on the unit, and that she (CNA #1) was not even thinking at the time, that it was considered a restraint. On 12/05/23, the Facility provided the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. Resident #1 was immediately assessed for any sign of injury or distress, none were noted, and he/she will continued to be monitored by staff, with support provided, as needed. B. 11/20//23, all residents on CNA #1's assignment were immediately assessed to ensure no other restraints were in place, were asked if there were any other concerns related to care and/or treatment provided by CNA #1. C. 11/20/23 through 12/11/23, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) completed house-wide staff re-education and training on the Facility's Restraint and Abuse Policy, which included the definition of a Restraint. D. 11/20/23 through 12/11/23, random inspections (and ongoing) conducted on all units, across all three shifts (by administrative personnel) to ensure staff understanding and compliance Restraint Policy. E. 11/20/23 through 11/24/23, audits (visual inspections) were performed by Maintenance Department Personnel, of all facility wheelchairs to make sure wheelchair brakes were adequately functioning and wheel functions were not obstructed. F. Area of concern was presented at the facility's monthly Quality Assurance Performance Improvement (QAPI) Committee Meeting, and will continue to reviewed by the committee monthly to ensure substantial compliance. G. CNA #1's employment was terminated by the facility. H. The Administrator, the Director of Nurses and/or their designee are responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was severely cognitively impaired, the Facility failed to ensure that staff implemented and followed their abuse policy related to the need to immediately report an allegation of potential abuse (use of a restraint) to the Administrator in an effort to protect other residents from potential abuse. Although Staff members on 05/20/23 at 5:40 A.M. discovered Resident #1 in a fetal position (legs tucked up into chest) with the bottom corners of his/her johnny tied (knotted) together (behind his/her back) restricting his/her ability to straighten out or move his/her legs at will, it was not reported to the Administrator and/or Director of Nurses until approximately 11 hours later. Findings include: Review of the Facility's Policy, titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated April 2021, indicated if resident abuse is suspected, the suspicion must be reported immediately to the administrator and to other officials in accordance to state law. Upon receiving any allegations of abuse, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. Review of Resident #1's medical record indicated his/her Massachusetts Health Care Proxy was activated on 10/04/21, due to cognitive impairment related to Dementia. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 04/19/23, indicated that Resident #1's cognitive patterns were severely impaired. Review of Resident #1's Hospice Care Plan, dated 02/09/23, indicated he/she was receiving end of life care related to Senile Degeneration of the Brain. The Hospice Care Plan interventions included the following: adjust provision of Activities of Daily Living to compensate for changing abilities; keep environment quiet and calm; keep linens clean, dry and wrinkle free; observe closely for signs of pain; and work closely with Hospice team to ensure spiritual, emotional, intellectual, physical and social needs are met. During an interview on 06/27/23 at 10:40 A.M., Certified Nurse Aide (CNA) #1 said at approximately 5:40 A.M. on 05/20/23 she removed Resident #1's blanket and sheet to find Resident #1 laying on his/her back, with his/her knees bent way up. CNA #1 said the bottom corners of Resident #1's johnny were together in an extremely tight knot, and was tied up behind him/her. CNA #1 said the johnny was also tied, appropriately, behind Resident #1's neck. CNA #1 said the knot at the bottom of the johnny confined Resident #1's legs and feet, so that his/her feet were up close to his/her buttocks, putting him/her in a fetal type position. CNA #1 said there was no space in the johnny to allow for Resident #1 to free his/her legs. CNA #1 said she immediately showed Nurse #1 (working as a Nurse Aide that evening) and Nurse #2 at 5:40 A.M. how a knot was tied in Resident #1's johnny to restrict his/her ability to straighten his/her legs. CNA #1 said she untied Resident #1 who immediately appeared relieved and straightened his/her legs. During an interview on 06/26/23 at 11:00 A.M., Nurse #1 said while working on the unit as a Nurse Aide on 05/20/23 at 5:40 A.M., CNA #1 asked her to see Resident #1. Nurse #1 said Resident #1 was lying in a fetal position in bed wearing a johnny. Nurse #1 said the bottom of his/her johnny was tied together into a knot preventing Resident #1 from straightening his/her legs. Nurse #1 said Nurse #2 was also asked to immediately see Resident #1. During an interview on 06/14/23 at 12:48 P.M., Nurse #2 said on 05/20/23 at 5:40 A.M. she was told to come see Resident #1, who was in bed. Nurse #2 said Resident #1's legs were bent at the knees, and the bottom of his/her johnny was tied (knotted) preventing him/her from being able to straighten them. Nurse #2 said she did not report the alleged incident of abuse to a nurse supervisor, the Director of Nurses or to the Administrator during her 3:00 P.M. to 11:00 P.M. shift on 05/20/23. Nurse #2 said she was focused on returning to her medication cart to complete the medication pass and had not reported the alleged incident of abuse immediately, as required. During an interview on 06/14/23 at 09:30 A.M. and at multiple times through the day of survey, the Director of Nurses said at approximately 5:00 P.M. on 05/20/23 (approximately 11 hours after the incident occurred) Nurse #1 called her to report that CNA #1 and herself had found Resident #1 (at approximately 5:40 A.M. on 05/20/23) in a fetal position with the bottom of his/her johnny tied in a knot that prevented Resident #1 from straightening his/her legs. The DON said no one, including Nurse #2, notified her or the Administrator immediately after Resident #1 was found to have been restrained by the use of a tied johnny.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was alleged to have be subjected to physical abuse via use of a restraint, after being found by in bed staff members curled up in the fetal position with his/her legs confined by his/her johnny, that had been tied in a knot at the bottom. Although Facility administration was made aware of the allegation on 5/20/23 at approximately 5:00 P.M., the Facility failed to ensure they submitted a report to the Department of Public Health (DPH) within the required reporting timeframe, when their report regarding the allegation was not submitted to the DPH until approximately 9:00 P.M., (which was four hours after becoming aware of the allegation). Findings include: Review of the Facility's Policy, titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated April 2021, indicated if resident abuse is suspected, the suspicion must be reported immediately to the the Administrator and to other officials in accordance to state law. The Policy indicated the Administrator or individual making the allegation immediately reports his or her suspicion to the state licensing/certification agency responsible for surveying/licensing the facility. The Policy indicated that immediately is defined as within two hours of an allegation of involving abuse. Review of Resident #1's medical record indicated his/her Massachusetts Health Care Proxy was activated on 10/04/21, due to cognitive impairment related to Dementia. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 04/19/23, indicated that Resident #1's cognitive patterns were severely impaired. During an interview on 06/14/23 at 02:35 P.M., the Director of Nurses said that on 05/20/23 at approximately 5:00 P.M., Nurse #1 called her to report that Certified Nurse Aide (CNA) #1 and herself had found Resident #1 (at approximately 5:40 A.M. on 05/20/23) in a fetal position with the bottom of his/her johnny tied in a knot that prevented Resident #1 from straightening his/her legs. The DON said she notified the Administrator of the allegation of abuse at approximately 5:00 P.M. on 05/20/23. The DON said she may not have reported the allegation of abuse to the Department of Public Health within two hours of being notified. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS) indicated the facility submitted their report regarding the allegation of physical abuse at 9:18 P.M. on 05/20/23, approximately four hours after the DON had been notified of the alleged incident by Nurse #1 (at 5:00 P.M. on 05/20/23).

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), who was dependent on staff to meet his/her care needs, the Facility failed to ensure Resident #1 received appropriate care and treatment related to his/her incontinence needs, when it was determined that after providing incontinence care to him/her, nursing staff had applied double briefs to Resident #1 by putting a pull-up style incontinence brief over facility incontinence brief, in an effort to inhibit his/her ability to remove it. Findings include: Review of Resident #1's clinical record indicated his/her Massachusetts Health Care Proxy was activated on 10/04/23 due to cognitive impairment related to Dementia. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 04/19/23, indicated that Resident #1's cognitive patterns were severely impaired. The MDS indicated Resident #1 was incontinent of bowel and bladder and required extensive assistance with one to two persons for Activities of Daily Living. Review of Resident #1's Care Plan related to Skin Integrity, dated 02/09/23, indicated he/she had the potential for pressure ulcer development related to incontinence of bowel and bladder, and decreased mobility. The Care Plan interventions included the following: follow policies and protocols for the prevention/treatment of skin breakdown; apply moisturizer barrier every shift to skin without massaging bony prominences; use of mild cleaners for peri-care/washing; document changes in skin status; and use of alternating pressure relieving/reducing mattress on bed. Review of Resident #1's Care Plan related to ADL care needs, dated 02/09/23, indicated he/she had bladder and bowel incontinence related to declining condition due to Dementia. The Care Plan interventions included to check for incontinence, and to wash, rinse, dry and change clothing as needed after incontinent episodes. Review of Resident #1's Care Plans indicated there was no documentation to support double briefing was indicated as an intervention. During an interview on 06/22/23 at 12:25 P.M., Certified Nurse Aide (CNA) #2 said sometime after supper on 05/19/23 she checked on Resident #1 to find he/she had pulled off his/her incontinent brief. CNA #2 said there was also a small amount of feces on his/her bed. CNA #2 said after incontinent care was provided, she put a clean incontinence brief on Resident #1 and then put a pull-up style brief over it. CNA #2 said she thought the pull-up brief would hold the incontinent brief in place, as it was unlikely Resident #1 would be able to remove the pull-up brief down his/her legs. CNA #2 said this was the first time she applied a double brief to a resident, and said she had not been instructed to do so by any staff. During an interview on 06/27/23 at 10:40 A.M., Certified Nurse Aide (CNA) #1 said at approximately 5:30 A.M. on 05/20/23 she entered Resident #1's room with the intention to provide incontinence care for him/her if needed. CNA #1 said she found Resident #1 to have a pull-up incontinence brief on over an incontinence brief. CNA #1 said she immediately found Nurse #2 on the Unit and showed her. CNA #1 said she removed both briefs, and applied only one incontinent brief after care was provided. Review of Nurse #2's written statement, dated 05/21/23, indicated that at 5:40 A.M. on 05/20/23 she was asked to see Resident #1. Nurse #2 indicated observing that Resident #1 was wearing two different adult briefs. During an interview on 06/28/23 at 2:45 P.M., the Director of Nurses (DON) said during a Facility investigation, CNA #2 and Nurse #1, who had worked during the 3:00 P.M. to 11:00 P.M. shift on 05/19/23, told her that during care rounds CNA #2 and Nurse Aide #1 applied a pull-up style incontinence brief over an incontinence brief on Resident #1 during first rounds, and then did it again separately, when they provided care on subsequent care rounds during the shift. The DON said CNA #2 and Nurse Aide #1 told her Resident #1 had removed his/her incontinence brief earlier during the shift and it was thought that double briefing in this manner would prevent removal of a brief. The DON said it was believed that Resident #1 was still wearing double briefs from the preceding shift (3:00 P.M. to 11:00 P.M. shift) when CNA #1 found Resident #1 wearing them during the 11:00 P.M. to 7:00 A.M. shift. The DON said it was against Facility practice to apply two briefs on any resident.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who experienced a near fall while being assisted into a shower chair by a staff member, and who had complained of pain to his/her right side after the incident, the Facility failed to ensure nursing notified the physician in a timely manner to obtain additional physician's orders or instructions, however, the physician was not made aware until two days after the incident occurred, at which time an order was obtained for x-rays to be obtained. Findings include: The Facility Policy titled Notification of Changes, undated, indicated that staff will make every attempt possible to notify the physician, family members, and/or legal guardian of any incident/accident, change in condition requiring provider intervention, change in physical, mental, or psychosocial status, a need to alter treatment, or a decision to transfer from the facility. Nursing staff is responsible to update the appropriate parties, including the provider, under the circumstances listed above. Nursing staff is responsible to document the communication in the nurses' notes. Resident #1 was admitted to the Facility in January of 2023, medical history included atrial fibrillation (irregular heat beat), that required anticoagulant therapy, congestive heart failure (CHF), diabetes, cerebral infarction (stroke) affecting the right arm and leg, severe aortic stenosis with valve replacement, high blood pressure, difficulty walking, Covid-19 infection and sacral pressure ulcer. During interview on 4/10/23 at 10:18 A.M., Certified Nurse Aide (CNA) #3 said that on 2/25/23 during the 7:00 A.M.- 3:00 P.M. shift Resident #1 was on her assignment and that she was familiar with his/her care needs. CNA #3 said she was transferring Resident #1 from the bed to the shower chair when the shower chair moved backwards and Resident #1 started falling backwards. CNA #3 said she caught Resident #3 under his/her arms, like a hug and heard a popping sound. CNA #3 said she then held one arm of the shower chair with her right hand and Resident #1 held the other shower chair arm with his/her left hand and he/she was successfully assisted to a sitting position in the shower chair. CNA #3 said she assisted Resident #1 with the shower and on return to his/her room, she asked Nurse #4 to assist her with transferring Resident #1 back to bed. CNA #3 said she reported the near fall to Nurse #4 at that time. CNA #3 said during the transfer back to bed, Resident #1 complained of pain on his/her right side. CNA #3 said she also reported the near fall again to the 3:00 P.M. - 11:00 P.M. nurse and on 2/26/23 to the 7:00 A.M. - 3:00 P.M. nurse. CNA #3 said that at the time of this incident, Resident #1 was awake, alert and able to make his/her needs known. Review of Resident #1's Progress Note written by Nurse #4 and dated 2/25/23, indicated Resident #1 was alert and oriented with some increased confusion over the last few days. The Note indicated Resident #1 continued with fatigue and listlessness and complained of pain in his/her back today, has a wound to the sacral area and complains of pain at that site. There was no documentation to support that Nurse #4 notified the physician or family of the near fall incident on 2/25/23, or that he/she had complained of pain. There was no documentation to support that Nurse #4 completed an Incident Report regarding Resident #1's near fall incident on 2/25/23, that occurred during his/her transfer to shower chair. The Surveyor was unable to interview Nurse #4 as she did not respond to the Departments request for an interview. During interview on 3/28/23 at 2:05 P.M., the Nurse Practitioner (NP), said that the Physician's Group was not notified on 2/25/23 of Resident #1's shower chair incident or of his/her complaints of right sided rib cage pain, until 2/27/23, and said a chest x-ray was ordered at that time. The NP said the physician should have been notified when the incident occurred. The NP said she examined Resident #1 on 2/28/23 regarding rib pain resulting from a non-displaced 5th rib fracture that occurred on 2/25/23 from the incident during transfer from bed to the shower chair. During interview on 3/28/23 at 5:15 P.M., Nurse #3 said on 2/27/23, during the 3:00 P.M. - 11:00 P.M., she had received the chest x-ray report indicating Resident #1 had a right non-displaced 5th rib fracture. Nurse #3 said she notified the Director of Nursing Services, Nurse Practitioner and Resident #1's family member of the findings. Nurse #3 said she obtained new orders for Tylenol and Lidoderm Patch and that Resident #1 had fair pain relief with the interventions. During interview 3/28/23 at 11:23 A.M., the Director of Nursing Services (DNS) said that according to Facility policy, CNA #3 should have reported the near fall to the nurse on duty 2/25/23 when the incident occurred. The DNS said that the nurse then should have reported the incident and the resident's complaint of right rib pain to the physician on 2/25/23. The DNS said an Incident Report should also have been completed by the nurse at the time of the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. For Resident #88 the facility failed to obtain an updated psychotropic consent for a prescribed antidepressant. Resident #88 was admitted to the facility in November 2021 with diagnoses including, dementia, benign prostatic hyperplasia without lower urinary tract symptoms, and acquired absence of kidney. Review of the most recent Minimum Data Set assessment dated , 12/29/22, indicated a Brief Interview for Mental Status score of 11 out of a possible 15 indicating moderate cognitive impairment. Review of Resident #88's medical record indicated the following: -A Physician order dated 12/13/22, Duloxetine capsule (an antidepressant) delayed release particles 20 mg (milligrams) Give 1 capsule by mouth one time a day for depression. -A Physician order dated 12/13/22, Risperdal tablet (an antipsychotic medication) 0.5 mg Give 1 tablet by mouth in the afternoon for agitation, ordered 12/13/22. -Review of Psychotropic consents failed to indicate an updated consent for duloxetine. The most recent consent was signed 2021. During an interview on 3/17/23 at 9:55 A.M., Unit Manager #1 confirmed Resident #88 did not have an updated consent for Duloxetine. Unit Manager #1 said expectation is for psychotropic consents to be completed. Based on record review and interview, the facility failed to obtain an informed consent for the use of psychotropic medication for 3 Residents (#12, #96 and #88) out of a total sample of 35 residents. Findings include: Based on the facility policy titled, Psychotropic Medications - Instruction Sheet, undated, indicated the following: *When an order to initiate a psychotropic medication is given, the provider must have a documented conversation with the resident or the HCP (if activated). These include all antipsychotics, antidepressants, and anxiolytics. *A psychotropic Med form must be filled out by the nurse. The patient or HCP has to sign the form with the nurse as a witness. The provider does not need to sign the form, but the date and time of the provider conversation must be documented on the form. *Consent forms need to be resigned and the provider has to have another documented conversation if the medication dose rates range changes from its original parameters, if a new Med is initiated, if the HCP changes hands or once per year. 1. Resident #12 was admitted to the facility in September 2021 with diagnoses including delusional disorders, unspecified dementia with severe agitation, psychotic disorder with delusions, major depression and anxiety. Review of Resident #12's most recent Minimum Data Set, dated [DATE] indicates the Resident has a Brief Interview for Mental Status (BIMS) score of 6 out of a possible 15 which indicates he/she has severe cognitive impairment. Review of Resident #12's physician orders indicated the following orders: *Quetiapine Fumarate (an antipsychotic) tablet. Give 1 tablet by mouth two times a day and give 2 tablets by mouth at bedtime, written 2/7/23. *Citalopram Hydrobromide (an anti-depressant) Tablet. Give 10 mg (milligrams) by mouth one time a day for depression, written 10/16/21. Review of Resident #12's medical record failed to indicate any psychotropic consent forms had been updated since 2021. During an interview on 3/16/23 at 7:47 A.M., Unit Manager #2 said residents who receive psychotropic medications are required to sign consents to take these medications. Unit Manager #2 said these consents need to be updated yearly and that she has not gotten around to doing this for the residents on her floor. 2. Resident #96 was admitted to the facility in May 2021 with diagnoses including Alzheimer's Disease, major depression, adjustment disorder and anxiety. Review of Resident #96's most recent Minimum Data Set, dated [DATE] indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) exam and the staff assessed him/her to have severe cognitive impairment. Review of Resident #96's physician orders indicated the following orders: *Trazodone (an anti-depressant medication) tablet. Give 0.5 tablet by mouth every 8 hours as needed for to help with anxiety and agitation until 03/23/2023, written 3/9/23. *Trazadone tablet. Give 50 mg by mouth at bedtime for insomnia, written 5/28/21. *Seroquel (an antipsychotic medication) Tablet. Give 1 tablet by mouth two times a day, written 5/5/22. *Sertraline (an antidepressant) tablet. Give 1 tablet by mouth one time a day, written 5/29/21. Review of Resident #96's medical record failed to indicate any psychotropic consent forms had been updated since 2021. During an interview on 3/16/23 at 7:47 A.M., Unit Manager #2 said residents who receive psychotropic medications are required sign consents to take these medications. Unit Manager #2 said these consents need to be updated yearly and that she has not gotten around to doing this for the residents on her floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to report a potential incident of abuse for 1 Resident (discharged Resident #1) out of 35 sampled residents. Findings include: Review of the facility policy titled Abuse Policy and Procedures, dated, April 1, 2017, indicated the following: *Any alleged violations and all substantiated incidents of any form of abuse or suspicious injuries of unknown origin will be reported to the state agency and to all other agencies as required by State and Federal regulations. *When an alleged or suspected case of abuse mistreatment, neglect, exploitation, misappropriation, of resident property, or injuries of unknown origin is reported, the Administrator, or designee, will immediately notify the State Agency but no later than 2 hours after the allegation are made. discharged Resident #1 was admitted to the facility in October 2022 with diagnoses that include unspecified fracture of femur, anxiety disorder and major depressive disorder. Review of discharged Resident #1's most recent Minimum Data Set (MDS) dated [DATE] indicated that he/she had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 indicating that he/she was cognitively intact. Further review of the MDS revealed that the Resident required extensive assistance and 2+ person assist with all Activities of Daily living and exhibited no behaviors. Review of the facility's grievance log indicated the following grievance written on 10/28/22: * At approximately 6 A.M., rang to ask for assistance to the commode. Certified Nursing Assistant (CNA) came into room discharged Resident #1 told her he/she needed to move bowels. CNA said she would have to use the bedpan not the commode and assisted discharged Resident #1 with the placement of a bedpan. discharged Resident #1 called for help again. CNA came and discharged Resident #1 asked to be placed on commode stating he/she had to go and the bedpan was difficult and uncomfortable to use. The CNA told discharged Resident #1 he/she was finished and put him/her in a brief and left room. discharged Resident #1 called again for assistance. A nurse came to assist. discharged Resident #1 explained to the nurse what had happened. The nurse said she would get him/her help. Another CNA came in the room and assisted him/her. discharged Resident #1 was very upset stating that this took over an hour and a half to get the assistance. The whole time he/she was left with feces on him/her. discharged Resident #1 was crying saying he/she just wants to leave. This is negligence. The grievance investigation was initiated on 10/28/22 and completed on 10/31/22 and signed by the facility Administrator. Review of the State Agency reporting system failed to indicate that the facility reported the allegation of potential abuse. During an interview on 3/17/23 at 10:19 A.M., the Administrator said any possible abuse allegations are followed up and reported immediately. During an interview on 3/20/23 at 8:45 A.M., the Administrator said we should have reported and investigated the situation even if no findings were found.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to provide assistance with meals for 2 Residents (#41 and #51) out of a total sample of 35 residents. Findings include: 1. Resident #41 was admitted to the facility in April 2022 with diagnoses including Alzheimer's disease. Review of Resident #41's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident has a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15 which indicates he/she has severe cognitive impairment. The MDS also indicates Resident #41 requires supervision during meals. On 3/15/23 at 8:18 A.M., Resident #41 was observed eating breakfast in bed. Resident #41 was attempting to eat scrambled eggs with his/her fingers without success. Resident #41 then began to use his/her finger to spread jelly on a piece of toast. Resident #41 was not observed eating any food from 8:18 A.M. to 8:37 A.M., and no staff entered the room to assist him/her or to provide supervision. On 3/15/23 at 12:39 P.M., Resident #41 was observed eating lunch alone in his/her room. There were no staff present to provide assistance or supervision. On 3/16/23 at 8:22 A.M., Resident #41 was observed eating breakfast in the hallway. The floor staff were on the opposite end of the hallway talking and waiting for the second meal truck. On 3/17/23 at 8:18 A.M., Resident #41 was observed eating breakfast while lying in bed. Resident #41 was eating eggs with his/her hands. The staff on the floor were passing out meal trays to other residents and were not in his/her room to provide assistance or supervision. Review of Resident #41's activity of daily living care plan indicated the following intervention: *Supervision for meals with setup During an interview on 3/17/23 at 9:27 A.M., Unit Manager #2 said the staff do not provide continual supervision during mealtimes. 2. Resident #51 was admitted to the facility in January 2021 with diagnoses including dementia, dysphagia (difficulty swallowing) and psychotic disorder. Review of Resident #51's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident has a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15 indicating he/she has severe cognitive impairment. The MDS also indicated Resident #51 requires supervision for feeding tasks. On 3/15/23 at 8:39 A.M., Resident #51 was observed eating breakfast while lying in bed. There were no staff present to provide assistance or supervision. On 3/16/23 at 8:24 A.M., Resident #51 was observed eating breakfast in the hallway. The floor staff were on the opposite end of the hallway talking and waiting for the second meal truck. The Resident was attempting to eat his/her eggs with his/her hands, not a utensil. The Resident's milk was out of reach and he/she was asking for help to move the milk closer. No staff were present to do this for him/her. On 3/17/23 at 8:18 A.M., Resident #51 was eating breakfast alone in his/her room while lying in bed. The staff on the floor were passing out meal trays to other residents and were not in his/his room to provide assistance or supervision. Review of Resident #51's activity of daily living care plan indicated the following intervention: *Continual supervision for meals with verbal cues. During an interview on 3/17/23 at 9:27 A.M., Unit Manager #2 said the staff do not provide continual supervision during mealtimes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #24 the facility failed to implement a physician ordered air mattress timely. Resident #24 was admitted to the facility in October 2021 with diagnoses including, lymphoid leukemia, dementia, chronic bronchitis, and chronic kidney disease. Review of the most recent Minimum Data Set Assessment (MDS) dated , 12/29/22, indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating intact cognition. During an observation on 3/15/23 at 11:05 A.M., Resident #24 was observed lying in bed, with eyes closed, no air mattress was observed on the bed. Review of Resident #24's medical record indicated the following: - A written physician order dated 3/10/23 for an air mattress. - A written physician order dated 3/10/23 indicated to apply skin prep to sacral skin tear daily. Review of a Norton Assessment (Skin Assessment for assessing skin injury risk) dated 3/14/23, indicated Resident #24 was high risk for pressure ulcers. During an interview on 3/16/23 at 2:30 P.M., Unit Manager #1 said air mattresses can be ordered and only take a day or two to come in. Unit Manager #1 said the expectation would be for the Resident to have the ordered air mattress. Based on observations, record reviews and interviews, the facility failed to ensure an air mattress was on the correct setting for 2 Residents (#51 and #24) who were at high risk of pressure ulcers, out of a total sample of 35 residents. Findings include: 1. Resident #51 was admitted to the facility in January 2021 with diagnoses including dementia, dysphagia and psychotic disorder. Review of Resident #51's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident has a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15 indicating he/she has severe cognitive impairment. The MDS also indicated Resident #51 requires supervision for feeding tasks. On 3/15/23 at 8:21 A.M., 3/16/23 at 8:24 A.M., and 3/17/23 at 8:18 A.M., Resident #51 was observed lying in bed with his/her air mattress set to 325 pounds. Review of Resident #51's most recent weight taken on 1/25/23, indicated Resident #51 weighs 164 pounds. Review of Resident #51's physician orders indicated an order written on 1/29/23 to monitor placement of air mattress every shift. Review of the Norton Pressure Ulcer Risk Scale dated 2/24/23, indicated Resident #51 was at high risk for pressure ulcer development. During an interview on 3/17/23 at 9:17 A.M., Unit Manager #2 said all air mattresses should be set to the resident's weight to ensure effective use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, policy review and interviews, the facility failed to prevent a fall for 1 Resident (#68) out of a total sample of 35 residents. Findings include: Review of the facility policy titled, Fall Prevention Policy, dated November 2022 indicated the following: *All of our residents are at risk for falls. Some residents happen to be at a higher risk than others related to medications, changes in medical condition, and competitive or physical decline. The most evidence based practice states that a patient who has sustained a recent fall is at the highest risk to fall again. *All (facility) staff are responsible for keeping residents safe. *IDT (Interdisciplinary Team) will determine the most appropriate and patient specific interventions for ongoing fall prevention. *Following a fall, the care plan is to be updated with intervention as related to the fall immediately after the incident if the resident is not transferred to the hospital - the new intervention will be relayed to all staff working the unit. Resident #68 was admitted to the facility in December 2021 with diagnoses including traumatic brain injury and need for assistance with personal care. Review of Resident #68's most recent Minimum Data Set, dated [DATE] indicated the Resident has a Brief Interview for Mental Status (BIMS) score of 4 out of a possible 15 indicating he/she has severe cognitive impairment. Review of the Fall Incident Report, dated 12/25/22, indicated Resident #68 fell in his/her room while eating alone. Following this fall, the nursing staff added an intervention to Resident #68's falls care plan for the Resident to eat meals under the supervision of nursing. The intervention was written on 12/25/22. Review of the Fall Incident Report dated 1/22/23 indicated Resident #68 fell in his/her room while unsupervised during a mealtime. On 3/17/23 at 8:13 A.M., Resident #68 was observed eating breakfast alone in his/her room. The privacy curtain between the two beds was drawn and Resident #68 was unable to be supervised or observed from the hallway. During an interview on 3/17/23 at 9:23 A.M., Unit Manager #2 said Resident #68 is unsafe and does not have the cognition to remember to call staff for help. Unit Manager #2 said an intervention to have staff supervise the Resident during mealtime went into place after he/she had a fall in his/her room while eating on 12/25/22. Unit Manager #2 said Resident #68 fell on 1/22/23 while eating breakfast in his/her room unsupervised even though the fall intervention was in place. Unit Manager #2 said Resident #68 doesn't eat as well when staff supervise him/her, so they stopped following the intervention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, policy review and interviews, the facility 1) failed to address a significant weight loss for 1 Resident (#74) and 2) failed to implement nutritional interventions for 2 Residents (#96 and #51), out of a total sample of 35 residents. Findings include: Review of the facility policy titled, Interventions for Unintended Weight Loss, dated 2021, indicated the following: *Unintended weight loss or gradual weight loss will be identified and monitored so that appropriate and individualized interventions can be implemented. 1. Resident #74 was admitted to the facility in April 2022 with diagnoses including Alzheimer's disease and dysphagia. Review of Resident #74's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident has a Brief Interview for Mental Status (BIMS) score of 4 out of a possible 15 which indicates he/she has severe cognitive impairment. Review of Resident #74's weights indicated the following: On 10/10/2022 Resident #74 weighed 138.0 Lbs. (pounds) On 10/24/2022 Resident #74 weighed 138.0 Lbs. On 11/07/2022 Resident #74 weighed 138.6 Lbs. On 11/14/2022 Resident #74 weighed 135.8 Lbs. On 01/18/2023 Resident #74 weighed 120.0 Lbs. (a 13.42% weight loss in 2 months) On 02/03/2023 Resident #74 weighed 120.0 Lbs. Review of the Nurse Practitioner note written on 1/26/23 indicated she was aware of Resident #74's weight loss and recommended the Resident be weighed twice a week for 2 weeks. Review of Resident #74's weight log failed to indicate the Nurse Practitioner's order for weights twice a week for 2 weeks was completed. Review of the weight change note written on 2/6/23 indicated the Dietitian was aware of Resident #74's significant weight loss and failed to indicate any new interventions to be trialed or that a full dietary assessment would be completed. Review of Resident #74's nutritional care plan failed to indicate any new nutritional interventions after the weight loss occurred on 1/18/23. Review of Resident #74's physician orders did indicate a new order for Remeron (an appetite stimulant) written on 3/10/23, 2 months after the weight loss had occurred. During an interview on 3/16/23 at 11:56 A.M., Unit Manager #2 said if a resident has a significant change in weight, the facility will obtain a re-weight within 48 hours. Unit Manager #2 said the dietitian, physician and resident/resident representative would all be notified of the significant change. Unit Manager #2 said she was unaware of Resident #74's significant weight loss or the Nurse Practitioner's orders for increased frequency of weights. During an interview on 3/16/23 at 11:04 A.M., the Dietitian said she closely follows all residents in the facility and monitors all weights. The Dietitian said the nursing staff does not always obtain weights as ordered and this makes it difficult to monitor weights and look for significant weight changes. The Dietitian said along with her monitoring the weights, the nursing staff should be notifying her of significant changes either at morning meeting or when she is on the nursing units, however, the communication regarding significant weight changes in the building is poor. The Dietitian said she will always add an intervention for a new significant weight change and she would first look at what food the resident is receiving and try to modify the food to increase caloric intake. She said after modifying the food, she would add supplements and then possibly have psychiatric services become involved. The Dietitian said she was aware of Resident #74's weight loss and had not added any interventions to address the weight loss or prevent further weight loss. During an interview on 3/16/23 at approximately 1:30 P.M., the Nurse Practitioner (NP) said the nursing staff do not always get weights as ordered. The NP said she was unaware the weights were not obtained for Resident #74 or that the Dietitian had not ordered any new interventions. 2a. Resident #96 was admitted to the facility in May 2021 with diagnoses including Alzheimer's Disease, major depression, adjustment disorder and anxiety. Review of Resident #96's most recent Minimum Data Set, dated [DATE] indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) exam and the staff assessed him/her to have severe cognitive impairment. Review of Resident #96's weights indicated the following: On 12/01/2022 Resident #96 weighed 204.0 Lbs. (pounds) On 01/25/2023 Resident #96 weighed 198.0 Lbs. On 02/03/2023 Resident #96 weighed 200.0 Lbs. On 03/01/2023 Resident #96 weighed 195.6 Lbs. Review of a nurse practitioner note written on 3/9/23 indicated the following: *The patient is at baseline cognitive/functional status. Eating/drinking adequately - 9 lb. weight loss noted since admission. CBC/BMP unremarkable - obtain TSH & HgbA1C, along with CMP (blood work). Consult dietician for assistance in case. Review of a nurse practitioner note written on 3/9/23 indicated the following: *The patient has lost an additional five pounds this month, in which all blood work was unremarkable for infectious/metabolic cause. I am unsure if patient was assessed via dietician. Will re-request dietary consult. Continue to promote well balanced diet. Review of Resident #96's medical record failed to indicate the Resident was seen by the dietitian after either of the nurse practitioner's requests. During an interview on 3/16/23 at 11:56 A.M., Unit Manager #2 said all recommendations made by the nurse practitioner are expected to be followed and it is the nurses' responsibility to ensure this occurs. Unit Manager #2 was unaware of the two recommendations made by the nurse practitioner and that the recommendations had not been followed. During an interview on 3/16/23 at 11:04 A.M., the Dietitian said she works closely with the nursing staff as well as the nurse practitioner to address all dietary concerns. The Dietitian said nursing should inform her of any recommendations made by the nurse practitioner asking her to assess a resident. The Dietitian said she was never made aware of either of the two nurse practitioner's request for dietary consults. During an interview on 3/16/23 at approximately 1:30 P.M., the Nurse Practitioner (NP) said she was unaware Resident #96 had not been seen by the dietitian. 2b. Resident #51 was admitted to the facility in January 2021 with diagnoses including dementia, dysphagia and psychotic disorder. Review of Resident #51's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident has a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15 indicating he/she has severe cognitive impairment. The MDS also indicated Resident #51 requires supervision for feeding tasks. 1. Review of Resident #51's weights indicated the following: On 10/3/2022 Resident #51 weighed 182.2 Lbs. (pounds) On 12/1/2022 Resident #51 weighed 165.4 Lbs. On 12/6/2022 Resident #51 weighed 165.7 Lbs. On 12/13/2022 Resident #51 weighed 182.2 Lbs. On 1/17/2023 Resident #51 weighed 165.2 Lbs. On 1/25/2023 Resident #51 weighed 164.0 Lbs. Review of Resident #51's physician orders indicated the following order: *Weekly weights x 4 weeks due to weight loss- notify NP if weight is below 162 lbs., written 2/20/23. Review of the nurse practitioner note dated 2/20/23 indicated the following: *1. Abnormal weight loss. Notes: The patient has reportedly lost 15 lbs. over the past year. Intake varies. Refuses supplemental shakes. CBC, CMP, TSH, HgbA1C (blood work) were unremarkable for infectious/metabolic cause but did reveal hypoalbuminemia- dietician has been following the patient. Will order weekly weights x 4 weeks. Notify NP of any further weight loss for further recommendations. Review of Resident #51's medical record failed to indicate weights were obtained as ordered. During an interview on 3/16/23 at 11:56 A.M., Unit Manager #2 said she was not aware of the order for weekly weights and that the order had also not been completed. During an interview on 3/16/23 at 11:04 A.M., the Dietitian said the nursing staff have a difficult time obtaining weights and weights are often missed in the building. During an interview on 3/16/23 at approximately 1:30 P.M., the Nurse Practitioner (NP) said she was unaware Resident #51 had not been weighed as ordered and said weights are often missed in the building. 2b. Review of Resident #51's physician orders indicated the following order: *Dietary consult- hypoalbuminemia, written 12/20/22 Review of the nurse practitioner note written on 1/12/23 indicated she again requested the dietician be consulted for Resident #51. Review of a dietary note written on 1/17/23 indicated the following: *Note Text: Found order for dietary consult from 12/20/22, RD was not notified, for hypoalbuminemia at 2.9 and Prealbumin was also low at 9.1. (The Resident) does not eat consistently well so additional protein would not likely improve serum proteins but will add liquid protein b.i.d. (twice per day) for 30 days and do prealbumin again. Review of Resident #51's medical record failed to indicate the protein supplement was added for 30 days or that the prealbumin level was re-checked. During an interview on 3/16/23 at 11:56 A.M., Unit Manager #2 said all recommendations made by the nurse practitioner are expected to be followed and it is the nurses' responsibility to ensure this occurs. Unit Manager #2 was unaware of the recommendation to add a protein supplement and for the prealbumin level to be checked and confirmed neither were implemented. Nurse #4 was present during the interview and said she stated she remembered the dietitian talking about the protein supplement but does not remember ever seeing an order for it. During an interview on 3/16/23 at 11:04 A.M., the Dietitian said she works closely with the nursing staff as well as the nurse practitioner to address all dietary concerns. The Dietitian said nursing should inform her of any recommendations made by the nurse practitioner asking her to assess a resident. The Dietitian could not remember why her recommendation to trial a protein supplement for Resident #51 had not been completed and also said she was unaware nursing did not follow her recommendation to recheck the Resident's prealbumin level again. During an interview on 3/16/23 at approximately 1:30 P.M., the Nurse Practitioner (NP) said she was not aware of the recommendation by the dietitian to trial a nutritional supplement and it had not been done.

Based on observation, interview and record review the facility failed to follow professional standards in changing tube feeding administration sets every 24 hours for 1 Resident (#188) out of a total sample of 35 residents. Review of facility policy titled, Enteral Tube Feeding-NG tube, G-tube, J-tube or other updated date April 2018 included: -Cover, label with initials and date, and refrigerate remaining formula. Use within 24 hours. -Change administration sets and administration supplies every 24 hours. Resident #188 was admitted to the facility in February 2023 with diagnoses including Multiple sclerosis, tracheostomy status, and gastrostomy status. Review of the most recent Minimum Data Set Assessment (MDS) dated , 3/14/23, indicated a Brief Interview for Mental Status score of 14 out of a possible 15 indicating intact cognition. The MDS indicated Resident #188 required total assistance for all hygiene tasks and required tube feedings. Further review indicated Resident #188 required oxygen, tracheostomy care and suctioning. During an observation on 3/17/23 at 8:21 A.M., Resident #188 was observed lying in bed with a tube feeding solution running and labeled/dated 3/16/23 at 2:30 A.M. This indicated the tube feeding administration set was 30 hours old. Review of Resident #188's medical record indicated the following: -Physician order dated 3/16/23, enteral feed every shift Jevity 1.5 at 60 mls/hour continuous via G-tube pump. During an interview on 3/17/23 at 10:09 A.M., Nurse #1 said she was unsure how often the tube feeding administration supplies should be changed. During an interview on 3/17/23 at 2:20 P.M., Unit Manager #1 said the expectation for tube feeding is to change the tubing and supplies every 24 hours. Unit Manager #1 said the tubing should have been changed overnight.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to 1). follow physicians' orders for oxygen use for one Resident (#188) and 2). failed to obtain a physician order for oxygen for one Resident (#24) out of a total of 35 sampled residents. Findings include: -Review of facility policy titled, Oxygen Administration, included: -Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 1. Resident #188 was admitted to the facility in February 2023 with diagnoses including acute respiratory failure, tracheostomy status, and multiple sclerosis. Review of the most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated a Brief Interview for Mental Status score of 14 out of a possible 15 indicating intact cognition. Further review of the MDS indicated Resident #188 required total assistance for all hygiene tasks and required abdominal feedings. Further review indicated Resident #188 required oxygen, tracheostomy care and suctioning. During an observation on 3/17/23 at 8:21 A.M., Resident #188 was observed lying in bed with tubing from an oxygen concentrator set to 5 liters per minute that was connected to a tracheostomy. Additional observations were made on 3/17/23 at 10:14 A.M. and 11:57 A.M., while Resident #188 was lying in bed and oxygen was set to 5 liters per minute. Review of Resident #188's medical record indicated the following: -A physician order dated 3/15/23 indicated, 8 portex trach tube humidified with 3L o2 (oxygen) bleed in (continuous). During interviews on 3/17/23 at 10:09 A.M. and 2:08 P.M., Nurse #1 said respiratory takes care of some of the tracheostomy care for Resident #188, but nursing was also responsible for it. Nurse #1 said she was unsure how many liters of oxygen Resident #188 was ordered to be on but thought it may be 5 liters. Nurse #1 reviewed Resident #188's orders with the surveyor and said the order was 3 liters of oxygen. Nurse #1 was unsure why Resident #188 was on 5 liters of oxygen. During an interview on 3/17/23 at 2:53 P.M., the Director of Nursing said the expectation of physician orders is for them to be followed. 2. Resident #24 was admitted to the facility in October 2021 with diagnoses including, lymphoid leukemia, dementia, chronic bronchitis, and chronic kidney disease. Review of the most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating intact cognition. During an observation on 3/15/23 at 8:16 A.M., Resident #24 was observed lying in bed with a nasal cannula (small plastic tube allowing oxygen to be administered through nares) applied to his/her face with 1 liter of oxygen. Additional observations were made on 3/16/23 at 8:16 A.M. and 3/17/23 at 8:10 A.M., and Resident #24 was observed with the nasal cannula supplying 1 liter of oxygen. Review of Resident #24's medical record indicated the following: Vital Signs oxygen saturation summary: -02/27/23 92% on oxygen via Nasal cannula -02/28/23 95% on oxygen via Nasal Cannula -03/07/23 92% on oxygen via Nasal Cannula -03/08/23 92% on oxygen via Nasal Cannula -03/09/23 92% on oxygen via Nasal Cannula -03/10/23 94% on oxygen via Nasal Cannula -03/11/23 94% on oxygen via Nasal Cannula -03/12/23 93% on oxygen via Nasal Cannula -03/16/23 90% on oxygen via Nasal Cannula -03/17/23 91% on oxygen via Nasal Cannula -03/18/23 95% on oxygen via Nasal Cannula -03/19/23 95% on oxygen via Nasal Cannula -Further review of the medical record failed to indicate a physician order for oxygen administration. During an interview on 3/16/23 at 2:17 P.M., Unit Manager #1 said the expectation for oxygen use is to have a physician order. Unit Manager #1 said she was unaware that Resident #24 didn't have a physician order for oxygen. During an interview on 3/17/23 at 2:53 P.M., the Director of Nursing said the expectation of physician orders is for them to be followed.

Based on interview and record review the facility failed to develop a dementia care plan with measurable goals and interventions to address the care and treatment for a resident with dementia for 1 Resident (#88) out of a total sample of 35 residents. Resident #88 was admitted to the facility in November 2021 with diagnoses including, dementia, benign prostatic hyperplasia without lower urinary tract symptoms, and acquired absence of kidney. Review of the most recent Minimum Data Set Assessment, dated 12/29/22, indicated a Brief Interview for Mental Status score of 11 out of a possible 15 indicating moderate cognitive impairment. Review of Resident #88's medical record indicated: -A Health status note dated 3/9/23, indicated Resident #88 had exhibited increased behaviors, including yelling/screaming and using foul language. -A Health status note dated 3/7/23, indicated Resident #88 had increased behaviors, only alert to self, confused and irritable. -A health status note dated 2/5/23, indicated Resident started to get agitated around 2:00 P.M. --A health status noted dated 2/4/23 indicated Resident #88 was resistant to care despite redirection. -A physician order dated 12/13/22, Risperdal tablet 0.5 milligrams give 1 tablet by mouth in the afternoon for agitation. -Review of the current Care Plan, failed to indicate an active care plan for dementia. During an interview on 3/17/23 at 9:55 A.M., Unit Manager #1 said Resident #88 has an active diagnosis of dementia and has behaviors especially in the afternoon he sundowns (a state of confusion occurring in the late afternoon and spanning into the night. Sundowning can cause a variety of behaviors, such as confusion, anxiety, aggression or ignoring directions.). Unit Manager #1 said the expectation for a Resident with a diagnosis of dementia would be to have a care plan in place for dementia. Unit Manager #1 was unaware that Resident #88 did not have a current dementia care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide rehab services in a timely manner for 1 Resident (#114) out of a total sample of 35 residents. Findings include: Resident #114 was admitted in 07/2022 with diagnoses including cellulitis. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #114 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the MDS indicated that Resident #114 requires limited assistance to dependence with all activities of daily living except eating. Review of the progress note, dated 7/5/23, indicated that Resident #114 was admitted for short term rehab following a hospitalization. Review of the hospital discharge note, dated 6/29/22, indicated that it was recommended that Resident #114 received continued skilled PT services 2-5 times per week. Review of the Physical Therapy Plan of Care note, dated 8/8/22, indicated the following: Patient seen for PT (physical therapy) eval to restart his/her PT after he/she was discharged from therapy due to lack of PT coverage. Review of the clinical record indicated that Resident #114 did not receive physical therapy for 1 week. During an interview on 3/20/23 at 9:00 A.M., the Rehab Director said that the physical therapist was out on vacation that week and she tried to get coverage, but unfortunately had to prioritize and had to discharge the Resident until the physical therapist came back from vacation. During an interview on 3/20/23 at 9:37 A.M. the Administrator said he was unaware there was no physical therapist to provide services for the week the physical therapist was on vacation. The Administrator said the company that provides therapy services to the building are contracted to provide services at all times and should keep him informed of any staffing difficulties.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to accurately document application of oxygen in the Treatment Administration Record (TAR) for 1 Resident (#188) out of a total sample of 35 residents. Resident #188 was admitted to the facility in February 2023 with diagnoses including Multiple sclerosis, tracheostomy status, and gastrostomy status. Review of the most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated a Brief Interview for Mental Status score of 14 out of a possible 15 indicating intact cognition. Further review of the MDS indicated Resident #188 required total assistance for all hygiene tasks and required abdominal feedings. Further review indicated Resident #188 required oxygen, tracheostomy care and suctioning. During an observation on 3/17/23 at 8:21 A.M., Resident #188 was observed lying in bed with tubing from an oxygen concentrator set to 5 liters per minute that was connected to a tracheostomy. Additional observations were made on 3/17/23 at 10:14 A.M. and 11:57 A.M., while Resident #188 was lying in bed and oxygen was set to 5 liters per minute. Review of Resident #188's medical record indicated the following: -A physician order dated, 3/15/23, indicated, 8 portex trach tube humidified with 3L O2 bleed in (continuous). Review of the Treatment Administration Record for March 2023 indicated: -A Treatment Order dated 3/8/23, humidified O2 to trach continuous at 2-3L O2. Documentation indicated this was administered on the day, evening, and night shift of 3/15/23 and 3/16/23 as well at day shift on 3/17/23. -A Treatment order dated 3/15/23, 8 portex trach tube humidified with 3L o2 bleed in (continuous) every shift. Documentation indicated this was administered on evening and night shift on 3/15/23, as well as day, evening, and night shift on 3/16/23 and the day shift on 3/17/23. During an interview on 3/17/23 at 10:09 A.M., Nurse #1 said respiratory takes care of some of the tracheostomy care for Resident #188 but nursing was also responsible for it. Nurse #1 said she was unsure how many liters of oxygen Resident #188 was ordered to be on but thought it may be 5 liters. Nurse #1 reviewed Resident #188's orders with the surveyor and said the order was 3 liters of oxygen. During an interview on 3/17/23 at 2:24 P.M., Unit Manager #1 said the expectation for documentation is to accurately document oxygen use. During an interview on 3/17/23 2:53 P.M., the Director of Nursing said nursing documentation should be accurate and she would not expect to see documentation for multiple oxygen orders.

2a. Resident #188 was admitted to the facility in February 2023 with diagnoses including tracheostomy status (a surgical opening in the neck where breathing primarily occurs), multiple sclerosis, and gastrostomy (a surgical opening in the abdomen that allows for nutrition to be provided). Review of the most recent Minimum Data Set Assessment (MDS) dated , 3/14/23, indicated a Brief Interview for Mental Status score of 14 out of a possible 15 indicating intact cognition. Further review of the MDS indicated Resident #188 required total assistance for all hygiene tasks and required tube feedings through a gastrostomy tube. Further review indicated Resident #188 required oxygen, tracheostomy care and suctioning. During an observation on 3/15/23 at 10:23 A.M., a foley catheter bag was observed from the doorway to Resident #188's room. The foley catheter bag did not have a privacy cover. Additional observations were made on 3/16/23 at 10:01 A.M. and 3/16/23 at 1:09 P.M. of the foley catheter without a privacy cover. During an interview on 3/16/23 at 1:19 P.M., Nurse #2 said the facility uses leg bags when a resident can move around the unit and when in their room, they keep the bag out of view for privacy. During an interview on 3/16/23 at 2:27 P.M., Unit Manager #1 said privacy bags are utilized to maintain a resident's dignity. 2b. On 3/16/23 at 10:01 A.M., Resident #188 was observed lying in bed with no top sheet or blanket and a gown on pulled up to his/her abdomen exposing the genital area. He/she was visible to his/her roommate. During an interview and observation on 3/16/23 at 1:13 P.M., Resident #188 was observed lying in bed with a gown on with no top sheet or blanket. Resident #188 said he/she wanted a blanket and did not prefer to be uncovered. During an interview on 3/16/23 at 1:19 P.M., Nurse #2 said residents should never be exposed. Based on observations, record reviews, policy reviews and interviews the facility failed to 1) provide a dignified dining experience for the residents on the Dementia Care Specialty Unity (DSCU) and 2a) failed to provide a dignified experience for 1 Resident (#188) by not providing a privacy bag for a foley catheter and 2b) For Resident #188 leaving him/her without a top sheet or blanket, leaving genitals exposed, out of a total sample of 35 residents. Findings include: 1. Review of the facility policy, Quality of Life - Dignity undated, indicated the following: *Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. *Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis or care needs. During observation of the breakfast meal on 3/16/23 at 8:17 A.M., the following was observed: *A Certified Nursing Assistant (CNA) passed out a breakfast tray to a Resident in his/her room. The CNA walked into the Resident's room without knocking on the door. She then put the breakfast tray on the Resident's side table and did not inform the Resident what was on the breakfast tray. She walked out of the room and turned the light on, without asking the Resident if she would like it on. During observation of the lunch time meal on the DSCU on 3/17/23 at 11:55 A.M., the surveyor observed the following: *Three different staff members referred to residents as feeds while passing out the lunch trays. *There were 3 residents dining at one table. The first resident was served his/her meal at 11:59 A.M. Another resident at the table began getting agitated at 12:27 P.M., while waiting for his/her meal. The resident did not receive his/her lunch until 12:32 P.M., 33 minutes after the first resident had been served. *There were 4 residents dining at one table. The first resident was served his/her meal at 11:58 A.M. The fourth resident did not receive his/her meal until 12:26 P.M., 28 minutes later. *There were 4 residents dining at one table. The first 3 residents were served their meals by 12:02 P.M. The fourth Resident never received a meal from the kitchen and staff did not call down for a meal until 12:32 P.M. From 12:01 P.M. - 12:32 P.M., the Resident complained of being hungry and was confused why others at the table were served a meal and he/she was not. During an interview on 3/17/23 at 12:12 P.M., Nurse #3 said they try to give residents who are more anxious their meals first. During an interview on 3/17/23 at 12:59 P.M., the Administrator said the upstairs dining halls need to become more organized. The Administrator said staff should not be using terminology describing residents by their abilities and meal times should be home like with all residents sitting at the same table receiving meals at the same time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4a. Resident #3 was admitted to the facility in June 2021 with diagnoses including peripheral vascular disease, overactive bladder and hemiplegia/hemiparesis following cerebral infarction. Review of the most recent Minimum Data Set Assessment (MDS) dated , 2/16/23, indicated a Brief Interview for Mental Status score of 13 out of a possible 15 indicating intact cognition. Further review of the MDS indicated Resident #3 required extensive assistance for toilet use. Review of Resident #3's medical record indicated the following: -Physician Order dated 3/7/23, order for Urinalysis with Culture and Sensitivity due to leukocytosis rule out acute cystitis. -Further review of the medical record failed to indicate results for the ordered Urinalysis or documentation indicating staff were unable to obtain the specimen During an interview on 3/17/23 at 2:22 P.M., Unit Manager #1 said when a resident has an order for a Urinalysis the expectation is to try to obtain it within three days. Unit Manager #1 said the expectation would be for the nursing staff to document when the lab is unable to be obtained. During an interview on 3/17/23 at 2:50 P.M., the Director of Nursing said the expectation for a physician ordered Urinalysis would be for it to be completed as soon as possible or documentation when it cannot be obtained. 4b. Resident #88 was admitted to the facility in November 2021 with diagnoses including, dementia, benign prostatic hyperplasia without lower urinary tract symptoms, and acquired absence of kidney. Review of the most recent Minimum Data Set assessment dated , 12/29/22, indicated Brief Interview for Mental Status score of 11 out of a possible 15 indicating moderate cognitive impairment. Review of Resident #88's medical record indicated the following: -A Care Plan revision date 1/31/22 with a focus on bladder incontinence with interventions for monitor/document signs and symptoms of UTI (Urinary Tract Infection). -A nursing progress noted dated 3/9/23 indicated Resident #88 had increased behaviors and a question of UTI when assisted to bed. -A physician order dated 3/10/23 to please obtain Urinalysis with culture and sensitivity. -Further review of the medical record failed to indicate documentation that a urinalysis had been obtained or had been attempted to be obtained. During an interview on 3/17/23 at 2:22 P.M., Unit Manager #1 said when a resident has an order for a Urinalysis the expectation is to try to obtain it within three days. Unit Manager #1 said the expectation would be for the nursing staff to document when the specimen is unable to be obtained. During an interview on 3/17/23 at 2:50 P.M., the Director of Nursing said the expectation for a physician ordered Urinalysis would be to be done as soon as possible and documentation completed when it cannot be obtained. Based on observations, record reviews and interviews, the facility failed to 1) develop a care plan for suicidal ideation for 1 Resident (#16), 2) failed to implement a physician order to off load heels for 1 Resident (#118), 3) failed to implement a physician order for ace wraps for 1 Resident (#239) and 4) failed to implement a physician order to obtain a urine culture for 2 Residents (#3 and #88) out of a total sample of 35 residents. Findings include: 1. Resident #16 was admitted to the facility in September 2021 with diagnoses including anxiety, depression, and dementia without behavioral disturbances. Review of Resident #16's most recent Minimum Data Set, dated [DATE], indicated the Resident has a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15, indicating he/she has moderate cognitive impairment. The MDS also indicated Resident #16 has had recent feelings of feeling down, depressed and hopeless. On 3/16/23 at 8:53 A.M., Resident #16 was observed yelling out on the unit at staff. While yelling, the Resident made the comments I'm going to escape and I will kill myself if I have to, and I'll jump out the window. The Resident also said he/she would rather die than be in the facility. The Resident was yelling and agitated for 20 minutes. Review of the hospital admission paperwork, dated 1/11/23, indicated Resident #16 was admitted to the hospital from the facility with increased agitation, disruptive behavior (yelling, throwing things, etc.) and suicidality. Review of Resident #16's care plans failed to indicate a care plan that included interventions for the Resident's suicidal ideation. During interviews on 3/16/23 at 8:57 A.M., and 3/17/23 at 9:05 A.M., Unit Manager #1 said Resident #16 has become increasingly agitated over the past several months and has had involuntary admissions to the hospital a few times. Unit Manager #2 said Resident #16 will often make suicidal comments about his/her desire to die. Unit Manager #1 said social services typically put in care plans for psychiatric needs as well as suicidal ideation care plans and said Resident #16 did not have a suicidal ideation care plan and should have one. During an interview on 3/17/23 at 10:17 A.M., the Social Services Director said any resident with a history of or active suicidal ideation should have a suicidal ideation care plan. 2. Resident #118 was admitted in March 2022 with diagnoses including stroke and diabetes. Review of Resident #118's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident has a Brief Interview for Mental Status (BIMS) score of a 2 out of a possible 15, indicating he/she has severe cognitive impairment. The MDS also indicated Resident #118 requires extensive assistance from staff for bed mobility tasks. On 3/16/23 at 9:18 A.M., Resident was observed lying in bed. Both heels were lying directly on the bed and not offloaded. On 3/17/23 at 8:03 A.M., Resident was observed lying in bed. Both heels were lying directly on the bed and not offloaded. On 3/17/23 at 11:55 A.M., Resident was observed lying in bed. Both heels were lying directly on the bed and not offloaded. Review of Resident #118's physician orders indicated an order for the Resident's heels to be offloaded. During an interview on 3/17/23 at 2:53 P.M., the Director of Nursing said she expects all written orders to be followed. 3. Resident #239 was admitted in 03/2023 with diagnoses including localized edema. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #239 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the physician's orders indicated that an order was initiated on 3/10/23 for ace wrap to left lower extremity daily prior to getting out of bed. Review of the behavior tracking documentation does not indicate that Resident #239 has any behaviors. During an observation on 3/15/23 at 7:54 A.M., Resident #239 was not wearing ACE wraps on his/her left lower extremity. During an observation on 3/17/23 at 11:26 A.M., Resident #239 was out of bed and not wearing ACE wraps on his/her left lower extremity. During an interview on 3/17/23 at 11:26 A.M., Resident #239 said that he/she has not had any ACE wraps on since admission. During an interview on 3/17/23 at 2:49 P.M., the Director of Nursing said that if there was an order for ACE wraps then it should have been followed.

Based on observation, interview and policy review, the facility failed to 1) properly store food items to prevent the risk of foodborne illness and 2) follow proper food handling practices to prevent the risk foodborne illness and contamination. Findings include: Review of the facility policy titled Food Storage, undated, indicated the following: *Leftover food will be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 72 hours or discarded. *Refrigerated food storage: Cooked foods will be stored above raw foods to prevent contamination. Raw animal foods must be separated from each other and stored on lower shelves (below cooked foods or raw fruits and vegetables) and in drip proof containers. Review of the facility policy titled General Food Preparation and Handling, undated, indicated the following: *Bare hands must never touch ready to eat raw food directly. Disposable gloves are a single use item and must be discarded after each use. Employees must wash hands prior to putting gloves on and after removing gloves. 1) During the initial walk through of the kitchen on 3/15/23 at 6:58 A.M., the surveyor observed the following: *A container labeled egg salad with an expiration date of 3/13/23 *A container labeled tuna salad with an expiration date of 3/13/23 *A container labeled pineapple with an expiration date of 3/11/23 *A container labeled ham with an expiration date of 3/9/23 *A container labeled turkey with an expiration date of 3/9/23. *A container labeled apple muffins containing ready to eat food that was stored on the raw meat defrosting rack below a box of raw ground beef. During observation of the 2 South Kitchenette on 3/17/23 at 6:47 A.M., the following was observed: *Wheat bread with the expiration date of 2/27/23. *A tuna salad sandwich dated 3/6/23-3/8/23. *Cranberry juice container in the refrigerator, undated, and sticking to the shelf. *Soup single boxes, not labeled or dated. *A package of cookies on the cabinet opened and not dated or labeled. During an interview on 3/15/23 at 7:10 A.M., the Food Service Director said food should be discarded by the written expiration date and that ready to eat foods should not be stored with raw meat products. 2) During the follow up visit to the kitchen on 3/17/23 at 11:46 A.M., the surveyor observed the following during the lunch service tray line: *The cook was observed grabbing the handle of the walk-in freezer with bare hands and entering it to grab food product, she then proceeded to touch the drying rack for the plate lids. She then proceeded to put on a disposable glove on her right hand without washing her hands prior and began cooking a veggie burger. The cook then entered the walk-in freezer with the same glove on her right hand and exited with a raw beef patty, removed the glove, did not wash her hands and began cooking the beef patty. The cook then put on a new glove on her right hand without washing her hands and grabbed ready-to-eat hamburger buns from the package with the gloved hand. She then grabbed ready-to-eat cheese with the same gloved hand and put it on a veggie burger that was cooking. The cook then removed her glove without washing her hands and left the kitchen to open a meal cart in the hallway. With bare hands, the cook then touched a pile of oven mitts, opened the reach-in refrigerator, touched the drying rack for the meal lids and began setting up a meal tray. The cook then put on a glove on her right hand without washing her hands and grabbed a ready-to-eat hamburger bun from the packaging with the gloved hand. During an interview on 3/17/23 at 1:57 P.M., the Food Service Director said her expectations are for staff to wash their hands when donning and doffing gloves as well as after they return from leaving the kitchen.

Based on observation and interviews, the facility failed to appropriately wear Personal Protective Equipment (PPE) to prevent the spread of infection on 2 out of 4 units. Findings include: Throughout the days of survey, the following was observed: On 3/15/23 at 7:30 A.M., two nurses were observed at the 2 North nursing station. One nurse was wearing a mask on her chin, not covering her mouth or nose and the second nurse was wearing her mask below her nose. There were several residents in the area. On 3/15/23 at 12:29 P.M., a Certified Nursing Assistant (CNA) was eating at the 2 South nursing station while talking with a resident. Her mask was on her chin. On 3/15/23 at 12:44 P.M. a nurse was sitting at the 2 North nursing station with her mask below her nose. There were several residents in the area. On 3/16/23 at 12:14 P.M., a nurse was standing at the 2 North nursing station not wearing a mask. There were several residents in the area. On 3/16/23 at 2:35 P.M., an activity assistant was in the 2 South activity room with residents and her mask was on her chin, below her mouth and nose. During an interview on 3/16/23 at 1:30 P.M., the Infection Preventionist said she completes in-services for PPE when needed. The IP said staff should be wearing when in patient areas and the masks should be covering both the nose and mouth area.

Based on record review and interview, the facility failed to ensure that 5 of 5 Certified Nursing Assistants reviewed, received 12 hours of mandatory in-service training in a year. During review of 5 of the facility's CNA education records on 3/17/23 at 1:30 P.M., there was no evidence that the CNA's received the 12 hours of required annual in-service education training. During an interview on 3/17/23 at 2:46 P.M., the Administrator said the facility did a poor job providing training last year and most of it had not been completed.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), who was alert and able to make his/her needs known, the Facility failed to ensure Resident #1's right to self-determination was honored and that staff supported his/her choices, when on 11/02/22 at approximately 9:00 P.M. despite Resident #1 saying he/she did not want to go to bed, staff transferred and left Resident #1 in bed against his/her wishes. Finding include: Review of the Facility's Policy titled Resident Rights, revised February 2021, indicated Federal and State laws guarantee certain basic rights to all residents of this facility. The Policy indicated that these rights include the following: - the resident's right to be treated with respect, kindness, and dignity, - self-determination. - be supported by the facility in exercising his or her rights - exercise his or her rights without interference, coercion, or reprisal, and - be informed of, and participate in, his or her care planning and treatment Review of Resident #1's clinical record indicated he/she was admitted to the Facility in November 2021, with diagnoses that included Dementia. Review of Resident #1's Annual Minimum Data Set assessment, dated 10/20/22, indicated his/her cognitive functions were intact, that he/she rejected care at times, displayed no physical or verbal behavioral symptoms toward others, felt it was very important to choose his/her own bedtime, and required two staff members to physically assist him/her with transfers, bed mobility and toilet use. Review of Resident #1's Activities of Daily Living Care Plan, reviewed and renewed with his/her Annual MDS, indicated he/she had self care deficits related to performance of activities of daily living, cognitive deficits, and a decline in independent mobility. The Care Plan indicated Resident #1 required the assistance of two staff members for transfers between surfaces as allowed and as necessary. The Care Plan indicated Resident #1 required staff assist with incontinence care. During an interview on 12/01/22 at 1:00 P.M., Resident #1 said on 11/02/22 in the evening (during the 3:00 P.M. to 11:00 P.M. shift) two nurses aides told him/her it was time to go to bed and told him/her that he/she had to go to bed. Resident #1 said he/she told the nurses aides he/she did not have to and did not want to go to bed then. Resident #1 said he/she hollered and yelled, pushed and tried to kick the nurses aides. Resident #1 said despite his/her refusal to go to bed, the nurses aides said he/she had to go to bed, then they transferred him/her to bed and left him/her there. During an interview on 12/01/22 at 11:25 A.M., Resident #2 (Resident #1's roommate) said while he/she was in the bathroom, he/she heard Resident #1 screaming that he/she did not want to go to bed. Resident #2 said he/she heard the nurses aides insist that he/she (Resident #1) needed to go to bed. Resident #2 said they put Resident #1 to bed and left him/her there. During an interview on 12/01/22 at 2:05 P.M., Certified Nurse Aide (CNA) #1 said at approximately 8:30 P.M. on 11/02/22, the nurse told her and Nurse Aide #1 that Resident #1 had to go to bed because he/she needed incontinence care. CNA #1 said Resident #2 (Resident #1's roommate) was in their shared bathroom at that time, so they could not toilet Resident #1. CNA #1 said they pulled the privacy curtain and told Resident #1 he/she had to be put back to bed so they could provide care. CNA #1 said Resident #1 replied stating words to the effect of I don't want to. CNA #1 said she stood on one side of Resident #1 and Nurse Aide #1 stood on the other side, to get ready to transfer him/her. CNA #1 said Resident #1 tried to hit and kick them while he/she was seated in the wheelchair, and during the transfer to bed. CNA #1 said once Resident #1 was in bed, they did not provide incontinence care at that time because he/she was loud and too aggravated, so left they Resident #1 in bed so he/she could calm down. During an interview on 12/19/22 at 12:30 P.M., Nurse Aide #1 said Resident #1 was in need of incontinence care and the nurse asked if she and CNA #1 could get him/her into bed to provide care. Nurse Aide #1 said she and CNA #1 stood Resident #1 up from the wheelchair and he/she grabbed the bed's side rail. Nurse Aide #1 said Resident #1 began fussing and screaming, saying he/she did not want to go to bed. Nurse Aide #1 said Resident #1 swung both his/her arms out, hitting CNA #1. Nurse Aide #1 said as they transferred and sat Resident #1 on the bed, again he/she said he/she did not want to go to bed. Nurse Aide #1 said during the transfer Resident #1 lifted his/her feet to try to kick her. Nurse Aide #1 said when they told Resident #1 he/she needed to be changed, he/she replied back no, so they left the room and left him/her laying in bed. During an interview on 12/01/22 at 10:30 P.M., the Social Worker said Resident #1 tends to get aggravated when asked to do something he/she does not want to do. The Social Worker said Resident #1 lets people know, even if not completely or clearly verbalized, what he/she wants or does not want. During an interview on 12/01/22 at 3:00 P.M., the Administrator said during the facility investigation, he was told a nurse asked that Resident #1 be put to bed a little early on the evening shift, and that it had been a request made by nursing staff on the overnight (11:00 P.M. to 7:00 A.M.) shift. The Administrator said Resident #1 said no to CNA #1 and Nurse Aide #1 when they told him/her they had to put him/her in bed that night, but they still transferred him/her to bed. The Administrator said once Resident #1 was put into bed, he/she became more vocal and they left the room.