**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who on 05/22/25, slid off the bed onto the floor during care, the Facility failed to ensure that nursing immediately notified the Physician that he/she had experienced a fall.Findings include:Review of the Facility Policy titled, Notification of Changes, dated as revised May 2025, indicated that the Facility promptly consults the resident's physician when there is a change requiring notification including accidents resulting in injury and potential to require physician intervention.Review of the Facility Policy titled, Fall Prevention Program, dated as revised May 2025, indicated that a fall is an event in which an individual unintentionally comes to rest on the floor. The Policy indicated that when a resident experiences a fall the physician is to be notified.Resident #1 was admitted to the Facility in October 2023, diagnoses included Cerebral Palsy, contractures of the right and left hand, and the right and left knee, kyphosis, convulsions, periprosthetic fracture of the right knee, atrial fibrillation, osteoarthritis, congestive heart failure and hearing loss.Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 03/27/25, indicated that Resident #1 had impairments of both upper extremities and lower extremities, and was dependent on staff for activities of daily living.Review of Resident #1's Fall Risk Evaluation, dated 03/21/2025, indicated Resident #1 was at risk for falls.Review of the Report submitted by the Facility via Health Care Reporting System (HCFRS), dated 05/24/25, indicated that Resident #1 was transferred to the hospital on [DATE] and on 05/24/25, the Facility was notified that a CT scan of the pelvis revealed an acute comminuted fracture of the right femur (thigh bone) (hip fracture resulting from trauma). The Report indicated that during morning care on 05/22/25, Certified Nurse Aide (CNA) #1 rolled Resident #1 onto his/her left side when he/she raised his/her right leg, which crossed over the left leg, and caused his/her legs to slide off the bed. The Report indicated that CNA #1 was unable to reposition Resident #1 back into the bed, held onto his/her upper body and lowered him/her to the floor. The Report indicated that CNA #1 notified Nurse #1 and Resident #1 was transferred back to bed using a mechanical lift.During a telephone interview on 07/16/25 at 6:30 A.M., Certified Nurse Aide (CNA) #1 (which also included review of her written witness statement dated 05/30/25) said that on 05/22/25 at approximately 6:30 A.M., she was providing care to Resident #1 in bed without the assistance of another staff member, rolled him/her onto his/her left side, and his/her right leg crossed over the left leg causing him/her to slide off the bed. CNA #1 said that she held onto Resident #1's upper body and lowered him/her to the floor. CNA #1 said that she notified the nurse (exact name unknown) of the fall.During a telephone interview on 7/16/25 at 9:29 A.M., Nurse #1 said that she worked the 11:00 P.M. to 7:00 A.M (from 5/21/25 into 5/22/25) shift. Nurse #1 said that on 5/22/25 at approximately 6:30 A.M., CNA #1 notified her that Resident #1 had slid out of bed. Nurse #1 said that when she entered Resident #1's room, he/she was lying on the floor on his/her back. Nurse #1 said that Resident #1 denied being in pain and she told the CNA's to transfer him/her into bed. Nurse #1 said that she did not notify the physician of the fall.During a telephone interview on 7/16/25 at 9:21 A.M., Nurse #2 said that on 5/22/25 she worked the 7:00 A.M. to 3:00 P.M. shift and received change of shift report from Nurse #1. Nurse #2 said that Nurse #1 never reported to her that Resident #1 had fallen out of bed. Nurse #2 said that she did not notify the physician that Resident #1 had a fall because she was not aware that he/she had a fall.Review of Resident #1's medical record indicated that there was no documentation to support that Nurse #1 completed an incident report, or that she notified the Physician of a fall.During an interview on 7/15/23 at 2:50 P.M., the Director of Nurses (DON) said she expected that all Nurses would notify the Physician of any falls or incidents and follow the Facility Policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed as being at risk for falls, had physical limitations in both upper and lower extremities due to contractures, and was dependent on staff for mobility including bed mobility, the Facility failed to ensure they developed an individualized comprehensive plan of care that included the number of staff members required during care, to appropriately meet his/her care needs. Findings include:Review of the Facility's Policy titled, Comprehensive, Person-Centered Care Plans, dated as revised May 2025, indicated the Facility will develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The Policy further indicated that the comprehensive care plan would include resident specific interventions that reflect the resident's strengths and needs as identified in the resident's comprehensive assessment.Resident #1 was admitted to the Facility in October 2023, diagnoses included Cerebral Palsy, contractures of the right and left hand, and the right and left knee, kyphosis, convulsions, periprosthetic fracture of the right knee, atrial fibrillation, osteoarthritis, congestive heart failure and hearing loss.Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 03/27/25, indicated that Resident #1 had impairments of both upper extremities and lower extremities, and was dependent on staff for activities of daily living, including bed mobility and turning and repositioning.Review of Resident #1's Fall Risk Evaluation, dated 03/21/2025, indicated Resident #1 was at risk for falls.Review of Resident #1's Certified Nurse Aide Activities of Daily Living Flowsheet for May 2025 indicated he/she was dependent on staff for personal hygiene and toilet hygiene. The Flowsheet indicated staff provided varying levels of staff assistance (one or two) with rolling left and right (positioning and bed mobility).Review of Resident #1's Activities of Living (ADL) Care Plan, reviewed and revised with the Quarterly MDS, dated [DATE], indicated he/she required extensive to total dependence with activities of daily living and was dependent on staff with bed mobility, personal hygiene and toileting/incontinence care.However, although Resident #1's ADL Care Plan indicated that he/she was totally dependent on staff with ADL's, there was no documentation to support the level of staff assistance (number of staff required) related to bed mobility, personal hygiene and toileting/incontinence care.Review of the Report submitted by the Facility via Health Care Reporting System (HCFRS), dated 05/24/25, indicated that during morning care on 05/22/25, Certified Nurse Aide (CNA) #1 rolled Resident #1 onto his/her left side when he/she raised his/her right leg which crossed over the left leg and caused his/her legs to slide off the bed. The Report indicated that CNA #1 was unable to reposition Resident #1 back into the bed, held onto his/her upper body and lowered him/her to the floor. The Report indicated that CNA #1 notified Nurse #1 and Resident #1 was transferred back to bed using a mechanical lift. The Report indicated that Resident #1 was transferred to the hospital on [DATE] and on 05/24/25, the Facility was notified that a CT scan of the pelvis revealed an acute comminuted fracture of the right femur (hip fracture resulting from trauma). During a telephone interview on 7/16/25 at 6:30 A.M., CNA #1 said that Resident #1's care plan just states that Resident #1 is dependent with bed mobility and personal hygiene but does not indicate the number of staff required to provide assistance, so she believed he/she was a one person assist with care. CNA #1 said that Resident #1 was a one person assist with care most of the time. CNA #1 said that Resident #1 usually holds onto the side rail when she turns him/her in bed. CNA #1 said that if she needed the assistance of another staff member, she would ask another CNA to help her. During an interview on 7/15/25 at 11:50 A.M., CNA #2 said that Resident #1 was very heavy and required the assistance of two staff with all care, including turning, repositioning, and bed mobility. CNA #2 said that she reviews the resident care plans daily and said she could not recall exactly what Resident #1's care plan stated but said she knows he/she required the assistance of two staff members with all care.During an interview on 7/15/25 at 12:11 P.M., CNA #4 said that Resident #1 was very heavy and required the assistance of two staff with all care, including turning, repositioning, and bed mobility. CNA #2 said that she reviews the resident care plans daily and said she believes the care plan stated that he/she required the assistance of two staff members with all care.During a telephone interview on 7/16/25 at 6:51 A.M., CNA #3 said that Resident #1 usually requires the assistance of one staff because he/she can assist with turning in bed. CNA #3 said that sometimes he/she needs assistance from another staff member and will get someone else to help her with bed mobility and personal care. Review of the CNA Job Description indicated there was no documentation to support that a CNA can make the determination as to what level of staff assistance a resident requires with ADL's.During a telephone interview on 7/16/25 at 9:21 A.M., Nurse #2 said that she could not recall the level of staff assistance Resident #1 required with bed mobility and personal hygiene. Nurse #2 said that the Resident specific ADL Care Plan's indicate the level of assistance the resident requires with ADL's. Nurse #2 said that Resident #1 now requires the assistance of two staff members with all care since the fall.During an interview on 7/15/25 at 2:50 P.M., the Director of Nurses (DON) said Resident #1 required the assistance of one staff member with care and bed mobility at the time of the incident. The DON said that if the Care Plan does not indicate that the resident requires two assists, then it means that the resident requires one assist. The DON said that if a staff member needed the assistance of another staff member with care, they could always ask for assistance from another CNA.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews for one of three sampled residents (Resident #1), who on 5/22/25 sustained a fall, the Facility failed to ensure care and treatment provided by nursing met professional standards of practice. When after Nurse #1 was notified by Certified Nurse Aide (CNA) #1 that Resident #1 slid out of bed and was on the floor in his/her room, Nurse #1 instructed the CNA's to put Resident #1 back to bed. There was no supporting documentation including assessments or nurse progress notes in Resident #1's medical record related to the fall, no incident report, and the oncoming shift nurse and the Physician were also not notified of the fall. The next day, Resident #1 was noted with swelling to his/her right hip/thigh area and was transferred to the Hospital Emergency Department (ED) for evaluation and was diagnosed with a right hip and femur (thigh bone) fractures and was admitted . Findings Include:Pursuant to Massachusetts General Law (M.I.T.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CRM) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Review of the Facility's Policy titled, Fall Prevention Program, dated as revised May 2025, indicated that a fall is an event in which an individual unintentionally comes to rest on the floor. The Policy indicated that when a resident experiences a fall, the facility will:-assess the resident;-complete a post-fall assessment;-complete an incident report;-notify the physician and family;-review the resident's care plan and update as indicated;-document all assessments and actions;-obtain witness statements in the case of injury.Review of the Facility's Policy titled, Incidents and Accidents, dated as revised May 2025, indicated the following:-it is the policy of the facility for staff to report, investigate and review any accidents or incidents that occur on facility property;-licensed staff will report incident/accidents;-a fall is an accident that requires an incident/accident report;-any injuries will be assessed by the licensed nurse;-the supervisor or designee will be notified of the incident/accident;-the nurse will contact the resident's practitioner to inform them of the incident/accident, report any injuries or other findings and obtain orders, if indicated;-the nurse will enter the incident/accident information into the appropriate form and will document all pertinent information;-documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications and orders obtained or follow-up interventions.Resident #1 was admitted to the Facility in October 2023, diagnoses included Cerebral Palsy, contractures of the right and left hand, and the right and left knee, kyphosis, convulsions, periprosthetic fracture of the right knee, atrial fibrillation, osteoarthritis, congestive heart failure and hearing loss.Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 03/27/25, indicated that Resident #1 had impairments of both upper extremities and lower extremities, and was dependent on staff for activities of daily living.Review of Resident #1's Fall Risk Evaluation, dated 03/21/2025, indicated Resident #1 was at risk for falls.Review of the Report submitted by the Facility via Health Care Reporting System (HCFRS), dated 05/24/25, indicated that during morning care on 05/22/25, Certified Nurse Aide (CNA) #1 rolled Resident #1 onto his/her left side when he/she raised his/her right leg which crossed over the left leg and caused his/her legs to slide off the bed. The Report indicated that CNA #1 was unable to reposition Resident #1 back into the bed, held onto his/her upper body and lowered him/her to the floor. The Report indicated that CNA #1 notified Nurse #1 and Resident #1 was transferred back to bed using a mechanical lift. The Report indicated that Resident #1 was transferred to the hospital on [DATE] and on 05/24/25, the Facility was notified that a CT scan of the pelvis revealed an acute comminuted fracture of the right femur (thigh bone) (hip fracture resulting from trauma). The Report indicated that during change of shift report, Nurse #1 reported to Nurse #2 that Resident #1 needed a wider bed because his/her leg was hanging over the edge of bed during care. The Report indicated that Nurse #1 did not report to Nurse #2 that Resident #1 had a fall. The Report indicated that (on 5/23/25) a CNA reported to Nurse #2 that Resident #1's right upper leg was swollen, and Nurse #2 did not notice any difference in the size of his/her upper legs and there were no signs of redness or bruising. The Report further indicated that Nurse #2 noted that Resident #1's respiratory rate was elevated and that Resident #1 was transferred to the hospital ED on 05/23/25 and on 05/24/25, the Facility was notified that a CT scan of the pelvis revealed an acute comminuted fracture of the right femur (thigh bone) (hip fracture resulting from trauma). Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated that Resident #1 presented to the ED from the nursing home with right leg swelling and a CT of the pelvis was ordered. The Summary indicated that the CT of the pelvis revealed an acute comminuted intertrochanteric fracture of the right femur, an avulsion fracture of the iliopsoas muscle from the right femur, bony demineralization and a dislocation of right knee arthroplasty. The Summary indicated that Resident #1 was admitted to the hospital.During a telephone interview on 07/16/25 at 6:30 A.M., Certified Nurse Aide (CNA) #1 (which also included review of her written witness statement dated 05/30/25) said that on 05/22/25 at approximately 6:30 A.M., she was providing care to Resident #1 in bed, without the assistance of another staff member, rolled him/her onto his/her left side, and his/her right leg crossed over the left leg causing him/her to slide off the bed. CNA #1 said that she held onto Resident #1's upper body and lowered him/her to the floor. CNA #1 said that she notified the nurse (exact name unknown) of the fall.During a telephone interview on 7/16/25 at 9:29 A.M., Nurse #1 said that she worked the 11:00 P.M. to 7:00 A.M (on 5/21/25 into 5/22/25) shift. Nurse #1 said that on 5/22/25 at approximately 6:30 A.M., CNA #1 notified her that Resident #1 had slid out of bed. Nurse #1 said that when she entered Resident #1's room, he/she was lying on the floor on his/her back. Nurse #1 said that Resident #1 denied being in pain and she told the CNA's to transfer him/her into bed. Nurse #1 said that she reported the fall to the day shift nurse. Nurse #1 said she could not recall if she documented the fall in the nurse's note or if she completed an incident report but said she should have. Nurse #1 said that she did not notify the physician of the fall.Review of Resident #1's medical record indicated that there was no documentation to support that Nurse #1 assessed Resident #1 for potential injuries, that she completed an incident report, or that she notified the Physician of a fall.During a telephone interview on 7/16/25 at 9:21 A.M., Nurse #2 said that on 5/22/25 she worked the 7:00 A.M. to 3:00 P.M. shift and received change of shift report from Nurse #1. Nurse #2 said that Nurse #1 told her that Resident #1 needed a bigger bed because he/she was leaning on the side of the bed when the CNA turned and rolled him/her during care. Nurse #2 said that Nurse #1 never reported that Resident #1 had fallen out of bed. During an interview on 7/15/23 at 2:50 P.M., the Director of Nurses (DON) said she expected that all Nurses would assess a resident after a fall, document the assessment in the nurse's notes, complete an incident report, report the fall to the oncoming shift, notify the Physician and family of any falls or incidents and follow the Facility Policy. The DON said that Nurse #1 did not follow the Facility's policy.

Based on interviews and documentation review, the facility failed to ensure packages were delivered in a timely manner to one Resident (#29), out of a total sample of 18 residents. Findings include: Resident #29 was admitted to the facility in June 2020. Review of the Minimum Data Set (MDS) assessment, dated 1/9/25, indicated Resident #29 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the Resident was cognitively intact. Review of Physician's orders indicated Resident #29's Healthcare Proxy (HCP) was invoked 6/15/2023. Review of a Social Service progress note, dated 1/15/25, indicated but was not limited to the following: -Social Service Care Plan meeting, present at the meeting was HCP, dietitian, executive director, assistant director of nurses and director of social services. Review of mail delivery, and review of purchases and extra clothes in the room. During an interview on 2/05/25 at 4:52 P.M., Resident #29 said he/she had a meeting with the Administrator about his/her missing clothing, and he/she was told to donate some clothes. During a telephonic interview on 2/06/25 at 10:24 A.M., Family Member (FM) #1 (Resident #29's HCP) said Resident #29 was upset and told him, he/she had 11 packages that were not delivered over Christmas until he/she got rid of stuff in his/her room. FM #1 said some of the packages contained Christmas presents for family members. FM #1 said he spoke with the woman who worked in Activities and informed her that Resident #29's packages were not delivered, and it was illegal for them to withhold packages and cited Federal law chapter 8, section 1701 and 1702. During an interview on 2/06/25 at 11:00 A.M., the surveyor informed the Administrator of FM #1's concern of packages being withheld until extra items in Resident #29's room were removed. The Administrator said FM #1 had expressed his concerns to her about Resident #29 not receiving some packages and he did cite the Federal law to her during a meeting in January. The Administrator said she did not keep any notes on the conversations with FM #1 and referred the surveyor to check the social service notes. The Administrator said she did not investigate why Resident #29's packages were held in the business office, and she did not file a grievance. During an interview on 2/06/25 at 11:18 A.M., the Front Desk Receptionist (FDR), with the Administrator present, said Resident #29 was complaining about packages not being delivered over Christmas. FDR said she told the Business Office Manager (BOM) about the complaints and never heard any more about the complaint. During an interview on 2/06/25 at 2:55 P.M., the Activity Director (AD) said she has been working with Resident #29 to get rid of some of his/her clothes. The AD said she was aware some of Resident #29's packages went up to the business office over Christmas, but she did not know why. She said after Christmas a lot of packages were brought down and delivered to Resident #29's room and she and Activity Assistant #1 helped Resident #29 put away the new clothes. The AD said she did speak with FM #1 and told him she did not think the packages were withheld on purpose it was just a miscommunication. During an interview on 2/06/25 at 3:05 P.M., Activity Assistant (AA) #1 said he was not aware of any packages being held at Christmas, but after Christmas he delivered a whole bunch of packages to Resident #29's room. AA #1 said he could not say how many packages but said it was a lot. During an interview on 2/06/25 at 3:30 P.M., the FDR said she did receive a couple packages for Resident #29 which she delivered to Resident #29's room. The FDR said packages are never held in the business office, if they are received after hours they are delivered the next day. The FDR said she does not know why Resident #29's packages went to the business office or why. During an interview on 2/07/25 at 9:02 A.M., Social Worker (SW) #1 said she knows around Christmas time the Activity Staff were trying to clean out Resident #29's room. SW #1 said she was aware Resident #29 had some packages that were in the business office, but she was not sure how or why they were in the business office. She said she called FM #1 at the beginning of January and asked him to come in and pick up some of Resident #29's extra belongings the facility was storing. She said at that time FM #1 brought the concerns of Resident #29 not receiving his/her packages, and FM #1 said it violated federal law. SW #1 said she notified the Administrator, and they decided to have a meeting with FM #1. SW #1 said the care plan meeting took place on 1/15/25 and mail delivery concerns were discussed, and they reviewed Resident #29's purchase of clothing and extra clothes in the room. SW #1 said FM #1 brought up the Federal law of delivery of packages and FM #1 was assured Resident #29 would receive his/her packages going forward. During a telephonic interview on 2/7/25 at 10:19 A.M., the BOM said due to staffing limitations around the Christmas holiday they could not process all Resident #29's packages. She said she brought 4-5 packages on 12/24/24, up to her office until they were later delivered to Resident #29 on 12/27/24. The BOM said after FM #1 complained about the delay in the packages being delivered, she said they had a telephonic meeting with FM #1, and no one asked why the packages were held up in her office. She said she did not inform Resident #29 she had packages delivered to the facility and she was holding them in her office. During an interview on 2/07/25 at 10:35 A.M., Corporate Nurse said she was not aware of FM #1's complaint that Resident #29 did not receive packages over Christmas until items were removed from the Resident's room. Refer to F609 and F610

Based on interview and record review, the facility failed to report allegations of abuse within the State mandated time frame for two Residents (#29 and #609), in a total sample of 18 residents. Specifically, the facility failed to: 1. For Resident #29, ensure an allegation of misappropriation of resident property by staff of withholding packages until the Resident cleaned out his/her room was reported to the State Survey Agency; and 2. For Resident #609, ensure an allegation of harassment by the Administrator was reported to the State Survey Agency. Findings include: Review of the facility's policy titled Abuse Policy, undated, indicated but was not limited to the following: Policies and procedures regarding investigation and reporting of alleged violations of federal or state laws involving mistreatment, neglect, abuse, injuries of unknown source, and misappropriation of resident's property. -Such violations will also be reported to state agencies in accordance with existing state law. -The facility will investigate each alleged violation thoroughly and report the results of the investigation to the Executive Director or his or her designee, as well as to state agencies as required by state and federal law. -Protection: -If the suspected perpetrator is an employee, the Executive Director shall place the employee on immediate investigatory suspension while completing the investigation. Investigation of suspected resident abuse/ mistreatment/misappropriation/neglect/injury of unknown origin: 1. If a family member, resident, or staff reports an incident of abuse/mistreatment/neglect, it is to be reported to the Director of Nursing or manager immediately and an incident/accident report is to be completed. 2. The supervisor is to initiate the following steps: -Send the initial report to the Department of Public Health via Virtual Gateway immediately but no later than two hours. 1. Resident #29 was admitted to the facility in June 2020. Review of the Minimum Data Set (MDS) assessment, dated 1/9/25, indicated Resident #29 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the Resident was cognitively intact. During an interview on 2/05/25 at 4:52 P.M., Resident #29 said he/she had a meeting with the Administrator about his/her missing clothing, and he/she was told to donate some clothes. During a telephonic interview on 2/6/25 at 10:24 A.M., Family Member (FM) #1 (Resident #29's Health Care Proxy) said Resident #29 was upset and told him, he/she had 11 packages that were not delivered over Christmas until he/she got rid of stuff in his/her room. FM #1 said some of the packages contained Christmas presents for family members. FM #1 said he spoke with the woman in Activities and informed her that Resident #29's packages were not delivered, and it was illegal for them to withhold packages and cited Federal law chapter 8, section 1701 and 1702. During an interview on 2/06/25 at 11:00 A.M., the surveyor informed the Administrator of FM #1's concern of packages being withheld until extra items in Resident #29's room were removed. The Administrator said FM #1 had expressed his concerns to her about Resident #29 not receiving some packages and he did cite the Federal law to her during a meeting in January about mail delivery. The Administrator said she did not keep any notes on the conversations with FM #1 and referred the surveyor to check the social service notes. The Administrator said she did not investigate why Resident #29's packages were held in the business office, and/or file a grievance. During an interview on 2/06/25 at 11:18 A.M., the Front Desk Receptionist (FDR), with the Administrator present, said Resident #29 was complaining about packages not being delivered over Christmas. FDR said she told the Business Office Manager (BOM) about the complaints and never heard any more about the complaint. During an interview on 2/07/25 at 9:02 A.M., Social Worker (SW) #1 said she called FM #1 at the beginning of January and asked him to come in and pick up some of Resident #29's extra belongings the facility was storing. She said at that time FM #1 brought the concerns of Resident #29 not receiving his/her packages, and FM #1 said it violated federal law. SW #1 said she notified the Administrator, and they decided to have a meeting with FM #1. SW #1 said the care plan meeting took place on 1/15/25 and mail delivery concerns were discussed, and they reviewed Resident #29's purchase of clothing and extra clothes in the room. SW #1 said FM #1 brought up the Federal law of delivery of packages and FM #1 was assured Resident #29 would receive his/her packages going forward. During an interview on 2/07/25 at 10:35 A.M., the Corporate Nurse said she was not aware of FM #1's complaint that Resident #29 did not receive packages over Christmas until items were removed from his/her room. On 2/7/25 at 11:30 A.M., the surveyor reviewed Health Care Facility Reporting System (HCFRS) which from 12/24/2024 through 2/7/25 failed to indicate any incidents of alleged misappropriation of Resident #29's property was reported by the facility. 2. Resident #609 was admitted to the facility in March 2024. Review of the MDS assessment, dated 12/19/24, indicated Resident #609 scored 15 out of 15 on the BIMS indicating he/she was cognitively intact. During an interview on 2/4/25 at 9:35 A.M., Resident #609 said he/she was just going to call the Department of Public Health (DPH) and file a complaint of harassment for payment and for ease dropping on his/her private conversation he/she had with their spouse. Resident #609 said the Administrator continues to harass him/her for payment and he/she was told by his/her lawyer to pay what you can. During an interview on 2/4/25 at 8:55 A.M., the Director of Nurses (DON) was notified of Resident #609's alleged complaints of harassment and ease dropping on a phone conversation against the Administrator. The DON said she was aware of Resident #609's complaint of ease dropping but was not aware of the harassment for payment. During an interview on 2/05/25 at 9:13 A.M., the Corporate Nurse said she was aware of the financial concerns relating to Resident #609, but she was not aware he/she made allegations of harassment yesterday. During an interview on 2/05/25 at 9:26 A.M., the Administrator said she was made aware yesterday of Resident #609's complaint of harassment for non-payment against her. She said she is fully aware of Resident #609's current financial issues and last week she called the local police on Resident #609 after he/she received a 30-day discharge notice and then threatened her in the lobby. The Administrator said because she knows what is going on with Resident #609, she did not report the allegations of harassment to the state as they were not substantiated. During an interview on 2/05/25 at 2:01 P.M., Corporate Nurse said a complaint of harassment requires reporting and an investigation. On 2/7/25 at 11:30 A.M., the surveyor reviewed HCFRS which from 2/4/25 through 2/7/25 failed to indicate any incidents of alleged harassment towards Resident #609 were reported by the facility.

Based on interview and record review, the facility failed to investigate an allegation of misappropriation of personal property for one Resident (#29), in a total sample of 18 residents. Specifically, the facility failed to investigate Resident #29's allegation that his/her packages were not delivered over Christmas until his/her room had items removed. Findings include: Review of the facility's policy titled Abuse Policy, undated, indicated but was not limited to the following: -Policies and procedures regarding investigation and reporting of alleged violations of federal or state laws involving mistreatment, neglect, abuse, injuries of unknown source and misappropriation of residence property. -Such violations will also be reported to state agencies in accordance with existing state law. -The facility will investigate each alleged violation thoroughly and report the results of the investigation to the executive director or his or her designee, as well as to state agencies as required by state and federal law. -Protection: -If the suspected perpetrator is an employee, the executive director shall place the employee on immediate investigatory suspension while completing the investigation. Investigation of suspected resident abuse/mistreatment/misappropriation/neglect/injury of unknown origin 1. If a family member resident or staff reports an incident of abuse/mistreatment neglect, it is to be reported to the director of nursing or manager immediately in an incident/accident report is to be completed. 2. The supervisor is to initiate the following steps: Reporting: -a. An employee who suspects an alleged violation shall immediately notify the executive director or his/her designee. The executive director shall also notify the appropriate state agency in accordance with state law. b. The results of all investigations must be reported immediately to the Executive Director or his/her designee and to the appropriate state agencies as required by state law with initial reports submitted within two hours and follow up within (5) working days of the violation. Policy and procedure: investigation of suspected resident abuse/mistreatment/misappropriation/neglect/injury unknown origin: 1. If a family member, resident or staff reports an incident of abuse/mistreatment/neglect, it is to be reported to the director of nursing services or manager immediately in an incident/accident report is to be completed. 2. The supervisor is to initiate the following steps: a. Immediate investigation into the alleged incident. b. Interview staff member implicated. Get written statements. c. Interview other staff members. Employees should document incident in written narrative. d. Interview with resident or resident witnesses. Supervise it to document written statement from resident(s). e. All statements should include date and time of alleged incident, and date of time statement was written. f. Employee involved is to be sent home pending investigation. g. Immediate notification to the Director of Nurses and Executive Director. h. Send initial report to the Department of Public health via Virtual Gateway immediately but no more than two hours. i. Notify the social worker who will interview the resident. Document in social service progress note. j. Internal written reports are to be initiated during the shift the incident occurred, and complete it within 24 to 48 hours. k. Final report to be submitted to the Department of Public health via Virtual Gateway within (5) business days of the initial report. Resident #29 was admitted to the facility in June 2020. Review of the Minimum Data Set (MDS) assessment, dated 1/9/25, indicated Resident #29 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the Resident was cognitively intact. During a telephonic interview on 2/06/25 at 10:24 A.M., Family Member (FM) #1 (Resident #29's Health Care Proxy) said Resident #29 was upset and told him, he/she had 11 packages that were not delivered over Christmas until he/she got rid of stuff in his/her room. FM #1 said some of the packages contained Christmas presents for family members. FM #1 said he spoke with the woman in Activities and informed her that Resident #29's packages were not delivered, and it was illegal for them to withhold packages and cited Federal law chapter 8, section 1701 and 1702. During an interview on 2/06/25 at 11:00 A.M., the surveyor informed the Administrator of FM #1's concern of packages being withheld until extra items in Resident #29's room were removed. The Administrator said FM #1 had expressed his concerns to her about Resident #29 not receiving some packages and he did cite the Federal law to her during a meeting in January about mail delivery. The Administrator said she did not keep any notes on the conversations with FM #1 and referred the surveyor to check the social service notes. The Administrator said she did not investigate why Resident #29's packages were held in the business office and/or file a grievance. During an interview on 2/06/25 at 11:18 A.M., the Front Desk Receptionist (FDR), with the Administrator present, said Resident #29 was complaining about packages not being delivered over Christmas. The FDR said she told the Business Office Manager (BOM) about the complaints and never heard any more about the complaint. During an interview on 2/07/25 at 9:02 A.M., Social Worker (SW) #1 said she called FM #1 at the beginning of January and asked him to come in and pick up some of Resident #29's extra belongings the facility was storing. She said at that time FM #1 brought the concerns of Resident #29 not receiving his/her packages, and FM #1 said it violated federal law. SW #1 said she notified the Administrator, and they decided to have a meeting with FM #1. SW #1 said the care plan meeting took place on 1/15/25 and mail delivery concerns were discussed, and they reviewed Resident #29's purchases of clothing and extra clothes in the room. SW #1 said FM #1 brought up the Federal law of delivery of packages and FM #1 was assured Resident #29 would receive his/her packages going forward. The facility did not provide the surveyor with an investigation into FM #1's allegations of misappropriation of Resident #29's personal packages dating back to at least 1/15/25.

Based on observation, record review, and interview, the facility failed to provide dental services for one Resident (44), out of a total sample of 18 residents. Specifically, the facility failed to schedule a dental appointment for new dentures as requested by the Resident. Findings include: Review of the facility's policy titled [Facility Corporation] Dental Services, dated May 2023, indicated but was not limited to: Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. - If dentures are damaged or lost, Residents will be referred for dental services within three days. - If the referral is not made within three days, documentation will be provided regarding what is being done to ensure that the resident is able to eat and drink adequately while awaiting the dental services; and the reason for delay. Resident #44 was admitted to the facility in November 2023 with diagnoses including chronic obstructive pulmonary disease, dysphagia, and vitamin B12 deficiency anemia. Review of the Minimum Data Set (MDS), assessment, dated 11/12/24, indicated Resident #44 scored 11 out of 15 on the Brief Interview for Mental Status (BIMS) exam indicating moderate cognitive impairment. The MDS further indicated Resident # 44 requires supervision to clean, insert and remove dentures into and from the mouth. During an interview on 2/4/25 at 2:30 P.M., Resident #44 said his/her dentures were missing; they were no longer in the container on their bedside table. Resident #44 said a dental appointment needed to be scheduled. Review of the Health Drive Request for Service Form, dated 11/8/23, indicated Resident #44 had signed consent for dental services. Further review of the medical record failed to indicate that Resident #44 had a scheduled dental appointment to replace the missing dentures as requested. During an interview on 02/06/25 at 03:11 P.M., Resident #44 said he/she needed an appointment to replace his/her lost dentures. The Resident said he/she spoke to the Unit Manager about it approximately three weeks ago, but she never got back to him/her. During an interview on 02/07/25 at 02:13 P.M., Nurse #1 said management is responsible for scheduling appointments for the residents. During an interview on 02/07/25 at 02:23 P.M., Resident #44 said he/she had spoken to Unit Manager #1 about scheduling the dental appointment, but she had not given him/her a date yet. During an interview on 02/07/25 at 02:25 P.M., Unit Manager #1 said approximately three weeks ago Resident #44 requested to schedule a dental appointment. Unit Manager #1 said she did not make the appointment in accordance with the resident's request. On 2/7/25 at 3:27 P.M., the surveyor made the Administrator and the Director of Nurses aware of this incident as neither knew that Resident #44's dentures were missing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a resident group meeting, staff interviews, and document review, the facility failed to ensure grievances and concerns from the Resident Council were documented to ensure they were acted upon timely and included the facility response and rationale for response and to ensure residents were able to hold meetings without staff present unless they desired to invite staff. Findings include: Review of the facility's policy titled Resident Council Meetings, dated as last reviewed/revised [DATE], indicated but was not limited to the following: -The Activity Director shall be designated, if approved by the group, to serve as a liaison between the group and the facility's administration and any other staff members. -The designated liaison shall be responsible for providing assistance with facilitating successful group meetings and responding to written requests from the group. -The facility shall act upon concerns and recommendations of the Council, make attempts to accommodate recommendations to the extent practicable, and communicate its decisions to the Council. Review of the facility's Complaint/Grievance Policy and Procedure, dated [DATE], indicated but was not limited to the following: -All residents and their responsible party will have a mechanism to voice grievances and complaints to the Grievance Official in order to facilitate communication and timely resolution of the matter. -Voiced grievances (e.g. those about treatment, care, management of funds, lost clothing, or violation of rights) are not limited to a formal, written process and may include a resident's verbalized complaint to facility staff. -Staff shall complete a grievance form when resident makes a verbal complaint, if not completed by the complainant. Review of the Resident Council Minutes from [DATE] through [DATE] indicated but were not limited to the following: [DATE] -Meeting was facilitated and moderated by the Ombudsman. No staff members were present. No meeting minutes/notes were compiled. [DATE] -Attendance: Eight Residents, the Activities Director, and six additional staff members. -Review of Old Business: TOPIC: Lack of Communication between Residents and Certified Nursing Assistants (CNAs). STATUS: This is still an issue, there will be education taught on it. -Open Discussion: Laundry isn't coming back. -Concern: Lack of Communication. How will Manager address this: in-service and education with CNA staff. -Concern: Laundry has gone missing. How will Manager address this: We are working on a better solution for labeling and delivering personal (items) and asking family members to bring the personal (items) to us to be labeled before going to the rooms. Further review of the [DATE] Resident Council Minutes failed to indicate that the facility filed grievances for the missing laundry items on behalf of the residents. [DATE] -Attendance: 13 Residents, the Activities Director, and two additional staff members. -Review of Old Business: TOPIC: Some Resident's laundry has gone missing. STATUS: While this is still an issue, some resident's laundry has been found. TOPIC: Lack of Communication between Residents and Certified Nursing Assistants (CNAs). STATUS: This is still an issue. They are the same as before. -Open Discussion: Laundry issue is still a major factor. While some of it has been found, most articles of clothing have gone missing. -Concern: Lack of Communication. How will Manager address this: staff have been in-serviced on greeting/acknowledging residents when they enter rooms. Further review of the [DATE] Resident Council Minutes failed to indicate that the facility filed grievances for the missing laundry items on behalf of the residents, and there was no resolution to the residents' concerns of the lack of communication with the CNAs and the residents' concerns of missing laundry originally brought forward in [DATE]. [DATE] -Attendance: Six Residents, the Activities Director, the Ombudsman, and one additional staff member. -Review of Old Business: TOPIC: Some Resident's laundry has gone missing. STATUS: While this is still an issue, some resident's laundry has been found. TOPIC: Lack of Communication between Residents and Certified Nursing Assistants (CNAs). STATUS: This has been resolved. -Open Discussion: Laundry issue is still a factor. While some of it has been found, most articles of clothing have gone missing. -Concern: Laundry has gone missing. How will Manager address this: We are still working on labeling the new clothes. (There are) a lot of no name clothes that we are trying to find the owners. Further review of the [DATE] Resident Council Minutes failed to indicate that the facility filed grievances for the missing laundry items on behalf of the residents, and there was no resolution to the residents' concerns of missing laundry originally brought forward in [DATE]. [DATE] -Attendance: 18 Residents, the Activities Director, and three additional staff members. -Review of Old Business: TOPIC: Some Resident's laundry has gone missing. STATUS: This has been completely resolved. All articles of clothing have been returned. -Open Discussion: no issues. On [DATE] at 1:30 P.M., the surveyor held a Resident Council Meeting with 11 residents in attendance. During the meeting the residents brought forth the following concerns: -They said during the meetings the Activity Director talks about the previous meeting and goes over their complaints, but they don't really address them. -They said staff are not supposed to come to our meetings, but they always want to, so they do. It was good when they did not come because the other residents would talk about concerns, but when they are all at the meeting, no one says anything, because they don't want the staff to go after them. They said the staff that come are not invited, they just want to come, so they do. They said there was one time we had a meeting with the Ombudsman, and we had to go around and tell everyone no staff was allowed. -4 of 11 Residents said they have had a lot of laundry go missing and the facility doesn't do anything about it. They do not resolve it, follow up with you, or reimburse you for the missing laundry. They said it's just gone. -They said sometimes they give you old unlabeled things, but they are not what went missing, they are donated or from someone that died. -They said the laundry is terrible, they don't resolve any issues, your stuff is just gone. -Resident #6 said he/she has had multiple missing clothing items and his/her cell phone has been missing for months and none of it has been addressed. -Resident #29 said they are missing a lot of clothing, amounting to hundreds of dollars, and a new bottle of perfume and nothing has been done about any of it. During an interview on [DATE] at 11:58 A.M., the Ombudsman said staff is always present at the Resident Council Meetings and she has reminded the group they can meet without staff and that the staff that attends the meeting should be invited by the group and not be inviting themselves. During an interview on [DATE] at 2:06 P.M., the Activity Director said she runs the meetings and sometimes her assistant takes the notes. She said staff is usually present, but they are invited. She said the Department Heads will address the concerns voiced by the residents, although missing laundry is the biggest concern, and they never come. She said the residents voice a lot of complaints about missing laundry. She said sometimes we find it in the no name pile. She said they are trying to make sure everything is labeled and will give them things from the donation pile if they need something. She said she will jot it down on a scrap of paper and look for things, but if she can't find it, the resident must take it up with laundry. She said she does not log anything that is reported missing, does not file a grievance on the resident's behalf, fill out a missing item form, or anything like that, and she never has. She said she thinks the Administrator deals with it and she thinks the facility pays for lost items but was unsure of the process. During an interview on [DATE] at 4:54 P.M., the Administrator said she did not know of specific things reported missing at Resident Council, but she would expect the Activity Director to fill out grievance forms and notify laundry of missing items. She said missing items are not always elevated to a grievance, but they should be, as it is part of the grievance process. She said if unable to find the missing item within 72 hours there should be a form filled out and it should be part of the grievance book. She said the Missing Item Forms are all part of the grievance book, and she did not have any for concerns that came from Resident Council.

4. Resident #29 was admitted to the facility in June 2020. Review of the MDS assessment, dated 1/9/25, indicated Resident #29 scored 15 out of 15 on the BIMS which indicated the Resident was cognitively intact. During an interview on 2/04/25 at 9:09 A.M., Resident #29 said Laundry has lost over $600 worth of his/her clothes. On 2/05/25 at 3:50 P.M., the surveyor reviewed the Grievance book for 2024 and 2025 and found only one grievance filed on behalf of Resident #29 which included: -Grievance filed 7/15/24 -Description of Complaint: Resident was missing a pair of pants not found, but all clothes will be labeled at the front desk and distributed to residents. -Summary Statement: Education was done for Resident and encouraged to send clothes to son's house, Salvation Army or throw out. -Steps Taken to Investigate: All clothes that are mailed to patients will be labeled upon arrival. -Summary of Findings (to include statement of whether grievance was confirmed or not confirmed: Patient has lost 50 lbs. (pounds) and will need to process old clothes that are too large and label all. -Corrective Action Taken or To Be Taken: Lost clothing has reduced to 0 for this resident. -Resolution Acceptable to Resident/Responsible person: The boxes yes or no were not checked and the date resolved was left blank. The Staff Development Coordinator (SDC) and Director of Nursing (DON) with Resident; he/she appears to accept the explanation. No evidence of grievance was resolved. During an interview on 2/05/25 at 4:52 P.M., Resident #29 said he/she had a meeting with the Administrator about his/her missing clothing, and he/she was told to donate some clothes. During an interview on 2/06/25 at 11:00 A.M., the Administrator said Resident #29's clothes were going missing, but he/she has had nothing missing for the last three months. The Administrator said prior to that we could not keep an inventory because he/she was receiving packages three times a week. The surveyor reviewed the grievance filed 7/15/2024 with the Administrator who said she was not aware of any other missing clothes since the incident of the missing pants in July 2024. The Administrator said the grievance written for the pants is weak and there was no resolution for the missing pants. The Administrator said there were no other grievances filed for missing clothes for Residents #29. During an interview on 2/04/25 at 9:09 A.M., Resident #29 said he/she just recently bought $300 worth of new clothes and is already missing a pink sweatshirt with the head of a cat and their paws on the front of it. Resident #29 said it has been missing for weeks. During an interview with the Director of Laundry and Laundry Staff #1 on 2/06/25 at 12:45 P.M., Laundry Staff #1 said she had been aware for weeks that Resident #29 was missing a pink sweatshirt with a cat's face and their paws on the front of it. Laundry Staff #1 said Resident #29 showed her a picture of the missing sweatshirt which he/she has been looking for and unable to find. Laundry Staff #1 showed the surveyor a picture of the missing sweatshirt on her phone. Laundry Staff #1 said if she can't find an item the resident is missing, then she reports it to the Activity Director. After that she does not know what will happen. During a telephonic interview on 2/06/25 at10:24 A.M., Family Member (FM) #1 (Resident #29's Health Care Proxy) said he has been in contact with the facility regarding at least 5-6 pieces of missing clothing, but you (the surveyor) would have to speak directly to Resident #29 to find out how much clothing is missing. FM #1 said they have never been reimbursed for any of the missing clothing, and it is simple if they (the facility) just labelled the clothing there would not be a problem. During an interview on 2/06/25 at 2:55 P.M., the Activity Director said she was aware Resident #29 was missing the pink sweatshirt with a cat face on the front for a couple of months. She said she never filed a grievance for Resident #29, but she still looks for the sweatshirt. Based on observation, record review, and interview, the facility failed to follow the grievance process for resident concerns reported at Resident Council, to ensure all grievances filed were thoroughly investigated with a documented resolution, and for two Residents (#6 and #29), out of a total sample of 18 residents. Specifically, the facility failed: 1. To ensure concerns brought forth during Resident Council including multiple concerns for missing laundry had a grievance filed on their behalf and were investigated through the grievance process; 2. To ensure grievances filed by residents/resident representatives/family/friends were thoroughly investigated with a documented resolution; 3. For Resident #6, to initiate an investigation when his/her cell phone was determined to be missing, file a grievance for the missing cell phone, and follow the grievance process; and 4. For Resident #29, to ensure a grievance was filed for missing clothing and was investigated through the grievance process with an adequate resolution. Findings include: Review of the facility's policy titled Resident Council Meetings, dated as last reviewed/revised December 2024, indicated but was not limited to the following: -The Activity Director shall be designated, if approved by the group, to serve as a liaison between the group and the facility's administration and any other staff members. -The designated liaison shall be responsible for providing assistance with facilitating successful group meetings and responding to written requests from the group. -The facility shall act upon concerns and recommendations of the Council, make attempts to accommodate recommendations to the extent practicable, and communicate its decisions to the Council. Review of the facility's Complaint/Grievance Policy and Procedure, dated September 2023, indicated but was not limited to the following: -All residents and their responsible party will have a mechanism to voice grievances and complaints to the Grievance Official in order to facilitate communication and timely resolution of the matter. -Voiced grievances (e.g. those about treatment, care, management of funds, lost clothing, or violation of rights) are not limited to a formal, written process and may include a resident's verbalized complaint to facility staff. -Staff shall complete a grievance form when a resident makes a verbal complaint, if not completed by the complainant. -The Grievance Official, or designee in his/her absence, will review the grievance within 24-48 hours. -The Grievance Official will complete the Grievance form to include date received, summary statement, steps taken to investigate, summary of findings, confirmation or no confirmation of grievance, corrective action taken or to be taken, and date written resolution was issued if requested. -The Grievance Official or Social Service Department will review the findings with the resident/responsible party and provide written resolution if requested. 1. Review of the Resident Council minutes from August 2024 through January 2025 indicated but were not limited to the following: SEPTEMBER 2024 Concern: Laundry has gone missing. NOVEMBER 2024 Concern: Laundry issue is still a major factor. While some of it has been found, most articles of clothing have gone missing. DECEMBER 2024 Concern: Resident's laundry has gone missing. While this is still an issue, some resident's laundry has been found. JANUARY 2025. Concern: Some Resident's laundry has gone missing. Status: This has been completely resolved. All articles of clothing have been returned. The facility failed to file grievances on behalf of the residents for the missing laundry items in September 2024, and November 2024 through January 2025. On 2/5/25 at 1:30 P.M., the Surveyor held a Resident Council Meeting with 11 residents in attendance. During the meeting, the residents brought forth the following concerns: -10 of 11 residents said they did not know what a grievance form was or how to file a grievance. -4 of 11 residents said they have had a lot of laundry go missing and the facility doesn't do anything about it. They do not resolve it, follow up with you, or reimburse you for the missing laundry. They said it's just gone. -They said sometimes they give you old unlabeled things, but they are not what was missing, they are donated or from someone that died. -They said the laundry is terrible, they don't resolve any issues, your stuff is just gone. During an interview on 2/6/25 at 2:06 P.M., the Activity Director said the Residents voice a lot of complaints about missing laundry. She said she will jot it down on a scrap of paper and look for things, but if she can't find it the Resident has to take it up with laundry. She said she does not log anything that is reported missing, does not file a grievance on the resident's behalf, fill out a missing item form or anything like that, and she never has. She said she thinks the Administrator deals with it and she thinks the facility pays for lost items but was unsure of the process. During an interview on 2/6/25 at 4:54 P.M., the Administrator said she did not know of specific things reported missing at Resident Council, but she would expect the Activity Director to fill out grievance forms and notify laundry of missing items. She said missing items are not always elevated to a grievance, but they should be, as it is part of the grievance process. She said if unable to find the missing item within 72 hours there should be a form filled out and it should be part of the grievance book. She said the Missing Item Forms are all part of the grievance book, and she did not have any for concerns that came from Resident Council. 2. Review of the Grievance Book from January 2024 through January 2025 indicated but was not limited to the following: JANUARY 2024 - 1 grievance on the log. -1/24/24 indicated Missing Dentures, located in room. Form failed to indicate family was updated on resolution. MARCH 2024 - 3 grievances on the log, but only 2 were in the book. -3/10/24 indicated education would be done with staff, and the education record attached was dated 10/24/24. Form failed to indicate resident was updated on resolution. MAY 2024- 6 grievances on the log. -5/10/24 indicated missing clothing, family to bring in receipts for reimbursement. Resolution indicated receipts provided did not contain dates. It failed to indicate resident/family was reimbursed. Form failed to indicate resolution was discussed and acceptable to the resident/family. -5/16/24 indicated phone was broken. Form failed to indicate resolution was discussed and acceptable to the resident/family. -5/20/24 indicated phone was broken. Form failed to indicate resolution was discussed and acceptable to the resident/family. JULY 2024 - 1 grievance on the log. -7/15/24 indicated missing pants. Not found. Summary indicated education regarding labeling of clothing. Form failed to indicate resolution was discussed and acceptable to the resident/family. AUGUST 2024 - 2 grievances on the log. 3 forms in the book. -8/11/24 indicated family reported resident drowsy and not answering the phone. Form failed to indicate resolution was discussed and acceptable to the resident/family. -8/11/24 indicated concern with wounds. Form failed to indicate resolution was discussed and acceptable to the resident/family. -8/28/24 indicated crumbs in drawer. Form failed to indicate resolution was discussed and acceptable to the resident/family. NOVEMBER 2024 - No log. 4 grievances in the book. -11/5/24 indicated food was thrown away in container. Summary indicated educate families on policy. Staff in-service attached. Form failed to indicate resolution was discussed and acceptable to the resident/family. -11/15/24 indicated resident menu complaint. Form failed to indicate resolution was discussed and acceptable to the resident/family. -11/29/24 indicated family complaint of menu. Form failed to indicate resolution was discussed and acceptable to the resident/family. DECEMBER 2024 - No log. 1 grievance in the book. -12/23/24 indicated a cell phone was missing. Form failed to indicate phone had been located or that resolution was discussed and acceptable to the resident/family. JANUARY 2025 - 3 grievances on the log. -1/24/24 indicated a missing item reported by family. Form failed to indicate resolution was discussed and acceptable to the resident/family. -1/30/24 indicated complaint of harassment. Form failed to indicate resolution was discussed and acceptable to the resident/family. During an interview on 2/6/25 at 4:54 P.M., the Administrator said they discuss grievances at morning meeting, they go to the Social Worker and then they come back to my office to note the resolution and sign off on it as completed. They all should have a resolution noted and be signed off as completed and they are not. The surveyor reviewed a grievance form from the grievance book dated 12/23/24 regarding a missing cell phone with the Administrator. The form failed to include a summary of the findings and failed to include a resolution. During an interview on 2/6/25 at 4:54 P.M., the Administrator said she did not know the status of the grievance for the missing phone or if the family had been updated. 3. Resident #6 was admitted to the facility in December 2023. Review of the Minimum Data Set (MDS) assessment, dated 12/19/24, indicated he/she scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. On 2/5/24 at 1:30 P.M., the surveyor held a Resident Council Meeting with 11 residents in attendance. During the meeting, Resident #6 said he/she has had multiple missing clothing items, and his/her cell phone has been missing for months and none of it has been addressed. During an interview on 2/6/25 at 2:00 P.M., Certified Nursing Assistant (CNA) #2 said Resident #6 had a cell phone since at least March 2024 when she started working at the facility, but she has not seen it for a couple months. She said he/she was accusing us of stealing it, everyone knew about it, but we did not find it. Additionally, she said Resident #6 was vocal about it at first but, she has not heard much about it recently, and did not know the status of the investigation. During an interview on 2/6/25 at 3:45 P.M., Resident #6 said the cell phone has been missing for a couple months. He/she said the phone was on the bed but when he/she returned from the bathroom it was gone. Resident #6 said he/she told the nurse at the desk, but they didn't care. He/she said nothing ever came of it. Additionally, he/she said there were multiple missing undergarments and was told he/she could just buy new ones and was shrugged off when reporting two blouses that were missing around Thanksgiving. Resident #6 said, Things just disappear, so I don't have anything nice anymore and won't buy any new things. During an interview on 2/6/25 at 4:05 P.M., CNA #2 said laundry is missing a lot. She said they look for it and if they don't find it, it's reported to the Unit Manager and she handles it. She said she was not aware of anything currently missing for Resident #6. During an interview on 2/6/25 at 4:25 P.M., Unit Manager #1 said if something is reported missing, they do an initial search and then fill out a Missing Item Form. She said they used to fill out the Grievance Form but now there is a Missing Item Form. She said it is all part of the grievance book, and the Administrator handles it. She said missing laundry is frequently a concern but was not aware of Resident #6 missing any laundry. Additionally, she said Resident #6's cell phone has been missing for a few months and did not know the status of the investigation. She said the Missing Item Form would have been filled out when it was deemed missing and then turned into the office. She said she does not keep a copy, nor follow up on the investigation after the forms are turned in. Additionally, she said there were no progress notes indicating a search or resolution for the missing cell phone in the medical record. During an interview on 2/6/25 at 4:54 P.M., the Administrator said she did not know Resident #6 was missing clothing or a cell phone. She said missing items are not always elevated to a grievance, but they should be, as it is part of the grievance process. She said if unable to find the missing item (clothes) within 72 hours there should be a form filled out and it should be part of the grievance book. She said things like cell phones should be reported right away. The Administrator said the Missing Item Forms are all part of the grievance book, and she did not have any for Resident #6.

Based on interviews and record review, the facility failed to ensure one Resident (#64), out of a total sample of 18 residents, received care and treatment to promote healing of pressure injuries. Specifically, the facility failed to implement wound care orders per physician recommendations for a Stage I pressure injury (localized area of non-blanchable redness on intact skin, usually over a bony prominence) to the left medial knee. Findings include: Review of the facility's policy titled Prevention of Pressure Ulcers/Injuries, dated as last revised May 2024, indicated but was not limited to the following: -Identify any signs of developing pressure injuries (non-blanchable erythema) -Inspect pressure points -Evaluate, report and document potential changes in the skin -Review the interventions and strategies for effectiveness Review of the facility's policy titled Charting and Documentation, dated as last revised May 2023, indicated but was not limited to the following: -All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, should be documented in the resident's medical record. -The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care -The following information is to be documented in the resident medical record: -Objective observations -Treatments or services performed -Progress toward or changes in the care plan goals and objectives -Documentation of procedures and treatments will include care-specific details Review of the facility's policy titled Skin Integrity Management, undated, indicated but was not limited to the following: -Residents with actual skin breakdown are identified, assessed, and provided treatment according to standards of practice. -Refer to wound MD/wound clinic as appropriate. -Implement wound care modalities Review of the Wound Clinic Services Agreement, dated January 2024, indicated but was not limited to the following: Facility Responsibilities: -Provide a dedicated nurse to round and communicate with the Provider. -Inform the resident's primary care provider of Provider's recommendation within 24 hours. -Discuss recommendations/wound care plan with the Provider on the day of rounds. Resident #64 was admitted to the facility in December 2023 with diagnoses including type II diabetes, severe protein calorie malnutrition, and pressure ulcers. Review of the Minimum Data Set (MDS) assessment, dated 1/15/25, indicated Resident #64 was mildly cognitively impaired as evidenced by a score of 12 out of 15 on the Brief Interview for Mental Status (BIMS). Additionally, Resident #64 had skin treatments and was dependent on staff for bed mobility. Review of the comprehensive care plan indicated but was not limited to the following: -Resident has a stage 1 pressure ulcer of the left medial knee related to immobility (1/16/25) -Administer treatments as ordered and monitor for effectiveness (1/16/25) Review of the medical record indicated Resident #64 was followed by a Wound Care Physician at the facility. Review of the Wound Evaluation and Management Summary, dated 1/15/25, indicated but was not limited to the following: -Stage 1 Pressure Wound of the Left Medial Knee measured 1.0 x 1.0 x not measurable centimeters (cm) -Dressing treatment plan: Skin prep once daily for 30 days. -Additional wound detail: This is a stage 1 pressure injury at the site of prior stage 2 wound -Pillow between knees -Additional information: The patient is resistant to repositioning and using a pillow between her knees Review of the skin/wound note, dated 1/16/25, written by the Assistant Director of Nursing (ADON), indicated Resident #64 was seen by wound physician and an order was received to apply skin prep to the stage 1 pressure injury on the left medial knee daily. Review of the January and February 2025 Physician's Orders/Treatment Administration Record (TAR) failed to indicate an order was implemented to apply skin prep to the stage 1 pressure injury of the left medial knee. Review of the Wound Evaluation and Management Summary, dated 1/21/25, indicated but was not limited to the following: -Stage 1 Pressure Wound of the Left Medial Knee measured 1.0 x 1.0 x not measurable cm -Dressing treatment plan: Skin prep once daily for 30 days. -Pillow between knees -Additional information: The patient is resistant to repositioning and using a pillow between her knees Review of the skin/wound note, dated 1/22/25, written by the ADON, indicated Resident #64 was seen by wound physician and to continue previously ordered treatment to the stage 1 pressure injury of the left medial knee. Review of the January and February 2025 Physician's Orders/TAR failed to indicate an order was implemented to apply skin prep to the stage 1 pressure injury of the left medial knee. Review of the Wound Evaluation and Management Summary, dated 2/4/25, indicated but was not limited to the following: -Stage 2 Pressure Wound of the Left Medial Knee measured 0.8 x 0.9 x 0.02 cm -Dressing treatment plan: gauze island with border apply every two days for 30 days -Discontinue skin prep -Pillow between knees -Additional information: The patient is resistant to repositioning and using a pillow between her knees Review of the skin/wound note dated 2/5/25, written by Unit Manager (UM) #1, indicated Resident #64 was seen by wound physician and an order was received to cleanse area with normal saline, cover with bordered gauze island dressing, change every two days to the stage II pressure injury of the left medial knee. Review of the February 2025 Physician's Orders/TAR indicated the following: -Left medial knee: Wash with normal saline, pat dry. Apply gauze island with border every other day for wound healing. During an interview on 2/6/25 at 10:09 A.M., UM #1 said she just started completing wound rounds on her unit with the wound physician this week. She said the wound physician communicates his recommendations verbally and then sends them over to the facility electronically the same day. UM #1 said she then notifies the medical director of the recommendations and documents the information in a nursing note. UM #1 said Resident #64's treatment was updated to apply a dressing for protection of the area and she implemented the new order yesterday. She said there was no other treatment order in place to the area, only to encourage a pillow between the knees. During an interview on 2/6/25 at 10:25 A.M., Nurse #1 said she provides care to Resident #64 on a consistent basis. She said Resident #64 did not have an order to apply skin prep to the left medial knee. Nurse #1 said she would place a pillow between the Resident's knees and encourage him/her to keep it in place. During an interview on 2/6/25 at 1:49 P.M., ADON said she completed rounds with the wound physician until last week. She said she would remove the dressings, and the wound physician would take measurements of the areas and give her recommendations verbally. She said she would document his verbal recommendations on a rounding sheet which included current treatment orders. The ADON said the wound evaluations are then sent over electronically to the medical record system. She then implements the orders, and documents it in a nursing note. She said the medical director defers treatment plans to the wound physician. The ADON and the surveyor reviewed Resident #64's wound evaluations, dated 1/15/25 and 1/22/25, nursing progress notes, and physician's orders in the medical record. She said Resident #64 was supposed to have an order to apply skin prep to the left medial knee, and documented it in her nursing note, however it was never put into place. The ADON said the Resident has an abundance of open areas, and it must have been an oversight. The ADON said she was going to notify the physician of the error. During an interview on 2/6/25 at 2:12 P.M., the Director of Nursing (DON) said her expectations are for the nurse who is completing rounds with the wound physician to transcribe and implement all the treatment orders on the day they are received. She said the order was never implemented as it should have been.

Based on record review and interview, the facility failed to ensure sufficient staffing to assure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed to have sufficient staffing on the weekends as indicated on the payroll-based journal (PBJ) report submitted to Centers for Medicare and Medicaid Services (CMS) for Fiscal Year (FY) Quarter 4, 2024. Findings include: Review of the PBJ Staffing Data Report, CASPER Report 1705D FY Quarter 4, 2024 (July 1 - September 30) indicated the following: This Staffing Data Report identifies areas of concern that will be triggered (e.g., requires follow-up during the survey). -Excessively Low Weekend Staffing - Triggered = Submitted Weekend Staffing data is excessively low. Review of the facility's healthcare Facility Assessment (FA), revised 1/7/2025, indicated the following: Part 1: Resident Profile -Number of residents you are licensed to provide care for - 98 -Average daily census: 88-92 Staffing Plan 3.2 Total Number Needed or Average or Range of Staff: - Licensed nurses (LN) providing direct care: 1:x LN ratio Days and Evenings. - Direct Care Staff (Nurse Aides): 1:x ratio The facility failed to indicate updated staffing patterns on the FA. Review of the facility's previous healthcare FA, revised 10/6/2023, last reviewed 10/29/2024, indicated the following: Part 1: Resident Profile -Number of residents you are licensed to provide care for - 99 -Average daily census (ADC): 85-92 -Current ADC: 72 Staffing Plan 3.2 Total Number Needed or Average or Range of Staff: - Licensed nurses (LN) providing direct care: RN or Unit Manager 1 for each unit (2 units Monday-Friday) Staff Nurse: 2 for each unit per shift; 1 on 11pm -7am. - Direct Care Staff (Nurse Aides-CNA): Nights 2 per unit. Review of the as worked staffing schedules and time sheets provided by the Scheduling Coordinator for licensed nurses and nurse aides during FY Quarter 4, 2024, indicated the total number of LN and nurse aides was below the needed or average range, per the FA, for the following dates: 7/6/24 -Total Census 74 -7pm-11pm one nurse on Popponessett Unit (one less than the minimum required) 7/13/24 Total Census 74 -7pm-11pm one nurse on Popponessett Unit (one less than the minimum required) 7/14/24 Total Census 74 -11pm-7am three total CNAs (one less than the minimum required) 7/20/24 Total Census 78 -7pm-11pm one nurse on Popponessett Unit (one less than the minimum required) 7/21/24 Total Census 79 -7pm-11pm one nurse on Popponessett Unit (one less than the minimum required) 7/27/24 Total Census 78 -7pm-11pm one nurse on Popponessett Unit (one less than the minimum required) -11pm-7am three total CNAs (one less than the minimum required) 7/28/24 Total Census 80 -7pm-11pm one nurse on Popponessett Unit (one less than the minimum required) 8/2/24 Total Census 76 -11pm-7am two total CNAs (two less than the minimum required) 8/10/24 Total Census 75 -11pm-7am two total CNAs (two less than the minimum required) -7pm-11pm one nurse on Popponessett Unit (one less than the minimum required) 8/11/24 Total Census 74 -7pm-11pm one nurse on Popponessett Unit (one less than the minimum required) 8/17/24 Total Census 83 -7pm-11pm one nurse on Popponessett Unit (one less than the minimum required) 8/18/24 Total Census 81 -11pm-7am three total CNAs (one less than the minimum required) 8/24/24 Total Census 87 -11pm-7am one CNA with one trainee (three less than the minimum required) 8/25/24 Total Census 87 -7pm-11pm one nurse on Popponessett Unit (one less than the minimum required) 8/28/24 Total Census 89 -11pm-7am three total CNAs (one less than the minimum required) 8/31/24 Total Census 89 -11pm-7am two total CNAs (two less than the minimum required) -7pm-11pm one nurse on Popponessett Unit (one less than the minimum required) 9/1/24 Total Census 90 -7pm-11pm one nurse on Popponessett Unit (one less than the minimum required) 9/7/24 Total Census 84 -7pm-11pm one nurse on Popponessett Unit (one less than the minimum required) 9/22/24 Total Census 83 -7pm-11pm one nurse on Popponessett Unit (one less than the minimum required) 9/28/24 Total Census 83 -7pm-11pm one nurse on Popponessett Unit (one less than the minimum required) 9/30/24 Total Census 83 -11pm-7am three total CNAs (one less than the minimum required) During an interview on 2/6/25 at 2:00 P.M., the Director of Nurse (DON) said with a Census of 70-80 our staffing pattern on the 3pm-11pm shift would be 2 nurses on each unit and on 11pm-7am shift the staffing pattern would be 2 CNAs on each unit. During an interview on 2/7/25 at 11:33 A.M., the Staffing Coordinator said on a typical day we staff 2 nurses on each unit on the 3pm-11pm shift and 2 CNAs on each unit on the 11pm-7am shift. She said if the census is lower than 70 then they will adjust. She said if there is a call out that can't be covered someone will stay late and/or come in early to cover the shift. She said occasionally there are only 3 CNAs on at night due to call ins and one will float to the other unit to help. She said it's not ideal, but it happens sometimes. She said there should never be one CNA on each unit and did not know how that happened. She said there were a lot of call ins during this time frame which made the schedule difficult to manage. Additionally, she said there is still a hole in the nursing schedule and the 7pm-11pm shift is hard to cover. She said it never used to be like that, but it has been for a while. She said she has been able to cover it more often than during the time frame reviewed. She said sometimes someone will stay until 9:30/10:00pm and leave when it's quiet, but not always, and not on these days, it appears both nurses left between 7pm and 7:30pm on these days. She said the weekend nurse working 7pm-7am was alone after 7pm. She said she tries to schedule a desk nurse to cover it, but she cannot always do that or sometimes the on-call nurse will come in, but during this time frame the previous DON would not even answer the phone. During an interview on 2/7/25 at 4:40 P.M., the Administrator said she was unsure why the staffing pattern did not carry over to the updated FA. She said the staffing pattern is the same as previously noted, 2 staff nurses on each unit for 3pm-11pm shift and there should be 2 CNAs on each unit on the 11pm-7am shift for the census that we have, if the census drops then we would adjust staffing accordingly. She said occasionally due to call out there may only be 3 CNAs in the building on 11pm-7am shift and they would have to help each other, but there should never just be one on each unit. During an interview on 2/7/25 at 4:50 P.M., the DON said if there is a hole in the schedule due to call ins generally, they would piece it together by having one nurse stay late and one come in early. She was unable to speak to FY Quarter 4 as she was not employed by the facility at that time. Additionally, she said there should never be just one CNA on each unit, someone should have been mandated to stay.

Based on record review and interview, the facility failed to utilize the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, with no nurse staffing waivers in place as required, placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurse Aides (CNA) that the RN was responsible for overseeing with the provision of resident care. Specifically, the facility failed to provide RN services on 1/11/25 and 1/12/25. Findings include: Review of the facility's policy titled Staffing, undated, indicated but was not limited to the following: -Facility maintains adequate staffing on each shift to ensure that our residents' needs and services are met based on Facility Assessment. Licensed nursing staff are available to provide and monitor the delivery of care services. Review of the as worked nursing schedules for 1/6/25 through 2/6/25 indicated but was not limited to the following: -Saturday, 1/11/25, there was no RN coverage for the 24-hour period. -Sunday, 1/12/25, there was no RN coverage for the 24-hour period. During Entrance Conference on 2/4/25 at 9:02 A.M., the Administrator said the facility did not have any nurse staffing waivers. During an interview on 2/6/25 at 2:00 P.M., the Administrator said there should be RN coverage for at least 8 hours every day. During an interview on 2/7/25 at 11:33 A.M., the Scheduling Coordinator said there should be an RN working every day and on 1/11/25 and 1/12/25 the RN called in and we must not have been able to get another one, because we did not have RN coverage on either of those days. During an interview on 2/7/25 at 4:50 P.M., the Director of Nurses said there should be RN coverage for at least 8 hours every day and she was not aware on 1/11/25 or 11/12/25 the facility did not have RN coverage.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had new physicians orders for wound care treatment to newly developed pressure injuries, the Facility failed to ensure they maintained a complete and accurate medical record when nursing failed to transcribe wound care orders that were obtained on 04/29/24 and 04/30/24, onto his/her Treatment Administration Record (TAR). Findings include: Review of the Facility's policy, titled Skin Integrity Management, dated December 2023, indicated the following: -Residents with actual skin breakdown are identified, assessed and provided treatment according to standards of practice; -perform and document wound assessment upon initial identification of altered skin integrity; -develop a comprehensive care plan to include wound treatments; -document all treatments per facility policy. Review of the Facility's policy, titled Medication and Treatment Order and Administration, undated, indicated that orders for treatments will be consistent with principles of safe and effective order writing. The Policy indicated that verbal orders must be recorded immediately in the resident's chart by the person receiving the order. Review of the Facility's policy, titled Charting and Documentation, dated May 2023, indicated the following: -all services provided to the resident, progress toward the care plan goals, or changes in the resident's physical, functional or psychosocial condition, shall be documented in the resident's medical record; -objective observations, treatments and changes in the resident's condition shall be documented in the resident medical record; -documentation of treatments will include care-specific details including: date and time treatment was provided, name and title of the individual who provided the care, assessment data obtained during the treatment, how the resident tolerated the treatment, notification of family, physician and the signature and title of the individual documenting. Resident #1 was admitted to the Facility in March 2018, diagnoses included dementia, chronic obstructive pulmonary disease, polyneuropathy, cardiac pacemaker, chronic kidney disease -stage 3, palliative care, embolism and thrombosis of deep veins of left upper extremity and peripheral vascular disease. Review of Resident #1's Nursing Progress Note, written by Nurse #1, dated as a late entry for 04/29/24, indicated Resident #1 was noted with areas (of skin breakdown) on the top of his/her right and left great toe, areas on his/her right and left heels and an area to his/her right ankle. During an interview on 05/29/24 at 1:00 P.M., Nurse #1 said that on 04/29/24 during the day shift (7:00 A.M. through 3:00 P.M.) she was notified that Resident #1 had open areas to his feet. Nurse #1 said that she assessed Resident # 1's wounds and noted that he/she had areas of skin breakdown to his/her right and left heel and right ankle, and his/her left and right great toes had scabs on them. Nurse #1 said that she notified the Nurse Practitioner (NP), who gave her treatment orders for wound care and that an order for a wound consultation was also given to her by the NP. Nurse #1 said she performed the treatments to Resident #1's wounds on 04/29/24. Nurse #1 said she could not remember what wound care treatment orders were that the NP gave her, but said she believed she had transcribed them into Resident #1's Electronic Medical Record (EMR) Point Click Care (PCC). Review of Hospice Skilled Nurse Progress Note, dated 04/30/24, indicated that Resident #1 was seen to reassess bilateral heels, a wedge cushion was added to the end of bed between mattress and foot board, and heel protectors applied. The Hospice Note included the following recommendations were provided related to his/her wound care: -normal saline cleanse to bilateral heels and left great toe, apply xeroform (a sterile occlusive, non-adhering protective dressing impregnated with a petrolatum blend) cover with a dry protective dressing and to change dressing daily; -apply skin prep (water-proof liquid that forms a transparent film over the skin to protect it from possible irritation) to right lateral malleolus (ankle) and right great toe twice a day. The Note indicated that the recommendations were reviewed with Nurse #1 and that Resident #1 was to be seen by the wound physician. During an interview on 06/03/24 at 10:44 A.M., the Hospice Nurse said that on 04/30/24, she assessed Resident #1's wounds, notified the physician (who was Resident #1's physician at the Facility as well as the Hospice Medical Director) of the new wounds, obtained orders for wound care, performed the treatments to the wounds and reviewed everything with Nurse #1. The Hospice Nurse said that the Facility Nurse (Nurse #1) was responsible for transcribing the wound orders into the EMR. Review of Resident #1's Physician's Orders, dated 4/29/24, indicated there was no documentation to support that the telephone orders that were given by the NP to Nurse #1 on 4/29/24 for the treatment of Resident #1's right and left ankle, right and left great toes and right medial ankle were transcribed in Resident #1's EMR. Review of Resident #1's Physician Orders, dated 4/30/24, indicated the following: - bilateral heel treatment: clean with normal saline, pat dry, apply xeroform to affected area only, cover with a dry protective dressing daily; -right ankle and left big toe blister: cleanse with normal saline, pat dry, apply wound gel, cover with dry protective dressing daily; -apply skin prep to right big toe twice daily. However, review of Resident #1's Treatment Administration Record (TAR) for the month of April 2024, indicated there was no documentation to support that a physician's orders for wound care to his/her right and left heels, to his/her right and left great toes and right ankle were transcribed onto the TAR on 04/29/24 by Nursing. Further review of Resident #1's April 2024 TAR indicated there was no documentation to support that the physician's orders for wound care to his/her right and left heels, to his/her left great toe and right ankle were transcribed onto the TAR on 04/30/24, by Nursing. During an interview on 06/05/24 at 10:39 A.M., the Director of Nurses (DON) said that it was her expectation that nursing write a telephone order for wound treatments and transcribed the wound care orders that were obtained on 04/29/24 and 04/30/24 into Resident #1's EMR (which included the TAR).

Based on interview, policy review, and record review, the facility failed to follow their policy and track grievances through the conclusion, lead investigations, and review findings with the resident/responsible person for one Resident (#57), out of a total sample size of 20 residents. Findings include: Review of the facility's policy titled Complaint Grievance Policy and Procedure, dated September 2023, indicated but was not limited to the following: -All residents and their responsible representative will have a mechanism to voice grievances and complaints to the grievance official in order to facilitate communication and timely resolution of the matter. -Residents and/or their representatives shall complete the form. -If a resident is unable to complete the form, a staff member shall assist them. -Staff shall complete a grievance form when residents or responsible representatives make verbal complaints, if not completed by the complainant. -Completed forms should be forwarded to the grievance official and notify the Executive Director. -The grievance official will oversee the process, track grievances through the conclusion, lead investigations, issue written decisions to residents if requested, and coordinate with state and federal agencies if necessary. -The grievance official will complete the grievance form to include date received, summary statement, steps taken to investigate, summary of findings, confirmation or no confirmation of grievance, corrective action taken or to be taken, and date written resolution was issued if requested. -The grievance official or social service department will review findings with the resident/responsible person and provide written resolution if requested. Resident #57 was admitted to the facility in May 2021 with the following diagnoses: functional quadriplegia, spinal stenosis, and dependence on wheelchair. Review of Resident #57's current care plan indicated Resident #57's Health Care Proxy (HCP) was activated 1/11/23. Review of Resident #57's HCP indicated Family Member (FM) #2 was named the HCP. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/24/23, indicated that Resident #57 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Further review of the MDS indicated section GG functional ability; Resident #57 was dependent rolling right to left in bed, transferring from bed to wheelchair complete dependence with helper doing all the effort and Resident does none of the effort to complete the activity, Resident uses a wheelchair and assessment for the Resident to wheel 50 feet with two turns was not attempted due to medical condition or safety concerns. During an interview on 11/29/23 at 12:05 P.M., Resident #57 said he/she is missing $120. Resident #57 said the business office manager gave him/her the money while in bed and he/she tucked the money between the left arm and chest and fell asleep. Resident #57 said when he/she woke up, someone had stolen the money. Resident #57 said he/she told multiple staff members about the missing money, and nothing has ever been done about it. Review of the Nursing Note titled Incident Note, dated 2/22/2023, indicated the writer entered Resident #57's room at 7:00 P.M. and Resident #57 stated Business office Manager gave me an envelope with $120 in it earlier today and I lost it. The writer searched underneath the bed, underneath the patient, bedside tables, and chairs next to the bed and was unable to locate the envelope or money. The writer searched for a large folder the resident had with paperwork in it. Inside the folder was an envelope containing $195. Resident stated this money is not the money received from the Business Office Manager today. The money was counted out with a certified nursing assistant (CNA) present and placed back into the folder and given to the Resident. The Administrator and Unit Manager were notified. A Grievance form was filled out. Review of the facility Grievance Book indicated on the log sheet that a grievance was filed on 2/22/23 for Resident #57, the nature of the Grievance was missing money in the amount of $120, and the staff addressing and investigating the grievance was the previous Administrator. The grievance resolution, action taken, and date presented to the resident was left blank. Further review of the Grievance Book indicated there was no grievance form present in the book. During an interview on 12/5/23 at 9:35 A.M., the Business Office Manager (BOM), with the Administrator present, said Resident #57 requested $120 in December 2022 to buy Christmas presents but did not receive the money in December 2022 due to being hospitalized . BOM said Resident #57 did receive and signed for the $120 on 2/22/23. She said she gave the money to Resident #57 while in bed, and he/she tucked the money and some papers under the left arm and told the Resident it was not a safe place to keep the money. The BOM said she knows Resident #57 filed a grievance, but she does not know the outcome, she had nothing to do with investigation. The surveyor, Administrator and BOM reviewed the Grievance Book, and the log indicated a grievance was filed with no resolution recorded and the actual grievance was not maintained in the grievance book. The Administrator said she spoke to the previous Administrator, and she said the investigation was completed and there were no findings. The surveyor requested the investigation and the Administrator said there was no investigation report available for review. During an interview on 12/5/23 at 10:21 A.M., the Administrator provided the surveyor with a written statement from the previous Administrator, dated 11/29/23, which indicated the previous Administrator investigated the missing money and determined it was thrown away in the trash. The surveyor asked the Administrator if there was any investigation from February 2023 and the Administrator said no. During a telephonic interview on 12/5/23 at 11:40 A.M. to 11:46 A.M., Family Member (FM) #2 said Resident #57 called him/her and said $120 dollars was stolen. FM #2 said the facility never called him/her to inform her about the missing money, FM #2 called the facility because she didn't understand the personal funds account and how Resident #57 was getting money. FM #2 said the facility said they thought Resident #57 had misplaced the money. FM #2 said Resident #57 can't get out of bed without the staff or mobilize due to his/her condition and can't understand if the money was not stolen, why the facility couldn't find the money in his/her room. FM #2 said he/she was never informed of a resolution of the missing $120. During an interview on 12/5/23 at 2:45 P.M., Regional Nurse #1 said it was her understanding the conclusion was Resident #57 had a pile of papers on their bedside table and the money was thrown out with the papers. She said in hindsight the previous Administrator should have filed a grievance. The surveyor showed Regional Nurse #1 the grievance log which indicated a grievance had been filed on 2/22/23 for the missing $120 and there was no resolution or grievance form found in the book. Regional Nurse #1 said they don't have any investigation or statements from 2/22/23 as to what happened and said it's difficult to recreate now what happened a year ago, it could have been handled better.

Based on policy review, record review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#57), out of a total sample of 20 residents. Specifically, the facility failed to report the alleged misappropriation of $120 to the state agency within two hours on 2/22/23. Findings include: Review of the facility's policy titled Abuse Policy, dated April 2017, indicated but was not limited to the following: -It is the policy of this facility to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown source and misappropriation of resident's property and to ensure that all alleged violations of federal and state laws which involve mistreatment, neglect, abuse, injuries of unknown source and misappropriation of resident property (alleged violations), are reported immediately to the Executive Director of the facility. Such violations will be reported to the state agencies in accordance with existing state law. -An employee who suspects an alleged violation shall immediately notify the executive director or his/her designee. The executive director shall also notify the appropriate State agency in accordance with the State law. -The results of all investigations must be reported immediately to the Executive Director or his/her designee and to the appropriate State agency, as required by state law with the initial report submitted within two hours and follow up within five working days of the violation. Resident #57 was admitted to the facility in May 2021 with the following diagnoses: functional quadriplegia, spinal stenosis, and dependence on wheelchair. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/24/23, indicated that Resident #57 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. During an interview on 11/29/23 at 12:05 P.M., Resident #57 said he/she is missing $120. Resident #57 said the Business Office Manager gave him/her the money while in bed and he/she tucked the money between the left arm and chest and fell asleep. Resident #57 said when he/she woke up, someone had stolen the money. Resident #57 said he/she told multiple staff members about the missing money, and nothing has ever been done about it. On 11/29/23 the surveyor reviewed the Health Care Facility Reporting System (HCFRS- a web-based system that health care facilities must use to report incidents of misappropriation) involving Resident #57 and there were no reports filed in the past year for missing money. Review of the Nursing Note titled Incident Note, dated 2/22/23, indicated the writer entered Resident #57's room at 7:00 P.M. and Resident #57 stated Business Office Manager gave me an envelope with $120 in it earlier today and I lost it. The writer searched underneath the bed, underneath the patient, bedside tables, and chairs next to the bed and was unable to locate the envelope or money. The writer searched for a large folder the Resident had with paperwork in it. Inside the folder was an envelope containing $195. Resident stated this money is not the money received from the Business Office Manager today. The money was counted out with a certified nursing assistant (CNA) present and placed back into the folder and given to the Resident. The Administrator and Unit Manager were notified. A Grievance form was filled out. Review of the facility Grievance Book indicated in the log in the front of the book, a grievance was filed on 2/22/23 for Residents #57, the nature of the Grievance was missing money in the amount of $120, and the staff addressing and investigating the grievance was the previous Administrator. The grievance resolution, action taken, and date presented to the resident was left blank. Further review of the Grievance Book indicated there was no grievance form present in the book. During an interview on 12/5/23 at 9:35 A.M., the Business Office Manager (BOM) with the Administrator present, said Resident #57 requested $120 in December 2022 to buy Christmas presents but did not receive the money in December 2022 due to being hospitalized . The BOM said Resident #57 received and signed for the $120 on 2/22/23. She said she gave the money to Resident #57 while in bed, and he/she tucked the money and some papers under their left arm and told the Resident it was not a safe place to keep the money. The BOM said she knows Resident #57 filed a grievance, but she does not know the outcome, she had nothing to do with investigation. The surveyor asked the Administrator if the facility reported the missing money in HCFRS and she said no, they don't have theft in this building and the money was missing, not stolen. The Administrator said she spoke to the previous Administrator, and she said the investigation was completed and there were no findings. The surveyor requested the investigation and the Administrator said there was no investigation report available for review.

Based on observations, interviews, policy review, and record review, the facility failed to ensure an individualized plan of care was followed for Resident #16, in a total sample of 20 residents. Specifically, the facility failed to ensure a care plan for smoking preferences and times was developed. Findings include: Review of the facility's policy titled Smoking Policy and Procedure, dated May 2023, indicated but was not limited to the following: -All residents expressing the desire to smoke tobacco products or use of E-cigarettes will be assessed upon admission to the center when there is a change in status and quarterly. Once the facility has assessed the resident, safety interventions will be implemented and added to the Resident's plan of care. -A specific care plan will be designed to meet the individual needs of the resident and will be reviewed quarterly and/or with changes in condition. All appropriate safety interventions will be included in this care plan, such as smoking apron, adaptive devices, etc. Resident #16 was admitted to the facility in September 2020 with the following diagnoses: metabolic encephalopathy (alteration of brain function), major depressive disorder, and dementia. Review of Resident #16's care plan on 11/29/23 failed to indicate that a care plan had been developed for Resident #16's smoking safety and preferences. During the entrance conference meeting on 11/29/23 at 8:19 A.M., the Director of Nurses (DON) said there were four residents who are independent smokers in the building. She said there is no scheduled time for smokers because the smokers are independent, they go out whenever they want to smoke. The surveyor requested a list of the current facility smokers. Review of the current facility list of smokers indicated Resident #16 was not included on the current list of smokers. During an interview on 11/29/23 at 3:11 P.M., Resident #16 said he/she is a smoker and goes out once a day with Family Member (FM) #1 to smoke. Resident #16 said he/she is not allowed to go out with staff to smoke because he/she is not an independent smoker. During an interview on 12/1/23 at 3:38 P.M., FM #1 said the facility knows Resident #16 is a smoker and he/she has met with the nursing staff and the social worker in the past and had been told, unless Resident #16 is an independent smoker, he/she can only go out to smoke when a family member takes him/her out. FM #1 said it would be nice if he/she couldn't make it, then somebody from the facility could take Resident #16 out to smoke. During an interview on 12/1/23 at 3:53 P.M., the DON said Resident #16 was not on the smoking list because Resident #16 does not go out to smoke with the staff, only with FM #1. The DON said she was aware Resident #16 was a smoker but said he/she never asked the DON to go out and smoke. The surveyor reviewed with the Administrator and the DON that Resident #16 only has a Smoking Safety Interaction form completed and does not have a smoking care plan or the full smoking assessment completed. The DON said Resident #16 should have a care plan for smoking.

Based on observation, record review, policy review, and interview, the facility failed to ensure that staff provided care and services according to accepted standards of clinical practice for three Residents (#38, #44, and #23), out of a total sample of 20 residents. Specifically, the facility failed to ensure: 1. For Resident #44, the Resident's pacemaker was monitored and evaluated as per the facility policy and standards of practice; 2. For Resident #38, a. the Resident's pacemaker was monitored and evaluated as per the facility policy and standards of practice, and b. a physician's order was obtained for the provision of psychotherapy services; and 3. For Resident #23, a physician's order was obtained for the provision of psychotherapy services. Findings include: Review of the facility's policy titled Care of a Resident with a Pacemaker, dated May 2023, included but was not limited to: -The purpose of this procedure is to provide information about and guidance for the care of a resident with a pacemaker. -Pacemakers are electronic devices that artificially stimulate the heart muscle with electrical impulses when the heart rhythm is too slow (bradycardia). -Pacemakers are programmed to sense the heart and respiratory rate and to administer electrical pulses when the heart rate falls below a set threshold. -Pacemakers can be permanently implanted or temporary. a. Permanent pacemakers are surgically implanted when the cause of arrhythmia is chronic, and it has been determined that the cause is not transient. b. Typically pacemakers are implanted just below the clavicle, under the skin but above the pectoral muscle. The lead runs through the veins and are secured at the heart muscle. The other ends of the leads are attached to the pulse generator. c. Note: Implanted pacemakers are NOT THE SAME as implantable cardioverter defibrillators (ICDs). ICDs can deliver a defibrillating shock, where a pacemaker cannot. Complications: -If the pulse generator or battery fails, or if the leads become displaced the pacemaker may not work properly, leading to bradyarrhythmias. Monitoring: -Monitor the resident for pacemaker failure by monitoring for signs and symptoms of bradyarrhythmias (an abnormally slow resting heart rate, typically below 60 beats per minute). -Symptoms associated with bradyarrhythmias may include: a. Syncope (fainting) b. Shortness of breathe c. Dizziness d. Fatigue and/or e. Confusion Documentation: -For each resident with a pacemaker, document the following in the medical record and on a pacemaker identification card upon admission: a. The name, address, and telephone number of the cardiologist; b. Type of pacemaker c. Type of leads d. Manufacturer and model e. Serial number f. Date of implant g. Paced rate -When the resident's pacemaker is monitored by the Physician, document the date and results of the pacemaker surveillance, including: a. How the resident's pacemaker was monitored (phone, office, Internet) b. Type of heart rhythm c. Functioning of the leads d. Frequency of utilization e. Battery life Review of the Behavioral Health Service Agreement between the consultant psychological and behavioral health services provider and the facility, signed by the Executive Director on 9/7/22, included but was not limited to: Professional Services by Agency: -Observe the rights of residents in arranging for services, performing services, and maintaining confidentiality of information. Facility Working with Agency: -The facility agrees to the following to allow Agency to perform agreed upon services: -Assure that all referrals to agency have been ordered by physician contracted with facility. 1. Resident #44 was admitted to the facility in July 2023 with diagnoses including atrial fibrillation and heart failure. Review of Comprehensive Care Plans included but was not limited to: -Focus: I have a pacemaker related to atrial fibrillation with RVR (rapid ventricular rate) -Interventions: monitor vital signs as ordered/per facility protocol and record. Notify MD of significant abnormalities (7/26/23); Monitor/document/report to MD as needed any signs/symptoms of altered cardiac output or pacemaker malfunction: dizziness, syncope, difficulty breathing, pulse rate lower than programmed rate, lower than baseline blood pressure (7/26/23) -Goal: I will remain free of signs/symptoms of altered cardiac output through review date (7/26/23) Further review of the medical record failed to indicate physician's orders for the care and management of the pacemaker, information on the type of pacemaker, type of leads, manufacturer and model, serial number, date of implantation, paced rate and monitoring schedule. The medical record failed to indicate Resident #44 was monitored for signs/symptoms of bradyarrhythmia per facility policy. During an interview with the Director of Nursing (DON), Unit Manager #1, and Staff Development Coordinator Assistant (SDCA) on 12/1/23 at 9:17 A.M., the SDCA said she maintains documentation on pacemakers in the facility and provided the surveyor with a copy of a Pacemaker Audit documentation which included a spreadsheet with columns for Resident room, Resident name, implant date, model number, cardiologist name/phone number, last check date, next check date, care planned (yes/no) and order in place (yes/no). Eleven residents were listed on the audit sheet including Resident #44. For Resident #44, there was no information on the model number, cardiologist name/phone number, last check date, next check date, care planned or order in place. The DON, Unit Manager and SDCA said they do not have any other information about the pacemaker device and need to get the information and have it available in the medical record. 2. Resident #38 was admitted to the facility in June 2020 with diagnoses including atherosclerotic heart disease, atrial fibrillation, presence of a cardiac pacemaker and depression. On 4/29/22, the Resident was found to be incapable of making health care decisions, and the physician activated his/her health care proxy. a. On 11/29/23 at 11:40 A.M., the surveyor observed Resident #38 sitting on the edge of his/her bed watching television. A white box was noted on the bedside table. The Resident said the device is used to check his/her pacemaker. Resident #38 said the cardiologist gives him/her dates to do the checks and he/she sometimes forgets, but eventually gets it done. The Resident said facility staff do not assist with the pacemaker checks. Review of Comprehensive Care Plans included but was not limited to: -Focus: I have congestive heart failure and a pacemaker (6/29/20) -Interventions: Check breath sounds and monitor/document for labored breathing. Monitor/document for the use of accessory muscles while breathing (6/29/20); Monitor/document/report to MD as needed any signs/symptoms of congestive heart failure: dependent edema of legs and feet, periorbital edema, shortness of breath upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, orthopnea, weakness and/or fatigue, increased heart rate (tachycardia) lethargy and disorientation (6/29/20); pacemaker checks as ordered. Cardiology follow up as indicated (12/24/20) -Goal: I will have no signs/symptoms of dehydration through next review date (2/24/23); I will have clear lung sounds, heart rate and rhythm within normal limits through the review date (6/29/20). Further review of the medical record failed to indicate physician's orders for the care and management of the pacemaker, information on the type of pacemaker, type of leads, manufacturer and model, serial number, date of implantation, paced rate, and monitoring schedule. The medical record failed to indicate Resident #38 was monitored for signs/symptoms of bradyarrhythmia per facility policy. Review of an after-visit summary for Resident #38's cardiologist, dated 11/8/23, indicated the Resident's pacemaker device was checked, but failed to document the results of the pacemaker surveillance, including the type of heart rhythm, functioning of the leads, frequency of utilization, and battery life. During an interview with the Director of Nursing (DON), Unit Manager #1, and Staff Development Coordinator Assistant (SDCA) on 12/1/23 at 9:17 A.M., the SDCA said she maintains documentation on pacemakers in the facility and provided the surveyor with a copy of a Pacemaker Audit documentation which included a spreadsheet with columns for Resident room, Resident name, implant date, model number, cardiologist name/phone number, last check date, next check date, care planned (yes/no) and order in place (yes/no). Eleven residents were listed on the audit sheet including Resident #38. For Resident #38, there was no information on the implant date, model number, care planned or order in place. The DON and Unit Manager said Resident #38 does pacemaker checks his/herself and they do not monitor or document when he/she conducts the pacemaker checks. The DON, Unit Manager, and SDCA said they do not have any other information about the pacemaker devices and need to get the information and have it available in the medical record. During a telephone interview on 12/4/23 at 10:21 A.M., Cardiology staff #1 said Resident #38 was last seen by the cardiologist on 11/8/23 and had the pacemaker device checked. She said the Resident is forgetful and sometimes misses remote monitoring appointments which are supposed to be every three months. Cardiology staff #1 said Resident #38 is supposed to do the next remote monitoring on 12/14/23, then 2/26/24 and has an in-person appointment with the cardiologist on 5/15/24. She said the Resident should be monitored for symptoms, and if he/she is having symptoms, an additional pacemaker check should be done at that time. She said there is no communication between the facility and the cardiology office and if the facility wants documentation from the cardiologist about device monitoring results, they can request it and it will be sent to them. b. Review of the medical record indicated clinical documentation from the facility's consultant psychotherapy provider as follows: -6/28/23: Progress Note -7/26/23: Progress Note -8/9/23: Progress Note -9/6/23: Progress Note -9/13/23: Progress Note -10/18/23: Progress Note -11/1/23: Progress Note -11/29/23: Progress Note Further review of the medical record indicated the following physician's order: -Resident may be seen by psychotherapist: one to four times a month and as needed for 12 weeks (3/15/23). Further review of the medical record failed to indicate a current physician's order was obtained for eight psychotherapy visits from the facility's consultant psychotherapy provider. During an interview on 12/1/23 at 2:05 P.M., Social Worker #2 reviewed Resident #38's physician's orders and psychotherapy documentation. She said there were no current physician's orders for Resident #38 to receive psychotherapy from the facility's consultant psychotherapy provider but there should be. 3. Resident #23 was admitted to the facility in June 2023 with diagnoses including anxiety. Review of the medical record indicated clinical documentation from the facility's consultant psychotherapy provider as follows: -8/9/23: Psychosocial Evaluation -8/23/23: Progress Note -9/6/23: Progress Note -9/13/23: Progress Note -9/20/23: Progress Note -10/18/23: Progress Note -11/8/23: Progress Note -11/15/23: Progress Note -11/29/23: Progress Note Further review of the medical record failed to indicate a physician's order was obtained for nine psychotherapy visits from the facility's consultant psychotherapy provider. During an interview on 12/1/23 at 2:05 P.M., Social Worker #2 reviewed Resident #23's physician's orders and psychotherapy documentation. She said there was no physician's order for Resident #23 to receive psychotherapy from the facility's consultant psychotherapy provider but there should be.

Based on observation, interview, policy review, and manufacturer's guidelines, the facility failed to store and label medication according to facility policy. Specifically, the facility failed: 1. For 1 of 2 medication carts observed, to ensure all medications were labeled when opened; and 2. For Resident #52, to ensure all drugs and biologicals were stored in locked compartments when not in use. Findings include: 1. Review of the facility's policy titled Administering Medications, dated as revised May 2023, indicated but was not limited to: -The expiration/beyond use date on the medication label is checked prior to administering -When opening a multi-dose container, the date opened is recorded on the container On 12/4/23 at 1:00 P.M., the surveyor observed the Santuit long hall medication cart with Nurse #1. The surveyor observed one bag containing four boxes/bottles of eye drops as follows: -Lumigan 0.01% (used to lower the pressure in the eye), not labeled with open or beyond use date. -Latanoprost 0.005% (used to lower the pressure in the eye), not labeled with open or beyond use date. -Two bottles of Timolol 0.5% (used to lower the pressure in the eye), not labeled with open or beyond use date. During an interview on 12/4/23 at 1:19 P.M., Nurse #1 said she did not know when the medication bottles were opened and could not identify the beyond use date. Nurse #1 said she did not know when the medication bottles should be discarded. Nurse #1 said eye drops should be labeled when they are opened. During an interview on 12/4/23 at 4:04 P.M., the Director of Nurses (DON) said multidose vials/bottles including eye drops should be labeled when opened so they are not administered after the use by date. 2. Review of the facility's policy titled Self-Administration of Medications, dated as revised May 2023, indicated but was not limited to: -Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room. Nursing will transfer the unopened medication to the resident when the resident requests them. Resident #52 was admitted to the facility in November 2023 with the following diagnoses: chronic respiratory failure, chronic obstructive pulmonary disease (COPD), and glaucoma. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/4/23, indicated Resident #52 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. On 12/4/23 at 4:38 P.M., the surveyor observed the following medication on Resident #52's overbed table: -one Albuterol Sulfate 90 micrograms inhaler (mcg) (used to relax muscles in the airways and increase air flow to the lungs) -one Stiolto Respimat 2.5 mcg-2.5 mcg inhaler (used to relax muscles in the airways to improve breathing) -one bottle of Latanoprost 0.005% During an interview on 12/4/23 at 4:40 P.M., the Resident said he/she kept the eye drops and inhalers on his/her bedside table so they are available when needed. During an interview on 12/4/23 at 4:42 P.M., Nurse #4 said Resident #52 was assessed and able to self-administer his/her medication. Nurse #4 said Resident #52 was unable to lock the medication up in his room, because there was no key to his bedside drawer and the medications were not secured in his/her room when not in use. During an interview on 12/5/23 at 9:25 A.M., Resident #52 said he/she did not realize the medication needed to be locked up when not in use and nobody had mentioned that it was an issue or concern. During an interview on 12/4/23 at 5:55 P.M., the Director of Nurses (DON) said even if a resident has been cleared to self-administer medication, the medication should be stored in a locked compartment when not in use.

Based on observation, interview, record review, and policy review, the facility failed to adhere to infection control practices reducing potential transmission of infection by ensuring that the appropriate hand hygiene was preformed and personal protective equipment (PPE) was worn by staff when providing care for residents on Transmission-Based Precautions (TBP, used for patients who may be infected or colonized with certain infectious agents requiring additional precautions to prevent the spread of infection). Findings include: Review of the facility's policy on TBP (untitled), revised May 2023, indicated but was not limited to: - Transmission Based Precautions are the second tier of basic infection control and are used in addition to standard-based precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed. - Contact transmission precautions is infection spread through direct contact with an infectious person (e.g., touching during a handshake) or with an article or surface that has become contaminated. Infection Control Measures for Contact Precautions include: - Standard precautions infection control measures, and - PPE, including gloves and gown, for all interactions that may involve contact with residents or resident's environment. Review of the facility's policy titled Clostridium Difficile [contagious infection of the intestine], undated, indicated but was not limited to: - Measures are taken to prevent the occurrence of Clostridium difficile infection (CDI) among residents. Precautions are taken while caring for residents with C. difficile to prevent transmission to other residents. - Residents with diarrhea associated with C. difficile (i.e., residents who are colonized and symptomatic) are placed on Contact Precautions. - Residents with diarrhea and suspected CDI are placed on Contact Precautions while awaiting laboratory results. - When caring for residents with CDI, staff is to maintain vigilant hand hygiene. Hand washing with soap and water is superior to ABHR for the mechanical removal of C. difficile spores from hands. According to the Centers for Disease Control and Prevention (CDC) Clostridioides difficile, last updated 2021, indicated but not limited to: - While caring for you and other patients with C. diff, healthcare professionals will use certain precautions, such as wearing a gown and gloves, to prevent the spread of C. diff to themselves and to other patients. - Using contact isolation precautions, including wearing gloves and a gown for patients with unexplained diarrhea - Following hand hygiene practices, including before seeing a patient and after removal of gloves - Use contact precautions for patients with known or suspected CDI: Wear gloves and a gown when entering CDI patient rooms and during their care - Washing with soap and water is the best way to prevent the spread from person to person. According to the 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, last updated July 2023, indicated but not limited to: - Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. According to the Centers for Disease Control and Prevention (CDC) (2023), contact precautions are intended to prevent the transmission of infectious agents. Healthcare personnel caring for residents on contact precautions must wear a gown and gloves for all interactions that involve contact with the resident and the resident's environment. Review of the CDC Contact Precautions Sign, utilized by the facility and posted at a resident room doorway indicated but was not limited to: - Everyone Must: Clean their hands including before entering and when leaving the room. - Providers and staff must also: - Put on gloves before room entry. Discard gloves before room exit. - Put on gown before room entry. Discard gown before room exit. During an interview on 11/29/23 at 8:10 A.M., Nurse #6 said Resident #325 is on precautions for possible Clostridium Difficile. On 11/29/23 at 12:01 P.M., the surveyor observed Certified Nursing Assistant (CNA) #1 enter the room of Resident #325 with a contact precaution sign posted at the doorway and deliver a lunch tray. CNA #1 failed to put on a gown or gloves. During an interview on 11/29/23 at 12:02 P.M., CNA #1 said she did not know the resident required contact precautions. On 11/29/23 at 12:05 P.M., the surveyor observed Nurse #6 deliver a lunch tray to Resident #24 with a contact precaution sign posted at the doorway. Nurse #6 failed to wear gloves and a gown and did not perform hand hygiene when entering and exiting the room. During an interview on 11/29/23 at 12:13 P.M., Nurse #6 said that Resident #24 was on contact precautions for suspected Clostridium Difficile and she would only have to gown and glove if she was performing direct care. Nurse #6 said that it is acceptable to use alcohol-based hand gel to sanitize your hands after being in contact with someone on contact precautions for Clostridium Difficile. On 11/29/23 at 1:57 P.M., the surveyor observed the Staff Development Coordinator (SDC) enter the room of Resident #24 with a contact precaution sign posted at the doorway. The SDC failed to perform hand hygiene and failed to put on a gown prior to assisting the Resident. During an interview on 11/29/23 at 1:59 PM., the SDC said when a resident is on contact precautions you don't have to put on a gown if you are not providing care. On 11/29/23 at 3:23 P.M., the surveyor observed Certified Occupational Therapy Assistant (COTA) #1 in Resident #325's room; a contact precaution sign was posted at the doorway. The COTA #1 was not wearing gloves or gown. During an interview on 11/29/23 at 3:25 P.M., COTA #1 said that she had not noticed the contact sign posted outside of the Resident's room. She said that because she was not providing care to the Resident, she did not have to wear a gown and gloves. On 11/30/23 at 8:50 A.M., the surveyor observed the Scheduler go into Resident #24's room; a contact precaution sign was posted at the doorway. The Scheduler removed Resident #24's breakfast tray and she was not wearing a gown or gloves. During an interview on 11/30/23 at 8:52 A.M., the Scheduler said she did not need to wear a gown and gloves, since she was only grabbing his/her tray. On 11/30/23 at 8:56 A.M., the surveyor observed the Scheduler go into Resident #24's room to deliver a coffee; a contact precaution sign was posted at the doorway. The Scheduler failed to perform hand hygiene and did not don (put on) gloves or a gown. On 12/4/23 at 10:11 A.M., the surveyor observed COTA #1 in Resident #326's room; a contact precaution sign was posted at the doorway. She was wearing gloves but was not wearing a gown. During an interview on 12/5/23 at 11:05 A.M., COTA #1 said on 12/4/23 she was only wearing gloves yesterday while helping Resident #326 (on transmission-based precautions) to dispose of a dirty tissue. COTA #1 said she did see the contact precaution sign but thought it was only required when providing care. During an interview on 12/4/23 at 11:05 A.M., the Infection Preventionist (IP) said, for a resident on contact precautions, that if the staff are dropping off a tray, then just gloves are acceptable, for everything else both a gown and gloves should be worn. The IP and surveyor reviewed the contact precautions sign utilized by the facility and the IP said when a resident is on contact precautions the employees should perform hand hygiene and don gloves and a gown prior to entering the room. The IP said the gown and gloves should be removed before exiting the room and hand hygiene should be performed.

Based on observation, record review, policy review, and interview, the facility failed to follow their policy and assess a smoker for safety to smoke with staff and provide smoking times when family was not available for one Resident (#16), out of a total sample of 20 residents. Findings include: Review of the facility's policy titled Smoking Policy and Procedure, dated May 2023, indicated but was not limited to the following: -It is the policy of the facility to provide a safe environment for residents, staff, and visitors through the enforcement of the smoking policy designed to reduce risk to residents who smoke tobacco products, reduce the risks of passive smoking for others and reduce the risks of fire. -Supervised Smoker: A resident who has been assessed to need supervision will follow these guidelines. A staff member will accompany the supervised smoker supervised smoking residents during the smoking time for safety. Each smoke break will be held for 15 minutes. -All residents expressing the desire to smoke tobacco products or use of E-cigarettes will be assessed upon admission to the center when there is a change in status and quarterly. Once the facility has assessed the resident, safety interventions will be implemented and added to the Resident's plan of care. -Smoking times will be held for all residents at designated times during the day, Monday through Sunday. For designated smoking time please see addendum A attached to this policy. -Each unit will be responsible for gathering and escorting supervised residents to the designated smoking area and supervising them until they are escorted back into the building safely. -A specific care plan will be designed to meet the individual needs of the resident and will be reviewed quarterly and/or with changes in condition. All appropriate safety interventions will be included in this care plan, such as smoking apron, adaptive devices, etc. Resident #16 was admitted to the facility in September 2020 with the following diagnoses: metabolic encephalopathy (alteration of brain function), major depressive disorder, and dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/24/23, indicated that Resident #16 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15, and indicated the Resident did not use tobacco. Review of the Physician's Orders indicated Resident #16's healthcare proxy was invoked on 9/7/2020, naming Family Member (FM) #1 as his/her representative. Review of a Nursing Behavior Note, dated 10/10/23 at 8:50 P.M., indicated Resident #16 had increased behaviors on the shift. The Resident asked a resident across the hallway to push him/her outside for a cigarette. The Resident in room across the hall was witnessed pushing Resident #16 in the wheelchair in the hallway. This nurse educated both residents that they could not assist others with mobility as it is a safety protocol. Resident #16 became very agitated, stating that the rule was stupid and that he/she wants a cigarette. This nurse educated Resident #16 that he/she does not have any cigarettes and that she could not go outside with him/her at this moment as it was dinner time. Resident #16 told staff to shut the F up. Attempt at redirecting Resident with no effect. Review of progress note Smoking and Safety, dated 11/21/2023 at 12:12 P.M., indicated the following: Smoking status: Resident uses tobacco products. The Resident has balance problems while sitting or standing. Residents follow the facility's policy on location and time of smoking. Completed Clinical Suggestions. Review of progress note Smoking and Safety, dated 8/24/2023 at 1:37 P.M., Late Entry: Smoking status: Resident uses tobacco products. The Resident has balance problems while sitting or standing. The Resident follows the facility's policy on location and time of smoking. Smoking safety note: only smokes when spouse comes and takes him/her out. Completed Clinical Suggestions. Review of progress note Smoking and Safety, dated 5/23/2023 at 3:55 P.M., Smoking status: Resident uses tobacco products. Smoking safety note: only smokes supervised by his/her spouse when visits. Completed Clinical Suggestions. Review of Resident #16's care plan on 11/29/23 indicated there was no care plan developed for smoking. During the entrance conference meeting on 11/29/23 at 8:19 A.M., the Director of Nurses (DON) said there were four residents who were independent smokers in the building. She said there is no scheduled time for smokers because the smokers are independent, they go out whenever they want to smoke. The surveyor requested a list of the current facility smokers. Review of the current facility list of smokers provided by the facility did not include Resident #16 as a current smoker in the facility. During an interview on 11/29/23 at 3:11 P.M., Resident #16 stated he/she is a smoker and goes out once a day with his/her spouse to smoke. The Resident said the staff will not take him/her out because he/she is not an independent smoker. During an interview on 12/1/23 at 3:12 P.M., Resident #16 said FM #1 takes him/her out to smoke almost every day; sometimes FM #1 is late or can't come, then he/she doesn't get to go out for a smoke. Resident #16 said nobody from the facility takes him/her out to smoke, when he/she has asked in the past, they tell him/her they can't assume responsibility if he/she falls. The Resident said FM #1 has spoken to the nurses in the past about letting him/her go out for a cigarette. Resident #16 said it's been like this for a long time here, unless you are an independent smoker you can't go out, unless your family brings you out. During an interview on 12/1/23 at 3:38 P.M., FM #1 said, he/she has been coming to the facility almost every afternoon for a couple of years to take Resident #16 out for a cigarette break before he/she goes to work. FM #1 said the facility knows Resident #16 is a smoker and he/she has met with the nursing staff and the social worker in the past and had been told, unless Resident #16 is an independent smoker, he/she can only go out to smoke when a family member is present. FM #1 said it would be nice if he/she couldn't make it somebody from the facility could take Resident #16 out to smoke. FM #1 said Resident #16 does not smoke a lot, but this is one of the few pleasures Resident #16 has left and he/she should be able to have a smoking break if FM #1 can't make it here. During an interview on 12/1/23 at 3:44 P.M., Unit Manager #1 and Nurse #4 said they are both aware Resident #16 is a smoker and smokes almost daily when FM #1 comes to the facility in the late afternoon. Unit Manager #1 said FM #1 won't leave cigarettes for Resident #16, so we don't take Resident #16 out to smoke. Unit Manager #1 reviewed the electronic medical record and said Resident #16 only has a brief safety smoking assessment completed that indicates Resident #16 is a smoker, but the normal smoking safety assessment was not completed for Resident #16. Nurse #4 said they used to have smoking times here but have not had any set times for over a year because all smokers are now independent. During an interview on 12/1/23 at 3:53 P.M., the DON said Resident #16 was not on the smoking list because Resident #16 does not go out to smoke with the staff, only with FM #1. The DON said she was aware Resident #16 was a smoker but said he/she never asked the DON to go out and smoke. The surveyor reviewed with the Administrator and the DON, Resident #16 only had a Smoking Safety Interaction form completed and does not have a smoking care plan or the full smoking assessment completed to determine the Resident's current smoking level of supervision or safety interventions. The DON said Resident #16 should have a care plan and a completed smoking assessment.

Based on policy review, review of Resident Council Minutes, and resident and staff interviews, the facility failed to ensure that staff addressed and promptly resolved repeated grievances brought forward during Resident Council Meetings held from 5/22/23 through 10/31/23. Findings include: Review of the facility's policy titled Resident Council, last revised May 2023, included but was not limited to: -Documentation will be kept of issues and their resolution. The facility department related to any issues will be responsible for addressing the item(s) of concern. Review of the Facility's Complaint/Grievance Policy and Procedure, undated, included but was not limited to: -All residents and their responsible representative will have a mechanism to voice grievances and complaints to the Grievance Official to facilitate communication and timely resolution of the matter. -Voiced grievances (e.g., those about treatment, care, management of funds, lost clothing, or violation of rights) are not limited to a formal, written process and may include a resident's verbalized complaint to facility staff. -The Grievance Official, or designee in his/her absence, will review the grievance within 24 business hours of receipt. -The Grievance Official will complete the Complaint/Grievance form within 72 business hours and submit it to the Social Services Department and Administrator (if not the Grievance Official). -The Grievance Official will oversee the process, track grievances through the conclusion, lead investigations, issue written decisions to residents if requested. -The Grievance Official will complete the Grievance form to include date received, summary statement, steps taken to investigate, summary of findings, confirmation or no confirmation of grievance, corrective action taken or to be taken, and date written resolution was issued if requested. -The Grievance Official or Social Service Department will review findings with the resident/responsible person and provide written resolution if requested. Review of the Resident Council Minutes, dated 5/22/23, indicated seven residents participated in the meeting, and brought forward the following grievances: -Residents request more Jello© and pudding. Some residents stated that there is too much fried food. Review of a Topic Form for the Food Service Director, dated 5/22/23, indicated residents' concerns raised during the 5/22/23 Resident Council Meeting included a request for more Jello© and pudding and there is too much fried food. The section labeled How to address this issue was blank and it was unsigned by the Food Director. A handwritten note at the bottom of the form, signed by the Activity Director, indicated she gave the form to the Food Director, but he never signed it and left his job. Review of the Resident Council Minutes, dated 6/22/23, indicated nine residents participated in the meeting, and brought forward the following grievances: -Food quality has decreased, and they want alternatives to be available. Resident would like sub rolls for meat sandwiches and a better selection of desserts. Review of a Topic Form for the Food Service Director, dated 6/22/23, indicated residents' concerns raised during the 6/22/23 Resident Council Meeting included: -decreased food quality -not an adequate selection for alternatives -alternatives are not available as listed and discussed at previous meetings -food is arriving cold, taste is poor, appearance is not appetizing -sandwich bread is wet when arriving in rooms -request sub rolls for meatball sandwiches and other meat sandwiches -request better dessert selections The section labeled How will manager address this (these) issues was blank and it was unsigned by the Food Service Director. An unsigned note attached to the form indicated, Topic form for the Director of Food Services was not filled out our signed by the Food Director because the facility (sic) was in the process of changing food companies. Review of the Resident Council Minutes, dated 7/27/23, indicated nine residents participated in the meeting, and brought forward the following grievances: -Food is still not good. Too much pasta. Want more salads. Would like to have a barbecue in August. Want more choices for food and meals. Review of a Topic Form for the Food Service Director, dated 6/22/23, indicated residents' concerns raised during the 6/22/23 Resident Council Meeting included: -food is still not good -too much pasta -want more salads -would like to have a barbecue in August -want more choices for food meals The section labeled How will manager address this (these) issues indicated a handwritten note signed by the Activity Director: Food Director left. New Food Director starting in September. Issues were reported to the kitchen. There were no August 2023 Resident Council Minutes available to review. The September 2023 Resident Council Meeting was canceled due to a COVID outbreak in the facility. Review of Resident Council Minutes, dated 10/31/23, indicated 13 residents participated in the meeting, and brought forward the following grievances: -food has been served on paper plates. -request more variety of foods Review of a Topic Form for the Food Service Director, dated 10/31/23, indicated residents' concerns raised during the 10/31/23 Resident Council Meeting included complaints that food has been cold during the day and is being served on paper plates. The form was signed by the Food Service Director. On 12/1/23 at 11:00 A.M., the surveyor held a Resident Group meeting with 11 residents in attendance. The surveyor reviewed grievances identified in the 5/22/23 through 10/31/23 Resident Council minutes as listed above. The residents said they are frustrated because nothing changes. They said these issues have been raised repeatedly during monthly Resident Council meetings, are unresolved and continue to be a problem. Ten out of 11 residents said the food quality is poor, their meals are served cold every day for every meal (worse on weekends), the food items on their tray do not match was listed on the diet slip on their trays and they are not aware of food alternatives if they do not like what is served to them. During an interview on 12/1/23 at 11:55 A.M., the Activity Director said she records the minutes of every Resident Council Meeting and forwards any concerns to each applicable department head using a Topic Form. She said the residents have had repeated food complaints for many months and they haven't been resolved yet. During an interview on 12/1/23 at 2:40 P.M., the Administrator identified herself as the Grievance Official. She said she is aware of the residents' ongoing issues with food. She was unable to provide any evidence that the residents' food grievances documented in the Resident Council Minutes from May through October 2023 have been addressed or any attempts have been made to resolve the issues.

Based on observation and interviews, the facility failed to ensure residents' rights to personal privacy and confidentiality was promoted and protected for five Residents (#13, #273, #38, #274, and #23), from a total sample of 20 residents. Specifically, the facility failed to ensure: 1. For Resident #13, personal privacy of his/her own physical body was maintained during a medical examination; 2. For Resident #273, personal privacy of his/her own physical body was maintained during a medical examination. 3. For Residents #38, privacy was provided during psychotherapy sessions conducted by the facility's consultant psychotherapist in the Resident's room; 4. For Resident #274, privacy was provided during psychotherapy sessions conducted by the facility's consultant psychotherapist in the Resident's room; and 5. For Resident #23, privacy was provided during psychotherapy sessions conducted by the facility's consultant psychotherapist in the Resident's room. Findings include: 1. On 11/29/23 at 9:56 A.M., the surveyor observed Nurse Practitioner (NP) #1 enter Resident #13's room and approach him/her while seated at the bedside. Without closing the door to the Resident's room or pulling the privacy curtain to provide privacy, the NP began to conduct a physical assessment of the Resident and speak loudly regarding the Resident's medical condition and treatment options. The Resident was in full view of any passersby in the hallway and the NP could be clearly heard discussing his/her protected health information. 2. On 12/1/23 at 9:05 A.M., the surveyor observed NP #1 conducting a physical examination of Resident #273 as he/she sat in the unit hallway and was in full view of any passerby in the hallway. The NP was speaking loudly while examining the Resident and was discussing the Resident's symptoms and treatment options while standing in the hallway in full view of other staff and residents. During an interview on 12/1/23 at 9:07 A.M., NP #1 said he should either have closed the door or pulled the privacy curtain while examining Resident #13 and should have brought Resident #273 into his/her room for privacy during the examination. 3. On 11/29/23 at 11:00 A.M., the surveyor observed the consultant psychotherapist enter Resident #38's room and speak to him/her. The door was opened wide, and the privacy curtain was not pulled around the bed to provide privacy. The therapist's voice could be clearly heard from the hallway. As the Surveyor walked by, the therapist turned to look at the Surveyor. Review of the medical record failed to indicate that Resident #38 had a preference to have his/her door open and/or privacy curtain open during sessions with the facility's consultant psychotherapist. 4. On 11/29/23 at 11:14 A.M., the surveyor observed the consultant psychotherapist enter Resident #274's room and speak to him/her. The door was opened wide, and the privacy curtain was not pulled around the bed to provide privacy. The therapist's voice could be clearly heard from the hallway. 5. On 11/29/23 at 11:27 A.M., the surveyor observed the consultant psychotherapist enter Resident #23's room and speak to him/her. The door was opened wide, and the privacy curtain was not pulled around the bed to provide privacy. The therapist's voice could be clearly heard from the hallway. During an interview on 12/1/23 at 2:05 P.M., Social Worker #2 said the psychotherapist should have closed the door or pulled the privacy curtain to maintain every Residents' privacy during therapy sessions.

Based on observation, policy review, and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure food was stored, labeled, and dated in one of two kitchenette refrigerators observed; 2. Handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene and prevent cross contamination. In addition, ensure the use of gloves was limited to a single use task; and 3. Maintain a professional routine service contract for the juice dispensing machine and identify and replace enclosed tubing that has become discolored to avoid contamination of the juice. Findings include: Review of the facility's policy titled Food Storage and Retention Guide, undated, indicated but was not limited to: -Specialty items - Shakes, Supplements, Thickened Beverages. Dry Storage per Manufacturer Guidelines. -Also refer to manufacturer's instructions for product specific guidelines. Review of the facility's policy titled Food Storage: Cold, dated May 2014, indicated but was not limited to: -It is the center policy to ensure all Time/Temperature Control for Safety (TCS), frozen and refrigerated food items, will be appropriately stored in accordance with guidelines of the USDA Food Code. -The Food Services Director/Cook(s) ensures that all food items are stored properly in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated but was not limited to: -3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3- 501.17(A), except time that the product is frozen; P (2) Is in a container or PACKAGE that does not bear a date or day; P or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3-501.17(A). During an observation with interview on 12/4/23 at 4:05 P.M., the surveyor observed two open containers of thickened juice dated 11/11 in the Popponesset kitchenette located right outside the unit, with no opened date or use by date. The Food Service Director (FSD) said the date 11/11 was the date the container was stocked and said several times the juice was safe to serve until the manufacturer's expiration date even if the container was opened. The surveyor pointed out to the FSD that both containers were opened. The surveyor and the FSD reviewed the containers and identified the manufacturer expiration dates were 3/3/24 and 3/29/24 and reviewed the manufacturer-specific directions to discard the product if not used within four days of opening. The FSD said those directions were new and were not there before; it did not always say that. The FSD did not discard the items at this time. The FSD said kitchen aides restock the kitchenette and check for expiration dates in the morning and evening. On 12/5/23 at 1:33 P.M., the surveyor observed the same two opened containers of thickened juice in the Popponesset kitchenette. During an interview on 12/5/23 at 12:30 P.M., the Regional Food Service Manager (RFSM) said kitchenettes were stocked by the dietary staff twice per day. The RFSM expects dietary staff to label and monitor expiration dates on kitchenette food items. During an interview on 12/5/23 at 1:45 P.M., the Registered Dietitian (RD) said dietary staff stocks and monitors kitchenettes for expired items. 2. Review of the facility's policy titled Food Preparation and Service, dated May 2023, indicated but was not limited to: -Food and nutrition services shall prepare and serve food in a manner that complies with safe food handling practices. -Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. -Bare hand contact with food is prohibited. Gloves must be worn when handling food directly. However, gloves can also become contaminated and/or soiled and must be changed between tasks. Disposable gloves are single-use items and shall be discarded after each use. Review of the facility's policy titled Food: Preparation, dated May 2014, indicated but was not limited to: -It is the center policy that all foods are prepared, in accordance with the guidelines of the USDA Food Code. -The Food Service Director ensures that all staff practice proper hand washing technique and practice proper glove use. -The Food Service Director or Cook(s) are responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated but was not limited to: -3-304.15 Gloves, Use Limitation. (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. On 11/30/23 at 12:05 P.M., the surveyor observed the Food Service Director (FSD) wearing a pair of gloves cooking a grilled cheese sandwich, handling the pan and utensils, and plating the sandwich. She then turned to the prep table, wearing the same gloves and opened a plastic bread bag and removed two slices of bread and placed them on a plate. She then left the prep table, opened the walk-in refrigerator door with gloved hand, and retrieved a container of tuna or chicken salad container and returned to the prep station still wearing the same gloves. The FSD was observed to still be wearing the same gloves, handling the bread as she prepared and cut the sandwich with both hands. During an interview on 11/30/23 at 12:05 P.M., the FSD said she should have changed her gloves when she left the station before returning to make the sandwich. On 11/30/23 at 4:50 P.M., the surveyor observed [NAME] #1 wearing a pair of blue gloves put a roll on a plate, leave the prep station carrying a scoop utensil in one hand, open the walk-in refrigerator with the other gloved hand, retrieve a scoop of tuna or chicken salad and walk back to the food prep station. [NAME] #1 did not change his gloves and handled the roll with his gloved hand as he assembled the sandwich. During an interview on 11/30/23 at 4:55 P.M., the FSD and the Regional Food Service Manager (RFSM) both said, if they leave the station, they must perform hand hygiene and change their gloves before handling the food. 2. Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated, but was not limited to: -4-602.11 Equipment Food-Contact Surfaces and Utensils. (E)(4) In EQUIPMENT such as ice bins and BEVERAGE dispensing nozzles and enclosed components of EQUIPMENT such as ice makers, cooking oil storage tanks and distribution lines, BEVERAGE and syrup dispensing lines or tubes, coffee bean grinders, and water vending EQUIPMENT: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. Review of the facility's cleaning checklists titled, A.M. Diet Aide and P.M. Diet Aide, both dated November 2023, indicated, but was not limited to: -Juice machine gun cleaned for the month of November 16 out of the 30 days in the morning. -Juice machine gun, table and rack were cleaned for the month of November 16 out of the 30 days in the evening. -Machine area/drawers/counter was cleaned for the month of November three of the four weeks. Review of a third-party service record titled Planned Maintenance/Service Activity, dated 10/18/22, indicated the last professional service performed on the juice machine was 10/18/22. Durina an interview on 11/30/23 at 2:00 P.M., the FSD said kitchen staff ran water through the juice dispenser's lines and soaked the nozzle. The FSD said the RFSM oversees the cleaning of the juice dispensing machine and the FSD believed a third-party maintenance program was in place. During an interview on 11/30/23 at 3:43 P.M., the FSD said kitchen staff routinely cleaned the dispenser gun components by soaking them in warm water. The FSD said there was no record of a routine maintenance program by a third-party in place for the juice dispensing machine. The FSD provided documentation showing the juice dispensing machine was last serviced on 10/18/22. The FSD said they had set up biannual routine maintenance with the vendor of the juice dispensing machine that day and provided documentation of the service order. On 12/5/23 at 12:25 P.M., the RFSM provided the facility cleaning schedule for November. The cleaning schedule performed by the diet aide included cleaning the juice dispenser gun in the morning, the dispenser gun, table, and rack in the evening, and cleaning the juice machine area/drawers/counter weekly. During an observation with interview on 12/5/23 at 4:00 P.M., the surveyor observed Beverage Maintenance (BM) Contractor #1 servicing the juice dispensing machine. BM Contractor #1 said this machine did not look as bad as some, but he pointed out the buildup of a blue substance inside the tubing and said this should be clear. He recommended the juice dispensing machine to have maintenance once per year by a professional. He pointed to the tube with blue discoloration the entire tube and a couple tubes that were discolored, and said these tubes should be clear and there should be no internal discoloration. He said best practice is, the facility calls for service as soon as the internal discoloration begin. The BM Contractor #1 said there was potential for the blue substance to build up and contaminate the final product.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had an invoked Health Care Proxy, and had developed pressure injuries, although Resident #1's Health Care Agent (HCA) was made aware his/her skin breakdown, the Facility failed to ensure that nursing notified and updated the HCA (Family Member #1) about physcian orders related to treatments to Resident #1's pressure injuries. Findings include: The Facility Policy, titled Change in a Resident's Condition or Status, undated, indicated the following: -the Facility shall promptly notify the resident, his or her attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care) -a significant change of condition is a decline or improvement in the resident's status that: will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions -Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative (sponsor) when: there is a significant change in the resident's physical, mental, or psychosocial status -The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status Resident #1 was admitted to the Facility in March 2023, diagnoses included Vascular dementia, Osteoarthritis, Muscle weakness, Ataxia (impaired balance/coordination), Hypertension, Macular degeneration, and Glaucoma. Review of Resident #1's Health Care Proxy Form, dated June/2006, indicated Family Member #1 was Resident #1's Health Care Agent. Review of Resident #1's Physician Determination Concerning Massachusetts Health Care Proxy, dated 03/13/2023, indicated Resident #1's Health Care Proxy was invoked. Review of Resident #1's admission Minimum Data Set (MDS) Assessment, dated 03/14/23, indicated that Resident #1 had moderate impaired decision making. During an interview on 4/10/23 at 2:19 P.M., Family Member #1 (HCA) said although she was aware of Resident #1's pressure injuries, said the Facility did not inform her that there were treatment orders in place. Family Member #1 said she was told by three different day shift (7:00 A.M. to 3:00 P.M.) nurses (exact names unknown) on separate days, that Resident #1 did not have treatment orders for his/her pressure injuries. Review of Resident #1's Physician orders for March 2023, indicated treatment orders related to his/her pressure injuries included the following: - 3/19/23, House barrier cream on left buttock pressure injury for protection and cover with foam dressing - 3/21/23, Right and left buttock (pressure injury) wounds-cleanse with normal saline; apply house barrier cream then cover with foam border dressing daily and prn (as needed) and discontinue house barrier cream on left buttock pressure injury for protection and cover with foam dressing During an interview on 4/25/2023 at 12:06 P.M., Nurse #3 said on 3/21/23 she notified Resident #1's Physician of the pressure injuries to his/her left and right buttock and obtained a treatment order. Nurse #3 said she was aware of the Facility's Policy that for any change in a resident's condition, if a resident's Health Care Proxy has been invoked, that nurses were supposed to notify the Health Care Agent of the change and of any new Physician orders. Nurse #3 said she was not sure if she notified Resident #1's HCA of the new treatment orders and said she would have documented it in Resident #1's progress notes if she had. During an interview on 4/11/23 at 2:13 P.M. and 4/19/23 at 1:12 P.M., the Unit Manager said on 3/19/23, Resident #1 developed a pressure injury to his/her left buttock and that she notified the Physician, obtained a treatment order, and made Family Member #1 aware. The Unit Manager said a couple days later Resident #1 developed a second pressure injury to his/her right buttock and she informed Family Member #1 of the treatment orders to his/her left and right buttocks. The Unit Manager said she did not document in Resident #1's progress notes that she notified his/her Health Care Agent. However, Review of Resident #1's Medical Record, indicated there was no documentation to support his/her Health Care Agent was notified on 3/19/23 and 3/21/23, of the Physician orders for treatments to his/her pressure injuries. During an interview on 4/11/23 at 4:37 P.M and 4/19/23 at 3:04 P.M., the Director of Nurses (DON) said she was not told that Resident #1 developed pressure injuries to his/her buttocks, was not aware that treatment orders were obtained by nursing and his/her Family Member was not notified of the new treatment orders. The DON said Resident #1's Health Care Proxy was invoked, and the Unit Manager should have notified his/her Health Care Agent of the new treatment orders that were obtained and documented the notification in his/her medical record.

Based on policy review, record review, and interview, the facility failed to ensure a resident representative was given information necessary to make health care decisions, including the risks and benefits of psychotropic medications and obtain consent for their use, prior to administration, for one Resident (#119), out of a total sample of 22 residents. Findings include: Review of the facility's policy and procedure for Informed Consent for Psychotropic Medications, revised November 2020, indicated, but is not limited to the following: -Facility staff will use the Informed Consent Form for Psychotropic Administration (provided from the Department of Public Health) to obtain informed consent for the prescribed (psychotropic) medication used to treat psychiatric diagnosis or symptom prior to the administration of the medication. -The resident, activated health care proxy, or court appointed guardian can consent to the psychotropic medication. -The completed Informed Consent form (a-k documentation) will be placed in the medical record under Consents. Resident #119 was admitted to the facility in May 2021 after a hospitalization for care of a surgical wound and to receive rehabilitation. Review of the medical record indicated the physician invoked the Resident's Health Care Proxy on 5/31/21. Medications prescribed on 5/23/21 by the physician included the anti-depressant, Citalopram Hydrobromide (Celexa) one 10 milligram (mg) tablet daily. Review of the Resident's Medication Administration Record (MAR), dated 5/23/21 to 5/31/21 and 6/1/21 to 6/7/21 indicated Celexa was administered daily. Review of Resident #119's medical record on 6/3/21 failed to indicate that informed consent was obtained from the Health Care Agent for use of the psychotropic medication. The Informed Consent for Psychotropic Medication form in the Resident's medical record (paper) was blank. During an interview on 6/8/21 at 8:15 A.M., Unit Manager (UM) #2 said consents were obtained and placed in the (paper) medical record. At a later time the form may be scanned electronically but was supposed to be placed in the resident's record. UM #2 reviewed the medical record with the surveyor and confirmed Resident #119's psychotropic medication consent form was blank and it had not been obtained prior to administration.

Based on policy review, record review, observations, and interviews, the facility failed to ensure medications were not self-administered without an assessment, a physician's order, and stored safely for two Residents (#119 and #369), out of a total sample of 22 residents. Findings include: Review of the facility's policy titled Administering Medications, dated April 2019 and reviewed April 2020, indicated residents may self-administer their own medications, only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. Review of the facility's policy titled Self-Administration of Medications, dated November 2020, indicated, but is not limited to the following: -The resident will be assessed on their mental and physical ability to determine whether a resident is capable to self-administer. -Self-administered medications must be stored in a safe and secure place, which is not accessible to other residents. -Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for bedside storage, for return to the family or responsible representative. 1. Resident #119 was admitted to the facility in May 2021, with diagnoses that included history of cerebral vascular disease. Review of the medical record indicated the physician invoked the Resident's health care proxy on 5/31/21 due to mild confusion. Review of the physician's orders, dated 5/23/21, indicated Fluticasone Propionate Suspension 50 micrograms (mcg)/ACT-2, spray in both nostrils one time a day for allergies. During an observation and interview on 6/2/21 at 10:05 A.M., the surveyor observed a bottle of normal saline solution, a small opened bottle of Fluticasone Propionate nasal spray, and one unopened box of Fluticasone Propionate nasal spray medication on the Resident's bedside table. Resident #119 said that the medication belonged to him/her, but was unable to explain when it was administered. On 6/03/21 at 11:00 A.M., the surveyor observed medications at the bedside that included a bottle of normal saline solution, a bottle Fluticasone Propionate nasal spray and an unopened Fluticasone Propionate box of nasal spray. During an interview on 6/8/21 at 8:00 A.M., Unit Manager #2 said he was not aware that Resident #119 had any medications stored at the bedside, or that the Resident had been assessed to self-administer medications. Unit Manager #2 confirmed that Resident #119 did not have a physician's order to have medications at the bedside, and that no assessment was completed for self-administration for Fluticasone Propionate nasal spray. 2. Resident #369 was admitted to the facility in May 2021 with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD) (lung disease that blocks airflow and makes it difficult to breathe). On 6/2/21 at 12:32 P.M., the surveyor observed two inhaler medications on Resident #369's overbed table. On 6/3/21 at 1:01 P.M., the surveyor observed two inhaler medications on the Resident's overbed table. Review of Resident #369's medical record failed to indicate any physician's orders, baseline care plans, or assessments for self-administration of medications. During an interview on 6/3/21 at 1:50 P.M., Resident #369 said the medications are from the facility and that the nurse agreed to leave them. The Resident said, I sometimes take them more than I'm supposed to. During an observation and interview on 6/4/21 at 10:49 A.M., the surveyor did not observe the inhalers at the Resident's bedside and asked the Resident about the inhalers. Resident #369 said Nurse #5 took them from him/her this morning and told him/her they couldn't stay at the bedside anymore. During an interview on 6/4/21 at 11:40 A.M., Nurse #5 said he removed the two inhalers from the Resident's bedside this morning. He said he does not have any orders or an assessment to self-administer for Resident #369. He said that leaving medications at the bedside without the assessment being completed was a safety hazard and staff is not allowed to leave medications at the bedside without the assessment being done. During an interview on 6/4/21 at 11:42 A.M., Unit Manager #2 said Resident #369 would have to fill out a form for self-administration and pass an assessment and that without a care plan and a physician's order, it is never safe for staff to leave medications at the bedside. He confirmed that the Resident did not have the necessary documentation and assessments in place and that the policy was not followed.

Based on interview, record review, and observation, the facility failed to develop an individualized person centered comprehensive care plan for two Residents (#10 and #30), out of total sample of 4 residents who smoked. Findings include: 1. Resident #10 was admitted to the facility in November 2019. Review of Resident #10's smoking evaluation, dated 4/30/21, indicated the Resident was an independent smoker. Review of Resident #10's care plans indicated: -Focus of Resident #10: enjoying going outside to smoke; -Intervention: nursing to evaluate for safe smoking with each assessment period. During an interview on 6/2/21 at 11:44 A.M., Resident #10 said he/she was unsupervised for smoking and could go out the back door on the unit whenever he/she wanted. The Resident said he/she had cigarettes and a lighter and kept them in his/her possession. Review of Resident #10's medical record did not include any documentation of an individualized care plan for the Resident to hold his/her own smoking materials, where the items would be kept for safety or resident education regarding smoking material safety. During an interview on 6/3/21 at 1:51 P.M., the Director of Nurses (DON) and Unit Manager (UM) #1 said Resident #10 kept his/her own smoking materials. They said the Resident had suffered significant losses and loss of control over anything else would be detrimental to his/her mental health. They said the Resident kept the materials on his/her person at all times and they had educated the Resident on safety. They said they were unaware there was no information regarding safety education or the individualized plan of care in the medical record. 2. Resident #30 was admitted to the facility in May 2019 with diagnoses which included delusional disorder, paranoia, anxiety, post-traumatic stress disorder, and obsessive compulsive disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/8/21, indicated Resident #30 had a Brief Interview for Mental Status (BIMS) of 14 out of 15, which indicated intact cognition. The MDS also indicated Resident had behaviors on 1-3 days which included delusions. Review of Resident #30's Social Worker Assessment, dated 4/6/21, indicated the Resident remained paranoid and delusional, but had a daily routine. The assessment further indicated the Resident presented with obsessive compulsive disorder type of behavior and had increased paranoia with any changes in his/her daily routine. Review of the Resident's Smoking Evaluation, dated 4/30/21, indicated the Resident was an independent smoker and independent with lighting cigarettes. Further review of the Resident's comprehensive care plans included a plan for smoking with the following measurable interventions listed: -complete smoking evaluation per policy; -keep all smoking materials at nurse's station; and -smoke only in designated areas. During an interview on 6/3/21 at 12:58 P.M., the Resident said he/she kept his/her lighter and cigarettes with him/her at all times and showed the surveyor. The Resident said staff and other residents could not be trusted and placed the smoking materials back in his/her pocket. During an interview on 6/3/21 at 1:51 P.M., the DON and UM #1 said the Resident kept his/her own smoking materials as the Resident had a history of paranoia and it would be in his/her best interest to hold on to his/her own smoking materials. UM #1 said the Resident kept the materials on his/her person at all times and said she and the DON were unaware there was no information regarding the person centered plan of care in the clinical record.

Based on staff interviews, observation, and record review, the facility failed to ensure that staff provided care and services according to accepted standards of clinical practice for 4 Residents (#221, #44, #41, and #63), out of a total sample of 22 residents. Specifically, 1) For Resident #221, the facility failed to ensure a.) the O2 (oxygen) flow rate was set at 2-3 liters, per physician's order; and b.) the Normal Saline (NS) flush for the Peripherally Inserted Central Catheter (PICC) was performed every 8 hours and prn (as needed); 2) For Resident #44 the facility staff failed to ensure that the Resident received Oxycodone (pain medication) every four hours, per physician's orders; 3) For Resident #41, the facility staff failed to obtain a physician's order and document that Gastrostomy/Jejunostomy Tube (J/G-Tube) placement was checked prior to administration of medications through the G-Tube; and 4) For Resident #63 the facility staff failed to implement a physician's order for weekly weights and follow the facility's policy for weight surveillance. . Findings include: 1. Resident #221 was admitted to the facility in May 2021, with diagnoses including respiratory failure, chronic obstructive pulmonary disease, and sepsis. The Resident had a PICC line for Intravenous (IV) antibiotic administration. a. Review of Resident #221's most recent physician's order indicated: -O2 sat (saturation) every shift; -O2 at 2-3 liters via n/c (nasal cannula) to maintain an O2 saturation greater than 90%. On 6/02/21 at 10:59 A.M., with the Resident's permission, the surveyor observed the oxygen concentrator settings, and it was set at four liters. Resident #221 told the surveyor that it should be set on two liters. On 6/2/21 at 11:00 A.M., the surveyor informed Nurse #2 of Resident #221's high oxygen flow rate set at four liters. Nurse #2 checked the physician's orders and confirmed the rate was ordered at 2-3 liters. On 6/02/21 at 11:30 A.M. the surveyor observed Resident #221's oxygen concentrator and it remained set incorrectly at four liters. During an interview on 6/2/21 at 11:35 A.M., the surveyor informed Unit Manager (UM) #2 of Resident #221's incorrect O2-liter flow rate. UM #2 said the Resident returned from the hospital on 6/1/21 and the EMT's put it at that liter. UM #2 said, It should have been checked before then. Review of Resident #221's O2 flow sheets with UM #2 indicated that the nursing staff were not documenting the specific liter flow rate of the O2, i.e., 2.0, 2.5, or 3.0 liters or the corresponding oxygen saturations rates. Since returning to the facility, the nursing staff had not checked the rate to ensure it was correct. b. Review of Resident #221's physician's order for the PICC line indicated to flush each lumen (port used to administer medication) with 10 milliliters (ml) of NS every 8 hours whenever the lumen is locked with no infusion currently running every eight hours as needed. The physician's order was incorrectly written as needed. The Resident received the last dose of IV antibiotics on 5/31/21. The PICC line remained in place. Review of the facility protocol for flushing a PICC line indicated: when the lumen is not currently in use, the lumen is to be flushed every eight hours to maintain patency until the line is discontinued. The surveyor reviewed the physician's order for the PICC flushes and the order had been entered incorrectly into the Electronic Medical Record (EMR) resulting in the PICC line not being flushed every eight hours. During an interview on 06/03/21 at 9:58 A.M., UM #2 said, It [the PICC line] was being flushed. UM #2 and the surveyor reviewed the documentation for the flushing of the PICC line and UM #2 said that it had not been flushed every eight hours when not used according to the facility's protocol. He said the physician's order was entered into the electronic medical record as a prn (as needed) and not as a standing order (every eight hours). UM #2 said that because of the error in the way the order had been written and entered into the EMR, the facility staff failed to ensure that the PICC line had been flushed with NS every eight hours. 2. Resident #44 was admitted to the facility in May 2021 with diagnoses including fractures of the left femur and the left elbow. Review of the Resident #44's physician's order, dated 6/1/21, indicated Oxycodone HCl tablet 5 milligram (mg) give one tablet by mouth every 4 hours. Review of the May 2021 Medication Administration Record (MAR) indicated the Resident received the medication at the following times: 1000-(10:00 A.M.) 1400-(2:00 P.M.) 1800-(6:00 P.M.) 2200-(10:00 P.M.) Review of the above times listed on the MAR for the administration of the Oxycodone was not every four hours as the physician had ordered but four times a day. During an interview and record review on 6/8/21 at 1:00 P.M., the Corporate Registered Nurse (RN) reviewed the Resident's medical record and confirmed that the Resident had not been receiving the Oxycodone every four hours as ordered by the physician. Further review indicated the order was not entered correctly into the Electronic Medical Record (EMR) resulting in every four hours not populating correctly in the record and on the MAR. This resulted in the Resident not receiving the Oxycodone every four hours as prescribed. During an interview on 6/8/21 at 1:52 P.M., the Director of Nursing was made aware of the order not being entered into the EMR correctly. 3. Resident #41 was admitted to the facility with diagnoses including cerebral infarction and muscular dystrophy. The Resident had a J/G-Tube in place. The GT placement is performed using either of the following methods: - Drawing 5 cubic centimeters (cc) to 10 cc of air into a syringe. Place a stethoscope on the left side of the abdomen just the waist. Gently inject air into G-Tube and listen to the stomach for an air rush (gurgling or growling sound). - Aspirate the stomach contents with a syringe by gently pulling back on the plunger to visualize stomach contents and then re-instill. Review of the facility's policy for Enteral Tube Medication Administration, dated August 2020, indicated, but is not limited to the following: - With gloves on, check for proper tube placement in accordance with facility policy (The facility checks GT placement by aspirating stomach contents). Review of the medical record indicated Resident #41 was receiving enteral feedings via the J-Tube port and medications through the GT port. Review of the current physician's orders, dated 6/3/21, indicated that there was no order to check for GT placement prior to administration of the Resident's medications. Review of Resident #41's medical record indicated that there was no documentation indicating that G-Tube placement had been checked prior to medication administration. During an interview on 6/3/21 at 1:30 P.M., the Director of Nursing and the Corporate Registered Nurse said that the facility staff failed to obtain a physician's order to check placement of Resident #41's GT prior to administration of medications resulting in failure to document that placement was checked prior to medication administration, as per the facility's policy. 4. Resident #63 was admitted to the facility in May 2021 with diagnoses that included Mild Protein Calorie Malnutrition and dysphagia (difficulty or discomfort in swallowing). Review of the facility's policy titled Weight Surveillance, dated December 2020, indicated weight will be obtained on admission and then daily for two days, then weekly thereafter unless otherwise ordered. Review of Resident #63's medical record indicated the Resident had two weights documented 5/10/21 and 5/21/21; an order for weekly weights that was initiated on 5/13/21. There were no daily weights after admission and no additional weekly weights to review. During an interview on 06/04/21 at 11:09 A.M., Unit Manager #2 said the Resident has not been weighed as ordered. He said neither the policy for weighing the Resident nor the physician's order for weekly weights was followed.

Based on record review and interviews, the facility failed to ensure the care and services for 1 out 1 Resident (#220) with an indwelling Foley catheter (a thin tube inserted into the bladder to drain urine) were provided in accordance with the facility's policy for Urinary Catheter Care. Specifically, the facility failed to follow the facility's policy for changing the Foley catheter drainage (CD) bag. Findings include: Review of the facility's policy titled Care of the Urinary Catheter, dated November 2020, indicated the following: If breaks in aseptic technique, disconnection or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment as ordered. Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended. Rather it is suggested to change catheters and drainage bags on clinical indications such as infection, obstruction, or when the closed system is compromised. Review of Resident #220's current physician's orders indicated the following: - Foley Catheter: Change CD bag Sunday 11:00 P.M. to 7:00 A.M., every Sunday. Further record review indicated that the CD bag was changed on 5/20/21 and was scheduled to be changed 6/6/21, 6/13/21, 6/20/21, and 6/27/21. During an interview on 6/8/21 at 1:00 P.M., the Corporate Registered Nurse (RN) and the Director of Nursing indicated that the CD bag should not be changed at fixed intervals and that the staff failed to implement facility policy/protocol for changing of the CD bag based on clinical indicators.

Based on observation, record review, policy review, and staff interview, the facility failed to obtain timely weights for one Resident (#119) identified at nutritional risk, per the facility's policy and standards of practice, out of a total sample of 22 residents. Specifically, the facility failed to obtain admission, readmission, and re-weigh weights timely, per the facility's policy. Findings include: Resident #119 was admitted to the facility in May 2021 with diagnoses including malnutrition requiring parenteral nutrition with weight loss. Review of hospital weight records indicated Resident #119 had a significant weight loss (one that is greater than 5% in 30 days) of 6.48% at discharge 5/11/21. Review of the facility's policy titled Weight Surveillance, dated December 2020, indicated, but is not limited to: the resident weights are an important indicator of nutritional and overall health status. Residents will be weighed .and include: -Height and weight will be obtained within 24 hours of admissions; -Each resident will be weighed on admission and on readmission and daily for two days, then weekly, unless ordered otherwise; and -Re-weights are to be obtained if there is three pound discrepancy from previous weight to verify accuracy. On 6/2/21 at 1:33 P.M., review of Resident #119's medical record indicated the Resident's admission weight of 106.2 pounds was recorded on 5/15/21, four days after admission, and not within 24 hours as indicated in the facility policy. Further record review indicated Resident #119 was hospitalized and upon return to the facility on 5/22/21 was not weighed until 5/25/21, three days after readmission, and not within 24 hours as indicated in the facility policy. The Resident's readmission weight was 106.8. Review of Resident #119's physician's orders indicated to obtain weekly weights. Review of the June 2021 treatment record indicated Resident #119 weighed 90.3 pounds on 6/4/21, representing a significant weight loss of 15%. Review of the Dietitian's note, dated 6/7/21, acknowledged the Resident's significant weight loss recorded on 6/4/21. The Dietitian indicated a re-weigh weight is pending. On 6/8/21 at 2:30 P.M., record review indicated there had been no reweigh weight obtained to verify Resident #119's weight documented on 6/4/21. During an interview on 6/8/21 at 3:17 P.M., the Dietitian confirmed that resident weights were not always obtained/available timely. The Dietitian said that a reweigh is expected to be done in 24 hours and was aware that a reweigh for Resident #119 was not available on 6/7/21, and had requested that one be obtained. On 6/8/21 at 4:20 P.M., the Director of Nurses (DON) presented a note which indicated the reweigh weight (obtained that day) of Resident #119 was 95 pounds. The DON said the facility was incorrect for not obtaining the reweigh weight timely, within 24 hours.

Based on record review and interviews, the facility failed to ensure that one Resident (#44), who requires hemodialysis, receives services consistent with professional standards of practice. Specifically, the facility staff failed to monitor the Arteriovenous (AV) fistula (a surgical connection made between an artery and a vein used to remove and return blood during hemodialylsis) as ordered by the physician. Findings include: The blood flow through an AV fistula is checked by placing your fingers over the fistula to feel the motion of the blood flowing through it (feels like a vibration). This sensation is the thrill. With a stethoscope, listen for a swishing sound. This is the bruit. The bruit and thrill is checked to ensure the AV fistula is patent. Resident #44 was admitted to the facility in May 2021, with diagnoses including end stage renal disease requiring hemodialysis. Review of Resident #44's medical record indicated a physician's order for the following: To monitor the left AV fistula every shift for bruit and thrill. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) indicated there was no documentation of the monitoring of the AV fistula every shift for bruit and thrill as ordered by the physician. During an interview and record review on 6/8/21 at 1:00 P.M., the surveyor and the Corporate Registered Nurse (RN) reviewed Resident #44's medical record. The RN said she could not find any documentation by the nursing staff for the monitoring of the AV Fistula. Further review indicated the order to monitor the AV Fistula had not been entered correctly into the Electronic Medical Record (EMR), resulting in it not populating to the MAR or TAR. Therefore, nursing staff did not monitor the AV fistula for bruit and thrill every shift. During an interview on 6/8/21 at 1:52 P.M., the Director of Nursing was made aware of the order not being entered into the EMR.

Based on interviews and documentation review, the facility failed to designate a person who met the minimum qualifications to serve as the Director of Food and Nutrition Services to ensure the function of the dietary department. Findings include: During an interview on 6/2/21 at 8:50 A.M., the Food Service Supervisor said he was in charge of the dietary department in the facility. The Food Service Supervisor said he had completed a dietary manager training program. The Food Service Supervisor said the Registered Dietitian worked at the facility part-time. Review of the Food Service Supervisor's personnel file indicated he was hired as the full-time Food Service Supervisor (FSS) position on 8/24/20. The personnel file also indicated that he completed a dietary manager training program (9/7/19 to 5/9/20), over a year ago. The file failed to indicate that the FSS took and passed the dietary manager certification exam to become certified. During an interview on 6/8/21 at 3:00 P.M., the Food Service Supervisor confirmed that he has not tried to schedule a date to take the Certified Dietary Manager exam to meet the required certification. During a telephone interview on 6/8/21 at 3:15 P.M., the Registered Dietitian said she worked at the facility part-time. On 6/8/21 at 3:20 P.M., the Administrator was informed of the FSS not meeting the dietary manager certification requirement due to not completing the testing examination.

Based on observations, staff interview, and policy review, the facility failed to maintain a safe and sanitary environment in 1 out of 2 resident unit nourishment kitchens. Findings include: The surveyor observed the Unit 1 resident nourishment kitchen and observed the microwave oven to be in an unsanitary condition as follows: - On 6/2/21 at 4:58 P.M., the microwave oven had dried food debris on the interior top, sides, and bottom/turntable. -On 6/03/21 at 8:26 A.M., the microwave oven had dried food splatters. - On 6/4/21 at 12:23 P.M., the microwave oven had a dried sticky substance on the exterior handle and keypad. The interior of the microwave had dried food splatters on the sides, top, door, and bottom including the turntable. - On 6/8/21 at 3:00 P.M., the microwave oven had dried particles on the interior sides, top, bottom, and turntable. During an interview on 6/8/21 at 3:10 P.M., the Food Service Supervisor said that the dietary staff is responsible to ensure the cleanliness of the nourishment units. Review of the facility's Nourishment Kitchen policy, undated, indicated that 1 (e) once daily or as directed an assigned dietary staff member will restock the nourishment kitchen according to par levels and will clean any observed spills and sanitize the area and the microwave. The dietary staff failed to follow the nourishment kitchen policy to ensure food safety and a sanitary environment for residents.

Based on record review, policy review, and interview, the facility failed to ensure a physician's order for discharge was obtained for one sampled Resident (#69) out of two closed records. Findings include: Review of Resident #69's closed record indicated the Resident was admitted to the facility in February 2021, with diagnoses including: dementia, hypertension, and pneumonia. Review of the Minimum Data Set (MDS) assessment, dated 3/3/21, indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status score of 14 out of 15, and had an expectation of discharge back to the community. Review of Resident #69's medical record, indicated the Resident was discharged home on 3/24/21 according to the nursing progress note, but the record had no documentation of a physician's order for his/her discharge from the facility. The facility's policy titled: Discharge of Resident to Home or Other Facility/Unit, dated November 2020, indicated a physician's order for discharge must be obtained. During an interview on 6/8/21 at 3:08 P.M., the Director of Nurses said there was no physician's order for the discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C. Resident #35 was admitted to the facility with diagnoses which included multiple sclerosis and spastic quadriplegic cerebral palsy. Review of Resident #35's clinical record indicated the Resident was admitted to Hospice Care on [DATE]. Further review of the facility clinical record failed to include any hospice documentation which indicated the directed coordinated plan of care. On [DATE] at 1:22 P.M., the surveyor reviewed a blue binder which was identified by Unit Manager #1 to be the binder/clinical record of the assigned hospice provider for Resident #35. The hospice binder included numerous dividers with identified sections to separate the hospice documentation. Further review of the entire hospice binder indicated only one document which was identified as a Hospice Progress Note, dated [DATE]. On [DATE] at 1:48 P.M., the surveyor reviewed the hospice binder with the Hospice Coordinator. Review of the entire hospice binder indicated only one document which was identified as a Hospice Progress Note, dated [DATE]. On [DATE] at 10:08 A.M., the surveyor reviewed the hospice binder. Review of the entire hospice binder indicated only one document which as identified as a Hospice Progress Note, dated [DATE]. On [DATE] at 12:02 P.M., the surveyor reviewed the hospice binder with Unit Manager #1. Review of the entire hospice binder indicated only one document which was identified as a Hospice Progress Note, dated [DATE]. Unit Manager #1 said the Hospice Coordinator was in the process of printing all hospice documentation to be placed in the hospice binder but did not have any additional documentation at that time to provide to the surveyor. Based on record review and interviews, the facility failed to ensure the Hospice provider provided information and documentation regarding care and services as required in the provider agreement, for 3 of 3 sampled Residents (#65, #66, and #35) from a total of 14 Hospice residents. Specifically, A) For Resident #65, the hospice provider failed to provide the facility information for services provided, as required in the provider agreement; B) For Resident #66, the hospice provider failed to provide the facility information for services provided, as required in the provider agreement. In addition, the quarterly Hospice recertification was expired; and C) For Resident #35, the facility failed to ensure the Hospice services provided complete Hospice information in the Residents record that included the Hospice plan of care to assure coordination and collaboration of care. Additionally, the record had no documentation of the Election form, Certification of the terminal illness and no documentation of the RN visits and the home aide visits. Findings include: Review of the facility and the Provider Agreement for Hospice and Palliative Care, signed [DATE], under the provision of information, indicated the following: The Hospice shall provide the facility with sufficient information to ensure that the provision of inpatient and facility services under this agreement in accordance with the Hospice patient's plan of care, assessments, and treatment planning and care coordination. At a minimum, Hospice shall provide the following information to the facility for each Hospice Patient residing at the facility: -The plan of care -The Election form -The Certification of the terminal illness -Contact information -On-Call system A. Review of Resident #65's medical record indicated a physician's order for Hospice services initiated on [DATE]. On [DATE], the surveyor attempted to review the hospice binder for Resident #65, but was unsuccessful. During an interview on [DATE] at 3:00 P.M., Unit Manager (UM) #1 and Nurse #1 said they could not locate the Hospice book for Resident #65, but UM #1 said, Someone must have it. During an interview on [DATE] at 9:00 A.M., UM #1 and Nurse #2 said they didn't know where the Hospice book is. Nurse #2 said the Hospice nurse is coming later today and you can ask her. During an interview on [DATE] at 1:48 P.M., the Hospice Coordinator said Resident #65 did not have a hospice binder. The Hospice Coordinator said, The office is behind in printing and she is trying to get the building up to speed. She went onto to say, I brought it to the attention of the team that the records were not up to par and none of the charts were in order. During an interview on [DATE] at 3:15 P.M., the Director of Nurses said, We meet often and the Hospice Coordinator has not expressed to me that the Hospice records were not in order. B. Review of Resident #66's medical record indicated the Resident has been receiving hospice services since [DATE]. Review of the Hospice binder for Resident #66 indicated the recertification for the terminal illness, which is done quarterly, expired [DATE]. Review of the Hospice binder for Resident #66 indicated only one RN progress note, dated [DATE], was available to review. There were no other reports for April and [DATE]. There were no health aide reports to review. During an interview on [DATE] at 1:48 P.M., the Hospice Coordinator reviewed the record and said we are trying to get the records in order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident #369 was admitted to the facility in May 2021 with diagnoses that include Chronic Obstructive Pulmonary Disease (COPD) (a lung disease that blocks airflow and makes it difficult to breathe). Review of Resident #369's medical record indicated there was no documentation in the medical record for a baseline plan of care for the self-administration of medications. During an interview on 6/8/21 at 10:17 A.M., Unit Manager #2 said that he did not see or start any baseline care plans on Resident #369. He said he has not participated in the creation of any baseline care plans, nor has he seen any baseline care plans or reviewed them. 6. Resident #371 was admitted to the facility in May 2021. Review of the medical record indicated Resident #371 had received one dose of the COVID-19 vaccine prior to admission to the facility. Further review indicated there was no documentation of the Resident having a baseline care plan in place for Transmission Based Precautions. Review of the facility's policy titled: Verifying Covid-19 Vaccination, dated May 2021 and Massachusetts Department of Public Health Guidance Memorandum Titled: Update to Caring for Long-Term Care Residents during the COVID-19 Emergency, dated: May 24, 2021 indicated that residents who have an unknown vaccination status or are not fully vaccinated for more than two weeks require to be quarantined upon admission to the facility. During an interview on 6/8/21 at 10:17 A.M., Unit Manager #2 said that he did not see or start any baseline care plans for Resident #371. 7. Resident #63 was admitted to the facility in May 2021, with diagnosis that included Mild Protein Calorie Malnutrition, Epilepsy, and Dysphagia. Review of Resident #63's medical record failed to indicate a baseline care plan was developed and implemented within 48 hours of admission. During an interview on 6/8/21 at 10:09 A.M., Social Worker #1 said she holds admission meetings but no care plans are created in the meeting and the resident or their representative does not get a copy of care plans at the meeting. She said there is no paper document or computerized baseline care plans and believes care plans are created when completing the Minimum Data Set (MDS). She said she has not seen any baseline care plans and it is a process the facility struggles with. During an interview on 6/8/21 at 10:17 A.M., Unit Manager #2 said that he did not see or start any baseline care plans for Resident #63. Based on record review, observation, interviews and policy review, the facility failed to ensure that a baseline care plan was developed within 48 hours of admission and included minimum healthcare information that met professional standards of quality care and provided to resident representatives for 7 Residents (#121, #119, #62, #120, #369, #371, and #63), out of a total sample of 22 residents. Findings include: 1. Resident #121 was admitted to the facility in May 2021 with diagnoses including shingles (a viral infection). Review of the medical record (paper) included a blank one a page care plan form. The electronic care plan provided for review on 6/3/21 at 12:30 P.M., dated 5/29/21 indicted the following focus care areas: - Resident at risk for isolation due to COVID restrictions for visitors (5/29/21) - Risk for infection for COVID-19 (5/29/21) - Acute/Chronic Pain (6/3/21) - Self Care Deficit (6/3/21) dressing, bathing, feeding - New Onset Visual Complaints (6/3/21) Review of the medical record and physician's orders, dated 5/29/21, indicated the Resident was prescribed Acyclovir Sodium Solution 500 milligram (mg) intravenously (IV) two times a day, 100 milliliters (ml) per hour (ordered 5/29/21 until 6/4/21) via midline peripheral intravenous catheter (PIC). Physician orders also included to maintain transmission/contact precautions each shift. Review of Resident #121's care plan failed to indicate and identify the Resident's baseline care needs for the care and use of an intravenous peripheral catheter for medication administration and for use of contact precautions for infection control prevention for a contagious viral infection. On 6/08/21 at 8:15 A.M., Unit Manager #2 said he has not completed any baseline care plans. He said usually social services meets with residents and their family but could not say the meetings occur within 48 hours. During an interview on 6/8/21 at 2:50 P.M., the Social Worker said she is not able to document a care plan note within 48 hours, or hold a meeting, but said she is in contact with residents and families. The Social Worker was not aware that the facility had a system or other process to assure a care plan was formulated and information provided to the resident and or family to meet the 48 hour requirement. 2. Resident #119 was admitted to the facility in May 2021, after a hospitalization for a small bowel obstruction and a history of hemorrhagic Cerebral Vascular Accident (CVA). Review of the Minimum Data Set (MDS), dated [DATE], indicated for section M that the Resident's skin status included a surgical wound and skin tear (lower extremity) and no pressure area. Review of Resident #119's care plan indicated a focus care area for risk of skin breakdown initiated on 5/15/21, with goals for no new breakdown and interventions to turn and reposition, a pressure relieving mattress, wheelchair cushion, apply protective ointments, and report any changes to the physician. Review of the medical record indicated that the Resident was hospitalized in May 2021. Upon readmission to the facility on 5/22/21, the Resident's skin evaluation, dated 5/24/21, indicated a new Stage II pressure area with measurements of 1.5 centimeters (cm) in length by 1.5 cm wide and 0.1 cm in depth was identified on 5/22/21. Team progress notes, dated 5/25/21, indicated the Resident had an open Stage II skin area on his/her coccyx with interventions to use a pressure device in chair and bed. Review of physician skin treatment orders, dated 5/26/21, indicated normal saline (NS) TAO (Topical Antibiotic Ointment), cover 2 x 2 border foam every day and eve shift for ulcer on buttock, complete daily treatment observation and notify MD of any signs/symptoms of infection. Review of Resident #119's medical record indicated the baseline care plan form was blank, and failed to indicate a care plan for the Resident's Stage II pressure area, which was identified upon readmission to the facility and on the skin evaluation. During an interview on 6/08/21 at 8:15 A.M., Unit Manager #2 said he has not completed any baseline care plans, and said social services meets with residents and families. During an interview on 6/8/21 at 2:50 P.M., the Social Worker said she is not able to always document a care plan note within 48 hours, or hold a meeting. The Social Worker was not aware that the facility had a system or other process to assure a care plan was formulated and written information provided to the resident/representative to meet the 48 hour requirement. 3. Resident #62 was admitted to the facility in May 2021 for rehabilitation due to a hip fracture. Progress notes indicated an initial care plan meeting was held on 5/27/21, to discuss pain concerns the Resident was voicing to family and not facility staff. During an interview on 6/8/21 at 8:20 A.M., Unit Manager #2 said the initial care plan would be in the Resident's record if one was done. Review of the medical record failed to include documentation that a baseline care plan was provided. During an interview on 6/8/21 at 2:50 P.M., the Social Worker said she admits to not being able to document a care plan note or have a meeting within 48 hours. The Social Worker said she is uncertain that a consistent process is followed to assure a baseline care plan is formulated and information provided to the resident and or family to meet the 48 hour requirement. 4. Resident #120 was admitted to the facility in May 2021 with diagnoses including respiratory failure, intestinal infection, and severe septic shock. During an interview on 6/2/21 at 4:55 P.M. and on 6/3/21 at 11:55 A.M., Resident #120 expressed concerns for not understanding placement and health coverage. Review of the medical record failed to include documentation that a baseline care plan was provided. During an interview on 6/8/21 at 8:25 A.M., Unit Manager #2 said the initial care plan would be in the Resident's record if one was done and confirmed there was no completed 48 hour care plan. During an interview on 6/08/21 at 2:57 P.M., the Social Worker said she had spent a lot of time talking with resident/representative but there is not a process to ensure a 48 baseline care plan is documented to indicate what information was shared with the family/resident.

Based on policy review, record review, and staff interview, the facility failed to ensure that care and treatment of a Peripherally Inserted Central Catheter (PICC) was provided in accordance with the facility's policy for three residents (#221, #121 and #369), out of a total sample of 22 residents. Specifically, 1) For Resident #221, the facility failed to document the measurement of the external catheter length and upper arm circumference with each dressing change and failed to change the dressing every 7 days; 2) For Resident #121, the facility failed to ensure care and treatment of the PICC; and 3) For Resident #369, the facility failed to document the measurement of the external catheter length and upper arm circumference with each dressing change. Findings include: 1. Resident #221 was admitted to the facility in May 2021 with diagnoses including sepsis. The Resident had a PICC line for Intravenous (IV) antibiotics. Review of the facility's policy titled Central Venous Access Devices: Site Care and Dressing Change and Central Venous and Catheter Dressing Changes, dated November 2020, indicated but is not limited to the following: -Change the transparent dressings at least every five to seven days and PRN (as needed when wet, soiled, or not intact). -Documentation in the medical record includes, but is not limited to: *Date and time *Site assessment *Length of external catheter *Upper arm circumference *Resident response to procedure and/or medication *Resident/significant other teaching -The purpose of measuring the external catheter length is to monitor for migration of the catheter out of the superior vena cava. The catheter length is measured in the same manner each time so that the measurements are consistent and accurate. -Documentation should be present within the medical record so that the catheter migration can be accurately assessed by the nurse who is responsible for the next dressing change and external catheter length measurement. Review of Resident #221's medical record indicated an initial dressing change was completed on 5/19/21 and then another dressing change was completed on 5/25/21; both failed to indicate that a measurement of the external catheter length or upper arm circumference were taken and documented, per facility policy. Further review of the medical record failed to indicate that the dressing change scheduled for 6/1/21 had been performed. There was no documentation of the dressing change or measurements of the external catheter length or upper circumference. During an interview on 6/03/21 at 9:58 A.M., Unit Manager #1 said that PICC Dressing changes are done once they are here and then every 7 days and as needed if they are wet or lifting and that the external catheter length measurements and upper arm circumferences are completed with the dressing changes. Unit Manager #1 reviewed the medical record with the surveyor and said that there was no order to measure the external catheter length or upper arm circumference, so it had not been done. During an interview on 6/03/21 at 10:58 A.M., the Director of Nursing (DON) said that the facility staff failed to ensure that care and treatment of a PICC (Peripherally Inserted Central Catheter) was provided in accordance with the facility policy. 3. Resident #369 was admitted to the facility in May 2021 with diagnoses that included cellulitis with the use of Intravenous (IV) antibiotics through a Peripherally Inserted Central line (PICC). Review of Resident #369's medical record indicated that an initial dressing change was completed on 5/28/21 and then another dressing change was completed on 6/3/21; both failed to indicate that the external catheter length or upper arm circumference were measured, per facility policy. During an interview on 6/4/21 at 11:19 A.M., Unit Manager #2 reviewed the medical record with the surveyor and said there was no information to review that indicated the measurements were done with the dressing changes and there is no documentation he could find confirming external length. He said the policy was not followed. 2. Resident #121 was admitted to the facility in May 2021 with diagnoses including shingles (contagious viral infection that causes a rash). Review of Resident #121's medical record, indicated that the Resident was admitted with a left peripheral intravenous midline catheter for antibiotic treatment. Review of the physician's orders for the PICC line, dated 5/29/21, indicated the following: - The medication Acyclovir Sodium Solution 500 milligram (mg) infusion to be given two times a day, 100 milliliters (ml) and ordered from 5/29/21 to 6/4/21 intravenously. - Baseline mid upper arm circumference on admission. - Measure external catheter length on admission measure from point of catheter insertion to specific landmark. - Change IV tubing every 24 hours for intermitted/disconnected IV system every day shift. Monitor site: - Every shift for signs and symptoms of infection for related IV complications. - Flush each lumen (port where medication is administered through) with 10 milliliters (ml) of normal saline every 8 hours whenever lumen is locked with no infusion currently running. - PICC - Flush catheter lumen pre and post medication administration with 10 ml of normal saline. Review of Resident #119's May and June 2021 Medication Administration Record (MAR) and Treatment Administration Record (TAR), both failed to indicate that normal saline flushes were administered as part of the care and services for the Resident's PICC. The MAR indicated an entry listed as PRN (only as needed) - Flush each lumen with 10 ml of normal saline every 8 hours whenever lumen is locked. There were no PRN or other flushes documented as given. For 6/1/21 to 6/4/21, there was no documentation that the line was flushed upon locking the line and there was no documentation of normal saline flushes administered before and after the Acyclovir Sodium Solution 500 mg. medication was infused twice a day. Further review of the June 2021 MAR and TAR failed to indicate that any measurements of the insertion site were obtained and documented per facility policy. Review of Resident #119's care plan on 6/3/21, failed to include any interim interventions for the intravenous catheter care. During an interview on 6/8/21 at 8:10 A.M., Unit Manager #2 confirmed that IV flushes were not documented consistently on the Resident's MAR or the TAR since admission. Unit Manager #2 explained that upon transcribing admission orders, they were not done correctly, and were entered as a PRN; and agreed there was no way to determine that nursing staff had administered the flushes as ordered.

Based on observations, record review, and staff interviews, the facility failed to: 1) ensure staff implemented Infection Prevention and Control measures for one Resident (#371) on Transmission Based Precautions, out of a sample of 22 residents, and 2) ensure staff wore appropriate Personal Protective Equipment (PPE) in resident care areas, per the facility policy. Findings include: 1) On 6/2/21, the surveyor observed Resident #371 receiving skilled rehabilitative therapy in his/her room. The surveyor did not observe any signage posted to indicate that the Resident was on quarantine/ Transmission Based Precautions. On 6/3/21 at 7:47 A.M., the surveyor observed signage posted outside of Resident #371's room indicating he/she was on quarantine and all staff must wear full PPE (a gown, mask, eye protection and gloves) when entering the Resident's room. During an interview on 6/3/21 at 7:48 A.M., Unit Manager #2 said he was unsure why the signage had changed and confirmed that the staff was providing care without the required gown on the day prior. Review of facility's policy titled Verifying Covid-19 Vaccination, dated May 2021, indicated new admissions would be placed under quarantine guidelines until they could provide proof of completed vaccination for Covid-19 or completed all requirements of the quarantine. Review of Resident #371's medical record and the Consents for Immunizations form, indicated the Resident self-identified upon admission as only having received one vaccination shot for COVID-19 and needed to arrange to get the second vaccination. The medical record failed to indicate that neither nursing nor the admitting physician was aware of the Resident's vaccination status. During an interview on 6/3/21 at 8:04 A.M., the Director of Nurses (DON) said Resident #371 was placed on quarantine because he/she was not fully vaccinated against COVID-19. The DON was made aware of observations by the surveyor that staff had provided direct care to the Resident without the proper PPE on 6/2/21. During an interview on 6/3/21 at 3:50 P.M., the Administrator and the DON had no explanation for why the Resident was not placed on quarantine status at the time of admission, three days prior. The DON said that Resident #371 should have been placed on quarantine upon admission to the facility. 2) Review of the facility's policy Massachusetts Department of Public Health Memorandum guidance titled Update to Caring for Long-Term Care Residents during the COVID-19 Emergency, dated 5/24/21, indicated Long-term care facilities should ensure all staff are using appropriate PPE when they are interacting with residents, in alignment with DPH and CDC guidance on conservation of PPE. All long-term care facility personnel should wear a facemask while they are in the facility and eye protection while in patient care areas. On 6/3/21 at 1:24 P.M., the surveyor observed Nurse #4 enter a resident room to administer an aerosolizing medication wearing prescription glasses, not considered PPE. Nurse #4 failed to put on the required eye protection (either goggles or a face shield). During an interview on 6/3/21 at 1:30 P.M., Nurse #4 said staff is required to wear both a mask and face shield/goggles at all times and that she forgot to put her goggles on. She said she should not be in a care area or in a resident room without the appropriate PPE and she needs to keep them in place while on the nursing unit. During an observation and interview on 6/3/21 at 3:33 P.M., the surveyor observed CNA #1 standing at the nurse's station without any eye protection in place. CNA #1 said she did not have any goggles or face shield with her and she was waiting for the nurse to get her goggles. She said the staff is required to wear both a mask and goggles when on the nursing unit at all times. During an observation and interview on 6/4/21 at 10:42 A.M., the surveyor observed CNA #2 at the nurse's station speaking with a resident. CNA #2's eye protection was resting on the top of her head, not over her eyes. CNA #2 said, I did not have my goggles on and I should have. She said while on any nursing unit staff is required to wear both a mask and eye goggles. During an observation and interview on 6/4/21 at 12:18 P.M., the surveyor observed the Food Service Director (FSD) in the main dining room assisting with resident meal service with his protective eye goggles resting on the top of his head. The FSD said staff is required to wear both a mask and eye protection in any resident area, including the main dining room. He said he had just come from a break and forgot to put his goggles back on and they should have been on prior to him entering the resident area.