2. Resident #53 was admitted to the facility in December 2024 with diagnoses including Alzheimer's Disease and resided on the Two North Unit. Review of the Nutrition Care Plan, initiated 12/23/24, indicated Resident #53 was at nutrition/hydration risk related to Alzheimer's Disease and included the following interventions: -provide Pureed Diet with thin liquids (double portions) -Resident has slow swallow reflex, take time feeding him/her and allow the Resident to finish swallowing before continuing to feed him/her. -Takes thin liquids well, give small sips at a time. Review of the ADL Fact Sheet (utilized by the CNAs to indicate the Resident's specific care needs), printed on 2/28/25, indicated the following: -required total staff assistance with feeding On 2/25/25, from 11:18 A.M. through 12:18 P.M., the surveyor observed the following on the Two North Unit: -11:18 A.M.: the lunch meal cart arrived to the unit. Staff was observed to assist residents to the Unit Dining Room. A plastic sleeve of disposable cups were observed on the top of the meal cart. -11:21 A.M.: ten residents were observed seated at tables and four staff were observed to distribute the lunch meal to the residents. The lunch meals were provided on trays which were placed in front of the residents (the lunch trays were not removed). Disposable cups were observed to be utilized for milk, juice and soda. -11:34 A.M.: three residents (including Resident #53) were not provided their meal trays and were seated at tables with other residents who were eating or being assisted by staff. -11:41 A.M.: one of the three residents was provided his/her covered meal tray which did not have utensils. -11:45 A.M.: Resident #53, who remained without his/her meal, was observed reaching towards his/her tablemate's meal tray. -11:47 A.M.: a CNA gathered utensils and sat next to the resident (without utensils) and began to assist him/her with the lunch meal. Two other residents (including Resident #53) remained without their meals. -11:49 A.M.: Resident #53 began to fidget in his/her wheelchair. -11: 52 A.M.: a CNA provided Resident #53 with his/her covered lunch tray and walked away. -11:54 A.M.: Resident #53 was heard to make audible vocal sounds and was observed to reach for his/her covered coffee cup, which he/she tipped over. A CNA who was assisting another resident removed Resident #53's covered meal tray from the table and placed it on top of the meal cart. -11:58 A.M.: Activities Assistant (AA) #1 provided Resident #53 with his/her lunch tray, sat beside the Resident and began to assist him/her with the meal. Resident #53's tablemate had finished his/her lunch meal and other residents seated at other tables were observed to finish and leave the Unit Dining Room. -12:04 P.M.: AA #1 stopped assisting Resident #53 and covered the Resident's meal and moved to assist another resident with the lunch meal. -12:13 P.M.: Resident #53 was heard to make occasional noises while still seated at the table with his/her covered meal tray positioned in front of him/her. -12:15 P.M.: CNA #3 sat beside Resident #53 and assisted him/her with the lunch meal. On 2/26/25, from 11:25 A.M. through 11:59 A.M., the surveyor observed the following on the Two North Unit: -11:31 A.M.: eight residents were observed seated in the Unit Dining Room. Three staff were observed in the Dining Room, and one staff was observed distributing the lunch meals to the residents. The meals were provided on meal trays positioned in front the residents and disposable cups were observed in use. -11:45 A.M.: Resident #53 was awake and seated at a table with two other residents who had been provided their lunch trays and were actively eating. Resident #53 did not have a meal. -11:51 A.M.: Resident #53 did not have a lunch meal while the seven other residents were observed eating or being assisted by staff. -11:53 A.M.: CNA #3 provided Resident #53 with his/her lunch meal, sat next to the Resident and began to assist him/her. On 2/27/25, from 4:20 P.M. through 4:32 P.M., the surveyor observed the following on the Two North Unit: -4:20 P.M.: the dinner meal cart arrived on the unit. -4:25 P.M.: nine residents were observed seated in the Unit Dining Room. All the residents (including Resident #53) had a dinner meal tray placed in front of them. Resident #53's meal tray was covered, and no assistance was being provided at the time. All of the other residents in the Dining Room were actively eating or being assisted by the staff. -Disposable cups were observed in use. During an interview on 2/26/25 at 4:32 P.M., Nurse #8 said there were three residents who required total assistance with their meals that included Resident #53. Nurse #8 said there were two other residents who needed to be assisted/closely monitored during meals. Nurse #8 said there was usually one Nurse and two CNAs on the unit during the dinner meals and they do the best they can to provide the residents with the assistance they need with meals but there was not enough staff to do this. 3. On 2/27/25 from 11:26 A.M. through 12:07 P.M., the surveyor observed the following during the lunch meal service on the One North Unit: -11:26 A.M.: the lunch cart arrived on the unit and was brought to the Unit Dining Room. -11:29 A.M.: the staff began to assist the residents into the Unit Dining Room for lunch. -11:46 A.M.: ten residents were observed in the Dining Room. Five staff were assisting with the lunch meal. All of the residents' lunch meals were provided on meal trays positioned in front of them and disposable cups were observed in use. During an interview on 2/27/25 at 11:46 A.M., Nurse #5 said disposable cups had always been used for resident drinks during meals and that the disposable cups were provided by the kitchen. Nurse #5 said if a resident was supposed to get a reusable cup, it would be indicated on the resident's meal ticket. Nurse #5 said the meals for residents had always been provided on the meal trays, and that this was the practice on all units, not just the North One Unit. Nurse #5 said there were four staff members on the One North Unit today, which was not typical and that they usually have one Nurse and two CNAs on most days. Nurse #5 said that many of the residents on the One North Unit required more assistance. Nurse #5 further said if they needed to remove the resident meals from the meal trays during meals, there would not be enough staff to do this because of the extra steps required. During an interview on 2/27/25 at 12:27 P.M., the surveyor and Unit Manager (UM) #2 reviewed the observations of meal service on the One North and Two North Units. UM #2 said providing resident meals on meal trays and with disposable cups was institutional. UM #2 said disposable cups were provided by the kitchen for meals and that the meal service had always been like this since she had worked at the facility. UM #2 said the units were usually staffed with one Nurse and two CNAs for all shifts, but because of the increased acuity, they were trying to add additional assistance. During an interview on 2/28/25 at 7:56 A.M., the Food Service Director (FSD) said he was aware of the meals being provided on meal trays and the use of disposable cups during communal meals and had been asking about this process. The FSD said serving meals in this manner was not homelike and they would have to look into this process. The surveyor relayed observations of residents in the unit dining rooms who were not provided their meals and/or meal assistance timely while other residents were eating, and the FSD said he was not aware of this but understood why this was a concern. During an interview on 2/28/25 at 8:39 A.M., the surveyor and the Director of Nursing (DON) reviewed the dining observations completed on the Two West, One North, and Two North Units. The DON said there was no policy relative to the dining experience that the facility utilized, and that the nursing staff oversaw the communal dining on the units. The DON said she was aware of the concern about the meals being provided on meal trays and the use of the disposable cups during meals. The surveyor relayed observations about residents who were seated with other residents and not provided their meals/meal assistance timely, and the DON said there should be enough staff to assist with assisting the residents with their meals. Based on observation, interview, and record review, the facility failed to ensure a dignified dining experience on three Units (Two West, One North, and Two North), out of ten units observed. Specifically, the facility failed to: 1a. provide meals and/or meal assistance timely to residents on the Two [NAME] Unit, ensure that staff were seated while assisting residents with eating, and ensure that meals served to the residents were not on trays. 1b. provide meals and/or meal assistance timely for Resident #202, and ensure that staff were seated while physically assisting Resident #202 to eat. 2. provide meals to Resident #53, and other residents who resided on the Two North Unit, at the same time while ensuring that Resident #53, who required total staff assistance did not have his/her meal further delayed when staff did not complete feeding assistance for an entire meal. -remove resident meals off the meal trays during communal dining. -utilize non-disposable dinnerware (cups) during resident meals. 3. provide meals and/or meal assistance timely to residents on the One North Unit, ensure that resident meals were removed off the meal trays during communal dining and that non-disposable dinnerware (cups) were utilized during resident meals. Findings include: 1a. On 2/26/25, between 11:38 A.M. and 12:10 P.M., the surveyor observed the following on the Two [NAME] Unit: -Six residents were sitting in the Solarium. -One resident was being assisted to eat his/her lunch meal by a staff member and one resident was eating his/her lunch meal without assistance. -The other four residents did not have any food or drink to consume. -At 11:59 A.M., the meal tray cart was delivered to the Solarium and staff began passing meal trays to the four residents who did not already have their meals. -Certified Nurses Aide (CNA) #4 remained standing while assisting one resident who was seated to eat. There was an available chair that was not in use positioned diagonally behind CNA #4. -CNA #4 bent over slightly and lowered her head when she spoke to the resident. -The last resident meal tray was passed at 12:10 P.M. -All resident meals were served cafeteria style (on trays). During an interview on 2/26/25 at 12:12 P.M., CNA #4 said that she stood to assist one of the residents in the Solarium to eat because the resident's chair was high, and CNA #4 was short. 1b. Resident #202 was admitted to the facility in May 2017 with diagnoses including Dementia. Review of Resident #202's Activities of Daily Living (ADL) Care Plan dated 1/25/25, indicated: -Encourage choices and participation in all aspects of ADL care. - .preserve Resident's dignity at all times, especially during ADL care. -The Resident required staff to feed him/her for all meals. Review of Resident #202's Minimum Data Set (MDS) Assessment, dated 1/29/25, indicated: -The Resident was severely cognitively impaired, as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of 15 total possible points. -The Resident was dependent on staff for eating. On 2/27/25, between 11:45 A.M. and 11:52 A.M., the surveyor observed the following in the Two [NAME] Unit Solarium: -Seven residents were sitting in the Solarium. -Two residents had their lunch meals and were eating, with one resident being assisted by staff. -The other five residents in the Solarium did not have any food or drink to consume. -Resident #202 was seated in a wheelchair with his/her back to the window, next to one of the residents who was eating and facing the other resident who was being assisted to eat. During an interview on 2/27/25 at 11:53 A.M., Nurse #3 said that the two residents who were eating at that time in the Solarium were always provided early meal trays because the residents ate slowly. Nurse #3 said that the other residents in the Solarium would receive their meal trays when the meal tray cart was delivered to the Unit. On 2/27/25, between 12:00 P.M. and 12:17 P.M., the surveyor observed the following in the Two [NAME] Unit Solarium: -The last resident tray was passed at 12:04 P.M. -CNA #2 placed a meal tray on the windowsill behind Resident #202. -CNA #2 uncovered the food items on the meal tray and remained standing while assisting Resident #202 to eat. There was an available chair on the opposite side of the room that was not in use. -CNA #2 was assisting with feeding Resident #202 his/her food from the meal tray that was diagonally behind the Resident, on the windowsill, and out of the Resident's view. -The Resident was required to turn and tilt his/her head up towards CNA #2 when CNA #2 spoke to the Resident throughout the meal. During an interview on 2/27/25 at 12:17 P.M., CNA #2 said that she stood while assisting Resident #202 to eat because it was too difficult for her to feed the Resident while sitting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #55 was admitted to the facility in December 2024 with diagnoses including Type Two Diabetes Mellitus with neuropathy and Alzheimer's Disease. Review of the facility policy titled Pressure Injury Risk Assessment and Wound Care Policy, last reviewed/revised 11/2024, indicated: >The purpose of the policy was to prevent the occurrence of pressure injury or other alterations in skin integrity . and to ensure those who have or are at risk for developing skin integrity issues are treated using evidence-based prevention and treatment plans. >The policy also included the following: -a head-to-toe skin assessment will be performed, and documentation completed on the Skin Integrity Eval [sic]/Injury Counts forms on the assigned shower day by the Nurse . and the Nurse will add any identified wound .then document wound assessment findings . -the Skin and Wound Care Guidelines approved by the Medical Director will be reviewed and protocol orders placed by the Nurse upon determining the level of skin breakdown and/or wound assessment. -the Attending Provider (medical doctor (MD)/nurse practitioner (NP) will be notified of the skin breakdown and initiation of the protocol order, will sign the order, if in agreement, within 24 hours. If not in agreement, a revised treatment plan will be initiated with new treatment orders placed. -based on the resident's skin condition, the contracted Wound Provider may be consulted by the Provider to complete a comprehensive wound assessment and make wound management recommendations. If the Wound Management Provider recommendations are agreed to by the Provider, the orders will be placed by the Provider. -treatment orders for the provision of wound care will be outlined to include: >the anatomic location of the wound >method for cleansing >primary and secondary dressing outlined >frequency of dressing changes >length of therapy noted. -upon completion of the treatment by the Nurse, he/she checks the corresponding box for the treatment under the Treatment Administration . -when the treatment is discontinued based on the length of the treatment, the order will no longer be assigned as a task. The discontinued order will be electronically sent to the Provider for electronic signature. Review of the Skin and Wound Care Guidelines, revised 1/31/25, indicated the following treatment guidelines for a fluid filled blister: -remove source of pressure or friction -reposition at least every hour if seated and every two hours while in bed -cleanse wound with wound cleanser or normal saline -apply Skin Prep to discolored intact skin. Allow to air dry . Review of the MDS assessment dated [DATE], indicated Resident #55: -had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 1 out of a possible 15 points -was dependent on staff with upper and lower body dressing and personal hygiene -did not have any pressure ulcers on admission Review of the Nurse's Progress Note dated 1/15/25, indicated that during foot care, a fluid filled intact blister was observed on the Resident's right heel. The Wound Nurse was notified and assessed the area to be a blister measuring 2.5 centimeters length (cm) by (X) 3.3 cm width. A recommendation (by?) was made to float the Resident's heels and to reposition while in bed. Review of the Nurse's Progress Note dated 1/19/25, indicated Resident #55 was observed scratching him/herself, was assessed and house moisturizing cream was applied to his/her dry skin (no body locations identified). Review of the January 2025 and February 2025 Physician's orders included the following treatment orders: -Skin Prep to be applied every shift to the Resident's right heel, initiated 1/15/25 and discontinued 1/29/25 -Ammonium Lactate 12% topical twice daily, (did not specify a body location), initiated 1/21/25. Review of the January 2025 Treatment Administration Record (TAR) indicated: -Skin Prep was applied to Resident #55's right heel as ordered from 1/15/25 on the evening shift through 1/29/25 on the day shift. -Ammonium Lactate 12% was applied twice daily (body location not specified) from 1/21/25 on the evening shift through 1/31/25. Review of the February 2025 TAR indicated: -Ammonium Lactate 12% was applied twice daily (body location not specified) from 2/1/25 on the day shift through 2/28/25 on the day shift. Review of Resident #55's clinical record indicated: -Skin Prep was documented as administered in the Nurse's Progress Notes on: 2/6/25, 2/8/25, 2/13/25, 2/17/25, 2/20/25, and 2/25/25 -Wound Assessment, dated 2/4/25 indicated Skin Prep was applied. On 2/27/25 at 7:58 A.M., the surveyor requested of Nurse #6 to observe when treatment was being provided to Resident #55's right heel. Nurse #6 said the Resident's treatment was Skin Prep to the right heel and that this would be completed sometime after breakfast. Nurse #6 said the Resident had an intact blister that was never open and was now eschar (dead skin tissue). During a follow-up interview on 2/27/25 at 8:28 A.M., Nurse #6 approached the surveyor and said the Resident was evaluated by the Wound Nurse on 2/26/25, and that there were no treatment orders at this time. During an interview on 2/27/25 at 5:30 P.M., the surveyor and the Director of Nursing (DON) reviewed Resident #55's wound documentation. The DON said the Resident's right heel wound was improved, and that the recommendation for treatment included offloading (relieving pressure) the heel and applying Skin Prep. The surveyor and the DON reviewed the Physician's order for Skin Prep which had been discontinued on 1/29/25, and found evidence in the clinical record that indicated the treatment had continued without a Physician's order. When the surveyor asked about the current Ammonium Lactate 12% treatment ordered twice daily that did not include a body location for the treatment, the DON said she would follow up with the surveyor after looking into the matter. During a follow-up interview on 2/28/25 at 9:57 A.M., the DON said there would need to be a Physician's order to apply Skin Prep because it was a treatment order. The DON said the Physician's order for the Ammonium Lactate 12% treatment should indicate the body location to where the treatment was being applied, and the order would need to be clarified. The DON further said she would have the Wound Nurse speak to the surveyor about the Resident's right heel treatment. On 2/28/25 at 10:08 A.M., the surveyor and the Wound Nurse reviewed Resident #55's clinical record. During an interview at the time, the Wound Nurse said there were Skin and Wound Care Guidelines that the Nurses have been trained to utilize when a new area was identified on a resident. The Wound Nurse said when a resident develops a new skin issue, the Nurse would complete an assessment of the area, obtain orders from the Physician for the area based on the facility skin care protocol, and would notify the Wound Nurse so she could assess and make recommendations as indicated. The Wound Nurse said she had been assessing Resident #55's right heel wound weekly and had made a recommendation to offload the right heel and to apply Skin Prep every shift for two weeks starting on 1/15/25. The Wound Nurse said the Skin Prep should have been administered for two weeks only per the Physician's order and was discontinued on 1/29/25. The Wound Nurse said if there was no Physician's order to apply Skin Prep to the Resident's right heel, then it should not have been applied. The Wound Nurse said she assessed the Resident's right heel after 1/29/25, and said the facility staff should continue with offloading and diabetic foot care as indicated in the current Physician's orders. The Wound Nurse said she was not sure what the Physician's order for the Ammonium Lactate 12% treatment was related to, and further said there should be a body location identified to apply the treatment, but there currently was none specified. Please Refer to F692. Based on observation, interview and record review, the facility failed to provide care and services according to professional standards of practice for two Residents (#104 and #55) out of a total sample of 24 residents. Specifically, the facility failed to: 1. For Resident #104, adhere to Physician's orders and hypoglycemic (low blood sugar) protocol when the Resident was assessed to be hypoglycemic, further increasing the risk for complications related to hypoglycemia. 2. For Resident #55, adhere to professional standards relative to skin and wound care when the facility staff: -continued to apply a discontinued treatment to a wound without a Physician's order. -clarify the body location that a Physician's ordered treatment was to be applied. Findings include: 1. Review of the facility's policy titled Hypoglycemia, dated July 2024, indicated the following: -The Purpose was to respond to hypoglycemic reactions. -Any resident whose finger stick blood sugar is below 70 milligrams (mg)/deciliter (dL) will receive intervention to prevent a serious hypoglycemic reaction. -Hypoglycemia - When blood sugar is 70 mg/dL or lower and the following symptoms may occur, but not limited to: -confusion -dizziness -feeling shaky -hunger -headache -irritability -heart racing -pale skin -sweating -weakness -anxiety -Use the attached Hypoglycemic Flowchart to determine next steps in treatment. Review of the facility's Hypoglycemic Flowchart, undated and attached to the facility's Hypoglycemia Policy, indicated: -If the resident's blood sugar is not above 50 mg/dL, inject Glucagon, one mg intramuscularly (IM) or subcutaneously (SC). Resident #104 was admitted to the facility in June 2022 with diagnoses including Diabetes Mellitus (DM). Review of Resident #104's Minimum Data Set (MDS) Assessment, dated 11/30/24, indicated: -The Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15 total possible points. -The Resident had a diagnosis of DM. -The Resident required the use of hypoglycemic medication. Review of Resident #104's DM Care Plan dated 1/30/25, indicated the following: -The Resident had DM and was dependent on Insulin. -The Resident experienced low FSBS (fingerstick blood sugar) levels. -Staff were required to monitor the Resident for observable signs of hypoglycemia. Review of Resident #104's February 2025 Physician's orders indicated: -Dextrose (Glucose-15) 40 percent (%), give one tube by mouth as directed PRN (as needed); give 15 grams (G) by mouth for blood sugar between 50-70 . Indication: hypoglycemic disorder, dated 9/8/24. -Glucagon HCL (Glucagon Emergency Kit) one (1) mg; inject 1 mg (1 vial) IM as directed PRN . for diabetic emergency, dated 9/8/24. -Glucose monitoring every two hours PRN ., dated 9/23/24. -Glucose monitoring . daily before meals, dated 10/3/24. -Hypoglycemia Protocol every shift . Please monitor for signs of hypoglycemia ., dated 11/15/24. Review of a Resident #104's Nursing Progress Note dated 2/19/25, indicated the following: -The Resident presented with confusion. -The Resident's FSBS was less than 39 mg/dL. Review of Resident #104's February 2025 Medication Administration Record (MAR) indicated the following for 2/19/25: -One tube of Dextrose (Glucose-15) 40% (to be administered for FSBS of 50-70 mg/dL) was administered by mouth to the Resident. -Glucagon HCL 1 mg injection was not administered to the Resident, as required per the Physician's order and the facility's Hypoglycemic Protocol for a FSBS below 50 mg/dL. During an interview on 2/28/25 at 1:15 P.M., Nurse #1 said that the facility had a Hypoglycemic Protocol and that the Hypoglycemic Protocol was secured to the outside cover of the glucose monitoring machine case. At the time, the surveyor and Nurse #1 reviewed the following: -The facility's Hypoglycemic Protocol. -Resident #104's active Physician order (9/8/24) for one tube of Dextrose 40% to be administered by mouth for a FSBS of 50-70 mg/dL. -Resident #104's active Physician order (9/8/24) for 1 mg of Glucagon HCL to be injected IM, PRN, for diabetic emergency. -Resident #104's Nursing Progress Note (2/19/25) indicating the Resident's signs and symptoms of confusion, FSBS of less than 39, and that one tube of Dextrose 40% had been administered by mouth to the Resident. Nurse #1 said that Resident #104 received one tube of Dextrose 40% when the Resident's FSBS was less than 39 mg/dL on 2/19/25, and that 1 mg of Glucagon HCL (IM) was not administered to the Resident as required, per the facility's Hypoglycemic Protocol and the Resident's Physician order. During an interview on 2/28/25 at 1:45 P.M., the Director of Nursing (DON) said that the facility's glucose monitor provided FSBS readings as low as 39 mg/dL. The DON said that FSBS readings below 50 mg/dL indicated a diabetic emergency, and that facility staff were required to initiate the facility's Hypoglycemic Protocol and adhere to the specified resident's Physician orders for hypoglycemia. The DON said that Resident #104 should have been administered 1 mg of Glucagon HCL (IM) on 2/19/25, when his/her FSBS was measured at less than 39 mg/dL, according to the facility's Hypoglycemic Protocol and the Resident's Physician orders. During an interview on 2/28/25 at 2:00 P.M., the Physician said that she reviewed Resident #104's clinical record and that the Resident should have received 1 mg of Glucagon HCL (IM) on 2/19/25, per the Physician order, when his/her FSBS was less than 39 mg/dL.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that therapeutic dietary supplements were implemented with an indication of weight loss for one Resident (#104) out of a total sample of 24 residents. Specifically, for Resident #104, the facility failed to offer a nutritional supplement (Glucerna) as ordered by the Physician when the Resident's meal intake was 50 percent or less, for the prevention of further weight loss. Findings include: Resident #104 was admitted to the facility in June 2022 with diagnoses including Hypertensive Heart Disease with heart failure, Dysphasia, Type 1 Diabetes and Chronic Kidney Disease (CKD). Review of the February 2025 Physician orders for Resident #104 indicated: -Dietary Supplement per protocol, PRN (as needed) Glucerna, Volume 8 oz (ounces). If intake is 50 percent (%) or < (less than). Indication: weight loss. Start date 11/6/24. Review of the Resident's Significant Weight Loss care plan, initiated on 11/15/24, indicated the following: -Monitor oral intake of food and fluid -Provide diet and supplements as prescribed .Glucerna if intake is <50%. Review of Resident #104's January 2025 Meal Acceptance log indicated: -For 93 total meals provided in January 2025, the meal intake percentage was documented 84 times and not documented 13 times. -Of the 84 meal intake percentages documented, Resident #104 consumed 50% or less of the meal, a total 33 times. Review of Resident #104's January 2025 Medication Administration Record (MAR) indicated: -no documentation that the Resident was offered Glucerna per Physician's order for the documented 33 occasions when the meal intake consumed was 50% or less. Review of the Nursing Progress Notes provided by the Director of Nursing (DON) on 2/28/25, indicated the following: -1/29/25 at 15:05 (3:05 P.M.) Glucerna offered and accepted. -Of the 33 occasions Resident #104 consumed 50% or less of his/her meals in January 2025, he/she was not offered the Glucerna supplement as ordered, on 32 occasions. The facility did not provide any additional nursing notes to indicate whether the Glucerna supplement had been offered to Resident #104 in January 2025, except for one occasion on 1/29/25. Review of the 2/1/25 through 2/27/25 Meal Acceptance log indicated the following: -For 81 total meals provided in February 2025, the meal intake percentage was documented 73 times and not documented eight times. -Of the 73 meal intake percentages documented, Resident #104 consumed 50% or less of the meal, a total 23 times. Review of the February 2025 MAR indicated Resident #104 had been offered and accepted Glucerna three times out of 23 possible occasions. Review of the Nursing Progress Notes provided by the DON on 2/28/25, indicated the following: -2/2/25 at 14:52 (2:52 P.M.) Glucerna offered and accepted -2/7/25 at 15:51 (3:51 P.M.) Glucerna offered and accepted -2/19/25 at 14:51 (2:51 P.M.) Glucerna offered and accepted -2/24/25 at 15:27 (3:27 P.M.) Glucerna offered and accepted Further review of both the February 2025 MAR and the Nursing Progress Notes indicated Resident #104 was not offered Glucerna supplements per the Physician's order, 16 times when he/she consumed 50% or less of meals. Review of the Nutrition Assessments dated 11/25/24, indicated the following in part: -Glucerna supplement ordered but no documentation reported to show if supplement was refused, offered or consumed. Review of the Nutrition assessment dated [DATE], indicated the following in part: -Summary of Nutritional Findings: .experienced significant weight loss related to poor appetite as evidence by 12.6.7 [sic] pound lb. weight loss (10%) x 180 days . -Glucerna is ordered if intake is < 50%, however, doesn't always accept supplement per nursing. During an interview on 2/27/25 at 10:26 A.M., Nurse #9 said Resident #104 would occasionally ask for a Glucerna supplement. Nurse #9 said that she would occasionally offer the Resident Glucerna as well. The surveyor and Nurse #9 reviewed the February 2025 MAR that indicated Glucerna had been offered and accepted on 2/1/25 and 2/7/25 (interview occurred prior to the time Glucerna was offered on 2/27/25) with no other information available. Nurse #9 said that Glucerna could have been offered and not documented on the other days, or maybe additional information could be found in the Nurse's notes. Nurse #9 reviewed the Physician's order and said that she could see that per the order, the Glucerna should have been offered to the Resident, and due to the lack of documentation it was difficult to decipher if the Glucerna had been offered or not. During an interview on 2/27/25 at 11:03 A.M., Dietician #1 said the facility had attempted other supplemental alternatives with Resident #104 and that the Glucerna was the current recommendation. Dietician #1 said she reviewed the MARs, nursing notes and talked with the staff to obtain information when she completed an assessment. Dietician #1 said that at times it could be difficult to determine how frequently Resident #104 was being offered, accepted or refused the Glucerna due to the lack of documentation. During an interview on 2/27/25 at 11:41 A.M., the DON said documentation was important so the staff could track if the Glucerna ordered for Resident #104 was being offered. The DON further said that the staff could not develop an appropriate plan if they did not know if the supplement was being offered or if the nutrition recommendation was effective. On 2/28/25 at 12:11 P.M., the surveyor observed Resident #104 was sitting on the edge of his/her bed with a rolling table in front of him/her that contained a meal tray with a covered plate of food. During an interview at the time, Resident #104 said that he/she had not yet eaten and uncovered the plate, displaying the untouched food. On 2/28/25 the surveyor observed the following: -12:30 P.M.: A staff member entered Resident #104's room and asked if the Resident had started his/her lunch yet. The Resident replied no. -12:37 P.M.: Resident #104 was lying in bed, and a meal tray and covered plate was on the rolling table. -1:15 P.M.: Resident #104 remained lying in bed, and a meal tray and covered plate remained on the rolling table. -1:25 P.M.: Resident #104 exited the room in a wheelchair. He/she said that he/she did not eat his/her lunch. The surveyor entered the Resident's room and observed the meal tray remained on the rolling table, all meal items were covered, and no meal items had been consumed. -3:10 P.M.: Resident #104 was seated on the edge of his/her bed. During an interview at the time, Resident #104 said he/she went to Bingo and had just returned. Resident #104 said that he/she had not been offered a shake (supplement) at all, and that he/she usually had to ask for the supplement. During an interview on 2/28/25 at 3:13 P.M., with Nurse #1, Nurse #2, Nurse #4 and Nurse #10, Nurse #1 and Nurse #2 said Resident #104 did not require any supplement that day and that the Glucerna was not offered to him/her. Nurse #1 and Nurse #2 said Resident #104 did not need the Glucerna because he/she ate all of his/her meals. The surveyor reviewed the Resident's lunch intake recorded as 0% consumed for the day's lunch and the surveyor observation of the Resident not consuming any of his/her lunch meal. When the surveyor inquired how the Nurses knew of how much of the Resident's meals were consumed and whether to offer Glucerna, Nurse #4 said that staff would record all resident meal intakes on the meal intake sheet. Nurse #4 said that the meal intakes recorded on the meal intake sheet had to be verified by the Nurse, then the Nurse would know whether a supplement was required to be offered. Nurse #1 said that she would not have expected Resident #104 to have eaten lunch that day because the Resident was a slow eater and did not finish breakfast until 10:30 A.M. Nurse #10 said that the Resident receives an early tray for supper daily and that the supper tray is provided for the Resident between 4:00 P.M. and 4:10 P.M. The surveyor reviewed with Nurse #1, Nurse #2, Nurse #4, and Nurse #10 that the Resident finished breakfast that same day at 10:30 A.M., consumed 0% of his/her lunch, that no Glucerna had been offered to the Resident, and the Resident's supper meal was due to be delivered to the Resident between 4:00 P.M. and 4:10 P.M. At this time, Nurse #1 said she could offer a Glucerna supplement to the Resident, and proceeded to leave the nurses station. During an interview on 2/28/25 at 4:45 P.M., Dietician #1 said the Resident was supposed to receive 8 oz of Glucerna if he/she consumed 50% or less at meals. Dietician #1 said this information was sometimes recorded in progress notes, other than that, the information was not available in the Resident's medical record, so she would ask staff verbally. Dietician #1 said the Glucerna was a supplement to meals, so it should be offered to the Resident when he/she consumed 50% or less, and staff should offer the Glucerna supplement based on the Physician's order. Dietician #1 said they had tried multiple supplements for the Resident previously, and that the Resident would take the supplements for a while and then will stop accepting them. The surveyor and Dietician #1 reviewed Resident #104's medical record, and Dietician #1 said that she could see that the supplement was offered three times for the month of February. Dietician #1 further said there were 16 meals documented that the Resident had consumed 50% or less, and there was no record that the Glucerna supplements had been offered/ administered as ordered.

Based on observation, interview, and record review, the facility failed to implement transmission-based precautions (TBPs) timely for one Resident (#201) of two applicable residents, out of a total sample of 24 residents. which increased the risk for facility transmission of infection. Specifically, the facility failed to implement Contact Precautions timely for Resident #201 when: -The Resident was recently on Contact Precautions and treated for Clostridium Difficile (C. diff: multidrug resistant organism [MDRO] that is infectious and causes diarrhea and colitis [inflammation of the colon]). -The Resident experienced symptoms of diarrhea eight days after the initial Contact Precautions were discontinued, and Contact Precautions were not immediately re-implemented. Findings include: Review of the facility's policy titled PPE (Personal Protective Equipment) Policy, dated March 2023, indicated the following in part: -The purpose was to protect employees from exposure to workplace hazards that may cause injury or disease .following . Center for Disease Control and Prevention (CDC) . guidelines. -PPE is equipment worn to minimize exposure to hazards that may cause workplace . illness. -TBPs are for patients who are known or suspected to be infected or colonized with infectious agents, including certain epidemiologically important pathogens, which require additional control measures to effectively prevent transmission. -TBPs are grouped into categories according to the route of transmission of the infectious agent. -TBPs include Contact Precautions. -Employees shall use PPE in accordance with instructions and training received. Review of the CDC document titled About C. Diff, dated 12/18/24, indicated the following: -C. diff is a germ that causes diarrhea and colitis and can be life-threatening. -C. diff can affect anyone. -Most cases of C. diff infection occur when you've been taking antibiotics or not long after you've finished the antibiotic course. -Symptoms of C. diff include: diarrhea, fever, stomach tenderness or pain, loss of appetite, and nausea. -People are up to 10 times more likely to get C. diff infection while taking an antibiotic or during the three months after, with longer courses potentially doubling their risk. -Other risk factors include: recent stay at a hospital or nursing home and previous infection with C. diff . -C. diff germs spread from person to person in poop, but the bacteria are often found in the environment. -When C. diff germs are outside the body, they become spores. These spores are an inactive form of the germ and have a protective coating allowing them to live for months or years on surfaces . Review of the CDC document titled Appendix A: -Type and Duration of Precautions Recommended for Selected Infections and Conditions, dated 2/7/25, indicated: >Contact Precautions and handwashing with soap and water are recommended for individuals with C. diff. Review of the facility's Infection Prevention Orientation Document, undated and printed on 2/26/25, indicated the following: -Learners will: -Be able to identify links in the chain of infection. -Be able to verbalize the principles and indications of . TBPs . and required PPE. -Describe MDROs, modes of transmission, prevention, . in a long-term care setting. -Germs can spread from other people or touching surfaces. -Examples of MDROs include . C. diff. -Modes of transmission include . contaminated environmental surfaces. Resident #201 was admitted to the facility in January 2025 with diagnoses including muscle weakness and lack of coordination. Review of Resident #201's Nursing Progress Note, dated 1/28/25 at 2:31 P.M., indicated the following: -The Resident was experiencing diarrhea. -A new order had been obtained for a stool sample for C. diff. -Enteric Precautions (measures used to prevent the spread of gastrointestinal infections) were implemented for the Resident. Review of Resident #201's Laboratory Test Result dated 1/28/25, indicated the Resident's stool sample was positive for C. diff. Review of Resident #201's Nursing Progress Note dated 1/28/25 at 10:17 P.M., indicated: -The Resident was on Enteric Contact Precautions for diarrhea. -The Resident had dark green, foul diarrhea two times that shift. -The Resident's stool sample was positive for C. diff. Review of Resident #201's Nursing Progress Note, dated 2/7/25, indicated: -The Resident's last loose bowel movement was on 2/4/25. -Enteric Contact Precautions were discontinued on 2/7/25. Review of Resident #201's Nursing Progress Note, dated 2/15/25 at 2:49 P.M., indicated: -The Resident had experienced two episodes of loose stools during the shift. -Will continue to monitor for changes. Review of a Nursing Progress Note, dated 2/16/25 at 1:27 P.M., indicated: -The Resident was incontinent of two medium loose stools. -The Resident's loose stools were foul smelling and contained mucus. -The Supervisor was made aware. Review of a Nursing Progress Note, dated 2/17/25 at 6:34 A.M., indicated: -The Resident was incontinent of one large foul smelling loose stool within the night. -The Night Supervisor was aware. Review of a Nursing Progress Note, dated 2/17/25 at 2:23 P.M., indicated: -The On-call (Physician) was notified of the Resident's loose stools that occurred on 2/16/25. -A new order was obtained for Vancomycin to be administered to the Resident. -The Resident was placed on Enteric Contact Precautions. On 2/25/25 at 9:40 A.M., the surveyor observed the following from the hallway outside of Resident #201's room: -Signage posted on the Resident's door which indicated Contact Precautions were required and included instructions for handwashing using soap and water. -A PPE bin, stocked with disposable gowns and gloves, was positioned in the hallway, just outside of the Resident's door. -The Resident was sitting in a wheelchair inside the room, watching television. During an interview at the time, Resident #201 said that he/she had been placed under quarantine due to infectious diarrhea. Resident #201 said that he/she would find out in a couple of days whether the quarantine and treatment worked to clear the infection. During an interview on 2/26/25 at 2:15 P.M., the Infection Preventionist (IP) said the facility did not have a policy specific to managing C.Diff infections. The IP said that staff were educated on infection prevention during orientation and annually, and that education relative to managing infectious diarrhea, including C. Diff was included in that education. The IP said that staff were required to implement Contact Precautions for residents as soon as symptoms for infectious diarrhea, including C. Diff., were exhibited. The IP said that Contact Precautions would remain in place for the resident until infectious diarrhea/C. Diff was ruled out. The IP further said that Contact Precautions should have been initiated immediately when Resident #201 became symptomatic again for C. Diff on 2/15/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the facility residents and resident representatives were informed on how to file a grievance and that grievance forms were readily accessible and/or available on eight Units (One North, Two North, Two East, Two South, Three East, Four East, Three [NAME] and Three North) out of ten units observed. Findings include: Review of the facility policy titled Grievance Policy, revised March 2021, indicated the following in part: -All veterans residing at the Soldiers Home in [NAME], their families and veteran representatives may voice a complaint or grievance. -Grievance forms will be placed on all units in a location that is easily accessible to our families and veterans their families and representatives will receive education regarding the grievance process. -Notification will be provided regarding the grievance committee and the process on all units and veterans and their families and representatives will receive written notification that everyone has the right to post a grievance. -If a grievance of any kind is noted the grievance intake form is used. During a pre-survey interview conducted via telephone on 2/24/25 at 12:40 P.M., the Ombudsman from the Massachusetts Long Term Care Ombudsman Program said residents at the facility have voiced concerns pertaining to grievances and the lack of response from the facility once the grievance had been filed. The Ombudsman said residents' grievances are provided to staff by the resident with the concern. The Ombudsman said after a concern had been filed, no staff member followed up with the resident who voiced the grievance, to explain how the facility acted upon the grievance, to find a resolution or what actions were taken to address the grievance. On 2/25/25 at 4:14 P.M., the surveyor observed the following on each unit: -One North: No Grievance Forms were available for the residents. -Two North: No Grievance Forms were available for the residents use. -Two East: A plastic file bin adhered to the wall, near the nurses station with a folder labeled Grievance Forms. The surveyor was unable to ascertain if there were Grievance Forms available in the folder as it was inaccessible due to the placement of a resident in a reclining wheelchair with his/her feet on footrests (indicating he/she was unable to move him/herself) directly in front of the plastic file bin. -Two South: No Grievance Forms were available. -Three East: No Grievance Forms were available. -Three West: Grievance Forms were available however, the forms were mixed in with the other papers for activities and dining menus. -Three North: One Grievance form in the file bin, but the form was curled down into the folder and difficult for the surveyor to see. -Four East: Grievance Forms were available but not labeled. During a Resident Council meeting held on 2/26/25 at 10:11 A.M., attended by five Resident's (#106, #110, #111, #112 and #113, [Resident #113 was not an active participant in the meeting and did not provide any information throughout the meeting]) the following was discussed: -Resident #111 said that he/she recently had an incident at 6:00 A.M., when he/she was told to go back to sleep by a Certified Nurses Aide (CNA) when Resident #111 asked to have something to eat. Resident #111 said that he/she had his/her own food in his/her room but is unable to access it independently and required assistance to do so. -Resident #111 said that he/she asked to speak to a supervisor and was told that no one was available. Resident #111 said that he/she was not aware of how to file an official grievance, because he/she would have done so for this incident. -Resident #110 said that he/she had a few instances that would have warranted filing a grievance, however he/she did not know how to. -When asked if the residents knew how to file a grievance, or if there was a form they or someone could help them complete, Resident's #106, #110, #111, and #112 said that they were unaware of the process of the Grievance Forms. -Resident #106 said that when he/she had a complaint he/she could verbally tell someone but did not know that he/she had the right to a formal process where he/she could write a complaint down. On 2/26/25 at 10:29 A.M., the surveyor requested Social Worker (SW) #1 discuss with the Residents in attendance at the Resident Council meeting regarding the grievance process. Resident #110 and Resident #111 explained to SW #1 that they did not know they could fill out a grievance form and that they would need staff to help them do that. SW #1 said that the facility will work on educating everyone on how to formally file a grievance. On 2/26/25, from 11:00 A.M. through 11:15 A.M., the surveyor and SW #1 observed the following on each unit: -One North: No Grievance Forms were available. -Two North: No Grievance Forms were available. During an interview at the time, Two North Unit Manager (UM) #2 said that she did not have grievance forms out as some residents might take them. UM #2 said that the resident rights are on the wall that references the right to file a grievance, but it does not talk about the process of how to file a grievance if a family member, friend, or employee would like to file one. UM #2 said that typically family would email her or call her if they had a concern and that the process had been working as far as she was aware. UM #2 further said grievance forms were available behind the nurses station, however that information was not readily visible. SW #1 said that the forms should be available on every unit and that the residents and families will be educated on how to file a grievance. -Two South: No Grievance Forms were available. -Three East: No Grievance Forms were available. -Three West: Grievance Forms were available however, the forms were mixed in with the other papers for activities and dining menus. -Three North: One Grievance form was curled down in the file bin and difficult to be seen. -Four East: Grievance Forms were available however not labeled. SW #1 said that the Grievance Forms should be available on every unit, be visible, and accessible to all residents, families, and staff.

Based on observation, and interview, the facility failed to ensure that individuals who were utilized as paid feeding assistants, completed a State-approved training program. Specifically, the facility failed to ensure the program utilized by the facility to train Activities Staff was approved by the State of Massachusetts, as required. Findings include: During the entrance conference interview on 2/25/25 at 7:44 A.M., the Administrator and Director of Nursing (DON) said that the facility did not utilize paid feeding assistants. On 2/25/25 from 11:18 A.M. through 12:18 P.M., during a lunch meal observation on the Two North Unit, the surveyor observed Activities Assistant (AA) #1 assist in feeding some of the residents in the Unit Dining Room. On 2/27/25 from 11:26 A.M. through 12:07 P.M., during a lunch meal observation on the One North Unit, the surveyor observed AA #2 assist in feeding a resident in the Unit Dining Room. During an interview on 2/28/25 at 8:39 A.M., the DON said all Activities Staff have been trained to feed residents. The DON said that AA #1 and AA #2 were assigned to One North and Two North Units, and that other Activities Staff were trained and assigned to the other units to assist with feeding residents during meals. The DON said she was not sure if the paid feeding assistant program they utilized was approved by the State and would look into the matter. During follow-up interviews on 2/28/25 at 9:52 A.M., 1:40 P.M. and 4:10 P.M, the DON provided the surveyor with the feeding assistant program utilized by the facility and a list of the completed training of all the Activities Staff completed on hire and annually thereafter. The DON said the feeding assistant program utilized by the facility had not been submitted to the State for approval and that they were currently completing an application. The DON said the Activities Staff would be assigned by the Certified Nurses Aides (CNAs) or Nurse to which residents they would assist. The DON said that the Activities Assistants should not be assisting residents who have swallowing difficulties. During an interview on 2/28/25 at 4:52 P.M., the Activities Director (AD) said she oversees the Activities Assistants on the units and that all of her staff, including herself, have been through the paid feeding assistant training program. The AD said the Activities Staff were instructed to check in with nursing staff during meals, were typically only available during the lunch meal, and would assist in feeding residents on an as needed basis. The AD said she could not speak to the requirements relative to which residents could be assisted by the Activities Staff as paid feeding assistants, and said they would refer to the Nurse or the CNAs. The AD further said she was not sure if there was always a Licensed Nurse supervising during meals, but a CNA was always present.